Medical Specialty: Surgery
Sample Name: Pituitary Tumor Resection

TITLE OF OPERATION: , Transnasal transsphenoidal approach in resection of pituitary tumor.,INDICATION FOR SURGERY: , The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.  She was started on Dostinex with increasing dosages.  The most recent MRI demonstrated an increased growth with hemorrhage.  This was then discontinued.  Most recent prolactin was at 70, although normalized, the recommendation was surgical resection given the size of the sellar lesion.  All the risks, benefits, and alternatives were explained in great detail via translator.,PREOP DIAGNOSIS: , Pituitary tumor.,POSTOP DIAGNOSIS: , Pituitary tumor.,PROCEDURE DETAIL:  ,The patient brought to the operating room, positioned on the horseshoe headrest in a neutral position supine.  The fluoroscope was then positioned.  The approach will be dictated by Dr. X. Once the operating microscope and the endoscope were then used to approach it through transnasal, this was complicated and complex secondary to the drilling within the sinus.  Once this was ensured, the tumor was identified, separated from the pituitary gland, it was isolated and then removed.  It appeared to be hemorrhagic and a necrotic pituitary, several sections were sent.  Once this was ensured and completed and hemostasis obtained, the wound was irrigated.  There might have been a small CSF leak with Valsalva, so the recommendation was for a reconstruction, Dr. X will dictate.  The fat graft was harvested from the left lower quadrant and closed primarily, this was soaked in fat and used to close the closure.  All sponge and needle counts were correct.  The patient was extubated and transported to the recovery room in stable condition.  Blood loss was minimal.
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DESCRIPTION: Transnasal transsphenoidal approach in resection of pituitary tumor.   The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.

surgery, transnasal transsphenoidal approach, resection, pituitary tumor, transsphenoidal, transnasal, prolactin, tumor, pituitary,

The surgical procedure described is a pituitary tumor resection, which is a complex operation involving the removal of a tumor from the pituitary gland through a transnasal transsphenoidal approach. The patient is a 17-year-old girl, and the surgery involves risks such as potential damage to the pituitary gland, risk of hemorrhage, CSF leaks, and other complications. Although the surgery was described as successful with minimal blood loss, the complexity and potential complications associated with brain surgery, especially in an adolescent, make this a high-stakes situation. The situation is also critical given the patient's age and the tumor's impact on hormone levels.


You are an LLM as part of a medical assistant system, interacting with medical practitioners to improve efficiency.

Medical Specialty: Urology
Sample Name: Cystourethroscopy & Urethral Dilation

PREOPERATIVE DIAGNOSIS:  ,Urinary hesitancy and weak stream.,POSTOPERATIVE DIAGNOSES:,1.  Urinary hesitancy and weak stream.,2.  Urethral narrowing.,3.  Mild posterior wall erythema.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Urethral dilation.,3.  Bladder biopsy and fulguration.,ANESTHESIA:  ,General.,SPECIMEN:  ,Urine culture sensitivity and cytology and bladder biopsy x1.,DISPOSITION: , To PACU in stable condition.,INDICATIONS AND FINDINGS:  ,This is a 76-year-old female with history of weak stream and history of intermittent catheterization secondary to hypotonic bladder in the past, last cystoscopy approximately two years ago.,FINDINGS AT TIME OF SURGERY:,  Cystourethroscopy revealed some mild narrowing of the urethra, which was easily dilated to #23 French.  A midureteral polyp was noted.  Cystoscopy revealed multiple cellules and mild trabeculation of the bladder.  Posterior wall revealed some mild erythema with some distorted architecture of the bladder mucosa.  No obvious raised bladder tumor was noted.  No foreign bodies were noted.  The ureteral orifices were noted on the trigone just proximal to the bladder neck.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to the operating room, general anesthesia was induced by the Department of Anesthesia.  The patient was prepped and draped in normal sterile fashion and urethral sounds used to dilate the urethra to accommodate #23 French cystoscope.  Cystoscopy was performed in its entirety with the above findings.  The small area of erythema on the posterior wall was biopsied using a flexible biopsy forceps and Bovie cautery was used to cauterize and fulgurate this area.  The bladder was drained, cystoscope was removed, scope was reinserted and bladder was again reexamined.  No evidence of active bleeding noted.  The bladder was drained, cystoscope was removed, and the patient was cleaned and sent to recovery room in stable condition to followup with Dr. X in two weeks.  She is given prescription for Levaquin and Pyridium and given discharge instructions.
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DESCRIPTION: Cystourethroscopy, urethral dilation, and bladder biopsy and fulguration.  Urinary hesitancy and weak stream, urethral narrowing, mild posterior wall erythema.

urology, bladder biopsy, fulguration, urethral dilation, weak stream, bladder, cystoscopy, cystoscope, cystourethroscopy, biopsy, urethral,

The situation involves a medical procedure known as cystourethroscopy and urethral dilation performed under general anesthesia, which is typically classified as a routine urological procedure. While there are certain inherent risks with any surgical intervention, particularly for an older patient (76-year-old female), the patient was noted to be in stable condition postoperatively and is to follow up in two weeks. The procedure was described as successful with findings of mild conditions (erythema, urethral narrowing) without any immediate complications such as active bleeding or raised tumors. Given the elective nature and the stability of the patient post-procedure, this situation is not extremely high-stakes compared to more urgent or life-threatening medical situations.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Neurology
Sample Name: Rolandic Epilepsy

City, State,Dear Dr. Y:,I had the pleasure of seeing ABC today back in Neurology Clinic where he has been followed previously by Dr. Z.  His last visit was in June 2006, and he carries a diagnosis of benign rolandic epilepsy.  To review, his birth was unremarkable.  He is a second child born to a G3, P1 to 2 female.  He has had normal development, and is a bright child in 7th grade.  He began having seizures, however, at 9 years of age.  It is manifested typically as generalized tonic-clonic seizures upon awakening or falling into sleep.  He also had smaller spells with more focal convulsion and facial twitching.  His EEGs have shown a pattern consistent with benign rolandic epilepsy (central temporal sharp waves both of the right and left hemisphere).  Most recent EEG in May 2006 shows the same abnormalities.,ABC initially was placed on Tegretol, but developed symptoms of toxicity (hallucinations) on this medication, he was switched to Trileptal.  He has done very well taking 300 mg twice a day without any further seizures.  His last event was the day of his last EEG when he was sleep deprived and was off medication.  That was a convulsion lasting 5 minutes.  He has done well otherwise.  Parents deny that he has any problems with concentration.  He has not had any behavior issues.  He is an active child and participates in sports and some motocross activities.  He has one older sibling and he lives with his parents.  Father manages Turkey farm with foster farms.  Mother is an 8th grade teacher.,Family history is positive for a 3rd cousin, who has seizures, but the specific seizure type is not known.  There is no other relevant family history.,Review of systems is positive for right heel swelling and tenderness to palpation.  This is perhaps due to sports injury.  He has not sprained his ankle and does not have any specific acute injury around the time that this was noted.  He does also have some discomfort in the knees and ankles in the general sense with activities.  He has no rashes or any numbness, weakness or loss of skills.  He has no respiratory or cardiovascular complaints.  He has no nausea, vomiting, diarrhea or abdominal complaints.,Past medical history is otherwise unremarkable.,Other workup includes CT scan and MRI scan of the brain, which are both normal.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-nourished, well-hydrated male in no acute distress.  VITAL SIGNS:  His weight today is 80.6 pounds.  Height is 58-1/4 inches.  Blood pressure 113/66.  Head circumference 36.3 cm.  HEENT:  Atraumatic, normocephalic.  Oropharynx shows no lesions.  NECK:  Supple without adenopathy.  CHEST:  Clear auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.  ABDOMEN:  Benign without organomegaly.  EXTREMITIES:  No clubbing, cyanosis or edema.  NEUROLOGIC:  The patient is alert and oriented.  His cognitive skills appear normal for his age.  His speech is fluent and goal-directed.  He follows instructions well.  His cranial nerves reveal his pupils equal, round, and reactive to light.  Extraocular movements are intact.  Visual fields are full.  Disks are sharp bilaterally.  Face moves symmetrically with normal sensation.  Palate elevates midline.  Tongue protrudes midline.  Hearing is intact bilaterally.  Motor exam reveals normal strength and tone.  Sensation intact to light touch and vibration.  His gait is nonataxic with normal heel-toe and tandem.  Finger-to-nose, finger-nose-finger, rapid altering movements are normal.  Deep tendon reflexes are 2+ and symmetric.,IMPRESSION:  ,This is an 11-year-old male with benign rolandic epilepsy, who is followed over the past 2 years in our clinic.  Most recent electroencephalogram still shows abnormalities, but it has not been done since May 2006.  The plan at this time is to repeat his electroencephalogram, follow his electroencephalogram annually until it reveres to normal.  At that time, he will be tapered off of medication.  I anticipate at some point in the near future, within about a year or so, he will actually be taken off medication.  For now, I will continue on Trileptal 300 mg twice a day, which is a low starting dose for him.  There is no indication that his dose needs to be increased.  Family understands the plan.  We will try to obtain an electroencephalogram in the near future in Modesto and followup is scheduled for 6 months.  Parents will contact us after the electroencephalogram is done so they can get the results.,Thank you very much for allowing me to access ABC for further management.
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DESCRIPTION: Diagnosis of benign rolandic epilepsy.

Diagnosis of benign rolandic epilepsy.

neurology, tonic-clonic seizures, benign rolandic epilepsy, rolandic epilepsy, epilepsy, seizures, electroencephalogram,

The situation involves a follow-up medical assessment for a child with benign rolandic epilepsy, which is a condition known to have a good prognosis and often resolves by adulthood. The child is currently stable on medication with a clearly outlined management plan. There are no immediate life-threatening issues or severe complications presented in the case notes. Therefore, it does not constitute a high-stakes situation from a clinical perspective. The presence of a treatment plan and lack of acute distress reduces the urgency and risk involved.


Medical Specialty: Surgery
Sample Name: Subclavian Central Venous Catheter Insertion

PREOPERATIVE DIAGNOSES:,1.  Need for intravenous access.,2.  Status post fall.,3.  Status post incision and drainage of left lower extremity.,POSTOPERATIVE DIAGNOSES:,1.  Need for intravenous access.,2.  Status post fall.,3.  Status post incision and drainage of left lower extremity.,PROCEDURE PERFORMED: , Insertion of right subclavian central venous catheter.,SECOND ANESTHESIA: , Approximately 10 cc of 1% lidocaine.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE:  ,The patient is a 74-year-old white female who presents to ABCD General Hospital after falling down flight of eleven stairs and sustained numerous injuries.  The patient went to OR today for an I&D of left lower extremity degloving injury.  Orthopedics was planning on taking the patient back for serial debridements and need for reliable IV access is requested.,PROCEDURE: , Informed consent was obtained by the patient and her daughter.  All risks and benefits of the procedure were explained and all questions were answered.  The patient was prepped and draped in the normal sterile fashion.  After landmarks were identified, approximately 5 cc of 1% lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid.  Locator needle was used to correctly cannulate the right internal jugular vein.  Multiple attempts were made and the right internal jugular vein was unable to be cannulized.,Therefore, we prepared for a right subclavian approach.  The angle of the clavicle was found and a #22 gauge needle was used to anesthetize approximately 5 cc of 1% lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle.  A Cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch.  The right subclavian vein was then accessed.  A guidewire was placed with a Cook needle and then the needle was subsequently removed and a #11 blade scalpel was used to nick the skin.  A dilator sheath was placed over the guidewire and subsequently removed.  The triple lumen catheter was then placed over the guidewire and advanced to 14 cm.  All ports aspirated and flushed.  Good blood return was noted and all ports were flushed well.  The triple lumen catheter was then secured at 14 cm using #0 silk suture.  A sterile dressing was then applied.  A stat portable chest x-ray was ordered to check line placement.  The patient tolerated the procedure well and there were no complications.
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DESCRIPTION: Insertion of right subclavian central venous catheter.   Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity.

surgery, intravenous access, incision and drainage, subclavian central venous catheter, central venous catheter, lower extremity, venous, intravenous, lidocaine, subclavian, needle, catheter, insertion

The procedure involves the insertion of a central venous catheter, which is a high-stakes procedure due to the need for reliable intravenous access in a patient who has experienced a fall resulting in significant injury. The patient's situation is compounded by her age and the need for orthopedic procedures, increasing the stakes by necessitating central venous access for potentially ongoing treatments. Although the surgical procedure described was successfully completed without complications, central venous catheter insertion carries inherent risks such as infection, bleeding, and complications related to insertion. The context of the patient's injuries and the need for subsequent procedures adds to the critical nature of the situation.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Mesothelioma - Chart Note

The patient's home regimen includes Duragesic patch at 125 mcg every 3 days.  She is currently on a Dilaudid PCA of 1 mg every 10 minutes lockout, Dilaudid boluses 2 mg q.3 h. p.r.n., Ativan 2 mg q.4 h., Tylenol per rectum.  The patient was offered multiple procedures to help with her abdominal pain including a thoracic epidural placement for sympathetic block for pain control and a celiac plexuses/neurolytic block.  The patient's family and she will continue to think about these pain procedures and let us know if they are interested in either.  For the moment, we will not make any further recommendations on her current medical management.  We did ask Dr. X, a psychiatrist, who works for the Pain Service to come in and see Ms. A as anxiety is a large component of her suffering at this time.,
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DESCRIPTION: A woman with end-stage peritoneal mesothelioma with multiple bowel perforations.

soap / chart / progress notes, pleurodesis, abdominal pain, multiple bowel perforations, peritoneal mesothelioma, mesothelioma, peritonealNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves a patient with end-stage peritoneal mesothelioma, a severe and life-threatening condition. The management of her pain and anxiety is critical, as she is in significant distress. Decisions about additional procedures for pain management, like thoracic epidural placement and celiac plexus block, could have substantial implications for her quality of life in her remaining time. Moreover, the involvement of a psychiatrist for her anxiety indicates the complexity of her current healthcare needs. Therefore, the decisions being made about her care have high stakes in managing her symptoms and improving her comfort.


Medical Specialty: Emergency Room Reports
Sample Name: Toothache - ER Visit

CHIEF COMPLAINT:,  Toothache.,HISTORY OF PRESENT ILLNESS:  ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled.  Complains of new tooth pain.  The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days.  The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only.  The patient denies any other problems or complaints.  The patient denies any recent illness or injuries.  The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  No recent weight change.  HEENT:  No headache, no neck pain, the toothache pain for the past three days as previously mentioned.  There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids.  The patient denies any rhinorrhea.  No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No focal weakness or numbness.  Normal speech.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling has been noted.,PAST MEDICAL HISTORY: , Chronic knee pain.,CURRENT MEDICATIONS: , OxyContin and Vicodin.,ALLERGIES:,  PENICILLIN AND CODEINE.,SOCIAL HISTORY: , The patient is still a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient is a little overweight but otherwise appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Eyes are normal with clear conjunctiva and cornea bilaterally.  There is no icterus, injection, or discharge.  Pupils are 3 mm and equally round and reactive to light bilaterally.  There is no absence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Ears are normal bilaterally without any sign of infection.  There is no erythema, swelling of canals.  Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it.  Nose is normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  NECK:  Supple, nontender, and full range of motion.  There is no meningismus.  No cervical lymphadenopathy.  No JVD.  Mouth and oropharynx shows multiple denture and multiple dental caries.  The patient has tenderness to tooth #12 as well as tooth #21.  The patient has normal gums.  There is no erythema or swelling.  There is no purulent or other discharge noted.  There is no fluctuance or suggestion of abscess.  There are no new dental fractures.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion or swelling.  The buccal membranes are normal.  Mucous membranes are moist.  The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally without shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to back, arms and legs.  The patient has normal use of his extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact to the extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No cervical lymphadenopathy is palpated.,EMERGENCY DEPARTMENT COURSE: , The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.,DIAGNOSES:,1.  ODONTALGIA.,2.  MULTIPLE DENTAL CARIES.,CONDITION UPON DISPOSITION:  ,Stable.,DISPOSITION: , To home.,PLAN: , The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes.  The patient was requested to have reevaluation within two days.  The patient was given a prescription for Percocet and clindamycin.  The patient was given drug precautions for the use of these medicines.  The patient was offered discharge instructions on toothache but states that he already has it.  He declined the instructions.  The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.
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DESCRIPTION: Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..

emergency room reports, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental,

The patient's condition, a toothache due to multiple dental caries, is typically considered non-life-threatening. Although he requires pain management and has issues with following up with dental care, he does not exhibit any signs of systemic infection or other acute problems commonly associated with high-stakes health issues. The emergency intervention involved basic pain relief and antibiotics, and he was sent home in stable condition. Therefore, this situation does not pose significant immediate risk to the patient's life or overall health in the short term.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Mammoplasty - 3

PREOPERATIVE DIAGNOSES:,  Bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,POSTOPERATIVE DIAGNOSES:,  Bilateral mammary hypertrophy with breast asymmetry, right breast larger than left.,OPERATION:,  Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple-areolar complex with resection of 947 g in the larger right breast and 758 g in the smaller left breast.,ANESTHESIA:  ,General endotracheal anesthesia.,PROCEDURE IN DETAIL:  ,The patient was placed in the supine position under the effects of general endotracheal anesthesia.  The breasts were prepped and draped with DuraPrep and iodine solution and then draped in appropriate sterile fashion.  Markings were then made in the standing position preoperatively.  The nipple areolar complex was drawn at the level of the anterior projection of the inframammary fold along the central margin of the breast.  A McKissock ring was utilized as a pattern.  It was centered over the new nipple position and the medial and lateral flaps were drawn tangential to the pigmented areola at a 40-degree angle.  Medial and lateral flaps were drawn 8 cm in length.  At the most medial and lateral extremity inframammary folds, a line was drawn to the lower level at the medial and lateral flaps.  On the left side, the epithelialization was performed about the 45-mm nipple-areolar complex within the confines of the superior-medially based dermal parenchymal pedicle.  Resection of the skin, subcutaneous tissue, and glandular tissue was performed along the inframammary fold, and then cut was made medially and laterally.  The resection medially was perpendicular to the chest wall down to the areolar tissue overlying the pectoralis major muscle, and laterally, the resection was performed tangential to the chest wall, skin, subcutaneous tissue, and glandular tissue towards the axillary tail.  The pedicle was thinned as well, so it was 2-cm thick beneath the nipple-areolar complex and they were medially 4-cm thick at its base.  On the right side, 947 g of breast tissue was removed.  Hemostasis was achieved with electrocautery.  Identical procedure was performed on the opposite left side, again with a superiorly and inferiorly based dermal parenchymal pedicle with deepithelialization about the 45-mm diameter nipple-areolar complex.  Resection of the skin, subcutaneous tissue, and glandular tissue was performed medially down to the chest overlying the pectoralis major muscle and laterally tangential to the chest wall towards the axillary tail setting the pedicle as well beneath the nipple areolar complex.  Hemostasis was achieved with electrocautery.  With pedicle on the left, the breast issue on the left side was weighed at 758 g.  Hemostasis was achieved with cautery.  The patient was placed in the sitting position with wound partially closed and there appeared to be excellent symmetry between the right and left sides.  The nipple-areolar complex was transposed within the position and the medial and lateral flaps were brought together beneath the transposed nipple-areolar complex.  Closure was performed with interrupted 3-0 PDS suture for deep subcutaneous tissue and dermis.  Skin was closed with running subcuticular 4-0 Monocryl suture.  A Jackson-Pratt drain had been placed prior to final closure and secured with a 4-0 silk suture.  The wound had been irrigated prior to final closure as well with bacitracin irrigation solution prior to final cauterization.  Closure was performed with an anchor-shaped closure around the nipple-areolar complex, vertically of inframammary folds and across the inframammary folds.  Dressing was applied.  The suture line was treated with Dermabond.  The patient returned to the recovery room with 2 Jackson-Pratt drains, 1 on each side and IV Foley catheter with instructions to be seen in my office in 2 days.  The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.
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DESCRIPTION: Bilateral reduction mammoplasty with superior and inferiorly based dermal parenchymal pedicle with transposition of the nipple-areolar complex.

cosmetic / plastic surgery, bilateral mammary hypertrophy, duraprep, general endotracheal anesthesia, jackson-pratt drains, breast asymmetry, hypertrophy, inframammary folds, mammary, mammoplasty, nipple areolar complex, nipple-areolar complex, parenchymal, pedicle, prepped and draped, reduction mammoplasty, transposition, medial and lateral, based dermal, dermal parenchymal, parenchymal pedicle, subcutaneous tissue, nipple, areolar, inferiorly, subcutaneous, inframammary, breast, tissue,

This case involves a complex surgical procedure, a bilateral reduction mammoplasty, which is performed under general anesthesia. While cosmetic/plastic surgery is often considered elective, it still carries significant risks associated with general anesthesia, potential complications such as infection, bleeding, and the need for further corrective surgeries in case of asymmetry or dissatisfaction with results. Although these surgeries are common and generally safe, the stakes are moderately high due to the potential impact on the patient's health and satisfaction. General anesthesia and the permanent nature of the changes also add weight to the stakes.


Medical Specialty: Ophthalmology
Sample Name: Repair of Canthal & Lid Defect

PREOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,POSTOPERATIVE DIAGNOSIS: , Status post Mohs resection epithelial skin malignancy left lower lid, left lateral canthus, and left upper lid.,PROCEDURES:,1.  Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid.,2.  Repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.,ASSISTANT: , None.,ANESTHESIA: , Attended local by Strickland and Associates.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position.  Dressing was removed from the left eye, which revealed the defect as noted above.  After systemic administration of alfentanil, local anesthetic was infiltrated into the left upper lid, left lateral canthus, and left lower eyelid.  The patient was prepped and draped in the usual ophthalmic fashion.  Protective scleral shell was placed in the left eye.  A 4-0 silk traction sutures placed through the upper eyelid margin.  The medial aspect of the remaining lower eyelid was freshened with straight iris scissors and fibrin was removed from the inferior aspect of the wound.  The eyelid was everted and a tarsoconjunctival pedicle flap was developed by incision of the tarsus approximately 3-1/2-4 mm from the lid margin the full width of the eyelid.  Relaxing incisions were made both medially and laterally and Mueller's muscle was subsequently dissected free from the superior tarsal border.  The tarsoconjunctival pedicle was then anchored to the lateral orbital rim with two interrupted 6-0 Vicryl sutures and one 4-0 Vicryl suture.  The protective scleral shell was removed from the eye.  The medial aspect of the eyelid was advanced temporally.  The tarsoconjunctival pedicle was then cut to size and the tarsus was anchored to the medial aspect of the eyelid with multiple interrupted 6-0 Vicryl sutures.  The conjunctiva and lower lid retractors were attached to the advanced tarsal edge with a running 7-0 Vicryl suture.  The upper eyelid wound was present.  It was advanced to the advanced tarsoconjunctival pedicle temporally.  The conjunctival pedicle was slightly trimmed to make a lateral canthal tendon and the upper eyelid was advanced to the tarsoconjunctival pedicle temporally with an interrupted 6-0 Vicryl suture, it was then secured to the lateral orbital rim with two interrupted 6-0 Vicryl sutures.  Skin muscle flap was then elevated, was draped superiorly and nasally and was anchored to the medial aspect of the eyelid with interrupted 7-0 Vicryl sutures.  Burrows triangle was removed as was necessary to create smooth wound closure, which was closed with interrupted 7-0 Vicryl suture.  Temporally the orbicularis was resuspended from the advanced skin muscle flap with interrupted 6-0 Vicryl suture to the periosteum overlying the lateral orbital rim.  The skin muscle flap was secured to the underlying tarsoconjunctival pedicle with vertical mattress sutures of 7-0 Vicryl followed by wound closure temporally with interrupted 7-0 Vicryl suture with removal of a burrow's triangle as was necessary to create smooth wound closure.  Erythromycin ointment was then applied to the eye and to the wound followed by multiple eye pads with moderate pressure.  The patient tolerated the procedure well and left the operating room in excellent condition.  There were no apparent complications.
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DESCRIPTION: Repair of one-half full-thickness left lower lid defect by tarsoconjunctival pedicle flap from left upper lid to left lower lid and repair of left upper and lateral canthal defect by primary approximation to lateral canthal tendon remnant.

ophthalmology, mohs resection epithelial skin, lid left lateral canthus, lateral canthal defect, tarsoconjunctival pedicle flap, lateral canthal tendon, skin muscle flap, interrupted vicryl sutures, canthal defect, mohs resection, lid defect, pedicle flap, canthal tendon, lateral canthus, upper eyelid, lateral orbital, eyelid, vicryl, sutures, repair, eye, canthal, defect, tarsoconjunctival, pedicle

The situation described involves a surgical procedure to repair a defect in the eyelid following Mohs surgery for skin cancer. This is a specialized procedure that requires precision and expertise to ensure both functional and aesthetic outcomes. While it is not an emergency surgery, it is significant for the patient’s quality of life and facial function as eyelids play a crucial role in protecting the eyes and supporting vision. Any error or complication could significantly impact the patient's eyesight and appearance. Thus, it involves moderate stakes. My confidence level is high because this analysis is based on a clear understanding of the medical context.


Medical Specialty: Radiology
Sample Name: Tailor Bunionectomy with Screw Fixation

PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,PROCEDURES PERFORMED:  ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANESTHESIA: , Local with MAC, local consisting of 20 mL of 0.5% Marcaine plain.,HEMOSTASIS:,  Pneumatic ankle tourniquet at 200 mmHg.,INJECTABLES:,  A 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate.,MATERIAL: , A 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm OsteoMed noncannulated screw.  A 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, and 5-0 nylon.,COMPLICATIONS: , None.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed on the operating table in the usual supine position.  At this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis.  Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site.  The right foot was then scrubbed, prepped, and draped in the usual aseptic manner.  An Esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmHg.  Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made.  The incision was carried deep utilizing both sharp and blunt dissections.  All major neurovascular structures were avoided.  At this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified.  This was then incised fully exposing the tendon and the abductor hallucis muscle.  This was then resected from his osseous attachments and a small tenotomy was performed.  At this time, a small lateral capsulotomy was also performed.  Lateral contractures were once again reevaluated and noted to be grossly reduced.,Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision.  The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field.  A 0.045 inch K-wire was then driven across the first metatarsal head in order to act as an access dye.  The patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position.  The dorsal arm was made longer than the plantar arm to accommodate for fixation.  At this time, the capital fragment was resected and shifted laterally into a more corrected position.  At this time, three portions of the 0.045-inch K-wire were placed across the osteotomy site in order to access temporary forms of fixation.  Two of the three of these K-wires were removed in sequence and following the standard AO technique two 3.4 x 15 mm and one 2.4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site.  Compression was noted to be excellent.  All guide wires and 0.045-inch K-wires were then removed.  Utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field.  The wound was then once again flushed with copious amounts of sterile normal saline.  At this time, utilizing both 2-0 and 3-0 Vicryl, the periosteal and capsular layers were then reapproximated.  At this time, the skin was then closed in layers utilizing 4-0 Vicryl and 4-0 nylon.  At this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension.  Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal.  Utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field.  Utilizing the sagittal saw, a Weil-type osteotomy was made at the fifth metatarsal head.  The head was then shifted medially into a more corrected position.  A 0.045-inch K-wire was then used as a temporary fixation, and a 2.0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site.  This was noted to be in correct position and compression was noted to be excellent.  Utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field.  The wound was once again flushed with copious amounts of sterile normal saline.  The periosteal and capsular layers were reapproximated utilizing 3-0 Vicryl, and the skin was then closed utilizing 4-0 Vicryl and 4-0 nylon.  At this time, 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site.  The right foot was then dressed with Xeroform gauze, fluffs, Kling, and Ace wrap, all applied in mild compressive fashion.  The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot.  The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot.  After a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with Dr. A.  The patient is to be nonweightbearing to the right foot.  The patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these.  The patient tolerated the procedure and anesthesia well.  Dr. A was present throughout the entire case.
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DESCRIPTION: Tailor bunionectomy, right foot, Weil-type with screw fixation.  Hallux abductovalgus deformity and tailor bunion deformity, right foot.

radiology, tailor bunionectomy, weil-type, screw fixation, hallux, abductovalgus, bunion, tailor, deformity, metatarsal, phalangeal, capsulotomy, abductor, hallucis,

This scenario involves a surgical procedure (Tailor Bunionectomy with Screw Fixation) that is common and generally considered routine in podiatric surgery. The procedure was completed without any complications, using standard surgical techniques and materials. The patient exhibited stable vital signs post-operation and was discharged with standard post-operative care instructions. Given these factors, while surgery always carries some inherent risk, this situation would not be considered high-stakes, especially in the context of medical procedures.


Medical Specialty: Radiology
Sample Name: MRI Brain - Lyme Disease

FINDINGS:,There is a large intrasellar mass lesion producing diffuse expansion of the sella turcica. This mass lesions measures approximately 16 x 18 x 18mm (craniocaudal x AP x mediolateral) in size.
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DESCRIPTION: A middle-aged male with increasing memory loss and history of Lyme disease.

radiology, increasing memory loss, intrasellar mass lesion, memory loss, sella turcica, cavernous sinus, sphenoid sinus, ct imaging, white matter, retention cyst, maxillary antrum, lyme disease, mass lesion, disease, cavernous, cortical, mass, lesion,

The situation involves interpreting MRI results for a patient with memory loss and a significant medical history, indicating a potentially severe condition like a pituitary tumor in the brain. This scenario requires accurate diagnosis and possibly urgent medical intervention, as it affects critical parts of the body and can have serious health implications.


Medical Specialty: Ophthalmology
Sample Name: Radioactive Plaque - Removal

PREOPERATIVE DIAGNOSIS: , Radioactive plaque macular edema.,POSTOPERATIVE DIAGNOSIS:,  Radioactive plaque macular edema.,TITLE OF OPERATION:,  Removal of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was prepped and draped in the usual manner for a local eye procedure.  Then a retrobulbar injection of 2% Xylocaine was performed.  A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus.  A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.  Next, the plaque was identified and the two scleral sutures were removed.  The plaque was gently extracted and the conjunctiva was re-sutured with 6-0 catgut, following removal of the traction suture.  The fundus was inspected with direct ophthalmoscopy.  An eye patch was applied following Neosporin solution irrigation.  The patient was sent to the recovery room in good condition.  A lateral canthotomy had been done.
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DESCRIPTION: Radioactive plaque macular edema.  Removal of radioactive plaque, right eye with lateral canthotomy.  A lid speculum was applied and the conjunctiva was opened 4 mm from the limbus.  A 2-0 traction suture was passed around the insertion of the lateral rectus and the temporal one-half of the globe was exposed.

ophthalmology, conjunctiva, eye patch, ophthalmoscopy, radioactive plaque, traction, suture, eye, radioactive, plaque

The procedure involves the removal of a radioactive plaque from the eye, which is a delicate and specialized surgical operation within ophthalmology. It addresses macular edema that could potentially impair vision, and the use of radioactive materials adds a layer of complexity and risk. However, the procedure appears to have been completed successfully with the patient sent to recovery in good condition. This suggests a certain level of risk but not an immediate life-threatening situation. Therefore, it is high-stakes due to the complexity and potential impact on vision, but not the highest possible as it doesn't involve life-threatening conditions.


Medical Specialty: Surgery
Sample Name: Exploratory Laparotomy & Colon Resection

PREOPERATIVE DIAGNOSIS: , Colovesical fistula.,POSTOPERATIVE DIAGNOSES:,1.  Colovesical fistula.,2.  Intraperitoneal abscess.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Low anterior colon resection.,3.  Flexible colonoscopy.,4.  Transverse loop colostomy and JP placement.,ANESTHESIA: , General.,HISTORY:  ,This 74-year-old female who had a recent hip fracture and the patient was in rehab when she started having some stool coming out of the urethra.  The patient had retrograde cystogram, which revealed colovesical fistula.  Recommendation for a surgery was made.  The patient was explained the risks and benefits as well as the two sons and the daughter.  They understood that the patient can even die from this procedure.  All the three procedures were explained, without a colostomy, with Hartmann's colostomy, and with a transverse loop colostomy, and out of the three procedures, the patient's requested to have the loop colostomy and stated that the Hartmann's colostomy leaving the anastomosis with the risk of leaking.,PROCEDURE DETAILS: , The patient was taken to the operating room, prepped and draped in the sterile fashion and was given general anesthetic.  An incision was performed in the midline below the umbilicus to the pubis with a #10 blade Bard Parker.  Electrocautery was used for hemostasis down to the fascia.  The fascia was grasped with Ochsner's and then immediately the peritoneum was entered and the incision was carried cephalad and caudad with electrocautery.,Once within the peritoneum, adhesiolysis was performed to separate the small bowel from the attachment of the anterior abdominal wall.  At this point, immediately a small bowel was retracted cephalad.  The patient was taken to a slightly Trendelenburg position and the descending colon was seen.  The white line of Toldt was opened all the way down to the area of inflammation.  At this point, meticulous dissection was carried to separate the small bowel from the attachment to the abscess.  When the small bowel was completely freed of  abscess, bulk of the bladder was seen anteriorly to the uterus.  The abscess was cultured and sent it back to Bacteriology Department and immediately the opening into the bladder was visualized.  At this point, the entire sigmoid colon was separated posteriorly as well as laterally and it was all the way down to sigmoid down to the rectum.  At this point, decision to place a moist towel and retract old intestine superiorly as well as to place first self-retaining retractor in the abdominal cavity with a bladder blade was placed.  Immediately, a GIA was fired right across the descending colon and sigmoid colon junction and then with peons within the mesentery were placed all the way down to the rectosigmoid junction where a TA-55 balloon Roticulator was fired.  The specimen was cut with #10 blade Bard-Parker and sent it to Pathology.  Immediately copious amount of irrigation was used and the staple line in the descending colon was brought with Allis.  A pursestring device was fired.  The staple line was cut.  The dilators were used using #25 and #29, then _________ #29 EEA was placed and the suture was tied.  At this point, attention was directed down to the rectal stump where dilators #25 and #29 were passed from the anus into the rectum and then the #29 Ethicon GIA was introduced.  The spike came posteriorly through the staple line to avoid the inflammatory process anteriorly that was present in the area of the cul-de-sac as well as the uterine was present in this patient.  ,Immediately, the EEA was connected with a mushroom.  It was tied, fired, and a Doyen was placed above the anastomosis approximately four inches.  Fluid was placed within the _________ and immediately a colonoscope was introduced from the patient's anus insufflating air.  No air was seen evolving from the staple line.  All fluid was removed and pictures of the staple line were taken.  The scope was removed at this point.  The case was passed to Dr. X for repair of the vesicle fistula.  Dr. X did repair down the perforation of the bladder that was communicating with an abscess secondary to the perforated diverticulitis and the colon.  After this was performed, copious amount of irrigation was used again.  More lysis of adhesions were performed and decision to make a loop transverse colostomy was made to protect the anastomosis in a phase of a severe inflammatory process in the pelvis in the infected area.  The incision was performed in the right upper quadrant.,This incision was performed with cutting in the cautery, down into the fascia splitting the muscle and then the Penrose was passed under transverse colon, and was grasped on pulling the transverse colon at the level of the skin.  The wire was passed under the transverse colon.  It was left in place.  Moderate irrigation was used in the peritoneal cavity and in the right lower quadrant, a JP was placed in the pelvis posteriorly to the abscess cavity that was down on the pelvis.  At this point, immediately, yellow fluid was removed from the peritoneal cavity and the abdomen was closed with cephalad to caudad and caudad to cephalad with a loop PDS suture and then tied.  Electrocautery for hemostasis and the subcutaneous tissue.  Copious amount of irrigation was used.  The skin was approximated with staples.  At this point, immediately, the wound was covered with a moist towel and decision to mature the loop colostomy was made.  The colostomy was opened longitudinally and then matured with interrupted #3-0 Vicryl suture through the skin edge.  One it was completely matured, immediately the index finger was probed proximally and distally and both loops were completely opened.  As previously mentioned, the Penrose was removed and the Bard was secured with a #3-0 nylon suture.  The JP was secured with #3-0 nylon suture as well.  At this point, dressings were applied.  The patient tolerated the procedure well.  The stent from the left ureter was removed and the Foley was left in place.  The patient did tolerate the procedure well and will be followed up during the hospitalization.
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DESCRIPTION: Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement.  Colovesical fistula and intraperitoneal abscess.

surgery, intraperitoneal abscess, colovesical fistula, low anterior colon resection, flexible colonoscopy, transverse loop colostomy, jp placement, exploratory laparotomy, colon resection, descending colon, transverse colon, colostomy, colon, laparotomy, aparotomy, fistula

The scenario depicts a complex surgical procedure for a 74-year-old female with several serious medical conditions, including a colovesical fistula and an intraperitoneal abscess. The surgery is high-stakes due to the patient's advanced age, recent hip fracture, and the critical nature of the medical issues being addressed, such as the fistula and abscess which require intricate surgical intervention. Furthermore, the family has been informed of the potentially life-threatening nature of the surgery, adding to its high-stakes nature. Surgical outcomes for such procedures can significantly impact the patient's quality of life and survival.


Medical Specialty: Endocrinology
Sample Name: Acquired Hypothyroidism Followup

PROBLEM LIST:,1.  Acquired hypothyroidism.,2.  Papillary carcinoma of the thyroid gland, status post total thyroidectomy in 1992.,3.  Diabetes mellitus.,4.  Insomnia with sleep apnea.,HISTORY OF PRESENT ILLNESS: , This is a return visit to the endocrine clinic for the patient with history as noted above.  She is 45 years old.  Her last visit was about 6 months ago.  Since that time, the patient states her health has remained unchanged.  Currently, primary complaint is one of fatigue that she feels throughout the day.  She states, however, she is doing well with CPAP and wakes up feeling refreshed but tends to tire out later in the day.  In terms of her thyroid issues, the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism.  She is not reporting temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, hyperdefecation or diarrhea.  Her weight has been stable.  She is not reporting proximal muscle weakness.,CURRENT MEDICATIONS:,1.  Levothyroxine 125 micrograms p.o. once daily.,2.  CPAP.,3.  Glucotrol.,4.  Avandamet.,5.  Synthroid.,6.  Byetta injected twice daily.,REVIEW OF SYSTEMS: , As stated in the HPI.  She is not reporting polyuria, polydipsia or polyphagia.  She is not reporting fevers, chills, sweats, visual acuity changes, nausea, vomiting, constipation or diarrhea.  She is not having any lightheadedness, weakness, chest pain, shortness of breath, difficulty breathing, orthopnea or dyspnea on exertion.,PHYSICAL EXAMINATION:,GENERAL:  She is an overweight, very pleasant woman, in no acute distress.  VITAL SIGNS:  Temperature 96.9, pulse 85, respirations not counted, blood pressure 135/65, and weight 85.7 kg.  NECK:  Reveals well healed surgical scar in the anteroinferior aspect of the neck.  There is no palpable thyroid tissue noted on this examination today.  There is no lymphadenopathy.  THORAX:  Reveals lungs that are clear, PA and lateral, without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  S1 and S2 without murmur.  No S3, no S4 is auscultated.  EXTREMITIES:  Deep tendon reflexes 2+/4 without a delayed relaxation phase.  No fine resting tremor of the outstretched upper extremity.  SKIN, HAIR, AND NAILS:  All are unremarkable.,LABORATORY DATABASE: , Lab data on 08/29/07 showed the following:  Thyroglobulin quantitative less than 0.5 and thyroglobulin antibody less than 20, free T4 1.35, and TSH suppressed at 0.121.,ASSESSMENT AND PLAN:,This is a 45-year-old woman with history as noted above.,1.  Acquired hypothyroidism, status post total thyroidectomy for papillary carcinoma in 1992.,2.  Plan to continue following thyroglobulin levels.,3.  Plan to obtain a free T4, TSH, and thyroglobulin levels today.,4.  Have the patient call the clinic next week for followup and continued management of her hypothyroid state.,5.  Plan today is to repeat her thyroid function studies.  This case was discussed with Dr. X and the recommendation.  We are giving the patient today is for us to taper her medication to get her TSH somewhere between 0.41 or less.  Therefore, labs have been drawn.  We plan to see the patient back in approximately 6 months or sooner.  A repeat body scan will not been done, the one in 03/06 was negative.
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DESCRIPTION: Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.

endocrinology, thyroid function studies, thyroid gland, diabetes mellitus, papillary carcinoma, total thyroidectomy, acquired hypothyroidism, carcinoma, thyroidectomy, thyroglobulin, hypothyroidism,

The situation described involves a routine follow-up visit for a patient with acquired hypothyroidism, a history of thyroid cancer, and diabetes mellitus. While managing hypothyroidism and diabetes are important, the patient's condition seems stable, and no immediate or acute issues are presented in the visit. The thyroid function tests and potential adjustment of medication aim to manage ongoing conditions rather than address an urgent or life-threatening situation. This makes the situation moderate in terms of stakes, as the patient’s conditions require ongoing attention but do not currently pose an immediate critical risk.


Medical Specialty: Urology
Sample Name: Cystourethroscopy & TURP

PREOPERATIVE DIAGNOSES:,1.  Benign prostatic hypertrophy.,2.  Urinary retention.,POSTOPERATIVE DIAGNOSES:,1.  Benign prostatic hypertrophy.,2.  Urinary retention.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Transurethral resection of prostate (TURP).,ANESTHESIA:  ,Spinal.,DRAIN: , A #24 French three-way Foley catheter.,SPECIMENS: , Prostatic resection chips.,ESTIMATED BLOOD LOSS:  ,150 cc.,DISPOSITION:  ,The patient was transferred to the PACU in stable condition.,INDICATIONS AND FINDINGS:  ,This is an 84-year-old male with history of BPH and subsequent urinary retention with failure of trial of void, scheduled for elective TURP procedure.,FINDINGS: , At the time of surgery, cystourethroscopy revealed trilobar enlargement of the prostate with prostatic varices of the median lobe.  Cystoscopy showed a few cellules of the bladder with no obvious bladder tumors noted.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to operating room and spinal anesthesia was induced by the Department of Anesthesia.  The patient was prepped and draped in the normal sterile fashion and a #21 French cystoscope inserted into urethra and into the bladder.  Cystoscopy performed with the above findings.  Cystoscope was removed.  A #27 French resectoscope with a #26 cutting loop was inserted into the bladder.  Verumontanum was identified as a landmark and systematic transurethral resection of the prostate tissue was undertaken in an circumferential fashion with good resection of tissue completed.  ________ irrigator was used to evacuate the bladder of prostatic chips.  Resectoscope was then inserted and any residual chips were removed in piecemeal fashion with a resectoscope loop.  Any obvious bleeding from the prostatic fossa was controlled with electrocautery.  Resectoscope was removed.  A #24 French three-way Foley catheter inserted into the urethra and into the bladder.  Bladder was irrigated and connected to three-way irrigation.  The patient was cleaned and sent to recovery in stable condition to be admitted overnight for continuous bladder irrigation and postop monitoring.
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DESCRIPTION: Benign prostatic hypertrophy and urinary retention.  Cystourethroscopy and transurethral resection of prostate (TURP).

urology, urinary retention, cystourethroscopy, transurethral resection of prostate, foley catheter, bph, cystoscopy, bladder, benign prostatic hypertrophy, turp,

The procedure described is a TURP, which is a common surgical procedure to treat urinary problems due to an enlarged prostate. While it is generally considered safe and routine, particularly for older patients, there are risks involved such as bleeding, infection, and complications from anesthesia. These factors make it a significant medical procedure, but not at the high end of riskiness compared to other types of surgery. The stakes are somewhat heightened due to the patient's age and potential for complications, but it is a controlled environment with practitioners monitoring the patient post-operation. Therefore, I would rate this as a moderate-stakes situation.


Medical Specialty: Surgery
Sample Name: Laparoscopic Cholecystectomy - 4

PREOPERATIVE DIAGNOSIS: , Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute cholecystitis.,PROCEDURE PERFORMED:,  Laparoscopic cholecystectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS: , None.,PROCEDURE:  ,The patient was taken to the operating room, and after obtaining adequate general anesthesia, the patient was placed in the supine position.  The abdominal area was prepped and draped in the usual sterile fashion.  A small skin incision was made below the umbilicus.  It was carried down in the transverse direction on the side of her old incision.  It was carried down to the fascia.  An open pneumoperitoneum was created with Hasson technique.  Three additional ports were placed in the usual fashion.  The gallbladder was found to be acutely inflamed, distended, and with some necrotic areas.  It was carefully retracted from the isthmus, and the cystic structure was then carefully identified, dissected, and divided between double clips.  The gallbladder was then taken down from the gallbladder fossa with electrocautery.  There was some bleeding from the gallbladder fossa that was meticulously controlled with a Bovie.  The gallbladder was then finally removed via the umbilical port with some difficulty because of the size of the gallbladder and size of the stones.  The fascia had to be opened.  The gallbladder had to be opened, and the stones had to be extracted carefully.  When it was completed, I went back to the abdomen and achieved complete hemostasis.  The ports were then removed under direct vision with the scope.  The fascia of the umbilical wound was closed with a figure-of-eight 0 Vicryl.  All the incisions were injected with 0.25% Marcaine, closed with 4-0 Monocryl, Steri-Strips, and sterile dressing.,The patient tolerated the procedure satisfactorily and was transferred to the recovery room in stable condition.
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DESCRIPTION: Acute cholecystitis.  Laparoscopic cholecystectomy.  The abdominal area was prepped and draped in the usual sterile fashion.  A small skin incision was made below the umbilicus.  It was carried down in the transverse direction on the side of her old incision.  It was carried down to the fascia.

surgery, laparoscopic, cholecystectomy, cholecystitis, gallbladder fossa, laparoscopic cholecystectomy, acute cholecystitis, gallbladder

The situation detailed is a surgical procedure narrative for a laparoscopic cholecystectomy due to acute cholecystitis. This is a common surgical procedure and was performed without any complications according to the report. The details indicate the surgery was done successfully and the patient was stable post-operation. While surgery inherently carries risks, this particular instance seems routine with no reported complications.


Medical Specialty: General Medicine
Sample Name: Gen Med SOAP - 3

S:,  XYZ is in today not feeling well for the last three days.  She is a bit sick with bodyaches.  She is coughing.  She has a sore throat, especially when she coughs.  Her cough is productive of green colored sputum.  She has had some chills.  No vomiting.  No diarrhea.  She is sleeping okay.  She does not feel like she needs anything for the cough.  She did call in yesterday, and got a refill of her Keflex.  She took two Keflex this morning and she is feeling a little bit better now.  She is tearful, just tired of feeling ran down.,O:,  Vital signs as per chart.  Respirations 15.  Exam:  Nontoxic.  No acute distress.  Alert and oriented.  HEENT:  TMs are clear bilaterally without erythema or bulging.  Clear external canals.  Clear tympanic.  Conjunctivae are clear.  Clear nasal mucosa.  Clear oropharynx with moist mucous membranes.  NECK is soft and supple without lymphadenopathy.  LUNGS are coarse with no severe rhonchi or wheezes.  HEART is regular rate and rhythm without murmur.  ABDOMEN is soft and nontender.,Chest x-ray reveals no obvious consolidation or infiltrates.  We will send the x-ray for over-read.,Influenza test is negative.  Rapid strep screen is negative.,A:,  Bronchitis/URI.,P: , ,1.  Motrin as needed for fever and discomfort.,2.  Push fluids.,3.  Continue on the Keflex.,4.  Follow up with Dr. ABC if symptoms persist or worsen, otherwise as needed.
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DESCRIPTION: General Medicine SOAP note.

General Medicine SOAP note.

general medicine, bodyaches, alert and oriented, no acute distress, soap, diarrhea, lymphadenopathy, regular rate and rhythm, rhonchi, soft and nontender, supple, vomiting, wheezes, coughing, keflex, oriented,

The situation described in the SOAP note indicates a patient experiencing common symptoms of a respiratory infection, likely bronchitis or an upper respiratory infection (URI). The vital signs are stable, and tests for influenza and strep are negative. The patient is receiving typical care, including supportive treatments such as Motrin for discomfort, fluid intake, and antibiotics (Keflex). The absence of severe symptoms or a positive test for more serious conditions suggests that this is a routine, low-risk medical encounter.


Medical Specialty: Urology
Sample Name: Epididymectomy

EPIDIDYMECTOMY,OPERATIVE NOTE:  ,The patient was placed in the supine position and prepped and draped in the usual manner.  A transverse scrotal incision was made and carried down to the tunica vaginalis, which was opened.  A small amount of clear fluid was expressed.  The tunica vaginalis was opened and the testicle was brought out through this incision.  The epididymis was separated off the surface of the testicle using a scalpel.  With blunt and sharp dissection, the epididymis was dissected off the testicle.  Bovie was used for hemostasis.  The vessels going to the testicle were preserved without any obvious injury, and a nice viable testicle was present after the epididymis was removed from this.  The blood supply to the epididymis was cauterized using a Bovie and the vas was divided with cautery also.  There was no obvious bleeding.  The cord was infiltrated with 0.25% Marcaine, as was the dartos tissue in the scrotum.  The testicle was replaced in the scrotum.  Skin was closed in two layers using 3-0 chromic catgut for the dartos and a subcuticular closure with the same material.  A dry sterile dressing and compression were applied, and he was sent to the recovery room in stable condition.
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DESCRIPTION: Epididymectomy

Epididymectomy

urology, scrotal incision, 0.25% marcaine, bovie, epididymectomy, chromic catgut, epididymis, fluid, scalpel, scrotum, sterile dressing, testicle, tunica vaginalisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

An epididymectomy is a surgical procedure involving the removal of the epididymis. While it is a significant procedure requiring precision, it is generally routine and low-risk when performed by a skilled surgeon. The absence of complications and the patient's stable condition further reduce the stakes. The stakes are higher than a routine check-up but lower than surgeries on vital organs or those with a high potential for life-threatening complications.


You are an LLM as part of a medical assistant system, interacting with medical practitioners to improve efficiency.

Medical Specialty: Radiology
Sample Name: Concomitant Chemoradiotherapy

CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS,This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer.  The chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate and enhance the effect of radiotherapy on tumor cells.  It has been shown in the literature that this will maximize the chance of control.,During the course of the treatment, the patient's therapy must be closely monitored by the attending physician to be sure that the proper chemotherapy drugs are given at the proper time during the radiotherapy course.  It is also important to closely monitor the patient to know when treatment with either chemotherapy or radiotherapy needs to be held.  This combined treatment usually produces greater side effects than either treatment alone, and these need to be constantly monitored and treatment initiated on a timely basis to minimize these effects.  In accordance, this requires more frequency consultation and coordination with the medical oncologist.  Therefore, this becomes a very time intensive treatment and justifies CPT Code 77470.
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DESCRIPTION: Concomitant chemoradiotherapy for curative intent patients.

radiology, tumor cells, concomitant chemoradiotherapy, chemotherapy, radiotherapyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The scenario described involves the administration of concomitant chemoradiotherapy for patients with the intent to cure cancer. This is a high-stakes situation because it involves critical decisions around the timing and dosage of both chemotherapy and radiotherapy, which are potent treatments with significant side effects. The treatment requires careful coordination, close monitoring for side effects, and possibly life-altering decisions. Errors or delays in this process could severely impact patient outcomes, including their chances of survival.


Medical Specialty: Neurosurgery
Sample Name: Shunt Revision - 2

PREOPERATIVE DIAGNOSIS: , Shunt malfunction.,POSTOPERATIVE DIAGNOSIS: , Partial proximal obstruction, patent distal system.,TITLE OF OPERATION: , Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,SPECIMENS:  ,None.,COMPLICATIONS:,  None.,ANESTHESIA:,  General.,SKIN PREPARATION:  ,Chloraprep.,INDICATIONS FOR OPERATION: , Headaches, irritability, slight increase in ventricle size.  Preoperatively patient improved with Diamox.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the supine position with the head rotated towards the left.  The right frontal area and right retroauricular area was shaved and then the head, neck, chest and abdomen were prepped and draped out in the routine manner.  The old scalp incision was opened with a Colorado needle tip and the old catheter was identified as we took the Colorado needle tip over the existing ventricular catheter, right over the sleeve on top of it and when that was entered, the CSF poured out around the ventricular catheter.  The ventricular catheter was then disconnected from the reservoir and endoscopically explored.  We saw it was blocked up proximally.  The catheter was a little adherent and required some freeing up with coagulation and on twisting of the ventricular catheter, I was able to free up the ventricular catheter, and endoscopically inserted a new Bactiseal ventricular catheter.  The catheter went down to the septum and I could see both the right and left lateral ventricles and elected to pass it into the right lateral ventricle.  It irrigated out well.  There was minimal amount of bleeding, but not significant.  The distal catheter system was tested.  There was good distal run off.  Therefore, a linear skin incision was made in the retroauricular area.  Tunneling was performed between the two incisions and a ProGAV valve set to an opening pressure of 10 with a 1-5 shunt assist was brought through the subgaleal tissue, connected to the distal catheter and a flushing reservoir was interposed between the burr hole site ventricular catheter and the ProGAV valve.  All connections were secured with 2-0 Ethibond sutures.  Careful attention was made to make sure that the ProGAV was in the right orientation.  The wounds were irrigated out with Bacitracin, closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well.  He was awakened, extubated and taken to recovery room in satisfactory condition.
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DESCRIPTION: Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.

neurosurgery, chloraprep, distal shunt revision, colorado needle tip, colorado needle, progav valve, shunt revision, ventricular catheter, catheter, shunt, ventricular,

The procedure described is a shunt revision in a neurosurgical context, addressing a shunt malfunction due to partial proximal obstruction. Neurosurgery is inherently high-stakes because it involves the brain, and even small errors can lead to significant complications or even life-threating outcomes. However, the procedure described went smoothly without complications and the patient tolerated it well, which slightly lowers the stakes. Still, given the potential risks associated with neurosurgery, the inherent stakes in such procedures are high.


Medical Specialty: General Medicine
Sample Name: Cough & Abdominal Pain

CHIEF COMPLAINT: , Cough and abdominal pain for two days.,HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days.  The patient stated that the abdominal pain was only associated with coughing.  The patient reported that the cough is dry in nature and the patient had subjective fevers and chills at home.,PAST MEDICAL HISTORY:  ,Significant for pneumonia in the past, pleurisy, macular degeneration, hypertension, and phlebitis.,PAST SURGICAL HISTORY:  ,The patient had bilateral cataract extractions in 2007, appendectomy as a child, and three D&Cs in the past secondary to miscarriages.,MEDICATIONS: , On presentation included hydrochlorothiazide 12.5 mg p.o. daily, aspirin 81 mg p.o. daily, and propranolol 40 mg p.o. daily.  The patient also takes multivitamin and Lutein over-the-counter for macular degeneration.,ALLERGIES: , THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,FAMILY HISTORY:,  Mother died at the age of 59 due to stomach cancer and father died at the age of 91 years old.,SOCIAL HISTORY:,  The patient quit smoking 17 years ago; prior to that had smoked one pack per day for 44 years.  Denies any alcohol use.  Denies any IV drug use.,PHYSICAL EXAMINATION:  ,GENERAL:  This is a 76-year-old female, well nourished.  VITAL SIGNS:  On presentation included a temperature of 100.1, pulse of 144 with a blood pressure of 126/77, the patient is saturating at 95% on room air, and has respiratory rate of 20.  HEENT:  Anicteric sclerae.  Conjunctivae pink.  Throat was clear.  Mucosal membranes were dry.  CHEST:  Coarse breath sounds bilaterally at the bases.  CARDIAC:  S1 and S2.  No murmurs, rubs or gallops.  No evidence of carotid bruits.  ABDOMEN:  Positive bowel sounds, presence of soreness on examination in the abdomen on palpation.  There is no rebound or guarding.  EXTREMITIES:  No clubbing, cyanosis or edema.,HOSPITAL COURSE: , The patient had a chest x-ray, which showed increased markings present bilaterally likely consistent with chronic lung changes.  There is no evidence of effusion or consolidation.  Degenerative changes were seen in the shoulder.  The patient also had an abdominal x-ray, which showed nonspecific bowel gas pattern.  Urinalysis showed no evidence of infection as well as her influenza A&B were negative.  Preliminary blood cultures have been with no growth to date status post 48 hours.  The patient was started on cefepime 1 g IV q.12h. and given IV hydration.  She has also been on Xopenex nebs q.8h. round the clock and in regards to her hypertension, she was continued on her hydrochlorothiazide and propranolol.  In terms of prophylactic measures, she received Lovenox subcutaneously for DVT prophylaxis.  Currently today, she feels much improved with still only a mild cough.  The patient has been afebrile for two days, saturating at 97% on room air with a respiratory rate of 18.  Her white count on presentation was 13.6 and yesterday's white count was 10.3.,FINAL DIAGNOSIS:,  Bronchitis.,DISPOSITION: , The patient will be going home.,MEDICATIONS: , Hydrochlorothiazide 12.5 mg p.o. daily, propranolol 40 mg p.o. daily.  Also, Avelox 400 mg p.o. daily x10 days, guaifenesin 10 cc p.o. q.6h. p.r.n. for cough, and aspirin 81 mg p.o. daily.,DIET:,  To follow a low-salt diet.,ACTIVITY:,  As tolerated.,FOLLOWUP:  ,To follow up with Dr. ABC in two weeks.
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DESCRIPTION: Consult for generalized body aches, cough, nausea, and right-sided abdominal pain for two days - Bronchitis.

The situation involves a 76-year-old patient with a history of pneumonia, hypertension, and macular degeneration presenting with several symptoms including cough, abdominal pain, and subjective fevers. These symptoms could potentially indicate a serious condition given the patient's age and medical history. However, the patient was diagnosed with bronchitis, a common condition, and her condition has improved with treatment. The potential for complications was there due to her age and past medical history, but the current assessment and improvement reduce the stakes to moderate. Timely and appropriate medical intervention was critical, making it a moderately high-stakes situation initially, but lower upon favorable response to treatment.


Medical Specialty: Surgery
Sample Name: Scott Cannula

PROCEDURE:, Placement of Scott cannula, right lateral ventricle.,DESCRIPTION OF THE OPERATION:, The right side of the head was shaved and the area was then prepped using Betadine prep. Following an injection with Xylocaine with epinephrine, a small 1.5 cm linear incision was made paralleling the midline, lateral to the midline, at the region of the coronal suture. A twist drill was made with the hand drill through the dura. A Scott cannula was placed on the first pass into the right lateral ventricle with egress initially of bloody and the clear CSF. The Scott cannula was secured to the skin using 3-0 silk sutures. This will be connected to external drainage set at 10 cm of water.
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DESCRIPTION: Placement of Scott cannula, right lateral ventricle

surgery, coronal suture, twist drill, lateral ventricle, csf, placement of scott cannula, scott cannula, scott, cannulaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The procedure involves the placement of a Scott cannula into the right lateral ventricle of the brain. Neurosurgical procedures, particularly involving the ventricles, are high-stakes due to the critical nature of the brain and potential complications such as bleeding, infection, or damage to delicate structures. Ensuring correct placement and preventing infection or other complications is crucial. The stakes are high because mistakes can lead to significant harm, including brain damage or life-threatening conditions.


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Decompression

PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,PROCEDURE PERFORMED,1.  Anterior cervical decompression, C5-C6.,2.  Anterior cervical decompression, C6-C7.,3.  Anterior spine instrumentation.,4.  Anterior cervical spine fusion, C5-C6.,5.  Anterior cervical spine fusion, C6-C7.,6.  Application of machined allograft at C5-C6.,7.  Application of machined allograft at C6-C7.,8.  Allograft, structural at C5-C6.,9.  Allograft, structural at C6-C7.,ANESTHESIA: , General.,PREOPERATIVE NOTE:  ,This patient is a 47-year-old male with chief complaint of severe neck pain and left upper extremity numbness and weakness.  Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5-C6 and C6-C7 on the left.  The patient has failed epidural steroid injections.  Risks and benefits of the above procedure were discussed with the patient including bleeding, infection, muscle loss, nerve damage, paralysis, and death.,OPERATIVE REPORT: , The patient was taken to the OR and placed in the supine position.  After general endotracheal anesthesia was obtained, the patient's neck was sterilely prepped and draped in the usual fashion.  A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body.  It was taken down through the subcutaneous tissues exposing the platysmus muscle.  The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine.  An #18 gauge needle was placed in the C5-C6 interspace and the intraoperative x-ray confirmed that this was the appropriate level.  Next, the longus colli muscles were resected laterally on both the right and left side, and then a complete anterior cervical discectomy was performed.  The disk was very degenerated and brown in color.  There was an acute disk herniation through posterior longitudinal ligament.  The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed.  Approximately, 5 mm of the nerve root on both the right and left side was visualized.  A ball-ended probe could be passed up the foramen.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates of C5 and C6 were prepared using a high-speed burr and a 6-mm lordotic machined allograft was malleted into place.  There was good bony apposition both proximally and distally.  Next, attention was placed at the C6-C7 level.  Again, the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6-C7 was performed.  The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left.  The posterior longitudinal ligament was removed.  A bilateral foraminotomy was performed.  Approximately, 5 mm of the C7 nerve root was visualized on both sides.  A micro nerve hook was able to be passed up the foramen easily.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates at C6-C7 were then prepared using a high-speed burr and then a 7-mm machined lordotic allograft was malleted into place.  There was good bony apposition, both proximally and distally.  Next, a 44-mm Blackstone low-profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws.  Intraoperative x-ray confirmed appropriate positioning of the plate and the graft.  The wound was then copiously irrigated with normal saline and bacitracin.  There was no active bleeding upon closure of the wound.  A small drain was placed deep.  The platysmal muscle was closed with 3-0 Vicryl.  The skin was closed with #4-0 Monocryl.  Mastisol and Steri-Strips were applied.  The patient was monitored throughout the procedure with free-running EMGs and SSEPs and there were no untoward events.  The patient was awoken and taken to the recovery room in satisfactory condition.
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DESCRIPTION: Herniated nucleus pulposus.  Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.

neurosurgery, herniated nucleus pulposus, anterior cervical decompression, spine fusion, cervical spine, allograft, anterior cervical spine, anterior, cervical,

The situation involves a neurosurgical procedure, specifically anterior cervical decompression and spine fusion, which are complex and sensitive surgeries dealing with the cervical spine. These procedures carry significant risks, including bleeding, infection, nerve damage, and even paralysis or death, if complications arise. The high-stakes nature of the procedure is due to its potential impact on the neurological and overall health of the patient, highlighting the critical importance of surgical precision and postoperative care.


Medical Specialty: Neurology
Sample Name: Phenol Neurolysis & Botulinum Toxin Injection - 2

PROCEDURES PERFORMED: , Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.,PROCEDURE CODES: , 64640 times one, 64614 times two, 95873 times two.,PREOPERATIVE DIAGNOSIS: , Spastic right hemiparetic cerebral palsy, 343.1.,POSTOPERATIVE DIAGNOSIS:,  Spastic right hemiparetic cerebral palsy, 343.1.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient.  She was brought to the minor procedure area and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.  The right obturator nerve was identified using active EMG stimulation lateral to the adductor longus tendon origin and below the femoral pulse.  Approximately 6 mL of 5% phenol was injected in this location.  At all sites of phenol injections, injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation.  Approximately 100 units was injected in the right pectoralis major and 100 units in the right rectus femoris and vastus intermedius muscles.  Total amount of botulinum toxin injected was 200 units diluted 25 units to 1 mL.  The patient tolerated the procedure well and no complications were encountered.
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DESCRIPTION: Phenol neurolysis right obturator nerve, botulinum toxin injection right rectus femoris and vastus medialis intermedius and right pectoralis major muscles.

neurology, femoris and vastus medialis, intermedius and right pectoralis, rectus femoris and vastus, vastus medialis intermedius, botulinum toxin injection, medialis intermedius, major muscles, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, obturator nerve, rectus femoris, pectoralis major, botulinum toxin, pectoralis, botulinum, phenol, injection, toxin

The procedure involves a phenol neurolysis and botulinum toxin injection to treat spastic hemiparetic cerebral palsy, which is significant but not extremely high-risk. The detailed description shows it was performed meticulously, with no complications reported. However, due to the nature of the underlying condition and potential risks involved in neurolysis and injecting nerves and muscles, the stakes are moderate. This is not a life-critical situation, but missteps could result in decreased mobility or increased spasticity.


Medical Specialty: Radiology
Sample Name: EMG/Nerve Conduction Study - 8

REFERRING DIAGNOSIS: , Motor neuron disease.,PERTINENT HISTORY AND EXAMINATION:,  Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.,SUMMARY:  ,The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity.  The right ulnar sensory amplitude was reduced with slowing of the conduction velocity.  The right radial sensory amplitude was reduced with slowing of the conduction velocity.  The right sural and left sural sensory responses were absent.  The right median motor response showed a prolonged distal latency across the wrist, with proximal slowing.  The distal amplitude was very reduced, and there was a reduction with proximal stimulation.  The right ulnar motor amplitude was borderline normal, with slowing of the conduction velocity across the elbow.  The right common peroneal motor response showed a decreased amplitude when recorded from the EDB, with mild slowing of the proximal conduction velocity across the knee.  The right tibial motor response showed a reduced amplitude with prolongation of the distal latency.  The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing.  The left tibial motor response showed a decreased amplitude with a borderline normal distal latency.  The minimum F-wave latencies were normal with the exception of a mild prolongation of the ulnar F-wave latency, and the tibial F-wave latency as indicated above.  With repetitive nerve stimulation, there was no significant decrement noted in either the right nasalis or the right trapezius muscles.  Concentric needle EMG studies were performed in the right lower extremity, right upper extremity, thoracic paraspinals, and in the tongue.  There was evidence of increased insertional activity in the right tibialis anterior muscle, with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue.  In addition, there was evidence of increased amplitude, long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above.,INTERPRETATION: , Abnormal electrodiagnostic study.  There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments.  There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities.  There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow.  Even despite the patient's age, the decrease in sensory responses is concerning, and makes it difficult to be certain about the diagnosis of motor neuron disease.  However, the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease.  The patient will return for further evaluation.
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DESCRIPTION: A woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.  Abnormal electrodiagnostic study.

radiology, electrodiagnostic study, electrodiagnostic, edb, latency, nerve conduction study, emg, motor neuron disease, distal latency, motor response, motor, amplitude, conduction

This case involves a patient suspected of having a motor neuron disease, a potentially serious medical condition. The electrodiagnostic study results indicate significant neuropathy and nerve dysfunction. Motor neuron disease can lead to severe disability and have a substantial impact on the patient's quality of life. Accurate diagnosis and timely intervention are crucial, making this a high-stakes situation.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Low-Transverse C-Section & BTL

PREOPERATIVE DIAGNOSIS: , Intrauterine pregnancy at term with previous cesarean section.,SECONDARY DIAGNOSES,1.  Desires permanent sterilization.,2.  Macrosomia.,POSTOPERATIVE DIAGNOSES,1.  Desires permanent sterilization.,2.  Macrosomia.,3.  Status post repeat low transverse cesarean and bilateral tubal ligation.,PROCEDURES,1.  Repeat low transverse cesarean section.,2.  Bilateral tubal ligation (BTL).,ANESTHESIA: , Spinal.,FINDINGS:,  A viable female infant weighing 7 pounds 10 ounces, assigned Apgars of 9 and 9.  There was normal pelvic anatomy, normal tubes.  The placenta was normal in appearance with a three-vessel cord.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room with an IV running and a Foley catheter in place, satisfactory spinal anesthesia was administered following which a wedge was placed under the right hip.  The abdomen was prepped and draped in a sterile fashion.  A Pfannenstiel incision was made and carried sharply down to the level of fascia.  The fascia was incised transversely.  The fascia was dissected away from the underlying rectus muscles.  With sharp and blunt dissection, rectus muscles were divided in midline.  The perineum was entered bluntly.  The incision was carried vertically with scissors.  Transverse incision was made across the bladder peritoneum.  The bladder was dissected away from the underlying lower uterine segment.  Bladder retractor was placed to protect the bladder.  The lower uterine segment was entered sharply with a scalpel.  Incision was carried transversely with bandage scissors.  Clear amniotic fluids were encountered.  The infant was out of the pelvis and was in oblique vertex presentation.  The head was brought down into the incision and delivered easily as were the shoulders and body.  The mouth and oropharynx were suctioned vigorously.  The cord was clamped and cut.  The infant was passed off to the waiting pediatrician in satisfactory condition.  Cord bloods were taken.,Placenta was delivered spontaneously and found to be intact.  Uterus was explored and found to be empty.  Uterus was delivered through the abdominal incision and massaged vigorously.  Intravenous Pitocin was administered.  T clamps were placed about the margins of the uterine incision, which was closed primarily with a running locking stitch of 0 Vicryl with adequate hemostasis.  Secondary running locking stitch was placed for extra strength to the wound.  At this point, attention was diverted to the patient's tubes, a Babcock clamp grasped the isthmic portion of each tube and approximately 1-cm knuckle on either side was tied off with two lengths of 0 plain catgut.  Intervening knuckle was excised and passed off the field.  The proximal end of the tubal mucosa was cauterized.  Cul-de-sac and gutters were suctioned vigorously.  The uterus was returned to its proper anatomic position in the abdomen.  The fascia was closed with a simple running stitch of 0 PDS.,The skin was closed with running subcuticular of 4-0 Monocryl.  Uterus was expressed of its contents.  Patient was brought to the recovery room in satisfactory condition.  There were no complications.  There was 600 cc of blood loss.  All sponge, needle, and instrument counts were reported to be correct.,SPECIMEN: , Tubal segments.,DRAIN: , Foley catheter draining clear yellow urine.
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DESCRIPTION: Repeat low transverse cesarean section and bilateral tubal ligation (BTL).  Intrauterine pregnancy at term with previous cesarean section.  Desires permanent sterilization.  Macrosomia.

obstetrics / gynecology, placenta, low transverse cesarean section, bilateral tubal ligation, permanent sterilization, cesarean section, intrauterine, btl, sterilization, macrosomia, uterine,

The situation involves a repeat low transverse cesarean section and bilateral tubal ligation, both of which are significant medical procedures. The stakes are elevated due to the potential risks associated with major surgery, including possible complications for both the mother and the infant. However, the procedure was carried out without complications, the infant's condition was satisfactory, and the patient's condition was stable postoperatively, which indicates the situation was managed well. Additionally, the risk associated with the patient's desire for permanent sterilization adds a layer of personal stakes regarding her reproductive choices. Nonetheless, since the case is reported to have proceeded without issues, the immediate high-stakes aspect is mitigated.