Medical Specialty: Pediatrics - Neonatal
Sample Name: Head Injury

CHIEF COMPLAINT:,  Head injury.,HISTORY: , This 16-year-old female presents to Children's Hospital via paramedic ambulance with a complaint at approximately 6 p.m. while she was at band practice using her flag device.  She struck herself in the head with the flag.  There was no loss of consciousness.  She did feel dizzy.  She complained of a headache.  She was able to walk.  She continued to participate in her flag practice.  She got dizzier.  She sat down for a while and walked and during the second period of walking, she had some episodes of diplopia, felt that she might faint and was assisted to the ground and was transported via paramedic ambulance to Children's Hospital for further evaluation.,PAST MEDICAL HISTORY: , Hypertension.,ALLERGIES:,  DENIED TO ME; HOWEVER, IT IS NOTED BEFORE SEVERAL ACCORDING TO MEDITECH.,CURRENT MEDICATIONS: , Enalapril.,PAST SURGICAL HISTORY: , She had some kind of an abdominal obstruction as an infant.,SOCIAL HISTORY: , She is here with mother and father who lives at home.  There is no smoking at home.  There is second-hand smoke exposure.,FAMILY HISTORY:  ,No noted family history of infectious disease exposure.,IMMUNIZATIONS:,  She is up-to-date on her shots, otherwise negative.,REVIEW OF SYSTEMS:  ,On the 10-plus systems reviewed with the section of those noted on the template.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Her temperature 100 degrees, pulse 86, respirations 20, and her initial blood pressure 166/116, and a weight of 55.8 kg.,GENERAL:  She is supine awake, alert, cooperative, and active child.,HEENT:  Head atraumatic, normocephalic.  Pupils equal, round, reactive to light.  Extraocular motions intact and conjugate.  Clear TMs, nose and oropharynx.  Moist oral mucosa without noted lesions.,NECK:  Supple, full painless nontender range motion.,CHEST:  Clear to auscultation, equal, stable to palpation.,HEART:  Regular without rubs or murmurs.,ABDOMEN:  No abdominal bruits are heard.,EXTREMITIES:  Equal femoral pulses are appreciated.  Equal radial and dorsalis pedis pulses are appreciated.  He moves all extremities without difficulty.  Nontender.  No deformity.  No swelling.,SKIN:  There was no significant bruising, lesions or rash about her abdomen.  No significant bruising, lesions or rash.,NEUROLOGIC:  Symmetric face and extremity motion.  Ambulates without difficulty.  She is awake, alert, and appropriate.,MEDICAL DECISION MAKING:,  The differential entertained includes head injury, anxiety, and hypertensive emergency.  She is evaluated in the emergency department with serial blood pressure examinations, which are noted to return to a more baseline state for her 130s/90s.  Her laboratory data shows a mildly elevated creatinine of 1.3.  Urine is within normal.  Urinalysis showing no signs of infection.  Head CT read by staff has no significant intracranial pathology.  No mass shift, bleed or fracture per Dr. X.  A 12-lead EKG reviewed preliminarily by myself noting normal sinus rhythm, normal axis rates of 90.  No significant ST-T wave changes.  No significant change from previous 09/2007 EKG.  Her headache has resolved.  She is feeling better.  I spoke with Dr. X at 0206 hours consulting Nephrology regarding this patient's presentation with the plan for home.  Follow up with her regular doctor.  Blood pressures have normalized for her.  She should return to emergency department on concern.  They are to call the family to Nephrology Clinic next week for optimization of her blood pressure control with a working diagnosis of head injury, hypertension, and syncope.
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DESCRIPTION: Head injury, anxiety, and hypertensive emergency.

The situation involves a minor with a head injury, dizziness, diplopia, and elevated blood pressure, but the patient did not lose consciousness, has resolved symptoms, and the CT scan showed no significant intracranial pathology. Despite the initial seriousness due to potential head injury and hypertensive episode, the medical evaluation ruled out immediate life-threatening conditions. There is a plan for follow-up care, and the patient's condition has stabilized. This makes the situation moderately high-stakes but not critical.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Triple Lumen Catheter Insertion

PREOPERATIVE DIAGNOSES:,1.  Hyperpyrexia/leukocytosis.,2.  Ventilator-dependent respiratory failure.,3.  Acute pancreatitis.,POSTOPERATIVE DIAGNOSES:,1.  Hyperpyrexia/leukocytosis.,2.  Ventilator-dependent respiratory failure.,3.  Acute pancreatitis.,PROCEDURE PERFORMED:,1.  Insertion of a right brachial artery arterial catheter.,2.  Insertion of a right subclavian vein triple lumen catheter.,ANESTHESIA: , Local, 1% lidocaine.,BLOOD LOSS:,  Less than 5 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 46-year-old Caucasian female admitted with severe pancreatitis.  She was severely dehydrated and necessitated some fluid boluses.  The patient became hypotensive, required many fluid boluses, became very anasarcic and had difficulty with breathing and became hypoxic.  She required intubation and has been ventilator-dependent in the Intensive Care since that time.  The patient developed very high temperatures as well as leukocytosis.  Her lines required being changed.,PROCEDURE:,1.  RIGHT BRACHIAL ARTERIAL LINE:  ,The patient's right arm was prepped and draped in the usual sterile fashion.  There was a good brachial pulse palpated.  The artery was cannulated with the provided needle and the kit.  There was good arterial blood return noted immediately.  On the first stick, the Seldinger wire was inserted through the needle to cannulate the right brachial artery without difficulty.  The needle was removed and a catheter was inserted over the Seldinger wire to cannulate the brachial artery.  The femoral catheter was used in this case secondary to the patient's severe edema and anasarca.  We did not feel that the shorter catheter would provide enough length.  The catheter was connected to the system and flushed without difficulty.  A good waveform was noted.  The catheter was sutured into place with #3-0 silk suture and OpSite dressing was placed over this.,2.  RIGHT SUBCLAVIAN TRIPLE LUMEN CATHETER:  ,The patient was prepped and draped in the usual sterile fashion.  1% Xylocaine was used to anesthetize an area just inferior and lateral to the angle of the clavicle.  Using the anesthetic needle, we checked down to the soft tissues anesthetizing, as we proceeded to the angle of the clavicle, this was also anesthetized.  Next, a #18 gauge thin walled needle was used following the same track to the angle of clavicle.  We roughed the needle down off the clavicle and directed it towards the sternal notch.  There was good venous return noted immediately.  The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein.  The needle was then removed.  A small skin nick was made with a #11 blade scalpel and the provided dilator was used to dilate the skin, soft tissue and vein.  Next, the triple lumen catheter was inserted over the guidewire without difficulty.  The guidewire was removed.  All the ports aspirated and flushed without difficulty.  The catheter was sutured into place with #3-0 silk suture and a sterile OpSite dressing was also applied.  The patient tolerated the above procedures well.  A chest x-ray has been ordered, however, it has not been completed at this time, this will be checked and documented in the progress notes.
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DESCRIPTION: Insertion of a right brachial artery arterial catheter and a right subclavian vein triple lumen catheter.  Hyperpyrexia/leukocytosis, ventilator-dependent respiratory failure, and acute pancreatitis.

cardiovascular / pulmonary, hyperpyrexia, leukocytosis, ventilator-dependen, respiratory failure, pancreatitis, brachial artery, arterial catheter, subclavian vein, triple lumen catheter, catheter, brachial, needle,

The situation involves the insertion of a triple lumen catheter and an arterial line in a critically ill patient with multiple severe conditions, including acute pancreatitis, ventilator dependency, and hyperpyrexia with leukocytosis. These procedures are high-stakes due to the patient's critical condition and the potential complications that can arise from the procedures themselves, such as infection, bleeding, or misplacement. Furthermore, the procedures are critical for ongoing intensive care management. However, the description indicates that the procedures were performed successfully without immediate complications. The stakes are high, both because of the complexity of the procedures and the patient's critical state.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Exercise Stress Test

INDICATION:  ,Chest pain.,INTERPRETATION: , Resting heart rate of 71, blood pressure 100/60.  EKG normal sinus rhythm.  The patient exercised on Bruce for 8 minutes on stage III.  Peak heart rate was 151, which is 87% of the target heart rate, blood pressure of 132/54.  Total METs was 10.1.  EKG revealed nonspecific ST depression in inferior and lateral leads.  The test was terminated because of fatigue.  The patient did have chest pain during exercise that resolved after termination of the exercise.,IN SUMMARY:,1.  Positive exercise ischemia with ST depression 0.5 mm.,2.  Chest pain resolved after termination of exercise.,3.  Good exercise duration, tolerance and double product.,NUCLEAR INTERPRETATION:,Resting and stress images were obtained with 10.1 mCi and 34.1 mCi of tetraphosphate injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogenous and uniform distribution with tracer uptake without any evidence of reversible or fixed defect.  Gated SPECT revealed normal wall motion, ejection fraction of 68%.  End-diastolic volume of 77, end-systolic volume of 24.,IN SUMMARY:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction of 68% by gated SPECT.
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DESCRIPTION: Exercise stress test with nuclear scan for chest pain.  Chest pain resolved after termination of exercise. Good exercise duration, tolerance and double product.  Normal nuclear myocardial perfusion scan.

cardiovascular / pulmonary, chest pain, ekg, sinus, st depression, mci, gated spect, nuclear myocardial perfusion scan, ejection fraction, myocardial perfusion, perfusion scan, heart rate, spect, stress, nuclear, chest

The situation presented involves an interpretation of an exercise stress test with nuclear imaging for a patient experiencing chest pain. The test shows positive exercise ischemia with ST depression but no evidence of reversible or fixed defects in the nuclear scan. While there are important medical insights such as potential ischemia and the resolution of chest pain post-exercise, the patient does not present with high-risk features such as significant myocardial defects or severe ischemic signs. However, given its implications for potential underlying coronary artery disease, it involves moderate stakes as further assessment or management might be warranted.


Medical Specialty: Radiology
Sample Name: Arterial Imaging

INDICATIONS:,  Peripheral vascular disease with claudication.,RIGHT:,  ,1.  Normal arterial imaging of right lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic.,4.  Ankle brachial index is 0.96.,LEFT:,1.  Normal arterial imaging of left lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic.,4.  Ankle brachial index is 1.06.,IMPRESSION,:,Normal arterial imaging of both lower extremities.
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DESCRIPTION: Arterial imaging of bilateral lower extremities.

radiology, peripheral vascular disease, ankle brachial index, arterial waveform, peak systolic velocity, arterial imaging, biphasic, claudication, lower extremities, lower extremity, posterior tibial artery, triphasic, systolic velocity is normal, arterial waveform is triphasic, waveform is triphasic, normal arterial imaging, systolic velocity, brachial index, velocity, brachial, imaging, arterial,

The situation involves analyzing medical imaging reports for arterial imaging, specifically checking for peripheral vascular disease. The findings indicate mostly normal results, with a minor anomaly in the left posterior tibial artery waveform that is biphasic instead of triphasic. The ankle-brachial indices are within the normal range, suggesting no immediate critical issue. Therefore, while the context is medical and involves patient health, it does not suggest an urgent or high-risk situation given the described results.


Medical Specialty: Consult - History and Phy.
Sample Name: Penile Cellulitis

CHIEF COMPLAINT:  ,Penile cellulitis status post circumcision.,HISTORY OF PRESENT ILLNESS: , The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge.  The child initially had a newborn circumcision at about 1 week of life and then developed a concealed or buried penis with extra skin and tightness of the skin.  He underwent a second circumcision with a general anesthetic approximately 8 to 9 days ago.  The mother states that on Thursday, he developed fairly significant swelling, scrotum was also swollen, the suprapubic region was swollen, and he was having a purulent discharge and a fairly significant fever to 102 to 103.  He was seen at Hospital, transferred to Children's Hospital for further care.  Since being hospitalized, his cultures apparently have grown Staph but is unknown yet whether it is methicillin-resistant.  He has been placed on clindamycin, and he is now currently afebrile and with marked improvement according to the mother.  I was requested a consultation by Dr. X because of the appearance of penis.  The patient has been voiding without difficulty throughout.,PAST MEDICAL HISTORY: , The patient has no known allergies.  He was a term delivery via vaginal delivery.  Surgeries; he has had 2 circumcisions.  No other hospitalizations.  He has had no heart murmurs, seizures, asthma, or bronchitis.,REVIEW OF SYSTEMS: , A 14-point review of systems was negative with the exception of the penile and scrotal cellulitis and the surgeries as mentioned.  He also had an ear infection about 1 to 2 weeks before his circumcision.,SOCIAL HISTORY: , The patient lives with both parents and no siblings.  There are smokers at home.,MEDICATIONS: , Clindamycin and bacitracin ointment.  Also Bactrim.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight is 14.9 kg.,GENERAL:  The patient was sleepy but easily arousable.,HEAD AND NECK:  Grossly normal.  His neck and chest are without masses.,NARES:  He had some crusted nares; otherwise, no other discharge.,LUNGS:  Clear.,CARDIAC:  Without murmurs or gallops.,ABDOMEN:  Soft without masses or tenderness.,GU:  He has a fairly prominent suprapubic fat pad, and he is quite a large child in any event; however, there were no signs of erythema.  There was some induration around the penis; however, there were no signs of active infection.  He has a buried appearance of the penis after recent circumcision with a normal appearing glans.  The tissue itself, however, was quite dull and is soft or readily retractable at this time.  The scrotum was normal, and there was no erythema, there was no tenderness.  Both testes were descended without hydroceles.,EXTREMITIES:  He has full range of motion of all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,BACK:  Normal.,IMPRESSION/PLAN: , The patient had a recent circumcision with a fairly prominent suprapubic fat pad but also has a penile and suprapubic cellulitis.  This is being treated, but it is most likely Staph and pending sensitivities.  I talked to the mother and told her that at this point the swelling that is present is a mixture of the resolving cellulitis from a suprapubic fat pad.  I recommended that he be treated most likely with Bactrim for a 10-day course at home, bacitracin, or some antibiotics ointment to the penis with each diaper change for the next 2 to 3 weeks with sitz bath once or twice a day.  I told the mother that initially the tissues are going to be quite dull because of the infection and the recent surgery, but she ultimately will have to gently retract the skin to keep it from adhering again because of the prominent suprapubic fat pad, which makes it more likely.  Otherwise, it is a fairly healthy-appearing tissue at the present time and she knows the reasons that he cannot be discharged once the hospitalist service believes that it is appropriate to do so.  He has a scheduled followup appointment with his urologist  and he should keep that appointment or followup sooner if there is any other problem arising.
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DESCRIPTION: The patient is a 16-month-old boy, who had a circumcision performed approximately 4 days before he developed penile swelling and fever and discharge.

consult - history and phy., newborn circumcision, suprapubic fat pad, penile cellulitis, penile swelling, cellulitis, penis, penile, suprapubic, circumcision,

The situation involves a 16-month-old boy experiencing complications after a circumcision, including penile cellulitis, significant swelling, fever, and purulent discharge. He has been hospitalized and treated with antibiotics. While his current condition shows improvement, the situation is still serious due to the potential for infection to worsen if not properly treated, especially given the young age of the patient. The presence of Staph infection and possible methicillin resistance increases the stakes, although he is now afebrile and under medical care. However, since the problem is being monitored, managed, and the patient shows improvement, it should not be considered extremely high-stakes.


Medical Specialty: Surgery
Sample Name: Lumbar Laminectomy

PREOPERATIVE DIAGNOSIS: , Lumbar stenosis.,POSTOPERATIVE DIAGNOSES:,  Lumbar stenosis and cerebrospinal fluid fistula.,TITLE OF THE OPERATION,1.  Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques.,2.  Repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.,INDICATIONS:,  The patient is an 82-year-old woman who has about a four-month history now of urinary incontinence and numbness in her legs and hands, and difficulty ambulating.  She was evaluated with an MRI scan, which showed a very high-grade stenosis in her lumbar spine, and subsequent evaluation included a myelogram, which demonstrated cervical stenosis at C4-C5, C5-C6, and C6-C7 as well as a complete block of the contrast at L4-L5 and no contrast at L5-S1 either and stenosis at L3-L4 and all the way up, but worse at L3-L4, L4-L5, and L5-S1.  Yesterday, she underwent an anterior cervical discectomy and fusions C4-C5, C5-C6, C6-C7 and had some improvement of her symptoms and increased strength, even in the recovery room.  She was kept in the ICU because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy.  The rationale for putting the surgery is close together that she is normally on Coumadin for atrial fibrillation, though she has been cardioverted.  She and her son understand the nature, indications, and risks of the surgery, and agreed to go ahead.,PROCEDURE: , The patient was brought from the Neuro ICU to the operating room, where general endotracheal anesthesia was obtained.  She was rolled in a prone position on the Wilson frame.  The back was prepared in the usual manner with Betadine soak, followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  Using the usual anatomical landmarks, linear midline incision was made presumed over L4-L5 and L5-S1.  Sharp dissection was carried down into subcutaneous tissue, then Bovie electrocautery was used to isolate the spinous processes.  A Kocher clamp was placed in the anterior spinous ligament and this turned out to be L5-S1.  The incision was extended rostrally and deep Gelpi's were inserted to expose the spinous processes and lamina of L3, L4, L5, and S1.  Using the Leksell rongeur, the spinous processes of L4 and L5 were removed completely, and the caudal part of L3.  A high-speed drill was then used to thin the caudal lamina of L3, all of the lamina of L4 and of L5.  Then using various Kerrison punches, I proceeded to perform a laminectomy.  Removing the L5 lamina, there was a dural band attached to the ligamentum flavum and this caused about a 3-mm tear in the dura.  There was CSF leak.  The lamina removal was continued, ligamentum flavum was removed to expose all the dura.  Then using 4-0 Nurolon suture, a running-locking suture was used to close the approximate 3-mm long dural fistula.  There was no CSF leak with Valsalva.,I then continued the laminectomy removing all of the lamina of L5 and of L4, removing the ligamentum flavum between L3-L4, L4-L5 and L5-S1.  Foraminotomies were accomplished bilaterally.  The caudal aspect of the lamina of L3 also was removed.  The dura came up quite nicely.  I explored out along the L4, L5, and S1 nerve roots after completing the foraminotomies, the roots were quite free.  Further more, the thecal sac came up quite nicely.  In order to ensure no CSF leak, we would follow the patient out of the operating room.  The dural closure was covered with a small piece of fat.  This was all then covered with DuraSeal glue.  Gelfoam was placed on top of this, then the muscle was closed with interrupted 0 Ethibond.  The lumbodorsal fascia was closed with multiple sutures of interrupted 0 Ethibond in a watertight fashion.  Scarpa's fascia was closed with a running 0 Vicryl, and finally the skin was closed with a running-locking 3-0 nylon.  The wound was blocked with 0.5% plain Marcaine.,ESTIMATED BLOOD LOSS:  Estimated blood loss for the case was about 100 mL.,SPONGE AND NEEDLE COUNTS:  Correct.,FINDINGS:  A very tight high-grade stenosis at L3-L4, L4-L5, and L5-S1.  There were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis.,The patient tolerated the procedure well with stable vitals throughout.
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DESCRIPTION: Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.  Lumbar stenosis and cerebrospinal fluid fistula.

surgery, microtechniques, fistula, duraseal, foraminotomies, lumbar, stenosis, cerebrospinal, lumbar laminectomy, ligamentum flavum, csf, laminectomy, lamina,

The situation described is a detailed account of a lumbar laminectomy surgery, which is inherently high-stakes due to the complexity of spinal surgery, the potential for complications, and the patient's age and medical condition. The additional presence of a cerebrospinal fluid (CSF) fistula increases the stakes, as proper repair is crucial to prevent infections or other complications. Spinal surgeries like these require precision and expertise, indicating a high-stakes scenario.


Medical Specialty: Neurosurgery
Sample Name: Discectomy, Osteophytectomy, & Foraminotomy

PREOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, and progressive quadriparesis.,POSTOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, progressive quadriparesis, and very poor bone quality as well as difficulty with hemostasis with the patient having been on aspirin.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression at C3-C4, C4-C5, and C5-C6.,2.  Microscope.,3.  Fusion with machined allografts at C3-C4, C4-C5, and C5-C6.,4.  Eagle titanium plate from C3 to C6.,5.  Jackson-Pratt drain placement.,6.  Intraoperative monitoring with EMGs and SSEPs.,ESTIMATED BLOOD LOSS: , 350 cc.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:  ,None.,COUNTS: , Correct.,SPECIMENS SENT:  ,None.,CLINICAL HISTORY:  ,The patient is a 77-year-old male who was admitted through the emergency room for progressive weakness and falling.  He was worked by the neurologist, Dr. X, and found to have cervical spondylosis with myelopathy.  I was consulted and elected to do a lumbar and cervical myelogram CT scan, which showed lumbar stenosis but also cervical stenosis with more pathology anteriorly than posteriorly.  The patient had worst disease at level C3-C4, C4-C5, and C5-C6.  The patient was significantly weak and almost quadriparetic, stronger on the right side than on the left side.  I thought that surgery was indicated to prevent progressive neurological deterioration, as well as to prevent a central cord syndrome if the patient were to get into a motor vehicle accident or simply fall.  Conservative management was not an option.  The patient was preoped and consented, and was medically cleared.  I discussed the indications, risks, and benefits of the surgery with the patient and the patient's family.  The risks of bleeding, hoarseness, swallowing difficulty, pseudoarthrosis as well as plate migration and hardware failure were all discussed with the patient.  An informed consent was obtained from the patient as such.  He was brought into the OR today for the operative procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the OR, intubated, and given a general anesthetic.  Intubation was done under C-spine precautions.  The patient received preoperative vancomycin and Decadron.  He was hooked up to the SSEP apparatus and had poor baselines and delays.,With a large a shoulder roll, I extended the patient's neck, and landmark incision in crease in the right upper neck, and the area was then prepped and sterilely draped.  All the lines had been put in and the arms were padded.,Using a knife and cautery, I took the incision down through the skin and subcutaneous tissue and arrived at the cervical spine.  Prominent osteophyte at C5-C6 was noted, lesser at C4-C5.  Intraoperative x-ray confirmed our levels, and we were fully exposed from C3-C6.,Trimline retractors were put in, and I cut the discs out as well as removed the superficial hyperstatic bone and osteophytes.,With the drill, I performed a superficial discectomy and endplate resection, curetting the endplate as I went.  I then brought in the microscope, under the microscopic guidance, firmly removed the end plates and drilled through the posterior longitudinal ligament to decompress the spinal cord.  Worst findings at C3-C4 followed C5-C6 and then C4-C5.  Excellent thecal sac decompression was achieved and foraminal decompression was also achieved.  With change in intraoperative monitoring, a microscope was used for this decompressive procedure.,The patient was very oozy throughout this procedure, and during the decompression part, the oozing was constant.  This was partly due to the patient's cancellous bone, but he had been on aspirin which was stopped only 2 days ago, and the option was not available to wait 2 to 3 weeks which would have made this man worse simply over time.  I thus elected to give him DDAVP, platelets, and used Horsley bone wax for excellent hemostasis.  This took literally half-an-hour to an hour and added to the complexity and difficulty of this case.  Eventually, with blood pressure controlled and all the other parameters under control, bleeding was somewhat slow.,I then selected two 10 and one 9-mm cadaveric allograft, which had soaking in bacitracin solution.  These were trimmed to the desired dimensions, and under slight distraction, these were tapped into position.  Excellent graft alignment was achieved.,I now brought in a DePuy titanium eagle plate, and I fixed it to the spine from C3 to C6.  Fourteen millimeter screws were used; all the screws were tightened and torqued.  The patient's bone quality was poor, but the screws did torque appropriately.  I inspected the plate, controlled the hemostasis, assessed post-fixation x-ray, and was really happy with the screw length and the overall alignment.,The wound was irrigated with antibiotic solution; a Jackson-Pratt drain 10-French was put in with trocar.  Decision was made to start the closure.  So, I closed the platysma with 3-0 Vicryl and used staples for the skin.  A simple Primapore or Medpore dressing was applied.  The patient was extubated in the OR and taken to the PSU in stable medical condition.,When I saw the patient in the ICU, he was awake, alert, and moving all four extremities, somewhat weak on the left side.  He had done well from the surgery.  Blood loss was 350 cc.  All instrument, needle, and sponge counts were correct.  No complications, no change in intraoperative monitoring.  No specimens were sent.,The patient's wife was spoken to and fully appraised of the intraoperative findings and the expected prognosis.  The patient will be kept n.p.o. tonight and will gradually advance his diet, and also will gradually advance his activity.  I will keep him on Decadron and keep the collar on.  I do not think there is need for halo rest.  We will be obtaining formal C-spine films in the morning.  Prognosis is guarded but favorable at this time.
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DESCRIPTION: Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs

The situation involves a complex neurosurgical procedure for a 77-year-old patient with significant neurological deficits and cervical spine issues. The procedure includes multiple surgeries at different levels of the spine and addresses serious preoperative conditions like progressive quadriparesis and spinal cord compression. The situation is high-stakes given the critical nature of the surgery, the risk of potential complications, and the severe preoperative condition of the patient. Successful outcomes are crucial to prevent further neurological deterioration.


Medical Specialty: Emergency Room Reports
Sample Name: Feeling Dizzy - ER Visit

REASON FOR CONSULTATION:,  This is a 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.,PAST MEDICAL HISTORY: , Hypertension.  The patient noncompliant,HISTORY OF PRESENT COMPLAINT: , This 66-year-old patient has history of hypertension and has not taken medication for several months.  She is a smoker and she drinks alcohol regularly.  She drinks about 5 glasses of wine every day.  Last drink was yesterday evening.  This afternoon, the patient felt palpitations and generalized weakness and came to the emergency room.  On arrival in the emergency room, the patient's heart rate was 121 and blood pressure was 195/83.  The patient received 5 mg of metoprolol IV, after which heart rate was reduced to the 70 and blood pressure was well controlled.  On direct questioning, the patient said she had been drinking a lot.  She had not had any withdrawal before.  Today is the first time she has been close to withdrawal.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever.,ENT:  Not remarkable.,RESPIRATORY:  No cough or shortness of breath.,CARDIOVASCULAR:  The patient denies chest pain.,GASTROINTESTINAL:  No nausea.  No vomiting.  No history of GI bleed.,GENITOURINARY:  No dysuria.  No hematuria.,ENDOCRINE:  Negative for diabetes or thyroid problems.,NEUROLOGIC:  No history of CVA or TIA.,Rest of review of systems is not remarkable.,SOCIAL HISTORY:  ,The patient is a smoker and drinks alcohol daily in considerable amounts.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  This is a 66-year-old lady with telangiectasia of the face.  She is not anxious at this moment and had no tremors.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.  Chest is tympanitic to percussion.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur was appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  There is no swelling.  No clubbing.  No cyanosis.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,DIAGNOSTIC DATA: , EKG shows sinus tachycardia, no acute ST changes.,LABORATORY DATA: , White count is 6.3, hemoglobin is 12.4, hematocrit 38, and platelets 488,000.  Glucose is 124, BUN is 18, creatinine is 1.07, sodium is 146, and potassium is 3.4.  Liver enzymes are within normal limits.  TSH is normal.,ASSESSMENT AND PLAN:,1.  Uncontrolled hypertension.  We will start the patient on beta-blockers.  The patient is to see her primary physician within 1 week's time.,2.  Tachycardia, probable mild withdrawal to alcohol.  The patient is stable now.  We will discharge home with diazepam p.r.n.  The patient had been advised that she should not take alcohol if she takes the diazepam.,3.  Tobacco smoking disorder.  The patient has been counseled.  She is not contemplating quitting at this time.,DISPOSITION: , The patient is discharged home.,DISCHARGE MEDICATIONS:,1.  Atenolol 50 mg p.o. b.i.d.,2.  Diazepam 5 mg tablet 1 p.o. q.8h. p.r.n., total of 5 tablets.,3.  Thiamine 100 mg p.o. daily.
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DESCRIPTION: A 66-year-old patient who came to the emergency room because she was feeling dizzy and was found to be tachycardic and hypertensive.

This situation involves a 66-year-old patient in the emergency room due to dizziness, tachycardia, and hypertension, with a history of noncompliance to hypertension medication and high alcohol consumption. While the immediate health threat was managed with medications leading to the patient being stabilized, there is significant concern about the patient's unmanaged chronic conditions, alcohol use, and potential for alcohol withdrawal. The stakes are considered high because unmanaged hypertension and alcohol use can lead to more severe health complications, and there is a risk of alcohol withdrawal. The patient has been stabilized, reducing immediate life-threatening risks, yet underlying issues pose future health risks.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 6

PRECATHETERIZATION DIAGNOSIS (ES):, Hypoplastic left heart, status post Norwood procedure and Glenn shunt.,POSTCATHETERIZATION DIAGNOSIS (ES):,1. Hypoplastic left heart.,A. Status post Norwood.,B. Status post Glenn.,2. Left pulmonary artery hypoplasia.,3. Diminished right ventricular systolic function.,4. Trivial neo-aortic stenosis.,5. Trivial coarctation.,6. Flow to right upper lobe more than left upper lobe from collaterals arising from branches of the aortic arch.,PROCEDURE (S):, Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.,I. PROCEDURES:, XXXXXX was brought to the catheterization lab and was anesthetized by anesthesia. He was intubated. His supplemental oxygen was weaned to 24%, on which all of his hemodynamics were obtained. The patient was prepped and draped in the routine sterile fashion, including both groins and the right neck. Xylocaine was administered in the right femoral area. A 6-French sheath was introduced into the right femoral vein percutaneously without complication. A 4-French sheath was introduced into the right femoral artery percutaneously without complication. A 4-French pigtail catheter was introduced and passed to the abdominal aorta.,Dr. Hayes, using the SiteRite device, introduced a 5-French sheath into the right internal jugular vein without complication.,A 5-French wedge catheter was introduced through the sheath in the right internal jugular vein and was passed to the left pulmonary artery and further to the left pulmonary capillary wedge position. This catheter would not pass to the right pulmonary artery. The wedge catheter was removed. A 5-French IMA catheter was then introduced and passed to the right pulmonary artery. After right pulmonary artery pressure was measured, this catheter was removed.,The 5 wedge catheter was advanced through the right femoral sheath and was passed to the following chambers or vessels: Inferior vena cava, right atrium, left atrium, and right ventricle.,The previously introduced 4 pigtail catheter was advanced to the ascending aorta. Simultaneous right ventricular and ascending aortic pressures were measured. A pullback from ascending aorta to descending aorta was then performed. Simultaneous measurements of right ventricular and descending aortic pressures were measured.,The wedge catheter was removed. A 5-French Berman catheter was advanced down the Glenn shunt to the right pulmonary artery, where a pullback from right pulmonary artery to Glenn shunt was performed. An injection was then performed using Omnipaque 16 mL at 8 mL per second with the Berman catheter positioned in the Glenn shunt. The 5-French Berman was removed.,A 6-French Berman was introduced through the right femoral vein sheath and was advanced to the right ventricle. A right ventriculogram was performed using Omnipaque 18 mL at 12 mL per second. The Berman catheter was pulled back to the inferior vena cava, where an inferior vena cavagram was performed using Omnipaque 10 mL at 8 mL per second.,The 4-French pigtail catheter was advanced to the ascending aorta and an ascending aortogram was performed using Omnipaque 16 mL at 12 mL per second.,Following the ascending angiograms, two kidneys and a bladder were noted. The catheters and sheaths were removed, and hemostasis was obtained by direct pressure. The estimated blood loss was less than 30 mL, and none was replaced. Heparin was administered following placement of all of the sheaths. Pulse oximetry saturation, pulse in the right foot, and EKG were monitored continuously.,II. PRESSURES:,A. Left pulmonary artery, mean of 11; left capillary wedge, mean of 9; main pulmonary artery, mean of 12; right pulmonary artery, mean of 10; descending aorta, 75/45, mean of 57; right atrium, A6 to 9, V6 to 8, mean 7; left atrium, mean 8; inferior vena cava, mean 7.,B. Ascending aorta, 65/35, with a simultaneous right ventricular pressure of 70/10; descending aorta, 60/35, with a right ventricular pressure of 72/10.,C. Pullbacks, left pulmonary artery to main pulmonary artery, mean of 11 to mean of 12; main pulmonary artery to Glenn, mean of 12 to mean of 13; right pulmonary artery to Glenn, mean of 12 to mean of 13; ascending aorta 68/35 to descending aorta 62/35.,INTERPRETATION:, Right and left pulmonary artery pressures are appropriate for this situation. There is a gradient of, at most, 2 mmHg on pullback from both the right and left pulmonary arteries to the Glenn shunt. The left atrial mean pressure is normal. Right ventricular end-diastolic pressure is, at most, slightly elevated. There is a trivial gradient between the right ventricle and ascending aorta consistent with trivial neo-aortic valve stenosis. There is a roughly 10-mm gradient between the right ventricle and descending aorta, consistent with additional coarctation of the aorta. On pullback from ascending to descending aorta, there is a 6-mmHg gradient between the two. Systemic blood pressure is normal.,III. OXIMETRY:, Superior vena cava 65, right pulmonary artery 67, left pulmonary artery 65, left atrium 96, right atrium 87, inferior vena cava 69, aorta 86, right ventricle 83.,INTERPRETATION:, Systemic arteriovenous oxygenation difference is normal, consistent with a normal cardiac output. Left atrial saturation is fairly normal, consistent with normal oxygenation in the lungs. The saturation falls passing from the left atrium to the right atrium and further to the right ventricle, consistent with mixing of pulmonary venous return and inferior vena cava return, as would be expected in this patient.,IV. SPECIAL PROCEDURE (S):, None done.,V. CALCULATIONS:,Please see the calculation sheet. Calculations were based upon an assumed oxygen consumption. The _____ saturation used was 67%, with a pulmonary artery saturation of 65%, a left atrial saturation of 96%, and an aortic saturation of 86%. Using the above information, the pulmonary to systemic flow ratio was 0.6. Systemic blood flow was 5.1 liters per minute per meter squared. Pulmonary blood flow was 3.2 liters per minute per meter squared. Systemic resistance was 9.8 Wood's units times meter squared, which is mildly diminished. Pulmonary resistance was 2.5 Wood's units times meter squared, which is in the normal range.,VI. ANGIOGRAPHY:, The injection to the Glenn shunt demonstrates a wide-open Glenn connection. The right pulmonary artery is widely patent, without stenosis. The proximal portion of the left pulmonary artery is significantly narrowed, but does open up near its branch point. The right pulmonary artery measures 6.5, the left pulmonary artery measures 3.0 mm. The aorta at the diaphragm on a later injection was 5.5 mm. There is a small collateral off the innominate vein passing to the left upper lobe. Flow to both upper lobes is diminished versus lower lung fields. There is normal return of the pulmonary veins from the right, with simultaneous filling of the left atrium and right atrium. There is normal return of the left lower pulmonary vein and left upper pulmonary vein. There is some reflux of dye into the inferior vena cava from the right atrium.,The right ventriculogram demonstrates a heavily pedunculated right ventricle with somewhat depressed right ventricular systolic function. The calculated ejection fraction from the LAO projection is only mildly diminished at 59%. There is no significant tricuspid regurgitation. The neo-aortic valve appears to open well with no stenosis. The ascending aorta is dilated. There is mild narrowing of the aorta at the isthmal area. On some projections, there appears to be a partial duplication of the aortic arch, probably secondary to this patient's style of Norwood reconstruction. There is some filling of the right upper and left upper lobes from collateral blood flow, with the left being more opacified than the right.,The inferior vena cavagram demonstrates normal return of the inferior vena cava to the right atrium.,The ascending aortogram demonstrates trivial aortic insufficiency, which is probably catheter-induced. The coronary arteries are poorly seen. Again, a portion of the aorta appears to be partially duplicated. There is faint opacification of the left upper lung from collateral blood flow. The above-mentioned narrowing of the aortic arch is again noted.
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DESCRIPTION: Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.

Cardiac catheterization is a complex and invasive procedure typically conducted to diagnose and sometimes treat conditions related to the heart and its surrounding structures. The patient has a hypoplastic left heart syndrome, which is a serious congenital heart defect requiring multiple surgeries including the Norwood procedure and Glenn shunt, as noted. The post-catheterization findings indicate several critical conditions like left pulmonary artery hypoplasia, diminished right ventricular systolic function, and trivial aortic stenosis, among others. These conditions, along with the patient's medical history, highlight the high stakes involved. Additionally, the interpretation of pressures and gradients can guide further treatment decisions, directly impacting the patient's life. Given the potential for complications and the necessity for ongoing medical management, this scenario represents a high-stakes situation for the medical team.


Medical Specialty: Surgery
Sample Name: Carpal Tunnel Release - 4

PREOPERATIVE DIAGNOSIS:  ,Bilateral carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Bilateral carpal tunnel syndrome.,PROCEDURES:,1.  Right open carpal tunnel release.,2.  Cortisone injection, left carpal tunnel.,ANESTHESIA: , General LMA.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,INDICATIONS:,  This patient is a 50-year-old male with bilateral carpal tunnel syndrome, which is measured out as severe.  He is scheduled for the above-mentioned procedures.  The planned procedures were discussed with the patient including the associated risks.  The risks included but are not limited to bleeding, infection, nerve damage, failure to heal, possible need for reoperation, possible recurrence, or any associated risk of the anesthesia.  He voiced understanding and agreed to proceed as planned.,DESCRIPTION OF PROCEDURE: , The patient was identified in the holding area and correct operative site was identified by the surgeon's mark.  Informed consent was obtained.  The patient was then brought to the operating room and transferred to the operating table in supine position.  Time-out was then performed at which point the surgeon, nursing staff, and anesthesia staff all confirmed the correct identification.,After adequate general LMA anesthesia was obtained, a well-padded tourniquet was placed on the patient's right upper arm.  The right upper extremity was then prepped and draped in the usual sterile fashion.  Planned skin incision was marked along the base of the patient's right palm.  Right upper extremity was then exsanguinated using Esmarch.  The tourniquet was then inflated to 250 mmHg.  Skin incision was then made and dissection was carried down with scalpel to the level of the palmar fascia which was sharply divided by the skin incision.  Bleeding points were identified with electrocautery using bipolar electrocautery.  Retractors were then placed to allow visualization of the distal extent of the transverse carpal ligament, and this was then divided longitudinally under direct vision.  Baby Metzenbaum scissors were used to dissect distal to this area to confirm the absence of any remaining crossing obstructing fibrous band.  Retractors were then replaced proximally to allow visualization of proximal extent of the transverse carpal ligament and the release was continued proximally until complete release was performed.  This was confirmed by visually and palpably.  Next, baby Metzenbaum scissors were used to dissect anteroposterior adjacent antebrachial fascia, and this was divided longitudinally under direct vision using baby Metzenbaum scissors to a level of approximately 3 cm proximal to the proximal extent of the skin incision.  Carpal canal was then inspected.  The median nerve was flattened and injected.  No other abnormalities were noted.  Wounds were then irrigated with normal saline and antibiotic additive.  Decadron 4 mg was then placed adjacent to the median nerve.  Skin incision was then closed with interrupted 5-0 nylon suture.  The wound was then dressed with Adaptic, 4 x 4s, Kling, and Coban.  The tourniquet was then deflated.  Attention was then directed to the left side.  Using sterile technique, the left carpal canal was injected with a mixture of 40 mg of Depo-Medrol, 1 cc of 1% lidocaine, and 1 cc of 0.25% Marcaine.  Band-Aid was then placed over the injection site.  The patient was then awakened, extubated, and transferred over to his hospital bed.  He was transported to recovery room in stable condition.  There were no intraoperative or immediate postoperative complications.  All counts were reported as correct.
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DESCRIPTION: Right open carpal tunnel release and cortisone injection, left carpal tunnel.

surgery, carpal tunnel syndrome, 4 x 4s, adaptic, carpal canal, coban, cortisone injection, esmarch, kling, metzenbaum, carpal tunnel release, electrocautery, fibrous band, palmar fascia, tourniquet, transverse carpal ligament, bilateral carpal tunnel, baby metzenbaum scissors, carpal ligament, bilateral carpal, metzenbaum scissors, carpal tunnel, carpal, tunnel,

The situation described involves a surgical procedure, specifically a carpal tunnel release and cortisone injection. Surgical procedures inherently carry risks such as bleeding, infection, and nerve damage. Although the estimated blood loss and complications were minimal and the procedure is common, the presence of potential risks and the need for anesthesia elevate the stakes. However, this is not a life-threatening surgery and is routine for treatment of carpal tunnel syndrome, suggesting a mid-level of stakes. The patient's condition was managed well without complications during the procedure, contributing to a moderate assessment of stakes.


Medical Specialty: 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.

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,

The scenario involves a surgical procedure, specifically a bilateral reduction mammoplasty, which inherently carries higher stakes due to the potential complications and risks associated with surgery, such as infection, bleeding, and adverse reaction to anesthesia. Additionally, specific challenges like achieving symmetrical results, preserving nipple sensation and blood supply, and the postoperative recovery can impact the patient's quality of life. Therefore, while it is a routine and commonly performed surgery, its high-stakes nature results from the need for surgical precision, patient safety, and desired aesthetic outcomes.


Medical Specialty: Ophthalmology
Sample Name: Ruptured Globe Repair - Sclera and Limbus

PREOPERATIVE DIAGNOSIS: , Ruptured globe with uveal prolapse OX.,POSTOPERATIVE DIAGNOSIS:,  Ruptured globe with uveal prolapse OX.,PROCEDURE:  ,Repair of ruptured globe with repositing of uveal tissue OX.,ANESTHESIA: ,General,SPECIMENS:,  None.,COMPLICATIONS:,  None.,INDICATIONS: , This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE: ,  The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was carefully placed to provide exposure. A two-armed 7 mm scleral laceration was seen in the supranasal quadrant. The laceration involved the sclera and the limbus in this area. There was a small amount of iris tissue prolapsed in the wound. The Westcott scissors and 0.12 forceps were used to carefully dissect the conjunctiva away from the wound to provide exposure. A cyclodialysis spatula was used to carefully reposit the prolapsed iris tissue back into the anterior chamber. The anterior chamber remained formed and the iris tissue easily resumed its normal position. The pupil appeared round. An 8-0 nylon suture was used to close the scleral portion of the laceration. Three sutures were placed using the 8-0 nylon suture. Then 9-0 nylon suture was used to close the limbal portion of the wound. After the wound appeared closed, a Superblade was used to create a paracentesis at approximately 2 o'clock. BSS was injected through the paracentesis to fill the anterior chamber. The wound was checked and found to be watertight. No leaks were observed. An 8-0 Vicryl suture was used to reposition the conjunctiva and close the wound. Three 8-0 Vicryl sutures were placed in the conjunctiva. All scleral sutures were completely covered. The anterior chamber remained formed and the pupil remained round and appeared so at the end of the case. Subconjunctival injections of Ancef and dexamethasone were given at the end of the case as well as Tobradex ointment. The lid speculum was carefully removed. The drapes were carefully removed. Sterile saline was used to clean around the XXX eye as well as the rest of the face. The area was carefully dried and an eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia without difficulty. (S)he was taken to the recovery area in good condition. There were no complications.
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DESCRIPTION: Repair of ruptured globe with repositing of uveal tissue - Sample/Template.

ophthalmology, ruptured globe, bss, subconjunctival, bleeding, conjunctiva, eye patch, infection, limbus, loss of the eye, loss of vision, re-operation, scleral laceration, supranasal quadrant, uveal prolapse, wire lid speculum, iris tissue, anterior chamber, laceration, iris, chamber, ruptured, globe, eye,

The situation involves a surgical procedure to repair a ruptured globe, which is serious due to the potential implications for the patient's vision and overall eye health. The stakes are high because, if unsuccessful, the patient could suffer permanent vision loss or even loss of the eye. The detailed description of the procedure, the use of general anesthesia, and the risks discussed with the patient all indicate a high-stakes scenario typical for such intricate surgeries.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 44

PAST MEDICAL HISTORY:  Include:,1.  Type II diabetes mellitus.,2.  Hypertension.,3.  Hyperlipidemia.,4.  Gastroesophageal reflux disease.,5.  Renal insufficiency.,6.  Degenerative joint disease, status post bilateral hip and bilateral knee replacements.,7.  Enterocutaneous fistula.,8.  Respiratory failure.,9.  History of atrial fibrillation.,10.  Obstructive sleep apnea.,11.  History of uterine cancer, status post total hysterectomy.,12.  History of ventral hernia repair for incarcerated hernia.,SOCIAL HISTORY:  The patient has been admitted to multiple hospitals over the last several months.,FAMILY HISTORY:  Positive for diabetes mellitus type 2 in both mother and her sister.,MEDICATIONS:  Currently include,,1.  Albuterol inhaler q.4 h.,2.  Paradox swish and spit mouthwash twice a day.,3.  Digoxin 0.125 mg daily.,4.  Theophylline 50 mg q.6 h.,5.  Prozac 20 mg daily.,6.  Lasix 40 mg daily.,7.  Humulin regular high dose sliding scale insulin subcu. q.6 h.,8.  Atrovent q.4 h.,9.  Lantus 12 units subcu. q.12 h.,10.  Lisinopril 10 mg daily.,11.  Magnesium oxide 400 mg three times a day.,12.  Metoprolol 25 mg twice daily.,13.  Nitroglycerin topical q.6 h.,14.  Zegerid 40 mg daily.,15.  Simvastatin 10 mg daily.,ALLERGIES:  Percocet, Percodan, oxycodone, and Duragesic.,REVIEW OF SYSTEMS:  The patient currently denies any pain, denies any headache or blurred vision.  Denies chest pain or shortness of breath.  She denies any nausea or vomiting.  Otherwise, systems are negative.,PHYSICAL EXAM:,General:  The patient is awake, alert, and oriented.  She is in no apparent respiratory distress.,Vital Signs:  Temperature 97.6, blood pressure is 139/53, pulse 100, respirations 24.  The patient has a tracheostomy in place.  She will also have an esophageal gastric tube in place.,Cardiac:  Regular rate and rhythm without audible murmurs, rubs or gallops.  Lungs are clear to auscultation bilaterally with slightly diminished breath sounds on the bases.  No adventitious sounds are noted.,Abdomen:  Obese.  There is an open wound on the ventral abdomen overlying the midline abdominal incision from previous surgery.  The area is covered with bandage with serosanguineous fluid.  Abdomen is nontender to palpation.  Bowel sounds are heard in all 4 quadrants.,Extremities:  Bilateral lower extremities are edematous and very cool to touch.,LABORATORY DATA:  Pending.  Capillary blood sugars thus far have been 132 and 135.,ASSESSMENT:  This is an 80-year-old female with an unfortunate past medical history with recent complications of sepsis and respiratory failure who is now receiving tube feeds.,PLAN:  For her diabetes mellitus, we will continue the patient on her current regimen of Lantus 12 units subcu. q.12 h. and Regular Insulin at a high dose sliding scale every 6 hours.  The patient had been previously controlled on this.  We will continue to check her sugars every 6 hours and adjust insulin as necessary.
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DESCRIPTION: An 80-year-old female with recent complications of sepsis and respiratory failure who is now receiving tube feeds.

The patient is an elderly woman with a complex medical history, including multiple chronic conditions that are significant in nature, such as type II diabetes, hypertension, hyperlipidemia, and respiratory failure. She also has a history of sepsis, which is a severe and potentially life-threatening condition. Her current physiological status is concerning, with factors such as tracheostomy, an esophageal gastric tube, cool edematous extremities, and a ventral abdominal wound. Overall, her situation is highly complex due to the interplay of multiple serious health issues that require careful monitoring and management. This increases the stakes significantly when it comes to her medical treatment and outcomes.


Medical Specialty: Neurosurgery
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

neurosurgery, 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 described is a neurosurgical procedure involving the placement of a Scott cannula in the right lateral ventricle. This type of procedure is high-stakes due to the complexity and potential risks associated with neurosurgery, such as infection, bleeding, or neurological damage. The brain is a highly sensitive and critical organ, and any procedure involving it requires precision and expertise. Ensuring the accurate placement and proper securing of the cannula is crucial for patient safety and effective treatment. The involvement of cerebrospinal fluid (CSF) and the need for external drainage indicate that the procedure is significant and requires careful monitoring.


Medical Specialty: Gastroenterology
Sample Name: Endoscopy With Biopsy

PROCEDURE:,  Upper endoscopy with biopsy.,PROCEDURE INDICATION: , This is a 44-year-old man who was admitted for coffee-ground emesis, which has been going on for the past several days.  An endoscopy is being done to evaluate for source of upper GI bleeding.,Informed consent was obtained.  Outlining the risks, benefits and alternatives of the procedure included, but not to risks of bleeding, infection, perforation, the patient agreed for the procedure.,MEDICATIONS: , Versed 4 mg IV push and fentanyl 75 mcg IV push given throughout the procedure in incremental fashion with careful monitoring of patient's pressures and vital signs.,PROCEDURE IN DETAIL:  ,The patient was placed in the left lateral decubitus position.  Medications were given.  After adequate sedation was achieved, the Olympus video endoscope was inserted into the mouth and advanced towards the duodenum.
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DESCRIPTION: Upper endoscopy with biopsy.   The patient admitted for coffee-ground emesis, which has been going on for the past several days.  An endoscopy is being done to evaluate for source of upper GI bleeding.

gastroenterology, coffee-ground emesis, gi bleeding, upper endoscopy, iv push, esophagus, duodenum, mucosa, stomach, endoscopy, biopsy,

The procedure described is an upper endoscopy with biopsy, which is being performed to evaluate the source of upper gastrointestinal bleeding in a patient presenting with coffee-ground emesis. Coffee-ground emesis suggests potential bleeding in the gastrointestinal tract. Although this situation is not immediately life-threatening, it does require prompt investigation and intervention to prevent complications such as significant blood loss or underlying serious conditions like ulcers or malignancy. The procedure itself carries inherent risks like bleeding, infection, and perforation, which add to the stakes. However, it is a common diagnostic procedure performed in controlled settings with measures in place to manage complications.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Difficulty Breathing - ER Visit

HISTORY:,  The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  Difficulty breathing began last night.  He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home.  They were home for about an hour when he began to get worse and they drove here to Children's Hospital.  He has a history of reactive airway disease.  He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing.  He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time.  He has been on albuterol off and on over that period.  He has had fever overnight.  No vomiting, no diarrhea.  Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department.  Normal urine output.  No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above.  No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:,  Up-to-date.,BIRTH HISTORY:,  The child was full term, no complications, home with mom.  No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home.  No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL:  The child is awake, alert, in moderate respiratory distress.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements are intact.  The TMs are clear.  The nares show some dry secretions.  Audible congestion and wheezing is noted.  Mucous membranes are dry.  Throat is clear.  No oral lesions noted.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Show inspiratory and expiratory wheezes in all fields.  Audible wheezes are noted.  There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART:  Shows tachycardia.  Regular rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding.  No rebound.  No hepatosplenomegaly.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed.  I felt the child was dehydrated on examination.  We gave 20 mL/kg bolus of normal saline over one hour.  The child was given Solu-Medrol 2 mg/kg IV.  He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally.  Normal heart size.  No evidence of pneumothorax.  No evidence of focal pneumonia.  After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time.  The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour.  The child's pulse ox on breathing treatments with 100% oxygen was 100%.  Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea.  The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time.  After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout.  After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia.  The child has a normal level of alertness; however, has not had any vomiting here.  I spoke with Dr. X, on call for hospitalist service.  She has come down and evaluated the patient.  We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family.  The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES:  ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT:  ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION:  ,Status asthmaticus, hypoxia.,PLAN:  ,Admitted to Pediatrics.
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DESCRIPTION: The patient is 14 months old, comes in with a chief complaint of difficulty breathing.

The situation described involves a 14-month-old patient with difficulty breathing, a history of reactive airway disease, and previous ER visits for similar issues. The child presented with severe respiratory distress, tachypnea, and hypoxia, necessitating high-dose albuterol and continuous monitoring. The patient did not respond adequately to outpatient treatment and required hospitalization for continued care and stabilization. This is a high-stakes situation due to the age of the child, the severity of respiratory symptoms, the risk of respiratory failure, and the need for intensive medical intervention to prevent further deterioration.


Medical Specialty: Ophthalmology
Sample Name: Lid Laceration Repair

PREOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,POSTOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,PROCEDURES:,1. Repair of XXX upper lid laceration.,2. Repair of XXX upper lid canalicular laceration.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with XXX eye upper eyelid laceration involving the canaliculus.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient was brought to the operating room and placed in the supine position, where (s)he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery, once the appropriate cardiac and respiratory monitoring was placed on him/her, and once general endotracheal anesthetic had been administered. The patient then had the wound freshened up with Westcott scissors and cotton-tip applications. Hemostasis was achieved with a high-temp disposable cautery. Once this had been done, the proximal end of the XXX upper lid canalicular system was intubated with a Monoka tube on a Prolene. The proximal end was then found and this was intubated with the same tubing system. Then, two 6-0 Vicryl sutures were used to reapproximate the medial canthal tendon. Once this had been done, the skin was reapproximated with interrupted 6-0 Vicryl sutures and interrupted 6-0 plain gut sutures. To ensure that the punctum was in the correct position and in the Monoka tube was seated with a seater, and the tube was cut short. The patient's nose was suctioned of blood, and (s)he was awakened from general endotracheal anesthesia and did well. (S)he left the operating room in good condition.
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DESCRIPTION: Repair of upper lid canalicular laceration - Sample/Template.

ophthalmology, laceration, monoka tube, westcott scissors, bleeding, canalicular laceration, canthal tendon, cotton-tip, infection, lid, lid canalicular system, lid laceration, loss of the eye, loss of vision, ophthalmic plastic reconstructive surgery, re-operation, upper lid, lid laceration repair, laceration repair, lid canalicular, canalicular

The situation involves a medical procedure for repairing an upper lid and canalicular laceration, specifically discussed in a sample/template report for an ophthalmology surgery. The stakes are moderately high due to the inherent risks associated with eye surgery, including potential loss of vision or the eye itself, and necessity for informed consent. However, it appears to be a typical scenario with no complications reported in this instance, suggesting no immediate crisis or life-threatening condition.


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

Medical Specialty: Obstetrics / Gynecology
Sample Name: Ultrasound OB - 4

GENERAL EVALUATION: ,(Twin A),Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Twin A lies to the maternal left.,Fetal Presentation: Cephalic,Placenta: Posterior fused placenta Grade I-II,Uterus: Normal,Cervix: Closed,Adnexa: Not seen,Amniotic Fluid: There is a single 3.9cm anterior pocket.,BIOMETRY:,BPD: 8.7cm consistent with 35 weeks, 1 day,HC: 30.3cm consistent with 33 weeks, 5 days.,AC: 28.2cm consistent with 32 weeks, 1 day,FL:
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DESCRIPTION: Twin pregnancy with threatened preterm labor.

The situation involves a twin pregnancy with threatened preterm labor, which is a high-stakes scenario in obstetrics and gynecology due to the potential risks to both the mother and the fetuses. Preterm labor can lead to preterm birth, which increases the risk of complications for the infants, including respiratory issues, developmental delays, and other health problems. Monitoring and timely intervention are critical to manage the situation effectively.


Medical Specialty: Gastroenterology
Sample Name: Dysphagia & Hematemesis

CHIEF COMPLAINT: , Dysphagia and hematemesis while vomiting.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old African American female with 15 years known history of HIV and hepatitis B, and known history of compensated heart failure, COPD, who presented today with complaint of stuck food in her esophagus, bloody cough, and bloody vomiting since 4 o'clock this vomiting, when she ate eggplant parmigiana meal.  The back and chest pain is 8/10, no radiation and is constant.  She denied fever, abdominal pain, or dysphagia before current event eating bones or fish.  This is the first episode of hematemesis and feeling of globus pallidus.  In the emergency room, the patient was treated with nitropaste, morphine, and Lopressor with positive results for chest pain.  CAT scan of the chest showed diffuse esophageal dilatation with residual food in it, no mediastinal air was identified.,REVIEW OF SYSTEMS: , The patient denied diarrhea, abdominal pain, fever, weight loss, dysphagia before this event.  Denied any exertional chest pain or shortness of breath.  No headache, limb weakness.  No joint pain or muscle ache.  No dysuria.,PAST MEDICAL HISTORY:  ,Remarkable for:,1.  Asthma.,2.  Hepatitis C - 1995.,3.  HIV, known since 1995 and followed up by Dr. X, ABCD Medical Center, the last visit was 08/09.  The patient does not take HIV medications against medical advice.,4.  Hypertension, known since 2008.,5.  Negative PPD test, 10/08.,PAST SURGICAL HISTORY: , Remarkable for hysterectomy in 2001, pilonidal cyst surgery in 2005.,FAMILY HISTORY: , Mother deceased at age 68 of cirrhosis.  She had history of alcohol abuse.  Father deceased at age 45, also has a history of alcohol abuse, cardiac disease, and hypertension.,ALLERGIES: , Not known allergies.,MEDICATIONS AT HOME: , Lisinopril 5 mg daily; metoprolol 25 mg twice daily; furosemide 40 mg once daily; Isentress 400 mg once daily, the patient does not take this medication for the last 3 months; Norvir 100 mg once daily; Prezista 400 mg once daily.  The patient does not take her HIV medications for the last 2 to 3 months.  Occasionally, she takes inhalation of albuterol and Ambien 10 mg once daily.,SOCIAL HISTORY: , She is single, lives with her 21-year-old daughter, works as CNA, smokes one pack per day for the last 8 years.  She had periods when she quit smoking and started again 2-1/2 years ago.  She denied alcohol abuse and she was using cocaine in the past, last time she used cocaine 10 years ago.,PHYSICAL EXAMINATION: , Temperature 99.8, pulse 106, respiratory rate 18, blood pressure 162/97, saturation 99 on room air.  African American female, not in acute respiratory distress, but uncomfortable, and showing some signs of back discomfort.  Oriented x3, mildly drowsy, calm and cooperative.  Eyes, EOMI, PERRLA.  Tympanic membranes normal appearance bilaterally.  External canal, no erythema or discharge.  Nose, no erythema or discharge.  Throat, dry mucous, no exudates.  No ulcers in oral area.  Full upper denture and extensive decayed lower teeth.  No cervical lymphadenopathy, no carotid bruits bilaterally.  Heart:  RRR, S1 and S2 appreciated.  No additional sounds or murmurs were auscultated.  Lung:  Good air entrance bilaterally.  No rales or rhonchi.  Abdomen:  Soft, nontender, nondistended.  No masses or organomegaly were palpated.  Legs:  No signs of DVT, peripheral pulses full, posterior dorsalis pedis 2+.  Skin:  No rashes or other lesions, warm and well perfused.  Nails:  No clubbing.  No other signs of skin infection.  Neurological exam:  Cranial nerves II through XII grossly intact.  No motor or sensory deficit was found.,CAT scan of the chest, which was done at 8 o'clock in the morning on 01/12/10.  Impression:  Cardiomegaly, normal aorta, large distention of esophagus containing food.  Chest x-ray:  Cardiomegaly, no evidence of CHF or pneumonia.  EKG:  Normal sinus rhythm, no signs of ischemia.,LABORATORY DATA: , Hemoglobin 10.4, hematocrit 30.6, white blood cells 7.3, neutrophils 75, platelets 197.  Sodium 140, potassium 3.1, chloride 104, bicarb 25, glucose 113, BUN 19, creatinine 1.1, GFR 55, calcium 8.8, total protein 8.1, albumin 3.1, globulin 5.0, bilirubin 0.3, alk phos 63, GOT 23, GPT 22, lipase 104, amylase 85, protime 10.2, INR 1, PTT 25.8.  Urine:  Negative for ketones, protein, glucose, blood, and nitrite, bacteria 2+.  Troponin 0.040.  BNP 1328.,PLAN:,1.  Diffuse esophageal dilatation/hematemesis.  We will put her n.p.o., we will give IV fluid, half normal saline D5 100 mL per hour.  I discussed the case with Dr. Y, gastroenterologist.  The patient planned for EGD starting today.  Differential diagnosis may include foreign body, achalasia, Candida infection, or CMV esophagitis.  We will treat according to the EGD findings.  We will give IV Nexium 40 mg daily for GI prophylaxis.  We will hold all p.o. medication.,2.  CHF.  Cardiomegaly on x-ray.  She is clinically stable.  Lungs are clear.  No radiological sign of CHF exacerbation.  We will restart lisinopril and metoprolol after EGD study will be completed.,3.  HIV - follow up by Dr. X, (ABCD Medical Center).  The last visit was on 08/08.  The patient was not taking her HIV medications for the last 3 months and does not know her CD4 number or viral load.  We will check CD4 number and viral load.  We will contact Dr. X (ID specialist in ABCD Med).,4.  Hypertension.  We will control blood pressor with Lopressor 5 mg IV p.r.n.  If blood pressure more than 160/90, we will hold metoprolol and lisinopril.,5.  Hepatitis C, known since 1995.  The patient does not take any treatment.,6.  Tobacco abuse.  The patient refused nicotine patch.,7.  GI prophylaxis as stated above; and DVT prophylaxis, compression socks.  We will restrain from using heparin or Lovenox.,ADDENDUM: , The patient was examined by Dr. Y, gastroenterologist, who ordered a CAT scan with oral contrast, which showed persistent distention of the esophagus with elementary debris within the lumen of the esophagus.  There is no evidence of leakage of the oral contrast.  There is decrease in size of periaortic soft tissue density around the descending aorta, this is associated with increase in very small left pleural effusion in the intervening time.  There is no evidence of pneumomediastinum or pneumothorax, lungs are clear, contrast is present in stomach.  After procedure, the patient had profuse vomiting with bloody content and spiked fever 102.  The patient felt relieved after vomiting.  The patient was started on aztreonam 1 g IV every 8 hours, Flagyl 500 mg IV every 8 hours.  ID consult was called and thoracic surgeon consult was ordered.
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DESCRIPTION: Dysphagia and hematemesis while vomiting.  Diffuse esophageal dilatation/hematemesis

The patient's condition involves several serious health issues that require immediate and coordinated medical attention. She presents with dysphagia and hematemesis, alongside a complex medical history including HIV, hepatitis B and C, heart failure, and COPD. The risk of esophageal rupture or significant gastrointestinal bleeding, along with the potential complications from untreated HIV and hepatitis, elevate the stakes. The management involves multiple specialists, including gastroenterologists, ID specialists, and potentially thoracic surgeons, indicating the critical nature of her condition. These factors make the situation high-stakes due to the potential for rapid deterioration and the need for timely, effective intervention.


Medical Specialty: Gastroenterology
Sample Name: Barium Swallow Study Evaluation - 1

HISTORY:  ,The patient is a 76-year-old male, with previous history of dysphagia, status post stroke.  The patient stated that he was at Hospital, secondary to his stroke, where he had his initial modified barium swallow study.  The patient stated that the results of that modified revealed aspiration with thin liquids only.  He is currently eating and drinking without difficulty and he feels that he can return to a regular diet with thin liquids.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,STUDY: , Modified barium swallow study was performed in the radiology suite in cooperation with Dr. X. The patient was seated upright and in a video-imaging chair throughout this assessment.,To evaluate the patient's swallowing function and safety, he was administered graduated amounts of liquid and food mixed with barium in the form of thin liquids (teaspoon x3, cup sip x3); nectar-thick liquid (teaspoon x2, cup sip x3); pureed consistency (teaspoon x3); solid consistency (1/4 cracker x1).,FINDINGS,ORAL STAGE: , The patient had no spillage out lips.  Oral residual after swallow with increased viscosity requiring multiple swallows to clear oral cavity.,The patient has reduced lingual retraction contributing to vallecula pooling after the swallow.  Trace premature spillage was noted with thin liquids during this assessment.,PHARYNGEAL STAGE: , Aspiration noted on cup sips of thin liquid.  Trace-to-mild penetration with teaspoon amounts of thin liquid during and after the swallow.  The penetration after the swallow occurred secondary to spillage on the piriform sinuses into the laryngeal vestibule.  The patient has incomplete laryngeal closure, which allowed the aspiration and penetration with thin liquids.  The patient had no aspiration or penetration occur with nectar-thick liquid, puree, and solid food.  The patient has a mildly reduced hyolaryngeal elevation and anterior movement that leads to incomplete epiglottic inversion that contributes to vallecula pooling.  Mild-to-moderate pooling in the vallecula after the swallow with liquids and puree, this residual did decrease with the solid feed presentation.  The patient has mild residual of pooling in the piriform sinuses after a swallow that did clear with sequential swallows.,CERVICAL ESOPHAGEAL STAGE: , The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: , Mild aspiration with cup sips of thin liquid, penetration during and after the swallow with teaspoon amounts of thin liquid.  No aspiration or penetration occurred with thick liquid, pureed, or solid food during this assessment.,PROGNOSTIC IMPRESSION: , With a modified diet, the patient's potential for swallowing safety is good.,PLAN:,Based on this evaluation, the following is recommended:,1.  The patient should be on a regular diet with nectar-thick liquids to help prevent aspiration and penetration.,2.  The patient should have unthickened water in between meals to help decrease his risk of dehydration.,3.  The patient should complete good oral care two times a day to decrease bacterial growth in mouth.,4.  The patient should be seated at a 90-degree angle when eating and drinking, as well as take small bites and small sips to help decrease risk of aspiration and penetration and reflux.,Thank you for the opportunity to evaluate the patient.  I look forward to working with him in the outpatient setting to improve his swallowing function and safety.  Outpatient skilled speech therapy is recommended for a trial of neuromuscular electrical stimulation therapy for muscle re-education, as well as to train patient to use swallowing techniques and maneuvers that should improve his swallowing function and safety.
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DESCRIPTION: The patient is a 76-year-old male, with previous history of dysphagia, status post stroke.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.

gastroenterology, oral stage, pharyngeal stage, cervical esophageal stage, nectar-thick liquids, aspiration, modified barium swallow, barium swallow study, dysphagia status, cup sips, barium swallow, swallow, teaspoon, barium, swallowing,

The situation involves evaluating a 76-year-old stroke patient's ability to safely swallow food and liquids, which is a medical concern with potentially serious complications like aspiration leading to pneumonia or other respiratory issues. While it isn't an immediate life-threatening emergency, ensuring the patient's diet is appropriately managed and monitored is crucial for their ongoing health and safety. Consistent follow-up with therapies and dietary adjustments is essential to prevent potential risks and ensure patient well-being.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 9

EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1.  Left heart catheterization, coronary angiography, left ventriculography.,2.  PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1.  IV Valium.,2.  IV Benadryl.,3.  Subcutaneous lidocaine.,4.  IV heparin.,5.  IV ReoPro.,6.  Intracoronary nitroglycerin.,ESTIMATED BLOOD LOSS: , 10 mL.,CONTRAST:  ,185 mL.,COMPLICATIONS: , None.,PROCEDURE: , The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG.  She was prepped and draped in the usual sterile fashion.  The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained.  The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed.  The needle was exchanged for 6 French sheath.  The wire was removed.  The sheath was washed with sterile saline.  Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed.  A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD.  The patient had an ACT check, received additional IV heparin and IV ReoPro.  The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures.  The balloon was deflated and angiography demonstrated establishment of flow.  Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres.  The balloon was deflated, reinflated at 12 atmospheres, deflated and removed.  Final angiography demonstrated excellent clinical result.  Additional angiography was performed with a wire out.  Following this, the wire and the catheter was removed.  Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views.  This catheter was removed.  The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve.  At the end of procedure, wires and catheter were removed.  Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site.  There was no hematoma.  Peripheral pulses _______ procedure.  The patient tolerated the procedure well.  Symptoms of chest pain resolved at the end of the procedure with no complications.,RESULTS:,1.  Coronary angiography.,A.  Left main free of obstruction.,B.  LAD, subtotal proximal stenosis.,C.  Circumflex large vessel with three large obtuse marginal branches.  No high-grade obstruction, evidence of minimal plaquing.,D.  Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.,2.  Left ventriculogram.  Left ventricular ejection fraction estimated at 45% to 50%.  There was an akinetic apical wall.,3.  Hemodynamics.  Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.,IMPRESSION:,1.  Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.,2.  Two-vessel coronary disease.,3.  Mild-to-moderate impaired LV systolic function.,4.  Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.,PLAN:  ,Overnight observation in ICU.  Start aspirin, Plavix, beta-blocker and ACE inhibitor.  Check serial cardiac enzymes.  Further recommendations to follow.  Check fasting lipid panel, in addition add a statin.  Further recommendations to follow.
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DESCRIPTION: Cardiac catheterization and coronary intervention report.

This scenario involves a cardiac catheterization and coronary intervention procedure conducted due to an acute ST-elevation myocardial infarction (STEMI). The immediate intervention and successful stenting were necessary to restore blood flow. STEMI is a critical medical condition that, if not treated promptly, can lead to significant morbidity or mortality. Additionally, the details include direct actions taken to address artery occlusion and ongoing monitoring plans in the ICU. These factors mark a high-stakes scenario in the medical context.


Medical Specialty: Neurology
Sample Name: Iliopsoas Hematoma - 2

CC: ,RLE weakness.,HX: ,This 42y/o RHM was found 2/27/95 slumped over the steering wheel of the Fed Ex truck he was driving. He was cyanotic and pulseless according to witnesses. EMT evaluation revealed him to be in ventricular fibrillation and he was given epinephrine, lidocaine, bretylium and electrically defibrillated and intubated in the field. Upon arrival at a local ER his cardiac rhythm deteriorated and he required more than 9 counter shocks (defibrillation) at 360 joules per shock, epinephrine and lidocaine. This had no effect. He was then given intracardiac epinephrine and a subsequent electrical defibrillation placed him in atrial fibrillation. He was then taken emergently to cardiac catherization and was found to have normal coronary arteries. He was then admitted to an intensive care unit and required intraortic balloon pump pressure support via the right gorin. His blood pressure gradually improved and his balloon pump was discontinued on 5/5/95. Recovery was complicated by acute renal failure and liver failure. Initail CK=13,780, the CKMB fraction was normal at 0.8.,On 3/10/95, the patient experienced CP and underwent cardiac catherization. This time he was found to have a single occlusion in the distal LAD with association inferior hypokinesis. Subsequent CK=1381 and CKMB=5.4 (elevated). The patient was amnestic to the event and for 10 days following the event. He was transferred to UIHC for cardiac electrophysiology study.,MEDS: ,Nifedipine, ASA, Amiodarone, Capoten, Isordil, Tylenol, Darvocet prn, Reglan prn, Coumadin, KCL, SLNTG prn, CaCO3, Valium prn, Nubain prn.,PMH:, hypercholesterolemia.,FHX:, Father alive age 69 with h/o TIAs. Mother died age 62 and had CHF, A-Fib, CAD. Maternal Grandfather died of an MI and had h/o SVT. Maternal Grandmother had h/o SVT.,SHX: ,Married, 7 children, driver for Fed Ex. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP112/74 HR64 RR16 Afebrile.,MS: A&O to person, place and time. Euthymic with appropriate affect.,CN: unremarkable.,Motor: Hip flexion 3/5, Hip extension 5/5, Knee flexion5/5, Knee extension 2/5, Plantar flexion, extension, inversion and eversion 5/5. There was full strength thoughout BUE.,Sensory: decreased PP/Vib/LT/TEMP about anterior aspect of thigh and leg in a femoral nerve distribution.,Coord: poor and slowed HKS on right due to weakness.,Station: no drift or Romberg sign.,Gait: difficulty bearing weight on RLE.,Reflexes: 1+/1+ throughout BUE. 0/2 patellae. 2/2 archilles. Plantar responses were flexor, bilaterally.,COURSE:, MRI Pelvis, 3/28/95, revealed increased T1 weighted signal within the right iliopsoas suggestive of hematoma. An intra-osseous lipoma was incidentally notice in the right sacrum. Neuropsychologic assessment showed moderately compromised anterograde verbal memory, and temporal orientation and retrograde recall were below expectations. These findings were consistent with mesial temporal dysfunction secondary to anoxic injury and were mild in lieu of his history. He underwent implantation of a Medtronic internal cardiac difibrillator. His cardiac electrophysiology study found no inducible ventricular tachycardia or fibrillation. He suffered mild to moderate permanent RLE weakness, especially involving the quadriceps. His femoral nerve compression had been present to long to warrant decompression. EMG/NCV studies revealed severe axonal degeneration.
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DESCRIPTION: Right iliopsoas hematoma with associated femoral neuropathy following cardiac catherization.

neurology, cardiac electrophysiology study, iliopsoas hematoma, rle weakness, balloon pump, femoral nerve, cardiac catherization, hematoma, iliopsoas, catherization, epinephrine, fibrillation, cardiac,

The scenario involves a patient with a complex set of medical complications, including cardiac arrest, cardiac catheterization results, and neurological impairments from a hematoma. This is a high-stakes situation due to the critical nature of the cardiac issues, the neurological damage from the iliopsoas hematoma, and the chronic implications of such complications. The situation described includes emergency medical interventions, intensive care management, and permanent physical impairments, all indicative of a high-stakes, life-altering medical condition.


Medical Specialty: Surgery
Sample Name: Adenoidectomy & Tonsillectomy & Lingual Frenulectomy

PREOPERATIVE DIAGNOSES:,1.  Chronic adenotonsillitis.,2.  Ankyloglossia,POSTOPERATIVE DIAGNOSES:,1.  Chronic adenotonsillitis.,2.  Ankyloglossia,PROCEDURE PERFORMED:,1.  Adenoidectomy and tonsillectomy.,2.  Lingual frenulectomy.,ANESTHESIA: , General endotracheal.,FINDINGS/SPECIMEN:,  Tonsil and adenoid tissue.,COMPLICATIONS: , None.,CONDITION:  ,The patient is stable and tolerated the procedure well, and sent to PACU.,HISTORY OF PRESENT ILLNESS: , This is a 3-year-old child with a history of adenotonsillitis.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion.  A curved hemostat was used to grasp the lingual frenulum.  The stat was removed and Metzenbaum scissors were used to free the lingual frenulum.  Cautery was used to allow hemostasis.  The patient was then turned.  McIvor mouth gag was inserted.  Tonsils and adenoids were exposed.  The patient's right tonsil was first grasped with a curved hemostat.  Needle tip cautery was used to free the superior pole of tonsil.  The tonsil was then grasped in medial superior aspect with a straight hemostat.  The tonsil fascia planes were identified with Bovie dissection along the plane.  The tonsil was freed from anterior pillar and posterior pillar.  Amputation occurred along the same plane as the patient's tongue.  Suction cautery was then used to allow for hemostasis.  The patient's adenoids were then viewed with an adenoid mirror.  An adenoid curet was used to remove the patient's adenoid tissue.  Specimen sent.  Suction cautery was used to allow for hemostasis.  Superior pole of left tonsil was then grasped with a curved hemostat.  Superior pole was freed using needle tip Bovie dissection.  Beginning with 15 desiccate, after superior pole was free, Bovie was switched to 15 fulgurate, and the tonsil was stripped from anterior and posterior pillars.  The tonsil was then amputated at the same plane as tongue base.  Hemostasis was achieved with using suction cautery.  Mouth gag was removed.  Dual position and occlusion were tested.  The patient was extubated and tolerated the procedure well and sent back to PACU.
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DESCRIPTION: Adenoidectomy and tonsillectomy and lingual frenulectomy.   Chronic adenotonsillitis and ankyloglossia.

surgery, adenotonsillitis, ankyloglossia, adenoidectomy, tonsillectomy, frenulectomy, tonsil, adenoid tissue, metzenbaum scissors, lingual frenulectomy, chronic adenotonsillitis, curved hemostat, suction cautery, hemostat, hemostasis, lingual, cautery

The procedure involves surgery on a 3-year-old child, which inherently carries significant risks given the child's age and the complexity of performing surgery under general anesthesia. Adenoidectomy, tonsillectomy, and lingual frenulectomy are common procedures usually with a low risk of serious complications, especially when performed by experienced surgeons. The description indicates that the surgery went well with no complications and the child is in stable condition post-operatively. However, the procedures are still invasive and require careful management, particularly in the context of ensuring a safe anesthesia experience and post-operative monitoring in a young patient.