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Medical Specialty: Surgery
Sample Name: Delayed ORIF

PREOPERATIVE DIAGNOSES:,1.  Right ankle trimalleolar fracture.,2.  Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,OPERATIVE PROCEDURE:  ,Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment, as well as medial malleolar fragment.,POSTOPERATIVE DIAGNOSES:,1.  Right ankle trimalleolar fracture.,2.  Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,TOURNIQUET TIME: , 80 minutes.,HISTORY: , This 50-year-old gentleman was from the area and riding his motorcycle in Kentucky.,The patient lost control of his motorcycle when he was traveling approximately 40 mile per hour.  He was on a curve and lost control.  He is unsure what exactly happened, but he thinks his right ankle was pinned underneath the motorcycle while he was sliding.  There were no other injuries.  He was treated in Kentucky.  A close reduction was performed and splint applied.  Orthopedic surgeon called myself with regards to this patient's fracture management and suggested a CT scan.  The patient returned to Ohio and his friend drove him all the way from Kentucky to Northwest Ohio overnight.  The patient showed up in the emergency department where a CT scan was asked to be performed.  This was performed and reviewed.  The patient, however, had significant amount of soft tissue swelling and therefore he was asked to follow up in 2 days.  At this time, he still had significant swelling, but because of the amount of swelling that he had particularly with the long car ride for many hours with his leg dependent, it was felt to be best to wait.,Indeed after 7 days, the patient started to develop fracture blisters on the posterior medial aspect of his ankle with large blisters measuring approximately 2 to 3 inches.  The patient was x-rayed in the office.  He had lost some of his reduction.  Therefore, he was re-reduced at approximately 7 days and then each time the patient had examination of tissues, he was re-reduced just to keep the pressure off the skin.,An x-ray showed the distal fibular fracture starting at the mortise region laterally.  It appeared as an abduction type injury with minimal rotation.  This was comminuted, fragmented, and impacted.,The medial malleolus fracture was an avulsion type.  The syndesmosis appeared to be intact.  This appeared as an AO type B fracture.  However, this was not a rotational injury.,There is a posterior malleolar fragment attached to the distal fibular fragment, which appeared to be avulsed as well, but comminuted.  CT scan revealed a more serious fracture with an anterior as well as posterior plafond fracture of an anterior fragment, which was undisplaced in the posterior medial corner.  A posterior Tillaux fragment appeared to be separate.  However, in this area, there was significant comminution in the mid portion of the ankle joint.,There were many fragments and defects in this region.,The medial mortise however appeared to be intact with regards to the tibial plafond even though there was an anterior undisplaced fragment.,We discussed delayed open reduction internal fixation with the patient.  He understood the risk of surgery including infection, decreased range of motion, stiffness, neurovascular injury, weakness, and numbness.  We discussed seriously the risk of osteoarthritis because of the comminution in the intraarticular surface shown on the CT scan.  We discussed deep vein thrombosis, pulmonary embolism, skin slough, skin necrosis, infection, and need for second surgery.  We discussed shortening, decreased strength, limited use, disability of operative extremity, malunion, nonunion, compartment syndrome, stiffness of the operative extremity, numbness, and weakness.  Examination of the patient revealed that he had slightly decreased sensation on the dorsum of his foot.,The patient was able to flex and extend his toes, had good capillary refill, good dorsalis pedis, and posterior tibial pulse.,The patient's tissues were edematous and we has waited approximately 10 days before performing the surgery when the skin could be wrinkled anteriorly.  We discussed his incision, the medial incision as well as lateral incision and the lateral incision would be more posterolateral to maintain a bridge of at least 6 to 8 cm between the 2 incisions.  We did discuss the skin slough as well as skin necrosis, particularly medially where the most skin pressure was because of displacement laterally.  He understood the posterolateral comminution of the tibial plafond, which would be reduced by aligning up the cortex posteriorly.,We discussed the posterolateral approach with reduction of the fibula.  We discussed that likely the distal fibula would not be removed completely to assess the articular surface as this would likely comminute the fibula, even more fragmentation would occur, and would not be able to obtain an anatomic reduction.  He understood this distal fibular fracture was comminuted and there were missing fragments of bone because they were impacted into intramedullary cancellous space.  With this, the patient understood that the hardware may necessitate removal as well in the future.  We discussed hardware irritation.  We also discussed risk of osteoarthritis, which was nearly 100% particularly because of comminution of this area posteriorly.  With these risks discussed and listed on the consent, the patient wanted the procedure.,OPERATIVE NOTE:,  The patient was brought to operating theater and given successful general anesthetic.  His right leg was prepped and draped in the usual fashion.  Before prep and drape was performed, a close reduction was tried to be obtained to see whether there was any obstruction to reduction.  It was felt that at one point the posterior tibialis tendon may be intraarticular.,The reduction appeared to line up.  However, there was significant gap of approximately 1.5 to 2 cm between the avulsed medial malleolus fragment and distal tibia.,A lateral incision was made over the fracture site approximately 8 cm long and was taken to subcutaneous tissue.  The superficial peroneal nerve was seen and this was avoided.  The incision was placed posterolateral to fibula.,This was to ensure good flap of tissue between the 2 incisions medial and laterally.  The fracture was seen.  The fracture was elevated and medialized and de-rotated.  The anterior portion of the distal fibula was significantly comminuted with defect.  The posterior aspect was still intact.  However, there were multiple fracture lines demonstrating a crush-type injury.  This was reduced manually.  At this point, dissection was performed bluntly behind the peroneal tendons in between this and flexor hallucis longus tendon.  No sharp dissection was performed.  The posterior malleolar fragment was palpated with the distal fibula reduced.  The posterior malleolar fragment appeared to be reduced as well.,X-ray views confirmed this.,An incision was made, standard incision, curvilinear, medially distal to the medial corner of the mortise and curving anterior and posteriorly around the tip of the medial malleolus.  This was taken only through subcutaneous tissue.  The saphenous vein was found, dissected out.  Its branches were cauterized.  Penrose drain was placed around this.,Dissection was undertaken.  The periosteal tissue was seen and was invaginated into the joint.,This was recovered and flipped back on both sides.  Next, the towel clip was used.  Ends were freshened up using irrigation.  The joint surface appeared to be congruent anteriorly and posteriorly medially.,Anatomic reduction was performed in the medial malleolus using 2 mm K-wires and exchanging these for a 35 mm and a 40 mm, anterior and posterior respectively, partially threaded cancellous screws.  Anatomic reduction was gained.  X-rays were taken showing excellent anatomic reduction.  Next, attention was drawn towards the fibula.  Standard 6-hole one-third tubular plate was applied to this.  Again, this was more of a transverse impacted fracture.  Therefore, interfragmentary screw on an angle could not be used.,The posterior cortex was used to assess anatomic reduction.  Screws were placed.  It was used as a spring plate pushing the distal fibular fragment medially.,Screw holes were filled.  They were double-checked.  Screws had excellent purchase and were tightened up.  At this point, lateral views were taken as well as palpation of posterior lateral fragment was performed in the plafond.  This appeared to show anatomic reduction and did not appear to be a step on the articular surface or the posterior cortex of the distal tibia.,The screw was then placed from anterior medial to posterior lateral into this comminuted fragment.,A 2 mm K-wire was used.  Finger was placed on this fragment and the pin was advanced even before the finger.  X-ray views could show the posterior cortex and location of the pin.  This was then exchanged for a 55 mm partially threaded cancellous screw after tapping was performed.  This was double checked to ensure good positioning and this was so.  On the lateral view, we could see this was not in the joint.  AP views and mortise views showed this was not in the joint.  One could palpate this as well.  The screw was placed slightly proximal to distal in the anteroposterior plane.  At the distal tip of it, it was just in the subchondral bone but not in the joint.  There was slight to excellent purchase of this posterior lateral fragment.  Wounds were copiously irrigated followed by closing using 2-0 Vicryl in inverted fashion followed by staples to skin.  Adaptic, 4 x 4s, abdominal pad was placed on wound, held in place with Kerlix followed by an extensor bandage.  Posterior splint was placed on the patient.  The patient's leg was placed in neutral position.  Significant amount of cast padding were used and large bulky trauma ABD type dressings.  The heel was padded and leg was padded with approximately 2 inches of padding.  Tourniquet was deflated.  The patient had good capillary refill, good pulses, and the patient returned to recovery room in stable condition with no complications.  Physician assistant assisted during the case with retracting as well as holding the medial malleolar fragment and fragments in position while placement screws were applied.  Positioning of the leg was accomplished by the physician assistant.  As well, physician assistant assisted in transport of patient to and from the recovery room, assisted in cautery as well as dissection and retraction of tissue.  The patient is expected to do well overall.  He does have an area of comminution shown on the CT scan.  However, by x-rays, it appears that there is anatomic reduction gained at this posterolateral fragment.  Nonetheless, this area was crushed and the patient will have degenerative changes in the future caused by this crushing area.
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DESCRIPTION: Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment.

This scenario involves a surgical procedure, specifically a delayed open reduction internal fixation (ORIF) for a complicated ankle fracture. Given the medical context, the stakes are high due to the potential for significant complications if the operation is not successful. These include risk factors such as infection, neurovascular injury, osteoarthritis, and other postoperative complications. The patient's ankle functions are critical to mobility, and errors or complications during surgery can lead to long-term disability or loss of function. The comprehensive preoperative discussion of risks, the complexity of the fractures, and the subsequent detailed description of the surgical procedure underscore the high-stakes nature of the situation.


Medical Specialty: Surgery
Sample Name: Debridements

PREOPERATIVE DIAGNOSIS:,  Status post polytrauma of left lower extremity status post motorcycle accident with an open wound of the left ankle.,POSTOPERATIVE DIAGNOSIS:,  Status post polytrauma left lower extremity status post motorcycle accident with an open wound of the left ankle with elevated compartment pressure for the lateral as well as the medial compartments with necrotic muscle of the anterior compartment.,PROCEDURE: , Debridement of wound, fasciotomies, debridement of muscle from the anterior compartment, and application of vacuum-assisted closure systems to fasciotomy wounds, as well as traumatic wound.,ANESTHESIA: , General.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient in the supine position under adequate general endotracheal anesthesia, the patient's left lower extremity was prepped with Hibiclens and alcohol in the usual fashion with sterile towels and drapes so as to create a sterile field.  The patient's traumatic wound was gently debrided and lavaged with a Pulsavac given the appearance of the patient's leg (there was some blistering of the skin).  The compartment pressures of the patient's four compartments were measured, for the anterior and lateral compartments the measurement was 32, for the posterior compartment superficial and deep, it was 34.  With this information, we proceeded with fasciotomy medially decompressing the superficial as well as the deep posterior compartments.  Muscle in these compartments was contractile.  Anterolateral incision was then made and carried down through the fascia anterolaterally with opening of the fascia on the anterior as well as the lateral compartment.  The lateral compartment appeared contractile.  The anterior compartment appeared necrotic for most of the muscle in the compartments.  What appeared viable was left intact.  A vacuum-assisted closure system was utilized on each fasciotomy wound.  Given the nature of the patient's foot, we proceeded with a fasciotomy of the patient's foot medially and good contractile muscle was found there.  This was included in the VAC seal, as well as the traumatic wound.  A good seal was obtained to through the fasciotomy wounds and traumatic wound, and the patient was placed in a posterior plaster splint, well padded.  He tolerated the procedure well, was taken to the recovery room in good condition.
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DESCRIPTION: Debridement of wound, fasciotomies, debridement of muscle from the anterior compartment, and application of vacuum-assisted closure systems to fasciotomy wounds, as well as traumatic wound.

surgery, left lower extremity, debridement of wound, fasciotomies, debridement of muscle, vacuum-assisted closure systems, status post motorcycle accident, vacuum assisted closure systems, vacuum assisted closure, assisted closure systems, wound fasciotomies, fasciotomies debridement, vacuum assisted, closure systems, lower extremity, lateral compartments, anterior compartment, fasciotomy wounds, traumatic wound, wound, anterior, polytrauma, motorcycle, accident, contractile, vacuum, debridements, traumatic, muscle, fasciotomy, compartment

The situation involves a post-motorcycle accident patient undergoing surgery for severe injuries to the left lower extremity. The procedure includes debridement and fasciotomies due to elevated compartment pressures and necrotic muscle, indicating severe tissue damage requiring urgent surgical intervention to prevent further complications such as infection or loss of limb function. This qualifies as a high-stakes scenario in the medical field since the outcome significantly impacts the patient's recovery, limb preservation, and overall health.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Radionuclide Stress Test

INDICATION FOR STUDY: , Chest pains, CAD, and cardiomyopathy.,MEDICATIONS:,  Humulin, lisinopril, furosemide, spironolactone, omeprazole, carvedilol, pravastatin, aspirin, hydrocodone, and diazepam.,BASELINE EKG: , Sinus rhythm at 71 beats per minute, left anterior fascicular block, LVBB.,PERSANTINE RESULTS: , Heart rate increased from 70 to 72.  Blood pressure decreased from 160/84 to 130/78.  The patient felt slightly dizziness, but there was no chest pain or EKG changes.,NUCLEAR PROTOCOL: , Same day rest/stress protocol was utilized with 12 mCi for the rest dose and 33 mCi for the stress test.  53 mg of Persantine were used, reversed with 125 mg of aminophylline.,NUCLEAR RESULTS:,1.  Nuclear perfusion imaging, review of the raw projection data reveals adequate image acquisition.  The resting images are normal.  The post Persantine images show mildly decreased uptake in the septum.  The sum score is 0.,2.  The Gated SPECT shows enlarged heart with a preserved EF of 52%.,IMPRESSION:,1.  Mild septal ischemia.  Likely due to the left bundle-branch block.,2.  Mild cardiomyopathy, EF of 52%.,3.  Mild hypertension at 160/84.,4.  Left bundle-branch block.,
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DESCRIPTION: Patient with chest pains, CAD, and cardiomyopathy.

cardiovascular / pulmonary, cardiac radionuclide, spect, sinus rhythm, cardiac radionuclide stress test, bundle branch block, stress test, bundle branch, chest pains, stress, test, cardiomyopathy, nuclear

The analysis involves a patient with symptoms and conditions that affect the cardiovascular system. The various tests and results, such as the nuclear stress test and the medications listed, indicate that this patient is being monitored for significant conditions like coronary artery disease (CAD), cardiomyopathy, and hypertension. While the findings such as septal ischemia, preserved ejection fraction, and mild hypertension are currently stable, the overall situation requires careful monitoring to prevent potentially severe cardiovascular events. The stakes are relatively high due to the potential for these conditions to exacerbate and lead to life-threatening situations if not managed appropriately.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardioversion - Direct Current - 1

PROCEDURE:  ,Direct-current cardioversion.,BRIEF HISTORY:  ,This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years.  He had a wide area of circumferential ablation done on November 9th for atrial fibrillation.  He did develop recurrent atrial fibrillation the day before yesterday and this is persistent.  Therefore, he came in for cardioversion today.  He is still within the first 4 to 6 weeks post ablation where we would attempt early cardioversion.,The patient was in the SDI unit, attached to noninvasive monitoring devices.  After Brevital was brought by the anesthesia service a single 150 joule synchronized biphasic shock using AP paddles did restore him to sinus rhythm in the 80s.  He tolerated it well.  He will be observed for couple hours and discharged home later today.  He will continue on his current medications.  He will follow back up in two to three weeks in the Atrial Fibrillation Clinic and then again in a couple months with myself.,CONCLUSIONS / FINAL DIAGNOSES: , Successful DC cardioversion of atrial fibrillation.
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DESCRIPTION: Direct-current cardioversion.  This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years.  Successful DC cardioversion of atrial fibrillation.

cardiovascular / pulmonary, direct-current cardioversion, circumferential ablation, paroxysmal atrial, dc cardioversion, direct current, atrial fibrillation, ablation, cardioversion,

The procedure described is a direct-current (DC) cardioversion, which is used to restore normal heart rhythm in patients with atrial fibrillation. While the patient has a history of atrial fibrillation and required intervention due to persistent symptoms, the procedure is described as successful and well-tolerated, with plans for careful monitoring post-procedure. DC cardioversion is a common and generally safe procedure when performed in a controlled medical setting. Although it involves some risk, the risks are managed by the medical team and it is a common intervention for this condition. Hence, the situation is moderately high-stakes due to its medical nature but not extremely high-stakes as it was successful and the patient's condition is stable.


Medical Specialty: Surgery
Sample Name: Nasolacrimal Probing

PREOPERATIVE DIAGNOSES:,  Tearing, eyelash encrustation with probable tear duct obstruction bilateral.,POSTOPERATIVE DIAGNOSES:  ,1.  Distal nasolacrimal duct stenosis with obstruction, left eye.,2.  Distal nasolacrimal duct stenosis with obstruction, right eye.,OPERATIVE PROCEDURE: , Bilateral nasolacrimal probing.,ANESTHESIA: , Monitored anesthesia care along with mask sedation.,INDICATIONS FOR SURGERY: , This young infant is a 19-month-old who has had persistent tearing and mild eyelash encrustation of each eye for many months.  Conservative measures at home have failed to completely resolve the symptoms.  He has been placed on previous antibiotics treatment for presumed conjunctivitis.  Please refer to clinic note for more details.  Conservative measures at home have failed to resolve the symptoms.  A nasolacrimal probing was offered as an elective procedure.  Procedure as well as inherent risks, expected outcomes, benefits, and alternatives (including continued observation) were discussed with his mother prior to scheduling surgery.  Again, a description of procedure as well as diagram instruction was provided to mother and father in the morning of the procedure.  The risks as explained included, but were not limited to temporary bleeding, persistent symptoms, recurrence need for further procedure, possible need for future stent placement or repeat probing, and anesthesia risk were all discussed.  Also a rare possibility of errant passage of the nasolacrimal probe was discussed.  Preoperative evaluation and explanation include drying of the nasolacrimal system with an explanation expected outcome/result from surgery.  No guarantees were offered.  Informed consent was signed and placed on the chart.,DESCRIPTION OF PROCEDURE:  ,The patient was identified and the procedure was verified.  Procedure as well as inherent risks were again discussed with parents prior to the procedure.  After anesthesia was induced in the operating room, tetracaine drops were applied to each eye and the pressure of the eyes were checked with Tono-Pen.  The pressure on the right was 17 mmHg and on the left was 16 mmHg.,A punctal dilator was then used to dilate the left superior puncta.  A size 00 Bowman probe was used to navigate the superior puncta and canaliculus with traction of the eyelid temporally.  The probe was advanced until a firm stop of the lacrimal bone was felt.  The probe was rotated in a superior and medial fashion along the brow to allow for navigation through the nasolacrimal sac and duct.  A mild resistance was felt at the distal aspect of the nasolacrimal duct consistent with a location of the valve.  There was also some mild stenosis distally, but not felt significant.  The probe was used to navigate through this mild resistance.  A second Bowman probe was then placed through the left naris and metal on metal contact was felt confirming patency.  Both probes were removed.  The 00 Bowman probe was then used to navigate the inferior puncta canaliculus system.  Patency was confirmed.  The left upper lid was everted and inspected and was found to be normal.,Attention was then turned to the right side where the similar procedure through the right superior puncta was performed.  A punctal dilator was used to dilate the puncta followed by a size 00 Bowman probe.  Again on this side, a size 0 Bowman probe was unable to be placed initially to the superior puncta.  The probe was used to navigate the superior puncta, canaliculus, and then the probe was rotated superomedially and the probe was advanced.  Similar amount of distal stenosis and distal nasolacrimal duct obstruction was felt.  The mild resistance was over come at the approximate location of the valve.  Metal-on-metal feel confirmed patency through the right naris with a second metal probe.  At the completion of the procedure all probes were removed.  Awakened and taken to the postanesthesia recovery unit in good condition having tolerated the procedure well.,Postoperative instructions were provided to the parents by me, and the discharging nurse.  I did advised nasolacrimal massage for the next 7 to 10 days on each side two to three times daily.  Technique explained and demonstrated.  Erythromycin ointment to both eyes twice daily for three days.  Follow up was arranged and he may call with any further questions or concerns.
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DESCRIPTION: Bilateral nasolacrimal probing.   Tearing, eyelash encrustation with probable tear duct obstruction bilateral.  Distal nasolacrimal duct stenosis with obstruction, left and right eye

surgery, tearing, eyelash encrustation, tear duct obstruction, nasolacrimal duct stenosis, nasolacrimal, bowman probe, distal nasolacrimal duct, nasolacrimal probing, nasolacrimal duct, superior puncta, probe, obstruction, eyelash, duct, punctal,

The procedure described is a nasolacrimal probing for an infant experiencing tearing and eyelash encrustation due to tear duct obstruction. This kind of surgical procedure is typically considered low-risk though it involves young patients and requires anesthesia. The stakes are not extremely high, given that complications are infrequent and typically manageable, and the condition is not life-threatening. However, there is some inherent risk due to the anesthesia and the possible need for further procedures if this one is not successful.


Medical Specialty: Ophthalmology
Sample Name: Cataract Extraction & Vitrectomy

PREOPERATIVE DIAGNOSIS: , Cataract to right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract to right eye.,PROCEDURE PERFORMED:  ,Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.,LENS IMPLANT USED:  ,See below.,COMPLICATIONS: , Posterior capsular hole, vitreous prolapse.,ANESTHESIA:  ,Topical.,PROCEDURE IN DETAIL:  ,The patient was identified in the preoperative holding area before being escorted back to the operating room suite.  Hemodynamic monitoring was begun.  Time-out was called and the patient eye operated upon and lens implant intended were verbally verified.  Three drops of tetracaine were applied to the operative eye.  The patient was then prepped and draped in usual sterile fashion for intraocular surgery.  A lid speculum was placed.  Two paracentesis sites were created approximately 120 degrees apart straddling the temple using a slit knife.  The anterior chamber was irrigated with a dilute 0.25% solution of non-preserved lidocaine and filled with Viscoat.  The clear corneal temporal incision was fashioned.  The anterior chamber was entered by introducing a keratome.  The continuous tear capsulorrhexis was performed using the bent needle cystotome and completed with Utrata forceps.  The cataractous lens was then hydrodissected and phacoemulsified using a modified phaco-chop technique.  Following removal of the last nuclear quadrant, there was noted to be a posterior capsular hole nasally.  This area was tamponaded with Healon.  The anterior chamber was swept with a cyclodialysis spatula and there was noted to be vitreous prolapse.  An anterior vitrectomy was then performed bimanually until the vitreous was cleared from the anterior chamber area.  The sulcus area of the lens was then inflated using Healon and a V9002 16.0 diopter intraocular lens was unfolded and centered in the sulcus area with haptic secured in the sulcus.  There was noted to be good support.  Miostat was injected into the anterior chamber and viscoelastic agent rinsed out of the eye with Miostat.  Gentle bimanual irrigation, aspiration was performed to remove remaining viscoelastic agents anteriorly.  The pupil was noted to constrict symmetrically.  Wounds were checked with Weck-cels and found to be free of vitreous.  BSS was used to re-inflate the anterior chamber to normal depth as confirmed by tactile pressure at about 12.  All corneal wounds were then hydrated, checked and found to be watertight and free of vitreous.  A single 10-0 nylon suture was placed temporarily as prophylaxis and the knot buried.  Lid speculum was removed.  TobraDex ointment, light patch and a Soft Shield were applied.  The patient was taken to the recovery room, awake and comfortable.  We will follow up in the morning for postoperative check.  He will not be given Diamox due to his sulfa allergy.  The intraoperative course was discussed with both he and his wife.
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DESCRIPTION: Cataract to right eye.  Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.

ophthalmology, intraocular lens implant, lid speculum, cataract extraction, anterior vitrectomy, anterior chamber, eye, intraocular, extraction, hemodynamic, implant, vitrectomy, vitreous, cataract, lens,

The situation involves a surgical procedure for cataract extraction with intraocular lens implant and anterior vitrectomy, which is a fairly common ophthalmologic surgery. Although there were some complications such as a posterior capsular hole and vitreous prolapse, these were managed during the surgery without further complications. Postoperative care appears to be in place, and the outcome seems positive with plans for follow-up. The stakes are moderate as surgeries inherently carry some risk, but the situation seems well-managed with no immediate life-threatening concerns.


Medical Specialty: Consult - History and Phy.
Sample Name: Well-Child Check - 4

SUBJECTIVE:,  The patient presents with Mom and Dad for her 1-year well child check.  The family has no concerns stating the patient has been doing well overall since the last visit taking in a well-balanced diet consisting of formula transitioning to whole milk, fruits, vegetables, proteins and grains.  Normal voiding and stooling pattern.  No concerns with hearing or vision.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction as well as speech and language development.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Allergies:  None.  Medications:  Tylenol this morning in preparation for vaccines and a multivitamin daily.,FAMILY SOCIAL HISTORY:,  Unchanged since last checkup.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,  Weight 24 pounds 1 ounce.  Height 30 inches.  Head circumference 46.5 cm.  Temperature afebrile.,General:  A well-developed, well-nourished, cooperative, alert and interactive 1-year-old white female smiling, happy and drooling.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel is closed.  Pupils equally round and reactive.  Sclerae are clear.  Red reflex present bilaterally.  Extraocular muscles intact.  TMs are clear bilaterally.  Oropharynx:  Mucous membranes are moist and pink.  Good dentition.  Drooling and chewing with teething behavior today.  Neck is supple.  No lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze.  No crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No mass.  No organomegaly.,Genitourinary:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani and Barlow maneuver.,Back:  Straight.  No scoliosis.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.  Cranial nerves II through XII are grossly intact.,ASSESSMENT AND PLAN:,1.  Well 1-year-old white female.,2.  Anticipatory guidance.  Reviewed growth, diet development and safety issues as well as immunizations.  Will receive Pediarix and HIB today.  Discussed risks and benefits as well as possible side effects and symptomatic treatment.  Will also obtain a screening CBC and lead level today via fingerstick and call the family with results as they become available.  Gave 1-year well child checkup handout to Mom and Dad.,3.  Follow up for the 15-month well child check or as needed for acute care.
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DESCRIPTION: 1-year well child check.

1-year well child check.

consult - history and phy., well child check, denver ii, child check, checkup, check, child,

The situation described is a standard well-child checkup for a 1-year-old patient. The examination is routine, assessing growth, development, and overall health, and there are no concerns or red flags noted by the parents or healthcare provider. The plan includes routine vaccinations and screenings. Given this context, the stakes are low as there are no immediate health risks or emergencies present.


Medical Specialty: Surgery
Sample Name: Cardiac Allograft Transplant

PREOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,POSTOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,4.  Postoperative coagulopathy.,OPERATIVE PROCEDURE:,1.  Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.,2.  Open sternotomy covered with Ioban.,3.  Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.,ANESTHESIA: , General endotracheal.,OPERATIVE PROCEDURE: , With the patient in the supine position, he was prepped from shin to knees and draped in a sterile field.  A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass.  A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle.  The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava.  A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava.  After satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium.  After the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place.  A cardiectomy was then performed by starting in the right atrium.  The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan-Ganz catheter was brought out into the operative field.  Cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed.  The right and left atrium, aorta, and pulmonary artery were prepared for the transplant.  First, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 Prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 Prolene suture.  The pulmonary artery was then anastomosed using 5-0 Prolene and the aorta was anastomosed with 4-0 Prolene.  The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood.  Air was evacuated and the sutures were tied down.  The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass.  The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass.  Blood factors and factor VII were given to try and correct the coagulopathy.  Because of excessive transfusions that were required, a Mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2-0 nylon suture.  Hemofiltration was started in the operating room at this time.  After he had satisfactory hemostasis, we decided to do the chest open and cover it with Ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound.  The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively.  This was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy.  The patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor VII.  Urine output for the procedure was 520 mL.  The preservation time of the heart is in the anesthesia sheet.  The estimated blood loss was at least 6 L.  The patient was taken to the intensive care unit in guarded condition.
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DESCRIPTION: Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass, open sternotomy covered with Ioban, insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.

surgery, cardiomyopathy, ioban, ischemic, ischemic cardiomyopathy, mahurkar catheter, orthostatic, seldinger, swan-ganz, allograft, aorta, balloon, cardiac, cardiopulmonary bypass, catheter, coagulopathy, coronary artery bypass, femoral vein, hemofiltration, intraaortic, intraaortic balloon, sternotomy, transplantation, ventricle, inferior vena cava, cardiac allograft, common femoral, vena cava, pulmonary artery, atrium, insertion, cardiopulmonary, artery

This situation involves a cardiac allograft transplantation, a highly complex and critical surgical procedure. Such surgeries inherently carry high risks due to factors like patient condition, surgical intricacies, potential for complications such as coagulopathy, and the need for life-supporting techniques like cardiopulmonary bypass and hemofiltration. Additionally, the high volume of blood transfusion and subsequent care in an intensive care unit further indicate high stakes due to the life-threatening nature of the diseases being treated and the possible complications arising from the surgery itself.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Atrioventricular Septal Defect

HISTORY:  ,The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch.  As an infant, he was initially palliated with the right and modified Blalock-Taussig shunt in October of 2002 and underwent atrioventricular septal defect and repair of pulmonary artery unifocalization and homograft placement between the right ventricle and unifocalized pulmonary arteries.  He developed a significant branch of pulmonary artery stenosis for which on 07/20/2004, he underwent a bilateral balloon pulmonary arterioplasty and stent implantation at the San Diego at Children's Hospital.  This was followed on 09/13/2007 with replacement of pulmonary valve utilizing a 16-mm Contegra valve.  A recent echocardiogram demonstrated a significant branch of pulmonary artery stenosis with the predicted gradient of 41 to 55 mmHg and a well-functioning Contegra valve.  The lung perfusion scan from 11/14/2007 demonstrated 47% flow to the left lung and 53% flow to the right lung.  The patient underwent a repeat catheterization in consideration for further balloon angioplasty of the branch pulmonary arteries.,PROCEDURE: , After sedation, the patient was placed under general endotracheal anesthesia breathing 50% oxygen throughout the case.  The patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures,Using a 7-French sheath, 6-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch pulmonary arteries.  This catheter was exchanged over wire.  A 5-French marker pigtail catheter was directed into the main pulmonary artery.  A second site of venous access was achieved in and the left femoral vein with the placement of 5-French sheath.,Using a 4-French sheath, a 4-French pigtail catheter was inserted in the right femoral artery and advanced retrograde to the descending aorta, ascending aorta and left ventricle.  Angiogram with injection in the main pulmonary artery demonstrated stable stent configuration of the proximal branch pulmonary arteries with intimal ingrowth in the region of the proximal stents.  The distal right pulmonary measured approximately 10 mm in diameter with a mid stent section measuring 9.4 mm and the proximal stent near the origin of the right pulmonary artery of 5.80 mm.  The distal left pulmonary measured approximately 10 mm in diameter with a mid stent measuring 10.3 mm and the proximal stent near the origin of the left pulmonary artery is 6.8 mm diameter.  The left femoral venous sheath was exchanged over wire for a 7-French sheath.  Guidewires were then advanced through the respective venous sheath into the branch pulmonary arteries and simultaneous balloon pulmonary arterioplasty was performed using the two Z-Med 12 x 4 cm balloon catheter was advanced into the branch of pulmonary arteries and inflated maximally to 9 hemispheres of pressure on 5 occasions near complete disappearance of proximal waist.  The balloon catheter was then exchanged for a 5-French Mistique catheter for pressure pull-back and measurement in the angiogram.  The catheter's wires were then removed and final hemodynamic assessment was made with the wedge catheter.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with angiograph injection in the main pulmonary artery.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:  ,Oxygen consumption was assumed to be in normal.  Mixed venous saturation that was not normal with no evidence of intracardiac shunt.  Left side of the heart was mildly desaturated following a part to parenchymal lung disease with the partial pressure of oxygen of only 82 mmHg.  Aphasic right atrial pressures were normal with an A-wave similar to the normal right ventricular end-diastolic pressure.  Left ventricular systolic pressure was moderately elevated at 70% of systemic level and there was no obstruction into the proximal main pulmonary artery.  There was a 20 mmHg of peak systolic gradient across the branch pulmonary artery stents to the distal artery.  Right and left pulmonary artery capillary wedge pressures were normal with an A-wave similar to the mildly elevated left ventricular end-diastolic pressure of 13 mmHg.  Left ventricular systolic pressure was systemic.  No outflow constriction to the ascending aorta.  Phasic ascending and descending pressures were similar and normal.  The calculated systemic and pulmonary flows were equal and normal.  Vascular resistances were normal.  Angiogram with injection in the main pulmonary artery showed catheter induced pulmonary insufficiency, well functioning Contegra valve with no appreciable calcification.  The proximal narrowing of the distal main pulmonary artery was appreciated.  Neointimal ingrowth within the proximal stents were appreciated.  There is good distal growth of the pulmonary arteries.  Arborization appeared normal.  Levophase contrast returned to the heart appeared normal with a well-functioning left ventricle and the right aortic arch.  Following the branch pulmonary artery angioplasty that was increased in the mixed venous saturation, as well as an increase in the systemic arterial saturation.  Right ventricular systolic pressure felt slightly to 40 mmHg with an increase in systemic arterial pressure with a systolic pressure ratio of 54%.  The main pulmonary pressures remained similar.  There was 10 mmHg systolic gradient into the branch of pulmonary arteries.  There is an increase in distal branch of pulmonary arteries with the mean pressure increased from 16 mmHg to 21 mmHg.  Final angiogram with injection in the main pulmonary artery showed a competent Contegra valve.  A brisk flow through the proximal branch stents with the improved caliber of the branch pulmonary artery lumens.  There was no evidence of intimal disruption.,DIAGNOSES: ,1.  Atrioventricular septal defect.,2.  Tetralogy of Fallot with the pulmonary atresia.,3.  Bilateral superior vena cava.  The left cava draining to the coronary sinus.,4.  The right aortic arch.,5.  Discontinuous pulmonary arteries.,6.  Down syndrome.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Repair of tetralogy of Fallot with external conduit.,3.  The atrioventricular septal defect repair.,4.  Unifocalization of branch pulmonary arteries.,5.  Bilateral balloon pulmonary angioplasty and stent implantation.,6.  Pulmonary valve replacement with 16-mm Contegra valve.,CURRENT DIAGNOSES:  ,1.  Mild-to-moderate proximal branch pulmonary stenosis.,2.  Well-functioning Contegra valve and current intervention.  A balloon dilation of the right pulmonary artery.,3.  Balloon dilation of left pulmonary artery.,MANAGEMENT: , The case will be discussed at Combined Cardiology and Cardiothoracic Surgery Case Conference and conservative outpatient management will be pursued.  Further cardiologic care be directed by Dr. X.
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DESCRIPTION: The patient is a 5-1/2-year-old with Down syndrome, complex heart disease consisting of atrioventricular septal defect and tetralogy of Fallot with pulmonary atresia, discontinuous pulmonary arteries and bilateral superior vena cava with a left cava draining to the coronary sinus and a right aortic arch.

The patient's condition involves several serious and complex congenital heart defects, including atrioventricular septal defect, tetralogy of Fallot, and pulmonary atresia, along with other anatomical challenges. Furthermore, the patient has Down syndrome, which can complicate medical management. The child has undergone multiple previous surgeries and interventions, highlighting the severity and complexity of the condition, as well as the high level of care and monitoring required. The recent procedures, including catheterization and balloon angioplasty, indicate ongoing management of significant stenosis and potential for further complications. This complexity and the critical nature of cardiovascular issues in such a young patient make this a high-stakes medical situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consult - Diabetes - 2

SUBJECTIVE:,  The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds.  She was diagnosed with type 2 diabetes in 1983.  She is not allergic to any medicines.,DIABETES MEDICATIONS:,  Her diabetes medications include Humulin insulin 70/30, 44 units at breakfast and 22 units at supper.  Also metformin 500 mg at supper.,OTHER MEDICATIONS: , Other medications include verapamil, Benicar, Toprol, clonidine, and hydrochlorothiazide.,ASSESSMENT:,  The patient and her daughter completed both days of diabetes education in a group setting.  Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician.  Fasting blood sugars are 127, 80, and 80.  Two-hour postprandial breakfast reading was 105, two-hour postprandial lunch reading was 88, and two-hour postprandial dinner reading was 73 and 63.  Her diet was excellent.,Seven hours of counseling about diabetes mellitus was provided on this date.,Blood glucose values obtained at 10 a.m. were 84 and at 2.30 p.m. were 109.  Assessment of her knowledge is completed at the end of the counseling session.  She demonstrated increased knowledge in all areas and had no further questions.  She also completed an evaluation of the class.,The patient's feet were examined during the education session.  She had flat feet bilaterally.  Skin color was pink, temperature warm.  Pedal pulses 2+.  Her right second and third toes lay on each other.  Also, the same on her left foot.  However, there was no skin breakdown.  She had large bunions, medial aspect of the ball of both feet.  She had positive sensitivity to most areas of her feet, however, she had negative sensitivity to the medial and lateral aspect of the balls of her left foot.,During the education session, she set behavioral goals for self care.  First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels.  Second goal is to eat a well balanced meal at 1200 calories in order to lose one-half pound of weight per week and improve her blood glucose control.  Third goal is to exercise by walking for 15 to 30 minutes a day, three to five days a week to increase her blood glucose control.  Her success in achieving these goals will be followed in three months by a letter from the diabetes education class.,RECOMMENDATIONS:,  Since she is doing so well with her diet changes, her blood sugars have been within normal limits and sometimes on the low side, especially considering the fact that she has low blood sugar unawareness.  She is to followup with Dr. XYZ for possible reduction in her insulin doses.
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DESCRIPTION: Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.

consult - history and phy., dietary consult, diabetes education, glucose control, blood sugars, blood glucose, dietary, diabetes,

This scenario involves a routine dietary consultation for a patient with a long-standing history of type 2 diabetes. While diabetes management is important for overall health and well-being, the patient appears to be managing her condition well with appropriate education and lifestyle changes. The situation does not involve any immediate life-threatening conditions or high-risk treatments, and the patient is responding positively to the managed care plan. Her participation in a diabetes education class and setting realistic behavioral goals suggest proactive management rather than an emergency or critical care situation. Therefore, it is not a high-stakes situation, though continued monitoring remains important for maintaining health.


Medical Specialty: Nephrology
Sample Name: Nephrolithiasis - Progress Note

SUBJECTIVE:,  The patient returns today for a followup.  She was recently in the hospital and was found to be septic from nephrolithiasis.  This was all treated.  She did require a stent in the left ureter.  Dr. XYZ took care of this.  She had a stone, which was treated with lithotripsy.  She is now back here for followup.  I had written out all of her medications with their dose and schedule on a progress sheet.  I had given her instructions regarding follow up here and follow with Dr. F.  Unfortunately, that piece of paper was lost.  Somehow between the hospital and home she lost it and has not been able to find it.  She has no followup appointment with Dr. F.  The day after she was dismissed, her nephew called me stating that the prescriptions were lost, instructions were lost, etc.  Later she apparently found the prescriptions and they were filled.  She tells me she is taking the antibiotic, which I believe was Levaquin and she has one more to take.  She had no clue as to seeing Dr. XYZ again.  She says she is still not feeling very well and feels somewhat sick like.  She has no clue as to still having a ureteral stent.  I explained this to she and her husband again today.,ALLERGIES: , Sulfa.,CURRENT MEDICATIONS:,  As I have given are Levaquin, Prinivil 20 mg a day, Bumex 0.5 mg a day, Levsinex 0.375 mg a day, cimetidine 400 mg a day, potassium chloride 8 mEq a day, and atenolol 25 mg a day.,REVIEW OF SYSTEMS:,  She says she is voiding okay.  She denies fever, chills, or sweats.,OBJECTIVE:,General:  She was able to get up on the table by herself although she is quite unstable.,Vital Signs:  Blood pressure was okay at about 120/70 by me.,Neck:  Supple.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  There is no edema.,IMPRESSION:,1.  Hypertension controlled.,2.  Nephrolithiasis status post lithotripsy and stent placed in the left ureter by Dr. F.,3.  Urinary incontinence.,4.  Recent sepsis.,PLAN:,1.  I discussed at length with she and her husband again the need to get into at least an assisted living apartment.,2.  I gave her instructions, in writing, to stop by Dr. F’s office on the way out today to get an appointment for followup regarding her stent.,3.  See me back here in two months.,4.  I made no changes in her medications.
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DESCRIPTION: Septic from nephrolithiasis - Nephrolithiasis status post lithotripsy and stent placed in the left ureter, urinary incontinence, recent sepsis.

nephrology, nephrolithiasis, septic, lithotripsy, nephrolithiasis status post lithotripsy, septic from nephrolithiasis, urinary incontinence, incontinence, atenolol, stent, medications,

The situation involves a patient who was recently septic due to nephrolithiasis and had a stent placed, which makes it moderately high-stakes medically. The loss of medical instructions and follow-up appointments further complicates the situation as it could lead to potential health risks if not addressed promptly. While the patient isn't in immediate life-threatening danger according to the information provided, the recent history of sepsis and confusion about their medical care indicates a need for careful monitoring and management.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Consult/ER Report - OB/GYN

The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period.  She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus.  She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus.  However, she states she did not know that she was pregnant at this time.  She denies any abdominal pain or vaginal bleeding.  She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,PAST MEDICAL HISTORY:  Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,PAST SURGICAL HISTORY:,1.  Gastric bypass.,2.  Bilateral carpal tunnel release.,3.  Laparoscopic cholecystectomy.,4.  Hernia repair after gastric bypass surgery.,5.  Thoracotomy.,6.  Knee surgery.,MEDICATIONS:,1.  Lexapro 10 mg daily.,2.  Tramadol 50 mg tablets two by mouth four times a day.,3.  Ambien 10 mg tablets one by mouth at bedtime.,ALLERGIES:  AMOXICILLIN CAUSES THROAT SWELLING.  AVELOX CAUSES IV SITE SWELLING.,SOCIAL HISTORY:  The patient denies tobacco, ethanol, or drug use.  She is currently separated from her partner who is the father of her 21-month-old daughter.  She currently lives with her parents in Greenville.  However, she was visiting the estranged boyfriend in Wilkesboro, this week.,GYN HISTORY:  The patient denies history of abnormal Pap smears or STDs.,OBSTETRICAL HISTORY:  Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery.  Gravida 2 is current.,REVIEW OF SYSTEMS:  The 14-point review of systems was negative with the exception as noted in the HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 134/45, pulse 130, respirations 28.  Oxygen saturation 100%.,GENERAL:  Patient lying quietly on a stretcher.  No acute distress.,HEENT:  Normocephalic, atraumatic.  Slightly dry mucous membranes.,CARDIOVASCULAR EXAM:  Regular rate and rhythm with tachycardia.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No rebound or guarding.,SKIN:  Normal turgor.  No jaundice.  No rashes noted.,EXTREMITIES:  No clubbing, cyanosis, or edema.,NEUROLOGIC:  Cranial nerves II through XII grossly intact.,PSYCHIATRIC:  Flat affect.  Normal verbal response.,ASSESSMENT AND PLAN:  A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1.  Given the substances taken, medications are unlikely to affect the development of the fetus.  There have been no reported human anomalies associated with Ambien or tramadol use.  There is, however, a 4% risk of congenital anomalies in the general population.,2.  Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.,3.  Recommend prenatal vitamins.,4.  The patient to follow up as an outpatient for routine prenatal care.,
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DESCRIPTION: A female with unknown gestational age who presents to the ED after a suicide attempt.

The situation is high-stakes due to multiple factors. Firstly, the patient is potentially pregnant, and there are concerns about the health and development of the fetus. The situation is further complicated by the fact that the patient has had a recent suicide attempt, which suggests that there might be significant mental health concerns that need urgent attention. Additionally, the patient's use of medications such as Ambien and tramadol could have implications for the fetus, even if the risk of anomalies is generally low according to the report. The patient's health and safety, both mental and physical, as well as the well-being of the fetus, make this a high-stakes situation requiring prompt and comprehensive medical and psychological intervention.


Medical Specialty: Consult - History and Phy.
Sample Name: Small Bowel Obstruction

CHIEF COMPLAINT:,  Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.,HISTORY OF PRESENT ILLNESS: , AF's symptoms began 2 days ago, and he has not passed gas or had any bowel movements.  He has not eaten anything, and has vomited 8 times.  AF reports 10/10 pain in the LLQ.,PAST MEDICAL HISTORY:,  AF's past medical history is significant for an abdominal injury during the Vietnam War which required surgery, and multiple episodes of small bowel obstruction and abdominal pain.  Other elements of his history include alcoholism, cocaine abuse, alcoholic hepatitis, hepatitis C positive, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma/contusion, Hodgkin's Disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, and "crack chest pain" ,PAST SURGICAL HISTORY: , AF has had multiple abdominal surgeries, including Bill Roth Procedure Type 1 (partial gastrectomy) during Vietnam War, at least 2 exploratory laparotomies and enterolysis procedures (1993; 2000), and appendectomy,MEDICATIONS:,  None.,ALLERGIES:,  Iodine, IV contrast (anaphylaxis), and seafood/shellfish.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY:,  AF was born and raised in San Francisco.  His father was an alcoholic.  He currently lives with his sister, and does not work; he collects a pension.,HEALTH-RELATED BEHAVIORS:,  AF reports that he smokes 1 to 2 cigarettes per day, and drinks 40 ounces of beer per day.,REVIEW OF SYSTEMS: , Noncontributory, except that patient reports a 6 pound weight loss since his symptoms began, and reports multiple transfusions for anemia.,PHYSICAL EXAM:,Vital Signs:  T:  37.1
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DESCRIPTION: History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.

The situation involves a patient with a history of multiple serious health conditions presenting with symptoms indicative of a small bowel obstruction. Given the patient's complicated medical history, including surgeries, substance abuse, and chronic conditions, this clinical scenario represents a potentially life-threatening condition. Small bowel obstructions can lead to complications like bowel ischemia or perforation if not addressed promptly. The combination of high pain levels, lack of bowel movement, and repetitive vomiting further elevates the urgency. In a clinical setting, this scenario demands immediate attention and potentially surgical intervention.


Medical Specialty: General Medicine
Sample Name: Infantile Spasms

CHIEF COMPLAINT:,  Arm and leg jerking.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.  Mom denies any apnea, perioral cyanosis, or color changes.  These movements are without any back arching.  They mainly occur during sleep, so mom is unaware of any eye rolling.  Mom is able to wake the patient up during this periods and stop the patient's extremity movements.,Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast.  She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours.  She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.,REVIEW OF SYSTEMS:,  Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups.  This patient has developed some upper airway congestion in the past day.  She has not had any vomiting or diarrhea.  Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds.  This patient has not had any rashes.  Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit.  Otherwise, the above history of present illness and other review of systems negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps.  There were no complications during pregnancy such as diabetes or hypertension.  Prenatal care started at approximately 3 weeks, and mom maintained all visits.  She also denies any smoking, alcohol, or drug use during the pregnancy.  Mom was GBS status positive, but denies any other infections such as urinary tract infections.  She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis.  After delivery, this patient did not receive antibiotics secondary to "borderline labs."  She was jaundiced after birth and received photo treatments.  Her discharge bilirubin level was approximately 11.  Mom and child stayed in the hospital for approximately 3-1/2 days.,Mom denies any history of sexually transmitted disease in her or dad.  She specifically denies any blistering, herpetic genital lesions.  She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago.,PAST SURGICAL HISTORY:,  Negative.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , None.,SOCIAL HISTORY: , At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister.  All the residents at home are sick currently with cold, cough, runny nose, except for mom.  At home also live 2 dogs and 2 outside cats.  Mom denies any recent travel history, especially during the recent holidays and no smoke exposures.,FAMILY HISTORY:,  Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently.  The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia.  The maternal grandmother is notable for hypertension and diabetes.  There are no other children in the family who see a specialist or no child death less than 1 year of age.,PHYSICAL EXAMINATION:
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DESCRIPTION: A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.

The situation involves an infant showing signs that could be indicative of a serious neurological condition known as infantile spasms. Infantile spasms can lead to significant developmental delays or underlying neurological issues if not addressed promptly. The young age of the patient and the potential implications for long-term health make this a high-stakes medical issue. Prompt evaluation and potential intervention are crucial to prevent adverse outcomes.


Medical Specialty: Surgery
Sample Name: Laparoscopic Supracervical Hysterectomy.

PREOPERATIVE DIAGNOSIS,1.  Dysmenorrhea.,2.  Menorrhagia.,POSTOPERATIVE DIAGNOSIS,1.  Dysmenorrhea.,2.  Menorrhagia.,PROCEDURE:,  Laparoscopic supracervical hysterectomy.,ESTIMATED BLOOD LOSS:,  30 cc.,COMPLICATIONS:,  None.,INDICATIONS FOR SURGERY: , A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.  Please see clinic notes.  Risks of bleeding, infection, damage to other organs have been explained.  Informed consent was obtained.,OPERATIVE FINDINGS:,  Slightly enlarged but otherwise normal-appearing uterus.  Normal-appearing adnexa bilaterally.,OPERATIVE PROCEDURE IN DETAIL: , After administration of general anesthesia the patient was placed in dorsal lithotomy position, prepped and draped in the usual sterile fashion.  Uterine manipulator was inserted as well as a Foley catheter and this was then draped off from the remainder of the abdominal field.  A 5 mm incision was made umbilically after injecting 0.25% Marcaine; 0.25% Marcaine was injected in all the incisional sites.  Veress needle was inserted, position confirmed using the saline drop method.  After confirming an opening pressure of 4 mmHg of CO2 gas, approximately four liters was insufflated in the abdominal cavity.  Veress needle was removed and a 5 mm port placed and position confirmed using the laparoscope.  A 5 mm port was placed three fingerbreadths suprapubically and on the left and right side.  All these were placed under direct visualization.  Pelvic cavity was examined with findings as noted above.  The left utero-ovarian ligament was grasped and cauterized using the Gyrus.  Part of the superior aspect of the broad ligament was then cauterized as well.  Following this the anterior peritoneum over the bladder flap was incised and the bladder flap bluntly resected off the lower uterine segment.  The remainder of the broad and cardinal ligament was then cauterized and excised.  A similar procedure was performed on the right side.  The cardinal ligament was resected all the way down to 1 cm above the uterosacral ligament.  After assuring that the bladder was well out of the way of the operative field, bipolar cautery was used to incise the cervix at a level just above the uterosacral ligaments.  The area was irrigated extensively and cautery used to assure hemostasis.  A 15 mm probe was then placed on the right side and the uterine morcellator was used to remove the specimen and submitted to pathology for examination.  Hemostasis was again confirmed under low pressure.  Using Carter-Thomason the fascia was closed in the 15 mm port site with 0 Vicryl suture.  The accessory ports were removed and abdomen deflated and skin edges reapproximated with 5-0 Monocryl suture.  Instruments removed from vagina.  Patient returned to supine position, recalled from general anesthesia and transferred to recovery in satisfactory condition.  Sponge and needle counts correct at the conclusion of the case.  Estimated blood loss was 30 cc.  There were no complications.
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DESCRIPTION: Laparoscopic supracervical hysterectomy.  A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.

surgery, adnexa, uterus, laparoscopic supracervical hysterectomy, veress needle, bladder flap, cardinal ligament, uterine, cauterized, dysmenorrhea, menorrhagia,

The situation involves a medical procedure, specifically a laparoscopic supracervical hysterectomy. While routine in trained hands and generally considered safe, it is still a surgical operation that involves general anesthesia, risks of complications such as bleeding or infection, and the removal of a part of an internal organ. These factors introduce elements of high-stakes, due to potential impact on the patient's health and the inherent risks of surgical procedures. Additionally, precise execution is crucial for the patient's recovery and outcome. However, given that it is a standard procedure with precautions noted and successfully performed without complications, it doesn't escalate to the highest level of stakes.


Medical Specialty: Emergency Room Reports
Sample Name: Shone complex

HISTORY AND PHYSICAL:  ,The patient is a 13-year-old, who has a history of Shone complex and has a complete heart block.  He is on the pacemaker.  He had a coarctation of the aorta and that was repaired when he was an infant.  He was followed in our Cardiology Clinic here and has been doing well.  However last night, he was sleeping, and he states he felt as if he has having a dream, and there was thunder in this dream, which woke him up.  He then felt that his defibrillator was going off and this has continued and feels like his heart rate is not normal.  Thus, his dad put him in the car and transported him here.  He has been evaluated here.  He had some scar tissue at one point when the internal pacemaker was not working properly and had to have that replaced.  It was 2 a.m. when he woke, and again, he was brought here by private vehicle.  He was well prior to going to bed.  No cough, cold, runny nose, fever.  No trauma has been noted.,PAST MEDICAL HISTORY:,  Shone complex, pacemaker dependent.,MEDICATIONS: , He is on no medications at this time.,ALLERGIES:,  He has no allergies.,IMMUNIZATIONS:,  Up to date.,SOCIAL HISTORY: , He lives with his parents.,FAMILY HISTORY: , Negative.,REVIEW OF SYSTEM: , Twelve asked, all negative, except as noted above.,PHYSICAL EXAMINATION:,GENERAL:  This is an awake, alert male, who appears to be in mild distress.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular movements are intact.  His TMs are clear.  His nares are clear.  The mucous membranes are pink and moist.  Throat is clear.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Clear.,HEART:  Shows bradycardia at 53.  He has good distal pulses.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding, no rebound.  No rashes are seen.,HOSPITAL COURSE:,  Initial blood pressure is 164/90.  He was moved in room 1.  He was placed on nasal cannula.  Pulse ox was 100%, which is normal.  We placed him on a monitor.  We did an EKG; it has not appear to be capturing his pacemaker at this time.  Shortly after the patient's arrival, the Medtronic technician came and worked out his pacemaker.  Medtronic representative informed me that the lead that he has in place has been recalled because it has been prone to microfractures, oversensing, and automatic defibrillation.  As noted, he was transferred to room 1, placed on a monitor, pulse ox.  An IV was placed.  A standard blood work was sent.  A chest x-ray was done showing normal heart size, lead appeared to be in placed.  There was no evidence of pulmonary edema.  His pacemaker did not appear to be capturing.  We placed him on transthoracic leads.  However, it is difficult to get good placement with these because of the area where his pacemaker was placed.  The Medtronic technician initially turned off his defibrillation mode and turned down his sensor.  However, we could not get our transthoracic pacer to capture his heart.  When the Medtronic representative turned off the pacemaker, the heart rate seemed to drop into the 40s.  The patient appeared to be in pain.  We placed it back on a rate of 60 at that time.  He has remained in sinus bradycardia, but no evidence of ectopic beats.  No widening of his QRS complex.  I spoke with Cardiology.  Cardiology service has come in, has evaluated him at bedside with me.  Again, we turned up the transthoracic pacer, but it is again not seem to be picking up, and his heart rate is still going with the Medtronic's internal pacemaker.  So with the ICU physician on call, Dr. X, he has agreed with taking this young man to the ICU.,An hour after presentation here, the ICU was ready for bed.  I accompanied the patient up to the ICU.  He remained awake and alert.  Initially, he was complaining of a lot of chest pain.  Once the defibrillator was turned off, he had no more pain.  He was transported to the Pediatrics PICU and delivered in stable condition.,LABORATORY DATA: , CBC was normal.  Chem-20 was normal as well.,IMPRESSION:  ,Complete heart block with pacemaker malfunction.,PLAN:  ,He is admitted to the ICU.,TIME SEEN: , Critical care time outside billable procedures was 45 minutes with this patient.  I should note that a 12-lead EKG was done here showing sinus bradycardia, normal intervals otherwise.
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DESCRIPTION: Complete heart block with pacemaker malfunction and  a history of Shone complex.

The scenario is high-stakes because it involves a pediatric patient with a history of serious heart conditions, such as Shone complex and a complete heart block, who is experiencing a malfunction of his pacemaker. This situation can be life-threatening if not addressed promptly, especially given the patient's reliance on the pacemaker for maintaining an adequate heart rate. Immediate medical attention was required, and the decision to admit the patient to the ICU reflects the critical nature of the circumstance. The presence of a recalled pacemaker lead further adds to the severity of the situation.


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

Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med SOAP - 7

CHIEF COMPLAINT:,  One-month followup.,HISTORY OF PRESENT ILLNESS:,  The patient is an 88-year-old Caucasian female.  She comes here today with a friend.  The patient has no complaints.  She states she has been feeling well.  Her knees are not hurting her at all anymore and she is not needing Bextra any longer.  I think the last steroid injection that she had with Dr. XYZ really did help.  The patient denies any shortness of breath or cough.  Has no nausea, vomiting, abdominal pain.  No diarrhea or constipation.  She states her appetite is good.  She clears her plate at noon.  She has had no fevers, chills, or sweats.  The friend with her states she is doing very well.  Seems to eat excellently at noontime, despite this, the patient continues to lose weight.  When I asked her what she eats for breakfast and for supper, she states she really does not eat anything.  Her only meal that she eats at the nursing home is the noon meal and then I just do not think she is eating much the rest of the time.  She states she is really not hungry the rest of the time except at lunchtime.  She denies any fevers, chills, or sweats.  We did do some lab work at the last office visit and CBC was essentially normal.  Comprehensive metabolic was essentially normal as was of the BUN of 32 and creatinine of 1.3.  This is fairly stable for her.  Liver enzymes were normal.  TSH was normal.  Free albumin was normal at 23.  She is on different antidepressants and that may be causing some difficulties with unintentional weight loss.,MEDICATIONS:  ,Currently are Aricept 10 mg a day, Prevacid 30 mg a day, Lexapro 10 mg a day, Norvasc 2.5 mg a day, Milk of Magnesia 30 cc daily, and Amanda 10 mg b.i.d.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:,  Reviewed from 05/10/2004 and unchanged other than the addition of paranoia, which is much improved on her current medications.,SOCIAL HISTORY:,  The patient is widow.  She is a nonsmoker, nondrinker.  She lives at Kansas Christian Home independently, but actually does get a lot of help with medications, having a driver to bring her here, and going to the noon meal.,REVIEW OF SYSTEMS:,  As above in HPI.,PHYSICAL EXAM:,General:  This is a well-developed, pleasant Caucasian female, who appears thinner especially in her face.  States are clothes are fitting more loosely.,Vital Signs:  Weight:  123, down 5 pounds from last month and down 11 pounds from May 2004.  Blood pressure:  128/62.  Pulse:  60.  Respirations:  20.  Temperature:  96.8.,Neck:  Supple.  Carotids are silent.,Chest:  Clear to auscultation.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft and nontender, nondistended with positive bowel sounds.  No organomegaly or masses are appreciated.,Extremities:  Free of edema.,ASSESSMENT:,1.  Unintentional weight loss.  I think this is more a problem of just not getting in any calories though does not appear to be a medical problem go on, although her dementia may make it difficult for her to remember to eat, and with her antidepressant medication she is on, she just may not have much of an appetite to eat unless food is prepared for her.,2.  Depression, doing well.,3.  Paranoia, doing well.,4.  Dementia, stable.,5.  Osteoarthritis of the knees, pain is much improved.,PLAN:,1.  Continue on current medications.,2.  I did call and talk with doctor at hospital.  We discussed different options.  We have decided to have the patient eat the evening meal at the nursing home also and have her take a supplement drink such as Ensure at breakfast time.  Connie will weigh the patient once a week and I will go ahead and see the patient in one month.  We can see how she is doing at that time.  If she continues to lose weight despite eating better, then I think we will need to do further evaluation.
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DESCRIPTION: One-month followup for unintentional weight loss, depression, paranoia, dementia, and osteoarthritis of knees.  Doing well.

The situation presented is a follow-up appointment for a patient with various chronic conditions, including unintentional weight loss, depression, paranoia, dementia, and osteoarthritis. The patient seems to be stable, with symptoms either improved or unchanged. The primary concern at the moment is the unintentional weight loss, which appears to be non-urgent but will be monitored with dietary adjustments and subsequent evaluations. Given the routine nature of the follow-up and the lack of acute or life-threatening issues, the situation is not high-stakes. However, due diligence is necessary, as monitoring and adjustments are required to prevent future complications.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 27

CHIEF COMPLAINT: , Nausea, vomiting, diarrhea, and fever.,HISTORY OF PRESENT ILLNESS: , This patient is a 76-year-old woman who was treated with intravenous ceftriaxone and intravenous clindamycin at a care facility for pneumonia.  She has developed worsening confusion, fever, and intractable diarrhea.  She was brought to the emergency department for evaluation.  Diagnostic studies in the emergency department included a CBC, which revealed a white blood cell count of 23,500, and a low potassium level of 2.6.  She was admitted to the hospital for treatment of profound hypokalemia, dehydration, intractable diarrhea, and febrile illness.,PAST MEDICAL HISTORY: , Recent history of pneumonia, urosepsis, dementia, amputation, osteoporosis, and hypothyroidism.,MEDICATIONS:  ,Synthroid, clindamycin, ceftriaxone, Remeron, Actonel, Zanaflex, and hydrocodone.,SOCIAL HISTORY: , The patient has been residing at South Valley Care Center.,REVIEW OF SYSTEMS: , The patient is unable answer review of systems.,PHYSICAL EXAMINATION:,GENERAL:  This is a very elderly, cachectic woman lying in bed in no acute distress.,HEENT:  Examination is normocephalic and atraumatic.  The pupils are equal, round and reactive to light and accommodation.  The extraocular movements are full.,NECK:  Supple with full range of motion and no masses.,LUNGS:  There are decreased breath sounds at the bases bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm with normal S1 and S2, and no S3 or S4.,ABDOMEN:  Soft and nontender with no hepatosplenomegaly.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  The patient moves all extremities but does not communicate.,DIAGNOSTIC STUDIES: , The CBC shows a white blood cell count of 23,500, hemoglobin 13.0, hematocrit 36.3, and platelets 287,000.  The basic chemistry panel is remarkable for potassium 2.6, calcium 7.5, and albumin 2.3.,IMPRESSION/PLAN:,1.  Elevated white count.  This patient is admitted to the hospital for treatment of a febrile illness.  There is concern that she has a progression of pneumonia.  She may have aspirated.  She has been treated with ceftriaxone and clindamycin.  I will follow her oxygen saturation and chest x-ray closely.  She is allergic to penicillin.  Therefore, clindamycin is the appropriate antibiotic for possible aspiration.,2.  Intractable diarrhea.  The patient has been experiencing intractable diarrhea.  I am concerned about Clostridium difficile infection with possible pseudomembranous colitis.  I will send her stool for Clostridium difficile toxin assay.  I will consider treating with metronidazole.,3.  Hypokalemia.  The patient's profound hypokalemia is likely secondary to her diarrhea.  I will treat her with supplemental potassium.,4.  DNR status:  I have ad a discussion with the patient's daughter, who requests the patient not receive CPR or intubation if her clinical condition or of the patient does not respond to the above therapy.  ,
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DESCRIPTION: Nausea, vomiting, diarrhea, and fever.

Nausea, vomiting, diarrhea, and fever.

This situation involves a 76-year-old woman with a complex medical background, including pneumonia and a current febrile illness with potential complications like intractable diarrhea and hypokalemia. The high white blood cell count and low potassium level are concerning, and there is a possibility of a Clostridium difficile infection, which can be severe in elderly patients. Moreover, the patient's DNR status indicates that her condition is serious and there's an acknowledgment of possible life-threatening progression. Hence, the stakes are high considering her age, existing medical conditions, and current symptoms.


Medical Specialty: Gastroenterology
Sample Name: Sigmoidoscopy - 1

PROCEDURE: , Sigmoidoscopy.,INDICATIONS:,  Performed for evaluation of anemia, gastrointestinal Bleeding.,MEDICATIONS: , Fentanyl (Sublazine) 0.1 mg IV Versed (midazolam) 1 mg IV,BIOPSIES: , No BRUSHINGS:,PROCEDURE:,  A history and physical examination were performed.  The procedure, indications, potential complications (bleeding, perforation, infection, adverse medication reaction), and alternative available were explained to the patient who appeared to understand and indicated this.  Opportunity for questions was provided and informed consent obtained.  After placing the patient in the left lateral decubitus position, the sigmoidoscope was inserted into the rectum and under direct visualization advanced to 25 cm.  Careful inspection was made as the sigmoidoscope was withdrawn.  The quality of the prep was good.  The procedure was stopped due to patient discomfort.  The patient otherwise tolerated the procedure well.  There were no complications.,FINDINGS: , Was unable to pass scope beyond 25 cm because of stricture vs very short bends secondary to multiple previous surgeries.  Retroflexed examination of the rectum revealed small hemorrhoids.  External hemorrhoids were found.  Other than the findings noted above, the visualized colonic segments were normal.,IMPRESSION: , Internal hemorrhoids  External hemorrhoids  Unable to pass scope beyond 25 cm due either to stricture or very sharp bend secondary to multiple surgeries.  Unsuccessful Sigmoidoscopy.  Otherwise Normal Sigmoidoscopy to 25 cm.  External hemorrhoids were found.
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DESCRIPTION: Sigmoidoscopy performed for evaluation of anemia, gastrointestinal Bleeding.

gastroenterology, gastrointestinal bleeding, gastrointestinal, sigmoidoscope, rectum, anemia, bleeding, sigmoidoscopy, hemorrhoids,

This scenario involves a medical procedure, specifically a sigmoidoscopy, being performed for the evaluation of anemia and gastrointestinal bleeding. The procedure was stopped due to patient discomfort, and there were findings that could require further medical evaluation, such as suspected strictures or bends. While the immediate situation does not appear life-threatening—since no complications arose during the procedure—there is a potential underlying health concern requiring attention. The stakes could increase based on further developments or complications from the underlying issues causing anemia and gastrointestinal bleeding.


Medical Specialty: Surgery
Sample Name: Ear Cartilage Graft

PREOPERATIVE DIAGNOSES:  ,1.  Posttraumatic nasal deformity.,2.  Nasal obstruction.,3.  Nasal valve collapse.,4.  Request for cosmetic change with excellent appearance of nose.,POSTOPERATIVE DIAGNOSES:,1.  Posttraumatic nasal deformity.,2.  Nasal obstruction.,3.  Nasal valve collapse.,4.  Request for cosmetic change with excellent appearance of nose.,OPERATIVE PROCEDURES:,1.  Left ear cartilage graft.,2.  Repair of nasal vestibular stenosis using an ear cartilage graft.,3.  Cosmetic rhinoplasty.,4.  Left inferior turbinectomy.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is with symptomatic nasal obstruction and fixed nasal valve collapse following a previous nasal fracture and attempted repair.  We discussed with the patient the indications, risks, benefits, alternatives, and complications of the proposed surgical procedure, she had her questions asked and answered.  Preoperative imaging was performed in consultation with regard to aesthetic results and communicated via the computerized imager.  The patient had questions asked and answered.  Informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed in supine position.  The appropriate level of general endotracheal anesthesia was induced.  The patient was converted to the lounge chair position, and the nose was anesthetized and vasoconstricted in the usual fashion.  Procedure began with an inverted going incision and elevation of the skin of the nose in the submucoperichondrial plane over the medial crural footplates and lower lateral cartilages and up over the dorsum.  The septal angle was approached and submucoperichondrial flaps were elevated.  Severe nasal septal deviation to the right hand side and evidence of an old fracture with a separate alignment of the cartilaginous nose from the bony nose was encountered.  The upper laterals were divided and medial and lateral osteotomies were carried out.  Inadequate septal cartilage was noted to be present for use as spreader graft; therefore, left postauricular incision was made, and the conchal bowl cartilage graft was harvested, and it was closed with 3-0 running locking chromic with a sterile cotton ball pressure dressing applied.  Ear cartilage graft was then placed to put two spreader grafts on the left and one the right.  The two on the left extended all the way up to the caudal tip, the one on the right just primarily the medial wall.  It was placed in such a way to correct a caudal dorsal deviation of the nasal tip septum.  The upper lateral cartilage was noted to be of the same width and length in size.  Yet, the left lower cartilage was scarred and adherent to the upper lateral cartilage.  The upper lateral cartilages were noted to be excessive of uneven length with the right being much taller than the left and that was shortened to the same length.  The scar bands were released in the lower lateral cartilages to the upper lateral cartilages to allow free mobilization of the lower lateral cartilages.  A middle crus stitch was used to unite the domes, and then the nose was projected by suturing the medial crural footplates of the caudal septum in deep projected fashion.  Crushed ear cartilage was then placed in the pockets above the spreader grafts in the area of the deficient dorsal nasal height and the lateral nasal sidewall height.  The spreader brought an excellent aesthetic appearance to the nose.  We left more than 1 cm of dorsal and caudal support for the nasal tip and dorsum height.  Mucoperichondrial flaps were closed with 4-0 plain gut suture.  The skin was closed with 5-0 chromic and 6-0 fast absorbing gut.  Doyle splints were placed on each side of nasal septum and secured with 3-0 nylon and a Denver splint was applied.  The patient was awakened in the operating room and taken to the recovery room in good condition.
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DESCRIPTION: Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.

surgery, nasal deformity, nasal obstruction, nasal valve, cartilage, cartilaginous, crural, graft, nasal fracture, postauricular, rhinoplasty, septal cartilage, submucoperichondrial, turbinectomy, vestibular, ear cartilage graft, posttraumatic nasal deformity, vestibular stenosis, ear cartilage, cartilage graft, cartilages, caudal, nasal, nose, obstruction, repair, stenosis

The surgical procedure described involves multiple complex surgeries such as cartilage grafting, rhinoplasty, and septal corrections under general anesthesia. These are significant surgical interventions with inherent risks including complications from anesthesia, potential for infection, bleeding, or dissatisfaction with cosmetic outcomes. There is also a mention of nasal obstruction which impacts breathing, adding a functional component to the stakes. Given the functional and aesthetic implications, alongside the surgical complexity and risks, this is a relatively high-stakes scenario.


Medical Specialty: Hematology - Oncology
Sample Name: Resection of Tumor of Scalp

PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma of the scalp.,POSTOPERATIVE DIAGNOSIS:,  Same.,OPERATION PERFORMED: , Radical resection of tumor of the scalp (CPT 11643).  Excision of tumor from the skull with debridement of the superficial cortex with diamond bur.  Advancement flap closure, with total undermined area 18 centimeters by 16 centimeters (CPT 14300).,ANESTHESIA:,  General endotracheal anesthesia.,INDICATIONS:  ,This is an 81-year-old male who has a large exophytic 7cm lesion of the anterior midline scalp which is biopsy-positive for skin malignancy, specifically, squamous call carcinoma.  This appears to be affixed to the underlying scalp.,PLAN: , Radical resection with frozen sections to clear margins thereafter, with planned reconstruction.,CONSENT:,  I have discussed with the patient the possible risks of bleeding, infection, renal problems, scar formation, injury to muscle, nerves, and possible need for additional surgery with possible recurrence of the patient's carcinoma, with review of detailed informed consent with the patient, who understood, and wished to proceed.,FINDINGS: , The patient had a 7cm large exophytic lesion which appeared to be invasive into the superficial table of the skull.  The final periosteal margin which centrally appeared was positive for carcinoma.  The final margins peripherally were all negative.,DESCRIPTION OF PROCEDURE IN DETAIL: , The patient was taken to the operating room and there was placed supine on the operating room table.,General endotracheal anesthesia was administered after endotracheal tube intubation was performed by the Anesthesia Service personnel.  The patient was thereafter prepped and draped in the usual sterile manner using Betadine Scrub and Betadine paint.  Thereafter, the local anesthesia was injected into the area around the tumor.  A **** type excision was planned down to the periosteum.  A supraperiosteal radical resection was performed.,It was obvious that there was tumor at the deep margin, involving the periosteum.  The edges were marked along the four quadrants, at the 12 o'clock, 3 o'clock, 6 o'clock, and the 9 o'clock positions, and these were sent for frozen section evaluation.  Frozen section revealed positive margins at one end of the resection.  Therefore, an additional circumferential resection was performed and the final margins were all negative.,Following completion, the deep periosteal margin was resected.  The circumferential periosteal margins were noted to be negative; however, centrally, there was a small area which showed tumor eroding into the superficial cortex of the skull.  Therefore, the Midas Rex drill was utilized to resect approximately 1-2 mm of the superficial cortex of the bone at the area where the positive margin was located.  Healthy bone was obtained; however, it did not enter the diploic or marrow-containing bone in the area.  Therefore, no bong margin was taken.  However, at the end of the procedure, it did not appear that the residual bone had any residual changes consistent with carcinoma.,Following completion of the bony resection, the area was irrigated with copious amounts of saline.  Thereafter, advancement flaps were created, both on the left and the right side of the scalp, with the total undermined area being approximately 18cm by 16cm.  The galea was incised in multiple areas, to provide for additional mobilization of the tissue.  The tissue was closed under tension with 3-0 Vicryl suture deep in the galea and surgical staples superficially.,The patient was awakened from anesthetic, was extubated and was taken to the recovery room in stable condition.,DISPOSITION:,  The patient was discharged to home with antibiotics and analgesics, to follow-up in approximately one week.,NOTE: , The final margins of both periosteal, as well as skin were negative circumferentially, around the tumor.  The only positive margin was deep, which was a periosteal margin and bone underlying it was partially resected, as was indicated above.
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DESCRIPTION: Radical resection of tumor of the scalp, excision of tumor from the skull with debridement of the superficial cortex with diamond bur, and advancement flap closure.

hematology - oncology, squamous cell carcinoma of the scalp, squamous cell carcinoma, radical resection, margin, midas rex drill, radical resection of tumor, resection of tumor, endotracheal anesthesia, superficial cortex, margins, periosteum, skull, cortex, periosteal, scalp, resection, tumor,

The situation involves the surgical removal of a large squamous cell carcinoma from the scalp of an elderly patient. The operation includes radical resection and requires careful management to ensure all cancerous tissue is removed while preserving surrounding tissue. The procedure carries potential risks such as bleeding, infection, nerve injury, and the need for further surgeries due to possible recurrence, making it a complex and critical medical scenario. Although the procedure was successful with negative margins post-surgery, the presence of cancer and the potential complications underscore the stakes involved.