Medical Specialty: Orthopedic
Sample Name: Pathology - Sesamoid Bone

GROSS DESCRIPTION: , Specimen labeled "sesamoid bone left foot" is received in formalin and consists of three irregular fragments of grey-brown, hard, bony tissue admixed with multiple fragments of brown-tan, rubbery, fibrocollagenous, soft tissue altogether measuring 3.1 x 1.5 x 0.9 cm.  The specimen is entirely submitted, after decalcification.,DIAGNOSIS:,  Acute Osteomyelitis, with foci of marrow fibrosis.,Focal acute and chronic inflammation of fascia and soft tissue.  Arteriosclerosis, severely occlusive.
---
DESCRIPTION: Specimen labeled "sesamoid bone left foot".

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

The scenario involves a pathological diagnosis of acute osteomyelitis and other conditions like inflammation and arteriosclerosis related to a sesamoid bone. Osteomyelitis is a serious condition that can lead to severe complications if not treated adequately and in a timely manner. It requires medical attention to prevent further deterioration of the patient's health, indicating a moderately high-stakes situation. Additionally, the presence of severely occlusive arteriosclerosis suggests a compromised blood supply, increasing the complexity and severity of the case.


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

Medical Specialty: Orthopedic
Sample Name: Patellar Tendon & Retinaculum Repair

PREOPERATIVE DIAGNOSIS:  , Patellar tendon retinaculum ruptures, right knee.,POSTOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,PROCEDURE PERFORMED: , Patellar tendon and medial and lateral retinaculum repair, right knee.,SPECIFICATIONS:  ,Intraoperative procedure done at Inpatient Operative Suite, room #2 of ABCD Hospital.  This was done under subarachnoid block anesthetic in supine position.,HISTORY AND GROSS FINDINGS: , The patient is a 45-year-old African-American male who suffered acute rupture of his patellar tendon diagnosed both by exam as well as x-ray the evening before surgical intervention.  He did this while playing basketball.,He had a massive deficit at the inferior pole of his patella on exam.  Once opened, he had complete rupture of this patellar tendon as well as a complete rupture of his medial lateral retinaculum.  Minimal cartilaginous pieces were at the patellar tendon.  He had grade II changes to his femoral sulcus as well as grade I-II changes to the undersurface of the patella.,OPERATIVE PROCEDURE: , The patient was laid supine on the operative table receiving a subarachnoid block anesthetic by Anesthesia Department.  A thigh high tourniquet was placed.  He is prepped and draped in the usual sterile manner.  Limb was elevated, exsanguinated and tourniquet placed at 325 mmHg for approximately 30 to 40 minutes.  Straight incision is carried down through skin and subcutaneous tissue anteriorly.  Hemostasis was controlled via electrocoagulation.  Patellar tendon was isolated along with the patella itself.,A 6 mm Dacron tape x2 was placed with a modified Kessler tendon stitch with a single limb both medially and laterally and a central limb with subsequent shared tape.  The inferior pole was freshened up.  Drill bit was utilized to make holes x3 longitudinally across the patella and the limbs strutted up through the patella with a suture passer.  This was tied over the bony bridge superiorly.  There was excellent reduction of the tendon to the patella.  Interrupted running #1-Vicryl suture was utilized for over silk.  A running #2-0 Vicryl for synovial closure medial and laterally as well as #1-Vicryl medial and lateral retinaculum.  There was excellent repair.  Copious irrigation was carried out.  Tourniquet was dropped and hemostasis controlled via electrocoagulation.  Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed through the skin.  Adaptic, 4 x 4s, ABDs, and sterile Webril were placed for compression dressing.  Digits were warm and no brawny pulses present at the end of the case.  The patient's leg was placed in a Don-Joy brace 0 to 20 degrees of flexion.  He will leave this until seen in the office.,Expected surgical prognosis on this patient is fair.
---
DESCRIPTION: Patellar tendon and medial and lateral retinaculum repair, right knee.   Patellar tendon retinaculum ruptures, right knee.

orthopedic, subarachnoid, patellar tendon retinaculum, tendon, patellar, tourniquet, knee, ruptures, retinaculum

The surgical case presented involves repairing a ruptured patellar tendon and retinaculum in a 45-year-old patient. While orthopedic surgeries can carry risks, this procedure is fairly routine in addressing tendon ruptures. The potential high-stakes factors include ensuring proper surgical repair to restore knee function and prevent complications. However, it is not a life-threatening emergency, and the surgical prognosis is described as 'fair,' indicating moderate expectations for recovery. Overall, while important for the patient's mobility and quality of life, it is not at the highest level of urgency or stakes seen in medical procedures.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Orthopedic
Sample Name: Osteotomy & Bunionectomy - 1

PREOPERATIVE DIAGNOSES:,1.  Plantar flex third metatarsal, right foot.,2.  Talus bunion, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Plantar flex third metatarsal, right foot.,2.  Talus bunion, right foot.,PROCEDURE PERFORMED:,1.  Third metatarsal osteotomy, right foot.,2.  Talus bunionectomy, right foot.,3.  Application of short-leg cast, right foot.,ANESTHESIA: , TIVA/local.,HISTORY:  ,This 31-year-old female presents to ABCD Preoperative Holding Area after keeping herself n.p.o., since mid night for surgery on her painful right third plantar flex metatarsal.  In addition, she complains of a painful right talus bunion to the right foot.  She has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief.  At this time she desires to attempt a surgical correction.  The risks versus benefits of the procedure have been explained to the patient by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL:  ,After IV was established by the Department Of Anesthesia, the patient was taken to the operating room via cart.  She was placed on the operating table in supine position and a safety strap was placed across her waist for retraction.  Next, copious amounts of Webril were applied around the right ankle and a pneumatic ankle tourniquet was applied.,Next, after adequate IV sedation was administered by the Department Of Anesthesia, a total of 10 cc mixture of 4.5 cc of 1% lidocaine/4.5 cc of 0.5% Marcaine/1 cc of Kenalog was injected into the right foot in an infiltrative type block.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  Next, the foot was lowered in the operative field and attention was directed to the dorsal third metatarsal area.  There was a plantar hyperkeratotic lesion and a plantar flex palpable third metatarsal head.  A previous cicatrix was noted with slight hypertrophic scarring.  Using a #10 blade, a lazy S-type incision was created over the dorsal aspect of the third metatarsal, approximately 3.5 cm in length.  Two semi-elliptical converging incisions were made over the hypertrophic scar and it was removed and passed off as a specimen.  Next, the #15 blade was used to deepen the incision down to the subcutaneous tissue.  Any small traversing veins were ligated with electrocautery.  Next, a combination of blunt and sharp dissection were used to undermine the long extensor tendon, which was tacked down with a moderate amount of fibrosis and fibrotic scar tissue.  Next, the extensor tendon was retracted laterally and the deep fascia over the metatarsals was identified.  A linear incision down to bone was made with a #15 blade to the capsuloperiosteal tissues.  Next, the capsuloperiosteal tissues were elevated using a sharp dissection with a #15 blade, off of the third metatarsal.  McGlamry elevator was carefully inserted around the head of the metatarsal and freed and all the plantar adhesions were freed.  A moderate amount of plantar adhesions were encountered.  The third toe was plantar flex and the third metatarsal was delivered into the wound.  Next, a V-shaped osteotomy with an apex distally was created using a sagittal saw.  The metatarsal head was allowed to float.  The wound was flushed with copious amounts of sterile saline.  #3-0 Vicryl was used to close the capsuloperiosteal tissues, which kept the metatarsal head contained.  Next, #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted suture technique.  Next, #4-0 nylon was used to close the skin in a simple interrupted technique.,Attention was directed to the right fifth metatarsal.  There was a large palpable hypertrophic prominence, which is the area of maximal pain, which the patient complained of preoperatively.  A #10 blade was used to make a 3 cm incision through the skin.  Next, a #15 blade was used to deepen the incision through the subcutaneous tissue.  Next, the medial and lateral aspects were undermined.  The abductor tendon was identified and retracted.  A capsuloperiosteal incision was made with a #15 blade in a linear fashion down to the bone.  The capsuloperiosteal tissues were elevated off the bone with a Freer elevator and a #15 blade.,Next, the sagittal saw was used to resect the large hypertrophic dorsal exostosis.  A reciprocating rasp was used to smooth all bony prominences.  The wound was flushed with copious amount of sterile saline.  #3-0 Vicryl was used to close the capsuloperiosteal tissues.  #4-0 Vicryl was used to close subcutaneous layer with a simple interrupted suture.  Next, #4-0 nylon was used to close the skin in a simple interrupted technique.  Next, attention was directed to the plantar aspect of the third metatarsal where a bursal sac was felt to be palpated under the plantar flex third metatarsal head.  A #15 blade was used to make a small linear incision under the third metatarsal head.  The incision was deepened through the dermal layer and curved hemostats and Metzenbaum scissors were used to undermine the skin from the underlying bursa.  The wound was flushed and two simple interrupted sutures with #4-0 nylon were applied.,Standard postoperative dressing was applied consisting of Xeroform, 4x4s, Kerlix, Kling, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,A sterile stockinet was placed on the toes just below the knee.  Copious amounts of Webril were placed on all bony prominences.  3 inch and 4 inch fiberglass cast tape was used to create a below the knee well-padded, well-moulded cast.  One was able to insert two fingers to the distal and proximal aspects of the _cast.  The capillary refill time to the digits was less than three seconds after cast application.  The patient tolerated the above anesthesia and procedures without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She was given standard postoperative instructions to rest, ice and elevate her right foot.  She was counseled on smoking cessation.  She was given Vicoprofen #30 1 p.o. q.4-6h p.r.n., pain.  She was given Keflex #30 1 p.o. t.i.d.  She is to follow up with Dr. X on Monday.  She is to be full weightbearing with a cast boot.  She was given emergency contact numbers to call us if problem arises.
---
DESCRIPTION: Plantar flex third metatarsal and talus bunion, right foot.  Third metatarsal osteotomy, talus bunionectomy, and application of short-leg cast, right foot.  Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief.  At this time she desires to attempt a surgical correction.

orthopedic, plantar flex, talus bunion, talus bunionectomy, metatarsal osteotomy, osteotomy, short-leg cast, hypertrophic scarring, subcutaneous tissue, sharp dissection, linear incision, foot talus, pneumatic ankle, capsuloperiosteal tissues, plantar, foot, metatarsal, capsuloperiosteal, bunionectomy

The described context involves a surgical intervention to correct foot deformities that have caused the patient significant discomfort and have not responded to conservative treatment. While all surgeries inherently carry some level of risk, the procedures in question—osteotomy and bunionectomy—are relatively routine within orthopedic surgery. The surgical process, anesthesia, and postoperative care are detailed to ensure patient safety. The scenario lacks immediate life-threatening elements, although it is important to provide appropriate care and monitor for complications post-surgery. The stakes are therefore moderate, given the nature of surgical intervention and its implications for the patient's mobility and quality of life.


Medical Specialty: Orthopedic
Sample Name: Orthopedic Consult - 3

CHIEF COMPLAINT:,  Back pain and right leg pain.  The patient has a three-year history of small cell lung cancer with metastases.,HISTORY OF PRESENT ILLNESS:,  The patient is on my schedule today to explore treatment of the above complaints.  She has a two-year history of small cell lung cancer, which she says has spread to metastasis in both femurs, her lower lumbar spine, and her pelvis.  She states she has had numerous chemotherapy and radiation treatments and told me that she has lost count.  She says she has just finished a series of 10 radiation treatments for pain relief.  She states she continues to have significant pain symptoms.  Most of her pain seems to be in her low back on the right side, radiating down the back of her right leg to her knee.  She has also some numbness in the bottom of her left foot, and some sharp pain in the left foot at times.  She complains of some diffuse, mid back pain.  She describes the pain as sharp, dull, and aching in nature.  She rates her back pain as 10, her right leg pain as 10, with 0 being no pain and 10 being the worst possible pain.  She states that it seems to be worse while sitting in the car with prolonged sitting, standing, or walking.  She is on significant doses of narcotics.  She has had multiple CT scans looking for metastasis.,PAST MEDICAL HISTORY:,  Significant for cancer as above.  She also has a depression.,PAST SURGICAL HISTORY:,  Significant for a chest port placement.,CURRENT MEDICATIONS:,  Consist of Duragesic patch 250 mcg total, Celebrex 200 mg once daily, iron 240 mg twice daily, Paxil 20 mg daily, and Percocet.  She does not know of what strength up to eight daily.  She also is on warfarin 1 mg daily, which she states is just to keep her chest port patent.  She is on Neurontin 300 mg three times daily.,HABITS:,  She smokes one pack a day for last 30 years.  She drinks beer approximately twice daily.  She denies use of recreational drugs.,SOCIAL HISTORY:,  She is married.  She lives with her spouse.,FAMILY HISTORY: , Significant for two brothers and father who have cancer.,REVIEW OF SYSTEMS:,  Significant mainly for her pain complaints.  For other review of systems the patient seems stable.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant somewhat emaciated Caucasian female.,Vital Signs:  Height is 5 feet 2 inches.  Weight is 130 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Chest:  Clear to auscultation.,Heart:  Regular rate and rhythm.,Abdomen:  Soft, regular bowel sounds.,Musculoskeletal:  Examination shows functional range of joint movements.  No focal muscle weakness.  She is deconditioned.,Neurologic:  She is alert and oriented with appropriate mood and affect.  The patient has normal tone and coordination.  Reflexes are 2+ in both knees and absent at both ankles.  Sensations are decreased distally in the left foot, otherwise intact to pinprick.,Spine:  Examination of her lumbar spine shows normal lumbar lordosis with fairly functional range of movement.  The patient had significant tenderness at her lower lumbar facet and sacroiliac joints, which seems to reproduce a lot of her low back and right leg complaints.,FUNCTIONAL EXAMINATION: , Gait has a normal stance and swing phase with no antalgic component to it.,INVESTIGATION: , She has had again multiple scans including a whole body bone scan, which showed abnormal uptake involving the femurs bilaterally.  She has had increased uptake in the sacroiliac joint regions bilaterally.  CT of the chest showed no evidence of recurrent metastatic disease.  CT of the abdomen showed no evidence of metastatic disease.  MRI of the lower hip joints showed heterogenous bone marrow signal in both proximal femurs.  CT of the pelvis showed a trabecular pattern with healed metastases.  CT of the orbits showed small amount of fluid in the mastoid air cells on the right, otherwise normal CT scan.  MR of the brain showed no acute intracranial abnormalities and no significant interval changes.,IMPRESSION:,1.  Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs.,2.  Symptomatic facet and sacroiliac joint syndrome on the right.,3.  Chronic pain syndrome.,RECOMMENDATIONS:,  Dr. XYZ and I discussed with the patient her pathology.  Dr. XYZ explained her although she does have lung cancer metastasis, she seems to be symptomatic with primarily pain at her lower lumbar facet and sacroiliac joints on the right.  Secondary to the patient's significant pain complaints today, Dr. XYZ will plan on injecting her right sacroiliac and facet joints under fluoroscopy today.  I explained the rationale for the procedure, possible complications, and she voiced understanding and wished to proceed.  She understands that she is on warfarin therapy and that we generally do not perform injections while they are on this.  We have asked for stat protime today.  She is on a very small dose, she states she has had previous biopsies while on this before, and did not have any complications.  She is on significant dose of narcotics already, however, she continues to have pain symptoms.  Dr. XYZ advised that if she continues to have pain, even after this injection, she could put on an extra 50 mcg patch and take a couple of extra Percocet if needed.  I will plan on evaluating her in the Clinic on Tuesday.  I have also asked that she stop her Paxil, and we plan on starting her on Cymbalta instead.  She voiced understanding and is in agreement with this plan.  I have also asked her to get an x-ray of the lumbar spine for further evaluation.  Physical exam, findings, history of present illness, and recommendations were performed with and in agreement with Dr. G's findings.  Peripheral neuropathy of her left foot is most likely secondary to her chemo and radiation treatments.
---
DESCRIPTION: Back pain and right leg pain.  Small cell lung cancer with metastasis at the lower lumbar spine, pelvis, and both femurs

This situation involves a patient with a history of small cell lung cancer with metastases, experiencing significant pain and undergoing complex treatment plans involving narcotics and potential joint injections. The patient is dealing with high levels of pain despite significant management efforts, and there's the presence of multiple metastases, making the patient's condition quite serious. The decision to proceed with invasive procedures like joint injections and the use of heavy narcotics, along with dealing with potential complications from medication interactions (like warfarin), creates a high-stakes medical scenario. The patient's quality of life is profoundly affected by pain, and the medical decisions being made may significantly impact their well-being.


Medical Specialty: Orthopedic
Sample Name: Orthopedic Consult - 1

SUBJECTIVE:,  The patient comes back to see me today.  She is a pleasant 73-year-old Caucasian female who had seen Dr. XYZ with low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.  Dr. XYZ had performed right and left facet and sacroiliac joint injections, subsequent right L3 to S1 medial branch blocks and radiofrequency ablation on the right from L3 to S1.  She was subsequently seen with some mid back pain and she had right T8-T9 and T9-T10 facet injections on 10/28/2004.  She was last seen on 04/08/2005 with recurrent pain in her low back on the right.  Dr. XYZ repeated her radiofrequency ablation on the right side from L3-S1 on 05/04/2005.,The patient comes back to see me today.  She states that the radiofrequency ablation has helped her significantly there, but she still has one spot in her low back that seems to be hurting her on the right, and seems to be pointing to her right sacroiliac joint.  She is also complaining of pain in both knees.  She says that 20 years ago she had a cortisone shot in her knees, which helped her significantly.  She has not had any x-rays for quite some time.  She is taking some Lortab 7.5 mg tablets, up to four daily, which help her with her pain symptoms.  She is also taking Celebrex through Dr. S’ office.,PAST MEDICAL HISTORY:,  Essentially unchanged from my visit of 04/08/2005.,PHYSICAL EXAMINATION:,General:  Reveals a pleasant Caucasian female.,Vital Signs:  Height is 5 feet 5 inches.  Weight is 183 pounds.  She is afebrile.,HEENT:  Benign.,Neck:  Shows functional range of movements with a negative Spurling's.,Musculoskeletal:  Examination shows degenerative joint disease of both knees, with medial and lateral joint line tenderness, with tenderness at both pes anserine bursa.  Straight leg raises are negative bilaterally.  Posterior tibials are palpable bilaterally.,Skin and Lymphatics:  Examination of the skin does not reveal any additional scars, rashes, cafe au lait spots or ulcers.  No significant lymphadenopathy noted.,Spine:  Examination shows decreased lumbar lordosis with tenderness that seems to be in her right sacroiliac joint.  She has no other major tenderness.  Spinal movements are limited but functional.,Neurological:  She is alert and oriented with appropriate mood and affect.  She has normal tone and coordination.  Reflexes are 2+ and symmetrical.  Sensation is intact to pinprick.,FUNCTIONAL EXAMINATION:,  Gait has a normal stance and swing phase with no antalgic component to it.,IMPRESSION:,1.  Low back syndrome with lumbar degenerative disc disease, lumbar spinal stenosis, and facet joint syndrome on the right L4-5 and L5-S1.,2.  Improved, spinal right L3-S1 radiofrequency ablation.,3.  Right sacroiliac joint sprain/strain, symptomatic.,4.  Left lumbar facet joint syndrome, stable.,6.  Right thoracic facet joint syndrome, stable.,7.  Lumbar spinal stenosis, primarily lateral recess with intermittent lower extremity radiculopathy, stable.,8.  Degenerative disc disease of both knees, symptomatic.,9.  Pes anserinus bursitis, bilaterally symptomatic.,10.  Chronic pain syndrome.,RECOMMENDATIONS:,  Dr. XYZ and I discussed with the patient her pathology.  She has some symptoms in her low back on the right side at the sacroiliac joint.  Dr. XYZ will plan having her come in and injecting her right sacroiliac joint under fluoroscopy.  She is also having pain in both knees.  We will plan on x-rays of both knees, AP and lateral, and plan on seeing her back on Monday or Friday for possible intraarticular and/or pes anserine bursa injections bilaterally.  I explained the rationale for each of these injections, possible complications and she wishes to proceed.  In the interim, she can continue on Lortab and Celebrex.  We will plan for the follow up following these interventions, sooner if needed.  She voiced understanding and agreement.  Physical exam findings, history of present illness, and recommendations were performed with and in agreement with Dr. Goel's findings.
---
DESCRIPTION: Low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet and sacroiliac joint syndrome, lumbar spinal stenosis primarily bilateral recess, intermittent lower extremity radiculopathy, DJD of both knees, bilateral pes anserinus bursitis, and chronic pain syndrome.

orthopedic, low back pain, lumbar degenerative disc disease, lumbar spondylosis, facet, sacroiliac joint syndrome, lumbar spinal stenosis, intermittent lower extremity radiculopathy, djd of both knees, bilateral pes anserinus bursitis, chronic pain syndrome, degenerative disc disease, pes anserinus bursitis, pes anserine bursa, sacroiliac joint, joint syndrome, degenerative disc, lumbar spinal, bilateral recess, lumbar, joint, intermittent, djd, pes, spinal, spondylosis, sacroiliac, syndrome,

This situation involves a 73-year-old patient with complex and chronic orthopedic issues, including lumbar degenerative disc disease, spinal stenosis, and joint problems. The stakes are significant due to the patient's age, chronic pain condition, and the need for ongoing and possibly invasive interventions like injections under fluoroscopy. While immediate life-threatening risks are relatively low, managing her pain and mobility is crucial for her quality of life. The need for precise treatment to avoid further complications or lack of relief adds to the stakes. Overall, it’s a moderate-stakes situation with potential risks and impacts on the patient’s well-being and daily life.


Medical Specialty: Orthopedic
Sample Name: Ortho - Letter - 1

XYZ, D.C.,Re:  ABC,Dear Dr. XYZ:,I had the pleasure of seeing your patient, ABC, today MM/DD/YYYY in consultation.  He is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on MM/DD/YYYY, where he was the driver of an automobile, which was struck on the front passenger's side.  The patient sustained impact injuries to his neck and lower back.  There was no apparent head injury or loss of consciousness and he denied any posttraumatic seizures.  He was taken to Hospital, x-rays were taken, apparently which were negative and he was released.,At the present time, he complains of neck and lower back pain radiating into his right arm and right leg with weakness, numbness, paraesthesia, and tingling in his right arm and right leg.  He has had no difficulty with bowel or bladder function.  He does experience intermittent headaches associated with his neck pain with no other associated symptoms.,PAST HEALTH:,  He was injured in a prior motor vehicle accident on MM/DD/YYYY.  At the time of his most recent injuries, he was completely symptom free and under no active therapy.  There is no history of hypertension, diabetes, heart disease, neurological disorders, ulcers or tuberculosis.,SOCIAL HISTORY: , He denies tobacco or alcohol consumption.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS:  ,None.,FAMILY HISTORY: , Otherwise noncontributory.,FUNCTIONAL INQUIRY: , Otherwise noncontributory.,REVIEW OF DIAGNOSTIC STUDIES:,  Includes an MRI scan of the cervical spine dated MM/DD/YYYY which showed evidence for disc bulging at the C6-C7 level.  MRI scan of the lumbar spine on MM/DD/YYYY, showed evidence of a disc herniation at the L1-L2 level as well as a disc protrusion at the L2-L3 level with disc herniations at the L3-L4 and L4-L5 level and disc protrusion at the L5-S1 level.,PHYSICAL EXAMINATION: , Reveals an alert and oriented male with normal language function.  Vital Signs:  Blood pressure was 105/68 in the left arm sitting.  Heart rate was 70 and regular.  Height was 5 feet 8 inches.  Weight was 182 pounds.  Cranial nerve evaluation was unremarkable.  Pupils were equal and reactive.  Funduscopic evaluation was clear.  There was no evidence for nystagmus.  There was decreased range of motion noted in both the cervical and lumbar regions to a significant degree, with tenderness and spasm in the paraspinal musculature.  Straight leg raising was limited to 45 degrees on the right and 90 degrees on the left.  Motor strength was 5/5 on the MRC scale.  Reflexes were 2+ symmetrical and active.  No pathological responses were noted.  Sensory examination showed a diffuse decreased sensation to pinprick in the right upper extremity.  Cerebellar function was normal.  There was normal station and gait.  Chest and cardiovascular evaluations were unremarkable.  Heart sounds were normal.  There were no extra sounds or murmurs.  Palpable trigger points were noted in the right trapezius and right cervical and lumbar paraspinal musculature.,CLINICAL IMPRESSION: , Reveals a 19-year-old male suffering from a posttraumatic cervical and lumbar radiculopathy, secondary to traumatic injuries sustained in a motor vehicle accident on MM/DD/YYYY.  In view of the persistent radicular complaints associated with the weakness, numbness, paraesthesia, and tingling as well as the objective sensory loss noted on today's evaluation as well as the non-specific nature of the radiculopathy, I have scheduled him for an EMG study on his right upper and right lower extremity in two week's time to rule out any nerve root irritation versus any peripheral nerve entrapment or plexopathy as the cause of his symptoms.  Palpable trigger points were noted on today's evaluation.  He is suffering from ongoing myofascitis.  His treatment plan will consist of a series of trigger point injections to be initiated at his next follow up visit in two weeks' time.  I have encouraged him to continue with his ongoing treatment program under your care and supervision.  I will be following him in two weeks' time.  Once again, thank you kindly for allowing me to participate in this patient's care and management.,Yours sincerely,,
---
DESCRIPTION: A 19-year-old right-handed male injured in a motor vehicle accident.

orthopedic, numbness paraesthesia and tingling, paraesthesia and tingling, cervical and lumbar, motor vehicle accident, mri scan, disc protrusion, paraspinal musculature, letter, musculature, radiculopathy, nerve, trigger, vehicle, accident, cervical, lumbar, evaluation, disc, ortho,

The situation involves a young patient who has suffered significant injuries from a motor vehicle accident, resulting in lasting symptoms that require medical evaluation and treatment. Although the injuries are not immediately life-threatening, they involve important neurological and orthopedic assessments and have the potential for long-term consequences if not properly managed. Therefore, the situation is more than routine but does not reach critical emergency levels.


Medical Specialty: Orthopedic
Sample Name: ORIF - 2

PREOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,POSTOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,OPERATIVE PROCEDURE:  ,Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.,ANESTHESIA: , General endotracheal.,PREOPERATIVE INDICATIONS: , This is a 52-year-old patient of mine who I have repaired both shoulder rotator cuffs, the most recent one in the calendar year 2007.  While he was climbing a ladder recently in the immediate postop stage, he fell suffering the aforementioned heavily comminuted Frykman fracture.  This fracture had a fragment that extended in the distal radial ulnar joint, a die-punch fragment in the center of the radius.  The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions.  He presented to my office the morning of April 3, 2007, having had a left reduction done elsewhere a day ago.  The reduction, although adequate, had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1-8, this was essentially an 8.  The best results have been either with external fixation or internal fixation, most recently volar plating of a locking variety has been popular, and I felt that this would be appropriate in his case.,Risks and benefits otherwise described were bleeding, infection, need to do operative revise or removal of hardware.  He is taking a job out of state in the next couple of months.  Hence I felt that even with close followup, this is a particularly difficult fracture as far as the morbidity of the injury proceeds.,OPERATIVE NOTE: , After adequate general endotracheal anesthesia was obtained, one gram of Ancef was given intravenously.  The left upper extremity was prepped and draped in supine position with the left hand in the arm table, magnification was used throughout.  The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient.  A small C-arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers.  A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator.  The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment.  The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them, specifically the distal radial ulnar joint and die-punch fragment.  At this point, a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws.  The ulnar styloid was not affixed in any portion of this repair.  The plate was viewed under the image intensification device, i.e., x-ray and the screws were placed in this order.  The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach, a locking 12-mm screw through 16-mm screws were placed in the following order.  Most proximal on the radial shaft of the plate, then the radial styloid, i.e., the most distal and lateral screw, the next most proximal shaft screw followed by the distal radial ulnar joint screw.  Three screws were locking across the die-punch fragment.  The remaining two screws were placed into the radial shaft.  All of these were locking screws of 2 mm in diameter and as the construct was created, the relative motion of the intra-articular fragment in dorsal comminution all diminished greatly, although the exposure as well as the amount of reduction force used was substantial.  The tourniquet time was 1.5 hours.  At this point, the tourniquet was let down.  The entire construct was irrigated with copious amounts of bacitracin and normal saline.  Closure was affected with 0 Vicryl underneath the skin surface followed by 3-0 Prolene in interrupted sutures in the volar wound.  Several image intensification x-rays were taken at the conclusion of the case to check screw length.  Screw lengths were changed out during the case as needed based on the x-ray findings.  The wound was injected with Marcaine, lidocaine, Depo-Medrol, and Kantrex.  A very heavily padded fluffy cotton Jones-type dressing was applied with a volar splint.  Estimated blood loss was 10 mL.  There were no specimens.  Tourniquet time was 1.5 hours.
---
DESCRIPTION: Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.

orthopedic, distal radius, c-arm, depo-medrol, frykman, jones-type dressing, kantrex, marcaine, open reduction and internal fixation, die-punch, intra-articular, lidocaine, pronator quadratus, radial styloid, ulnar styloid, distal radial ulnar joint, radial ulnar joint, distal, screws, orif, fracture, radial

The situation involves a complex orthopedic surgical procedure (Open Reduction and Internal Fixation) for a severely comminuted Frykman VIII distal radius fracture. This is a high-stakes medical scenario because it involves a detailed surgical operation with significant potential risks, such as bleeding, infection, and possible complications like compartment syndrome. The procedure's complexity and the risks involved, along with the critical nature of ensuring proper reduction and fixation of the fracture to restore function, underscore its high-stakes nature. The patient's ongoing recovery and potential relocation also add urgency to achieving successful surgical outcomes.


Medical Specialty: Orthopedic
Sample Name: ORIF - 3

PREOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,POSTOPERATIVE DIAGNOSIS (ES):, Left supracondylar, intercondylar distal femur fracture.,PROCEDURE:, Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture (27513).,OPERATIVE FINDINGS:, He had intercondylar split, and then he had a medial Hoffa fracture. He also had some comminution of the medial femoral condyle which prohibited an anatomic key between the two segments of the medial condyle.,IMPLANTS:, We used 2.4 and 3.5 cortical screws, as well as a LISS Synthes femoral locking plate.,COMPLICATIONS:, None.,IV FLUIDS:, 2000,ANESTHESIA:, General endotracheal.,ESTIMATED BLOOD LOSS:, 40 mL,URINE OUTPUT:, 650,HISTORY: ,This 45-year-old male had a ground-level fall, sustaining this injury. He was admitted for definitive operative fixation. Risks and benefits were discussed, he agreed to go ahead with the procedure.,DESCRIPTION OF THE OPERATION:, The patient was identified in preop holding, then taken to the operating room. Once adequate anesthesia was obtained, his left lower extremity was prepped and draped in a routine sterile fashion. He was given antibiotics. He placed a traction pin through his proximal tibia, and pulled weight off the end of the bed. I made a midline approach and then did the lateral parapatellar arthrotomy. We excised some of the fat pad to give us better visibility into the notch. We excised a good bit of his synovium and synovial pouch. At this time we were able to identify the fracture fragments. Again, there was an intercondylar split and then two free pieces of the medial condyle. The femur fracture was very distal through the metaphysis. At this time we thoroughly cleaned out all the clot between all the fracture fragments and cleaned the cortical margins.,Next we began the reduction. There was no reduction key between the two segments of the Hoffa fracture. Therefore, we reduced the anterior portion of the medial condyle to the lateral condyle, held it with point-of-reduction clamp and K-wires, and then secured it with 2.4 mini fragment lag screws. Next, with this medial anterior piece in place, we had some contour over the notch with which we were able to reduce the posterior medial Hoffa fragment. This gave us a nice notch contour. Again, there was some comminution laterally so that the fracture between the Hoffa segments did not have a perfect key. Once we had it reduced, based on the notch reduction, we then held it with K-wires. We secured it with two 3.5 cortical screws from the lateral condyle into this posterior segment. We then secured it with 2.4 cortical screws from the anterior medial to the posterior medial segment just subchondral. Then, finally, we secured it with a 3.5 cortical screw from the anterior medial to the posterior medial piece. All screws ran between and out of the notch.,With the condyle now well reduced, we reduced it to the metaphysis. We slid a 13-hole LISS plate submuscularly. We checked on AP and lateral views that showed we had good reduction of the fracture and appropriate plate placement. We placed the tip threaded guidewire through the A-hole of the plate jig and got it parallel to the joint. We then clamped the plate down to the bone. Proximally, we made a stab incision for the trocar at the 13-hole position, placed our tip threaded guidewire in the lateral aspect of the femur, checked it on lateral view, and had it in good position.,With the jig in appropriate position and clamped, we then proceeded to fill the distal locking screws to get purchase into the condyles. We then placed multiple unicortical locking screws in the shaft and metaphyseal segment. Our most proximal screw was proximal to the tip of the prosthesis.,At this time we took the jig off and put the final screw into the A-hole of the plate. We then took final C-arm views which showed we had a good reduction on AP and lateral views, the plate was in good position, we had full range of motion of the knee, and good reduction clinically and radiographically. We then pulse lavaged the knee with 3 liters of fluid. We closed the quad tendon and lateral retinaculum with interrupted 0 Vicryl over a Hemovac drain. Subdermal tissue was closed with 2-0 Vicryl, skin with staples. Sterile dressing and a hinged knee brace were applied. The patient was awakened from anesthesia and taken to Recovery in stable condition.,PLAN:,1. Nonweightbearing for 3 months.,2. CPM for 0 to 90 degrees as tolerated.
---
DESCRIPTION: Open reduction internal fixation of the left supracondylar, intercondylar distal femur fracture.

The procedure described involves Open Reduction and Internal Fixation (ORIF) of a complex left femur fracture, which is a significant orthopedic surgery. While the procedure description mentioned no complications and indicates the patient was in stable condition post-operatively, the stakes are relatively high due to the nature of the surgery involved. Complex femur fractures require precise surgical intervention to ensure proper healing and to preserve limb function. Risks in such surgical procedures include infection, improper healing, and joint dysfunction, which can all significantly impact the patient's recovery and overall quality of life. Additionally, the effects of being non-weightbearing for an extended period and ensuring proper rehabilitation post-surgery add to the stakes of the overall situation.


Medical Specialty: Orthopedic
Sample Name: ORIF - Fifth Metatarsal

PREOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,POSTOPERATIVE DIAGNOSIS: , Fractured right fifth metatarsal.,PROCEDURE PERFORMED:,1.  Open reduction and internal screw fixation right fifth metatarsal.,2.  Application of short leg splint.,ANESTHESIA:,  TIVA/local.,HISTORY: , This 32-year-old female presents to Preoperative Holding Area after keeping herself n.p.o., since mid night for open reduction and internal fixation of a fractured right fifth metatarsal.  The patient relates that approximately in mid-June that she was working as a machinist at Detroit Diesel and dropped a large set of tools on her right foot.  She continued to walk on the foot and found nothing was wrong despite the pain.  She was recently seen by Dr. X and was referred to Dr. Y for surgery.  The risks versus benefits of the procedure had been explained to the patient in detail by Dr. Y.  The consent is available on the chart for review.  The urine beta was taken in the preoperative area and was negative.,PROCEDURE IN DETAIL:  ,After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in the supine position.  A safety strap was placed across her waist for her protection.  Copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 0.5% Marcaine plain was used to perform an infiltrative type block to the right fifth metatarsal area of the right foot.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operative field and a sterile stocking was reflected.  Attention was directed to the right fifth metatarsal base.  The Xi-scan and fluoroscopic unit was used to visualize the fractured fifth metatarsal.  An avulsion fracture of the right fifth metatarsal base was visualized.  The fracture was linear in nature from distal lateral to proximal medial.  There appeared to be a pseudoarthrosis on the lateral view.  A skin scrub was used to carefully mark out all the landmarks including the peroneus longus and brevis tendons in the fifth metatarsal and the sural nerve.  A linear incision was created with a #10 blade.  A #15 blade was used to deepen the incision through the subcutaneous tissue.  All small veins traversing the subcutaneous tissue were ligated with electrocautery.  Next, using combination of sharp and blunt dissection, the deep fascia was reached.  Next a linear capsuloperiosteal incision was made down to the bone using a #15 blade.  Next, using a periosteal elevator and a #15 blade, the capsuloperiosteal tissues were stripped from the bone.  The fracture site was not clearly visualized due to bony callus.  A #25 gauge needle was introduced into the fracture site under fluoroscopy.  The fracture site was easily found.  An osteotome was used to separate the pseudoarthrosis.,A curette was used to remove the hypertrophic excessive pseudoarthrotic bone.  Next, a small ball burr was used to resect the remaining hypertrophic bone.  Next, a #1.0 drill bit was used to drill the subchondral bone on either side of the fracture site and a good healthy bleeding bone.  Next, a bone clamp was applied and the fracture was reduced.  Next, a threaded K-wire was thrown from the proximal base of the fifth metatarsal across the fracture site distally.  A #4-0 mm Synthes partially threaded, cannulated 50 mm screw was thrown using standard AO technique from the proximal fifth metatarsal base down the shaft and the fracture site was fixated rigidly.  All this was done under fluoroscopy.  Next, the wound was flushed with copious amounts of sterile saline.  The fracture site was found to have rigid compression.  The hypertrophic bone on the lateral aspect of the metatarsal was reduced with a ball burr and the wound was again flushed.  Next, the capsuloperiosteal tissues were closed with #3-0 Vicryl in a simple interrupted fashion.  A few fibers of the peroneus brevis tendon that were stripped from the base of the proximal phalanx were reattached carefully with Vicryl.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted suture technique.  Next, the skin was closed with #5-0 Prolene in a horizontal mattress technique.  A postoperative fluoroscopic x-ray was taken and the bony alignment was found to be intact and the screw placement had excellent appearance.  A dressing consisting of Owen silk, 4x4s, fluff, and Kerlix were applied.,A sterile stockinet was applied over the foot.  Next, copious amounts of Webril were applied to pad all bony prominences.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits.  Next, 4-inch, pre-moulded, well-padded posterior splint was applied.  The capillary refill time of the digits was less than three seconds.  The patient tolerated the above anesthesia and procedure without complications.  After anesthesia was reversed, she was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She was given Vicodin 5/500 mg #30 1-2 p.o. q.4-6h. p.r.n., pain, Naprosyn 500 mg p.o. b.i.d. p.c., Keflex 500 mg #30 one p.o. t.i.d., till gone.  She was given standard postoperative instructions to be non-weightbearing and was dispensed with crutches.  She will rest, ice, and elevate her right leg.  She is to follow up in the clinic on 08/26/03 at 10:30 a.m..  She was given emergency contact numbers and will call or return if problems arise earlier.
---
DESCRIPTION: Fractured right fifth metatarsal.  Open reduction and internal screw fixation right fifth metatarsal.  Application of short leg splint.

orthopedic, metatarsal, internal screw fixation, leg splint, fractured right fifth metatarsal, pneumatic ankle tourniquet, ankle tourniquet, metatarsal base, fracture site, fractured, hypertrophic, bernstein, orif

The described situation involves a surgical procedure to address a fractured right fifth metatarsal bone through open reduction and internal screw fixation. While orthopedic surgeries generally carry certain risks, such as infection or issues with bone healing, this procedure is relatively standard and routine in the field of orthopedics. The patient's condition is not life-threatening, and the operation details suggest that the procedure went smoothly without complications. Therefore, while it is important and requires medical expertise, the stakes are not considered very high compared to emergencies or more complex surgeries.


Medical Specialty: Orthopedic
Sample Name: ORIF - 1

PREOPERATIVE DIAGNOSES:,1.  Displaced intraarticular fracture, right distal radius.,2.  Right carpal tunnel syndrome.,PREOPERATIVE DIAGNOSES:,1.  Displaced intraarticular fracture, right distal radius.,2.  Right carpal tunnel syndrome.,OPERATIONS PERFORMED:,1.  Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture.,2.  Right carpal tunnel release.,ANESTHESIA: , General.,CLINICAL SUMMARY: , The patient is a 37-year-old right-hand dominant Hispanic female who sustained a severe fracture to the right wrist approximately one week ago.  This was an intraarticular four-part fracture that was displaced dorsally.  In addition, the patient previously undergone a carpal tunnel release, but had symptoms of carpal tunnel preop.  She is admitted for reconstructive operation.  The symptoms of carpal tunnel were present preop and worsened after the injury.,OPERATION:,  The patient was brought from the ambulatory care unit and placed on the operating table in a supine position and administered general anesthetic by Anesthesia.  Once adequate anesthesia had been obtained, the right upper extremity was prepped and draped in the usual sterile manner.  Tourniquet was placed around the right upper extremity.  The upper extremity was then elevated and exsanguinated using an Esmarch dressing.  The tourniquet was elevated to 250 mmHg.  The entire operation was performed with 4.5 loop magnification.  At this time an approximately 8 cm longitudinal incision was then made overlying the right flexor carpi radialis tendon from the flexion crease to the wrist proximally.  This was carried down to the flexor carpi radialis, which was then retracted ulnarly.  The floor of the flexor carpi radialis was then incised exposing the flexor pronator muscles.  The flexor pollicis longus was retracted ulnarly and the pronator quadratus was longitudinally incised 1 cm from its origin.  It was then elevated off of the fracture site exposing the fracture site, which was dorsally displaced.  This was an intraarticular four-part fracture.  Under image control, the two volar pieces and dorsal pieces were then carefully manipulated and reduced.  Then, 2.06 two-inch K-wires were drilled radial into the volar ulnar fragment and then a second K-wire was then drilled from the dorsal radial to the dorsal ulnar piece.  A third K-wire was then drilled from the volar radial to the dorsal ulnar piece.  The fracture was then manipulated.  The fracture ends were copiously irrigated with normal saline and curetted and then the fracture was reduced in the usual fashion by recreating the defect and distracting it.  Further K-wires were then placed through the radial styloid into the proximal fragment.  A Hand Innovations DVR plate of regular size for the right wrist was then fashioned over and placed over the distal radius and secured with two K-wires.  At this time, the distal screws were then placed.  The distal screws were the small screws.  These were non-locking screws, all eight screws were placed.  They were placed in the usual fashion by drilling with a small drill bit removing the small introducers and then using its depth.  Again, these were 18-20 mm screws.  After placing three of the screws it was necessary to remove the K-wires.  There was excellent reduction of the fragments and the fracture; excellent reduction of the intraarticular component and the fracture.  After the distal screws were placed, the fracture was reduced and held in place with K-wires, which were replaced and the proximal screws were drilled with the drill guide and the larger drill bit.  The screws were then placed.  These were 12 mm screws.  They were placed 4 in number.  The K-wires were then removed.  Finally, a 3 cm intrathenar incision was made beginning 1 cm distal to the flexor crease of the wrist.  This was carried down to the transverse carpal ligament, which was divided throughout the length of the incision, upon entering the carpal canal, the median nerve was found to be adherent to the undersurface of the structure.  It was dissected free from the structure out to its trifurcation.  The motor branches seen entering the thenar fascia and obstructed.  The nerve was then retracted dorsally and the patient had a great deal of scar tissue in the area of the volar flexion crease to the wrist where she had a previous incision that extended from the volar flexion crease of the wrist overlying the palmaris longus proximally for 1 cm.  In this area, careful dissection was performed in order to move the nerve from the surrounding structures and the most proximal aspect of the transverse carpal ligament, the more proximally located volar carpal ligament was then divided 5 cm into the distal forearm on the ulnar side of the palmaris longus tendon.  Incisions were then copiously irrigated with normal saline.  Homeostasis was maintained with electrocautery.  The pronator quadratus was closed with 3-0 Vicryl and the above skin incisions were closed proximally with 4-0 nylon and palmar incision with 5-0 nylon in the horizontal mattress fashion.  A large bulky dressing was then applied with a volar short-arm splint maintaining the wrist in neutral position.  The tourniquet was let down.  The fingers were immediately pink.  The patient was awakened and taken to the recovery room in good condition.  There were no operative complications.  The patient tolerated the procedure well.
---
DESCRIPTION: Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture and right carpal tunnel release.

orthopedic, intraarticular fracture, esmarch, k-wires, open reduction and internal fixation, tourniquet, carpal tunnel release, carpal tunnel syndrome, flexor carpi radialis, flexor pronator muscles, intraarticular, right distal radius, transverse carpal ligament, volar flexion crease, pronator quadratus, flexor carpi, carpi radialis, flexion crease, carpal ligament, carpal tunnel, carpal, volar

The described medical procedure involves an open reduction and internal fixation of a displaced intraarticular four-piece fracture of the right distal radius, as well as a right carpal tunnel release. These are significant surgical interventions necessary for restoring function and relieving pain in a patient's wrist, especially given the patient experienced worsening symptoms due to the fracture. This type of surgery is intricate and critical to the patient's recovery and quality of life, particularly considering the patient's right-hand dominance and the complexity of the fracture. While it is not as immediately life-threatening as some other surgeries, the complexity, potential complications, and significant impact on the patient's life and functionality suggest this is a relatively high-stakes situation.


Medical Specialty: Orthopedic
Sample Name: Nerve & Tendon Repair - Finger

PREOPERATIVE DIAGNOSIS:,  Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2.  25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.,PROCEDURE PERFORMED:,1.  Repair of nerve and tendon, right ring finger.,2.  Exploration of digital laceration.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,TOTAL TOURNIQUET TIME:  ,57 minutes.,COMPLICATIONS: , None.,DISPOSITION:  ,To PACU in stable condition.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.,GROSS OPERATIVE FINDINGS: , After wound exploration, it was found there was a 100% laceration to the ulnar digital neurovascular bundle.  The FDS had a partial ulnar slip laceration and the FDP had a 25% transverse laceration as well.  The radial neurovascular bundle was found to be completely intact.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room and placed in the supine position.  All bony prominences were adequately padded.  Tourniquet was placed on the right upper extremity after being packed with Webril, but not inflated at this time.  The right upper extremity was prepped and draped in the usual sterile fashion.  The hand was inspected.  Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx, which was approximated with nylon suture.  The sutures were removed and the wound was explored.  It was found that the ulnar digital neurovascular bundle was 100% transected.  The radial neurovascular bundle on the right ring finger was found to be completely intact.  We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25% laceration in a transverse fashion to the FDP.  We copiously irrigated the wound.  Repair was undertaken of the FDS with #3-0 undyed Ethibond suture.  The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact.  Attention during our repair at the flexor tendon, the A1 pulley was incised for better visualization as well as better tendon excursion after repair.  Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury.  The digital nerve was dissected proximally and distally to likely visualize the nerve.  The nerve was then approximated using microvascular technique with #8-0 nylon suture.  The hands were well approximated.  The nerve was not under undue tension.  The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture.  Sterile dressing was placed and a dorsal extension Box splint was placed.  The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition.  Overall prognosis is good.
---
DESCRIPTION: Repair of nerve and tendon, right ring finger and exploration of digital laceration.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.

orthopedic, laceration, flexor tendon, volar laceration, digital laceration, ulnar slip, flexor digitorum, neurovascular bundle, nerve, injury, ring, finger, neurovascular, fds, bundle, tendon, repair, flexor, digital, ulnar,

The procedure described involves the repair of nerve and tendon in a finger following a laceration. While it is a delicate surgery requiring precision, especially with nerve involvement, it is not typically considered to be life-threatening or involve systemic health risks. The operative procedure also concluded without any complications, and the patient's prognosis is noted as good. Therefore, it is a significant situation because it involves surgical intervention and nerve repair but not as high-stakes as procedures involving critical or life-sustaining organs.


Medical Specialty: Orthopedic
Sample Name: Olecranon Bursa - Excision

PREOPERATIVE DIAGNOSIS: , Acute infected olecranon bursitis, left elbow.,POSTOPERATIVE DIAGNOSIS: , Infection, left olecranon bursitis.,PROCEDURE PERFORMED:,1.  Incision and drainage, left elbow.,2.  Excision of the olecranon bursa, left elbow.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,NEEDLE AND SPONGE COUNT: , Correct.,SPECIMENS: , Excised bursa and culture specimens sent to the microbiology.,INDICATION:  ,The patient is a 77-year-old male who presented with 10-day history of pain on the left elbow with an open wound and drainage purulent pus followed by serous drainage.  He was then scheduled for I&D and excision of the bursa.  Risks and benefits were discussed.  No guarantees were made or implied.,PROCEDURE: , The patient was brought to the operating room and once an adequate sedation was achieved, the left elbow was injected with 0.25% plain Marcaine.  The left upper extremity was prepped and draped in standard sterile fashion.  On examination of the left elbow, there was presence of thickening of the bursal sac.  There was a couple of millimeter opening of skin breakdown from where the serous drainage was noted.  An incision was made midline of the olecranon bursa with an elliptical incision around the open wound, which was excised with skin.  The incision was carried proximally and distally.  The olecranon bursa was significantly thickened and scarred.  Excision of the olecranon bursa was performed.  There was significant evidence of thickening of the bursa with some evidence of adhesions.  Satisfactory olecranon bursectomy was performed.  The wound margins were debrided.  The wound was thoroughly irrigated with Pulsavac irrigation lavage system mixed with antibiotic solution.  There was no evidence of a loose body.  There was no bleeding or drainage.  After completion of the bursectomy and I&D, the skin margins, which were excised were approximated with 2-0 nylon in horizontal mattress fashion.  The open area of the skin, which was excised was left _________ and was dressed with 0.25-inch iodoform packing.  Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias.  The patient tolerated the procedure very well.  He was then extubated and transferred to the recovery room in a stable condition.  There were no intraoperative complications noticed.
---
DESCRIPTION: Incision and drainage and excision of the olecranon bursa, left elbow.  Acute infected olecranon bursitis, left elbow.

orthopedic, incision and drainage, infected olecranon, olecranon bursitis, olecranon bursa, olecranon, wound, excision, drainage, elbow, bursa

The surgical procedure described involves the excision of an infected olecranon bursa on a 77-year-old patient which is a fairly routine orthopedic procedure. While it involves some level of risk due to the patient's age and the presence of infection, the procedure itself is considered minor with no reported complications and the patient tolerated it well. It is not life-threatening and is commonly performed to address infection and relieve symptoms. Therefore, it involves moderate stakes primarily due to the infection and patient's age but is not considered extremely high-stakes.


Medical Specialty: Orthopedic
Sample Name: Open Plantar Fasciotomy

PREOPERATIVE DIAGNOSIS: , Chronic plantar fasciitis, right foot.,POSTOPERATIVE DIAGNOSIS:,  Chronic plantar fasciitis, right foot.,PROCEDURE: , Open plantar fasciotomy, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY:,  The patient has had a longstanding history of foot problems.  The foot problem has been progressive in nature and has not been responsive to conservative care despite multiple attempts at conservative care.  The preoperative discussion with the patient including alternative treatment options, the procedure itself was explained, and risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, falling arch, digital contracture, and the postoperative management were discussed.  The patient has been advised, although no guarantee for success could be given, most of the patients have improved function and less pain.  All questions were thoroughly answered.  The patient requested for surgical repair since the problem has reached a point to interfere with normal daily activities.  The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF THE PROCEDURE:  ,The patient was given 1 g Ancef for antibiotic prophylaxis 30 minutes prior to the procedure.  The patient was brought to the operating room and placed in the supine position.  Following a light IV sedation, a posterior tibial nerve block and local infiltrate of the operative site was performed with 10 mL, and a 1:1 mixture of 1% lidocaine with epinephrine, and 0.25% Marcaine was affected.  The lower extremity was prepped and draped in the usual sterile manner.  Balance anesthesia was obtained.,PROCEDURE:, Plantar fasciotomy, right foot.  The plantar medial tubercle of the calcaneus was palpated and a vertical oblique incision, 2 cm in length with the distal aspect overlying the calcaneal tubercle was affected. Blunt dissection was carried out to expose the deep fascia overlying the abductor hallucis muscle belly and the medial plantar fascial band.  A periosteal elevator did advance laterally across the inferior aspect of the medial and central plantar fascial bands, creating a small and narrow soft tissue tunnel.  Utilizing a Metzenbaum scissor, transection of the medial two-third of the plantar fascia band began at the junction of the deep fascia of the abductor hallucis muscle belly and medial plantar fascial band, extending to the lateral two-thirds of the band.  The lateral plantar fascial band was left intact.  Visualization and finger probe confirmed adequate transection.  The surgical site was flushed with normal saline irrigation.,The deep layer was closed with 3-0 Vicryl and the skin edges coapted with combination of 1 horizontal mattress and simples.  The dressing consisted of Adaptic, 4 x 4, conforming bandages, and an ACE wrap to provide mild compression.  The patient tolerated the procedure and anesthesia well, and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact.  A walker boot was dispensed and applied.  The patient will be allowed to be full weightbearing to tolerance, in the boot to encourage physiological lengthening of the release of plantar fascial band.,The next office visit will be in 4 days.  The patient was given prescriptions for Keflex 500 mg 1 p.o. three times a day x10 days and Lortab 5 mg #40, 1 to 2 p.o. q.4-6 h. p.r.n. pain, 2 refills, along with written and oral home instructions.  After a short recuperative period, the patient was discharged home with vital signs stable and in no acute distress.
---
DESCRIPTION: Chronic plantar fasciitis, right foot.  Open plantar fasciotomy, right foot.

orthopedic, plantar fascial band, plantar fasciitis, plantar fasciotomy, plantar fascial, anesthesia, plantar, fascia, fasciotomy, fascial, band, foot,

The described procedure, an open plantar fasciotomy, is a relatively routine surgical intervention for chronic plantar fasciitis that has not responded to conservative treatments. While surgery always carries some risks, the stakes here are moderate because plantar fasciitis is not typically a life-threatening condition, and the surgery is aimed at improving quality of life by alleviating pain. The surgery was performed under local anesthesia with IV sedation, indicating less complexity and overall lower risk compared to procedures requiring general anesthesia. The patient is described as having tolerated the procedure well and was discharged in stable condition, suggesting a successful outcome. However, there are risks discussed such as infection, continued pain, and recurrence, which need to be considered, but these are common considerations and do not elevate the stakes to a high level.


Medical Specialty: Orthopedic
Sample Name: Neck Pain - Discharge Summary

ADMISSION DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,DISCHARGE DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression C4-C5, C5-C6, and C6-C7.,2.  Arthrodesis with anterior interbody fusion C4-C5, C5-C6, and C6-C7.,3.  Spinal instrumentation C4 through C7.,4.  Implant.,5.  Allograft.,COMPLICATIONS:,  None.,COURSE ON ADMISSION: , This is the case of a very pleasant 41-year-old Caucasian female who was seen in clinic as an initial consultation on 09/13/07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient's hand.  The patient's symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now.  The patient has been treated with medications, which has been unrelenting.  The patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at C4-C5, C5-C6 and C6-C7.  The patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness, which was treated well with IV morphine.  The patient has resolution of the pain down the arm, but she does have some tingling of the right thumb and right index finger.  The patient apparently is doing well with slight dysphagia, we treated her with Decadron and we will send her home with Medrol.  The patient will have continued pain medication coverage with Darvocet and Flexeril.  The patient will follow up with me as scheduled.  Instructions have been given.
---
DESCRIPTION: Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.

orthopedic, radiculopathy, cervical spondylosis, neck pain, anterior cervical discectomy, herniated nucleus pulposus, cervical, anterior, herniated,

The situation involves a detailed discharge summary following a complex orthopedic surgery (anterior cervical discectomy with fusion and spinal instrumentation) due to significant neck pain and radiculopathy caused by cervical spondylosis and herniated discs. While the surgery and condition both indicate a significant health event necessitating careful management post-discharge, the absence of complications and the patient's stable condition post-operation suggest a favorable prognosis. The implications are noteworthy but not life-threatening, thus it doesn't reach the highest level of stakes. However, the necessity of follow-up and medication indicates the importance of ongoing care to avoid future complications.


Medical Specialty: Orthopedic
Sample Name: MRI Wrist - 1

FINDINGS:,There are posttraumatic cysts along the volar midline and volar lateral aspects of the lunate which are likely posttraumatic. There is no acute marrow edema (series #12 images #5-7). Marrow signal is otherwise normal in the distal radius and ulna, throughout the carpals and throughout the proximal metacarpals.,There is a partial tear of the volar component of the scapholunate ligament in the region of the posttraumatic lunate cyst with retraction and thickening towards the scaphoid (series #6 image #5, series #8 images #22-36). There is tearing of the membranous portion of the ligament. The dorsal component is intact.,The lunatotriquetral ligament is thickened and lax, but intact (series #8 image #32).,There is no tearing of the radial or ulnar attachment of the triangular fibrocartilage (series #6 image #7). There is a mildly positive ulnar variance. Normal ulnar collateral ligament.,The patient was positioned in dorsiflexion. Carpal alignment is normal and there are no tears of the dorsal or ventral intercarpal ligaments (series #14 image #9).,There is a longitudinal split tear of the ECU tendon which is enlarged both at the level of and distal to the ulnar styloid with severe synovitis (series #4 images #8-16, series #3 images #9-16).,There is thickening of the extensor tendon sheaths within the fourth dorsal compartment with intrinsically normal tendons (series #4 image #12).,There is extensor carpi radialis longus and brevis synovitis in the second dorsal compartment (series #4 image #13).,Normal flexor tendons within the carpal tunnel. There is mild thickening of the tendon sheaths and the median nerve demonstrates increased signal without compression or enlargement (series #3 image #7, series #4 image #7).,There are no pathological cysts or soft tissue masses.,IMPRESSION:,Partial tear of the volar and membranous components of the scapholunate ligament with an associated posttraumatic cyst in the lunate. There is thickening and laxity of the lunatotriquetral ligament.,Longitudinal split tear of the ECU tendon with tendinosis and severe synovitis.,Synovitis of the second dorsal compartment and tendon sheath thickening in the fourth dorsal compartment.,Tendon sheath thickening within the carpal tunnel with increased signal within the median nerve.
---
DESCRIPTION: Patient with wrist pain and swelling, status post injury.

orthopedic, fourth dorsal compartment, tendon sheath thickening, tendon sheaths, dorsal compartment, volar, carpals, tear, ulnar, synovitis, sheaths, ligament, thickening, dorsal, tendon, injury,

The MRI findings indicate multiple issues in the wrist, including ligament tears, tendon thickening, and synovitis. While these findings suggest serious injury and potential for significant pain and dysfunction if not treated, they are generally not life-threatening. However, timely intervention is needed to prevent long-term functional impairment or chronic pain, which can affect the patient's quality of life and ability to perform daily activities. The stakes are significant in terms of orthopedic health and functionality, but not at the level of life-critical conditions.


Medical Specialty: Orthopedic
Sample Name: MRI T-Spine

CC:, BLE weakness.,HX:, This 82y/o RHM was referred to the Neurology service by the Neurosurgery service for evaluation of acute onset paraplegia. He was in his usual state of health until 5:30PM on 4/6/95, when he developed sudden "pressure-like" epigastric discomfort associated with bilateral lower extremity weakness, SOB, lightheadedness and diaphoresis. He knelt down to the floor and "went to sleep." The Emergency Medical Service was alert and arrived within minutes, at which time he was easily aroused though unable to move or feel his lower extremities. No associated upper extremity or bulbar dysfunction was noted. He was taken to a local hospital where an INR was found to be 9.1. He was given vitamin K 15mg, and transferred to UIHC to rule out spinal epidural hemorrhage. An MRI scan of the T-spine was obtained and the preliminary reading was "normal." The Neurology service was then asked to evaluate the patient.,MEDS:, Coumadin 2mg qd, Digoxin 0.25mg qd, Prazosin 2mg qd.,PMH:, 1)HTN. 2)A-Fib on coumadin. 3)Peripheral vascular disease:s/p left Femoral-popliteal bypass (8/94) and graft thrombosis-thrombolisis (9/94). 4)Adenocarcinoma of the prostate: s/p TURP (1992).,FHX: ,unremarkable.,SHX:, Farmer, Married, no Tobacco/ETOH/illicit drug use.,EXAM:, BP165/60 HR86 RR18 34.2C SAO2 98% on room air.,MS: A&O to person, place, time. In no acute distress. Lucid.,CN: unremarkable.,MOTOR: 5/5 strength in BUE. Flaccid paraplegia in BLE,Sensory: T6 sensory level to LT/PP, bilaterally. Decreased vibratory sense in BLE in a stocking distribution, distally.,Coord: Intact FNF and RAM in BUE. Unable to do HKS.,Station: no pronator drift.,Gait: not done.,Reflexes: 2/2 BUE, Absent in BLE, plantar responses were flexor, bilaterally.,Rectal: decreased rectal tone.,GEN EXAM: No carotid bruitts. Lungs: bibasilar crackles. CV: Irregular rate and rhythm with soft diastolic murmur at the left sternal border. Abdomen: flat, soft, non-tender without bruitt or pulsatile mass. Distal pulses were strong in all extremities.,COURSE:, Hgb 12.6, Hct 40%, WBC 11.7, Plt 154k, INR 7.6, PTT 50, CK 41, the GS was normal. EKG showed A-Fib at 75BPM with competing junctional pacemaker, essentially unchanged from 9/12/94.,It was suspected that the patient sustained an anterior-cervico-thoracic spinal cord infarction with resultant paraplegia and T6 sensory level. A CXR was done in the ER prior to admission. This revealed cardiomegaly and a widened mediastinum. He returned from the x-ray suite and suddenly became unresponsive and went into cardiopulmonary arrest. Resuscitative measures failed. Pericardiocentesis was unremarkable. Autopsy revealed a massive aortic dissection extending from the aortic root to the origin of the iliac arteries with extensive pericardial hematoma. The dissection was seen in retrospect on the MRI T-spine.
---
DESCRIPTION: MRI T-spine and CXR - Aortic Dissection.

orthopedic, mri, a&o, aortic dissection, cxr, irregular rate and rhythm, mri scan, neurology service, t-spine, carotid bruitts, epidural hemorrhage, mediastinum, paraplegia, person, place, stocking distribution, time, weakness, mri t spine, sensory level, neurology, spine,

The scenario involves a critical medical case of an 82-year-old patient who experienced sudden paraplegia and other symptoms leading to a cardiopulmonary arrest. The high INR levels, administration of vitamin K, and subsequent MRI reveal significant medical concerns, highlighting the potential for severe outcomes. Additionally, the retrospective finding of a massive aortic dissection illustrates the substantial diagnostic challenge and consequences. The situation was time-sensitive and life-threatening, demonstrating the high-stakes nature of the medical scenario.


Medical Specialty: Orthopedic
Sample Name: MRI L-Spine - Subarachnoid Seeding

CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of "drop" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice.
---
DESCRIPTION: MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.

orthopedic, glioblastoma multiforme, gbm, steroid myopathy, hemiplegia, progressive lower extremity weakness, mri l spine, lower extremity weakness, frontal glioblastoma, subarachnoid seeding, lower extremity, glioblastoma, subarachnoid, spine, mri, lower, weakness,

The patient's condition reflects a progression of an existing serious health issue, glioblastoma multiforme, which has now apparently led to subarachnoid seeding—an indication of cancer spreading to the spinal region. The worsening symptoms, including progressively severe weakness and the reliance on a wheelchair, further emphasize the critical nature of her health status. This is compounded by the fact that she ultimately entered hospice care, suggesting end-of-life considerations. The clinical decisions made here could potentially affect the quality of life and treatment outcomes. Given these factors, the situation is high-stakes due to the severity and progression of cancer, potential treatment implications, and the consideration of palliative care.


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

Medical Specialty: Orthopedic
Sample Name: MRI Shoulder - 2

EXAM:,MRI LEFT SHOULDER,CLINICAL:,This is a 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months. Received for second opinion. Study performed on 10/04/05.,FINDINGS:,The patient was scanned in a 1.5 Tesla magnet.,There is a flat undersurface of the acromion (Type I) morphology, with anterior downsloping orientation.,There is inflammation of the anterior rotator interval capsule with peritendinous edema involving the intracapsular long biceps tendon best appreciated on the (axial gradient echo T2 series #3 images #6-9). There is edema with thickening of the superior glenohumeral ligament (axial T2 series #3 image #7). There is flattening of the long biceps tendon as it enters the bicipital groove (axial T2 series #3 image #9-10), but no subluxation. The findings suggest early changes of a “hidden” lesion.,Normal biceps labral complex and superior labrum, and there is no demonstrated superior labral tear.,There is minimal tendinitis with intratendinous edema of the insertion of the subscapularis tendon (axial T2 series #3 image #10). There is minimal fluid within the glenohumeral joint capsule within normal physiologic volume limits.,Normal anterior and posterior glenoid labra.,Normal supraspinatus, infraspinatus, and teres minor tendons.,Normal muscles of the rotator cuff and there is no muscular atrophy.,There is minimal fluid loculated within the labral ligamentous capsular complex along the posterior-superior labrum (sagittal T2 series #7 image #5; coronal T2 series #5 image #7), but there is no demonstrated posterior-superior labral tear or paralabral cyst or ganglion.,Normal acromioclavicular articulation.,IMPRESSION:,Inflammation of the anterior rotator interval capsule with interstitial edema of the superior glenohumeral ligament.,Flattening of the long biceps tendon as it enters the bicipital groove, but no subluxation. Findings suggest early changes of a hidden lesion.,Mild tendinitis of the distal insertion of the subscapularis tendon, but no tendon tear.,Normal supraspinatus, infraspinatus, and teres minor tendons and muscular complexes.,Type I morphology with an anterior downsloping orientation of the acromion, but no inferior acromial osteophyte.
---
DESCRIPTION: A 51-year-old female with left shoulder pain and restricted external rotation and abduction x 6 months.

orthopedic, insertion of the subscapularis, supraspinatus infraspinatus and teres, infraspinatus and teres minor, axial t series, supraspinatus infraspinatus, teres minor, minor tendons, posterior superior, biceps tendon, rotator, capsule, glenohumeral, tendon, series, superior

The situation involves an MRI report on a patient's left shoulder pain, providing details about inflammation and early changes of a potential hidden lesion. The findings indicate mild tendinitis and no major tears or severe damage. As this report is crucial for diagnosis and directing potential treatment plans, it holds some importance. However, as there is no immediate life-threatening condition identified, the report primarily informs a longer-term treatment strategy for a non-critical condition. Thus, the stakes are moderate as it impacts the patient's quality of life but not immediately life-threatening.


Medical Specialty: Orthopedic
Sample Name: MRI L-S Spine - Cauda Equina Syndrome

CC: ,Low Back Pain (LBP) with associated BLE weakness.,HX:, This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE, on 12/6/95; then down the LLE, on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE, but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were "negative." He was then referred to UIHC.,MEDS: ,SLNTC, Coumadin 4mg qd, Propranolol, Procardia XL, Altace, Zaroxolyn.,PMH: ,1) MI 11/9/78, 2) Cholecystectomy, 3) TURP for BPH 1980's, 4) HTN, 5) Amaurosis Fugax, OD, 8/95 (Mayo Clinic evaluation--TEE (-), but Carotid Doppler (+) but "non-surgical" so placed on Coumadin).,FHX:, Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95.,SHX:, retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.,EXAM:, BP130.56, HR68, RR16, Afebrile.,MS: A&O to person, place, time. Speech fluent without dysarthria. Lucid. Appeared uncomfortable.,CN: Unremarkable.,MOTOR: 5/5 strength in BUE. Lower extremity strength: Hip flexors & extensors 4-/4-, Hip abductors 3+/3+, Hip adductors 5/5, Knee flexors & extensors 4/4-, Ankle flexion 4-/4-, Tibialis Anterior 2/2-, Peronei 3-/3-. Mild atrophy in 4 extremities. Questionable fasciculations in BLE. Spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). No rigidity and essential normal muscle tone on passive motion.,SENSORY: Decreased vibratory sense in stocking distribution from toes to knees in BLE (worse on right). No sensory level. PP/LT/TEMP testing unremarkable.,COORD: Normal FNF-RAM. Slowed HKS due to weakness.,Station: No pronator drift. Romberg testing not done.,Gait: Unable to stand.,Reflexes: 2/2 BUE. 1/trace patellae, 0/0 Achilles. Plantar responses were flexor, bilaterally. Abdominal reflex was present in all four quadrants. Anal reflex was illicited from all four quadrants. No jaw jerk or palmomental reflexes illicited.,Rectal: normal rectal tone, guaiac negative stool.,GEN EXAM: Bilateral Carotid Bruits, No lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields.,COURSE: ,WBC 11.6, Hgb 13.4, Hct 38%, Plt 295. ESR 40 (normal 0-14), CRP 1.4 (normal <0.4), INR 1.5, PTT 35 (normal), Creatinine 2.1, CK 346. EKG normal. The differential diagnosis included Amyotrophy, Polymyositis, Epidural hematoma, Disc Herniation and Guillain-Barre syndrome. An MRI of the lumbar spine was obtained, 12/13/95. This revealed an L3-4 disc herniation extending inferiorly and behind the L4 vertebral body. This disc was located more on the right than on the left , compromised the right neural foramen, and narrowed the spinal canal. The patient underwent a L3-4 laminectomy and diskectomy and subsequently improved. He was never seen in follow-up at UIHC.
---
DESCRIPTION: MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness.

orthopedic, ble weakness, carotid doppler, disc herniation, guillain-barre syndrome, amyotrophy, polymyositis, epidural hematoma, mri l s spine, cauda equina syndrome, flexors & extensors, cauda equina, herniation, cauda, equina, extensors, reflexes, mri, hip, flexors, weakness,

The situation involves a medical case where a 75-year-old patient is experiencing progressively worsening low back pain (LBP), bilateral lower extremity (BLE) weakness, numbness, and difficulty walking. These symptoms are concerning for cauda equina syndrome, a serious condition that requires prompt medical intervention to prevent permanent neurological damage. Cauda equina syndrome can lead to permanent loss of bowel and bladder function, motor weakness, and sexual dysfunction if not treated timely. The high-stakes nature is underscored by the need for a surgical intervention, a laminectomy and diskectomy, to relieve the pressure caused by the herniated disc. Timely diagnosis and surgical intervention are crucial in such cases to prevent irreversible damage.


Medical Specialty: Orthopedic
Sample Name: MRI Cervical Spine - 2

EXAM:,MRI SPINAL CORD CERVICAL WITHOUT CONTRAST,CLINICAL:,Right arm pain, numbness and tingling.,FINDINGS:,Vertebral alignment and bone marrow signal characteristics are unremarkable. The C2-3 and C3-4 disk levels appear unremarkable.,At C4-5, broad based disk/osteophyte contacts the ventral surface of the spinal cord and may mildly indent the cord contour. A discrete cord signal abnormality is not identified. There may also be some narrowing of the neuroforamina at this level.,At C5-6, central disk-osteophyte contacts and mildly impresses on the ventral cord contour. Distinct neuroforaminal narrowing is not evident.,At C6-7, mild diffuse disk-osteophyte impresses on the ventral thecal sac and contacts the ventral cord surface. Distinct cord compression is not evident. There may be mild narrowing of the neuroforamina at his level.,A specific abnormality is not identified at the C7-T1 level.,IMPRESSION:,Disk/osteophyte at C4-5 through C6-7 with contact and may mildly indent the ventral cord contour at these levels. Some possible neuroforaminal narrowing is also noted at levels as stated above.
---
DESCRIPTION: MRI Cervical Spine without contrast.

MRI Cervical Spine without contrast.

orthopedic, mri cervical spine, ventral cord contour, cervical spine, spinal cord, cord contour, ventral cord, mri, narrowing, ventral, cord

The situation involves interpreting an MRI of the cervical spine, with findings that show disk/osteophyte formations contacting and possibly mildly indenting the spinal cord at the C4-5 through C6-7 levels, which may relate to the patient's symptoms of right arm pain, numbness, and tingling. While the findings are suggestive of some spinal issues, there is no distinct spinal cord compression or serious abnormalities identified. However, given that the spinal cord and nerve roots are involved, the stakes are moderate due to potential implications on the patient's quality of life if left unaddressed. This situation is clinically significant for the patient's treatment plan but not acute or life-threatening at the moment.


Medical Specialty: Orthopedic
Sample Name: MRI Ankle - 2

EXAM:,MRI OF THE RIGHT ANKLE,CLINICAL:,Pain.,FINDINGS:,The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding the ankle joint.,IMPRESSION,: NORMAL MRI OF THE RIGHT ANKLE.
---
DESCRIPTION: MRI right ankle.

MRI right ankle.

orthopedic, ankle joint, bone, mri, ankle

The situation involves the interpretation of an MRI report which indicates a normal result for an orthopedic patient experiencing pain. While any medical interpretation holds some weight, in this case, the MRI findings show no abnormalities, indicating no immediate or critical issues. This generally represents a standard part of a diagnostic process rather than an emergency or high-stakes scenario.


Medical Specialty: Orthopedic
Sample Name: Medial Branch Rhizotomy

PROCEDURE: , Medial branch rhizotomy, lumbosacral.,INFORMED CONSENT:,  The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,SEDATION: , The patient was given conscious sedation and monitored throughout the procedure.  Oxygenation was given.  The patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,PROCEDURE:  ,The patient remained awake throughout the procedure in order to interact and give feedback.  The x-ray technician was supervised and instructed to operate the fluoroscopy machine.  The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.  With fluoroscopy, a Teflon coated needle, ***, was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of ***.  Specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen.  Needle localization was confirmed with AP and lateral radiographs.,The following technique was used to confirm placement at the Medial Branch nerves.  Sensory stimulation was applied to each level at 50 Hz; paresthesias were noted at,*** volts.  Motor stimulation was applied at 2 Hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** volts.,Following this, the needle Trocar was removed and a syringe containing 1% lidocaine was attached.  At each level, after syringe aspiration with no blood return, 1cc 1% lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue.  After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds.  All injected medications were preservative free.  Sterile technique was used throughout the procedure.,COMPLICATIONS:,  None.  No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.
---
DESCRIPTION: Medial branch rhizotomy, lumbosacral.  Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.

orthopedic, lumbosacral, medial branch rhizotomy, medial branch nerves, rhizotomy, fluoroscopy,

Medial branch rhizotomy is a specialized procedure used primarily to relieve back pain by targeting the nerves that transmit pain signals from the facet joints. The procedure involves precision techniques and carries several risks such as infection, bleeding, allergic reactions, and nerve or spinal cord injury. These are important considerations but are generally well-managed with careful technique and monitoring. The patient’s vital signs were stable, and there were no complications, indicating it was performed successfully. While the procedure isn't typically life-threatening, the implications of errors could be severe due to possible nerve damage or other complications.