Medical Specialty: Orthopedic
Sample Name: Anterior Cervical Decompression

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

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

An anterior cervical decompression and fusion operation is a significant surgical procedure. It addresses severe and symptomatic issues due to herniated discs in the cervical spine. The potential risks, including nerve damage, paralysis, and even death, highlight the high-stakes nature. Despite the routine nature of such operations for professionals, the potential for severe complications makes it inherently high-stakes.


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

Medical Specialty: Surgery
Sample Name: Meniscoplasty & Chondroplasty

PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear of the right knee.,POSTOPERATIVE DIAGNOSES:,1.  Medial meniscal tear, right knee.,2.  Lateral meniscal tear, right knee.,3.  Osteochondral lesion, medial femoral condyle, right knee.,4.  Degenerative joint disease, right knee.,5.  Patella grade-II chondromalacia.,6.  Lateral femoral condyle grade II-III chondromalacia.,PROCEDURE PERFORMED:,1.  Arthroscopy, right knee.,2.  Medial meniscoplasty, right knee.,3.  Lateral meniscoplasty, right knee.,4.  Medial femoral chondroplasty, right knee.,5.  Medical femoral microfracture, right knee.,6.  Patellar chondroplasty.,7.  Lateral femoral chondroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,BRIEF HISTORY AND INDICATION FOR PROCEDURE: , The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice.  The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure.,PROCEDURE:,  The patient was taken to the Operative Suite at ABCD General Hospital on 09/08/03, placed on the operative table in supine position.  Department of Anesthesia administered general anesthetic.  Once adequately anesthetized, the right lower extremity was placed in a Johnson knee holder.  Care was ensured that all bony prominences were well padded and she was positioned and secured.  After adequately positioned, the right lower extremity was prepped and draped in the usual sterile fashion.  Attention was then directed to creation of the arthroscopic portals, both medial and lateral portal were made for arthroscope and instrumentation respectively.  The arthroscope was advanced through the inferolateral portal taking in a suprapatellar pouch.  All compartments were then examined in sequential order with photodocumentation of each compartment.  The patella was noted to have grade-II changes of the inferior surface, otherwise appeared to track within the trochlear groove.  There was mild grooving of the trochlear cartilage.  The medial gutter was visualized.  There was no evidence of loose body.  The medial compartment was then entered.  There was noted to be a large defect on the medial femoral condyle grade III-IV chondromalacia changes with exposed bone in evidence of osteochondral displaced fragment.  There was also noted to be a degenerative meniscal tear of the posterior horn of the medial meniscus.  The arthroscopic probe was then introduced and the meniscus and chondral surfaces were probed throughout its entirety and photos were taken.  At this point, a meniscal shaver was then introduced and the chondral surfaces were debrided as well as any loose bodies removed.  This gave a smooth shoulder to the chondral lesion.  After this, the meniscus was debrided until it had been smooth over the frayed edges.  At this point, the shaver was removed.  The meniscal binder was then introduced and the meniscus was further debrided until the tear was adequately contained at this point.  The shaver was reintroduced and all particles were again removed and the meniscus was smoothed over the edge.  The probe was then reintroduced and the shaver removed, the meniscus was probed ___________ and now found to be stable.  At this point, attention was directed to the rest of the knee.  The ACL was examined.  It was intact and stable.  The lateral compartment was then entered.  There was noted to be a grade II-III changes of the lateral femoral condyle.  Again, with the edge of some friability at the shoulder of this cartilage lesion.  There was noted to be some mild degenerative fraying of the posterior horn of the lateral meniscus.  The probe was introduced and the remaining meniscus appeared stable.  This was then removed and the stapler was introduced.  A chondroplasty and meniscoplasty were then performed until adequately debrided and smoothed over.  The lateral gutter was then visualized.  There was no evidence of loose bodies.  Attention was then redirected back to the medial and femoral condyles.,At this point, a 0.62 K-wire was then placed in through the initial portal, medial portal, as well as an additional poke hole, so we can gain access and proper orientation to the medial femoral lesion.  Microfacial technique was then used to introduce the K-wire into the subchondral bone in multiple areas until we had evidence of some bleeding to allow ___________ of this lesion.  After this was performed, the shaver was then reintroduced and the loose bodies and loose fragments were further debrided.  At this point, the shaver was then moved to the suprapatellar pouch and the patellar chondroplasty was then performed until adequately debrided.  Again, all compartments were then re-visualized and there was no further evidence of other pathology or loose bodies.  The knee was then copiously irrigated and suctioned dry.  All instrumentation was removed.  Approximately 20 cc of 0.25% plain Marcaine was injected into the portal site and the remaining portion intraarticular.  Sterile dressings of Adaptic, 4x4s, ABDs, and Webril were then applied.  The patient was then transferred back to the gurney in supine position.,DISPOSITION:  The patient tolerated the procedure well with no complications.  The patient was transferred to PACU in satisfactory condition.
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DESCRIPTION: Arthroscopy, medial meniscoplasty, lateral meniscoplasty, medial femoral chondroplasty, and medical femoral microfracture, right knee.  Patellar chondroplasty.  Lateral femoral chondroplasty.   Meniscal tear, osteochondral lesion, degenerative joint disease, and chondromalacia,

The described situation involves a surgical procedure for addressing multiple complex issues in the knee, including meniscal tears, osteochondral lesions, and degenerative conditions. Surgery, especially involving multiple detailed procedures and general anesthesia, generally carries inherent risks such as infection, complications from anesthesia, and the need for post-operative rehabilitation. However, the procedure went smoothly, with minimal blood loss and no complications reported. The stakes in surgical contexts are usually elevated due to these inherent risks and the patient’s history of significant pain and dysfunction. Hence, this situation is high-stakes, but given the successful outcome, it is not at the extreme end of the spectrum.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Urology
Sample Name: Microhematuria - Consult

HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above.  He was seen a few weeks ago for routine followup, and he was noted for microhematuria.  Due to his history of kidney stone, renal ultrasound as well as IVP was done.  He presents today for followup.  He denies any dysuria, gross hematuria or flank pain issues.  Last stone episode was over a year ago.  No history of smoking.  Daytime frequency 3 to 4 and nocturia 1 to 2, good stream, empties well with no incontinence.,Creatinine 1.0 on June 25, 2008, UA at that time was noted for 5-9 RBCs, renal ultrasound of 07/24/2008 revealed 6 mm left intrarenal stone, with no hydronephrosis.  IVP same day revealed a calcification over the left kidney, but without bilateral hydronephrosis.  The calcification previously noted on the ureter appears to be outside the course of the ureter.  Otherwise unremarkable.  This is discussed.,IMPRESSION:  ,1.  A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP.  The patient is asymptomatic.  We have discussed surgical intervention versus observation.  He indicates that this stone is not bothersome, prefers observation, need for hydration with a goal of making over 2 liters of urine within 24 hours is discussed.,2.  Microhematuria, we discussed possible etiologies of this, and the patient is agreeable to cystoscopy in the near future.  Urine sent for culture and sensitivity.,PLAN: , As above.  The patient will follow up for cystoscopy, urine sent for cytology, continue hydration.  Call if any concern.  The patient is seen and evaluated by myself.
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DESCRIPTION: A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP.

urology, intrarenal stone, ivp, ultrasound, microhematuria, hydration, kidney stone, renal ultrasound

The situation involves a consultation for a urology patient with a nonobstructing kidney stone and microhematuria. The condition is not presenting severe or immediate symptoms, and the patient is largely asymptomatic. The patient prefers observation over surgical intervention and will undergo follow-up procedures like cystoscopy. While kidney stones can become serious if they obstruct the urinary tract, this particular case is currently stable. Thus, the situation is more about careful monitoring than immediate high-stakes intervention.


Medical Specialty: Surgery
Sample Name: Cystourethroscopy & TURP - 1

PREOPERATIVE DIAGNOSES:,1.  Urinary retention.,2.  Benign prostate hypertrophy.,POSTOPERATIVE DIAGNOSES:,1.  Urinary retention.,2.  Benign prostate hypertrophy.,PROCEDURES PERFORMED:,1.  Cystourethroscopy.,2.  Transurethral resection of prostate (TURP).,ANESTHESIA:,  Spinal.,RESECTION TIME:,  Less than one hour.,INDICATION FOR PROCEDURE:  ,This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.,PROCEDURE:  PROCEDURE: , Informed written consent was obtained.  The patient was taken to the operative suite, administered spinal anesthetic and placed in dorsal lithotomy position.  She was sterilely prepped and draped in normal fashion.  A #27-French resectoscope was inserted utilizing the visual obturator blanching the bladder.  The bladder was visualized in all quadrants, no bladder tumors or stones were noted.  Ureteral orifices were visualized and did appear to be near the enlarged median lobe.  Prostate showed trilobar prostatic enlargement.  There were some cellules and tuberculations noted.  The visual obturator was removed.  The resectoscope was then inserted utilizing the #26 French resectoscope loop.  Resection was performed initiating at the bladder neck and at the median lobe.,This was taken down to the circular capsular fibers.  Attention was then turned to the left lateral lobe and this was resected from 12 o'clock to 3 o'clock down to the capsular fibers maintaining hemostasis along the way and taking care not to resect beyond the level of the verumontanum.  Ureteral orifices were kept out of harm's way throughout the case.  Resection was then performed from the 3 o'clock position to the 6 o'clock position in similar fashion.  Attention was then turned to the right lateral lobe and this was resected again in a similar fashion maintaining hemostasis along the way.  The resectoscope was then moved to the level of the proximal external sphincter and trimming of the apex was performed.  Open prostatic fossa was noted.  All chips were evacuated via Ellik evacuator and #24 French three-way Foley catheter was inserted and irrigated.  Clear return was noted.  The patient was then hooked up to better irrigation.  The patient was cleaned, reversed for anesthetic, and transferred to recovery room in stable condition.,PLAN:  ,We will admit with antibiotics, pain control, and bladder irrigation possible void trial in the morning.
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DESCRIPTION: Cystourethroscopy and tTransurethral resection of prostate (TURP).  Urinary retention and benign prostate hypertrophy.  This is a 62-year-old male with a history of urinary retention and progressive obstructive voiding symptoms and enlarged prostate 60 g on ultrasound, office cystoscopy confirmed this.

surgery, urinary retention, transurethral resection of prostate, prostate, enlarged, obstructive voiding symptoms, benign prostate hypertrophy, ureteral orifices, prostate hypertrophy, cystourethroscopy, turp, hypertrophy, resectoscope, urinary, bladder, resection,

The situation involves a surgical procedure called Transurethral Resection of the Prostate (TURP), which is conducted to address urinary retention due to benign prostatic hypertrophy in a 62-year-old patient. This type of surgery, while common and generally safe with experienced hands, is invasive and requires careful management given the risks associated with anesthesia, potential for post-operative complications such as bleeding or infection, and the general considerations required for patient recovery after surgery. Considering these factors, the stakes can be considered moderately high as the patient's health outcomes directly depend on the success of the surgery and post-operative care.


Medical Specialty: Consult - History and Phy.
Sample Name: Annual Health Maintenance Exam

HISTORY OF PRESENT ILLNESS:  ,This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health.  Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dyslipidemia well controlled with niacin, history of hemorrhoids with occasional external bleeding, although no problems in the last 6 months, and also history of concha bullosa of the left nostril, followed by ENT associated with slight septal deviation.  There are no other medical problems.  He has no symptoms at this time and remains in excellent health.,PAST MEDICAL HISTORY: , Otherwise noncontributory.  There is no operation, serious illness or injury other than as noted above.,ALLERGIES: , There are no known allergies.,FAMILY HISTORY: , Father died of an MI at age 67 with COPD and was a heavy smoker.  His mother is 88, living and well, status post lung cancer resection.  Two brothers, living and well.  One sister died at age 20 months of pneumonia.,SOCIAL HISTORY:,  The patient is married.  Wife is living and well.  He jogs or does Cross Country track 5 times a week, and weight training twice weekly.  No smoking or significant alcohol intake.  He is a physician in allergy/immunology.,REVIEW OF SYSTEMS:,  Otherwise noncontributory.  He has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology.  No symptoms other than as described above.,PHYSICAL EXAMINATION:,GENERAL:  He appears alert, oriented, and in no acute distress with excellent cognitive function.  VITAL SIGNS:  His height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16.  SKIN:  Warm and dry.  There is no pallor, cyanosis or icterus.  HEENT:  Tympanic membranes benign.  The pharynx is benign.  Nasal mucosa is intact.  Pupils are round, regular, and equal, reacting equally to light and accommodation.  EOM intact.  Fundi reveal flat discs with clear margins.  Normal vasculature.  No hemorrhages, exudates or microaneurysms.  No thyroid enlargement.  There is no lymphadenopathy.  LUNGS:  Clear to percussion and auscultation.  Normal sinus rhythm.  No premature beat, murmur, S3 or S4.  Heart sounds are of good quality and intensity.  The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally.  ABDOMEN:  Benign without guarding, rigidity, tenderness, mass or organomegaly.  NEUROLOGIC:  Grossly intact.  EXTREMITIES:  Normal.  GU:  Genitalia normal.  There are no inguinal hernias.  There are mild hemorrhoids in the anal canal.  The prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality.  There is no rectal mass.  The stool is Hemoccult negative.,IMPRESSION:,1.  Comprehensive annual health maintenance examination.,2.  Dyslipidemia.,3.  Tinnitus, left ear.,4.  Hemorrhoids.,PLAN:,  At this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin E 400 units daily; and vitamin C 500 mg daily.  Consider adding lycopene, selenium, and flaxseed to his regimen.  All appropriate labs will be obtained today.  Followup fasting lipid profile and ALT in 6 months.
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DESCRIPTION: Comprehensive annual health maintenance examination, dyslipidemia, tinnitus in left ear, and hemorrhoids.

consult - history and phy., tinnitus, dyslipidemia, annual health maintenance, health, hemorrhoids, benign

The situation described is a routine annual health maintenance exam for a 59-year-old male in good overall health. While the patient has a few chronic conditions such as dyslipidemia, tinnitus, and a history of hemorrhoids, these are well-managed, and there are no new or worsening symptoms reported. Such evaluations are standard preventive measures and do not involve immediate or life-threatening concerns. Consequently, the stakes are relatively low, focused primarily on continued health maintenance and monitoring.


Medical Specialty: Surgery
Sample Name: Bilateral Inguinal Herniorrhaphy

PREOPERATIVE DIAGNOSIS: , Bilateral inguinal hernias.,POSTOPERATIVE DIAGNOSIS:,  Bilateral inguinal hernias.,OPERATION PERFORMED:  ,Bilateral inguinal herniorrhaphy.,ANESTHESIA: , General.,INDICATIONS: , This 3-1/2-year-old presents with bilateral scrotal swellings, which both reduce and are consistent with bilateral inguinal hernias.  He comes to the operating room today for the repair.,OPERATIVE PROCEDURE:  ,After the induction of general anesthetic, the abdomen and perineum were prepped and draped in usual manner.  Transverse right lower quadrant skin fold incision was made and carried down through skin and subcutaneous tissue with sharp dissection.  The external oblique fascia identified upon course of its fibers.  The hernia sac was identified and brought into the operative field.  Hernia sac was grasped with hemostat and the cord structures were carefully stripped away from it until the entire circumference of the sac could be identified.  The sac clamped and divided.  The distal sac was then dissected down to where the large hydrocele with the testicle would be brought up and the sac opened, the fluid drained, and a portion of the sac removed.  The testicle was returned to the scrotum.  The proximal sac was then dissected free of the cord up to the peritoneal reflection at the internal ring where it was ligated with a #3-0 Vicryl stick tie and a #3-0 Vicryl free tie.  The excess removed.  The cord returned to the inguinal canal and external oblique fascia closed with interrupted sutures of #3-0 Vicryl and subcutaneous tissue with the same, skin closed with #5-0 subcuticular Monocryl.  Sterile dressing applied.  Attention was then turned to the left side where an identical procedure was carried out for his left hernia, although the only difference being with the sac was somewhat smaller and did not have the large hydrocele around the testicle.  Otherwise the procedure was carried down in identical manner.  Sterile dressings were then applied to both sides.  The child awakened and taken to the recovery room in satisfactory condition.
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DESCRIPTION: 3-1/2-year-old presents with bilateral scrotal swellings consistent with bilateral inguinal hernias.

surgery, perineum, hernia sac, bilateral inguinal herniorrhaphy, external oblique fascia, bilateral inguinal hernias, inguinal herniorrhaphy, scrotal swellings, subcutaneous tissue, oblique fascia, inguinal, scrotal, herniorrhaphy, testicle, hernias

The case involves a surgical procedure on a child, specifically a bilateral inguinal herniorrhaphy, which is a common surgery to correct inguinal hernias. While it requires general anesthesia and involves the careful handling of the hernia sacs and cord structures, it is generally considered a routine procedure with a high success rate when performed by experienced surgeons. The stakes are moderate due to the general anesthesia and the patient's young age, which always carry certain risks, but the situation is not usually life-threatening given the surgical procedure's commonality and well-understood nature.


Medical Specialty: Hematology - Oncology
Sample Name: Anaplastic Astrocytoma - Letter

XYZ,RE:  ABC,MEDICAL RECORD#:  123,Dear Dr. XYZ:,I saw ABC back in Neuro-Oncology Clinic today.  He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.,Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion.  The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent.  It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective.  Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.,After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen.  They came in with a list of eight possible agents that they would like to be administered within the next two weeks.  They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.,From my view, I noticed a man whose language has deteriorated in the week since I last saw him.  This is very worrisome.  Today, for the first time, I felt that there was a definite right facial droop as well.  Therefore, there is no doubt that he is becoming symptomatic from his growing tumor.  It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.,Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation.  Despite an hour, this again amazingly was not possible.  It is not that he does not want treatment, however.  Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen.  We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days.  In addition, we will stop thalidomide 100 mg/day.  If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us.  At this stage, we are thinking of using Accutane at that point.,While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval.  In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later.  I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.,I will keep you apprised of followups.  If you have any questions or if I could be of any further assistance, feel free to contact me.,Sincerely,
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DESCRIPTION: Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.

hematology - oncology, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma

The situation involves a patient with anaplastic astrocytoma, a potentially life-threatening brain tumor. The patient is ambivalent about recommended radiation treatment and proposes an unproven chemotherapy regimen, underscoring a critical decision point in care that could significantly impact the patient's health and prognosis. The case is high-stakes due to the potentially severe implications for the patient's survival and quality of life.


Medical Specialty: Surgery
Sample Name: BCCa Excision - Nasal Tip

PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,OPERATION PERFORMED: , Excision of nasal tip basal carcinoma.  Total area of excision, approximately 1 cm to 12 mm frozen section x2, final margins clear.,INDICATION: , A 66-year-old female for excision of nasal basal cell carcinoma.  This area is to be excised accordingly and closed.  We had multiple discussions regarding types of closure.,SUMMARY: , The patient was brought to the OR in satisfactory condition and placed supine on the OR table.  Underwent general anesthesia along with Marcaine in the nasal tip areas for planned excision.  The area was injected, after sterile prep and drape, with Marcaine 0.25% with 1:200,000 adrenaline.,The specimen was sent to pathology.  Margins were still positive at the inferior 6 o'clock ***** margin and this was resubmitted accordingly.  Final margins were clear.,Closure consisted of undermining circumferentially.  Advancement closure with dog ear removal distally and proximally was accomplished without difficulty.  Closure with interrupted 5-0 Monocryl running 7-0 nylon followed by Xeroform gauze, light pressure dressing, and Steri-Strips.,The patient is discharged on minocycline and Darvocet-N 100.,NOTE:,  The 2.6 mm loupe magnification was utilized throughout the procedure.  No complications noted with excellent and all clear margins at the termination.  An advancement closure technique was utilized.
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DESCRIPTION: Excision of nasal tip basal carcinoma, previous positive biopsy.

surgery, basal cell carcinoma, closure, steri-strips, xeroform gauze, excision, light pressure dressing, loupe magnification, nasal tip, basal carcinoma, basal cell, cell carcinoma, biopsy, basal, carcinoma, nasal

This surgical procedure involves the excision of basal cell carcinoma from the nasal tip. While basal cell carcinoma is a common and typically non-life-threatening form of skin cancer, any surgery, especially on the face, can be considered high-stakes due to the need for precision and the potential aesthetic impact. Additionally, ensuring clear margins is crucial to prevent recurrence, adding to the stakes. However, the operation was conducted without complications, and the final margins were clear, which suggests effective management. Thus, it's not as high-stakes as surgeries involving critical organs or life-threatening conditions, but it still requires a considerable degree of precision and care.


Medical Specialty: Surgery
Sample Name: Prostatectomy - Robotic Radical Retropubic

PREOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS: , Adenocarcinoma of the prostate.,PROCEDURE,1.  Radical retropubic prostatectomy, robotic assisted.,2.  Bladder suspension.,ANESTHESIA:,  General by intubation.,The patient understands his diagnosis, grade, stage and prognosis.  He understands this procedure, options to it and potential benefits from it.  He strongly wishes to proceed.  He accepts all treatment-associated risks to include but not be limited to bleeding requiring transfusion; infection; sepsis; heart attack; stroke; bladder neck contractures; need to convert to an open procedure; urinary fistulae; impotence; incontinence; injury to bowel/rectum/bladder/ureters, etc.; small-bowel obstruction; abdominal hernia; osteitis pubis/chronic pelvic pain, etc.,DESCRIPTION OF THE CASE:  ,The patient was taken to the operating room, given a successful general anesthetic, placed in the lithotomy position, prepped with Betadine solutions and draped in the usual sterile fashion.  My camera ports were then placed in the standard fan array.  A camera port was placed in the midline above the umbilicus using the Hasson technique.  The balloon port was placed, the abdomen insufflated, and all other ports were placed under direct vision.  My assistant was on the right.  The patient was then placed in the steep Trendelenburg position, and the robot brought forward and appropriately docked.,I then proceeded to drop the bladder into the peritoneal cavity by incising between the right and left medial umbilical ligaments and carrying that dissection laterally along these ligaments deep into the pelvis.  This nicely exposed the space of Retzius.  I then defatted the anterior surface of the prostate and endopelvic fascia.,The endopelvic fascia was then opened bilaterally.  The levator ani muscles were carefully dissected free from the prostate and pushed laterally.  Dissection was continued posteriorly toward the bundles and caudally to the apex.  The puboprostatic ligaments were then transected.  A secure ligature of 0 Vicryl was placed around the dorsal venous complex.,I then approached the bladder neck.  The anterior bladder neck was transected down to the level of the Foley catheter, which was lifted anteriorly in the wound.  I then transected the posterior bladder neck down to the level of the ampullae of the vas.  The ampullae were mobilized and transected.  These were lifted anteriorly in the field, exposing the seminal vesicles, which were similarly mobilized.  Hemostasis was obtained using the bipolar Bovie.,I then identified the Denonvilliers fascia, and this was incised sharply.  Dissection was continued caudally along the anterior surface of the rectum and laterally toward the bundles.  I was able to then identify the pedicles over the seminal vesicles, which were hemoclipped and transected.,The field was then copiously irrigated with sterile water.  Hemostasis was found to be complete.  I then carried out a urethrovesical anastomosis.  This was accomplished with 3-0 Monocryl ligatures.  Two of these were tied together in the midline.  They were placed at the 6 o'clock position, and one was run in a clockwise and the other in a counterclockwise direction to the 12 o'clock position where they were securely tied.  A new Foley catheter was then easily delivered into the bladder and irrigated without extravasation.  The patient was given indigo carmine, and there was prompt blue urine in the Foley., ,I then carried out a bladder suspension.  This was done in hopes of obtaining early urinary control.  This was accomplished with 0 Vicryl ligatures.  One was placed at the bladder neck and through the dorsal venous complex and then the other along the anterior surface of the bladder to the posterior surface of the pubis.  This nicely re-retroperitonealized the bladder.,The prostate was then placed in an Endocatch bag and brought out through an extended camera port incision.  A JP drain was brought in through the 4th arm port and sutured to the skin with 2-0 silk.  The camera port fascia was closed with running 0 Vicryl.  The skin incisions were closed with a running, subcuticular 4-0 Monocryl.,The patient tolerated the procedure very well.  There were no complications.  Sponge and instrument counts were reported correct at the end of the case.
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DESCRIPTION: Radical retropubic prostatectomy, robotic assisted and bladder suspension.  Adenocarcinoma of the prostate.

surgery, adenocarcinoma, prostate, radical retropubic prostatectomy, robotic assisted, bladder, uspension, bladder neck, intubation, robotic, retropubic, prostatectomy

The situation involves a surgical procedure for adenocarcinoma of the prostate, which is a serious medical condition. The procedure includes a radical retropubic prostatectomy and bladder suspension, performed robotically. The potential risks of the surgery include severe complications such as heart attack, stroke, sepsis, and impotence, indicating that this is a complex and high-stakes situation. The patient's understanding of the risks and decision to proceed further underscores the seriousness of his condition and the importance of the surgery to his health prognosis.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lung adenocarcinoma Path Report

CLINICAL HISTORY:  ,Probable right upper lobe lung adenocarcinoma.,SPECIMEN: , Lung, right upper lobe resection.,GROSS DESCRIPTION:,  Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung".  It consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.cm.  The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable.  Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass.  This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum.  There is no necrosis or hemorrhage evident.  The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.,FINAL DIAGNOSIS:,  Right lung, upper lobe, lobectomy:  Bronchioloalveolar carcinoma, mucinous type,COMMENT:,  Right upper lobe, lobectomy.,Tumor type:  Bronchioloalveolar carcinoma, mucinous type.,Histologic grade:  Well differentiated.,Tumor size (greatest diameter):  3.6 cm.,Blood/lymphatic vessel invasion:  Absent.,Perineural invasion:  Absent.,Bronchial margin:  Negative.,Vascular margin:  Negative.,Inked surgical margin:  Negative.,Visceral pleura:  Not involved.,In situ carcinoma:  Absent.,Non-neoplastic lung:  Emphysema.,Hilar lymph nodes:  Number of positive lymph nodes:  0; Total number of lymph nodes:  1.,P53 immunohistochemical stain is negative in the tumor.
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DESCRIPTION: Probable right upper lobe lung adenocarcinoma.  Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung".

cardiovascular / pulmonary, bronchioloalveolar carcinoma, mucinous, mucoid mass, lymph nodes, upper lobe, visceral, bronchioloalveolar, carcinoma, lymph, pleural, margin, tumor, adenocarcinoma, specimen, lobe, lung,

The pathology report describes a case of lung adenocarcinoma, specifying detailed histological findings including the tumor type, size, and other characteristics. Given that this involves a patient diagnosed with cancer, decision-making about treatment paths (e.g., surgery, chemotherapy, radiation) can significantly affect patient outcomes. Although the tumor does not seem aggressive, as indicated by the well-differentiated nature, absence of invasion, and clear margins, cancer diagnoses generally have substantial implications for patient health and require careful clinical management.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Fiberoptic Bronchoscopy - 1

PREOPERATIVE DIAGNOSIS:,1.  Hemoptysis.,2.  History of lung cancer.,POSTOPERATIVE DIAGNOSIS:,  Tumor occluding right middle lobe with friability.,PROCEDURE PERFORMED:,  Fiberoptic bronchoscopy, diagnostic.,LOCATION: , Endoscopy suite #4.,ANESTHESIA:,  General per Anesthesia Service.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain.  Due to her prior history, it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis.  She was brought to endoscopy suite #4 and informed consent was obtained.  ,PROCEDURE DETAILS:  ,The patient was placed in the supine position and intubated by the Anesthesia Service.  Intravenous sedation was given as per Anesthesia.  The fiberoptic scope was passed through the #8 endotracheal tube into the main trachea.  The right mainstem bronchus was examined.  The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted.  Upon examining the right middle lobe, there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe.,The clot was lavaged with normal saline and there was noted to be tumor behind this clot.  Tumor completely occluded both segments of the right middle lobe.  Scope was then passed to the subsegments of the right lower lobe, which were individually examined and noted to be grossly free of endobronchial lesions.  Scope was pulled back to the level of the midtrachea, passed into the left mainstem bronchus.  Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions.  The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions.  There were some secretions noted throughout the left lung.  The scope was retracted and passed again to the right mainstem bronchus.  The area of the right middle lobe was reexamined.  The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation.  It did not appear as if a scope or cannula could be passed distal to the tumor.  Due to continued oozing, 1 cc of epinephrine was applied topically with adequate hemostasis obtained.  The area was examined for approximately one minute for assurance of adequate hemostasis.  The scope was then retracted and the patient was sent to the recovery room in stable condition.  She will be extubated as per the Anesthesia Service.  Cytology and cultures were not sent due to the patient's known diagnosis.  Further recommendations are pending at this time.
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DESCRIPTION: Fiberoptic bronchoscopy, diagnostic.  Hemoptysis and history of lung cancer.  Tumor occluding right middle lobe with friability.

cardiovascular / pulmonary, hemoptysis, lung cancer, tumor, fiberoptic, bronchoscopy, endoscopy suite, adequate hemostasis, fiberoptic bronchoscopy, endobronchial lesions, middle lobe, lobe,

The procedure described is a fiberoptic bronchoscopy on a patient with acute hemoptysis and a history of lung cancer. This procedure was necessary to investigate the cause of the hemoptysis, which was found to be a tumor occluding the right middle lobe. The stakes are high because the identification, management, and treatment of the tumor could significantly impact the patient's prognosis and quality of life. The potential for serious complications such as severe bleeding or airway obstruction also increases the stakes. However, the procedure was completed without complication and with minimal blood loss, leading to a stable postoperative condition.


Medical Specialty: Surgery
Sample Name: Tonsillectomy & Adenoidectomy - 2

PREOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,OPERATION PERFORMED: , Tonsillectomy & adenoidectomy.,ANESTHESIA: , General endotracheal.,FINDINGS: , The tonsils were 3+ enlarged and cryptic.,DESCRIPTION OF OPERATION:,  Under general anesthesia with an endotracheal tube, the patient was placed in supine position.  A mouth gag was inserted and suspended from Mayo stand.  Red rubber catheter was placed through the nose and pulled up through the mouth with elevation of the palate.  The adenoid area was inspected.  The adenoids were small.  The left tonsil was grasped with a tonsil tenaculum.  The tonsil was removed with the Gold laser.  The apposite tonsil was removed in a similar manner.  Hemostasis was secured with electrocautery.  Both tonsillar fossae were injected with 0.25% Marcaine with adrenaline.  The patient tolerated the procedure well and left the operating room in good condition.
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DESCRIPTION: Tonsillectomy & adenoidectomy.  Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.

surgery, tonsil, gold laser, adenoids, chronic tonsillitis, adenoid hypertrophy, tonsillectomy, adenoidectomy, endotracheal, tonsillitis, symptomatic, hypertrophy

The described procedure, tonsillectomy and adenoidectomy, is a routine surgical procedure often performed to resolve chronic tonsillitis and airway obstruction issues. While surgery always carries some risk, this procedure is generally considered low-risk, especially since the patient tolerated the procedure well and left the operating room in good condition. There are no indications of complications or extraordinary circumstances.


Medical Specialty: ENT - Otolaryngology
Sample Name: Bilateral Myringotomies

PREOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,FINAL DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,4.  Acute and chronic adenoiditis.,OPERATIONS PERFORMED,1.  Bilateral myringotomies.,2.  Placement of ventilating tubes.,3.  Nasal endoscopy.,4.  Adenoidectomy.,DESCRIPTION OF OPERATIONS: , The patient was brought to the operating room, endotracheal intubation carried out by Dr. X. Both sides of the patient's nose were then sprayed with Afrin.  Ears were inspected then with the operating microscope.  The anterior inferior quadrant myringotomy incisions were performed.  Then, a modest amount of serous and a trace of mucoid material encountered that was evacuated.  The middle ear mucosa looked remarkably clean.  Armstrong tubes were inserted.  Ciprodex drops were instilled.  Ciprodex will be planned for two postoperative days as well.  Nasal endoscopy was carried out, and evidence of acute purulent adenoiditis was evident in spite of the fact that clinically the patient has shown some modest improvement following cessation of all milk products.  The adenoids were shaved back, flushed with curette through a traditional transoral route with thick purulent material emanating from the crypts, and representative cultures were taken.  Additional adenoid tissue was shaved backwards with the RADenoid shaver.  Electrocautery was used to establish hemostasis, and repeat nasal endoscopy accomplished.  The patient still had residual evidence of inter choanal adenoid tissue, and video photos were taken.  That remaining material was resected, guided by the nasal endoscope using the RADenoid shaver to remove the material and flush with the posterior nasopharynx.  Electrocautery again used to establish hemostasis.  Bleeding was trivial.  Extensive irrigation accomplished.  No additional bleeding was evident.  The patient was awakened, extubated, taken to the recovery room in a stable condition.  Discharge anticipated later in the day on Augmentin 400 mg twice daily, Lortab or Tylenol p.r.n. for pain.  Office recheck would be anticipated if stable and doing well in approximately two weeks.  Parents were instructed to call, however, regarding the outcome of the culture on Monday next week to ensure adequate antibiotic coverage before cessation of the antibiotic.
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DESCRIPTION: Bilateral myringotomies, placement of ventilating tubes, nasal endoscopy, and adenoidectomy.

ent - otolaryngology, bilateral middle ear effusions, recurrent acute otitis media, chronic rhinitis, recurrent adenoiditis with adenoid hypertrophy, adenoiditis, bilateral myringotomies, ventilating tubes, nasal endoscopy, adenoidectomy, adenoid hypertrophy, myringotomies, otitis, media, hypertrophy, endoscopy, intubation, nasal,

The situation involves a surgical procedure on a patient, specifically bilateral myringotomies, placement of ventilating tubes, nasal endoscopy, and adenoidectomy. These operations are typically performed to address recurrent acute otitis media and adenoid issues, which, while being common conditions, involve a surgical intervention under general anesthesia. Although the procedure itself is routine and the risks are generally low for healthy patients, it still involves inherent surgical risks such as anesthesia complications, bleeding, and infection. The stakes are therefore moderate due to the surgical nature and the requirement for postoperative care and monitoring.


Medical Specialty: Orthopedic
Sample Name: Meniscoplasty & Chondroplasty

PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear of the right knee.,POSTOPERATIVE DIAGNOSES:,1.  Medial meniscal tear, right knee.,2.  Lateral meniscal tear, right knee.,3.  Osteochondral lesion, medial femoral condyle, right knee.,4.  Degenerative joint disease, right knee.,5.  Patella grade-II chondromalacia.,6.  Lateral femoral condyle grade II-III chondromalacia.,PROCEDURE PERFORMED:,1.  Arthroscopy, right knee.,2.  Medial meniscoplasty, right knee.,3.  Lateral meniscoplasty, right knee.,4.  Medial femoral chondroplasty, right knee.,5.  Medical femoral microfracture, right knee.,6.  Patellar chondroplasty.,7.  Lateral femoral chondroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,BRIEF HISTORY AND INDICATION FOR PROCEDURE: , The patient is a 47-year-old female who has knee pain since 03/10/03 after falling on ice.  The patient states she has had inability to bear significant weight and had swelling, popping, and giving away, failing conservative treatment and underwent an operative procedure.,PROCEDURE:,  The patient was taken to the Operative Suite at ABCD General Hospital on 09/08/03, placed on the operative table in supine position.  Department of Anesthesia administered general anesthetic.  Once adequately anesthetized, the right lower extremity was placed in a Johnson knee holder.  Care was ensured that all bony prominences were well padded and she was positioned and secured.  After adequately positioned, the right lower extremity was prepped and draped in the usual sterile fashion.  Attention was then directed to creation of the arthroscopic portals, both medial and lateral portal were made for arthroscope and instrumentation respectively.  The arthroscope was advanced through the inferolateral portal taking in a suprapatellar pouch.  All compartments were then examined in sequential order with photodocumentation of each compartment.  The patella was noted to have grade-II changes of the inferior surface, otherwise appeared to track within the trochlear groove.  There was mild grooving of the trochlear cartilage.  The medial gutter was visualized.  There was no evidence of loose body.  The medial compartment was then entered.  There was noted to be a large defect on the medial femoral condyle grade III-IV chondromalacia changes with exposed bone in evidence of osteochondral displaced fragment.  There was also noted to be a degenerative meniscal tear of the posterior horn of the medial meniscus.  The arthroscopic probe was then introduced and the meniscus and chondral surfaces were probed throughout its entirety and photos were taken.  At this point, a meniscal shaver was then introduced and the chondral surfaces were debrided as well as any loose bodies removed.  This gave a smooth shoulder to the chondral lesion.  After this, the meniscus was debrided until it had been smooth over the frayed edges.  At this point, the shaver was removed.  The meniscal binder was then introduced and the meniscus was further debrided until the tear was adequately contained at this point.  The shaver was reintroduced and all particles were again removed and the meniscus was smoothed over the edge.  The probe was then reintroduced and the shaver removed, the meniscus was probed ___________ and now found to be stable.  At this point, attention was directed to the rest of the knee.  The ACL was examined.  It was intact and stable.  The lateral compartment was then entered.  There was noted to be a grade II-III changes of the lateral femoral condyle.  Again, with the edge of some friability at the shoulder of this cartilage lesion.  There was noted to be some mild degenerative fraying of the posterior horn of the lateral meniscus.  The probe was introduced and the remaining meniscus appeared stable.  This was then removed and the stapler was introduced.  A chondroplasty and meniscoplasty were then performed until adequately debrided and smoothed over.  The lateral gutter was then visualized.  There was no evidence of loose bodies.  Attention was then redirected back to the medial and femoral condyles.,At this point, a 0.62 K-wire was then placed in through the initial portal, medial portal, as well as an additional poke hole, so we can gain access and proper orientation to the medial femoral lesion.  Microfacial technique was then used to introduce the K-wire into the subchondral bone in multiple areas until we had evidence of some bleeding to allow ___________ of this lesion.  After this was performed, the shaver was then reintroduced and the loose bodies and loose fragments were further debrided.  At this point, the shaver was then moved to the suprapatellar pouch and the patellar chondroplasty was then performed until adequately debrided.  Again, all compartments were then re-visualized and there was no further evidence of other pathology or loose bodies.  The knee was then copiously irrigated and suctioned dry.  All instrumentation was removed.  Approximately 20 cc of 0.25% plain Marcaine was injected into the portal site and the remaining portion intraarticular.  Sterile dressings of Adaptic, 4x4s, ABDs, and Webril were then applied.  The patient was then transferred back to the gurney in supine position.,DISPOSITION:  The patient tolerated the procedure well with no complications.  The patient was transferred to PACU in satisfactory condition.
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DESCRIPTION: Arthroscopy, medial meniscoplasty, lateral meniscoplasty, medial femoral chondroplasty, and medical femoral microfracture, right knee.  Patellar chondroplasty.  Lateral femoral chondroplasty.   Meniscal tear, osteochondral lesion, degenerative joint disease, and chondromalacia,

The situation involves a detailed and complex orthopedic surgical procedure on a patient's knee, addressing multiple issues like meniscal tears, osteochondral lesions, and degenerative joint disease. While each patient scenario can vary, surgeries inherently carry higher stakes due to potential risks associated with anesthesia and the surgical interventions themselves. However, the case seems standard with no reported complications or significant estimated blood loss. This would classify it as moderate stakes from a surgical perspective, but higher stakes for the patient's mobility and quality of life.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy & Fusion - 8

PROCEDURES PERFORMED: , C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.,ESTIMATED BLOOD LOSS: , 10 mL.,CLINICAL NOTE: , This is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain.  We decided go ahead with anterior cervical discectomy at C5-C6 and fusion.  The risks of lack of pain relief, paralysis, hoarse voice, nerve injuries, and infection were explained and the patient agreed to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where a general endotracheal anesthesia was induced without complication.  The patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut.  He had tape placed over the shoulders during intraoperative x-rays and his elbows were well padded.  The tape was placed and his arms were well padded.  He was prepped and draped in a sterile fashion.  A linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle.  We separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle.  We then dissected sharply medial to carotid artery, which we palpated to the prevertebral region.  We placed Caspar retractors for medial and lateral exposure over the C5-C6 disc space, which we confirmed with the lateral cervical spine x-ray including 18-gauge needle in the disc space.  We then marked the disc space.  We then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space.  We then under magnification removed all the disc material, we could possibly see down to bleeding bone and both the endplates.  We took down posterior longitudinal ligament as well.  We incised the 6-mm cornerstone bone.  We placed a 6-mm parallel medium bone nicely into the disc space.  We then sized a 23-mm plate.  We inserted the screws nicely above and below.  We tightened down the lock-nuts.  We irrigated the wound.  We assured hemostasis using bone wax prior to placing the plate.  We then assured hemostasis once again.  We reapproximated the platysma using 3-0 Vicryl in a simple interrupted fashion.  The subcutaneous level was closed using 3-0 Vicryl in a simple buried fashion.  The skin was closed with 3-0 Monocryl in a running subcuticular stitch.  Steri-Strips were applied.  Dry sterile dressing with Telfa was applied over this.  We obtained an intraoperative x-ray to confirm the proper level and good position of both plates and screw construct on the lateral x-ray and the patient was transferred to the recovery room, moving all four extremities with stable vital signs.  I was present as a primary surgeon throughout the entire case.
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DESCRIPTION: C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.

surgery, allograft fusion, anterior cervical discectomy, neck pain, cervical spine, discectomy, fusion, sternocleidomastoid muscle, assured hemostasis, anterior cervical, cervical discectomy, disc space, cervical, anterior, allograft

The procedure described is an anterior cervical discectomy and fusion (ACDF), which involves surgical intervention on the cervical spine. This is considered a high-stakes medical procedure due to the complexity and potential risks involved, such as nerve damage, infection, and paralysis, as well as the critical function of the cervical spine in terms of neurological control, particularly because it's close to the spinal cord. Successful outcomes are crucial for the patient's quality of life due to the potential for alleviating severe pain and preventing further neurological issues. However, the surgical team has indicated that the procedure was conducted without reported complications, and the patient was stable post-operatively.


Medical Specialty: Surgery
Sample Name: Spermatocelectomy, Epididymectomy, & Vasectomy

PREOPERATIVE DIAGNOSES:,1.  Left spermatocele.,2.  Family planning.,POSTOPERATIVE DIAGNOSES:,1.  Left spermatocele.,2.  Family planning.,PROCEDURE PERFORMED:,1.  Left spermatocelectomy/epididymectomy.,2.  Bilateral partial vasectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Minimal.,SPECIMEN: , Left-sided spermatocele, epididymis, and bilateral partial vasectomy.,DISPOSITION:  ,To PACU in stable condition.,INDICATIONS AND FINDINGS: , This is a 48-year-old male with a history of a large left-sided spermatocele with significant discomfort.  The patient also has family status complete and desired infertility.  The patient was scheduled for elective left spermatocelectomy and bilateral partial vasectomy.,FINDINGS: , At this time of the surgery, significant left-sided spermatocele was noted encompassing almost the entirety of the left epididymis with only minimal amount of normal appearing epididymis remaining.,DESCRIPTION OF PROCEDURE:,  After informed consent was obtained, the patient was moved to the operating room.  A general anesthesia was induced by the Department of Anesthesia.,The patient was prepped and draped in the normal sterile fashion for a scrotal approach.  A #15 blade was used to make a transverse incision on the left hemiscrotum.  Electrocautery was used to carry the incision down into the tunica vaginalis and the testicle was delivered into the field.  The left testicle was examined.  A large spermatocele was noted.  Metzenbaum scissors were used to dissect the tissue around the left spermatocele.  Once the spermatocele was identified, as stated above, significant size was noted encompassing the entire left epididymis.  Metzenbaum scissors as well as electrocautery was used to dissect free the spermatocele from its testicular attachments and spermatocelectomy and left epididymectomy was completed with electrocautery.  Electrocautery was used to confirm excellent hemostasis.  Attention was then turned to the more proximal aspect of the cord.  The vas deferens was palpated and dissected free with Metzenbaum scissors.  Hemostats were placed on the two aspects of the cord, approximately 1 cm segment of cord was removed with Metzenbaum scissors and electrocautery was used to cauterize the lumen of the both ends of vas deferens and silk ties used to ligate the cut ends.  Testicle was placed back in the scrotum in appropriate anatomic position.  The dartos tissue was closed with running #3-0 Vicryl and the skin was closed in a horizontal interrupted mattress fashion with #4-0 chromic.  Attention was then turned to the right side.  The vas was palpated in the scrotum.  A small skin incision was made with a #15 blade and the vas was grasped with a small Allis clamp and brought into the surgical field.  A scalpel was used to excise the vas sheath and vas was freed from its attachments and grasped again with a hemostat.  Two ends were hemostated with hemostats and divided with Metzenbaum scissors.  Lumen was coagulated with electrocautery.  Silk ties used to ligate both cut ends of the vas deferens and placed back into the scrotum.  A #4-0 chromic suture was used in simple fashion to reapproximate the skin incision.  Scrotum was cleaned and bacitracin ointment, sterile dressing, fluffs, and supportive briefs applied.  The patient was sent to Recovery in stable condition.  He was given prescriptions for doxycycline 100 mg b.i.d., for five days and Vicodin ES 1 p.o. q.4h. p.r.n., pain, #30 for pain.  The patient is to followup with Dr. X in seven days.
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DESCRIPTION: Left spermatocelectomy/epididymectomy and bilateral partial vasectomy.  Left spermatocele and family planning.

surgery, partial vasectomy, spermatocele, epididymis, family planning, vas deferens, metzenbaum scissors, vasectomy, spermatocelectomy, epididymectomy, testicle, deferens, hemostats, electrocautery,

The surgical procedures described are relatively routine and elective rather than emergency or life-saving. A spermatocelectomy addresses a benign condition causing discomfort, and the vasectomy is for family planning, indicating a planned and considered decision by the patient. While surgery always involves inherent risks, such as complications from anesthesia or infection, these procedures do not typically impact the patient's immediate health or life expectancy. Thus, it is not classified as high-stakes compared to emergency or critical surgeries.


Medical Specialty: Consult - History and Phy.
Sample Name: Cardiomyopathy & Hypotension - Consult

REASON FOR CONSULTATION:,  Cardiomyopathy and hypotension.,HISTORY OF PRESENT ILLNESS:,  I am seeing the patient upon the request of Dr. X.  The patient is very well known to me, an 81-year-old lady with dementia, a native American with coronary artery disease with prior bypass, reduced LV function, recurrent admissions for diarrhea and hypotension several times in November and was admitted yesterday because of having diarrhea with hypotension and acute renal insufficiency secondary to that.  Because of her pre-existing coronary artery disease and cardiomyopathy with EF of about 30%, we were consulted to evaluate the patient.  The patient denies any chest pain or chest pressure.  Denies any palpitations.  No bleeding difficulty.  No dizzy spells.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever or chills.,EYES:  No visual disturbances.,ENT:  No difficulty swallowing.,CARDIOVASCULAR:  Basically, no angina or chest pressure.  No palpitations.,RESPIRATORY:  No wheezes.,GI:  No abdominal pain, although she had diarrhea.,GU:  No specific symptoms.,MUSCULOSKELETAL:  Have sores on the back.,NEUROLOGIC:  Have dementia.,All other systems are otherwise unremarkable as far as the patient can give me information.,PAST MEDICAL HISTORY:,1.  Positive for coronary artery disease for about two to three years.,2.  Hypertension.,3.  Anemia.,4.  Chronic renal insufficiency.,5.  Congestive heart failure with EF of 25% to 30%.,6.  Osteoporosis.,7.  Compression fractures.,8.  Diabetes mellitus.,9.  Hypothyroidism.,PAST SURGICAL HISTORY:,1.  Coronary artery bypass grafting x3 in 2008.,2.  Cholecystectomy.,3.  Amputation of the right second toe.,4.  ICD implantation.,CURRENT MEDICATIONS AT HOME:,1.  Amoxicillin.,2.  Clavulanic acid or Augmentin every 12 hours.,3.  Clopidogrel 75 mg daily.,4.  Simvastatin 20 mg daily.,5.  Sodium bicarbonate 650 mg twice daily.,6.  Gabapentin 300 mg.,7.  Levothyroxine once daily.,8.  Digoxin 125 mcg daily.,9.  Fenofibrate 145 mg daily.,10.  Aspirin 81 mg daily.,11.  Raloxifene once daily.,12.  Calcium carbonate and alendronate.,13.  Metoprolol 25 mg daily.,14.  Brimonidine ophthalmic once daily.,ALLERGIES: , She has no known allergies.,FAMILY HISTORY:
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DESCRIPTION: Cardiomyopathy and hypotension.  A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times.

The patient in the consultation has multiple complex and serious medical conditions, including cardiomyopathy, coronary artery disease, chronic renal insufficiency, and congestive heart failure with a significantly reduced ejection fraction. Her situation is compounded by her age, dementia, and recurrent acute issues like diarrhea leading to hypotension. Given these overlapping chronic and acute problems, along with her history of multiple hospital admissions, this is a high-stakes situation that could impact her survival and quality of life. Her medical team needs to carefully manage her condition to prevent further deterioration.


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

Medical Specialty: Radiology
Sample Name: Carotid & Cerebral Arteriograms

EXAM: , Carotid and cerebral arteriograms.,INDICATION: , Abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.,IMPRESSION:,1.  Complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.,2.  Mild stenosis of the right internal carotid artery measured at 20%.,3.  Patent bilateral vertebral arteries.,4.  No significant disease was identified of the anterior cerebral vessels.,DISCUSSION:  ,Carotid and cerebral arteriograms were performed on Month DD, YYYY, previous studies are not available for comparison.,The right groin was sterilely cleansed and draped.  Lidocaine 1% buffered with sodium bicarbonate was used as local anesthetic.  A 19-French needle was then advanced into the common femoral artery and a wire was advanced.  Over the wire, a sheath was placed.  A wire was then advanced into the abdominal aorta and over the wire and the flushed catheter was then advanced to the arch of the aorta over a wire.  Flushed arteriogram was performed.  Arteriogram demonstrated no significant disease of the great vessels at their origins.  There is demonstration of complete occlusion of the left common carotid artery approximately 3 cm distal to its origin.  The vertebral arteries were widely patent.  Following this, the flushed catheter was exchanged for ***** catheter and selective catheterization of the common carotid artery on the right was performed.  Carotid and cerebral arteriograms were performed.  The carotid arteriograms on the right demonstrated the carotid bulb to be unremarkable.  The external carotid artery on the right is quite tortuous in its appearance.  The internal carotid artery demonstrates a mild plaque creating stenosis, which is measured approximately 20%.  Cerebral arteriogram on the right demonstrated the A1 and M1 segments bilaterally to be normal.  No significant stenosis identified.  There is complete cross-filling into the left brain via the right.  No significant stenosis was appreciated.,Following this, the catheter was parked at the origin of the left common carotid artery and ejection demonstrated complete occlusion.,The patient tolerated the procedure well.  No complications occurred during or immediately after the procedure.  Stasis was achieved of the puncture site using a VasoSeal.  The patient will be observed for at least 2-1/2 hours prior to being discharged to home.
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DESCRIPTION: Carotid and cerebral arteriogram - abnormal carotid duplex studies demonstrating occlusion of the left internal carotid artery.

radiology, carotid, arteriogram, bulb, carotid duplex, catheter, cerebral, distal, femoral artery, internal carotid artery, needle, occlusion, sheath, stenosis, vertebral arteries, vessels, cerebral arteriograms, carotid artery, artery, arteriograms, wire,

The report describes a medical procedure, specifically carotid and cerebral arteriograms, used to diagnose the extent of arterial blockages and stenoses in a patient with known occlusion of the left internal carotid artery. The findings indicate complete occlusion in one artery and mild stenosis in another. While the procedure carries risk, it was successfully completed without complications. The situation involves potential risk factors for stroke, making it medically significant but not immediately life-threatening or requiring urgent intervention due to the absence of acute issues. Therefore, it is moderate-stakes due to its potential complications and implications on the patient's health.


Medical Specialty: Gastroenterology
Sample Name: ER Report - Stomach Pain

CHIEF COMPLAINT:, Stomach pain for 2 weeks.,HISTORY OF PRESENT ILLNESS:, The patient is a 45yo Mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. The pain was initially crampy and burning in character and was relieved with food intake. He also reports that it initially was associated with a sour taste in his mouth. He went to his primary care physician who prescribed cimetidine 400mg qhs x 5 days; however, this did not relieve his symptoms. In fact, the pain has worsened such that the pain now radiates to the back but is waxing and waning in duration. It is relieved with standing and ambulation and exacerbated when lying in a supine position. He reports a decrease in appetite associated with a 4 lb. wt loss over the last 2 wks. He does have nausea with only one episode of non-bilious, non-bloody emesis on day of admission. He reports a 2 wk history of subjective fever and diaphoresis. He denies any diarrhea, constipation, dysuria, melena, or hematochezia. His last bowel movement was during the morning of admission and was normal. He denies any travel in the last 9 years and sick contacts.,PAST MEDICAL HISTORY:, Right inguinal groin cyst removal 15 years ago. Unknown etiology. No recurrence.,PAST SURGICAL HISTORY:, Left femoral neck fracture with prosthesis secondary to a fall 4 years ago.,FAMILY HISTORY:, Mother with diabetes. No history of liver disease. No malignancies.,SOCIAL HISTORY:, The patient was born in central Mexico but moved to the United States 9 years ago. He is on disability due to his prior femoral fracture. He denies any tobacco or illicit drug use. He only drinks alcohol socially, no more than 1 drink every few weeks. He is married and has 3 healthy children. He denies any tattoos or risky sexual behavior.,ALLERGIES:, NKDA.,MEDICATIONS:, Tylenol prn (1-2 tabs every other day for the last 2 wks), Cimetidine 400mg po qhs x 5 days.,REVIEW OF SYSTEMS:,  No headache, vision changes. No shortness of breath. No chest pain or palpitations.,PHYSICAL EXAMINATION:,Vitals: T 100.9-102.7 BP 136/86 Pulse 117 RR 12 98% sat on room air,Gen: Well-developed, well-nourished, no apparent distress.,HEENT: Pupils equal, round and reactive to light. Anicteric. Oropharynx clear and moist.,Neck: Supple. No lymphadenopathy or carotid bruits. No thyromegaly or masses.,CHEST: Clear to auscultation bilaterally.,CV: Tachycardic but regular rhythm, normal S1/S2, no murmurs/rubs/gallops.,Abd: Soft, active bowel sounds. Tender in the epigastrium and right upper quadrant with palpation associated with slight guarding. No rebound tenderness. No hepatomegaly. No splenomegaly.,Rectal: Stool was brown and guaiac negative.,Ext: No cyanosis/clubbing/edema.,Neurological: He was alert and oriented x3. CN II-XII intact. Normal 2+ DTRs. No focal neurological deficit.,Skin: No jaundice. No skin rashes or lesions.,IMAGING DATA:,CT Abdomen with contrast ( 11/29/03 ):  There is a 6x6 cm multilobular hypodense mass seen at the level of the hepatic hilum and caudate lobe which is resulting in mass effect with dilatation of the intrahepatic radicals of the left lobe of the liver. The rest of the liver parenchyma is homogeneous. The gallbladder, pancreas, spleen, adrenal glands and kidneys are within normal limits. The retroperitoneal vascular structures are within normal limits. There is no evidence of lymphadenopathy, free fluid or fluid collections.,HOSPITAL COURSE:,  The patient was admitted to the hospital for further evaluation. A diagnostic procedure was performed.
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DESCRIPTION: Patient presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days.

The situation described is potentially high-stakes due to several concerning findings. The patient has a 6x6 cm mass at the hepatic hilum and caudate lobe, resulting in mass effect and dilatation of intrahepatic radicals, which could indicate a possible liver tumor or other serious condition. Additionally, the symptoms have worsened despite initial medical treatment, and there are systemic signs like fever and tachycardia. While not an immediate life-threatening emergency, the potential for significant health implications due to the mass location and the need for further diagnostic evaluation make it a high-stakes medical situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Peripheral Effusion - Consult

REASON FOR CONSULT: , Peripheral effusion on the CAT scan.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.  The patient had a visiting nurse for Christmas and started having abdominal pain, nausea and vomiting for which, she was admitted.  She had a CAT scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested.  She had an echo done, which shows moderate pericardial effusion with early tamponade.  The patient has underlying shortness of breath because of COPD, emphysema and chronic cough.  However, denies any dizziness, syncope, presyncope, palpitation.  Denies any prior history of coronary artery disease.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , At this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, Ambien.  She is on oxygen and nebulizer.,PAST MEDICAL HISTORY: , History of COPD, emphysema, pneumonia, and lung cancer.,PAST SURGICAL HISTORY:  ,Hip surgery and resection of the lung cancer 10 years ago.,SOCIAL HISTORY:,  Still smokes, but less than before.  Drinks socially.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS: , Denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable not in any distress.,VITAL SIGNS:  Blood pressure 121/79, Pulse rate 94, respiratory rate 19, and temperature 97.6.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Breath sounds vesicular.  Clear on auscultation.,HEART:  PMI could not be localized.  S2 and S2 regular.  No S3, no S4.  No murmur.,ABDOMEN:  Soft and nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,EKG shows normal sinus rhythm, low voltage.,LABORATORY DATA: , White cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000.  Sodium 135, potassium 5, BUN 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,DIAGNOSTIC STUDIES:,  Chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______.  CT abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,ASSESSMENT:,1.  Moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2.  Lung cancer with metastasis most likely.,3.  Pneumonia.,4.  COPD.,PLAN: , We will get CT surgery consult for pericardial window.  Continue present medication.
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DESCRIPTION: Peripheral effusion on the CAT scan.  The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.

The patient in this scenario has a significant medical history that includes lung cancer with metastasis, COPD, pneumonia, and a current pericardial effusion with early signs of tamponade. These conditions are serious, especially since cardiac tamponade can become life-threatening if not treated promptly. The decision to consult CT surgery for a pericardial window indicates that immediate medical intervention is necessary to prevent potential complications, such as respiratory distress or cardiac arrest. The complexity and acuity of the patient's conditions make this a high-stakes situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Acne Vulgaris - H&P

CHIEF COMPLAINT (1/1): , This 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use.  Location:  She indicates the problem location is the chin, right temple and left temple locally.  Severity:  Severity of condition is worsening.,Menses:  Onset:  13 years old.  Interval:  22-27 days.  Duration:  4-6 days.  Flow:  light.  Complications:  none.,ALLERGIES: , Patient admits allergies to penicillin resulting in difficulty breathing.,MEDICATION HISTORY:,  Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by Obstetrician-Gynecologist A.,PAST MEDICAL HISTORY:,  Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.,PAST SURGICAL HISTORY:,  No previous surgeries.,FAMILY HISTORY: , Patient admits a family history of anxiety, stress disorder associated with mother.,SOCIAL HISTORY:,  Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history.,REVIEW OF SYSTEMS:,  Integumentary: (+) periodic reddening of face, (+) acne problems, Allergic /,Immunologic: (-) allergic or immunologic symptoms, Constitutional Symptoms: (-) constitutional symptoms,such as fever, headache, nausea, dizziness.,PHYSICAL EXAM:,  Patient is a 19 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.  Skin:  Examination of scalp shows no abnormalities.  Hair growth and distribution is normal.  Inspection of skin outside of affected area reveals no abnormalities.  Palpation of skin shows no abnormalities.  Inspection of eccrine and apocrine glands shows no evidence of hyperidrosis, chromidrosis or bromhidrosis.  Face shows keratotic papule.,IMPRESSION:,  Acne vulgaris.,PLAN:,  Recommended treatment is antibiotic therapy.  Patient received extensive counseling about acne.  She understands acne treatment is usually long-term.  Return to clinic in 4 week (s).,PATIENT INSTRUCTIONS:,  Patient received literature regarding acne vulgaris.  Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion.,PRESCRIPTIONS:,  Tetracycline  Dosage:  250 mg capsule  Sig:  BID  Dispense:  60  Refills:  0  Allow Generic:  Yes
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DESCRIPTION: Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris

The situation involves a medical assessment and treatment of acne vulgaris for a 19-year-old female. Acne itself, while often distressing, is typically not a life-threatening or critical medical condition, especially in a controlled healthcare setting. The description reveals that the patient has been prescribed antibiotics after a proper examination, and she has been counseled on the treatment plan. Although the patient has an allergy to penicillin, the prescribed medication (Tetracycline) does not belong to the penicillin family, reducing immediate risk. As this is primarily a routine dermatological issue with a non-critical prescription treatment plan, it is not considered high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Bilateral Hip Pain

HISTORY OF PRESENT ILLNESS:  ,The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration.  The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip.  The pain is located laterally as well as anteriorly into the groin.  She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip.  She is here for evaluation for the first time.  She sought no previous medical attention for this.,PAST MEDICAL HISTORY:  ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES:  ,The patient has no known drug allergies.,SOCIAL HISTORY:  ,The patient is married.  She is employed as an office manager.  She does smoke cigarettes, one pack per day for the last 20 years.  She consumes alcohol 3 to 5 drinks daily.  She uses no illicit drugs.  She exercises monthly mainly walking and low impact aerobics.  She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression.  The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds.  The patient ambulates independently without an assist device with normal stance and gait.  Inspection of the hips reveals normal contour and appearance and good symmetry.  The patient is able to do an active straight leg raise against gravity and against resistance bilaterally.  She has no significant trochanteric tenderness.  She does, however, have some tenderness in the groin bilaterally.  There is no crepitus present with passive or active range of motion of the hips.  She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:,  X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip.  There are no acute findings.  No fractures or dislocations.  There are minimal degenerative changes noted in the joint.  There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:,  After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip.  We will get that done as soon as possible.  In the meantime, she is asked to moderate her activities.  She will follow up as soon as the MRIs are performed.
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DESCRIPTION: A woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration.  The pain is located laterally as well as anteriorly into the groin.

consult - history and phy., bilateral hip pain, femoroacetabular, impingement, hip,

The situation involves a 38-year-old woman experiencing bilateral hip pain for over two years, with the right side being more affected than the left. She has not sought medical attention for this before. The X-ray suggests possible femoroacetabular impingement, and an MRI is recommended to further evaluate the condition. While the symptoms are affecting her quality of life, the situation is not immediately life-threatening, and the proposed treatment plan involves further diagnostics rather than emergency intervention. The condition could potentially worsen if left untreated, and the patient’s lifestyle factors, such as smoking and alcohol consumption, may impact her long-term joint health. Hence, it is moderately high-stakes as it requires timely medical intervention to avoid further complications and improve quality of life.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 10

CHIEF COMPLAINT:,  The patient is here for two-month followup.,HISTORY OF PRESENT ILLNESS:,  The patient is a 55-year-old Caucasian female.  She has hypertension.  She has had no difficulties with chest pain.  She has some shortness of breath only at walking up the stairs.  She has occasional lightheadedness only if she bends over then stands up quickly.  She has had no nausea, vomiting, or diarrhea.  She does have severe osteoarthritis of the left knee and is likely going to undergo total knee replacement with Dr. XYZ in January of this coming year.  The patient is wanting to lose weight before her surgery.  She is concerned about possible coronary disease or stroke risk.  She has not had any symptoms of cardiac disease other than some shortness of breath with exertion, which she states has been fairly stable.  She has had fairly normal lipid panel, last being checked on 11/26/2003.  Cholesterol was 194, triglycerides 118, HDL 41, and LDL 129.  The patient is a nonsmoker.  Her fasting glucose in November 2003 was within normal limits at 94.  Her fasting insulin level was normal.  Repeat nonfasting glucose was 109 on 06/22/2004.  She does not have history of diabetes.  She does not exercise regularly and is not able to because of knee pain.  She also has had difficulties with low back pain.  X-ray of the low back did show a mild compression fracture of L1.  She has had no falls that would contribute to a compression fracture.  She has had a normal DEXA scan on 11/07/2003 that does not really correlate with having a compression fracture of the lumbar spine; however, it is possible that arthritis could contribute to falsely high bone density reading on DEXA scan.  She is wanting to consider treatment for prevention of further compression fractures and possible osteoporosis.,CURRENT MEDICATIONS:,  Hydrochlorothiazide 12.5 mg a day, Prozac 20 mg a day, Vioxx 25 mg a day, vitamin C 250 mg daily, vitamin E three to four tablets daily, calcium with D 1500 mg daily, multivitamin daily, aspirin 81 mg daily, Monopril 40 mg daily, Celexa p.r.n.,ALLERGIES:  ,Bactrim, which causes nausea and vomiting, and adhesive tape.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  Depression.,3.  Myofascitis of the feet.,4.  Severe osteoarthritis of the knee.,5.  Removal of the melanoma from the right thigh in 1984.,6.  Breast biopsy in January of 1997, which was benign.,7.  History of Holter monitor showing ectopic beat.  Echocardiogram was normal.  These were in 1998.,8.  Compression fracture of L1, unknown cause.  She had had no injury.  Interestingly, DEXA scan was normal 11/07/2003, which is somewhat conflicting.,SOCIAL HISTORY:,  The patient is married.  She is a nonsmoker and nondrinker.,REVIEW OF SYSTEMS:,  As per the HPI.,PHYSICAL EXAMINATION:,General:  This is a well-developed, well-nourished, pleasant Caucasian female, who is overweight.,Vital signs:  Weight:  Refused.  Blood pressure:  148/82, on recheck by myself with a large cuff, it was 125/60.  Pulse:  64.  Respirations:  20.  Temperature:  96.3.,Neck:  Supple.  Carotids are silent.,Chest:  Clear to auscultation.,Cardiovascular:  Revealed a regular rate and rhythm without murmur, S3, or S4.,Extremities:  Revealed no edema.,Neurologic:  Grossly intact.,RADIOLOGY:  EKG revealed normal sinus rhythm, rate 61, borderline first degree AV block, and poor R-wave progression in the anterior leads.,ASSESSMENT:,1.  Hypertension, well controlled.,2.  Family history of cerebrovascular accident.,3.  Compression fracture of L1, mild.,4.  Osteoarthritis of the knee.,5.  Mildly abnormal chest x-ray.,PLAN:,1.  We will get a C-reactive protein cardiac.,2.  We discussed weight loss options.  I would recommend Weight Watchers or possibly having her see a dietician.  She will think about these options.  She is not able to exercise regularly right now because of knee pain.,3.  We would recommend a screening colonoscopy.  She states that we discussed this in the past and she canceled her appointment to have that done.  She will go ahead and make an appointment to see Dr. XYZ for screening colonoscopy.,4.  We will start Fosamax 70 mg once weekly.  She is to take this in the morning on an empty stomach with full glass of water.  She is not to eat, lie down, or take other medications for at least 30 minutes after taking Fosamax.,5.  I would like to see her back in one to two months.  At that time, we can do preoperative evaluation and we will probably send her to a cardiologist because of mildly abnormal EKG for preoperative cardiac testing.  One would also consider preoperative beta-blocker for cardiac protection.
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DESCRIPTION: Patient comes in for two-month followup - Hypertension, family history of CVA, Compression fracture of L1, and osteoarthritis of knee.

The medical progress note details a patient with several chronic conditions, namely hypertension, osteoarthritis, and a history of compression fracture. The main goal is a follow-up with some concerns about cardiac health due to a mildly abnormal EKG and preparation for an upcoming knee surgery. While the note indicates some elevated risks, such as family history of cerebrovascular accident and mildly abnormal EKG, the current management plan involves routine procedures such as cardiac testing and a screening colonoscopy. There's no acute or life-threatening condition being addressed immediately, which makes the situation more routine in the context of managing chronic conditions and surgical prep.


Medical Specialty: Ophthalmology
Sample Name: Premature retina and vitreous

OCULAR FINDINGS: , Anterior chamber space:  Cornea, iris, lens, and pupils all unremarkable on gross examination in each eye.,Ocular adnexal spaces appear very good in each eye.,Cyclomydril x2 was used to dilate the pupil in each eye.,Medial spaces are clear and the periphery is still hazy in each eye.,Ocular disc space, normal size and shape with a pink color with clear margin in each eye.,Macular spaces are normal in appearance for the age in each eye.,Posterior pole.  No dilated blood vessels seen in each eye.,Periphery:  The peripheral retina is still hazy and retinopathy of prematurity cannot be ruled out at this time in each eye.,IMPRESSION:  ,Premature retina and vitreous, each eye.,PLAN:  ,Recheck in two weeks.,
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DESCRIPTION: Small office note on premature retina and vitreous.

ophthalmology, eye ocular, premature retina, pupils, periphery, premature, vitreous, retina, eye,

The situation involves a medical examination and follow-up for a condition related to premature retina and vitreous, specifically noting the possibility of retinopathy of prematurity. This is a potentially serious condition in newborns that requires careful monitoring and prompt management to prevent vision problems. The stake level is moderate because it involves the potential for significant health impacts, i.e., vision impairment, in a vulnerable population - premature infants. The plan is to recheck in two weeks, indicating ongoing monitoring is crucial, but there is no immediate indication of a critical situation or urgent intervention required at this moment.


Medical Specialty: Surgery
Sample Name: Closed Reduction - 2

PREOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,PROCEDURE:,  Closed reduction with splint application with use of image intensifier.,INDICATIONS: , Mr. ABC is an 11-year-old boy who sustained a fall on 07/26/2008.  Evaluation in the emergency department revealed both-bone forearm fracture.  Considering the amount of angulation, it was determined that we should proceed with conscious sedation and closed reduction.  After discussion with parents, verbal and written consent was obtained.,DESCRIPTION OF PROCEDURE:  ,The patient was induced with propofol for conscious sedation via the emergency department staff.  After it was confirmed that appropriate sedation had been reached, a longitudinal traction in conjunction with re-creation of the injury maneuver was applied reducing the fracture.  Subsequently, this was confirmed with image intensification, a sugar-tong splint was applied and again reduction was confirmed with image intensifier.  The patient was aroused from anesthesia and tolerated the procedure well.  Post-reduction plain films revealed some anterior displacement of the distal fragment.  At this time, it was determined this fracture proved to be unstable.,DISPOSITION: , After review of the reduction films, it appears that there is some element of fracture causing displacement.  We will proceed to the operating room for open reduction and internal fixation versus closed reduction and percutaneous pinning as our operative schedule allows.,
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DESCRIPTION: Left distal both-bone forearm fracture.  Closed reduction with splint application with use of image intensifier.

surgery, closed reduction, reduction with splint application, distal both bone forearm, distal both bone, splint application, emergency department, conscious sedation, image intensifier, bone forearm, forearm fracture, reduction, emergency, department, conscious, displacement, splint, sedation, tong, distal, bone, image, intensifier, forearm, fracture

This medical procedure initially involves a closed reduction for a forearm fracture in an 11-year-old patient, which is a common orthopedic procedure. However, there is an indication of instability with residual displacement, suggesting a need for potential surgical intervention (open reduction and internal fixation or closed reduction with pinning) if nonsurgical means do not maintain the fracture position. The situation could become high-stakes if the non-invasive methods fail, necessitating surgery, but initially, it is a moderate-stakes situation considering the current steps and standard nature of the procedure.