Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy & Arthrodesis - 2

PREOPERATIVE DIAGNOSIS:  ,Cervical spondylosis and herniated nucleus pulposus of C4-C5.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis and herniated nucleus pulposus of C4-C5.,TITLE OF OPERATION:,  Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,OPERATIVE PROCEDURE IN DETAIL: , After identification, the patient was taken to the operating room and placed in supine position.  Following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position.  A preoperative x-ray was obtained to identify the operative level and neck position.  An incision was marked at the C4-C5 level on the right side.  The incision was opened with #10 blade knife.  Dissection was carried down through subcutaneous tissues using Bovie electrocautery.  The platysma muscle was divided with the cautery and mobilized rostrally and caudally.  The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection.  The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia.  This was opened with scissors and dissected rostrally and caudally with the peanut dissectors.  The operative level was confirmed with an intraoperative x-ray.  The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator.  The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5.  Self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of C4 and C5, and distraction was instituted.  We then incise the annulus of C4-C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes.  Operating microscope was draped and brought into play.  Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went.  We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally.  Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch.  There was a transligamentous disc herniation, which was removed during this process.  We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent.  Cord was seen to be pulsating freely behind the dura.  There appeared to be no complications and the decompression appeared adequate.  We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body.  An 8 mm lordotic trial was used and appeared perfect.  We then used a corticocancellous 8 mm lordotic graft.  This was tapped into position.  Distraction was released, appeared to be in excellent position.  We then positioned an 18 mm Vector plate over the inner space.  Intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position.  We then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion.  All of the screws locked to the plate and this was confirmed on visual inspection.  Intraoperative x-ray was again obtained.  Construct appeared satisfactory.  Attention was then directed to closure.  The wound was copiously irrigated.  All of the self-retaining retractors were removed.  Bleeding points were controlled with bone wax and bipolar electrocautery.  The platysma layer was now closed with interrupted 3-0 Vicryl sutures.  The skin was closed with running 3-0 Vicryl subcuticular stitch.  Steri-Strips were applied.  A sterile bandage was applied.  All sponge, needle, and cottonoid counts were reported as correct.  The patient tolerated the procedure well.  He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition.
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DESCRIPTION: Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.  Cervical spondylosis and herniated nucleus pulposus of C4-C5.

surgery, synthes vector plate, lordotic, acf spacer, corticocancellous, arthrodesis, anterior cervical discectomy, herniated nucleus pulposus, anterior, cervical, spacer, screws, discectomy,

The given situation describes a surgical procedure involving anterior cervical discectomy and arthrodesis, which are complex operations typically necessary to address spinal issues such as cervical spondylosis and herniated discs. These procedures are inherently high-stakes due to their proximity to critical spinal structures, nerves, and the spinal cord. Complications can include nerve damage, infection, or issues with the hardware used for stabilization, which could have significant health implications for the patient. The need for precision and accuracy during the surgery, combined with the potential consequences of any errors, indicates that this is a high-stakes situation.


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

Medical Specialty: Dentistry
Sample Name: Dental Pain - Emergency Visit

CHIEF COMPLAINT: , Dental pain.,HISTORY OF PRESENT ILLNESS: , This is a 45-year-old Caucasian female who states that starting last night she has had very significant pain in her left lower jaw.  The patient states that she can feel an area with her tongue and one of her teeth that appears to be fractured.  The patient states that the pain in her left lower teeth kept her up last night.  The patient did go to Clinic but arrived there later than 7 a.m., so she was not able to be seen there will call line for dental care.  The patient states that the pain continues to be very severe at 9/10.  She states that this is like a throbbing heart beat in her left jaw.  The patient denies fevers or chills.  She denies purulent drainage from her gum line.  The patient does believe that there may be an area of pus accumulating in her gum line however.  The patient denies nausea or vomiting.  She denies recent dental trauma to her knowledge.,PAST MEDICAL HISTORY:,1.  Coronary artery disease.,2.  Hypertension.,3.  Hypothyroidism.,PAST SURGICAL HISTORY:  ,Coronary artery stent insertion.,SOCIAL HABITS: , The patient denies alcohol or illicit drug usage.  Currently she does have a history of tobacco abuse.,MEDICATIONS:,1.  Plavix.,2.  Metoprolol.,3.  Synthroid.,4.  Potassium chloride.,ALLERGIES:,1.  Penicillin.,2.  Sulfa.,PHYSICAL EXAMINATION:,GENERAL:  This is a Caucasian female who appears of stated age of 45 years.  She is well-nourished, well-developed, in no acute distress.  The patient is pleasant but does appear to be uncomfortable.,VITAL SIGNS:  Afebrile, blood pressure 145/91, pulse of 78, respiratory rate of 18, and pulse oximetry of 98% on room air.,HEENT:  Head is normocephalic.  Pupils are equal, round and reactive to light and accommodation.  Sclerae are anicteric and noninjected.  Nares are patent and free of mucoid discharge.  Mucous membranes are moist and free of exudate or lesion.  Bilateral tympanic membranes are visualized and free of infection or trauma.  Dentition shows significant decay throughout the dentition.  The patient has had extraction of teeth 17, 18, and 19.  The patient's tooth #20 does have a small fracture in the posterior section of the tooth and there does appear to be a very minor area of fluctuance and induration located at the alveolar margin at this site.  There is no pus draining from the socket of the tooth.  No other acute abnormality to the other dentition is visualized.,DIAGNOSTIC STUDIES: , None.,PROCEDURE NOTE:  ,The patient does receive an injection of 1.5 mL of 0.5% bupivacaine for inferior alveolar nerve block on the left mandibular teeth.  The patient undergoes this all procedure without complication and does report some mild decrease of her pain with this and patient was also given two Vicodin here in the Emergency Department and a dose of Keflex for treatment of her dental infection.,ASSESSMENT:  ,Dental pain with likely dental abscess.  ,PLAN: , The patient was given a prescription for Vicodin.  She is also given prescription for Keflex, as she is penicillin allergic.  She has tolerated a dose of Keflex here in the Emergency Department well without hypersensitivity.  The patient is strongly encouraged to follow up with Dental Clinic on Monday, and she states that she will do so.  The patient verbalizes understanding of treatment plan and was discharged in satisfactory condition from the ER.,
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DESCRIPTION: Significant pain in left lower jaw.

Significant pain in left lower jaw.

The patient's situation involves severe dental pain with a suspected fractured tooth and a likely dental abscess. While the dental pain is intense, rated at 9 out of 10, and has affected her sleep, she is not in acute distress and has managed the initial treatment well. The presence of other medical conditions like coronary artery disease and hypertension adds complexity but doesn't significantly elevate the immediate stakes of this situation. The fact that she was treated with pain relief, an antibiotic, and encouraged to seek dental follow-up suggests that while this situation demands attention to prevent escalation, it is not immediately life-threatening. Dental issues can escalate if not treated, but current interventions have stabilized the situation for now.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 42

HISTORY AND CLINICAL DATA:  ,The patient is an 88-year-old gentleman followed by Dr. X, his primary care physician, Dr. Y for the indication of CLL and Dr. Z for his cardiovascular issues.  He presents to the Care Center earlier today with approximately a one-week history of increased progressive shortness of breath, orthopnea over the course of the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea presenting this morning.,He reports no clear-cut chest discomfort or difficulty with angina.  He has had no dizziness, lightheadedness, no near or true syncope, nothing supportive of CVA, TIA, nor peripheral vascular claudication.,REVIEW OF SYSTEMS:,  General review of system is significant for difficulty with intermittent constipation, which has been problematic recently.  He reports no fever, shaking chills, nothing supportive of GI or GU blood loss, no productive or nonproductive cough.,PAST MEDICAL HISTORY:,  Remarkable for hypertension, diabetes, prostate cancer, status post radium seed implant, COPD, single vessel coronary disease, esophageal reflux, CLL, osteopenia, significant hearing loss, anxiety, and degenerative joint disease.,SOCIAL HISTORY: , Remarkable for being married, retired, quit smoking in 1997, rare use of alcohol, lives locally with his wife.,MEDICATIONS AT HOME:,  Include, Lortab 7.5 mg up to three times daily for chronic arthritic discomfort, Miacalcin nasal spray once daily, omeprazole 20 mg daily, Diovan 320 mg daily, Combivent two puffs t.i.d., folate, one adult aspirin daily, glyburide 5 mg daily, atenolol 50 mg daily, furosemide 40 mg daily, amlodipine 5 mg daily, hydralazine 50 mg p.o. t.i.d., in addition to Tekturna 150 mg daily, Zoloft 25 mg daily.,ALLERGIES:  ,He has known history of allergy to clonidine, Medifast does fatigue.,DIAGNOSTIC AND LABORATORY DATA: , Chest x-ray upon presentation to the Ellis Emergency Room this evening demonstrate significant congestive heart failure with moderate-sized bilateral pleural effusions.,A 12-lead EKG, sinus rhythm at a rate of 68 per minute, right bundle-branch block type IVCV with moderate nonspecific ST changes.  Low voltage in the limb leads.,WBC 29,000, hemoglobin 10.9, hematocrit 31, platelets 187,000.  Low serum sodium at 132, potassium 4, BUN 28, creatinine 1.2, random glucose 179.  Low total protein 5.7.  Magnesium level 2.3, troponin 0.404 with the B-natriuretic peptide of 8200.,PHYSICAL EXAMINATION:  ,He is an elderly gentleman, who appears to be in no acute distress, lying comfortably flat at 30 degrees, measured pressure of 150/80 with a pulse of 68 and regular.  JVD difficult to assess.  Normal carotids with obvious bruits.  Conjunctivae pink.  Oropharynx clear.  Mild kyphosis.  Diffusely depressed breath sounds halfway up both posterior lung fields.  No active wheezing.  Cardiac Exam:  Regular, soft, 1-2/6 early systolic ejection murmur best heard at the base.  Abdomen:  Soft, nontender, protuberant, benign.  Extremities:  2+ bilateral pitting edema to the level of the knees.  Neuro Exam:  Appears alert, oriented x3.  Appropriate manner and affect, exceedingly hard of hearing.,OVERALL IMPRESSION:,  An 88-year-old white male with the following major medical issues:,1.  Presentation consists with subclinical congestive heart failure possibly systolic, no recent echocardiogram available for review.,2.  Hypertension with suboptimal controlled currently.,3.  Diabetes.,4.  Prostate CA, status post radium seed implant.,5.  COPD, on metered-dose inhaler.,6.  CLL followed by Dr. Y.,7.  Single-vessel coronary disease, no recent anginal quality chest pain, no changes in ECG suggestive of acute ischemia; however, initial troponin 0.4 - to be followed with serial enzyme determinations and telemetry.,8.  Hearing loss, anxiety.,9.  Significant degenerative joint disease.,PLAN:,1.  Admit to A4 with telemetry, congestive heart failure pathway, intravenous diuretic therapy.,2.  Strict I&O, Foley catheter has already been placed.,3.  Daily BMP.,4.  Two-dimensional echocardiogram to assess left ventricular systolic function.  Serum iron determination to exclude the possibility of a subclinical ischemic cardiac event.  Further recommendations will be forthcoming pending his clinical course and hospital.
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DESCRIPTION: Patient with one-week history of increased progressive shortness of breath, orthopnea for the past few nights, mild increase in peripheral edema, and active wheezing with dyspnea.  Medifast does fatigue

The situation involves an 88-year-old patient presenting with symptoms likely related to congestive heart failure, among other serious health conditions such as diabetes, COPD, and coronary artery disease. The patient has a complicated medical history and is experiencing acute symptoms that warrant hospital admission and further diagnostic testing. The presentation of congestive heart failure, along with potential subclinical ischemic events, infers a situation that demands immediate medical attention and monitoring. This makes it relatively high-stakes, as the patient's condition could deteriorate quickly without appropriate management. Medical professionals need to closely monitor and manage these symptoms to prevent further complications, which increases the critical nature of the situation.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Cervical Spinal Stenosis

REASON FOR VISIT:  ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC returns today for followup regarding her cervical spinal stenosis.  I have last seen her on 06/19/07.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,I referred her to obtain a cervical spine MRI.,She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck.  She had some physical therapy, which has been helping with the neck pain.  The right hand weakness continues.  She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity.  She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms.,She denies any bowel and bladder dysfunction.  No lower back pain, no lower extremity pain, and no instability with ambulation.,REVIEW OF SYSTEMS:,  Negative for fevers, chills, chest pain, and shortness of breath.,FINDINGS:  ,On examination, Ms. ABC is a very pleasant well-developed, well-nourished female in no apparent distress.  Alert and oriented x3.  Normocephalic and atraumatic.  Afebrile to touch.,She ambulates with a normal gait.,Motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,Light touch sensation decreased in the right greater than left C6 distribution.  Biceps and brachioradialis reflexes are 3 plus.  Hoffman sign normal bilaterally.,Lower extremity strength is 5 out of 5 in all muscle groups.  Patellar reflex is 3 plus.  No clonus.,Cervical spine radiographs dated 06/21/07 are reviewed.,They demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at C4-5, C5-6, C6-7, and C3-4 demonstrates only minimal if any degenerative disk disease.  There is no significant instability seen on flexion-extension views.,Updated cervical spine MRI dated 06/21/07 is reviewed.,It demonstrates evidence of moderate stenosis at C4-5, C5-6.  These stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the C6-7 level.  Minimal degenerative disk disease is seen at the C6-7.  This stenosis is greater than C5-6 and the next level is more significantly involved at C4-5.,Effacement of the ventral and dorsal CSF space is seen at C4-5, C5-6.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination, and radiographic findings are compatible with C4-5, C5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,I spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,I laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,The patient states she would like to avoid injections and is somewhat afraid of having these done.  I explained to her that they may help to improve her symptoms, although they may not help with the weakness.,She feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,I described the procedure consisting of C4-5, C5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,I explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain.  She understands.,I discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age.  Of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,I also discussed the option of disk arthroplasty.  She understands.,She would like to proceed with the surgery, relatively soon.  She has her birthday coming up on 07/20/07 and would like to hold off, until after then.  Our tentative date for the surgery is 08/01/07.  She will go ahead and continue the preoperative testing process.
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DESCRIPTION: Followup cervical spinal stenosis.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.

This case involves a patient with worsening symptoms from cervical spinal stenosis, including pain, weakness, and paresthesias of the upper extremities. The patient has been undergoing nonoperative management but is considering surgical intervention due to insufficient improvement. The stakes are high due to the complexity and risks associated with spinal surgery, as well as the potential for serious consequences from both the condition and the surgery, such as paralysis and neurovascular injury.


Medical Specialty: Orthopedic
Sample Name: Osteosynthesis

PREOPERATIVE DIAGNOSIS:,  Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,POSTOPERATIVE DIAGNOSIS:,  Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,PROCEDURES:,1.  Osteosynthesis of acetabular fracture on the left, complex variety.,2.  Total hip replacement.,ANESTHESIA: , General.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient in the left side up lateral position under adequate general endotracheal anesthesia, the patient's left lower extremity and buttock area were prepped with iodine and alcohol in the usual fashion, draped with sterile towels and drapes so as to create a sterile field.  Kocher Langenbeck variety incision was utilized and carried down through the fascia lata with the split fibers of the gluteus maximus in line.  The femoral insertion of gluteus maximus was tenotomized close to its femoral insertion.  The piriformis and obturator internus tendons and adjacent gemelli were tenotomized close to their femoral insertion, tagged, and retractor was placed in the lesser notch as well as a malleable retractor in the greater notch enabling the exposure of the posterior column.  The major transverse fracture was freed of infolded soft tissue, clotted blood, and lavaged copiously with sterile saline solution and then reduced anatomically with the aid of bone hook in the notch and provisionally stabilized utilizing a tenaculum clamp and definitively stabilized utilizing a 7-hole 3.5 mm reconstruction plate with the montage including two interfragmentary screws.  It should be mentioned that prior to reduction and stabilization of the acetabular fracture its femoral head component was removed from the joint enabling direct visualization of the articular surface.  Once a stable fixation of the reduced fracture of the acetabulum was accomplished, it should be mentioned that in the process of doing this, the posterior wall fragment was hinged on its soft tissue attachments and a capsulotomy was made in the capsule in line with the rent at the level of the posterior wall.  Once this was accomplished, the procedure was turned over to Dr. X and his team, who proceeded with placement of cup and femoral components as well and cup was preceded by placement of a trabecular metal tray for the cup with screw fixation of same.  This will be dictated in separate note.  The patient tolerated the procedure well.  The sciatic nerve was well protected and directly visualized to the level of the notch.
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DESCRIPTION: Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.  Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement.

orthopedic, hip replacement, osteosynthesis, intertrochanteric variety, femoral insertion, acetabular fracture, fracture, acetabular, intertrochanteric, femoral

The situation described involves a complex orthopedic surgical procedure to address an acetabular fracture and intertrochanteric fracture in the hip, combined with a total hip replacement. These types of surgeries are significant due to their complexity and the critical nature of the hip joint. They require precise execution to restore mobility and prevent complications post-surgery. However, the procedure was completed without complications, implying that it was planned and executed competently. While large surgeries inherently carry risks and require significant expertise, they are routine procedures for orthopedic specialists. Given these factors, the situation is moderately high-stakes within the orthopedic field but not at the highest level due to the absence of complications and the routine nature of the procedures for trained professionals.


Medical Specialty: Gastroenterology
Sample Name: CT Abdomen & Pelvis - 2

EXAM: , CT scan of the abdomen and pelvis without and with intravenous contrast.,CLINICAL INDICATION: , Left lower quadrant abdominal pain.,COMPARISON: , None.,FINDINGS: , CT scan of the abdomen and pelvis was performed without and with intravenous contrast.  Total of 100 mL of Isovue was administered intravenously.  Oral contrast was also administered.,The lung bases are clear.  The liver is enlarged and decreased in attenuation.  There are no focal liver masses.,There is no intra or extrahepatic ductal dilatation.,The gallbladder is slightly distended.,The adrenal glands, pancreas, spleen, and left kidney are normal.,A 12-mm simple cyst is present in the inferior pole of the right kidney.  There is no hydronephrosis or hydroureter.,The appendix is normal.,There are multiple diverticula in the rectosigmoid.  There is evidence of focal wall thickening in the sigmoid colon (image #69) with adjacent fat stranding in association with a diverticulum.  These findings are consistent with diverticulitis.  No pneumoperitoneum is identified.  There is no ascites or focal fluid collection.,The aorta is normal in contour and caliber.,There is no adenopathy.,Degenerative changes are present in the lumbar spine.,IMPRESSION: , Findings consistent with diverticulitis.  Please see report above.
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DESCRIPTION: CT scan of the abdomen and pelvis without and with intravenous contrast.

gastroenterology, extrahepatic ductal dilatation, gallbladder, glands, pancreas, spleen, kidney, adrenal, abdomen and pelvis, ct scan, intravenous, abdomen,

The CT scan results indicate findings consistent with diverticulitis, which is a medical condition where pouches in the colon (diverticula) become inflamed or infected. While diverticulitis can be painful and needs medical attention to prevent complications like perforation or abscess, it is not typically a life-threatening condition if treated promptly with antibiotics and potentially dietary changes. The report does not indicate any immediate life-threatening conditions such as severe organ dysfunction, internal bleeding, or malignancies, which lowers the stakes in the given context.


Medical Specialty: Discharge Summary
Sample Name: GI Bleed - Discharge Summary

CHIEF COMPLAINT:,  GI bleed.,HISTORY OF PRESENT ILLNESS:,  The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue.  CBC revealed microcytic anemia with hemoglobin of 8.9.  Stool dark brown, strongly OB positive.  The patient denied any shortness of breath.  No chest pain.  No GI complaints.  The patient was admitted to ABCD for further evaluation.,PAST MEDICAL HISTORY:  ,Significant for atrial fibrillation, hypertension, osteoarthritis of the knees, hypercholesterolemia, non-insulin-dependent diabetes mellitus, asthma, and hypothyroidism.,PHYSICAL EXAMINATION:,GENERAL:  The patient is in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Benign.,NECK:  Supple.  No adenopathy.,LUNGS:  Clear with good air movement.,HEART:  Irregularly regular.  No gallops.,ABDOMEN:  Positive bowel sounds, soft, and nontender.  No masses or organomegaly.,EXTREMITIES:  1+ lower extremity edema bilaterally.,HOSPITAL COURSE: , The patient underwent upper endoscopy performed by Dr. A, which revealed erosive gastritis.  Colonoscopy did reveal diverticulosis as well as polyp, which was resected.  The patient tolerated the procedure well.  She was transfused, and prior to discharge hemoglobin was stable at 10.7.  The patient was without further GI complaints.  Coumadin was held during hospital stay and recommendations were given by GI to hold Coumadin for an additional three days after discharge then resume.  The patient was discharged with outpatient PMD, GI, and Cardiology followup.,DISCHARGE DIAGNOSES:,1.  Upper gastrointestinal bleed.,2.  Anemia.,3.  Atrial fibrillation.,4.  Non-insulin-dependent diabetes mellitus.,5.  Hypertension.,6.  Hypothyroidism.,7.  Asthma.,CONDITION UPON DISCHARGE: , Stable.,MEDICATIONS: , Feosol 325 mg daily, multivitamins one daily, Protonix 40 mg b.i.d., KCl 20 mEq daily, Lasix 40 mg b.i.d., atenolol 50 mg daily, Synthroid 80 mcg daily, Actos 30 mg daily, Mevacor 40 mg daily, and lisinopril 20 mg daily.,ALLERGIES:,  None.,DIET: , 1800-calorie ADA.,ACTIVITY: , As tolerated.,FOLLOWUP: , The patient to hold Coumadin through weekend.  Followup CBC and INR were ordered.  Outpatient followup as arranged.
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DESCRIPTION: GI bleed.   Upper gastrointestinal bleed.  CBC revealed microcytic anemia.

The situation involves the discharge summary of a patient who was hospitalized for a GI bleed, a potentially serious medical condition. While the patient appears to have been stabilized and was discharged with a follow-up plan, there are still significant health considerations. These include managing anticoagulation therapy (Coumadin), monitoring hemoglobin levels, and ensuring proper follow-up with multiple specialists. The stakes are moderately high due to the patient's age, multiple comorbidities, and the need for careful post-discharge management to prevent complications such as re-bleeding or stroke due to atrial fibrillation.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychosocial Eval for Kidney Transplant

HISTORY OF PRESENT ILLNESS:,  In 2002, the patient had a blood test during her routine screening, which revealed anemia and an elevated creatinine.  Two weeks later she saw a nephrologist at ABCDE were she worked at that time.  An ultrasound revealed that she had Parenchymal disease in which tissue around the kidney is diseased.  No particular treatment was advised.  She was laid off 6 months later.  In 2004, she began working at The ABCD Hospital and began seeing Dr. A.  She was put on Procrit, but could not keep the stringent appointment scheduled for the injection because of her work.  She began seeing Dr. B and was put on Procrit and Renagel.  She was advised to go on dialysis, but she felt she did not have enough information to such a drastic step.  She saw an endocrinologist for some thyroid problem and her blood work showed that her creatinine was now at 7.  She was referred to Dr. Xyz who found after a parathyroid scan that she may have an adenoma.  Her creatinine is now 7.4.,TREATMENT AND IMPACT OF DISEASE:,  She is on several medications.  She is not on a renal diet yet.  Her energy is good and she is still working full time.,TRANSPLANT FIRST MENTIONED AS TREATMENT OPTION: , She has wanted to transplant ever since dialysis was first mentioned.,EMOTIONAL REACTION TO DIAGNOSIS AND TREATMENT COURSE:,  She is frustrated by the lack of information about what exactly has caused her renal failure and has had a real feeling of helplessness in her efforts to pursue this understanding.,OTHER SIGNIFICANT MEDICAL HISTORY/SURGERIES:,  She had a Bartholin cyst removed in 2002.,PSYCHIATRIC HISTORY:,  None.,COPING STRATEGIES:,  She used to exercise vigorously, but has stopped at this time.  She enjoys watching movies with her children.,COMPLIANCE:,  She feels she watches her diet and medication regimen very closely.  She said she communicates daily with Dr. Xyz,PAST AND PRESENT SMOKING:,  She began smoking 2 cigarettes a day when she was 22, but stopped after a year.,PAST AND PRESENT ALCOHOL USE:,  None.,PAST AND PRESENT DRUG USE:,  None.,LEGAL ISSUES:,  None.,TATTOOS:,  None.,MARITAL STATUS:  LENGTH OF THE TIME MARRIED:,  She has been married for 25 years.,AGE AND HEALTH OF SPOUSE:,  Xyz is 62 and in good health.,CHILDREN:,  Four, all are in good health.,FATHER:,  Father died in 2001, at the age of 62 of cardiac cancer.,MOTHER:,  Dolorous Massey is 63 and in good health.,SIBLINGS:,  Ben Doherty died in 1984 at the age of 26 in an automobile accident; Steven Doherty is 46 and is in good health.,PREVIOUS MARRIAGES AND DURATION OF EACH:,  None.,PERSONS LIVING IN HOUSEHOLD:,  Six.,RELATIONSHIP WITH FAMILY MEMBERS/IDENTIFIED PRIMARY SUPPORT SYSTEM:,  She is close to her brother.,HIGHEST LEVEL OF EDUCATION:,  She has 2 years of college at ABCD College.  She is a licensed LVN.,MILITARY SERVICE:,  None.
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DESCRIPTION: Psychosocial Evaluation of patient before kidney transplant.

The situation involves the psychosocial evaluation of a patient preparing for a potential kidney transplant. The stakes here are relatively high due to the medical severity and life-altering nature of a kidney transplant procedure. The patient's history of kidney disease, elevated creatinine levels, and lack of definitive cause for renal failure compounding her frustration suggest that her emotional and psychological readiness is crucial for the transplant process. While she seems to have coping mechanisms and no psychiatric history, the emotional impact and adherence to treatment protocols before a major surgery like a kidney transplant add layers of complexity. However, this is still a routine part of the transplant assessment process in healthcare settings, so it doesn't reach the highest stakes compared to other life-or-death or immediate emergency situations.


Medical Specialty: Hematology - Oncology
Sample Name: MediPort Placement

PREOPERATIVE DIAGNOSIS:,  Rhabdomyosarcoma of the left orbit.,POSTOPERATIVE DIAGNOSIS:,  Rhabdomyosarcoma of the left orbit.,PROCEDURE: , Left subclavian vein MediPort placement (7.5-French single-lumen).,INDICATIONS FOR PROCEDURE: , This patient is a 16-year-old girl, with newly diagnosed rhabdomyosarcoma of the left orbit.  The patient is being taken to the operating room for MediPort placement.  She needs chemotherapy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's neck, chest, and shoulders were prepped and draped in usual sterile fashion.  An incision was made on the left shoulder area.  The left subclavian vein was cannulated.  The wire was passed, which was in good position under fluoro, using Seldinger Technique.  Near wire incision site made a pocket above the fascia and sutured in a size 7.5-French single-lumen MediPort into the pocket in 4 places using 3-0 Nurolon.  I then sized the catheter under fluoro and placed introducer and dilator over the wire, removed the wire and dilator, placed the catheter through the introducer and removed the introducer.  The line tip was in good position under fluoro.  It withdrew and flushed well.  I then closed the incision using 4-0 Vicryl, 5-0 Monocryl for the skin, and dressed with Steri-Strips.  Accessed the ports with a 1-inch 20-gauge Huber needle, and it withdrew and flushed well with final heparin flush.  We secured this with Tegaderm.  The patient is then to undergo bilateral bone marrow biopsy and lumbar puncture by Oncology.
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DESCRIPTION: Rhabdomyosarcoma of the left orbit.  Left subclavian vein MediPort placement.  Needs chemotherapy.

hematology - oncology, rhabdomyosarcoma of the left orbit, single lumen, subclavian vein, mediport placement, chemotherapy, rhabdomyosarcoma, mediport,

The situation involves a medical procedure for a 16-year-old girl newly diagnosed with rhabdomyosarcoma of the left orbit. The placement of a MediPort is critical for administering chemotherapy, which is necessary for treating her cancer. The procedure involves general anesthesia and has potential risks associated with surgical interventions and the management of a cancer diagnosis in a young patient. The stakes are high due to the nature of the condition and the importance of the procedure in allowing for ongoing cancer treatment.


Medical Specialty: Surgery
Sample Name: Delivery Note - 10

DELIVERY NOTE:  ,This is a 30-year-old G6, P5-0-0-5 with unknown LMP and no prenatal care, who came in complaining of contractions and active labor.  The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks.  The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.  Rupture of membranes occurred on 12/25/08 at 2008 hours via artificial rupture of membranes.  No meconium was noted.  Infant was delivered on 12/25/08 at 2154 hours.  Two doses of ampicillin was given prior to rupture of membranes.  GBS status unknown.  Intrapartum events, no prenatal care.  The patient had epidural for anesthesia.  No observed abnormalities were noted on initial newborn exam.  Apgar scores were 9 and 9 at one and five minutes respectively.  There was a nuchal cord x1, nonreducible, which was cut with two clamps and scissors prior to delivery of body of child.  Placenta was delivered spontaneously and was normal and intact.  There was a three-vessel cord.  Baby was bulb suctioned and then sent to newborn nursery.  Mother and baby were in stable condition.  EBL was approximately 500 mL, NSVD with postpartum hemorrhage.  No active bleeding was noted upon deliverance of the placenta.  Dr. X attended the delivery with second year resident, Dr. X. Upon deliverance of the placenta, the uterus was massaged and there was good tone.  Pitocin was started following deliverance of the placenta.  Baby delivered vertex from OA position.  Mother following delivery had a temperature of 100.7, denied any specific complaints and was stable following delivery.
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DESCRIPTION: The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks.  The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.

surgery, spontaneous vaginal delivery, rupture of membranes, gestational age, vaginal delivery, intact perineum, prenatal care, gestational, placentaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves a childbirth, which generally carries significant risk for both the mother and infant, particularly with unknown details like no prenatal care and GBS status unknown. Although there were complications such as a non-reducible nuchal cord, the situation was managed without any major issues arising. The delivery ended with both the mother and infant being stable, indicating that the immediate high stakes were mitigated satisfactorily. However, childbirth with these factors inherently presents high stakes due to potential for severe outcomes.


Medical Specialty: Orthopedic
Sample Name: Ligament Reconstruction & Tendon Interposition Arthroplasty

OPERATION PERFORMED:,  Ligament reconstruction and tendon interposition arthroplasty of right wrist.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the right upper extremity was prepped and draped in a sterile manner.,Attention was turned to the base of the thumb where a longitudinal incision was made over the anatomic snuffbox and extended out onto the carpometacarpal joint.  Using blunt dissection radial sensory nerve was dissected and retracted out of the operative field.  Further blunt dissection exposed the radial artery, which was dissected and retracted off the trapezium.  An incision was then made across the scaphotrapezial joint distally onto the trapezium and out onto the carpometacarpal joint.  Sharp dissection exposed the trapezium, which was then morselized and removed in toto with care taken to protect the underlying flexor carpi radialis tendon.  The radial beak of the trapezoid was then osteotomized off the head of the scaphoid.  The proximal metacarpal was then fenestrated with a 4.5-mm drill bit.  Four fingers proximal to the flexion crease of the wrist a small incision was made over the FCR tendon and blunt dissection delivered the FCR tendon into this incision.  The FCR tendon was divided and this incision was closed with 4-0 nylon sutures.  Attention was returned to the trapezial wound where longitudinal traction on the FCR tendon delivered the FCR tendon into the wound.,The FCR tendon was then threaded through the fenestration in the metacarpal.  A bone anchor was then placed distal to the metacarpal fenestration.  The FCR tendon was then pulled distally and the metacarpal reduced to an anatomic position.  The FCR tendon was then sutured to the metacarpal using the previously placed bone anchor.  Remaining FCR tendon was then anchovied and placed into the scaphotrapezoidal and trapezial defect.  The MP joint was brought into extension and the capsule closed using interrupted 3-0 Tycron sutures.,Attention was turned to the MCP joint where the MP joint was brought in to 15 degrees of flexion and pinned with a single 0.035 Kirschner wire.  The pin was cut at the level of the skin.,All incisions were closed with running 3-0 Prolene subcuticular stitch.,Sterile dressings were then applied.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.
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DESCRIPTION: Ligament reconstruction and tendon interposition arthroplasty of right wrist.

orthopedic, arthroplasty, ligament, tendon, fcr, tendon interposition arthroplasty, ligament reconstruction, reconstruction, trapezium, metacarpal, joint, interposition,

The described ligament reconstruction and tendon interposition arthroplasty is a surgical procedure with inherent risks typical of orthopedic surgeries. While it is serious and requires precision to avoid complications like nerve damage or improper joint repair, it is generally not life-threatening like some other surgeries might be. The stakes come from ensuring functional and pain relief outcomes for the patient, rather than immediate survival. Therefore, it is not considered extremely high-stakes in a critical medical sense.


Medical Specialty: Radiology
Sample Name: Ultrasound - Carotid - 1

RIGHT:,1.  Mild heterogeneous plaque seen in common carotid artery.,2.  Moderate heterogeneous plaque seen in the bulb and internal carotid artery.,3.  Severe heterogeneous plaque seen in external carotid artery with degree of stenosis around 70%.  ,4.  Peak systolic velocity is normal in common carotid, bulb, and internal carotid artery.,5.  Peak systolic velocity is 280 cm/sec in external carotid artery with moderate spectral broadening.,LEFT: , ,1.  Mild heterogeneous plaque seen in common carotid artery and external carotid artery.,2.  Moderate heterogeneous plaque seen in the bulb and internal carotid artery with degree of stenosis less than 50%.,3.  Peak systolic velocity is normal in common carotid artery and in the bulb.,4.  Peak systolic velocity is 128 cm/sec in internal carotid artery and 156 cm/sec in external carotid artery.,VERTEBRALS:,  Antegrade flow seen bilaterally.
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DESCRIPTION: Right and Left carotid ultrasound

Right and Left carotid ultrasound

radiology, carotid ultrasound, antegrade flow, peak systolic velocity, bulb, carotid artery, homogeneous plaque, plaque, spectral broadening, bulb and internal carotid, velocity is normal, common carotid artery, internal carotid artery, external carotid artery, internal carotid, external carotid, peak systolic, systolic velocity, artery, carotid, ultrasound, velocity, heterogeneous,

The ultrasound results show the presence of plaques and stenosis in the carotid arteries. Carotid artery stenosis can lead to significant health risks, such as an increased chance of stroke, which is a high-stakes health issue. The presence of severe stenosis (70%) in the right external carotid artery, and the moderate levels in other regions, imply that this is a serious medical finding requiring intervention or close monitoring. This impacts the patient’s health significantly and necessitates appropriate and timely medical response.


Medical Specialty: Gastroenterology
Sample Name: GI Consultation - 4

CHIEF COMPLAINT:, Nausea and abdominal pain after eating.,GALL BLADDER HISTORY:, The patient is a 36 year old white female.  Patient's complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. The patient's symptoms have been present for 3 months. Complaints are relieved with lying on right side and antacids. Prior workup by referring physicians have included abdominal ultrasound positive for cholelithiasis without CBD obstruction. Laboratory studies that are elevated include total bilirubin and elevated WBC.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, Diagnostic laparoscopic exam for pelvic pain/adhesions.,ALLERGIES:, No known drug allergies.,CURRENT MEDICATIONS:, No current medications.,OCCUPATIONAL /SOCIAL HISTORY:, Marital status: married. Patient states smoking history of 1 pack per day. Patient quit smoking 1 year ago. Admits to no history of using alcohol. States use of no illicit drugs.,FAMILY MEDICAL HISTORY:, There is no significant, contributory family medical history.,OB GYN HISTORY:, LMP: 5/15/1999. Gravida: 1. Para: 1.  Date of last pap smear: 1/15/1998.,REVIEW OF SYSTEMS:,Cardiovascular: Denies angina, MI history, dysrhythmias, palpitations, murmur, pedal edema, PND, orthopnea, TIA's, stroke, amaurosis fugax.,Pulmonary: Denies cough, hemoptysis, wheezing, dyspnea, bronchitis, emphysema, TB exposure or treatment.,Neurological: Patient admits to symptoms of seizures and ataxia.,Skin: Denies scaling, rashes, blisters, photosensitivity.,PHYSICAL EXAMINATION:,Appearance: Healthy appearing. Moderately overweight.,HEENT: Normocephalic. EOM's intact. PERRLA. Oral pharynx without lesions.,Neck: Neck mobile. Trachea is midline.,Lymphatic: No apparent cervical, supraclavicular, axillary or inguinal adenopathy.,Breast: Normal appearing breasts bilaterally, nipples everted.  No nipple discharge, skin changes.,Chest: Normal breath sounds heard bilaterally without rales or rhonchi.  No pleural rubs. No scars.,Cardiovascular: Regular heart rate and rhythm without murmur or gallop.,Abdominal: Bowel sounds are high pitched.,Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted. Range of motion is normal.,Skin: Normal color, temperature, turgor and elasticity; no significant skin lesions.,IMPRESSION DIAGNOSIS:  ,  Gall Bladder Disease. Abdominal Pain.,DISCUSSION:, Laparoscopic Cholecystectomy handout was given to the patient, reviewed with them and questions answered. The patient has given both verbal and written consent for the procedure.,PLAN:, We will proceed with Laparoscopic Cholecystectomy with intraoperative cholangiogram.,MEDICATIONS PRESCRIBED:,
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DESCRIPTION: Nausea and abdominal pain after eating - Gall bladder disease - Laparoscopic cholecystectomy scheduled.

The situation involves a medical case where the patient has gallbladder disease and symptoms that have persisted for three months. The recommended procedure, laparoscopic cholecystectomy, is a common and relatively low-risk surgery for treating gallbladder issues. The symptoms, while causing discomfort, do not appear immediately life-threatening or severe without prompt intervention, as the condition has persisted for months. Therefore, this situation is not extremely high-stakes but requires attention to alleviate the patient's symptoms and prevent future complications. The patient has already given consent for the recommended procedure, indicating a planned and controlled medical intervention.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Aortobifemoral Bypass

PREOPERATIVE DIAGNOSIS:,  Aortoiliac occlusive disease.,POSTOPERATIVE DIAGNOSIS:, Aortoiliac occlusive disease.,PROCEDURE PERFORMED:, Aortobifemoral bypass.,OPERATIVE FINDINGS: , The patient was taken to the operating room.  The abdominal contents were within normal limits.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.,PROCEDURE: , The patient was taken to the operating room, placed in a supine position, and prepped and draped in the usual sterile manner with Betadine solution.  A longitudinal incision was made after a Betadine-coated drape was placed over the incisional area.  Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges.  Attention was then turned to the abdomen, where a longitudinal incision was made from the pubis xiphoid, carried down subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery.  Mild adhesions were lysed.  The omentum was freed.  The small and large intestine were run with no evidence of abnormalities.  The liver and gallbladder were within normal limits.  No abnormalities were noted.  At this point, the Bookwalter retractor was placed.  NG tube was placed in the stomach and placed on suction.  The intestines were gently packed intraabdominally and laterally.  The rest of the peritoneum was then opened.  The aorta was cleared, both proximally and distally.  The left iliac was completely occluded.  The right iliac was to be cleansed.  At this point, 5000 units of aqueous heparin was administered to allow take effect.  The aorta was then clamped below the renal arteries and opened in a longitudinal fashion.  A single lumbar was ligated with #3-0 Prolene.  The inferior mesenteric artery was occluded intraluminally and required no suture closure.  Care was taken to preserve collaterals.  The aorta was measured, and a 16 mm Gore-Tex graft was brought on the field and anastomosed to the proximal aorta using #3-0 Prolene in a running fashion.  Last stitch was tied.  Hemostasis was excellent.  The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis.  At this point, strong pulses were present within the graft.  The limbs were vented and irrigated.  Using bimanual technique, the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin.  The grafts were then brought through these, care being taken to avoid twisting of the graft.  At this point, the right iliac was then ligated using #0 Vicryl and the clamp was removed.  Hemostasis was excellent.  The right common femoral artery was then clamped proximally and distally, opened with #11 blade extended with Potts scissors.  The graft was _____ and anastomosed to the artery using #5-0 Prolene in a continuous fashion with a stitch _______ running fashion.  Prior to tying the last stitch, the graft and artery were vented and the last stitch was tied.  Flow was initially restored proximally then distally with good results.  Attention was then turned to the left groin and the artery grafts were likewise exposed, cleared proximally and distally.  The artery was opened, extended with a Potts scissors and anastomosis was performed with #5-0 Prolene again with satisfactory hemostasis.  The last stitch was tied.  Strong pulses were present within the artery and graft itself.  At this point, 25 mg of protamine was administered.  The wounds were irrigated with antibiotic solution.  The groins were repacked.  Attention was then returned to the abdomen.  The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present.  The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft.  The intraabdominal contents were then allowed to resume their normal position.  There was no evidence of ischemia to the large or small bowel.  At this point, the omentum and stomach were repositioned.  The abdominal wall was closed in a running single layer fashion using #1 PDS.  The skin was closed with skin staples.  The groins were again irrigated, closed with #3-0 Vicryl and #4-0 undyed Vicryl and Steri-Strips.  The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well.  Sponges and instrument counts were correct.  Estimated blood loss 900 cc.
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DESCRIPTION: Aortoiliac occlusive disease.  Aortobifemoral bypass.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.

cardiovascular / pulmonary, aorta, bypass, arteriosclerosis, abdominal contents, aortoiliac occlusive disease, gore tex graft, aortobifemoral bypass, longitudinal incision, aortobifemoral, hemostasis, artery, graft,

This document describes a detailed surgical procedure, specifically an aortobifemoral bypass, which is a significant operation to treat aortoiliac occlusive disease. This type of surgery is associated with serious conditions, potential risks, and complications. The surgery involves major blood vessels, poses a risk of significant blood loss as noted with an estimated 900 cc of blood loss, and has a critical impact on the patient's vascular health. All these factors indicate that this situation is high-stakes because it directly impacts the patient's survival and quality of life. The detailed account of the surgery highlights the critical nature of the procedure and the precision required.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Tubal Ligation

DIAGNOSIS: , Multiparous female, desires permanent sterilization.,NAME OF OPERATION: , Laparoscopic bilateral tubal ligation with Falope rings.,ANESTHESIA: , General, ET tube.,COMPLICATIONS:,  None.,FINDINGS:  ,Normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid.,PROCEDURE: , The patient was taken to the operating room and placed on the table in the supine position.  After adequate general anesthesia was obtained, she was placed in the lithotomy position and examined.  She was found to have an anteverted uterus and no adnexal mass.  She was prepped and draped in the usual fashion.  The Foley catheter was placed.  A Hulka cannula was inserted into the cervix and attached to the anterior lip of the cervix.,An infraumbilical incision was made with the knife.  A Veress needle was inserted into the abdomen.  Intraperitoneal location was verified with approximately 10 cc of sterile solution.  A pneumoperitoneum was created.  The Veress needle was then removed, and a trocar was inserted directly without difficulty.  Intraperitoneal location was verified visually with the laparoscope.  There was no evidence of any intra-abdominal trauma.,Each fallopian tube was elevated with a Falope ring applicator, and a Falope ring was placed on each tube with a 1-cm to 1.5-cm portion of the tube above the Falope ring.,The pneumoperitoneum was evacuated, and the trocar was removed under direct visualization.  An attempt was made to close the fascia with a figure-of-eight suture.  However, this was felt to be more subcutaneous.  The skin was closed in a subcuticular fashion, and the patient was taken to the recovery room awake with vital signs stable.
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DESCRIPTION: Laparoscopic bilateral tubal ligation with Falope rings.

obstetrics / gynecology, sterilization, laparoscopic bilateral tubal ligation with falope rings, falope ring applicator, laparoscopic bilateral tubal ligation, bilateral tubal ligation, veress needle, tubal ligation, falope rings, anesthesia, tubal, ligation, falope

The situation involves a medical procedure for a patient seeking permanent sterilization, which is generally considered a routine surgical procedure for someone seeking this form of contraception. The detail that there were no complications and that the patient's vital signs remained stable indicates that the situation was straightforward and not high-stakes. However, as with any surgery, there are inherent risks, and the need for general anesthesia adds some level of complexity. Overall, it's a controlled and planned procedure with low risk, given the absence of any complications.


Medical Specialty: Neurology
Sample Name: Video EEG - 3

PROCEDURE: , EEG during wakefulness demonstrates background activity consisting of moderate-amplitude beta activity seen bilaterally.  The EEG background is symmetric.  Independent, small, positive, sharp wave activity is seen in the frontotemporal regions bilaterally with sharp-slow wave discharges seen more predominantly in the right frontotemporal head region.  No clinical signs of involuntary movements are noted during synchronous video monitoring.  Recording time is 22 minutes and 22 seconds.  There is attenuation of the background, faster activity during drowsiness and some light sleep is recorded.  No sustained epileptogenic activity is evident, but the independent bilateral sharp wave activity is seen intermittently.  Photic stimulation induced a bilaterally symmetric photic driving response.,IMPRESSION:,  EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.  The EEG findings are consistent with potentially epileptogenic process.  Clinical correlation is warranted.
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DESCRIPTION: EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.

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

The EEG results indicate potentially epileptogenic activity, which could be a sign of a neurological disorder such as epilepsy. Detecting and properly managing epilepsy is crucial since seizures can have significant impacts on a patient's life, including safety risks and quality of life concerns. Therefore, this situation is high-stakes as it involves identifying a critical health issue that requires further clinical correlation and potentially immediate medical intervention.


Medical Specialty: Surgery
Sample Name: Craniotomy & Neuronavigation

PROCEDURES:,1.  Right frontal craniotomy with resection of right medial frontal brain tumor.,2.  Stereotactic image-guided neuronavigation for resection of tumor.,3.  Microdissection and micro-magnification for resection of brain tumor.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR THE PROCEDURE:  ,The patient is a 71-year-old female with a history of left-sided weakness and headaches.  She has a previous history of non-small cell carcinoma of the lung, treated 2 years ago.  An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor.  After informed consent was obtained, the patient was brought to the operating room for surgery.,PREOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift.,POSTOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift, probable metastatic lung carcinoma.,DESCRIPTION OF THE PROCEDURE: , The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube.  She was positioned on the operating room table in the Sugita frame with the head secured.,Using the preoperative image-guided MRI, we carefully registered the fiducials and then obtained the stereotactic image-guided localization to guide us towards the tumor.  We marked external landmarks.  Then we shaved the head over the right medial frontal area.  This area was then sterilely prepped and draped.,Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted.,A horseshoe shaped flap was based on the right and then brought across to the midline.  This was opened and hemostasis obtained using Raney clips.  The skin flap was retracted medially.  Two burr holes were made and were carefully connected.  One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap.  Hemostasis was obtained.  Using the neuronavigation, we identified where the tumor was.  The dura was then opened based on a horseshoe flap based on the medial sinus.  We retracted this medially and carefully identified the brain.  The brain surface was discolored and obviously irritated consistent with the tumor.,We used the stereotactic neuronavigation to identify the tumor margins.,Then we used a bipolar to coagulate a thin layer of brain over the tumor.  Subsequently, we entered the tumor.  The tumor itself was extremely hard.  Specimens were taken and send for frozen section analysis, which showed probable metastatic carcinoma.,We then carefully dissected around the tumor margins.,Using the microscope, we then brought microscopic magnification and dissection into the case.  We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly, medially, inferiorly, and laterally.,Then using the Cavitron, we cored out the central part of the tumor.  Then we collapsed the tumor on itself and removed it entirely.  In this fashion, microdissection and magnification resection of the tumor was carried out.  We resected the entire tumor.  Neuronavigation was used to confirm that no further tumor residual was remained.,Hemostasis was obtained using bipolar coagulation and Gelfoam.  We also lined the cavity with Surgicel.  The cavity was nicely dry and excellent hemostasis was obtained.,The dura was closed using multiple interrupted 4-0 Nurolon sutures in a watertight fashion.  Surgicel was placed over the dural closure.  The bone flap was repositioned and held in place using CranioFIX cranial fixators.  The galea was re-approximated and the skin was closed with staples.  The wound was dressed.  The patient was returned to the intensive care unit.  She was awake and moving extremities well.  No apparent complications were noted.  Needle and sponge counts were listed as correct at the end of the procedure.  Estimated intraoperative blood loss was approximately 150 mL and none was replaced.
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DESCRIPTION: Right frontal craniotomy with resection of right medial frontal brain tumor.  Stereotactic image-guided neuronavigation and  microdissection and micro-magnification for resection of brain tumor.

surgery, stereotactic image-guided neuronavigation, micro-magnification, resection of brain tumor, frontal craniotomy, mass effect, brain shift, stereotactic image, brain tumor, brain, tumor, craniotomy, endotracheal, carcinoma, neuronavigation, microdissection,

The situation involves a complex surgical procedure, a craniotomy with tumor resection assisted by neuronavigation, microdissection, and micro-magnification. This is inherently high-stakes because it involves operating on a vulnerable part of the body (the brain), carries risks such as damage to brain tissues, potential neurological deficits, and is being performed on an elderly patient with a history of cancer. Moreover, the stakes are heightened due to the risks associated with anesthesia and possible postoperative complications. Successfully executing this procedure is crucial for the patient's health outcomes and quality of life.


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

Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 30

CHIEF COMPLAINT: , Mental changes today.,HISTORY OF PRESENT ILLNESS: , This patient is a resident from Mazatlan, Mexico, visiting her son here in Utah, with a history of diabetes.  She usually does not take her meal on time, and also not having her regular meals lately.  The patient usually still takes her diabetic medication.  Today, the patient was found to have decrease in mental alertness, but no other GI symptoms.  Some sweating and agitation, but no fever or chills.  No other rash.  Because of the above symptoms, the patient was treated in the emergency department here.  She was found to glucose in 30 range, and hypertension.  There was some question whether she also take her blood pressure medication or not.  Because of the above symptoms, the patient was admitted to the hospital for further care.  The patient was given labetalol IV and also Norvasc blood pressure, and also some glucose supplement.  At this time, the patient's glucose was in the 175 range.,PAST MEDICAL HISTORY: , Diabetes, hypertension.,PAST SURGICAL HISTORY:,  None.,FAMILY HISTORY: , Unremarkable.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  In Spanish label.  They are the diabetic medication, and also blood pressure medication.  She also takes aspirin a day.,SOCIAL HISTORY:  ,The patient is a Mazatlan, Mexico resident, visiting her son here.,PHYSICAL EXAMINATION:,GENERAL:  The patient appears to be no acute distress, resting comfortably in bed, alert, oriented x3, and coherent through interpreter.,HEENT:  Clear, atraumatic, normocephalic.  No sinus tenderness.  No obvious head injury or any laceration.  Extraocular movements are intact.  Dry mucosal linings.,HEART:  Regular rate and rhythm, without murmur.  Normal S1, S2.,LUNGS:  Clear.  No rales.  No wheeze.  Good excursion.,ABDOMEN:  Soft, active bowel sounds in 4 quarters, nontender, no organomegaly.,EXTREMITIES:  No edema, clubbing, or cyanosis.  No rash.,LABORATORY FINDINGS: , On Admission:  CPK, troponin are negative.  CMP is remarkable for glucose of 33.  BMP is remarkable for BUN of 60, creatinine is 4.3, potassium 4.7.  Urinalysis shows specific gravity of 10.30.  CT of the brain showed no hemorrhage.  Chest x-ray showed no acute cardiomegaly or any infiltrates.,IMPRESSION:,1.  Hypoglycemia due to not eating her meals on a regular basis.,2.  Hypertension.,3.  Renal insufficiency, may be dehydration, or diabetic nephropathy.,PLAN: , Admit the patient to the medical ward, IV fluid, glucometer checks, and adjust the blood pressure medication and also diabetic medication.
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DESCRIPTION: Patient was found to have decrease in mental alertness

The patient is experiencing acute health issues, including hypoglycemia, decreased mental alertness, hypertension, and potential renal insufficiency, which required treatment in an emergency department and subsequent hospital admission. These conditions are serious and can be life-threatening if not managed promptly and appropriately, especially given her underlying diabetes and hypertension. The complexity of managing multiple acute and chronic conditions that could lead to severe consequences like coma or severe renal damage, warrants a high-stakes situation. Ensuring accurate medication management is crucial, especially considering language barriers with medication labels in Spanish.


Medical Specialty: Orthopedic
Sample Name: Anterior Cervical Discectomy

PREOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1.  Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2.  Bilateral C6 nerve root decompression.,3.  Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4.  Bilateral C5 nerve root decompression.,5.  Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6.  Bilateral C4 nerve root decompression.,7.  Harvesting of autologous bone from the vertebral bodies.,8.  Grafting of allograft bone for creation of arthrodesis.,9.  Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12.  Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6.  There was a herniated disk with cord compression and radiculopathy at C4-C5.  C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels.  Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives.  He clearly understands and has no further questions and requests that I proceed.,PROCEDURE:  ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease.  Dissection was carried down through the platysma musculature and the anterior spine was exposed.  The medial borders of the longus colli muscle were dissected free from their attachments to the spine.  Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained.  A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space.  The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies.  The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament.  The ligament was incised and the underlying dura was exposed.  I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen.  There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact.  However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right.  The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5.  I worked down through bony osteophytes and identified the posterior longitudinal ligament.  The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces.  The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen.  The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it.  Again the microscope was angled to the left side where similar decompression was achieved.  Central decompression was achieved here where there was a moderate amount of spinal cord compression.  This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space.  Here there were large osteophytes projecting posteriorly against the cord.  I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord.  This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord.  I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right.  The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis.  A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration.  Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis.  Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4.  Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge.  I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks.  The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described.  An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation.  Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate.  The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush.  The holes were drilled and the screws were placed.  Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6.  All eight screws had good purchase.  The locking screws were tightly applied.  An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure.  The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained.  A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct.  There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.
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DESCRIPTION: Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression.  Harvesting of autologous bone from the vertebral bodies.  Grafting of allograft bone for creation of arthrodesis.

This scenario describes a complex surgical procedure involving multiple levels of the cervical spine. An anterior cervical discectomy is a significant surgery aimed at addressing severe conditions such as cervical spondylosis with myelopathy and herniated discs, which can cause considerable pain and neurological deficits. The stakes are high due to the potential risks involved, including complications such as spinal cord and nerve root injury, infection, and issues with the graft or instrumentation. The stakes are elevated further considering the patient's age and medical history, including recent smoking cessation. The successful outcome directly impacts the patient's neurological function and quality of life.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Lens Implantation - 4

OPERATION PERFORMED:, Phacoemulsification of cataract and posterior chamber lens implant, right eye., ,ANESTHESIA:, Retrobulbar nerve block, right eye, ,DESCRIPTION OF OPERATION: ,The patient was brought to the operating room where local anesthetic was administered to the right eye followed by a dilute drop of Betadine and a Honan balloon.  Once anesthesia was achieved, the right eye was prepped with Betadine, rinsed with saline, and draped in a sterile fashion.  A lid speculum was placed and 4-0 silk sutures passed under the superior and inferior rectus muscles stabilizing the globe.  A fornix-based conjunctival flap was prepared superiorly from 10 to 12 o'clock and episcleral vessels were cauterized using a wet-field.  A surgical groove was applied with a 69 Beaver blade 1 mm posterior to the limbus in a frown configuration in the 10 to 12 o'clock position.  A lamellar dissection was carried anteriorly to clear cornea using a crescent knife.  A stab incision was applied with a Superblade at the 2 o'clock position at the limbus.  The chamber was also entered through the lamellar groove using a 3-mm keratome in a beveled fashion.  Viscoat was injected into the chamber and an anterior capsulorrhexis performed.  Hydrodissection was used to delineate the nucleus and the phacoemulsification tip was inserted into the chamber.  A deep linear groove was dissected through the nucleus vertically and the nucleus was rotated 90 degrees with the assistance of a spatula through the side-port incision.  A second groove was dissected perpendicular to the first and the nucleus was fractured into quadrants.  Each quadrant was emulsified under burst power within the capsular bag.  The epinuclear bowl was manipulated with vacuum, flipped into the iris plane, and emulsified under pulse power.  I&A was used to aspirate cortex from the capsular bag.  A scratcher was used to polish the capsule, and Viscoat was injected inflating the capsular bag and chamber.  The wound was enlarged with a shortcut blade to 5.5 mm.  The intraocular lens was examined, found to be adequate, irrigated with balanced salt, and inserted into the capsular bag.  The lens centralized nicely and Viscoat was removed using the I&A.  Balanced salt was injected through the side-port incision.  The wound was tested, found to be secure, and a single 10-0 nylon suture was applied to the wound with the knot buried within the sclera.  The conjunctiva was pulled over the suture, and Ancef 50 mg and Decadron 4 mg were injected sub-Tenon in the inferonasal and inferotemporal quadrants.  Maxitrol ointment was applied topically followed by an eye pad and shield.  The patient tolerated the procedure and was taken from the operating room in good condition.
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DESCRIPTION: Phacoemulsification of cataract and posterior chamber lens implant, right eye.

ophthalmology, retrobulbar nerve block, posterior chamber lens implant, phacoemulsification of cataract, lens implantation, capsular bag, cataract, phacoemulsification, nucleus, capsular, lens, eye

The situation described is a detailed account of a routine cataract surgery procedure known as phacoemulsification, coupled with lens implantation. While surgeries always carry certain risks, cataract surgery is one of the most common and routinely performed operations with a high success rate and low risk of complications when performed by skilled ophthalmic surgeons. Given this context, the stakes involved here are moderate, primarily because it is an invasive procedure on a delicate part of the body, but it is also a well-understood and frequently performed operation with standard procedures and protocols in place to manage risks.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Subxiphoid Pericardiotomy

PREOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,POSTOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,PROCEDURE PERFORMED:,  Subxiphoid pericardiotomy.,ANESTHESIA:,  General via ET tube.,ESTIMATED BLOOD LOSS: , 50 cc.,FINDINGS:,  This is a 70-year-old black female who underwent a transhiatal esophagectomy in November of 2003.  She subsequently had repeat chest x-rays and CT scans and was found to have a moderate pericardial effusion.  She had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.  Also, during that time, she had become significantly more short of breath.  A dobutamine stress echocardiogram was performed, which was negative with the exception of the pericardial effusions.  She had no tamponade physiology.,INDICATION FOR THE PROCEDURE: , For therapeutic and diagnostic management of this symptomatic pericardial effusion.  Risks, benefits, and alternative measures were discussed with the patient.  Consent was obtained for the above procedure.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion.  A 4 cm incision was created in the midline above the xiphoid.  Dissection was carried down through the fascia and the xiphoid was resected.  The sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium.  An #0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart.,This suture was used to retract the pericardium and the pericardium was nicked with #15 blade under direct visualization.  Serous fluid exited through the pericardium and was sent for culture, cytology, and cell count etc.  A section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed.  The heart was visualized and appeared to be contracting well with no evidence of injury to the heart.  The pericardium was then palpated.  There was no evidence of studding.  A right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium.  It was sewn into place with #0 silk suture.  There was some air leak of the left pleural cavity, so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium.  It was sewn in the similar way to the other chest tube.  Once again, the area was inspected and found to be hemostatic and then closed with #0 Vicryl suture for fascial stitch, then #3-0 Vicryl suture in the subcutaneous fat, and then #4-0 undyed Vicryl in a running subcuticular fashion.  The patient tolerated the procedure well.  Chest tubes were placed on 20 cm of water suction.  The patient was taken to PACU in stable condition.
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DESCRIPTION: Subxiphoid pericardiotomy.  Symptomatic pericardial effusion.  The patient had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.

cardiovascular / pulmonary, subxiphoid pericardiotomy, symptomatic pericardial effusion, chest x-rays, echocardiogram, dobutamine, pleural cavity, chest tube, pericardial effusion, pericardium, inflammatory, subxiphoid, pericardiotomy, heart, chest, effusion, pericardial

The procedure described is a subxiphoid pericardiotomy conducted to manage symptomatic pericardial effusion. Although the procedure was done on a 70-year-old patient, it is a common method to relieve fluid in the pericardium and was indicated as being necessary due to the patient's symptoms. The patient's stable condition post-surgery suggests that it was appropriately managed and generally routine for such symptoms. However, performing surgery on an older patient, especially one with a history of significant prior surgery (esophagectomy), does add complexity and some risk, elevating the stakes to some degree.


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

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

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

The case involves a medical procedure requiring phenol neurolysis and botulinum toxin injections on a patient diagnosed with spastic right hemiparetic cerebral palsy. Both procedures are minimally invasive treatments commonly used for managing muscle spasticity in such conditions. While these are specialized procedures performed under sedation, and therefore warrant careful monitoring, they are generally considered routine in the field of neurosurgery for managing spasticity. The report notes no complications and that the patient tolerated the procedures well, indicating a standard situation with minimal immediate risk.


Medical Specialty: Surgery
Sample Name: Synovectomy - Partial

PREOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,OPERATION PERFORMED: , Arthroscopic irrigation and debridement of same with partial synovectomy.,ANESTHESIA:,  LMA.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,DRAINS:,  None.,INDICATIONS:,  The patient is an 81-year-old female, who is approximately 10 years status post total knee replacement performed in another state, who presented a couple of days ago to the office with worsening pain without injury and whose symptoms have been present for approximately a month following a possible urinary tract infection.  The patient' knee was aspirated in the office and cultures were positive for Escherichia coli.  She presents for operative therapy.,DESCRIPTION OF OPERATION: , After obtaining informed consent and the administration of antibiotics since her cultures had already been obtained, the patient was taken to the operating room and following satisfactory induction and the patient was placed on the table in supine position.  The left upper extremity was prepped and draped without a tourniquet.  The knee was injected with 30 mL of normal saline and standard arthroscopy portals were created.  The arthroscopy was inserted and a complete diagnostic was performed.  Arthroscopic pictures were taken throughout the procedure.  The knee was copiously irrigated with 9 L of irrigant.  A partial synovectomy was performed in all compartments.  Minimal amount of polyethylene wear was noted.  The total knee components were identified arthroscopically for future revision surgery.  The knee was then drained and the arthroscopic instruments were removed.  The portals were closed with 4-0 nylon and local anesthetic was injected.  A sterile dressing was applied and the patient was placed in a knee immobilizer, awakened from anesthesia and transported to the recovery room in stable condition and tolerated the procedure well.
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DESCRIPTION: Arthroscopic irrigation and debridement of same with partial synovectomy.  Septic left total knee arthroplasty.

surgery, total knee arthroplasty, arthroscopic irrigation, debridement, partial synovectomy, knee, arthroscopic, irrigation, arthroscopy, synovectomy,

The scenario described involves a surgical procedure on an 81-year-old patient with a septic knee arthroplasty. This indicates a significant health condition requiring surgical intervention to manage an infection. The stakes are high due to the patient's age and the risks associated with surgery, such as potential complications from infection, anesthesia, and the patient's overall health. However, there were no immediate complications reported in the procedure, and the patient tolerated the surgery well, which slightly reduces the urgency. Nonetheless, surgery is inherently higher stakes because of the potential impact on the patient’s health if not performed successfully.


Medical Specialty: Surgery
Sample Name: Youngswick Bunionectomy

PREOPERATIVE DIAGNOSES:,1.  Hallux rigidus, left foot.,2.  Elevated first metatarsal, left foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux rigidus, left foot.,2.  Elevated first metatarsal, left foot.,PROCEDURE PERFORMED:,1.  Austin/Youngswick bunionectomy with Biopro implant.,2.  Screw fixation, left foot.,HISTORY: , This 51-year-old male presents to ABCD General Hospital with the above chief complaint.  The patient states that he has had degenerative joint disease in his left first MPJ for many years that has been progressively getting worse and more painful over time.  The patient desires surgical treatment.,PROCEDURE IN DETAIL: , An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 7 cc of 0.5% Marcaine plain was injected in a Mayo-type block.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was then inflated to 250 mmHg.  The foot was lowered to the operating table, the stockinet was reflected, and the foot was cleansed with wet and dry sponge.,Attention was then directed to the left first metatarsophalangeal joint.  Approximately a 6 cm dorsomedial incision was created over the first metatarsophalangeal joint, just medial to the extensor hallucis longus tendon.  The incision was then deepened with a #15 blade.  All vessels encountered were ligated for hemostasis.  The skin and subcutaneous tissue was undermined medially, off of the joint capsule.  A dorsal linear capsular incision was then made.  Care was taken to identify and preserve the extensor hallucis longus tendon.  The capsule and periosteum were then reflected off of the head of the first metatarsal as well as the base of the proximal phalanx.  There was noted to be a significant degenerative joint disease.  There was little to no remaining healthy articular cartilage left on the head of the first metatarsal.  There was significant osteophytic formation medially, dorsally, and laterally in the first metatarsal head as well as at the base of the proximal phalanx.  A sagittal saw was then used to resect the base of the proximal phalanx.  Care was taken to ensure that the resection was parallel to the nail.  After the bone was removed in toto, the area was inspected and the flexor tendon was noted to be intact.  The sagittal saw was then used to resect the osteophytic formation medially, dorsally, and laterally on the first metatarsal.  The first metatarsal was then re-modelled and smoothed in a more rounded position with a reciprocating rasp.  The sizers were then inserted for the Biopro implant.  A large was noted to be of the best size.  There was noted to be some hypertrophic bone laterally in the base of the proximal phalanx.  Following inspection, the sagittal saw was used to clean both the medial and lateral sides of the base.  A small bar drill was then used to pre-drill for the Biopro sizer.  The bone was noted to be significantly hardened.  The sizer was placed and a large Biopro was deemed to be the correct size implant.  The sizer was removed and bar drill was then again used to ream the medullary canal.  The hand reamer with a Biopro set was then used to complete the process.  The Biopro implant was then inserted and tamped with a hammer and rubber mallet to ensure tight fit.  There was noted to be distally increased range of motion after insertion of the implant.,Attention was then directed to the first metatarsal.  A long dorsal arm Austin osteotomy was then created.  A second osteotomy was then created just plantar and parallel to the first osteotomy site.  The wedge was then removed in toto.  The area was feathered to ensure high compression of the osteotomy site.  The head was noted to be in a more plantar flexed position.  The capital fragment was then temporarily fixated with two 0.45 K-wires.  A 2.7 x 16 mm screw was then inserted in the standard AO fashion.  A second more proximal 2.7 x 60 mm screw was also inserted in a standard AO fashion.  With both screws, there was noted to be tight compression at the osteotomy sites.,The K-wires were removed and the areas were then smoothed with reciprocating rash.  A screw driver was then used to check and ensure screw tightness.  The area was then flushed with copious amounts of sterile saline.  Subchondral drilling was performed with a 1.5 drill bit.  The area was then flushed with copious amounts of sterile saline.  Closure consisted of capsular closure with #3-0 Vicryl followed by subcutaneous closure with #4-0 Vicryl, followed by running subcuticular stitch of #5-0 Vicryl.  Dressings consisted of Steri-Strips, Owen silk, 4x4s, Kling, Kerlix, and Coban.  A total of 10 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain was injected intraoperatively for further anesthesia.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well.  The patient was transported to PACU with vital signs stable and vascular status intact to the right foot.  The patient was given postoperative pain prescription for Vicodin ES and instructed to take 1 q.  4-6h. p.o. p.r.n. pain.  The patient was instructed to ice and elevate his left lower extremity as much as possible to help decrease postoperative edema.  The patient is to follow up with Dr. X in his office as directed.
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DESCRIPTION: Austin & Youngswick bunionectomy with Biopro implant.  Screw fixation, left foot.

surgery, hallux rigidus, metatarsal, youngswick, bunionectomy, screw fixation, ankle tourniquet, metatarsophalangeal joint, biopro implant, proximal phalanx, foot, austin, anesthesia, osteotomy, screw,

The situation described is a surgical procedure involving an Austin/Youngswick bunionectomy with the use of a Biopro implant and screw fixation on a patient's foot. Surgery inherently carries risks such as infection, complications from anesthesia, or issues related to the implant or fixation process. Given the complexity and potential for complications in any surgical procedure, this situation can be considered high-stakes from a medical standpoint, although not the highest possible stakes compared to, say, life-saving surgeries. The patient’s postoperative condition is stable, which indicates appropriate handling, but initial stakes are significant due to the nature of surgery and associated risks.