Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pulmonary Atresia

HISTORY: , The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.  He also has VACTERL association with hydrocephalus.  As an infant, he underwent placement of a right modified central shunt.  On 05/26/1999, he underwent placement of a bidirectional Glenn shunt, pulmonary artery angioplasty, takedown of the central shunt, PDA ligation, and placement of a 4 mm left-sided central shunt.  On 08/01/2006, he underwent cardiac catheterization and coil embolization of the central shunt.  A repeat catheterization on 09/25/2001 demonstrated elevated Glenn pressures and significant collateral vessels for which he underwent embolization.  He then underwent repeat catheterization on 11/20/2003 and further embolization of residual collateral vessels.  Blood pressures were found to be 13 mmHg with the pulmonary vascular resistance of 2.6-3.1 Wood units.  On 03/22/2004, he returned to the operating room and underwent successful 20 mm extracardiac Fontan with placement of an 8-mm fenestration and main pulmonary artery ligation.  A repeat catheterization on 09/07/2006, demonstrated mildly elevated Fontan pressures in the context of a widely patent Fontan fenestration and intolerance of Fontan fenestration occlusion.  The patient then followed conservatively since that time.  The patient is undergoing a repeat evaluation to assess his candidacy for a Fontan fenestration occlusion, as well as consideration for a tricuspid valvuloplasty in attempt to relieve right ventricular hypertension and associated membranous ventricular aneurysm protruding into the left ventricular outflow tract.,PROCEDURE:,  After sedation and local Xylocaine anesthesia, the patient was placed under general endotracheal anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava along the Fontan conduit into the main left pulmonary artery, as well as the superior vena cava.  This catheter was then exchanged for a 5-French VS catheter of a distal wire.  Apposition of the right pulmonary artery over, which the wedge catheter was advanced.  The wedge catheter could then be easily advanced across the Fontan fenestration into the right atrium and guidewire manipulation allowed access across the atrial septal defect to the pulmonary veins, left atrium, and left ventricle.,Using a 5-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  Attempt was then made to cross the tricuspid valve from the right atrium and guidewire persisted to prolapse through the membranous ventricular septum into the left ventricle.  The catheter distal wire position was finally achieved across what appeared to be the posterior aspect of the tricuspid valve, both angiographically as well as equal guidance.  Left ventricular pressure was found to be suprasystemic.  A balloon valvoplasty was performed using a Ranger 4 x 2 cm balloon catheter with no waste at minimal inflation pressure.  Echocardiogram, which showed no significant change in the appearance of a tricuspid valve and persistence of aneurysmal membranous ventricular septum.  Further angioplasty was then performed first utilizing a 6 mm cutting balloon directed through 7-French flexor sheath positioned within the right atrium.  There was a disappearance of a mild waist prior to spontaneous tear of the balloon.  The balloon catheter was then removed in its entirety.,Echocardiogram again demonstrated no change in the appearance of the tricuspid valve.  A final angioplasty was performed utilizing a 80 mm cutting balloon with the disappearance of a distinctive waste.  Echocardiogram; however, demonstrated no change and intact appearing tricuspid valve and no decompression of the right ventricle.  Further attempts to cross tricuspid valve were thus abandoned.  Attention was then directed to a Fontan fenestration.  A balloon occlusion then demonstrated minimal increase in Fontan pressures from 12 mmHg to 15 mmHg.  With less than 10% fall in calculated cardiac index.  The angiogram in the inferior vena cava demonstrated a large fenestration measuring 6.6 mm in diameter with a length of 8 mm.  A 7-French flexor sheath was again advanced cross the fenestration.  A 10-mm Amplatzer muscular ventricular septal defect occluder was loaded on delivery catheter and advanced through the sheath where the distal disk was allowed to be figured in the right atrium.  Entire system was then brought into the fenestration and withdrawal of the sheath allowed reconfiguration of the proximal disk.  Once the stable device configuration was confirmed, device was released from the delivery catheter.  Hemodynamic assessment and the angiograms were then repeated.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Angiograms with injection in the right coronary artery, left coronary artery, superior vena cava, inferior vena cava, and right ventricle.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was low due to systemic arterial desaturation.  There was modest increased saturation of the branch pulmonary arteries due to the presumed aortopulmonary collateral flow.  The right pulmonary veins were fully saturated.  Left pulmonary veins were not entered.  There was a fall in saturation within the left ventricle and descending aorta due to a right to left shunt across the Fontan fenestration.  Mean Fontan pressures were 12 mmHg with a 1 mmHg fall in mean pressure into the distal left pulmonary artery.  Right and left pulmonary capillary wedge pressures were similar to left atrial phasic pressure with an A-wave similar to the normal left ventricular end-diastolic pressure of 11 mmHg.  Left ventricular systolic pressure was normal with at most 5 mmHg systolic gradient pressure pull-back to the ascending aorta.  Phasic ascending and descending aortic pressures were similar and normal.  The calculated systemic flow was normal.  Pulmonary flow was reduced to the QT-QS ratio of 0.7621.  Pulmonary vascular resistance was normal at 1 Wood units.,Angiogram with injection in the right coronary artery demonstrated diminutive coronary with an extensive sinusoidal communication to the rudimentary right ventricle.  The left coronary angiogram showed a left dominant system with a brisk flow to the left anterior descending and left circumflex coronary arteries.  There was communication to the right-sided coronary sinusoidal communication to the rudimentary right ventricle.  Angiogram with injection in the superior vena cava showed patent right bidirectional Glenn shunt with mild narrowing of the proximal right pulmonary artery, as well as the central pulmonary artery, diameter of which was augmented by the Glenn anastomosis and the Fontan anastomosis.  There was symmetric contrast flow to both pulmonary arteries.  A large degree of contrast flowed retrograde into the Fontan and shunting into the right atrium across the fenestration.  There is competitive flow to the upper lobes presumably due to aortopulmonary collateral flow.  The branch pulmonaries appeared mildly hypoplastic.  Levo phase contrast returned into the heart, appeared unobstructed demonstrating good left ventricular contractility.  Angiogram with injection in the Fontan showed a widely patent anastomosis with the inferior vena cava.  Majority of the contrast flowing across the fenestration into the right atrium with a positive flow to the branch pulmonary arteries.,Following the device occlusion of Fontan fenestration, the Fontan and mean pressure increased to 15 mmHg with a 3 mmHg, a mean gradient in the distal left pulmonary artery and no gradient into the right pulmonary artery.  There was an increase in the systemic arterial pressures.  Mixed venous saturation increased from the resting state as with increase in systemic arterial saturation to 95%.  The calculated systemic flow increased slightly from the resting state and pulmonary flow was similar with a QT-QS ratio of 0.921.  Angiogram with injection in the inferior vena cava showed a stable device configuration with a good disk apposition to the anterior surface of the Fontan with no protrusion into the Fontan and no residual shunt and no obstruction to a Fontan flow.  An ascending aortogram that showed a left aortic arch with trace aortic insufficiency and multiple small residual aortopulmonary collateral vessels arising from the intercostal arteries.  A small degree of contrast returned to the heart.,INITIAL DIAGNOSES:  ,1.  Pulmonary atresia.,2.  VACTERL association.,3.  Persistent sinusoidal right ventricle to the coronary communications.,4.  Hydrocephalus.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Systemic to pulmonary shunts.,2.  Right bidirectional Glenn shunt.,3.  Revision of the central shunt.,4.  Ligation and division of patent ductus arteriosus.,5.  Occlusion of venovenous and arterial aortopulmonary collateral vessels.,6.  Extracardiac Fontan with the fenestration.,CURRENT DIAGNOSES:  ,1.  Favorable Fontan hemodynamics.,2.  Hypertensive right ventricle.,3.  Aneurysm membranous ventricular septum with mild left ventricle outflow tract obstruction.,4.  Patent Fontan fenestration.,CURRENT INTERVENTION:  ,1.  Balloon dilation tricuspid valve attempted and failed.,2.  Occlusion of a Fontan fenestration.,MANAGEMENT:  ,He will be discussed at Combined Cardiology/Cardiothoracic Surgery case conference.  A careful monitoring of ventricle outflow tract will be instituted with consideration for a surgical repair.  Further cardiologic care will be directed by Dr. X.
---
DESCRIPTION: The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.

The medical situation described involves a complex case of a pediatric patient with congenital heart defects, specifically pulmonary atresia, as well as VACTERL association and other complications. The case describes multiple past surgeries including the placement of shunts and an extracardiac Fontan procedure. The current interventions include an attempted but failed tricuspid valve dilation and occlusion of a Fontan fenestration. The patient is under consideration for further surgical intervention. Given the complexity and history of the patient's condition, along with the need for further invasive procedures, the stakes are high due to the potential risks and the significance of the condition on the patient's life expectancy and quality of life. Any decisions made regarding further interventions could have critical impacts on the patient's health outcomes.


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

Medical Specialty: ENT - Otolaryngology
Sample Name: Tonsillectomy & Adenoidectomy - 1

PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA:,  General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia.  The McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,The nasopharynx was inspected with a laryngeal mirror.  The adenoid tissue was fulgurated with the suction Bovie set at 35.  The catheters and the dental gauze roll were then removed.  The anterior tonsillar pillars were infiltrated with 0.5% Marcaine and epinephrine.  Using the radiofrequency wand, the tonsils were ablated bilaterally.  If bleeding occurred, it was treated with the wand on coag mode using a coag mode of 3 and an ablation mode of 9.  The tonsillectomy was completed.,The nasopharynx and nasal passages were suctioned free of debris, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.
---
DESCRIPTION: Tonsillectomy and adenoidectomy.  McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.

ent - otolaryngology, tongue, nasal passage, palate, mcivor mouth gag, gauze roll, nasopharynx, tonsillectomy, adenoidectomy,

Tonsillectomy and adenoidectomy are relatively common procedures performed to remove the tonsils and adenoids, usually in cases of chronic infections or sleep apnea. The description indicates the use of general anesthesia and standard surgical equipment. While these surgeries are routine and have a high success rate, they still involve general anesthesia, which carries inherent risks. Therefore, the stakes are moderate due to the potential risks associated with any surgical procedure and the use of general anesthesia.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Ischemic Cardiac Disease - Progress Note

HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old man who returns for recheck.  He has a history of ischemic cardiac disease, he did see Dr. XYZ in February 2004 and had a thallium treadmill test.  He did walk for 8 minutes.  The scan showed some mild inferior wall scar and ejection fraction was well preserved.  He has not had difficulty with chest pain, palpitations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS: , He had tonsillectomy at the age of 8.  He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure.  He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise.,MEDICATIONS:,  Kerlone 10 mg 1/2 pill daily, gemfibrozil 600 mg twice daily, Crestor 80 mg 1/2 pill daily, aspirin 325 mg daily, vitamin E 400 units daily, and Citrucel one daily.,ALLERGIES: , None known.,FAMILY HISTORY:  ,Father died at the age of 84.  He had a prior history of cancer of the lung and ischemic cardiac disease.  Mother died in her 80s from congestive heart failure.  He has two brothers and six sisters living who remain in good health.,PERSONAL HISTORY:  ,Quit smoking in 1996.  He occasionally drinks alcoholic beverages.,REVIEW OF SYSTEMS:,Endocrine:  He has hypercholesterolemia treated with diet and medication.  He reports that he did lose 10 pounds this year.,Neurologic:  Denies any TIA symptoms.,Genitourinary:  He has occasional nocturia.  Denies any difficulty emptying his bladder.,Gastrointestinal:  He has a history of asymptomatic cholelithiasis.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  225 pounds.  Blood pressure:  130/82.  Pulse:  83.  Temperature:  96.4 degrees.,General Appearance:  He is a middle-aged man who is not in any acute distress.,HEENT:  Mouth:  The posterior pharynx is clear.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1, S2, without gallops or rubs.,Abdomen:  Without tenderness or masses.,Extremities:  Without edema.,IMPRESSION/PLAN:,1.  Ischemic cardiac disease.  This remains stable.  He will continue on the same medication.  He reports he has had some laboratory studies today.,2.  Hypercholesterolemia.  He will continue on the same medication.,3.  Facial tic.  We also discussed having difficulty with the facial tic at the left orbital region.  This occurs mainly when he is under stress.  He has apparently had numerous studies in the past and has seen several doctors in Wichita about this.  At one time was being considered for some type of operation.  His description, however, suggests that they were considering an operation for tic douloureux.  He does not have any pain with this tic and this is mainly a muscle spasm that causes his eye to close.  Repeat neurology evaluation was advised.  He will be scheduled to see Dr. XYZ in Newton on 09/15/2004.,4.  Immunization.  Addition of pneumococcal vaccination was discussed with him but had been decided by him at the end of the appointment.  We will have this discussed with him further when his laboratory results are back.
---
DESCRIPTION: Patient with a history of ischemic cardiac disease and hypercholesterolemia.

The situation involves a 68-year-old patient with ischemic cardiac disease, which is a significant but stable condition as indicated by the document. The patient has a history of myocardial infarction, coronary bypass surgery, and is on multiple medications. While his condition is under control and he is not currently in acute distress, his medical history indicates he has had serious heart problems in the past. Heart conditions can escalate quickly in severity, making it a somewhat high-stakes situation. However, given the current stability and absence of acute symptoms, it does not rank as extremely high-stakes at this moment.


Medical Specialty: Surgery
Sample Name: Ganglion Excision

PREOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,POSTOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,OPERATION: , Excision of ganglion.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,OPERATION: , After a successful anesthetic, the patient was positioned on the operating table.  A tourniquet applied to the upper arm.  The extremity was prepped in a usual manner for a surgical procedure and draped off.  The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.  By blunt and sharp dissection, it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted.  The small superficial vessels were electrocoagulated and instilled after closing the skin with 4-0 Prolene, into the area was approximately 6 to 7 mL of 0.25 Marcaine with epinephrine.  A Jackson-Pratt drain was inserted and then after the tourniquet was released, it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room.  The dressings applied to the hand were that of Xeroform, 4x4s, ABD, Kerlix, and elastic wrap over a volar fiberglass splint.  The tourniquet was released.  Circulation returned to the fingers.  The patient then was allowed to awaken and left the operating room in good condition.
---
DESCRIPTION: Excision of ganglion of the left wrist.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.

surgery, curved incision, superficial vessels, tourniquet, excision, dorsal, wrist, ganglion

The surgical procedure described is a ganglion excision, which is generally considered a routine and low-risk surgery typically performed to remove a nonmalignant cyst on the wrist. The operation is well-documented with proper precautions such as the use of a tourniquet, general anesthesia, and minimal blood loss. Post-operative recovery is straightforward, and the patient left the operating room in good condition. Thus, this scenario is not high-stakes compared to major surgeries involving critical organs or life-threatening conditions.


Medical Specialty: Podiatry
Sample Name: McBride Bunionectomy & Wedge Osteotomy

PREOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1.  Right McBride bunionectomy.,2.  Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle cuff.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in a supine position.  The right foot was prepared and draped in usual sterile manner.  Anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint.  Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg.  At this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made.  The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure.  The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection.  Using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp.  At this time, attention was directed to the first inner space using sharp and blunt dissection.  Dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments.  The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment.  At this time, the lateral release was stressed and was found to be complete.  The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw.  The area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted.  At this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length.  The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption.  At this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint.  At this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge.  The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3.0 x 22 mm.  The screw was placed following proper technique.  The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing.  A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy.  The packing of the cancellous bone was held in place with bone wax.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed.  At this time, a deep closure was achieved utilizing #2-0 Vicryl suture, subcuticular closure was achieved using #4-0 Vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion.  The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site.  At this time, the surgical site was postoperatively injected with 0.5 Marcaine plain as well as dexamethasone 4 mg primarily.  The surgical sites were then dressed with sterile Xeroform, sterile 4x4s, cascading, and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion.  The tourniquet was dropped and color and temperature of all digits returned to normal.  The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided.  The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.,
---
DESCRIPTION: Right hallux abductovalgus deformity.  Right McBride bunionectomy.  Right basilar wedge osteotomy with OrthoPro screw fixation.

podiatry, hallux, abductovalgus, bunionectomy, mcbride, basilar, wedge, osteotomy, orthopro, screw, fixation, wedge osteotomy

The medical procedure being described is a McBride Bunionectomy and wedge osteotomy, which are surgeries performed to correct a deformity in the foot known as hallux abductovalgus (commonly referred to as a bunion). While this type of surgery is significant for the patient's health and mobility, it is generally a well-documented and routinely performed procedure within the field of podiatry. It is not considered high-stakes in the sense of life-threatening or complex procedures like open-heart surgery. However, it is important for the patient's quality of life and long-term mobility, and there is always a risk of potential complications, which necessitates medical expertise and careful postoperative management.


Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy - 7

PREOPERATIVE DIAGNOSIS:,  Positive peptic ulcer disease.,POSTOPERATIVE DIAGNOSIS:,  Gastritis.,PROCEDURE PERFORMED: , Esophagogastroduodenoscopy with photography and biopsy.,GROSS FINDINGS:,  The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.,Upon endoscopy, gastroesophageal junction was at 40 cm, no esophageal tumor, varices, strictures, masses, or no reflux esophagitis was noted.  Examination of the stomach reveals mild inflammation of the antrum of the stomach, no ulcers, erosions, tumors, or masses.  The profundus and the cardia of the stomach were unremarkable.  The pylorus was concentric.  The duodenal bulb and sweep with no inflammation, tumors, or masses.,OPERATIVE PROCEDURE: , The patient taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position.  She was given IV sedation using Demerol and Versed.  Olympus videoscope was inserted in the hypopharynx, upon deglutition passed into the esophagus.  Using air insufflation, the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep.  The above gross findings noted.  The panendoscope was withdrawn back from the stomach, deflected upon itself.  The lesser curve fundus and cardiac were well visualized.  Upon examination of these areas, panendoscope was returned to midline.  Photographs and biopsies were obtained of the antrum of the stomach.  Air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel.,Photographs and biopsies were obtained as appropriate.  The patient is sent to recovery room in stable condition.
---
DESCRIPTION: Positive peptic ulcer disease.  Gastritis.  Esophagogastroduodenoscopy with photography and biopsy.   The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.

surgery, antrum, esophageal tumor, varices, strictures, masses, duodenal bulb, peptic ulcer, duodenal, esophagus, esophagogastroduodenoscopy, panendoscope, peptic, inflammation, ulcer, disease, stomach

This situation involves a medical procedure, specifically an esophagogastroduodenoscopy with photography and biopsy, performed to evaluate and diagnose conditions related to peptic ulcer disease and gastritis. While the procedure is relatively routine and the patient remained in stable condition afterward, the context of surgery inherently involves certain risks and the potential for complications. Therefore, it is considered a moderate to high-stakes situation due to the medical and diagnostic nature involved, but not an emergency or life-theatening condition post-procedure.


Medical Specialty: Lab Medicine - Pathology
Sample Name: Pathology - Sesamoid Bone

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

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

The situation involves a pathology report detailing a diagnosis of acute osteomyelitis in the sesamoid bone of the left foot, along with inflammation and severely occlusive arteriosclerosis. While osteomyelitis and arteriosclerosis are serious conditions that require medical attention, the stakes are not immediately life-threatening. However, if left untreated, they can lead to significant complications, such as infection spreading, chronic pain, or severe vascular issues. So, timely diagnosis and treatment are critical to prevent these potential outcomes.


Medical Specialty: General Medicine
Sample Name: Accidental Celesta Ingestion - ER Visit

HISTORY OF PRESENT ILLNESS:,  Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.  Mom called to the poison control center and the recommendation was to take the patient to the emergency room and be evaluated.  The patient was alert and did not vomit during the transport to the emergency room.  Mom left the patient and his little one-year-old brother in the room by themselves and she went outside of the house for a couple of minutes, and when came back, she saw the patient having the Celesta foils in his hands and half of tablet was moist and on the floor.  The patient said that the pills "didn't taste good," so it is presumed that the patient actually ingested at least two-and-a-half tablets of Celesta, 40 mg per tablet.,PAST MEDICAL HISTORY:,  Baby was born premature and he required hospitalization, but was not on mechanical ventilation.  He doesn't have any hospitalizations after the new born.  No surgeries.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , NOT KNOWN DRUG ALLERGIES.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature 36.2 Celsius, pulse 112, respirations 24, blood pressure 104/67, weight 15 kilograms.,GENERAL:  Alert, in no acute distress.,SKIN:  No rashes.,HEENT:  Head:  Normocephalic, atraumatic.  Eyes:  EOMI, PERRL.  Nasal mucosa clear.  Throat and tonsils, normal.  No erythema, no exudates.,NECK:  Supple, no lymphadenopathy, no masses.,LUNGS:  Clear to auscultation bilateral.,HEART:  Regular rhythm and rate without murmur.  Normal S1, S2.,ABDOMEN:  Soft, nondistended, nontender, present bowel sounds, no hepatosplenomegaly, no masses.,EXTREMITIES:  Warm.  Capillary refill brisk.  Deep tendon reflexes present bilaterally.,NEUROLOGICAL:  Alert.  Cranial nerves II through XII intact.  No focal exam.  Normal gait.,RADIOGRAPHIC DATA: , Patient has had an EKG done at the admission and it was within normal limits for the age.,EMERGENCY ROOM COURSE: , Patient was under observation for 6 hours in the emergency room.  He had two more EKGs during observation in the emergency room and they were all normal.  His vital signs were monitored every hour and were within normal limits.  There was no vomiting, no diarrhea during observation.  Patient did not receive any medication or has had any other lab work besides the EKG.,ASSESSMENT AND PLAN: , Three years old male with accidental ingestion of Celesta.  Discharged home with parents, with a followup in the morning with his primary care physician.
---
DESCRIPTION: Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.

general medicine, accidental ingestion of celesta, celesta, tablets, ingestion,

The situation involves the accidental ingestion of medication by a three-year-old child, which is certainly concerning due to potential toxicity, especially considering the dosage (80-120 mg) relative to a child's body weight. However, the child's observation period showed normal vital signs, no vomiting or diarrhea, no need for medication, and normal EKGs. The child was also alert and in no distress. Thus, while any ingestion of medication by a young child can be critical, the specific clinical signs and the observation results indicate that this particular case did not escalate to a high-stakes medical emergency, as the child was safely discharged and advised to follow up with their PCP.


Medical Specialty: Gastroenterology
Sample Name: Appendectomy Laparoscopic

PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,PROCEDURE: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Patient is a pleasant 31-year-old gentleman who presented to the hospital with acute onset of right lower quadrant pain.  History as well as signs and symptoms are consistent with acute appendicitis as was his CAT scan.  I evaluated the patient in the emergency room and recommended that he undergo the above-named procedure.  The procedure, purpose, risks, expected benefits, potential complications, alternative forms of therapy were discussed with him and he was agreeable with surgery.,FINDINGS: , Patient was found to have acute appendicitis with an inflamed appendix, which was edematous, but essentially no suppuration.,TECHNIQUE:  ,The patient was identified and then taken into the operating room, where after induction of general endotracheal anesthesia, the abdomen was prepped with Betadine solution and draped in sterile fashion.  An infraumbilical incision was made and carried down by blunt dissection to the level of the fascia, which was grasped with an Allis clamp and two stay sutures of 2-0 Vicryl were placed on either side of the midline.  The fascia was tented and incised and the peritoneum entered by blunt finger dissection.  A Hasson cannula was placed and a pneumoperitoneum to 15 mmHg pressure was obtained.  Patient was placed in the Trendelenburg position, rotated to his left, whereupon under direct vision, the 12-mm midline as well as 5-mm midclavicular and anterior axillary ports were placed.  The appendix was easily visualized, grasped with a Babcock's.  A window was created in the mesoappendix between the appendix and the cecum and the Endo GIA was introduced and the appendix was amputated from the base of the cecum.  The mesoappendix was divided using the Endo GIA with vascular staples.  The appendix was placed within an Endo bag and delivered from the abdominal cavity.  The intra-abdominal cavity was irrigated.  Hemostasis was assured within the mesentery and at the base of the cecum.  All ports were removed under direct vision and then wounds were irrigated with saline antibiotic solution.  The infraumbilical defect was closed with a figure-of-eight 0 Vicryl suture.  The remaining wounds were irrigated and then everything was closed subcuticular with 4-0 Vicryl suture and Steri-Strips.  Patient tolerated the procedure well, dressings were applied, and he was taken to recovery room in stable condition.
---
DESCRIPTION: Laparoscopic appendectomy.  Acute appendicitis.

gastroenterology, endo gia, babcock's, laparoscopic appendectomy, direct vision, abdominal cavity, acute appendicitis, appendectomy, hemostasis, laparoscopic, infraumbilical, appendix, appendicitis, endotracheal,

The situation described involves a laparoscopic appendectomy to treat acute appendicitis. While appendectomies are common and generally safe surgical procedures, they still involve inherent risks due to anesthesia and potential surgical complications. The situation requires surgical intervention, but since the procedure is routine and the patient was stable post-operation, it is not considered extremely high-stakes compared to more complex or life-threatening conditions requiring surgery.


Medical Specialty: Surgery
Sample Name: Complex Cyanotic Congenital Heart Disease

HISTORY:,  The patient is a 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.  He had undergone staged repair beginning on 04/21/1997 with a right modified Blalock-Taussig shunt followed on 09/02/1999 with a bilateral bidirectional Glenn shunt, and left pulmonary artery to main pulmonary artery pericardial patch augmentation.  These procedures were performed at Medical College Hospital.  Family states that they moved to the United States.  Evaluation at the Children's Hospital earlier this year demonstrated complete occlusion of the right bidirectional Glenn shunt as well as occlusion of the proximal right pulmonary artery.  He was also found to have elevated Glenn pressures at 22 mmHg, transpulmonary gradient axis of 14 mmHg.  The QP:QS ratio of 0.6:1.  A large decompressing venous collateral was also appreciated.  The patient was brought back to cardiac catheterization in an attempt to reconstitute the right caval pulmonary anastomosis and to occlude the venous collateral vessel.,DESCRIPTION OF PROCEDURE: , After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 6-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava into the right-sided atrium pulmonary veins and the right ventricle.,Using a 6-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta and ascending aorta.  A separate port of arterial access was obtained in the left femoral artery utilizing a 5-French sheath.,Percutaneous access into the right jugular vein was attempted, but unsuccessful.  Ultrasound on the right neck demonstrated a complete thrombosis of the right internal jugular vein.  Using percutaneous technique and a 5-French sheath, 5-French wedge catheter was inserted into the left internal jugular vein and advanced along the left superior vena cava across the left caval-pulmonary anastomosis into the main pulmonary artery and left pulmonary artery with aid of guidewire.  This catheter then also advanced into the bridging innominate vein.  The catheter was then exchanged over wire for a 4-French Bernstein catheter, which was advanced to the blind end of the right superior vena cava.  A balloon wedge angiogram of the right lower pulmonary vein demonstrated back filling of a small right lower pulmonary artery.  There was no vascular continuity to the stump of the right Glenn.  The jugular venous catheter and sheaths were exchanged over a wire for a 6-French flexor sheath, which was advanced to the proximal right superior vena cava.  The Bernstein catheter was then reintroduced using a Terumo guidewire.  Probing of the superior vena cava facilitated access into the right lower pulmonary artery.  The angiogram in the right pulmonary artery showed a diminutive right lower pulmonary artery and severe long segment proximal stenosis.  The distal pulmonary measured approximately 5.5 to 60 mm in diameter with a long segment stenosis measuring approximately 31 mm in length.  The length of the obstruction was balloon dilated using ultra-thin SD 4 x 2 cm balloon catheter with complete disappearance of the waist.  This facilitated advancement of a flexor sheath into the proximal portion of the stenosis.  A PG 2960 BPX Genesis stent premounted on a 6 mm OptiProbe.  A balloon catheter was advanced across the area of narrowing and inflated with a near-complete disappearance of proximal waist.  Angiogram demonstrated a good stent apposition to the caval wall.  Further angioplasty was then performed utilizing an ultra-thin SDS 8 x 3 cm balloon catheter inflated to 19 atmospheres pressure with complete disappearance of a distinct proximal waist.  Angiogram demonstrated wide patency of reconstituted right caval pulmonary anastomosis though there was no flow seen to the right upper pulmonary artery.  The balloon wedge angiograms were then obtained in the right upper pulmonary veins suggesting the presence of right upper pulmonary artery and not contiguous with the right lower pulmonary artery.  Bernstein catheter was advanced into the main pulmonary artery where a wire probing of the stump of the proximal right pulmonary artery facilitated access to the right upper pulmonary artery.  Angiogram demonstrated severe long segment stenosis of the proximal right pulmonary artery.  Angioplasty of the right pulmonary was then performed using the OptiProbe 6-mm balloon catheter inflated to 16 atmospheres pressure with disappearance of a distinct waist.  Repeat angiogram showed improvement in caliber of right upper pulmonary artery with filling defect of the proximal right pulmonary artery.  The proximal right pulmonary artery was then dilated and stent implanted using a PG 2980 BPX Genesis stent premounted on 8-mm OptiProbe balloon catheter and implanted with complete disappearance of the waist.  Distal right upper pulmonary artery was then dilated and stent implanted utilizing a PG 1870 BPX Genesis stent premounted on 7-mm OptiProbe balloon catheter.  Repeat angiograms were then performed.  Attention was then directed to the large venous collateral vessel arising from the left superior vena cava with a contrast filling of a left-sided azygos vein.  A selective angiogram demonstrated a large azygos vein of the midsection measuring approximately 9.4 mm in diameter.  An Amplatzer 12 mm vascular plug was loaded on the delivery catheter and advanced through the flexor sheath into the azygos vein.  Once stable device was confirmed, the device was released from the delivery catheter.  The 4-French Bernstein catheter was then reintroduced and 5 inch empirical 0.038 inch, 10 cm x 8 mm detachable coils were then implanted above the vascular plug filling the proximal azygos vein.  A pigtail catheter was then introduced into the left superior vena cava for final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection of the coronary sinus of pulmonary veins, the innominate vein, superior vena cava, the main pulmonary artery, and azygos vein.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION:,  Oxygen consumption was assumed to be normal mixed venous saturation, but was low due to systemic arterial desaturation of 79%.  The pulmonary veins were fully saturated with partial pressure of oxygen ranging between 120 and 169 mmHg in 30% oxygen.  Remaining saturations reflected complete admixture.  There was increased saturation in the left pulmonary artery due to aortopulmonary collateral flow.  Phasic right atrial pressures were normal with an A-wave somewhat to the normal right ventricular end-diastolic pressure of 9 mmHg.  Left ventricular systolic pressure was systemic with no outflow obstruction to the ascending aorta.  Phasic ascending, descending pressures were similar and normal.  Mean Glenn pressures at initiation of the case were slightly elevated at 14 mmHg with a transpulmonary gradient of 9 mmHg.  The calculated systemic flow was a normal pulmonary flows reduced with a QP:QS ratio of 0.6:1.  The pulmonary vascular resistance was elevated at 4.4 Woods units.  Following stent implantation in the right caval pulmonary anastomosis and right pulmonary artery, there was a slight increase in the Glenn venous pressures to 16 mmHg.  Following embolization of the azygos vein, there was increase in systemic arterial saturation to 84% and increase in mixed venous saturation.  There was similar increase in Glenn pressures to 28 mmHg with a transpulmonary gradient of 14 mmHg.  There was an increase in arterial pressure.  The calculated systemic flow increased from 3.1 liters /minute/meter squared to 4.3 liters/minute/meter squared.  Angiogram within the innominate vein following stent implantation demonstrated appropriate stent position without significant distortion of the innominate vein or proximal cava.  There appeared unobstructed contrast flow to the right lower pulmonary artery of a 1-mmHg mean pressure gradient.  There was absence of contrast filling of the right middle and right upper pulmonary artery.  Final angiogram with a contrast injection in the left superior vena cava showed a forward flow through the right Glenn, a good contrast filling of the right lower pulmonary artery, and a widely patent left Glenn negative contrast washout of the proximal right pulmonary artery and left pulmonary artery presumably due to aortopulmonary collateral flow.  Contrast injection within the right upper pulmonary artery following the stent implantation demonstrated widely patent proximal right pulmonary artery along the length of the implanted stents though with retrograde contrast flow.,INITIAL DIAGNOSES:  ,1.  Asplenia syndrome.,2.  Dextrocardia bilateral superior vena cava.,3.  Atrioventricular septal defect.,4.  Total anomalous pulmonary venous return to the right-sided atrium.,5.  Double outlet right ventricle with malposed great vessels.,6.  Severe pulmonary stenosis.,7.  Separate hepatic venous drainage into the atria.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Right modified Blalock-Taussig shunt.,2.  Bilateral bidirectional Glenn shunt.,3.  Patch augmentation of the main pulmonary to left pulmonary artery.,CURRENT DIAGNOSES:  ,1.  Obstructed right caval pulmonary anastomosis.,2.  Obstructed right proximal pulmonary artery.,3.  Venovenous collateral vessel.,CURRENT INTERVENTION:  ,1.  Balloon dilation of the right superior vena cava and stent implantation.,2.  Balloon dilation of the proximal right pulmonary artery, stent implantation.,3.  Embolization of venovenous collateral vessel.,MANAGEMENT: , The case will be discussed in Combined Cardiology Cardiothoracic Surgery case conference.  A repeat catheterization is recommended in 3 months to assess for right pulmonary artery growth and to assess candidacy for Fontan completion.  The patient will be maintained on anticoagulant medications of aspirin and Plavix.  Further cardiology care will be directed by Dr. X.
---
DESCRIPTION: A 10-1/2-year-old born with asplenia syndrome with a complex cyanotic congenital heart disease characterized by dextrocardia bilateral superior vena cava, complete atrioventricular septal defect, a total anomalous pulmonary venous return to the right-sided atrium, and double-outlet to the right ventricle with malposed great vessels, the aorta being anterior with a severe pulmonary stenosis.

This situation involves a highly complex medical case of a child with congenital heart disease requiring multiple interventional and surgical procedures. The stakes are high because the patient's life and health are directly impacted by these interventions, and the procedures described are intricate, likely requiring skilled specialists to ensure successful outcomes. Any missteps could result in significant adverse health effects or even be life-threatening. The need for continuous monitoring and future planned interventions further indicates the critical nature of the case.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Poison Ivy - SOAP

SUBJECTIVE:,  He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing.  He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackman; it looked like it was Depo-Medrol 80 mg.  He said that it worked fairly well, although it seemed to still take awhile to get rid of it.  He has been using over-the-counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back.,OBJECTIVE:,Vitals:  Temperature is 99.2.  His weight is 207 pounds.,Skin:  Examination reveals a raised, maculopapular rash in kind of a linear pattern over his arms, legs and chest area which are consistent with a poison ivy or a poison oak.,ASSESSMENT AND ,PLAN:,  Poison ivy.  Plan would be Solu-Medrol 125 mg IM X 1.  Continue over-the-counter Benadryl or Rx allergy medicine that he was given the last time he was here, which is a one-a-day allergy medicine; he can not exactly remember what it is, which would also be fine rather than the over-the-counter Benadryl if he would like to use that instead.
---
DESCRIPTION: Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.

soap / chart / progress notes, poison ivy, steroid injection, depo-medrol, maculopapular rash, poison oak, maculopapular, chest, ivy, poison

The situation involves a common allergic reaction to poison ivy, which though uncomfortable and requiring treatment, seldom poses immediate life-threatening consequences. The patient's previous experiences with similar symptoms and the medical plan of using medications like Solu-Medrol and antihistamines suggest it is generally manageable with standard treatments. Given his stable vitals and the non-critical nature of the condition, this situation does not represent a high-stakes medical scenario.


Medical Specialty: Endocrinology
Sample Name: Tracheostomy & Thyroid Isthmusectomy

PREOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Multiple strokes.,POSTOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Multiple strokes.,PROCEDURES PERFORMED:,1.  Tracheostomy.,2.  Thyroid isthmusectomy.,ANESTHESIA: , General endotracheal tube.,BLOOD LOSS: , Minimal, less than 25 cc.,INDICATIONS:,  The patient is a 50-year-old gentleman who presented to the Emergency Department who had had multiple massive strokes.  He had required ventilator assistance and was transported to the ICU setting.  Because of the numerous deficits from the stroke, he is expected to have a prolonged ventilatory course and he will be requiring long-term care.,PROCEDURE: , After all risks, benefits, and alternatives were discussed with multiple family members in detail, informed consent was obtained.  The patient was brought to the Operative Suite where he was placed in supine position and general anesthesia was delivered through the existing endotracheal tube.  The neck was then palpated and marked appropriately in the cricoid cartilage sternal notch and thyroid cartilage marked appropriately with felt-tip marker.  The skin was then anesthetized with a mixture of 1% lidocaine and 1:100,000 epinephrine solution.  The patient was prepped and draped in usual fashion.  The surgeons were gowned and gloved.  A vertical skin incision was then made with a #15 blade scalpel extending from approximately two fingerbreadths above the level of the sternum approximately 1 cm above the cricoid cartilage.  Blunt dissection was then carried down until the fascia overlying the strap muscles were identified.  At this point, the midline raphe was identified and the strap muscles were separated utilizing the Bovie cautery.  Once the strap muscles have been identified, palpation was performed to identify any arterial aberration.  A high-riding innominate was not identified.  At this point, it was recognized that the thyroid gland was overlying the trachea could not be mobilized.  Therefore, dissection was carried down through to the cricoid cartilage at which point hemostat was advanced underneath the thyroid gland, which was then doubly clamped and ligated with Bovie cautery.  Suture ligation with #3-0 Vicryl was then performed on the thyroid gland in a double interlocking fashion.  This cleared a significant portion of the trachea.  The overlying pretracheal fascia was then cleared with use of pressured forceps as well as Bovie cautery.  Now, a tracheal hook was placed underneath the cricoid cartilage in order to stabilize the trachea.  The second tracheal ring was identified.  The Bovie cautery reduced to create a tracheal window beneath the second tracheal ring that was inferiorly based.  At this point, the anesthetist was appropriately alerted to deflate the endotracheal tube cuff.  The airway was entered and inferior to the base, window was created.  The anesthetist then withdrew the endotracheal tube until the tip of the tube was identified.  At this point, a #8 Shiley tracheostomy tube was inserted freely into the tracheal lumen.  The balloon was inflated and the ventilator was attached.  He was immediately noted to have return of the CO2 waveform and was ventilating appropriately according to the anesthetist.  Now, all surgical retractors were removed.  The baseplate of the tracheostomy tube was sutured to the patient's skin with #2-0 nylon suture.  The tube was further secured around the patient's neck with IV tubing.  Finally, a drain sponge was placed.  At this point, procedure was felt to be complete.  The patient was returned to the ICU setting in stable condition where a chest x-ray is pending.
---
DESCRIPTION: Tracheostomy and thyroid isthmusectomy.  Ventilator-dependent respiratory failure and multiple strokes.

endocrinology, ventilator-dependent respiratory failure, multiple strokes, thyroid, thyroid isthmusectomy, ventilator dependent, respiratory failure, strap muscles, thyroid gland, endotracheal tube, cricoid cartilage, bovie cautery, tracheostomy, ventilator, strokes, cartilage, tracheal, isthmusectomy

The situation involves a 50-year-old patient with ventilator-dependent respiratory failure and a history of multiple strokes, requiring a tracheostomy and thyroid isthmusectomy. Both procedures are significant due to their involvement with maintaining an airway and the need for long-term respiratory care. Given the patient's complex medical history and the necessity to manage airway and ventilation challenges, this case is quite high-stakes. The tracheostomy itself is a critical procedure that provides an artificial airway for patients unable to breathe independently, necessitating significant postoperative care and monitoring. The added complexity of the thyroid isthmusectomy further amplifies the stakes. The stakes are high because failure to establish a secure airway could result in severe complications or be life-threatening.


Medical Specialty: ENT - Otolaryngology
Sample Name: Cauterization - Epistaxis

PREOPERATIVE DIAGNOSIS: , Epistaxis and chronic dysphonia.,POSTOPERATIVE DIAGNOSES:,1.  Atrophic dry nasal mucosa.,2.  Epistaxis.,3.  Atrophic laryngeal changes secondary to inhaled steroid use.,PROCEDURE PERFORMED:,1.  Cauterization of epistaxis, left nasal septum.,2.  Fiberoptic nasal laryngoscopy.,ANESTHESIA: , Neo-Synephrine with lidocaine nasal spray.,FINDINGS:,1.  Atrophic dry cracked nasal mucosa.,2.  Atrophic supraglottic and glottic changes likely secondary to inhaled steroids and recent endotracheal tube intubation.,INDICATIONS: , The patient is a 37-year-old African-American female who was admitted to ABCD General Hospital with a left wrist abscess.  The patient was taken to the operating room for incision and drainage.  Postoperatively, the patient was placed on nasal cannula oxygen and developed subsequent epistaxis.  Upon evaluating the patient, the patient complains of epistaxis from the left naris as well as some chronic dysphonia that had become exacerbated after surgery.  The patient does report of having endotracheal tube intubation during anesthesia.  The patient also gives a history of inhaled steroid use for her asthma.,The patient was extubated after surgery without difficulty, but continued to have some difficulty and the Department of Otolaryngology was asked to evaluate the patient regarding epistaxis and dysphonia.,PROCEDURE DETAILS:,  After the procedure was described, the patient was placed in the seated position.  The fiberoptic nasal laryngoscope was then inserted into the patient's left naris.  The nasal mucosal membranes were dry and atrophic throughout.  There was no evidence of any mass lesions.  The nasal laryngoscope was then advanced towards the posterior aspect of the nasal cavity.  There was no evidence of mass, ulceration, lesion, or obstruction.  The nasolaryngoscopy continued to be advanced into the oropharynx and the vallecula and the base of the tongue were evaluated and were without evidence of mass lesion or ulceration.,The fiberoptic scope was further advanced and visualization of the larynx revealed some atrophic, dry, supraglottic, and glottic changes.  There was no evidence of any local mass lesion, nodule, or ulcerations.  There was no evidence of any erythema.  Upon phonation, the vocal cords approximated completely and upon inspiration, the true vocal cords were abducted in a normal fashion and was symmetric.  The airway was stable and patent throughout the entire examination.  The nasal laryngoscope was then slowly withdrawn from the supraglottic region and the scope was further advanced into the oropharynx and nasopharynx.  The eustachian tube was completely visualized and was patent without obstruction.  The scope was then further removed without difficulty.  The patient tolerated the procedure well and remained in stable condition.,RECOMMENDATIONS AND PLAN: , The patient would benefit from Ocean nasal spray as well as bacitracin ointment applied to the anterior naris.  At this time, we were unable to discontinue the patient's inhaled steroids that she is using for her asthma.  If this becomes possible in the future, this may provide her some relief of her chronic dysphonia.  The patient is to follow up with Department of Otolaryngology after discharge from the hospital for further evaluation of these problems.
---
DESCRIPTION: Cauterization of epistaxis, left nasal septum.  Fiberoptic nasal laryngoscopy.  Atrophic dry nasal mucosa.  Epistaxis.  Atrophic laryngeal changes secondary to inhaled steroid use.

ent - otolaryngology, laryngeal, inhaled steroid use, dry nasal mucosa, fiberoptic nasal laryngoscopy, nasal mucosa, atrophic, cauterization, mucosa, supraglottic, laryngoscope, fiberoptic, dysphonia, lesions, epistaxis,

The scenario involves a medical procedure for addressing epistaxis (nosebleeds) and dysphonia, conditions that although uncomfortable, are relatively common and typically not life-threatening when managed correctly. While the patient's chronic conditions (such as the use of inhaled steroids leading to atrophic changes) require monitoring, the procedure detailed is routine and was performed without complications. The patient tolerated the procedure well, remains stable, and recommendations have been made for follow-up care. Thus, it is not a high-stakes situation in the immediate sense but requires ongoing medical attention.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 3

CHIEF COMPLAINT:, Blood-borne pathogen exposure., ,HISTORY OF PRESENT ILLNESS: ,The patient is a 54-year-old right-handed male who works as a phlebotomist and respiratory therapist at Hospital. The patient states that he was attempting to do a blood gas. He had his finger of the left hand over the pulse and was inserting a needle using the right hand. He did have a protective clothing including use of gloves at the time of the incident. As he advanced the needle, the patient jerked away, this caused him to pull out of the arm and inadvertently pricked the tip of his index finger. The patient was seen and evaluated at the emergency department at the time of incident and had baseline studies drawn, and has been followed by employee health for his injury. The source patient was tested for signs of disease and was found to be negative for HIV, but was found to be a carrier for hepatitis C. The patient has had periodic screening including a blood tests and returns now for his final exam., ,REVIEW OF SYSTEMS: ,The patient prior to today has been very well without any signs or symptoms of viral illness, but yesterday he began to experience symptoms of nausea, had an episode of vomiting last night. Has low appetite. There were no fevers, chills, or malaise. No headache. No congestion or cold. No coughing. He had no sore throat. There was no chest pain or troubled breathing. He did have abdominal symptoms as described above but no abdominal pain. There were no urinary symptoms. No darkening of the skin or eyes. He had no yellowing or darkening of the urine. He had no rash to the skin. There was no local infection at the side of the fingerstick. All other systems were negative., ,PAST MEDICAL HISTORY: ,Significant for degenerative disc disease in the back., ,MEDICATIONS: ,Nexium., ,ALLERGIES:, IV contrast., ,CURRENT WORK STATUS:, He continues on full duty work., ,PHYSICAL EXAMINATION:, The patient was awake and alert. He was seated upright. He did not appear ill or toxic, and was well hydrated. His temperature was 97.2 degrees, pulse was 84, respirations 14 and unlabored, and blood pressure 102/70. HEENT exam, the sclerae were clear. Ocular movements were full and intact. His oropharynx was clear. There was no pharyngeal erythema. No tonsillar enlargement. His neck was supple and nontender. He had no masses. There was no adenopathy in his cervical or axillary chain. Breath sounds were clear and equal without wheeze or rales. Heart tones were regular without murmur or gallop. His abdomen was soft, flat, and nontender. There was no enlargement of the liver or spleen. His extremities were without rash or edema. He had normal gait and balance without ataxia., ,ASSESSMENT: ,The patient presents for evaluation after a contaminated needlestick to the index finger. The source patient was tested and found to be negative for HIV. However, he did test positive for hepatitis C. He was described as a carrier without active disease. The patient has been followed with periodic evaluation including blood testing. He has completed a 3 shot series for hepatitis B and had titers drawn that showed protected antibodies. He also was up-to-date on his immunization including tetanus. The patient has been well during this time except for the onset of a intestinal illness being investigated with some squeakiness and vomiting. He had no other symptoms that were suggestive of acute hepatitis. His abdominal exam was normal. He had no generalized lymphadenopathy and no fever. Blood tests were drawn on 02/07/2005. The results of which were reviewed with the patient. His liver function test was normal at 18. His hepatitis C and HIV, both of which were negative. He had no local signs of infection, and otherwise has been doing well except for his acute intestinal illness as described above., ,IMPRESSION:, Blood-borne pathogen exposure secondary to contaminated needlestick., ,PLAN: ,The patient is now six months out from his injury. He had negative lab studies. There were no physical findings that were suggestive of disease transmission. He was counseled on ways to prevent exposure in the future including use of protective gear including gloves, which he states that he always does. He was counseled that ways to prevent transmission or exposure to intimate contacts., ,WORK STATUS:, He was released to regular work., ,CONDITION: ,He was reassured that no signs of disease transmission had occurred as result of his injury. He therefore was found to be medically stationary without signs of impairment of today's date.
---
DESCRIPTION: Examination due to blood-borne pathogen exposure.

The situation involves a healthcare worker who experienced a needlestick injury with potential exposure to hepatitis C, a serious blood-borne pathogen. However, the source patient was merely a carrier without active disease, and the healthcare worker has had negative follow-up tests indicating no transmission. Needlestick injuries can be concerning due to the risk of infectious disease transmission and potential long-term impact on the worker's health, but in this case, the tests are negative and no disease transmission has occurred. The worker's health is not in immediate danger, and the incident seems to be well-managed with follow-up care and precautionary measures. Thus, while the stakes could be high due to the nature of potential exposure, the actual risk in this case appears low as outcomes have been favorable.


Medical Specialty: Dermatology
Sample Name: Buttock Abscess

CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain.  She started off with a little pimple on the buttock.  She was soaking it at home without any improvement.  She came to the hospital on the first.  The patient underwent incision and drainage in the emergency department.  She was admitted to the hospitalist service with elevated blood sugars.  She has had positive blood cultures.  Surgery is consulted today for evaluation.,PAST MEDICAL HISTORY:  ,Diabetes type II, poorly controlled, high cholesterol.,PAST SURGICAL HISTORY: , C-section and D&C.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , Insulin, metformin, Glucotrol, and Lipitor.,FAMILY HISTORY: , Diabetes, hypertension, stroke, Parkinson disease, and heart disease.,REVIEW OF SYSTEMS: , Significant for pain in the buttock.  Otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  This is an overweight African-American female not in any distress.,VITAL SIGNS:  She has been afebrile since admission.  Vital signs have been stable.  Blood sugars have been in the 200 range.,HEENT:  Normal to inspection.,NECK:  No bruits or adenopathy.,LUNGS:  Clear to auscultation.,CV:  Regular rate and rhythm.,ABDOMEN:  Protuberant, soft, and nontender.,EXTREMITIES:  No clubbing, cyanosis or edema.,RECTAL EXAM:  The patient has a drained abscess on the buttock cheek.  There is some serosanguineous drainage.  There is no longer any purulent drainage.  The wound appears relatively clean.  I do not see a lot of erythema.,ASSESSMENT AND PLAN: , Left buttock abscess, status post incision and drainage.  I do not believe surgical intervention is warranted.  I have recommended some local wound care.  Please see orders for details.
---
DESCRIPTION: Left buttock abscess, status post incision and drainage.   Recommended some local wound care

dermatology, buttock pain, pimple, incision and drainage, local wound care, blood sugars, diabetes, buttock, abscess,

In this scenario, the patient has a buttock abscess that required incision and drainage. While this can cause discomfort and risk infection, the case appears to be managed effectively with local wound care and no need for further surgical intervention. The presence of elevated blood sugar levels due to poorly controlled Type II diabetes elevates the risk slightly, as it can complicate healing and increase infection risk. However, there is no current indication of critical conditions, such as sepsis, as the patient is stable and afebrile. Therefore, while it needs attentive management, it's not imminently life-threatening.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - 4

PREOPERATIVE DIAGNOSIS:  ,Tracheal stenosis and metal stent complications.,POSTOPERATIVE DIAGNOSIS:  ,Tracheal stenosis and metal stent complications.,ANESTHESIA:  ,General endotracheal.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Subglottic stenosis down to 5 mm with mature cicatrix.,3.  Tracheal granulation tissue growing through the stents at the midway point of the stents.,5.  Three metallic stents in place in the proximal trachea.,6.  Distance from the true vocal cords to the proximal stent, 2 cm.,7.  Distance from the proximal stent to the distal stent, 3.5 cm.,8.  Distance from the distal stent to the carina, 8 cm.,9.  Distal airway is clear.,PROCEDURES:,1.  Rigid bronchoscopy with dilation.,2.  Excision of granulation tissue tumor.,3.  Application of mitomycin-C.,4.  Endobronchial ultrasound.,TECHNIQUE IN DETAIL:  ,After informed consent was obtained from the patient and her husband, she was brought to the operating theater after sequence induction was done.  She had a Dedo laryngoscope placed.  Her airways were inspected thoroughly with findings as described above.  She was intermittently ventilated with an endotracheal tube placed through the Dedo scope.  Her granulation tissue was biopsied and then removed with a microdebrider.  Her proximal trachea was dilated with a combination of balloon, Bougie, and rigid scopes.  She tolerated the procedure well, was extubated, and brought to the PACU.
---
DESCRIPTION: Rigid bronchoscopy with dilation, excision of granulation tissue tumor, application of mitomycin-C, endobronchial ultrasound.

cardiovascular / pulmonary, tracheal stenosis, dedo scope, bronchoscopy, cicatrix, dilation, endotracheal, granulation, metal stent, mitomycin-c, proximal trachea, vocal cords, endobronchial ultrasound, granulation tissue, proximal, tracheal, stent,

The procedure involves complex issues with tracheal stenosis and metal stent complications, which can significantly impact a patient's ability to breathe and require careful handling during surgery. The need for anesthesia and the use of mitomycin-C indicate a serious medical intervention with potential risks. The context involves a critical airway management issue which is inherently high-stakes due to the patient's dependence on airway patency for survival.


Medical Specialty: Consult - History and Phy.
Sample Name: Not Feeling Well - ER Visit

CHIEF COMPLAINT:  ,The patient does not have any chief complaint.,HISTORY OF PRESENT ILLNESS:,  This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well.  The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generalized complaint of not feeling well.  The neighbor suspects that this may have been due to the patient taking too many of her Tylenol PM, which the patient has been known to do.  The patient was a little somnolent early this morning and was found only to be oriented x1 with EMS upon their arrival to the patient's house.  The patient states that she just simply felt funny and does not give any more specific details than this.  The patient denies any pain at any time.  She did not have any shortness of breath.  No nausea or vomiting.  No generalized weakness.  The patient states that all that has gone away since arrival here in the hospital, that she feels at her usual self, is not sure why she is here in the hospital, and thinks she should go.  The patient's primary care physician, Dr. X reports that the patient spoke with him yesterday and had complained of shortness of breath, nausea, dizziness, as well as generalized weakness, but the patient states that all this has resolved.  The patient was actually seen here two days ago for those same symptoms and was found to have exacerbation of her COPD and CHF.  The patient was discharged home after evaluation in the emergency room.  The patient does use home O2.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  The patient had complained of generalized fatigue and weakness two days ago in the emergency room and yesterday to her primary care physician.  The patient denies having any other symptoms today.  The patient denies any fever or chills.  Has not had any recent weight change.  HEENT:  The patient denies any headache.  No neck pain.  No rhinorrhea.  No sinus congestion.  No sore throat.  No any vision or hearing change.  No eye or ear pain.  CARDIOVASCULAR:  The patient denies any chest pain.  RESPIRATIONS:  No shortness of breath.  No cough.  No wheeze.  The patient did report having shortness of breath and wheeze with her presentation to the emergency room two days ago and shortness of breath to her primary care physician yesterday, but the patient states that all this has resolved.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  No change in the bowel movements.  There has not been any diarrhea or constipation.  No melena or hematochezia.  GENITOURINARY:  No dysuria, hematuria, urgency, or frequency.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  No pain or abnormalities to any portion of the body.  SKIN:  No rashes or lesions.  NEUROLOGIC:  The patient reported dizziness to her primary care physician yesterday over the phone, but the patient denies having any problems with dizziness over the past few days.  The patient denies any dizziness at this time.  No syncope or no near-syncope.  The patient denies any focal weakness or numbness.  No speech change.  No difficulty with ambulation.  The patient has not had any vision or hearing change.  PSYCHIATRIC:  The patient denies any depression.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  COPD, CHF, hypertension, migraines, previous history of depression, anxiety, diverticulitis, and atrial fibrillation.,PAST SURGICAL HISTORY:,  Placement of pacemaker and hysterectomy.,CURRENT MEDICATIONS: , The patient takes Tylenol PM for insomnia, Lasix, Coumadin, Norvasc, Lanoxin, Diovan, atenolol, and folic acid.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient used to smoke, but quit approximately 30 years ago.  The patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 99.1 oral, blood pressure 139/65, pulse is 72, respirations 18, and oxygen saturation is 92% on room air and interpreted as low normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear sclerae and cornea bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx are normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  No cervical lymphadenopathy.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  The patient does have +1 bilateral lower extremity edema.  RESPIRATIONS:  The patient has coarse breath sounds bilaterally, but no dyspnea.  Good air movement.  No wheeze.  No crackles.  The patient speaks in full sentences without any difficulty.  The patient does not exhibit any retractions, accessory muscle use or abdominal breathing.  GASTROINTESTINAL:  Abdomen is soft, nontender, and nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruits, no mass, no pulsatile mass, and no inguinal lymphadenopathy.  MUSCULOSKELETAL:  No abnormalities noted to the back, arms or legs.  SKIN:  No rashes or lesions.  NEUROLOGICAL:  Cranial nerves II through XII are intact.  Motor is 5/5 and equal to bilateral arms and legs.  Sensory is intact to light touch.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is awake, alert, and oriented x3 although the patient first stated that the year was 1908, but did manage to correct herself up on addressing this with her.  The patient has normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  There is no evidence of lymphadenopathy.,EMERGENCY DEPARTMENT TESTING: , EKG is a rate of 72 with evidence of a pacemaker that has good capture.  There is no evidence of acute cardiac disease on the EKG and there is no apparent change in the EKG from 03/17/08.  CBC has no specific abnormalities of issue.  Chemistry has a BUN of 46 and creatinine of 2.25, glucose is 135, and an estimated GFR is 20.  The rest of the values are normal and unremarkable.  LFTs are all within normal limits.  Cardiac enzymes are all within normal limits.  Digoxin level is therapeutic at 1.6.  Chest x-ray noted cardiomegaly and evidence of congestive heart failure, but no acute change from her chest x-ray done two days ago.  CAT scan of the head did not identify any acute abnormalities.  I spoke with the patient's primary care physician, Dr. X who stated that he would be able to follow up with the patient within the next day.  I spoke with the patient's neighbor who contacted the ambulance service who stated that the patient just reported not feeling well and appeared to be a little somnolent and confused at the time, but suspected that she may have taken too many of her Tylenol PM as she often has done in the past.  The neighbor is XYZ and he says that he checks on her three times a day every day.  ABC is the patient's son and although he lives out of town he calls and checks on her every day as well.  He states that he spoke to her yesterday.  She sounded fine, did not express any other problems that she had apparently been in contact with her primary care physician.  She sounded her usual self to him.  Mr. ABC also spoke to the patient while she was here in the emergency room and she appears to be her usual self and has her normal baseline mental status to him.  He states that he will be able to check on her tomorrow as well.  Although it is of some concern that there may be problems with development of some early dementia, the patient is adamant about not going to a nursing home and has been placed in a Nursing Home in the past, but Dr. Y states that she has managed to be discharged after two previous nursing home placements.  The patient does have Home Health that checks on her as well as housing care in between the two services they share visits every single day  by them as well as the neighbor who checks on her three times a day and her son who calls her each day as well.  The patient although she lives alone, does appear to have good followup and the patient is adamant that she wishes to return home.,DIAGNOSES,1.  EARLY DEMENTIA.,2.
---
DESCRIPTION: A 93-year-old female called up her next-door neighbor to say that she was not feeling well.  The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern.

The situation involves a 93-year-old patient with several chronic health conditions, including COPD, CHF, and potential early dementia, who was taken to the ER after feeling unwell. The concern from the neighbor is that she might have taken too much Tylenol PM. Older patients, particularly those with multiple health issues, are at higher risk for serious complications from medication errors and sudden changes in health status. This patient has previously been in a nursing home, indicating the complexity of her health care needs. The stakes are high because of her age, the involvement of multiple chronic conditions, and potential medication misuse, which could lead to serious health risks.


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

Medical Specialty: Allergy / Immunology
Sample Name: Chronic Sinusitis

HISTORY:,  I had the pleasure of meeting and evaluating the patient referred today for evaluation and treatment of chronic sinusitis.  As you are well aware, she is a pleasant 50-year-old female who states she started having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.  She states she really has sinus problems, but this infection has been rather severe and she notes she has not had much improvement with antibiotics.  She had a CT of her paranasal sinuses identifying mild mucosal thickening of right paranasal sinuses with occlusion of the ostiomeatal complex on the right and turbinate hypertrophy was also noted when I reviewed the films and there is some minimal nasal septum deviation to the left.  She currently is not taking any medication for her sinuses.  She also has noted that she is having some problems with her balance and possible hearing loss or at least ear popping and fullness.  Her audiogram today demonstrated mild high frequency sensorineural hearing loss, normal tympanometry, and normal speech discrimination.  She has tried topical nasal corticosteroid therapy without much improvement.  She tried Allegra without much improvement and she believes the Allegra may have caused problems with balance to worsen.  She notes her dizziness to be much worse if she does quick positional changes such as head turning or sudden movements, no ear fullness, pressure, humming, buzzing or roaring noted in her ears.  She denies any previous history of sinus surgery or nasal injury.  She believes she has some degree of allergy symptoms.,PAST MEDICAL HISTORY:  ,Seasonal allergies, possible food allergies, chronic sinusitis, hypertension and history of weight change.  She is currently 180 pounds.,PAST SURGICAL HISTORY:,  Lower extremity vein stripping, tonsillectomy and adenoidectomy.,FAMILY HISTORY: , Strong for heart disease and alcoholism.,CURRENT MEDICATIONS: , DynaCirc.,ALLERGIES: , Egg-based products cause hives.,SOCIAL HISTORY:  ,The patient used to smoke cigarettes for about 20 years, one-half pack a day.  She currently does not, which was encouraged to continue.  She rarely drinks any alcohol-containing beverages.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Age 50, blood pressure is 136/74, pulse 84, temperature is 98.4, weight is 180 pounds, and height is 5 feet 3 inches.,GENERAL:  The patient is healthy appearing; alert and oriented to person, place and time; responds appropriately; in no acute distress.,HEAD:  Normocephalic.  No masses or lesions noted.,FACE:  No facial tenderness or asymmetry noted.,EYES:  Pupils are equal, round and reactive to light and accommodation bilaterally.  Extraocular movements are intact bilaterally.  No nystagmus.,EARS:  During Hallpike examination, the patient did not become dizzy until she would be placed back into sitting in the upright position.  No nystagmus was appreciated; however, the patient did subjectively report dizziness, which was repeated twice.  No evidence of any orthostatic hypotension was noted during the exam.  Tympanic membranes were noted to be intact.  No signs of middle ear effusion or ear canal inflammation.,NOSE:  The patient appears congested.  Turbinate hypertrophy is noted.  There are no signs of any acute sinusitis.  Septum is midline, slightly deviated to the left.,THROAT:  There is clear postnasal drip.  Oral hygiene is good.  No masses or lesions noted.  Both vocal cords move well to midline.,NECK:  The neck is supple with no adenopathy or masses palpated.  The trachea is midline.  The thyroid gland is of normal size with no nodules.,LUNGS:  Clear to auscultation bilaterally.  No wheeze noted.,HEART:  Regular rate and rhythm.  No murmur noted.,NEUROLOGIC:  Facial nerve is intact bilaterally.  The remaining cranial nerves are intact without focal deficit.,PROCEDURE: , Fiberoptic nasopharyngoscopy identifying turbinate hypertrophy and nasal septum deviation to the left, more significant posteriorly.,IMPRESSION:  ,1.  Probable increasing problems with allergic rhinitis and chronic sinusitis, both contributing to the patient's symptoms.,2.  Subjective dizziness, etiology uncertain; however, consider positional vertigo versus vestibular neuronitis as possible ear causes of dizziness, cannot rule out systemic, central or medication or causes at this time.,3.  Inferior turbinate hypertrophy.,4.  Nasal septum deformity.,RECOMMENDATIONS:,  An ENG was ordered to evaluate vestibular function.  She was placed on Veramyst nasal spray two sprays each nostril daily and even twice daily if symptoms are worsening.  A Medrol Dosepak was prescribed as directed.  The patient was given instruction on use of nasal saline irrigation to be used twice daily and Clarinex 5 mg daily was recommended.  After the patients' ENG examination, we will see the patient back for further evaluation and treatment recommendations.  In light of the patient's atypical dizziness symptoms, I cannot rule out other pathology at this time, and I informed her if there are any acute changes or problems with regards to her balance or any other acute changes, which she attributes associated with her dizziness, she most likely should pursue an emergent visit to the emergency room.,Thank you for allowing me to participate with the care of your patient.
---
DESCRIPTION: Patient having severe sinusitis about two to three months ago with facial discomfort, nasal congestion, eye pain, and postnasal drip symptoms.

The situation involves a patient experiencing chronic sinusitis along with symptoms of dizziness and balance issues. While chronic sinusitis is a common and often treatable condition, the dizziness and balance issues present additional concerns that warrant further investigation. The presence of these symptoms could indicate more complex underlying conditions, such as positional vertigo or vestibular neuronitis. However, the immediate steps being taken, such as ordering an ENG and prescribing medications, suggest that the situation is being managed with appropriate medical oversight. The recommendation for emergent care if symptoms worsen adds a precautionary measure. Overall, while this situation requires careful monitoring and further diagnostic work, it is not immediately life-threatening or broadly impactful, therefore it is not extremely high-stakes.


Medical Specialty: Urology
Sample Name: Hypospadias Repair & Chordee Release - 1

PREOPERATIVE DIAGNOSES: , Coronal hypospadias with chordee and asthma.,POSTOPERATIVE DIAGNOSES:,  Coronal hypospadias with chordee and asthma.,PROCEDURE: , Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).,ANESTHETIC: , General inhalational anesthetic with a caudal block.,FLUIDS RECEIVED:  ,300 mL of crystalloid.,ESTIMATED BLOOD LOSS:  ,20 mL.,TUBES/DRAINS:  ,An 8-French Zaontz catheter.,INDICATIONS FOR OPERATION:  ,The patient is a 17-month-old boy with hypospadias abnormality.  The plan is for repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, a caudal block was placed.  IV antibiotics were given.  He was then placed in the supine position.  The foreskin was retracted and cleansed.  He was then sterilely prepped and draped.  A stay stitch of 4-0 Prolene was then placed on the glans.  The urethra was calibrated with the lacrimal duct probes to an 8-French.  We then marked out the coronal cuff, the penile shaft skin as well as the glanular plate for future surgery with a marking pen.,We then used a 15-blade knife to circumscribe the penis around the coronal cuff.  We then degloved the penis using the curved tenotomy scissors, and electrocautery was used for hemostasis.  The patient had some splaying of the spongiosum tissue, which was also incised laterally and rotated to make a secondary flap.  Once the penis was degloved, and the excessive chordee tissue was released, we then placed a vessel loop tourniquet around the base of the penis and using IV grade saline injected the penis for an artifical erection.  He was still noted to have chordee, so a midline incision through the Buck fascia was made with a 15-blade knife and Heineke-Mikulicz closure using 5-0 Prolene was then used for the chordee Nesbit tuck.  We repeated the artificial erection and the penis was straight.  We then incised the urethral plate with an ophthalmic blade in the midline, and then elevated the glanular wings using a 15-blade knife to elevate and then incise them.  Using the curved iris scissors, we then also further mobilized the glanular wings.  The 8-French Zaontz was then placed while the tourniquet was still in place into the urethral plate.  The upper aspect of the distal meatus was then closed with an interrupted suture of 7-0 Vicryl, and then using a running subcuticular closure, we closed the urethral plates over the Zaontz catheter.  We then mobilized subcutaneous tissue from the penile shaft skin, and the inner perpetual skin on the dorsum, and then buttonholed the flap, placed it over the head of the penis, and then, used it to cover of the hypospadias repair with tacking sutures of 7-0 Vicryl.  We then rolled the spongiosum flap to cover the distal urethra that was also somewhat dysplastic; 7-0 Vicryl was used for that as well.  5-0 Vicryl was used to roll the glans with 2 deep sutures, and then, horizontal mattress sutures of 7-0 Vicryl were used to reconstitute the glans.  Interrupted sutures of 7-0 Vicryl were used to approximate the urethral meatus to the glans.  Once this was done, we then excised the excessive penile shaft skin, and used the interrupted sutures of 6-0 chromic to attach the penile shaft skin to the coronal cuff.  On the ventrum itself, we used horizontal mattress sutures to close the defect.,At the end of the procedure, the Zaontz catheter was sutured into place with a 4-0 Prolene suture, Dermabond tissue adhesive, and Surgicel was used as a dressing and a second layer of Telfa and clear eye tape was then used to tape it into place.  IV Toradol was given at the procedure.  The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room.
---
DESCRIPTION: Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).

urology, coronal hypospadias with chordee, coronal hypospadias, tissue flap relocation, nesbit tuck, hypospadias with chordee, horizontal mattress sutures, chordee release, zaontz catheter, coronal cuff, hypospadias repair, penile shaft, zaontz, glans, urethral, repair, coronal, hypospadias, penis, chordee,

The situation involves a surgical procedure on a 17-month-old child for hypospadias repair and chordee release, which is a relatively common but specialized pediatric urological surgery. While the procedure is standard and the estimated blood loss is low, surgeries on infants can be inherently higher stakes due to the patient's young age, potential for complications, and the need for precise surgical execution to ensure normal development and function. Additionally, there are considerations of anesthesia and postoperative recovery in a very young patient. However, the patient was in stable condition post-operation, suggesting the procedure went as planned, reducing immediate critical stakes.


Medical Specialty: Pain Management
Sample Name: Thoracic epidural steroid injection

PROCEDURE: , Thoracic epidural steroid injection without fluoroscopy.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the sitting position and the back was prepped with Betadine.  Lidocaine 1.5% was used for skin wheal made between __________.  An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique with no cerebrospinal fluid or blood noted.  After negative aspiration, a mixture of 7 cc preservative free normal saline and 160 mg preservative free Depo-Medrol was injected.  Neosporin and band-aid were applied over the puncture site.  The patient was discharged to recovery room in stable condition.
---
DESCRIPTION: Thoracic epidural steroid injection without fluoroscopy.  An 18-gauge Tuohy needle was then placed into the epidural space using loss of resistance technique.

pain management, loss of resistance, cerebrospinal fluid, thoracic epidural steroid injection, fluoroscopy, thoracic, steroid, epidural, injection,

The thoracic epidural steroid injection involves inserting a needle into the epidural space, which carries risks such as nerve damage, infection, and allergic reactions. However, this procedure is typically routine for pain management specialists. The absence of complications in this case and its standard nature without fluoroscopy suggests moderate stakes, primarily due to the potential for adverse events if not performed correctly.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Circumcision Followup

REASON FOR VISIT: , Followup circumcision.,HISTORY OF PRESENT ILLNESS: , The patient had his circumcision performed on 09/16/2007 here at Children's Hospital.  The patient had a pretty significant phimosis and his operative course was smooth.  He did have a little bit of bleeding when he woke in recovery room, which required placement of some additional sutures, but after that, his recovery has been complete.  His mom did note that she had to him a couple of days of oral analgesics, but he seems to be back to normal and pain free now.  He is having no difficulty urinating, and his bowel function remains normal.,PHYSICAL EXAMINATION:  ,Today, The patient looks healthy and happy.  We examined his circumcision site.  His Monocryl sutures are still in place.  The healing is excellent, and there is only a mild amount of residual postoperative swelling.  There was one area where he had some recurrent adhesions at the coronal sulcus, and I gently lysed this today and applied antibiotic ointment showing this to mom had to especially lubricate this area until the healing is completed.,IMPRESSION: , Satisfactory course after circumcision for severe phimosis with no perioperative complications.,PLAN:  ,The patient came in followup for his routine care with Dr. X, but should not need any further routine surgical followup unless he develops any type of difficulty with this surgical wound.  If that does occur, we will be happy to see him back at any time.,
---
DESCRIPTION: Followup circumcision.  The patient had a pretty significant phimosis and his operative course was smooth.  Satisfactory course after circumcision for severe phimosis with no perioperative complications.

soap / chart / progress notes, circumcision, adhesions, followup circumcision, sutures, phimosis,

The situation described is a follow-up visit after a circumcision, a routine surgical procedure. The original procedure was performed to address phimosis and appears to have healed well, with minor issues (like mild postoperative swelling and slight adhesions) that are being managed without complications. There are no indications of major issues or emergencies, reducing the immediate stakes involved. As such, the stakes here are lower, focused primarily on ensuring uneventful recovery and minor wound care.