Medical Specialty: Discharge Summary
Sample Name: Death Summary

CAUSE OF DEATH:,1.  Acute respiratory failure.,2.  Chronic obstructive pulmonary disease exacerbation.,SECONDARY DIAGNOSES:,1.  Acute respiratory failure, probably worsened by aspiration.,2.  Acute on chronic renal failure.,3.  Non-Q wave myocardial infarction.,4.  Bilateral lung masses.,5.  Occlusive carotid disease.,6.  Hypertension.,7.  Peripheral vascular disease.,HOSPITAL COURSE:  ,This 80-year-old patient with a history of COPD had had recurrent admissions over the past few months.  The patient was admitted again on 12/15/08, after he had been discharged the previous day.  Came in with acute on chronic respiratory failure, with CO2 of 57.  The patient was in rapid atrial fibrillation.  RVR with a rapid ventricular response of 160 beats per minute.  The patient was on COPD exacerbation and CHF due to rapid atrial fibrillation.  The patient's heart rate was controlled with IV Cardizem.  Troponin was consistent with non-Q wave MI.  The patient was treated medically transfer to catheterize the patient to evaluate her coronary artery disease.  Echocardiogram showed normal ejection fraction, normal left and right side, but stage 3 restrictive physiology.  There was also prosthetic aortic valve.  The patient was admitted to Intensive Care Unit and was intubated.  Pulmonary was managed by Critical Care, Dr. X.,The patient was successfully extubated.  Was tapered from IV steroids and put on p.o. steroids.  The patient's renal function has stabilized with a creatinine of between 2.1 and 2.3.  There was contemplation as to whether left heart catheterization should proceed since Nephrology was concerned about the patient's renal status.  Wife decided catheterization should be canceled and the patient managed conservatively.  The patient was transferred to the telemetry floor.  While in telemetry floor, the patient's renal function started deteriorating, went up from 2.08 to 2.67 in two days.  The patient had nausea and vomiting.  Was unable to tolerate p.o.  Was put on cautious hydration.  The patient went into acute respiratory distress.  Intubation showed the patient had aspirated.  He was in acute respiratory failure with bronchospasms and exacerbation of COPD.  X-ray of chest did not show any infiltrate, but showed dilatation of the stomach.  The patient was transferred to the Intensive Care Unit because of acute respiratory failure, was intubated by Critical Care, Dr. X.  The patient was put on the vent.  Overnight, the patient's condition did not improve.  Continued to be severely hypoxic.,The patient expired on the morning of 12/24/08 from acute respiratory failure.
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DESCRIPTION: Death summary of an 80-year-old patient with a history of COPD.

discharge summary, myocardial infarction, intensive care unit, acute respiratory failure, death summary, atrial fibrillation, renal function, telemetry floor, respiratory failure, death, chronic, exacerbation, infarction, respiratory

The document details the medical history and hospital course leading to the death of a patient. Although the document itself represents a completed event (the patient's passing), it encapsulates decisions and conditions that were high-stakes during the patient's care, such as decisions around intubation, medication administration, and managing multiple severe medical conditions. However, in its current context (a discharge summary), the stakes are primarily administrative and informational regarding record keeping and informing future care strategies rather than immediate life-and-death decisions.


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

Medical Specialty: Orthopedic
Sample Name: Discectomy, Osteophytectomy, & Foraminotomy

PREOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, and progressive quadriparesis.,POSTOPERATIVE DIAGNOSES:,  Cervical degenerative disc disease, spondylosis, severe myelopathy, spinal cord compression especially at C3-C4, C4-C5, and C5-C6, progressive quadriparesis, and very poor bone quality as well as difficulty with hemostasis with the patient having been on aspirin.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression at C3-C4, C4-C5, and C5-C6.,2.  Microscope.,3.  Fusion with machined allografts at C3-C4, C4-C5, and C5-C6.,4.  Eagle titanium plate from C3 to C6.,5.  Jackson-Pratt drain placement.,6.  Intraoperative monitoring with EMGs and SSEPs.,ESTIMATED BLOOD LOSS: , 350 cc.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:  ,None.,COUNTS: , Correct.,SPECIMENS SENT:  ,None.,CLINICAL HISTORY:  ,The patient is a 77-year-old male who was admitted through the emergency room for progressive weakness and falling.  He was worked by the neurologist, Dr. X, and found to have cervical spondylosis with myelopathy.  I was consulted and elected to do a lumbar and cervical myelogram CT scan, which showed lumbar stenosis but also cervical stenosis with more pathology anteriorly than posteriorly.  The patient had worst disease at level C3-C4, C4-C5, and C5-C6.  The patient was significantly weak and almost quadriparetic, stronger on the right side than on the left side.  I thought that surgery was indicated to prevent progressive neurological deterioration, as well as to prevent a central cord syndrome if the patient were to get into a motor vehicle accident or simply fall.  Conservative management was not an option.  The patient was preoped and consented, and was medically cleared.  I discussed the indications, risks, and benefits of the surgery with the patient and the patient's family.  The risks of bleeding, hoarseness, swallowing difficulty, pseudoarthrosis as well as plate migration and hardware failure were all discussed with the patient.  An informed consent was obtained from the patient as such.  He was brought into the OR today for the operative procedure.,DESCRIPTION OF PROCEDURE:  ,The patient was brought into the OR, intubated, and given a general anesthetic.  Intubation was done under C-spine precautions.  The patient received preoperative vancomycin and Decadron.  He was hooked up to the SSEP apparatus and had poor baselines and delays.,With a large a shoulder roll, I extended the patient's neck, and landmark incision in crease in the right upper neck, and the area was then prepped and sterilely draped.  All the lines had been put in and the arms were padded.,Using a knife and cautery, I took the incision down through the skin and subcutaneous tissue and arrived at the cervical spine.  Prominent osteophyte at C5-C6 was noted, lesser at C4-C5.  Intraoperative x-ray confirmed our levels, and we were fully exposed from C3-C6.,Trimline retractors were put in, and I cut the discs out as well as removed the superficial hyperstatic bone and osteophytes.,With the drill, I performed a superficial discectomy and endplate resection, curetting the endplate as I went.  I then brought in the microscope, under the microscopic guidance, firmly removed the end plates and drilled through the posterior longitudinal ligament to decompress the spinal cord.  Worst findings at C3-C4 followed C5-C6 and then C4-C5.  Excellent thecal sac decompression was achieved and foraminal decompression was also achieved.  With change in intraoperative monitoring, a microscope was used for this decompressive procedure.,The patient was very oozy throughout this procedure, and during the decompression part, the oozing was constant.  This was partly due to the patient's cancellous bone, but he had been on aspirin which was stopped only 2 days ago, and the option was not available to wait 2 to 3 weeks which would have made this man worse simply over time.  I thus elected to give him DDAVP, platelets, and used Horsley bone wax for excellent hemostasis.  This took literally half-an-hour to an hour and added to the complexity and difficulty of this case.  Eventually, with blood pressure controlled and all the other parameters under control, bleeding was somewhat slow.,I then selected two 10 and one 9-mm cadaveric allograft, which had soaking in bacitracin solution.  These were trimmed to the desired dimensions, and under slight distraction, these were tapped into position.  Excellent graft alignment was achieved.,I now brought in a DePuy titanium eagle plate, and I fixed it to the spine from C3 to C6.  Fourteen millimeter screws were used; all the screws were tightened and torqued.  The patient's bone quality was poor, but the screws did torque appropriately.  I inspected the plate, controlled the hemostasis, assessed post-fixation x-ray, and was really happy with the screw length and the overall alignment.,The wound was irrigated with antibiotic solution; a Jackson-Pratt drain 10-French was put in with trocar.  Decision was made to start the closure.  So, I closed the platysma with 3-0 Vicryl and used staples for the skin.  A simple Primapore or Medpore dressing was applied.  The patient was extubated in the OR and taken to the PSU in stable medical condition.,When I saw the patient in the ICU, he was awake, alert, and moving all four extremities, somewhat weak on the left side.  He had done well from the surgery.  Blood loss was 350 cc.  All instrument, needle, and sponge counts were correct.  No complications, no change in intraoperative monitoring.  No specimens were sent.,The patient's wife was spoken to and fully appraised of the intraoperative findings and the expected prognosis.  The patient will be kept n.p.o. tonight and will gradually advance his diet, and also will gradually advance his activity.  I will keep him on Decadron and keep the collar on.  I do not think there is need for halo rest.  We will be obtaining formal C-spine films in the morning.  Prognosis is guarded but favorable at this time.
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DESCRIPTION: Anterior cervical discectomy, osteophytectomy, foraminotomies, spinal cord decompression, fusion with machined allografts, Eagle titanium plate, Jackson-Pratt drain placement, and intraoperative monitoring with EMGs and SSEPs

The case involves a complex spinal surgery on a 77-year-old patient with multiple serious diagnoses such as severe cervical degenerative disc disease, myelopathy, and progressive quadriparesis. Such a procedure carries significant risks and requires careful consideration due to the patient's age and existing medical condition. The potential for complications during surgery, the detailed procedure involving decompression, and fusion, as well as the risks of bleeding due to aspirin use, further elevate the stakes. The outcome impacts the patient's quality of life and functional capabilities, thus making it a high-stakes situation.

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

CHIEF COMPLAINT:,  Abdominal pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.  She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was "normal."  She was given oral antibiotics of Cipro and Flagyl.  She has had no nausea and vomiting, but has had persistent associated anorexia.  She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago.  She denies any bright red blood per rectum and no history of recent melena.  Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice.  The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY:  ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy.  She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS:  Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT:  Head is grossly atraumatic and normocephalic.  Sclerae are anicteric.  The conjunctivae are non-injected.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Generally nondistended and soft.  She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness.  There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC:  Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES:  Grossly and neurovascularly intact.,LABORATORY VALUES:  ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal.  Alkaline phosphatase elevated at 184.  Liver function tests otherwise normal.  Electrolytes normal.  Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:,  EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant.  Currently is a nonacute abdomen.  The working diagnosis would be sigmoid diverticulitis.  She does have a history in the distant past of sigmoid diverticulitis.  I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth.  The patient was seen 5 years ago by Dr. Y in Colorectal Surgery.  We will consult her also for evaluation.  The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically.  The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.
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DESCRIPTION: The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.

The situation involves a 71-year-old female with persistent abdominal pain potentially due to sigmoid diverticulitis. The medical issue requires careful examination, including a repeat CT scan, and close observation to decide whether surgical intervention might be needed in the future. The patient's stable vital signs and the absence of acute symptoms reduce immediate risks. However, the situation still demands careful monitoring due to the patient's age and medical history, which include past diverticulitis and surgeries. It's important but not immediately life-threatening, thus moderate high-stakes.


Medical Specialty: Gastroenterology
Sample Name: EGD with Biopsy - 1

PROCEDURE PERFORMED: , EGD with biopsy.,INDICATION: , Mrs. ABC is a pleasant 45-year-old female with a history of severe diabetic gastroparesis, who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago.  She was admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.  A CT scan done yesterday revealed evidence of feeding tube remnant still seen within the stomach.  The endoscopy is done to confirm this and remove it, as well as determine if there are any other causes to account for her symptoms.  Physical examination done prior to the procedure was unremarkable, apart from upper abdominal tenderness.,MEDICATIONS: , Fentanyl 25 mcg, Versed 2 mg, 2% lidocaine spray to the pharynx.,INSTRUMENT: , GIF 160.,PROCEDURE REPORT:,  Informed consent was obtained from Mrs. ABC's sister, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications.  Consent was not obtained from Mrs. Morales due to her recent narcotic administration.  Conscious sedation was achieved with the patient lying in the left lateral decubitus position.  The endoscope was then passed through the mouth, into the esophagus, the stomach, where retroflexion was performed, and it was advanced into the second portion of the duodenum.,FINDINGS:,1.  ESOPHAGUS:  There was evidence of grade C esophagitis, with multiple white-based ulcers seen from the distal to the proximal esophagus, at 12 cm in length.  Multiple biopsies were obtained from this region and placed in jar #1.,2.  STOMACH:  Small hiatal hernia was noted within the cardia of the stomach.  There was an indentation/scar from the placement of the previous PEG tube and there was suture material noted within the body and antrum of the stomach.  The remainder of the stomach examination was normal.  There was no feeding tube remnant seen within the stomach.,3.  DUODENUM:  This was normal.,COMPLICATIONS:,  None.,ASSESSMENT:,1.  Grade C esophagitis seen within the distal, mid, and proximal esophagus.,2.  Small hiatal hernia.,3.  Evidence of scarring at the site of the previous feeding tube, as well as suture line material seen in the body and antrum of the stomach.,PLAN: , Followup results of the biopsies and will have radiology replace her gastrojejunal feeding tube.
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DESCRIPTION: Patient admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.

gastroenterology, recurrent nausea and vomiting, egd with biopsy, nausea and vomiting, gastrojejunal feeding tube, feeding tube remnant, recurrent nausea, gej feeding, gastrojejunal feeding, proximal esophagus, hiatal hernia, feeding tube, egd, biopsy, nausea, vomiting, gej, gastrojejunal, duodenum, esophagitis, multiple, distal, biopsies, hiatal, hernia, antrum, esophagus, feeding, tube, stomach,

The procedure described, an Esophagogastroduodenoscopy (EGD) with biopsy, is a common and relatively routine procedure used to diagnose and treat conditions affecting the esophagus, stomach, and duodenum. In this case, the stakes are moderately high due to the patient's existing gastroparesis and the concern of a dislocated feeding tube, which could potentially complicate her condition further if not addressed. However, the procedure itself is routine for a specialist and has no reported complications, lowering the overall stakes. The circumstances might be more critical if the findings indicated a life-threatening condition or if the procedure had a high risk due to the patient's condition, but based on the information given, it does not seem to be the case.


Medical Specialty: Surgery
Sample Name: Post Hemithyroidectomy

PREOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,POSTOPERATIVE DIAGNOSES: , Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.,PROCEDURE:  ,The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.,FINDINGS: , Normal-appearing thyroid gland with a possible lump in the inferior aspect, there was a parathyroid gland that by frozen section _________  was not thyroid, it was reimplanted to the left lower sternocleidomastoid region.,ESTIMATED BLOOD LOSS:  ,Approximately 10 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS: , None.,DRAINS: , Rubber band drain in the neck.,CONDITION:,  Stable.,PROCEDURE:  ,The patient placed supine under general anesthesia.  First, a shoulder roll was placed, 1% lidocaine and 1:100,000 epinephrine was injected into the old scar, natural skin fold, and Betadine prep.  Sterile dressing was placed.  The laryngeal monitoring was noted to be working fine.  Then, an incision was made in this area in a curvilinear fashion through the old scar, taken through the fat and the platysma level.  The strap muscles were found and there was scar tissue along the trachea and the strap muscles were elevated off of the left thyroid, the thyroid gland was then found.  Then, using bipolar cautery and a Coblation dissector, the thyroid gland inferiorly was dissected off and the parathyroid gland was left inferiorly and there was scar tissue that was released and laterally, the thyroid gland was released, then came into the Berry ligaments.  The Berry ligament was dissected off and the gland came off all the way to the superior and inferior thyroid vessels, which were crossed with the Harmonic scalpel and removed.  No bleeding was seen.  There was a small nick in the external jugular vein that was tied with a 4-0 Vicryl suture ligature.  After this was completed, on examining the specimen, there appeared to be a lobule on it and it was sent off as possibly parathyroid, therefore it was reimplanted in the left lower sternocleidomastoid region using the silk suture ligature.  After this was completed, no bleeding was seen.  The laryngeal nerve could be seen and intact and then Rubber band  drain was placed throughout the neck along the thyroid bed and 4-0 Vicryl was used to close the strap muscles in an interrupted fashion along with the platysma region and subcutaneous region and a running 5-0 nylon was used to close the skin and Mastisol and Steri-Strips were placed along the skin edges and then on awakening, both laryngeal nerves were working normally.  Procedure was then terminated at that time.
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DESCRIPTION: The patient with left completion hemithyroidectomy and reimplantation of the left parathyroid and left sternocleidomastoid region in the inferior 1/3rd region.  Papillary carcinoma of the follicular variant of the thyroid in the right lobe, status post right hemithyroidectomy.

surgery, thyroid, rubber band drain, berry ligaments, papillary carcinoma, follicular variant, strap muscles, thyroid gland, sternocleidomastoid, parathyroid, hemithyroidectomy,

The situation involves a surgical procedure for a patient who has undergone a hemithyroidectomy, with the presence of papillary carcinoma, which indicates cancer management. While the procedure was described as having no complications, the surgical context inherently involves high stakes due to the nature of cancer treatment, the need for precise surgical intervention, and the potential consequences of errors, such as damage to the laryngeal nerve or inadequate resection of cancerous tissue. The health and potentially the life of the patient could be at risk if the surgery is not performed correctly, making this a high-stakes scenario.


Medical Specialty: Radiology
Sample Name: CT Stone Protocol

EXAM: , CT stone protocol.,REASON FOR EXAM:,  History of stones, rule out stones.,TECHNIQUE: , Noncontrast CT abdomen and pelvis per renal stone protocol.,FINDINGS: , Correlation is made with a prior examination dated 01/20/09.,Again identified are small intrarenal stones bilaterally.  These are unchanged.  There is no hydronephrosis or significant ureteral dilatation.  There is no stone along the expected course of the ureters or within the bladder.  There is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith.  There is no asymmetric renal enlargement or perinephric stranding.,The appendix is normal.  There is no evidence of a pericolonic inflammatory process or small bowel obstruction.,Scans through the pelvis disclose no free fluid or adenopathy.,Lung bases aside from very mild dependent atelectasis appear clear.,Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. Bilateral intrarenal stones, no obstruction.,2. Normal appendix.
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DESCRIPTION: Noncontrast CT abdomen and pelvis per renal stone protocol.

radiology, noncontrast ct, abdomen and pelvis, renal stone protocol, renal stone, intrarenal stones, stone protocol, ureteral, adenopathy, renal, ct, protocol, pelvis, intrarenal, stone, abdomen, noncontrast,

The situation involves interpreting a radiology report to assess the presence of kidney stones and potential complications. The findings indicate the presence of bilateral intrarenal stones but no obstruction or significant complications. While the information is important for patient management, the absence of obstruction or acute findings suggests that this is not an immediate high-stakes situation. The procedure and interpretation align with routine follow-up care for a patient with a history of kidney stones.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Stress Test Adenosine Myoview

INDICATIONS:,  Ischemic cardiomyopathy, status post inferior wall myocardial infarction, status post left anterior descending PTCA and stenting.,PROCEDURE DONE:,  Adenosine Myoview stress test.,STRESS ECG RESULTS:,  The patient was stressed by intravenous adenosine, 140 mcg/kg/minute infused over four minutes.  The baseline resting electrocardiogram revealed an electronic pacemaker depolarizing the ventricles regularly at a rate of 70 beats per minute.  Underlying atrial fibrillation noted, very wide QRS complexes.  The heart rate remained unchanged at 70 beats per minute as the blood pressure decreased from 140/80 to 110/70 with adenosine infusion.
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DESCRIPTION: Stress test - Adenosine Myoview.  Ischemic cardiomyopathy.  Inferoseptal and apical transmural scar.

cardiovascular / pulmonary, stress test, adenosine, adenosine myoview stress test, ischemic cardiomyopathy, spect, cardiomyopathy, electrocardiogram, myocardial infarction, stress test adenosine myoview, adenosine myoview stress, myoview stress test, ptca and stenting, myoview stress, transmural scar, adenosine infusion, septal motion, adenosine myoview, myocardial perfusion, hypokinesis, inferoseptal, ischemic, myocardial, myoview, perfusion, scan

The context provided involves conducting a stress test on a patient with serious cardiovascular conditions such as ischemic cardiomyopathy and a history of myocardial infarction. The results and reactions of the patient under stress are critical for assessing heart function and guiding further treatment. Given the potential implications for the patient's health and well-being, this situation is high-stakes. It directly affects treatment decisions and the management of potentially life-threatening cardiac conditions.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Cholecystectomy - 4

PREOPERATIVE DIAGNOSIS: , Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute cholecystitis.,PROCEDURE PERFORMED:,  Laparoscopic cholecystectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS: , None.,PROCEDURE:  ,The patient was taken to the operating room, and after obtaining adequate general anesthesia, the patient was placed in the supine position.  The abdominal area was prepped and draped in the usual sterile fashion.  A small skin incision was made below the umbilicus.  It was carried down in the transverse direction on the side of her old incision.  It was carried down to the fascia.  An open pneumoperitoneum was created with Hasson technique.  Three additional ports were placed in the usual fashion.  The gallbladder was found to be acutely inflamed, distended, and with some necrotic areas.  It was carefully retracted from the isthmus, and the cystic structure was then carefully identified, dissected, and divided between double clips.  The gallbladder was then taken down from the gallbladder fossa with electrocautery.  There was some bleeding from the gallbladder fossa that was meticulously controlled with a Bovie.  The gallbladder was then finally removed via the umbilical port with some difficulty because of the size of the gallbladder and size of the stones.  The fascia had to be opened.  The gallbladder had to be opened, and the stones had to be extracted carefully.  When it was completed, I went back to the abdomen and achieved complete hemostasis.  The ports were then removed under direct vision with the scope.  The fascia of the umbilical wound was closed with a figure-of-eight 0 Vicryl.  All the incisions were injected with 0.25% Marcaine, closed with 4-0 Monocryl, Steri-Strips, and sterile dressing.,The patient tolerated the procedure satisfactorily and was transferred to the recovery room in stable condition.
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DESCRIPTION: Acute cholecystitis.  Laparoscopic cholecystectomy.  The abdominal area was prepped and draped in the usual sterile fashion.  A small skin incision was made below the umbilicus.  It was carried down in the transverse direction on the side of her old incision.  It was carried down to the fascia.

gastroenterology, laparoscopic, cholecystectomy, cholecystitis, gallbladder fossa, laparoscopic cholecystectomy, acute cholecystitis, gallbladder

The situation involves a laparoscopic cholecystectomy for acute cholecystitis, a common but still significant surgical procedure. Laparoscopic cholecystectomy is typically a routine surgery with relatively low risk; complications can occur but are not common. The document indicates that the surgery was performed without complications and the patient tolerated the procedure well. Given that no immediate complications arose and the procedure went as planned, the stakes are moderate as it involves a surgical procedure but not an extreme situation.


Medical Specialty: Pain Management
Sample Name: Epidural Steroid Injection - 1

PREOPERATIVE DIAGNOSIS:,  Herniated lumbar disk with intractable back pain.,POSTOPERATIVE DIAGNOSIS: , Herniated lumbar disk with intractable back pain.,OPERATION PERFORMED: , L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.,ANESTHESIA: , Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY:  ,The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion.  The patient was given sedation and monitored.  Local anesthetic was used to insufflate the skin over sacral hiatus.  A 16-gauge RK needle was placed at the sacral hiatus into the caudal canal with no CSF or blood.  A Racz tunnel catheter was then placed to the needle and guided up to the L3-L4 level.  After negative aspiration 4 cc of 0.5% Marcaine and 80 mg of Depo-Medrol were injected.  The catheter was then repositioned at the L4-L5 level where after negative aspiration same local anesthetic steroid mixture was injected.  Needle and catheter were removed intact.  The patient was discharged in stable condition.
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DESCRIPTION: L3-L5 epidural steroid injection with epidural catheter under fluoroscopy.

pain management, epidural catheter, epidural steroid injection, lumbar disk, steroid injection, fluoroscopy, herniated, lumbar, needle, steroid, epidural, catheter, injection

The procedure described involves injecting steroids into the epidural space of the spine to manage pain related to herniated discs. While it is a common procedure in the field of pain management, it is not without its risks, including infection, bleeding, or nerve damage. However, it is not considered a life-threatening procedure, and the described scenario had no complications with the patient discharged safely. Thus, the situation is moderately high-stakes due to the potential for significant impact on the patient's condition and quality of life, although not highly critical in terms of immediate life risks.


Medical Specialty: Surgery
Sample Name: Thyroidectomy

TITLE OF OPERATION:  ,Total thyroidectomy for goiter.,INDICATION FOR SURGERY:  ,This is a 41-year-old woman who notes that compressive thyroid goiter and symptoms related to such who wishes to undergo surgery.  Risks, benefits, alternatives of the procedures were discussed in great detail with the patient.  Risks include but were not limited to anesthesia, bleeding, infection, injury to nerve, vocal fold paralysis, hoarseness, low calcium, need for calcium supplementation, tumor recurrence, need for additional treatment, need for thyroid medication, cosmetic deformity, and other.  The patient understood all these issues and they wished to proceed.,PREOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,POSTOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,ANESTHESIA: , General endotracheal.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine in a operating room table.  After establishing general anesthesia via oral endotracheal intubation with a 6 Nerve Integrity monitoring system endotracheal tube.  The eyes were then tacked with Tegaderm.  The Nerve Integrity monitoring system, endotracheal tube was confirmed to be working adequately.  Essentially a 7 cm incision was employed in the lower skin crease of the neck.  A 1% lidocaine with 1:100,000 epinephrine were given.  Shoulder roll was applied.  The patient prepped and draped in a sterile fashion.  A 15-blade was used to make the incision.  Subplatysmal flaps were raised to the thyroid notch and sternal respectively.  The strap muscles were separated in the midline.  As we then turned to the left side where the sternohyoid muscle was separated from the sternothyroid muscle there was a very dense and firm thyroid mass on the left side.  The sternothyroid muscle was transected horizontally.  Similar procedure was performed on the right side.,Attention was then turned to identify the trachea in the midline.  Veins in this area and the pretracheal region were ligated with a harmonic scalpel.  Subsequently, attention was turned to dissecting the capsule off of the left thyroid lobe.  Again this was very firm in nature.  The superior thyroid pole was dissected in the superior third artery, vein, and the individual vessels were ligated with a harmonic scalpel.  The inferior and superior parathyroid glands were protected.  Recurrent laryngeal nerve was identified in the tracheoesophageal groove.  This had arborized early as a course underneath the inferior thyroid artery to a very small tiny anterior motor branch.  This was followed superiorly.  The level of cricothyroid membrane upon complete visualization of the entire nerve, Berry's ligament was transected and the nerve protected and then the thyroid gland was dissected over the trachea.  A prominent pyramidal level was also appreciated and dissected as well.,Attention was then turned to the right side.  There was significant amount of thyroid tissue that was very firm.  Multiple nodules were appreciated.  In a similar fashion, the capsule was dissected.  The superior and inferior parathyroid glands protected and preserved.  The superior thyroid artery and vein were individually ligated with the harmonic scalpel and the inferior thyroid artery was then ligated close to the thyroid gland capsule.  Once the recurrent laryngeal nerve was identified again on this side, the nerve had arborized early prior to the coursing underneath the inferior thyroid artery.  The anterior motor branch was then very fine, almost filamentous and stimulated at 0.5 milliamps, completely dissected toward the cricothyroid membrane with complete visualization.  A small amount of tissue was left at the Berry's ligament as the remainder of thyroid level was dissected over the trachea.  The entire thyroid specimen was then removed, marked with a stitch upon the superior pole.  The wound was copiously irrigated, Valsalva maneuver was given, bleeding points controlled.  The parathyroid glands appeared to be viable.  Both the anterior motor branches that were tiny were stimulated at 5 milliamps and confirmed to be working with the Nerve Integrity monitoring system.,Attention was then turned to burying the Surgicel on the wound bed on both sides.  The strap muscles were reapproximated in the midline using a 3-0 Vicryl suture of the sternothyroid horizontal transection and the strap muscles in the midline were then reapproximated.  The 1/8th inch Hemovac drain was placed and secured with a 3-0 nylon.  The incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin.  The patient has a history of keloid formation and approximately 1 cubic centimeter of 40 mg per cubic centimeter Kenalog was injected into the incisional line using a tuberculin syringe and 25-gauge needle.  The patient tolerated the procedure well, was extubated in the operating room table, and sent to postanesthesia care unit in a good condition.  Upon completion of the case, fiberoptic laryngoscopy revealed intact bilateral true vocal fold mobility.
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DESCRIPTION: Total thyroidectomy for goiter.  Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.

surgery, total thyroidectomy, goiter, multinodular thyroid goiter, multinodular, thyroid nodules, parathyroid glands, thyroid goiter, thyroid artery, thyroidectomy

The situation involves a surgical procedure, which is inherently high-stakes due to the risks associated with surgery, such as complications from anesthesia, bleeding, infection, and potential damage to nearby structures. The specific surgery mentioned, a total thyroidectomy, involves delicate handling to preserve critical nerves and parathyroid glands, making it even more high-stakes. An adverse outcome could significantly impact the patient's quality of life, such as vocal changes or the need for lifelong thyroid medication. Although the nodules have been proven benign, the potential complications and the complexity of the procedure warrant a high-stakes assessment.


Medical Specialty: Orthopedic
Sample Name: Dorsal Ganglion - Excision

PREOPERATIVE DIAGNOSIS:,  Dorsal ganglion, right wrist.,POSTOPERATIVE DIAGNOSIS:,  Dorsal ganglion, right wrist.,OPERATIONS PERFORMED:,  Excision dorsal ganglion, right wrist.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME:,  minutes.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated and the tourniquet was elevated to 290 mm/Hg.  A transverse incision was made over the dorsal ganglion.  Using blunt dissection the dorsal ulnar sensory nerve branches and radial sensory nerve branches were dissected and retracted out of the operative field.  The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field.  The ganglion was then further dissected to its origin from the dorsal distal scapholunate interosseus ligament and excised in toto.  Care was taken to protect ligament integrity.  Reactive synovium was then removed using soft tissue rongeur technique.  The wound was then infiltrated with 0.25% Marcaine.  The tendons were allowed to resume their normal anatomical position.  The skin was closed with 3-0 Prolene subcuticular stitch.  Sterile dressings were applied.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.
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DESCRIPTION: Excision dorsal ganglion, right wrist.   The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field.

orthopedic, excision dorsal ganglion, extensor tendon, extensor retinaculum, dorsal ganglion, retinaculum, ganglion

The procedure described is a surgical excision of a dorsal ganglion on the right wrist, which is typically a routine and low-risk operation in orthopedic practice. There are no indications of complications during the procedure, and the patient tolerated it well, highlighting that this procedure is considered low in complexity and risk. Moreover, the use of monitored anesthesia care with regional anesthesia suggests a standard level of caution for outpatient or minimally invasive procedures.


Medical Specialty: Surgery
Sample Name: Surgical Closure of Gastrostomy

PREOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,POSTOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,OPERATION PERFORMED: , Surgical closure of gastrostomy.,ANESTHESIA: , General.,INDICATIONS: , This 1-year-old child had a gastrostomy placed due to feeding difficulties.  Since then, he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy.  The tube was, therefore, removed, but the tract has not shown signs of spontaneous closure.  He, therefore, comes to the operating room today for surgical closure of his gastrostomy.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner.  An elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection.  The tract and the stomach were freed.  Stay sutures were then placed on either side of the tract.  The tract was amputated.  The intervening stomach was then closed with interrupted #4-0 Lembert, Nurolon sutures.  The fascia was then closed over the stomach using #3-0 Vicryl sutures.  The skin was closed with #5-0 subcuticular Monocryl.  A dressing was applied, and the child was awakened and taken to the recovery room in satisfactory condition.
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DESCRIPTION: Closure of gastrostomy placed due to feeding difficulties.

surgery, gastrocutaneous fistula, nurolon, closure of gastrostomy, feeding difficulties, surgical closure, gastrostomy

The case involves a surgical procedure on a 1-year-old child, which inherently carries some level of risk given the patient's age and the use of general anesthesia. However, the surgery itself, a closure of a gastrostomy tract, seems relatively straightforward for an experienced surgical team and was performed successfully. The stakes are heightened due to the age of the patient and the requirement for general anesthesia, but they are moderated by the fact that the child has been deemed fit for the procedure and was taken to the recovery room in satisfactory condition.


Medical Specialty: Gastroenterology
Sample Name: Thoracotomy & Esophageal Exploration

PREOPERATIVE DIAGNOSIS:  ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:,  Esophageal rupture.,OPERATION PERFORMED,1.  Left thoracotomy with drainage of pleural fluid collection.,2.  Esophageal exploration and repair of esophageal perforation.,3.  Diagnostic laparoscopy and gastrostomy.,4.  Radiographic gastrostomy tube study with gastric contrast, interpretation.,ANESTHESIA: , General anesthesia.,INDICATIONS OF THE PROCEDURE: , The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching.  He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.,DETAILS OF THE PROCEDURE: , After an extensive informed consent discussion process, the patient was brought to the operating room.  He was placed in a supine position on the operating table.  After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll.  Left chest was prepped and draped in a usual sterile fashion.  After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace.  The left lung was deflated and the pleural cavity entered.  The Finochietto retractor was used to help provide exposure.  The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,Immediately encountered was left pleural fluid including some purulent fluid.  Cultures of this were sampled and sent for microbiology analysis.  The left pleural space was then copiously irrigated.  A careful expiration demonstrated that the rupture appeared to be sealed.  There was crepitus within the mediastinal cavity.  The mediastinum was opened and explored and the esophagus was explored.  The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus.  It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area.  The area was copiously irrigated, this provided nice coverage and repair.  After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French.  These were secured at the left axillary line region at the skin level with #0-silk.,The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures.  Muscle layers were closed with running #1 Vicryl sutures.  The wound was irrigated and the skin was closed with skin staples.,The patient was then turned and placed in a supine position.  A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed.  A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced.  The laparoscope was introduced.  A single additional left-sided separator trocar was introduced.  It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance.  The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely.  The skin incision was made and the gastric lumen was then accessed with the Seldinger technique.  Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire.  #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated.  We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall.  The T-fasteners were all crimped and secured into position.  As was in the plan, the gastrostomy was secured to the skin and into the tube.  Sterile dressing was applied.  Aspiration demonstrated gastric content.,Gastrostomy tube study, with interpretation.  Radiographic gastrostomy tube study with gastric contrast, with
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DESCRIPTION: Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.

gastroenterology, esophageal rupture, thoracotomy, drainage of pleural fluid, esophageal perforation, esophageal exploration, laparoscopy, gastrostomy, pleural fluid, diagnostic laparoscopy, radiographic gastrostomy, gastric lumen, gastrostomy tube, gastric contrast, gastric, interpretation, abdominal, pleural, lumen, esophageal, tube,

The situation describes a complex surgical procedure involving an esophageal rupture, which is a critical condition that necessitates immediate intervention to prevent severe complications, such as infection or sepsis. The patient's current state and the nature of the surgery make it a high-stakes situation since the success of the operation and the patient's recovery are crucial. Furthermore, the procedure involves potential complications that could have significant implications on the patient's health and well-being.


Medical Specialty: Obstetrics / Gynecology
Sample Name: OB/GYN Consultation - 4

CHIEF COMPLAINT - REASON FOR VISIT: ,Pelvic Pain and vaginal discharge.,ABNORMAL PAP HISTORY:, Date of abnormal pap:  1998. Findings: High grade squamous intraepithelial lesions. Previous colposcopic exam and biopsies showed mild dysplasia or CIN 1. Patient is sexually active and has had 1 partner. There is no history of STD’s.,PELVIC PAIN HISTORY:, The patient complains of a gradual onset of pelvic pain 1 year ago and states condition is recurrent. Location of pain is left lower quadrant. Severity is moderately severe, intermittent and lasts for 2 hours. Quality of pain is crampy, sharp and variable.  Pain requires NSAIDs. Menstrual quality is light, flow lasts for 7 days and interval lasts for 28 days. There was no radiation of pain.,VAGINITIS HISTORY:, Symptoms have lasted for 2 weeks and persistent.  Discharge appears thin, white and with odor. Denies any itching sensation. Denies irritation. The patient denies any self treatment.,PERSONAL / SOCIAL HISTORY:, Tobacco history: Smoke’s 1 pack of cigarettes per day.  Denies the past history of alcohol. Denies past / present illegal drug use of any kind. Marital Status: Married.,PAST MEDICAL HISTORY:, Negative.,FAMILY MEDICAL HISTORY:, Negative.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, There are no current medications.,PAST SURGICAL HISTORY:, D & C.  1993,REVIEW OF SYSTEMS:,Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,Genitourinary: Patient denies any genitourinary problems.,Gynecological: Refer to current history.,Pulmonary: Denies cough, dyspnea, tachypnea, hemoptysis.,GU: Denies frequency, nocturia and hematuria.,Neuro: Denies any problems, no seizures, no numbness, no dizziness.,PHYSICAL EXAMINATION:,Vital Signs: Weight:  104. BP:  100/70.,Chest: Lungs have equal bilateral expansion and are clear to percussion and auscultation.,Cardiovascular / Heart: Regular heart rate and rhythm without murmur or gallop.,Breast: No palpable masses.  No dimpling or retraction. No discharge. No axillary lymphadenopathy.,Abdomen: Tenderness is located in the left upper quadrant. Tenderness is mild. Bowel sounds are normal. No masses palpated.,Gynecologic: Inspection reveals the external genitalia to be normal anatomically. Cervix appears inflamed, bloody discharge and without aceto-white areas. Vagina appears normal. Vaginal discharge was white and watery.  Uterus is normal anteverted. The uterus is normal size and shape, tender to movement and movable. Bladder not tender. ,Rectal: No additional findings.,LAB / TESTS:, Hgb: 17.1 U/A: pH 6.0, spgr 1.025, trace protein, trace blood,IMPRESSION / DIAGNOSIS,1. Endometritis / Endomyometritis (615.9). ,2. Cervicitis - Endocervicitis (616.0). ,3. Pelvic Pain (625.9).,PLAN:, Pap smear done. Take metronidazole first then the Doxycycline. Return in three weeks for reevaluation.,MEDICATIONS PRESCRIBED: ,Metronidazole 500 mg #14 1 BID for 7 days.  Doxycycline 100 mg #14 1 BID.
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DESCRIPTION: Pelvic Pain and vaginal discharge

Pelvic Pain and vaginal discharge

The situation involves a patient with a history of high-grade squamous intraepithelial lesions, presenting with pelvic pain and vaginal discharge, both of which can indicate significant gynecologic issues including infection or other complications. The patient is prescribed specific antibiotics for treatment, and given her history and symptoms, it's important to address these issues timely to avoid further complications such as progression to more severe cervical dysplasia or uncontrolled infection. While not immediately life-threatening, the condition's management is crucial for the patient's health and well-being.


Medical Specialty: Surgery
Sample Name: Port Insertion

PREOPERATIVE DIAGNOSES,1.  Metastatic carcinoma of the bladder.,2.  Bowel obstruction.,POSTOPERATIVE DIAGNOSES,1.  Metastatic carcinoma of the bladder.,2.  Bowel obstruction.,PROCEDURE: , Port insertion through the right subclavian vein percutaneously under radiological guidance.,PROCEDURE DETAIL:  ,The patient was electively taken to the operating room after obtaining an informed consent.  A time-out process was followed.  Antibiotics were given.  Then, the patient's right deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated.  The right subclavian vein was percutaneously cannulated without any difficulty.  Then using the Seldinger technique, the catheter part of the port, which was a single-lumen port, was passed through the introducer under x-ray guidance and placed in the junction of the superior vena cava and the right atrium.,A pocket had been fashioned and a single-lumen drum of the port was connected to the catheter, which had been trimmed and affixed to the pectoralis fascia with couple of sutures of Vicryl.  Then, the fascia was closed using subcuticular suture of Monocryl.  The drum was aspirated and irrigated with heparinized saline and then was put in the pocket and the skin was closed.  A dressing was applied including the needle and the port with the catheter so that the floor could use the catheter right away.,The patient tolerated the procedure well and was sent to recovery room in satisfactory condition.  A chest x-ray was performed that showed that there were no complications of procedure and that the catheter was in right place.
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DESCRIPTION: Port insertion through the right subclavian vein percutaneously under radiological guidance.  Metastatic carcinoma of the bladder and bowel obstruction.

surgery, metastatic carcinoma of the bladder, percutaneously, subclavian vein, port insertion, metastatic carcinoma, bowel obstruction, catheter

The situation involves a surgical procedure for a patient with metastatic carcinoma of the bladder and a bowel obstruction. These are serious preoperative diagnoses that require port insertion for administering treatment such as chemotherapy. The procedure involves access to major veins and the use of radiological guidance, highlighting the complexity and the potential risks, though there were no complications reported. Given the patient's condition and the nature of the procedure, this is a high-stakes situation as it requires precision and has significant implications for the patient's treatment and health outcomes.


Medical Specialty: Surgery
Sample Name: Hallux Infected Bone Resection

PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:,  This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux.  The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration.  He has failed outpatient antibiotic therapy and conservative methods.  At this time, he desires to attempt surgical correction.  The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone.  He was counseled preoperatively about the strong probability of the hallux being a "floppy tail" after the surgery and accepts the fact.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL:  ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively.  The wound was on the planar medial, distal and dorsal medial.  The wound's bases were fibrous.  They did not break the bone at this point.  They were each approximately 0.5 cm in diameter.  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied.  Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block.  Next, the foot was prepped and draped in the usual aseptic fashion.  It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected.  Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium.  Next, the incision was deepened through the subcutaneous tissue.  A heavy amount of bleeding was encountered.  Therefore, a Penrose drain was applied at the tourniquet, which failed.  Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis.  Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery.  Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon.  The long extensor tendon was thickened and overall exhibited signs of hypertrophy.  The transverse incision through the long extensor tendon was made with a #15 blade.  Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint.  Next, the extensor tendon was peeled dorsally and distally off the bone.  Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx.  This bone was removed with a sharp dissection.  Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx.  This was passed off as the infected bone specimen for microbiology and pathology.  Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx.  Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins.  The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline.  Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin.  This bone was found to be hard and healthy appearing.  The wound after irrigation was free of all debris and infected tissue.  Therefore anaerobic and aerobic cultures were taken and sent to microbiology.  Next, OsteoSet beads, tobramycin-impregnated, were placed.  Six beads were placed in the wound.  Next, the extensor tendon was re-approximated with #3-0 Vicryl.  The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits.  A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap.  The patient tolerated the above anesthesia and procedure without complications.  He was transported via a cart to the Postanesthesia Care Unit.  His vitals signs were stable and vascular status was intact.  He was given a medium postop shoe that was well-formed and fitting.  He is to elevate his foot, but not apply ice.  He is to follow up with Dr. X.  He was given emergency contact numbers.  He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home.  The patient was discharged in stable condition.
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DESCRIPTION: Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.  Osteomyelitis, left hallux.

surgery, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal,

The situation entails a surgical procedure for a chronic and potentially severe medical condition, namely, osteomyelitis of the left hallux. Osteomyelitis can lead to severe complications, particularly in diabetic patients like the one described, including loss of function or even the need for amputation if not properly treated. The operation, a resection of infected bone, aims to address years of ongoing infection that has not responded to other treatments. The stakes involve whether the procedure successfully removes the infection, preserves function, and prevents further complications or the need for more drastic interventions. Given the patient's medical history, the potential for complications, and the impact on quality of life, this is a high-stakes situation.


Medical Specialty: Radiology
Sample Name: Transesophageal Echocardiogram - 2

REASON FOR EXAM: , Vegetation and bacteremia.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION: , The procedure and its complications were explained to the patient in detail and formal consent was obtained.  The patient was brought to special procedure unit.  His throat was anesthetized with lidocaine spray.  Subsequently, 2 mg of IV Versed was given for sedation.  The patient was positioned.  Probe was introduced without any difficulty.  The patient tolerated the procedure very well.  Probe was taken out.  No complications were noted.  Findings are as mentioned below.,FINDINGS:,1.  Left ventricle has normal size and dimensions with normal function.  Ejection fraction of 60%.,2.  Left atrium and right-sided chambers were of normal size and dimensions.,3.  Left atrial appendage is clean without any clot or smoke effect.,4.  Atrial septum is intact.  Bubble study was negative.,5.  Mitral valve is structurally normal.,6.  Aortic valve reveals echodensity suggestive of vegetation.,7.  Tricuspid valve was structurally normal.,8.  Doppler reveals moderate mitral regurgitation and moderate-to-severe aortic regurgitation.,9.  Aorta is benign.,IMPRESSION:,1.  Normal left ventricular size and function.,2.  Echodensity involving the aortic valve suggestive of endocarditis and vegetation.,3.  Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.
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DESCRIPTION: Transesophageal echocardiogram due to vegetation and bacteremia. Normal left ventricular size and function.  Echodensity involving the aortic valve suggestive of endocarditis and vegetation. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.

radiology, ventricle, atrium, atrial, septum, mitral valv, aortic valve, tricuspid valve, doppler, ventricular size, transesophageal echocardiogram, severe aortic, bacteremia, transesophageal, echocardiogram, echodensity, vegetation, valve, aortic,

The situation involves findings from a Transesophageal Echocardiogram that indicate the presence of echodensity on the aortic valve suggestive of endocarditis and vegetation. This condition can lead to severe complications, including heart failure, stroke, or the spread of infection. The stakes are high due to the potential implications on the patient’s health and the need for prompt medical treatment to prevent adverse outcomes. However, it is not immediately life-threatening, but still requires significant attention and treatment. Therefore, it's a high-stakes situation but not the most critical level possible.


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

Medical Specialty: Office Notes
Sample Name: Normal Physical Exam Template - 1

GENERAL: , Vital signs and temperature as documented in nursing notes.  The patient appears stated age and is adequately developed.,EYES:,  Pupils are equal, round, reactive to light and accommodation.  Lids and conjunctivae reveal no gross abnormality.,ENT:  ,Hearing appears adequate.  No obvious asymmetry or deformity of the ears and nose.,NECK: , Trachea midline.  Symmetric with no obvious deformity or mass; no thyromegaly evident.,RESPIRATORY:,  The patient has normal and symmetric respiratory effort.  Lungs are clear to auscultation.,CARDIOVASCULAR: , S1, S2 without significant murmur.,ABDOMEN: , Abdomen is flat, soft, nontender.  Bowel sounds are active.  No masses or pulsations present.,EXTREMITIES: , Extremities reveal no remarkable dependent edema or varicosities.,MUSCULOSKELETAL:  ,The patient is ambulatory with normal and symmetric gait.  There is adequate range of motion without significant pain or deformity.,SKIN: , Essentially clear with no significant rash or lesions.  Adequate skin turgor.,NEUROLOGICAL: , No acute focal neurologic changes.,PSYCHIATRIC:,  Mental status, judgment and affect are grossly intact and normal for age.
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DESCRIPTION: An example normal physical exam

An example normal physical exam

office notes, vital signs, equal, round, reactive, normal physical exam, physical exam,

The situation is a documentation of a normal physical exam, presented as a template for medical office notes. This is a standard procedure in the healthcare field, useful for consistent recording and not indicative of any immediate medical emergencies. It provides a baseline for an uneventful checkup, where no high-stakes decisions or actions are required since the exam results do not suggest the presence of any urgent or serious conditions.


Medical Specialty: Surgery
Sample Name: Cryosurgical Ablation of Prostate

PREOPERATIVE DIAGNOSIS:  ,Carcinoma of the prostate, clinical stage T1C.,POSTOPERATIVE DIAGNOSIS: , Carcinoma of the prostate, clinical stage T1C.,TITLE OF OPERATION: , Cystoscopy, cryosurgical ablation of the prostate.,FINDINGS:  ,After measurement of the prostate, we decided to place 5 rows of needles--row #1 had 3 needles, row #2 at the level of the mid-prostate had 4 needles, row #3 had 2 needles in the right lateral peripheral zone, row #4 was a single needle directly the urethra, and in row #5 were 2 needles placed in the left lateral peripheral zone.  Because of the length of the prostate, a pull-back was performed, pulling row #2 approximately 3 mm and rows #3, #4 and #5 approximately 1 cm back before refreezing.,OPERATION IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  After adequate general endotracheal anesthesia was obtained, the patient was positioned in the dorsal lithotomy position.  Full bowel prep had been obtained prior to the procedure.  After performing flexible cystoscopy, a Foley catheter was placed per urethra into the bladder.  Next, the ultrasound probe was placed into the stabilizer and advanced into the rectum.  An excellent ultrasound image was visualized of the entire prostate, which was re-measured.  Next, the probe template was positioned over the perineum and the template guide brought up on the ultrasound screen in order to guide needle placement.  Then 17-gauge needles were serially placed into the prostate, from an anterior to posterior direction into the prostate.  Ultrasound guidance demonstrated that these needles, numbering approximately 14 to 15 needles, were well placed and spaced throughout the prostate to obtain excellent freezing of the entire gland while sparing the urethra.  Repeat cystoscopy demonstrated a single needle passing through the urethra; and due to the high anterior location of this needle, it was removed.  The CMS urethral warmer was then passed per urethra into the bladder, and flow instituted.  After placing these 17-gauge needles, the prostate was then frozen down to minus 150 degrees for 10 minutes in sequential fashion from anterior to posterior.  The ice ball was monitored and was seen to extend through the capsule of the prostate toward the rectum but not through the rectal wall itself.  Active warming was then performed before refreezing the prostate again and then passively warming it back to room temperature.  The urethral warmer was left on after the needles were removed and the patient brought to the recovery room.  The patient tolerated the procedure well and left the operating room in stable condition.
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DESCRIPTION: Cystoscopy, cryosurgical ablation of the prostate.

surgery, carcinoma of the prostate, ablation, cystoscopy, cryosurgical ablation, prostate, ultrasound, cryosurgical, urethra,

The procedure described involves the treatment of prostate cancer through cryosurgical ablation, which is a significant surgical intervention but not the most invasive type. The stakes are moderate to high because it addresses cancer treatment, which is always serious, but the patient tolerated the procedure well and left in stable condition, indicating that immediate life-threatening risks were not present during this surgery. However, it still involves important considerations and potential complications such as tissue damage and addressing cancer effectively, which makes it relatively high-stakes in the medical field.


Medical Specialty: Hematology - Oncology
Sample Name: True Cut Needle Biopsy - Breast

PREOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,POSTOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,PROCEDURE PERFORMED: , True cut needle biopsy of the breast.,GROSS FINDINGS:  ,This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.  At this time, a true cut needle biopsy was performed.,PROCEDURE: , The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion.  The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine.  Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion.  Hemostasis was controlled with pressure.  The patient tolerated the procedure well, pending the results of biopsy.
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DESCRIPTION: True cut needle biopsy of the breast.  This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.

hematology - oncology, carcinoma, true cut needle biopsy, nipple, discharge, dimpling, puckering, breast,

This situation involves a medical procedure related to a suspected or confirmed breast carcinoma, which is a serious medical condition. The biopsy is being performed to obtain a definitive diagnosis, which can significantly impact the patient's treatment plan and prognosis. Given the potential implications for the patient's health and life, this situation is high-stakes.


Medical Specialty: Surgery
Sample Name: Lid Laceration Repair

PREOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,POSTOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,PROCEDURES:,1. Repair of XXX upper lid laceration.,2. Repair of XXX upper lid canalicular laceration.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with XXX eye upper eyelid laceration involving the canaliculus.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient was brought to the operating room and placed in the supine position, where (s)he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery, once the appropriate cardiac and respiratory monitoring was placed on him/her, and once general endotracheal anesthetic had been administered. The patient then had the wound freshened up with Westcott scissors and cotton-tip applications. Hemostasis was achieved with a high-temp disposable cautery. Once this had been done, the proximal end of the XXX upper lid canalicular system was intubated with a Monoka tube on a Prolene. The proximal end was then found and this was intubated with the same tubing system. Then, two 6-0 Vicryl sutures were used to reapproximate the medial canthal tendon. Once this had been done, the skin was reapproximated with interrupted 6-0 Vicryl sutures and interrupted 6-0 plain gut sutures. To ensure that the punctum was in the correct position and in the Monoka tube was seated with a seater, and the tube was cut short. The patient's nose was suctioned of blood, and (s)he was awakened from general endotracheal anesthesia and did well. (S)he left the operating room in good condition.
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DESCRIPTION: Repair of upper lid canalicular laceration - Sample/Template.

surgery, laceration, monoka tube, westcott scissors, bleeding, canalicular laceration, canthal tendon, cotton-tip, infection, lid, lid canalicular system, lid laceration, loss of the eye, loss of vision, ophthalmic plastic reconstructive surgery, re-operation, upper lid, lid laceration repair, laceration repair, lid canalicular, canalicular

The situation involves a surgical procedure for repairing an upper lid canalicular laceration. This procedure, while not uncommon, still involves various risks such as infection, bleeding, and more severe potential complications like loss of vision. Surgery around the eye area can have significant consequences, so while it's a standard procedure, the stakes are higher due to the potential impact on vision and eye function. Additionally, general anesthesia involves inherent risks, making the situation more critical than minor medical procedures.


Medical Specialty: Surgery
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 5

PREOPERATIVE DIAGNOSES,1.  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.,2.  Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.,3.  Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation.  He is intubated and ventilated.,POSTOPERATIVE DIAGNOSES:,  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.  Primary ventricular arrhythmia.  Occluded left anterior descending artery, successfully re-canalized with angioplasty and implantation of the drug-eluting stent.  Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery, well collateralized.,PROCEDURES:,  Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.,DESCRIPTION OF PROCEDURE:  ,The patient arrived from the emergency room intubated and ventilated.  He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated.  The right femoral area was prepped and draped in usual sterile fashion.  Lidocaine 2 mL was then filled locally.  The right femoral artery was cannulated with an 18-guage needle followed by a 6-French vascular sheath.  A guiding catheter XB 3.5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained.  A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery, which is well collateralized.  An angioplasty wire with present wire was advanced into the left anterior descending artery, and could cross the area of occlusion within the stent.  An angioplasty balloon measuring 2.0 x 15 was advanced and three inflations were obtained.  It successfully re-canalized the artery.  There is evidence of residual stenosis within the distal aspect of the previous stents.  A drug-eluting stent Xience 2.75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres.  The intermittent result was improved.  An additional inflation was obtained more proximally.  His blood pressure fluctuated and dropped in the 70s, correlating with additional sedation.  There is patency of the left anterior descending artery and good antegrade flow.  The guiding catheter was replaced with a 5-French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained.  The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve.  The right femoral vein was cannulated with an 18-guage needle followed by an 8-French vascular sheath.  A 8-French Swan-Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle, pulmonary artery, and pulmonary capillary wedge position.  Cardiac catheter was determined by thermal dilution.  The procedure was then concluded, well tolerated and without complications.  The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring.  Fluoroscopy time was 8.2 minutes.  Total amount of contrast was 113 mL.,HEMODYNAMICS:,  The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization.  His initial blood pressure was 96/70 with a mean of 83 and the left ventricular pressure was 17 mmHg.  There was no gradient across the aortic valve.  Closing pressure was 97/68 with a mean of 82.,Right heart catheterization with right atrial pressure at 13, right ventricle 31/9, pulmonary artery 33/19 with a mean of 25, and capillary wedge pressure of 19.  Cardiac output was 5.87 by thermal dilution.,CORONARIES:,  On fluoroscopy, there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution.,A.  Left main coronary:  The left main coronary artery is of good caliber and has no evidence of obstructive lesions.,B.  Left anterior descending artery:  The left anterior descending artery was initially occluded within the previously stented proximal-to-mid segment.  There is minimal collateral flow.,C.  Circumflex:  Circumflex is a nondominant circulation.  It supplies a first obtuse marginal branch on good caliber.  There is an outline of the stent in the midportion, which has mild 30% stenosis.  The rest of the vessel has no significant obstructive lesions.  It also supplies significant collaterals supplying the occluded right coronary artery.,D.  Right coronary artery:  The right coronary artery is a weekly dominant circulation.  The vessel is occluded in intermittent portion and has a minimal collateral flow distally.,ANGIOPLASTY: , The left anterior descending artery was the site of re-canalization by angioplasty and implantation of a drug-eluting stent (Xience 15 mm length deployed at 2.9 mm) final result is good with patency of the left anterior descending artery, good antegrade flow and no evidence of dissection.  The stent was deployed proximal to the bifurcation with a second diagonal branch, which has remained patent.  There is a septal branch overlapped by the stent, which is also patent, although presenting a proximal stenosis.  The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery.  There is good antegrade flow and no evidence of distal embolization.,CONCLUSION: , Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution, complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support.,Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery.,Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution related to in-stent thrombosis of the left anterior descending artery, successfully re-canalized with angioplasty and a drug-eluting stent.  There is mild-to-moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery, well collateralized.,Right femoral arterial and venous vascular access.,RECOMMENDATION:,  Integrilin infusion is maintained until tomorrow.  He received aspirin and Plavix per nasogastric tube.  Titrated doses of beta-blockers and ACE inhibitors are initiated.  Additional revascularization therapy will be adjusted according to the clinical evaluation.
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DESCRIPTION: Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.

surgery, ventricular arrhythmia, coronary artery syndrome, st segment elevation, heart catheterization, selective bilateral coronary angiography, ventriculography, catheterization, swan-ganz catheter, anterior descending artery, drug eluting stent, coronary artery, angioplasty, stent, coronary, anterior, angiography, artery, heart,

The procedure described involves a complex set of surgeries and interventions for a patient with acute coronary artery syndrome and other significant cardiovascular issues. This is a high-stakes situation as it directly pertains to the patient's immediate health and survival, requiring careful management and precise execution of the procedures. The outcome critically affects the patient's life, highlighting the risks involved with potential complications such as arrhythmias and the need for revascularization. The medical team must ensure continuous monitoring and appropriate postoperative care. Such medical scenarios are inherently high-risk due to the nature of the conditions and interventions being addressed.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 35

Chief Complaint:, Confusion and hallucinations.,History of Present Illness:, The patient was a 27-year-old Hispanic man who presented to St. Luke's Episcopal Hospital with a five day history of confusion and hallucinations. The patient was doing well until three months prior to admission when he developed wheezing and shortness of breath upon exertion. He was seen by his primary care physician and was prescribed Salmeterol and Fluticasone nasal inhaler for presumed asthma. His wheezing improved with treatment.,Over the five days prior to admission, his family noticed the patient's increasing confusion and bizarre behavior. The patient was intermittently unable to recognize his family members or surroundings. He was restless and anxious, paced the floor at night, and complained of insomnia. He stated he was unable to sleep because he feared his family was trying to hurt him. When he did sleep, he described night terrors. He also complained of both auditory and visual hallucinations. He stated the voices "told him to do good things". He denied any previous history of depression or manic episodes. The patient denied suicidal or homicidal ideation. He admitted he had recently lost weight although he was unable to quantify how much. He stated his appetite was good, but he had not been eating for fear of being poisoned.,The patient denied having headaches or a history of trauma. He denied fevers or chills but he complained of recent night sweats. He denied nausea, vomiting, diarrhea, or dysuria. He denied chest pain, palpitations, or episodic flushing; but he complained of lightheadedness. He denied orthopnea or paroxysmal nocturnal dyspnea. The shortness of breath symptoms had resolved.,Past Medical History:, None. No history of hypertension or of cardiac, renal, lung, or liver disease.,Past Surgical History:, None,Past Psychological History: None,Social History:, The patient was from Brazil. He moved to the United States one year ago. He denied any history of tobacco, alcohol, or illicit drug use. He was married and monogamous. He worked as an engineer/manager, and stated that his job was "very stressful". He had recently been admitted to an MBA program. The patient denied recent travel or exposures of any kind.,Family History:, The patient had a second-degree relative with a history of depression and "nervous breakdown".,Allergies:, There were no known drug allergies.,Medications:, Prescribed medications were Salmeterol inhaler, prn; and Fluticasone nasal inhaler. The patient was taking no over the counter or alternative medicines.,Physical Examination:, The patient was a 27-year-old Hispanic man who presented with symptoms of confusion and hallucinations. He was a thin man but appeared to be well developed and well nourished. The patient paced the room during the examination. He appeared anxious and distracted. He was coherent, yet he had poor concentration and was unable to cooperate fully with the examination. The patient had a pulse rate of 110 beats per minute and blood pressure of 186/101 mm Hg when reclining; and a pulse rate of 122 beats per minute and blood pressure of 166/92 mm Hg when standing. His oral temperature was 100.8 degrees Fahrenheit, and his respiratory rate was 12 breaths per minute.,HEENT: Conjunctivae were pink; sclerae anicteric; mucous membranes moist and pink without lesions.,NECK: The neck was supple, normal jugular venous pressure, no carotid bruits, no thyromegaly.,LUNGS: The lungs were clear to auscultation bilaterally; no wheezes, rales or rhonchi.,HEART: The heart had a regular rhythm, tachycardic, II/VI systolic ejection murmur LUSB, no rubs or gallops, PMI nondisplaced, hyperdynamic precordium.,ABDOMEN: The abdomen was soft, nontender and nondistended; normoactive bowel sounds, no hepatosplenomegaly, no masses; positive bruit heard throughout mid-abdomen, positive bilateral femoral bruits.,EXTREMITIES: No clubbing, cyanosis, or edema; 2+ pulses.,GENITOURINARY: Normal male phallus, no testicular masses.,RECTAL: Guaiac negative, no masses.,LYMPH NODES: Negative in the anterior and posterior clavicular, supraclavicular, axillary, and inguinal regions.,SKIN: Acneiform eruption over back and trunk, no papules or vesicles.,NEUROLOGICAL EXAMINATION: The patient was alert and oriented to self and year, but not to month or place. He had difficulty with mathematics and following commands (when asked to stand on his heels, the patient stood on his toes and turned on the television). Cranial nerves II-XII intact, motor 5/5 throughout all extremities; reflexes 2+ and symmetrical throughout. Sensory: Intact to light touch, vibration, proprioception, and temperature. Cerebellar: intact finger to nose, no ataxia. Romberg negative.,PSYCHOLOGICAL EXAMINATION: The patient's mood was elevated and euphoric; affect was appropriate; his speech was normal in rate, volume, and tone.,Hospital Course:, The patient was admitted to St. Luke's Episcopal Hospital and a workup for his altered mental status was begun. The following studies were performed:,Twelve-lead EKG: sinus tachycardia.,CXR (PA/lat): normal cardiac silhouette and normal lung fields.,CT scan of head without contrast: ventricles were normal in size and position. There was no evidence of mass or hemorrhage.,Lumbar puncture: clear, colorless; WBC--0; RBC--56; protein--45; glucose--126; VDRL--negative; cryptococcal Ag--negative; cultures--negative.,MRI with gadolinium: no discrete areas of abnormal signal intensity.,EEG: no focal or epileptiform activity.,The patient was treated with haldol and risperidone for his agitation, and further diagnostic testing was performed.
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DESCRIPTION: Patient with confusion and hallucinations.

The situation is potentially high-stakes because the symptoms of confusion and hallucinations could indicate serious underlying conditions, such as encephalitis, psychiatric disorders, or even metabolic imbalances. Delays in proper diagnosis and treatment can lead to complications or worsening of the patient's condition. The presence of tachycardia and elevated blood pressure further adds to the urgency of managing the patient's symptoms appropriately. However, immediate life-threatening conditions seem to have been ruled out initially, such as no evidence of hemorrhage or mass in the CT scan. Thus, while urgent, it is not at the absolute highest level of stakes.


Medical Specialty: Surgery
Sample Name: EGD Template - 2

The patient was placed in the left lateral decubitus position, medicated with the above medications to achieve and maintain a conscious sedation.  Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.,The Olympus single-channel endoscope was passed under direct visualization through the oral cavity and advanced to the second portion of the duodenum.,FINDINGS:,ESOPHAGUS:  Proximal and mid esophagus were without abnormalities.,STOMACH:  Insufflated and retroflexed visualization of the gastric cavity revealed,DUODENUM:  Normal.
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DESCRIPTION: Common description of EGD.

Common description of EGD.

surgery, gastric cavity, lateral decubitus position, endoscope, olympus, egd, visualization, cavity, duodenum, esophagusNOTE

The situation described is a routine endoscopic procedure (EGD) where the patient was under conscious sedation, and vital signs were stable throughout. There were no abnormalities detected in the esophagus, stomach, or duodenum, which indicates a negative result for any issues. In general, this type of procedure is low-risk and considered low-stakes since it’s routine and both the procedure and patient monitoring encountered no complications.


Medical Specialty: Radiology
Sample Name: Intensity-Modulated Radiation Therapy Simulation

INTENSITY-MODULATED RADIATION THERAPY SIMULATION,The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures.  The target volume is adjacent to significant radiosensitive structures.,Initially, the preliminary isocenter is set on a fluoroscopically-based simulation unit.  The patient is appropriately immobilized using a customized immobilization device.  Preliminary simulation films are obtained and approved by me.  The patient is marked and transferred to the CT scanner.  Sequential images are obtained and transferred electronically to the treatment planning software.  Extensive analysis then occurs.  The target volume, including margins for uncertainty, patient movement and occult tumor extension are selected.  In addition organs at risk are outlined.  Appropriate doses are selected, both for the target, as well as constraints for organs at risk.  Inverse treatment planning is performed by the physics staff under my supervision.  These are reviewed by the physician and ultimately performed only following approval by the physician and completion of successful quality assurance.
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DESCRIPTION: Intensity-modulated radiation therapy simulation note.  The patient will receive intensity-modulated radiation therapy in order to deliver high-dose treatment to sensitive structures.

radiology, target volume, intensity modulated radiation therapy, simulationNOTE,: 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 intensity-modulated radiation therapy (IMRT) simulation note describes a highly technical and precise medical procedure used to plan and deliver radiation treatment for cancer patients. IMRT requires careful planning to ensure that the high-dose radiation targets the tumor while sparing surrounding healthy tissues and organs. The process involves multiple steps, from simulation to treatment planning, and must be reviewed and approved by a physician. Any errors in this process can have serious consequences for patient health, such as underdosing the tumor or overdosing healthy tissues. This makes it a high-stakes situation.


Medical Specialty: Radiology
Sample Name: Ultrasound - Neck Soft Tissue

EXAM:  ,Ultrasound neck/soft tissue, head.,HISTORY: , Right-sided facial swelling and draining wound.,TECHNIQUE AND FINDINGS:,  Ultrasound of the right mandibular region was performed.,No focal collection is identified.  This whole region appears to be phlegmonous.  It is hard to adequately delineate the exact margins of this region.,IMPRESSION:  ,Abnormal appearing right mandibular region has more phlegmonous changes.  No focal fluid collection.,Had a discussion with Dr. xx.  Consider CT for further evaluation.
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DESCRIPTION: Ultrasound of the right mandibular region.

radiology, soft tissue, mandibular region, tissue, draining, phlegmonous, mandibular, ultrasound,

The situation involves analyzing an ultrasound report that shows potential issues in the right mandibular region of a patient. The report identifies phlegmonous changes, which indicate inflammation and potential infection, and suggests a further CT scan for evaluation. While this isn't immediately life-threatening, it is important for diagnosing and managing the patient's condition appropriately. Therefore, it requires timely attention but not immediate emergency action.


Medical Specialty: Surgery
Sample Name: Subxiphoid Pericardiotomy

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

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

The situation describes a surgical procedure known as a subxiphoid pericardiotomy, performed to treat symptomatic pericardial effusion. This procedure involves entering the area around the heart and could carry significant risks like bleeding, infection, and potential injury to the heart, even though these complications were seemingly avoided in this instance. Furthermore, the procedure is therapeutic and diagnostic, indicating its importance in managing the patient's symptoms and potential underlying conditions. Therefore, the stakes are moderately high due to the potential risks and the critical nature of the surgery involving the heart and surrounding structures.