Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lung Biopsy Discussion

CHART NOTE:,  She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow.  Dr. XYZ had seen her because of her complaints of shortness of breath.  Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis, but wanted her to have an open lung biopsy so he had her see Dr. XYZ Estep.  He had concurred with Dr. XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr. XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy.  She was ready to go ahead with this and felt that it was important she find out why she is short of breath.  She is very concerned about the findings on her CAT scan and pulmonary function test.  She seemed alarmed to report that Dr. XYZ had found that her lung capacity was reduced to 60% of what should be normal.  However, I told her that two years ago Dr. XYZ did pulmonary function studies which showed the same change in function.  And that really her pulmonary function test, at least compared from two years ago, had not really changed over this period of time.  After discussing the serious nature of an open lung biopsy, the fact that her pulmonary function studies have not changed in two years, the fact that she likely has a number of other things that are contributing to her being out of breath, which is deconditioning and obesity, she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy.  In fact when I called Dr. XYZ to talk to him about cancelling the procedure, he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed.  I also explained to patient that I did not think Dr. XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those.  And also I spoke with Dr. XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate, that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities.,I had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it.  I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan, x-ray, and pulmonary function tests.  And if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy.  But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her.  She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful.,We are going to see her back in a month to see how her breathing is doing.  We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time.  I told her I would try to talk to her sister sometime in the next day or two.
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DESCRIPTION: Patient is here to discuss possible open lung biopsy.

cardiovascular / pulmonary, discuss, interstitial pneumonitis, lung biopsy, lung capacity, pulmonary function test, shortness of breath, pulmonary function studies, pulmonary function, function, biopsy, lung, interstitial, pulmonaryNOTE,: 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.,

This situation involves a decision about whether to proceed with an open lung biopsy, which is a significant surgical procedure with inherent risks, especially given the patient's pulmonary conditions. The stakes are high medically and personally, as it involves evaluating her serious symptoms (shortness of breath) and making a decision that affects her health and quality of life. The decision hinges on understanding complex medical information and balancing risks, patient concerns, and potential benefits. However, since the procedure is being postponed due to reconsideration of its necessity and because the patient’s condition has been stable for two years, the immediate stakes might be slightly lower than if the procedure were urgent or if her condition were rapidly deteriorating.


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

Medical Specialty: Surgery
Sample Name: Chest Wall Mass Removal

PREOPERATIVE DIAGNOSIS:,  Chest wall mass, left.,POSTOPERATIVE DIAGNOSIS: , Chest wall mass, left.,PROCEDURE:,  Removal of chest wall mass.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was brought to the operating room where he underwent a general endotracheal anesthetic.  The time-out process was followed and preoperative antibiotics were given.  The patient was in the supine position and was prepped and draped in the usual fashion.,The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected.  An incision was made directly on the mass and carried down to the ribs.  This is where the several chondral cartilages of the lower ribs meet.  So I believe they were isolated in 9th rib anteriorly and I was able to encircle it.  The medial area was __________.  There was no way to perform same procedure there, so what I did, I took an electric saw and proceeded to divide the calcified cartilages of the sternum and also the attachments to the lower ribs.  There was also a separate sharp growth of the mass growing superiorly.  Apparently, I was able to excise the mass and actually it was much larger than it was palpated externally.  This may be due to an extension towards the inside of his chest.  Hemostasis was revised.  The internal mammary was intact and there was no obvious penetration of the pleural cavity.  The specimen was sent to Pathology and then we proceeded to close the defect.  Obviously, the space between the ribs cannot be approximated.  So what we did was approximate the pectoralis major operative defect and then the soft tissues and the skin with subcuticular suture of Monocryl.,The patient tolerated the procedure well.  Estimated blood loss was minimal and he was sent to the recovery room in satisfactory condition.
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DESCRIPTION: Removal of chest wall mass.  The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected.

surgery, chest wall mass, local anesthetic, lower ribs, chest wall, mass, cartilages, wall, chest, ribs,

The case involves the surgical removal of a chest wall mass, a procedure that can range from routine to complex depending on the size, location, and nature of the mass. Although the procedure was completed successfully with minimal blood loss and no major complications, surgery inherently carries risks, including potential damage to nearby structures, bleeding, infection, or anesthetic complications. The stakes are increased slightly by the presence of a mass in the chest area, which could involve critical structures. The successful completion without complications, as described, indicates moderate but not extremely high stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Discharge Summary
Sample Name: Cognitive Linguistic Impairment - Discharge

DIAGNOSIS: , Cognitive linguistic impairment secondary to stroke.,NUMBER OF SESSIONS COMPLETED:,  5,HOSPITAL COURSE:  ,The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.  Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall.  The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities.  At this time, the patient has accomplished all 5 of her short-term therapy goals.  She is able to complete functional mass tasks with 100% accuracy independently.  She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently.,She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently.  She is able to state 15 items in a broad category within a minute and a half independently.  The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently.  The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home.  The patient is no longer in need of skilled speech therapy and is discharged from my services.  She did quite well in therapy and also agreed with this discharge.
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DESCRIPTION: Cognitive linguistic impairment secondary to stroke.  The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.

discharge summary, stroke, linguistic deficits, speech therapy, skilled speech therapy, linguistic impairment, cognitive linguistic, cognitive, linguistic,

The situation involves the discharge summary of a patient who has successfully completed a speech therapy program following a stroke. The stakes here are moderate: while the patient's progress is important for her autonomy and quality of life, the discharge indicates successful rehabilitation without immediate health threats or complex medical treatments remaining. The decision to discharge, agreed upon by both the therapist and the patient, indicates a stable and satisfactory recovery, suggesting a well-resolved case rather than an urgent or life-critical situation.


Medical Specialty: General Medicine
Sample Name: Normal ROS Template - 2

GENERAL:,  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:,  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: , Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  ,Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: , Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:,  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: , Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: , Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.,MUSCULOSKELETAL:,  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: , See psychiatric evaluation.,ENDOCRINE: , No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.
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DESCRIPTION: Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.

general medicine, nose and throat, cardiovascular, integumentary, negative weakness, neurologic, throat, psychiatric, weakness,

The task relates to a routine process of documenting a review of systems (ROS) in general medicine, which involves assessing the presence or absence of common symptoms across various body systems. It is a standard procedure meant for thorough documentation and doesn't involve any urgent or life-threatening scenarios based on the provided information, which indicates no concerning symptoms or history. Therefore, the stakes involved are low, as there are no immediate implications for the patient's health that require urgent attention.


Medical Specialty: Consult - History and Phy.
Sample Name: Dysphagia & Hematemesis

CHIEF COMPLAINT: , Dysphagia and hematemesis while vomiting.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old African American female with 15 years known history of HIV and hepatitis B, and known history of compensated heart failure, COPD, who presented today with complaint of stuck food in her esophagus, bloody cough, and bloody vomiting since 4 o'clock this vomiting, when she ate eggplant parmigiana meal.  The back and chest pain is 8/10, no radiation and is constant.  She denied fever, abdominal pain, or dysphagia before current event eating bones or fish.  This is the first episode of hematemesis and feeling of globus pallidus.  In the emergency room, the patient was treated with nitropaste, morphine, and Lopressor with positive results for chest pain.  CAT scan of the chest showed diffuse esophageal dilatation with residual food in it, no mediastinal air was identified.,REVIEW OF SYSTEMS: , The patient denied diarrhea, abdominal pain, fever, weight loss, dysphagia before this event.  Denied any exertional chest pain or shortness of breath.  No headache, limb weakness.  No joint pain or muscle ache.  No dysuria.,PAST MEDICAL HISTORY:  ,Remarkable for:,1.  Asthma.,2.  Hepatitis C - 1995.,3.  HIV, known since 1995 and followed up by Dr. X, ABCD Medical Center, the last visit was 08/09.  The patient does not take HIV medications against medical advice.,4.  Hypertension, known since 2008.,5.  Negative PPD test, 10/08.,PAST SURGICAL HISTORY: , Remarkable for hysterectomy in 2001, pilonidal cyst surgery in 2005.,FAMILY HISTORY: , Mother deceased at age 68 of cirrhosis.  She had history of alcohol abuse.  Father deceased at age 45, also has a history of alcohol abuse, cardiac disease, and hypertension.,ALLERGIES: , Not known allergies.,MEDICATIONS AT HOME: , Lisinopril 5 mg daily; metoprolol 25 mg twice daily; furosemide 40 mg once daily; Isentress 400 mg once daily, the patient does not take this medication for the last 3 months; Norvir 100 mg once daily; Prezista 400 mg once daily.  The patient does not take her HIV medications for the last 2 to 3 months.  Occasionally, she takes inhalation of albuterol and Ambien 10 mg once daily.,SOCIAL HISTORY: , She is single, lives with her 21-year-old daughter, works as CNA, smokes one pack per day for the last 8 years.  She had periods when she quit smoking and started again 2-1/2 years ago.  She denied alcohol abuse and she was using cocaine in the past, last time she used cocaine 10 years ago.,PHYSICAL EXAMINATION: , Temperature 99.8, pulse 106, respiratory rate 18, blood pressure 162/97, saturation 99 on room air.  African American female, not in acute respiratory distress, but uncomfortable, and showing some signs of back discomfort.  Oriented x3, mildly drowsy, calm and cooperative.  Eyes, EOMI, PERRLA.  Tympanic membranes normal appearance bilaterally.  External canal, no erythema or discharge.  Nose, no erythema or discharge.  Throat, dry mucous, no exudates.  No ulcers in oral area.  Full upper denture and extensive decayed lower teeth.  No cervical lymphadenopathy, no carotid bruits bilaterally.  Heart:  RRR, S1 and S2 appreciated.  No additional sounds or murmurs were auscultated.  Lung:  Good air entrance bilaterally.  No rales or rhonchi.  Abdomen:  Soft, nontender, nondistended.  No masses or organomegaly were palpated.  Legs:  No signs of DVT, peripheral pulses full, posterior dorsalis pedis 2+.  Skin:  No rashes or other lesions, warm and well perfused.  Nails:  No clubbing.  No other signs of skin infection.  Neurological exam:  Cranial nerves II through XII grossly intact.  No motor or sensory deficit was found.,CAT scan of the chest, which was done at 8 o'clock in the morning on 01/12/10.  Impression:  Cardiomegaly, normal aorta, large distention of esophagus containing food.  Chest x-ray:  Cardiomegaly, no evidence of CHF or pneumonia.  EKG:  Normal sinus rhythm, no signs of ischemia.,LABORATORY DATA: , Hemoglobin 10.4, hematocrit 30.6, white blood cells 7.3, neutrophils 75, platelets 197.  Sodium 140, potassium 3.1, chloride 104, bicarb 25, glucose 113, BUN 19, creatinine 1.1, GFR 55, calcium 8.8, total protein 8.1, albumin 3.1, globulin 5.0, bilirubin 0.3, alk phos 63, GOT 23, GPT 22, lipase 104, amylase 85, protime 10.2, INR 1, PTT 25.8.  Urine:  Negative for ketones, protein, glucose, blood, and nitrite, bacteria 2+.  Troponin 0.040.  BNP 1328.,PLAN:,1.  Diffuse esophageal dilatation/hematemesis.  We will put her n.p.o., we will give IV fluid, half normal saline D5 100 mL per hour.  I discussed the case with Dr. Y, gastroenterologist.  The patient planned for EGD starting today.  Differential diagnosis may include foreign body, achalasia, Candida infection, or CMV esophagitis.  We will treat according to the EGD findings.  We will give IV Nexium 40 mg daily for GI prophylaxis.  We will hold all p.o. medication.,2.  CHF.  Cardiomegaly on x-ray.  She is clinically stable.  Lungs are clear.  No radiological sign of CHF exacerbation.  We will restart lisinopril and metoprolol after EGD study will be completed.,3.  HIV - follow up by Dr. X, (ABCD Medical Center).  The last visit was on 08/08.  The patient was not taking her HIV medications for the last 3 months and does not know her CD4 number or viral load.  We will check CD4 number and viral load.  We will contact Dr. X (ID specialist in ABCD Med).,4.  Hypertension.  We will control blood pressor with Lopressor 5 mg IV p.r.n.  If blood pressure more than 160/90, we will hold metoprolol and lisinopril.,5.  Hepatitis C, known since 1995.  The patient does not take any treatment.,6.  Tobacco abuse.  The patient refused nicotine patch.,7.  GI prophylaxis as stated above; and DVT prophylaxis, compression socks.  We will restrain from using heparin or Lovenox.,ADDENDUM: , The patient was examined by Dr. Y, gastroenterologist, who ordered a CAT scan with oral contrast, which showed persistent distention of the esophagus with elementary debris within the lumen of the esophagus.  There is no evidence of leakage of the oral contrast.  There is decrease in size of periaortic soft tissue density around the descending aorta, this is associated with increase in very small left pleural effusion in the intervening time.  There is no evidence of pneumomediastinum or pneumothorax, lungs are clear, contrast is present in stomach.  After procedure, the patient had profuse vomiting with bloody content and spiked fever 102.  The patient felt relieved after vomiting.  The patient was started on aztreonam 1 g IV every 8 hours, Flagyl 500 mg IV every 8 hours.  ID consult was called and thoracic surgeon consult was ordered.
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DESCRIPTION: Dysphagia and hematemesis while vomiting.  Diffuse esophageal dilatation/hematemesis

The situation described is high-stakes because the patient presents with multiple serious and potentially life-threatening medical conditions, including dysphagia, hematemesis, and esophageal dilatation. Additionally, the patient has a history of HIV, not taking her antiretroviral therapy, hepatitis B, compensated heart failure, and COPD, which complicates her condition. The combination of these factors creates a complex medical scenario requiring immediate and specialized intervention. The risks are heightened by the patient's symptoms of bloody vomiting, chest and back pain, as well as the potential for further complications such as infection, which is evident by the fever and the need for antibiotics. The ongoing medical interventions, consultations with specialists, and potential need for surgery highlight the urgency and complexity of this case, making it high-stakes.


Medical Specialty: Neurology
Sample Name: Diagnostic Cerebral Angiogram

EXAM:,1.  Diagnostic cerebral angiogram.,2.  Transcatheter infusion of papaverine.,ANESTHESIA: , General anesthesia,FLUORO TIME: , 19.5 minutes,CONTRAST:,  Visipaque-270, 100 mL,INDICATIONS FOR PROCEDURE: , The patient is a 13-year-old boy who had clipping for a left ICA bifurcation aneurysm.  He was referred for a routine postop check angiogram.  He is doing fine clinically.  All questions were answered, risks explained, informed consent taken and patient was brought to angio suite.,TECHNIQUE: , After informed consent was taken patient was brought to angio suite, both groin sites were prepped and draped in sterile manner.  Patient was placed under general anesthesia for entire duration of the procedure.  Groin access was obtained with a stiff micropuncture wire and a 4-French sheath was placed in the right common femoral artery and connected to a continuous heparinized saline flush.  A 4-French angled Glide catheter was then taken up into the descending thoracic aorta was double flushed and connected to a continuous heparinized saline flush.  The catheter was then taken up into the aortic arch and both common and internal carotid arteries were selectively catheterized followed by digital subtraction imaging in multiple projections.  The images showed spasm of the left internal carotid artery and the left A1, it was thought planned to infused papaverine into the ICA and the left A1.  After that the diagnostic catheter was taken up into the distal internal carotid artery.  SL-10 microcatheter was then prepped and was taken up with the support of Transcend platinum micro guide wire.  The microcatheter was then taken up into the internal carotid artery under biplane roadmapping and was taken up into the distal internal carotid artery and was pointed towards the A1.  60 mg of papaverine was then slowly infused into the internal carotid artery and the anterior cerebral artery.  Post-papaverine infusion images showed increased caliber of the internal carotid artery as well as the left A1.  The catheter was then removed from the patient, pressure was held for 10 minutes leading to hemostasis.  Patient was then transferred back to the ICU in the Children's Hospital where he was extubated without any deficits.,INTERPRETATION OF IMAGES:,1.  LEFT COMMON/INTERNAL CAROTID ARTERY INJECTIONS:  The left internal carotid artery is of normal caliber.  In the intracranial projection there is moderate spasm of the left internal carotid artery and moderately severe spasm of the left A1.  There is poor filling of the A2 through left internal carotid artery injection.  There is opacification of the ophthalmic and the posterior communicating artery MCA along with the distal branches are filling normally.  Capillary filling and venous drainage in MCA distribution is normal and it is very slow in the ACA distribution,2.  RIGHT INTERNAL CAROTID ARTERY INJECTION:  The right internal carotid artery is of normal caliber.  There is opacification of the right ophthalmic and the posterior communicating artery.  The right ACA A1 is supplying bilateral A2 and there is no spasm of the distal anterior cerebral artery.  Right MCA along with the distal branches are filling normally.  Capillary filling and venous drainage are normal.,3.  POST-PAPAVERINE INJECTION:  The post-papaverine injection shows increased caliber of the internal carotid artery as well as the anterior cerebral artery.  Of note the previously clipped internal carotid ICA bifurcation aneurysm is well clipped and there is no residual neck or filling of the dome of the aneurysm.,IMPRESSION:,1.  Well clipped left ICA bifurcation aneurysm.,2.  Moderately severe spasm of the internal carotid artery and left A1.  60 milligrams of papaverine infused leading to increased flow in the aforementioned vessels.
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DESCRIPTION: Diagnostic cerebral angiogram and transcatheter infusion of papaverine

neurology, transcatheter infusion of papaverine, internal carotid artery, heparinized saline flush, diagnostic cerebral angiogram, ica bifurcation aneurysm, anterior cerebral artery, carotid artery, internal carotid, saline flush, venous drainage, papaverine injection, ica bifurcation, bifurcation aneurysm, anterior cerebral, cerebral artery, artery injections, infusion, carotid, artery, angiogram, diagnostic, ica, aneurysm, cerebral, papaverine,

The situation involves a 13-year-old patient undergoing a diagnostic cerebral angiogram as part of a postoperative check for a previously clipped cerebral aneurysm. The procedure was performed under general anesthesia, indicating significant medical intervention. Although the procedure appears to have gone well with the patient extubated without deficits, cerebral angiograms and interventions like papaverine infusion to manage arterial spasms always carry inherent risks such as stroke, bleeding, or other complications, especially in pediatric patients. Given the patient's young age and the nature of the procedure, this scenario is considered high-stakes due to the potential for serious neurological outcomes if complications arise.


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

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,PROCEDURE: , Anterior cervical discectomy with fusion C5-C6.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion.  An incision was made from midline to the anterior border of the sternocleidomastoid in the right side.  Skin and subcutaneous tissue were divided sharply.  Trachea and esophagus were retracted medially.  Carotid sheath was retracted laterally.  Longus colli muscles were dissected away from the vertebral bodies of C5-C6.  We confirmed our position by taking intraoperative x-rays.  We then used the operating microscope and cleaned out the disk completely.  We then sized the interspace and then tapped in a #7 mm cortical cancellous graft.  We then used the DePuy Dynamic plate with 14-mm screws.  Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed in layers using 2-0 Vicryl for muscle and fascia.  The blood loss was less than 10-20 mL.  No complication.  Needle count, sponge count, and cottonoid count was correct.
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DESCRIPTION: Herniated nucleus pulposus, C5-C6, with spinal stenosis.  Anterior cervical discectomy with fusion C5-C6.

surgery, carotid sheath, jackson-pratt drain, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, herniated nucleus, nucleus pulposus, spinal stenosis, discectomy, fusion, herniated, nucleus, pulposus, spinal, stenosis, anterior

The situation involves a detailed description of an anterior cervical discectomy and fusion surgery, which is a significant surgical procedure on the cervical spine. Such surgeries carry inherent risks due to their proximity to the spinal cord and critical structures like the trachea and esophagus. Although the described surgery was seemingly routine and without complications, it involves high-stakes elements such as potential nerve damage, infection, or other surgical complications given its nature.


Medical Specialty: Surgery
Sample Name: Laminectomy & Foraminotomy & Cervical Fusion

PREOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,OPERATIVE PROCEDURES,1.  Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy.,2.  Posterior cervical fusion C4-C5.,3.  Songer wire.,4.  Right iliac bone graft.,TECHNIQUE:  ,The patient was brought to the operating room.  Preoperative evaluations included previous cervical spine surgery.  The patient initially had some relief; however, his left arm pain did recur and gradually got worse.  Repeat studies including myelogram and postspinal CTs revealed some blunting of the nerve root at C4-C5 and C5-C6.  There was also noted to be some annular bulges at C3-C4, and C6-C7.  The CT scan in March revealed that the fusion was not fully solid.  X-rays were done in November including flexion and extension views, it appeared that the fusion was solid.,The patient had been on pain medication.  The patient had undergone several nonoperative treatments.  He was given the option of surgical intervention.  We discussed Botox, I discussed with the patient and posterior cervical decompression.  I explained to the patient this will leave a larger scar on his neck, and that no guarantee would help, there would be more bleeding and more pain from the posterior surgery than it was from the anterior surgery.  If at the time of surgery there was some motion of the C4-C5 level, I would recommend a fusion.  The patient was a smoker and had been advised to quit smoking but has not quit smoking.  I have therefore recommended that he use iliac bone graft.  I explained to the patient that this would give him a scar over the back of the right pelvis and could be a source of chronic pain for the patient for the rest of his life.  Even if this type of bone graft was used, there was no guarantee that it will fuse and he should stop smoking completely.,The patient also was advised that if I did a fusion, I would also use post instrumentation, which was a wire.  The wire would be left permanently.,Even with all these procedures, there was no guarantee that his symptoms would improve.  His numbness, tingling, and weakness could get worse rather than better, his neck pain and arm pain could persist.  He still had some residual bursitis in his left shoulder and this would not be cured by this procedure.  Other procedures may be necessary later.  There is still with a danger of becoming quadriplegic or losing total control of bowel or bladder function.  He could lose total control of his arms or legs and end up in the bed for the rest of his life.  He could develop chronic regional pain syndromes.  He could get difficulty swallowing or eating.  He could have substantial weakness in the arm.  He was advised that he should not undergo the surgery unless the pain is persistent, severe, and unremitting.,He was also offered his records if he would like any other pain medications or seek other treatments, he was advised that Dr. X would continue to prescribe pain medication if he did not wish to proceed with surgery.,He stated he understood all the risks.  He did not wish to get any other treatments.  He said the pain has reached the point that he wished to proceed with surgery.,PROCEDURE IN DETAIL: , In the operating room, he was given general endotracheal anesthesia.,I then carefully rolled the patient on thoracic rolls.  His head was controlled by a horseshoe holder.  The anesthesiologist checked the eye positions to make sure there was no pressure on the orbits and the anesthesiologist continued to check them every 15 minutes.  The arms, the right hip, and the neck was then prepped and draped.  Care was taken to position both arms and both legs.  Pulses were checked.,A midline incision was made through the skin and subcutaneous tissue on the cervical spine.  A loupe magnification and headlamp illumination was used.  Bleeding vessels were cauterized.  Meticulous hemostasis was carried out throughout the procedure.  Gradually and carefully I exposed the spinous process of the C6, C5, and C4.  A lateral view was done after an instrument in place.  This revealed the C6-C7 level.  I therefore did a small laminotomy opening at C4-C5.  I placed an instrument and x-rays confirmed C4-C5 level.,I stripped the muscles from the lamina and then moved them laterally and held with a self-retaining retractor.,Once I identified the level, I then used a bur to thin the lamina of C5.  I used a 1-mm, followed by a 2-mm Kerrison rongeur to carefully remove the lamina off C5 on the left.  I removed some of the superior lamina of C6 and some of the inferior lamina of C4.  This allowed me to visualize the dura and the nerve roots and gradually do neural foraminotomies for both the C5 and C6 nerve roots.  There was some bleeding from the epidural veins and a bipolar cautery was used.  Absolutely no retractors were ever placed in the canal.  There was no retraction.  I was able to place a small probe underneath the nerve root and check the disc spaces to make sure there was no fragments of disc or herniation disc and none were found.,At the end of the procedure, the neuroforamen were widely patent.  The nerve roots had been fully decompressed.,I then checked stability.  There was micromotion at the C4-C5 level.  I therefore elected to proceed with a fusion.,I debrided the interspinous ligament between C4 and C5.  I used a bur to roughen up the surface of the superior portion of the spinous process of C5 and the inferior portion of C4.  Using a small drill, I opened the facet at C4-C5.  I then used a very small curette to clean up the articular cartilage.  I used a bur then to roughen up the lamina at C4-C5.,Attention was turned to the right and left hip, which was also prepped.  An incision made over the iliac crest.  Bleeding vessels were cauterized.  I exposed just the posterior aspect of the crest.  I removed some of the bone and then used the curette to remove cancellous bone.,I placed the Songer wire through the base of the spinous process of C4 and C5.  Drill holes made with a clip.  I then packed cancellous bone between the decorticated spinous process.  I then tightened the Songer wire to the appropriate tension and then cut off the excess wire.,Prior to tightening the wire, I also packed cancellous bone with facet at C4-C5.  I then laid bone upon the decorticated lamina of C4 and C5.,The hip wound was irrigated with bacitracin and Kantrex.  Deep structures were closed with #1 Vicryl, subcutaneous suture and subcuticular tissue was closed.,No drain was placed in the hip.,A drain was left in the posterior cervical spine.  The deep tissues were closed with 0 Vicryl, subcutaneous tissue and skin were then closed.  The patient was taken to the recovery room in good condition.
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DESCRIPTION: Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5.  Songer wire.  Right iliac bone graft.

This surgical procedure is high-stakes due to several critical factors. The surgical intervention itself involves spine surgery, which inherently carries risks such as potential damage to the spinal cord or nerve roots. Complications like quadriplegia, loss of bowel or bladder control, chronic pain, and worsening of symptoms were explicitly discussed with the patient. Additionally, the patient's ongoing issue of smoking complicates the potential success of the bone graft and fusion, increasing the stakes by potentially compromising the surgery's outcome. The gravity of the potential complications and the major life-impacting consequences make this situation high-stakes.


Medical Specialty: ENT - Otolaryngology
Sample Name: Tonsillectomy & Adenoidectomy - 4

PREOPERATIVE DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,POSTOPERATIVE DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,FINAL DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,OPERATION PERFORMED,1.  Tonsillectomy and adenoidectomy.,2.  Left superficial nasal cauterization.,DESCRIPTION OF OPERATION:,  The patient was brought to the operating room.  Endotracheal intubation carried out by Dr. X. The McIvor mouth gag was inserted and gently suspended.  Afrin was instilled in both sides of the nose and allowed to take effect for a period of time.  The hypertrophic tonsils were then removed by the suction and snare.  Deeply cryptic changes as expected were evident.  Bleeding was minimal and controlled with packing followed by electrocautery followed by extensive additional irrigation.  An inspection of the nasopharynx confirmed that the adenoids were in fact hypertrophic rubbery cryptic and obstructive.  They were shaved back, flushed with prevertebral fascia with curette.  Hemostasis established with packing followed by electrocautery.  In light of his history of recurring nosebleeds, both sides of the nose were carefully inspected.  A nasal endoscope was used to identify the plexus of bleeding, which was predominantly on the left mid portion of the septum that was controlled with broad superficial cauterization using a suction cautery device.  The bleeding was admittedly a bit of a annoyance.  An additional control was established by infiltrating slowly with a 1% Xylocaine with epinephrine around the perimeter of the bleeding site and then cauterizing the bleeding site itself.  No additional bleeding was then evident.  The oropharynx was reinspected, clots removed, the patient was extubated, taken to the recovery room in stable condition.  Discharge will be anticipated later in the day on Lortab plus amoxicillin plus Ponaris nose drops.  Office recheck anticipated if stable and doing well in three to four weeks.
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DESCRIPTION: Tonsillectomy and adenoidectomy and Left superficial nasal cauterization.  Recurrent tonsillitis.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.  Residual adenoid hypertrophy and recurrent epistaxis.

ent - otolaryngology, tonsillitis, cryptic hypertrophic tonsils, tonsillolith, nasal cauterization, adenoid hypertrophy, hypertrophic tonsils, adenoidectomy, nasal, cauterization, hypertrophy, epistaxis, tonsils, hypertrophic, intubation, tonsillectomy

The scenario describes a fairly routine surgical procedure, specifically a combined tonsillectomy and adenoidectomy with additional nasal cauterization. Such procedures are common in ENT practice and typically involve low to moderate risk, with predictable outcomes and common postoperative care. While it is a surgical procedure that requires precision and attention to patient safety, it is not considered high-stakes in the context of otolaryngology surgeries. The patient's condition is well-managed, and they are expected to be discharged on the same day with a follow-up in a few weeks.


Medical Specialty: Gastroenterology
Sample Name: EGD - 1

HISTORY OF PRESENT ILLNESS:,  Briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus.  He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture that may need to be dilated, or any other mucosal abnormality.,PROCEDURE PERFORMED: , EGD.,PREP: , Cetacaine spray, 100 mcg of fentanyl IV, and 5 mg of Versed IV.,FINDINGS:,  The tip of the endoscope was introduced into the esophagus, and the entire length of the esophagus was dotted with numerous, white, punctate lesions, suggestive of eosinophilic esophagitis.  There were come concentric rings present.  There was no erosion or flame hemorrhage, but there was some friability in the distal esophagus.  Biopsies throughout the entire length of the esophagus from 25-40 cm were obtained to look for eosinophilic esophagitis.  There was no stricture or Barrett mucosa.  The bony and the antrum of the stomach are normal without any acute peptic lesions.  Retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia.  There were no acute lesions and no evidence of ulcer, tumor, or polyp.  The pylorus was easily entered, and the first, second, and third portions of the duodenum are normal.  Adverse reactions:  None.,FINAL IMPRESSION:  ,Esophageal changes suggestive of eosinophilic esophagitis.  Biopsies throughout the length of the esophagus were obtained for microscopic analysis.  There was no evidence of stricture, Barrett, or other abnormalities in the upper GI tract.
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DESCRIPTION: Problems with dysphagia to solids and had food impacted in the lower esophagus.  Upper endoscopy to evaluate the esophagus.

gastroenterology, length of the esophagus, food impacted, lower esophagus, upper endoscopy, entire length, eosinophilic esophagitis, egd, dysphagia, solids, impacted, endoscopy, mucosal, endoscope, biopsies, barrett, stomach, stricture, eosinophilic, esophagitis, esophagus,

The situation involves evaluating a patient with potential eosinophilic esophagitis through an EGD procedure. While it involves medical investigation requiring expertise, it doesn't present immediate life-threatening implications like a cardiac event or severe allergic reaction. The procedure is routine in gastroenterological evaluations and the findings suggest a manageable condition with no immediate stricture, erosion, or malignancy detected.


Medical Specialty: Consult - History and Phy.
Sample Name: Foot Infection Management

REASON FOR CONSULTATION:  ,Management for infection of the left foot.,HISTORY: , The patient is a 26-year-old short Caucasian male who appears in excellent health, presented a week ago as he felt some pain in the ball of his left foot.  He noticed a small dark spot.  He did not remember having had any injuries to that area specifically no puncture wounds.  He had not been doing any outdoor works or activities.  No history of working outdoors, has not been to the beach or to the lake, has not been out of town.  His swelling progressed so he went to see Dr. X 4 days ago.  The area was debrided in the office and he was placed on Keflex.  It was felt that may be he had a foreign body, but nothing was found in the office and x-ray was negative for opaque foreign bodies.  His foot got worse with more swelling and at this time purulent, too red and was admitted to the hospital today, is scheduled for surgical exploration this evening.  Ancef and Cipro were prescribed today.  He denies any fever, chills, red streaks, lymphadenitis.  He had a tetanus shot in 2002 most recently.  He had childhood asthma.  He uses alcohol socially.  He works full time.  He is an electrician.,ALLERGIES:,  ACCUTANE.,PHYSICAL EXAMINATION,GENERAL:  Well-developed, well-nourished adult Caucasian male in no acute distress.,VITAL SIGNS:  His weight is 190 pounds, height 69 inches, temperature 98, respirations 20, pulse 78, and blood pressure 143/63, O2 sat 98% on room air.,HEENT:  Mouth unremarkable.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Regular rate rhythm.  No murmur or gallop.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  Left foot on the plantar side by the head of the first metatarsal has an open wound of about 10 mm in diameter with thick reddish purulent discharge and surrounding edema.  There is bloodied blister around it.  The area is tender to touch, warm with a slight edema of the rest of the foot with very faint erythema.  There is some mild intertrigo between the fourth and fifth left toes.  Palpable pedal pulses.  Leg unremarkable.  No femoral or inguinal lymphadenopathy.,LABORATORY: , Labs show white cell count of 6300, hemoglobin 13.6, platelet count of _____ with 80 monos, 17 eos _____, creatinine 1.3, BUN of 16, glucose 110.  Calcium, ferritin, albumin, bilirubin, ALT, AST, alkaline phosphatase are normal.  PT and PTT normal and the sed rate was 35 mm per hour.,IMPRESSION:  ,Abscess of the left foot, etiology unclear at this time.  Possibility of foreign body.,RECOMMENDATIONS/PLAN: , He is going to be discharged in about half-an-hour.  Cultures, Gram stain, fungal cultures, and smear to be obtained.  I have changed his antibiotic to vancomycin plus Maxipime.  He is currently on tetanus immunizations so no need for booster at this time.,
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DESCRIPTION: Abscess of the left foot, etiology unclear at this time.  Possibility of foreign body.

consult - history and phy., accutane, possibility of foreign body, foot etiology, foreign body, infection, foot, abscess,

The situation involves a 26-year-old male who was admitted to a hospital due to a foot infection with an abscess of unclear etiology. The infection has shown signs of worsening despite initial treatment, necessitating surgical exploration and a change in antibiotics. While the condition is not immediately life-threatening, it requires timely and effective medical intervention to prevent complications such as further infection spread, sepsis, or long-term damage to the foot. The stakes are significant since a mismanagement could result in serious health consequences.


Medical Specialty: Ophthalmology
Sample Name: Trabeculectomy

PREOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Trabeculectomy with mitomycin C, XXX eye 0.3 c per mg times three minutes.,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox, Ocular, and pilocarpine. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion and the microscope was brought in position. A Lieberman lid speculum was used to provide exposure. Vannas scissors and smooth forceps were used to create a 6 mm limbal peritomy superiorly. This was dissected posteriorly with Vannas scissors to produce a fornix based conjunctival flap. Residual episcleral vessels were cauterized with Eraser-tip cautery. Sponges soaked in mitomycin C 0.3 mm per cc were then placed underneath the conjunctival flap and allowed to sit there for 3 minutes checked against the clock. Sponges were removed and area was copiously irrigated with balanced salt solution. A Super blade was then used to fashion a partial thickness limbal based trapezoidal scleral flap. This was dissected anteriorly with a crescent blade to clear cornea. A temporal paracentesis was then made. Scleral flap was lifted and a Super blade was used to enter the anterior chamber. A Kelly-Descemet punch was used to remove a block of limbal tissue. DeWecker scissors were used to perform a surgical iridectomy. The iris was then carefully reposited back into place and the iridectomy was visible through the clear cornea. A scleral flap was then re- approximated back on the bed. One end of the scleral flap was closed with a #10-0 nylon suture in interrupted fashion and the knot was buried. The other end of the scleral flap was closed with #10-0 nylon suture in interrupted fashion and the knot was buried. The anterior chamber was then refilled with balanced salt solution and a small amount of fluid was noted to trickle out of the scleral flap with slow shallowing of the chamber. Therefore it was felt that another #10-0 nylon suture should be placed and it was therefore placed in interrupted fashion half way between each of the end sutures previously placed. The anterior chamber was then again refilled with balanced salt solution and it was noted that there was a small amount of fluid tricking out of the scleral flap and the pressure was felt to be adequate in the anterior chamber. Conjunctiva was then re-approximated to the limbus and closed with #9-0 Vicryl suture on a TG needle at each of the peritomy ends. Then a horizontal mattress style #9-0 Vicryl suture was placed at the center of the conjunctival peritomy. The conjunctival peritomy was checked for any leaks and was noted to be watertight using Weck- cel sponge. The anterior chamber was inflated and there was noted that the superior bleb was well formed. At the end of the case, the pupil was round, the chamber was formed and the pressure was felt to be adequate. Speculum and drapes were carefully removed. Ocuflox and Maxitrol ointment were placed over the eye. Atropine was also placed over the eye. Then an eye patch and eye shield were placed over the eye. The patient was taken to the recovery room in good condition. There were no complications.
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DESCRIPTION: Trabeculectomy with mitomycin C - Sample/Template.

ophthalmology, trabeculectomy, kelly-descemet punch, maxitrol ointment, open angle glaucoma, tg needle, bleeding, corneal edema, corneal hemorrhage hypotony, diplopia, elevated pressure, glaucoma, infection, iridectomy, loss of the eye, loss of vision, mitomycin c, ptosis, reoperation, retinal detachment, temporal paracentesis, worsening of glaucoma, balanced salt solution, anterior chamber, scleral flap, eye, angle, mitomycin, conjunctival, chamber, flap,

The situation described involves a trabeculectomy procedure with mitomycin C for a patient with open-angle glaucoma. Trabeculectomy is a surgical intervention often performed when glaucoma cannot be controlled with medication alone. While the procedure is relatively common in ophthalmology, it carries significant risks such as bleeding, infection, loss of vision, and even loss of the eye, making it potentially high-stakes for the patient. The detailed procedure steps indicate careful handling to mitigate these risks. Given the potential consequences and the need for surgery due to uncontrolled glaucoma, this scenario is moderately high-stakes.


Medical Specialty: Orthopedic
Sample Name: Arthroscopic Debridement - Shoulder

PREOPERATIVE DIAGNOSIS: , Recurrent anterior dislocating left shoulder.,POSTOPERATIVE DIAGNOSIS:,  Recurrent anterior dislocating left shoulder.,PROCEDURE PERFORMED:,  Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.,PROCEDURE:  ,The patient was taken to OR #2, administered general anesthetic after ineffective interscalene block had been administered in the preop area.  The patient was positioned in the modified beachchair position utilizing the Mayfield headrest.  The left shoulder was propped posteriorly with a rolled towel.  His head was secured to the Mayfield headrest.  The left shoulder and upper extremity were then prepped and draped in the usual manner.  A posterior lateral port was made for _____ the arthroscopic cannula.  The scope was introduced into the glenohumeral joint.  There was noted to be a complete tear of the anterior glenoid labrum off from superiorly at about 11:30 extending down inferiorly to about 6 o'clock.  The labrum was adherent to the underlying capsule.  The margin of the glenoid was frayed in this area.  The biceps tendon was noted to be intact.  The articular surface of the glenoid was fairly well preserved.  The articular surface on the humeral head was intact; however, there was a large Hill-Sachs lesion on the posterolateral aspect of the humeral head.  The rotator cuff was visualized and noted to be intact.  The axillary pouch was visualized and it was free of injury.  There were some cartilaginous fragments within the axillary pouch.  Attention was first directed after making an anterior portal to fixation of the anterior glenoid labrum.  Utilizing the Chirotech system through the anterior cannula, the labrum was secured with the pin and drill component and was then tacked back to the superior glenoid rim at about the 11 o'clock position.  A second tack was then placed at about the 8 o'clock position.  The labrum was then probed and was noted to be stable.  With some general ranging of the shoulder, the tissue was pulled out from the tacks.  An attempt was made at placement of two other tacks; however, the tissue was not of good quality to be held in position.  Therefore, all tacks were either buried down to a flat surface or were removed from the anterior glenoid area.  At this point, it was deemed that an open Bankart arthroplasty was necessary.  The arthroscopic instruments were removed.  An anterior incision was made extending from just lateral of the coracoid down toward the axillary fold.  The skin incision was taken down through the skin.  Subcutaneous tissues were then separated with the coag Bovie to provide hemostasis.  The deltopectoral fascia was identified.  It was split at the deltopectoral interval and the deltoid was reflected laterally.  The subdeltoid bursa was then removed with rongeurs.  The conjoint tendon was identified.  The deltoid and conjoint tendons were then retracted with a self-retaining retractor.  The subscapularis tendon was identified.  It was separated about a centimeter from its insertion, leaving the tissue to do sew later.  The subscapularis was reflected off superiorly and inferiorly and the muscle retracted medially.  This allowed for visualization of the capsule.  The capsule was split near the humeral head insertion leaving a tag for repair.  It was then split longitudinally towards the glenoid at approximately 9 o'clock position.  This provided visualization of the glenohumeral joint.  The friable labral and capsular tissue was identified.  The glenoid neck was already prepared for suturing, therefore, three Mitek suture anchors were then positioned to place at approximately 7 o'clock, 9 o'clock, and 10 o'clock.  The sutures were passed through the labral capsular tissue and tied securely.  At this point, the anterior glenoid rim had been recreated.  The joint was then copiously irrigated with gentamicin solution and suctioned dry.  The capsule was then repaired with interrupted #1 Vicryl suture and repaired back to its insertion site with #1 Vicryl suture.  This later was then copiously irrigated with gentamicin solution and suctioned dry.  Subscapularis was reapproximated on to the lesser tuberosity of the humerus utilizing interrupted #1 Vicryl suture.  This later was then copiously irrigated as well and suctioned dry.  The deltoid fascia was approximated with running #2-0 Vicryl suture.  Subcutaneous tissues were approximated with interrupted #2-0 Vicryl and the skin was approximated with a running #4-0 subcuticular Vicryl followed by placement of Steri-Strips.  0.25% Marcaine was placed in the subcutaneous area for postoperative analgesia.  The patient was then placed in a shoulder immobilizer after a bulky dressing had been applied.  The patient was then transferred to the recovery room in apparent satisfactory condition.
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DESCRIPTION: Recurrent anterior dislocating left shoulder.  Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.

orthopedic, dislocating, bankart, arthroplasty, bankart repair, arthroscopic debridement, anterior, arthroscopic, debridement, deltoid, glenoid, humeral, interrupted, shoulder, subscapularis

The situation involves a surgical procedure to address a recurrent anterior dislocating shoulder, a condition that is potentially disabling and painful for the patient. Surgery, especially involving arthroscopic techniques and open arthroplasty, has inherent risks such as infection, complications from anesthesia, and the potential for non-optimal outcomes, which can impact the patient's mobility and quality of life significantly. Additionally, it includes attempts at arthroscopic repair followed by more invasive open surgery, suggesting complexity and challenges faced during the procedure. The stakes are elevated due to these factors, yet it is not life-threatening under standard conditions.


Medical Specialty: Dentistry
Sample Name: ORIF Mandibular Fracture & Dental Implant Removal

PREOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,POSTOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,PROCEDURE PERFORMED: , Open reduction and internal fixation (ORIF) of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.,ANESTHESIA: , General nasotracheal.,ESTIMATED BLOOD LOSS: , 125 mL.,FLUIDS GIVEN: , 1 L of crystalloids.,SPECIMEN: , Soft tissue from the fracture site sent for histologic diagnosis.,CULTURES: , Also sent for Gram stain, aerobic and anaerobic, culture and sensitivity.,INDICATIONS FOR THE PROCEDURE: , The patient is a 79-year-old male, who fell in his hometown, following an episode of syncope.  He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above-mentioned fracture.  He was admitted to hospital in Harleton, Texas, where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass.  His mandible fracture was not noted initially.  The patient also has a history of prostate cancer and a renal cell carcinoma.  The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending.  The patient later saw a local oral surgeon.  He diagnosed his mandible fracture and advised him to seek treatment in Houston.  He presented to my office for evaluation on January 18, 2010, and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant, which had been placed approximately 15 years ago.  The patient had significant discomfort and could eat foods and drink fluids with difficulty.  Due to the nature of his fracture and the complex medical history, he was sent to the hospital for admission and following cardiac clearance, he was scheduled for surgery today.,PROCEDURE IN DETAIL: , The patient was taken to the operating room, and placed in a supine position.  Following a nasal intubation and induction of general anesthesia, the surgeon then scrubbed, gowned, and gloved in the normal sterile fashion.  The patient was then prepped and draped in a manner consistent with sterile procedures.  A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region, approximately 1.5 cm medial to the inferior border of the mandible.  A 1 mL of lidocaine 1% with 1:100,000 epinephrine was then infiltrated along the incision and then a 15-blade was used to incise through the skin and subcutaneous tissue.  A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible.  Electrocautery as well as 4.0 silk ties were used for hemostasis.  A 15-blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site.  The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound.  Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis.  Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11-hole Synthes reconstruction plate was then used to stand on the fracture site.  Since there was an area of weakness in the right parasymphysis region, in the location of another dental implant, the bone plate was extended posterior to that site.  When the plate was adapted to the mandible, it was then secured to the bone with 9 screws, each being 2 mm in diameter and each screw was placed bicortically.  All the screws were also locking screws.  Following placement of the screws, there was felt to be excellent stability of the fracture, so the wound was irrigated with a copious amount of normal saline.  The incision was closed in multiple layers with 4.0 Vicryl in the muscular and subcutaneous layers and 5.0 nylon in the skin.  A sterile dressing was then placed over the incision.  The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs.  Estimated blood loss is 125 mL.
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DESCRIPTION: Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.  The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.

dentistry, atrophic mandibular fracture, dental implant, open reduction and internal fixation, orif, mandibular fracture, mandible, atrophic, mandibular, dental, implant,

The situation involves a surgical procedure (ORIF mandibular fracture and dental implant removal) for a 79-year-old patient with a complex medical history, including a recent fall causing multiple fractures, syncope, and a previous cancer diagnosis. While the surgical procedure is routine in oral and maxillofacial surgeries, the age of the patient, his existing health conditions, and the fact that the mandibular fracture was initially missed by earlier evaluations increase the stakes. Anesthesia and surgery always present inherent risks, particularly in older patients with comorbidities. The patient's ability to eat and drink was already compromised, raising the importance of successful surgical intervention.


Medical Specialty: General Medicine
Sample Name: Ecstasy Ingestion - ER Visit

CHIEF COMPLAINT:,  "I took Ecstasy.",HISTORY OF PRESENT ILLNESS: , This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.  The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis.  Mother called the EMS service when the patient vomited.  On arrival here, the patient states that she no longer has any nausea and that she feels just fine.  The patient states she feels wired but has no other problems or complaints.  The patient denies any pain.  The patient does not have any auditory of visual hallucinations.  The patient denies any depression or suicidal ideation.  The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself.  The patient denies any homicidal ideation.  The patient denies any recent illness or recent injuries.  The mother states that the daughter appears to be back to her usual self now.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No recent illness.  No fever or chills.  HEENT:  No headache.  No neck pain.  No vision change or hearing change.  No eye or ear pain.  No rhinorrhea.  No sore throat.  CARDIOVASCULAR:  No chest pain.  No palpitations or racing heart.  RESPIRATIONS:  No shortness of breath.  No cough.  GASTROINTESTINAL: One episode of nonbloody, nonbilious emesis this morning without any nausea since then.  The patient denies any abdominal pain.  No change in bowel movements.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No dizziness, syncope, or near syncope.  PSYCHIATRIC:  The patient denies any depression, suicidal ideation, homicidal ideation, auditory hallucinations or visual hallucinations.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  None.,PAST SURGICAL HISTORY: , Appendectomy when she was 9 years old.,CURRENT MEDICATIONS: , Birth control pills.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies smoking cigarettes.  The patient does drink alcohol and also uses illicit drugs.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure 140/86, pulse is 79, respirations 16, oxygen saturation 100% on room air and is interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, and well developed, appears to be healthy.  The patient is calm and comfortable, in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctiva bilaterally.  The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally.  No evidence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Ears are normal without any sign of infection.  Mouth and oropharynx are normal without any signs of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +3 and bounding.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, normal and benign.  MUSCULOSKELETAL:  No abnormalities noted in back, arms, or legs.  The patient is normal use of her extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact in all extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  The patient does not have any smell of alcohol and does not exhibit any clinical intoxication.  The patient is quite pleasant, fully cooperative.  HEMATOLOGIC/LYMPHATIC: NO lymphadenitis is noted.  No bruising is noted.,DIAGNOSES:,1.  ECSTASY INGESTION.,2.  ALCOHOL INGESTION.,3.  VOMITING SECONDARY TO STIMULANT ABUSE.,CONDITION UPON DISPOSITION: , Stable disposition to home with her mother.,PLAN:,  I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation.  The patient was advised to stop drinking alcohol, and taking Ecstasy as this is not only in the interest of her health, but was also illegal.  The patient is asked to return to the emergency room should she have any worsening of her condition, develop any other problems or symptoms of concern.
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DESCRIPTION: Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.

general medicine, nonbilious emesis, hallucinations, visual, auditory, ecstasy ingestion, suicidal ideation, homicidal ideation, ingestion, infection, alcohol, ecstasy,

The situation involves a 17-year-old who ingested a significant amount of ecstasy along with alcohol. While the patient is currently stable and denies severe symptoms, the potential for complications from this amount of substance use is significant. Ecstasy can cause severe health complications like hyperthermia, heart issues, and neurological effects, and the combination with alcohol raises the stakes further. The situation is high-stakes due to the potential for acute adverse effects and the need for monitoring and behavior modification to prevent future occurrences.


Medical Specialty: General Medicine
Sample Name: Normal Female Exam Template - 2

VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE:,  Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT: , Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:,  Lungs are bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI nondisplaced.  Chest wall unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS:,  In the seated and supine position unremarkable.,ABDOMEN: , No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and no intraabdominal bruit auscultated.,EXTERNAL GENITALIA: , Normal for age.,RECTAL: , Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK:,  Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC:,  Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN: , Unremarkable for any premalignant or malignant condition with normal changes for age.
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DESCRIPTION: An example/template for a routine normal female physical exam.

general medicine, heent, general appearance, hepatosplenomegaly, mass, tenderness, rebound, rigidity, pulse, bruit, adenopathy, chest, percussion, inspection, palpation, signs, tongue,

The given template is a standard, routine medical examination template for a healthy female patient. It outlines normal findings in various systems of the body, with no indication of any acute or serious issues. Routine exams are generally low-stakes since they are preventative or confirmatory, rather than addressing immediate life-threatening concerns. The description further specifies this is a template example, implying no real patient is involved in the scenario, further lowering the stakes.


Medical Specialty: Surgery
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 situation involves a complex cervical spine surgery on an elderly patient with significant preoperative issues such as cervical degenerative disc disease, myelopathy, and spinal cord compression. These conditions can lead to severe neurological deficits if not managed appropriately. The surgery aims to prevent further deterioration and improve the patient's quality of life. Given the complexity of the surgery and the critical nature of the condition, any complications could have severe consequences, including further neurological impairment or even paralysis. The surgery has proceeded without complications, but the situation remains high-stakes due to the potential risks involved and the patient's age and medical history.


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

Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Atrial Flutter - Progress Note

HISTORY OF PRESENT ILLNESS: , Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response, which was resistant to treatment with diltiazem and amiodarone, being followed by Dr. X of cardiology through most of the day.  This afternoon, when I am seeing the patient, nursing informs me that rate has finally been controlled with esmolol, but systolic blood pressures have dropped to the 70s with a MAP of 52.  Dr. X was again consulted from the bedside.  We agreed to try fluid boluses and then to consider Neo-Synephrine pressure support if this is not successful.  In addition, over the last 24 hours, extensive discussions have been held with the family and questions answered by nursing staff concerning the patient's possible move to Tahoe Pacific or a long-term acute care.  Other issues requiring following up today are elevated transaminases, continuing fever, pneumonia, resolving adult respiratory distress syndrome, ventilatory-dependent respiratory failure, hypokalemia, non-ST-elevation MI, hypernatremia, chronic obstructive pulmonary disease, BPH, atrial flutter, inferior vena cava filter, and diabetes.,PHYSICAL EXAMINATION,VITAL SIGNS:  T-max 103.2, blood pressure at this point is running in the 70s/mid 40s with a MAP of 52, heart rate is 100.,GENERAL:  The patient is much more alert appearing than my last examination of approximately 3 weeks ago.  He denies any pain, appears to have intact mentation, and is in no apparent distress.,EYES:  Pupils round, reactive to light, anicteric with external ocular motions intact.,CARDIOVASCULAR:  Reveals an irregularly irregular rhythm.,LUNGS:  Have diminished breath sounds but are clear anteriorly.,ABDOMEN:  Somewhat distended but with no guarding, rebound, or obvious tenderness to palpation.,EXTREMITIES:  Show trace edema with no clubbing or cyanosis.,NEUROLOGICAL:  The patient is moving all extremities without focal neurological deficits.,LABORATORY DATA: , Sodium 149; this is down from 151 yesterday.  Potassium 3.9, chloride 114, bicarb 25, BUN 35, creatinine 1.5 up from 1.2 yesterday, hemoglobin 12.4, hematocrit 36.3, WBC 16.5, platelets 231,000.  INR 1.4.  Transaminases are continuing to trend upwards of SGOT 546, SGPT 256.  Also noted is a scant amount of very concentrated appearing urine in the bag.,IMPRESSION: , Overall impressions continues to be critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,PLAN,1.  Hypotension.  I would aggressively try and fluid replete the patient giving him another liter of fluids.  If this does not work as discussed with Dr. X, we will start some Neo-Synephrine, but also continue with aggressive fluid repletion as I do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started.,2.  Increased transaminases.  Presumably this is from increased congestion.  This is certainly concerning.  We will continue to follow this.  Ultrasound of the liver was apparently negative.,3.  Fever and elevated white count.  The patient does have a history of pneumonia and empyema.  We will continue current antibiotics per infectious disease and continue to follow the patient's white count.  He is not exceptionally toxic appearing at this time.  Indeed, he does look improved from my last examination.,4.  Ventilatory-dependent respiratory failure.  The patient has received a tracheostomy since my last examination.  Vent management per PMA.,5.  Hypokalemia.  This has resolved.  Continue supplementation.,6.  Hypernatremia.  This is improving somewhat.  I am hoping that with increased fluids this will continue to do so.,7.  Diabetes mellitus.  Fingerstick blood glucoses are reviewed and are at target.  We will continue current management.  This is a critically ill patient with multiorgan dysfunction and signs of worsening renal, hepatic, and cardiovascular function with extremely guarded prognosis.  Total critical care time spent today 37 minutes.
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DESCRIPTION: A critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.

soap / chart / progress notes, rapid ventricular response, volume depletion, atrial flutter, atrial, hypotension, flutter,

The patient described is critically ill, with multiple serious medical conditions including atrial flutter with rapid ventricular response, hypotension, respiratory failure, possible liver congestion, renal issues, and infections. The case involves critical care management and potential life-threatening complications, indicating that the situation is high-stakes.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - ATV Accident

ADMITTING DIAGNOSIS: , Trauma/ATV accident resulting in left open humerus fracture.,DISCHARGE DIAGNOSIS:,  Trauma/ATV accident resulting in left open humerus fracture.,SECONDARY DIAGNOSIS:,  None.,HISTORY OF PRESENT ILLNESS: , For complete details, please see dictated history and physical by Dr. X dated July 23, 2008.  Briefly, the patient is a 10-year-old male who presented to the Hospital Emergency Department following an ATV accident.  He was an unhelmeted passenger on ATV when the driver lost control and the ATV rolled over throwing the passenger and the driver approximately 5 to 10 meters.  The patient denies any loss of consciousness.  He was not amnestic to the event.  He was taken by family members to the Iredell County Hospital, where he was initially evaluated.  Due to the extent of his injuries, he was immediately transferred to Hospital Emergency Department for further evaluation.,HOSPITAL COURSE: , Upon arrival in the Hospital Emergency Department, he was noted to have an open left humerus fracture.  No other apparent injuries.  This was confirmed with radiographic imaging showing that the chest and pelvis x-rays were negative for any acute injury and that the cervical spine x-ray was negative for fracture malalignment.  The left upper extremity x-ray did demonstrate an open left distal humerus fracture.  The orthopedic surgery team was then consulted and upon their evaluation, the patient was taken emergently to the operating room for surgical repair of his left humerus fracture.  In the operating room, the patient was prepared for an irrigation and debridement of what was determined to be an open type 3 subcondylar left distal humerus fracture.  In the operating room, his upper extremity was evaluated for neurovascular status and great care was taken to preserve these structures.  Throughout the duration of the procedure, the patient had a palpable distal radial pulse.  The orthopedic team then completed an open reduction and internal fixation of the left supracondylar humerus fracture.  A wound VAC was then placed over the wound at the conclusion of the procedure.  The patient tolerated this procedure well and was returned to the Pediatric Intensive Care Unit for postsurgical followup and monitoring.  His diet was advanced and his pain was controlled with pain medication.  The day following his surgery, the patient was evaluated for a potential for closed head injury given the nature of his accident and the fact that he was not wearing a helmet during his accident.  A CT of the brain without contrast showed no acute intracranial abnormalities moreover his cervical spine was radiographically and clinically cleared and his C-collar was removed at that point.  Once his C spine had been cleared and the absence of a closed head injury was confirmed.  The patient was then transferred from the Intensive Care Unit to the General Floor bed.  His clinical status continued to improve and on July 26, 2008, he was taken back to the operating room for removal of the wound VAC and closure of his left upper extremity wound.  He again tolerated this procedure well on his return to the General Pediatrics Floor.  Throughout his stay, there was concern for compartment syndrome due to the nature and extent of his injuries.  However, frequent checks of his distal pulses indicated that he had strong peripheral pulses in the left upper extremity.  Moreover, the patient had no complaints of paresthesia.  There was no demonstration of pallor or pain on passive motion.  There was good capillary refill to the digits of the left hand.  By the date of the discharge, the patient was on a full pediatric select diet and was tolerating this well.  He had no abdominal tenderness and there were no abdominal injuries on exam or radiographic studies.  He was afebrile and his vital signs were stable and once cleared by Orthopedics, he was deemed appropriate for discharge.,PROCEDURES DURING THIS HOSPITALIZATION:,1.  Irrigation and debridement of open type 3 subcondylar left distal humerus fracture (July 23, 2008).,2.  Open reduction and internal fixation of the left supracondylar humerus fracture (July 23, 2008).,3.  Negative pressure wound dressing (July 23, 2008).,4.  Irrigation and debridement of left elbow fracture (July 26, 2008).,5.  CT of the brain without contrast (July 24, 2008).,DISPOSITION:  ,Home with parents.,INVASIVE LINES: , None.,DISCHARGE INSTRUCTIONS:  ,The patient was instructed that he can return home with his regular diet and he was asked not to do any strenuous activities, move furniture, lift heavy objects, or use his left upper extremity.  He was asked to followup with return appointment in one week to see Dr. Y in Orthopedics.  Additionally, he was told to call his pediatrician, if he develops any fevers, pain, loss of sensation, loss of pulse, or discoloration of his fingers, or paleness to his hand.
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DESCRIPTION: Trauma/ATV accident resulting in left open humerus fracture.

discharge summary, humerus fracture, trauma, irrigation and debridement, atv accident, upper extremity, humerus, fracture, orthopedic,

This discharge summary covers a patient who was involved in an ATV accident, resulting in a significant injury: an open humerus fracture. The patient underwent surgery and other medical procedures to address the injury and potential complications. While open fractures can be serious due to the risk of infection and the possibility of neurovascular damage, the discharge indicates that the patient is stable and did not suffer from any additional severe injuries, such as a closed head injury or compartment syndrome. The discharge plan includes instructions for at-home care and follow-up, typical for such cases. Given that the immediate life-threatening conditions seem to have been ruled out by the time of discharge, this situation ranks slightly above average in stakes due to the initial severity of the injury and the potential consequences of inadequate follow-up or recovery.


Medical Specialty: Surgery
Sample Name: Appendectomy Laparoscopic

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

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

The situation involves a surgical procedure, specifically a laparoscopic appendectomy, to address acute appendicitis. While this is a common and routine procedure with a high success rate, it still involves general anesthesia and surgery, which carry inherent risks. Additionally, the importance of timely surgical intervention for acute appendicitis is crucial to prevent complications like perforation or peritonitis. Therefore, it is a moderate-stakes situation due to the surgical procedure's routine nature and the necessity to address the appendicitis promptly.


Medical Specialty: Hematology - Oncology
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.

hematology - oncology, 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.

In the context of medical treatments, especially those related to cancer such as intensity-modulated radiation therapy (IMRT), the stakes are typically high because treatment planning directly impacts the patient's health outcomes. The process involves precise targeting of radiation, minimizing exposure to surrounding healthy tissues, and ensuring that the correct dose is delivered to maximize efficacy while minimizing side effects. Miscalculations or errors in planning could lead to inadequate treatment of the cancer or unnecessary damage to healthy tissues, which can have serious consequences for the patient's health and prognosis.


Medical Specialty: General Medicine
Sample Name: Cellulitis - Discharge Summary

DISCHARGE DIAGNOSIS:  ,Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.,ADDITIONAL DISCHARGE DIAGNOSES:,1.  Chronic pain.,2.  Tobacco use.,3.  History of hepatitis C.,REASON FOR ADMISSION:,  The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound.  He has had prolonged hospitalizations because of this problem.  He was recently discharged when he was noted to develop as an outpatient swollen, red tender leg.  Examination in the emergency room revealed significant concern for significant cellulitis.  Decision was made to admit him to the hospital.,HOSPITAL COURSE:,  The patient was admitted on 03/26/08 and was started on IV antibiotics elevation, was also counseled to minimizing the cigarette smoking.  The patient had edema of his bilateral lower extremities.  The hospital consult was also obtained to address edema issue question was related to his liver hepatitis C.  Hospital consult was obtained.  This included an ultrasound of his abdomen, which showed just mild cirrhosis.  His leg swelling was thought to be secondary to chronic venostasis and with likely some contribution from his liver as well.  The patient eventually grew MRSA in a moderate amount.  He was treated with IV vancomycin.  Local wound care and elevation.  The patient had slow progress.  He was started on compression, and by 04/03/08 his leg got much improved, minimal redness and swelling was down with compression.  The patient was thought safe to discharge home.,DISCHARGE INSTRUCTIONS: , The patient was discharged on doxycycline 100 mg p.o. b.i.d. x10 days.  He was also given prescription for Percocet and OxyContin, picked up at my office.  He is instructed to do daily wound care and also wrap his leg with an Ace wrap.  Followup was arranged in a couple of weeks.,DISCHARGE CONDITION: , Stable.
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DESCRIPTION: Complex open wound right lower extremity complicated by a methicillin-resistant staphylococcus aureus cellulitis.  The patient is a 52-year-old male who has had a very complex course secondary to a right lower extremity complex open wound.

general medicine, chronic pain, methicillin-resistant staphylococcus aureus cellulitis, complex open wound, staphylococcus aureus, wound care, cellulitis, wound, hepatitis,

The situation entails a patient's discharge from the hospital after hospitalization due to a serious infection with methicillin-resistant Staphylococcus aureus (MRSA), a drug-resistant bacterial infection. The presence of chronic conditions such as hepatitis C and a history of tobacco use further complicates the case. While the patient is stable for discharge, the complex health profile and the seriousness of the MRSA infection suggest that this is a moderately high-stakes situation considering the potential for complications or readmission if issues are not managed properly post-discharge.