Medical Specialty: Radiology
Sample Name: CT Abdomen & Pelvis - 7

REASON FOR EXAM: , Lower quadrant pain with nausea, vomiting, and diarrhea.,TECHNIQUE: , Noncontrast axial CT images of the abdomen and pelvis are obtained.,FINDINGS: , Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,Gallstones are seen within the gallbladder lumen.  No abnormal pericholecystic fluid is seen.,The liver is normal in size and attenuation.,The spleen is normal in size and attenuation.,A 2.2 x 1.8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas.  No pancreatic ductal dilatation is seen.  There is no abnormal adjacent stranding.  No suspected pancreatitis is seen.,The kidneys show no stone formation or hydronephrosis.,The large and small bowels are normal in course and caliber.  There is no evidence for obstruction.  The appendix appears within normal limits.,In the pelvis, the urinary bladder is unremarkable.  There is a 4.2 cm cystic lesion of the right adnexal region.  No free fluid, free air, or lymphadenopathy is detected.,There is left basilar atelectasis.,IMPRESSION:,1.  A 2.2 cm low attenuation lesion is seen at the pancreatic tail.  This is felt to be originating from the pancreas, a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised.  Additionally, when the patient's creatinine improves, a contrast-enhanced study utilizing pancreatic protocol is needed.  Alternatively, an MRI may be obtained.,2.  Cholelithiasis.,3.  Left basilar atelectasis.,4.  A 4.2 cm cystic lesion of the right adnexa, correlation with pelvic ultrasound is advised.
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DESCRIPTION: Lower quadrant pain with nausea, vomiting, and diarrhea.  CT abdomen without contrast and CT pelvis without contrast.  Noncontrast axial CT images of the abdomen and pelvis are obtained.

radiology, ct abdomen, ct pelvis, neoplasm, lesion, attenuation, hydronephrosis, stone formation, ct images, cystic lesion, abdomen, cystic, pancreatic, ct, pelvis, intravenous, noncontrast

The findings from the CT scan report several potential issues that could be of varying severity. The presence of a 2.2 cm lesion at the pancreatic tail could indicate a cystic pancreatic neoplasm, which might require follow-up or a biopsy. Furthermore, the right adnexal cystic lesion requires correlation with a pelvic ultrasound. These findings suggest possible serious conditions that need further investigation, particularly pancreatic neoplasms which can be significant. Overall, patient management will depend on follow-up examinations and could significantly affect treatment decisions. This context implies a moderate to high-stakes situation, especially considering the potential implications for patient health.


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Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization & Ventriculogram

PROCEDURE PERFORMED:,1.  Right heart catheterization.,2.  Left heart catheterization.,3.  Left ventriculogram.,4.  Aortogram.,5.  Bilateral selective coronary angiography.,ANESTHESIA:,  1% lidocaine and IV sedation including Versed 1 mg.,INDICATION:,  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.  She has had atrial fibrillation and previous episodes of congestive heart failure.  She has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea.,PROCEDURE:,  After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing.  The patient was taken to the Cardiac Catheterization Lab where the procedure was performed.  The right inguinal area was thoroughly cleansed with Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been attained, a thing wall Argon needle was used to cannulate the right femoral vein.  A guidewire was advanced into the lumen of the vein without resistance.  The needle was removed and the guidewire was secured to the sterile field.  The needle was flushed and then used to cannulate the right femoral artery.  A guidewire was advanced through the lumen of the needle without resistance.  A small nick was made in the skin and the needle was removed.  This pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed.  FiO2 sample was obtained and the sheath was flushed.  An #8 French sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed.  A Swan-Ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated.  An angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to a manifold and flushed.  Left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured.  Using dual transducers together and the mitral valve radius was estimated.  The balloon was deflated and mixed venous sample was obtained.  Hemodynamics were measured.  The catheter was pulled back in to the pulmonary artery right ventricle and right atrium.  The right atrial sample was obtained and was negative for shunt.  The Swan-Ganz catheter was then removed and a left ventriculogram was performed in the RAO projection with a single power injection of non-ionic contrast material.  Pullback was then performed which revealed a minimal LV-AO gradient.  Since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the LAO projection with a single power injection of non-ionic contrast material.  The pigtail catheter was then removed and a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged.  Using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views.  This catheter was then removed and a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views.  This catheter was removed.  The sheaths were flushed final time.  The patient was taken to the Postcatheterization Holding Area in stable condition.,FINDINGS:,HEMODYNAMICS: , Right atrial pressure 9 mmHg, right ventricular pressure is 53/14 mmHg, pulmonary artery pressure 62/33 mmHg with a mean of 46 mmHg.  Pulmonary capillary wedge pressure is 29 mmHg.  Left ventricular end diastolic pressure was 13 mmHg both pre and post left ventriculogram.  Cardiac index was 2.4 liters per minute/m2.  Cardiac output 4.0 liters per minute.  The mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2.  The aortic valve area is calculated to be 2.08 cm2.,LEFT VENTRICULOGRAM: , No segmental wall motion abnormalities were noted.  The left ventricle was somewhat hyperdynamic with an ejection fraction of 70%.  2+ to 3+ mitral regurgitation was noted.,AORTOGRAM: , There was 2+ to 3+ aortic insufficiency noted.  There was no evidence of aortic aneurysm or dissection.,LEFT MAIN CORONARY ARTERY: , This was a moderate caliber vessel and it is rather long.  It bifurcates into the LAD and left circumflex coronary artery.  No angiographically significant stenosis is noted.,LEFT ANTERIOR DESCENDING ARTERY:,  The LAD begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove.  It tapers in its mid portion to become small caliber vessel.  Luminal irregularities are present, however, no angiographically significant stenosis is noted.,LEFT CIRCUMFLEX CORONARY ARTERY: , The left circumflex coronary artery begins as a moderate caliber vessel.  Small obtuse marginal branches are noted and this is the nondominant system.  Lumen irregularities are present throughout the circumflex system.  However no angiographically significant stenosis is noted.,RIGHT CORONARY ARTERY: , This is the moderate caliber vessel and it is the dominant system.  No angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel.,IMPRESSION:,1.  Nonobstructive coronary artery disease.,2.  Severe mitral stenosis.,3.  2+ to 3+ mitral regurgitation.,4.  2+ to 3+ aortic insufficiency.
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DESCRIPTION: Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography.  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.

The procedure described is complex and involves significant cardiovascular interventions such as heart catheterization and ventriculogram, which are invasive and typically performed in a cardiac catheterization lab. The patient has serious health conditions, including severe mitral stenosis, pulmonary hypertension, and previous episodes of congestive heart failure. These initial conditions elevate the stakes due to potential risks and complications, especially considering the patient is being evaluated for possible valve repair or replacement. The outcomes of this procedure will heavily influence her treatment plan, indicating a high-stakes situation.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Lysis of Pelvic Adhesions

PREOPERATIVE DIAGNOSIS: , Multiple pelvic adhesions.,POSTOPERATIVE DIAGNOSIS: , Multiple pelvic adhesions.,PROCEDURE PERFORMED: ,Lysis of pelvic adhesions.,ANESTHESIA: , General with local.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY: , The patient is a 32-year-old female who had an 8 cm left ovarian mass, which was evaluated by Dr. X.  She had a ultrasound, which demonstrated the same.  The mass was palpable on physical examination and was tender.  She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy.  During the surgery, there were multiple pelvic adhesions between the left ovarian cyst and the sigmoid colon.  These adhesions were taken down sharply with Metzenbaum scissors.,PROCEDURE: , A pelvic laparotomy had been performed by Dr. X.  Upon exploration of the abdomen, multiple pelvic adhesions were noted as previously stated.  A 6 cm left ovarian cyst was noted with adhesions to the sigmoid colon and mesentery.  These adhesions were taken down sharply with Metzenbaum scissors until the sigmoid colon was completely freed from the ovarian cyst.  The ureter had been identified and isolated prior to the adhesiolysis.  There was no evidence of bleeding.  The remainder of the case was performed by Dr. X and this will be found in a separate operative report.
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DESCRIPTION: Lysis of pelvic adhesions.  The patient had an 8 cm left ovarian mass.   The mass was palpable on physical examination and was tender.  She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy.

surgery, lysis of pelvic adhesions, pelvic adhesions, pelvic, adhesions, salpingooophorectomy, lysis, laparotomy, sigmoid, colon, mass, ovarian,

The situation described involves a surgical procedure with an elective pelvic laparotomy and lysis of pelvic adhesions. While surgery does carry inherent risks such as complications, the procedure described seems to have gone smoothly without complications and is elective, not an emergency. Therefore, the stakes, while significant, do not reach the level of being extremely high as might be the case in emergency or life-threatening conditions.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pulmonary Function Test - 5

OBSERVATIONS: , FEV1 is 3.76, 103% predicted.  FVC is 4.98, 110% predicted.  Ratio is 75.  FEF 25-75 is 3.053, 82% predicted, postbronchodilator improves by 35%.  DLCO is 35, 121% predicted.  Residual volume is 3.04, 139% predicted.  Total lung capacity is 8.34, 120% predicted.,Flow volume loop reviewed.,INTERPRETATION:,  Mild restrictive airflow limitation.  Clinical correlation is recommended.
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DESCRIPTION: Pulmonary function test.  Mild restrictive airflow limitation.  Clinical correlation is recommended.

cardiovascular / pulmonary, fev1, fvc, fef, dlco, lung capacity, postbronchodilator, pulmonary function test, restrictive airflowNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The context involves the interpretation of pulmonary function tests, which are typically routine diagnostic assessments for evaluating respiratory health. The results suggest mild restrictive airflow limitation, indicating a potential, but not immediately critical, pulmonary condition. The recommendation for clinical correlation suggests a follow-up but does not indicate an emergency or severe condition. Generally, without additional information suggesting an urgent health risk, this situation is of moderate stakes in medical practices.


Medical Specialty: Neurology
Sample Name: Carotid Ultrasound

EXAM:,  Bilateral carotid ultrasound.,REASON FOR EXAM: , Headache.,TECHNIQUE:  ,Color grayscale and Doppler analysis is employed.,FINDINGS:,  On the grayscale images, the right common carotid artery demonstrates patency with mild intimal thickening only.  At the level of the carotid bifurcation, there is heterogeneous hard plaque present, but without grayscale evidence of greater than 50% stenosis.  Right common carotid waveform is normal with a peak systolic velocity of 0.474 m/second and an end-diastolic velocity of 0.131 m/second.  The right ECA is patent as well with the velocity measurement 0.910 m/second.,The right internal carotid artery at the bifurcation demonstrates plaque formation, but no evidence of greater than 50% stenosis.  Proximal peak systolic velocity in the internal carotid artery is 0.463 m/second with proximal end-diastolic velocity of 0.170.  The mid internal carotid peak systolic velocity is 0.564 m/second, and mid ICA end-diastolic velocity is 0.199 m/second.  Right ICA distal PSV 0.580 m/second, right ICA distal EDV 0.204 m/second.  Vertebral flow is antegrade on the right at 0.469 m/second.,On the left, the common carotid artery demonstrates intimal thickening, but is otherwise patent.  At the level of the bifurcation, however, there is more pronounced plaque formation with approximately 50% stenosis by the grayscale analysis.  See the velocity measurements below:,Left carotid ECA measurement 0.938 m/second.  Left common carotid PSV 0.686 m/second, and left common carotid end-diastolic velocity 0.137 m/second.,Left internal carotid artery again demonstrates prominent focus of hard plaque with up to at least 50% stenosis.  This should be further assessed with CTA for more precise measurement.  The left proximal ICA/PSV 0.955 m/second, left proximal ICA/EDV 0.287 m/second.  There is spectral broadening in the proximal aspect of the carotid waveform.  The left carotid ICA mid PSV 0.895, left carotid ICA mid EDV 0.278 with also spectral broadening present.,The left distal ICA/PSV 0.561, left distal ICA/EDV 0.206, again the spectral broadening present.  Vertebral flow is antegrade at 0.468 m/second.,IMPRESSION: , The study demonstrates bilateral hard plaque at the bifurcation, left greater than right.  There is at least 50% stenosis of the left internal carotid artery at its bifurcation and a followup CTA is recommended for further assessment.
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DESCRIPTION: Bilateral carotid ultrasound.

Bilateral carotid ultrasound.

neurology, doppler analysis, headache, edv, ica, eca, psv, distal ica/edv, hard plaque, bilateral carotid ultrasound, peak systolic velocity, internal carotid artery, plaque formation, carotid ultrasound, carotid artery, carotid, stenosis, proximal, artery, velocity

In this medical case, the bilateral carotid ultrasound reveals the presence of plaque and approximately 50% stenosis in the left internal carotid artery. Although this condition can potentially lead to significant health issues such as stroke if left untreated or if it progresses, the current findings do not indicate an immediate or critical state such as severe stenosis or complete occlusion. Follow-up with CTA (Computed Tomography Angiography) for further assessment suggests that further action is needed, but there is no immediate high-risk outcome as per the current data. Hence, it is moderate stakes, with the urgency associated with preventing potential future complications.


Medical Specialty: Orthopedic
Sample Name: Arthroscopic Debridement & Labral Repair - Hip

PREOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,POSTOPERATIVE DIAGNOSIS: , Femoroacetabular impingement.,OPERATIONS PERFORMED,1.  Left hip arthroscopic debridement.,2.  Left hip arthroscopic femoral neck osteoplasty.,3.  Left hip arthroscopic labral repair.,ANESTHESIA: , General.,OPERATION IN DETAIL: , The patient was taken to the operating room, where he underwent general anesthetic.  His bilateral lower extremities were placed under traction on the Hana table.  His right leg was placed first.  The traction post was left line, and the left leg was placed in traction.  Sterile Hibiclens and alcohol prep and drape were then undertaken.  A fluoroscopic localization was undertaken.  Gentle traction was applied.  Narrow arthrographic effect was obtained.  Following this, the ProTrac portal was made under the fluoro visualization, and then, a direct anterolateral portal made and a femoral neck portal made under direct visualization.  The diagnostic arthroscopy showed the articular surface to be intact with a moderate anterior lip articular cartilage delamination injury that propagated into the acetabulum.  For this reason, the acetabular articular cartilage was taken down and stabilized.  This necessitated takedown of the anterior lip of the acetabulum and subsequent acetabular osteoplasty debridement with associated labral repair.  The labrum was repaired using absorbable Smith & Nephew anchors with a sliding SMC knot.  After stabilization of the labrum and the acetabulum, the ligamentum teres was assessed and noted to be stable.  The remnant articular surface of the femoral artery and acetabulum was stable.  The posterior leg was stable.  The traction was left half off, and the anterolateral aspect of the head and neck junction was identified.  A stable femoral neck decompression was accomplished starting laterally and proceeding anteriorly.  This terminated with the hip coming out of traction and indeterminable flexion.  A combination of burs and shavers was utilized to perform a stable femoral neck osteoplasty decompression.  The decompression was completed with thorough irrigation of the hip.  The cannula was removed, and the portals were closed using interrupted nylon.  The patient was placed into a sterile bandage and anesthetized intraarticularly with 10 mL of ropivacaine subcutaneously with 20 mL of ropivacaine and at this point was taken to the recovery room.  He tolerated the procedure very well with no signs of complications.
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DESCRIPTION: Femoroacetabular impingement.  Left hip arthroscopic debridement, femoral neck osteoplasty, and labral repair.

orthopedic, labral repair, femoral neck osteoplasty, arthroscopic debridement, femoroacetabular impingement, arthroscopic, femoroacetabular, impingement, debridement, osteoplasty, acetabulum

The procedure described is orthopedic surgery for treating femoroacetabular impingement through arthroscopic methods. While this is a significant medical procedure, involving anesthesia and potential complications, it is generally considered routine in the field of orthopedic surgery. The stakes are moderate since the patient's quality of life can significantly improve post-surgery if successful, but the procedure is not typically life-threatening and is relatively well-understood and often performed by orthopedic surgeons.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Coronary CT Angiography (CCTA) - 2

CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY,PROCEDURE: , Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time.  Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV.  Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.,Retrospective ECG gating was performed.  The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan.  The average heart rate was 62 beats/min.,The patient had no adverse reaction to the contrast.  Multiphase retrospective reconstructions were performed.  Small field of view cardiac and coronary images were analyzed on a 3D work station.  Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.,CORONARY CTA:,1.  The technical quality of the scan is adequate.,2.  The coronary ostia are in their normal position.  The coronary anatomy is right dominant.,3.  LEFT MAIN:  The left main coronary artery is patent without angiographic stenosis.,4.  LEFT ANTERIOR DESCENDING ARTERY:  The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity.  Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.,5.  The ramus intermedius is a small vessel with minor irregularities.,6.  LEFT CIRCUMFLEX:  The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.,7.  RIGHT CORONARY ARTERY:  The right coronary artery is a large and dominant vessel.  It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity.  Left ventricular ejection fraction is calculated to be 69%.  There are no wall motion abnormalities.,8.  Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.,ANCILLARY FINDINGS: , None.,FINAL IMPRESSION:,1.  Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.,2.  Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.,Thank you for referring this patient to us.
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DESCRIPTION: CCTA with Cardiac Function/Calcium Scoring

cardiovascular / pulmonary, coronary ct angiography, ventricular ejection fraction, anterior descending artery, coronary artery disease, coronary ct, ct angiography, cardiac ct, obtuse marginal, ventricular ejection, ejection fraction, coronary artery, artery, angiography, coronary, ccta, atherosclerosis, ventricular, beats/min, anterior, vessel, stenosis, ct, cardiac, disease,

The situation involves a medical evaluation of a patient's cardiovascular health using Coronary CT Angiography (CCTA). The findings describe mild coronary artery disease with specific details on plaque and stenosis, but no immediate severe findings requiring emergency intervention. The recommendation is for medical management rather than surgical or immediate invasive procedures, indicating a non-critical situation. However, cardiovascular evaluations and management are still significant given potential long-term health implications.


Medical Specialty: Surgery
Sample Name: Cardiac Catheterization - 5

PROCEDURE PERFORMED:,1. Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.,2. Right femoral selective angiogram.,3. Closure device the seal the femoral arteriotomy using an Angio-Seal.,INDICATIONS FOR PROCEDURE: ,The patient with known coronary atherosclerotic heart disease and multiple risk factors of coronary disease, who had her last coronary arteriogram performed in 2004. She has had complaints of progressive chest discomfort, and has ongoing risks including current smoking, diabetes, hypertension, hyperlipidemia to name a few. The decision was made to proceed on with percutaneous evaluation and possible intervention given her known disease and the possibility of disease progression.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, The patient was taken to cardiac catheterization lab where her procedure was performed. She was prepped and prepared on the table; after which, her right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery over a standard 0.035 guide wire. Coronary angiography and left ventricular measurement and angiography were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery. A 6-French JR4 diagnostic catheter to image the right groin and her artery and the saphenous vein graft conduit. Subsequently, a 6-French angled pigtail catheter was used to measure left ventricular pressures and to perform a power injection, a left ventriculogram at 8 mL per second for a total of 30 mL. At the conclusion of the diagnostic evaluation, the patient had selective arteriography of her right femoral artery, which showed the right femoral artery to be free of significant atherosclerotic plaque. Did have a normal bifurcation into the superficial femoral and profunda femoris arteries and to have an arteriotomy that was in the common femoral artery away from the bifurcation. As such, an initial attempt to advance a Perclose device failed to allow the device descend to _____ tract and into the appropriate position within the artery. As such, the Perclose was never deployed and was removed intact over the wire from the system. We then replaced this with a 6-French Angio-Seal which was used to seal the femoral arteriotomy with achievement of hemostasis. The patient was subsequently dispositioned back to the MAC Unit where she will complete her bedrest prior to her disposition to home.,HEMODYNAMIC DATA:, Opening aortic pressure 125/60, left ventricular pressure 108/4 with an end-diastolic pressure of 16. There was no significant gradient across the aortic valve on pullback from the left ventricle. Left ventricular ejection fraction was 55%. Mitral regurgitation was less than or equal to 1+. There was normal wall motion in the RAO projection.,CORONARY ANGIOGRAM:, The left main coronary artery had mild atherosclerotic plaque. The proximal LAD was 100% occluded. The left circumflex had mild diffuse atherosclerotic plaque. The obtuse marginal branch which operates as an OM-2 had a mid approximately 80% stenosis at a kink in the artery. This appears to be the area of a prior anastomosis, the saphenous vein graft to the OM. This is a very small-caliber vessel and is 1.5-mm in diameter at best. The right coronary artery is dominant. The native right coronary artery had mild proximal and mid atherosclerotic plaque. The distal right coronary artery has an approximate 40% stenosis. The posterior left ventricular branch has a proximal 50 to 60% stenosis. The proximal PDA has a 40 to 50% stenosis. The saphenous vein graft to the right PDA is widely patent. There was competitive flow noted between the native right coronary artery and the saphenous vein graft to the PDA. The runoff from the PDA is nice with the native proximal PDA and PLV disease as noted above. There is also some retrograde filling of the right coronary artery from the runoff of this graft. The saphenous vein graft to the left anterior descending is widely patent. The LAD beyond the distal anastomosis is a relatively small-caliber vessel. There is some retrograde filling that allows some filling into a more proximal diagonal branch. The saphenous vein graft to the obtuse marginal was known to be occluded from the prior study in 2004. Overall, this study does not look markedly different than the procedure performed in 2004.,CONCLUSION:, 100% proximal LAD mild left circumflex disease with an OM that is a small-caliber vessel with an 80% lesion at a kink that is no amenable to percutaneous intervention. The native right coronary artery has mild to moderate distal disease with moderate PLV and PDA disease. The saphenous vein graft to the OM is known to be 100% occluded. The saphenous vein graft to the PDA and the saphenous vein graft to the LAD are open. Normal left ventricular systolic function.,PLAN:, The plan will be for continued medical therapy and risk factor modification. Aggressive antihyperlipidemic and antihypertensive control. The patient's goal LDL will be at or below 70 with triglyceride level at or below 150, and it is very imperative that the patient stop smoking.,After her bedrest is complete, she will be dispositioned to home, after which, she will be following up with me in the office within 1 month. We will also plan to perform a carotid duplex Doppler ultrasound to evaluate her carotid bruits.
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DESCRIPTION: Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.

surgery, catheterization, vein graft, angiography, angiogram, angio-seal, closure device, coronary atherosclerotic heart disease, saphenous vein graft, ventricular pressure, coronary artery, saphenous vein, atherosclerotic, coronary, artery, bifurcation, pda, ventricular, saphenous

Cardiac catheterization is a procedure performed on patients with coronary artery disease to evaluate the condition of their coronary arteries, heart chambers, and blood flow. In this particular case, the patient has a history of coronary artery disease, with significant existing conditions such as 100% occlusion of the proximal LAD and an 80% stenosis in a small-caliber obtuse marginal branch, amongst other cardiovascular issues. Although the immediate procedure here is diagnostic, not interventional, it is high-stakes due to the patient's underlying severe coronary conditions, which could result in significant complications if not properly managed. The stakes are also elevated by the patient's risk factors, including smoking and diabetes, and the necessity for precise medical decision-making. A slight complication or oversight could have serious consequences given the patient's cardiovascular state.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 6

INDICATIONS: , This is a 55-year-old female who is having a colonoscopy to screen for colon cancer.  There is no family history of colon cancer and there has been no blood in the stool.,PROCEDURE PERFORMED:  ,Colonoscopy.,PREP: , Fentanyl 100 mcg IV and 3 mg Versed IV.,PROCEDURE:,  The tip of the endoscope was introduced into the rectum.  Retroflexion of the tip of the endoscope failed to reveal any distal rectal lesions.  The rest of the colon through to the cecum was well visualized.  The cecal strap, ileocecal valve, and light reflex in the right lower quadrant were all identified.  There was no evidence of tumor, polyp, mass, ulceration, or other focus of inflammation.  Adverse reactions none.,IMPRESSION:,  Normal colonic mucosa through to the cecum.  There was no evidence of tumor or polyp.
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DESCRIPTION: Colonoscopy to screen for colon cancer

Colonoscopy to screen for colon cancer

gastroenterology, versed iv, colon, tumor, polyp, mass, ulceration, focus of inflammation, tip of the endoscope, evidence of tumor, colon cancer, endoscope, cecum, cancer, colonoscopy,

The situation involves a routine medical procedure, a colonoscopy, performed for cancer screening in a 55-year-old female. There have been no adverse reactions, and the results showed no evidence of tumors or polyps. The absence of complications or findings reduces the stakes of this particular procedure. However, since this is a medical procedure related to cancer screening, it maintains some importance for health purposes.


Medical Specialty: Hospice - Palliative Care
Sample Name: Hospice Visit - CHF

HISTORY:,  This is an initial visit for this 95-year-old gentleman with a Hospice diagnosis of CHF.  He was referred to us by Dr. ABC, who reveals a long history of cardiomyopathy and a recent decrease in his ejection fraction to approximately 20-25%.  The patient was seen in the office approximately three days ago with a clinical diagnosis of bronchitis.  The FES, as well as the daughter report that he has had significant clinical and functional decline over the last two to three weeks.  He is no longer ambulatory.  His appetite is significantly decreased and he had significant unmeasured weight loss.  He is notably more weak.  He is unable to perform any of the activities of daily living and he is increasingly somnolent with poor sleep at night.  The patient says that he is ready to die, that he is after all 95 years old and is aware that his clinical and functional status has been declining.  He worked as a chef for almost seven decades and retired approximately two years ago.  He denies pain.  He admits to some cough, but he believes the cough is improved on the current antibiotic.  He does note that he sleeps poorly and unable to indicate a cause for that difficulty in sleeping.  He reports that he recently made a trip to California where he said goodbye to his children that live there.  The patient reports that his goals of care are to stay at home.  He has never been hospitalized with the exception of some surgery on his back in Houston, Texas decades ago that he has no interest in going to a hospital and that he would be happy to sign a DNR form and that he would like no heroics performed in the event that his heart or breathing stops.  He denies anxiety or depression and feels that his life has been quite full and quite successful and that when time comes, he is ready to go.,MEDICATIONS:,  His medications include Avelox 400 mg.  He is on day four of a seven-day dose.  He is on Coreg 3.125 mg a day, lisinopril 5 mg a day, Coumadin 2.5 mg a day, digoxin 0.125 mg every other day, Lasix 80 mg twice daily, Inspra twice daily, and he is on a transdermal nitro patch 12 hours on and 12 hours off.  He takes Tylenol extra strength every four to six hours for bilateral shoulder pain typically one to two doses a day.,PHYSICAL EXAMINATION: , Exam reveals a cachectic somnolent gentleman, who appears to be comfortable.  His blood pressure is 90/60.  His heart rate is 80 and irregular.  His respiratory rate is 14.  Head reveals marked temporal wasting.  He is anicteric.  The pupils are equal and round.  There is jugular venous distention noted approximately 2-3 cm above the notch.  Chest shows good air entry bilaterally with scattered rhonchi.  No audible wheezing.  His heart sounds are irregular and there is a musical systolic ejection murmur radiating to the axilla.  The abdomen is soft with a large midline well-healed surgical scar.  The bowel sounds are normoactive.  There is no tenderness or palpable organomegaly.  He has 2+ edema of his lower extremities with some weeping of the right lower extremity and no evidence of infection.  Neurologically, while somnolent easily aroused and speech is quite clear.  He identities the date as October of 2008, but is otherwise oriented.  His short-term memory is quite poor.  His insight is also poor.  He appears to be somewhat sad.  There are mild regular tremors, right hand worse than left, but there is otherwise no focal neurological deficit.,A phone conversation with his daughter, Xyz, his health care proxy, ensued.  His daughter is very concerned with his clinical decline and is raising the question of whether he would benefit from hospitalization.  She reports that her mother died after a many-year course with heart failure and had upwards of three dozen hospitalizations.  At each hospitalization, she seem to derive benefit and wondered if her dad would drive equal benefit from hospitalizations.  She is aware that he is unwilling to be hospitalized and I believe hopefully that the Hospice team might persuade him.  She also reports that he has been talking about dying for nearly five years.,ASSESSMENT:,  A 95-year-old gentleman with endstage CHF with recent significant clinical and functional decline.  The patient appears to have relatively little in the way of symptoms, although perhaps some sleep hygiene might be of help.  While today the patient appears to be very calm and sedated, the history is one of significant emotional lability.  Family is having great difficulty accepting the terminality of the patient's circumstances.,PLAN:,  A DNR was placed in the house after the above-noted conversation was had.  I believe the patient might benefit from low-dose hypnotic and 7.5 mg of Restoril was ordered.  Reassessment of the patient's condition is warranted.  A family meeting will be offered to review the circumstances of the patient's condition in hopes that family might better accept his wishes and to develop a plan of care for this gentleman.
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DESCRIPTION: Initial visit for a 95-year-old gentleman with a Hospice diagnosis of CHF.

hospice - palliative care, hospice, chf, dnr, dnr was placed, hospice team, air entry, appetite, bronchitis, cardiomyopathy, clinical diagnosis, ejection fraction, functional decline, hospitalization, hospitalized, initial visit, plan of care, somnolent, weight loss,

The situation is high-stakes because it involves end-of-life care decisions for a patient with advanced congestive heart failure (CHF). The patient, who is 95 years old, has significant clinical decline and has expressed wishes to avoid hospitalization and aggressive treatment. The family, however, is struggling with accepting the terminal nature of the patient's condition. The patient, his family, and the healthcare providers must navigate sensitive and challenging decisions regarding the patient's care, comfort, and final wishes. Such decisions can profoundly impact the patient's remaining quality of life and the family's emotional well-being.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Allograft Transplant

PREOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,POSTOPERATIVE DIAGNOSES:,1.  Ischemic cardiomyopathy.,2.  Status post redo coronary artery bypass.,3.  Status post insertion of intraaortic balloon.,4.  Postoperative coagulopathy.,OPERATIVE PROCEDURE:,1.  Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass.,2.  Open sternotomy covered with Ioban.,3.  Insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.,ANESTHESIA: , General endotracheal.,OPERATIVE PROCEDURE: , With the patient in the supine position, he was prepped from shin to knees and draped in a sterile field.  A right common femoral artery vein were then exposed through a longitudinal incision in the right groin and prepared for cardiopulmonary bypass.  A sternotomy incision was then opened and the lesions from the previous operative procedures were lysed and they were very dense and firm, freeing up the right atrium and the ascending aorta and anterior right ventricle.  The patient was heparinized and then a pursestring suture was placed in the right atrium superior and inferior just above the superior and inferior vena cava.  A percutaneous catheter for arterial return was placed using Seldinger technique through exposed right femoral artery and then two 3-mm catheters were inserted with two pursestring sutures in the right atrium just superior to inferior vena cava.  After satisfactory heparinization has been obtained, the patient was placed on cardiopulmonary bypass and another pursestring suture was placed in the right superior pulmonary vein and a catheter was placed for suction in the left atrium.  After the heart was brought to the operating room and triggered, the patient had the ascending aorta clamped and tapes were placed around superior and inferior vena cava and were secured in place.  A cardiectomy was then performed by starting in the right atrium.  The wires from the pacemaker and defibrillator were transected coming from the superior vena cava and the Swan-Ganz catheter was brought out into the operative field.  Cardiectomy was then performed, first resecting the anterior portion of the right atrium and then transecting the aorta, the pulmonary artery, the septum between the right and left atriums, and then the heart was removed.  The right and left atrium, aorta, and pulmonary artery were prepared for the transplant.  First, we did a side-to-side anastomosis, continued to the left atrium and this was performed using 3-0 Prolene suture and a right atrial anastomosis side-to-side was performed using 3-0 Prolene suture.  The pulmonary artery was then anastomosed using 5-0 Prolene and the aorta was anastomosed with 4-0 Prolene.  The arterial anastomosis in the pulmonary artery and aorta were not completed until the heart was filled with blood.  Air was evacuated and the sutures were tied down.  The clamp on the ascending aorta was removed and the patient was gradually overtime weaned from cardiopulmonary bypass.  The patient had a postoperative coagulopathy which prolonged the period of time in the operating room after completion and weaning off of the cardiopulmonary bypass.  Blood factors and factor VII were given to try and correct the coagulopathy.  Because of excessive transfusions that were required, a Mahurkar catheter was inserted through the left common femoral vein, first placing a needle into the vein and then guidewire removed, and the needle dilators were then placed and then the Mahurkar catheter was then placed with 2-0 nylon suture.  Hemofiltration was started in the operating room at this time.  After he had satisfactory hemostasis, we decided to do the chest open and cover it with Ioban, which we did, and one chest tube was inserted into the mediastinum through a separate stab wound.  The patient also had an intraaortic balloon for counterpulsation which had been inserted into the left subclavian vein preoperatively.  This was left in place and the pulse generation, the pacemaker was in a right infraclavicular position, which was left in place because of the coagulopathy.  The patient received 11 units of packed red blood cells, 7 platelets, 23 fresh-frozen plasma, 20 cryoprecipitates, and factor VII.  Urine output for the procedure was 520 mL.  The preservation time of the heart is in the anesthesia sheet.  The estimated blood loss was at least 6 L.  The patient was taken to the intensive care unit in guarded condition.
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DESCRIPTION: Orthostatic cardiac allograft transplantation utilizing total cardiopulmonary bypass, open sternotomy covered with Ioban, insertion of Mahurkar catheter for hemofiltration via the left common femoral vein.

cardiovascular / pulmonary, cardiomyopathy, ioban, ischemic, ischemic cardiomyopathy, mahurkar catheter, orthostatic, seldinger, swan-ganz, allograft, aorta, balloon, cardiac, cardiopulmonary bypass, catheter, coagulopathy, coronary artery bypass, femoral vein, hemofiltration, intraaortic, intraaortic balloon, sternotomy, transplantation, ventricle, inferior vena cava, cardiac allograft, common femoral, vena cava, pulmonary artery, atrium, insertion, cardiopulmonary, artery

The procedure described is a cardiac transplant surgery, which is inherently high-stakes due to its complexity and critical nature. It involves a patient with existing serious conditions such as ischemic cardiomyopathy and requires careful coordination of cardiovascular and pulmonary management. The risks include postoperative complications like coagulopathy, massive blood loss, and the need for intensive post-surgical care. Heart transplantation is one of the most significant surgical interventions both in terms of the procedure itself and the post-operative recovery and monitoring required.


Medical Specialty: IME-QME-Work Comp etc.
Sample Name: IME & Record Review - Orthopedic

INTRODUCTION: , The opinions expressed in this report are those of the physician.  The opinions do not reflect the opinions of Evergreen Medical Panel, Inc.  The claimant was informed that this examination was at the request of the Washington State Department of Labor and Industries (L&I).  The claimant was also informed that a written report would be sent to L&I, as requested in the assignment letter from the claims manager.  The claimant was also informed that the examination was for evaluative purposes only, intended to address specific injuries or conditions as outlined by L&I, and was not intended as a general medical examination.,CHIEF COMPLAINTS: , This 51-year-old married male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall that occurred on November 20, 2008.,HISTORY OF INDUSTRIAL INJURY:,  This patient was injured on November 20, 2008.  He works at the Purdy Correctional Facility and an inmate had broken some overhead sprinklers, the floor was thus covered with water and the patient slipped landing on the back of his head, then on his back.  The patient said he primarily landed on the left side.  After the accident he states that he was generally stun and someone at the institute advised him to be evaluated.  He went to a Gig Harbor urgent care facility and they sent him on to Tacoma General Hospital.  At the Tacoma General, he indicates that a whiplash and a concussion were diagnosed and it was advised that he have a CT scan.  The patient describes that he had a brain CT and a dark spot was found.  It was recommended that he have a followup MRI and this was done locally and showed a recurrent acoustic neuroma.  Before, when the patient initially had developed an acoustic neuroma, the chiropractor had seen the patient and suggested that he have a scan and this was how his original acoustic neuroma was diagnosed back in October 2005.  The patient has been receiving adjustments by the chiropractor since and he also has had a few massage treatments.  Overall his spine complaints have improved substantially.,After the fall, he also saw at Prompt Care in the general Bremerton area, XYZ, an Osteopathic Physician and she examined him and released him full duty and also got an orthopedic consult from XYZ.  She ordered an MRI of his neck.  Cervically this showed that he had a mild disc bulge at C4-C5, but this actually was the same test that diagnosed a recurrent acoustic neuroma and the patient now is just recovering from neurosurgical treatment for this recurrent acoustic neuroma and some radiation is planned.,Since 2002 the patient has been seeing the chiropractor, XYZ for general aches and pain and this has included some treatments on his back and neck.,CURRENT SYMPTOMS:  ,The patient describes his current pain as being intermittent.,PAST MEDICAL HISTORY:,Illnesses:  The patient had a diagnosis in 2005 of an acoustic neuroma.  It was benign, but treated neurosurgically.  In February 2004 and again in August 2009 he has had additional treatments for recurrence and he currently has some skull markers in place because radiation is planned as a followup, although the tumor was still indicated to be benign.,Operations:  He has a history of an old mastoidectomy.  He has a past history of removal of an acoustic neuroma in 2005 as noted.,Medications:  The patient takes occasional Tylenol and occasional Aleve.,Substance Use:,Tobacco:  He does not smoke cigarettes.,Alcohol:  He drinks about five beers a week.,FAMILY HISTORY:,  His father died of mesothelioma and his mother died of Lou Gehrig's disease.,SOCIOECONOMIC HISTORY:,Marital Status and Dependents:  The patient has been married three times; longest marriage is of two years duration.  He has two children.  These dependents are ages 15 and twins and are his wife's dependents.,Education:  The patient has bachelor's degree.,Military History:  He served six years in the army and received an honorable discharge.,Work History:  He has worked at Purdy Correctional Institute in Gig Harbor for 19 years.,CHART REVIEW: , Review of the chart indicates a date of injury of November 20, 2008.  He was seen at Tacoma General Hospital with a diagnosis of head contusion and cervical strain.  He had a CT of his head done because of a fall with possible loss of consciousness, which showed a left cerebellar hypodensity and further evaluation was recommended.  He has a history of an old mastoidectomy.  He was then seen on November 24, 2008 by XYZ at Prompt Care on November 24, 2008.  There is no clearcut history that he had lost consciousness.  He has a past history of removal of an acoustic neuroma in 2005 as noted.  A diagnosis of concussion and cervical strain status post fall was made along with an underlying history of abnormal CT and previous resection of an acoustic neuroma.  Some symptoms of loss of balance and confusion were noted.  She recommended additional testing and neurologic evaluation.,The notes from the treating chiropractor begin on November 24, 2008.  Adjustments are given to the cervical, thoracic, and lumbar spine.,He was seen back by XYZ on December 9, 2008 and he had been released to full duties.  It was recognized the new MRI suggested recurrence of the acoustic neuroma and he was advised to seek further care in this regard.  There were some concerns of his feeling of being wobbly since the fall which might be related to the recurrent neuroma.  He continued to have chiropractic adjustments.  He was seen back at Prompt Care on January 8, 2009.  Dr. X indicated that she thought most of his symptoms were related to the tumor, but that the cervical and thoracic stiffness were from the fall.,A followup note by his chiropractor on January 26, 2009 indicates that cervical x-rays have been taken and that continued chiropractic adjustments along with manual traction would be carried out.,On April 13, 2009, he was seen again at Prompt Care for his cervical and thoracic strain.  He was indicated to be improving and there was suggestion that he has some physical therapy and an orthopedic consult was felt appropriate.  Therapy was not carried out and obviously was then involved with the treatment of his recurrent neuroma.,On April 17, 2009, he was seen by Dr. X, another chiropractor for consultation and further chiropractic treatments were recommended based on cervical and thoracolumbar subluxation complexes and strain.,A repeat consult was carried out on April 29, 2009 by XYZ.  He felt that this was hyperextension cervical injury.  It might take a period of time to recover.  He mentioned that the patient might have a slight ulnar neuropathy.  He felt the patient was capable of full duty and the patient was at that time having ongoing treatment for his neuroma.,This concludes the chart review.,PHYSICAL EXAMINATION: , The patient is 6 feet in height, weighs 255 pounds.,Orthopedic Examination:  He can walk with a normal gait, but he has, as indicated, a positive Romberg test and he himself has noticed that if he closes his eyes he loses his balance.  Overall the patient is a seemingly good historian.  There is a visible 3 cm scar at the left base of the neck near the hairline and there are multiple areas where his head has been shaved both anteriorly and posteriorly.  These are secondary to drawing for the skull markers.  There is a scar behind the patient's left ear from the original treatment of the acoustic neuroma.  This was well healed.  The patient can perform a toe-heel gait without difficulty.  One visibly can see that he has some facial asymmetry and he indicates that the acoustic neuroma has caused some numbness in the left side of his face and also some asymmetry that is now recovering.  The patient states he now thinks his recovery is going to get disregarded and that the facial asymmetry and numbness developed from the first surgery he had.  The patient has a full range of motion in both of his shoulders.  The patient has a full range of motion in his lumbar spine to include 90 degrees of forward bend, lateral bending of 30 degrees in either direction and extension of 10 degrees.  There is full range of motion in the patient's cervical spine to include flexion of 50 degrees at which time he can touch his chin on his chest.  He extends 40 degrees, laterally bends 30 degrees, and rotates to 80 degrees in either direction.  There is slight tenderness on palpating over the right cervical musculature.  There is no evidence of any cervical or lumbar muscle spasms.  Reflexes in the upper extremities include 1+ biceps and triceps and 1+ brachioradialis.  Knee jerks are 2+ and ankle jerks are 1+.  Tinel's test was tested at the elbow, it is negative bilaterally with percussion; however, he has slight tingling bilaterally.  The patient's grip tested with a Jamar dynamometer increases from 70 to 80 pounds bilaterally.  Sensory testing of lower extremities reveal that the patient has slightly decreased sensation to sharp stimulus in his dorsal aspect of the right first toe and a lesser extent to the left.  Testing of muscle strength in the upper and lower extremities is normal.  The patient upper arms measured four fingerbreadths above the flexion crease of the elbow measure 35 cm bilaterally.  The forearms measured four fingerbreadths below the flexion crease of the elbow measure 30 cm bilaterally.  The thighs measured four fingerbreadths above the superior pole of the patella measure 48 cm and the lower legs measured four fingerbreadths below the tibial tubercles measure 41 cm.  Pressure on the vertex of the head does not bother the patient.  Axial loading is negative.  As already indicated straight leg raising is entirely negative both sitting and lying for any radiculitis.,DIAGNOSTIC STUDIES: , X-rays the patient brings with him taken by his treating chiropractor dated 11/24/08 showed that there appears to be a little bit of narrowing of the L4-5 disc space.  The hip joints are normal.  Views of his thoracic spine are normal.  Cervical x-rays are in the file.  These are of intermittent quality, but the views do show a very slight degree of anterior spurring at the C4-5 with possible slight narrowing of the disc.  There is a view of the right shoulder that is unremarkable.,CONCLUSIONS:,  The accepted condition under the claim is a sprain of the neck, thoracic, and lumbar.,DIAGNOSES: , Diagnosis based on today's examination is a sprain of the cervical spine and lumbar spine superimposed upon some early degenerative changes.,Additional diagnosis is one of recurrent acoustic neuroma, presumably benign with upcoming additional treatment of radiation plan.  The patient also has a significant degree overweight for his height and it will be improved as he himself recognizes by some weight loss and exercise.,DISCUSSION: , He is fixed and stable at this time and his industrial case can be closed relative to his industrial injury of November 20, 2008.  Further chiropractic treatments would be entirely palliative and serve no additional medical purpose due to the fact that he has very minimal symptoms and a basis for these symptoms based on mild or early degenerative changes in both cervical and lumbar spine.  He is category I relative to the cervical spine under 296-20-240 and category I to the lumbosacral spine under WAC 296-20-270.  His industrial case should be closed and there is, as indicated, no basis for any disability award.
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DESCRIPTION: A male presents complaining of some right periscapular discomfort, some occasional neck stiffness, and some intermittent discomfort in his low back relative to an industrial fall.

The report involves a medical evaluation for a worker's compensation claim following an industrial fall. While it is important for the individual's health and potentially has financial implications, it is primarily an evaluation report with a conclusion that the case should be closed due to the patient's stable status. The content does not suggest immediate life-threatening conditions, but rather focuses on the ongoing management and implications of past injuries and recurrent conditions.


Medical Specialty: Endocrinology
Sample Name: Laryngectomy & Thyroid Lobectomy

TITLE OF OPERATION:,  Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.,INDICATION FOR SURGERY: , A 58-year-old gentleman who has had a history of a T3 squamous cell carcinoma of his glottic larynx having elected to undergo a laser excision procedure in late 06/07.  Subsequently, biopsy confirmed tumor persistence in the right glottic region.  Risks, benefits, and alternatives of the surgical intervention versus possibility of chemoradiation therapy were discussed with the patient in detail.  Also concerned for a CT scan finding of possible cartilaginous invasion at the cricoid level.  The patient understood the issues regarding surgical intervention and wished to undergo a surgical intervention despite a clear understanding of risks, benefits, and alternatives.  He was accompanied by his wife and daughter.  Risks included, but were not limited to anesthesia, bleeding, infection, injury of the nerves including lower lip weakness, tongue weakness, tongue numbness, shoulder weakness, need for physical therapy, possibility of total laryngectomy, possibility of inability to speak or swallow, difficulty eating, wound care issues, failure to heal, need for additional treatment, and the patient understood all of these issues and they wished to proceed.,PREOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,POSTOP DIAGNOSIS: , Squamous cell carcinoma of the larynx.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine on the operating room table.  After the establishment of the general anesthesia via oral endotracheal intubation, the patient had his eyes protected with Tegaderm.  A #6 endotracheal tube was placed initially.  Direct laryngoscopy was performed with a Lindholm laryngoscope.  A 0-degree endoscope was used to take pictures of what was apparently a recurrence of tumor along the right true vocal fold extending into the anterior arytenoid area and extending about 1 cm below into the subglottis.  Subsequently, a decision was then made to go ahead and perform the surgical intervention.  A hemi-apron incision was employed, and 1% lidocaine with 1:100,000 epinephrine was injected.  A shoulder roll was applied after the patient was prepped and draped in a sterile fashion.  Subsequently, a hemi-apron incision was performed.  Subplatysmal flaps were raised at the hyoid bone into the clavicle.  Attention was then turned to the right side, where a level 2, 3, 4 neck dissection was performed.  Submandibular fascia was appreciated inferiorly along the submandibular gland, this was incised allowing for identification of the digastric muscle.  Digastric tunnel was performed posteriorly to the level of the sternocleidomastoid muscle.  The fascia along the sternocleidomastoid muscle was then dissected along the anterior aspect until the cranial nerve XI was identified.  Level 2A contents were then dissected off the floor of the neck including levels 3 and 4.  Preservation of the phrenic nerve was obtained by identification, and subsequently cross-clamping fibrofatty tissue and lymph nodes just adjacent to the jugular vein inferiorly at level 4.  The specimen was then mobilized over the internal jugular vein with preservation of hypoglossal nerve.  Levels 2, 3, 4 neck dissection specimens were then labeled appropriately, attached with staples, and sent for histopathological evaluation.,Attention was then turned to attempting to perform a partial laryngectomy up front with a possibility of total laryngectomy as discussed.  Subsequently, the strap muscles were separated in the midline.  The trachea was identified in the midline.  The thyroid isthmus was plicated using the Harmonic scalpel, and attention was then turned to transecting the strap muscles at the superior aspect of the thyroid cartilage.  Once this was performed, sinuses were mobilized from the thyroid cartilage both on the right and left side respectively.  The cricothyroid joint was then freed on the left side and then on the right side with noting on the right side that this cartilage was a bit more irregular.  Attention was then turned to performing a cricothyrotomy.  Upon performing this, it was obvious that there was tumor just above the level of the cricothyrotomy incision.  A #7 anode tube was then placed in this area and secured.  Attention was then turned to performing the laryngotomy at the level of the petiole of epiglottis.  Subsequently, the cuts were made on the left side with visualization of the vocalis process and coming down to the level of the cricoid cartilage, and the thyroid cartilage was then intentionally fractured along the anterior spine.  It was evident that this tumor had extended more than 1 cm into the subglottic region.  Careful dissection of larynx from an inferior margin and portion of cricoid cartilage resection then was performed posteriorly, though it was evident that the cricoid cartilage was invaded.  Frozen section biopsy then confirmed this finding as read by Dr. X of Surgical Pathology.,In light of this finding with cartilaginous invasion and inability to preserve the cricoid cartilage, the patient's case was then converted into a total laryngectomy.  Subsequently, the trachea was transected at the level 3, 4 tracheal ring into cartilaginous space and anterior tracheal stoma was fashioned using 3-0 vertical mattress sutures for the skin.  A W-plasty was also performed to allow for enlargement of the stoma.  Attention was then turned to identifying the common parting wall of the trachea and the esophagus.  Attention was then turned to resecting the hyoid bone.  The remainder of the specimen cuts were made superior from sinus preserving a modest amount of pharyngeal mechanism.  The wound was copiously irrigated.  Subsequently, a tracheoesophageal puncture site was performed using a right-angled hemostat at about approximately 1 cm from the posterior tracheal wall superior aspect.  Once this was performed, a running 3-0 canal stitch was used to close the pharynx.  Subsequently, interrupted 4-0 chromic stitches were then used as reinforcement line from superior to inferior, and fibrin glue was applied.  Two #10 JP drains were placed on the right side and one on the left side and secured appropriately with 3-0 nylon.  The wound was then closed using interrupted 3-0 Vicryl for the platysma and staples for the skin.  The patient tolerated the procedure well and was brought to the Weinberg Intensive Care Unit with the endotracheal tube still in place to be decannulated later.
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DESCRIPTION: Squamous cell carcinoma of the larynx.  Total laryngectomy, right level 2, 3, 4 neck dissection, tracheoesophageal puncture, cricopharyngeal myotomy, right thyroid lobectomy.

endocrinology, laryngectomy, neck dissection, tracheoesophageal, cricopharyngeal myotomy, thyroid lobectomy, squamous cell carcinoma, larynx, thyroid cartilage, cricoid cartilage, total laryngectomy, thyroid, cartilage

The situation involves a complex surgical procedure addressing a recurrent and advanced laryngeal cancer that includes a total laryngectomy and other invasive interventions. This is high-stakes because it involves potential life-threatening conditions, major surgical risks, and significant impact on the patient's quality of life, including loss of natural speech and change in airway function. There are substantial risks and implications involved both for patient safety during surgery and for long-term outcomes. Additionally, the stakes are high given the irreversible nature of a total laryngectomy and the need for thorough postoperative care and rehabilitation.


Medical Specialty: Hematology - Oncology
Sample Name: Endometrial Cancer Followup

CHIEF COMPLAINT:,1.  Stage IIIC endometrial cancer.,2.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.  In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus.  CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis.  On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy.  The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion.  Four of 30 lymph nodes were positive for disease.  The left ovary was positive for metastatic disease.  Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease.  The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup.  Of note, we had sent off genetic testing which was denied back in June.  I have been trying to get this testing completed.,CURRENT MEDICATIONS: , Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.,ALLERGIES:
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DESCRIPTION: Stage IIIC endometrial cancer.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.  The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.

hematology - oncology, adjuvant, adjuvant chemotherapy, cisplatin, adriamycin, abraxane, endometrial cancer, lymphadenectomy, chemotherapy, endometrial, disease,

The case involves a patient with stage IIIC endometrial cancer undergoing follow-up after major surgery (hysterectomy and appendectomy) and chemotherapy. Stage IIIC cancer signifies a high level of disease advancement, with significant involvement of lymph nodes and potential metastasis, presenting a serious threat to the patient's health and necessitating careful management. Additionally, the patient has already completed five out of six chemotherapy cycles, and there's concern about metastatic disease, indicating that outcomes could significantly impact the patient's prognosis and quality of life.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Carbohydrate Counting

SUBJECTIVE:,  This is a 62-year-old female who comes for dietary consultation for carbohydrate counting for type I diabetes.  The patient reports that she was hospitalized over the weekend for DKA.  She indicates that her blood sugar on Friday night was 187 at bedtime and that when she woke up in the morning her blood sugar was 477.  She gave herself, in smaller increments, a total of 70 extra units of her Humalog.  Ten of those units were injectable; the others were in the forms of pump.  Her blood sugar was over 600 when she went to the hospital later that day.  She is here at this consultation complaining of not feeling well still because she has a cold.  She realizes that this is likely because her immune system was so minimized in the hospital.,OBJECTIVE:,  Current insulin doses on her insulin pump are boluses set at 5 units at breakfast, 6 units at lunch and 11 units at supper.  Her basal rates have not been changed since her last visit with Charla Yassine and totaled 30.5 units per 24 hours.  A diet history was obtained.  I instructed the patient on carbohydrate counting at 1 unit of insulin for every 10 g carbohydrate ratio was recommended.  A correction dose of approximately 1 unit of insulin to bring the blood sugars down 30 mg/dl was also recommended.  The Lilly guide for meal planning was provided and reviewed.  Additional carbohydrate counting book was provided.,ASSESSMENT:,  The patient was taught an insulin-to-carbohydrate ratio of 1 unit to 10 g of carbohydrates as recommended at the previous visit two years ago, which she does not recall.  It is based on the 500 rule which suggests this ratio.  We did identify carbohydrate sources in the food supply, recognizing 15-g equivalents.  We also identified the need to dose her insulin at the time that she is eating her carbohydrate sources.  She does seem to have a pattern of fixing blood sugars later in the day after they are elevated.  We discussed the other option of trying to eat a consistent amount of carbohydrates at meals from day to day and taking a consistent amount of insulin at those meals.  With this in mind, she was recommended to follow with three servings or 45 g of carbohydrate at breakfast, three servings or 45 g of carbohydrate at lunch and four servings or 60 g of carbohydrate at dinner.  Joanne Araiza joined our consultation briefly to discuss whether her pump was working appropriately.  The patient was given an 800 number for the pump to contact should there be any question about its failure to deliver insulin appropriately.,PLAN:,  Recommend the patient use 1 unit of insulin for every 10-g carbohydrate load consumed.  Recommend the patient either use this as a carbohydrate counting tool or work harder at keeping carbohydrate content consistent at meals from day to day.  This was a one-hour consultation.  Provided my name and number should additional needs arise.
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DESCRIPTION: Dietary consultation for carbohydrate counting for type I diabetes.

soap / chart / progress notes, insulin pump, carbohydrate load, immune system, dietary consultation, carbohydrate ratio, blood sugars, carbohydrate counting, carbohydrate, dietary, blood, counting, insulin

The situation involves a patient with Type 1 diabetes who was recently hospitalized for diabetic ketoacidosis (DKA), a serious condition requiring medical intervention. Proper dietary management and insulin dosing are critical for preventing future episodes and maintaining the patient's health. The consultation involves teaching the patient to effectively manage carbohydrate intake and adjust insulin doses correctly—essential skills for diabetes management. Since the consequences of mismanagement can be severe, including hospital readmission or worse, this consultation carries significant stakes for the patient's health.


Medical Specialty: Surgery
Sample Name: Endoscopy With Biopsy

PROCEDURE:,  Upper endoscopy with biopsy.,PROCEDURE INDICATION: , This is a 44-year-old man who was admitted for coffee-ground emesis, which has been going on for the past several days.  An endoscopy is being done to evaluate for source of upper GI bleeding.,Informed consent was obtained.  Outlining the risks, benefits and alternatives of the procedure included, but not to risks of bleeding, infection, perforation, the patient agreed for the procedure.,MEDICATIONS: , Versed 4 mg IV push and fentanyl 75 mcg IV push given throughout the procedure in incremental fashion with careful monitoring of patient's pressures and vital signs.,PROCEDURE IN DETAIL:  ,The patient was placed in the left lateral decubitus position.  Medications were given.  After adequate sedation was achieved, the Olympus video endoscope was inserted into the mouth and advanced towards the duodenum.
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DESCRIPTION: Upper endoscopy with biopsy.   The patient admitted for coffee-ground emesis, which has been going on for the past several days.  An endoscopy is being done to evaluate for source of upper GI bleeding.

surgery, coffee-ground emesis, gi bleeding, upper endoscopy, iv push, esophagus, duodenum, mucosa, stomach, endoscopy, biopsy,

The situation involves a medical procedure that is necessary to evaluate an upper GI bleeding source, identified as coffee-ground emesis. This indicates a potential serious medical condition that needs timely diagnosis and possible treatment to prevent further complications. The patient consented after being informed of the risks, which includes bleeding, infection, and organ perforation. The procedure, while routine for medical professionals, carries intrinsic risks given the patient's symptoms and the need to accurately identify the cause of bleeding.


Medical Specialty: General Medicine
Sample Name: Cut on Foot - ER Visit

CHIEF COMPLAINT:,  Cut on foot.,HISTORY OF PRESENT ILLNESS:,  This is a 32-year-old male who had a piece of glass fall on to his right foot today.  The patient was concerned because of the amount of bleeding that occurred with it.  The bleeding has been stopped and the patient does not have any pain.  The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort.  The patient denies any injuries to any other portion of his body.  He has not had any recent illness.  The patient has no other problems or complaints.,PAST MEDICAL HISTORY:,  Asthma.,CURRENT MEDICATION: , Albuterol.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16.  Oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well-nourished, well-developed, the patient 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 conjunctiva and cornea bilaterally.  NECK:  Supple with full range of motion.  CARDIOVASCULAR:  Peripheral pulse is +2 to the right foot.  Capillary refills less than two seconds to all the digits of the right foot.  RESPIRATIONS:  No shortness of breath.  MUSCULOSKELETAL:  The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot.  There is no palpable foreign body, no foreign body is visualized.  There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels.  It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home.  The patient does not have any tenderness to the foot.  The patient has full range of motion to all the joints, all the toes, as well as the ankles.  The patient ambulates well without any difficulty or discomfort.  There are no other injuries noted to the rest of the body.  SKIN:  The 4-mm partial thickness laceration to the right foot as previously described.  No other injuries are noted.  NEUROLOGIC:  Motor is 5/5 to all the muscle groups of the right lower extremity.  Sensory is intact to light touch to all the dermatomes of the right foot.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No active bleeding is occurring at this time.  No evidence of bruising is noted to the body.,EMERGENCY DEPARTMENT COURSE:,  The patient had antibiotic ointment and a bandage applied to his foot.,DIAGNOSES:,1.  A 4-MM LACERATION TO THE RIGHT FOOT.,2.  ACUTE RIGHT FOOT PAIN, NOW RESOLVED.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  To home.  The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection.  The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on.
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DESCRIPTION: Patient had a piece of glass fall on to his right foot.  A 4-mm laceration.  Acute foot pain, now resolved.   The patient was given discharge instructions on wound care.

general medicine, foot pain, cut on foot, piece of glass, foreign body, active bleeding, foot, injuries, atraumatic, laceration, bleeding, body,

The situation described involves a 32-year-old male who sustained a 4-mm laceration from glass on his foot, leading to a brief emergency room visit. There was concern predominantly due to the bleeding. However, the bleeding was controlled, there were no signs of systemic infection or other complicating factors like foreign body retention that couldn't be managed at home with careful monitoring. The patient was stable, and the laceration was not associated with significant complications such as nerve or vascular damage. The condition was resolved enough to discharge the patient with instructions for self-care and follow-up if symptoms worsen. Generally, such cases are not considered high-stakes in emergency medicine unless there are complications or significant risk factors present, which are not indicated here.


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

Medical Specialty: Surgery
Sample Name: Thoracoabdominal Aneurysm

POSTOPERATIVE DIAGNOSIS: , Type 4 thoracoabdominal aneurysm.,OPERATION/PROCEDURE: , A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.,DESCRIPTION OF PROCEDURE IN DETAIL: , Patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube.  Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle.  The left groin, abdominal and chest were prepped and draped in a sterile fashion.  A thoracoabdominal incision was made.  The 8th interspace was entered.  The costal margin was divided.  The retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta.  The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm.  It was dissected free circumferentially.  The aortic bifurcation was dissected free, dissecting free both iliac arteries.  The left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 Prolene was placed on this.  The patient was heparinized.  Through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet.  This was hooked to a venous inflow of left heart bypass machine.  A pursestring of 4-0 Prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow.  Bypass was instituted.  The aneurysm was cross clamped just above T10 and also, cross clamped just below the diaphragm.  The area was divided at this point.  A 26-mm graft was then sutured in place with running 3-0 Prolene suture.  The graft was brought into the diaphragm.  Clamps were then placed on the iliacs, and the pump was shut off.  The aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation.  The SMA, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete Carrell patch.  The island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 Prolene suture with pledgetted 4-0 Prolene sutures around the circumference.  The clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels.  The graft was cut to fit the bifurcation and sutured in place with running 3-0 Prolene suture.  All clamps were removed, and flow was re-established.  An 8-mm graft was sutured end-to-end to the Carrell patch and to the left renal.  A partial-occlusion clamp was placed.  An area of graft was removed.  The end of the graft was cut to fit this and sutured in place with running Prolene suture.  The partial-occlusion clamp was removed.  Protamine was given.  Good hemostasis was noted.  The arterial cannula, of course, had been removed when that part of the aneurysm was removed.  The venous cannula was removed and oversewn with a 4-0 Prolene suture.  Good hemostasis was noted.  A 36 French posterior and a 32 French anterior chest tube were placed.  The ribs were closed with figure-of-eight #2 Vicryl.  The fascial layer was closed with running #1 Prolene, subcu with running 2-0 Dexon and the skin with running 4-0 Dexon subcuticular stitch.  Patient tolerated the procedure well.
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DESCRIPTION: A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.

surgery, dacron graft, thoracoabdominal, cerebrospinal, thoracoabdominal aneurysm, running prolene, prolene suture, dissected free, graft, interposition, aneurysm, dacron, cannula, bifurcation, aorta, endotracheal, proleneNOTE

The case involves a complex surgical procedure addressing a Type 4 thoracoabdominal aneurysm, which includes replacement with a 26-mm Dacron graft, re-implanting major arteries, and utilizing heart bypass. Such surgeries are inherently high-stakes due to the critical nature of the aorta, involvement of major abdominal and renal arteries, and the potential for severe complications if not executed properly. Postoperative management is also critical for patient recovery.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 17

FINAL DIAGNOSIS/REASON FOR ADMISSION:,1.  Acute right lobar pneumonia.,2.  Hypoxemia and hypotension secondary to acute right lobar pneumonia.,3.  Electrolyte abnormality with hyponatremia and hypokalemia - corrected.,4.  Elevated liver function tests, etiology undetermined.,5.  The patient has a history of moderate-to-severe dementia, Alzheimer's type.,6.  Anemia secondary to current illness and possible iron deficiency.,7.  Darkened mole on the scalp, status post skin biopsy, pending pathology report.,OPERATION AND PROCEDURE: , The patient underwent a scalp skin biopsy with pathology specimen obtained on 6/11/2009.  Dr. X performed the procedure, thoracentesis on 6/12/2009 both diagnostic and therapeutic.  Dr. Y's results pending.,DISPOSITION: , The patient discharged to long-term acute facility under the care of Dr. Z.,CONDITION ON DISCHARGE: , Clinically improved, however, requiring acute care.,CURRENT MEDICATIONS:  ,Include those on admission combined with IV Flagyl 500 mg every 8 hours and Levaquin 500 mg daily.,HOSPITAL SUMMARY: , This is one of several admissions for this 68-year-old female who over the initial 48 hours preceding admission had a complaint of low-grade fever, confusion, dizziness, and a nonproductive cough.  Her symptoms progressed and she presented to the emergency room at Brighton Gardens where a chest x-ray revealed evolving right lobar infiltrate.  She was started on antibiotics.  Infectious Disease was consulted.  She was initially begun on vancomycin.  Blood, sputum, and urine cultures were obtained; the results of which were negative for infection.  She was switched to IV Levaquin and received IV Flagyl for possible C. diff colitis as well as possible cholecystitis.  During her hospital stay, she initially was extremely relatively hypotensive with mild symptoms and she became dizzy with upright positioning.  Her systolic blood pressure was 60-70 mmHg despite rather aggressive IV fluid management up to 250 mL an hour.  She was seen in consultation by Dr. Y who monitored her fluid and pulmonary treatment.  Due to some elevated liver function tests, she was seen in consultation by Dr. X.  An ultrasound was negative; however, she did undergo CT scan of the chest and abdomen and there was a suspicion of fluid circling the gallbladder.  A HIDA scan was performed and revealed no evidence of gallbladder dysfunction.  Liver functions were monitored throughout her stay and while elevated, did reduce to approximately 1.5 times normal value.  She also was seen in consultation by Infectious Disease who followed her for several days and agreed with current management of antibiotics.  Over her week-stay, the patient was moderately hypoxemic with room air pulse oximetry of 90%.  She was placed on incentive spirometry and over the succeeding days, she did have improved pulmonary function.,LABORATORY TESTS: , Initially revealed a white count of 13,000, however, approximately 24 hours following admission her white count stabilized and in fact remained normal throughout her stay.  Blood cultures were negative at 5 days.  Sputum culture was negative.  Urine culture was negative and thoracentesis culture negative at 24 hours.  The patient did receive 2 units of packed red cells with the hemoglobin drop to 9 for cardiovascular support, as no evidence of GI bleeding was obtained.  Her most recent blood work on 6/14/2009 revealed a white count of 7000 and hemoglobin of 12.1 with a hematocrit of 36.8.  Her PT and PTT were normal.  Occult blood studies were negative for occult blood.  Hepatitis B antigen was negative.  Hepatitis A antibody IgM was negative.  Hepatitis B core IgM negative, and hepatitis C core antibody was negative.  At the time of discharge on 6/14/2009, sodium was 135, potassium was 3.7, calcium was 8.0, her ALT was 109, AST was 70, direct bilirubin was 0.2, LDH was 219, serum iron was 7, total iron unbound 183, and ferritin level was 267.,At the time of discharge, the patient had improved.  She complained of some back discomfort and lumbosacral back x-ray did reveal some evidence of mild degenerative disk disease with no obvious compression fracture acute noted and she will be followed by Dr. Z.
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DESCRIPTION: The patient underwent a scalp skin biopsy with pathology specimen obtained.   At the time of discharge, the patient had improved.

discharge summary, pneumonia, hypoxemia, hypotension, electrolyte abnormality, anemia, scalp skin biopsy, liver function tests, lobar pneumonia, infectious disease, skin biopsy, white count, cultures

The discharge summary indicates a complex medical situation with multiple diagnoses, including acute pneumonia leading to hypoxemia and hypotension, electrolyte imbalances, and elevated liver function tests. Additionally, the patient has a history of moderate-to-severe dementia, making her care more complicated. The involvement of multiple specialists and the fact that she is being discharged to a long-term acute care facility highlight the severity of her condition and the need for continued acute care. However, the patient is clinically improved, and her conditions are managed and monitored. This situation is high-stakes due to the complexity and seriousness of the medical conditions, the critical interventions required during the hospital stay, and the continuing need for acute care post-discharge.


Medical Specialty: Consult - History and Phy.
Sample Name: Gagging - 3-year-old

HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging.  She was doing well until about 2 days ago, when she developed gagging.  No vomiting.  No fever.  She has history of constipation.  She normally passes stool every two days after giving an enema.  No rectal bleeding.  She was brought to the Hospital with some loose stool.  She was found to be dehydrated.  She was given IV fluid bolus, but then she started bleeding from G-tube site.  There was some fresh blood coming out of the G-tube site.  She was transferred to PICU.  She is hypertensive.  Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007.  Right above knee amputation.,ALLERGIES:,  None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:,  Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000.  KUB showed large stool with dilated small and large bowel loops.  Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1.  Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000.  PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL:  She is intubated.,HEENT:  Atraumatic.  She is intubated.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Distended.  Decreased bowel sounds.,GENITALIA:  Grossly normal female.,CNS:  She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy.  She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN:  ,Plan is to give vitamin K, FFP, blood transfusion.  Consider upper endoscopy.  Procedure and informed consent discussed with the family.
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DESCRIPTION: Pediatric Gastroenterology - History of gagging.

consult - history and phy., g-tube, peho syndrome, tube site, gagging, constipation, endoscopy, peho, hemoglobin, hematocrit, intubated, bleeding, blood, fundoplication, tube,

The situation involves a 3-year-old patient with complex medical history, presenting with potentially serious symptoms like bleeding from G-tube site and coagulopathy, leading to sedation and transfer to PICU. These symptoms indicate possible acute deterioration, requiring immediate medical intervention including endoscopy and potential surgical procedures. Given the patient's young age, underlying conditions, and current severe symptoms, this situation is high-stakes as it involves significant risk to the patient's health and requires urgent and careful medical management.


Medical Specialty: Surgery
Sample Name: Orchiopexy - Bilateral

PREOPERATIVE DIAGNOSIS:  ,Bilateral undescended testes.,POSTOPERATIVE DIAGNOSIS: , Bilateral undescended testes.,OPERATION PERFORMED: , Bilateral orchiopexy.,ANESTHESIA: , General.,HISTORY: , This 8-year-old boy has been found to have a left inguinally situated undescended testes.  Ultrasound showed metastasis to be high in the left inguinal canal.  The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum.  Both testes appeared to be normal in size for the boy's age.,OPERATIVE FINDINGS: , As above, both testes appeared viable and normal in size, no masses.  There is a hernia on the left side.  The spermatic cord was quite short on the left and required Prentiss Maneuver to achieve adequate length for scrotal placement.,OPERATIVE PROCEDURE: , The boy was taken to the operating room, where he was placed on the operating table.  General anesthesia was administered by Dr. X, after which the boy's lower abdomen and genitalia were prepared with Betadine and draped aseptically.  A 0.25% Marcaine was infiltrated subcutaneously in the skin crease in the left groin in the area of the intended incision.  An inguinal incision was then made through this area, carried through the subcutaneous tissues to the anterior fascia.  External ring was exposed with dissection as well.  The fascia was opened in direction of its fibers exposing the testes, which lay high in the canal.  The testes were freed with dissection by removing cremasteric and spermatic fascia.  The hernia sac was separated from the cord, twisted and suture ligated at the internal ring.  Lateral investing bands of the spermatic cords were divided high into the inguinal internal ring.  However, this would only allow placement of the testes in the upper scrotum with some tension.,Therefore, the left inguinal canal was incised and the inferior epigastric artery and vein were ligated with #4-0 Vicryl and divided.  This maneuver allowed for placement of the testes in the upper scrotum without tension.,A sub dartos pouch was created by separating the abdominal fascia from the scrotal skin after making an incision in the left hemiscrotum in the direction of the vessel.  The testes were then brought into the pouch and anchored with interrupted #4-0 Vicryl sutures.  The skin was approximated with interrupted #5-0 chromic catgut sutures.  Inspection of the spermatic cord in the inguinal area revealed no twisting and the testicular cover was good.  Internal oblique muscle was approximated to the shelving edge and Poupart ligament with interrupted #4-0 Vicryl over the spermatic cord and the external oblique fascia was closed with running #4-0 Vicryl suture.  Additional 7 mL of Marcaine was infiltrated subfascially and the skin was closed with running #5-0 subcuticular after placing several #4-0 Vicryl approximating sutures in the subcutaneous tissues.,Attention was then turned to the opposite side, where an orchiopexy was performed in a similar fashion.  However, on this side, there was no inguinal hernia.  The testes were located in a superficial pouch of the inguinal canal and there was adequate length on the spermatic cord, so that the Prentiss maneuver was not required on this side.  The sub dartos pouch was created in a similar fashion and the wounds were closed similarly as well.,The inguinal and scrotal incisions were cleansed after completion of the procedure.  Steri-Strips and Tegaderm were applied to the inguinal incisions and collodion to the scrotal incision.  The child was then awakened and transported to post-anesthetic recovery area apparently in satisfactory condition.  Instrument and sponge counts were correct.  There were no apparent complications.  Estimated blood loss was less than 20 to 30 mL.
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DESCRIPTION: Bilateral orchiopexy.  This 8-year-old boy has been found to have a left inguinally situated undescended testes.  Ultrasound showed metastasis to be high in the left inguinal canal.  The right testis is located in the right inguinal canal on ultrasound and apparently ultrasound could not be displaced into the right hemiscrotum.

surgery, bilateral orchiopexy, bilateral undescended testes, prentiss maneuver, subcutaneous tissues, internal ring, dartos pouch, scrotal incisions, undescended testes, spermatic cord, inguinal canal, testes, inguinally, orchiopexy, undescended, cord, vicryl, ultrasound, spermatic, canal,

The surgical procedure described, bilateral orchiopexy, is fairly common in pediatric urology/surgery for correcting undescended testes. The procedure is important for preventing future complications like infertility or potential testicular cancer. However, given the detailed operative findings and the fact that the surgery was completed without complications, with minimal blood loss, it suggests this is a routine and controlled situation rather than a high-stakes one. The stakes do increase slightly because the patient is a child and the importance of preserving reproductive and hormonal health. Nonetheless, the successful report without complications keeps it moderate in stakes.