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

Medical Specialty: Surgery
Sample Name: Laparoscopic Appendectomy - 4

PREOPERATIVE DIAGNOSIS:,  Acute appendicitis with perforation.,POSTOPERATIVE DIAGNOSIS:  ,Acute appendicitis with perforation.,ANESTHESIA:,  General.,PROCEDURE: , Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old little boy, who has been sick for several days and was seen in our Emergency Department yesterday where a diagnosis of possible constipation was made, but he was sent home with a prescription for polyethylene glycol but became more acutely ill and returned today with tachycardia, high fever and signs of peritonitis.  A CT scan of his abdomen showed evidence of appendicitis with perforation.  He was evaluated in the Emergency Department and placed on the appendicitis critical pathway for this acute appendicitis process.  He required several boluses of fluid for tachycardia and evidence of dehydration.,I met with Carlos' parents and talked to them about the diagnosis of appendicis and surgical risks, benefits, and alternative treatment options.  All their questions have been answered and they agree with the surgical plan.,OPERATIVE FINDINGS: , The patient had acute perforated appendicitis with diffuse suppurative peritonitis including multiple intraloop abscesses and purulent debris in all quadrants of the abdomen including the perihepatic and subphrenic recesses as well.,DESCRIPTION OF PROCEDURE: , The patient came to the operating room and had an uneventful induction of general anesthesia.  A Foley catheter was placed for decompression, and his abdomen was prepared and draped in a standard fashion.  A 0.25% Marcaine was infiltrated in the soft tissues around his umbilicus and in the suprapubic and left lower quadrant locations chosen for trocar insertion.  We conducted our surgical timeout and reiterated all of Carlos' unique and important identifying information and confirmed the diagnosis of appendicitis and planned laparoscopic appendectomy as the procedure.  A 1-cm vertical infraumbilical incision was made and an open technique was used to place a 12-mm Step trocar through the umbilical fascia.  CO2 was insufflated to a pressure of 15 mmHg and then two additional 5-mm working ports were placed in areas that had been previously anesthetized.,There was a lot of diffuse purulent debris and adhesions between the omentum and adjacent surfaces of the bowel and the parietal peritoneum.  After these were gently separated, we began to identify the appendix.  In the __________ due to the large amount of small bowel dilatation and distension, I used the hook cautery with the lowest intraperitoneal __________ profile to coagulate the mesoappendix.  The base of the appendix was then ligated with 2-0 PDS Endoloops, and the appendix was amputated and withdrawn through the umbilical port.  I spent the next 10 minutes irrigating purulent fluid and debris from the peritoneal cavity using 2 L of sterile crystalloid solution and a suction power irrigation system.  When this was complete, the CO2 was released one final time and as much of the fluid was drained from the peritoneal cavity as possible.  The umbilical fascia was closed with figure-of-eight suture of 0 Monocryl and the skin incisions were closed with subcuticular 5-0 Monocryl and Steri-Strips.  The patient tolerated the operation well.  He was awakened and taken to the recovery room in satisfactory condition.  His blood loss was less than 10 mL, and he received only crystalloid fluid during the procedure.
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DESCRIPTION: Acute appendicitis with perforation.  Laparoscopic appendectomy.   A CT scan of abdomen showed evidence of appendicitis with perforation.

surgery, adhesions, peritoneum, purulent debris, umbilical fascia, peritoneal cavity, laparoscopic appendectomy, appendectomy, constipation, purulent, debris, umbilical, appendix, abdomen, laparoscopic, perforation, appendicitis,

The situation involves a complex surgical procedure on a 4-year-old child with acute perforated appendicitis and diffuse suppurative peritonitis. The stakes are high due to the child's young age, the risk of sepsis from the perforation, the rapid deterioration of the child's condition, and the intricacy of the necessary laparoscopic procedure. Additionally, the involvement of multiple abcesses and purulent debris increases surgical complexity and risk. Successful surgery is crucial for the child's immediate health and recovery, making this a high-stakes situation.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Obstetrics / Gynecology
Sample Name: Needle Localized Excision - Breast Neoplasm

PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED:  ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS:  ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast.  After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity.  This too was excised.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room, placed in supine position in the operating table.  Intravenous sedation was administered by the Anesthesia Department.  The Kopans wire was trimmed to an appropriate length.  The patient was sterilely prepped and draped in the usual manner.  Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision.  A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire.  The wire was stabilized and brought to protrude through the incision.  Skin flaps were then generated with electrocautery.  A generous core tissue was grasped with Allis forceps and excised with electrocautery.  Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short.  The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along.  The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.,The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm.  On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen.  Hemostasis was obtained with electrocautery.  Good hemostasis was obtained.  The incision was closed in two layers.  The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl.  The second layer consisted of Steri-Strips on the epidermis.  A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied.  The patient tolerated the surgery well.
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DESCRIPTION: Nonpalpable neoplasm, right breast.  Needle localized wide excision of nonpalpable neoplasm, right breast.

obstetrics / gynecology, neoplasm, needle localized wide excision, needle localized, nonpalpable neoplasm, needle, incision, electrocautery, excision, breast

The procedure described is a needle localized wide excision for a nonpalpable breast neoplasm, which involves surgical intervention for a condition that could potentially be malignant. The stakes are relatively high because the outcome can significantly impact the patient’s health, especially if the neoplasm is cancerous. The deferral of the diagnosis for pathology adds further tension, as the final outcome is not immediately known, impacting treatment decisions. These factors contribute a significant level of seriousness to the situation.


Medical Specialty: Neurosurgery
Sample Name: Lumbar Puncture - 2

PROCEDURE PERFORMED:,  Lumbar puncture.,The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form.  Alternatives were explained.  They agreed to proceed with the lumbar puncture.  Permit was signed and is on the chart.  The indication was to rule out toxoplasmosis or any other CNS infection. ,DESCRIPTION: , The area was prepped and draped in a sterile fashion.  Lidocaine 1% of 5 mL was applied to the L3-L4 spinal space after the area had been prepped with Betadine three times.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.  The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.,COMPLICATIONS:,  None.  The patient was resting comfortably and tolerated the procedure well.,ESTIMATED BLOOD LOSS: , None.,DISPOSITION: , The patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact.  Labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,The opening pressure was 292, the closing pressure was 190.
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DESCRIPTION: Lumbar puncture.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.

neurosurgery, spinal needle, lumbar puncture, lumbar, gauge, csf

The procedure described is a lumbar puncture, which is an invasive medical procedure but is generally considered low-risk when performed correctly. It is often done to diagnose or rule out central nervous system infections, like toxoplasmosis in this case. The stakes are higher than everyday activities or non-invasive procedures due to potential complications such as infection or bleeding; however, complications in this specific case were noted as none. Therefore, while there is a baseline level of risk involved with any spinal procedure, the lack of complications and the successful outcome as described suggest a moderate level of stakes overall.


Medical Specialty: Surgery
Sample Name: Heart Cath & Coronary Angiography

PROCEDURE PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,ANESTHESIA: , 1% lidocaine and IV sedation, including fentanyl 25 mcg.,INDICATION: , The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.  It was accompanied by diaphoresis and shortness of breath.  The patient was felt to be a candidate for mitral valve repair versus mitral valve replacement and underwent a stress test as part of his evaluation for chest pain.  He underwent adenosine Cardiolite, which revealed 2 mm ST segment depression in leads II, III aVF, and V3, V4, and V5.  Stress images revealed left ventricular dilatations suggestive of multivessel disease.  He is undergoing evaluation today as a part of preoperative evaluation and because of the positive stress test.,PROCEDURE: , After risks, benefits, alternatives of the above mentioned procedure were explained to the patient in detail, informed consent was obtained both verbally and writing.  The patient was taken to the Cardiac Catheterization Laboratory where the procedure was performed.  The right inguinal area was sterilely cleansed with a 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 obtained, a thin-walled Argon needle was used to cannulate the right femoral artery.,The guidewire was then advanced through the lumen of the needle without resistance and a small nick was made in the skin.  The needle was removed and a pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed and the sheath was flushed.  A Judkins left #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with the use of the guidewire.  The guidewire was removed and the catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged and limited evaluation was performed after noticing that the patient had a significant left main coronary artery stenosis.  The catheter was withdrawn from the ostium of the left main coronary artery and the guidewire was inserted through the tip of the catheter.  The catheter was removed over guidewire and a Judkins right #4 catheter was advanced to the ascending aorta under direct fluoroscopic visualization with use of a guidewire.  The guidewire was removed and the catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was carefully engaged and using hand injections of nonionic contrast material, the right coronary artery was evaluated in both diagonal views.  This catheter was removed.  The sheath was flushed the final time.  The patient was taken to the postcatheterization holding area in stable condition.,FINDINGS:,LEFT MAIN CORONARY ARTERY:,  This vessel is seen to be heavily calcified throughout its course.  Begins as a moderate caliber vessel.  There is a 60% stenosis in the distal portion with extension of the lesion to the ostium and proximal portions of the left anterior descending and left circumflex coronary artery.,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  This vessel is heavily calcified in its proximal portion.  It is of moderate caliber and seen post anteriorly in the intraventricular groove and wraps around the apex.  There is a 90% stenosis in the proximal portion and 90% ostial stenosis in the first and second anterolateral branches.  There is sequential 80% and 90% stenosis in the mid-portion of the vessel.  Otherwise, the LAD is seen to be diffusely diseased.,LEFT CIRCUMFLEX CORONARY ARTERY:  ,This vessel is also calcified in its proximal portion.  There is a greater than 90% ostial stenosis, which appears to be an extension of the lesion in the left main coronary artery.  There is a greater than 70% stenosis in the proximal portion of the first large obtuse marginal branch, otherwise, the circumflex system is seen to be diffusely diseased.,RIGHT CORONARY ARTERY: , This is a large caliber vessel and is the dominant system.  There is diffuse luminal irregularities throughout the vessel and a 80% to 90% stenosis at the bifurcation above the posterior descending artery and posterolateral branch.,IMPRESSION:,1.  Three-vessel coronary artery disease as described above.,2.  Moderate mitral regurgitation per TEE.,3.  Status post venous vein stripping of the left lower extremity and varicosities in both lower extremities.,4.  Long-standing history of phlebitis.,PLAN: , Consultation will be obtained with Cardiovascular and Thoracic Surgery for CABG and mitral valve repair versus replacement.
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DESCRIPTION: Left heart catheterization and bilateral selective coronary angiography.   The patient is a 65-year-old male with known moderate mitral regurgitation with partial flail of the P2 and P3 gallops who underwent outpatient evaluation for increasingly severed decreased functional capacity and retrosternal chest pain that was aggravated by exertion and decreased with rest.

surgery, left heart catheterization, bilateral selective coronary angiography, regurgitation, gallops, diaphoresis, shortness of breath, coronary angiography, proximal portions, catheterization, artery, coronary, bilateral, selective, angiography, mitral, stenosis, vessel, guidewire,

The procedure involves evaluating a patient with significant and advanced cardiac conditions, including three-vessel coronary artery disease, severe stenoses, and mitral regurgitation. The findings have immediate implications for surgical intervention, specifically CABG (coronary artery bypass graft) and mitral valve repair or replacement, which are high-risk surgeries due to the patient's condition and complexity of the diseases involved. The outcome of these procedures can significantly impact the patient's health and longevity, indicating a high-stakes situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Hip Fracture - Rehab Consult

ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay.  He had left hip fracture identified on x-rays at that time.  Pain and inability to ambulate brought him in.  He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia.  His medical issues are under good control.  The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03.  The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension.  Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy.  He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation.  Remote history of subdural hematoma precluding the use of Coumadin.  History of depression, panic attacks on Doxepin.  Perioperative anemia.  Swallowing difficulties.,ALLERGIES:,  Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1.  Heparin.,2.  Albuterol inhaler.,3.  Combivent.,4.  Aldactone.,5.  Doxepin.,6.  Xanax.,7.  Aspirin.,8.  Amiodarone.,9.  Tegretol.,10.  Synthroid.,11.  Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there.  Speech and language pathology following with current swallowing dysfunction.  He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:,  Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT:  Oropharynx clear.,CV:  Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended.  Bowel sounds positive.,EXTREMITIES:  Without clubbing, cyanosis, or edema.,NEUROLOGIC:  There are no focal motor or sensory losses to the lower extremities.  Bulk and tone normal in the lower extremities.  Wound site has healed well with staples out.,IMPRESSION ,1.  Status post left hip fracture and hemiarthroplasty.,2.  History of panic attack, anxiety, depression.,3.  Myocardial infarction with stent placement.,4.  Hypertension.,5.  Hypothyroidism.,6.  Subdural hematoma.,7.  Seizures.,8.  History of chronic obstructive pulmonary disease.  Recent respiratory insufficiency.,9.  Renal insufficiency.,10.  Recent pneumonia.,11.  O2 requiring.,12.  Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared.
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DESCRIPTION: Status post left hip fracture and hemiarthroplasty.   Rehab transfer as soon as medically cleared.

This situation involves a 70-year-old patient with multiple complex medical conditions being managed post-hip fracture and surgery. The patient has a significant medical history including congestive heart failure, chronic renal insufficiency, and recent pneumonia, among others. While the patient's current status seems stable and ready for rehab transfer, the complexity and multitude of the medical issues, combined with the patient's age, make this a relatively high-stakes situation. Proper management is crucial to prevent complications and ensure successful rehabilitation.


Medical Specialty: Consult - History and Phy.
Sample Name: School Physical - 2

CHIEF COMPLAINT:,  Well-child check and school physical.,HISTORY OF PRESENT ILLNESS:,  This is a 9-year-old African-American male here with his mother for a well-child check.  Mother has no concerns at the time of the visit.  She states he had a pretty good school year.  He still has some fine motor issues, especially writing, but he is receiving help with that and math.  He continues to eat well.  He could do better with milk intake, but Mother states he does eat cheese and yogurt.  He brushes his teeth daily.  He has regular dental visits every six months.  Bowel movements are without problems.  He is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors.,DEVELOPMENTAL ASSESSMENT:,  Social:  He has a sense of humor.  He knows his rules.  He does home chores.  Fine motor:  He is as mentioned before.  He can draw a person with six parts.  Language:  He can tell time.  He knows the days of the week.  He reads for pleasure.  Gross motor:  He plays active games.  He can ride a bicycle.,REVIEW OF SYSTEMS:,  He has had no fever and no vision problems.  He had an eye exam recently with Dr. Crum.  He has had some headaches which precipitated his vision exam.  No earache or sore throat.  No cough, shortness of breath or wheezing.  No stomachache, vomiting or diarrhea.  No dysuria, urgency or frequency.  No excessive bleeding or bruising.,MEDICATIONS:,  No daily medications.,ALLERGIES:,  Cefzil.,IMMUNIZATIONS:,  His immunizations are up to date.,PHYSICAL EXAMINATION:,General:  He is alert and in no distress, afebrile.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  TMs are clear bilaterally.  Nares:  Patent.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Tanner III.,Extremities:  Symmetrical.  Femoral pulses 2+ bilaterally.  Full range of motion of all extremities.,Back:  No scoliosis.,Neurological:  Grossly intact.,Skin:  Normal turgor.  No rashes.,Hearing:  Grossly normal.,ASSESSMENT:,  Well child.,PLAN:,  Anticipatory guidance for age.  He is to return to the office in one year.
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DESCRIPTION: Well-child check and school physical.

Well-child check and school physical.

The situation is a routine well-child check-up and school physical for a 9-year-old boy, which is generally not considered high-stakes. The child is healthy, with no significant medical concerns, and is receiving assistance where needed, such as with fine motor skills and math. The areas of concern, like behavior issues, are being monitored, and there are no acute medical issues present. Routine check-ups are important but do not typically involve immediate health risks or urgent medical interventions.


Medical Specialty: Discharge Summary
Sample Name: Occupational Therapy Discharge Summary

DIAGNOSES: , Traumatic brain injury, cervical musculoskeletal strain.,DISCHARGE SUMMARY: , The patient was seen for evaluation on 12/11/06 followed by 2 treatment sessions.  Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion, strength, and coordination; functional mobility training; self-care training; cognitive retraining; caregiver instruction; and home exercise program.  Goals were not achieved, as the patient was admitted to inpatient rehabilitation center.,RECOMMENDATIONS: , Discharged from OT this date, as the patient has been admitted to Inpatient Rehabilitation Center.,Thank you for this referral.
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DESCRIPTION: Occupational therapy discharge summary.  Traumatic brain injury, cervical musculoskeletal strain.

discharge summary, musculoskeletal strain, occupational therapy, traumatic, brain, cervical, musculoskeletal, rehabilitation,

The discharge summary describes the patient's transition from outpatient to inpatient care due to a traumatic brain injury and cervical musculoskeletal strain. Although the immediate stakes for the occupational therapy discharge are not critical (as the patient is already receiving further care), the underlying conditions themselves are serious. However, since this is a standard procedural summary and the patient has been moved to an appropriate care setting, the stakes of the summary itself are moderate.


Medical Specialty: Surgery
Sample Name: TAH & BSO

PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Dysmenorrhea.,3.  Dyspareunia.,4.  Endometriosis.,5.  Enlarged uterus.,6.  Menorrhagia.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Dysmenorrhea.,3.  Dyspareunia.,4.  Endometriosis.,5.  Enlarged uterus.,6.  Menorrhagia.,PROCEDURE: , Total abdominal hysterectomy and bilateral salpingo-oophorectomy.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,DRAINS: , Foley.,ANESTHESIA:,  General.,This 28-year-old white female who presented to undergo TAH-BSO secondary to chronic pelvic pain and a diagnosis of endometriosis.,At the time of the procedure, once entering into the abdominal cavity, there was no gross evidence of abnormalities of the uterus, ovaries or fallopian tube.  All endometriosis had been identified laparoscopically from a previous surgery.  At the time of the surgery, all the tissue was quite thick and difficult to cut as well around the bladder flap and the uterus itself.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed in supine position, at which time general form of anesthesia was administered by the anesthesia department.  The patient was then prepped and draped in the usual fashion for a low transverse incision.  Approximately two fingerbreadths above the pubic symphysis, a first knife was used to make a low transverse incision.  This was extended down to the level of the fascia.  The fascia was nicked in the center and extended in a transverse fashion.  The edges of the fascia were grasped with Kocher.  Both blunt and sharp dissection both caudally and cephalic was then completed consistent with Pfannenstiel technique.  The abdominal rectus muscle was divided in the midline and extended in a vertical fashion.  Perineum was entered at the high point and extended in a vertical fashion as well.  An O'Connor-O'Sullivan retractor was put in place on either side.  A bladder blade was put in place as well.  Uterus was grasped with a double-tooth tenaculum and large and small colon were packed away cephalically and held in place with free wet lap packs and a superior blade.  The bladder flap was released with Metzenbaum scissors and then dissected away caudally.  EndoGIA were placed down both sides of the uterus in two bites on each side with the staples reinforced with a medium Endoclip.  Two Heaney were placed on either side of the uterus at the level of cardinal ligaments.  These were sharply incised and both pedicles were tied off with 1 Vicryl suture.  Two _____ were placed from either side of the uterus at the level just inferior to the cervix across the superior part of the vaginal vault.  A long sharp knife was used to transect the uterus at the level of Merz forceps and the uterus and cervix were removed intact.  From there, the corners of the vaginal cuff were reinforced with figure-of-eight stitches.  Betadine soaked sponge was placed in the vaginal vault and a continuous locking stitch of 0 Vicryl was used to re-approximate the edges with a second layer used to reinforce the first.  Bladder flap was created with the use of 3-0 Vicryl and Gelfoam was placed underneath.  The EndoGIA was used to transect both the fallopian tube and ovaries at the infundibulopelvic ligament and each one was reinforced with medium clips.  The entire area was then re-peritonized and copious amounts of saline were used to irrigate the pelvic cavity.  Once this was completed, Gelfoam was placed into the cul-de-sac and the O'Connor-O'Sullivan retractor was removed as well as all the wet lap pack.  Edges of the peritoneum were grasped in 3 quadrants with hemostat and a continuous locking stitch of 2-0 Vicryl was used to re-approximate the peritoneum as well as abdominal rectus muscle.  The edges of the fascia were grasped at both corners and a continuous locking stitch of 1 Vicryl was used to re-approximate the fascia with overlapping in the center.  The subcutaneous tissue was irrigated.  Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the tissue and the skin edges were re-approximated with sterile staples.  Sterile dressing was applied and Betadine soaked sponge was removed from the vaginal vault and the vaginal vault was wiped clean of any remaining blood.  The patient was taken to recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.
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DESCRIPTION: Total abdominal hysterectomy and bilateral salpingo-oophorectomy.

surgery, tah, bso, total abdominal hysterectomy, bilateral salpingo-oophorectomy, hysterectomy, pelvic pai, dysmenorrhea, dyspareunia, endometriosis, uterus, menorrhagia, betadine soaked sponge, bladder flap, vaginal vault, abdominal, fascia, rectus,

The described situation involves a surgical procedure, specifically a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO). Surgical procedures are generally high-stakes due to potential risks such as infection, bleeding, and complications from anesthesia. The patient's conditions such as chronic pelvic pain and endometriosis also contribute to the seriousness of the situation. Although the procedure was completed successfully with stable condition reported post-operatively, the inherent risks involved in surgery justify a high-stakes rating.


Medical Specialty: Pain Management
Sample Name: Lumbar Epidural Steroid Injection - 2

PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE: , Lumbar epidural steroid injection, L5-S1.,ANESTHESIA: , Local.,SPECIAL EQUIPMENT: , Fluoroscopic unit.,DETAILS OF PROCEDURE: , The patient was taken to the Radiology Suite and was placed in the prone position where the entire back region was scrubbed, prepped, and draped in a sterile fashion with Betadine solution.  The lumbar area was then draped with sterile towels and sterile drapes.  The surgeon was gloved with sterile gloves and mask in order to create a sterile environment for the epidural injection.  The fluoroscopy x-ray unit was then brought into the sterile field for a PA x-ray visualization of the spine.  A Steinmann pin was then placed across the spine to localize the level of the planned injection.  Local infiltration using 0.5% preservative-free Xylocaine via a 25-gauge needle was then placed into the dermis and subcutaneous tissue.  A Tuohy needle was then oriented perpendicular to the skin and was then advanced through the dermis and subcutaneous tissues.  Continuous injection of 0.5% preservative-free Xylocaine was used during the advancement of the Tuohy needle into the deeper spinous tissues.  A solution of 80 mg of Depo-Medrol with 2 cc of 1% Xylocaine injectable and 5 cc of normal saline were then injected into the epidural space.
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DESCRIPTION: Lumbar epidural steroid injection, L5-S1.  Low back pain.

pain management, back pain, lumbar epidural steroid injection, tuohy needle, steroid injection, subcutaneous, epidural, steroid, lumbar, sterile, injection

The described situation involves a lumbar epidural steroid injection procedure for treating low back pain. While this is a routine medical procedure, it involves specific steps that require precision and adherence to sterile techniques to prevent infection and complications. However, it is considered a low to moderate-risk procedure in medical practice, and not life-threatening if performed correctly. The stakes depend on accurately performing the procedure to avoid complications such as infection or nerve damage.


Medical Specialty: Consult - History and Phy.
Sample Name: Weight Gain and Edema

HISTORY OF PRESENT ILLNESS:,  This is a 55-year-old female with a history of I-131-induced hypothyroidism years ago who presents with increased weight and edema over the last few weeks with a 25-pound weight gain.  She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.  She has noticed increasing abdominal girth as well as increasing edema in her legs.  She has been on Norvasc and lisinopril for years for hypertension.  She has occasional sweats with no significant change in her bowel status.  She takes her thyroid hormone apart from her Synthroid.  She had been on generic for the last few months and has had difficulty with this in the past.,MEDICATIONS: , Include levothyroxine 300 mcg daily, albuterol, Asacol, and Prilosec.  Her amlodipine and lisinopril are on hold.,ALLERGIES:,  Include IV DYE, SULFA, NSAIDS, COMPAZINE, and DEMEROL.,PAST MEDICAL HISTORY:,  As above includes I-131-induced hypothyroidism, inflammatory bowel disease with Crohn, hypertension, fibromyalgia, COPD, and disc disease.,PAST SURGICAL HISTORY: , Includes a hysterectomy and a cholecystectomy.,SOCIAL HISTORY: , She does not smoke or drink alcohol.,FAMILY HISTORY: , Positive for thyroid disease but the sister has Graves disease, as well a sister with Hashimoto thyroiditis.,REVIEW OF SYSTEMS: , Positive for fatigue, sweats, and weight gain of 20 pounds.  Denies chest pain or palpitations.  She has some loosening stools, but denies abdominal pain.  Complains of increasing girth and increasing leg swelling.,PHYSICAL EXAMINATION:,GENERAL:  She is an obese female.,VITAL SIGNS:  Blood pressure 140/70 and heart rate 84.  She is afebrile.,HEENT:  She has no periorbital edema.  Extraocular movements were intact.  There was moist oral mucosa.,NECK:  Supple.  Her thyroid gland is atrophic and nontender.,CHEST:  Good air entry.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Benign.,EXTREMITIES:  Showed 1+ edema.,NEUROLOGIC:  She was awake and alert.,LABORATORY DATA:,  TSH 0.28, free T4 1.34, total T4 12.4 and glucose 105.,IMPRESSION/PLAN:,  This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  Hypothyroidism is secondary to radioactive iodine for Graves disease many years ago.  She is clinically and biochemically euthyroid.  Her TSH is mildly suppressed, but her free T4 is normal and with her weight gain I will not decrease her dose of levothyroxine.  I will continue on 300 mcg daily of Synthroid.  If she wanted to lose significant weight, I shall repeat thyroid function test in six weeks' time to ensure that she is not hyperthyroid.
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DESCRIPTION: This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism.  She also has a history of fibromyalgia, inflammatory bowel disease, Crohn disease, COPD, and disc disease as well as thyroid disorder.

The patient's situation involves a long list of medical conditions, including hypothyroidism, inflammatory bowel disease, COPD, and others, accompanied by recent weight gain and edema. While the patient's condition is not immediately life-threatening, it is complex due to multiple comorbidities which require careful management to prevent complications. Ensuring proper medication management and monitoring are critical to avoid exacerbating existing conditions or causing new complications.


Medical Specialty: Orthopedic
Sample Name: Laminectomy & Foraminotomy Followup

REASON FOR VISIT:,  Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC returns today for followup status post L4-L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion on 06/08/07.,Preoperatively, her symptoms, those of left lower extremity are radicular pain.,She had not improved immediately postoperatively.  She had a medial breech of a right L4 pedicle screw.  We took her back to the operating room same night and reinserted the screw.  Postoperatively, her pain had improved.,I had last seen her on 06/28/07 at which time she was doing well.  She had symptoms of what she thought was "restless leg syndrome" at that time.  She has been put on ReQuip for this.,She returned.  I had spoken to her 2 days ago and she had stated that her right lower extremity pain was markedly improved.  I had previously evaluated this for a pain possibly relating to deep venous thrombosis and ultrasound was negative.  She states that she had recurrent left lower extremity pain, which was similar to the pain she had preoperatively but in a different distribution, further down the leg.  Thus, I referred her for a lumbar spine radiograph and lumbar spine MRI and she presents today for evaluation.,She states that overall, she is improved compared to preoperatively.  She is ambulating better than she was preoperatively.  The pain is not as severe as it was preoperatively.  The right leg pain is improved.  The left lower extremity pain is in a left L4 and L5 distribution radiating to the great toe and first web space on the left side.,She denies any significant low back pain.  No right lower extremity symptoms.,No infectious symptoms whatsoever.  No fever, chills, chest pain, shortness of breath.  No drainage from the wound.  No difficulties with the incision.,FINDINGS:  ,On examination, Ms. ABC is a pleasant, well-developed, well-nourished female in no apparent distress.  Alert and oriented x 3.  Normocephalic, atraumatic.  Respirations are normal and nonlabored.  Afebrile to touch.,Left tibialis anterior strength is 3 out of 5, extensor hallucis strength is 2 out of 5.  Gastroc-soleus strength is 3 to 4 out of 5.  This has all been changed compared to preoperatively.  Motor strength is otherwise 4 plus out of 5.  Light touch sensation decreased along the medial aspect of the left foot.  Straight leg raise test normal bilaterally.,The incision is well healed.  There is no fluctuance or fullness with the incision whatsoever.  No drainage.,Radiographs obtained today demonstrate pedicle screw placement at L4 and L5 bilaterally without evidence of malposition or change in orientation of the screws.,Lumbar spine MRI performed on 07/03/07 is also reviewed.,It demonstrates evidence of adequate decompression at L4 and L5.  There is a moderate size subcutaneous fluid collection seen, which does not appear compressive and may be compatible with normal postoperative fluid collection, especially given the fact that she had a revision surgery performed.,ASSESSMENT AND PLAN:  ,Ms. ABC is doing relatively well status post L4 and L5 laminectomy and bilateral foraminotomies, and posterior spinal fusion with instrumentation on 07/08/07.  The case is significant for merely misdirected right L4 pedicle screw, which was reoriented with subsequent resolution of symptoms.,I am uncertain with regard to the etiology of the symptoms.  However, it does appear that the radiographs demonstrate appropriate positioning of the instrumentation, no hardware shift, and the MRI demonstrates only a postoperative suprafascial fluid collection.  I do not see any indication for another surgery at this time.,I would also like to hold off on an interventional pain management given the presence of the fluid collection to decrease the risk of infection.,My recommendation at this time is that the patient is to continue with mobilization.  I have reassured her that her spine appears stable at this time.  She is happy with this.,I would like her to continue ambulating as much as possible.  She can go ahead and continue with ReQuip for the restless leg syndrome as her primary care physician has suggested.  I have also her referred to Mrs. Khan at Physical Medicine and Rehabilitation for continued aggressive management.,I will see her back in followup in 3 to 4 weeks to make sure that she continues to improve.  She knows that if she has any difficulties, she may follow up with me sooner.
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DESCRIPTION: Followup status post L4-L5 laminectomy and bilateral foraminotomies, and L4-L5 posterior spinal fusion with instrumentation.

orthopedic, spinal fusion, restless leg syndrome, posterior spinal fusion, pedicle screw, lumbar spine, bilateral foraminotomies, fluid collection, foraminotomy, instrumentation, laminectomy, screw, spine,

The situation is a follow-up appointment after a surgical procedure, specifically an L4-L5 laminectomy and bilateral foraminotomies with spinal fusion. The patient is showing overall improvement with some lingering symptoms. The stakes include ensuring the recovery is on track and monitoring for complications like infection or hardware issues. The patient's background indicates potential past complications, such as a misdirected pedicle screw that required immediate correction. While the stakes involve patient well-being and the avoidance of further interventions, the current management plan suggests that no immediate high-risk issues are present since surgery or further invasive measures are not required immediately. Therefore, while important for the patient's recovery, it does not represent a crisis or critical high-stakes situation at this moment.


Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy - 5

MEDICATIONS:,1.  Versed intravenously.,2.  Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent, the patient was placed in the left lateral decubitus position and Cetacaine spray was applied to the posterior pharynx.  The patient was sedated with the above medications.  The Olympus video panendoscope was advanced under direct vision into the esophagus.  The esophagus was normal in appearance and configuration.  The gastroesophageal junction was normal.  The scope was advanced into the stomach, where the fundic pool was aspirated and the stomach was insufflated with air.  The gastric mucosa appeared normal.  The pylorus was normal.  The scope was advanced through the pylorus into the duodenal bulb, which was normal, then into the second part of the duodenum, which was normal as well.  The scope was pulled back into the stomach.  Retroflexed view showed a normal incisura, lesser curvature, cardia and fundus.  The scope was straightened out, the air removed and the scope withdrawn.  The patient tolerated the procedure well.  There were no apparent complications.,
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DESCRIPTION: Esophagogastroduodenoscopy.  The Olympus video panendoscope was advanced under direct vision into the esophagus.  The esophagus was normal in appearance and configuration.  The gastroesophageal junction was normal.

surgery, duodenal bulb, gastric mucosa, olympus video, video panendoscope, gastroesophageal junction, esophagogastroduodenoscopy, gastroesophageal, pylorus, stomach, esophagus, scopeNOTE

The procedure described is an Esophagogastroduodenoscopy (EGD), which is generally a routine diagnostic procedure used to examine the lining of the esophagus, stomach, and first part of the small intestine. It involves minimal risk and is commonly performed with sedation. The document states that the patient tolerated the procedure well and there were no complications, indicating a successful and uneventful procedure. Therefore, although surgical procedures inherently carry some level of risk, this specific case seems to involve low-stakes due to the routine nature and successful outcome.


Medical Specialty: General Medicine
Sample Name: Normal Male Exam Template

MULTISYSTEM EXAM,CONSTITUTIONAL:  ,The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES:  ,The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT:  ,The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK:  ,The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR:  ,Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,GASTROINTESTINAL: , The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU: , The scrotal elements were normal.  The testes were without discrete mass.  The penis showed no lesion, no discharge.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN: , Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC:  ,Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC: , The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.
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DESCRIPTION: Sample/template for a normal male multisystem exam.

general medicine, within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue,

The situation involves the documentation of a standard physical exam for a patient in general medicine. It is a routine checkup with normal findings and no immediate concerns or abnormalities noted. Given the routine nature of the physical exam and absence of any critical issues, the stakes are quite low.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 48

HISTORY:,  The patient presents today for medical management.  The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity.  Stomach gets upset with pain.  She has been off her supplements for four weeks with some improvement.  She has loose bowel movements.  She complains of no bladder control.  She has pain in her hips.  The peripheral neuropathy is in both legs, her swelling has increased and headaches in the back of her head.,DIAGNOSES:,1.  Type II diabetes mellitus.,2.  Generalized fatigue and weakness.,3.  Hypertension.,4.  Peripheral neuropathy with atypical symptoms.,5.  Hypothyroidism.,6.  Depression.,7.  Long-term use of high-risk medications.,8.  Postmenopausal age-related symptoms.,9.  Abdominal pain with nonspecific irritable bowel type symptoms, intermittent diarrhea.,CURRENT MEDICATIONS: , Her list of medicines is as noted on 04/22/03.  There is a morning and evening lift.,PAST SURGICAL HISTORY:,  As listed on 04/22/04 along with allergies 04/22/04.,FAMILY HISTORY: , Basically unchanged.  Her father died of an MI at 65, mother died of a stroke at 70.  She has a brother, healthy.,SOCIAL HISTORY:  ,She has two sons and an adopted daughter.  She is married long term, retired from Avon.  She is a nonsmoker, nondrinker.,REVIEW OF SYSTEMS:,GENERAL:  Certainly at the present time on general exam no fever, sweats or chills and no significant weight change.  She is 189 pounds currently and she was 188 pounds in January.,HEENT:  HEENT, there is no marked decrease in visual or auditory function.  ENT, there is no change in hearing or epistaxis, sore throat or hoarseness.,RESPIRATORY:  Chest, there is no history of palpitations, PND or orthopnea.  The chest pains are nonspecific, tenderness to palpation has been reported.  There is no wheezing or cough reported.,CARDIOVASCULAR:  No PND or orthopnea.  Thromboembolic disease history.,GASTROINTESTINAL:  Intermittent symptoms of stomach pain, they are nonspecific.  No nausea or vomiting noted.  Diarrhea is episodic and more related to nerves.,GENITOURINARY:  She reports there is generally poor bladder control, no marked dysuria, hematuria or history of stones.,MUSCULOSKELETAL:  Peripheral neuropathy and generalized muscle pain, joint pain that are sporadic.,NEUROLOGICAL:  No marked paralysis, paresis or paresthesias.,SKIN:  No rashes, itching or changes in the nails.,BREASTS:  No report of any lumps or masses.,HEMATOLOGY AND IMMUNE:  No bruising or bleeding-type symptoms.,PHYSICAL EXAMINATION:,WEIGHT:  189 pounds.  BP:  140/80.  PULSE:  76.  RESPIRATIONS:  20.  GENERAL APPEARANCE:  Well developed, well nourished.  No acute distress.,HEENT:  Head is normocephalic.  Ears, nose, and throat, normal conjunctivae.  Pupils are reactive.  Ear canals are patent.  TMs are normal.  Nose, nares patent.  Septum midline.  Oral mucosa is normal in appearance.  No tonsillar lesions, exudate or asymmetry.  Neck, adequate range of motion.  No thyromegaly or adenopathy.,CHEST:  Symmetric with clear lungs clear to auscultation and percussion.,HEART:  Rate and rhythm is regular.  S1 and S2 audible.  No appreciable murmur or gallop.,ABDOMEN:  Soft.  No masses, guarding, rigidity, tenderness or flank pain.,GU:  No examined.,EXTREMITIES:  No cyanosis, clubbing or edema currently.,SKIN AND INTEGUMENTS:  Intact.  No lesions or rashes.,NEUROLOGIC:  Nonfocal to cranial nerve testing II through XII, motor, sensory, gait and random motion.,Additional information, the patient has been off metformin for few months and this is not part of her medication list.,IMPRESSION:,
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DESCRIPTION: The patient presents to the office today with complaints of extreme fatigue, discomfort in the chest and the back that is not related to any specific activity.  Stomach gets upset with pain.

The patient presents with multiple chronic health conditions including Type II diabetes, hypertension, hypothyroidism, depression, and peripheral neuropathy, all of which could significantly impact their quality of life and require careful management. Additionally, the presence of symptoms like extreme fatigue, chest discomfort, poor bladder control, and stomach pain add to the complexity of the case and suggest a need for comprehensive evaluation and adjustment of treatment plans. While the patient is not in immediate life-threatening distress, the cumulative nature of these conditions and symptoms indicates a moderately high-stakes scenario due to the potential for worsening health or complications if improperly managed.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Female Exam Template - 2

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

consult - history and phy., heent, general appearance, hepatosplenomegaly, mass, tenderness, rebound, rigidity, pulse, bruit, adenopathy, chest, percussion, inspection, palpation, signs, tongue,

The provided situation is a template for a routine female physical exam, with no immediate health concerns or abnormalities noted. It serves as a documentation guide for medical practitioners and does not involve any urgent health decisions or high-risk implications. Therefore, it is low-stakes.


Medical Specialty: Endocrinology
Sample Name: Post Hemithyroidectomy

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

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

The case involves a surgical procedure for a patient with papillary thyroid carcinoma, which is high-stakes due to the complexity and potential complications of the surgery. The procedure involves hemithyroidectomy and parathyroid reimplantation, which requires precision and expertise, particularly to avoid damage to the laryngeal nerves and ensure the proper function of remaining parathyroid tissue. While the postoperative condition of the patient is stable, the stakes remain high considering the patient's cancer diagnosis and the potential long-term implications of thyroid function and cancer treatment. However, given that there were no complications and the procedure went as planned, the immediate stakes may be considered controlled.


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

Medical Specialty: Surgery
Sample Name: Frontotemporoparietal Craniotomy

PREOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,POSTOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,OPERATION PERFORMED:  ,Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma.,ANESTHESIA: , General endotracheal.,PREPARATION: , Povidone.,INDICATION:,  This is an 83-year-old male with herniation syndrome with large subdural hematoma 100%.  This procedure is being done as an emergency procedure in an attempt to save his life and maximize the potential for recovery.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room intubated.  The patient previously was given fresh frozen plasma plus recombinant activated factor VII.  The patient had a roll placed on his right shoulder, head was maintained three point fixation with a Mayfield headholder.  The right side of the head was shaved, thoroughly prepped and draped, a large ? scalp incision was marked, infiltrated with local and incised with a scalpel, Raney clips were applied to the scalp margins, hemostasis, temporalis muscle and fascia, pericranium opened and aligned with incision, flap was reflected anteriorly.  Burr holes are placed low in the temporal bone at the keyhole posteriorly and then superiorly with a perforator, then using Midas Rex drill with a B1 foot plate a free flap was turned.  The dura was opened in a cruciate fashion, acute subdural hematoma was evacuated.  There was a small arterial bleeder in the anterior parietal region, which was controlled with bipolar electrocautery.  Using suction and biopsy forceps, acute clot was resected from the frontotemporoparietal and occipital poles, subdural space was irrigated, no further bleeders were encountered.  Dura was closed with 4-0 Nurolon.  A subdural Camino ICP catheter was placed in the subdural space.  Bone flaps secured in place with neuro clips with 5 mm screws, central pack up suture was placed, dural tack up sutures were placed using 4-0 Nurolon prior to placement of the bone flap.  The wound was irrigated with saline, temporalis muscle and fascia closed with 2-0 Vicryl, subgaleal Hemovac was placed, galea was closed with 2-0 Vicryl, and scalp with staples.  ICP monitor and the Hemovac were sutured in place with 2-0 Vicryl.  The patient was taken out of the head holder, a sterile dressing placed.  The head was wrapped.  The patient was taken directly to ICU, still intubated in guarded condition.  Brain was nicely soft and pulsatile.  At the termination of the procedure, no significant contusion of the brain was identified.  Final sponge and needle counts are correct.  Estimated blood loss 400 cc.
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DESCRIPTION: Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma.   Acute subdural hematoma, right, with herniation syndrome.

surgery, subdural hematoma, craniotomy, herniation, subdural, temporalis, frontotemporoparietal, hematoma,

The situation described involves an emergency surgical procedure to address an acute subdural hematoma with herniation syndrome, performed on an 83-year-old patient. The severity of the condition, the urgency of the procedure to save the patient's life, and the fact that the patient was taken directly to ICU in a guarded condition indicate a very high-stakes medical scenario. Additionally, brain surgeries carry significant risks and potential complications.


Medical Specialty: Surgery
Sample Name: Epididymectomy

EPIDIDYMECTOMY,OPERATIVE NOTE:  ,The patient was placed in the supine position and prepped and draped in the usual manner.  A transverse scrotal incision was made and carried down to the tunica vaginalis, which was opened.  A small amount of clear fluid was expressed.  The tunica vaginalis was opened and the testicle was brought out through this incision.  The epididymis was separated off the surface of the testicle using a scalpel.  With blunt and sharp dissection, the epididymis was dissected off the testicle.  Bovie was used for hemostasis.  The vessels going to the testicle were preserved without any obvious injury, and a nice viable testicle was present after the epididymis was removed from this.  The blood supply to the epididymis was cauterized using a Bovie and the vas was divided with cautery also.  There was no obvious bleeding.  The cord was infiltrated with 0.25% Marcaine, as was the dartos tissue in the scrotum.  The testicle was replaced in the scrotum.  Skin was closed in two layers using 3-0 chromic catgut for the dartos and a subcuticular closure with the same material.  A dry sterile dressing and compression were applied, and he was sent to the recovery room in stable condition.
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DESCRIPTION: Epididymectomy

Epididymectomy

surgery, scrotal incision, 0.25% marcaine, bovie, epididymectomy, chromic catgut, epididymis, fluid, scalpel, scrotum, sterile dressing, testicle, tunica vaginalisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

This situation involves the surgical procedure of an epididymectomy, which is a procedure to remove the epididymis from the testicle. While it is a significant surgical procedure, it is considered a routine operation within the scope of urological surgeries and does not typically involve life-threatening complications if performed correctly. The stakes here are related to the surgical competence and postoperative recovery, rather than an immediate risk to life. However, as with any surgery, there are inherent risks such as infection or injury to the testicle or surrounding structures. Nonetheless, these risks are generally well-managed within standard medical practice.


Medical Specialty: ENT - Otolaryngology
Sample Name: Tympanostomy & Myringotomy Tube Placement

PREOPERATIVE DIAGNOSES:,1.  Chronic otitis media with effusion.,2.  Conductive hearing loss.,POSTOPERATIVE DIAGNOSES:,1.  Chronic otitis media with effusion.,2.  Conductive hearing loss.,PROCEDURE PERFORMED: , Bilateral tympanostomy with myringotomy tube placement _______ split tube 1.0 mm.,ANESTHESIA:  ,Total IV general mask airway.,ESTIMATED BLOOD LOSS:  ,None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:,  The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy.  After risks, complications, consequences, and questions were addressed with the family, a written consent was obtained for the procedure.,PROCEDURE:,  The patient was brought to the operative suite by Anesthesia.  The patient was placed on the operating table in supine position.  After this, the patient was then placed under general mask airway and the patient's head was then turned to the left.,The Zeiss operative microscope and medium-sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to #5 suction.  After this, the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma.  A myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a #5 suction demonstrating dry contents.  A _____ split tube 1.0 mm was then placed in the myringotomy incision utilizing a alligator forcep.  Cortisporin Otic drops were placed followed by cotton balls.  Attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed.  The external auditory canal was removed off of its cerumen with a #5 suction which led to the direct visualization of the tympanic membrane.  The tympanic membrane appeared with no signs of retraction pockets, cholesteatoma or air fluid levels.  A myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1.0 mm was then placed with an alligator forcep.  After this, the patient had Cortisporin Otic drops followed by cotton balls placed.  The patient was then turned back to Anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well.  The patient will be followed up approximately in one week and was sent home with a prescription for Ciloxan ear drops to be used as directed and with instructions not to get any water in the ears.
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DESCRIPTION: Bilateral tympanostomy with myringotomy tube placement.    The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy.

ent - otolaryngology, chronic otitis media with effusion, conductive hearing loss, bilateral tympanostomy, myringotomy tube placement, cortisporin otic drops, otitis media, tympanostomy, tympanic, membrane, otitis, media, effusion, conductive, hearing, ear, tube, myringotomy

This is a surgical procedure involving a 1-year-old patient, which naturally adds to the seriousness due to the age of the patient and the involvement of general anesthesia. The surgery is considered routine and low-risk, particularly without complications or blood loss reported. The stakes are not negligible due to the necessity of addressing the child's hearing issues and the use of general anesthesia, but they are not as high as a complex or life-threatening operation.


Medical Specialty: Neurology
Sample Name: MRI Brain - Lyme Disease

FINDINGS:,There is a large intrasellar mass lesion producing diffuse expansion of the sella turcica. This mass lesions measures approximately 16 x 18 x 18mm (craniocaudal x AP x mediolateral) in size.
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DESCRIPTION: A middle-aged male with increasing memory loss and history of Lyme disease.

neurology, increasing memory loss, intrasellar mass lesion, memory loss, sella turcica, cavernous sinus, sphenoid sinus, ct imaging, white matter, retention cyst, maxillary antrum, lyme disease, mass lesion, disease, cavernous, cortical, mass, lesion,

The findings indicate a large intrasellar mass, which could potentially compress or affect critical structures in the brain (e.g., the pituitary gland or optic chiasm). Given this mass in a middle-aged male with increasing memory loss and history of Lyme disease, it suggests a possibly serious neurological condition or secondary complication that requires urgent evaluation and possibly surgical intervention. The implications for brain function and quality of life are significant.


Medical Specialty: Radiology
Sample Name: AVM with Hemorrhage

CC:, Headache.,HX:, 63 y/o RHF first seen by Neurology on 9/14/71 for complaint of episodic vertigo. During that evaluation she described a several year history of "migraine" headaches. She experienced her first episode of vertigo in 1969. The vertigo (clockwise) typically began suddenly after lying down, and was not associated with nausea/vomiting/headache. The vertigo had not been consistently associated with positional change and could last hours to days.,On 3/15/71, after 5 day bout of vertigo, right ear ache, and difficulty ambulating (secondary to the vertigo) she sought medical attention and underwent an audiogram which reportedly showed a 20% decline in low tone acuity AD. She complained of associated tinnitus which she described as a "whistle." In addition, her symptoms appeared to worsen with changes in head position (i.e. looking up or down). The symptoms gradually resolved and she did well until 8/71 when she experienced a 19-day episode of vertigo, tinnitus and intermittent headaches. She was seen 9/14/71, in Neurology, and admitted for evaluation.,Her neurologic exam at that time was unremarkable except for prominent bilateral systolic carotid bruits. Cerebral angiogram revealed an inoperable 7 x 6cm AVM in the right parietal region. The AVM was primarily fed by the right MCA. Otolaryngologic evaluation concluded that she probably also suffered from Meniere's disease.,On 10/14/74 she underwent a 21 day admission for SAH secondary to right parietal AVM.,On 11/23/91 she was admitted for left sided weakness (LUE > LLE), headache, and transient visual change. Neurological exam confirmed left sided weakness, and dysesthesia of the LUE only. Brain CT confirmed a 3 x 4 cm left parietal hemorrhage. She underwent unsuccessful embolization. Neuroradiology had planned to do 3 separate embolizations, but during the first, via the left MCA, they were unable to cannulate many of the AVM vessels and abandoned the procedure. She recovered with residual left hemisensory loss.,In 12/92 she presented with an interventricular hemorrhage and was managed conservatively and refused any future neuroradiologic intervention.,In 1/93 she reconsidered neurointerventional procedure and was scheduled for evaluation at the Barrows Neurological Institute in Phoenix, AZ.
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DESCRIPTION: MRI - Arteriovenous malformation with hemorrhage.

radiology, arteriovenous malformation, avm, brain ct, cerebral angiogram, headache, neurology, audiogram, carotid bruits, difficulty ambulating, hemorrhage, interventricular hemorrhage, migraine, tinnitus, vertigo, visual change, weakness, episode of vertigo, evaluation,

The situation described involves the management and treatment of a patient with a diagnosed arteriovenous malformation (AVM) and associated hemorrhages, which are high-risk medical conditions. AVMs can lead to serious complications such as life-threatening hemorrhages or neurological deficits. The history of attempted embolization procedures and consideration of further interventions at a specialized neurological institute further highlights the complexity and seriousness of the situation. The stakes are high due to the potential for severe neurological outcomes and the need for specialized treatment.


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

PREOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,POSTOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.  In addition to this, he had a large herniated disk at C3-C4 in the midline.,PROCEDURE: , Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.,PROCEDURE IN DETAIL: , The patient placed in the supine position, the neck was prepped and draped in the usual fashion.  Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4.  Skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially.  The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4-C5.  It appeared that the C5-C6 disk area had fused spontaneously.  We then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at C3-C4, C4-C5.,After placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at C3-C4, C4-C5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,Next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation.  We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments.  This was then removed with 2-mm Kerrison rongeur.  After we removed the posterior longitudinal ligament, we could see the dura pulsating nicely.  We did foraminotomies at C3-C4 as well as C4-C5 as well.  After having totally decompressed both the cord as well as the nerve roots of C3-C4, C4-C5, we proceeded to the next step, which was a fusion.,We sized two 8-mm cortical cancellous grafts and after distracting the bone at C3-C4, C4-C5, we gently tapped the grafts into place.  The distraction was removed and the grafts were now within.  We went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,We then placed a titanium ABC plate from C3-C5, secured it with 16-mm titanium screws.  X-rays showed good position of the screws end plate.,The next step was to place Jackson-Pratt drain to the vertebral fascia.  Meticulous hemostasis was obtained.  The wound was closed in layers using 2-0 Vicryl for the subcutaneous tissue.  Steri-Strips were used for skin closure.  Blood loss less than about 200 mL.  No complications of the surgery.  Needle counts, sponge count, and cottonoid count was correct.
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DESCRIPTION: Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.

surgery, titanium plates fixation, bone black bone procedure, anterior cervical discectomy, titanium plates, cervical discectomy, spondylotic myelopathy, cord compression, cervical spondylosis, foraminotomies, cervical, anterior

The procedure described is an anterior cervical discectomy and fusion (ACDF) which is a significant surgical intervention for treating severe conditions affecting the cervical spine, such as cervical spondylotic myelopathy with cord compression. This surgery involves the removal of herniated or degenerative discs in the neck region, followed by spinal fusion to stabilize the affected area. The stakes are high because the spinal cord is involved, and there is a potential for serious complications, including neurological deficits, if anything goes wrong. The patient's condition is such that it involves compression of the spinal cord, which is serious and requires skillful surgical intervention to prevent further neurological impairment. As such, this is a high-stakes situation.


Medical Specialty: Surgery
Sample Name: Phalanx Amputation

PREOPERATIVE DIAGNOSIS:,  Osteomyelitis, right hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, right hallux.,PROCEDURE PERFORMED:,  Amputation distal phalanx and partial proximal phalanx, right hallux.,ANESTHESIA:,  TIVA/local.,HISTORY:,  This 44-year-old male patient was admitted to ABCD General Hospital on 09/02/2003 with a diagnosis of osteomyelitis of the right hallux and cellulitis of the right lower extremity.  The patient has a history of diabetes and has had a chronic ulceration to the right hallux and has been on outpatient antibiotics, which he failed.  The patient after a multiple conservative treatments such as wound care antibiotics, the patient was given the option of amputation as a treatment for the chronic resistant osteomyelitis.  The patient desires to attempt a surgical correction.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X.  The consent was available on the chart for review.,PROCEDURE IN DETAIL: , After patient was taken to the operating room via cart and placed on the operating table in the supine position, a safety strap was placed across his waist.  Adequate IV sedation was administered by the Department of Anesthesia and a total of 3.5 cc of 1:1 mixture 1% lidocaine and 0.5% Marcaine plain were injected into the right hallux as a digital block.  The foot was prepped and draped in the usual aseptic fashion lowering the operative field.,Attention was directed to the hallux where there was a full-thickness ulceration to the distal tip of the hallux measuring 0.5 cm x 0.5 cm.  There was a ________ tract, which probed through the distal phalanx and along the sides of the proximal phalanx laterally.  The toe was 2.5 times to the normal size.  There were superficial ulcerations in the medial arch of both feet secondary to history of a burn, which were not infected.  The patient had dorsalis pedis and posterior tibial pulses that were found to be +2/4 bilaterally preoperatively.  X-ray revealed complete distraction of the distal phalanx and questionable distraction of the lateral aspect of the proximal phalanx.  A #10 blade was used to make an incision down the bone in a transverse fashion just proximal to the head of the proximal phalanx.  The incision was carried mediolaterally and plantarly encompassing the toe leaving a large amount of plantar skin intact.  Next, the distal phalanx was disarticulated at the interphalangeal joint and removed.  The distal toe was amputated and sent to laboratory for bone culture and sensitivity as well as tissue pathology.  Next, the head of the proximal phalanx was inspected and found to be soft on the distal lateral portion as suspected.  Therefore, a sagittal saw was used to resect approximately 0.75 cm of the distal aspect of head of the proximal phalanx.  This bone was also sent off for culture and was labeled proximal margin.  Next, the flexor hallucis longus tendon was identified and retracted as far as possible distally and transected.  The flexor tendon distally was gray discolored and was not viable.  A hemostat was used to inspect the flexor sheath to ensure no infection tracking up the sheath proximally.  None was found.  No purulent drainage or abscess was found.  The proximal margin of the surgical site tissue was viable and healthy.  There was no malodor.  Anaerobic and aerobic cultures were taken and passed this as a specimen to microbiology.  Next, copious amounts of gentamicin and impregnated saline were instilled into the wound.,A #3-0 Vicryl was used to reapproximate the deep subcutaneous layer to release skin tension.  The plantar flap was viable and was debulked with Metzenbaum scissors.  The flap was folded dorsally and reapproximated carefully with #3-0 nylon with a combination of simple interrupted and vertical mattress sutures.  Iris scissors were used to modify and remodel the plantar flap.  An excellent cosmetic result was achieved.  No tourniquet was used in this case.  The patient tolerated the above anesthesia and surgery without apparent complications.  A standard postoperative dressing was applied consisting of saline-soaked Owen silk, 4x4s, Kerlix, and Coban.  The patient was transported via cart to Postanesthesia Care Unit with vital signs able and vascular status intact to right foot.  He will be readmitted to Dr. Katzman where we will continue to monitor his blood pressure and regulate his medications.  Plan is to continue the antibiotics until further IV recommendations.,He will be nonweightbearing to the right foot and use crutches.  He will elevate his right foot and rest the foot, keep it clean and dry.  He is to follow up with Dr. X on Monday or Tuesday of next week.
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DESCRIPTION: Amputation distal phalanx and partial proximal phalanx, right hallux.   Osteomyelitis, right hallux.

surgery, osteomyelitis, phalanx, phalanx amputation, proximal margin, plantar flap, distal phalanx, proximal phalanx, proximal, hallux, amputation, foot, plantarly, distal

The case involves a surgical procedure for a patient with osteomyelitis of the right hallux, a condition that can lead to severe complications if left untreated, especially in a patient with diabetes. While the surgery itself seems routine and was completed without complications, the stakes are high because the procedure aims to address a chronic and resistant infection. The patient's diabetes adds significant risk to both the progression of the infection and the potential for postoperative complications, elevating the stakes of the procedure. However, given that the operation was a planned, elective surgery with informed consent and a clear postoperative plan, it is not as high-stakes as an emergency procedure but still involves moderate to high risk.


Medical Specialty: Consult - History and Phy.
Sample Name: Cardiac Consultation

HISTORY OF PRESENT ILLNESS: , The patient is a 71-year-old woman with history of coronary artery disease for which she has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1.  She also has a significant history of chronic renal insufficiency and severe COPD.  The patient and her husband live in ABC but they have family in XYZ.  She came to our office today as she is in the area visiting her family.  She complains of having shortness of breath for the past month that has been increasingly getting worse.  She developed a frequent nonproductive cough about 2 weeks ago.  She has also had episodes of paroxysmal nocturnal dyspnea, awaking in the middle of the night, panicking from dyspnea and shortness of breath.  She has also gained about 15 pounds in the past few months and has significant peripheral edema.  In the office, she is obviously dyspnea and speaking in 2 to 3 word sentences.,PAST MEDICAL HISTORY: , Coronary artery disease, anemia secondary to chronic renal insufficiency, stage IV chronic kidney disease, diabetic nephropathy, hypertension, hyperlipidemia, COPD, insulin-dependent diabetes, mild mitral valve regurgitation, severe tricuspid valve regurgitation, sick sinus syndrome, gastritis, and heparin-induced thrombocytopenia.,PAST SURGICAL HISTORY: , Status post pacemaker implantation, status post CABG x4 in 1999 and status post CABG x2 in 2003, status post PCA stenting x1 to the left anterior descending artery, cholecystectomy, back surgery, bladder surgery, and colonic polypectomies.,SOCIAL HISTORY:  ,The patient is married.  Lives with her husband.  They are retired from ABC.,MEDICATIONS:,1.  Plavix 75 mg p.o. daily.,2.  Aspirin 81 mg p.o. daily.,3.  Isosorbide mononitrate 60 mg p.o. daily.,4.  Colace 100 mg p.o. b.i.d.,5.  Atenolol 50 mg p.o. daily.,6.  Lantus insulin 15 units subcutaneously every evening.,7.  Protonix 40 mg p.o. daily.,8.  Furosemide 40 mg p.o. daily.,9.  Norvasc 5 mg p.o. daily.,ALLERGIES: , SHE IS ALLERGIC TO HEPARIN AGENTS, WHICH CAUSE HEPARIN-INDUCED THROMBOCYTOPENIA.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Positive for generalized fatigue and malaise.,HEAD AND NECK:  Negative for diplopia, blurred vision, visual disturbances, hearing loss, tinnitus, epistaxis, vertigo, sinusitis, and gum or oral lesions.,CARDIOVASCULAR:  Positive for epigastric discomfort x2 weeks, negative for palpitations, syncope or near-syncopal episodes, chest pressure, and chest pain.,RESPIRATORY:  Positive for dyspnea at rest, paroxysmal nocturnal dyspnea, orthopnea, and frequent nonproductive cough.  Negative for wheezing.,ABDOMEN:  Negative for abdominal pain, bloating, nausea, vomiting, constipation, melena, or hematemesis.,GENITOURINARY:  Negative for dysuria, polyuria, hematuria, or incontinence.,MUSCULOSKELETAL:  Negative for recent trauma, stiffness, deformities, muscular weakness, or atrophy.,SKIN:  Negative for rashes, petechiae, and hair or nail changes.  Positive for easy bruising on forearms.,NEUROLOGIC:  Negative for paralysis, paresthesias, dysphagia, or dysarthria.,PSYCHIATRIC:  Negative for depression, anxiety, or mood swings.,All other systems reviewed are negative.,PHYSICAL EXAMINATION,VITAL SIGNS:  Her blood pressure in the office was 188/94, heart rate 70, respiratory rate 18 to 20, and saturations 99% on room air.  Her height is 63 inches.  She is weighs 195 pounds and her BMI is 34.6.,CONSTITUTIONAL:  A 71-year-old woman in significant distress from shortness of breath and dyspnea at rest.,HEENT:  Eyes:  Pupils are reactive.  Sclera is nonicteric.  Ears, nose, mouth, and throat.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.  Swallow is intact.,CARDIOVASCULAR:  Positive JVD at 45 degrees.  Heart tones are distant.  S1 and S2.  No murmurs.,EXTREMITIES:  Have 3+ edema in the feet and ankles bilaterally that extends up to her knees.  Femoral pulses are weakly palpable.  Posterior tibial pulses are not palpable.  Capillary refill is somewhat sluggish.,RESPIRATORY:  Breath sounds are clear with some bilateral basilar diminishment.  No rales and no wheezing.  Speaking in 2 to 3 word sentences.  Diaphragmatic excursions are limited.  AP diameter is expanded.,ABDOMEN:  Soft and nontender.  Active bowel sounds x4 quadrants.  No hepatosplenomegaly.  No masses are appreciated.,GENITOURINARY:  Deferred.,MUSCULOSKELETAL:  Adequate range of motion along with extremities.,SKIN:  Warm and dry.  No lesions or ulcerations are noted.,NEUROLOGIC:  Alert and oriented x3.  Head is normocephalic and atraumatic.  No focal, motor, or sensory deficits.,PSYCHIATRIC:  Normal affect.,IMPRESSION,1.  Coronary artery disease.
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DESCRIPTION: A woman with history of coronary artery disease, has had coronary artery bypass grafting x2 and percutaneous coronary intervention with stenting x1.  She also has a significant history of chronic renal insufficiency and severe COPD.

The patient in question is presenting with multiple severe and potentially life-threatening medical conditions including coronary artery disease, chronic renal insufficiency, and severe COPD. She also has a history of significant cardiac interventions and an array of complex co-morbid conditions. Currently, she is experiencing worsening shortness of breath, significant peripheral edema, and paroxysmal nocturnal dyspnea, which could represent acute heart failure or another urgent cardiac or pulmonary condition. She is in physical distress as evidenced by speaking in 2-3 word sentences and is exhibiting signs of potential heart failure (e.g., JVD, significant edema). Her high blood pressure also poses additional risks. Given her extensive medical history, current symptoms, and the risk of acute exacerbation of her conditions, this is a high-stakes medical situation requiring immediate and careful management by healthcare professionals.


Medical Specialty: Consult - History and Phy.
Sample Name: T-Cell Lymphoma Consult

CHIEF COMPLAINT: , Newly diagnosed T-cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago.  He was originally treated with antibiotics as a possible tooth abscess.  Prior to this event, in March of 2010, he was treated for strep throat.  The pain at that time was on the right side.  About a month ago, he started having night sweats.  The patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked.  All these symptoms were preceded by overwhelming fatigue and exhaustion.  He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home.  With the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable.  He also reports occasional headaches with some stabbing and pain in his feet and legs.  He also complains of some left groin pain.,PAST MEDICAL HISTORY: , Significant for HIV diagnosed in 2000.  He also had mononucleosis at that time.  The patient reports being on anti-hepatitis viral therapy period that was very intense.  He took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells.  He reports no other history of transfusions.  He has history of spontaneous pneumothorax.  The first episode was 1989 on his right lung.  In 1990 he had a slow collapse of the left lung.  He reports no other history of pneumothoraces.  In 2003, he had shingles.  He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy.,FAMILY HISTORY: , Notable for his mother who is currently battling non-small cell lung cancer.  She is a nonsmoker.  His sister is Epstein-Barr virus positive.  The patient's mother also reports that she is Epstein-Barr virus positive.  His maternal grandfather died from complications from melanoma.  His mother also has diabetes.,SOCIAL HISTORY: , The patient is single.  He currently lives with his mother in house for several both in New York and here in Colorado.  His mother moved out to Colorado eight years ago and he has been out here for seven years.  He currently is self employed and does antiquing.  He has also worked as nurses' aide and worked in group home for the state of New York for the developmentally delayed.  He is homosexual, currently not sexually active.  He does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day.  He does not use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , As mentioned above his weight has been fairly stable.  Although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years.  He has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath.  He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck.  He has had fevers as well.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:
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DESCRIPTION: Newly diagnosed T-cell lymphoma.  The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago.

consult - history and phy., t-cell lymphoma, submandibular, tooth abscess, strep throat, submandibular region, lymphoma, neck,

The patient has been diagnosed with T-cell lymphoma, a type of cancer, which inherently makes this a high-stakes situation. The history of HIV and significant past medical issues such as a profound anemia history and spontaneous pneumothorax add complexity and severity. The patient is experiencing specific symptoms that align with systemic lymphoma symptoms, like night sweats and fatigue, which could indicate disease progression or complications. Considering the existing serious medical conditions, the implications of lymphoma, and the need for immediate and effective treatment and management, this case is high-stakes in terms of both health risk and treatment urgency.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy & Polypectomy - 1

PREOPERATIVE DIAGNOSIS:,  History of colitis.,POSTOPERATIVE DIAGNOSIS: , Small left colon polyp.,PROCEDURE PERFORMED: , Total colonoscopy and polypectomy.,ANESTHESIA:,  IV Versed 8 mg and 175 mcg of IV fentanyl.,CLINICAL HISTORY: , This patient had a tough time with colitis 10 years ago and has intermittent problems with bleeding.  He has been admitted to the hospital now for colonoscopy and polyp surveillance.,PROCEDURE:  ,The patient was prepped and draped in a left lateral decubitus position.  The flexible 165 cm CF video Olympus colonoscope was inserted through the anus and passed under TV-directed monitor through the area of the rectum, sigmoid colon, left colon, transverse colon, right colon, and cecum.  He had an excellent prep.  He had a 2-3 mm polyp in the left colon that was removed with a jumbo biopsy forceps.  He tolerated the procedure well.  There was no other evidence of any cancer, growth, tumor, colitis, or problems throughout the entire colon.  His exam that he had in 1997 showed a small amount of colitis at that time and he has had some intermittent symptoms since.  Representative pictures were taken throughout the entire exam.  There was no other evidence any problems.  On withdrawal of the scope, the same findings were noted.,FINAL IMPRESSION: , Small, left colon polyp in a patient with intermittent colitis-like symptoms and bleeding.
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DESCRIPTION: Total colonoscopy and polypectomy

Total colonoscopy and polypectomy

gastroenterology, anus, lateral decubitus position, colon, colonoscopy and polypectomy, total colonoscopy, colon polyp, colonoscopy, bleeding, colitis, polypectomy, intermittent,

The situation involves a routine colonoscopy and polypectomy based on the provided information. While the patient has a history of colitis and intermittent bleeding, the procedure was conducted without complications and no evidence of cancer or other significant issues was found. Colonoscopies and polypectomies, although important for cancer prevention and management of conditions like colitis, are common and routine procedures. Consequently, there are no immediate high-stakes risks or urgent complications described in the scenario.


Medical Specialty: Gastroenterology
Sample Name: Cholecystectomy - Open

PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, None apparent.,ESTIMATED BLOOD LOSS:, 275 mL.,SPECIMENS:,1. Gallbladder.,2. Lymph node.,DRAINS:, One 19-French round Blake.,DESCRIPTION OF THE OPERATION:, After consent was obtained and the patient was properly identified, the patient was transported to the operating room and after induction of general endotracheal anesthesia, the patient was prepped and draped in a normal sterile fashion.,After infiltration with local, a vertical incision was made at the umbilicus and utilizing graspers, the underlying fascia was incised and was divided sharply. Dissecting further, the peritoneal cavity was entered. Once this done, a Hasson trocar was secured with #1 Vicryl and the abdomen was insufflated without difficulty. A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space. A second trocar was placed in the standard fashion in the subxiphoid area; this was a 10/12 mm non-bladed trocar. Once this was done, a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin; this was a 5-mm port placed, it was non-bladed and placed in the usual fashion under direct visualization without difficulty. A grasper was used to mobilize free the omentum which was acutely friable and after a significant time-consuming effort was made to mobilize the omentum, it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open.,The trocars were removed and a right subcostal incision was made incorporating the 10/12 subxiphoid port. The subcutaneous space was divided with electrocautery, as well as the muscles and fascia. The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space. Then utilizing a right-angle and electrocautery, the omentum was freed from the gallbladder. An ensuing retrograde cholecystectomy was performed, in which, electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa; this was done down to the infundibulum. After meticulous dissection, the cystic artery was identified and it was ligated between 3-0 silks. Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified, was skeletonized, and a 3-0 stick tie was placed on the proximal portion of it. After it was divided, the gallbladder was freed from the field.,Once this was done, the liver bed was inspected for hemostasis and this was achieved with electrocautery. Copious irrigation was also used. A 19-French Blake drain was placed in Morrison's pouch lateral to the gallbladder fossa and was secured in place with 2-0 nylon; this was a 19-French round Blake. Once this was done, the umbilical port was closed with #1 Vicryl in an interrupted fashion and then the wound was closed in two layers with #1 Vicryl in an interrupted fashion. The skin was closed with and absorbable stitch.,The patient was then awakened from anesthesia, extubated, and transported to the recovery room in stable condition.
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DESCRIPTION: Open cholecystectomy (attempted laparoscopic cholecystectomy).

gastroenterology, cholelithiasis, cholecystitis, gangrenous, cholecystectomy, laparoscopic, gallbladder, blake, omentum, hasson, electrocautery, gallbladder fossa, endotracheal, subhepatic, french,

The situation involves a detailed surgical procedure, specifically an open cholecystectomy which was initially attempted laparoscopically. The stakes are significant as this is an invasive surgery addressing acute perforated gangrenous cholecystitis, making it critical due to potential complications like infection, bleeding, or injury to surrounding structures. However, the operation was completed without apparent complications, and the patient was stable post-surgery. This mitigates the stakes somewhat compared to if complications or instability were present. Nonetheless, the nature of the condition and the emergency conversion to open surgery indicate a moderately high-stakes situation.