Medical Specialty: Radiology
Sample Name: CT Brain - Aneurysm

CC:, Decreasing visual acuity.,HX: ,This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.,PMH:, 1) depression. 2) Blind OS,MEDS:, None.,SHX/FHX: ,unremarkable for cancer, CAD, aneurysm, MS, stroke. No h/o Tobacco or ETOH use.,EXAM:, T36.0, BP121/85, HR 94, RR16,MS: Alert and oriented to person, place and time. Speech fluent and unremarkable.,CN: Pale optic disks, OU. Visual acuity: 20/70 (OD) and able to detect only shadow of hand movement (OS). Pupils were pharmacologically dilated earlier. The rest of the CN exam was unremarkable.,MOTOR: 5/5 throughout with normal bulk and tone.,Sensory: no deficits to LT/PP/VIB/PROP.,Coord: FNF-RAM-HKS intact bilaterally.,Station: No pronator drift. Gait: ND,Reflexes: 3/3 BUE, 2/2 BLE. Plantar responses were flexor bilaterally.,Gen Exam: unremarkable. No carotid/cranial bruits.,COURSE:, CT Brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. Differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. MRI Brain findings were consistent with an aneurysm. The patient underwent 3 vessel cerebral angiogram on 12/29/92. This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. Emergent HCT showed no evidence of hemorrhage or sign of infarct. Emergent carotid duplex showed no significant stenosis or clot. The patient was left with an expressive aphasia and right hemiparesis. SPECT scans were obtained on 1/7/93 and 2/24/93. They revealed hypoperfusion in the distribution of the left MCA and decreased left basal-ganglia perfusion which may represent in part a mass effect from the LICA aneurysm. She was discharged home and returned and underwent placement of a Selverstone Clamp on 3/9/93. The clamp was gradually and finally closed by 3/14/93. She did well, and returned home. On 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. A HCT then showed SAH around her aneurysm, which had thrombosed. She was place on Nimodipine. Her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. An emergent HCT demonstrated a left ACA and left MCA infarction. She required intubation and worsened as cerebral edema developed. She was pronounced brain dead. Her organs were donated for transplant.
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DESCRIPTION: CT Brain: Suprasellar aneurysm, pre and post bleed.

radiology, ct brain, hct, mri brain, suprasellar, suprasellar aneurysm, aneurysm, cerebral angiogram, craniopharyngioma, internal carotid artery, loss of visual acuity, pituitary adenoma, suprasellar-sellar mass, visual acuity, expressive aphasia, cerebral, ct, hemiparesis, aphasia, brain,

This case involves a serious medical condition where a patient suffers from a brain aneurysm leading to significant complications and ultimately death. The situation involves critical decisions regarding the diagnosis and management of the aneurysm, as well as handling emergency situations like aphasia, hemiparesis, and subsequent complications of cerebral edema and brain death. Timely and accurate medical intervention is vital, underscoring the high stakes involved in treatment outcomes and patient safety.


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

Medical Specialty: Surgery
Sample Name: Lymph Node Excisional Biopsy

PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:,  LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only.  Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast.  Patient has been following with Dr. Diener and Dr. Wilmot.  I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both.  She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion.  I recommended that she have this lymph node removed.  The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion.  An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia.  I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures.  The lymph node was excised in its entirety.  The wound was irrigated.  The lymph node sent to pathology.  The wound was then closed.  Hemostasis was assured and the patient was taken to recovery room in stable condition.
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DESCRIPTION: Left axillary lymph node excisional biopsy.  Left axillary adenopathy.

surgery, axillary lymph node excisional biopsy, sharp dissection, excisional biopsy, lymph node, axillary, excisional, biopsy

The situation involves a surgical procedure on a patient with a history of breast cancer. While the lymph node excisional biopsy is a common procedure, the stakes are elevated due to the patient's previous choice to refuse recommended adjuvant therapy and the potential implication of cancer recurrence or spread. Additionally, adequate preparation and post-surgical care are crucial for patient outcomes. Given the context of cancer, the decision-making process, and follow-up care, this situation is moderately high-stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Anterior Cervical Decompression

PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,PROCEDURE PERFORMED,1.  Anterior cervical decompression, C5-C6.,2.  Anterior cervical decompression, C6-C7.,3.  Anterior spine instrumentation.,4.  Anterior cervical spine fusion, C5-C6.,5.  Anterior cervical spine fusion, C6-C7.,6.  Application of machined allograft at C5-C6.,7.  Application of machined allograft at C6-C7.,8.  Allograft, structural at C5-C6.,9.  Allograft, structural at C6-C7.,ANESTHESIA: , General.,PREOPERATIVE NOTE:  ,This patient is a 47-year-old male with chief complaint of severe neck pain and left upper extremity numbness and weakness.  Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5-C6 and C6-C7 on the left.  The patient has failed epidural steroid injections.  Risks and benefits of the above procedure were discussed with the patient including bleeding, infection, muscle loss, nerve damage, paralysis, and death.,OPERATIVE REPORT: , The patient was taken to the OR and placed in the supine position.  After general endotracheal anesthesia was obtained, the patient's neck was sterilely prepped and draped in the usual fashion.  A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body.  It was taken down through the subcutaneous tissues exposing the platysmus muscle.  The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine.  An #18 gauge needle was placed in the C5-C6 interspace and the intraoperative x-ray confirmed that this was the appropriate level.  Next, the longus colli muscles were resected laterally on both the right and left side, and then a complete anterior cervical discectomy was performed.  The disk was very degenerated and brown in color.  There was an acute disk herniation through posterior longitudinal ligament.  The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed.  Approximately, 5 mm of the nerve root on both the right and left side was visualized.  A ball-ended probe could be passed up the foramen.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates of C5 and C6 were prepared using a high-speed burr and a 6-mm lordotic machined allograft was malleted into place.  There was good bony apposition both proximally and distally.  Next, attention was placed at the C6-C7 level.  Again, the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6-C7 was performed.  The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left.  The posterior longitudinal ligament was removed.  A bilateral foraminotomy was performed.  Approximately, 5 mm of the C7 nerve root was visualized on both sides.  A micro nerve hook was able to be passed up the foramen easily.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates at C6-C7 were then prepared using a high-speed burr and then a 7-mm machined lordotic allograft was malleted into place.  There was good bony apposition, both proximally and distally.  Next, a 44-mm Blackstone low-profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws.  Intraoperative x-ray confirmed appropriate positioning of the plate and the graft.  The wound was then copiously irrigated with normal saline and bacitracin.  There was no active bleeding upon closure of the wound.  A small drain was placed deep.  The platysmal muscle was closed with 3-0 Vicryl.  The skin was closed with #4-0 Monocryl.  Mastisol and Steri-Strips were applied.  The patient was monitored throughout the procedure with free-running EMGs and SSEPs and there were no untoward events.  The patient was awoken and taken to the recovery room in satisfactory condition.
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DESCRIPTION: Herniated nucleus pulposus.  Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.

surgery, herniated nucleus pulposus, anterior cervical decompression, spine fusion, cervical spine, allograft, anterior cervical spine, anterior, cervical,

This case concerns a surgical procedure to address a herniated cervical disc in a patient experiencing severe neck pain and numbness in the upper extremity. The surgery involves anterior cervical decompression, spinal fusion, and instrumentation, all of which are intricate and potentially risky due to the proximity to the spinal cord and critical nerves. The stakes are high due to the potential complications, which include bleeding, infection, paralysis, and even death, making it a high-stakes scenario in medical practice.


Medical Specialty: Surgery
Sample Name: Nephrectomy - Partial (Laparoscopic )

PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED: , Laparoscopic right partial nephrectomy.,ESTIMATED BLOOD LOSS:,  250 mL.,X-RAYS: , None.,SPECIMENS: , Included right renal mass as well as biopsies from the base of the resection.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS: , None.,DRAINS: , Included a JP drain in the right flank as well as a #16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 60-year-old gentleman with a history of an enhancing right renal mass approximately 2 cm in diameter.  I had a long discussion with him concerning variety of options.  We talked in particular about extirpated versus ablative surgery.  Based on his young age and excellent state of health, decision was made at this point to proceed to a right partial nephrectomy laparoscopically.  All questions were answered, and he wished to proceed with surgery as planned.  Note that the patient does have a positive family history of renal cell carcinoma.,PROCEDURE IN DETAIL: , After acquisition of proper informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table.  After institution of adequate general anesthetic via endotracheal rod, he was placed into the right anterior flank position with his right side elevated on a roll and his right arm across his chest.  All pressure points were carefully padded, and he was securely taped to the table.  Note that sequential compression devices were in place on both lower extremities and were activated prior to induction of anesthesia.  His abdomen was then prepped and draped in a standard surgical fashion.  Note that a #16-French Foley catheter was in place per urethra as well as an orogastric tube.  The abdomen was insufflated at the right lateral abdomen using the Veress needle to a pressure of 15 without incident.  We then placed a Visiport 10 x 12 trocar in the right lateral abdomen.  With the trocar in place, we were able to place the remaining trocars under direct laparoscopic visualization.  We placed three additional trocars.  An 11 mm screw type trocar at the umbilicus, a 6 screw type trocar 7 cm in the midline above the umbilicus, and a 10 x 12 trocar to serve as a retractor port approximately 8 cm inferior in the midline.,The procedure was begun by reflecting the right colon by incising the white line of Toldt.  The colon was reflected medially, and the retroperitoneum was exposed on that side.  This was a fairly superficial lesion, so decision was made in advance to potentially not perform vascular clamping, however, I did feel it important to get high level control prior to proceeding to the partial.  With the colon reflected, the duodenum was identified, and it was reflected medially under Kocher maneuver.  The ureter and gonadal vein were identified on the right side and elevated.  The space between the ureter and the gonadal vein was then developed, and the gonadal vein was dropped elevating only the ureter, and carrying this plane dissection up towards the renal hilum.  Once we got up to the renal hilum, we were able to skeletonize the renal hilar vessels partially, and in particular, we did develop some of the upper pole dissection above the level of the hilum to provide for access for a Satinsky clamp or bulldogs.  The remainder of the kidney was then freed off its lateral and superior attachments primarily using the Harmonic scalpel and the LigaSure device.,With the kidney free and the hilum prepared, the Gerota fascia was taken down overlying the kidney exposing the renal parenchyma, and using this approach, we were able to identify the 2-cm, right renal mass located in the lower pole laterally.  A cap of fat was left overlying this mass.  Based on the position of the mass, we performed intraoperative laparoscopic ultrasound, which showed the mass to be somewhat deeper than initially anticipated.  Based on this finding, I decided to go ahead and clamp the renal hilum during resection.  A Satinsky clamp was introduced through the lower most trocar site and used to clamp the renal hilum en bloc.  Note that the patient had been receiving renal protection protocol including fenoldopam and mannitol throughout the procedure, and he also received Lasix prior to clamping the renal hilum.  With the renal hilum clamped, we did resect the tumor using cold scissors.  There was somewhat more bleeding than would be expected based on the hilar clamping; however, we were able to successfully resect this lesion.  We also took a biopsy at the base of the resection and passed off the table as a specimen for frozen section.  With the tumor resected, the base of the resection was then cauterized using the Argon beam coagulator, and several bleeding vessels were oversewn using figure-of-eight 3-0 Vicryl sutures with lap ties for tensioning.  We then placed a FloSeal into the wound and covered it with a Surgicel and held the pressure.  We then released the vascular clamp.  Total clamp time was 11 minutes.  There was minimal bleeding and occlusion of this maneuver, and after unclamping the kidney, the kidney pinked up appropriately and appeared well perfused after removal of the clamp.  We then replaced the kidney within its Gerota envelope and closed that with 3-0 Vicryl using lap ties for tensioning.  A JP drain was introduced through the right flank and placed adjacent to the kidney and sutured the skin with 2-0 nylon.  The specimen was placed into a 10-mm Endocatch bag and extracted from the lower most trocar site after extending it approximately 1 cm.  It was evaluated on the table and passed off the table for Pathology to evaluate.  They stated that the tumor was close to the margin, but there appeared to be 1-2 mm normal parenchyma around the tumor.  In addition, the frozen section biopsies from the base of the resection were negative for renal cell carcinoma.  Based on these findings, the lower most trocar site was closed using a running 0 Vicryl suture in the fascia.  We then re-insufflated the abdomen and carefully evaluated the entire intraoperative field for hemostasis.  Any bleeding points were controlled primarily using bipolar cautery or hemoclips.  The area was copiously irrigated with normal saline.  The colon was then replaced into its normal anatomic position.  The mesentry was evaluated.  There were no defects noted.  We closed the 10 x 12 lateral most trocar site using a Carter-Thompson closure device with 0-Vicryl.  All trocars were removed under direct visualization, and the abdomen was desufflated prior to removal of the last trocar.  The skin incisions were irrigated with normal saline and infiltrated with 0.25% Marcaine, and the skin was closed using a running 4-0 Monocryl in subcuticular fashion.  Benzoin and Steri-Strips were placed.  The patient was returned in supine position and awoken from general anesthetic without incident.  He was then transferred to hospital gurney and taken to the postanesthesia care unit for postoperative monitoring.  At the end of the case, sponge, instrument, and needle counts were correct.  I was scrubbed and present throughout the entire case.
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DESCRIPTION: Laparoscopic right partial nephrectomy due to right renal mass.

surgery, renal mass, foley catheter, gerota fascia, jp drain, kocher maneuver, laparoscopic, ligasure device, satinsky clamp, toldt, bulldogs, nephrectomy, renal parenchyma, resection, urethra, vicryl sutures, partial nephrectomy, gonadal vein, renal hilum, satinsky, renal, kidney, hilum, foley, endotracheal,

The situation described involves a surgical procedure, specifically a laparoscopic right partial nephrectomy, to remove a renal mass. Surgery inherently carries risks such as bleeding, infection, or complications from anesthesia, making it higher stakes. However, the procedure went smoothly, with no complications reported, and the patient was stable post-operation. The stakes are high due to the potential for critical outcomes if complications arose, yet this specific operation was executed successfully with standard measures in place for risk management.


Medical Specialty: Hematology - Oncology
Sample Name: BCCa Excision - Nasal Tip

PREOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,POSTOPERATIVE DIAGNOSIS: , Basal cell carcinoma, nasal tip, previous positive biopsy.,OPERATION PERFORMED: , Excision of nasal tip basal carcinoma.  Total area of excision, approximately 1 cm to 12 mm frozen section x2, final margins clear.,INDICATION: , A 66-year-old female for excision of nasal basal cell carcinoma.  This area is to be excised accordingly and closed.  We had multiple discussions regarding types of closure.,SUMMARY: , The patient was brought to the OR in satisfactory condition and placed supine on the OR table.  Underwent general anesthesia along with Marcaine in the nasal tip areas for planned excision.  The area was injected, after sterile prep and drape, with Marcaine 0.25% with 1:200,000 adrenaline.,The specimen was sent to pathology.  Margins were still positive at the inferior 6 o'clock ***** margin and this was resubmitted accordingly.  Final margins were clear.,Closure consisted of undermining circumferentially.  Advancement closure with dog ear removal distally and proximally was accomplished without difficulty.  Closure with interrupted 5-0 Monocryl running 7-0 nylon followed by Xeroform gauze, light pressure dressing, and Steri-Strips.,The patient is discharged on minocycline and Darvocet-N 100.,NOTE:,  The 2.6 mm loupe magnification was utilized throughout the procedure.  No complications noted with excellent and all clear margins at the termination.  An advancement closure technique was utilized.
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DESCRIPTION: Excision of nasal tip basal carcinoma, previous positive biopsy.

hematology - oncology, basal cell carcinoma, closure, steri-strips, xeroform gauze, excision, light pressure dressing, loupe magnification, nasal tip, basal carcinoma, basal cell, cell carcinoma, biopsy, basal, carcinoma, nasal

The excision of nasal tip basal cell carcinoma is a significant medical procedure but is generally routine and not life-threatening. Basal cell carcinoma is a common type of skin cancer with a high cure rate when treated properly. This particular case involved a positive biopsy indicating the presence of carcinoma, and the procedure involved excision and ensuring clear margins, which were achieved without difficulty. The inclusion of general anesthesia and clear postoperative notes suggest that this is a standard procedure in the medical field, reducing the stakes substantially compared to more invasive or life-threatening conditions. The operation appears to have been executed smoothly with a successful outcome, characterized by clear margins post-surgery and no noted complications.


Medical Specialty: Nephrology
Sample Name: CT Abdomen & Pelvis - 8

CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:,  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.,FINDINGS: , The liver is normal in size and attenuation.,The gallbladder is normal.,The spleen is normal in size and attenuation.,The adrenal glands and pancreas are unremarkable.,The kidneys are normal in size and attenuation.,No hydronephrosis is detected.  Free fluid is seen within the right upper quadrant within the lower pelvis.  A markedly thickened loop of distal small bowel is seen.  This segment measures at least 10-cm long.  No definite pneumatosis is appreciated.  No free air is apparent at this time.  Inflammatory changes around this loop of bowel.  Mild distention of adjacent small bowel loops measuring up to 3.5 cm is evident.  No complete obstruction is suspected, as there is contrast material within the colon.  Postsurgical changes compatible with the partial colectomy are noted.  Postsurgical changes of the anterior abdominal wall are seen.  Mild thickening of the urinary bladder wall is seen.,IMPRESSION:,1.  Marked thickening of a segment of distal small bowel is seen with free fluid within the abdomen and pelvis.  An inflammatory process such as infection or ischemia must be considered.  Close interval followup is necessary.,2.  Thickening of the urinary bladder wall is nonspecific and may be due to under distention.  However, evaluation for cystitis is advised.
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DESCRIPTION: Generalized abdominal pain, nausea, diarrhea, and recent colonic resection.  CT abdomen with and without contrast and CT pelvis with contrast.  Axial CT images of the abdomen were obtained without contrast.  Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.

nephrology, abdominal pain, nausea, diarrhea, colonic resection, axial ct images, ct abdomen, isovue, inflammatory, urinary, bladder, abdominal, colonic, wall, thickening, axial, bowel, contrast, attenuation, pelvis, ct, abdomen

The situation described is a follow-up medical examination involving a CT scan in a patient with recent major abdominal surgery (colonic resection). The findings indicate potential complications, such as an inflammatory process in the small bowel, that might require further medical intervention. The stakes are considered relatively high because the interpretation of the CT results can affect the patient's immediate health management and could potentially require urgent treatment to address complications such as infection or ischemia.


Medical Specialty: Allergy / Immunology
Sample Name: Followup on Asthma

SUBJECTIVE: , This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma.  She says her asthma has been worse over the last three months.  She has been using her inhaler daily.  Her allergies seem to be a little bit worse as well.  Her husband has been hauling corn and this seems to aggravate things.  She has not been taking Allegra daily but when she does take it, it seems to help somewhat.  She has not been taking her Flonase which has helped her in the past.  She also notes that in the past she was on Advair but she got some vaginal irritation with that.,She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle.  She has been more impatient around that time.  Says otherwise her mood is normal during the rest of the month.  It usually is worse the week before her cycle and improves the day her menstrual cycle starts.  Menses have been regular but somewhat shorter than in the past.  Occasionally she will get some spotting after her cycles.  She denies any hot flashes or night sweats with this.  In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously.  Her urine has not been rechecked.  She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,REVIEW OF SYSTEMS: , As above.  No fevers, no headaches, no shortness of breath currently.  No chest pain or tightness.  No abdominal pain, no heartburn, no constipation, diarrhea or dysuria.  Occasional stress incontinence.  No muscle or joint pain.  No concerns about her skin.  No polyphagia, polydipsia or polyuria.,PAST MEDICAL HISTORY: , Significant for asthma, allergic rhinitis and cervical dysplasia.,SOCIAL HISTORY: , She is married.  She is a nonsmoker.,MEDICATIONS: , Proventil and Allegra.,ALLERGIES: , Sulfa.,OBJECTIVE:,Vital signs:  Her weight is 151 pounds.  Blood pressure is 110/60.  Pulse is 72.  Temperature is 97.1 degrees.  Respirations are 20.,General:  This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress.  Affect is appropriate and is pleasant.,HEENT:  Normocephalic, atraumatic.  Tympanic membranes are clear.  Conjunctivae are clear.  Pupils are equal, round and reactive to light.  Nares without turbinate edema.  Oropharynx is nonerythematous.,Neck:  Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm without murmur.,Abdomen:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No masses or organomegaly to palpation.,Extremities:  Without cyanosis or edema.,Skin:  Without abnormalities.,Breasts:  Normal symmetrical breasts without dimpling or retraction.  No nipple discharge.  No masses or lesions to palpation.  No axillary masses or lymphadenopathy.,Genitourinary:  Normal external genitalia.  The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted.  Cervix is visualized without lesion.  She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault.  No cervical motion tenderness.  No adnexal tenderness or fullness.,ASSESSMENT/PLAN:,1.  Asthma.  Seems to be worse than in the past.  She is just using her Proventil inhaler but is using it daily.  We will add Flovent 44 mcg two puffs p.o. b.i.d.  May need to increase the dose.  She did get some vaginal irritation with Advair in the past but she is willing to retry that if it is necessary.  May also need to consider Singulair.  She is to call me if she is not improving.  If her shortness of breath worsens she is to call me or go into the emergency department.  We will plan on following up for reevaluation in one month.,2.  Allergic rhinitis.  We will plan on restarting Allegra and Flonase daily for the time being.,3.  Premenstrual dysphoric disorder.  She may have some perimenopausal symptoms.  We will start her on fluoxetine 20 mg one tablet p.o. q.d.,4.  Hematuria.  Likely this is secondary to urinary tract infection but we will repeat a UA to document clearing.  She does have some frequent dysuria but is not having it currently.,5.  Cervical dysplasia.  Pap smear is taken.  We will notify the patient of results.  If normal we will go back to yearly Pap smear.  She is scheduled for screening mammogram and instructed on monthly self-breast exam techniques.  Recommend she get 1200 mg of calcium and 400 U of vitamin D a day.
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DESCRIPTION: A female for a complete physical and follow up on asthma with allergic rhinitis.

The scenario involves a medical follow-up for a 42-year-old female who is experiencing worsening asthma symptoms. The medical practitioner is tasked with managing her asthma, allergic rhinitis, potential premenstrual dysphoric disorder, and monitoring for cervical dysplasia. While the situation involves multiple health issues that require attention and could impact the patient's quality of life, no immediate life-threatening conditions are present. The medical interventions and follow-up plans suggest ongoing management rather than an urgent crisis response.


Medical Specialty: Consult - History and Phy.
Sample Name: Adult Hydrocephalus

REASON FOR VISIT: , The patient is a 74-year-old woman who presents for neurological consultation referred by Dr. X.  She is accompanied to the appointment by her husband and together they give her history.,HISTORY OF PRESENT ILLNESS: , The patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus.  Danish is her native language, but she has been in the United States for many many years and speaks fluent English, as does her husband.,With respect to her walking and balance, she states "I think I walk funny."  Her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture.  Her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself.  She has difficulty stepping up on to things like a scale because of this imbalance.  She does not festinate.  Her husband has noticed some slowing of her speed.  She does not need to use an assistive device.  She has occasional difficulty getting in and out of a car.  Recently she has had more frequent falls.  In March of 2007, she fell when she was walking to the bedroom and broke her wrist.  Since that time, she has not had any emergency room trips, but she has had other falls.,With respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency.,The patient does not have headaches.,With respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, "I do not feel as smart as I used to be."  She feels that her thinking has slowed down.  Her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing.,The patient has not had trouble with syncope.  She has had past episodes of vertigo, but not recently.,PAST MEDICAL HISTORY:  ,Significant for hypertension diagnosed in 2006, reflux in 2000, insomnia, but no snoring or apnea.  She has been on Ambien, which is no longer been helpful.  She has had arthritis since year 2000, thyroid abnormalities diagnosed in 1968, a hysterectomy in 1986, and a right wrist operation after her fall in 2007 with a titanium plate and eight screws.,FAMILY HISTORY: , Her father died with heart disease in his 60s and her mother died of colon cancer.  She has a sister who she believes is probably healthy.  She has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy.  She has two normal vaginal deliveries.,SOCIAL HISTORY:  ,She lives with her husband.  She is a nonsmoker and no history of drug or alcohol abuse.  She does drink two to three drinks daily.  She completed 12th grade.,ALLERGIES: , Codeine and sulfa.,She has a Living Will and if unable to make decisions for herself, she would want her husband, Vilheim to make decisions for her.,MEDICATIONS,:  Premarin 0.625 mg p.o. q.o.d., Aciphex 20 mg p.o. q. daily, Toprol 50 mg p.o. q. daily, Norvasc 5 mg p.o. q. daily, multivitamin, Caltrate plus D, B-complex vitamins, calcium and magnesium, and vitamin C daily.,MAJOR FINDINGS: , On examination today, this is a pleasant and healthy appearing woman.,VITAL SIGNS:  Blood pressure 154/72, heart rate 87, and weight 153 pounds.  Pain is 0/10.,HEAD:  Head is normocephalic and atraumatic.  Head circumference is 54 cm, which is in the 10-25th percentile for a woman who is 5 foot and 6 inches tall.,SPINE:  Spine is straight and nontender.  Spinous processes are easily palpable.  She has very mild kyphosis, but no scoliosis.,SKIN:  There are no neurocutaneous stigmata.,CARDIOVASCULAR EXAM:  Regular rate and rhythm.  No carotid bruits.  No edema.  No murmur.  Peripheral pulses are good.  Lungs are clear.,MENTAL STATUS:  Assessed for recent and remote memory, attention span, concentration, and fund of knowledge.  She scored 30/30 on the MMSE when attention was tested with either spelling or calculations.  She had no difficulty with visual structures.,CRANIAL NERVES:  Pupils are equal.  Extraocular movements are intact.  Face is symmetric.  Tongue and palate are midline.  Jaw muscles strong.  Cough is normal.  SCM and shrug 5 and 5.  Visual fields intact.,MOTOR EXAM:  Normal for bulk, strength, and tone.  There was no drift or tremor.,SENSORY EXAM:  Intact for pinprick and proprioception.,COORDINATION:  Normal for finger-to-nose.,REFLEXES:  Are 2+ throughout.,GAIT:  Assessed using the Tinetti assessment tool.  She was fairly quick, but had some unsteadiness and a widened base.  She did not need an assistive device.  I gave her a score of 13/16 for balance and 9/12 for gait for a total score of 22/28.,REVIEW OF X-RAYS: , MRI was reviewed from June 26, 2008.  It shows mild ventriculomegaly with a trace expansion into the temporal horns.  The frontal horn span at the level of foramen of Munro is 3.8 cm with a flat 3rd ventricular contour and a 3rd ventricular span of 11 mm.  The sylvian aqueduct is patent.  There is no pulsation artifact.  Her corpus callosum is bowed and effaced.  She has a couple of small T2 signal abnormalities, but no significant periventricular signal change.,ASSESSMENT:  ,The patient is a 74-year-old woman who presents with mild progressive gait impairment and possible slowing of her cognition in the setting of ventriculomegaly suggesting possible adult hydrocephalus.,PROBLEMS/DIAGNOSES:,1.  Possible adult hydrocephalus (331.5).,2.  Mild gait impairment (781.2).,3.  Mild cognitive slowing (290.0).,PLAN: , I had a long discussion with the patient her husband.,I think it is possible that the patient is developing symptomatic adult hydrocephalus.  At this point, her symptoms are fairly mild.  I explained to them the two methods of testing with CSF drainage.  It is possible that a large volume lumbar puncture would reveal whether she is likely to respond to shunt and I described that test.  About 30% of my patients with walking impairment in a setting of possible adult hydrocephalus can be diagnosed with a large volume lumbar puncture.  Alternatively, I could bring her into the hospital for four days of CSF drainage to determine whether she is likely to respond to shunt surgery.  This procedure carries a 2% to 3% risk of meningitis.  I also explained that it would be reasonable to start with an outpatient lumbar puncture and if that is not sufficient we could proceed with admission for the spinal catheter protocol.
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DESCRIPTION: The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus.  Mild gait impairment and mild cognitive slowing.

The situation involves a medical consultation for a 74-year-old woman with potential adult hydrocephalus. Her symptoms include mild gait impairment and mild cognitive slowing, which are currently not severe but could affect her quality of life significantly if the condition progresses. Decisions regarding diagnostic testing and potential treatment with shunt surgery need to be made, with procedures carrying some risk. While not immediately life-threatening, the situation requires careful evaluation and decision-making to prevent future complications.


Medical Specialty: Surgery
Sample Name: Abdominosacrocolpopexy

PREOPERATIVE DIAGNOSES:,1.  Vault prolapse.,2.  Enterocele.,PREOPERATIVE DIAGNOSES:,1.  Vault prolapse.,2.  Enterocele.,OPERATIONS:,1.  Abdominosacrocolpopexy.,2.  Enterocele repair.,3.  Cystoscopy.,4.  Lysis of adhesions.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,SPECIMEN: , None.,BRIEF HISTORY:,  The patient is a 53-year-old female with history of hysterectomy presented with vaginal vault prolapse.  The patient had good support in the anterior vagina and in the posterior vagina but had significant apical prolapse.  Options such as watchful waiting, pessary, abdominal surgery, robotic sacrocolpopexy versus open sacrocolpopexy were discussed.,The patient already had multiple abdominal scars.  Risk of open surgery was little bit higher for the patient.  After discussing the options the patient wanted to proceed a Pfannenstiel incision and repair of the sacrocolpopexy.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, mesh erogenic exposure, complications with mesh were discussed.  The patient understood the risks of recurrence, etc, and wanted to proceed with the procedure.  The patient was told to perform no heavy lifting for 3 months, etc.  The patient was bowel prepped, preoperative antibiotics were given.,DETAILS OF THE OPERATION: , The patient was brought to the OR, anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A Pfannenstiel low abdominal incision was done at the old incision site.  The incision was carried through the subcutaneous tissue through the fascia and the fascia was lifted off the rectus abdominus muscle.  The muscle was split in the middle and peritoneum was entered using sharp mets.  There was no injury to the bowel upon entry.  There were significant adhesions which were unleashed.  All the adhesions in the sigmoid colon from the right lower quadrant and left lower quadrant were released, similarly colon was mobilized.  There was minimal space, everything was packed, Bookwalter placed then over the sacral bone.  The middle of the sacral bone was identified.  The right ureter was clearly identified and was lateral to where the posterior peritoneum was opened.  The ligament over the sacral or sacral __________ was easily identified, 0 Ethibond stitches were placed x3.  A 1 cm x 5 cm mesh was cut out.  This was a Prolene soft mesh which was tied at the sacral ligament.  The bladder was clearly off the vault area which was exposed, in the raw surface 0 Ethibond stitches were placed x3.  The mesh was attached.  The apex was clearly up enterocele sac was closed using 4-0 Vicryl without much difficulty.  The ureter was not involved at all in this process.  The peritoneum was closed over the mesh.  Please note that the peritoneum was opened and it was brought around and over the mesh so that the mesh would not be exposed to the bowel.  Prior to closure antibiotic irrigation was done using Ancef solution.  The mesh has been exposed in antibiotic solution prior to the usage.,After a through irrigation with L and half of antibiotic solution.  All the solution was removed.  Good hemostasis was obtained.  All the packing was removed.  Count was correct.  Rectus abdominus muscle was brought together using 4-0 Vicryl.  The fascia was closed using loop #1 PDS in running fascia from both sides and was tied in the middle.  Subcutaneous tissue was closed using 4-0 Vicryl and the skin was closed using 4-0 Monocryl in subcuticular fashion.  Cystoscopy was done at the end of the procedure.  Please note that the Foley was in place throughout the entire procedure which was placed thoroughly at the beginning of the procedure.  Cystoscopy was done and indigo carmine has been given.  There was good efflux of indigo carmine in both of the ureteral opening.  There was no injury to the rectum or the bladder.  The bladder appeared completely normal.  The rectal exam was done at the end of the procedure after the cystoscopy.  After the cysto was done, the scope was withdrawn, Foley was placed back.  The patient was brought to recovery in the stable condition.
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DESCRIPTION: Abdominosacrocolpopexy, enterocele repair, cystoscopy, and lysis of adhesions.

surgery, enterocele repair, cystoscopy, lysis of adhesions, enterocele, ethibond stitches, indigo carmine, vault prolapse, sacrocolpopexy, peritoneum, abdominosacrocolpopexy,

The described situation involves a surgical procedure that carries inherent risks, such as potential complications from anesthesia, bleeding, infection, and other surgery-related issues. These factors, combined with the specific operation and its complexity, elevate the stakes. However, given that it is a planned procedure in a controlled environment, with risks discussed and managed, it is not the highest level of stakes compared to emergency or life-threatening surgeries.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Lens Implantation - 3

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,PROCEDURE:,  Phacoemulsification with intraocular lens placement, right eye.,ANESTHESIA: , Monitored anesthesia care,ESTIMATED BLOOD LOSS: , None,COMPLICATIONS:,  None,SPECIMENS:,  None,PROCEDURE IN DETAIL: , The patient had previously been examined in the clinic and was found to have a visually significant cataract in the right eye.  The patient had the risks and benefits of surgery discussed.  After discussion, the patient decided to proceed and the consent was signed.,On the day of surgery, the patient was taken from the holding area to the operating suite by the anesthesiologist and monitors were placed.  Following this, the patient was sterilely prepped and draped in the usual fashion.  After this, a lid speculum was placed, preservative-free lidocaine drops were placed, and the SuperSharp blade was used to make an anterior chamber paracentesis.  Preservative-free lidocaine was instilled into the anterior chamber, and then Viscoat was instilled into the eye.,The 3.0 diamond keratome was then used to make a clear corneal temporal incision.  Following this, the cystotome was used to make a continuous tear-type capsulotomy.  After this, BSS was used to hydrodissect and hydrodelineate the lens.  The phacoemulsification unit was used to remove the cataract.  The I&A unit was used to remove the residual cortical material.  Following this, Provisc was used to inflate the bag.  The lens, a model SA60AT of ABCD diopters, serial #1234, was inserted into the bag and rotated into position using the Lester pusher.,After this, the residual Provisc was removed.  Michol was instilled and then the corneal wound was hydrated with BSS, and the wound was found to be watertight.  The lid speculum was removed.  Acular and Vigamox drops were placed.  The patient tolerated the procedure well without complications and will be followed up in the office tomorrow.
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DESCRIPTION: Cataract, right eye.  Phacoemulsification with intraocular lens placement, right eye.

ophthalmology, capsulotomy, diopters, intraocular lens placement, lid speculum, anterior chamber, phacoemulsification, lens, cataract, intraocular

The situation described is a routine cataract surgery with phacoemulsification and lens implantation. Cataract surgeries are among the most common and generally low-risk procedures in ophthalmology. The documentation indicates that the procedure went as planned, with no blood loss or complications noted. The patient tolerated the procedure well and will have a follow-up appointment. Given its routine nature and the absence of complications, this situation is considered low-stakes in the context of medical procedures.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Carotid Endarterectomy

PREOPERATIVE DIAGNOSES:,1.  Right carotid stenosis.,2.  Prior cerebrovascular accident.,POSTOPERATIVE DIAGNOSES:,1.  Right carotid stenosis.,2.  Prior cerebrovascular accident.,PROCEDURE PERFORMED:  ,Right carotid endarterectomy with patch angioplasty.,ESTIMATED BLOOD LOSS:  ,250 cc.,OPERATIVE FINDINGS: , The common and internal carotid arteries were opened.  A high-grade narrowing was present at the proximal internal carotid and this tapered well to a slightly small diameter internal carotid.  This was repaired with a Dacron patch and the patient tolerated this well under regional anesthetic without need for shunting.,PROCEDURE:  ,The patient was taken to the operating room, placed in supine position, prepped and draped in the usual sterile manner with Betadine solution.  Longitudinal incisions were made along the anterior border of the sternocleidomastoid, carried down through subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The platysmal muscle was divided.  The carotid sheath was identified and opened.  The vagus nerve, ansa cervicalis, and hypoglossal nerves were identified and avoided.  The common internal and external carotids were then freed from the surrounding tissue.  At this point, 10,000 units of aqueous heparin were administered and allowed to take effect.  The external and common carotids were then clamped.  The patient's neurological status was evaluated and found to be unchanged from preoperative levels.,Once sufficient time had lapsed, we proceeded with the procedure.  The carotid bulb was opened with a #11 blade and extended with Potts scissors through the very tight lesion into normal internal carotid.  The plaque was then sharply excised proximally and an eversion endarterectomy was performed successfully at the external.  The plaque tapered nicely on the internal and no tacking sutures were necessary.  Heparinized saline was injected and no evidence of flapping or other debris was noted.  The remaining carotid was examined under magnification, which showed no debris of flaps present.  At this point, a Dacron patch was brought on to the field, cut to appropriate length and size, and anastomosed to the artery using #6-0 Prolene in a running fashion.  Prior to the time of last stitch, the internal carotid was back-bled through this.  The last stitch was tied.  Hemostasis was excellent.  The internal was again gently occluded while flow was restored to the common and external carotids for several moments and then flow was restored to the entire system.  At this point, a total of 50 mg of Protamine was administered and allowed to take effect.  Hemostasis was excellent.  The wound was irrigated with antibiotic solution and closed in layers using #3-0 Vicryl and #4-0 undyed Vicryl.  The patient was then taken to the recovery room in satisfactory condition after tolerating the procedure well.  Sponge, needles, and instrument count were correct.  Estimated blood loss was 250 cc.
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DESCRIPTION: Right carotid stenosis and prior cerebrovascular accident. Right carotid endarterectomy with patch angioplasty.

cardiovascular / pulmonary, carotid stenosis, cerebrovascular, platysmal, dacron patch, carotid endarterectomy, cerebrovascular accident, internal carotid, carotid, stenosis, carotids, endarterectomy

The scenario involves a detailed description of a surgical procedure known as carotid endarterectomy, which is performed to remove plaque from the carotid artery. This is a high-stakes medical procedure given the potential for serious complications, such as stroke, if not carried out properly. The procedure addresses issues of right carotid stenosis and prior cerebrovascular accident, which are significant medical conditions. The procedure was performed successfully with the patient tolerating it well, indicating that the immediate high-risk concerns were managed effectively. However, due to the inherent risks associated with such surgeries, the stakes remain high.


Medical Specialty: Obstetrics / Gynecology
Sample Name: OB/GYN Consultation - 3

Pap smear in November 2006 showed atypical squamous cells of undetermined significance.  She has a history of an abnormal Pap smear.  At that time, she was diagnosed with CIN 3 as well as vulvar intraepithelial neoplasia.  She underwent a cone biopsy that per her report was negative for any pathology.  She had no vulvar treatment at that time.  Since that time, she has had normal Pap smears.  She denies abnormal vaginal bleeding, discharge, or pain.  She uses Yaz for birth control.  She reports one sexual partner since 1994 and she is a nonsmoker.,She states that she has a tendency to have yeast infections and bacterial vaginosis.  She is also being evaluated for a possible interstitial cystitis because she gets frequent urinary tract infections.  She had a normal mammogram done in August 2006 and a history of perirectal condyloma that have been treated by Dr. B.  She also has a history of chlamydia when she was in college.,PAST MEDICAL HX: , Depression.,PAST SURGICAL HX: , None.,MEDICATIONS: , Lexapro 10 mg a day and Yaz.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,OB HX: , Normal spontaneous vaginal delivery at term in 2001 and 2004, Abc weighed 8 pounds 7 ounces and Xyz weighed 10 pounds 5 ounces.,FAMILY HX:  ,Maternal grandfather who had a MI which she reports is secondary to tobacco and alcohol use.  He currently has metastatic melanoma, mother with hypertension and depression, father with alcoholism.,SOCIAL HX:,  She is a public relations consultant.  She is a nonsmoker, drinks infrequent alcohol and does not use drugs.  She enjoys horseback riding and teaches jumping.,PE: , VITALS: Height: 5 feet 6 inches.  Weight: 139 lb.  BMI: 22.4.  Blood Pressure: 102/58.  GENERAL: She is well-developed and well-nourished with normal habitus and no deformities.  She is alert and oriented to time, place, and person and her mood and affect is normal.  NECK: Without thyromegaly or lymphadenopathy.  LUNGS: Clear to auscultation bilaterally.  HEART: Regular rate and rhythm without murmurs.  BREASTS: Deferred.  ABDOMEN: Soft, nontender, and nondistended.  There is no organomegaly or lymphadenopathy.  PELVIC: Normal external female genitalia.  Vulva, vagina, and urethra, within normal limits.  Cervix is status post cone biopsy; however, the transformation zone grossly appears normal and cervical discharge is clear and normal in appearance.  GC and chlamydia cultures as well as a repeat Pap smear were done.,Colposcopy is then performed without and with acetic acid.  This shows an entirely normal transformation zone, so no biopsies are taken.  An endocervical curettage is then performed with Cytobrush and curette and sent to pathology.  Colposcopy of the vulva is then performed again with acetic acid.  There is a thin strip of acetowhite epithelium located transversely on the clitoral hood that is less than a centimeter in diameter.  There are absolutely no abnormal vessels within this area.  The vulvar colposcopy is completely within normal limits.,A/P: , ASCUS Pap smear with history of a cone biopsy in 1993 and normal followup.,We will check the results of the Pap smear, in addition we have ordered DNA testing for high-risk HPV.  We will check the results of the ECC.  She will return in two weeks for test results.  If these are normal, she will need two normal Pap smears six months apart, and I think followup colposcopy for the vulvar changes.
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DESCRIPTION: Consultation for an ASCUS Pap smear.

Consultation for an ASCUS Pap smear.

obstetrics / gynecology, lmp, ascus, pap smear, abnormal pap smear, atypical, bacterial vaginosis, chlamydia, cone biopsy, infection, interstitial cystitis, intraepithelial, mammogram, neoplasia, perirectal condyloma, squamous, vaginal bleeding, vulvar, yeast infection, pap smears, pap, ob/gyn, colposcopy, smear,

The case involves a consultation for an atypical Pap smear result with a history of high-grade cervical intraepithelial neoplasia (CIN 3) and vulvar intraepithelial neoplasia, conditions that can potentially lead to cervical cancer if not monitored and managed. While the current findings are normal, the history necessitates careful follow-up to ensure there are no precancerous changes, making the situation moderately high-stakes due to the implications on the patient's health if ignored.


Medical Specialty: Neurology
Sample Name: Multiple Neurological Symptoms

HISTORY OF PRESENT ILLNESS: , The patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms.  I asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems.  He first mentioned that he has neck pain.  He states that he has had this for at least 15 years.  It is worse with movement.  It has progressed very slowly over the course of 15 years.  It is localized to the base of his neck and is sharp in quality.  He also endorses a history of gait instability.  This has been present for a few years and has been slightly progressively worsening.  He describes that he feels unsteady on his feet and "walks like a duck."  He has fallen about three or four times over the past year and a half.,He also describes that he has numbness in his feet.  When I asked him to describe this in more detail, the numbness is actually restricted to his toes.  Left is slightly more affected than the right.  He denies any tingling or paresthesias.  He also described that he is slowly losing control of his hands.  He thinks that he is dropping objects due to weakness or incoordination in his hands.  This has also been occurring for the past one to two years.  He has noticed that buttoning his clothes is more difficult for him.  He also does not have any numbness or tingling in the hands.  He does have a history of chronic low back pain.,At the end of the visit, when I asked him which symptom was most bothersome to him, he actually stated that his fatigue was most troublesome.  He did not even mention this on the initial part of my history taking.  When I asked him to describe this further, he states that he experiences a general exhaustion.  He basically lays in bed all day everyday.  I asked him if he was depressed, he states that he is treated for depression.  He is unsure if this is optimally treated.  As I just mentioned, he stays in bed almost all day long and does not engage in any social activities.  He does not think that he is necessarily sad.  His appetite is good.  He has never undergone any psychotherapy for depression.,When I took his history, I noticed that he is very slow in responding to my questions and also had a lot of difficulty recalling details of his history as well as names of physicians who he had seen in the past.  I asked if he had ever been evaluated for cognitive difficulties and he states that he did undergo testing at Johns Hopkins a couple of years ago.  He states that the results were normal and that specifically he did not have any dementia.,When I asked him when he was first evaluated for his current symptoms, he states that he saw Dr. X several years ago.  He believes that he was told that he had neuropathy but that it was unclear if it was due to his diabetes.  He told me that more recently he was evaluated by you after Dr. Y referred him for this evaluation.  He also saw Dr. Z for neurosurgical consultation a couple of weeks ago.  He reports that she did not think there was any surgical indication in his neck or back at this point in time.,PAST MEDICAL HISTORY: , He has had diabetes for five years.  He also has had hypercholesterolemia.  He has had Crohn's disease for 25 or 30 years.  He has had a colostomy for four years.  He has arthritis, which is reportedly related to the Crohn's disease.  He has hypertension and coronary artery disease and is status post stent placement.  He has depression.  He had a kidney stone removed about 25 years ago.,CURRENT MEDICATIONS: , He takes Actos, Ambien, baby aspirin, Coreg, Entocort, folic acid, Flomax, iron, Lexapro 20 mg q.h.s., Lipitor, Pentasa, Plavix, Protonix, Toprol, Celebrex and Zetia.,ALLERGIES: , He states that Imuran caused him to develop tachycardia.,SOCIAL HISTORY:,  He previously worked with pipeline work, but has been on disability for five years.  He is unsure which symptoms led him to go on disability.  He has previously smoked about two packs of cigarettes daily for 20 years, but quit about 20 years ago.  He denies alcohol or illicit drug use.  He lives with his wife.  He does not really have any hobbies.,FAMILY HISTORY: , His father died of a cerebral hemorrhage at age 49.  His mother died in her 70s from complications of congestive heart failure.  He has one sister who died during a cardiac surgery two years ago.  He has another sister with diabetes.  He has one daughter with hypercholesterolemia.  He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , He has dyspnea on exertion.  He states that he was evaluated by a pulmonologist and had a normal evaluation.  He has occasional night sweats.  His hearing is poor.  He occasionally develops bloody stools, which he attributes to his Crohn's disease.  He also was diagnosed with sleep apnea.  He does not wear his CPAP machine on a regular basis.  He has a history of anemia.  Otherwise, a complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  Blood pressure 160/86 HR 100 RR 16 Wt 211 pounds Pain 3/10,General Appearance:  He is well appearing in no acute distress.  He has somewhat of a flat affect.,Cardiovascular:  He has a regular rhythm without murmurs, gallops, or rubs.  There are no carotid bruits.,Chest:  The lungs are clear to auscultation bilaterally.,Skin:  There are no rashes or lesions.,Musculoskeletal:  He has no joint deformities or scoliosis.,NEUROLOGICAL EXAMINATION:,Mental Status:  His speech is fluent without dysarthria or aphasia.  He is alert and oriented to name, place, and date.  Attention, concentration, and fund of knowledge are intact.  He has 3/3 object registration and 1/3 recall in 5 minutes.,Cranial Nerves:  Pupils are equal, round, and reactive to light and accommodation.  Visual fields are full.  Optic discs are normal.  Extraocular movements are intact without nystagmus.  Facial sensation is normal.  There is no facial, jaw, palate, or tongue weakness.  Hearing is grossly intact.  Shoulder shrug is full.,Motor:  He has normal muscle bulk and tone.  There is no atrophy.  He has few fasciculations in his calf muscles bilaterally.  Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.  There is no action or percussion myotonia or paramyotonia.,Sensory:  He has absent vibratory sensation at the left toe.  This is diminished at the right toe.  Joint position sense is intact.  There is diminished sensation to light touch and temperature at the feet to the knees bilaterally.  Pinprick is intact.  Romberg is absent.  There is no spinal sensory level.,Coordination:  This is intact by finger-nose-finger or heel-to-shin testing.  He does have a slight tremor of the head and outstretched arms.,Deep Tendon Reflexes:  They are 2+ at the biceps, triceps, brachioradialis, patellas, and ankles.  Plantar reflexes are flexor.  There is no ankle clonus, finger flexors, or Hoffman's signs.  He has crossed adductors bilaterally.,Gait and Stance:  He has a slightly wide-based gait.  He has some difficulty with toe walking, but he is able to walk on his heels and tandem walk.  He has difficulty with toe raises on the left.,RADIOLOGIC DATA: , MRI of the cervical spine, 09/30/08:  Chronic spondylosis at C5-C6 causing severe bilateral neuroforamining and borderline-to-mold cord compression with normal cord signal.  Spondylosis of C6-C7 causing mild bilateral neuroforamining and left paracentral disc herniation causing borderline cord compression.,Thoracic MRI spine without contrast:  Minor degenerative changes without stenosis.,I do not have the MRI of the lumbar spine available to review.,LABORATORY DATA: , 10/07/08:  Vitamin B1 210 (87-280), vitamin B6 6, ESR 6, AST 25, ALT 17, vitamin B12 905, CPK 226 (0-200), T4 0.85, TSH 3.94, magnesium 1.7, RPR nonreactive, CRP 4, Lyme antibody negative, SPEP abnormal (serum protein electrophoresis), but no paraprotein by manifestation, hemoglobin A1c 6.0, aldolase 3.9 and homocystine 9.0.,ASSESSMENT: , The patient is a 63-year-old gentleman with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue.  His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.  He has fairly normal or very mild increased reflexes including notably the presence of normal ankle jerks.,I think that the etiology of his symptoms is multifactorial.  He probably does have a mild peripheral neuropathy, but the sparing of ankle jerks suggested either the neuropathy is mild or that there is a superimposed myelopathic process such as a cervical or lumbosacral myelopathy.  He really is most concerned about the fatigue and I think it is possible due to suboptimally treated depression and suboptimally treated sleep apnea.  Whether he has another underlying muscular disorder such as a primary myopathy remains to be seen.,RECOMMENDATIONS:,1.  I scheduled him for repeat EMG and nerve conduction studies to evaluate for evidence of neuropathy or myopathy.,2.  I will review his films at our spine conference tomorrow although I am confident in Dr. Z's opinion that there is no surgical indication.,3.  I gave him a prescription for physical therapy to help with gait imbalance training as well as treatment for his neck pain.,4.  I believe that he needs to undergo psychotherapy for his depression.  It may also be worthwhile to adjust his medications, but I will defer to his primary care physician for managing this or for referring him to a therapist.  The patient is very open about proceeding with this suggestion.,5.  He does need to have his sleep apnea better controlled.  He states that he is not compliant because the face mask that he uses does not fit him well.  This should also be addressed.
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DESCRIPTION: The patient is with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue.  His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.

The patient presents with complex and multifactorial neurological and non-neurological symptoms that include gait instability, numbness, decreased dexterity, and severe fatigue. While these may not individually indicate an immediately life-threatening condition, collectively they suggest a significant impact on the patient's quality of life and potential progression of underlying conditions. Additionally, the presence of depression and untreated sleep apnea can exacerbate his current health status. The need for further diagnostic evaluation and treatment adjustments heightens the clinical stakes. Therefore, the situation is moderately high-stakes, warranting thorough and prompt attention to prevent further deterioration of the patient's health.


Medical Specialty: Consult - History and Phy.
Sample Name: H&P - Gen Med - 1

CHIEF COMPLAINT:, Diarrhea, vomiting, and abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. She was found by EMS sitting on the toilet having diarrhea, and apparently had also just vomited. Upon my questioning of the patient, she can confirm that she has been sick to her stomach and has vomited. She cannot tell me how many times. She is also unable to describe the vomitus. She also tells me that her belly has been hurting. I am unable to get any further history from the patient because, again, she is an extremely poor historian and very hard of hearing.,PAST MEDICAL HISTORY:, Per the ER documentation is hypertension, diverticulosis, blindness, and sciatica.,MEDICATIONS:, Lorazepam 0.5 mg, dosing interval is not noted; Tylenol PM; Klor-Con 10 mEq; Lexapro; calcium with vitamin D.,ALLERGIES:, SHE IS ALLERGIC TO PENICILLIN.,FAMILY HISTORY:, Unknown.,SOCIAL HISTORY:, Also unknown.,REVIEW OF SYSTEMS:, Unobtainable secondary to the patient's condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 80. Respiratory rate 18. Blood pressure 130/80. Temperature 97.6.,GENERAL: Elderly black female who is initially sleeping upon my evaluation, but is easily arousable.,NECK: No JVD. No thyromegaly.,EARS, NOSE, AND THROAT: Her oropharynx is dry. Her hearing is very diminished.,CARDIOVASCULAR: Regular rhythm. No lower extremity edema.,GI: Mild epigastric tenderness to palpation without guarding or rebound. Bowel sounds are normoactive.,RESPIRATORY: Clear to auscultation bilaterally with a normal effort.,SKIN: Warm, dry, no erythema.,NEUROLOGICAL: The patient attempts to answer questions when asked, but is very hard of hearing. She is seen to move all extremities spontaneously.,DIAGNOSTIC DATA:, White count 9.6, hemoglobin 15.9, hematocrit 48.2, platelet count 345, PTT 24, PT 13.3, INR 0.99, sodium 135, potassium 3.3, chloride 95, bicarb 20, BUN 54, creatinine 2.2, glucose 165, calcium 10.3, magnesium 2.5, total protein 8.2, albumin 3.8, AST 33, ALT 26, alkaline phosphatase 92. Cardiac isoenzymes negative x1. EKG shows sinus rhythm with a rate of 96 and a prolonged QT interval.,ASSESSMENT AND PLAN:,1. Pancreatitis. Will treat symptomatically with morphine and Zofran, and also IV fluids. Will keep NPO.,2. Diarrhea. Will check stool studies.,3. Volume depletion. IV fluids.,4. Hyperglycemia. It is unknown whether the patient is diabetic. I will treat her with sliding scale insulin.,5. Hypertension. If the patient takes blood pressure medications, it is not listed on the only medication listing that is available. I will prescribe clonidine as needed.,6. Renal failure. Her baseline is unknown. This is at least partly prerenal. Will replace volume with IV fluids and monitor her renal function.,7. Hypokalemia. Will replace per protocol.,8. Hypercalcemia. This is actually rather severe when adjusted for the patient's low albumin. Her true calcium level comes out to somewhere around 12. For now, I will just treat her with IV fluids and Lasix, and monitor her calcium level.,9. Protein gap. This, in combination with the calcium, may be suggestive of multiple myeloma. It is my understanding that the family is seeking hospice placement for the patient right now. I would have to discuss with the family before undertaking any workup for multiple myeloma or other malignancy.
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DESCRIPTION: An 85-year-old female with diarrhea, vomiting, and abdominal pain.

The situation involves a highly vulnerable patient, an 85-year-old female, presenting with serious symptoms such as diarrhea, vomiting, and abdominal pain. The patient has multiple existing medical conditions including hypertension, diverticulosis, and renal failure, and is also experiencing acute issues like pancreatitis, volume depletion, and potential multiple myeloma. The complexity of her condition, coupled with challenges in obtaining a comprehensive medical history due to her poor hearing and being a poor historian, increases the stakes. Furthermore, the patient’s advanced age, the potential for rapid deterioration, and the fact that the family is seeking hospice placement all indicate high-stakes. The situation requires careful management to stabilize the patient while considering end-of-life care discussions with the family.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Atrial Fibrillation Management

REASON FOR CONSULTATION: , Atrial fibrillation management.,HISTORY OF PRESENT ILLNESS: ,The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred by Dr. X for evaluation and management of atrial fibrillation.  The patient states that on Monday during routine Holt exam, it was detected by Dr. X that her heart was irregular on exam.  EKG obtained after that revealed atrial fibrillation, and subsequently the patient was started on Coumadin as well as having Toprol and referred for evaluation.  The patient states that for the last 3 years, she has had episodes of her heart racing.  It may last for minutes up to most 1 hour, and it will occasionally be related to eating a heavy meal or her caffeine or chocolate intake.  Denies dyspnea, diaphoresis, presyncope or syncope with the events, and she has had no episodes of chest pain.  They subsequently resolve on their own and do not limit her in anyway.  However, she states that for the last several years may be up to 7 years that she can recollect that she has been fatigued, and over the past couple of years, her symptoms have become more severe.  She said she can walk no more than 25 feet without becoming tired.  She states that she has to rest then her symptoms will go away, but she has been limited from that standpoint.  Denies peripheral edema, PND, orthopnea, abdominal pain, swelling, recent fever or chills.  She actually today has no complaints, and states that she has been compliant with her medications and has started taking her Coumadin as directed.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  Myocardial infarction in 2003.,3.  Left heart catheterization at University Hospital.,4.  Hypercholesterolemia.,5.  Arthritis.,6.  CVA in 2002 and in 2003 with right eye blindness.,PAST SURGICAL HISTORY:,1.  Left total knee replacement in 2002.,2.  Left lower quadrant abscess drainage in 12/07,FAMILY MEDICAL HISTORY: , Significant for lung and brain cancer.  There is no history that she is aware of cardiovascular disease in her family nor has any family member had sudden cardiac death.,SOCIAL HISTORY: , She is retired as a cook in a school cafeteria, where she worked for 34 years.  She retired 7 years ago because of low back pain.  She used to smoke 2-1/2 packs per day for 32 years, but quit in 1995.  Denies alcohol, and denies IV or illicit drug use.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,1.  Coumadin 5 mg a day.,2.  Toprol-XL 50 mg a day.,3.  Aspirin 81 mg a day.,4.  Hydrochlorothiazide 25 mg a day.,5.  Plendil 10 mg daily.,6.  Lipitor 40 mg daily.,REVIEW OF SYSTEMS:  ,As above stating that following her stroke, she has right eye blindness, but she does have some minimal vision in her periphery.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 138/66, pulse 96, and weight 229 pounds or 104 kg.  GENERAL:  A well-developed, well-nourished, middle-aged African American female in no acute distress.  NECK:  Supple.  No JVD.  No carotid bruits.  CARDIOVASCULAR:  Irregularly irregular rate and rhythm.  Normal S1 and S2.  No murmurs, gallops or rubs.  LUNGS:  Clear to auscultation bilaterally.  ABDOMEN:  Bowel sounds positive, soft, nontender, and nondistended.  No masses.  EXTREMITIES:  No clubbing, cyanosis or edema.  Pulses 2+ bilaterally.,LABORATORY DATA: , EKG today revealed atrial fibrillation with nonspecific lateral T-wave abnormalities and a rate of 94.,IMPRESSION:  ,The patient is a very pleasant 62-year-old African American female with atrial fibrillation of unknown duration with symptoms of paroxysmal episodes of palpitations, doing well today.,RECOMMENDATIONS:,1.  Her rate is suboptimally controlled, we will increase her Toprol-XL to 75 mg per day.,2.  We will obtain a transthoracic echocardiogram to evaluate her LV function as well as her valvular function.,3.  We will check a thyroid function panel.,4.  We will continue Coumadin as directed and to follow up with Dr. X for INR management.,5.  Given the patient's history of a stroke in her age and recurrent atrial fibrillation, the patient should be continued on Coumadin indefinitely.,6.  Depending upon the results of her transthoracic echocardiogram, the patient may benefit from repeat heart catheterization.  We will await results of transthoracic echocardiogram.,7.  We will arrange for the patient to wear a Holter monitor to monitor the rate controlled on a 24-hour period.  She will then return to the electrophysiology clinic in 1 month for followup visit with Dr. Y.,The patient was seen, discussed, and examined with Dr. Y in electrophysiology.
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DESCRIPTION: The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred for evaluation and management of atrial fibrillation.

The scenario involves the management of atrial fibrillation in a patient with a complex medical history, including hypertension, past myocardial infarction, strokes, and significant lifestyle changes. Atrial fibrillation can lead to complications such as stroke, and the patient already has a history of cerebrovascular accidents, making her management crucial. However, the situation is elective and follows standard protocols (medication adjustment, monitoring, echocardiogram), meaning it isn't an immediate life-or-death situation, but it does carry moderate risk given the potential for severe complications if not managed properly.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 45

REASON FOR CONSULT: , For evaluation of left-sided chest pain, 5 days post abdominal surgery.,PAST MEDICAL HISTORY:, None.,HISTORY OF PRESENT COMPLAINT: , This 87-year-old patient has been admitted in this hospital on 12/03/08.  The patient underwent laparoscopic appendicectomy by Dr. X.  The patient had postoperative paralytic ileus, which has resolved.  The patient had developed left-sided chest pain yesterday.  In the postoperative period, the patient has had fluid retention, had gain about 25 pounds, and he had swelling of the lower extremities.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS:  No recent fever.,ENT:  Unremarkable.,RESPIRATORY:  He denies cough but develop this left-sided chest pain, which does not increase with inspiration, pain is located on the left posterior axillary line and over the fourth and fifth rib.,CARDIOVASCULAR:  No known heart problems.,GASTROINTESTINAL:  The patient denies nausea or vomiting.  He is status post laparoscopic appendicectomy, and he is tolerating oral diet.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  Negative for diabetes or thyroid problems.,NEUROLOGIC:  No history of CVA or TIA.,Rest of review of systems unremarkable.,SOCIAL HISTORY:  ,The patient is a nonsmoker.  He denies use of alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  An 87-year-old gentleman, not toxic looking.,HEAD AND NECK:  Oral mucosa is moist.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.  There is reproducible tenderness over the left posterior-lateral axis.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Slightly distended.  Bowel sounds are positive.,EXTREMITIES:  He has 2+ to 3+ pedal swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA: , White count is 12,500, hemoglobin is 13, hematocrit is 39, and platelets 398,000.  Glucose is 123, total protein is 6, and albumin is 2.9.,ASSESSMENT AND PLAN:,1.  Ruptured appendicitis.  The patient is 6 days post surgery.  He is tolerating oral fluids and moving bowels.,2.  Left-sided chest pain, need to rule out PE by distance of pretty low probability.  The patient, however, has low-oxygen saturation.  We will do ultrasound of the lower extremity and if this is positive we would proceed with the CT angiogram.,3.  Fluid retention, manage as per surgeon.,4.  Paralytic ileus, resolving.,5.  Leukocytosis, we will monitor.
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DESCRIPTION: For evaluation of left-sided chest pain, 5 days post abdominal surgery.

The evaluation is for an 87-year-old patient who developed left-sided chest pain after abdominal surgery. Given the age of the patient and the potential for serious complications such as pulmonary embolism (PE) indicated by low-oxygen saturation, the situation requires thorough investigation given the potential life-threatening outcomes if a PE is present. Additionally, the patient's history of fluid retention and swelling of the lower extremities could complicate post-operative recovery. Although the probability of PE is considered low in this case, due to the age and post-operative status, the stakes are considerably high.


Medical Specialty: Orthopedic
Sample Name: Bbunionectomy & Metatarsal Osteotomy

PREOPERATIVE DIAGNOSIS:  ,Tailor's bunion and neuroma of the second and third interspace of the left foot.,POSTOPERATIVE DIAGNOSIS:, Tailor's bunion and neuroma of the second and third interspace, left foot.,PROCEDURE PERFORMED:,1.  Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.,2.  Excision of nerve lesion with implantation of the muscle belly of the left second interspace.,3.  Excision of nerve lesion in the left third interspace.,ANESTHESIA:  ,Monitored IV sedation with local.,HISTORY:  ,This is a 37-year-old female who presents to ABCD's preoperative holding area, n.p.o. since mid night, last night for surgery of her painful left second and third interspaces and her left fifth metatarsal.  The patient has attempted conservative correction and injections with minimal improvement.  The patient desires surgical correction at this time.  The patient states that her pain has been increasingly worsening with activity and with time and it is currently difficult for her to ambulate and wear shoes.  At this time, the patient desires surgical intervention and correction.  The risks versus benefits of the procedure have been explained to the patient in detail by Dr. X and consent was obtained.,PROCEDURE IN DETAIL: , After an IV was instituted by the Department of Anesthesia in the preoperative holding area, the patient was taken to the Operating Suite via cart and placed on the operating table in the supine position.  A safety strap was placed across her waist for protection.,Next, a pneumatic ankle tourniquet was applied around her left ankle over copious amounts of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of a mixture of 4.5 cc of 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1 cc of Solu-Medrol per 10 cc dose was administered to the patient for local anesthesia.  The foot was then prepped and draped in the usual sterile orthopedic manner.  The foot was then elevated and a tourniquet was then placed at 230 mmHg after applying Esmarch bandage.  The foot was then lowered down the operative field and sterile stockinet was draped.  The stockinet was then reflected.  Attention was then directed to the second intermetatarsal interspace.  After testing the anesthesia, a 4 cm incision was placed using a #10 blade over the dorsal surface of the foot in the second intermetatarsal space beginning from proximal third of the metatarsals distally to and beyond the metatarsal head.  Then, using #15 blade the incision was deepened through the skin into the subcutaneous tissue.  Care was taken to identify and avoid or to cauterize any local encountered vascular structures.  Incision was deepened using the combination of blunt and dull dissection using Mayo scissors, hemostat, and a #15 blade.  The incision was deepened distally down to the level of the deep transverse metatarsal ligament which was reflected and exposure of the intermetatarsal space was appreciated.  The individual branches of the plantar digital nerve were identified extending into the second and third digits plantarly.  These endings were dissected distally and cut at their most distal portions.  Following this, the nerve was dissected proximally into the common nerve and dissected proximally into the proximal portion of the intermetatarsal space.  Using careful meticulous dissection, there was noted to a be a enlarged bulbous mass of fibers and nerve tissue embedded with the adipose tissue.  This was also cut and removed.  The proximal portion of the nerve stump was identified and care was taken to suture this into the lumbrical muscle to leave no free nerve ending exposed.  Following this, the interspace was irrigated with copious amounts of sterile saline and interspace explored for any other portions of nerve which may been missed on the previous dissection.  It was noted that no other portions of the nerve were detectable and the proximal free nerve ending was embedded and found to be ________ the lumbrical muscle belly.  Following this, the interspace was packed using iodoform gauze packing and was closed in layers with the packing extruding from the wound.  Attention was then directed to the third interspace where in a manner as mentioned before.  A dorsal linear incision which measured 5 cm was made over the third interspace extending from the proximal portion of the metatarsal distally to the metatarsal head.  Like before, using a combination of blunt and dull dissection, with sharp dissection the incision was deepened down with care taken to cauterize all retracting vascular structures which were encountered.,The incision was deepened down to the level of the subcutaneous tissue and then down deeper to the interspace of the third and fourth metatarsal.  The dissection was deepened distally down to the level of the transverse intermetatarsal ligament, where upon this was reflected and the nerve fibers to the third and fourth digit plantarly were identified.  These were once again dissected distally out and transected at their most distal portions.  Care was then taken to dissect the nerve proximally into the proximal metatarsal region.  No other branches of the nerve were identified and the nerve in its entirety along with fibrous tissue encountered in the area was removed.  The proximal portion of the nerve which remained was not large enough to suture into lumbrical muscle as was done in the previous interspace.  Half of the nerve was transected proximally as was feasible and no exposed ending was noted.  Incision was then flushed and irrigated using sterile saline.  Following this, the incision wound was packed with iodoform gauze packed and closed in layers using as before #4-0 Vicryl and #4-0 nylon suture.,Following this, attention was directed to the fifth metatarsal head where a lateral 4 cm incision was placed along the lateral distal shaft and head of the fifth metatarsal using a fresh #10 blade.  The incision was then deepened using #15 blade down to the level of the subcutaneous tissue.  Care was taken to reflect any neurovascular structures which were encountered.  Following this the incision was deepened down to the level of the periosteum and periosteum was reflected, using the sharp dissection, to expose the head of the metatarsal along with the neck region.  After adequate exposure of the fifth metatarsal head was achieved, an oblique incision directed from distal lateral to proximal medial in a sagittal plane was performed and the head of the fifth metatarsal was shifted medially.  Following this, an OrthoSorb pin was retrograded through the fifth metatarsal head into the neck of the fifth metatarsal and was cut off first with the lateral surfaces of bone.  OrthoSorb pin was noted to be intact and the fifth metatarsal head was in good alignment and position.  Following this, the sagittal saw and the #138 blade were used to provide rasping and smoothing of the sharp acute edges of bone laterally.  Following this, the periosteum was closed using #4-0 Vicryl and the skin was closed in layers using #4-0 Vicryl and closed with running subcuticular #4-0 Monocryl suture.  Upon completion of this, the foot was noted to be in good position with good visual alignment of the fifth metatarsal head and digit.  The incisions in foot were then ________ draped in the normal manner using Owen silk, 4 x 4s, Kling, and Kerlix and covered with Coban bandage.  The tourniquet was then deflated with the total tourniquet time of 103 minutes at 230 mmHg and immediate hyperemia was noted to end digits one through five of the left foot.,The patient was then transferred to the cart and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  The patient tolerated the procedure well without any complications.  The patient was then given prescriptions for Vicoprofen #30 and Augmentin #14 to be taken twice daily.  The patient was instructed to followup with Dr. X after the weekend on Tuesday in his office.  The patient also given postoperative instructions and was placed in a postoperative shoe and instructed to limit weightbearing to the heel only, ice and elevate her foot 20 minutes every hour as tolerated.  The patient also instructed to take her medications and prescriptions as directed.  She was given the emergency contact numbers.  Postoperative x-rays were taken and the patient was discharged home in stable condition upon conclusion of this.
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DESCRIPTION: Tailor's bunionectomy with metatarsal osteotomy of the left fifth metatarsal.  Excision of nerve lesion with implantation of the muscle belly of the left second interspace.  Excision of nerve lesion in the left third interspace.

orthopedic, tailor's bunion, neuroma, nerve lesion, interspace, metatarsal, osteotomy, metatarsal osteotomy, metatarsal head, foot, distally, head, incision, nerve, intermetatarsal, portions,

The procedure described is a complex orthopedic surgery involving bunionectomy, metatarsal osteotomy, and nerve lesion excision. While surgical procedures inherently carry some level of risk, the surgery seems to have been completed without complications, and appropriate postoperative care instructions were provided. The fact that the patient was discharged in stable condition indicates that the stakes, while significant, are not at the highest level. However, as with any surgery, particularly involving the nervous system, there is a substantial risk due to potential complications that can impact the patient's mobility and overall quality of life. Hence, it is a moderately high-stakes situation from an orthopedic surgery perspective, not due to any immediate life-threatening aspects, but due to the significant impact on patient recovery and rehabilitation.