Medical Specialty: Ophthalmology
Sample Name: Decreased Vision Consult

She has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003.  She also has a history of glaucoma diagnosed in 1990 and macular degeneration.  She has been followed in her home country and is here visiting family.  She had the above-mentioned observation and was brought in on an urgent basis today.,Her past medical history includes hypertension and hypercholesterolemia and hypothyroidism.,Her medications include V-optic 0.5% eye drops to both eyes twice a day and pilocarpine 2% OU three times a day.  She took both the drops this morning.  She also takes Eltroxin which is for hypothyroidism, Plendil for blood pressure, and pravastatin.,She is allergic to Cosopt.,She has a family history of blindness in her brother as well as glaucoma and hypertension.,Her visual acuity today at distance without correction are 20/25 in the right and count fingers at 3 feet in the left eye.  Manifest refraction showed no improvement in either eye.  The intraocular pressures by applanation were 7 on the right and 18 in the left eye.  Gonioscopy showed grade 4 open angles in both eyes.  Humphrey visual field testing done elsewhere showed diffuse reduction in sensitivity in both eyes.  The lids were normal OU.  She has mild dry eye OU.  The corneas are clear OU.  The anterior chamber is deep and quiet OU.  Irides appear normal.  The lenses show well centered posterior chamber intraocular lenses OU.,Dilated fundus exam shows clear vitreous OU.  The optic nerves are normal in size.  They both appear to have mild pallor.  The optic cups in both eyes are shallow.  The cup-to-disc ratio in the right eye is not overtly large, would estimated 0.5 to 0.6; however, she does have very thin rim tissue inferotemporally in the right eye.  In the left eye, the glaucoma appears to be more advanced to the larger cup-to-disc ratio and a thinner rim tissue.,The macula on the right shows drusen with focal areas of RPE atrophy.  I do not see any evidence of neovascularization such as subretinal fluid, lipid or hemorrhage.  She does have a punctate area of RPE atrophy which is just adjacent to the fovea of the right eye.  In the left eye, she has also several high-risk drusen, but no evidence of neovascularization.  The RPE in the left eye does appear to be more diffusely abnormal although these changes do appear somewhat mild.  I do not see any dense or focal areas of frank RPE atrophy or hypertrophy.,The peripheral retinas are attached in both eyes.,Ms. ABC has pseudophakia OU which is stable and she is doing well in this regard.  She has glaucoma which likely is worse in the left eye and also likely explains her poor vision in the left eye.  The intraocular pressure in the mid-to-high teens in the left eye is probably high for her.  She has allergic reaction to Cosopt.  I will recommend starting Xalatan OS nightly.  I think the intraocular pressure in the right eye is acceptable and is probably a stable pressure for her OD.  She will need followup in the next 1 or 2 months after returning home to Israel later this week after starting the new medication which is Xalatan.,Regarding the macular degeneration, she has had high-risk changes in both eyes.  The vision in the right eye is good, but she does have a very concerning area of RPE atrophy just adjacent to the fovea of the right eye.  I strongly recommend that she see a retina specialist before returning to Israel in order to fully discuss prophylactic measures to prevent worsening of her macular degeneration in the right eye.
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DESCRIPTION: One-week history of decreased vision in the left eye.  Past ocular history includes cataract extraction with lens implants in both eyes.

ophthalmology, cataract extraction, lens implants, decreased vision, macular degeneration, intraocular pressures, rpe atrophy, eye, degeneration, glaucoma, macular, vision,

The situation involves a patient with a complex ocular history including glaucoma, macular degeneration, and recent decreased vision in one eye, prompting an urgent consultation. The patient is at risk of potential vision loss or decline in quality of life, requiring immediate attention from a retina specialist for macular degeneration and adjustment of glaucoma treatment. The stakes are high due to the possibility of irreversible vision impairment, but it is not life-threatening. The situation demands timely and precise medical intervention to prevent deterioration of the patient's condition.


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

Medical Specialty: Surgery
Sample Name: Dilatation & Curettage - D&C

PREOPERATIVE DIAGNOSIS: , Postmenopausal bleeding.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:  ,Fractional dilatation and curettage.,SPECIMENS: , Endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding.  An office endometrial biopsy was unable to be performed secondary to a stenotic internal cervical os.,FINDINGS: , Examination under anesthesia revealed a retroverted, retroflexed uterus with fundal diameter of 6.5 cm.  The uterine cavity was smooth upon curettage.  Curettings were fairly copious.  Sounding depth was 8 cm.,PROCEDURE:,  The patient was brought to the Operating Room with an IV in place.  The patient was given a general anesthetic and was placed in the lithotomy position.  Examination under anesthesia was completed with findings as noted.  She was prepped and draped and a speculum was placed into the vagina.  ,Tenaculum was placed on the cervix.  The endocervical canal was curetted using a Kevorkian curette, and the sound was used to measure the overall depth of the uterus.  The endocervical canal was dilated without difficulty to a size 16 French dilator.  A small, sharp curette was passed into the uterine cavity and curettings were obtained.,After completion of the curettage, polyp forceps were passed into the uterine cavity.  No additional tissue was obtained.  Upon completion of the dilatation and curettage, minimum blood loss was noted.,The patient was awakened from her anesthetic, and taken to the post anesthesia care unit in stable condition.
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DESCRIPTION: Fractional dilatation and curettage

Fractional dilatation and curettage

surgery, postmenopausal bleeding, endometrial, fractional dilatation, fractional dilatation and curettage, endocervical, dilatation and curettage, endocervical canal, uterine cavity, curetted, dilatation, curettings, curettage

The procedure described is a fractional dilatation and curettage (D&C), which is a common surgical procedure typically used to diagnose and treat conditions affecting the uterus, such as postmenopausal bleeding. While it involves general anesthesia and surgical intervention, and is invasive, it is generally considered routine and carries a low risk when performed under appropriate medical conditions and by trained professionals. However, the stakes are higher than a non-invasive procedure because of the need for anesthesia and potential (though minimal) surgical complications. Thus, it involves moderate stakes due to the inherent risks of surgery and the importance of the diagnosis for further treatment decisions, especially in the context of postmenopausal bleeding which can sometimes signify more serious conditions.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: D&C & Laparoscopy - 1

PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Hypermenorrhea.,3.  Desire for future fertility.,4.  Failed conservative medical therapy.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Hypermenorrhea.,3.  Desire for future fertility.,4.  Failed conservative medical therapy.,5.  Possible adenomyosis.,6.  Left hydrosalpinx.,7.  Suspicion for endometriosis.,PROCEDURES PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Harmonic scalpel ablation of lesion which is suspicious for endometriosis.,ANESTHESIA: , General with endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:,  None.,INDICATIONS: , This is a 35-year-old Caucasian female gravida 1, para 0-0-1-0 with a history of spontaneous abortion.  This patient had approximately greater than ten years of chronic pelvic pain with dysmenorrhea which has significantly affected her activities of daily living.  Symptoms have not improved with prescription of oral contraceptives.,The patient has had one prior surgery for a left ovarian cystectomy done by laparoscopy in 1996.  The cyst was not diagnosed as an endometrioma.  The patient does desire future fertility; however, would like a definitive diagnosis.  Conservative medical therapy was offered i.e.  Lupron or repeat oral contraceptives, but declined.,FINDINGS:,  Bimanual exam reveals a small retroverted uterus which is easily mobile.  There were no adnexal masses.  The cervix was normal on palpation.  A fibrotic band was noted at the internal os during dilation.  On laparoscopic exam, the uterus was found to be small with mild spongy texture.  On palpation, the right ovary and adnexa were grossly normal with no evidence of endometriosis.  The left ovary was grossly normal.  The left fallopian tube had a mild hydrosalpinx present.  The left uterosacral ligament had three to four 1 mm to 2 mm lesions that were vesicular in nature consistent with endometriosis.  The vesicouterine reflection in the anterior aspect of the uterus were within normal limits as were the posterior cul-de-sac.  The liver appeared grossly normal.  There were no obvious pelvic adhesions.  The left internal inguinal ring is somewhat patent, however, there is no bowel or viscera protruding through it.,PROCEDURE:  ,The patient was seen in the preop suite.  History was reviewed and all questions were answered.  The patient was then taken to the operative suite where she was placed under general anesthesia with endotracheal tube.  She was placed in a dorsal lithotomy position in Allen stirrups.  She was prepped and draped in the normal sterile fashion.  Her bladder was drained with a red Robinson catheter producing approximately 100 cc of clear yellow urine.  A bimanual exam was performed by Dr. X, Dr. Y, and Dr. Z with above findings noted.  A sterile weighted speculum was placed in posterior aspect of the vagina and the anterior aspect of the cervix was grasped with vulsellum tenaculum.  There was an attempt to place the uterine sound through the external and internal cervical os, however, secondary to a fibrotic band at the internal os that was impossible.  A #9 dilator was allowed to remain in the cervix for minimal manipulation while attention was then turned to the abdomen.  An infraumbilical incision was made using skin scalpel.  The Veress needle was placed and CO2 was insufflated.  It was immediately noticed that the pressures were inconsistent with intraabdominal insufflation and the CO2 was discontinued and Veress needle was completely removed.  A second attempt placement of the Veress needle into the abdomen was successful and CO2 was insufflated approximately 3 liters with minimal intraabdominal pressure.  The #12 port was placed and the laparoscope was inserted.  Attention was then turned back to the uterus and with the assistance of current hemostat to bluntly dissect the fibrotic band of the internal os.,Successful sounding of the uterus showed an 8-cm uterus that was in a retroverted position.  The cervix was serially dilated using Hank dilators to allow for introduction of the sharp curette.  A curettage was then performed and specimen of the endometrium was sent for pathologic evaluation.  This procedure was performed under direct laparoscopic visualization.  Laparoscopic evaluation of the pelvis was performed and the above findings noted.  A second abdominal incision was performed suprapubically using a skin scalpel and the Veress needle was placed through the incision successfully under direct visualization.  A #5 port was then placed through the sheath and the uterine manipulator was used to complete visualization.  The manipulator was then removed and the Harmonic scalpel was placed through the #5 port.  The Harmonic scalpel was used then to ablate the 1 mm vesicular lesions on the left uterosacral ligament.  The lesions were suspect for endometriosis, however, they were not diagnostic of endometriosis.  There was also present a 3 mm to 5 mm submucosal uterine fibroid on the right lower uterine segment.  The Harmonic scalpel was removed from the abdomen as was the #5 port.  The incision was internally found to be hemostatic.  The laparoscope was then removed from the abdomen.  The abdomen was desufflated.  The introducer was then replaced into the #12 port and the #12 port was removed from the abdomen.  The uterine manipulator was removed from the uterus and the cervix was found to be hemostatic.  The weighted speculum was then removed.  The patient taken out of dorsal lithotomy position.  She was recovered from general anesthesia and taken to the postoperative suite for complete recovery.  The patient's discharge instructions will include a followup in one to two weeks in Dr. X's office for discussion of pathology.  Her family was notified of the findings.  She will be instructed not to have intercourse or use tampons or douche for the next two weeks.  The patient will be sent home with a prescription for Darvocet for pain.
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DESCRIPTION: Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis.  Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative medical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.

The situation involves a surgical procedure to address chronic pelvic pain, hypermenorrhea, and investigate possible conditions like adenomyosis and endometriosis in a patient with a desire for future fertility. Any surgery carries inherent risks, including anesthesia-related risks, risk of infection, complications, and the potential impact on future fertility. The stakes are heightened by the patient's reproductive considerations. However, the surgery was performed successfully with no complications and minimal estimated blood loss, which mitigates some of the stakes. Nevertheless, due to the complexity and potential implications for the patient's future fertility and quality of life, this scenario can be considered relatively high-stakes.


Medical Specialty: Orthopedic
Sample Name: Total Hip Replacement - 1

PROCEDURE:,  Total hip replacement.,PROCEDURE DESCRIPTION:,  The patient was bought to the operating room and placed in the supine position.  After induction of anesthesia, the patient was turned on the side and secured in the hip table.  An incision was made, centered over the greater trochanter.  Dissection was sharply carried down through the subcutaneous tissues.  The gluteus maximus was incised and split proximally.  The piriformis and external rotators were identified.  These were removed from their insertions on the greater trochanter as a sleeve with the hip capsule.  The hip was dislocated.  A femoral neck cut was made using the guidance of preoperative templating.  The femoral head was removed.  Extensive degenerative disease was found on the femoral head as well as in the acetabulum.,Baseline leg-length measurements were taken.  The femur was retracted anteriorly and a complete labrectomy was performed.  Reaming of the acetabulum was then performed until adequate bleeding subchondral bone was identified in the key areas.  The trial shell was placed and found to have an excellent fit.  The real shell was opened and impacted into position in the appropriate amount of anteversion and abduction.  Screws were placed by drilling into the pelvis, measuring, and placing the appropriate length screw.  Excellent purchase was obtained.  The trial liner was placed.,The femur was then flexed and internally rotated.  The extra trochanteric bone was removed, as was any leftover lateral soft tissue at the piriformis insertion.  An intramedullary hole was drilled into the femur to define the canal.  Reaming was performed until the appropriate size was reached.  The broaches were then used to prepare the femur with the appropriate amount of version.  Once the appropriate size broach was reached, it was used as a trial with head and neck placement.  Hip range-of-motion was checked in all planes, including flexion-internal rotation, the position of sleep, and extension-external rotation.  The hip was found to have excellent stability with the final chosen head-neck combination.  Leg length measurements were taken and found to be within acceptable range, given the necessity for stability.,The real stem was opened and impacted into position.  The real head was impacted atop the stem.  If cement was used, the canal was thoroughly washed and dried and plugged with a restrictor, and then the cement was injected and pressurized and the stem was implanted in the appropriate version.  Excess cement was removed from the edges of the component.  Range of motion and stability were once again checked and found to be excellent.  Adequate hemostasis was obtained.  Vigorous power irrigation was used to remove all debris from the joint prior to final reduction.,The arthrotomy and rotators were closed using #1 Ethibond through drill holes in the bone, recreating the posterior hip structural anatomy.  The gluteus maximus was repaired using 0 Ethibond and 0 Vicryl.  The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures.  The skin was closed with nylon.  Xeroform and a sterile dressing were applied followed by a cold pack and Ace wrap.  The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.
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DESCRIPTION: Total hip replacement.  An incision was made, centered over the greater trochanter.  Dissection was sharply carried down through the subcutaneous tissues.

orthopedic, range-of-motion, hip, total hip replacement, gluteus maximus, femoral head, subcutaneous tissues, incision, ethibond, trochanter, subcutaneous, acetabulum, femur

The situation involves an orthopedic surgery for total hip replacement. This is a significant surgical procedure that carries inherent risks, such as infection, blood clots, and complications related to implant positioning and stability. Although it is a routine procedure with generally good outcomes, it is still high-stakes due to the potential for life-altering consequences if complications arise. Additionally, the surgical process requires precision and expertise to ensure long-term success and patient mobility.


Medical Specialty: Neurology
Sample Name: Status Epilepticus

CHIEF COMPLAINT:,  Status epilepticus.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 6-year-old male who is a former 27-week premature infant who suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis.  At baseline, he can put about 2 to 4 words together in brief sentences.  His speech is not always easily understood; however, he is in a special education classroom in kindergarten.  He ambulates independently, but falls often.  He has difficulty with his left side compared to the right, and prefers to use the right upper extremity more than the left.  Mother reports he postures the left upper extremity when running.  He is being followed by Medical Therapy Unit and has also been seen in the past by Dr. X.  He has not received Botox or any other interventions with regard to his cerebral palsy.,The patient did require one shunt revision, but since then his shunt has done well.,The patient developed seizures about 2 years ago.  These occurred periodically, but they are always in the same and with the involvement of the left side more than right and he had an eye deviation forcefully to the left side.  His events, however, always tend to be prolonged.  He has had seizures as long as an hour and a half.  He tends to require multiple medications to stop them.  He has been followed by Dr. Y and was started on Trileptal.  At one point, The patient was taken off his medication for presumed failure to prevent his seizures.  He was more recently placed on Topamax since March 2007.  His last seizures were in March and May respectively.  He is worked up to a dose of 25 mg capsules, 2 capsules twice a day or about 5 mg/kg/day at this point.,The patient was in his usual state of health until early this morning and was noted to be in seizure.  His seizure this morning was similar to the previous seizures with forced deviation of his head and eyes to the left side and convulsion more on the left side than the right.  Family administered Diastat 7.5 mg x1 dose.  They did not know they could repeat this dose.  EMS was called and he received lorazepam 2 mg and then in the emergency department, 15 mg/kg of fosphenytoin.  His seizures stopped thereafter, since that time, he had gradually become more alert and is eating, and is nearly back to baseline.  He is a bit off balance and tends to be a bit weaker on the left side compared to baseline postictally.,REVIEW OF SYSTEMS: , At this time, he is positive for a low-grade fever, he has had no signs of illness otherwise.  He does have some fevers after his prolonged seizures.  He denies any respiratory or cardiovascular complaints.  There is no numbness or loss of skills.  He has no rashes, arthritis or arthralgias.  He has no oropharyngeal complaints.  Visual or auditory complaints.,PAST MEDICAL HISTORY: , Also positive for some mild scoliosis.,SOCIAL HISTORY: , The patient lives at home with mother, father, and 2 other siblings.  There are no ill contacts.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-nourished, well-hydrated male, in no acute distress.,VITAL SIGNS:  His vital signs are stable and he is currently afebrile.,HEENT:  Atraumatic and normocephalic.  Oropharynx shows no lesions.,NECK:  Supple without adenopathy.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm, no murmurs.,ABDOMEN:  Benign without organomegaly.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  The patient is alert and will follow instructions.  His speech is very dysarthric and he tends to run his words together.  He is about 50% understandable at best.  He does put words and sentences together.  His cranial nerves reveal his pupils are equal, round, and reactive to light.  His extraocular movements are intact.  His visual fields are full.  Disks are sharp bilaterally.  His face shows left facial weakness postictally.  His palate elevates midline.  Vision is intact bilaterally.  Tongue protrudes midline.,Motor exam reveals clearly decreased strength on the left side at baseline.  His left thigh is abducted at the hip at rest with the right thigh and leg straight.  He has difficulty using the left arm and while reaching for objects, shows exaggerated tremor/dysmetria.  Right upper extremity is much more on target.  His sensations are intact to light touch bilaterally.  Deep tendon reflexes are 2+ and symmetric.  When sitting up, he shows some truncal instability and tendency towards decreased truncal tone and kyphosis.  He also shows some scoliotic curve of the spine, which is mild at this point.  Gait was not tested today.,IMPRESSION: , This is a 6-year-old male with recurrent status epilepticus, left hemiparesis, history of prematurity, and intraventricular hemorrhage.  He is on Topamax, which is at a moderate dose of 5 mg/kg a day or 50 mg twice a day.  At this point, it is not clear whether this medication will protect him or not, but the dose is clearly not at maximum, and he is tolerating the dose currently.  The plan will be to increase him up to 50 mg in the morning, and 75 mg at night for 2 weeks, and then 75 mg twice daily.  Reviewed the possible side effects of higher doses of Topamax, they will monitor him for language issues, cognitive problems or excessive somnolence.  I also discussed his imaging studies, which showed significant destruction of the cerebellum compared to other areas and despite this, the patient at baseline has a reasonable balance.  The plan from CT standpoint is to continue stretching program, continue with medical therapy unit.  He may benefit from Botox.,In addition, I reviewed the Diastat protocol with parents and given the patient tends to go into status epilepticus each time, they can administer Diastat immediately and not wait the standard 2 minutes or even 5 minutes that they were waiting before.  They are going to repeat the dose within 10 minutes and they can call EMS at any point during that time.  Hopefully at home, they need to start to abort these seizures or the higher dose of Topamax will prevent them.  Other medication options would include Keppra, Zonegran or Lamictal.,FOLLOWUP: , Followup has already been scheduled with Dr. Y in February and they will continue to keep that date for followup.
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DESCRIPTION: A 6-year-old male who is a former 27-week premature infant, suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis.

Status epilepticus is a severe neurological condition where the brain is in a state of persistent seizure, requiring immediate medical intervention to prevent significant brain damage or even death. The patient, having a history of prolonged seizures, developmental delay, and being a former premature infant with additional complications such as a history of intraventricular hemorrhage, is at a high risk due to these combined factors. The situation is critical because frequent prolonged seizures can severely impact the child's neurological development and overall health. The management plan includes medication adjustment and emergency protocols, indicating the seriousness of the condition.


Medical Specialty: Radiology
Sample Name: Echocardiogram - 2

EXAM:,  Echocardiogram.,INDICATION: , Aortic stenosis.,INTERPRETATION: , Transthoracic echocardiogram was performed of adequate technical quality.  Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function.  Ejection fraction is 60% without any obvious wall motion abnormality.  Left atrium and right side chambers are of normal size and dimensions.  Aortic root has normal diameter.,Mitral and tricuspid valves are structurally normal except for minimal annular calcification.  Valvular leaflet excursion is adequate.  Aortic valve reveals annular calcification.  Fibrocalcific valve leaflets with decreased excursion.  Atrial and ventricular septum are intact.  Pericardium is intact without any effusion.  No obvious intracardiac mass or thrombi noted.,Doppler reveals mild mitral regurgitation, mild-to-moderate tricuspid regurgitation.  Estimated pulmonary pressure of 48.  Systolic consistent with mild-to-moderate pulmonary hypertension.  Peak velocity across the aortic valve is 3.0 with a peak gradient of 37, mean gradient of 19, valve area calculated at 1.1 sq. cm consistent with moderate aortic stenosis.,IN SUMMARY:,1. Concentric hypertrophy of the left ventricle with normal function.,2. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm.
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DESCRIPTION: Echocardiogram for aortic stenosis.  Transthoracic echocardiogram was performed of adequate technical quality.  Concentric hypertrophy of the left ventricle with normal function.  Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm

radiology, moderate aortic stenosis, annular calcification, concentric hypertrophy, aortic stenosis, echocardiogram, stenosis, valve, aortic,

The echocardiogram results indicate the presence of concentric hypertrophy of the left ventricle with normal function and moderate aortic stenosis, among other findings like mild regurgitation and signs of pulmonary hypertension. While these conditions are concerning and require medical attention, especially the moderate aortic stenosis that could progress, the current stage (moderate) does not imply an immediate life-threatening situation. Thus, it doesn't classify as extremely high-stakes at this moment, but it does require careful monitoring and possibly medical intervention to prevent progression. This interpretation would be used in the context of continuous patient management and follow-up care.


Medical Specialty: Surgery
Sample Name: Electrofulguration - Bladder Tumor

PREOPERATIVE DIAGNOSIS: , Recurrent bladder tumors.,POSTOPERATIVE DIAGNOSIS:,  Recurrent bladder tumors.,OPERATION: , Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.,ANESTHESIA:,  General.,INDICATIONS: , A 79-year-old woman with recurrent bladder tumors of the bladder neck.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, prepped and draped in lithotomy position under satisfactory general anesthesia.  A #21-French cystourethroscope was inserted into the bladder.  Examination of the bladder showed approximately a 3-cm area of erythema and recurrent papillomatosis just above and lateral to the left ureteral orifice.  No other lesions were noted.  Using a cold punch biopsy forceps, a random biopsy was obtained.  The entire area was electrofulgurated using the Bugbee electrode.  The patient tolerated the procedure well and left the operating room in satisfactory condition.
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DESCRIPTION: Cystoscopy, TUR, and electrofulguration of recurrent bladder tumors.

surgery, bladder neck, bladder tumors, cystoscopy, tur, electrofulguration, bladder

The case involves a surgical procedure on a 79-year-old woman with recurrent bladder tumors. The procedure includes cystoscopy, transurethral resection (TUR), and electrofulguration. Given the patient's age and the recurrent nature of her condition, there is a significant underlying health concern. Surgery always carries inherent risks, including those related to anesthesia, potential complications from the procedure, and the condition itself, which in this case involves recurrent tumors, suggesting cancer. However, the procedure was described as being completed successfully with the patient in satisfactory condition. This indicates that while the stakes are high due to the nature of surgical intervention and potential cancer, the situation was managed well.


Medical Specialty: Dentistry
Sample Name: Jaw Pain - ER Visit

CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS:  ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear.  Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began.  The patient denies any facial swelling.  No headache.  No swelling to the throat.  No sore throat.  No difficulty swallowing liquids or solids.  No neck pain.  No lymph node swelling.  The patient denies any fever or chills.  Denies any other problems or complaints.,REVIEW OF SYSTEMS:,  CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  HEENT:  No headache.  No neck pain.  No eye pain or vision change.  No rhinorrhea.  No sinus congestion, pressure, or pain.  No sore throat.  No throat swelling.  The patient does have the toothache on the left lower side that radiates towards his left ear as previously described.  The patient does not have ear pain or hearing change.  No pressure in the ear.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath.  GASTROINTESTINAL:  No nausea or vomiting.  No abdominal pain.  MUSCULOSKELETAL:  No back pain.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No speech change.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY:,  None.,CURRENT MEDICATIONS: , None.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient smokes marijuana.  The patient does not smoke cigarettes.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be healthy.  The patient is calm, comfortable in no acute distress, looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctivae bilaterally.  Nose, normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  Ears are normal without any sign of infection.  No erythema or swelling of the canals.  Tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it.  MOUTH:  The patient has a dental fracture at tooth #18.  The patient states that the fracture is a couple of months old.  The patient does not have any obvious dental caries.  The gums are normal without any erythema, swelling, or evidence of infection.  There is no fluctuance or suggestion of abscess.  There is slight tenderness of the tooth #18.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion, or swelling.  Mucous membranes are moist.  Floor of the mouth is normal without any tenderness or swelling.  No suggestion of abscess.  There is no pre or post auricular lymphadenopathy either.  NECK:  Supple.  Nontender.  Full range of motion.  No meningismus.  No cervical lymphadenopathy.  No JVD.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to the back, arms, or legs.  The patient has normal use of the extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  No evidence of clinical intoxification.  HEMATOLOGIC/LYMPHATIC:  No lymphadenitis is palpated.,DIAGNOSES:,1.  ACUTE LEFT JAW PAIN.,2.  #18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE.,3.  ELEVATED BLOOD PRESSURE.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  Home.,PLAN: , We will have the patient follow up with his dentist Dr. X in three to five days for reevaluation.  The patient was encouraged to take Motrin 400 mg q.6h. as needed for pain.  The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain.  He was given precautions for drowsiness and driving with the use of this medication.  The patient was also given a prescription for pen V.  The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern.
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DESCRIPTION: Patient started out having toothache, now radiating into his jaw and towards his left ear.  Ellis type II dental fracture.

dentistry, jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema,

The case involves a 58-year-old male presenting with jaw pain stemming from a toothache. The pain radiates into the jaw and towards the ear, and a dental fracture (Ellis type II) is identified. While the symptoms are uncomfortable and possibly painful for the patient, there are no immediate life-threatening signs such as swelling, fever, difficulty swallowing, or breathing issues. The patient's vital signs are mostly normal, with slightly elevated blood pressure, but no other systemic issues are noted. The patient is discharged with pain management instructions and a follow-up with a dentist. Given the lack of severe or life-threatening symptoms, the situation does not appear to be high-stakes on a medical emergency scale.


Medical Specialty: Radiology
Sample Name: Lower Extremity Arterial Doppler

RIGHT LOWER EXTREMITY:,  The arterial system was visualized showing triphasic waveform from the common femoral to popliteal and biphasic waveform at the posterior tibial artery with ankle brachial index of 0/8.,LEFT LOWER EXTREMITY:,  The arterial system was visualized with triphasic waveform from the common femoral to the popliteal artery, with biphasic waveform at the posterior tibial artery.  Ankle brachial index of 0.9.,IMPRESSION: , Mild bilateral lower extremity arterial obstructive disease.,
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DESCRIPTION: Lower Extremity Arterial Doppler

Lower Extremity Arterial Doppler

radiology, lower extremity arterial doppler, posterior tibial artery, ankle brachial index, arterial doppler, triphasic waveform, common femoral, biphasic waveform, tibial artery, ankle brachial, brachial index, lower extremity, doppler, triphasic, femoral, popliteal, brachial, waveform, extremity, arterial,

The situation describes medical imaging results that indicate mild bilateral lower extremity arterial obstructive disease. While this condition requires medical attention and follow-up, it is described as mild, suggesting that it doesn't pose an immediate life-threatening risk. However, it is still important as it could affect the patient's quality of life and requires monitoring. The stakes involve ensuring proper diagnosis and management to prevent progression.


Medical Specialty: Gastroenterology
Sample Name: Colostomy Failure

CHIEF COMPLAINT:, Colostomy failure. ,HISTORY OF PRESENT ILLNESS:, This patient had a colostomy placed 9 days ago after resection of colonic carcinoma. Earlier today, he felt nauseated and stated that his colostomy stopped filling. He also had a sensation of "heartburn." He denies vomiting but has been nauseated. He denies diarrhea. He denies hematochezia, hematemesis, or melena. He denies frank abdominal pain or fever. ,PAST MEDICAL HISTORY:, As above. Also, hypertension. ,ALLERGIES:, "Fleet enema." ,MEDICATIONS:, Accupril and vitamins. ,REVIEW OF SYSTEMS:,SYSTEMIC: The patient denies fever or chills.,HEENT: The patient denies blurred vision, headache, or change in hearing.,NECK: The patient denies dysphagia, dysphonia, or neck pain.,RESPIRATORY: The patient denies shortness of breath, cough, or hemoptysis.,CARDIAC: The patient denies history of arrhythmia, swelling of the extremities, palpitations, or chest pain.,GASTROINTESTINAL: See above.,MUSCULOSKELETAL: The patient denies arthritis, arthralgias, or joint swelling.,NEUROLOGIC: The patient denies difficulty with balance, numbness, or paralysis.,GENITOURINARY: The patient denies dysuria, flank pain, or hematuria.,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 183/108, pulse 76, respirations 16, temperature 98.7. ,HEENT: Cranial nerves are grossly intact. There is no scleral icterus. ,NECK: No jugular venous distention. ,CHEST: Clear to auscultation bilaterally. ,CARDIAC: Regular rate and rhythm. No murmurs. ,ABDOMEN: Soft, nontender, nondistended. Bowel sounds are decreased and high-pitched. There is a large midline laparotomy scar with staples still in place. There is no evidence of wound infection. Examination of the colostomy port reveals no obvious fecal impaction or site of obstruction. There is no evidence of infection. The mucosa appears normal. There is a small amount of nonbloody stool in the colostomy bag. There are no masses or bruits noted. ,EXTREMITIES: There is no cyanosis, clubbing, or edema. Pulses are 2+ and equal bilaterally. ,NEUROLOGIC: The patient is alert and awake with no focal motor or sensory deficit noted. ,MEDICAL DECISION MAKING:, Failure of colostomy to function may repre- sent an impaction; however, I did not appreciate this on physical examination. There may also be an adhesion or proximal impaction which I cannot reach, which may cause a bowel obstruction, failure of the shunt, nausea, and ultimately vomiting. ,An abdominal series was obtained, which confirmed this possibility by demonstrating air-fluid levels and dilated bowel. ,The CBC showed WBC of 9.4 with normal differential. Hematocrit is 42.6. I interpret this as normal. Amylase is currently pending. ,I have discussed this case with Dr. S, the patient's surgeon, who agrees that there is a possibility of bowel obstruction and the patient should be admitted to observation. Because of the patient's insurance status, the patient will actually be admitted to Dr. D on observation. I have discussed the case with Dr. P, who is the doctor on call for Dr. D. Both Dr. S and Dr. P have been informed of the patient's condition and are aware of his situation. ,FINAL IMPRESSION:, Bowel obstruction, status post colostomy. ,DISPOSITION:, Admission to observation. The patient's condition is good. He is hemodynamically stable.
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DESCRIPTION: Patient in ER due to colostomy failure - bowel obstruction.

The situation involves a patient experiencing colostomy failure potentially due to bowel obstruction after a surgery for colonic carcinoma. While the patient is currently hemodynamically stable and under observation, bowel obstructions following colostomy can become serious if not managed properly, potentially leading to complications like ischemia, necrosis, or infection. Given the current stable condition but potential for serious complications if not addressed, this presents a moderate to high-stakes medical scenario.


Medical Specialty: Surgery
Sample Name: Blepharoplasty - Lower Lid

An orbital block was done.  An infraorbital block was also performed with a 25 gauge needle.  A skin muscle flap was elevated by sharp dissection down to the orbital rim area.  The herniated periorbital fat was removed by opening the orbital septum with sharp dissection using a 15 blade, teasing the periorbital fat out, cross clamping the fat and removing the fat with a scissor over the clamp.  The clamp was cauterized with needle cautery and then the clamp was scarped with a 15 blade.,The remaining fat was left to fall back into the orbit.  This was done in three compartments, the middle, medial and lateral compartments.  Fat was removed from all three compartments.  Then with the mouth open and the eyes in upward gaze, the lower skin muscle flap was redraped on the eyelids and tailored to fit exactly into place and then sutured into place with multiple 6-0 silk sutures.,Bleeding was minimal.  The patient tolerated the procedure well.
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DESCRIPTION: Lower lid blepharoplasty.

Lower lid blepharoplasty.

surgery, lower lid, wydase, blepharoplasty, infraorbital block, muscle flap, orbital rim area, orbital septum, periorbital fat, subciliary incision, upward gaze, orbital, clampingNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The description details a surgical procedure known as lower lid blepharoplasty. While any surgical procedure has inherent risks, this appears to be a routine cosmetic surgery, indicated by the procedure's description involving the removal of herniated periorbital fat and repositioning of the eyelid skin. The patient tolerated the procedure well, and bleeding was minimal, suggesting it was uneventful. Although surgery involves a moderate level of stakes due to potential complications, such as infection or adverse reactions, this specific procedure description suggests it was low-risk and completed successfully without complications.


Medical Specialty: Neurology
Sample Name: Lumbosacral Polyradiculopathy

HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old woman who reports that on the 30th of October 2008, she had a rupture of her membranes at nine months of pregnancy, and was admitted to hospital and was given an epidural anesthetic.  I do not have the records from this hospital admission, but apparently the epidural was administered for approximately 14 to 18 hours.  She was sitting up during the epidural.,She did not notice any difference in her lower extremities at the time she had the epidural; however, she reports that she was extremely sleepy and may not have been aware of any change in strength or sensation in her lower extremities at that time.  She delivered on the 31st of October, by Cesarean section, because she had failed to progress and had pyrexia.,She also had a Foley catheter placed at that time.  On the 1st of November 2008, they began to mobilize her and it was at that time that she first noticed that she could not walk.  She was aware that she could not move her legs at all, and then within a few days, she was aware that she could move toes in the left foot but could not move her right foot at all.  Since that time, there has been a gradual improvement in strength to the point that she now has limited movement in her left leg and severely restricted movement in her right leg.  She is not able to walk by herself, and needs assistance to stand.  She was discharged from hospital after the Cesarean section on the 3rd of November.  Unfortunately, we do not have the records and we do not know what the discussion was between the anesthesiologist and the patient at the time of discharge.  She was then seen at ABC Hospital on November 05, 2008.  She had an MRI scan of her spine, which showed no evidence of an abnormality, specifically there were no cord changes and no evidence of a hematoma.  She also had an EMG study at that time by Dr. X, which was abnormal but not diagnostic and this was repeated again in December.  At the present time, she also complains of a pressure in both her legs and in her thighs.  She complains that her right foot hurts and that she has some hyperesthesia there.  She has been taking gabapentin to try to reduce the discomfort, although she is on a very low dose and the effect is minimal.  She has no symptoms in her arms, her bowel and bladder function is normal, and her bulbar function is normal.  There is no problem with her vision, swallowing, or respiratory function.,PAST MEDICAL HISTORY: , Unremarkable except as noted above.  She has seasonal allergies.,CURRENT MEDICATIONS:,  Gabapentin 300 mg b.i.d., Centrum once a day, and another multivitamin.,ALLERGIES: , She has no medication allergies, but does have seasonal allergies.,FAMILY HISTORY: , There is a family history of diabetes and hypertension.  There is no family history of a neuropathy or other neurological disease.  She has one child, a son, born on October 31, 2008.,SOCIAL HISTORY: , The patient is a civil engineer, who currently works from home.  She is working approximately half time because of limitations imposed on her by her disability, need to attend frequent physical therapy, and also the needs of looking after her baby.  She does not smoke and does not drink and has never done either.,GENERAL PHYSICAL EXAMINATION:,VITAL SIGNS:  P 74, BP 144/75, and a pain score of 0.,GENERAL:  Her general physical examination was unremarkable.,CARDIOVASCULAR:  Normal first and second heart sound, regular pulse with normal volume.,RESPIRATORY:  Unremarkable, both lung bases were clear, and respiration was normal.,GI:  Unremarkable, with no organomegaly and normal bowel sounds.,NEUROLOGICAL EXAM:,MSE:  The patient's orientation was normal, fund of knowledge was normal, memory was normal, speech was normal, calculation was normal, and immediate and long-term recall was normal.  Executive function was normal.,CRANIAL NERVES:  The cranial nerve examination II through XII was unremarkable.  Both disks were normal, with normal retina.  Pupils were equal and reactive to light.  Eye movements were full.  Facial sensation and strength was normal.  Bulbar function was normal.  The trapezius had normal strength.,MOTOR:  Muscle tone showed a slight increase in tone in the lower extremities, with normal tone in the upper extremities.  Muscle strength was 5/5 in all muscle groups in the upper extremities.  In the lower extremities, the hip flexors were 1/5 bilaterally, hip extensors were 1/5 bilaterally, knee extension on the right was 1/5 and on the left was 3-/5, knee flexion was 2/5 on the right and 3-/5 on the left, foot dorsiflexion was 0/5 on the right and 1/5 on the left, foot plantar flexion was 4-/5 on the right and 4+/5 on the left, toe extension was 0/5 on the right and 4-/5 on the left, toe flexion was 4-/5 on the right and 4+/5 on the left.,REFLEXES:  Reflexes in the upper extremities were 2+ bilaterally.  In the lower extremities, they were 0 bilaterally at the knee and ankles.  The abdominal reflexes were present above the umbilicus and absent below the umbilicus.  The plantar responses were mute.  The jaw reflex was normal.,SENSATION:  Vibration was moderately decreased in the right great toe and was mildly decreased in the left great toe.  There was a sensory level to light touch at approximately T7 posteriorly and approximately T9 anteriorly.  There was a range of sensation, but clearly there was a decrease in sensation below this level but not complete loss of sensation.  To pain, the sensory level is even less clear, but appeared to be at about T7 on the right side.  In the lower extremities, there was a slight decrease in pin and light touch in the right great toe compared to the left.  There was no evidence of allodynia or hyperesthesia.  Joint position sense was mildly reduced in the right toe and normal on the left.,COORDINATION:  Coordination for rapid alternating movements and finger-to-nose testing was normal.  Coordination could not be tested in the lower extremities.,GAIT:  The patient was unable to stand and therefore we were unable to test gait or Romberg's.  There was no evidence of focal back tenderness.,REVIEW OF OUTSIDE RECORDS: , I have reviewed the records from ABC Hospital, including the letter from Dr. Y and the EMG report dated 12/17/2008 from Dr. X. The EMG report shows evidence of a lumbosacral polyradiculopathy below approximately T6.  The lower extremity sensory responses are essentially normal; however, there is a decrease in the amplitude of the motor responses with minimal changes in latency.  I do have the MRI of lumbar spine report from 11/06/2008 with and without contrast.  This showed a minimal concentric disc bulge of L4-L5 without disc herniation, but was otherwise unremarkable.  The patient brought a disc with a most recent MRI study; however, we were unable to open this on our computers.  The verbal report is that the study was unremarkable except for some gadolinium enhancement in the lumbar nerve roots.  A Doppler of the lower extremities showed no evidence of deep venous thrombosis in either lower extremity.  Chest x-ray showed some scoliosis on the lumbar spine, curve to the left, but no evidence of other abnormalities.  A CT pelvis study performed on November 07, 2008 showed some nonspecific fluid in the subcutaneous fat of the back, posterior to L4 and L5 levels; however, there were no pelvic masses or other abnormalities.  We were able to obtain an update of the report from the MRI of the lumbar spine with and without contrast dated 12/30/2008.  The complete study included the cervical, thoracic, and lumbar spine.  There was diffuse enhancement of the nerve roots of the cauda equina that had increased in enhancement since prior exam in November.  It was also reported that the patient was given intravenous methylprednisolone and this had had no effect on strength in her lower extremities.,IMPRESSION: , The patient has a condition that is temporarily related to the epidural injection she was given at the end of October 2008, prior to her Cesarean section.  It appears she became aware of weakness within two days of the administration of the epidural, she was very tired during the epidural and may have missed some change in her neurological function.  She was severely weak in both lower extremities, slightly worse on the right than the left.  There has been some interval improvement in her strength since the beginning of November 2008.  Her EMG study from the end of December is most consistent with a lumbosacral polyradiculopathy.  The MRI findings of gadolinium enhancement in the lumbar nerve roots would be most consistent with an inflammatory radiculitis most likely related to the epidural anesthesia or administration of the epidural.  There had been no response to IV methylprednisolone given to her at ABC.  The issue of having a lumbar puncture to look for evidence of inflammatory cells or an elevated protein had been discussed with her at both ABC and by myself.  The patient did not wish to consider a lumbar puncture because of concerns that this might worsen her condition.  At the present time, she is able to stand with aid but is unable to walk.  There is no evidence on her previous EMG of a demyelinating neuropathy.,RECOMMENDATIONS:,1.  The diagnostic issues were discussed with the patient at length.  She is informed that this is still early in the course of the problem and that we expect her to show some improvement in her function over the next one to two years, although it is unclear as to how much function she will regain.,2.  She is strongly recommended to continue with vigorous physical therapy, and to continue with the plan to mobilize her as much as possible, with the goal of trying to get her ambulatory.  If she is able to walk, she will need bilateral AFOs for her ankles, to improve her overall mobility.  I am not prescribing these because at the present time she does not need them.,3.  We discussed increasing the dose of gabapentin.  The paresthesias that she has may indicate that she is actually regaining some sensory function, although there is a concern that as recovery continues, she may be left with significant neuropathic pain.  If this is the case, I have advised her to increase her gabapentin dose from 300 mg b.i.d. gradually up to 300 mg four times a day and then to 600 mg to 900 mg four times a day.  She may need other neuropathic pain medications as needed.  She will determine whether her current symptoms are significant enough to require this increase in dosage.,4.  The patient will follow up with Dr. Y and his team at ABC Hospital.  She will also continue with physical therapy within the ABC system.
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DESCRIPTION: Briefly, the patient has a lumbosacral polyradiculopathy that is temporally related to the epidural anesthesia given to her in October of 2008.

This situation involves a significant medical condition with potential long-term impacts on the patient's mobility and quality of life. It involves a complex neurological issue that arose following an epidural during childbirth, leading to marked weakness and mobility impairment. The involvement of potential iatrogenic factors and the need for ongoing management and specialist consultations adds to the complexity and stakes of the situation, as it affects the patient's ability to function independently and care for her child. Therefore, the stakes are considered high due to the potential for permanent disability and the impact on the patient's personal and professional life.


Medical Specialty: Neurology
Sample Name: Comprehensive Neurological Evaluation

As you know, the patient is a 50-year-old right-handed Caucasian female, who works as an independent contractor and as a human resources consultant.,Her neurological history first begins in December of 1987, when she had a rather sudden onset of slurred speech and the hesitancy when she started to walk.  She had HMO insurance at that time and saw a neurologist, whose name she does not recall.  She thinks that she underwent MRI scan of the brain and possibly visual evoked response and brainstem auditory evoked response tests.  She was told that all the tests were normal and no diagnosis was made.,The slurred speech resolved after a few weeks, but her gait hesitancy persisted for a number of years and then finally partially improved.  She also began to note that she would fatigue after very prolonged walking.,In about 1993, she developed bladder urgency and frequency along with some nocturia.  She saw a urologist and underwent urodynamic testing.  She was diagnosed as having "overactive bladder", but the cause of this was never determined.  She was treated with medications, possibly Ditropan, without much benefit.  She also developed a dry mouth from the medication and so she discontinued it.,Also in about 1993, she began to note an uncomfortable "stiffness" in her feet and slight swelling of the ankles.  Apparently, the swelling was not visible by others.  She saw multiple physicians and was told that it was "not arthritis", but no definite diagnosis was ever established.  She saw at least two rheumatologists on several occasions and blood tests were all normal.  No clear-cut diagnosis was ever made and the patient simply learned to live with these symptoms.,However, over time she noted that the symptoms in her legs seemed to worsen somewhat.  She states from time-to-time she could "barely walk".  She felt as if her balance is impaired and she felt as if she were "walking on stilts".  She tried arch supports from a podiatrist without any benefit.  She began to tire more easily when walking.,In 2002 she was seen by a podiatrist, who noticed an abnormal gait and recommended that she see a neurologist.,In the fall of 2002, she was seen by Dr. X.  He ordered an MRI scan of her brain and lumbar spine.  He also did some sort of nerve testing and possibly visual evoked response testing.  After reviewing everything, he diagnosed multiple sclerosis.  However, prior to starting her on immunomodulatory therapy, he referred her for a second opinion to Dr. Y, in January of 2003.  Dr. Y confirmed the diagnosis of multiple sclerosis.,The patient then returned to Dr. X and was started on Avonex.  She continued on it for about six months.  However, it made her feel much more stiff and delayed and so she finally stopped it.  She also recalled being tried on baclofen by Dr. X, but again it did not benefit her and made her feel slightly dizzy.  So, she discontinued it also.,At that point in time, she decided to try a program of "good nutrition, vitamin supplements, and fish oil".,In December 2004 and extending up to February 2005, she began to note progressively more severe swelling and stiffness in the distal lower extremities.  She began to have to use a cane.  She was seen in neurological consultation by Dr. Z.  She was treated with a Medrol Dosepak.  Her spasticity and swelling seemed to improve dramatically.  However, within about two weeks symptoms were back to baseline.,She was then treated with intravenous Solu-Medrol 500 mg daily for five days followed by a prednisone or Medrol taper (July 2005).  This seemed to be less helpful than the oral steroids, but was partially beneficial.  However, it wore off once again.,A repeat MRI scan of the brain in April 2005 was said to "look better".  She was started on Zanaflex for her lower extremity spasticity without benefit.,Finally six days ago, she was restarted on oral prednisone 10 mg tablets.  She takes one-half tablet daily and this again has seemed to reduce the swelling and stiffness in her legs.  She continues on the prednisone in the same dosage for relief of the spasticity.,She has not been on any other immunomodulatory agents.,The patient does note some complaints of mild heat sensitivity and mild easy fatigability.  There is no history of diplopia, dysarthria, aphasia, focal weakness, numbness, paresthesias, cognitive dysfunction, or memory dysfunction.,PAST MEDICAL HISTORY: , Essentially noncontributory.,ALLERGIES:,  The patient is allergic to LOBSTER and VICODIN.  She feels that she is probably allergic to IODINE.,SOCIAL HISTORY:,  She does not smoke.  She takes one glass of wine per day.,PAST SURGICAL HISTORY: , She has not had any prior surgeries.  Her general health has been excellent except for the above-indicated problems.,REVIEW OF OUTSIDE RADIOLOGICAL STUDIES:,  The patient brought with her today MRI scans of the brain, thoracic spine, and lumbosacral spine performed on 11/14/02 on a 1.5-Tesla magnet.  There are numerous T2 hyperintense lesions in the periventricular and subcortical white matter of the brain and at least one lesion is in the corpus callosum.  There appear to be Dawson's fingers.  The MRI of the thoracic and lumbosacral spines did not reveal any significant abnormalities.,Also available are the MRI scans of the brain, cervical spine, thoracic spine, and lumbosacral spine performed on a 0.35-Tesla magnet on 04/22/05.  The MRI of the brain shows that one of the prior lesions has resolved and there appear to be one or two more lesions.,However, the quality of the newer scan is only 0.35-Tesla and is suboptimal.  Visualization of the cord is also suboptimal, but there are no clear-cut extraaxial or complexities of the spinal cord.  It is difficult to be certain that there are no intra-axial lesions, but I could not clearly see one.,PHYSICAL EXAMINATION:,Vital signs:  Blood pressure 151/88, pulse 92, temperature 99.5ºF, and weight 124 lb (dressed).,General:  Well-developed, well-nourished female in no acute distress.,Head:  Normocephalic, without evidence of trauma or bruits.,Neck:  Supple, with full range of motion.  No spasm or tenderness.  Carotid pulsations are of normal volume and contour bilaterally without bruits.  No thyromegaly or adenopathy.,Extremities:  No clubbing, cyanosis, edema, or deformity.  Range of motion full throughout.,NEUROLOGICAL EXAMINATION:,Mental Status:  Awake, alert, oriented to time, place, and person; appropriate.  Recent and remote memory intact.  No evidence of right-left confusion, finger agnosia, dysnomia or aphasia.,CRANIAL NERVES,:,II:  Visual fields full to confrontation.  Fundi benign.,III, IV, VI:  Extraocular movements full throughout, without nystagmus.  No ptosis.  Pupils equal, round and react briskly to light and accommodation.,V:  Normal sensation to light touch and pinprick bilaterally.  Corneal reflexes equal bilaterally.  Motor function normal.,VII:  No facial asymmetry.,VIII:  Hears finger rub bilaterally.  Weber and Rinne tests normal.,IX & X:  Palate elevates symmetrically bilaterally with phonation.  Gag reflex equal bilaterally.,XI:  Sternocleidomastoid and upper trapezius normal tone, bulk and strength bilaterally.,XII:  Tongue midline without atrophy or fasciculations.  Rapid alternating movements normal.  No dysarthria.,Motor:  Tone, bulk, and strength are normal in both upper extremities.  In the lower extremities, there is moderate spasticity on the right and moderately severe spasticity on the left.  There are bilateral Achilles' contractures more so on the left than the right and also a slight left knee flexion contracture.,Strength in the lower extremities is rated as follows on a 5-point scale (right/left):  Iliopsoas 4+/5-, quadriceps 5-/5-, tibialis anterior 4+/4+, and gastrocnemius 5/5.  There are no tremors, fasciculations or abnormal involuntary movements.
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DESCRIPTION: A woman presents for neurological evaluation with regards to a diagnosis of multiple sclerosis.

The situation involves a comprehensive neurological evaluation addressing multiple sclerosis in a patient with a complex medical history. Multiple sclerosis is a chronic, potentially disabling disease of the brain and spinal cord, and the patient has a history of significant symptoms affecting her quality of life. High-stakes evaluations might involve diagnostic uncertainty, rapid progression of symptoms, or decisions that could affect the patient’s long-term management and well-being. Given that diagnosis and management of multiple sclerosis can significantly impact the patient’s lifestyle and health outcomes, this evaluation carries important consequences.


Medical Specialty: Orthopedic
Sample Name: Carpal Tunnel Release

PROCEDURE PERFORMED: , Carpal tunnel release.,INDICATIONS FOR SURGERY: , Nerve conduction study tests diagnostic of carpal tunnel syndrome.  The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.,PROCEDURE:  ,The patient was brought to the operating room and, following a Bier block to the operative arm, the arm was prepped and draped in the usual manner.,Utilizing an incision that was laid out to extend not more distally than the thumb web space or proximally to a position short of crossing the most prominent base of the palm and in line with the longitudinal base of the thenar eminence in line with the fourth ray, the soft tissue dissection was carried down sharply through the skin and subcutaneous fat to the transverse carpal ligament.  It was identified at its distal edge.  Using a hemostat to probe the carpal tunnel, sharp dissection utilizing scalpel and iris scissors were used to release the carpal tunnel from a distal-to-proximal direction in its entirety.  The canal was probed with a small finger to verify no evidence of any bone prominences.  The nerve was examined for any irregularity.  There was slight hyperemia of the nerve and a slight hourglass deformity.  Following an irrigation, the skin was approximated using interrupted simple and horizontal mattress #5 nylon suture.  A sterile dressing was applied.,The patient was taken to the recovery room in satisfactory condition.,The time of the Bier block was 30 minutes.,COMPLICATIONS: , None noted.
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DESCRIPTION: Carpal tunnel release.  Nerve conduction study tests diagnostic of carpal tunnel syndrome.  The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.

orthopedic, carpal tunnel syndrome, carpal ligament, nerve conduction study, carpal tunnel release, bier block, carpal tunnel, tunnel, carpal,

The procedure described is a carpal tunnel release, which is a common orthopedic surgery aimed at relieving pressure on the median nerve. This procedure is typically performed on an outpatient basis and is considered routine, especially given that there were no noted complications. While all surgeries carry some level of risk, carpal tunnel release is generally considered low-risk with a high success rate. Therefore, the stakes involved in this particular case are relatively low.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 29

CHIEF COMPLAINT: , This is a previously healthy 45-year-old gentleman.  For the past 3 years, he has had some intermittent episodes of severe nausea and abdominal pain.  On the morning of this admission, he had the onset of severe pain with nausea and vomiting and was seen in the emergency department, where Dr. XYZ noted an incarcerated umbilical hernia.  He was able to reduce this, with relief of pain.  He is now being admitted for definitive repair.,PAST MEDICAL HISTORY: , Significant only for hemorrhoidectomy.  He does have a history of depression and hypertension.,MEDICATIONS: , His only medications are Ziac and Remeron.,ALLERGIES:,  No allergies.,FAMILY HISTORY: , Negative for cancer.,SOCIAL HISTORY:,  He is single.  He has 2 children.  He drinks 4-8 beers per night and smokes half a pack per day for 30 years.  He was born in Salt Lake City.  He works in an electronic assembly for Harmony Music.  He has no history of hepatitis or blood transfusions.,PHYSICAL EXAMINATION:,GENERAL:  Examination shows a moderate to markedly obese gentleman in mild distress since his initial presentation to the emergency department.,HEENT:  No scleral icterus.,NECK:  No cervical, supraclavicular, or axillary adenopathy.,LUNGS:  Clear.,HEART:  Regular.  No murmurs or gallops.,ABDOMEN:  As noted, obese with mildly visible bulging in the umbilicus at the superior position.  With gentle traction, we were able to feel both herniated contents, which when reduced, reveals an approximately 2-cm palpable defect in the umbilicus.,DIAGNOSTIC STUDIES:  ,Normal sinus rhythm on EKG, prolonged QT.  Chest x-ray was negative.  The abdominal x-rays were read as being negative.  His electrolytes were normal.  Creatinine was 0.9.  White count was 6.5, hematocrit was 48, and platelet count was 307.,ASSESSMENT AND PLAN:,  Otherwise previously healthy gentleman, who presents with an incarcerated umbilical hernia, now for repair with mesh.
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DESCRIPTION: Patient with intermittent episodes of severe nausea and abdominal pain.

general medicine, sinus rhythm, ekg, prolonged qt, platelet count, hematocrit, umbilical hernia, emergency department, healthy, incarcerated, intermittent,

The patient is a 45-year-old who has an incarcerated umbilical hernia, which required immediate medical attention in the emergency department. While the hernia was temporarily reduced, he requires admission for surgical repair. Hernia repair, if delayed, can lead to serious complications, including bowel obstruction or ischemia. Considering this, the situation is moderately high-stakes as it involves a planned surgical intervention to prevent potential severe complications.


Medical Specialty: Pain Management
Sample Name: Lumbar Discogram

PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.
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DESCRIPTION: Lumbar discogram L2-3, L3-4, L4-5, and L5-S1.  Low back pain.

pain management, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle,

The lumbar discogram procedure described is an invasive diagnostic procedure used to evaluate low back pain, which involves multiple disc spaces being injected and assessed under fluoroscopy. The stakes can be considered moderately high due to the invasive nature of the procedure, the use of sedation, and the potential for complications such as infection, nerve damage, or exacerbation of pain. These factors make it important for the procedure to be performed accurately and safely to avoid adverse outcomes.


Medical Specialty: Consult - History and Phy.
Sample Name: Carbohydrate Counting

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

consult - history and phy., insulin pump, carbohydrate load, immune system, dietary consultation, carbohydrate ratio, blood sugars, carbohydrate counting, carbohydrate, dietary, blood, counting, insulin

The situation involves a 62-year-old patient with type I diabetes who recently experienced diabetic ketoacidosis (DKA), which is a serious complication of diabetes. The consultation focuses on carbohydrate counting to better manage her condition. Given her recent hospitalization for DKA and current elevated blood sugar levels, this is a high-stakes situation as improper management or misunderstanding of diet and insulin dosing could lead to severe health consequences, including another episode of DKA or other complications. The complexity of insulin management and the need for accurate carbohydrate counting make this a critical issue, demanding close attention and adherence to medical advice.


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

Medical Specialty: Gastroenterology
Sample Name: GI Consultation - 2

PROBLEM:  ,Chronic abdominal pain, nausea, vomiting, abnormal liver function tests., ,HISTORY: , The patient is a 23-year-old female referred for evaluation due to a chronic history of abdominal pain and extensive work-up for abnormal liver function tests and this chronic nausea and vomiting referred here for further evaluation due to the patient's recent move from Eugene to Portland.  The patient is not a great historian.  Most of the history is obtained through the old history and chart that the patient has with her.  According to what we can make out, she began experiencing nausea, vomiting, recurrent epigastric and right upper quadrant pain in 2001.  She was initially seen by Dr. A back in September 2001 for abdominal pain, nausea and vomiting.  During those times, it was suspected that part of her symptoms may be secondary to biliary disease and underwent a cholecystectomy performed in Oregon by Dr.  A in August 2001.  It was assumed that this was caused by biliary dyskinesia.  Previous to that, an upper endoscopy was performed by Dr. B in July 2001 that showed to be mild gastritis secondary to anti-inflammatory use.  Postoperatively she continued to have nausea and vomiting, right upper quadrant abdominal pain and epigastric pain similar to her gallbladder pain in the past.
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DESCRIPTION: GI Consultation for chronic abdominal pain, nausea, vomiting, abnormal liver function tests.

The situation involves a patient with chronic gastrointestinal symptoms, including abdominal pain, nausea, vomiting, and abnormal liver function tests, which have persisted over several years despite previous interventions like a cholecystectomy. These symptoms significantly impact the patient's quality of life and could be indicative of underlying serious medical conditions. However, they are not immediately life-threatening in an emergency sense, placing them at a medium level of urgency and complexity. The stakes are raised by the potential for a serious undiagnosed condition, but at this moment, there is no indication of an acute life-threatening emergency.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Tubal Ligation - Laparoscopic

PREOPERATIVE DIAGNOSIS:,  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE: , Laparoscopic tubal ligation, Falope ring method.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 10 mL.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY:  ,A 35-year-old female, P4-0-0-4, who desires permanent sterilization.  The risks of bleeding, infection, damage to other organs, and subsequent ectopic pregnancy was explained.  Informed consent was obtained.,OPERATIVE FINDINGS: , Normal appearing uterus and adnexa bilaterally.,DESCRIPTION OF PROCEDURE: , After administration of general anesthesia, the patient was placed in the dorsal lithotomy position, and prepped and draped in the usual sterile fashion.  The speculum was placed in the vagina, the cervix was grasped with the tenaculum, and a uterine manipulator inserted.  This area was then draped off the remainder of the operative field.,A 5-mm incision was made umbilically after injecting 0.25% Marcaine, 2 mL.  A Veress needle was inserted to confirm an opening pressure of 2 mmHg.  Approximately 4 liters of CO2 gas was insufflated into the abdominal cavity.  The Veress needle was removed, and a 5-mm port placed.  Position was confirmed using a laparoscope.  A second port was placed under direct visualization, 3 fingerbreadths suprapubically, 7 mm in diameter, after 2 mL of 0.25% Marcaine was injected.  This was done under direct visualization.  The pelvic cavity was examined with the findings as noted above.  The Falope rings were then applied to each tube bilaterally.  Good segments were noted to be ligated.  The accessory port was removed.  The abdomen was deflated.  The laparoscope and sheath was removed.  The skin edges were approximated with 5-0 Monocryl suture in subcuticular fashion.  The instruments were removed from the vagina.  The patient was returned to the supine position, recalled from anesthesia, and transferred to the recovery room in satisfactory condition.  Sponge and needle counts correct at the conclusion of the case.  Estimated blood loss was minimal.
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DESCRIPTION: Desires permanent sterilization.  Laparoscopic tubal ligation, Falope ring method.  Normal appearing uterus and adnexa bilaterally.

obstetrics / gynecology, tenaculum, uterine manipulator, veress needle, tubal ligation, permanent sterilization, uterus, adnexa, cavity, laparoscope, laparoscopic, needle, sterilization

The situation described is a routine surgical procedure for permanent sterilization through laparoscopic tubal ligation using the Falope ring method. While surgery always carries some level of risk, this procedure is standard practice for individuals seeking permanent sterilization and is generally considered low-risk with minimal complications. All indications are that the procedure went smoothly, with minimal blood loss and no complications reported. The stakes are relatively low from a medical perspective given the absence of complications and the routine nature of the procedure.


Medical Specialty: Urology
Sample Name: TURBT

PREOPERATIVE DIAGNOSIS:  ,Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder.,POSTOPERATIVE DIAGNOSIS: , Clinical stage Ta Nx Mx transitional cell carcinoma of the urinary bladder.,TITLE OF OPERATION: , Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy.,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 59-year-old white male, who had an initial occurrence of a transitional cell carcinoma 5 years back.  He was found to have a new tumor last fall, and cystoscopy in November showed Ta papillary-appearing lesion inside the bladder neck anteriorly.  The patient had coronary artery disease and required revascularization, which occurred at the end of December prior to the tumor resection.  He is fully recovered and cleared by Cardiology and taken to the operating room at this time for TURBT.,FINDINGS: , Cystoscopy of the anterior and posterior urethra was within normal limits.  From 12 o'clock to 4 o'clock inside the bladder neck, there was a papillary tumor with some associated blood clot.  This was completely resected.  There was an abnormal dysplastic area in the left lateral wall that was biopsied, and the remainder of the bladder mucosa appeared normal.  The ureteral orifices were in the orthotopic location.  Prostate was 15 g and benign on rectal examination, and there was no induration of the bladder.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite, and after adequate general laryngeal mask anesthesia obtained, placed in the dorsal lithotomy position and his perineum and genitalia were sterilely prepped and draped in usual fashion.  He had been given oral ciprofloxacin for prophylaxis.  Rectal bimanual examination was performed with the findings described.  Cystourethroscopy was performed with a #23-French ACMI panendoscope and 70-degree lens with the findings described.  A barbotage urine was obtained for cytology.  The cystoscope was removed and a #24-French continuous flow resectoscope sheath was introduced over visual obturator and cold cup biopsy forceps introduced.  Several biopsies were taken from the tumor and sent to the tumor bank.  I then introduced the Iglesias resectoscope element and resected all the exophytic tumor and the lamina propria.  Because of the Ta appearance, I did not intentionally dissect deeper into the muscle.  Complete hemostasis was obtained.  All the chips were removed with an Ellik evacuator.  Using the cold cup biopsy forceps, biopsy was taken from the dysplastic area in the left bladder and hemostasis achieved.  The irrigant was clear.  At the conclusion of the procedure, the resectoscope was removed and a #24-French Foley catheter was placed for efflux of clear irrigant.  The patient was then returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.
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DESCRIPTION: Cystoscopy, transurethral resection of medium bladder tumor (4.0 cm in diameter), and direct bladder biopsy.

urology, transitional cell carcinoma, urinary bladder, bladder tumor, cystoscopy, transurethral resection, acmi panendoscope, foley catheter, cold cup biopsy forceps, ta nx mx, cold cup biopsy, laryngeal mask, bladder neck, bladder, biopsy, tumor,

The situation involves a medical procedure called transurethral resection of a bladder tumor (TURBT) in a patient with a history of bladder cancer and coronary artery disease. While this procedure is relatively common in urology for non-muscle-invasive bladder cancer, it still involves general anesthesia and surgical resection, with risks related to the patient's cardiac history. Moreover, the presence of cancer represents significant stakes concerning the patient's health outcomes. However, the procedure itself is a standard treatment with well-understood risks and is part of routine management for early-stage bladder cancer. While there are important considerations, the situation does not indicate an immediate life-threatening condition, thus not extremely high stakes.


Medical Specialty: Orthopedic
Sample Name: Knee Arthroscopy

PREOPERATIVE DIAGNOSIS: , Left patellar chondromalacia.,POSTOPERATIVE DIAGNOSIS:,  Left patellar chondromalacia with tight lateral structures.,PROCEDURE:,  Left knee arthroscopy with lateral capsular release.,ANESTHESIA: , Surgery performed under general anesthesia.,TOURNIQUET TIME:  ,47 minutes.,MEDICATION:  ,The patient received 0.5% Marcaine local anesthetic 32 mL.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 14-year-old girl who started having left knee pain in the fall of 2007.  She was not seen in Orthopedic Clinic until November 2007.  The patient had an outside MRI performed that demonstrated left patellar chondromalacia only.  The patient was referred to physical therapy for patellar tracking exercises.  She was also given a brace.  The patient reported increasing pain with physical therapy and mother strongly desired other treatment.  It was explained to the mother in detail that this is a difficult problem to treat although majority of the patients get better with physical therapy.  Her failure with nonoperative treatment is below the standard 6-month trial; however, given her symptoms and severe pain, lateral capsular release was offered.  Risk and benefits of surgery were discussed.  Risks of surgery including risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure of procedure to relieve pain, need for postoperative rehab, and significant postoperative swelling.  All questions were answered, and mother and daughter agreed to the above plans.,PROCEDURE NOTE: , The patient was taken to the operating room and placed on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of left thigh.  The extremity was then prepped and draped in the standard surgical fashion.  A medial suprapatellar portal was marked on the skin as well as anteromedial and anterolateral joint line.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  Esmarch was then removed.  Incisions were then made.  Camera was initially inserted into the lateral joint line.  Visualization of patellofemoral joint revealed type 2 chondromalacia with slight lateral subluxation.  The patient did have congruent articulation about 30 degrees of knee flexion.  Visualization of the medial joint line revealed no loose bodies.  There was a small plica.  Visualization of the medial joint line revealed no significant chondromalacia.  Menisci was probed and tested with no signs of tears and instability.  ACL was noted to be intact.  The intercondylar notch and lateral joint line also revealed no significant chondromalacia or meniscal pathology.  Lateral gutter also demonstrated no loose bodies or plica.  The camera was then removed and inserted into the anteromedial portal using two 18-gauge needles.  The extent of lateral capsular release was marked using a monopolar coblator, lateral capsular release was performed.  The patient had significant improvement in anteromedial translation from 25% to 50%.  At the end of the case, all instruments were removed.  The knee was injected with 32 mL of 0.5% Marcaine with additional epinephrine.  Please note, the patient received 30 mL of 1:500,000 dilution epinephrine at the beginning of the case.  The portals were then closed using 4-0 Monocryl.  The wound was clean and dry, and dressed with Steri-Strips, Xeroform, and 4 x 4s.  The kneecap was translated medially under pressure and a bias placed.  The tourniquet was released at 47 minutes.  The patient was then placed in the knee immobilizer.  The patient tolerated the procedure well and was subsequently extubated and taken to the recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will weightbear as tolerated in the knee immobilizer.  She will start physical therapy within 1 to 2 weeks to work on patella mobilization as well as reconditioning and strengthening.  Intraoperative findings were relayed to the mother.  All questions were answered.
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DESCRIPTION: Left knee arthroscopy with lateral capsular release.

orthopedic, knee arthroscopy, lateral capsular release, chondromalacia, patellar, lateral joint line, medial joint line, lateral joint, medial joint, capsular release, joint line, arthroscopy, tourniquet, knee,

The situation described involves a surgical procedure (knee arthroscopy with lateral capsular release) on a 14-year-old patient. While knee arthroscopy is a common procedure, surgery always carries inherent risks such as anesthesia complications, infection, and failure to relieve pain. Additionally, the procedure is being performed on a young patient, which could add concerns regarding growth and long-term impacts. However, there were no complications during the surgery and the procedure is aimed at improving the patient's quality of life by addressing knee pain and mobility issues. Given these considerations, it is a moderately high-stakes situation due to the factors of surgery, patient age, and the need for continued post-operative care.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Mayoview

PROCEDURE DONE:  ,Resting Myoview and adenosine Myoview SPECT.,INDICATIONS:,  Chest pain.,PROCEDURE:,  13.3 mCi of Tc-99m tetrofosmin was injected and resting Myoview SPECT was obtained.  Pharmacologic stress testing was done using adenosine infusion.  Patient received 38 mg of adenosine infused at 140 mcg/kg/minute over a period of four minutes.  Two minutes during adenosine infusion, 31.6 mCi of Tc-99m tetrofosmin was injected.  Resting heart rate was 90 beats per minute.  Resting blood pressure was 130/70.  Peak heart rate obtained during adenosine infusion was 102 beats per minute.  Blood pressure obtained during adenosine infusion was 112/70.  During adenosine infusion, patient experienced dizziness and shortness of breath.  No significant ST segment, T wave changes, or arrhythmias were seen.,Resting Myoview and adenosine Myoview SPECT showed uniform uptake of isotope throughout myocardium without any perfusion defect.  Gated dynamic imaging showed normal wall motion and normal systolic thickening throughout left ventricular myocardium.  Left ventricular ejection fraction obtained during adenosine Myoview SPECT was 77%.  Lung heart ratio was 0.40.  TID ratio was 0.88.,IMPRESSION:,  Normal adenosine Myoview myocardial perfusion SPECT.  Normal left ventricular regional and global function with left ventricular ejection fraction of 77%.
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DESCRIPTION: Resting Myoview and adenosine Myoview SPECT

cardiovascular / pulmonary, myoview, gated dynamic imaging, myoview spect, resting myoview, spect, tc-99m, adenosine myoview, adenosine infusion, ejection fraction, myocardium, systolic thickening, tetrofosmin, adenosine myoview spect, adenosine,

This procedure involves a pharmacologic stress test using adenosine and radioactive isotopes to assess heart function and perfusion. While the procedure did cause the patient to experience dizziness and shortness of breath, the test results were normal and no serious complications occurred. Given the context, the situation is of moderate stakes due to the inherent risks involved with pharmacologic stress testing and the use of radioactive materials, but not critically high since the procedure was completed without adverse myocardial findings or significant arrhythmias.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Normal Newborn H&P Template

HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **.  Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound.  ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear.  The baby was vertex presentation.  The baby was dried, stimulated, and bulb suctioned.  Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:,  The mother is a **-year-old, G**, P** female with blood type **.  She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative.  Mother was group B strep **.  Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits.  She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:,  Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature **, heart rate **, respiratory rate **.  Dextrose stick **.  Ballard score by the RN is ** weeks.  Birth weight is ** grams, which is the ** percentile for gestational age.  Length is ** centimeters which is ** percentile for gestational age.  Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL:  **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT:  Anterior fontanelle open and flat.  Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags.  Nares patent.  Palate intact.  Mucous membranes moist.,NECK:  Full range of motion.,CARDIOVASCULAR:  Normal precordium, regular rate and rhythm.  No murmurs.  Normal femoral pulses.,RESPIRATORY;  Clear to auscultation bilaterally.  No retractions.,ABDOMEN:  Soft, nondistended.  Normal bowel sounds.  No hepatosplenomegaly.  Umbilical stump is clean, dry, and intact.,GENITOURINARY:  Normal tanner I **.  Anus patent.,MUSCULOSKELETAL:  Negative Barlow and Ortolani.  Clavicles intact.  Spine straight.  No sacral dimple or hair tuft.  Leg lengths grossly symmetric.  Five fingers on each hand and five toes on each foot.,SKIN:  Warm and pink with brisk capillary refill.  No jaundice.,NEUROLOGICAL:  Normal tone.  Normal root, suck, grasp, and Moro reflexes.  Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:,  **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1.  Routine newborn care.,2.  Anticipatory guidance.,3.  Hepatitis B immunization prior to discharge.,
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DESCRIPTION: Template for History and Physical for a newborn.

The document outlines a template for recording information about a newborn's health and medical history. This is a routine, standardized procedure for documenting the history and physical examination of newborns. The stakes are relatively standard in a medical context as these documents ensure comprehensive recording for future reference and care. However, as it deals with newborn health, the stakes are moderately high because newborns are fragile and early detection of any issues is crucial for quick intervention. But since this is a routine template, not a critical incident or emergency, the stakes are not extremely high.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pulmonary Embolism

REASON FOR CONSULTATION: , Pulmonary embolism.,HISTORY:,  The patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life.  The patient was walking in a store when she felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.  At that time, her daughter was with her.  No tonic-clonic movements.  No cyanosis.  The patient woke up on her own.  The patient currently feels fine, has mild shortness of breath upon exertion, but this is her usual for the last several years.  She cannot get up one flight of stairs, but feels short of breath.  She gets exerted and thinks to take a shower.  She does not have any chest pain, no fever or syncopal episodes.,PAST MEDICAL HISTORY,1.  Pulmonary embolism diagnosed one year ago.  At that time, she has had an IVC filter placed due to massive GI bleed from diverticulosis and gastric ulcers.  Paroxysmal atrial fibrillation and no anticoagulation due to history of GI bleed.,2.  Coronary artery disease status post CABG at that time.  She has had to stay in the ICU according to the daughter for 3 weeks due to again lower GI bleed.,3.  Mitral regurgitation.,4.  Gastroesophageal reflux disease.,5.  Hypertension.,6.  Hyperlipidemia.,7.  History of aortic aneurysm.,8.  History of renal artery stenosis.,9.  Peripheral vascular disease.,10.  Hypothyroidism.,PAST SURGICAL HISTORY,1.  CABG.,2.  Hysterectomy.,3.  IVC filter.,4.  Tonsillectomy.,5.  Adenoidectomy.,6.  Cosmetic surgery.,7.  Renal stent.,8.  Right femoral stent.,HOME MEDICATIONS,1.  Aspirin.,2.  Potassium.,3.  Lasix.,4.  Levothyroxine.,5.  Lisinopril.,6.  Pacerone.,7.  Protonix.,8.  Toprol.,9.  Vitamin B.,10.  Zetia.,11.  Zyrtec.,ALLERGIES:,  SULFA,SOCIAL HISTORY: , She used to be a smoker, not anymore.  She drinks 2 to 3 glasses of wine per week.  She is retired.,REVIEW OF SYSTEMS: , She has a history of snoring, choking for breath at night, and dry mouth in the morning.,PHYSICAL EXAMINATION,GENERAL APPEARANCE:  In no acute distress.,VITAL SIGNS:  Temperature 98.6, respirations 18, pulse 61, blood pressure 155/57, and oxygen saturation 93-98% on room air.,HEENT:  No lymph nodes or masses.,NECK:  No jugular venous distension.,LUNGS:  Clear to auscultation bilaterally.
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DESCRIPTION: Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.

The situation involves a 78-year-old woman with a significant medical history, including a previous pulmonary embolism, coronary artery disease status post-CABG, and various other serious cardiovascular and systemic conditions. The patient experienced a syncopal episode with dizziness and mild shortness of breath, symptoms that can be associated with critical cardiovascular events. Given her complex medical history and the potential life-threatening nature of recurrent pulmonary embolism or cardiovascular compromise, this is considered high-stakes.