Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Cholecystectomy - 5

PREOPERATIVE DIAGNOSIS: , Biliary colic.
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DESCRIPTION: Biliary colic.   Laparoscopic cholecystectomy.  Laparoscopic examination showed no injury from entry.  Marcaine was then injected just subxiphoid, and a 5-mm port was placed under direct visualization for the laparoscope.

gastroenterology, veress needle, gallbladder, laparoscope, laparoscopic examination, endotracheal intubation, laparoscopic cholecystectomy, biliary colic, abdomen, cholecystectomy, endotracheal, umbilicus, laparoscopic,

A laparoscopic cholecystectomy is a common surgical procedure used to remove the gallbladder when a patient experiences biliary colic, often due to gallstones. While it is a routine and minimally invasive surgery, it involves general anesthesia and requires surgical expertise to avoid complications such as bile duct injury or infection. Although not considered emergency surgery, it still carries the inherent risks associated with surgical interventions. This makes the situation moderately high-stakes due to the potential for complications and the need for careful execution by the medical team.


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

Medical Specialty: Surgery
Sample Name: Sacral Decubitus Debridement

PREOPERATIVE DIAGNOSIS:,  Stage IV necrotic sacral decubitus.,POSTOPERATIVE DIAGNOSIS:,  Stage IV necrotic sacral decubitus.,PROCEDURE PERFORMED:,  Debridement of stage IV necrotic sacral decubitus.,GROSS FINDINGS: , This is a 92-year-old African-American female who was brought into the office 48 hours earlier with a chief complaint of necrotic foul-smelling wound in the sacral region and upon examination was found to have absolutely necrosis of the fat and subcutaneous tissue in the sacral region approximately 15 cm x 15 cm.  A long discussion with the family ensued that it needs to be debrided and then cleaned and then if she cannot keep the stool out of the wound that she will probably need a diverting colostomy.,OPERATIVE PROCEDURE:  ,The patient was properly prepped and draped under local sedation.  A 0.25% Marcaine was injected circumferentially around the necrotic decubitus.  A wide excision and debridement of the necrotic decubitus taken down to the presacral fascia and all necrotic tissue was electrocauterized and removed.  All bleeding was cauterized with electrocautery and then a Kerlix stack was then placed and a pressure dressing applied.  The patient was sent to recovery in satisfactory condition.
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DESCRIPTION: Stage IV necrotic sacral decubitus.  Debridement of stage IV necrotic sacral decubitus.

surgery, diverting colostomy, sacral decubitus debridement, necrotic sacral decubitus, wound, tissue, debridement, sacral, decubitus, necrotic,

The situation involves a surgical procedure for a stage IV necrotic sacral decubitus, which is a severe pressure ulcer. These types of ulcers indicate extensive tissue damage and carry high risks of infection and other complications. The procedure involves significant medical intervention, and the potential use of a diverting colostomy if conditions like contamination with stool cannot be managed. The patient is also an elderly individual, which adds to the complexity and risk of the procedure. This makes it a high-stakes situation, as it has significant health implications for the patient.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - Respiratory Failure

DISCHARGE DIAGNOSIS:,1.  Respiratory failure improved.,2.  Hypotension resolved.,3.  Anemia of chronic disease stable.,4.  Anasarca improving.,5.  Protein malnourishment improving.,6.  End-stage liver disease.,HISTORY AND HOSPITAL COURSE:  ,The patient was admitted after undergoing a drawn out process with a small bowel obstruction.  His bowel function started to improve.  He was on TPN prior to coming to Hospital.  He has remained on TPN throughout his time here, but his appetite and his p.o. intake have improved some.  The patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the Intensive Care Unit on dopamine.  At one point, we were unsuccessful at weaning him off the dopamine, but after approximately 11 days, he finally started to tolerate weaning parameters, was successfully removed from dopamine, and has maintained his blood pressure without difficulty.  The patient also was requiring BiPAP to help with his oxygenation and it appeared that he developed a left-sided pneumonia.  This has been treated successfully with Zyvox and Levaquin and Diflucan.  He seems to be currently doing much better.  He is only using BiPAP in the evening.  As stated above, he is eating better.  He had some evidence of redness and exquisite swelling around his genital and lower abdominal region.  This may be mainly dependent edema versus anasarca.  The patient has been diuresed aggressively over the last 4 to 5 days, and this seems to have made some improvement in his swelling.  This morning, the patient denies any acute distress.  He states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation.  He will be discharged to Garden Court skilled nursing facility.,DISCHARGE MEDICATIONS/INSTRUCTIONS:,  He is going to be going with Protonix 40 mg daily, metoclopramide 10 mg every 6 hours, Zyvox 600 mg daily for 5 days, Diflucan 150 mg p.o. daily for 3 days, Bumex 2 mg p.o. daily, Megace 400 mg p.o. b.i.d., Ensure 1 can t.i.d. with meals, and MiraLax 17 gm p.o. daily.  The patient is going to require physical therapy to help with assistance in strength training.  He is also going to need respiratory care to work with his BiPAP.  His initial settings are at a rate of 20, pressure support of 12, PEEP of 6, FIO2 of 40%.  The patient will need a sleep study, which the nursing home will be able to set up.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On the day of discharge, heart rate 99, respiratory rate 20, blood pressure 102/59, temperature 98.2, O2 sat 97%.,GENERAL:  A well-developed white male who appears in no apparent distress.,HEENT:  Unremarkable.,CARDIOVASCULAR:  Positive S1, S2 without murmur, rubs, or gallops.,LUNGS:  Clear to auscultation bilaterally without wheezes or crackles.,ABDOMEN:  Positive for bowel sounds.  Soft, nondistended.  He does have some generalized redness around his abdominal region and groin.  This does appear improved compared to presentation last week.  The swelling in this area also appears improved.,EXTREMITIES:  Show no clubbing or cyanosis.  He does have some lower extremity edema, 2+ distal pedal pulses are present.,NEUROLOGIC:  The patient is alert and oriented to person and place.  He is alert and aware of surroundings.  We have not had any difficulties with confusion here lately.,MUSCULOSKELETAL:  The patient moves all extremities without difficulty.  He is just weak in general.,LABORATORY DATA: , Lab work done today shows the following:  White count 4.2, hemoglobin 10.2, hematocrit 30.6, and platelet count 184,000.  Electrolytes show sodium 139, potassium 4.1, chloride 98, CO2 26, glucose 79, BUN 56, and creatinine 1.4.  Calcium 8.8, phosphorus is a little high at 5.5, magnesium 2.2, albumin 3.9.,PLAN:  ,Discharge this gentleman from Hospital and admit him to Garden Court SNF where they can continue with his rehab and conditioning.  Hopefully, long-term planning will be discharge home.  He has a history of end-stage liver disease with cirrhosis, which may make him a candidate for hospice upon discharge.  The family initially wanted to bring the patient home, but he is too weak and requires too much assistance to adequately consider this option at this time.
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DESCRIPTION: The patient was admitted after undergoing a drawn out process with a small bowel obstruction.

discharge summary, respiratory failure, hypotension, anemia, anasarca, end-stage liver disease, drawn out process, bowel obstruction, blood pressure, dopamine, discharge,

This discharge summary outlines a patient with multiple serious health conditions such as respiratory failure, hypotension, anemia of chronic disease, and end-stage liver disease. However, the patient is stabilized and being discharged to a skilled nursing facility for continued care. While the patient's condition is serious, it is not immediately life-threatening due to the improvement in symptoms and the existence of a clear care plan, including medications and therapeutic interventions. Therefore, while the situation involves severe health issues, the stakes are not as high as an acute unmanaged crisis. The discharge plan indicates stability and ongoing care, suggesting lower immediate risk.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CVA - Discharge Summary

DIAGNOSES ON ADMISSION,1.  Cerebrovascular accident (CVA) with right arm weakness.,2.  Bronchitis.,3.  Atherosclerotic cardiovascular disease.,4.  Hyperlipidemia.,5.  Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1.  Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2.  Old coronary infarct, anterior aspect of the right external capsule.,3.  Acute bronchitis with reactive airway disease.,4.  Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5.  Atherosclerotic cardiovascular disease.,6.  Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room.  Plavix was started  in addition to baby aspirin.  He was kept on oral Zithromax for his cough.  He was given Xopenex treatment, because of his respiratory distress.  Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid.  Dr. X saw him in consultation and recommended CT angiogram.  This showed no significant obstructive lesion other than what was known on the ultrasound.  Head MRI was done and revealed the above findings.  The patient was begun on PT and improved.  By discharge, he had much improved strength in his right arm.  He had no further progressions.  His cough improved with oral Zithromax and nebulizer treatments.  His platelets also improved as well.  By discharge, his platelets was up to 107,000.  His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential.  Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate.  Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1.  PT/INR on admission was 1.03, PTT 34.7.  At the time of discharge, the patient's cough was much improved.  His right arm weakness has much improved.  His lung examination has just occasional rhonchi.  He was changed to a metered dose inhaler with albuterol.  He is being discharged home.  An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation.  He will follow up in my office in 1 week.  He is to start PT and OT as an outpatient.  He is to avoid driving his car.  He is to notify, if further symptoms.  He has 2 more doses of Zithromax at home, he will complete.  His prognosis is good.
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DESCRIPTION: Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.  2.  Old coronary infarct, anterior aspect of the right external capsule.  Acute bronchitis with reactive airway disease.

cardiovascular / pulmonary, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident

The discharge summary situation involves a patient who has experienced a cerebrovascular accident (CVA), old coronary infarct, acute bronchitis, and other significant health concerns. These are serious medical conditions that require careful management and follow-up. The document outlines a complex hospital course with various treatments and improvements, and stresses the need for outpatient physical therapy and the patient's prognosis. The stakes are high because managing and recovering from such conditions is critical to the patient's long-term health and preventing further complications.


Medical Specialty: Surgery
Sample Name: Craniotomy - Frontal Zygomatic

PREOPERATIVE DIAGNOSIS:,  Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS:,  Metopic synostosis with trigonocephaly.,PROCEDURES:  ,1.  Bilateral orbital frontal zygomatic craniotomy (skull base approach).,2.  Bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts.,3.  Bilateral forehead reconstruction with autologous graft.,4.  Advancement of the temporalis muscle bilaterally.,5.  Barrel-stave osteotomies of the parietal bones.,ANESTHESIA: , General.,PROCEDURE: , After induction of general anesthesia, the patient was placed supine on the operating room table with a roll under his shoulders and his head resting on a foam doughnut.  Scalp was clipped.  He was prepped with ChloraPrep.  Incision was infiltrated with 0.5% Xylocaine with epinephrine 1:200,000 and he received antibiotics and he was then reprepped and draped in a sterile manner.,A bicoronal zigzag incision was made and Raney clips used for hemostasis.  Subcutaneous flaps were developed and reflected anteriorly and slightly posteriorly.  These were subgaleal flaps.  Bipolar and Bovie cautery were used for hemostasis.  The craniectomy was outlined with methylene blue.  The pericranium was incised exposing the bone along the outline of the craniotomy.,Paired bur holes were drilled anteriorly and posteriorly straddling the metopic suture.  One was just above the nasion and the other was near the bregma.  Also bilateral pterional bur holes were drilled.  There was a little bit of bleeding from a tributary of the sagittal sinus anteriorly and so bone wax was used for hemostasis in all the bur holes.,The dura was separated with a #4 Penfield dissector and then the craniotomies were fashioned or cut.  I should say with the Midas Rex drill using the V5 bit and the footplate attachment, the bilateral craniotomies were cut and then the midline piece was elevated separately.  Great care was taken when removing the bone from the midline.  Bipolar cautery was used for bleeding points on the dura and especially over the sagittal sinus and the bleeding was controlled.,The wound was irrigated with bacitracin irrigation.,The next step was to perform the orbital osteotomies with careful protection of the orbital contents.  Osteotomies were made with the Midas Rex drill using the V5 bit in the orbital roof bilaterally.  This was a very thick and vertically oriented orbital roof on each side.  Midas Rex drill and osteotomes and mallet were used to cut these osteotomies using retractors to protect the orbital contents and the dura.  The osteotomies were carried down through the tripod of the orbit and down through the lateral orbital rim and all the way down to the inferior orbital rim using the osteotome and mallet.  Bone wax was used for hemostasis.  It was necessary to score the undersurface of the bone at the midline because it was so thick and pointed.  So we were not going to be able to effect the orbital advancement without scoring the bone and thinning it out a bit.  This was done with the Midas Rex drill using B5 bit.  Also, the marked ridge just above the nasion was burred down with the Midas Rex drill.  The osteotomies were also carried down through the zygoma.  At this point, with a gentle rocking motion and sustained pressure using the osteotomes, it was then possible to carefully advance the orbital rims bilaterally, first on the right and then on the left again using just a careful rocking motion against the remaining bone to gently bend the orbital rims outward bilaterally.,Dr. X cut the bone grafts from the bone flaps and I fashioned a shelf to secure the bone graft by burring a ledge on the internal surface of the superior orbital rim.  This created a shelf for the notched bone graft to lean against basically anteriorly.  The posterior notch of the bone graft was able to be braced by the ledge of orbital roof posteriorly.,The left medial orbital rim greenstick fractured a bit, but the bone graft appeared to stay in place.,Holes were then cut in the supraorbital rim for advancement of the temporalis muscle and then a Synthes mesh was placed anteriorly using absorbable screw hardware and attached the mesh where the forehead bone flaps turned around and recontoured to make a nice bilateral forehead for Isaac.,At this point the undersurface of the temporalis muscle was scored using the Bovie cautery to allow advancement of the muscle anteriorly and we sutured it to the supraorbital rims bilaterally with #3-0 Vicryl suture.  This helped fill-in the indentation left by the orbital advancement at the temporal region.,Also, I separated the undersurface of the dura from the bone bilaterally and cut multiple barrel-stave osteotomies in the parietal bones and then greenstick fractured these barrel-staves outward to create a more normal contour of the bone slightly posteriorly.,At this point, Gelfoam had been used to protect the dura over the sagittal sinus during this part of the procedure.,The wound was then irrigated with bacitracin irrigation.  Bleeding had been controlled during the procedure with Bovie and bipolar electrocautery, even so the blood loss was fairly significant adding up to about 300 or 400 mL and he received that much in packed cells and he also received a unit of fresh frozen plasma.,At this point, the reconstruction looked good.  The advancement was about 1 cm and we were pleased with the results.  The wound was irrigated and then the Gelfoam over the midline dura was left in place and the galea was then closed with #4-0 and some #3-0 Vicryl interrupted suture and #5-0 mild chromic on the skin.  The patient tolerated procedure well.  No complications.  Sponge and needle counts were correct.  Again, blood loss was bout 300 to 400 mL and he received 2 units of blood and some fresh frozen plasma.
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DESCRIPTION: Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.

surgery, metopic synostosis, trigonocephaly, bilateral orbital frontal zygomatic craniotomy, skull base approach, orbital advancement, c-shaped osteotomies, forehead reconstruction, temporalis muscle, midas rex drill, frontal zygomatic, sagittal sinus, orbital roof, orbital rim, bone grafts, forehead, bone, orbital, craniotomy, osteotomies,

The described scenario involves a craniotomy and complex reconstructive surgery to address metopic synostosis with trigonocephaly, a condition affecting skull formation in infants. This type of procedure is high-stakes due to several factors: the inherent risks of cranial surgery, the potential for significant blood loss, the need for precision to avoid complications such as damage to the brain or major blood vessels, and the critical importance of achieving satisfactory cosmetic and functional outcomes for the developing child. The mention of specific precautions taken during surgery, such as controlling bleeding and protecting the brain, further emphasizes the complexity and high-stakes nature of the procedure.


Medical Specialty: Surgery
Sample Name: Knee Arthroplasty

PREOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,POSTOPERATIVE DIAGNOSIS: , Bilateral degenerative arthritis of the knees.,PROCEDURE PERFORMED: , Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , Bilateral procedure was 400 cc.,TOTAL TOURNIQUET TIME:  ,75 minutes.,COMPONENTS: , Include the Zimmer NexGen complete knee solution system, which include a size F right cruciate retaining femoral component, a size #8 peg tibial component precoat, a All-Poly standard size 38, 9.5 mm thickness patellar component, and a prolonged highly cross-linked polyethylene NexGen cruciate retaining tibial articular surface size blue 12 mm height.,HISTORY OF PRESENT ILLNESS: , The patient is a 69-year-old male who presented to the office complaining of bilateral knee pain for a couple of years.  The patient complained of clicking noises and stiffness, which affected his daily activities of living.,PROCEDURE: , After all potential complications, risks as well as anticipated benefits of the above-named procedure was discussed at length, the patient's informed consent was obtained.,Operative extremities were then confirmed with the operating surgeons as well as the nursing staff, Department of Anesthesia, and the patient.  The patient was then transferred to preoperative area to operative suite #2 and placed on the operating room table in supine position.  All bony prominences were well padded at this time.  At this time, Department of Anesthesia administered general anesthetic to the patient.  The patient was allowed in DVT study and the right extremity was in the Esmarch study as well as the left.  The nonsterile tourniquet was then applied to the right upper thigh of the patient, but not inflated at this time.  The right lower extremity was sterilely prepped and draped in the usual sterile fashion.  The right upper extremity was then elevated and exsanguinated using an Esmarch and the tourniquet was inflated using 325 mmHg.  The patient was a consideration for a unicompartmental knee replacement.  So, after all bony and soft tissue landmarks were identified, a limited midline longitudinal incision was made directly over the patella.  A sharp dissection was then taken down to the level of the fascia in line with the patella as well as the quadriceps tendon.  Next, a medial parapatellar arthrotomy was performed using the #10 blade scalpel.  Upon viewing of the articular surfaces, there was significant ware in the trochlear groove as well as the medial femoral condyle and it was elected to proceed with total knee replacement.  At this time, the skin incisions as well as the deep incisions were extended proximally and distally in a midline fashion.  Total incision now measured approximately 25 cm.  Retractors were placed.  Next, attention was directed to establishing medial and lateral flaps of the proximal tibia.  Reciprocating osteal elevator was used to establish soft tissue plane and then an electrocautery was then used to subperiosteal strip medially and laterally on the proximal tibia.  At this time, the patella was then everted.  The knee was flexed up to 90 degrees.  Next, using the large drill bit, the femoral canal was then opened in appropriate position.  The intramedullary sizing guide was then placed and the knee was sized to a size F. At this time, the three degrees external rotation holes were then drilled after carefully assessing the epicondylar access as well as the white sideline.  The guide was then removed.  The intramedullary guide was then placed with nails holding the guide in three degrees of external rotation.  Next, the anterior femoral resection guide was then placed and clamped into place using a pointed _________________ was then used to confirm that there would no notching performed.  Next, soft tissue retractors were placed and an oscillating saw was used to make the anterior femoral cut.  Upon checking, it was noted to be flat with no oscillations.  The anterior guide was then removed and the distal femoral resection guide was placed in five degrees of valgus.  It was secured in place using nails.  The intramedullary guide was then removed and the standard distal femoral cut was then made using oscillating saw.,This was then removed and the size F distal finishing femoral guide was then placed on the femur in proper position.  Bony and soft tissue landmarks were confirmed and the resection guide was then held in place using nail as well as spring screws.  Again, the collateral ligament retractors were then placed and the oscillating saw was used to make each of the anterior and posterior as well as each chamfer cut.  A reciprocating saw was then used to cut the trochlear cut and the peg holes were drilled as well.  The distal finishing guide was then removed and osteotome was then used to remove all resected bone.  The oscillating saw was then used to complete the femoral notch cut.  Upon viewing, there appeared to be proper amount of bony resection and all bone was removed completely.  There was no posterior osteophytes noted and no fragments to the posterior aspect.  Next, attention was directed towards the tibia.  The external tibial guide was reflected.  This was placed on the anterior tibia and held in place using nails after confirming the proper varus and valgus position.  The resection guide was then checked and appeared to be sufficient amount of resection in both medial and lateral condyles of the tibia.  Next, collateral ligament retractors were placed as well as McGill retractors for the PCL.  Oscillating saw was then used to make the proximal tibial cut.  Osteotome was used to remove this excess resected bone.  The laminar spreader was then used to check the flexion and extension.  The gaps appeared to be equal.  The external guide was then removed and trial components were placed to a size F femoral component and a 12 mm tibial component on a size 8 tray.  The knee was taken through range of motion and had very good flexion as well as full extension.  There appeared to be good varus and valgus stability as well.  Next, attention was directed towards the patella.  There noted to be a sufficient ware and it was selected to replace the patella.  It was sized with caliper, pre-cut and noted to be 26 mm depth.  The sizing guide was then used and a size 51 resection guide selected.  A 51 mm reamer was then placed and sufficient amount of patella was then removed.  The calcar was then used to check again and there was noted to be 15 mm remaining.  The 38 mm patella guide was then placed on the patella.  It was noted to be in proper size and the three drill holes for the pegs were used.  A trial component was then placed.  The knee was taken through range of motion.  There was noted to be some subluxation lateral to the patellar component and a lateral release was performed.  After this, the component appeared to be tracking very well.  There remained a good range of motion in the knee and extension as well as flexion.  At this time, an AP x-ray of the knee was taken with the trial components in place.  Upon viewing this x-ray, it appeared that the tibial cut was in neutral, all components in proper positioning.  The knee was then copiously irrigated and dried.  The knee was then flexed ___________ placed, and the peg drill guide was placed on the tibia in proper position, held in place with nails.,The four peg holes were then drilled.  The knee again was copiously irrigated and suction dried.  The final components were then selected again consisting of size F femoral components.  A peg size 8 tibial component, a 12 mm height articular surface, size blue, and a 38 mm 9.5 mm thickness All-Poly patella.  Polymethyl methacrylate was then prepared at this time.  The proximal tibia was dried and the cement was then pressed into place.  The cement was then placed on the backside of the tibial component and the tibial component was then impacted into proper positioning.  Next, the proximal femur was cleaned and dried.  Polymethyl methacrylate was placed on the resected portions of the femur as well as the backside of the femoral components.  This was then impacted in place as well.  At this time, all excess cement was removed from both the tibial and femoral components.  A size 12 mm trial tibial articular surface was then put in place.  The knee was reduced and held in loading position throughout the remaining drying position of the cement.  Next, the resected patella was cleaned and dried.  The cement was placed on the patella as well as the backside of the patellar component.  The component was then put in proper positioning and held in place with a clamp.  All excess polymethyl methacrylate was removed from this area as well.  This was held until the cement had hardened sufficiently.  Next, the knee was examined.  All excess cement was then removed.  The knee was taken through range of motion with sufficient range of motion as well as stability.  The final 12 mm height polyethylene tibial component was then put into place and snapped down in proper position.  Again range of motion was noted to be sufficient.  The knee was copiously irrigated and suction dried once again.  A drain was then placed within the knee.  The wound was then closed first using #1 Ethibond to close the arthrotomy oversewn with a #1 Vicryl.  The knee was again copiously irrigated and dried.  The skin was closed using #2-0 Vicryl in subcuticular fashion followed by staples on the skin.  The ConstaVac was then _______ to the drain.  Sterile dressing was applied consisting of Adaptic, 4x4, ABDs, Kerlix, and a 6-inch Dupre roll from foot to thigh.  Department of Anesthesia then reversed the anesthetic.  The patient was transferred back to the hospital gurney to Postanesthesia Care Unit.  The patient tolerated the procedure well and there were no complications.
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DESCRIPTION: Bilateral degenerative arthritis of the knees.  Right total knee arthroplasty done in conjunction with a left total knee arthroplasty, which will be dictated separately.

surgery, degenerative, arthritis, zimmer nexgen, all-poly, cruciate, patellar component, total knee arthroplasty, knee arthroplasty, tibial component, femoral, patellar, tibial, knee, arthroplasty, anesthesia,

The situation involves a surgical procedure for knee arthroplasty, which is a major surgery. It requires general anesthesia, precise execution, and presents potential risks and complications. Given the nature of surgery and the need for meticulous post-operative care and recovery management, it is inherently high-stakes. The absence of complications in this case is positive, but does not diminish the potential severity of the procedure itself.


Medical Specialty: Orthopedic
Sample Name: Consult - Back & Leg Pain

Her axial back pain is greatly improved, but not completely eradicated.  There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:,  Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdominal surgery, and knee surgery.,CURRENT MEDICATIONS:,  Lipitor and Lexapro.,ALLERGIES: , She is allergic to sulfa medications.,SOCIAL HISTORY: , She is married, retired.  Denies tobacco or ethanol use.,FAMILY HISTORY:,  Father died of mesothelioma.  Mother gastric problems.,REVIEW OF SYSTEMS: , No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia.  Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.,PHYSICAL EXAMINATION:,  Physical exam can be found in great detail in the patient's chart.,ASSESSMENT AND PLAN:  ,The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome.  Her lumbar facet joints were denervated approximately 6 months ago.  The denervation procedure helped her axial back pain approximately 40% when standing.  With extension and rotation it helped her axial back pain approximately 70%.  She is now able to swing a golf club.  She was unable to swing a golf club due to the rotational movements before her rhizotomy.  She is currently playing golf.  Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.,I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d.  We will follow her up in 1 month's time.,
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DESCRIPTION: The patient has been suffering from intractable back and leg pain.

orthopedic, multilevel lumbar internal disc disruption, denervation procedure, lumbar facet joint syndrome, swing a golf, lumbar internal disc, internal disc disruption, lumbar internal, internal disc, disc disruption, intractable, surgery, disc, lumbar

The situation involves a patient with back and leg pain who has undergone treatments that have brought some improvement but is not completely resolved. It is not a medical emergency or surgical case at present, but requires ongoing management. The stakes involve continuing to manage and alleviate pain to improve the patient's quality of life, which is important but not critical or life-threatening.


Medical Specialty: Urology
Sample Name: Pyeloureteroscopy

PREOPERATIVE DIAGNOSES: , Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,POSTOPERATIVE DIAGNOSES:,  Left obstructed renal ureteropelvic junction obstruction status post pyeloplasty, percutaneous procedure, and pyeloureteroscopy x2, and status post Pseudomonas pyelonephritis x6, renal insufficiency, and solitary kidney.,PROCEDURE:  ,Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.,ANESTHESIA:  ,General endotracheal anesthetic with a caudal block x2.,FLUIDS RECEIVED:  ,1000 mL crystalloid.,ESTIMATED BLOOD LOSS:  ,Less than 10 mL.,SPECIMENS: , Tissue sent to pathology is a renal biopsy.,ABNORMAL FINDINGS: , A stenotic scarred ureteropelvic junction with dilated ureter and dilated renal pelvis.,TUBES AND DRAINS:  ,A 10-French silicone Foley catheter with 3 mL in balloon and a 4.7-French ureteral double J-stent multilength.,INDICATIONS FOR OPERATION:  ,The patient is a 3-1/2-year-old boy, who has a solitary left kidney with renal insufficiency with creatinine of 1.2, who has had a ureteropelvic junction repair performed by Dr. Chang.  It was subsequently obstructed with multiple episodes of pyelonephritis, two percutaneous tube placements, ureteroscopy with balloon dilation of the system, and continued obstruction.  Plan is for co surgeons due to the complexity of the situation and the solitary kidney to do surgical procedure to correct the obstruction.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operative room.  Surgical consent, operative site, and patient identification were verified.  Dr. X and Dr. Y both agreed upon the procedures in advance.  Dr. Y then, once the patient was anesthetized, requested IV antibiotics with Fortaz, the patient had a caudal block placed, and he was then placed in lithotomy position.  Dr. Y then calibrated the urethra with the bougie a boule to 8, 10, and up to 12 French.  The 9.5-French cystoscope sheath was then placed within the patient's bladder with the offset scope, and his bladder had no evidence of cystitis.  I was able to locate the ureteral orifice bilaterally, although no urine coming from the right.  We then placed a 4-French ureteral catheter into the ureter as far as we could go.  An antegrade nephrostogram was then performed, which shows that the contrast filled the dilated pelvis, but did not go into the ureter.  A retrograde was performed, and it was found that there was a narrowed band across the two.  Upon draining the ureter allowing to drain to gravity, the pelvis which had been clamped and its nephrostomy tube did not drain at all.  Dr. Y then placed a 0.035 guidewire into the ureter after removing the 4-French catheter and then placed a 4.7-French double-J catheter into the ureter as far as it would go allowing it to coil in the bladder.  Once this was completed, we then removed the cystoscope and sheath, placed a 10-French Foley catheter, and the patient was positioned by Dr. X and Dr. Y into the flank position with the left flank up after adequate padding on the arms and legs as well as a brachial plexus roll.  He was then sterilely prepped and draped.  Dr. Y then incised the skin with a 15-blade knife through the old incision and then extended the incision with curved mosquito clamp and Dr. X performed cautery of the areas advanced to be excised.  Once this was then dissected, Dr. Y and Dr. X divided the lumbosacral fascia; at the latissimus dorsi fascia, posterior dorsal lumbotomy maneuver using the electrocautery; and then using curved mosquito clamps __________.  At this point, Dr. X used the cautery to enter the posterior retroperitoneal space through the posterior abdominal fascia.  Dr. Y then used the curved right angle clamp and dissected around towards the ureter, which was markedly adherent to the base of the retroperitoneum.  Dr. X and Dr. Y also needed dissection on the medial and lateral aspects with Dr. Y being on the lateral aspect of the area and Dr. X on the medial to get an adequate length of this.  The tissue was markedly inflamed and had significant adhesions noted.  The patient's spermatic vessels were also in the region as well as the renal vessels markedly scarred close to the ureteropelvic junction.  Ultimately, Dr. Y and Dr. X both with alternating dissection were able to dissect the renal pelvis to a position where Dr. Y put stay sutures and a 4-0 chromic to isolate the four quadrant area where we replaced the ureter.  Dr. X then divided the ureter and suture ligated the base, which was obstructed with a 3-0 chromic suture.  Dr. Y then spatulated the ureter for about 1.5 cm, and the stent was gently delivered in a normal location out of the ureter at the proximal and left alone in the bladder.  Dr. Y then incised the renal pelvis and dissected and opened it enough to allow the new ureteropelvic junction repair to be performed.  Dr. Y then placed interrupted sutures of 5-0 Monocryl at the apex to repair the most dependent portion of the renal pelvis, entered the lateral aspect, interrupted sutures of the repair.  Dr. X then was able to without much difficulty do interrupted sutures on the medial aspect.  The stent was then placed into the bladder in the proper orientation and alternating sutures by Dr. Y and Dr. X closed the ureteropelvic junction without any evidence of leakage.  Once this was complete, we removed the extra stay stitches and watched the ureter lay back into the retroperitoneum in a normal position without any kinking in apparently good position.  This opening was at least 1.5 cm wide.  Dr. Y then placed 2 stay sutures of 2-0 chromic in the lower pole of the kidney and then incised wedge biopsy and excised the biopsy with a 15-blade knife and curved iris scissors for renal biopsy for determination of renal tissue health.  Electrocautery was used on the base.  There was no bleeding, however, and the tissue was quite soft.  Dermabond and Gelfoam were placed, and then Dr. Y closed the biopsy site over with thrombin-Gelfoam using the 2-0 chromic stay sutures.  Dr. X then closed the fascial layers with running suture of 3-0 Vicryl in 3 layers.  Dr. Y closed the Scarpa fascia and the skin with 4-0 Vicryl and 4-0 Rapide respectively.  A 4-0 nylon suture was then placed by Dr. Y around the previous nephrostomy tube, which was again left clamped.  Dermabond tissue adhesive was placed over the incision and then a dry sterile dressing was placed by Dr. Y over the nephrostomy tube site, which was left clamped, and the patient then had a Foley catheter placed in the bladder.  The Foley catheter was then taped to his leg.  A second caudal block was placed for anesthesia, and he is in stable condition upon transfer to recovery room.
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DESCRIPTION: Cystoscopy under anesthesia, retrograde and antegrade pyeloureteroscopy, left ureteropelvic junction obstruction, difficult and open renal biopsy.

urology, cystoscopy, pyeloureteroscopy, ureteropelvic junction obstruction, pseudomonas pyelonephritis, renal insufficiency, fortaz, ureteropelvic junction repair, nephrostomy tube, renal biopsy, renal pelvis, foley catheter, ureteropelvic junction, renal, ureteropelvic,

The situation described involves a complex surgical procedure on a 3.5-year-old patient with a solitary kidney and renal insufficiency. Given the patient's medical history, including multiple previous procedures and infections, along with the complexity of the current surgery, this is a high-stakes situation. Correcting the obstruction is critical to preventing further renal damage or failure, which could have severe health implications for the child.


Medical Specialty: Surgery
Sample Name: Symes Amputation - Hallux

PREOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1.  Excision of mass, left second toe.,2.  Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot.  The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  The patient also has history of shave biopsy in the past.  The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  The foot was lowered to the operating table.  The stockinet was reflected and the foot was cleansed with wet and dry sponge.  A distal Syme's incision was planned over the distal aspect of the left hallux.  The incision was performed with a #10 blade and deepened with #15 down to the level of bone.  The dorsal skin flap was removed and dissected in toto off of the distal phalanx.  There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer.  Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  The area was inspected for any remaining suspicious tissues.  Any suspicious tissue was removed.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe.  There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  A linear incision was made just medial to the tissue mass.  The mass was then dissected from the overlying skin and off of the underlying capsule.  This tissue mass was hard, round, and pearly-gray in appearance.  It does not invade into any other surrounding tissues.  The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed.  The patient will be contacted immediately pending the results of pathology.  Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.
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DESCRIPTION: Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy.  Mass, left second toe.  Tumor.  Left hallux bone invasion of the distal phalanx.

surgery, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux

This situation involves a surgical procedure for a patient with a rapidly growing mass and suspected tumor with bone invasion in the toe. Surgery, especially involving potential cancer, is usually considered high-stakes because of the implications for the patient's health, the need for precise execution, and the outcomes of pathology results. Moreover, decisions made during surgery can significantly affect the patient's prognosis and quality of life. Given these factors, this scenario reflects a significant level of risk and consequence associated with healthcare and surgical procedures.


Medical Specialty: Radiology
Sample Name: Stress Test Adenosine Myoview

INDICATIONS:,  Ischemic cardiomyopathy, status post inferior wall myocardial infarction, status post left anterior descending PTCA and stenting.,PROCEDURE DONE:,  Adenosine Myoview stress test.,STRESS ECG RESULTS:,  The patient was stressed by intravenous adenosine, 140 mcg/kg/minute infused over four minutes.  The baseline resting electrocardiogram revealed an electronic pacemaker depolarizing the ventricles regularly at a rate of 70 beats per minute.  Underlying atrial fibrillation noted, very wide QRS complexes.  The heart rate remained unchanged at 70 beats per minute as the blood pressure decreased from 140/80 to 110/70 with adenosine infusion.
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DESCRIPTION: Stress test - Adenosine Myoview.  Ischemic cardiomyopathy.  Inferoseptal and apical transmural scar.

radiology, stress test, adenosine, adenosine myoview stress test, ischemic cardiomyopathy, spect, cardiomyopathy, electrocardiogram, myocardial infarction, stress test adenosine myoview, adenosine myoview stress, myoview stress test, ptca and stenting, myoview stress, transmural scar, adenosine infusion, septal motion, adenosine myoview, myocardial perfusion, hypokinesis, inferoseptal, ischemic, myocardial, myoview, perfusion, scan

The given radiology report describes a stress test performed on a patient with a history of ischemic cardiomyopathy and previous myocardial infarctions, which are serious cardiovascular conditions. The test is evaluating the heart's function and identifying any residual ischemia. This situation is high-stakes because improper evaluation or unnoticed abnormalities could have severe implications for the patient's health, including the risk of heart failure or future cardiac events.


Medical Specialty: Orthopedic
Sample Name: Carpal Ligament Release - 1

PREOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,PROCEDURE: , Endoscopic release of left transverse carpal ligament.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia provided by surgeon.  ,TOURNIQUET TIME: , 12 minutes.,OPERATIVE PROCEDURE IN DETAIL: , With the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mmHg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the palm between FCR and FCU, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,Hamate sounds were then used to palpate the Hood of Hamate.  The Agee Inside Job was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.  The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the Agee Inside Job was withdrawn, dividing transverse carpal ligament under direct vision.  After complete division of transverse carpal ligament, the Agee Inside Job was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished.  One cc of Celestone was then introduced into the carpal tunnel and irrigated free.  ,The wound was then closed with a running 3-0 Prolene subcuticular stitch.  Steri-strips were applied and a sterile dressing was applied over the Steri-strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.
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DESCRIPTION: Endoscopic release of left transverse carpal ligament.

orthopedic, carpal tunnel syndrome, antebrachial fascia, carpal, ligament, palmar, synovium, tourniquet, transverse carpal ligament, transverse incision, agee inside job, transverse carpal, carpal ligament, carpal tunnel, antebrachial, release, endoscopic,

The described procedure is a surgical intervention for carpal tunnel syndrome, which is common but not typically life-threatening. The risks involved are standard for surgical procedures, such as infection or complications from anesthesia, but these are usually well-managed in a controlled medical environment. The stakes are not extremely high compared to surgeries involving critical organs or life-saving procedures.


Medical Specialty: ENT - Otolaryngology
Sample Name: Recurrent nasal obstruction

CHIEF COMPLAINT: , Recurrent nasal obstruction.,HISTORY OF PRESENT ILLNESS:,  The patient is a 5-year-old male, who was last evaluated by Dr. F approximately one year ago for suspected nasal obstruction, possible sleep apnea.  Dr. F's assessment at that time was the patient not had sleep apnea and did not truly even seem to have allergic rhinitis.  All of his symptoms had resolved when he had seen Dr. F, so no surgical plan was made and no further followup was needed.  However, the patient reports again today with his mother that they are now having continued symptoms of nasal obstruction and questionable sleep changes.  Again, the mother gives a very confusing sleep history but it does not truly sound like the child is having apneic events that are obstructive in nature.  It sounds like he is snoring loudly and does have some nasal obstruction at nighttime.  He also is sniffing a lot through his nose.  He has been tried on some nasal steroids but they only use this on a p.r.n. basis about one or two days every month and we are unsure if that has even helped at all, probably not.  The child is not having any problems with his ears including ear infections or hearing.  He is also not having any problems with strep throat.,PAST MEDICAL HISTORY: , Eczema.,PAST SURGICAL HISTORY: , None.,MEDICATIONS:,  None.,ALLERGIES:,  No known drug allergies.,FAMILY HISTORY: , No family history of bleeding diathesis or anesthesia difficulties.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight 43 pounds, height 37 inches, temperature 97.4, pulse 65, and blood pressure 104/48.,GENERAL:  The patient is a well-nourished male in no acute distress.  Listening to his voice today in the clinic, he does not sound to have a hyponasal voice and has a wide range of consonant pronunciation.,NOSE:  Anterior rhinoscopy does demonstrate boggy turbinates bilaterally with minimal amount of watery rhinorrhea.,EARS:  The patient tympanic membranes are clear and intact bilaterally.  There is no middle ear effusion.,ORAL CAVITY:  The patient has 2+ tonsils bilaterally.  There are clearly nonobstructive.  His uvula is midline.,NECK:  No lymphadenopathy appreciated.,ASSESSMENT AND PLAN: , This is a 5-year-old male, who presents for repeat evaluation of a possible nasal obstruction, questionable sleep apnea.  Again, the mother gives a confusing sleep history but it does not really sound like he is having apneic events.  They deny any actual gasping events.  It sounds like true obstructive events.  He clearly has some symptoms at this point that would suggest possible allergic rhinitis or chronic rhinitis.  I think the most appropriate way to proceed would be to first try this child on a nasal corticosteroid and use it appropriately.  I have given them prescription for Nasacort Aqua one spray to each nostril twice a day.  I instructed them on correct way to use this and the importance to use it on a daily basis.  They may not see any benefit for several weeks.  I would like to evaluate him in six weeks to see how we are progressing.  If he continues to have problems, I think at that point we may consider performing a transnasal exam in the office to examine his adenoid bed and that would really be the only surgical option for this child.  He may also need an allergy evaluation at that point if he continues to have problems.  However, I would like to be fairly conservative in this child.  Should the mother still have concerns regarding his sleeping at our next visit or should his symptoms worsen (I did instruct her call us if it worsens), we may even need to pursue a sleep study just to settle that issue once and for all.  We will see him back in six weeks.
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DESCRIPTION: Patient with suspected nasal obstruction, possible sleep apnea.

ent - otolaryngology, recurrent nasal obstruction, allergic rhinitis, apneic events, sleep apnea, nasal obstruction, nasal, apnea, allergic, obstruction, sleep,

The situation involves a 5-year-old male suspected of having nasal obstruction and possible sleep apnea. While these conditions must be managed properly to ensure the child's well-being and quality of sleep, the immediate health risks appear to be low. There are no signs of acute distress, no family history complicating anesthesia, and the initial examination does not indicate emergency concerns. The treatment plan is conservative, involving nasal corticosteroids and a follow-up in six weeks, with options for further investigation if needed. Hence, this situation is not high-stakes but requires appropriate monitoring and follow-up.


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

CC:, Headache,HX: ,37 y/o RHF presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours. The headachese were dull to throbbing in character. She was initially treated with Parafon-forte for tension type headaches, but the pain did not resolve. She subsequently underwent HCT in early 12/90 which revealed a right frontal mass lesion.,PMH: ,1)s/p tonsillectomy. 2)s/p elective abortion.,FHX:, Mother with breast CA, MA with "bone cancer." AODM both sides of family.,SHX: ,Denied tobacco or illicit drug use. Rarely consumes ETOH. Married with 2 teenage children.,EXAM: ,VItal signs unremarkable.,MS: Alert and oriented to person, place, time. Lucid thought process per NSG note.,CN: unremarkable.,Motor: full strength with normal muscle bulk and tone.,Sensory: unremarkable.,Coordination: unremarkable.,Station/Gait: unremarkable.,Reflexes: unremarkable.,Gen. Exam: unremarkable.,COURSE:, MRI Brain: large solid and cystic right frontal lobe mass with a large amount of surrounding edema. There is apparent tumor extension into the corpus callosum across the midline. Tumor extension is also suggested in the anterior limb of the interanl capsule on the right. There is midline mass shift to the left with effacement of the anterior horn of the right lateral ventricle. The MRI findings are most consistent with glioblastoma.,The patient underwent right frontal lobectomy. The pathological diagnosis was xanthomatous astrocytoma. The literature at the time was not clear as to optimal treatment protocol. People have survived as long as 25 years after diagnosis with this type of tumor. XRT was deferred until 11/91 when an MRI and PET Scan suggested extension of the tumor. She then received 5580 cGy of XRT in divided segments. She developed olfactory auras shortly after lobectomy at was treated with PB with subsequent improvement. She was treated with BCNU chemotherapy protocol in 1992.
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DESCRIPTION: Headache.  Right frontal lobe glioma.

Headache.  Right frontal lobe glioma.

consult - history and phy., frontal lobe, tumor extension, glioma, headache, lobectomy, astrocytoma,

The situation involves a medical case with significant implications for the patient's health. The patient has been diagnosed with a right frontal lobe glioma, a serious condition. The medical decisions regarding surgical intervention and ongoing treatment (e.g., lobectomy, XRT, chemotherapy) have direct impacts on the patient’s quality of life and possibly their survival. Additionally, the complexity of the treatment decisions (e.g., choosing when to defer or administer treatment like XRT and chemotherapy) adds to the stakes, as these decisions need to be carefully considered to balance potential benefits and risks. Therefore, the stakes are high given the potential outcomes and implications of the treatment options.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Thrombectomy

PREOPERATIVE DIAGNOSES:,1.  Thrombosed left forearm loop fistula graft.,2.  Chronic renal failure.,3.  Hyperkalemia.,POSTOPERATIVE DIAGNOSES:,1.  Thrombosed left forearm loop fistula graft.,2.  Chronic renal failure.,3.  Hyperkalemia.,PROCEDURE PERFORMED: , Thrombectomy of the left forearm loop graft.,ANESTHESIA: , Local with sedation.,ESTIMATED BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS:, None.,OPERATIVE FINDINGS:,  The venous outflow was good.  There was stenosis in the mid-venous limb of the graft.,INDICATIONS: , The patient is an 81-year-old African-American female who presents with an occluded left forearm loop graft.  She was not able to have her dialysis as routine.  Her potassium was dramatically elevated at 7 the initial evening of anticipated surgery.  Both Surgery and Anesthesia thought this would be too risky to do.  Thus, she was given medications to decrease her potassium and a temporary hemodialysis catheter was placed in the femoral vein noted for her to have dialysis that night as well as this morning.  This morning her predialysis potassium was 6, and thus she was scheduled for surgery after her dialysis.,PROCEDURE: , The patient was taken to the operative suite and prepped and draped in the usual sterile fashion.  A transverse incision was made at the region of the venous anastomosis of the graft.  Further dissection was carried down to the catheter.  The vein appeared to be soft and without thrombus.  This outflow did not appear to be significantly impaired.  A transverse incision was made with a #11 blade on the venous limb of the graft near the anastomosis.  Next, a thrombectomy was done using a #4 Fogarty catheter.  Some of the clot and thrombus was removed from the venous limb.  The balloon did hang up in the multiple places along the venous limb signifying some degree of stenosis.  Once removing most of the clots from the venous limb prior to removing the plug, dilators were passed down the venous limb also indicating the area of stenosis.  At this point, we felt the patient would benefit from a curettage of the venous limb of the graft.  This was done and subsequent passes with the dilator and the balloon were then very easy and smooth following the curettage.  The Fogarty balloon was then passed beyond the clot and the plug.  The plug was visualized and inspected.  This also gave a good brisk bleeding from the graft.  The patient was heparinized and hep saline solution was injected into the venous limb and the angle vascular clamp was applied to the venous limb.  Attention was directed up to its anastomosis and the vein.  Fogarty balloon and thrombectomy was also performed well enough into this way.  There was good venous back bleeding following this.  The area was checked for any stenosis with the dilators and none was present.  Next, a #6-0 Prolene suture was used in a running fashion to close the graft.  Just prior to tying the suture, the graft was allowed to flush to move any debris or air.  The suture was also checked at that point for augmentation, which was good.  The suture was tied down and the wound was irrigated with antibiotic solution.  Next, a #3-0 Vicryl was used to approximate the subcutaneous tissues and a #4-0 undyed Vicryl was used in a running subcuticular fashion to approximate the skin edges.  Steri-Strips were applied and the patient was taken to recovery in stable condition.  She tolerated the procedure well.  She will be discharged from recovery when stable.  She is to resume her regular dialysis schedule and present for dialysis tomorrow.
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DESCRIPTION: Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia.  Thrombectomy of the left forearm loop graft.  The venous outflow was good.  There was stenosis in the mid-venous limb of the graft.

cardiovascular / pulmonary, thrombosed, hyperkalemia, thrombectomy, forearm loop graft, venous outflow, chronic renal failure, venous limb, loop graft, forearm loop, limb, forearm, graft, venous, anastomosis, stenosis,

The situation described involves a medical procedure known as thrombectomy on a patient with several serious health conditions: a thrombosed graft, chronic renal failure, and hyperkalemia. The procedure was necessary because the patient's dialysis was disrupted, and hyperkalemia at a level of 7 is life-threatening, requiring urgent intervention. The procedure was conducted successfully, with potential risks addressed preoperatively, such as managing the elevated potassium level and using temporary dialysis. The patient tolerated the procedure well and was stable post-operation. While the procedure holds typical operational risks, it was elective after improving the patient's potassium level, and the outcome was positive. However, given the patient's age, existing chronic conditions, and initial high potassium levels, the situation is moderately high-stakes, as uncontrolled hyperkalemia or failure in dialysis access could have led to severe consequences.


Medical Specialty: Radiology
Sample Name: CT of Chest with Contrast

EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE:  ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS:  ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates.  The remainder of the lung parenchyma is clear.  There is no pneumothorax or effusion.  The heart size and pulmonary vessels appear unremarkable.  There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.
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DESCRIPTION: CT of chest with contrast.  Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe.

radiology, ct chest, air-space, axillary, chest x-ray, consolidation, contrast, contrast-enhanced, effusion, hilar, infiltrates, lung, lymphadenopathy, mass, mediastinal, parenchyma, patchy air-space, pneumonia, pneumothorax, right upper lobe, spiral images, with contrast, air space opacities, upper lobe, opacities, ct, lobe, chest

The situation involves interpreting a CT scan with a history of an abnormal chest x-ray. The findings suggest the presence of pneumonia, which is a common and treatable condition. While accurate diagnosis is important for the patient's treatment plan, this scenario does not involve immediate life-threatening circumstances, thus it is not extremely high-stakes compared to other medical emergencies.


Medical Specialty: Surgery
Sample Name: Ulnar Nerve Decompression

PREOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,POSTOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,PROCEDURE PERFORMED: , Decompression of the ulnar nerve, left elbow.,ANESTHESIA: , General.,FINDINGS OF THE OPERATION:,  The ulnar nerve appeared to be significantly constricted as it passed through the cubital tunnel.  There was presence of hourglass constriction of the ulnar nerve.,PROCEDURE: , The patient was brought to the operating room and once an adequate general anesthesia was achieved, his left upper extremity was prepped and draped in standard sterile fashion.  A sterile tourniquet was positioned and tourniquet was inflated at 250 mmHg.  Perioperative antibiotics were infused.  Time-out procedure was called.  The medial epicondyle and the olecranon tip were well palpated.  The incision was initiated at equidistant between the olecranon and the medial epicondyle extending 3-4 cm proximally and 6-8 cm distally.  The ulnar nerve was identified proximally.  It was mobilized with a blunt and a sharp dissection proximally to the arcade of Struthers, which was released sharply.  The roof of the cubital tunnel was then incised and the nerve was mobilized distally to its motor branches.  The ulnar nerve was well-isolated before it entered the cubital tunnel.  The arch of the FCU was well defined.  The fascia was elevated from the nerve and both the FCU fascia and the Osborne fascia were divided protecting the nerve under direct visualization.  Distally, the dissection was carried between the 2 heads of the FCU.  Decompression of the nerve was performed between the heads of the FCU.  The muscular branches were well protected.  Similarly, the cutaneous branches in the arm and forearm were well protected.  The venous plexus proximally and distally were well protected.  The nerve was well mobilized from the cubital tunnel preserving the small longitudinal vessels accompanying it.  Proximally, multiple vascular leashes were defined near the incision of the septum into the medial epicondyle, which were also protected.  Once the in situ decompression of the ulnar nerve was performed proximally and distally, the elbow was flexed and extended.  There was no evidence of any subluxation.  Satisfactory decompression was performed.  Tourniquet was released.  Hemostasis was achieved.  Subcutaneous layer was closed with 2-0 Vicryl and skin was approximated with staples.  A well-padded dressing was applied.  The patient was then extubated and transferred to the recovery room in stable condition.  There were no intraoperative complications noted.  The patient tolerated the procedure very well.
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DESCRIPTION: Decompression of the ulnar nerve, left elbow.  Left cubital tunnel syndrome and ulnar nerve entrapment.

surgery, ulnar nerve entrapment, ulnar nerve, ulnar nerve decompression, cubital tunnel syndrome, ulnar, nerve, fascia, decompression, cubital, tunnel

This surgical procedure, ulnar nerve decompression for cubital tunnel syndrome, is significant but not usually considered high-stakes relative to surgeries involving vital organs or life-threatening conditions. However, it is important as it deals with nerve function, and improper execution could lead to complications affecting the patient's arm and hand functionality. The situation involves general anesthesia, which adds some risk, but overall, this type of surgery is routine and usually performed without severe complications.


Medical Specialty: Psychiatry / Psychology
Sample Name: Major Depressive Disorder - IME Consult

IDENTIFYING DATA:  ,Mr. T is a 45-year-old white male.,CHIEF COMPLAINT: , Mr. T presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.  His confidence and self-esteem are significantly low.  He stated he has excessive somnolence, his energy level is extremely low, motivation is low, and he has a lack for personal interests.  He has had suicidal ideation, but this is currently in remission.  Furthermore, he continues to have hopeless thoughts and crying spells.  Mr. T stated these symptoms appeared approximately two months ago.,HISTORY OF PRESENT ILLNESS: , On March 25, 2003, Mr. T was fired from his job secondary, to an event at which he stated he was first being harassed by another employee." This other, employee had confronted Mr. T with a very aggressive, verbal style, where this employee had placed his face directly in front of Mr. T was spitting on him, and called him "bitch." Mr. T then retaliated, and went to hit the other employee.  Due to this event, Mr. T was fired.  It should be noted that Mr. T stated he had been harassed by this individual for over a year and had reported the harassment to his boss and was told to "deal with it.",There are no other apparent stressors in Mr. T's life at this time or in recent months.  Mr. T stated that work was his entire life and he based his entire identity on his work ethic.  It should be noted that Mr. T was a process engineer for Plum Industries for the past 14 years.,PAST PSYCHIATRIC HISTORY:,  There is no evidence of any psychiatric hospitalizations or psychiatric interventions other than a recent visit to Mr. T's family physician, Dr. B at which point Mr. T was placed on Lexapro with an unknown dose at this time.  Mr. T is currently seeing Dr. J for psychotherapy where he has been in treatment since April, 2003.,PAST PSYCHIATRIC REVIEW OF SYSTEMS:,  Mr. T denied any history throughout his childhood, adolescence, and early adulthood for depressive, anxiety, or psychotic disorders.  He denied any suicide attempts, or profound suicidal or homicidal ideation.  Mr. T furthermore stated that his family psychiatric history is unremarkable.,SUBSTANCE ABUSE HISTORY:,  Mr. T stated he used alcohol following his divorce in 1993, but has not used it for the last two years.  No other substance abuse was noted.,LEGAL HISTORY: , Currently, charges are pending over the above described incident.,MEDICAL HISTORY: , Mr. T denied any hospitalizations, surgeries, or current medications use for any heart disease, lung disease, liver disease, kidney disease, gastrointestinal disease, neurological disease, closed head injury, endocrine disease, infectious, blood or muscles disease other than stating he has a hiatal hernia and hypercholesterolemia.,PERSONAL AND SOCIAL HISTORY: , Mr. T was born in Dwyne, Missouri, with no complications associated with his birth.  Originally, he was raised by both parents, but they separated at an early age.  When he was about seven years old, he was raised by his mother and stepfather.  He did not sustain a relationship with his biological father from that time on.  He stated his parents moved a lot, and because this many times he was picked on in his new environments, Mr. T stated he was, at times, a rebellious teenager, but he denied any significant inability to socialize, and denied any learning disabilities or the need for special education.,Mr. T stated his stepfather was somewhat verbally abusive, and that he committed suicide when Mr. T was 18 years old.  He graduated from high school and began work at Dana Corporation for two to three years, after which he worked as an energy, auditor for a gas company.  He then became a homemaker while his wife worked for Chrysler for approximately two years.  Mr. T was married for eleven years, and divorced in 1993.  He has a son who is currently 20 years old.  After being a home maker, Mr. T worked for his mother in a restaurant, and moved on from there to work for Borg-Warner corporation for one to two years before beginning at Plum Industries, where he worked for 14 years and worked his way up to lead engineer.,Mental Status Exam:  Mr. T presented with a hyper vigilant appearance, his eye contact was appropriate to the interview, and his motor behavior was tense.  At times he showed some involuntary movements that would be more akin to a resting tremor.  There was no psychomotor retardation, but there was some mild psychomotor excitement.  His speech was clear, concise, but pressured.  His attitude was overly negative and his mood was significant for moderate depression, anxiety, anhedonia and loneliness, and mild evidence of anger.  There was no evidence of euphoria or diurnal mood variation.  His affective expression was restricted range, but there was no evidence of lability.  At times, his affective tone and facial expressions were inappropriate to the interview.  There was no evidence of auditory, visual, olfactory, gustatory, tactile or visceral hallucinations.  There was no evidence of illusions, depersonalizations, or derealizations.  Mr. T presented with a sequential and goal directed stream of thought.  There was no evidence of incoherence, irrelevance, evasiveness, circumstantiality, loose associations, or concrete thinking.  There was no evidence of delusions; however, there was some ambivalence, guilt, and self-derogatory thoughts.  There was evidence of concreteness for similarities and proverbs.  His intelligence was average.  His concentration was mildly impaired, and there was no evidence of distractibility.  He was oriented to time, place, person and situation.  There was no evidence of clouded consciousness or dissociation.  His memory was intact for immediate, recent, and remote events.,He presented with poor appetite, easily fatigued, and decreased libidinal drive, as well as excessive somnolence.  There was a moderate preoccupation with his physical health pertaining to his headaches.  His judgment was poor for finances, family relations, social relations, employment, and, at this time, he had no future plans.  Mr. T's insight is somewhat moderate as he is aware of his contribution to the problem.  His motivation for getting well is good as he accepts offered treatment, complies with recommended treatment, and seeks effective treatments.  He has a well-developed empathy for others and capacity for affection.,There was no evidence of entitlement, egocentricity, controllingness, intimidation, or manipulation.  His credibility seemed good.  There was no evidence for potential self-injury, suicide, or violence.  The reliability and completeness of information was very good, and there were no barriers to communication.  The information gathered was based on the patient's self-report and objective testing and observation.  His attitude toward the examiner was neutral and his attitude toward the examination process was neutral.  There was no evidence for indices of malingering as there was no marked discrepancy between claimed impairment and objective findings, and there was no lack of cooperation with the evaluation or poor compliance with treatment, and no evidence of antisocial personality disorder.,IMPRESSIONS: , Major Depressive Disorder, single episode,RECOMMENDATIONS AND PLAN: , I recommend Mr. T continue with psychopharmacologic care as well as psychotherapy.  At this time, the excessive amount of psychiatric symptoms would impede Mr. T from seeking employment.  Furthermore, it appears that the primary precipitating event had occurred on March 25, 2003, when Mr. T was fired from his job after being harassed for over a year.  As Mr. T placed his entire identity and sense of survival on his work, this was a deafening blow to his psychological functioning.  Furthermore, it only appears logical that this would precipitate a major depressive episode.
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DESCRIPTION: Patient presented with significant muscle tremor, constant headaches, excessive nervousness, poor concentration, and poor ability to focus.

psychiatry / psychology, muscle tremor, headaches, excessive nervousness, poor concentration, independent medical evaluation, psychopharmacologic, poor ability to focus, major depressive disorder, tremor, depressive, psychiatric,

The situation involves a patient, Mr. T, experiencing a Major Depressive Disorder significantly impacting his daily life and his ability to work. While his suicidal ideation is in remission, the persistence of depressive symptoms such as significant muscle tremor, headaches, nervousness, and hopelessness coupled with a moderate impairment in concentration and poor judgment, particularly concerning his employment situation, suggests a highly impactful mental health condition. However, Mr. T is seeking and complying with treatment, which suggests some positive outlook regarding his recovery. Given that his suicidal ideation is in remission and there are no ongoing risk factors for self-harm currently, it is not at the highest level of crisis. Nonetheless, the situation remains highly impactful and potentially life-altering if not properly managed.


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

Medical Specialty: Radiology
Sample Name: CT Abdomen & Pelvis - 9

CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain with swelling at the site of the ileostomy.,TECHNIQUE:,  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable.  Punctate calcifications in the gallbladder lumen likely represent a gallstone.,CT PELVIS:  ,Postsurgical changes of a left lower quadrant ileostomy are again seen.  There is no evidence for an obstruction.  A partial colectomy and diverting ileostomy is seen within the right lower quadrant.  The previously seen 3.4 cm subcutaneous fluid collection has resolved.  Within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed.  This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded.  No obstruction is seen.  The appendix is not clearly visualized.  The urinary bladder is unremarkable.,IMPRESSION:,1.  Resolution of the previously seen subcutaneous fluid collection.,2.  Left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance.  These findings may be due to a pelvic abscess.,3.  Right lower quadrant ileostomy has not significantly changed.,4.  Cholelithiasis.
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DESCRIPTION: Generalized abdominal pain with swelling at the site of the ileostomy.  CT abdomen with contrast and CT pelvis with contrast.  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.

radiology, axial ct images, isovue-300, ct pelvis, ct abdomen, fluid collection, abdomen, obstruction, subcutaneous, abscess, pelvic, fluid, collection, pelvis, ileostomy, ct, isovue,

The findings indicate a potential pelvic abscess, a condition that requires medical attention due to the risk of infection and complications if untreated. Additionally, the patient's symptoms of generalized abdominal pain and swelling, possibly linked to post-surgical changes, further emphasize the importance of monitoring and potentially addressing these issues. However, an immediate life-threatening condition is not confirmed, but there is significant potential for serious complications if not managed appropriately.


Medical Specialty: ENT - Otolaryngology
Sample Name: Laryngectomy & Thyroid Lobectomy

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

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

The situation involves a complex and major surgical procedure for a patient with squamous cell carcinoma of the larynx. This type of surgery, which includes a total laryngectomy and neck dissection, is typically high-stakes due to the potential risks and significant implications for the patient's quality of life, including the possible loss of the ability to speak and swallow. The patient was informed of substantial risks, such as nerve injuries and the need for ongoing medical care. The decision to opt for surgery over chemoradiation further highlights the severity and complexity of the case. Given the nature of the surgery and the life-altering consequences, this situation is high-stakes.


Medical Specialty: Gastroenterology
Sample Name: Flex Sig - 3

PROCEDURE: , Flexible sigmoidoscopy.,PREOPERATIVE DIAGNOSIS:,  Rectal bleeding.,POSTOPERATIVE DIAGNOSIS:  ,Diverticulosis.,MEDICATIONS: , None.,DESCRIPTION OF PROCEDURE:  ,The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal descending colon.  At this point, stool occupied the lumen, preventing further passage.  The colon distal to this was well cleaned out and easily visualized.  The mucosa was normal throughout the regions examined.  Numerous diverticula were seen.  There was no blood or old blood or active bleeding.  A retroflexed view of the anorectal junction showed no hemorrhoids.  He tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Sigmoid and left colon diverticulosis.,2.  Otherwise normal flexible sigmoidoscopy to the proximal descending colon.,3.  The bleeding was most likely from a diverticulum, given the self limited but moderately severe quantity that he described.,RECOMMENDATIONS:,1.  Follow up with Dr. X as needed.,2.  If there is further bleeding, a full colonoscopy is recommended.
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DESCRIPTION: Flexible sigmoidoscopy.  Sigmoid and left colon diverticulosis; otherwise, normal flexible sigmoidoscopy to the proximal descending colon.

gastroenterology, olympus, gastroscope, rectal bleeding, flexible sigmoidoscopy, colon diverticulosis, descending colon, diverticulosis, hemorrhoids, flexible, sigmoidoscopy, colon

The situation involves a medical procedure (flexible sigmoidoscopy) and its findings. The identified condition is diverticulosis, which can be a chronic issue leading to potential complications like bleeding. The procedure showed no active bleeding at the time, and the patient tolerated the procedure well. Recommendations include monitoring and potentially more comprehensive follow-up with a full colonoscopy if bleeding continues. While important for patient health management, the immediate situation is not life-threatening or highly urgent, but it does require monitoring and follow-up as diverticulosis can lead to further complications.


Medical Specialty: Surgery
Sample Name: Spontaneous Vaginal Delivery

PREOPERATIVE DIAGNOSIS: , Term pregnancy at 40 and 3/7th weeks.,PROCEDURE PERFORMED: , Spontaneous vaginal delivery.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 36-year-old African-American female who is a G-2, P-2-0-0-2 with an EDC of 08/30/2003.  She is blood type AB -ve with antibody screen negative and is also rubella immune, VDRL nonreactive, hepatitis B surface antigen negative, and HIV nonreactive.  She does have a history of sickle cell trait.  She presented to Labor and Delivery Triage at 40 and 3/7th weeks gestation with complaint of contractions every ten minutes.  She also stated that she has lost her mucous plug.  She did have fetal movement, noted no leak of fluid, did have some spotting.  On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.  She was evaluated by sterile vaginal exam and was noted to be 4 cm dilated, 70% effaced, and -3 station.  This was a change from her last office exam, at which she was 1 cm to 2 cm dilated.,PROCEDURE DETAILS:,  The patient was admitted to Labor and Delivery for expected management of labor and AROM was performed and the amniotic fluid was noted to be meconium stained.  After her membranes were ruptured, contractions did increase to every two to three minutes as well as the intensity increased.  She was given Nubain for discomfort with good result.,She had a spontaneous vaginal delivery of a live born female at 11:37 with meconium stained fluid as noted from ROA position.  After controlled delivery of the head, tight nuchal cord was noted, which was quickly double clamped and cut and the shoulders and body were delivered without difficulty.  The infant was taken to the awaiting pediatrician.  Weight was 2870 gm, length was 51 cm.  The Apgars were 6 at 1 minute and 9 at 5 minutes.  There was initial neonatal depression, which was treated by positive pressure ventilation and the administration of Narcan.,Spontaneous delivery of an intact placenta with a three-vessel cord was noted at 11:45.  On examination, there were no noted perineal abrasions or lacerations.  On vaginal exam, there were no noted cervical or vaginal sidewall lacerations.  Estimated blood loss was less than 250 cc.  Mother and infant are in recovery doing well at this time.
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DESCRIPTION: Spontaneous vaginal delivery.   Term pregnancy at 40 and 3/7th weeks.  On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.

surgery, roa position, arom, labor and delivery, spontaneous vaginal delivery, term pregnancy, contracting, meconium, lacerations, pregnancy, contractions, vaginal,

The situation involves a medical procedure related to childbirth, specifically a spontaneous vaginal delivery. While it is a routine medical procedure, there are inherent risks associated with childbirth, especially with the presence of a nuchal cord and meconium-stained amniotic fluid, which require careful management to ensure the health and safety of both the mother and child. The presence of a tight nuchal cord and initial neonatal depression, which were managed effectively, also adds to the complexity. However, given the routine nature of the delivery and the successful outcome with both mother and infant doing well in recovery, the situation is of moderate stakes typically handled competently by trained medical professionals.


Medical Specialty: Surgery
Sample Name: Carotid Endarterectomy - 1

PREOPERATIVE DIAGNOSIS:,  Right common, internal and external carotid artery stenosis.,POSTOPERATIVE DIAGNOSIS:,  Right common, internal and external carotid artery stenosis.,OPERATIONS,1.  Right common carotid endarterectomy.,2.  Right internal carotid endarterectomy.,3.  Right external carotid endarterectomy.,4.  Hemashield patch angioplasty of the right common, internal and external carotid arteries.,ANESTHESIA:,  General endotracheal anesthesia.,URINE OUTPUT: , Not recorded,OPERATION IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Next the right neck was prepped and draped in the standard surgical fashion.  A #10-blade scalpel was used to make an incision at the anterior tip of the sternocleidomastoid muscle.  Dissection was carried down to the level of the carotid artery using Bovie electrocautery and sharp dissection with Metzenbaum scissors.  The common, internal and external carotid arteries were identified.  The facial vein was ligated with #3-0 silk.  The hypoglossal nerve was identified and preserved as it coursed across the carotid artery.  After dissecting out an adequate length of common, internal and external carotid artery, heparin was given.  Next, an umbilical tape was passed around the common carotid artery.  A #0 silk suture was passed around the internal and external carotid arteries.  The hypoglossal nerve was identified and preserved.  An appropriate sized Argyle shunt was chosen.  A Hemashield patch was cut to the appropriate size.  Next, vascular clamps were placed on the external carotid artery.  DeBakey pickups were used to control the internal carotid artery and common carotid artery.  A #11-blade scalpel was used to make an incision on the common carotid artery.  The arteriotomy was lengthened onto the internal carotid artery.  Next, the Argyle shunt was placed.  It was secured in place.  Next, an endarterectomy was performed; and this was done on the common, internal carotid and external carotid arteries.  An inversion technique was used on the external carotid artery.  The artery was irrigated and free debris was removed.  Next, we sewed the Hemashield patch onto the artery using #6-0 Prolene in a running fashion.  Prior to completion of our anastomosis, we removed our shunt.  We completed the anastomosis.  Next, we removed our clamp from the external carotid artery, followed by the common carotid artery, and lastly by the internal carotid artery.  There was no evidence of bleeding.  Full-dose protamine was given.  The incision was closed with #0 Vicryl, followed by #2-0 Vicryl, followed by #4-0 PDS in a running subcuticular fashion.  A sterile dressing was applied.
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DESCRIPTION: Right common carotid endarterectomy, internal carotid endarterectomy, external carotid endarterectomy, and Hemashield patch angioplasty of the right common, internal and external carotid arteries.

surgery, angioplasty, common carotid artery, external carotid artery, hemashield patch, common carotid, carotid endarterectomy, external, artery, carotid, hemashield, endarterectomy

The situation involves performing a carotid endarterectomy and patch angioplasty, which are high-stakes surgical procedures aimed at preventing stroke by addressing significant carotid artery stenosis. The complexity and potential complications, like neurological deficits, bleeding, or recurrent stenosis, make this a high-stakes medical procedure. Any errors or unexpected occurrences during surgery could have critical consequences for the patient's health.