Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Consultation

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

The situation involves a 71-year-old woman with a complex medical history, including coronary artery disease, chronic renal insufficiency, severe COPD, and several other significant conditions. She presents with worsening symptoms, including shortness of breath, peripheral edema, and paroxysmal nocturnal dyspnea, which could indicate worsening heart failure or pulmonary issues. The presence of such symptoms in a patient with multiple comorbidities and a complicated cardiovascular history suggests that this is a high-stakes situation. Immediate medical intervention might be necessary to prevent further deterioration of her health, making it crucial for the medical team to carefully assess and manage her condition.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Organic Brain Syndrome

REASON FOR CONSULT:,  Organic brain syndrome in the setting of multiple myeloma.,SOURCE OF HISTORY:  ,The patient himself is not able to give a good history.  History has obtained through discussion with Dr. X over the phone and the nurse taking care of the patient despite reviewing the chart on the floor.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words.  Not a very clear history at this time and the patient himself is not able to give any history despite no family member was present in the room.  Neurology consult was called to evaluate any organic brain syndrome in the setting of multiple myeloma.  The patient since the morning has improved, but still not completely back to the baseline.  Even I evaluated the patient previously, hence not very sure about his baseline.,PAST MEDICAL HISTORY:,  History of IgG subtype multiple myeloma.,SURGICAL HISTORY:,  Nothing significant.,PSYCHIATRIC HISTORY:  ,Nothing significant.,SOCIAL HISTORY:  ,No history of any smoking, alcohol or drug abuse.,ALLERGIES: , CODEINE AND FLAGYL.,IMMUNIZATION HISTORY: , Nothing significant.,FAMILY HISTORY: , Unobtainable.,REVIEW OF SYSTEMS:  ,The patient was considered to ask question for systemic review including neurology, psychiatry, sleep, ENT, ophthalmology, pulmonary, cardiology, gastroenterology, genitourinary, hematology, rheumatology, dermatology, allergy/immunology, endocrinology, toxicology, oncology, and found to be positive for the symptoms mentioned in the history of the presenting illness.  The patient himself is not able to give any history only source is the chart.  For details, please review the chart.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure of 97/54, heart rate of 97, respiratory rate of 19, and temperature 98.5.  The patient on supplemental oxygen was FiO2 on 2 L 96%.  Limited physical examination.,HEENT:  Head, normocephalic and atraumatic.  Throat clear.  No discharge from the ear and the nose.  No discoloration of conjunctivae and the sclerae.,NECK:  Supple.  No signs of any meningismus.  Though a limited examination, the patient does appear to have arthritic changes, questioning contracture deformities, as not able to follow the commands to show full range of motion.  No bruit auscultated over the neck and the orbits.,LUNGS:  Clear to auscultation.,HEART:  Normal heart sounds.,ABDOMEN:  Benign.,EXTREMITIES:  No edema, clubbing or cyanosis.  No rash.  No leptomeningeal or neurocutaneous disorder.,NEUROLOGIC:  Examination is limited.  Mental state examination, the patient is awake, alert, and oriented to himself, not able follow commands, and give a proper history, and still appeared to be confuse and disoriented.  Cranial nerve examination limited, but apparently nonfocal.  Motor examination is very limited except for the grips, which were strong enough.  I was not able to obtain much.  Deep tendon reflexes were not reliable.  Toes equivocal and downgoing.  Sensory examination is not reliable, though intact for painful stimuli with limited examination.  Coordination could not be tested.  Gait could not be tested.,IMPRESSION:,  History of multiple myeloma and altered mental status in multiple myeloma setting.  Rule out brain metastasis including lepto-meningismus, possible transient ischemic attack related to hyperviscosity syndrome or provoked seizure related to ischemia, and delirium related to any electrolyte imbalance or underlying infarction.,PLAN AND RECOMMENDATIONS: , The patient is to continue with current level of management.  I will review the chart before ordering any further testing that may include a CT scan of the brain, if has not been ordered, EEG, urine test, and the latest CBC with diff. to rule out any urinary tract infection or indication of any other seen of infection.  No other intervention at this time.  The patient may be started on aspirin, if it is okay with Dr. X.
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DESCRIPTION: Organic brain syndrome in the setting of multiple myeloma.  The patient is a 56-year-old male with the history of multiple myeloma, who has been admitted for complains of being dehydrated and was doing good until this morning, was found to be disoriented and confused, was not able to communicate properly, and having difficulty leaving out the words.

The situation involves a 56-year-old male patient with multiple myeloma who is experiencing significant neurologic symptoms, including confusion and disorientation. These symptoms could be indicative of serious conditions such as brain metastasis, transient ischemic attack, or a metabolic disorder. Given the complexity and potential severity of the patient's condition, combined with the challenges in obtaining a reliable medical history and the need for further diagnostic work, this is a high-stakes medical situation. The management and outcome of the condition can significantly impact the patient's health and survival.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Pain Management
Sample Name: Cervical Epidural Steroid Injection - 1

OPERATION PERFORMED: , Cervical epidural steroid injection C7-T1.,ANESTHESIA:,  Local and Versed 2 mg IV.,COMPLICATIONS:  ,None.,DESCRIPTION OF PROCEDURE:  ,The patient was placed in the seated position with the neck flexed the forehead was placed on a cervical rest.  The head and cervical spine were restrained.  The patient was monitored with a blood pressure cuff, EKG and pulse oximetry.  The skin was prepped and draped in sterile classical fashion.  Excess cleansing solution was removed from the skin.  Local anesthesia was injected at C7-T1.  An 18-gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach.,Once the epidural space was identified, a negative aspiration for heme or CSF was done.  This was followed by the injection of 6 cc of saline mixed with methyl prednisolone acetate 120 mg in aliquots of 2 cc.  Negative aspirations were done prior to each injection.  The needle was cleared with saline prior to its withdrawal.  The patient tolerated the procedure well without any apparent difficulties or complications.
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DESCRIPTION: Cervical epidural steroid injection C7-T1.  An 18-gauge Tuohy needle was then placed in the epidural space with loss of resistance technique and a saline-filled syringe utilizing a midline intralaminar approach.

pain management, tuohy needle, cleansing solution, epidural space, loss of resistance, cervical epidural steroid injection, resistance technique, steroid injection, injection, intralaminar, steroid, epidural,

The procedure described is a cervical epidural steroid injection, which is a common and generally safe procedure used to relieve neck pain. While it involves inserting a needle near the spinal cord, which could pose risks—like infection, bleeding, or nerve damage—such complications are rare when performed by trained professionals. The operation appears to have been completed without complications, and the situation does not involve any emergencies or high-risk conditions. Therefore, the situation is not of particularly high-stakes.


Medical Specialty: Radiology
Sample Name: Full-Field Digital Mammogram (FFDM) - 1

EXAM: , Digital screening mammogram.,HISTORY:,  51-year-old female presents for screening mammography.  Patient denies personal history of breast cancer.  Breast cancer was reported in her maternal aunt.,TECHNIQUE:,  Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy.  Comparison is made with the previous performed on mm/dd/yy. iCAD Second Look proprietary software was utilized.,FINDINGS:  ,The breasts demonstrate a mixture of adipose and fibroglandular elements.  Composition appears similar.  Multiple tiny punctate benign-appearing calcifications are visualized bilaterally.  No dominant mass, areas of architecture distortion, or malignant-type calcifications are seen.  Skin overlying both breasts is unremarkable.,IMPRESSION: , Stable and benign mammographic findings.  Continued yearly mammographic screening is recommended.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized.
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DESCRIPTION: Bilateral Screening Mammogram Full-Field Digital Mammography (FFDM) (Benign Findings)

radiology, mediolateral, craniocaudal, fibroglandular, bilateral screening mammogram, breast cancer, screening mammogram, mammographic, mammogram, breasts, screening, mammography

The scenario describes a routine mammogram screening with benign findings and a recommended follow-up for continued yearly screening. While monitoring for breast health is important, the findings are stable and benign, which indicates that there is no immediate health threat based on this information alone. Given the absence of suspicious findings and the recommendation simply to continue regular screenings, this situation is not high-stakes in the immediate sense. However, it's important to recognize the broader significance of continued screening in monitoring health, but the urgency in this case specifically is low.


Medical Specialty: Surgery
Sample Name: Liposuction

PREOPERATIVE DIAGNOSES:,1.  Deformity, right breast reconstruction.,2.  Excess soft tissue, anterior abdomen and flank.,3.  Lipodystrophy of the abdomen.,POSTOPERATIVE DIAGNOSES:,1.  Deformity, right breast reconstruction.,2.  Excess soft tissue, anterior abdomen and flank.,3.  Lipodystrophy of the abdomen.,PROCEDURES:,1.  Revision, right breast reconstruction.,2.  Excision, soft tissue fullness of the lateral abdomen and flank.,3.  Liposuction of the supraumbilical abdomen.,ANESTHESIA: , General.,INDICATION FOR OPERATION:,  The patient is a 31-year-old white female who previously has undergone latissimus dorsi flap and implant, breast reconstruction.  She now had lateralization of the implant with loss of medial fullness for which she desired correction.  It was felt that mobilization of the implant medially would provide the patient significant improvement and this was discussed with the patient at length.  The patient also had a small dog ear in the flank area on the right from the latissimus flap harvest, which was to be corrected.  She had also had liposuction of the periumbilical and infraumbilical abdomen with desire to have great improvement superiorly, was felt to be a candidate for such.  The above-noted procedure was discussed with the patient in detail.  The risks, benefits and potential complications were discussed.  She was marked in the upright position and then taken to the operating room for the above-noted procedure.,OPERATIVE PROCEDURE: , The patient was taken to the operating room and placed in the supine position.  Following adequate induction of general LMA anesthesia, the chest and abdomen was prepped and draped in the usual sterile fashion.  The supraumbilical abdomen was then injected with a solution of 5% lidocaine with epinephrine, as was the dog ear.  At this time, the superior central scar was then excised, dissection continued through the subcutaneous tissue, the underlying latissimus muscle until the capsule of the implant was reached.  This was then opened.  The implant was removed and placed on the back table in antibiotic solution.  Using Bovie cautery, the medial capsule was released and undermining was then performed with release of the muscle to the level of the proposed medial projection of the breast.  The inframammary fold medially was secured with 2-0 PDS suture to create greater takeoff point at this level which in the upright position and using a sizer produced a good form.  The lateral pocket was diminished by series of 2-0 PDS suture to provide medialization of the implant.  The implant was then placed back into the submuscular pocket with much improved positioning and medial fullness.  With this completed, the implant was again removed, antibiotic irrigation was performed.  A drain was placed and brought out through a separate inferior stab wound incision and hemostasis was confirmed.  The implant was then replaced and the wound was then closed in layers using 2-0 PDS running suture on the muscle and 3-0 Monocryl Dermabond subcuticular sutures.  The 2.5 cm dog ear was then excised into and including the subcutaneous tissue, even contouring was achieved and this was closed with two layers using 3-0 Monocryl suture.  Using a #3 cannula, a superior umbilical incision, liposuction was carried out into the supraumbilical abdomen, removing approximately 40 to 50 mL of fat with improved supraumbilical contours.  This was closed with 6-0 Prolene suture.  The patient was placed in a compressive garment after treating the incision with Dermabond, Steri-Strips and antibiotic ointment around the drain site and umbilicus.  A Kerlix dressing and a surgical bra was placed to the chest area.  A compressive garment was placed.  The patient was then aroused from anesthesia, extubated, and taken to the recovery room in stable condition.  Sponge, needle, lap, instrument counts were all correct.  The patient tolerated the procedure well.  There were no complications.  The estimated blood loss was approximately 25 mL.
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DESCRIPTION: Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.

surgery, breast reconstruction, excess, lma anesthesia, lipodystrophy, liposuction, abdomen, drain site, flank, latissimus dorsi flap, soft tissue, supraumbilical, surgical bra, supraumbilical abdomen, reconstruction, breast, tissue, implant,

The surgical procedure described involves a combination of cosmetic and reconstructive surgeries, including right breast reconstruction revision and abdominal liposuction. These procedures typically involve risks associated with general anesthesia, potential complications such as infection, bleeding, and issues with healing or aesthetic outcomes. Although not life-threatening, these surgeries can significantly affect the patient's quality of life and satisfaction. The stakes are higher than routine low-risk surgeries due to the patient's previous complex medical history involving breast reconstruction and the associated expectations for cosmetic outcomes. The medical team must manage these risks carefully to ensure a successful outcome.


Medical Specialty: Surgery
Sample Name: TLIF

PREOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,POSTOPERATIVE DIAGNOSIS (ES):, L4-L5 and L5-S1 degenerative disk disease/disk protrusions/spondylosis with radiculopathy.,PROCEDURE:,1. Left L4-L5 and L5-S1 Transforaminal Lumbar Interbody Fusion (TLIF).,2. L4 to S1 fixation (Danek M8 system).,3. Right posterolateral L4 to S1 fusion.,4. Placement of intervertebral prosthetic device (Danek Capstone spacers L4-L5 and L5-S1).,5. Vertebral autograft plus bone morphogenetic protein (BMP).,COMPLICATIONS:, None.,ANESTHESIA:, General endotracheal.,SPECIMENS:, Portions of excised L4-L5 and L5-S1 disks.,ESTIMATED BLOOD LOSS:, 300 mL.,FLUIDS GIVEN:, IV crystalloid.,OPERATIVE INDICATIONS:, The patient is a 37-year-old male presenting with a history of chronic, persistent low back pain as well as left lower extremity of radicular character were recalcitrant to conservative management. Preoperative imaging studies revealed the above-noted abnormalities. After a detailed review of management considerations with the patient and his wife, he was elected to proceed as noted above.,Operative indications, methods, potential benefits, risks and alternatives were reviewed. The patient and his wife expressed understanding and consented to proceed as above.,OPERATIVE FINDINGS:, L4-L5 and L5-S1 disk protrusion with configuration as anticipated from preoperative imaging studies. Pedicle screw placement appeared satisfactory with satisfactory purchase and positioning noted at all sites as well as satisfactory findings upon probing of the pedicular tracts at each site. In addition, all pedicle screws were stimulated with findings of above threshold noted at all sites. Spacer snugness and positioning appeared satisfactory. Electrophysiological monitoring was carried out throughout the procedure and remained stable with no undue changes reported.,DESCRIPTION OF THE OPERATION:, After obtaining proper patient identification and appropriate preoperative informed consent, the patient was taken to the operating room on a hospital stretcher in the supine position. After the induction of satisfactory general endotracheal anesthesia and placement of appropriate monitoring equipment by Anesthesiology as well as placement of electrophysiological monitoring equipment by the Neurology team, the patient was carefully turned to the prone position and placed upon the padded Jackson table with appropriate additional padding placed as needed. The patient's posterior lumbosacral region was thoroughly cleansed and shaved. The patient was then scrubbed, prepped and draped in the usual manner. After local infiltration with 1% lidocaine with 1: 200,000 epinephrine solution, a posterior midline skin incision was made extending from approximately L3 to the inferior aspect of the sacrum. Dissection was continued in the midline to the level of the posterior fascia. Self-retaining retractors were placed and subsequently readjusted as needed. The fascia was opened in the midline, and the standard subperiosteal dissection was then carried out to expose the posterior and posterolateral elements from L3-L4 to the sacrum bilaterally with lateral exposure carried out to the lateral aspect of the transverse processes of L4 and L5 as well as the sacral alae bilaterally. _____ by completing the exposure, pedicle screw fixation was carried out in the following manner. Screws were placed in systematic caudal in a cranial fashion. The pedicle screw entry sites were chosen using standard dorsal landmarks and fluoroscopic guidance as needed. Cortical openings were created at these sites using a small burr. The pedicular tracts were then preliminarily prepared using a Lenke pedicle finder. They were then probed and subsequently tapped employing fluoroscopic guidance as needed. Each site was "under tapped" and reprobed with satisfactory findings noted as above. Screws in the following dimensions were placed. 6.5-mm diameter screws were placed at all sites. At S1, 40-mm length screws were placed bilaterally. At L5, 40-mm length screws were placed bilaterally, and at L4, 40-mm length screws were placed bilaterally with findings as noted above. The rod was then contoured to span from the L4 to the S1 screws on the right. The distraction was placed across the L4-L5 interspace, and the connections were temporarily secured. Using a matchstick burr, a trough was then carefully created slightly off the midline of the left lamina extending from its caudal aspect to its more cranial aspect at the foraminal level. This was longitudinally oriented. A transverse trough was similarly carefully created from the cranial point of the longitudinal trough out to the lateral aspect of the pars against the foraminal level that is slightly caudal to the L4 pedicle. This trough was completed to the level of the ligamentum flavum using small angled curettes and Kerrison rongeurs, and this portion of the lamina along with the inferior L4 articular process was then removed as a unit using rongeurs and curettes. The cranial aspect of the left L5 superior articular process was then removed using a small burr and angled curettes and Kerrison rongeurs. A superior laminotomy was performed from the left L5 lamina and flavectomy was then carried out across this region of decompression, working from caudally to cranially and medially to laterally, again using curettes and Kerrison rongeurs under direct visualization. In this manner, the left lateral aspect of the thecal sac passing left L5 spinal nerve and exiting left L4 spinal nerve along with posterolateral aspect of disk space was exposed. Local epidural veins were coagulated with bipolar and divided. Gelfoam was then placed in this area. This process was then repeated in similar fashion; thereby, exposing the posterolateral aspect of the left L5-S1 disk space. As noted, distraction had previously been placed at L4-L5, this was released. Distraction was placed across the L5-S1 interspace. After completing satisfactory exposure as noted, a annulotomy was made in the posterolateral left aspect of the L5-S1 disk space. Intermittent neural retraction was employed with due caution afforded to the neural elements throughout the procedure. The disk space was entered, and diskectomy was carried out in routine fashion using pituitary rongeurs followed by the incremental sized disk space shavers as well as straight and then angled TLIF curettes to prepare the front plate. Herniated portions of the disk were also removed in routine fashion. The diskectomy and endplate preparation were carried out working progressively from the left towards the right aspect of the disk across the midline in routine fashion. After completing this disk space preparation, Gelfoam was again placed. The decompression was assessed and appeared to be satisfactory. The distraction was released, and attention was redirected at L4-L5, where again, distraction was placed and diskectomy and endplate preparation was carried out at this interspace again in similar fashion. After completing the disk space preparation, attention was redirected to L5-S1. Distraction was released at L4-L5 and again, reapplied at L5-S1, incrementally increasing size. Trial spaces were used, and a 10-mm height by 26-mm length spacer was chosen. A medium BMP kit was appropriately reconstituted. A BMP sponge containing morcellated vertebral autograft was then placed into the anterior aspect of the disk space. The spacer was then carefully impacted into position. The distraction was released. The spacer was checked with satisfactory snugness and positioning noted. This process was then repeated in similar fashion at L4-L5, again with placement of a 10-mm height by 26-mm length Capstone spacer, again containing BMP and again with initial placement of a BMP sponge with vertebral autograft anteriorly within the interspace. This spacer was also checked again with satisfactory snugness and positioning noted. The prior placement of the spacers and BMP, the wound was thoroughly irrigated and dried with satisfactory hemostasis noted. Surgicel was placed over the exposed dura and disk space. The distraction was released on the right and compression plates across the L5-S1 and L4-L5 interspaces and the connections fully tightened in routine fashion. The posterolateral elements on the right from L4 to S1 were prepared for fusion in routine fashion, and BMP sponges with supplemental vertebral autograft was placed in the posterolateral fusion bed as well as the vertebral autograft in the dorsal aspect of the L4-L5 and L5-S1 facets on the right in a routine fashion. A left-sided rod was appropriated contoured and placed to span between the L4 to S1 screws. Again compression was placed across the L4-L5 and L5-S1 segments, and these connections were fully secured. Thorough hemostasis was ascertained after checking the construct closely and fluoroscopically. The wound was closed using multiple simple interrupted 0-Vicryl sutures to reapproximate the deep paraspinal musculature in the midline. The superficial paraspinal musculature in posterior fashion was closed in the midline using multiple simple interrupted 0-Vicryl sutures. The suprafascial subcutaneous layers were closed using multiple simple interrupted #0 and 2-0 Vicryl sutures. The skin was then closed using staples. Sterile dressings were then applied and secured in place. The patient tolerated the procedure well and was to the recovery room in satisfactory condition.
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DESCRIPTION: Transforaminal lumbar interbody fusion, placement of intervertebral prosthetic device.

surgery, degenerative disk disease, disk protrusions, spondylosis, radiculopathy, tlif, transforaminal lumbar interbody fusio, danek m8, intervertebral prosthetic device, danek capstone, matchstick burr, capstone, bmp, vertebral autograft, screws were placed bilaterally, pedicle screw, kerrison rongeurs, disk space, disk, spacers, kerrison, interbody, rongeurs, pedicle, lumbar, screws,

The transforaminal lumbar interbody fusion (TLIF) is a significant surgical procedure performed to alleviate back pain and radiculopathy resulting from degenerative disc disease. This operation involves the insertion of bone graft, placement of spacers, and screw fixation to stabilize the spine. The procedure is high-stakes due to its potential risks, such as spinal nerve damage, infection, and the complexity of ensuring proper alignment and stability of spinal constructs. The detailed description emphasizes the care taken during surgery, which underscores the critical nature of this operation.


Medical Specialty: Emergency Room Reports
Sample Name: Colostomy Failure

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

The situation involves a patient with a colostomy experiencing failure, likely due to bowel obstruction. While the patient is currently hemodynamically stable and not in acute distress, bowel obstructions can potentially escalate into serious emergencies if not managed properly. Immediate medical intervention and monitoring in a hospital setting are required to prevent complications. However, since the patient is stable and admitted for observation, it's not at an immediate critical level.


Medical Specialty: Neurology
Sample Name: CT Scan of  Brain w/o Contrast

REASON FOR EXAMINATION:  Face asleep.,COMPARISON EXAMINATION:  None.,TECHNIQUE:  Multiple axial images were obtained of the brain.  5 mm sections were acquired.  2.5-mm sections were acquired without injection of intravenous contrast.  Reformatted sagittal and coronal images were obtained.,DISCUSSION:  No acute intracranial abnormalities appreciated.  No evidence for hydrocephalus, midline shift, space occupying lesions or abnormal fluid collections.  No cortical based abnormalities appreciated.  The sinuses are clear.  No acute bony abnormalities identified.,Preliminary report given to emergency room at conclusion of exam by Dr. Xyz.,IMPRESSION:  No acute intracranial abnormalities appreciated.,
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DESCRIPTION: CT Scan of  brain without contrast.

CT Scan of  brain without contrast.

neurology, ct scan, multiple axial images, asleep, brain, coronal, coronal images, hydrocephalus, intracranial, intravenous contrast, sagittal, without contrast, ct, scan, contrast, abnormalities,

The situation involves a CT scan being conducted to assess potential neurological issues given the symptom 'Face asleep.' The CT scan results show no acute intracranial abnormalities. While the absence of immediate issues provides relief, the symptom prompting the scan could indicate an underlying neurological problem that requires further investigation. However, the current findings suggest no immediate threat to health. The stakes are moderate as the scan helps rule out acute conditions, but further medical evaluation may be required to address the underlying symptoms.


Medical Specialty: Urology
Sample Name: Spermatocelectomy

PREOPERATIVE DIAGNOSIS:,  Right spermatocele.,POSTOPERATIVE DIAGNOSIS:  ,Right spermatocele.,OPERATIONS PERFORMED:,1.  Right spermatocelectomy.,2.  Right orchidopexy.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT:  ,The patient is a 77-year-old male who comes to the office with a large right spermatocele.  The patient says it does bother him on and off, has occasional pain and discomfort with it, has difficulty with putting clothes on etc. and wanted to remove.  Options such as watchful waiting, removal of the spermatocele or needle drainage were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, risk of infection, scrotal pain, and testicular pain were discussed.  The patient was told that his scrotum may enlarge in the postoperative period for about a month and it will settle down.  The patient was told about the risk of recurrence of spermatocele.  The patient understood all the risks, benefits, and options and wanted to proceed with removal.,DETAILS OF THE PROCEDURE:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient's scrotal area was shaved, prepped, and draped in the usual sterile fashion.  A midline scrotal incision was made measuring about 2 cm in size.  The incision was carried through the dartos through the scrotal sac and the spermatocele was identified.  All the layers of the spermatocele were removed.  Clear layer was visualized, was taken all the way up to the base, the base was tied.  Entire spermatocele sac was removed.  After removing the entire spermatocele sac, hemostasis was obtained.  The testicle was not in normal orientation.  The testis and epididymis was removed, which is a small appendage on the superior aspect of the testicle.  The testicle was placed in a normal orientation.  Careful attention was drawn not to twist the cord.  Orchidopexy was done to allow the testes to stay stable in the postoperative period using 4-0 Vicryl and was tied at 3 different locations.  Absorbable sutures were used, so that the patient does not feel the sutures in the postoperative period.  The dartos was closed using 2-0 Vicryl in running locking fashion.  There was excellent hemostasis.  The skin was closed using 4-0 Monocryl.  Dermabond was applied.  The patient tolerated the procedure well.  The patient was brought to the recovery room in stable condition.
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DESCRIPTION: Spermatocelectomy and orchidopexy

Spermatocelectomy and orchidopexy

urology, orchidopexy, spermatocele, spermatocelectomy, scrotal

The procedure described is a surgical intervention on a 77-year-old male patient to remove a right spermatocele and stabilize the testicle with orchidopexy. While this is a routine procedure in urology with minimal estimated blood loss and carried out under local MAC anesthesia, it does involve risks common to surgeries such as infection, bleeding, testicular pain, and anesthesia-related complications. The patient is also elderly, potentially increasing the stakes due to age-related risks during surgery. However, all risks and management options were explained to the patient, who understood and consented. Despite these factors, this surgery is usually low-stakes within the context of surgical procedures and considering the patient's stable condition post-operation.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Neonatal Discharge Summary - 1

ADMITTING DIAGNOSES:,  Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.,HISTORY OF PRESENTING ILLNESS: , The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.  Baby was born at ABCD Hospital at 1333 on 07/14/2006.  Mother is a 20-year-old gravida 1, para 0 female who received prenatal care.  Prenatal course was complicated by low amniotic fluid index and hypertension.  She was evaluated for evolving preeclampsia and had a C-section secondary to the nonreassuring fetal status.  Baby delivered operatively, Apgar scores were 8 and 9 initially taken to level 2 satellite nursery and arrangements were to transfer to Children's Hospital.  Infant was transferred to Children's Hospital for higher level of care, stayed at Children's Hospital for approximately 2 weeks, and was transferred back to ABCD where he stayed until he was discharged on 08/16/2006.,HOSPITAL COURSE: , At the time of transfer to ABCD, these were the following issues.,FEEDING AND NUTRITION: , Baby was on TPN and p.o. feeds had been started and were advanced 1 ml q.6h.  Baby was tolerating p.o. feeds of expressed breast milk and baby began to experience some abdominal distention.  The p.o. feeds were held and IV D10 water was given.  Baby was started on Mylicon drops and glycerin suppositories.  Abdominal ultrasound showed gaseous distention without signs of obstruction.  OG tube was passed.  Baby improved after couple of days when p.o. feedings were restarted.  Baby was also given Reglan.  At the time of discharge, baby was tolerating p.o. feeds well of BM fortified with 22-cal NeoSure.  Feeding amounts at the time of discharge was between 35 to 50 mL per feed and weight was 1797 grams.,RESPIRATIONS: , At the time of admission, baby was not having any apnea spells, no bradycardia or desaturations, was saturating well on room air and continued to do well on room air until the time of discharge.,HYPOGLYCEMIA: , Baby began to experience hypoglycemic episodes on 07/24/2006.  Blood glucose level was as low as 46.  D10 was given initially as bolus.  Baby continued to experience hypoglycemic episodes.  Diazoxide was started 5 mg/kg per os every 8 hours and fingersticks were done to monitor blood glucose level.  The baby improved with diazoxide, hypoglycemic issues resolved and then began again.  Diazoxide was discontinued, but the hypoglycemic issues restarted.  The Diazoxide was restarted again.  Blood glucose level stabilized and then diazoxide was weaned off until daily dose of 6 mg/kg and then the diazoxide was discontinued.  At the time of discharge, blood glucose levels were not being stable for 24 hours.,CARDIOVASCULAR: , Infant was hemodynamically stable on admission from Madera.  Infant has a closed PDA.  Infant had two cardiac echograms done.  The lab showing normal antegrade flow across the right coronary artery as well as the left main and left anterior descending coronary artery, then the circumflex coronary artery.,CNS:,  Infant had a head ultrasound done to rule out intracranial abnormalities and intracranial hemorrhage.  The ultrasound was negative for intracranial hemorrhage.,INFECTIOUS DISEASE:,  The patient had been on antibiotics during the stay at Madera.  At the time of admission to the ABCD, the patient was not on any antibiotics and his clinically condition has remained stable.,HEMATOLOGY: , The patient is status post phototherapy at Madera and was started on iron.,OPHTHALMOLOGY: ,  Exam on 07/17/2006 showed immature retina.  The patient is to get followup exam after discharge.,DISCHARGE DIAGNOSIS: , Stable ex-32-weeks preemie.,DISCHARGE INSTRUCTIONS: , The patient has been educated on CPR measures.  Followup appointment has been made at Kid's Care.  Calcium challenge has been done.  The patient's parents are comfortable with feeding.  The patient has been discharged on NeoSure and expressed breast milk.,
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DESCRIPTION: Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.  The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.

pediatrics - neonatal, delivered, preeclampsia, immaturity, intrauterine, prenatal, coronary artery, blood glucose, discharge, baby, coronary, intracranial, hypoglycemia, hypoglycemic, infant,

The situation involves the discharge of a neonatal patient with multiple complex medical issues, including respiratory distress syndrome, hypoglycemia, and retinal immaturity. Neonatal care is inherently high-stakes due to the vulnerability and fragility of infants. Ensuring proper follow-up care is crucial for the baby's ongoing health, highlighting the importance of accurate discharge summaries and instructions.


Medical Specialty: Neurosurgery
Sample Name: Ventriculostomy Placement

PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:,  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PROCEDURE:  ,The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage.  His condition is felt to be critical.  In a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy.  I have discussed this with patient's wife who agrees and asked that we proceed emergently.,After a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic.  Subsequently a 1 cm incision was made over Kocher's point.  Hemostasis was obtained.  Then a twist drill was made over this area.  Bones strips were irrigated away.  The dura was perforated with a spinal needle.,A Camino monitor was connected and zeroed.  This was then passed into the left lateral ventricle on the first pass.  Excellent aggressive very bloody CSF under pressure was noted.  This stopped, slowed, and some clots were noted.  This was irrigated and then CSF continued.  Initial opening pressures were 30, but soon arose to 80 or a 100.,The patient tolerated the procedure well.  The wound was stitched shut and the ventricular drain was then connected to a drainage bag.,Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding.
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DESCRIPTION: Placement of left ventriculostomy via twist drill.  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.

neurosurgery, intraventricular hemorrhage, hydrocephalus, intracranial pressure, camino monitor, twist drill, ventriculostomy, hemorrhage, intracranial, pressure, intraventricular

The procedure described involves the placement of a ventriculostomy, which is a critical neurosurgical intervention used to alleviate massive intracranial pressure due to intraventricular hemorrhage and hydrocephalus. The patient's condition is described as critical, indicating a life-threatening situation. The procedure is performed emergently to prevent potential brain damage or death. Given the nature of the medical situation and the potential outcomes of not proceeding with the surgery, this is a high-stakes scenario.


Medical Specialty: Consult - History and Phy.
Sample Name: Mesothelioma - Consult

REASON FOR CONSULTATION: , Mesothelioma.,HISTORY OF PRESENT ILLNESS: , The patient is a 73-year-old pleasant Caucasian male who is known to me from his previous hospitalization.  He has also been seen by me in the clinic in the last few weeks.  He was admitted on January 18, 2008, with recurrent malignant pleural effusion.  On the same day, he underwent VATS and thoracoscopic drainage of the pleural effusion with right pleural nodule biopsy, lysis of adhesions, and directed talc insufflation by Dr. X.  He was found to have 2.5L of bloody pleural effusions, some loculated pleural effusion, adhesions, and carcinomatosis in the parenchyma.  His hospital course here has been significant for dyspnea, requiring ICU stay.  He also had a chest tube, which was taken out few days ago.  He has also had paroxysmal atrial fibrillation, for which he has been on amiodarone by cardiologist.  The biopsy from the pleural nodule done on the right on January 18, 2008, shows malignant epithelioid neoplasm consistent with mesothelioma.  Immunohistochemical staining showed tumor cells positive for calretinin and focally positive for D2-40, MOC-31.  Tumor cells are negative for CDX-2, and monoclonal CEA.,The patient at this time reports that overall he has been feeling better with decrease in shortness of breath and cough over the last few days.  He does have edema in his lower extremities.  He is currently on 4L of oxygen.  He denies any nausea, vomiting, abdominal pain, recent change in bowel habit, melena, or hematochezia.  No neurological or musculoskeletal signs or symptoms.  He reports that he is able to ambulate to the bathroom, but gets short of breath on exertion.  He denies any other complaints.,PAST MEDICAL HISTORY:,  Left ventricular systolic dysfunction as per the previous echocardiogram done in December 2007, history of pneumonia in December 2007, admitted to XYZ Hospital.  History of recurrent pleural effusions, status post pleurodesis and locally advanced non-small cell lung cancer as per the biopsy that was done in XYZ Hospital.,ALLERGIES:,  No known drug allergies.,CURRENT MEDICATIONS:  ,In the hospital are amiodarone, diltiazem, enoxaparin, furosemide, methylprednisolone, pantoprazole, Zosyn, p.r.n. acetaminophen, and hydrocodone.,SOCIAL HISTORY: , The patient is married and lives with his spouse.  He has history of tobacco smoking and also reports history of alcohol abuse.  No history of illicit drug abuse.,FAMILY HISTORY:  ,Significant for history of ?cancer? in the mother and history of coronary artery disease in the father.,REVIEW OF SYSTEMS: , As stated above.  He denies any obvious asbestos exposure, as far as he can remember.,PHYSICAL EXAMINATION,GENERAL:  He is awake, alert, in no acute distress.  He is currently on 4L of oxygen by nasal cannula.,VITAL SIGNS:  Blood pressure 97/65 mmHg, respiration is 20 per minute, pulse is 72 per minute, and temperature 98.3 degrees Fahrenheit.,HEENT:  No icterus or sinus tenderness.  Oral mucosa is moist.,NECK:  Supple.  No lymphadenopathy.,LUNGS:  Clear to auscultation except few diffuse wheezing present bilaterally.,CARDIOVASCULAR:  S1 and S2 normal.,ABDOMEN:  Soft, nondistended, and nontender.  No hepatosplenomegaly.  Bowel sounds are present in all four quadrants.,EXTREMITIES:  Bilateral pedal edema is present in both the extremities.  No signs of DVT.,NEUROLOGICAL:  Grossly nonfocal.,INVESTIGATION:,  Labs done on January 28, 2008, showed BUN of 23 and creatinine of 0.9.  Liver enzymes checked on January 17, 2008, were unremarkable.  CBC done on January 26, 2008, showed WBC of 19.8, hemoglobin of 10.7, hematocrit of 30.8, and platelet count of 515,000.  Chest x-ray from yesterday shows right-sided Port-A-Cath, diffuse right lung parenchymal and pleural infiltration without change, mild pulmonary vascular congestion.,ASSESSMENT,1.  Mesothelioma versus primary lung carcinoma, two separate reports as for the two separate biopsies done several weeks apart.,2.  Chronic obstructive pulmonary disease.,3.  Paroxysmal atrial fibrillation.,4.  Malignant pleural effusion, status post surgery as stated above.,5.  Anemia of chronic disease.,RECOMMENDATIONS,1.  Compare the slides from the previous biopsy done in December at XYZ Hospital with recurrent pleural nodule biopsy slides.  I have discussed regarding this with Dr. Y in Pathology here at Methodist XYZ Hospital.  I will try to obtain the slides for comparison from XYZ Hospital for comparison and immunohistochemical staining.,2.  I will also discuss with Dr. X and also with intervention radiologist at XYZ Hospital regarding the exact sites of the two biopsies.,3.  Once the results of the above are available, I will make further recommendations regarding treatment.  The patient has significantly decreased performance status with dyspnea on exertion and is being planned for transfer to Triumph Hospital for rehab, which I agree with.,4.  Continue present care.,Discussed regarding the above in great details with the patient and his wife and daughter and answered the questions to their satisfaction.  They clearly understand the above.  They also understand his very poor performance status at this time, and the risks and benefits of delaying chemotherapy due to this.
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DESCRIPTION: Mesothelioma versus primary lung carcinoma, Chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, malignant pleural effusion, status post surgery as stated above, and anemia of chronic disease.

The patient is diagnosed with mesothelioma, a serious form of cancer, and has multiple complex health issues, including COPD and atrial fibrillation. The stakes are high given the life-threatening nature of the cancers, complications from the health conditions, and possible treatment decisions that need to be made cautiously considering the patient's health status.


Medical Specialty: Urology
Sample Name: Hypospadias Repair

PREOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Coronal hypospadias with chordee.,PROCEDURE: , Hypospadias repair (urethroplasty plate incision with tissue flap relocation and chordee release).,ANESTHESIA: , General inhalation anesthetic with a 0.25% Marcaine dorsal block and ring block per surgeon, 7 mL given.,TUBES AND DRAINS: , An 8-French Zaontz catheter.,ESTIMATED BLOOD LOSS:  ,10 mL.,FLUIDS RECEIVED:,  300 mL.,INDICATIONS FOR OPERATION: , The patient is a 6-month-old boy with the history of coronal hypospadias with chordee.  Plan is for repair.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room with surgical consent, operative site, and the patient identification were verified.  Once he was anesthetized, IV antibiotics were given.  The dorsal hood was retracted and cleansed.  He was then sterilely prepped and draped.  Stay suture of #4-0 Prolene was then placed in the glans.  His urethra was calibrated to 10-French bougie-a-boule.  We then marked the coronal cuff and the penile shaft skin, as well as the periurethral meatal area on the ventrum.  Byers flaps were also marked.  Once this was done, the skin was then incised around the coronal cuff with 15-blade knife and further extended with the curved tenotomy scissors to deglove the penis.  On the ventrum, the chordee tissue was removed and dissected up towards the urethral plate to use as secondary tissue flap coverage.  Once this was done, an electrocautery was used for hemostasis were then used.  A vessel loop tourniquet and IV grade saline was used for achieve artificial erection and chordee.  We then incised Buck fascia at the area of chordee in the ventrum and then used the #5-0 Prolene as a Heinecke-Mikulicz advancement suture.  Sutures were placed burying the knot and then artificial erection was again performed showing the penis was straight.  We then left the tourniquet in place, although loosened it slightly and then marked out the transurethral incision plate with demarcation for the glans and the ventral midline of the plate.  We then incised it with the ophthalmic micro lancet blade in the midline and along the __________ to elevate the glanular wings.  Using the curved iris scissors, we then elevated the wings even further.  Again, electrocautery was used for hemostasis.  An 8-French Zaontz catheter was then placed into the urethral plate and then interrupted suture of #7-0 Vicryl was used to mark the distal most extent of the urethral meatus and then the urethral plate was rolled using a subcutaneous closure using the #7-0 Vicryl suture.  There were two areas of coverage with the tissue flap relocation from the glanular wings.  The tissue flap that was rolled with the Byers flap was used to cover this, as well as the chordee tissue with interrupted sutures of #7-0 Vicryl.  Once this was completed, the glans itself had been rolled using two deep sutures of #5-0 Vicryl.  Interrupted sutures of #7-0 Vicryl were used to create the neomeatus and then horizontal mattress sutures of #7-0 Vicryl used to roll the glans in the midline.  The extra dorsal hood tissue of preputial skin was then excised.  An interrupted sutures of #6-0 chromic were then used to approximate penile shaft skin to the coronal cuff and on the ventrum around the midline.  The patient's scrotum was slightly asymmetric; however, this was due to the tissue configuration of the scrotum itself.  At the end of the procedure, stay suture of #4-0 Prolene was used to tack the drain into place and a Dermabond and Surgicel were used for dressing.  Telfa and the surgical eye tape was then used for the final dressing.  IV Toradol was given.  The patient tolerated the procedure well and was in stable condition upon transfer to recovery room.
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DESCRIPTION: Hypospadias repair. Urethroplasty plate incision with tissue flap relocation and chordee release.

urology, tissue flap relocation, urethroplasty plate incision, penile shaft skin, chordee release, zaontz catheter, penile shaft, hypospadias repair, flap relocation, coronal cuff, urethral plate, tissue flap, hypospadias, flap, chordee,

The described situation involves a surgical procedure for a young infant, specifically a 6-month-old boy, undergoing a hypospadias repair. This type of surgery, while routine and common in infant urology, involves general anesthesia and surgical intervention on sensitive anatomical structures. Potential risks include bleeding, infection, and complications related to anesthesia. The stakes are high, given the patient's age and the necessity for a successful outcome to avoid future complications or further surgeries. However, the operation appears to have been conducted without complications, and the child was stable post-operation, which indicates effective risk management and reduces the immediate stakes slightly. Thus, while not the most critical scenario, it remains a significantly high-stakes situation due to the factors involved.


Medical Specialty: Orthopedic
Sample Name: MRI T-Spine - Spinal Mets

CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:,  T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation.
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DESCRIPTION: MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.

This situation involves a 59-year-old patient with severe neurological symptoms due to metastatic spinal cancer, specifically an adenocarcinoma at T3-T4 causing spinal cord compression. The symptoms include significant motor and sensory deficits, bladder dysfunction, and signs of spinal cord compression, which require immediate medical attention to prevent further neurological deterioration or paralysis. The stakes are high as the patient's condition is life-threatening, demonstrating potential for rapid progression without intervention. The intervention included emergent surgery and radiation, highlighting the critical nature of the case.


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

CHIEF REASON FOR CONSULTATION:,  Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.,HISTORY OF PRESENT ILLNESS:,  This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes.  During this time, patient felt extremely short of breath and dizzy.  Palpitations lasted for about five to ten minutes without any recurrence.  Patient also gives history of having tightness in the chest after she walks briskly up to a block.  Chest tightness starts in the retrosternal area with radiation across the chest.  Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest.  Patient gives history of having hypertension for the last two months.  Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.,MEDICATIONS: , ,1.  Astelin nasal spray.,2.  Evista 60 mg daily.,3.  Lopressor 25 mg daily.,4.  Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office.,PAST HISTORY:,  The patient underwent right foot surgery and C-section.,FAMILY HISTORY:,  The patient is married, has six children who are doing fine.  Father died of a stroke many years ago.  Mother had arthritis.,SOCIAL HISTORY:, The patient does not smoke or take any drinks.  ,ALLERGIES:,  THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS.,REVIEW OF SYSTEMS:,  Otherwise negative.  ,PHYSICAL EXAMINATION: , ,GENERAL:  Well-built, well-nourished white female in no acute distress. ,VITAL SIGNS:  Blood pressure is 160/80.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Patient weighs 133 pounds, height 64 inches.  BMI is 22.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good.,NECK:  Supple.  No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries.  Trachea in midline. Thyroid not enlarged.  JVP flat at 45°.,CHEST:  Chest is symmetrical on both sides, moves well with respirations.  Vesicular breath sounds heard over the lung fields.  No wheezing, crepitation, or pleural friction rub heard.  ,CARDIOVASCULAR SYSTEM:  PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.  There is no diastolic murmur or gallop heard.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or ascites.  No bruit heard over the aorta or renal vessels.,EXTREMITIES:  No pedal edema.  Femoral arterial pulsations are 3+, popliteal 2+.  Dorsalis pedis and posterior tibialis are 1+ on both sides.,NEURO:  Normal.,EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes.  Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal.,IMPRESSION:,
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DESCRIPTION: To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.

The patient's symptoms, including exercise-induced chest pain, palpitations, dizziness, and shortness of breath, alongside an abnormal EKG, suggest potential cardiovascular issues. At the age of 72, these symptoms could indicate serious conditions such as angina or heart disease, which can have significant health implications if left untreated. The presence of hypertension adds to the risk. Evaluating these symptoms in a timely and thorough manner is crucial to prevent potential life-threatening events such as a heart attack. Hence, the situation is high-stakes due to the potential for serious health consequences.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Neuroblastoma - Consult

REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.
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DESCRIPTION: The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.

The situation involves a pediatric patient, an 11-month-old diagnosed with neuroblastoma, which is a serious and potentially life-threatening condition. The patient is undergoing chemotherapy and has required significant medical intervention, including surgery and supportive care for side effects such as immunosuppression and mucosal candidiasis. The ongoing treatment and monitoring underscore the severity of the condition. Additionally, there is mention of immunosuppression, which indicates a heightened risk for complications. The stakes are high given the age of the patient, the nature of the cancer, and the complexity of the treatment plan.


Medical Specialty: Nephrology
Sample Name: Laparoscopic Pyeloplasty

PREOPERATIVE DIAGNOSIS:  ,Right ureteropelvic junction obstruction.,POSTOPERATIVE DIAGNOSES:,1.  Right ureteropelvic junction obstruction.,2.  Severe intraabdominal adhesions.,3.  Retroperitoneal fibrosis.,PROCEDURES PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Attempted laparoscopic pyeloplasty.,3.  Open laparoscopic pyeloplasty.,ANESTHESIA:,  General.,INDICATION FOR PROCEDURE:  ,This is a 62-year-old female with a history of right ureteropelvic junction obstruction with chronic indwelling double-J ureteral stent.  The patient presents for laparoscopic pyeloplasty.,PROCEDURE: , After informed consent was obtained, the patient was taken to the operative suite and administered general anesthetic.  The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient's positioning for bowel retraction.  Hassan technique was performed for the initial trocar placement in the periumbilical region.  Abdominal insufflation was performed.  There were significant adhesions noted.  A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two-and-half hours, also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus, an additional 5 mm port in the right upper quadrant subcostal and midclavicular.  After adhesions were taken down, the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially.  The kidney was able to be palpated within Gerota's fascia.  The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter.  The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction.  The renal pelvis was also identified and dissected free.  There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes.  We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open.  An incision was made from the right upper quadrant port extending towards the midline.  This was carried down through the subcutaneous tissue, anterior fascia, muscle layers, posterior fascia, and peritoneum.  A Bookwalter retractor was placed.  The renal pelvis and the ureter were again identified.  Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery.  The tissue was sent down to Pathology for analysis.  Please note that upon entering the abdomen, all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted.  Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place.  The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue.  At this point, the indwelling double-J ureteral stent was removed.  At this time, the ureter was spatulated laterally and at the apex of this spatulation a #4-0 Vicryl suture was placed.  This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated.  The back wall of the ureteropelvic anastomosis was then approximated with running #4-0 Vicryl suture.  At this point, a double-J stent was placed with a guidewire down into the bladder.  The anterior wall of the uteropelvic anastomosis was then closed again with a #4-0 running Vicryl suture.  Renal sinus fat was then placed around the anastomosis and sutured in place.  Please note in the inferior pole of the kidney, there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue.  This was repaired with horizontal mattress sutures #2-0 Vicryl.  FloSeal was placed over this and the renal capsule was placed over this.  A good hemostasis was noted.  A #10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis.  The initial trocar incision was closed with #0 Vicryl suture.  The abdominal incision was also then closed with running #0 Vicryl suture incorporating all layers of muscle and fascia.  The Scarpa's fascia was then closed with interrupted #3-0 Vicryl suture.  The skin edges were then closed with staples.  Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator.  We placed the patient on IV antibiotics and pain medications.  We will obtain KUB and x-rays for stent placement.  Further recommendations to follow.
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DESCRIPTION: Laparoscopic lysis of adhesions, attempted laparoscopic pyeloplasty, and open laparoscopic pyeloplasty.  Right ureteropelvic junction obstruction, severe intraabdominal adhesions, and retroperitoneal fibrosis.

nephrology, retroperitoneal, fibrosis, pyeloplasty, laparoscopic, lysis of adhesions, ureteropelvic junction obstruction, laparoscopic pyeloplasty, ureteropelvic junction, junction, ureteropelvic, intraabdominal, adhesions,

This medical note describes a surgical procedure involving laparoscopic pyeloplasty which needed to be converted to an open procedure due to severe intraabdominal adhesions and retroperitoneal fibrosis. This situation is relatively high-stakes due to the complexity of the procedure, the risks involved with surgery, the patient's underlying conditions, and the need for conversion to an open surgery due to complications. However, it is a controlled medical environment with an experienced team, which slightly mitigates the stakes. Thus, while the situation is complex and involves significant medical risks, it is not at the extremes of high-stakes scenarios.


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

Medical Specialty: Bariatrics
Sample Name: Discharge Summary - Gastric Bypass

ADMISSION DIAGNOSIS:,  Morbid obesity.  BMI is 51.,DISCHARGE DIAGNOSIS: , Morbid obesity.  BMI is 51.,PROCEDURE: , Laparoscopic gastric bypass.,SERVICE: , Surgery.,CONSULT: , Anesthesia and pain.,HISTORY OF PRESENT ILLNESS: , Ms. A is a 27-year-old woman, who suffered from morbid obesity for many years.  She has made multiple attempts at nonsurgical weight loss without success.  She underwent a preoperative workup and clearance for gastric bypass and was found to be an appropriate candidate.  She underwent her procedure.,HOSPITAL COURSE: , Ms. A underwent her procedure.  She tolerated without difficulty.  She was admitted to the floor post procedure.  Her postoperative course has been unremarkable.  On postoperative day 1, she was hemodynamically stable, afebrile, normal labs, and she was started on a clear liquid diet, which she has tolerated without difficulty.  She has ambulated and had no complaints.  Today, on postoperative day 2, the patient continues to do well.  Pain controlled with p.o. pain medicine, ambulating without difficulty, tolerating a liquid diet.  At this point, it is felt that she is stable for discharge.  Her drain was discontinued.,DISCHARGE INSTRUCTIONS:,  Liquid diet x1 week, then advance to pureed and soft as tolerated.  No heavy lifting, greater than 10 pounds x4 weeks.  The patient is instructed to not engage in any strenuous activity, but maintain mobility.  No driving for 1 to 2 weeks.  She must be able to stop in an emergency and be off narcotic pain medicine.  She may shower.  She needs to keep her wounds clean and dry.  She needs to follow up in my office in 1 week for postoperative evaluation.  She is instructed to call for any problems of shortness of breath, chest pain, calf pain, temperature greater than 101.5, any redness, swelling, or foul smelling drainage from her wounds, intractable nausea, vomiting, and abdominal pain.  She is instructed just to resume her discharge medications.,DISCHARGE MEDICATIONS:,  She was given a scripts for Lortab Elixir, Flexeril, ursodiol, and Colace.
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DESCRIPTION: Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.

bariatrics, laparoscopic gastric bypass, gastric bypass, morbid obesity, liquid diet, bmi, discharge,

The case involves a patient undergoing a laparoscopic gastric bypass due to morbid obesity. While this type of surgery is generally routine and the patient has shown a stable postoperative course, surgery always carries inherent risks, especially in morbidly obese patients who might have underlying health issues. Additionally, the discharge instructions highlight potential severe complications like shortness of breath or infection. Given these factors, it's a moderate-stakes situation.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 3

PREOPERATIVE DIAGNOSIS:,  Prior history of neoplastic polyps.,POSTOPERATIVE DIAGNOSIS:,  Small rectal polyps/removed and fulgurated.,PREMEDICATIONS:,  Prior to the colonoscopy, the patient complained of a sever headache and she was concerned that she might become ill.  I asked the nurse to give her 25 mg of Demerol IV.,Following the IV Demerol, she had a nausea reaction.  She was then given 25 mg of Phenergan IV.  Following this, her headache and nausea completely resolved.  She was then given a total of 7.5 mg of Versed with adequate sedation.  Rectal exam revealed no external lesions.  Digital exam revealed no mass.,REPORTED PROCEDURE:,  The P160 colonoscope was used.  The scope was placed in the rectal ampulla and advanced to the cecum.  Navigation through the sigmoid colon was difficult.  Beginning at 30 cm was a very tight bend.  With gentle maneuvering, the scope passed through and then entered the cecum.  The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, and descending colon were normal.  The sigmoid colon was likewise normal.  There were five very small (punctate) polyps in the rectum.  One was resected using the electrocautery snare and the other four were ablated using the snare and cautery.  There was no specimen because the polyps were so small.  The scope was retroflexed in the rectum and no further abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Five small polyps as described, all fulgurated.,2.  Otherwise unremarkable colonoscopy.
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DESCRIPTION: Colonoscopy to evaluate prior history of neoplastic polyps.

surgery, colonoscopy, demerol, phenergan, rectal exam, versed, ascending colon, cecum, colonoscope, descending colon, fulgurated, hepatic flexure, neoplastic, polyps, punctate, rectal ampulla, splenic flexure, transverse colon, scope

This medical situation involves a routine colonoscopy to evaluate a prior history of neoplastic polyps, which is a fairly common procedure in surgical practice. The main point of concern is the management of the patient's pre-medication reaction, but this was effectively resolved with Phenergan, leading to a successful procedure. Given that the polyps were small and effectively removed, with no other abnormalities found, the situation does not involve any immediate or life-threatening risks. However, it still involves a surgical procedure with inherent risks and necessary follow-up due to the patient's history.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Ultrasound OB - 5

GENERAL EVALUATION:,Fetal Cardiac Activity: Normal with a heart rate of 135BPM,Fetal Presentation: Cephalic.,Placenta: Anterior,Placentral grade: II,Previa: ? None.,Amniotic Fluid: 1.5 + 2.5 + 0.0 + 0.0 = 4cm compatible with oligohydramnios.,BIOMETRY:,BPD: 9.0cm consistent with 36weeks, 4days gestation,HC: 34.6cm which equals 40weeks and 1day gestational age.,FL: 6.9cm which equals 35weeks and 3days gestational age.,AC: 34.6cm which equals 38weeks and 4days gestational age.,CI (BPD/OFD):  (70-86) 73,FL/BPD: (71-87) 77,FL/HC: (20.8-22.6) 19.9,FL/AC (20-24) 20,HC/AC: (0.92-1.05) 1.00,GESTATIONAL AGE BY CURRENT ULTRASOUND: 37weeks 4days.,FETAL WEIGHT BY CURRENT ULTRASOUND: 3289grams (7pounds 4ounces).,ESTIMATED FETAL WEIGHT PERCENTILE: 24%.,EDD BY CURRENT ULTRASOUND: 06/04/07.,GESTATIONAL AGE BY DATES: 40weeks 0days.,L M P: Unknown.,EDD BY DATES: 05/18/07.,DATE OF PREVIOUS ULTRASOUND: 03/05/07.,EDD BY PREVIOUS ULTRASOUND: 05/24/07.,FETAL ANATOMY:,Fetal Ventricles: Normal,Fetal Cerebellum: Normal,Fetal Cranium: Normal,Fetal Face: Normal Nose and Mouth,Fetal Heart (4 Chamber View): Normal,Fetal Diaphragm: Normal,Fetal Stomach: Normal,Fetal Cord: Normal three-vessel cord,Fetal Abdominal Wall: Normal,Fetal Spine: Normal,Fetal Kidneys: Normal,Fetal Bladder: Normal,Fetal Limbs: Normal,IMPRESSION:,Active intrauterine pregnancy with a sonographic gestational age of 37weeks and 4days.,AFI=4cm compatible with mild oligohydramnios.,Fetal weight equals 3289grams (7pounds 4ounces). EFW percentile is 24%.,Placental grade is II.,No evidence of gross anatomical abnormality, with a biophysical profile total equal to 8 out of 8.,
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DESCRIPTION: This is a 24-year-old pregnant patient to evaluate fetal weight and placental grade.

The situation references an ultrasound evaluation in a pregnancy which identifies oligohydramnios, a condition where there is less amniotic fluid than expected. While the biophysical profile is normal and there are no gross anatomical abnormalities, oligohydramnios can lead to complications such as fetal growth restriction, preterm birth, and labor complications. The stakes are moderately high due to the potential risks associated with the condition, but it is not immediately life-threatening based on the current data provided.


Medical Specialty: Podiatry
Sample Name: Keller Bunionectomy

PROCEDURE: , Keller Bunionectomy.,For informed consent, the more common risks, benefits, and alternatives to the procedure were thoroughly discussed with the patient.  An appropriate consent form was signed, indicating that the patient understands the procedure and its possible complications.,This 59 year-old female was brought to the operating room and placed on the surgical table in a supine position.  Following anesthesia, the surgical site was prepped and draped in the normal sterile fashion.,Attention was then directed to the right foot where, utilizing a # 15 blade, a 6 cm. linear incision was made over the 1st metatarsal head, taking care to identify and retract all vital structures.  The incision was medial to and parallel to the extensor hallucis longus tendon.  The incision was deepened through subcutaneous underscored, retracted medially and laterally - thus exposing the capsular structures below, which were incised in a linear longitudinal manner, approximately the length of the skin incision.  The capsular structures were sharply underscored off the underlying osseous attachments, retracted medially and laterally.,Utilizing an osteotome and mallet, the exostosis was removed, and the head was remodeled with the Liston bone forceps and the bell rasp.  The surgical site was then flushed with saline.  The base of the proximal phalanx of the great toe was osteotomized approximately 1 cm. distal to the base and excised to toto from the surgical site.,Superficial closure was accomplished using Vicryl 5-0 in a running subcuticular fashion.  Site was dressed with a light compressive dressing.  The tourniquet was released.  Excellent capillary refill to all the digits was observed without excessive bleeding noted.,ANESTHESIA: , local.,HEMOSTASIS: , Accomplished with pinpoint electrocoagulation.,ESTIMATED BLOOD LOSS: , 10 cc.,MATERIALS:,  None.,INJECTABLES:,  Agent used for local anesthesia was Lidocaine 2% without epi.,PATHOLOGY:,  Sent no specimen.,DRESSINGS: , Site was dressed with a light compressive dressing.,CONDITION: , Patient tolerated procedure and anesthesia well.  Vital signs stable.  Vascular status intact to all digits.  Patient recovered in the operating room.,SCHEDULING: , Return to clinic in 2 week (s).
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DESCRIPTION: Procedure note on Keller Bunionectomy

Procedure note on Keller Bunionectomy

podiatry, keller bunionectomy, metatarsal head, incision, capsular, osteotome, compressive dressing, keller, bunionectomy,

The Keller Bunionectomy procedure is a standard surgical operation to remove a bunion from the foot, typically not considered high-stakes but a routine podiatric procedure. The procedure was conducted under local anesthesia, had minimal blood loss, and the patient tolerated it well. While all surgeries carry some risks, this case involved no acute complications and a positive patient condition post-procedure, indicating it was not high-stakes.


Medical Specialty: Office Notes
Sample Name: Status Post T&A

SUBJECTIVE:,  A 6-year-old boy who underwent tonsillectomy and adenoidectomy two weeks ago.  Also, I cleaned out his maxillary sinuses.  Symptoms included loud snoring at night, sinus infections, throat infections, not sleeping well, and fatigue.  The surgery went well, and I had planned for him to stay overnight, but Mom reminds me that by about 8 p.m. the night nurse gotten him to take fluids well and we let him go home then that evening.  He finished up his Augmentin, by a day or two later he was off the Lortab.  Mom has not noticed any unusual voice change.  No swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce.  He has not had any nasal discharge or ever had any bleeding.  He seems to be breathing better.,OBJECTIVE:,  Exam looks good.  The pharynx is well healed.  Tongue mobility is normal.  Voice sounds clear.  Nasal passages reveal no discharge or crusting.,RECOMMENDATION:,  I told Mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive.  He says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth.  It is okay to chew gum and it is okay to eat crunchy foods such as potato chips.  The pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis, and there were no atypical findings on the laboratories.,I am glad he has healed up well.  There are no other restrictions or limitations.  I told Mom, I had written to Dr. XYZ to let her know of the findings.  The child will continue his regular followup visits with his family doctor, and I told Mom I would be happy to see him anytime if needed.  He did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure.
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DESCRIPTION: Underwent tonsillectomy and adenoidectomy two weeks ago.

office notes, tonsillectomy and adenoidectomy, tonsillectomy, adenoidectomy, maxillary, nasal, sinuses,

The situation involves a follow-up note for a common and routine surgical procedure (tonsillectomy and adenoidectomy) on a 6-year-old boy. The post-operative recovery appears normal without complications such as unusual voice changes, bleeding, or infection. This suggests that there are no immediate health threats or concerns that would categorize the situation as high-stakes. The recommendations provided are standard post-operative advice which does not indicate an urgent situation.


Medical Specialty: Urology
Sample Name: Meatotomy Template

OPERATIVE NOTE:  ,The patient was taken to the operating room and was placed in the supine position on the operating room table.  A general inhalation anesthetic was administered.  The patient was prepped and draped in the usual sterile fashion.  The urethral meatus was calibrated with a small mosquito hemostat and was gently dilated.  Next a midline ventral type incision was made opening the meatus.  This was done after clamping the tissue to control bleeding.  The meatus was opened for about 3 mm.  Next the meatus was calibrated and easily calibrated from 8 to 12 French with bougie sounds.  Next the mucosal edges were everted and reapproximated to the glans skin edges with approximately five interrupted 6-0 Vicryl sutures.  The meatus still calibrated between 10 and 12 French.  Antibiotic ointment was applied.  The procedure was terminated.  The patient was awakened and returned to the recovery room in stable condition.
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DESCRIPTION: An example/template for meatotomy.

An example/template for meatotomy.

urology, urethral meatus, mosquito hemostat, meatus, mucosal edges, glans, meatotomyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The document describes a standard surgical procedure known as meatotomy, often undertaken to address urethral stricture issues. While it involves surgery under general anesthesia and there are inherent risks such as infection or complications from anesthesia, it is considered a routine, minor procedure in urology with well-established protocols. The patient was reported to be stable post-operation, indicating a successful procedure without immediate complications. Thus, it presents as a low-risk, low-stakes situation within the context of urological surgeries.