Medical Specialty: Nephrology
Sample Name: Chronic Kidney Disease Followup - 1

PROBLEMS LIST:,1.  Type 1 diabetes mellitus, insulin pump requiring.,2.  Chronic kidney disease, stage III.,3.  Sweet syndrome.,4.  Hypertension.,5.  Dyslipidemia.,6.  Osteoporosis.,7.  Anemia.,8.  A 25-hydroxy-vitamin D deficiency.,9.  Peripheral neuropathy manifested by insensate feet.,10.  Hypothyroidism.,11.  Diabetic retinopathy.,HISTORY OF PRESENT ILLNESS:,  This is a return visit to the renal clinic for the patient where she is followed up for diabetes and kidney disease management.  Her last visit to this clinic was approximately three months ago.  Since that time, the patient states that she has had some variability in her glucose control too largely to recent upper and lower respiratory illnesses.  She did not seek attention for these, and the symptoms have begun to subside on their own and in the meantime, she continues to have some difficulties with blood sugar management.  Her 14-day average is 191.  She had a high blood sugar this morning, which she attributed to a problem with her infusion set; however, in the clinic after an appropriate correction bolus, she subsequently became quite low.  She was treated appropriately with glucose and crackers, and her blood sugar came back up to over 100.  She was able to manage this completely on her own.  In the meantime, she is not having any other medical problems that have interfered with glucose control.  Her diet has been a little bit different in that she had been away visiting with her family for some period of time as well.,CURRENT MEDICATIONS:,1.  A number of topical creams for her rash.,2.  Hydroxyzine 25 mg 4 times a day.,3.  Claritin 5 mg a day.,4.  Fluoxetine 20 mg a day.,5.  Ergocalciferol 800 international units a day.,6.  Protonix 40 mg a day.,7.  Iron sulfate 1.2 cc every day.,8.  Actonel 35 mg once a week.,9.  Zantac 150 mg daily.,10.  Calcium carbonate 500 mg 3 times a day.,11.  NovoLog insulin via insulin pump about 30 units of insulin daily.,12.  Zocor 40 mg a day.,13.  Valsartan 80 mg daily.,14.  Amlodipine 5 mg a day.,15.  Plavix 75 mg a day.,16.  Aspirin 81 mg a day.,17.  Lasix 20 mg a day.,18.  Levothyroxine 75 micrograms a day.,REVIEW OF SYSTEMS: , Really not much change.  Her upper respiratory symptoms have resolved.  She is not describing fevers, chills, sweats, nausea, vomiting, constipation, diarrhea or abdominal pain.  She is not having any decreased appetite.  She is not having painful urination, any blood in the urine, frequency or hesitancy.  She is not having polyuria, polydipsia or polyphagia.  Her visual acuity has declined, but she does not appear to have any acute change.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.1, pulse 56, respirations 16, blood pressure 117/48, and weight is 109.7 pounds.  HEENT:  Examination found her to be atraumatic and normocephalic.  She has pupils that are equal, round, and reactive to light.  Extraocular muscles intact.  Sclerae and conjunctivae are clear.  The paranasal sinuses are nontender.  The nose is patent.  The external auditory canal and tympanic membranes are clear A.U.  Oral cavity and oropharynx examination is free of lesions.  The mucosus membranes are moist.  NECK:  Supple.  There is no lymphadenopathy.  There is no thyromegaly.  THORAX:  Reveals lungs that are clear, PA and lateral, without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  EXTREMITIES:  Reveal no edema and is otherwise deferred.,ASSESSMENT AND PLAN: , This is a return visit to the renal clinic for the patient with history as noted above.  She has had variability in her glucose control, and the plan today is to continue her current regimen, which includes the following:  Basal rate, 12 a.m. 0.6 units per hour, 4 a.m. 0.7 units per hour, and 9 a.m. 0.6 units per hour.  Her target pre-meal is 120 and bedtime is 150.  Her insulin/carbohydrate ratio is 10 and her correction factor is 60.  We are not going to make any changes to her insulin pump settings at this time.  I have encouraged her to watch the number of processed high-calorie foods that she is consuming late at night.  She has agreed to try that and cut back on this a little bit.  I want to get fasting labs to include her standard labs for us today but include a fasting C-peptide and a hemoglobin A1C, so that we can make arrangements for her to get an upgraded insulin pump.  She states to me that she has been having some battery problems in the recent past, although she says the last time that she went four weeks without having to change batteries and that is about the appropriate amount of time.  Nonetheless, she is out of warranty and we will try to get her a new pump.,Plan to see the patient back here in approximately two months, and we will try to get the new pump through Medicare.
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DESCRIPTION: Type 1 diabetes mellitus, insulin pump requiring.  Chronic kidney disease, stage III.  Sweet syndrome, hypertension, and dyslipidemia.

The situation involves a patient with several complex and potentially serious chronic health conditions, including type 1 diabetes managed by an insulin pump, stage III chronic kidney disease, hypertension, and other health issues. While the current situation doesn't involve an immediate life-threatening circumstance or an emergency, the management of these conditions is critical to prevent complications. The potential need for a new insulin pump also underscores the importance of proper diabetes management. The patient's risk factors, along with the discussion of upgrading medical equipment through Medicare, does present more long-term and ongoing stakes rather than immediate high-stakes. However, given the complexity of the health issues, the stakes are moderately high.


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

Medical Specialty: Gastroenterology
Sample Name: Appendectomy

PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis, nonperforated.,PROCEDURE PERFORMED:,  Appendectomy.,ANESTHESIA: , General endotracheal.,PROCEDURE: , After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,A transverse right lower quadrant incision was made directly over the point of maximal tenderness.  Sharp dissection utilizing Bovie electrocautery was used to expose the external oblique fascia.  The fascia of the external oblique was incised in the direction of the fibers, and the muscle was spread with a clamp.  The internal oblique fascia was similarly incised and its muscular fibers were similarly spread.  The transversus abdominis muscle, transversalis fascia and peritoneum were incised sharply gaining entrance into the abdominal cavity without incident.  Upon entering the peritoneal cavity, the peritoneal fluid was noted to be clean.,The cecum was then grasped along the taenia with a moist gauze sponge and was gently mobilized into the wound.  After the appendix was fully visualized, the mesentery was divided between Kelly clamps and ligated with 2-0 Vicryl ties.  The base of the appendix was crushed with a clamp and then the clamp was reapplied proximally on the appendix.  The base was ligated with 2-0 Vicryl tie over the crushed area, and the appendix amputated along the clamp.  The stump of the appendix was cauterized and the cecum was returned to the abdomen.,The peritoneum was irrigated with warm sterile saline.  The mesoappendix and cecum were examined for hemostasis which was present.  The wound was closed in layers using 2-0 Vicryl for the peritoneum and 0 Vicryl for the internal oblique and external oblique layers.  The skin incision was approximated with 4-0 Monocryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was placed on the wound.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently extubated and taken to the recovery room in good and stable condition.
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DESCRIPTION: Appendicitis, nonperforated.  Appendectomy.  A transverse right lower quadrant incision was made directly over the point of maximal tenderness.

gastroenterology, peritoneal cavity, peritoneal fluid, abdominal cavity, abdominis muscle, transversalis fascia, peritoneum, internal oblique fascia, vicryl ties, appendectomy, appendicitis, appendix,

This is a standard appendectomy procedure due to nonperforated appendicitis, which is considered a routine surgical operation. While appendicitis can potentially become serious if not treated (e.g., it could perforate), once diagnosed and an appendectomy is performed without complications, the situation is generally not considered high-stakes. The patient was stable post-operation and there were no complications or unusual circumstances mentioned in the procedure note.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Foul-Smelling Urine

CHIEF COMPLAINT:,  Foul-smelling urine and stomach pain after meals.,HISTORY OF PRESENT ILLNESS:,  Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time.  She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI.  This visit was in July 2010.,REVIEW OF SYSTEMS:,  HEENT:  No headaches.  No visual disturbances, no eye irritation.  No nose drainage or allergic symptoms.  No sore throat or masses.  Respiratory:  No shortness of breath.  No cough or wheeze.  No pain.  Cardiac:  No palpitations or pain.  Gastrointestinal:  Pain and cramping.  Denies nausea, vomiting, or diarrhea.  Has some regurgitation with gas after meals.  Genitourinary:  "Smelly" urine.  Musculoskeletal:  No swelling, pain, or numbness.,MEDICATION ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION:,General:  Unremarkable.,HEENT:  PERRLA.  Gaze conjugate.,Neck:  No nodes.  No thyromegaly.  No masses.,Lungs:  Clear.,Heart:  Regular rate without murmur.,Abdomen:  Soft, without organomegaly, without guarding or tenderness.,Back:  Straight.  No paraspinal spasm.,Extremities:  Full range of motion.  No edema.,Neurologic:  Cranial nerves II-XII intact.  Deep tendon reflexes 2+ bilaterally.,Skin:  Unremarkable.,LABORATORY STUDIES:,  Urinalysis was done, which showed blood due to her period and moderate leukocytes.,ASSESSMENT:,1.  UTI.,2.  GERD.,3.  Dysphagia.,4.  Contraception consult.,PLAN:,1.  Cipro 500 mg b.i.d. x five days.  Ordered BMP, CBC, and urinalysis with microscopy.,2.  Omeprazole 20 mg daily and famotidine 20 mg b.i.d.,3.  Prescriptions same as #2.  Also referred her for a barium swallow series to rule out a stricture.,4.  Ortho Tri-Cyclen Lo.,
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DESCRIPTION: Foul-smelling urine and stomach pain after meals.

The case involves multiple medical conditions such as foul-smelling urine, which suggests a UTI, and gastrointestinal symptoms consistent with GERD. The patient has been experiencing these symptoms for over a year and requires treatment and further diagnostic procedures. While the situation requires medical attention, the conditions mentioned (UTI and GERD) are common and typically not life-threatening if managed properly. There's no indication of an acute or immediate life-threatening situation. However, the persistence and combination of symptoms over an extended period, coupled with the need for additional tests (like the barium swallow), do suggest the need for careful and prompt medical intervention to prevent complications.


Medical Specialty: Discharge Summary
Sample Name: Cardio/Pulmo Discharge Summary

ADMISSION DIAGNOSIS:,1. Respiratory arrest.,2 . End-stage chronic obstructive pulmonary disease.,3. Coronary artery disease.,4. History of hypertension.,DISCHARGE DIAGNOSIS:,1. Status post-respiratory arrest.,2. Chronic obstructive pulmonary disease.,3. Congestive heart failure.,4. History of coronary artery disease.,5. History of hypertension.,SUMMARY:,  The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea.,ADMISSION PHYSICAL EXAMINATION:,GENERAL: Showed a well-developed, slightly obese man who was in extremis.,NECK: Supple, with no jugular venous distension.,HEART: Showed tachycardia without murmurs or gallops.,PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes.,EXTREMITIES: Free of edema.,HOSPITAL COURSE:,  The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a,significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an outpatient basis.,DIAGNOSTIC DATA:,  The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of 7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands.,DISPOSITION:,  The patient was discharged home.,DISCHARGE INSTRUCTIONS:,  His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250 mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch h.s., K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge.
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DESCRIPTION: A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.

discharge summary, ada diet, congestive heart failure, coronary artery disease, respiratory arrest, chest pain, chronic obstructive pulmonary disease, emergency room, hypertension, sputum, wheezing, respiratory distress, myocardial infarctions, respiratory failure, pulmonary disease, basilar rales, heart failure, infarctions, heart, wheezes, coronary, pulmonary, discharge, respiratory,

The patient in the discharge summary has multiple serious chronic health conditions, including end-stage COPD, coronary artery disease, recurrent myocardial infarctions, and congestive heart failure. The recent episode of respiratory arrest and requirement for intubation indicate the patient's life was in immediate danger during the hospital stay. While the patient was stabilized enough to be discharged, the combination of ongoing complex medical needs and the need for close follow-up make this situation relatively high-stakes. Managing these complex conditions inadequately could again lead to life-threatening situations.


Medical Specialty: Consult - History and Phy.
Sample Name: Gastric Bypass Discussion - 2

HISTORY: , The patient is scheduled for laparoscopic gastric bypass.  The patient has been earlier seen by Dr. X, her physician.  She has been referred to us from Family Practice.  In short, she is a 33-year-old lady with a BMI of 43, otherwise healthy with unsuccessful nonsurgical methods of weight loss. ,She was on laparoscopic gastric bypass for weight loss. ,She meets the National Institute of Health Criteria.  She is very well educated and motivated and has no major medical contraindications for the procedure.,PHYSICAL EXAMINATION:,  On physical examination today, she weighs 216 pounds with a BMI of 43.5, pulse is 96, temperature is 97.6, blood pressure is 122/80.  Lungs are clear.  Abdomen is soft, nontender.  There is stigmata for morbid obesity.  She has cesarean section scars in the lower abdomen with no herniation. ,DISCUSSION: , I had a long talk with the patient about laparoscopic gastric bypass, possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines.  I also explained to her complications including rare cases of death secondary to DVT, PE, leak , peritonitis, sepsis, shock, multisystem organ failure, need for re-operation including for leak or bleeding, gastrostomy or jejunostomy for feeding, rare case of respiratory failure requiring mechanical ventilation, etc., with myocardial infarction, pneumonia, atelectasis in the postoperative period were also discussed. ,Short-term complications of gastric bypass including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or anti-inflammatory drug intake which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which were discussed.  The patient would alert us for earlier intervention.  Symptomatic gallstone formation secondary to rapid weight loss were also discussed.  How to avoid it by taking ursodiol were also discussed.  Long-term complications of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, need for major lifestyle and exercise and habit changes, avoiding pregnancy in the first two years, etc., were all stressed.  The patient understands.  She wants to go to surgery. ,In preparation of surgery, she will undergo very low-calorie diet through Medifast to decrease the size of the liver to make laparoscopic approach more successful and also to optimize her cardiopulmonary and metabolic comorbidities.  She will also see a psychologist, nutritionist, and exercise physiologist for a multidisciplinary effort for short and long-term success for weight loss surgery.  I will see her two weeks before the plan of surgery for further discussion and any other questions at that point of time.
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DESCRIPTION: Patient scheduled for laparoscopic gastric bypass.

consult - history and phy., medifast, laparoscopic gastric bypass, short-term complications, long-term complications, gastric bypass, complications of gastric bypass, weight loss,

The situation involves a scheduled laparoscopic gastric bypass surgery, a significant surgical procedure for a patient with a high BMI. The stakes are high due to the inherent risks and potential complications such as DVT, PE, and surgical complications that could result in serious health outcomes, and the need for long-term lifestyle changes. Additionally, the patient needs to adhere to preoperative preparation and multidisciplinary follow-up. However, the situation seems well-managed with comprehensive discussions and preparations in place.


Medical Specialty: Diets and Nutritions
Sample Name: Dietary Consult - 1

SUBJECTIVE:,  His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it.  The patient started improving his diet when he received the letter explaining his lipids are elevated.  He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc.  He has started packing his lunch three to four times per week instead of eating out so much.  He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time.  He is in training for a triathlon.  He says he is already losing weight due to his efforts.,OBJECTIVE:,  Height:  6 foot 2 inches.  Weight:  204 pounds on 03/07/05.  Ideal body weight:  190 pounds, plus or minus ten percent.  He is 107 percent standard of midpoint ideal body weight.  BMI:  26.189.  A 48-year-old male.  Lab on 03/15/05:  Cholesterol:  251.  LDL:  166.  VLDL:  17.  HDL:  68.  Triglycerides:  87.  I explained to the patient the dietary guidelines to help improve his lipids.  I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight.  I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read.  I encouraged him to continue as he is doing.,ASSESSMENT:,  Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories.  His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake.  He needs to continue as he is doing.  He verbalized understanding and seemed receptive.,PLAN:,  The patient plans to recheck his lipids through Dr. XYZ  I gave him my phone number and he is to call me if he has any further questions regarding his diet.
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DESCRIPTION: Elevated cholesterol and is on medication to lower it.

diets and nutritions, vegetarian, lipids, cholesterol intake, elevated cholesterol, losing weight, body weight, dietary, cholesterol

The situation involves a patient's dietary management to address elevated cholesterol levels. While it touches on health-related issues, the patient is already making significant lifestyle changes by improving his diet, increasing physical activity, and is on medication. These efforts suggest it's a managed situation rather than an emergency. Additionally, there's existing engagement with healthcare professionals for ongoing monitoring and support, which reduces urgency. Therefore, it is not extremely high-stakes, but it does have some level of importance because it pertains to a health condition that needs management.


Medical Specialty: Letters
Sample Name: Letter - Dentistry

XYZ, S.,RE:  ABC,Dear Dr. XYZ,On your kind referral, I had the pleasure of meeting and consulting with ABC on MM/DD/YYYY for evaluation regarding extraction of his mandibular left second molar tooth #18.  This previously root-canaled tooth, now failed, is scheduled for removal.  As per your request, I agree that placement of an implant in the #20 and #19 positions would allow for immediate functional replacement of the bridge which has recently been lost in this area.,I have given Mr. ABC an estimate for the surgical aspects of this case and suggested he combine this with your prosthetic or restorative fees in order to have a full understanding of the costs involved with this process.,We will plan to place two Straumann implants as per our normal protocol, one each in the #19 and 20 positions, with the #19 implant being a wide-neck, larger diameter implant.  I will plan on providing the prosthetic abutments, the lab analogue, and temporary healing cap at the end of the four-month integration period.  If you have any additional suggestions or concerns, please give me a call.,Best regards,,
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DESCRIPTION: Letter on evaluation regarding extraction of mandibular left second molar tooth #18.

letters, molar tooth, extraction, mandibular, straumann, wide-neck, placement, positions, prosthetic, implant, tooth

The situation involves a routine dental procedure regarding the extraction of a tooth and the placement of dental implants. While dental surgeries can have complexities, the letter describes a relatively standard procedure with a clear treatment plan and coordination between professionals. There is no indication of urgent or life-threatening health risks involved, making it low-stakes.


Medical Specialty: Surgery
Sample Name: Bronchoscopy - Fiberoptic

HISTORY OF PRESENT ILLNESS:,  A 67-year-old gentleman who presented to the emergency room with chest pain, cough, hemoptysis, shortness of breath, and recent 30-pound weight loss.  He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.  There was also a question of liver metastases at that time.,OPERATION PERFORMED:,  Fiberoptic bronchoscopy with endobronchial biopsies.,The bronchoscope was passed into the airway and it was noted that there was a large, friable tumor blocking the bronchus intermedius on the right.  The tumor extended into the carina, involving the lingula and the left upper lobe, appearing malignant.  Approximately 15 biopsies were taken of the tumor.,Attention was then directed at the left upper lobe and lingula.  Epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review.  Approximately eight biopsies were taken of the left upper lobe.
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DESCRIPTION: Fiberoptic bronchoscopy with endobronchial biopsies.  A CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.

surgery, endobronchial, intermedius, fiberoptic bronchoscopy, lung carcinoma, bronchoscopy, fiberoptic, chest, tumor, lobeNOTE

The situation involves a patient with a suspected primary lung carcinoma, which is indicated by the CT scan findings and the direct observations during the bronchoscopy procedure. The presence of a large, friable tumor blocking the bronchus and extending into crucial lung areas suggests aggressive cancer, potentially life-threatening. The need to perform multiple biopsies for diagnosis and the potential liver metastases further complicate the situation, indicating a critical health issue that requires urgent medical intervention and careful handling. Given the patient's symptoms and the serious nature of the findings, this scenario is high-stakes as it directly impacts the patient's health and survival.


Medical Specialty: Endocrinology
Sample Name: Thyroid Mass Consult

REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy.  The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004.  An ultrasound examination had reportedly been done in the past and the mass is being observed.  When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there.  The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma.  The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction.  She has no weight changes consistent with either hyper or hypothyroidism.  There is no family history of thyroid cancer in her family.  She has no notable discomfort with this lesion.  There have been no skin changes.  Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:,  Essentially unremarkable.  The patient has never been hospitalized in the past for any major illnesses.  She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS:  ,Currently taking no routine medications.  She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter.  This was done in Tijuana.  His mom is from central portion of Mexico.  There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY:  ,The patient is a junior at Hoover High School.  She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress.  She was alert and oriented x3 and had an appropriate affect.,HEENT:  The head and neck examination is most significant.  There is mild amount of facial acne.  The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK:  There is a slightly visible midline bulge in the region of the thyroid isthmus.  A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid.  This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine.  There are some shotty adenopathy in the area.  No supraclavicular nodes were noted.,CHEST:  Excursions are symmetric with good air entry.,LUNGS:  Clear.,CARDIOVASCULAR:  Normal.  There is no tachycardia or murmur noted.,ABDOMEN:  Benign.,EXTREMITIES:  Extremities are anatomically correct with full range of motion.,GENITOURINARY:  External genitourinary exam was deferred at this time and can be performed later during anesthesia.  This is same as too for her rectal examination.,SKIN:  There is no acute rash, purpura, or petechiae.,NEUROLOGIC:  Normal and no focal deficits.  Her voice is strong and clear.  There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range.  T4 and TSH levels were recorded as normal.  Free thyroxine was normal, and the serum pregnancy test was negative.  There was no level of thyroglobulin recorded on this.  A urinalysis and comprehensive metabolic panel was unremarkable.  A chest x-ray was obtained, which I personally reviewed.  There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease.  I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease.  During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy.  We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation.  We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well.  I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them.  I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit.  This will have some impact on the postoperative adjunctive therapy.  The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case.  I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity.  All of the family's questions have been answered.  This is a very anxious and anxiety provoking time in the family.  I have made every effort to get the patient under schedule within the next 48 hours to have this operation done.  We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.
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DESCRIPTION: Thyroid mass diagnosed as papillary carcinoma.  The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.

The situation involves a 16-year-old patient diagnosed with papillary thyroid carcinoma showing signs of miliary metastatic disease, indicating a more advanced cancer stage. Papillary carcinoma typically has a good prognosis, but the presence of metastatic lesions significantly complicates the situation. The consultation involves discussing complex surgical options, potential complications, and postoperative treatments, including radioactive iodine therapy and parathyroid gland management. These factors create high-stakes due to the patient's young age, the cancer's advanced stage, and the potential impact on the patient's future health and quality of life.


Medical Specialty: Gastroenterology
Sample Name: Appendectomy Laparoscopic - 1

PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Acute suppurative appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal and Marcaine 0.25% local.,INDICATIONS:,  This 29-year-old female presents to ABCD General Hospital Emergency Department on 08/30/2003 with history of acute abdominal pain.  On evaluation, it was noted that the patient has clinical findings consistent with acute appendicitis.  However, the patient with additional history of loose stools for several days prior to event.  Therefore, a CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis.  There was no evidence of colitis on the CAT scan.  With this in mind and the patient's continued pain at present, the patient was explained the risks and benefits of appendectomy.  She agreed to procedure and informed consent was obtained.,GROSS FINDINGS: , The appendix was removed without difficulty with laparoscopic approach.  The appendix itself noted to have a significant inflammation about it.  There was no evidence of perforation of the appendix.,PROCEDURE DETAILS:,  The patient was placed in supine position.  After appropriate anesthesia was obtained and sterile prep and drape completed, a #10 blade scalpel was used to make a curvilinear infraumbilical incision.  Through this incision, a Veress needle was utilized to create a CO2 pneumoperitoneum of 15 mmHg.  The Veress needle was then removed.  A 10 mm trocar was then introduced through this incision into the abdomen.  A video laparoscope was then inserted and the above noted gross findings were appreciated upon evaluation.  Initially, bilateral ovarian cysts were appreciated, however, there was no evidence of acute disease on evaluation.  Photodocumentation was obtained.,A 5 mm port was then placed in the right upper quadrant.  This was done under direct visualization and a blunt grasper was utilized to mobilize the appendix.  Next, a 12 mm port was placed in the left lower quadrant lateral to the rectus musculature under direct visualization.  Through this port, the dissector was utilized to create a small window in the mesoappendix.  Next, an EndoGIA with GI staples was utilized to fire across the base of the appendix, which was done noting it to be at the base of the appendix.  Next, staples were changed to vascular staples and the mesoappendix was then cut and vessels were then ligated with vascular staples.  Two 6 X-loupe wires with EndoGIA were utilized in this prior portion of the procedure.  Next, an EndoCatch was placed through the 12 mm port and the appendix was placed within it.  The appendix was then removed from the 12 mm port site and taken off the surgical site.  The 12 mm port was then placed back into the abdomen and CO2 pneumoperitoneum was recreated.  The base of the appendix was reevaluated and noted to be hemostatic.  Aspiration of warm saline irrigant then done and noted to be clear.  There was a small adhesion appreciated in the region of the surgical site.  This was taken down with blunt dissection without difficulty.  There was no evidence of other areas of disease.  Upon re-exploration with a video laparoscope in the abdomen and after this noting the appendix base to be hemostatic and intact.  The instruments were removed from the patient and the port sites were then taken off under direct visualization.  The CO2 pneumoperitoneum was released into the air and the fascia was approximated in the 10 mm and 12 mm port sites with #0 Vicryl ligature x2.  Marcaine 0.25% was then utilized in all three incision sites and #4-0 Vicryl suture was used to approximate the skin and all three incision sites.  Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and taken to Postoperative Care Unit in stable condition and monitored under General Medical Floor on IV antibiotics, pain medications, and return to diet.
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DESCRIPTION: Laparoscopic appendectomy.  Acute suppurative appendicitis.  A CAT scan of the abdomen and pelvis was obtained revealing findings consistent with acute appendicitis.  There was no evidence of colitis on the CAT scan.

gastroenterology, abdomen, pelvis, laparoscopic appendectomy, suppurative appendicitis, veress needle, acute appendicitis, appendix, appendectomy, pneumoperitoneum, laparoscopic, appendicitis

The situation describes a standard surgical procedure, laparoscopic appendectomy, being performed on a 29-year-old female diagnosed with acute suppurative appendicitis. While the procedure itself is routine and generally has a low complication rate in a controlled medical environment, it remains a surgical intervention that carries inherent risks associated with anesthesia, infection, and postoperative recovery. Hence, while not life-threatening under normal circumstances and considering the patient tolerated the procedure well, any surgery involving anesthesia could have potential complications. The scenario is moderately high-stakes because the procedure demands medical expertise and careful postoperative monitoring.


Medical Specialty: Neurology
Sample Name: Cerebral Angiogram - Left ICA/PCA Aneurysm

CC:, Fluctuating level of consciousness.,HX:, 59y/o male experienced a "pop" in his head on 10/10/92 while showering in Cheyenne, Wyoming. He was visiting his son at the time. He was found unconscious on the shower floor 1.5 hours later. His son then drove him Back to Iowa. Since then he has had recurrent headaches and fluctuating level of consciousness, according to his wife. He presented at local hospital this AM, 10/13/92. A HCT there demonstrated a subarachnoid hemorrhage. He was then transferred to UIHC.,MEDS:, none.,PMH:, 1) Right hip and clavicle fractures many years ago. 2) All of his teeth have been removed., ,FHX:, Not noted.,SHX:, Cigar smoker. Truck driver.,EXAM: , BP 193/73.  HR 71.  RR 21.  Temp 37.2C.,MS: A&O to person, place and time. No note regarding speech or thought process.,CN: Subhyaloid hemorrhages, OU. Pupils 4/4 decreasing to 2/2 on exposure to light. Face symmetric. Tongue midline. Gag response difficult to elicit. Corneal responses not noted.,MOTOR: 5/5 strength throughout.,Sensory: Intact PP/VIB.,Reflexes: 2+/2+ throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, The patient underwent Cerebral Angiography on 10/13/92. This revealed a lobulated aneurysm off the supraclinoid portion of the left internal carotid artery close to the origin of the posterior communication artery. The patient subsequently underwent clipping of this aneurysm. He recovery was complicated severe vasospasm and bacterial meningitis. HCT on 10/19/92 revealed multiple low density areas in the left hemisphere in the LACA-LPCA watershed, left fronto-parietal area and left thalamic region. He was left with residual right hemiparesis, urinary incontinence, some (unspecified) degree of mental dysfunction. He was last seen 2/26/93 in Neurosurgery clinic and had stable deficits.
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DESCRIPTION: Cerebral Angiogram - Lobulated aneurysm of the supraclinoid portion of the left internal carotid artery close to the origin of the left posterior communicating artery.

neurology, consciousness, level of consciousness, hct, subhyaloid hemorrhages, cerebral angiography, carotid artery, communication artery, laca-lpca, fluctuating level of consciousness, internal carotid artery, lobulated aneurysm, lobulated, supraclinoid, cerebral, aneurysm, artery, angiogram,

This scenario describes a critical medical situation involving a cerebral angiogram for a patient who has suffered a subarachnoid hemorrhage and has been found with an aneurysm. The situation involves complications such as severe vasospasm and bacterial meningitis, leading to significant neurological deficits. This is a high-stakes scenario due to the life-threatening nature of the condition, the complexity of the medical intervention required, and the potential for severe, long-lasting consequences for the patient.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 52

CHIEF COMPLAINT: , Anxiety, alcohol abuse, and chest pain.,HISTORY OF PRESENT ILLNESS:,  This is a pleasant 40-year-old male with multiple medical problems, basically came to the hospital yesterday complaining of chest pain.  The patient states that he complained of this chest pain, which is reproducible, pleuritic in both chest radiating to the left back and the jaw, complaining of some cough, nausea, questionable shortness of breath.  The patient describes the pain as aching, sharp and alleviated with pain medications, not alleviated with any nitrates.  Aggravated by breathing, coughing, and palpation over the area.  The pain was 9/10 in the emergency room and he was given some pain medications in the ER and was basically admitted.  Labs were drawn, which were essentially, potassium was about 5.7 and digoxin level was drawn, which was about greater than 5.  The patient said that he missed 3 doses of digoxin in the last 3 days after being discharged from Anaheim Memorial and then took 3 tablets together.  The patient has a history prior digoxin overdose of the same nature.,MEDICATIONS:,  Digoxin 0.25 mg, metoprolol 50 mg, Naprosyn 500 mg, metformin 500 mg, lovastatin 40 mg, Klor-Con 20 mEq, Advair Diskus, questionable Coreg.,PAST MEDICAL HISTORY: , MI in the past and atrial fibrillation, he said that he has had one stent put in, but he is not sure.  The last cardiologist he saw was Dr. X and his primary doctor is Dr. Y.,SOCIAL HISTORY:,  History of alcohol use in the past.,He is basically requesting for more and more pain medications.  He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid.  His pain is tolerable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Stable.,GENERAL:  Alert and oriented x3, no apparent distress.,HEENT:  Extraocular muscles are intact.,CVS:  S1, S2 heard.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema or clubbing.,NEURO:  Grossly intact.  Tender to palpate over the left chest, no obvious erythema or redness, or abnormal exam is found.,EKG basically shows atrial fibrillation, rate controlled, nonspecific ST changes.,ASSESSMENT AND PLAN:,1.  This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse.  Now, he has had significant block with EKG changes as stated.  Continue to follow the patient clinically at this time.  The patient has been admitted to ICU and will be changed to DOU.,2.  Chronic chest pain with a history of myocardial infarction in the past, has been ruled out with negative cardiac enzymes.  The patient likely has opioid dependence and requesting more and more pain medications.  He is also bargaining for pain medications with me.  The patient was advised that he will develop more opioid dependence and I will stop the pain medications for now and give him only oral pain medications in the anticipation of the discharge in the next 1 or 2 days.  The patient was likely advised to also be seen by a pain specialist as an outpatient after being referred.  We will try to verify his pain medications from his primary doctor and his pharmacy.  The patient said that he has been on Dilaudid and Vicodin ES and Norco and all these medications in the past.
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DESCRIPTION: Anxiety, alcohol abuse, and chest pain.   This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse.  Now, he has had significant block with EKG changes as stated.

general medicine, anxiety, alcohol abuse, chest pain, digoxin toxicity, digoxin overuse, atrial fibrillation, opioid dependence, toxicity, dilaudid,

This medical situation involves several serious health concerns, including digoxin toxicity from likely intentional overuse, a history of myocardial infarction, atrial fibrillation, and opioid dependence. The digoxin toxicity is potentially life-threatening due to the risk of cardiac arrhythmias and requires close monitoring and adjustment of medication. Additionally, the patient's request for specific opioid medications indicates possible drug-seeking behavior, complicating the management of his pain and addiction issues. The presence of these intertwined acute and chronic medical and substance abuse problems makes this a high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lower Extremity Arterial Doppler

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

Lower Extremity Arterial Doppler

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

The report indicates mild bilateral lower extremity arterial obstructive disease, which implies some level of obstruction in blood flow in the patient's lower extremities. While this condition does require medical attention to prevent further complications, the term 'mild' suggests it is not currently life-threatening or immediately severe. It requires monitoring and possibly lifestyle or medical intervention but doesn't indicate an imminent high-stakes situation.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Cholecystectomy - 8

PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:  ,Chronic cholecystitis.,PROCEDURE PERFORMED:  ,Laparoscopic cholecystectomy.,BLOOD LOSS: , Minimal.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS: , None.,DISPOSITION:  ,To recovery room and to home.,FLUIDS:  ,Crystalloid.,FINDINGS: , Consistent with chronic cholecystitis.  Final pathology is pending.,INDICATIONS FOR THE PROCEDURE:  ,Briefly, the patient is a 38-year-old male referred with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.  He presented now after informed consent for the above procedure.,PROCEDURE IN DETAIL:  ,The patient was identified in the preanesthesia area, then taken to the operating room, placed in the supine position on the operating table, and induced under general endotracheal anesthesia.  The patient was correctly positioned, padded at all pressure points, had antiembolic TED hose and Flowtrons in the lower extremities.  The anterior abdomen was then prepared and draped in a sterile fashion.  Preemptive local anesthetic was infiltrated with 1% lidocaine and 0.5% ropivacaine.  The initial incision was made sharply at the umbilicus with a #15-scalpel blade and carried down through deeper tissues with Bovie cautery, down to the midline fascia with a #15 scalpel blade.  The blunt-tipped Hasson introducer cannula was placed into the abdominal cavity under direct vision where it was insufflated using carbon dioxide gas to a pressure of 15 mmHg.  The epigastric and right subcostal trocars were placed under direct vision.  The right upper quadrant was well visualized.  The gallbladder was noted to be significantly distended with surrounding dense adhesions.  The fundus of the gallbladder was grasped and retracted anteriorly and superiorly, and the surrounding adhesions were then taken down off the gallbladder using a combination of the bullet-nose Bovie dissector and the blunt Kittner peanut dissector.  Further dissection allowed identification of the infundibulum and cystic duct junction where the cystic duct was identified and dissected out further using a right-angle clamp.  The cystic duct was clipped x3 and then divided.  The cystic artery was dissected out in like fashion, clipped x3, and then divided.  The gallbladder was then taken off the liver bed in a retrograde fashion using the hook-tip Bovie cautery with good hemostasis.  Prior to removal of the gallbladder, all irrigation fluid was clear.  No active bleeding or oozing was seen.  All clips were noted to be secured and intact and in place.  The gallbladder was placed in a specimen pouch after placing the camera in the epigastric port.  The gallbladder was retrieved through the umbilical fascial defect and submitted to Pathology.  The camera was placed back once again into the abdominal cavity through the umbilical port, and all areas remained clean and dry and the trocar was removed under direct visualization.  The insufflation was allowed to escape.  The umbilical fascia was closed using interrupted #1 Vicryl sutures.  Finally, the skin was closed in a layered subcuticular fashion with interrupted 3-0 and 4-0 Monocryl.  Sterile dressings were applied.  The patient tolerated the procedure well.,
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DESCRIPTION: Chronic cholecystitis.   Laparoscopic cholecystectomy.  Patient with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.

gastroenterology, abdomen, bovie cautery, endotracheal anesthesia, laparoscopic cholecystectomy, cystic duct, chronic cholecystitis, abdominal, laparoscopic, cholecystectomy, cholecystitis, gallbladder,

The situation described involves a standard laparoscopic cholecystectomy performed to address chronic cholecystitis. The procedure is routine for surgeons and generally considered low-risk, especially when no complications occur during surgery, as mentioned. The patient's condition is stable post-surgery, findings were consistent with the preoperative diagnosis, blood loss was minimal, and the patient is expected to be discharged to home. Therefore, the stakes are low in a medical context as the surgery followed standard protocols with no complications.


Medical Specialty: Orthopedic
Sample Name: Arthroscopic Rotator Cuff Repair - 2

PROCEDURES,1.  Arthroscopic rotator cuff repair.,2.  Arthroscopic subacromial decompression.,3.  Arthroscopic extensive debridement, superior labrum anterior and posterior tear.,PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified.  The patient was placed on the operating room table in supine position and given general anesthetic.  Once the patient was under general anesthetic, a careful examination of the shoulder was performed.  It revealed no patholigamentous laxity.  The patient was then carefully positioned into a beach-chair position.  We maintained the natural alignment of the head, neck, and thorax at all times.  The shoulder and upper extremity was then prepped and draped in the usual sterile fashion.,Once we fully prepped and draped, we then began the surgery.  We injected the glenohumeral joint with sterile saline with a spinal needle.  This consisted of 60 cc of fluid.  We then made a posterior incision for our portal, 2 cm inferior and 2 cm medial to the posterolateral angle of the acromion.  Through this incision, a blunt trocar and cannula were placed in the glenohumeral joint.  Through the cannula, a camera was placed; and the shoulder was insufflated with sterile saline through a preoperative feed.  We then carefully examined the glenohumeral joint.,We found the articular surface to be in good condition.  There was a superior labral tear (SLAP).  This was extensively debrided using a shaver through an anterior portal.  We also found a full thickness rotator cuff tear.  We then drained the glenohumeral joint.  We redirected our camera into the subacromial space.  An anterolateral portal was made, both superior and inferior.,We then proceeded to perform a subacromial decompression using high-speed shaver.  The bursa was extensively debrided.  We then abraded the bone over the footprint of where the rotator cuff is usually attached.  The corkscrew anchors were used to perform a rotator cuff repair.  Pictures were taken.,Through a separate incision, an indwelling pain catheter was then placed.  It was carefully positioned.  Pictures were taken.  We then drained the joint.  All instruments were removed.  The patient did receive IV antibiotic preoperatively.  All portals were closed using 4-0 nylon sutures.,Xeroform, 4 x 4s, and OpSite were applied over the pain pump.  ABD, tape, and a sling were also applied.  A Cryo/Cuff was also placed over the shoulder.  The patient was taken out of the beach-chair position maintaining the neutral alignment of the head, neck, and thorax.  The patient was extubated and brought to the recovery room in stable condition.  I then went out and spoke with the family, going over the case, postoperative instructions, and followup care.
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DESCRIPTION: Arthroscopic rotator cuff repair, arthroscopic subacromial decompression, and arthroscopic extensive debridement, superior labrum anterior and posterior tear.

orthopedic, debridement, superior labrum, patholigamentous, laxity, arthroscopic rotator cuff repair, subacromial decompression, glenohumeral joint, rotator cuff, arthroscopic, decompression, repair, glenohumeral, subacromial, rotator, cuff,

The procedure described involves multiple arthroscopic surgeries on the shoulder, which, while complex, are relatively common in orthopedic surgery. Complications can arise during any surgical procedure, impacting the patient's outcome and recovery, making this situation high-stakes compared to non-surgical scenarios. However, these procedures are not rare or among the most dangerous types of surgeries and are routine for orthopedic surgeons. The patient's condition was stable post-operation, and follow-up care was planned, indicating good management of the situation.


Medical Specialty: Orthopedic
Sample Name: Anterior Cervical Discectomy & Arthrodesis - 2

PREOPERATIVE DIAGNOSIS:  ,Cervical spondylosis and herniated nucleus pulposus of C4-C5.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis and herniated nucleus pulposus of C4-C5.,TITLE OF OPERATION:,  Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,OPERATIVE PROCEDURE IN DETAIL: , After identification, the patient was taken to the operating room and placed in supine position.  Following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position.  A preoperative x-ray was obtained to identify the operative level and neck position.  An incision was marked at the C4-C5 level on the right side.  The incision was opened with #10 blade knife.  Dissection was carried down through subcutaneous tissues using Bovie electrocautery.  The platysma muscle was divided with the cautery and mobilized rostrally and caudally.  The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection.  The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia.  This was opened with scissors and dissected rostrally and caudally with the peanut dissectors.  The operative level was confirmed with an intraoperative x-ray.  The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator.  The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5.  Self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of C4 and C5, and distraction was instituted.  We then incise the annulus of C4-C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes.  Operating microscope was draped and brought into play.  Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went.  We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally.  Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch.  There was a transligamentous disc herniation, which was removed during this process.  We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent.  Cord was seen to be pulsating freely behind the dura.  There appeared to be no complications and the decompression appeared adequate.  We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body.  An 8 mm lordotic trial was used and appeared perfect.  We then used a corticocancellous 8 mm lordotic graft.  This was tapped into position.  Distraction was released, appeared to be in excellent position.  We then positioned an 18 mm Vector plate over the inner space.  Intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position.  We then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion.  All of the screws locked to the plate and this was confirmed on visual inspection.  Intraoperative x-ray was again obtained.  Construct appeared satisfactory.  Attention was then directed to closure.  The wound was copiously irrigated.  All of the self-retaining retractors were removed.  Bleeding points were controlled with bone wax and bipolar electrocautery.  The platysma layer was now closed with interrupted 3-0 Vicryl sutures.  The skin was closed with running 3-0 Vicryl subcuticular stitch.  Steri-Strips were applied.  A sterile bandage was applied.  All sponge, needle, and cottonoid counts were reported as correct.  The patient tolerated the procedure well.  He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition.
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DESCRIPTION: Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.  Cervical spondylosis and herniated nucleus pulposus of C4-C5.

orthopedic, synthes vector plate, lordotic, acf spacer, corticocancellous, arthrodesis, anterior cervical discectomy, herniated nucleus pulposus, anterior, cervical, spacer, screws, discectomy,

The operation described is an Anterior Cervical Discectomy and Arthrodesis, which is a surgical procedure that involves disc removal and fusion of the cervical spine. While cervical spine surgeries are not as high-risk as some other neurosurgeries, they do carry significant high-stakes implications. There is a risk of complications such as nerve damage, infection, and issues with the structural integrity of the spine post-surgery. That being said, the procedure described seems to have gone smoothly with no complications noted, which can lower the perceived stakes. However, the nature of the surgery itself inherently makes it higher stakes given its impact on the spine and the potential consequences of any surgical mishap.


Medical Specialty: Urology
Sample Name: Hematuria & Urinary Retention

REASON FOR CONSULTATION:,  Hematuria and urinary retention.,BRIEF HISTORY: , The patient is an 82-year-old, who was admitted with the history of diabetes, hypertension, hyperlipidemia, coronary artery disease, presented with urinary retention and pneumonia.  The patient had hematuria, and unable to void.  The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed.  Foley catheter was repositioned 18 Coude was used.  About over a liter of fluids of urine was obtained with light pink urine, which was irrigated.  The bladder and the suprapubic area returned to normal after the Foley placement.  The patient had some evidence of clots upon irrigation.  The patient has had a chest CT, which showed possible atelectasis versus pneumonia.,PAST MEDICAL HISTORY:  ,Coronary artery disease, diabetes, hypertension, hyperlipidemia, Parkinson's, and CHF.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , Married and lives with wife.,HABITS:,  No smoking or drinking.,REVIEW OF SYSTEMS: , Denies any chest pain, denies any seizure disorder, denies any nausea, vomiting.  Does have suprapubic tenderness and difficulty voiding.  The patient denies any prior history of hematuria, dysuria, burning, or pain.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Vitals are stable.,GENERAL:  The patient is a thin gentleman,GENITOURINARY:  Suprapubic area was distended and bladder was palpated very easily.  Prostate was 1+.  Testes are normal.,LABORATORY DATA: , The patient's white counts are 20,000.  Creatinine is normal.,ASSESSMENT AND PLAN:,1.  Pneumonia.,2.  Dehydration.,3.  Retention.,4.  BPH.,5.  Diabetes.,6.  Hyperlipidemia.,7.  Parkinson's.,8.  Congestive heart failure.,About 30 minutes were spent during the procedure and the Foley catheter was placed, Foley was irrigated and significant amount of clots were obtained.  Plan is for urine culture, antibiotics.  Plan is for renal ultrasound to rule out any pathology.  The patient will need cystoscopy and evaluation of the prostate.  Apparently, the patient's PSA is 0.45, so the patient is at low to no risk of prostate cancer at this time.  Continued Foley catheter at this point.  We will think about starting the patient on alpha-blockers once the patient's over all medical condition is improved and stable.
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DESCRIPTION: The patient had hematuria, and unable to void.  The patient had a Foley catheter, which was not in the urethra, possibly inflated in the prostatic urethra, which was removed.

The patient is an 82-year-old with multiple serious medical conditions, including diabetes, hypertension, coronary artery disease, Parkinson's, and congestive heart failure, who presented with urinary retention and hematuria. Misplacement of the Foley catheter can lead to potential complications, and there is the presence of clots in the urine which requires further investigation. While immediate life-threatening conditions such as severe infection or life-threatening hemorrhage do not appear present, the complexity and interconnectedness of the patient's various health conditions, along with the potential for complications from urinary issues, indicate a high stakes situation for ensuring the patient's safety and stabilizing their condition.


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

Medical Specialty: Surgery
Sample Name: Cranial Vault Reconstruction

INDICATION FOR OPERATION:,  Right coronal synostosis with left frontal compensatory bossing causing plagiocephaly.,PREOPERATIVE DIAGNOSIS:,  Syndromic craniosynostosis.,POSTOPERATIVE DIAGNOSIS: , Syndromic craniosynostosis.,TITLE OF OPERATION: , Anterior cranial vault reconstruction with fronto-orbital bar advancement.,SPECIMENS: , None.,DRAINS: , One subgaleal drain exiting from the left posterior aspect of wound.,DESCRIPTION OF PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was started, the patient was placed on the operating table in supine position with the head held on a horseshoe-shaped headrest and the head was prepped and draped down the routine manner.  Here, the proposed scalp incision was infiltrated with 1% Xylocaine and then a zigzag scalp incision was made from one ear to the other ear, posterior to the coronal suture.  Scalp incision was reflected anteriorly and then the periosteum was taken off of the bone and then the temporalis muscles were reflected anterolaterally until the anterior cranial vault was exposed and then the periorbital rim, nasion and orbital part of the zygomatic arch were all dissected out as well as the pterion.  Using a craniotome, several bur holes were made; two on the either side of the midline posteriorly and then two posterolaterally.  The two posterior bur holes were then connected with a punch over the superior sagittal sinus and then the craniotome was used to fashion a flap first on the left and then on the right, going paramedian along the superior sagittal sinus in the midline and then curving over the fronto-orbital bar.  We then dissected superior sagittal sinus off of the inner table of the right bundle flap and then connected the right bundle flap going across the pterion on the right, which was abnormal.  The pterion on the right was then run short down after removing both bone flaps and then the dura was dissected off from the orbital roofs.  On the right, the orbital roof was jagged and abnormal and we had to repair a CSF leak from where the dura was punctured by the orbital roof.  The orbital rim was then dissected out and then using the saw and chisels, we were able to make the releasing cuts to free up the orbital rims, zygomatic arch and then remove the orbital bar going posteriorly and then the distal bar was split in the middle and then reapproximated with a bone graft in the middle to move the orbits out a little bit and the orbital bar was held together using absorbable plate.  It was then replaced and advanced and then relaxing, barrel-staving incisions were made in the bone flaps and the orbital rim and it was held on the right side with an absorbable plate to fix it in the proper position.  The bone flaps were then reapproximated using absorbable plates and screws, as well as #2-0 Vicryl to secure back into place.  Some of the places were also secured in the midline posteriorly, as well as off to the right where the bony defects were in place.  The periosteum was then brought over the skull and fastened in place and the temporalis muscles were tacked up to the periosteum.  The wounds were irrigated out.  A drain was left in posteriorly and then the wounds were closed in a routine manner using Vicryl for the galea and fast-absorbing gut for the skin followed by sterile dressings.  The patient tolerated the procedure well and did receive blood transfusions.
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DESCRIPTION: Anterior cranial vault reconstruction with fronto-orbital bar advancement.

surgery, coronal synostosis, syndromic craniosynostosis, craniosynostosis, plagiocephaly, fronto-orbital bar, cranial vault reconstruction, cranial vault, orbital bar, orbital, cranial,

Cranial vault reconstruction is a major surgical procedure due to the complex anatomy of the cranial structure and the intricate nature of the surgery. The stakes are high because it involves intricate work around critical structures such as the brain, blood vessels, and dura mater, with significant risks including bleeding, infection, and neurological damage. Therefore, the situation described involves a high-stakes surgical procedure.


Medical Specialty: Consult - History and Phy.
Sample Name: Knee DJD - Consult

CHIEF COMPLAINT: , Left knee pain and stiffness.,HISTORY OF PRESENT ILLNESS: , The patient is a 57-year-old with severe bilateral knee DJD, left greater than right, with significant pain and limitations because of both.  He is able to walk approximately a 1/2-mile a day but is limited because of his knees.  Stairs are negotiated 1 at a time.  His problems with bilateral knee DJD have been well documented.  He had arthroscopy in the 1991/199two time frame for both of these.  He has been on long-standing conservative course for these including nonsteroidals, narcotics, injections.  At this point because of his progressive and persistent limitations he has opted for total joint surgery on the left side.  He does have other arthritic complaints including multiple back surgeries for spinal stenosis including decompression and epidural steroids.  Significant pain is handled by narcotic medication.  His attending physician is Dr. X.,PAST MEDICAL HISTORY: , Hypertension.,PRIOR SURGERIES:,1.  Inguinal hernia on the left.,2.  Baker's cyst.,3.  Colon cancer removal.,4.  Bilateral knee scopes.,5.  Right groin hernia.,6.  Low back surgery for spinal stenosis.,7.  Status post colon cancer second surgery.,MEDICATIONS:,1.  Ambien 12.5 mg nightly.,2.  Methadone 10 mg b.i.d.,3.  Lisinopril 10 mg daily.,IV MEDICATIONS FOR PAIN:  ,Demerol appears to work the best.,ALLERGIES: , Levaquin and Cipro cause rashes; ibuprofen causes his throat to swell, Fortaz causes an unknown reaction.,REVIEW OF SYSTEMS:  ,He does have paresthesias down into his thighs secondary to spinal stenosis.,SOCIAL HISTORY: , Married.  He is retired, being a Pepsi-Cola driver secondary to his back and knees.,HABITS: , No tobacco or alcohol.  Chewed until 2003.,RECREATIONAL PURSUITS:  ,Golfs, gardens, woodworks.,FAMILY HISTORY:,1.  Cancer.,2.  Coronary artery disease.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE:  A pleasant, cooperative 57-year-old white male.,VITAL SIGNS:  Height 5' 9", weight 167.  Blood pressure 148/86.  Pulse 78 per minute and regular.,HEENT:  Unremarkable.  Extraocular movements are full.  Cranial nerves II-XII intact.,NECK:  Supple.,CHEST:  Clear.,CARDIOVASCULAR:  Regular rhythm.  Normal S1 and 2.,ABDOMEN:  No organomegaly.  No tenderness.  Normal bowel sounds.,NEUROLOGIC:  Intact.,MUSCULOSKELETAL:  Left knee reveals a range of -10 degrees extension, 126 flexion.  His extensor mechanism is intact.  There is mild varus.  He has good stability at 30 degrees of flexion.  Lachman's and posterior drawer are negative.  He has good muscle turgor.  Dorsalis pedis pulse 2+.,DIAGNOSTICS:  ,X-rays revealed severe bilateral knee DJD with joint space narrowing medially as well as the patellofemoral joint with large osteophytes, left greater than right.,IMPRESSION:,1.  Bilateral knee degenerative joint disease.,2.  Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.
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DESCRIPTION: Left knee pain and stiffness.  Bilateral knee degenerative joint disease (DJD).  Significant back pain, status post lumbar stenosis surgery with pain being controlled on methadone 10 mg b.i.d.

The patient, a 57-year-old male, is experiencing significant limitations in physical activity due to severe bilateral knee degenerative joint disease (DJD) and is considering total joint surgery on the left knee. This surgery is a critical decision as it involves major orthopedic surgery, which carries inherent risks and will impact his ability to perform activities of daily living. Additionally, the patient manages chronic back pain and is on methadone, indicating a complex pain management scenario which can complicate postoperative recovery. Although the situation is medically significant and requires careful consideration and planning, it is not life-threatening in the immediate sense and is a common procedure for patients with similar conditions. Therefore, it doesn't represent the highest degree of stakes when compared to life-threatening medical emergencies.


Medical Specialty: Surgery
Sample Name: Phacoemulsification & Cataract Extraction - 3

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,TITLE OF OPERATION:  ,Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Retrobulbar block.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room where retrobulbar anesthesia was induced.  The patient was then prepped and draped using standard procedure.  A wire lid speculum was inserted to keep the eye open and the eye rotated downward with a 0.12.  The anterior chamber was entered by making a small superior limbal incision with a crescent blade and then entering the anterior chamber with a keratome.  The chamber was then filled with viscoelastic and a continuous-tear capsulorrhexis performed.  The phacoemulsification was then instilled in the eye and a linear incision made in the lens.  The lens was then cracked with a McPherson forceps, and the remaining lens material removed with the phacoemulsification tip.  The remaining cortex was removed with an I&A.  The capsular bag was then inflated with viscoelastic and the wound extended slightly with the keratome.  The folding posterior chamber lens was then inserted in the capsular bag and rotated into position.  The remaining viscoelastic was removed from the eye with the I&A.  The wound was checked for watertightness and found to be watertight.  Tobramycin drops were instilled in the eye and a shield placed over it.  The patient tolerated the procedure well.
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DESCRIPTION: Cataract, right eye.  Phacoemulsification with intraocular lens insertion, right eye.  A wire lid speculum was inserted to keep the eye open and the eye rotated downward.

surgery, tobramycin, limbal, lid speculum, intraocular lens, capsular bag, eye, phacoemulsification, lens, intraocular

The procedure described is a standard cataract surgery, which is quite common and routine in ophthalmology. While it is a surgical procedure, it generally has a high success rate and low risk of complications when performed by experienced surgeons. The report indicates that there were no complications, and the surgery was well-tolerated by the patient. However, as with all surgical procedures, there is inherent risk, especially if unforeseen complications arise. Therefore, it is slightly higher than the lowest stakes due to the nature of surgery, but it is still considered routine and straightforward in the field.


Medical Specialty: Consult - History and Phy.
Sample Name: Syncope - ER Visit - 1

REASON FOR VISIT:,  Syncope.,HISTORY:,  The patient is a 75-year-old lady who had a syncopal episode last night.  She went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up, the cereal was on the floor.  She did not have any residual deficit.  She had a headache at that time.  She denies chest pains or palpitations.,PAST MEDICAL HISTORY: , Arthritis, first episode of high blood pressure today.  She had a normal stress test two years ago.,MEDICATIONS: , Her medication is one dose of hydrochlorothiazide today because her blood pressure was so high at 150/70.,SOCIAL HISTORY: , She does not smoke and she does not drink.  She lives with her daughter.,PHYSICAL EXAMINATION:,GENERAL:  Lady in no distress.,VITAL SIGNS:  Blood pressure 172/91, came down to 139/75, heart rate 91, and respirations 20.  Afebrile.,HEENT:  Head is normal.,NECK:  Supple.,LUNGS:  Clear to auscultation and percussion.,HEART:  No S3, no S4, and no murmurs.,ABDOMEN:  Soft.,EXTREMITIES:  Lower extremities, no edema.,DIAGNOSTIC DATA: , Her EKG shows sinus rhythm with nondiagnostic Q-waves in the inferior leads.,ASSESSMENT:  ,Syncope.,PLAN:  ,She had a CT scan of the brain that was negative today.  The blood pressure is high.  We will start Maxzide.  We will do an outpatient Holter and carotid Doppler study.  She has had an echocardiogram along with the stress test before and it was normal.  We will do an outpatient followup.
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DESCRIPTION: The patient had a syncopal episode last night.   She did not have any residual deficit.  She had a headache at that time.  She denies chest pains or palpitations.

consult - history and phy., residual deficit, headache, ct scan, syncopal episode, stress test, blood pressure, syncope,

The situation involves a 75-year-old patient who experienced syncope, which requires medical evaluation to understand the underlying cause. While syncope can be a serious issue, the patient currently does not exhibit any alarming symptoms such as chest pain or palpitations. The CT scan and prior stress test were normal, and follow-up plans are in place to monitor her condition. The stakes are moderate because of her age and the potential risks associated with high blood pressure, but the situation is stable and not immediately life-threatening.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Hysteroscopy & Laproscopy with Salpingooophorectomy

PREOPERATIVE DIAGNOSES:,1.  Thickened endometrium and tamoxifen therapy.,2.  Adnexal cyst.,POSTOPERATIVE DIAGNOSES:,1.  Thickened endometrium and tamoxifen therapy.,2.  Adnexal cyst.,3.  Endometrial polyp.,4.  Right ovarian cyst.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Hysteroscopy.,3.  Laparoscopy with right salpingooophorectomy and aspiration of cyst fluid.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:,  None.,INDICATIONS: , This patient is a 44-year-old gravida 2, para 1-1-1-2 female who was diagnosed with breast cancer in December of 2002.  She has subsequently been on tamoxifen.  Ultrasound did show a thickened endometrial stripe as well as an adnexal cyst.  The above procedures were therefore performed.,FINDINGS:  ,On bimanual exam, the uterus was found to be slightly enlarged and anteverted.  The external genitalia was normal.  Hysteroscopic findings revealed both ostia well visualized and a large polyp on the anterolateral wall of the endometrium.  Laparoscopic findings revealed a normal-appearing uterus and normal left ovary.  There was no evidence of endometriosis on the ovaries bilaterally, the ovarian fossa, the cul-de-sac, or the vesicouterine peritoneum.  There was a cyst on the right ovary which appeared simple in nature.  The cyst was aspirated and the fluid was blood tinged.  Therefore, the decision to perform oophorectomy was made.  The liver margins appeared normal and there were no pelvic or abdominal adhesions noted.  The polyp removed from the hysteroscopic portion of the exam was found to be 4 cm in size.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped and placed in the dorsal lithotomy position.  Her bladder was drained with a red Robinson catheter.  A bimanual exam was performed, which revealed the above findings.  A weighted speculum was then placed in the posterior vaginal vault in the 12 o'clock position and the cervix was grasped with vulsellum tenaculum.  The cervix was then sounded in the anteverted position to 10 cm.  The cervix was then serially dilated using Hank and Hegar dilators up to a Hank dilator of 20 and Hagar dilator of 10.  The hysteroscope was then inserted and the above findings were noted.  A sharp curette was then introduced and the 4 cm polyp was removed.  The hysteroscope was then reinserted and the polyp was found to be completely removed at this point.  The polyp was sent to Pathology for evaluation.  The uterine elevator was then placed as a means to manipulate the uterus.  The weighted speculum was removed.  Gloves were changed.  Attention was turned to the anterior abdominal wall where 1 cm infraumbilical skin incision was made.  While tenting up the abdominal wall, the Veress needle was inserted without difficulty.  Using a sterile saline drop test, appropriate placement was confirmed.  The abdomen was then insufflated with appropriate volume inflow of CO2.  The #11 step trocar was placed without difficulty.  The above findings were then visualized.  A 5 mm port was placed 2 cm above the pubic symphysis.  This was done under direct visualization and the grasper was inserted through this port for better visualization.  A 12 mm port was then made in the right lateral aspect of the abdominal wall and the Endo-GIA was inserted through this port and the fallopian tube and ovary were incorporated across the infundibulopelvic ligament.  Prior to this, the cyst was aspirated using 60 cc syringe on a needle.  Approximately, 20 cc of blood-tinged fluid was obtained.  After the ovary and fallopian tube were completely transected, this was placed in an EndoCatch bag and removed through the lateral port site.  The incision was found to be hemostatic.  The area was suction irrigated.  After adequate inspection, the port sites were removed from the patient's abdomen and the abdomen was desufflated.  The infraumbilical port site and laparoscope were also removed.  The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips.  10 cc of 0.25% Marcaine was then injected locally.  The patient tolerated the procedure well.  The sponge, lap, and needle counts were correct x2.  She will be followed up on an outpatient basis.
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DESCRIPTION: Dilation and curettage (D&C), hysteroscopy, and laparoscopy with right salpingooophorectomy and aspiration of cyst fluid.  Thickened endometrium and tamoxifen therapy, adnexal cyst, endometrial polyp, and right ovarian cyst.

obstetrics / gynecology, adnexal cyst, endometrial, ovarian cyst, dilation and curettage, d&c, hysteroscopy, laparoscopy, salpingooophorectomy, aspiration of cyst fluid, thickened endometrium, tamoxifen therapy, abdominal wall, cyst, ovarian, endometrium,

The situation described pertains to a series of surgical procedures performed on a woman with a history of breast cancer and subsequent tamoxifen therapy, which led to the development of a thickened endometrium and adnexal cysts. The procedures include dilation and curettage, hysteroscopy, and laparoscopy with salpingooophorectomy and aspiration of ovarian cyst fluid. This is a high-stakes scenario as it involves surgery on reproductive organs in a cancer patient, potentially impacting her health significantly. Surgical procedures inherently carry risks such as infections, bleeding, or complications from anesthesia. Moreover, the findings and outcomes from these procedures could have implications for ongoing cancer management and the patient's overall prognosis.


Medical Specialty: ENT - Otolaryngology
Sample Name: Ear Pain - Drainage

CHIEF COMPLAINT:,  Right ear pain with drainage.,HISTORY OF PRESENT ILLNESS:,  This is a 12-year-old white male here with his mother for complaints of his right ear hurting.  Mother states he has been complaining for several days.  A couple of days ago she noticed drainage from the right ear.  The patient states it has been draining for several days and it has a foul smell to it.  He has had some low-grade fever.  The patient was seen in the office about a week ago with complaints of a sore throat, headache and fever.  The patient was evaluated for Strep throat which was negative and just had been doing supportive care.  He did have a recent airplane ride a couple of weeks ago also.  There has been no cough, shortness of breath or wheezing.  No vomiting or diarrhea.,PHYSICAL EXAM:,General:  He is alert in no distress.,Vital Signs:  Temperature:  99.1 degrees.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  The left TM is clear.  The right TM is poorly visualized secondary to purulent secretions in the right ear canal.  There is no erythema of the ear canals.  Nares is patent.  Oropharynx is clear.  The patient does wear braces.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,ASSESSMENT:,1.  Right otitis media.,2.  Right otorrhea.,PLAN:,  Ceftin 250 mg by mouth twice a day for 10 days.  Ciprodex four drops to the right ear twice a day.  The patient is to return to the office in two weeks for followup.
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DESCRIPTION: Right ear pain with drainage - otitis media and otorrhea.

ent - otolaryngology, drainage, ear hurting, ear pain, otitis media, otorrhea, ear pain with drainage, otitis, media, ear,

The situation involves a case of right ear pain with drainage, diagnosed as otitis media and otorrhea, in a 12-year-old male. While this is a medical concern that requires treatment, it is a common condition and not life-threatening when managed properly with antibiotics and ear drops. The plan includes appropriate follow-up, indicating that the situation is being monitored. Given the lack of severe symptoms or complications and the routine nature of the condition, it's not considered extremely high-stakes.


Medical Specialty: Urology
Sample Name: Prostate Adenocarcinoma - 4

PHYSICAL EXAMINATION:,  Patient is a 46-year-old white male seen for annual physical exam and had an incidental PSA elevation of 4.0.  All other systems were normal.,PROCEDURES:  ,Sextant biopsy of the prostate.,Radical prostatectomy:  Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.,PATHOLOGY:,Prostate biopsy:  Right lobe, negative.  Left lobe, small focus of adenocarcinoma, Gleason's 3 + 3 in approximately 5% of the tissue.,Radical prostatectomy:  Negative lymph nodes.  Prostate gland showing moderately differentiated infiltrating adenocarcinoma, Gleason 3 + 2 extending to the apex involving both lobes of the prostate, mainly right.  Tumor overall involved less than 5% of the tissue.  Surgical margin was reported and involved at the apex.  The capsule and seminal vesicles were free.,DISCHARGE NOTE:,  Patient has made good post-op recovery other than mild urgency incontinence.  His post-op PSA is 0.1 mg/ml.
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DESCRIPTION: Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.

urology, capsule, bladder neck, surgical margin, moderately differentiated infiltrating adenocarcinoma, pelvic lymph nodes, prostate gland, infiltrating adenocarcinoma, radical prostatectomy, seminal vesicles, gleason's, seminal, vesicles, adenocarcinoma, prostate,

This situation involves the diagnosis and treatment of prostate adenocarcinoma in a relatively young patient (age 46), which is a serious and potentially life-threatening condition. Despite early-stage cancer detection and successful surgery, the stakes are high due to the need for ongoing monitoring and management of post-surgery symptoms like urgency incontinence. The patient also faces psychological impacts and potential changes in quality of life. However, the cancer involved less than 5% of the tissue, and post-op PSA levels are low, indicating a good immediate prognosis, which slightly lowers the overall stakes.


Medical Specialty: Surgery
Sample Name: Tonsillectomy & Adenoidectomy - 4

PREOPERATIVE DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,POSTOPERATIVE DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,FINAL DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,OPERATION PERFORMED,1.  Tonsillectomy and adenoidectomy.,2.  Left superficial nasal cauterization.,DESCRIPTION OF OPERATION:,  The patient was brought to the operating room.  Endotracheal intubation carried out by Dr. X. The McIvor mouth gag was inserted and gently suspended.  Afrin was instilled in both sides of the nose and allowed to take effect for a period of time.  The hypertrophic tonsils were then removed by the suction and snare.  Deeply cryptic changes as expected were evident.  Bleeding was minimal and controlled with packing followed by electrocautery followed by extensive additional irrigation.  An inspection of the nasopharynx confirmed that the adenoids were in fact hypertrophic rubbery cryptic and obstructive.  They were shaved back, flushed with prevertebral fascia with curette.  Hemostasis established with packing followed by electrocautery.  In light of his history of recurring nosebleeds, both sides of the nose were carefully inspected.  A nasal endoscope was used to identify the plexus of bleeding, which was predominantly on the left mid portion of the septum that was controlled with broad superficial cauterization using a suction cautery device.  The bleeding was admittedly a bit of a annoyance.  An additional control was established by infiltrating slowly with a 1% Xylocaine with epinephrine around the perimeter of the bleeding site and then cauterizing the bleeding site itself.  No additional bleeding was then evident.  The oropharynx was reinspected, clots removed, the patient was extubated, taken to the recovery room in stable condition.  Discharge will be anticipated later in the day on Lortab plus amoxicillin plus Ponaris nose drops.  Office recheck anticipated if stable and doing well in three to four weeks.
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DESCRIPTION: Tonsillectomy and adenoidectomy and Left superficial nasal cauterization.  Recurrent tonsillitis.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.  Residual adenoid hypertrophy and recurrent epistaxis.

surgery, tonsillitis, cryptic hypertrophic tonsils, tonsillolith, nasal cauterization, adenoid hypertrophy, hypertrophic tonsils, adenoidectomy, nasal, cauterization, hypertrophy, epistaxis, tonsils, hypertrophic, intubation, tonsillectomy

The situation described involves a surgical procedure, tonsillectomy and adenoidectomy, which inherently carries some risk due to factors like anesthesia, bleeding, and infection. In this case, there is also a mention of recurrent epistaxis (nosebleeds) and management of bleeding during surgery, indicating additional complexities. While tonsillectomy and adenoidectomy are routine and common procedures, the presence of recurrent bleeding issues raises the stakes slightly. However, since the patient was moved to the recovery room in stable condition and discharge was anticipated later in the day, it suggests the outcome was managed well without complications. The context is still within a controlled surgical environment, so while it is serious, it is not considered the highest-risk scenario.