Medical Specialty: Neurology
Sample Name: Frameless Stereotactic Radiosurgery

PREOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:,  CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM.  He was referred for stereotactic radiosurgery.  The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits.  The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment.  He was placed on the treatment table.  The Aquaplast mask was constructed.  Initial imaging was obtained by the CyberKnife system.  The patient was then transported over to the CT scanner at Stanford.  Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered.  Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices.  These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me.  I outlined the tumor volume.  Inverse treatment planning was used to generate the treatment plan for this patient.  This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator.  The maximum dose within this center of treatment volume was 23.81 Gy.  The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm.  The volume treated at the reference dose was 98%.  The coverage isodose line was 79%.  The conformality index was 1.74 and modified conformality index was 1.55.  The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite.  He was placed on the treatment table.  The Aquaplast mask was applied.  Initial imaging was used to bring the patient into optimal position.  The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin.  He tolerated the procedure well.  He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months.  The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note.
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DESCRIPTION: CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.

neurology, ct-guided, occipital, cyberknife, frameless stereotactic radiosurgery, occipital arteriovenous malformation, conformality index, arteriovenous malformation, malformation, avm, arteriovenous,

This is a high-stakes situation due to several factors. First, the procedure involves treating a right occipital arteriovenous malformation, which is a serious neurological condition that can lead to significant complications if untreated. The procedure itself, frameless stereotactic radiosurgery, is complex and carries risks such as failure to obliterate the AVM, radiation injury, and potential neurological deficits. The involvement of advanced technology like the CyberKnife system and the need for precise execution underscore the potential consequences of errors or complications, which could result in severe neurological damage or even be life-threatening.


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

Medical Specialty: Radiology
Sample Name: MRI Elbow - 2

FINDINGS:,There is diffuse subcutis space edema extending along the posteromedial aspect of the elbow adjacent to the medial epicondyle, extending to the olecranon process and along the superficial aspect of the epicondylo-olecranon ligament. There is no demonstrated solid, cystic or lipomatous mass lesion. There is enlargement with hyperintense signal of the ulnar nerve within the cubital tunnel. There is inflammation with mild laxity of the epicondylo-olecranon ligament. The combined findings are most consistent with a ulnar nerve neuritis possibly secondary to a subluxing ulnar nerve however the ulnar nerve at this time is within the cubital tunnel. There is no accessory muscle within the cubital tunnel. The common flexor tendon origin is normal.,Normal ulnar collateral ligamentous complex.,There is mild epimysial sheath edema of the pronator teres muscle consistent with a mild epimysial sheath sprain but no muscular tear.,There is minimal intratendinous inflammation of the common extensor tendon origin consistent with a mild tendinitis. There is no demonstrated common extensor tendon tear. Normal radial collateral ligamentous complex.,Normal radiocapitellum and ulnotrochlear articulations.,Normal triceps and biceps tendon insertions.,There is peritendinous inflammation of the brachialis tendon insertion but an intrinsically normal tendon.,IMPRESSION:,Edema of the subcutis adipose space overlying the posteromedial aspect of the elbow with interstitial inflammation of the epicondylo-olecranon ligament.,Enlarged edematous ulnar nerve most compatible with ulnar nerve neuritis.,The above combined findings suggest a subluxing ulnar nerve.,Mild epimysial sheath strain of the pronator teres muscle but no muscular tear.,Mild lateral epicondylitis with focal tendinitis of the origin of the common extensor tendon.,Peritendinous edema of the brachialis tendon insertion.,No solid, cystic or lipomatous mass lesion.,
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DESCRIPTION: MRI of elbow - A middle-aged female with moderate pain, severe swelling and a growth on the arm.

radiology, growth on the arm, subluxing ulnar nerve, collateral ligamentous complex, common extensor tendon, posteromedial aspect, epimysial sheath, extensor tendon, tendon insertions, ulnar nerve, elbow, edema, olecranon, inflammation, nerve, ulnar, tendon

The findings from the MRI report indicate conditions like ulnar nerve neuritis, mild tendinitis, and mild strain, which are typically not life-threatening but can be painful and affect the patient's quality of life and functionality. Nonetheless, they do not necessitate emergency intervention, and treatment can often involve physical therapy, medication, or, in some cases, surgical intervention, suggesting moderate stakes. The mention of a 'growth' without further alarming characteristics in the report could relate to swelling rather than a dangerous mass, decreasing the urgency of the situation.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Urology
Sample Name: Hydrocelectomy.

PREOPERATIVE DIAGNOSIS: , Left hydrocele.,OPERATION: , Left hydrocelectomy.,POSTOPERATIVE DIAGNOSIS: , Left hydrocele.,ANESTHESIA: , General,INDICATIONS AND STUDIES: , This is a 67-year-old male with pain, left scrotum.  He has had an elevated PSA and also has erectile dysfunction.  He comes in now for a left hydrocelectomy.  Physical exam confirmed obvious hydrocele, left scrotum, approximately 8 cm.  Laboratory data included a hematocrit of 43.5, hemoglobin of 15.0, and white count 4700.  Creatinine 1.3, sodium 141, and potassium 4.0.  Calcium 8.6.  Chest x-ray was unremarkable.  EKG was normal.,PROCEDURE: , The patient was satisfactorily given general anesthesia, prepped and draped in supine position, and left scrotal incision was made, carried down to the tunica vaginalis forming the hydrocele.  This was dissected free from the scrotal wall back to the base of the testicle and then excised back to the spermatic cord.  In the fashion, the hydrocele was excised and fluid drained.,Cord was infiltrated with 5 mL of 0.25% Marcaine.  The edges of the tunica vaginalis adjacent to the spermatic cord were oversewn with interrupted 3-0 Vicryl sutures for hemostasis.  The left testicle was replaced into the left scrotal compartment and affixed to the overlying Dartos fascia with a 3-0 Vicryl suture through the edge of the tunica vaginalis and the overlying Dartos fascia.,The left scrotal incision was closed, first closing the Dartos fascia with interrupted 3-0 Vicryl sutures.  Skin was closed with an interrupted running 4-0 chromic suture.  A sterile dressing was applied.  The patient was sent to the recovery room in good condition, upon awakening from general anesthesia.  Plan is to discharge the patient and see him back in the office in a week or 2 in followup.  Further plans will depend upon how he does.
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DESCRIPTION: Left hydrocelectomy.   This is a 67-year-old male with pain, left scrotum.  He has had an elevated PSA and also has erectile dysfunction.  He comes in now for a left hydrocelectomy.  Physical exam confirmed obvious hydrocele, left scrotum.

urology, hydrocele, erectile dysfunction, spermatic cord, tunica vaginalis, vicryl sutures, dartos fascia, hydrocelectomy, psa, testicle, scrotum, scrotal,

The situation involves a surgical procedure, specifically a hydrocelectomy, performed on a 67-year-old male with a painful hydrocele. While any surgical procedure has risks and requires professionalism, this is considered a routine elective surgery with a low complication rate. The patient's age and elevated PSA may raise caution, but overall, without specific complications or emergencies, this is not considered high-stakes compared to more complex or emergent surgeries.


Medical Specialty: Surgery
Sample Name: Shockwave Lithotripsy

PREOPERATIVE DIAGNOSIS:,  Right renal stone.,POSTOPERATIVE DIAGNOSIS:  ,Right renal stone.,PROCEDURE: , Right shockwave lithotripsy, cystoscopy, and stent removal x2.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS:,  Minimal.  The patient was given antibiotics preoperatively.,HISTORY: , This is a 47-year-old male who presented with right renal stone and right UPJ stone.  The right UPJ stone was removed using ureteroscopy and laser lithotripsy and the stone in the kidney.  The plan was for shockwave lithotripsy.  The patient had duplicated system on the right side.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE was discussed.  Options such as watchful waiting, passing the stone on its own, and shockwave lithotripsy were discussed.  The patient wanted to proceed with the shockwave to break the stone into small pieces as possible to allow the stones to pass easily.  Consent was obtained.,DETAILS OF THE OPERATION:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the supine position.  Using Dornier lithotriptor total of 2500 shocks were applied.  Energy levels were slowly started at O2 increased up to 7; gradually the stone seem to have broken into smaller pieces as the number of shocks went up.  The shocks were started at 60 per minute and slowly increased up to 90 per minute.  The patient's heart rate and blood pressure were stable throughout the entire procedure.,After the end of the shockwave lithotripsy the patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion and cystoscopy was done.  Using graspers, the stent was grasped x2 and pulled out, both stents were removed.  The patient tolerated the procedure well.  The patient was brought to recovery in stable condition.  The plan was for the patient to follow up with us and plan for KUB in about two to three months.
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DESCRIPTION: Right shockwave lithotripsy, cystoscopy, and stent removal x2.

surgery, renal stone, stent removal, upj stone, shockwave lithotripsy, cystoscopy, stent, renal, shocks, upj, shockwave, lithotripsy, stone

Shockwave lithotripsy is a common procedure used to treat kidney stones, and while it is generally safe, it involves some inherent risks such as anesthesia, bleeding, or infection. These risks are standard for surgical procedures but are typically well-managed in a controlled clinical environment. The procedure followed standard protocols, with minimal blood loss and stable vital signs throughout. The patient also recovered in stable condition which suggests that the immediate severe risks were low. However, in a surgical context, especially involving internal organs, there is always some level of inherent risk, including postoperative complications such as infection or the need for further intervention if the treatment does not succeed in completely resolving the stone issue.


Medical Specialty: Office Notes
Sample Name: Normal Physical Exam Template - 4

GENERAL:  ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX.  Height XXX, weight XXX.,HEAD: , Normocephalic.  Negative lesions, negative masses.,EYES: , PERLA, EOMI.  Sclerae clear.  Negative icterus, negative conjunctivitis.,ENT:,  Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates.  Negative ear obstructions, negative exudates.  Negative inflammation in external auditory canals.  Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers.  No tattoos.,NECK:,  Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:,  Regular rate and rhythm.  Negative rubs, negative gallops, negative murmurs.,LUNGS:,  Clear to auscultation.  Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds.  Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing.  Pulses adequate bilaterally.,MUSCULOSKELETAL:,  Negative muscle atrophy, negative masses.  Strength adequate bilaterally.  Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact.  Negative gait disturbance.  Balance and coordination intact.  Negative Romberg, negative Babinski.  DTRs equal bilaterally.,GENITOURINARY:  ,Deferred.,
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DESCRIPTION: Normal physical exam template.  Normocephalic.  Negative lesions, negative masses.

The content provided is a normal physical exam template used for routine documentation of a patient's health status during a check-up. Such a template includes various vital signs and conditions of different body systems that are standardly recorded in medical assessments. The use of 'negative' throughout suggests no abnormalities. The template is a part of non-emergency medical documentation indicating general procedure rather than immediate medical decision-making situations. Therefore, it denotes routine and non-urgent monitoring, making the situation low-stakes.


Medical Specialty: Pain Management
Sample Name: Facet Arthrogram & Injection

PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1.  Bilateral facet Arthrogram at L34, L45, L5S1.,2.  Bilateral facet injections at L34, L45, L5S1.,3.  Interpretation of radiograph.,ANESTHESIA:  ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS:  ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view.  A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left.  Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side.  This was performed using the oblique view under fluoroscopy to the enable the view of the "Scotty Dog," After obtaining the "Scotty Dog" view the joints were easily seen.  Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow.  After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected.  Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint.  The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint.  The 22-gauge needle was then removed.  Pressure was place over the puncture site for approximately one minute.  This exact same procedure was then repeated along the left-sided facets at L45, and L5S1.  This exact same procedure was then repeated on the right side.  At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1.  Visualizing the "Scotty Dog" technique under fluoroscopy facilitated this.  Dye spread into each joint space is visualized.  No venous or arterial run-off is noted.  No epidural run-off is noted.  The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis.
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DESCRIPTION: Bilateral facet Arthrogram and injections at L34, L45, L5S1.  Interpretation of radiograph.  Low Back Syndrome - Low Back Pain.

pain management, low back syndrome, low back pain, facet injection, fluoroscopy, iv sedation, spinal fluid, facet arthrogram, aspiration, arthrogram, injection, facet,

Facet arthrogram and injections are specialized pain management procedures used to diagnose and treat pain originating from facet joints in the spine. While any invasive procedure carries some risks such as infection or damage to surrounding tissues, this particular procedure is generally considered routine in pain management practices and is performed under controlled settings with minimal blood loss and no complications noted in this case. The stakes are higher than a non-invasive procedure due to risks associated with anesthesia and potential complications, but the lack of immediate complications and the routine nature of the procedure keep this at a moderate risk level.


Medical Specialty: Obstetrics / Gynecology
Sample Name: CT Abdomen & Pelvis - OB-GYN

EXAM:,  CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:,  Abdominal pain.,TECHNIQUE:  ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration.  Oral contrast was not administered.  There was no comparison of studies.,FINDINGS,CT PELVIS:,Within the pelvis, the uterus demonstrates a thickened-appearing endometrium.  There is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology.  There is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid.  Several smaller fibroids were also suspected.,The ovaries are unremarkable in appearance.  There is no free pelvic fluid or adenopathy.,CT ABDOMEN:,The appendix has normal appearance in the right lower quadrant.  There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis.  The small and large bowels are otherwise unremarkable.  The stomach is grossly unremarkable.  There is no abdominal or retroperitoneal adenopathy.  There are no adrenal masses.  The kidneys, liver, gallbladder, and pancreas are in unremarkable appearance.  The spleen contains several small calcified granulomas, but no evidence of masses.  It is normal in size.  The lung bases are clear bilaterally.  The osseous structures are unremarkable other than mild facet degenerative changes at L4-L5 and L5-S1.,IMPRESSION:,1.  Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2.  Multiple uterine fibroids.,3.  Prominent endometrium.,4.  Followup pelvic ultrasound is recommended.
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DESCRIPTION: Abdominal pain.  CT examination of the abdomen and pelvis with intravenous contrast.

obstetrics / gynecology, ovaries, pelvic fluid, adenopathy, uterine segment, cervix, hypodense mass, ct examination, fibroids, pelvic, ct, pelvis, isovue, abdomen

The situation involves a medical examination with a focus on a potentially serious condition given the anomalous findings in the CT scan, such as a hypodense mass in the cervix and uterine segment of uncertain etiology. The recommended follow-up with a pelvic ultrasound indicates concern about the findings that require further exploration. While not immediately life-threatening, the stakes are raised by the uncertainty surrounding the mass, as it could potentially lead to more serious diagnoses such as cancer, or benign conditions that require different management.


Medical Specialty: Emergency Room Reports
Sample Name: Ecstasy Ingestion - ER Visit

CHIEF COMPLAINT:,  "I took Ecstasy.",HISTORY OF PRESENT ILLNESS: , This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.  The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis.  Mother called the EMS service when the patient vomited.  On arrival here, the patient states that she no longer has any nausea and that she feels just fine.  The patient states she feels wired but has no other problems or complaints.  The patient denies any pain.  The patient does not have any auditory of visual hallucinations.  The patient denies any depression or suicidal ideation.  The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself.  The patient denies any homicidal ideation.  The patient denies any recent illness or recent injuries.  The mother states that the daughter appears to be back to her usual self now.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No recent illness.  No fever or chills.  HEENT:  No headache.  No neck pain.  No vision change or hearing change.  No eye or ear pain.  No rhinorrhea.  No sore throat.  CARDIOVASCULAR:  No chest pain.  No palpitations or racing heart.  RESPIRATIONS:  No shortness of breath.  No cough.  GASTROINTESTINAL: One episode of nonbloody, nonbilious emesis this morning without any nausea since then.  The patient denies any abdominal pain.  No change in bowel movements.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No dizziness, syncope, or near syncope.  PSYCHIATRIC:  The patient denies any depression, suicidal ideation, homicidal ideation, auditory hallucinations or visual hallucinations.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  None.,PAST SURGICAL HISTORY: , Appendectomy when she was 9 years old.,CURRENT MEDICATIONS: , Birth control pills.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies smoking cigarettes.  The patient does drink alcohol and also uses illicit drugs.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure 140/86, pulse is 79, respirations 16, oxygen saturation 100% on room air and is interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, and well developed, appears to be healthy.  The patient is calm and comfortable, in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctiva bilaterally.  The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally.  No evidence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Ears are normal without any sign of infection.  Mouth and oropharynx are normal without any signs of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +3 and bounding.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, normal and benign.  MUSCULOSKELETAL:  No abnormalities noted in back, arms, or legs.  The patient is normal use of her extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact in all extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  The patient does not have any smell of alcohol and does not exhibit any clinical intoxication.  The patient is quite pleasant, fully cooperative.  HEMATOLOGIC/LYMPHATIC: NO lymphadenitis is noted.  No bruising is noted.,DIAGNOSES:,1.  ECSTASY INGESTION.,2.  ALCOHOL INGESTION.,3.  VOMITING SECONDARY TO STIMULANT ABUSE.,CONDITION UPON DISPOSITION: , Stable disposition to home with her mother.,PLAN:,  I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation.  The patient was advised to stop drinking alcohol, and taking Ecstasy as this is not only in the interest of her health, but was also illegal.  The patient is asked to return to the emergency room should she have any worsening of her condition, develop any other problems or symptoms of concern.
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DESCRIPTION: Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.

emergency room reports, nonbilious emesis, hallucinations, visual, auditory, ecstasy ingestion, suicidal ideation, homicidal ideation, ingestion, infection, alcohol, ecstasy,

The situation involves a 17-year-old taking a significant amount of Ecstasy along with alcohol, leading to a visit to the emergency room. While the patient appears stable and without serious acute symptoms at the time of examination, the ingestion of multiple substances poses a high risk of acute and long-term health issues. Ecstasy can lead to severe complications like dehydration, hyperthermia, or serotonin syndrome, particularly in large quantities. Additionally, legal and social implications are involved due to underage drinking and illegal drug use. These factors contribute to it being a high-stakes medical scenario.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Ultrasound OB - 7

GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 150BPM.  Fetal Lie: Longitudinal.  Fetal Presentation: Cephalic.  Placenta: Anterior Grade I.  Uterus: Normal.  Cervix: Closed.  Adnexa: Not seen.  Amniotic Fluid: Normal.,BIOMETRY:,BPD: 8.4 cm consistent with 33 weeks, 6 days gestation,HC: 29.8 cm consistent with 33 weeks, 0 days gestation,AC: 29.7 cm consistent with 33 weeks, 5 days gestation,FL:
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DESCRIPTION: A 27-year-old female with a size and date discrepancy.

The ultrasound report indicates a discrepancy between the size and gestation date, which could potentially be significant in prenatal care. Such discrepancies can suggest a range of issues, from inaccurate dating to potential fetal growth restrictions or anomalies. While the current findings about fetal cardiac activity and other aspects are normal, ongoing monitoring is essential to ensure maternal and fetal health. Although this is an important situation requiring follow-up, it does not currently indicate an immediate threat to life or health, thus not extremely high-stakes.


Medical Specialty: Ophthalmology
Sample Name: Blepharoplasty - Lower Lid

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

Lower lid blepharoplasty.

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

The described situation involves a lower lid blepharoplasty, a surgical procedure generally considered routine in the field of ophthalmology or plastic surgery, particularly when performed by a trained and experienced surgeon. While all surgeries have inherent risks, this specific case mentions minimal bleeding and that the patient tolerated the procedure well, suggesting that there were no complications. Additionally, there is no immediate information indicating any critical or life-threatening scenarios during the procedure. Therefore, considering typical procedures, this does not qualify as a high-stakes situation.


Medical Specialty: Orthopedic
Sample Name: MRI Knee - 5

EXAM:,MRI RIGHT KNEE WITHOUT GADOLINIUM,CLINICAL:,This is a 21-year-old male with right knee pain after a twisting injury on 7/31/05. Patient has had prior lateral meniscectomy in 2001.,FINDINGS:,Examination was performed on 8/3/05,Normal medial meniscus without intrasubstance degeneration, surface fraying or discrete meniscal tear.,There is subtle irregularity along the superior and inferior articular surfaces of the lateral meniscus, likely reflecting previous partial meniscectomy and contouring, although subtle surface tearing cannot be excluded, particularly along the undersurface of the lateral meniscus (series #3, image #17). There is no displaced tear or displaced meniscal fragment.,There is a mild interstitial sprain of the anterior cruciate ligament without focal tear or discontinuity.,Normal posterior cruciate ligament.,Normal medial collateral ligament.,There is a strain of the popliteus muscle and tendon without complete tear.,There is a sprain of the posterolateral and posterocentral joint capsule (series #5 images #10-18). There is marrow edema within the posterolateral corner of the tibia, and there is linear signal adjacent to the cortex suggesting that there may be a Segond fracture for which correlation with radiographs is recommended (series #6, images #4-7).,Biceps femoris tendon and iliotibial band are intact and there is no discrete fibular collateral ligament tear. Normal quadriceps and patellar tendons.,There is contusion within the posterior non-weight bearing surface of the medial femoral condyle, as well as in the posteromedial corner of the tibia. There is linear vertically oriented signal within the distal tibial diaphyseal-metaphyseal junction (series #7, image #8; series #2, images #4-5). There is no discrete fracture line, and this is of uncertain significance, but this should be correlated with radiographs.,The patellofemoral joint is congruent without patellar tilt or subluxation. Normal medial and lateral patellar retinacula. There is a joint effusion.,IMPRESSION:,Changes within the lateral meniscus most likely reflect previous partial meniscectomy and re-contouring although a subtle undersurface tear in the anterior horn may be present.,Mild anterior cruciate ligament interstitial sprain.,There is a strain of the popliteus muscle and tendon and there is a sprain of the posterolateral and posterocentral joint capsule with a possible Second fracture which should be correlated with radiographs.,
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DESCRIPTION: MRI right knee without gadolinium

MRI right knee without gadolinium

orthopedic, mri right knee, posterolateral and posterocentral, posterocentral joint capsule, lateral meniscus, cruciate ligament, mri, meniscectomy, cruciate, tendon, posterolateral, patellar, ligament, tear

The situation involves assessing an MRI for a young male who has sustained a knee injury, specifically looking for damage such as potential tears and sprains associated with prior surgery and a recent twisting injury. This type of exam is critical for diagnosing the extent of the injury, informing treatment decisions, and planning potential surgeries, but does not appear to be life-threatening. Hence, while important, the stakes are not life or death but rather pertain to the patient's future mobility and quality of life.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Patent Ductus Arteriosus Ligation

TITLE OF OPERATION: , Ligation (clip interruption) of patent ductus arteriosus.,INDICATION FOR SURGERY: , This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.  She has now been put forward for operative intervention.,PREOP DIAGNOSIS:  ,1.  Patent ductus arteriosus.,2.  Severe prematurity.,3.  Operative weight less than 4 kg (600 grams).,COMPLICATIONS: , None.,FINDINGS: , Large patent ductus arteriosus with evidence of pulmonary over circulation.  After completion of the procedure, left recurrent laryngeal nerve visualized and preserved.  Substantial rise in diastolic blood pressure.,DETAILS OF THE PROCEDURE: , After obtaining information consent, the patient was positioned in the neonatal intensive care unit, cribbed in the right lateral decubitus, and general endotracheal anesthesia was induced.  The left chest was then prepped and draped in the usual sterile fashion and a posterolateral thoracotomy incision was performed.  Dissection was carried through the deeper planes until the second intercostal space was entered freely with no damage to the underlying lung parenchyma.  The lung was quite edematous and was retracted anteriorly exposing the area of the isthmus.  The pleura overlying the ductus arteriosus was inside and the duct dissected in a nearly circumferential fashion.  It was then test occluded and then interrupted with a medium titanium clip.  There was preserved pulsatile flow in the descending aorta.  The left recurrent laryngeal nerve was identified and preserved.  With excellent hemostasis, the intercostal space was closed with 4-0 Vicryl sutures and the muscular planes were reapproximated with 5-0 Caprosyn running suture in two layers.  The skin was closed with a running 6-0 Caprosyn suture.  A sterile dressing was placed.  Sponge and needle counts were correct times 2 at the end of the procedure.  The patient was returned to the supine position in which palpable bilateral femoral pulses were noted.,I was the surgical attending present in the neonatal intensive care unit and in-charge of the surgical procedure throughout the entire length of the case.
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DESCRIPTION: Ligation (clip interruption) of patent ductus arteriosus.  This premature baby with operative weight of 600 grams and evidence of persistent pulmonary over circulation and failure to thrive has been diagnosed with a large patent ductus arteriosus originating in the left-sided aortic arch.

pediatrics - neonatal, clip interruption, ligation, patent ductus arteriosus, premature baby, intercostal space, arteriosus, interruption, pulmonary, circulation

The situation involves a surgical procedure on a premature infant weighing only 600 grams with a patent ductus arteriosus, a condition that can significantly impact the infant's health due to issues like pulmonary over circulation and failure to thrive. Performing surgery on such a small and fragile patient presents high risks, including potential complications from anesthesia, surgical error, or postoperative issues. The outcome of this surgery is critical for the infant's survival and future health, making it a high-stakes medical situation.


Medical Specialty: ENT - Otolaryngology
Sample Name: Laryngoscopy & Vocal Cord Biopsy

PREOPERATIVE DIAGNOSES:,1.  Hoarseness.,2.  Bilateral true vocal cord lesions.,3.  Leukoplakia.,POSTOPERATIVE DIAGNOSES:,1.  Hoarseness.,2.  Bilateral true vocal cord lesions.,3.  Leukoplakia.,PROCEDURE PERFORMED:  ,Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:  The patient is a 33-year-old Caucasian male with a history of chronic hoarseness and bilateral true vocal cord lesions, and leukoplakia discovered on a fiberoptic nasal laryngoscopy in the office.  Discussed risks, complications, and consequences of a surgical biopsy of the left true vocal cord and consent was obtained.,PROCEDURE: , The patient was brought to operative suite by anesthesia, placed on the operating table in supine position.  After this, the patient was placed under general endotracheal intubation anesthesia and the operative table was turned 90 degrees by the Department of Anesthesia.  A shoulder roll was then placed followed by the patient being placed in reverse Trendelenburg.,After this, a mouthguard was placed in the upper teeth and a Dedo laryngoscope was placed in the patient's oral cavity and advanced through the oral cavity in the oropharynx down into the hypopharynx.  The patient's larynx was then brought into view with the true vocal cords hidden underneath what appeared to be redundant false vocal cords.  The left true vocal cord was then first addressed and appeared to have an extensive area of leukoplakia extending from the posterior one-third up to the anterior third.  The false vocal cord also appeared to be very full on the left side along with fullness in the subglottic region.  The patient's anterior commissure appeared to be clear.  The false cord on the right side also appeared to be very redundant and overshadowing the true vocal cord.  Once the true vocal cord was retracted laterally, there was revealed a second area of leukoplakia involving the right true vocal cord in the anterior one-third aspect.  The patient's subglottic region was very edematous and with redundant mucosal tissue.  The areas of leukoplakia appeared to be cobblestoned in appearance, irregularly bordered, and very hard to the touch.  The left true vocal cord was then first addressed, was stripped from posteriorly to anteriorly utilizing a #45 laryngeal forceps.  After this, the patient had pressure placed upon this area with tropical adrenaline and a rectal swab to maintain hemostasis.  The specimen was passed off the field and was sent to Pathology for evaluation.  Hemostasis was maintained on the left side.  Prior to taking this biopsy, the Louie arm was attached to the laryngoscope and then suspended on the Mayo stand.  The Zeiss operating microscope was then brought into view to directly visualize the vocal cords.  The biopsies were taken under direct visualization utilizing the Zeiss operating microscope.  After the specimen was taken and the laryngoscope was desuspended from the Mayo stand and Louie arm was removed, the scope was then pulled more cephalad and the piriform sinuses, valecula, and base of the tongue were all directly visualized, which appeared normal except for the left base of tongue appeared to be full.  This area was biopsied multiple times with a straight laryngeal forceps and passed off the field and sent to Pathology as specimen.  The scope was then pulled back into the superior aspect of hypopharynx into the oropharynx and the oral cavity demonstrated no signs of any gross lesions.  A bimanual examination was then performed, which again demonstrated a fullness on the left base of tongue region with no signs of any other gross lesions.  There were no signs of any palpable cervical lymphadenopathy.  The tooth guard was removed and the patient was then turned back to anesthesia.  The patient did receive intraoperatively 10 mg of Decadron.  The patient tolerated the procedure well and was extubated in the operating room.,The patient was transferred to recovery room in stable condition and tolerated the procedure well.  The patient will be sent home with prescriptions for Medrol DOSEPAK, Tylenol with Codeine, Elixir, and amoxicillin 250 mg per 5 cc.
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DESCRIPTION: Microscopic suspension direct laryngoscopy with biopsy of left true vocal cord stripping.  Hoarseness, bilateral true vocal cord lesions, and leukoplakia.

ent - otolaryngology, direct laryngoscopy, zeiss operating microscope, vocal cord lesions, vocal cord, cord, vocal, microscopic, laryngoscopy, hoarseness, biopsy, leukoplakia

The situation involves a medical procedure, specifically a laryngoscopy and vocal cord biopsy for a patient with chronic hoarseness, vocal cord lesions, and leukoplakia. While the procedure itself is routine in the field of ENT, the presence of leukoplakia and lesions on the vocal cords could indicate potentially serious underlying conditions, such as cancer. The biopsy is essential for diagnosing the nature of these lesions. Although the reported complications are none and the patient tolerated the procedure well, the stakes are raised by the potential for a serious diagnosis. Thus, the circumstances are moderately high-stakes due to the implications of the diagnosis rather than the procedure itself.


Medical Specialty: General Medicine
Sample Name: Normal Physical Exam Template - 6

VITAL SIGNS:,  Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.,CONSTITUTIONAL: , Normal appearance for chronological age, does not appear chronically ill.,HEENT: , The pupils are equal and reactive.  Funduscopic examination is normal.  Posterior pharynx is normal.  Tympanic membranes are clear.,NECK:  ,Trachea is midline.  Thyroid is normal.  The neck is supple.  Negative nodes.,RESPIRATORY:,  Lungs are clear to auscultation bilaterally.  The patient has a normal respiratory rate, no signs of consolidation and no egophony.  There are no retractions or secondary muscle use.  Good bilateral breath sounds are noted.,CARDIOVASCULAR: , No jugular venous distention or carotid bruits.  No increase in heart size to percussion.  There is no murmur.  Normal S1 and S2 sounds are noted without gallop.,ABDOMEN: , Soft to palpation in all four quadrants.  There is no organomegaly and no rebound tenderness.  Bowel sounds are normal.  Obturator and psoas signs are negative.,GENITOURINARY: , No bladder tenderness, negative flank pain.,MUSCULOSKELETAL:,  Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.,NEUROLOGIC: , Normal Glasgow Coma Scale.  Cranial nerves II through XII appear grossly intact.  Normal motor and cerebellar tests.  Reflexes are normal.,HEME/LYMPH:  ,No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.,PSYCHIATRIC: , Normal with no overt depression or suicidal ideations.
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DESCRIPTION: Normal physical exam template.  Normal appearance for chronological age, does not appear chronically ill.

general medicine, jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds,

The situation involves evaluating a normal physical examination template for a general medicine practice. This is a routine task and is part of the standard procedure in medical practice, used primarily for documentation and developing familiarity with normal findings. It does not involve critical decision-making or direct patient intervention, but rather focuses on ensuring accurate record-keeping. Consequently, while accurate record-keeping is important, the stakes are very low given that the scenario describes a conclusion of normal findings, typical in many routine exams.


Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy - 3

PROCEDURES:,  Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,REASON FOR PROCEDURE: , Child with abdominal pain and rectal bleeding.  Rule out inflammatory bowel disease, allergic enterocolitis, rectal polyps, and rectal vascular malformations.,CONSENT:,  History and physical examination was performed.  The procedure, indications, alternatives available, and complications, i.e. bleeding, perforation, infection, adverse medication reaction, the possible need for blood transfusion, and surgery should a complication occur were discussed with the parents who understood and indicated this.  Opportunity for questions was provided and informed consent was obtained.,MEDICATION:  ,General anesthesia.,INSTRUMENT: , Olympus GIF-160.,COMPLICATIONS:,  None.,FINDINGS: , With the patient in the supine position and intubated, the endoscope was inserted without difficulty into the hypopharynx.  The esophageal mucosa and vascular pattern appeared normal.  The lower esophageal sphincter was located at 25 cm from the central incisors.  It appeared normal.  A Z-line was identified within the lower esophageal sphincter.  The endoscope was advanced into the stomach, which distended with excess air.  Rugal folds flattened completely.  Gastric mucosa appeared normal throughout.  No hiatal hernia was noted.  Pyloric valve appeared normal.  The endoscope was advanced into the first, second, and third portions of duodenum, which had normal mucosa, coloration, and fold pattern.  Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  Additional 2 biopsies were obtained for CLO testing in the antrum.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated that part of procedure well.  The patient was turned and the scope was advanced with some difficulty to the terminal ileum.  The terminal ileum mucosa and the colonic mucosa throughout was normal except at approximately 10 cm where a 1 x 1 cm pedunculated juvenile-appearing polyp was noted.  Biopsies were obtained x2 in the terminal ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid, and rectum.  Then, the polyp was snared right at the base of the polyp on the stalk and 20 watts of pure coag was applied in 2-second bursts x3.  The polyp was severed.  There was no bleeding at the stalk after removal of the polyp head.  The polyp head was removed by suction.  Excess air was evacuated from the colon.  The patient tolerated that part of the procedure well and was taken to recovery in satisfactory condition.  Estimated blood loss approximately 5 mL.,IMPRESSION: , Normal esophagus, stomach, duodenum, and colon as well as terminal ileum except for a 1 x 1-cm rectal polyp, which was removed successfully by polypectomy snare.,PLAN:  ,Histologic evaluation and CLO testing.  I will contact the parents next week with biopsy results and further management plans will be discussed at that time.
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DESCRIPTION: Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.

surgery, esophagus, stomach, duodenum, rectal polyp, polypectomy snare, olympus gif-160, endoscope was advanced, clo testing, polyp head, terminal ileum, polypectomy, biopsies, esophagogastroduodenoscopy, ileum, mucosa, colonoscopy,

The situation involves a medical procedure on a child to investigate potential gastrointestinal issues including inflammatory bowel disease and rectal polyps. The procedure is invasive, requiring general anesthesia and has inherent risks such as bleeding and infection. While the procedure went smoothly, it is crucial as it helps rule out serious conditions and involved removing a polyp which could indicate further health risks if not addressed. Pediatric procedures require additional caution due to the age and vulnerability of the patient.


Medical Specialty: Surgery
Sample Name: Exploratory Laparotomy

PREOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,POSTOPERATIVE DIAGNOSIS: ,  Leaking anastomosis from esophagogastrectomy. ,PROCEDURE: ,  Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,COMPLICATIONS:,  None. ,ANESTHESIA: , General oroendotracheal intubation. ,PROCEDURE:  , After adequate general anesthesia was administered, the patient's abdomen was prepped and draped aseptically. Sutures and staples were removed. The abdomen was opened. The were some very early stage adhesions that were easy to separate. Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon. This was retracted caudally to expose the stomach. There were a number of adhesions to the stomach. These were carefully dissected to expose initially the closure over the gastrotomy site. Initially this looked like this was leaking but it was actually found to be intact.  The pyloroplasty was identified and also found to be intact with no evidence of leakage. Further dissection up toward the hiatus revealed an abscess collection. This was sent for culture and sensitivity and was aspirated and lavaged. Cavity tracked up toward the hiatus. Stomach itself appeared viable, there was no necrotic sections. Upper apex of the stomach was felt to be viable also. I did not pull the stomach and esophagus down into the abdomen from the mediastinum, but placed a sucker up into the mediastinum where additional turbid fluid was identified. Carefully placed a 10 mm flat Jackson-Pratt drain into the mediastinum through the hiatus to control this area of leakage. Two additional Jackson-Pratt drains were placed essentially through the gastrohepatic omentum. This was the area that most of the drainage had collected in. As I had previously discussed with Dr. Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient. I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair. Once the drains were secured, they were brought out through the anterior abdominal wall and secured with 3-0 silk sutures and secured to bulb suction. The midline fascia was then closed using running #2 Prolene sutures bolstered with retention sutures. Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples. Dry gauze dressing was placed. The patient tolerated the procedure well, there were no complications.
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DESCRIPTION: Leaking anastomosis from esophagogastrectomy.   Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage.

surgery, drainage, oroendotracheal, intubation, intra abdominal, abdominal abscesses, jackson pratt, exploratory laparotomy, anastomosis, esophagogastrectomy, mediastinum, abdomen, stomach

The situation involves a leaking anastomosis from an esophagogastrectomy, which is a significant complication that can lead to severe consequences, including infection and sepsis. Addressing this with an exploratory laparotomy and drainage is a complex procedure requiring high skill. The patient's health is at risk without successful intervention, and the procedure involves significant surgical tasks such as handling adhesions, drainage of abscesses, and ensuring no further leakage. These elements indicate a high-stakes situation due to the potential for serious complications if not properly managed.


Medical Specialty: Consult - History and Phy.
Sample Name: Connective Tissue Disorder

Her past medical history includes a presumed diagnosis of connective tissue disorder.  She has otherwise, good health.  She underwent a shoulder ligament repair for joint laxity.,She does not take any eye medications and she takes Seasonale systemically.  She is allergic to penicillin.,The visual acuity today, distance with her current prescription was 20/30 on the right and 20/20 on the left eye.  Over refraction on the right eye showed -0.50 sphere with acuity of 20/20 OD.  She is wearing -3.75 +1.50 x 060 on the right and -2.50 +0.25 x 140, OS.  Intraocular pressures are 13 OU and by applanation.  Confrontation, visual fields, extraocular movement, and pupils are normal in both eyes.  Gonioscopy showed normal anterior segment angle morphology in both eyes.  She does have some fine iris strength crossing the angle, but the angle is otherwise open 360 degrees in both eyes.,The lids were normal in both eyes.  Conjunctivae were quite, OU.  Cornea were clear in both eyes.  The anterior chamber is deep and quiet, OU.  She has clear lenses, which are in good position, OU.  Dilated fundus exam shows moderately optically clear vitreous, OU.  The optic nerves are normal in size.  The cup-to-disc ratios were approximately 0.4, OU.  The nerve fiber layers are excellent, OU.  The macula, vessels, and periphery were normal in both eyes.  No evidence of peripheral retinal degeneration is present in either eye.,Ms. ABC has optically clear vitreous.  She does not have any obvious risk factors for retinal detachment at present such as peripheral retinal degeneration and her anterior chamber angles are normal in both eyes.,She does have moderate myopia, however.,This combination of findings suggests and is consistent with her systemic connective tissue disorder such as a Stickler syndrome or a variant of Stickler syndrome.,I discussed with her the symptoms of retinal detachment and advised her to contact us immediately if they occur.  Otherwise, I can see her in 1 to 2 years.
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DESCRIPTION: She is sent for evaluation of ocular manifestations of systemic connective tissue disorders.  Denies any eye problems and history includes myopia with astigmatism.

consult - history and phy., systemic connective tissue disorder, stickler syndrome, anterior chamber angles, retinal degeneration, connective tissue disorder, vitreous, degeneration, detachment, myopia, optically, astigmatism, eyes

The situation involves a medical evaluation for ocular manifestations of a systemic connective tissue disorder, possibly Stickler syndrome, which can have serious implications if not monitored properly. However, the findings are largely normal with no immediate risk of retinal detachment or other severe complications. The patient has been advised on potential symptoms and a follow-up is suggested in 1 to 2 years, indicating that while the patient's condition requires attention, it is not immediately critical. This places the situation at a moderate level of concern, but not high-stakes.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Barium Swallow Study Evaluation - 1

HISTORY:  ,The patient is a 76-year-old male, with previous history of dysphagia, status post stroke.  The patient stated that he was at Hospital, secondary to his stroke, where he had his initial modified barium swallow study.  The patient stated that the results of that modified revealed aspiration with thin liquids only.  He is currently eating and drinking without difficulty and he feels that he can return to a regular diet with thin liquids.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,STUDY: , Modified barium swallow study was performed in the radiology suite in cooperation with Dr. X. The patient was seated upright and in a video-imaging chair throughout this assessment.,To evaluate the patient's swallowing function and safety, he was administered graduated amounts of liquid and food mixed with barium in the form of thin liquids (teaspoon x3, cup sip x3); nectar-thick liquid (teaspoon x2, cup sip x3); pureed consistency (teaspoon x3); solid consistency (1/4 cracker x1).,FINDINGS,ORAL STAGE: , The patient had no spillage out lips.  Oral residual after swallow with increased viscosity requiring multiple swallows to clear oral cavity.,The patient has reduced lingual retraction contributing to vallecula pooling after the swallow.  Trace premature spillage was noted with thin liquids during this assessment.,PHARYNGEAL STAGE: , Aspiration noted on cup sips of thin liquid.  Trace-to-mild penetration with teaspoon amounts of thin liquid during and after the swallow.  The penetration after the swallow occurred secondary to spillage on the piriform sinuses into the laryngeal vestibule.  The patient has incomplete laryngeal closure, which allowed the aspiration and penetration with thin liquids.  The patient had no aspiration or penetration occur with nectar-thick liquid, puree, and solid food.  The patient has a mildly reduced hyolaryngeal elevation and anterior movement that leads to incomplete epiglottic inversion that contributes to vallecula pooling.  Mild-to-moderate pooling in the vallecula after the swallow with liquids and puree, this residual did decrease with the solid feed presentation.  The patient has mild residual of pooling in the piriform sinuses after a swallow that did clear with sequential swallows.,CERVICAL ESOPHAGEAL STAGE: , The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.,DIAGNOSTIC IMPRESSION: , Mild aspiration with cup sips of thin liquid, penetration during and after the swallow with teaspoon amounts of thin liquid.  No aspiration or penetration occurred with thick liquid, pureed, or solid food during this assessment.,PROGNOSTIC IMPRESSION: , With a modified diet, the patient's potential for swallowing safety is good.,PLAN:,Based on this evaluation, the following is recommended:,1.  The patient should be on a regular diet with nectar-thick liquids to help prevent aspiration and penetration.,2.  The patient should have unthickened water in between meals to help decrease his risk of dehydration.,3.  The patient should complete good oral care two times a day to decrease bacterial growth in mouth.,4.  The patient should be seated at a 90-degree angle when eating and drinking, as well as take small bites and small sips to help decrease risk of aspiration and penetration and reflux.,Thank you for the opportunity to evaluate the patient.  I look forward to working with him in the outpatient setting to improve his swallowing function and safety.  Outpatient skilled speech therapy is recommended for a trial of neuromuscular electrical stimulation therapy for muscle re-education, as well as to train patient to use swallowing techniques and maneuvers that should improve his swallowing function and safety.
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DESCRIPTION: The patient is a 76-year-old male, with previous history of dysphagia, status post stroke.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.

consult - history and phy., oral stage, pharyngeal stage, cervical esophageal stage, nectar-thick liquids, aspiration, modified barium swallow, barium swallow study, dysphagia status, cup sips, barium swallow, swallow, teaspoon, barium, swallowing,

This medical situation involves evaluating a patient's risk for aspiration after a stroke, which can lead to serious complications like pneumonia if not managed properly. The barium swallow study revealed mild aspiration with thin liquids, which necessitates dietary adjustments and possibly rehabilitation through speech therapy. However, the condition appears to be manageable with appropriate interventions, including a modified diet and therapy. The stakes involve the patient's immediate health by preventing further complications and improving quality of life, but since measures are in place to manage these risks, it is not an extreme high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Consult - Congestive Heart Failure

REASON FOR CONSULTATION: , Congestive heart failure.,HISTORY OF PRESENT ILLNESS: , The patient is a 75-year-old gentleman presented through the emergency room.  Symptoms are of shortness of breath, fatigue, and tiredness.  Main complaints are right-sided and abdominal pain.  Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure.  Given history and his multiple risk factors and workup recently, which has been as mentioned below, the patient was admitted for further evaluation.  Incidentally, his x-ray confirms pneumonia.,CORONARY RISK FACTORS: , History of hypertension, no history of diabetes mellitus, active smoker, cholesterol elevated, questionable history of coronary artery disease, and family history is positive.,FAMILY HISTORY: , Positive for coronary artery disease.,PAST SURGICAL HISTORY: , The patient denies any major surgeries.,MEDICATIONS:  ,Aspirin, Coumadin adjusted dose, digoxin, isosorbide mononitrate 120 mg daily, Lasix, potassium supplementation, gemfibrozil 600 mg b.i.d., and metoprolol 100 mg b.i.d.,ALLERGIES: , None reported.,PERSONAL HISTORY:,  Married, active smoker, does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, smoking history, coronary artery disease, cardiomyopathy, COPD, and presentation as above.  The patient is on anticoagulation on Coumadin, the patient does not recall the reason.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  History of blurry vision and hearing impaired.  No glaucoma.,CARDIOVASCULAR:  Shortness of breath, congestive heart failure, and arrhythmia.  Prior history of chest pain.,RESPIRATORY:  Bronchitis and pneumonia.  No valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, melena, or abdominal pain.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Non-significant.,NEUROLOGICAL:  No TIA.  No CVA or seizure disorder.,ENDOCRINE:  Non-significant.,HEMATOLOGICAL:  Non-significant.,PSYCHOLOGICAL:  Anxiety.  No depression.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 60, blood pressure of 129/73, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  Neck veins flat.,LUNGS:  Air entry bilaterally decreased in the basilar areas with scattered rales, especially right side greater than left lung.,HEART:  PMI displaced.  S1 and S2, regular.  Systolic murmur.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  Trace edema of the ankle.  Pulses are feebly palpable.  Clubbing plus.  No cyanosis.,CNS:  Grossly intact.,MUSCULOSKELETAL:  Arthritic changes.,PSYCHOLOGICAL:  Normal affect.,LABORATORY AND DIAGNOSTIC DATA: , EKG shows sinus bradycardia, intraventricular conduction defect.  Nonspecific ST-T changes.,Laboratories noted with H&H 10/32 and white count of 7.  INR 1.8.  BUN and creatinine within normal limits.  Cardiac enzyme profile first set 0.04, BNP of 10,000.,Nuclear myocardial perfusion scan with adenosine in the office done about a couple of weeks ago shows ejection fraction of 39% with inferior reversible defect.,IMPRESSION: , The patient is a 75-year-old gentleman admitted for:
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DESCRIPTION: Congestive heart failure (CHF).  The patient is a 75-year-old gentleman presented through the emergency room.  Symptoms are of shortness of breath, fatigue, and tiredness.  Main complaints are right-sided and abdominal pain.  Initial blood test in the emergency room showed elevated BNP suggestive of congestive heart failure.

The case involves a 75-year-old patient with congestive heart failure presenting with symptoms of shortness of breath and fatigue, and already has significant comorbidities like hypertension, coronary artery disease, and COPD. His BNP is elevated, indicating a serious heart condition, and he presented through the emergency room, which suggests an acute exacerbation or deterioration. The presence of pneumonia and other underlying risks like smoking and hyperlipidemia increases the risks and complexity of this case. The situation requires thorough medical assessment and potential intervention, carrying moderate to high stakes due to the patient's age, multiple health issues, and the acute nature of his symptoms.


Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 3

CHIEF COMPLAINT:, Followup on diabetes mellitus, hypercholesterolemia, and sinusitis. ,SUBJECTIVE:,  A 70-year-old female who was diagnosed with diabetes mellitus last fall.  She has been checking her Accu-Cheks generally once a day, and they range from 82 to a high of 132.  She feels well.  She walks 1-2 miles most days.  If the weather is bad, they go to a local mall.  Otherwise they walk outside.  She does complain of some sinus congestion and drainage for the last several days.  She is up-to-date on her mammogram that she had at the Baylis Building.  She sees Dr. Cheng for her gynecological care.  She is a nonsmoker.  Denies abdominal pain, nausea, vomiting, diarrhea, constipation, blood in her urine, blood in her stools.  She has nocturia x 1.  Denies swelling in her ankles.  She checks her feet regularly., ,PAST MEDICAL HISTORY:,  Refer to chart.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt:  185 B/P: 142/70.  When she checks it at the mall and other places, it is usually about 120/56. T: 96.5 P:  84 and regular.,General: A 70-year-old female who does not appear to be in acute distress.  ,HEENT: She has frontal and maxillary sinus tenderness on the right to palpation.  The right TM is slightly dull.
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DESCRIPTION: Sample progress note - Gen Med.

Sample progress note - Gen Med.

The situation involves a routine follow-up examination of a 70-year-old female patient with diabetes mellitus, hypercholesterolemia, and sinusitis. The patient's diabetes seems well-managed, as indicated by her Accu-Chek readings and her active lifestyle. There is some concern with her blood pressure readings, as there is a noted difference between at-home and clinical measurements. Her sinusitis might need attention, given the symptoms. However, there are no immediate life-threatening issues or critical symptoms mentioned. It involves common chronic conditions manageable in an outpatient setting. Thus, this situation does not represent a high-stakes scenario.


Medical Specialty: Gastroenterology
Sample Name: GI Consultation - 3

PROBLEM:  ,Prescription evaluation for Crohn's disease., ,HISTORY: , This is a 46-year-old male who is here for a refill of Imuran.  He is taking it at a dose of 100 mg per day.  He is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years.  In fact, he had an episode three weeks ago in which he was seen at the emergency room after experiencing sudden onset of abdominal pain and vomiting. An x-ray was performed, which showed no signs of obstruction per his report.  He thinks that the inciting factor of this incident was too many grapes eaten the day before.  He has had similar symptoms suggestive of obstruction when eating oranges or other high-residue fruits in the past.  The patient's normal bowel pattern is loose stools and this is unchanged recently.  He has not had any rectal bleeding. He asks today about a rope-like vein on his anterior right arm that has been a little tender and enlarged after he was in the emergency room and they had difficulty with IV insertion.  He has not had any fever, red streaking up the arm, or enlargement of lymph nodes.  The tenderness has now completely resolved.  , ,He had a colonoscopy performed in August of 2003, by Dr. S.  An anastomotic stricture was found at the terminal ileum/cecum junction.  Dr. S recommended that if the patient experienced crampy abdominal pain or other symptoms of obstruction, that he may consider balloon dilation.  No active Crohn's disease was found during the colonoscopy.  , ,Earlier this year, he experienced a non-specific hepatitis with elevation of his liver function tests.  At that time he was taking a lot of Tylenol for migraine-type headaches.  Under Dr. S's recommendation, he stopped the Imuran for one month and reduced his dose of Tylenol.  Since that time his liver enzymes have normalized and he has restarted the Imuran with no problems.  , ,He also reports heartburn that is occurring on a slightly more frequent basis than it has in the past.  It used to occur once a week only, but has now increased in frequency to twice a week.  He takes over-the-counter H2 blockers as needed, as well as Tums.  He associates the onset of his symptoms with eating spicy Mexican food., ,PAST MEDICAL HISTORY: , Reviewed and unchanged.,ALLERGIES: , No known allergies to medications.,OPERATIONS: , Unchanged.,ILLNESSES: , Crohn's disease, vitamin B12 deficiency.,MEDICATIONS:,  Imuran, Nascobal, Vicodin p.r.n., ,REVIEW OF SYSTEMS: , Dated 08/04/04 is reviewed and noted.  Please see pertinent GI issues as discussed above.  Otherwise unremarkable., ,PHYSICAL EXAMINATION:  , GENERAL:  Pleasant male in no acute distress.  Well nourished and well developed. SKIN: indurated, cord-like superficial vein on the right anterior forearm, approx. 3 cm in length.  Non-tender to palpation. No erythema or red streaking.  No edema. LYMPH:  No epitrochlear or axillary lymph node enlargement or tenderness on the right side. , ,DATA REVIEWED: Labs from June 8th and July 19th reviewed.  Liver function tests normal with AST 14 and ALT 44.  WBCs were slightly low at 4.8.  Hemoglobin dropped slightly from 14.1 on 6/8 to 12.9 on 7/19. Hematocrit dropped slightly as well from 43.2 on 6/804 to 40.0 on 7/19/04.  These results were reviewed by Dr. S and lab results letter sent., ,IMPRESSION:  ,1. Crohn's disease, status post terminal ileum resection, on Imuran.  Intermittent symptoms of bowel obstruction.  Last episode three weeks ago.,2.  History of non-specific hepatitis while taking high doses of Tylenol.  Now resolved. ,2.  Increased frequency of reflux symptoms.,3.  Superficial thrombophlebitis, resolving. ,4.  Slightly low H&H., ,PLAN:  ,1.  We discussed Dr. S's recommendation that the patient undergo balloon dilation for recurrent bowel obstruction type symptoms.  The patient emphatically states that he does not want to consider dilation at this time.  The patient is strongly encouraged to call us when he does experience any obstructive symptoms, including abdominal pain, nausea, vomiting, or change in bowel habits.  He states understanding of this. Advised to maintain low residue diet to avoid obstructions. ,2.  Continue with liver panel and ABC every month per Dr. S's instructions.,3.  Continue Imuran 100 mg per day.,4.  Continue to minimize Tylenol use.  The patient is wondering if he can take another type of medication for migraines that is not Tylenol or antiinflammatories or aspirin.  Dr. S is consulted and agrees that Imitrex is an acceptable alternative for migraine headaches since he does not have advanced liver disease. The patient will make an appointment with his primary care provider to discuss this further. ,5.  Reviewed the importance of prophylactic treatment of reflux-type symptoms.  Encouraged the patient to take over-the-counter H2 blockers on a daily basis to prevent symptoms from occurring.  The patient will try this and if he remains symptomatic, then he will call our office and a prescription for Zantac 150 mg per day will be provided.  Reviewed the potential need for upper endoscopy should his symptoms continue or become more frequent.  He does not want to undergo any type of procedure such as that at this time.,6.
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DESCRIPTION: GI Consultation for Chrohn's disease.

GI Consultation for Chrohn's disease.

The situation involves a consultation for a patient with a complex medical history of Crohn's disease, previous bowel resection, and other symptoms that could potentially lead to severe health complications if not managed properly. The discussion includes medication management, possible procedures, and dietary recommendations, all of which are critical for the patient's health maintenance. However, the current state of the patient is stable and not in immediate life-threatening distress, so it is not at the highest possible stakes. Yet, given the chronic nature and potential complications of Crohn's disease, it is quite significant.


Medical Specialty: Surgery
Sample Name: Phacoemulsification of Cataract

PREOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,PROCEDURE:, Right phacoemulsification of cataract with intraocular lens implantation.,DESCRIPTION OF THE OPERATION:, Under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positioned under the operating microscope. A lid speculum was applied to the right eye, and a stab incision into the anterior chamber was done close to the limbus at about the 1 o'clock position with a Superblade, and Xylocaine 1% preservative free 0.25 mL was injected into the anterior chamber, which was then followed by Healon to deepen the anterior chamber. Using a keratome, another stab incision was done close to the limbus at about the 9 o'clock position and with the Utrata forceps, anterior capsulorrhexis was performed, and the torn anterior capsule was totally removed. Hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with BSS. The tip of the phaco unit was introduced into the anterior chamber, and anterior sculpting of the nucleus was performed until about more than two-thirds of the nucleus was removed. Using the phaco tip and the Drysdale hook, the nucleus was broken up into 4 pieces and then phacoemulsified.,The phaco tip was then exchanged for the aspiration/irrigation tip, and cortical materials were aspirated. Posterior capsule was polished with a curette polisher, and Healon was injected into the capsular bag. Using the Monarch intraocular lens inserter, the posterior chamber intraocular lens model SN60WF power +19.50 was placed into the inserter after applying some Healon, and the tip of the inserter was gently introduced through the cornea tunnel wound, into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument. Intraocular lens was then rotated about half a turn with a collar button hook. Healon was removed with the aspiration/irrigation tip, and balanced salt solution was injected through the side port to deepen the anterior chamber. It was found that there was no leakage of fluid through the cornea tunnel wound. For this reason, no suture was applied. Vigamox, Econopred and Nevanac eye drops were instilled and the eye was covered with a perforated shield. The patient tolerated the procedure well. There were no complications.
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DESCRIPTION: Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye.

surgery, cataract, implantation, intraocular, intraocular lens, lens implantation, phacoemulsification, capsular bag, capsule, intraocular lens implantation, cornea tunnel wound, phacoemulsification of cataract, cornea tunnel, anterior chamber, anesthesia, cornea, lens, chamber,

The procedure described is a phacoemulsification of a cataract, a common surgical procedure performed to restore vision in patients with cataracts. While it is a routine surgery, it involves delicate work on the eye, which has inherent risks such as infection, bleeding, or damage to the eye structures. However, the case presented had no complications and the patient tolerated it well, indicating a successful outcome. Nonetheless, any surgery involving the eye is significant due to the potential impact on vision, hence it is moderately high-stakes. The specific situation described, being complication-free, suggests the stakes for this individual case are slightly lower than the maximum for such procedures.


Medical Specialty: Hematology - Oncology
Sample Name: Iron deficiency anemia

CHIEF COMPLAINT: , Iron deficiency anemia.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 19-year-old woman, who was recently hospitalized with iron deficiency anemia.  She was seen in consultation by Dr. X.  She underwent a bone marrow biopsy on 07/21/10, which showed a normal cellular marrow with trilineage hematopoiesis.  On 07/22/10, her hemoglobin was 6.5 and therefore she was transfused 2 units of packed red blood cells.  Her iron levels were 5 and her percent transferrin was 2.  There was no evidence of hemolysis.  Of note, she had a baby 5 months ago; however she does not describe excessive bleeding at the time of birth.  She currently has an IUD, so she is not menstruating.  She was discharged from the hospital on iron supplements.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.  She specifically denies melena or hematochezia.,CURRENT MEDICATIONS: , Iron supplements and Levaquin.,ALLERGIES: , Penicillin.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:  ,She is status post birth of a baby girl 5 months ago.  She is G1, P1.  She is currently using an IUD for contraception.,SOCIAL HISTORY: , She has no tobacco use.  She has rare alcohol use.  No illicit drug use.,FAMILY HISTORY: , Her maternal grandmother had stomach cancer.  There is no history of hematologic malignancies.,PHYSICAL EXAM:,GEN:
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DESCRIPTION: Iron deficiency anemia.  She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis.

hematology - oncology, trilineage hematopoiesis, cellular marrow, bone marrow biopsy, iron deficiency anemia, bone marrow, anemia, hemoglobin, lymphadenopathy, deficiency, tobacco,

The situation involves a 19-year-old woman with iron deficiency anemia, a relatively common condition that can often be managed with routine medical treatment such as oral iron supplements or, in more severe cases, blood transfusions, which she has already received. Although her hemoglobin was quite low at 6.5, her condition does not involve immediate life-threatening factors since she has received treatment and is being monitored. The absence of more severe or complex symptoms, such as hemolysis or signs of hematologic malignancies, indicates a lower immediate threat level. Overall, this is a manageable condition with ongoing medical oversight, thus not classifying as high-stakes.


Medical Specialty: Neurology
Sample Name: Iliopsoas Hematoma - 1

CC: ,Gait difficulty.,HX: ,This 59 y/o RHF was admitted with complaint of gait difficulty. The evening prior to admission she noted sudden onset of LUE and LLE weakness. She felt she favored her right leg, but did not fall when walking. She denied any associated dysarthria, facial weakness, chest pain, SOB, visual change, HA, nausea or vomiting.,PMH:, tonsillectomy, adenoidectomy, skull fx 1954, HTN, HA.,MEDS: ,none on day of exam.,SHX: ,editorial assistant at newspaper, 40pk-yr Tobacco, no ETOH/Drugs.,FHX: ,noncontributory,ADMIT EXAM: ,P95 R20, T36.6, BP169/104,MS: A&O to person, place and time. Speech fluent and without dysarthria, Naming-comprehension-reading intact. Euthymic with appropriate affect.,CN: Pupils 4/4 decreasing to 2/2 on exposure to light, Fundi flat, VFFTC, EOMI, Face symmetric with intact sensation, Gag-shrug-corneal reflexes intact, Tongue ML with full ROM,Motor: Full strength throughout right side. Mildly decreased left grip and left extensor hallucis longus. Biceps/Triceps/Wrist flexors and extensor were full strength on left. However she demonstrated mild LUE pronator drift and had difficulty standing on her LLE despite full strength on bench testing of the LLE.,Sensory: No deficit to PP/T/Vib/Prop/ LT,Coord: decreased speed and magnitude of FNF, Finger tapping and HKS, on left side only.,Station: mild LUE upward drift.,Gait: tendency to drift toward the left. Difficulty standing on LLE.,Reflexes were symmetric, plantar responses were flexor bilaterally.,Gen exam unremarkable.,COURSE: ,Admit Labs: ESR, PT/PTT, GS, UA, EKG, and HCT were unremarkable. Hgb 13.9, Hct 41%, Plt 280k, WBC 5.5.,The patient was diagnosed with a probable lacunar stroke and entered into the TOAST study (Trial of ORG10172[a low molecular weight heparin] in Acute Stroke Treatment).,Carotid Duplex: 16-49%RICA and 0-15%LICA stenosis with anterograde vertebral artery flow, bilaterally. Transthoracic echocardiogram showed mild mitral regurgitation, mild tricuspid regurgitation and a left to right shunt. There was no evidence of blood clot.,Hospital course: 5 days after admission the patient began to complain of proximal LLE and left flank pain. On exam, she had weakness of the quadriceps and hip flexors of the LLE. Her pain increased with left hip flexion. In addition, she complained of paresthesias about the lateral aspect of the medial anterior left thigh; and upon on sensory testing, she had decreased PP/TEMP sensation in a left femoral nerve distribution. She denied any back/neck pain and the rest of her neurologic exam remained unchanged from admission.,Abdominal CT Scan, 2/4/96, revealed a large left retroperitoneal iliopsoas hematoma.,Hgb 8.9g/dl. She was transfused with 4 units of pRBCs. She underwent surgical decompression and evacuation of the hematoma via a posterior flank approach on 2/6/96. Her postoperative course was uncomplicated. She was discharged home on ASA.,At follow-up, on 2/23/96, she complained of left sided paresthesias (worse in the LLE than in the LUE) and feeling of "swollen left foot." These symptoms had developed approximately 1 month after her stroke. Her foot looked normal and her UE strength was 5/4+ proximally and distally, and LE strength 5/4+ proximally and 5/5- distally. She was ambulatory. There was no evidence of LUE upward drift. A somatosensory evoked potential study revealed an absent N20 and normal P14 potentials. This was suggestive of a lesion involving the right thalamus which might explain her paresthesia/dysesthesia as part of a Dejerine-Roussy syndrome.
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DESCRIPTION: Left Iliopsoas hematoma.  Gait difficulty.

The situation involves a neurological diagnosis and treatment process for a 59-year-old patient who experienced gait difficulty, left-sided weakness, and was found to have a left iliopsoas hematoma. The case also involves the management of a probable lacunar stroke and subsequent neurological assessment and treatment. This situation is high-stakes due to the neurological implications, potential for disability, and the complexities related to diagnosis, treatment of the hematoma, and its aftermath. The high stakes are further compounded by the possible involvement of the right thalamus and Dejerine-Roussy syndrome, which can have lasting impacts on the patient's sensory and motor functions.


Medical Specialty: Surgery
Sample Name: Osteosynthesis

PREOPERATIVE DIAGNOSIS:,  Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,POSTOPERATIVE DIAGNOSIS:,  Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.,PROCEDURES:,1.  Osteosynthesis of acetabular fracture on the left, complex variety.,2.  Total hip replacement.,ANESTHESIA: , General.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , The patient in the left side up lateral position under adequate general endotracheal anesthesia, the patient's left lower extremity and buttock area were prepped with iodine and alcohol in the usual fashion, draped with sterile towels and drapes so as to create a sterile field.  Kocher Langenbeck variety incision was utilized and carried down through the fascia lata with the split fibers of the gluteus maximus in line.  The femoral insertion of gluteus maximus was tenotomized close to its femoral insertion.  The piriformis and obturator internus tendons and adjacent gemelli were tenotomized close to their femoral insertion, tagged, and retractor was placed in the lesser notch as well as a malleable retractor in the greater notch enabling the exposure of the posterior column.  The major transverse fracture was freed of infolded soft tissue, clotted blood, and lavaged copiously with sterile saline solution and then reduced anatomically with the aid of bone hook in the notch and provisionally stabilized utilizing a tenaculum clamp and definitively stabilized utilizing a 7-hole 3.5 mm reconstruction plate with the montage including two interfragmentary screws.  It should be mentioned that prior to reduction and stabilization of the acetabular fracture its femoral head component was removed from the joint enabling direct visualization of the articular surface.  Once a stable fixation of the reduced fracture of the acetabulum was accomplished, it should be mentioned that in the process of doing this, the posterior wall fragment was hinged on its soft tissue attachments and a capsulotomy was made in the capsule in line with the rent at the level of the posterior wall.  Once this was accomplished, the procedure was turned over to Dr. X and his team, who proceeded with placement of cup and femoral components as well and cup was preceded by placement of a trabecular metal tray for the cup with screw fixation of same.  This will be dictated in separate note.  The patient tolerated the procedure well.  The sciatic nerve was well protected and directly visualized to the level of the notch.
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DESCRIPTION: Acetabular fracture on the left posterior column/transverse posterior wall variety with an accompanying displaced fracture of the intertrochanteric variety to the left hip.  Osteosynthesis of acetabular fracture on the left, complex variety and total hip replacement.

surgery, hip replacement, osteosynthesis, intertrochanteric variety, femoral insertion, acetabular fracture, fracture, acetabular, intertrochanteric, femoral

The situation described involves a complex surgical procedure, specifically the osteosynthesis of an acetabular fracture along with a total hip replacement. These types of surgeries are inherently high-stakes because they involve significant risks such as infection, complications during or post-surgery, and potential impacts on the patient's mobility and quality of life. Furthermore, such operations require precise execution and expertise, underscoring the gravity of the situation.


Medical Specialty: Surgery
Sample Name: Hemangioma Debulking & Rhinoplasty

PREOPERATIVE DIAGNOSIS: , Hemangioma, nasal tip.,POSTOPERATIVE DIAGNOSIS:,  Hemangioma, nasal tip.,PROCEDURE PERFORMED:  ,1.  Debulking of hemangioma of the nasal tip through an open rhinoplasty approach.,2.  Rhinoplasty.,ESTIMATED BLOOD LOSS:  ,Minimal.,FINDINGS: , Large hemangioma involving the midline of the columella separated the lower lateral cartilages at a level of the columella and the nasal domes.,CONDITION:  ,Condition of the patient at end of the procedure stable, transferred to recovery room.,INDICATIONS FOR THE PROCEDURE: , The patient is a 2-year-old female with a history of a nasal tip hemangioma.  The hemangioma has involved at her upper tongue.  There has not been any change in the last 6 months.  We have discussed with the parents the situation and decided to proceed with the debulking of the nasal tip hemangioma.  They understand the nature of the incision, the nature of the surgery, and the possibility of future revision surgeries.  They understand the risk of bleeding, infection, dehiscence, scarring, need for future revision surgery, and minor asymmetry.  They wished to proceed with surgery.,Because of the procedure, informed consent is obtained.  The patient is taken to operating room and placed in the supine position.  General anesthetic is administrated to an oroendotracheal tube.  The face is prepped and draped in the usual manner.  The incision is designed to the lower aspect of the hemangioma, which corresponds to the columella and upper lip junction and then the remaining of the incision is designed as an open rhinoplasty with bilateral rim incisions.  The area is infiltrated with lidocaine with epinephrine.  We waited 7 minutes for the hemostatic effect and proceeded with the incision.  The incision was then done with a 15 C blade starting at the columella and then going laterally to the level of the rim and the double hook is placed at the level of the dome and the intracartilage incision is done through the mucosa, then extended laterally and upward to follow the lower lateral cartilage.  This is done in both sides.  Further incision is done.  A small tenotomy scissors is used and with the help of retraction of the lower lateral cartilage, the hemangioma is separated gently from the lower lateral cartilage on both sides and I proceeded to leave that the central part of the incision lifting up the entire columella to the level of the nasal tip.  The hemangioma is removed and is found to be involving the medial aspects of both medial crura.  This gently separated from the medial crura and from the soft tissue care is taken not to remove the entire hemangioma from the skin as the nose not to devascularize the distal columella portion.  Hemostasis is achieved with electrocautery.  Then, we proceed to place some interdomal stitches with the help of a 6-0 clear nylon and intercrural stitches are placed and then an interdomal stitch, a single one was placed.  The skin is redraped and the nose found to have satisfactory shape.  The columellar piece was tailored on the lateral aspect corresponding to rim incisions to match the newly created width of the columella.  Portions of skin and hemangioma are taken laterally on both sides of the columella distally.  The skin was closed with 6-0 mild chromic stitches, including the portion at the level of the columella and rim incisions medially.  The remaining of the internal incisions are closed with 5-0 chromic interrupted stitches.  The nose is irrigated and suctioned.  The patient tolerated the procedure without complications.  I was present and participated in all aspects of the procedure.  Sponge and instrument count were complete at the end of the procedure.
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DESCRIPTION: Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.

surgery, rhinoplasty approach, debulking of hemangioma, nasal domes, lower lateral cartilages, nasal tip, columella, hemangioma, debulking, cartilages, rhinoplasty, nasal,

The case involves a surgical procedure on a 2-year-old patient, which inherently raises the stakes due to the vulnerability and special considerations needed for such young patients. The surgery addresses a hemangioma at the nasal tip, requiring skillful debulking to prevent complications such as bleeding and to achieve an aesthetically satisfactory outcome. While the estimated blood loss is minimal and the patient's condition post-procedure is stable, the surgery necessitates general anesthesia, which is always significant, especially in pediatric cases. Additionally, the risk of future revision surgeries and potential complications like scarring or minor asymmetry contribute to the stakes of the procedure. Consent was informed, indicating a thorough risk discussion, but due to the young age of the patient and the complexity involved in anatomical reconstruction, the stakes remain elevated.


Medical Specialty: Surgery
Sample Name: Pacemaker (Single Chamber)

SINGLE CHAMBER PACEMAKER IMPLANTATION,PREOPERATIVE DIAGNOSIS: , Mobitz type II block with AV dissociation and syncope.,POSTOPERATIVE DIAGNOSIS: , Mobitz type II block, status post single chamber pacemaker implantation, Boston Scientific Altrua 60, serial number 123456.,PROCEDURES:,1.  Left subclavian access under fluoroscopic guidance.,2.  Left subclavian venogram under fluoroscopic evaluation.,3.  Insertion of ventricular lead through left subclavian approach and ventricular lead is Boston Scientific Dextrose model 12345, serial number 123456.,4.  Insertion of single-chamber pacemaker implantation, Altrua, serial number 123456.,5.  Closure of the pocket after formation of pocket for pacemaker.,PROCEDURE IN DETAIL:  ,The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient was brought to the cath lab, draped and prepped in the usual sterile fashion, received 1.5 mg of versed and 25 mg of Benadryl for conscious sedation.,Access to the right subclavian was successful after the second attempt.  The first attempt accessed the left subclavian artery.  The needle was removed and manual compression applied for five minutes followed by re-accessing the subclavian vein successfully.  The J-wire was introduced into the left subclavian vein.,The anterior wall chest was anesthetized with lidocaine 2%, 2-inch incision using a #10 blade was used.,The pocket was formed using blunt dissection as he was using the Bovie cautery for hemostasis.  The patient went asystole during the procedure.  The transcutaneous pacer was used.  The patient was oxygenating well.  The patient had several compression applied by the nurse.  However, her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby.,After that, the J-wire was tunneled into the pocket and then used to put the #7-French sheath into the left subclavian vein.  The lead from the Boston Scientific Dextrose model 12345, serial number 12345 was inserted through the left subclavian to the right atrium; however, it was difficult to really enter the right ventricle; and while the lead was in place, the side port of the sheath was used to inject 15 mL of contrast to assess the subclavian and the right atrium.  The findings were showing different anatomy, may be consistent with persistent left superior vena cava, and the angle to the right ventricle was different.  At that point, the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place.,At that point, the lead was actively fixated.  The stylet was removed.  The R-wave measured at 40 millivolts.  The impedance was 580 and the threshold was 1.3 volt.  The numbers were accepted and because of the patient's fragility and the different anatomy noticed in the right atrium, concern about putting a second lead with re-access of the subclavian was high.  I decided to proceed with a single-chamber pacemaker as a backup system.,After that, the lead sleeve was used to actively fixate the lead in the anterior chest with two Ethibond sutures in the usual fashion.,The lead was attached to the pacemaker in the header.  The pacemaker was single-chamber pacemaker Altura 60, serial number 123456.  After that, the pacemaker was put in the pocket.  Pocket was irrigated with normal saline and was closed into two layers, deep interrupted #3-0 Vicryl and surface as continuous #4-0 Vicryl continuous.,The pacemaker was programmed as VVI 60, and with history is 10 to 50 beats per minute.  The lead position will be evaluated with chest x-ray.,No significant bleeding noticed.,CONCLUSION:  ,Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.  No significant bleed.
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DESCRIPTION: Single chamber pacemaker implantation.  Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.

surgery, mobitz, av dissociation, syncope, mobitz type ii block, boston scientific altrua, subclavian, venogram, ventricular, single chamber pacemaker implantation, single chamber pacemaker, pacemaker implantation, pacemaker, vein, chest, atrium, ventricle, atrial, implantation, chamber,

The situation described involves a surgical procedure to implant a single-chamber pacemaker. This is inherently a high-stakes scenario due to the complexity of the procedure, the risks involved, such as asystole (a potentially life-threatening condition where the heart stops beating) during the surgery, and the overall importance of the procedure in maintaining the patient's heart rhythm. The fact that the procedure was successful and that spontaneous resolution of asystole occurred during the procedure indicate that it was managed well, but the potential risks justify a high-stakes classification.


Medical Specialty: Consult - History and Phy.
Sample Name: Multilobar Pneumonia

REASON FOR CONSULTATION: , Loculated left effusion, multilobar pneumonia.
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DESCRIPTION: Loculated left effusion, multilobar pneumonia.  Patient  had a diagnosis of multilobar pneumonia along with arrhythmia and heart failure as well as renal insufficiency.

consult - history and phy., neck bruits, nasal cannula, rhythm, pneumonia, chest tube, fluid collection, pleural effusion, multilobar pneumonia, pleural, loculations, multilobar,

The patient is experiencing multiple severe health conditions simultaneously, including multilobar pneumonia, cardiac arrhythmia, heart failure, and renal insufficiency. Each condition alone can be life-threatening, and in combination, they significantly increase the patient's risk. Treatment decisions can have a critical impact on the patient's outcomes, indicating a high-stakes situation.