Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Urinary Retention - Followup

HISTORY OF PRESENT ILLNESS: , The patient presents today for followup.  No dysuria, gross hematuria, fever, chills.  She continues to have urinary incontinence, especially while changing from sitting to standing position, as well as urge incontinence.  She is voiding daytime every 1 hour in the morning especially after taking Lasix, which tapers off in the afternoon, nocturia time 0.  No incontinence.  No straining to urinate.  Good stream, emptying well.  No bowel issues, however, she also indicates that while using her vaginal cream, she has difficulty doing this as she feels protrusion in the vagina, and very concerned if she has a prolapse.,IMPRESSION:  ,1.  The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse, especially while using the cream.,2.  Rule out ascites, with no GI issues other than lower extremity edema.,PLAN: , Following a detailed discussion with the patient, she elected to proceed with continued Flomax and will wean off the Urecholine to two times daily.  She will follow up next week, request Dr. X to do a pelvic exam, and in the meantime, she will obtain a CT of the abdomen and pelvis to further evaluate the cause of the abdominal distention.  All questions answered.
---
DESCRIPTION: The patient noted for improving retention of urine, postop vaginal reconstruction, very concerned of possible vaginal prolapse.

soap / chart / progress notes, urinary retention, dysuria, gross hematuria, postop vaginal reconstruction, vaginal reconstruction, vaginal prolapse, urinary, retention, prolapse, vaginal, incontinence,

This situation involves a patient with ongoing urinary incontinence issues and concerns about potential vaginal prolapse. These are important health concerns but not immediately life-threatening. The situation is being managed with a follow-up plan, medication adjustments, and additional diagnostic tests. Thus, while it requires medical follow-up and could significantly impact the patient's quality of life, it does not constitute a high-stakes emergency at this point.


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

Medical Specialty: Radiology
Sample Name: Lumbar Discogram

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

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

The procedure described is a lumbar discogram, which is a diagnostic test performed to identify problems with the intervertebral discs in the spine, often to diagnose sources of back pain. This is a minimally invasive procedure typically done under sedation and involves some risks, such as infection or nerve damage, but it is considered routine in interventional radiology. The stakes are higher than non-invasive assessments due to the involvement of needles in the spine and anesthesia. However, it is not life-threatening and is performed under controlled conditions.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Lipectomy - Breast

PREOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,POSTOPERATIVE DIAGNOSIS,Mammary hypertrophy with breast ptosis.,OPERATION,Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.,ANESTHESIA,General endotracheal anesthesia.,PROCEDURE,The patient was placed in the supine position.  Under effects of general endotracheal anesthesia, markings were made preoperatively for the mastopexy.  An eccentric circle was drawn around the nipple and a wedge drawn from the inferior border of the areola to the inframammary fold.  A stab incision was made bilaterally and tumescent infiltration of anesthesia, lactated ringers with 1 cc of epinephrine to 1000 cc of lactated ringers was infused with a tumescent blunt needle.  200 cc was infiltrated on each side.  This was followed by power-assisted liposuction and manual liposuction with removal of 350 cc of supernatant fat from both sides utilizing a radial tunneling technique with a 4-mm cannula.  This was followed by the epithelialization of skin between the inner circle corresponding to the diameter of the areola 4 cm diameter and the outer eccentric circle with a tangent at the 6 o'clock position.  This would result in an elevation of the nipple-areolar complex with transposition.  The epithelialization of the wedge inferiorly equalized the circumference distance between the inner circle and the outer circle.  Hemostasis was achieved with electrocautery.  After the epithelialization was performed on both sides, nipple-areolar complex was transposed to new nipple position and the wedge was closed with transposition of the nipple-areolar complex beneath the transposed nipple.  Closure was performed with interrupted 3-0 PDS suture on deep subcutaneous tissue and dermal skin closure with running subcuticular 4-0 Monocryl suture.  Dermabond was applied followed by Adaptic and Kerlix in the suturing spaces supportive mildly compressive dressing.  The patient tolerated the procedure well.  The patient was returned to recovery room in satisfactory condition.
---
DESCRIPTION: Suction-assisted lipectomy of the breast with removal of 350 cc of breast tissue from both sides and two mastopexies.

cosmetic / plastic surgery, breast ptosis, dermabond, mammary hypertrophy, monocryl, anesthesia, breast tissue, endotracheal anesthesia, lipectomy, mastopexies, mastopexy, nipple, nipple-areolar complex, suction assisted lipectomy, nipple areolar complex, lactated ringers, nipple areolar, areolar complex, epithelialization, areolar, breast,

The procedure described involves cosmetic surgery, specifically a lipectomy with mastopexy, which, while complex, is generally considered routine in the field of cosmetic breast surgery. The patient was under general anesthesia, and everything went smoothly according to the description provided. The stakes are moderate, considering the potential for complications associated with surgery and anesthesia, but it is not life-threatening unless severe complications arise. Hence, this is not extremely high-stakes compared to emergency or life-saving procedures.


Medical Specialty: Physical Medicine - Rehab
Sample Name: Physical Therapy - Outpatient Rehab

SUMMARY:  ,The patient has attended physical therapy from 11/16/06 to 11/21/06.  The patient has 3 call and cancels and 3 no shows.  The patient has been sick for several weeks due to a cold as well as food poisoning, so has missed many appointments.,SUBJECTIVE:  ,The patient states pain still significant, primarily 1st seen in the morning.  The patient was evaluated 1st thing in the morning and did not take his pain medications, so objective findings may reflect that.  The patient states overall functionally he is improving where he is able to get out in the house and visit and do activities outside the house more.  The patient does feel like he is putting on more muscle girth as well.  The patient states he is doing well with his current home exercise program and feels like pool therapy is also helping as well.,OBJECTIVE: , Physical therapy has consisted of:,1.  Pool therapy incorporating endurance and general lower and upper extremity strengthening.,2.  Clinical setting incorporating core stabilization and general total body strengthening and muscle wasting.,3.  The patient has just begun this, so it is on a very beginners level at this time.,ASSESSMENT, DONE ON 12/21/06,STRENGTH,Activities
---
DESCRIPTION: Outpatient rehabilitation physical therapy progress note.  A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.

The situation described involves a physical therapy patient who is showing signs of improvement but has missed several appointments due to illness. The stakes in this context relate to the patient's recovery and overall health improvement. While it is important for the patient to attend therapy sessions to maximize recovery, the situation does not involve immediate life-threatening risks or critical decisions that could severely impact the patient's long-term health. The presence of chronic pain and muscle debilitation indicates a need for ongoing treatment, but the report suggests the patient is improving functionally and benefiting from the therapy they are receiving.


Medical Specialty: Surgery
Sample Name: Tesio Hemodialysis Catheter Insertion

OPERATION,1.  Insertion of a left subclavian Tesio hemodialysis catheter.,2.  Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and MAC anesthesia was administered.  Next, the patient's chest and neck were prepped and draped in the standard surgical fashion.  Lidocaine 1% was used to infiltrate the skin in the region of the procedure.  Next a #18-gauge finder needle was used to locate the left subclavian vein.  After aspiration of venous blood, Seldinger technique was used to thread a J wire through the needle.  This process was repeated.  The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next, the subcutaneous tunnel was created.  The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff.  A dilator and sheath were passed over the individual J wires.  The dilator and wire were removed, and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn.  The process was repeated.  Both distal tips were noted to be in good position.  The Tesio hemodialysis catheters were flushed and aspirated without difficulty.  The catheters were secured at the cuff level with a 2-0 nylon.  The skin was closed with 4-0 Monocryl.  Sterile dressing was applied.  The patient tolerated the procedure well and was transferred to the PACU in good condition.
---
DESCRIPTION: Insertion of a left subclavian Tesio hemodialysis catheter and surgeon-interpreted fluoroscopy.

surgery, needle, tesio hemodialysis catheter, hemodialysis catheter, fluoroscopy, catheters, catheter, tesio, hemodialysisNOTE,: 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 procedure described, insertion of a Tesio hemodialysis catheter, is significant due to its role in patients requiring dialysis, which is a critical treatment for those with kidney failure. The operation involves invasive steps such as using guidewires, catheters, and involves the risk of complications like bleeding, infection, or improper placement, though these are managed by experienced surgical teams. While the stakes are high due to the potential for serious complications and the importance of correctly performing the procedure for the patient's health, it is a routine procedure in surgical settings with a standardized process to minimize risks.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: ER Report - Chest Pain

CHIEF COMPLAINT:, The patient complains of chest pain. ,HISTORY OF PRESENT ILLNESS: ,The patient is a 20-year-old male who states that he has had two previous myocardial infarctions related to his use of amphetamines. The patient has not used amphetamines for at least four to five months, according to the patient; however, he had onset of chest pain this evening. ,The patient describes the pain as midsternal pain, a burning type sensation that lasted several seconds. The patient took one of his own nitroglycerin tablets without any relief. The patient became concerned and came into the emergency department. ,Here in the emergency department, the patient states that his pain is a 1 on a scale of 1 to 10. He feels much more comfortable. He denies any shortness of breath or dizziness, and states that the pain feels unlike the pain of his myocardial infarction. The patient has no other complaints at this time. ,PAST MEDICAL HISTORY:, The patient's past medical history is significant for status post myocardial infarction in February of 1995 and again in late February of 1995. Both were related to illegal use of amphetamines. ,ALLERGIES:, None. ,CURRENT MEDICATIONS:, Include nitroglycerin p.r.n. ,PHYSICAL EXAMINATION: ,VITAL SIGNS: Blood pressure 131/76, pulse 50, respirations 18, temperature 96.5. ,GENERAL: The patient is a well-developed, well-nourished white male in no acute distress. The patient is alert and oriented x 3 and lying comfortably on the bed. ,HEENT: Atraumatic, normocephalic. The pupils are equal, round, and reactive. Extraocular movements are intact. ,NECK: Supple with full range of motion. No rigidity or meningismus. ,CHEST: Nontender. ,LUNGS: Clear to auscultation. ,HEART: Regular rate and rhythm. No murmur, S3, or S4. ,ABDOMEN: Soft, nondistended, nontender with active bowel sounds. No masses or organomegaly. No costovertebral angle tenderness. ,EXTREMITIES: Unremarkable. ,NEUROLOGIC: Unremarkable. ,EMERGENCY DEPARTMENT LABS:, The patient had a CBC, minor chemistry, and cardiac enzymes, all within normal limits. Chest x-ray, as read by me, was normal. Electrocardiogram, as read by me, showed normal sinus rhythm with no acute ST or T-wave segment changes. There were no acute changes seen on the electrocardiogram. O2 saturation, as interpreted by me, is 99%. ,EMERGENCY DEPARTMENT COURSE: ,The patient had a stable, uncomplicated emergency department course. The patient received 45 cc of Mylanta and 10 cc of viscous lidocaine with complete relief of his chest pain. The patient had no further complaints and stated that he felt much better shortly thereafter. ,AFTERCARE AND DISPOSITION: ,The patient was discharged from the emergency department in stable, ambulatory, good condition with instructions to use Mylanta for his abdominal pain and to follow up with his regular doctor in the next one to two days. Otherwise, return to the emergency department as needed for any problem. The patient was given a copy of his labs and his electrocardiogram. The patient was advised to decrease his level of activity until then. The patient left with final diagnosis of: ,FINAL DIAGNOSIS: ,1. Evaluation of chest pain. ,2. Possible esophageal reflux.
---
DESCRIPTION: Patient complains of chest pain - possible esophageal reflux

The situation involves a young male with a history of serious cardiovascular events (myocardial infarctions) linked to previous amphetamine use, presenting with chest pain. While initial assessments in the emergency department show no immediate danger (normal labs, ECG, and successful pain relief with Mylanta), any presentation of chest pain where there's a history of heart attacks is concerning. The stakes are moderate-high because there's a potential for life-threatening events given his history, even if the immediate episode seems non-critical. Additionally, unresolved or misdiagnosed esophageal issues could lead to further complications. The patient is advised to follow up with his regular doctor, which suggests an ongoing need for evaluation and monitoring.


Medical Specialty: Surgery
Sample Name: Nasal Septoplasty & Tonsillectomy

PREOPERATIVE DIAGNOSES,1.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2.  Tonsillitis with hypertrophy.,3.  Edema to the uvula and soft palate.,POSTOPERATIVE DIAGNOSES,1.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2.  Tonsillitis with hypertrophy.,3.  Edema to the uvula and soft palate.,OPERATION PERFORMED,1.  Nasal septoplasty.,2.  Bilateral submucous resection of the inferior turbinates.,3.  Tonsillectomy and resection of soft palate.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Chris is a very nice 38-year-old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction.  He also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis.  He also has developed tremendous edema to his posterior palate and uvula, which is causing choking.  Correction of these mechanical abnormalities is indicated.,DESCRIPTION OF OPERATION:  ,The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1% lidocaine with 1:100,000 epinephrine using approximately 10 mL.  Afrin-soaked pledgets were placed in the nasal cavity bilaterally.  The face was prepped with pHisoHex and draped in a sterile fashion.  A hemitransfixion incision was performed on the left with a #15 blade and submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator.  Anterior to the septal deflection, the septal cartilage was incised and an opposite-sided submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator.  The deviated portion of the nasal septal cartilage and bone was removed with a Takahashi forceps, and a large inferior septal spur was removed with a V-chisel.  Once the septum was reduced in the midline, the hemitransfixion incision was closed with a 4-0 Vicryl in an interrupted fashion.  The right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree Storz endoscope.  Hemostasis was acquired by using suction electrocautery.  The turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked Doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3-0 nylon suture.  The table was then turned.  A shoulder roll placed under the shoulders and the face was draped in a clean fashion.  A McIvor mouth gag was applied.  The tongue was retracted and the McIvor was gently suspended from the Mayo stand.  The left tonsil was grasped with a curved Allis forceps, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole to inferior pole using a Bovie electrocautery in its entirety in a subcapsular fashion.  The right tonsil was grasped in a similar fashion, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole to inferior pole using Bovie electrocautery in its entirety in a subcapsular fashion.  The inferior, middle, and superior pole vessels were further cauterized with suction electrocautery.  The extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3-0 Vicryl in a figure-of-eight interrupted fashion.  Copious saline irrigation of the oral cavity was then performed.  There was no further identifiable bleeding at the termination of the procedure.  The estimated blood loss was less than 10 mL.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.
---
DESCRIPTION: Nasal septoplasty, bilateral submucous resection of the inferior turbinates, and tonsillectomy and resection of soft palate.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.  Tonsillitis with hypertrophy.  Edema to the uvula and soft palate.

surgery, nasal septal deviation, turbinate hypertrophy, nasal septoplasty, submucous resection, resection of soft palate, tonsillectomy, bilateral inferior turbinate, bovie electrocautery, nasal septal, inferior turbinates, turbinates, nasal, tonsillitis, electrocautery, hypertrophy,

The situation describes a medical operation involving nasal septoplasty, bilateral submucous resection of the inferior turbinates, and tonsillectomy with resection of the soft palate. These are invasive surgical procedures performed under general anesthesia, intended to correct structural issues that cause symptoms like nasal obstruction, tonsillitis, and choking. The stakes are moderate to high due to the invasive nature of the surgery, the use of general anesthesia, and the potential for complications, despite none occurring in this case. However, it's not life-threatening surgery per se, but the need for careful management of the patient's airway and potential complications arise from the surgery, which elevates the stakes.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Cheek-Neck Facelift

PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis.  Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:,  Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825).  Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-old female who has progressive aging changes of the face and neck.  The patient demonstrates the deformities described above and has requested surgical correction.  The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient.  The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table.  An intravenous line was started and anesthesia was maintained throughout the case.  The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line.  A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline.  In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift.  The incision was marked in the submental crease for the submental lipectomy and liposuction.  The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine.  This provided local anesthesia and vasoconstriction.  The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery.  A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible.  4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly.  The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels.  Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area.  A similar procedure was performed with the 4 mm cannula cleaning the area.  Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle.  A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion.  5-0 plain catgut was used for closure in a running interlocking fashion.  The wound was cleaned at the end, dried, and Mastisol applied.  Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal.  A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region.  A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin.  The incision was made in the temporal area beveling parallel with the hair follicles.  (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid.  The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim.  At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible.  This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl.  Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS.  The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region.  When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected.  At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM.  The SMAS flap was then advanced posteriorly and superiorly.  The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum.  The excess SMAS was trimmed and excised from the portion anterior to the auricle.  The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained.  The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture.  The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period.  Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area.  The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion.  5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing.  The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut.  The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation.  Any small amount of fluid was expressed post-auricularly.  A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure.  A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas.  This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion.  The entire dressing complex was secured with a pre-formed elastic stretch wrap device.  All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well.  The patient left the operating room in satisfactory condition.  A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition.
---
DESCRIPTION: Temporal cheek-neck facelift  and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides.

cosmetic / plastic surgery, neck skin ptosis, lipotosis, rhytides, facelift, submental suction assisted lipectomy, pre and post auricular, cheek neck facelift, auricular region, neck facelift, cheek neck, post auricular, auricular, incision, postoperative, cheek, submental, dissection, neck,

This situation involves a cosmetic/plastic surgery procedure, specifically a cheek-neck facelift with submental lipectomy. While cosmetic surgeries are elective and often not medically necessary, they involve significant risks associated with any surgical procedure, including anesthesia, infection, bleeding, and adverse reactions. The success of this surgery depends on the execution of complex procedures and a patient's recovery can be critical for desired outcomes. Despite being elective, such operations can have considerable psychological and physical consequences for the patient. Nevertheless, since this is not an emergency or life-threatening situation, it is not classified as extremely high-stakes like life-saving surgeries might be.


Medical Specialty: Discharge Summary
Sample Name: Psychiatric Discharge Summary

DISCHARGE DISPOSITION:,  The patient was discharged by court as a voluntary drop by prosecution.  This was AMA against hospital advice.,DISCHARGE DIAGNOSES:,AXIS I:  Schizoaffective disorder, bipolar type.,AXIS II:  Deferred.,AXIS III:  Hepatitis C.,AXIS IV:  Severe.,AXIS V:  19.,CONDITION OF PATIENT ON DISCHARGE: , The patient remained disorganized.  The patient was suffering from prolactinemia secondary to medications.,DISCHARGE FOLLOWUP:  ,To be arranged per the patient as the patient was discharged by court.,DISCHARGE MEDICATIONS: , A 2-week supply of the following was phoned into the patient's pharmacy:  Seroquel 25 mg p.o. nightly.  Zyprexa 5 mg p.o. b.i.d.,MENTAL STATUS AT THE TIME OF DISCHARGE:,  Attitude was cooperative.  Appearance showed fair hygiene and grooming.  Psychomotor behavior showed restlessness.  No EPS or TD was noted.  Affect was restricted.  Mood remained anxious and speech was pressured.  Thoughts remained tangential, and the patient endorsed paranoid delusions.  The patient denied auditory hallucinations.  The patient denied suicidal or homicidal ideation, was oriented to person and place.  Overall, insight into her illness remained impaired.,HISTORY AND HOSPITAL COURSE: , The patient is a 22-year-old female with a history of bipolar affective disorder, was initially admitted for evaluation of increasing mood lability, disorganization, and inappropriate behaviors.  The patient reportedly was asking her father to have sex with her and tried to pull down her mother's pants.  The patient took her clothing off, was noted to be very disorganized sexually, and religiously preoccupied, and endorsed auditory hallucinations of voices telling her to calm herself and others.  The patient has a history of depression versus bipolar disorder, last hospitalized in Pierce County in 2008, but without recent treatment.  The patient on admission interview was noted to be labile and disorganized.  The patient was initiated on Risperdal M-Tab 2 mg p.o. b.i.d. for psychosis and mood lability, and also medically evaluated by Rebecca Richardson, MD.  The patient remained labile and suspicious during her hospital stay.  The patient continued to be sexually preoccupied and had poor insight into her need for treatment.  The patient denied further auditory hallucinations.  The patient was treated with Seroquel for persistent mood lability and psychosis.  The patient was noted to develop prolactinemia with Risperdal and this was changed to Zyprexa prior to discharge.  The patient remained disorganized, but was given a voluntary drop by prosecution against medical advice when she went to court on 01/11/2010.  The patient was discharged to return home to her parents and was referred to Community Mental Health Agencies.  The patient was thus discharged in symptomatic condition.
---
DESCRIPTION: The patient was discharged by court as a voluntary drop by prosecution.

discharge summary, schizoaffective disorder, bipolar type, mood lability, disorganization, bipolar affective disorder, voluntary drop, auditory hallucinations, psychiatric, axis,

The discharge summary indicates a potentially high-stakes situation due to several reasons. The patient was discharged against medical advice, which inherently carries risk as they are leaving without stabilizing their condition adequately according to the healthcare providers. The patient is suffering from schizoaffective disorder with psychotic symptoms, and their insight into their illness is impaired. Given the patient's history and current mental health condition, there is a risk for deterioration without proper follow-up and treatment, which could result in harm to herself or others. The legal aspect of a court-mandated discharge increases the stakes, as it implies the involvement of judicial systems in the patient's healthcare decisions. These factors together contribute to considering this as a fairly high-stakes situation.


Medical Specialty: Surgery
Sample Name: Pulmonary Atresia

HISTORY: , The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.  He also has VACTERL association with hydrocephalus.  As an infant, he underwent placement of a right modified central shunt.  On 05/26/1999, he underwent placement of a bidirectional Glenn shunt, pulmonary artery angioplasty, takedown of the central shunt, PDA ligation, and placement of a 4 mm left-sided central shunt.  On 08/01/2006, he underwent cardiac catheterization and coil embolization of the central shunt.  A repeat catheterization on 09/25/2001 demonstrated elevated Glenn pressures and significant collateral vessels for which he underwent embolization.  He then underwent repeat catheterization on 11/20/2003 and further embolization of residual collateral vessels.  Blood pressures were found to be 13 mmHg with the pulmonary vascular resistance of 2.6-3.1 Wood units.  On 03/22/2004, he returned to the operating room and underwent successful 20 mm extracardiac Fontan with placement of an 8-mm fenestration and main pulmonary artery ligation.  A repeat catheterization on 09/07/2006, demonstrated mildly elevated Fontan pressures in the context of a widely patent Fontan fenestration and intolerance of Fontan fenestration occlusion.  The patient then followed conservatively since that time.  The patient is undergoing a repeat evaluation to assess his candidacy for a Fontan fenestration occlusion, as well as consideration for a tricuspid valvuloplasty in attempt to relieve right ventricular hypertension and associated membranous ventricular aneurysm protruding into the left ventricular outflow tract.,PROCEDURE:,  After sedation and local Xylocaine anesthesia, the patient was placed under general endotracheal anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 7-French sheath, a 6-French wedge catheter was inserted in the right femoral vein and advanced from the inferior vena cava along the Fontan conduit into the main left pulmonary artery, as well as the superior vena cava.  This catheter was then exchanged for a 5-French VS catheter of a distal wire.  Apposition of the right pulmonary artery over, which the wedge catheter was advanced.  The wedge catheter could then be easily advanced across the Fontan fenestration into the right atrium and guidewire manipulation allowed access across the atrial septal defect to the pulmonary veins, left atrium, and left ventricle.,Using a 5-French sheath, a 5-French pigtail catheter was inserted into the right femoral artery and advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  Attempt was then made to cross the tricuspid valve from the right atrium and guidewire persisted to prolapse through the membranous ventricular septum into the left ventricle.  The catheter distal wire position was finally achieved across what appeared to be the posterior aspect of the tricuspid valve, both angiographically as well as equal guidance.  Left ventricular pressure was found to be suprasystemic.  A balloon valvoplasty was performed using a Ranger 4 x 2 cm balloon catheter with no waste at minimal inflation pressure.  Echocardiogram, which showed no significant change in the appearance of a tricuspid valve and persistence of aneurysmal membranous ventricular septum.  Further angioplasty was then performed first utilizing a 6 mm cutting balloon directed through 7-French flexor sheath positioned within the right atrium.  There was a disappearance of a mild waist prior to spontaneous tear of the balloon.  The balloon catheter was then removed in its entirety.,Echocardiogram again demonstrated no change in the appearance of the tricuspid valve.  A final angioplasty was performed utilizing a 80 mm cutting balloon with the disappearance of a distinctive waste.  Echocardiogram; however, demonstrated no change and intact appearing tricuspid valve and no decompression of the right ventricle.  Further attempts to cross tricuspid valve were thus abandoned.  Attention was then directed to a Fontan fenestration.  A balloon occlusion then demonstrated minimal increase in Fontan pressures from 12 mmHg to 15 mmHg.  With less than 10% fall in calculated cardiac index.  The angiogram in the inferior vena cava demonstrated a large fenestration measuring 6.6 mm in diameter with a length of 8 mm.  A 7-French flexor sheath was again advanced cross the fenestration.  A 10-mm Amplatzer muscular ventricular septal defect occluder was loaded on delivery catheter and advanced through the sheath where the distal disk was allowed to be figured in the right atrium.  Entire system was then brought into the fenestration and withdrawal of the sheath allowed reconfiguration of the proximal disk.  Once the stable device configuration was confirmed, device was released from the delivery catheter.  Hemodynamic assessment and the angiograms were then repeated.,Flows were calculated by the Fick technique using an assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Angiograms with injection in the right coronary artery, left coronary artery, superior vena cava, inferior vena cava, and right ventricle.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was low due to systemic arterial desaturation.  There was modest increased saturation of the branch pulmonary arteries due to the presumed aortopulmonary collateral flow.  The right pulmonary veins were fully saturated.  Left pulmonary veins were not entered.  There was a fall in saturation within the left ventricle and descending aorta due to a right to left shunt across the Fontan fenestration.  Mean Fontan pressures were 12 mmHg with a 1 mmHg fall in mean pressure into the distal left pulmonary artery.  Right and left pulmonary capillary wedge pressures were similar to left atrial phasic pressure with an A-wave similar to the normal left ventricular end-diastolic pressure of 11 mmHg.  Left ventricular systolic pressure was normal with at most 5 mmHg systolic gradient pressure pull-back to the ascending aorta.  Phasic ascending and descending aortic pressures were similar and normal.  The calculated systemic flow was normal.  Pulmonary flow was reduced to the QT-QS ratio of 0.7621.  Pulmonary vascular resistance was normal at 1 Wood units.,Angiogram with injection in the right coronary artery demonstrated diminutive coronary with an extensive sinusoidal communication to the rudimentary right ventricle.  The left coronary angiogram showed a left dominant system with a brisk flow to the left anterior descending and left circumflex coronary arteries.  There was communication to the right-sided coronary sinusoidal communication to the rudimentary right ventricle.  Angiogram with injection in the superior vena cava showed patent right bidirectional Glenn shunt with mild narrowing of the proximal right pulmonary artery, as well as the central pulmonary artery, diameter of which was augmented by the Glenn anastomosis and the Fontan anastomosis.  There was symmetric contrast flow to both pulmonary arteries.  A large degree of contrast flowed retrograde into the Fontan and shunting into the right atrium across the fenestration.  There is competitive flow to the upper lobes presumably due to aortopulmonary collateral flow.  The branch pulmonaries appeared mildly hypoplastic.  Levo phase contrast returned into the heart, appeared unobstructed demonstrating good left ventricular contractility.  Angiogram with injection in the Fontan showed a widely patent anastomosis with the inferior vena cava.  Majority of the contrast flowing across the fenestration into the right atrium with a positive flow to the branch pulmonary arteries.,Following the device occlusion of Fontan fenestration, the Fontan and mean pressure increased to 15 mmHg with a 3 mmHg, a mean gradient in the distal left pulmonary artery and no gradient into the right pulmonary artery.  There was an increase in the systemic arterial pressures.  Mixed venous saturation increased from the resting state as with increase in systemic arterial saturation to 95%.  The calculated systemic flow increased slightly from the resting state and pulmonary flow was similar with a QT-QS ratio of 0.921.  Angiogram with injection in the inferior vena cava showed a stable device configuration with a good disk apposition to the anterior surface of the Fontan with no protrusion into the Fontan and no residual shunt and no obstruction to a Fontan flow.  An ascending aortogram that showed a left aortic arch with trace aortic insufficiency and multiple small residual aortopulmonary collateral vessels arising from the intercostal arteries.  A small degree of contrast returned to the heart.,INITIAL DIAGNOSES:  ,1.  Pulmonary atresia.,2.  VACTERL association.,3.  Persistent sinusoidal right ventricle to the coronary communications.,4.  Hydrocephalus.,PRIOR SURGERIES AND INTERVENTIONS:  ,1.  Systemic to pulmonary shunts.,2.  Right bidirectional Glenn shunt.,3.  Revision of the central shunt.,4.  Ligation and division of patent ductus arteriosus.,5.  Occlusion of venovenous and arterial aortopulmonary collateral vessels.,6.  Extracardiac Fontan with the fenestration.,CURRENT DIAGNOSES:  ,1.  Favorable Fontan hemodynamics.,2.  Hypertensive right ventricle.,3.  Aneurysm membranous ventricular septum with mild left ventricle outflow tract obstruction.,4.  Patent Fontan fenestration.,CURRENT INTERVENTION:  ,1.  Balloon dilation tricuspid valve attempted and failed.,2.  Occlusion of a Fontan fenestration.,MANAGEMENT:  ,He will be discussed at Combined Cardiology/Cardiothoracic Surgery case conference.  A careful monitoring of ventricle outflow tract will be instituted with consideration for a surgical repair.  Further cardiologic care will be directed by Dr. X.
---
DESCRIPTION: The patient is a 9-year-old born with pulmonary atresia, intact ventricular septum with coronary sinusoids.

The situation involves a 9-year-old patient with a complex congenital heart defect, specifically pulmonary atresia and associated complications. The history includes multiple significant surgeries and interventions such as the Fontan procedure and catheterizations. The current evaluation is to assess potential further interventions like Fontan fenestration occlusion and tricuspid valvuloplasty. Decisions regarding these procedures are critical and can significantly impact the patient's long-term health and outcomes. Additionally, detailed monitoring and a case conference indicate the high level of complexity and risk involved. The consequences of surgical decisions in such cases are life-altering, potentially affecting survival and quality of life.


Medical Specialty: Surgery
Sample Name: Arthroscopic Debridement - Shoulder

PREOPERATIVE DIAGNOSIS: , Recurrent anterior dislocating left shoulder.,POSTOPERATIVE DIAGNOSIS:,  Recurrent anterior dislocating left shoulder.,PROCEDURE PERFORMED:,  Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.,PROCEDURE:  ,The patient was taken to OR #2, administered general anesthetic after ineffective interscalene block had been administered in the preop area.  The patient was positioned in the modified beachchair position utilizing the Mayfield headrest.  The left shoulder was propped posteriorly with a rolled towel.  His head was secured to the Mayfield headrest.  The left shoulder and upper extremity were then prepped and draped in the usual manner.  A posterior lateral port was made for _____ the arthroscopic cannula.  The scope was introduced into the glenohumeral joint.  There was noted to be a complete tear of the anterior glenoid labrum off from superiorly at about 11:30 extending down inferiorly to about 6 o'clock.  The labrum was adherent to the underlying capsule.  The margin of the glenoid was frayed in this area.  The biceps tendon was noted to be intact.  The articular surface of the glenoid was fairly well preserved.  The articular surface on the humeral head was intact; however, there was a large Hill-Sachs lesion on the posterolateral aspect of the humeral head.  The rotator cuff was visualized and noted to be intact.  The axillary pouch was visualized and it was free of injury.  There were some cartilaginous fragments within the axillary pouch.  Attention was first directed after making an anterior portal to fixation of the anterior glenoid labrum.  Utilizing the Chirotech system through the anterior cannula, the labrum was secured with the pin and drill component and was then tacked back to the superior glenoid rim at about the 11 o'clock position.  A second tack was then placed at about the 8 o'clock position.  The labrum was then probed and was noted to be stable.  With some general ranging of the shoulder, the tissue was pulled out from the tacks.  An attempt was made at placement of two other tacks; however, the tissue was not of good quality to be held in position.  Therefore, all tacks were either buried down to a flat surface or were removed from the anterior glenoid area.  At this point, it was deemed that an open Bankart arthroplasty was necessary.  The arthroscopic instruments were removed.  An anterior incision was made extending from just lateral of the coracoid down toward the axillary fold.  The skin incision was taken down through the skin.  Subcutaneous tissues were then separated with the coag Bovie to provide hemostasis.  The deltopectoral fascia was identified.  It was split at the deltopectoral interval and the deltoid was reflected laterally.  The subdeltoid bursa was then removed with rongeurs.  The conjoint tendon was identified.  The deltoid and conjoint tendons were then retracted with a self-retaining retractor.  The subscapularis tendon was identified.  It was separated about a centimeter from its insertion, leaving the tissue to do sew later.  The subscapularis was reflected off superiorly and inferiorly and the muscle retracted medially.  This allowed for visualization of the capsule.  The capsule was split near the humeral head insertion leaving a tag for repair.  It was then split longitudinally towards the glenoid at approximately 9 o'clock position.  This provided visualization of the glenohumeral joint.  The friable labral and capsular tissue was identified.  The glenoid neck was already prepared for suturing, therefore, three Mitek suture anchors were then positioned to place at approximately 7 o'clock, 9 o'clock, and 10 o'clock.  The sutures were passed through the labral capsular tissue and tied securely.  At this point, the anterior glenoid rim had been recreated.  The joint was then copiously irrigated with gentamicin solution and suctioned dry.  The capsule was then repaired with interrupted #1 Vicryl suture and repaired back to its insertion site with #1 Vicryl suture.  This later was then copiously irrigated with gentamicin solution and suctioned dry.  Subscapularis was reapproximated on to the lesser tuberosity of the humerus utilizing interrupted #1 Vicryl suture.  This later was then copiously irrigated as well and suctioned dry.  The deltoid fascia was approximated with running #2-0 Vicryl suture.  Subcutaneous tissues were approximated with interrupted #2-0 Vicryl and the skin was approximated with a running #4-0 subcuticular Vicryl followed by placement of Steri-Strips.  0.25% Marcaine was placed in the subcutaneous area for postoperative analgesia.  The patient was then placed in a shoulder immobilizer after a bulky dressing had been applied.  The patient was then transferred to the recovery room in apparent satisfactory condition.
---
DESCRIPTION: Recurrent anterior dislocating left shoulder.  Arthroscopic debridement of the left shoulder with attempted arthroscopic Bankart repair followed by open Bankart arthroplasty of the left shoulder.

surgery, dislocating, bankart, arthroplasty, bankart repair, arthroscopic debridement, anterior, arthroscopic, debridement, deltoid, glenoid, humeral, interrupted, shoulder, subscapularis

The situation involves a surgical procedure on a patient's shoulder, specifically addressing a recurrent dislocation issue through both arthroscopic and open surgical methods. Surgical procedures inherently involve significant risk due to potential complications such as infection, damage to surrounding tissues, or adverse reactions to anesthesia. Additionally, this particular surgery transitioned from an attempted arthroscopic repair to an open Bankart arthroplasty, indicating complexity and potential challenges in the procedure. Therefore, while the procedure is not uncommon and is generally well-managed, the stakes are high due to the nature of surgery and the need for precise technique to ensure patient recovery and shoulder stability.


Medical Specialty: Surgery
Sample Name: Exploratory Laparotomy - 2

PREOPERATIVE DIAGNOSES,1.  Pelvic mass.,2.  Suspected right ovarian cyst.,POSTOPERATIVE DIAGNOSES,1.  Pelvic mass.,2.  Suspected right ovarian cyst.,PROCEDURES,1.  Exploratory laparotomy.,2.  Extensive lysis of adhesions.,3.  Right salpingo-oophorectomy.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , 200 mL,SPECIMENS:  ,Right tube and ovary.,COMPLICATIONS: , None.,FINDINGS: , Extensive adhesive disease with the omentum and bowel walling of the entire pelvis, which required more than 45 minutes of operating time in order to establish visualization and to clear the bowel and other important structures from the ovarian cyst, tube, and ovary in order to remove them.  The large and small bowels were completely enveloping a large right ovarian cystic mass.  Normal anatomy was difficult to see due to adhesions.  Cyst was ruptured incidentally intraoperatively with approximately 150 mL to 200 mL of turbid fluid.  Cyst wall, tube, and ovary were stripped away from the bowel.  Posterior peritoneum was also removed in order to completely remove the cyst wall ovary and tube.  There was excellent postoperative hemostasis.,PROCEDURE:  ,The patient was taken to the operating room, where general anesthesia was achieved without difficulty.  She was then placed in a dorsal supine position and prepped and draped in the usual sterile fashion.  A vertical midline incision was made from the umbilicus and extended to the symphysis pubis along the line of the patient's prior incision.  Incision was carried down carefully until the peritoneal cavity was reached.  Care was taken upon entry of the peritoneum to avoid injury of underlying structures.  At this point, the extensive adhesive disease was noted, again requiring greater than 45 minutes of dissection in order to visualize the intended anatomy for surgery.  The omentum was carefully stripped away from the patient's right side developing a window.  This was extended down along the inferior portion of the incision removing the omentum from its adhesions to the anterior peritoneum and what appears to be the vesicouterine peritoneum.  A large mass of bowel was noted to be adherent to itself causing a quite tortuous course.  Adhesiolysis was performed in order to free up the bowel in order to pack it out of the pelvis.  Excellent hemostasis was noted.  The bowel was then packed over of the pelvis allowing visualization of a matted mass of large and small bowel surrounding a large ovarian cyst.  Careful adhesive lysis and dissection enabled the colon to be separated from the posterior wall of the cyst.  Small bowel and portion of the colon were adherent anteriorly on the cyst and during the dissection of these to remove them from their attachment, the cyst was ruptured.  Large amount of turbid fluid was noted and was evacuated.  The cyst wall was then carefully placed under tension and stripped away from the patient's small and large bowel.  Once the bowel was freed, the remnants of round ligament was identified, elevated, and the peritoneum was incised opening the retroperitoneal space.,The retroperitoneal space was opened following the line of the ovarian vessels, which were identified and elevated and a window made inferior to the ovarian vessels, but superior to the course of the ureter.  This pedicle was doubly clamped, transected, and tied with a free tie of #2-0 Vicryl.  A suture ligature of #0 Vicryl was used to obtain hemostasis.  Excellent hemostasis was noted at this pedicle.  The posterior peritoneum and portion of the remaining broad ligament were carefully dissected and shelled out to remove the tube and ovary, which was still densely adherent to the peritoneum.  Care was taken at the side of the remnant of the uterine vessels.  However, a laceration of the uterine vessels did occur, which was clamped with a right-angle clamp, and carefully sutured ligated with excellent hemostasis noted.  Remainder of the specimen was then shelled out including portions of the posterior and sidewall peritoneum and removed.,The opposite tube and ovary were identified, were also matted behind a large amount of large bowel and completely enveloped and wrapped in the fallopian tube.  Minimal dissection was performed in order to ascertain and ensure that the ovary appeared completely normal.  It was then left in situ.  Hemostasis was achieved in the pelvis with the use of electrocautery.  The abdomen and pelvis were copiously irrigated with warm saline solution.  The peritoneal edges were inspected and found to have good hemostasis after the side of the uterine artery pedicle, and the ovarian vessel pedicle.  The areas of the bowel had previously been dissected and due to adhesive disease, it was carefully inspected and excellent hemostasis was noted.,All instruments and packs removed from the patient's abdomen.  The abdomen was closed with a running mattress closure of #0 PDS, beginning at the superior aspect of the incision, and extending inferiorly.  Excellent closure of the incision was noted.  The subcutaneous tissues were then copiously irrigated.  Hemostasis was achieved with the use of cautery.  Subcutaneous tissues were reapproximated to close the edge space with a several interrupted sutures of #0 plain gut suture.  The skin was closed with staples.,Incision was sterilely clean and dressed.  The patient was awakened from general anesthesia and taken to the recovery room in stable condition.  All counts were noted correct times three.
---
DESCRIPTION: Exploratory laparotomy.  Extensive lysis of adhesions.  Right salpingo-oophorectomy.   Pelvic mass, suspected right ovarian cyst.

surgery, pelvic mass, ovarian cyst, exploratory laparotomy, lysis of adhesions, salpingo-oophorectomy, cyst, bowel, adhesions, uterine, abdomen, pelvis, ovary, peritoneum, ovarian, hemostasis,

The procedure described is an exploratory laparotomy with a right salpingo-oophorectomy due to a pelvic mass and adhesions, which are quite serious medical conditions. The operation involved general anesthesia and delicate surgical procedures, including dissection of adhesions and removal of the ovarian cyst, tube, and ovary. Additionally, the surgery had to handle complications like a ruptured cyst and laceration of uterine vessels, both of which require careful management to prevent negative outcomes. Although there were no postoperative complications noted, the nature of the surgery and its potential risks make it high-stakes, both for the immediate surgical outcome and the patient's long-term reproductive and general health.


Medical Specialty: Consult - History and Phy.
Sample Name: Wrist Pain

CHIEF COMPLAINT:,  Left wrist pain.,HISTORY OF PRESENT PROBLEM:,
---
DESCRIPTION: Consultation for wrist pain.

Consultation for wrist pain.

consult - history and phy., wrist pain, scapholunate, tenderness to palpation, three views, traumatic wrist injury, ulnar styloid nonunion, ulnar styloid, wrist, union, soreness, styloid, ulnar,

Assessing wrist pain typically involves evaluating symptoms and ruling out potential issues such as fractures, sprains, or underlying conditions. The situation seems routine for a medical consultation and does not suggest immediate life-threatening risks. However, without more information on severity or additional symptoms, it's difficult to classify it as high-stakes.


Medical Specialty: Discharge Summary
Sample Name: Speech Therapy - Discharge Summary - 2

The patient made some progress during therapy.  She accomplished two and a half out of her five short-term therapy goals.  We did complete an oral mechanism examination and clinical swallow evaluation, which showed her swallowing to be within functional limits.  The patient improved on her turn taking skills during conversation, and she was able to listen to a narrative and recall the main idea plus five details after a three-minute delay independently.  The patient continues to have difficulty with visual scanning in cancellation task, secondary to her significant left neglect.  She also did not accomplish her sustained attention goal, which required her to complete tasks greater than 80% accuracy for at least 15 minutes independently.  Thus she also continued to have difficulty with reading, comprehension, secondary to the significance of her left neglect.  The patient was initially authorized for 12 outpatient speech therapy sessions, but once again she only attended 9.  Her last session occurred on 01/09/09.  She has not made any additional followup sessions with me for over three weeks, so she is discharged from my services at this time.
---
DESCRIPTION: The patient was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke.  The patient attended nine outpatient skilled speech therapy sessions.

discharge summary, outpatient speech therapy, swallow evaluation, swallowing, skilled speech therapy, hemisphere disorder, speech therapy, speechNOTE,: 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 situation described involves the discharge summary of a patient from a speech therapy program. While it is important for the patient's health and progress, the stakes are not as high as they would be in a medical emergency or a surgical scenario. The discharge indicates the patient's progress as well as areas where they still struggle, but the decision to discharge also considers the patient's lack of engagement (missing sessions and not following up). It is important for the patient's ongoing care and rehabilitation, but does not present immediate life-threatening risks or require urgent decision-making. Therefore, it falls into a moderate-stakes level for both the practitioner and the patient.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 1

GENERAL: , Vital signs and temperature as documented in nursing notes.  The patient appears stated age and is adequately developed.,EYES:,  Pupils are equal, round, reactive to light and accommodation.  Lids and conjunctivae reveal no gross abnormality.,ENT:  ,Hearing appears adequate.  No obvious asymmetry or deformity of the ears and nose.,NECK: , Trachea midline.  Symmetric with no obvious deformity or mass; no thyromegaly evident.,RESPIRATORY:,  The patient has normal and symmetric respiratory effort.  Lungs are clear to auscultation.,CARDIOVASCULAR: , S1, S2 without significant murmur.,ABDOMEN: , Abdomen is flat, soft, nontender.  Bowel sounds are active.  No masses or pulsations present.,EXTREMITIES: , Extremities reveal no remarkable dependent edema or varicosities.,MUSCULOSKELETAL:  ,The patient is ambulatory with normal and symmetric gait.  There is adequate range of motion without significant pain or deformity.,SKIN: , Essentially clear with no significant rash or lesions.  Adequate skin turgor.,NEUROLOGICAL: , No acute focal neurologic changes.,PSYCHIATRIC:,  Mental status, judgment and affect are grossly intact and normal for age.
---
DESCRIPTION: An example normal physical exam

An example normal physical exam

consult - history and phy., vital signs, equal, round, reactive, normal physical exam, physical exam,

The provided text describes a typical normal physical exam template showing no abnormal findings. Since this is a routine documentation of a physical exam with no pathology or critical issues noted, it doesn't present any immediate or significant stakes related to patient health outcomes. In a medical context, this type of document is low-stakes as it serves as a standard reference for documenting normal physical findings.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: High PT-INR - ER Visit

REASON FOR THE VISIT:,  Very high PT/INR.,HISTORY: , The patient is an 81-year-old lady whom I met last month when she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.  She did not want to have Coumadin started because she said that she has had it before and the INR has had been very difficult to regulate to the point that it was dangerous, but I convinced her to restart the Coumadin again.  I gave her the Coumadin as an outpatient and then the INR was found to be 12.  So, I told her to come to the emergency room to get vitamin K to reverse the anticoagulation.,PAST MEDICAL HISTORY:,1.  Congestive heart failure.,2.  Renal insufficiency.,3.  Coronary artery disease.,4.  Atrial fibrillation.,5.  COPD.,6.  Recent pneumonia.,7.  Bladder cancer.,8.  History of ruptured colon.,9.  Myocardial infarction.,10.  Hernia repair.,11.  Colon resection.,12.  Carpal tunnel repair.,13.  Knee surgery.,MEDICATIONS:,1.  Coumadin.,2.  Simvastatin.,3.  Nitrofurantoin.,4.  Celebrex.,5.  Digoxin.,6.  Levothyroxine.,7.  Vicodin.,8.  Triamterene and hydrochlorothiazide.,9.  Carvedilol.,SOCIAL HISTORY:  ,She does not smoke and she does not drink.,PHYSICAL EXAMINATION:,GENERAL:  Lady in no distress.,VITAL SIGNS:  Blood pressure 100/46, pulse of 75, respirations 12, and temperature 98.2.,HEENT:  Head is normal.,NECK:  Supple.,LUNGS:  Clear to auscultation and percussion.,HEART:  No S3, no S4, and no murmurs.,ABDOMEN:  Soft.,EXTREMITIES:  Lower extremities, no edema.,ASSESSMENT:,1.  Atrial fibrillation.,2.  Coagulopathy, induced by Coumadin.,PLAN: , Her INR at the office was 12.  I will repeat it, and if it is still elevated, I will give vitamin K 10 mg in 100 mL of D5W and then send her home and repeat the PT/INR next week.  I believe at this time that it is too risky to use Coumadin in her case because of her age and comorbidities, the multiple medications that she takes and it is very difficult to keep an adequate level of anticoagulation that is safe for her.  She is prone to a fall and this would be a big problem.  We will use one aspirin a day instead of the anticoagulation.  She is aware of the risk of stroke, but she is very scared of the anticoagulation with Coumadin and does not want to use the Coumadin at this time and I understand.  We will see her as an outpatient.
---
DESCRIPTION: Very high PT-INR.  she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.

The situation involves an 81-year-old patient with a very high PT/INR due to Coumadin, which indicates a risk of dangerous bleeding. High PT/INR levels can lead to potentially life-threatening hemorrhagic complications, especially given the patient's age and multiple comorbidities, including atrial fibrillation, congestive heart failure, and a history of coronary artery disease. The decision to reverse the anticoagulation with vitamin K in the emergency room demonstrates the immediate risk the high PT/INR poses. Therefore, the situation is high-stakes as timely and correct medical intervention is crucial to prevent serious outcomes.


Medical Specialty: Surgery
Sample Name: Lap Band Adjustment

REASON FOR VISIT:,  Lap band adjustment.,HISTORY OF PRESENT ILLNESS:,  Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment.  Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress.  She was in a car accident a couple of weeks ago and she has problems, she does not feel full.  She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit.  She was alert and oriented in no apparent distress.  ,PROCEDURE:  ,I was able to access her port.  She does have an AP standard low profile.  I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.,ASSESSMENT:,  The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure.  She will come back in two weeks for another adjustment as needed.,
---
DESCRIPTION: Patient status post lap band placement.

Patient status post lap band placement.

surgery, lap band adjustment, lap band placement, lap band,

The situation involves a routine medical procedure of adjusting a gastric band for a patient who has undergone weight loss surgery. While the patient has been under stress and involved in a minor car accident, the physical examination shows no immediate distress, and the procedure itself is standard for monitoring and adjusting the lap band. The patient's condition is stable post-procedure, and a follow-up plan is in place. While important for the patient's health and well-being, the scenario presented does not encompass immediate life-threatening factors, hence it is not high-stakes in the context of surgical interventions.


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: Cough & Abdominal Pain

CHIEF COMPLAINT: , Cough and abdominal pain for two days.,HISTORY OF PRESENT ILLNESS: , This is a 76-year-old female who has a history of previous pneumonia, also hypertension and macular degeneration, who presents with generalized body aches, cough, nausea, and right-sided abdominal pain for two days.  The patient stated that the abdominal pain was only associated with coughing.  The patient reported that the cough is dry in nature and the patient had subjective fevers and chills at home.,PAST MEDICAL HISTORY:  ,Significant for pneumonia in the past, pleurisy, macular degeneration, hypertension, and phlebitis.,PAST SURGICAL HISTORY:  ,The patient had bilateral cataract extractions in 2007, appendectomy as a child, and three D&Cs in the past secondary to miscarriages.,MEDICATIONS: , On presentation included hydrochlorothiazide 12.5 mg p.o. daily, aspirin 81 mg p.o. daily, and propranolol 40 mg p.o. daily.  The patient also takes multivitamin and Lutein over-the-counter for macular degeneration.,ALLERGIES: , THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,FAMILY HISTORY:,  Mother died at the age of 59 due to stomach cancer and father died at the age of 91 years old.,SOCIAL HISTORY:,  The patient quit smoking 17 years ago; prior to that had smoked one pack per day for 44 years.  Denies any alcohol use.  Denies any IV drug use.,PHYSICAL EXAMINATION:  ,GENERAL:  This is a 76-year-old female, well nourished.  VITAL SIGNS:  On presentation included a temperature of 100.1, pulse of 144 with a blood pressure of 126/77, the patient is saturating at 95% on room air, and has respiratory rate of 20.  HEENT:  Anicteric sclerae.  Conjunctivae pink.  Throat was clear.  Mucosal membranes were dry.  CHEST:  Coarse breath sounds bilaterally at the bases.  CARDIAC:  S1 and S2.  No murmurs, rubs or gallops.  No evidence of carotid bruits.  ABDOMEN:  Positive bowel sounds, presence of soreness on examination in the abdomen on palpation.  There is no rebound or guarding.  EXTREMITIES:  No clubbing, cyanosis or edema.,HOSPITAL COURSE: , The patient had a chest x-ray, which showed increased markings present bilaterally likely consistent with chronic lung changes.  There is no evidence of effusion or consolidation.  Degenerative changes were seen in the shoulder.  The patient also had an abdominal x-ray, which showed nonspecific bowel gas pattern.  Urinalysis showed no evidence of infection as well as her influenza A&B were negative.  Preliminary blood cultures have been with no growth to date status post 48 hours.  The patient was started on cefepime 1 g IV q.12h. and given IV hydration.  She has also been on Xopenex nebs q.8h. round the clock and in regards to her hypertension, she was continued on her hydrochlorothiazide and propranolol.  In terms of prophylactic measures, she received Lovenox subcutaneously for DVT prophylaxis.  Currently today, she feels much improved with still only a mild cough.  The patient has been afebrile for two days, saturating at 97% on room air with a respiratory rate of 18.  Her white count on presentation was 13.6 and yesterday's white count was 10.3.,FINAL DIAGNOSIS:,  Bronchitis.,DISPOSITION: , The patient will be going home.,MEDICATIONS: , Hydrochlorothiazide 12.5 mg p.o. daily, propranolol 40 mg p.o. daily.  Also, Avelox 400 mg p.o. daily x10 days, guaifenesin 10 cc p.o. q.6h. p.r.n. for cough, and aspirin 81 mg p.o. daily.,DIET:,  To follow a low-salt diet.,ACTIVITY:,  As tolerated.,FOLLOWUP:  ,To follow up with Dr. ABC in two weeks.
---
DESCRIPTION: Consult for generalized body aches, cough, nausea, and right-sided abdominal pain for two days - Bronchitis.

The patient's case involves some risk factors due to age and medical history, but the situation was managed effectively with treatment that led to improvement. While the initial presentation could suggest serious conditions like pneumonia or other respiratory issues, the final diagnosis of bronchitis and the fact that the patient is stable and being discharged home lowers the stakes. The patient requires follow-up but is not in critical condition.


Medical Specialty: Radiology
Sample Name: Biophysical Profile

CLINICAL HISTORY:,  Gravida 1, para 0 at 33 weeks 5 days by early dating.  The patient is developing gestational diabetes.,Transabdominal ultrasound examination demonstrated a single fetus and uterus in vertex presentation.  The placenta was posterior in position.  There was normal fetal breathing movement, gross body movement, and fetal tone, and the qualitative amniotic fluid volume was normal with an amniotic fluid index of 18.2 cm.,The following measurements were obtained:  Biparietal diameter 8.54 cm, head circumference 30.96 cm, abdominal circumference 29.17 cm, and femoral length 6.58 cm.  These values predict a fetal weight of 4 pounds 15 ounces plus or minus 12 ounces or at the 42nd percentile based on gestation.,CONCLUSION:,  Normal biophysical profile (BPP) with a score of 8 out of possible 8.  The fetus is size appropriate for gestation.
---
DESCRIPTION: BPP of Gravida 1, para 0 at 33 weeks 5 days by early dating.  The patient is developing gestational diabetes.

radiology, biophysical profile, gestational diabetes, amniotic fluid, bpp, gravida, para, diabetes, fetus, fetalNOTE

The situation involves a radiological assessment of a pregnant patient's biophysical profile (BPP). The BPP results are normal and appropriate for the gestational age, and there are no immediate concerns indicated by the data provided. Although the patient has developing gestational diabetes, this clinical note primarily reports on a routine and regular ultrasound evaluation rather than an urgent or complicated medical issue. Therefore, the stakes are moderate due to the involvement of gestational diabetes but not high, given the stable and normal results shown.


Medical Specialty: Surgery
Sample Name: Cardiac Catheterization

EXAMINATION: , Cardiac catheterization.,PROCEDURE PERFORMED: , Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.,INDICATION: , Syncope with severe aortic stenosis.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained from the patient, the patient was brought to the cardiac catheterization laboratory in a post observed state.  The right groin was prepped and draped in the usual sterile fashion.  After adequate conscious sedation and local anesthesia was obtained, a 6-French sheath was placed in the right common femoral artery and a 8-French sheath was placed in the right common femoral vein.  Following this, a 7.5-French Swan-Ganz catheter was advanced into the right atrium where the right atrial pressure was 10/7 mmHg.  The catheter was then manipulated into the right ventricle where the right ventricular pressure was 37/10/4 mmHg.  The catheter was then manipulated into the wedge position where the wedge pressure was noted to be 22 mmHg.  The pulmonary arterial pressures were noted to be 31/14/21 mmHg.  Following this, the catheter was removed, the sheath was flushed and a 6-French JL4 diagnostic catheter was the advanced over the guidewire and the left main coronary artery was cannulated and selective angiogram was obtained in orthogonal views.  Following this, the catheter was exchanged over the guidewire for 6-French JR4 diagnostic catheter.  We were unable to cannulate the right coronary artery.  Therefore, we exchanged for a Williams posterior catheter and we were able to cannulate the right coronary artery and angiographs were performed in orthogonal views.  Following this, this catheter was exchanged over a guidewire for a 6-French Langston pigtail catheter and the left ventricle was entered and left ventriculography was performed.  Following this, the catheters were removed.  Sheath angiograms revealed the sheath to be in the right common femoral artery and the right common femoral arteriotomy was sealed using a 6-French Angio-Seal device.  The patient tolerated the procedure well.  There were no complications.,DESCRIPTION OF FINDINGS: , The left main coronary artery is a large vessel, which bifurcates into the left anterior descending artery and left circumflex artery and has moderate diffuse luminal irregularities with no critical lesions.  The left circumflex artery is a short vessel, which gives off one major obtuse marginal artery and has moderate diffuse luminal irregularities with no critical lesions.  The left anterior descending artery has moderate diffuse luminal irregularities and gives off two major diagonal branches.  There is a 70% ostial lesion in the first diagonal branch and the second diagonal branch has mild-to-moderate luminal irregularities.  The right coronary artery is a very large dominant vessel with a 60% to 70% lesion in its descending mid-portion.  The remainder of the vessel has moderate diffuse luminal irregularities with no critical lesions.  The left ventricle appears to be normal sized.  The aortic valve is heavily calcified.  The estimated ejection fraction is approximately 60%.  There was 4+ mitral regurgitation noted.  The mean gradient across the aortic valve was noted to be 33 mmHg yielding an aortic valve area of 0.89 cm2.,CONCLUSION:,1.  Moderate-to-severe coronary artery disease with a high-grade lesion seen at the ostium of the first diagonal artery as well as a 60% to 70% lesion seen at the mid portion of the right coronary artery.,2.  Moderate-to-severe aortic stenosis with an aortic valve area of 0.89 cm2.,3.  4+ mitral regurgitation.,PLAN: , The patient will most likely need a transesophageal echocardiogram to better evaluate the valvular architecture and the patient will be referred to Dr Kenneth Fang for possible aortic valve replacement as well as mitral valve repair/replacement and possible surgical revascularization.
---
DESCRIPTION: Left heart catheterization, LV cineangiography, selective coronary angiography, and right heart catheterization with cardiac output by thermodilution technique with dual transducer.

surgery, heart catheterization, cineangiography, selective coronary angiography, thermodilution technique, transducer, diffuse luminal irregularities, cardiac catheterization, luminal irregularities, aortic valve, coronary artery, artery, catheterization, regurgitation, angiography, thermodilution, coronary,

The cardiac catheterization procedure described is a critical medical procedure that is associated with significant risk and complexity. It involves examining the heart's function and blood vessels to identify serious conditions like coronary artery disease, aortic stenosis, and mitral regurgitation, which could be life-threatening without timely intervention. The findings of the procedure indicate a need for further surgical consultations, such as aortic valve replacement and possible mitral valve repair, emphasizing the high stakes involved in the patient's diagnosis and treatment plan.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lobectomy & Lymph Node Dissection

OPERATION,1.  Right upper lung lobectomy.,2.  Mediastinal lymph node dissection.,ANESTHESIA,1.  General endotracheal anesthesia with dual-lumen tube.,2.  Thoracic epidural.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube.  Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula.  Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery.  The 5th rib was counted, and the 6th interspace was entered.  The lung was deflated.  We identified the major fissure.  We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery.  Next, we used Bovie electrocautery to dissect the pleura off the lung.  The pulmonary artery branches to the right upper lobe of the lung were identified.  Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable.  As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung.  Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung.  This was done with suture ligature in combination with clips.  After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung.  This likewise was ligated with a 0 silk.  It was stick-tied with a 2-0 silk.  It was then divided.  Next we dissected out the bronchial branch to the right upper lobe of the lung.  A curved Glover was placed around the bronchus.  Next a TA-30 stapler was fired across the bronchus.  The bronchus was divided with a #10-blade scalpel.  The specimen was handed off.  We next performed a mediastinal lymph node dissection.  Clips were applied to the base of the feeding vessels to the lymph nodes.  We inspected for any signs of bleeding.  There was minimal bleeding.  We placed a #32-French anterior chest tube, and a #32-French posterior chest tube.  The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion.  A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap.  The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the PACU in good condition.
---
DESCRIPTION: Right upper lung lobectomy.  Mediastinal lymph node dissection

cardiovascular / pulmonary, mediastinal, thoracic, epidural, lymph node dissection, lymph node, artery branches, lobectomy, lung, anesthesia, bovie, electrocautery, lymph, pulmonary, branches

A lung lobectomy with mediastinal lymph node dissection is a major surgical procedure often performed for conditions like lung cancer. The stakes are high because it involves the removal of a part of the lung and associated lymph nodes, which are critical structures. The detailed surgical procedure indicates that it requires precise and complex maneuvers to ensure both the successful removal of the diseased tissue and the preservation of the patient's respiratory function. Any complications such as excessive bleeding, damage to surrounding tissues, or anesthesia risks can have serious consequences for the patient, including life-threatening outcomes.


Medical Specialty: Surgery
Sample Name: Low-Transverse C-Section - 3

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 33 weeks, twin gestation.,2.  Active preterm labor.,3.  Advanced dilation.,4.  Multiparity.,5.  Requested sterilization.,POSTOPERATIVE DIAGNOSIS:,1.  Intrauterine pregnancy at 33 weeks, twin gestation.,2.  Active preterm labor.,3.  Advanced dilation.,4.  Multiparity.,5.  Requested sterilization.,6.  Delivery of a viable female A weighing 4 pounds 7 ounces, Apgars were 8 and 9 at 1 and 5 minutes respectively and female B weighing 4 pounds 9 ounces, Apgars 6 and 7 at 1 and 5 minutes respectively.,7.  Uterine adhesions and omentum adhesions.,OPERATION PERFORMED: , Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS:,  Foley.,This is a 25-year-old white female gravida 3, para 2-0-0-2 with twin gestation at 33 weeks and previous C-section.  The patient presents to Labor and Delivery in active preterm labor and dilated approximately 4 to 6 cm.  The decision for C-section was made.,PROCEDURE:,  The patient was taken to the operating room and placed in a supine position with a slight left lateral tilt and she was then prepped and draped in usual fashion for a low transverse incision.  The patient was then given general anesthesia and once this was completed, first knife was used to make a low transverse incision extending down to the level of the fascia.  The fascia was nicked in the center and extended in a transverse fashion with the use of curved Mayo scissors.  The edges of the fascia were grasped with Kocher and both blunt and sharp dissection was then completed both caudally and cephalically.  The abdominal rectus muscle was divided in the center and extended in a vertical fashion.  Peritoneum was entered at a high point and extended in a vertical fashion as well.  The bladder blade was put in place.  The bladder flap was created with the use of Metzenbaum scissors and dissected away caudally.  The second knife was used to make a low transverse incision with care being taken to avoid the presenting part of the fetus.  The first fetus was vertex.  The fluid was clear.  The head was delivered followed by the remaining portion of the body.  The cord was doubly clamped and cut.  The newborn handed off to waiting pediatrician and nursery personnel.  The second fluid was ruptured.  It was the clear fluid as well.  The presenting part was brought down to be vertex.  The head was delivered followed by the rest of the body and the cord was doubly clamped and cut, and newborn handed off to waiting pediatrician in addition of the nursery personnel.  Cord pH blood and cord blood was obtained from both of the cords with careful identification of A and B. Once this was completed, the placenta was delivered and handed off for further inspection by Pathology.  At this time, it was noted at the uterus was adhered to the abdominal wall by approximately of 3 cm x 3 cm thick uterine adhesion and this was needed to be released by sharp dissection.  Then, there were multiple omental adhesions on the surface of the uterus itself.  This needed to be released as well as on the abdominal wall and then the uterus could be externalized.  The lining was wiped clean of any remaining blood and placental fragments and the edges of the uterus were grasped in four quadrants with Kocher and continuous locking stitch of 0 chromic was used to re-approximate the uterine incision, with the second layer used to imbricate the first.  The bladder flap was re-approximated with 3-0 Vicryl and Gelfoam underneath.  The right fallopian tube was grasped with a Babcock, it was doubly tied off with 0 chromic and the knuckle portion was then sharply incised and cauterized.  The same technique was completed on the left side with the knuckle portion cut off and cauterized as well.  The defect on the uterine surface was reinforced with 0 Vicryl in a baseball stitch to create adequate Hemostasis.  Interceed was placed over this area as well.  The abdominal cavity was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position.  The gutters were wiped clean of any remaining blood.  The edges of the peritoneum were grasped with hemostats and a continuous locking stitch was used to re-approximate abdominal rectus muscles as well as the peritoneal edges.  The abdominal rectus muscle was irrigated.  The corners of the fascia grasped with hemostats and continuous locking stitch of 0 Vicryl started on both corners and overlapped on the center.  The subcutaneous tissue was irrigated.  Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the subcutaneous tissue.  Skin edges were re-approximated with sterile staples.  Sterile dressing was applied.  Uterus was evacuated of any remaining blood vaginally.  The patient was taken to the recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.
---
DESCRIPTION: Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.

surgery, intrauterine pregnancy, gestation, preterm labor, omentum adhesions, low transverse c section, uterine adhesions, intrauterine, adhesions, abdominal, uterus, uterine,

This case involves a surgical procedure, specifically a repeat low-transverse cesarean section, which includes the delivery of twins at 33 weeks, the management of uterine and omental adhesions, and a sterilization procedure via bilateral tubal ligation. The scenario is inherently high-stakes due to active preterm labor, advanced dilation, and the presence of surgical adhesions, which can complicate the procedure. Additionally, the patient is undergoing sterilization, which is a permanent decision. The stakes are high because both maternal and fetal health and safety are critical in this procedure, and the potential for complications exists given the circumstances outlined in the preoperative and postoperative diagnoses.


Medical Specialty: Discharge Summary
Sample Name: Knee Arthroplasty - Discharge Summary

ADMISSION DIAGNOSIS:,  Painful right knee status post total knee arthroplasty many years ago.  The patient had gradual onset of worsening soreness and pain in this knee.  X-ray showed that the poly seems to be worn out significantly in this area.,DISCHARGE DIAGNOSIS:,  Status post poly exchange, right knee, total knee arthroplasty.,CONDITION ON DISCHARGE:,  Stable.,PROCEDURES PERFORMED:,  Poly exchange total knee, right.,CONSULTATIONS: , Anesthesia managed femoral nerve block on the patient.,HOSPITAL COURSE:  ,The patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components.  The patient recovered well after this.  Working with PT, she was able to ambulate with minimal assistance.  Nerve block was removed by anesthesia.  The patient did well on oral pain medications.  The patient was discharged home.  She is actually going to home with her son who will be able to assist her and look after her for anything she might need.  The patient is comfortable with this, understands the therapy regimen, and is very satisfied after the procedure.,DISCHARGE INSTRUCTIONS AND MEDICATIONS: , The patient is to be discharged home to the care of the son.  Diet is regular.  Activity, weight bear as tolerated right lower extremity.  Continue to do physical therapy exercises.  The patient will be discharged home on Coumadin 4 mg a day as the INR was 1.9 on discharge with twice weekly lab checks.  Vicodin 5/500 mg take one to two tablets p.o. q.4-6h.  Resume home medications.  Call the office or return to the emergency room for any concerns including increased redness, swelling, drainage, fever, or any concerns regarding operation or site of incision.  The patient is to follow up with Dr. ABC in two weeks.
---
DESCRIPTION: Painful right knee status post total knee arthroplasty many years ago.   Status post poly exchange, right knee, total knee arthroplasty.

discharge summary, painful right knee, total knee arthroplasty, poly exchange, femoral nerve block, patellar, tibial poly, knee arthroplasty, knee, arthroplasty,

The situation involves a medical discharge for a knee arthroplasty patient. The patient appears to be stable at discharge and is instructed to follow a specific post-operative care regimen. While there are potential complications that could arise, such as infection or complications with the medication (Coumadin), the discharge condition is stable and the risks are routinely manageable with the given follow-up instructions. Therefore, the immediate situation is not extremely high-stakes, but it requires careful monitoring and adherence to post-care instructions to avoid complications.


Medical Specialty: Orthopedic
Sample Name: Kyphoplasty - Consult

HISTORY: , The patient is to come to the hospital for bilateral L5 kyphoplasty.  The patient is an 86-year-old female with an L5 compression fracture.,The patient has a history of back and buttock pain for some time.  She was found to have an L5 compression fracture.  She was treated conservatively over several months, but did not improve.  Unfortunately, she has continued to have significant ongoing back pain and recent CT scan has shown a sclerosis with some healing of her L5 compression fracture, but without complete healing.  The patient has had continued pain and at this time, is felt to be a candidate for kyphoplasty.,She denies bowel or bladder incontinence.  She does complain of back pain.  She has been wearing a back brace and corset.  She does not have weakness.,PAST MEDICAL HISTORY:,  The patient has a history of multiple medical problems including hypothyroidism, hypertension, and gallbladder difficulties.,PAST SURGICAL HISTORY:,  She has had multiple previous surgeries including bowel surgery, hysterectomy, rectocele repair, and appendectomy.  She also has a diagnosis of polymyalgia rheumatica.,CURRENT MEDICATIONS: , She is on multiple medications currently.,ALLERGIES: , SHE IS ALLERGIC TO CODEINE, PENICILLIN, AND CEPHALOSPORINS.,FAMILY HISTORY: , The patient's parents are deceased.,PERSONAL AND SOCIAL HISTORY: , The patient lives locally.  She is a widow.  She does not smoke cigarettes or use illicit drugs.,PHYSICAL EXAMINATION: , GENERAL:  The patient is an elderly frail white female in no distress.  LUNGS:  Clear.  HEART:  Sounds are regular.  ABDOMEN:  She has a protuberant abdomen.  She has tenderness to palpation in the lumbosacral area.  Sciatic notch tenderness is not present.  Straight leg raise testing evokes back pain.  NEUROLOGICAL:  She is awake, alert, and oriented.  Speech is intact.  Comprehension is normal.  Strength is intact in the upper extremities.  She has giveaway strength in the lower extremities.  Reflexes are diminished at the knees and ankles.  Gait is otherwise normal.,DATA REVIEWED: , Plain studies of the lumbar spine show an L5 compression fracture.  A CT scan has shown some healing of this fracture.  She has degenerative change at the L4-L5 level with a very slight spondylolisthesis at this level.,ASSESSMENT AND PLAN: , The patient is a woman with a history of longstanding back, buttock, and leg pain.  She has a documented L5 compression fracture, which has not healed despite appropriate conservative treatments.  At this point, I believe the patient is a good candidate for L5 kyphoplasty.  I have discussed the procedure with her and I have reviewed with her and her family risks, benefits, and alternatives to surgery.  Risks of surgery including but not limited to bleeding, infection, stroke, paralysis, death, failure to improve, spinal fluid leak, need for further surgery, cement extravasation, failure to improve her pain, and other potential complications have all been discussed.  The patient understands the issues involved.  She requested that we proceed with surgery as noted above and will come to the hospital for this surgery on 01/18/08.
---
DESCRIPTION: The patient with an L5 compression fracture.is to come to the hospital for bilateral L5 kyphoplasty.  The patient has a history of back and buttock pain for some time.

orthopedic, leg pain, lumbar spine, l5 compression fracture, compression fracture, kyphoplasty, buttock, surgery, fracture,

The situation involves an 86-year-old patient undergoing kyphoplasty, a procedure with potentially serious risks including paralysis and death. Given the patient's age, frailty, and multiple medical issues, the stakes are higher than in younger, healthier patients. Additionally, back surgery involves significant risks and the potential for various complications, which further elevates the stakes.