Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Closure of Amputation Wounds

PREOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,POSTOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,PROCEDURES:,1.  Left abdominal flap 5 x 5 cm to left forearm.,2.  Debridement of skin, subcutaneous tissue, muscle, and bone.,3.  Closure of wounds, simple closure approximately 8 cm.,4.  Placement of VAC negative pressure wound dressing.,INDICATIONS: , This 3-year-old male suffered amputation of his left upper extremity with complications of injury.  He presents at this time for further attempts at closure.,OPERATIVE FINDINGS: , A clean wound to left upper extremity with partial dehiscence of previously closed wounds and also the closure was satisfactory.,DESCRIPTION OF PROCEDURE: , Under inhalational anesthesia, he was prepped and draped in usual fashion exposing left upper extremity and also exposing continuity of the left abdomen, chest, and groin.  He underwent systematic evaluation of his wound of his left upper extremity and we excised first the whole wound prior to doing some additional closure.  Some areas were dehisced and appeared to be because it was approximation of granulation tissue and as a result the edges were freshened up prior to approximating them.  In this fashion, simple closure was accomplished and its total length was approximately 8 cm.  It should be noted that prior to doing any procedure that appropriate timeout was performed and he received prophylactic antibiotics as indicated and did not require DVT prophylaxis.  At this time, once we accomplished debridement and simple closure removing skin, subcutaneous tissue, muscle and bone as well as closing the arm, we could design our flap for the abdomen.  The flap was designed as a slightly greater than 1:1 ellipse of skin from just below the costal margin.  This was elevated at the level of the external oblique and then laid on the left forearm.  The donor's site was closed using interrupted 4-0 Vicryl in the deep dermis and running subcuticular 4-0 Monocryl on the skin.  Steri-Strips were applied.  At this time, the flap was inset using again 4-0 Monocryl sutures and then ultimately the VAC negative pressure wound dressing was applied to help hold this in place and optimize the vascularization of the flap.  The patient tolerated the procedure well and he returned to the recovery room in satisfactory condition.
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DESCRIPTION: Left upper extremity amputation.  This 3-year-old male suffered amputation of his left upper extremity with complications of injury.  He presents at this time for further attempts at closure.  Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, placement of VAC negative pressure wound dressing.

cosmetic / plastic surgery, abdominal flap, debridement, skin, subcutaneous tissue, muscle, bone, closure of wounds, vac, vac negative, upper extremity, closure, wounds, flap, extremity, amputation

The surgical procedure involves a 3-year-old with a left upper extremity amputation and requires complex surgical intervention like flap creation and wound closure. The high-stakes nature comes from the fact that it's a surgical procedure on a young child, which inherently involves higher risks due to the patient's age, the need for precise surgical execution to ensure proper healing, and to prevent infection and complications. Given the intricacies involved in wound management and flap surgery, including careful debridement and precise suturing for optimal results, this scenario leans towards high stakes in ensuring a successful recovery and minimizing further complications.


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: Consult - Congestive Heart Failure

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

The patient is a 75-year-old with multiple comorbidities including congestive heart failure, hypertension, smoking history, and COPD. The elevated BNP levels, the presence of pneumonia, and symptoms like shortness of breath and fatigue indicate a complex medical situation. This combination of factors makes the scenario high-stakes since the patient's age and medical history increase the risk of complications and potential adverse outcomes. Immediate and careful medical management is required to stabilize the patient's condition.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Mediastinal Mass Resection

PREOPERATIVE DIAGNOSIS:,  Posterior mediastinal mass with possible neural foraminal involvement.,POSTOPERATIVE DIAGNOSIS: , Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,OPERATION PERFORMED:,  Left thoracotomy with resection of posterior mediastinal mass.,INDICATIONS FOR PROCEDURE:  ,The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina.  For this reason, Dr. X and I agreed to operate on this patient together.  Please note that two surgeons were required for this case due to the complexity of it.  The indications and risks of the procedure were explained and the patient gave her informed consent.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating suite and placed in the supine position.  General endotracheal anesthesia was given with a double lumen tube.  The patient was positioned for a left thoracotomy.  All pressure points were carefully padded.  The patient was prepped and draped in usual sterile fashion.  A muscle sparing incision was created several centimeters anterior to the tip of the scapula.  The serratus and latissimus muscles were retracted.  The intercostal space was opened.  We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization.  Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass.  This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta.  The lung was deflated and allowed to retract anteriorly.  With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass.  We began by opening the tumor and taking a very wide large biopsy.  This was sent for frozen section, which revealed a benign nerve sheath tumor.  Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass.  This left the external surface of the mass much more malleable and easier to retract.  Using a bipolar cautery and endoscopic scissors we were then able to completely resect it.  Once the tumor was resected, it was then sent for permanent sections.  The entire hemithorax was copiously irrigated and hemostasis was complete.  In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space.  A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace.  The wounds were then closed in multiple layers.  A #2 Vicryl was used to approximate the ribs.  The muscles of the chest wall were allowed to return to their normal anatomic position.  A 19 Blake was placed in the subcutaneous tissues.  Subcutaneous tissues and skin were closed with running absorbable sutures.  The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition.
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DESCRIPTION: Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).  Left thoracotomy with resection of posterior mediastinal mass.

cardiovascular / pulmonary, posterior mediastinal mass, neural foraminal, nerve sheath tumor, frozen section, thoracotomy, mediastinal mass, foraminal, neural, sheath, mediastinal,

The situation involves a significant surgical procedure, a mediastinal mass resection, with potential neural foraminal involvement. This type of surgery carries substantial risks, such as potential damage to surrounding organs and structures including nerves, major blood vessels like the aorta and subclavian artery, and the lung. Such operations are often complex and delicate, requiring the skills of two surgeons as indicated, further highlighting the high-stakes nature. While the mass is benign, the involvement of critical anatomical structures increases the stakes. The patient’s condition post-operation was stable, which suggests successful management of immediate risks.


Medical Specialty: Surgery
Sample Name: G-tube placement

PREOPERATIVE DIAGNOSIS:,  Neurologic devastation secondary to nonaccidental trauma.,POSTOPERATIVE DIAGNOSES: , Neurologic devastation secondary to nonaccidental trauma.,PROCEDURE: , Laparoscopic G-tube placement (14-French 1.2-cm MIC-Key).,INDICATIONS FOR PROCEDURE: , This patient is a 5-month-old baby boy who presented unfortunately because of nonaccidental trauma.  The patient suffered neurologic devastation.  In order to facilitate enteral feedings, the plan is to place a G-tube as the patient cannot take by mouth.  Consent was obtained by court order as the patient is a ward of the state.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's abdomen was prepped and draped in the usual sterile fashion.  An incision was made through the umbilicus.  Peritoneal cavity entered bluntly.  A 5-mm trocar was introduced.  Abdomen was insufflated with a 5-mm scope.  No obvious pathology noted.  We visualized the stomach.  We chose the spot in the left upper quadrant for future G-tube site.  I made a small incision on the skin there, put another 5-mm trocar at that site.  Using a Babcock, we grasped the stomach along the greater curvature site for further G-tube.  I pulled a knuckle of stomach through the incision and secured with 4-0 Vicryl.  I then used 3-0 Prolene sutures as tacking sutures on either side of the future G-tube site taking full-thickness abdominal wall through stomach and back out the abdominal wall.  I then pulled the knuckle of stomach back up through the incision, made a gastrotomy, and then put a 4-0 pursestring around the gastrotomy site, introduced the 14, 1.2- cm MIC-Key into the stomach.  The gastrotomy site insufflated with 5 mL of saline.  We then tied down the pursestring.  On the laparoscopy, the G-tube looked to be in good position.  I insufflated the stomach through the G-tube, which I did and removed air subsequently.  I then placed 2 x 2 underneath the G-tube and tied down tacking sutures around the G-tube itself, placed the G-tube to gravity, desufflated the abdomen, closed the umbilical port site fascia with 3-0 Vicryl, closed skin with 5-0 Monocryl, and dressed with bacitracin, 2 x 2, and Steri-Strips.  The patient was extubated in the operating room and taken back to recovery room.  The patient tolerated the procedure well.
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DESCRIPTION:

surgery, neurologic devastation, g-tube placement, mic-key, laparoscopic g-tube placement, babcock, g-tube site, gastrotomy, mic key, abdominal wall, gastrotomy site, nonaccidental trauma, tube, stomach,

The situation involves a surgical procedure on a 5-month-old infant who has suffered neurologic devastation due to nonaccidental trauma. The procedure, G-tube placement, is necessary for the patient's feeding as they cannot eat by mouth due to their condition. This is a high-stakes situation because: 1) it involves a very young patient, increasing the complexity and potential risks of surgery; 2) there's an emotional aspect due to the cause being nonaccidental trauma, implicating potential legal or social services involvement; and 3) the procedure, while generally routine, requires precision and care due to the patient's fragile state. The necessity of court-ordered consent indicates that the child's situation is under legal scrutiny, adding another layer of complexity and pressure. Given these factors, the stakes in terms of medical, legal, and ethical considerations are significantly high.


Medical Specialty: Dermatology
Sample Name: Acne Vulgaris

ACNE VULGARIS,, commonly referred to as just acne, is a chronic inflammation of the skin that occurs most often during adolescence but can occur off and on throughout life.  The skin eruptions most often appear on the face, chest, back and upper arms and are more common in males than females.,SIGNS AND SYMPTOMS:,*  Blackheads the size of a pinhead.,*  Whiteheads similar to blackheads.,*  Pustules - lesions filled with pus.,*  Redness and inflamed skin.,*  Cysts - large, firm swollen lesions in severe acne.,*  Abscess - infected lesion that is swollen, tender, inflamed, filled with pus, also seen in severe acne.,CAUSES:,Oil glands in the skin become plugged for reasons unknown but during adolescence, sex-hormone changes play some role.  When oil backs up in the plugged gland, a bacteria normally present on skin causes an infection.  Acne is NOT caused by foods, uncleanliness or masturbation.  Cleaning the skin can decrease its severity but sexual activity has no effect on it.  A family history of acne can indicate if an individual will get acne and how severe it might be.  Currently, acne can't be prevented.,ACNE CAN BE BROUGHT ON OR MADE WORSE BY:,*  Hot or cold temperatures.,*  Emotional stress.,*  Oily skin.,*  Endocrine (hormone) disorder.,*  Drugs such as cortisones, male hormones, or oral contraceptives.,*  Some cosmetics.,*  Food sensitivities.  Again, foods do not cause acne but some certain ones may make it worse.  To discover any food sensitivities, eliminate suspicious foods from your diet and then start eating them again one at a time.  If acne worsens 2-3 days after consumption, then avoid this food.  Acne usually improves in summer so some foods may be tolerated in summer that can't be eaten in winter.,TREATMENT:,*  Most cases of acne respond well to treatment and will likely disappear once adolescence is over.  Even with adequate treatment, acne will tend to flare up from time to time and sometimes permanent facial scars or pitting of the skin may occur.,*  If your skin is oily, gently clean face with a fresh, clean wash cloth using unscented soap for 3- 5 minutes; an antibacterial soap may work better.  A previously used wet washcloth will harbor bacteria.  Don't aggressively scrub tender lesions as this may spread infection; be gentle.  Rinse the soap off for a good 1-2 minutes.  Dry face carefully with a clean towel and use an astringent such as rubbing alcohol that will remove the skin oil.,OTHER TIPS THAT MAY HELP ACNE:,*  Shampoo hair at least twice a week.  Keep hair off of face even while sleeping as hair can spread oil and bacteria.  If you have dandruff, use a dandruff shampoo.  Avoid cream hair rinses.,*  Wash sweat and skin oil off as soon as possible after sweating and exercising.,*  Use thinner, water-based cosmetics instead of the heavier oil-based ones.,*  Avoid skin moisturizers unless recommended by your doctor.,*  Do not squeeze, pick, rub or scratch your skin or the acne lesions.  This may damage the skin causing scarring and delay healing of acne.  Only a doctor should remove blackheads.,*  Keep from resting face on hands while reading, studying or watching TV.,*  Try to avoid pressing the phone receiver on you chin while talking on the phone.,*  Ultraviolet light may be a treatment recommended by your doctor but this is by no means a license to sunbathe!  Don't use the sun to treat acne.,*  Dermabrasion may be another option to treat acne scars.  This is a type of cosmetic surgery to help remove unsightly scars.,MEDICATIONS THAT MAY BE PRESCRIBED TO HELP ACNE INCLUDE:,*  Oral or topical antibiotics.,*  Cortisone injections into acne lesions.,*  Oral contraceptives.,*  Tretinoin, which may increase sun sensitivity and excessive dryness,  is not recommended during pregnancy.,*  Accutane (isotretinoin) is a powerful drug to treat acne but causes birth defects.  A woman taking this drug,must be on two types of birth control and have negative pregnancy tests.  This drug also increases sun,sensitivity.  Other more serious side effects can occur and your doctor will discuss those with you if Accutane is to be prescribed.,TETRACYCLINE:,Tetracycline is a very safe antibiotic.  It is not related to penicillin and an allergy to it is unusual.  There are several potential side effects:,1.  Tetracycline can cause nausea or heartburn.,2.  Tetracycline can cause vaginitis.,3.  Tetracycline can cause excessive sun burn.,CAUTIONS ON TETRACYCLINE:,1.  Do not take Tetracycline with milk or milk products (ice cream, cheese, yogurt, etc.).  This will cancel out the Tetracycline.  Separate the Tetracycline from these products by one and one-half hours before and after each capsule.  Do have a small amount of non milk-containing food in your stomach first to prevent nausea.,2.  Do not take Tetracycline if you are pregnant.
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DESCRIPTION: A simple note on Acne Vulgaris.

A simple note on Acne Vulgaris.

The situation involves a medical condition, acne vulgaris, which is a common dermatological issue. Although acne can impact quality of life and self-esteem, especially in teenagers, it is not typically life-threatening. However, some treatments, like Accutane (isotretinoin), require careful management due to potential severe side effects, particularly in relation to pregnancy. While acne treatment is an important aspect of dermatological practice, it generally doesn't involve immediate life-or-death decisions, and thus doesn't constitute a high-stakes situation.

This analysis considers the chronic nature of the condition and potential severe side effects of certain medications which require careful management, but ultimately the overall risk associated with acne vulgaris itself is relatively low.


Medical Specialty: Surgery
Sample Name: Knee Amputation

PREOPERATIVE DIAGNOSES:,1.  Left diabetic foot abscess and infection.,2.  Left calcaneus fracture with infection.,3.  Right first ray amputation.,POSTOP DIAGNOSES:,1.  Left diabetic foot abscess and infection.,2.  Left calcaneus fracture with infection.,3.  Right first ray amputation.,OPERATION AND PROCEDURE:,1.  Left below-the-knee amputation.,2.  Dressing change, right foot.,ANESTHESIA: , General.,BLOOD LOSS: , Less than 100 mL.,TOURNIQUET TIME:,  24 minutes on the left, 300 mmHg.,COMPLICATIONS:,  None.,DRAINS: , A one-eighth-inch Hemovac.,INDICATIONS FOR SURGERY: , The patient is a 62 years of age with diabetes.  He developed left heel abscess.  He had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads.  After re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation.  We are going to change the dressing on the right side also.  The risks, benefits, and alternatives of surgery were discussed.  The risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery.  He understood all the risks and desired operative treatment.,OPERATIVE PROCEDURE IN DETAIL: , After appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position.  General anesthesia induced.  Once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied.  The right leg was redressed.  I took the dressing down.  There was a small bit of central drainage, but it was healing nicely.  Adaptic and new sterile dressings were applied.,The left lower extremity was then prepped and draped in usual sterile fashion.,A transverse incision made about the mid shaft of the tibia.  A long posterior flap was created.  It was taken to the subcutaneous tissues with electrocautery.  Please note that tourniquet had been inflated after exsanguination of the limb.  Superficial peroneal nerve identified, clamped, and cut.  Anterior compartment was divided.  The anterior neurovascular bundle identified, clamped, and cut.  The plane was taken between the deep and superficial compartments.  The superficial compartment was reflected posteriorly.  Tibial nerve identified, clamped, and cut.  Tibial vessels identified, clamped, and cut.,Periosteum of the tibia elevated proximally along with the fibula.  The tibia was then cut with Gigli saw.  It was beveled anteriorly and smoothed down with a rasp.  The fibula was cut about a cm and a half proximal to this using a large bone cutter.  The remaining posterior compartment was divided.  The peroneal bundle identified, clamped, and cut.  The leg was then passed off of the field.  Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie.  The nerves were each pulled at length, injected with 0.25% Marcaine with epinephrine, cut, and later retracted proximally.  The tourniquet was released.  Good bleeding from the tissues and hemostasis obtained with electrocautery.  Copious irrigation performed using antibiotic-impregnated solution.  A one-eighth-inch Hemovac drain placed in the depth of wound adhering on the medial side.  A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 Vicryl in an interrupted fashion.  The remaining fascia was closed with #1 Vicryl.  Subcutaneous tissues were then closed with 2-0 PDS suture using 2-0 Monocryl suture in interrupted fashion.  Skin closed with skin staples.  Xeroform gauze, 4 x 4, and a padded soft dressing applied.  He was placed in a well-padded anterior and posterior slab splint with the knee in extension.  He was then awakened, extubated, and taken to recovery in stable condition.  There were no immediate operative complications, and he tolerated the procedure well.
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DESCRIPTION: Left below-the-knee amputation.  Dressing change, right foot.

surgery, infection, adaptic, gigli saw, hemovac, abscess, amputation, below-the-knee amputation, calcaneus fracture, debridement, diabetic foot, ray amputation, tourniquet, transverse incision, knee amputation, knee, dressing, clamped,

The case involves a surgical procedure, specifically a left below-the-knee amputation, in a patient with complications from diabetes. Surgery inherently carries high stakes due to the potential for complications, the need for precision, and the significant impact on the patient's quality of life post-operation. The decision for amputation indicates a severe infection that was not manageable with less invasive methods. While the postoperative report indicates no complications, the seriousness of the procedure itself and the specialized care involved make it high-stakes.


Medical Specialty: Neurosurgery
Sample Name: Frontotemporoparietal Craniotomy

PREOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,POSTOPERATIVE DIAGNOSES: , Acute subdural hematoma, right, with herniation syndrome.,OPERATION PERFORMED:  ,Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma.,ANESTHESIA: , General endotracheal.,PREPARATION: , Povidone.,INDICATION:,  This is an 83-year-old male with herniation syndrome with large subdural hematoma 100%.  This procedure is being done as an emergency procedure in an attempt to save his life and maximize the potential for recovery.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room intubated.  The patient previously was given fresh frozen plasma plus recombinant activated factor VII.  The patient had a roll placed on his right shoulder, head was maintained three point fixation with a Mayfield headholder.  The right side of the head was shaved, thoroughly prepped and draped, a large ? scalp incision was marked, infiltrated with local and incised with a scalpel, Raney clips were applied to the scalp margins, hemostasis, temporalis muscle and fascia, pericranium opened and aligned with incision, flap was reflected anteriorly.  Burr holes are placed low in the temporal bone at the keyhole posteriorly and then superiorly with a perforator, then using Midas Rex drill with a B1 foot plate a free flap was turned.  The dura was opened in a cruciate fashion, acute subdural hematoma was evacuated.  There was a small arterial bleeder in the anterior parietal region, which was controlled with bipolar electrocautery.  Using suction and biopsy forceps, acute clot was resected from the frontotemporoparietal and occipital poles, subdural space was irrigated, no further bleeders were encountered.  Dura was closed with 4-0 Nurolon.  A subdural Camino ICP catheter was placed in the subdural space.  Bone flaps secured in place with neuro clips with 5 mm screws, central pack up suture was placed, dural tack up sutures were placed using 4-0 Nurolon prior to placement of the bone flap.  The wound was irrigated with saline, temporalis muscle and fascia closed with 2-0 Vicryl, subgaleal Hemovac was placed, galea was closed with 2-0 Vicryl, and scalp with staples.  ICP monitor and the Hemovac were sutured in place with 2-0 Vicryl.  The patient was taken out of the head holder, a sterile dressing placed.  The head was wrapped.  The patient was taken directly to ICU, still intubated in guarded condition.  Brain was nicely soft and pulsatile.  At the termination of the procedure, no significant contusion of the brain was identified.  Final sponge and needle counts are correct.  Estimated blood loss 400 cc.
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DESCRIPTION: Right frontotemporoparietal craniotomy, evacuation of acute subdural hematoma.   Acute subdural hematoma, right, with herniation syndrome.

neurosurgery, subdural hematoma, craniotomy, herniation, subdural, temporalis, frontotemporoparietal, hematoma,

The procedure detailed is a right frontotemporoparietal craniotomy to evacuate an acute subdural hematoma associated with herniation syndrome. This is a high-stakes and life-saving surgical intervention. The patient is an 83-year-old male in critical condition, requiring emergency surgery to relieve pressure on the brain and prevent further neurological damage or death. Neurosurgical procedures, particularly in elderly patients with conditions like herniation syndrome, are inherently high-risk due to the potential for severe consequences, including death, if not successfully performed. The stakes are further heightened by the complexity of the surgery and the patient's fragile state.


Medical Specialty: Neurology
Sample Name: MRI of Brain w/o Contrast.

EXAM: , MRI of the brain without contrast.,HISTORY: , Daily headaches for 6 months in a 57-year-old.,TECHNIQUE:  ,Noncontrast axial and sagittal images were acquired through the brain in varying degrees of fat and water weighting.,FINDINGS: , The brain is normal in signal intensity and morphology for age.  There are no extraaxial fluid collections.  There is no hydrocephalus/midline shift.  Posterior fossa, 7th and 8th nerve complexes and intraorbital contents are within normal limits.  The normal vascular flow volumes are maintained.  The paranasal sinuses are clear.,Diffusion images demonstrate no area of abnormally restricted diffusion that suggests acute infarct.,IMPRESSION: , Normal MRI brain.  Specifically, no findings to explain the patient's headaches are identified.
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DESCRIPTION: MRI of the brain without contrast to evaluate daily headaches for 6 months in a 57-year-old.

neurology, mri, diffusion, posterior fossa, axial, brain, contrast, extraaxial, flow, fluid collections, headaches, hydrocephalus, intraorbital, morphology, paranasal, sagittal, sinuses, vascular, weighting, without contrast, mri of the brain, noncontrast,

The situation involves interpreting an MRI of the brain in a 57-year-old patient who has experienced daily headaches for six months. While headaches can indicate various conditions, the MRI results are normal with no acute findings, such as infarcts or abnormalities in the brain structure, which typically would be concerning signs. The examination seems to be part of a diagnostic process to rule out serious concerns related to the headaches rather than responding to an immediate life-threatening situation.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 14

HISTORY OF PRESENT ILLNESS: , The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat.  She had an EGD and colonoscopy with Dr. ABC a few days prior to this admission.  Colonoscopy did reveal diverticulosis and EGD showed retained bile and possible gastritis.  Biopsies were done.  The patient presented to our emergency room for worsening abdominal pain as well as swelling of the right lower leg.,PAST MEDICAL HISTORY: , Extensive and well documented in prior charts.,PHYSICAL EXAMINATION: , Abdomen was diffusely tender.  Lungs clear.  Blood pressure 129/69 on admission.  At the time of admission, she had just a trace of bilateral lower edema.,LABORATORY STUDIES: , White count 6.7, hemoglobin 13, hematocrit 39.3.  Potassium of 3.2 on 08/15/2007.,HOSPITAL COURSE: , Dr. ABC apparently could not advance the scope into the cecum and therefore warranted a barium enema.  This was done and did not really show what the cecum on the barium enema.  There was some retained stool in that area and the patient had a somewhat prolonged hospital course on the remaining barium from the colon.  She did have some enemas.  She had persistent nausea, headache, neck pain throughout this hospitalization.  Finally, she did improve enough to the point where she could be discharged home.,DISCHARGE DIAGNOSIS: , Nausea and abdominal pain of uncertain etiology.,SECONDARY DIAGNOSIS:  ,Migraine headache.,COMPLICATIONS:  ,None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN:  ,Follow up with me in the office in 5 to 7 days to resume all pre-admission medications.  Diet and activity as tolerated.
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DESCRIPTION: The patient is a 60-year-old female patient who off and on for the past 10 to 12 months has had almost daily diarrhea, nausea, inability to eat.

discharge summary, diarrhea, nausea, inability to eat, egd, colonoscopy, biopsies, barium enema, cecum, barium, admission,

The situation described involves a medical discharge summary of a patient with persistent and unclear symptoms including abdominal pain, nausea, and a secondary diagnosis of migraine headaches. However, the immediate situation is not critical, as the patient is well enough to be discharged with plans for follow-up care. The potential severity of undiagnosed medical conditions adds some level of risk, but since the patient is stable enough to be discharged, this is not an immediately high-stakes scenario.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Laparotomy & Salpingectomy

PREOPERATIVE DIAGNOSES:,1.  Right ectopic pregnancy.,2.  Severe abdominal pain.,3.  Tachycardia.,POSTOPERATIVE DIAGNOSES:,1.  Right ectopic pregnancy.,2.  Severe abdominal pain.,3.  Tachycardia.,PROCEDURE PERFORMED:,  Exploratory laparotomy and right salpingectomy.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , 200 mL.,COMPLICATIONS:  ,None.,FINDINGS: , Right ectopic pregnancy with brisk active bleeding approximately 1L of blood found in the abdomen cavity.  Normal-appearing ovaries bilaterally, normal-appearing left fallopian tube, and normal-appearing uterus.,INDICATIONS:  ,The patient is a 23-year-old gravida P2, P0 at approximately who presented to ER at approximately 8 weeks gestational age with vaginal bleeding and severe abdominal pain.  The patient states she is significant for a previous right ectopic pregnancy diagnosed in 08/08 and treated appropriately and adequately with methotrexate.  Evaluation in the emergency room reveals a second right ectopic pregnancy.  Her beta quant was found to be approximately 13,000.  The ultrasound showed right adnexal mass with crown-rump length measuring consistent with an 8 weeks gestation and a moderate free fluid in the abdominal cavity.  Given these findings as well as physical examination findings a recommendation was made proceed with an exploratory laparotomy and right salpingectomy.  The procedure was discussed with the patient in detail including risks of bleeding, infection, injury to surrounding organs and possible need for further surgery.  Informed consult was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where general anesthesia was administered without difficulty.  The patient was prepped and draped in the usual sterile fashion.  A Pfannenstiel skin incision was made with scalpel and carried through to the underlying layer of fascia using the Bovie.  The fascia was incised in the midline and extended laterally using Mayo scissors.  Kocher clamps were used to grasp the superior aspect of the fascial incision, which was elevated and the underlying rectus muscles were dissected off bluntly using Mayo scissors, attention was then turned to the inferior aspect, which was grasped with Kocher clamps, elevated and the underlying rectus muscles dissected up bluntly using Mayo scissors.  The rectus muscles were dissected in the midline.  The peritoneum was identified using blunt dissection and entered in this manner and extended superiorly and inferiorly with good visualization of the bladder.  At this time, the blood found in the abdomen was suctioned.  The bowel was packed with moist laparotomy sponge.  The right ectopic pregnancy was identified.  The fallopian tube was clamped x2, excised, and ligated x2 using 0-Vicryl suture.  Hemostasis was visualized.  At this time, the left tube and ovary were examined and were found to be normal in appearance.  The pelvis was cleared off clots and was copiously irrigated.  The fallopian tube was reexamined and it was noted to be hemostatic.,At this time, the laparotomy sponges were removed.  The rectus muscles were reapproximated using 3-0 Vicryl.  The fascia was reapproximated with #0 Vicryl sutures.  The subcutaneous layer was closed with 3-0 plain gut.  The skin was closed with 4-0 Monocryl.  Sponge, lap, and instrument counts were correct x2.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.
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DESCRIPTION: Exploratory laparotomy and right salpingectomy.

obstetrics / gynecology, ectopic pregnancy, salpingectomy, exploratory laparotomy, fallopian tube, mayo scissors, rectus muscles,

The situation involves a surgical procedure to address a right ectopic pregnancy. Ectopic pregnancies are serious medical conditions that can lead to life-threatening complications, such as internal bleeding, if not treated promptly. The procedure, an exploratory laparotomy and right salpingectomy, is major surgery, necessitated by active internal bleeding, and carries risks of bleeding and injury to surrounding organs. The quick and efficient management of this condition is crucial to the patient's health and possibly her life.


Medical Specialty: Neurology
Sample Name: Anaplastic Astrocytoma - Letter

XYZ,RE:  ABC,MEDICAL RECORD#:  123,Dear Dr. XYZ:,I saw ABC back in Neuro-Oncology Clinic today.  He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.,Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion.  The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent.  It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective.  Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.,After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen.  They came in with a list of eight possible agents that they would like to be administered within the next two weeks.  They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.,From my view, I noticed a man whose language has deteriorated in the week since I last saw him.  This is very worrisome.  Today, for the first time, I felt that there was a definite right facial droop as well.  Therefore, there is no doubt that he is becoming symptomatic from his growing tumor.  It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.,Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation.  Despite an hour, this again amazingly was not possible.  It is not that he does not want treatment, however.  Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen.  We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days.  In addition, we will stop thalidomide 100 mg/day.  If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us.  At this stage, we are thinking of using Accutane at that point.,While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval.  In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later.  I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.,I will keep you apprised of followups.  If you have any questions or if I could be of any further assistance, feel free to contact me.,Sincerely,
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DESCRIPTION: Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.

neurology, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma

This situation involves a patient with anaplastic astrocytoma, a serious and progressive brain tumor. The patient exhibits symptoms indicating worsening condition (deteriorating language, right facial droop), which are concerning for the progression of the disease. The patient is hesitant to undergo radiation, which is suggested as the most effective treatment option at this stage. The alternative treatment plan is not ideal and relies heavily on monitoring and compromise, reflecting uncertainty about its effectiveness. Such medical decisions could significantly impact the patient's quality of life and survival, making this a high-stakes situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Psych Consult - Lethargy

REASON FOR CONSULTATION: , Lethargy.,HISTORY OF PRESENT ILLNESS:,  The patient is a 62-year-old white female with a past medical history of left frontal glioblastoma with subsequent craniotomy infection for PE, DVT, hyperlipidemia, and hypertension who is according to the patient's daughter expressing signs of depression.  Symptoms began on February 5, 2007, upon receiving the unexpected news, the patient would need three to four more days of chemotherapy and radiation therapy for her glioblastoma, described as a sudden onset of symptoms including hypersomnia (18 to 20 hours per day), drastic decrease in energy level, anhedonia, feelings of hopelessness and helplessness, psychomotor retardation, and past history of suicidal ideations.  The patient's appetite is unknown since she had been fed by NG tube after being diagnosed with neuromuscular oropharyngeal dysphagia.  Prior to receiving the news for needing more cancer therapy, the patient was described as being "fine," participating in physical therapy and talking regularly as she was looking forward to leaving the hospital.  Now, the patient has become angry, socially withdrawn, not wanting to see anyone including her own grandchildren, and not participating in physical therapy.  Has been on a daily dose of Lexapro since January 08, 2007, was increased from 10 mg to 20 mg on January 24, 2007, which is her current dose.  Has been on Provigil 100 mg b.i.d. since February 06, 2007, but has not noticed an impact.  Had been on Zyprexa 2.5 mg p.o. q.p.m. from December 20, 2006, to February 01, 2007, but has been discontinued.  Currently, the patient has not displayed any manic symptoms, auditory or visual hallucinations, or symptoms of anxiety.  Also, denies any homicidal ideations.,PAST PSYCHIATRIC HISTORY:,  Was prescribed Prozac for depression, felt during husband's successful battle with prostate cancer.  Never been diagnosed with psychiatric illness.  Displayed some psychotic symptoms, status post craniotomy while in ICU, treated with Zyprexa and Xanax during hospitalization in 2006.,PAST MEDICAL HISTORY:,  Craniotomy November 2006 with subsequent CSF infection of enterobacter, status post glioblastoma multiforme, PE, DVT, hypertension, SIADH, and IVC filter.  No history of thyroid problems, seizures, strokes, or traumatic head injuries.,HOME MEDICATIONS:,  Norvasc 5 mg daily, TriCor 145 mg daily, aspirin one tablet daily, Tylenol, and glucosamine chondroitin sulfate.,CURRENT MEDICATIONS:,  Norvasc 10 mg p.o. daily, Decadron injection 6 mg IV q.12h., Colace 100 mg liquid b.i.d., Cardura 2 mg p.o. daily, Lexapro 20 mg p.o. daily, Lopressor 50 mg p.o. q.12h., Flagyl 500 mg via PEG tube q.8h., modafinil 100 mg p.o. b.i.d., Lovenox 60 mg subcu q.12h., insulin sliding scale, Tylenol suppositories 650 mg rectal q.4h. p.r.n., and Ambien 5 mg p.o. q.h.s. p.r.n.,ALLERGIES:,  PHENYTOIN (STEVENS-JOHNSON SYNDROME), CODEINE, NOVOCAIN, UNKNOWN ALLERGY.,FAMILY MEDICAL HISTORY:,  Father had lung cancer, was smoker for 40 years.  Father's aunt have heart disease.,SOCIAL AND DEVELOPMENTAL HISTORY:,  Currently lives with husband of 40 years in League City, has a Masters in Education, is a retired reading specialist which she did it for 33 years.  Has one younger brother, one daughter.  Denies use of tobacco, alcohol and illicit drugs.  The child as per daughter was picked on and has a strained relationship with her mother, but they still are communicating.,MENTAL STATUS EXAMINATION:,  The patient is a 62-year-old white female, lying in hospital bed, with gown on, eyes closed, short shaven hair, and golf ball-sized indentation in the anterior fontanelle from craniotomy.  Psychomotor retardation, poor eye contact, speech low volume, slow rate, poor flexion, essentially unresponsive, and somnolent during interview.  Poor concentration, mood unknown (the patient did not respond to questions), affect flat, thought process logical and goal directed, thought content unable to assess from the patient but the patient's daughter denied delusions and homicidal ideations.  Positive for passive suicidal ideations and perceptions.  No auditory or visual hallucinations.  Sensorium stuporous, did not answer orientation questions.  Memory information, intelligence, judgment, and insight unknown.,Mini-Mental status examination unable to be performed.,ASSESSMENT:,  A 62-year-old white female status post craniotomy for glioblastoma multiforme with subsequent CNS infection and currently has been displaying symptoms of depression for the past seven days and hence was told she needed more chemotherapy and radiation therapy.,Axis I:  Depression, NOS.  Rule out depression secondary to general medical condition.,Axis II:  Deferred.,Axis III:  Craniotomy with subsequent CSF infection, PE, DVT, and hypertension.,Axis IV:  Hospitalization.,Axis V:  11.,PLAN:,  Continue Lexapro 20 mg p.o. daily.  Discontinue Provigil, begin Ritalin 5 mg p.o. q.a.m. and q. noon.,Thank you for the consultation.
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DESCRIPTION: Psychiatric consultation of patient with lethargy.

The situation involves a 62-year-old female patient with a serious medical history including glioblastoma and depression symptoms following news of extended chemotherapy and radiation treatment. There are also concerns about psychiatric well-being, including depressive symptoms and past suicidal ideations. The situation is high-stakes due to the complexity of the patient's medical condition, the potential for severe psychological impact, and the significant implications for the patient's treatment and quality of life.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Carotid Endarterectomy - 1

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

cardiovascular / pulmonary, angioplasty, common carotid artery, external carotid artery, hemashield patch, common carotid, carotid endarterectomy, external, artery, carotid, hemashield, endarterectomy

The situation involves a detailed description of a carotid endarterectomy procedure, which is a surgical operation to remove atherosclerotic plaque from the carotid artery to prevent strokes. This type of surgery is considered high-stakes due to its direct impact on blood flow to the brain, the potential risks of anesthesia, the importance of precise surgical technique to prevent complications such as stroke or bleeding, and the need for meticulous post-operative care to ensure patient recovery. Since this concerns the cardiovascular system and involves significant surgical intervention, the stakes are notably high.


Medical Specialty: Gastroenterology
Sample Name: Flex Sig - 2

PROCEDURE IN DETAIL: , Following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal.  The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.  Withdrawal notes an otherwise normal descending, rectosigmoid and rectum.  Retroflexion noted no abnormality of the internal ring.  No hemorrhoids were noted.  Withdrawal from the patient terminated the procedure.
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DESCRIPTION: Flexible sigmoidoscopy.  The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.

gastroenterology, flexible sigmoidoscopy, flex sig, colonoscope, olympus video colonoscope, rectumNOTE,: 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 is a routine medical examination called a flexible sigmoidoscopy, used to examine the lower part of the colon and rectum. It seems to be a straightforward case where no abnormalities were found, which indicates it went normally. However, any medical procedure can have underlying risks, though in this situation, it appears to be low-risk as it's a part of standard medical care and no complications are mentioned.


Medical Specialty: Orthopedic
Sample Name: Knee Arthroplasty

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

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

The situation involves a surgical procedure, specifically a right total knee arthroplasty, which is a common but significant orthopedic surgery. The procedure went without complication, and the patient tolerated it well. Nevertheless, surgery inherently carries a higher level of risk compared to non-invasive medical situations due to the potential for complications like infections, bleeding, or postoperative issues, albeit none were reported here. Given that surgery's success is crucial for the patient's mobility and quality of life, it adds to the overall stakes.


Medical Specialty: Gastroenterology
Sample Name: Flex Sig - 1

INDICATION:  , Rectal bleeding.,PREMEDICATION:, See procedure nurse NCS form.,PROCEDURE:  ,
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DESCRIPTION: Flexible sigmoidoscopy due to rectal bleeding.

gastroenterology, rectal bleeding, digital rectal exam, pentax video, anal verge, angiodysplasia, colonic mucosa, diverticula, endoscope, flexible, flexible sigmoidoscopy, hemorrhoids, masses, polyps, rectum, sigmoidoscopy, sphincter tone, internal hemorrhoids, bleeding, rectal

The procedure involves a flexible sigmoidoscopy, which is a diagnostic procedure to investigate rectal bleeding. While this is a routine procedure, the indication of rectal bleeding can sometimes hint at serious underlying conditions like colorectal cancer or other gastrointestinal diseases. However, by itself, the procedure is generally low-risk and moderately routine within gastroenterology, unless there are known complications or high-risk patient factors.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Endotracheal Intubation

PROCEDURE: , Endotracheal intubation.,INDICATION: , Respiratory failure.,BRIEF HISTORY: , The patient is a 52-year-old male with metastatic osteogenic sarcoma.  He was admitted two days ago with small bowel obstruction.  He has been on Coumadin for previous PE and currently on heparin drip.  He became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness.  A code blue was called.  On my arrival, the patient's vital signs are stable.  His blood pressure is systolically in 140s and heart rate 80s.  He however has 0 respiratory effort and is unresponsive to even painful stimuli.  The patient was given etomidate 20 mg.,DESCRIPTION OF PROCEDURE:  ,The patient positioned appropriate equipment at the bedside, given 20 mg of etomidate and 100 mg of succinylcholine.  Mac-4 blade was used.  A 7.5 ET tube placed to 24th teeth.  There is good color change on the capnographer with bilateral breath sounds.  Following intubation, the patient's blood pressure began to drop.  He was given 2 L of bolus.  I started him on dopamine drip at 10 mcg.  Dr. X was at the bedside, who is the primary caregiver, he assumed the care of the patient, will be transferred to the ICU.  Chest x-ray will be reviewed and Pulmonary will be consulted.
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DESCRIPTION: Endotracheal intubation.  Respiratory failure.  The patient is a 52-year-old male with metastatic osteogenic sarcoma.  He was admitted two days ago with small bowel obstruction.

cardiovascular / pulmonary, metastatic osteogenic sarcoma, respiratory failure, bowel obstruction, blood pressure, endotracheal intubation, endotracheal, sarcoma

The scenario describes a medical situation where a 52-year-old patient with metastatic cancer has experienced respiratory failure necessitating an urgent endotracheal intubation. The patient is in critical condition with no respiratory effort and minimal responsiveness, signaling a life-threatening emergency. Endotracheal intubation is a high-stakes procedure because it directly relates to securing the airway and stabilizing breathing, which are critical for patient survival. The patient's deteriorating condition, including the drop in blood pressure post-intubation and the need for a dopamine drip and ICU transfer, underscores the high-risk, high-stakes nature of this scenario.


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: Bariatric Consult - Surgical Weight Loss - 2

PAST MEDICAL HISTORY:  ,She had a negative stress test four to five years ago.  She gets short of breath in walking about 30 steps.  She has had non-insulin dependent diabetes for about eight years now.  She has a left knee arthritis and history of hemorrhoids.,PAST SURGICAL HISTORY: , Pertinent for laparoscopic cholecystectomy, tonsillectomy, left knee surgery, and right breast lumpectomy.,PSYCHOLOGICAL HISTORY: , Negative except that she was rehabilitated for alcohol addiction in 1990.,SOCIAL HISTORY: , The patient is married.  She is an office manager for a gravel company.  Her spouse is also overweight.  She drinks on a weekly basis and she smokes,about two packs of cigarettes over a week's period of time.  She is doing this for about 35 years.,FAMILY HISTORY: , Diabetes and hypertension.,MEDICATIONS:,  Include Colestid 1 g daily, Actos 30 mg daily, Amaryl 2 mg daily, Soma, and meloxicam for her back pain.,ALLERGIES:,  She has no allergies; however, she does get tachycardic with caffeine, Sudafed, or phenylpropanolamine.,REVIEW OF SYSTEMS: , Otherwise, negative.,PHYSICAL EXAM: , This is a pleasant female in no acute distress.  Alert and oriented x 3.  HEENT:  Normocephalic, atraumatic.  Extraocular muscles intact, nonicteric sclerae.  Chest is clear.  Abdomen is obese, soft, nontender and nondistended.  Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN: , This is a 51-year-old female with a BMI of 43 who is interested in the Lap-Band as opposed to gastric bypass.  ABC will be asking for a letter of medical necessity from XYZ.  She will also need an EKG and clearance for surgery.  She will also see my nutritionist and social worker and once this is completed, we will submit her to her insurance company for approval.
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DESCRIPTION: Evaluation for elective surgical weight loss via the Lap-Band as opposed to gastric bypass.

consult - history and phy., elective surgical weight loss, surgical weight loss, weight loss, lap band, gastric bypass, loss, weight, lap, band, lost, gained, diabetes, gastric, bypass, overweight, surgical

The situation is a medical assessment for elective bariatric surgery, specifically the Lap-Band procedure. While it involves surgery and has health implications, it is elective and primarily aimed at addressing obesity rather than an immediate life-threatening condition. The patient's past medical history includes non-insulin dependent diabetes, knee arthritis, and a history of alcohol rehabilitation. While these factors can increase health risks, the procedure itself is routine with standard protocols. The stakes are moderately high due to surgical and anaesthetic risks, especially given the patient's obesity and related health conditions, but they are not considered extremely high as in emergency or critical care situations.


Medical Specialty: Surgery
Sample Name: Carpal Ligament Release - 2

PREOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome.,2.  Stenosing tenosynovitis of right middle finger (trigger finger).,POSTOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome.,2.  Stenosing tenosynovitis of right middle finger (trigger finger).,PROCEDURES:,1.  Endoscopic release of left transverse carpal ligament.,2.  Steroid injection, stenosing tenosynovitis of right middle finger.,ANESTHESIA:  ,Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME: , Left upper extremity was 15 minutes.,OPERATIVE PROCEDURE IN DETAIL:,  With the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mmHg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the palm between FCR and FCU, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,Hamate sounds were then used to palpate the Hood of Hamate.  The Agee Inside Job was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.  The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the Agee Inside Job was withdrawn, dividing transverse carpal ligament under direct vision.  After complete division of transverse carpal ligament, the Agee Inside Job was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished.  One mL of Celestone was then introduced into the carpal tunnel and irrigated free.  ,The wound was then closed with a running 3-0 Prolene subcuticular stitch.  Steri-strips were applied and a sterile dressing was applied over the Steri-strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.,Attention was turned to the right palm where after a sterile prep, the right middle finger flexor sheath was injected with 0.5 mL of 1% plain Xylocaine and 0.5 mL of Depo-Medrol 40 mg/mL.  A Band-Aid dressing was then applied.,The patient was then awakened from the anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.
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DESCRIPTION: Endoscopic release of left transverse carpal ligament.  Steroid injection, stenosing tenosynovitis of right middle finger.

surgery, carpal tunnel syndrome, agee inside job, steroid injection, antebrachial fascia, forearm, ring ray, synovial elevator, tenosynovitis, tourniquet, transverse incision, trigger finger, tenosynovitis of right middle, transverse carpal ligament, transverse carpal, carpal ligament, steri strips, stenosing tenosynovitis, middle finger, ligament, carpal, endoscopic, finger

The procedure described involves surgery for left carpal tunnel syndrome and a steroid injection for stenosing tenosynovitis of the right middle finger. These are common procedures in orthopedic and hand surgery with usually predictable outcomes. The use of monitored anesthesia care and regional anesthesia indicates that it is a relatively minor and routine surgical procedure, which generally entails low risk and is often performed on an outpatient basis. However, any surgical procedure can have complications, making it necessary to ensure proper adherence to protocol.


Medical Specialty: Radiology
Sample Name: Magnified Airway Study

EXAM:,  Magnified airway.,CLINICAL HISTORY: , An 11-month-old female with episodes of difficulty in breathing, cough.,TECHNIQUE: , Multiple fluoroscopic spot images of the pharyngeal airway, trachea, and mainstem bronchi were performed in various phases of respiration.,FINDINGS:,  The airway is patent throughout its course.  Specifically, the trachea and both mainstem bronchi do not demonstrate evidence of dynamic collapse greater than 50%.,No filling defects are identified.,The vocal cords demonstrate normal opening and closing.,IMPRESSION: , Normal magnified airway examination.
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DESCRIPTION: Magnified Airway Study - An 11-month-old female with episodes of difficulty in breathing, cough.

radiology, magnified airway study, difficulty in breathing, airway study, breathing cough, mainstem bronchi, magnified airway, cough, trachea, mainstem, bronchi, airway

The examination involves a medical assessment of an 11-month-old infant experiencing breathing difficulties and cough, which are concerning symptoms in such a young child. However, the findings indicate a normal study with no dynamic collapse or filling defects in the airway, effectively ruling out some severe airway obstruction concerns. The assessment helps in understanding the child's respiratory health, but since the findings are normal, the immediate stakes are lowered. However, the situation still involves assessing an infant's health, which always carries some importance due to the vulnerability of the age group and potential for underlying issues.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Transthoracic Echocardiography

REASON FOR EXAM: , Coronary artery bypass surgery and aortic stenosis.,FINDINGS: , Transthoracic echocardiogram was performed of technically limited quality.  The left ventricle was normal in size and dimensions with normal LV function.  Ejection fraction was 50% to 55%.  Concentric hypertrophy noted with interventricular septum measuring 1.6 cm, posterior wall measuring 1.2 cm.  Left atrium is enlarged, measuring 4.42 cm.  Right-sided chambers are normal in size and dimensions.  Aortic root has normal diameter.,Mitral and tricuspid valve reveals annular calcification.  Fibrocalcific valve leaflets noted with adequate excursion.  Similar findings noted on the aortic valve as well with significantly adequate excursion of valve leaflets.  Atrial and ventricular septum are intact.  Pericardium is intact without any effusion.  No obvious intracardiac mass or thrombi noted.,Doppler study reveals mild-to-moderate mitral regurgitation.  Severe aortic stenosis with peak velocity of 2.76 with calculated ejection fraction 50% to 55% with severe aortic stenosis.  There is also mitral stenosis.,IMPRESSION:,1.  Concentric hypertrophy of the left ventricle with left ventricular function.,2.  Moderate mitral regurgitation.,3.  Severe aortic stenosis, severe.,RECOMMENDATIONS: , Transesophageal echocardiogram is clinically warranted to assess the aortic valve area.
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DESCRIPTION: Coronary artery bypass surgery and aortic stenosis.  Transthoracic echocardiogram was performed of technically limited quality.  Concentric hypertrophy of the left ventricle with left ventricular function.  Moderate mitral regurgitation.  Severe aortic stenosis, severe.

cardiovascular / pulmonary, coronary artery bypass surgery, aortic stenosis, annular calcification, tricuspid, mitral, regurgitation, severe aortic stenosis, concentric hypertrophy, mitral regurgitation, transthoracic, echocardiogram, hypertrophy, ventricular, valve, stenosis, aortic

The situation involves the cardiovascular health of a patient who has undergone coronary artery bypass surgery and has severe aortic stenosis, among other conditions. These conditions can be quite serious, potentially affecting the patient's quality of life and risk of further cardiovascular events. Therefore, clinical interpretation and treatment are high-stakes, as incorrect or delayed management could have significant implications for the patient's health.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Lens Implantation

PREOPERATIVE DIAGNOSIS:,  Cataract, nuclear sclerotic, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, nuclear sclerotic, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with intraocular lens implantation, right eye.,ANESTHESIA: , Topical tetracaine, intracameral lidocaine, monitored anesthesia care.,IOL: , AMO Model SI40 NB, power *** diopters.,INDICATIONS FOR SURGERY: , This patient has been experiencing difficulty with eyesight regarding activities in their daily life.  There has been a progressive and gradual decline in the visual acuity.  By examination, this was found to be related to cataracts.  The risks, benefits, and alternatives (including observation or spectacles) were discussed in detail.  The patient accepted these risks and elected to proceed with cataract surgery.  All questions were answered and informed consent was obtained.,Questions were answered in personal conference with the patient to ensure that the patient had a good grasp of the operative goals, risks, and alternatives involved as well as the postoperative instructions.  A preoperative surgical history and physical examination was done to ensure that the patient was in optimal general health for cataract surgery.  To minimize and decrease the chance of bacterial infection, the patient was started on a course of antibiotic drops for two days prior to surgery.,DESCRIPTION OF PROCEDURE:  ,The patient was identified and the procedure was verified.  The pupil was dilated per protocol.  The patient was taken to the operating room and placed in a comfortable supine position.  The operative table was placed in Trendelenburg head-up tilt to decrease orbital congestion and posterior vitreous pressure.  The patient was prepped and draped in the usual ophthalmic sterile fashion.  The lids and periorbita were prepped with full-strength Betadine solution with care taken to concentrate on sterilizing the eyelid margins.  The conjunctival cul-de-sac was also prepped in dilute Betadine solution.  The fornices were also prepped.  The drape was done meticulously to ensure complete eyelash inclusion.,An eyelid speculum was placed to separate the eyelids.  A paracentesis site was made.  Intracameral preservative-free lidocaine was injected.  Amvisc Plus was then used to stabilize the anterior chamber.  A 3-mm diamond blade was then used to carefully construct a clear corneal incision in the temporal location.  A 25-gauge pre-bent cystotome was used to begin a capsulorrhexis.  The capsular flap was removed.  A 27-gauge blunt cannula was used for hydrodissection.  The lens was able to be freely rotated within the capsular bag.  Divide-and-conquer technique was used for phacoemulsification.  After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment.  Each of the four nuclear quadrants was phacoemulsified.  Aspiration was used to remove remaining cortex with the I/A handpiece.  Viscoelastic was used to re-inflate the capsular bag.  The intraocular lens was injected into the capsular bag.  The lens was then dialed into position.  The lens was well-centered and stable.  Viscoelastic was aspirated.  BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure along with stromal hydration.  A Weck-Cel sponge was used to check both incision sites for leaks and none were identified.  The incision sites remained well approximated and dry with a well-formed anterior chamber and well-centered intraocular lens.  The eyelid speculum was removed and the patient was cleaned free of Betadine.  Zymar and Pred Forte drops were applied.  A firm eye shield was taped over the operative eye.  The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed.  All questions were answered.  The discharge instructions were also reviewed with the patient by the discharging nurse.  The patient was comfortable and was discharged with followup in 24 hours.
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DESCRIPTION: Cataract, nuclear sclerotic, right eye.  Phacoemulsification with intraocular lens implantation, right eye.

ophthalmology, nuclear sclerotic, diopters, viscoelastic, capsulorrhexis, amvisc plus, lens implantation, intraocular lens, intraocular, topical, cataract, phacoemulsification, lens

The procedure described is a cataract surgery, which is a common and routine ophthalmic procedure. While any surgical procedure carries risks, cataract surgeries are generally low-risk with high success rates. This particular procedure appears to have been conducted without complications, and the patient tolerated it well. Postoperative instructions and follow-up care are standard practices to ensure recovery. Given that cataract surgeries are performed regularly and have a high rate of success, the situational stakes here are relatively low compared to other more complex or life-threatening surgeries.


Medical Specialty: Surgery
Sample Name: Laminectomy & Facetectomy

PREOPERATIVE DIAGNOSIS:,  Dural tear, postoperative laminectomy, L4-L5.,POSTOPERATIVE DIAGNOSES,1.  Dural tear, postoperative laminectomy, L4-L5.,2.  Laterolisthesis, L4-L5.,3.  Spinal instability, L4-L5.,OPERATIONS PERFORMED,1.  Complete laminectomy, L4.,2.  Complete laminectomy plus facetectomy, L3-L4 level.,3.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.,4.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.,5.  Posterior spinal fusion, L4 to S1.,6.  Insertion of morselized autograft, L4 to S1.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,DRAINS:  ,Hemovac x1.,DISPOSITION: , Vital signs stable, taken to the recovery room in a satisfactory condition, extubated.,INDICATIONS FOR OPERATION: , The patient is a 48-year-old gentleman who has had a prior decompression several weeks ago.  He presented several days later with headaches as well as a draining wound.  He was subsequently taken back for a dural repair.  For the last 10 to 11 days, he has been okay except for the last two days he has had increasing headaches, has nausea, vomiting, as well as positional migraines.  He has fullness in the back of his wound.  The patient's risks and benefits have been conferred him due to the fact that he does have persistent spinal leak.  The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively.,PROCEDURE IN DETAIL:,  After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #7.  The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties.  The patient was given intraoperative antibiotics.  The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion.,Initially, a midline incision was made from the cephalad to caudad level.  Full-thickness skin flaps were developed.  It was seen immediately that there was large amount of copious fluid emanating from the wound, clear-like fluid, which was the cerebrospinal fluid.  Cultures were taken, aerobic, anaerobic, AFB, fungal.  Once this was done, the paraspinal muscles were affected from the posterior elements.  It was seen that there were no facet complexes on the right side at L4-L5 and L5-S1.  It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4-5 level from the listhesis.  Once this was done; however, the fluid emanating from the dura could not be seen appropriately.  Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left.  Complete laminectomy at L3 was done.  Once this was done within the subarticular recess on the right side at the L4 pedicle level, a rent in the dura was seen.  Once this was appropriately cleaned, the dural edges were approximated using a running 6-0 Prolene suture.  A Valsalva confirmed no significant lead after the repair was made.  There was a significant laterolisthesis at L4-L5 and due to the fact that there were no facet complexes at L5-S1 and L4-L5 on the right side as well as there was a significant concavity on the right L4-L5 disk space which was demonstrated from intraoperative x-rays and compared to preoperative x-rays, it was decided from an instrumentation.  The lateral pedicle screws were placed at L4, L5, and S1 using the standard technique of Magerl.  After this the standard starting point was made.  Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall.  Once this was done, this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall.  The screws were subsequently placed.  Tricortical purchase was obtained at S1 ________ appropriate size screws.  Precontoured titanium rod was then appropriately planned and placed between the screws at L4, L5, and S1.  This was done on the right side first.  The screw was torqued at S1 appropriately and subsequently at L5.  Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4.  Neutral compression distraction was obtained on the left side.  Screws were torqued at L4, L5, and S1 appropriately.  Good placement was seen both in AP and lateral planes using fluoroscopy.  Laterolisthesis corrected appropriately at L4 and L5.,Posterior spinal fusion was completed by decorticating the posterior elements at L4-L5 and the sacral ala with a curette.  Once good bleeding subchondral bone was appreciated, the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix.  This was placed in the posterior lateral gutters.  DuraGen was then placed over the dural repair, and after this, fibrin glue was placed appropriately.  Deep retractors then removed from the confines of the wound.  Fascia was closed using interrupted Prolene running suture #1.  Once this was done, suprafascial drain was placed appropriately.  Subcutaneous tissues were opposed using a 2-0 Prolene suture.  The dermal edges were approximated using staples.  Wound was dressed sterilely using bacitracin ointment, Xeroform, 4 x 4's, and tape.  The drain was connected appropriately.  The patient was rolled on stretcher in usual supine position, extubated uneventfully, and taken back to the recovery room in a satisfactory stable condition.  No complications arose.
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DESCRIPTION: Complete laminectomy, L4. and facetectomy, L3-L4 level.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.  Posterior spinal fusion, L4 to S1.  Insertion of morselized autograft, L4 to S1.

The scenario described involves a complex surgical procedure on the spine, including a laminectomy, facetectomy, dural repair, spinal instrumentation, and fusion. The preoperative and postoperative diagnoses indicate significant issues such as a dural tear and spinal instability, which are serious medical concerns. The patient has a history of surgery complications, evident from postoperative symptoms like headaches, nausea, and vomiting due to cerebrospinal fluid leakage. The surgery involves high risks, including potential complications from dural tears and spinal instability, which can have severe consequences for the patient's mobility and overall health. Thus, this situation is high-stakes due to the complexity, potential risks, and the critical nature of correct surgical intervention.


Medical Specialty: Urology
Sample Name: Excretory Urogram - IVP

There is normal and symmetrical filling of the caliceal system.  Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally.  The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. The postvoid films demonstrate normal emptying of the collecting system, including the urinary bladder.,IMPRESSION:,  Negative intravenous urogram.,
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DESCRIPTION: Common Excretory Urogram - IVP template

Common Excretory Urogram - IVP template

urology, intravenous urogram, caliceal system, urinary bladder, excretory urogram, collecting systems, ivp, urogram, intravenousNOTE,: 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 presents routine findings from an excretory urogram that show normal results in a urology context. There are no abnormalities or urgent medical issues identified, such as obstructions or defects that would require immediate attention. Therefore, it is low-stakes as there is no indication of a pressing medical problem.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Cataract - Second Opinion

SUBJECTIVE:  ,The patient seeks evaluation for a second opinion concerning cataract extraction.  She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery.  Past ocular surgery history is significant for neurovascular age-related macular degeneration.  She states she has had laser four times to the macula on the right and two times to the left, she sees Dr. X for this.,OBJECTIVE: , On examination, visual acuity with correction measures 20/400 OU.  Manifest refraction does not improve this.  There is no afferent pupillary defect.  Visual fields are grossly full to hand motions.  Intraocular pressure measures 17 mm in each eye.  Slit-lamp examination is significant for clear corneas OU.  There is early nuclear sclerosis in both eyes.  There is a sheet like 1-2+ posterior subcapsular cataract on the left.  Dilated examination shows choroidal neovascularization with subretinal heme and blood in both eyes.,ASSESSMENT/PLAN:  ,Advanced neurovascular age-related macular degeneration OU, this is ultimately visually limiting.  Cataracts are present in both eyes.  I doubt cataract removal will help increase visual acuity; however, I did discuss with the patient, especially in the left, cataract surgery will help Dr. X better visualize the macula for future laser treatment so that her current vision can be maintained.  This information was conveyed with the use of a translator.,
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DESCRIPTION: The patient seeks evaluation for a second opinion concerning cataract extraction.

soap / chart / progress notes, advanced neurovascular age-related macular degeneration, neurovascular age, macular degeneration, visual acuity, cataract extraction, neurovascular, degeneration, visual, eyes, macular, cataract,

This situation involves evaluating a medical procedure (cataract extraction) for a patient with complex ocular history, including advanced neurovascular age-related macular degeneration. Although the cataract surgery itself is a common procedure, decisions affecting vision, especially given the patient's existing conditions, require careful consideration due to their impact on quality of life. However, as it is a second opinion consultation, it's not the immediate decision-making moment for a critical or emergency intervention. The stakes are moderate as it could influence the management and future vision prognosis.