Medical Specialty: Surgery
Sample Name: Tracheotomy - 1

PREOPERATIVE DIAGNOSIS: , Respiratory failure.,POSTOPERATIVE DIAGNOSIS:  ,Respiratory failure.,OPERATIVE PROCEDURE: , Tracheotomy.,ANESTHESIA:  ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General inhalational anesthesia was administered through the patient's existing 4.0 endotracheal tube.  The neck was extended and secured with tape and incision in the midline of the neck approximately 2 fingerbreadths above the sternal notch was outlined.  The incision measured approximately 1 cm and was just below the palpable cricoid cartilage and first tracheal ring.  The incision area was infiltrated with 1% Xylocaine with epinephrine 1:100,000.  A #67 blade was used to perform the incision.  Electrocautery was used to remove excess fat tissue to expose the strap muscles.  The strap muscles were grasped and divided in the midline with a cutting electrocautery.  Sharp dissection was used to expose the anterior trachea and cricoid cartilage.  The thyroid isthmus was identified crossing just below the cricoid cartilage.  This was divided in the midline with electrocautery.  Blunt dissection was used to expose adequate cartilaginous rings.  A 4.0 silk was used for stay sutures to the midline of the cricoid.  Additional stay sutures were placed on each side of the third tracheal ring.  Thin DuoDerm was placed around the stoma.  The tracheal incision was performed with a #11 blade through the second, third, and fourth tracheal rings.  The cartilaginous edges were secured to the skin edges with interrupted #4-0 Monocryl.  A 4.5 PED tight-to-shaft cuffed Bivona tube was placed and secured with Velcro ties.  A flexible scope was passed through the tracheotomy tube.  The carina was visualized approximately 1.5 cm distal to the distal end of the tracheotomy tube.  Ventilation was confirmed.  There was good chest rise and no appreciable leak.  The procedure was terminated.  The patient was in stable condition.  Bleeding was negligible and she was transferred back to the Pediatric intensive care unit in stable condition.
---
DESCRIPTION: Tracheotomy for patient with respiratory failure.

surgery, bivona tube, duoderm, tracheotomy tube, respiratory failure, cricoid cartilage, tracheotomy, tracheal,

The scenario involves a tracheotomy procedure performed on a patient with respiratory failure, which is a critical situation. A tracheotomy is a significant medical procedure required to ensure the patient's airway; thus, the stakes are naturally high as this can be life-saving. Complications such as bleeding, infection, or incorrect placement could have serious consequences. However, the specific report indicates that the procedure went smoothly, the patient was stable post-procedure, and there was negligible bleeding, which slightly reduces the immediate stakes. Nonetheless, the overall situation involves a critical lifesaving surgical intervention.


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 for New Wheelchair

HISTORY OF PRESENT ILLNESS:,  This 42-year-old male was referred to Wheelchair Clinic for evaluation for a new wheelchair.  The client has a power wheelchair at home and it is two years old.  However, he is unable to transfer throughout the community.  The client does have two teenage children for which he does need to keep up with.  He has a quickie revolution manual wheelchair that is greater than seven years old and in a complete state of repair.  His past medical history includes TIA, complete spinal cord injury resulting from a gunshot wound in 1995, diabetes mellitus, right forearm fracture, bilateral hip fracture, right fifth tendon repair, left great toe surgery, and spinal surgery.,SOCIAL HISTORY: , The patient lives with his wife and two children, ages 15 and 16 in a single floor apartment with rear entry.  The client does not work; however, he does fix some type of computers as his hobby.  His wife transports him in an oversized four-door vehicle.,FUNCTIONAL STATUS:, The patient is modified and independent for all transfers utilizing the lateral technique.  However, he does require a sideboard for tub transfers as well as car transfers.  He is independent with his bed mobility.  He is unable to ambulate due to his level of injury.  At home, he does have an extended tub bench for showering.  His wheelchair mobility has succeeded to modified independent level as well as wheelchair management and pressure release.  He is dependent for community mobility with his manual wheelchair.  The patient is unable to function, propel with ultra lightweight manual wheelchair throughout the community therefore putting him at the dependent level for this activity.,ACTIVITY OF DAILY LIVING: , The patient is independent with his self care, completing this from the bed or chair level.  He self casts every four to six hours a day independently and as previously mentioned completes this from the chair.  Instrumental ADLs completed with assistance from his wife.  He stays indoors 12 plus hours.  His cognition is alert and oriented x 4.,PHYSICAL EXAMINATION:,EXTREMITIES:  Upper extremity range of motion is within functional limits, has 4-5 strength proximally and 5/5 distally.  He is right hand dominant.  Sitting posture reveals sacral sitting with a partially flexible posterior pelvic tilt.  When taken out of his posterior tilt the client has loosed his trunk control.  He has decreased postural control as he is unable to elevate his upper extremities greater than 90 degrees in unsupported sit.,His skin integrity is currently intact.  His vision is within normal limits.  Lower extremity range of motion is within normal limits with 0-5 strength throughout.,EQUIPMENT RECOMMENDATION: , The patient was seen at clinic for evaluation for a new sitting system. He is unable to ambulate due to his level of injury.  He is able to propel in ultra lightweight manual wheelchair.  However, he does have difficulty propelling throughout the community when trying to maintain his level of activities with two teenage children.  Therefore the following ultra lightweight wheelchair with powered six wheels is recommended.,1.  Invacare Crossfire T6.  As previously mentioned the client is unable to ambulate secondary to spinal cord injury.  He does require manual wheelchair for all forms of mobility.  He is very active in his wheelchair.  He completes his self care as well as his __________ from the chair.  He has two teenage children and he participates in community activities with.  The patient also fixes computers at the wheelchair level.,2.  Emotion power six wheels.  The client has a history of right forearm fracture as well as fifth tendon repair.  He has 4/5 shoulder strength bilaterally.  He is an active computer user making it extremely difficult for him to propel his wheelchair over the varied terrain.  Due to the patient's young age, he has many years that he will be depending on his upper extremities for all transfers and wheelchair mobility.  It is important to be proactive in order to minimize the wear and tear on the joint as he already has upper extremity pain from repetitively propelling.,3.  Flat-free inserts.  The patient is at risk for flats due to his level of activity.  He does require maintenance free wheelchair as he is unable to ambulate.,4.  Removable covers.  This is required for increased apprehension specifically in the winter.,5.  Extra battery pack.  This will allow the client to always have available power for these wheels.  This is required as he is an extremely active user.,6.  V-front end.  This set up will keep his lower extremities close and prohibit external rotation and abduction of his lower extremities.,7.  Frog leg suspension.  This is required in order to absorb the shock in order to prevent his lower extremity from displacing from the foot plate.,8.  Ergonomic seat with a tapered front end.  This style will support the client at his widest point which is his pelvis/thigh/back of the knee.,9.  Adjustable height push handles.  This will accommodate various heights of the caregivers when pushed or bend up and down the stairs.,10.  Soft roll caster.  The client needs the extra width of a caster in order for use of community mobility rolling over the cracks as well as the stone in the community.,11.  Plastic coated hand ends.  This is required for increased __________ with propulsion.,12.  Frame protector.  This will protect his skin, specifically his lateral shins.,13.  Positioning strap.  This is required for pelvic positioning and safety.,14.  Folding side guards.  These will protect the clothing, however, may also be folded it in order to be moved out of the way for transfers.,15.  Anti-tipper.  These will prevent posterior tipping with all ramp and threshold use.,16.  3 inch locking Star cushion.  The client is currently utilizing an air cushion without skin issues.  The locking mechanism is required for stability with all of his transfers.,The above chair was decided upon after a safe and independent trial.  This report will serve as the letter of medical necessity.  We have staff who will follow up with the vendor and the patient to ensure that he has an appropriate effective manual wheelchair with power assist wheels.  This request for consultation is greatly appreciated.,
---
DESCRIPTION: A male referred to Wheelchair Clinic for evaluation for a new wheelchair.

The situation involves a patient with significant mobility issues due to a spinal cord injury seeking a new wheelchair to maintain independence and participate in community activities, including keeping up with two teenage children. While this is important for the patient's quality of life, social engagement, and management of daily living activities, it does not directly involve life-threatening conditions. It involves ensuring mobility and minimizing physical strain in the long term, which is significant for the patient's well-being but not immediately critical or life-threatening. Therefore, the stakes are moderate as it impacts the patient's independence and lifestyle, but does not represent an immediate high-stakes medical emergency.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 6

PREOPERATIVE DIAGNOSES,1.  Dyspnea on exertion with abnormal stress echocardiography.,2.  Frequent PVCs.,3.  Metabolic syndrome.,POSTOPERATIVE DIAGNOSES,1.  A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.,2.  Frequent PVCs.,3.  Metabolic syndrome.,PROCEDURES,1.  Left heart catheterization with left ventriculography.,2.  Selective coronary angiography.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory in fasting state.  Both groins were prepped and draped in the usual sterile fashion.  Xylocaine 1% was used as local anesthetic.  Versed and fentanyl were used for conscious sedation.  Next, a #6-French sheath was placed in the right femoral artery using modified Seldinger technique.  Next, selective angiography of the left coronary artery was performed in multiple views using #6-French JL4 catheter.  Next, selective angiography of the right coronary artery was performed in multiple views using #6-French 3DRC catheter.  Next, a #6-French angle pigtail catheter was advanced into the left ventricle.  The left ventricular pressure was then recorded.  Left ventriculography was the performed using 36 mL of contrast injected over 3 seconds.  The left heart pull back was then performed.  The catheter was then removed.,Angiography of the right femoral artery was performed.  Hemostasis was obtained by Angio-Seal closure device.  The patient left the Cardiac Catheterization Laboratory in stable condition.,HEMODYNAMICS,1.  LV pressure was 163/0 with end-diastolic pressure of 17.  There was no significant gradient across the aortic valve.,2.  Left ventriculography showed old inferior wall hypokinesis.  Global left ventricular systolic function is normal.  Estimated ejection fraction was 58%.  There is no significant mitral regurgitation.,3.  Significant coronary artery disease.,4.  The left main is approximately 7 or 8 mm proximally.  It trifurcates into left anterior descending artery, ramus intermedius artery, and left circumflex artery.  The distal portion of the left main has an ulcerated excentric plaque, up to about 50% in severity.,5.  The left anterior descending artery is around 4 mm proximally.  It extends slightly beyond the apex into the inferior wall.  It gives rises to several medium size diagonal branches as well as small to medium size multiple septal perforators.  At the ostium of the left anterior descending artery, there was an eccentric plaque up to 70% to 80%, best seen in the shallow LAO with caudal angulation.,There was no other flow-limiting disease noted in the rest of the left anterior descending artery or its major branches.,The ramus intermedius artery is around 3 mm proximally, but shortly after its origin, it bifurcates into two medium size branches.  There was no significant disease noted in the ramus intermedius artery however.,The left circumflex artery is around 2.5 mm proximally.  It gave off a recurrent atrial branch and a small AV groove branch prior to terminating into a bifurcating medium size obtuse marginal branch.  The mid to distal circumflex has a moderate disease, which is relatively diffuse up to about 40% to 50%.,The right coronary artery is around 4 mm in diameter.  It gives off conus branch, two medium size acute marginal branches, relatively large posterior descending artery and a posterior lateral branch.  In the mid portion of the right coronary artery at the origin of the first acute marginal branch, there is a relatively discrete stenosis of about 80% to 90%.  Proximally, there is an area of eccentric plaque, but seem to be non-flow limiting, at best around 20% to 30%.  Additionally, there is what appears to be like a shell-like lesion in the proximal segment of the right coronary artery as well.  The posterior descending artery has an eccentric plaque of about 40% to 50% in its mid segment.,PLAN:  ,Plan to consult cardiovascular surgery for consideration of coronary artery bypass surgery.  Continue risk factor modification, aspirin, and beta blocker.
---
DESCRIPTION: Left heart catheterization with left ventriculography and selective coronary angiography.  A 50% distal left main and two-vessel coronary artery disease with normal left ventricular systolic function.  Frequent PVCs.  Metabolic syndrome.

surgery, heart catheterization, ventriculography, coronary angiography, dyspnea, metabolic syndrome, two-vessel coronary artery disease, echocardiography, selective coronary angiography, anterior descending artery, branches, coronary, angiography, artery, catheterization,

The described medical procedure and findings involve heart catheterization along with angiography. This is typically conducted to assess coronary artery disease, which is a serious condition that can lead to heart attacks and other severe cardiovascular events. The procedure itself is invasive and carries risks, although no complications were noted in this instance. Given the identification of significant coronary artery disease (with up to 80-90% stenosis in some arteries) and the potential need for coronary artery bypass surgery, the stakes are high. The plan involves consulting cardiovascular surgery, which is a major decision impacting the patient's health significantly. Therefore, this scenario involves a critical evaluation of a patient's cardiovascular condition, guiding potential surgical intervention.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 49

HISTORY OF PRESENT ILLNESS: , This is a 70-year-old female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot.  The patient says that the right hand was very swollen, very painful, could not move the fingers, and also, the left foot was very swollen and very painful, and again could not move the toes, came to emergency room, diagnosed with gout and gouty attacks.  I was asked to see the patient regarding chronic kidney disease.,PAST MEDICAL HISTORY:,1.  Diabetes mellitus type 2.,2.  Diabetic nephropathy.,3.  Chronic kidney disease, stage 4.,4.  Hypertension.,5.  Hypercholesterolemia and hyperlipidemia.,6.  Peripheral vascular disease, status post recent, last week PTA of right lower extremity.,SOCIAL HISTORY:,  Negative for smoking and drinking.,CURRENT HOME MEDICATIONS:,  NovoLog 20 units with each meal, Lantus 30 units at bedtime, Crestor 10 mg daily, Micardis 80 mg daily, Imdur 30 mg daily, Amlodipine 10 mg daily, Coreg 12.5 mg b.i.d., Lasix 20 mg daily, Ecotrin 325 mg daily, and calcitriol 0.5 mcg daily.,REVIEW OF SYSTEMS: , The patient denies any complaints, states that the right hand and left foot was very swollen and very painful, and came to emergency room.  Also, she could not urinate and states as soon as they put Foley in, 500 mL of urine came out.  Also they started her on steroids and colchicine, and the pain is improving and the swelling is getting better.  Denies any fever and chills.  Denies any dysuria, frequency or hematuria.  States that the urine output was decreased considerably, and she could not urinate.  Denies any cough, hemoptysis or sputum production.  Denies any chest pain, orthopnea or paroxysmal nocturnal dyspnea.,PHYSICAL EXAMINATION:,General:  The patient is alert and oriented, in no acute distress.,Vital Signs:  Blood pressure 126/67, temperature 97.9, pulse 71, and respirations 20.  The patient's weight is 105.6 kg.,Head:  Normocephalic.,Neck:  Supple.  No JVD.  No adenopathy.,Chest:  Symmetric.  No retractions.,Lungs:  Clear.,Heart:  RRR with no murmur.,Abdomen:  Obese, soft, and nontender.  No rebound.  No guarding.,Extremity:  She has 2+ pretibial edema bilaterally at the lower extremity, but also the left foot, in dorsum of left foot and also right hand is swollen and very tender to move the toes and also fingers in those extremities.,LAB TESTS: , Showed that urine culture is negative up to date.  The patient's white cell is 12.7, hematocrit 26.1.  The patient has 90% segs and 0% bands.  Serum sodium 133, potassium 5.9, chloride 100, bicarb 21, glucose 348, BUN 57, creatinine is 2.39, calcium 8.9, and uric acid yesterday was 10.9.  Sed rate was 121.  BNP was 851.  Urinalysis showed 15 to 20 white cells, 3+ protein, 3+ blood with 25 to 30 red blood cells also.,IMPRESSION:,1.  Urinary tract infection.,2.  Acute gouty attack.,3.  Diabetes mellitus with diabetic nephropathy.,4.  Hypertension.,5.  Hypercholesterolemia.,6.  Peripheral vascular disease, status post recent PTA in the right side.,7.  Chronic kidney disease, stage 4.,PLAN: , At this time is I agree with treatment.  We will add allopurinol 50 mg daily.  This is secondary to the patient is already on colchicine, and also we will discontinue Micardis, we will increase Lasix to 40 b.i.d., and we will follow with the lab results.
---
DESCRIPTION: A female with a past medical history of chronic kidney disease, stage 4; history of diabetes mellitus; diabetic nephropathy; peripheral vascular disease, status post recent PTA of right leg, admitted to the hospital because of swelling of the right hand and left foot.

The situation involves a 70-year-old woman with several severe chronic health issues, including stage 4 chronic kidney disease, diabetes with nephropathy, and peripheral vascular disease, who is currently suffering from an acute gouty attack and suspected urinary tract infection. These conditions are significant and could lead to severe complications if not properly managed, especially given her history of kidney disease and cardiovascular risk factors. The addition of new treatments like allopurinol and adjustments to her medication regimen indicate critical therapeutic decisions. The treatment of her symptoms and continuation of monitoring her labs are essential to prevent further acute deterioration of her health. Considering the complexity and potential for severe outcomes, this situation would be considered high-stakes.


Medical Specialty: Podiatry
Sample Name: Bunionectomy & Metatarsal Osteotomy

PREOPERATIVE DIAGNOSES:,1.  Bunion left foot.,2.  Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1.  Bunion left foot.,2.  Hammertoe, left second toe.,PROCEDURE PERFORMED:,1.  Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2.  Arthroplasty left second toe.,HISTORY:  ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint.  The patient states that she has had bunion for many months.  It has been progressively getting more painful at this time.  The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preop holding area.  The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap.  Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff.  After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table.  The stockinette was reflected.  The foot was cleansed with wet and dry sponge.  Attention was then directed to the first metatarsophalangeal joint of the left foot.  An incision was created over this area approximately 6 cm in length.  The incision was deepened with a #15 blade.  All vessels encountered were ligated for hemostasis.  The skin and subcutaneous tissue was then dissected from the capsule.  Care was taken to preserve the neurovascular bundle.  Dorsal linear capsular incision was then created.  The capsule was then reflected from the head of the first metatarsal.  Attention was then directed to the first interspace where a lateral release was performed.  A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected.  A lateral capsulotomy was performed.  Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence.  The incision was then extended proximally with further dissection down to the level of the bone.  Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy.  A standard SCARF osteotomy was then performed.  The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle.  After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire.  A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted.  A second 3.0 x 14 mm screw was also inserted with tight compression noted.  The remaining prominent medial eminence medially was then resected with a sagittal saw.  Reciprocating rasps were then used to smooth any sharp bony edges.  The temporary fixation wires were then removed.  The screws were again checked for tightness, which was noted.  Attention was directed to the medial capsule where a medial capsulorrhaphy was performed.  A straight stat was used to assist in removing a portion of the capsule.  The capsule was then reapproximated with #2-0 Vicryl medially.  Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion.  The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl.  The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe.  A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe.  The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally.  An incision was made on either side of the extensor digitorum longus tendon.  A curved mosquito stat was then used to reflex the tendon laterally.  The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx.  A sagittal saw was then used to resect the head of the proximal head.  The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto.  The extensor digitorum longus tendon was inspected and noted to be intact.  Any sharp edges were then smoothed with reciprocating rasp.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban.  Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact to the left foot.  The patient is to follow up with Dr. X in his clinic as directed.
---
DESCRIPTION: Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe.  Bunion left foot and hammertoe, left second toe.

podiatry, hammertoe, osteotomy, internal screw fixation, scarf type, extensor digitorum, metatarsal osteotomy, foot, toe, metatarsal, bunionectomy,

The situation involves a detailed description of a podiatric surgical procedure, specifically a bunionectomy and metatarsal osteotomy with internal screw fixation, as well as an arthroplasty in the second toe. While surgical procedures inherently carry a certain level of risk and importance, in the context of medical emergencies and life-threatening conditions, this type of planned podiatric surgery is generally considered moderate in stakes. The procedure seems routine for treating bunions and hammertoes in a stable, non-emergent setting, with the patient tolerating the procedure well and no complications reported. Therefore, it does not entail immediate life-threatening scenarios typically classified as high-stakes.


Medical Specialty: Surgery
Sample Name: Hysteroscopy & Laproscopy with Salpingooophorectomy

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

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

The situation involves a surgical operation which has inherent risks associated with patient safety and potential complications, particularly given the patient's history of breast cancer and ongoing tamoxifen therapy. However, the surgery proceeded without complications and involved common procedures (D&C, hysteroscopy, and laparoscopy). While surgical procedures are serious and require attention to ensure patient safety, the fact that it was performed without incident and the patient tolerated it well suggests the stakes are elevated due to the nature of surgery, but not extremely high in context. The stakes could be considered higher due to the patient's cancer history and treatment, necessitating careful monitoring. Overall, it is a moderate-high stakes medical situation.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Chiropractic Progress Note

CHIEF COMPLAINT:  ,Hip pain.,HISTORY OF PRESENTING ILLNESS:  ,The patient is a very pleasant 41-year-old white female that is known to me previously from our work at the Pain Management Clinic, as well as from my residency training program, San Francisco. We have worked collaboratively for many years at the Pain Management Clinic and with her departure there, she has asked to establish with me for clinic pain management at my office.  She reports moderate to severe pain related to a complicated past medical history.  In essence, she was seen at a very young age at the clinic for bilateral knee and hip pain and diagnosed with bursitis at age 23.  She was given nonsteroidals at that time, which did help with this discomfort.  With time, however, this became inadequate and she was seen later in San Francisco in her mid 30s by Dr. V, an orthopedist who diagnosed retroverted hips at Hospital.  She was referred for rehabilitation and strengthening.  Most of this was focused on her SI joints.  At that time, although she had complained of foot discomfort, she was not treated for it.  This was in 1993 after which she and her new husband moved to the Boston area, where she lived from 1995-1996.  She was seen at the Pain Center by Dr. R with similar complaints of hip and knee pain.  She was seen by rheumatologists there and diagnosed with osteoarthritis as well as osteophytosis of the back.  Medications at that time were salicylate and Ultram.,When she returned to Portland in 1996, she was then working for Dr. B.  She was referred to a podiatrist by her local doctor who found several fractured sesamoid bones in her both feet, but this was later found not to be the case.  Subsequently, nuclear bone scans revealed osteoarthritis.  Orthotics were provided.  She was given Paxil and Tramadol and subsequently developed an unfortunate side effect of grand mal seizure.  During this workup of her seizure, imaging studies revealed a pericardial fluid-filled cyst adhered to her ventricle.  She has been advised not to undergo any corrective or reparative surgery as well as to limit her activities since.  She currently does not have an established cardiologist having just changed insurance plans.  She is establishing care with Dr. S, of Rheumatology for her ongoing care.  Up until today, her pain medications were being written by Dr. Y prior to establishing with Dr. L.,Pain management in town had been first provided by the office of Dr. F. Under his care, followup MRIs were done which showed ongoing degenerative disc disease, joint disease, and facet arthropathy in addition to previously described sacroiliitis.  A number of medications were attempted there, including fentanyl patches with Flonase from 25 mcg titrated upwards to 50 mcg, but this caused oversedation.  She then transferred her care to Ab Cd, FNP under the direction of Dr. K.  Her care there was satisfactory, but because of her work schedule, the patient found this burdensome as well as the guidelines set forth in terms of monthly meetings and routine urine screens.  Because of a previous commitment, she was unable to make one unscheduled request to their office in order to produce a random urine screen and was therefore discharged.,PAST MEDICAL HISTORY:  ,1.  Attention deficit disorder.,2.  TMJ arthropathy.,3.  Migraines.,4.  Osteoarthritis as described above.,PAST SURGICAL HISTORY:,1.  Cystectomies.,2.  Sinuses.,3.  Left ganglia of the head and subdermally in various locations.,4.  TMJ and bruxism.,FAMILY HISTORY:  ,The patient's father also suffered from bilateral hip osteoarthritis.,MEDICATIONS:,1.  Methadone 2.5 mg p.o. t.i.d.,2.  Norco 10/325 mg p.o. q.i.d.,3.  Tenormin 50 mg q.a.m.,4.  Skelaxin 800 mg b.i.d. to t.i.d. p.r.n.,5.  Wellbutrin SR 100 mg q.d.,6.  Naprosyn 500 mg one to two pills q.d. p.r.n.,ALLERGIES: , IV morphine causes hives.  Sulfa caused blisters and rash.,PHYSICAL EXAMINATION: , A well-developed, well-nourished white female in no acute distress, sitting comfortably and answering questions appropriately, making good eye contact, and no evidence of pain behavior.,VITAL SIGNS:  Blood pressure 110/72 with a pulse of 68.,HEENT:  Normocephalic.  Atraumatic.  Pupils are equal and reactive to light and accommodation.  Extraocular motions are intact.  No scleral icterus.  No nystagmus.  Tongue is midline.  Mucous membranes are moist without exudate.,NECK:  Free range of motion without thyromegaly.,CHEST:  Clear to auscultation without wheeze or rhonchi.,HEART:  Regular rate and rhythm without murmur, gallop, or rub.,ABDOMEN:  Soft, nontender.,MUSCULOSKELETAL:  There is musculoskeletal soreness and tenderness found at the ankles, feet, as well as the low back, particularly above the SI joints bilaterally.  Passive hip motion also elicits bilateral hip pain referred to the ipsilateral side.  Toe-heel walking is performed without difficulty.  Straight leg raises are negative.  Romberg's are negative.,NEUROLOGIC:  Grossly intact.  Intact reflexes in all extremities tested.  Romberg is negative and downgoing.,ASSESSMENT:,1. Osteoarthritis.,2. Chronic sacroiliitis.,3. Lumbar spondylosis.,4. Migraine.,5. TMJ arthropathy secondary to bruxism.,6. Mood disorder secondary to chronic pain.,7. Attention deficit disorder, currently untreated and self diagnosed.,RECOMMENDATIONS:,1. Agree with Rheumatology referral and review.  I would particularly be interested in the patient pursuing a bone density scan as well as thyroid and parathyroid studies.,2. Given the patient's previous sulfa allergies, we would recommend decreasing her Naprosyn usage.
---
DESCRIPTION: Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.

The situation involves the management of a patient with a complex medical history, including chronic pain conditions like osteoarthritis, lumbar spondylosis, and sacroiliitis. While managing chronic pain can significantly affect a patient's quality of life, this situation is a routine interaction between healthcare providers and a patient. It involves a detailed assessment and planning for ongoing management rather than an emergency or life-threatening scenario. Therefore, it does not present immediate high-stakes risks but reflects ongoing and potentially challenging management requirements for the patient.


Medical Specialty: Orthopedic
Sample Name: Arthrotomy & Subscapularis Tendon Repair

TITLE OF OPERATION:  ,1.  Arthrotomy, removal humeral head implant, right shoulder.,2.  Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.,3.  Debridement glenohumeral joint.,4.  Biopsy and culturing the right shoulder.,INDICATION FOR SURGERY: , The patient had done well after a previous total shoulder arthroplasty performed by Dr. X.  However, the patient was lifted with subsequent significant pain and apparent tearing of his subscapularis.  Risks and benefits of the procedure had been discussed with the patient at length including, but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, continued instability, retearing of the tendon, need for revision of his arthroplasty, permanent nerve or artery damage, etc.  The patient understood and wished to proceed.,PREOP DIAGNOSIS:  ,1.  Torn subscapularis tendon, right shoulder.,2.  Right total shoulder arthroplasty (Biomet system).,POSTOP DIAGNOSIS:  ,1.  Torn subscapularis tendon, right shoulder.,2.  Right total shoulder arthroplasty (Biomet system).,3.  Diffuse synovitis, right shoulder.,PROCEDURE: , The patient was anesthetized in the supine position.  A Foley catheter was placed in his bladder.  He was then placed in a beach chair position.  He was brought to the side of the table and the torso secured with towels and tape.  His head was then placed in the neutral position with no lateral bending or extension.  It was secured with paper tape over his forehead.  Care was taken to stay off his auricular cartilages and his orbits.  Right upper extremity was then prepped and draped in the usual sterile fashion.  The patient was given antibiotics well before the beginning of the procedure to decrease any risk of infection.  Once he had been prepped and draped with the standard prep, he was prepped a second time with a chlorhexidine-type skin prep.  This was allowed to dry and the skin was then covered with Ioban bandages also to decrease his risk of infection.,Also, preoperatively, the patient had his pacemaker defibrillator function turned off as a result during this case.  Bipolar type cautery had to be used as opposed to monopolar cautery.,The patient's deltopectoral incision was then opened and extended proximally and distally.  The patient had significant amount of scar already in this interval.  Once we got down to the deltoid and pectoralis muscle, there was no apparent cephalic vein present, as a result the rotator cuff interval had to be developed through an area of scar.  This created a significant amount of bleeding.  As a result a very slow and meticulous dissection was performed to isolate his coracoid and then his proximal humerus.  Care was taken to stay above the pectoralis minor and the conjoint tendon.  The deltoid had already started to scar down the proximal humerus as a result a very significant amount of dissection had to be performed to release the deltoid from proximal humerus.  Similarly, the deltoid insertion had to be released approximately 50% of its width to allow us enough mobility of the proximal humerus to be able to visualize the joint or the component.  It was clear that the patient had an avulsion of the subscapularis tendon as the tissue on the anterior aspect of the shoulder was very thin.  The muscle component of the subscapularis could be located approximately 1 cm off the glenoid rim and approximately 3 cm off the lesser tuberosity.  The soft tissue in this area was significantly scarred down to the conjoint tendon, which had to be very meticulously released.  The brachial plexus was identified as was the axillary nerve.  Once this was completed, an arthrotomy was then made leaving some tissue attached to the lesser tuberosity in case it was needed for closure later.  This revealed sanguineous fluid inside the joint.  We did not feel it was infected based upon the fluid that came from the joint.  The sutures for the subscapularis repair were still located in the proximal humerus with no tearing through the bone, which was fortunate because in that we could use the bone later for securing the sutures.  The remaining sutures were seen to be retracted medially to an area of the subscapularis as mentioned previously.  Some more capsule had to be released off the inferior neck in order for us to gain exposure during the scarring.  This was done also very meticulously.  The upper one half of the latissimus dorsi tendon was also released.  Once this was completed, the humerus could be subluxed enough laterally that we could remove the head.  This was done with no difficulty.  Fortunately, the humeral component stayed intact.  There were some exudates beneath the humeral head, which were somewhat mucinous.  However, these do not really appear to be infected, however, we sent them to pathology for a frozen section.  This frozen section later returned as possible purulent material.  I discussed this personally with the pathologist at that point.  We told him that the procedure is only 3 weeks old, but he was concerned that there might be more white blood cells in the tissue than he would expect.  As a result, all the mucinous exudates were carefully removed.  We also performed a fairly extensive synovectomy of the joint primarily to gain vision of the components, but also we irrigated the joint throughout the case with antibiotic impregnated irrigation.  At that point, we also had sent portions of this mucinous material to pathology for a stat Gram stain.  This came back as no organisms seen.  We also sent portions for culture and sensitivity both aerobic and anaerobic.,Once this was completed, attention was then directed to the glenoid.  The patient had significant amount of scar already.  The subscapularis itself was significantly scarred down to the anterior rim.  As a result, the adhesions along the anterior edge were released using a knife.  Also adhesions in the subcoracoid space area were released very carefully and meticulously to prevent any injury to the brachial plexus.  Two long retractors were placed medially to protect the brachial plexus during all portions of suturing of the subscapularis.  The subscapularis was then tagged with multiple number 2 Tycron sutures.  Adhesions were released circumferentially and it was found that with the arm in internal rotation about neutral degrees, the subscapularis could reach the calcar region without tension.  As a result, seven number 2 Tycron sutures were placed from the bicipital groove all the way down to the inferior calcar region of the humerus.  These all had excellent security in bone.  Once the joint had been debrided and irrigated, the real humeral head was then placed back on the proximal humerus.  Care was taken to remove fluid off the Morse taper.  The head was then impacted.  It should be noted that we tried multiple head sizes to see if a smaller or larger head size might be more appropriate for this patient.  Unfortunately, any of the larger head sizes would overstep the joint and any smaller sizes would not give good coverage to the proximal humerus.  As a result, it was felt to place the offset head back on the humerus, we did insert a new component as opposed to using the old component.  The old component was given to the family postoperatively.,With the arm in internal rotation, the Tycron sutures were then placed through the subscapularis tendon in the usual horizontal mattress fashion.  Also, it should be noted that the rotator cuff interval had to be released as part of the exposure.  We started the repair by closing the rotator cuff interval.  Anterior and posterior translation was then performed and was found to be very stable.  The remaining sutures were then secured through the subscapularis tendon taking care to make sure that very substantial bites were obtained.  This was then reinforced with the more flimsy tissue laterally being sewn into the tissue around the bicipital tuberosity essentially provided us with a two-layer repair of the subscapularis tendon.  After the tendon had been repaired, there was no tension on repair until 0 degrees external rotation was reached with the arm to the side.  Similarly with the arm abducted 90 degrees, tension was on repair at 0 degrees of external rotation.  It should be noted that the wound was thoroughly irrigated throughout with antibiotic impregnated irrigation.  The rotator cuff interval was closed with multiple number 2 Tycron sutures.  It was reinforced with 0 Vicryl sutures.  Two Hemovac drains were then placed inferiorly at the deltoid.  The deltopectoral interval was then closed with 0 Vicryl sutures.  A third drain was placed in the subcutaneous tissues to prevent any infections or any fluid collections.  This was sewn into place with the drain pulled out superiorly.  Once all the sutures have been secured and the drain visualized throughout this part of the closure, the drain was pulled distally until it was completely covered.  There were no signs that it had been tagged or hung up by any sutures.,The superficial subcutaneous tissues were closed with interrupted with 2-0 Vicryl sutures.  Skin was closed with staples.  A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer.  The patient was sent to the intensive care unit in stable and satisfactory condition.,Due to the significant amount of scar and bleeding in this patient, a 22 modifier is being requested for this case.  This was a very difficult revision case and was significantly increased in technical challenges and challenges in the dissection and exposure of this implant compared to a standard shoulder replacement.  Similarly, the repair of the subscapularis tendon presented significantly more challenges than that of a standard rotator cuff repair because of the implant.  This was being dictated for insurance purposes only and reflects no inherent difficulties with this case.  The complexity and the time involved in this case was approximately 30% greater than that of a standard shoulder replacement or of a rotator cuff repair.  This is being dictated to indicate this was a revision case with significant amount of scar and bleeding due to the patient's situation with his pacemaker.  This patient also had multiple medical concerns, which increased the complexity of this case including the necessity to place him in intensive care unit postoperatively for observation.
---
DESCRIPTION: Arthrotomy, removal humeral head implant, right shoulder.  Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.  Debridement glenohumeral joint.  Biopsy and culturing the right shoulder.

orthopedic, arthrotomy, repair of torn subscapularis tendon, glenohumeral joint, biomet system, arthroplasty, diffuse synovitis, proximal humerus, torn subscapularis tendon, subscapularis tendon, rotator cuff, humerus, sutures, tendon, head, shoulder, subscapularis, torn,

The given surgical scenario describes a complex orthopedic procedure involving an arthrotomy and subscapularis tendon repair, which includes the removal of a humeral head implant, debridement of the glenohumeral joint, and subsequent biopsies and cultures. The complexity of the case is increased by the presence of significant scarring, a pacemaker requiring special considerations for cautery, and potential infection concerns. These factors contribute to the high-stakes nature of the procedure, as it involves potential risks such as nerve or artery damage, infection, and the need for intensive monitoring post-operatively. The patient's condition is delicate, necessitating careful surgical planning and execution, as well as specialized postoperative care in the ICU. The high technical demands of this revision surgery indicate a situation with significant potential for complications, making it a high-stakes medical scenario.


Medical Specialty: Neurosurgery
Sample Name: Craniotomy - Temporal

PREOPERATIVE DIAGNOSIS:,  Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:,  Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1.  Left temporal craniotomy.,2.  Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoulder roll, and the head was turned to the right side.  The entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation.  Next, we made an inverted-U fashion base over the asterion over temporoparietal area of the skull.  A free flap was elevated after the scalp that was reflected using the burr hole and craniotome.  The bone flap was placed aside and soaked in the bacitracin solution.,The dura was then opened in an inverted-U fashion.  Using the Stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle.  We head through the vein of Labbe, and we made great care to preserve this.  We saw where the tumor almost made to the surface.  Here we made a small corticectomy using the Stealth for guidance.  We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid.  This was submitted to pathology.  We biopsied this very abnormal tissue and submitted it to pathology.  They gave us a frozen section diagnosis of glioblastoma multiforme.  With the operating microscope and Greenwood bipolar forceps, we then systematically debulked this tumor.  It was very vascular and we really continued to remove this tumor until all visible tumors was removed.  We appeared to get two gliotic planes circumferentially.  We could see it through the ventricle.  After removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal.  The bone flap was then replaced and sutured with the Lorenz titanium plate system.  The muscle fascia galea was closed with interrupted 2-0 Vicryl sutures.  Skin staples were used for skin closure.  The blood loss of the operation was about 200 cc.  There were no complications of the surgery per se.  The needle count, sponge count, and the cottonoid count were correct.,COMMENT:  ,Operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain.
---
DESCRIPTION: Left temporal craniotomy and removal of brain tumor.

neurosurgery, temporal lobe, brain tumor, lorenz titanium plate, burr hole, cortex, corticectomy, craniotome, craniotomy, frozen section, glioblastoma multiforme, temporal craniotomy, temporoparietal, ventricle, white matter, tumor, temporal, brain,

This situation involves a craniotomy for the removal of a brain tumor diagnosed as glioblastoma multiforme. This is a high-stakes surgery given the complexity and risks associated with neurosurgical procedures, the critical functions associated with the temporal lobe, and the aggressive nature of glioblastoma. The stakes are heightened by the need for precise execution to minimize damage to surrounding brain tissue and ensure the most complete tumor removal possible. Successful outcomes have significant implications for the patient's survival and quality of life.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Refractory Hypertension - Followup

PROBLEM LIST:,1.  Refractory hypertension, much improved.,2.  History of cardiac arrhythmia and history of pacemaker secondary to AV block.,3.  History of GI bleed in 1995.,4.  History of depression.,HISTORY OF PRESENT ILLNESS:,  This is a return visit to the renal clinic for this patient.  She is an 85-year-old woman with history as noted above.  Her last visit was approximately four months ago.  Since that time, the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she had had for many visits previously.  She is not reporting any untoward side effect.  She is not having weakness, dizziness, lightheadedness, nausea, vomiting, constipation, diarrhea, abdominal pain, chest pain, shortness of breath or difficulty breathing.  She has no orthopnea.  Her exercise capacity is about the same.  The only problem she has is musculoskeletal and that pain in the right buttock, she thinks originating from her spine.  No history of extremity pain.,CURRENT MEDICATIONS:,1.  Triamterene/hydrochlorothiazide 37.5/25 mg.,2.  Norvasc 10 mg daily.,3.  Atenolol 50 mg a day.,4.  Atacand 32 mg a day.,5.  Cardura 4 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.2, pulse 47, respirations 16, and blood pressure 157/56.  THORAX:  Revealed lungs that are clear, PA and lateral without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  S1 and S2 without murmur.  No S3.  I could not hear murmur today.  ABDOMEN:  Above plane, but nontender.  EXTREMITIES:  Revealed no edema.,ASSESSMENT:,  This is a return visit for this patient who has refractory hypertension.  This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously.  We had discussed with her in the past beginning to see an internist at the senior center.  She apparently had an appointment scheduled and it was missed.  We are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of GFR that is greater than 60%.,PLAN: , The plan will be for her to follow up at the senior center for her routine health care, and should the need arise for further management of blood pressure, a referral back to us.  In the meantime, we will discharge her from our practice.  Should there be confusion or difficulty getting in the senior center, we can always see her back in followup
---
DESCRIPTION: Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.

soap / chart / progress notes, cardiac arrhythmia, av block, refractory hypertension, blood pressure, pacemaker, atenolol, arrhythmia

This scenario involves the follow-up of a medical patient with refractory hypertension, among other medical conditions. The patient's condition has improved, indicating the management was effective. The patient is elderly, has a complex medical history with multiple conditions to monitor, and is on several medications. Although their current status seems stable, the presence of potential cardiac issues (low pulse, pacemaker) and a history of gastrointestinal bleeding presents a moderate risk.

The stakes here are moderate because improper management could escalate existing conditions or lead to adverse events. The potential for complications exists, but the current stability and the ongoing management plan reduce the immediate risk. The ongoing need for careful monitoring and proper follow-up referrals signals moderate stakes.


Medical Specialty: Emergency Room Reports
Sample Name: Not Feeling Well - ER Visit

CHIEF COMPLAINT:  ,The patient does not have any chief complaint.,HISTORY OF PRESENT ILLNESS:,  This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well.  The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generalized complaint of not feeling well.  The neighbor suspects that this may have been due to the patient taking too many of her Tylenol PM, which the patient has been known to do.  The patient was a little somnolent early this morning and was found only to be oriented x1 with EMS upon their arrival to the patient's house.  The patient states that she just simply felt funny and does not give any more specific details than this.  The patient denies any pain at any time.  She did not have any shortness of breath.  No nausea or vomiting.  No generalized weakness.  The patient states that all that has gone away since arrival here in the hospital, that she feels at her usual self, is not sure why she is here in the hospital, and thinks she should go.  The patient's primary care physician, Dr. X reports that the patient spoke with him yesterday and had complained of shortness of breath, nausea, dizziness, as well as generalized weakness, but the patient states that all this has resolved.  The patient was actually seen here two days ago for those same symptoms and was found to have exacerbation of her COPD and CHF.  The patient was discharged home after evaluation in the emergency room.  The patient does use home O2.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  The patient had complained of generalized fatigue and weakness two days ago in the emergency room and yesterday to her primary care physician.  The patient denies having any other symptoms today.  The patient denies any fever or chills.  Has not had any recent weight change.  HEENT:  The patient denies any headache.  No neck pain.  No rhinorrhea.  No sinus congestion.  No sore throat.  No any vision or hearing change.  No eye or ear pain.  CARDIOVASCULAR:  The patient denies any chest pain.  RESPIRATIONS:  No shortness of breath.  No cough.  No wheeze.  The patient did report having shortness of breath and wheeze with her presentation to the emergency room two days ago and shortness of breath to her primary care physician yesterday, but the patient states that all this has resolved.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  No change in the bowel movements.  There has not been any diarrhea or constipation.  No melena or hematochezia.  GENITOURINARY:  No dysuria, hematuria, urgency, or frequency.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  No pain or abnormalities to any portion of the body.  SKIN:  No rashes or lesions.  NEUROLOGIC:  The patient reported dizziness to her primary care physician yesterday over the phone, but the patient denies having any problems with dizziness over the past few days.  The patient denies any dizziness at this time.  No syncope or no near-syncope.  The patient denies any focal weakness or numbness.  No speech change.  No difficulty with ambulation.  The patient has not had any vision or hearing change.  PSYCHIATRIC:  The patient denies any depression.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  COPD, CHF, hypertension, migraines, previous history of depression, anxiety, diverticulitis, and atrial fibrillation.,PAST SURGICAL HISTORY:,  Placement of pacemaker and hysterectomy.,CURRENT MEDICATIONS: , The patient takes Tylenol PM for insomnia, Lasix, Coumadin, Norvasc, Lanoxin, Diovan, atenolol, and folic acid.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient used to smoke, but quit approximately 30 years ago.  The patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 99.1 oral, blood pressure 139/65, pulse is 72, respirations 18, and oxygen saturation is 92% on room air and interpreted as low normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear sclerae and cornea bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx are normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  No cervical lymphadenopathy.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  The patient does have +1 bilateral lower extremity edema.  RESPIRATIONS:  The patient has coarse breath sounds bilaterally, but no dyspnea.  Good air movement.  No wheeze.  No crackles.  The patient speaks in full sentences without any difficulty.  The patient does not exhibit any retractions, accessory muscle use or abdominal breathing.  GASTROINTESTINAL:  Abdomen is soft, nontender, and nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruits, no mass, no pulsatile mass, and no inguinal lymphadenopathy.  MUSCULOSKELETAL:  No abnormalities noted to the back, arms or legs.  SKIN:  No rashes or lesions.  NEUROLOGICAL:  Cranial nerves II through XII are intact.  Motor is 5/5 and equal to bilateral arms and legs.  Sensory is intact to light touch.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is awake, alert, and oriented x3 although the patient first stated that the year was 1908, but did manage to correct herself up on addressing this with her.  The patient has normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  There is no evidence of lymphadenopathy.,EMERGENCY DEPARTMENT TESTING: , EKG is a rate of 72 with evidence of a pacemaker that has good capture.  There is no evidence of acute cardiac disease on the EKG and there is no apparent change in the EKG from 03/17/08.  CBC has no specific abnormalities of issue.  Chemistry has a BUN of 46 and creatinine of 2.25, glucose is 135, and an estimated GFR is 20.  The rest of the values are normal and unremarkable.  LFTs are all within normal limits.  Cardiac enzymes are all within normal limits.  Digoxin level is therapeutic at 1.6.  Chest x-ray noted cardiomegaly and evidence of congestive heart failure, but no acute change from her chest x-ray done two days ago.  CAT scan of the head did not identify any acute abnormalities.  I spoke with the patient's primary care physician, Dr. X who stated that he would be able to follow up with the patient within the next day.  I spoke with the patient's neighbor who contacted the ambulance service who stated that the patient just reported not feeling well and appeared to be a little somnolent and confused at the time, but suspected that she may have taken too many of her Tylenol PM as she often has done in the past.  The neighbor is XYZ and he says that he checks on her three times a day every day.  ABC is the patient's son and although he lives out of town he calls and checks on her every day as well.  He states that he spoke to her yesterday.  She sounded fine, did not express any other problems that she had apparently been in contact with her primary care physician.  She sounded her usual self to him.  Mr. ABC also spoke to the patient while she was here in the emergency room and she appears to be her usual self and has her normal baseline mental status to him.  He states that he will be able to check on her tomorrow as well.  Although it is of some concern that there may be problems with development of some early dementia, the patient is adamant about not going to a nursing home and has been placed in a Nursing Home in the past, but Dr. Y states that she has managed to be discharged after two previous nursing home placements.  The patient does have Home Health that checks on her as well as housing care in between the two services they share visits every single day  by them as well as the neighbor who checks on her three times a day and her son who calls her each day as well.  The patient although she lives alone, does appear to have good followup and the patient is adamant that she wishes to return home.,DIAGNOSES,1.  EARLY DEMENTIA.,2.
---
DESCRIPTION: A 93-year-old female called up her next-door neighbor to say that she was not feeling well.  The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern.

The case involves a 93-year-old female with a history of multiple chronic conditions, including COPD, CHF, and early dementia, who presented to the emergency room. Although she currently denies specific acute symptoms, her past few days include episodes of dizziness, shortness of breath, and somnolence, potentially due to overuse of Tylenol PM. Given her age, medical history, possible medication misuse, and living situation, these factors collectively present a high-stakes scenario. The patient's health could rapidly deteriorate if not closely monitored, especially with the overlap of early dementia symptoms that may complicate her ability to manage her health effectively. While she appears stable at the moment and has a decent support system, potential for serious health complications remains high given her clinical picture and recurrent ER visits.


Medical Specialty: Podiatry
Sample Name: MRI Ankle - 1

EXAM:,MRI RIGHT ANKLE,CLINICAL:,This is a 51 year old female who first came into the office 3/4/05 with right ankle pain. She stepped on ice the evening prior and twisted her ankle. PF's showed no frank fracture, dislocation, or subluxations.,FINDINGS:,Received for interpretation is an MRI examination performed on 4/28/2005.,There is a "high ankle sprain" of the distal tibiofibular syndesmotic ligamentous complex involving the anterior tibiofibular ligament with marked ligamentous inflammatory thickening and diffuse interstitial edema. There is osteoarthritic spur formation at the anterior aspect of the fibula with a small 2mm osseous structure within the markedly thickened anterior talofibular ligament suggesting a small ligamentous osseous avulsion. The distal tibiofibular syndesmotic ligamentous complex remains intact without a complete rupture. There is no widening of the ankle mortis. The posterior talofibular ligament remains intact.,There is marked ligamentous thickening of the anterior talofibular ligament of the lateral collateral ligamentous complex suggesting the sequela of a remote lateral ankle sprain. There is thickening of the posterior talofibular and calcaneofibular ligaments.,There is a flat retromalleolar sulcus.,There is a full-thickness longitudinal split tear of the peroneus brevis tendon within the retromalleolar groove. The tear extends to the level of the inferior peroneal retinaculum. There is anterior displacement of the peroneus longus tendon into the split peroneus tendon tear.,There is severe synovitis of the peroneus longus tendon sheath with prominent fluid distention. The synovitis extends to the level of the inferior peroneal retinaculum.,There is a focal area of chondral thinning of the hyaline cartilage of the medial talar dome with a focal area of subchondral plate cancellous marrow resorption consistent with and area of prior talar dome contusion but there is no focal osteochondral impaction or osteochondral defect.,There is minimal fluid within the tibiotalar articulation.,There is minimal fluid within the posterior subtalar articulation with mild anterior capsular prolapse. Normal talonavicular and calcaneocuboid articulations. The anterior superior calcaneal process is normal.,There is mild tenosynovitis of the posterior tibialis tendon sheath but an intrinsically normal tendon. There is an os navicularis (Type II synchondrosis) with an intact synchondrosis and no active marrow stress phenomenon.,Normal flexor digitorum longus tendon.,There is prominent fluid distention of the flexor hallucis longus tendon sheath with capsular distention proximal to the posterior talar processes with prominent fluid distention of the synovial sheath.,There is a loculated fluid collection within Kager’s fat measuring approximately 1 x 1 x 2.5cm in size, extending to the posterior subtalar facet joint consistent with a ganglion of either posterior subtalar facet origin or arising from the flexor hallucis longus tendon sheath.,There is mild tenosynovitis of the Achilles tendon with mild fusiform enlargement of the non-insertional Watershed zone of the Achilles tendon but there is no demonstrated tendon tear or tenosynovitis. There is a low-lying soleus muscle that extends to within 4cm of the teno-osseous insertion of the Achilles tendon. There is no Haglund’s deformity.,There is a plantar calcaneal spur measuring approximately 6mm in size, without a reactive marrow stress phenomenon. Normal plantar fascia.,IMPRESSION:,Partial high ankle sprain with diffuse interstitial edema of the anterior tibiofibular ligament with a ligamentous chip avulsion but without a disruption of the anterior tibiofibular ligament.,Marked ligamentous thickening of the lateral collateral ligamentous complex consistent with the sequela of a remote lateral ankle sprain.,Full-thickness longitudinal split tear of the peroneus brevis tendon with severe synovitis of the peroneal tendon sheath.,Post-traumatic deformity of the medial talar dome consistent with a prior osteochondral impaction injury but no osteochondral defect. Residual subchondral plate cancellous marrow edema.,Severe synovitis of the flexor hallucis longus tendon sheath with prominent fluid distention of the synovial sheath proximal to the posterior talar processes.,Septated cystic structure within Kager’s fat triangle extending along the superior aspect of the calcaneus consistent with a ganglion of either articular or synovial sheath origin.,Plantar calcaneal spur but no reactive marrow stress phenomenon.,Mild tendinosis of the Achilles tendon but no tendinitis or tendon tear.,Os navicularis (Type II synchondrosis) without an active marrow stress phenomenon.
---
DESCRIPTION: Patient with right ankle pain.

Patient with right ankle pain.

The case involves a patient with a history of ankle pain due to a prior injury, and the MRI findings reveal multiple issues including a partial high ankle sprain, a split tear of the peroneus brevis tendon, synovitis, and other related pathologies. While these findings indicate significant structural and inflammatory issues that could impact the patient's mobility and quality of life if untreated, they do not appear to be life-threatening. The patient likely requires medical intervention, such as physical therapy, possibly surgery, and pain management, which are common in podiatry. However, the situation does not pose an immediate critical risk to the patient's life or long-term well-being if appropriately managed.


Medical Specialty: Radiology
Sample Name: Laparoscopic Cholecystectomy & Cholangiogram

PREOPERATIVE DIAGNOSIS:,  Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute gangrenous cholecystitis with cholelithiasis.,OPERATION PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,FINDINGS:  ,The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.,COMPLICATIONS:  ,None.,EBL: , Scant.,SPECIMEN REMOVED: , Gallbladder with stones.,DESCRIPTION OF PROCEDURE:  ,The patient was prepped and draped in the usual sterile fashion under general anesthesia.  A curvilinear incision was made below the umbilicus.  Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization.  Once this complete, insufflation was begun.  Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant.  Once all four ports were placed, the right upper quadrant was then explored.  The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis.  This was taken down using Bovie cautery to free up visualization of the gallbladder.  The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall.  Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area.  Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction.  At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed.  The cystic duct and cystic artery were serially clipped and transected.  The gallbladder was removed from the gallbladder fossa removing the entire gallbladder.  Adequate hemostasis with Bovie cautery was achieved.  The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port.  A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture.  Next, the right upper quadrant was copiously irrigated out using the suction irrigator.  Once this was complete, the additional ports were able to be removed.  The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion.  All skin incisions were injected using Marcaine 1/4 percent plain.  The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique.  The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition.
---
DESCRIPTION: Laparoscopic cholecystectomy with cholangiogram.  Acute gangrenous cholecystitis with cholelithiasis.  The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.

radiology, acute cholecystitis, cholangiogram, cholelithiasis, cholecystitis, gallbladder, gangrenous cholecystitis, bovie cautery, cystic duct, laparoscopic cholecystectomy, laparoscopic, cholecystectomy, cystic, duct,

The situation involves a surgical procedure for acute gangrenous cholecystitis, which is a severe and potentially life-threatening condition. The surgery appears to have been performed successfully without complications, which is positive, but the nature of the condition and the requirement for surgical intervention make it relatively high-stakes. The successful completion and recovery are critical for the patient's health.


Medical Specialty: General Medicine
Sample Name: Normal Male Exam Template - 2

MALE PHYSICAL EXAMINATION,Eye:  Eyelids normal color, no edema.  Conjunctivae with no erythema, foreign body, or lacerations.  Sclerae normal white color, no jaundice.  Cornea clear without lesions.  Pupils equally responsive to light.  Iris normal color, no lesions.  Anterior chamber clear.  Lacrimal ducts normal.  Fundi clear.,Ear:  External ear has no erythema, edema, or lesions.  Ear canal unobstructed without edema, discharge, or lesions.  Tympanic membranes clear with normal light reflex.  No middle ear effusions.,Nose:  External nose symmetrical.  No skin lesions.  Nares open and free of lesions.  Turbinates normal color, size and shape.  Mucus clear.  No internal lesions.,Throat:  No erythema or exudates.  Buccal mucosa clear.  Lips normal color without lesions.  Tongue normal shape and color without lesion.  Hard and soft palate normal color without lesions.  Teeth show no remarkable features.  No adenopathy.  Tonsils normal shape and size.  Uvula normal shape and color.,Neck:  Skin has no lesions.  Neck symmetrical.  No adenopathy, thyromegaly, or masses.  Normal range of motion, nontender.  Trachea midline.,Chest:  Symmetrical.  Clear to auscultation bilaterally.  No wheezing, rales or rhonchi.  Chest nontender.  Normal lung excursion.  No accessory muscle use.,Cardiovascular:  Heart has regular rate and rhythm with no S3 or S4.  Heart rate is normal.,Abdominal:  Soft, nontender, nondistended, bowel sounds present.  No hepatomegaly, splenomegaly, masses, or bruits.,Genital:  Penis normal shape without lesions.  Testicles normal shape and contour without tenderness.  Epididymides normal shape and contour without tenderness.  Rectum normal tone to sphincter.  Prostate normal shape and contour without nodules.  Stool hemoccult negative.  No external hemorrhoids.  No skin lesions.,Musculoskeletal:  Normal strength all muscle groups.  Normal range of motion all joints.  No joint effusions.  Joints normal shape and contour.  No muscle masses.,Foot:  No erythema.  No edema.  Normal range of motion all joints in the foot.  Nontender.  No pain with inversion, eversion, plantar or dorsiflexion.,Ankle:  Anterior and posterior drawer test negative.  No pain with inversion, eversion, dorsiflexion, or plantar flexion.  Collateral ligaments intact.  No joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.,Knee:  Normal range of motion.  No joint effusion, erythema, nontender.  Anterior and posterior drawer tests negative.  Lachman's test negative.  Collateral ligaments intact.  Bursas nontender without edema.,Wrist:  Normal range of motion.  No edema or effusion, nontender.  Negative Tinel and Phalen tests.  Normal strength all muscle groups.,Elbow:  Normal range of motion.  No joint effusion or erythema.  Normal strength all muscle groups.  Nontender.  Olecranon bursa flat and nontender, no edema.  Normal supination and pronation of forearm.  No crepitus.,Hip:  Negative swinging test.  Trochanteric bursa nontender.  Normal range of motion.  Normal strength all muscle groups.  No pain with eversion and inversion.  No crepitus.  Normal gait.,Psychiatric:  Alert and oriented times four.  No delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality.  Affect is appropriate.  No psychomotor slowing or agitation.  Eye contact is appropriate.
---
DESCRIPTION: An example/template for a routine normal male physical exam.

general medicine, male exam, normal, physical exam, normal range of motion, male physical, nontender, lesions, dorsiflexion, sclerae, contour, muscle, erythema, joints, edema, shape,

The situation described is a routine physical examination with normal findings. It is a template for documenting a standard physical exam in general medicine, which is a typical part of regular healthcare maintenance. There are no signs of acute or emergent medical issues within the information provided. This setting is low-stakes as it primarily involves routine documentation and likely serves as a reference or template for practitioners.


Medical Specialty: Radiology
Sample Name: Ultrasound - Abdomen

EXAM: , Ultrasound abdomen, complete.,HISTORY: , 38-year-old male admitted from the emergency room 04/18/2009, decreased mental status and right upper lobe pneumonia.  The patient has diffuse abdominal pain.  There is a history of AIDS.,TECHNIQUE:,  An ultrasound examination of the abdomen was performed.,FINDINGS:,  The liver has normal echogenicity.  The liver is normal sized.  The gallbladder has a normal appearance without gallstones or sludge.  There is no gallbladder wall thickening or pericholecystic fluid.  The common bile duct has a normal caliber at 4.6 mm.  The pancreas is mostly obscured by gas.  A small portion of the head of pancreas is visualized which has a normal appearance.  The aorta has a normal caliber.  The aorta is smooth walled.  No abnormalities are seen of the inferior vena cava.  The right kidney measures 10.8 cm in length and the left kidney 10.5 cm.  No masses, cysts, calculi, or hydronephrosis is seen.  There is normal renal cortical echogenicity.  The spleen is somewhat prominent with a maximum diameter of 11.2 cm.  There is no ascites.  The urinary bladder is distended with urine and shows normal wall thickness without masses.  The prostate is normal sized with normal echogenicity.,IMPRESSION:  ,1.  Spleen size at the upper limits of normal.,2.  Except for small portions of pancreatic head, the pancreas could not be visualized because of bowel gas.  The visualized portion of the head had a normal appearance.,3.  The gallbladder has a normal appearance without gallstones.  There are no renal calculi.
---
DESCRIPTION: Ultrasound abdomen, complete

Ultrasound abdomen, complete

radiology, echogenicity, gallbladder, ultrasound abdomen complete, ultrasound abdomen, abdomen, liver, gallstones, kidney, calculi, renal, spleen, pancreas, ultrasound

The examination results indicate mostly normal findings except a slightly enlarged spleen and difficulty visualizing the pancreas due to bowel gas. However, there is no direct indication of an immediate threat or life-critical condition causing high stakes in this specific scenario. The patient has a history of AIDS, which may generally increase medical complexity, but the ultrasound findings themselves do not suggest an urgent issue in this report.


Medical Specialty: Urology
Sample Name: Paraphimosis

PREOPERATIVE DIAGNOSIS: , Phimosis.,POSTOPERATIVE DIAGNOSIS: , Phimosis.,PROCEDURE: , Reduction of paraphimosis.,ANESTHESIA:  ,General inhalation anesthetic with 0.25% Marcaine, penile block and ring block about 20 mL given.,FLUIDS RECEIVED: , 100 mL.,SPECIMENS:,  No tissues sent to pathology.,COUNTS: , Sponge and needle counts were not necessary.,TUBES/DRAINS: , No tubes or drains were used.,FINDINGS: , Paraphimosis with moderate swelling.,INDICATIONS FOR OPERATION: , The patient is a 15-year-old boy who had acute alcohol intoxication had his foreskin retracted with a Foley catheter placed at another institution.  When they removed the catheter they forgot to reduce the foreskin and he developed paraphimosis.  The plan is for reduction.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, with manual pressure and mobilization of the shaft skin we were able to reduce the paraphimosis.  Using Betadine and alcohol cleanse, we then did a dorsal penile block and a ring block by surgeon with 0.25% Marcaine, 20 mL were given.  He did quite well after the procedure and was transferred to the recovery room in stable condition.
---
DESCRIPTION: Reduction of paraphimosis.

Reduction of paraphimosis.

urology, dorsal penile block, reduction of paraphimosis, penile block, phimosis, paraphimosis,

The situation involves a 15-year-old boy who developed paraphimosis due to a medical error during a previous procedure involving a Foley catheter. While the procedure to correct paraphimosis is relatively straightforward when caught in time, the condition itself can potentially lead to serious complications if untreated, including impaired blood flow and tissue damage. Given that this scenario involves resolving a surgical urgency with a young patient and due to the nature of the error that led to the condition, it is not routine care but does not reach the highest level of stakes given the successful outcome and the patient's stability post-procedure.


Medical Specialty: General Medicine
Sample Name: Hyperthyroidism Following Pregnancy

HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain.  She had been previously diagnosed with hyperthyroidism.  Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm.  She had been experiencing palpitations and tachycardia.  She had no diaphoresis, no nausea, vomiting, or dyspnea.,She had a significant TSH of 0.004 and a free T4 of 19.3.  Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL, respectively.  Her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency.  She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards.  She complained of sweating, but has experienced no diarrhea and no change in appetite.  She was given isosorbide mononitrate and IV steroids in the ER.,FAMILY HISTORY:,  Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.,SOCIAL HISTORY:,  She had a baby five months ago.  She smokes a half pack a day.  She denies alcohol and drug use.,MEDICATIONS:,  Citalopram 10mg once daily for depression; low dose tramadol PRN pain.,PHYSICAL EXAMINATION: , Temperature 98.4; Pulse 123; Respiratory Rate 16; Blood Pressure 143/74.,HEENT:  She has exophthalmos and could not close her lids completely.,Cardiovascular:  tachycardia.,Neurologic:  She had mild hyperreflexiveness.,LAB:,  All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122.  Urine pregnancy test was negative.,HOSPITAL COURSE: , After admission, she was given propranolol at 40mg daily and continued on telemetry.  On the 2nd day of treatment, the patient still complained of chest pain.  EKG again showed tachycardia.  Propranolol was increased from 40mg daily to 60mg twice daily., A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours.  The normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake.  Endocrine consult recommended radioactive I-131 for treatment of Graves disease.,Two days later she received 15.5mCi of I-131.  She was to return home after the iodine treatment.  She was instructed to avoid contact with her baby for the next week and to cease breast feeding.,ASSESSMENT / PLAN:,1. Treatment of hyperthyroidism.  Patient underwent radioactive iodine 131 ablation therapy.,2. Management of cardiac symptoms stemming from hyperthyroidism.  Patient was discharged on propranolol 60mg, one tablet twice daily.,3. Monitor patient for complications of I-131 therapy such as hypothyroidism.  She should return to Endocrine Clinic in six weeks to have thyroid function tests performed.  Long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. Prevention of pregnancy for one year post I-131 therapy.  Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. Monitor ocular health.  Patient was given methylcellulose ophthalmic, one drop in each eye daily.  She should follow up in 6 weeks with the Ophthalmology clinic.,6. Management of depression.  Patient will be continued on citalopram 10 mg.
---
DESCRIPTION: Chief complaint of chest pain, previously diagnosed with hyperthyroidism.

general medicine, hyperthyroidism, diabetes, hypertension, hospital course, thyroid function, tachycardia, pregnancy,

The situation involves a young woman experiencing severe symptoms of hyperthyroidism following pregnancy, including chest pain and significant cardiac symptoms like tachycardia. The stakes are high because untreated or improperly managed hyperthyroidism can lead to serious complications, such as heart problems and thyroid storm, especially considering her age and recent pregnancy. She also has prescribed treatment that involves radioactive iodine and needs careful monitoring for potential complications such as hypothyroidism. Furthermore, the patient's need to avoid contact with her baby and to cease breastfeeding adds a social and emotional element to the health stakes.


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

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

HISTORY OF PRESENT ILLNESS:,  The patient is a 74-year-old white woman who has a past medical history of hypertension for 15 years, history of CVA with no residual hemiparesis and uterine cancer with pulmonary metastases, who presented for evaluation of recent worsening of the hypertension.  According to the patient, she had stable blood pressure for the past 12-15 years on 10 mg of lisinopril.  In August of 2007, she was treated with doxorubicin and, as well as Procrit and her blood pressure started to go up to over 200s.  Her lisinopril was increased to 40 mg daily.  She was also given metoprolol and HCTZ two weeks ago, after she visited the emergency room with increased systolic blood pressure.  Denies any physical complaints at the present time.  Denies having any renal problems in the past.,PAST MEDICAL HISTORY:,  As above plus history of anemia treated with Procrit.  No smoking or alcohol use and lives alone.,FAMILY HISTORY:,  Unremarkable.,PRESENT MEDICATIONS: , As above.,REVIEW OF SYSTEMS: , Cardiovascular:  No chest pain.  No palpitations.  Pulmonary:  No shortness of breath, cough, or wheezing.  Gastrointestinal:  No nausea, vomiting, or diarrhea.  GU:  No nocturia.  Denies having gross hematuria.  Salt intake is minimal.  Neurological:  Unremarkable, except for history of old CVA.,PHYSICAL EXAMINATION: , Blood pressure today is 182/78.  Examination of the head is unremarkable.  Neck is supple with no JVD.  Lungs are clear.  There is no abdominal bruit.  Extremities 1+ edema bilaterally.,LABORATORY DATA:,  Urinalysis done in the office shows 1+ proteinuria; same is shown by urinalysis done at Hospital.  The creatinine is 0.8.  Renal ultrasound showed possible renal artery stenosis and a 2 cm cyst in the left kidney.  MRA of the renal arteries was essentially unremarkable with no suspicion for renal artery stenosis.,IMPRESSION AND PLAN:,  Accelerated hypertension.  No clear-cut etiology for recent worsening since renal artery stenosis was ruled out by negative MRA.  I could only blame Procrit initiation, as well as possible fluid retention as a cause of the patient's accelerated hypertension.  She was started on hydrochlorothiazide less than two weeks ago with some improvement in her hypertension.  At this point, I would not pursue a diagnosis of renal artery stenosis.  Since she is maxed out on lisinopril and her pulse is 60, I would not increase beta-blocker or ACE inhibitor.  I will continue HCTZ at 24 mg daily.  The patient was also given a sample of Tekturna, which would hopefully improve her systolic blood pressure.  The patient was told to be stick with her salt intake.  She will report to me in 10 days with the result of her blood pressure.  She will also repeat an SMA7 to rule out possible hyperkalemia due to Tekturna.
---
DESCRIPTION: Patient with a past medical history of hypertension for 15 years.

consult - history and phy., hypertension, ace inhibitor, accelerated hypertension, hctz, mra of the renal arteries, procrit, sma7, anemia, beta-blocker, doxorubicin, hemiparesis, history of cva, hyperkalemia, no abdominal bruit, uterine cancer, renal artery stenosis, artery stenosis, blood pressure, blood, pressure, renal,

The situation involves a 74-year-old patient with a history of hypertension, past CVA, and cancer with metastases, facing worsening hypertension. Her condition is being managed with medications, and there's a suspicion of drug-induced hypertension or fluid retention. Although the patient's current condition isn't life-threatening and is under management, the potential for rapid escalation in blood pressure poses significant health risks, particularly in older adults with complex medical histories, making it moderately high-stakes. However, the physician's confidence in managing the situation with medications mitigates some of the immediacy of danger.


Medical Specialty: Surgery
Sample Name: Cardiac Catheterization - 9

EXAM: , Cardiac catheterization and coronary intervention report.,PROCEDURES:,1.  Left heart catheterization, coronary angiography, left ventriculography.,2.  PTCA/Endeavor stent, proximal LAD.,INDICATIONS: , Acute anterior ST-elevation MI.,ACCESS: , Right femoral artery 6-French.,MEDICATIONS:,1.  IV Valium.,2.  IV Benadryl.,3.  Subcutaneous lidocaine.,4.  IV heparin.,5.  IV ReoPro.,6.  Intracoronary nitroglycerin.,ESTIMATED BLOOD LOSS: , 10 mL.,CONTRAST:  ,185 mL.,COMPLICATIONS: , None.,PROCEDURE: , The patient was brought to the cardiac catheterization laboratory with acute ST-elevation MI and EKG.  She was prepped and draped in the usual sterile fashion.  The right femoral region was infiltrated with subcutaneous lidocaine, adequate anesthesia was obtained.  The right femoral artery was entered with _______ modified Seldinger technique and a J wire was passed.  The needle was exchanged for 6 French sheath.  The wire was removed.  The sheath was washed with sterile saline.  Following this, the left coronary was attempted to be cannulated with an XP catheter, however, the catheter folded on itself and could not reach the left main, this was removed.  A second 6-French JL4 guiding catheter was then used to cannulate the left main and initial guiding shots demonstrated occlusion of the proximal LAD.  The patient had an ACT check, received additional IV heparin and IV ReoPro.  The lesion was crossed with 0.014 BMW wire and redilated with a 2.5 x 20-mm balloon at nominal pressures.  The balloon was deflated and angiography demonstrated establishment of flow.  Following this, the lesion was stented with a 2.5 x 18-mm Endeavor stent at 10 atmospheres.  The balloon was deflated, reinflated at 12 atmospheres, deflated and removed.  Final angiography demonstrated excellent clinical result.  Additional angiography was performed with a wire out.  Following this, the wire and the catheter was removed.  Following this, the right coronary was selectively cannulated with diagnostic catheter and angiographic views were obtained in multiple views.  This catheter was removed.  The pigtail catheter was placed in the left ventricle and left ventriculography was performed with pullback pressures across the aortic valve.  At the end of procedure, wires and catheter were removed.  Right femoral angiography was performed and a right femoral Angio-Seal kit was deployed at the right femoral arteriotomy site.  There was no hematoma.  Peripheral pulses _______ procedure.  The patient tolerated the procedure well.  Symptoms of chest pain resolved at the end of the procedure with no complications.,RESULTS:,1.  Coronary angiography.,A.  Left main free of obstruction.,B.  LAD, subtotal proximal stenosis.,C.  Circumflex large vessel with three large obtuse marginal branches.  No high-grade obstruction, evidence of minimal plaquing.,D.  Right coronary 70% mid vessel stenosis and 50% mid to distal stenosis before giving rise to a right dominant posterior lateral and posterior descending artery.,2.  Left ventriculogram.  Left ventricular ejection fraction estimated at 45% to 50%.  There was an akinetic apical wall.,3.  Hemodynamics.  Aortic pressure 145/109, left ventricular pressure 147/13, left ventricular end-diastolic pressure 34 mmHg.,IMPRESSION:,1.  Acute ST-elevation myocardial infarction, culprit lesion, left anterior descending occlusion.,2.  Two-vessel coronary disease.,3.  Mild-to-moderate impaired LV systolic function.,4.  Successful stent left anterior descending, 100% occlusion, 0% residual stenosis.,PLAN:  ,Overnight observation in ICU.  Start aspirin, Plavix, beta-blocker and ACE inhibitor.  Check serial cardiac enzymes.  Further recommendations to follow.  Check fasting lipid panel, in addition add a statin.  Further recommendations to follow.
---
DESCRIPTION: Cardiac catheterization and coronary intervention report.

The described situation involves a cardiac catheterization procedure on a patient experiencing an acute anterior ST-elevation myocardial infarction (MI), a potentially life-threatening condition. The procedure's objective was to intervene and treat the blockage causing the heart attack. Any cardiac intervention, especially in the context of an acute MI, is inherently high-stakes due to the risk of complications, the critical nature of the underlying condition, and the potential for severe outcomes if the procedure is unsuccessful. The report details various aspects to ensure the procedure was successful without complications, indicating a high level of seriousness and expertise involved.