Medical Specialty: Orthopedic
Sample Name: Osteotomy & Bunionectomy

PREOPERATIVE DIAGNOSES:,1.  Metatarsus primus varus with bunion deformity, right foot.,2.  Hallux abductovalgus with angulation deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Metatarsus primus varus with bunion deformity, right foot.,2.  Hallux abductovalgus with angulation deformity, right foot.,PROCEDURES:,1.  Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.,2.  Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.,ANESTHESIA:,Local infiltrate with IV sedation.,INDICATION FOR SURGERY: , The patient has had a longstanding history of foot problems.  The foot problem has been progressive in nature and has not been responsive to conservative treatment.  The preoperative discussion with the patient included the alternative treatment options.,The procedure was explained in detail and risk factors such as infection, swelling, scarred tissue; numbness, continued pain, recurrence, and postoperative management were explained in detail.  The patient has been advised, although no guaranty for success could be given, most patients have improved function and less pain.  All questions were thoroughly answered.  The patient requested surgical repair since the problem has reached a point that interferes with her normal daily activities.  The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF PROCEDURE:  ,The patient was brought to the operating room and placed in a supine position.  No tourniquet was utilized.  IV sedation was administered and during that time local anesthetic consisting of approximately 10 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine with epinephrine was locally infiltrated proximal to the operative site.  The lower extremity was prepped and draped in the usual sterile manner.  Balanced anesthesia was obtained.,PROCEDURE #1: , Distal metaphyseal osteotomy with internal screw fixation with bunionectomy, right foot.  A dorsal curvilinear incision medial to the extensor hallucis longus tendon was made, extending from the distal third of the shaft of the first metatarsal to a point midway on the shaft of the proximal phalanx.  Care was taken to identify and retract the vital structures and when necessary, vessels were ligated via electrocautery.  Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and then down to the capsular and periosteal layer, which was visualized.  A linear periosteal capsular incision was made in line with the skin incision.  The capsular tissue and periosteal layer were underscored, free from its underlying osseous attachments, and they refracted to expose the osseous surface.  Inspection revealed increased first intermetatarsal angle and hypertrophic changes to the first metatarsal head.  The head of the first metatarsal was dissected free from its attachment medially and dorsally, delivered dorsally and may be into the wound.,Inspection revealed the first metatarsophalangeal joint surface appeared to be in satisfactory condition.  The sesamoid was in satisfactory condition.  An oscillating saw was utilized to resect the hypertrophic portion of the first metatarsal head to remove the normal and functional configuration.  Care was taken to preserve the sagittal groove.  The rough edges were then smoothed with a rasp.,Attention was then focused on the medial mid portion of the first metatarsal head where a K-wire access guide was positioned to define the apex and direction of displacement for the capital fragment.  The access guide was noted to be in good position.  A horizontally placed, through-and-through osteotomy with the apex distal and the base proximal was completed.  The short plantar arm was from the access guide to proximal plantar and the long dorsal arm was from the access guide to proximal dorsal.  The capital fragment was distracted off the first metatarsal, moved laterally to decrease the intermetatarsal angle to create a more anatomical and functional position of the first metatarsal head.  The capital fragment was impacted upon the metatarsal.,Inspection revealed satisfactory reduction of the intermetatarsal angle and good alignment of the capital fragment.  It was then fixated with 1 screw.  A guide pin was directed from the dorsal aspect of the capital fragment to the plantar aspect of the shaft and first metatarsal in a distal dorsal to proximal plantar direction.  The length was measured, __________ mm cannulated cortical screw was placed over the guide pin and secured in position.  Compression and fixation were noted to be satisfactory.  Inspection revealed good fixation and alignment at the operative site.  Attention was then directed to the medial portion of the distal third of the shaft of the first metatarsal where an oscillating saw was used to resect the small portion of the bone that was created by shifting the capital fragment laterally.  All rough edges were rasped smooth.  Examination revealed there was still lateral deviation of the hallux.  A second procedure, the reposition osteotomy of the proximal phalanx with internal screw fixation to correct angulation deformity was indicated., ,PROCEDURE #2:,  Reposition osteotomy with internal screw fixation to correct angulation deformity, proximal phalanx, right hallux.  The original skin incision was extended from the point just distal to the interphalangeal joint.  All vital structures were identified and retracted.  Sharp and blunt dissection was carried down through the subcutaneous tissue, superficial fascia, and down to the periosteal layer, which was underscored, free from its underlying osseous attachments and reflected to expose the osseous surface.  The focus of the deformity was noted to be more distal on the hallux.  Utilizing an oscillating saw, a more distal, wedge-shaped transverse oblique osteotomy was made with the apex being proximal and lateral and the base medial distal was affected.  The proximal phalanx was then placed in appropriate alignment and stabilized with a guide pin, which was then measured, __________ 14 mm cannulated cortical screw was placed over the guide pin and secured into position.,Inspection revealed good fixation and alignment at the osteotomy site.  The alignment and contour of the first way was now satisfactorily improved.  The entire surgical wound was flushed with copious amounts of sterile normal saline irrigation.  The periosteal and capsular layer was closed with running sutures of #3-0 Vicryl.  The subcutaneous tissue was closed with #4-0 Vicryl and the skin edges coapted well with #4-0 nylon with running simples, reinforced with Steri-Strips.,Approximately 6 mL total in a 1:1 mixture of 0.25% Marcaine and 1% lidocaine plain was locally infiltrated proximal to the operative site for postoperative anesthesia.  A dressing consisting of Adaptic and 4 x 4 was applied to the wound making sure the hallux was carefully splinted, followed by confirming bandages and an ACE wrap to provide mild compression.  The patient tolerated the procedure and anesthesia well and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact as evident by the normal capillary fill time.,A walker boot was dispensed and applied.  The patient should wear it when walking or standing., ,The next office visit will be in 4 days.  The patient was given prescriptions for Percocet 5 mg #40 one p.o. q.4-6h. p.r.n. pain, along with written and oral home instructions.  The patient was discharged home with vital signs stable in no acute distress.
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DESCRIPTION: Distal metaphyseal osteotomy and bunionectomy with internal screw fixation, right foot.  Reposition osteotomy with internal screw fixation to correct angulation deformity of proximal phalanx, right foot.

The surgical procedure described here involves an osteotomy and bunionectomy, which are common orthopedic surgeries aimed at correcting bone deformities in the foot. While surgery is inherently a serious medical intervention, this type of procedure is routine for orthopedic surgeons and is considered moderate in the spectrum of surgical risk. The stakes are higher than a minor procedure due to the necessity for precise bone manipulation and potential complications like infection or improper healing, but it is not critical compared to major or life-saving surgeries. The patient's life is not at immediate risk from the condition itself, and the procedure is elective to improve quality of life.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Selective Coronary Angiography & Angioplasty

PREOPERATIVE DIAGNOSIS AND INDICATIONS:,  Acute non-ST-elevation MI.,POSTOPERATIVE DIAGNOSIS AND SUMMARY:,  The patient presented with an acute non-ST-elevation MI.  Despite medical therapy, she continued to have intermittent angina.  Angiography demonstrated the severe LAD as the culprit lesion.  This was treated as noted above with angioplasty alone as the stent could not be safely advanced.  She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above.  She will be continued on her medical therapy.  At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,PROCEDURE PERFORMED: , Selective coronary angiography, coronary angioplasty.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position.  The area of the right femoral artery was prepped and draped in a sterile fashion.  Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance.  With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system.  The catheter was removed.  The sheath flushed.  The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery.  The cath removed, the sheath flushed.,It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI.  The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower.  We repeated the level and it was slightly higher.  We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV.  Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.,A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal.  An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated.  Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent.  The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium.  The balloon was inflated and removed, repeat angiography performed.  We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification.  The stent was removed.  Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful.  It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed.  Repeat angiography demonstrated no evidence of dissection.  One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal.  I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed.  The guidewires and guide cath were removed.  The sheath flushed and sutured into position.  The patient moved to ICU in stable condition with no chest discomfort at all.,CONTRAST: , Isovue-370, 120 mL.,FLUORO TIME: , 9.4 minutes.,ESTIMATED BLOOD LOSS: , 30 mL.,HEMODYNAMICS:,  Aorta 185/54.,Left ventriculography was not performed.  I did not make an attempt to cross this severely stenotic aortic valve.,The left main is a large vessel, giving rise to LAD and circumflex vessels.  The left main has no significant disease other than calcification in the walls.,The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal.  The LAD has significant calcification proximally.  There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent.  This resulted in a 30% residual, mostly eccentric calcified plaque.  Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal.  This was not ballooned.  Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal.  These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal.  As noted above, this area was not stented because I could not safely advance the stent.  Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches.  The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal.  The remainder of the vessel was without significant disease.,The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch.  The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch.  The remainder of the right coronary and its branches were without significant disease.
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DESCRIPTION: Selective coronary angiography, coronary angioplasty.  Acute non-ST-elevation MI.

cardiovascular / pulmonary, non-st-elevation mi, selective coronary angiography, coronary angioplasty, calcified plaque, coronary angiography, st elevation, stenosis, lad, coronary, selective, angiography, angioplasty, balloon, vessel, stent,

The situation involves the management of a 90-year-old patient with acute non-ST-elevation myocardial infarction (MI), who underwent coronary angioplasty. There were complications such as calcification preventing the advancement of a stent, decisions to avoid potentially risky procedures given the patient's advanced age and severe aortic stenosis, and the constant evaluation of hemodynamic status. These factors, combined with the patient's advanced age and pre-existing severe cardiac issues, make this a high-stakes medical situation, as the outcome could potentially be life-threatening.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Chiropractic
Sample Name: Qualified Medical Evaluation Report

HISTORY OF INJURY AND PRESENT COMPLAINTS: , The patient is a 59-year-old gentleman.  He is complaining chiefly of persistent lower back pain.  He states the pain is of a rather constant nature.  He describes it as a rather constant dull ache, sometimes rather sharp and stabbing in nature, most localized to the right side of his back more so than the left side of his lower back.  He states he has difficulty with prolonged standing or sitting.  He can only stand for about 5-10 minutes, then he has to sit down.  He can only sit for about 15-20 minutes, he has to get up and move about because it exacerbates his back pain.  He has difficulty with bending and stooping maneuvers.  He describes an intermittent radiating pain down his right leg, down from the right gluteal hip area to the back of the thigh to the calf and the foot.  He gets numbness along the lateral aspect of the foot itself.  He also describes chronic pain complaints with associated tension in the back of his neck.  He states the pain is of a constant nature in his neck.  He states he gets pain that radiates into the right shoulder girdle area and the right forearm.  He describes some numbness along the lateral aspect of the right forearm.  He states he has trouble trying to use his arm at or above shoulder height.  He has difficulty pushing, pulling, gripping, and grasping with the right upper extremity.  He describes pain at the anterior aspect of his shoulder, in particular.  He denies any headache complaints.  He is relating his above complaints to two industrial injuries that he sustained while employed with Frito Lay Company as a truck driver or delivery person.  He relates an initial injury that occurred on 06/29/1994, when apparently he was stepping out of the cab of his truck.  He lost his footing and fell.  He reached out to grab the hand railing.  He fell backwards on his back and his right shoulder.  He had immediate onset of shoulder pain, neck pain, and low back pain.  He had pain into his right leg.  He initially came under the care of Dr. H, an occupational physician in Modesto.  Initially, he did not obtain any MRIs or x-rays.  He did undergo some physical therapy and received some medications.  Dr. H referred him to Dr. Q, a chiropractor for three visits, which the patient was not certain was very helpful.  The patient advises he then changed treating physicians to Dr. N, D.C., whom he had seen previously for some back pain complaints back in 1990.  He felt that the chiropractic care was helping his back, neck, and shoulder pain complaints somewhat.  He continues with rather persistent pain in his right shoulder.  He underwent an MRI of the right shoulder performed on 08/16/1994 which revealed prominent impingement with biceps tenosynovitis as well as supraspinatus tendonitis superimposed by a small pinhole tear of the rotator cuff.  The patient was referred to Dr. P, an orthopedic surgeon who suggested some physical therapy for him and some antiinflammatories.  He felt that the patient might require a cortisone injection or possibly a surgical intervention.  The patient also underwent an MRI of the cervical spine on 08/03/1994, which again revealed multilevel degenerative disc disease in his neck.  There is some suggestion of bilateral neuroforaminal encroachment due to degenerative changes and disc bulges, particularly at C5-6 and C6-7 levels.  The patient was also seen by Dr. P, a neurologist for a Neurology consult.  It is unclear to me as to whether or not Dr. P had performed an EMG or nerve conduction studies of his upper or lower extremities.  The patient was off work for approximately six months following his initial injury date that occurred on 06/29/1994.  He returned back to regular duty.  Dr. N declared him permanent and stationary on 04/04/1995.  The patient then had a recurrence or flare-up or possibly new injury, again, particularly to his lower back while working for Frito Lay on 03/29/1997, when he was loading some pallets on the back of a trailer.  At that time, he returned to see Dr. N for chiropractic care, who is his primary treating physician.  Dr. N took him off work again.  He was off work again for approximately another six months, during which time, he was seen by Dr. M, M.D., a neurosurgeon.  He had a new MRI of his lumbar spine performed.  The MRI was performed on 05/20/1997.  It revealed L4-5 disc space narrowing with prominent disc bulge with some mild spinal stenosis.  The radiologist had noted he had a prior disc herniation at this level with some improvement from prior exam.  Dr. M saw him on 09/18/1997 and noted that there was some improvement in his disc herniation at the L4-5 level following a more recent MRI exam of 05/20/1997, from previous MRI exam of 1996 which revealed a rather prominent right-sided L4-5 disc herniation.  Dr. M felt that there was no indication for a lumbar spine surgery, but he mentioned with regards to his cervical spine, he felt that EMG studies of the right upper extremity should be obtained and he may require a repeat MRI of the cervical spine, if the study was positive.  The patient did undergo some nerve conduction studies of his lower extremities with Dr. K, M.D., which suggested a possible abnormal EMG with evidence of possible L5 radiculopathy, both right and left.  Unfortunately, I had no medical reports from Dr. P suggesting that he may have performed nerve conduction studies or EMGs of the upper and lower extremities.  The patient did see Dr. R for a neurosurgical consult.  Dr. R evaluated both his neck and lower back pain complaints on several occasions.  Dr. R suggested that the patient try some cervical epidural steroid injections and lumbar selective nerve root blocks.  The patient underwent these injections with Dr. K.  The patient reported only very slight relief temporarily with regards to his back and leg symptoms following the injections.  It is not clear from the medical record review whether the patient ever had a cervical epidural steroid injection; it appears that he had some selective nerve root blocks performed in the lumbar spine.  Dr. R on 12/15/2004 suggested that the patient had an MRI of the cervical spine revealing a right-sided C5-6 herniated nucleus pulposus which would explain his C-6 distribution numbness.  The patient also was noted to have a C4-5 with rather severe degenerative disc disease.  He felt the patient might be a candidate for a two-level ACDF at C4-5 and C5-6.  Dr. R in another report of 08/11/2004 suggested that the patient's MRI of 05/25/2004 of the lumbar spine reveals multilevel degenerative disc disease.  He had an L4-5 slight anterior spondylolisthesis, this may be a transitional vertebrae at the L6 level as well, with lumbarization of S1.  He felt that his examination suggested a possible right S1 radiculopathy with discogenic back pain.  He would suggest right-sided S1 selective nerve root blocks to see if this would be helpful; if not, he might be a candidate for a lumbar spine fusion, possibly a Dynesys or a fusion or some major spine surgery to help resolve his situation., ,The patient relates that he really prefers a more conservative approach of treatment regarding his neck, back, and right shoulder symptoms.  He continued to elect chiropractic care which he has found helpful, but apparently the insurance carrier is no longer authorizing chiropractic care for him.  He is currently taking no medications to manage his pain complaints.  He states regarding his work status, he was off work again for another six months following the 03/29/1997 injury.  He returned back to work and continued to work regular duty up until about a year ago, at which time, he was taken back off work again and placed on TTD status by Dr. N, his primary treating physician.  The patient states he has not been back to work since.  He has since applied for social security disability and now is receiving social security disability benefits.  The patient states he has tried some Myox therapy with Dr. H on 10 sessions, which he found somewhat helpful.  Overall, the patient does not feel that he could return back to his usual and customary work capacity as a delivery driver for Frito Lay.,
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DESCRIPTION: Qualified medical evaluation report of a patient with back pain.

The situation involves a patient with longstanding and severe back and neck pain due to multiple work-related injuries, resulting in chronic pain, disability, and unemployment. While it does describe significant personal distress and impacts on the patient's life, the report narrates a medical evaluation and the patient's treatment history. The patient's preference for conservative treatment over surgical intervention indicates that immediate life-threatening consequences are unlikely. However, the implications for the patient's quality of life, work capacity, and financial situation due to reliance on disability benefits suggest moderate stakes. These factors collectively render it a serious, yet not critically high-stakes medical situation.


Medical Specialty: Hematology - Oncology
Sample Name: Consult - Breast Cancer - 1

CHIEF COMPLAINT: , Left breast cancer.,HISTORY:,  The patient is a 57-year-old female, who I initially saw in the office on 12/27/07, as a referral from the Tomball Breast Center.  On 12/21/07, the patient underwent image-guided needle core biopsy of a 1.5 cm lesion at the 7 o'clock position of the left breast (inferomedial).  The biopsy returned showing infiltrating ductal carcinoma high histologic grade.  The patient stated that she had recently felt and her physician had felt a palpable mass in that area prior to her breast imaging.  She prior to that area, denied any complaints.  She had no nipple discharge.  No trauma history.  She has had been on no estrogen supplementation.  She has had no other personal history of breast cancer.  Her family history is positive for her mother having breast cancer at age 48.  The patient has had no children and no pregnancies.  She denies any change in the right breast.  Subsequent to the office visit and tissue diagnosis of breast cancer, she has had medical oncology consultation with Dr. X and radiation oncology consultation with Dr. Y.  I have discussed the case with Dr. X and Dr. Y, who are both in agreement with proceeding with surgery prior to adjuvant therapy.  The patient's metastatic workup has otherwise been negative with MRI scan and CT scanning.  The MRI scan showed some close involvement possibly involving the left pectoralis muscle, although thought to also possibly represent biopsy artifact.  CT scan of the neck, chest, and abdomen is negative for metastatic disease.,PAST MEDICAL HISTORY:,  Previous surgery is history of benign breast biopsy in 1972, laparotomy in 1981, 1982, and 1984, right oophorectomy in 1984, and ganglion cyst removal of the hand in 1987.,MEDICATIONS:,  She is currently on omeprazole for reflux and indigestion.,ALLERGIES:,  SHE HAS NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,  Negative for any recent febrile illnesses, chest pains or shortness of breath.  Positive for restless leg syndrome.  Negative for any unexplained weight loss and no change in bowel or bladder habits.,FAMILY HISTORY:,  Positive for breast cancer in her mother and also mesothelioma from possible asbestosis or asbestos exposure.,SOCIAL HISTORY:  ,The patient works as a school teacher and teaching high school.,PHYSICAL EXAMINATION,GENERAL:  The patient is a white female, alert and oriented x 3, appears her stated age of 57.,HEENT:  Head is atraumatic and normocephalic.  Sclerae are anicteric.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,BREASTS:  Exam reveals an approximately 1.5 cm relatively mobile focal palpable mass in the inferomedial left breast at the 7 o'clock position, which clinically is not fixed to the underlying pectoralis muscle.  There are no nipple retractions.  No skin dimpling.  There is some, at the time of the office visit, ecchymosis from recent biopsy.  There is no axillary adenopathy.  The remainder of the left breast is without abnormality.  The right breast is without abnormality.  The axillary areas are negative for adenopathy bilaterally.,ABDOMEN:  Soft, nontender without masses.  No gross organomegaly.  No CVA or flank tenderness.,EXTREMITIES:  Grossly neurovascularly intact.,IMPRESSION: , The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.,RECOMMENDATIONS: , I have discussed with the patient in detail about the diagnosis of breast cancer and the surgical options, and medical oncologist has discussed with her issues about adjuvant or neoadjuvant chemotherapy.  We have decided to recommend to the patient breast conservation surgery with left breast lumpectomy with preoperative sentinel lymph node injection and mapping and left axillary dissection.  The possibility of further surgery requiring wider lumpectomy or even completion mastectomy was explained to the patient.  The procedure and risks of the surgery were explained to include, but not limited to extra bleeding, infection, unsightly scar formation, the possibility of local recurrence, the possibility of left upper extremity lymphedema was explained.  Local numbness, paresthesias or chronic pain was explained.  The patient was given an educational brochure and several brochures about the diagnosis and treatment of breast cancers.  She was certainly encouraged to obtain further surgical medical opinions prior to proceeding.  I believe the patient has given full informed consent and desires to proceed with the above.
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DESCRIPTION: The patient is a 57-year-old female with invasive ductal carcinoma of the left breast, T1c, Nx, M0 left breast carcinoma.

The situation involves a medical case of a 57-year-old female diagnosed with invasive ductal carcinoma of the left breast, which is a significant medical condition. Breast cancer is a potentially life-threatening disease, and the treatment decisions, including surgery and possible adjuvant therapies, are critical and could significantly impact the patient's prognosis and quality of life. The case involves coordination with multiple specialists, detailed discussions about treatment options, and potential risks associated with surgery, making it a high-stakes scenario due to the complexity and potential consequences of the decisions made.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Nipple Reconstruction

PREOPERATIVE DIAGNOSES,1.  Surgical absence of left nipple areola with personal history of breast cancer.,2.  Breast asymmetry.,POSTOPERATIVE DIAGNOSES,1.  Surgical absence of left nipple areola with personal history of breast cancer.,2.  Breast asymmetry.,PROCEDURE,1.  Left nipple areolar reconstruction utilizing a full-thickness skin graft from the left groin.,2.  Redo right mastopexy.,ANESTHESIA,General endotracheal.,COMPLICATIONS,None.,DESCRIPTION OF PROCEDURE IN DETAIL,The patient was brought to the operating room and placed on the table in the supine position and after suitable induction of general endotracheal anesthesia, the patient was placed in a frog-leg position and prepped and draped in usual fashion for the above-noted procedure.  The initial portion of the procedure was harvesting a full-thickness skin graft from the left groin region.  This was accomplished by ellipsing out a 42-mm diameter circle of skin just below the thigh, peroneal crease.  The defect was then closed with 3-0 Vicryl followed by 3-0 chromic suture in a running locked fashion.  The area was dressed with antibiotic ointment and then a Peri-Pad.  The patient's legs were brought out frog-leg back to the midline and sterile towels were placed over the opening in the drapes.  Surgical team's gloves were changed and then attention was turned to the planning of the left nipple flap.,A maltese cross pattern was employed with a 1-cm diameter nipple and a 42-mm diameter nipple areolar complex.  Once the maltese cross had been designed on the breast at the point where the nipple was to be placed, the areas of the portion of flap were de-epithelialized.  Then, when this had been completed, the dermis about the maltese cross was incised full thickness to allow mobilization of the flap to form the neonipple.  At this point, a Bovie electrocautery was used to control bleeding points and then 4-0 chromic suture was used to suture the arms of the flap together creating the nipple.  When this had been completed, the skin graft, which had been harvested from the left groin was brought onto the field where it was prepared by removing all subcutaneous tissue from the posterior aspect of the graft and carefully removing the hair follicles encountered within the graft.  At this point, the graft was sutured into position in the defect using 3-0 chromic in an interrupted fashion and then trimming the ellipse to an appropriate circle to fill the areola.  At this point, 4-0 chromic was used to run around the perimeter of the full-thickness skin graft and then at this point the nipple was delivered through a cruciate incision in the middle of the skin graft and then inset appropriately with 4-0 chromic.  The areolar skin graft was pie crusted.  Then, at this point, the area of areola was dressed with silicone gel sheeting.  A silo was placed over the neonipple with 3-0 nylon through the apex of the neonipple to support the nipple in an erect position.  Mastisol and Steri-Strips were then applied.,At this point, attention was turned to the right breast where a 2-cm wide ellipse transversely oriented and with its inferior most aspect just inferior to the transverse mastopexy incision line was made.  The skin was removed from the area and then a layered closure of 3-0 Vicryl followed by 3-0 PDS in a running subcuticular fashion was carried out.  When this had been completed, the Mastisol and Steri-Strips were applied to the transverse right breast incision.  Fluff dressings were applied to the right breast as well as the area around the silo on the left breast around the reconstructed nipple areola.  The patient was then placed in Surgi-Bra and then was taken from the operating room to the recovery room in good condition.
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DESCRIPTION: Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy

cosmetic / plastic surgery, nipple areola, breast asymmetry, general endotracheal, peri-pad, surgi-bra, breast cancer, frog-leg position, full-thickness skin graft, general endotracheal anesthesia, mastopexy, nipple areolar complex, nipple areolar reconstruction, nipple flap, prepped and draped, transverse mastopexy, areolar reconstruction, skin graft, graft, nipple, areolar, breast

The situation involves a cosmetic/plastic surgery procedure with a detailed description of a nipple reconstruction after breast cancer treatment. Cosmetic surgeries, while significant for personal and psychological well-being, typically do not involve life-threatening risks unless complications such as infection or anesthesia issues arise. Given that there were no complications reported in the procedure and the patient was noted to be in good condition post-operation, the stakes of this specific situation are not extremely high in medical terms. However, the procedure's success impacts the patient's emotional and psychological health, making it more significant than a routine low-risk procedure.


Medical Specialty: Surgery
Sample Name: Indwelling Catheter Insertion

PREOPERATIVE DIAGNOSIS: , Chronic renal failure.,POSTOPERATIVE DIAGNOSIS:  ,Chronic renal failure.,PROCEDURE PERFORMED:,  Insertion of left femoral circle-C catheter.,ANESTHESIA: , 1% lidocaine.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,HISTORY: , The patient is a 36-year-old African-American male presented to ABCD General Hospital on 08/30/2003 for evaluation of elevated temperature.  He was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.  He did require a short-term of Levophed for hypotension.  He is felt to have an infected dialysis catheter, which was removed.  He was planned to undergo replacement of his Perm-A-Cath, dialysis catheter, however, this was not possible.  He will still require a dialysis and will require at least a temporary dialysis catheter until which time a long-term indwelling catheter can be established for dialysis.  He was explained the risks, benefits, and complications of the procedure previously.  He gave us informed consent to proceed.,OPERATIVE PROCEDURE: , The patient was placed in the supine position.  The left inguinal region was shaved.  His left groin was then prepped and draped in normal sterile fashion with Betadine solution.  Utilizing 1% lidocaine, the skin and subcutaneous tissue were anesthetized with 1% lidocaine.  Under direct aspiration technique, the left femoral vein was cannulated.  Next, utilizing an #18 gauge Cook needle, the left femoral vein was cannulated.  Sutures were removed, nonpulsatile flow was observed and a Seldinger guidewire was inserted within the catheter.  The needle was then removed.  Utilizing #11 blade scalpel, a small skin incision was made adjacent to the catheter.  Utilizing a #10 French dilator, the skin, subcutaneous tissue, and left femoral vein were dilated over the Seldinger guidewire.  Dilator was removed and a preflushed circle-C 8 inch catheter was inserted over the Seldinger guidewire.  The guidewire was retracted out from the blue distal port and grasped.  The catheter was then placed in the left femoral vessel _______.  This catheter was then fixed to the skin with #3-0 silk suture.  A mesenteric dressing was then placed over the catheter site.  The patient tolerated the procedure well.  He was turned to the upright position without difficulty.  He will undergo dialysis today per Nephrology.
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DESCRIPTION: Insertion of left femoral circle-C catheter (indwelling catheter).  Chronic renal failure.  The patient was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.

surgery, chronic renal failure, femoral circle-c catheter, indwelling catheter, catheter, insertion, seldinger, guidewire, indwelling, femoral, dialysis,

The procedure described involves the insertion of a temporary dialysis catheter in a patient with chronic renal failure who had a previous infection related to a catheter. The stakes are moderately high due to the patient's chronic condition and the history of MRSA bacteremia, which can complicate recovery and increase the risk of complications in this procedure. However, the actual procedure description reports minimal blood loss, no complications, and was conducted under local anesthesia, suggesting a standard level of risk for an experienced team. The patient's need for dialysis and previous complications elevate the stakes but not to an extreme degree.


Medical Specialty: Surgery
Sample Name: Esophagoscopy & Foreign Body Removal

PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:,  Esophageal foreign body, US penny.,PROCEDURE: , Esophagoscopy with foreign body removal.,ANESTHESIA: , General.,INDICATIONS: , The patient is a 17-month-old baby girl with biliary atresia, who had a delayed diagnosis and a late attempted Kasai portoenterostomy, which failed.  The patient has progressive cholestatic jaundice and is on the liver transplant list at ABCD.  The patient is fed by mouth and also with nasogastric enteral feeding supplements.  She has had an __________ cough and relatively disinterested in oral intake for the past month.  She was recently in the GI Clinic and an x-ray was ordered to check her tube placement and an incidental finding of a coin in the proximal esophagus was noted.  Based on the history, it is quite possible this coin has been there close to a month.  She is brought to the operating room now for attempted removal.  I met with the parents and talked to them at length about the procedure and the increased risk in a child with a coin that has been in for a prolonged period of time.  Hopefully, there will be no coin migration or significant irrigation that would require prolonged hospitalization.,OPERATIVE FINDINGS: , The patient had a penny lodged in the proximal esophagus in the typical location.  There was no evidence of external migration and surrounding irritation was noted, but did not appear to be excessive.  The coin actually came out with relative ease after which endoscopically identified.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had induction of general anesthesia.  She was slow to respond to the usual propofol and other inducing agents and may be has some difficulty with tolerance or __________ tolerance to these medications.  After her endotracheal tube was placed and securely taped to the left side of her mouth, I positioned the patient with a prominent shoulder roll and neck hyperextension and then used the laryngoscope to elevate the tiny glottic mechanism.  A rigid esophagoscope was then inserted into the proximal esophagus, and the scope was gradually advanced with the lumen directly in frontal view.  This was facilitated by the nasoenteric feeding tube that was in place, which I followed carefully until the edge of the coin could be seen.  At this location, there was quite a bit of surrounding mucosal inflammation, but the coin edge could be clearly seen and was secured with the coin grasping forceps.  I then withdrew the scope, forceps, and the coin as one unit, and it was easily retrieved.  The patient tolerated the procedure well.  There were no intraoperative complications.  There was only one single coin noted, and she was awakened and taken to the recovery room in good condition.
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DESCRIPTION: Esophageal foreign body, US penny.  Esophagoscopy with foreign body removal.  The patient had a penny lodged in the proximal esophagus in the typical location.

surgery, portoenterostomy, foreign body removal, proximal esophagus, coin, esophagoscopy, esophageal, esophagus,

The situation involves a 17-month-old baby girl with a complex medical history, including biliary atresia and initially missed diagnosis, who is awaiting a liver transplant. The presence of a US penny in her esophagus for potentially a month makes this a concerning scenario. Although the operation to remove the foreign body was described as successful with no complications, any surgical procedure on a young child, especially one with a compromised liver condition, carries significant risk. The fact that the penny had been lodged for an extended period also increases the potential for complications. Therefore, this situation is of high-stakes, given the age of the patient, her medical background, and the potential risks involved.


Medical Specialty: Surgery
Sample Name: Rectus Recession

PREOPERATIVE DIAGNOSIS:,  Congenital bilateral esotropia, 42 prism diopters.,PROCEDURE:,  Bilateral rectus recession with the microscopic control, 8 mm, both eyes.,POSTOPERATIVE DIAGNOSIS: , Congenital bilateral esotropia, 42 prism diopters.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , The patient was taken to the Surgery Room and placed in the supine position.  The general anesthesia was achieved with intubation with no problems.  Both eyes were prepped and draped in usual manner.  The attention was turned the right eye and a hole was made in the drape and a self-retaining eye speculum was placed ensuring eyelash in the eye drape.  The microscope was focused on the palpebral limbus and the eyeball was rotated medially and laterally with no problem.  The eyeball rotated medially and upwards by holding the limbus at 7 o'clock position.  Inferior fornix conjunctival incision was made and Tenons capsule buttonholed.  The lateral rectus muscle was engaged over the muscle hook and the Tenons capsule was retracted with the tip of the muscle hook.  The Tenons capsule was buttonholed.  The tip of the muscle hook and Tenons capsule was cleaned from the insertion of the muscle.  __________ extension of the muscle was excised.  The 7-0 Vicryl sutures were placed at the insertion of the muscle and double locked at the upper and lower borders.  The muscle was disinserted from original insertion.  The suture was passed 8 mm posterior to the insertion of the muscle in double sewed fashion.  The suture was pulled, tied, and cut.  The muscle was in good position.  The conjunctiva was closed with 7-0 Vicryl suture in running fashion.  The suture was pulled, tied, and cut.  The eye speculum was taken out.,Similar procedure performed on the left rectus muscle and it was recessed by 8 mm from its original insertion.  The suture was pulled, tied and cut.  The eye speculum was taken out after the conjunctiva was sewed up and the suture was cut.  TobraDex eye drops were instilled in both eyes and the patient extubated and was in good condition.  To be seen in the office in 1 week.
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DESCRIPTION: Bilateral rectus recession with the microscopic control, 8 mm, both eyes.

surgery, congenital bilateral esotropia, esotropia, tenons capsule, rectus muscle, bilateral rectus recession, rectus recession, eye speculum, muscle hook, eyes, muscle, rectus,

The situation involves a surgical procedure for correcting congenital bilateral esotropia, which is a condition where both eyes are turned inward. A rectus recession surgery is a common ophthalmologic procedure aimed at aligning the eyes. The details provided indicate that the surgery was completed without complications and the patient was in good condition postoperatively. While eye surgeries are delicate, the absence of complications in this report suggests a lower risk level compared to more invasive or high-risk surgeries in other medical fields.


Medical Specialty: Radiology
Sample Name: MRI Brain - Cryptococcus

CC: ,Headache.,HX: ,This 37y/o LHM was seen one month prior to this presentation for HA, nausea and vomiting. Gastrointestinal evaluation at that time showed no evidence of bowel obstruction and he was released home. These symptoms had been recurrent since onset.,At presentation he complained of mild blurred vision (OU), difficulty concentrating and HA which worsened upon sitting up. The headaches were especially noticeable in the early morning. He described them as non-throbbing headaches. They begin in the bifrontal region and radiate posteriorly. They occurred up to 6 times/day. The HA improved with lying down or dropping the head down between the knees towards the floor. The headaches were associated with blurred vision, nausea,vomiting, photophobia, and phonophobia. He denied any scotomata or positive visual phenomena. He denies any weakness, numbness, tingling, dysarthria or diplopia. His weight has fluctuated from 163# to 148# over the past 3 months and at present he weighs 154#. His appetite has been especially poor in the past month.,MEDS:,Sulfasalazine qid. Tylenol 650mg q4hours.,PMH:, 1)Ulcerative Colitis dx 1989. 2)HTN 3) occasional HAs since the early 1980s which are different in character and much less severe than his current HAs. They were not associated with nausea, vomiting, photophobia, phonophobia or difficulty thinking.,FHX:, MGF with h/o stroke. Mother and Father were healthy. No h/o of migraine in family.,SHX:, Single. Works as a newpaper printing press worker. Denies tobacco, ETOH or illicit drug use, but admits he was a heavy drinker until the last 1970s when he quit.,EXAM: ,BP159/92 HR 48 (sitting): BP126/70 HR48 (supine). RR14 36.2C,MS: A&O to person, place and time. Speech clear. Appears uncomfortable but acts appropriately and cooperatively. No difficulty with short and long term memory.,CN: Grad 2-3 papilledema OS; Grade 1 papilledema (@2 o'clock) OD. Pupils 4/4 decreasing to 2/2 on exposure to light. Bilateral horizontal sustained nystagmus on right and leftward gaze. Bilateral vertical sustained nystagmus on up and downward gaze. Face symmetric with full movement and PP sensation. Tongue midline with full ROM. Gag and SCM were intact bilaterally.,Motor: Full strength throughout with normal muscle bulk and tone.,Sensory: Unremarkable.,Coord: Mild dysynergia on FNF movements in BUE. HNS and RAM were unremarkable.,Station: Unsteady with and without eyes open on Romberg test. No drift in any particular direction.,Gait: Wide based, ataxic and to some degree magnetic and apraxic.,Gen Exam: Unremarkable.,COURSE:, Urinalysis revealed 1-2RBC, 2-3WBC and bacteria were noted. Repeat Urinalysis was negative the next day. PT, PTT, CXR and GS were normal. CBC revealed 10.4WBC with 7.1Granulocytes. HCT, 10/18/95, revealed hydrocephalus. MRI, 10/18/95, revealed ventriculomegaly of the lateral, 3rd and 4th ventricles. There was enhancement of the meninges about the prepontine cisterna and internal auditory canals, and enhancement of a scar or inflammed lining of the foramen of Magendie. These changes were felt suggestive of bacterial or granulomatous meningitis. The patient underwent ventriculostomy on 10/19/94. CSF taken on 10/19/94 via V-P shunt insertion revealed: 22 WBC (21 lymphocytes, 1 monocyte), 380 RBC, Glucose 58, Protein 29, GS negative, Cultures (bacterial, fungal, AFB) negative, Cryptococcal Antigen and India Ink were negative. Numerous CSF samples were taken from the lumbar region and shunt reservoir and these were consistantly unremarkable except for an occasional CSF protein of up to 99mg/dl. Serum and CSF toxoplasma titers and ACE levels were negative on multiple occasions. VDRL and HIV testing was unremarkable. 10/27/94 and 10/31/94 CSF cultures taken from the cervical region eventually grew non-encapsulated crytococcus neoformans. The patient was treated with amphotericin and showed some improvement. However, scarring had probably occurred by then and the V-P shunt was left in place.
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DESCRIPTION: MRI Brain: Ventriculomegaly of the lateral, 3rd and 4th ventricles secondary to obstruction of the foramen of Magendie secondary to Cryptococcus (unencapsulated) in a non-immune suppressed, HIV negative, individual.

radiology, ventriculomegaly, foramen of magendie, mri brain, blurred vision, headache, brain, ventricles, cryptococcus, foramen, csf,

The situation involves a potentially severe medical condition where the patient presents with hydrocephalus caused by Cryptococcus meningitis, a serious fungal infection affecting the brain. Despite being HIV negative and not immunocompromised, the patient has a condition requiring surgery (ventriculostomy) and treatment with potent antifungal medication (amphotericin). The stakes are significant due to the potential for long-term neurological damage or other complications if not adequately treated. Proper diagnosis, timely intervention, and ongoing monitoring are crucial for the patient's recovery, making this a high-stakes situation in the medical context.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy - 2

PROCEDURE:,  Esophagogastroduodenoscopy with biopsy.,REASON FOR PROCEDURE:,  The child with history of irritability and diarrhea with gastroesophageal reflux.  Rule out reflux esophagitis, allergic enteritis, and ulcer disease, as well as celiac disease.  He has been on Prevacid 7.5 mg p.o. b.i.d. with suboptimal control of this irritability.,Consent history and physical examinations were performed.  The procedure, indications, alternatives available, and complications i.e. bleeding, perforation, infection, adverse medication reactions, possible need for blood transfusion, and surgery associated complication occur were discussed with the mother who understood and indicated this.  Opportunity for questions was provided and informed consent was obtained.,MEDICATIONS:  ,General anesthesia.,INSTRUMENT: , Olympus GIF-XQ 160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FINDINGS: , With the patient in the supine position intubated under general anesthesia, the endoscope was inserted without difficulty into the hypopharynx.  The proximal, mid, and distal esophagus had normal mucosal coloration and vascular pattern.  Lower esophageal sphincter appeared normal and was located at 25 cm from the central incisors.  A Z-line was identified within the lower esophageal sphincter.  The endoscope was advanced into the stomach, which was distended with excess air.  The rugal folds flattened completely.  The gastric mucosa was entirely normal.  No hiatal hernia was seen and the pyloric valve appeared normal.  The endoscope was advanced into first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  Ampule of Vater was identified and found to be normal.  Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  Additional two antral biopsies were obtained for CLO testing.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated the procedure well.  The patient was taken to recovery room in satisfactory condition.,IMPRESSION:,  Normal esophagus, stomach, and duodenum.,PLAN:,  Histologic evaluation and CLO testing.  Continue Prevacid 7.5 mg p.o. b.i.d.  I will contact the parents next week with biopsy results and further management plans will be discussed at that time.
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DESCRIPTION: Esophagogastroduodenoscopy with biopsy.

Esophagogastroduodenoscopy with biopsy.

gastroenterology, olympus gif-xq 160, diarrhea, gastroesophageal, esophagitis, reflux, clo testing, esophagogastroduodenoscopy with biopsy, endoscope, esophagus, stomach, duodenum, esophagogastroduodenoscopy

The procedure being described is an esophagogastroduodenoscopy (EGD) with biopsy, conducted on a child with symptoms that may indicate serious conditions like reflux esophagitis, allergic enteritis, ulcer disease, or celiac disease. The procedure requires general anesthesia and carries risks such as bleeding, perforation, infection, and adverse reactions to medication. Though the procedure was performed without complications and the initial findings were normal, the stakes involve diagnosing potentially serious gastrointestinal issues in a child, which could have significant health implications if not properly diagnosed and treated.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Infected Toenails

S - ,This patient has reoccurring ingrown infected toenails.  He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border.  The right great toenail is ingrown on the lateral nail border only.  There is mild redness and granulation tissue growing on the borders of the toes.  One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe.  These lesions measure 0.5 cm in diameter each.  I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1.  Onychocryptosis.,
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DESCRIPTION: This patient has reoccurring ingrown infected toenails.

soap / chart / progress notes, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected,

The scenario involves a medical consultation for patient with recurring ingrown infected toenails. This condition, known as onychocryptosis, while painful and potentially leading to infection, is generally not life-threatening if treated appropriately. However, it can cause significant discomfort and if left untreated, can lead to more serious infections. The scenario involves managing a chronic issue, but it does not indicate immediate life-threatening danger.


Medical Specialty: Surgery
Sample Name: Colonoscopy with Biopsy - 4

PREOPERATIVE DIAGNOSIS: , Antibiotic-associated diarrhea.  ,POSTOPERATIVE DIAGNOSIS:  ,Antibiotic-associated diarrhea.  ,OPERATION PERFORMED: , Colonoscopy with random biopsies and culture.,INDICATIONS: , The patient is a 50-year-old woman who underwent hemorrhoidectomy approximately one year ago.  She has been having difficulty since that time with intermittent diarrhea and abdominal pain.  She states this happens quite frequently and can even happen when she uses topical prednisone for her ears or for her eyes.  She presents today for screening colonoscopy, based on the same.,OPERATIVE COURSE:  , The risks and benefits of colonoscopy were explained to the patient in detail.  She provided her consent.  The morning of the operation, the patient was transported from the preoperative holding area to the endoscopy suite.  She was placed in the left lateral decubitus position.  In divided doses, she was given 7 mg of Versed and 125 mcg of fentanyl.  A digital rectal examination was performed, after which time the scope was intubated from the anus to the level of the hepatic flexure.  This was intubated fairly easily; however, the patient was clearly in some discomfort and was shouting out, despite the amount of anesthesia she was provided.  In truth, the pain she was experiencing was out of proportion to any maneuver or difficulty with the procedure.  While more medication could have been given, the patient is actually a fairly thin woman and diminutive and I was concerned that giving her any more sedation may lead to respiratory or cardiovascular collapse.  In addition, she was really having quite some difficulty staying still throughout the procedure and was putting us all at some risk.  For this reason, the procedure was aborted at the level of the hepatic flexure.  She was noted to have some pools of stool.  This was suctioned and sent to pathology for C difficile, ova and parasites, and fecal leukocytes.  Additionally, random biopsies were performed of the colon itself.  It is unfortunate we were unable to complete this procedure, as I would have liked to have taken biopsies of the terminal ileum.  However, given the degree of discomfort she had, again, coupled with the relative ease of the procedure itself, I am very suspicious of irritable bowel syndrome.  The patient tolerated the remainder of the procedure fairly well and was sent to the recovery room in stable condition, where it is anticipated she will be discharged to home.,PLAN:,  She needs to follow up with me in approximately 2 weeks' time, both to follow up with her biopsies and cultures.  She has been given a prescription for VSL3, a probiotic, to assist with reculturing the rectum.  She may also benefit from an antispasmodic and/or anxiolytic.  Lastly, it should be noted that when she next undergoes endoscopic procedure, propofol would be indicated.
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DESCRIPTION: Colonoscopy with random biopsies and culture.

surgery, colonoscopy with random biopsies, hepatic flexure, topical, culture, antibiotic, hepatic, flexure, diarrhea, biopsies, colonoscopy

The situation involves a medical procedure with its own inherent risks, as the patient experienced significant pain despite sedation, leading to an incomplete colonoscopy. However, the patient was stable post-procedure and the main concern appears to be determining a correct diagnosis and ensuring the patient can be managed comfortably in the future. While there's a risk of not obtaining the full diagnostic detail due to the incomplete procedure, the stakes primarily revolve around managing patient comfort and correctly diagnosing the underlying condition for appropriate treatment.


Medical Specialty: Surgery
Sample Name: Shoulder Hemi-resurfacing

PREOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right shoulder.,POSTOPERATIVE DIAGNOSIS:,  Severe degenerative joint disease of the right shoulder.,PROCEDURE: , Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,COMPLICATIONS:,  None.  The patient was taken to Postanesthesia Care Unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS: , The patient is a 55-year-old female who has had increased pain in to her right shoulder.  X-rays as well as an MRI showed a severe arthritic presentation of the humeral head with mild arthrosis of the glenoid.  She had an intact rotator cuff being at a young age and with potential of glenoid thus it was felt that a hemi-resurfacing was appropriate for her right shoulder focusing in the humeral head.  All risks, benefits, expectations and complications of surgery were explained to her in detail including nerve and vessel damage, infection, potential for hardware failure, the need for revision surgery with potential of some problems even with surgical intervention.  The patient still wanted to proceed forward with surgical intervention.  The patient did receive 1 g of Ancef preoperatively.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operating table.  The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well.  The patient was moved to a beach chair position.  All extremities were well padded.  Her head was well padded to the table.  Her right upper extremity was draped in sterile fashion.  A saber incision was made from the coracoid down to the axilla.  Skin was incised down to the subcutaneous tissue, the cephalic vein was retracted as well as all neurovascular structures were retracted in the case.  Dissecting through the deltopectoral groove, the subscapularis tendon was found as well as the bicipital tendon, 1 finger breadth medial to the bicipital tendon an incision was made.  Subscapularis tendon was released.  The humeral head was brought in to; there were large osteophytes that were removed with an osteotome.  The glenoid then was evaluated and noted to just have mild arthrosis, but there was no need for surgical intervention in this region.  A sizer was placed.  It was felt that size 5 was appropriate for this patient, after which the guide was used to place the stem and pin.  This was placed, after which a reamer was placed along the humeral head and reamed to a size 5.  All extra osteophytes were excised.  The supraspinatus and infraspinatus tendons were intact.  Next, the excess bone was removed and irrigated after which reaming of the central portion of the humeral head was performed of which a trial was placed and showed that there was adequate fit and appropriate fixation.  The arm had excellent range of motion.  There are no signs of gross dislocation.  Drill holes were made into the humeral head after which a size 5 Copeland hemi-resurfacing component was placed into the humeral head, kept down in appropriate position, had excellent fixation into the humeral head.  Excess bone that had been reamed was placed into the Copeland metal component, after which this was tapped into position.  After which the wound site was copiously irrigated with saline and antibiotics and the humeral head was reduced and taken through range of motion; had adequate range of motion, full internal and external rotation as well as forward flexion and abduction.  There was no gross sign of dislocation.  Wound site once again it was copiously irrigated with saline antibiotics.  The subscapularis tendon was approximated back into position with #2 Ethibond after which the bicipital tendon did have significant tear to it; therefore it was tenodesed in to the pectoralis major tendon.  After which, the wound site again was irrigated with saline antibiotics after which subcutaneous tissue was approximated with 2-0 Vicryl.  The skin was closed with staples.  A sterile dressing was placed.  The patient was awakened from general anesthetic and transferred to hospital gurney to the postanesthesia care unit in stable condition.
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DESCRIPTION: Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.  Severe degenerative joint disease of the right shoulder.

surgery, degenerative joint disease, hemi-resurfacing, biomet copeland, shoulder hemi resurfacing, humeral, head, degenerative, glenoid, subscapularis, antibiotics, resurfacing, tendon, shoulder,

The procedure described is a surgical operation involving the shoulder joint, which inherently carries some level of risk due to its invasive nature. However, the specifics of the case, such as the patient's stable condition post-surgery, no complications, a low estimated blood loss, and successful fixation, suggest that the immediate high-stakes risks commonly associated with surgeries were well-mitigated in this case. While surgery can be considered a high-stakes event due to potential life-altering consequences and risks such as nerve or vessel damage, the controlled and successful outcome here implies that, relative to the range of surgical procedures, this particular situation is medium in terms of urgency and consequence.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Overactive Bladder

REASON FOR VISIT: , Overactive bladder with microscopic hematuria.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder.  Her cystoscopy performed was unremarkable.  She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night.  No gross hematuria, dysuria, pyuria, no other outlet obstructive and/or irritative voiding symptoms.  The patient had been previously on Ditropan and did not do nearly as well.  At this point, what we will try is a different medication.  Renal ultrasound is otherwise unremarkable, notes no evidence of any other disease.,IMPRESSION: , Overactive bladder with microscopic hematuria most likely some mild atrophic vaginitis is noted.  She has no other significant findings other than her overactive bladder, which had continued.  At this juncture what I would like to do is try a different anticholinergic medication.  She has never had any side effects from her medication.,PLAN: , The patient will discontinue Ditropan.  We will start Sanctura XR and we will follow up as scheduled.  Otherwise we will continue to follow her urinalysis over the next year or so.
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DESCRIPTION: Overactive bladder with microscopic hematuria.

soap / chart / progress notes, overactive bladder with microscopic hematuria, irritative voiding symptoms, anticholinergic, microscopic hematuria, overactive bladder, ditropan, microscopic, hematuria, bladder, overactive

The situation involves a medical condition, specifically an overactive bladder with microscopic hematuria. However, the condition is being actively managed with regular monitoring and medication adjustments. There are no indications of severe or life-threatening symptoms at present. The patient's cystoscopy and renal ultrasound were unremarkable, suggesting no immediate severe underlying issues. Thus, while it is a medical condition requiring attention, it does not seem to be urgent or highly critical at this time.


Medical Specialty: Nephrology
Sample Name: Nephrectomy

PREOPERATIVE DIAGNOSIS: , Left renal mass, left renal bleed.,POSTOPERATIVE DIAGNOSIS:  ,Left renal mass, left renal bleed.,PROCEDURE PERFORMED: , Left laparoscopic hand-assisted nephrectomy.,ANESTHESIA:,  General endotracheal.,EBL: , 100 mL.,The patient had a triple-lumen catheter A-line placed.,BRIEF HISTORY:,  The patient is a 54-year-old female with history of diabetic nephropathy, diabetes, hypertension, left BKA, who presented with abdominal pain with left renal bleed.  The patient was found to have a complex mass in the upper pole and the lower pole of the kidney.  MRI and CAT scan showed questionable renal mass, which could be malignant.  Initial plan was to let the patient stabilize for 2 weeks and perform the nephrectomy.  At this point, the patient was unable to go home.  The patient continually complained of pain.  The patient required about 3 to 4 units of blood transfusions prior.  The patient initially came in with hemoglobin less than 5.  The hemoglobin prior to surgery was 10.,Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, respiratory failure, morbidity and mortality of the procedure due to her low ejection fraction were discussed.  Cardiac clearance was obtained.  The patient was high risk, family and the patient knew about the risk.  The recommendation from the pulmonologist, cardiologist, and medical team was to get the kidney out at this point because the patient and the family stated that they would not do well at home without any intervention.  The patient and family understood all the risks and benefits in order to proceed with the surgery.,DETAILS OF THE PROCEDURE:,  The patient was brought to the OR.  Anesthesia was applied.  The patient had A-line triple-lumen catheter.  The patient was placed in left side up, right side down oblique position.  All the pressure points were well padded.  The right fistula was carefully padded completely around it.  Axilla was protected.  The fistula was checked throughout the procedure to ensure that it was stable.  The arms, ankles, knees, and joints were all padded with foam.  The patient was taped to the table using 2-inch wide tape.  OG and a Foley catheter were in place.  A supraumbilical incision was made about 6 cm in size and incision was carried through the subcutaneous tissue and through the fascia and peritoneum was entered sharply.  There were some adhesions where the omentum was into the umbilical hernia, which was completely stuck.  The omentum was released out of that just so we could obtain pneumoperitoneum.  Pneumoperitoneum was obtained after using GelPort.  Two 12-mm ports were placed in the left anterior axillary line, and mid clavicular line.  The colon was reflected medially.  Kidney was dissected laterally behind and inferiorly.  There was large hematoma visualized with significant amount of old blood, which was irrigated out.  Dissection was carried superiorly and the spleen was reflected medially.  The spleen and colon were all intact at the end of the procedure.  They were stable all throughout.  Using endovascular GIA stapler, all the medial and lateral dissection was carried through the stapler to ensure that the patient had minimal bleeding due to low cardiac reserve.  Hemostasis was obtained.  The renal vein and the renal artery were stapled and there was excellent hemostasis.,The dissection was carried lateral to the adrenal and medial to the right kidney.  The adrenal was preserved.  The entire kidney was removed through the hand port.  Irrigation was performed.  There was excellent hemostasis at the end of the nephrectomy.  Fibrin glue and Surgicel were applied just in case the patient had delayed DIC.  The colon was placed back and 12-mm ports were closed under direct palpation using 0 Vicryl.  The fascia was closed using loop #1 PDS in a running fashion and was tied in the middle.  Please note that prior to the fascial closure, the peritoneum was closed using 0 Vicryl in running fashion.  The subcuticular tissue was brought together using 4-0 Vicryl.  The skin was closed using 4-0 Monocryl.  Dermabond was applied.  The patient was brought to the recovery in a stable condition.
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DESCRIPTION: Left laparoscopic hand-assisted nephrectomy.

nephrology, laparoscopic, nephrectomy, laparoscopic hand assisted nephrectomy, triple lumen catheter, lumen catheter, running fashion, renal mass, renal bleed, dissection, hemostasis, kidney, renal

The case in question involves a high-stakes medical procedure, namely a nephrectomy, which is made even more critical by the patient's complex medical history. The patient's history includes diabetic nephropathy, low hemoglobin levels, and an existing renal bleed, all of which present significant surgical risks. Additionally, the patient has a history of cardiac issues and underwent a major surgical procedure. Significant risks were identified and communicated to the patient and family, including potential complications from anesthesia, bleeding, and other serious risks like respiratory failure or mortality. Given these factors, the situation involves high stakes due to the potential impact on the patient's health and life.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Discharge Summary - Respiratory Failure

DISCHARGE DIAGNOSIS:,1.  Respiratory failure improved.,2.  Hypotension resolved.,3.  Anemia of chronic disease stable.,4.  Anasarca improving.,5.  Protein malnourishment improving.,6.  End-stage liver disease.,HISTORY AND HOSPITAL COURSE:  ,The patient was admitted after undergoing a drawn out process with a small bowel obstruction.  His bowel function started to improve.  He was on TPN prior to coming to Hospital.  He has remained on TPN throughout his time here, but his appetite and his p.o. intake have improved some.  The patient had an episode while here where his blood pressure bottomed out requiring him to spend multiple days in the Intensive Care Unit on dopamine.  At one point, we were unsuccessful at weaning him off the dopamine, but after approximately 11 days, he finally started to tolerate weaning parameters, was successfully removed from dopamine, and has maintained his blood pressure without difficulty.  The patient also was requiring BiPAP to help with his oxygenation and it appeared that he developed a left-sided pneumonia.  This has been treated successfully with Zyvox and Levaquin and Diflucan.  He seems to be currently doing much better.  He is only using BiPAP in the evening.  As stated above, he is eating better.  He had some evidence of redness and exquisite swelling around his genital and lower abdominal region.  This may be mainly dependent edema versus anasarca.  The patient has been diuresed aggressively over the last 4 to 5 days, and this seems to have made some improvement in his swelling.  This morning, the patient denies any acute distress.  He states he is feeling good and understands that he is being discharged to another facility for continued care and rehabilitation.  He will be discharged to Garden Court skilled nursing facility.,DISCHARGE MEDICATIONS/INSTRUCTIONS:,  He is going to be going with Protonix 40 mg daily, metoclopramide 10 mg every 6 hours, Zyvox 600 mg daily for 5 days, Diflucan 150 mg p.o. daily for 3 days, Bumex 2 mg p.o. daily, Megace 400 mg p.o. b.i.d., Ensure 1 can t.i.d. with meals, and MiraLax 17 gm p.o. daily.  The patient is going to require physical therapy to help with assistance in strength training.  He is also going to need respiratory care to work with his BiPAP.  His initial settings are at a rate of 20, pressure support of 12, PEEP of 6, FIO2 of 40%.  The patient will need a sleep study, which the nursing home will be able to set up.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On the day of discharge, heart rate 99, respiratory rate 20, blood pressure 102/59, temperature 98.2, O2 sat 97%.,GENERAL:  A well-developed white male who appears in no apparent distress.,HEENT:  Unremarkable.,CARDIOVASCULAR:  Positive S1, S2 without murmur, rubs, or gallops.,LUNGS:  Clear to auscultation bilaterally without wheezes or crackles.,ABDOMEN:  Positive for bowel sounds.  Soft, nondistended.  He does have some generalized redness around his abdominal region and groin.  This does appear improved compared to presentation last week.  The swelling in this area also appears improved.,EXTREMITIES:  Show no clubbing or cyanosis.  He does have some lower extremity edema, 2+ distal pedal pulses are present.,NEUROLOGIC:  The patient is alert and oriented to person and place.  He is alert and aware of surroundings.  We have not had any difficulties with confusion here lately.,MUSCULOSKELETAL:  The patient moves all extremities without difficulty.  He is just weak in general.,LABORATORY DATA: , Lab work done today shows the following:  White count 4.2, hemoglobin 10.2, hematocrit 30.6, and platelet count 184,000.  Electrolytes show sodium 139, potassium 4.1, chloride 98, CO2 26, glucose 79, BUN 56, and creatinine 1.4.  Calcium 8.8, phosphorus is a little high at 5.5, magnesium 2.2, albumin 3.9.,PLAN:  ,Discharge this gentleman from Hospital and admit him to Garden Court SNF where they can continue with his rehab and conditioning.  Hopefully, long-term planning will be discharge home.  He has a history of end-stage liver disease with cirrhosis, which may make him a candidate for hospice upon discharge.  The family initially wanted to bring the patient home, but he is too weak and requires too much assistance to adequately consider this option at this time.
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DESCRIPTION: The patient was admitted after undergoing a drawn out process with a small bowel obstruction.

cardiovascular / pulmonary, respiratory failure, hypotension, anemia, anasarca, end-stage liver disease, drawn out process, bowel obstruction, blood pressure, dopamine, discharge,

The situation described involves a complex medical case with multiple serious health conditions, including respiratory failure, end-stage liver disease, and an episode requiring ICU care. However, the patient is currently stable and being discharged to a skilled nursing facility for continued care and rehabilitation, which suggests that immediate high-stakes decisions have been managed, and the focus is now on ongoing recovery and rehabilitation. This mitigates the stakes compared to a critical unaddressed medical episode. Nonetheless, careful management and monitoring are necessary given the patient's ongoing health challenges.


Medical Specialty: Orthopedic
Sample Name: FCR tendinitis

HISTORY OF PRESENT PROBLEM:,  XYZ was seen by Dr. ABC for an FCR tendinitis.  We do not have his reports, but by history she has had two cortisone shots.  She plays musical instruments, and it does bother her from time to time.  She was considering surgery, but she takes ibuprofen and it seems to be well-controlled.  She is here now for consultation. ,CLINICAL/PHYSICAL EXAMINATION: , ,General:  The patient is alert and oriented times three in no acute distress. ,Skin:  No skin breakdown or hyperhidrosis.,Vascular:  2+ radial and ulnar artery pulses.,Musculoskeletal:  Wrist, elbow, shoulder and neck exams reveal no focal findings except for some tenderness to palpation over the FCR tendon on the scaphoid tubercle, but there is no SL instability and no signs of lunotriquetral instability or midcarpal instability.  The DRUJ is stable.  Flexion/extension of the fingers is all intact.  Forearm, elbow and shoulder exams reveal no other focal tenderness to palpation.,Neurologic:  Negative Tinel's, Phalen's and compression median nerve test.  APB, EPL and first dorsal interosseous have 5/5 strength.  Forearm, elbow and shoulder exams reveal no neurologic compromise.,Gait:  Normal.,Neck:  Negative Spurling sign.  Negative signs of thoracic outlet.,HEENT:  Pupils equal and reactive with no asymmetry.,CLINICAL IMPRESSION:,  By history, possible FCR tendinitis.,EVALUATION/TREATMENT PLAN:  At this point, we have asked her some questions again.  She is not that sore at this point, and she has had a couple of cortisone shots.  Without being the initial treating physician, she has FCR tendinitis that fails to respond to cortisone shots.  She is a candidate for an FCR tunnel release.  It has been described and is effective for those patients with that problem.  My only consideration would be, if the patient should choose, to get an MRI when she is symptomatic to confirm the FCR tendinitis.  She will followup with Dr. ABC as needed or come back to us when she is thinking more along the lines of surgery.
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DESCRIPTION: Consultation for FCR tendinitis

Consultation for FCR tendinitis

orthopedic, fcr tendinitis, fcr tunnel release, cortisone shot, tendinitis, tunnel release, signs, oriented, shoulder, fcr

The situation involves a patient with FCR tendinitis, considering surgery after previous treatments like cortisone shots and ibuprofen. While it affects her ability to play musical instruments, the condition is not life-threatening and seems to be managed with medication. Surgery is an option but not an immediate necessity, and an MRI could help in confirming the diagnosis if symptoms worsen. The decision to undergo surgery, though impactful on her quality of life and professional activities, is not urgent, making it a moderate-stakes situation.


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

Medical Specialty: Orthopedic
Sample Name: Pinning - Ulna

PREOPERATIVE DIAGNOSIS:,  Right both bone forearm refracture.,POSTOPERATIVE DIAGNOSIS: , Right both bone forearm refracture.,PROCEDURE:,  Closed reduction and pinning of the right ulna with placement of a long-arm cast.,ANESTHESIA: , Surgery performed under general anesthesia.  Local anesthetic was 10 mL of 0.25% Marcaine plain.,COMPLICATIONS: , No intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HARDWARE:  ,Hardware was 0.79 K-wire.,HISTORY AND PHYSICAL: , The patient is a 5-year-old male who sustained refracture of his right forearm on 12/05/2007.  The patient was seen in the emergency room.  The patient had a complete fracture of both bones with shortening bayonet apposition.  Treatment options were offered to the family including casting versus closed reduction and pinning.  The parents opted for the latter.  Risks and benefits of surgery were discussed.  Risks of surgery included risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, and need for later hardware removal, cast tightness.  All questions were answered, and the parents agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  The right upper extremity was then prepped and draped in standard surgical fashion.  A small incision was made at the tip of the olecranon.  Initially, a 1.11 guidewire was placed, but this was noted to be too wide for this canal.  This was changed for a 0.79 K-wire.  This was driven up to the fracture site.  The fracture was manually reduced and then the K-wire passed through the distal segment.  This demonstrated adequate fixation and reduction of both bones.  The pin was then cut short.  The fracture site and pin site was infiltrated with 0.25% Marcaine.  The incision was closed using 4-0 Monocryl.  The wounds were cleaned and dried.  Dressed with Xeroform, 4 x 4.  The patient was then placed in a well-moulded long-arm cast.  He tolerated the procedure well.  He was subsequently taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be maintain current pin, and long-arm cast for 4 weeks at which time he will return for cast removal.  X-rays of the right forearm will be taken.  The patient may need additional mobilization time.  Once the fracture has healed, we will take the pin out, usually at the earliest 3 to 4 months.  Intraoperative findings were relayed to the parents.  All questions were answered.
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DESCRIPTION: Closed reduction and pinning of the right ulna with placement of a long-arm cast.

orthopedic, closed reduction, pinning, forearm refracture, fracture site, arm cast,

The situation involves a surgical procedure performed on a 5-year-old patient for a refracture of the forearm. While this is a surgical intervention and requires proper care, such orthopedic procedures are relatively common and typically have predictable outcomes with low-risk complications. The patient tolerated the procedure well, and there were no intraoperative complications. The stakes are not extremely high, as recovery and healing are expected, though it is important for the child's proper future arm function and development.


Medical Specialty: Dermatology
Sample Name: Acne Vulgaris - H&P

CHIEF COMPLAINT (1/1): , This 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use.  Location:  She indicates the problem location is the chin, right temple and left temple locally.  Severity:  Severity of condition is worsening.,Menses:  Onset:  13 years old.  Interval:  22-27 days.  Duration:  4-6 days.  Flow:  light.  Complications:  none.,ALLERGIES: , Patient admits allergies to penicillin resulting in difficulty breathing.,MEDICATION HISTORY:,  Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by Obstetrician-Gynecologist A.,PAST MEDICAL HISTORY:,  Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.,PAST SURGICAL HISTORY:,  No previous surgeries.,FAMILY HISTORY: , Patient admits a family history of anxiety, stress disorder associated with mother.,SOCIAL HISTORY:,  Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history.,REVIEW OF SYSTEMS:,  Integumentary: (+) periodic reddening of face, (+) acne problems, Allergic /,Immunologic: (-) allergic or immunologic symptoms, Constitutional Symptoms: (-) constitutional symptoms,such as fever, headache, nausea, dizziness.,PHYSICAL EXAM:,  Patient is a 19 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.  Skin:  Examination of scalp shows no abnormalities.  Hair growth and distribution is normal.  Inspection of skin outside of affected area reveals no abnormalities.  Palpation of skin shows no abnormalities.  Inspection of eccrine and apocrine glands shows no evidence of hyperidrosis, chromidrosis or bromhidrosis.  Face shows keratotic papule.,IMPRESSION:,  Acne vulgaris.,PLAN:,  Recommended treatment is antibiotic therapy.  Patient received extensive counseling about acne.  She understands acne treatment is usually long-term.  Return to clinic in 4 week (s).,PATIENT INSTRUCTIONS:,  Patient received literature regarding acne vulgaris.  Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion.,PRESCRIPTIONS:,  Tetracycline  Dosage:  250 mg capsule  Sig:  BID  Dispense:  60  Refills:  0  Allow Generic:  Yes
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DESCRIPTION: Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris

The clinical scenario involves a common dermatological condition, acne vulgaris, in a 19-year-old female. While acne can affect quality of life, given its impact on self-esteem and mental health, the situation is medically routine and non-life-threatening. Treatment involves standard antibiotic therapy, and there are no immediate severe health risks. The patient's allergy to penicillin is noted, but tetracycline has been prescribed, which is unrelated to the allergy. Overall, this situation is not high-stakes from a medical perspective.


Medical Specialty: Consult - History and Phy.
Sample Name: Multiple Neurological Symptoms

HISTORY OF PRESENT ILLNESS: , The patient is a 63-year-old left-handed gentleman who presents for further evaluation of multiple neurological symptoms.  I asked him to discuss each symptom individually as he had a very hard time describing the nature of his problems.  He first mentioned that he has neck pain.  He states that he has had this for at least 15 years.  It is worse with movement.  It has progressed very slowly over the course of 15 years.  It is localized to the base of his neck and is sharp in quality.  He also endorses a history of gait instability.  This has been present for a few years and has been slightly progressively worsening.  He describes that he feels unsteady on his feet and "walks like a duck."  He has fallen about three or four times over the past year and a half.,He also describes that he has numbness in his feet.  When I asked him to describe this in more detail, the numbness is actually restricted to his toes.  Left is slightly more affected than the right.  He denies any tingling or paresthesias.  He also described that he is slowly losing control of his hands.  He thinks that he is dropping objects due to weakness or incoordination in his hands.  This has also been occurring for the past one to two years.  He has noticed that buttoning his clothes is more difficult for him.  He also does not have any numbness or tingling in the hands.  He does have a history of chronic low back pain.,At the end of the visit, when I asked him which symptom was most bothersome to him, he actually stated that his fatigue was most troublesome.  He did not even mention this on the initial part of my history taking.  When I asked him to describe this further, he states that he experiences a general exhaustion.  He basically lays in bed all day everyday.  I asked him if he was depressed, he states that he is treated for depression.  He is unsure if this is optimally treated.  As I just mentioned, he stays in bed almost all day long and does not engage in any social activities.  He does not think that he is necessarily sad.  His appetite is good.  He has never undergone any psychotherapy for depression.,When I took his history, I noticed that he is very slow in responding to my questions and also had a lot of difficulty recalling details of his history as well as names of physicians who he had seen in the past.  I asked if he had ever been evaluated for cognitive difficulties and he states that he did undergo testing at Johns Hopkins a couple of years ago.  He states that the results were normal and that specifically he did not have any dementia.,When I asked him when he was first evaluated for his current symptoms, he states that he saw Dr. X several years ago.  He believes that he was told that he had neuropathy but that it was unclear if it was due to his diabetes.  He told me that more recently he was evaluated by you after Dr. Y referred him for this evaluation.  He also saw Dr. Z for neurosurgical consultation a couple of weeks ago.  He reports that she did not think there was any surgical indication in his neck or back at this point in time.,PAST MEDICAL HISTORY: , He has had diabetes for five years.  He also has had hypercholesterolemia.  He has had Crohn's disease for 25 or 30 years.  He has had a colostomy for four years.  He has arthritis, which is reportedly related to the Crohn's disease.  He has hypertension and coronary artery disease and is status post stent placement.  He has depression.  He had a kidney stone removed about 25 years ago.,CURRENT MEDICATIONS: , He takes Actos, Ambien, baby aspirin, Coreg, Entocort, folic acid, Flomax, iron, Lexapro 20 mg q.h.s., Lipitor, Pentasa, Plavix, Protonix, Toprol, Celebrex and Zetia.,ALLERGIES: , He states that Imuran caused him to develop tachycardia.,SOCIAL HISTORY:,  He previously worked with pipeline work, but has been on disability for five years.  He is unsure which symptoms led him to go on disability.  He has previously smoked about two packs of cigarettes daily for 20 years, but quit about 20 years ago.  He denies alcohol or illicit drug use.  He lives with his wife.  He does not really have any hobbies.,FAMILY HISTORY: , His father died of a cerebral hemorrhage at age 49.  His mother died in her 70s from complications of congestive heart failure.  He has one sister who died during a cardiac surgery two years ago.  He has another sister with diabetes.  He has one daughter with hypercholesterolemia.  He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , He has dyspnea on exertion.  He states that he was evaluated by a pulmonologist and had a normal evaluation.  He has occasional night sweats.  His hearing is poor.  He occasionally develops bloody stools, which he attributes to his Crohn's disease.  He also was diagnosed with sleep apnea.  He does not wear his CPAP machine on a regular basis.  He has a history of anemia.  Otherwise, a complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  Blood pressure 160/86 HR 100 RR 16 Wt 211 pounds Pain 3/10,General Appearance:  He is well appearing in no acute distress.  He has somewhat of a flat affect.,Cardiovascular:  He has a regular rhythm without murmurs, gallops, or rubs.  There are no carotid bruits.,Chest:  The lungs are clear to auscultation bilaterally.,Skin:  There are no rashes or lesions.,Musculoskeletal:  He has no joint deformities or scoliosis.,NEUROLOGICAL EXAMINATION:,Mental Status:  His speech is fluent without dysarthria or aphasia.  He is alert and oriented to name, place, and date.  Attention, concentration, and fund of knowledge are intact.  He has 3/3 object registration and 1/3 recall in 5 minutes.,Cranial Nerves:  Pupils are equal, round, and reactive to light and accommodation.  Visual fields are full.  Optic discs are normal.  Extraocular movements are intact without nystagmus.  Facial sensation is normal.  There is no facial, jaw, palate, or tongue weakness.  Hearing is grossly intact.  Shoulder shrug is full.,Motor:  He has normal muscle bulk and tone.  There is no atrophy.  He has few fasciculations in his calf muscles bilaterally.  Manual muscle testing reveals MRC grade 5/5 strength in all proximal and distal muscles of the upper and lower extremities.  There is no action or percussion myotonia or paramyotonia.,Sensory:  He has absent vibratory sensation at the left toe.  This is diminished at the right toe.  Joint position sense is intact.  There is diminished sensation to light touch and temperature at the feet to the knees bilaterally.  Pinprick is intact.  Romberg is absent.  There is no spinal sensory level.,Coordination:  This is intact by finger-nose-finger or heel-to-shin testing.  He does have a slight tremor of the head and outstretched arms.,Deep Tendon Reflexes:  They are 2+ at the biceps, triceps, brachioradialis, patellas, and ankles.  Plantar reflexes are flexor.  There is no ankle clonus, finger flexors, or Hoffman's signs.  He has crossed adductors bilaterally.,Gait and Stance:  He has a slightly wide-based gait.  He has some difficulty with toe walking, but he is able to walk on his heels and tandem walk.  He has difficulty with toe raises on the left.,RADIOLOGIC DATA: , MRI of the cervical spine, 09/30/08:  Chronic spondylosis at C5-C6 causing severe bilateral neuroforamining and borderline-to-mold cord compression with normal cord signal.  Spondylosis of C6-C7 causing mild bilateral neuroforamining and left paracentral disc herniation causing borderline cord compression.,Thoracic MRI spine without contrast:  Minor degenerative changes without stenosis.,I do not have the MRI of the lumbar spine available to review.,LABORATORY DATA: , 10/07/08:  Vitamin B1 210 (87-280), vitamin B6 6, ESR 6, AST 25, ALT 17, vitamin B12 905, CPK 226 (0-200), T4 0.85, TSH 3.94, magnesium 1.7, RPR nonreactive, CRP 4, Lyme antibody negative, SPEP abnormal (serum protein electrophoresis), but no paraprotein by manifestation, hemoglobin A1c 6.0, aldolase 3.9 and homocystine 9.0.,ASSESSMENT: , The patient is a 63-year-old gentleman with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue.  His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.  He has fairly normal or very mild increased reflexes including notably the presence of normal ankle jerks.,I think that the etiology of his symptoms is multifactorial.  He probably does have a mild peripheral neuropathy, but the sparing of ankle jerks suggested either the neuropathy is mild or that there is a superimposed myelopathic process such as a cervical or lumbosacral myelopathy.  He really is most concerned about the fatigue and I think it is possible due to suboptimally treated depression and suboptimally treated sleep apnea.  Whether he has another underlying muscular disorder such as a primary myopathy remains to be seen.,RECOMMENDATIONS:,1.  I scheduled him for repeat EMG and nerve conduction studies to evaluate for evidence of neuropathy or myopathy.,2.  I will review his films at our spine conference tomorrow although I am confident in Dr. Z's opinion that there is no surgical indication.,3.  I gave him a prescription for physical therapy to help with gait imbalance training as well as treatment for his neck pain.,4.  I believe that he needs to undergo psychotherapy for his depression.  It may also be worthwhile to adjust his medications, but I will defer to his primary care physician for managing this or for referring him to a therapist.  The patient is very open about proceeding with this suggestion.,5.  He does need to have his sleep apnea better controlled.  He states that he is not compliant because the face mask that he uses does not fit him well.  This should also be addressed.
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DESCRIPTION: The patient is with multiple neurologic and nonneurologic symptoms including numbness, gait instability, decreased dexterity of his arms and general fatigue.  His neurological examination is notable for sensory loss in a length-dependent fashion in his feet and legs with scant fasciculations in his calves.

This case involves a 63-year-old male with a combination of neurological symptoms (e.g., gait instability, decreased dexterity, numbness) and non-neurological issues (e.g., depression, fatigue, sleep apnea). Though these symptoms are indeed concerning and require thorough evaluation to determine whether they indicate a significant underlying pathology such as peripheral neuropathy or cervical myelopathy, they don't seem to present an immediate life-threatening risk. However, the combination of multiple chronic conditions and their effects on the patient’s quality of life, such as depression and potential non-compliance with treatment (e.g., for sleep apnea), elevate the stakes somewhat as they could lead to significant deterioration in his daily functioning and well-being if not addressed properly. The stakes are therefore moderate, as they lie in preventing further decline rather than addressing an immediate critical condition.