Medical Specialty: General Medicine
Sample Name: Annual Health Maintenance Exam

HISTORY OF PRESENT ILLNESS:  ,This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health.  Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dyslipidemia well controlled with niacin, history of hemorrhoids with occasional external bleeding, although no problems in the last 6 months, and also history of concha bullosa of the left nostril, followed by ENT associated with slight septal deviation.  There are no other medical problems.  He has no symptoms at this time and remains in excellent health.,PAST MEDICAL HISTORY: , Otherwise noncontributory.  There is no operation, serious illness or injury other than as noted above.,ALLERGIES: , There are no known allergies.,FAMILY HISTORY: , Father died of an MI at age 67 with COPD and was a heavy smoker.  His mother is 88, living and well, status post lung cancer resection.  Two brothers, living and well.  One sister died at age 20 months of pneumonia.,SOCIAL HISTORY:,  The patient is married.  Wife is living and well.  He jogs or does Cross Country track 5 times a week, and weight training twice weekly.  No smoking or significant alcohol intake.  He is a physician in allergy/immunology.,REVIEW OF SYSTEMS:,  Otherwise noncontributory.  He has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology.  No symptoms other than as described above.,PHYSICAL EXAMINATION:,GENERAL:  He appears alert, oriented, and in no acute distress with excellent cognitive function.  VITAL SIGNS:  His height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16.  SKIN:  Warm and dry.  There is no pallor, cyanosis or icterus.  HEENT:  Tympanic membranes benign.  The pharynx is benign.  Nasal mucosa is intact.  Pupils are round, regular, and equal, reacting equally to light and accommodation.  EOM intact.  Fundi reveal flat discs with clear margins.  Normal vasculature.  No hemorrhages, exudates or microaneurysms.  No thyroid enlargement.  There is no lymphadenopathy.  LUNGS:  Clear to percussion and auscultation.  Normal sinus rhythm.  No premature beat, murmur, S3 or S4.  Heart sounds are of good quality and intensity.  The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally.  ABDOMEN:  Benign without guarding, rigidity, tenderness, mass or organomegaly.  NEUROLOGIC:  Grossly intact.  EXTREMITIES:  Normal.  GU:  Genitalia normal.  There are no inguinal hernias.  There are mild hemorrhoids in the anal canal.  The prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality.  There is no rectal mass.  The stool is Hemoccult negative.,IMPRESSION:,1.  Comprehensive annual health maintenance examination.,2.  Dyslipidemia.,3.  Tinnitus, left ear.,4.  Hemorrhoids.,PLAN:,  At this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin E 400 units daily; and vitamin C 500 mg daily.  Consider adding lycopene, selenium, and flaxseed to his regimen.  All appropriate labs will be obtained today.  Followup fasting lipid profile and ALT in 6 months.
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DESCRIPTION: Comprehensive annual health maintenance examination, dyslipidemia, tinnitus in left ear, and hemorrhoids.

general medicine, tinnitus, dyslipidemia, annual health maintenance, health, hemorrhoids, benign

This scenario outlines a routine annual health maintenance examination for a generally healthy 59-year-old male. The patient's existing medical issues, such as controlled dyslipidemia, tinnitus, and hemorrhoids, are stable and not life-threatening. The examination does not reveal any new or acute health concerns, and the physician's plan involves continuing current medications and a follow-up in six months for routine lab tests. The stakes are low because there are no immediate or severe health threats requiring urgent intervention.


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Medical Specialty: Gastroenterology
Sample Name: Upper Endoscopy - Foreign Body Removal

PROCEDURE:, Upper endoscopy with foreign body removal.,PREOPERATIVE DIAGNOSIS (ES):, Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS (ES):, Penny in proximal esophagus.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,After informed consent was obtained, the patient was taken to the pediatric endoscopy suite. After appropriate sedation by the anesthesia staff and intubation, an upper endoscope was inserted into the mouth, over the tongue, into the esophagus, at which time the foreign body was encountered. It was grasped with a coin removal forcep and removed with an endoscope. At that time, the endoscope was reinserted, advanced to the level of the stomach and stomach was evaluated and was normal. The esophagus was normal with the exception of some mild erythema, where the coin had been sitting. There were no erosions. The stomach was decompressed of air and fluid. The scope was removed without difficulty.,SUMMARY:, The patient underwent endoscopic removal of esophageal foreign body.,PLAN:, To discharge home, follow up as needed.
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DESCRIPTION: Upper endoscopy with foreign body removal (Penny in proximal esophagus).

gastroenterology, upper endoscopy, endoscopy, endoscopy suite, esophagus, foreign body, foreign body removal, esophageal foreign body, stomach,

The situation involves a medical procedure to remove a foreign object from a child's esophagus, specifically a penny, using an upper endoscopy. While it is a minimally invasive procedure, it involves sedation and intubation, which carry inherent risks. However, the endoscopy was completed successfully without complications or blood loss, and the patient is planned to be discharged home, indicating a successful and straightforward procedure. The stakes are moderate because the procedure addresses a potentially dangerous situation, but the outcome was positive with no complications.

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Medical Specialty: Gastroenterology
Sample Name: Umbilical Hernia Repair - 1

PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:,  After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  The sac was cleared of overlying adherent tissue, and the fascial defect was delineated.  The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect.  The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures.  The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia.,The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The skin was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.
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DESCRIPTION: Umbilical hernia repair. A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.

gastroenterology, fascial defect, umbilical hernia repair, curvilinear umbilical, hernia sac, metzenbaum scissors, umbilical hernia, bovie electrocautery, electrocautery, hernia, incision, umbilical,

The situation involves a standard umbilical hernia repair, which is a common and relatively low-risk surgical procedure. The description indicates that the procedure went smoothly without any complications, and the patient was stable post-operation. While surgery always carries some level of risk, this particular procedure is routinely performed and is generally considered low-stakes in the context of surgeries.


Medical Specialty: Gastroenterology
Sample Name: Ttriple-Lumen Central Line

PREOPERATIVE DIAGNOSES,1.  Bowel obstruction.,2.  Central line fell off.,POSTOPERATIVE DIAGNOSES,1.  Bowel obstruction.,2.  Central line fell off.,PROCEDURE: , Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.,PROCEDURE DETAIL: , This lady has a bowel obstruction.  She was being fed through a central line, which as per the patient was just put yesterday and this slipped out.  At the patient's bedside after obtaining an informed consent, the patient's right deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in Trendelenburg position, she had her right subclavian vein percutaneously cannulated without any difficulty.  A Seldinger technique was used and a triple-lumen catheter was inserted.  There was a good flow through all three ports, which were irrigated with saline prior to connection to the IV solutions.,The catheter was affixed to the skin with sutures and then a dressing was applied.,The postprocedure chest x-ray revealed that there were no complications to the procedure and that the catheter was in good place.
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DESCRIPTION: Insertion of a triple-lumen central line through the right subclavian vein by the percutaneous technique.  This lady has a bowel obstruction.  She was being fed through a central line, which as per the patient was just put yesterday and this slipped out.

gastroenterology, central line, triple lumen central line, subclavian vein, bowel obstruction, lumen, percutaneous, bowel, obstruction

The situation involves a patient with a bowel obstruction who relies on a central line for nutrition. The task of inserting a new central line is medically significant, given the patient's dependency on intravenous feeding coupled with the complexity and risks associated with line insertion. However, the procedure was completed without complications, reducing immediate urgency. The stakes are moderate to high due to the critical nature of maintaining access for nutrition and fluid management in a patient with a bowel obstruction.


Medical Specialty: Gastroenterology
Sample Name: Ultrasound - Abdomen

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

Ultrasound abdomen, complete

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

The ultrasound findings indicate mostly normal anatomy and no urgent issues, except for the spleen being at the upper limits of normal, which might warrant monitoring but isn't immediately life-threatening. However, the inability to fully visualize the pancreas due to bowel gas could pose a concern if there are symptoms suggesting pancreatic issues, though there is no immediate evidence of such. Given the patient's history of AIDS and current symptoms, this examination is critical to their ongoing diagnostic assessment, but the ultrasound itself does not reveal high-stakes findings.


Medical Specialty: Gastroenterology
Sample Name: Surgical Closure of Gastrostomy

PREOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,POSTOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,OPERATION PERFORMED: , Surgical closure of gastrostomy.,ANESTHESIA: , General.,INDICATIONS: , This 1-year-old child had a gastrostomy placed due to feeding difficulties.  Since then, he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy.  The tube was, therefore, removed, but the tract has not shown signs of spontaneous closure.  He, therefore, comes to the operating room today for surgical closure of his gastrostomy.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner.  An elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection.  The tract and the stomach were freed.  Stay sutures were then placed on either side of the tract.  The tract was amputated.  The intervening stomach was then closed with interrupted #4-0 Lembert, Nurolon sutures.  The fascia was then closed over the stomach using #3-0 Vicryl sutures.  The skin was closed with #5-0 subcuticular Monocryl.  A dressing was applied, and the child was awakened and taken to the recovery room in satisfactory condition.
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DESCRIPTION: Closure of gastrostomy placed due to feeding difficulties.

gastroenterology, gastrocutaneous fistula, nurolon, closure of gastrostomy, feeding difficulties, surgical closure, gastrostomy

The case involves the surgical closure of a gastrostomy in a 1-year-old child following feeding difficulties. The child now eats completely by mouth, rendering the gastrostomy unnecessary. While the surgery itself is a standard procedure and the child was in satisfactory condition post-operation, it involves a young patient and requires general anesthesia, which increases the potential risks. Additionally, surgical procedures, especially in young children, can have complications, emphasizing the importance of careful execution and monitoring. However, it is not a highly critical or life-threatening procedure compared to other surgical scenarios.


Medical Specialty: Gastroenterology
Sample Name: Stamm Gastrostomy Tube Placement

PREOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,POSTOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,PROCEDURE:,1. Failed percutaneous endoscopic gastrostomy tube placement.,2. Open Stamm gastrotomy tube.,3. Lysis of adhesions.,4. Closure of incidental colotomy.,ANESTHESIA:, General endotracheal anesthesia.,IV FLUIDS:, Crystalloid 1400 ml.,ESTIMATED BLOOD LOSS:, Thirty ml.,DRAINS:, Gastrostomy tube was placed to Foley.,SPECIMENS:, None.,FINDINGS:, Stomach located high in the peritoneal cavity. Multiple adhesions around the stomach to the diaphragm and liver.,HISTORY: ,The patient is a 59-year-old black male who is indigent, an ethanol and tobacco abuse. He presented initially to the emergency room with throat and bleeding. Following evaluation by ENT and biopsy, it was determined to be squamous cell carcinoma of the right tonsil and soft palate, The patient is to undergo radiation therapy and possibly chemotherapy and will need prolonged enteral feeding with a bypass route from the mouth. The malignancy was not obstructing. Following obtaining informed consent for percutaneous endoscopic gastrostomy tube with possible conversion to open procedure, we elected to proceed following diagnosis of squamous cell carcinoma and election for radiation therapy.,DESCRIPTION OF PROCEDURE:, The patient was placed in the supine position and general endotracheal anesthesia was induced. Preoperatively, 1 gram of Ancef was given. The abdomen was prepped and draped in the usual sterile fashion. After anesthesia was achieved, an endoscope was placed down into the stomach, and no abnormalities were noted. The stomach was insufflated with air and the endoscope was positioned in the midportion and directed towards the anterior abdominal wall. With the room darkened and intensity turned up on the endoscope, a light reflex was noted on the skin of the abdominal wall in the left upper quadrant at approximately 2 fingerbreadths inferior from the most inferior rib. Finger pressure was applied to the light reflex with adequate indentation on the stomach wall on endoscopy. A 21-gauge 1-1/2 inch needle was initially placed at the margin of the light reflex, and this was done twice. Both times it was not visualized on the endoscopy. At this point, repositioning was made and, again, what was felt to be adequate light reflex was obtained, and the 14-gauge angio catheter was placed. Again, after two attempts, we were unable to visualize the needle in the stomach endoscopically. At this point, decision was made to convert the procedure to an open Stamm gastrostomy.,OPEN STAMM GASTROSTOMY: ,A short upper midline incision was made and deepened through the subcutaneous tissues. Hemostasis was achieved with electrocautery. The linea alba was identified and incised, and the peritoneal cavity was entered. The abdomen was explored. Adhesions were lysed with electrocautery under direct vision. The stomach was identified, and a location on the anterior wall near the greater curvature was selected. After lysis of adhesions was confirmed, we sufficiently moved the original chosen site without tension. A pursestring suture of #3-0 silk was placed on the interior surface of the stomach, and a second #3-0 pursestring silk stitch was placed exterior to that pursestring suture. An incision was then made at the location of the anterior wall which was near the greater curvature and was dissected down to the anterior abdominal wall. A Vanderbilt was used to pass through the abdominal wall in through the skin and then returned to the level of the skin and pulled the Bard feeding tube through the anterior wall into the field. An incision in the center of the pursestring suture on the anterior surface of the stomach was then made with electrocautery. The interior pursestring suture was sutured into place in such a manner as to inkwell the stomach around the catheter. The second outer concentric pursestring suture was then secured as well and tied to further inkwell the stomach. The stomach was then tacked to the anterior abdominal wall at the catheter entrance site with four #2-0 silk sutures in such a manner as to prevent leakage or torsion. The catheter was then secured to the skin with two #2-0 silk sutures. Hemostasis was checked and the peritoneal cavity was washed out and brought to the surgical field. Prior to the initiation of the gastrotomy, the bowel was run and at that time there was noted to be one incidental colotomy. This was oversewn with three #4-0 silk Lembert sutures. At the completion of the operation, the fascia was closed with #1 interrupted Vicryl suture, and the skin was closed with staples. The patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition.
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DESCRIPTION: Open Stamm gastrotomy tube, lysis of adhesions, and closure of incidental colotomy

The situation involves a detailed surgical procedure for a patient with squamous cell carcinoma who requires a feeding tube due to potential complications of their cancer treatment. The narrative outlines challenges during the procedure, such as the need to convert from a percutaneous to an open gastrostomy due to visualization issues. Additionally, there are potential postoperative complications and considerations given the patient's medical and social background, including substance abuse and indigence. These factors make it a high-stakes situation as the procedure is critical to the patient's nutritional intake and overall treatment plan, and the patient's complex medical and social background adds layers of risk to the situation.


Medical Specialty: Gastroenterology
Sample Name: SOAP - Cholecystitis

SUBJECTIVE: , She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago.  The patient has required conversion to an open procedure due to difficult anatomy.  Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan.  The patient is starting to improve, gain more strength.  She is tolerating her regular diet.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Today, her temperature is 98.4, heart rate 84, respirations 20, and BP is 140/72.,LUNGS:  Clear to auscultation.  No wheezes, rales, or rhonchi.,HEART:  Regular rhythm and rate.,ABDOMEN:  Soft, less tender.,LABORATORY DATA:,  Her white count continues to come down.  Today, it is 11.6, H&H of 8.8 and 26.4, platelets 359,000.  We have ordered type and cross for 2 units of packed red blood cells.  If it drops below 25, she will receive a transfusion.  Her electrolytes today show a glucose of 107, sodium 137, potassium 4.0, chloride 103.2, bicarbonate 29.7.  Her AST is 43, ALT is 223, her alkaline phosphatase is 214, and her bilirubin is less than 0.10.,ASSESSMENT AND PLAN:,  She had a bowel movement today and is continuing to improve.,I anticipate another 3 days in the hospital for strengthening and continued TPN and resolution of elevated white count.
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DESCRIPTION: She is a 79-year-old female who came in with acute cholecystitis and underwent attempted laparoscopic cholecystectomy 8 days ago.  The patient has required conversion to an open procedure due to difficult anatomy.  Her postoperative course has been lengthened due to a prolonged ileus, which resolved with tetracycline and Reglan.  The patient is starting to improve, gain more strength.  She is tolerating her regular diet.

gastroenterology, laparoscopic cholecystectomy, anatomy, acute cholecystitis, prolonged ileus, white count, cholecystitis

The situation involves post-operative care of an elderly patient who experienced complications after surgery for acute cholecystitis. While the patient is currently improving, there is a potential for high-stakes outcomes due to her age and the fact that she underwent an open procedure after a failed laparoscopic attempt. Key concerns include monitoring her hemoglobin levels to determine the need for a blood transfusion and ensuring her white blood cell count continues to normalize, indicating recovery. The situation warrants close observation to prevent complications, which makes it moderately high-stakes.


Medical Specialty: Gastroenterology
Sample Name: Rectal Bleeding - Consult

REASON FOR ADMISSION: , Rectal bleeding.,HISTORY OF PRESENT ILLNESS:  ,The patient is a very pleasant 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  He states that he had some stomach discomfort in the last 4 weeks.  He has had some physical therapy for his lower back secondary to pain after hernia repair.  He states that the pain worsened after this.  He has had previous history of rectal bleeding and a colonoscopy approximately 8 years ago that was normal.  He denies any dysuria.  He denies any hematemesis.  He denies any pleuritic chest pain.  He denies any hemoptysis.,PAST MEDICAL HISTORY:,1.  History of bilateral hernia repair by Dr. X in 8/2008.,2.  History of rectal bleeding.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Cipro.,2.  Lomotil.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Pulse 117, respirations 18, and blood pressure 117/55.  Saturating 98% on room air.,GENERAL:  The patient is alert and oriented x3.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Oropharynx is clear without exudates.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Tachycardic.  Regular rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally both anteriorly and posteriorly.,ABDOMEN:  Positive bowel sounds.  Soft and nontender with no guarding.,EXTREMITIES:  No clubbing, cyanosis or edema in the upper or lower extremities.,NEUROLOGIC:  Nonfocal.,LABORATORY STUDIES:,  Sodium 131, potassium 3.9, chloride 94, CO2 25, BUN 15, creatinine 0.9, glucose 124, INR 1.2, troponin less than 0.04, white count 17.5, hemoglobin 12.3, and platelet count 278 with 91% neutrophils.  EKG shows sinus tachycardia.,PROBLEM LIST:,1.  Colitis.,2.  Sepsis.,3.  Rectal bleeding.,RECOMMENDATIONS:,1.  GI consult with Dr. Y's group.,2.  Continue Levaquin and Flagyl.,3.  IV fluids.,4.  Send for fecal WBCs, O&P, and C. diff.,5.  CT of the abdomen and pelvis to rule out abdominal pathology.,6.  PPI for PUD prophylaxis.
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DESCRIPTION: A 68-year-old male with history of bilateral hernia repair, who presents with 3 weeks of diarrhea and 1 week of rectal bleeding.  He states that he had some stomach discomfort in the last 4 weeks.

The patient, a 68-year-old male with a history of previous rectal bleeding and a recent hernia repair, is presenting with significant and concerning symptoms including 3 weeks of diarrhea and 1 week of rectal bleeding. There are signs of potential colitis and sepsis, both of which can be serious and require prompt medical intervention. The patient's elevated heart rate (tachycardia) and the white blood cell count indicate a potential systemic infection (sepsis), and the low sodium level suggests an electrolyte imbalance, possibly from prolonged diarrhea. The situation poses a risk of serious complications, justifying the current thorough investigative and treatment approach. While the situation is clinically serious, the patient is currently stable, reducing the immediate high-stakes urgency but maintaining the need for timely intervention.


Medical Specialty: Gastroenterology
Sample Name: Open Cholecystectomy

PREOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute hemorrhagic cholecystitis.,PROCEDURE PERFORMED: , Open cholecystectomy.,ANESTHESIA: , Epidural with local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN:  ,Gallbladder.,BRIEF HISTORY:  ,The patient is a 73-year-old female who presented to ABCD General Hospital on 07/23/2003 secondary to a fall at home from which the patient suffered a right shoulder as well as hip fracture.  The patient subsequently went to the operating room on 07/25/2003 for a right hip hemiarthroplasty per the Orthopedics Department.  Subsequently, the patient was doing well postoperatively, however, the patient does have severe O2 and steroid-dependent COPD and at an extreme risk for any procedure.  The patient began developing abdominal pain over the course of the next several days and a consultation was requested on 08/07/2003 for surgical evaluation for upper abdominal pain.  During the evaluation, the patient was found to have an acute acalculous cholecystitis in which nonoperative management was opted for and on 08/08/03, the patient underwent a percutaneous cholecystostomy tube placement to drain the gallbladder.  The patient did well postdrainage.  The patient's laboratory values and biliary values returned to normal and the patient was planned for a removal of the tube with 48 hours of the tubing clamp.  However, once the tube was removed, the patient re-obstructed with recurrent symptoms and a second tube was needed to be placed; this was done on 08/16/2003.  A HIDA scan had been performed, which showed no cystic duct obstruction.  A tube cholecystogram was performed, which showed no cystic or common duct obstruction.  There was abnormal appearance of the gallbladder, however, the pathway was patent.  Thus after failure of two nonoperative management therapies, extensive discussions were made with the family and the patient's only option was to undergo a cholecystectomy.  Initial thoughts were to do a laparoscopic cholecystectomy, however, with the patient's severe COPD and risk for ventilator management, the options were an epidural and an open cholecystectomy under local was made and to be performed.,INTRAOPERATIVE FINDINGS:  ,The patient's gallbladder had some patchy and necrosis areas.  There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.  The patient also had no plane between the gallbladder and the liver bed.,OPERATIVE PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and discussed with the patient's family.  The patient was brought to the operating room after an epidural was performed per anesthesia.  Local anesthesia was given with 1% lidocaine.  A paramedian incision was made approximately 5 cm in length with a #15 blade scalpel.  Next, hemostasis was obtained using electro Bovie cautery.  Dissection was carried down transrectus in the midline to the posterior rectus fascia, which was grasped with hemostats and entered with a #10 blade scalpel.  Next, Metzenbaum scissors were used to extend the incision and the abdomen was entered .  The gallbladder was immediately visualized and brought up into view, grasped with two ring clamps elevating the biliary tree into view.  Dissection with a ______ was made to identify the cystic artery and cystic duct, which were both easily identified.  The cystic artery was clipped, two distal and one proximal to the gallbladder cutting between with Metzenbaum scissors.  The cystic duct was identified.  A silk tie #3-0 silk was placed one distal and one proximal with #3-0 silk and then cutting in between with a Metzenbaum scissors.  The gallbladder was then removed from the liver bed using electro Bovie cautery.  A plane was created.  The hemostasis was obtained using the electro Bovie cautery as well as some Surgicel.  The gallbladder was then removed as specimen, sent to pathology for frozen sections for diagnosis, of which the hemorrhagic cholecystitis was diagnosed on frozen sections.  Permanent sections are still pending.  The remainder of the fossa was hemostatic with the Surgicel and attention was next made to closing the abdomen.  The peritoneum as well as posterior rectus fascia was approximated with a running #0 Vicryl suture and then the anterior rectus fascia was closed in interrupted figure-of-eight #0 Vicryl sutures.  Skin staples were used on the skin and sterile dressings were applied and the patient was transferred to recovery in stable condition.
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DESCRIPTION: Acute acalculous cholecystitis.  Open cholecystectomy.  The patient's gallbladder had some patchy and necrosis areas.  There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.

gastroenterology, open cholecystectomy, hemorrhagic, gallbladder, serosal, liver bed, acute acalculous, acalculous cholecystitis, cystic duct, bovie cautery, rectus fascia, metzenbaum scissors, fascia, cholecystitis, cholecystectomy, cystic,

The situation involves a 73-year-old patient undergoing an open cholecystectomy due to acute hemorrhagic cholecystitis after failed non-operative management. The patient has severe O2 and steroid-dependent COPD, which poses significant perioperative risks. The stakes are relatively high given the patient's age, comorbidities, and the necessity of surgery after other treatments failed. However, the surgical procedure itself was completed without complications and the patient was stable postoperatively, which lowers the immediate stakes of the situation.


Medical Specialty: Gastroenterology
Sample Name: Nissen Fundoplication

PROCEDURE PERFORMED: , Nissen fundoplication.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained detailing the risks of infection, bleeding, esophageal perforation and death, the patient was brought to the operative suite and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was then placed in a modified lithotomy position taking great care to pad all extremities.  TEDs and Venodynes were placed as prophylaxis against deep venous thrombosis.  Antibiotics were given for prophylaxis against surgical infection.,A 52-French bougie was placed in the proximal esophagus by Anesthesia, above the cardioesophageal junction.  A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.  A 1-2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident.  Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adaptor in order to occlude the fascial opening.  Pneumoperitoneum was then established using carbon dioxide insufflation to a steady state of pressure of 16 mmHg.  A 30-degree laparoscope was inserted through this port and used to guide the remaining trocars.,The remaining trocars were then placed into the abdomen taking care to make the incisions along Langer's line, spreading the subcutaneous tissue with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar.  A total of 4 other 10/11 mm trocars were placed.  Under direct vision 1 was inserted in the right upper quadrant at the midclavicular line, at a right supraumbilical position; another at the left upper quadrant at the midclavicular line, at a left supraumbilical position; 1 under the right costal margin in the anterior axillary line; and another laterally under the left costal margin on the anterior axillary line.  All of the trocars were placed without difficulty.  The patient was then placed in reverse Trendelenburg position.,The triangular ligament was taken down sharply, and the left lobe of the liver was retracted superolaterally using a fan retractor placed through the right lateral cannula.  The gastrohepatic ligament was then identified and incised in an avascular plane.  The dissection was carried anteromedially onto the phrenoesophageal membrane.  The phrenoesophageal membrane was divided on the anterior aspect of the hiatal orifice.  This incision was extended to the right to allow identification of the right crus.  Then along the inner side of the crus, the right esophageal wall was freed by dissecting the cleavage plane.,The liberation of the posterior aspect of the esophagus was started by extending the dissection the length of the right diaphragmatic crus.  The pars flaccida of the lesser omentum was opened, preserving the hepatic branches of the vagus nerve.  This allowed free access to the crura, left and right, and the right posterior aspect of the esophagus, and the posterior vagus nerve.,Attention was next turned to the left anterolateral aspect of the esophagus.  At its left border, the left crus was identified.  The dissection plane between it and the left aspect of the esophagus was freed.  The gastrophrenic ligament was incised, beginning the mobilization of the gastric pouch.  By dissecting the intramediastinal portion of the esophagus, we elongated the intra-abdominal segment of the esophagus and reduced the hiatal hernia.,The next step consisted of mobilization of the gastric pouch.  This required ligation and division of the gastrosplenic ligament and several short gastric vessels using the harmonic scalpel.  This dissection started on the stomach at the point where the vessels of the greater curvature turned towards the spleen, away from the gastroepiploic arcade.  The esophagus was lifted by a Babcock inserted through the left upper quadrant port.  Careful dissection of the mesoesophagus and the left crus revealed a cleavage plane between the crus and the posterior gastric wall.  Confirmation of having opened the correct plane was obtained by visualizing the spleen behind the esophagus.  A one-half inch Penrose drain was inserted around the esophagus and sewn to itself in order to facilitate retraction of the distal esophagus.  The retroesophageal channel was enlarged to allow easy passage of the antireflux valve.,The 52-French bougie was then carefully lowered into the proximal stomach, and the hiatal orifice was repaired.  Two interrupted 0 silk sutures were placed in the diaphragmatic crura to close the orifice.,The last part of the operation consisted of the passage and fixation of the antireflux valve.  With anterior retraction on the esophagus using the Penrose drain, a Babcock was passed behind the esophagus, from right to left.  It was used to grab the gastric pouch to the left of the esophagus and to pull it behind, forming the wrap.  The,52-French bougie was used to calibrate the external ring.  Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior superior iliac spine and around the wound for postanesthetic pain control.  The skin incision was approximated with skin staples.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.
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DESCRIPTION: Nissen fundoplication.   A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process.

gastroenterology, umbilicus, insufflation, phrenoesophageal membrane, nissen fundoplication, gastric pouch, esophagus, penrose, antireflux, nissen, fundoplication, trocars, ligament,

Nissen fundoplication is a surgical procedure performed to treat gastroesophageal reflux disease (GERD) and hiatal hernia. It involves wrapping the upper part of the stomach around the lower end of the esophagus and is generally considered major surgery with potential risks including infection, bleeding, and esophageal perforation. Given that the procedure description includes detailed surgical steps and potential severe complications, it is considered a high-stakes situation. The successful execution of this complex procedure is critical to ensuring patient safety and requires skilled surgical technique.


Medical Specialty: Gastroenterology
Sample Name: Progress Note - Liver Cirrhosis

HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old Hispanic male who was seen initially in the office February 15, 2006, with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.  The patient at that time stated that he had established diagnosis of liver cirrhosis.  Since the last visit the patient was asked to sign a lease of information form and we sent request for information from the doctor the patient saw before, Dr. X in Las Cruces and his primary care physician in Silver City, and unfortunately we did not get any information from anybody.  Also the patient had admission in Gila Medical Center with epigastric pain, diarrhea, and confusion.  He spent 3 days in the hospital.  He was followed by Dr. X and unfortunately we also do not have the information of what was wrong with the patient.  From the patient's report he was diagnosed with some kind of viral infection.  At the time of admission he had a lot of epigastric pain, nausea, vomiting, fever, and chills.,PHYSICAL EXAMINATION,VITAL SIGNS:  Weight 107, height 6 feet 1 inch, blood pressure 128/67, heart rate 74, saturation 98%; pain is 3/10 with localization of the pain in the epigastric area.,HEENT:  PERRLA.  EOM intact.  Oropharynx is clear of lesions.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.,LUNGS:  Clear to auscultation and percussion bilateral.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs, rubs, or gallops.,ABDOMEN:  Not tender, not distended.  Splenomegaly about 4 cm under the costal margin.  No hepatomegaly.  Bowel sounds present.,MUSCULOSKELETAL:  No cyanosis, no clubbing, no pitting edema.,NEUROLOGIC:  Nonfocal.  No asterixis.  No costovertebral tenderness.,PSYCHE:  The patient is oriented x4, alert and cooperative.,LABORATORY DATA: , We were able to collect lab results from Medical Center; we got only CMP from the hospital which showed glucose level 79, BUN 9, creatinine 0.6, sodium 136, potassium 3.5, chloride 104, CO2 23.7, calcium 7.3, total protein 5.9, albumin 2.5, total bilirubin 5.63.  His AST 56, ALT 37, alkaline phosphatase 165, and his ammonia level was 53.  We do not have any other results back.  No hepatitis panels.  No alpha-fetoprotein level.  The patient told me today that he also got an ultrasound of the abdomen and the result was not impressive, but we do not have this result despite calling medical records in the hospital to release this information.,ASSESSMENT AND PLAN:,  The patient is a 55-year-old with established diagnosis of liver cirrhosis, unknown cause.,1.  Epigastric pain.  The patient had chronic pain syndrome, he had multiple back surgeries, and he has taken opiate for a prolonged period of time.  In the office twice the patient did not have any abdominal pain on physical exam.  His pain does not sound like obstruction of common bile duct and he had these episodes of abdominal pain almost continuously.  He probably requires increased level of pain control with increased dose of opiates, which should be addressed with his primary care physician.,2.  End-stage liver disease.  Of course, we need to find out the cause of the liver cirrhosis.  We do not have hepatitis panel yet and we do not have information about the liver biopsy which was performed before.  We do not have any information of any type of investigation in the past.  Again, patient was seen by gastroenterologist already in Las Cruces, Dr. X.  The patient was advised to contact Dr. X by himself to convince him to send available information because we already send release information form signed by the patient without any result.  It will be not reasonable to repeat unnecessary tests in that point in time.,We are waiting for the hepatitis panel and alpha-fetoprotein level.  We will also need to get information about ultrasound which was done in Gila Medical Center, but obviously no tumor was found on this exam of the liver.  We have to figure out hepatitis status for another reason if he needs vaccination against hepatitis A and B.  Until now we do not know exactly what the cause of the patient's end-stage liver disease is and my differential diagnosis probably is hepatitis C.  The patient denied any excessive alcohol intake, but I could not preclude alcohol-related liver cirrhosis also.  We will need to look for nuclear antibody if it is not done before.  PSC is extremely unlikely but possible.  Wilson disease also possible diagnosis but again, we first have to figure out if these tests were done for the patient or not.  Alpha1-antitrypsin deficiency will be extremely unlikely because the patient has no lung problem.  On his end-stage liver disease we already know that he had low platelet count splenomegaly.  We know that his bilirubin is elevated and albumin is very low.  I suspect that at the time of admission to the hospital the patient presented with encephalopathy.  We do not know if INR was checked to look for coagulopathy.  The patient had an EGD in 2005 as well as colonoscopy in Silver City.  We have to have this result to evaluate if the patient had any varices and if he needs any intervention for that.,At this point in time, I recommended the patient to continue to take lactulose 50 mL 3 times daily.  The patient tolerated it well; no diarrhea at this point in time.  I also recommended for him to contact his primary care physician for increased dose of opiates for him.  As a primary prophylaxis of GI bleeding in patient with end-stage liver disease we will try to use Inderal.  The patient got a prescription for 10 mg pills.  He will take 10 mg twice daily and we will gradually increase his dose until his heart rate will drop to 25% from 75% to probably 60-58.  The patient was educated how to use Inderal and he was explained why we decided to use this medication.  The patient will hold this medication if he is orthostatic or bradycardic.,Again, the patient and his wife were advised to contact all offices they have seen before to get information about what tests were already done and if on the next visit in 2 weeks we still do not have any information we will need to repeat all these tests I mentioned above.,We also discussed nutrition issues.  The patient was provided information that his protein intake is supposed to be about 25 g per day.  He was advised not to over-eat protein and advised not to starve.  He also was advised to stay away from alcohol.  His next visit is in 2 weeks with all results available.
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DESCRIPTION: Patient seen initially with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.

gastroenterology, abdominal pain, nausea, dizziness, liver disease, epigastric pain, liver cirrhosis, liver, abdominal, cirrhosis, epigastric, hepatitis,

The situation involves a patient with a serious medical condition, liver cirrhosis, which can lead to life-threatening complications. The patient has been experiencing significant symptoms and has potentially been diagnosed with end-stage liver disease. There is a need for an accurate diagnosis and treatment plan, which is complicated by missing medical records and test results. The stakes are high primarily because of the patient's fragile health status and the importance of timely and correct medical intervention to prevent further deterioration or complications. However, it is being managed with some level of medical oversight, reducing the immediacy of the stakes.


Medical Specialty: Gastroenterology
Sample Name: Liver Biopsy

TITLE OF PROCEDURE: , Percutaneous liver biopsy.,ANALGESIA: , 2% Lidocaine.,ALLERGIES: , The patient denied any allergy to iodine, lidocaine or codeine.,PROCEDURE IN DETAIL:  ,The procedure was described in detail to the patient at a previous clinic visit and by the medical staff today.  The patient was told of complications which might occur consisting of bleeding, bile peritonitis, bowel perforation, pneumothorax, or death.  The risks and benefits of the procedure were understood, and the patient signed the consent form freely.,With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.  The area was prepped and cleaned with povidone iodine following which the skin, subcutaneous tissue, and serosal surfaces were infiltrated with 2% lidocaine down to the capsule of the liver.  Next, a small incision was made with a Bard-Parker #11 scalpel.  A 16-gauge modified Klatskin needle was inserted through the incision and into the liver on one occasion with the patient in deep expiration.  Liver cores measuring *** cm were obtained and will be sent to Pathology for routine histologic study.,POST-PROCEDURE COURSE AND DISPOSITION: , The patient will remain under close observation in the medical treatment room for four to six hours and then be discharged home without medication.  Normal activities can be resumed tomorrow.  The patient is to contact me if severe abdominal or chest pain, fever, melena, light-headedness or any unusual symptoms develop.  An appointment will be made for the patient to see me in the clinic in the next few weeks to discuss the results of the liver biopsy so that management decisions can be made.,COMPLICATIONS:,  None.,RECOMMENDATIONS: , Prior to discharge, hepatitis A and B vaccines will be recommended.  Risks and benefits for vaccination have been addressed and the patient will consider this option.
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DESCRIPTION: Percutaneous liver biopsy.   With the patient lying in the supine position and the right hand underneath the head, an area of maximal dullness was identified in the mid-axillary location by percussion.

gastroenterology, bile peritonitis, bowel perforation, pneumothorax, klatskin needle, mid axillary, liver biopsy, percutaneous, lidocaine, biopsy, liver

The procedure described is a percutaneous liver biopsy, which is an invasive medical procedure with a documented risk of significant complications such as bleeding, infection, and potential injury to surrounding organs. Despite being a routine procedure, the potential consequences and risks make it a high-stakes situation. The attention to pre-procedural explanation, consent, and post-procedural observation further underscores the risk involved. The lack of immediate complications in this instance is noted, but the inherent risks attached to the procedure itself justifies a high-stakes categorization.


Medical Specialty: Gastroenterology
Sample Name: Lower Quadrant Pain

REASON:,  Right lower quadrant pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 48-year-old female with an approximately 24-hour history of right lower quadrant pain, which she describes as being stabbed with a knife, radiating around her side to her right flank.  She states that is particularly bad when up and walking around, goes away when she is lying down.  She has no nausea or vomiting, no dysuria, no fever or chills, though she said she did feel warm.  She states that she feels a bit like she did when she had her gallbladder removed nine years ago.  Additionally, I should note that the patient is currently premenopausal with irregular menses, going anywhere from one to two months between cycles.  She has no abnormal vaginal discharge, and she is sexually active.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS,1.  Hydrochlorothiazide 25 mg p.o. daily.,2.  Lisinopril 10 mg p.o. daily.,3.  Albuterol p.r.n.,PAST MEDICAL HISTORY:  ,Hypertension and seasonal asthma.,PAST SURGICAL HISTORY: , Left bilateral breast biopsy for benign disease.  Cholecystitis/cholecystectomy following tubal pregnancy 22 years ago.,FAMILY HISTORY: , Mother is alive and well.  Father with coronary artery disease.  She has siblings who have increased cholesterol.,SOCIAL HISTORY:  ,The patient does not smoke.  She quit 25 years ago.  She drinks one beer a day.  She works as a medical transcriptionist.,REVIEW OF SYSTEMS: , Positive for an umbilical hernia, but otherwise negative with the exception of what is noted above.,PHYSICAL EXAMINATION,GENERAL:  Reveals a morbidly obese female who is alert and oriented x3, pleasant and well groomed, and in mild discomfort.,VITAL SIGNS:  Her temperature is 38.7, pulse 113, respirations 18, and blood pressure 144/85.,HEENT:  Normocephalic and atraumatic.  Sclerae are without icterus.  Conjunctivae are not injected.,NECK:  Neck is supple.  Carotids 2+.  Trachea is midline.  Carotids are without bruits.,LYMPH NODES:  There is no cervical, supraclavicular, or occipital adenopathy.,LUNGS:  Clear to auscultation.,CARDIAC:  Regular rate and rhythm.,ABDOMEN:  Soft.  No hepatosplenomegaly.  She has a positive Rovsing sign and a positive obturator sign.  She is tender in the right lower quadrant with mild rebound and no guarding.,EXTREMITIES:  Reveal 2+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses.  She has only trace edema with varicosities around the bilateral ankles.,CNS:  Without gross neurologic deficits.,INTEGUMENTARY:  Skin integrity is excellent.,DIAGNOSTICS: , Urine, specific gravity is 1.010, blood is 50, leukocytes 1+, white blood cells 10 to 25, rbc's 2 to 5, and 2 to 5 squamous epithelial cells.  White blood cell count is 20,000 with 75 polys and 16 lymphs.  H&H is 13.7 and 39.7.  Total bilirubin 1.3, direct bilirubin 0.2, and alk phos 98.  Sodium 138, potassium 3.1, chloride 101, CO2 26, calcium 9.5, glucose 103, BUN 16, and creatinine 0.91.  Lipase is 19.  CAT scan is negative for acute appendicitis.  In fact, it mentions that the appendix is not discretely identified.  There are no focal inflammatory masses, abscess, ascites, or pneumoperitoneum.,IMPRESSION: , Abdominal pain right lower quadrant, etiology is unclear.,PLAN:,  Plan is to admit the patient.  Recheck the white blood cell count in the morning.  Re-examine her and further plan is pending, the results of that evaluation.
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DESCRIPTION: Abdominal pain right lower quadrant, radiating around her side to her right flank.  Etiology is unclear.

The situation involves a patient with acute abdominal pain in the right lower quadrant, high white blood cell count suggesting infection or inflammation, and potential signs of appendicitis, although CT scan is negative. Teaching hospital admission for observation indicates significant concern. The patient's presentation and vital signs, including fever and elevated pulse, necessitate careful monitoring and further diagnostic workup to rule out surgical emergencies or other serious conditions. The diagnostic uncertainty and potential for serious underlying conditions make this a moderately high-stakes situation.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopy & Sigmoidoscopy

PREOPERATIVE DIAGNOSES:,1.  Acute pain.,2.  Fever postoperatively.,POSTOPERATIVE DIAGNOSIS:,1.  Acute pain.,2.  Fever postoperatively.,3.  Hemostatic uterine perforation.,4.  No bowel or vascular trauma.,PROCEDURE PERFORMED:,1.  Diagnostic laparoscopy.,2.  Rigid sigmoidoscopy by Dr. X.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Scant.,SPECIMEN:,  None.,INDICATIONS:  ,This is a 17-year-old African-American female, gravida-1, para-1, and had a hysteroscopy and dilation curettage on 09/05/03.  The patient presented later that evening after having increasing abdominal pain, fever and chills at home with a temperature up to 101.2.  The patient denied any nausea, vomiting or diarrhea.  She does complain of some frequent urination.  Her vaginal bleeding is minimal.,FINDINGS: , On bimanual exam, the uterus is approximately 6-week size, anteverted, and freely mobile with no adnexal masses appreciated.  On laparoscopic exam, there is a small hemostatic perforation noted on the left posterior aspect of the uterus.  There is approximately 40 cc of serosanguineous fluid in the posterior cul-de-sac.  The bilateral tubes and ovaries appeared normal.  There is no evidence of endometriosis in the posterior cul-de-sac or along the bladder flap.  There is no evidence of injury to the bowel or pelvic sidewall.  The liver margin, gallbladder and remainder of the bowel including the appendix appeared normal.,PROCEDURE: , After consent was obtained, the patient was taken to the Operating Room where general anesthetic was administered.  The patient was placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  A sterile speculum was placed in the patient's vagina and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterine manipulator was then placed into the patient's cervix and the vulsellum tenaculum and sterile speculum were removed.  Gloves were changed and attention was then turned to the abdomen where approximately 10 mm transverse infraumbilical incision was made.  Veress needle was placed through this incision and the gas turned on.  When good flow and low abdominal pressures were noted, the gas was turned up and the abdomen was allowed to insufflate.  A 11 mm trocar was then placed through this incision.  The camera was placed with the above findings noted.  A 5 mm step trocar was placed 2 cm superior to the pubic bone and along the midline.  A blunt probe was placed through this trocar to help for visualization of the pelvic and abdominal organs.  The serosanguineous fluid of the cul-de-sac was aspirated and the pelvis was copiously irrigated with sterile saline.  At this point, Dr. X was consulted.  He performed a rigid sigmoidoscopy, please see his dictation for further details.  There does not appear to be any evidence of colonic injury.  The saline in the pelvis was then suctioned out using Nezhat-Dorsey.  All instruments were removed.  The 5 mm trocar was removed under direct visualization with excellent hemostasis noted.  The camera was removed and the abdomen was allowed to desufflate.  The 11 mm trocar introducer was replaced and the trocar removed.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  Approximately 10 cc of 0.25% Marcaine was injected into the incision sites for postoperative pain relief.  Steri-Strips were then placed across the incision.  The uterine manipulator was then removed from the patient's cervix with excellent hemostasis noted.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct at the end of the procedure.  The patient was taken to the recovery room in satisfactory condition.,She will be followed immediately postoperatively within the hospital and started on IV antibiotics.
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DESCRIPTION: Diagnostic laparoscopy and rigid sigmoidoscopy.  Acute pain, fever postoperatively, hemostatic uterine perforation, no bowel or vascular trauma.

gastroenterology, uterine perforation, vascular, bowel, diagnostic laparoscopy, vulsellum tenaculum, uterine manipulator, excellent hemostasis, rigid sigmoidoscopy, laparoscopy, sigmoidoscopy, postoperatively, trocar,

The situation described involves a medical procedure with potential complications. The patient, a 17-year-old female, experienced acute pain, fever, and was found to have a hemostatic uterine perforation following a hysteroscopy and dilation curettage. While there were no bowel or vascular injuries and no complications were reported during the laparoscopy and sigmoidoscopy, the presence of a uterine perforation and the need for immediate postoperative monitoring and antibiotics make this a moderate to high-stakes situation. Uterine perforation and post-procedural fever in a young patient require careful attention to prevent further complications.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Gastric Bypass

PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS:  ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.  She has been to our Bariatric Surgery Seminar, received some handouts, and signed the consent.  The risks and benefits of the procedure have been explained to the patient.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  All pressure points were carefully padded.  She was given general anesthesia with endotracheal intubation.  SCD stockings were placed on both legs.  Foley catheter was placed for bladder decompression.  The abdomen was then prepped and draped in standard sterile surgical fashion.  Marcaine was then injected through umbilicus.  A small incision was made.  A Veress needle was introduced into the abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg.  A 12-mm VersaStep port was placed through the umbilicus.  I then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side.  I placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, I placed a 12-mm VersaStep port.  On the left side, just anterior to the midaxillary line and just subcostal, I placed a 5-mm port.  A few centimeters below and medial to that, I placed a 15-mm port.  I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz.  I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler.  I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device.  I then ran the distal bowel down, approximately 100 cm, and at 100 cm, I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and I passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis.  I reapproximated the edges of the defect.  I lifted it up and stapled across it with another white load stapler.  I then closed the mesenteric defect with interrupted Surgidac sutures.  I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic.  I then put the patient in reverse Trendelenburg.  I placed a liver retractor, identified, and dissected the angle of His.  I then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space.  I fired transversely across the stomach with a 45 blue load stapler.  I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His, thereby creating my gastric pouch.  I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil.  I pulled the anvil into place, and I then opened up my 15-mm port site and passed my EEA stapler.  I passed that in the end of my Roux limb and had the spike come out antimesenteric.  I joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my Roux limb with a white load GI stapler, and removed it with an Endocatch bag.  I put some additional 2-0 Vicryl sutures in the anastomosis for further security.  I then placed a bowel clamp across the bowel.  I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch.  I distended gastric pouch with air.  There was no air leak seen.  I could pass the scope easily through the anastomosis.  There was no bleeding seen through the scope.  We closed the 15-mm port site with interrupted 0 Vicryl suture utilizing Carter-Thomason.  I copiously irrigated out that incision with about 2 L of saline.  I then closed the skin of all incisions with running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.
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DESCRIPTION: Morbid obesity.  Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.  This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.

gastroenterology, gastric bypass, eea anastomosis, roux-en-y, antegastric, antecolic, morbid obesity, roux limb, gastric pouch, intubation, laparoscopic, bypass, roux, endotracheal, anastomosis, gastric

This situation involves a laparoscopic gastric bypass surgery for a patient with morbid obesity. Bariatric surgery, such as the Roux-en-Y gastric bypass, is a significant medical procedure with considerable potential benefits (such as weight loss and improvement in obesity-related conditions) but also risks (including surgical complications and anesthesia-related risks). The surgery requires skilled coordination, precise execution, and always has inherent risk due to the invasiveness of the procedure and the use of general anesthesia. Hence, it is considered high-stakes due to the life-changing impact it can have on the patient's health and the potential for surgical complications.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Cholecystectomy & Liver Cyst Excision

PREOPERATIVE DIAGNOSES:,1.  Chronic cholecystitis.,2.  Cholelithiasis.,POSTOPERATIVE DIAGNOSES:,1.  Chronic cholecystitis.,2.  Cholelithiasis.,3.  Liver cyst.,PROCEDURES PERFORMED:,1.  Laparoscopic cholecystectomy.,2.  Excision of liver cyst.,ANESTHESIA:  ,General endotracheal and injectable 0.25% Marcaine with 1% lidocaine.,SPECIMENS: , Include,1.  Gallbladder.,2.  Liver cyst.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,OPERATIVE FINDINGS:,  Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder.  Additionally, there was a notable liver cyst.  The remainder of the abdomen remained free of any adhesions.,BRIEF HISTORY: , This is a 66-year-old Caucasian female who presented to ABCD General Hospital for an elective cholecystectomy.  The patient complained of intractable nausea, vomiting, and abdominal bloating after eating fatty foods.  She had had multiple attacks in the past of these complaints.  She was discovered to have had right upper quadrant pain on examination.  Additionally, she had an ultrasound performed on 08/04/2003, which revealed cholelithiasis.  The patient was recommended to undergo laparoscopic cholecystectomy for her recurrent symptoms.  She was explained the risks, benefits, and complications of the procedure and she gave informed consent to proceed.,OPERATIVE PROCEDURE:  ,The patient was brought to the operative suite and placed in the supine position.  The patient received preoperative antibiotics with Kefzol.  The abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  The patient did undergo general endotracheal anesthesia.  Once the adequate sedation was achieved, a supraumbilical transverse incision was created with a #10 blade scalpel.  Utilizing a Veress needle, the Veress needle was inserted intra-abdominally and was hooked to the CO2 insufflation.  The abdomen was insufflated to 15 mmHg.  After adequate insufflation was achieved, the laparoscopic camera was inserted into the abdomen and to visualize a distended gallbladder as well as omental adhesion adjacent to the gallbladder.  Decision to proceed with laparoscopic cystectomy was decided.  A subxiphoid transverse incision was created with a #10 blade scalpel and utilizing a bladed 12 mm trocar, the trocar was inserted under direct visualization into the abdomen.  Two 5 mm ports were placed, one at the midclavicular line 2 cm below the costal margin and a second at the axillary line, one hand length approximately below the costal margin.  All ports were inserted with bladed 5 mm trocar then under direct visualization.  After all trocars were inserted, the gallbladder was grasped at the fundus and retracted superiorly and towards the left shoulder.  Adhesions adjacent were taken down with a Maryland dissector.  Once this was performed, the infundibulum of the gallbladder was grasped and retracted laterally and anteriorly.  This helped to better delineate the cystic duct as well as the cystic artery.  Utilizing Maryland dissector, careful dissection of the cystic duct and cystic artery were created posteriorly behind each one.  Utilizing Endoclips, clips were placed on the cystic duct and cystic artery, one proximal to the gallbladder and two distally.  Utilizing endoscissors, the cystic duct and cystic artery were ligated.  Next, utilizing electrocautery, the gallbladder was carefully dissected off the liver bed.  Electrocautery was used to stop any bleeding encountered along the way.  The gallbladder was punctured during dissection and cleared, biliary contents did drained into the abdomen.  No evidence of stones were visualized.  Once the gallbladder was completely excised from the liver bed, an EndoCatch was placed and the gallbladder was inserted into EndoCatch and removed from the subxiphoid port.  This was sent off as an specimen, a gallstone was identified within the gallbladder.  Next, utilizing copious amounts of irrigation, the abdomen was irrigated.  A small liver cyst that have been identified upon initial aspiration was grasped with a grasper and utilizing electrocautery was completely excised off the left lobe of the liver.  This was also taken and sent off as specimen.  The abdomen was then copiously irrigated until clear irrigation was identified.  All laparoscopic ports were removed under direct visualization.  The abdomen was de-insufflated.  Utilizing #0 Vicryl suture, the abdominal fascia was approximated with a figure-of-eight suture in the supraumbilical and subxiphoid region.  All incisions were then closed with #4-0 undyed Vicryl.  Two midline incisions were closed with a running subcuticular stitch and the lateral ports were closed with interrupted sutures.  The areas were cleaned and dried.  Steri-Strips were placed.  On the incisions, sterile dressing was applied.  The patient tolerated the procedure well.  She was extubated following procedure.  She is seen to tolerate the procedure well and she will follow up with Dr. X within one week for a follow-up evaluation.
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DESCRIPTION: Chronic cholecystitis, cholelithiasis, and liver cyst.  Laparoscopic cholecystectomy and excision of liver cyst.  Exploration of the abdomen revealed multiple adhesions of omentum overlying the posterior aspect of the gallbladder.

gastroenterology, excision of liver cyst, gallbladder, omentum, cystic artery, gallstone, laparoscopic cholecystectomy, cystic duct, liver cyst, liver, abdomen, electrocautery, cholelithiasis, cholecystectomy, adhesions, laparoscopic, cyst, cystic,

The procedure described, a laparoscopic cholecystectomy and liver cyst excision, is common yet still carries important surgical risks typical of such operations, like bleeding, infection, and organ damage. However, the patient was stable, there were no intraoperative complications, and the blood loss was minimal. The surgery seems to have been elective and successful, reducing some immediate high-stakes aspects. Postoperative care and follow-up are required, but given the routine nature and the successful completion of the procedure, this situation has a moderate level of stakes for a medical context.


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

Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Cholecystectomy - 6

PREOPERATIVE DIAGNOSIS:,  Cholelithiasis; possible choledocholithiasis.
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DESCRIPTION: Cholelithiasis; possible choledocholithiasis.  Laparoscopic cholecystectomy and intraoperative cholangiogram.  A small incision was made in the umbilicus, and a Veress needle was introduced into the abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg, and a 12-mm VersaStep port was placed into the umbilicus.

gastroenterology, choledocholithiasis, cholangiogram, co2 insufflation, umbilicus, common bile duct, bile duct, laparoscopic cholecystectomy, cystic duct, intraoperative, laparoscopic, cholecystectomy, cholelithiasis, endotracheal, gallbladder, cystic, duct,

The situation describes a laparoscopic cholecystectomy procedure, which is a common surgery to remove the gallbladder. While generally routine and performed regularly with low-risk complications, it is still surgery with potential risks like injury to bile ducts or bleeding. However, given its routine nature in a controlled medical environment, it is not extremely high-stakes. The possible presence of choledocholithiasis adds complexity but is commonly managed with intraoperative cholangiogram. Hence, the stakes are moderate.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Cholecystectomy - 10

PREOPERATIVE DIAGNOSIS: , Biliary colic and biliary dyskinesia.,POSTOPERATIVE DIAGNOSIS:,  Biliary colic and biliary dyskinesia.,PROCEDURE PERFORMED:,  Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,DISPOSITION:  ,The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY:  ,This patient is a 42-year-old female who presented to Dr. X's office with complaints of upper abdominal and back pain, which was sudden onset for couple of weeks.  The patient is also diabetic.  The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.  The patient was then scheduled for laparoscopic cholecystectomy for biliary colic and biliary dyskinesia.,INTRAOPERATIVE FINDINGS: , The patient's abdomen was explored.  There was no evidence of any peritoneal studding or masses.  The abdomen was otherwise within normal limits.  The gallbladder was easily visualized.  There was an intrahepatic gallbladder.  There was no evidence of any inflammatory change.,PROCEDURE:,  After informed written consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought into the operating suite.,After general endotracheal intubation, the patient was prepped and draped in normal sterile fashion.  Next, an infraumbilical incision was made with a #10 scalpel.  The skin was elevated with towel clips and a Veress needle was inserted.  The abdomen was then insufflated to 15 mmHg of pressure.  The Veress needle was removed and a #10 blade trocar was inserted without difficulty.  The laparoscope was then inserted through this #10 port and the abdomen was explored.  There was no evidence of any peritoneal studding.  The peritoneum was smooth.  The gallbladder was intrahepatic somewhat.  No evidence of any inflammatory change.  There were no other abnormalities noted in the abdomen.  Next, attention was made to placing the epigastric #10 port, which again was placed under direct visualization without difficulty.  The two #5 ports were placed, one in the midclavicular and one in the anterior axillary line again in similar fashion under direct visualization.  The gallbladder was then grasped out at its fundus, elevated to patient's left shoulder.  Using a curved dissector, the cystic duct was identified and freed up circumferentially.  Next, an Endoclip was used to distal and proximal to the gallbladder, Endoshears were used in between to transect the cystic duct.  The cystic artery was transected in similar fashion.  Attention was next made in removing the gallbladder from the liver bed using electrobovie cautery and spatulated tip.  It was done without difficulty.  The gallbladder was then grasped via the epigastric port and removed without difficulty and sent to pathology.  Hemostasis was maintained using electrobovie cautery.  The liver bed was then copiously irrigated and aspirated.  All the fluid and air was then aspirated and then all ports were removed under direct visualization.  The two #10 ports were then closed in the fascia with #0 Vicryl and a UR6 needle.  The skin was closed with a running subcuticular #4-0 undyed Vicryl.  0.25% Marcaine was injected and Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and was transferred to Recovery in stable condition.
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DESCRIPTION: Laparoscopic cholecystectomy.  Biliary colic and biliary dyskinesia.  The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.

gastroenterology, electrobovie cautery, laparoscopic cholecystectomy, biliary colic, biliary dyskinesia, biliary, laparoscopic, cholecystectomy, colic, abdomen, dyskinesia, gallbladder

The situation describes a laparoscopic cholecystectomy, a common and typically low-risk surgical procedure to remove the gallbladder. While any surgical procedure inherently carries some degree of risk, this case did not present complications, and the patient was stable post-surgery. Therefore, this is considered a routine surgical procedure with manageable risk.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Appendectomy - 3

PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis. ,PROCEDURE: , Laparoscopic appendectomy. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  His abdomen was prepped and draped in a standard, sterile surgical fashion.  A Foley catheter was placed for bladder decompression.  Marcaine was injected into his umbilicus.  A small incision was made.  A Veress needle was introduced in his abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus.  A 5-mm port was then placed just to the right side of the umbilicus.  Another 5-mm port was placed just suprapubic in the midline.  Upon inspection of the cecum, I was able find an inflamed and indurated appendix.  I was able to clear the mesentery at the base of the appendix between the appendix and the cecum.  I fired a white load stapler across the appendix at its base and fired a grey load stapler across the mesentery, and thereby divided the mesentery and freed the appendix.  I put the appendix in an Endocatch bag and removed it through the umbilicus.  I irrigated out the abdomen.  I then closed the fascia of the umbilicus with interrupted 0 Vicryl suture utilizing Carter-Thomason and closed the skin of all incisions with a running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.
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DESCRIPTION: Appendicitis.  Laparoscopic appendectomy.   CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus.

gastroenterology, foley catheter, co2 insufflation, endotracheal intubation, laparoscopic appendectomy, appendectomy, intubation, cecum, laparoscopic, appendicitis, endotracheal, abdomen, mesentery, umbilicus, appendix,

The situation involves performing a surgical procedure, specifically a laparoscopic appendectomy, which is generally a routine and low-risk surgical procedure. However, it still entails anesthesia and potential surgical complications. Given that this is a medical context with inherent risks associated with surgeries, it is not without stakes. However, the surgery is successfully completed without complications, reducing the stakes further. Thus, it can be considered moderate-stakes, primarily due to the nature of medical procedures rather than any extraordinary circumstances reported.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Appendectomy - 4

PREOPERATIVE DIAGNOSIS:,  Acute appendicitis with perforation.,POSTOPERATIVE DIAGNOSIS:  ,Acute appendicitis with perforation.,ANESTHESIA:,  General.,PROCEDURE: , Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old little boy, who has been sick for several days and was seen in our Emergency Department yesterday where a diagnosis of possible constipation was made, but he was sent home with a prescription for polyethylene glycol but became more acutely ill and returned today with tachycardia, high fever and signs of peritonitis.  A CT scan of his abdomen showed evidence of appendicitis with perforation.  He was evaluated in the Emergency Department and placed on the appendicitis critical pathway for this acute appendicitis process.  He required several boluses of fluid for tachycardia and evidence of dehydration.,I met with Carlos' parents and talked to them about the diagnosis of appendicis and surgical risks, benefits, and alternative treatment options.  All their questions have been answered and they agree with the surgical plan.,OPERATIVE FINDINGS: , The patient had acute perforated appendicitis with diffuse suppurative peritonitis including multiple intraloop abscesses and purulent debris in all quadrants of the abdomen including the perihepatic and subphrenic recesses as well.,DESCRIPTION OF PROCEDURE: , The patient came to the operating room and had an uneventful induction of general anesthesia.  A Foley catheter was placed for decompression, and his abdomen was prepared and draped in a standard fashion.  A 0.25% Marcaine was infiltrated in the soft tissues around his umbilicus and in the suprapubic and left lower quadrant locations chosen for trocar insertion.  We conducted our surgical timeout and reiterated all of Carlos' unique and important identifying information and confirmed the diagnosis of appendicitis and planned laparoscopic appendectomy as the procedure.  A 1-cm vertical infraumbilical incision was made and an open technique was used to place a 12-mm Step trocar through the umbilical fascia.  CO2 was insufflated to a pressure of 15 mmHg and then two additional 5-mm working ports were placed in areas that had been previously anesthetized.,There was a lot of diffuse purulent debris and adhesions between the omentum and adjacent surfaces of the bowel and the parietal peritoneum.  After these were gently separated, we began to identify the appendix.  In the __________ due to the large amount of small bowel dilatation and distension, I used the hook cautery with the lowest intraperitoneal __________ profile to coagulate the mesoappendix.  The base of the appendix was then ligated with 2-0 PDS Endoloops, and the appendix was amputated and withdrawn through the umbilical port.  I spent the next 10 minutes irrigating purulent fluid and debris from the peritoneal cavity using 2 L of sterile crystalloid solution and a suction power irrigation system.  When this was complete, the CO2 was released one final time and as much of the fluid was drained from the peritoneal cavity as possible.  The umbilical fascia was closed with figure-of-eight suture of 0 Monocryl and the skin incisions were closed with subcuticular 5-0 Monocryl and Steri-Strips.  The patient tolerated the operation well.  He was awakened and taken to the recovery room in satisfactory condition.  His blood loss was less than 10 mL, and he received only crystalloid fluid during the procedure.
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DESCRIPTION: Acute appendicitis with perforation.  Laparoscopic appendectomy.   A CT scan of abdomen showed evidence of appendicitis with perforation.

gastroenterology, adhesions, peritoneum, purulent debris, umbilical fascia, peritoneal cavity, laparoscopic appendectomy, appendectomy, constipation, purulent, debris, umbilical, appendix, abdomen, laparoscopic, perforation, appendicitis,

The situation involves a 4-year-old child with acute perforated appendicitis, a serious medical condition requiring urgent surgical intervention. The stakes are high due to the patient's age, the risk of complications from peritonitis, and the need for quick surgical response to prevent further deterioration. The surgical procedure is critical for the patient's recovery, making this a high-stakes medical scenario.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Cholecystectomy - 3

PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis without cholelithiasis.,POSTOPERATIVE DIAGNOSIS:  ,Chronic cholecystitis without cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy.,BRIEF DESCRIPTION: , The patient was brought to the operating room and anesthesia was induced.  The abdomen was prepped and draped and ports were placed.  The gallbladder was grasped and retracted.  The cystic duct and cystic artery were circumferentially dissected and a critical view was obtained.  The cystic duct and cystic artery were then doubly clipped and divided and the gallbladder was dissected off the liver bed with electrocautery and placed in an endo catch bag.  The gallbladder fossa and clips were examined and looked good with no evidence of bleeding or bile leak.  The ports were removed under direct vision with good hemostasis.  The Hasson was removed.  The abdomen was desufflated.  The gallbladder in its endo catch bag was removed.  The ports were closed.  The patient tolerated the procedure well.  Please see full hospital dictation.
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DESCRIPTION: Chronic cholecystitis without cholelithiasis.

gastroenterology, chronic cholecystitis without cholelithiasis, laparoscopic cholecystectomy, cystic duct, cystic artery, endo catch, chronic cholecystitis, laparoscopic, cholecystectomy, abdomen, cholecystitis, cholelithiasis, gallbladder, cystic

The laparoscopic cholecystectomy procedure described is a common surgical procedure in gastroenterology. While surgery always involves some degree of risk, this procedure is typically not considered high-stakes compared to other surgeries that involve life-threatening conditions or potential complications. The patient's diagnosis and post-operative outcome indicate that there were no complications such as bleeding or bile leaks, which implies that the stakes were not high in this instance.


Medical Specialty: Gastroenterology
Sample Name: Juxtarenal Abdominal Aortic Aneurysm Repair

PREOPERATIVE DIAGNOSIS:  Large juxtarenal abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS:  Large juxtarenal abdominal aortic aneurysm.,ANESTHESIA:  General endotracheal anesthesia.,OPERATIVE TIME:  Three hours.,ANESTHESIA TIME:  Four hours.,DESCRIPTION OF PROCEDURE:  After thorough preoperative evaluation, the patient was brought to the operating room and placed on the operating table in supine position and after placement of upper extremity IV access and radial A-line, general endotracheal anesthesia was induced.  A Foley catheter was placed and a right internal jugular central line was placed.  The chest, abdomen, both groin, and perineum were prepped widely with Betadine and draped as a sterile field with an Ioban drape.  A long midline incision from xiphoid to pubis was created with a scalpel and the abdomen was carefully entered.  A sterile Omni-Tract was introduced into the field to retract the abdominal wall and gentle exploration of the abdomen was performed.  With the exception of the vascular findings to be described, there were no apparent intra-abdominal abnormalities.,The transverse colon retracted superiorly.  The small bowel was wrapped in moist green towel and retracted in the right upper quadrant.  The posterior peritoneum overlying the aneurysm was scribed mobilizing the ligament of Treitz thoroughly ligating and dividing the inferior mesenteric vein.  Dissection continued superiorly to identify the left renal vein and the right and left inferior renal arteries.  The mid left renal artery was likewise identified.  The perirenal aorta was prepared for clamp superior to the inferior left renal artery.  During this portion of the dissection, the patient was given multiple small doses of intravenous mannitol to establish an osmotic diuresis.  The distal dissection was then completed exposing each common iliac artery.  The arteries were suitable for control.,The patient was then given 8000 units of intravenous sodium heparin and systemic anticoagulation verified by activated clotting time.  The aneurysm was repaired.,First, the common carotid arteries were controlled with atraumatic clamps.  The inferior left renal artery was controlled with a microvascular clamp and a straight aortic clamp was used to control the aorta superior to this renal artery.  The aneurysm was opened on the right anterior lateral aspect and an endarterectomy of the aneurysm sac was performed.  There was a high-grade stenosis at the origin of the inferior mesenteric artery and an eversion endarterectomy was performed at this site.  The vessel was controlled with a microvascular clamp.  Two pairs of lumbar arteries were oversewn with 2-0 silk.  A 14 mm Hemashield tube graft was selected and sewn end-to-end fashion to the proximal aorta using a semi continuous 3-0 Prolene suture.  At the completion of anastomosis three patch stitches of 3-0 Prolene were required for hemostasis.  The graft was cut to appropriate length and sewn end-to-end at the iliac bifurcation using semi-continuous 3-0 Prolene suture.  Prior to completion of this anastomosis, the graft was flushed of air and debris and blood flow was reestablished slowly to the distal native circulation first to the pelvis with external compression on the femoral vessels and finally to the distal native circulation.  The distal anastomosis was competent without leak.,The patient was then given 70 mg of intravenous protamine and final hemostasis obtained using electrocoagulation.  The back bleeding from the inferior mesenteric artery was assessed and was pulsatile and vigorous.  The colon was normal in appearance and this vessel was oversewn using 2-0 silk.  The aneurysm sac was then closed about the grafts snuggly using 3-0 PDS in a vest-over-pants fashion.  The posterior peritoneum was reapproximated using running 3-0 PDS.  The entire large and small bowel were inspected and these structures were well perfused with a strong pulse within the SMA normal appearance of the entire viscera.  The NG tube was positioned in the fundus of the stomach and the viscera returned to their anatomic location.  The midline fascia was then reapproximated using running #1 PDS suture.  The subcutaneous tissues were irrigated with bacitracin and kanamycin solution.  The skin edges coapted using surgical staples.,At the conclusion of the case, sponge and needle counts were correct and a sterile occlusive compressive dressing was applied.
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DESCRIPTION: Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft.

gastroenterology, inferior left renal artery, semi continuous prolene suture, juxtarenal abdominal aortic aneurysm, inferior mesenteric artery, continuous prolene suture, abdominal aortic aneurysm, hemashield tube, inferior mesenteric, renal artery, aortic aneurysm, aneurysm, iliac, endarterectomy, viscera, hemashield, abdomen, prolene, arteries, juxtarenal, graft, aortic, endotracheal, renal, artery,

Repairing a juxtarenal abdominal aortic aneurysm is a significant surgical procedure due to the critical nature of the aorta and surrounding structures. The surgery involves complex dissection near vital organs, requires precise vascular control, and the use of anesthesia and anticoagulation, which involve their own risks. The stakes are high due to the potential for complications such as bleeding, organ damage, or postoperative issues. This is a high-stakes medical procedure due to the critical nature of the condition being treated and the complexity of the surgery.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Appendectomy

PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,OPERATIVE PROCEDURE:,  Laparoscopic appendectomy.,INTRAOPERATIVE FINDINGS: , Include inflamed, non-perforated appendix.,OPERATIVE NOTE:  ,The patient was seen by me in the preoperative holding area.  The risks of the procedure were explained.  She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery.  General anesthesia was carried out without difficulty and a Foley catheter was inserted.  The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion.  A 5-mm blunt port was inserted infra-umbilically at the level of the umbilicus under direct vision of a 5-mm 0-degree laparoscope.  Once we were inside the abdominal cavity, CO2 was instilled to attain an adequate pneumoperitoneum.  A left lower quadrant 5-mm port was placed under direct vision and a 12-mm port in the suprapubic region.  The 5-mm scope was introduced at the umbilical port and the appendix was easily visualized.  The base of the cecum was acutely inflamed but not perforated.  I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix.  The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty.  I reloaded with a red vascular cartridge, came across the mesoappendix without difficulty.  I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty.  I reinserted the suprapubic port and irrigated out the right lower quadrant until dry.  One final inspection revealed no bleeding from the staple line.  We then removed all ports under direct vision, and there was no bleeding from the abdominal trocar sites.  The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0-Vicryl suture.  The skin incision was injected with 0.25% Marcaine and closed with 4-0 Monocryl suture.  Steri-strips and sterile dressings were applied.  No complications.  Minimal blood loss.  Specimen is the appendix.  Brought to the recovery room in stable condition.
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DESCRIPTION: Laparoscopic appendectomy.  Acute appendicitis.

gastroenterology, appendix, endobag, laparoscopic appendectomy, acute appendicitis, appendectomy, umbilically, abdominal, pneumoperitoneum, laparoscopic, appendicitis, suprapubic, mesoappendix,

A laparoscopic appendectomy, while generally routine and low-risk, still involves surgery, anesthesia, and potential complications. Acute appendicitis needs timely surgical intervention to prevent escalation into a more serious condition like a ruptured appendix, which can be life-threatening. This specific case notes the appendix was inflamed but not perforated, suggesting timely intervention. However, given it is described as a routine procedure with no complications, minimal blood loss, and the patient in stable condition post-op, it doesn't elevate to the highest stakes level.


Medical Specialty: Gastroenterology
Sample Name: Ischemic Cecum - Consult

REASON FOR CONSULTATION: , Pneumatosis coli in the cecum.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 87-year-old gentleman who was admitted on 10/27/07 with weakness and tiredness with aspiration pneumonia.  The patient is very difficult to obtain information from; however, he appears to be having frequent nausea and vomiting with an aspiration pneumonia and abdominal discomfort.  In addition, this hospitalization, he has undergone an upper endoscopy, which found a small ulcer after dropping his hematocrit and becoming anemic.  He had a CT scan on Friday, 11/02/07, which apparently showed pneumatosis and his cecum worrisome for ischemic colitis as well as bilateral hydronephrosis and multiple liver lesions, which could be metastatic disease versus cysts.  In discussions with the patient, he had multiple bowel movements yesterday and is currently passing flatus and has epigastric pain.,PAST MEDICAL HISTORY:  ,Obtained from the medical chart.  Chronic obstructive pulmonary disease, history of pneumonia, and aspiration pneumonia, osteoporosis, alcoholism, microcytic anemia.,MEDICATIONS: , Per his current medical chart.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient had a long history of smoking but quit many years ago.  He does have chronic alcohol use.,PHYSICAL EXAMINATION:,GENERAL:  A very thin white male who is dyspneic and having difficulty breathing at the moment.,VITAL SIGNS:  Afebrile.  Heart rate in the 100s to 120s at times with atrial fibrillation.  Respiratory rate is 17-20.  Blood pressure 130s-150s/60s-70s.,NECK:  Soft and supple, full range of motion.,HEART:  Regular.,ABDOMEN:  Distended with tenderness mainly in the upper abdomen but very difficult to localize due to his difficulty providing information.  He does appear to have tenderness but does not have rebound and does not have peritoneal signs.,DIAGNOSTICS: , A CT scan done on 11/02/07 shows pneumatosis in the cecum with an enlarged cecum filled with stool and air fluid levels with chronically dilated small bowel.,ASSESSMENT: , Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.,PLAN: , The patient appears to have pneumatosis from a CT scan 2 days ago.  Nothing was done about it at that time as the patient appeared to not be symptomatic, but he continues to have nausea and vomiting with abdominal pain, but the fact that pneumatosis was found 2 days ago and the patient has survived this long indicates this may be a benign process at the moment, and I would recommend getting a repeat CT scan to assess it further to see if there is worsening of pneumatosis versus resolution to further evaluate the liver lesions and make decisions regarding planning at that time.  The patient has frequent desaturations secondary to his aspiration pneumonia, and any surgical procedure or any surgical intervention would certainly require intubation, which would then necessitate long-term ventilator care as he is not someone who would be able to come off of a ventilator very well in his current state.  So we will look at the CT scan and make decisions based on the findings as far as that is concerned.
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DESCRIPTION: Pneumatosis coli in the cecum.  Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.

gastroenterology, ischemic cecum, metastatic disease, bilateral hydronephrosis, chronic alcohol abuse, acute renal failure, copd, anemia, gastric ulcer, pneumatosis coli, cecum, aspiration pneumonia, aspiration, ischemic, atrial, metastatic, hydronephrosis, fibrillation, pneumatosis, pneumonia,

The patient's condition involves multiple serious health issues: possible ischemic cecum, metastatic disease, aspiration pneumonia, acute renal failure, and COPD among others. The presence of pneumatosis coli could indicate a range of issues from benign to life-threatening ischemic conditions. Additionally, any surgical intervention poses a high risk due to the patient's severe respiratory compromise and hemodynamic instability. These factors combined make this a potentially life-threatening situation, hence high-stakes.