Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy & Gastrostomy Tube Insertion

PREOPERATIVE DIAGNOSES:,1.  Neuromuscular dysphagia.,2.  Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSES:,1.  Neuromuscular dysphagia.,2.  Protein-calorie malnutrition.,PROCEDURES PERFORMED:,1.  Esophagogastroduodenoscopy with photo.,2.  Insertion of a percutaneous endoscopic gastrostomy tube.,ANESTHESIA:,  IV sedation and local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well without difficulty.,BRIEF HISTORY:  ,The patient is a 50-year-old African-American male who presented to ABCD General Hospital on 08/18/2003 secondary to right hemiparesis from a CVA.  The patient deteriorated with several CVAs and had became encephalopathic requiring a ventilator-dependency with respiratory failure.  The patient also had neuromuscular dysfunction.  After extended period of time, per the patient's family request and requested by the ICU staff, decision to place a feeding tube was decided and scheduled for today.,INTRAOPERATIVE FINDINGS: , The patient was found to have esophagitis as well as gastritis via EGD and was placed on Prevacid granules.,PROCEDURE: , After informed written consent, the risks and benefits of the procedure were explained to the patient and the patient's family.  First, the EGD was to be performed.,The Olympus endoscope was inserted through the mouth, oropharynx and into the esophagus.  Esophagitis was noted.  The scope was then passed through the esophagus into the stomach.  The cardia, fundus, body, and antrum of the stomach were visualized.  There was evidence of gastritis.  The scope was passed into the duodenal bulb and sweep via the pylorus and then removed from the duodenum retroflexing on itself in the stomach looking at the hiatus.  Next, attention was made to transilluminating the anterior abdominal wall for the PEG placement.  The skin was then anesthetized with 1% lidocaine.  The finder needle was then inserted under direct visualization.  The catheter was then grasped via the endoscope and the wire was pulled back up through the patient's mouth.  The Ponsky PEG tube was attached to the wire.  A skin nick was made with a #11 blade scalpel.  The wire was pulled back up through the abdominal wall point and Ponsky PEG back up through the abdominal wall and inserted into position.  The endoscope was then replaced confirming position.  Photograph was taken.  The Ponsky PEG tube was trimmed and the desired attachments were placed and the patient did tolerate the procedure well.  We will begin tube feeds later this afternoon.
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DESCRIPTION: Esophagogastroduodenoscopy with photo.  Insertion of a percutaneous endoscopic gastrostomy tube.  Neuromuscular dysphagia.  Protein-calorie malnutrition.

gastroenterology, neuromuscular dysphagia, protein-calorie malnutrition, esophagogastroduodenoscopy, endoscopic, gastrostomy, percutaneous, gastrostomy tube, percutaneous endoscopic gastrostomy tube, protein calorie malnutrition, abdominal wall, dysphagia, stomach, abdominal, neuromuscular, tube,

The situation involves a medical procedure related to serious conditions like neuromuscular dysphagia and protein-calorie malnutrition, particularly in a patient with a history of multiple cerebrovascular accidents (CVAs) and ventilator dependency. This signifies a high-risk patient population, and the insertion of a percutaneous endoscopic gastrostomy (PEG) tube is a significant intervention for maintaining nutritional intake. Any complications could severely impact the patient's health, making the situation relatively high-stakes. However, it should be noted that the procedure was completed successfully without complications, which slightly lowers the urgency and risk level presently.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pacemaker - DDDR

PROCEDURE PERFORMED:  ,DDDR permanent pacemaker.,INDICATION: , Tachybrady syndrome.,PROCEDURE:,  After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein.  Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  The needle was then removed over the guidewire and the guidewire was secured to the field.  A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen.  Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field.  Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area.  A #11-knife blade was used to make a deeper incision.  Hemostasis was made complete.  The edges of the incision were grasped and retracted.  Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane.  Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator.  Metzenbaum scissors were then used to dissect cephalad to expose the guide wires.  The guidewires were then pulled through the pacemaker pocket.  One guidewire was secured to the field.,A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance.  The guidewire and dilator were then removed.  Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.  The pacemaker lead was then placed in the appropriate position in the right ventricle.  Pacing and sensing thresholds were obtained.  The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________.  Pacing and sensing threshold were then reconfirmed.  Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen.  The guidewire and dilator were then removed.  Under fluoroscopic guidance, the atrial lead was passed into the right atrium.  The sheath was then turned away in standard fashion.  Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position.  Pacing and sensing thresholds were obtained.  The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________.  Sensing and pacing thresholds were then reconfirmed.  The leads were wiped free of blood and placed into the pacemaker generator.  The pacemaker generator leads were then placed into pocket with the leads posteriorly.  The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion.  A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch.  Steri-Strips overlaid.  A sterile gauge dressing was placed over the site.  The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.,PACEMAKER DATA (GENERATOR DATA):,Manufacturer:  Medtronics.,Model:  Sigma.,Model #:  1234.,Serial #:  123456789.,LEAD INFORMATION:,Right Atrial Lead:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,VENTRICULAR LEAD:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,PACING AND SENSING THRESHOLDS:,Right Atrial Bipolar Lead:  Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.,Ventricular Bipolar Lead:  Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.,PARAMETER SETTINGS:,  Pacing mode DDDR:  Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,IMPRESSION:,  Successful implantation of DDDR permanent pacemaker.,PLAN:,1.  The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2.  The patient will be placed on antibiotics for five days to avoid pacemaker infection.
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DESCRIPTION: DDDR permanent pacemaker.   Tachybrady syndrome.  A ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.

The procedure described is the implantation of a DDDR permanent pacemaker, which involves surgical intervention to address tachybrady syndrome. This condition involves irregular heart rhythms that can compromise the heart's ability to pump blood effectively. The procedure is high-stakes due to its complexity, the use of anesthesia, the need for precise placement of the pacemaker leads, and the potential risks associated with surgical interventions like infection, device failure, or procedural complications. Despite the procedural success reported, continuous monitoring and a course of antibiotics have been planned to mitigate post-procedural risks. The potential consequences of the procedure not being successful or encountering complications are significant and can affect the patient’s health critically, thus making it a high-stakes situation.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Orthopedic
Sample Name: MRI Ankle - 1

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

Patient with right ankle pain.

The situation described involves a detailed examination report for an ankle MRI, revealing multiple injuries and conditions affecting the patient's right ankle. Although the conditions mentioned, such as ligamentous sprains, tendon tears, and synovitis, can cause significant pain and mobility issues, they do not seem immediately life-threatening. However, they do require medical attention and could impact the patient's quality of life if not managed properly. The stakes are moderate as the treatment and management of these findings are crucial for the patient's recovery and may require surgical intervention. However, since there is no immediate threat to life or major risk of permanent disability, the stakes are not extremely high.


Medical Specialty: ENT - Otolaryngology
Sample Name: Otitis Media - Discharge Summary

ADMITTING DIAGNOSES:,1.  Fever.,2.  Otitis media.,3.  Possible sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-month-old male who was seen in the office 1 day prior to admission.  He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes.  He has been taking Tylenol and Advil to help decrease the fevers, but the fever has continued to rise.  He was noted to have some increased workup of breathing and parents returned to the office on the day of admission.,PAST MEDICAL HISTORY: , Significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce.,PHYSICAL EXAMINATION: , On exam, he was moderately ill appearing and lethargic.  HEENT:  Atraumatic, normocephalic.  Pupils are equal, round, and reactive to light.  Tympanic membranes were red and yellow, and opaque bilaterally.  Nares were patent.  Oropharynx was slightly moist and pink.  Neck was soft and supple without masses.  Heart is regular rate and rhythm without murmurs.  Lungs showed increased workup of breathing, moderate tachypnea.  No rales, rhonchi or wheezes were noted.  Abdomen:  Soft, nontender, nondistended.  Active bowel sounds.  Neurologic exam showed good muscle strength, normal tone.  Cranial nerves II through XII are grossly intact.,LABORATORY FINDINGS: , He had electrolytes, BUN and creatinine, and glucose all of which were within normal limits.  White blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection.  Urinalysis was completely unremarkable.  Chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest.,HOSPITAL COURSE: , The patient was admitted to the hospital and allowed a clear liquid diet.  Activity is as tolerates.  CBC with differential, blood culture, electrolytes, BUN, and creatinine, glucose, UA, and urine culture all were ordered.  Chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia.  Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94%.  Gave D5 and quarter of normal saline at 45 mL per hour, which was just slightly above maintenance rate to help with hydration.  He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis, and I will add Tylenol and ibuprofen as needed for fevers.  Overnight, he did have his oxygen saturations drop and went into oxygen overnight.  His lungs remained clear, but because of the need for O2, we instituted albuterol aerosols every 6 hours to help maintain good lung function.  The nurses were instructed to attempt to wean O2 if possible and advance the diet.  He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient.  He did well the following evening with no further oxygen requirement.  He continued to spike fevers but last fever was around 13:45 on the previous day.  At the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees F. with clear lungs.  He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning.,CONDITION OF THE PATIENT AT DISCHARGE: , He was at 100% oxygen saturations on room air with no further dips at night.  He has become afebrile and was having no further increased work of breathing.,DISCHARGE DIAGNOSES:,1.  Bilateral otitis media.,2.  Fever.,PLAN:  ,Recommended discharge.  No restrictions in diet or activity.  He was continued Omnicef 125 mg/5 mL one teaspoon p.o. once daily and instructed to follow up with Dr. X, his primary doctor, on the following Tuesday.  Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy.
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DESCRIPTION: Fever, otitis media, and possible sepsis.

ent - otolaryngology, sepsis, cough, nasal congestion, rhinorrhea, oxygen saturations, otitis media, otitis, breathing, lungs, oropharynx, fever

The situation involves a 10-month-old child admitted to the hospital with fever, otitis media, and possible sepsis, which are potentially serious conditions in such a young patient. The child required oxygen support and was treated with antibiotics, indicating a significant health concern. However, the child improved and was discharged with a plan for continued care and follow-up. This makes the situation not extremely high-stakes, but still critical due to the initial concern for possible sepsis and the age of the patient.


Medical Specialty: Radiology
Sample Name: Ultrasound - Lower Extremity - 1

EXAM:  ,Ultrasound left lower extremity, duplex venous,REASON FOR EXAM: , Swelling and rule out DVT.,FINDINGS: , Duplex and color Doppler interrogation of the left lower extremity deep venous system was performed. Compressibility, augmentation, and color flow as well as Doppler flow was demonstrated within the common femoral vein, superficial femoral vein, and popliteal vein. The posterior tibial vein also demonstrated flow along its proximal visualized extent.,IMPRESSION: , No evidence of left lower extremity deep venous thrombosis.
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DESCRIPTION: Ultrasound left lower extremity, duplex venous, due to swelling and to rule out DVT.  Duplex and color Doppler interrogation of the left lower extremity deep venous system was performed.

radiology, color doppler, superficial femoral vein, popliteal vein, common femoral vein, deep venous, lower extremity, ultrasound, doppler, duplex, vein, venous

The situation involves a medical exam to rule out deep vein thrombosis (DVT), which is a serious condition since DVT can lead to life-threatening complications like pulmonary embolism if not detected and treated promptly. However, the findings indicate no evidence of DVT, reducing the immediate stakes. Nonetheless, diagnosing DVT is critical and not receiving a proper examination could lead to serious health risks.


Medical Specialty: Hematology - Oncology
Sample Name: Excision of Squamous Cell Carcinoma

PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,NAME OF OPERATION: , Re-excision of squamous cell carcinoma site, right hand.,ANESTHESIA:,  Local with monitored anesthesia care.,INDICATIONS:,  Patient, 72,  status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb.  The deep margin was positive.  Other margins were clear.  He was brought back for re-excision.,PROCEDURE:,  The patient was brought to the operating room and placed in the supine position.  He was given intravenous sedation.  The right hand was prepped and draped in the usual sterile fashion.  Three cubic centimeters of 1% Xylocaine mixed 50/50 with 0.5% Marcaine with epinephrine was instilled with local anesthetic around the site of the excision, and the site of the cancer was re-excised with an elliptical incision down to the extensor tendon sheath.  The tissue was passed off the field as a specimen.,The wound was irrigated with warm normal saline.  Hemostasis was assured with the electrocautery.  The wound was closed with running 3-0 nylon without complication.  The patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied.
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DESCRIPTION: Re-excision of squamous cell carcinoma site, right hand.

hematology - oncology, monitored anesthesia care, elliptical incision, squamous cell carcinoma site, squamous cell carcinoma, squamous cell, excision, squamous, carcinoma

The procedure involves a re-excision of squamous cell carcinoma, which is a serious but usually manageable form of cancer. Although squamous cell carcinoma can spread if not fully excised, the stakes are somewhat minimized in this situation because the patient is returning for what appears to be a routine follow-up surgical procedure to ensure complete removal. The patient tolerated the procedure well, suggesting it was successful and not highly complicated, although any cancer-related surgery inherently carries some level of risk. The stakes are more moderate, as it is not immediately life-threatening, but still important due to the potential for cancer spread if not fully excised.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Mammoplasty - 1

PREOPERATIVE DIAGNOSIS,Bilateral macromastia.,POSTOPERATIVE DIAGNOSIS,Bilateral macromastia.,OPERATION,Bilateral reduction mammoplasty.,ANESTHESIA,General.,FINDINGS,The patient had large ptotic breasts bilaterally and had had chronic difficulty with pain in the back and shoulder.  Right breast was slightly larger than the left this was repaired with a basic wise pattern reduction mammoplasty with anterior pedicle.,PROCEDURE,With the patient under satisfactory general endotracheal anesthesia, the entire chest was prepped and draped in usual sterile fashion.  A previously placed mark to identify the neo-nipple site was re-identified and carefully measured for asymmetry and appeared to be satisfactory.  A keyhole wire ring was then used to outline the basic wise pattern with 6-cm lamps inferiorly.  This was then carefully checked for symmetry and appeared to be satisfactory.  All marks were then completed and lightly incised on both breasts.  The right breast was approached first.  The neo-nipple site was de-epithelialized superiorly and then the inferior pedicle was de-epithelialized using cutting cautery.  After this had been completed, cutting cautery was used to carry down an incision along the inferior aspect of the periosteum starting immediately.  This was taken down to the prepectoral fashion dissected for short distance superiorly, and then blunt dissection was used to mobilize under the superior portion of the breast tissues to the lateral edge of the pectoral muscle.  There was very little bleeding with this procedure.  After this had been completed, attention was directed to the lateral side, and the inferior incision was made and taken down to the serratus.  Cautery dissection was then used to carry this up superiorly over the lateral edge of the pectoral muscle to communicate with the previous pocket.  After this had been completed, cutting cautery was used to cut around the inferior pedicle completely freeing the superior breast from the inferior breast.  Hemostasis was obtained with electrocautery.  After this had been completed, cutting cautery was used to cut along the superior edge of the redundant tissue and this was tapered under the superior flaps.  On the right side, there was a small palpable lobule, which had shown up on mammogram, but nothing except some fat density was identified.  This site had been previously marked carefully, and there were no unusual findings and the superior tissue was then sent out separately for pathology.  After this had been completed, final hemostasis obtained, and the wound was irrigated and a tagging suture placed to approximate the tissues.  The breast cleared and the nipple appeared good.,Attention was then directed to the left breast, which was completed in the similar manner.  After this had been completed, the patient was placed in a near upright position, and symmetry appeared good, but it was a bit poor on the lateral aspect of the right side, which was little larger and some suction lipectomy was carried out in this area.  After completion of this, 1860 grams had been removed from the right and 1505 grams was removed from the left.  Through separate stab wounds on the lateral aspect, 10-mm flat Blake drains were brought out and sutures were then placed **** and irrigated.  The wounds were then closed with interrupted 4-0 Monocryl on the deep dermis and running intradermal 4-0 Monocryl on the skin, packing sutures and staples were removed as they were approached.  The nipple was sutured with running intradermal 4-0 Monocryl.  Vascularity appeared good throughout.  After this had been completed, all wounds were cleaned and Steri-Stripped.  The patient tolerated the procedure well.  All counts were correct.  Estimated blood loss was less than 150 mL, and she was sent to recovery room in good condition.
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DESCRIPTION: Bilateral reduction mammoplasty for bilateral macromastia

cosmetic / plastic surgery, macromastia, estimated blood loss, monocryl, steri-stripped, dermis, inferior breast, mammoplasty, neo-nipple, prepped and draped, ptotic breasts, recovery room in good condition, reduction mammoplasty, superior breast, upright position, bilateral macromastia, incision, superiorly, breasts

The situation involves a surgical procedure, specifically a bilateral reduction mammoplasty, which is a standard cosmetic surgery for reducing breast size. This type of surgery, while generally routine for experienced surgeons, carries inherent risks such as bleeding, infection, and possible complications from anesthesia. However, the description indicates that the procedure was completed successfully with no immediate complications, and the patient was in stable condition post-operation. While any surgical procedure carries risk, this particular scenario does not involve life-threatening elements, complex complications, or urgent unforeseen issues that would elevate it to a high-stakes situation. Therefore, it is considered moderate in terms of stakes.


Medical Specialty: Urology
Sample Name: Prostate Brachytherapy

PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION,This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation.  The original consultation and treatment planning will be separately performed.  At the time of the implantation, special coordination will be required.  Stepping ultrasound will be performed and utilized in the pre-planning process.  Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process.  Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound.  Modifications will be made in real time to add or subtract needles and seeds as required.  This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.,The brachytherapy must be customized to fit the individual's tumor and prostate.  Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.
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DESCRIPTION: Prostate Brachytherapy - Prostate I-125 Implantation

urology, i-125 implantation, tumor, prostate, prostate brachytherapy, implantationNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Prostate brachytherapy is a specialized medical procedure involving the implantation of radioactive seeds directly into the prostate. This procedure requires precise coordination and planning, as well as intraoperative adjustments to ensure the accurate delivery of radiation while minimizing exposure to surrounding healthy tissues. The potential consequences of mistakes during this procedure could include ineffective treatment of the prostate cancer or radiation damage to the rectum and bladder, which are significant health risks. The need for specialized skills, coordination among medical professionals, and potential for serious complications if errors occur, make this a high-stakes medical situation.


Medical Specialty: Obstetrics / Gynecology
Sample Name: D&C, Laparoscopy, & Salpingectomy

PREOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Ectopic pregnancy.,3.  Hemoperitoneum.,PROCEDURES PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Right salpingectomy.,4.  Lysis of adhesions.,5.  Evacuation of hemoperitoneum.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Scant from the operation, however, there was approximately 2 liters of clotted and old blood in the abdomen.,SPECIMENS:,  Endometrial curettings and right fallopian tube.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small anteverted uterus, it is freely mobile.  No adnexal masses, however, were appreciated on the bimanual exam.  Laparoscopically, the patient had numerous omental adhesions to the vesicouterine peritoneum in the fundus of the uterus.  There were also adhesions to the left fallopian tube and the right fallopian tube.  There was a copious amount of blood in the abdomen approximately 2 liters of clotted and unclotted blood.  There was some questionable gestational tissue ________ on the left sacrospinous ligament.  There was an apparent rupture and bleeding ectopic pregnancy in the isthmus portion of the right fallopian tube.,PROCEDURE:,  After an informed consent was obtained, the patient was taken to the operating room and the general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  A weighted speculum was then placed in the vagina.  The interior wall of vagina elevated with the uterine sound and the anterior lip of the cervix was grasped with the vulsellum tenaculum.  The cervix was then serially dilated with Hank dilators to a size #20 Hank and then a sharp curettage was performed obtaining a moderate amount of decidual appearing tissue and the tissue was then sent to pathology.  At this point, the uterine manipulator was placed in the cervix and attached to the anterior cervix and vulsellum tenaculum and weighted speculum were removed.  Next, attention was then turned to the abdomen.  The surgeons all are removed the dirty gloves in the previous portion of the case.  Next, a 2 cm incision was made immediately inferior to umbilicus.  The superior aspect of the umbilicus was grasped with a towel clamp and a Veress needle was inserted through this incision.  Next, a syringe was used to inject normal saline into the Veress needle.  The normal saline was seen to drop freely, so a Veress needle was connected to the CO2 gas which was started at its lowest setting.  The gas was seen to flow freely with normal resistance, so the CO2 gas was advanced to a higher setting.  The abdomen was insufflated to an adequate distension.  Once an adequate distention was reached, the CO2 gas was disconnected.  The Veress needle was removed and a size #11 step trocar was placed.  The introducer was removed and the trocar was connected to the CO2 gas and a camera was inserted.  Next, a 1 cm incision was made in the midline approximately two fingerbreadths below the pubic symphysis after transilluminating with the camera.  A Veress needle and a step sheath were inserted through this incision.  Next, the Veress needle was removed and a size #5 trocar was inserted under direct visualization.  Next a size #5 port was placed approximately five fingerbreadths to the left of the umbilicus in a similar fashion.  A size #12 port was placed in a similar fashion approximately six fingerbreadths to the right of the umbilicus and also under direct visualization.  The laparoscopic dissector was inserted through the suprapubic port and this was used to dissect the omental adhesions bluntly from the vesicouterine peritoneum and the bilateral fallopian tubes.  Next, the Dorsey suction irrigator was used to copiously irrigate the abdomen.  Approximate total of 3 liters of irrigation was used and the majority of all blood clots and free blood was removed from the abdomen.,Once the majority of blood was cleaned from the abdomen, the ectopic pregnancy was easily identified and the end of the fallopian tube was grasped with the grasper from the left upper quadrant and the LigaSure device was then inserted through the right upper quadrant with # 12 port.  Three bites with the LigaSure device were used to transect the mesosalpinx inferior to the fallopian tube and then transect the fallopian tube proximal to the ectopic pregnancy.  An EndoCatch bag was then placed to the size #12 port and this was used to remove the right fallopian tube and ectopic pregnancy.  This was then sent to the pathology.  Next, the right mesosalpinx and remains of the fallopian tube were examined again and they were seemed to be hemostatic.  The abdomen was further irrigated.  The liver was examined and appeared to be within normal limits.  At this point, the two size #5 ports and a size #12 port were removed under direct visualization.  The camera was then removed.  The CO2 gas was disconnected and the abdomen was desufflated.  The introducer was then replaced in a size #11 port and the whole port and introducer was removed as a single unit.  All laparoscopic incisions were closed with a #4-0 undyed Vicryl in a subcuticular interrupted fashion.  They were then steri-stripped and bandaged appropriately.  At the end of the procedure, the uterine manipulator was removed from the cervix and the patient was taken to Recovery in stable condition.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She was discharged home with a postoperative hemoglobin of 8.9.  She was given iron 325 mg to be taken twice a day for five months and Darvocet-N 100 mg to be taken every four to six hours for pain.  She will follow up within a week in the OB resident clinic.
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DESCRIPTION: Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum.  Pelvic pain, ectopic pregnancy, and hemoperitoneum.

obstetrics / gynecology, pelvic pain, ectopic pregnancy, hemoperitoneum, d&c, dilation, laparoscopy, curettage, salpingectomy, lysis of adhesions, bimanual exam, veress needle, fallopian tube, umbilicus, cervix, ectopic, pregnancy, abdomen, tube,

The situation involves a complex surgical procedure addressing an ectopic pregnancy, pelvic pain, and hemoperitoneum. Ectopic pregnancies can be life-threatening if not treated promptly, as they involve the risk of internal bleeding. The procedure also involved significant blood loss, with approximately 2 liters of clotted blood in the abdomen, indicating a serious hemorrhagic event. Although the procedure was completed successfully and without complications, the stakes were high due to the potentially life-threatening nature of the ectopic pregnancy and internal bleeding.


Medical Specialty: Neurology
Sample Name: Cervical Spinal Stenosis

REASON FOR VISIT:  ,Followup cervical spinal stenosis.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC returns today for followup regarding her cervical spinal stenosis.  I have last seen her on 06/19/07.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident on 06/04/07, when she thought she had exacerbated her conditions while lifting several objects.,I referred her to obtain a cervical spine MRI.,She returns today stating that she continues to have right upper extremity pain, paresthesias, weakness, which she believes radiates from her neck.  She had some physical therapy, which has been helping with the neck pain.  The right hand weakness continues.  She states she has a difficult time opening jars, and doors, and often drops items from her right greater than left upper extremity.  She states she have several occasions when she is sleeping at night, she has had sharp shooting radicular pain and weakness down her left upper extremity and she feels that these symptoms somewhat scare her.,She has been undergoing nonoperative management by Dr. X and feels this has been helping her neck pain, but not the upper extremity symptoms.,She denies any bowel and bladder dysfunction.  No lower back pain, no lower extremity pain, and no instability with ambulation.,REVIEW OF SYSTEMS:,  Negative for fevers, chills, chest pain, and shortness of breath.,FINDINGS:  ,On examination, Ms. ABC is a very pleasant well-developed, well-nourished female in no apparent distress.  Alert and oriented x3.  Normocephalic and atraumatic.  Afebrile to touch.,She ambulates with a normal gait.,Motor strength is 4 plus out of 5 in the bilateral deltoids, biceps, triceps muscle groups, 4 out of 5 in the bilateral hand intrinsic muscle groups, grip strength 4 out of 5, 4 plus out of 5 bilateral wrist extension and wrist flexion.,Light touch sensation decreased in the right greater than left C6 distribution.  Biceps and brachioradialis reflexes are 3 plus.  Hoffman sign normal bilaterally.,Lower extremity strength is 5 out of 5 in all muscle groups.  Patellar reflex is 3 plus.  No clonus.,Cervical spine radiographs dated 06/21/07 are reviewed.,They demonstrate evidence of spondylosis including degenerative disk disease and anterior and posterior osteophyte formation at C4-5, C5-6, C6-7, and C3-4 demonstrates only minimal if any degenerative disk disease.  There is no significant instability seen on flexion-extension views.,Updated cervical spine MRI dated 06/21/07 is reviewed.,It demonstrates evidence of moderate stenosis at C4-5, C5-6.  These stenosis is in the bilateral neural foramina and there is also significant disk herniation noted at the C6-7 level.  Minimal degenerative disk disease is seen at the C6-7.  This stenosis is greater than C5-6 and the next level is more significantly involved at C4-5.,Effacement of the ventral and dorsal CSF space is seen at C4-5, C5-6.,ASSESSMENT AND PLAN: , Ms. ABC's history, physical examination, and radiographic findings are compatible with C4-5, C5-6 cervical spinal stenosis with associated right greater than left upper extremity radiculopathy including weakness.,I spent a significant amount of time today with the patient discussing the diagnosis, prognosis, natural history, nonoperative, and operative treatment options.,I laid out the options as continued nonoperative management with physical therapy, the same with the addition of cervical epidural steroid injections and surgical interventions.,The patient states she would like to avoid injections and is somewhat afraid of having these done.  I explained to her that they may help to improve her symptoms, although they may not help with the weakness.,She feels that she is failing maximum nonoperative management and would like to consider surgical intervention.,I described the procedure consisting of C4-5, C5-6 anterior cervical decompression and fusion to the patient in detail on a spine model.,I explained the rationale for doing so including the decompression of the spinal cord and improvement of her upper extremity weakness and pain.  She understands.,I discussed the risks, benefits, and alternative of the procedure including material risks of bleeding, infection, neurovascular injury, dural tear, singular or multiple muscle weakness, paralysis, hoarseness of voice, difficulty swallowing, pseudoarthrosis, adjacent segment disease, and the risk of this given the patient's relatively young age.  Of note, the patient does have a hoarse voice right now, given the fact that she feels she has allergies.,I also discussed the option of disk arthroplasty.  She understands.,She would like to proceed with the surgery, relatively soon.  She has her birthday coming up on 07/20/07 and would like to hold off, until after then.  Our tentative date for the surgery is 08/01/07.  She will go ahead and continue the preoperative testing process.
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DESCRIPTION: Followup cervical spinal stenosis.  Her symptoms of right greater than left upper extremity pain, weakness, paresthesias had been worsening after an incident when she thought she had exacerbated her conditions while lifting several objects.

The situation involves a patient with significant cervical spinal stenosis causing neurological symptoms, and she is considering spine surgery. The stakes are high because surgery is a major intervention with potential risks such as neurovascular injury, paralysis, and infection. The decision is crucial for her quality of life and long-term health. Given that this decision could impact her ability to function normally, it should be considered a high-stakes situation.


Medical Specialty: Emergency Room Reports
Sample Name: Dental Pain - Emergency Visit

CHIEF COMPLAINT: , Dental pain.,HISTORY OF PRESENT ILLNESS: , This is a 45-year-old Caucasian female who states that starting last night she has had very significant pain in her left lower jaw.  The patient states that she can feel an area with her tongue and one of her teeth that appears to be fractured.  The patient states that the pain in her left lower teeth kept her up last night.  The patient did go to Clinic but arrived there later than 7 a.m., so she was not able to be seen there will call line for dental care.  The patient states that the pain continues to be very severe at 9/10.  She states that this is like a throbbing heart beat in her left jaw.  The patient denies fevers or chills.  She denies purulent drainage from her gum line.  The patient does believe that there may be an area of pus accumulating in her gum line however.  The patient denies nausea or vomiting.  She denies recent dental trauma to her knowledge.,PAST MEDICAL HISTORY:,1.  Coronary artery disease.,2.  Hypertension.,3.  Hypothyroidism.,PAST SURGICAL HISTORY:  ,Coronary artery stent insertion.,SOCIAL HABITS: , The patient denies alcohol or illicit drug usage.  Currently she does have a history of tobacco abuse.,MEDICATIONS:,1.  Plavix.,2.  Metoprolol.,3.  Synthroid.,4.  Potassium chloride.,ALLERGIES:,1.  Penicillin.,2.  Sulfa.,PHYSICAL EXAMINATION:,GENERAL:  This is a Caucasian female who appears of stated age of 45 years.  She is well-nourished, well-developed, in no acute distress.  The patient is pleasant but does appear to be uncomfortable.,VITAL SIGNS:  Afebrile, blood pressure 145/91, pulse of 78, respiratory rate of 18, and pulse oximetry of 98% on room air.,HEENT:  Head is normocephalic.  Pupils are equal, round and reactive to light and accommodation.  Sclerae are anicteric and noninjected.  Nares are patent and free of mucoid discharge.  Mucous membranes are moist and free of exudate or lesion.  Bilateral tympanic membranes are visualized and free of infection or trauma.  Dentition shows significant decay throughout the dentition.  The patient has had extraction of teeth 17, 18, and 19.  The patient's tooth #20 does have a small fracture in the posterior section of the tooth and there does appear to be a very minor area of fluctuance and induration located at the alveolar margin at this site.  There is no pus draining from the socket of the tooth.  No other acute abnormality to the other dentition is visualized.,DIAGNOSTIC STUDIES: , None.,PROCEDURE NOTE:  ,The patient does receive an injection of 1.5 mL of 0.5% bupivacaine for inferior alveolar nerve block on the left mandibular teeth.  The patient undergoes this all procedure without complication and does report some mild decrease of her pain with this and patient was also given two Vicodin here in the Emergency Department and a dose of Keflex for treatment of her dental infection.,ASSESSMENT:  ,Dental pain with likely dental abscess.  ,PLAN: , The patient was given a prescription for Vicodin.  She is also given prescription for Keflex, as she is penicillin allergic.  She has tolerated a dose of Keflex here in the Emergency Department well without hypersensitivity.  The patient is strongly encouraged to follow up with Dental Clinic on Monday, and she states that she will do so.  The patient verbalizes understanding of treatment plan and was discharged in satisfactory condition from the ER.,
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DESCRIPTION: Significant pain in left lower jaw.

Significant pain in left lower jaw.

The case involves a patient with severe dental pain likely due to a dental abscess. While the patient is experiencing high levels of pain, there is no immediate life-threatening situation evident from the details provided, such as fever, significant vital sign instability, or systemic infection. The patient’s conditions such as coronary artery disease and hypertension are not immediately exacerbated by the dental issue based on the examination. Additionally, the patient has been provided with pain management and antibiotics and has been advised to follow up with a dental clinic. While the situation is uncomfortable, it is not life-threatening, hence it is of moderate stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Acute Cystitis & Diabetes Type II

HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old male complaining of abdominal pain.  The patient also has a long-standing history of diabetes which is treated with Micronase daily.,PAST MEDICAL HISTORY: , There is no significant past medical history noted today.,PHYSICAL EXAMINATION:,HEENT:  Patient denies ear abnormalities, nose abnormalities and throat abnormalities.,Cardio:  Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.,Resp:  Patient denies asthma, lung infections and lung lesions.,GI:  Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer disease.,GU:  Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney disorder.,Endocrine:  Patient has history of diabetes, but does not have hormonal irregularities and thyroid abnormalities.,Dermatology:  Patient denies allergic reactions, rashes and skin lesions.,MEDS:,  Micronase 2.5 mg Tab PO QAM #30.  Bactrim 400/80 Tab PO BID #30.,SOCIAL HISTORY:,  No known history of drug or alcohol abuse.  Work, diet, and exercise patterns are within normal limits.,FAMILY HISTORY:,  No significant family history.,REVIEW OF SYSTEMS:,  Non-contributory.,Vital Signs:  Height = 72 in.  Weight =184 lbs.  Upright BP = 120/80 mmHg.  Pulse = 80 bpm.  Resp =12 pm.  Patient is afebrile.,Neck:  The neck is supple.  There is no jugular venous distension.  The thyroid is nontender, or normal size and conto.,Lungs:  Lung expansion and excursions are symmetric.  The lungs are clear to auscultation and percussion.,Cardio:  There is a regular rhythm.  SI and S2 are normal.  No abnormal heart sounds are detected.  Blood pressure is equal bilaterally.,Abdomen:  Normal bowel sounds are present.  The abdomen is soft; The abdomen is nontender; without organomegaly; There is no CVA tenderness.  No hernias are noted.,Extremities:  There is no clubbing, cyanosis, or edema.,ASSESSMENT: , Diabetes type II uncontrolled.  Acute cystitis.,PLAN: , Endocrinology Consult, complete CBC.  ,RX: , Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.
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DESCRIPTION: The patient complaining of abdominal pain, has a long-standing history of diabetes treated with Micronase daily.

The patient in this scenario has type II diabetes, which is currently assessed as uncontrolled, and is experiencing acute cystitis. Both conditions require medical attention, but they are not life-threatening if managed properly. The plan includes consultation with endocrinology and a complete CBC, along with continued medication, which indicates an approach to stabilizing the patient's conditions. Uncontrolled diabetes can lead to more serious complications if left untreated, but there is no immediate life-threatening risk evident from the current situation described. Therefore, while it is important to address the issues, the situation is not extremely high-stakes at this moment.


Medical Specialty: Consult - History and Phy.
Sample Name: Cut on Foot - ER Visit

CHIEF COMPLAINT:,  Cut on foot.,HISTORY OF PRESENT ILLNESS:,  This is a 32-year-old male who had a piece of glass fall on to his right foot today.  The patient was concerned because of the amount of bleeding that occurred with it.  The bleeding has been stopped and the patient does not have any pain.  The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort.  The patient denies any injuries to any other portion of his body.  He has not had any recent illness.  The patient has no other problems or complaints.,PAST MEDICAL HISTORY:,  Asthma.,CURRENT MEDICATION: , Albuterol.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16.  Oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well-nourished, well-developed, the patient appears to be healthy.  The patient is calm and comfortable in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear conjunctiva and cornea bilaterally.  NECK:  Supple with full range of motion.  CARDIOVASCULAR:  Peripheral pulse is +2 to the right foot.  Capillary refills less than two seconds to all the digits of the right foot.  RESPIRATIONS:  No shortness of breath.  MUSCULOSKELETAL:  The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot.  There is no palpable foreign body, no foreign body is visualized.  There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels.  It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home.  The patient does not have any tenderness to the foot.  The patient has full range of motion to all the joints, all the toes, as well as the ankles.  The patient ambulates well without any difficulty or discomfort.  There are no other injuries noted to the rest of the body.  SKIN:  The 4-mm partial thickness laceration to the right foot as previously described.  No other injuries are noted.  NEUROLOGIC:  Motor is 5/5 to all the muscle groups of the right lower extremity.  Sensory is intact to light touch to all the dermatomes of the right foot.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No active bleeding is occurring at this time.  No evidence of bruising is noted to the body.,EMERGENCY DEPARTMENT COURSE:,  The patient had antibiotic ointment and a bandage applied to his foot.,DIAGNOSES:,1.  A 4-MM LACERATION TO THE RIGHT FOOT.,2.  ACUTE RIGHT FOOT PAIN, NOW RESOLVED.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  To home.  The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection.  The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on.
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DESCRIPTION: Patient had a piece of glass fall on to his right foot.  A 4-mm laceration.  Acute foot pain, now resolved.   The patient was given discharge instructions on wound care.

consult - history and phy., foot pain, cut on foot, piece of glass, foreign body, active bleeding, foot, injuries, atraumatic, laceration, bleeding, body,

The situation described involves a relatively minor injury (4-mm laceration caused by a piece of glass), which has been treated and resolved. The patient is stable, with no active bleeding, intact foot function, and no significant complications identified in the examination. Despite potential concerns like retained glass or infection risk, the overall condition is managed with discharge and follow-up instructions, indicating low immediate medical risk.


Medical Specialty: Ophthalmology
Sample Name: Rectus Recession

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

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

Rectus recession is a routine surgical procedure in ophthalmology used to correct certain forms of strabismus, such as esotropia. The details provided indicate no complications or adverse events occurred during the procedure, and the patient was in good condition postoperatively. Despite being a surgical intervention, this procedure is relatively low-risk with a high success rate in correcting the condition. Additionally, the patient will be followed up in one week, indicating standard postoperative care. Therefore, while all surgical interventions carry some risk, this specific case is not high-stakes.


Medical Specialty: Surgery
Sample Name: Trigger Finger Release

PROCEDURE: , Trigger finger release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made over the digit's A1 pulley.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease.  Meticulous hemostasis was maintained with bipolar electrocautery.,The tendons were identified and atraumatically pulled to ensure that no triggering remained.  The patient then actively moved the digit, and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.
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DESCRIPTION: Trigger finger release.  A longitudinal incision was made over the digit's A1 pulley.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease.

surgery, a1 pulley, neurovascular bundles, trigger finger release, proximal digital, digital crease, trigger finger, trigger, finger, sheath, incision

Trigger finger release surgery involves precision and carries risks such as infection, nerve damage, or excessive bleeding, typical of surgical procedures. However, it is a localized and relatively standard procedure without systemic impact if complications arise. While there are serious considerations in any surgical procedure, in the grand scale of surgical operations, it is not extremely high-stakes compared to life-threatening surgeries like cardiac or brain procedures.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Non-Hodgkin lymphoma Followup

CHIEF COMPLAINT:,  Follicular non-Hodgkin's lymphoma.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 69 year-old gentleman, who I follow for his follicular lymphoma.  His history is that in February of 1988 he had a biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma.  From 03/29/88 to 08/02/88, he received six cycles of CHOP chemotherapy.  In 1990, his CT scan showed retroperitoneal lymphadenopathy.  Therefore from 04/02/90 to 08/20/90, he received seven cycles of CVP.  In 1999, he was treated with m-BACOD.  He also received radiation to his pelvis.  On 03/21/01, he had a right cervical lymph node biopsy, which again showed follicular lymphoma.  His most recent PET scan dated 12/31/08 showed resolution of previously described hypermetabolic lymph nodes in the right lower neck.,Overall, he is doing well.  He has a good energy level, his ECOG performance status is 0.  He denies any fever, chills or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Avelox 400 mg q.d. p.r.n., cefuroxime 200 mg q.d. to be altered monthly with doxycycline 100 mg q.d., Coumadin 5 mg on Monday and 2.5 mg on all other days, dicyclomine 10 mg q.d., Coreg 6.25 mg b.i.d., Vasotec 2.5 mg b.i.d., Zantac 150 mg q.d., Claritin D q.d., Centrum q.d., calcium q.d., omega-3 b.i.d., Metamucil q.d., and Lasix 40 mg t.i.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:  ,As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He has chronic lymphedema of the bilateral lower extremities secondary to his pelvic radiation.,2.  He had bilateral ureteral obstruction and is status post a stent placement.  The obstruction was secondary to his pelvic radiation.,3.  History of congestive heart failure.,4.  History of schwannoma resection.  It was resected from T12 to L1 in 1991.,5.  He has chronic obstruction of his inferior vena cava.,6.  Recurrent lower extremity cellulitis.,SOCIAL HISTORY:  ,He has no tobacco use.  No alcohol use.  He is married.  He is a retired Methodist minister.,FAMILY HISTORY: , His mother just died two days ago.  There is no history of solid tumors or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:
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DESCRIPTION: Follicular non-Hodgkin's lymphoma.  Biopsy of a left posterior auricular lymph node and pathology showed follicular non-Hodgkin's lymphoma.  Received six cycles of CHOP chemotherapy.

This follow-up note details the medical history and current state of a patient with follicular non-Hodgkin's lymphoma, a type of cancer. While cancer treatment is serious, the patient's condition appears stable at this time, with no new symptoms and a good performance status (ECOG status 0). The stakes can become high if the condition worsens, but currently, it's a routine follow-up without acute issues, suggesting moderate stakes.


Medical Specialty: Hematology - Oncology
Sample Name: Sickle Cell Anemia - ER Visit

HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia.  He comes to the emergency room on his own with 3-day history of back pain.  He is on no medicines.  He does live with a room mate.  Appetite is decreased.  No diarrhea, vomiting.  Voiding well.  Bowels have been regular.  Denies any abdominal pain.  Complains of a slight headaches, but his main concern is back ache that extends from above the lower T-spine to the lumbosacral spine.  The patient is not sure of his immunizations.  The patient does have sickle cell and hemoglobin is followed in the Hematology Clinic.,ALLERGIES: , THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.,MEDICATIONS: , He was previously on folic acid.  None at the present time.,PAST SURGICAL HISTORY: , He has had no surgeries in the past.,FAMILY HISTORY: , Positive for diabetes, hypertension and cancer.,SOCIAL HISTORY: , He denies any smoking or drug usage.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute,  respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.,GENERAL:  He is alert, speaks in full sentences, he does not appear to be in distress.,HEENT:  Normal.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular.,ABDOMEN:  Soft.  He has pain over the mid to lower spine.,SKIN:  Color is normal.,EXTREMITIES:  He moves all extremities well.,NEUROLOGIC:  Age appropriate.,ER COURSE: , It was indicated to the patient that I will be drawing labs and giving him IV fluids.  Also that he will get morphine and Benadryl combination.  The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour.  CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4.  Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect.  The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m.  He received morphine 5 mg and Benadryl 25 mg.  I subsequently spoke to Dr. X and it was decided to admit the patient.,The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning.  He stated that he has a job interview in the morning.  The resident service did come to evaluate him.  The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration.  He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.,IMPRESSION:  ,Sickle cell crisis.,DIFFERENTIAL DIAGNOSIS: , Veno-occlusive crisis, and diskitis.
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DESCRIPTION: A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.

The situation involves a patient with sickle cell anemia experiencing a sickle cell crisis, marked by substantial back pain and possibly requiring acute medical intervention, including pain control and IV hydration. Sickle cell crisis can lead to significant complications if not managed properly, highlighting the medical team's need for careful observation and treatment. While the patient wishes to attend a job interview, his health condition necessitates hospitalization and medical supervision, which increases the stakes due to the potential for escalated health risks and the impact on his daily life.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Cardiac Consultation - 7

HISTORY OF PRESENT ILLNESS: , The patient is a 41-year-old African-American male previously well known to me.  He has a previous history of aortic valve disease, status post aortic valve replacement on 10/15/2007, for which he has been on chronic anticoagulation.  There is a previous history of paroxysmal atrial fibrillation and congestive heart failure, both of which have been stable prior to this admission.  He has a previous history of transient ischemic attack with no residual neurologic deficits.,The patient has undergone surgery by Dr. X for attempted nephrolithotomy.  The patient has experienced significant postoperative bleeding, for which it has been necessary to discontinue all anticoagulation.  The patient is presently seen at the request of Dr. X for management of anticoagulation and his above heart disease.,PAST MEDICAL AND SURGICAL HISTORY:,1.  Type I diabetes mellitus.,2.  Hyperlipidemia.,3.  Hypertension.,4.  Morbid obesity.,5.  Sleep apnea syndrome.,6.  Status post thyroidectomy for thyroid carcinoma.,REVIEW OF SYSTEMS:,General:  Unremarkable.,Cardiopulmonary:  No chest pain, shortness of breath, palpitations, or dizziness.,Gastrointestinal:  Unremarkable.,Genitourinary:  See above.,Musculoskeletal:  Unremarkable.,Neurologic:  Unremarkable.,FAMILY HISTORY: , There are no family members with coronary artery disease.  His mother has congestive heart failure.,SOCIAL HISTORY:  ,The patient is married.  He lives with his wife.  He is employed as a barber.  He does not use alcohol, tobacco, or illicit drugs.,MEDICATIONS PRIOR TO ADMISSION:,1.  Clonidine 0.3 mg b.i.d.,2.  Atenolol 50 mg daily.,3.  Simvastatin 80 mg daily.,4.  Furosemide 40 mg daily.,5.  Metformin 1000 mg b.i.d.,6.  Hydralazine 25 mg t.i.d.,7.  Diovan 320 mg daily.,8.  Lisinopril 40 mg daily.,9.  Amlodipine 10 mg daily.,10.  Lantus insulin 50 units q.p.m.,11.  KCl 20 mEq daily.,12.  NovoLog sliding scale insulin coverage.,13.  Warfarin 7.5 mg daily.,14.  Levothyroxine 0.2 mg daily.,15.  Folic acid 1 mg daily.,ALLERGIES: , None.,PHYSICAL EXAMINATION:,General:  A well-appearing, obese black male.,Vital Signs:  BP 140/80, HR 88, respirations 16, and afebrile.,HEENT:  Grossly normal.,Neck:  Normal.  Thyroid, normal.  Carotid, normal upstroke, no bruits.,Chest:  Midline sternotomy scar.,Lungs:  Clear.,Heart:  PMI fifth intercostal space mid clavicular line.  Normal S1 and prosthetic S2.  No murmur, rub, gallop, or click.,Abdomen:  Soft and nontender.  No palpable mass or hepatosplenomegaly.
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DESCRIPTION: The patient has a previous history of aortic valve disease, status post aortic valve replacement, a previous history of paroxysmal atrial fibrillation, congestive heart failure, a previous history of transient ischemic attack with no residual neurologic deficits.

The situation involves a patient with a complex medical history including aortic valve replacement, atrial fibrillation, congestive heart failure, and previous transient ischemic attack. The patient is experiencing significant postoperative bleeding, which required discontinuation of chronic anticoagulation. Managing anticoagulation properly is crucial to prevent potentially life-threatening complications such as strokes or clot formation due to his heart condition and atrial fibrillation. Additionally, the patient's multiple comorbidities including diabetes, hypertension, and obesity further complicate his care. This scenario involves careful coordination and adjustments to his medication regimen, which are high-stakes decisions given the potential for serious complications.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy - 4

PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS:  ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1.  C5-C6 anterior cervical discectomy.,2.  Bone bank allograft.,3.  Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain.  He had multiple levels of disease, but clinically, it was C6 radiculopathy.  We tested him in the office and he had weakness referable to that nerve.  The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed.  General endotracheal anesthesia was obtained.  He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner.  An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes.  We patiently drilled through them to the posterior ligament.  We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side.  The C6 foramen was narrowed by uncovertebral joint overgrowth.  The foramen was open widely.,An allograft was placed.  An anterior Steffee plate was placed.  Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin.  A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination.
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DESCRIPTION: C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate.   Left cervical radiculopathy.

surgery, cervical radiculopathy, anterior cervical discectomy, bank allograft, cervical discectomy, anterior, cervical, foramen, discectomy, allograft, radiculopathy,

The narrative describes a surgical procedure involving an anterior cervical discectomy for a patient with left cervical radiculopathy. Surgery, especially involving the spine, is generally considered high-stakes due to the complexity of the procedure and the potential for serious short and long-term complications or outcomes, like nerve damage or infection. The stakes are heightened by the fact that the intervention could significantly alleviate the patient's pain and improve quality of life if successful, or conversely, could lead to complications if errors occur.


Medical Specialty: Radiology
Sample Name: HCT - Calcification of Basal Ganglia

CC:, Memory loss.,HX:, This 77 y/o RHF presented with a one year history of progressive memory loss. Two weeks prior to her evaluation at UIHC she agreed to have her sister pick her up for church at 8:15AM, Sunday morning. That Sunday she went to pick up her sister at her sister's home and when her sister was not there (because the sister had gone to pick up the patient) the patient left. She later called the sister and asked her if she (sister) had overslept. During her UIHC evaluation she denied she knew anything about the incident. No other complaints were brought forth by the patients family.,PMH:, Unremarkable.,MEDS:, None,FHX: ,Father died of an MI, Mother had DM type II.,SHX: , Denies ETOH/illicit drug/Tobacco use.,ROS:, Unremarkable.,EXAM:, Afebrile, 80BPM, BP 158/98, 16RPM. Alert and oriented to person, place, time. Euthymic. 29/30 on Folstein's MMSE with deficit on drawing. Recalled 2/6 objects at five minutes and could not recite a list of 6 objects in 6 trials. Digit span was five forward and three backward. CN: mild right lower facial droop only. MOTOR: Full strength throughout. SENSORY: No deficits to PP/Vib/Prop/LT/Temp. COORD: Poor RAM in LUE only. GAIT: NB and ambulated without difficulty. STATION: No drift or Romberg sign. REFLEXES: 3+ bilaterally with flexor plantar responses. There were no frontal release signs.,LABS:, CMB, General Screen, FT4, TSH, VDRL were all WNL.,NEUROPSYCHOLOGICAL EVALUATION, 12/7/92: ,Verbal associative fluency was defective. Verbal memory, including acquisition, and delayed recall and recognition, was severely impaired. Visual memory, including immediate and delayed recall was also severely impaired. Visuoperceptual discrimination was mildly impaired, as was 2-D constructional praxis.,HCT, 12/7/92: , Diffuse cerebral atrophy with associative mild enlargement of the ventricles consistent with patient's age. Calcification is seen in both globus pallidi and this was felt to be a normal variant.
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DESCRIPTION: HCT for memory loss and for calcification of basal ganglia (globus pallidi).

radiology, memory loss, romberg sign, hct, cerebral atrophy, calcification of basal ganglia, basal ganglia, globus pallidi, basal, ganglia, globus, pallidi, calcification,

The described scenario involves a 77-year-old patient experiencing progressive memory loss and showing neurological signs of cognitive decline, with a history of atypical behavior and impaired neuropsychological testing results. The CT scan reveals diffuse cerebral atrophy and calcifications in the globus pallidi, a finding that the note attributes to be a normal variant. However, given that the patient is 77, these symptoms and findings could be indicative of a neurodegenerative condition, such as dementia. In this context, the situation is significant for the patient as it impacts her health, safety, and requires a comprehensive evaluation and management plan. However, the calcifications themselves are noted as a normal variant, slightly reducing the immediate severity or emergency level of the situation.


Medical Specialty: Emergency Room Reports
Sample Name: Accidental Celesta Ingestion - ER Visit

HISTORY OF PRESENT ILLNESS:,  Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.  Mom called to the poison control center and the recommendation was to take the patient to the emergency room and be evaluated.  The patient was alert and did not vomit during the transport to the emergency room.  Mom left the patient and his little one-year-old brother in the room by themselves and she went outside of the house for a couple of minutes, and when came back, she saw the patient having the Celesta foils in his hands and half of tablet was moist and on the floor.  The patient said that the pills "didn't taste good," so it is presumed that the patient actually ingested at least two-and-a-half tablets of Celesta, 40 mg per tablet.,PAST MEDICAL HISTORY:,  Baby was born premature and he required hospitalization, but was not on mechanical ventilation.  He doesn't have any hospitalizations after the new born.  No surgeries.,IMMUNIZATIONS: , Up-to-date.,ALLERGIES: , NOT KNOWN DRUG ALLERGIES.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature 36.2 Celsius, pulse 112, respirations 24, blood pressure 104/67, weight 15 kilograms.,GENERAL:  Alert, in no acute distress.,SKIN:  No rashes.,HEENT:  Head:  Normocephalic, atraumatic.  Eyes:  EOMI, PERRL.  Nasal mucosa clear.  Throat and tonsils, normal.  No erythema, no exudates.,NECK:  Supple, no lymphadenopathy, no masses.,LUNGS:  Clear to auscultation bilateral.,HEART:  Regular rhythm and rate without murmur.  Normal S1, S2.,ABDOMEN:  Soft, nondistended, nontender, present bowel sounds, no hepatosplenomegaly, no masses.,EXTREMITIES:  Warm.  Capillary refill brisk.  Deep tendon reflexes present bilaterally.,NEUROLOGICAL:  Alert.  Cranial nerves II through XII intact.  No focal exam.  Normal gait.,RADIOGRAPHIC DATA: , Patient has had an EKG done at the admission and it was within normal limits for the age.,EMERGENCY ROOM COURSE: , Patient was under observation for 6 hours in the emergency room.  He had two more EKGs during observation in the emergency room and they were all normal.  His vital signs were monitored every hour and were within normal limits.  There was no vomiting, no diarrhea during observation.  Patient did not receive any medication or has had any other lab work besides the EKG.,ASSESSMENT AND PLAN: , Three years old male with accidental ingestion of Celesta.  Discharged home with parents, with a followup in the morning with his primary care physician.
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DESCRIPTION: Patient is a three years old male who about 45 minutes prior admission to the emergency room ingested about two to three tablets of Celesta 40 mg per tablets.

emergency room reports, accidental ingestion of celesta, celesta, tablets, ingestion,

The situation involves a young child accidentally ingesting medication, which poses a potential poisoning risk, especially since the child reportedly took 80 to 120 mg of the medication. However, the child was observed in the ER for 6 hours without developing symptoms or abnormal findings, suggesting that the situation was under control and not life-threatening. Despite the potential seriousness, the quick response and lack of symptoms during observation lower the stakes in this specific instance.


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

ADMITTING DIAGNOSIS: , Intractable migraine with aura.,DISCHARGE DIAGNOSIS:,  Migraine with aura.,SECONDARY DIAGNOSES:,1.  Bipolar disorder.,2.  Iron deficiency anemia.,3.  Anxiety disorder.,4.  History of tubal ligation.,PROCEDURES DURING THIS HOSPITALIZATION:,1.  CT of the head with and without contrast, which was negative.,2.  An MRA of the head and neck with and without contrast also negative.,3.  The CTA of the neck also read as negative.,4.  The patient also underwent a lumbar puncture in the Emergency Department, which was grossly unremarkable though an opening pressure was not obtained.,HOME MEDICATIONS:,1.  Vicodin 5/500 p.r.n.,2.  Celexa 40 mg daily.,3.  Phenergan 25 mg p.o. p.r.n.,4.  Abilify 10 mg p.o. daily.,5.  Klonopin 0.5 mg p.o. b.i.d.,6.  Tramadol 30 mg p.r.n.,7.  Ranitidine 150 mg p.o. b.i.d.,ALLERGIES:,  SULFA drugs.,HISTORY OF PRESENT ILLNESS: , The patient is a 25-year-old right-handed Caucasian female who presented to the emergency department with sudden onset of headache occurring at approximately 11 a.m. on the morning of the July 31, 2008.  She described the headache as worse in her life and it was also accompanied by blurry vision and scotoma.  The patient also perceived some swelling in her face.  Once in the Emergency Department, the patient underwent a very thorough evaluation and examination.  She was given the migraine cocktail.  Also was given morphine a total of 8 mg while in the Emergency Department.  For full details on the history of present illness, please see the previous history and physical.,BRIEF SUMMARY OF HOSPITAL COURSE:  ,The patient was admitted to the neurological service after her headache felt to be removed with the headache cocktail.  The patient was brought up to 4 or more early in the a.m. on the August 1, 2008 and was given the dihydroergotamine IV, which did allow some minimal resolution in her headache immediately.  At the time of examination this morning, the patient was feeling better and desired going home.  She states the headache had for the most part resolved though she continues to have some diffuse trigger point pain.,PHYSICAL EXAMINATION AT THE TIME OF DISCHARGE: , General physical exam was unremarkable.  HEENT:  Pupils were equal and respond to light and accommodation bilaterally.  Extraocular movements were intact.  Visual fields were intact to confrontation.  Funduscopic exam revealed no disc pallor or edema.  Retinal vasculature appeared normal.  Face is symmetric.  Facial sensation and strength are intact.  Auditory acuities were grossly normal.  Palate and uvula elevated symmetrically.  Sternocleidomastoid and trapezius muscles are full strength bilaterally.  Tongue protrudes in midline.  Mental status exam: revealed the patient alert and oriented x 4.  Speech was clear and language is normal.  Fund of knowledge, memory, and attention are grossly intact.  Neurologic exam:  Vasomotor system revealed full power throughout.  Normal muscle tone and bulk.  No pronator drift was appreciated.  Coordination was intact to finger-to-nose, heel-to-shin and rapid alternating movement.  No tremor or dysmetria.  Excellent sensory.  Sensation is intact in all modalities throughout. The patient does have notable trigger points diffusely including the occiput, trapezius bilaterally, lumbar, back, and sacrum.  Gait was assessed, the patient's routine and tandem gait were normal.  The patient is able to balance on heels and toes.  Romberg is negative.  Reflexes are 2+ and symmetric throughout.  Babinski reflexes are plantar.,DISPOSITION:,  The patient is discharged home.,INSTRUCTIONS FOR FOLLOWUP:  ,The patient is to followup with her primary care physician as needed.
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DESCRIPTION: Intractable migraine with aura.  The patient is discharged home.  Secondary diagnoses are Bipolar disorder, iron deficiency anemia, anxiety disorder, and history of tubal ligation.

The discharge summary indicates a resolved medical issue, with the migraine being effectively managed during the hospital stay. The patient was discharged in stable condition with instructions for follow-up as needed, primarily for ongoing management of existing conditions like bipolar disorder and anxiety. The absence of critical conditions or immediate health risks signifies that the situation is not high-stakes. However, the presence of multiple chronic conditions does require attention, just not urgent in this context.


Medical Specialty: Surgery
Sample Name: Laparoscopy - 3

PREOPERATIVE DIAGNOSIS: , Chronic pelvic pain, probably secondary to endometriosis.,POSTOPERATIVE DIAGNOSIS:,  Mild pelvic endometriosis.,PROCEDURE:,1.  Attempted laparoscopy.,2.  Open laparoscopy.,3.  Fulguration of endometrial implant.,ANESTHESIA: , General endotracheal.,BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS:  ,The patient is a 21-year-old single female with chronic recurrent pelvic pain unresponsive to both estrogen and progesterone-containing birth control pills, either cyclically or daily as well as progestational medication only, who had a negative GI workup recently including colonoscopy, and desired definitive operative evaluation and diagnosis prior to initiation of a 6-month course of Depo-Lupron.,PROCEDURE: , After an adequate plane of general anesthesia had been obtained, the patient was placed in a dorsal lithotomy position.  She was prepped and draped in the usual sterile fashion for pelviolabdominal surgery.  Bimanual examination revealed a mid position normal-sized uterus with benign adnexal area.,In the high lithotomy position, a weighted speculum was placed into the posterior vaginal wall.  The anterior lip of the cervix was grasped with a single-tooth tenaculum.  A Hulka tenaculum was placed transcervically.  The other instruments were removed.  A Foley catheter was placed transurethrally to drain the bladder intraoperatively.,In the low lithotomy position and in steep Trendelenburg, attention was turned to the infraumbilical region.  Here, a stab wound incision was made through which the 120 mm Veress needle was placed and approximately 3 L of carbon dioxide used to create a pneumoperitoneum.  The needle was removed, the incision minimally enlarged, and the #5 trocar and cannula were placed.  The trocar was removed and the scope placed confirming a preperitoneal insufflation.,The space was drained off the insufflated gas and 2 more attempts were made, which failed due to the patient's adiposity.  Attention was turned back to the vaginal area where in the high lithotomy position, attempts were made at a posterior vaginal apical insertion.  The Hulka tenaculum was removed, the posterior lip of the cervix grasped with a single-tooth tenaculum, and the long Allis clamp used to grasp the posterior fornix on which was placed traction.  The first short and subsequently 15 cm Veress needles were attempted to be placed, but after several passes, no good pneumoperitoneum could be established via this route also.  It was elected not to do a transcervical intentional uterine perforation, but to return to the umbilical area.  The 15 cm Veress needle was inserted several times, but again a pneumo was preperitoneal.,Finally, an open laparoscopic approach was undertaken.  The skin incision was expanded with a knife blade.  Blunt dissection was used to carry the dissection down to the fascia.  This was grasped with Kocher clamps, entered sharply and opened transversely.  Four 0 Vicryl sutures were placed as stay sutures and tagged with hemostats and needles were cutoff.  Dissection continued between the rectus muscle and finally the anterior peritoneum was reached, grasped, elevated, and entered.,At this juncture, the Hasson cannula was placed and tied snugly with the above stay sutures while the pneumoperitoneum was being created, a #10 scope was placed confirming the intraperitoneal positioning.,Under direct visualization, a suprapubic 5 mm cannula and manipulative probe were placed.  Clockwise inspection of the pelvis revealed a benign vesicouterine pouch, normal uterus and fundus, normal right tube and ovary.  In the cul-de-sac, there were 3 clusters of 3 to 5 carbon charred type endometrial implants and those more distally in the greatest depth had created puckering and tenting.  The left tube and ovary were normal.  There were no adhesions.  There was no evidence of acute pelvic inflammatory disease.,The Endoshears and subsequently cautery on a hook were placed and the implants fulgurated.  Pictures were taken for confirmation both before and after the burn.,The carbon chars were irrigated and aspirated.  The smoke plume was removed without difficulty.  Approximately 50 mL of irrigant was left in the pelvis.  Due to the difficulty in placing and maintaining the Hasson cannula, no attempts were made to view the upper abdominal quadrant, specifically the liver and gallbladder.,The suprapubic cannula was removed under direct visualization, the pneumo released, the scope removed, the stay sutures cut, and the Hasson cannula removed.  The residual sutures were then tied together to completely occlude the fascial opening so that there will be no future hernia at this site.  Finally, the skin incisions were approximated with 3-0 Dexon subcuticularly.  They had been preincisionally injected with bupivacaine to which the patient said she had no known allergies.  The vaginal instruments were removed.  All counts were correct.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.
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DESCRIPTION: Attempted laparoscopy, open laparoscopy and fulguration of endometrial implant.   Chronic pelvic pain, probably secondary to endometriosis.

surgery, endometriosis, fulguration, endometrial, single tooth tenaculum, endometrial implant, hulka tenaculum, veress needle, hasson cannula, pneumoperitoneum, laparoscopy, cannula,

The situation involves a surgical procedure with multiple complex steps, including laparoscopy and the treatment of endometrial implants. Surgery always carries inherent risks such as injury, infection, or complications with anesthesia, even though this particular case notes minimal blood loss and no complications. The procedure description indicates challenges were faced, particularly with the placement of the instruments due to the patient's adiposity, requiring an open laparoscopic approach. These factors elevate the stakes to a moderate level. However, the patient was stable post-procedure without complications, which moderates the stakes. Therefore, it is not extremely high-stakes but remains moderate given the complexities involved.


Medical Specialty: General Medicine
Sample Name: Detox from Heroin

CHIEF COMPLAINT:,  Detox from heroin.,HISTORY OF PRESENT ILLNESS: , This is a 52-year-old gentleman with a long history of heroin abuse, who keeps relapsing, presents once again, trying to get off the heroin, last use shortly prior to arrival including cocaine.  The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.,PAST MEDICAL HISTORY: , Remarkable for chronic pain.  He has had multiple stab wounds, gunshot wounds, and a variety of other injuries that resulted him having chronic pain and he states that is what triggers of him getting on heroin to try to get out of pain.  He has previously been followed by ABC but has not seen him for several years.,REVIEW OF SYSTEMS:  ,The patient states that he did use heroin as well as cocaine earlier today and feels under the influence.  Denies any headache or visual complaints.  No hallucinations.  No chest pain, shortness of breath, abdominal pain or back pain.  Denies any abscesses.,SOCIAL HISTORY: , The patient is a smoker.  Admits to heroin use, alcohol abuse as well.  Also admits today using cocaine.,FAMILY HISTORY:,  Noncontributory.,MEDICATIONS: , He has previously been on analgesics and pain medications chronically.  Apparently, he just recently got out of prison.  He has previously also been on Klonopin and lithium.  He was previously on codeine for this pain.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient is afebrile.  He is markedly hypertensive, 175/104 and pulse 117 probably due to the cocaine onboard.  His respiratory rate is normal at 18.  GENERAL:  The patient is a little jittery but lucid, alert, and oriented to person, place, time, and situation.  HEENT:  Unremarkable.  Pupils are actually moderately dilated about 4 to 5 mm, but reactive.  Extraoculars are intact.  His oropharynx is clear.  NECK:  Supple.  His trachea is midline.  LUNGS:  Clear.  He has good breath sounds and no wheezing.  No rales or rhonchi.  Good air movement and no cough.  CARDIAC:  Without murmur.  ABDOMEN:  Soft and nontender.  He has multiple track marks, multiple tattoos, but no abscesses.  NEUROLOGIC:  Nonfocal.,IMPRESSION: , MEDICAL EXAMINATION FOR THE PATIENT WHO WILL BE DETOXING FROM HEROIN.,ASSESSMENT AND PLAN:  ,At this time, I think the patient can be followed up at XYZ.  I have written a prescription of clonidine and Phenergan for symptomatic relief and this has been faxed to the pharmacy.  I do not think he needs any further workup at this time.  He is discharged otherwise in stable condition.
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DESCRIPTION: A gentleman with a long history of heroin abuse, trying to get off the heroin, last use shortly prior to arrival including cocaine.  The patient does have a history of alcohol abuse, but mostly he is concerned about the heroin abuse.

general medicine, phenergan, detox from heroin, alcohol abuse, heroin abuse, detox, heroin, alcohol, cocaine, abuse,

The situation involves a 52-year-old patient with a long history of heroin and other substance abuse presenting to detox from heroin. His recent use included both heroin and cocaine, which puts him at high risk of health complications during withdrawal. Additionally, he has chronic pain and a history of severe injuries, further complicating detox efforts. While he is stable enough to be discharged with a plan for follow-up, the potential risks of withdrawal and relapse, coupled with his history of chronic pain and substance abuse, indicate a high-stakes medical situation. Managing this requires careful medical oversight to prevent potential life-threatening withdrawal symptoms and to offer a pathway to recovery.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy & Polypectomy - 2

PREPROCEDURE DIAGNOSIS: , Colon cancer screening.,POSTPROCEDURE DIAGNOSIS:  ,Colon polyps, diverticulosis, hemorrhoids.,PROCEDURE PERFORMED: , Colonoscopy, conscious sedation, and snare polypectomy.  ,INDICATIONS:  ,The patient is a 63-year-old male who has myelodysplastic syndrome, who was referred for colonoscopy.  He has had previous colonoscopy.  There is no family history of bleeding, no current problems with his bowels.  On examination, he has internal hemorrhoids.  His prostate is enlarged and increased somewhat in firmness.  He has scattered diverticular disease of a moderate degree and he has two polyps, one 1 cm in the mid ascending colon, and one in the left transverse colon, which is also 1 cm.  These were removed with snare polypectomy technique.  I would recommend that the patient have an increased fiber diet and repeat colonoscopy in 5 years or sooner if he develops bowel habit change or bleeding.,PROCEDURE: , After explaining the operative procedure, the risks and potential complications of bleeding and perforation, the patient was given 175 mcg fentanyl, and 8 mg Versed intravenously for conscious sedation.  Blood pressure 115/60, pulse 98, respiration 18, and saturation 92%.  A rectal examination was done and then the colonoscope was inserted through the anorectum, rectosigmoid, descending, transverse, and ascending colon, to the ileocecal valve.  The scope was withdrawn to the mid ascending colon, where the polyp was encircled with a snare and removed with a mixture of cutting and coagulating current, then retrieved through the suction port.  The scope was withdrawn into the left transverse colon, where the second polyp was identified.  It was encircled with a snare and removed with a mixture of cutting and coagulating current, and then removed through the suction port as well.  The scope was then gradually withdrawn the remaining distance and removed.  The patient tolerated the procedure well.
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DESCRIPTION: Colonoscopy, conscious sedation, and snare polypectomy.

gastroenterology, colon polyps, diverticulosis, hemorrhoids, cutting and coagulating, transverse colon, snare polypectomy, ascending colon, colonoscopy, polyps, bowels, coagulating, sedation, scope, ascending, snare, polypectomy,

The procedure described is a routine colonoscopy and snare polypectomy for screening purposes, primarily to remove discovered polyps and to check for colon cancer, diverticulosis, and hemorrhoids. While important for the patient's health, especially considering the patient's age and medical history, such as myelodysplastic syndrome, it is a relatively standard and low-risk procedure in a controlled medical environment with the patient having tolerated the procedure well. The importance of early detection in cancer screening makes this significant, but given no complications arose, and it was performed as a precautionary screening, the situation is not extremely high-stakes.