Medical Specialty: Obstetrics / Gynecology
Sample Name: Delivery Note - 3

DELIVERY NOTE: , On 12/23/08 at 0235 hours, a 23-year-old G1, P0, white female, GBS negative, under epidural anesthesia, delivered a viable female infant with Apgar scores of 7 and 9.  Points taken of for muscle tone and skin color.  Weight and length are unknown at this time.  Delivery was via spontaneous vaginal delivery.  Nuchal cord x1 were tight and reduced.  Infant was DeLee suctioned at perineum.  Cord clamped and cut and infant handed to the awaiting nurse in attendance.  Cord blood sent for analysis, intact.  Meconium stained placenta with three-vessel cord was delivered spontaneously at 0243 hours.  A 15 units of Pitocin was started after delivery of the placenta.  Uterus, cervix, and vagina were explored and a mediolateral episiotomy was repaired with a 3-0 Vicryl in a normal fashion.  Estimated blood loss was approximately 400 mL.  The patient was taken to the recovery room in stable condition.  Infant was taken to Newborn Nursery in stable condition.  The patient tolerated the procedure well.  The only intrapartum event that occurred was thick meconium.  Otherwise, there were no other complications.  The patient tolerated the procedure well.
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DESCRIPTION: Delivery was via spontaneous vaginal delivery.  Nuchal cord x1 were tight and reduced.  Infant was DeLee suctioned at perineum.

obstetrics / gynecology, nuchal cord, spontaneous, nuchal, delee, delivered, meconium, placenta, vaginal, perineum, delivery, infantNOTE,: 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.,

This delivery note describes a childbirth procedure, an inherently high-stakes situation as it involves the health and safety of both the mother and baby. Key aspects include a nuchal cord and meconium-stained placenta, which could complicate delivery. While there were no significant complications beyond thick meconium, these factors necessitate careful monitoring to prevent potential adverse outcomes. The description overall indicates a successful delivery since both mother and infant are stable, but the potential risks involved in childbirth make this a high-stakes situation.


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

Medical Specialty: Surgery
Sample Name: Mandible Fractures Closed Reduction

HISTORY OF PRESENT ILLNESS: , The patient is a 22-year-old male who sustained a mandible fracture and was seen in the emergency department at Hospital.  He was seen in my office today and scheduled for surgery today for closed reduction of the mandible fractures.,PREOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,POSTOPERATIVE DIAGNOSES: , Left angle and right body mandible fractures.,PROCEDURE: , Closed reduction of mandible fractures with Erich arch bars and elastic fixation.,ANESTHESIA:,  General nasotracheal.,COMPLICATIONS:,  None.,CONDITION:,  Stable to PACU.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed on the table in a supine position and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, the patient was prepped and draped in the usual fashion for placement of arch bars.  Gauze throat pack was placed and upper and lower arch bars were placed on the maxillary and mandibular dentition with a 25-gauge circumdental wires.  After the placement of the arch bars, the occlusion was checked and found to be satisfactory and stable.  The throat pack was then removed.  An NG tube was then passed and approximately 50 cc of stomach contents were suctioned out.,The elastic fixation was then placed on the arch bars holding the patient in maxillomandibular fixation and at this point, the procedure was terminated and the patient was then awakened, extubated, and taken to the PACU in stable condition.
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DESCRIPTION: Closed reduction of mandible fractures with Erich arch bars and elastic fixation.  Left angle and right body mandible fractures.

surgery, closed reduction of mandible fractures, erich arch bars, elastic fixation, throat pack, arch bars, arch, erich, mandible, fractures

The situation involves a surgical procedure for mandible fractures, which is a serious but relatively routine operation in oral and maxillofacial surgery. The surgery went as planned without complications, and the patient's condition is stable post-operation. While surgery always carries risks, the absence of complications and a stable outcome indicate that this is a moderate-stakes situation. However, because surgery is involved and it's crucial for the patient's recovery, it is not considered low-stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Exploratory Laparotomy - 1

PREOPERATIVE DIAGNOSIS:,  History of perforated sigmoid diverticuli with Hartmann's procedure.,POSTOPERATIVE DIAGNOSES:  ,1.  History of perforated sigmoid diverticuli with Hartmann's procedure.,2.  Massive adhesions.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Lysis of adhesions and removal.,3.  Reversal of Hartmann's colostomy.,4.  Flexible sigmoidoscopy.,5.  Cystoscopy with left ureteral stent.,ANESTHESIA: , General.,HISTORY: , This is a 55-year-old gentleman who had a previous perforated diverticula.  Recommendation for reversal of the colostomy was made after more than six months from the previous surgery for a sigmoid colon resection and Hartmann's colostomy.,PROCEDURE:  ,The patient was taken to the operating room placed into lithotomy position after being prepped and draped in the usual sterile fashion.  A cystoscope was introduced into the patient's urethra and to the bladder.  Immediately, no evidence of cystitis was seen and the scope was introduced superiorly, measuring the bladder and immediately a #5 French ____ was introduced within the left urethra.  The cystoscope was removed, a Foley was placed, and wide connection was placed attaching the left ureteral stent and Foley.  At this point, immediately the patient was re-prepped and draped and immediately after the ostomy was closed with a #2-0 Vicryl suture, immediately at this point, the abdominal wall was opened with a #10 blade Bard-Parker down with electrocautery for complete hemostasis through the midline.,The incision scar was cephalad due to the severe adhesions in the midline.  Once the abdomen was entered in the epigastric area, then massive lysis of adhesions was performed to separate the small bowel from the anterior abdominal wall.  Once the small bowel was completely free from the anterior abdominal wall, at this point, the ostomy was taken down with an elliptical incision with cautery and then meticulous dissection with Metzenbaum scissors and electrocautery down to the anterior abdominal wall, where a meticulous dissection was carried with Metzenbaum scissors to separate the entire ostomy from the abdominal wall.  Immediately at this point, the bowel was dropped within the abdominal cavity, and more lysis of adhesions was performed cleaning the left gutter area to mobilize the colon further down to have no tension in the anastomosis.  At this point, the rectal stump, where two previous sutures with Prolene were seen, were brought with hemostats.  The rectal stump was free in a 360 degree fashion and immediately at this point, a decision to perform the anastomosis was made.  First, a self-retaining retractor was introduced in the abdominal cavity and a bladder blade was introduced as well.  Blue towel was placed above the small bowel retracting the bowel to cephalad and at this point, immediately the rectal stump was well visualized, no evidence of bleeding was seen, and the towels were placed along the edges of the abdominal wound.  Immediately, the pursestring device was fired approximately 1 inch from the skin and on the descending colon, this was fired.  The remainder of the excess tissue was closed with Metzenbaum scissors and immediately after dilating #25 and #29 mushroom tip from the T8 Ethicon was placed within the colon and then #9-0 suture was tied.  Immediately from the anus, the dilator #25 and #29 was introduced dilating the rectum.  The #29 EEA was introduced all the way anteriorly to the staple line and this spike from the EEA was used to perforate the rectum and then the mushroom from the descending colon was attached to it.  The EEA was then fired.  Once it was fired and was removed, the pelvis was filled with fluid.  Immediately both doughnuts were ____ from the anastomosis.  A Doyen was placed in both the anastomosis.  Colonoscope was introduced.  No bubble or air was seen coming from the anastomosis.  There was no evidence of bleeding.  Pictures of the anastomosis were taken.  The scope then was removed from the patient's rectum.  Copious amount of irrigation was used within the peritoneal cavity.  Immediately at this point, all complete sponge and instrument count was performed.  First, the ostomy site was closed with interrupted figure-of-eight #0 Vicryl suture.  The peritoneum was closed with running #2-0 Vicryl suture.  Then, the midline incision was closed with a loop PDS in cephalad to caudad and caudad to cephalad tight in the middle.  Subq tissue was copiously irrigated and the staples on the skin.,The iodoform packing was placed within the old ostomy site and then the staples on the skin as well.  The patient did tolerate the procedure well and will be followed during the hospitalization.  The left ureteral stent was removed at the end of the procedure.  _____ were performed.  Lysis of adhesions were performed.  Reversal of colostomy and EEA anastomosis #29 Ethicon.
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DESCRIPTION: Exploratory laparotomy, lysis of adhesions and removal, reversal of Hartmann's colostomy, flexible sigmoidoscopy, and cystoscopy with left ureteral stent.

surgery, reversal of hartmann's colostomy, flexible sigmoidoscopy, cystoscopy, ureteral stent, lysis of adhesions, exploratory laparotomy, hartmann's colostomy, abdominal wall, immediately, adhesions, colostomy, sigmoidoscopy, bowel, anastomosis, abdominal

The situation involves a complex surgical procedure with multiple steps and potential complications, such as exploratory laparotomy, lysis of adhesions, and reversal of Hartmann's colostomy. These procedures are high-risk due to the potential for significant bleeding, infection, or injury to other organs. The outcome can significantly impact the patient's quality of life and recovery, hence making it high-stakes.


Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy with Biopsies -2

PREOPERATIVE DIAGNOSIS: , Refractory dyspepsia.,POSTOPERATIVE DIAGNOSIS:,1.  Hiatal hernia.,2.  Reflux esophagitis.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with pseudo and esophageal biopsy.,ANESTHESIA:,  Conscious sedation with Demerol and Versed.,SPECIMEN: , Esophageal biopsy.,COMPLICATIONS: , None.,HISTORY:,  The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.  She has been on multiple medical regimens and continues with dyspeptic symptoms.,PROCEDURE: , After proper informed consent was obtained, the patient was brought to the endoscopy suite.  She was placed in the left lateral position and was given IV Demerol and Versed for sedation.  When adequate level of sedation achieved, the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated.  At the GE junction, a hiatal hernia was present.  There were mild inflammatory changes consistent with reflux esophagitis.  The scope was then passed into the stomach.  It was insufflated and the scope was coursed along the greater curvature to the antrum.  The pylorus was patent.  There was evidence of bile reflux in the antrum.  The duodenal bulb and sweep were examined and were without evidence of mass, ulceration, or inflammation.  The scope was then brought back into the antrum.,A retroflexion was attempted multiple times, however, the patient was having difficulty holding the air and adequate retroflexion view was not visualized.  The gastroscope was then slowly withdrawn.  There were no other abnormalities noted in the fundus or body.  Once again at the GE junction, esophageal biopsy was taken.  The scope was then completely withdrawn.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.  She will return to the General Medical Floor.  We will continue b.i.d proton-pump inhibitor therapy as well as dietary restrictions.  She should also attempt significant weight loss.
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DESCRIPTION: Esophagogastroduodenoscopy with pseudo and esophageal biopsy.  Hiatal hernia and reflux esophagitis. The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.

surgery, refractory dyspepsia, hiatal hernia, reflux esophagitis, esophagogastroduodenoscopy, esophageal, pseudo, esophageal biopsy, ge junction, hiatal, hernia, esophagitis, antrum, gerd,

The situation involves a surgical procedure with potential implications for ongoing health management, such as esophagogastroduodenoscopy with biopsies due to refractory dyspepsia and confirmed diagnoses of hiatal hernia and reflux esophagitis. While the procedure itself was performed without complications and the patient was stable, the underlying condition and the patient's demographic (morbid obesity contributing to GERD symptoms) present significant health risks if not managed properly. Further complications from inadequate management of GERD could lead to more severe esophageal conditions. Thus, while the immediate procedure was low-stakes, the ongoing management of the patient's condition has higher stakes due to the potential long-term health consequences.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Mantle Cell Lymphoma

PRINCIPAL DIAGNOSES:,1.  A 61-year-old white male with a diagnosis of mantle cell lymphoma, diagnosed in 2001, status post autologous transplant with BEAM regimen in 04/02 followed by relapse.,2.  Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.,3.  Graft versus host disease involving GI tracts, skin, and liver presently off immunosuppression.,4.  Diabetes.,5.  Bipolar disorder.,6.  Chronic muscle aches.,7.  Chronic lower extremity edema.,8.  ECOG performance status 1.,INTERIM HISTORY: , The patient comes to the clinic today for followup.  I am seeing him once every 4 to 8 weeks.  He is off of all immunosuppression.  He does have mild chronic GVHD but not enough to warrant any therapy and the disease has been under control and he is 4-1/2-years posttransplant.,He has multiple complaints.  He has had hematochezia.  I referred him to gastroenterology.  They did an upper and lower endoscopy.  No evidence of ulcers or any abnormality was found.  Some polyps were removed.  They were benign.  He may have mild iron deficiency, but he is fatigued and has several complaints related to his level of activity.,CURRENT MEDICATIONS:,1.  Paxil 40 mg once daily.,2.  Cozaar.,3.  Xanax 1 mg four times a day.,4.  Prozac 20 mg a day.,5.  Lasix 40 mg a day.,6.  Potassium 10 mEq a day.,7.  Mirapex two tablets every night.,8.  Allegra 60 mg twice a day.,9.  Avandamet 4/1000 mg daily.,10.  Nexium 20 mg a day.,11.  NovoLog 25/50.,REVIEW OF SYSTEMS:,  Fatigue, occasional rectal bleeding, and obesity.  Other systems were reviewed and were found to be unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Today revealed that temperature 35.8, blood pressure 120/49, pulse 85, and respirations 18.  HEENT:  Oral cavity, no mucositis.  NECK:  No nodes.  AXILLA:  No nodes.  LUNGS:  Clear.  CARDIAC:  Regular rate and rhythm without murmurs.  ABDOMEN:  No palpable masses.  Morbid obesity.  EXTREMITIES:  Mild lower extremity edema.  SKIN:  Mild dryness.  CNS:  Grossly intact.,LABORATORY DATA:,  White count 4.4, hemoglobin 10.1, platelet count 132,000, sodium 135, potassium 3.9, chloride 105, bicarbonate 24, BUN 15, and creatinine 0.9.  Normal alkaline phosphatase 203, AST 58, and ALT 31.,ASSESSMENT AND PLAN:,1.  The patient with mantle cell lymphoma who is 4-1/2 years post allotransplant.  He is without evidence of disease at the present time.  Since he is 4-1/2 years posttransplant, I do not plan to scan him or obtain chimerisms unless there is reason to.,2.  He is slightly anemic, may be iron deficient.  He has had recurrent rectal bleeding.  I told him to take multivitamin with iron and see how that helps the anemia.,3.  Regarding the hematochezia, he had an endoscopy.  I reviewed the results from the previous endoscopy.  It appears that he has polyps, but there is no evidence of graft versus host disease.,4.  Regarding the fatigue, I just reassured him that he should increase his activity level, but I am not sure how realistic that is going to be.,5.  He is followed for his diabetes by his internist.,6.  If he should have any fever or anything suggestive of infection, I advised him to call me.  I will see him back in about 2 months from now.
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DESCRIPTION: A 61-year-old white male with a diagnosis of mantle cell lymphoma status post autologous transplant with BEAM regimen followed by relapse.  Allogeneic peripheral stem cell transplant from match-related brother and the patient is 53 months out from transplant.

The main situation involves a patient with a history of mantle cell lymphoma and multiple other health conditions, including a complex history of stem cell transplant and chronic management issues like GVHD, diabetes, and bipolar disorder. His conditions, particularly the hematological, post-transplant, and ongoing management of GVHD, suggest that significant medical decisions and follow-ups are needed, which carry potential life-impacting consequences. However, the patient is currently stable, without active evidence of disease, suggesting that the immediate stakes aren't extremely high. Nevertheless, given the complexity of the medical background and the potential risk to the patient's health if any issues were to arise, this represents a moderately high-stakes situation.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Neurologic Examination

NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented.  There is no evidence of cognitive or language dysfunction.  Cranial nerves:  Visual fields are full.  Funduscopic examination is normal.  Extraocular movements full.  Pupils equal, round,  react to light.  There is no evidence of nystagmus noted.  Fifth nerve function is normal.  There is no facial asymmetry noted.  Lower cranial nerves are normal.  ,Manual motor testing reveals good tone and bulk throughout.  There is no evidence of pronator drift or decreased fine finger movements.  Muscle strength is 5/5 throughout.  Deep tendon reflexes are 2+ throughout with downgoing toes.  Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk.  Finger-to-nose and heel-to-shin moves are normal.  Romberg sign negative.  I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.
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DESCRIPTION: Neurologic examination sample.

Neurologic examination sample.

soap / chart / progress notes, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE

The situation described involves a neurological examination which is routine for assessing the basic neurological function of a patient. The findings indicate that the patient currently has normal neurological functioning with no acute issues observed in the examination or CT scan. Although neurological examinations can be crucial in diagnosing serious conditions, this specific case shows no signs of abnormalities and does not suggest a high-risk scenario. Thus, it appears to be low-stakes in this context.


Medical Specialty: Sleep Medicine
Sample Name: Sleep Difficulties

CLINICAL HISTORY: , This is a 16-year-old man evaluated for sleep difficulties.  He states he is "feeling bad in the mornings" that he has daytime somnolence and "whenever I wake up I experience dizziness, weakness, stomachache, loss of appetite, drowsiness, overall sore body and a general feeling of unwell."  He does state that he has only rarely he got anything suggestive of restless leg syndrome, is unaware of any apnea or like symptoms.  He has a mouth breather.  He states he wakens up during the night, usually goes to bed at 10 to 11, gets up at 7 to 7:30.  In the weekends, he stays up late and sleeps until 1 in the afternoon.  He lists sporadic use of melatonin and Benadryl, and Tylenol PM for sleep.  His other medicines are Accutane, Nasonex and oxymetazoline.  There is no smoking, no alcohol intake.  He does have three caffeinated beverages a week.  He is 75 inches, 185 pounds, BMI 23.1.  He rated himself 4/7 on the Stanford Sleepiness Scale at the onset of the study and 6 on the Epworth Sleeping Scale, said that his night sleep in the lab was characterized by a longer than usual sleep onset latency with more arousals than usual.  He woke up feeling equally rested and the only comment he made on the post sleep questionnaire was "some of the wires" is the source of problems.,TECHNIQUE: , The study was performed with the following parameters measured throughout the entirety of the recording:,Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.,The record was scored for sleep and the various other parameters in 30-second epochs.,RESULTS: , This study was performed in 61 minutes in duration during which he slept 432 minutes after 19 minutes sleep onset latency; thereafter, he had 10 awakenings for 6 minutes of wakefulness giving him a normal sleep efficiency of 95%.  Sleep staging was actually fairly deep and normal for age with 5% stage I, 51% stage II, 22% slow wave sleep and 22% REM.  He had 5 REM periods during the night.  The first beginning 66 minutes after sleep onset.  He did have 63 arousals, giving him a borderline elevated arousal index of 8.8, 16 were driven by limb movements, 41 of unclear origin, 6 from hypopneas.,EEG PARAMETERS: , No abnormalities.,EKG PARAMETERS: , Normal sinus rhythm, mean rate 76, no ectopics noted.,EMG PARAMETERS: , 88 PLMs were noted.  There was fairly small excursion with a movement index of 12, only 16 led to arousals with a movement arousal index of 2.2, not considered as a significant feature for sleep fragmentation.,RESPIRATORY PARAMETERS:,  Breathing rate in the high teens, reaching as high as 20 in REM.  There was really no snoring noted.  He slept in all positions and during the night had 9 respiratory events, one was a postarousal central event, the other eight were obstructive hypopneas mean duration 26 seconds, little worse in the supine position where his AHI was 4.7, but overall his AHI was 1.3.  This is only a marginal abnormality and is well below the threshold for CPAP intervention.,IMPRESSION:,  Largely normal polysomnogram demonstrating very modest obstructive sleep apnea in the supine position and a very modest periodic limb movement disturbance.
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DESCRIPTION: Electroencephalogram, electromyogram of the chin and lower extremities, electrooculogram, electrocardiogram, air flow from the nose and mouth, respiratory effort at the chest and abdomen, and finger oximetry.

sleep medicine, sleep, sleep difficulties, mouth breather, epworth sleeping scale, stanford sleepiness scale, sleep onset latency, arousals, electroencephalogram, electromyogram, electrooculogram, electrocardiogram, polysomnogram, sleep apnea, periodic limb movement, hypopneas, accutane,

The situation involves a 16-year-old experiencing sleep difficulties and undergoing a sleep study. The findings show largely normal polysomnogram results with very modest obstructive sleep apnea and periodic limb movement disturbance, neither of which are severe. The patient reports feeling unwell and experiencing various symptoms upon waking, but there are no immediate life-threatening conditions identified. While addressing sleep disturbances can significantly impact quality of life, this case does not appear to indicate acutely high-risk health concerns that require immediate intervention.


Medical Specialty: Surgery
Sample Name: Hydrocelectomy

PREOPERATIVE DIAGNOSIS:,  Bilateral hydroceles.,POSTOPERATIVE DIAGNOSIS:,  Bilateral hydroceles.,PROCEDURE: , Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,FLUIDS RECEIVED: , 800 mL.,TUBES AND DRAINS: , A 0.25-inch Penrose drains x4.,INDICATIONS FOR OPERATION:  ,The patient is a 17-year-old boy, who has had fairly large hydroceles noted for some time.  Finally, he has decided to have them get repaired.  Plan is for surgical repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then shaved, prepped, and then sterilely prepped and draped.  IV antibiotics were given.  Ancef 1 g given.  A scrotal incision was then made in the right hemiscrotum with a 15-blade knife and further extended with electrocautery.  Electrocautery was used for hemostasis.  Once we got to the hydrocele sac itself, we then opened and delivered the testis, drained clear fluid.  There was moderate amount of scarring on the testis itself from the tunica vaginalis.  It was then wrapped around the back and sutured in place with a running suture of 4-0 chromic in a Lord maneuver.  Once this was done, a drain was placed in the base of the scrotum and then the testis was placed back into the scrotum in the proper orientation.  A similar procedure was performed on the left, which has also had a hydrocele of the cord, which were both addressed and closed with Lord maneuver similarly.  This testis also was normal but had moderate amount of scarring on the tunic vaginalis from this.  A similar drain was placed.  The testes were then placed back into the scrotum in a proper orientation, and the local wound instillation and wound block was then placed using 30 mL of 0.5% Marcaine without epinephrine.  IV Toradol was given at the end of the procedure.  The skin was then sutured with a running interlocking suture of 3-0 Vicryl and the drains were sutured to place with 3-0 Vicryl.  Bacitracin dressing, ABD dressing, and jock strap were placed.  The patient was in stable condition upon transfer to the recovery room.
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DESCRIPTION: Bilateral scrotal hydrocelectomies, large for both, and 0.5% Marcaine wound instillation, 30 mL given.

surgery, bilateral scrotal hydrocelectomies, bilateral hydroceles, lord maneuver, hydrocelectomy, hydroceles,

The procedure described is a hydrocelectomy for a 17-year-old patient with bilateral hydroceles. While this is a surgical procedure and every surgery carries some degree of risk, hydrocelectomy is generally considered a routine, elective surgery with a low complication rate. The estimated blood loss was minimal, and the procedure was described with no complications. The patient was stable post-operation, indicating a low-risk outcome. However, since it is a surgery on a young patient, it does have some significance and requires precision and care.


Medical Specialty: Letters
Sample Name: Anaplastic Astrocytoma - Letter

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

letters, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma

The situation involves critical decision-making for a patient with anaplastic astrocytoma, a type of brain tumor that is aggressive and usually requires prompt and appropriate treatment to manage progression and improve survival chances. The patient is struggling with choosing between treatment options and facing deterioration in condition, which necessitates urgent clinical decisions. The stakes are high due to the severe implications of disease advancement and potential impact of treatment on quality of life and survival. The patient's reluctance and symptoms indicate urgency and complexity, adding to the stakes involved.


Medical Specialty: Endocrinology
Sample Name: Total Thyroidectomy

PREOPERATIVE DIAGNOSIS:  ,Thyroid goiter with substernal extension on the left.,POSTOPERATIVE DIAGNOSIS:,  Thyroid goiter with substernal extension on the left.,PROCEDURE PERFORMED:,  Total thyroidectomy with removal of substernal extension on the left.,THIRD ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Approximately 200 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:,  The patient is a 54-year-old Caucasian male with a history of an enlarged thyroid gland who presented to the office initially with complaints of dysphagia and some difficulty in breathing while lying supine.  The patient subsequently then had a CT scan which demonstrated a very large thyroid gland, especially on the left side with substernal extension down to the level of the aortic arch.  The patient was then immediately set up for surgery.  After risks, complications, consequences, and questions were addressed with the patient, a written consent was obtained.,PROCEDURE:,  The patient was brought to the operative suite by Anesthesia and placed on the operative table in the supine position.  The patient was then placed under general endotracheal intubation anesthesia and the patient then had a shoulder roll placed.  After this, the patient then had the area marked initially.  The preoperative setting was then localized with 1% lidocaine and epinephrine 1:100,000 approximately 10 cc total.  After this, the patient was then prepped and draped in the usual sterile fashion.  A #15 Bard-Parker was then utilized to make a skin incision horizontally, approximately 5 cm on either side from midline.  After this, a blunt dissection was then utilized to dissect the subcutaneous fat from the platysmal muscle.  There appeared to be a natural dehiscence of the platysma in the midline.  A sub-platysmal dissection was then performed in the superior, inferior, and lateral directions with the help of a bear claw, Metzenbaum scissors and DeBakey forceps.  Any bleeding was controlled with monopolar cauterization.  After this, the two anterior large jugular veins were noted and resected laterally.  The patient's trachea appeared to be slightly deviated to the right with identification finally of the midline raphe, off midline to the right.  This was grasped on either side with a DeBakey forceps and dissected with monopolar cauterization and dissected with a Metzenbaum scissors.  After this was dissected, the sternohyoid muscles were resected laterally and separated from the sternothyroid muscles.  The sternothyroid muscles were then bluntly freed and dissected from the right thyroid gland.  After this, attention was then drawn to the left gland, where the sternothyroid muscle was dissected bluntly on this side utilizing finger dissection and Kitners.  The left thyroid gland was freed initially superiorly and worked inferiorly and laterally until the gland was pulled from the substernal region by blunt dissection and reflected and pulled anteriorly.  After this, the superior and inferior parathyroid glands were noted.  The dissection was carried very close to the thyroid gland to try to select these parathyroids posteriorly.  After this, the superior pole was then identified and the superior laryngeal artery and vein were cross clamped and tied with __________ undyed Vicryl tie.  The superior pole was finally freed and a small little feeding branched vessels from this area were cauterized with the bipolar cautery and cut with Metzenbaum scissors.  After this, the thyroid gland was further freed down to the level of the Berry's ligament inferiorly and the dissection was carried once again more superiorly.  The fine stats were then utilized to dissect along the superior aspect of the recurrent laryngeal nerve on the left side with freeing of the connective Berry's ligament tissue from the gland with the bipolar cauterization and the fine stat.  Finally, attention was then drawn back to the patient's right side where the gland was rotated more anteriorly with fine dissection utilizing a fine stat to reflect the superior and inferior parathyroid glands laterally and posteriorly.  The recurrent laryngeal nerve on this side was identified and further dissection was carried superiorly and anteriorly through this nerve to finally free the right side of the gland to Berry's ligament.  The middle thyroid vein and inferior thyroid arteries were cross clamped and tied with #2-0 undyed Vicryl ties and also bipolared with the bipolar cauterization bilaterally.  The Berry's ligament was then finally freed and the gland was then passed to scrub tech and passed off the field to Pathology.  The neck was then thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization.  After this, Surgicel was then placed in the bilateral neck regions and a #10 Jackson-Pratt drain was then placed within the left neck region with some extension over to the right neck region.  This was brought out through the inferior skin incision and secured to the skin with a #2-0 nylon suture.  The strap muscles were then reapproximated with a running #3-0 Vicryl suture followed by reapproximation of the platysma and subcutaneous tissue with a #4-0 undyed Vicryl.  The skin was then reapproximated with a #5-0 Prolene subcuticular along with a #6-0 fast over the top.  After this, Mastisol Steri-Strips and Bacitracin along with a sterile dressing and a __________ dressing were then placed.  The patient intraoperatively did have approximately 50 cc of bloody drainage from this area within the JP drain.  The patient was then turned back to Anesthesia, extubated in the operating room and transferred to Recovery in stable condition.  The patient tolerated the procedure well and remained stable throughout.
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DESCRIPTION: Total thyroidectomy with removal of substernal extension on the left.  Thyroid goiter with substernal extension on the left.

endocrinology, thyroid goiter, goiter, thyroid, total thyroidectomy, berry's ligament, dissection, gland, thyroidectomy, anesthesia, berry's, ligament, cauterization, extension, substernal,

The case describes a surgical procedure, specifically a total thyroidectomy for a 54-year-old male with a thyroid goiter and substernal extension. Surgery inherently involves moderate to high stakes due to the risks of complications during and after the procedure, potential impacts on the patient's health, and the precision required to avoid damage to critical structures such as the recurrent laryngeal nerve. However, considering there were no complications noted and the patient had a stable outcome, the stakes are somewhat tempered. Moreover, the procedure appears to have been standard and routine for the condition described.


Medical Specialty: Surgery
Sample Name: Stab Wound Closure

PREPROCEDURE DIAGNOSIS:,  Stab wound, left posterolateral chest.,POST PROCEDURE DIAGNOSIS: , Stab wound, left posterolateral chest.,PROCEDURE PERFORMED: , Closure of stab wound.,ANESTHESIA: , 1% lidocaine with epinephrine by local infiltration.,NARRATIVE:  ,The wound was irrigated copiously with 500 mL of irrigation and closed in 1 layer with staples after locally anesthetizing with 1% lidocaine with epinephrine.  The patient tolerated the procedure well without apparent complications.
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DESCRIPTION: Stab wound, left posterolateral chest.   Closure of stab wound.

surgery, posterolateral chest, stab wound, lidocaine, epinephrine, infiltration, closure,

The procedure involves the closure of a stab wound, which is a serious medical condition potentially involving critical organs and structures. While the immediate steps described, such as local anesthesia and wound stapling, seem standard and were performed without complications, the context of a stab wound to the chest can still have high-stakes implications due to potential internal injuries and the risk of infection. Therefore, the situation while managed well in this case, is inherently high-stakes due to the nature of the injury.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal ROS Template - 3

HEENT:,  No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.,GASTROINTESTINAL:,  No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.,GENITOURINARY: , No dysuria, hematuria, frequency, incontinence or colic.,NERVOUS SYSTEM: , No gait problems, strokes, numbness or muscle weakness.,PSYCHIATRIC: , No history of emotional lability, depression or sleep disturbances.,ONCOLOGIC:,  No history of any cancer, change in moles or rashes.  No history of weight loss.  The patient has a good energy level.,ALLERGIC/LYMPH: , No history of systemic allergy, abnormal lymph nodes or swelling.,MUSCULOSKELETAL: , No fractures, motor weakness, arthritis or other joint pains.
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DESCRIPTION: Normal review of systems template.  No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.

consult - history and phy., review of systems, tinnitus, sinusitis, sore, mouth, hoarseness, goiter, heart, appetite, bowel, weakness, loss, swelling,

This interaction appears to be a routine consultation or review of systems for a patient with no notable complaints or medical history concerns. It is not associated with immediate medical decisions or emergencies, which are common indicators of high-stakes situations. The details provided are typical of a normal history intake process focusing on ensuring comprehensive documentation rather than addressing acute healthcare needs.


Medical Specialty: Surgery
Sample Name: Port-A-Cath Insertion - 1

PREOPERATIVE DIAGNOSES: ,1.  Bilateral breast carcinoma.,2.  Chemotherapy required.,POSTOPERATIVE DIAGNOSES:,1.  Bilateral breast carcinoma.,2.  Chemotherapy required.,OPERATION: , Right subclavian Port-a-Cath insertion.,FINDINGS AND PROCEDURE:  ,With the patient under satisfactory general orotracheal anesthesia and in the supine position, the right upper anterior chest, neck, and arm were prepared with Betadine in the usual fashion.  The skin, subcutaneous tissue, and fascia of the pectoralis major muscle medially beneath the inferior third of the right clavicle was infiltrated with 0.5% Marcaine with epinephrine.  An incision transverse, parallel, and inferior to the middle third of the right clavicle was performed.  A subcutaneous pocket on the surface of the pectoralis major muscle was created.  The muscular fascia was also infiltrated with 0.5% Marcaine with epinephrine.  With the patient in the Trendelenburg position, utilizing the provided introducer needle, the right subclavian vein was cannulated.  A guidewire was passed without difficulty and the needle was removed.  Fluoroscopy confirmed satisfactory position of the guidewire in the right atrium.  A dilator and sheath was passed over the guidewire.  The guidewire and dilator were removed and a provided catheter was inserted through the sheath and the sheath was carefully withdrawn.  Fluoroscopy again confirmed satisfactory position of the catheter and the catheter under fluoroscopic guidance was retracted into the superior vena cava.  The catheter had been preflushed with dilute heparin solution (100 units/mL).  The port, which had been preflushed with saline, was attached to the catheter at approximately 13 cm level.  The locking cap had been placed on the catheter.  The port was connected to the catheter and the locking cap was secured.  The port was again flushed with dilute heparin solution and placed within the subcutaneous pocket.  Fluoroscopy again confirmed satisfactory position.  A hard copy of the fluoroscopy was obtained.  The catheter and port were secured to the pectoralis fascia in four locations with 2-0 Prolene suture.  Site was irrigated with saline.  Hemostasis was verified.  The subcutaneous tissue was approximated with interrupted 2-0 Vicryl suture.  The subcutaneous and dermis were closed with a running subcuticular 3-0 Vicryl suture.  A 0.25-inch Steri-Strips were applied.  The provided needle and butterfly attachment was flushed with saline, passed through the skin into the port, and then flushed again with dilute heparin solution thus confirmed satisfactory.  The site was dressed with Tegaderm type dressing and the needle catheters were covered with 4x4's and paper tape.  Estimated blood loss was less than 15 mL.  The patient tolerated the procedure well and left the operating room in good condition.
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DESCRIPTION: Right subclavian Port-a-Cath insertion in a patient with bilateral breast carcinoma.

surgery, carcinoma, bilateral breast carcinoma, chemotherapy, fluoroscopy, port-a-cath, catheter, insertion, pectoralis fascia, subclavian, subclavian port a cath, port a cath insertion, port a cath, cath insertion, heparin,

The insertion of a Port-a-Cath is a critical procedure for a patient requiring chemotherapy due to bilateral breast carcinoma. The procedure involves accessing major veins and requires precision to avoid complications like bleeding, infection, or improper catheter positioning, which could be serious. However, it is a routine procedure with established protocols and low probability of critical failure when performed by trained surgeons. Despite the importance, it is not considered highly risky compared to other more complex surgical interventions. Given the information and the context, the stakes are moderate.


Medical Specialty: Orthopedic
Sample Name: Delayed ORIF

PREOPERATIVE DIAGNOSES:,1.  Right ankle trimalleolar fracture.,2.  Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,OPERATIVE PROCEDURE:  ,Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment, as well as medial malleolar fragment.,POSTOPERATIVE DIAGNOSES:,1.  Right ankle trimalleolar fracture.,2.  Right distal tibia plafond fracture with comminuted posterolateral impacted fragment.,TOURNIQUET TIME: , 80 minutes.,HISTORY: , This 50-year-old gentleman was from the area and riding his motorcycle in Kentucky.,The patient lost control of his motorcycle when he was traveling approximately 40 mile per hour.  He was on a curve and lost control.  He is unsure what exactly happened, but he thinks his right ankle was pinned underneath the motorcycle while he was sliding.  There were no other injuries.  He was treated in Kentucky.  A close reduction was performed and splint applied.  Orthopedic surgeon called myself with regards to this patient's fracture management and suggested a CT scan.  The patient returned to Ohio and his friend drove him all the way from Kentucky to Northwest Ohio overnight.  The patient showed up in the emergency department where a CT scan was asked to be performed.  This was performed and reviewed.  The patient, however, had significant amount of soft tissue swelling and therefore he was asked to follow up in 2 days.  At this time, he still had significant swelling, but because of the amount of swelling that he had particularly with the long car ride for many hours with his leg dependent, it was felt to be best to wait.,Indeed after 7 days, the patient started to develop fracture blisters on the posterior medial aspect of his ankle with large blisters measuring approximately 2 to 3 inches.  The patient was x-rayed in the office.  He had lost some of his reduction.  Therefore, he was re-reduced at approximately 7 days and then each time the patient had examination of tissues, he was re-reduced just to keep the pressure off the skin.,An x-ray showed the distal fibular fracture starting at the mortise region laterally.  It appeared as an abduction type injury with minimal rotation.  This was comminuted, fragmented, and impacted.,The medial malleolus fracture was an avulsion type.  The syndesmosis appeared to be intact.  This appeared as an AO type B fracture.  However, this was not a rotational injury.,There is a posterior malleolar fragment attached to the distal fibular fragment, which appeared to be avulsed as well, but comminuted.  CT scan revealed a more serious fracture with an anterior as well as posterior plafond fracture of an anterior fragment, which was undisplaced in the posterior medial corner.  A posterior Tillaux fragment appeared to be separate.  However, in this area, there was significant comminution in the mid portion of the ankle joint.,There were many fragments and defects in this region.,The medial mortise however appeared to be intact with regards to the tibial plafond even though there was an anterior undisplaced fragment.,We discussed delayed open reduction internal fixation with the patient.  He understood the risk of surgery including infection, decreased range of motion, stiffness, neurovascular injury, weakness, and numbness.  We discussed seriously the risk of osteoarthritis because of the comminution in the intraarticular surface shown on the CT scan.  We discussed deep vein thrombosis, pulmonary embolism, skin slough, skin necrosis, infection, and need for second surgery.  We discussed shortening, decreased strength, limited use, disability of operative extremity, malunion, nonunion, compartment syndrome, stiffness of the operative extremity, numbness, and weakness.  Examination of the patient revealed that he had slightly decreased sensation on the dorsum of his foot.,The patient was able to flex and extend his toes, had good capillary refill, good dorsalis pedis, and posterior tibial pulse.,The patient's tissues were edematous and we has waited approximately 10 days before performing the surgery when the skin could be wrinkled anteriorly.  We discussed his incision, the medial incision as well as lateral incision and the lateral incision would be more posterolateral to maintain a bridge of at least 6 to 8 cm between the 2 incisions.  We did discuss the skin slough as well as skin necrosis, particularly medially where the most skin pressure was because of displacement laterally.  He understood the posterolateral comminution of the tibial plafond, which would be reduced by aligning up the cortex posteriorly.,We discussed the posterolateral approach with reduction of the fibula.  We discussed that likely the distal fibula would not be removed completely to assess the articular surface as this would likely comminute the fibula, even more fragmentation would occur, and would not be able to obtain an anatomic reduction.  He understood this distal fibular fracture was comminuted and there were missing fragments of bone because they were impacted into intramedullary cancellous space.  With this, the patient understood that the hardware may necessitate removal as well in the future.  We discussed hardware irritation.  We also discussed risk of osteoarthritis, which was nearly 100% particularly because of comminution of this area posteriorly.  With these risks discussed and listed on the consent, the patient wanted the procedure.,OPERATIVE NOTE:,  The patient was brought to operating theater and given successful general anesthetic.  His right leg was prepped and draped in the usual fashion.  Before prep and drape was performed, a close reduction was tried to be obtained to see whether there was any obstruction to reduction.  It was felt that at one point the posterior tibialis tendon may be intraarticular.,The reduction appeared to line up.  However, there was significant gap of approximately 1.5 to 2 cm between the avulsed medial malleolus fragment and distal tibia.,A lateral incision was made over the fracture site approximately 8 cm long and was taken to subcutaneous tissue.  The superficial peroneal nerve was seen and this was avoided.  The incision was placed posterolateral to fibula.,This was to ensure good flap of tissue between the 2 incisions medial and laterally.  The fracture was seen.  The fracture was elevated and medialized and de-rotated.  The anterior portion of the distal fibula was significantly comminuted with defect.  The posterior aspect was still intact.  However, there were multiple fracture lines demonstrating a crush-type injury.  This was reduced manually.  At this point, dissection was performed bluntly behind the peroneal tendons in between this and flexor hallucis longus tendon.  No sharp dissection was performed.  The posterior malleolar fragment was palpated with the distal fibula reduced.  The posterior malleolar fragment appeared to be reduced as well.,X-ray views confirmed this.,An incision was made, standard incision, curvilinear, medially distal to the medial corner of the mortise and curving anterior and posteriorly around the tip of the medial malleolus.  This was taken only through subcutaneous tissue.  The saphenous vein was found, dissected out.  Its branches were cauterized.  Penrose drain was placed around this.,Dissection was undertaken.  The periosteal tissue was seen and was invaginated into the joint.,This was recovered and flipped back on both sides.  Next, the towel clip was used.  Ends were freshened up using irrigation.  The joint surface appeared to be congruent anteriorly and posteriorly medially.,Anatomic reduction was performed in the medial malleolus using 2 mm K-wires and exchanging these for a 35 mm and a 40 mm, anterior and posterior respectively, partially threaded cancellous screws.  Anatomic reduction was gained.  X-rays were taken showing excellent anatomic reduction.  Next, attention was drawn towards the fibula.  Standard 6-hole one-third tubular plate was applied to this.  Again, this was more of a transverse impacted fracture.  Therefore, interfragmentary screw on an angle could not be used.,The posterior cortex was used to assess anatomic reduction.  Screws were placed.  It was used as a spring plate pushing the distal fibular fragment medially.,Screw holes were filled.  They were double-checked.  Screws had excellent purchase and were tightened up.  At this point, lateral views were taken as well as palpation of posterior lateral fragment was performed in the plafond.  This appeared to show anatomic reduction and did not appear to be a step on the articular surface or the posterior cortex of the distal tibia.,The screw was then placed from anterior medial to posterior lateral into this comminuted fragment.,A 2 mm K-wire was used.  Finger was placed on this fragment and the pin was advanced even before the finger.  X-ray views could show the posterior cortex and location of the pin.  This was then exchanged for a 55 mm partially threaded cancellous screw after tapping was performed.  This was double checked to ensure good positioning and this was so.  On the lateral view, we could see this was not in the joint.  AP views and mortise views showed this was not in the joint.  One could palpate this as well.  The screw was placed slightly proximal to distal in the anteroposterior plane.  At the distal tip of it, it was just in the subchondral bone but not in the joint.  There was slight to excellent purchase of this posterior lateral fragment.  Wounds were copiously irrigated followed by closing using 2-0 Vicryl in inverted fashion followed by staples to skin.  Adaptic, 4 x 4s, abdominal pad was placed on wound, held in place with Kerlix followed by an extensor bandage.  Posterior splint was placed on the patient.  The patient's leg was placed in neutral position.  Significant amount of cast padding were used and large bulky trauma ABD type dressings.  The heel was padded and leg was padded with approximately 2 inches of padding.  Tourniquet was deflated.  The patient had good capillary refill, good pulses, and the patient returned to recovery room in stable condition with no complications.  Physician assistant assisted during the case with retracting as well as holding the medial malleolar fragment and fragments in position while placement screws were applied.  Positioning of the leg was accomplished by the physician assistant.  As well, physician assistant assisted in transport of patient to and from the recovery room, assisted in cautery as well as dissection and retraction of tissue.  The patient is expected to do well overall.  He does have an area of comminution shown on the CT scan.  However, by x-rays, it appears that there is anatomic reduction gained at this posterolateral fragment.  Nonetheless, this area was crushed and the patient will have degenerative changes in the future caused by this crushing area.
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DESCRIPTION: Delayed open reduction internal fixation with plates and screws, 6-hole contoured distal fibular plate and screws reducing posterolateral malleolar fragment as well as medial malleolar fragment.

The situation involves a complex orthopedic surgery following a motorcycle accident, where the patient has sustained significant fractures requiring delayed open reduction and internal fixation. The stakes are high due to the nature of the injuries, the complexity of the surgical procedure, the potential for significant complications (e.g., infections, neurovascular injury, osteoarthritis, disability), and the impact on the patient's quality of life. Given these factors, the stakes of this medical situation are substantial. However, the surgery was performed successfully, which slightly mitigates the overall stakes.


Medical Specialty: Surgery
Sample Name: Blepharoplasty - Direct Brow Repair

PREOPERATIVE DX:, Dermatochalasis, mechanical ptosis, brow ptosis.,POSTOPERATIVE DX:, Same,PROCEDURE:,: Upper lid blepharoplasty and direct brow lift,ANESTHESIA:, Local with sedation,INDICATIONS FOR SURGERY: , In the preoperative evaluation the patient was found to have visually significant and symptomatic dermatochalasis and brow ptosis causing mechanical ptosis and visual field obstruction.  Visual field testing showed *% superior hemifield loss on the right, and *% superior hemifield loss on the left.  These field losses resolved with upper eyelid taping which simulates the expected surgical correction.  Photodocumentation also showed the upper eyelids resting on the upper eyelashes, as well as a decrease in the effective superior marginal reflex distance.  The risks, benefits, limitations, alternatives, and expected improvement in symptoms and visual field loss were discussed in preoperative evaluation.,DESCRIPTION OF PROCEDURE:, On the day of surgery, the surgical site and procedure were verified by the physician with the patient.  An informed consent was signed and witnessed.  EMLA cream was applied to the eyelids and eyebrow region for 10 minutes to provide skin anesthesia.  Two drops of topical proparacaine eye drops were placed on the ocular surface.  The skin was cleaned with alcohol prep pads.  The patient received 3 to 4 mL of 2% Lidocaine with epinephrine and 0.5% Marcaine mixture to each upper lid.  5 to 6 mL of local were also given to the brow region along the entire length.  Pressure was applied over each site for 5 minutes.  The patient was then prepped and draped in the normal sterile fashion for oculoplastic surgery.,The desired amount of redundant brow tissue to be excised was carefully marked with a surgical marking pen on each side.  The contour of the outline was created to provide a greater temporal lift.  Care was taken to preserve a natural contour to the brow shape consistent with the patient’s desired features.  Using a #15 blade, the initial incision was placed just inside the superior most row of brow hairs, in parallel with the follicle growth orientation.  The incision extended in a nasal to temporal fashion with the nasal portion incision being carried down to muscle and becoming progressively shallower toward the tail of the incision line.  The dimensions of the redundant tissue measured * horizontally and * vertically.  The redundant tissue was removed sharply with Westcott scissors.  Hemostasis was maintained with hand held cautery and/or electrocautery.  The closure was carried out in multiple layers.  The deepest muscular/subcutaneous tissue was closed with 4-0 transparent nylon in a horizontal mattress fashion.  The intermediate layer was closed with 5-0 Vicryl similarly.  The skin was closed with 6-0 nylon in a running lock fashion.  Iced saline gauze pads were placed over the incision sites.  This completed the brow repair portion of the case.,Using a surgical marking pen, a vertical line was drawn from the superior punctum to the eyebrow.  An angled line was drawn from the ala of the nares to the lateral canthus edge and extending to the tail of the brow.  These lines served as the relative boundary for the horizontal length of the blepharoplasty incision.  The desired amount of redundant tissue to be excised was carefully pinched together with 0.5 forceps.  This tissue was outlined with a surgical marking pen.  Care was taken to avoid excessive skin removal near the brow region.  A surgical ruler was used to ensure symmetry.  The skin and superficial orbicularis were incised with a #15 blade on the first upper lid.  This layer was removed with Westcott scissors.,Hemostasis was achieved with high-temp hand held pen cautery.  The remaining orbicularis and septum were grasped superiorly and inferiorly on each side of the incision and tented upward.  The high temp cautery pen was then used to incise these layers in a horizontal fashion until preapeuronotic fat was identified.  * amount of central preaponeurotic fat was removed with cautery.  * amount of nasal fat pad was removed in the same fashion.  Care was taken to not disturb the levator aponeurosis.  A symmetric amount of fat was removed from each side.  Iced gauze saline was placed over the site and the entire procedure repeated on the fellow eyelid.  Skin hooks were placed on either side of the incision and the skin was closed in a continuous running fashion with 6-0 nylon.  Erythromycin ophthalmic ointment was placed over the incision site and on the ocular surface.  Saline gauze and cold packs were placed over the upper lids.  The patient was taken from the surgical suite in good condition.,DISCHARGE:,  In the recovery area the results of surgery were discussed with the patient and their family.  Specific instructions to resume all p.o. oral medications including anticoagulants/antiplatelets were given.  Written instructions and restrictions after eyelid surgery were reviewed with the patient and family member.  Instructions on antibiotic ointment use were reviewed.  The incision sites were checked prior to release.  The patient was released to home with a driver after vital signs were deemed stable.
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DESCRIPTION: Blepharoplasty with direct brow repair.

Blepharoplasty with direct brow repair.

surgery, dermatochalasis, erythromycin ophthalmic, saline gauze, blepharoplasty, brow ptosis, cold packs, direct brow lift, follicle growth, hemifield loss, marginal reflex, mechanical ptosis, ocular surface, superficial orbicularis, visual field, surgical marking pen, direct brow, redundant tissue, incision sites, incision, brow, ptosis, surgical

This scenario involves a surgical procedure to correct dermatochalasis and brow ptosis, which are causing mechanical ptosis and visual field obstruction. Surgery always carries inherent risks, including potential complications from anesthesia and the procedure itself. The surgery is performed to improve the patient's vision and quality of life, indicating its importance. Although it is typically an elective, non-life-threatening procedure, it still involves considerations about achieving the desired cosmetic and functional outcomes. The stakes include potential postoperative complications, patient satisfaction, and visual improvements, making it moderately high-stakes in a medical context.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 12

SUBJECTIVE: , The patient was seen and examined.  He feels much better today, improved weakness and decreased muscular pain.  No other complaints.,PHYSICAL EXAMINATION:,GENERAL:  Not in acute distress, awake, alert and oriented x3.,VITAL SIGNS:  Blood pressure 147/68, heart rate 82, respiratory rate 20, temperature 97.7, O2 saturation 99% on 3 L.,HEENT:  NC/T, PERRLA, EOMI.,NECK:  Supple.,HEART: Regular rate and rhythm.,RESPIRATORY:  Clear bilateral.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses present bilateral.,LABORATORY DATA: , Total CK coming down 70,142 from 25,573, total CK is 200, troponin is 2.3 from 1.9 yesterday.,BNP, blood sugar 93, BUN of 55.7, creatinine 2.7, sodium 137, potassium 3.9, chloride 108, and CO2 of 22.,Liver function test, AST 704, ALT 298, alkaline phosphatase 67, total bilirubin 0.3.  CBC, WBC count 9.1, hemoglobin 9.9, hematocrit 29.2, and platelet count 204.  Blood cultures are still pending.,Ultrasound of abdomen, negative abdomen, both kidneys were echogenic, cortices suggesting chronic medical renal disease.  Doppler of lower extremities negative for DVT., ,ASSESSMENT AND PLAN:,1.  Rhabdomyolysis, most likely secondary to statins, gemfibrozil, discontinue it on admission.  Continue IV fluids.  We will monitor.,2.  Acute on chronic renal failure.  We will follow up with Nephrology recommendation.,3.  Anemia, drop in hemoglobin most likely hemodilutional.  Repeat CBC in a.m.,4.  Leukocytosis, improving.,5.  Elevated liver enzyme, most likely secondary to rhabdomyolysis.  The patient denies any abdominal pain and ultrasound is unremarkable.,6.  Hypertension.  Blood pressure controlled.,7.  Elevated cardiac enzyme, follow up with Cardiology recommendation.,8.  Obesity.,9.  Deep venous thrombosis prophylaxis.  Continue Lovenox 40 mg subcu daily.
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DESCRIPTION: Rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity.

soap / chart / progress notes, rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity, cardiac enzyme, blood pressure,

The situation pertains to a medical progress note that documents a patient's condition with multiple health issues including rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, and other concerns. The patient seems to be stable and improving, with a structured plan in place for treatment and monitoring. While the health concerns are significant, particularly the renal failure and elevated cardiac enzyme, the patient is under close supervision, suggesting that the situation is not a medical emergency but still requires careful management. The stakes are medium-high due to the potential for complications if the conditions are not managed properly.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Thoracoscopy/Thoracotomy

PREOPERATIVE DIAGNOSES:,  Empyema of the left chest and consolidation of the left lung.,POSTOPERATIVE DIAGNOSES:,  Empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.,OPERATIVE PROCEDURE: , Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.,ANESTHESIA:,  General.,FINDINGS: , The patient has a complex history, which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax.  There was also noted to be some mild infiltrates of the right lung.  The patient had a 30-year history of cigarette smoking.  A chest tube was placed at the other hospital, which produced some brownish fluid that had foul odor, actually what was thought to be a fecal-like odor.  Then an abdominal CT scan was done, which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT.  The patient was started on antibiotics and was then taken to the operating room, where there was to be a thoracoscopy performed.  The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions, but there was bloody mucous in the left main stem bronchus and this was suctioned out.  This was suctioned out with the addition of the use of saline ***** in the bronchus.  Following the bronchoscopy, a double lumen tube was placed, but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day.,The patient was transferred for continued evaluation and treatment.  Today, the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted.  These were suctioned, but it was enough to produce a temporary obstruction of the left mainstem bronchus.  Eventually, the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that.  The chest tube tract, which was about in the sixth or seventh intercostal space, but it was not possible to dissect enough down to get a acceptable visualization through this tract.  A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity.  Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout.  Remarkably, the surface of the lower lobe laterally was not completely covered with a fibrotic line, but it was more the line anterior and posterior and more of it over the left upper lobe.  There were many pockets of purulent material, which had a gray-white appearance to it.  There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe.  The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time.  There seemed to be an abscess that was about 3 cm in dimension, all the lateral basilar segment of the lower lobe near the area where the chest tube was placed.  Many cultures were taken from several areas.  The most remarkable finding was a large cavity, which was probably about 11 cm in dimension, containing grayish pus and also caseous-like material, it was thought to be perhaps necrotic lung tissue, perhaps a deposit related to tuberculosis in the cavity.,The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm.,PROCEDURE AND TECHNIQUE:,  With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner.  The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract, but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this.  Therefore, the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved, but it was clear that we would be unable to complete the procedure by thoracoscopy.  Therefore posterolateral thoracotomy incision was made, entering the pleural space and what is probably the sixth intercostal space.  Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity.  Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense.  Suture ligatures of Prolene were required.  When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity, which appeared to be from pulmonary veins and these were sutured with a "tissue pledget" of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures.,Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14-French Foley catheter was passed into the area of the tear and the balloon was inflated, which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed.  The patch was sutured onto the pulmonary artery tear.  A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity.  Also on the pulmonary artery repair some ***** material was used and also thrombin, Gelfoam and Surgicel.  After reasonably good hemostasis was established pleural cavity was irrigated with saline.  As mentioned, biopsies were taken from multiple sites on the pleura and on the edge and on the lung.  Then two #24 Blake chest tubes were placed, one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk.  One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex.  These were later connected to water-seal suction at 40 cm of water with negative pressure.,Good hemostasis was observed.  Sponge count was reported as being correct.  Intercostal nerve blocks at probably the fifth, sixth, and seventh intercostal nerves was carried out.  Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib.  Metallic clip was passed through the rib to facilitate passage of an intracostal suture, but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table, so that pericostal sutures were used with #1 Vicryl.  The chest wall was closed with running #1 Vicryl and then 2-0 Vicryl subcutaneous and staples on the skin.  The chest tubes were connected to water-seal drainage with 40 cm of water negative pressure.  Sterile dressings were applied.  The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen.  The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition.
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DESCRIPTION: Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.

cardiovascular / pulmonary, empyema, biopsies, bronchus, declaudication, endothoracic, hydropneumothorax, left lower lobe, left lung, left upper lobe, mainstem, pleura, thoracoscopy, thoracotomy, thoracotomy with declaudication, declaudication and drainage, double lumen tube, sixth intercostal space, lung abscesses, pleural cavity, intercostal space, upper lobe, double lumen, chest tube, cavity, tube, chest, lung, pulmonary, pleural, intercostal,

This case involves a surgical procedure (thoracoscopy and thoracotomy) to address serious complications related to the patient's lung, including empyema, consolidation, and lung abscesses. The complexity and risks associated with the surgical intervention, including the potential for significant bleeding and the extensive involvement of lung tissue, elevate the stakes of the situation. Furthermore, the patient has a history of significant health concerns, such as a long smoking history, which complicates the clinical picture. The presence of infections, the risk of complications during and after surgery, and the need for postoperative intensive care suggest that the situation is high-stakes, as the outcomes can significantly affect the patient's health and recovery.


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

Medical Specialty: Neurology
Sample Name: CT Scan of Brain with Contrast

CC:, Confusion.,HX: , A 71 y/o RHM ,with a history of two strokes ( one in 11/90 and one in 11/91), had been in a stable state of health until 12/31/92 when he became confused, and displayed left-sided weakness and difficulty speaking. The symptoms resolved within hours and recurred the following day. He was then evaluated locally and HCT revealed an old right parietal stroke. Carotid duplex scan revealed a "high grade stenosis" of the RICA. Cerebral Angiogram revealed 90%RICA and 50%LICA stenosis. He was then transferred to UIHC Vascular Surgery for carotid endarterectomy. His confusion persisted and he was evaluated by Neurology on 1/8/93 and transferred to Neurology on 1/11/93.,PMH:, 1)cholecystectomy. 2)inguinal herniorrhaphies, bilaterally. 3)ETOH abuse: 3-10 beers/day. 4)Right parietal stroke 10/87 with residual left hemiparesis (Leg worse than arm). 5) 2nd stoke in distant past of unspecified type.,MEDS:, None on admission.,FHX:, Alzheimer's disease and stroke on paternal side of family.,SHX:, 50+pack-yr cigarette use.,ROS:, no weight loss. poor appetite/selective eater.,EXAM:, BP137/70 HR81 RR13 O2Sat 95% Afebrile.,MS: Oriented to city and month, but did not know date or hospital. Naming and verbal comprehension were intact. He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2-3 objects in two minutes, but both with assistance only. Incorrectly spelled "world" backward, as "dlow.",CN: unremarkable except neglects left visual field to double simultaneous stimulation.,Motor: Deltoids 4+/4-, biceps 5-/4, triceps 5/4+, grip 4+/4+, HF4+/4-, HE 4+/4+, Hamstrings 5-/5-, AE 5-/5-, AF 5-/5-.,Sensory: intact PP/LT/Vib.,Coord: dysdiadochokinesis on RAM, bilaterally.,Station: dyssynergic RUE on FNF movement.,Gait: ND,Reflexes: 2+/2+ throughout BUE and at patellae. Absent at ankles. Right plantar was flexor; and Left plantar was equivocal.,COURSE:, CBC revealed normal Hgb, Hct, Plt and WBC, but Mean corpuscular volume was large at 103FL (normal 82-98). Urinalysis revealed 20+WBC. GS, TSH, FT4, VDRL, ANA and RF were unremarkable. He was treated for a UTI with amoxacillin. Vitamin B12 level was reduced at 139pg/ml (normal 232-1137). Schillings test was inconclusive dure to inability to complete a 24-hour urine collection. He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days; then qMonth. He was also placed on Thiamine 100mg qd, Folate 1mg qd, and ASA 325mg qd. His ESR and CRP were elevated on admission, but fell as his UTI was treated.,EEG showed diffuse slowing and focal slowing in the theta-delta range in the right temporal area. HCT with contrast on 1/19/93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct; and an old right parietal hypodensity (infarct). His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency. He was lost to follow-up and did not undergo carotid endarterectomy.
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DESCRIPTION: Brain CT with contrast - Abnormal Gyriform enhancing lesion (stroke) in the left parietal region, not seen on non-contrast HCTs.

neurology, ct scan, abnormal gyriform enhancing lesion, brain ct, ct with contrast, carotid duplex scan, confusion, hct, difficulty speaking, left-sided weakness, non-contrast hct, parietal region, stroke, theta-delta, with contrast, gyriform enhancing lesion, gyriform enhancing, enhancing lesion, parietal stroke, carotid endarterectomy, ct, scan, gyriform, endarterectomy, contrast, hcts, brain, parietal,

The situation involves a 71-year-old patient with a complex medical history, including prior strokes, high-grade carotid artery stenosis, vitamin B12 deficiency, UTI, and possible cognitive impairment. The stakes are high due to the immediate risk of further strokes or complications from the carotid stenosis, which can be life-threatening. Additionally, the patient's confusion and recent symptomatic episodes suggest an ongoing or worsening neurological condition that requires careful management. The potential for mismanagement or failure to follow up, as evidenced by the patient being lost to follow-up and not receiving a planned carotid endarterectomy, further elevates the stakes.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy with Biopsy

INDICATIONS FOR PROCEDURE: , A 79-year-old Filipino woman referred for colonoscopy secondary to heme-positive stools.  Procedure done to rule out generalized diverticular change, colitis, and neoplasia.,DESCRIPTION OF PROCEDURE: , The patient was explained the procedure in detail, possible complications including infection, perforation, adverse reaction of medication, and bleeding.  Informed consent was signed by the patient.,With the patient in left decubitus position, had received a cumulative dose of 4 mg of Versed and 75 mg of Demerol, using Olympus video colonoscope under direct visualization was advanced to the cecum.  Photodocumentation of appendiceal orifice and the ileocecal valve obtained.  Cecum was slightly obscured with stool but the colon itself was adequately prepped.  There was no evidence of overt colitis, telangiectasia, or overt neoplasia.  There was moderately severe diverticular change, which was present throughout the colon and photodocumented.  The rectal mucosa was normal and retroflexed with mild internal hemorrhoids.  The patient tolerated the procedure well without any complications.,IMPRESSION:,1.  Colonoscopy to the cecum with adequate preparation.,2.  Long tortuous spastic colon.,3.  Moderately severe diverticular changes present throughout.,4.  Mild internal hemorrhoids.,RECOMMENDATIONS:,1.  Clear liquid diet today.,2.  Follow up with primary care physician as scheduled from time to time.,3.  Increase fiber in diet, strongly consider fiber supplementation.
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DESCRIPTION: A woman referred for colonoscopy secondary to heme-positive stools.  Procedure done to rule out generalized diverticular change, colitis, and neoplasia.

gastroenterology, olympus video colonoscope, advanced to the cecum, heme-positive stools, diverticular change, colitis, colonoscopy to the cecum, spastic colon, colonoscopy with biopsy, liver disease, biopsy, hepatitis, chronic, liver, disease, mucosa, polyp, rectal, colonoscopy,

This situation involves a 79-year-old woman undergoing a colonoscopy to investigate heme-positive stools, a potential indicator of serious underlying issues such as colorectal cancer, diverticular disease, or colitis. While the procedure itself appears to have been completed without complications and found no evidence of overt neoplasia or colitis, the presence of moderately severe diverticular change requires attention. Given the age of the patient and the initial symptoms, the scenario has significant implications for her health, especially if not monitored or treated appropriately. However, the immediate findings were not life-threatening, making it not extremely high-stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - 8

PREOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,POSTOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,PROCEDURE:,  Bronchoscopy with brush biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia.  A time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube.  First the trachea and the carina had normal appearance.  The scope was passed into the left side and the bronchial system was found to be normal.  There were scars and mucoid secretions.  Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB.  First, the basal lobes were explored and found to be normal.  Then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated.  Then, the bronchi going to the three segments were visualized and no abnormalities or mass were found.  Brush biopsy was obtained from one of the segments and sent to Pathology.,The procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of Ambu bagging, he recovered satisfactorily.,At the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.,
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DESCRIPTION: Bronchoscopy with brush biopsies.  Persistent pneumonia, right upper lobe of the lung, possible mass.

cardiovascular / pulmonary, persistent pneumonia, bronchoscopy, brush biopsies, endotracheal tube, biopsies, bronchial, abnormalities, pneumonia, secretions, endotracheal,

The situation described involves a medical procedure to investigate persistent pneumonia with a possible mass in the lung. Although bronchoscopies are routine procedures, the mention of 'possible mass' in the lung could imply a suspicion of a serious condition like cancer. Moreover, the procedure experienced interruptions due to the patient's desaturation, which is a critical incident requiring immediate management to stabilize the patient. Collectively, these factors contribute to a high-stakes situation in terms of both immediate clinical risk and potential implications for the patient's diagnosis and treatment plan.


Medical Specialty: Hematology - Oncology
Sample Name: Head & Neck Cancer Consult

REASON FOR CONSULTATION:,  Newly diagnosed head and neck cancer.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old gentleman who was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.  He was also noted to have palpable level 2 cervical lymph nodes.  His staging is T3 N2c M0 Stage IV invasive squamous cell carcinoma of the head and neck.  The patient comes in to the clinic today after radiation Oncology consultation.  His Otolaryngologist performed a direct laryngoscopy with biopsy on July 29, 2010.  The patient reports that in December-January timeframe, he had noted some difficulty swallowing and ear pain.  He had a work up by his local physician that was relatively negative, and he was treated for gastroesophageal reflux disease.  His symptoms continued to progress, and he developed difficulty with his speech, dysphagia, otalgia and odynophagia.  He was then referred to Dr. X and examination revealed a mass at the right base of the tongue that extended across the midline to include the left base of the tongue as well as posterior extension involved in the right tonsillar fossa.  He was noted to have bilateral neck nodes.  His biopsy was positive for squamous cell carcinoma.,PAST MEDICAL HISTORY:,  Significant for mild hypertension.  He has had cataract surgery, gastroesophageal reflux disease and a history of biceps tendon tear.,ALLERGIES: ,  Penicillin.,CURRENT MEDICATIONS: , Lisinopril/hydrochlorothiazide 20/25 mg q.d., alprazolam 0.5 mg q.d., omeprazole 20 mg b.i.d., Lortab 7.5/500 mg q 4h p.r.n.,FAMILY HISTORY: , Significant for father who has stroke and grandfather with lung cancer.,SOCIAL HISTORY: , The patient is married but has been separated from his wife for many years, they remain close, and they have two adult sons.  He is retired from the Air Force, currently works for Lockheed Martin.  He was born and raised in New York.  He does have a smoking history, about a 20 pack-year history and he reports quitting on July 27.  He does drink alcohol socially. No use of illicit drugs.,REVIEW OF SYSTEMS:  ,The patient's chief complaint is fatigue.  He has difficulty swallowing and dysphagia.  He is responding well to Lortab and Tylenol for pain control.  He denies any chest pain, shortness of breath, fevers, chills and night sweats.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:
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DESCRIPTION: Newly diagnosed head and neck cancer.  The patient was recently diagnosed with squamous cell carcinoma of the base of the tongue bilaterally and down extension into the right tonsillar fossa.

The case involves a diagnosis of Stage IV invasive squamous cell carcinoma of the head and neck, which is a serious and life-threatening condition. The patient requires careful management and treatment planning, likely involving multiple medical specialties including oncology, surgery, and potentially palliative care. The patient's history of significant symptoms and the recent discovery of the cancerous mass add urgency to the situation. The case's complexity, the need for timely interventions, and the potential impact on the patient's life all contribute to its high-stakes nature.