Medical Specialty: Neurology
Sample Name: Craniotomy - Frontotemporal

PREOPERATIVE DIAGNOSIS:,  Right frontotemporal chronic subacute subdural hematoma.,POSTOPERATIVE DIAGNOSIS:,  Right frontotemporal chronic subacute subdural hematoma.,TITLE OF THE OPERATION: , Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,ASSISTANT: , None.,INDICATIONS: , The patient is a 75-year-old man with a 6-week history of decline following a head injury.  He was rendered unconscious by the head injury.  He underwent an extensive syncopal workup in Mississippi.  This workup was negative.  The patient does indeed have a heart pacemaker.  The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma.  There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes.  I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity.  The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where general and endotracheal anesthesia was obtained.  The head was turned over to the left side and was supported on a cushion.  There was a roll beneath the right shoulder.  The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline.  Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia.  Weitlaner retractors were inserted.  A single bur hole was placed underneath the temporalis muscle.  I placed the craniotomy a bit low in order to have better cosmesis.  A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm.  The bone was set aside.  The dura was clearly discolored and very tense.  The dura was opened in a cruciate fashion with a #15 blade.  There was immediate flow of a thin motor oil fluid under high pressure.  Literally the fluid shot out several inches with the first nick in the membranous cavity.  The dura was reflected back and biopsy of the membranes was taken and sent for permanent section.  The margins of the membrane were coagulated.  The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery.  The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none.  The dura was then closed in a watertight fashion using running locking 4-0 Nurolon.  Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system.  The wound was irrigated thoroughly once more and was closed in layers.  Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl.  Finally, the skin was closed with running locking 3-0 nylon.,Estimated blood loss for the case was less than 30 mL.  Sponge and needle counts were correct.,FINDINGS: , Chronic subdural hematoma with multiple septations and thickened subdural membrane.,I might add that the arachnoid was not violated at all during this procedure.  Also, it was noted that there was no subarachnoid blood but only subdural blood.
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DESCRIPTION: Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.

neurology, frontotemporal, weitlaner, calvarium, cookie cutter type, craniotomy, dura, frontotemporal craniotomy, galea, hematoma, subdural, subdural hematoma, syncopal, temporalis, subacute subdural hematoma, temporalis muscle,

The situation involves a clinical scenario where a 75-year-old male patient undergoes a frontotemporal craniotomy to evacuate a chronic subdural hematoma. This type of procedure carries inherent risks such as bleeding, infection, and damage to surrounding brain tissue. Additionally, the patient has a history of previous medical issues, including bladder tumors and unconsciousness from head injury, increasing the stakes of the surgery. Due to these factors and the critical nature of brain surgery, this situation is high-stakes because the outcome could significantly impact the patient's quality of life and survival.


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

Medical Specialty: Neurology
Sample Name: Consult - Normal Pressure Hydrocephalus

REASON FOR VISIT: , The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.  He is accompanied by his wife and daughter.,HISTORY OF PRESENT ILLNESS:,  I first saw him nearly a year ago on December 20, 2007.  At that time, he had had a traumatic deterioration over the course of approximately eight months.  This included severe cognitive impairment, gait impairment, and incontinence.  He had actually been evaluated at Hospital with CSF drainage via a temporary spinal catheter, but there was no response that was noted.  When I saw him, there were findings consistent with cervical stenosis and I ordered an MRI scan of the cervical spine.  I subsequently referred him to Dr. X, who performed a cervical laminectomy and instrumented fusion on July 16, 2008.  According to his notes this went well.,According to the family, there has not been any improvement.,With regard to the gait and balance, they actually think that he is worse now than he was a year ago.  He is virtually unable to walk at all.  He needs both a walker and support from an assistant to be able to stand or walk.  Therefore, he is always in the wheelchair.,He is completely incontinent.  He never indicates his need to the go to the bathroom.  On the other hand when asked, he will indicate that he needs to go.  He wears a Depends undergarment all the time.,He has no headaches.,His thinking and memory are worse.  For the most part, he is apathetic.  He does not talk very much.  He lives in a skilled nursing facility in the Alzheimer's section.  He does have some daytime activities.  He takes a nap once a day.  He does not read very much.  On the other hand, he did recently exercise the right to vote in the presidential election.  He needs full assistance at the nursing home.,MEDICATIONS:,  From the list by the nursing home are Aricept 10 mg in the evening, carbidopa/levodopa 25/100 mg three times a day, citalopram (Celexa) 40 mg daily, Colace 100 mg twice a day, finasteride (Proscar) 5 mg once a day, Flomax (tamsulosin) 0.4 mg once a day, multivitamin with iron once a day, omeprazole (Prilosec) 20 mg once a day, senna 8.6 mg twice a day, Tylenol 650 mg as needed, and promethazine 25 mg as needed.,PHYSICAL EXAM: , On examination today, this is a pleasant 81-year-old man who is brought back from the clinic waiting area in a wheelchair.  He is well developed, well nourished, and kempt.,Vital Signs:  Temperature 96.7, pulse 62, respirations 16, and blood pressure 123/71.,Head:  The head is normocephalic and atraumatic.,Mental Status:  Assessed for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  The Mini-Mental State Exam score was 14/30.  He was not at all oriented.  He did know we were at Sinai Hospital on the second floor.  He could spell 'world' forward, but was mute when asked to spell backwards.  He was mute when asked to recall 3/3 objects for delayed recall.  He could not copy a diagram of intersecting pentagons.  For comparison, the Mini-Mental State exam score last December was 20/30 when attention was tested by having him spell 'world' backwards and 28/30 when tested with serial 7 subtractions.  Additionally, there are times when he stutters or stammers.  I do not see any paraphasic errors.  There is some evidence of ideomotor apraxia.  He is also stimulus bound.  There is a tendency to mimic.,Cranial Nerve Exam:  There is no upgaze that I can elicit today.  The horizontal gaze and down gaze are intact.  This is a change from a year ago.  The muscles of facial expiration are intact as are hearing, head turning, cough, tongue, and palate movement.,Motor Exam:  Normal bulk and strength.  The tone is characterized by paratonia.  There is no atrophy, fasciculations, drift, or tremor.,Sensory Exam:  Intact to light touch.,Cerebellar Exam:  Intact for finger-to-nose testing that he can perform only by mimicking, but not by following verbal commands.,Gait:  Severely impaired.  When in the wheelchair, he leans to one side.  He cannot getup on his own.  He needs assistance.  Once up, he can bear weight, but cannot maintain his balance.  This would amount to a Tinetti score of zero.,REVIEW OF X-RAYS: , I personally reviewed the CT scan of the brain from November 1, 2008 and compared it to the MRI scan from a year ago.  The ventricles appear larger to me now in comparison to a year ago.  The frontal horn span is now 6 cm, whereas previously it was about 5.5 cm.  The 3rd ventricular span is about 15 mm.  There is no obvious atrophy, although there may be some subtle bilateral perisylvian atrophy.  The scan from a year ago showed that there was a patent sylvian aqueduct.,ASSESSMENT:,  The patient has had worsening of his gait, his dementia, and his incontinence.  The new finding for me today is the limited upgaze.  This would be consistent either with progressive supranuclear palsy, which was one of the differential diagnoses a year ago, or it could be consistent with progressive enlargement of the ventricles.,PROBLEMS/DIAGNOSES:,1.  Question of idiopathic normal pressure hydrocephalus (331.5).,2.  Possible supranuclear palsy.,3.  Severe gait impairment.,4.  Urinary urgency and incontinence.,5.  Dementia.,PLAN: , I had a long talk with him and his family.  Even though he has already had a trial of CSF drainage via spinal catheter at Hospital over a year ago, I offered this test to them again.  I do so on the basis that there is further enlargement of the ventricles on the scan.  His family and I discussed the facts that it is not likely to be only hydrocephalus.  Instead we are trying to answer the question of whether hydrocephalus is contributing sufficiently to his symptoms that progressing with shunt surgery would make a difference.  I have advised them to think it over for a day and contact my office to see whether they would wish to proceed.  I gave them a printed prescription of the protocol including its rationale, risks, benefits, and alternatives.  I specifically mentioned the 3% chance of infection, which mean a 97% chance of no infection.
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DESCRIPTION: The patient is an 84-year-old man who returns for revaluation of possible idiopathic normal pressure hydrocephalus.

This case involves a complex medical condition of an elderly patient with possible idiopathic normal pressure hydrocephalus, along with other potential neurological issues such as progressive supranuclear palsy. The stakes are high due to the patient's severe symptoms including cognitive decline, gait impairment, and incontinence that impact his quality of life and require comprehensive care. Additionally, the decision to potentially undergo shunt surgery carries both potential benefits and risks, which contributes to the high-stakes nature of the situation. Therefore, the decision-making process here is crucial and bears significant consequences for the patient's health and well-being.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Neurology
Sample Name: Consult - Cerebral Peduncle Infarction

FAMILY HISTORY AND SOCIAL HISTORY:,  Reviewed and remained unchanged.,MEDICATIONS:,  List remained unchanged including Plavix, aspirin, levothyroxine, lisinopril, hydrochlorothiazide, Lasix, insulin and simvastatin.,ALLERGIES:,  She has no known drug allergies.,FALL RISK ASSESSMENT: , Completed and there was no history of falls.,REVIEW OF SYSTEMS:  ,Full review of systems again was pertinent for shortness of breath, lack of energy, diabetes, hypothyroidism, weakness, numbness and joint pain.  Rest of them was negative.,PHYSICAL EXAMINATION:,Vital Signs:  Today, blood pressure was 170/66, heart rate was 66, respiratory rate was 16, she weighed 254 pounds as stated, and temperature was 98.0.,General:  She was a pleasant person in no acute distress.,HEENT:  Normocephalic and atraumatic.  No dry mouth.  No palpable cervical lymph nodes.  Her conjunctivae and sclerae were clear.,NEUROLOGICAL EXAMINATION:,  Remained unchanged.,Mental Status:  Normal.,Cranial Nerves:  Mild decrease in the left nasolabial fold.,Motor:  There was mild increased tone in the left upper extremity.  Deltoids showed 5-/5.  The rest showed full strength.  Hip flexion again was 5-/5 on the left.  The rest showed full strength.,Reflexes:  Reflexes were hypoactive and symmetrical.,Gait:  She was mildly abnormal.  No ataxia noted.  Wide-based, ambulated with a cane.,IMPRESSION: , Status post cerebrovascular accident involving the right upper pons extending into the right cerebral peduncle with a mild left hemiparesis, has been clinically stable with mild improvement.  She is planned for surgical intervention for the internal carotid artery.,RECOMMENDATIONS: , At this time, again we discussed continued use of antiplatelet therapy and statin therapy to reduce her risk of future strokes.  She will continue to follow with endocrinology for diabetes and thyroid problems.  I have recommended a strict control of her blood sugar, optimizing cholesterol and blood pressure control, regular exercise and healthy diet and I have discussed with Ms. A and her daughter to give us a call for post surgical recovery.  I will see her back in about four months or sooner if needed.
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DESCRIPTION: Patient with a history of right upper pons and right cerebral peduncle infarction.

neurology, internal carotid artery, cerebral peduncle infarction, carotid artery, blood pressure, upper pons, infarction, cerebral, peduncle,

The situation involves a patient with cerebral peduncle infarction, a type of stroke affecting important brain structures, leading to symptoms like hemiparesis. The patient is undergoing medical management and will have surgical intervention. The involvement of multiple medications and chronic conditions further complicates the situation. Thus, this is a high-stakes medical scenario due to its impact on the patient's neurological function and the need for careful monitoring and follow-up.


Medical Specialty: Neurology
Sample Name: Chest CT - Myasthenia Gravis

CC:, Intermittent binocular horizontal, vertical, and torsional diplopia.,HX: ,70y/o RHM referred by Neuro-ophthalmology for evaluation of neuromuscular disease. In 7/91, he began experiencing intermittent binocular horizontal, vertical and torsional diplopia which was worse and frequent at the end of the day, and was eliminated when closing one either eye. An MRI Brain scan at that time was unremarkable. He was seen at UIHC Strabismus Clinic in 5/93 for these symptoms. On exam, he was found to have intermittent right hypertropia in primary gaze, and consistent diplopia in downward and rightward gaze. This was felt to possibly represent Grave's disease. Thyroid function studies were unremarkable, but orbital echography suggested Graves orbitopathy. The patient was then seen in the Neuro-ophthalmology clinic on 12/23/92. His exam remained unchanged. He underwent Tensilon testing which was unremarkable. On 1/13/93, he was seen again in Neuro-ophthalmology. His exam remained relatively unchanged and repeat Tensilon testing was unremarkable. He then underwent a partial superior rectus resection, OD, with only mild improvement of his diplopia. During his 8/27/96 Neuro-ophthalmology clinic visit he was noted to have hypertropia OD with left pseudogaze palsy and a right ptosis. The ptosis improved upon administration of Tensilon and he was placed on Mestinon 30mg tid. His diplopia subsequently improved, but did not resolve. The dosage was increased to 60mg tid and his diplopia worsened and the dose decreased back to 30mg tid. At present he denied any fatigue on repetitive movement. He denied dysphagia, SOB, dysarthria, facial weakness, fevers, chills, night sweats, weight loss or muscle atrophy.,MEDS: , Viokase, Probenecid, Mestinon 30mg tid.,PMH:, 1) Gastric ulcer 30 years ago, 2) Cholecystectomy, 3) Pancreatic insufficiency, 4) Gout, 5) Diplopia.,FHX:, Mother died age 89 of "old age." Father died age 89 of stroke. Brother, age 74 with CAD, Sister died age 30 of cancer.,SHX:, Retired insurance salesman and denies history of tobacco or illicit drug us. He has no h/o ETOH abuse and does not drink at present.,EXAM: ,BP 155/104.  HR 92. RR 12.  Temp 34.6C. WT 76.2kg.,MS: Unremarkable. Normal speech with no dysarthria.,CN: Right hypertropia (worse on rightward gaze and less on leftward gaze). Minimal to no ptosis, OD. No ptosis, OS. VFFTC. No complaint of diplopia. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,SENSORY: No deficits appreciated on PP/VIB/LT/PROP/TEMP testing.,Coordination/Station/Gait: Unremarkable.,Reflexes: 2/2 throughout. Plantar responses were flexor on the right and withdrawal on the left.,HEENT and GEN EXAM: Unremarkable.,COURSE:, EMG/NCV, 9/26/96: Repetitive stimulation studies of the median, facial, and spinal accessory nerves showed no evidence of decrement at baseline, and at intervals up to 3 minutes following exercise. The patient had been off Mestinon for 8 hours prior to testing. Chest CT with contrast, 9/26/96, revealed a 4x2.5x4cm centrally calcified soft tissue anterior mediastinal mass adjacent to the aortic arch. This was highly suggestive of a thymoma. There were diffuse emphysematous disease with scarring in the lung bases. A few nodules suggestive of granulomas and few calcified perihilar lymph nodes. He underwent thoracotomy and resection of the mass. Pathologic analysis was consistent with a thymoma, lymphocyte predominant type, with capsular and pleural invasion, and extension to the phrenic nerve resection margin. Acetylcholine Receptor-binding antibody titer 12.8nmol/L (normal<0.7), Acetylcholine receptor blocking antibody <10% (normal), Acetylcholine receptor modulating antibody 42% (normal<19), Striated muscle antibody 1:320 (normal<1:10). Striated muscle antibody titers tend to be elevated in myasthenia gravis associated with thymoma. He was subsequently treated with XRT and continued to complain of fatigue at his 4/18/97 Oncology visit.
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DESCRIPTION: Chest CT - Thymoma and history of ocular myasthenia gravis.

neurology, diplopia, neuromuscular disease, muscle antibody titers, chest ct, intermittent binocular, rightward gaze, striated muscle, myasthenia gravis, intermittent, torsional, binocular, myasthenia, chest, thymoma, ophthalmology, antibody,

The case involves a 70-year-old patient with myasthenia gravis and a thymoma, both of which are serious conditions requiring continuous medical attention. Myasthenia gravis, especially with thymoma, can lead to complications, such as respiratory failure, and requires careful management. The presence of a thymoma, furthermore, suggests a potential surgical intervention, followed by radiation therapy, which adds to the complexity and severity of the situation. The ongoing symptoms and need for adjustment in medication dosages highlight the complexity and critical nature of managing this patient's health. While the patient's condition appears to be managed, the potential for severe complications makes this a high-stakes situation.


Medical Specialty: Neurology
Sample Name: Cervical Cord Lesion - Consult

HISTORY OF PRESENT ILLNESS:, This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased symptoms with more and more difficulty with coordination. He fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. He fell from three to five feet and landed on his back. He began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this.,He has had mid and low back pain intermittently. He took a 10-day course of Cipro believing that he had a UTI. He denies, however, any bowel or bladder problems. There is no incontinence and he does not feel that he is having any difficulty voiding.,PAST SURGICAL HISTORY:, He has a history of surgery on the left kidney, when it was "rebuilt." He has had knee surgery, appendectomy and right inguinal hernia repair.,MEDICATIONS:, His only home medications had been Cipro and Aleve. However, he does take aspirin and several over the counter supplements including a multivitamin with iron, "natural" potassium, Starlix and the aspirin.,ALLERGIES:, HE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, He smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. He is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. He had been a golfer in the past.,PAST MEDICAL HISTORY:, He has had documented cervical spondylosis, apparently with an evaluation over 15 years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 156/101, pulse was 88, respirations 18. He is afebrile.,MENTAL STATUS: He is alert.,CRANIAL NERVES: His pupils were reactive to light. He had a dense left cataract present. The right disk margin appears sharp. His eye movements were full. The face was symmetric. Pain and temperature sensation were intact over both sides of the face. The tongue was midline.,NECK: His neck was supple.,MUSCULOSKELETAL: He has intact strength and normal tone in the upper extremities. He had increased tone in both lower extremities. He had hip flexion of 4/5 on the left. He had intact strength on the right lower extremity, although had slight hammertoe deformity bilaterally.,NEUROLOGIC: His reflexes were 2+ in the upper extremities, 3+ at the knees and 1+ at the ankles. He withdrew to plantar stimulation on the left, but did not have a Babinski response clearly present. He had intact finger-to-nose testing. Marked impairment in heel-to-shin testing. He was able to sit unassisted. He stood with assistance, but had a markedly ataxic gait. On sensory exam, he had a slight distal gradient to pin and vibratory sense in both lower extremities, but also had a decrease in sensation to pin over the right lower extremity compared to the left.,CARDIOVASCULAR: He had no carotid bruits. His heart rhythm was regular.,BACK: There was no focal back pain present. He did have a slight sensory level at the upper T spine at approximately T3, both anteriorly and posteriorly.,RADIOLOGIC DATA:, MRI by my view showed essentially unremarkable T spine. The MRI of his C spine showed significant spondylosis in the mid and lower C spine with spondylolisthesis at C7-T1. There is an abnormal signal in the cord which begins at approximately this level, but descends approximately 2 cm. There is slight enhancement at the mid-portion of the lesion. This appears to be an intrinsic lesion to the cord, not clearly associated with mild to moderate spinal stenosis at the level of the spondylolisthesis.,LABORATORY: ,His initial labs were unremarkable.,IMPRESSION: ,Cervical cord lesion at the C7 to T2 level of unclear etiology. Consider a transverse myelitis, tumor, contusion or ischemic lesion.,PLAN:, Will check labs including sedimentation rate, MRI of the brain, chest x-ray. He will probably need a lumbar puncture. He also appears to have a mild peripheral neuropathy, which I suspect is an independent problem. We will request labs for this.
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DESCRIPTION: Patient reports a six to eight-week history of balance problems with later fatigue and weakness.

The situation involves a potential cervical cord lesion with unclear etiology, which is affecting the patient's motor control and possibly indicating serious underlying conditions such as transverse myelitis, tumor, contusion, or ischemic lesion. Given the neurological compromise, the potential for significant impact on mobility and quality of life, and the need for urgent diagnostic tests and interventions, it constitutes a high-stakes medical situation requiring prompt and thorough evaluation.


Medical Specialty: Neurology
Sample Name: Cerebral Angiogram

CC: ,Headache (HA),HX:, 10 y/o RHM awoke with a bilateral parieto-occipital HA associated with single episode of nausea and vomiting, 2 weeks prior to presentation. The nausea and vomiting resolved and did not recur. However, he continued to experience similar HA 3-4 times per week during the early morning upon awakening. He never felt the HA awakened him from sleep. The HA were partially relieved by Tylenol or Advil, and he distracted himself from the pain by remaining active. One week prior to presentation, he started to experience short episodes of blurred vision and diplopia. He also became fatigued, less active, and frequently yawned.,He had no prior history of HA and he and his family denied any sign or symptom of focal weakness or numbness, dysphagia, dysarthria, or loss of consciousness.,The patient underwent an MRI brain scan prior to transfer to UIHC. This revealed a mass in the left frontal region adjacent to the left temporal horn. The mass was an inhomogeneous blend of signals on T1 and T2 images giving a suggestion of acute bleeding, hemosiderin deposition and multiple vessels within the mass.,MEDS:, None.,PMH:, 1) He was a 7# 15oz. product of a full term, uncomplicated pregnancy and spontaneous vaginal delivery. His post-partum course was unremarkable. 2)Developmental milestones were reached at the appropriate times; though he was diagnosed with dyslexia 4 years ago. 3) No significant illnesses or hospitalizations.,FHX:, MGF (meningioma). PGF (lymphoma). Mother (migraine HA). Father and 22yr old brother are alive and well.,SHX: ,lives with parents and attends mainstream 5th grade classes.,EXAM:, BP124/93 HR96 RR20 37.9C (tympanic),MS:  A & O to person, place, time. Cooperative and interactive. Speech fluent and without dysarthria.,CN: EOM intact. VFFTC, Pupils 3/3 decreasing to 2/2 on exposure to light. Fundoscopy: optic disks flat, no evidence of hemorrhage. The rest of the CN exam was unremarkable.,MOTOR: full strength throughout all 4 extremities. Normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station: no pronator drift or Romberg sign,Gait: unremarkable.,Reflexes: 2+ in RUE and RLE. 3 in LUE and LLE. Plantar responses were flexor, bilaterally.,HEENT: no meningismus. no cranial bruits. no skull defects palpated.,GEN EXAM: unremarkable.,COURSE:, GS, PT/PTT, CBC were unremarkable. The MRI finding above lead to a differential diagnosis of Venous Angioma, Arteriovenous Malformation, Ependymoma, Neurocytoma, Glioma: all with associated hemorrhage.,He underwent cerebral angiography on 1/25/93. Upon injection of the RCCA an avascular mass was identified in the right temporal lobe displacing the anterior choroidal artery, and temporal branches of the middle cerebral arteries. The internal cerebral vein is displaced to the left suggesting mass effect. There is a hypoplastic A1 segment and fetal origin of the LPCA. The mass was felt by neuroradiology to represent a hematoma.,He underwent a right frontal craniotomy, 1/28/93. Pathological evaluation of the resected tissue was consistent with a vascular malformation with inclusive reactive glial tissue and evidence of recurrent and remote hemorrhage. There were dilated vascular channels having walls of variable thickness, but without evidence of elastic lamina by elastic staining. This was consistent with venous angioma/malformation.
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DESCRIPTION: Cerebral Angiogram for avascular mass - cavernous angioma (with hematoma on MRI and Bx).

The case involves a 10-year-old patient with a neurologic condition characterized by headaches, nausea, vision changes, and a significant finding of a mass on MRI, which was suspected to be a hemorrhagic vascular malformation. The decision to conduct a cerebral angiogram and subsequent neurosurgical intervention (craniotomy) indicates a high-stakes medical situation. The potential for life-threatening complications, such as bleeding within the brain, justified these invasive procedures, highlighting the urgency and complexity of the case.


Medical Specialty: Neurology
Sample Name: Brain Stimulator Electrode

PREOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,POSTOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,ANESTHESIA:,  MAC (monitored anesthesia care) with local anesthesia.,TITLE OF PROCEDURES:,1.  Left frontal craniotomy for placement of deep brain stimulator electrode.,2.  Right frontal craniotomy for placement of deep brain stimulator electrode.,3.  Microelectrode recording of deep brain structures.,4.  Stereotactic volumetric CT scan of head for target coordinate determination.,5.  Intraoperative programming and assessment of device.,INDICATIONS:  ,The patient is a 61-year-old woman with a history of dystonic tremor.  The movements have been refractory to aggressive medical measures, felt to be candidate for deep brain stimulation.  The procedure is discussed below.,I have discussed with the patient in great deal the risks, benefits, and alternatives.  She fully accepted and consented to the procedure.,PROCEDURE IN DETAIL:,  The patient was brought to the holding area and to the operating room in stable condition.  She was placed on the operating table in seated position.  Her head was shaved.  Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50:50 mixture of 0.5% Marcaine and 2% lidocaine in all planes.  IV antibiotics were administered as was the sedation.  She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken.  The images were then transported to the surgery planned work station where a 3-D reconstruction was performed and the target coordinates were then chosen.  Target coordinates chosen were 20 mm to the left of the AC-PC midpoint, 3 mm anterior to the AC-PC midpoint, and 4 mm below the AC-PC midpoint.  Each coordinate was then transported to the operating room as Leksell coordinates.,The patient was then placed on the operating table in a seated position once again.  Foley catheter was placed, and she was secured to the table using the Mayfield unit.  At this point then the patient's right frontal and left parietal bossings were cleaned, shaved, and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes.  Sterile drapes placed around the perimeter of the field.  This same scalp region was then anesthetized with same local anesthetic mixture.,A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings.  Bur holes were created on either side of the midline just behind the coronal suture.  Hemostasis was controlled using bipolar and Bovie, and self-retaining retractors had been placed in the field.  Using the drill, then two small grooves were cut in the frontal bone with a 5-mm cutting burs and Stryker drill.  The bur holes were then curetted free, the dura cauterized, and then opened in a cruciate manner on both sides with a #11 blade.  The cortical surface was then nicked with a #11 blade on both sides as well.  The Leksell arc with right-sided coordinate was dialed in, was then secured to the frame.  Microelectrode drive was secured to the arc.  Microelectrode recording was then performed.  The signatures of the cells were recognized.  Microelectrode unit was removed.  Deep brain stimulating electrode holding unit was mounted.  The DBS electrode was then loaded into target and intraoperative programming and testing was performed.  Using the screener box and standard parameters, the patient experienced some relief of symptoms on her left side.  This electrode was secured in position using bur-hole ring and cap system.,Attention was then turned to the left side, where left-sided coordinates were dialed into the system.  The microelectrode unit was then remounted.  Microelectrode recording was then undertaken.  After multiple passes, the microelectrode unit was removed.  Deep brain stimulator electrode holding unit was mounted at the desired trajectory.  The DBS electrode was loaded into target, and intraoperative programming and testing was performed once again using the screener box.  Using standard parameters, the patient experienced similar results on her right side.  This electrode was secured using bur-hole ring and cap system.  The arc was then removed.  A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel.,We then closed the electrode, replaced subgaleally.  Copious amounts of Betadine irrigation were used.  Hemostasis was controlled using the bipolar only.  Closure was instituted using 3-0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples.  Sterile dressings were applied.  The Leksell arc was then removed.,She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition.  All needle, sponge, cottonoid, and blade counts were correct x2 as verified by the nurses.
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DESCRIPTION: Frontal craniotomy for placement of deep brain stimulator electrode.  Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.

neurology, dystonic, ac-pc, ct scan, dbs electrode, intraoperative programming, microelectrode, stereotactic, tremor, brain stimulator, craniotomy, device, dystonic tremor, electrode, frontal, screener box, target coordinate, volumetric, deep brain stimulator electrode, brain stimulator electrode, volumetric ct, stimulator, brain,

The situation described involves a complex neurosurgical procedure for the placement of deep brain stimulator electrodes in a patient with dystonic tremor. These surgeries are high-stakes due to their invasive nature, potential risks (such as infection, bleeding, or neurological damage), and the critical need for precise execution to achieve the desired therapeutic outcomes. Additionally, the procedure requires meticulous preoperative planning, intraoperative coordination, and postoperative care, all of which are essential for patient safety and the success of the intervention.


Medical Specialty: Neurology
Sample Name: AVM with Hemorrhage

CC:, Headache.,HX:, 63 y/o RHF first seen by Neurology on 9/14/71 for complaint of episodic vertigo. During that evaluation she described a several year history of "migraine" headaches. She experienced her first episode of vertigo in 1969. The vertigo (clockwise) typically began suddenly after lying down, and was not associated with nausea/vomiting/headache. The vertigo had not been consistently associated with positional change and could last hours to days.,On 3/15/71, after 5 day bout of vertigo, right ear ache, and difficulty ambulating (secondary to the vertigo) she sought medical attention and underwent an audiogram which reportedly showed a 20% decline in low tone acuity AD. She complained of associated tinnitus which she described as a "whistle." In addition, her symptoms appeared to worsen with changes in head position (i.e. looking up or down). The symptoms gradually resolved and she did well until 8/71 when she experienced a 19-day episode of vertigo, tinnitus and intermittent headaches. She was seen 9/14/71, in Neurology, and admitted for evaluation.,Her neurologic exam at that time was unremarkable except for prominent bilateral systolic carotid bruits. Cerebral angiogram revealed an inoperable 7 x 6cm AVM in the right parietal region. The AVM was primarily fed by the right MCA. Otolaryngologic evaluation concluded that she probably also suffered from Meniere's disease.,On 10/14/74 she underwent a 21 day admission for SAH secondary to right parietal AVM.,On 11/23/91 she was admitted for left sided weakness (LUE > LLE), headache, and transient visual change. Neurological exam confirmed left sided weakness, and dysesthesia of the LUE only. Brain CT confirmed a 3 x 4 cm left parietal hemorrhage. She underwent unsuccessful embolization. Neuroradiology had planned to do 3 separate embolizations, but during the first, via the left MCA, they were unable to cannulate many of the AVM vessels and abandoned the procedure. She recovered with residual left hemisensory loss.,In 12/92 she presented with an interventricular hemorrhage and was managed conservatively and refused any future neuroradiologic intervention.,In 1/93 she reconsidered neurointerventional procedure and was scheduled for evaluation at the Barrows Neurological Institute in Phoenix, AZ.
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DESCRIPTION: MRI - Arteriovenous malformation with hemorrhage.

neurology, arteriovenous malformation, avm, brain ct, cerebral angiogram, headache, audiogram, carotid bruits, difficulty ambulating, hemorrhage, interventricular hemorrhage, migraine, tinnitus, vertigo, visual change, weakness, episode of vertigo, evaluation,

The patient has a complex and serious medical condition involving an arteriovenous malformation (AVM) with multiple episodes of hemorrhage, which leads to significant neurological symptoms such as left-sided weakness and sensory loss. AVMs are typically life-threatening and can be exacerbated by the risk of future bleeds or complications during attempted interventions. The patient's condition requires careful and ongoing medical management, making the situation high-stakes, especially considering her previous unsuccessful embolization attempts and her reconsideration for intervention. Her refusal of procedures before indicates a complex decision-making process and potential for acute events.


Medical Specialty: Neurology
Sample Name: Arnold Chiari II with Syrinx

CC:, Right sided numbness.,HX:, 28 y/o male presented with a 3 month history of progressive right sided numbness; now anesthetic to pain. In addition, he experienced worsening balance, and episodes of aspiration while eating.,PMH:, 1) Born prematurely and weighed 3#2oz., 2) Multiple episodes of aspiration pneumonia as an infant and child, 3) ASD repair age 14, 4) Left ptosis repair age 11, 5) Scoliosis, 6) Gait abnormality, 7) Poor pharyngeal reflexes.,SHX/FHX: ,Mainstream high school education, no mental retardation, ambulatory, works at cardboard shop for the disabled.,EXAM:, Short stature. Head tilt to right.,CN: Left ptosis, decreased left nasolabial fold, decreased gag reflex bilaterally.,Motor: Full strength,Sensory: Marked hypesthesia on entire right side.,Coord: Slowed RAM on left.,Station: No drift,Gait: ND,Reflexes: 3+ throughout; Babinski signs bilaterally. 8 beat ankle clonus on right and 3 beat ankle clonus on left.,MRI:, Arnold Chiari II with syrinx: Severe basilar invagination, marked compression of ventral pontomedullary junction, downward descension of cerebellar tonsils and vermis.,COURSE:, Patient underwent transpalatal/pharyngeal ventral decompression of pons/medulla with resection of clivus/odontoid and tracheostomy placement. on 9/29/92. Halo vest and ring were removed 6/18/93. 6 months later his Philadelphia collar was removed. He was last seen 4/8/94 and he had mildly spastic gait with good strength and hyperreflexia throughout. His gag response had returned and he was eating without difficulty. Sensation had returned to his extremities.
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DESCRIPTION: MRI for Arnold Chiari II with syrinx

MRI for Arnold Chiari II with syrinx

neurology, right sided numbness, arnold chiari ii with syrinx, cerebellar tonsils, vermis, philadelphia collar, arnold chiari ii, ankle clonus, mri, numbness, chiari, syrinx, gait, reflexes, arnold

This medical case involves a patient with Arnold Chiari II malformation and syrinx, which are serious neurological conditions that can lead to significant disability and complications such as worsening balance, numbness, and aspiration. Given the history of progressive symptoms, including severe basilar invagination and compression at critical areas of the brainstem, the stakes are high as these can lead to life-threatening issues. A surgical intervention was performed, indicating the critical nature of the condition. This situation requires careful ongoing monitoring and management to ensure no further complications arise.


Medical Specialty: Neurology
Sample Name: Bell's Palsy

SUBJECTIVE:,  The patient is a 75-year-old female who comes in today with concerns of having a stroke.  She states she feels like she has something in her throat.  She started with some dizziness this morning and some left hand and left jaw numbness.  She said that she apparently had something about three weeks ago where she was dizzy and ended up falling down and she saw Dr. XYZ for that who gave her some Antivert.  She said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face, as well as the left side of her neck.  She said she had an earache a day or so ago.  She has not had any cold symptoms.,ALLERGIES:,  Demerol and codeine.,MEDICATIONS: , Lotensin, Lopid, metoprolol, and Darvocet.,REVIEW OF SYSTEMS:,  The patient says that she feels little bit nauseated at times.  She denies chest pain or shortness of breath and again feels like she has something in her throat.  She has been able to swallow liquids okay.  She said that she did brush her teeth this morning and did not have any fluid dripping out of her mouth.  She does say that she occasionally has numbness in her left hand prior to today.,PHYSICAL EXAMINATION:,General:  She is awake and alert, no acute distress.,Vital Signs:  Blood pressure:  175/86.  Temperature:  She is afebrile.  Pulse:  78.  Respiratory rate:  20.  O2 sat:  93% on room air.,HEENT:  Her TMs are normal bilaterally.  Posterior pharynx is unremarkable.  It should be noted that her uvula did not deviate and neither did her tongue.  When she smiles though she has some drooping of the left side of her face, as well as some mild nasolabial fold flattening.,Neck:  Without adenopathy or thyromegaly.  Carotids pulses are brisk without bruits.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur.,Extremities:  Her muscle strength is symmetrical and intact bilaterally.  DTRs are 2+/4+ bilaterally and muscle strength is intact in the upper extremities.  She has a positive Tinel’s sign on her left wrist.,Neurological:  I also took monofilament and she could sense it easily when testing her sensation on her face.,ASSESSMENT:,  Bell’s Palsy.,PLAN:,  We did get an EKG showed some ST segment changes anterolaterally.  The only EKG I have here is from 1998 and she actually had bypass in 1999, but there certainly does not appear to be anything acute on his EKG.  I assured her that it does not look like she has a stroke.  If she wants to prevent a stroke, obviously quitting her smoking would help.  It should be noted she also takes Synthroid and Zocor.  We are going to give her Valtrex 1 g t.i.d. for seven days and then if she starts noticing any other drooping or worsening of her symptoms on the left side of her face, she needs to come back, but I will not start her on steroids at this time, which she agreed with.
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DESCRIPTION: A 75-year-old female comes in with concerns of having a stroke.

neurology, stroke, bell’s palsy, st segment changes, ekg, dizziness, numbness, dizzy, muscle strength, palsy, bell’s

The situation involves a patient with symptoms that resemble a stroke, which is a potentially life-threatening condition. However, the final assessment pointed towards Bell's Palsy, which although concerning, is less immediately life-threatening than a stroke. The patient's age and the initial fear of a stroke add to the stakes, as any delay in the correct diagnosis and treatment can have significant consequences. Given the initial symptoms, doctor's evaluation, and their management plan, the stakes appear moderate to high as proper diagnosis and observation are crucial.


Medical Specialty: Nephrology
Sample Name: Pyeloplasty - Robotic

PROCEDURES:,1.  Robotic-assisted pyeloplasty.,2.  Anterograde right ureteral stent placement.,3.  Transposition of anterior crossing vessels on the right.,4.  Nephrolithotomy.,DIAGNOSIS:,  Right ureteropelvic junction obstruction.,DRAINS:,1.  Jackson-Pratt drain times one from the right flank.,2.  Foley catheter times one.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,SPECIMENS:,1.  Renal pelvis.,2.  Kidney stones.,INDICATIONS:  ,The patient is a 30-year-old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries.  Up on consideration of various modalities and therapy, the patient decided to undergo surgical therapy.,PROCEDURE IN DETAIL:  ,The patient was verified by armband and the procedure being robotic-assisted right pyeloplasty with nephrolithotomy was verified, and the procedure was carried out.  After institution of general endotracheal anesthesia and intravenous preoperative antibiotics, the patient was positioned into the right flank position with his right flank elevated.  Great care was taken to pad all pressure points and a right arm hanger was used.  The patient was flexed slightly, and a kidney rest was used.  Sequential compression devices were also placed.  Next, the patient was prepped and draped in normal sterile fashion with povidone-iodine.  Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test.  A low pressure, high flow pneumoperitoneum was adequately obtained using CO2 gas.  Next, a 12-mm camera port was placed near the umbilicus.  The camera was inserted, and no bowel injury was seen.  Next, under direct vision flanking 8 mm camera ports, a 12 mm assist port, a 5 mm liver retraction port, and 5 mm assist port were placed.  The robot was docked and the instruments passed through respective checks.  Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially.  Next, the right lateral duodenum was cauterized for further access to the right retroperitoneum.  At this point, the right kidney was in clear view, and the fascia was entered.  Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection.  It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole.  These arteries were dissected carefully and vessel loops were applied.  Next, a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out.  The pyelotomy was extended so that the renal collecting system could be directly inspected.  Sequentially, each major calyx was inspected under direct vision and irrigated.  A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient.  At this point, we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis.  The proximal ureter was spatulated using cold scissors.  Next, redundant renal pelvis was excised using cold scissors and sent for permanent section.  We then identified the most inferior/dependent portion of the renal pelvis and placed a heel stitch at this for ureteral-renal pelvis anastomosis in a semi running fashion.  3-0 Monocryl sutures were used to re-anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis.  Next, remainder of the pyelotomy was closed to itself also using 2-0 Monocryl sutures.  Before final stitches were placed, a 6x28 ureteral stent was placed anterograde.  This was accomplished by placing the stents over a guidewire, placing the guidewire under direct vision anterograde through the ureter.  This was done until the proximal end was in the renal pelvis, the guidewire was removed, and good proximal curl was verified by direct vision.  Then, the pyelotomy was completely closed again with 2-0 Monocryl sutures.  Next, attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis.  Good pulsation was verified by direct vision proximal and distal to these pexy sutures.  Next, Gerota's fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum.  Hemostasis appeared excellent at this point.  There was no obvious urine extravasation.  At this time, the procedure was terminated.  The robot was undocked.  Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion.  Then, all skin port sites were closed with 4-0 Monocryl in a subcuticular fashion and Dermabond and band-aids were applied over this.  Also, notably a Jackson-Pratt drain was placed in the area of the right kidney and additional right flank stab incision.  The patient tolerated the procedure well and no immediate perioperative complication was noted.,DISPOSITION: , The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery.
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DESCRIPTION: Right ureteropelvic junction obstruction.  Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.

nephrology, pyeloplasty, ureteral stent placement, nephrolithotomy, ureteropelvic junction obstruction, jackson-pratt drain, foley catheter, renal pelvis, kidney stones, monocryl sutures, pelvis, renal, ureteropelvic, sutures,

The situation involves a detailed description of a complex surgical procedure, specifically a robotic-assisted pyeloplasty with additional interventions like ureteral stent placement and nephrolithotomy for a patient with right ureteropelvic junction obstruction. Given the nature of the surgery, it involves precision, potential risks related to the patient's kidney function, and the management of intraoperative and postoperative complications. Such surgeries can be high-stakes due to the critical role of the kidneys in maintaining homeostasis and the potential for serious consequences if complications occur. However, the description notes no complications and an estimated blood loss of less than 30cc, suggesting a well-managed procedure.


Medical Specialty: Neurology
Sample Name: Adult Hydrocephalus

REASON FOR VISIT: , The patient is a 74-year-old woman who presents for neurological consultation referred by Dr. X.  She is accompanied to the appointment by her husband and together they give her history.,HISTORY OF PRESENT ILLNESS: , The patient is a lovely 74-year-old woman who presents with possible adult hydrocephalus.  Danish is her native language, but she has been in the United States for many many years and speaks fluent English, as does her husband.,With respect to her walking and balance, she states "I think I walk funny."  Her husband has noticed over the last six months or so that she has broadened her base and become more stooped in her pasture.  Her balance has also gradually declined such that she frequently touches walls and furniture to stabilize herself.  She has difficulty stepping up on to things like a scale because of this imbalance.  She does not festinate.  Her husband has noticed some slowing of her speed.  She does not need to use an assistive device.  She has occasional difficulty getting in and out of a car.  Recently she has had more frequent falls.  In March of 2007, she fell when she was walking to the bedroom and broke her wrist.  Since that time, she has not had any emergency room trips, but she has had other falls.,With respect to her bowel and bladder, she has no issues and no trouble with frequency or urgency.,The patient does not have headaches.,With respect to thinking and memory, she states she is still able to pay the bills, but over the last few months she states, "I do not feel as smart as I used to be."  She feels that her thinking has slowed down.  Her husband states that he has noticed, she will occasionally start a sentence and then not know what words to use as she is continuing.,The patient has not had trouble with syncope.  She has had past episodes of vertigo, but not recently.,PAST MEDICAL HISTORY:  ,Significant for hypertension diagnosed in 2006, reflux in 2000, insomnia, but no snoring or apnea.  She has been on Ambien, which is no longer been helpful.  She has had arthritis since year 2000, thyroid abnormalities diagnosed in 1968, a hysterectomy in 1986, and a right wrist operation after her fall in 2007 with a titanium plate and eight screws.,FAMILY HISTORY: , Her father died with heart disease in his 60s and her mother died of colon cancer.  She has a sister who she believes is probably healthy.  She has had two sons one who died of a blood clot after having been a heavy smoker and another who is healthy.  She has two normal vaginal deliveries.,SOCIAL HISTORY:  ,She lives with her husband.  She is a nonsmoker and no history of drug or alcohol abuse.  She does drink two to three drinks daily.  She completed 12th grade.,ALLERGIES: , Codeine and sulfa.,She has a Living Will and if unable to make decisions for herself, she would want her husband, Vilheim to make decisions for her.,MEDICATIONS,:  Premarin 0.625 mg p.o. q.o.d., Aciphex 20 mg p.o. q. daily, Toprol 50 mg p.o. q. daily, Norvasc 5 mg p.o. q. daily, multivitamin, Caltrate plus D, B-complex vitamins, calcium and magnesium, and vitamin C daily.,MAJOR FINDINGS: , On examination today, this is a pleasant and healthy appearing woman.,VITAL SIGNS:  Blood pressure 154/72, heart rate 87, and weight 153 pounds.  Pain is 0/10.,HEAD:  Head is normocephalic and atraumatic.  Head circumference is 54 cm, which is in the 10-25th percentile for a woman who is 5 foot and 6 inches tall.,SPINE:  Spine is straight and nontender.  Spinous processes are easily palpable.  She has very mild kyphosis, but no scoliosis.,SKIN:  There are no neurocutaneous stigmata.,CARDIOVASCULAR EXAM:  Regular rate and rhythm.  No carotid bruits.  No edema.  No murmur.  Peripheral pulses are good.  Lungs are clear.,MENTAL STATUS:  Assessed for recent and remote memory, attention span, concentration, and fund of knowledge.  She scored 30/30 on the MMSE when attention was tested with either spelling or calculations.  She had no difficulty with visual structures.,CRANIAL NERVES:  Pupils are equal.  Extraocular movements are intact.  Face is symmetric.  Tongue and palate are midline.  Jaw muscles strong.  Cough is normal.  SCM and shrug 5 and 5.  Visual fields intact.,MOTOR EXAM:  Normal for bulk, strength, and tone.  There was no drift or tremor.,SENSORY EXAM:  Intact for pinprick and proprioception.,COORDINATION:  Normal for finger-to-nose.,REFLEXES:  Are 2+ throughout.,GAIT:  Assessed using the Tinetti assessment tool.  She was fairly quick, but had some unsteadiness and a widened base.  She did not need an assistive device.  I gave her a score of 13/16 for balance and 9/12 for gait for a total score of 22/28.,REVIEW OF X-RAYS: , MRI was reviewed from June 26, 2008.  It shows mild ventriculomegaly with a trace expansion into the temporal horns.  The frontal horn span at the level of foramen of Munro is 3.8 cm with a flat 3rd ventricular contour and a 3rd ventricular span of 11 mm.  The sylvian aqueduct is patent.  There is no pulsation artifact.  Her corpus callosum is bowed and effaced.  She has a couple of small T2 signal abnormalities, but no significant periventricular signal change.,ASSESSMENT:  ,The patient is a 74-year-old woman who presents with mild progressive gait impairment and possible slowing of her cognition in the setting of ventriculomegaly suggesting possible adult hydrocephalus.,PROBLEMS/DIAGNOSES:,1.  Possible adult hydrocephalus (331.5).,2.  Mild gait impairment (781.2).,3.  Mild cognitive slowing (290.0).,PLAN: , I had a long discussion with the patient her husband.,I think it is possible that the patient is developing symptomatic adult hydrocephalus.  At this point, her symptoms are fairly mild.  I explained to them the two methods of testing with CSF drainage.  It is possible that a large volume lumbar puncture would reveal whether she is likely to respond to shunt and I described that test.  About 30% of my patients with walking impairment in a setting of possible adult hydrocephalus can be diagnosed with a large volume lumbar puncture.  Alternatively, I could bring her into the hospital for four days of CSF drainage to determine whether she is likely to respond to shunt surgery.  This procedure carries a 2% to 3% risk of meningitis.  I also explained that it would be reasonable to start with an outpatient lumbar puncture and if that is not sufficient we could proceed with admission for the spinal catheter protocol.
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DESCRIPTION: The patient is a 74-year-old woman who presents for neurological consultation for possible adult hydrocephalus.  Mild gait impairment and mild cognitive slowing.

Adult hydrocephalus can potentially progress to a serious condition that may require surgical intervention. The decision involves diagnostic procedures which carry risks, such as meningitis, and may lead to further treatment decisions including surgery. While her current symptoms are mild, the implications of misdiagnosis or delayed treatment could be significant, affecting her quality of life and mobility. Therefore, the stakes involve balancing the potential benefits of intervention against the risks of procedure and progression of illness.


Medical Specialty: Nephrology
Sample Name: Pyelonephritis - Discharge Summary

ADMISSION DIAGNOSES:,1.  Pyelonephritis.,2.  History of uterine cancer and ileal conduit urinary diversion.,3.  Hypertension.,4.  Renal insufficiency.,5.  Anemia.,DISCHARGE DIAGNOSES:,1.  Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit.,2.  Hypertension.,3.  Mild renal insufficiency.,4.  Anemia, which has been present chronically over the past year.,HOSPITAL COURSE:,  The patient was admitted with suspected pyelonephritis.  Renal was consulted.  It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr. X.  Her symptoms responded to IV antibiotics and she remained clinically stable.  Klebsiella was isolated in this urine, which was sensitive to Bactrim and she was discharged on p.o.  Bactrim.  She was scheduled on 08/07/2007 for further surgery.  She is to follow up with Dr. Y in 7-10 days.  She also complained of right knee pain and the right knee showed no sign of effusion.  She was exquisitely tender to touch of the patellar tendon.  It was thought that this did not represent intraarticular process.  She was advised to use ibuprofen over-the-counter two to three tabs t.i.d.
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DESCRIPTION: Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.

nephrology, uterine cancer, renal insufficiency, pyelonephritis, mucous plugging, ileal conduit

The situation described involves a patient with pyelonephritis, a history of uterine cancer with urinary diversion, hypertension, renal insufficiency, and chronic anemia. The patient was hospitalized and treated with antibiotics and released on oral Bactrim. The presence of pyelonephritis and renal insufficiency suggests significant medical conditions that require careful management, but the patient has been stabilized and discharged with a follow-up plan. While it is not an immediate life-or-death scenario, the complexity of the medical conditions indicates a moderate level of stakes. It's important to monitor the patient closely, especially given the history of cancer and current renal issues.


Medical Specialty: Nephrology
Sample Name: Nephrology Consultation - 1

REASON FOR CONSULTATION: , Renal failure.,HISTORY OF PRESENT ILLNESS:,  Thank you for referring Ms. Abc to ABCD Nephrology.  As you know she is a 51-year-old lady who was found to have a creatinine of 2.4 on a recent hospital admission to XYZ Hospital.  She had been admitted at that time with chest pain and was subsequently transferred to University of A and had a cardiac catheterization, which did not show any coronary artery disease.  She also was found to have a urinary tract infection at that time and this was treated with ciprofloxacin.  Her creatinine both at XYZ Hospital and University of A was elevated at 2.4.  I do not have the results from the prior years.  A repeat creatinine on 08/16/06 was 2.3.  The patient reports that she had gastric bypass surgery in 1975 and since then has had chronic diarrhea and recurrent admissions to the hospital with nausea, vomiting, diarrhea, and dehydration.  She also mentioned that lately she has had a lot of urinary tract infections without any symptoms and was in the emergency room four months ago with a urinary tract infection.  She had bladder studies a long time ago.  She complains of frequency of urination for a long time but denies any dysuria, urgency, or hematuria.  She also mentioned that she was told sometime in the past that she had kidney stones but does not recall any symptoms suggestive of kidney stones.  She denies any nonsteroidal antiinflammatory drug use.  She denies any other over-the-counter medication use.  She has chronic hypokalemia and has been on potassium supplements recently.  She is unsure of the dose.  ,PAST MEDICAL HISTORY: ,1.  Hypertension on and off for years.  She states she has been treated intermittently but lately has again been off medications.,2.  Gastroesophageal reflux disease.,3.  Gastritis.,4.  Hiatal hernia.,5.  H. pylori infection x3 in the last six months treated.,6.  Chronic hypokalemia secondary to chronic diarrhea.,7.  Recurrent admissions with nausea, vomiting, and dehydration.  ,8.  Renal cysts found on a CAT scan of the abdomen.,9.  No coronary artery disease with a recent cardiac catheterization with no significant coronary artery disease.  ,10.  Stomach bypass surgery 1975 with chronic diarrhea.,11.  History of UTI multiple times recently.,12.  Questionable history of kidney stones.,13.  History of gingival infection secondary to chronic steroid use, which was discontinued in July 2001.,14.  Depression.,15.  Diffuse degenerative disc disease of the spine.,16.  Hypothyroidism.,17.  History of iron deficiency anemia in the past.  ,18.  Hyperuricemia.  ,19.  History of small bowel resection with ulcerative fibroid.  ,20.  Occult severe GI bleed in July 2001.,PAST SURGICAL HISTORY: ,  The patient has had multiple surgeries including gastric bypass surgery in 1975, tonsils and adenoidectomy as a child, multiple tubes in the ears as a child, a cyst removed in both breasts, which were benign, a partial hysterectomy in 1980, history of sinus surgery, umbilical hernia repair in 1989, cholecystectomy in 1989, right ear surgery in 1989, disc surgery in 1991, bilateral breast cysts removal in 1991 and 1992, partial intestinal obstruction with surgery in 1992, pseudomyxoma peritonei in 1994, which was treated with chemotherapy for nine months, left ovary resection and fallopian tube removal in 1994, right ovarian resection and appendectomy and several tumor removals in 1994, surgery for an abscess in the rectum in 1996, fistulectomy in 1996, lumbar hemilaminectomy in 1999, cyst removal from the right leg and from the shoulder in 2000, cyst removed from the right side of the neck in 2003, lymph node resection in the neck April 24 and biopsy of a tumor in the neck and was found to be a schwannoma of the brachial plexus, and removal of brachial plexus tumor August 4, 2005.  ,CURRENT MEDICATIONS: ,1.  Nexium 40 mg q.d.,2.  Synthroid 1 mg q.d. ,3.  Potassium one q.d., unsure about the dose.  ,4.  No history of nonsteroidal drug use.,ALLERGIES:
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DESCRIPTION: Nephrology Consultation - Patient with renal failure.

The consultation involves a patient with renal failure, a serious medical condition that requires careful management and monitoring. The patient's complex medical history, including multiple surgeries, chronic conditions, and ongoing renal issues, adds to the stakes of the consultation. The potential for further complications and the need for a comprehensive assessment and treatment plan make this situation relatively high-stakes. The patient's kidney function and related health issues are critical to her overall health and wellbeing.


Medical Specialty: Nephrology
Sample Name: Nephrology Consultation - 2

HISTORY:,  The patient was in the intensive care unit setting; he was intubated and sedated.  The patient is a 55-year-old patient, who was admitted secondary to a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory as well as renal failure and found to be intubated.  He has been significantly hypotensive during his stay in the intensive care unit and has had minimal urine output.  His creatinine has gone from 2.1 to 4.2 overnight and the patient also developed florid acidosis and hypokalemia.  Nephrology input has been requested for management of acute renal failure and acidosis.,PAST MEDICAL HISTORY:,1.  Pancreatitis.,2.  Poison ivy.  The patient has recently been on oral steroids.,3.  Hypertension.,MEDICATIONS: , Include Ambien, prednisone, and blood pressure medication, which is not documented in the record at the moment.,INPATIENT MEDICATIONS: , Include Protonix IV, half-normal saline at 125 mL an hour, D5W with 3 ounces of bicarbonate at 150 mL an hour.  The patient was initially on dopamine, which has now been discontinued.  The patient remains on Levophed and Invanz 1 g IV q.24 h.,PHYSICAL EXAMINATION:,  Vitals, emergency room presentation, the blood pressure was 82/45.  His blood pressure in the ICU had dipped down into the 60s systolic, most recent blood pressure is 108/67 and he has been maintained on 100% FiO2.  The patient has had minimal urine output since admission.  HEENT, the patient is intubated at the moment.  Neck examination, no overt lymph node enlargement.  No jugular venous distention.  Lungs examination is benign in terms of crackles.  The patient has some harsh breath sounds secondary to being intubated.  CVS, S1 and S2 are fairly regular at the moment.  There is no pericardial rub.  Abdominal examination, obese, but benign.  Extremity examination reveals no lower extremity edema.  CNS, the patient is intubated and sedated.,LABORATORY DATA: , Blood work, sodium 152, potassium 2.7, bicarbonate 13, BUN 36, and creatinine 4.2.  The patient's BUN and creatinine yesterday were 23 and 2.1 respectively.  H&H of 17.7 and 51.6, white cell count of 8.4 from earlier on this morning.  The patient's liver function tests are all out of whack and his alkaline phosphatase is 226, ALT is 539, CK 1103, INR 1.66, and ammonia level of 55.  Latest ABGs show a pH of 7.04, bicarbonate of 10.7, pCO2 of 40.3, and pO2 of 120.7.,ASSESSMENT:,1.  Acute renal failure, which in all probability is secondary to acute tubular necrosis and sepsis and significant hypotension, but the patient is at the moment on 100% FiO2.  He has been given intravenous fluid at a high rate to replete intravascular volume and to hopefully address his acidosis.  The patient also has significant acidosis and his creatinine has increased from 2.1 to 4.2 overnight.  Given the fact that he would need dialytic support for his electrolyte derangements and for volume control, I would suggest continuous venovenous hemodiafiltration as opposed to conventional hemodialysis as the patient will not be able to tolerate conventional hemodialysis given his hemodynamic instability.,2.  Hypotension, which is significant and is related to his sepsis.  Now the patient has been maintained on Levophed and high rate of intravenous fluid at the moment.,3.  Acidosis, which is again secondary to his renal failure.  The patient was administered intravenous bicarbonate as mentioned above.  Dialytic support in the form of continuous venovenous hemodiafiltration was highly recommended for possible correction of his electrolyte derangements.,4.  Pancreatitis, which has been managed by his gastroenterologist.,5.  Sepsis, the patient is on broad-spectrum antibiotic therapy.,6.  Hypercalcemia.  The patient has been given calcium chloride.  We will need to watch for rebound hypercalcemia.,7.  Hypoalbuminemia.,8.  Hypokalemia, which has been repleted.,RECOMMENDATIONS: , Again include continuation of IV fluid and bicarbonate infusion as well as transfer to the Piedmont Hospital for continuous venovenous hemodiafiltration.
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DESCRIPTION: Patient with a diagnosis of pancreatitis, developed hypotension and possible sepsis and respiratory, as well as renal failure.

nephrology, intubated, consultation, hypercalcemia, hypoalbuminemia, iv fluid, acidosis, creatinine, hemodiafiltration, hypokalemia, hypotension, intravenous, pancreatitis, renal failure, respiratory, urine output, continuous venovenous hemodiafiltration, electrolyte derangements, conventional hemodialysis, continuous venovenous, venovenous hemodiafiltration, blood pressure, venovenous, bicarbonate, sepsis,

The situation involves a critically ill patient in the intensive care unit with multiple organ failures including acute renal failure, hypotension, and respiratory failure, in addition to significant electrolyte imbalances. The patient's condition is life-threatening, requiring intensive monitoring and potentially life-saving procedures such as continuous venovenous hemodiafiltration. Such a medical scenario is considered high-stakes due to the severity and complexity of the patient's condition, which demands immediate and meticulous medical intervention.


Medical Specialty: Nephrology
Sample Name: Nephrectomy - Partial (Laparoscopic )

PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED: , Laparoscopic right partial nephrectomy.,ESTIMATED BLOOD LOSS:,  250 mL.,X-RAYS: , None.,SPECIMENS: , Included right renal mass as well as biopsies from the base of the resection.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS: , None.,DRAINS: , Included a JP drain in the right flank as well as a #16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 60-year-old gentleman with a history of an enhancing right renal mass approximately 2 cm in diameter.  I had a long discussion with him concerning variety of options.  We talked in particular about extirpated versus ablative surgery.  Based on his young age and excellent state of health, decision was made at this point to proceed to a right partial nephrectomy laparoscopically.  All questions were answered, and he wished to proceed with surgery as planned.  Note that the patient does have a positive family history of renal cell carcinoma.,PROCEDURE IN DETAIL: , After acquisition of proper informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table.  After institution of adequate general anesthetic via endotracheal rod, he was placed into the right anterior flank position with his right side elevated on a roll and his right arm across his chest.  All pressure points were carefully padded, and he was securely taped to the table.  Note that sequential compression devices were in place on both lower extremities and were activated prior to induction of anesthesia.  His abdomen was then prepped and draped in a standard surgical fashion.  Note that a #16-French Foley catheter was in place per urethra as well as an orogastric tube.  The abdomen was insufflated at the right lateral abdomen using the Veress needle to a pressure of 15 without incident.  We then placed a Visiport 10 x 12 trocar in the right lateral abdomen.  With the trocar in place, we were able to place the remaining trocars under direct laparoscopic visualization.  We placed three additional trocars.  An 11 mm screw type trocar at the umbilicus, a 6 screw type trocar 7 cm in the midline above the umbilicus, and a 10 x 12 trocar to serve as a retractor port approximately 8 cm inferior in the midline.,The procedure was begun by reflecting the right colon by incising the white line of Toldt.  The colon was reflected medially, and the retroperitoneum was exposed on that side.  This was a fairly superficial lesion, so decision was made in advance to potentially not perform vascular clamping, however, I did feel it important to get high level control prior to proceeding to the partial.  With the colon reflected, the duodenum was identified, and it was reflected medially under Kocher maneuver.  The ureter and gonadal vein were identified on the right side and elevated.  The space between the ureter and the gonadal vein was then developed, and the gonadal vein was dropped elevating only the ureter, and carrying this plane dissection up towards the renal hilum.  Once we got up to the renal hilum, we were able to skeletonize the renal hilar vessels partially, and in particular, we did develop some of the upper pole dissection above the level of the hilum to provide for access for a Satinsky clamp or bulldogs.  The remainder of the kidney was then freed off its lateral and superior attachments primarily using the Harmonic scalpel and the LigaSure device.,With the kidney free and the hilum prepared, the Gerota fascia was taken down overlying the kidney exposing the renal parenchyma, and using this approach, we were able to identify the 2-cm, right renal mass located in the lower pole laterally.  A cap of fat was left overlying this mass.  Based on the position of the mass, we performed intraoperative laparoscopic ultrasound, which showed the mass to be somewhat deeper than initially anticipated.  Based on this finding, I decided to go ahead and clamp the renal hilum during resection.  A Satinsky clamp was introduced through the lower most trocar site and used to clamp the renal hilum en bloc.  Note that the patient had been receiving renal protection protocol including fenoldopam and mannitol throughout the procedure, and he also received Lasix prior to clamping the renal hilum.  With the renal hilum clamped, we did resect the tumor using cold scissors.  There was somewhat more bleeding than would be expected based on the hilar clamping; however, we were able to successfully resect this lesion.  We also took a biopsy at the base of the resection and passed off the table as a specimen for frozen section.  With the tumor resected, the base of the resection was then cauterized using the Argon beam coagulator, and several bleeding vessels were oversewn using figure-of-eight 3-0 Vicryl sutures with lap ties for tensioning.  We then placed a FloSeal into the wound and covered it with a Surgicel and held the pressure.  We then released the vascular clamp.  Total clamp time was 11 minutes.  There was minimal bleeding and occlusion of this maneuver, and after unclamping the kidney, the kidney pinked up appropriately and appeared well perfused after removal of the clamp.  We then replaced the kidney within its Gerota envelope and closed that with 3-0 Vicryl using lap ties for tensioning.  A JP drain was introduced through the right flank and placed adjacent to the kidney and sutured the skin with 2-0 nylon.  The specimen was placed into a 10-mm Endocatch bag and extracted from the lower most trocar site after extending it approximately 1 cm.  It was evaluated on the table and passed off the table for Pathology to evaluate.  They stated that the tumor was close to the margin, but there appeared to be 1-2 mm normal parenchyma around the tumor.  In addition, the frozen section biopsies from the base of the resection were negative for renal cell carcinoma.  Based on these findings, the lower most trocar site was closed using a running 0 Vicryl suture in the fascia.  We then re-insufflated the abdomen and carefully evaluated the entire intraoperative field for hemostasis.  Any bleeding points were controlled primarily using bipolar cautery or hemoclips.  The area was copiously irrigated with normal saline.  The colon was then replaced into its normal anatomic position.  The mesentry was evaluated.  There were no defects noted.  We closed the 10 x 12 lateral most trocar site using a Carter-Thompson closure device with 0-Vicryl.  All trocars were removed under direct visualization, and the abdomen was desufflated prior to removal of the last trocar.  The skin incisions were irrigated with normal saline and infiltrated with 0.25% Marcaine, and the skin was closed using a running 4-0 Monocryl in subcuticular fashion.  Benzoin and Steri-Strips were placed.  The patient was returned in supine position and awoken from general anesthetic without incident.  He was then transferred to hospital gurney and taken to the postanesthesia care unit for postoperative monitoring.  At the end of the case, sponge, instrument, and needle counts were correct.  I was scrubbed and present throughout the entire case.
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DESCRIPTION: Laparoscopic right partial nephrectomy due to right renal mass.

nephrology, renal mass, foley catheter, gerota fascia, jp drain, kocher maneuver, laparoscopic, ligasure device, satinsky clamp, toldt, bulldogs, nephrectomy, renal parenchyma, resection, urethra, vicryl sutures, partial nephrectomy, gonadal vein, renal hilum, satinsky, renal, kidney, hilum, foley, endotracheal,

This procedure involves a laparoscopic partial nephrectomy for a right renal mass, which is a significant surgical intervention due to the association with potential malignancy (renal cell carcinoma) and the technical challenges of performing kidney surgery. Although the operation was completed without complications, the stakes are high because errors or complications could lead to significant issues such as uncontrolled bleeding, damage to surrounding tissues, or incomplete removal of a cancerous mass. Additionally, the patient's positive family history for renal cell carcinoma adds to the stakes, as does the need for vigilant postoperative management to ensure recovery and detect possible malignancy. The patient’s health condition and potential impact on renal function also raise the stakes. Given these factors, this procedure is high-stakes for the patient’s immediate and long-term health.


Medical Specialty: Nephrology
Sample Name: Nephrectomy - Partial

PREOPERATIVE DIAGNOSIS:,  Left renal mass, 5 cm in diameter.,POSTOPERATIVE DIAGNOSIS:,  Left renal mass, 5 cm in diameter.,OPERATION PERFORMED: , Left partial nephrectomy.,ANESTHESIA: , General with epidural.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , About 350 mL.,REPLACEMENT: , Crystalloid and Cell Savers from the case.,INDICATIONS FOR SURGERY:  ,This is a 64-year-old man with a left renal mass that was confirmed to be renal cell carcinoma by needle biopsy.  Due to the peripheral nature of the tumor located in the mid to lower pole laterally, he has elected to undergo a partial nephrectomy.  Potential complications include but are not limited to,,1.  Infection.,2.  Bleeding.,3.  Postoperative pain.,4.  Herniation from the incision.,PROCEDURE IN DETAIL:,  Epidural anesthesia was administered in the holding area, after which the patient was transferred into the operating room.  General endotracheal anesthesia was administered, after which the patient was positioned in the flank standard position.  A left flank incision was made over the area of the twelfth rib.  The subcutaneous space was opened by using the Bovie.  The ribs were palpated clearly and the fascia overlying the intercostal space between the eleventh and twelfth rib was opened by using the Bovie.  The fascial layer covering of the intercostal space was opened completely until the retroperitoneum was entered.  Once the retroperitoneum had been entered, the incision was extended until the peritoneal envelope could be identified.  The peritoneum was swept medially.  The Finochietto retractor was then placed for exposure.  The kidney was readily identified and was mobilized from outside Gerota's fascia.  The ureter was dissected out easily and was separated with a vessel loop.  The superior aspect of the kidney was mobilized from the superior attachment.  The pedicle of the left kidney was completely dissected revealing the vein and the artery.  The artery was a single artery and was dissected easily by using a right-angle clamp.  A vessel loop was placed around the renal artery.  The tumor could be easily palpated in the lateral lower pole to mid pole of the left kidney.  The Gerota's fascia overlying that portion of the kidney was opened in the area circumferential to the tumor.  Once the renal capsule had been identified, the capsule was scored using a Bovie about 0.5 cm lateral to the border of the tumor.  Bulldog clamp was then placed on the renal artery.  The tumor was then bluntly dissected off of the kidney with a thin rim of a normal renal cortex.  This was performed by using the blunted end of the scalpel.  The tumor was removed easily.  The argon beam coagulation device was then utilized to coagulate the base of the resection.  The visible larger bleeding vessels were oversewn by using 4-0 Vicryl suture.  The edges of the kidney were then reapproximated by using 2-0 Vicryl suture with pledgets at the ends of the sutures to prevent the sutures from pulling through.  Two horizontal mattress sutures were placed and were tied down.  The Gerota's fascia was then also closed by using 2-0 Vicryl suture.  The area of the kidney at the base was covered with Surgicel prior to tying the sutures.  The bulldog clamp was removed and perfect hemostasis was evident.  There was no evidence of violation into the calyceal system.  A 19-French Blake drain was placed in the inferior aspect of the kidney exiting the left flank inferior to the incision.  The drain was anchored by using silk sutures.  The flank fascial layers were closed in three separate layers in the more medial aspect.  The lateral posterior aspect was closed in two separate layers using Vicryl sutures.  The skin was finally reapproximated by using metallic clips.  The patient tolerated the procedure well.
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DESCRIPTION: Left partial nephrectomy due to left renal mass.

nephrology, renal mass, bovie, finochietto retractor, gerota's fascia, herniation, bulldog clamp, needle biopsy, nephrectomy, partial nephrectomy, renal cell carcinoma, retroperitoneum, vicryl suture, gerota's, kidney, partial, renal, sutures, vicryl,

The procedure described is a surgical operation to remove a part of the kidney due to a tumor. While nephrectomy is a relatively common procedure, it involves significant risk due to the complexity of the surgery, potential complications such as bleeding, infection, or damage to adjacent organs, and the fact that it involves cancer treatment. In this specific case, the surgery proceeded without complications and the patient tolerated it well, which lowers the stakes slightly. Still, performing surgery on a vital organ like the kidney inherently carries substantial stakes, especially given the cancer diagnosis and the need to preserve as much kidney function as possible.


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

Medical Specialty: Nephrology
Sample Name: Kidney Transplant - Followup

REASON FOR VISIT:,  Kidney transplant.,HISTORY OF PRESENT ILLNESS: , The patient is a 52-year-old gentleman with ESRD secondary to hypertension, status post kidney transplant in February 2006.  He had to back down on his WelChol because of increased backache.  He actually increased his Pravachol and is tolerating this with minimal problems.  He comes in for followup.,ALLERGIES: , Aspirin and Altace caused cough, Lipitor and Pravachol at higher doses caused myalgias, Zetia caused myalgias.,MEDICATIONS:,  Gengraf 125/50 mg daily, CellCept 500 mg q.i.d., acyclovir 800 mg q.i.d., DexFol daily, ferrous sulfate Mondays, Wednesdays and Fridays, metoprolol 50 mg b.i.d., vitamin C daily, baby aspirin 81 mg daily, Bactrim Single Strength daily, Cozaar 50 mg daily, WelChol 625 mg daily, and Pravachol 10 mg daily.,PAST MEDICAL HISTORY:,1.  ESRD secondary to hypertension.,2.  Cadaveric kidney in February 2006.,3.  Gunshot wound in Southeast Asia.,4.  Hyperlipidemia.,REVIEW OF SYSTEMS: , Cardiovascular:  No chest pain, dyspnea on exertion, orthopnea, PND or edema.  GU:  No hematuria, foamy urine, pyuria, frequency or dysuria.  He has occasional tingling over his graft, but this is not bothering him today.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Pulse 82.  Blood pressure is 108/64.  Weight is 64.5 kg.  GENERAL:  He is in no apparent distress.  HEART:  Regular rate and rhythm.  No murmurs, rubs or gallops.  LUNGS:  Clear bilaterally.  ABDOMEN:  Soft, nontender, and nondistended.  Multiple scars.  Right lower quadrant graft is unremarkable.  EXTREMITIES:  No edema.,LABORATORY DATA:,  Labs dated 07-11-06, hematocrit 34.8, sodium 137, magnesium 1.9, potassium 4.9, chloride 102, CO2 25, BUN is 37, creatinine is 1.3, calcium 10.1, phosphorus 3.7, and albumin 4.4.  LFTs unremarkable.  Cholesterol 221, triglycerides 104, HDL 42, LDL 158, and cyclosporine 163.,IMPRESSION:,1.  Status post cadaveric kidney transplant with stable function.,2.  Hypertension under excellent control.,3.  Hyperlipidemia not at goal.  He simply is not tolerating higher doses of medications.,PLAN:,1.  We will add over-the-counter fish oil b.i.d.,2.  Continue all current medications.,3.  Recheck labs today including urinalysis.,4.  He will see transplant in two weeks and me in four weeks.  We will plan to send urine for decoy cells on his next visit.
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DESCRIPTION: Status post cadaveric kidney transplant with stable function.

nephrology, esrd secondary to hypertension, status post cadaveric kidney transplant, transplant with stable function, cadaveric kidney transplant, secondary to hypertension, stable function, cadaveric kidney, kidney transplant, esrd, hyperlipidemia, edema, cadaveric, welchol, orthopnea, kidney, transplant,

This situation involves a follow-up for a 52-year-old patient who has received a kidney transplant. Post-transplant follow-ups are crucial as they can help monitor the status of the organ, detect any rejection or complications early, and adjust medications as needed. While the immediate concerns appear to be under control and the patient's current condition seems stable, it's important to note that kidney transplant follow-ups inherently carry substantial importance due to the potential for severe complications. However, since the patient appears stable and the visit is routine, the stakes are not at the maximum level.


Medical Specialty: Nephrology
Sample Name: Laparoscopic Cryoablation

PREOPERATIVE DIAGNOSIS: , Bilateral renal mass.,POSTOPERATIVE DIAGNOSIS:,  Bilateral renal mass.,OPERATION: , Right hand-assisted laparoscopic cryoablation of renal lesions x2.  Lysis of adhesions and renal biopsy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  100 Ml.,FLUIDS: , Crystalloid.,The patient was bowel prepped and was given preoperative antibiotics.,BRIEF HISTORY: , The patient is a 73-year-old male, who presented to us with a referral from Dr. X's office with bilateral renal mass and renal insufficiency.  The patient's baseline creatinine was around 1.6 to 1.7.  The patient was found to have a 3 to 4-cm exophytic right renal mass, 1-cm renal mass inferior to that, and about 2-cm left renal mass.  Since the patient had bilateral renal disease and the patient had renal insufficiency, the best option at this time had been cryoprocedure for the kidney versus partial nephrectomy, one kidney at a time.  The patient understood all his options, had done some research on cryotherapy and wanted to proceed with the procedure.  The patient had a renal biopsy done, which showed a possibility of an oncocytoma, which also would indicate that if this is not truly a cancerous lesion, but there is an associated risk of renal cell carcinoma that the patient will benefit from a cryo of the kidney.,Risk of anesthesia, bleeding, infection, pain, hernia, bowel obstruction, ileus, injury to bowel, postoperative bleeding, etc., were discussed.  The patient understood the risk of delayed bleeding, the needing for nephrectomy, renal failure, renal insufficiency, etc., and wanted to proceed with the procedure.,DETAILS OF THE OR:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was given preoperative antibiotics.  The patient was bowel prepped.  The patient was placed in right side up, left side down, semiflank, with kidney rest up.  All the pressure points are very well padded using foam and towels.  The left knee was bent and the right knee was straight.  There was no tension on any of the joints.  All pressure points were well padded.  The patient was taped to the table using 2-inch wide tape all the way around.  A Foley catheter and OG tube were in place prior to prepping and draping the patient.  A periumbilical incision measuring about 6 cm was made.  The incision was carried through the subcutaneous tissue through the fascia using sharp dissection.  The peritoneum was open.  Abdomen was entered.  There were some adhesions on the right side of the abdomen, which were released using metz.  Two 12-mm ports were placed in the anteroaxillary line and one in the midclavicular line.  A gel porter was placed.  Pneumoperitoneum was obtained.  All ports were placed under direct vision, and the right colon was reflected medially.  Duodenum was cauterized.  Minimal dissection was done on the hilum and the Gerota's was opened laterally, and the renal masses were clearly visualized all the way around.  Pictures were taken.  Superficial biopsies were taken of 2 renal lesions using 3 different probes.  The 2 lesions were frozen.  The 2 probes were 2.4 mm and the other one was 3.1 mm in diameter.  So the R3.8 and R2.4 long probes were used.  Freezing/thawing, two cycles were done.  The temperatures were -131, -137, -150 and the freezing time was 5 and 10 minutes each and passive sign was done.  The exact times or exact temperatures are on the chart.  There was a nice ice ball with each freezing and with passive sign.  The probes were removed.,The probes were placed directly percutaneously through the skin into the renal lesions.,After freezing/thawing, the probes were removed and to seal with Surgicel were placed.  Pictures were taken after following total of 20 minutes were spent looking at the renal mass to make sure that there was no delayed bleeding.  From the time the probes were removed, until the time the laparoscope was removed, was total of 30 minutes.  So the masses were visualized for a total of 30 minutes without any pneumoperitoneum.  Pneumoperitoneum was obtained again.  Fibrin glue was placed over it just for precautionary measure.  There was about a total of 100 mL of blood loss overall with the entire procedure.  Please note that towels were used to prep off the colon and the liver to ensure there was no freezing of any other organ.  The kidney was kept in the left hand at all times.  Careful attention was drawn to make sure that the probe was deep enough, at least 3.5 to 4 cm in, to get the medial aspect of the tumors frozen.  The laparoscopic vacuum ultrasound showed that there was complete resolution of these lesions.  At the end of the procedure, after freezing/thawing and putting the fibrin glue, Surgicel, and EndoSeal, the colon was reflected medially.  Please note that the perirenal fat was placed over the lesion to ensure that the frozen area of the kidney was not exposed to the bowel.  Lap count was correct.  Please note that renal biopsy for permanent section was performed on the superficial aspect of the lesions.  No deeper biopsies were done to minimize the risk of bleeding.  The 12-mm ports were closed using 0-Vicryl and the middle incision.  The hand-port incision was closed using looped #1 PDS from both sides and was tied in the middle.  Please note that the pneumoperitoneum was closed using 0-Vicryl in running fashion.  After closing the abdomen, 4-0 Monocryl was used to close the skin and Dermabond was applied.,The patient was brought to recovery in a stable condition.
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DESCRIPTION: Right hand-assisted laparoscopic cryoablation of renal lesions x2.  Lysis of adhesions and renal biopsy.

nephrology, hand-assisted laparoscopic cryoablation, laparoscopic, cryoablation, bilateral renal mass, fibrin glue, laparoscopic cryoablation, renal insufficiency, renal lesions, renal biopsy, renal mass, insufficiency, renal, freezing/thawing, lesions

The scenario involves a medical procedure with significant complexities and potential complications. The patient is undergoing laparoscopic cryoablation for bilateral renal masses, which indicates serious underlying health issues, compounded by the patient's age (73) and renal insufficiency. The stakes are high due to the nature of the procedure, the risks of anesthesia, bleeding, renal failure, and the potential need for further surgical intervention. However, the procedure was successfully completed without major complications and the patient was stable post-operation. Therefore, while it is high-stakes due to the medical context and potential complications, the successful completion lowers the immediate risk level.


Medical Specialty: Nephrology
Sample Name: Hemodialysis Fistula Construction

PREOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with failing AV dialysis fistula.,PROCEDURE: , Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein.,ANESTHESIA: , Endotracheal.,DESCRIPTION OF OPERATIVE PROCEDURE: , General endotracheal anesthesia was initiated without difficulty.  The right arm, axilla, and chest wall were prepped and draped in sterile fashion.  Longitudinal skin incision was made from the lower axilla distally down the medial aspect of the arm and the basilic vein was not apparent.  The draining veins are the deep brachial veins.  The primary vein was carefully dissected out and small tributaries clamped, divided, and ligated with #3-0 Vicryl suture.  A nice length of vein was obtained to the distal one third of the arm.  This appeared to be of adequate length to transpose the vein through the subcutaneous tissue to an old occluded fistula vein, which remains patent through a small collateral vein.  A transverse skin incision was made over the superior aspect of the old fistula vein.  This vein was carefully dissected out and encircled with vascular tapes.  The brachial vein was then tunneled in a gentle curve above the bicep to the level of the cephalic vein fistula.  The patient was sensible, was then systemically heparinized.  The existing fistula vein was clamped proximally and distally, incised longitudinally for about a centimeter.  The brachial vein end was spatulated.  Subsequently, a branchial vein to arterialized fistula vein anastomosis was then constructed using running #6-0 Prolene suture in routine fashion.  After the completion of the anastomosis, the fistula vein was forebled and the branchial vein backbled.  The anastomosis was completed.  A nice thrill could be palpated over the outflow brachial vein.  Hemostasis was noted.  A 8 mm Blake drain was placed in the wound and brought out through inferior skin stab incision and ___ the skin with #3-0 nylon suture.  The wounds were then closed using interrupted #4-0 Vicryl and deep subcutaneous tissue ___ staples closed the skin.  Sterile dressings were applied.  The patient was then x-ray'd and taken to Recovery in satisfactory condition.  Estimated blood loss 50 mL, drains 8 mm Blake.  Operative complication none apparent, final sponge, needle, and instrument counts reported as correct.
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DESCRIPTION: Construction of right upper arm hemodialysis fistula with transposition of deep brachial vein.  End-stage renal disease with failing AV dialysis fistula.

nephrology, end-stage renal disease, av dialysis fistula, brachial vein, upper arm hemodialysis fistula, fistula, vein, hemodialysis, av, dialysis, anastomosis, brachial

The construction of a hemodialysis fistula for a patient with end-stage renal disease is a significant medical procedure. It is high-stakes because it involves surgical intervention critical for the patient's ongoing dialysis treatment, which is vital for their survival given their kidney failure. The procedure is technical and involves risks, although the operative note reports it as having no apparent complications. The outcome of the surgery directly impacts the patient's quality of life and dialysis efficiency.