Medical Specialty: Orthopedic
Sample Name: MRI Brain and C-T Spine

CC:, Weakness.,HX:, This 30 y/o RHM was in good health until 7/93, when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. He then went to a local neurosurgeon and a cervical spine CT scan, 9/25/92, revealed an intramedullary lesion at C2-3 and an extramedullary lesion at C6-7. He underwent a C6-T1 laminectomy with exploration and decompression of the spinal cord. His clinical condition improved over a 3 month post-operative period, and then progressively worsened. He developed left sided paresthesia and upper extremity weakness (right worse than left). He then developed ataxia, nausea, vomiting, and hyperreflexia. On 8/31/93, MRI C-spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. On 9/1/93, he underwent suboccipital craniotomy with tumor excision, decompression, and biopsy which was consistent with hemangioblastoma. His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9/93 through 1/19/94.,He was evaluated in the NeuroOncology clinic on 10/26/95 for consideration of chemotherapy. He complained of progressive proximal weakness of all four extremities and dysphagia. He had difficulty putting on his shirt and raising his arms, and he had been having increasing difficulty with manual dexterity (e.g. unable to feed himself with utensils). He had difficulty going down stairs, but could climb stairs. He had no bowel or bladder incontinence or retention.,MEDS:, none.,PMH:, see above.,FHX:, Father with Von Hippel-Lindau Disease.,SHX:, retired truck driver. smokes 1-3 packs of cigarettes per day, but denied alcohol use. He is divorced and has two sons who are healthy. He lives with his mother.,ROS:, noncontributory.,EXAM:, Vital signs were unremarkable.,MS: A&O to person, place and time. Speech fluent and without dysarthria. Thought process lucid and appropriate.,CN: unremarkable exept for 4+/4+ strength of the trapezeii. No retinal hemangioblastoma were seen.,MOTOR: 4-/4- strength in proximal and distal upper extremities. There is diffuse atrophy and claw-hands, bilaterally. He is unable to manipulate hads to any great extent. 4+/4+ strength throughout BLE. There is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities.,SENSORY: There was a right T3 and left T8 cord levels to PP on the posterior thorax. Decreased LT in throughout the 4 extremities.,COORD: difficult to assess due to weakness.,Station: BUE pronator drift.,Gait: stands without assistance, but can only manage to walk a few steps. Spastic gait.,Reflexes: Hyperreflexic on left (3+) and Hyporeflexic on right (1). Babinski signs were present bilaterally.,Gen exam: unremarkable.,COURSE: ,9/8/95, GS normal. By 11/14/95, he required NGT feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies.MRI Brain, 2/19/96, revealed several lesions (hemangioblastoma) in the cerebellum and brain stem. There were postoperative changes and a cyst in the medulla.,On 10/25/96, he presented with a 1.5 week h/o numbness in BLE from the mid- thighs to his toes, and worsening BLE weakness. He developed decubitus ulcers on his buttocks. He also had had intermittent urinary retention for month, chronic SOB and dysphagia. He had been sitting all day long as he could not move well and had no daytime assistance. His exam findings were consistent with his complaints. He had had no episodes of diaphoresis, headache, or elevated blood pressures. An MRI of the C-T spine, 10/26/96, revealed a prominent cervicothoracic syrinx extending down to T10. There was evidence of prior cervical laminectomy of C6-T1 with expansion of the cord in the thecalsac at that region. Multiple intradural extra spinal nodular lesions (hyperintense on T2, isointense on T1, enhanced gadolinium) were seen in the cervical spine and cisterna magna. The largest of which measures 1.1 x 1.0 x 2.0cm. There are also several large ring enhancing lesions in cerebellum. The lesions were felt to be consistent with hemangioblastoma. No surgical or medical intervention was initiated. Visiting nursing was provided. He has since been followed by his local physician
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DESCRIPTION: MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease.

This patient's situation is quite severe due to the diagnosis of multiple hemangioblastomas associated with Von Hippel-Lindau Disease, which is a genetic condition with potentially life-threatening complications. The patient has undergone significant neurological deficits, including weakness, atrophy, and difficulty with basic self-care, and has developed new neurological symptoms consistent with worsening disease. These include further neurological decline and complications such as dysphagia and aspiration risk, necessitating feeding tube placement. The presence of a prominent cervicothoracic syrinx and multiple intradural lesions exacerbate the complexity and severity of the case. Despite this, the fact that surgical or medical interventions are limited might also reflect the perceived prognosis or available treatment options at this stage. Hence, the situation is high-stakes due to the life-threatening nature, significant impairment of quality of life, and the complexity of managing a condition like Von Hippel-Lindau Disease.


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

Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy & Fusion - 9

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,PROCEDURE:,  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.,FIRST ASSISTANT: , Nurse practitioner.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion for anterior discectomy and fusion.  An incision was made midline to the anterior body of the sternocleidomastoid at C5-C6 level.  The skin, subcutaneous tissue, and platysma muscle was divided exposing the carotid sheath, which was retracted laterally.  Trachea and esophagus were retracted medially.  After placing the self-retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at C5 and C6 and confirming our position with intraoperative x-rays, we then proceeded with the discectomy.,We then cleaned out the disc at C5-C6 after incising the annulus fibrosis.  We cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes, and the next step was to clean out the disc space totally.  With this having been done, we then turned our attention with the operating microscope to the osteophytes.  We drilled off the vertebral osteophytes at C5-C6, as well as the uncovertebral osteophytes.  This was removed along with the posterior longitudinal ligament.  After we had done this, the dural sac was opposed very nicely and both C6 nerve roots were thoroughly decompressed.  The next step after the decompression of the thecal sac and both C6 nerve roots was the fusion.  We observed that there was a ____________ in the posterior longitudinal ligament.  There was a free fragment disc, which had broken through the posterior longitudinal ligament just to the right of midline.,The next step was to obtain the bone from the back bone, using cortical cancellous graft 10 mm in size after we had estimated the size.  That was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor.,After we had tapped in the bone plug, we then removed the distraction and the bone plug was fitting nicely.,We then use the Aesculap cervical titanium instrumentation with the 16-mm screws.  After securing the C5-C6 disc with four screws and titanium plate, x-rays showed good alignment of the spine, good placement of the bone graft, and after x-rays showed excellent position of the bone graft and instrumentation, we then placed in a Jackson-Pratt drain in the prevertebral space brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and skin was closed with Steri-Strips.  Blood loss during the operation was less than 10 mL.  No complications of the surgery.  Needle count, sponge count, and cottonoid count were correct.,
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DESCRIPTION: Herniated nucleus pulposus C5-C6.  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.

surgery, aesculap, titanium dynamic plating system, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, operating microscope, longitudinal ligament, discectomy, anterior, instrumentation, cervical, titanium

This document describes a surgical procedure involving an anterior cervical discectomy and fusion at the C5-C6. Such spinal surgeries are high-stakes due to the risks of complications such as nerve damage, infection, or complications related to anesthesia. The surgery affects critical structures like nerve roots and involves delicately handling the spinal column, which can lead to significant consequences if not executed properly. The success of this procedure is crucial for the patient's quality of life and neurological function.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Biceps Tendon Repair

PREOPERATIVE DIAGNOSIS: , Ruptured distal biceps tendon, right elbow.,POSTOPERATIVE DIAGNOSIS:,  Ruptured distal biceps tendon, right elbow.,PROCEDURE PERFORMED: , Repair of distal biceps tendon, right elbow.,PROCEDURE:  ,The patient was taken to OR, Room #2 and administered a general anesthetic.  The right upper extremity was then prepped and draped in the usual manner.  A sterile tourniquet was placed on the proximal aspect of the right upper extremity.  The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg.  Tourniquet time was 74 minutes.  A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin.  Hemostasis was achieved utilizing electrocautery.  Subcutaneous fat was separated and the skin flaps elevated.  The _________ was identified.  It was incised.  The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found.  There was some serosanguineous fluid from the previous rupture.  This area was suctioned clean.  The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface.  At this point, the #2 fiber wire was then passed through the tendon.  Two fiber wires were utilized in a Krackow-type suture.  Once this was completed, dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously.  The radial tuberosity was palpated.  Just ulnar to this, a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow.  A skin incision was made over this area.  Approximately two inches down to the skin and subcutaneous tissues, the fascia was split and the extensor muscle was also split.,A stat was then attached through the tip of that stat and passed back up through the antecubital fossa.  The tails of the fiber wire suture were grasped and pulled down through the second incision.  At this point, they were placed to the side.  Attention was directed at exposure of the radial tuberosity with a forearm fully pronated.  The tuberosity came into view.  The margins were cleared with periosteal elevator and sharp dissection.  Utilizing the power bur, a trough approximately 1.5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity.  Three small drill holes were then placed along the margin for passage of the suture.  The area was then copiously irrigated with gentamicin solution.  A #4-0 pullout wire was utilized to pass the sutures through the drill holes, one on each outer hole and two in the center hole.  The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated.  The suture was tied over the bone islands.  Both wounds were then copiously irrigated with gentamicin solution and suctioned dry.  Muscle fascia was closed with running #2-0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted #2-0 Vicryl and small staples.  The anterior incision was approximated with interrupted #2-0 Vicryl for Subq. and then skin was approximated with small staples.  Both wounds were infiltrated with a total of 30 cc of 0.25% Marcaine solution for postop analgesia.  A bulky fluff dressing was applied to the elbow, followed by application of a long-arm plaster splint maintaining the forearm in the supinated position.  Tourniquet was inflated prior to application of the splint.  Circulatory status returned to the extremity immediately.  The patient was awakened.  He was rather boisterous during his awakening, but care was taken to protect the right upper extremity.  He was then transferred to the recovery room in apparent satisfactory condition.
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DESCRIPTION: Ruptured distal biceps tendon, right elbow.  Repair of distal biceps tendon, right elbow.

surgery, ruptured distal biceps tendon, gentamicin solution, antecubital fossa, distal biceps, biceps tendon, tendon, tuberosity, biceps, elbow,

The situation involves a surgical procedure for repairing a ruptured distal biceps tendon. This is a specialized medical operation requiring precision and expertise, as it involves delicate handling of tendons, muscles, and bones, and the use of general anesthesia. The description indicates a systematic surgical process, outlining preoperative and postoperative considerations, as well as the technical steps involved in the procedure. Such surgeries are high-stakes due to the potential for significant impact on a patient's future mobility and function, the need for sterile technique to prevent infection, and the exacting nature of tendon repair. Additionally, general anesthesia introduces risks, further elevating the high-stakes nature of the situation.


Medical Specialty: Hematology - Oncology
Sample Name: Lymph Node Excisional Biopsy

PREOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,POSTOPERATIVE DIAGNOSIS: , Left axillary adenopathy.,PROCEDURE: , Left axillary lymph node excisional biopsy.,ANESTHESIA:,  LMA.,INDICATIONS: , Patient is a very pleasant woman who in 2006 had breast conservation therapy with radiation only.  Note, she refused her CMF adjuvant therapy and this was for a triple-negative infiltrating ductal carcinoma of the breast.  Patient has been following with Dr. Diener and Dr. Wilmot.  I believe that genetic counseling had been recommended to her and obviously the CMF was recommended, but she declined both.  She presented to the office with left axillary adenopathy in view of the high-risk nature of her lesion.  I recommended that she have this lymph node removed.  The procedure, purpose, risk, expected benefits, potential complications, alternative forms of therapy were discussed with her and she was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken into the operating room where after induction of appropriate anesthesia, her left chest, neck, axilla, and arm were prepped with Betadine solution, draped in a sterile fashion.  An incision was made at the hairline, carried down by sharp dissection through the clavipectoral fascia.  I was able to easily palpate the lymph node and grasp it with a figure-of-eight 2-0 silk suture and by sharp dissection, was carried to hemoclip all attached structures.  The lymph node was excised in its entirety.  The wound was irrigated.  The lymph node sent to pathology.  The wound was then closed.  Hemostasis was assured and the patient was taken to recovery room in stable condition.
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DESCRIPTION: Left axillary lymph node excisional biopsy.  Left axillary adenopathy.

hematology - oncology, axillary lymph node excisional biopsy, sharp dissection, excisional biopsy, lymph node, axillary, excisional, biopsy

The situation involves a surgical procedure on a patient who has had a history of breast cancer and is currently exhibiting left axillary adenopathy. The stakes are increased due to the patient's refusal of prior recommended treatments for a high-risk breast condition, and the need for the biopsy results to determine any further oncological concerns. Given the potential implications for cancer treatment and management, this is a moderately high-stakes scenario, as it involves potential life-altering outcomes based on the biopsy results.


Medical Specialty: Surgery
Sample Name: Delivery Note - 2

Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete, and then as she began to push, there were additional decelerations of the baby's heart rate, which were suspicions of cord around the neck.  These were variable decelerations occurring late in the contraction phase.  The baby was in a +2 at a 3 station in an occiput anterior position, and so a low-forceps delivery was performed with Tucker forceps using gentle traction, and the baby was delivered with a single maternal pushing effort with retraction by the forceps.  The baby was a little bit depressed at birth because of the cord around the neck, and the cord had to be cut before the baby was delivered because of the tension, but she responded quickly to stimulus and was given an Apgar of 8 at 1 minute and 9 at 5 minutes.  The female infant seemed to weigh about 7.5 pounds, but has not been officially weighed yet.  Cord gases were sent and the placenta was sent to Pathology.  The cervix, the placenta, and the rectum all seemed to be intact.  The second-degree episiotomy was repaired with 2-O and 3-0 Vicryl.  Blood loss was about 400 mL.,Because of the hole in the dura, plan is to keep the patient horizontal through the day and a Foley catheter is left in place.  She is continuing to be attended to by the anesthesiologist who will manage the epidural catheter.  The baby's father was present for the delivery, as was one of the patient's sisters.  All are relieved and pleased with the good outcome.
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DESCRIPTION: Pitocin was started quickly to allow for delivery as quickly as possible.  Baby was delivered with a single maternal pushing effort with retraction by the forceps.

surgery, labor, delivery, pitocin, tucker forceps, apnea, cerebrospinal fluid, contraction, epidural, episiotomy, fetal heart tones, baby was delivered, baby's heart rate, heart rate, catheter, placenta, cordNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

This situation involves the delivery of a baby where complications arose due to decelerations in the baby's heart rate and suspicion of a nuchal cord (cord around the neck). However, the baby was quickly delivered with the help of low-forceps delivery, and the baby responded well after initial depression. Given these factors, the situation had the potential for significant risks to both mother and baby, but it was managed efficiently, leading to a positive outcome. The use of additional support methods like Pitocin, forceps, and attentive medical care underscores the high-stakes nature of delivering a baby when complications arise.


Medical Specialty: Radiology
Sample Name: CT Neck

TECHNIQUE: , Sequential axial CT images were obtained from the base of the brain to the thoracic inlet following the uneventful administration of 100 CC Optiray 320 intravenous contrast.,FINDINGS:,  Scans through the base of the brain are unremarkable.  The oropharynx and nasopharynx are within normal limits.  The airway is patent.  The epiglottis and epiglottic folds are normal.  The thyroid, submandibular, and parotid glands enhance homogenously.  The vascular and osseous structures in the neck are intact.  There is no lymphadenopathy.  The visualized lung apices are clear.,IMPRESSION:  ,No acute abnormalities.
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DESCRIPTION: Common CT Neck template.

Common CT Neck template.

radiology, sequential axial ct images, optiray, parotid glands, epiglottic folds, epiglottis, base of the brain, ct neckNOTE

The situation presented is a routine radiology report from a CT neck scan that shows no acute abnormalities or concerning findings. This is a common scenario in radiology practices where a CT scan results come back normal. There is no immediate threat to patient health or significant clinical decision-making involved based on this report alone.


Medical Specialty: Consult - History and Phy.
Sample Name: Lumbar Radiculopathy - Consult

FAMILY HISTORY:,  Her father died from leukemia.  Her mother died from kidney and heart failure.  She has two brothers; five sisters, one with breast cancer; two sons; and a daughter.  She describes cancer, hypertension, nervous condition, kidney disease, high cholesterol, and depression in her family.,SOCIAL HISTORY:,  She is divorced.  She does not have support at home.  She denies tobacco, alcohol, and illicit drug use.,ALLERGIES: , Hypaque dye when she had x-rays for her kidneys.,MEDICATIONS: , Prempro q.d., Levoxyl 75 mcg q.d., Lexapro 20 mg q.d., Fiorinal as needed, currently she is taking it three times a day, and aspirin as needed.  She also takes various supplements including multivitamin q.d., calcium with vitamin D b.i.d., magnesium b.i.d., Ester-C b.i.d., vitamin E b.i.d., flax oil and fish oil b.i.d., evening primrose 1000 mg b.i.d., Quercetin 500 mg b.i.d., Policosanol 20 mg two a day, glucosamine chondroitin three a day, coenzyme-Q 10 30 mg two a day, holy basil two a day, sea vegetables two a day, and very green vegetables.,PAST MEDICAL HISTORY:,  Anemia, high cholesterol, and hypothyroidism.,PAST SURGICAL HISTORY:,  In 1979, tubal ligation and three milk ducts removed.  In 1989 she had a breast biopsy and in 2007 a colonoscopy.  She is G4, P3, with no cesarean section.,REVIEW OF SYSTEMS:  ,HEENT:  For headaches and sore throat.  Musculoskeletal:  She is right handed with joint pain, stiffness, and decreased range of motion.  Cardiac:  For heart murmur.  GI:  Negative and noncontributory.  Respiratory:  Negative and noncontributory.  Urinary:  Negative and noncontributory.  Hem-Onc:  Negative and noncontributory.  Vascular:  Negative and noncontributory.  Psychiatric:  Negative and noncontributory.  Genital:  Negative and noncontributory.  She denies any bowel or bladder dysfunction or loss of sensation in her genital area.,PHYSICAL EXAMINATION: , She is 5 feet 2 inches tall.  Current weight is 132 pounds, weight one year ago was 126 pounds.  BP is 122/68.  On physical exam, patient is alert and oriented with normal mentation and appropriate speech, in no acute distress.  General, a well-developed and well-nourished female in no acute distress.  HEENT exam, head is atraumatic and normocephalic.  Eyes, sclerae are anicteric.  Teeth good dentition.  Cranial nerves II, III, IV, and VI, vision is intact, visual fields are full to confrontation, EOMs full bilaterally, and pupils are equal, round, and reactive to light.  Cranial nerves V and VII, normal facial sensation and symmetrical facial movement.  Cranial nerve VIII, hearing intact.  Cranial nerves IX, X, and XII, tongue protrudes midline and palate elevates symmetrically.,Cranial nerve XI, strong and symmetrical shoulder shrugs against resistance.  Cardiac, regular rate and rhythm.  Chest and lungs are clear bilaterally.  Skin is warm and dry, normal turgor and texture.  No rashes or lesions are noted.  General musculoskeletal exam reveals no gross deformities, fasciculations, or atrophy.  Peripheral vascular, no cyanosis, clubbing, or edema.  Examination of the low back reveals some mild paralumbar spasms.  She is nontender to palpation of her spinous processes, SI joints, and paralumbar musculature.  She does have some poking sensation to deep palpation into the left buttock where she describes some zinging sensation.  Deep tendon reflexes are 2+ bilateral knees and ankles.  No ankle clonus is elicited.  Babinski, toes are downgoing.  Straight leg raising is negative bilaterally.  Strength on manual exam is 5/5 and equal bilateral lower extremity.  She is able to ambulate on her toes and her heels without any difficulty.  She is able to get up standing on one foot on to the toes.  She does have some difficulty getting up on to her heels when standing on one foot.  She has trouble with this on the left and right.  She complains of increased pain while doing this as well.  She also has positive Patrick/FABER on the right with pain with internal and external rotation, negative on the left.  Sensation is intact.  She has good accuracy to pinprick, dull versus sharp.,FINDINGS: , The patient brings in lumbar spine MRI dated November 20, 2007, which demonstrates degenerative disc disease throughout.  At L4-L5, there is an annular disc bulge with fissuring with facet arthrosis and ligamentum flavum hypertrophy yielding moderate central stenosis and neuroforaminal narrowing but the nerves do not appear to be impinged.  At L5-S1, in the right neuroforamina, there appears to be soft tissue density just lateral and posterior to the nerve root, which may cause some displacement, but it is unclear.  This could represent a facet synovial cyst.  This is lateral to the facet.  She does not have x-rays for review.  She has had hip and knee x-rays taken but does not bring them in with her.,ASSESSMENT: , Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.,PLAN: , We discussed treatment options with this patient including:,1  Do nothing.,2.  Conservative therapies.,3.  Surgery.,She seems to have some issues with her right hip, so I would like for her to fax us over the report of her hip and knee x-rays.  We will also order some x-rays of her lumbar spine as well as lower extremity EMG.,At this point, the patient has not exhausted conservative measures and would like to start with epidural steroid injections, so we will go ahead and send her out for that.  After she has gotten her second epidural injection, she will return to the office for a followup visit to see how she is doing.  All questions and concerns were addressed.  If she should have any further questions, concerns, or complications, she will contact our office immediately.  Otherwise, we will see her as scheduled.  Case was reviewed and discussed with Dr. L.
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DESCRIPTION: Low back pain, lumbar radiculopathy, degenerative disc disease, lumbar spinal stenosis, history of anemia, high cholesterol, and hypothyroidism.

consult - history and phy., back pain, hip pain, low back pain, x-rays, lumbar spinal stenosis, degenerative disc disease, spinal stenosis, lumbar spine, lumbar radiculopathy, cranial nerves, lumbar, degenerative, anemia,

The situation involves a medical consultation for a patient with lumbar radiculopathy, degenerative disc disease, and other health conditions. While this scenario addresses health issues that require medical attention, including potential treatments like surgery or epidural steroid injections, it doesn't involve immediate life-threatening conditions at present. The treatment plan is methodical and conservative, starting with non-invasive measures before considering surgery. The stakes are higher than routine medical check-ups or trivial conditions but lower than critical emergencies. Overall, it is an important medical scenario with moderate stakes as it involves management of chronic conditions with potential implications for the patient's quality of life.


Medical Specialty: Psychiatry / Psychology
Sample Name: Mental Status Evaluation

COMPREHENSIVE MENTAL STATUS EVALUATION,REASON FOR REFERRAL/GENERAL OBSERVATIONS:,  The patient was referred for a Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability.  He is a 43-year-old married, white male who came unaccompanied to the evaluation.  He drove himself suggesting that he drives regularly.  He reportedly has been on Disability since around 2002.  He was a good historian, freely offering information.  He was dressed and groomed casually, yet neat and appropriate in appearance.  He was cooperative with all questions presented and the information collected is felt to be a reliable indication of current functioning.  No censorship of data was indicated.  ,PRESENT PROBLEMS:,  The claimant described his recent problems as, "serious depression.  Very hard to concentrate.  Very short tempered.  Usually distracted." ,The claimant reportedly has had significant problems with depression since around 1997.,The claimant last worked about six weeks ago.  He was drafting at a company in Stanfield, North Carolina, for almost six months and was laid off because "I had a breakdown and ended up in the hospital.  They said that I wasn't reliable enough and laid me off."  Prior to that he worked for two and a half months doing drafting at another company and was laid off because he was no longer needed.  ,The claimant has had significant emotional problems since around 1997.  He was first hospitalized in that year and has been hospitalized five more times since then.  The last hospitalization was last month in Atlanta, Georgia.  He has tried to overdose in the past as well as cut his wrist.  He even had to undergo electroconvulsive therapy in 2001, because of depression.  He also, supposedly, has a history of sexual assault towards a minor and his on probation for that incident.  Details regarding this episode of child sexual assault were not forthcoming.,The claimant now takes Effexor 75 mg b.i.d.  He is not involved in outpatient therapy.  ,PERSONAL, FAMILY AND SOCIAL HISTORY:,  The claimant indicated that he graduated from high school in regular classes.  He did have to repeat the kindergarten because he was too young.  He worked for about 10 years at a company in Massachusetts.  He was not advancing on that job and therefore quit.  He has had three subsequent jobs and a number of emotional problems since.  He indicated usually getting along with others but stated, "I had trouble taking direction from someone younger than me.  I resent getting nagged at.  I'd get angry or just seethe."  He has been let go from his last two jobs because of emotional issues.  ,The claimant was married the first time for five years.  He has no children.  He now lives at home with his wife., ,The claimant denied any legal problems.  He suggested that his mother had bipolar disorder.  He has never served in the military.,The claimant denied the use or abuse of tobacco, alcohol or illicit drugs.  He stopped drinking in 1997.  Prior to that he drank about a six pack of beer per day for about 15 years.,The claimant takes the no other prescribed medications., ,DAILY ACTIVITIES AND FUNCTIONING:,  The claimant described his typical day as follows, "I usually get up about 7:00 to 7:30.  Have breakfast.  Take a shower about 8:30.  Do errands.  Me and my wife are out of the house by 9:00.  Check e-mail at the library.  I like the computer.  We have lunch 11:30 or 12:00.  Do errands or watch talk shows or I'll read.  I love to read.  Around 5:00 to 5:30, have supper.  Watch the news, game shows.  In bed by 10:00."  He will help with vacuuming, doing the dishes or yard work.  His wife does most of the house cleaning.  He does no cooking.  He and his wife get out every day usually for three or four hours.  He has a neighbor next door that he will see twice a week.  He used to go to the gym but has not been in a few weeks.  No other family contact was described and he does not go to church.  When asked what he enjoys he stated, "read, use my computer or go ride my bike.", ,MENTAL STATUS EVALUATION:,  On interview, the claimant looked his stated age of 43 years.  He was tall in stature and thin in weight.  He was neat and clean in appearance.  Posture was somewhat tense but psychomotor activity was not remarkable.  Eye contact was fleeting with fair social skills evident.  Facial expression was tense and affect was restricted with little animation noted.  General mood appeared dysphoric.  Speech was clear, coherent, logical, goal-directed and relevant.  He was cooperative in attitude toward the examiner.  He described his recent mood as, "cloudy, gray because we've got a lot of personal problems right now.  I'm frustrated because I don't know where things are going."  He described some problems with falling asleep and staying asleep at night as well as decreased energy level.  He denied appetite disturbance.  He has lost interest in some activities suggesting mild anhedonia.  He has trouble with attention and concentration stating, "I have trouble recalling how to do things on the computer. I've always been technically minded, but now it's harder."  He has thoughts of suicide about once or twice a week and has often fled situations in the past.  He stated, "I try to keep myself from running away."  He denied any plan or intent for suicide.  He suggested significant anxiety problems as well.  He stated, "I'm dealing with pedophilia.  I try to time it so that I don't go to a store with lots of people around.  If there is people I get real edgy, heart pounds, shortness of breath.  A lot of chest discomfort."  He has these panic symptoms quite regularly and they have occurred ever since 1997.  That was the time that he engaged in some type of sexual assault with a minor and spent about a week in jail.  No phobic processes were suggested.  No psychotic symptoms were revealed.  He denied hallucinations and no delusional material was elicited.  Thought content was appropriate to mood and circumstances.,The claimant was oriented in all spheres.  He evidenced adequate memory for both recent and remote events.  He was able to recall 3 of 3 words after a 1 minute and 10 minute delay.  Fair sustained attention and concentration skills were shown.  He was able to spell a word backward and performed a serial 7 subtraction task affectively.  Basic calculation skills were intact and no language-based dysfunction was noted.  Social judgment was also intact as he gave a good response to finding a wallet in the street, "find who the owner was, bring it to the police station or contact the person," and to seeing smoke in a theater, "Get a hold of staff so they could evacuate."  Adequate conceptual abilities was shown with similarity comparisons.  Somewhat limited abstraction was shown with proverb interpretation, glass houses, "don't do anything you're not supposed to do."  Premorbid intellect is estimated to be at least in the average range.  Insight regarding his situation was fair.,DIAGNOSTIC IMPRESSION:,Axis I:  Major Depression, recurrent, moderate.  Panic disorder without agoraphobia.,SUMMARY AND CONCLUSIONS:,  Based on this evaluation, I believe the claimant's current condition would continue to result in difficulty with work-related activities.  He continues to show significant problems with depression and anxiety.  He is quite withdrawn and socially isolated and has panic attacks whenever he is confronted with public situations.  He relies on his wife to take care of most all household task.  He engages in very few simple, routine and repetitive activities. Cognitive capacity was relatively intact suggesting no significant problems in maintaining focus and pace with task.,RECOMMENDATIONS/CAPABILITY:,  The claimant was strongly encouraged to get some additional help for his emotional problems.  He would benefit from having someone to speak with on a regular basis and some referrals were offered. ,It is the opinion of this examiner that the claimant is capable of handling his own funds if so assigned.
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DESCRIPTION: Comprehensive Mental Status Evaluation for the purpose of assisting in the determination of eligibility for Disability

The situation described is a comprehensive mental status evaluation to determine eligibility for disability benefits. The evaluation delves into significant mental health issues, including major depression and a panic disorder, with a history of hospitalizations and self-harm. These factors influence the individual's capability to work and maintain daily functions. The stakes are high from the perspective of the individual's mental health and well-being, as well as their financial stability and future support. Moreover, considering the claimant's struggle with pedophilic tendencies, ongoing anxiety, and societal reintegration, the outcome of this evaluation could seriously impact their access to necessary resources or rehabilitation programs.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Acquired Hypothyroidism Followup

PROBLEM LIST:,1.  Acquired hypothyroidism.,2.  Papillary carcinoma of the thyroid gland, status post total thyroidectomy in 1992.,3.  Diabetes mellitus.,4.  Insomnia with sleep apnea.,HISTORY OF PRESENT ILLNESS: , This is a return visit to the endocrine clinic for the patient with history as noted above.  She is 45 years old.  Her last visit was about 6 months ago.  Since that time, the patient states her health has remained unchanged.  Currently, primary complaint is one of fatigue that she feels throughout the day.  She states, however, she is doing well with CPAP and wakes up feeling refreshed but tends to tire out later in the day.  In terms of her thyroid issues, the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism.  She is not reporting temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, hyperdefecation or diarrhea.  Her weight has been stable.  She is not reporting proximal muscle weakness.,CURRENT MEDICATIONS:,1.  Levothyroxine 125 micrograms p.o. once daily.,2.  CPAP.,3.  Glucotrol.,4.  Avandamet.,5.  Synthroid.,6.  Byetta injected twice daily.,REVIEW OF SYSTEMS: , As stated in the HPI.  She is not reporting polyuria, polydipsia or polyphagia.  She is not reporting fevers, chills, sweats, visual acuity changes, nausea, vomiting, constipation or diarrhea.  She is not having any lightheadedness, weakness, chest pain, shortness of breath, difficulty breathing, orthopnea or dyspnea on exertion.,PHYSICAL EXAMINATION:,GENERAL:  She is an overweight, very pleasant woman, in no acute distress.  VITAL SIGNS:  Temperature 96.9, pulse 85, respirations not counted, blood pressure 135/65, and weight 85.7 kg.  NECK:  Reveals well healed surgical scar in the anteroinferior aspect of the neck.  There is no palpable thyroid tissue noted on this examination today.  There is no lymphadenopathy.  THORAX:  Reveals lungs that are clear, PA and lateral, without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  S1 and S2 without murmur.  No S3, no S4 is auscultated.  EXTREMITIES:  Deep tendon reflexes 2+/4 without a delayed relaxation phase.  No fine resting tremor of the outstretched upper extremity.  SKIN, HAIR, AND NAILS:  All are unremarkable.,LABORATORY DATABASE: , Lab data on 08/29/07 showed the following:  Thyroglobulin quantitative less than 0.5 and thyroglobulin antibody less than 20, free T4 1.35, and TSH suppressed at 0.121.,ASSESSMENT AND PLAN:,This is a 45-year-old woman with history as noted above.,1.  Acquired hypothyroidism, status post total thyroidectomy for papillary carcinoma in 1992.,2.  Plan to continue following thyroglobulin levels.,3.  Plan to obtain a free T4, TSH, and thyroglobulin levels today.,4.  Have the patient call the clinic next week for followup and continued management of her hypothyroid state.,5.  Plan today is to repeat her thyroid function studies.  This case was discussed with Dr. X and the recommendation.  We are giving the patient today is for us to taper her medication to get her TSH somewhere between 0.41 or less.  Therefore, labs have been drawn.  We plan to see the patient back in approximately 6 months or sooner.  A repeat body scan will not been done, the one in 03/06 was negative.
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DESCRIPTION: Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.

soap / chart / progress notes, thyroid function studies, thyroid gland, diabetes mellitus, papillary carcinoma, total thyroidectomy, acquired hypothyroidism, carcinoma, thyroidectomy, thyroglobulin, hypothyroidism,

The situation involves a follow-up visit for a patient with multiple ongoing health conditions, including acquired hypothyroidism, a history of thyroid cancer, and diabetes mellitus. While these conditions require careful management and monitoring, the patient is currently stable and not in acute distress. The fatigue mentioned by the patient is a concern but seems to be managed by CPAP therapy. The plan includes adjustments to medication, routine lab tests, and a scheduled follow-up, which are standard practices in chronic disease management. Thus, while the situation involves important medical decisions, it is not currently a high-stakes or emergency situation.


Medical Specialty: Orthopedic
Sample Name: Hallux Infected Bone Resection

PREOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,POSTOPERATIVE DIAGNOSIS: , Osteomyelitis, left hallux.,PROCEDURES PERFORMED: , Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.,ANESTHESIA: , TIVA/Local.,HISTORY:,  This 77-year-old male presents to ABCD preoperative holding area after keeping himself NPO since mid night for surgery on his infected left hallux.  The patient has a history of chronic osteomyelitis and non-healing ulceration to the left hallux of almost 10 years' duration.  He has failed outpatient antibiotic therapy and conservative methods.  At this time, he desires to attempt surgical correction.  The patient is not interested in a hallux amputation at this time; however, he is consenting to removal of infected bone.  He was counseled preoperatively about the strong probability of the hallux being a "floppy tail" after the surgery and accepts the fact.  The risks versus benefits of the procedure were discussed with the patient in detail by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL:  ,The patient's wound was debrided with a #15 blade and down to good healthy tissue preoperatively.  The wound was on the planar medial, distal and dorsal medial.  The wound's bases were fibrous.  They did not break the bone at this point.  They were each approximately 0.5 cm in diameter.  After IV was established by the Department of Anesthesia, the patient was taken to the operating room and placed on the operating table in supine position with safety straps placed across his waist for his protection.,Due to the patient's history of diabetes and marked calcifications on x-ray, a pneumatic ankle tourniquet was not applied.  Next, a total of 3 cc of a 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine plain was used to infiltrate the left hallux and perform a digital block.  Next, the foot was prepped and draped in the usual aseptic fashion.  It was lowered in the operative field and attention was directed to the left hallux after the sterile stockinet was reflected.  Next, a #10 blade was used to make a linear incision approximately 3.5 cm in length along the dorsal aspect of the hallux from the base to just proximal to the eponychium.  Next, the incision was deepened through the subcutaneous tissue.  A heavy amount of bleeding was encountered.  Therefore, a Penrose drain was applied at the tourniquet, which failed.  Next, an Esmarch bandage was used to exsanguinate the distal toes and forefoot and was left in the forefoot to achieve hemostasis.  Any small veins crossing throughout the subcutaneous layer were ligated via electrocautery.  Next, the medial and lateral margins of the incision were under marked with a sharp dissection down to the level of the long extension tendon.  The long extensor tendon was thickened and overall exhibited signs of hypertrophy.  The transverse incision through the long extensor tendon was made with a #15 blade.  Immediately upon entering the joint, yellow discolored fluid was drained from the interphalangeal joint.  Next, the extensor tendon was peeled dorsally and distally off the bone.  Immediately the head of the proximal phalanx was found to be lytic, disease, friable, crumbly, and there were free fragments of the medial aspect of the bone, the head of the proximal phalanx.  This bone was removed with a sharp dissection.  Next, after adequate exposure was obtained and the collateral ligaments were released off the head of proximal phalanx, a sagittal saw was used to resect the approximately one-half of the proximal phalanx.  This was passed off as the infected bone specimen for microbiology and pathology.  Next, the base of the distal phalanx was exposed with sharp dissection and a rongeur was used to remove soft crumbly diseased medial and plantar aspect at the base of distal phalanx.  Next, there was diseased soft tissue envelope around the bone, which was also resected to good healthy tissue margins.  The pulse lavage was used to flush the wound with 1000 cc of gentamicin-impregnated saline.  Next, cleaned instruments were used to take a proximal section of proximal phalanx to label a clean margin.  This bone was found to be hard and healthy appearing.  The wound after irrigation was free of all debris and infected tissue.  Therefore anaerobic and aerobic cultures were taken and sent to microbiology.  Next, OsteoSet beads, tobramycin-impregnated, were placed.  Six beads were placed in the wound.  Next, the extensor tendon was re-approximated with #3-0 Vicryl.  The subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #4-0 nylon in a horizontal mattress technique.,The Esmarch bandage was released and immediate hyperemic flush was noted at the digits.  A standard postoperative dressing was applied consisting of 4 x 4s, Betadine-soaked #0-1 silk, Kerlix, Kling, and a loosely applied Ace wrap.  The patient tolerated the above anesthesia and procedure without complications.  He was transported via a cart to the Postanesthesia Care Unit.  His vitals signs were stable and vascular status was intact.  He was given a medium postop shoe that was well-formed and fitting.  He is to elevate his foot, but not apply ice.  He is to follow up with Dr. X.  He was given emergency contact numbers.  He is to continue the Vicodin p.r.n. pain that he was taking previously for his shoulder pain and has enough of the medicine at home.  The patient was discharged in stable condition.
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DESCRIPTION: Resection of infected bone, left hallux, proximal phalanx, and distal phalanx.  Osteomyelitis, left hallux.

orthopedic, osteomyelitis, proximal phalanx, distal phalanx, infected bone, proximal, bone, phalanx, healing, hallux, infected, tissue, distal,

The situation involves a surgical procedure on a 77-year-old patient to address osteomyelitis in the left hallux, which has been chronic and non-responsive to conservative treatments for nearly a decade. While the surgery itself appears to be routine in the context of orthopedic procedures, the stakes are higher due to the patient's age, the chronicity of the condition, and the risk of infection spreading if not properly addressed. However, the patient was stabilized post-surgery, and there were no immediate complications, which mitigates the risk. The stakes are also moderated by the fact that it is not a life-threatening procedure assuming proper care and monitoring post-operation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pacemaker (Single Chamber)

SINGLE CHAMBER PACEMAKER IMPLANTATION,PREOPERATIVE DIAGNOSIS: , Mobitz type II block with AV dissociation and syncope.,POSTOPERATIVE DIAGNOSIS: , Mobitz type II block, status post single chamber pacemaker implantation, Boston Scientific Altrua 60, serial number 123456.,PROCEDURES:,1.  Left subclavian access under fluoroscopic guidance.,2.  Left subclavian venogram under fluoroscopic evaluation.,3.  Insertion of ventricular lead through left subclavian approach and ventricular lead is Boston Scientific Dextrose model 12345, serial number 123456.,4.  Insertion of single-chamber pacemaker implantation, Altrua, serial number 123456.,5.  Closure of the pocket after formation of pocket for pacemaker.,PROCEDURE IN DETAIL:  ,The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient was brought to the cath lab, draped and prepped in the usual sterile fashion, received 1.5 mg of versed and 25 mg of Benadryl for conscious sedation.,Access to the right subclavian was successful after the second attempt.  The first attempt accessed the left subclavian artery.  The needle was removed and manual compression applied for five minutes followed by re-accessing the subclavian vein successfully.  The J-wire was introduced into the left subclavian vein.,The anterior wall chest was anesthetized with lidocaine 2%, 2-inch incision using a #10 blade was used.,The pocket was formed using blunt dissection as he was using the Bovie cautery for hemostasis.  The patient went asystole during the procedure.  The transcutaneous pacer was used.  The patient was oxygenating well.  The patient had several compression applied by the nurse.  However, her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby.,After that, the J-wire was tunneled into the pocket and then used to put the #7-French sheath into the left subclavian vein.  The lead from the Boston Scientific Dextrose model 12345, serial number 12345 was inserted through the left subclavian to the right atrium; however, it was difficult to really enter the right ventricle; and while the lead was in place, the side port of the sheath was used to inject 15 mL of contrast to assess the subclavian and the right atrium.  The findings were showing different anatomy, may be consistent with persistent left superior vena cava, and the angle to the right ventricle was different.  At that point, the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place.,At that point, the lead was actively fixated.  The stylet was removed.  The R-wave measured at 40 millivolts.  The impedance was 580 and the threshold was 1.3 volt.  The numbers were accepted and because of the patient's fragility and the different anatomy noticed in the right atrium, concern about putting a second lead with re-access of the subclavian was high.  I decided to proceed with a single-chamber pacemaker as a backup system.,After that, the lead sleeve was used to actively fixate the lead in the anterior chest with two Ethibond sutures in the usual fashion.,The lead was attached to the pacemaker in the header.  The pacemaker was single-chamber pacemaker Altura 60, serial number 123456.  After that, the pacemaker was put in the pocket.  Pocket was irrigated with normal saline and was closed into two layers, deep interrupted #3-0 Vicryl and surface as continuous #4-0 Vicryl continuous.,The pacemaker was programmed as VVI 60, and with history is 10 to 50 beats per minute.  The lead position will be evaluated with chest x-ray.,No significant bleeding noticed.,CONCLUSION:  ,Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.  No significant bleed.
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DESCRIPTION: Single chamber pacemaker implantation.  Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.

cardiovascular / pulmonary, mobitz, av dissociation, syncope, mobitz type ii block, boston scientific altrua, subclavian, venogram, ventricular, single chamber pacemaker implantation, single chamber pacemaker, pacemaker implantation, pacemaker, vein, chest, atrium, ventricle, atrial, implantation, chamber,

The procedure involves a medical intervention of implanting a single-chamber pacemaker, which is a standard yet complex cardiac procedure. It is potentially life-saving for patients with certain types of heart block, such as Mobitz type II with syncope and AV dissociation. The case involves challenges like unexpected asystole, requiring transcutaneous pacing and manual compressions, highlighting the risks involved. Since any interruption in heart rhythm stability can be critical, especially when under anesthesia for such a procedure, this situation carries significant stakes. The patient's unique anatomy and the decision not to place a second lead due to fragility adds to the complexity and potential risks involved. Thus, it concerns a significant matter of health with potential consequences on survival and wellbeing.


Medical Specialty: Urology
Sample Name: Inguinal Herniorrhaphy & Circumcision

PREOPERATIVE DIAGNOSIS: , Recurrent right inguinal hernia, as well as phimosis.,POSTOPERATIVE DIAGNOSIS:,  Recurrent right inguinal hernia, as well as phimosis.,PROCEDURE PERFORMED: , Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery room in stable condition.,SPECIMEN: , Foreskin.,BRIEF HISTORY: , This patient is a 66-year-old African-American male who presented to Dr. Y's office with recurrent right inguinal hernia for the second time requesting hernia repair.  The procedure was discussed with the patient and the patient opted for laparoscopic repair due to multiple attempts at the open inguinal repair on the right.  The patient also is requesting circumcision with phimosis at the same operating time setting.,INTRAOPERATIVE FINDINGS: , The patient was found to have a right inguinal hernia with omentum and bowel within the hernia, which was easily reduced.  The patient was also found to have a phimosis, which was easily removed.,PROCEDURE:,  After informed consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought to operating suite, after general endotracheal intubation, prepped and draped in the normal sterile fashion.  An infraumbilical incision was made with a #15 Bard-Parker scalpel.  The umbilical skin was elevated with a towel clip and the Veress needle was inserted without difficulty.  Saline drop test proved entrance into the abdominal cavity and then the abdomen was insufflated to sufficient pressure of 15 mmHg.  Next, the Veress was removed and #10 bladed trocar was inserted without difficulty.  The 30-degree camera laparoscope was then inserted and the abdomen was explored.  There was evidence of a large right inguinal hernia, which had omentum as well as bowel within it, easily reducible.  Attention was next made to placing a #12 port in the right upper quadrant, four fingerbreadths from the umbilicus.  Again, a skin was made with a #15 blade scalpel and the #12 port was inserted under direct visualization.  A #5 port was inserted in the left upper quadrant in similar fashion without difficulty under direct visualization.  Next, a grasper with blunt dissector was used to reduce the hernia and withdraw the sac and using an Endoshears, the peritoneum was scored towards the midline and towards the medial umbilical ligament and lateral.  The peritoneum was then spread using the blunt dissector, opening up and identifying the iliopubic tract, which was identified without difficulty.  Dissection was carried out, freeing up the hernia sac from the peritoneum.  This was done without difficulty reducing the hernia in its entirety.  Attention was next made to placing a piece of Prolene mesh, it was placed through the #12 port and placed into the desired position, stapled into place in its medial aspect via the 4 mm staples along the iliopubic tract.  The 4.8 mm staples were then used to staple the superior edge of the mesh just below the peritoneum and then the patient was re-peritonealized, re-approximating edge of the perineum with the 4.8 mm staples.  This was done without difficulty.  All three ports were removed under direct visualization.  No evidence of bleeding and the #10 and #12 mm ports were closed with #0-Vicryl and UR6 needle.  Skin was closed with running subcuticular #4-0 undyed Vicryl.  Steri-Strips and sterile dressings were applied.  Attention was next made to carrying out the circumcision.  The foreskin was retracted back over the penis head.  The desired amount of removing foreskin was marked out with a skin marker.  The foreskin was then put on tension using a clamp to protect the penis head.  A #15 blade scalpel was used to remove the foreskin and sending off as specimen.  This was done without difficulty.  Next, the remaining edges were retracted, hemostasis was obtained with Bovie electrocautery and the skin edges were re-approximated with #2-0 plain gut in simple interrupted fashion and circumferentially.  This was done without difficulty maintaining hemostasis.,A petroleum jelly was applied with a Coban dressing.  The patient tolerated this procedure well and was well and was transferred to recovery after extubation in stable condition.
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DESCRIPTION: Laparoscopic right inguinal herniorrhaphy with mesh, as well as a circumcision.   Recurrent right inguinal hernia, as well as phimosis.

urology, herniorrhaphy with mesh, laparoscopic, blunt dissector, inguinal herniorrhaphy, inguinal hernia, hernia, inguinal, peritoneum, circumcision, phimosis, foreskin

This medical situation involves a surgical procedure that is generally routine, but the stakes are increased due to the fact that it involves general anesthesia, a repeated surgery for an inguinal hernia (which can complicate the surgical process), and both herniorrhaphy and circumcision being performed simultaneously. Despite the lack of complications reported, any surgery involving general anesthesia carries inherent risks. The patient's age and history of recurring hernia add additional considerations. Therefore, it is a moderate to high-stakes situation in a medical context.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Male Exam Template - 2

MALE PHYSICAL EXAMINATION,Eye:  Eyelids normal color, no edema.  Conjunctivae with no erythema, foreign body, or lacerations.  Sclerae normal white color, no jaundice.  Cornea clear without lesions.  Pupils equally responsive to light.  Iris normal color, no lesions.  Anterior chamber clear.  Lacrimal ducts normal.  Fundi clear.,Ear:  External ear has no erythema, edema, or lesions.  Ear canal unobstructed without edema, discharge, or lesions.  Tympanic membranes clear with normal light reflex.  No middle ear effusions.,Nose:  External nose symmetrical.  No skin lesions.  Nares open and free of lesions.  Turbinates normal color, size and shape.  Mucus clear.  No internal lesions.,Throat:  No erythema or exudates.  Buccal mucosa clear.  Lips normal color without lesions.  Tongue normal shape and color without lesion.  Hard and soft palate normal color without lesions.  Teeth show no remarkable features.  No adenopathy.  Tonsils normal shape and size.  Uvula normal shape and color.,Neck:  Skin has no lesions.  Neck symmetrical.  No adenopathy, thyromegaly, or masses.  Normal range of motion, nontender.  Trachea midline.,Chest:  Symmetrical.  Clear to auscultation bilaterally.  No wheezing, rales or rhonchi.  Chest nontender.  Normal lung excursion.  No accessory muscle use.,Cardiovascular:  Heart has regular rate and rhythm with no S3 or S4.  Heart rate is normal.,Abdominal:  Soft, nontender, nondistended, bowel sounds present.  No hepatomegaly, splenomegaly, masses, or bruits.,Genital:  Penis normal shape without lesions.  Testicles normal shape and contour without tenderness.  Epididymides normal shape and contour without tenderness.  Rectum normal tone to sphincter.  Prostate normal shape and contour without nodules.  Stool hemoccult negative.  No external hemorrhoids.  No skin lesions.,Musculoskeletal:  Normal strength all muscle groups.  Normal range of motion all joints.  No joint effusions.  Joints normal shape and contour.  No muscle masses.,Foot:  No erythema.  No edema.  Normal range of motion all joints in the foot.  Nontender.  No pain with inversion, eversion, plantar or dorsiflexion.,Ankle:  Anterior and posterior drawer test negative.  No pain with inversion, eversion, dorsiflexion, or plantar flexion.  Collateral ligaments intact.  No joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.,Knee:  Normal range of motion.  No joint effusion, erythema, nontender.  Anterior and posterior drawer tests negative.  Lachman's test negative.  Collateral ligaments intact.  Bursas nontender without edema.,Wrist:  Normal range of motion.  No edema or effusion, nontender.  Negative Tinel and Phalen tests.  Normal strength all muscle groups.,Elbow:  Normal range of motion.  No joint effusion or erythema.  Normal strength all muscle groups.  Nontender.  Olecranon bursa flat and nontender, no edema.  Normal supination and pronation of forearm.  No crepitus.,Hip:  Negative swinging test.  Trochanteric bursa nontender.  Normal range of motion.  Normal strength all muscle groups.  No pain with eversion and inversion.  No crepitus.  Normal gait.,Psychiatric:  Alert and oriented times four.  No delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality.  Affect is appropriate.  No psychomotor slowing or agitation.  Eye contact is appropriate.
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DESCRIPTION: An example/template for a routine normal male physical exam.

consult - history and phy., male exam, normal, physical exam, normal range of motion, male physical, nontender, lesions, dorsiflexion, sclerae, contour, muscle, erythema, joints, edema, shape,

The information provided is a detailed template of a routine physical examination of a normal male patient. It features standard medical terminology and outcomes indicative of a healthy individual without any abnormalities. Such templates are commonly used for documentation purposes in medical practice to streamline the recording of examinations, and do not involve any critical or urgent health issues. Since the example describes a standard, uneventful examination without any concerning findings, it does not involve high-stakes decision-making or outcomes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Mediastinal Exploration & Right Atrium Repair

PREOPERATIVE DIAGNOSES:,1.  Cardiac tamponade.,2.  Status post mitral valve repair.,POSTOPERATIVE DIAGNOSES:,1.  Cardiac tamponade.,2.  Status post mitral valve repair.,PROCEDURE PERFORMED: , Mediastinal exploration with repair of right atrium.,ANESTHESIA: , General endotracheal.,INDICATIONS: , The patient had undergone mitral valve repair about seven days ago.  He had epicardial pacing wires removed at the bedside.  Shortly afterwards, he began to feel lightheaded and became pale and diaphoretic.  He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires.  He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.,DETAILS OF PROCEDURE:  ,The patient was taken emergently to the operating room and placed supine on the operating room table.  His chest was prepped and draped prior to induction under general anesthesia.  Incision was made through the previous median sternotomy chest incision.  Wires were removed in the usual manner and the sternum was retracted.  There were large amounts of dark blood filling the mediastinal chest cavity.  Large amounts of clot were also removed from the pericardial well and chest.  Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation.  This was repaired with two horizontal mattress pledgeted #5-0 Prolene sutures.  An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis.  No other sites of bleeding were identified.  The mediastinum was then irrigated with copious amounts of antibiotic saline solution.  Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube.  The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures.  The skin was then closed with a running subcuticular stitch.  The patient was then taken to the Intensive Care Unit in a critical but stable condition.
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DESCRIPTION: The patient had undergone mitral valve repair about seven days ago.

cardiovascular / pulmonary, mitral valve repair, exploration, median sternotomy chest incision, pericardial, mediastinal exploration, pacing wires, cardiac tamponade, chest tubes, mitral valve, valve repair, mediastinal, mitral, wires, atrium, repair,

The scenario involves a critical medical procedure addressing cardiac tamponade following a recent mitral valve repair. Cardiac tamponade is a life-threatening condition where fluid accumulates around the heart, restricting its function, and immediate surgical intervention is required to prevent severe complications or death. The urgency of bringing the patient to the operating room and the critical condition post-operation highlight the high stakes involved in this medical situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Flexible Bronchoscopy

PROCEDURE:, Flexible bronchoscopy.,PREOPERATIVE DIAGNOSIS (ES):, Chronic wheezing.,INDICATIONS FOR PROCEDURE:, Evaluate the airway.,DESCRIPTION OF PROCEDURE: ,This was done in the pediatric endoscopy suite with the aid of Anesthesia. The patient was sedated with sevoflurane and propofol. One mL of 1% lidocaine was used for airway anesthesia. The 2.8-mm flexible pediatric bronchoscope was passed through the left naris. The upper airway was visualized. The epiglottis, arytenoids, and vocal cords were all normal. The scope was passed below the cords. The subglottic space was normal. The patient had normal tracheal rings and a normal membranous portion of the trachea. There was noted to be slight deviation of the trachea to the right. At the carina, the right and left mainstem were evaluated. The right upper lobe, right middle lobe, and right lower lobe were all anatomically normal. The scope was wedged in the right middle lobe, 10 mL of saline was infused, 10 was returned. This was sent for cell count, cytology, lipid index, and quantitative bacterial cultures. The left side was then evaluated and there was noted to be the normal cardiac pulsations on the left. There was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle. The left upper lobe and left lower lobe were normal. The scope was withdrawn. The patient tolerated the procedure well.,ENDOSCOPIC DIAGNOSIS:, Left mainstem bronchomalacia.
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DESCRIPTION: Flexible bronchoscopy  to evaluate the airway (chronic wheezing).

cardiovascular / pulmonary, flexible bronchoscopy, airway, arytenoids, bronchomalacia, bronchoscopy, endoscopy suite, epiglottis, mainstem, subglottic, vocal cords, wheezing, chronic wheezing, tracheal, lobe,

The procedure described is a flexible bronchoscopy performed on a pediatric patient to evaluate chronic wheezing, which can be an important diagnostic tool. Although it involves sedation and potential risks such as airway compromise, in the context of specialist procedures, it is relatively routine. It is not considered extremely high-stakes compared to certain other medical procedures, but still carries moderate risks inherent to invasive diagnostic procedures in pediatric patients.


Medical Specialty: Surgery
Sample Name: Gangrene Surgery

PREOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,POSTOPERATIVE DIAGNOSIS: , Gangrene osteomyelitis, right second toe.,OPERATIVE REPORT:  ,The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema.  The patient has history of previous right foot infection requiring first ray resection.  The patient has ulcerations of right second toe dorsally at the proximal interphalangeal joint, which has failed to respond to conservative treatment.  The patient now has exposed bone and osteomyelitis in the second toe.  The patient has been on IV antibiotics as an outpatient and has failed to respond to these and presents today for surgical intervention.,After an IV was started by the Department of Anesthesia, the patient was taken back to the operating room and placed on the operative table in the supine position.  A restraint belt was placed around the patient's waist using copious amounts of Webril and an ankle pneumatic tourniquet was placed around the patient's right ankle and the patient was made comfortable by the Department of Anesthesia.  After adequate amounts of sedation had been given to the patient, we administered a block of 10 cc of 0.5% Marcaine plain in proximal digital block around the second digit.  The foot and ankle were then prepped in the normal sterile orthopedic manner.  The foot was elevated and an Esmarch bandage applied to exsanguinate the foot.  The tourniquet was then inflated to 250 mmHg and the foot was brought back onto the table.  Using Band-Aid scissors, the stockinet was cut and reflected and using a wet and dry sponge, the foot was wiped, cleaned, and the second toe identified.,Using a skin scrape, a racket type incision was planned around the second toe to allow also remodelling of previous operative site.  Using a fresh #10 blade, skin incision was made circumferentially in the racket-shaped manner around the second digit.  Then, using a fresh #15 blade, the incision was deepened and was taken down to the level of the second metatarsophalangeal joint.  Care was taken to identify bleeders and cautery was used as necessary for hemostasis.  After cleaning up all the soft tissue attachments, the second digit was disarticulated down to the level of the metatarsophalangeal joint.  The head of the second metatarsal was inspected and was noted to have good glistening white cartilage with no areas of erosion evident by visual examination.  Attention was then directed to closure of the wound.  All remaining tissue was noted to be healthy and granular in appearance with no necrotic tissue evident.  Areas of subcutaneous tissue were then removed through a sharp dissection in order to allow better approximation of the skin edges.  Due to long-standing lower extremity lymphedema and postoperative changes on previous surgery, I thought that we were unable to close the incision in entirety.  Therefore, after copious amounts of irrigation using sterile saline, it was determined to use modified dental rolls using #4-0 gauze to remove tension from the skin.  Deep vertical mattress sutures were used in order to reapproximate more closely, the skin edges and bring the plantar flap of skin up to the dorsal skin.  This was obtained using #2-0 nylon suture.  Following this, the remaining exposed tissue from the wound was covered using moist to dry saline soaked 4 x 4 gauze.  The wound was then dressed using 4 x 4 gauze fluffed with abdominal pads, then using Kling and Kerlix and an ACE bandage to provide compression.  The tourniquet was deflated at 42 minutes' time and hemostasis was noted to be achieved.  The ACE bandage was extended up to just below the knee and no bleeding striking to the bandages was appreciated.  The patient tolerated the procedure well and was escorted to the Postanesthesia Care Unit with vital signs stable and vascular status intact, as was evidenced by capillary bleeding, which was present during the procedure.  Sedation was given postoperative introductions, which include to remain nonweightbearing to her right foot.  The patient was instructed to keep the foot elevated and to apply ice behind her knee as necessary, no more than 20 minutes each hour.  The patient was instructed to continue her regular medications.  The patient was to continue IV antibiotic course and was given prescription for Vicoprofen to be taken q.4h. p.r.n. for moderate to severe pain #30.  The patient will followup with Podiatry on Monday morning at 8:30 in the Podiatry Clinic for dressing change and evaluation of her foot at that time.,The patient was instructed as to signs and symptoms of infection, was instructed to return to the Emergency Department immediately if these should present.  The second digit was sent to Pathology for gross and micro.
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DESCRIPTION: Gangrene osteomyelitis, right second toe.  The patient is a 58-year-old female with poorly controlled diabetes with severe lower extremity lymphedema.  The patient has history of previous right foot infection requiring first ray resection.

surgery, dorsally, toe, ulcerations, foot infection, ray resection, metatarsophalangeal joint, ace bandage, gangrene osteomyelitis, foot, infection, gangrene, digital,

This situation is high-stakes due to several factors: the patient's underlying health conditions, including poorly controlled diabetes and severe lymphedema, which complicate healing and increase the risk of complications. The presence of osteomyelitis further complicates the scenario as it indicates bone infection, which can lead to serious outcomes if not properly managed. Additionally, the surgical procedure itself involves risks associated with anesthesia and surgery, especially in a patient with such comorbidities. Postoperative care and potential complications like infection or further amputations also heighten the stakes.


Medical Specialty: Surgery
Sample Name: Phacoemulsification & Cataract Extraction - 4

PREOPERATIVE DIAGNOSIS:  ,Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,PROCEDURE: , Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation.  ME 30, AC 25.0 diopter lens was used.,COMPLICATIONS:  ,None.,ANESTHESIA: , Local 2%, peribulbar lidocaine.,PROCEDURE NOTE:  ,Right eye was prepped and draped in the normal sterile fashion.  Lid speculum placed in his right eye.  Paracentesis made supratemporally.  Viscoat injected into the anterior chamber.  A 2.8 mm metal keratome blade was then used to fashion a clear corneal beveled incision temporally.  This was followed by circular capsulorrhexis and hydrodissection of the nucleus would be assessed.  Nuclear material removed via phacoemulsification.  Residual cortex removed via irrigation and aspiration.  The posterior capsule was clear and intact.  Capsular bag was then filled with Provisc solution.  The wound was enlarged to 3.5 mm with the keratoma.  The lens was folded in place into the capsular bag.  Residual Provisc was irrigated from the eye.  The wound was secured with one 10-0 nylon suture.  The lid speculum was removed.  One drop of 5% povidone-iodine prep was placed into the eye as well as a drop of Vigamox and TobraDex ointment.  He had a patch placed on it.  The patient was transported to the recovery room in stable condition.
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DESCRIPTION: Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation.  Cataract, right eye.

surgery, provisc, intraocular lens implantation, intraocular lens, lens implantation, lid speculum, capsular bag, cataract extraction, phacoemulsification, cataract, intraocular

The situation involves a standard cataract surgery procedure known as phacoemulsification. While cataract surgery is a common and typically very safe procedure, it is still surgery, which inherently carries risks such as infection, bleeding, or complications during the procedure. However, this particular case was straightforward with no complications reported and the patient was stable post-operation. Thus, while it is not a zero-stakes scenario due to the inherent risks of surgery, it is not extremely high-stakes compared to more complex or life-threatening surgeries.


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

Medical Specialty: Orthopedic
Sample Name: CT Head, Facial Bones, Cervical Spine

EXAM: , CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.,REASON FOR EXAM:,  A 68-year-old status post fall with multifocal pain.,COMPARISONS: , None.,TECHNIQUE: , Sequential axial CT images were obtained from the vertex to the thoracic inlet without contrast.  Additional high-resolution sagittal and/or coronal reconstructed images were obtained through the facial bones and cervical spine for better visualization of the osseous structures.,INTERPRETATIONS:,HEAD:,There is mild generalized atrophy.  Scattered patchy foci of decreased attenuation is seen in the subcortical and periventricular white matter consistent with chronic small vessel ischemic changes.  There are subtle areas of increased attenuation seen within the frontal lobes bilaterally.  Given the patient's clinical presentation, these likely represent small hemorrhagic contusions.  Other differential considerations include cortical calcifications, which are less likely.  The brain parenchyma is otherwise normal in attenuation without evidence of mass, midline shift, hydrocephalus, extra-axial fluid, or acute infarction.  The visualized paranasal sinuses and mastoid air cells are clear.  The bony calvarium and skull base are unremarkable.,FACIAL BONES:,The osseous structures about the face are grossly intact without acute fracture or dislocation.  The orbits and extra-ocular muscles are within normal limits.  There is diffuse mucosal thickening in the ethmoid and right maxillary sinuses.  The remaining visualized paranasal sinuses and mastoid air cells are clear.  Diffuse soft tissue swelling is noted about the right orbit and right facial bones without underlying fracture.,CERVICAL SPINE:,There is mild generalized osteopenia.  There are diffuse multilevel degenerative changes identified extending from C4-C7 with disk space narrowing, sclerosis, and marginal osteophyte formation.  The remaining cervical vertebral body heights are maintained without acute fracture, dislocation, or spondylolisthesis.  The central canal is grossly patent.  The pedicles and posterior elements appear intact with multifocal facet degenerative changes.  There is no prevertebral or paravertebral soft tissue masses identified.  The atlanto-dens interval and dens are maintained.,IMPRESSION:,1.Subtle areas of increased attenuation identified within the frontal lobes bilaterally suggesting small hemorrhagic contusions.  There is no associated shift or mass effect at this time.  Less likely, this finding could be secondary to cortical calcifications.  The patient may benefit from a repeat CT scan of the head or MRI for additional evaluation if clinically indicated.,2.Atrophy and chronic small vessel ischemic changes in the brain.,3.Ethmoid and right maxillary sinus congestion and diffuse soft tissue swelling over the right side of the face without underlying fracture.,4.Osteopenia and multilevel degenerative changes in the cervical spine as described above.,5.Findings were discussed with Dr. X from the emergency department at the time of interpretation.
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DESCRIPTION: CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.

orthopedic, sagittal, coronal, soft tissue swelling, paranasal sinuses, mastoid air, acute fracture, maxillary sinuses, tissue swelling, underlying fracture, multilevel degenerative, ct head, soft tissue, facial bones, cervical spine, ct, facial, bones, spine, cervical

The CT findings reveal a 68-year-old patient who has fallen and presents with multiple areas of concern including potential small hemorrhagic contusions in the frontal lobes, chronic ischemic changes, and diffuse soft tissue swelling in the facial area. These findings, particularly the potential hemorrhagic contusions, which can indicate a traumatic brain injury, make this a high-stakes situation. Traumatic brain injuries can have serious implications especially considering the patient's age, which may predispose them to more severe outcomes. The need for potential follow-up imaging underscores the seriousness of the situation. Although there is no immediate evidence of midline shift or acute fracture, the presence of these injuries, especially after a fall, warrants close medical management.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiomyopathy & Hypotension - Consult

REASON FOR CONSULTATION:,  Cardiomyopathy and hypotension.,HISTORY OF PRESENT ILLNESS:,  I am seeing the patient upon the request of Dr. X.  The patient is very well known to me, an 81-year-old lady with dementia, a native American with coronary artery disease with prior bypass, reduced LV function, recurrent admissions for diarrhea and hypotension several times in November and was admitted yesterday because of having diarrhea with hypotension and acute renal insufficiency secondary to that.  Because of her pre-existing coronary artery disease and cardiomyopathy with EF of about 30%, we were consulted to evaluate the patient.  The patient denies any chest pain or chest pressure.  Denies any palpitations.  No bleeding difficulty.  No dizzy spells.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever or chills.,EYES:  No visual disturbances.,ENT:  No difficulty swallowing.,CARDIOVASCULAR:  Basically, no angina or chest pressure.  No palpitations.,RESPIRATORY:  No wheezes.,GI:  No abdominal pain, although she had diarrhea.,GU:  No specific symptoms.,MUSCULOSKELETAL:  Have sores on the back.,NEUROLOGIC:  Have dementia.,All other systems are otherwise unremarkable as far as the patient can give me information.,PAST MEDICAL HISTORY:,1.  Positive for coronary artery disease for about two to three years.,2.  Hypertension.,3.  Anemia.,4.  Chronic renal insufficiency.,5.  Congestive heart failure with EF of 25% to 30%.,6.  Osteoporosis.,7.  Compression fractures.,8.  Diabetes mellitus.,9.  Hypothyroidism.,PAST SURGICAL HISTORY:,1.  Coronary artery bypass grafting x3 in 2008.,2.  Cholecystectomy.,3.  Amputation of the right second toe.,4.  ICD implantation.,CURRENT MEDICATIONS AT HOME:,1.  Amoxicillin.,2.  Clavulanic acid or Augmentin every 12 hours.,3.  Clopidogrel 75 mg daily.,4.  Simvastatin 20 mg daily.,5.  Sodium bicarbonate 650 mg twice daily.,6.  Gabapentin 300 mg.,7.  Levothyroxine once daily.,8.  Digoxin 125 mcg daily.,9.  Fenofibrate 145 mg daily.,10.  Aspirin 81 mg daily.,11.  Raloxifene once daily.,12.  Calcium carbonate and alendronate.,13.  Metoprolol 25 mg daily.,14.  Brimonidine ophthalmic once daily.,ALLERGIES: , She has no known allergies.,FAMILY HISTORY:
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DESCRIPTION: Cardiomyopathy and hypotension.  A lady with dementia, coronary artery disease, prior bypass, reduced LV function, and recurrent admissions for diarrhea and hypotension several times.

The consultation involves an 81-year-old woman with multiple serious and chronic conditions, including cardiomyopathy, hypotension, coronary artery disease, and reduced left ventricular function, which significantly impact her current health status. Given her medical history and the complexity of her condition, including her age, dementia, and acute renal insufficiency triggered by hypotension, this situation is high-stakes. Effective management is critical not only for her cardiovascular health but also to stabilize her renal function and prevent further deterioration. The risks associated with such comorbidities and their potential for severe complications make this a high-stakes scenario.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Syncope

REASON FOR CONSULTATION: , Syncope.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 69-year-old gentleman, a good historian, who relates that he was brought in the Emergency Room following an episode of syncope.  The patient relates that he may have had a seizure activity prior to that.  Prior to the episode, he denies having any symptoms of chest pain or shortness of breath.  No palpitation.  Presently, he is comfortable, lying in the bed.  As per the patient, no prior cardiac history.,CORONARY RISK FACTORS: , History of hypertension.  No history of diabetes mellitus.  Nonsmoker.  Cholesterol status is borderline elevated.  No history of established coronary artery disease.  Family history noncontributory.,PAST MEDICAL HISTORY:  ,Hypertension, hyperlipidemia, recently diagnosed with Parkinson's, as a Parkinson's tremor, admitted for syncopal evaluation.,PAST SURGICAL HISTORY: ,Back surgery, shoulder surgery, and appendicectomy.,FAMILY HISTORY: , Nonsignificant.,MEDICATIONS:,1.  Pain medications.,2.  Thyroid supplementation.,3.  Lovastatin 20 mg daily.,4.  Propranolol 20 b.i.d.,5.  Protonix.,6.  Flomax.,ALLERGIES:,  None.,PERSONAL HISTORY:,  He is married.  Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  No weakness, fatigue, or tiredness.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  No congestive heart failure.  No arrhythmias.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No nausea, vomiting, hematemesis, or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis and muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGIC:  No TIA or CVA.  No seizure disorder.,ENDOCRINE/HEMATOLOGIC:  Nonsignificant.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 93, blood pressure of 158/93, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.  No significant carotid bruits.,LUNGS:  Air entry is bilaterally decreased.,HEART:  PMI is displaced.  S1 and S2 are regular.,ABDOMEN:  Soft and nontender.  Bowel sounds are present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.  The patient is moving all extremities; however, the patient has tremors.,RADIOLOGICAL DATA: , EKG reveals normal sinus rhythm with underlying nonspecific ST-T changes secondary to tremors.,LABORATORY DATA: , H&H stable.  White count of 14.  BUN and creatinine are within normal limits.  Cardiac enzyme profile is negative.  Ammonia level is elevated at 69.  CT angiogram of the chest, no evidence of pulmonary embolism.  Chest x-ray is negative for acute changes.  CT of the head, unremarkable, chronic skin changes.  Liver enzymes are within normal limits.,IMPRESSION:,1.  The patient is a 69-year-old gentleman, admitted with syncopal episode and possible seizure disorder.
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DESCRIPTION: Patient was brought in the Emergency Room following an episode of syncope.  The patient relates that he may have had a seizure activity prior to that.  Prior to the episode, he denies having any symptoms of chest pain or shortness of breath.

The situation involves a 69-year-old patient who experienced a syncope episode, with potential seizure activity, and has underlying health conditions including hypertension, hyperlipidemia, and Parkinson's disease. Syncope can lead to serious complications, especially in elderly patients. Additionally, the elevated ammonia level and neurological symptoms are concerning and warrant further investigation to rule out serious underlying causes such as cardiac, neurological, or metabolic disorders.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Aortic Valve Replacement

DIAGNOSIS: , Aortic valve stenosis with coronary artery disease associated with congestive heart failure.  The patient has diabetes and is morbidly obese.,PROCEDURES: , Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,ANESTHESIA: , General endotracheal,INCISION: , Median sternotomy,INDICATIONS: , The patient presented with severe congestive heart failure associated with the patient's severe diabetes.  The patient was found to have moderately stenotic aortic valve.  In addition, The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system.  The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient's right system.  It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure.,FINDINGS: , The left ventricle is certainly hypertrophied· The aortic valve leaflet is calcified and a severe restrictive leaflet motion.  It is a tricuspid type of valve.  The coronary artery consists of a large left anterior descending artery which is associated with 60% stenosis but a large obtuse marginal artery which has a tight proximal stenosis.,The radial artery was used for the left anterior descending artery.  Flow was excellent.  Looking at the targets in the posterior descending artery territory, there did not appear to be any large branches.  On the angiogram these vessels appeared to be quite small.  Because this is a chronically occluded vessel and the patient has limited conduit due to the patient's massive obesity, attempt to bypass to this area was not undertaken.  The patient was brought to the operating room,PROCEDURE: , The patient was brought to the operating room and placed in supine position.  A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh.  The patient weighs nearly three hundred pounds.  There was concern as to taking down the left internal mammary artery.  Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory.  The patient was cannulated after the aorta and atrium were exposed and full heparinization.,The patient went on cardiopulmonary bypass and the aortic cross-clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner.  The patient was cooled to 32 degrees.  Iced slush was applied to the heart.  The aortic valve was then exposed through the aortic root by transverse incision.  The valve leaflets were removed and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures.  At this point, aortotomy was closed.,The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow.  Proximal anastomosis was then carried out to the foot of the aorta.  The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end-to-side manner.  The two proximal anastomoses were then carried out to the root of the aorta.,The patient came off cardiopulmonary bypass after aortic cross-clamp was released.  The patient was adequately warmed.  Protamine was given without adverse effect.  Sternal closure was then done using wires.  The subcutaneous layers were closed using Vicryl suture.  The skin was approximated using staples.
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DESCRIPTION: Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.

cardiovascular / pulmonary, coronary artery bypass grafting, saphenous vein graft, radial artery graft, coronary artery disease, congestive heart failure, descending artery territory, aortic cross clamp, aortic valve replacement, coronary artery bypass, obtuse marginal artery, anterior descending artery, mechanical valve, artery bypass, bypass grafting, marginal artery, radial artery, aortic valve, coronary artery, anterior descending, descending artery, valve, artery, aortic, grafting,

The situation involves a complex cardiac surgical procedure: aortic valve replacement along with coronary artery bypass grafting in a patient with significant comorbidities such as morbid obesity, severe diabetes, and coronary artery disease associated with congestive heart failure. This type of procedure is inherently high-stakes due to the potential risks and complications, including those arising from the patient's existing medical conditions. The use of cardiopulmonary bypass and general endotracheal anesthesia further increases the complexity of the procedure. Successful outcome is critical for the patient's survival and quality of life.


Medical Specialty: Surgery
Sample Name: Sebaceous Cyst Excision

PREOPERATIVE DIAGNOSIS: , Sebaceous cyst, right lateral eyebrow.,POSTOPERATIVE DIAGNOSIS:,  Sebaceous cyst, right lateral eyebrow.,PROCEDURE PERFORMED: , Excision of sebaceous cyst, right lateral eyebrow.,ASSISTANT: , None.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,ANESTHESIA: , General endotracheal anesthesia.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable.  Transferred to the recovery room.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old with a history of sebaceous cyst.  The patient is undergoing PE tubes by Dr. X and I was asked to remove the cyst on the right lateral eyebrow.  I saw the patient in my clinic.  I explained to the mother in Spanish the risk and benefits.  Risk included but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgery.  We will proceed with the surgery.,PROCEDURE IN DETAIL: , The patient was taken into the operating room, placed in the supine position.  General anesthetic was administered.  A prophylactic dose of antibiotic was given.  The patient was prepped and draped in a usual manner.  The procedure began by infiltrating lidocaine with epinephrine around the cyst area.  Then, I proceeded with the help of a 15C blade to make an incision and remove a small wedge of tissue that includes a comedo point.  The incision was done superiorly then inferiorly to a full thickness and to the skin down to the cyst.  The cyst was detached of the surrounding structure with the help of blunt dissection.  Hemostasis was achieved with electrocautery.  The wound was closed with 5-0 Vicryl deep dermal interrupted stitches and Dermabond.  The patient tolerated the procedure well without complications and transferred to recovery room in stable condition.  I was present and participated in all aspects of the procedure.  Sponge, needle, and instrument counts were completed at the end of the procedure.
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DESCRIPTION: Excision of sebaceous cyst, right lateral eyebrow.

surgery, lateral eyebrow, excision of sebaceous cyst, sebaceous cyst, cyst, eyebrow, sebaceous,

The procedure described is a sebaceous cyst excision, which is generally considered a routine and low-risk surgical procedure. The patient's age (4 years old) and use of general anesthesia add some degree of risk, but there were no reported complications, blood loss was minimal, and the patient was stable post-surgery. The short note does not suggest any complex circumstances that would elevate the stakes significantly.