Medical Specialty: Surgery
Sample Name: Sinus Surgery - Endoscopic

PREOPERATIVE DIAGNOSES:,1.  Nasopharyngeal mass.,2.  Right upper lid skin lesion.,POSTOPERATIVE DIAGNOSES:,1.  Nasopharyngeal tube mass.,2.  Right upper lid skin lesion.,PROCEDURES PERFORMED:,1.  Functional endoscopic sinus surgery.,2.  Excision of nasopharyngeal mass via endoscopic technique.,3.  Excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient is a 51-year-old Caucasian female with a history of a nasopharyngeal mass discovered with patient's chief complaint of nasal congestion and chronic ear disease.  The patient had a fiberoptic nasopharyngoscopy performed in the office which demonstrated the mass and confirmed also on CT scan.  The patient also has had this right upper lid skin lesion which appears to be a cholesterol granuloma for numerous months.  It appears to be growing in size and is irregularly bordered.  After risks, complications, consequences, and questions were addressed to the patient, a written consent was obtained for the procedure.,PROCEDURE: , The patient was brought to the operating suite by Anesthesia and placed on the operating table in supine position.  After this, the patient was turned to 90 degrees by the Department of Anesthesia.  The right upper eyelid skin lesion was injected with 1% lidocaine with epinephrine 1:100,000 approximately 1 cc total.  After this, the patient's bilateral nasal passages were then packed with cocaine-soaked cottonoids of 10% solution of 4 cc total.  The patient was then prepped and draped in usual sterile fashion and the right upper lid skin was then first cut around the skin lesion utilizing a Superblade.  After this, the skin lesion was then grasped with a ________ in the  superior aspect and the skin lesion was cut and removed in the subcutaneous plane utilizing Westcott scissors.  After this, the ________ was then hemostatically controlled with monopolar cauterization.  The patient's skin was then reapproximated with a running #6-0 Prolene suture.  A Mastisol along with a single Steri-Strip was in place followed Maxitrol ointment.  Attention then was drawn to the nasopharynx.  The cocaine-soaked cottonoids were removed from the nasal passages bilaterally and zero-degree otoscope was placed all the way to the patient's nasopharynx.  The patient had a severely deviated nasal septum more so to the right than the left.  There appeared to be a spur on the left inferior aspect and also on the right posterior aspect.  The nasopharyngeal mass appeared polypoid in nature almost lymphoid tissue looking.  It was then localized with 1% lidocaine with epinephrine 1:100,000 of approximately 3 cc total.  After this, the lesion was then removed on the right side with the XPS blade.  The torus tubarius was noted on the left side with the polypoid lymphoid tissue involving this area completely.  This area was taken down with the XPS blade.  Prior to taking down this lesion with the XPS, multiple biopsies were taken with a straight biter.  After this, a cocaine-soaked cottonoid was placed back in the patient's left nasal passage region and the nasopharynx and the attention was then drawn to the right side.  The zero-degree otoscope was placed in the patient's right nasal passage and all the way to the nasopharynx.  Again, the XPS was then utilized to take down the nasopharyngeal mass in its entirety with some involvement overlying the torus tubarius.  After this, the patient was then hemostatically controlled with suctioned Bovie cauterization.  A FloSeal was then placed followed by bilateral Merocels and bacitracin-coated ointment.  The patient's Meroceles were then tied together to the patient's forehead and the patient was then turned back to the Anesthesia.  The patient was extubated in the operating room and was transferred to the recovery room in stable condition.  The patient tolerated the procedure well and sent home and with instructions to followup approximately in one week.  The patient will be sent home with a prescription for Keflex 500 mg one p.o. b.i.d, and Tylenol #3 one to two p.o. q.4-6h. pain #30.
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DESCRIPTION: Functional endoscopic sinus surgery, excision of nasopharyngeal mass via endoscopic technique, and excision of right upper lid skin lesion 1 cm in diameter with adjacent tissue transfer closure.

surgery, nasopharyngeal tube mass, lymphoid tissue, torus tubarius, sinus surgery, nasal passages, nasopharyngeal mass, skin lesion, lesion, nasopharynx, endoscopic, nasopharyngeal,

Sinus surgery, especially involving the excision of a nasopharyngeal mass and eyelid lesion under general anesthesia, involves multiple potential risks and significant complexity. Although no complications were reported, surgeries on such delicate areas as the nasopharynx and eyelid are inherently high-stakes due to risks like bleeding, infection, and damage to adjacent tissues. Successful management requires precise surgical skills and the ability to manage any unexpected complications during or after surgery.


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

Medical Specialty: Surgery
Sample Name: ERCP

PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesia.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, aspiration, and post ERCP pancreatitis.,DESCRIPTION OF PROCEDURE: ,After informed consent and appropriate sedation, the duodenoscope was inserted into the oropharynx, down the esophagus, and into the stomach. The scope was then advanced through the pylorus to the ampulla. The ampulla had a markedly abnormal appearance, as it was enlarged and very prominent. It extended outward with an almost polypoid shape. It had what appeared to be adenomatous-appearing mucosa on the tip. There also was ulceration noted on the tip of this ampulla. The biliary and pancreatic orifices were identified. This was located not at the tip of the ampulla, but rather more towards the base. Cannulation was performed with a Wilson-Cooke TriTome sphincterotome with easy cannulation of the biliary tree. The common bile duct was mildly dilated, measuring approximately 12 mm. The intrahepatic ducts were minimally dilated. There were no filling defects identified. There was felt to be a possible stricture within the distal common bile duct, but this likely represented an anatomic variant given the abnormal shape of the ampulla. The patient has no evidence of obstruction based on lab work and clinically. Nevertheless, it was decided to proceed with brush cytology of this segment. This was done without any complications. There was adequate drainage of the biliary tree noted throughout the procedure. Multiple efforts were made to access the pancreatic ductal anatomy; however, because of the shape of the ampulla, this was unsuccessful. Efforts were made to proceed in a long scope position, but still were unsuccessful. Next, biopsies were obtained of the ampulla away from the biliary orifice. Four biopsies were taken. There was some minor oozing which had ceased by the end of the procedure. The stomach was then decompressed and the endoscope was withdrawn.,FINDINGS:,1. Abnormal papilla with bulging, polypoid appearance, and looks adenomatous with ulceration on the tip; biopsies taken.,2. Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture, although I think this is likely an anatomic variant; brush cytology obtained.,3. Unable to access the pancreatic duct.,RECOMMENDATIONS:,1. NPO except ice chips today.,2. Will proceed with MRCP to better delineate pancreatic ductal anatomy.,3. Follow up biopsies and cytology.
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DESCRIPTION: Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy.

surgery, endoscopic retrograde cholangiopancreatography, biopsy, brush cytology, cholangiopancreatography, pancreatitis, endoscopy, duodenoscope, wilson-cooke tritome, ampulla, common bile duct, ercp, endoscopic, biliary, pancreatic, duct, biopsies, cytology

The situation involves a medical procedure known as ERCP, which is used to diagnose and treat conditions related to the bile and pancreatic ducts. The procedure has identified an abnormal ampulla, and biopsies with brush cytology have been taken to investigate potential issues that could range from benign to malignant. Potential complications from the procedure, such as bleeding, perforation, or post-ERCP pancreatitis, could have significant health implications for the patient. However, the immediate outcomes described in the procedure note do not indicate any major complications occurred. Considering the potential for serious health issues if the abnormal ampulla is found to be cancerous or the patient develops post-procedure complications, the stakes are significant.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Basilic Vein Transposition

PREOPERATIVE DIAGNOSIS:,  End-stage renal disease with need for a long-term hemodialysis access.,POSTOPERATIVE DIAGNOSIS: , End-stage renal disease with need for a long-term hemodialysis access.,PROCEDURE: , Right basilic vein transposition.,ANESTHESIA:  ,General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,FINDINGS:,  Excellent flow through fistula following the procedure.,STATEMENT OF MEDICAL NECESSITY:  ,The patient is a 68-year-old black female who recently underwent a brachiobasilic AV fistula, but without transposition.  She has good flow, excellent physical exam, and now is ready for superficialization of the basilic vein.  After discussing the risks and benefits of the procedure with the patient preoperatively, the patient voiced understanding and signed informed consent.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room, placed supine on the operating table.  After adequate general endotracheal anesthesia was obtained, the right arm was circumferentially prepped and draped in a standard sterile fashion.  A longitudinal incision was made from just above the antecubital crease along the medial aspect of the arm overlying the palpable thrill using a 15 blade knife.  The sharp dissection was then used to identify dissection created of the basilic vein from its surrounding tissues.  This was continued and the incision was elongated up the arm as the vein was exposed in a serial fashion.  Branch points were then taken down using multitude of techniques based upon the luminal diameter of the branch before transection.  The basilic vein was ultimately freed in its entirety from just above the antecubital crease to the axilla at the level of the axillary vein.  There was noted to be excellent flow through the vein.  A pocket was then created just lateral to the incision in the subcutaneous tissue.  The vein was then placed into this pocket securing with multiple interrupted 3-0 Vicryl sutures.  The bed of dissection of the basilic vein was then treated with fibrin sealant.  The subcutaneous tissue was then reapproximated with 3-0 Vicryl sutures in interrupted fashion.  The skin was closed using 4-0 Monocryl suture for a subcuticular stitch.  Dermabond was applied to the incision.  Again, there was noted to be good palpable thrill throughout the superficialized vein.  The patient was then awakened, and taken to the recovery room in stable condition.
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DESCRIPTION: Right basilic vein transposition.  End-stage renal disease with need for a long-term hemodialysis access.  Excellent flow through fistula following the procedure.

surgery, end-stage renal disease, hemodialysis, av fistula, brachiobasilic, basilic vein transposition, hemodialysis access, vein, basilic,

The situation involves a surgical procedure on a patient with end-stage renal disease who needs long-term hemodialysis access. This is inherently high-stakes because access to hemodialysis is vital for the patient's survival. However, the procedure itself seems to have gone without complications, indicated by minimal blood loss and excellent flow through the fistula. Hence, it is crucial but routine within surgical practice, placing it at a moderately high-stakes level.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Exercise Stress Test - 2

INDICATION: , This 69-year-old man is undergoing a preoperative evaluation for anticipated prostate surgery.  He is having a transurethral prostate resection performed by Dr. X for treatment of severely symptomatic prostatic hypertrophy.  He has recently completed radiation therapy to T11 for a plasmacytoma.  He has recently complained of left anterior chest pain, which radiates down the left upper arm towards the elbow.  This occurs during quiet periods such as in bed at night.  It may last all night and still be present in the morning.  It usually dissipates as the day progresses.  There are no obvious triggers and there are no obvious alleviating factors.  The patient has no known cardiac risk factors.  He is currently taking Avodart 0.5 mg daily, Wellbutrin 300 mg daily, Xanax 0.25 mg p.r.n., Uroxatral 10 mg daily, and omeprazole 20 mg daily.,PHYSICAL EXAMINATION: , On physical examination, the patient appears pale and fatigued.  He is 66 inches tall, 205 pounds for a body mass index of 32.  His resting heart rate is 80.  His resting blood pressure is 120/84.  His lungs are clear.  His heart exam reveals a regular rhythm and normal S1 and S2 without murmur, gallop, or rub appreciated.  The carotid upstroke is normal with no bruit identified.  The peripheral pulses are intact.  The resting electrocardiogram showed a sinus rhythm at 68 beats per minute and is normal.,DESCRIPTION: , The patient exercised according to the standard Bruce protocol stopping at 4 minutes and 39 seconds with fatigue.  He did not experience his left anterior chest pain with exercise.  He did achieve a maximal heart rate of 129 beats per minute, which is 85% of his maximal predicted heart rate.  His maximal blood pressure was 200/84, double product of 24,000 and achieving 7 METs.  As noted the resting electrocardiogram was normal.  With exercise, there were no significant deviations from baseline and no arrhythmias.,CONCLUSION:,1.  Reduced exercise capacity for age.,2.  No chest pain with exercise.,3.  No significant ST segment changes with exercise.,4.  Symptoms of left anterior chest pain were not provoked with exercise.,5.  Hypertensive response noted with exercise.
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DESCRIPTION: Reduced exercise capacity for age, no chest pain with exercise, no significant ST segment changes with exercise, symptoms of left anterior chest pain were not provoked with exercise, and hypertensive response noted with exercise.

cardiovascular / pulmonary, regular rhythm, s1, s2, chest pain, hypertensive, bruce protocol, exercise stress test, blood pressure, resting electrocardiogram, anterior chest, heart rate, rhythm, electrocardiogram, stress, chest, heart

The situation involves a medical evaluation of a 69-year-old man, who has expressed symptoms that could potentially indicate a cardiac issue in the context of an upcoming surgery. While the patient experienced left anterior chest pain previously, which could suggest angina or other cardiac issues, the exercise stress test did not provoke these symptoms, nor did it indicate significant cardiac issues such as ST segment changes or arrhythmias. However, the patient did have a hypertensive response to exercise. The need for cardiological assessment before surgery is significant as underlying cardiovascular disease could increase risks. Hence, this situation has moderate stakes due to the potential implications for surgical planning and patient safety.


Medical Specialty: Nephrology
Sample Name: CT Stone Protocol

EXAM: , CT stone protocol.,REASON FOR EXAM:,  History of stones, rule out stones.,TECHNIQUE: , Noncontrast CT abdomen and pelvis per renal stone protocol.,FINDINGS: , Correlation is made with a prior examination dated 01/20/09.,Again identified are small intrarenal stones bilaterally.  These are unchanged.  There is no hydronephrosis or significant ureteral dilatation.  There is no stone along the expected course of the ureters or within the bladder.  There is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith.  There is no asymmetric renal enlargement or perinephric stranding.,The appendix is normal.  There is no evidence of a pericolonic inflammatory process or small bowel obstruction.,Scans through the pelvis disclose no free fluid or adenopathy.,Lung bases aside from very mild dependent atelectasis appear clear.,Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. Bilateral intrarenal stones, no obstruction.,2. Normal appendix.
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DESCRIPTION: Noncontrast CT abdomen and pelvis per renal stone protocol.

nephrology, noncontrast ct, abdomen and pelvis, renal stone protocol, renal stone, intrarenal stones, stone protocol, ureteral, adenopathy, renal, ct, protocol, pelvis, intrarenal, stone, abdomen, noncontrast,

The provided CT scan report indicates a follow-up for kidney stones without any significant changes or complications like obstruction, hydronephrosis, or ureteral dilation, which would typically require urgent intervention. The presence of small intrarenal stones, no hydronephrosis, and a normal appendix suggest a stable condition. Therefore, while the health issues indicated by the scan should be monitored, they do not appear to be immediately life-threatening or critical.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: SOAP - Lung Mass

SUBJECTIVE:,  The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation.  The patient is doing fairly well.  This afternoon, she called me because heart rate was in the range of 120 to 140.  The patient is lying down.  She does have shortness of breath, but denies any other significant symptoms.,PAST MEDICAL HISTORY:,  History of mastectomy, chest tube placement, and atrial fibrillation; chronic.,MEDICATIONS:,1.  Cardizem, which is changed to 60 mg p.o. t.i.d.,2.  Digoxin 0.25 mg daily.,3.  Coumadin, adjusted dose.,4.  Clindamycin.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse 122 and blood pressure 102/68.,LUNGS:  Air entry decreased.,HEART:  PMI is displaced.  S1 and S2 are irregular.,ABDOMEN:  Soft and nontender.,IMPRESSION:,1.  Pulmonary disorder with lung mass.,2.  Pleural effusion.,3.  Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.,RECOMMENDATIONS:,1.  From cardiac standpoint, follow with pulmonary treatment.,2.  The patient has an INR of 2.09.  She is on anticoagulation.  Atrial fibrillation is chronic with the rate increased.,Adjust the medications accordingly as above.
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DESCRIPTION: Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation.

cardiovascular / pulmonary, lung mass, pleural effusion, chest tube placement, chest tube, pulmonary disorder, atrial fibrillation, chest, anticoagulation, effusion, lung, pulmonary, atrial, fibrillation,

The situation involves several serious health conditions including a lung mass, pleural effusion, and chronic atrial fibrillation. The patient is experiencing symptoms such as shortness of breath and an elevated heart rate. These issues indicate a significant health risk that requires careful management and monitoring. Sudden changes or deterioration in the patient's condition can lead to life-threatening complications, highlighting the high importance of medical decisions and interventions in this scenario.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Followup on Asthma

SUBJECTIVE: , This is a 42-year-old white female who comes in today for a complete physical and follow up on asthma.  She says her asthma has been worse over the last three months.  She has been using her inhaler daily.  Her allergies seem to be a little bit worse as well.  Her husband has been hauling corn and this seems to aggravate things.  She has not been taking Allegra daily but when she does take it, it seems to help somewhat.  She has not been taking her Flonase which has helped her in the past.  She also notes that in the past she was on Advair but she got some vaginal irritation with that.,She had been noticing increasing symptoms of irritability and PMS around her menstrual cycle.  She has been more impatient around that time.  Says otherwise her mood is normal during the rest of the month.  It usually is worse the week before her cycle and improves the day her menstrual cycle starts.  Menses have been regular but somewhat shorter than in the past.  Occasionally she will get some spotting after her cycles.  She denies any hot flashes or night sweats with this.  In reviewing the chart it is noted that she did have 3+ blood with what appeared to be a urinary tract infection previously.  Her urine has not been rechecked.  She recently had lab work and cholesterol drawn for a life insurance application and is going to send me those results when available.,REVIEW OF SYSTEMS: , As above.  No fevers, no headaches, no shortness of breath currently.  No chest pain or tightness.  No abdominal pain, no heartburn, no constipation, diarrhea or dysuria.  Occasional stress incontinence.  No muscle or joint pain.  No concerns about her skin.  No polyphagia, polydipsia or polyuria.,PAST MEDICAL HISTORY: , Significant for asthma, allergic rhinitis and cervical dysplasia.,SOCIAL HISTORY: , She is married.  She is a nonsmoker.,MEDICATIONS: , Proventil and Allegra.,ALLERGIES: , Sulfa.,OBJECTIVE:,Vital signs:  Her weight is 151 pounds.  Blood pressure is 110/60.  Pulse is 72.  Temperature is 97.1 degrees.  Respirations are 20.,General:  This is a well-developed, well-nourished 42-year-old white female, alert and oriented in no acute distress.  Affect is appropriate and is pleasant.,HEENT:  Normocephalic, atraumatic.  Tympanic membranes are clear.  Conjunctivae are clear.  Pupils are equal, round and reactive to light.  Nares without turbinate edema.  Oropharynx is nonerythematous.,Neck:  Supple without lymphadenopathy, thyromegaly, carotid bruit or JVD.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm without murmur.,Abdomen:  Soft, nontender, nondistended.  Normoactive bowel sounds.  No masses or organomegaly to palpation.,Extremities:  Without cyanosis or edema.,Skin:  Without abnormalities.,Breasts:  Normal symmetrical breasts without dimpling or retraction.  No nipple discharge.  No masses or lesions to palpation.  No axillary masses or lymphadenopathy.,Genitourinary:  Normal external genitalia.  The walls of the vaginal vault are visualized with normal pink rugae with no lesions noted.  Cervix is visualized without lesion.  She has a moderate amount of thick white/yellow vaginal discharge in the vaginal vault.  No cervical motion tenderness.  No adnexal tenderness or fullness.,ASSESSMENT/PLAN:,1.  Asthma.  Seems to be worse than in the past.  She is just using her Proventil inhaler but is using it daily.  We will add Flovent 44 mcg two puffs p.o. b.i.d.  May need to increase the dose.  She did get some vaginal irritation with Advair in the past but she is willing to retry that if it is necessary.  May also need to consider Singulair.  She is to call me if she is not improving.  If her shortness of breath worsens she is to call me or go into the emergency department.  We will plan on following up for reevaluation in one month.,2.  Allergic rhinitis.  We will plan on restarting Allegra and Flonase daily for the time being.,3.  Premenstrual dysphoric disorder.  She may have some perimenopausal symptoms.  We will start her on fluoxetine 20 mg one tablet p.o. q.d.,4.  Hematuria.  Likely this is secondary to urinary tract infection but we will repeat a UA to document clearing.  She does have some frequent dysuria but is not having it currently.,5.  Cervical dysplasia.  Pap smear is taken.  We will notify the patient of results.  If normal we will go back to yearly Pap smear.  She is scheduled for screening mammogram and instructed on monthly self-breast exam techniques.  Recommend she get 1200 mg of calcium and 400 U of vitamin D a day.
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DESCRIPTION: A female for a complete physical and follow up on asthma with allergic rhinitis.

The situation involves a medical follow-up for a patient with multiple health issues, including worsening asthma, allergic rhinitis, possible premenopausal symptoms, and a history of cervical dysplasia. While the asthma and other conditions are not immediately life-threatening, an exacerbation of asthma could become serious if not addressed. Furthermore, the patient's history of cervical dysplasia requires monitoring. However, with the patient currently in no acute distress and a planned follow-up in place, the situation is not acute or critical at this moment. The stakes are moderate due to the potential for conditions to worsen if not treated properly.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Duplex Ultrasound - Legs

DUPLEX ULTRASOUND OF LEGS,RIGHT LEG:,  Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound.  Deep veins were imaged at the level of the common femoral and popliteal veins.  All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis.  The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression.  The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.,LEFT LEG:,  Duplex imaging was carried out according to normal protocol with a 7.5 Mhz imaging probe using B-mode ultrasound.  Deep veins were imaged at the level of the common femoral and popliteal veins.  All deep veins demonstrated compressibility without evidence of intraluminal thrombus or increased echogenicity.,The long saphenous system displayed compressibility without evidence of thrombosis.  The long saphenous vein measured * cm at the proximal thigh with reflux of * seconds after release of distal compression and * cm at the knee with reflux of * seconds after release of distal compression.  The small saphenous system measured * cm at the proximal calf with reflux of * seconds after release of distal compression.
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DESCRIPTION: Duplex ultrasound of legs

Duplex ultrasound of legs

cardiovascular / pulmonary, duplex ultrasound, b-mode ultrasound, duplex imaging, compression, echogenicity, femoral, intraluminal thrombus, popliteal, saphenous vein, thrombosis, release of distal compression, calf with reflux, distal compression, duplex, ultrasound, legs, saphenous, release, distal, veins,

The duplex ultrasound results for the legs show that all deep veins and saphenous systems display compressibility without evidence of thrombosis, which is a positive finding as it rules out deep vein thrombosis. However, there are measurements marked with '*', which typically imply the clinician needs to fill these in with specific values and may indicate reflux, suggesting potential venous insufficiency. This is not typically life-threatening but could have implications for the patient's health depending on the severity. Generally, the stakes are not extremely high in this case as there is no immediate indication of life-threatening conditions.


Medical Specialty: Surgery
Sample Name: Culdoplasty & Vaginal Hysterectomy

PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic inflammatory disease.,2.  Pelvic adhesions.,3.  Pelvic pain.,4.  Fibroid uterus.,5.  Enterocele.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic inflammatory disease.,2.  Pelvic adhesions.,3.  Pelvic pain.,4.  Fibroid uterus.,5.  Enterocele.,PROCEDURE PERFORMED:,1.  Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy.,2.  McCall's culdoplasty.,3.  Cystoscopy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 350 cc.,INDICATIONS:  ,The patient is a 45-year-old Caucasian female with complaints of long standing pelvic pain throughout the menstrual cycle and worse with menstruation, uncontrolled with Anaprox DS also with complaints of dyspareunia.  On laparoscopy in May of 2003, PID, adenomyosis, and uterine fibroids were demonstrated.  The patient desires definitive treatment.,FINDINGS AT THE TIME OF SURGERY:  ,Uterus was retroverted and somewhat boggy on bimanual examination without any palpable adnexal abnormalities.  On laparoscopic examination, the uterus was quite soft and boggy consistent with the uterine adenomyosis.  There was also evidence of fibroid change in the right fundal aspect of the uterus.  There was a white exudative material covering the uterus as well as bilateral ovaries and fallopian tubes.  There were filmy adhesions to the right pelvic side wall, as well as left pelvic side wall.,PROCEDURE: , The patient taken to the operative suite where anesthesia was found to be adequate.  She was then prepared and draped in the normal sterile fashion.  A Foley catheter was initially placed and was noted to be draining clear to yellow urine.  A weighted speculum was placed in the patient's vagina.  The bladder was elevated and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus sounded to 7 cm and the cervix was then progressively dilated.  A #20 Hank dilator, which was left within the cervix used in conjunction with the vulsellum tenaculum as a uterine manipulator.  At this time, after the gloves were changed, attention was then turned to the patient's abdomen.  A small approximately 1 cm infraumbilical incision was made with the scalpel.  A Veress needle was then inserted through this incision and a pneumoperitoneum was created with CO2 gas with appropriate volumes and pressures.  A #10 mm step trocar was then inserted through this site and intraabdominal placing was confirmed with the laparoscope.  On entrance into the patient's abdomen and pelvis, survey of the abdomen and pelvis revealed the operative area to be relatively free of adhesions except for the right pelvic saddle in which there were filmy adhesions.  There was also white exudate noted covering the surface of the uterus and adnexa and the uterus had a quite boggy appearance.  At this time, under transillumination in the left anterior axillary line, a second incision was made with a scalpel and through this site a #12 mm step trocar was inserted under direct visualization by the laparoscope.  A third incision was made in the right anterior axillary line under transillumination and through this site a second #12 mm step trocar was placed under direct visualization by the laparoscope.  Then 2 cm above the pubic symphysis in the midline and fourth incision was made and a #5 mm step trocar was inserted through this site.  The uterus was elevated and deviated to the patient's right and infundibulopelvic ligament on the left was placed on tension with the aid of a grasper.  The Endo-GIA was placed through the left sided port and was fired was to cross the infundibulopelvic ligament and down passed to the level of the round ligament, transecting and stapling at the same time.  Attention was then turned to the right adnexa.,The uterus was brought over to the patient's left and the right infundibulopelvic ligament was placed on tension with the aid of a grasper.  An Endo-GIA was used to transect and staple this vasculature and down passed to the level of round ligament.  At this time, there was noted to be a small remnant of the round ligament on the right and a Harmonic scalpel was used to complete the transection and was found to be hemostatic.  In addition, on the left the same procedure was performed to completely transect the round ligament on the left and a good hemostasis was noted.  At this time, the uterus was dropped and the vesicouterine peritoneum was grasped with graspers.  The bladder was then dissected off of the lower uterine segment with the aid of a Harmonic scalpel and hemostasis was appreciated.  The anterior cervix of the uterus was scored in the midline up to the level of the fundus with the aid of a Harmonic scalpel and then out to the adnexa bilaterally to aid in orientation during the vaginal portion of the procedure.  At this time, copious suction irrigation was performed and the operative sites were found to be hemostatic.  The pneumoperitoneum was the evacuated and the attention was then turned to the vaginal portion of the procedure.  The weighted speculum was placed into the patient's vagina.  At this time, the Foley catheter was noted to have ________ and there was noted to be a small puncture site noted into the Foley bulb.  The Foley catheter was replaced and the bladder was to be filled at a later time with methylene blue to rule out any bladder injury during the laparoscopic part of the procedure.  The cervix was then grasped from right to left with a Lahey clamps and the anterior vaginal mucosa was placed on stretch with aid of Allis clamps.  The vaginal mucosa anteriorly was then incised with aid of a scalpel from the 9 o'clock position to 3 o'clock position.  The anterior vaginal mucosa and bladder were suctioned and were then dissected away from the lower uterine segment with the aid of Mayo scissors and blunt dissection until anteriorly the peritoneal cavity was entered at which time the peritoneal incision was extended bluntly.  Next, using Lahey clamps serially following the ________ placed by the Harmonic scalpel from above were followed up to the pubic uterine fundus until the uterus was delivered into the vagina anteriorly.  At this time, two curved Heaney clamps were placed across the uterine artery on the right.  This was then transected and suture ligated with #0 Vicryl suture.  The second clamp was advanced to incorporate the cardinal ligament complex and this was then transected and suture ligated with #0 Vicryl suture.  Attention was then turned to the left uterine artery which was again doubly clamped with curved Heaney clamps, transected and suture ligated with #0 Vicryl suture.  This second clamp was then advanced to capture the vasculature and the cardinal ligament complex.  This was again transected and suture ligated with #0 Vicryl suture.,Next, the uterosacral were clamped off with the curved Heaney clamps and this clamp was met in the midline by another clamp just underneath the cervix and clamping off of the vaginal cuff.  Next the uterus, ovaries and cervix were transected away from the vaginal cuff with the aid of double pointed scissors and this specimen was handed off to pathology.  At this time, the bladder was instilled with approximately 800 cc of methylene blue and there was no evidence of any leak of blue dye as could be seen from the prospective of the vaginal portion of the procedure.  Next, the posterior vaginal cuff and posterior peritoneum were incorporated in a running lock stitch of #0 Chromic beginning at the 9'o clock position over to the 3'o clock position.  Next, the anterior vaginal mucosa was grasped with the Allis clamp and the peritoneum was identified anteriorly.  The angles of the vaginal cuff were then closed with #0 Chromic suture figure-of-eight stitch with care taken to incorporate the anterior vaginal mucosa, the anterior peritoneum, and the previously closed posterior vaginal mucosa and the posterior peritoneum.  Two additional sutures medially were placed and these were tagged and not tied in place.  A #0 Vicryl suture on a UR6 needle was used to perform the McCall's culdoplasty type approximation with the vaginal cuff to open and the uterosacral ligament visualized.  This was then tied in place and the remainder of the vaginal cuff was closed with #0 Chromic suture with figure-of-eight stitches.  At this time, the gloves were changed and attention was returned to the laparoscopic portion of the procedure at which time the abdomen was re-insufflated and the patient was placed in Trendelenburg.  The bowel was moved out of the way and copious suction irrigation was performed and all operative areas were noted to be hemostatic.  The bladder was again filled with approximately 400 cc methylene blue and from the laparoscopic ________ point there was no evidence of leakage of blue dye at this time.  The pneumoperitoneum was then evacuated and a cystoscopy was performed filling the bladder with approximately 400 cc of normal saline and there was noted to be a pinpoint perforation right on bladder dome which was found to be hemostatic and was not found to have any leakage at this time.  The bladder was then drained and the Foley catheter was replaced and after gloves changed, attention was turned to the abdomen with the laparoscopic instruments removed from the patient's abdomen.  The skin incisions were closed with #4-0 undyed Vicryl in a subcuticular fashion.  Approximately 10 cc of 0.25% Marcaine in total were injected at incision site for additional analgesia.  The Steri-Strips were placed.  The patient tolerated the procedure well and taken to recovery in stable condition.  Sponge, lap, and needle counts were correct x2.  The specimens include the uterus, cervix, bilateral ovaries, and fallopian tubes.  The patient will have her Foley catheter maintained for approximately 7 to 10 days.
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DESCRIPTION: Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, culdoplasty, and cystoscopy.  Chronic pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, and enterocele.

surgery, pelvic inflammatory disease, pelvic adhesions, pelvic pain, fibroid uterus, enterocele, salpingo-oophorectomy, mccall's culdoplasty, cystoscopy, laparoscopic assisted vaginal hysterectomy, foley catheter, vaginal mucosa, vaginal cuff, bladder, ligament, clamps, suture, pelvic, uterus, vaginal, inflammatory, laparoscopic,

The described scenario involves a complex surgical procedure with multiple steps and significant potential for complications, such as blood loss and inadvertent injury to surrounding structures like the bladder. This procedure addresses critical health issues including chronic pelvic inflammatory disease, fibroid uterus, and pelvic pain. The potential for complications, especially given the postoperative management of a Foley catheter for up to 10 days, indicates a high-stakes situation. Surgical outcomes can significantly affect the patient's quality of life and health status.


Medical Specialty: Bariatrics
Sample Name: Bariatric Consult - Surgical Weight Loss - 1

PAST MEDICAL HISTORY: , She has a history of hypertension and shortness of breath.,PAST SURGICAL HISTORY: , Pertinent for cholecystectomy.,PSYCHOLOGICAL HISTORY: , Negative.,SOCIAL HISTORY: , She is single.  She drinks alcohol once a week.  She does not smoke.,FAMILY HISTORY: , Pertinent for obesity and hypertension.,MEDICATIONS: , Include Topamax 100 mg twice daily, Zoloft 100 mg twice daily, Abilify 5 mg daily, Motrin 800 mg daily, and a multivitamin.,ALLERGIES: , She has no known drug allergies.,REVIEW OF SYSTEMS: , Negative.,PHYSICAL EXAM:  ,This is a pleasant female in no acute distress.  Alert and oriented x 3.  HEENT:  Normocephalic, atraumatic.  Extraocular muscles intact, nonicteric sclerae.  Chest is clear to auscultation bilaterally.  Cardiovascular is normal sinus rhythm.  Abdomen is obese, soft, nontender and nondistended.  Extremities show no edema, clubbing or cyanosis.,ASSESSMENT/PLAN:  ,This is a 34-year-old female with a BMI of 43 who is interested in surgical weight via the gastric bypass as opposed to Lap-Band.  ABC will be asking for a letter of medical necessity from Dr. XYZ.  She will also see my nutritionist and social worker and have an upper endoscopy.  Once this is completed, we will submit her to her insurance company for approval.
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DESCRIPTION: Evaluation for elective surgical weight loss via the gastric bypass as opposed to Lap-Band.

bariatrics, elective surgical weight loss, surgical weight loss, weight loss, loss, weight, bmi, surgical, pounds,

The consultation is about evaluating a patient for elective surgical weight loss. While obesity and related comorbidities (like hypertension) are serious health concerns, the situation here is for an elective procedure. This suggests that the medical stableness of the patient allows for planned weight loss surgery rather than an emergency or lifesaving procedure. The proper protocol is being followed for pre-surgical screening and insurance approval, which implies a controlled non-urgent environment. Consequently, the stakes are not extremely high compared to an immediate or emergency medical situation.


Medical Specialty: Surgery
Sample Name: Bladder Biopsies & Fulguration

PREOPERATIVE DIAGNOSIS:,  Bladder lesions with history of previous transitional cell bladder carcinoma.,POSTOPERATIVE DIAGNOSIS: , Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.,OPERATION PERFORMED:  ,Cystoscopy, bladder biopsies, and fulguration.,ANESTHESIA: , General.,INDICATION FOR OPERATION: , This is a 73-year-old gentleman who was recently noted to have some erythematous, somewhat raised bladder lesions in the bladder mucosa at cystoscopy.  He was treated for a large transitional cell carcinoma of the bladder with TURBT in 2002 and subsequently underwent chemotherapy because of pulmonary nodules.  He has had some low grade noninvasive small tumor recurrences on one or two occasions over the past 18 months.  Recent cystoscopy raises suspicion of another recurrence.,OPERATIVE FINDINGS: , The entire bladder was actually somewhat erythematous with mucosa looking somewhat hyperplastic particularly in the right dome and lateral wall of the bladder.  Scarring was noted along the base of the bladder from the patient's previous cysto TURBT.  Ureteral orifice on the right side was not able to be identified.  The left side was unremarkable.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room.  He was placed on the operating table.  General anesthesia was administered after which the patient was placed in the dorsal lithotomy position.  The genitalia and lower abdomen were prepared with Betadine and draped subsequently.  The urethra and bladder were inspected under video urology equipment (25 French panendoscope) with the findings as noted above.  Cup biopsies were taken in two areas from the right lateral wall of the bladder, the posterior wall of bladder, and the bladder neck area.  Each of these biopsy sites were fulgurated with Bugbee electrodes.  Inspection of the sites after completing the procedure revealed no bleeding and bladder irrigant was clear.  The patient's bladder was then emptied.  Cystoscope removed and the patient was awakened and transferred to the postanesthetic recovery area.  There were no apparent complications, and the patient appeared to tolerate the procedure well.  Estimated blood loss was less than 15 mL.
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DESCRIPTION: Cystoscopy, bladder biopsies, and fulguration.  Bladder lesions with history of previous transitional cell bladder carcinoma, pathology pending.

surgery, cystoscope, carcinoma, transitional cell bladder carcinoma, bladder lesions, bladder, fulguration, biopsies, cystoscopy,

The situation involves a surgical procedure on a patient with a history of bladder cancer, raising concerns about a potential recurrence. While the procedure itself (cystoscopy with biopsies and fulguration) is relatively standard and was completed without complications, the stakes are elevated due to the patient's medical history and the awaiting pathology results, which could have significant implications for further treatment and prognosis. Given the implications for the patient's health outcomes, this can be considered moderately high-stakes, particularly because of the potential for a recurring malignancy.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lobectomy - Left Lower

OPERATION: , Left lower lobectomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed.  The patient was placed in the right lateral decubitus position.  The left chest and back were prepped and draped in a sterile fashion.  A right lateral thoracotomy incision was made.  Subcutaneous flaps were raised.  The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly.  The posterior border of the pectoralis was freed up and it was retracted anteriorly.  The 5th intercostal space was entered.,The inferior pulmonary ligament was then taken down with electrocautery.  The major fissure was then taken down and arteries identified.  The artery was dissected free and it was divided with an Endo GIA stapler.  The vein was then dissected free and divided with an Endo GIA stapler.  The bronchus was then cleaned of all nodal tissue.  A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.,Then the lobe was removed and sent to pathology where margins were found to be free of tumor.  Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen.  Hemostasis noted.  Posterior 28-French and anterior 24-French chest tubes were placed.,The wounds were closed with #2 Vicryl.  A subcutaneous drain was placed.  Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.
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DESCRIPTION: Left lower lobectomy.

Left lower lobectomy.

cardiovascular / pulmonary, lower lobectomy, electrocautery, endo gia stapler, subcutaneous drain, endotracheal, subcutaneous, lobectomy,

The document describes a left lower lobectomy, which is a surgical procedure to remove a lobe of the lung, typically due to conditions such as lung cancer or severe infection. Surgical procedures generally involve risks including bleeding, infection, and complications related to anesthesia. Given these aspects, and its impact on lung function and overall health, the operation can be considered high-stakes for the patient's well-being.


Medical Specialty: Autopsy
Sample Name: Autopsy - 8

SUMMARY OF CLINICAL HISTORY:,  The patient was a 35-year-old African-American male with no significant past medical history who called EMS with shortness of breath and chest pain.  Upon EMS arrival, patient was tachypneic at 40 breaths per minute with oxygen saturation of 90%.  At the scene, EMS administered breathing treatments and checked lung sounds that did not reveal any evidence of fluid in the lung fields.  EMS also reports patient was agitated upon their arrival at his residence.  Two minutes after arrival at UTMB at 1500, the patient became unresponsive, apneic, and had oxygen saturations from 80-90%.  The patient's heart rate decreased to asystole, was intubated with good breath sounds and air movement.  Patient then had wide complex bradycardia and ACLS protocol for pulseless electrical activity was followed for 45 minutes.  The patient was administered TPA with no improvement.  Bedside echocardiogram showed no pericardial effusion.  The patient was administered D5W, Narcan, and multiple rounds of epinephrine and atropine, calcium chloride, and sodium bicarbonate.  The patient had three episodes of ventricular tachycardia/fibrillation with cardioversion/defibrillation resulting in asystole.  The patient was pronounced dead at 1605 with fixed, dilated pupils, no heart sounds, no pulse and no spontaneous respirations.,DESCRIPTION OF GROSS LESIONS,EXTERNAL EXAMINATION:,  The body is that of a 35-year-old well-developed, well-nourished male.  There is no peripheral edema of the extremities.  There is an area of congestion/erythema on the upper chest and anterior neck.  There are multiple small areas of hemorrhage bilaterally in the conjunctiva.  A nasogastric tube and endotracheal tube are in place.  There is an intravenous line in the right hand and left femoral region.  The patient has multiple lead pads on the thorax.  The patient has no other major surgical scars.,INTERNAL EXAMINATION (BODY CAVITIES):,  The right and left pleural cavity contains 10 ml of clear fluid with no adhesions.  The pericardial sac is yellow, glistening without adhesions or fibrosis and contains 30 ml of a straw colored fluid.  There is minimal fluid in the peritoneal cavity.,HEART:,  The heart is large with a normal shape and a weight of 400 grams.  The pericardium is intact.  The epicardial fat is diffusely firm.  As patient was greater than 48 hours post mortem, no TTC staining was utilized.  Upon opening the heart was grossly normal without evidence of infarction.  There were slightly raised white plaques in the left ventricle wall lining.  The left ventricle measures 2.2 cm, the right ventricle measures 0.2 cm, the tricuspid ring measures 11 cm, the pulmonic right measures 8 cm, the mitral ring measures 10.2 cm, and the aortic ring measures 7 cm.  The foramen ovale is closed.  The circulation is left dominant.  Examination of the great vessels of the heart reveals minimal atherosclerosis with the area of greatest stenosis (20% stenosis) at the bifurcation of the LAD.,AORTA:,  There is minimal atherosclerosis with no measurable plaques along the full length of the ascending and descending aorta.,LUNGS: , The right lung weighed 630 grams, the left weighed 710 grams.  The lung parenchyma is pink without evidence of congestion of hemorrhage.  The bronchi are grossly normal.  In the right lung, there are two large organizing thrombo-emboli.  The first is located at the first branch of the pulmonary artery with an older, organizing area adherent to the vessel wall measuring 1.0 x 1.0 x 2.5 cm.  Surrounding this organizing area is a newer area of apparent thrombosis completely occluding the bifurcation.  The other large organizing, adherent embolus is located further in out in the vasculature measuring approximately 1.0 x 1.0 x 1.5 cm.  There are multiple other emboli located in smaller pulmonary vessels that show evidence of distending the vessels they are located inside.,GASTROINTESTINAL SYSTEM:,  The esophagus and stomach are normal in appearance without evidence of ulcers or varices.  The stomach contains approximately 800 ml, without evidence of any pills or other non-foodstuff material.  The pancreas shows a normal lobular cut surface with evidence of autolysis.  The duodenum, ileum, jejunum and colon are all grossly normal without evidence of abnormal vasculature or diverticula.  An appendix is present and is unremarkable.  The liver weighs 2850 grams and the cut surface reveals a normal liver with no fibrosis present grossly.  The gallbladder is in place with a probe patent bile duct through to the ampulla of Vater.,RETICULOENDOTHELIAL SYSTEM:,  The spleen is large weighing 340 grams, the cut surface reveals a normal appearing white and red pulp.  No abnormally large lymph nodes were noted.,GENITOURINARY SYSTEM:,  The right kidney weighs 200 grams, the left weighs 210 grams.  The left kidney contains a 1.0 x 1.0 x 1.0 simple cyst containing a clear fluid.  The cut surface reveals a normal appearing cortex and medulla with intact calyces.  The prostate and seminal vessels were cut revealing normal appearing prostate and seminal vesicle tissue without evidence of inflammation or embolus.,ENDOCRINE SYSTEM:,  The adrenal glands are in the normal position and weigh 8.0 grams on the right and 11.6 grams on the left.  The cut surface of the adrenal glands reveals a normal appearing cortex and medulla.  The thyroid gland weighs 12.4 grams and is grossly normal.,EXTREMITIES:,  Both legs and calves were measured and found to be very similar in circumference.  Both legs were also milked and produced no clots in the venous system.,CLINICOPATHOLOGIC CORRELATION,This patient died shortly after a previous pulmonary embolus completely occluded the right pulmonary artery vasculature., ,The most significant finding on autopsy was the presence of multiple old and new thromboemboli in the pulmonary vasculature of the right lung.  The autopsy revealed evidence of multiple emboli in the right lung that were at least a few days old because the emboli that were organizing were adherent to the vessel wall.  In order to be adherent to the vessel wall, the emboli must be in place long enough to evoke a fibroblast response, which takes at least a few days.  The fatal event was not the old emboli in the right lung, but rather the thrombosis on top of the large saddle thrombus residing in the pulmonary artery.  This created a high-pressure situation that the right ventricle could not handle resulting in cardiac dysfunction and ultimately the patient's demise.,Although this case is fairly straight forward in terms of what caused the terminal event, perhaps the more interesting question is why a relatively healthy 35-year-old man would develop a fatal pulmonary embolism.  Virchow's triad suggests we should investigate endothelial injury, stasis and a hypercoagulable state as possible etiologies.  The age of the patient probably precludes venous stasis as the sole reason for the embolus although it could have certainly contributed.  The autopsy revealed no evidence of endothelial damage in the pulmonary vasculature that would have caused the occlusion.  The next logical reason would be a hypercoagulable state.  Some possibilities include obesity, trauma, surgery, cancer, Factor V Leiden deficiency (as well as other inherited disorders-prothrombin gene mutation, deficiencies in protein C, protein S, or antithrombin III, and disorders of plasminogen), and Lupus anticoagulant.  Of these risks factors, obesity was the only risk factor the patient was known to have.  The patient had no evidence of trauma, surgery, cancer or the stigmata of SLE, therefore these are unlikely.  Perhaps the most fruitful search would be an examination of the genetic possibilities for a hypercoagulable state (Factor V Leiden being the most common).,In summary, this patient died of a pulmonary embolism, the underlying cause of which is currently undetermined.  A definitive diagnosis may be ascertained with either genetic or other laboratory tests and a more detailed history.,SUMMARY AND REFLECTION,WHAT I LEARNED FROM THIS AUTOPSY:,  I learned that although a cause of death may sometimes be obvious, the underlying mechanism for the death may still be elusive.  This patient was an otherwise completely healthy 35-year-old man with one known risk factor for a hypercoagulable state.,REMAINING UNANSWERED QUESTIONS:,  Basically the cause of the hypercoagulable state is undetermined.  Once that question is answered I believe this autopsy will have done a great service for the patient's family.
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DESCRIPTION: The patient died of a pulmonary embolism, the underlying cause of which is currently undetermined.

This case involves a fatal pulmonary embolism in a relatively young and otherwise healthy individual. While the immediate cause of death is clear, determining the underlying hypercoagulable state is crucial for potential genetic or inherited risk factors. Identifying these could have significant implications for patient family screening and understanding the potential for similar occurrences in relatives. While the outcome for the patient is unfortunately already determined, understanding the cause is important for prevention in others, adding some level of urgency and importance to the case. However, these factors align more with moderate stakes, as they influence future health decisions rather than immediate life-threatening scenarios.


Medical Specialty: Radiology
Sample Name: Single Frontal View - Chest - Pediatric

EXAM:,  Single frontal view of the chest.,HISTORY:,  Respiratory distress.  The patient has a history of malrotation.  The patient is back for a re-anastomosis of the bowel with no acute distress.,TECHNIQUE:,  Single frontal view of the chest was evaluated and correlated with the prior film dated MM/DD/YY.,FINDINGS:,  A single frontal view of the chest was evaluated.  It reveals interval placement of an ET tube and an NG tube.  ET tube is midway between the patient's thoracic inlet and carina.  NG tube courses with the distal tip in the left upper quadrant beneath the left hemidiaphragm.  There is no evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.  The mediastinum seen was slightly prominent; however, this may be secondary to thymus and/or technique.  There is a slight increase seen with regards to the central pulmonary vessels.  Again, this may represent a minimal amount of pulmonary vascular congestion.  There is paucity of bowel gas seen in the upper abdomen.  The osseous thorax appears to be grossly intact and symmetrical.  Slightly low lung volumes, however, this may be secondary to the film being taken on the expiratory phase of respiration.,IMPRESSION:,1.  No evidence of any focal areas of consolidation, pneumothoraces, or pleural effusions.,2.  Slight prominence to the mediastinum which may be secondary to thymus and/or technique.,3.  Slight prominence of some of the central pulmonary vasculature which may represent a minimal amount of vascular congestion.
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DESCRIPTION: Single frontal view of the chest. Respiratory distress.  The patient has a history of malrotation.

radiology, malrotation, consolidation, pneumothoraces, single frontal view, respiratory distress, vascular congestion, frontal view, effusions, mediastinum, vascular, congestion, respiratory, anastomosis, pulmonary, single, frontal, chest

The presented case involves a pediatric patient who is returning for a bowel surgery (re-anastomosis) and experiencing respiratory distress. However, the radiology findings indicate no immediate acute or critical issues, such as consolidation, pneumothoraces, or pleural effusions, which are often serious concerns in respiratory distress scenarios. The prominence of the mediastinum and pulmonary vasculature may require monitoring, but these findings alone do not suggest an immediate life-threatening situation. Situations in pediatric care, particularly involving respiratory distress, tend to be carefully monitored, but the absence of acute findings de-escalates the high-stakes nature slightly.


Medical Specialty: Consult - History and Phy.
Sample Name: Thyroid Mass Consult

REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy.  The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004.  An ultrasound examination had reportedly been done in the past and the mass is being observed.  When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there.  The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma.  The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction.  She has no weight changes consistent with either hyper or hypothyroidism.  There is no family history of thyroid cancer in her family.  She has no notable discomfort with this lesion.  There have been no skin changes.  Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:,  Essentially unremarkable.  The patient has never been hospitalized in the past for any major illnesses.  She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS:  ,Currently taking no routine medications.  She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter.  This was done in Tijuana.  His mom is from central portion of Mexico.  There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY:  ,The patient is a junior at Hoover High School.  She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress.  She was alert and oriented x3 and had an appropriate affect.,HEENT:  The head and neck examination is most significant.  There is mild amount of facial acne.  The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK:  There is a slightly visible midline bulge in the region of the thyroid isthmus.  A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid.  This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine.  There are some shotty adenopathy in the area.  No supraclavicular nodes were noted.,CHEST:  Excursions are symmetric with good air entry.,LUNGS:  Clear.,CARDIOVASCULAR:  Normal.  There is no tachycardia or murmur noted.,ABDOMEN:  Benign.,EXTREMITIES:  Extremities are anatomically correct with full range of motion.,GENITOURINARY:  External genitourinary exam was deferred at this time and can be performed later during anesthesia.  This is same as too for her rectal examination.,SKIN:  There is no acute rash, purpura, or petechiae.,NEUROLOGIC:  Normal and no focal deficits.  Her voice is strong and clear.  There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range.  T4 and TSH levels were recorded as normal.  Free thyroxine was normal, and the serum pregnancy test was negative.  There was no level of thyroglobulin recorded on this.  A urinalysis and comprehensive metabolic panel was unremarkable.  A chest x-ray was obtained, which I personally reviewed.  There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease.  I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease.  During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy.  We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation.  We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well.  I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them.  I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit.  This will have some impact on the postoperative adjunctive therapy.  The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case.  I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity.  All of the family's questions have been answered.  This is a very anxious and anxiety provoking time in the family.  I have made every effort to get the patient under schedule within the next 48 hours to have this operation done.  We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.
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DESCRIPTION: Thyroid mass diagnosed as papillary carcinoma.  The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.

The situation involves a 16-year-old girl diagnosed with papillary thyroid carcinoma, a type of cancer, with evidence of potential metastasis in the lungs. This is a serious medical condition requiring urgent surgical intervention and further treatment, such as radioactive iodine therapy. It also involves implications for the patient's long-term health, including potential complications from surgery and the stress on her and her family. The stakes are high due to the immediate need for surgical treatment, the complexity of the condition due to possible metastasis, and the young age of the patient, which could impact her development and quality of life.


Medical Specialty: Emergency Room Reports
Sample Name: Bronchiolitis - 2-month-old

CHIEF COMPLAINT: , Increased work of breathing.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-month-old female with a 9-day history of illness.  Per mom's report, the illness started 9 days ago with a dry cough.  The patient was eating normal up until approximately three days ago.  Mom was using a vaporizer at night, which she feels to have helped.  The patient's cough gradually worsened and three days ago, the patient had a significant increasing cough.  At that time, the patient also had significant increasing congestion.  Two days ago the patient was taken to the primary care physician's office and the patient was given Xopenex 2 puffs every 4 to 6 hours for home regimen, but this per mom's report, did not help the patient's symptoms.  On Wednesday evening, the patient's congestion and work of breathing increased and the patient was gagging after feedings.  The patient was brought to Children's Hospital Emergency Room at which time the patient was evaluated.  A chest x-ray was obtained and was noted to be normal.  The patient's saturations were noted to be normal and the patient was discharged home.  Last night, the patient was having multiple episodes of emesis after feedings with coughing and today was noted to have decreasing activity.  The patient had a 101 temperature on Wednesday evening, but has had no true fevers.  The patient has had a mild decrease in urine output today and secondary to the persistent increased work of breathing, coughing, and posttussive emesis, the patient was brought to Children's Hospital for reevaluation.,REVIEW OF SYSTEMS: , The remainder of the review of system is otherwise negative, all systems being reviewed, outside of pertinent positives as stated above.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS:  ,As above.,IMMUNIZATIONS:,  None.,PAST MEDICAL HISTORY:  ,No hospitalizations.  No surgeries.,BIRTH HISTORY: , The patient was born to a G8, P2, A6 mom via normal spontaneous vaginal delivery.  Birth weight 6 pounds 12 ounces.  Mom stated she had a uterine infection during her pregnancy and at the time of delivery, but the patient was only in the hospital for 24 hours with mom after delivery.  The patient was full term and mom was noted to have gestational diabetes controlled with diet during her pregnancy.,FAMILY HISTORY: , Brother, mother, and father all have asthma.  Mom was noted to have gestational diabetes.,SOCIAL HISTORY: , The patient lives with mother, father, and a brother.  There is one bird.  There are smokers in the household.  There are sick contacts.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 97.7 and pulse is 181, but the patient is fussy.  Respiratory rate ranged between 36 and 44.  The patient is saturating 100% on one-half liter and 89% on room air.,GENERAL APPEARANCE:  Nontoxic child, but with increased work of breathing.  No respiratory distress.,HEENT:  Head is normocephalic and atraumatic.  Anterior fontanelle flat.  Pupils are equal, round, and reactive to light bilaterally.  Tympanic membranes are clear bilaterally.  Nares are congested.  Mucous membranes are moist without erythema.,NECK:  Supple.  No lymphadenopathy.,CHEST:  Exhibits symmetric expansion and retractions.,LUNGS:  The patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi.,CARDIOVASCULAR:  Heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder.,ABDOMEN:  Soft, nondistended, and nondistended.  Good bowel sounds noted in all 4 quadrants.,GU:  Normal female.  No discharge or erythema.,BACK:  Normal with a normal curvature.,EXTREMITIES:  A 2+ pulses in the bilateral upper lower extremities.  No evidence of clubbing, cyanosis, or edema.  Capillary refill less than 3 seconds.,LABORATORY DATA: , Labs in the emergency room include a CBC, which showed a white blood cell count of 20.8 with a hemoglobin of 10.7, hematocrit of 31.3 with platelet count of 715,000 with 40% neutrophils, 2 bands, and 70% monocytes.  A urinalysis obtained in the emergency room was noted to be negative.  CRP was noted to be 2.0.  The chest x-ray, reviewed by myself in the emergency room, showed no significant change from previous x-ray, but the patient does has some bronchial wall thickening.,ASSESSMENT AND PLAN: , This is a 2-month-old female who presents to Children's Hospital with examination consistent with bronchiolitis.  At this time, the patient will be placed on the bronchiolitis pathway providing this patient with aggressive suctioning and supplemental oxygen as needed.  Currently, at this time, I feel no respiratory treatments are indicated in this patient.  I hear no evidence of wheezing or reactive airway disease.  We will continue to monitor and reassess this patient closely for this as there is a strong family history of reactive airway disease; however, at this time, the patient will be monitored without any medications and the remainder of the clinical course will be determined by her presentation during the course of this illness.
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DESCRIPTION: 2-month-old female - increased work of breathing.

The situation involves a 2-month-old infant who is experiencing significant respiratory symptoms consistent with bronchiolitis, which is a serious condition at such a young age. Given the age of the patient, the history of increasing work of breathing, coughing, and post-tussive emesis, and a family history of asthma, the situation is critical. Infants can deteriorate quickly when faced with respiratory issues, making appropriate and timely interventions crucial. The need for hospitalization and close monitoring underscores the high-stakes nature of this case.


Medical Specialty: Surgery
Sample Name: Mammoplasty - 1

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

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

This situation involves a surgical procedure, which inherently carries risks and requires precision and expertise. The procedure described is a bilateral reduction mammoplasty for treating bilateral macromastia, which addresses both physical discomfort and potential health complications related to back and shoulder pain. The operation has multiple stages and uses general anesthesia, adding complexity and risk. While it is a routine procedure within the specialty of surgery, the stakes are higher due to the inherent risks of surgery, the need for symmetry, and potential post-operative complications. Furthermore, any surgical procedure with general anesthesia and significant tissue removal like this one has a higher level of risk compared to non-surgical medical management.


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

Medical Specialty: Gastroenterology
Sample Name: CT Scan of Abdomen & Pelvis with Contrast

EXAM: , CT scan of the abdomen and pelvis with contrast.,REASON FOR EXAM: , Abdominal pain.,COMPARISON EXAM: , None.,TECHNIQUE: , Multiple axial images of the abdomen and pelvis were obtained.  5-mm slices were acquired after injection of 125 cc of Omnipaque IV.  In addition, oral ReadiCAT was given.  Reformatted sagittal and coronal images were obtained.,DISCUSSION:,  There are numerous subcentimeter nodules seen within the lung bases.  The largest measures up to 6 mm.  No hiatal hernia is identified.  Consider chest CT for further evaluation of the pulmonary nodules.  The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys are within normal limits.  No dilated loops of bowel.  There are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat.  In addition, there is soft tissue stranding seen of the lower pelvis.  In addition, the uterus is not identified.  Correlate with history of recent surgery.  There is no free fluid or lymphadenopathy seen within the abdomen or pelvis.  The bladder is within normal limits for technique.,No acute bony abnormalities appreciated.  No suspicious osteoblastic or osteolytic lesions.,IMPRESSION:,1.  Postoperative changes seen within the pelvis without appreciable evidence for free fluid.,2.  Numerous subcentimeter nodules seen within the lung bases.  Consider chest CT for further characterization.
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DESCRIPTION: CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan.

gastroenterology, ct scan, abdominal pain, multiple axial images, abdomen and pelvis, adrenal glands, chest ct, coronal, gallbladder, kidneys, liver, lymphadenopathy, nodules, osteoblastic, osteolytic, pancreas, sagittal, spleen, with contrast, free fluid, ct, abdomen, pelvis,

The CT scan report reveals findings that may not be immediately life-threatening but do require further evaluation. Subcentimeter nodules in the lung bases could potentially represent a serious underlying condition, such as metastatic disease, especially if there is a history of cancer, but this is not confirmed without further testing. Additionally, the mention of postoperative changes suggests recent surgery, which could have implications depending on the surgical outcome and recovery process. These factors indicate that while it is not an acute emergency, there is a significant need for follow-up to rule out serious conditions.


Medical Specialty: Consult - History and Phy.
Sample Name: Agitation - ER Visit

HISTORY OF PRESENT ILLNESS:  This is a 91-year-old female who was brought in by family.  Apparently, she was complaining that she felt she might have been poisoned at her care facility.  The daughter who accompanied the patient states that she does not think anything is actually wrong, but she became extremely agitated and she thinks that is the biggest problem with the patient right now.  The patient apparently had a little bit of dry heaves, but no actual vomiting.  She had just finished eating dinner.  No one else in the facility has been ill.,PAST MEDICAL HISTORY: Remarkable for previous abdominal surgeries.  She has a pacemaker.  She has a history of recent collarbone fracture.,REVIEW OF SYSTEMS:  Very difficult to get from the patient herself.  She seems to deny any significant pain or discomfort, but really seems not particularly intent on letting me know what is bothering her.  She initially stated that everything was wrong, but could not specify any specific complaints.  Denies chest pain, back pain, or abdominal pain.  Denies any extremity symptoms or complaints.,SOCIAL HISTORY:  The patient is a nonsmoker.  She is accompanied here with daughter who brought her over here.  They were visiting the patient when this episode occurred.,MEDICATIONS:  Please see list.,ALLERGIES:  NONE.,PHYSICAL EXAMINATION:  VITAL SIGNS:  The patient is afebrile, actually has a very normal vital signs including normal pulse oximetry at 99% on room air.  GENERAL:  The patient is an elderly frail looking little lady lying on the gurney.  She is awake, alert, and not really wanted to answer most of the questions I asked her.  She does have a tremor with her mouth, which the daughter states has been there for "many years".  HEENT:  Eye exam is unremarkable.  Oral mucosa is still moist and well hydrated.  Posterior pharynx is clear.  NECK:  Supple.  LUNGS:  Actually clear with good breath sounds.  There are no wheezes, no rales, or rhonchi.  Good air movement.  CARDIAC:  Without murmur.  ABDOMEN:  Soft.  I do not elicit any tenderness.  There is no abdominal distention.  Bowel sounds are present in all quadrants.  SKIN:  Skin is without rash or petechiae.  There is no cyanosis.  EXTREMITIES:  No evidence of any trauma to the extremities.,EMERGENCY DEPARTMENT COURSE:  I had a long discussion with the family and they would like the patient receive something for agitation, so she was given 0.5 mg of Ativan intramuscularly.  After about half an hour, I came back to talk to the patient and the family, the patient states that she feels better.  Family states she seems more calm.  They do not want to pursue any further workup at this time.,IMPRESSION:  ACUTE EPISODE OF AGITATION.,PLAN:  At this time, I had reviewed the patient's records and it is not particularly enlightening as to what could have triggered off this episode.  The patient herself has good vital signs.  She does not seem to have any specific acute process going on and seemed to feel comfortable after the Ativan was given, a small quantity was given to the patient.  Family and daughter specifically did not want to pursue any workup at this point, which at this point I think is reasonable and we will have her follow up with ABC.  She is discharged in stable condition.
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DESCRIPTION: Acute episode of agitation.  She was complaining that she felt she might have been poisoned at her care facility.

consult - history and phy., acute episode of agitation, agitation,

The situation involves an elderly patient experiencing acute agitation and concerns about potential poisoning. However, there are no clear signs of poisoning, and her agitation appears to be resolved with Ativan. Her stable vital signs and the family's decision not to pursue further workup suggest it is not a medical emergency, but given her age and the initial concern of poisoning, it remains a situation requiring some attention. Thus, it is not extremely high-stakes but still requires careful monitoring and follow-up.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Laparoscopy - Drainage of Cyst

PREOPERATIVE DIAGNOSIS:,  Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:,  General,NAME OF OPERATION:,  Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:,  The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced.  An infraumbilical incision was made, and Veress needle placed without difficulty.  Gas was entered into the abdomen at two liters.  The laparoscope was entered, and the abdomen was visualized.  The second puncture site was made, and the second trocar placed without difficulty.  The cyst was noted on the left, a 3-cm, ovarian cyst.  This was needled, and a hole cut in it with the scissors.  Hemostasis was intact.  Instruments were removed.  The patient was awakened and taken to the recovery room in good condition.
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DESCRIPTION: Diagnostic laparoscopy and drainage of cyst.

obstetrics / gynecology, ovarian cyst, infraumbilical incision, drainage of cyst, diagnostic laparoscopy, laparoscopy, drainage, ovarian,

The case describes a routine laparoscopic procedure to drain a persistent ovarian cyst. Such procedures are common and generally considered low-risk when performed by experienced medical professionals under controlled conditions. There is anesthesia involved, which always presents some risk, but overall, the stakes are not extremely high compared to more complex surgical procedures. The outcome was favorable as the patient was taken to the recovery room in good condition.


Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 8

SUBJECTIVE:,  The patient is an 89-year-old lady.  She actually turns 90 later this month, seen today for a short-term followup.  Actually, the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved.  Blood pressure is better even though she is not currently on the higher dose Mavik likely recommended.  She apparently did not feel well with the higher dose, so she just went back to her previous dose of 1 mg daily.  She thinks, she also has an element of office hypertension.  Also, since she is on Mavik plus verapamil, she could switch over to the combined drug Tarka.  However, when we gave her samples of that she thought they were too big for her to swallow.  Basically, she is just back on her previous blood pressure regimen.  However, her blood pressure seems to be better today.  Her daughter says that they do check it periodically and it is similar to today’s reading.  Her right arm symptoms are basically resolved and she attributed that to her muscle problem back in the right shoulder blade.  We did do a C-spine and right shoulder x-ray and those just mainly showed some degenerative changes and possibly some rotator cuff injury with the humeral head quite high up in the glenoid in the right shoulder, but this does not seem to cause her any problems.  She has some vague “stomach problems”, although apparently it is improved when she stopped Aleve and she does not have any more aches or pains off Aleve.  She takes Tylenol p.r.n., which seems to be enough for her.  She does not think she has any acid reflux symptoms or heartburn.  She does take Tums t.i.d. and also Mylanta at night.  She has had dentures for many, many years and just recently I guess in the last few months, although she was somewhat vague on this, she has had some sores in her mouth.  They do heal up, but then she will get another one.  She also thinks since she has been on the Lexapro, she has somewhat of a tremor of her basically whole body at least upper body including the torso and arms and had all of the daughters who I not noticed to speak of and it is certainly difficult to tell her today that she has much tremor.  They do think the Lexapro has helped to some extent.,ALLERGIES: , None.,MEDICATION: , Verapamil 240 mg a day, Mavik 1 mg a day, Lipitor 10 mg one and half daily, vitamins daily, Ocuvite daily, Tums t.i.d., Tylenol 2-3 daily p.r.n., and Mylanta at night.,REVIEW OF SYSTEMS:,  Mostly otherwise as above.,OBJECTIVE:,General:  She is a pleasant elderly lady.  She is in no acute distress, accompanied by daughter.,Vital signs:  Blood pressure:  128/82.  Pulse:  68.  Weight:  143 pounds.,HEENT:  No acute changes.  Atraumatic, normocephalic.  On mouth exam, she does have dentures.  She removed her upper denture.  I really do not see any sores at all.  Her mouth exam was unremarkable.,Neck:  No adenopathy, tenderness, JVD, bruits, or mass.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Extremities:  No significant edema.  Reasonable pulses.  No clubbing or cyanosis, may be just a minimal tremor in head and hands, but it is very subtle and hardly noticeable.  No other focal or neurological deficits grossly.,IMPRESSION:,1.  Hypertension, better reading today.,2.  Right arm symptoms, resolved.,3.  Depression probably somewhat improved with Lexapro and she will just continue that.  She only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it.,4.  Perhaps a very subtle tremor.  I will just watch that.,5.  Osteoporosis.,6.  Osteoarthritis.,PLAN:,  I think I will just watch everything for now.  I would continue the Lexapro, we gave her more samples plus a prescription for the 20 mg that she can cut in half.  I offered to see her for again short-term followup.  However, they both preferred just to wait until the annual check up already set up for next April and they know they can call sooner.  She might get a flu shot here in the next few weeks.  Daughter mentioned here today that she thinks her mom is doing pretty well, especially given that she is turning 90 here later this month and I would tend to agree with that.
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DESCRIPTION: Short-term followup - Hypertension, depression, osteoporosis, and osteoarthritis.

general medicine, osteoporosis, osteoarthritis, hypertension, depression, short term followup, blood pressure, progress, blood, pressure, dose,

The situation involves an elderly patient undergoing a routine follow-up for multiple mild-to-moderate chronic conditions such as hypertension, depression, osteoporosis, and osteoarthritis. The conditions are being managed with medications, and there are no acute or life-threatening symptoms present. The medical concerns described are common in elderly individuals and are being monitored with regular check-ups. The patient's daughter is present and engaged, which is supportive for the patient's care. Therefore, while it involves important aspects of the patient's health management, it does not carry immediate high-stakes risks or require urgent intervention.


Medical Specialty: Neurology
Sample Name: EMG/Nerve Conduction Study - 4

NERVE CONDUCTION STUDIES:,  Bilateral ulnar sensory responses are absent.  Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude.  The left radial sensory response is normal and robust.  Left sural response is absent.  Left median motor distal latency is prolonged with attenuated evoked response amplitude.  Conduction velocity across the forearm is mildly slowed.  Right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity.  The left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow.  Conduction velocities across the forearm and across the elbow are prolonged.  Conduction velocity proximal to the elbow is normal.  The right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist.  There is mild diminution of response around the elbow.  Conduction velocity slows across the elbow.  The left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head.  F-waves are prolonged.,NEEDLE EMG: , Needle EMG was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle.  It revealed spontaneous activity in lower cervical paraspinals, left abductor pollicis brevis, and first dorsal interosseous muscles.  There were signs of chronic reinnervation in triceps, extensor digitorum communis, flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  A sensory motor length-dependent neuropathy consistent with diabetes.,2.  A severe left ulnar neuropathy.  This is probably at the elbow, although definitive localization cannot be made.,3.  Moderate-to-severe left median neuropathy.  This is also probably at the carpal tunnel, although definitive localization cannot be made.,4.  Right ulnar neuropathy at the elbow, mild.,5.  Right median neuropathy at the wrist consistent with carpal tunnel syndrome, moderate.,6.  A left C8 radiculopathy (double crush syndrome).,7.  There is no evidence for thoracic radiculitis.,The patient has made very good response with respect to his abdominal pain since starting Neurontin.  He still has mild allodynia and is waiting for authorization to get insurance coverage for his Lidoderm patch.  He is still scheduled for MRI of C-spine and T-spine.  I will see him in followup after the above scans.
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DESCRIPTION: EMG/Nerve Conduction Study showing sensory motor length-dependent neuropathy consistent with diabetes, severe left ulnar neuropathy, and moderate-to-severe left median neuropathy,

neurology, emg, nerve conduction study, nerve conduction studies, needle emg, electrical study, neuropathy, ulnar neuropathy, median neuropathy, severely attenuated evoked response, normal evoked response amplitude, attenuated evoked response amplitude, median motor distal latency, motor distal latency, abductor pollicis, pollicis brevis, dorsal interosseous, carpal tunnel, conduction, emg/nerve, needle,

The nerve conduction study and EMG results indicate multiple neuropathies, some of which are severe, and a potential diabetic neuropathy. These conditions can significantly impact a patient's quality of life and may require different interventions or changes in management. However, the situation doesn't currently present as immediately life-threatening, but it does suggest significant ongoing medical management is needed. The ongoing symptoms and need for further imaging exemplify the complexity of managing chronic neuropathic conditions.


Medical Specialty: Radiology
Sample Name: CT Abdomen & Pelvis - OB-GYN

EXAM:,  CT examination of the abdomen and pelvis with intravenous contrast.,INDICATIONS:,  Abdominal pain.,TECHNIQUE:  ,CT examination of the abdomen and pelvis was performed after 100 mL of intravenous Isovue-300 contrast administration.  Oral contrast was not administered.  There was no comparison of studies.,FINDINGS,CT PELVIS:,Within the pelvis, the uterus demonstrates a thickened-appearing endometrium.  There is also a 4.4 x 2.5 x 3.4 cm hypodense mass in the cervix and lower uterine segment of uncertain etiology.  There is also a 2.5 cm intramural hypodense mass involving the dorsal uterine fundus likely representing a fibroid.  Several smaller fibroids were also suspected.,The ovaries are unremarkable in appearance.  There is no free pelvic fluid or adenopathy.,CT ABDOMEN:,The appendix has normal appearance in the right lower quadrant.  There are few scattered diverticula in the sigmoid colon without evidence of diverticulitis.  The small and large bowels are otherwise unremarkable.  The stomach is grossly unremarkable.  There is no abdominal or retroperitoneal adenopathy.  There are no adrenal masses.  The kidneys, liver, gallbladder, and pancreas are in unremarkable appearance.  The spleen contains several small calcified granulomas, but no evidence of masses.  It is normal in size.  The lung bases are clear bilaterally.  The osseous structures are unremarkable other than mild facet degenerative changes at L4-L5 and L5-S1.,IMPRESSION:,1.  Hypoattenuating mass in the lower uterine segment and cervix of uncertain etiology measuring approximately 4.4 x 2.5 x 3.4 cm.,2.  Multiple uterine fibroids.,3.  Prominent endometrium.,4.  Followup pelvic ultrasound is recommended.
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DESCRIPTION: Abdominal pain.  CT examination of the abdomen and pelvis with intravenous contrast.

radiology, ovaries, pelvic fluid, adenopathy, uterine segment, cervix, hypodense mass, ct examination, fibroids, pelvic, ct, pelvis, isovue, abdomen

The radiology report describes a CT scan revealing a hypodense mass in the cervix and lower uterine segment, as well as multiple uterine fibroids and a prominent endometrium. These findings may suggest serious gynecological conditions, including potential malignancies, which require further investigation and follow-up. The recommendation for a follow-up pelvic ultrasound indicates that the findings could significantly impact the patient's treatment and health outcomes, making it a high-stakes situation.