Medical Specialty: Orthopedic
Sample Name: Arthroscopy - Glenoid Labrum

PREOPERATIVE DIAGNOSIS:,  Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Massive rotator cuff tear, right shoulder.,2.  Near complete biceps tendon tear, right shoulder.,3.  Chondromalacia of glenohumeral joint, right shoulder.,4.  Glenoid labrum tear, right shoulder.,PROCEDURE PERFORMED:  ,1.  Arthroscopy of the arthroscopic glenoid labrum.,2.  Rotator cuff debridement shaving glenoid and humeral head.,3.  Biceps tenotomy, right shoulder.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under interscalene block anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS: , This is a 61-year-old white male who is dominantly right-handed.  He had increasing right shoulder pain and dysfunction for a number of years prior to surgical intervention.  This was gradually done over a period of time.  No specific accident or injury could be seen or pointed.  He was refractory to conservative outpatient therapy.  After discussing alternatives of the care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Preoperatively, the patient did not have limitation of motion.  He had gross weakness to his supraspinatus, mildly to the infraspinatus and subscapularis upon strength testing prior to his anesthetic.,Intraarticularly, the patient had an 80% biceps tendon tear that was dislocated.  His rotator interval was resolved as well as his subscapularis with tearing.  The supraspinatus was completely torn, retracted back beyond the level of the labrum and approximately one-third or so of the infraspinatus was involved with the remaining portion being greatly thinned as far as we could observe.  Glenoid labrum had degenerative tear in the inferior surface.  Gross chondromalacia was present to approximately 50% of the humeral head and approximately the upper 40% of the glenoid surface.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table.  After receiving interscalene block anesthetic by the Anesthesia Department, he was safely placed in a modified beachchair position.  He was prepped and draped in the usual sterile manner.  The portals were created outside the end posteriorly and then anteriorly.  A full and complete diagnostic arthroscopy was carried out with the above-noted findings.  The shaver was placed anteriorly.  Debridement was carried out to the glenoid labrum tear and the last 20% of the biceps tendon tear was completed.  Debridement was carried out to the end or attachment of the bicep itself.,Debridement was carried out to what could be seen of the remaining rotator cuff there, but then the scope was redirected in a subacromial direction and gross bursectomy carried out.  Debridement was then carried out to the rotator cuff remaining tendon near the tuberosity.  No osteophytes were present.  Because of the massive nature of the tear, the CA ligament was maintained and there were no substantial changes to the subacromial region to necessitate burring.  There was concern because of instability that could be present at the end of this.,Another portal was created laterally to do all of this.  We did what we could to mobilize all sections of the rotator cuff, superiorly, posteriorly, and anteriorly.  We took this back to the level of coracoid base.  We released the coracohumeral ligament basically all but there was no excursion basically all to the portion of the rotator cuff torn.  Because of this, further debridement was carried out.  Debridement had been previously carried out to the humeral head as well as glenoid surface to debride the chondromalacia and take this down to the smooth edge.  Care was taken to not to debride deeper than that.  This was done prior to the above.,All instrumentation was removed.  A Pain-Buster catheter was placed into a separate anterolateral portal cut to length.  Interrupted #4-0 nylon was utilized for portal closures.  Adaptic, 4x4s, ABDs, Elastoplast tape were placed for a compression dressing.,The patient's arm was placed in an arm sling.  He was transferred to his cart and to the PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is quite guarded because of the above-noted pathology.
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DESCRIPTION: Arthroscopy of the arthroscopic glenoid labrum, rotator cuff debridement shaving glenoid and humeral head, and biceps tenotomy, right shoulder.  Massive rotator cuff tear, right shoulder, near complete biceps tendon tear of right shoulder, chondromalacia of glenohumeral joint or right shoulder, and glenoid labrum tear of right shoulder.

orthopedic, modified beachchair position, rotator cuff tear, glenoid labrum tear, glenohumeral joint, interscalene block, glenoid labrum, rotator cuff, rotator, debridement, glenoid, shoulder, tear, arthroscopy, arthroscopic, tenotomy, glenohumeral, supraspinatus, infraspinatus, subscapularis, chondromalacia, biceps, labrum, cuff,

This medical situation involves a surgical procedure addressing multiple complex injuries in a patient's shoulder, including a massive rotator cuff tear, near complete biceps tendon tear, and chondromalacia. The procedure described is intricate and has a guarded prognosis, indicating potential challenges in the patient's recovery and future mobility. Shoulder surgeries like this one can significantly impact quality of life, particularly for a 61-year-old right-handed male, if complications arise or full function is not restored. Therefore, the stakes are relatively high as they involve his physical health and daily functioning.


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

Medical Specialty: Radiology
Sample Name: MRI L-Spine - Subarachnoid Seeding

CC:, Progressive lower extremity weakness.,HX: ,This 52y/o RHF had a h/o right frontal glioblastoma multiforme (GBM) diagnosed by brain biopsy/partial resection, on 1/15/1991. She had been healthy until 1/6/91, when she experienced a generalized tonic-clonic type seizure during the night. She subsequently underwent an MRI brain scan and was found to have a right frontal enhancing lesion in the mesial aspect of the right frontal lobe at approximately the level of the coronal suture. There was minimal associated edema and no mass effect. Following extirpation of the tumor mass, she underwent radioactive Iodine implantation and 6020cGy radiation therapy in 35 fractions. In 11/91 she received BCNU and Procarbazine chemotherapy protocols. This was followed by four courses of 5FU/Carboplatin (3/92, 6/92, 9/92 ,10/92) chemotherapy.,On 10/12/92 she presented for her 4th course of 5FU/Carboplatin and complained of non-radiating dull low back pain, and proximal lower extremity weakness, but was still able to ambulate. She denied any bowel/bladder difficulty.,PMH: ,s/p oral surgery for wisdom tooth extraction.,FHX/SHX: ,1-2 ppd cigarettes. rare ETOH use. Father died of renal CA.,MEDS: ,Decadron 12mg/day.,EXAM: ,Vitals unremarkable.,MS: Unremarkable.,Motor: 5/5 BUE, LE: 4+/5- prox, 5/5 distal to hips. Normal tone and muscle bulk.,Sensory: No deficits appreciated.,Coord: Unremarkable.,Station: No mention in record of being tested.,Gait: Mild difficulty climbing stairs.,Reflexes: 1+/1+ throughout and symmetric. Plantar responses were down-going bilaterally.,INITIAL IMPRESSION:, Steroid myopathy. Though there was enough of a suspicion of "drop" metastasis that an MRI of the L-spine was obtained.,COURSE:, The MRI L-spine revealed fine linear enhancement along the dorsal aspect of the conus medullaris, suggestive of subarachnoid seeding of tumor. No focal mass or cord compression was visualized. CSF examination revealed: 19RBC, 22WBC, 17 Lymphocytes, and 5 histiocytes, Glucose 56, Protein 150. Cytology (negative). The patient was discharged home on 10/17/92, but experienced worsening back pain and lower extremity weakness and became predominantly wheelchair bound within 4 months. She was last seen on 3/3/93 and showed signs of worsening weakness (left hemiplegia: R > L) as her tumor grew and spread. She then entered a hospice.
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DESCRIPTION: MRI L-spine - History of progressive lower extremity weakness, right frontal glioblastoma with lumbar subarachnoid seeding.

radiology, glioblastoma multiforme, gbm, steroid myopathy, hemiplegia, progressive lower extremity weakness, mri l spine, lower extremity weakness, frontal glioblastoma, subarachnoid seeding, lower extremity, glioblastoma, subarachnoid, spine, mri, lower, weakness,

The situation involves a patient with a history of right frontal glioblastoma multiforme (GBM) who now presents with suspected subarachnoid seeding in the lumbar spine, resulting in progressive lower extremity weakness. The implications of detecting subarachnoid seeding include a significant change in prognosis, as it indicates the spread of cancer through the cerebrospinal fluid, which is associated with a poor outcome. This progression has led the patient to become predominantly wheelchair bound and to enter hospice care due to the growing and spreading tumor. The situation is high-stakes because it involves a severe, life-limiting condition with a rapidly declining health status, requiring significant interventions and consideration of end-of-life care.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Radiology
Sample Name: Biophysical Profile - 1

HISTORY: , Advanced maternal age and hypertension.,FINDINGS:,  There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid.  The amniotic fluid index is 23.2 cm.  Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03/28/08.  Based on fetal measurements obtained today, estimated fetal weight is 3249 plus or minus 396 g, 7 pounds 3 ounces plus or minus 14 ounces, which places the fetus in the 66th percentile for the estimated gestational age.  Fetal heart motion at a rate of 156 beats per minute is documented.  The cord Doppler ratio is normal at 2.2.  The biophysical profile score, assessing fetal breathing movement, gross body movement, fetal tone, and qualitative amniotic fluid volume is 8/8.,IMPRESSION:,1.  Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03/28/08.,2.  Biophysical profile (BPP) score 8/8.
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DESCRIPTION: Ultrasound BPP - Advanced maternal age and hypertension.

radiology, ultrasound, bpp, maternal age, intrauterine pregnancy, biophysical profile, amniotic fluid, gestational age, amniotic, gestational, fetal,

The biophysical profile (BPP) of a fetus is an important test during pregnancy, especially in cases involving advanced maternal age and hypertension, which can increase risks for complications. This particular case reflects a good BPP score of 8/8, indicating the fetus is currently healthy and no immediate concerns are noted. However, the context of advanced maternal age and hypertension implies a higher risk pregnancy overall, requiring close monitoring, which elevates the stakes to some extent. The accurate and timely management of such pregnancies is crucial to ensure the health and safety of both the mother and the fetus; however, based on the findings here, there are no immediate high-stakes issues present.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 24

CHIEF COMPLAINT:, Headache and pain in the neck and lower back.,HISTORY OF PRESENT ILLNESS:, The patient is a 34 year old white man with AIDS (CD4 -67, VL -341K) and Castleman’s Disease who presents to the VA Hospital complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks. He was hospitalized 3 months prior to his current presentation with abdominal pain and diffuse lymphadenopathy. Excisional lymph node biopsy during that admission showed multicentric Castleman’s Disease. He was started on cyclophosphamide and prednisone and his lymphadenopathy dramatically improved. His hospitalization was complicated by the development of acute renal failure from tumor lysis syndrome and he required hemodialysis for only a few sessions. The patient was discharged on HAART and later returned for 2 cycles of modified CHOP chemotherapy.,Approximately five weeks prior to his current presentation, the patient was involved in a motor vehicle accident at 40 mph. He said he was not wearing his seatbelt and had hit his head on the roof of the car. He did not lose consciousness. The patient went to the VA ER but left against medical advice prior to being fully evaluated. Records showed that the patient had complained of some neck soreness but he was able to move his neck without any difficulty.,Two weeks later, the patient started having headaches, neck and lower back pain during a road trip with his family to Mexico . He returned to Houston and approximately one week prior to admission, the patient presented to the VA ER for further evaluation. Spinal films were unremarkable and the patient was sent home on pain medications with a diagnosis of muscle strain. The patient followed up with his primary care physician and was admitted for further workup.,On the day of admission, the patient complains of severe pain that is worse in the lower back than in the neck. The pain is 7-8 out of 10 and does not radiate. He also complains of diffuse headaches and intermittent blurriness of his vision. He complains of having a very stiff neck that hurts when he bends it. He denies any fevers, chills, or night sweats. He denies any numbness or tingling of his extremities and he denies any bowel or bladder incontinence. None of the medications that he takes provides adequate relief of his pain.,Regarding his AIDS and Castleman’s Disease, his lymphadenopathy have completely resolved by physical exam. He no longer has any of the symptoms from his previous hospitalization. He is scheduled to have his next cycle of chemotherapy during the week of his current admission. He has been noncompliant with his HAART and has been off the medications for >3 weeks.,Past Medical History:, HIV diagnosed 11 years ago. No history of opportunistic infections. Recently diagnosed with Castleman’s Disease (9/03) from excisional lymph node biopsy s/p cyclophosphamide/prednisone ( 9/25/03 ) and modified CHOP ( 10/15/03 , 11/10/03 ). Last CD4 count is 67 and viral load is 341K (9/03). Currently is off HAART x 3 weeks because of noncompliance.,PAST SURGICAL HISTORY:, Excisional lymph node biopsy (9/03).,FAMILY HISTORY:, There was no history of hypertension, coronary artery disease, stroke, cancer or diabetes.,SOCIAL HISTORY:, Patient is single and he lives alone. He is heterosexual and has a history of sexual encounter with prostitutes in Japan. He works as a plumber over the last 5 years. He smokes and drinks occasionally and denies any history of IV drug use. No blood transfusion. No history of incarceration. Recently traveled to Mexico .,MEDICATION:, Tylenol #3 q6h prn, ibuprofen 800 mg q8h prn, methocarbamol 750 mg qid.,ALLERGIES:, ,  Sulfa (rash).,REVIEW OF SYSTEMS:, The patient complains of feeling weak and fatigued. He has no appetite over the past week and has lost 8 pounds during this period. No chest pain, palpitations, shortness of breath or coughing. He denies any nausea, vomiting, or abdominal pain. No focal neuro deficits. Otherwise, as stated in HPI.,PHYSICAL EXAM:,VS: T 98 BP 121/89 P 80 R 20 O2 Sat 100% on room air.,Ht: 5'9" Wt: 159 lbs.,GEN: Well developed man in no apparent distress. Alert and Oriented X 3.,HEENT: Pupils equally round and reactive to light. Extra-ocular movements intact. Anicteric. Papilledema present bilaterally. Moist mucous membranes. No oropharyngeal lesions.,NECK: Stiff, difficulty with neck flexion; no lymphadenopathy,LUNGS: Clear to auscultation bilaterally.,CV: Regular rate and rhythm. No murmurs, gallops, rubs.,ABD: Soft with active bowel sounds. Nontender/Nondistended. No rebound or guarding. No hepatosplenomegaly.,EXT: No clubbing, cyanosis, or edema. 2+ pulses bilaterally.,BACK: No point tenderness to spine,NEURO: Cranial nerves intact. 2+ DTRs bilaterally and symmetrically. Motor strength and sensation within the normal limits.,LYMPH: No cervical, axillary, or inguinal lymph nodes palpated,SKIN: warm, no rashes, no lesions,STUDIES:,C-spine/lumbosacral spine (11/30):  Within normal limits.,CXR (12/8):  Normal heart size, no infiltrate. Hila and mediastinum are not enlarged.,CT Head with and without contrast (12/8): Ventriculomegaly and potentially minor hydrocephalus. Otherwise normal CT scan of the brain. No evidence of abnormal enhancement of the brain or mass lesions within the brain or dura.,HOSPITAL COURSE:,  The patient was admitted to the medicine floor and a lumbar puncture was performed. The opening pressure was greater than 55. The CSF results are shown in the table. A diagnostic study was sent.
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DESCRIPTION: Patient complaining of headaches, neck pain, and lower back pain over the last 2-3 weeks.

This medical case involves a patient with AIDS, a history of Castleman's Disease, recent chemotherapy, and a high-risk health profile, including noncompliance with HAART and a protein count indicating severe immunosuppression (CD4 count of 67). While his primary complaints are headaches, neck pain, and lower back pain, there are indicators of potentially serious underlying issues: the presence of papilledema, altered CSF opening pressure suggesting possible intracranial hypertension, history of recent trauma, and significant weight loss. These factors, combined with his complex medical history, render the situation potentially life-threatening if not promptly and accurately addressed. His health status is precarious, and decisions taken here could significantly impact his short and long-term health outcomes.


Medical Specialty: Radiology
Sample Name: CT Facial

TECHNIQUE: , Sequential axial CT images were obtained through the facial bones without contrast.  Additional high resolution coronal reconstructed images were also obtained for better visualization of the osseous structures.,FINDINGS:,  The osseous structures within the face are intact with no evidence of fracture or dislocation.  The visualized paranasal sinuses and mastoid air cells are clear.  The orbits and extra-ocular muscles are within normal limits.  The soft tissues are unremarkable.  ,IMPRESSION: , No acute abnormalities.
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DESCRIPTION: Common CT Facial template.

Common CT Facial template.

radiology, sequential axial ct image, ct facial, osseous structuresNOTE

The provided scenario involves the interpretation of a CT scan in radiology. The results indicate 'no acute abnormalities,' suggesting a routine examination with no immediate concerns. While the accurate reading of such images is crucial in healthcare, this particular result reflects a non-urgent situation with no immediate medical threat to the patient. Hence, this scenario is lower on the stakes scale compared to situations that involve critical or life-threatening findings.


Medical Specialty: Consult - History and Phy.
Sample Name: Trouble Breathing - H&P

CHIEF COMPLAINT: , "I have had trouble breathing for the past 3 days",HISTORY: , 69-year-old Caucasian male complaining of difficulty breathing for 3 days.  He also states that he has been coughing accompanying with low-grade type fever.  He also admits to having intermittent headaches and bilateral chest pain that does not radiate to upper extremities and jaws but worse with coughing.  Patient initially had this type of episodes about 10 months ago but has intermittently getting worse since.,PMH: , DM, HTN, COPD, CAD,PSH:  ,CABG, appendectomy, tonsillectomy,FH:,  Non-contributory,SOCH: , Divorce and live alone, retired postal worker, has 3 children, 7 grandchildren.  He smokes 1 pack a day of Newport for 30 years and is a social drinker.  He denies any illicit drug use.,TRAVEL HISTORY: , Denies any recent travel overseas,ALLERGIES: , Denies any drug allergies,HOME MEDICATIONS:,  Advair 1 puff bid Lisinopril 10 mg qd Lopressor 50 mg bid Aspirin 81 mg qd Plavix 75 mg qd Multivitamins Feso4 1 tab qd Colace 100 mg qd,REVIEW OF SYSTEMS REVEALS:,  Same as above,PHYSICAL EXAM:,Vital signs are:  Temp.  99.3 F / BP 138/92, Resp.  22, P 88,General:  Patient is in mild acute respiratory distress,HEENT:,Head:  Atraumatic, normocephalic,,Eyes:
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DESCRIPTION: History and Physical for a 69-year-old Caucasian male complaining of difficulty breathing for 3 days.

The situation described involves a 69-year-old male with a history of chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), and several other health issues presenting with breathing difficulties, chest pain, fever, and cough. These symptoms are potentially indicative of a severe respiratory or cardiac issue such as pneumonia, a COPD exacerbation, or even heart failure, making timely and appropriate medical assessment and intervention critical. Given his age, existing comorbidities, and the potential for rapid deterioration in his condition, this is a high-stakes clinical scenario.


Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy - 10

PREOPERATIVE DIAGNOSIS: , Nausea and vomiting and upper abdominal pain.,POST PROCEDURE DIAGNOSIS:  ,Normal upper endoscopy.,OPERATION: , Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.,ANESTHESIA:,  IV sedation 50 mg Demerol, 8 mg of Versed.,PROCEDURE: , The patient was taken to the endoscopy suite.  After adequate IV sedation with the above medications, hurricane was sprayed in the mouth as well as in the esophagus.  A bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus, stomach, and pylorus.  The first, second, and third portions of the duodenum were normal.  The scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for H. pylori.  The scope was retroflexed which showed a normal GE junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia.  The scope was withdrawn at the GE junction which was in a normal position with a normal transition zone.  The scope was then removed throughout the esophagus which was normal.  The patient tolerated the procedure well.,The plan is to obtain a HIDA scan as the right upper quadrant ultrasound appeared to be normal, although previous ultrasounds several years ago showed a gallstone.
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DESCRIPTION: Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.  Nausea and vomiting and upper abdominal pain.

surgery, h. pylori, forceps, antral biopsies, ge junction, esophagogastroduodenoscopy, pylori, esophagus, antral,

The situation described involves a medical procedure known as esophagogastroduodenoscopy, which is generally a routine procedure used to diagnose and sometimes treat conditions related to the esophagus, stomach, and duodenum. The fact that the procedure revealed normal results and that the patient tolerated it well suggests that, in this particular case, the stakes are not very high. However, the presence of symptoms like nausea, vomiting, and upper abdominal pain, and the plan to perform further diagnostic tests (HIDA scan) indicates moderate concern to ensure accurate diagnosis and treatment. In the context of surgical procedures, it's important but not high-stakes as there are no immediate life-threatening findings.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy With Photos

PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Diverticulosis coli.,2.  Internal hemorrhoids.,3.  Poor prep.,PROCEDURE PERFORMED:,  Colonoscopy with photos.,ANESTHESIA: , Conscious sedation per Anesthesia.,SPECIMENS:,  None.,HISTORY:,  The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia.  She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time.  A coloscopy is now being performed for completion.,PROCEDURE:,  After proper informed consent was obtained, the patient was brought to the Endoscopy Suite.  She was placed in the left lateral position and was given sedation by the Anesthesia Department.  A digital rectal exam was performed and there was no evidence of mass.  The colonoscope was then inserted into the rectum.  There was some solid stool encountered.  The scope was maneuvered around this.  There was relatively poor prep as the scope was advanced through the sigmoid colon and portions of the descending colon.  The scope was then passed through the transverse colon and ascending colon to the cecum.  No masses or polyps were noted.  Visualization of the portions of the colon was however somewhat limited.  There were scattered diverticuli noted in the sigmoid.,The scope was slowly withdrawn carefully examining all walls.  Once in the rectum, the scope was retroflexed and nonsurgical internal hemorrhoids were noted.  The scope was then completely withdrawn.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  She will be placed on a high-fiber diet and Colace and we will continue to monitor her hemoglobin.
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DESCRIPTION: Colonoscopy with photos.  The patient is an 85-year-old female who was admitted to the hospital with a markedly decreased hemoglobin and blood loss anemia.  She underwent an EGD and attempted colonoscopy; however, due to a very poor prep, only a flexible sigmoidoscopy was performed at that time.  A coloscopy is now being performed for completion.

gastroenterology, blood loss anemia, diverticulosis coli, internal hemorrhoids, poor prep, colonoscopy, sigmoidoscopy, hemoglobin, coloscopy, colonoscopy with photos, attempted colonoscopy, flexible sigmoidoscopy, photos, anemia, scope

The medical procedure described involves an 85-year-old patient undergoing a colonoscopy due to blood loss anemia and decreased hemoglobin levels, which are significant health concerns requiring thorough investigation. Given the patient's age and the conditions being investigated (diverticulosis coli and internal hemorrhoids), there is a reasonable level of urgency, but it is mitigated by the fact that the patient is stable following the procedure and will continue to be monitored. The issue of 'poor prep' suggests some potential limitations in findings but does not inherently elevate the immediate risk further. This situation is moderate in stakes due to the potential implications of untreated blood loss but is currently stable and under control.


Medical Specialty: Autopsy
Sample Name: Autopsy - 2

CLOTHING: , The body is clad in a light green hospital gown, which is intact, dry and clean. There is no jewelry present.,EXTERNAL EXAMINATION:,  The body is that of a well-developed, well-nourished white woman appearing the offered age of 39 years. The body measures 71 inches and weighs 178 pounds.,The unembalmed body is well preserved and cool to touch due to refrigeration. Rigor mortis is fully developed in the major muscle groups. Livor mortis is fixed and purple posteriorly except over pressure points. However, during initial examination in the emergency room, there was no rigor and lividity was at a minimum and unfixed. The skin is intact and shows no evidence of trauma except for medical intervention. The scalp hair is blond and measures up to 5 inches in length in the frontal area and up to 19 inches in length in the back and on top of the head. There are multiple blonde hair extensions including several pink strands attached to the natural hair, which shows light brown roots. The irides are hazel and the pupils are equal, each measuring 0.5 centimeter in diameter. The corneae are clear and the sclerae and conjunctivae are free of petechiae. The nasal bones are intact by palpation. The nares are patent and contain no foreign matter. There is a 3-millimeter raised nodule on the right side of the nose. The natural teeth are in good condition. The frenula are intact. The oral mucosa and tongue are free of injuries. The external ears have no injuries. There are bilateral earlobe piercings; no earring or jewelry were present. There are no earlobe creases.,The neck is symmetrical and shows no masses or injuries. The trachea is in the midline. The shoulders are symmetrical and are free of scars.,The chest is symmetrical and shows no evidence of injury. There were bilateral breasts with asymmetry of the left breast due to scarring. The flat abdomen has no injuries. There are piercings above and below the umbilicus. The back is symmetrical. The buttocks have inconspicuous small scars, bilaterally. There is a flat, round scar on the lower aspect of the left buttock approximately 1/2 inch in diameter.,The genitalia are those of a normally developed adult woman. There is no evidence of injury. The anus is unremarkable.,The upper extremities are symmetrical and have no injuries. The fingernails are long and clean. There is a linear 1/2 inch scar on the anterior right forearm. Two parallel linear scars measuring 1 inch and 2 inches are on the anterior surface of the left forearm.  The lower extremities are symmetrical. The toenails are short and clean. There is no edema of the legs or ankles.  There is no abnormal motion of the neck, the shoulders, the elbows, the wrists, the fingers, the hips and ankles. There is no bony crepitus or cutaneous crepitus present.,EVIDENCE OF INJURY: , A dissection of the posterior neck and upper back show a 2-1/4 x 2-3/4 inch reddish, recent contusion of the subcutaneous and superficial muscle layer of the left posterior shoulder. A recent, reddish, 1-3/4 x 1-1/2 inch reddish contusion is present on the right posterior shoulder involving the superficial muscular layer.,EVIDENCE OF RECENT MEDICAL TREATMENT: , A properly positioned size 8 endotracheal tube retained by a Thomas clamp is present at the mouth with the marker 22 at the anterior teeth.  ,Electrocardiogram pads are on the anterior chest in the following order: two on the right anterior shoulder, two on the left anterior shoulder, one on the upper anterior left arm, one each on the anterior side, one each on the anterior leg.,Two defibrillator pads are present: one to the right of the midline, above the right breast, and one to the left of the midline, below the left breast.,There is intravenous line placement at the right anterior neck with hemorrhage into the anterior strap muscles of the neck. One recent needle puncture mark is in the right antecubital fossa and two recent needle puncture marks are at the anterior left elbow with surrounding ecchymoses. There is one recent needle puncture into the medial one-third of the left anterior forearm with surrounding ecchymosis. A recent needle puncture mark is at the left anterior wrist with surrounding reddish ecchymosis, 1 inch in diameter.,OTHER IDENTIFYING FEATURES: , There are multiple scars and tattoos on the body.,SCARS:,  A 3/4 x 1/2 inch flat scar is on the upper inner aspect of the right breast quadrant. A 1/2 x 3/8-inch scar is on the medial aspect of the left nipple. There are circular scars adjacent to both areolae. The right inframammary skin has a linear transverse 3/4 inch remote "chest tube" scar. There were bilateral inframammary and transverse linear 3-3/4 inch scars compatible with left and right mammoplasty with breast implants. There are circular scars surrounding piercings above and below the umbilicus. A flat 3/8 inch in diameter scar is present on the middle third of the anterior surface of the right thigh. Lateral to this scar is a 1/2 inch in diameter flat scar. There are several scattered small inconspicuous scars on both buttocks. There is a cluster of multiple, parallel, linear, well-healed scars on the anterior and lateral aspects of the right leg covered by a tattoo.,TATTOOS: , There is a pair of red lips in the right lower abdominal quadrant.,Two red cherries are on the right mid pelvis.,A "Playboy Bunny" is on the left anterior mid pelvis.,The words "Daniel" and "Papas" are on the mid anterior pelvis region.,A mixed tattoo on the right lower leg and ankle represents: Christ's head; Our Lady of,Guadalupe; the Holy Bible; the naked torso of a woman; the smiling face of Marilyn Monroe; a,cross; a heart and shooting flames.,A mermaid on a flower bed with a pair of lips underneath it laying across the lower back.,INTERNAL EXAMINATION:  ,The body was opened with the usual Y incision. The breast tissues, when incised, revealed bilateral implants, each containing 700ml of clear fluid. The implants were surrounded by a thick connective tissue capsule with a thick yellow fluid. The content of each capsule was collected for bacteriological cultures.,BODY CAVITIES: , The muscles of the chest and abdominal wall are normal in color and consistency. The lungs are neither hyperinflated nor atelectatic when the pleural cavities are opened. The right lung shows adherence to the parietal pleura and to the diaphragm interiorly. The ribs, sternum and spine exhibit no fractures. The right and left pleural cavities have no free fluid. There are extensive right pleural fibrous adhesions. The mediastinum is in the midline. The pericardial sac has a normal amount of clear yellow fluid. The diaphragm has no abnormality. The subcutaneous abdominal fat measures 3 centimeters in thickness at the umbilicus. The abdominal cavity is lined with glistening serosa and has no collections of free fluid. The organs are normally situated. The mesentery and omentum are unremarkable.,NECK: , The soft tissues and the strap muscles of the neck, aside from the previously described focal hemorrhages, exhibit no abnormalities. The hyoid bone and the cartilages of the larynx and thyroid are intact and show no evidence of injury. The larynx and trachea are lined by smooth pink-tan mucosa, are patent and contain no foreign matter. There is a focal area of reddish hyperemia at the carina associated with the endotracheal tube. The epiglottis and vocal cords are unremarkable. The cervical vertebral column is intact. The carotid arteries and jugular veins are unremarkable.,CARDIOVASCULAR SYSTEM: , The heart and great vessels contain dark red liquid blood and little postmortem clots. The heart weighs 305 grams. The epicardial surface has a normal amount of glistening, yellow adipose tissue. The coronary arteries are free of atherosclerosis. The cut surfaces of the brown myocardium show no evidence of hemorrhage or necrosis.,The pulmonary trunk and arteries are opened in situ and there is no evidence of thromboemboli. The intimal surface of the aorta is smooth with a few scattered yellow atheromata. The ostia of the major branches are of normal distribution and dimension. The inferior vena cava and tributaries have no antemortem clots (See attached cardiopathology report for additional details).,RESPIRATORY SYSTEM:  ,The lungs weigh 550 grams and 500 grams, right and left, respectively. There is a small amount of subpleural anthracotic pigment within all the lobes. The pleural surfaces are free of exudates; right-sided pleural adhesions have been described above. The trachea and bronchi have smooth tan epithelium. The cut surfaces of the lungs are red-pink and have mild edema. The lung parenchyma is of the usual consistency and shows no evidence of neoplasm, consolidation, thromboemboli, fibrosis or calcification.,HEPATOBILIARY SYSTEM:  ,The liver weighs 2550 grams. The liver edge is somewhat blunted. The capsule is intact. The cut surfaces are red-brown and of normal consistency. There are no focal lesions. The gallbladder contains 15 milliliters of dark green bile. There are no stones. The mucosa is unremarkable. The large bile ducts are patent and non-dilated.,HEMOLYMPHATIC SYSTEM:  ,The thymus is not identified. The spleen weighs 310 grams. The capsule is shiny, smooth and intact. The cut surfaces are firm and moderately congested. The lymphoid tissue in the spleen is within a normal range. The lymph nodes throughout the body are not enlarged.,GASTROINTESTINAL SYSTEM:  ,The tongue shows a small focus of submucosal hemorrhage near the tip. The esophagus is empty and the mucosa is unremarkable. The stomach contains an estimated 30 milliliters of thick sanguinous fluid. The gastric mucosa shows no evidence or ulceration. There is a mild flattening of the rugal pattern within the antrum with intense hyperemia. The duodenum contains bile-stained thick tan fluid. The jejunum, ileum, and the colon contain yellowish fluid with a thick, cloudy, particulate matter. There is no major alteration to internal and external inspection and palpation except for a yellowish/white shiny discoloration of the mucosa. The vermiform appendix is identified. The pancreas is tan, lobulated and shows no neoplasia, calcification or hemorrhage.,There are no intraluminal masses or pseudomenbrane.,UROGENITAL SYSTEM:
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DESCRIPTION: Autopsy of a white female who died of acute combined drug intoxication.

This autopsy report pertains to a deceased individual and the cause of death is acute combined drug intoxication. The information presented is part of a routine autopsy report, focusing on documenting physical characteristics, injuries, and any findings that might help determine the cause of death. While the process of an autopsy is sensitive and significant, especially for the deceased's family or if involved in a legal investigation, it doesn't imply an immediate high-stakes situation for the medical practitioner involved in documenting the case in this context. The outcome is past and the focus is on record-keeping and analysis. However, it could be high-stakes in legal or investigative contexts outside the practitioner's immediate involvement.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 11

ADMISSION DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, and hypertension.,DISCHARGE DIAGNOSES: , Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.,PROCEDURE: , Laparoscopic cholecystectomy.,SERVICE: , Surgery.,HISTORY OF PRESENT ILLNESS:,  Ms. ABC is a 57-year-old woman.  She suffers from morbid obesity.  She also has diabetes and obstructive sleep apnea.  She was evaluated in the Bariatric Surgical Center for placement of a band.  During her workup, she was noted to have evidence of cholelithiasis.  It was felt that the patient would benefit from removal of her gallbladder prior to having band placement secondary to her diabetes and the risk of infection of the band.  The patient was scheduled to undergo her procedure on 12/31/09; however, at blood glucose check, the patient was noted to be hyperglycemic, her sugar was 438.  She was admitted to the hospital for treatment of her hyperglycemia.,HOSPITAL COURSE: , Ms. ABC was admitted to the hospital.  She was seen by Dr. A.  He put her on an insulin drip.  Her sugars slowly did come down to normal down to between 115 and 134.  On the next day, she was then taken to the operating room, where she underwent her laparoscopic cholecystectomy.  She was noted to be a difficult intubation for the procedure.  There were some indications of chronic cholecystitis, a little bit of edema, mild edema and adhesions of omentum around the gallbladder.  She underwent the procedure.  She tolerated without difficulty.  She was recovered in the Postoperative Care Unit and then returned to the floor.  Her blood sugar postprocedure was noted to be 233.  She was started back on a sliding scale insulin.  She continued to do well and was felt to be stable for discharge following the procedure.,DISCHARGE INSTRUCTIONS:  ,To return to the Medifast diet.  To continue with her blood glucose.  She needs to follow up with Dr. B, and she will see me next week on Friday.  We will determine if we will proceed with her lap band at that time.  She may shower.  She needs to keep her wounds clean and dry.  No heavy lifting.  No driving on narcotic pain medicines.  She needs to continue with her CPAP machine and continue to monitor her sugars.
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DESCRIPTION: Hyperglycemia, cholelithiasis, obstructive sleep apnea, diabetes mellitus, hypertension, and cholecystitis.

discharge summary, medifast, hyperglycemia, laparoscopic cholecystectomy, medifast diet, cholecystitis, cholelithiasis, diabetes mellitus, hypertension, morbid obesity, obstructive sleep apnea, sleep apnea, diabetes,

The discharge summary outlines a medical situation but does not present an immediate life-threatening event. The patient underwent a routine surgical procedure (laparoscopic cholecystectomy) which was necessary due to cholelithiasis and associated risks given her diabetes. There were some challenges such as hyperglycemia and difficult intubation, but these were managed effectively during her hospital stay. She has chronic conditions that need ongoing management, such as diabetes and obstructive sleep apnea, but the current situation does not involve acute critical care needs. The situation requires careful follow-up for her health conditions; however, it represents a standard post-operative recovery and management of existing medical conditions.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Breast Cancer Followup

CHIEF COMPLAINT:,1.  Metastatic breast cancer.,2.  Enrolled is clinical trial C40502.,3.  Sinus pain.,HISTORY OF PRESENT ILLNESS: , She is a very pleasant 59-year-old nurse with a history of breast cancer.  She was initially diagnosed in June 1994.  Her previous treatments included Zometa, Faslodex, and Aromasin.  She was found to have disease progression first noted by rising tumor markers.  PET/CT scan revealed metastatic disease and she was enrolled in clinical trial of CTSU/C40502.  She was randomized to the ixabepilone plus Avastin.  She experienced dose-limiting toxicity with the fourth cycle.  The Ixempra was skipped on day 1 and day 8.  She then had a dose reduction and has been tolerating treatment well with the exception of progressive neuropathy.  Early in the month she had concerned about possible perforated septum.  She was seen by ENT urgently.  She was found to have nasal septum intact.  She comes into clinic today for day eight Ixempra.,CURRENT MEDICATIONS:  ,Zometa monthly, calcium with Vitamin D q.d., multivitamin q.d., Ambien 5 mg q.h.s., Pepcid AC 20 mg q.d., Effexor 112 mg q.d., Lyrica 100 mg at bedtime, Tylenol p.r.n., Ultram p.r.n., Mucinex one to two tablets b.i.d., Neosporin applied to the nasal mucosa b.i.d. nasal rinse daily.,ALLERGIES:  ,Compazine.,REVIEW OF SYSTEMS: , The patient is comfort in knowing that she does not have a septal perforation.  She has progressive neuropathy and decreased sensation in her fingertips.  She makes many errors when keyboarding.  I would rate her neuropathy as grade 2.  She continues to have headaches respond to Ultram which she takes as needed.  She occasionally reports pain in her right upper quadrant as well as right sternum.  He denies any fevers, chills, or night sweats.  Her diarrhea has finally resolved and her bowels are back to normal.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:
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DESCRIPTION: A nurse with a history of breast cancer enrolled is clinical trial C40502.  Her previous treatments included Zometa, Faslodex, and Aromasin.  She was found to have disease progression first noted by rising tumor markers.

soap / chart / progress notes, zometa, faslodex, aromasin, dose-limiting toxicity, metastatic breast cancer, perforated septum, nasal septum, clinical trial, breast cancer, disease, metastatic, breast, cancer,

The situation involves a patient with metastatic breast cancer, which is a severe and potentially life-threatening condition. The patient is also participating in a clinical trial and experiencing side effects, such as progressive neuropathy, which require careful management. This is high-stakes due to the nature of metastatic cancer and the need for careful monitoring during experimental treatment. Furthermore, the situation involves ongoing decisions about balancing cancer treatment with quality of life factors, like managing side effects.


Medical Specialty: Sleep Medicine
Sample Name: Electroencephalogram

DESCRIPTION OF RECORD:  ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system.  Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical.  During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly.  The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age.
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DESCRIPTION: Normal awake and drowsy (stage I sleep) EEG for patient's age.

sleep medicine, gold-plated surface disc electrodes, paroxysmal activity, eeg, drowsy stage, sleep eeg, stage, sleep, electrodes, awake, moderate, activity

The provided EEG record and description indicate normal findings for a patient's age, both awake and drowsy. This suggests that the patient's brain activity is within expected limits, with no signs of abnormalities such as focal slowing or paroxysmal activity. The situation does not involve any critical or abnormal findings that require immediate intervention, such as epilepsy or other serious neurological conditions. Therefore, it is considered low-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Occupational Medicine Consult - 1

ALLOWED CONDITIONS:,  Left knee strain, meniscus tear left knee.,CONTESTED CONDITION:,  Osteoarthritis of the left knee.,EMPLOYER:,  ABCD.,I examined Xxxxx today September 14, 2007, for the above allowed conditions and also the contested condition of osteoarthritis of his left knee.  He is a 57-year-old assembly worker who was injured on June 13, 2007, which according to his FROI was due to "repairing cars, down on knees to work on concrete floors."  In addition, he slipped on an air hose on the floor at work on March 7, 2007, re-injuring his left knee.  He developed pain and swelling in his left knee.  He denies having any difficulties with his left knee prior to the injury of June 13, 2002.,DIAGNOSTIC STUDIES: , August 2, 2002, MRI of the left knee showed low-grade chondromalacia of the left patellofemoral joint space and a posterior horn tear of the medial meniscus, likely degenerative in nature, and also grade II to III chondromalacia of the medial joint space.  On June 26, 2007, MRI of his left knee was referred to in the injury management report of June 19, 2007, as showing osteoarthritis of the medial compartment has advanced.  He brought with him copies of x-rays taken July 16, 2007, of his left knee, which I reviewed and which showed marked narrowing of the medial compartment of his left knee with spurs on the margins of the joint medially and also spurs on the patella.  There was subluxation of the tibia on the femur with standing.,After his injury, he received treatment from Dr. X for patellofemoral syndrome with knee sleeve.  He also received treatment from Dr. Y also for left knee sprain and patellar pain.  He also did exercise, does use a knee sleeve and Aleve.  On December 5, 2002, he underwent arthroscopy of the left knee by Dr. Z who did a partial resection of a torn medial meniscus.  He also noticed grade III chondromalacia of the patella as well as the torn medial meniscus.  He states that he was asymptomatic until he slipped on an air hose while at work on March 7, 2007, and again developed pain and swelling in his left knee.  Standing aggravates his pain.  He has had one injection of cortisone by Dr. Z about a month ago, which has helped his pain.  He takes one hydrocodone 7.5/750 mg daily.,Examination of his left knee revealed there was bilateral varus deformity, healed arthroscopy incisional scars, there was a 1/2 atrophy of the left calf.  There was patellar crepitus with knee motion.  There was no motor weakness or reflex changes.  He walked without a limp and could stand on his heels and toes equally well.  There was no instability of the knee and no effusion.  Range of motion was 0 to 120 degrees.,QUESTION: , Xxxxx has recently filed to reactivate this claim.  Please give me your opinion as to whether Xxxxx's current clinical presentation is related to the industrial injury stated above.,ANSWER:, Yes.  His original MRI of August 2, 2002, did show low-grade chondromalacia of the patellofemoral joint and also grade II to III chondromalacia of the medial joint space, which was the beginning of osteoarthritis.  Also, it is well known that torn medial meniscus can result in osteoarthritis of the knee; therefore, the osteoarthritis is related to his original injury of June 13, 2007, specifically to the torn medial meniscus.,QUESTION:  ,Do I believe that claim #123 should be reactivated to allow for treatment of the allowed conditions as stated?,ANSWER:, Yes, I believe it should be reactivated to allow treatment of the contested condition of osteoarthritis of his left knee.,QUESTION:,  Xxxxx has filed an application for additional allowance of osteoarthritis of the left knee.  Based on the current objective findings, mechanism of injury, medical records, and diagnostic studies, does the medical evidence support the existence of the requested condition?,ANSWER: ,Yes.  Please see the discussion in the answer to question no one.  In addition, x-rays of July 16, 2007, do reveal medial compartment and patellofemoral compartment osteoarthritis of the left knee.,QUESTION: , If you find this condition exists, is it a direct and proximate result of the June 13, 2002, injury?,ANSWER:, Yes.  See discussion in answer to question number one.,QUESTION: , Do you find that Xxxxx's injury or disability was caused by the natural deterioration of tissue, an organ or part of body?,ANSWER: ,No.  I believe the osteoarthritis was the result of the torn medial meniscus as discussed under question number one.,QUESTION: , In addition, if you find the condition exists, are there non-occupational activities or intervening injuries, which could have contributed to Xxxxx's condition?,ANSWER:, No.  He does not give any history of any intervening injuries.,If you opine the requested condition should be additionally recognized, please include the condition as an allowed condition in the discussion of the following questions.,QUESTION:,  Based on the objective findings is the request for 10 sessions of physical therapy per C-9 dated July 27, 2007, medically necessary and appropriate for the allowed conditions of the claim of osteoarthritis of left knee?,ANSWER:,  Yes.,
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DESCRIPTION: Occupational medicine consult with questions-answers.

The situation involves a medical consultation to determine the cause and appropriate response to a patient's knee condition, specifically regarding the reactivation of a claim related to occupational injury. Although medical decisions and claim reactivation can have significant personal and professional implications, the case itself is relatively routine in the context of occupational medicine, with established procedures for evaluating such conditions. There is no immediate threat to life or health, and the outcome, while important, is part of standard medical-legal proceedings. Hence, this scenario is moderate in stakes for the parties involved.


Medical Specialty: Consult - History and Phy.
Sample Name: Chronic Kidney Disease - Consult

HISTORY OF PRESENT ILLNESS: , This is a 48-year-old black male with stage IV chronic kidney disease, likely secondary to HIV nephropathy who presents to clinic for followup having missed prior clinic appointments.  He was last seen in this clinic on 05/29/2007 by Dr. X.  This is the first time that I have met the patient.  The patient's history of renal insufficiency dates back to 06/2006 when he was hospitalized for an HIV-associated complication.  He is unclear of the exact reason for his hospitalization at that time, but he was diagnosed with renal insufficiency and was followed in our Renal Clinic for approximately one year.  He had a baseline creatinine during that time of between 3.2 to 3.3.  When he was initially diagnosed with renal insufficiency, he had been noncompliant with his HAART regimen.  Since that time, he has been very compliant with treatment for his HIV and is seeing Dr. Y in our Infectious Disease Clinic.  He is currently on three-drug antiretroviral therapy.  His last CD4 count in 03/2008 was 350.  He has had no HIV complications since he was last seen in our clinic.  The patient is also followed by Dr. Z at the outpatient VA Clinic, here in ABCD, although he has not seen her in approximately one year.  The patient has an AV fistula that was placed in late 2006.  The latest blood work that I have is from 06/11/2008 and shows a serum creatinine of 3.8, which represents a GFR of 22 and a potassium of 5.9.  These laboratories were drawn by his infectious disease doctor and the results prompted their recommendation for him to return to our clinic for further evaluation.  The only complaint that the patient has at this time is some difficulty sleeping.  He was given Ambien by his primary care doctor, but this has not helped significantly with his difficulty sleeping.  He says that he has trouble getting to sleep.  The Ambien will allow him to sleep for about two hours, and then he is awake again.  He is tired during the day, but is not taking any daytime naps.  He has no history of excessive snoring or apneic periods.  He has no history of falling asleep at work or while driving.  He has never had a formal sleep study.  He does continue to work in sales at a local butcher shop.,REVIEW OF SYSTEMS:  ,He denies any change in his appetite.  He has actually gained some weight in recent months.  He denies any nausea, vomiting, or abdominal discomfort.  He denies any pruritus.  He denies any lower extremity edema.  All other systems are reviewed and negative.,PAST MEDICAL HISTORY:,1.  Stage IV chronic kidney disease with most recent GFR of 22.,2.  HIV diagnosed in 09/2006 with the most recent CD4 count of 350 in 03/2008.,3.  Hyperlipidemia.,4.  Hypertension.,5.  Secondary hyperparathyroidism.,6.  Status post right upper extremity AV fistula in the fall of 2006.,7.  History of a right brachial plexus palsy.,8.  Recent lower back pain, status post lumbar steroid injection.,ALLERGIES:,  HE SAYS THAT VITAMIN D HAS CAUSED HEADACHES.,MEDICATIONS:,1.  Kaletra daily.,2.  Epivir one daily.,3.  Ziagen two daily.,4.  Lasix 20 mg b.i.d.,5.  Valsartan 20 mg b.i.d.,6.  Ambien 10 mg q.h.s.,SOCIAL HISTORY: , He lives here in ABCD.  He is employed at the sales counter of a local butcher shop.  He continues to smoke one pack of cigarettes daily, as he has for the past 28 years.  He denies any alcohol or illicit substances.,FAMILY HISTORY:,  His mother is deceased.  He said that she had some type of paralysis before she died.  His father is deceased at age 64 of a head and neck cancer.  He has a 56-year-old brother with type-two diabetes and blindness secondary to diabetic retinopathy.  He has a 41-year-old brother who has hypertension.  He has a sister who has thyroid disease.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight is 191 pounds.  His temperature is 97.1.  Pulse is 94.  Blood pressure by automatic cuff 173/97, by manual cuff 180/90.,HEENT:  His oropharynx is clear without thrush or ulceration.,NECK:  Supple without lymphadenopathy or thyromegaly.,HEART:  Regular with normal S1 and S2.  There are no murmurs, rubs, or gallops.  He has no JVD.,LUNGS:  Clear to auscultation bilaterally without wheezes, rhonchi, or crackles.,ABDOMEN:  Soft, nontender, nondistended, without abdominal bruit or organomegaly.,MUSCULOSKELETAL:  He has difficulty with abduction of his right shoulder.,ACCESS:  He has a right forearm AV fistula with an audible bruit and a palpable thrill.  There is no sign of stenosis.  The vascular access looks like it is ready to use.,EXTREMITIES:  No peripheral edema.,SKIN:  No bruises, petechiae, or rash.,LABS:  ,Sodium was 140, potassium 5.9, chloride 114, bicarbonate 18.  BUN is 49, creatinine 4.3.  GFR is 19.  Albumin 3.2.  Protein 7.  AST 17, ALT 16, alkaline phosphatase 106.  Total bilirubin 0.4.  Calcium 9.1., phosphorus 4.7, PTH of 448.  The corrected calcium was 9.7.  WBC is 8.9, hemoglobin 13.4, platelet 226.  Total cholesterol 234, triglycerides 140, LDL 159, HDL 47.  His ferritin is 258, iron is 55, and percent sat is 24.,IMPRESSION:  ,This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.,RECOMMENDATIONS:,1.  Renal.  His serum creatinine is progressively worsening.  His creatinine was 3.2 the last time we saw him in 05/2007 and today is 4.3.  This represents a GFR of 19.  This is stage IV chronic kidney disease.  He does have vascular access and this appears to be ready to use.  He is having some difficulty sleeping and it is possible that this represents some early signs of uremia.  Otherwise, he has no signs or symptoms of uremia at this time.  I am going to touch base with the dialysis educator and try to get The patient in to the dialysis teaching classes.  He has already received some literature for the dialysis teaching, but has not yet enrolled in the classes.  I have encouraged him to continue to exercise his right forearm.  I am also going to contact the transplant coordinator and see if he can be evaluated for possible transplant.  Given his progression of his chronic kidney disease, I will anticipate that he will need to start dialysis soon.,2.  Hypertension.  I have added labetolol 100 mg b.i.d. to his antihypertensive regimen.  He shows no signs at this point of volume overload, although if he does demonstrate this in the future, his Lasix could be increased.  Goal blood pressure would be less than 130/80.,3.  Hyperkalemia.  I am going to instruct him in a low-potassium diet and decrease his valsartan to 20 mg daily.  I will have him return in one week to recheck his potassium.  If his potassium continues to remain elevated, he may require initiation of dialysis for this.,4.  Bone metabolism.  His PTH is elevated and I am going to add PhosLo 800 mg t.i.d. with meals.  His corrected calcium is 9.7, and I would like to avoid calcium-containing phosphate bonders in this situation.,5.  Acid base.  His bicarbonate is 18 and I will initiate the sodium bicarbonate 650 mg three tablets t.i.d.,6.  Anemia.  His hemoglobin is at goal for this stage of chronic kidney disease.  His iron stores are adequate.
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DESCRIPTION: This is a 48-year-old black male with stage IV chronic kidney disease likely secondary to HIV nephropathy, although there is no history of renal biopsy, who has been noncompliant with the Renal Clinic and presents today for followup at the recommendation of his Infection Disease doctors.

The patient is at stage IV chronic kidney disease, which is a serious condition requiring careful monitoring and potential immediate interventions like dialysis. Additionally, the patient has several other medical conditions including HIV, hypertension, and hyperlipidemia, which complicate management. Non-compliance in attending clinic appointments also raises concerns about adherence to treatment plans, which is crucial for managing such critical health issues. The situation involves potential life-threatening risks if not managed correctly, indicating high stakes.


Medical Specialty: Surgery
Sample Name: Aortobifemoral Bypass

PREOPERATIVE DIAGNOSIS:,  Aortoiliac occlusive disease.,POSTOPERATIVE DIAGNOSIS:, Aortoiliac occlusive disease.,PROCEDURE PERFORMED:, Aortobifemoral bypass.,OPERATIVE FINDINGS: , The patient was taken to the operating room.  The abdominal contents were within normal limits.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.,PROCEDURE: , The patient was taken to the operating room, placed in a supine position, and prepped and draped in the usual sterile manner with Betadine solution.  A longitudinal incision was made after a Betadine-coated drape was placed over the incisional area.  Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges.  Attention was then turned to the abdomen, where a longitudinal incision was made from the pubis xiphoid, carried down subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery.  Mild adhesions were lysed.  The omentum was freed.  The small and large intestine were run with no evidence of abnormalities.  The liver and gallbladder were within normal limits.  No abnormalities were noted.  At this point, the Bookwalter retractor was placed.  NG tube was placed in the stomach and placed on suction.  The intestines were gently packed intraabdominally and laterally.  The rest of the peritoneum was then opened.  The aorta was cleared, both proximally and distally.  The left iliac was completely occluded.  The right iliac was to be cleansed.  At this point, 5000 units of aqueous heparin was administered to allow take effect.  The aorta was then clamped below the renal arteries and opened in a longitudinal fashion.  A single lumbar was ligated with #3-0 Prolene.  The inferior mesenteric artery was occluded intraluminally and required no suture closure.  Care was taken to preserve collaterals.  The aorta was measured, and a 16 mm Gore-Tex graft was brought on the field and anastomosed to the proximal aorta using #3-0 Prolene in a running fashion.  Last stitch was tied.  Hemostasis was excellent.  The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis.  At this point, strong pulses were present within the graft.  The limbs were vented and irrigated.  Using bimanual technique, the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin.  The grafts were then brought through these, care being taken to avoid twisting of the graft.  At this point, the right iliac was then ligated using #0 Vicryl and the clamp was removed.  Hemostasis was excellent.  The right common femoral artery was then clamped proximally and distally, opened with #11 blade extended with Potts scissors.  The graft was _____ and anastomosed to the artery using #5-0 Prolene in a continuous fashion with a stitch _______ running fashion.  Prior to tying the last stitch, the graft and artery were vented and the last stitch was tied.  Flow was initially restored proximally then distally with good results.  Attention was then turned to the left groin and the artery grafts were likewise exposed, cleared proximally and distally.  The artery was opened, extended with a Potts scissors and anastomosis was performed with #5-0 Prolene again with satisfactory hemostasis.  The last stitch was tied.  Strong pulses were present within the artery and graft itself.  At this point, 25 mg of protamine was administered.  The wounds were irrigated with antibiotic solution.  The groins were repacked.  Attention was then returned to the abdomen.  The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present.  The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft.  The intraabdominal contents were then allowed to resume their normal position.  There was no evidence of ischemia to the large or small bowel.  At this point, the omentum and stomach were repositioned.  The abdominal wall was closed in a running single layer fashion using #1 PDS.  The skin was closed with skin staples.  The groins were again irrigated, closed with #3-0 Vicryl and #4-0 undyed Vicryl and Steri-Strips.  The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well.  Sponges and instrument counts were correct.  Estimated blood loss 900 cc.
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DESCRIPTION: Aortoiliac occlusive disease.  Aortobifemoral bypass.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.

surgery, aorta, bypass, arteriosclerosis, abdominal contents, aortoiliac occlusive disease, gore tex graft, aortobifemoral bypass, longitudinal incision, aortobifemoral, hemostasis, artery, graft,

The aortobifemoral bypass is a major surgical procedure aimed at treating aortoiliac occlusive disease. This type of surgery is often necessary to restore adequate blood flow to the lower extremities in patients with severe arteriosclerosis. Given the complexity involved, such as handling the aorta and femoral arteries, the procedure carries significant risks, including bleeding, infection, and complications related to anesthesia. The nature of this type of surgery directly affects vital blood circulation, and the outcome can have profound impacts on the patient's overall health and mobility. Therefore, it is considered a high-stakes situation.


Medical Specialty: Surgery
Sample Name: Vasectomy

PREOPERATIVE DIAGNOSIS: , Voluntary sterility.,POSTOPERATIVE DIAGNOSIS: , Voluntary sterility.,OPERATIVE PROCEDURE:,  Bilateral vasectomy.,ANESTHESIA:,  Local.,INDICATIONS FOR PROCEDURE:  ,A gentleman who is here today requesting voluntary sterility.  Options were discussed for voluntary sterility and he has elected to proceed with a bilateral vasectomy.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, and after appropriately identifying the patient, the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the OR table.  Then, 0.25% Marcaine without epinephrine was used to anesthetize the scrotal skin.  A small incision was made in the right hemiscrotum.  The vas deferens was grasped with a vas clamp.  Next, the vas deferens was skeletonized.  It was clipped proximally and distally twice.  The cut edges were fulgurated.  Meticulous hemostasis was maintained.  Then, 4-0 chromic was used to close the scrotal skin on the right hemiscrotum.  Next, the attention was turned to the left hemiscrotum, and after the left hemiscrotum was anesthetized appropriately, a small incision was made in the left hemiscrotum.  The vas deferens was isolated.  It was skeletonized.  It was clipped proximally and distally twice.  The cut edges were fulgurated.  Meticulous hemostasis was maintained.  Then, 4-0 chromic was used to close the scrotal skin.  A jockstrap and sterile dressing were applied at the end of the case.  Sponge, needle, and instruments counts were correct.
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DESCRIPTION: Voluntary sterility.  Bilateral vasectomy.  The vas deferens was grasped with a vas clamp.  Next, the vas deferens was skeletonized.  It was clipped proximally and distally twice.

surgery, hemiscrotum, bilateral vasectomy, voluntary sterility, vas deferens, vasectomy, skeletonized, scrotal, sterility, deferens

The situation involves a surgical procedure, specifically a bilateral vasectomy, which is a relatively common, straightforward outpatient surgery associated with low risk. Vasectomy is an elective procedure requested by the patient for voluntary sterility. The potential stakes include procedural risks like infection or bleeding, but these are generally low due to the nature of the procedure and are often well-managed with standard medical practices. There is no immediate life-threatening condition involved, and it is a routine surgical procedure for experienced practitioners. Therefore, it is not considered high-stakes in the medical field.


Medical Specialty: Endocrinology
Sample Name: Diabetes Mellitus - SOAP Note - 1

CHIEF COMPLAINT:  ,Followup diabetes mellitus, type 1., ,SUBJECTIVE:,  Patient is a 34-year-old male with significant diabetic neuropathy.  He has been off on insurance for over a year.  Has been using NPH and Regular insulin to maintain his blood sugars.  States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago.  Reports that his blood sugar dropped too low which caused the accident.  Since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. Also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer., ,Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time.  Reports that he had some indications of kidney damage when first diagnosed.  His urine microalbumin today is 100.  His last hemoglobin A1C drawn at the end of December is 11.9.  Reports that at one point, he was on Lantus which worked well and he did not worry about his blood sugars dropping too low. While using Lantus, he was able to get his hemoglobin A1C down to 7.  His last CMP shows an elevated alkaline phosphatase level of 168. He denies alcohol or drug use and is a non smoker.  Reports he quit drinking 3 years ago. I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today.  Patient also has a history of gastroparesis and impotence.  Patient requests Nexium and Viagra, neither of which are covered under the Health Plan.  , ,Patient reports that he was in a scooter accident one week ago, fell off his scooter, hit his head.  Was not wearing a helmet.  Reports that he did not go to the emergency room and had a headache for several days after this incident.  Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room.  Patient did not comply.  Reports that the headache has resolved.  Denies any dizziness, nausea, vomiting, or other neurological abnormalities., ,PHYSICAL EXAMINATION: , WD, WN.  Slender, 34-year-old white male.  VITAL SIGNS:  Blood sugar 145, blood pressure 120/88, heart rate 104, respirations 16.  Microalbumin 100. SKIN:  There appears to be 2 skin lacerations on the left parietal region of the scalp, each approximately 1 inch long.  No signs of infection.  Wound is closed with new granulation tissue.  Appears to be healing well.  HEENT:  Normocephalic.  PERRLA.  EOMI.  TMs pearly gray with landmarks present.  Nares patent.  Throat with no redness or swelling.  Nontender sinuses.  NECK:  Supple.  Full ROM.  No LAD. CARDIAC:
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DESCRIPTION: Followup diabetes mellitus, type 1.

Followup diabetes mellitus, type 1.

endocrinology, diabetes mellitus, nph, regular insulin, sggt, diabetic neuropathy, dizziness, followup, glucometer, hypoglycemia, microalbumin, nausea, neurological, vomiting, mellitus type, blood sugars, blood, diabetes, mellitus, sugars

This situation involves a patient with poorly controlled Type 1 Diabetes Mellitus, evidenced by a very high hemoglobin A1C level of 11.9 and a history of diabetic complications such as neuropathy, potential kidney damage, gastroparesis, and impotence. Additionally, the patient is managing their diabetes in an unorthodox and risky way by not regularly checking blood glucose levels and relying on feeling alone, which could have severe health implications. The patient's fear of hypoglycemia following a past accident further complicates proper disease management. There is also a recent incident involving head trauma due to a scooter accident where the patient did not seek appropriate medical care, indicating neglect of serious health risks. All these factors suggest significant medical risks involved.


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

Medical Specialty: Nephrology
Sample Name: Renal Failure - Consult

REASON FOR CONSULTATION:, Acute renal failure.,HISTORY: , Limited data is available; I have reviewed his admission notes. Apparently this man was found down by a family member, was taken to Medical Center, and subsequently flown here. He has got respiratory failure, multi-organ system failure syndrome, and has renal insufficiency, as well. Markers of renal function have been fairly stable. I do not presently see indicators that he historically has been oliguric. The BUN and creatinine have been fairly stable. It is not clear whether he was taking his lisinopril up until the time of his demise, and it is also not clear whether he was taking his diuretic. Earlier thoughts had been that he could have had rhabdomyolysis, but the highest CPK I find recorded is 1500, the phosphorus is not elevated, though I acknowledge the serum calcium is low. I see no markers of myoglobinuria nor serum level of myoglobin. He has received IV fluid resuscitation, good broad-spectrum antibiotic coverage, continues mechanically ventilated, and is on parenteral nutrition.,PAST MEDICAL HISTORY:, Not obtained from the patient, but is reviewed in other physician's notes and seems notable for probably atherosclerotic cardiovascular disease wherein he was taking Imdur and digoxin, reportedly. A suggestion of hypertensive disease versus BPH, he was on terazosin. Suggestion of CHF versus hypertension versus volume overload, treated with Lasix. He was iron, I presume for anemia. He was on potassium, lisinopril and aspirin.,ALLERGIES:, OTHER PHYSICIAN'S NOTES INDICATE NO KNOWN ALLERGIES.,FAMILY HISTORY:, Not available.,SOCIAL HISTORY:, Not available.,REVIEW OF SYSTEMS:, Not available.,PHYSICAL EXAMINATION:,GENERAL: An older white male who is intubated, edematous, and appears uncomfortable.,HEENT: Male pattern baldness. Pupils equally round, no icterus. Intubated. OG tube in place.,NECK: Not tested for suppleness, no carotid bruits are heard. Neck vein distention is not seen.,LUNGS: He has diffuse expiratory wheezing anteriorly, laterally and posteriorly. I would describe the wheezes as coarse. I hear no present rales. Breath sounds otherwise are symmetrical.,HEART: Heart tones regular to auscultation, currently without audible rub or gallop sounds.,BREASTS: Not enlarged.,ABDOMEN: On plane. Bowel sounds presently are normal. Abdomen, I believe, is soft on plane, normal bowel sounds, no bruits, no liver edge felt, no HJR, no spleen tip, no suprapubic fullness.,GU: Catheter draining a dark yellow urine.,EXTREMITIES: Very edematous. Pulses not palpable. Cyanosis not observed. Fungal changes are not observed.,NEUROLOGICAL: Not otherwise assessed.,LABORATORY DATA:, Reviewed.,IMPRESSION:,1. Acute renal failure, suspected. Likely due to multi-organ system failure syndrome, with antecedent lisinopril use at home and at time of demise. He also reportedly was on Lasix prior to hospitalization, ? hypovolemia as a consequence.,2. Multi-organ system failure/systemic inflammatory response syndrome, with septic shock.,3. I am under-whelmed presently with the diagnosis of rhabdomyolysis, if the maximum CK recorded is 1500.,4. Antecedent hypoxemia, with renal hypoperfusion.,5. Diffuse aspiration pneumonitis suggested.,DISCUSSION/PLAN: ,I think the renal function will follow the patient. Supportive care, attention to stability of a euvolemic state, will be important at this time. He is currently nonoliguric, has apparently stable, diffuse, bilateral wheezing, with adequate gas exchange. He is on TPN, antimicrobials, and has been on vasopressive agents. Blood pressures are close to acceptable, he may now be wearing off his lisinopril, assuming he was taking it prior to admission.,I would use diuretics to maintain central euvolemia. Recorded I's are substantially O's during the course of the hospitalization, I presume as part of his resuscitation effort. No central pressures or monitoring of same is currently available. I will follow with you. No present indication for hemodialysis. Antimicrobials are being handled by others.
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DESCRIPTION: Acute renal failure, suspected, likely due to multi-organ system failure syndrome.

The situation involves a medical consultation regarding acute renal failure, likely due to multi-organ system failure syndrome, with potential septic shock and other critical conditions. These are serious health concerns that can significantly impact the patient's prognosis and require immediate and effective medical intervention. Decisions made in such cases can be life-saving or life-threatening, highlighting the high-stakes nature of the situation.


Medical Specialty: Emergency Room Reports
Sample Name: Abrasions & Lacerations - ER Visit

HISTORY OF PRESENT ILLNESS: , This is a 12-year-old male, who was admitted to the Emergency Department, who fell off his bicycle, not wearing a helmet, a few hours ago.  There was loss of consciousness.  The patient complains of neck pain.,CHRONIC/INACTIVE CONDITIONS:,  None.,PERSONAL/FAMILY/SOCIAL HISTORY/ILLNESSES:,  None.,PREVIOUS INJURIES: , Minor.,MEDICATIONS: , None.,PREVIOUS OPERATIONS: , None.,ALLERGIES:  ,NONE KNOWN.,FAMILY HISTORY: , Negative for heart disease, hypertension, obesity, diabetes, cancer or stroke.,SOCIAL HISTORY: , The patient is single.  He is a student.  He does not smoke, drink alcohol or consume drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  The patient denies weight loss/gain, fever, chills.,ENMT:  The patient denies headaches, nosebleeds, voice changes, blurry vision, changes in/loss of vision.,CV:  The patient denies chest pain, SOB supine, palpitations, edema, varicose veins, leg pains.,RESPIRATORY:  The patient denies SOB, wheezing, sputum production, bloody sputum, cough.,GI:  The patient denies heartburn, blood in stools, loss of appetite, abdominal pain, constipation.,GU:  The patient denies painful/burning urination, cloudy/dark urine, flank pain, groin pain.,MS:  The patient denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains, muscle weakness.,NEURO:  The patient had a loss of consciousness during the accident.  He does not recall the details of the accident.  Otherwise, negative for blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors, paralysis.,PSYCH:  Negative for anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances, suicidal thoughts.,INTEGUMENTARY:  Negative for unusual hair loss/breakage, skin lesions/discoloration, unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL:  Blood pressure 150/75, pulse rate 80, respirations 18, temperature 37.4, saturation 97% on room air.  The patient shows moderate obesity.,NECK:  The neck is symmetric, the trachea is in the midline, and there are no masses.  No crepitus is palpated.  The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATIONS:  Normal respiratory effort.  There is no intercostal retraction or action by the accessory muscles.  Normal breath sounds bilaterally with no rhonchi, wheezing or rubs.,CARDIOVASCULAR:  The PMI is palpable at the 5ICS in the MCL.  No thrills on palpation.  S1 and S2 are easily audible.  No audible S3, S4, murmur, click or rub.  Abdominal aorta is not palpable.  No audible abdominal bruits.  Femoral pulses are 3+ bilaterally, without audible bruits.  Extremities show no edema or varicosities.,GASTROINTESTINAL:  No palpable tenderness or masses.  Liver and spleen are percussed but not palpable under the costal margins.  No evidence for umbilical or groin herniae.,LYMPHATIC:  No nodes over 3 mm in the neck, axillae or groins.,MUSCULOSKELETAL:  Normal gait and station.  The patient is on a stretcher.  Symmetric muscle strength and normal tone, without signs of atrophy or abnormal movements.,SKIN:  There is a hematoma in the forehead and one in the occipital scalp, and there are abrasions in the upper extremities and abrasions on the knees.  No induration or subcutaneous nodules to palpation.,NEUROLOGIC:  Normal sensation by touch.  The patient moves all four extremities.,PSYCHIATRIC:  Oriented to time, place, and person.  Appropriate mood and affect.,LABORATORY DATA:  Reviewed chest x-ray, which is normal, right hand x-ray, which is normal, and an MRI of the head, which is normal.,DIAGNOSES,1.  Concussion.,2.  Facial abrasion.,3.  Scalp laceration.,4.  Knee abrasions.,PLANS/RECOMMENDATIONS:,  Admitted for observation.
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DESCRIPTION: A 12-year-old  fell off his bicycle, not wearing a helmet, a few hours ago.  There was loss of consciousness.  The patient complains of neck pain.

The situation involves a 12-year-old male who fell off a bicycle without a helmet, experiencing loss of consciousness and neck pain. These are significant concerns as loss of consciousness can indicate a concussion, and neck pain could suggest potential spinal injury. Although initial diagnostics like X-rays and an MRI of the head have returned normal, the patient is admitted for observation, which emphasizes the seriousness of the situation. In emergency medicine, such situations are high-stakes as they require careful monitoring and management to prevent further complications or identify latent issues promptly.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 4

PREOPERATIVE DIAGNOSIS:,  Diarrhea, suspected irritable bowel.,POSTOPERATIVE DIAGNOSIS:,  Normal colonoscopy., PREMEDICATIONS: , Versed 5 mg, Demerol 75 mg IV.,REPORTED PROCEDURE:,  The rectal exam revealed no external lesions.  The prostate was normal in size and consistency.,The colonoscope was inserted into the cecum with ease.  The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,  Normal colonoscopy - no evidence of inflammatory disease, polyp, or other neoplasm.  These findings are certainly consistent with irritable bowel syndrome.
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DESCRIPTION: Colonoscopy - Diarrhea, suspected irritable bowel

gastroenterology, diarrhea, ascending colon, cecum, colonoscope, colonoscopy, descending colon, hepatic flexure, inflammatory disease, irritable bowel syndrome, irritable bowel., polyp, rectal exam, rectum, sigmoid colon, splenic flexure, transverse colon, normal colonoscopy, irritable bowel, flexure, irritable, bowel,

The situation involves a diagnostic procedure (colonoscopy) to evaluate symptoms of diarrhea and suspected irritable bowel syndrome. While these symptoms can impact the patient's quality of life, the procedure is routine, and the findings were normal with no major complications or critical conditions identified. Therefore, this is a standard medical situation with no immediate threats to the patient's life or health, indicating it is not a high-stakes scenario.


Medical Specialty: Urology
Sample Name: Flexible Cystoscopy - BPH

PREOPERATIVE DIAGNOSIS: , Microscopic hematuria.,POSTOPERATIVE DIAGNOSIS:,  Microscopic hematuria with lateral lobe obstruction, mild.,PROCEDURE PERFORMED: , Flexible cystoscopy.,COMPLICATIONS: , None.,CONDITION: , Stable.,PROCEDURE: , The patient was placed in the supine position and sterilely prepped and draped in the usual fashion.  After 2% lidocaine was instilled, the anterior urethra is normal.  The prostatic urethra reveals mild lateral lobe obstruction.  There are no bladder tumors noted.,IMPRESSION:,  The patient has some mild benign prostatic hyperplasia.  At this point in time, we will continue with conservative observation.,PLAN: , The patient will follow up as needed.
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DESCRIPTION: Microscopic hematuria with lateral lobe obstruction, mild.

urology, benign prostatic hyperplasia, urethra, lateral lobe obstruction, flexible cystoscopy, microscopic hematuria, cystoscopy, hematuria, obstruction,

The situation involves a medical procedure (flexible cystoscopy) to evaluate microscopic hematuria, with findings indicating mild benign prostatic hyperplasia. The procedure was completed without complications and the patient's condition is stable. The plan is to continue with conservative observation, indicating non-urgent follow-up care. Thus, the stakes are relatively low as there are no immediate serious health threats or invasive interventions required.


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Fusion - 8

PROCEDURES PERFORMED: , C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.,ESTIMATED BLOOD LOSS: , 10 mL.,CLINICAL NOTE: , This is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain.  We decided go ahead with anterior cervical discectomy at C5-C6 and fusion.  The risks of lack of pain relief, paralysis, hoarse voice, nerve injuries, and infection were explained and the patient agreed to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where a general endotracheal anesthesia was induced without complication.  The patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut.  He had tape placed over the shoulders during intraoperative x-rays and his elbows were well padded.  The tape was placed and his arms were well padded.  He was prepped and draped in a sterile fashion.  A linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle.  We separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle.  We then dissected sharply medial to carotid artery, which we palpated to the prevertebral region.  We placed Caspar retractors for medial and lateral exposure over the C5-C6 disc space, which we confirmed with the lateral cervical spine x-ray including 18-gauge needle in the disc space.  We then marked the disc space.  We then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space.  We then under magnification removed all the disc material, we could possibly see down to bleeding bone and both the endplates.  We took down posterior longitudinal ligament as well.  We incised the 6-mm cornerstone bone.  We placed a 6-mm parallel medium bone nicely into the disc space.  We then sized a 23-mm plate.  We inserted the screws nicely above and below.  We tightened down the lock-nuts.  We irrigated the wound.  We assured hemostasis using bone wax prior to placing the plate.  We then assured hemostasis once again.  We reapproximated the platysma using 3-0 Vicryl in a simple interrupted fashion.  The subcutaneous level was closed using 3-0 Vicryl in a simple buried fashion.  The skin was closed with 3-0 Monocryl in a running subcuticular stitch.  Steri-Strips were applied.  Dry sterile dressing with Telfa was applied over this.  We obtained an intraoperative x-ray to confirm the proper level and good position of both plates and screw construct on the lateral x-ray and the patient was transferred to the recovery room, moving all four extremities with stable vital signs.  I was present as a primary surgeon throughout the entire case.
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DESCRIPTION: C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.

neurosurgery, allograft fusion, anterior cervical discectomy, neck pain, cervical spine, discectomy, fusion, sternocleidomastoid muscle, assured hemostasis, anterior cervical, cervical discectomy, disc space, cervical, anterior, allograft

The procedure detailed is an anterior cervical discectomy and fusion, a common yet complex neurosurgical operation. It involves surgical manipulation of the spinal cord and surrounding nerves, with potential risks including paralysis and nerve injury, which makes it high-stakes. Although the patient is stable post-operation, the inherent risks and the critical nature of ensuring success in maintaining neurological function elevate the stakes significantly.


Medical Specialty: Radiology
Sample Name: CT Abdomen & Pelvis

EXAM:,  CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement.  No oral or rectal contrast was utilized.  Comparison is made with the prior CT abdomen and pelvis dated 10/20/05.  There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 AP.  Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips.  The size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen.  There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak.  Further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either.  No exoluminal leakage is identified at any level.  There is no retroperitoneal hematoma present.  The findings are unchanged from the prior exam.  ,The liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present.  There is advanced atrophy of the left kidney.  No hydronephrosis is present.  No acute findings are identified elsewhere in the abdomen. ,The lung bases are clear. ,Concerning the remainder of the pelvis, no acute pathology is identified.  There is prominent streak artifact from the left total hip replacement.  There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis.  The bladder grossly appears normal.  A hysterectomy has been performed.  ,IMPRESSION:,1.  No complications identified regarding endoluminal aortoiliac graft repair as described.  The findings are stable compared to the study of 10/20/04.  ,2.  Stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level.  ,3.  No other acute findings noted. ,4.  Advanced left renal atrophy.
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DESCRIPTION: CT Abdomen & Pelvis W&WO Contrast

CT Abdomen & Pelvis W&WO Contrast

radiology, aortobiiliac graft repair, renal atrophy, ct abdomen & pelvis, w&wo contrast, aortic aneurysm, renal artery, mural thrombus, endoluminal leak, ct abdomen, ct, contrast, pelvis, abdomen,

The situation involves interpreting a CT imaging study following an aortobiiliac graft repair, with a focus on identifying any complications such as leaks or new pathologies. Given the context of post-surgical monitoring for aortic aneurysm and graft repair, while stable findings suggest a lower immediate risk of complications, the stakes remain significant because any changes could have serious implications for patient health. Therefore, monitoring and accurate interpretation are crucial to prevent potential life-threatening issues.


Medical Specialty: Surgery
Sample Name: Thrombectomy

PREOPERATIVE DIAGNOSES:,1.  Thrombosed left forearm loop fistula graft.,2.  Chronic renal failure.,3.  Hyperkalemia.,POSTOPERATIVE DIAGNOSES:,1.  Thrombosed left forearm loop fistula graft.,2.  Chronic renal failure.,3.  Hyperkalemia.,PROCEDURE PERFORMED: , Thrombectomy of the left forearm loop graft.,ANESTHESIA: , Local with sedation.,ESTIMATED BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS:, None.,OPERATIVE FINDINGS:,  The venous outflow was good.  There was stenosis in the mid-venous limb of the graft.,INDICATIONS: , The patient is an 81-year-old African-American female who presents with an occluded left forearm loop graft.  She was not able to have her dialysis as routine.  Her potassium was dramatically elevated at 7 the initial evening of anticipated surgery.  Both Surgery and Anesthesia thought this would be too risky to do.  Thus, she was given medications to decrease her potassium and a temporary hemodialysis catheter was placed in the femoral vein noted for her to have dialysis that night as well as this morning.  This morning her predialysis potassium was 6, and thus she was scheduled for surgery after her dialysis.,PROCEDURE: , The patient was taken to the operative suite and prepped and draped in the usual sterile fashion.  A transverse incision was made at the region of the venous anastomosis of the graft.  Further dissection was carried down to the catheter.  The vein appeared to be soft and without thrombus.  This outflow did not appear to be significantly impaired.  A transverse incision was made with a #11 blade on the venous limb of the graft near the anastomosis.  Next, a thrombectomy was done using a #4 Fogarty catheter.  Some of the clot and thrombus was removed from the venous limb.  The balloon did hang up in the multiple places along the venous limb signifying some degree of stenosis.  Once removing most of the clots from the venous limb prior to removing the plug, dilators were passed down the venous limb also indicating the area of stenosis.  At this point, we felt the patient would benefit from a curettage of the venous limb of the graft.  This was done and subsequent passes with the dilator and the balloon were then very easy and smooth following the curettage.  The Fogarty balloon was then passed beyond the clot and the plug.  The plug was visualized and inspected.  This also gave a good brisk bleeding from the graft.  The patient was heparinized and hep saline solution was injected into the venous limb and the angle vascular clamp was applied to the venous limb.  Attention was directed up to its anastomosis and the vein.  Fogarty balloon and thrombectomy was also performed well enough into this way.  There was good venous back bleeding following this.  The area was checked for any stenosis with the dilators and none was present.  Next, a #6-0 Prolene suture was used in a running fashion to close the graft.  Just prior to tying the suture, the graft was allowed to flush to move any debris or air.  The suture was also checked at that point for augmentation, which was good.  The suture was tied down and the wound was irrigated with antibiotic solution.  Next, a #3-0 Vicryl was used to approximate the subcutaneous tissues and a #4-0 undyed Vicryl was used in a running subcuticular fashion to approximate the skin edges.  Steri-Strips were applied and the patient was taken to recovery in stable condition.  She tolerated the procedure well.  She will be discharged from recovery when stable.  She is to resume her regular dialysis schedule and present for dialysis tomorrow.
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DESCRIPTION: Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia.  Thrombectomy of the left forearm loop graft.  The venous outflow was good.  There was stenosis in the mid-venous limb of the graft.

surgery, thrombosed, hyperkalemia, thrombectomy, forearm loop graft, venous outflow, chronic renal failure, venous limb, loop graft, forearm loop, limb, forearm, graft, venous, anastomosis, stenosis,

The situation involves performing a surgical thrombectomy on an elderly patient with chronic renal failure and significant hyperkalemia, which initially presented a high potassium level making immediate surgery risky. Hyperkalemia is a potentially life-threatening condition if not managed promptly, especially in a patient needing regular dialysis. This makes the scenario high-stakes as both the condition and the treatment have critical implications on the patient's health. However, the procedure was completed successfully without complications, and the patient was stable post-operatively, which mitigates the immediate high-stakes nature of the situation.


Medical Specialty: Surgery
Sample Name: I&D - Neck Abscess

PREOPERATIVE DIAGNOSIS: , Left neck abscess.,POSTOPERATIVE DIAGNOSIS: , Left neck abscess.,OPERATIVE PROCEDURE: , Incision and drainage of left neck abscess.,ANESTHESIA:  ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to operating room and placed supine on the operating table.  General inhalational anesthesia was administered.  The patient was draped in usual fashion.  The prominent area of the left submandibular swelling was noted and a 1-cm incision was outlined with a marking pen and the area was infiltrated with 0.5 mL of local anesthetic using 1% Xylocaine with epinephrine 1:100,000.  The incision was performed with a #15 blade.  An 18-gauge needle and 10 mL syringe was used to evacuate a small amount of the purulence from the abscess cavity.  This was submitted for culture and sensitivity, anaerobic cultures and Gram stain.  The cavity was opened with a small hemostat and a great deal of grossly purulent material was evacuated.  The cavity was irrigated with peroxide and saline.  A 0.25-inch Penrose drain was placed and secured with a single #3-0 nylon suture.  A 4 x 4 dressing was applied.  Bleeding was negligible.  There were no untoward complications.  The patient tolerated the procedure well and was transferred to the recovery room in stable condition.
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DESCRIPTION: Incision and drainage of left neck abscess.

surgery, i&d, incision and drainage, neck abscess, drainage, cavity, incision,

The situation involves a surgical procedure for draining a neck abscess. While the procedure itself is described as being performed without complications, surgical interventions always carry inherent risks, including infection and complications from anesthesia. However, since this was a routine procedure, managed effectively, and the patient was stable at the end, it doesn't qualify as extremely high-stakes. Any surgical procedure is generally considered somewhat high-stakes due to potential risks, but given the straightforward nature of this scenario and the patient's stable condition post-operation, it reasonably occupies the lower to mid-range of high-stakes situations.