Medical Specialty: Emergency Room Reports
Sample Name: Blood per Rectum

CHIEF COMPLAINT:, Bright red blood per rectum ,HISTORY OF PRESENT ILLNESS: ,This 73-year-old woman had a recent medical history significant for renal and bladder cancer, deep venous thrombosis of the right lower extremity, and anticoagulation therapy complicated by lower gastrointestinal bleeding. Colonoscopy during that admission showed internal hemorrhoids and diverticulosis, but a bleeding site was not identified. Five days after discharge to a nursing home, she again experienced bloody bowel movements and returned to the emergency department for evaluation. ,REVIEW OF SYMPTOMS: ,No chest pain, palpitations, abdominal pain or cramping, nausea, vomiting, or lightheadedness. Positive for generalized weakness and diarrhea the day of admission. ,PRIOR MEDICAL HISTORY:, Long-standing hypertension, intermittent atrial fibrillation, and hypercholesterolemia. Renal cell carcinoma and transitional cell bladder cancer status post left nephrectomy, radical cystectomy, and ileal loop diversion 6 weeks prior to presentation, postoperative course complicated by pneumonia, urinary tract infection, and retroperitoneal bleed. Deep venous thrombosis 2 weeks prior to presentation, management complicated by lower gastrointestinal bleeding, status post inferior vena cava filter placement. ,MEDICATIONS: ,Diltiazem 30 mg tid, pantoprazole 40 mg qd, epoetin alfa 40,000 units weekly, iron 325 mg bid, cholestyramine. Warfarin discontinued approximately 10 days earlier. ,ALLERGIES: ,Celecoxib (rash).,SOCIAL HISTORY:, Resided at nursing home. Denied alcohol, tobacco, and drug use. ,FAMILY HISTORY:, Non-contributory.,PHYSICAL EXAM: ,Temp = 38.3C BP =146/52 HR= 113 RR = 18 SaO2 = 98% room air ,General: Pale, ill-appearing elderly female. ,HEENT: Pale conjunctivae, oral mucous membranes moist. ,CVS: Irregularly irregular, tachycardia. ,Lungs: Decreased breath sounds at the bases. ,Abdomen: Positive bowel sounds, soft, nontender, nondistended, gross blood on rectal exam. ,Extremities: No cyanosis, clubbing, or edema. ,Skin: Warm, normal turgor. ,Neuro: Alert and oriented. Nonfocal. ,LABS: ,CBC: ,WBC count: 6,500 per mL ,Hemoglobin: 10.3 g/dL ,Hematocrit:31.8% ,Platelet count: 248 per mL ,Mean corpuscular volume: 86.5 fL ,RDW: 18% ,CHEM 7: ,Sodium: 131 mmol/L ,Potassium: 3.5 mmol/L ,Chloride: 98 mmol/L ,Bicarbonate: 23 mmol/L ,BUN: 11 mg/dL ,Creatinine: 1.1 mg/dL ,Glucose: 105 mg/dL ,COAGULATION STUDIES: ,PT 15.7 sec ,INR 1.6 ,PTT 29.5 sec ,HOSPITAL COURSE: ,The patient received 1 liter normal saline and diltiazem (a total of 20 mg intravenously and 30 mg orally) in the emergency department. Emergency department personnel made several attempts to place a nasogastric tube for gastric lavage, but were unsuccessful. During her evaluation, the patient was noted to desaturate to 80% on room air, with an increase in her respiratory rate to 34 breaths per minute. She was administered 50% oxygen by nonrebreadier mask, with improvement in her oxygen saturation to 89%. Computed tomographic angiography was negative for pulmonary embolism.
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DESCRIPTION: Status post colonoscopy.  After discharge, experienced bloody bowel movements and returned to the emergency department for evaluation.

The situation involves a 73-year-old woman with a history of renal and bladder cancer, DVT, anticoagulation therapy, and recent surgery. She is experiencing bright red blood per rectum, indicating possible severe gastrointestinal bleeding, a potentially life-threatening condition. She presented with symptoms including generalized weakness, tachycardia, and respiratory distress, and required supplemental oxygen due to desaturation. The complexity and potential seriousness of her medical issues, combined with her age and recent history, suggest a high-stakes scenario where timely and effective medical intervention is crucial.


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Medical Specialty: Hematology - Oncology
Sample Name: Mantle Cell Lymphoma - Consult

CHIEF COMPLAINT:,  Newly diagnosed mantle cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old woman who presented with abdominal pain in September 2006.  On chest x-ray, she had a possible infiltrate and it was thought she might have pneumonia and she was treated with antibiotics and prednisone.  Symptoms improved temporarily, but did not completely resolve.  By the end of September, her pain had worsened and she was seen in the emergency room at ABC.  Chest x-ray was compatible with pleurisy and she was treated with Percocet.  Few days later, she was seen and given a prescription for Ultram because Percocet was causing nausea.  Eventually, she was seen by Dr. X and noted to have splenomegaly.  Repeat ultrasound was done and showed the spleen enlarged at 19 cm.  In retrospect, this was not changed in comparison to an ultrasound that was done in September.  She underwent positron emission tomography (PET) scanning, which showed diffuse hypermetabolic lymph nodes measuring 1 to 2 cm in diameter, as well as a hypermetabolic spleen that was enlarged.,The patient underwent lymph node biopsy on the right neck on 10/27/2006.  Pathology is consistent with mantle cell lymphoma.,On 10/31/2006, she had a bone marrow biopsy.  This does show involvement of bone marrow with lymphoma.,She was noted to have circulating lymphoma cells on peripheral smear as well.,Although CBC was normal, MCV was low and the ferritin was assessed and was low at 8, consistent with iron deficiency.,ALLERGIES:,  NONE.,MEDICATIONS:  ,1.  Estradiol/Prometrium.  ,2.  Ultram p.r.n.  ,3.  Baby aspirin.  ,4.  Lunesta for sleep.  ,5.  She has been started on iron supplements.,PAST MEDICAL HISTORY:  ,1.  Tubal ligation in 1986.,2.  Possible cyst removed from the left neck in 1991.,3.  Tonsillectomy.,4.  Migraines, which are rare.,SOCIAL HISTORY: , She does not smoke cigarettes and drinks alcohol only occasionally.  She is married and has two children, ages 24 and 20.  She works as a project administrator.,FAMILY HISTORY:  ,Father is deceased.  He had emphysema and colon cancer at age 68.  Mother has arrhythmia and hypertension.  Her sister has hypertension and her brother is healthy.,PHYSICAL EXAMINATION:  ,GENERAL:  She is in no acute distress.,VITAL SIGNS:  Her weight is 168 pounds, and she is afebrile with a normal blood pressure and pulse.,HEENT:  The oropharynx is benign.,SKIN:  The skin is warm and dry and shows no jaundice.,NECK:  There is shotty adenopathy in the neck.,CARDIAC:  Regular rate without murmur.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Soft and nontender and shows the spleen palpable about 10 cm below the right costal margin.,EXTREMITIES:  No peripheral edema is noted.,LABORATORY DATA: , CBC and chemistry panel are pending.  CBC was normal last week.  PT/INR was normal as well.,IMPRESSION:,  Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.  Toxicities have already been discussed with her including myelosuppression, mucositis, diarrhea, nausea, alopecia, the low risk for cardiac toxicity, bladder toxicity, neuropathy, constipation, etc.  Written materials were provided to her last week.,PLAN: , Plan will be to add Rituxan a little later in her course because she has circulating lymphoma cells.  She will be started on allopurinol today as well as hydration further to avoid the possibility of tumor lysis syndrome.,Plan will be to have her evaluated for bone marrow transplant in first remission.  I will have Dr. Y see her while she is in the hospital.,The patient is anxious, and will be given Ativan as needed.  We will discontinue aspirin for now, but continue estradiol/Prometrium.,Iron deficiency will be treated with oral iron supplements and we will follow her counts.  She may well have gastrointestinal (GI) involvement, which is not uncommon with mantle cell lymphoma.  After she undergoes remission, we will consider colonoscopy for biopsies prior to proceeding to transplant.
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DESCRIPTION: Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.

The scenario involves a newly diagnosed case of mantle cell lymphoma, which is a serious form of cancer. The patient is at the stage of beginning chemotherapy, a critical and intensive treatment process. The management plan also includes a potential bone marrow transplant in the future, which further indicates the seriousness of the condition. The stakes are high given the implications of treatment and the potential impact on the patient's health and life expectancy.

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Medical Specialty: General Medicine
Sample Name: Hydrocarbon Aspiration - ER Visit

SUBJECTIVE: , The patient is a 20-year-old Caucasian male admitted via ABCD Hospital Emergency Department for evaluation of hydrocarbon aspiration.  The patient ingested "tiki oil" (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting.  He was seen in the ABCD Hospital Emergency Department, toxic appearing with an abnormal chest x-ray demonstrating bilateral lower lobe infiltrates, greater on the right.  He had a temperature of 38.3 with tachycardia approximating 130.  White count was 59,300 with a marked left shift.  Arterial blood gases showed pH 7.48, pO2 79, and pCO2 35.  He was admitted for further medical management.,PAST MEDICAL HISTORY:,  Aplastic crisis during childhood requiring splenectomy and a cholecystectomy at age 9.,DRUG ALLERGIES: , NONE KNOWN.,CURRENT MEDICATIONS: , None.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,The patient works at a local Christmas tree farm.  He smokes cigarettes approximately one pack per day.,REVIEW OF SYSTEMS:,  Ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain.,PHYSICAL EXAMINATION,GENERAL:  A toxic-appearing 20-year-old Caucasian male, in mild respiratory distress.,VITAL SIGNS:  Blood pressure 122/74, pulse 130 and regular, respirations 24, temperature 38.3, and oxygen saturation 93%.,SKIN:  No rashes, petechiae or ecchymoses.,HEENT:  Within normal limits.  Pupils are equally round and reactive to light and accommodation.  Ears clean.  Throat clean.,NECK:  Supple without thyromegaly.  Lymph nodes are nonpalpable.,CHEST:  Decreased breath sounds bilaterally, greater on the right, at the right base.,CARDIAC:  No murmur or gallop rhythm.,ABDOMEN:  Mild direct diffuse tenderness without rebound.  No detectable masses, pulsations or organomegaly.,EXTREMITIES:  No edema.  Pulses are equal and full bilaterally.,NEUROLOGIC:  Nonfocal.,DATABASE: , Chest x-ray, bilateral lower lobe pneumonia, greater on the right.  EKG, sinus tachycardia, rate of 130, normal intervals, no ST changes.  Arterial blood gases on 2 L of oxygen, pH 7.48, pO2 79, and pCO2 35.,BLOOD STUDIES: , Hematocrit is 43, WBC 59,300 with a left shift, and platelet count 394,000.  Sodium is 130, potassium 3.8, chloride 97, bicarbonate 24, BUN 14, creatinine 0.8, random blood sugar 147, and calcium 9.4.,IMPRESSION,1.  Hydrocarbon aspiration.,2.  Bilateral pneumonia with pneumonitis secondary to aspiration.,3.  Asplenic patient.,PLAN,1.  ICU monitoring.,2.  O2 protocol.,3.  Hydration.,4.  Antiemetic therapy.,5.  Parenteral antibiotics.,6.  Prophylactic proton pump inhibitors.,The patient will need ICU monitoring and Pulmonary Medicine evaluation pending clinical course.,
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DESCRIPTION: The patient ingested tiki oil (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting.

The situation involves a young adult male who has ingested a toxic substance (tiki oil containing kerosene, liquid paraffin, and citronella oil), leading to significant respiratory distress, bilateral pneumonia, and a high white blood cell count indicating systemic infection or inflammation. The patient also has a history of an asplenic condition due to a prior splenectomy, which increases his susceptibility to severe infections. Given these complications, including the need for ICU monitoring, oxygen therapy, and parenteral antibiotics, this scenario is high-stakes due to the potential for rapid deterioration and the need for acute intervention.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Endometrial Cancer Followup

CHIEF COMPLAINT:,1.  Stage IIIC endometrial cancer.,2.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.  In March 2010, she had an abnormal endometrial ultrasound with thickening of the endometrium and an enlarged uterus.  CT scan of the abdomen on 03/22/2010 showed an enlarged uterus, thickening of the endometrium, and a mass structure in the right and left adnexa that was suspicious for ovarian metastasis.  On 04/01/2010, she had a robotic modified radical hysterectomy with bilateral salpingo-oophorotomy and appendectomy with pelvic and periaortic lymphadenectomy.  The pathology was positive for grade III endometrial adenocarcinoma, 9.5 cm in size with 2 cm of invasion.  Four of 30 lymph nodes were positive for disease.  The left ovary was positive for metastatic disease.  Postsurgical PET/CT scan showed left lower pelvic side wall seroma and hypermetabolic abdominal and right pelvic retroperitoneal lymph nodes suspicious for metastatic disease.  The patient has completed five of planned six cycles of chemotherapy and comes in to clinic today for followup.  Of note, we had sent off genetic testing which was denied back in June.  I have been trying to get this testing completed.,CURRENT MEDICATIONS: , Synthroid q.d., ferrous sulfate 325 mg b.i.d., multivitamin q.d., Ativan 0.5 mg q.4 hours p.r.n. nausea and insomnia, gabapentin one tablet at bedtime.,ALLERGIES:
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DESCRIPTION: Stage IIIC endometrial cancer.  Adjuvant chemotherapy with cisplatin, Adriamycin, and Abraxane.  The patient is a 47-year-old female who was noted to have abnormal vaginal bleeding in the fall of 2009.

obstetrics / gynecology, adjuvant, adjuvant chemotherapy, cisplatin, adriamycin, abraxane, endometrial cancer, lymphadenectomy, chemotherapy, endometrial, disease,

The situation involves a patient with stage IIIC endometrial cancer who has undergone significant surgical procedures and is in the process of receiving chemotherapy. She is attending a follow-up appointment, a critical phase in cancer treatment to assess the effectiveness of chemotherapy and to monitor for any progression or recurrence of the disease. This follow-up is crucial for determining the next steps in her treatment plan and potentially modifying treatment based on her current status and any test results. The stakes are high due to the serious nature of cancer and the importance of effectively managing the disease to improve patient outcomes.


Medical Specialty: Orthopedic
Sample Name: Lumbar Laminectomy

PREOPERATIVE DIAGNOSIS: , Lumbar stenosis.,POSTOPERATIVE DIAGNOSES:,  Lumbar stenosis and cerebrospinal fluid fistula.,TITLE OF THE OPERATION,1.  Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques.,2.  Repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.,INDICATIONS:,  The patient is an 82-year-old woman who has about a four-month history now of urinary incontinence and numbness in her legs and hands, and difficulty ambulating.  She was evaluated with an MRI scan, which showed a very high-grade stenosis in her lumbar spine, and subsequent evaluation included a myelogram, which demonstrated cervical stenosis at C4-C5, C5-C6, and C6-C7 as well as a complete block of the contrast at L4-L5 and no contrast at L5-S1 either and stenosis at L3-L4 and all the way up, but worse at L3-L4, L4-L5, and L5-S1.  Yesterday, she underwent an anterior cervical discectomy and fusions C4-C5, C5-C6, C6-C7 and had some improvement of her symptoms and increased strength, even in the recovery room.  She was kept in the ICU because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy.  The rationale for putting the surgery is close together that she is normally on Coumadin for atrial fibrillation, though she has been cardioverted.  She and her son understand the nature, indications, and risks of the surgery, and agreed to go ahead.,PROCEDURE: , The patient was brought from the Neuro ICU to the operating room, where general endotracheal anesthesia was obtained.  She was rolled in a prone position on the Wilson frame.  The back was prepared in the usual manner with Betadine soak, followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  Using the usual anatomical landmarks, linear midline incision was made presumed over L4-L5 and L5-S1.  Sharp dissection was carried down into subcutaneous tissue, then Bovie electrocautery was used to isolate the spinous processes.  A Kocher clamp was placed in the anterior spinous ligament and this turned out to be L5-S1.  The incision was extended rostrally and deep Gelpi's were inserted to expose the spinous processes and lamina of L3, L4, L5, and S1.  Using the Leksell rongeur, the spinous processes of L4 and L5 were removed completely, and the caudal part of L3.  A high-speed drill was then used to thin the caudal lamina of L3, all of the lamina of L4 and of L5.  Then using various Kerrison punches, I proceeded to perform a laminectomy.  Removing the L5 lamina, there was a dural band attached to the ligamentum flavum and this caused about a 3-mm tear in the dura.  There was CSF leak.  The lamina removal was continued, ligamentum flavum was removed to expose all the dura.  Then using 4-0 Nurolon suture, a running-locking suture was used to close the approximate 3-mm long dural fistula.  There was no CSF leak with Valsalva.,I then continued the laminectomy removing all of the lamina of L5 and of L4, removing the ligamentum flavum between L3-L4, L4-L5 and L5-S1.  Foraminotomies were accomplished bilaterally.  The caudal aspect of the lamina of L3 also was removed.  The dura came up quite nicely.  I explored out along the L4, L5, and S1 nerve roots after completing the foraminotomies, the roots were quite free.  Further more, the thecal sac came up quite nicely.  In order to ensure no CSF leak, we would follow the patient out of the operating room.  The dural closure was covered with a small piece of fat.  This was all then covered with DuraSeal glue.  Gelfoam was placed on top of this, then the muscle was closed with interrupted 0 Ethibond.  The lumbodorsal fascia was closed with multiple sutures of interrupted 0 Ethibond in a watertight fashion.  Scarpa's fascia was closed with a running 0 Vicryl, and finally the skin was closed with a running-locking 3-0 nylon.  The wound was blocked with 0.5% plain Marcaine.,ESTIMATED BLOOD LOSS:  Estimated blood loss for the case was about 100 mL.,SPONGE AND NEEDLE COUNTS:  Correct.,FINDINGS:  A very tight high-grade stenosis at L3-L4, L4-L5, and L5-S1.  There were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis.,The patient tolerated the procedure well with stable vitals throughout.
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DESCRIPTION: Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.  Lumbar stenosis and cerebrospinal fluid fistula.

orthopedic, microtechniques, fistula, duraseal, foraminotomies, lumbar, stenosis, cerebrospinal, lumbar laminectomy, ligamentum flavum, csf, laminectomy, lamina,

The situation involves a complex surgical procedure, a lumbar laminectomy for decompression and the repair of a cerebrospinal fluid (CSF) fistula in an elderly patient (82 years old) with severe lumbar stenosis. These surgeries are high-stakes as they involve the spinal column and require precision to avoid nerve damage or complications. Additionally, the repair of the CSF fistula necessitates careful handling to prevent leaks which could lead to complications such as infections or further neurological issues. The patient's history of atrial fibrillation and recent cervical spine surgery add to the complexity and risk. Overall, this situation has significant implications for the patient's neurological function and overall health, making it high-stakes.


Medical Specialty: Orthopedic
Sample Name: Mumford Procedure & Acromioplasty

PREOPERATIVE DIAGNOSES:,1.  Partial rotator cuff tear with impingement syndrome.,2.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.,POSTOPERATIVE DIAGNOSES:,1.  Partial rotator cuff tear with impingement syndrome.,2.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic rotator cuff debridement.,2.  Anterior acromioplasty.,3.  Mumford procedure left shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operative Suite, Room #1 at ABCD General Hospital.  This was done in a modified beach chair position with interscalene and subsequent general anesthetic.,HISTORY AND GROSS FINDINGS: , This is a 38-year-old morbidly obese white male suffering increasing pain in his left shoulder for a number of months prior to surgical intervention.  He was refractory to conservative outpatient therapy.  He had injection of his AC joint, which removed symptoms but was not long lasting.  After discussing the alternatives of the care as well as advantages and disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Intraarticular viewing of the joint revealed a partial rotator cuff tear on the supraspinatus insertion on the joint side.  All else was noted to be intact including the glenohumeral joint, the long head of the biceps, and the labrum.  The remainder of the rotator cuff observed was noted to be intact.  Subacromially, the patient was noted to have increased synovitis.  Degenerative changes were noted upon observation of the distal clavicle.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table.  After receiving interscalene block anesthetic by Anesthesia Department, the patient was placed in modified beach chair position.  He was prepped and draped in the usual sterile manner.  Portals were created posteriorly and anteriorly from outside to in.  A full and complete diagnostic intraarticular arthroscopy was carried out.  Debridement was carried out through a 3.5 meniscal shaver to the 4.2 meniscal shaver to the undersurface of the partial tear of the rotator cuff.  Retrospectively it was approximately 25% of the generalized thickness.,Attention was then turned to the subacromial region.  The scope was directed subacromially.  A portal was created laterally.  Ultimately, the patient needed a general anesthetic once we were closer to the distal clavicle.  Gross bursectomy was carried out with a 4.2 meniscal shaver.  #18-gauge spinal needles have been placed to outline the anterior acromion prior to this.,It was difficult to control the patient's blood pressure with systolics ranging anywhere from 165 or 170 up to 200.  Because of this and difficulties with his anesthetic, it was elected to change to an open procedure.  Thus, the patient was anesthetized safely and secured.  An oblique incision was carried at the cross Langer's line across the outlet of the shoulder through the skin and subcutaneous tissue.  Hemostasis was controlled via electrocoagulation.  Flaps were created.  Anterior deltoid was reflected inferiorly.  Anterior acromioplasty was carried out with a saw then a Micro-Aire and then a beaver-tail rasp.  An excellent decompression was present.  CA ligament had been previously resected.  We then took the incision over the distal clavicle.  The end of the distal clavicle approximately 12 mm to 14 mm was isolated and removed with the Micro-Aire saw.  The beaver-tail rasp was utilized to smooth off the edges.  Pain buster catheter was placed deep to closure of the AC capsule and then to the deltoid with interrupted #1 Vicryl.  Transosseous sutures were placed across the acromion and the deltoid was elevated and closed with the same.  A superficial running #2-0 Vicryl suture was utilized for deltoid closure distally.  Interrupted #2-0 Vicryl was utilized to subcutaneous fat closure, running #4-0 subcuticular stitch for skin closure and Adaptic, 4x4s, ABDs, and Elastoplast tape placed for compression dressing.  0.25% Marcaine was flooded into the joint prior to the skin closure.  Pain buster catheter was hooked up.  The patient's arm was placed in arm sling.  He was safely transferred to the PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.
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DESCRIPTION: Arthroscopy with arthroscopic rotator cuff debridement, anterior acromioplasty, and Mumford procedure left shoulder.  Partial rotator cuff tear with impingement syndrome.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.

orthopedic, slap lesion, acromioclavicular joint, impingement syndrome, mumford procedure, acromioplasty, arthroscopy, arthroscopic, arthroscopic rotator cuff debridement, anterior acromioplasty, rotator cuff tear, arthroscopic rotator, meniscal shaver, cuff tear, rotator cuff, debridement, osteoarthritis, acromioclavicular, clavicle, deltoid, rotator, cuff, shoulder, joint

The described procedure involves significant complexities due to the patient's underlying health conditions, which include morbid obesity, and complications with anesthesia and blood pressure control. The surgery required conversion from minimally invasive to open surgery due to these complications. This indicates a higher level of risk than usual orthopedic surgeries. The surgery addresses multiple issues, including partial rotator cuff tear and degenerative osteoarthritis, through specific orthopedic procedures such as Mumford and acromioplasty. While it is a serious surgery with potential implications for recovery, it is not life-threatening in the immediate sense. However, due to the anesthetic risks and the complexity involved in managing the patient's condition during the procedure, it carries a moderate to high level of stakes.


Medical Specialty: Surgery
Sample Name: CABG - 2

PREOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Angina and coronary artery disease.,NAME OF OPERATION: , Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft.  Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.,ANESTHESIA: , General.,PROCEDURE DETAILS: , The patient was brought to the operating room and placed in the supine position upon the table.  After adequate general anesthesia, the patient was prepped with Betadine soap and solution in the usual sterile manner.  Elbows were protected to avoid ulnar neuropathy, chest wall expansion avoided to avoid ulnar neuropathy, phrenic nerve protectors used to protect the phrenic nerve and removed at the end of the case.,A midline sternal skin incision was made and carried down through the sternum which was divided with the saw.  Pericardial and thymus fat pad was divided.  The left internal mammary artery was harvested and spatulated for anastomosis.  Heparin was given.,Vein resected from the thigh, side branches secured using 4-0 silk and Hemoclips.  The thigh was closed multilayer Vicryl and Dexon technique.  A Pulsavac wash was done, drain was placed.,The left internal mammary artery is sewn to the left anterior descending using 7-0 running Prolene technique with the Medtronic off-pump retractors.  After this was done, the patient was fully heparinized, cannulated with a 6.5 atrial cannula and a 2-stage venous catheter and begun on cardiopulmonary bypass and maintained normothermia.  Medtronic retractors used to expose the circumflex.  Prior to going on pump, we stapled the vein graft in place to the aorta.,Then, on pump, we did the distal anastomosis with a 7-0 running Prolene technique.  The right side graft was brought to the posterior descending artery using running 7-0 Prolene technique.  Deairing procedure was carried out.  The bulldogs were removed.  The patient maintained good normal sinus rhythm with good mean perfusion.  The patient was weaned from cardiopulmonary bypass.  The arterial and venous lines were removed and doubly secured.  Protamine was delivered.  Meticulous hemostasis was present.  Platelets were given for coagulopathy.  Chest tube was placed and meticulous hemostasis was present.  The anatomy and the flow in the grafts was excellent.  Closure was begun.,The sternum was closed with wire, followed by linea alba and pectus fascia closure with running 0 Vicryl sutures in double-layer technique.  The skin was closed with subcuticular 4-0 Dexon suture technique.  The patient tolerated the procedure well and was transferred to the intensive care unit in stable condition.,We minimized the pump time to 16 minutes for just the distal anastomosis of the circumflex in order to lessen the insult to the kidneys as the patient already has kidney failure with a creatinine of 3.0.
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DESCRIPTION: Coronary artery bypass grafting (CABG) x2, left internal mammary artery to the left anterior descending and reverse saphenous vein graft to the circumflex, St. Jude proximal anastomosis used for vein graft.  Off-pump Medtronic technique for left internal mammary artery, and a BIVAD technique for the circumflex.

surgery, coronary artery disease, angina, coronary artery bypass grafting, internal mammary artery, coronary artery, vein graft, artery, bivad, cabg, medtronic, anastomosis, mammary, vein, circumflex,

The situation pertains to a double coronary artery bypass graft (CABG) surgery, which is inherently high-stakes due to the nature of the procedure. CABG is a major surgical operation performed to improve blood flow to the heart in patients with severe coronary artery disease. The stakes are further increased by the patient's pre-existing conditions, such as angina and coronary artery disease, as well as kidney failure with an elevated creatinine level, which poses an additional risk. Successful surgery is critical for the patient's heart and overall survival, therefore making this a high-stakes situation.


Medical Specialty: Orthopedic
Sample Name: Laminectomy & Foraminotomy Revision

PREOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1.  Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS:  ,Approximately 1000 cc.,CELL SAVER RETURNED:  ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain.  He had previous lumbar laminectomy at L4-L5.  He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable.  He is suffering from neurogenic claudication.  He was unresponsive to extensive conservative treatment.  He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia.  He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded.  His lumbar spine was then sterilely prepped and draped in the usual fashion.  A previous midline incision was extended from approximate level of L3 to S1.  This was in the midline.  Skin and subcutaneous tissue were debrided sharply.  Electrocautery provided hemostasis.  ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia.  The lumbar fascia was identified and split in the midline.  Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1.  Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4.  Once this was completed, a self-retaining retractor was then placed.  With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable.  These were readily mobile with digital palpation.  A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1.  This bone was morcellized and placed on the back table for utilization for bone grafting.  The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1.  Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained.  Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1.  The microscope was utilized during this portion of procedure for visualization.  There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure.  Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5.  Once this was identified, foraminotomies were created to allow additional mobility.  The wound was then copiously irrigated with antibiotic solution and suctioned dry.  Working type screws, provisional titanium screws were then placed at L4-l5.  This was to allow distraction and reduction of the spondylolisthesis.  These were placed in the pedicles of L4 and L5 under direct intensification.  The position of the screws were visualized, both AP and lateral images.  They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5.  This allowed for additional decompression of the L5 and L4 nerve roots.  Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed.  Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval.  This was taken in sequence up to a 13 mm space.  This was then reduced to a 11 mm as it was much more anatomic in nature.  Once this was completed, the spacers were then placed on the left side and distraction obtained.  Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally.  Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried.  A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft.  There were impacted at the interspace of L4-L5 under direct image intensification.  Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried.  The provisional screws and plates were removed.  This allowed for additional compression along L4-L5 with the cage instrumentation.  Permanent screws were then placed at L4, L5, and S1 bilaterally.  This was performed under direct image intensification.  The position was verified in both AP and lateral images.  Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally.  A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1.  Appropriate cross connecters were applied and the construct was placed over the pedicle screws.  They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra.  Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory.  All connections were tightened and retightened in Torque 2 specifications.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The dura was inspected and noted to be free of tension.  At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors.  An 8-inch Hemovac drain was placed exiting the wound.  The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin.  The remainder of the Hemovac was assembled.  Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape.  He was turned and taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded.
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DESCRIPTION: Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.

The situation involves a complex orthopedic surgical procedure, specifically a revision surgery for a patient with unstable spondylolisthesis, recurrent spinal stenosis, and other spinal issues. Spinal surgeries are generally high-stakes due to the potential for significant complications, the involvement of critical structures such as nerve roots, and the need for precise execution to avoid adverse outcomes like paralysis or persistent pain. The stakes are heightened by the patient's history of previous surgeries and unresponsive conservative treatments, indicating that this surgery is a critical measure for improving quality of life. The complexity of the surgery, as well as the potential for serious complications, contribute to it being a high-stakes situation.


Medical Specialty: Neurology
Sample Name: HCT - Calcification of Basal Ganglia

CC:, Memory loss.,HX:, This 77 y/o RHF presented with a one year history of progressive memory loss. Two weeks prior to her evaluation at UIHC she agreed to have her sister pick her up for church at 8:15AM, Sunday morning. That Sunday she went to pick up her sister at her sister's home and when her sister was not there (because the sister had gone to pick up the patient) the patient left. She later called the sister and asked her if she (sister) had overslept. During her UIHC evaluation she denied she knew anything about the incident. No other complaints were brought forth by the patients family.,PMH:, Unremarkable.,MEDS:, None,FHX: ,Father died of an MI, Mother had DM type II.,SHX: , Denies ETOH/illicit drug/Tobacco use.,ROS:, Unremarkable.,EXAM:, Afebrile, 80BPM, BP 158/98, 16RPM. Alert and oriented to person, place, time. Euthymic. 29/30 on Folstein's MMSE with deficit on drawing. Recalled 2/6 objects at five minutes and could not recite a list of 6 objects in 6 trials. Digit span was five forward and three backward. CN: mild right lower facial droop only. MOTOR: Full strength throughout. SENSORY: No deficits to PP/Vib/Prop/LT/Temp. COORD: Poor RAM in LUE only. GAIT: NB and ambulated without difficulty. STATION: No drift or Romberg sign. REFLEXES: 3+ bilaterally with flexor plantar responses. There were no frontal release signs.,LABS:, CMB, General Screen, FT4, TSH, VDRL were all WNL.,NEUROPSYCHOLOGICAL EVALUATION, 12/7/92: ,Verbal associative fluency was defective. Verbal memory, including acquisition, and delayed recall and recognition, was severely impaired. Visual memory, including immediate and delayed recall was also severely impaired. Visuoperceptual discrimination was mildly impaired, as was 2-D constructional praxis.,HCT, 12/7/92: , Diffuse cerebral atrophy with associative mild enlargement of the ventricles consistent with patient's age. Calcification is seen in both globus pallidi and this was felt to be a normal variant.
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DESCRIPTION: HCT for memory loss and for calcification of basal ganglia (globus pallidi).

neurology, memory loss, romberg sign, hct, cerebral atrophy, calcification of basal ganglia, basal ganglia, globus pallidi, basal, ganglia, globus, pallidi, calcification,

The situation involves a 77-year-old patient experiencing progressive memory loss and potential cognitive decline, with associated findings such as calcification of the basal ganglia. While this is a serious medical condition that requires thorough evaluation and management by healthcare professionals, it is not immediately life-threatening in the way that a heart attack or stroke might be. The condition seems to be managed through clinical evaluations and is a part of normal aging in some cases, as suggested by the 'normal variant' comment in the HCT results. Therefore, it is not typically urgent or high-stakes in the sense of requiring immediate intervention to prevent imminent harm.


Medical Specialty: Surgery
Sample Name: Cystourethroscopy & TURP

PREOPERATIVE DIAGNOSES:,1.  Benign prostatic hypertrophy.,2.  Urinary retention.,POSTOPERATIVE DIAGNOSES:,1.  Benign prostatic hypertrophy.,2.  Urinary retention.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Transurethral resection of prostate (TURP).,ANESTHESIA:  ,Spinal.,DRAIN: , A #24 French three-way Foley catheter.,SPECIMENS: , Prostatic resection chips.,ESTIMATED BLOOD LOSS:  ,150 cc.,DISPOSITION:  ,The patient was transferred to the PACU in stable condition.,INDICATIONS AND FINDINGS:  ,This is an 84-year-old male with history of BPH and subsequent urinary retention with failure of trial of void, scheduled for elective TURP procedure.,FINDINGS: , At the time of surgery, cystourethroscopy revealed trilobar enlargement of the prostate with prostatic varices of the median lobe.  Cystoscopy showed a few cellules of the bladder with no obvious bladder tumors noted.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to operating room and spinal anesthesia was induced by the Department of Anesthesia.  The patient was prepped and draped in the normal sterile fashion and a #21 French cystoscope inserted into urethra and into the bladder.  Cystoscopy performed with the above findings.  Cystoscope was removed.  A #27 French resectoscope with a #26 cutting loop was inserted into the bladder.  Verumontanum was identified as a landmark and systematic transurethral resection of the prostate tissue was undertaken in an circumferential fashion with good resection of tissue completed.  ________ irrigator was used to evacuate the bladder of prostatic chips.  Resectoscope was then inserted and any residual chips were removed in piecemeal fashion with a resectoscope loop.  Any obvious bleeding from the prostatic fossa was controlled with electrocautery.  Resectoscope was removed.  A #24 French three-way Foley catheter inserted into the urethra and into the bladder.  Bladder was irrigated and connected to three-way irrigation.  The patient was cleaned and sent to recovery in stable condition to be admitted overnight for continuous bladder irrigation and postop monitoring.
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DESCRIPTION: Benign prostatic hypertrophy and urinary retention.  Cystourethroscopy and transurethral resection of prostate (TURP).

surgery, urinary retention, cystourethroscopy, transurethral resection of prostate, foley catheter, bph, cystoscopy, bladder, benign prostatic hypertrophy, turp,

The situation involves a surgical procedure called Transurethral Resection of the Prostate (TURP) for an elderly male patient with benign prostatic hypertrophy and urinary retention. The procedure involves risks associated with surgery and anesthesia, particularly given the patient's age. However, TURP is considered a routine and common procedure for urologists, and the patient was transferred in stable condition postoperatively. While there are inherent risks, they are managed and anticipated, indicating that the stakes are moderate.


Medical Specialty: Urology
Sample Name: Cystolithalopaxy

PREOPERATIVE DIAGNOSES:,1.  Prostatism.,2.  Bladder calculus.,OPERATION:,  Holmium laser cystolithalopaxy.,POSTOPERATIVE DIAGNOSES:,1.  Prostatism.,2.  Bladder calculus.,ANESTHESIA:  ,General.,INDICATIONS:,  This is a 62-year-old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections.  The cystoscopy showed a large bladder calculus, short but obstructing prostate.  He comes in now for transurethral resection of his prostate and holmium laser cystolithotripsy.,He is a diabetic with obesity.,LABORATORY DATA:  ,Includes urinalysis showing white cells too much to count, 3-5 red cells, occasional bacteria.  He had a serum creatinine of 1.2, sodium 138, potassium 4.6, glucose 190, calcium 9.1.  Hematocrit 40.5, hemoglobin 13.8, white count 7,900.,PROCEDURE: , The patient was satisfactorily given general anesthesia.  Prepped and draped in the dorsal lithotomy position.  A 27-French Olympus rectoscope was passed via the urethra into the bladder.  The bladder, prostate, and urethra were inspected.  He had an obstructing prostate.  He had marked catheter reaction in his bladder.  He had a lot of villous changes, impossible to tell from frank tumor.  He had a huge bladder calculus.  It was white and round.,I used the holmium laser with the largest fiber through the continuous flow resectoscope and sheath, and broke up the stone, breaking up approximately 40 grams of stone.  There was still stone left at the end of the procedure.  Most of the chips that could be irrigated out of the bladder were irrigated out using Ellik.,Then the scope was removed and a 24-French 3-way Foley catheter was passed via the urethra into the bladder.,The plan is to probably discharge the patient in the morning and then we will get a KUB.  We will probably bring him back for a second stage cystolithotripsy, and ultimately do a TURP.  We broke up the stone for over an hour, and my judgment continuing with litholapaxy transurethrally over an hour begins to markedly increase the risk to the patient.
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DESCRIPTION: Holmium laser cystolithalopaxy.  A diabetic male in urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections.  The cystoscopy showed a large bladder calculus, short but obstructing prostate.

urology, prostatism, holmium laser cystolithalopaxy, urinary tract infections, holmium laser, bladder calculus, bladder, cystolithalopaxy, diabetic, urethra, urinary, catheterization, stone, calculus, prostate,

The situation involves a surgical procedure for a patient with complex medical conditions, including diabetes, urinary retention, neurogenic bladder, and recent urinary tract infections. The operation is necessary due to the presence of a large bladder calculus and obstructing prostate. The procedure carries certain risks, particularly because of the patient's health issues and the noted risks of extending the procedure duration. While not immediately life-threatening, it is a critical healthcare situation that needs careful handling to avoid complications.


Medical Specialty: Emergency Room Reports
Sample Name: Syncope - ER Visit - 1

REASON FOR VISIT:,  Syncope.,HISTORY:,  The patient is a 75-year-old lady who had a syncopal episode last night.  She went to her room with a bowl of cereal and then blacked out for a few seconds and then when she woke up, the cereal was on the floor.  She did not have any residual deficit.  She had a headache at that time.  She denies chest pains or palpitations.,PAST MEDICAL HISTORY: , Arthritis, first episode of high blood pressure today.  She had a normal stress test two years ago.,MEDICATIONS: , Her medication is one dose of hydrochlorothiazide today because her blood pressure was so high at 150/70.,SOCIAL HISTORY: , She does not smoke and she does not drink.  She lives with her daughter.,PHYSICAL EXAMINATION:,GENERAL:  Lady in no distress.,VITAL SIGNS:  Blood pressure 172/91, came down to 139/75, heart rate 91, and respirations 20.  Afebrile.,HEENT:  Head is normal.,NECK:  Supple.,LUNGS:  Clear to auscultation and percussion.,HEART:  No S3, no S4, and no murmurs.,ABDOMEN:  Soft.,EXTREMITIES:  Lower extremities, no edema.,DIAGNOSTIC DATA: , Her EKG shows sinus rhythm with nondiagnostic Q-waves in the inferior leads.,ASSESSMENT:  ,Syncope.,PLAN:  ,She had a CT scan of the brain that was negative today.  The blood pressure is high.  We will start Maxzide.  We will do an outpatient Holter and carotid Doppler study.  She has had an echocardiogram along with the stress test before and it was normal.  We will do an outpatient followup.
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DESCRIPTION: The patient had a syncopal episode last night.   She did not have any residual deficit.  She had a headache at that time.  She denies chest pains or palpitations.

emergency room reports, residual deficit, headache, ct scan, syncopal episode, stress test, blood pressure, syncope,

The situation involves a 75-year-old woman who had a syncopal episode, which is an episode of fainting or blackout. There is a possibility of underlying cardiovascular issues or other health concerns, given her age and elevated blood pressure. However, the immediate physical examination did not reveal any acute distress, and diagnostic tests (CT scan) were negative for serious conditions such as stroke. The patient will have further diagnostic testing on an outpatient basis. Prompt medical attention and further testing are required, but the situation at this moment does not appear to involve an immediate life-threatening emergency.


Medical Specialty: Orthopedic
Sample Name: Pain Management Consult - 2

HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing. The severity of the pain ranges from mild to severe. The pain is severe occasionally. It is present constantly. The pain is made worse by sitting, riding in a car, twisting and lifting. The pain is made better by rest. The patient's symptoms appear to be soft tissue (spine), myofascial (spine) and musculoskeletal (spine) in origin. Sleep alteration because of pain: positive and wakes up after getting to sleep nightly. Systemic signs/symptoms relevant or potentially relevant to the spine: none. Patient reports the following symptoms: depressed mood, loss of interest or pleasure in all or most activities, insomnia, inability to concentrate, fatigue and loss of energy.,WORK STATUS:,
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DESCRIPTION: Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.

This is a medical consultation scenario involving pain management for a work-related orthopedic injury. While it involves the well-being of the patient, which is important, the situation described does not have immediate life-threatening implications. However, it may significantly impact the patient's quality of life and work status. The presence of mental health symptoms, like depression and insomnia, adds to the concern, but it still remains a medical consultation typically managed with appropriate care plans rather than high-stakes urgent intervention.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pacemaker Interrogation

PROCEDURE NOTE: , Pacemaker ICD interrogation.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old gentleman who was admitted to the hospital.  He has had ICD pacemaker implantation.  This is a St. Jude Medical model current DRRS, 12345 pacemaker.,DIAGNOSIS: , Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,FINDINGS: , The patient is a DDD mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec.  Interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, R sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms.  The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only.  VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2.  VF detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5.  The patient is in normal sinus rhythm.,IMPRESSION:  ,Normally functioning pacemaker ICD post implant day number 1.
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DESCRIPTION: Pacemaker ICD interrogation.  Severe nonischemic cardiomyopathy with prior ventricular tachycardia.

cardiovascular / pulmonary, cardiomyopathy, ventricular, tachycardia, pacemaker icd interrogation, millivolts, impendence, interrogation, pacemaker,

This is a routine procedure for a patient with a history of severe nonischemic cardiomyopathy and prior ventricular tachycardia, who has recently had a pacemaker/ICD implanted. The note describes the interrogation of the device to ensure it is functioning properly. Proper functioning of a pacemaker is vital for the patient's health, as it addresses serious cardiac conditions. However, since the interrogation showed normal functionality and it wasn't an emergency situation, the stakes are significant but not at an immediate life-and-death level.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy

PROCEDURE:, Esophagogastroduodenoscopy with biopsy and snare polypectomy.,INDICATION FOR THE PROCEDURE:, Iron-deficiency anemia.,MEDICATIONS:, MAC.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration.,PROCEDURE:, After informed consent and appropriate sedation, the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum. The duodenal mucosa was completely normal. The pylorus was normal. In the stomach, there was evidence of diffuse atrophic-appearing nodular gastritis. Multiple biopsies were obtained. There also was a 1.5-cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum. There was mild ulceration on the tip of this polyp. It was decided to remove the polyp via snare polypectomy. Retroflexion was performed, and this revealed a small hiatal hernia in the distal esophagus. The Z-line was identified and was unremarkable. The esophageal mucosa was normal.,FINDINGS:,1. Hiatal hernia.,2. Diffuse nodular and atrophic appearing gastritis, biopsies taken.,3. A 1.5-cm polyp with ulceration along the greater curvature, removed.,RECOMMENDATIONS:,1. Follow up biopsies.,2. Continue PPI.,3. Hold Lovenox for 5 days.,4. Place SCDs.
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DESCRIPTION: Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia

gastroenterology, esophagogastroduodenoscopy, iron-deficiency, iron-deficiency anemia, anemia, biopsy, endoscope, esophageal mucosa, esophagus, hiatal hernia, polypectomy, snare polypectomy, esophagogastroduodenoscopy with biopsy, iron deficiency anemia,

The situation involves a medical procedure with inherent risks such as bleeding, perforation, and medication reaction. These are significant risks, but they are commonly associated with this type of procedure and are typically well-managed by healthcare professionals. Additionally, it involves follow-up actions to ensure patient recovery and to address the underlying condition (iron-deficiency anemia). While it is important, it is a routine procedure in gastroenterology and not life-threatening under normal circumstances.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pulmonary Function Test - 1

HISTORY: , Smoking history 50-pack years of smoking.,INDICATION: , Dyspnea.,PROCEDURE: , FVC was 59%.  FEV1 was 45%.  FEV1/FVC ratio was 52%. The predicted was 67%.  FEF 25/75% was 22%, improved about 400-cc, which represents 89% improvement with bronchodilator.  SVC was 91%. Inspiratory capacity was 70%.  Residual volume was 225% of its predicted.  Total lung capacity was 128%.  ,IMPRESSION:,1.  Moderate obstructive lung disease with some improvement with bronchodilator indicating bronchospastic element.,2.  Probably there is some restrictive element because of fibrosis.  The reason for that is that the inspiratory capacity was limited and the total lung capacity did not increase to the same extent as the residual volume and expiratory residual volume.,3.  Diffusion capacity was not measured.  The flow volume loop was consistent with the above.,
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DESCRIPTION: Pulmonary Function Test in a patient with smoking history.

cardiovascular / pulmonary, pulmonary function test, diffusion capacity, dyspnea, fef, fev1, fev1/fvc ratio, fvc, pft, residual volume, svc, smoking history, bronchodilator, bronchospastic, fibrosis, inspiratory capacity, lung capacity, obstructive lung disease, pulmonary function,

The situation involves the interpretation of a pulmonary function test on a patient with a significant smoking history. The results indicate moderate obstructive lung disease with bronchospastic and possibly restrictive elements due to fibrosis. This situation involves a medical assessment with important implications for the patient's health and management but is not an immediate emergency or life-threatening situation since it's an interpretation of routine tests. The stakes are medium as this will guide future management and treatment plans.


Medical Specialty: Radiology
Sample Name: CT Brain - Calcification of Basal Ganglia

CC:, Episodic mental status change and RUE numbness, and chorea (found on exam).,HX:, This 78y/o RHM was referred for an episode of unusual behavior and RUE numbness. In 9/91, he experienced near loss of consciousness, generalized weakness, headache and vomiting. Evaluation at that time revealed an serum glucose of >500mg/dL and he was placed on insulin therapy with subsequent resolution of his signs and symptoms. Since then, he became progressively more forgetful, and at the time of evaluation, 1/17/93, had lost his ability to perform his job repairing lawn mowers. His wife had taken over the family finances.,He had also been "stumbling," when ambulating, for 2 months prior to presentation. He was noted to be occasionally confused upon awakening for last several months. On 1/15/93, he was lying on a couch when he suddenly began throwing pillows and blankets for no apparent reason. There had been no change in sleep, appetite, or complaint of depression.,In addition, for two months prior to presentation, he had been experiencing 10-15minute episodes of RUE numbness. There was no face or lower extremity involvement.,During the last year he had developed unusual movements of his extremities.,MEDS:, NPH Humulin 12U qAM and 6U qPM. Advil prn.,PMH:, 1) Traumatic amputation of the 4th and 5th digits of his left hand.  2) Hospitalized for an unknown "nervous" condition in the 1940's.,SHX/FHX:, Retired small engine mechanic who worked in a poorly ventilated shop. Married with 13 children. No history of ETOH, Tobacco or illicit drug use. Father had tremors following a stroke. Brother died of brain aneurysm. No history of depression, suicide, or Huntington's disease in family.,ROS:, no history of CAD, Renal or liver disease, SOB, Chest pain, fevers, chills, night sweats or weight loss. No report of sign of bleeding.,EXAM:, BP138/63 HR65 RR15 36.1C,MS: Alert and oriented to self, season; but not date, year, or place. Latent verbal responses and direction following. Intact naming, but able to repeat only simple but not complex phrases. Slowed speech, with mild difficulty with word finding. 2/3 recall at one minute and 0/3 at 3 minutes. Knew the last 3 presidents. 14/27 on MMSE: unable to spell "world" backwards. Unable to read/write for complaint of inability to see without glasses.,CN: II-XII appeared grossly intact. EOM were full and smooth and without unusual saccadic pursuits. OKN intact. Choreiform movements of the tongue were noted.,Motor: 5/5 strength throughout with Guggenheim type resistance. there were choreiform type movements of all extremities bilaterally. No motor impersistence noted.,Sensory: unreliable.,Cord: "normal" FNF, HKS, and RAM, bilaterally.,Station: No Romberg sign.,Gait: unsteady and wide-based.,Reflexes: BUE 2/2, Patellar 2/2, Ankles Trace/Trace, Plantars were flexor bilaterally.,Gen Exam: 2/6 Systolic ejection murmur in aortic area.,COURSE:, No family history of Huntington's disease could be elicited from relatives. Brain CT, 1/18/93: bilateral calcification of the globus pallidi and a high attenuation focus in the right occipital lobe thought to represent artifact. Carotid duplex, 1/18/93: RICA 0-15%, LICA 16-49% stenosis and normal vertebral artery flow bilaterally. Transthoracic Echocardiogram (TTE),1/18/93: revealed severe aortic fibrosis or valvular calcification with "severe" aortic stenosis in the face of "normal" LV function. Cardiology felt the patient the patient had asymptomatic aortic stenosis. EEG, 1/20/93, showed low voltage Delta over the left posterior quadrant and intermittent background slowing over the same region consistent with focal dysfunction in this quadrant. MRI Brain, 1/22/93: multiple focal and more confluent areas of increased T2 signal in the periventricular white matter, more prominent on the left; in addition, there were irregular shaped areas of increased T2 signal and decreased T1 signal in both cerebellar hemispheres; and age related atrophy; incidentally, there is a cavum septum pellucidum et vergae and mucosal thickening of the maxillary sinuses. Impression: diffuse bilateral age related ischemic change, age related atrophy and maxillary sinus disease. There were no masses or areas of abnormal enhancement. TSH, FT4, Vit B12, VDRL, Urine drug and heavy metal screens were unremarkable. CSF,1/19/93: glucose 102 (serum glucose 162mg/dL), Protein 45mg/dL, RBC O, WBC O, Cultures negative. SPEP negative. However serum and CSF beta2 microglobulin levels were elevated at 2.5 and 3.1mg/L, respectively. Hematology felt these may have been false positives. CBC, 1/17/93: Hgb 10.4g/dL (low), HCT 31% (low), RBC 3/34mil/mm3 (low), WBC 5.8K/mm3, Plt 201K/mm3. Retic 30/1K/mm3 (normal). Serum Iron 35mcg/dL (low), TIBC 201mcg/dL (low), FeSat 17% (low), CRP 0.1mg/dL (normal), ESR 83mm/hr (high). Bone Marrow Bx: normal with adequate iron stores. Hematology felt the finding were compatible with anemia of chronic disease. Neuropsychologic evaluation on 1/17/93 revealed significant impairments in multiple realms of cognitive function (visuospatial reasoning, verbal and visual memory, visual confrontational naming, impaired arrhythmatic, dysfluent speech marked by use of phrases no longer than 5 words, frequent word finding difficulty and semantic paraphasic errors) most severe for expressive language, attention and memory. The pattern of findings reveals an atypical aphasia suggestive of left temporo-parietal dysfunction. The patient was discharged1/22/93 on ASA 325mg qd. He was given a diagnosis of senile chorea and dementia (unspecified type). 6/18/93 repeat Neuropsychological evaluation revealed moderate decline in all areas tested reflecting severe dementia.
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DESCRIPTION: CT Brain to evaluate episodic mental status change, RUE numbness, chorea, and calcification of Basal Ganglia (globus pallidi).

radiology, episodic mental status change, huntington's disease, brain ct, transthoracic echocardiogram, carotid duplex, mental status change, ct brain, basal ganglia, mental status, globus pallidi, aortic stenosis, maxillary sinuses, rue numbness, basal, ganglia, globus, pallidi, therapy, chorea, ct, rue, brain,

The situation involves diagnosing and managing potential serious and complex neurological conditions in an elderly patient with dementia and chorea, a condition that can significantly affect the patient's quality of life and may indicate underlying severe neurological diseases such as Huntington's disease or another neurodegenerative disorder. There is evidence of cerebral and vascular changes from the imaging studies, which require careful evaluation by the treating physician. While not immediately life-threatening, these conditions could severely impact the patient's life and functional status if not appropriately managed.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Exercise Stress Test - 3

INDICATIONS: , An 82-year-old man entering the cardiac rehabilitation program 6 weeks after a porcine aortic valve replacement and single-vessel coronary bypass graft procedure.  The patient has had a complicated postoperative course with rapid atrial fibrillation, pleural effusions, anemia and thrombocytopenia.  He is currently stabilized and improving in strength.  He is living in Nantucket with his daughter Debra Anderson while he recuperates and completes the cardiac rehabilitation program.  He has a few other significant medical problems.,MEDICATIONS:,1.  Toprol-XL 25 mg daily.,2.  Simvastatin 80 mg daily.,3.  Aspirin 81 mg daily.,4.  Synthroid 0.5 mg daily.,5.  Warfarin 1.5 mg daily.,PHYSICAL EXAMINATION: , The patient appears pale and fragile.  He is comfortable at rest.  His resting heart rate is 80.  His resting blood pressure is 112/70.  His conjunctivae are pale.  His lungs have decreased breath sounds throughout and dullness at the bases bilaterally.  Heart exam reveals a distant S1 and S2.  There is a short 2/6 systolic ejection murmur.  The extremities are normal without clubbing, cyanosis or edema.,The resting echocardiogram showed a sinus rhythm at 70 beats per minute.  There is poor R wave progression across the pericardium and Q waves inferiorly.,DESCRIPTION:  ,The patient exercised according to the modified Bruce protocol stopping at 3 minutes and 20 seconds with fatigue and shortness of breath.  He did not experience chest pain with exercise.  He did achieve a maximal heart rate of 100, which is 72% of his maximal predicted heart rate.  His maximal blood pressure was 190/70 resulting in a double product of 19,000 and achieving 2.3 METS.  As noted, the resting electrocardiogram had inferior Q waves and poor R wave progression.  There were no significant ST segment changes with exercise.  There were only rare ventricular premature beats with exercise.,CONCLUSION:,1.  Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure.,2.  No chest pain with exercise.,3.  No significant ECG changes with exercise.,4.  The patient is considered stable to enter our cardiac rehabilitation program.  I recommend the patient have a complete blood count, basic metabolic profile, and TSH obtained prior to entering the rehab program.
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DESCRIPTION: No chest pain with exercise and no significant ECG changes with exercise. Poor exercise capacity 6 weeks following an aortic valve replacement and single-vessel bypass procedure.

cardiovascular / pulmonary, bruce protocol, exercise stress test, cardiac rehabilitation program, blood pressure, cardiac rehabilitation, heart rate, stress, rehabilitation, heart, atrial,

This situation is moderately high-stakes due to the patient's complex medical history and recent cardiac surgery. The patient is still in recovery, with poor exercise capacity noted on the test, which could indicate underlying issues affecting his rehabilitation and overall cardiac health. While currently stable and eligible for cardiac rehabilitation, continuous monitoring is required due to the patient's age, recent cardiac surgeries, and other complications in his medical profile such as rapid atrial fibrillation and anemia. The exercise stress test results guide further management and adjustment of the rehabilitation program, which is crucial for the patient's recovery and long-term health outcomes.


Medical Specialty: Podiatry
Sample Name: MRI Ankle - 2

EXAM:,MRI OF THE RIGHT ANKLE,CLINICAL:,Pain.,FINDINGS:,The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding the ankle joint.,IMPRESSION,: NORMAL MRI OF THE RIGHT ANKLE.
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DESCRIPTION: MRI right ankle.

MRI right ankle.

This situation involves the interpretation of an MRI scan of a patient's right ankle. The findings indicate a normal result with no abnormalities. This suggests that there are no immediate concerns of fractures, contusions, or other pathological issues, making the situation non-urgent and low-stakes. While accurate interpretation is important for patient care, the lack of findings diminishes urgency and risk.


Medical Specialty: Orthopedic
Sample Name: I&D & Foreign Body Removal

PREOPERATIVE DIAGNOSIS:,  Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Incision and drainage, right foot.,2.  Removal of foreign body, right foot.,HISTORY: , This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.,PROCEDURE:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on the operating table in a supine position with a safety strap across his lap.  General anesthesia was administered by the Department of Anesthesia.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The stockinette was reflected and the foot was cleansed with wet and dry sponge.  There was noted to be some remaining periwound erythema.  There was noted to be some mild crepitation about 2 cm proximal from the entry wound.  The entry wound was noted to be over the third metatarsal head dorsally.  Upon inspection of the wound, there was noted to be hard foreign filling substance deep within the wound.  The entry site from the foreign body was extended proximally approximately about 0.5 cm.  At this time, a large wooden foreign body was visualized and removed with a straight stat.,The area was carefully inspected for any remaining piece of foreign body.  Several small pieces were noted and they were removed.  The area was palpated and there was no more remaining foreign body noted.  At this time, the wound was inspected thoroughly.  There was noted to be an area along the third metatarsal head more distally that did probe to the bone.  There was no purulent drainage expressed.  Area was flushed with copious amounts of sterile saline.  Pulse lavage was performed with 3 liters of plain sterile saline.  Wound cultures were obtained, aerobic and aerobic.  The wound was then again inspected for any remaining foreign body or purulent drainage.  None was noticed.  The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s, ABDs, Kling, and Kerlix.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to the PACU with vital signs stable and vascular status intact.  The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry.  The patient had a postoperative pain prescription written for Tylenol, Elixir with codeine as needed.
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DESCRIPTION: Incision and drainage and removal of foreign body, right foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.

orthopedic, incision and drainage, removal of foreign body, purulent drainage, foreign body, metatarsal head, metatarsal, i&d, incision, drainage, foot

The situation describes a surgical procedure on a 7-year-old patient to remove a foreign body from the right foot following a fall. As the current procedure is not the first intervention and follows previous incision and drainage due to continued purulent drainage, it is important to ensure complete removal of the foreign body to prevent further infection and potential complications. However, the surgery is not life-threatening, and the patient tolerated the procedure well, indicating it was successful and without complications. The stakes involve the child’s recovery and prevention of complications, but they are not extremely high in terms of life-and-death situations.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CABG - Redo

OPERATIVE PROCEDURE:,1.  Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,2.  Placement of a right femoral intraaortic balloon pump.,DESCRIPTION: , The patient was brought to the operating room and placed in the supine position.  After adequate endotracheal anesthesia was induced, appropriate monitoring lines were placed.  Chest, abdomen an legs were prepped and draped in sterile fashion.  The femoral artery on the right was punctured and a guidewire was placed.  The track was dilated and intraaortic balloon pump was placed in the appropriate position, sewn in place and ballooning started.,The left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4-0 silk and flushed with vein solution.  The leg was closed with running 3-0 Dexon subcu and running 4-0 Dexon on the skin.,The old mediastinal incision was opened.  The wires were cut and removed.  The sternum was divided in the midline.  Retrosternal attachments were taken down.  The left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The heart was dissected free of its adhesions.  The patient was fully heparinized and cannulated with a single aorta and single venous cannula.  Retrograde cardioplegia cannula was attempted to be placed, but could not be fitted into the coronary sinus safely, therefore, it was banded and oversewn with 5-0 Prolene.  An antegrade cardioplegia needle sump was placed and secured to the ascending aorta.  Cardiopulmonary bypass ensued.  The ascending aorta was cross clamped.  Cold-blood potassium cardioplegia was given antegrade, a total of 10 cc/kg.  It was followed by sumping the ascending aorta.  The obtuse marginal was identified and opened and an end-to-side anastomosis was performed with a running 7-0 Prolene suture.  The vein was cut to length.  Antegrade cardioplegia was given, a total of 200 cc.  The posterior descending branch of the right coronary artery was identified, opened and end-to-side anastomosis then performed with a running 7-0 Prolene suture.  The vein was cut to length.  Antegrade cardioplegia was given.  The mammary was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified, opened and end-to-side anastomosis then performed with running 8-0 Prolene suture and warm blood potassium cardioplegia was given.  The cross clamp was removed.  A partial-occlusion clamp was placed.  Aortotomies were made.  The vein was cut to fit these and sutured in place with running 5-0 Prolene suture.  The partial-occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Atrial and ventricular pacing wires were placed.  The patient was fully warmed and ventilation was commenced.  The patient was weaned from cardiopulmonary bypass, ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass.  The patient was decannulated in routine fashion.  Protamine was given.  Good hemostasis was noted.  A single mediastinal chest tube and bilateral pleural Blake drains were placed.  The sternum was closed with figure-of-eight stainless steel wire.  The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.
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DESCRIPTION: Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.  Placement of a right femoral intraaortic balloon pump.

cardiovascular / pulmonary, coronary bypass grafting, internal mammary, cardiopulmonary, intraaortic, femoral artery, cabg, running prolene suture, intraaortic balloon, balloon pump, ascending aorta, prolene suture, cardiopulmonary bypass, potassium, aorta, anastomosis, prolene, coronary, cardioplegia, bypass,

The given situation involves a complex cardiac surgery procedure known as 'Redo coronary bypass grafting.' This type of surgery is high-stakes due to the inherent risks associated with heart surgery, potential complications during the procedure, and the critical nature of the cardiovascular system. The procedure description indicates several significant interventions, including cardiopulmonary bypass, which are used in high-risk surgeries. Additionally, the need for myocardial protection and the use of an intraaortic balloon pump imply a critical condition that further elevates the stakes.


Medical Specialty: General Medicine
Sample Name: H&P - Nausea & Vomiting

CHIEF COMPLAINT:, Intractable nausea and vomiting.,HISTORY OF PRESENT ILLNESS:, This is a 43-year-old black female who was recently admitted and discharged yesterday for the same complaint. She has a long history of gastroparesis dating back to 2000, diagnosed by gastroscopy. She also has had multiple endoscopies revealing gastritis and esophagitis. She has been noted in the past multiple times to be medically noncompliant with her medication regimen. She also has very poorly controlled hypertension, diabetes mellitus and she also underwent a laparoscopic right adrenalectomy due to an adrenal adenoma in January, 2006. She presents to the emergency room today with elevated blood pressure and extreme nausea and vomiting. She was discharged on Reglan and high-dose PPI yesterday, and was instructed to take all of her medications as prescribed. She states that she has been compliant, but her symptoms have not been controlled. It should be noted that on her hospital admission she would have times where she would feel extremely sick to her stomach, and then soon after she would be witnessed going outside to smoke.,PAST MEDICAL HISTORY:,1. Diabetes mellitus (poorly controlled).,2. Hypertension (poorly controlled).,3. Chronic renal insufficiency.,4. Adrenal mass.,5. Obstructive sleep apnea.,6. Arthritis.,7. Hyperlipidemia.,PAST SURGICAL HISTORY:,1. Removal of ovarian cyst.,2. Hysterectomy.,3. Multiple EGDs with biopsies over the last six years. Her last EGD was in June, 2005, which showed esophagitis and gastritis.,4. Colonoscopy in June, 2005, showing diverticular disease.,5. Cardiac catheterization in February, 2002, showing normal coronary arteries and no evidence of renal artery stenosis.,6. Laparoscopic adrenalectomy in January, 2006.,MEDICATIONS:,1. Reglan 10 mg orally every 6 hours.,2. Nexium 20 mg orally twice a day.,3. Labetalol.,4. Hydralazine.,5. Clonidine.,6. Lantus 20 units at bedtime.,7. Humalog 30 units before meals.,8. Prozac 40 mg orally daily.,SOCIAL HISTORY:, She has a 27 pack year smoking history. She denies any alcohol use. She does have a history of chronic marijuana use.,FAMILY HISTORY:, Significant for diabetes and hypertension.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,HEENT: See has had headaches, and some dizziness. She denies any vision changes.,CARDIAC: She denies any chest pain or palpitations.,RESPIRATORY: She denies any shortness of breath.,GI: She has had persistent nausea and vomiting. She denies diarrhea, melena or hematemesis.,NEUROLOGICAL: She denies any neurological deficits.,All other systems were reviewed and were negative unless otherwise mentioned in HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure: 220/130. Heart rate: 113. Respiratory rate: 18. Temperature: 98.,GENERAL: This is a 43-year-old obese African-American female who appears in no acute distress. She has a depressed mood and flat affect, and does not answer questions elaborately. She will simply state that she does not feel well.,HEENT: Normocephalic, atraumatic, anicteric. PERRLA. EOMI. Mucous membranes moist. Oropharynx is clear.,NECK: Supple. No JVD. No lymphadenopathy.,LUNGS: Clear to auscultation bilaterally, nonlabored.,HEART: Regular rate and rhythm. S1 and S2. No murmurs, rubs, or gallops.
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DESCRIPTION: Intractable nausea and vomiting/history of diabetic gastroparesis/multiple endoscopies revealing gastritis and esophagitis.

The situation involves a patient with multiple chronic conditions, including poorly controlled hypertension and diabetes, chronic renal insufficiency, and a history of surgical interventions. The patient is experiencing intractable nausea and vomiting, which are significant symptoms given her medical history. The very high blood pressure reading (220/130) also suggests a hypertensive crisis, which is a critical condition that could lead to acute complications such as stroke or heart attack if not promptly addressed. Additionally, the patient's history of medical noncompliance adds complexity to the management of her conditions, increasing the stakes for her health outcomes. The combination of these factors indicates a high-stakes medical situation requiring urgent attention and careful management.


Medical Specialty: Gastroenterology
Sample Name: Gastroscopy - 1

PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum.  The hypopharynx was normal.  The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors.  There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair.  There was no sign of reflux esophagitis.  On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body.  It had 2 to 3 mm diameter.  This was broken up using a scope into smaller pieces.  There was no retained gastric liquid.  The antrum appeared normal and the pylorus was patent.  The scope passed easily into the duodenum, which was normal through the second portion.  On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing.  The scope was withdrawn.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Normal postoperative hernia repair.,2.  Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.,3.  Otherwise normal upper endoscopy to the descending duodenum.,RECOMMENDATIONS:,1.  Continue proton pump inhibitors.,2.  Use Reglan 10 mg three to four times a day.
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DESCRIPTION: Dysphagia, possible stricture.  Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.

The situation involves a medical procedure (Gastroscopy) which is used to diagnose and address potential serious gastrointestinal issues such as dysphagia, possible stricture, and gastroparesis. The patient has a history of hiatal hernia repair and is experiencing issues related to gastroparesis, evidenced by a large bezoar. While the procedure itself was normal without complications, the underlying condition of gastroparesis can significantly affect quality of life and requires medical management. Therefore, there is a moderate risk involved both in terms of diagnosis and future management of the condition.


Medical Specialty: Orthopedic
Sample Name: Lumbar Radiculopathy - Consult

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

orthopedic, back pain, hip pain, low back pain, x-rays, lumbar spinal stenosis, degenerative disc disease, spinal stenosis, lumbar spine, lumbar radiculopathy, cranial nerves, lumbar, degenerative, anemia,

The patient's situation involves chronic and potentially painful conditions like degenerative disc disease and lumbar spinal stenosis. While these conditions can affect quality of life significantly and require careful management, the immediate situation is not life-threatening. The treatment plan includes options for conservative management and surgery, indicating a standard approach to such conditions. Although the patient's social situation and lack of support at home may complicate her ability to manage her health effectively, which adds some level of concern, it does not elevate the situation to high-stakes as defined by imminent risk to life or immediate need for drastic intervention.


Medical Specialty: Sleep Medicine
Sample Name: Video EEG - 3

PROCEDURE: , EEG during wakefulness demonstrates background activity consisting of moderate-amplitude beta activity seen bilaterally.  The EEG background is symmetric.  Independent, small, positive, sharp wave activity is seen in the frontotemporal regions bilaterally with sharp-slow wave discharges seen more predominantly in the right frontotemporal head region.  No clinical signs of involuntary movements are noted during synchronous video monitoring.  Recording time is 22 minutes and 22 seconds.  There is attenuation of the background, faster activity during drowsiness and some light sleep is recorded.  No sustained epileptogenic activity is evident, but the independent bilateral sharp wave activity is seen intermittently.  Photic stimulation induced a bilaterally symmetric photic driving response.,IMPRESSION:,  EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.  The EEG findings are consistent with potentially epileptogenic process.  Clinical correlation is warranted.
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DESCRIPTION: EEG during wakefulness and light sleep is abnormal with independent, positive sharp wave activity seen in both frontotemporal head regions, more predominant in the right frontotemporal region.

sleep medicine, epileptogenic, wakefulness, eeg, frontotemporal, activityNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves interpretation of an EEG, which is critical in diagnosing neurological conditions, such as epilepsy. The presence of abnormal sharp wave activity suggests a potentially epileptogenic process, meaning it could be related to seizure activity. This has significant implications for the patient's health and treatment, making it high-stakes. Accurate diagnosis is essential to prescribe appropriate treatment and manage the condition, highlighting the importance and urgency of this analysis.