Medical Specialty: Neurology
Sample Name: Arachnoid Cyst

CC:, Seizures.,HX: ,The patient was initially evaluated at UIHC at 7 years of age. He had been well until 7 months prior to evaluation when he started having spells which were described as "dizzy spells" lasting from several seconds to one minute in duration. They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration. In addition, in the 3 months prior to evaluation, the right upper extremity would become tonic and flexed during the episodes, and he began to experience post ictal fatigue.,BIRTH HX:, 32 weeks gestation to a G4 mother and weighed 4#11oz. He was placed in an incubator for 3 weeks. He was jaundiced, but there was no report that he required treatment.,PMH: ,Single febrile convulsion lasting "3 hours" at age 2 years.,MEDS: ,none.,EXAM:, Appears healthy and in no acute distress. Unremarkable general and neurologic exam.,Impression: Psychomotor seizures.,Studies: Skull X-Rays were unremarkable.,EEG showed "minimal spike activity during hyperventilation, as well as random sharp delta activity over the left temporal area, in drowsiness and sleep. This record also showed moderate amplitude asymmetry ( left greater than right) over the frontal central and temporal areas, which is a peculiar finding.",COURSE:, The patient was initially treated with Phenobarbital; then Dilantin was added (early 1970's); then Depakene was added ( early 1980's) due to poor seizure control. An EEG on 8/22/66 showed "Left mid-temporal spike focus with surrounding slow abnormality, especially posterior to the anterior temporal areas (sparing the parasagittal region). In addition, the right lateral anterior hemisphere voltage is relatively depressed. ...this suggests two separate areas of cerebral pathology." He underwent his first HCT scan in Sioux City in 1981, and this revealed an right temporal arachnoid cyst. The patient had behavioral problems throughout elementary/junior high/high school. He underwent several neurosurgical evaluations at UIHC and Mayo Clinic and was told that surgery was unwarranted. He was placed on numerous antiepileptic medication combinations including Tegretol, Dilantin, Phenobarbital, Depakote, Acetazolamide, and Mysoline. Despite this he averaged 2-3 spells a month. He was last seen, 6/19/95, and was taking Dilantin and Tegretol. His typical spells were described as sudden in onset and without aura. He frequently becomes tonic or undergoes tonic-clonic movement and falls with associated loss of consciousness. He usually has rapid recovery and can return to work in 20 minutes. He works at a Turkey packing plant. Serial HCT scans showed growth in the arachnoid cyst until 1991, when growth arrest appeared to have occurred.
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DESCRIPTION: CT Brain - arachnoid cyst Arachnoid cyst diagnosed by CT brain.

neurology, arachnoid cyst, hct scan, seizures, serial hct scans, dizzy spells, drowsiness, hyperventilation, loss of consciousness, moderate amplitude asymmetry, temporal area, tonic-clonic movement, phenobarbital, dilantin, cyst, temporal, arachnoid

The situation describes a patient with a long history of neurological issues stemming from an arachnoid cyst, leading to persistent and poorly controlled seizures. While these seizures are serious and impact the patient's quality of life, they have been somewhat managed and the arachnoid cyst growth seems to have halted since 1991. The patient's seizures can be controlled with medications and he is able to work, which somewhat reduces the urgency. However, given the complexity, potential for serious complications, and the need for regular medical monitoring, it is a moderately high-stakes situation.


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

Medical Specialty: Pain Management
Sample Name: Kenalog Injection

PROCEDURE:,  Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance.,INDICATIONS:  ,The patient is a 78-year-old female with back pain referring into the left side.  She has had a couple of epidurals in the past, both of which led to only short-term improvement with intralaminar and caudal placements.  Therefore, transforaminal approach was selected for today's procedure.,Risks and benefits were discussed with the patient.  She agreed to accept the risks and signed informed consent to proceed.,PROCEDURE DETAILS:,  The patient was placed prone on the table.  The skin was thoroughly cleansed with betadine swabs x3 and wiped off with a sterile gauze.  The subcutaneous intramuscular and interligamentous region was anesthetized with buffered 1% lidocaine.,A 5-inch, 22-gauge spinal needle was directed under intermittent fluoroscopic guidance using an oblique approach at the opening of the L5 nerve root.  Once bony contact was made, a lateral was obtained and showed the needle tip to be against the posterior spinal body in the anterior epidural space.  Then an AP view was obtained which showed the needle tip to be below the 6 o'clock position of the pedicle.,EPIDUROGRAM: , Omnipaque 300, 1 mL, was placed through the foraminal opening of the L5 nerve root on the left.  This did show dye spread pattern which was narrowed consistent with foraminal stenosis.  The dye did traverse the foraminal opening and was seen spreading around the pedicle into the anterior epidural space.  It was also spreading peripherally along the L5 nerve root.,The patient tolerated the procedure well.  She did feel that the needle tip was placed at the epicenter of her pain, and this was improved with the placement of the anesthetic.,I will see the patient back in the office in the next few weeks to monitor response of the injection.
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DESCRIPTION: Left L5 transforaminal epidural steroid injection with 40 mg of Kenalog under fluoroscopic guidance.  The patient is a 78-year-old female with back pain referring into the left side.

pain management, transforaminal approach, epidural steroid injection, nerve root, needle tip, kenalog, transforaminal, fluoroscopic, guidance, foraminal, injection

This medical situation involves a standard procedure for pain management through a transforaminal epidural steroid injection, which is typically low to moderate risk when performed by experienced practitioners. Although the patient is elderly, which can increase general medical risk factors, there does not appear to be any immediate life-threatening risk associated with the procedure as it is described. The stakes might increase if there are complications such as infection or incorrect placement of the needle, but the procedure itself is routinely performed successfully. However, due to the patient's age and the nature of the procedure involving the spine, it is more significant than a very low-stakes situation.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Gastroenterology
Sample Name: CT Abdomen & Pelvis - 9

CT ABDOMEN WITH CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain with swelling at the site of the ileostomy.,TECHNIQUE:,  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.,CT ABDOMEN:  ,The liver, spleen, pancreas, adrenal glands, and kidneys are unremarkable.  Punctate calcifications in the gallbladder lumen likely represent a gallstone.,CT PELVIS:  ,Postsurgical changes of a left lower quadrant ileostomy are again seen.  There is no evidence for an obstruction.  A partial colectomy and diverting ileostomy is seen within the right lower quadrant.  The previously seen 3.4 cm subcutaneous fluid collection has resolved.  Within the left lower quadrant, a 3.4 cm x 2.5 cm loculated fluid collection has not significantly changed.  This is adjacent to the anastomosis site and a pelvic abscess cannot be excluded.  No obstruction is seen.  The appendix is not clearly visualized.  The urinary bladder is unremarkable.,IMPRESSION:,1.  Resolution of the previously seen subcutaneous fluid collection.,2.  Left pelvic 3.4 cm fluid collection has not significantly changed in size or appearance.  These findings may be due to a pelvic abscess.,3.  Right lower quadrant ileostomy has not significantly changed.,4.  Cholelithiasis.
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DESCRIPTION: Generalized abdominal pain with swelling at the site of the ileostomy.  CT abdomen with contrast and CT pelvis with contrast.  Axial CT images of the abdomen and pelvis were obtained utilizing 100 mL of Isovue-300.

gastroenterology, axial ct images, isovue-300, ct pelvis, ct abdomen, fluid collection, abdomen, obstruction, subcutaneous, abscess, pelvic, fluid, collection, pelvis, ileostomy, ct, isovue,

The CT scan reveals several findings: resolution of a previous fluid collection, a persistent left pelvic fluid collection that could be a pelvic abscess, and gallstones. The potential pelvic abscess is of particular concern as it can lead to serious complications if untreated, such as infection or sepsis. Managing this issue involves timely intervention to prevent such outcomes. The other findings are less immediately alarming but still require monitoring. Overall, the implications for the patient's health and the need for appropriate follow-up and possible intervention make this a high-stakes situation.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Cholecystectomy & Cholangiogram

PREOPERATIVE DIAGNOSIS:,  Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute gangrenous cholecystitis with cholelithiasis.,OPERATION PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,FINDINGS:  ,The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.,COMPLICATIONS:  ,None.,EBL: , Scant.,SPECIMEN REMOVED: , Gallbladder with stones.,DESCRIPTION OF PROCEDURE:  ,The patient was prepped and draped in the usual sterile fashion under general anesthesia.  A curvilinear incision was made below the umbilicus.  Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization.  Once this complete, insufflation was begun.  Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant.  Once all four ports were placed, the right upper quadrant was then explored.  The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis.  This was taken down using Bovie cautery to free up visualization of the gallbladder.  The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall.  Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area.  Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction.  At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed.  The cystic duct and cystic artery were serially clipped and transected.  The gallbladder was removed from the gallbladder fossa removing the entire gallbladder.  Adequate hemostasis with Bovie cautery was achieved.  The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port.  A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture.  Next, the right upper quadrant was copiously irrigated out using the suction irrigator.  Once this was complete, the additional ports were able to be removed.  The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion.  All skin incisions were injected using Marcaine 1/4 percent plain.  The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique.  The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition.
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DESCRIPTION: Laparoscopic cholecystectomy with cholangiogram.  Acute gangrenous cholecystitis with cholelithiasis.  The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.

gastroenterology, acute cholecystitis, cholangiogram, cholelithiasis, cholecystitis, gallbladder, gangrenous cholecystitis, bovie cautery, cystic duct, laparoscopic cholecystectomy, laparoscopic, cholecystectomy, cystic, duct,

The situation described involves a laparoscopic cholecystectomy performed on a patient diagnosed with acute gangrenous cholecystitis. Gangrenous cholecystitis indicates a severe form of inflammation that can lead to dangerous complications if not surgically treated timely. The surgery itself is risky due to the necrotic nature of the gallbladder and potential complications associated with removing it, such as damage to surrounding organs or bile ducts. However, the procedure was completed without complications and the patient was stable post-operation, which slightly reduces the stakes. Nonetheless, considering the nature of the condition and potential risks of surgery, this remains a high-stakes situation.


Medical Specialty: Urology
Sample Name: Circumcision & Chordee Release

PREOPERATIVE DIAGNOSES: , Phimosis and adhesions.,POSTOPERATIVE DIAGNOSES:  ,Phimosis and adhesions.,PROCEDURES PERFORMED: , Circumcision and release of ventral chordee.,ANESTHESIA:  ,Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.  The patient was given antibiotics preop.,BRIEF HISTORY: , This is a 43-year-old male who presented to us with significant phimosis, difficulty retracting the foreskin.  The patient had buried penis with significant obesity issues in the suprapubic area.  Options such as watchful waiting, continuation of slowly retracting the skin, applying betamethasone cream, and circumcision were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, and CVA risks were discussed.  The patient had discussed this issue with Dr Khan and had been approved to get off of the Plavix.  Consent had been obtained.  Risk of scarring, decrease in penile sensation, and unexpected complications were discussed.  The patient was told about removing the dressing tomorrow morning, okay to shower after 48 hours, etc.  Consent was obtained.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in supine position.  The patient was prepped and draped in usual sterile fashion.  Local MAC anesthesia was applied.  After draping, 17 mL of mixture of 0.25% Marcaine and 1% lidocaine plain were applied around the dorsal aspect of the penis for dorsal block.  The patient had significant phimosis and slight ventral chordee.  Using marking pen, the excess foreskin was marked off.  Using a knife, the ventral chordee was released.  The urethra was intact.  The excess foreskin was removed.  Hemostasis was obtained using electrocautery.  A 5-0 Monocryl stitches were used for 4 interrupted stitches and horizontal mattresses were done.  The patient tolerated the procedure well.  There was excellent hemostasis.  The penis was straight.  Vaseline gauze and Kerlix were applied.  The patient was brought to the recovery in stable condition.  Plan was for removal of the dressing tomorrow.  Okay to shower after 48 hours.
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DESCRIPTION: Circumcision and release of ventral chordee.

urology, phimosis, adhesions, release of ventral chordee, ventral chordee, circumcision, penis, chordee, foreskin,

The procedure described is a circumcision and chordee release in a 43-year-old patient with significant phimosis. While any surgical procedure carries risks such as anesthesia complications, bleeding, and infection, the document specifies that the estimated blood loss was minimal and the patient tolerated the procedure well. The patient was considered stable post-operation. The procedure was well-planned and involved standard surgical practices. Therefore, although it involves surgical intervention, it does not involve life-threatening conditions, rather addressing difficulty with foreskin retraction and ventral chordee, a condition affecting the curvature of the penis.


Medical Specialty: Consult - History and Phy.
Sample Name: Guillain-Barre Syndrome

CHIEF COMPLAINT: , Followup of hospital discharge for Guillain-Barre syndrome.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed woman with hypertension, diabetes mellitus, a silent stroke involving right basal ganglia who was in her usual state of baseline health until late June of 2006 when she had onset of blurred vision, diplopia, and possible weakness in the right greater than left arm and left-sided ptosis.  She was admitted to the hospital.  The MRI showed only an old right basal ganglion infarct.  She subsequently had a lumbar puncture, which showed increased protein, and an EMG/nerve conduction study performed by Dr. X on July 3rd, showed early signs of AIDP.  The patient was treated with intravenous gamma globulin and had some mild improvement in her symptoms.  Her vital capacities were normal during the hospitalization.  Her chest x-ray was negative for any acute process.  She was discharged to rehab from July 12, 2006 to July 20, 2006.  She made some progress in which she notes that her walking is definitely better.  However, she notes that she still has some problems with eye movement and her vision.  This is possibly her main problem.  She also reports tightness and pain in her mid back.,REVIEW OF SYSTEMS:,  Documented in the clinic note.  The patient has problems with diabetes, double vision, blurry vision, muscle pain, weakness, trouble walking, and headaches about two to three times per week.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  Diabetes mellitus.,3.  Stroke involving the right basal ganglion.,4.  Guillain-Barre syndrome diagnosed in June of 2006.,5.  Bilateral knee replacements.,6.  Total abdominal hysterectomy and cholecystectomy.,FAMILY HISTORY:,  Multiple family members have diabetes mellitus.,SOCIAL HISTORY:,  The patient is retired on disability due to her knee replacements.  She does not smoke, drink or use any illicit drugs.,MEDICATIONS:,  Percocet 5/325 mg 4-6 hours p.r.n., Neurontin 100 mg per day, insulin, Protonix 40 mg per day, Toprol-XL 50 mg q.d., Norvasc 10 mg q.d., glipizide ,10 mg q.d., fluticasone 50 mcg nasal spray, Lasix 20 mg b.i.d., and Zocor 1 mg q.d.,ALLERGIES: , No known drug allergies.,PHYSICAL EXAMINATION: , Blood pressure 122/74, heart rate 68, respiratory rate 16, and weight 228 pounds.  Pain scale 5/10.  Please see the written note for details.  General exam is benign other than mild obesity.  On neuro examination, mental status is normal.  Cranial nerves are significant for full visual fields and pupils are equal and reactive.  However, extraocular movements are very limited.  She has some adduction of the left eye and she has minimal upgaze of both eyes, but otherwise the eyes do not move.  Face is symmetric.  Sensation is intact.  Tongue and uvula are in midline.  Palate is elevated symmetrically.  Shoulder shrug is strong.  The patient's muscle exam shows normal bulk and tone throughout.  She has no weakness of the left upper extremity.  In the right upper extremity, she has only about 2/5 strength in the right shoulder, but is otherwise 5/5.  There is no drift or orbit.  Reflexes are absent throughout.  Sensory exam is intact to light touch, pinprick, vibration, and proprioception is normal.  There is no dysmetria.  Gait is somewhat limited possibly by her vision and possibly also by her balance problems.,PERTINENT DATA:,  As reviewed previously.,DISCUSSION: , This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant.  The patient has shown some improvement with IVIG and continues to show some gradual improvement.  I discussed with the patient the course of disease, which is often weeks to about a month or so of worsening followed by many months of gradual improvement.,I told her that it is possible she may not recover 100%, but that certainly there is still plenty of time for her to have additional recovery over what she has right now.  She is scheduled to see an ophthalmologist.  I think it is reasonable for close followup of her visual symptoms progress.  However, I certainly would not take any corrective measures at this point as I suspect her vision will improve gradually.,I discussed with the patient that with respect to her back pain certainly the Neurontin is relatively at low dose and this could be increased further.  I wanted her to start taking the Neurontin 300 mg per day and then 300 mg b.i.d. after one week.  She will call me in approximately three weeks' time to let me know how she is doing and if needed we will titrate up further.,She was apparently given some baclofen by her internist and I think this is not unreasonable.  I definitely hope to get her off the Percocet in the future.,IMPRESSION:,1.  Guillain-Barre Miller-Fisher variant.,2.  Hypertension.,3.  Diabetes mellitus.,4.  Stroke.,RECOMMENDATIONS:,1.  The patient is to start taking aspirin 162 mg per day.,2.  Followup with ophthalmology.,3.  Increase Neurontin to 300 mg per day x 1 week and then 300 mg b.i.d.,4.  Followup by phone in three to four weeks.,5.  Followup in this clinic in approximately two months' time.,6.  Call for any questions or problems.
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DESCRIPTION: This is a 62-year-old woman with hypertension, diabetes mellitus, prior stroke who has what sounds like Guillain-Barre syndrome, likely the Miller-Fisher variant.

The situation involves following up on a patient with Guillain-Barre Syndrome, specifically the Miller-Fisher variant, which can be a serious condition characterized by muscle weakness and, in some cases, respiratory issues. However, the patient is currently stable and showing gradual improvement with treatment, such as IVIG. The stakes are not life-threatening at this moment, as the patient is being monitored, and there are clear plans for follow-up and medication adjustments. The situation does not involve acute, life-threatening deterioration, but it requires attention due to the patient's complex medical history and current symptoms impacting quality of life.


Medical Specialty: Radiology
Sample Name: Right Foot Series

EXAM: , Right foot series.,REASON FOR EXAM:  ,Injury.,FINDINGS: , Three images of the right foot were obtained.  On the AP image only, there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal.  Also on a single image, there is a lucency seen in the lateral aspect of the calcaneus that is seen on the oblique image only.  Fractures in these bones cannot be completely excluded.  There is soft tissue swelling seen overlying the calcaneus within this region.,IMPRESSION: , Cannot exclude nondisplaced fractures in the lateral aspect of the calcaneus or at the base of the fourth and fifth metatarsals.  Recommend correlation with site of pain in addition to conservative management and followup imaging.  A phone call will be placed to the emergency room regarding these findings.
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DESCRIPTION: Right foot series after a foot injury.

Right foot series after a foot injury.

radiology, sclerosis, calcaneus, metatarsal, foot series

The findings from the right foot series indicate the possibility of nondisplaced fractures, which can potentially be serious as they involve the metatarsals and calcaneus. These require careful follow-up because if not managed properly, they can lead to complications like improper healing, chronic pain, or mobility issues. Additionally, the communication to the emergency room underlines the need for timely assessment and intervention. However, these conditions are typically manageable with appropriate medical care, and there is no immediate life-threatening risk. Thus, the situation is important but not critical.


Medical Specialty: Consult - History and Phy.
Sample Name: Intractable Epilepsy

CHIEF COMPLAINT:,  Intractable epilepsy, here for video EEG.,HISTORY OF PRESENT ILLNESS: , The patient is a 9-year-old male who has history of global developmental delay and infantile spasms.  Ultimately, imaging study shows an MRI with absent genu of the corpus callosum and thinning of the splenium of the corpus callosum, showing a pattern of cerebral dysgenesis.  He has had severe global developmental delay, and is nonverbal.  He can follow objects with his eyes, but has no ability to interact with his environment to any great degree.  He has noted if any purposeful use of the hands.  He has abnormal movements constantly, which are more choreiform and dystonic.  He has spastic quadriparesis, which is variable at times.  The patient is unable to sit or stand, and receives all his nutrition via G-tube.,The patient began having seizures in infancy presenting as infantile spasms.  I began seeing him at 20 months of age.  At that point, he had undergone workup in Seattle, Washington and then was seeing Dr. X, child neurologist in Mexico, who started Vigabatrin for infantile spasms.  The patient had benefit from this medication, and was doing well at that time with regard to that seizure type.  He initially was on phenobarbital, which failed to give him benefit.  He continued on phenobarbital; however, for a long period time thereafter.  The patient then began having more tonic seizures after his episodic spasms had subsided, and failed several medication trials including valproic acid, Topamax, and Zonegran at least briefly.  Upon starting Lamictal, he began to have benefit and then actually had 1-year seizure freedom before having an isolated seizure or 2.  Over the next 6 months to a year, he only had few further seizures, and was doing well in a general sense.  It was more recently that he began having new seizure events that have not responded to higher doses of Lamictal up to 15 mg/kg/day.  These events manifest as tonic spells with eye deviation and posturing.  Mother reports flexion of the upper extremities, extension with lower extremities.  During that time, he is not able to cry or say any sounds.  These events last from seconds to minutes, and occur at least multiple times per week.  There are times where he has none for a few days and other times where he has multiple days in a row with events.  He has another event manifesting as flexion of the upper extremities and extension lower extremities where he turns red and cries throughout.  He may vomit after these episodes, then seems to calm down.  It is unclear whether this is a seizure or whether the patient is still responsive.,MEDICATIONS:,  The patient's medications include Lamictal for a total of 200 mg twice a day.  It is a 150 mg tablet and 25 mg tablets.  He is on Zonegran using 25 mg capsules 2 capsules twice daily, and baclofen 10 mg three times day.  He has other medications including the Xopenex and Atrovent.,REVIEW OF SYSTEMS: , At this time is negative any fevers, nausea, vomiting, diarrhea, abdominal complaints, rashes, arthritis, or arthralgias.  No respiratory or cardiovascular complaints.  He has no change in his skills at this point.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a slender male who is microcephalic.  He has EEG electrodes in place and is on the video EEG at that time.,HEENT:  His oropharynx shows no lesions.,NECK:  Supple without adenopathy.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.,ABDOMEN:  Benign with G-tube in place.,EXTREMITIES:  Reveal no clubbing, cyanosis, or edema.,NEUROLOGICAL:  The patient is alert and has bilateral esotropia.  He is able to fix and follow objects briefly.  He is unable to reach for objects.  He exhibits constant choreiform movements when excited.  These are more prominent in the upper extremities and lower extremities.  He has some dystonic posture with flexion of the wrist and fingers bilaterally.  He also has plantar flexion at the ankles bilaterally.  His cranial nerves reveal that his pupils are equal, round, and reactive to light.  Extraocular movements are intact other than bilateral esotropia.  His face moves symmetrically.  Palate elevates in midline.  Hearing appears intact bilaterally.,Motor exam reveals dystonic and variable tone, overall there is mild in spasticity both upper and lower extremities as described above.  He has clonus at the ankles bilaterally, and some valgus contracture of the ankles.  His sensation is intact to light touch bilaterally.  Deep tendon reflexes are 2 to 3+ bilaterally.,IMPRESSION/PLAN: , This is a 9-year-old male with congenital brain malformation and intractable epilepsy.  He has microcephaly as well as dystonic cerebral palsy.  He had a re-emergence of seizures, which are difficult to classify, although some sound like tonic episodes and others are more concerning for non-epileptic phenomenon, such as discomfort.  He is admitted for video EEG to hopefully capture both of these episodes and further clarify the seizure type or types.  He will remain hospitalized for probably at least 48 hours to 72 hours.  He could be discharged sooner if multiple events are captured.  His medications, we will continue his current dose of Zonegran and Lamictal for now.  Both of these medications are very long acting, discontinuing them while in the hospital may simply result in severe seizures after discharge.
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DESCRIPTION: Intractable epilepsy, here for video EEG.

consult - history and phy., brain malformation, congenital, intractable epilepsy, global developmental delay, video eeg, seizures, intractable, eeg,

The scenario involves a young patient with a severe neurological condition characterized by intractable epilepsy, developmental delays, and cerebral dysgenesis, which necessitates careful monitoring, specialized medical evaluation, and management. The stakes are high due to the patient's complex medical history, the risk of severe seizures, and the need for precise diagnosis through video EEG monitoring to adjust treatment effectively. The outcome will significantly impact his health and quality of life.


Medical Specialty: Urology
Sample Name: Orchiopexy & Herniorrhaphy - 1

PREOPERATIVE DIAGNOSIS:,  Right undescended testicle.,POSTOPERATIVE DIAGNOSIS:,  Right undescended testicle.,OPERATIONS:,1.  Right orchiopexy.,2.  Right herniorrhaphy.,ANESTHESIA: , LMA.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Sac.,BRIEF HISTORY: , This is a 10-year-old male who presented to us with his mom with consultation from Craig Connor at Cottonwood with right undescended testis.  The patient and mother had seen the testicle in the right hemiscrotum in the past, but the testicle seemed to be sliding.  The testis was identified right at the external inguinal ring.  The testis was unable to be brought down into the scrotal sac.  The patient could have had sliding testicle in the past and now the testis has become undescended as the child has grown.  Options such as watchful waiting and wait for puberty to stimulate the descent of the testicle, HCG stimulation, orchiopexy were discussed.  Risk of anesthesia, bleeding, infection, pain, hernia, etc. were discussed.  The patient and parents understood and wanted to proceed with right orchiopexy and herniorrhaphy.,PROCEDURE IN DETAIL: , The patient was brought to the OR, anesthesia was applied.  The patient was placed in supine position.  The patient was prepped and draped in the inguinal and scrotal area.  After the patient was prepped and draped, an inguinal incision was made on the right side about 1 cm away for the anterior superior iliac spine going towards the external ring over the inguinal canal.  The incision came through the subcutaneous tissue and external oblique fascia was identified.  The external oblique fascia was opened sharply and was taken all the way down towards the external ring.  The ilioinguinal nerve was identified right underneath the external oblique fascia, which was preserved and attention was drawn throughout the entire case to ensure that it was not under any tension or pinched or got hooked in the suture.  After dissecting proximally, the testis was identified in the distal end of the inguinal canal.  The testis was pulled up.  The cremasteric muscle was divided and dissection was carried all the way up to the internal inguinal ring.  There was very small hernia, which was removed and was tied at the base.  PDS suture was used to tie this hernia sac all the way up to the base.  There was a Y right at the vas and cord indicating there was enough length into the scrotal sac.  The testis was easily brought down into the scrotal sac.  One centimeter superior scrotal incision was made and a Dartos pouch was created.  The testicle was brought down into the pouch and was placed into the pouch.  Careful attention was done to ensure that there was no torsion of the cord.  The vas was medial all the way throughout and the cord was lateral all the way throughout.  The epididymis was in the posterolateral location.  The testicle was pexed using 4-0 Vicryl into the scrotal sac.  Skin was closed using 5-0 Monocryl.  The external oblique fascia was closed using 2-0 PDS.  Attention was drawn to re-create the external inguinal ring.  A small finger was easily placed in the external inguinal ring to ensure that there was no tightening of the cord.  Marcaine 0.25% was applied, about 15 mL worth of this was applied for local anesthesia.  After closing the external oblique fascia, the Scarpa was brought together using 4-0 Vicryl and the skin was closed using 5-0 Monocryl in subcuticular fashion.  Dermabond and Steri-Strips were applied.,The patient was brought to recovery room in stable condition at the end of the procedure.,Please note that the testicle was viable.  It was smaller than the other side, probably by 50%.  There were no palpable testicular masses.  Plan was for the patient to follow up with us in about 1 month.  The patient was told not to do any heavy lifting for at least 3 months, okay to shower in 48 hours.  No tub bath for 2 months.  The patient and family understood all the instructions.
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DESCRIPTION: Right undescended testicle.  Orchiopexy & Herniorrhaphy.

urology, undescended testicle, orchiopexy & herniorrhaphy, external oblique fascia, inguinal ring, scrotal sac, oblique fascia, testicle, herniorrhaphy, orchiopexy, inguinal

The situation involves a surgical procedure for a 10-year-old male with a right undescended testicle, requiring orchiopexy and herniorrhaphy. Although the procedure is generally straightforward and commonly performed, any surgery involving anesthesia inherently carries some risks, like anesthesia complications, bleeding, infection, and potential surgery-specific complications. However, there was minimal blood loss and the patient was stable post-procedure. The condition was not life-threatening, and there were plans for follow-up care to ensure recovery. Therefore, while there are some risks involved, this situation is not extremely high-stakes.


Medical Specialty: Gastroenterology
Sample Name: Status Post Liver Transplant

HISTORY OF PRESENT ILLNESS:,  This is a 10-year-old who was found with biliary atresia and underwent a Kasai procedure and did not really well because she ended up having a liver transplant.  The patient did well after the liver transplant and the only problems started:,1.  History of food allergies.,2.  History of dental cavities.,At this time, the patient came for a followup and is complaining of a left upper molar pain.  There are no other complaints.,DIET: , Lactose-limited diet.,MEDICATIONS: , Please see the MRC form.,ALLERGIES: , There are no allergies.,SOCIAL HISTORY:,  The patient lives with the parents in Lindsay, California and has a good environment.,FAMILY HISTORY: , Negative for gastrointestinal illness except that a sibling has ulcerative colitis.,REVIEW OF SYSTEMS: , The system review was only positive for molar pain, but rest of the 13 review of systems were negative to date.,PHYSICAL EXAMINATION:  ,MEASUREMENTS:  Height 135 cm and weight 28.1 kg.,VITAL SIGNS:  Temperature 98.9 and blood pressure 105/57.,GENERAL:  A well-developed, well-nourished child in no acute distress.,HEENT:  Atraumatic and normocephalic.  The pupils are equal, round, and reactive to light.  Full EOMs.  The conjunctivae and sclerae are clear.  The TMs show normal landmarks.  The nasal mucosa is pink and moist.  The teeth and gums are in good condition.  The pharynx is clear.,NECK:  Supple, without thyromegaly and without masses.,LYMPHATIC:  No adenopathy.,LUNGS:  Clear to auscultation, with no retractions.,CORONARY:  Regular rhythm without murmur.  S1 and S2 are normal.  The pulses are full and symmetrical bilaterally.,ABDOMEN:  Normal bowel sounds.  No hepatosplenomegaly, no masses, and no tenderness.,GENITALIA:  Normal female by inspection.,SKIN:  No unusual lesions.,BACK:  No scoliosis, hairy patch, lipoma, or sacral dimple.,EXTREMITIES:  No cyanosis, clubbing, or edema.,CENTRAL NERVOUS SYSTEM:  Developmentally appropriate for age.  DTRs are 2+ and symmetrical.  The toes are downgoing bilaterally.  Motor and sensory without asymmetry.  Cranial nerves II through XII are grossly intact.,LABORATORY DATA:,  Laboratory data from 12/30/2007 tacrolimus 3.1 and negative Epstein-Barr, CMV was not detected.,FINAL IMPRESSION:,  This is a 10-year-old with history of:,1.  Biliary atresia.,2.  Status post orthotopic liver transplantation.,3.  Dental cavities.,4.  Food allergies.,5.  History of urinary tract infections.,PLAN: , Our plan would be to continue with the medications as follows:,1.  Prograf 0.5 mg p.o. b.i.d.,2.  Valganciclovir 420 mg p.o. b.i.d.,3.  Labs every 2 to 3 months.,4.  To return to clinic in 4 months.,5.  To refer this patient to a pediatric dentist for assessment of the dental cavities.
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DESCRIPTION: A 10-year-old with a history of biliary atresia and status post orthotopic liver transplantation.

The scenario involves a 10-year-old patient with a history of a significant medical condition, specifically a liver transplant following biliary atresia. While the patient is currently stable and the primary complaint is a dental issue, the background of having undergone a liver transplant both increases the complexity and raises the stakes of any medical follow-up due to the risks associated with transplant rejection and immunosuppression. Although the immediate concern of molar pain is not life-threatening, maintaining the overall health of a transplanted organ is inherently high-stakes. Regular follow-ups and medication adherence are crucial to prevent rejection and other complications.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Slipped Capital Femoral Epiphysis (SCFE)

EXAM: , Two views of the pelvis.,HISTORY:,  This is a patient post-surgery, 2-1/2 months.  The patient has a history of slipped capital femoral epiphysis (SCFE) bilaterally.,TECHNIQUE: , Frontal and lateral views of the hip and pelvis were evaluated and correlated with the prior film dated MM/DD/YYYY.  Lateral view of the right hip was evaluated.,FINDINGS:,  Frontal view of the pelvis and a lateral view of the right hip were evaluated and correlated with the patient's most recent priors dated MM/DD/YYYY.  Current films reveal stable appearing post-surgical changes.  Again demonstrated is a single intramedullary screw across the left femoral neck and head.  There are 2 intramedullary screws through the greater trochanter of the right femur.  There is a lucency along the previous screw track extending into the right femoral head and neck.  There has been interval removal of cutaneous staples and/or surgical clips.  These were previously seen along the lateral aspect of the right hip joint.,Deformity related to the previously described slipped capital femoral epiphysis is again seen.,IMPRESSION:,1.  Stable-appearing right hip joint status-post pinning.,2.  Interval removal of skin staples as described above.
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DESCRIPTION: Frontal and lateral views of the hip and pelvis.

pediatrics - neonatal, scfe, frontal and lateral views, slipped capital femoral epiphysis, lateral views, slipped, capital, epiphysis, frontal, pelvis, femoral, hip

The situation involves a follow-up examination post-surgery for a pediatric patient with a prior condition of slipped capital femoral epiphysis (SCFE). This is a standard medical follow-up to assess the stability of the surgical intervention and healing process. While important for the patient's recovery and future mobility, it does not represent an immediate life-threatening scenario or an urgent decision-making moment that might classify it as high-stakes. The surgery is already completed, and the report indicates stability in the post-surgical state.


Medical Specialty: Radiology
Sample Name: Echocardiogram - 1

EXAM:,  Echocardiogram.,INTERPRETATION: , Echocardiogram was performed including 2-D and M-mode imaging, Doppler analysis continuous wave and pulse echo outflow velocity mapping was all seen in M-mode.  Cardiac chamber dimensions, left atrial enlargement 4.4 cm.  Left ventricle, right ventricle, and right atrium are grossly normal.  LV wall thickness and wall motion appeared normal.  LV ejection fraction is estimated at 65%.  Aortic root and cardiac valves appeared normal.  No evidence of pericardial effusion.  No evidence of intracardiac mass or thrombus.  Doppler analysis outflow velocity through the aortic valve normal, inflow velocities through the mitral valve are normal.  There is mild tricuspid regurgitation.  Calculated pulmonary systolic pressure 42 mmHg.,ECHOCARDIOGRAPHIC DIAGNOSES:,1.  LV Ejection fraction, estimated at 65%.,2.  Mild left atrial enlargement.,3.  Mild tricuspid regurgitation.,4.  Mildly elevated pulmonary systolic pressure.
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DESCRIPTION: Echocardiogram was performed including 2-D and M-mode imaging.

radiology, lv ejection fraction, ejection fraction, tricuspid regurgitation, systolic pressure, valves, atrial, echocardiogram,

The echocardiogram results indicate some mild abnormalities, such as mild left atrial enlargement, mild tricuspid regurgitation, and mildly elevated pulmonary systolic pressure. However, overall heart function, as indicated by the left ventricular ejection fraction, is normal at 65%. These findings may require monitoring and potential treatment adjustments, but they typically don't suggest immediate high-stakes concerns like acute heart failure or severe valvular disease. Hence, while the situation requires medical attention and follow-up, it is not immediately life-threatening.


Medical Specialty: Orthopedic
Sample Name: Pectoralis Tendon Repair

PREOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,POSTOPERATIVE DIAGNOSIS: , Right pectoralis major tendon rupture.,OPERATION PERFORMED: , Open repair of right pectoralis major tendon.,ANESTHESIA:,  General with an interscalene block.,COMPLICATIONS:,  None.,Needle and sponge counts were done and correct.,INDICATION FOR OPERATION:  ,The patient is a 26-year-old right hand dominant male who works in sales, who was performing heavy bench press exercises when he felt a tearing burning pain severe in his right shoulder.  The patient presented with mild bruising over the proximal arm of the right side with x-ray showing no fracture.  Over concerns for pectoralis tendon tear, he was sent for MRI evaluation where a complete rupture of a portion of the pectoralis major tendon was noted.  Due to the patient's young age and active lifestyle surgical treatment was recommended in order to obtain best result.  The risks and benefits of the procedure were discussed in detail with the patient including, but not limited to scarring, infection, damage to blood vessels and nerves, re-rupture, need further surgery, loss of range of motion, inability to return to heavy activity such as weight lifting, complex usual pain syndrome, and deep vein thrombosis as well as anesthetic risks.  Understanding all risks and benefits, the patient desires to proceed with surgery as planned.,FINDINGS:,1.  Following deltopectoral approach to the right shoulder, the pectoralis major tendon was encountered.  The clavicular head was noted to be intact.  There was noted to be complete rupture of the sternal head of the pectoralis major tendon with an oblique-type tear having some remaining cuff on the humerus and some tendon attached to the retracted portion.,2.  Following freeing of adhesions using tracks and sutures, the pectoralis major tendon was able to reapproximated to its insertion site on the humerus just lateral to the biceps.,3.  A soft tissue repair was performed with #5 FiberWire suture and a single suture anchor of 5 x 5 bioabsorbable anchor was placed in order to decrease tension at the repair site.  Following repair of soft tissue and using the bone anchor, there was noted to be good apposition of the tendon with edges and a solid repair.,OPERATIVE REPORT IN DETAIL: , The patient was identified in the preop holding area.  His right shoulder was identified, marked his appropriate surgical site after verification with the patient.  He was then taken to the operating room where he was transferred to the operative table in supine position and placed under general anesthesia by anesthesiology team.  He then received prophylactic antibiotics.  A time-out was then undertaken verifying the correct patient, extremity, surgery performed, administration of antibiotics, and the availability of equipment.  At this point, the patient was placed to a modified beech chair position with care taken to ensure all appropriate pressure points were padded and there was no pressure over the eyes.  The right upper extremity was then prepped and draped in the usual sterile fashion.  Preoperative markings were still visible at this point.  A deltopectoral incision was made utilizing the inferior portion.  Dissection was carried down.  The deltoid was retracted laterally.  The clavicular head of the pectoralis major was noted to be intact with the absence of the sternal insertion.  There was a small cuff of tissue left on the proximal humerus associated with the clavicular head.  Gentle probing medially revealed the end of the sternal retracted portion, traction sutures of #5 Ethibond were used in this to allow for retraction and freeing from light adhesion.  This allowed reapproximation of the retracted tendon to the tendon stump.  At this point, a repair using #5 FiberWire was then performed of the pectoralis major tendon back to stump on the proximal humerus noting good apposition of the tendon edges and no gapping of the repair site.  At this point, a single metal suture anchor was attempted to be implanted just lateral to the insertion of the pectoralis in order to remove tension off the repair site; however, the inserted device attached to the metal anchor broke during insertion due to significant hardness of the bone.  For this reason, the starting hole was tapped and a 5x5 bioabsorbable anchor was placed, doubly loaded.  The sutures were then weaved through the lateral aspect of the torn tendon and a modified Krackow type performed and sutured thereby relieving tension off the soft tissue repair.  At this point, there was noted to be excellent apposition of the soft tissue ends and a solid repair to gentle manipulation.  Aggressive external rotation was not performed.  The wound was then copiously irrigated.  The cephalic vein was not injured during the case.  The skin was then closed using a 2-0 Vicryl followed by a 3-0 subcuticular Prolene suture with Steri-Strips.  Sterile dressing was then placed.  Anesthesia was then performed, interscalene block.  The patient was then awakened from anesthesia and transported to postanesthesia care in stable condition in a shoulder immobilizer with the arm adducted and internally rotated.,Plan for this patient, the patient will remain in the shoulder immobilizer until followup visit in approximately 10 days.  We will then start a gentle Codman type exercises and having limited motion until the 4-6 week point based on the patient's progression.
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DESCRIPTION: Open repair of right pectoralis major tendon.   Right pectoralis major tendon rupture.  On MRI evaluation, a complete rupture of a portion of the pectoralis major tendon was noted.

orthopedic, tendon rupture, interscalene block, pectoralis major tendon rupture, pectoralis major tendon, repair, pectoralis, interscalene, tendon, rupture, sutures,

The pectoralis tendon repair surgery describes a procedure conducted to repair a rupture of the pectoralis major tendon in a young, active individual. Although the repair is described as a routine surgical orthopedic procedure, the stakes are moderately high due to potential risks such as infection, damage to blood vessels and nerves, and re-rupture. However, the procedure is elective and was performed without complications. The young patient’s lifestyle and occupation add some urgency to a complete recovery, but given the absence of complications and clear postoperative care plan, the stakes remain moderate rather than extremely high. It is a serious medical procedure, but not life-threatening or highly complex in the realm of surgeries.


Medical Specialty: General Medicine
Sample Name: Sepsis - Consult

REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.
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DESCRIPTION: Sepsis.  The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.

The patient is an elderly male with a complex medical history and a current diagnosis of sepsis, which is a severe and life-threatening condition. The presence of an obstruction, bilateral hydronephrosis, and hydroureter further complicates the situation. Sepsis can lead to septic shock and organ failure if not treated promptly and effectively. Given the patient's age, dementia, and other health issues, his ability to respond to treatment may be compromised. These factors make the situation high-stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Progress Note - Liver Cirrhosis

HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old Hispanic male who was seen initially in the office February 15, 2006, with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.  The patient at that time stated that he had established diagnosis of liver cirrhosis.  Since the last visit the patient was asked to sign a lease of information form and we sent request for information from the doctor the patient saw before, Dr. X in Las Cruces and his primary care physician in Silver City, and unfortunately we did not get any information from anybody.  Also the patient had admission in Gila Medical Center with epigastric pain, diarrhea, and confusion.  He spent 3 days in the hospital.  He was followed by Dr. X and unfortunately we also do not have the information of what was wrong with the patient.  From the patient's report he was diagnosed with some kind of viral infection.  At the time of admission he had a lot of epigastric pain, nausea, vomiting, fever, and chills.,PHYSICAL EXAMINATION,VITAL SIGNS:  Weight 107, height 6 feet 1 inch, blood pressure 128/67, heart rate 74, saturation 98%; pain is 3/10 with localization of the pain in the epigastric area.,HEENT:  PERRLA.  EOM intact.  Oropharynx is clear of lesions.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.,LUNGS:  Clear to auscultation and percussion bilateral.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs, rubs, or gallops.,ABDOMEN:  Not tender, not distended.  Splenomegaly about 4 cm under the costal margin.  No hepatomegaly.  Bowel sounds present.,MUSCULOSKELETAL:  No cyanosis, no clubbing, no pitting edema.,NEUROLOGIC:  Nonfocal.  No asterixis.  No costovertebral tenderness.,PSYCHE:  The patient is oriented x4, alert and cooperative.,LABORATORY DATA: , We were able to collect lab results from Medical Center; we got only CMP from the hospital which showed glucose level 79, BUN 9, creatinine 0.6, sodium 136, potassium 3.5, chloride 104, CO2 23.7, calcium 7.3, total protein 5.9, albumin 2.5, total bilirubin 5.63.  His AST 56, ALT 37, alkaline phosphatase 165, and his ammonia level was 53.  We do not have any other results back.  No hepatitis panels.  No alpha-fetoprotein level.  The patient told me today that he also got an ultrasound of the abdomen and the result was not impressive, but we do not have this result despite calling medical records in the hospital to release this information.,ASSESSMENT AND PLAN:,  The patient is a 55-year-old with established diagnosis of liver cirrhosis, unknown cause.,1.  Epigastric pain.  The patient had chronic pain syndrome, he had multiple back surgeries, and he has taken opiate for a prolonged period of time.  In the office twice the patient did not have any abdominal pain on physical exam.  His pain does not sound like obstruction of common bile duct and he had these episodes of abdominal pain almost continuously.  He probably requires increased level of pain control with increased dose of opiates, which should be addressed with his primary care physician.,2.  End-stage liver disease.  Of course, we need to find out the cause of the liver cirrhosis.  We do not have hepatitis panel yet and we do not have information about the liver biopsy which was performed before.  We do not have any information of any type of investigation in the past.  Again, patient was seen by gastroenterologist already in Las Cruces, Dr. X.  The patient was advised to contact Dr. X by himself to convince him to send available information because we already send release information form signed by the patient without any result.  It will be not reasonable to repeat unnecessary tests in that point in time.,We are waiting for the hepatitis panel and alpha-fetoprotein level.  We will also need to get information about ultrasound which was done in Gila Medical Center, but obviously no tumor was found on this exam of the liver.  We have to figure out hepatitis status for another reason if he needs vaccination against hepatitis A and B.  Until now we do not know exactly what the cause of the patient's end-stage liver disease is and my differential diagnosis probably is hepatitis C.  The patient denied any excessive alcohol intake, but I could not preclude alcohol-related liver cirrhosis also.  We will need to look for nuclear antibody if it is not done before.  PSC is extremely unlikely but possible.  Wilson disease also possible diagnosis but again, we first have to figure out if these tests were done for the patient or not.  Alpha1-antitrypsin deficiency will be extremely unlikely because the patient has no lung problem.  On his end-stage liver disease we already know that he had low platelet count splenomegaly.  We know that his bilirubin is elevated and albumin is very low.  I suspect that at the time of admission to the hospital the patient presented with encephalopathy.  We do not know if INR was checked to look for coagulopathy.  The patient had an EGD in 2005 as well as colonoscopy in Silver City.  We have to have this result to evaluate if the patient had any varices and if he needs any intervention for that.,At this point in time, I recommended the patient to continue to take lactulose 50 mL 3 times daily.  The patient tolerated it well; no diarrhea at this point in time.  I also recommended for him to contact his primary care physician for increased dose of opiates for him.  As a primary prophylaxis of GI bleeding in patient with end-stage liver disease we will try to use Inderal.  The patient got a prescription for 10 mg pills.  He will take 10 mg twice daily and we will gradually increase his dose until his heart rate will drop to 25% from 75% to probably 60-58.  The patient was educated how to use Inderal and he was explained why we decided to use this medication.  The patient will hold this medication if he is orthostatic or bradycardic.,Again, the patient and his wife were advised to contact all offices they have seen before to get information about what tests were already done and if on the next visit in 2 weeks we still do not have any information we will need to repeat all these tests I mentioned above.,We also discussed nutrition issues.  The patient was provided information that his protein intake is supposed to be about 25 g per day.  He was advised not to over-eat protein and advised not to starve.  He also was advised to stay away from alcohol.  His next visit is in 2 weeks with all results available.
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DESCRIPTION: Patient seen initially with epigastric and right upper quadrant abdominal pain, nausea, dizziness, and bloating.

soap / chart / progress notes, abdominal pain, nausea, dizziness, liver disease, epigastric pain, liver cirrhosis, liver, abdominal, cirrhosis, epigastric, hepatitis,

The situation described involves a patient with potential end-stage liver disease, which can be life-threatening and requires careful and timely medical management. The note suggests a complex medical history with difficulties in acquiring past medical records and determining the exact cause of liver cirrhosis. Liver disease can lead to serious complications like liver failure, bleeding, and encephalopathy if not managed properly. The patient's report indicates a need for medication adjustment and further diagnostic work-up to prevent worsening of the condition. Given the potentially severe nature of liver cirrhosis and the challenges in managing this case due to missing information, this is considered a high-stakes medical situation.


Medical Specialty: Letters
Sample Name: Pediatric - Letter

Sample Address,RE:  Sample Patient,Dear Doctor:,We had the pleasure of seeing Abc and his mother in the clinic today.  As you certainly know, he is now a 9-month-old male product of a twin gestation complicated by some very mild prematurity.  He has been having problems with wheezing, cough and shortness of breath over the last several months.  You and your partners have treated him aggressively with inhaled steroids and bronchodilator.  Despite this, however; he has had persistent problems with a cough and has been more recently started on both a short burst of prednisolone as well as a more prolonged alternating day course.  ,Although there is no smoke exposure there is a significant family history with both Abc's father and uncle having problems with asthma as well as his older sister.  The parents now maintain separate households and there has been a question about the consistency of his medication administration at his father's house.  ,On exam today, Abc had some scattered rhonchi which cleared with coughing but was otherwise healthy.  ,We spent the majority of our 45-minute just reviewing basic principles of asthma management and I believe that Abc's mother is fairly well versed in this.  I think the most important thing to realize is that Abc probably does have fairly severe childhood asthma and fortunately has avoided hospitalization.  ,I think it would be prudent to continue his alternate day steroids until he is completely symptom free on the days off steroids but it would be reasonable to continue to wean him down to as low as 1.5 milligrams (0.5 milliliters on alternate days).  I have encouraged his mother to contact our office so that we can answer questions if necessary by phone.,Thanks so much for allowing us to be involved in his care.  ,Sincerely,
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DESCRIPTION: 9-month-old male product of a twin gestation complicated by some very mild prematurity having problems with wheezing, cough and shortness of breath over the last several months.

letters, gestation, bronchodilator, childhood, childhood asthma, cough, father, healthy, letter, mother, pediatric, prematurity, shortness of breath, sister, wheezing, wheezing cough, asthma,

The letter describes a case of a 9-month-old male with persistent asthma symptoms and medication compliance issues due to separate parenting households. While asthma in young children and medication compliance are important medical concerns requiring careful management, this scenario does not currently indicate an immediate high-risk or life-threatening situation, as the child has fortunately avoided hospitalization and the management plan is in place.


Medical Specialty: Neurology
Sample Name: EMG/Nerve Conduction Study - 8

REFERRING DIAGNOSIS: , Motor neuron disease.,PERTINENT HISTORY AND EXAMINATION:,  Briefly, the patient is an 83-year-old woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.,SUMMARY:  ,The right median sensory response showed a borderline normal amplitude for age with mild slowing of conduction velocity.  The right ulnar sensory amplitude was reduced with slowing of the conduction velocity.  The right radial sensory amplitude was reduced with slowing of the conduction velocity.  The right sural and left sural sensory responses were absent.  The right median motor response showed a prolonged distal latency across the wrist, with proximal slowing.  The distal amplitude was very reduced, and there was a reduction with proximal stimulation.  The right ulnar motor amplitude was borderline normal, with slowing of the conduction velocity across the elbow.  The right common peroneal motor response showed a decreased amplitude when recorded from the EDB, with mild slowing of the proximal conduction velocity across the knee.  The right tibial motor response showed a reduced amplitude with prolongation of the distal latency.  The left common peroneal response recorded from the EDB showed a decreased amplitude with mild distal slowing.  The left tibial motor response showed a decreased amplitude with a borderline normal distal latency.  The minimum F-wave latencies were normal with the exception of a mild prolongation of the ulnar F-wave latency, and the tibial F-wave latency as indicated above.  With repetitive nerve stimulation, there was no significant decrement noted in either the right nasalis or the right trapezius muscles.  Concentric needle EMG studies were performed in the right lower extremity, right upper extremity, thoracic paraspinals, and in the tongue.  There was evidence of increased insertional activity in the right tibialis anterior muscle, with evidence of fasciculations noted in several lower and upper extremity muscles and in the tongue.  In addition, there was evidence of increased amplitude, long duration and polyphasic motor units with a decreased recruitment noted in most muscles tested as indicated in the table above.,INTERPRETATION: , Abnormal electrodiagnostic study.  There is electrodiagnostic evidence of a disorder of the anterior motor neurons affecting at least four segments.  There is also evidence of a more generalized neuropathy that seems to be present in both the upper and lower extremities.  There is also evidence of a right median mononeuropathy at the wrist and a right ulnar neuropathy at the elbow.  Even despite the patient's age, the decrease in sensory responses is concerning, and makes it difficult to be certain about the diagnosis of motor neuron disease.  However, the overall changes on the needle EMG would be consistent with a diagnosis of motor neuron disease.  The patient will return for further evaluation.
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DESCRIPTION: A woman with a history of progression of dysphagia for the past year, dysarthria, weakness of her right arm, cramps in her legs, and now with progressive weakness in her upper extremities.  Abnormal electrodiagnostic study.

neurology, electrodiagnostic study, electrodiagnostic, edb, latency, nerve conduction study, emg, motor neuron disease, distal latency, motor response, motor, amplitude, conduction

This situation is high-stakes due to the patient's age, symptoms, and the potential diagnosis of a motor neuron disease, which can be life-threatening and significantly impact quality of life. The electrodiagnostic findings suggest a serious and progressive condition that requires careful monitoring and management. Moreover, the patient's difficulties with swallowing and speaking (dysphagia and dysarthria) along with progressive weakness highlight the urgency and critical nature of the medical assessment and intervention required.


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

Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Prostate Adenocarcinoma - 3

PHYSICAL EXAMINATION: , The patient is a 63-year-old executive who was seen by his physician for a company physical.  He stated that he was in excellent health and led an active life.  His physical examination was normal for a man of his age.  Chest x-ray and chemical screening blood work were within normal limits.  His PSA was elevated.,IMAGING:,Chest x-ray:  Normal.,CT scan of abdomen and pelvis:  No abnormalities.,LABORATORY:,  PSA 14.6.,PROCEDURES: , Ultrasound guided sextant biopsy of prostate:  Digital rectal exam performed at the time of the biopsy showed a 1+ enlarged prostate with normal seminal vesicles.,PATHOLOGY:  ,Prostate biopsy:  Left apex:  adenocarcinoma, moderately differentiated, Gleason's score 3 + 4 = 7/10.  Maximum linear extent in apex of tumor was 6 mm.  Left mid region prostate:  moderately differentiated adenocarcinoma, Gleason's 3 + 2 = 5/10.  Left base, right apex, and right mid-region and right base:  negative for carcinoma.,TREATMENT:,  The patient opted for low dose rate interstitial prostatic implants of I-125.  It was performed as an outpatient on 8/10.
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DESCRIPTION: Moderately differentiated adenocarcinoma, 1+ enlarged prostate with normal seminal vesicles.

soap / chart / progress notes, sextant biopsy, vesicles, seminal, apex, interstitial prostatic implants, moderately differentiated adenocarcinoma, normal seminal vesicles, enlarged prostate, gleason's, moderately, differentiated, prostate, adenocarcinoma

The situation involves a diagnosis of prostate adenocarcinoma, where the patient has elevated PSA levels and a biopsy showing moderately differentiated cancer. This is a serious medical condition, but not immediately life-threatening due to its early stage (Gleason score suggests a lower-grade tumor). The treatment has been defined and is underway, implying a structured medical plan. The stakes are relatively high because it involves cancer, but given the moderate differentiation and existing treatment plan, it is not the most critical stage of cancer management.


Medical Specialty: Emergency Room Reports
Sample Name: Acute Inferior Myocardial Infarction

CHIEF COMPLAINT: , Chest pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 40-year-old white male who presents with a chief complaint of "chest pain".,The patient is diabetic and has a prior history of coronary artery disease.  The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent.  The severity of the pain has progressively increased.  He describes the pain as a sharp and heavy pain which radiates to his neck & left arm.  He ranks the pain a 7 on a scale of 1-10.  He admits some shortness of breath & diaphoresis.  He states that he has had nausea & 3 episodes of vomiting tonight.  He denies any fever or chills.  He admits prior episodes of similar pain prior to his PTCA in 1995.  He states the pain is somewhat worse with walking and seems to be relieved with rest.  There is no change in pain with positioning.  He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain.  The patient ranks his present pain a 4 on a scale of 1-10.  The most recent episode of pain has lasted one-hour.,The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,REVIEW OF SYSTEMS:,  All other systems reviewed & are negative.,PAST MEDICAL HISTORY:,  Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC.,SOCIAL HISTORY: , Denies alcohol or drugs.  Smokes 2 packs of cigarettes per day.  Works as a banker.,FAMILY HISTORY: , Positive for coronary artery disease (father & brother).,MEDICATIONS: , Aspirin 81 milligrams QDay.  Humulin N. insulin 50 units in a.m.  HCTZ 50 mg QDay.  Nitroglycerin 1/150 sublingually PRN chest pain.,ALLERGIES: , Penicillin.,PHYSICAL EXAM: , The patient is a 40-year-old white male.,General:  The patient is moderately obese but he is otherwise well developed & well nourished.  He appears in moderate discomfort but there is no evidence of distress.  He is alert, and oriented to person place and circumstance.  There is no evidence of respiratory distress.  The patient ambulates
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DESCRIPTION: Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction.

The scenario involves a 40-year-old male with chest pain and a history of coronary artery disease, diabetes, and other risk factors. The presentation of symptoms such as radiating chest pain, shortness of breath, and diaphoresis, combined with partial relief from nitroglycerin, strongly suggests an acute myocardial infarction (heart attack). This condition requires immediate medical attention and poses a significant risk to the patient's health and survival if not managed promptly. Thus, it's considered a high-stakes medical emergency.


Medical Specialty: Orthopedic
Sample Name: AC Separation Revision & Hardware Removal

PREOPERATIVE DIAGNOSIS:,  Right AC separation.,POSTOPERATIVE DIAGNOSIS:,  Right AC separation.,PROCEDURES:,  Removal of the hardware and revision of right AC separation.,ANESTHESIA:,  General.,BLOOD LOSS:,  100 cc.,COMPLICATIONS:,  None.,FINDINGS: , Loose hardware with superior translation of the clavicle implants.,IMPLANTS: , Arthrex bioabsorbable tenodesis screws.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion.  The incision was reopened and the hardware was removed without difficulty.  The AC joint was inspected and reduced.  An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle.  And two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability.  This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy.  The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied.  He was awakened from anesthesia and taken to recovery room in a stable condition.,Final needle and instrument counts were correct.
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DESCRIPTION: Removal of the hardware and revision of right AC separation.  Loose hardware with superior translation of the clavicle implants.  Arthrex bioabsorbable tenodesis screws.

orthopedic, loose hardware, superior translation, clavicle implants, ac separation, removal of the hardware, arthrex bioabsorbable tenodesis screws, bioabsorbable tenodesis, tenodesis screws, translation, implants, bioabsorbable, tenodesis, clavicle, separation, hardware

The procedure described involves surgery to address an AC separation by removing hardware and performing a revision. While the procedure is not uncommon and the preoperative and postoperative diagnoses were the same, surgeries inherently carry some degree of risk due to the use of general anesthesia and potential complications during or after the operation. However, in this case, there were no complications reported, blood loss was minimal, and the patient was stable post-operation. Thus, while there is always some risk with surgery, the stakes of this particular procedure appear to be moderate due to the non-critical nature of the orthopedic issue and the absence of complications.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Thoracoscopy & Thoracotomy - Mesothelioma

PREOPERATIVE DIAGNOSIS: , Left mesothelioma, focal.,POSTOPERATIVE DIAGNOSIS: , Left pleural-based nodule.,PROCEDURES PERFORMED:,1.  Left thoracoscopy.,2.  Left mini thoracotomy with resection of left pleural-based mass.,FINDINGS:,  Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.,FLUIDS: , 800 mL of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS, TUBES, CATHETERS: , 24-French chest tube in the left thorax plus Foley catheter.,SPECIMENS: , Left pleural-based nodule.,INDICATION FOR OPERATION:  ,The patient is a 59-year-old female with previous history of follicular thyroid cancer, approximately 40 years ago, status post resection with recurrence in the 1980s, who had a left pleural-based mass identified on chest x-ray.  Preoperative evaluation included a CT scan, which showed focal mass.  CT and PET confirmed anterior lesion.  Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction.  In the outpatient setting, the patient was willing to proceed.,PROCEDURE PERFORMED IN DETAIL: , After informed consent was obtained, the patient identified correctly.  She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty.  She was sedated and intubated with double-lumen endotracheal tube without difficulty.  She was positioned with left side up.  Appropriate pressure points were padded.  The left chest was prepped and draped in the standard surgical fashion.  The skin incision was made in the posterior axillary line, approximately 7th intercostal space with #10 blade, taken down through tissues and Bovie electrocautery.,Pleura was entered.  There was good deflation of the left lung.  __________ port was placed, followed by the 0-degree 10-mm scope with appropriate patient positioning.  Posteriorly a pedunculated 2.5 x 3-cm pleural-based mass was identified on the anterior chest wall.  There were thin adhesions to the pleura, but no invasion of the chest wall that could be identified.  The tumor was very mobile and was on a pedunculated stalk, approximately 1.5 cm.  It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk.,Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion.  Camera was placed through this port.  Laparoscopic scissors were placed through the posterior port, but it was necessary to have another instrument to provide more tension than just gravity.  Therefore because of the need to bring the specimen through the chest wall, a small 3-cm thoracotomy was made, which incorporated the posterior port site.  This was taken down to the subcutaneous tissue with Bovie electrocautery.  Periosteal elevator was used to lift the intercostal muscle off.  The ribs were not spread.  Through this 3-cm incision, both the laparoscopic scissors as well as Prestige graspers could be placed.  Prestige graspers were used to pull the specimen from the chest wall.  Care was taken not to injure the capsule.  The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall.  Care was taken not to transect the stalk.  Specimen came off the chest wall very easily.  There was good hemostasis.,At this point, the EndoCatch bag was placed through the incision.  Specimen was placed in the bag and then removed from the field.  There was good hemostasis.  Camera was removed.  A 24-French chest tube was placed through the anterior port and secured with 2-0 silk suture.  The posterior port site was closed 1st with 2-0 Vicryl in a running fashion for the intercostal muscle layer, followed by 2-0 closure of the latissimus fascia as well as subdermal suture, 4-0 Monocryl was used for the skin, followed by Steri-Strips and sterile drapes.  The patient tolerated the procedure well, was extubated in the operating room and returned to the recovery room in stable condition.
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DESCRIPTION: Left mesothelioma, focal.  Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.

cardiovascular / pulmonary, mini thoracotomy, pleural based mass, pleural based nodule, chest wall, mesothelioma focal, pleural, chest, thoracotomy, mesothelioma, laparoscopic, thoracoscopy,

The described medical procedure involves thoracoscopy and thoracotomy for a left pleural-based nodule suspected of mesothelioma, which is a serious condition. The operation involves significant surgical intervention, albeit with minimal estimated blood loss and a stable postoperative condition. The patient's history of thyroid cancer adds complexity, but the immediate postoperative outlook is stable. Procedures involving resection of pleural masses carry inherent risks given the proximity to critical thoracic structures and potential malignancy, making this a relatively high-stakes situation in terms of immediate surgical risk and long-term implications if malignancy is confirmed.


Medical Specialty: Neurology
Sample Name: Suspected Seizure Activity

XYZ Street,City, State,Dear Dr. CD:,Thank you for seeing Mr. XYZ, a pleasant 19-year-old male who has seen you in 2005 for suspected seizure activity.  He comes to my office today continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.  He is requesting to come off the Dilantin at this point.  Upon reviewing your 2005 note there was some discrepancy as to the true nature of his episodes to the emergency room and there was consideration to reconsider medication use.  His physical exam, neurologically, is normal at this time.  His Dilantin level is slightly low at 12.5.,I will appreciate your evaluation and recommendation as to whether we need to continue the Dilantin at this time.  I understand this will probably entail repeating his EEG and so please coordinate this through Health Center.  I await your response and whether we should continue this medication.  If you require any laboratory, we use ABC Diagnostic and any further testing that is needed should be coordinated at Health Center prior to scheduling.
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DESCRIPTION: Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.

neurology, eeg, suspected seizure activity, seizure activity, seizure episode, seizure, dilantinNOTE,: 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 a patient who has been free of seizure episodes for 2.5 years while on medication and is now considering discontinuing the medication. This decision can significantly impact the patient's quality of life and involves careful medical evaluation to avoid potential health risks if the medication is prematurely discontinued. However, the patient has been stable, and the situation is managed by a healthcare professional. Therefore, while the situation has potential risks, they are being managed. The stakes are moderate due to the potential health implications but not extremely high due to current stability and professional oversight.


Medical Specialty: Consult - History and Phy.
Sample Name: OB/GYN Consultation - 1

PAST MEDICAL HX: , Significant for asthma, pneumonia, and depression.,PAST SURGICAL HX: , None.,MEDICATIONS:,  Prozac 20 mg q.d.  She desires to be on the NuvaRing.,ALLERGIES:,  Lactose intolerance.,SOCIAL HX: , She denies smoking or alcohol or drug use.,PE:,  VITALS: Stable.  Weight: 114 lb.  Height: 5 feet 2 inches.  GENERAL: Well-developed, well-nourished female in no apparent distress.  HEENT: Within normal limits. NECK: Supple without thyromegaly.  HEART: Regular rate and rhythm.  LUNGS: Clear to auscultation.  ABDOMEN: Soft and nontender.  There is no rebound or guarding.  No palpable masses and no peritoneal signs.  EXTREMITIES: Within normal limits.  SKIN: Warm and dry.  GU: External genitalia is without lesion.  Vaginal is clean without discharge.  Cervix appears normal; however, a colposcopy was performed using acetic acid, which showed a thick acetowhite ring around the cervical os and extending into the canal.  BIMANUAL: Reveals significant cervical motion tenderness and fundal tenderness.  She had no tenderness in her adnexa.  There are no palpable masses.,A:,  Although unlikely based on the patient's exam and pain, I have to consider subclinical pelvic inflammatory disease.  GC and chlamydia was sent and I treated her prophylactically with Rocephin 250 mg and azithromycin 1000 mg.  Repeat biopsies were not performed based on her colposcopy as well as her previous Pap and colposcopy by Dr. A.  A LEEP is a reasonable approach even in this 16-year-old.,P:,  We will schedule LEEP in the near future.  Even though she has already been exposed HPV Gardasil would still be beneficial in this patient to help prevent recurrence of low-grade lesions as well as high-grade lesions.  Now, we have her given her first shot.
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DESCRIPTION: Female referred for evaluation of an abnormal colposcopy, low-grade Pap with suspicious high-grade features.

consult - history and phy., gravida, ecc, external genitalia, hpv, leep, pap, acetowhite, biopsies, blood with urination, cervical os, colposcopy, intraepithelial, right lower quadrant, squamous, suspicious, vaginal discharge, low grade pap, low grade,

The patient is a 16-year-old female with a history of HPV-related cervical issues and was referred for further evaluation. The discovery of a thick acetowhite ring during colposcopy suggests potential cervical dysplasia, which could lead to pre-cancerous or cancerous changes if not treated. The patient was treated prophylactically for possible pelvic inflammatory disease and is scheduled for a LEEP procedure. While these findings are concerning, the situation is not immediately life-threatening. The high-stakes element comes from the need to manage cervical dysplasia in a young patient, which could have long-term health implications if not addressed appropriately.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Thoracotomy & Esophageal Exploration

PREOPERATIVE DIAGNOSIS:  ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:,  Esophageal rupture.,OPERATION PERFORMED,1.  Left thoracotomy with drainage of pleural fluid collection.,2.  Esophageal exploration and repair of esophageal perforation.,3.  Diagnostic laparoscopy and gastrostomy.,4.  Radiographic gastrostomy tube study with gastric contrast, interpretation.,ANESTHESIA: , General anesthesia.,INDICATIONS OF THE PROCEDURE: , The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching.  He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.,DETAILS OF THE PROCEDURE: , After an extensive informed consent discussion process, the patient was brought to the operating room.  He was placed in a supine position on the operating table.  After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll.  Left chest was prepped and draped in a usual sterile fashion.  After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace.  The left lung was deflated and the pleural cavity entered.  The Finochietto retractor was used to help provide exposure.  The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,Immediately encountered was left pleural fluid including some purulent fluid.  Cultures of this were sampled and sent for microbiology analysis.  The left pleural space was then copiously irrigated.  A careful expiration demonstrated that the rupture appeared to be sealed.  There was crepitus within the mediastinal cavity.  The mediastinum was opened and explored and the esophagus was explored.  The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus.  It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area.  The area was copiously irrigated, this provided nice coverage and repair.  After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French.  These were secured at the left axillary line region at the skin level with #0-silk.,The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures.  Muscle layers were closed with running #1 Vicryl sutures.  The wound was irrigated and the skin was closed with skin staples.,The patient was then turned and placed in a supine position.  A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed.  A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced.  The laparoscope was introduced.  A single additional left-sided separator trocar was introduced.  It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance.  The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely.  The skin incision was made and the gastric lumen was then accessed with the Seldinger technique.  Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire.  #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated.  We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall.  The T-fasteners were all crimped and secured into position.  As was in the plan, the gastrostomy was secured to the skin and into the tube.  Sterile dressing was applied.  Aspiration demonstrated gastric content.,Gastrostomy tube study, with interpretation.  Radiographic gastrostomy tube study with gastric contrast, with
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DESCRIPTION: Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.

cardiovascular / pulmonary, esophageal rupture, thoracotomy, drainage of pleural fluid, esophageal perforation, esophageal exploration, laparoscopy, gastrostomy, pleural fluid, diagnostic laparoscopy, radiographic gastrostomy, gastric lumen, gastrostomy tube, gastric contrast, gastric, interpretation, abdominal, pleural, lumen, esophageal, tube,

The situation describes a surgical procedure involving a thoracotomy and esophageal exploration to address an esophageal rupture in a patient with a chronic esophageal stricture. This type of surgery is complex, involves multiple steps such as drainage of the pleural fluid and repairing the esophageal perforation, and carries significant risk due to possible complications. The presence of purulent fluid and the described complications with stitching the tissue add to the complexity and potential severity of the operation. These factors make this a high-stakes medical scenario, particularly because the patient's life could be at risk if the rupture leads to further complications like infection or respiratory distress.


Medical Specialty: Nephrology
Sample Name: Ultrasound - Kidney

EXAM: , AP abdomen and ultrasound of kidney.,HISTORY:,  Ureteral stricture.,AP ABDOMEN ,FINDINGS:,  Comparison is made to study from Month DD, YYYY.  There is a left lower quadrant ostomy.  There are no dilated bowel loops suggesting obstruction.  There is a double-J right ureteral stent, which appears in place.  There are several pelvic calcifications, which are likely vascular.  No definite pathologic calcifications are seen overlying the regions of the kidneys or obstructing course of the ureters.  Overall findings are stable versus most recent exam.,IMPRESSION: , Properly positioned double-J right ureteral stent.  No evidence for calcified renal or ureteral stones.,ULTRASOUND KIDNEYS,FINDINGS:,  The right kidney is normal in cortical echogenicity of solid mass, stone, hydronephrosis measuring 9.0 x 2.9 x 4.3 cm.  There is a right renal/ureteral stent identified.  There is no perinephric fluid collection.,The left kidney demonstrates moderate-to-severe hydronephrosis.  No stone or solid masses seen.  The cortex is normal.,The bladder is decompressed.,IMPRESSION:,1.  Left-sided hydronephrosis.,2.  No visible renal or ureteral calculi.,3.  Right ureteral stent.
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DESCRIPTION: AP abdomen and ultrasound of kidney.

AP abdomen and ultrasound of kidney.

nephrology, ureteral stricture, ap abdomen, bowel loops, calcified, calculi, double-j, echogenicity, hydronephrosis, kidney, left lower quadrant, obstruction, ostomy, perinephric, renal, solid mass, stent, ultrasound, ureteral stent, ureteral stones, ureters, ureteral,

The findings indicate moderate-to-severe hydronephrosis in the left kidney, which suggests potential obstruction, along with a right ureteral stent in place. While there are no visible stones or masses, the hydronephrosis could suggest a significant issue that needs prompt attention to prevent kidney damage. This situation might impact patient health substantially if not addressed. However, the findings seem stable compared to previous results, which may indicate current management is adequate. Given that this scenario involves potential kidney damage, it is moderately high-stakes in a medical context.


Medical Specialty: Cardiovascular / Pulmonary
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.

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

The scenario described is a coronary artery bypass grafting (CABG) surgery, which is a complex and major surgical procedure typically performed to improve blood flow to the heart in patients with coronary artery disease. The stakes are high because it involves significant risks, including those from anesthesia, potential for complications during or after the surgery such as heart attack, stroke, or death. The patient's pre-existing conditions, such as angina, coronary artery disease, and kidney failure, further increase the complexity and risk of the procedure. Therefore, the situation is considered high-stakes due to the potential for life-threatening outcomes and the serious nature of the surgery.