Medical Specialty: Orthopedic
Sample Name: Transpedicular Decompression

PREOPERATIVE DIAGNOSIS: , Foraminal disc herniation of left L3-L4.,POSTOPERATIVE DIAGNOSES:,1.  Foraminal disc herniation of left L3-L4.,2.  Enlarged dorsal root ganglia of the left L3 nerve root.,PROCEDURE PERFORMED:, Transpedicular decompression of the left L3-L4 with discectomy.,ANESTHESIA:,  General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , None.,HISTORY: , This is a 55-year-old female with a four-month history of left thigh pain.  An MRI of the lumbar spine has demonstrated a mass in the left L3 foramen displacing the nerve root, which appears to be a foraminal disc herniation effacing the L3 nerve root.  Upon exploration of the nerve root, it appears that there was a small disc herniation in the foramen, but more impressive was the abnormal size of the dorsal root ganglia that was enlarged more medially than laterally.  There was no erosion into the bone surrounding the area rather in the pedicle above or below or into the vertebral body, so otherwise the surrounding anatomy is normal.  I was prepared to do a discectomy and had not consented the patient for a biopsy of the nerve root.  But because of the sequela of cutting into a nerve root with residual weakness and persistent pain that the patient would suffer, at this point I was not able to perform this biopsy without prior consent from the patient.  So, surgery ended decompressing the L3 foramen and providing a discectomy with idea that we will obtain contrasted MRIs in the near future and I will discuss the findings with the patient and make further recommendations.,OPERATIVE PROCEDURE: , The patient was taken to OR #5 at ABCD General Hospital in a gurney.  Department of Anesthesia administered general anesthetic.  Endotracheal intubation followed.  The patient received the Foley catheter.  She was then placed in a prone position on a Jackson table.  Bony prominences were well padded.  Localizing x-rays were obtained at this time and the back was prepped and draped in the usual sterile fashion.  A midline incision was made over the L3-L4 disc space taking through subcutaneous tissues sharply, dissection was then carried out to the left of the midline with lumbodorsal fascia incised and the musculature was elevated in a supraperiosteal fashion from the level of L3.  Retractors were placed into the wound to retract the musculature.  At this point, the pars interarticularis was identified and the facet joint of L2-L3 was identified.  A marker was placed over the pedicle of L3 and confirmed radiographically.  Next, a microscope was brought onto the field.  The remainder of the procedure was noted with microscopic visualization.  A high-speed drill was used to remove the small portions of the lateral aspects of the pars interarticularis.  At this point, soft tissue was removed with a Kerrison rongeur and the nerve root was clearly identified in the foramen.  As the disc space of L3-L4 is identified, there is a small prominence of the disc, but not as impressive as I would expect on the MRI.  A discectomy was performed at this time removing only small portions of the lateral aspect of the disc.  Next, the nerve root was clearly dissected out and visualized, the lateral aspect of the nerve root appears to be normal in structural appearance.  The medial aspect with the axilla of the nerve root appears to be enlarged.  The color of the tissue was consistent with a nerve root tissue.  There was no identifiable plane and this is a gentle enlargement of the nerve root.  There are no circumscribed lesions or masses that can easily be separated from the nerve root.  As I described in the initial paragraph, since I was not prepared to perform a biopsy on the nerve and the patient had not been consented, I do not think it is reasonable to take the patient to this procedure, because she will have persistent weakness and pain in the leg following this procedure.  So, at this point there is no further decompression.  A nerve fork was passed both ventral and dorsal to the nerve root and there was no compression for lateral.  The pedicle was palpated inferiorly and medially and there was no compression, as the nerve root can be easily moved medially.  The wound was then irrigated copiously and suctioned dry.  A concoction of Duramorph and ______ was then placed over the nerve root for pain control.  The retractors were removed at this point.  The fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissues with #2 Vicryl sutures, and Steri-Strips covering the incision.  The patient transferred to the hospital gurney, extubated by Anesthesia, and subsequently transferred to Postanesthesia Care Unit in stable condition.
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DESCRIPTION: Foraminal disc herniation of left L3-L4.  Enlarged dorsal root ganglia of the left L3 nerve root.  Transpedicular decompression of the left L3-L4 with discectomy.

orthopedic, dorsal root ganglia, nerve root, discectomy, foraminal disc herniation, transpedicular decompression, lateral aspects, disc herniation, nerve, anesthesia, foraminal

The situation describes an orthopedic surgical procedure for treating foraminal disc herniation via transpedicular decompression. The surgery involved general anesthesia and handling of spinal structures, which inherently carries some risks, such as nerve damage or complications from anesthesia. However, the surgery had minimal blood loss, no immediate complications, and the patient was stable post-operation. The stakes are certainly moderate as this involves spinal surgery, which can significantly affect the patient's quality of life, but it is not classified as life-threatening or highly complex like certain cardiac or neurological surgeries.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 9

PROCEDURE:,  Left heart catheterization, left ventriculography, selective coronary angiography.,INDICATION: , This lady with a previous left internal mammary graft to left anterior descending, saphenous vein graft to obtuse margin branch, saphenous vein graft to the diagonal branch, and saphenous vein graft to the right coronary artery presented with recurrent difficulties with breathing.  This was felt to be related largely to chronic obstructive lung disease.  She had dynamic T-wave changes in precordial leads.  Cardiac enzymes were indeterminate.  She was evaluated by Dr. X and given her previous history and multiple risk factors it was elected to proceed with cardiac catheterization and coronary angiography.,Risks of the procedure including risks of conscious sedation, death, cerebrovascular accident, dye reaction, need for emergency surgery, vascular access injury and/or infection, and risks of cath-based interventions were discussed in detail.  The patient understood and agreed to proceed.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the cardiac catheterization laboratory.  Under Versed and fentanyl sedation, the right groin was sterilely prepped and draped.  Local anesthesia was obtained with 2% Xylocaine.  The right femoral artery was entered using modified Seldinger technique and a 4-French introducer sheath placed in that vessel.  Through the indwelling femoral arterial sheath, a JL4 4-French catheter was advanced over the wire to the ascending aorta, appropriately aspirated and flushed.  Ascending aortic root pressures obtained.  This catheter was utilized in an attempt to cannulate the left coronary ostium.  This catheter was too small, was exchanged for a JL5 4-French catheter, which was advanced over the wire to the ascending aorta, the cath appropriately aspirated and flushed, and advanced to left coronary ostium and multiple views of left coronary artery obtained.,This catheter was then exchanged for a 4-French right coronary catheter, which was advanced over the wire to the ascending aorta.  The catheter appropriately aspirated and flushed.  The catheter was advanced in the right coronary artery.  Multiple views of that vessel were obtained.  The catheter was then sequentially advanced to the saphenous vein graft to the diagonal branch, saphenous vein graft to the obtuse marginal branch, and left internal mammary artery, left anterior descending coronary artery, and multiple views of those vessels were obtained.  This catheter was then exchanged for a 4-French pigtail catheter, which was advanced over the wire to the ascending aorta.  The catheter was appropriately aspirated and flushed and advanced to left ventricle, baseline left ventricular pressures obtained.,Following this, left ventriculography was performed in a 30-degree RAO projection using 30 mL of contrast injected over 3 seconds.  Post left ventriculography pressures were then obtained as was a pullback pressure across the aortic valve.  Videotapes were then reviewed.  It was elected to terminate the procedure at that point in time.,The vascular sheath was removed and manual compression carried out.  Excellent hemostasis was obtained.  The patient tolerated the procedure without complication.,RESULTS OF PROCEDURE,1.  ,HEMODYNAMICS:,  Left ventricular end-diastolic filling pressure was 24.  There was no gradient across the aortic valve.,2.  ,LEFT VENTRICULOGRAPHY: , Left ventriculography demonstrated well-preserved left ventricular systolic function.  Mild inferobasilar hypokinesis was noted.  No significant mitral regurgitation noted.  Ejection fraction was estimated at 60%.,3.  ,CORONARY ARTERIOGRAPHY,A.  ,LEFT MAIN CORONARY: , The left main coronary was patent.,B.  ,LEFT ANTERIOR DESCENDING CORONARY ARTERY:,  Left anterior descending coronary was occluded shortly after a very small first septal perforator was given.,C.  ,CIRCUMFLEX CORONARY ARTERY:,  Circumflex coronary artery was occluded at its origin.,D.  ,RIGHT CORONARY ARTERY,.  Right coronary artery was occluded in its mid portion.,4.  ,SAPHENOUS VEIN GRAFT ANGIOGRAPHY,A.  ,SAPHENOUS VEIN GRAFT TO THE DIAGONAL BRANCH: , The saphenous vein graft to diagonal branch was widely patent at its origin and insertion sites.  Excellent flow was noted in the diagonal system with some retrograde flow.,B.  There was retrograde flow as well in the left anterior descending system.,C.  ,SAPHENOUS VEIN GRAFT TO THE OBTUSE MARGINAL SYSTEM:,  Saphenous vein graft to the obtuse marginal system was widely patent at its origin and insertion sites.  There was no graft disease noted.  Excellent flow was noted in the bifurcating marginal system.,D.  ,SAPHENOUS VEIN GRAFT TO RIGHT CORONARY ARTERY:,  Saphenous vein graft to right coronary was widely patent with no graft disease.  Origin and insertion sites were free of disease.  Distal flow in the graft to the posterior descending was normal.,5.  ,LEFT INTERNAL MAMMARY ARTERY ANGIOGRAPHY: , Left internal mammary artery angiography demonstrated a widely patent left internal mammary at its origin and insertion sites.  There was no focal disease noted, inserted into the mid-to-distal LAD which was a small-caliber vessel.  Retrograde filling of a small septal system was noted.,SUMMARY OF RESULTS,1.  Elevated left ventricular end-diastolic filling pressure with normal left ventricular systolic function and mild hypokinesis of inferobasilar segment.
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DESCRIPTION: Left heart catheterization, left ventriculography, selective coronary angiography.

The description of the medical procedure involves a patient undergoing a left heart catheterization, ventriculography, and selective coronary angiography. These are invasive and high-risk procedures, particularly given the patient's complex clinical background, including previous graft surgeries and recurrent breathing issues. Risks highlighted include death, cerebrovascular accident, dye reaction, and potential need for emergency surgery. The stakes are high because the procedure directly pertains to the cardiovascular health of the patient and involves critical decision-making that could impact their survival and quality of life.

Filled in based on scale_labels and scale_label_confidence


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

HISTORY OF PRESENT ILLNESS:  ,This is a 23-year-old married man who had an onset of aplastic anemia in December, underwent a bone marrow transplant in the end of March, has developed very severe graft-versus-host reaction.  Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.,The patient gives a significant history of behavioral problems from late adolescence until the onset of illness, states he had lot of trouble with law, he was convicted of assault, he was also arrested with small amount of cannabis, states he served one year incarcerated in ABCD that was about two years ago.  Gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program, he was discharged from that on 05/28/2006 and states he has been clean and sober since then.  Prior to going to rehabilitation, he was using intravenous heroin couple of times a week since age 17, which would have been over a period of about five years, reports heavy use of cannabis, smoking pot up to five times a day if he could.  He would drink up to half of a fifth of rum on a daily basis when available.,The patient is currently on Lexapro 10 mg in the morning and diazepam 10 mg at bedtime.  He complained of some depressive and some anxiety symptoms, but these do not appear to be out of proportion to his medical issues and, for this individual, the frustrations of his treatments.  He would have a limited support system here in Colorado.  He married in January and states that the marriage is not going particularly well, being young, sick, and hospitalized, has not helped his relationship with his new wife who apparently is expecting a child in July.  I would recommend some couples counseling as a part of their treatment here.,The patient was fairly drowsy during the interview and full past and developmental history was not obtained.  The patient's comment is that he grew up all over, that his parents had separated, that he lived with his mother, that he dropped out of school in eleventh grade, at that time was living in XYZ area because he did not like school.,PHYSICAL EXAMINATION:  ,GENERAL: , This is a cooperative man, speech is soft and difficult to understand.  There is no thought disorder and no hallucination.  He denies being suicidal, but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital.,VITAL SIGNS: , Temperature 97.2, pulse 117, respirations 16, blood pressure 127/74, oxygen saturation 97%, and weight is 154 pounds.,PSYCHIATRY:,  There is no thought disorder, no paranoia, no delusions, and no psychotic symptoms.  Activities of daily living (ADLs) appear intact.  On formal testing, he is oriented to place.  He can give a reasonable recitation of his medical history.  He is oriented to the year, knows it is the 15th, but gave the month as June instead of May.  He can memorize four items, repeats three out of four at five minutes, gives the fourth through the category, which places short-term memory in normal limits.  He can do serial three subtractions accurately, can name objects appropriately.,LABORATORY DATA:,  Sodium of 135, BUN of 24, and glucose 119.  GGT of 355, ALT of 97, LDH of 703, and alk phos of 144.  FK506 is 28.8, which is elevated tacrolimus level.  Hematocrit 29% and white count is 7000.,DIAGNOSES:  ,AXIS I:,  Depressive disorder secondary to the underlying medical condition of graft-versus-host reaction.,AXIS II: , Personality disorder, not otherwise specified (NOS).,AXIS III: , History of polysubstance abuse, in remission.,RECOMMENDATIONS:  ,1.  This patient appears to retain the ability to make decisions on his own behalf.  I think he is mentally competent.  Unfortunately, his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness.  If the patient refuses treatment, he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die.,2.  The patient does complain of depressed mood, also of anxiety.  We did discuss medications.  He appeared somewhat sedated at the time of my interview.  I would recommend that we try Seroquel 25 mg twice daily on an as-needed basis to see if this diminishes anxiety.  I will have Dr. X followup with him.,Please feel free to contact me at digital pager if additional information is needed.,My overall recommendation would be that the patient be on some random urine drug screening, that he use cell phone if he goes off the unit, to be called back up when treatments are scheduled, and hopefully he will be agreeable to complying with this.
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DESCRIPTION: Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.

consult - history and phy., noncompliant, confusion, graft versus host reaction, psychiatric consultation, willful behavior, cannabis,

The situation involves a patient with a complex medical history, including a recent bone marrow transplant and severe graft-versus-host disease, who is noncompliant with treatment in a hospital setting. There are significant mental health concerns, including depression, anxiety, and a personality disorder, that may affect decision-making and treatment compliance. If the patient continues to refuse treatment, it could hasten mortality due to the severity of his condition. This elevates the situation to high-stakes as it involves potential life-threatening consequences. Moreover, there are interpersonal issues affecting his support system, as he is recently married, expecting a child, and has limited support due to geographic and personal circumstances.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 1

CHIEF COMPLAINT:,  Followup on diabetes mellitus, status post cerebrovascular accident.,SUBJECTIVE:,  This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side.  We have done EMG studies.  He has noticed it since his stroke about five years ago.  He has been to see a neurologist.  We have tried different medications and it just does not seem to help.  He checks his blood sugars at home two to three times a day.  He kind of adjusts his own insulin himself.  Re-evaluation of symptoms is essentially negative.  He has a past history of heavy tobacco and alcohol usage.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular.  ,General:  A 70-year-old male who does not appear to be in acute distress but does look older than his stated age.  He has some missing dentition.,Skin:  Dry and flaky. ,CV:  Heart tones are okay, adequate carotid pulsations.  He has 2+ pedal pulse on the left and 1+ on the right.,Lungs: Diminished but clear.,Abdomen:  Scaphoid.,Rectal:  His prostate check was normal per Dr. Gill.,Neuro:  Sensation with monofilament testing is better on the left than it is on the right.,IMPRESSION:,1.  Diabetes mellitus.,2.  Neuropathy.,3.  Status post cerebrovascular accident.,PLAN:,  Refill his medications x 3 months.  We will check an A1c and BMP.  I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood.  We will check a PSA.  Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n.
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DESCRIPTION: Sample progress note - Gen Med.

Sample progress note - Gen Med.

soap / chart / progress notes, diabetes mellitus, neuropathy, genernal medicine, post cerebrovascular accident, progerss note, post cerebrovascular, cerebrovascular accident, accident, cerebrovascular, neurologist, insulin,

The patient's situation involves managing chronic conditions like diabetes and the after-effects of a cerebrovascular accident (stroke), which are significant health matters but appear to be under continuous monitoring and care. There is no indication of an immediate life-threatening issue, and the patient is already in a follow-up setup with planned future assessments and medication refills. However, the patient's ability to self-manage insulin and the past history of substance abuse add some complications. The regular monitoring and reassessment make it not extremely high-stakes, but given the chronic conditions, it certainly requires attention.


Medical Specialty: General Medicine
Sample Name: Gen Med H&P - 1

CHIEF COMPLAINT:, Left leg pain.,HISTORY OF PRESENT ILLNESS:, The patient is a 59-year-old gravida 1, para 0-0-1-0, with a history of stage IIIC papillary serous adenocarcinoma of the ovary who presented to the office today with left leg pain that started on Saturday. The patient noticed the pain in her left groin and left thigh and also noticed swelling in that leg. A Doppler ultrasound of her leg that was performed today noted a DVT. She is currently on course one, day 14 of 21 of Taxol and carboplatin. She is scheduled for intraperitoneal port placement for intraperitoneal chemotherapy to begin next week. She denies any chest pain or shortness of breath, nausea, vomiting, or dysuria. She has a positive appetite and ambulates without difficulty.,PAST MEDICAL HISTORY:,1. Gastroesophageal reflux disease.,2. Mitral valve prolapse.,3. Stage IIIC papillary serous adenocarcinoma of the ovaries.,PAST SURGICAL HISTORY:,1. A D and C.,2. Bone fragment removed from her right arm.,3. Ovarian cancer staging.,OBSTETRICAL HISTORY:, Spontaneous miscarriage at 3 months approximately 30 years ago.,GYNECOLOGICAL HISTORY: ,The patient started menses at age 12; she states that they were regular and occurred every month. She finished menopause at age 58. She denies any history of STDs or abnormal Pap smears. Her last mammogram was in April 2005 and was within normal limits.,FAMILY HISTORY:,1. A sister with breast carcinoma who was diagnosed in her 50s.,2. A father with gastric carcinoma diagnosed in his 70s.,3. The patient denies any history of ovarian, uterine, or colon cancer in her family.,SOCIAL HISTORY:, No tobacco, alcohol, or drug abuse.,MEDICATIONS:,1. Prilosec.,2. Tramadol p.r.n.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,PHYSICAL EXAMINATION:,VITAL SIGNS: Temperature 97.3, pulse 91, respiratory rate 18, blood pressure 142/46, O2 saturation 99% on room air.,GENERAL: Alert, awake, and oriented times three, no apparent distress, a well-developed, well-nourished white female.,HEENT: Normocephalic and atraumatic. The oropharynx is clear. The pupils are equal, round, and reactive to light.,NECK: Good range of motion, nontender, no thyromegaly.,CHEST: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi.,CARDIOVASCULAR: Regular rate and rhythm with a 2/6 systolic ejection murmur on her left side.,ABDOMEN: Positive bowel sounds, soft, nontender, nondistended, no hepatosplenomegaly, a well-healing midline incision.,EXTREMITIES: 2+ pulses bilaterally, right leg without swelling, nontender, no erythema, negative Homans' sign bilaterally, left thigh swollen, erythematous, and warm to the touch compared to the right. Her left groin is slightly tender to palpation.,LYMPHATICS: No axillary, groin, clavicular, or mandibular nodes palpated.,LABORATORY DATA:, White blood cell count 15.5, hemoglobin 11.4, hematocrit 34.5, platelets 159, percent neutrophils 88%, absolute neutrophil count 14,520. Sodium 142, potassium 3.3, chloride 103, CO2 26, BUN 15, creatinine 0.9, glucose 152, calcium 8.7. PT 13.1, PTT 28, INR 0.97.,ASSESSMENT AND PLAN:, Miss Bolen is a 59-year-old gravida 1, para 0-0-1-0 with stage IIIC papillary serous adenocarcinoma of the ovary. She is postop day 21 of an exploratory laparotomy with ovarian cancer staging. She is currently with a left leg DVT.,1. The patient is doing well and is currently without any complaints. We will start Lovenox 1 mg per kg subcu daily and Coumadin 5 mg p.o. daily. The patient will receive INR in the morning; the goal was obtain an INR between 2.5 and 3.0 before the Lovenox is instilled. The patient is scheduled for port placement for intraperitoneal chemotherapy and this possibly may be delayed.,2. Aranesp 200 mcg subcu was given today. The patient's absolute neutrophil count is 14,520.
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DESCRIPTION: History and Physical - A history of stage IIIC papillary serous adenocarcinoma of the ovary, presented to the office today left leg pain (left leg DVT).

The case involves a patient with a recent diagnosis of deep vein thrombosis (DVT) in the context of ongoing chemotherapy for stage IIIC papillary serous adenocarcinoma of the ovary. DVT is a serious condition due to the risk of pulmonary embolism, which can be life-threatening. The patient requires anticoagulation therapy, and there's consideration for delaying port placement for chemotherapy if anticoagulation cannot be controlled. While it's a serious condition, it seems the medical team has a plan in place for treatment, including Lovenox and Coumadin, to manage the DVT. Overall, the situation has notable health risks but appears to be under medical management.


Medical Specialty: Surgery
Sample Name: Pacemaker (Dual Chamber)

CLINICAL HISTORY: ,This 78-year-old black woman has a history of hypertension, but no other cardiac problems. She noted complaints of fatigue, lightheadedness, and severe dyspnea on exertion. She was evaluated by her PCP on January 31st and her ECG showed sinus bradycardia with a rate of 37 beats per minute. She has had intermittent severe sinus bradycardia alternating with a normal sinus rhythm, consistent with sinoatrial exit block, and she is on no medications known to cause bradycardia. An echocardiogram showed an ejection fraction of 70% without significant valvular heart disease.,PROCEDURE:, Implantation of a dual chamber permanent pacemaker.,APPROACH:, Left cephalic vein.,LEADS IMPLANTED: ,Medtronic model 12345 in the right atrium, serial number 12345. Medtronic 12345 in the right ventricle, serial number 12345.,DEVICE IMPLANTED: ,Medtronic EnRhythm model 12345, serial number 12345.,LEAD PERFORMANCE: ,Atrial threshold less than 1.3 volts at 0.5 milliseconds. P wave 3.3 millivolts. Impedance 572 ohms. Right ventricle threshold 0.9 volts at 0.5 milliseconds. R wave 10.3. Impedance 855.,ESTIMATED BLOOD LOSS:, 20 mL.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the electrophysiology laboratory in a fasting state and intravenous sedation was provided as needed with Versed and fentanyl. The left neck and chest were prepped and draped in the usual manner and the skin and subcutaneous tissues below the left clavicle were infiltrated with 1% lidocaine for local anesthesia. A 2-1/2-inch incision was made below the left clavicle and electrocautery was used for hemostasis. Dissection was carried out to the level of the pectoralis fascia and extended caudally to create a pocket for the pulse generator. The deltopectoral groove was explored and a medium-sized cephalic vein was identified. The distal end of the vein was ligated and a venotomy was performed. Two guide wires were advanced to the superior vena cava and peel-away introducer sheaths were used to insert the two pacing leads. The venous pressures were elevated and there was a fair amount of back-bleeding from the vein, so a 3-0 Monocryl figure-of-eight stitch was placed around the tissue surrounding the vein for hemostasis. The right ventricular lead was placed in the high RV septum and the right atrial lead was placed in the right atrial appendage. The leads were tested with a pacing systems analyzer and the results are noted above. The leads were then anchored in place with #0-silk around their suture sleeve and connected to the pulse generator. The pacemaker was noted to function appropriately. The pocket was then irrigated with antibiotic solution and the pacemaker system was placed in the pocket. The incision was closed with two layers of 3-0 Monocryl and a subcuticular closure of 4-0 Monocryl. The incision was dressed with Steri-Strips and a sterile bandage and the patient was returned to her room in good condition.,IMPRESSION: ,Successful implantation of a dual chamber permanent pacemaker via the left cephalic vein. The patient will be observed overnight and will go home in the morning.
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DESCRIPTION: Implantation of a dual chamber permanent pacemaker

surgery, medtronic enrhythm, cephalic vein, dual chamber, dual chamber permanent pacemaker, dyspnea on exertion, echocardiogram, fatigue, hypertension, lightheadedness, normal sinus rhythm, pacemaker, permanent pacemaker, sinoatrial exit block, sinus bradycardia, valvular heart disease, bradycardia, medtronic, atrial,

The procedure described involves the implantation of a dual chamber pacemaker, which is a surgical intervention in response to a significant cardiac issue, namely severe bradycardia. This type of surgery is typically considered high-stakes due to the critical nature of the cardiac health issues it addresses, the potential complications that could arise during or after the procedure, and the importance of ensuring correct device placement and function. However, the specific case described mentions no complications, successful implantation, and typical post-operative care, suggesting it proceeded as expected without unusual risk factors beyond those inherent to the procedure itself.


Medical Specialty: Emergency Room Reports
Sample Name: ER Report - Stomach Pain

CHIEF COMPLAINT:, Stomach pain for 2 weeks.,HISTORY OF PRESENT ILLNESS:, The patient is a 45yo Mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. The pain was initially crampy and burning in character and was relieved with food intake. He also reports that it initially was associated with a sour taste in his mouth. He went to his primary care physician who prescribed cimetidine 400mg qhs x 5 days; however, this did not relieve his symptoms. In fact, the pain has worsened such that the pain now radiates to the back but is waxing and waning in duration. It is relieved with standing and ambulation and exacerbated when lying in a supine position. He reports a decrease in appetite associated with a 4 lb. wt loss over the last 2 wks. He does have nausea with only one episode of non-bilious, non-bloody emesis on day of admission. He reports a 2 wk history of subjective fever and diaphoresis. He denies any diarrhea, constipation, dysuria, melena, or hematochezia. His last bowel movement was during the morning of admission and was normal. He denies any travel in the last 9 years and sick contacts.,PAST MEDICAL HISTORY:, Right inguinal groin cyst removal 15 years ago. Unknown etiology. No recurrence.,PAST SURGICAL HISTORY:, Left femoral neck fracture with prosthesis secondary to a fall 4 years ago.,FAMILY HISTORY:, Mother with diabetes. No history of liver disease. No malignancies.,SOCIAL HISTORY:, The patient was born in central Mexico but moved to the United States 9 years ago. He is on disability due to his prior femoral fracture. He denies any tobacco or illicit drug use. He only drinks alcohol socially, no more than 1 drink every few weeks. He is married and has 3 healthy children. He denies any tattoos or risky sexual behavior.,ALLERGIES:, NKDA.,MEDICATIONS:, Tylenol prn (1-2 tabs every other day for the last 2 wks), Cimetidine 400mg po qhs x 5 days.,REVIEW OF SYSTEMS:,  No headache, vision changes. No shortness of breath. No chest pain or palpitations.,PHYSICAL EXAMINATION:,Vitals: T 100.9-102.7 BP 136/86 Pulse 117 RR 12 98% sat on room air,Gen: Well-developed, well-nourished, no apparent distress.,HEENT: Pupils equal, round and reactive to light. Anicteric. Oropharynx clear and moist.,Neck: Supple. No lymphadenopathy or carotid bruits. No thyromegaly or masses.,CHEST: Clear to auscultation bilaterally.,CV: Tachycardic but regular rhythm, normal S1/S2, no murmurs/rubs/gallops.,Abd: Soft, active bowel sounds. Tender in the epigastrium and right upper quadrant with palpation associated with slight guarding. No rebound tenderness. No hepatomegaly. No splenomegaly.,Rectal: Stool was brown and guaiac negative.,Ext: No cyanosis/clubbing/edema.,Neurological: He was alert and oriented x3. CN II-XII intact. Normal 2+ DTRs. No focal neurological deficit.,Skin: No jaundice. No skin rashes or lesions.,IMAGING DATA:,CT Abdomen with contrast ( 11/29/03 ):  There is a 6x6 cm multilobular hypodense mass seen at the level of the hepatic hilum and caudate lobe which is resulting in mass effect with dilatation of the intrahepatic radicals of the left lobe of the liver. The rest of the liver parenchyma is homogeneous. The gallbladder, pancreas, spleen, adrenal glands and kidneys are within normal limits. The retroperitoneal vascular structures are within normal limits. There is no evidence of lymphadenopathy, free fluid or fluid collections.,HOSPITAL COURSE:,  The patient was admitted to the hospital for further evaluation. A diagnostic procedure was performed.
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DESCRIPTION: Patient presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days.

The situation involves a 45-year-old patient presenting to the emergency room with significant and worsening abdominal pain, associated weight loss, and a mass in the liver area identified on a CT scan. The pain has persisted for 14 days and has associated symptoms that could suggest a serious condition such as a liver or biliary abnormality, especially given the mass effect and dilatation of the intrahepatic radicals. While not imminently life-threatening, the presence of the mass and consistent symptoms over two weeks make this a potentially serious medical issue requiring further investigation. Therefore, it's reasonably high-stakes within the medical context.


Medical Specialty: Surgery
Sample Name: Temporal Artery Biopsy

PREOPERATIVE DIAGNOSIS:,  Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS:  ,Rule out temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsy.,ANESTHESIA:,  Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:,  I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis.  I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way.  After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery.  The temporal artery was identified and was grossly normal on both sides.  Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult.  The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm.  They were sent as separate specimens, right and left labeled.  The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond.  She tolerated the procedure well.
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DESCRIPTION: Bilateral temporal artery biopsy.  Rule out temporal arteritis.

surgery, headaches, bilateral temporal artery, temporal artery biopsy, temporal arteritis, temporal artery, temporal, biopsy, arteritis

Temporal artery biopsy is a diagnostic procedure to confirm or rule out temporal arteritis, a serious condition that requires prompt treatment to prevent complications like vision loss. Although the procedure itself is routine and not highly complex, the stakes come from the potential consequences of missing or misdiagnosing temporal arteritis. Prompt diagnosis and treatment are crucial. However, since the procedure is done under local anesthesia and the patient tolerated it well, it isn't as high-stakes as more invasive surgical interventions.


Medical Specialty: ENT - Otolaryngology
Sample Name: CT Neck

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

Common CT Neck template.

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

The CT Neck scan results indicate that everything is within normal limits and there are no acute abnormalities identified. Therefore, this represents a routine and normal finding in the medical field of otolaryngology. The situation does not indicate any immediate danger or high-stakes scenarios because there are no urgent or severe findings that require immediate intervention.


Medical Specialty: Hematology - Oncology
Sample Name: Leiomyosarcoma

ADMITTING DIAGNOSES:,1.  Leiomyosarcoma.,2.  History of pulmonary embolism.,3.  History of subdural hematoma.,4.  Pancytopenia.,5.  History of pneumonia.,PROCEDURES DURING HOSPITALIZATION:,1.  Cycle six of CIVI-CAD (Cytoxan, Adriamycin, and DTIC) from 07/22/2008 to 07/29/2008.,2.  CTA, chest PE study showing no evidence for pulmonary embolism.,3.  Head CT showing no evidence of acute intracranial abnormalities.,4.  Sinus CT, normal mini-CT of the paranasal sinuses.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC is a pleasant 66-year-old Caucasian female who first palpated a mass in the left posterior arm in spring of 2007.  The mass increased in size and she was seen by her primary care physician and referred to orthopedic surgeon.  MRI showed inflammation and was thought to be secondary to rheumatoid arthritis.  The mass increased in size.  She eventually underwent a partial resection found to have pathologic grade 2 leiomyosarcoma, margins were impossible to assess, but were likely positive.  She was evaluated by Dr. X and Dr. Y and a decision was made to proceed with preoperative chemotherapy.  She began treatment with CIVI-CAD in December 2007.  Her course was complicated by pulmonary embolus, pneumonia, and subdural hematoma while on anticoagulation.  She eventually underwent surgical resection on May 1, 2008 with small area of residual disease, but otherwise clear margins.,HOSPITAL COURSE:,1.  Leiomyosarcoma, the patient was admitted to Hem/Onco B Service under attending Dr. XYZ for cycle six of continuous IV infusion Cytoxan, Adriamycin, and DTIC, which she tolerated well.,2.  History of pulmonary embolism.  Upon admission, the patient reported an approximate two-week history of dyspnea on exertion and some mild chest pain.  She underwent a CTA, which showed no evidence of pulmonary embolism and the patient was started on prophylactic doses of Lovenox at 40 mg a day.  She had no further complaints throughout the hospitalization with any shortness of breath or chest pain.,3.  History of subdural hematoma, also on admission the patient noted some mild intermittent headaches that were fleeting in nature, several a day that would resolve on their own.  Her headaches were not responding to pain medication and so on 07/24/2008, we obtained a head CT that showed no evidence of acute intracranial abnormalities.  The patient also had a history of sinusitis and so a sinus CT scan was obtained, which was normal.,4.  Pancytopenia.  On admission, the patient's white blood count was 3.4, hemoglobin 11.3, platelet count 82, and ANC of 2400.  The patient's counts were followed throughout admission.  She did not require transfusion of red blood cells or platelets; however, on 07/26/2008 her ANC did dip to 900 and she was placed on neutropenic diet.  At discharge her ANC is back up to 1100 and she is taken off neutropenic diet.  Her white blood cell count at discharge was 1.4 and her hemoglobin was 11.2 with a platelet count of 140.,5.  History of pneumonia.  During admission, the patient did not exhibit any signs or symptoms of pneumonia.,DISPOSITION: , Home in stable condition.,DIET: , Regular and less neutropenic.,ACTIVITY: , Resume same activity.,FOLLOWUP:  ,The patient will have lab work at Dr. XYZ on 08/05/2008 and she will also return to the cancer center on 08/12/2008 at 10:20 a.m.  The patient is also advised to monitor for any fevers greater than 100.5 and should she have any further problems in the meantime to please call in to be seen sooner.
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DESCRIPTION: Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.

hematology - oncology, leiomyosarcoma, embolism, hematoma, pneumonia, acute intracranial abnormalities, white blood, platelet count, blood cells, neutropenic diet, subdural hematoma, pulmonary embolism, intracranial, pancytopenia, neutropenic, subdural, pulmonary,

The patient's discharge summary indicates a complex medical situation involving leiomyosarcoma, history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia. The patient is undergoing chemotherapy, which has several risks including pancytopenia and the potential for severe infections. While the patient is being discharged in stable condition, they are instructed to monitor their health closely, indicating that while stable, their condition remains precarious. The involvement of a serious cancer, history of life-threatening complications, and ongoing need for close monitoring suggest a high-stakes situation due to the potential for rapid change in the patient's health status.


Medical Specialty: Surgery
Sample Name: McBride Bunionectomy & Wedge Osteotomy

PREOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1.  Right McBride bunionectomy.,2.  Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle cuff.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in a supine position.  The right foot was prepared and draped in usual sterile manner.  Anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint.  Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg.  At this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made.  The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure.  The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection.  Using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp.  At this time, attention was directed to the first inner space using sharp and blunt dissection.  Dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments.  The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment.  At this time, the lateral release was stressed and was found to be complete.  The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw.  The area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted.  At this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length.  The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption.  At this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint.  At this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge.  The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3.0 x 22 mm.  The screw was placed following proper technique.  The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing.  A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy.  The packing of the cancellous bone was held in place with bone wax.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed.  At this time, a deep closure was achieved utilizing #2-0 Vicryl suture, subcuticular closure was achieved using #4-0 Vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion.  The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site.  At this time, the surgical site was postoperatively injected with 0.5 Marcaine plain as well as dexamethasone 4 mg primarily.  The surgical sites were then dressed with sterile Xeroform, sterile 4x4s, cascading, and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion.  The tourniquet was dropped and color and temperature of all digits returned to normal.  The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided.  The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.,
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DESCRIPTION: Right hallux abductovalgus deformity.  Right McBride bunionectomy.  Right basilar wedge osteotomy with OrthoPro screw fixation.

surgery, hallux, abductovalgus, bunionectomy, mcbride, basilar, wedge, osteotomy, orthopro, screw, fixation, wedge osteotomy

The situation described involves a surgical procedure for a bunion and osteotomy, which are fairly common surgeries for foot deformities. While the stakes are higher than routine check-ups due to the surgical nature, it is not considered extremely high-risk as bunion surgery is often elective and typically has a straightforward recovery process. The procedure seems to have gone smoothly, with proper post-operative care instructions given. Overall, this scenario does not exhibit the characteristics of an extremely high-stakes medical situation.


Medical Specialty: Surgery
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.

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

The described surgical procedure, a laparoscopic cholecystectomy with cholangiogram for an acute gangrenous cholecystitis, is indeed a high-stakes situation. This is because the patient's condition was serious, with a 'dead gallbladder' and necrotic tissues, which could lead to severe complications like infection or bile leakage if not handled properly. However, since the procedure was completed without complications and the patient was stabilized, the stakes were managed successfully. Given the patient's critical preoperative condition and the potential for severe outcomes if the surgery were not successful, the stakes are high.


Medical Specialty: Surgery
Sample Name: Carpal Tunnel Release - Endoscopic

PREOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: , Endoscopic carpal tunnel release.,ANESTHESIA: , MAC,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,I made a transverse incision one fingerbreadth proximal to the distal volar wrist crease.  Dissection was carried down to the antebrachial fascia, which was cut in a distally based fashion.  Bipolar electrocautery was used to maintain meticulous hemostasis.  I then performed an antebrachial fasciotomy proximally.  I entered the extra bursal space deep into the transverse carpal ligament and used the spatula probe and then the dilators and then the square probe to enlarge the area.  Great care was taken to feel the washboard undersurface of the transverse carpal ligament and the hamate on the ulnar side.  Great care was taken with placement.  A good plane was positively identified.  I then placed the endoscope in and definitely saw the transverse striations of the deep surface of the transverse carpal ligament.,Again, I felt the hook of the hamate ulnar to me.  I had my thumb on the distal aspect of the transverse carpal ligament.  I then partially deployed the blade, and starting 1 mm from the distal edge, the transverse carpal ligament was positively identified.  I pulled back and cut and partially tightened the transverse carpal ligament.  I then feathered through the distal ligament and performed a full-thickness incision through the distal half of the ligament.  I then checked to make sure this was properly performed and then cut the proximal aspect.  I then entered the carpal tunnel again and saw that the release was complete, meaning that the cut surfaces of the transverse carpal ligament were separated; and with the scope rotated, I could see only one in the field at a time.  Great care was taken and at no point was there any longitudinal structure cut.  Under direct vision through the incision, I made sure that the distal antebrachial fascia was cut.  Following this, I irrigated and closed the skin.  The patient was dressed and sent to the recovery room in good condition.
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DESCRIPTION: Carpal tunnel syndrome.  Endoscopic carpal tunnel release.  After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.

surgery, endoscopic, carpal tunnel syndrome, carpal tunnel release, carpal ligament, tourniquet, carpal, esmarch, tunnel, transverse, ligament

The described procedure is a common and relatively routine surgical operation aimed at alleviating the symptoms of carpal tunnel syndrome. Although surgical procedures inherently carry some level of risk, endoscopic carpal tunnel release is typically low-risk with a high success rate. It is performed under local or mild anesthesia (MAC), which indicates it is not highly invasive. The stakes are primarily in ensuring the procedure is performed correctly to avoid complications. However, the potential for major complications is low, making this a low to moderate-stakes situation.


Medical Specialty: Urology
Sample Name: Prostatectomy - Radical Retropubic

PREOPERATIVE DIAGNOSIS:,  Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATIVE PROCEDURE: , Radical retropubic prostatectomy with pelvic lymph node dissection.,ANESTHESIA:  ,General epidural,ESTIMATED BLOOD LOSS: , 800 cc.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: , This is a 64-year-old man with adenocarcinoma of the prostate confirmed by needle biopsies.  He has elected to undergo radical retropubic prostatectomy with pelvic lymph node dissection.  Potential complications include, but are not limited to:,1.  Infection.,2.  Bleeding.,3.  Incontinence.,4.  Impotence.,5.  Deep venous thrombosis.,6.  Recurrence of the cancer.,PROCEDURE IN DETAIL: , Epidural anesthesia was administered by the anesthesiologist in the holding area.  Preoperative antibiotic was also given in the preoperative holding area.  The patient was then taken into the operating room after which general LMA anesthesia was administered.  The patient was shaved and then prepped using Betadine solution.  A sterile 16-French Foley catheter was inserted into the bladder with clear urine drain.  A midline infraumbilical incision was performed.  The rectus fascia was opened sharply.  The perivesical space and the retropubic space were developed bluntly.  Bookwalter retractor was then placed.  Bilateral obturator pelvic lymphadenectomy was performed.  The obturator nerve was identified and was untouched.  The margin for the resection of the lymph node bilaterally were the Cooper's ligament, the medial edge of the external iliac artery, the bifurcation of the common iliac vein, the obturator nerve, and the bladder.  Both hemostasis and lymphostasis was achieved by using silk ties and Hemo clips.  The lymph nodes were palpably normal and were set for permanent section.  The Bookwalter retractor was then repositioned and the endopelvic fascia was opened bilaterally using Metzenbaum scissors.  The puboprostatic ligament was taken down sharply.  The superficial dorsal vein complex over the prostate was bunched up by using the Allis clamp and then tied by using 2-0 silk sutures.  The deep dorsal vein complex was then bunched up by using the Allis over the membranous urethral area.  The dorsal vein complex was ligated by using 0 Vicryl suture on a CT-1 needle.  The Allis clamp was removed and the dorsal vein complex was transected by using Metzenbaum scissors.  The urethra was then identified and was dissected out.  The urethral opening was made just distal to the apex of the prostate by using Metzenbaum scissors.  This was extended circumferentially until the Foley catheter could be seen clearly.  2-0 Monocryl sutures were then placed on the urethral stump evenly spaced out for the anastomosis to be performed later.  The Foley catheter was removed and the posteriormost aspect of urethra and rectourethralis muscle was transected.  The lateral pelvic fascia was opened bilaterally to sweep the neurovascular bundles laterally on both sides.  The plane between Denonvilliers' fascia and the perirectal fat was developed sharply.  No tension was placed on the neurovascular bundle at any point in time.  The prostate dissected off the rectal wall easily.  Once the seminal vesicles were identified, the fascia covering over them were opened transversely.  The seminal vesicles were dissected out and the small bleeding vessels leading to them were clipped by using medium clips and then transected.  The bladder neck was then dissected out carefully to spare most of the bladder neck muscles.  Once all of the prostate had been dissected off the bladder neck circumferentially the mucosa lining the bladder neck was transected releasing the entire specimen.  The specimen was inspected and appeared to be completely intact.  It was sent for permanent section.  The bladder neck mucosa was then everted by using 4-0 chromic sutures.  Inspection at the prostatic bed revealed no bleeding vessels.  The sutures, which were placed previously onto the urethral stump, were then placed onto the bladder neck.  Once the posterior sutures had been placed, the Foley was placed into the urethra and into the bladder neck.  A 20-French Foley Catheter was used.  The anterior sutures were then placed.  The Foley was then inflated.  The bed was straightened and the sutures were tied down sequentially from anteriorly to posteriorly.  Mild traction of the Foley catheter was placed to assure the anastomosis was tight.  Two #19-French Blake drains were placed in the perivesical spaces.  These were anchored to the skin by using 2-0 silk sutures.  The instrument counts, lab counts, and sponge counts were verified to be correct, the patient was closed.  The fascia was closed in running fashion using #1 PDS.  Subcutaneous tissue was closed by using 2-0 Vicryl suture.  Skin was approximated by using metallic clips.  The patient tolerated the operation well.
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DESCRIPTION: Radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer.

urology, prostate cancer, foley catheter, metzenbaum scissors, prostate, adenocarcinoma, bladder, lymphadenectomy, pelvic lymph node dissection, perivesical, prostatectomy, retropubic, urethra, radical retropubic prostatectomy, lymph node dissection, dorsal vein complex, radical retropubic, lymph node, dorsal vein, vein complex, bladder neck, sutures, foley, urethral,

The procedure described is a radical retropubic prostatectomy, a major surgical intervention for prostate cancer. Prostate cancer is a serious medical condition, and this surgery is critical to managing the disease, potentially affecting the patient's survival and quality of life. The document outlines the operation details, including the absence of complications and successful completion, which is positive. However, the stakes are high due to potential complications (incontinence, impotence, cancer recurrence) and the overall impact on the patient's health. Given its importance in cancer treatment and management, this situation is indeed high-stakes.


Medical Specialty: Neurology
Sample Name: Feet & Hand Cramping

HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old right-handed gentleman who presents for further evaluation of feet and hand cramps.  He states that for the past six months he has experienced cramps in his feet and hands.  He describes that the foot cramps are much more notable than the hand ones.  He reports that he develops muscle contractions of his toes on both feet.  These occur exclusively at night.  They may occur about three times per week.  When he develops these cramps, he stands up to relieve the discomfort.  He notices that the toes are in an extended position.  He steps on the ground and they seem to "pop into place."  He develops calf pain after he experiences the cramp.  Sometimes they awaken him from his sleep.,He also has developed cramps in his hands although they are less severe and less frequent than those in his legs.  These do not occur at night and are completely random.  He notices that his thumb assumes a flexed position and sometimes he needs to pry it open to relieve the cramp.,He has never had any symptoms like this in the past.  He started taking Bactrim about nine months ago.  He had taken this in the past briefly, but has never taken it as long as he has now.  He cannot think of any other possible contributing factors to his symptoms.,He has a history of HIV for 21 years.  He was taking antiretroviral medications, but stopped about six or seven years ago.  He reports that he was unable to tolerate the medications due to severe stomach upset.  He has a CD4 count of 326.  He states that he has never developed AIDS.  He is considering resuming antiretroviral treatment.,PAST MEDICAL HISTORY:,  He has diabetes, but this is well controlled.  He also has hepatitis C and HIV.,CURRENT MEDICATIONS: , He takes insulin and Bactrim.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , He lives alone.  He recently lost his partner.  This happened about six months ago.  He denies alcohol, tobacco, or illicit drug use.  He is now retired.  He is very active and walks about four miles every few days.,FAMILY HISTORY: , His father and mother had diabetes.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  Blood pressure 130/70
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DESCRIPTION: Patient presents for further evaluation of feet and hand cramps. He describes that the foot cramps are much more notable than the hand ones.  He reports that he develops muscle contractions of his toes on both feet.  These occur exclusively at night.

The situation involves muscle cramps in a patient with a complex medical history, including HIV, diabetes, and hepatitis C. While cramping is usually not life-threatening, when combined with an existing complex medical history, potential drug interactions, and possibly HIV-related complications, the stakes could be higher. The patient’s CD4 count suggests a compromised immune system, which may complicate his overall health status. However, currently, there are no signs of an immediately life-threatening condition. Therefore, the stakes are moderate as further evaluation may identify a more serious underlying issue, but immediate risk appears low.


Medical Specialty: Surgery
Sample Name: Flap revision

PREOPERATIVE DIAGNOSES,1.  Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2.  Bilateral breast asymmetry.,3.  Right breast macromastia.,4.  Right abdominal scar deformity.,5.  Left abdominal scar deformity.,6.  A 1.3 cm lesion right inferior breast.,7.  Lesion measuring 0.5 cm right inferior breast lateral.,POSTOPERATIVE DIAGNOSES,1.  Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2.  Bilateral breast asymmetry.,3.  Right breast macromastia.,4.  Right abdominal scar deformity.,5.  Left abdominal scar deformity.,6.  A 1.3 cm lesion right inferior breast.,7.  Lesion measuring 0.5 cm right inferior breast lateral.,PROCEDURES,1.  Left breast flap revision.,2.  Right breast flap revision.,3.  Right breast reduction mammoplasty.,4.  Right nipple reconstruction.,5.  Left abdominal scar deformity.,6.  Right abdominal scar deformity.,7.  Excision of right breast medial lesion enclosure.,8.  Excision of right breast lateral lesion enclosure.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,DRAINS:,  None.,SPECIMENS:,  Right breast skin and lesions x2.,COMPLICATIONS:, None.,INDICATIONS:,  This patient is a 54-year-old white female who presents for a revision of her previous bilateral breast reconstruction.  The patient had asymmetry as well as right breast hypertrophy, and therefore, the procedures named above were indicated.  The patient was informed about the possible risks and complications of the above procedures and gave an informed consent.,PROCEDURE:,  The patient was brought to the operating room, placed supine on the operative table.  After adequate endotracheal anesthesia was established and IV prophylactic antibiotics were given, the chest and abdomen were prepped and draped in standard surgical fashion.,Attention was first turned to the left breast where liposuction was performed laterally to allow for better contour and minimize the outer quadrant.  The incision was made for this and was then closed with 5-0 Prolene interrupted suture.,Attention was then turned to the right breast where liposuction was also performed to reduce the medial superior and lateral quadrants.  Once this was performed, the vertical reduction mammoplasty was outlined.  Prior to that, the nipple reconstruction was performed with a keyhole pattern flap.  The flap was elevated with 15-blade and hemostasis was then obtained with the Bovie.  The flap was then sutured onto itself and secured with 5-0 Prolene interrupted sutures.  Then the lateral and medial limbs were undermined to close the defect and this was performed with 3-0 Monocryl interrupted sutures.  Subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to Pathology. ,Hemostasis was then obtained with the Bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions.  Once this was performed, a 3-0 Monocryl interrupted sutures were used to close the inferior limb.  Subsequently 2-0 PDS continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex.  Once this was performed, the remaining incision was then closed with 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures.  Subsequently, the 2 lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to Pathology.  They were closed in 2 layers using 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required.  Subsequently the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 10 x 3 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the contralateral left side where there was a larger defect.  There was a larger excision required measuring approximately 15 x 3 cm.  The superior and inferior edges of skin were undermined and closed primarily using 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures.  Steri-Strips were placed on all incisions followed by surgical bra.,The patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition.  All instruments, needle counts, and sponges were correct at the end of the case.
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DESCRIPTION: Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.

Flap revision surgery, particularly focused on breast reconstruction and asymmetry correction, is complex and involves several detailed procedures as noted in the operations performed: flap revision, nipple reconstruction, and lesion excision among others. Although the surgery went smoothly with no complications, the stakes are moderately high because of the complexity of the procedures, potential cosmetic and psychological impacts, and the precision required to avoid any complications during reconstruction surgeries. Further, there is a consideration of the patient's previous surgical history which adds to the complexity. However, without acute life-threatening circumstances, the stakes are moderate rather than extremely high.


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

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

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

The detection of a hypodense mass in the cervix and lower uterine segment, along with multiple uterine fibroids and a thickened endometrium, indicates potential serious health issues that may require further investigation. Conditions such as uterine fibroids are common and usually benign, but the mass of uncertain etiology could potentially indicate a more serious condition like a tumor. This uncertainty and the need for follow-up imaging make it a moderate to high-stakes situation, as these findings could have significant implications for the patient's health depending on the final diagnosis after further testing.


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: Anemia & Leukemia Followup

CHIEF COMPLAINT:,1.  Chronic lymphocytic leukemia (CLL).,2.  Autoimmune hemolytic anemia.,3.  Oral ulcer.,HISTORY OF PRESENT ILLNESS: , The patient is a 72-year-old gentleman who was diagnosed with chronic lymphocytic leukemia in May 2008.  He was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.  He has been on chronic steroids to control his hemolysis and is currently on prednisone 5 mg every other day.  He comes in to clinic today for follow-up and complete blood count.  At his last office visit we discontinued this prophylactic antivirals and antibacterial.,CURRENT MEDICATIONS:,  Prilosec 20 mg b.i.d., levothyroxine 50 mcg q.d., Lopressor 75 mg q.d., vitamin C 500 mg q.d., multivitamin q.d., simvastatin 20 mg q.d., and prednisone 5 mg q.o.d.,ALLERGIES:  ,Vicodin.,REVIEW OF SYSTEMS:  ,The patient reports ulcer on his tongue and his lip.  He has been off of Valtrex for five days.  He is having some difficulty with his night vision with his left eye.  He has a known cataract.  He denies any fevers, chills, or night sweats.  He continues to have headaches.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:
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DESCRIPTION: Chronic lymphocytic leukemia (CLL), autoimmune hemolytic anemia, and oral ulcer.  The patient was diagnosed with chronic lymphocytic leukemia and was noted to have autoimmune hemolytic anemia at the time of his CLL diagnosis.

soap / chart / progress notes, oral ulcer, leukemia, anemia, hemolysis, blood count, chronic lymphocytic leukemia, autoimmune hemolytic anemia, hemolytic, cll, lymphocytic, autoimmune,

The patient's medical condition involves chronic lymphocytic leukemia (CLL) and autoimmune hemolytic anemia, both of which can have significant health implications. The follow-up involves monitoring and managing these serious conditions, including adjusting medications like prednisone. While the situation is not an immediate life-or-death emergency, it involves careful management of chronic and potentially life-threatening health issues, making it moderately high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Huntington's Disease

CC:, Slowing of motor skills and cognitive function.,HX: ,This 42 y/o LHM presented on 3/16/93 with gradually progressive deterioration of motor and cognitive skills over 3 years. He had difficulty holding a job. His most recent employment ended 3 years ago as he was unable to learn the correct protocols for the maintenance of a large conveyer belt. Prior to that, he was unable to hold a job in the mortgage department of a bank as could not draw and figure property assessments. For 6 months prior to presentation, he and his wife noted (his) increasingly slurred speech and slowed motor skills (i.e. dressing himself and house chores). His walk became slower and he had difficulty with balance. He became anhedonic and disinterested in social activities, and had difficulty sleeping for frequent waking and restlessness. His wife noticed "fidgety movements" of his hand and feet.,He was placed on trials of Sertraline and Fluoxetine for depression 6 months prior to presentation by his local physician. These interventions did not appear to improve his mood and affect.,MEDS:, Fluoxetine.,PMH: ,1)Right knee arthroscopic surgery 3 yrs ago. 2)Vasectomy.,FHX:, Mother died age 60 of complications of Huntington Disease (dx at UIHC). MGM and two MA's also died of Huntington Disease. His 38 y/o sister has attempted suicide twice.,He and his wife have 2 adopted children.,SHX: ,unemployed. 2 years of college education. Married 22 years.,ROS: ,No history of Dopaminergic or Antipsychotic medication use.,EXAM:, Vital signs normal.,MS: A&O to person, place, and time. Dysarthric speech with poor respiratory control.,CN: Occasional hypometric saccades in both horizontal directions. No vertical gaze abnormalities noted. Infrequent spontaneous forehead wrinkling and mouth movements. The rest of the CN exam was unremarkable.,Motor: Full strength throughout and normal muscle tone and bulk. Mild choreiform movements were noted in the hands and feet.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: unremarkable, except that during tandem walking mild dystonic and choreiform movements of BUE became more apparent.,Reflexes: 2/2 throughout. Plantar responses were flexor, bilaterally.,There was no motor impersistence on tongue protrusion or hand grip.,COURSE:, He was thought to have early manifestations of Huntington Disease. A HCT was unremarkable. Elavil 25mg qhs was prescribed. Neuropsychologic assessment revealed mild anterograde memory loss only.,His chorea gradually worsened during the following 4 years. He developed motor impersistence and more prominent slowed saccadic eye movements. His mood/affect became more labile.,6/5/96 genetic testing revealed a 45 CAg trinucleotide repeat band consistent with Huntington Disease. MRI brain, 8/23/96, showed caudate nuclei atrophy, bilaterally.
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DESCRIPTION: Caudate Nuclei atrophy, bilaterally, in patient with Huntington Disease.

This case involves the diagnosis and management of Huntington's Disease, a progressive and fatal genetic disorder that severely impacts the patient's quality of life. Given the hereditary nature and potential for serious psychological and physical symptoms, this is a high-stakes medical situation. The condition also carries significant emotional implications for the patient and their family, including potential genetic transmission to offspring. Therefore, the stakes are high due to both immediate healthcare needs and long-term family planning and psychological considerations.


Medical Specialty: Orthopedic
Sample Name: Laminectomy & Facetectomy

PREOPERATIVE DIAGNOSIS:,  Dural tear, postoperative laminectomy, L4-L5.,POSTOPERATIVE DIAGNOSES,1.  Dural tear, postoperative laminectomy, L4-L5.,2.  Laterolisthesis, L4-L5.,3.  Spinal instability, L4-L5.,OPERATIONS PERFORMED,1.  Complete laminectomy, L4.,2.  Complete laminectomy plus facetectomy, L3-L4 level.,3.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.,4.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.,5.  Posterior spinal fusion, L4 to S1.,6.  Insertion of morselized autograft, L4 to S1.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,DRAINS:  ,Hemovac x1.,DISPOSITION: , Vital signs stable, taken to the recovery room in a satisfactory condition, extubated.,INDICATIONS FOR OPERATION: , The patient is a 48-year-old gentleman who has had a prior decompression several weeks ago.  He presented several days later with headaches as well as a draining wound.  He was subsequently taken back for a dural repair.  For the last 10 to 11 days, he has been okay except for the last two days he has had increasing headaches, has nausea, vomiting, as well as positional migraines.  He has fullness in the back of his wound.  The patient's risks and benefits have been conferred him due to the fact that he does have persistent spinal leak.  The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively.,PROCEDURE IN DETAIL:,  After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #7.  The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties.  The patient was given intraoperative antibiotics.  The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion.,Initially, a midline incision was made from the cephalad to caudad level.  Full-thickness skin flaps were developed.  It was seen immediately that there was large amount of copious fluid emanating from the wound, clear-like fluid, which was the cerebrospinal fluid.  Cultures were taken, aerobic, anaerobic, AFB, fungal.  Once this was done, the paraspinal muscles were affected from the posterior elements.  It was seen that there were no facet complexes on the right side at L4-L5 and L5-S1.  It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4-5 level from the listhesis.  Once this was done; however, the fluid emanating from the dura could not be seen appropriately.  Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left.  Complete laminectomy at L3 was done.  Once this was done within the subarticular recess on the right side at the L4 pedicle level, a rent in the dura was seen.  Once this was appropriately cleaned, the dural edges were approximated using a running 6-0 Prolene suture.  A Valsalva confirmed no significant lead after the repair was made.  There was a significant laterolisthesis at L4-L5 and due to the fact that there were no facet complexes at L5-S1 and L4-L5 on the right side as well as there was a significant concavity on the right L4-L5 disk space which was demonstrated from intraoperative x-rays and compared to preoperative x-rays, it was decided from an instrumentation.  The lateral pedicle screws were placed at L4, L5, and S1 using the standard technique of Magerl.  After this the standard starting point was made.  Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall.  Once this was done, this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall.  The screws were subsequently placed.  Tricortical purchase was obtained at S1 ________ appropriate size screws.  Precontoured titanium rod was then appropriately planned and placed between the screws at L4, L5, and S1.  This was done on the right side first.  The screw was torqued at S1 appropriately and subsequently at L5.  Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4.  Neutral compression distraction was obtained on the left side.  Screws were torqued at L4, L5, and S1 appropriately.  Good placement was seen both in AP and lateral planes using fluoroscopy.  Laterolisthesis corrected appropriately at L4 and L5.,Posterior spinal fusion was completed by decorticating the posterior elements at L4-L5 and the sacral ala with a curette.  Once good bleeding subchondral bone was appreciated, the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix.  This was placed in the posterior lateral gutters.  DuraGen was then placed over the dural repair, and after this, fibrin glue was placed appropriately.  Deep retractors then removed from the confines of the wound.  Fascia was closed using interrupted Prolene running suture #1.  Once this was done, suprafascial drain was placed appropriately.  Subcutaneous tissues were opposed using a 2-0 Prolene suture.  The dermal edges were approximated using staples.  Wound was dressed sterilely using bacitracin ointment, Xeroform, 4 x 4's, and tape.  The drain was connected appropriately.  The patient was rolled on stretcher in usual supine position, extubated uneventfully, and taken back to the recovery room in a satisfactory stable condition.  No complications arose.
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DESCRIPTION: Complete laminectomy, L4. and facetectomy, L3-L4 level.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.  Posterior spinal fusion, L4 to S1.  Insertion of morselized autograft, L4 to S1.

This case involves surgical intervention for complications following a previous operation, specifically to address a dural tear and spinal instability at the L4-L5 vertebrae. The procedure outlined is complex, involving a complete laminectomy, dural repair, and spinal instrumentation and fusion. Given the previous complications such as a cerebrospinal fluid leak and significant spinal instability, this surgery addresses critical spinal issues which, if not resolved, could severely impact the patient's health and mobility. Although this type of surgery is routine for an orthopedic surgeon, the stakes are inherently high due to the potential for significant neurological impact if complications arise. Furthermore, the indication for operation mentions severe symptoms such as headaches, nausea, and vomiting related to the condition, highlighting the need for timely and effective surgical intervention.


Medical Specialty: Hematology - Oncology
Sample Name: Neck Mass Biopsy

PREOPERATIVE DIAGNOSIS: , Malignant mass of the left neck.,POSTOPERATIVE DIAGNOSIS:,  Malignant mass of the left neck, squamous cell carcinoma.,PROCEDURES,1.  Left neck mass biopsy.,2.  Selective surgical neck dissection, left.,DESCRIPTION OF PROCEDURE:,  After obtaining an informed, the patient was taken to the operating room where a time-out process was followed.  Preoperative antibiotic was given and Dr. X proceeded to intubate the patient after a detailed anesthetic preparation that started in the Same Day Surgery and followed in the operating room.  Finally, a 5.5-French endotracheal tube was inserted and the patient was able to tolerate that and did have stable vital signs and a proper oxygenation.,Then, the patient was positioned with the neck slightly distended and turned toward the opposite side of the operation.  The neck was prepped and draped in the usual fashion.  I proceeded to mark the site of the mass and then also to mark the proposed site for the creation of a flap.  Then, I performed an extensive anesthetic block of the area.,Then, an incision was made along the area marked for development of the flap, but in a very limited extent, just to expose the cervical mass.  The cervical mass, which was about 4 cm in diameter and very firm and rubbery, was found lodged between the sternocleidomastoid muscle and the internal jugular vein in the area III of the neck.  A wedge sample was sent to Pathology for frozen section.  At the same time, we waited for the result and the initial report was not clear in the sense that a lot of lymphoepithelial reaction was seen.  Therefore, a larger sample was sent to Pathology and at that particular time, the fresh frozen was reported as having squamous elements.  This was not totally clear in my mind and therefore I proceeded to excise the full mass, which luckily was not attached to any structures except in the very deep surface.  There, there were some attachments to branches of the external carotid artery, which had to be suture ligated.  At any rate, the whole specimen was to the lab and finally the diagnosis was that of a metastatic squamous cell carcinoma.,With that information in hand, we proceeded to continue with a neck dissection and proceeded to make an incision along the previously marked sites of the flap, which basically involved a reverse U shape on the left neck.  This worked out quite nicely.  The external jugular vein was out of the way, so initially we did not deal with it.  We proceeded to tackle the area III and extended into II-A.  When we excised the mass, the upper end was in intimate relationship with the parotid gland, which was relatively large in this patient, but it looked normal otherwise.  Also, I felt that the submaxillary gland was enlarged.  At any rate, we decided to clean up the areas III and IV and a few nodes from II-A that were removed, and then we went into the posterior triangle where we identified the spinal accessory nerve, which we protected, actually did not even dissect close to it.,The same nerve had been already identified anterior to the internal jugular vein, very proximally behind the digastric and the sternocleidomastoid muscle.  At any rate, there were large nodes in the posterior triangle, in areas V-A and V-B, which were excised and sent to Pathology for examination.  Also, there was a remnant of a capsule of the main mass that we proceeded to excise and sent to Pathology as an extra specimen.  Hemostasis was revised and found to be adequate.  The flaps had been protected by folding it to the chest and protected by wet sponges on both sides of the flap.  The flap was replaced in its position.  A soft Jackson-Pratt catheter was left in the area, and then we proceeded to approximate the flap with a number of subcutaneous sutures of Vicryl and then running sutures of subcuticular Monocryl to the skin.  I would like to mention that also the facial vein was excised and the external jugular vein was ligated.  It was in very lateral location and it was on the site of the drain, so we ligated that but did not excise it.  A pressure dressing was applied.,The patient tolerated the procedure well.  Estimated blood loss was no more than 100 mL.  The patient was extubated in the operating room and sent for recovery.
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DESCRIPTION: Malignant mass of the left neck, squamous cell carcinoma.  Left neck mass biopsy and selective surgical neck dissection, left.

hematology - oncology, neck mass biopsy, surgical neck dissection, internal jugular vein, external jugular vein, squamous cell carcinoma, neck mass, malignant mass, neck dissection, mass, neck, wedge, vein,

This situation involves a patient undergoing a biopsy and neck dissection due to a malignant neck mass diagnosed as squamous cell carcinoma. The stakes are high because the outcome could significantly affect the patient's health and treatment options. Cancer diagnoses and surgical procedures like these often carry significant risks and implications for treatment and prognosis.


Medical Specialty: General Medicine
Sample Name: Pyelonephritis - Discharge Summary

ADMISSION DIAGNOSES:,1.  Pyelonephritis.,2.  History of uterine cancer and ileal conduit urinary diversion.,3.  Hypertension.,4.  Renal insufficiency.,5.  Anemia.,DISCHARGE DIAGNOSES:,1.  Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit.,2.  Hypertension.,3.  Mild renal insufficiency.,4.  Anemia, which has been present chronically over the past year.,HOSPITAL COURSE:,  The patient was admitted with suspected pyelonephritis.  Renal was consulted.  It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr. X.  Her symptoms responded to IV antibiotics and she remained clinically stable.  Klebsiella was isolated in this urine, which was sensitive to Bactrim and she was discharged on p.o.  Bactrim.  She was scheduled on 08/07/2007 for further surgery.  She is to follow up with Dr. Y in 7-10 days.  She also complained of right knee pain and the right knee showed no sign of effusion.  She was exquisitely tender to touch of the patellar tendon.  It was thought that this did not represent intraarticular process.  She was advised to use ibuprofen over-the-counter two to three tabs t.i.d.
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DESCRIPTION: Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.

general medicine, uterine cancer, renal insufficiency, pyelonephritis, mucous plugging, ileal conduit

The medical situation involves a patient with multiple concurrent conditions, including pyelonephritis, a history of uterine cancer, ileal conduit urinary diversion, hypertension, renal insufficiency, and chronic anemia. While pyelonephritis can be serious, it seems to have been addressed effectively during the hospital stay. The patient responded well to treatment and is being discharged on appropriate antibiotics. The follow-up plans are clearly stated and the situation does not appear to involve immediate life-threatening conditions. However, the complexity, especially with the history of cancer and renal issues, indicates a moderate level of risk if follow-up care is neglected.


Medical Specialty: Surgery
Sample Name: Colpocleisis

PREOPERATIVE DIAGNOSES: , Vault prolapse and rectocele.,POSTOPERATIVE DIAGNOSES:,  Vault prolapse and rectocele.,OPERATION: , Colpocleisis and rectocele repair.,ANESTHESIA:  ,Spinal.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: , This is an 85-year-old female who presented to us with a vaginal mass.  On physical exam, the patient was found to have grade 3 rectocele and poor apical support, and history of hysterectomy.  The patient had good anterior support at the bladder.  Options were discussed such as watchful waiting, pessary, repair with and without mesh, and closing of the vagina (colpocleisis) were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, morbidity, and mortality of the procedure were discussed., ,Risk of infection and abscess formation were discussed.  The patient understood all the risks and benefits and wanted to proceed with the procedure.  Risk of retention and incontinence were discussed.  Consent was obtained through the family members.,DETAILS OF THE OR:,  The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient had a Foley catheter placed.  The posterior side of the rectocele was visualized with grade 3 rectocele and poor apical support.  A 1% lidocaine with epinephrine was applied for posterior hydrodissection, which was very difficult to do due to the significant scarring of the posterior part.  Attempts were made to lift the vaginal mucosa off of the rectum, which was very, very difficult to do at this point due to the patient's overall poor medical condition in terms of poor mobility and significant scarring.  Discussion was done with the family in the waiting area regarding simply closing the vagina and doing a colpocleisis since the patient is actually inactive.  Family agreed that she is not active and they rather not have any major invasive procedure especially in light of scarring and go ahead and perform the colpocleisis.  Oral consent was obtained from the family and her surgery was preceded.  The vaginal mucosa was denuded off using electrocautery and Metzenbaum scissors.  Using 0 Vicryl, 2 transverse longitudinal stitches were placed to bring the anterior and the posterior part of the vagina together and was started at the apex and was brought all the way out to the introitus.  The vaginal mucosa was pretty much completely closed off all the way up to the introitus.  Indigo carmine was given.  Cystoscopy revealed there was a good efflux of urine from both of the ureteral openings.  There was no injury to the bladder or kinking of the ureteral openings.  The bladder was normal.  Rectal exam was normal at the end of the colpocleisis repair.  There was good hemostasis., ,At the end of the procedure, Foley was removed and the patient was brought to recovery in a stable condition.
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DESCRIPTION: Colpocleisis and rectocele repair.

Colpocleisis and rectocele repair.

surgery, vault prolapse, rectocele repair, rectocele, vaginal mass, metzenbaum scissors, ureteral openings, vaginal mucosa, colpocleisis, vaginal, infection,

The situation involves a surgical procedure on an elderly patient. While the surgery itself, colpocleisis, is considered less invasive, the patient's age, her existing medical conditions, and the complexity due to scarring increase the risks associated with any surgical intervention. These factors can lead to potential complications such as infection, bleeding, or issues arising from anesthesia, which were discussed with the family. The decision to avoid more invasive procedures further underscores the potential risks. Thus, the stakes are moderate, given the balance between the patient's health status and the nature of the surgery.