Medical Specialty: ENT - Otolaryngology
Sample Name: Deviated Septum Repair - Followup

CHIEF COMPLAINT: , Septal irritation.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old African-American female status post repair of septal deviation but unfortunately, ultimately ended with a large septal perforation.  The patient has been using saline nasal wash 2-3 times daily, however, she states that she still has discomfort in her nose with a "stretching" like pressure.  She says her nose is frequently dry and she occasionally has nosebleeds due to the dry nature of her nose.  She has no other complaints at this time.,PHYSICAL EXAM:,GENERAL:  This is a pleasant African-American female resting in the examination room chair in no apparent distress.,ENT:  External auditory canals are clear.  Tympanic membrane shows no perforation, is intact.,NOSE:  The patient has a slightly deviated right septum.  Septum has a large perforation in the anterior 2/3rd of the septum.  This appears to be well healed.  There is no sign of crusting in the nose.,ORAL CAVITY:  No lesions or sores.  Tonsils show no exudate or erythema.,NECK:  No cervical lymphadenopathy.,VITAL SIGNS:  Temperature 98 degrees Fahrenheit, pulse 77, respirations 18, blood pressure 130/73.,ASSESSMENT AND PLAN:  ,The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation.  At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.  At this time, I counseled the patient on the risks and benefits of surgery.  She will consider surgery but at this time, would like to continue using the saline nasal wash as well as occasional Bactroban to the nose if there is occasional irritation or crusting, which she will apply with the edge of a Q-tip.  We will see her back in 3 weeks and if the patient does not feel relieved from the Bactroban as well as saline nasal spray wash, we will consider setting the patient for surgery at that time.
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DESCRIPTION: The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation.  At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.

ent - otolaryngology, saline nasal wash, deviated septum, saline nasal, septal perforation, nose, septum, septal, perforation

The patient's current condition involves a septal perforation following a deviated septum repair. While this is causing discomfort, dryness, and occasional nosebleeds, it is not life-threatening at this time. The situation is in a follow-up stage where conservative management is preferred. The plan involves monitoring and potential surgical intervention only if current treatments do not alleviate symptoms. Thus, the stakes are relatively low because there is currently no immediate threat to life or severe health impairment.


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

Medical Specialty: Dermatology
Sample Name: Dermatitis - SOAP

SUBJECTIVE:,  This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04.  She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema.  I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion.  She comes in today for reevaluation because she is flaring.  Her hands are very dry, they are cracked, she has been washing with soap.  She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin.  She has been wearing some gloves also apparently.  The patient is single.  She is unemployed.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has asthma, sinus, hives, and history of psoriasis.  No known drug allergies.,MEDICATIONS: , The patient is a nonsmoker.  No bad sunburns or blood pressure problems in the past.,CURRENT MEDICATIONS:,  Claritin and Zyrtec p.r.n.,PHYSICAL EXAMINATION:,  The patient has very dry, cracked hands bilaterally.,IMPRESSION:,  Hand dermatitis.,TREATMENT:,1.  Discussed further treatment with the patient and her interpreter.,2.  Apply Aristocort ointment 0.1% and equal part of Polysporin ointment t.i.d. and p.r.n. itch.,3.  Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion.,4.  Keflex 500 mg b.i.d. times two weeks with one refill.  Return in one month if not better; otherwise, on a p.r.n. basis and send Dr. XYZ a letter on this office visit.
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DESCRIPTION: Hand dermatitis.

Hand dermatitis.

dermatology, cetaphil cleansing lotion, hand dermatitis, aristocort, wash, ointment, hand, lotion, dermatitis

While the patient's condition involves discomfort and requires attention to prevent worsening, hand dermatitis is a common dermatological condition. It typically does not pose a severe or immediate threat to the patient's health like acute or life-threatening conditions might. The situation involves managing symptoms and improving the patient's quality of life rather than addressing an urgent medical emergency. Thus, it is not considered high-stakes in a medical context.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Frameless Stereotactic Radiosurgery

PREOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:,  CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM.  He was referred for stereotactic radiosurgery.  The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits.  The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment.  He was placed on the treatment table.  The Aquaplast mask was constructed.  Initial imaging was obtained by the CyberKnife system.  The patient was then transported over to the CT scanner at Stanford.  Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered.  Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices.  These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me.  I outlined the tumor volume.  Inverse treatment planning was used to generate the treatment plan for this patient.  This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator.  The maximum dose within this center of treatment volume was 23.81 Gy.  The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm.  The volume treated at the reference dose was 98%.  The coverage isodose line was 79%.  The conformality index was 1.74 and modified conformality index was 1.55.  The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite.  He was placed on the treatment table.  The Aquaplast mask was applied.  Initial imaging was used to bring the patient into optimal position.  The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin.  He tolerated the procedure well.  He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months.  The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note.
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DESCRIPTION: CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.

surgery, ct-guided, occipital, cyberknife, frameless stereotactic radiosurgery, occipital arteriovenous malformation, conformality index, arteriovenous malformation, malformation, avm, arteriovenous,

The situation involves a medical procedure on a patient with a right occipital arteriovenous malformation, which is complex and potentially life-threatening if not managed properly. Radiosurgery carries significant risks, including radiation injury and potential neurological deficits. Also, the procedure requires precise targeting and the involvement of skilled practitioners, without a qualified resident available. Considering all these factors, the procedure's success has serious implications for the patient's health, making it high-stakes.


Medical Specialty: Surgery
Sample Name: Coronary Angiography & Abdominal Aortography

NAME OF PROCEDURE,1.  Selective coronary angiography.,2.  Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.,3.  Abdominal aortography.,INDICATIONS:  ,The patient is a 65-year-old gentleman with a history of exertional dyspnea and a cramping-like chest pain.  Thallium scan has been negative.  He is undergoing angiography to determine if his symptoms are due to coronary artery disease.,NARRATIVE:  ,The right groin was sterilely prepped and draped in the usual fashion and the area of the right coronary artery anesthetized with 2% lidocaine.  Constant sedation was obtained using Versed 1 mg and fentanyl 50 mcg.  Received additional Versed and fentanyl during the procedure.  Please refer to the nurses' notes for dosages and timing.,The right femoral artery was entered and a 4-French sheath was placed.  Advancement of the guidewire demonstrated some obstruction at the level of abdominal aorta.  Via the right Judkins catheter, the guidewire was easily infiltrated to the thoracic aorta and over aortic arch.  The right Judkins catheter was advanced to the origin of the right coronary artery where selective angiograms were performed.  This revealed a very high-grade lesion at the proximal right coronary artery.  This catheter was exchanged for a left #4 Judkins catheter which was advanced to the ostium of the left main coronary artery where selective angiograms were performed.,The patient was found to have the above mentioned high-grade lesion in the right coronary artery and a coronary intervention was performed.  A 6-French sheath and a right Judkins guide was placed.  The patient was started on bivalarudin.  A BMW wire was easily placed across the lesion and into the distal right coronary artery.  A 3.0 x 15 mm Voyager balloon was placed and deployed at 10 atmospheres.  The intermediate result was improved with TIMI-3 flow to the terminus of the vessel.  Following this, a 3.0 x 18 mm Xience stent was placed across the lesion and deployed at 17 atmospheres.  This revealed excellent result however at the very distal of the stent there was an area of haziness but no definite dissection.  This was stented with a 3.0 x 8 mm Xience stent deployed again at 17 atmospheres.  Final angiograms revealed excellent result with TIMI-3 flow at the terminus of the right coronary artery and approximately 10% residual stenosis at the worst point of the narrowing.  The guiding catheter was withdrawn over wire and a pigtail was placed.  This was advanced to the abdominal aorta at the area of obstruction and small injection of contrast was given demonstrating that there was a small aneurysm versus a small retrograde dissection in that area with some dye hang up after injection.  The catheter was removed.  The bivalarudin was stopped at the termination of procedure.  A small injection of contrast given through arterial sheath and Angio-Seal was placed without incident.,It should also be noted that an 8-French sheath was placed in the right femoral vein.  This was placed initially as the patient was going to have a right heart catheterization as well because of the dyspnea.,Total contrast media, 205 mL, total fluoroscopy time was 7.5 minutes, X-ray dose, 2666 milligray.,HEMODYNAMICS: , Rhythm was sinus throughout the procedure.  Aortic pressure was 170/81 mmHg.,The right coronary artery is a dominant vessel.  This vessel gives rise to conus branch and two small RV free wall branches and PDA and a small left ventricular branch.  It should be noted that there was competitive flow in the posterior left ventricular branch and that the distal right coronary artery fills via left sided collaterals.  In the proximal right coronary artery, there is a large ulcerative plaque followed immediately by a severe stenosis that is subtotal in severity.  After intervention, there is TIMI-3 flow to the terminus of the right coronary with better fill into the distal right coronary artery and loss of competitive flow.  There was approximately 10% residual stenosis at the worst part of the previous stenosis.,The left main is without disease and trifurcates into a moderate-sized ramus intermedius, the LAD and the circumflex.  The ramus intermedius is free of disease.  The LAD terminates at the LV apex and has elongated area of mild stenosis at its mid segment.  This measures 25% to 30% at its worst point.  The circumflex is a large caliber vessel.  There is a proximal 15% to 20% stenosis and an area of ectasia in the proximal circumflex.  Distally, this circumflex gives rise to a large bifurcating marginal artery and beyond that point, the circumflex is a small vessel within the AV groove.,The aortogram demonstrates eccentric aneurysm formation.  This may represent a small retrograde dissection as well.  There was some dye hang up in the wall.,IMPRESSION,1.  Successful stenting of subtotal stenosis of the proximal coronary artery.,2.  Non-obstructive coronary artery disease in the mid left anterior descending as described above and ectasia of the proximal circumflex coronary artery.,3.  Left to right collateral filling noted prior to coronary intervention.,4.  Small area of eccentric aneurysm formation in the abdominal aorta.
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DESCRIPTION: Selective coronary angiography.  Placement of overlapping 3.0 x 18 and 3.0 x 8 mm Xience stents in the proximal right coronary artery.  Abdominal aortography.

surgery, xience stents, thallium scan, coronary artery, coronary angiography, abdominal aortography, artery, coronary, angiography, stents, flow, vessel, abdominal, catheter, circumflex, stenosis, proximal,

The situation described involves a 65-year-old patient undergoing a coronary angiography to address chest pain and dyspnea, indicative of possible coronary artery disease. The procedure revealed a high-grade lesion in the right coronary artery, requiring stenting, which is a significant and potentially risky intervention given the patient's symptoms and findings. Additionally, the discovery of a small aneurysm or retrograde dissection in the abdominal aorta complicates the clinical picture. These factors point towards high stakes, as the patient's life may be at risk due to the severe cardiovascular conditions, and the interventions carry significant risks, despite the successful outcome described.


Medical Specialty: ENT - Otolaryngology
Sample Name: Rhinectomy & Nasal Endoscopy

PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma, left nasal cavity.,POSTOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma, left nasal cavity.,OPERATIONS PERFORMED:,1.  Nasal endoscopy.,2.  Partial rhinectomy.,ANESTHESIA:,  General endotracheal.,INDICATIONS: , This is an 81-year-old gentleman who underwent septorhinoplasty many years ago.  He also has a history of a skin lesion, which was removed from the nasal ala many years ago, the details of which he does not recall.  He has been complaining of tenderness and induration of his nasal tip for approximately two years and has been treated unsuccessfully for folliculitis and cellulitis of the nasal tip.  He was evaluated by Dr. A, who performed the septorhinoplasty, and underwent an intranasal biopsy, which showed histologic evidence of invasive squamous cell carcinoma.  The preoperative examination shows induration of the nasal tip without significant erythema.  There is focal tenderness just cephalad to the alar crease.  There is no lesion either externally or intranasally.,PROCEDURE AND FINDINGS: , The patient was taken to the operating room and placed in supine position.  Following induction of adequate general endotracheal anesthesia, the left nose was decongested with Afrin.  He was prepped and draped in standard fashion.  The left nasal cavity was examined by anterior rhinoscopy.  The septum was midline.  There was slight asymmetry of the nares.  No lesion was seen within the nasal cavity either in the area of the intercartilaginous area, which was biopsied by Dr. A, the septum, the lateral nasal wall, and the floor.  The 0-degree nasal endoscope was then used to examine the nasal cavity more completely.  No lesion was detectable.  A left intercartilaginous incision was made with a #15 blade since this was the area of previous biopsy by Dr. A.  The submucosal tissue was thickened diffusely, but there was no identifiable distinct or circumscribed lesion present.  Random biopsies of the submucosal tissue were taken and submitted to pathology for frozen section.  A diagnosis of diffuse invasive squamous cell carcinoma was rendered.  An alar incision was made with a #15 blade and the full-thickness incision was completed with the electrocautery.  The incision was carried more cephalad through the lower lateral cartilage up to the area of the upper lateral cartilage at the superior margin.  The full unit of the left nasal tip was excised completely and submitted to pathology after tagging and labeling it.  Frozen section examination again revealed diffuse squamous cell carcinoma throughout the soft tissues involving all margins.  Additional soft tissue was then taken from all margins tagging them for the pathologist.  The inferior margins were noted to be clear on the next frozen section report, but there was still disease present in the region of the upper lateral cartilage at its insertion with the nasal bone.  A Joseph elevator was used to elevate the periosteum off the maxillary process and off the inferior aspect of the nasal bone.  Additional soft tissue was taken in these regions along the superior margin.  The frozen section examination revealed persistent disease medially and additional soft tissue was taken and submitted to pathology.  Once all margins had been cleared histologically, additional soft tissue was taken from the entire wound.  A 5-mm chisel was used to take down the inferior aspect of the nasal bone and the medial-most aspect of the maxilla.  This was all submitted to pathology for routine permanent examination.  Xeroform gauze was then fashioned to cover the defect and was sutured along the periphery of the wound with interrupted 6-0 nylon suture to provide a barrier and moisture.  The anesthetic was then discontinued as the patient was extubated and transferred to the PACU in good condition having tolerated the procedure well.  Sponge and needle counts were correct.
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DESCRIPTION: Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma, left nasal cavity.

ent - otolaryngology, nasal cavity, joseph elevator, squamous cell carcinoma, endoscopy, intranasally, maxilla, nasal ala, nasal tip, rhinectomy, septorhinoplasty, nasal endoscopy, lateral cartilage, frozen section, additional soft, squamous cell, cell carcinoma, nasal, cartilage, squamous, carcinoma, cavity, tissue

The scenario describes a complex surgical procedure performed on an elderly patient with squamous cell carcinoma in the nasal cavity. This situation involves significant health risks due to the nature of cancer and the invasiveness of the surgical intervention (nasal endoscopy and partial rhinectomy) required to remove it. The potential consequences of not successfully removing all cancerous tissue, possible complications from the surgery itself, and the patient's advanced age increase the stakes. Furthermore, the procedure requires general anesthesia, which adds to the risks. Given these factors, the situation is considered high-stakes clinically and for the patient’s well-being.


Medical Specialty: Surgery
Sample Name: Low-Transverse C-Section - 9

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy of 39 weeks.,2.  Herpes simplex virus, positive by history.,3.  Hepatitis C, positive by history with low elevation of transaminases.,4.  Cephalopelvic disproportion.,5.  Asynclitism.,6.  Postpartum macrosomia.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy of 39 weeks.,2.  Herpes simplex virus, positive by history.,3.  Hepatitis C, positive by history with low elevation of transaminases.,4.  Cephalopelvic disproportion.,5.  Asynclitism.,6.  Postpartum macrosomia.,7.  Delivery of viable 9 lb female neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , About 600 cc.,Baby is doing well.  The patient's uterus is intact, bladder is intact.,HISTORY: , The patient is an approximately 25-year-old Caucasian female with gravida-4, para-1-0-2-1.  The patient's last menstrual period was in December of 2002 with a foreseeable due date on 09/16/03 confirmed by ultrasound.,The patient has a history of herpes simplex virus to which there is no active prodromal and no evidence of lesions.  The patient has a history of IVDA and contracted hepatitis C with slightly elevated liver transaminases.  The patient had been seen through our office for prenatal care.  The patient is on Valtrex.  The patient was found to be 3 cm about 40%, 0 to 9 engaged.  Bag of waters was ruptured.  She was on Pitocin.  She was contracting appropriately for a couple of hours or so with appropriate ________.  There was no cervical change noted.  Most probably because there was a sink vertex and that the head was too large to descend into the pelvis.  The patient was advised of this and we recommended cesarean section.  She agreed.  We discussed the surgery, foreseeable risks and complications, alternative treatment, the procedure itself, and recovery in layman's terms.  The patient's questions were answered.  I personally made sure that she understood every aspect of the consent and that she was comfortable with the understanding of what would transpire.,PROCEDURE:  ,The patient was then taken back to operative suite.  She was given anesthetic and sterilely prepped and draped.  Pfannenstiel incision was used.  A second knife was used to carry the incision down to the anterior rectus fascia.  Anterior rectus fascia was incised in the midline and carried bilaterally and the fascia was lifted off the underlying musculature.  The rectus muscles were separated.  The patient's peritoneum tented up towards the umbilicus and we entered the abdominal cavity.  There was a very thin lower uterine segment.  There seemed to be quite a large baby.  The patient had a small nick in the uterus.  Following the blunt end of the bladder knife going through the innermost layer of the myometrium and into the endometrial cavity, clear amniotic fluid was obtained.  A blunt low transverse cervical incision was made.  Following this, we placed a ________ on the very large fetal head.  The head was delivered following which we were able to deliver a large baby girl, 9 lb, good at tone and cry.  The patient then underwent removal of the placenta after the cord blood and ABG were taken.  The patient's uterus was examined.  There appeared to be no retained products.  The patient's uterine incision was reapproximated and sutured with #0 Vicryl in a running non-interlocking fashion, the second imbricating over the first.  The patient's uterus was hemostatic.  Bladder flap was reapproximated with #0 Vicryl.  The patient then underwent an irrigation at every level of closure and the patient was quite hemostatic.  We reapproximated the rectus musculature with care being taken not to incorporate any underlying structures.  The patient had three interrupted sutures of this.  The fascia was reapproximated with two stitches of #0 Vicryl going from each apex towards the midline.  The Scarpa's fascia was reapproximated with #0 gut.  There was noted no fascial defects and the skin was closed with #0 Vicryl.,Prior to closing the abdominal cavity, the uterus appeared to be intact and bladder appeared to have clear urine and appeared to be intact.  The patient was hemostatic.  All counts were correct and the patient tolerated the procedure well.  We will see her back in recovery.
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DESCRIPTION: Primary low transverse cervical cesarean section.   Intrauterine pregnancy of 39 weeks, Herpes simplex virus positive by history, hepatitis C positive by history with low elevation of transaminases, cephalopelvic disproportion, asynclitism, postpartum macrosomia, and delivery of viable 9 lb female neonate.

surgery, intrauterine pregnancy, herpes simplex virus, hepatitis c, cephalopelvic disproportion, asynclitism, postpartum, macrosomia, low transverse cervical cesarean section, rectus fascia, cesarean section, intrauterine, transaminases, herpes, uterus, fascia,

The situation described is a surgical procedure for a cesarean section, which is inherently high-stakes due to the medical complexities and potential risks involved both for the mother and the baby. The patient has additional complicating factors such as a history of herpes simplex virus, hepatitis C, and cephalopelvic disproportion, which increase the stakes as they require careful management during surgery. Despite the mention of no complications during the surgery, the operation of a C-section and the associated risks and complexities involved in ensuring both mother and child's safety classify this as a high-stakes medical procedure.


Medical Specialty: Surgery
Sample Name: Needle-Localized Excisional Biopsy - Breast

PREOPERATIVE DIAGNOSIS:,  Suspicious microcalcifications, left breast.,POSTOPERATIVE DIAGNOSIS:,  Suspicious microcalcifications, left breast.,PROCEDURE PERFORMED:,  Needle-localized excisional biopsy, left breast.,ANESTHESIA:,  Local with sedation.,SPECIMEN:  ,Left breast with specimen mammogram.,COMPLICATIONS:,  None.,HISTORY: , The patient is a 71-year-old black female who had a routine mammogram, which demonstrated suspicious microcalcifications in the left breast.  She had no palpable mass on physical exam.  She does have significant family history with two daughters having breast cancer.  The patient also has a history of colon cancer.  A surgical biopsy was recommended and she was scheduled electively.,PROCEDURE:,  After proper informed consent was obtained, she was placed in the operative suite.  This occurred after undergoing preoperative needle localization.  She was placed in the operating room in the supine position.  She was given sedation by the Anesthesia Department.  The left breast was prepped and draped in the usual sterile fashion.  The skin was infiltrated with local and a curvilinear incision was made in the left lower outer quadrant.  The breast tissue was grasped with Allis clamps and a core of tissue was removed around the localization wire.  There were some fibrocystic changes noted.  The specimen was then completely removed and was sent to Radiology for mammogram.  The calcifications were seen in specimen per Dr. X.  Meticulous hemostasis was achieved with electrocautery.  The area was irrigated and suctioned.,The aspirant was clear.  The skin was then reapproximated using #4-0 undyed Vicryl in a running subcuticular fashion.  Steri-Strips and sterile dressing on the patient's bra were applied.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.
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DESCRIPTION: Needle-localized excisional biopsy, left breast.  The patient is a 71-year-old black female who had a routine mammogram, which demonstrated suspicious microcalcifications in the left breast.  She had no palpable mass on physical exam.  She does have significant family history with two daughters having breast cancer.

surgery, suspicious microcalcifications, needle-localized excisional biopsy, needle localized excisional biopsy, routine mammogram, breast cancer, excisional biopsy, breast, needle, biopsy, mammogram, microcalcifications

The situation involves a surgical procedure related to suspicious microcalcifications in the breast, which could potentially indicate breast cancer. Given the patient's age, prior history of colon cancer, and a strong family history of breast cancer, the situation is medically significant, as the biopsy will help determine the presence of cancer. The stakes are high because the outcome could lead to a cancer diagnosis requiring further treatment. However, as the procedure was elective and there were no reported complications, it is not as high-stakes as emergency surgery.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Cardiology Progress Note

SUBJECTIVE:,  The patient is a 78-year-old female with the problem of essential hypertension.  She has symptoms that suggested intracranial pathology, but so far work-up has been negative.,She is taking hydrochlorothiazide 25-mg once a day and K-Dur 10-mEq once a day with adequate control of her blood pressure.  She denies any chest pain, shortness of breath, PND, ankle swelling, or dizziness.,OBJECTIVE:,  Heart rate is 80 and blood pressure is 130/70.  Head and neck are unremarkable.  Heart sounds are normal.  Abdomen is benign.  Extremities are without edema.,ASSESSMENT AND PLAN:,  The patient reports that she had an echocardiogram done in the office of Dr. Sample Doctor4 and was told that she had a massive heart attack in the past.  I have not had the opportunity to review any investigative data like chest x-ray, echocardiogram, EKG, etc.  So, I advised her to have a chest x-ray and an EKG done before her next appointment, and we will try to get hold of the echocardiogram on her from the office of Dr. Sample Doctor4.  In the meantime, she is doing quite well, and she was advised to continue her current medication and return to the office in three months for followup.
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DESCRIPTION: Problem of essential hypertension.  Symptoms that suggested intracranial pathology.

soap / chart / progress notes, cardiology, ekg, k-dur, progerss note, soap, ankle swelling, blood pressure, chest x-ray, echocardiogram, essential hypertension, heart attack, hydrochlorothiazide, hypertension, pathology, chest, heart, intracranial,

The scenario involves a 78-year-old patient with a history of essential hypertension and the potential of a past major cardiac event. While her current symptoms are well-managed and investigations thus far have not confirmed serious complications, the mention of a 'massive heart attack' in the past and the need for further diagnostic evaluations, such as chest x-ray and EKG, indicate that it is important to monitor and manage her condition carefully. However, since she is currently stable with adequate blood pressure control and no alarming symptoms, the urgency is moderate. The situation does not appear to be immediately life-threatening but requires attentive monitoring and evaluation, which places it at a medium stake level.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 4

GENERAL:  ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX.  Height XXX, weight XXX.,HEAD: , Normocephalic.  Negative lesions, negative masses.,EYES: , PERLA, EOMI.  Sclerae clear.  Negative icterus, negative conjunctivitis.,ENT:,  Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates.  Negative ear obstructions, negative exudates.  Negative inflammation in external auditory canals.  Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers.  No tattoos.,NECK:,  Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:,  Regular rate and rhythm.  Negative rubs, negative gallops, negative murmurs.,LUNGS:,  Clear to auscultation.  Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds.  Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing.  Pulses adequate bilaterally.,MUSCULOSKELETAL:,  Negative muscle atrophy, negative masses.  Strength adequate bilaterally.  Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact.  Negative gait disturbance.  Balance and coordination intact.  Negative Romberg, negative Babinski.  DTRs equal bilaterally.,GENITOURINARY:  ,Deferred.,
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DESCRIPTION: Normal physical exam template.  Normocephalic.  Negative lesions, negative masses.

The provided situation involves a standardized template for documenting a normal physical exam. This documentation is routine and indicates that the patient does not present any immediate or concerning symptoms requiring urgent attention. As such, the stakes are low because the examination details a general, uneventful physical assessment with no identified medical concerns. The potential implications for patient health in this context are minimal, as all findings are within expected normal limits.


Medical Specialty: Surgery
Sample Name: Infected Toenails

S - ,This patient has reoccurring ingrown infected toenails.  He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border.  The right great toenail is ingrown on the lateral nail border only.  There is mild redness and granulation tissue growing on the borders of the toes.  One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe.  These lesions measure 0.5 cm in diameter each.  I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1.  Onychocryptosis.,
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DESCRIPTION: This patient has reoccurring ingrown infected toenails.

surgery, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected,

Reoccurring ingrown toenails, while uncomfortable and potentially painful, are typically not considered high-stakes from a medical perspective. They are a common condition that can often be managed with proper at-home care or minor surgical procedures in a clinical setting. The description does not mention any systemic infections or other serious complications that would elevate the stakes.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 2

ADMISSION DIAGNOSIS (ES):,1. Chronic obstructive pulmonary disease.,2. Pneumonia.,3. Congestive heart failure.,4. Diabetes mellitus.,5. Neuropathy.,6. Anxiety.,7. Hypothyroidism.,8. Depression.,9. Hypertension.,DISCHARGE DIAGNOSIS (ES):,1. Severe chronic obstructive pulmonary disease.,2. Diabetes mellitus.,3. Hypothyroidism.,4. Altered mental status, less somnolent, likely secondary to medications, resolved.,5. Lower gastrointestinal bleed.,6. Status post episode of atrial fibrillation.,7. Status post diverticular bleed.,DISCHARGE MEDICATIONS:,1. Albuterol inhaler q.i.d.,2. Xanax 1 mg t.i.d.,3. Cardizem CD 120 mg daily.,4. Colace 100 mg b.i.d.,5. Iron sulfate 325 mg b.i.d.,6. NPH 10 units subcutaneous b.i.d.,7. Atrovent inhaler q.i.d.,8. Statin oral suspension p.o. q.i.d., swish and spit.,9. Paxil 10 mg daily.,10. Prednisone 20 mg daily.,11. Darvocet Darvocet-N 100, one q.4h PRN pain.,12. Metamucil one pack b.i.d.,13. Synthroid 50 mcg daily.,14. Nexium 40 mg daily.,HOSPITAL COURSE:, The patient was a 66-year-old who presented with complaints of shortness of breath and was found to have acute COPD exacerbation. She had previously been at outlying hospital and had left AMA after 10 sets of BiPAP use. Here she was able to be kept off BiPAP later and slowly improved her exacerbation of COPD with the assistance of pulmonary. She was thought to have bronchitis as well and was treated with antibiotics. During hospitalization she developed acute lower GI bleed and was transferred to intensive care unit and transfused packed red blood cells. GI was consulted, performed endoscopy, revealing diverticular disease of the sigmoid colon, with this being the suspected cause of hemorrhage. Plavix is being held for at least 10 days. Lovenox held as well. No further signs of bleeding. The patient's respiratory status did slowly improve to baseline. She is discharged and given the above noted medications. Followup with Dr. Pesce, of diagnostic pulmonary, in the outpatient setting. She will also followup with Dr. Pesce, in the outpatient setting.
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DESCRIPTION: Patient with complaints of shortness of breath and was found to have acute COPD exacerbation.

The discharge summary indicates that the patient has multiple chronic conditions, including severe COPD, diabetes, and hypothyroidism, which are complex and require ongoing medical management. Additionally, there were acute issues during the hospital stay, such as a lower GI bleed and atrial fibrillation, which required intensive care unit intervention. The need for follow-up with specialists and the detailed discharge medication list imply that comprehensive and careful outpatient management is critical. Nevertheless, the immediate hospital course was managed, and the patient was stable for discharge. This makes the situation moderately high-stakes due to the complexity of managing multiple comorbidities and ensuring patient adherence to a complicated medication regimen and follow-up schedule.


Medical Specialty: Ophthalmology
Sample Name: Radioactive Plaque - Insertion

PREOPERATIVE DIAGNOSIS:,  Macular edema, right eye.,POSTOPERATIVE DIAGNOSIS:  ,Macular edema, right eye.,TITLE OF OPERATION: , Insertion of radioactive plaque, right eye with lateral canthotomy.,OPERATIVE PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the usual manner for a local eye procedure.  Initially, a 5 cc retrobulbar injection of 2% Xylocaine was done.  Then, a lid speculum was inserted and the conjunctiva was incised 4 mm posterior to the limbus.  A 2-0 silk traction suture was placed around the insertion of the lateral rectus muscle and, with gentle traction, the temporal one-half of the globe was exposed.  The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron.  The placement was confirmed with indirect ophthalmoscopy.  Next, the eye was irrigated with Neosporin and the conjunctiva was closed with 6-0 plain catgut.  The intraocular pressure was found to be within normal limits.  An eye patch was applied and the patient was sent to the Recovery Room in good condition.  A lateral canthotomy had been done.
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DESCRIPTION: Macular edema, right eye.  Insertion of radioactive plaque, right eye with lateral canthotomy.  The plaque was positioned on the scleral surface immediately behind the macula and secured with two sutures of 5-0 Dacron.  The placement was confirmed with indirect ophthalmoscopy.

ophthalmology, canthotomy, ophthalmoscopy, radioactive plaque, scleral surface, macular edema, lateral canthotomy, macular

The procedure involves the insertion of a radioactive plaque in the eye, which is a highly critical and specialized operation due to the sensitive and essential nature of ocular structures. Proper plaque placement and management are vital to avoid complications that could result in severe consequences, including loss of vision or further retinal damage. Additionally, the use of radioactive materials inherently poses unique risks. Therefore, this is a high-stakes situation.


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

ADMITTING DIAGNOSES,1. Prematurity.,2. Appropriate for gestational age.,3. Maternal group B streptococcus positive culture.,DISCHARGE DIAGNOSES,1. Prematurity, 34 weeks' gestation, now 5 days old.,2. Group B streptococcus exposure, but no sepsis.,3. Physiologic jaundice.,4. Feeding problem.,HISTORY OF ILLNESS:  ,This is a 4-pound female infant born to a 26-year-old gravida 1, now para 1-0-0-1 lady with an EDC of November 19, 2003.  Group B streptococcus culture was positive on September 29, 2003, and betamethasone was given 1 dose prior to delivery.  Mother also received 1 dose of penicillin approximately 1-1/2 hours prior to delivery.  The infant delivered vaginally, had a double nuchal cord and required CPAP and free flow oxygen.  Her Apgars were 8 at 1 minute and 9 at 5 minutes.  At the end of delivery, it was noted there was a partial placental abruptio.,HOSPITAL COURSE:  ,The infant has had a basically uncomplicated hospital course.  She did not require oxygen.  She did have antibiotics, ampicillin and gentamicin for approximately 48 hours to cover for possible group B streptococcus.  The culture was negative and the antibiotics were stopped at 48 hours.,The infant was noted to have physiologic jaundice and her highest bilirubin was 7.1.  She was treated for approximately 24 hours with phototherapy and the bilirubin on October 15, 2003 was 3.4.,FEEDING: , The infant has had some difficulty with feeding, but at the time of discharge, she is taking approximately 30 mL every feeding and is taking Formula or breast milk, that is, ___ 24 calories per ounce.,PHYSICAL EXAMINATION:, ,VITAL SIGNS:  At discharge, reveals a well-developed infant whose temperature is 98.3, pulse 156, respirations 35, her weight is 1779 g (1% below her birthweight).,HEENT:  Head is normocephalic.  Eyes are without conjunctival injection.  Red reflex is elicited bilaterally.  TMs not well visualized.  Nose and throat are patent without palatal defect.,NECK:  Supple without clavicular fracture.,LUNGS:  Clear to auscultation.,HEART:  Regular rate without murmur, click or gallop present.,EXTREMITIES:  Pulses are 2/4 for brachial and femoral.  Extremities without evidence of hip defects.,ABDOMEN:  Soft, bowel sounds present.  No masses or organomegaly.,GENITALIA:  Normal female, but the clitoris is not covered by the labia majora.,NEUROLOGICAL:  The infant has good Moro, grasp, and suck reflexes.,INSTRUCTIONS FOR CONTINUING CARE,The infant will be discharged home.  She will have home health visits one time per week for 3 weeks, and she will be seen in followup at San Juan Pediatrics the week of October 20, 2003.  She is to continue feeding with either breast milk or Formula, that is, ___ to 24 calories per ounce.,CONDITION: , Her condition at discharge is good.
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DESCRIPTION: Prematurity, 34 weeks' gestation, now 5 days old, group B streptococcus exposure, but no sepsis, physiologic jaundice, and feeding problem.

The discharge summary describes a premature infant who had some complications at birth, including exposure to group B streptococcus and a feeding problem. However, the infant's condition at discharge is noted to be good, and steps have been taken to monitor her health through home health visits and a follow-up appointment. The fact that no severe complications like sepsis developed and that she is considered well enough to go home with follow-up care suggests the situation is not extremely high-stakes. Nonetheless, because this involves the health of a vulnerable newborn, there are still some significant considerations.


Medical Specialty: Surgery
Sample Name: Blepharon & Entropion Repair

PREOPERATIVE DIAGNOSES:,1.  Entropion, left upper lid.,2.  Entropion and some blepharon, right lower lid.,TITLE OF OPERATION:,1.  Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.,2.  Repairs of blepharon, entropion, right lower lid with mucous membrane graft.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room and prepped and draped in the usual fashion.  The left upper lid and right lower lid were all infiltrated with 2% Xylocaine with Epinephrine.,The lid was then everted with special clips and the mucotome was then used to cut a large mucous membrane graft from the lower lid measuring 0.5 mm in thickness.  The graft was placed in saline and a 4 x 4 was placed over the lower lid.,Attention was then drawn to the left upper lid and the operating microscope was found to place.  An incision was made in the gray line nasally in the area of trichiasis and entropion, and the dissection was carried anterior to the tarsal plate and an elliptical piece of the anterior lamella was excised.  Bleeding was controlled with the wet-field cautery and the cryoprobe was then used with a temperature of -8 degree centigrade in the freeze-thaw-refreeze technique to treat the bed of the excised area.,Attention was then drawn to the right lower lid with the operating microscope and a large elliptical area of the internal aspect of the lid margin was excised with a super blade.  Some of the blepharon were dissected from the globe and bleeding was controlled with the wet-field cautery.  An elliptical piece of mucous membrane was then fashioned and placed into the defect in the lower lid and sutured with a running 6-0 chromic catgut suture anteriorly and posteriorly.,The graft was in good position and everything was satisfactory at the end of procedure.  Some antibiotic steroidal ointment was instilled in the right eye and a light pressure dressing was applied.  No patch was applied to the left eye.  The patient tolerated the procedure well and was sent to recovery room in good condition.
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DESCRIPTION: Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.  Repairs of blepharon, entropion, right lower lid with mucous membrane graft.

surgery, entropion, blepharon, catgut suture, cryoprobe, cryotherapy, freeze-thaw-refreeze, lamella, lid, lower lid, tarsal plate, trichiasis, upper lid, mucous membrane graft, anterior lamella, mucous membrane, membrane

The scenario detailed involves a surgical procedure, specifically a repair of eyelid conditions (entropion and blepharon), which are relatively common but still involve surgical intervention. While this is not life-threatening surgery, there are inherent risks with any surgical procedure, such as infection, bleeding, reaction to anesthesia, and potential for surgical complications affecting the patient's vision or aesthetic outcome. The procedure's success is important for the patient's quality of life and comfort. Therefore, the stakes are moderately high.


Medical Specialty: General Medicine
Sample Name: Abdominal Pain - Consult

CHIEF COMPLAINT:,  Abdominal pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.  She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was "normal."  She was given oral antibiotics of Cipro and Flagyl.  She has had no nausea and vomiting, but has had persistent associated anorexia.  She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago.  She denies any bright red blood per rectum and no history of recent melena.  Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice.  The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY:  ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy.  She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS:  Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT:  Head is grossly atraumatic and normocephalic.  Sclerae are anicteric.  The conjunctivae are non-injected.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Generally nondistended and soft.  She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness.  There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC:  Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES:  Grossly and neurovascularly intact.,LABORATORY VALUES:  ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal.  Alkaline phosphatase elevated at 184.  Liver function tests otherwise normal.  Electrolytes normal.  Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:,  EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant.  Currently is a nonacute abdomen.  The working diagnosis would be sigmoid diverticulitis.  She does have a history in the distant past of sigmoid diverticulitis.  I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth.  The patient was seen 5 years ago by Dr. Y in Colorectal Surgery.  We will consult her also for evaluation.  The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically.  The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.
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DESCRIPTION: The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.

The situation involves a 71-year-old female with persistent abdominal pain localized to the left lower quadrant. Although the condition is non-acute and there is no indication for immediate surgical intervention, the patient has a history of significant medical conditions like atrial fibrillation and previous surgeries. There is a concern for sigmoid diverticulitis, which requires close observation and further diagnostic workup, including a repeat CT scan and consultation with a colorectal surgeon. While the condition does not currently present life-threatening symptoms, the patient's age, medical history, and the potential for complications if not properly managed make this a moderately high-stakes situation.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 45

REASON FOR CONSULT: , For evaluation of left-sided chest pain, 5 days post abdominal surgery.,PAST MEDICAL HISTORY:, None.,HISTORY OF PRESENT COMPLAINT: , This 87-year-old patient has been admitted in this hospital on 12/03/08.  The patient underwent laparoscopic appendicectomy by Dr. X.  The patient had postoperative paralytic ileus, which has resolved.  The patient had developed left-sided chest pain yesterday.  In the postoperative period, the patient has had fluid retention, had gain about 25 pounds, and he had swelling of the lower extremities.,REVIEW OF SYSTEMS:,CONSTITUTIONAL SYMPTOMS:  No recent fever.,ENT:  Unremarkable.,RESPIRATORY:  He denies cough but develop this left-sided chest pain, which does not increase with inspiration, pain is located on the left posterior axillary line and over the fourth and fifth rib.,CARDIOVASCULAR:  No known heart problems.,GASTROINTESTINAL:  The patient denies nausea or vomiting.  He is status post laparoscopic appendicectomy, and he is tolerating oral diet.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  Negative for diabetes or thyroid problems.,NEUROLOGIC:  No history of CVA or TIA.,Rest of review of systems unremarkable.,SOCIAL HISTORY:  ,The patient is a nonsmoker.  He denies use of alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  An 87-year-old gentleman, not toxic looking.,HEAD AND NECK:  Oral mucosa is moist.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.  There is reproducible tenderness over the left posterior-lateral axis.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Slightly distended.  Bowel sounds are positive.,EXTREMITIES:  He has 2+ to 3+ pedal swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA: , White count is 12,500, hemoglobin is 13, hematocrit is 39, and platelets 398,000.  Glucose is 123, total protein is 6, and albumin is 2.9.,ASSESSMENT AND PLAN:,1.  Ruptured appendicitis.  The patient is 6 days post surgery.  He is tolerating oral fluids and moving bowels.,2.  Left-sided chest pain, need to rule out PE by distance of pretty low probability.  The patient, however, has low-oxygen saturation.  We will do ultrasound of the lower extremity and if this is positive we would proceed with the CT angiogram.,3.  Fluid retention, manage as per surgeon.,4.  Paralytic ileus, resolving.,5.  Leukocytosis, we will monitor.
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DESCRIPTION: For evaluation of left-sided chest pain, 5 days post abdominal surgery.

The situation involves an 87-year-old patient who experienced left-sided chest pain following abdominal surgery. Though the patient is post-laparoscopic appendicectomy and is experiencing fluid retention and pedal swelling, the primary concern is ruling out a potential pulmonary embolism (PE), which is a high-stakes medical concern. PE can be life-threatening if not diagnosed and treated promptly. The medical team is planning diagnostic testing, including ultrasound and potentially a CT angiogram, to rule out PE, indicating that this is taken seriously. Given the potential severity of PE and the combination of the patient's age and recent surgery, this situation is moderately high-stakes.


Medical Specialty: Radiology
Sample Name: CT Brain: Subdural Hemorrhage.

CC: ,Difficulty with speech.,HX:, This 84 y/o RHF presented with sudden onset word finding and word phonation difficulties. She had an episode of transient aphasia in 2/92 during which she had difficulty with writing, written and verbal comprehension, and exhibited numerous semantic and phonemic paraphasic errors of speech. These problems resolved within 24 hours of onset and she had no subsequent speech problems prior to this presentation. Workup at that time revealed a right to left shunt on trans-thoracic echocardiogram. Carotid doppler studies showed 0-15% BICA stenosis and a LICA aneurysm (mentioned above). Brain CT was unremarkable. She was placed on ASA after the 2/92 event.,In 5/92 she was involved in a motor vehicle accident and suffered a fractured left humerus and left occipital scalp laceration. HCT at that time showed a small area of slightly increased attenuation at the posterior right claustrum only. This was not felt to be a contusion; nevertheless, she was placed on Dilantin seizure prophylaxis. Her left arm was casted and she returned home.,5 hours prior to presentation today, the patient began having difficulty finding words and putting them into speech. She was able to comprehend speech. This continued for an hour; then partially resolved for one hour; then returned; then waxed and waned. There was no reported weakness, numbness, incontinence, seizure-like activity, incoordination, HA, nausea, vomiting, or lightheadedness,MEDS:, ASA , DPH, Tenormin, Premarin, HCTZ,PMH:, 1)transient fluent aphasia 2/92 (which resolved), 2)bilateral carotid endarterectomies 1986, 3)HTN, 4)distal left internal carotid artery aneurysm.,EXAM:,  BP 168/70, Pulse 82, RR 16, 35.8F,MS:A & O x 3, Difficulty following commands, Speech fluent, and without dysarthria. There were occasional phonemic paraphasic errors.,CN: Unremarkable.,Motor: 5/5 throughout except for 4+ right wrist extension and right knee flexion.,Sensory: unremarkable.,Coordination: mild left finger-nose-finger dysynergia and dysmetria.,Gait: mildly unsteady tandem walk.,Station: no Romberg sign.,Reflexes: slightly more brisk at the left patella than on the right. Plantar responses were flexor bilaterally.,The remainder of the neurologic exam and the general physical exam were unremarkable.,LABS:, CBC WNL, Gen Screen WNL, , PT/PTT WNL, DPH 26.2mcg/ml, CXR WNL, EKG: LBBB, HCT revealed a left subdural hematoma.,COURSE:, Patient was taken to surgery and the subdural hematoma was evacuated. Her mental status, language skills, improved dramatically. The DPH dosage was adjusted appropriately.
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DESCRIPTION: HCT: Subdural hemorrhage.

HCT: Subdural hemorrhage.

radiology, ct brain, ct, difficulty with speech, hct, subdural hemorrhage, hemorrhage, phonation difficulties, subdural, transient fluent aphasia, phonemic paraphasic errors, hematoma, carotid, speech,

The situation involves an elderly patient who presented with neurological symptoms and was found to have a subdural hematoma, a potentially life-threatening condition. The timely diagnosis via CT scan and the subsequent surgical intervention are critical to prevent serious, potentially permanent neurological damage or death. The stakes are high due to the need for quick decision-making and surgical intervention to relieve the pressure caused by the hemorrhage.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Psych Consult - Dementia

REASON FOR CONSULT,:  Dementia.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 33-year-old black female, referred to the hospital by a neurologist in Tyler, Texas for disorientation and illusions.  Symptoms started in June of 2006, when the patient complained of vision problems and disorientation.  The patient was seen wearing clothes inside out along with other unusual behaviors.  In August or September of 2006, the patient reported having a sudden onset of headaches, loss of vision, and talking sporadically without making any sense.  The patient sought treatment from an ophthalmologist.  We did not find any abnormality in the Behavior Center in Tyler, Texas.  The Behavior Center referred the patient to Dr. Abc, a neurologist in Tyler, who then referred the patient to this hospital.,According to the mother, the patient has had no past major medical or psychiatric illnesses.  The patient was functioning normally before June 2006, working as accounting tech after having completed 2 years of college.  She reports of worsening in symptoms, mainly unable to communicate about auditory or visual hallucinations or any symptoms of anxiety.  Currently, the patient lives with mother and requires her assistance to perform ADLs and the patient has become ataxic since November 2006.  Sleeping patterns and the amount is unknown.  Appetite is okay.,PAST PSYCHIATRIC HISTORY:,  The patient was diagnosed with severe depression in November 2006 at the Behavior Center in Tyler, Texas, where she was given Effexor.  She stopped taking it soon after, since they worsened her eye vision and balance.,PAST MEDICAL HISTORY: , In 2001 diagnosed with Meniere disease, was treated such that she could function normally in everyday activities including work.  No current medications.  Denies history of seizures, strokes, diabetes, hypertension, heart disease, or head injury.,FAMILY MEDICAL HISTORY:  ,Father's grandmother was diagnosed with Alzheimer disease in her 70s with symptoms similar to the patient described by the patient's mother.  Both, the mother's father and father's mother had "nervous breakdowns" but at unknown dates.,SOCIAL HISTORY: , The patient lives with a mother, who takes care of the patient's ADLs.  The patient completed school, up to two years in college and worked as accounting tech for eight years.  Denies use of alcohol, tobacco, or illicit drugs.,MENTAL STATUS EXAMINATION: , The patient is 33-year-old black female wearing clean clothes, a small towel on her head and over a wheel chair with her head rested on a pillow and towel.  Decreased motor activity, but did blink her eyes often, but arrhythmically.  Poor eye contact.  Speech illogic.  Concentration was not able to be assessed.  Mood is unknown.  Flat and constricted affect.  Thought content, thought process and perception could not be assessed.  Sensorial memory, information, intelligence, judgment, and insight could not be evaluated due to lack of communication by the patient.,MINI-MENTAL STATUS EXAM: , Unable to be performed.,AXIS I:  Rapidly progressing early onset of dementia, rule out dementia secondary to general medical condition, rule out dementia secondary to substance abuse.,AXIS II:  Deferred.,AXIS III:  Deferred.,AXIS IV:  Deferred.,AXIS V:  1.,ASSESSMENT: , The patient is a 32-year-old black female with rapid and early onset of dementia with no significant past medical history.  There is no indication as to what precipitated these symptoms, as the mother is not aware of any factors and the patient is unable to communicate.  The patient presented with headaches, vision forms, and disorientation in June 2006.  She currently presents with ataxia, vision loss, and illusions.,PLAN: , Wait for result of neurological tests.  Thank you very much for the consultation.
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DESCRIPTION: Psychiatric Consultation of patient with dementia.

consult - history and phy., reason for consult:, concentration, dementia, mood, psychiatric consultation, sensorial memory, affect, disorientation, illusions, information, insight, intelligence, judgment, loss of vision, motor activity, neurologist, thought process, unusual behaviors, mental status examination, consultation, headaches,

The situation involves a 33-year-old patient with rapidly progressing early onset dementia accompanied by severe functional impairments, which directly impacts their quality of life and daily functioning. The stakes are high as the correct diagnosis and treatment plan are crucial for managing her symptoms and potentially halting or slowing the progression of her condition. However, immediate life-threatening risks are not mentioned, slightly lowering the stakes from the highest possible level.


Medical Specialty: ENT - Otolaryngology
Sample Name: Ear Cartilage Graft

PREOPERATIVE DIAGNOSES:  ,1.  Posttraumatic nasal deformity.,2.  Nasal obstruction.,3.  Nasal valve collapse.,4.  Request for cosmetic change with excellent appearance of nose.,POSTOPERATIVE DIAGNOSES:,1.  Posttraumatic nasal deformity.,2.  Nasal obstruction.,3.  Nasal valve collapse.,4.  Request for cosmetic change with excellent appearance of nose.,OPERATIVE PROCEDURES:,1.  Left ear cartilage graft.,2.  Repair of nasal vestibular stenosis using an ear cartilage graft.,3.  Cosmetic rhinoplasty.,4.  Left inferior turbinectomy.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is with symptomatic nasal obstruction and fixed nasal valve collapse following a previous nasal fracture and attempted repair.  We discussed with the patient the indications, risks, benefits, alternatives, and complications of the proposed surgical procedure, she had her questions asked and answered.  Preoperative imaging was performed in consultation with regard to aesthetic results and communicated via the computerized imager.  The patient had questions asked and answered.  Informed consent was obtained.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed in supine position.  The appropriate level of general endotracheal anesthesia was induced.  The patient was converted to the lounge chair position, and the nose was anesthetized and vasoconstricted in the usual fashion.  Procedure began with an inverted going incision and elevation of the skin of the nose in the submucoperichondrial plane over the medial crural footplates and lower lateral cartilages and up over the dorsum.  The septal angle was approached and submucoperichondrial flaps were elevated.  Severe nasal septal deviation to the right hand side and evidence of an old fracture with a separate alignment of the cartilaginous nose from the bony nose was encountered.  The upper laterals were divided and medial and lateral osteotomies were carried out.  Inadequate septal cartilage was noted to be present for use as spreader graft; therefore, left postauricular incision was made, and the conchal bowl cartilage graft was harvested, and it was closed with 3-0 running locking chromic with a sterile cotton ball pressure dressing applied.  Ear cartilage graft was then placed to put two spreader grafts on the left and one the right.  The two on the left extended all the way up to the caudal tip, the one on the right just primarily the medial wall.  It was placed in such a way to correct a caudal dorsal deviation of the nasal tip septum.  The upper lateral cartilage was noted to be of the same width and length in size.  Yet, the left lower cartilage was scarred and adherent to the upper lateral cartilage.  The upper lateral cartilages were noted to be excessive of uneven length with the right being much taller than the left and that was shortened to the same length.  The scar bands were released in the lower lateral cartilages to the upper lateral cartilages to allow free mobilization of the lower lateral cartilages.  A middle crus stitch was used to unite the domes, and then the nose was projected by suturing the medial crural footplates of the caudal septum in deep projected fashion.  Crushed ear cartilage was then placed in the pockets above the spreader grafts in the area of the deficient dorsal nasal height and the lateral nasal sidewall height.  The spreader brought an excellent aesthetic appearance to the nose.  We left more than 1 cm of dorsal and caudal support for the nasal tip and dorsum height.  Mucoperichondrial flaps were closed with 4-0 plain gut suture.  The skin was closed with 5-0 chromic and 6-0 fast absorbing gut.  Doyle splints were placed on each side of nasal septum and secured with 3-0 nylon and a Denver splint was applied.  The patient was awakened in the operating room and taken to the recovery room in good condition.
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DESCRIPTION: Left ear cartilage graft, repair of nasal vestibular stenosis using an ear cartilage graft, cosmetic rhinoplasty, left inferior turbinectomy.

ent - otolaryngology, nasal deformity, nasal obstruction, nasal valve, cartilage, cartilaginous, crural, graft, nasal fracture, postauricular, rhinoplasty, septal cartilage, submucoperichondrial, turbinectomy, vestibular, ear cartilage graft, posttraumatic nasal deformity, vestibular stenosis, ear cartilage, cartilage graft, cartilages, caudal, nasal, nose, obstruction, repair, stenosis

The procedure described involves multiple surgical operations on the patient's nose and ear, addressing both functional problems (nasal obstruction and valve collapse) and cosmetic concerns. The high level of detail in the procedural description indicates the complexity of the operations. Additionally, the use of general anesthesia and the potential risks associated with surgery highlight the stakes involved. While the procedures are quite common in otolaryngology and cosmetic surgery, they hold significant importance for the patient's breathing functionality and appearance, affecting quality of life both medically and aesthetically. However, it's not an emergency or life-threatening procedure, which is why the stakes are not at the absolute highest level.


Medical Specialty: Gastroenterology
Sample Name: Endoscopy - 1

PROCEDURE:,  Upper endoscopy.,PREOPERATIVE DIAGNOSIS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,1.  GERD, biopsied.,2.  Distal esophageal reflux-induced stricture, dilated to 18 mm.,3.  Otherwise normal upper endoscopy.,MEDICATIONS: , Fentanyl 125 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 50-year-old white male with dysphagia, which has improved recently with Aciphex.,FINDINGS: , The patient was placed in the left lateral decubitus position and the above medications were administered.  The oropharynx was sprayed with Cetacaine.  The endoscope was passed, under direct visualization, into the esophagus.  The squamocolumnar junction was irregular and edematous.  Biopsies were obtained for histology.  There was a mild ring at the LES, which was dilated with a 15 to 18 mm balloon, with no resultant mucosal trauma.  The entire gastric mucosa was normal, including a retroflexed view of the fundus.  The entire duodenal mucosa was normal to the second portion.  The patient tolerated the procedure well without complication.,IMPRESSION:,1.  Gastroesophageal reflux disease, biopsied.,2.  Distal esophageal reflux-induced stricture, dilated to 18 mm.,3.  Otherwise normal upper endoscopy.,PLAN:,I will await the results of the biopsies.  The patient was told to continue maintenance Aciphex and anti-reflux precautions.  He will follow up with me on a p.r.n. basis.
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DESCRIPTION: Upper endoscopy, patient with dysphagia.

gastroenterology, lateral decubitus position, gastroesophageal reflux disease, gerd, normal upper endoscopy, mucosa was normal, esophageal reflux, stricture dilated, upper endoscopy, distal, esophageal, aciphex, biopsies, dysphagia, endoscopy, reflux,

The procedure described is an upper endoscopy performed on a patient with dysphagia. The endoscopy identified gastroesophageal reflux disease (GERD) and a reflux-induced esophageal stricture, which was treated during the procedure. Such procedures, while invasive, are generally low-risk, and no complications were noted. Biopsies were taken to rule out any more serious conditions, and the findings were addressed with ongoing medication and care. Although GERD and esophageal strictures can affect quality of life significantly if untreated, they are common issues that are typically manageable. The situation does not involve life-threatening conditions or immediate danger.


Medical Specialty: Nephrology
Sample Name: Azotemia Consult

REASON FOR CONSULTATION: , Azotemia.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 36-year-old gentleman admitted to the hospital because he passed out at home.,Over the past week, he has been noticing increasing shortness of breath.  He also started having some abdominal pain; however, he continued about his regular activity until the other day when he passed out at home.  His wife called paramedics and he was brought to the emergency room.,The patient has had a workup at this time which shows bilateral pulmonary infarcts.  He has been started on heparin and we are asked to see him because of increasing BUN and creatinine.,The patient has no past history of any renal problems.  He feels that he has been in good health until this current episode.  His appetite has been good.  He denies swelling in his feet or ankles.  He denies chest pain.  He denies any problems with bowel habits.  He denies any unexplained weight loss.  He denies any recent change in bowel habits or recent change in urinary habits.,PHYSICAL EXAMINATION:,GENERAL:  A gentleman seen who appears his stated age.,VITAL SIGNS:  Blood pressure is 130/70.,CHEST:  Chest expands equally bilaterally.  Breath sounds are heard bilaterally.,HEART:  Had a regular rhythm, no gallops or rubs.,ABDOMEN:  Obese.  There is no organomegaly.  There are no bruits.  There is no peripheral edema.  He has good pulse in all 4 extremities.  He has good muscle mass.,LABORATORY DATA: , The patient's current chemistries include a hemoglobin of 14.8, white count of 16.3, his sodium 133, potassium 5.1, chloride 104, CO2 of 19, a BUN of 26, and a creatinine of 3.5.  On admission to the hospital, his creatinine on 6/27/2009 was 0.9.,The patient has had several studies including a CAT scan of his abdomen, which shows poor perfusion to his right kidney.,IMPRESSION:,1.  Acute renal failure, probable renal vein thrombosis.,2.  Hypercoagulable state.,3.  Deep venous thromboses with pulmonary embolism.,DISCUSSION: , We are presented with a 36-year-old gentleman who has been in good health until this current event.  He most likely has a hypercoagulable state and has bilateral pulmonary emboli.  Most likely, the patient has also had emboli to his renal veins and it is causing renal vein thrombosis.,Interestingly, the urine protein was obtained which is not that elevated and I would suspect that it would have been higher.  Unfortunately, the patient has been exposed to IV dye and my anxiety is that this too is contributing to his current problem.,The patient's urine output is about 30 to 40 mL per hour.,Several chemistries have been ordered.  A triple renal scan has been ordered.,I reviewed all of this with the patient and his wife.  Hopefully under his current anticoagulation, there will be some resolution of his renal vein thrombosis.  If not and his renal failure progresses, we are looking at dialytic intervention.  Both he and his wife were aware of this.  ,Thank you very much for asking to see this acutely ill gentleman in consultation with you.
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DESCRIPTION: Acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism.

nephrology, urine output, deep venous thromboses, renal failure, pulmonary embolism, renal, azotemia, hypercoagulable, vein, thrombosis, pulmonary,

The consultation involves a 36-year-old male patient with acute renal failure, probable renal vein thrombosis, hypercoagulable state, and deep venous thromboses with pulmonary embolism (PE). These conditions are potentially life-threatening and can lead to significant morbidity if not properly managed. Renal failure may require dialysis, and PE can be fatal if not treated. The high levels of BUN and creatinine suggest significant kidney impairment. The consultation aims to address these serious medical issues and consider the potential need for dialysis, indicating high stakes due to the severity and complexity of the patient's condition.


Medical Specialty: Radiology
Sample Name: Astrocytoma

CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The "stroke" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.,PMH:, Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.,MEDS:, DPH and ASA,SHX/FHX:, 2-4 Beers/day. 1-2 packs of cigarettes per day.,EXAM:, BP 111/68, P 68BPM, 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally.,LAB:, Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.,Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.,CXR:, 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.,EEG:, 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect.,NEUROPSYCHOLOGICAL TESTING:, Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.,COURSE: ,Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed.
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DESCRIPTION: MRI - Right temporal lobe astrocytoma.

MRI - Right temporal lobe astrocytoma.

radiology, confusion, gfap, gfap staining, mri scan, astrocytoma, hippocampus, memory loss, palpitation, signal, stroke, temporal lobe, tongue-biting, tonic/clonic movement, weakness, increased t signal, mri brain, mri, temporal,

The situation involves a detailed medical case of a patient with an astrocytoma, a type of brain tumor. The procedural history includes diagnosis and treatment, including surgery and radiation therapy, which are critical aspects of the patient's care pathway. This makes it a potentially high-stakes situation because the diagnosis and treatment of brain tumors involve significant risk, complex decision-making, and potential for serious outcomes. Given the nature of the medical condition (astrocytoma), the oncologic implications, and the interventions undertaken, the stakes are quite high.


Medical Specialty: Urology
Sample Name: Penile Prosthesis Replacement

PREOPERATIVE DIAGNOSES:,1.  Nonfunctioning inflatable penile prosthesis.,2.  Peyronie's disease.,POSTOPERATIVE DIAGNOSES:,1.  Nonfunctioning inflatable penile prosthesis.,2.  Peyronie's disease.,PROCEDURE PERFORMED: , Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700.,ANESTHESIA:,  General LMA.,SPECIMEN: , Old triple component inflatable penile prosthesis.,PROCEDURE:  ,This is a 64-year-old male with prior history of Peyronie's disease and prior placement of a triple component inflatable penile prosthesis, which had worked for years for him, but has stopped working and subsequently has opted for ex-plantation and replacement of inflatable penile prosthesis.,OPERATIVE PROCEDURE: , After informed consent, the patient was brought to the operative suite and placed in the supine position.  General endotracheal intubation was performed by the Anesthesia Department and the perineum, scrotum, penis, and lower abdomen from the umbilicus down was prepped and draped in the sterile fashion in a 15-minute prep including iodine solution in the urethra.  The bladder was subsequently drained with a red Robinson catheter.  At that point, the patient was then draped in a sterile fashion and an infraumbilical midline incision was made and taken down through the subcutaneous space.  Care was maintained to avoid all bleeding as possible secondary to the fact that we could not use Bovie cautery secondary to the patient's pacemaker and monopolar was only source of hemostasis besides suture.  At that point, we got down to the fascia and the dorsal venous complex was easily identified as were both corporal bodies.  Attention was taken then to the tubing, going up to the reservoir in the right lower quadrant.  This was dissected out bluntly and sharply with Metzenbaum scissors and monopolar used for hemostasis.  At this point, as we tracked this proximally to the area of the rectus muscle, we found that the tubing was violated and this was likely the source of his malfunctioned inflatable penile prosthesis.  As we tried to remove the tubing and get to the reservoir, the tubing in fact completely broke as due to wire inside the tubing and the reservoir was left in its place secondary to risk of going after it and bleeding without the use of cautery.  At that point, this tubing was then tracked down to the pump, which was fairly easily removed from the dartos pouch in the right scrotum.  This was brought up into _________ incision and the two tubings going towards the two cylinders were subsequently tracked, first starting on the right side where a corporotomy incision was made at the placement of two #3-0 Prolene stay ties, staying lateral and anterior on the corporal body.  The corporal body was opened up and the cylinder was removed from the right side without difficulty.  However, we did have significant difficulty separating the tube connecting the pump to the right cylinder since this was surrounded by dense connective tissue and without the use of Bovie cautery, this was very difficult and was very time consuming, but we were able to do this and attention was then taken to the left side where the left proximal corporotomy was made after placement of two stick tie stay sutures.  This was done anterior and lateral staying away from the neurovascular bundle in the midline and this was done proximally on the corporal body.  The left cylinder was then subsequently explanted and this was very difficult as well trying to tract the tubing from the left cylinder across the midline back to the right pump since this was also densely scarred in and _________ a small amount of bleeding, which was controlled with monopolar and cautery was used on three different occasions, but just simple small burst under the guidance of anesthesia and there was no ectopy noted.  After removal of half of the pump, all the tubing, and both cylinders, these were passed off the table as specimen.  Both corporal bodies were then dilated with the Pratt dilators.  These were already fairly well dilated secondary to explantation of our cylinders and antibiotic irrigation was copiously used at this point and irrigated out both of our corporal spaces.  At this point, using the Farlow device, corporal bodies were measured first proximally then distally and they both measured out to be 9 cm proximally and 12 cm distally.  He had an 18 cm with rear tips in place, which were removed.  We decided to go ahead to and use another 18 cm inflatable penile prosthesis.  Confident with our size, we then placed rear tips, originally 3 cm rear tips, however, we had difficulty placing the rear tips into the left crest.  We felt that this was just a little bit too long and replaced both rear tips and down sized from 2 cm to 1 cm.  At this point, we went ahead and placed the right cylinder using the Farlow device and the Keith needle, which was brought out through the glans penis and hemostated and the posterior rear tip was subsequently placed proximally, entered the crest without difficulty.  Attention was then taken to the left side with the same thing was carried out, however, we did happen to dilate on two separate occasions both proximally and distally secondary to a very snug fit as well as buckling of the cylinders.  This then forced us to down size to the 1 cm rear tips, which slipping very easily with the Farlow device through the glans penis.  There was no crossover and no violation of the tunica albuginea.  The rear tips were then placed without difficulty and our corporotomies were closed with #2-0 PDS in a running fashion.  ________ starting on the patient's right side and then on the left side without difficulty and care was maintained to avoid damage or needle injury to the implants.  At that point, the wound was copiously irrigated and the device was inflated multiple times.  There was a very good fit and we had a very good result.  At that point, the pump was subsequently placed in the dartos pouch, which already has been created and was copiously irrigated with antibiotic solution.  This was held in place with a Babcock as well not to migrate proximally and attention was then taken to our connection from the reservoir to the pump.  Please also note that before placement of our pump, attention was then taken up to the left lower quadrant where an incision was then made in external oblique aponeurosis, approximately 3 cm dissection down underneath the rectus space was developed for our reservoir device, which was subsequently placed without difficulty and three simple interrupted sutures of #2-0 Vicryl used to close the defect in the rectus and at that point after placement of our pump, the connection was made between the pump and the reservoir without difficulty.  The entire system pump and corporal bodies were subsequently flushed and all air bubbles were evacuated.  After completion of the connection using a straight connector, the prosthesis was inflated and we had very good results with air inflation with good erection in both cylinders with a very slight deviation to the left, but this was able to be ________ with good cosmetic result.  At that point, after irrigation again of the space, the area was simply dry and hemostatic.  The soft tissue was reapproximated to separate the cylinder so as not to lie in rope against one another and the wound was closed in multiple layers.  The soft tissue and the skin was then reapproximated with staples.  Please also note that prior to the skin closure, a Jackson-Pratt drain was subsequently placed through the left skin and left lower quadrant and subsequently placed just over tubings, would be left in place for approximately 12 to 20 hours.  This was also sutured in place with nylon.  Sterile dressing was applied.  Light gauze was wrapped around the penis and/or sutures that begin at the tip of the glans penis were subsequently cut and removed in entirety bilaterally.  Coban was used then to wrap the penis and at the end of the case the patient was straight catheted, approximately 400 cc of amber-yellow urine.  No Foley catheter was used or placed.,The patient was awoken in the operative suite, extubated, and transferred to recovery room in stable condition.  He will be admitted overnight to the service of Dr. McDevitt.  Cardiology will be asked to consult with Dr. Stomel for a pacer placement and he will be placed on the Telemetry floor and kept on IV antibiotics.
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DESCRIPTION: Ex-plantation of inflatable penile prosthesis and then placement of second inflatable penile prosthesis AMS700.  Nonfunctioning inflatable penile prosthesis and Peyronie's disease.

urology, inflatable penile prosthesis, peyronie's disease, perineum, scrotum, penis, penile prosthesis, bovie cautery, corporal body, glans penis, pump, cylinders, penile, prosthesis, inflatable, corporal

The situation involves a surgical procedure for a 64-year-old male patient with nonfunctioning penile prosthesis and Peyronie's disease, requiring the replacement of an inflatable penile prosthesis. This type of surgery, while typically not life-threatening, involves complexities such as careful handling due to a pacemaker and a prior history of connective tissue issues. Potential risks include infection, bleeding, and mechanical issues during such a surgery. While serious, the procedure is usually well-managed in a medical setting, and the conditions addressed, although severely impacting quality of life, are generally not immediately life-threatening. Therefore, the stakes are moderate.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Salpingooophorectomy - Laparoscopic

PREOPERATIVE DIAGNOSES:,1.  Right pelvic pain.,2.  Right ovarian mass.,POSTOPERATIVE DIAGNOSES:,1.  Right pelvic pain.,2.  Right ovarian mass.,3.  8 cm x 10 cm right ovarian cyst with ovarian torsion.,PROCEDURE PERFORMED:  ,Laparoscopic right salpingooophorectomy.,ANESTHESIA:  ,General with endotracheal tube.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,TUBES: , None.,DRAINS:,  None.,PATHOLOGY: , The right tube and ovary sent to pathology for review.,FINDINGS: , On exam under anesthesia, a normal-appearing vulva and vagina and normally palpated cervix, a uterus that was normal size, and a large right adnexal mass.  Laparoscopic findings demonstrated a 8 cm x 10 cm smooth right ovarian cyst that was noted to be torsed twice.  Otherwise, the uterus, left tube and ovary, bowel, liver margins, appendix, and gallbladder were noted all to be within normal limits.  There was no noted blood in the pelvis.,INDICATIONS FOR THIS PROCEDURE:,  The patient is a 26-year-old G1 P1 who presented to ABCD General Emergency Room with complaint of right lower quadrant pain since last night, which has been increasing in intensity.  The pain persisted despite multiple pain medications given in the Emergency Room.  The patient reports positive nausea and vomiting.  There was no vaginal bleeding or discharge.  There was no fevers or chills.  Her cultures done in the Emergency Room were pending.  The patient did have an ultrasound that demonstrated an 8 cm right ovarian cyst, questionable hemorrhagic.  The uterus and left ovary were within normal limits.  There was a positive flow noted to bilateral ovaries on ultrasound.  Therefore, it was felt appropriate to take the patient for a diagnostic laparoscopy with a possible oophorectomy.,PROCEDURE:,  After informed consent was obtained, and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where general anesthesia was obtained without any difficulty.  She was placed in dorsal lithotomy position with the use of Allis strips and prepped and draped in the usual sterile fashion.  Her bladder was drained with a red Robinson catheter and she was examined under anesthesia and was noted to have the findings as above.  She was prepped and draped in the usual sterile fashion.  A weighted speculum was placed in the patient's vagina with excellent visualization of the cervix.  The cervix was grasped at 12 o'clock position with a single-toothed tenaculum and pulled into the operative field.  The uterus was then sounded to approximately 3.5 inches and then a uterine elevator was placed.  The vulsellum tenaculum was removed.  The weighted speculum was removed.  Attention was then turned to the abdomen where 1 cm infraumbilical incision was made in the infraumbilical fold.  The Veress step needle was then placed into the abdomen while the abdomen was being tented up with towel clamp.  The CO2 was then turned on with unoccluded flow and excellent pressures.  This was continued till a normal symmetrical pneumoperitoneum was obtained.  Then, a #11 mm step trocar and sleeve were placed into the infraumbilical port without any difficulty and placement was confirmed by laparoscope.  Laparoscopic findings are as noted above.  A suprapubic incision was made with the knife and then a #12 mm step trocar and sleeve were placed in the suprapubic region under direct visualization.  Then, a grasper was used to untorse the ovary.  Then, a #12 mm port was placed in the right flank region under direct visualization using a LigaSure vessel sealing system.  The right tube and ovary were amputated and noted to be hemostatic.  The EndoCatch bag was then placed through the suprapubic port and the ovary was placed into the bag.  The ovary was too large to fit completely into the bag.  Therefore, a laparoscopic needle with a 60 cc syringe was used to aspirate the contents of the ovary while it was still inside the bag.,There was approximately 200 cc of fluid aspirated from the cyst.  This was a clear yellow fluid.  Then, the bag was closed and the ovary was removed from the suprapubic port.  The suprapubic port did have to be extended somewhat to allow for the removal of the ovary.  The trocar and sleeve were then placed back into the port.  The abdomen was copiously irrigated with warm normal saline using the Nezhat-Dorsey suction irrigator and the incision site was noted to be hemostatic.  The pelvis was clear and clean.  ,Pictures were obtained.  The suprapubic port was then removed under direct visualization and then using a #0-vicyrl and UR6.  Two figure-of-eight sutures were placed in the fascia of suprapubic port and fascia was closed and the pneumoperitoneum was maintained after the sutures were placed.  Therefore, the peritoneal surface was noted to be hemostatic.  Therefore, the camera was removed.  All instruments were removed.  The abdomen was allowed to completely deflate and then the trocars were placed back through the sleeves of the right flank #12 port and the infraumbilical port and these were removed.  The infraumbilical port was examined and noted to have a small fascial defect which was repaired with #0-Vicryl and UR6.  The right flank area was palpated and there was no facial defect noted.  The skin was then closed with #4-0 undyed Vicryl in subcuticular fashion.  Dressings were changed.  The weighted speculum was removed from the patient's cervix.  The cervix noted to be hemostatic.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2 and the patient was taken to the Recovery in stable condition.
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DESCRIPTION: Laparoscopic right salpingooophorectomy.  Right pelvic pain and ovarian mass.  Right ovarian cyst with ovarian torsion.

The situation described involves a medical procedure known as a laparoscopic right salpingooophorectomy, which is performed due to a right ovarian mass and torsion. The procedure itself was necessary due to significant symptoms experienced by the patient such as severe pelvic pain, nausea, and vomiting, and the risk of complications from the ovarian torsion. This is a high-stakes situation because the patient's condition requires prompt surgical intervention to relieve pain, prevent potential complications like ovarian necrosis, and ensure the patient's overall well-being. The urgency and necessity of surgical intervention for an ovarian cyst with torsion underscore the high-stakes nature of the situation.


Medical Specialty: Dentistry
Sample Name: Bone Impacted Tooth Removal

PREOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,POSTOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,PROCEDURE:,  Removal of benign cyst and extraction of full bone impacted tooth #17.,ANESTHESIA:  ,General anesthesia with nasal endotracheal intubation.,SPECIMEN: , Cyst and section tooth #17.,ESTIMATED BLOOD LOSS:,  10 mL.,FLUIDS:,  1200 of Lactated Ringer's.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated and transported to the PACU in good condition.  Breathing spontaneously.,INDICATION FOR PROCEDURE:  ,The patient is a 38-year-old Caucasian male who was referred to clinic to evaluate a cyst in his left mandible.  Preoperatively, a biopsy of the cyst was obtained and it was noted to be a benign dentigerous cyst.,After evaluation of the location of the cyst and the impacted wisdom tooth approximately the inferior border of the mandible, it was determined that the patient would benefit from removal of the cyst and removal of tooth #17 under general anesthesia in the operating room.  Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:,  The patient was taken to the operating room #1 at Hospital and laid in the supine fashion on the operating room table.  As stated, general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics.  The patient was prepped and draped in usual oro-maxillofacial surgery fashion.,Approximately, #6 mL of 2% lidocaine with 1:100,000 epinephrine was injected in the usual nerve block fashion.  After waiting appropriate time for local anesthesia to take effect, a moistened Ray-Tec sponge was placed in the posterior pharynx.  Peridex mouth rinse was used to prep the oral cavity.  This was removed with suction.,Using a #15 blade a sagittal split osteotomy incision was made along the left ramus.  A full-thickness mucoperiosteal flap was elevated and the crest of the bone was identified where the crown had super-erupted since the biopsy 6 weeks earlier.  Using a Hall drill, a buccal osteotomy was developed, the tooth was sectioned in half, fractured with an elevator and delivered in two pieces.  Using a double-ended curette, the remainder of the cystic lining was removed from the left mandible and sent to pathology with the tooth for review.,The area was irrigated with copious amounts of sterile water and closed with 3-0 chromic gut suture.  The throat pack was removed.  The procedure was then determined to be over, and the patient was extubated, breathing spontaneously, and transported to the PACU in good condition.
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DESCRIPTION: Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.  Removal of benign cyst and extraction of full bone impacted tooth #17.

dentistry, dentigerous, wisdom tooth, extraction, bone impacted tooth, nasal endotracheal, dentigerous cyst, cyst, intubation, osteotomy, mandible,

The situation involves a dental surgical procedure to remove a benign cyst and an impacted wisdom tooth. While the procedure is invasive and requires general anesthesia, it is routine and considered low-risk for a healthy patient. The use of general anesthesia does elevate the stakes slightly due to associated risks, but the absence of any complications, the minimal blood loss, and the patient being in good condition post-operation indicate that the stakes are not particularly high.