Medical Specialty: Urology
Sample Name: Cystoscopy & TURP

PREOPERATIVE DIAGNOSES:,1.  Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2.  Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3.  Inability to pass a Foley catheter x3.,POSTOPERATIVE DIAGNOSES:,1.  Ta grade III TIS transitional cell carcinoma of the urinary bladder.,2.  Lower tract outlet obstructive symptoms secondary to benign prostatic hypertrophy.,3.  Inability to pass a Foley catheter x3.,PROCEDURES:,1.  Cystoscopy.,2.  Transurethral resection of the prostate (TURP).,ANESTHESIA: , General laryngeal mask.,INDICATIONS: , This patient is a 61-year-old white male who has been treated at the VA in Houston for a bladder cancer.  His history dates back to 2003 when he had a non-muscle invasive bladder cancer.  He had multiple cystoscopies and followups since that time with no evidence of recurrence.  However, on recent cystoscopy, he had what appeared to be a recurrent tumor and was taken to the operating room and had this resected with findings of a Ta grade III transitional cell carcinoma associated with carcinoma in situ.  Retrograde pyelograms were suspicious on the right and cleared with ureteroscopy and the left renal pelvic washing was positive but this may represent contamination from the lower urinary tract as radiographically, there were no abnormalities.  I had cystoscoped the patient in the office showed during the period of time when he had significant irritative burning symptoms, and there were still healing biopsy sites.  We elected to allow his bladder to recover before starting the BCG.  We were ready to do that last week but two doctors and a nurse including myself were unable to pass Foley catheter.  I repeated a cystoscopy in the office with findings of a high bladder neck and BPH.  After a lengthy discussion with the patient and his wife, we elected to proceed with TURP after a full informed consent.,FINDINGS: , At cystoscopy, there was bilobular prostatic hyperplasia and a very high riding bladder neck, which may have been the predominant cause of his difficulty catheterizing and obstructive symptoms.  There were mucosal changes on the left posterior wall in the midline suspicious for carcinoma in situ.,PROCEDURE IN DETAIL: , The patient was brought to the cystoscopy suite and after adequate general laryngeal mask anesthesia obtained and placed in the dorsal lithotomy position, his perineum and genitalia were sterilely prepped and draped in the usual fashion.  A cystourethroscopy was performed with a #23 French ACMI panendoscope and 70-degree lens with the findings as described.  We removed the cystoscope and passed a #28 French continuous flow resectoscope sheath under visual obturator after dilating the meatus to #32 French with van Buren sounds.  Inspection of bladder again was made noting the location of the ureteral orifices relative to the bladder neck.  The groove was cut at 6 o'clock to open the bladder neck to verumontanum and then the left lobe was resected from 1 o'clock to 5 o'clock.  Hemostasis was achieved, and then a similar procedure performed in the right side.  We resected the anterior stromal tissue and the apical tissue and then obtained complete hemostasis.  Chips were removed with Ellik evacuator.  There was no bleeding at the conclusion of the procedure, and the resectoscope was removed.  A #24 French three-way Foley catheter was placed with efflux of clear irrigant.  The patient was returned to the supine position, awakened, extubated, and taken on a stretcher to the recovery room in satisfactory condition.
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DESCRIPTION: Cystoscopy.  Transurethral resection of the prostate.

urology, urinary bladder, benign prostatic hypertrophy, transurethral resection of the prostate, turp, acmi panendoscope, van buren sounds, transitional cell carcinoma, foley catheter, bladder neck, bladder, carcinoma, cystoscopy

This medical scenario involves a surgical procedure for a patient with recurrent bladder cancer and benign prostatic hyperplasia (BPH), two serious urological conditions. The procedure involves cystoscopy and transurethral resection of the prostate (TURP), which are standard but invasive procedures with potential risks and complications. Given that the patient has a history of transitional cell carcinoma and difficulty in catheterization affecting their quality of life, the stakes are relatively high in terms of ensuring a successful procedure and managing the cancer. However, these types of procedures are routinely performed, and the medical team appears to be following standard practices.


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

Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Arthrodesis - 2

PREOPERATIVE DIAGNOSIS:  ,Cervical spondylosis and herniated nucleus pulposus of C4-C5.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis and herniated nucleus pulposus of C4-C5.,TITLE OF OPERATION:,  Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,OPERATIVE PROCEDURE IN DETAIL: , After identification, the patient was taken to the operating room and placed in supine position.  Following the induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  A shoulder roll was placed between the scapula and the head was rested on a doughnut in a slightly extended position.  A preoperative x-ray was obtained to identify the operative level and neck position.  An incision was marked at the C4-C5 level on the right side.  The incision was opened with #10 blade knife.  Dissection was carried down through subcutaneous tissues using Bovie electrocautery.  The platysma muscle was divided with the cautery and mobilized rostrally and caudally.  The anterior border of sternocleidomastoid muscle was then dissected rostrally and caudally with sharp and blunt dissection.  The avascular plane was then entered and dissection was carried bluntly down to the anterior cervical fascia.  This was opened with scissors and dissected rostrally and caudally with the peanut dissectors.  The operative level was confirmed with an intraoperative x-ray.  The longus colli muscles were mobilized bilaterally using bipolar electrocautery and periosteal elevator.  The anterior longitudinal ligament was then taken down with the insulated Bovie electrocautery tip exposing the vertebral bodies of C4 and C5.  Self-retaining retractor was placed in submuscular position, and distraction pins were placed in the vertebral bodies of C4 and C5, and distraction was instituted.  We then incise the annulus of C4-C5 and a discectomy was now carried out using pituitary rongeurs and straight and angled curettes.  Operating microscope was draped and brought into play.  Dissection was carried down through the disc space to the posterior aspect of the disc space removing the disc with the angled curette as we went.  We now use the diamond bit to thin the posterior bone spurs and osteophytes at the uncovertebral joints bilaterally.  Bone was then removed with 2 mm Kerrison punch and then we were able to traverse the posterior longitudinal ligament and this ligament was now removed in a piecemeal fashion with a 2 mm Kerrison punch.  There was a transligamentous disc herniation, which was removed during this process.  We then carried out bilateral foraminotomies with removal of the uncovertebral osteophytes until the foramina were widely patent.  Cord was seen to be pulsating freely behind the dura.  There appeared to be no complications and the decompression appeared adequate.  We now used a cutting bit to prepare the inner space for arthrodesis fashioning a posterior ledge on the posterior aspect of the C5 vertebral body.  An 8 mm lordotic trial was used and appeared perfect.  We then used a corticocancellous 8 mm lordotic graft.  This was tapped into position.  Distraction was released, appeared to be in excellent position.  We then positioned an 18 mm Vector plate over the inner space.  Intraoperative x-ray was obtained with the stay screw in place; plates appeared to be in excellent position.  We then use a 14 mm self-tapping variable angle screws in each of the four locations drilling 14 mm pilot holes at each location prior to screw insertion.  All of the screws locked to the plate and this was confirmed on visual inspection.  Intraoperative x-ray was again obtained.  Construct appeared satisfactory.  Attention was then directed to closure.  The wound was copiously irrigated.  All of the self-retaining retractors were removed.  Bleeding points were controlled with bone wax and bipolar electrocautery.  The platysma layer was now closed with interrupted 3-0 Vicryl sutures.  The skin was closed with running 3-0 Vicryl subcuticular stitch.  Steri-Strips were applied.  A sterile bandage was applied.  All sponge, needle, and cottonoid counts were reported as correct.  The patient tolerated the procedure well.  He was subsequently extubated in the operating room and transferred to PACU in satisfactory condition.
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DESCRIPTION: Anterior cervical discectomy C4-C5 arthrodesis with 8 mm lordotic ACF spacer, corticocancellous, and stabilization with Synthes Vector plate and screws.  Cervical spondylosis and herniated nucleus pulposus of C4-C5.

neurosurgery, synthes vector plate, lordotic, acf spacer, corticocancellous, arthrodesis, anterior cervical discectomy, herniated nucleus pulposus, anterior, cervical, spacer, screws, discectomy,

The situation involves a detailed surgical procedure known as Anterior Cervical Discectomy and Arthrodesis, a complex and delicate operation on the cervical spine to treat cervical spondylosis and herniated nucleus pulposus. Such surgeries are inherently high-stakes because they involve critical structures like the spinal cord and surrounding nerves. Any complications could lead to significant neurological deficits or even paralysis. Furthermore, the surgery's precision and successful outcome can have a profound impact on the patient's quality of life. The procedure went smoothly without complications, indicating proficient handling, but the potential risks associated with spinal surgery remain high.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Oligoarticular Arthritis - 1

HISTORY:,  A is here for a follow up appointment at our Pediatric Rheumatology Clinic as well as the CCS Clinic.  A is a 17-year-old male with oligoarticular arthritis of his right knee.  He had a joint injection back in 03/2007 and since then he has been doing relatively well.  He is taking Indocin only as needed even though he said he has pain regularly, and he said that his knee has not changed since the beginning, but he said he only takes the medicine when he has pain, which is not every day, but almost every day.  He denies any swelling more than what it was before, and he denies any other joints are affected at this moment.  Denies any fevers or any rashes.,PHYSICAL EXAMINATION:,  On physical examination, his temperature is 98.6, weight is 104.6 kg; which is 4.4 kg less than before, 108/70 is his blood pressure, weight is 91.0 kg, and his pulse is 80.  He is alert, active, and oriented in no distress.  He has no facial rashes, no lymphadenopathy, no alopecia.  Funduscopic examination is within normal limit.  He has no cataracts and symmetric pupils to light and accommodation.  His chest is clear to auscultation.  The heart has a regular rhythm with no murmur.  The abdomen is soft and nontender with no :  visceromegaly.  Musculoskeletal examination showed good range of motion of all his upper extremities with no swelling or tenderness.  Lower extremities:  He still has some weakness of the knees, hip areas, and the calf muscles.  He does have minus/plus swelling of the right knee with a very hypermobile patella.  There is no limitation in his range of motion, and the swelling is very minimal with some mild tenderness.,In terms of his laboratories, they were not done today.,ASSESSMENT: , This is a 17-year-old male with oligoarticular arthritis.  He is HLA-B27 negative.,PLAN:,  In terms of the plan, I discussed with him what things he should be taking and the fact that since he has persistent symptoms, he should be on medication every day.  I am going to switch him to Indocin 75 mg SR just to give more sustained effect to his joints, and if he does not respond to this or continue with the symptoms, we may need to get an MRI.  We will see him back in three months.  He was evaluated by our physical therapist, who gave him some recommendations in terms of exercise for his lower extremities.  Future plans for A may include physical therapy and more stronger medications as well as imaging studies with an MRI.  Today he received his flu shot.  Discussed this with A and his aunt and they had no further questions.
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DESCRIPTION: A 17-year-old male with oligoarticular arthritis of his right knee.

consult - history and phy., rheumatology, rheumatology clinic, lower extremities, oligoarticular arthritis, arthritis, oligoarticular, knee, swelling,

The situation involves a medical follow-up for a 17-year-old male with oligoarticular arthritis in a pediatric rheumatology clinic. While managing chronic conditions like arthritis can impact quality of life and long-term joint health, this specific consultation doesn't indicate an immediate life-threatening condition or emergency. The patient is being monitored, and there are plans to adjust treatment based on his symptoms. Although managing symptoms effectively is important, this does not constitute a high-stakes situation in terms of immediate risk to the patient's life or health.


Medical Specialty: Surgery
Sample Name: Circumcision - 7

PROCEDURE:,  Circumcision.,ANESTHESIA: , EMLA.,FINDINGS: , Normal penis.  The foreskin was normal in appearance and measured 1.6 cm.  There was no bleeding at the circumcision site.,PROCEDURE:,  Patient was placed on the circumcision restraint board.  EMLA had been applied approximately 90 minutes before.  A time-out was completed satisfactorily per protocol.  The area was prepped with Betadine.  The foreskin was grasped with sterile clamps and was dissected away from the corona and the glans penis with blunt dissection.  A Mogen clamp was applied to the cervix.  The excess foreskin was excised with the scalpel.  The clamp was removed.  At this point, the procedure was terminated.  Sterile Vaseline and gauze was applied to the glans penis.  There were no complications.  There was minimal blood loss.
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DESCRIPTION: Normal penis.  The foreskin was normal in appearance and measured 1.6 cm.  There was no bleeding at the circumcision site.

surgery, mogen clamp, glans penis, emla, penis, foreskin, circumcision

The situation describes a surgical procedure, specifically circumcision, which is generally considered routine and low-risk. The description indicates there were no complications, no significant bleeding, and minimal blood loss, suggesting the procedure went smoothly. While all surgical procedures carry some inherent risks, the details provided suggest this was a textbook case with no issues, thereby making it relatively low-stakes.


Medical Specialty: Radiology
Sample Name: Ultrasound - Carotid - 2

EXAM: , Ultrasound carotid, bilateral.,REASON FOR EXAMINATION: , Pain.,COMPARISON:,  None.,FINDINGS: , Bilateral common carotid arteries/branches demonstrate minimal, predominantly noncalcified plaquing with mild calcific plaquing in the left internal carotid artery.  There are no different colors or spectral Doppler waveform abnormalities.,PARAMETRIC DATA:,  Right CCA PSV 0.72 m/s.  Right ICA PSV is 0.595 m/s.  Right ICA EDV 0.188 m/s.  Right vertebral 0.517 m/s. Right IC/CC is 0.826. Left CCA PSV 0.571 m/s, left ICA PSV 0.598 m/s.  Left ICA EDV 0.192 m/s.  Left vertebral 0.551 m/s.  Left IC/CC is 1.047.,IMPRESSION:,1.  No evidence for clinically significant stenosis.,2.  Minimal, predominantly soft plaquing.,
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DESCRIPTION: Bilateral carotid ultrasound to evaluate pain.

radiology, carotid, cca psv, doppler, ic/cc, ica edv, ica psv, ultrasound, arteries, calcific plaquing, common carotid, internal carotid artery, spectral, stenosis, waveform, ultrasound carotid bilateral, ultrasound carotid, plaquing,

The ultrasound findings indicate the presence of minimal noncalcified and mild calcific plaquing in the carotid arteries, but no evidence of clinically significant stenosis. This suggests that while there is some plaque buildup, it is not currently severe enough to pose an immediate high risk to the patient. The situation requires monitoring but does not suggest an urgent or critical medical condition.


Medical Specialty: Orthopedic
Sample Name: Knee Arthroscopy - 1

PROCEDURE IN DETAIL: , After written consent was obtained from the patient, the patient was brought back into the operating room and identified.  The patient was placed in the operating room table in supine position and given general anesthetic.,Ancef 1 g was given for infectious prophylaxis.  Once the patient was under general anesthesia, the knee was prepped and draped in usual sterile fashion.  Once the knee was fully prepped and draped, then we made 2 standard portals medial and lateral.  Through the lateral portal, the camera was placed.  Through the medial portal, tools were placed.  We proceeded to examine scarring of the patellofemoral joint.  Then we probed the patellofemoral joint.  A chondroplasty was performed using a shaver.  Then we moved down to the lateral gutter.  Some loose bodies were found using a shaver and dissection.  We moved down the medial gutter.  No plica was found.,We moved into the medial joint; we found that the medial meniscus was intact.  We moved to the lateral joint and found that the lateral meniscus was intact.  Pictures were taken.  We drained the knee and washed out the knee with copious amounts of sterile saline solution.  The instruments were removed.  The 2 portals were closed using 3-0 nylon suture.  Xeroform, 4 x 4s, Kerlix x2, and TED stocking were placed.  The patient was successfully extubated and brought to the recovery room in stable condition.  I then spoke with the family going over the case, postoperative instructions, and followup care.
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DESCRIPTION: Arthroscopic procedure of the knee.

Arthroscopic procedure of the knee.

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

Knee arthroscopy is a common orthopedic surgical procedure used to diagnose and treat problems in the knee joint. While it is a critical surgical procedure that requires precision and care, it is generally considered to be low-risk compared to more invasive surgeries. The procedure described went smoothly without complications, the patient was successfully moved to recovery, and postoperative care was discussed with the family. Hence, the stakes involved, while meaningful, are not extremely high compared to major surgeries or life-threatening situations.


Medical Specialty: ENT - Otolaryngology
Sample Name: Septoplasty

PREOPERATIVE DIAGNOSES:,1.  Nasal septal deviation.,2.  Bilateral internal nasal valve collapse.,3.  Bilateral external nasal valve collapse.,POSTOPERATIVE DIAGNOSES:,1.  Nasal septal deviation.,2.  Bilateral internal nasal valve collapse.,3.  Bilateral external nasal valve collapse.,PROCEDURES:,1.  Revision septoplasty.,2.  Repair of internal nasal valve collapse using auricular cartilage.,3.  Repair of bilateral external nasal valve collapse using auricular cartilage.,4.  Harvest of right auricular cartilage.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Approximately 20 mL.,IV FLUIDS: , Include a liter of crystalloid fluid.,URINE OUTPUT: , None.,FINDINGS: , Include that of significantly deviated septum with postoperative changes and a significant septal spur along the floor.  There is also evidence of bilateral internal as well as external nasal valve collapse.,INDICATIONS:  ,The patient is a pleasant 49-year-old gentleman who had undergone a previous septorhinoplasty after significant trauma in his 20s.  He now presents with significant upper airway resistance and nasal obstruction and is unable to tolerate a CPAP machine.  Therefore, for repair of the above-mentioned deformities including the internal and external nasal valve collapse as well as straightening of the deviated septum, the risks and benefits of the procedure were discussed with him included but not limited to bleeding, infection, septal perforation, need for further surgeries, external deformity, and he desired to proceed with surgery.,DESCRIPTION OF THE PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and laid supine upon the OR table.  After the induction of general endotracheal anesthesia, the nose was decongested using Afrin-soaked pledgets followed by the injection of % lidocaine with 1:100,000 epinephrine in the submucoperichondrial planes bilaterally.  Examination revealed significant deviation of the nasal septum and the bony cartilaginous junction as well as the large septal spur along the floor.  The caudal septum appeared to be now in adequate position.  There was evidence that there had been a previous caudal septal graft on the right nares and it was decided to leave this in place.  Following the evaluation of the nose, a hemitransfixion incision was made on the left revealing a large septal spur consisting primarily down on the floor of the left nostril creating nearly a picture of the vestibular stenosis on the side.  Very carefully, the mucoperichondrial flaps were elevated over this, and it was excised using an osteotome taking care to preserve the 1.5 cm dorsal and caudal strap of the nasal septum and keep it attached to the nasal spine.  Very carefully, the bony cartilaginous junction was identified and a small piece of the bone, where the spur was, was carefully removed.  Following this, it was noted that the cartilaginous region was satisfactory in quantity as well as quality to perform adequate grafting procedures.  Therefore, attention was turned to harvesting the right-sided auricular cartilage, which was done after the region had adequately been prepped and draped in a sterile fashion.  Postauricular incision using a #15 blade, the area of the submucoperichondrial plane was elevated in order to preserve the nice lining and identifiable portion of the cartilage taking care to preserve the ridge of the helix at all times.  This was very carefully harvested.  This area had been injected previously with 1% lidocaine and 1:100,000 epinephrine.  Following this, the cartilage was removed.  It was placed in saline, noted to be fashioned in the bilateral spreader graft and alar rim graft as well as a small piece of crush which was used to be placed along the top of the dorsal irregularity.  The spreader grafts were sutured in place using submucoperichondrial pockets.  After an external septorhinoplasty approach had been performed and reflection of the skin and soft tissue envelope had been performed, adequately revealing straight septum with significant narrowing with what appeared to be detached perhaps from his ipsilateral cartilages rather from his previous surgery.  These were secured in place in the pockets using a 5-0 PDS suture in a mattress fashion in two places.  Following this, attention was turned to placing the alar rim grafts where pockets were created along the caudal aspect of the lower lateral cartilage and just along the alar margin.  Subsequently, the alar rim grafts were placed and extended all the way to the piriform aperture.  This was sutured in place using a 5-0 self-absorbing gut suture.  The lower lateral cartilage has had some inherent asymmetry.  This may have been related to his previous surgery with some asymmetry of the dome; however, this was left in place as he did not desire any changes in the tip region, and there was adequate support.  An endodermal suture was placed just to reenforce the region using a 5-0 PDS suture.  Following all this, the area was closed using a mattress 4-0 plain gut on a Keith needle followed by the application of ***** 5-0 fast-absorbing gut to close the hemitransfixion incision.  Very carefully, the skin and subcutaneous tissue envelopes were reflected.  The curvilinear incision was closed using a Vicryl followed by interrupted 6-0 Prolene sutures.  The marginal incisions were then closed using 5-0 fast-absorbing gut.  Doyle splints were placed and secured down using a nylon suture.  They had ointment also placed on them.  Following this, nasopharynx was suctioned.  There were no further abnormalities noted and everything appeared to be in nice position.  Therefore, an external splint was placed after the application of Steri-Strips.  The patient tolerated the procedure well.  He was awakened in the operating room.  He was extubated and taken to the recovery room in stable condition.
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DESCRIPTION: Revision septoplasty, repair of internal nasal valve collapse using auricular cartilage, repair of bilateral external nasal valve collapse using auricular cartilage, harvest of right auricular cartilage.

ent - otolaryngology, nasal septal deviation, nasal septal, auricular cartilage, nasal, nasal obstruction, nasal valve, septoplasty, submucoperichondrial, upper airway, internal nasal valve, external nasal valve, hemitransfixion incision, revision septoplasty, septal spur, valve collapse, auricular, cartilage, collapse, septum, valve,

The situation involves a revision septoplasty surgery, which is performed to correct nasal septal deviation and valve collapse, conditions that can significantly impact breathing. The procedure described is detailed and complex, involving general anesthesia, harvest of cartilage, and multiple intricate surgical steps. While it addresses a non-life-threatening condition, the potential risks include bleeding, infection, or the need for further surgeries, all of which have significant implications for the patient's quality of life. The use of general anesthesia also adds to the stakes, as it involves more risks compared to local anesthesia. However, it is not an emergency or life-threatening situation, which keeps it from being extremely high-stakes.


Medical Specialty: Surgery
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.

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

This surgical procedure involves the removal and replacement of a nonfunctioning penile prosthesis. It addresses a condition (Peyronie's disease accompanied by prosthesis malfunction) that significantly impacts the patient's quality of life. The procedure itself is relatively specialized and involves considerations related to the patient's pacemaker, which adds complexity. While this is not a life-threatening surgery, the presence of complex factors like the patient's pacemaker and the requirement for general anesthesia contribute to a moderate level of risk and complexity. Therefore, it is of moderate stakes, not being a critical life-saving operation but also being more than routine due to these factors.


Medical Specialty: Pain Management
Sample Name: Intercostal Block

PREOPERATIVE DIAGNOSIS: , Severe post thoracotomy pain.,POSTOPERATIVE DIAGNOSIS: , Severe post thoracotomy pain.,PROCEDURE: , Intercostal block, left.,PROCEDURE DETAIL: , With the patient in the ICU bed who was having a large amount of intravenous narcotic to control his thoracotomy pain, after obtaining informed consent, his left posterior chest was prepped and draped in the usual fashion and Marcaine 0.025% was injected in the spaces four to eight sequentially.  A total of 40 mL of Marcaine was used.,The patient tolerated the procedure well and experienced immediate benefit out of the procedure.
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DESCRIPTION: Intercostal block, left.   Severe post thoracotomy pain.

pain management, thoracotomy pain, intercostal block, marcaine, thoracotomy, intercostal,

The patient is in the ICU requiring significant pain management with intravenous narcotics for post-thoracotomy pain, which indicates a complex and potentially life-threatening situation. The intervention, an intercostal block, is intended to manage severe pain, which is critical for the patient's recovery and well-being. Managing severe pain is crucial in preventing complications and improving patient outcomes in the ICU setting. Thus, this situation has significant medical implications.


Medical Specialty: ENT - Otolaryngology
Sample Name: Flexible Nasal Laryngoscopy

PREOPERATIVE DIAGNOSIS:  ,Oropharyngeal foreign body.,POSTOPERATIVE DIAGNOSES:,1.  Foreign body, left vallecula at the base of the tongue.,2.  Airway is patent and stable.,PROCEDURE PERFORMED: , Flexible nasal laryngoscopy.,ANESTHESIA:,  ______ with viscous lidocaine nasal spray.,INDICATIONS: , The patient is a 39-year-old Caucasian male who presented to ABCD General Hospital Emergency Department with acute onset of odynophagia and globus sensation.  The patient stated his symptoms began around mid night after returning home _________ ingesting some chicken.  The patient felt that he had ingested a chicken bone, tried to dislodge this with fluids and other solid foods as well as sticking his finger down his throat without success.  The patient subsequently was seen in the Emergency Department where it was discovered that the patient had a left vallecular foreign body.  Department of Otolaryngology was asked to consult for further evaluation and treatment of this foreign body.,PROCEDURE: , After verbal informed consent was obtained, the patient was placed in the upright position.  The fiberoptic nasal laryngoscope was inserted in the patient's right naris and then the left naris.  There was visualized some bilateral caudal spurring of the septum.  The turbinates were within normal limits.  There was some posterior nasoseptal deviation to the left.  The nasal laryngoscope was then inserted back into the right naris and it was advanced along the floor of the nasal cavity.  The nasal mucous membranes were pink and moist.  There was no evidence of mass, ulceration, lesion, or obstruction.,The scope was further advanced to the level of the nasopharynx where the eustachian tubes were visualized bilaterally.  There was evidence of some mild erythema in the right fossa Rosenmüller.  There was no evidence of mass lesion or ulceration in this area, however.  The eustachian tubes were patent without obstruction.  The scope was further advanced to the level of the oropharynx where the base of the tongue, vallecula, and epiglottis were visualized.  There was evidence of a 1.5 cm left vallecular white foreign body.  The rest of the oropharynx was without abnormality.  The epiglottis was within normal limits and was noted to be omega in shape.  There was no edema or erythema to the epiglottis.  The scope was then further advanced to the level of the hypopharynx to the level of the true vocal cords.  There was no evidence of erythema or edema of the posterior commissure, arytenoid cartilage, or superior surface of the vocal cords.  The laryngeal surface of the epiglottis was within normal limits.  There was no evidence of mass lesion or nodularity of the vocal cords.  The patient was asked to Valsalva and the piriform sinuses were observed without evidence of foreign body or mass lesion.  The patient did have complete glottic closure upon phonation and the airway was patent and stable throughout the exam.  The glottic aperture was completely patent with inspiration.  The anterior commissure, epiglottic folds, false vocal cords, and piriform sinuses were all within normal limits.  The scope was then removed without difficulty.  The patient tolerated the procedure well and remained in stable condition.,FINDINGS:,1.  A 1.5 cm white foreign body consistent with a chicken bone at the left vallecular region.  There is no evidence of supraglottic or piriform sinuses foreign body.,2.  Mild erythema of the right nasopharynx in the region of the fossa Rosenmüller.  No mass is appreciated at this time.,PLAN:,  The patient is to go to the operating room for direct laryngoscopy/microscopic suspension direct laryngoscopy for removal of foreign body under anesthesia this a.m.  Airway precautions were instituted.  The patient currently remained in stable condition.
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DESCRIPTION: Flexible nasal laryngoscopy.  Foreign body, left vallecula at the base of the tongue.   Airway is patent and stable.

ent - otolaryngology, oropharyngeal foreign body, flexible nasal laryngoscopy, nasal spray, foreign body, tongue, laryngoscopy, erythema, epiglottis, nasal, oropharyngeal

The situation involves a 39-year-old male patient who has ingested a suspected chicken bone, leading to an oropharyngeal foreign body being lodged at the base of the tongue. While the patient's airway is currently stable, the presence of a foreign body near the airway is potentially life-threatening. Prompt intervention is necessary to remove the object under anesthesia to prevent airway obstruction or other complications. Airway management is a critical aspect of the procedure, indicating that it is a high-stakes situation. However, the patient is stable and preparations are being made for a controlled surgical procedure, which lowers the immediate criticality slightly.


Medical Specialty: Surgery
Sample Name: D&C & Hysteroscopy - 1

PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Status post spontaneous vaginal delivery.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Status post spontaneous vaginal delivery.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Hysteroscopy.,ANESTHESIA: , IV sedation with paracervical block.,ESTIMATED BLOOD LOSS:,  Less than 10 cc.,INDICATIONS:  ,This is a 17-year-old African-American female that presents 7 months status post spontaneous vaginal delivery without complications at that time.  The patient has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.,PROCEDURE:,  The patient was consented and seen in the preoperative suite.  She was taken to the operative suite, placed in a dorsal lithotomy position, and placed under IV sedation.  She was prepped and draped in the normal sterile fashion.  Her bladder was drained with the red Robinson catheter which produced approximately 100 cc of clear yellow urine.  A bimanual exam was done, was performed by Dr. X and Dr. Z.  The uterus was found to be anteverted, mobile, fully involuted to a pre-pregnancy stage.  The cervix and vagina were grossly normal with no obvious masses or deformities.  A weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum.,The uterus was sounded to 8 cm.  The cervix was sterilely dilated with Hank dilator and then Hagar dilator.  At the time of blunt dilation, it was noticed that the dilator passed posteriorly with greater ease than it had previously.  The dilation was discontinued at that time because it was complete and the hysteroscope was placed into the uterus.  Under direct visualization, the ostia were within normal limits.  The endometrial lining was hyperplastic, however, there was no evidence of retained products or endometrial polyps.  The hyperplastic tissue did not appear to have calcification or other abnormalities.  There was a small area of the lower uterine segment posteriorly that was suspicious for endometrial perforation, however this area was hemostatic, no evidence of bowel involvement and was approximately 1 x 1 cm in nature.  The hysteroscope was removed and a sharp curette was placed intrauterine very carefully using a anterior wall for guidance.  Endometrial curettings were obtained and the posterior aspect suspicious for perforation was gently probed and seemed to have clamped down since the endometrial curetting.  The endometrial sampling was placed on Telfa pad and sent to Pathology for evaluation.  A rectal exam was performed at the end of the procedure which showed no hematoma formation in the posterior cul-de-sac.  There was a normal consistency of the cervix and the normal step-off.  The uterine curette was removed as well as the vulsellum tenaculum and the weighted speculum.  The cervix was found to be hemostatic.  The patient was taken off the dorsal lithotomy position and recovered from her IV sedation in the recovery room.  The patient will be sent home once stable from anesthesia.  She will be instructed to followup in the office in two weeks for discussion of the pathologic report of the endometrial curettings.  The patient is sent home on Tylenol #3 prescription as she is allergic to Motrin.  The patient is instructed to refrain from intercourse douching or using tampons for the next two weeks.  The patient is also instructed to contact us if she has any problems with further bleeding, fevers, or difficulty with urination.
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DESCRIPTION: Dilation and curettage (D&C) and hysteroscopy.  A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.

surgery, dilation and curettage, hysteroscopy, abnormal uterine bleeding, spontaneous vaginal delivery, endometrial curettings, vaginal delivery, uterine bleeding, endometrial, d&c, cervix, vaginal, uterine, delivery,

This case involves a common gynecological surgical procedure that is usually low risk, but given the patient's history of abnormal uterine bleeding and the finding of a suspicious fundal mass, it requires careful attention. The potential for endometrial perforation noted during the procedure slightly increases the stakes. However, the procedure was conducted without significant complications and the patient was stable post-operation. The need to wait for pathology results for a definitive diagnosis adds a bit of uncertainty, but doesn't significantly increase the stakes at this time.


Medical Specialty: Bariatrics
Sample Name: Gastric Bypass Discussion - 1

HISTORY OF PRESENT ILLNESS: , In short, the patient is a 55-year-old gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7 with comorbidities of hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and also osteoarthritis of the lower extremities.  He is also an ex-smoker.  He is currently smoking and he is planning to quit and at least he should do this six to eight days before for multiple reasons including decreasing the DVT, PE rates and marginal ulcer problems after surgery, which will be discussed later on. ,PHYSICAL EXAMINATION: , On physical examination today, he weighs 514.8 pounds, he has gained 21 pounds since the last visit with us.  His pulse is 78, temperature is 97.5, blood pressure is 132/74.  Lungs are clear.  He is a pleasant gentleman with stigmata of supermorbid obesity expected of his size.  Abdomen is soft, nontender.  No incisions.  No umbilical hernia, no groin hernia, has a large abdominal pannus.  No hepatosplenomegaly.  Lower extremities; no pedal edema.  No calf tenderness.  Deep tendon reflexes are normal.  Lungs are clear.  S1, S2 is heard.  Regular rate and rhythm. ,DISCUSSION:,  I had a long talk with the patient about laparoscopic gastric bypass possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines.  I also explained to him complications including rare cases of death secondary to DVT, PE, leak, peritonitis, sepsis shock, multisystem organ failure, need for reoperations, need for endoscopy for bleeding or leak, operations which could be diagnostic laparoscopy, exploratory laparotomy, drainage procedure, gastrostomy, jejunostomy for feeding, bleeding requiring blood transfusion, myocardial infarction, pneumonia, atelectasis, respiratory failure requiring mechanical ventilation, rarely tracheostomy, rare cases of renal failure requiring dialysis, etc., were all discussed. ,All these are going to be at high risk for this patient secondary to his supermorbid obese condition. ,I also explained to him specific gastric bypass related complications including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or antiinflammatory drug intake, which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which are described, so the patient could alert us for earlier intervention, symptomatic gallstone formation during rapid weight loss, how to avoid it by taking ursodiol, which will be prescribed in the postoperative period. ,Long-term complication of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, psychosocial and marital issues, addiction transfer, etc., were all discussed with the patient.  The patient is at higher risk than usual set of patients secondary to his supermorbid obesity of BMI nearing 70 and also major cardiopulmonary and metabolic comorbidities.  Smoking of course does not help and increase the risk for cardiopulmonary complications and is at increased risk for cardiac risk.  He will be seen by cardiologist, pulmonologist.  He will also undergo long Medifast dieting under our guidance, which is a very low-calorie diet to decrease the size of the liver and also to optimize his cardiopulmonary and metabolic comorbidities.  He will also see a psychologist, nutritionist, and exercise physiologist in preparation for surgery for a multidisciplinary approach for short and long-term success. ,Especially for him in view of his restricted mobility, supermorbid obesity status, and possibility of a pulmonary hypertension secondary to sleep apnea, he has been advised to have retrievable IVC filter and also will go home on Lovenox.  He also needs to start exercising to increase his flexibility and muscle tone before surgery and also to start getting the habit of doing so.  All these were discussed with the patient.  The patient understands.  He wants to go to surgery.  All questions were answered.  I will see him in few weeks before the planned date of surgery.
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DESCRIPTION: Gentleman with long-standing morbid obesity, resistant to nonsurgical methods of weight loss with BMI of 69.7

bariatrics, medifast, medifast dieting, hypertension, atrial fibrillation, hyperlipidemia, sleep apnea, morbid obesity, metabolic comorbidities, weight loss, supermorbid obesity, gastric bypass, bypass,

This situation is high-stakes because it involves a patient with supermorbid obesity (BMI of 69.7) and multiple comorbidities such as hypertension, atrial fibrillation, and possible sleep apnea. The patient is considering gastric bypass surgery, which carries significant risks, including potential death from complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), or sepsis. Additionally, the complexity of managing his postoperative care due to his comorbid conditions, smoking status, and the need for a multidisciplinary approach adds to the stakes. Such surgical interventions in high-risk patients require careful planning and consideration due to the high likelihood of complications.


Medical Specialty: Consult - History and Phy.
Sample Name: Discoid Lupus

HISTORY:  ,A is 12-year-old female who comes today for follow-up appointment and a CCS visit.  She has the diagnosis of discoid lupus and we have been following her for her conditions, her treatments, and also to watch her for any development of her systemic lupus.  A has been doing well with just Plaquenil alone and mother said that during the summer, the rash gets brighter, but now that it is getting darker and she is at school, the rash is starting to become lighter again.  She has been using her cream, which is hydrocortisone at night and applying it with no problems.  She denies any hair losses, denies any decrease in appetite, actually, she has been gaining some weight.  She denies any ulcerations in her mouth, eye problems, or any lumps in her body.  She denies any fevers or any problems with the urine.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Today temperature is 100.1, weight is 73.5 kg, blood pressure is 121/61, height is 158, and pulse is 84.,GENERAL:  She is alert, active, and oriented in no distress.,HEENT:  She had a head full of hair with no bald spots.  She has a macular rash on her cheeks bilaterally with hyperpigmented circles.  No scales, no excoriations, and no palpable erythema.  Oral mucosa is clear with no ulcerations.,NECK:  Soft with no masses.  She does have acanthosis nigricans on the base of the neck.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm with no murmur.,ABDOMEN:  Soft and nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation, swelling, or tenderness in any of her joints.,SKIN:  Shows a discoid rash with macules approximately 1 cm in diameter in different shapes and size, but most of them are about 1 cm in diameter, which are hyperpigmented.  No erythema, no purpura, no petechiae, and no raised borders.  They look more like cigarette points.  She has this in her upper extremities especially in the forearms and also on her lower extremities, on the legs, but just very few lesions and very light.  She has some periungual erythema, as well as some palmar erythema, but this is minimal.,LABORATORY DATA:,  Laboratories today done, we have a CBC with a white blood cell count of 7.9, hemoglobin is 14.3, platelet count is 321,000, sed rate is only 11, and CMP shows no abnormalities.  Pending is antinuclear antibody complement level.,ASSESSMENT: , She is 12-year-old with discoid lupus on the control with optimal regimen.  We are going to switch her to Protopic at night, especially in the face.  Continue on Plaquenil, get some laboratories and wait for the results.  Diet evaluation today because of the gaining weight and acanthosis nigricans, and will see her back in about 3 months for follow-up.  Future plans will be depending on whether or not she evolves into a full-blown lupus.  I discussed the plan with her mother and they had no further questions.
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DESCRIPTION: A 12-year-old with discoid lupus on the control with optimal regimen.

consult - history and phy., lupus, systemic lupus, acanthosis nigricans, discoid lupus, extremities, rash, erythema, discoid,

This is a medical consultation for a 12-year-old with discoid lupus, which currently appears to be well-managed with medication. While lupus can potentially evolve into systemic lupus erythematosus, which is a more serious condition, at present, her symptoms are under control, and there are no immediate signs of systemic involvement. Regular follow-ups and laboratory tests are planned to monitor her condition. The management plan seems thorough and cautious, aiming to prevent complications. While there is potential for the condition to become more serious over time, the current situation appears stable and not urgent.


Medical Specialty: Neurosurgery
Sample Name: Laminectomy & Foraminotomy & Cervical Fusion

PREOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Post anterior cervical discectomy and fusion at C4-C5 and C5-C6 with possible pseudoarthrosis at C4-C5.,2.  Cervical radiculopathy involving the left arm.,3.  Disc degeneration at C3-C4 and C6-C7.,OPERATIVE PROCEDURES,1.  Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy.,2.  Posterior cervical fusion C4-C5.,3.  Songer wire.,4.  Right iliac bone graft.,TECHNIQUE:  ,The patient was brought to the operating room.  Preoperative evaluations included previous cervical spine surgery.  The patient initially had some relief; however, his left arm pain did recur and gradually got worse.  Repeat studies including myelogram and postspinal CTs revealed some blunting of the nerve root at C4-C5 and C5-C6.  There was also noted to be some annular bulges at C3-C4, and C6-C7.  The CT scan in March revealed that the fusion was not fully solid.  X-rays were done in November including flexion and extension views, it appeared that the fusion was solid.,The patient had been on pain medication.  The patient had undergone several nonoperative treatments.  He was given the option of surgical intervention.  We discussed Botox, I discussed with the patient and posterior cervical decompression.  I explained to the patient this will leave a larger scar on his neck, and that no guarantee would help, there would be more bleeding and more pain from the posterior surgery than it was from the anterior surgery.  If at the time of surgery there was some motion of the C4-C5 level, I would recommend a fusion.  The patient was a smoker and had been advised to quit smoking but has not quit smoking.  I have therefore recommended that he use iliac bone graft.  I explained to the patient that this would give him a scar over the back of the right pelvis and could be a source of chronic pain for the patient for the rest of his life.  Even if this type of bone graft was used, there was no guarantee that it will fuse and he should stop smoking completely.,The patient also was advised that if I did a fusion, I would also use post instrumentation, which was a wire.  The wire would be left permanently.,Even with all these procedures, there was no guarantee that his symptoms would improve.  His numbness, tingling, and weakness could get worse rather than better, his neck pain and arm pain could persist.  He still had some residual bursitis in his left shoulder and this would not be cured by this procedure.  Other procedures may be necessary later.  There is still with a danger of becoming quadriplegic or losing total control of bowel or bladder function.  He could lose total control of his arms or legs and end up in the bed for the rest of his life.  He could develop chronic regional pain syndromes.  He could get difficulty swallowing or eating.  He could have substantial weakness in the arm.  He was advised that he should not undergo the surgery unless the pain is persistent, severe, and unremitting.,He was also offered his records if he would like any other pain medications or seek other treatments, he was advised that Dr. X would continue to prescribe pain medication if he did not wish to proceed with surgery.,He stated he understood all the risks.  He did not wish to get any other treatments.  He said the pain has reached the point that he wished to proceed with surgery.,PROCEDURE IN DETAIL: , In the operating room, he was given general endotracheal anesthesia.,I then carefully rolled the patient on thoracic rolls.  His head was controlled by a horseshoe holder.  The anesthesiologist checked the eye positions to make sure there was no pressure on the orbits and the anesthesiologist continued to check them every 15 minutes.  The arms, the right hip, and the neck was then prepped and draped.  Care was taken to position both arms and both legs.  Pulses were checked.,A midline incision was made through the skin and subcutaneous tissue on the cervical spine.  A loupe magnification and headlamp illumination was used.  Bleeding vessels were cauterized.  Meticulous hemostasis was carried out throughout the procedure.  Gradually and carefully I exposed the spinous process of the C6, C5, and C4.  A lateral view was done after an instrument in place.  This revealed the C6-C7 level.  I therefore did a small laminotomy opening at C4-C5.  I placed an instrument and x-rays confirmed C4-C5 level.,I stripped the muscles from the lamina and then moved them laterally and held with a self-retaining retractor.,Once I identified the level, I then used a bur to thin the lamina of C5.  I used a 1-mm, followed by a 2-mm Kerrison rongeur to carefully remove the lamina off C5 on the left.  I removed some of the superior lamina of C6 and some of the inferior lamina of C4.  This allowed me to visualize the dura and the nerve roots and gradually do neural foraminotomies for both the C5 and C6 nerve roots.  There was some bleeding from the epidural veins and a bipolar cautery was used.  Absolutely no retractors were ever placed in the canal.  There was no retraction.  I was able to place a small probe underneath the nerve root and check the disc spaces to make sure there was no fragments of disc or herniation disc and none were found.,At the end of the procedure, the neuroforamen were widely patent.  The nerve roots had been fully decompressed.,I then checked stability.  There was micromotion at the C4-C5 level.  I therefore elected to proceed with a fusion.,I debrided the interspinous ligament between C4 and C5.  I used a bur to roughen up the surface of the superior portion of the spinous process of C5 and the inferior portion of C4.  Using a small drill, I opened the facet at C4-C5.  I then used a very small curette to clean up the articular cartilage.  I used a bur then to roughen up the lamina at C4-C5.,Attention was turned to the right and left hip, which was also prepped.  An incision made over the iliac crest.  Bleeding vessels were cauterized.  I exposed just the posterior aspect of the crest.  I removed some of the bone and then used the curette to remove cancellous bone.,I placed the Songer wire through the base of the spinous process of C4 and C5.  Drill holes made with a clip.  I then packed cancellous bone between the decorticated spinous process.  I then tightened the Songer wire to the appropriate tension and then cut off the excess wire.,Prior to tightening the wire, I also packed cancellous bone with facet at C4-C5.  I then laid bone upon the decorticated lamina of C4 and C5.,The hip wound was irrigated with bacitracin and Kantrex.  Deep structures were closed with #1 Vicryl, subcutaneous suture and subcuticular tissue was closed.,No drain was placed in the hip.,A drain was left in the posterior cervical spine.  The deep tissues were closed with 0 Vicryl, subcutaneous tissue and skin were then closed.  The patient was taken to the recovery room in good condition.
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DESCRIPTION: Decompressive left lumbar laminectomy C4-C5 and C5-C6 with neural foraminotomy. Posterior cervical fusion C4-C5.  Songer wire.  Right iliac bone graft.

The scenario provided involves detailed medical information about a complex neurosurgery procedure, specifically a decompressive laminectomy and fusion with associated risks. Such surgeries can have life-altering consequences including potential for quadriplegia, persistent pain, or other complications as detailed in the preoperative discussion. The procedure is critical to address severe symptoms caused by nerve and spinal cord compression, and the stakes involve significant health and quality of life considerations.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: MGUS Followup

CHIEF COMPLAINT: , MGUS.,HISTORY OF PRESENT ILLNESS:,  This is an extremely pleasant 86-year-old gentleman, who I follow for his MGUS.  I initially saw him for thrombocytopenia when his ANC was 1300.  A bone marrow biopsy was obtained.  Interestingly enough, at the time of his bone marrow biopsy, his hemoglobin was 13.0 and his white blood cell count was 6.5 with a platelet count of 484,000.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.,Overall, he is doing well.  Since I last saw him, he tells me that he has had onset of atrial fibrillation.  He has now started going to the gym two times per week, and has lost over 10 pounds.  He has a good energy level and his ECOG performance status is 0.  He denies any fever, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Multivitamin q.d., aspirin one tablet q.d., Lupron q. three months, Flomax  0.4 mg q.d., and Warfarin 2.5 mg q.d.,ALLERGIES:  ,No known drug allergies.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post left inguinal hernia repair.,2.  Prostate cancer diagnosed in December 2004, which was a Gleason 3+4.  He is now receiving Lupron.,SOCIAL HISTORY: , He has a very remote history of tobacco use.  He has one to two alcoholic drinks per day.  He is married.,FAMILY HISTORY: , His brother had prostate cancer.,PHYSICAL EXAM:,VIT:
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DESCRIPTION: MGUS.  His bone marrow biopsy showed a normal cellular bone marrow; however, there were 10% plasma cells and we proceeded with the workup for a plasma cell dyscrasia.  All his tests came back as consistent with an MGUS.

The note describes a follow-up for a condition called Monoclonal Gammopathy of Undetermined Significance (MGUS). While MGUS can progress to more serious conditions like multiple myeloma, this patient's condition is currently stable as there is no immediate life-threatening situation presented in the summary. The patient is doing well overall, with good energy levels and is maintaining regular gym visits. The patient’s medical history is significant for prostate cancer and atrial fibrillation, but both conditions appear to be managed given the details provided. While it is vital to monitor the patient, the absence of acute symptoms and the current stable state suggests this is not extremely high-stakes.


Medical Specialty: Surgery
Sample Name: Port-A-Cath Insertion - 2

PREOPERATIVE DIAGNOSIS:,1.  Anal cancer.,2.  Need for IV access.,POSTOPERATIVE DIAGNOSIS:,1.  Anal cancer.,2.  Need for IV access.,OPERATIVE PROCEDURE:,1.  Placement of a Port-A-Cath.,2.  Fluoroscopic guidance.,ANESTHESIA:,  General LMA.,ESTIMATED BLOOD LOSS:,  Minimum.,IV FLUIDS: , Per anesthesia.,RECURRENT COMPLICATIONS: , None.,FINDINGS: , Good port placement on C-arm.,INDICATIONS AND PROCEDURE IN DETAIL: , This is a 55-year-old female who presents with anal cancer, who is beginning chemoradiation and needs IV access for chemotherapy.  Risks and benefits of the procedure explained, the patient appeared to understand, and agreed to proceed.  The patient was taken to the operating room, placed in supine position.  General LMA anesthesia was administered.  She is prepped and draped in the usual sterile fashion.  She was placed in the Trendelenburg position and the left subclavian vein was cannulated and a guide wire placed through the wire.  Fluoroscopy was used to confirm appropriate guide wire location in the subclavian vein to the superior vena cava.  The incision was then made around the guide wire, taken to the subcutaneous tissues with electric Bovie cautery.  A pocket was made in the subcutaneous tissue of adequate size for the port which was cut at 16 cm for appropriate locationing which was cut at 16 cm based on superficial measurements.  The 2-0 Vicryl sutures were used to secure the port in place and the sheath introducer was placed over the guide wire and the guide wire removed with a Port catheter being placed into the sheath introducer.  Fluoroscopy was used to confirm appropriate positioning of the catheter and the skin was closed using interrupted 3-0 Vicryl followed by running 4-0 Vicryl subcuticular stitch.  Heparin flush was used to flush the port.  Steri-Strips were applied and the patient was awakened and extubated in the OR taken to the PACU in good condition.  All counts were reported as correct and I was present for the entire procedure.
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DESCRIPTION: Placement of a Port-A-Cath under fluoroscopic guidancein a patient with anal cancer.

surgery, anal cancer, fluoroscopic, fluoroscopy, iv access, port-a-cath, trendelenburg position, chemotherapy, subclavian vein, port a cath, subcutaneous tissues, insertion, subclavian

The situation involves a surgical procedure for a patient with anal cancer, where a Port-A-Cath is being placed to facilitate chemotherapy. While it is a standard medical procedure, it is still invasive and requires precision to avoid complications such as infection or incorrect placement. The stakes are higher than a routine non-invasive medical check-up but lower than a high-risk, major surgical intervention. Thus, it is moderately high-stakes because it directly impacts the patient's ability to receive essential treatment for cancer.


Medical Specialty: General Medicine
Sample Name: Obesity Hypoventilation Syndrome

HISTORY OF PRESENT ILLNESS: , This is a 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study, on CPAP and oxygen to evaluate her for difficulty in initiating and maintaining sleep.  She returns today to review results of an inpatient study performed approximately two weeks ago.,In the meantime, the patient reports she continues on substantial doses of opiate medication to control leg pain from mononeuritis multiplex.,She also takes Lasix for lower extremity edema.,The patient reports that she generally initiates sleep on CPAP, but rips her mask off, tosses and turns throughout the night and has "terrible quality sleep.",MEDICATIONS: , Current medications are as previously noted.  Changes include reduction in prednisone from 9 to 6 mg by mouth every morning.  She continues to take Ativan 1 mg every six hours as needed.  She takes imipramine 425 mg at bedtime.,Her MS Contin dose is 150 mg every 8 to 12 hours and an immediate release morphine preparation, 45 to 75 mg by mouth every 8 hours as needed.,FINDINGS: , Vital signs:  Blood pressure 153/81, pulse 90, respiratory rate 20, weight 311.8 pounds (up 10 pounds from earlier this month), height 5 feet 6 inches, temperature 98.4 degrees, SaO2 is 88% on room air at rest.  Chest is clear.  Extremities show lower extremity pretibial edema with erythema.,LABORATORIES: , An arterial blood gas on room air showed a pH of 7.38, PCO2 of 52, and PO2 of 57.,CPAP compliance monitoring over the past two to three weeks showed average use of 3 hours 26 minutes on nights used.  She used it for greater than 4 hours per night on 67% of night surveyed.  Her estimated apnea/hypopnea index was 3 per hour.  Her average leak flow was 67 liters per minute.,The patient's overnight sleep study was performed as an inpatient sleep study during a routine hospitalization for intravenous gamma globulin therapy.  She slept for a total sleep time of 257 minutes out of 272 minutes in bed (sleep efficiency approximately 90%).  Sleep stage distribution was relatively normal with 2% stage I, 72% stage II, 24% stage III, IV, and 2% stage REM sleep.,There were no periodic limb movements during sleep.,There was evidence of a severe predominantly central sleep apnea during non-REM sleep at 173 episodes per hour and during REM sleep at 77 episodes per hour.  Oxyhemoglobin saturations during non-REM sleep fluctuated from the baseline of 92% to an average low of 82%.  During REM sleep, the baseline oxyhemoglobin saturation was 87% , decreased to 81% with sleep-disordered breathing episodes.,Of note, the sleep study was performed on CPAP at 10.5 cm of H2O with oxygen at 8 liters per minute.,ASSESSMENT:,1.  Obesity hypoventilation syndrome.  The patient has evidence of a well-compensated respiratory acidosis, which is probably primarily related to severe obesity.  In addition, there may be contribution from large doses of opiates and standing doses of gabapentin.,2.  Severe central sleep apnea, on CPAP at 10 cmH2O and supplemental oxygen at 8 liters per minute.  The breathing pattern is that of cluster or Biot's breathing throughout sleep.  The primary etiology is probably opiate use, with contribution with further exacerbation by severe obesity which acts to lower the baseline oxyhemoglobin saturation, and worsen desaturations during apneic episodes.,3.  Mononeuritis multiplex with pain requiring significant substantial doses of analgesia.,4.  Hypoxemia primarily due to obesity, hypoventilation, and presumably basilar atelectasis and a combination of V/Q mismatch and shunt on that basis.,PLANS: , My overall impression is that we should treat this patient's sleep disruption with measures to decrease central sleep apnea during sleep.  These will include, (1).  Decrease in evening doses of MS Contin, (2).  Modest weight loss of approximately 10 to 20 pounds, and (3).  Instituting Automated Servo Ventilation via nasal mask.  With regard to latter, the patient will be returning for a trial of ASV to examine its effect on sleep-disordered breathing patterns.,In addition, the patient will benefit from modest diuresis, with improvement of oxygenation, as well as nocturnal desaturation and oxygen requirements.  I have encouraged the patient to increase her dose of Lasix from 100 to 120 mg by mouth every morning as previously prescribed.  I have also asked her to add Lasix in additional late afternoon to evening dose of Lasix at 40 mg by mouth at that time.  She was instructed to take between one and two K-Tab with her evening dose of Lasix (10 to 20 mEq).,In addition, we will obtain a complete set of pulmonary function studies to evaluate this patient for underlying causes of parenchymal lung disease that may interfere with oxygenation.  Further workup for hypoxemia may include high-resolution CT scanning if evidence for significant pulmonary restriction and/or reductions in diffusion capacity is evident on pulmonary function testing.
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DESCRIPTION: Obesity hypoventilation syndrome.  A 61-year-old woman with a history of polyarteritis nodosa, mononeuritis multiplex involving the lower extremities, and severe sleep apnea returns in followup following an overnight sleep study.

general medicine, polyarteritis nodosa, obesity hypoventilation syndrome, pulmonary function, obesity hypoventilation, mononeuritis multiplex, sleep apnea, sleep study, rem sleep, ativan, sleep, hypoventilation, obesity,

The patient is dealing with a complex set of medical issues that interact with each other, including obesity hypoventilation syndrome, severe central sleep apnea likely exacerbated by opiate use, and mononeuritis multiplex. The patient's current medication regimen is extensive and includes opiates, which may contribute to her sleep apnea and hypoventilation issues. Additionally, her low oxygen saturation levels and respiratory parameters indicate a significant degree of respiratory compromise, which if not properly managed, could lead to serious outcomes such as respiratory failure. The plan includes adjustments to her medication and a trial of a different ventilation strategy, both of which are critical interventions. Given the complexity and potential for serious health consequences if not properly managed, this situation is high-stakes.


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Medical Specialty: Nephrology
Sample Name: ESRD - Discharge Summary

ADMISSION DIAGNOSIS:,  End-stage renal disease (ESRD).,DISCHARGE DIAGNOSIS: , End-stage renal disease (ESRD).,PROCEDURE:,  Cadaveric renal transplant.,HISTORY OF PRESENT ILLNESS: , This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis since 1993 and is also status post cadaveric kidney transplant in 1996 with chronic rejection.,PAST MEDICAL HISTORY:  ,1.  Diabetes mellitus diagnosed 12 years ago.,2.  Hypertension.,3.  Coronary artery disease with a myocardial infarct in September of 2006.,4.  End-stage renal disease.,PAST SURGICAL HISTORY: , Coronary artery bypass graft x5 in 1995 and cadaveric renal transplant in 1996.,SOCIAL HISTORY:  ,The patient denies tobacco or ethanol use.,FAMILY HISTORY:,  Hypertension.,PHYSICAL EXAMINATION:  ,GENERAL:  The patient was alert and oriented x3 in no acute distress, healthy-appearing male.,VITAL SIGNS:  Temperature 96.6, blood pressure 166/106, heart rate 83, respiratory rate 18, and saturations 96% on room air.,CARDIOVASCULAR:  Regular rate and rhythm.,PULMONARY:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, and nondistended with positive bowel sounds.,EXTREMITIES:  No clubbing, cyanosis, or edema.,PERTINENT LABORATORY DATA: , White blood cell count 6.4, hematocrit 34.6, and platelet count 182.  Sodium 137, potassium 5.4, BUN 41, creatinine 7.9, and glucose 295.  Total protein 6.5, albumin 3.4, AST 51, ALT 51, alk phos 175, and total bilirubin 0.5.,COURSE IN HOSPITAL: , The patient was admitted postoperatively to the surgical intensive care unit.  Initially, the patient had a decrease in hematocrit from 30 to 25.  The patient's hematocrit stabilized at 25.  During the patient's stay, the patient's creatinine progressively decreased from 8.1 to a creatinine at the time of discharge of 2.3.  The patient was making excellent urine throughout his stay.  The patient's Jackson-Pratt drain was removed on postoperative day #1 and he was moved to the floor.  The patient was advanced in diet appropriately.  The patient was started on Prograf by postoperative day #2.  Initial Prograf levels came back high at 18.  The patient's Prograf doses were changed accordingly and today, the patient is deemed stable to be discharged home.  During the patient's stay, the patient received four total doses of Thymoglobulin.  Today, he will complete his final dose of Thymoglobulin prior to being discharged.  In addition, today, the patient has an elevated blood pressure of 198/96.  The patient is being given an extra dose of metoprolol for this blood pressure.  In addition, the patient has an elevated glucose of 393 and for this reason he has been given an extra dose of insulin.  These labs will be rechecked later today and once his blood pressure has decreased to systolic blood pressure less than 116 and his glucose has come down to a more normal level, he will be discharged to home.,DISCHARGE INSTRUCTIONS: , The patient is discharged with instructions to seek medical attention in the event if he develops fevers, chills, nausea, vomiting, decreased urine output, or other concerns.  He is discharged on a low-potassium diet with activity as tolerated.  He is instructed that he may shower; however, he is to undergo no underwater soaking activities for approximately two weeks.  The patient will be followed up in the Transplant Clinic at ABCD tomorrow, at which time, his labs will be rechecked.  The patient's Prograf levels at the time of discharge are pending; however, given that his Prograf dose was decreased, he will be followed tomorrow at the Renal Transplant Clinic.
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DESCRIPTION: This is a 46-year-old gentleman with end-stage renal disease (ESRD) secondary to diabetes and hypertension, who had been on hemodialysis and is also status post cadaveric kidney transplant with chronic rejection.

The given situation involves the discharge summary of a patient with end-stage renal disease (ESRD) who underwent a cadaveric renal transplant. This is considered a critical medical context due to the complexity and seriousness of the patient's condition. End-stage renal disease and renal transplants involve significant medical management and a high risk of complications such as transplant rejection. Additionally, the patient's history of other serious conditions, including diabetes, hypertension, and coronary artery disease, further elevates the stakes. Ensuring proper medication levels (such as Prograf) and managing post-operative complications, including elevated blood pressure and glucose levels, are crucial. The discharge instructions reflect the need for close monitoring and follow-up care. Therefore, this is a high-stakes medical situation.


Medical Specialty: Surgery
Sample Name: ORIF Mandibular Fracture & Dental Implant Removal

PREOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,POSTOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,PROCEDURE PERFORMED: , Open reduction and internal fixation (ORIF) of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.,ANESTHESIA: , General nasotracheal.,ESTIMATED BLOOD LOSS: , 125 mL.,FLUIDS GIVEN: , 1 L of crystalloids.,SPECIMEN: , Soft tissue from the fracture site sent for histologic diagnosis.,CULTURES: , Also sent for Gram stain, aerobic and anaerobic, culture and sensitivity.,INDICATIONS FOR THE PROCEDURE: , The patient is a 79-year-old male, who fell in his hometown, following an episode of syncope.  He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above-mentioned fracture.  He was admitted to hospital in Harleton, Texas, where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass.  His mandible fracture was not noted initially.  The patient also has a history of prostate cancer and a renal cell carcinoma.  The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending.  The patient later saw a local oral surgeon.  He diagnosed his mandible fracture and advised him to seek treatment in Houston.  He presented to my office for evaluation on January 18, 2010, and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant, which had been placed approximately 15 years ago.  The patient had significant discomfort and could eat foods and drink fluids with difficulty.  Due to the nature of his fracture and the complex medical history, he was sent to the hospital for admission and following cardiac clearance, he was scheduled for surgery today.,PROCEDURE IN DETAIL: , The patient was taken to the operating room, and placed in a supine position.  Following a nasal intubation and induction of general anesthesia, the surgeon then scrubbed, gowned, and gloved in the normal sterile fashion.  The patient was then prepped and draped in a manner consistent with sterile procedures.  A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region, approximately 1.5 cm medial to the inferior border of the mandible.  A 1 mL of lidocaine 1% with 1:100,000 epinephrine was then infiltrated along the incision and then a 15-blade was used to incise through the skin and subcutaneous tissue.  A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible.  Electrocautery as well as 4.0 silk ties were used for hemostasis.  A 15-blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site.  The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound.  Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis.  Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11-hole Synthes reconstruction plate was then used to stand on the fracture site.  Since there was an area of weakness in the right parasymphysis region, in the location of another dental implant, the bone plate was extended posterior to that site.  When the plate was adapted to the mandible, it was then secured to the bone with 9 screws, each being 2 mm in diameter and each screw was placed bicortically.  All the screws were also locking screws.  Following placement of the screws, there was felt to be excellent stability of the fracture, so the wound was irrigated with a copious amount of normal saline.  The incision was closed in multiple layers with 4.0 Vicryl in the muscular and subcutaneous layers and 5.0 nylon in the skin.  A sterile dressing was then placed over the incision.  The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs.  Estimated blood loss is 125 mL.
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DESCRIPTION: Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.  The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.

surgery, atrophic mandibular fracture, dental implant, open reduction and internal fixation, orif, mandibular fracture, mandible, atrophic, mandibular, dental, implant,

The situation involves a surgical procedure to correct a mandibular fracture and remove a failed dental implant in a 79-year-old patient with a complex medical history, including prostate cancer and renal cell carcinoma. This patient presentation poses a higher risk due to the patient's age, medical history, presence of an atrophic mandible, and the surgical involvement of general anesthesia. Additionally, there are pending results from a biopsy of a mediastinal mass and prior injuries related to a fall. Considering the medical complexity and the surgical intervention, this situation can be considered high-stakes. The risk factors, including potential complication from the surgery and anesthesia in an older patient, as well as the concurrent medical conditions like previous cancers, further increase the stakes of this situation.


Medical Specialty: Surgery
Sample Name: Flex Sig - 3

PROCEDURE: , Flexible sigmoidoscopy.,PREOPERATIVE DIAGNOSIS:,  Rectal bleeding.,POSTOPERATIVE DIAGNOSIS:  ,Diverticulosis.,MEDICATIONS: , None.,DESCRIPTION OF PROCEDURE:  ,The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal descending colon.  At this point, stool occupied the lumen, preventing further passage.  The colon distal to this was well cleaned out and easily visualized.  The mucosa was normal throughout the regions examined.  Numerous diverticula were seen.  There was no blood or old blood or active bleeding.  A retroflexed view of the anorectal junction showed no hemorrhoids.  He tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Sigmoid and left colon diverticulosis.,2.  Otherwise normal flexible sigmoidoscopy to the proximal descending colon.,3.  The bleeding was most likely from a diverticulum, given the self limited but moderately severe quantity that he described.,RECOMMENDATIONS:,1.  Follow up with Dr. X as needed.,2.  If there is further bleeding, a full colonoscopy is recommended.
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DESCRIPTION: Flexible sigmoidoscopy.  Sigmoid and left colon diverticulosis; otherwise, normal flexible sigmoidoscopy to the proximal descending colon.

surgery, olympus, gastroscope, rectal bleeding, flexible sigmoidoscopy, colon diverticulosis, descending colon, diverticulosis, hemorrhoids, flexible, sigmoidoscopy, colon

The situation involves a medical procedure and post-procedure diagnosis, which are crucial for the patient's health. Flexible sigmoidoscopy is a diagnostic procedure used to investigate rectal bleeding, a symptom that can indicate serious conditions. However, in this case, the most severe identified condition was diverticulosis, which is common and often not high-stakes unless complications such as bleeding or diverticulitis occur. The procedure showed no active bleeding and no other immediate concerns, indicating it’s a routine finding. Recommendations for follow-up with the doctor and a possible full colonoscopy if symptoms persist suggest monitoring rather than immediate critical intervention. The stakes are moderate due to the potential need for further investigation if the symptoms recur, but currently not extremely high.


Medical Specialty: Surgery
Sample Name: Vitrectomy Opening

VITRECTOMY OPENING,The patient was brought to the operating room and appropriately identified.  General anesthesia was induced by the anesthesiologist.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.  A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants.  Hemostasis was maintained with wet-field cautery.  Calipers were set at XX mm and the mark was made XX mm posterior to the limbus in the inferotemporal quadrant.  A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark.  The MVR blade was used to make a sclerotomy between the preplaced sutures.  An 8-0 nylon suture was then preplaced for a later sclerotomy closure.  The infusion cannula was inspected and found to be in good working order.  The infusion cannula was placed into the vitreous cavity and secured with the preplaced suture.  The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.  Additional sclerotomies were made XX mm posterior to the limbus in the supranasal and supratemporal quadrants.
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DESCRIPTION: Vitrectomy opening.  A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants.

surgery, westcott scissors, inferotemporal quadrants, conjunctival, peritomy, sclerotomy, vitrectomy, supranasal, supratemporal, cannula, inferotemporalNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The provided text describes the initial stages of a vitrectomy, which is a surgical procedure that involves the removal of the vitreous gel from the eye. This procedure is critical and intricate, as it requires precise handling to prevent complications like retinal detachment or hemorrhage. Any errors during the procedure could potentially lead to severe vision loss or blindness. Therefore, the situation involves a high degree of risk and responsibility, making the stakes high.


Medical Specialty: Surgery
Sample Name: Endoscopy - 4

PROCEDURE: , Endoscopy.,CLINICAL INDICATIONS: , Intermittent rectal bleeding with abdominal pain.,ANESTHESIA: , Fentanyl 100 mcg and 5 mg of IV Versed.,PROCEDURE:,  The patient was taken to the GI lab and placed in the left lateral supine position.  Continuous pulse oximetry and blood pressure monitoring were in place.  After informed consent was obtained, the video endoscope was inserted over the dorsum of the tongue without difficulty.  With swallowing, the scope was advanced down the esophagus into the body of the stomach.  The scope was further advanced down to the antrum and through the pylorus into the duodenum, which was visualized into its second portion.  It appeared free of stricture, neoplasm, or ulceration.  Samples were obtained from the antrum and prepyloric area to check for Helicobacter, rapid urease, and additional samples were sent to pathology.  Retroflexion view of the fundus of the stomach was normal without evidence of a hiatal hernia.  The scope was then slowly removed.  The distal esophagus appeared benign with a normal-appearing gastroesophageal sphincter and no esophagitis.  The remaining portion of the esophagus was normal.,IMPRESSION:,  Abdominal pain.  Symptoms most consistent with gastroesophageal reflux disease without endoscopic evidence of hiatal hernia.,RECOMMENDATIONS:,  Await results of CLO testing and biopsies.  Return to clinic with Dr. Spencer in 2 weeks for further discussion.
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DESCRIPTION: Intermittent rectal bleeding with abdominal pain.

surgery, duodenum, stomach, hiatal hernia, endoscopy, antrum, hiatal, hernia, gastroesophageal, scope, esophagus, abdominal

This situation involves a medical procedure (endoscopy) due to symptoms like intermittent rectal bleeding and abdominal pain, which could indicate significant underlying conditions. Although the procedure is routine, the stakes are moderately high because the findings can directly affect patient management and treatment decisions. Since the findings exclude severe conditions like stricture or hiatal hernia and only indicate possible GERD, the immediate criticality is lowered, but the overall situation remains important due to potential underlying issues that need addressing.


Medical Specialty: Neurology
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.

neurology, 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 the diagnosis and treatment of a brain tumor (Grade 2 Astrocytoma) in a 65-year-old patient. This is considered high-stakes due to the potential impact on the patient's neurological functions and overall prognosis. Brain tumors can have significant health implications, leading to cognitive decline, physical dysfunctions, and can be life-threatening. The need for surgery and radiation therapy further underscores the seriousness of the condition.