Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Preop Cardiac Consult

HISTORY OF PRESENT ILLNESS: , I was kindly asked to see Ms. ABC by Dr. X for cardiology consultation regarding preoperative evaluation for right hip surgery.  She is a patient with a history of coronary artery disease status post bypass surgery in 1971 who tripped over her oxygen last p.m. she states and fell.  She suffered a right hip fracture and is being considered for right hip replacement.  The patient denies any recent angina, but has noted more prominent shortness of breath.,Past cardiac history is significant for coronary artery disease status post bypass surgery, she states in 1971, I believe it was single vessel.  She has had stress test done in our office on September 10, 2008, which shows evidence of a small apical infarct, no area of ischemia, and compared to study of December of 2005, there is no significant change.  She had a transthoracic echocardiogram done in our office on August 29, 2008, which showed normal left ventricular size and systolic function, dilated right ventricle with septal flattening of the left ventricle consistent with right ventricular pressure overload, left atrial enlargement, severe tricuspid regurgitation with estimated PA systolic pressure between 75-80 mmHg consistent with severe pulmonary hypertension, structurally normal aortic and mitral valve.  She also has had some presumed atrial arrhythmias that have not been sustained.  She follows with Dr. Y my partner at Cardiology Associates.,PAST MEDICAL HISTORY:  ,Other medical history includes severe COPD and she is oxygen dependent, severe pulmonary hypertension, diabetes, abdominal aortic aneurysm, hypertension, dyslipidemia.  Last ultrasound of her abdominal aorta done June 12, 2009 states that it was fusiform, infrarenal shaped aneurysm of the distal abdominal aorta measuring 3.4 cm unchanged from prior study on June 11, 2008.,MEDICATIONS:,  As an outpatient:,1.  Lanoxin 0.125 mg, 1/2 tablet once a day.,2.  Tramadol 50 mg p.o. q.i.d. as needed.,3.  Verapamil 240 mg once a day.,4.  Bumex 2 mg once a day.,5.  ProAir HFA.,6.  Atrovent nebs b.i.d.,7.  Pulmicort nebs b.i.d.,8.  Nasacort 55 mcg, 2 sprays daily.,9.  Quinine sulfate 325 mg p.o. q.h.s. p.r.n.,10.  Meclizine 12.5 mg p.o. t.i.d. p.r.n.,11.  Aldactone 25 mg p.o. daily.,12.  Theo-24 200 mg p.o., 2 in the morning.,13.  Zocor 40 mg once a day.,14.  Vitamin D 400 units twice daily.,15.  Levoxyl 125 mcg once a day.,16.  Trazodone 50 mg p.o. q.h.s. p.r.n.,17.  Janumet 50/500, 1 tablet p.o. b.i.d.,ALLERGIES: , To medications are listed as:,1.  LEVAQUIN.,2.  AZITHROMYCIN.,3.  ADHESIVE TAPE.,4.  BETA BLOCKERS.  When I talked to the patient about the BETA BLOCKER, she states that they made her more short of breath in the past.,She denies shrimp, seafood or dye allergy.,FAMILY HISTORY:  ,Significant for heart problems she states in her mother and father.,SOCIAL HISTORY:  ,She used to smoke cigarettes and smoked from the age of 14 to 43 and quit at the time of her bypass surgery.  She does not drink alcohol nor use illicit drugs.  She lives alone and is widowed.  She is a retired custodian at University.  Of note, she is accompanied with her verbal consent by her daughter and grandson at the bedside.,REVIEW OF SYSTEMS:  ,Unable to obtain as the patient is somnolent from her pain medication, but she is alert and able to answer my direct questions.,PHYSICAL EXAM: , Height 5'2", weight 160 pounds, temperature is 99.5 degrees ranging up to 101.6, blood pressure 137/67 to 142/75, pulse 92, respiratory rate 16, O2 saturation 93-89%.  On general exam, she is an elderly, chronically ill appearing woman in no acute distress.  She is able to lie flat, she does have pain if she moves.  HEENT shows the cranium is normocephalic, atraumatic.  She has dry mucosal membranes.  Neck veins are not distended.  There are no carotid bruits.  Visible skin is warm and she appears pale.  Affect appropriate and she is somnolent from her pain medications, but arouses easily and answers my direct questions appropriately.  Lungs are clear to auscultation anteriorly, no wheezes.  Cardiac exam S1, S2 regular rate, soft holosystolic murmur heard over the tricuspid region.  No rub nor gallop.  PMI is nondisplaced, unable to appreciate RV heave.  Abdomen soft, mildly distended, appears benign.  Extremities with trivial peripheral edema.  Pulses grossly intact.  She has quite a bit of pain at the right hip fracture.,DIAGNOSTIC/LABORATORY DATA:  ,Sodium 135, potassium 4.7, chloride 99, bicarbonate 33, BUN 22, creatinine 1.3, glucose 149, troponin was 0.01 followed by 0.04.  Theophylline level 16.6 on January 23, 2009.  TSH 0.86 on March 10, 2009.  INR 1.06.  White blood cell count 9.5, hematocrit 35, platelet count 160.,EKG done July 16, 2009 at 7:31:15, shows sinus rhythm, which showed PR interval of about 118 milliseconds, nonspecific T wave changes.  When compared to EKG done July 15, 2009 at 1948, previously there more frequent PVCs seen.  This ECG appears similar to the ones she has had done previously in our office including on June 11, 2009, although the T wave changes are a bit more prominent, which is a nonspecific finding.,IMPRESSION: , She is an 81-year-old woman with severe O2 requiring chronic obstructive pulmonary disease with evidence of right heart overload, as well as known coronary artery disease status post single-valve bypass in 1971 suffering a right hip fracture for whom a right hip replacement is being considered.  I have had a long discussion with the patient, as well as her daughter and grandson at the bedside today.  There are no clear absolute cardiac contraindications that I can see.  Of note at the time of this dictation a chest x-ray report is pending.  With that being said, however, she is extremely high risk more from a pulmonary than cardiac standpoint.  We did also however review that untreated hip fractures themselves have very high morbidity and mortality incidences.  The patient is deciding on surgery and is clearly aware that she is very high risk for proposed surgery, as well as if she were to not pursue surgery.,PLAN/RECOMMENDATIONS:,1.  The patient is going to decide on surgery.  If she does have the right hip surgery, I would recommend overnight observation in the intensive care unit.,2.  Optimize pulmonary function and pursue aggressive DVT prophylaxis.,3.  Continue digoxin and verapamil.  Again, the patient describes clear INTOLERANCE TO BETA BLOCKERS by her history.
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DESCRIPTION: Cardiology consultation regarding preoperative evaluation for right hip surgery.  Patient with a history of coronary artery disease status post bypass surgery

This situation involves a preoperative cardiac consultation for a patient with significant medical history and current conditions that present high risks. The patient has severe chronic obstructive pulmonary disease (COPD) requiring oxygen, pulmonary hypertension, and a history of coronary artery disease with past bypass surgery, among other conditions. The evaluation is crucial to assess if the patient can safely undergo hip replacement surgery given her complex medical conditions. The decision on surgery carries high stakes because the untreated hip fracture itself has high morbidity and mortality, and the surgery poses high risks due to her health conditions.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 5

PROCEDURE PERFORMED:,1. Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.,2. Right femoral selective angiogram.,3. Closure device the seal the femoral arteriotomy using an Angio-Seal.,INDICATIONS FOR PROCEDURE: ,The patient with known coronary atherosclerotic heart disease and multiple risk factors of coronary disease, who had her last coronary arteriogram performed in 2004. She has had complaints of progressive chest discomfort, and has ongoing risks including current smoking, diabetes, hypertension, hyperlipidemia to name a few. The decision was made to proceed on with percutaneous evaluation and possible intervention given her known disease and the possibility of disease progression.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, The patient was taken to cardiac catheterization lab where her procedure was performed. She was prepped and prepared on the table; after which, her right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery over a standard 0.035 guide wire. Coronary angiography and left ventricular measurement and angiography were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery. A 6-French JR4 diagnostic catheter to image the right groin and her artery and the saphenous vein graft conduit. Subsequently, a 6-French angled pigtail catheter was used to measure left ventricular pressures and to perform a power injection, a left ventriculogram at 8 mL per second for a total of 30 mL. At the conclusion of the diagnostic evaluation, the patient had selective arteriography of her right femoral artery, which showed the right femoral artery to be free of significant atherosclerotic plaque. Did have a normal bifurcation into the superficial femoral and profunda femoris arteries and to have an arteriotomy that was in the common femoral artery away from the bifurcation. As such, an initial attempt to advance a Perclose device failed to allow the device descend to _____ tract and into the appropriate position within the artery. As such, the Perclose was never deployed and was removed intact over the wire from the system. We then replaced this with a 6-French Angio-Seal which was used to seal the femoral arteriotomy with achievement of hemostasis. The patient was subsequently dispositioned back to the MAC Unit where she will complete her bedrest prior to her disposition to home.,HEMODYNAMIC DATA:, Opening aortic pressure 125/60, left ventricular pressure 108/4 with an end-diastolic pressure of 16. There was no significant gradient across the aortic valve on pullback from the left ventricle. Left ventricular ejection fraction was 55%. Mitral regurgitation was less than or equal to 1+. There was normal wall motion in the RAO projection.,CORONARY ANGIOGRAM:, The left main coronary artery had mild atherosclerotic plaque. The proximal LAD was 100% occluded. The left circumflex had mild diffuse atherosclerotic plaque. The obtuse marginal branch which operates as an OM-2 had a mid approximately 80% stenosis at a kink in the artery. This appears to be the area of a prior anastomosis, the saphenous vein graft to the OM. This is a very small-caliber vessel and is 1.5-mm in diameter at best. The right coronary artery is dominant. The native right coronary artery had mild proximal and mid atherosclerotic plaque. The distal right coronary artery has an approximate 40% stenosis. The posterior left ventricular branch has a proximal 50 to 60% stenosis. The proximal PDA has a 40 to 50% stenosis. The saphenous vein graft to the right PDA is widely patent. There was competitive flow noted between the native right coronary artery and the saphenous vein graft to the PDA. The runoff from the PDA is nice with the native proximal PDA and PLV disease as noted above. There is also some retrograde filling of the right coronary artery from the runoff of this graft. The saphenous vein graft to the left anterior descending is widely patent. The LAD beyond the distal anastomosis is a relatively small-caliber vessel. There is some retrograde filling that allows some filling into a more proximal diagonal branch. The saphenous vein graft to the obtuse marginal was known to be occluded from the prior study in 2004. Overall, this study does not look markedly different than the procedure performed in 2004.,CONCLUSION:, 100% proximal LAD mild left circumflex disease with an OM that is a small-caliber vessel with an 80% lesion at a kink that is no amenable to percutaneous intervention. The native right coronary artery has mild to moderate distal disease with moderate PLV and PDA disease. The saphenous vein graft to the OM is known to be 100% occluded. The saphenous vein graft to the PDA and the saphenous vein graft to the LAD are open. Normal left ventricular systolic function.,PLAN:, The plan will be for continued medical therapy and risk factor modification. Aggressive antihyperlipidemic and antihypertensive control. The patient's goal LDL will be at or below 70 with triglyceride level at or below 150, and it is very imperative that the patient stop smoking.,After her bedrest is complete, she will be dispositioned to home, after which, she will be following up with me in the office within 1 month. We will also plan to perform a carotid duplex Doppler ultrasound to evaluate her carotid bruits.
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DESCRIPTION: Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.

cardiovascular / pulmonary, catheterization, vein graft, angiography, angiogram, angio-seal, closure device, coronary atherosclerotic heart disease, saphenous vein graft, ventricular pressure, coronary artery, saphenous vein, atherosclerotic, coronary, artery, bifurcation, pda, ventricular, saphenous

The procedure described is a cardiac catheterization, which is a significant medical procedure used to diagnose and potentially treat conditions such as coronary artery disease. Given the patient's existing health risks (e.g., coronary disease, smoking, diabetes) and the discovery of a 100% occlusion in the proximal LAD, the stakes are relatively high. The procedure findings will directly influence the management of the patient's conditions, making it crucial for her ongoing treatment. However, the procedure itself was completed without immediate complications, and the plan involves continuation of medical therapy rather than immediate surgical intervention, which slightly reduces the immediate stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 6

VITAL SIGNS:,  Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.,CONSTITUTIONAL: , Normal appearance for chronological age, does not appear chronically ill.,HEENT: , The pupils are equal and reactive.  Funduscopic examination is normal.  Posterior pharynx is normal.  Tympanic membranes are clear.,NECK:  ,Trachea is midline.  Thyroid is normal.  The neck is supple.  Negative nodes.,RESPIRATORY:,  Lungs are clear to auscultation bilaterally.  The patient has a normal respiratory rate, no signs of consolidation and no egophony.  There are no retractions or secondary muscle use.  Good bilateral breath sounds are noted.,CARDIOVASCULAR: , No jugular venous distention or carotid bruits.  No increase in heart size to percussion.  There is no murmur.  Normal S1 and S2 sounds are noted without gallop.,ABDOMEN: , Soft to palpation in all four quadrants.  There is no organomegaly and no rebound tenderness.  Bowel sounds are normal.  Obturator and psoas signs are negative.,GENITOURINARY: , No bladder tenderness, negative flank pain.,MUSCULOSKELETAL:,  Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.,NEUROLOGIC: , Normal Glasgow Coma Scale.  Cranial nerves II through XII appear grossly intact.  Normal motor and cerebellar tests.  Reflexes are normal.,HEME/LYMPH:  ,No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.,PSYCHIATRIC: , Normal with no overt depression or suicidal ideations.
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DESCRIPTION: Normal physical exam template.  Normal appearance for chronological age, does not appear chronically ill.

consult - history and phy., jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds,

The situation describes a normal physical exam template used in a consult for history and physical examination. There are no abnormal findings or indications that the patient is in any distress or suffering from any conditions that would be considered high-stakes. The examination notes that everything appears normal across various systems (vital signs, respiratory, cardiovascular, etc.). Therefore, this situation is routine and low-stakes from a clinical perspective.


Medical Specialty: Consult - History and Phy.
Sample Name: Well-Child Check - 1

CHIEF COMPLAINT:,  Well-child check.,HISTORY OF PRESENT ILLNESS:,  This is a 12-month-old female here with her mother for a well-child check.  Mother states she has been doing well.  She is concerned about drainage from her left eye.  Mother states she was diagnosed with a blocked tear duct on that side shortly after birth, and normally she has crusted secretions every morning.  She states it is worse when the child gets a cold.  She has been using massaging when she can remember to do so.  The patient is drinking whole milk without problems.  She is using solid foods three times a day.  She sleeps well without problems.  Her bowel movements are regular without problems.  She does not attend daycare.,DEVELOPMENTAL ASSESSMENT:,  Social:  She can feed herself with fingers.  She is comforted by parent’s touch.  She is able to separate and explore.  Fine motor:  She scribbles.  She has a pincer grasp.  She can drink from a cup.  Language:  She says dada.  She says one to two other words and she indicates her wants.  Gross motor:  She can stand alone.  She cruises.  She walks alone.  She stoops and recovers.,PHYSICAL EXAMINATION:,General:  She is alert, in no distress.,Vital signs:  Weight:  25th percentile.  Height:  25th percentile.  Head circumference:  50th percentile.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Left eye with watery secretions and crusted lashes.  Conjunctiva is clear.  TMs are clear bilaterally.  Nares are patent.  Mild nasal congestion present.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Female external genitalia.,Extremities:  Symmetrical.  Femoral pulses are 2+ bilaterally.  Full range of motion of all extremities.,Neurologic:  Grossly intact.,Skin:  Normal turgor.,Testing:  Hearing and vision assessments grossly normal.,ASSESSMENT:,1.  Well child.,2.  Left lacrimal duct stenosis.,PLAN:,  MMR #1 and Varivax #1 today.  VIS statements given to Mother after discussion.  Evaluation and treatment as needed with Dr. XYZ with respect to the blocked tear duct.  Anticipatory guidance for age.  She is to return to the office in three months.
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DESCRIPTION: Well child - Left lacrimal duct stenosis

consult - history and phy., well-child check, drainage, eye, lacrimal duct stenosis, lacrimal duct, mmr, varivax, vis statements, tear duct, lacrimal, percentile, mother, child,

The situation involves a routine well-child check for a 12-month-old but includes concern about a blocked tear duct, which is a known issue without serious immediate implications. The exam results and developmental milestones are normal, with vaccinations being conducted as per schedule. While blocked tear ducts are common and often resolve without invasive treatment, monitoring and possible further evaluation is advised. However, this is not a high-stakes medical situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 14

HISTORY OF PRESENT ILLNESS:,  A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache.  Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved.  She is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay.  She continues to have some left-sided jaw pain.  Denies any headache, fever, cough, or sore throat.  She had used Cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that.  She has also had problems with sinusitis in the past and chronic left-sided headache.,FAMILY HISTORY:,  Reviewed and unchanged.,ALLERGIES: , To cephalexin.,CURRENT MEDICATIONS:,  Ibuprofen.,SOCIAL HISTORY:,  She is a nonsmoker.,REVIEW OF SYSTEMS:,  As above.  No nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, and in no acute distress.,Vital Signs:  Weight:  121 pounds.  Temperature:  97.9 degrees.,Skin:  Reveals scattered erythematous plaques with some mild lichenification on the nuchal region and behind the knees.,Eyes:  PERRLA.  Conjunctivae are clear.,Ears:  Left TM with some effusion.  Right TM is clear.  Canals are clear.  External auricles are nontender to manipulation.,Nose:  Nasal mucosa is pink and moist without discharge.,Throat:  Nonerythematous.  No tonsillar hypertrophy or exudate.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.  Respirations are regular and unlabored.,Heart:  Regular rate and rhythm at rate of 100 beats per minute.,ASSESSMENT:,1.  Serous otitis.,2.  Atopic dermatitis.,PLAN:,1.  Nasacort AQ two sprays each nostril daily.,2.  Duraphen II one b.i.d.,3.  Refills Cutivate cream 0.05% to apply to affected areas b.i.d.  Recheck p.r.n.
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DESCRIPTION: Complaint of left otalgia (serous otitis) and headache.  History of atopic dermatitis.

The case involves a 49-year-old female presenting with symptoms primarily related to otalgia, sinus pressure, and dermatitis. While the patient has a history of sinusitis and is currently dealing with discomfort, there are no acute or life-threatening symptoms reported. The physical examination indicates no distress, and the treatment plan involves non-critical interventions such as medication refills and nasal sprays. The situation is routine in the context of general medical practice and does not involve any immediate risk to the patient's health.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Atrial Flutter - Progress Note

HISTORY OF PRESENT ILLNESS: , Hospitalist followup is required for continuing issues with atrial flutter with rapid ventricular response, which was resistant to treatment with diltiazem and amiodarone, being followed by Dr. X of cardiology through most of the day.  This afternoon, when I am seeing the patient, nursing informs me that rate has finally been controlled with esmolol, but systolic blood pressures have dropped to the 70s with a MAP of 52.  Dr. X was again consulted from the bedside.  We agreed to try fluid boluses and then to consider Neo-Synephrine pressure support if this is not successful.  In addition, over the last 24 hours, extensive discussions have been held with the family and questions answered by nursing staff concerning the patient's possible move to Tahoe Pacific or a long-term acute care.  Other issues requiring following up today are elevated transaminases, continuing fever, pneumonia, resolving adult respiratory distress syndrome, ventilatory-dependent respiratory failure, hypokalemia, non-ST-elevation MI, hypernatremia, chronic obstructive pulmonary disease, BPH, atrial flutter, inferior vena cava filter, and diabetes.,PHYSICAL EXAMINATION,VITAL SIGNS:  T-max 103.2, blood pressure at this point is running in the 70s/mid 40s with a MAP of 52, heart rate is 100.,GENERAL:  The patient is much more alert appearing than my last examination of approximately 3 weeks ago.  He denies any pain, appears to have intact mentation, and is in no apparent distress.,EYES:  Pupils round, reactive to light, anicteric with external ocular motions intact.,CARDIOVASCULAR:  Reveals an irregularly irregular rhythm.,LUNGS:  Have diminished breath sounds but are clear anteriorly.,ABDOMEN:  Somewhat distended but with no guarding, rebound, or obvious tenderness to palpation.,EXTREMITIES:  Show trace edema with no clubbing or cyanosis.,NEUROLOGICAL:  The patient is moving all extremities without focal neurological deficits.,LABORATORY DATA: , Sodium 149; this is down from 151 yesterday.  Potassium 3.9, chloride 114, bicarb 25, BUN 35, creatinine 1.5 up from 1.2 yesterday, hemoglobin 12.4, hematocrit 36.3, WBC 16.5, platelets 231,000.  INR 1.4.  Transaminases are continuing to trend upwards of SGOT 546, SGPT 256.  Also noted is a scant amount of very concentrated appearing urine in the bag.,IMPRESSION: , Overall impressions continues to be critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.,PLAN,1.  Hypotension.  I would aggressively try and fluid replete the patient giving him another liter of fluids.  If this does not work as discussed with Dr. X, we will start some Neo-Synephrine, but also continue with aggressive fluid repletion as I do think that indications are that with diminished and concentrated urine that he may still be down and fluids will still be required even if pressure support is started.,2.  Increased transaminases.  Presumably this is from increased congestion.  This is certainly concerning.  We will continue to follow this.  Ultrasound of the liver was apparently negative.,3.  Fever and elevated white count.  The patient does have a history of pneumonia and empyema.  We will continue current antibiotics per infectious disease and continue to follow the patient's white count.  He is not exceptionally toxic appearing at this time.  Indeed, he does look improved from my last examination.,4.  Ventilatory-dependent respiratory failure.  The patient has received a tracheostomy since my last examination.  Vent management per PMA.,5.  Hypokalemia.  This has resolved.  Continue supplementation.,6.  Hypernatremia.  This is improving somewhat.  I am hoping that with increased fluids this will continue to do so.,7.  Diabetes mellitus.  Fingerstick blood glucoses are reviewed and are at target.  We will continue current management.  This is a critically ill patient with multiorgan dysfunction and signs of worsening renal, hepatic, and cardiovascular function with extremely guarded prognosis.  Total critical care time spent today 37 minutes.
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DESCRIPTION: A critically ill 67-year-old with multiple medical problems probably still showing signs of volume depletion with hypotension and atrial flutter with difficult to control rate.

cardiovascular / pulmonary, rapid ventricular response, volume depletion, atrial flutter, atrial, hypotension, flutter,

The situation is highly complex, involving a critically ill patient with multiple organ dysfunctions, including cardiovascular, hepatic, and respiratory issues. The patient has hypotension, atrial flutter, signs of worsening renal function, and elevated transaminases, among other concerns. Immediate, coordinated interventions are required, and there is mention of possible pressure support and fluid management to stabilize the patient. Therefore, the situation is high-stakes due to the critical nature of the patient's condition, the decisions to be made regarding treatment and intervention, and the potential impact on the patient's survival and quality of life.


Medical Specialty: Consult - History and Phy.
Sample Name: Ankle Pain - Consult

IDENTIFICATION: , The patient is a 15-year-old female.,CHIEF COMPLAINT: , Right ankle pain.,HISTORY OF PRESENT ILLNESS:,  The patient was running and twisted her right ankle.  There were no other injuries.  She complains of right ankle pain on the lateral aspect.  She is brought in by her mother.  Her primary care physician is Dr. Brown.,REVIEW OF SYSTEMS:,  Otherwise negative except as stated above.,PAST MEDICAL HISTORY:,  None.,PAST SURGICAL HISTORY: , None.,MEDICATIONS:,  None.,SOCIAL HISTORY: , Mother appears loving and caring.  There is no evidence of abuse.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION: , General:  The patient is alert and oriented x4 in mild distress without diaphoresis.  She is nonlethargic and nontoxic.  Vitals:  Within normal limits.  The right ankle shows no significant swelling.  There is no ecchymosis.  There is no significant tenderness to palpation.  The ankle has good range of motion.  The foot is nontender.  Vascular:  +2/2 dorsalis pedis pulse.  All compartments are soft.  Capillary refill less than 2 seconds.,DIAGNOSTIC TEST:,  The patient had an x-ray of the right ankle, which interpreted by myself shows no acute fracture or dislocation.,MEDICAL DECISION MAKING: , Due to the fact this patient has no evidence of an ankle fracture, she can be safely discharged to home.  She is able to walk on it without significant pain, thus I recommend rest for 1 week and follow up with the doctor if she has persistent pain.  She may need to see a specialist, but at this time this is a very mild ankle injury.  There is no significant physical finding, and I foresee no complications.  I will give her 1 week off of PE.,MORBIDITY/MORTALITY:,  I expect no acute complications.  A full medical screening exam was done and no emergency medical condition exists upon discharge.,COMPLEXITY:,  Moderate.  The differential includes fracture, contusion, abrasion, laceration, and sprain.,ASSESSMENT:,  Right ankle sprain.,PLAN:,  Discharge the patient home and have her follow up with her doctor in 1 week if symptoms persist.  She is advised to return immediately p.r.n. severe pain, worsening, not better, etc.
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DESCRIPTION: The patient was running and twisted her right ankle - right ankle sprain.

The situation involves a 15-year-old patient with a right ankle sprain that does not show any acute fracture or dislocation, as confirmed by an x-ray. The patient is in mild distress but does not exhibit any alarming symptoms such as significant swelling or inability to bear weight. She is discharged with instructions for rest and follow-up if symptoms persist. The medical decision indicates that this is a mild injury with no expected complications. Overall, while there is a need for medical attention, the situation is not high-stakes as there are no immediate life-threatening conditions or severe injury involved.


Medical Specialty: Dermatology
Sample Name: Hyperesthesia

SUBJECTIVE:,  This 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh.  It cleared for awhile.  This has been an intermittent problem.  Now it is back again on his right lower abdomen.  At first, it was thought that he may have early zoster.  This started six weeks before the holidays and is still going on, more so in the past eight days on his abdomen and right hip area.  He has had no treatment on this; there are no skin changes at all.  The patient bathes everyday but tries to use little soap.  The patient is married.  He works as an airplane mechanic.,FAMILY, SOCIAL, AND ALLERGY HISTORY:,  The patient has sinus and CVA.  He is a nonsmoker.  No known drug allergies.,CURRENT MEDICATIONS:,  Lipitor, aspirin, folic acid.,PHYSICAL EXAMINATION:,  The patient is well developed, appears stated age.  Overall health is good.  He does have psoriasis with some psoriatic arthritis, and his skin looks normal today.  On his trunk, he does have the hyperesthesia.  As you touch him, he winces.,IMPRESSION:,  Hyperesthesia, question etiology.,TREATMENT:,1.  Discussed condition and treatment with the patient.,2.  Discontinue hot soapy water to these areas.,3.  Increase moisturizing cream and lotion.,4.  I referred him to Dr. ABC or Dr. XYZ for neurology evaluation.  We did not see anything on skin today.  Return p.r.n. flare.
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DESCRIPTION: Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.

dermatology, abdomen, hyperesthesia, soapy water, moisturizing cream, initial evaluation

The situation describes a patient visiting a dermatologist for hyperesthesia, which is an abnormal increase in sensitivity to stimuli. The case involves recurrent symptoms but no serious immediate medical conditions are identified. The patient is referred to neurology for further evaluation. Overall health is good, and there are no alarming features in his medical history or current medications that suggest a life-threatening issue. Therefore, while the patient experiences discomfort, the situation does not suggest an acute or critical risk to life or health.


Medical Specialty: General Medicine
Sample Name: Normal Male Exam Template - 4

VITAL SIGNS:,  Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE: , Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT:,  Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  No papilledema, glaucoma, or cataracts.  Ears:  Normal set and shape with normal hearing and normal TMs. Nose and Sinus:  Unremarkable.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without carotid bruit, JVD, or significant cervical adenopathy.  Trachea is midline without stridor, shift, or subcutaneous emphysema.  Thyroid is palpable, nontender, not enlarged, and free of nodularity.,CHEST: , Lungs bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI is nondisplaced.  Chest wall is unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS: , Normal male breast tissue.,ABDOMEN:,  No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and intraabdominal bruit on auscultation.,EXTERNAL GENITALIA: , Normal for age.  Normal penis with bilaterally descended testes that are normal in size, shape, and contour, and without evidence of hernia or hydrocele.,RECTAL:,  Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool and normal-sized prostate that is free of nodularity or tenderness.  No rectal masses palpated.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK: , Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC: , Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN:  ,Unremarkable for any premalignant or malignant condition with normal changes for age.
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DESCRIPTION: An example/template for a routine normal male physical exam.

general medicine, digital palpation, hemoccult-negative, heent, palpation, breasts, male, tenderness, tongue,

The text provided is a template for a routine normal male physical exam and does not indicate any specific medical emergency or high-risk situation. It outlines standard observations expected during a general examination in a male patient, confirming that there are no abnormal findings. This template serves as a baseline for comparison in general practice rather than an urgent health situation.


Medical Specialty: Surgery
Sample Name: Lumbar Re-exploration

PREOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,POSTOPERATIVE DIAGNOSIS: , Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.,PROCEDURE: , Lumbar re-exploration for removal of fractured internal fixation plate from T11 through L2 followed by a repositioning of the L2 pedicle screws and evaluation of the fusion from T11 through L2 followed by a bilateral hemilaminectomy and diskectomy for decompression at L4-5 and L5-S1 with posterior lumbar interbody fusion using morselized autograft bone and the synthetic spacers from the Capstone system at L4-5 and L5-S1 followed by placement of the pedicle screw fixation devices at L3, L4, L5, and S1 and insertion of a 20 cm fixation plate that range from the T11 through S1 levels and then subsequent onlay fusion using morselized autograft bone and bone morphogenetic soaked sponge at L1-2 and then at L3-L4, L4-L5, and L5-S1 bilaterally.,DESCRIPTION OF PROCEDURE:  ,This is a 68-year-old lady who presents with a history of osteomyelitis associated with the percutaneous vertebroplasty that was actually treated several months ago with removal of the infected vertebral augmentation and placement of a posterior pedicle screw plate fixation device from T11 through L2.  She subsequently actually done reasonably well until about a month ago when she developed progressive severe intractable pain.  Imaging study showed that the distal hardware at the plate itself had fractured consistent with incomplete fusion across her osteomyelitis area.  There was no evidence of infection on the imaging or with her laboratory studies.  In addition, she developed a pretty profound stenosis at L4-L5 and L5-S1 that appeared to be recurrent as well.  She now presents for revision of her hardware, extension of fusion, and decompression.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  She was placed on the operative table in the prone position.  Back was prepared with Betadine, iodine, and alcohol.  We elliptically excised her old incision and extended this caudally so that we had access from the existing hardware fixation all the way down to her sacrum.  The locking nuts were removed from the screw post and both plates refractured or significantly weakened and had a crease in it.  After these were removed, it was obvious that the bottom screws were somewhat loosened in the pedicle zone so we actually tightened one up and that fit good snugly into the nail when we redirected so that it actually reamed up into the upper aspect of the vertebral body in much more secure purchase.  We then dressed the L4-L5 and L5-S1 levels which were profoundly stenotic.  This was a combination of scar and overgrown bone.  She had previously undergone bilateral hemilaminectomies at L4-5 so we removed scar bone and actually cleaned and significantly decompressed the dura at both of these levels.  After completing this, we inserted the Capstone interbody spacer filled with morselized autograft bone and some BMP sponge into the disk space at both levels.  We used 10 x 32 mm spacers at both L4-L5 and L5-S1.  This corrected the deformity and helped to preserve the correction of the stenosis and then after we cannulated the pedicles of L4, L5 and S1 tightened the pedicle screws in L3.  This allowed us to actually seat a 20 cm plate contoured to the lumbar lordosis onto the pedicle screws all the way from S1 up to the T11 level.  Once we placed the plate onto the screws and locked them in position, we then packed the remaining BMP sponge and morselized autograft bone through the plate around the incomplete fracture healing at the L1 level and then dorsolaterally at L4-L5 and L5-S1 and L3-L4, again the goal being to create a dorsal fusion and enhance the interbody fusion as well.  The wound was then irrigated copiously with bacitracin solution and then we closed in layers using #1 Vicryl in muscle and fascia, 3-0 in subcutaneous tissue and approximated staples in the skin.  Prior to closing the skin, we confirmed correct sponge and needle count.  We placed a drain in the extrafascial space and then confirmed that there were no other foreign bodies.  The Cell Saver blood was recycled and she was given two units of packed red blood cells as well.  I was present for and performed the entire procedure myself or supervised.
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DESCRIPTION: Recurrent degenerative spondylolisthesis and stenosis at L4-5 and L5-S1 with L3 compression fracture adjacent to an instrumented fusion from T11 through L2 with hardware malfunction distal at the L2 end of the hardware fixation.

surgery, degenerative spondylolisthesis, spondylolisthesis, stenosis, lumbar re-exploration, internal fixation plate, hemilaminectomy, diskectomy, synthetic spacers, pedicle screws, fusion, lumbar, pedicle, fixation, hardware,

This surgical situation involves a complex lumbar re-exploration procedure, focusing on addressing significant issues with spinal hardware and decompressing the lumbar region. The patient has a history of osteomyelitis and previous surgeries, which increase the complexity and potential risks. Such a procedure is high-stakes due to the potential for neurological impairment, severe pain management issues, and risks associated with spinal surgeries, such as infections or complications from anesthesia. The involvement of hardware malfunction and the need for extensive correction to preserve spinal function further highlight the critical nature of this surgery.


Medical Specialty: Surgery
Sample Name: Endoscopic Carpal Tunnel Rlease

PREOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Left carpal tunnel syndrome.,OPERATIONS PERFORMED:,  Endoscopic carpal tunnel release.,ANESTHESIA:,  I.V. sedation and local (1% Lidocaine).,ESTIMATED BLOOD LOSS:,  Zero.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mm/Hg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the wrist, between FCR and FCU, one fingerbreadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal-based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A proximal forearm fasciotomy was performed under direct vision.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.  Hamate sounds were then used to palpate the hook of hamate.  The endoscopic instrument was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, the transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.,The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the endoscopic instrument was withdrawn, dividing the transverse carpal ligament under direct vision.  After complete division o the transverse carpal ligament, the instrument was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified, and complete release was confirmed.,The wound was then closed with running subcuticular stitch.  Steri-Strips were applied, and sterile dressing was applied over the Steri-Strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the Recovery Room in satisfactory condition, having tolerated the procedure well.
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DESCRIPTION: Endoscopic carpal tunnel release.  Left carpal tunnel syndrome.

surgery, fcr, fcu, antebrachial fascia, endoscopic carpal tunnel release, carpal tunnel release, carpal tunnel syndrome, carpal, endoscopic, ligament, tourniquet, transverse,

The situation described is a routine surgical procedure, endoscopic carpal tunnel release, which is typically considered low to moderate risk. The details indicate that the surgery was performed without complications, with zero blood loss and under effective anesthesia. The patient's condition was stable post-procedure. While all surgeries carry inherent risks, in this specific case, the absence of complications and the successful completion of the procedure reduce the stakes significantly.


Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 2

CHIEF COMPLAINT:,  Followup on hypertension and hypercholesterolemia.,SUBJECTIVE:,  This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago.  He has done well with that.  He does most of the things that he wants to do.  He travels at every chance he has, and he just got back from a cruise.  He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations.  He sees Dr. Ferguson.  He is known to have Crohn's and he takes care of that for him.  He sees Dr. Roszhart for his prostate check.  He is a nonsmoker and denies swelling in his ankles.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION:, ,Vitals:  Wt; 172 lbs, up 2 lbs,  B/P; 150/60, T; 96.4, P; 72 and regular.  ,General:  A 78-year-old male who does not appear to be in any acute distress.  Glasses.  Good dentition.,CV: Distant S1, S2 without murmur or gallop. No carotid bruits. P: 2+ all around.,Lungs: Diminished with increased AP diameter. ,Abdomen:  Soft, bowel sounds active x 4 quadrants. No tenderness, no distention, no masses or organomegaly noted.,Extremities:  Well-healed surgical scar on the right knee.  No edema.  Hand grasps are strong and equal.,Back:  Surgical scar on the lower back.,Neuro: Intact.  A&O. Moves all four with no focal motor or sensory deficits.,IMPRESSION:,1.  Hypertension.,2.  Hypercholesterolemia.,3.  Osteoarthritis.,4.  Fatigue.,PLAN:,  We will check a BMP, lipid, liver profile, CPK, and CBC.  Refill his medications x 3 months.  I gave him a copy of Partners in Prevention.  Increase his Altace to 5 mg day for better blood pressure control.  Diet, exercise, and weight loss, and we will see him back in three months and p.r.n.
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DESCRIPTION: Sample progress note - Gen Med.

Sample progress note - Gen Med.

general medicine, progress note, fatigue, osteoarthritis, back surgery, chest pain, cough, heaviness, hypercholesterolemia, hypertension, palpitations, pressure, shortness of breath, tightness, surgical scar, progress,

The situation described involves a routine follow-up for a 78-year-old male with a focus on managing conditions like hypertension and hypercholesterolemia. While it involves the management of chronic conditions, the absence of acute distress, serious symptoms, or life-threatening conditions makes it a standard follow-up appointment rather than a high-stakes situation. The patient's overall health appears stable, and the plan includes standard lab tests and medication adjustments typical for managing these conditions.


Medical Specialty: Consult - History and Phy.
Sample Name: Hyperthyroidism Following Pregnancy

HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain.  She had been previously diagnosed with hyperthyroidism.  Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm.  She had been experiencing palpitations and tachycardia.  She had no diaphoresis, no nausea, vomiting, or dyspnea.,She had a significant TSH of 0.004 and a free T4 of 19.3.  Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL, respectively.  Her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency.  She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards.  She complained of sweating, but has experienced no diarrhea and no change in appetite.  She was given isosorbide mononitrate and IV steroids in the ER.,FAMILY HISTORY:,  Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.,SOCIAL HISTORY:,  She had a baby five months ago.  She smokes a half pack a day.  She denies alcohol and drug use.,MEDICATIONS:,  Citalopram 10mg once daily for depression; low dose tramadol PRN pain.,PHYSICAL EXAMINATION: , Temperature 98.4; Pulse 123; Respiratory Rate 16; Blood Pressure 143/74.,HEENT:  She has exophthalmos and could not close her lids completely.,Cardiovascular:  tachycardia.,Neurologic:  She had mild hyperreflexiveness.,LAB:,  All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122.  Urine pregnancy test was negative.,HOSPITAL COURSE: , After admission, she was given propranolol at 40mg daily and continued on telemetry.  On the 2nd day of treatment, the patient still complained of chest pain.  EKG again showed tachycardia.  Propranolol was increased from 40mg daily to 60mg twice daily., A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours.  The normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake.  Endocrine consult recommended radioactive I-131 for treatment of Graves disease.,Two days later she received 15.5mCi of I-131.  She was to return home after the iodine treatment.  She was instructed to avoid contact with her baby for the next week and to cease breast feeding.,ASSESSMENT / PLAN:,1. Treatment of hyperthyroidism.  Patient underwent radioactive iodine 131 ablation therapy.,2. Management of cardiac symptoms stemming from hyperthyroidism.  Patient was discharged on propranolol 60mg, one tablet twice daily.,3. Monitor patient for complications of I-131 therapy such as hypothyroidism.  She should return to Endocrine Clinic in six weeks to have thyroid function tests performed.  Long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. Prevention of pregnancy for one year post I-131 therapy.  Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. Monitor ocular health.  Patient was given methylcellulose ophthalmic, one drop in each eye daily.  She should follow up in 6 weeks with the Ophthalmology clinic.,6. Management of depression.  Patient will be continued on citalopram 10 mg.
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DESCRIPTION: Chief complaint of chest pain, previously diagnosed with hyperthyroidism.

consult - history and phy., hyperthyroidism, diabetes, hypertension, hospital course, thyroid function, tachycardia, pregnancy,

The patient is experiencing significant health issues related to severe hyperthyroidism, which is causing cardiac symptoms and requiring radioactive treatment. Additionally, she has postpartum considerations and must manage multiple medications and avoid certain activities like breastfeeding and close contact with her baby post-treatment. These factors indicate the situation involves critical care needs and significant personal implications such as family planning, making it relatively high-stakes.


Medical Specialty: Surgery
Sample Name: Hemicraniectomy

TITLE OF OPERATION:,  Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.,INDICATION FOR SURGERY: ,  The patient is a patient well known to my service.  She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull.  I took her to the operating a few days ago for a large right-sided hemicraniectomy to save her life.  I spoke with the family, the mom, especially about the risks, benefits, and alternatives of this procedure, most especially given the fact that she had undergone a very severe traumatic brain injury with a very poor GCS of 3 in some brainstem reflexes.  I discussed with them that this was a life-saving procedure and the family agreed to proceed with surgery as a level 1.  We went to the operating room at that time and we did a very large right-sided hemicraniectomy.  The patient was put in the intensive care unit.  We had placed also at that time a left-sided intracranial pressure monitor both which we took out a few days ago.  Over the last few days, the patient began to slowly deteriorate little bit on her clinical examination, that is, she was at first localizing briskly with the right side and that began to be less brisk.  We obtained a CT scan at this point, and we noted that she had a fair amount of swelling in the left hemisphere with about 1.5 cm of midline shift.  At this point, once again I discussed with the family the possibility of trying to save her life and go ahead and doing a left-sided very large hemicraniectomy with this __________  this was once again a life-saving procedure and we proceeded with the consent of mom to go ahead and do a level 1 hemicraniectomy of the left side.,PROCEDURE IN DETAIL: , The patient was taken to the operating room.  She was already intubated and under general anesthesia.  The head was put in a 3-pin Mayfield headholder with one pin in the forehead and two pins in the back to be able to put the patient with the right-hand side down and the left-hand side up since on the right-hand side, she did not have a bone flap which complicated matters a little bit, so we had to use a 3-pin Mayfield headholder.  The patient tolerated this well.  We sterilely prepped everything and we actually had already done a midline incision prior to this for the prior surgery, so we incorporated this incision into the new incision, and to be able to open the skin on the left side, we did a T-shaped incision with T vertical portion coming from anterior to the ear from the zygoma up towards the vertex of the skull towards the midline of the skin.  We connected this.  Prior to this, we brought in all surgical instrumentation under sterile and standard conditions.  We opened the skin as in opening a book and then we also did a myocutaneous flap.  We brought in the muscle with it.  We had a very good exposure of the skull.  We identified all the important landmarks including the zygoma inferiorly, the superior sagittal suture as well as posteriorly and anteriorly.  We had very good landmarks, so we went ahead and did one bur hole and the middle puncta right above the zygoma and then brought in the craniotome and did a very large bone flap that measured about 7 x 9 cm roughly, a very large decompression of the left side.  At this point, we opened the dura and the dura as soon as it was opened, there was a small subdural hematoma under a fair amount of pressure and cleaned this very nicely irrigated completely the brain and had a few contusions over the operculum as well as posteriorly.  All this was irrigated thoroughly.  Once we made sure we had absolutely great hemostasis without any complications, we went ahead and irrigated once again and we had controlled the meddle meningeal as well as the superior temporal artery very nicely.  We had absolutely good hemostasis.  We put a piece of Gelfoam over the brain.  We had opened the dura in a cruciate fashion, and the brain clearly bulging out despite of the fact that it was in the dependent position.  I went ahead and  irrigated everything thoroughly putting a piece of DuraGen as well as a piece of Gelfoam with very good hemostasis and proceeded to close the skin with running nylon in place.  This running nylon we put in place in order not to put any absorbables, although I put a few 0 popoffs just to approximate the skin nicely.  Once we had done this, irrigated thoroughly once again the skin.  We cleaned up everything and then we took the patient off __________ anesthesia and took the patient back to the intensive care unit.  The EBL was about 200 cubic centimeters.  Her hematocrit went down to about 21 and I ordered the patient to receive one unit of blood intraoperatively which they began to work on as we began to continue to do the work and the sponges and the needle counts were correct.  No complications.  The patient went back to the intensive care unit.
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DESCRIPTION: Left-sided large hemicraniectomy for traumatic brain injury and increased intracranial pressure.  She came in with severe traumatic brain injury and severe multiple fractures of the right side of the skull.

surgery, large hemicraniectomy, intracranial pressure, multiple fractures, skull, traumatic brain injury, mayfield headholder, injury, hemicraniectomyNOTE

The situation involves a critical surgical procedure, a hemicraniectomy, performed in response to a life-threatening condition caused by traumatic brain injury and increased intracranial pressure. The patient's condition is severe, with a Glasgow Coma Scale (GCS) of 3, indicating deep coma or brain death. The decision to proceed with the surgery is framed as a life-saving measure, emphasizing the high stakes of the operation, as the patient's survival and neurological outcomes heavily depend on its success. Any complications or failure in the procedure could be fatal or lead to significant impairment.


Medical Specialty: Surgery
Sample Name: Cholangiopancreatography (Endoscopic)

PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesia.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, aspiration, and post ERCP pancreatitis.,DESCRIPTION OF PROCEDURE:, After informed consent and appropriate sedation, the duodenoscope was inserted into the oropharynx, down the esophagus, and into the stomach. The scope was then advanced through the pylorus to the ampulla. The ampulla had a markedly abnormal appearance, as it was enlarged and very prominent. It extended outward with an almost polypoid shape. It had what appeared to be adenomatous-appearing mucosa on the tip. There also was ulceration noted on the tip of this ampulla. The biliary and pancreatic orifices were identified. This was located not at the tip of the ampulla, but rather more towards the base. Cannulation was performed with a Wilson-Cooke TriTome sphincterotome with easy cannulation of the biliary tree. The common bile duct was mildly dilated, measuring approximately 12 mm. The intrahepatic ducts were minimally dilated. There were no filling defects identified. There was felt to be a possible stricture within the distal common bile duct, but this likely represented an anatomic variant given the abnormal shape of the ampulla. The patient has no evidence of obstruction based on lab work and clinically. Nevertheless, it was decided to proceed with brush cytology of this segment. This was done without any complications. There was adequate drainage of the biliary tree noted throughout the procedure. Multiple efforts were made to access the pancreatic ductal anatomy; however, because of the shape of the ampulla, this was unsuccessful. Efforts were made to proceed in a long scope position, but still were unsuccessful. Next, biopsies were obtained of the ampulla away from the biliary orifice. Four biopsies were taken. There was some minor oozing which had ceased by the end of the procedure. The stomach was then decompressed and the endoscope was withdrawn.,FINDINGS:,1. Abnormal papilla with bulging, polypoid appearance, and looks adenomatous with ulceration on the tip; biopsies taken.,2. Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture, although I think this is likely an anatomic variant; brush cytology obtained.,3. Unable to access the pancreatic duct.,RECOMMENDATIONS:,1. NPO except ice chips today.,2. Will proceed with MRCP to better delineate pancreatic ductal anatomy.,3. Follow up biopsies and cytology.
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DESCRIPTION: Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.

surgery, cholangiogram, ercp, endoscopic, endoscopic retrograde cholangiopancreatography, mrcp, wilson-cooke tritome sphincterotome, abdominal pain, ampulla, bile duct, brush cytology, cholangiopancreatography, pancreatitis, papilla, polypoid, retrograde cholangiopancreatography, cholangiopancreatography with brush cytology, brush cytology and biopsy, shape of the ampulla, pancreatic ductal anatomy, common bile duct, cannulation, brush, pancreatic, cytology

The procedure described is an endoscopic retrograde cholangiopancreatography (ERCP), which is an advanced endoscopic technique used for diagnostic and therapeutic purposes involving the pancreatic and biliary ducts. It is high-stakes due to its inherent risks, such as bleeding, perforation, infection, and post-ERCP pancreatitis, all of which are serious complications. The patient in this scenario is also under general anesthesia, adding another layer of risk. The presence of abnormal findings such as an adenomatous ampulla and the need for further investigation and biopsies further elevate the stakes of this procedure.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: VVIR Permanent Pacemaker Insertion

PROCEDURE PERFORMED:,  Insertion of a VVIR permanent pacemaker.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,SITE:,  Left subclavian vein access.,INDICATION: , This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias and therefore, this is indicated so that we can give better control of heart rate and to maintain beta-blocker therapy in the order of treatment.  It is overall a Class-II indication for permanent pacemaker insertion.,PROCEDURE:,  The risks, benefits, and alternative of the procedure were all discussed with the patient and the patient's family in detail at great length.  Overall options and precautions of the pacemaker and indications were all discussed.  They agreed to the pacemaker.  The consent was signed and placed in the chart.  The patient was taken to the Cardiac Catheterization Lab, where she was monitored throughout the whole procedure.  The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion.  Myself and Dr. Wildes spoke for approximately 8 minutes before insertion for the procedure.  Using a lidocaine with epinephrine, the area of the left subclavian vein and left pectodeltoid region was anesthetized locally.,IV sedation, increments, and analgesics were given.  Using a #18 gauge needle, the left subclavian vein access was cannulated without difficulty.  A guidewire was then passed through the Cook needle and the Cook needle was then removed.  The wire was secured in place with the hemostat.  Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectoral deltoid region where the skin was dissected and blunted down into the pectoris major muscle fascia.  The skin was then undermined used to make a pocket for the pacemaker.  The guidewire was then tunneled through the pacer pocket.  Cordis sheath was then inserted through the guidewire.  The guidewire and dilator were removed.  ___ cordis sheath was in placed within.  This was used for insertion of the ventricular screw and steroid diluted leads where under fluoroscopy.  It was placed into the apex.  Cordis sheath was then split apart and removed and after the ventricular lead was placed in its appropriate position and good thresholds were obtained, the lead was then sutured in place with #1-0 silk suture to the pectoris major muscle.  The lead was then connected on pulse generator.  The pocket was then irrigated and cleansed.  Pulse generator and the wire was then inserted into the ____ pocket.  The skin was then closed with gut suture.  The skin was then closed with #4-0 Poly___ sutures using a subcuticular uninterrupted technique.  The area was then cleansed and dried.  Steri-Strips and pressure dressing was then applied.  The patient tolerated the procedure well. there was no complications.,These are the settings on the pacemaker:,IMPLANT DEVICE: , Pulse Generator Model Name:  Sigma, model #:  12345, serial #:  123456.,VENTRICLE LEAD:,  Model #:  12345, the ventricular lead serial #:  123456.,Ventricle lead was a screw and steroid diluted lead placed into the right ventricle apex.,BRADY PARAMETER SETTINGS ARE AS FOLLOWS:,  Amplitude was set at 3.5 volts with a pulse of 0.4, sensitivity of 2.8.  The pacing mode was set at VVIR, lower rate of 60 and upper rate of 120.,STIMULATION THRESHOLDS:  ,The right ventricular lead and bipolar, threshold voltage is 0.6 volts, 1 milliapms current, 600 Ohms resistance, R-wave sensing 11 millivolts.,The patient tolerated the procedure well.  There was no complications.  The patient went to recovery in stable condition.  Chest x-ray will be ordered.  She will be placed on IV antibiotics and continue therapy for congestive heart failure and tachybrady arrhythmia.,Thank you for allowing me to participate in her care.  If you have any questions or concerns, please feel free to contact.
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DESCRIPTION: Insertion of a VVIR permanent pacemaker.  This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias

cardiovascular / pulmonary, aortic stenosis, vvir permanent pacemaker, permanent pacemaker insertion, congestive heart failure, tachybrady arrhythmias, subclavian vein, cordis sheath, ventricular lead, pulse generator, permanent pacemaker, insertion, ventricle, vvir, ventricular, permanent, pacemaker, leads,

The insertion of a VVIR permanent pacemaker is a significant medical procedure, especially given the patient's condition of critical aortic stenosis and recurrent congestive heart failure symptoms. The procedure involves invasive surgery and precise placement of medical devices, which are high-stakes due to the critical role they play in maintaining the patient's cardiac function and overall health. Additionally, the age of the patient adds to the complexity and potential risks associated with the surgery. While the procedure was completed with no complications, the stakes remain high because it directly impacts the patient's heart function and survival.


Medical Specialty: Ophthalmology
Sample Name: Cataract Surgery

NORMAL CATARACT SURGERY,PROCEDURE DETAILS: , The patient was taken to the operating room where the Rand-Stein anesthesia protocol was followed using alfentanil and Brevital.  Topical tetracaine drops were applied.  The operative eye was prepped and draped in the usual sterile fashion.  A lid speculum was inserted.,Under the Zeiss operating microscope, a lateral clear corneal approach was utilized.  A stab incision was made with a diamond blade to the right of the lateral limbus and the anterior chamber filled with intracameral lidocaine and viscoelastic.  A 3-mm single pass clear corneal incision was made just anterior to the vascular arcade of the temporal limbus using a diamond keratome.  A 5- to 5.5-mm anterior capsulorrhexis was created.  The nucleus was hydrodissected and hydrodelineated, and was freely movable in the capsular bag.  The nucleus was then phacoemulsified using a quadrantic divide-and-conquer technique.  Following the deep groove formation, the lens was split bimanually and the resultant quadrants and epicortex removed under high-vacuum burst-mode phacoemulsification.  Peripheral cortex was removed with the irrigation and aspiration handpiece.  The posterior capsule was polished.  The capsular bag was expanded with viscoelastic.  The implant was inspected under the microscope and found to be free of defects.  The implant was inserted into the cartridge system under viscoelastic and placed in the capsular bag.  The trailing haptic was positioned with the cartridge system.  Residual viscoelastic was removed from the anterior chamber and from behind the implant.  The corneal wound was hydrated with balanced salt solution.  The anterior chamber was fully re-formed through the side-port incision.  The wound was inspected and found to be watertight.  The intraocular pressure was adjusted as necessary.  The lid speculum was removed.  Topical Timoptic drops, Eserine and Dexacidin ointment were applied.  The eye was shielded.  The patient appeared to tolerate the procedure well and left the operating room in stable condition.  Followup appointment is with Dr. X on the first postoperative day.
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DESCRIPTION: Normal cataract surgery.

Normal cataract surgery.

ophthalmology, zeiss, peripheral cortex, phacoemulsified, hydrodissected, rand-stein, lid speculum, anterior chamber, capsular bag, cataract, viscoelasticNOTE,: 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.,

This detailed account describes a routine cataract surgery, a common and generally low-risk procedure. Given its frequency and high success rate, it is considered low-stakes in comparison to more complex or emergency surgeries. The procedure went smoothly without any reported complications, further lowering the stakes.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Thoracoabdominal Aneurysm

POSTOPERATIVE DIAGNOSIS: , Type 4 thoracoabdominal aneurysm.,OPERATION/PROCEDURE: , A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.,DESCRIPTION OF PROCEDURE IN DETAIL: , Patient was brought to the operating room and put in supine position, and general endotracheal anesthesia was induced through a double-lumen endotracheal tube.  Patient was placed in the thoracoabdominal position with the left chest up and the hips back to a 30-degree angle.  The left groin, abdominal and chest were prepped and draped in a sterile fashion.  A thoracoabdominal incision was made.  The 8th interspace was entered.  The costal margin was divided.  The retroperitoneal space was entered and bluntly dissected free to the psoas, bringing all the peritoneal contents to the midline, exposing the aorta.  The inferior pulmonary ligament was then taken down so the aorta could be dissected free at the T10 level just above the diaphragm.  It was dissected free circumferentially.  The aortic bifurcation was dissected free, dissecting free both iliac arteries.  The left inferior pulmonary vein was then dissected free, and a pursestring of 4-0 Prolene was placed on this.  The patient was heparinized.  Through a stab wound in the center of this, a right-angle venous cannula was then placed at the left atrium and secured to a Rumel tourniquet.  This was hooked to a venous inflow of left heart bypass machine.  A pursestring of 4-0 Prolene was placed on the aneurysm and through a stab wound in the center of this, an arterial cannula was placed and hooked to outflow.  Bypass was instituted.  The aneurysm was cross clamped just above T10 and also, cross clamped just below the diaphragm.  The area was divided at this point.  A 26-mm graft was then sutured in place with running 3-0 Prolene suture.  The graft was brought into the diaphragm.  Clamps were then placed on the iliacs, and the pump was shut off.  The aorta was opened longitudinally, going posterior between the left and right renal arteries, and it was completely transected at its bifurcation.  The SMA, celiac and right renal artery were then dissected free as a complete island, and the left renal was dissected free as a complete Carrell patch.  The island was laid in the graft for the visceral liner, and it was sutured in place with running 4-0 Prolene suture with pledgetted 4-0 Prolene sutures around the circumference.  The clamp was then moved below the visceral vessels, and the clamp on the chest was removed, re-establishing flow to the visceral vessels.  The graft was cut to fit the bifurcation and sutured in place with running 3-0 Prolene suture.  All clamps were removed, and flow was re-established.  An 8-mm graft was sutured end-to-end to the Carrell patch and to the left renal.  A partial-occlusion clamp was placed.  An area of graft was removed.  The end of the graft was cut to fit this and sutured in place with running Prolene suture.  The partial-occlusion clamp was removed.  Protamine was given.  Good hemostasis was noted.  The arterial cannula, of course, had been removed when that part of the aneurysm was removed.  The venous cannula was removed and oversewn with a 4-0 Prolene suture.  Good hemostasis was noted.  A 36 French posterior and a 32 French anterior chest tube were placed.  The ribs were closed with figure-of-eight #2 Vicryl.  The fascial layer was closed with running #1 Prolene, subcu with running 2-0 Dexon and the skin with running 4-0 Dexon subcuticular stitch.  Patient tolerated the procedure well.
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DESCRIPTION: A 26-mm Dacron graft replacement of type 4 thoracoabdominal aneurysm from T10 to the bifurcation of the aorta, re-implanting the celiac, superior mesenteric artery and right renal as an island and the left renal as a 8-mm interposition Dacron graft, utilizing left heart bypass and cerebrospinal fluid drainage.

cardiovascular / pulmonary, dacron graft, thoracoabdominal, cerebrospinal, thoracoabdominal aneurysm, running prolene, prolene suture, dissected free, graft, interposition, aneurysm, dacron, cannula, bifurcation, aorta, endotracheal, proleneNOTE

The described situation involves a complex cardiovascular surgical procedure for the replacement of a type 4 thoracoabdominal aneurysm. This type of surgery is high-stakes due to the potential risks, such as severe bleeding, organ damage, or even death. The use of techniques like left heart bypass and cerebrospinal fluid drainage underscores the complexity and critical nature of the surgery. Additionally, the procedure involves major blood vessels and requires careful management to ensure patient safety. Given the potential consequences if the procedure were not successful or if complications arose, this is a high-stakes medical situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Congestion - 21-day-old

CHIEF COMPLAINT:,  Congestion, tactile temperature.,HISTORY OF PRESENT ILLNESS: , The patient is a 21-day-old Caucasian male here for 2 days of congestion - mom has been suctioning yellow discharge from the patient's nares, plus she has noticed some mild problems with his breathing while feeding (but negative for any perioral cyanosis or retractions).  One day ago, mom also noticed a tactile temperature and gave the patient Tylenol.,Baby also has had some decreased p.o. intake.  His normal breast-feeding is down from 20 minutes q.2h. to 5 to 10 minutes secondary to his respiratory congestion.  He sleeps well, but has been more tired and has been fussy over the past 2 days.  The parents noticed no improvement with albuterol treatments given in the ER.  His urine output has also decreased; normally he has 8 to 10 wet and 5 dirty diapers per 24 hours, now he has down to 4 wet diapers per 24 hours.  Mom denies any diarrhea.  His bowel movements are yellow colored and soft in nature.,The parents also noticed no rashes, just his normal neonatal acne.  The parents also deny any vomiting, apnea.,EMERGENCY ROOM COURSE: , In the ER, the patient received a lumbar puncture with CSF fluid sent off for culture and cell count.  This tap was reported as clear, then turning bloody in nature.  The patient also received labs including a urinalysis and urine culture, BMP, CBC, CRP, blood culture.  This patient also received as previously noted, 1 albuterol treatment, which did not help his respiratory status.  Finally, the patient received 1 dose of ampicillin and cefotaxime respectively each.,REVIEW OF SYSTEMS: , See above history of present illness.  Mom's nipples are currently cracked and bleeding.  Mom has also noticed some mild umbilical discharge as well as some mild discharge from the penile area.  He is status post a circumcision.  Otherwise, review of systems is negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pounds 13 ounces' term baby born 1 week early via a planned repeat C-section.  Mom denies any infections during pregnancy, except for thumb and toenail infections, treated with rubbing alcohol (mom denies any history of boils in the family).  GBS status was negative.  Mom smoked up to the last 5 months of the pregnancy.  Mom and dad both deny any sexually transmitted diseases or genital herpetic lesions.  Mom and baby were both discharged out of the hospital last 48 hours.  This patient has received no hospitalizations so far.,PAST SURGICAL HISTORY:,  Circumcision.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  Tylenol.,IMMUNIZATIONS:,  None of the family members this year have received a flu vaccine.,SOCIAL HISTORY:,  At home lives mom, dad, a 2-1/2-year-old brother, and a 5-1/2-year-old maternal stepbrother.  Both brothers at home are sick with cold symptoms including diarrhea and vomiting.  The brother (2-1/2-year-old) was seen in the ER tonight with this patient and discharged home with an albuterol prescription.  A nephew of the mom with an ear infection.  Mom also states that she herself was sick with the flu soon after delivery.  There has been recent travel exposure to dad's family over the Christmas holidays.  At this time, there is also exposure to indoor cats and dogs.  This patient also has positive smoking exposure coming from mom.,FAMILY HISTORY: , Paternal grandmother has diabetes and hypertension, paternal grandfather has emphysema and was a smoker.  There are no children needing the use of a pediatric subspecialist or any childhood deaths less than 1 year of age.,PHYSICAL EXAMINATION:  ,VITALS:  Temperature max is 99, heart rate was 133 to 177, blood pressure is 114/43 (while moving), respiratory rate was 28 to 56 with O2 saturations 97 to 100% on room air.  Weight was 4.1 kg.,GENERAL:  Not in acute distress, sneezing, positive congestion with breaths taken.,HEENT:  Normocephalic, atraumatic head.  Anterior fontanelle was soft, open, and flat.  Bilateral red reflexes were positive.  Oropharynx is clear with palate intact, negative rhinorrhea.,CARDIOVASCULAR:  Heart was regular rate and rhythm with a 2/6 systolic ejection murmur heard best at the upper left sternal border, vibratory in nature.  Capillary refill was less than 3 seconds.,LUNGS:  Positive upper airway congestion, transmitted sounds; negative retractions, nasal flaring, or wheezes.,ABDOMEN:  Bowel sounds are positive, nontender, soft, negative hepatosplenomegaly.  Umbilical site was with scant dried yellow discharge.,GU:  Tanner stage 1 male, circumcised.  There was mild hyperemia to the penis with some mild yellow dried discharge.,HIPS:  Negative Barlow or Ortolani maneuvers.,SKIN:  Positive facial erythema toxicum.,LABORATORY DATA: , CBC drawn showed a white blood cell count of 14.5 with a differential of 25 segmental cells, 5% bands, 54% lymphocytes.  The hemoglobin was 14.4, hematocrit was 40.  The platelet count was elevated at 698,000.  A CRP was less than 0.3.,A hemolyzed BMP sample showed a sodium of 139, potassium of 5.6, chloride 105, bicarb of 21, and BUN of 4, creatinine 0.4, and a glucose of 66.,A cath urinalysis was negative.,A CSF sample showed 0 white blood cells, 3200 red blood cells (again this was a bloody tap per ER personnel), CSF glucose was 41, CSF protein was 89.  A Gram stain showed rare white blood cells, many red blood cells, no organisms.,ASSESSMENT: , A 21-day-old with:,1.  Rule out sepsis.,2.  Possible upper respiratory infection.,Given the patient's multiple sick contacts, he is possibly with a viral upper respiratory infection causing his upper airway congestion plus probable fever.  The bacterial considerations although to consider in this child include group B streptococcus, E. coli, and Listeria.  We should also consider herpes simplex virus, although these 3200 red blood cells from his CSF could be due to his bloody tap in the ER.  Also, there is not a predominant lymphocytosis of his CSF sample (there is 0 white blood cell count in the cell count).,Also to consider in this child is RSV.  The patient though has more congested, nasal breathing more than respiratory distress, for example retractions, desaturations, or accessory muscle use.  Also, there is negative apnea in this patient.,PLAN:  ,1.  We will place this patient on the rule out sepsis pathway including IV antibiotics, ampicillin and gentamicin for at least 48 hours.,2.  We will follow up with his blood, urine, and CSF cultures.
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DESCRIPTION: Congestion, tactile temperature.

Congestion, tactile temperature.

This situation involves a 21-day-old infant with potential sepsis or a severe infection, which can be life-threatening in newborns. The stakes are high due to the infant's young age and the symptoms of congestion, decreased feeding, tactile temperature, and a history suggestive of possible serious infections like sepsis or RSV. The child has multiple sick contacts, enhancing the urgency. The infant's current treatment includes antibiotics and close monitoring for potentially life-threatening conditions.


Medical Specialty: Psychiatry / Psychology
Sample Name: Neurobehavioral Assessment

BENDER-GESTALT TEST: , Not organic.,BECK TESTING:,Depression: 37,Anxiety: 41,Hopelessness: 10,Suicide Ideation:  18,SUMMARY:,  The patient was cooperative and appeared to follow the test instructions. There is no evidence of organicity on the Bender. He endorsed symptoms of depression and anxiety. He has moderately negative expectancies regarding his future and is expressing suicidal ideation. Great care should be taken to confirm the accuracy of the results as the patients seems over-medicated and/or drunk.
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DESCRIPTION: Bender-Gestalt Neurological Battery and Beck testing.

psychiatry / psychology, bender-gestalt neurological battery, beck anxiety inventory, beck depression inventory, beck hopelessness scale, beck scale, suicide ideation, bender-gestalt test, beck testing, bender gestalt, beck,

This situation is high-stakes because the patient has reported a significant level of suicidal ideation, as indicated by the score of 18 on the Suicide Ideation section of the Beck Testing. The presence of suicidal thoughts, particularly when coupled with depression and anxiety, requires immediate and careful attention due to the potential risk to the patient’s safety. Additionally, the note about the patient appearing over-medicated or intoxicated adds complexity to the situation, indicating the need for careful cross-evaluation and possibly urgent intervention to ensure the patient's safety.


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

SUBJECTIVE:,  Mr. Sample Patient returns to the Sample Clinic with the chief complaint of painful right heel.  The patient states that the heel has been painful for approximately two weeks, it is starts with the first step in the morning and gets worse with activity during the day.  The patient states that he is currently doing no treatment for it.  He states that most of his pain is along medial tubercle of the right calcaneus and extends to the medial arch.  The patient states that he has no change in the past medical history since his last visit and denies any fever, chills, vomiting, headache, chest, or shortness of breath.,OBJECTIVE:,  Upon removal of shoes and socks bilaterally, neurovascular status remains unchanged since the last visit.  There is tenderness to palpation to the medial tubercle of the right foot.  The pain is elicited along the medial arch as well.  There are no open areas or signs of infection noted.,ASSESSMENT:,  Plantar fascitis/heel spur syndrome, right foot.,PLAN:,  The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.  He was given a low dye strapping and a heel lift was placed in his right shoe.  The patient will be seen back in approximately one month for further evaluation if necessary.  He was told to call if anything should occur before that.  The patient was told to continue with the good work on his diabetic control.
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DESCRIPTION: Plantar fascitis/heel spur syndrome.  The patient was given injections of 3 cc 2:1 mixture of 1% lidocaine plain with dexamethasone phospate.

soap / chart / progress notes, progress note, plantar fascitis, podiatry, soap, dexamethasone phospate, heel lift, heel spur syndrome, lidocaine, low dye strapping, mixture of 1% lidocaine, dexamethasone, phospate, injections, heel

The scenario involves a patient's visit to the clinic for a painful right heel. While the pain seems to impact the patient's daily life and could potentially affect mobility, the condition described is plantar fasciitis/heel spur syndrome, which is a common and treatable issue. The treatment plan is straightforward and includes a follow-up. There's no indication of severe risk to the patient's immediate health or life. This situation is low-stakes in terms of urgency or critical health deterioration.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Pulmonary Hypertension - Pediatric Consult

INDICATION FOR CONSULTATION: , Increasing oxygen requirement.,HISTORY: , Baby boy, XYZ, is a 29-3/7-week gestation infant.  His mother had premature rupture of membranes on 12/20/08.  She then presented to the Labor and Delivery with symptoms of flu.  The baby was then induced and delivered.  The mother had a history of premature babies in the past.  This baby was doing well, and then, we had a significant increasing oxygen requirement from room air up to 85%.  He is now on 60% FiO2.,PHYSICAL FINDINGS,GENERAL:  He appears to be pink, well perfused, and slightly jaundiced.,VITAL SIGNS:  Pulse 156, 56 respiratory rate, 92% sat, and 59/28 mmHg blood pressure.,SKIN:  He was pink.,He was on the high-frequency ventilator with good wiggle.,His echocardiogram showed normal structural anatomy.  He has evidence for significant pulmonary hypertension.  A large ductus arteriosus was seen with bidirectional shunt.  A foramen ovale shunt was also noted with bidirectional shunt.  The shunting for both the ductus and the foramen ovale was equal left to right and right to left.,IMPRESSION: , My impression is that baby boy, XYZ, has significant pulmonary hypertension.  The best therapy for this is to continue oxygen.  If clinically worsens, he may require nitric oxide.  Certainly, Indocin should not be used at this time.  He needs to have lower pulmonary artery pressures for that to be considered.,Thank you very much for allowing me to be involved in baby XYZ's care.
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DESCRIPTION: Increasing oxygen requirement.  Baby boy has significant pulmonary hypertension.

pediatrics - neonatal, high-frequency ventilator, structural anatomy, foramen ovale, oxygen requirement, hypertension, pulmonary

This scenario involves a neonate with increasing oxygen requirements and diagnosed significant pulmonary hypertension. Neonatal pulmonary hypertension is a critical condition that can lead to severe complications or even be life-threatening if not managed appropriately. The requirement for high levels of oxygen and potential consideration for nitric oxide therapy indicates the severity of the condition. In neonatal care, such conditions are considered high-stakes due to the vulnerability of the patient and the urgency required in managing the situation.


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

REASON FOR THE CONSULT: , Sepsis, possible SBP.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse, who presented in the emergency room on 01/07/09 for ground-level fall secondary to weak knees.  He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month.  He ran out of prescription medications 1 month ago.  In the ER he was initially afebrile, but then spiked up to 101.3 with heart rate of 130, respiratory rate of 24.  White blood cell count was slightly low at 4 and platelet count was only 22,000.  Abdominal ultrasound showed mild-to-moderate ascites.  He was given 1 dose of Zosyn and then started on levofloxacin and Flagyl last night.  Dr. X was called early this morning due to hypotension, SBP in the 70s.  He then changed antibiotic regiment to vancomycin and doripenem.,PAST MEDICAL HISTORY: , Hepatitis C, cirrhosis, coronary artery disease, hyperlipidemia, chronic venous stasis, gastroesophageal reflux disease, history of exploratory laparotomy for stab wounds, chronic recurrent leg wounds, and hepatic encephalopathy.,SOCIAL HISTORY: , The patient is a former smoker, reportedly quit in 2007.  He used cocaine in the past, reportedly quit in 2005.  He also has a history of alcohol abuse, but apparently quit more than 10 years ago.,ALLERGIES:,  None known.,CURRENT MEDICATIONS: , Vancomycin, doripenem, thiamine, Protonix, potassium chloride p.r.n., magnesium p.r.n., Zofran. p.r.n., norepinephrine drip, and vitamin K.,REVIEW OF SYSTEMS: , Not obtainable as the patient is drowsy and confused.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS:  Heart rate 101, respiratory rate 17, blood pressure 92/48, temperature 97.5, and oxygen saturation 98% on 2 L nasal cannula.,GENERAL APPEARANCE:  The patient is drowsy.  Morbidly obese.  Height 5 feet 8 inches, body weight 182 kilos.,EYES:  Slightly pale conjunctivae, icteric sclerae.  Pupils equal, brisk reaction to light.,EARS, NOSE, MOUTH AND THROAT:  Intact gross hearing.  Moist oral mucosa.  No oral lesions.,NECK:  No palpable neck masses.  Thyroid is not enlarged on inspection.,RESPIRATORY:  Regular inspiratory effort.  No crackles or wheezes.,CARDIOVASCULAR:  Regular cardiac rhythm.  No rales or rubs.  Positive bipedal edema, 2+, right worse than left.,GASTROINTESTINAL:  Globular abdomen.  Soft.  No guarding, no rigidity.  Tender on palpation of n right upper quadrant and epigastric area.  Mildly tender on palpation of right upper quadrant and epigastric area.,LYMPHATIC:  No cervical lymphadenopathy.,SKIN:  Positive diffuse jaundice.  No palpable subcutaneous nodules.,PSYCHIATRIC:  Poor judgment and insight.,LABORATORY DATA: , White blood cell count from 01/08/09 is 9 with 68% neutrophils, 20% bands, H&H 9.7/28.2, platelet count 24,000.  INR 3.84, PTT more than 240.  BUN and creatinine 26.8/1.2.  AST 76, ALT 27, alkaline phosphatase 48, total bilirubin 17.85.  Total CK 1198.6, LDH 873.2.  Troponin 0.09, myoglobin 2792.  Urinalysis from 01/07/09 shows small leucocyte esterase, positive nitrites, 1 to 3 wbc's, 0 to 1 rbc's, 2+ bacteria.  Two sets of blood cultures from 01/07/09 still pending.,RADIOLOGY:,  Chest x-ray from 01/07/09 did not show any pathologic abnormalities of the heart, mediastinum, lung fields, bony or soft tissue structures.  Left knee x-rays on 01/07/09 showed advanced osteoarthritis.  Abdominal ultrasound on 01/07/09 showed mild-to-moderate ascites, mild prominence of the gallbladder with thickened ball and pericholecystic fluid.  Preliminary report of CAT scan of the abdomen showed changes consistent to liver cirrhosis and portal hypertension with mild ascites, splenomegaly, and dilated portal/splenic and superior mesenteric vein.  Appendix was not clearly seen, but there was no evidence of pericecal inflammation.,IMPRESSION:,1.  Septic shock.,2.  Possible urinary tract infection.,3.  Ascites, rule out spontaneous bacterial peritenonitis.,4.  Hyperbilirubinemia, consider cholangitis.,5.  Alcoholic liver disease.,6.  Thrombocytopenia.,7.  Hepatitis C.,8.  Cryoglobulinemia.,RECOMMENDATIONS:,1.  Continue with vancomycin and doripenem at this point.,2.  Agree with paracentesis.,3.  Send ascitic fluid for cell count, differential and cultures.,4.  Follow up with result of blood cultures.,5.  We will get urine culture from the specimen on admission.,6.  The patient needs hepatitis A vaccination.,Additional ID recommendations as appropriate upon followup.
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DESCRIPTION: Sepsis, possible SBP.  A 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse presented in the emergency room for ground-level fall secondary to weak knees.  He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month.

The patient is in septic shock, a life-threatening condition requiring immediate medical attention. This situation involves multiple complex health issues: sepsis, liver disease with ascites possibly due to spontaneous bacterial peritonitis, and other complications like thrombocytopenia and potential infections. The patient's vital signs, lab results, and existing medical history indicate a high risk of rapid deterioration. The involvement of specialized treatment such as antibiotics and medical consultation underscores the critical nature of this situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 5

GENERAL: , Well developed, well nourished, alert, in no acute distress.  GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F.  Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva.  No lesions.  Pupils equal, round, reactive to light and accommodation.  Irises symmetrical, undilated.  Funduscopic exam reveals no hemorrhages or discopathy.  Ears, Nose, Mouth, and throat:  External ears without lesions.  Nares patent.  Septum midline.  Tympanic membranes without erythema, bulging or retraction.  Canals without lesion.  Hearing is grossly intact.  Lips, teeth, gums, palate without lesion.  Posterior oropharynx:  No erythema.  No tonsillar enlargement, crypt formation or abscess.,NECK:  ,Supple and symmetric.  No masses. Thyroid midline, non enlarged.  No JVD.  Neck is nontender.  Full range of motion without pain.,RESPIRATORY: , Good respiratory effort.  Clear to auscultation.  Clear to percussion.  Chest:  Symmetrical rise and fall.  Symmetrical expansion.  No egophony or tactile fremitus.,CARDIOVASCULAR:,  Regular rate and rhythm.  No murmur, gallops, clicks, heaves or rub.  Cardiac palpation within normal limits.  Pulses equal at carotid.  Femoral and pedal pulses:  No peripheral edema.,GASTROINTESTINAL:  ,No tenderness or mass.  No hepatosplenomegaly.  No hernia.  Bowel sounds equal times four quadrants.  Abdomen is nondistended.  No rebound, guarding, rigidity or ecchymosis.,MUSCULOSKELETAL: , Normal gait and station.  No pathology to digits or nails.  Extremities move times four.  No tenderness or effusion.  Range of motion adequate.  Strength and tone equal bilaterally, stable.,BACK: , Nontender on midline.  Full range of motion with flexion, extension and sidebending.,SKIN:,  Inspection within normal limits.  Well hydrated.  No diaphoresis.  No obvious wound.,LYMPH:,  Cervical lymph nodes.  No lymphadenopathy.,NEUROLOGICAL:  ,Cranial nerves II-XII grossly intact.  DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle.  Motor strength 4/4 bilateral upper and lower extremity.  Straight leg raise is negative bilaterally.,PSYCHIATRIC: , Judgment and insight adequate.  Alert and oriented times three.  Memory and mood within normal limits.  No delusions, hallucinations.  No suicidal or homicidal ideation.
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DESCRIPTION: Normal Physical Exam Template.  Well developed, well nourished, alert, in no acute distress.

consult - history and phy., respiratory, abdomen, normal physical exam, pulses, tenderness, strength, lymph, extremity, midline, range, motion, lesions, symmetrical,

The situation described involves a routine physical exam using a standard template. The results indicate that the patient is in good health, with no acute distress or significant findings that would cause concern. As such, this scenario is typical in a clinical setting and does not involve any high-stakes decisions or immediate medical interventions.