Medical Specialty: Gastroenterology
Sample Name: Laparoscopy, Laparotomy, & Cholecystectomy

PREOPERATIVE DIAGNOSES: , Cholelithiasis, cholecystitis, and recurrent biliary colic.,POSTOPERATIVE DIAGNOSES: , Severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity.,PROCEDURES PERFORMED: , Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.,ANESTHESIA: , General.,INDICATIONS: , This is a 63-year-old white male patient with multiple medical problems including hypertension, diabetes, end-stage renal disease, coronary artery disease, and the patient is on hemodialysis, who has had recurrent episodes of epigastric right upper quadrant pain.  The patient was found to have cholelithiasis on last admission.  He was being worked up for this including cardiac clearance.  However, in the interim, he returned again with another episode of same pain.  The patient had a HIDA scan done yesterday, which shows nonvisualization of the gallbladder consistent with cystic duct obstruction.  Because of these, laparoscopic cholecystectomy was advised with cholangiogram.  Possibility of open laparotomy and open procedure was also explained to the patient.  The procedure, indications, risks, and alternatives were discussed with the patient in detail and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia.  The entire abdomen was prepped and draped.  A small transverse incision was made about 2-1/2 inches above the umbilicus in the midline under local anesthesia.  The patient has a rather long torso.  Fascia was opened vertically and stay sutures were placed in the fascia.  Peritoneal cavity was carefully entered.  Hasson cannula was inserted into the peritoneal cavity and it was insufflated with CO2.  Laparoscopic camera was inserted and examination at this time showed difficult visualization with a part of omentum and hepatic flexure of the colon stuck in the subhepatic area.  The patient was placed in reverse Trendelenburg and rotated to the left.  An 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region.  Slowly, the dissection was carried out in the right subhepatic area.  Initially, I was able to dissect some of the omentum and hepatic flexure off the undersurface of the liver.  Then, some inflammatory changes were noted with some fatty necrosis type of changes and it was not quite clear whether this was part of the gallbladder or it was just pericholecystic infection/inflammation.  The visualization was extremely difficult because of the patient's obesity and a lot of fat intra-abdominally, although his abdominal wall is not that thick.  After evaluating this for a little while, we decided that there was no way that this could be done laparoscopically and proceeded with formal laparotomy.  The trocars were removed.,A right subcostal incision was made and peritoneal cavity was entered.  A Bookwalter retractor was put in place.  The dissection was then carried out on the undersurface of the liver.  Eventually, the gallbladder was identified, which was markedly scarred down and shrunk and appeared to have palpable stone in it.  Dissection was further carried down to what was felt to be the common bile duct, which appeared to be somewhat larger than normal about a centimeter in size.  The duodenum was kocherized.  The gallbladder was partly intrahepatic.  Because of this, I decided not to dig it out of the liver bed causing further bleeding and problem.  The inferior wall of the gallbladder was opened and two large stones, one was about 3 cm long and another one about 1.5 x 2 cm long, were taken out of the gallbladder.,It was difficult to tell where the cystic duct was.  Eventually after probing near the neck of the gallbladder, I did find the cystic duct, which was relatively very short.  Intraoperative cystic duct cholangiogram was done using C-arm fluoroscopy.  This showed a rounded density at the lower end of the bile duct consistent with the stone.  At this time, a decision was made to proceed with common duct exploration.  The common duct was opened between stay sutures of 4-0 Vicryl and immediately essentially clear bile came out.  After some pressing over the head of the pancreas through a kocherized maneuver, the stone did fall into the opening in the common bile duct.  So, it was about a 1-cm size stone, which was removed.  Following this, a 10-French red rubber catheter was passed into the common bile duct both proximally and distally and irrigated generously.  No further stones were obtained.  The catheter went easily into the duodenum through the ampulla of Vater.  At this point, a choledochoscope was inserted and proximally, I did not see any evidence of any common duct stones or proximally into the biliary tree.  However, a stone was found distally still floating around.  This was removed with stone forceps.  The bile ducts were irrigated again.  No further stones were removed.  A 16-French T-tube was then placed into the bile duct and the bile duct was repaired around the T-tube using 4-0 Vicryl interrupted sutures obtaining watertight closure.  A completion T-tube cholangiogram was done at this time, which showed slight narrowing and possibly a filling defect proximally below the confluence of the right and left hepatic duct, although externally, I was unable to see anything or palpate anything in this area.  Because of this, the T-tube was removed, and I passed the choledochoscope proximally again, and I was unable to see any evidence of any lesion or any stone in this area.  I felt at this time this was most likely an impression from the outside, which was still left over a gallbladder where the stone was stuck and it was impressing on the bile duct.  The bile duct lumen was widely open.  T-tube was again replaced into the bile duct and closed again and a completion T-tube cholangiogram appeared to be more satisfactory at this time.  The cystic duct opening through which I had done earlier a cystic duct cholangiogram, this was closed with a figure-of-eight suture of 2-0 Vicryl, and this was actually done earlier and completion cholangiogram did not show any leak from this area.,The remaining gallbladder bed, which was left in situ, was cauterized both for hemostasis and to burn off the mucosal lining.  Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution.  Hemostasis was good.  A 10-mm Jackson-Pratt drain was left in the foramen of Winslow and brought out through the lateral 5-mm port site.  The T-tube was brought out through the middle 5-mm port site, which was just above the incision.  Abdominal incision was then closed in layers using 0 Vicryl running suture for the peritoneal layer and #1 Novafil running suture for the fascia.  Subcutaneous tissue was closed with 3-0 Vicryl running sutures in two layers.  Subfascial and subcutaneous tissues were injected with a total of 20 mL of 0.25% Marcaine with epinephrine for postoperative pain control.  The umbilical incision was closed with 0 Vicryl figure-of-eight sutures for the fascia, 2-0 Vicryl for the subcutaneous tissues, and staples for the skin.  Sterile dressing was applied, and the patient transferred to recovery room in stable condition.
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DESCRIPTION: Laparoscopy, laparotomy, cholecystectomy with operative cholangiogram, choledocholithotomy with operative choledochoscopy and T-tube drainage of the common bile duct.

gastroenterology, cholelithiasis, cholecystitis, biliary colic, choledocholithiasis, laparoscopy, laparotomy, cholecystectomy, cholangiogram, choledocholithotomy, choledochoscopy, t-tube drainage, cystic duct cholangiogram, common bile duct, peritoneal cavity, gallbladder

The scenario involves a complex surgical procedure on a 63-year-old male patient with significant comorbidities like hypertension, diabetes, end-stage renal disease, and coronary artery disease, who is on hemodialysis. The procedure had to be escalated from a laparoscopic approach to a more invasive open laparotomy due to complications encountered during the surgery. The presence of severe cholecystitis, cholelithiasis, choledocholithiasis, and morbid obesity further complicates the patient's situation. These factors contribute to a high-risk surgical procedure, with potential serious implications for the patient's health. Preoperative and postoperative care are crucial given the patient's other medical conditions, making this a high-stakes situation.


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

Medical Specialty: Surgery
Sample Name: Trigger Thumb Release - 1

PREOPERATIVE DIAGNOSIS:  ,Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:,  Right trigger thumb.,OPERATIONS PERFORMED:,  Trigger thumb release.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia applied by surgeon with local.,COMPLICATIONS:,
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DESCRIPTION: Trigger thumb release.  Right trigger thumb.  The A-1 pulley was divided along its radial border, completely freeing the stenosing tenosynovitis (trigger release).

surgery, trigger thumb, trigger thumb release, tenosynovitis trigger, tenosynovitis, release, thumb, tourniquet, trigger,

The procedure described is a common surgical intervention for trigger thumb, which is a condition that causes pain and difficulty in moving the thumb. While it is a surgical procedure, it is generally considered low-risk and routine for experienced surgeons. The description does not mention any complications, indicating that the operation likely went smoothly as planned. The use of local and regional anesthesia suggests a focus on patient comfort during what is typically a straightforward procedure.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Tracheotomy - 1

PREOPERATIVE DIAGNOSIS: , Respiratory failure.,POSTOPERATIVE DIAGNOSIS:  ,Respiratory failure.,OPERATIVE PROCEDURE: , Tracheotomy.,ANESTHESIA:  ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General inhalational anesthesia was administered through the patient's existing 4.0 endotracheal tube.  The neck was extended and secured with tape and incision in the midline of the neck approximately 2 fingerbreadths above the sternal notch was outlined.  The incision measured approximately 1 cm and was just below the palpable cricoid cartilage and first tracheal ring.  The incision area was infiltrated with 1% Xylocaine with epinephrine 1:100,000.  A #67 blade was used to perform the incision.  Electrocautery was used to remove excess fat tissue to expose the strap muscles.  The strap muscles were grasped and divided in the midline with a cutting electrocautery.  Sharp dissection was used to expose the anterior trachea and cricoid cartilage.  The thyroid isthmus was identified crossing just below the cricoid cartilage.  This was divided in the midline with electrocautery.  Blunt dissection was used to expose adequate cartilaginous rings.  A 4.0 silk was used for stay sutures to the midline of the cricoid.  Additional stay sutures were placed on each side of the third tracheal ring.  Thin DuoDerm was placed around the stoma.  The tracheal incision was performed with a #11 blade through the second, third, and fourth tracheal rings.  The cartilaginous edges were secured to the skin edges with interrupted #4-0 Monocryl.  A 4.5 PED tight-to-shaft cuffed Bivona tube was placed and secured with Velcro ties.  A flexible scope was passed through the tracheotomy tube.  The carina was visualized approximately 1.5 cm distal to the distal end of the tracheotomy tube.  Ventilation was confirmed.  There was good chest rise and no appreciable leak.  The procedure was terminated.  The patient was in stable condition.  Bleeding was negligible and she was transferred back to the Pediatric intensive care unit in stable condition.
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DESCRIPTION: Tracheotomy for patient with respiratory failure.

cardiovascular / pulmonary, bivona tube, duoderm, tracheotomy tube, respiratory failure, cricoid cartilage, tracheotomy, tracheal,

The situation involves a medical procedure, specifically a tracheotomy, being performed on a patient with respiratory failure—a potentially life-threatening condition. The success and precision of this procedure directly impact the patient's ability to breathe and their overall survival, indicating that this is a high-stakes situation within the medical context.


Medical Specialty: Surgery
Sample Name: Craniotomy - Occipital

PREOPERATIVE DIAGNOSIS: , Brain tumors, multiple.,POSTOPERATIVE DIAGNOSES:,  Brain tumors multiple - adenocarcinoma and metastasis from breast.,PROCEDURE:,  Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.,PROCEDURE:,  The patient was placed in the prone position after general endotracheal anesthesia was administered.  The scalp was prepped and draped in the usual fashion.  The CUSA was brought in to supplement the use of operating microscope as well as the stealth, which was used to localize the tumor.  Following this, we then made a transverse linear incision, the scalp galea was reflected and the quadrilateral bone flap was removed after placing burr holes in the midline and over the parietal areas directly over the tumor.  The bone flap was elevated.  The ultrasound was then used.  The ultrasound showed the tumors directly I believe are in the interhemispheric fissure.  We noticed that the dura was quite tense despite that the patient had slight hyperventilation.  We gave 4 ounce of mannitol, the brain became more pulsatile.  We then used the stealth to perform a ventriculostomy.  Once this was done, the brain began to pulsate nicely.  We then entered the interhemispheric space after we incised the dura in an inverted U fashion based on the superior side of the sinus.  After having done this we then used operating microscope and slight self-retaining retraction was used.  We obtained access to the tumor.  We biopsied this and submitted it.  This was returned as a malignant brain tumor - metastatic tumor, adenocarcinoma compatible with breast cancer.,Following this we then debulked this tumor using CUSA and then removed it in total.  After gross total removal of this tumor, the irrigation was used to wash the tumor bed and a meticulous hemostasis was then obtained using bipolar cautery.  The next step was after removal of this tumor, closure of the wound, a large piece of Duragen was placed over the dural defect and the bone flap was reapproximated and held secured with Lorenz plates.  The tumors self extend into the ventricle and after we had removed the tumor, we could see our ventricular catheter in the occipital horn of the ventricle.  This being the case, we left this ventricular catheter in, brought it out through a separate incision and connected to sterile drainage.  The next step was to close the wound after reapproximating the bone flap.  The galea was closed with 2-0 Vicryl and the skin was closed with interrupted 3-0 nylon sutures inverted with mattress sutures.  The sterile dressings were applied to the scalp.  The patient returned to the recovery room in satisfactory condition.  Hemodynamically remained stable throughout the operation.,Once again, we performed occipital craniotomy, total removal of her large metastatic tumor involving the parietal lobe using a biparietal craniotomy.  The tumor was removed using the combination of CUSA, ultrasound, stealth guided-ventriculostomy and the patient will have a second operation today, we will perform a selective craniectomy to remove another large tumor in the posterior fossa.
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DESCRIPTION: Occipital craniotomy, removal of large tumor using the inner hemispheric approach, stealth system operating microscope and CUSA.

surgery, brain tumor, cusa, occipital, adenocarcinoma, bone flap, craniotomy, malignant, metastatic, scalp galea, transverse linear incision, ventriculostomy, occipital craniotomy, tumor, stealth, brain,

The case involves a complex surgical procedure known as a craniotomy for the removal of multiple brain tumors. This is inherently high-stakes due to several factors: the critical location of the tumors in the brain, the use of advanced surgical techniques and equipment, the involvement of metastasis indicating cancer has spread, and the need for subsequent operations. Brain surgeries are typically high-stakes due to the potential for significant complications, impacts on critical functions, and the serious underlying conditions they address. Furthermore, the potential for worsening or complications intraoperatively or postoperatively increases the stakes.


Medical Specialty: Gastroenterology
Sample Name: Endoscopy Template

INDICATIONS:,  Dysphagia.,PREMEDICATION:,  Topical Cetacaine spray and Versed IV.,PROCEDURE:,:  The scope was passed into the esophagus under direct vision.  The esophageal mucosa was all unremarkable.  There was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis.  The scope was passed on down into the stomach.  The gastric mucosa was all examined including a retroflexed view of the fundus and there were no abnormalities seen.  The scope was then passed into the duodenum and the duodenal bulb and second and third portions of the duodenum were unremarkable.  The scope was again slowly withdrawn through the esophagus and no evidence of narrowing was present.  The scope was then withdrawn.,IMPRESSION:,  Normal upper GI endoscopy without any evidence of anatomical narrowing.
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DESCRIPTION: Normal upper GI endoscopy.

Normal upper GI endoscopy.

gastroenterology, dysphagia, cetacaine spray, esophagus, esophageal mucosa, duodenum, scope was passed, upper gi, gi endoscopy, gi, endoscopy, scope

The procedure described is a routine diagnostic endoscopy for examining the GI tract, specifically due to symptoms of dysphagia. The results were normal, indicating no abnormalities or concerns that require immediate attention or intervention. The stakes involved are low since there are no findings that necessitate urgent medical action or imply a severe health condition, and the report reassures that the patient's upper GI tract appears normal.


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

ADMITTING DIAGNOSES:,  Left renal cell carcinoma, left renal cyst.,DISCHARGE DIAGNOSIS:,  Left renal cell carcinoma, left renal cyst.,SECONDARY DIAGNOSES:,1.  Chronic obstructive pulmonary disease.,2.  Coronary artery disease.,PROCEDURES: , Robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.,HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 70-year-old male who has been diagnosed with a left renal cell carcinoma with multiple renal cysts.  He has undergone MRI of the abdomen on June 18, 2008 revealing an enhancing mass of the upper pole of the left kidney consistent with his history of renal cell carcinoma.  Of note, there are no other enhancing solid masses seen on this MRI.  After discussion of multiple management strategies with the patient including:,1.  Left partial nephrectomy.,2.  Left radical nephrectomy.,3.  Left renal cyst decortication.  The patient is likely to undergo the latter procedure.,HOSPITAL COURSE:  ,The patient was admitted to undergo left renal cyst decortication as well as a cystoscopy.  Intraoperatively, approximately four enlarged renal cysts and six smaller renal cysts were initially removed.  The contents were aspirated and careful dissection of the cyst wall was performed.  Multiple specimens of the cyst wall were sent for pathology.  Approximately one liter of cystic fluid was drained during the procedure.  The renal bed was inspected for hemostasis, which appear to be adequate.  There were no complications with the procedure.  Single JP drain was left in place.  Additionally, the patient underwent flexible cystoscopy, which revealed no gross strictures or any other abnormalities in the penile nor prostatic urethra.  Furthermore, no gross lesions were encountered in the bladder.  The patient left OR with transfer to the PACU and subsequently to the hospital floor.,The patient's postoperative course was relatively uneventful.  His diet and activity were gradually advanced without complication.  On postoperative day #2, he was passing flatus and has had bowel movements.  His Jackson-Pratt drain was discontinued on postoperative day #3 that being the day of discharge.  His Foley catheter was removed on the morning of discharge and the patient subsequently passed the voiding trial without difficultly.  At the time of discharge, he was afebrile.  His vital signs indicated hemodynamic stability and he had no evidence of infection.  The patient was instructed to follow up with Dr. XYZ on 8/12/2008 at 1:50 p.m. and was given prescription for pain medications as well as laxative.,DISPOSITION: , To home.,DISCHARGE CONDITION:,  Good.,MEDICATIONS:  ,Please see attached medication list.,INSTRUCTIONS: , The patient was instructed to contact Dr. XYZ's office for fever greater than 101.5, intractable pain, nausea, vomiting, or any other concerns.,FOLLOWUP: , The patient will follow up with Dr. XYZ for a postoperative check on 08/12/2008 at 1:50 p.m. and he was made aware of this appointment.
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DESCRIPTION: Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.

discharge summary, decortication, cystoscopy, pain, nausea, vomiting, renal cyst decortication, renal cell carcinoma, robotic assisted, renal cyst, renal, robotic, laparoscopic, nephrectomy, cysts, cell, carcinoma, discharge,

The situation describes the discharge summary of a patient who underwent a successful surgical procedure to address left renal cell carcinoma and left renal cyst. The patient had a smooth postoperative course with no complications reported, and they were discharged in good condition. This scenario is not high-stakes because the patient is stable, the procedure went as planned, and the follow-up is routine. The discharge instructions highlight precautions typical for postoperative care, indicating that any serious or high-risk concerns would be addressed promptly by contacting a medical professional.


Medical Specialty: Surgery
Sample Name: Internal Jugular Vein Catheter Insertion

PREOPERATIVE DIAGNOSES:,1.  Acute on chronic renal failure.,2.  Uremia.,POSTOPERATIVE DIAGNOSES:,1.  Acute on chronic renal failure.,2.  Uremia.,PROCEDURE PERFORMED:  ,Insertion of a right internal jugular vein hemodialysis catheter.,ANESTHESIA: , 1% local lidocaine.,BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS: , None.,HISTORY: , The patient is a 74-year-old Caucasian male who presents via direct admission for acute on chronic renal failure with uremia.  The patient incidentally was in a car accident ten days ago and has been feeling pretty awful since that time.  He is slightly short of breath with mild difficulty in breathing.  A pre-procedure x-ray was obtained, which showed no pneumothorax.  He did have a significant right pleural effusion and a mild left pleural effusion.  We decided to insert the catheter on the right side.,PROCEDURE:  ,The patient was prepped and draped in the usual sterile fashion.  1% lidocaine was used to anesthetize the area two fingerbreadths above the clavicle just posterior to the right sternocleidomastoid muscle and below the external jugular vein.  Using the same anesthetic needle, the right internal jugular vein was used to cannulate with good venous blood return.  The tract was noted.,The needle was removed and a second #18 gauge thin-walled needle was used along same tract to cannulate the right internal jugular vein also without difficulty and good venous blood return.  The syringe was removed and a Seldinger guidewire was inserted through the needle to cannulate the vein also without difficulty.  The needle was removed and an #11 blade was used to make a small skin incision provided skin and vein dilators were used.  The circle-C 8-inch hemodialysis catheter was then inserted over the guidewire without difficulty.  The guidewire was removed.  Both of the ports were aspirated venous blood without difficulty and both flushed also without difficulty.  The ports were flushed with injectable normal saline secondary to the patient going for dialysis today.  Thus, he will not need heparinization of the lines.  Again, he tolerated the procedure well.  A postoperative x-ray would be obtained to check catheter placement and rule out pneumothorax.
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DESCRIPTION: Acute on chronic renal failure and uremia.  Insertion of a right internal jugular vein hemodialysis catheter.

surgery, uremia, internal jugular vein hemodialysis catheter, pneumothorax, jugular vein, dialysis, chronic renal failure, internal jugular vein, pleural effusion, hemodialysis catheter, renal failure, cannulate, guidewire, insertion, jugular, catheter, hemodialysis, vein

The insertion of an internal jugular vein catheter for hemodialysis is a critical procedure, especially in a patient with acute on chronic renal failure and uremia. The procedure is necessary for renal replacement therapy, which is essential to manage the patient's condition. Any complications could have severe consequences, including potentially life-threatening outcomes. The procedure's success and complication-free outcome are crucial for the patient's immediate health needs, making this situation high-stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Acne - SOAP

SUBJECTIVE:,  The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004.  She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back.  On examination, this is a flaring of her acne with small folliculitis lesions.  The patient has been taking amoxicillin 500 mg b.i.d. and using Tazorac cream 0.1, and her face is doing well, but she has been out of her medicine now for three days also.  She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products, etc.  The patient is married.  She is a secretary.,FAMILY, SOCIAL, AND ALLERGY HISTORY:,  She has hay fever, eczema, sinus, and hives.  She has no melanoma or skin cancers or psoriasis.  Her mother had oral cancer.  The patient is a nonsmoker.  No blood tests.  Had some sunburn in the past.  She is on benzoyl peroxide and Daypro.,CURRENT MEDICATIONS:,  Lexapro, Effexor, Ditropan, aspirin, vitamins.,PHYSICAL EXAMINATION:,  The patient is well developed, appears stated age.  Overall health is good.  She has a couple of acne lesions, one on her face and neck but there are a lot of small folliculitis-like lesions on her abdomen, chest, and back.,IMPRESSION:,  Acne with folliculitis.,TREATMENT:,1.  Discussed condition and treatment with the patient.,2.  Continue the amoxicillin 500 mg two at bedtime.,3.  Add Septra DS every morning with extra water.,4.  Continue the Tazorac cream 0.1; it is okay to use on back and chest also.,5.  Referred to ABC clinic for an aesthetic consult.  Return in two months for followup evaluation of her acne.
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DESCRIPTION: Acne with folliculitis.

Acne with folliculitis.

soap / chart / progress notes, acne with folliculitis, tazorac cream, acne, dermatology, tazorac, cream, folliculitis,

The situation involves a medical evaluation of a patient with acne and folliculitis, which are generally non-life-threatening skin conditions, especially in the context provided. The patient is stable and the treatment plan is aimed at improving dermatological conditions primarily for comfort and cosmetic reasons. It doesn't involve emergency care or critical health risks.


Medical Specialty: Urology
Sample Name: Circumcision - 4

The patient tolerated the procedure well and was sent to the Recovery Room in stable condition.
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DESCRIPTION: Normal Circumcision

Normal Circumcision

urology, circumcision, circumferential proximal incisions, hemostasis, vaseline soaked gauze, catgut, foreskin, needlepoint bovie, pain block, shaft of the penis, supine position, penisNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The situation describes a patient undergoing a routine circumcision procedure in the field of urology. The description indicates that the procedure was normal and the patient was sent to recovery in stable condition. As a routine procedure with a typical outcome and no mention of complications, it is considered relatively low-stakes in the medical context.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Male ROS Template - 1

REVIEW OF SYSTEMS:,CONSTITUTIONAL:  Patient denies fevers, chills, sweats and weight changes.,EYES:  Patient denies any visual symptoms.,EARS, NOSE, AND THROAT:  No difficulties with hearing.  No symptoms of rhinitis or sore throat.,CARDIOVASCULAR:  Patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,RESPIRATORY:  No dyspnea on exertion, no wheezing or cough.,GI:  No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,GU:  No urinary hesitancy or dribbling.  No nocturia or urinary frequency.  No abnormal urethral discharge.,MUSCULOSKELETAL:  No myalgias or arthralgias.,NEUROLOGIC:  No chronic headaches, no seizures.  Patient denies numbness, tingling or weakness.,PSYCHIATRIC:  Patient denies problems with mood disturbance.  No problems with anxiety.,ENDOCRINE:  No excessive urination or excessive thirst.,DERMATOLOGIC:  Patient denies any rashes or skin changes.
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DESCRIPTION: An example/template for a routine normal male ROS.

consult - history and phy., review of systems, normal male ros, normal male, male ros, male, ros, throat, urinary

The Review of Systems (ROS) template provided is a standard medical checklist used to document a patient's reported symptoms across various bodily systems. The situation involves the completion and use of a form that records a patient's health status based on their self-reported observations. This is a typical and routine part of medical assessments, especially in annual physical exams or initial consultations, and does not involve immediate decision-making that could impact someone's health critically. Since there are no indicated issues in the ROS, and this is presented as a template example for routine use, it does not present any urgency or high-stakes decision-making.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal ENT Exam - 1

EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis.  There are no signs of acute trauma.  The nose is normal to palpation and inspection externally without evidence of acute trauma.  Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling.  The tympanic membranes are without disruption or infection.  Hearing intact bilaterally to normal level speech.  Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation.  The septum is without acute traumatic lesions or disruption.  The turbinates are without abnormal swelling.  There is no unusual rhinorrhea or bleeding.  ,LIPS/TEETH/GUMS:  ,The lips are without infection, mass lesion or traumatic lesions.  The teeth are intact without obvious signs of infection.  The gingivae are normal to palpation and inspection.  ,OROPHARYNX:  ,The oral mucosa is normal.  The salivary glands are without swelling.  The hard and soft palates are intact.  The tongue is without masses or swelling with normal movement.  The tonsils are without inflammation.  The posterior pharynx is without mass lesion with good patent oropharyngeal airway.
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DESCRIPTION: Sample normal ear, nose, mouth, and throat exam.

consult - history and phy., oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling,

The situation described is a routine ENT examination with all findings reported as normal. There are no indications of acute or critical medical issues present in this description. Such assessments are typically low-risk because they are conducted to ensure general health and to identify any potential issues early. There is no evidence of any urgent or life-threatening conditions in the provided information.


Medical Specialty: Surgery
Sample Name: Chest Closure

PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.  Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management.  He is now taken back to the operative room for delayed primary chest closure.,PREOP DX: , Open chest status post modified stage 1 Norwood operation.,POSTOP DX:,  Open chest status post modified stage 1 Norwood operation.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,FINDINGS:,  No evidence of intramediastinal purulence or hematoma.  He tolerated the procedure well.,DETAILS OF PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion.  The previously placed AlloDerm membrane was removed.  Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned.  Both cavities were also irrigated and suctioned.  The drains were flushed and repositioned.  Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line.  The sternum was then smeared with a vancomycin paste.  The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side.  The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches.  The skin was closed with interrupted nylon sutures and a sterile dressing was placed.  The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed.  The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.
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DESCRIPTION: Delayed primary chest closure.  Open chest status post modified stage 1 Norwood operation.  The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.

surgery, open chest, stage 1 norwood operation, hypoplastic left heart syndrome, delayed primary chest closure, chest closure, norwood operation

The procedure described involves a delayed primary chest closure for a newborn who has undergone a modified stage 1 Norwood operation. This type of surgery is complex and high-risk due to the intricate nature of congenital heart defects like hypoplastic left heart syndrome, and the critical condition of the patient being an infant. The success of this procedure is crucial for the patient's recovery and overall survival post-operatively, making it high-stakes.


Medical Specialty: Emergency Room Reports
Sample Name: Urgent Cardiac Cath

PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest.  The right groin was prepped and draped in usual manner.  Under 2% lidocaine anesthesia, the right femoral artery was entered.  A 6-French sheath was placed.  The patient was already on anticoagulation.  Selective coronary angiograms were then performed using a left and a 3DRC catheter.  The catheters were reviewed.  The catheters were then removed and an Angio-Seal was placed.  There was some hematoma at the cath site.,RESULTS,1.  The left main was free of disease.,2.  The left anterior descending and its branches were free of disease.,3.  The circumflex was free of disease.,4.  The right coronary artery was free of disease.  There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram.,
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DESCRIPTION: Urgent cardiac catheterization with coronary angiogram.

emergency room reports, cardiac catheterization, coronary angiogram, angiogram

The situation involves an urgent cardiac catheterization performed on a patient who was in cardiac arrest, which inherently indicates a life-threatening, high-stakes medical situation. The procedure was conducted in an emergency setting, emphasizing the immediate need to address potential life-threatening coronary issues. However, the results were normal, alleviating immediate concerns but not lowering the stakes of the decision-making and procedural environment. Due to the patient's unstable condition requiring intubation and anticoagulation, the scenario is high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Back & Leg Pain

Her axial back pain is greatly improved, but not completely eradicated.  There is absolutely no surgery at this point in time that would be beneficial for her axial back pain due to her lumbar internal disc disruption.,PAST MEDICAL HISTORY:,  Significant for anxiety disorder.,PAST SURGICAL HISTORY: , Foot surgery, abdominal surgery, and knee surgery.,CURRENT MEDICATIONS:,  Lipitor and Lexapro.,ALLERGIES: , She is allergic to sulfa medications.,SOCIAL HISTORY: , She is married, retired.  Denies tobacco or ethanol use.,FAMILY HISTORY:,  Father died of mesothelioma.  Mother gastric problems.,REVIEW OF SYSTEMS: , No recent history of night sweats, fevers, weight loss, visual changes, loss of consciousness, convulsion, or dysphagia.  Otherwise, review of systems is unremarkable, and a detailed history can be found in the patient's chart.,PHYSICAL EXAMINATION:,  Physical exam can be found in great detail in the patient's chart.,ASSESSMENT AND PLAN:  ,The patient is suffering from multilevel lumbar internal disc disruption as well as an element of lumbar facet joint syndrome.  Her lumbar facet joints were denervated approximately 6 months ago.  The denervation procedure helped her axial back pain approximately 40% when standing.  With extension and rotation it helped her axial back pain approximately 70%.  She is now able to swing a golf club.  She was unable to swing a golf club due to the rotational movements before her rhizotomy.  She is currently playing golf.  Her L4 radicular symptoms have resolved since her therapeutic transforaminal injection.,I am going to have her fitted with a low profile back brace and I am starting her on diclofenac 75 mg p.o. b.i.d.  We will follow her up in 1 month's time.,
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DESCRIPTION: The patient has been suffering from intractable back and leg pain.

consult - history and phy., multilevel lumbar internal disc disruption, denervation procedure, lumbar facet joint syndrome, swing a golf, lumbar internal disc, internal disc disruption, lumbar internal, internal disc, disc disruption, intractable, surgery, disc, lumbar

The situation described is not immediately life-threatening, as the patient shows improvement and can participate in activities such as golfing. The medical decision involves pain management and does not require immediate or high-risk surgical intervention. While chronic pain can significantly impact quality of life, the stakes here involve careful monitoring and management of the condition rather than an urgent medical crisis.


Medical Specialty: ENT - Otolaryngology
Sample Name: Ear Laceration Repair

PREOPERATIVE DIAGNOSIS:,  Bilateral ear laceration deformities.,POSTOPERATIVE DIAGNOSIS:,  Bilateral ear laceration deformities.,PROCEDURE:,1.  Repair of left ear laceration deformity Y-V plasty 2 cm.,2.  Repair of right ear laceration deformity, complex repair 2 cm.,ANESTHESIA: , 1% Xylocaine, 1:100,000 epinephrine local.,BRIEF CLINICAL NOTE: , This patient was brought to the operating room today for the above procedure.,OPERATIVE NOTE: , The patient was laid in supine position, adequately anesthetized with the above anesthesia, sterilely prepped and draped.  The left ear laceration deformity was very close to the bottom of her ear and therefore it was transected through the centrifugal edge of the ear lobe and pared.  The marsupialized epithelialized tracts were pared to raw tissue.  They were pared in a fashion to create a Y-V plasty with de-epithelialization of the distal V and overlap of the undermined from the proximal cephalad edge.  The 5-0 chromic sutures were used to approximate anteriorly, posteriorly, and anterior centrifugal edge in the Y-V plasty fashion to decrease the risk of notching.  Bacitracin, Band-Aid was placed.  Next, attention was turned to the contralateral ear where an elongated laceration deformity was pared of the marsupialized epithelialized edges anteriorly, posteriorly to create raw edges.  This was not taken through the edge of the lobe to decrease the risk of notch deformity.  The laceration was repaired anteriorly and posteriorly in a pleated fashion to decrease length of the incision and to decrease any deformity toward the edge or any dog-ear deformity toward the edge.  The 5-0 chromic sutures were used in interrupted fashion for this.  The patient tolerated the procedure well.  Band-Aid and bacitracin were placed.  She left the operating room in stable condition.
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DESCRIPTION: Repair of left ear laceration deformity Y-V plasty 2 cm.  Repair of right ear laceration deformity, complex repair 2 cm.

ent - otolaryngology, bilateral ear laceration, dog-ear deformity, ear laceration deformity, band aid, laceration deformity, ear laceration, laceration, deformity, ear, repair

The scenario involves a routine ENT surgical procedure to repair bilateral ear lacerations. While surgery inherently involves risks, this particular procedure appears to be straightforward and not life-threatening. The patient tolerated the procedure well and was stable post-operatively. Given the elective and reconstructive nature of the surgery, this is considered low-stakes in terms of immediate health impact.


Medical Specialty: Neurology
Sample Name: Alzheimer Disease

CC:, Memory difficulty.,HX: ,This 64 y/o RHM had had difficulty remembering names, phone numbers and events for 12 months prior to presentation, on 2/28/95. This had been called to his attention by the clerical staff at his parish--he was a Catholic priest. He had had no professional or social faux pas or mishaps due to his memory. He could not tell whether his problem was becoming worse, so he brought himself to the Neurology clinic on his own referral.,MEDS:, None.,PMH: ,1)appendectomy, 2)tonsillectomy, 3)childhood pneumonia, 4)allergy to sulfa drugs.,FHX:, Both parents experienced memory problems in their ninth decades, but not earlier. 5 siblings have had no memory trouble. There are no neurological illnesses in his family.,SHX:, Catholic priest. Denied Tobacco/ETOH/illicit drug use.,EXAM:,  BP131/74, HR78, RR12, 36.9C, Wt. 77kg, Ht. 178cm.,MS: A&O to person, place and time. 29/30 on MMSE; 2/3 recall at 5 minutes. 2/10 word recall at 10 minutes. Unable to remember the name of the President (Clinton). 23words/60 sec on Category fluency testing (normal). Mild visual constructive deficit.,The rest of the neurologic exam was unremarkable and there were no extrapyramidal signs or primitive reflexes noted.,COURSE:, TSH 5.1, T4 7.9, RPR non-reactive. Neuropsychological evaluation, 3/6/95, revealed: 1)well preserved intellectual functioning and orientation, 2) significant deficits in verbal and visual memory, proper naming, category fluency and working memory, 3)performances which were below expectations on tests of speed of reading, visual scanning, visual construction and clock drawing, 4)limited insight into the scope and magnitude of cognitive dysfunction. The findings indicated multiple areas of cerebral dysfunction. With the exception of the patient's report of minimal occupational dysfunction ( which may reflect poor insight), the clinical picture is consistent with a progressive dementia syndrome such as Alzheimer's disease. MRI brain, 3/6/95, showed mild generalized atrophy, more severe in the occipital-parietal regions.,In 4/96, his performance on repeat neuropsychological evaluation was relatively stable. His verbal learning and delayed recognition were within normal limits, whereas delayed recall was "moderately severely" impaired. Immediate and delayed visual memory were slightly below expectations. Temporal orientation and expressive language skills were below expectation, especially in word retrieval. These findings were suggestive of particular, but not exclusive, involvement of the temporal lobes.,On 9/30/96, he was evaluated for a 5 minute spell of visual loss, OU. The episode occurred on Friday, 9/27/96, in the morning while sitting at his desk doing paperwork. He suddenly felt that his gaze was pulled toward a pile of letters; then a "curtain" came down over both visual fields, like "everything was in the shade." During the episode he felt fully alert and aware of his surroundings. He concurrently heard a "grating sound" in his head. After the episode, he made several phone calls, during which he reportedly sounded confused, and perseverated about opening a bank account. He then drove to visit his sister in Muscatine, Iowa, without accident. He was reportedly "normal" when he reached her house. He was able to perform Mass over the weekend without any difficulty. Neurologic examination, 9/30/96, was notable for: 1)category fluency score of 18items/60 sec. 2)VFFTC and EOM were intact. There was no RAPD, INO, loss of visual acuity. Glucose 178 (elevated), ESR ,Lipid profile, GS, CBC with differential, Carotid duplex scan, EKG, and EEG were all normal. MRI brain, 9/30/96, was unchanged from previous, 3/6/95.,On 1/3/97, he had a 30 second spell of lightheadedness without vertigo, but with balance difficulty, after picking up a box of books. The episode was felt due to orthostatic changes.,1/8/97 neuropsychological evaluation was stable and his MMSE score was 25/30 (with deficits in visual construction, orientation, and 2/3 recall at 1 minute). Category fluency score 23 items/60 sec. Neurologic exam was notable for graphesthesia in the left hand.,In 2/97, he had episodes of anxiety, marked fluctuations in job performance and resigned his pastoral position. His neurologic exam was unchanged. An FDG-PET scan on 2/14/97 revealed decreased uptake in the right posterior temporal-parietal and lateral occipital regions.
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DESCRIPTION: MRI brain & PET scan - Dementia of Alzheimer type with primary parietooccipital involvement.

neurology, dementia, a&o to person, alzheimer's disease, alzheimer's type, mmse, mmse score, mri brain, memory difficulty, neuropsychological, balance difficulty, category fluency, faux pas, minimal occupational dysfunction, parieto-occipital, progressive dementia syndrome, visual acuity, visual loss, visual memory, pet scan, neuropsychological evaluation, alzheimer's, neurological, memory,

The patient is experiencing cognitive decline consistent with Alzheimer's disease, a progressive and serious condition affecting memory and other critical cognitive functions. While the patient's life is not immediately at risk, the stakes are high because Alzheimer's is a degenerative disease that affects the patient's quality of life and independence, and requires significant medical attention and possibly long-term care planning. The situation also involves diagnostic procedures such as MRI and PET scans to assess brain involvement, indicative of the complexity and seriousness of the condition.


Medical Specialty: Surgery
Sample Name: Low-Transverse C-Section - 8

PREOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 35-1/7.,2.  Rh isoimmunization.,3.  Suspected fetal anemia.,4.  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 35-1/7.,2.  Rh isoimmunization.,3.  Suspected fetal anemia.,4.  Desires permanent sterilization.,OPERATION PERFORMED: , Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization.,ANESTHESIA:,  Spinal anesthesia.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,500 mL.,INTRAOPERATIVE FLUIDS: , 1000 mL crystalloids.,URINE OUTPUT: , 300 mL clear urine at the end of procedure.,SPECIMENS:,  Cord gases, hematocrit on cord blood, placenta, and bilateral tubal segments.,INTRAOPERATIVE FINDINGS: , Male infant, vertex position, very bright yellow amniotic fluid.  Apgars 7 and 8 at 1 and 5 minutes respectively.  Weight pending at this time.  His name is Kasson as well as umbilical cord and placenta stained yellow.  Otherwise normal appearing uterus and bilateral tubes and ovaries.,DESCRIPTION OF OPERATION:,  After informed consent was obtained, the patient was taken to the operating room where spinal anesthesia was obtained by Dr. X without difficulties.  The patient was placed in supine position with leftward tilt.  Fetal heart tones were checked and were 140s, and she was prepped and draped in a normal sterile fashion.  At this time, a Pfannenstiel skin incision made with a scalpel and carried down to the underlying fascia with electrocautery.  The fascia was nicked sharply in the midline.  The fascial incision was extended laterally with Mayo scissors.  The inferior aspect of the fascial incision was grasped with Kocher x2, elevated, and rectus muscles dissected sharply with the use of Mayo scissors.  Attention was then turned to the superior aspect of the fascial incision.  Fascia was grasped, elevated, and rectus muscles dissected off sharply.  The rectus muscles were separated in the midline bluntly.  The peritoneum was identified, grasped, and entered sharply and the peritoneal incision extended inferiorly and superiorly with good visualization of bladder.  Bladder blade was inserted.  Vesicouterine peritoneum was tented up and a bladder flap was created using Metzenbaum scissors.  Bladder blade was reinserted to effectively protect the bladder from the operative field and the lower uterine segment incised in a transverse U-shaped fashion with the scalpel.  Uterine incision was extended laterally and manually.  Membranes were ruptured and bright yellow clear amniotic fluid was noted.  Infant's head was in a floating position, able to flex the head, push against the incision, and then easily brought it to the field vertex.  Nares and mouth were suctioned with bulb suction.  Remainder of the infant was delivered atraumatically.  The infant was very pale upon delivery.  Cord was doubly clamped and cut and immediately handed to the awaiting intensive care nursery team.  An 8 cm segment of the tube was doubly clamped and transected.  Cord gases were obtained.  Cord was then cleansed, laid on a clean laparotomy sponge, and cord blood was drawn for hematocrit measurements.  At this time, it was noted that the cord was significantly yellow stained as well as the placenta.  At this time, the placenta was delivered via gentle traction on the cord and exterior uterine massage.  Uterus was exteriorized and cleared off all clots and debris with dry laparotomy sponge and the lower uterine segment was closed with 1-0 chromic in a running locked fashion.  Two areas of oozing were noted and separate figure-of-eight sutures were placed to obtain hemostasis.  At this time, the uterine incision was hemostatic.  The bladder was examined and found to be well below the level of the incision repair.  Tubes and ovaries were examined and found to be normal.  The patient was again asked if she desires permanent sterilization of which she agrees and therefore the right fallopian tube was identified and followed out to the fimbriated end and grasped at the mid portion with a Babcock clamp.  Mesosalpinx was divided with electrocautery and a 4-cm segment of tube was doubly tied and transected with a 3-cm segment of tube removed.  Hemostasis was noted.  Then, attention was turned to the left fallopian tube which in similar fashion was grasped and brought out through the fimbriated end and grasped the midline portion with Babcock clamp.  Mesosalpinx was incised and 3-4 cm tube doubly tied, transected, and excised and excellent hemostasis was noted.  Attention was returned to the uterine incision which is seemed to be hemostatic and uterus was returned to the abdomen.  Gutters were cleared off all clots and debris.  Lower uterine segments were again re-inspected and found to be hemostatic.  Sites of tubal sterilization were also visualized and were hemostatic.  At this time, the peritoneum was grasped with Kelly clamps x3 and closed with running 3-0 Vicryl suture.  Copious irrigation was used.  Rectus muscle belly was examined and found to be hemostatic and tacked and well approximated in the midline.  At this time, the fascia was closed using 0 Vicryl in a running fashion.  Manual palpation confirms thorough and adequate closure of the fascial layer.  Copious irrigation was again used.  Hemostasis noted, and skin was closed with staples.  The patient tolerated the procedure well.  Sponge, lap, needle, and instrument counts were correct x3 and the patient was sent to the recovery room awake and stable condition.  Infant assumed the care of the intensive care nursery team and being followed and workup up for isoimmunization and fetal anemia.  The patient will be followed for her severe right upper quadrant pain post delivery.  If she continues to have pain, may need a surgical consult for gallbladder and/or angiogram for evaluation of right kidney and questionable venous plexus.  This all will be relayed to Dr. Y, her primary obstetrician who was on call starting this morning at 7 a.m. through the weekend.
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DESCRIPTION: Primary low transverse cesarean section by Pfannenstiel skin incision with bilateral tubal sterilization.   Intrauterine pregnancy at 35-1/7.  Rh isoimmunization.  Suspected fetal anemia.  Desires permanent sterilization.

surgery, intrauterine pregnancy, rh isoimmunization, primary low transverse cesarean section, bilateral tubal sterilization, pfannenstiel skin incision, fascial incision, uterine incision, fetal anemia, permanent sterilization, rectus muscles, incision, tubes, cord,

This case involves a cesarean section at 35 weeks of gestation with complications such as Rh isoimmunization and suspected fetal anemia. The operation is performed due to these risky conditions and also includes bilateral tubal sterilization. Additionally, the infant required immediate intensive care due to being very pale at delivery, suggesting significant concerns about the infant’s health. The situation has potential life-threatening implications for both the mother and the infant, making it a high-stakes scenario.


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

Medical Specialty: General Medicine
Sample Name: Normal Physical Exam Template - 3

PHYSICAL EXAMINATION,GENERAL APPEARANCE: , Well developed, well nourished, in no acute distress.,VITAL SIGNS:,  ***,SKIN:  ,Inspection of the skin reveals no rashes, ulcerations or petechiae.,HEENT:,  The sclerae were anicteric and conjunctivae were pink and moist.  Extraocular movements were intact and pupils were equal, round, and reactive to light with normal accommodation.  External inspection of the ears and nose showed no scars, lesions, or masses.  Lips, teeth, and gums showed normal mucosa.  The oral mucosa, hard and soft palate, tongue and posterior pharynx were normal.,NECK:  ,Supple and symmetric.  There was no thyroid enlargement, and no tenderness, or masses were felt.,CHEST: , Normal AP diameter and normal contour without any kyphoscoliosis.,LUNGS: , Auscultation of the lungs revealed normal breath sounds without any other adventitious sounds or rubs.,CARDIOVASCULAR:  ,There was a regular rate and rhythm without any murmurs, gallops, rubs.  The carotid pulses were normal and 2+ bilaterally without bruits.  Peripheral pulses were 2+ and symmetric.,ABDOMEN:  ,Soft and nontender with normal bowel sounds.  The liver span was approximately 5-6 cm in the right midclavicular line by percussion.  The liver edge was nontender.  The spleen was not palpable.  There were no inguinal or umbilical hernias noted.  No ascites was noted.,RECTAL:  ,Normal perineal exam.  Sphincter tone was normal.  There was no external hemorrhoids or rectal masses.  Stool Hemoccult was negative.  The prostate was normal size without any nodules appreciated (men only).,LYMPH NODES: , No lymphadenopathy was appreciated in the neck, axillae or groin.,MUSCULOSKELETAL: , Gait was normal.  There was no tenderness or effusions noted.  Muscle strength and tone were normal.,EXTREMITIES: , No cyanosis, clubbing or edema.,NEUROLOGIC:  ,Alert and oriented x 3.  Normal affect.  Gait was normal.  Normal deep tendon reflexes with no pathological reflexes.  Sensation to touch was normal.
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DESCRIPTION: Normal physical exam template.  Well developed, well nourished, in no acute distress.

The situation involves a description of a normal physical examination template used in general medicine. It doesn't present any pressing issues, critical information, or immediate risks concerning a patient's health. It is routine documentation of a typical, healthy physical condition. There are no indicators of high risk or emergency in this context.


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

CHIEF COMPLAINT: , Right knee. ,HISTORY OF THE PRESENT ILLNESS: , The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great.  Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left.,Pain:  Localized to the bilateral knees right worse than left.,Quality:  There is no swelling, no redness, or warmth.  The pain is described as aching occasionally.  There is no burning. ,Duration:  Months.,Associated symptoms:  Includes stiffness and weakness.  There is no sleep loss and no instability.  ,Hip Pain:  None. ,Back pain: None. ,Radicular type pain:  None. ,Modifying factors: Includes weight bearing pain and pain with ambulation.  There is no sitting, and no night pain.  There is no pain with weather change.,VISCOSUPPLEMENTATION IN PAST:,  No Synvisc.,VAS PAIN SCORE: , 10 bilaterally.,WOMAC SCORE: , 8,A-1 WOMAC SCORE: , 0,See the enclosed WOMAC osteoarthritis index, which accompanies the patient's chart, for complete details of the patient's limitations to activities of daily living.  ,REVIEW OF SYSTEMS:,  No change.,Constitutional:  Good appetite and energy.  No fever.  No general complaints.,HEENT:  No headaches, no difficulty swallowing, no change in vision, no change in hearing.,CV - RESP:  No shortness of breath at rest or with exertion.  No paroxysmal nocturnal dyspnea, orthopnea, and without significant cough, hemoptysis, or sputum.  No chest pain on exertion.,GI:
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DESCRIPTION: Orthopedic progress note for follow up of osteoarthritis, knees.

The progress note details a follow-up for a common condition, osteoarthritis, and describes the patient's condition as stable. There is no indication of immediate life-threatening symptoms or urgent medical interventions required. While the pain levels assessed are high (VAS pain score of 10), osteoarthritis is typically a chronic condition managed over time. Therefore, the stakes are primarily related to ongoing management rather than immediate medical crisis.


Medical Specialty: Radiology
Sample Name: MRI Brain - Bilateral Thalamic Strokes

CC:, Sudden onset blindness.,HX:, This 58 y/o RHF was in her usual healthy state, until 4:00PM, 1/8/93, when she suddenly became blind. Tongue numbness and slurred speech occurred simultaneously with the loss of vision. The vision transiently improved to "severe blurring" enroute to a local ER, but worsened again once there. While being evaluated she became unresponsive, even to deep noxious stimuli. She was transferred to UIHC for further evaluation. Upon arrival at UIHC her signs and symptoms were present but markedly improved.,PMH:, 1) Hysterectomy many years previous. 2) Herniorrhaphy in past. 3) DJD, relieved with NSAIDs.,FHX/SHX:, Married x 27yrs. Husband denied Tobacco/ETOH/illicit drug use for her.,Unremarkable FHx.,MEDS:, none.,EXAM:, Vitals: 36.9C.  HR 93.  BP 151/93.  RR 22.  98% O2Sat.,MS: somnolent, but arousable to verbal stimulation. minimal speech. followed simple commands on occasion.,CN: Blinked to threat from all directions. EOM appeared full, Pupils 2/2 decreasing to 1/1. +/+Corneas. Winced to PP in all areas of Face. +/+Gag. Tongue midline. Oculocephalic reflex intact.,Motor: UE 4/5 proximally. Full strength in all other areas. Normal tone and muscle bulk.,Sensory: Withdrew to PP in all extremities.,Gait: ND.,Reflexes: 2+/2+ throughout UE, 3/3 patella, 2/2 ankles, Plantar responses were flexor bilaterally.,Gen exam: unremarkable.,COURSE: ,MRI Brain revealed bilateral thalamic strokes. Transthoracic echocardiogram (TTE) showed an intraatrial septal aneurysm with right to left shunt. Transesophageal echocardiogram (TEE) revealed the same. No intracardiac thrombus was found. Lower extremity dopplers were unremarkable. Carotid duplex revealed 0-15% bilateral ICA stenosis. Neuroophthalmologic evaluation revealed evidence of a supranuclear vertical gaze palsy OU (diminished up and down gaze). Neuropsychologic assessment 1/12-15/93 revealed severe impairment of anterograde verbal and visual memory, including acquisition and delayed recall and recognition. Speech was effortful and hypophonic with very defective verbal associative fluency. Reading comprehension was somewhat preserved, though she complained that despite the ability to see type clearly, she could not make sense of words. There was impairment of 2-D constructional praxis. A follow-up Neuropsychology evaluation in 7/93 revealed little improvement. Laboratory studies, TSH, FT4, CRP, ESR, GS, PT/PTT were unremarkable. Total serum cholesterol 195, Triglycerides 57, HDL 43, LDL 141. She was placed on ASA and discharged1/19/93.,She was last seen on 5/2/95 and was speaking fluently and lucidly. She continued to have mild decreased vertical eye movements. Coordination and strength testing were fairly unremarkable. She continues to take ASA 325 mg qd.
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DESCRIPTION: MRI Brain to evaluate sudden onset blindness - Basilar/bilateral thalamic strokes.

radiology, blindness, mri, transthoracic echocardiogram, transesophageal echocardiogram, tsh, ft4, crp, esr, gs, pt/ptt, bilateral thalamic strokes, sudden onset blindness, mri brain, thalamic strokes, brain, thalamic, strokes,

This case involves a sudden and significant medical event: bilateral thalamic strokes leading to sudden onset blindness, altered consciousness, and neurocognitive impairments in a patient. Strokes represent a severe medical condition with potential life-threatening consequences if not promptly diagnosed and treated. The neurological symptoms indicate a critical situation requiring urgent medical evaluation to prevent further deterioration and optimize long-term outcomes. The diagnosis of bilateral thalamic strokes, a specific and serious condition, necessitates rapid and specialized care. Consequently, this scenario qualifies as a high-stakes medical situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Consult - Atrial Fibrillation

REASON FOR CONSULTATION:,  Atrial fibrillation.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old, Hispanic woman with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.  Apparently, the patient is a resident of Lake Harris Port Square long-term facility after her stroke.  She was found to have confusion while in her facility.  She then came to the emergency room and found to have a right sided acute stroke.  12-lead EKG performed on August 10, 2009, found to have atrial fibrillation.  Telemetry also revealed atrial fibrillation with rapid ventricular response.  Currently, the telemetry is normal sinus rhythm.  Because of the finding of atrial fibrillation, cardiology was consulted.,The patient is a poor historian.  She did not recall why she is in the hospital, she said she had a stroke.  She reported no chest discomfort, no shortness of breath, no palpitations.,The following information was obtained from the patient's chart:,PAST MEDICAL HISTORY:,1.  Coronary artery disease status post bypass grafting surgery.  Unable to obtain the place, location, anatomy, and the year it was performed.,2.  Carotid artery stenosis status post right carotid artery stenting.  Again, the time was unknown.,3.  Diabetes.,4.  Hypertension.,5.  Hyperlipidemia.,6.  History of stroke with left side hemiplegia.,ALLERGIES: , No known drug allergies.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:,  The patient is a resident of Lake Harris Port Square.  She has no history of alcohol use.,CURRENT MEDICATIONS: , Please see attached list including hydralazine, Celebrex, Colace, metformin, aspirin, potassium, Lasix, Levaquin, Norvasc, insulin, Plavix, lisinopril, and Zocor.,REVIEW OF SYSTEMS: , Unable to obtain.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 133/44, pulse 98, O2 saturation is 98% on room air.  Temperature 99, respiratory rate 16.,GENERAL:  The patient is sitting in the chair at bedside.  Appears comfortable.  Left facial droop.  Left side hemiplegia.,HEAD AND NECK:  No JVP seen.  Right side carotid bruit heard.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  PMI not displaced, regular rhythm.  Normal S1 and S2.  Positive S4.  There is a 2/6 systolic murmur best heard at the left lower sternal border.,ABDOMEN:  Soft.,EXTREMITIES:  Not edematous.,DATA:,  A 12-lead EKG performed on August 9, 2009, revealed atrial fibrillation with a ventricular rate of 96 beats per minute, nonspecific ST wave abnormality.,Review of telemetry done the last few days, currently the patient is in normal sinus rhythm at the rate of 60 beats per minute.  Atrial fibrillation was noted on admission noted August 8 and August 10; however, there was normal sinus rhythm on August 10.,LABORATORY DATA: , WBC 7.2, hemoglobin 11.7.  The patient's hemoglobin was 8.2 a few days ago before blood transfusion.  Chemistry-7 within normal limits.  Lipid profile:  Triglycerides 64, total cholesterol 106, HDL 26, LDL 17.  Liver function tests are within normal limits.  INR was 1.1.,A 2D echo was performed on August 11, 2009, and revealed left ventricle normal in size with EF of 50%.  Mild apical hypokinesis.  Mild dilated left atrium.  Mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation.  No intracardiac masses or thrombus were noted.  The aortic root was normal in size.,ASSESSMENT AND RECOMMENDATIONS:,1.  Paroxysmal atrial fibrillation.  It is unknown if this is a new onset versus a paroxysmal atrial fibrillation.  Given the patient has a recurrent stroke, anticoagulation with Coumadin to prevent further stroke is indicated.  However, given the patient's current neurologic status, the safety of falling is unclear.  We need to further discuss with the patient's primary care physician, probably rehab physician.  If the patient's risk of falling is low, then Coumadin is indicated.  However, if the patient's risk for falling is high, then a course using aspirin and Plavix will be recommended.  Transesophageal echocardiogram probably will delineate possible intracardiac thrombus better, however will not change our current management.  Therefore, I will not recommend transesophageal echocardiogram at this point.  Currently, the patient's heart rate is well controlled, antiarrhythmic agent is not recommended at this point.,2.  Carotid artery stenosis.  The patient underwent a carotid Doppler ultrasound on this admission and found to have a high-grade increased velocity of the right internal carotid artery.  It is difficult to assess the severity of the stenosis given the history of possible right carotid stenting.  If clinically indicated, CT angio of the carotid will be indicated to assess for stent patency.  However, given the patient's current acute stroke, revascularization is not indicated at this time.,3.  Coronary artery disease.  Clinically stable.  No further test is indicated at this time.
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DESCRIPTION: Patient with past medical history significant for coronary artery disease status post bypass grafting surgery and history of a stroke with residual left sided hemiplegia.

The situation involves a medical consultation for a patient with atrial fibrillation, a history of coronary artery disease, previous strokes, and a potential new acute stroke, which are all serious medical conditions. The decision regarding anticoagulation treatment is also significant due to the patient's risk factors and current health status. The assessment involves balancing the risk of stroke against the risk of falls due to anticoagulation. These decisions can have a major impact on the patient's health outcomes. Therefore, this medical consultation scenario is high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Nephrology Consultation - 4

HISTORY: , The patient is a 61-year-old male patient.  I was asked to evaluate this patient because of the elevated blood urea and creatinine.  The patient has ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, history of congestive heart failure status post AICD.  The patient has a history of exposure to asbestos in the past, history of diabetes mellitus of 15 years duration, hypertension, and peripheral vascular disease.  The patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall.  The patient has been having increasing distention of the abdomen and frequent nosebleeds.,PAST MEDICAL HISTORY:,  As above.,PAST SURGICAL HISTORY: , The patient had a pacemaker placed.,ALLERGIES: , NKDA.,REVIEW OF SYSTEMS: , Showed no history of fever, no chills, no weight loss.  No history of sore throat.  No history of any ascites.  No history of nausea, vomiting, or diarrhea.  No black stools.  No history of any rash.  No back pain.  No leg pain.  No neuropsychiatric problems.,FAMILY HISTORY: , History of hypertension, diabetes present.,SOCIAL HISTORY:,  He is a nonsmoker, nonalcoholic, and not a drug user.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure is 124/66, heart rate around 68 per minute, and temperature 96.4.,HEENT:  The patient is atraumatic and normocephalic.  Pupils are equal and reactive to light.  Extraocular muscles are intact.,NECK:  Supple.  No JVD and no thyromegaly.,HEART:  S1 and S2 heard.  No murmurs or extra sounds.,ABDOMEN:  Distention of the abdomen present.,EXTREMITIES:  No pedal edema.,LABORATORY: , His lab investigation showed WBC of 6.2, H&H is 11 and 34.  PT, PTT, and INR is normal.  Urinalysis showed 2+ protein and 3+ blood, and 5 to 10 rbc's.  Potassium is 5.3, BUN of 39, and creatinine of 1.9.  Liver function test, ALT was 12, AST 15, albumin 3, TSH of 4.8, and T3 of 1.33.,IMPRESSION AND PLAN:  ,The patient is admitted with a diagnosis of acute on chronic renal insufficiency, rule out hepatorenal insufficiency could be secondary to congestive heart failure, cardiac cirrhosis, rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule, rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis.  The patient has hematuria could be secondary to benign prostatic hypertrophy, rule out malignancy.  We will do urine for cytology.  We will do a renal ultrasound, and 24-hour urine collection for protein/creatinine, creatinine clearance, immunofixation, serum electrophoresis, serum uric acid, serum iron, TIBC, and serum ferritin levels.  We will send a PSA level and if needed may be a urology consult.
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DESCRIPTION: The patient is admitted with a diagnosis of acute on chronic renal insufficiency.

consult - history and phy., mesothelioma, ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, congestive heart failure, aicd, hepatorenal insufficiency, pulmonary nodule, diabetic nephropathy, chronic renal insufficiency, nodules, serum, insufficiency,

The situation described involves a medical consultation for a 61-year-old male with multiple complex health issues, including acute on chronic renal insufficiency, potential hepatorenal syndrome, history of asbestos exposure, and other serious conditions like coronary artery disease and congestive heart failure. Given the patient's complexity, multiple differential diagnoses, and the need for extensive testing, this situation is high-stakes. The stakes are elevated due to the possibility of serious outcomes if conditions like malignancy or mesothelioma are confirmed, as well as the risk associated with acute renal failure.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Cone Biopsy

PREOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,POSTOPERATIVE DIAGNOSIS: , Cervical carcinoma in situ.,OPERATION PERFORMED:,  Cervical cone biopsy, dilatation & curettage.,SPECIMENS:  ,Cone biopsy, endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with a Pap smear showing probable adenocarcinoma in situ.  The patient was advised to have cone biopsy to fully assess endocervical glands.,FINDINGS: , During the examination, under anesthesia, the vulva, vagina, and cervix were grossly unremarkable.  The uterus was smooth with no palpable cervical nodularity and no adnexal masses were noted.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place.  Anesthetic was administered and she was placed in the lithotomy position.  The patient was prepped and draped after which a weighted speculum was placed in the vagina and a tenaculum was placed on the cervix for traction.  Angle stitches of 0 Vicryl sutures were placed at 3 o'clock and 9 o'clock in the lateral vagina fornices.  The cervix was stained with Lugol's iodine solution. ,After the cervix was stained, a scalpel was used to excise a cone shaped biopsy circumferentially around the cervical os.  The specimen was removed intact, after which the uterine cavity was sounded to a depth of 8 cm.  A Kevorkian curette was used to obtain endocervical curettings.  The cone biopsy site was sutured using a running lock stitch of 0 Vicryl suture.  Upon completion of the suture placement, the endocervical canal was sounded to assure patency.  A prophylactic application of Monsel's solution completed the procedure.  ,The patient was awakened from her anesthetic and taken to the post anesthesia care unit in stable condition.  Final sponge, needle, and instrument counts were.
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DESCRIPTION: Cervical cone biopsy, dilatation & curettage

obstetrics / gynecology, cervical carcinoma in situ, cervical cone biopsy, endometrial curettings, endocervical, endometrial, dilatation & curettage, carcinoma in situ, cone biopsy, dilatation, curettage, carcinoma, vicryl, curettings, vagina, sutures, cervix, cervical, cone, biopsy,

This scenario involves a surgical procedure, which inherently carries certain risks, such as anesthetic complications, bleeding, or infection. The context of this procedure is particularly critical because it relates to the diagnosis of cervical carcinoma in situ, a pre-cancerous condition that requires precise surgical intervention. The stakes are further elevated by the need for accurate diagnosis and prevention of progression to invasive cancer. Also, the procedure involves the use of anesthesia, which increases the risk factors. Therefore, the situation is high-stakes from both a medical and patient safety perspective.


Medical Specialty: Orthopedic
Sample Name: Wrist Ganglion Excision

PREOPERATIVE DIAGNOSIS: , Wrist ganglion.,POSTOPERATIVE DIAGNOSIS: , Wrist ganglion.,TITLE OF PROCEDURE: , Excision of dorsal wrist ganglion.,PROCEDURE: , After administering appropriate antibiotics and general anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with an Esmarch and tourniquet inflated to 250 mmHg.  I made a transverse incision directly over the ganglion.  Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.  I then excised the ganglion and its stalk.  In addition, approximately a square centimeter of the dorsal capsule was removed at the origin of stalk, leaving enough of a defect to prevent formation of a one-way valve.  We then identified the scapholunate ligament, which was uninjured.  I irrigated and closed in layers and injected Marcaine with epinephrine.  I dressed and splinted the wound.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.
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DESCRIPTION: Excision of dorsal wrist ganglion.  Made a transverse incision directly over the ganglion.  Dissection was carried down through the extensor retinaculum, identifying the 3rd and the 4th compartments and retracting them.

orthopedic, origin of stalk, extensor retinaculum, wrist ganglion, incision, excision, dorsal, tourniquet, wrist, ganglion

The given scenario describes a surgical procedure for excision of a dorsal wrist ganglion. These types of procedures are generally considered routine in orthopedic surgery with relatively low risk. The patient is described as having tolerated the procedure well and was sent to the recovery room in good condition. Therefore, while there is always some level of risk associated with surgery, the stakes are not particularly high in this context.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Consult - Abnormal EKG

REASON FOR CONSULTATION: , Abnormal EKG and rapid heart rate.,HISTORY OF PRESENT ILLNESS: , The patient is an 86-year-old female.  From the last few days, she is not feeling well, fatigue, tiredness, weakness, nausea, no vomiting, no hematemesis or melena.  The patient relates to have some low-grade fever.  The patient came to the emergency room.  Initially showed atrial fibrillation with rapid ventricular response.  It appears that the patient has chronic atrial fibrillation.  As per the medications, they are not very clear.  Husband has gone out to brief her medications.  She denies any specific chest pain.  Her main complaint is shortness of breath and symptoms as above.,CORONARY RISK FACTORS: , No hypertension or diabetes mellitus.  Nonsmoker.  Cholesterol status is normal.  Questionable history of coronary artery disease.  Family history noncontributory.,FAMILY HISTORY:,  Nonsignificant.,PAST SURGICAL HISTORY: , Questionable coronary artery bypass surgery versus valve replacement.,MEDICATIONS: , Unclear at this time, but she does take Coumadin.,ALLERGIES: , ASPIRIN.,PERSONAL HISTORY: , She is married, nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY: , Symptoms as above, atrial fibrillation, history of open heart surgery, possible bypass surgery; however, after further query, husband relates that she may had just a valve surgery.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  Weakness, fatigue, and tiredness.,HEENT:  No history of cataract, history of blurry vision and hearing impairment.,CARDIOVASCULAR:  Irregular heart rhythm with congestive heart failure, questionable coronary artery disease.,RESPIRATORY:  Shortness of breath, questionable pneumonia.  No valley fever.,GASTROINTESTINAL:  No nausea, no vomiting, hematemesis or melena.,UROLOGICAL:  No frequency or urgency.,MUSCULOSKELETAL:  Arthritis, muscle weakness.,CNS:  No TIA.  No CVA.  No seizure disorder.,SKIN:  Nonsignificant.,PSYCHOLOGIC:  Anxiety and depression.,ALLERGIES:  Nonsignificant except as mentioned above for medications.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 122, blood pressure 148/78, afebrile, and respiratory rate 18 per minute.,HEENT AND NECK:  Neck is supple.  Atraumatic and normocephalic.  Neck veins are flat.  No thyromegaly.,LUNGS:  Air entry bilaterally fair.  Decreased breath sounds especially in the right basilar areas.  Few crackles.,HEART:  Normal S1 and S2, irregular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulse is palpable.  No clubbing or cyanosis.,CNS:  Grossly intact.,MUSCULOSKELETAL:  Arthritic changes.,PSYCHOLOGICAL:  None significant.,DIAGNOSTIC DATA: , EKG, atrial fibrillation with rapid ventricular response, and nonspecific ST-T changes.  INR of 4.5, H and H 10 and 30.  BUN and creatinine are within normal limits.  Chest x-ray confirmed right lower lobe patchy infiltrate, and trace of pneumonia.,IMPRESSION:,1.  The patient is an 86-year-old female who has questionable bypass surgery, questionable valve surgery with a rapid atrial heart rate, chronic atrial fibrillation with rapid ventricular response, exacerbated by most likely underlying pneumonia by chest x-ray findings.,2.  Symptoms as above.,RECOMMENDATIONS:,1.  We will start her on a low dose of beta-blocker for rate control and antibiotic for pneumonia.  Once, if she is stable, we will consider further cardiac workup.,2.  We will also obtain an echocardiogram to assess valves such as whether she had a prior valve surgery versus coronary artery bypass surgery.
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DESCRIPTION: Abnormal EKG and rapid heart rate.  The patient came to the emergency room.  Initially showed atrial fibrillation with rapid ventricular response.  It appears that the patient has chronic atrial fibrillation.  She denies any specific chest pain.  Her main complaint is shortness of breath and symptoms as above.

The provided medical case involves an 86-year-old female patient presenting with abnormal EKG, rapid heart rate, and chronic atrial fibrillation, which are significant cardiovascular concerns. Given her age and symptoms, including shortness of breath and possible pneumonia, the situation is potentially life-threatening if not managed correctly. Additionally, her unclear medication history and potential past surgeries add complexity to her treatment. These factors collectively make the clinical situation high-stakes due to the risks of complications from atrial fibrillation and possible pneumonia.


Medical Specialty: Surgery
Sample Name: Cardiac Catheterization - 1

INDICATIONS FOR PROCEDURE:, A 51-year-old, obese, white female with positive family history of coronary disease and history of chest radiation for Hodgkin disease 20 years ago with no other identifiable risk factors who presents with an acute myocardial infarction with elevated enzymes. The chest pain occurred early Tuesday morning. She was treated with Plavix, Lovenox, etc., and transferred for coronary angiography and possible PCI. The plan was discussed with the patient and all questions answered.,PROCEDURE NOTE:, Following sterile prep and drape, the right groin and instillation of 1% Xylocaine anesthesia, the right femoral artery was percutaneously entered with a single wall puncture. A 6-French sheath inserted. Selective left and right coronary injections performed using Judkins coronary catheters with a 6-French pigtail catheter used to obtain left ventricle pressures, and a left ventriculography. The left pullback pressure. The catheters withdrawn. Sheath injection. Hemostasis obtained with a 6-French Angio-Seal device. She tolerated the procedure well.,Left ventricular end-diastolic pressure equals 25 mmHg post A wave. No aortic valve or systolic gradient on pullback.,ANGIOGRAPHIC FINDINGS:,I. Left coronary artery: The left main coronary artery is,normal. The left anterior descending extends to the apex and has only minor luminal irregularities within the midportion of the vessel. Normal diagonal branches. Normal septal perforator branches. The left circumflex is a nondominant vessel with only minor irregularities with normal obtuse marginal branches.,II. Right coronary artery: The proximal right coronary artery has a focal calcification. There is minor plaque with luminal irregularity in the proximal and midportion of the vessel with no narrowing greater than 10 to 20% at most. The right coronary artery is a dominant system which gives off normal posterior,descending and posterior lateral branches. TIMI 3 flow is present.,III. Left ventriculogram: The left ventricle is slightly enlarged with normal contraction of the base, but, with wall motion abnormality involving the anteroapical and inferoapical left ventricle with hypokinesis within the apical portion. Ejection fraction estimated 40%, 1+ mitral regurgitation (echocardiogram ordered).,DISCUSSION:, Recent inferoapical mild myocardial infarction by left ventriculography and cardiac enzymes with elevated left ventricular end-diastolic pressure post A wave, but, only minor residual coronary artery plaque with calcification proximal right coronary artery.,PLAN:, Medical treatment is contemplated, including ACE inhibitor, a beta blocker, aspirin, Plavix, nitrates. An echocardiogram is ordered to exclude apical left ventricular thrombus and to further assess ejection fraction.
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DESCRIPTION: Cardiac Catheterization - An obese female with a family history of coronary disease and history of chest radiation for Hodgkin disease, presents with an acute myocardial infarction with elevated enzymes.

surgery, cardiac catheterization, hodgkin disease, beta blocker, coronary angiography, coronary artery, coronary disease, elevated enzymes, inferoapical, myocardial infarction, ventriculogram, ventriculography, acute myocardial infarction, proximal right coronary, diastolic pressure, ejection fraction, coronary, echocardiogram, cardiac, catheterization, myocardial, enzymes, infarction, artery

The situation involves a 51-year-old patient undergoing cardiac catheterization following an acute myocardial infarction, which is a serious medical condition. The procedure and the patient's health history, including past chest radiation and obesity, increase the risk factors for complications during or after the procedure. The stakes are high due to the possibility of life-threatening complications or poor outcomes without proper intervention and treatment.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Consultation - 2

CHIEF REASON FOR CONSULTATION:,  Evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.,HISTORY OF PRESENT ILLNESS:,  This 72-year-old female had a spell of palpitations that lasted for about five to ten minutes.  During this time, patient felt extremely short of breath and dizzy.  Palpitations lasted for about five to ten minutes without any recurrence.  Patient also gives history of having tightness in the chest after she walks briskly up to a block.  Chest tightness starts in the retrosternal area with radiation across the chest.  Chest tightness does not radiate to the root of the neck or to the shoulder, lasts anywhere from five to ten minutes, and is relieved with rest.  Patient gives history of having hypertension for the last two months.  Patient denies having diabetes mellitus, history suggestive of previous myocardial infarction, or cerebrovascular accident.,MEDICATIONS: , ,1.  Astelin nasal spray.,2.  Evista 60 mg daily.,3.  Lopressor 25 mg daily.,4.  Patient was given a sample of Diovan 80 mg daily for the control of hypertension from my office.,PAST HISTORY:,  The patient underwent right foot surgery and C-section.,FAMILY HISTORY:,  The patient is married, has six children who are doing fine.  Father died of a stroke many years ago.  Mother had arthritis.,SOCIAL HISTORY:, The patient does not smoke or take any drinks.  ,ALLERGIES:,  THE PATIENT IS NOT ALLERGIC TO ANY MEDICATIONS.,REVIEW OF SYSTEMS:,  Otherwise negative.  ,PHYSICAL EXAMINATION: , ,GENERAL:  Well-built, well-nourished white female in no acute distress. ,VITAL SIGNS:  Blood pressure is 160/80.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Patient weighs 133 pounds, height 64 inches.  BMI is 22.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good.,NECK:  Supple.  No cervical lymphadenopathy. Carotid upstroke is good. No bruit heard over the carotid or subclavian arteries.  Trachea in midline. Thyroid not enlarged.  JVP flat at 45°.,CHEST:  Chest is symmetrical on both sides, moves well with respirations.  Vesicular breath sounds heard over the lung fields.  No wheezing, crepitation, or pleural friction rub heard.  ,CARDIOVASCULAR SYSTEM:  PMI felt in fifth left intercostal space within midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.  There is no diastolic murmur or gallop heard.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or ascites.  No bruit heard over the aorta or renal vessels.,EXTREMITIES:  No pedal edema.  Femoral arterial pulsations are 3+, popliteal 2+.  Dorsalis pedis and posterior tibialis are 1+ on both sides.,NEURO:  Normal.,EKG from Dr. Xyz's office shows normal sinus rhythm, ST and T wave changes.  Lipid profile, random blood sugar, BUN, creatinine, CBC, and LFTs are normal.,IMPRESSION:,
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DESCRIPTION: To evaluate exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG.

The consultation is needed to evaluate a combination of potentially serious cardiovascular symptoms: exercise-induced chest pain, palpitations, dizzy spells, shortness of breath, and abnormal EKG findings. These symptoms, particularly in a 72-year-old patient with a history of hypertension, may indicate significant cardiovascular issues such as angina or coronary artery disease. The presence of a systolic murmur and the family history of stroke further raise concerns. The stakes are high as these symptoms and findings could indicate a risk of major cardiac events if not promptly investigated and managed.


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

GENERAL:  Negative for any nausea, vomiting, fevers, chills, or weight loss.,NEUROLOGIC:  Negative for any blurry vision, blind spots, double vision, facial asymmetry, dysphagia, dysarthria, hemiparesis, hemisensory deficits, vertigo, ataxia.,HEENT:  Negative for any head trauma, neck trauma, neck stiffness, photophobia, phonophobia, sinusitis, rhinitis.,CARDIAC:  Negative for any chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema.,PULMONARY:  Negative for any shortness of breath, wheezing, COPD, or TB exposure.,GASTROINTESTINAL:  Negative for any abdominal pain, nausea, vomiting, bright red blood per rectum, melena.,GENITOURINARY:  Negative for any dysuria, hematuria, incontinence.,INTEGUMENTARY:  Negative for any rashes, cuts, insect bites.,RHEUMATOLOGIC:  Negative for any joint pains, photosensitive rashes, history of vasculitis or kidney problems.,HEMATOLOGIC:  Negative for any abnormal bruising, frequent infections or bleeding.
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DESCRIPTION: Negative for any nausea, vomiting, fevers, chills, or weight loss.

consult - history and phy., review of systems, trauma, neck, dyspnea, rashes, nausea, vomiting,

The scenario described is a review of systems template often used in medical consultations to ensure a comprehensive check for any symptoms patient might have. The ROS (Review of Systems) includes multiple medical aspects that are general negative indicators for common illnesses. Though it ensures thoroughness in assessment, reviewing the patient's medical symptoms in a template format typically does not involve high-stakes decision-making because it is part of a routine evaluation process, and no urgent or life-threatening issues are identified by the negative statements listed.