Medical Specialty: Neurology
Sample Name: MCA Aneurysm

HX: ,This 46y/o RHM with HTN was well until 2 weeks prior to exam when he experienced sudden onset dizziness and RUE clumsiness. The symptoms resolved within 10 min. He did well until the afternoon of admission when while moving the lawn he experienced lightheadedness, RUE dysfunction and expressive aphasia (could not get the words out). His wife took him to his local MD, and on the way there his symptoms resolved. His aphasia recurred at his physician's office and a CT scan of the brain revealed a left temporal mass. He was transferred to UIHC.,PMH:, HTN for many years,MEDS:, Vasotec and Dyazide,SHX/FHX:, ETOH abuse (quit '92), 30pk-yr Cigarettes (quit '92),EXAM:, BP158/92, HR91, RR16,MS: Speech fluent without dysarthria,CN: no deficits noted,Motor: no weakness or abnormal tone noted,Sensory: no deficits noted,Coord: normal,Station: no drift,Gait ND,Reflexes: 3+ throughout. Plantars down-going bilaterally.,Gen exam: unremarkable,STUDIES:, WBC14.3K, Na 132, Cl 94, CO2 22, Glucose 129.,CT Brain without contrast: Calcified 2.5 x 2.5cm mass arising from left sylvian fissure/temporal lobe.,MRI Brain, 8/31/92: right temporo-parietal mass with mixed signal on T1 and T2 images. It has a peripheral dark rim on T1 and T2 with surrounding edema. This suggests a component of methemoglobin and hemosiderin within it. Slight peripheral enhancement was identified. There are two smaller foci of enhancement in the posterior parietal lobe on the right. There is nonspecific white matter foci within the pons and right thalamus. Impression: right temporoparietal hemorrhage, suggesting aneurysm or mass. The two smaller foci may suggest metastasis. The white matter changes probably reflect microvascular disease.,3 Vessel cerebroangiogram, 8/31/92: Lobulated fusiform aneurysm off a peripheral branch of the left middle cerebral artery with slow flow into the vessel distal to the aneurysm.,COURSE:, The aneurysm was felt to be inoperable and he was discharged home on Dilantin, ASA, and Diltiazem.
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DESCRIPTION: Patient with sudden onset dizziness and RUE clumsiness.  Giant Left MCA Aneurysm.

neurology, mca aneurysm, rue clumsiness, white matter, aneurysm, mca, dizziness, aphasia, matter, clumsiness, brain, peripheral,

The situation involves a 46-year-old male patient with a giant left MCA (Middle Cerebral Artery) aneurysm, indicated by neurological symptoms such as sudden dizziness, right upper extremity clumsiness, and expressive aphasia. This condition is high-stakes because an MCA aneurysm poses a significant risk for subarachnoid hemorrhage or stroke, which can lead to severe neurological damage or death. Despite being inoperable, the aneurysm presents a substantial ongoing risk that must be managed carefully with medication and monitoring, highlighting the critical nature of this medical scenario.


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

Medical Specialty: Neurosurgery
Sample Name: Craniotomy - Biparietal

PREOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,POSTOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,TITLE OF THE OPERATION:,1.  Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.,2.  Insertion of left lateral ventriculostomy under Stealth stereotactic guidance.,3.  Right suboccipital craniectomy and excision of tumor.,4.  Microtechniques for all the above.,5.  Stealth stereotactic guidance for all of the above and intraoperative ultrasound.,INDICATIONS: , The patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago.  A year ago, she was diagnosed with cranial metastases and underwent whole brain radiation.  She recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair.  Metastatic workup does reveal multiple bone metastases, but no spinal cord compression.  She had a consult with Radiation-Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed.  Consequently, this operation is performed.,PROCEDURE IN DETAIL: , The patient underwent a planning MRI scan with Stealth protocol.  She was brought to the operating room with fiducial still on her scalp.  General endotracheal anesthesia was obtained.  She was placed on the Mayfield head holder and rolled into the prone position.  She was well padded, secured, and so forth.  The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions.  The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint.  This was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system.  Sterile drapes were applied and the accuracy of the system was confirmed.  A biparietal incision was performed.  A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation.  A biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system.  The dura was opened and reflected back to the midline.  An inner hemispheric approach was used to reach the very large metastatic tumor.  This was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor.  The tumor was wrapped around and included the choroidal vessels.  At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region.  Bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled.  Complete removal of the tumor was confirmed by intraoperative ultrasound.,Once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area.  A linear incision was made just lateral to the greater occipital nerve.  Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull.  A burr hole was placed down low using a craniotome.  A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter.  It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus.  Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum.  The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining CSF relieving pressure in the posterior fossa.  Upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy.,At the posterior fossa, a corticectomy was accomplished and the tumor was countered directly.  The tumor, as the one above, was removed, both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator.  A gross total excision of this tumor was obtained as well.,I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter.,Meticulous hemostasis was obtained for this wound as well.,The posterior fossa wound was then closed in layers.  The dura was closed with interrupted and running mattress of 4-0 Nurolon.  The dura was watertight, and it was covered with blue glue.  Gelfoam was placed over the dural closure.  Then, the muscle and fascia were closed in individual layers using #0 Ethibond.  Subcutaneous was closed with interrupted inverted 2-0 and 0 Vicryl, and the skin was closed with running locking 3-0 Nylon.,For the cranial incision, the ventriculostomy was brought out through a separate stab wound.  The bone flap was brought on to the field.  The dura was closed with running and interrupted 4-0 Nurolon.  At the beginning of the case, dural tack-ups had been made and these were still in place.  The sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked Gelfoam to take care of any small bleeding areas in the sinuses.,Once the dura was closed, the bone flap was returned to the wound and held in place with the Lorenz microplates.  The wound was then closed in layers.  The galea was closed with multiple sutures of interrupted 2-0 Vicryl.  The skin was closed with a running locking 3-0 Nylon.,Estimated blood loss for the case was more than 1 L.  The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid.,Nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady.
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DESCRIPTION: Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.

neurosurgery, metastatic lesion, biparietal, mayfield head holder, microtechniques, stealth, craniotomy, excision, fiducial, infratentorial, parietooccipital, stereotactic, suboccipital, subtentorial, ventriculostomy, lesions to the brain, removal of the tumor, parietal occipital region, running locking nylon, biparietal craniotomy, posterior fossa, tumor, brain, dura, lesions,

This situation involves a complex neurosurgical operation to manage brain metastases from breast cancer. The patient has deteriorated significantly and the surgery aims to improve survival and neurological function. The stakes are high due to the complex nature of the surgery, significant blood loss, involvement of critical brain areas, and the patient's critical condition. Such situations are inherently high-stakes due to the potential for serious complications or impacts on quality of life.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: OssaTron Extracorporeal Shockwave Therapy

PREOPERATIVE DIAGNOSIS:,  Right lateral epicondylitis.,POSTOPERATIVE DIAGNOSIS:,  Right lateral epicondylitis.,OPERATION PERFORMED:,  OssaTron extracorporeal shockwave therapy to right lateral epicondyle.,ANESTHESIA:,  Bier block.,DESCRIPTION OF PROCEDURE: , With the patient under adequate Bier block anesthesia, the patient was positioned for extracorporeal shockwave therapy.  The OssaTron equipment was brought into the field and the nose piece for treatment was placed against the lateral epicondyle targeting the area previously determined with the patient's input of maximum pain.  Then using standard extracorporeal shockwave protocol, the OssaTron treatment was applied to the lateral epicondyle of the elbow.  After completion of the treatment, the tourniquet was deflated, and the patient was returned to the holding area in satisfactory condition having tolerated the procedure well.
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DESCRIPTION: OssaTron extracorporeal shockwave therapy to right lateral epicondyle.  Right lateral epicondylitis.

surgery, epicondylitis, ossatron extracorporeal shockwave therapy, bier block, epicondyle, ossatron, extracorporeal, shockwave,

The procedure described is a non-invasive treatment for right lateral epicondylitis, commonly known as tennis elbow. It involves the use of extracorporeal shockwave therapy, which is generally considered a low-risk procedure. The use of Bier block anesthesia adds some complexity but is typically well-managed in a surgical setting. The post-procedure note indicates the patient tolerated the procedure well, with no complications reported. While all medical procedures carry some level of risk, this particular procedure does not involve life-threatening risks or high-level surgical interventions. Therefore, the situation is not high-stakes in nature.


Medical Specialty: Consult - History and Phy.
Sample Name: Syncope - ER Visit

REASON FOR CONSULTATION:,  Syncope.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old lady followed by Dr. X in our practice with history of coronary artery disease, status post coronary artery bypass grafting in 2005 presented to the emergency room following a syncopal episode.  According to the patient and the daughter who was with her, she was shopping when she felt abdominal discomfort with nausea, profuse sweating, and passed out.  As soon as she was laid on the floor and her leg raised up, she woke up with no post-event confusion.  According to the daughter, she has had episodes of weakness, but no syncope.  She has blood pressure medications and has had some postural hypotensions, which has been managed by Dr. X. She also states there was a history of pulmonary embolism and the presentation at that time was very similar when she had a syncopal episode.  At that time, she was admitted at Hospital, had a V/Q scan, which was positive for PE.  Initial V/Q scan done at Hospital was negative.  She was anticoagulated with Coumadin resulting in severe GI bleed.  Anticoagulation was stopped and an IVC filter was placed at that time.  She has a history of malignant hypertension and has had a renal stent placed in February 2007.  She also has peripheral vascular disease with stent placements.  There is a history of spinal canal stenosis and iron deficiency anemia, currently on Procrit injections every two weeks done by Dr. Y. The patient denies any chest pain or any worsening of any shortness of breath.  There are no acute EKG changes or cardiac enzyme elevations.  She has had no stress test done following a bypass surgery.,PAST MEDICAL HISTORY,1.  Coronary artery disease, status post coronary artery bypass grafting.,2.  History of mitral regurgitation, unable to repair the valve.,3.  History of paroxysmal atrial fibrillation, on amiodarone.,4.  Gastroesophageal reflux disease.,5.  Hypertension.,6.  Hyperlipidemia.,7.  History of abdominal aortic aneurysm.,8.  Carotid artery disease, mild-to-moderate on recent carotid ultrasound.,9.  Peripheral vascular disease.,10.  Hypothyroidism.,11.  Pulmonary embolism.,PAST SURGICAL HISTORY,1.  Coronary artery bypass grafting.,2.  Hysterectomy.,3.  IVC filter.,4.  Tonsillectomy and adenoidectomy.,5.  Cosmetic surgery to breast and abdomen.,HOME MEDICATIONS,1.  Aspirin 81 mg once a day.,2.  Klor-Con 10 mEq once a day.,3.  Lasix 40 mg once a day.,4.  Levothyroxine 125 mcg once a day.,5.  Lisinopril 20 mg once a day.,6.  Pacerone 200 mg once a day.,7.  Protonix 40 mg once a day.,8.  Toprol 50 mg once a day.,9.  Vitamin B once a day.,10.  Zetia 10 mg once a day.,11.  Zyrtec 10 mg once a day.,ALLERGIES:,  CODEINE, ERYTHROMYCIN, SULFA, VICODIN, AND ZOCOR.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  The patient denies any fevers, chills, recent weight gain or weight loss.  She has had abdominal symptoms with diarrhea.,EYES:  Decreased visual acuity.,ENT:  Sinus drainage.,CARDIOVASCULAR:  As described above.  Denies any chest pains.,RESPIRATORY:  He has chronic shortness of breath.  No cough or sputum production.,GI:  History of reflux symptoms.,GU:  No history of dysuria or hematuria.,ENDOCRINE:  No history of diabetes.,MUSCULOSKELETAL:  Denies arthritis, but has leg pain.,SKIN:  No history of rash.,PSYCHIATRIC:  No history of anxiety or depression.
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DESCRIPTION: Patient with a history of coronary artery disease, status post coronary artery bypass grafting presented to the emergency room following a syncopal episode.

The situation involves a 78-year-old patient with a complex medical history, experiencing a syncopal episode—possibly related to her significant cardiovascular issues. Given her age, history of coronary artery disease, previous bypass surgery, pulmonary embolism, and multiple other comorbidities, the situation could imply serious underlying conditions requiring immediate medical evaluation to prevent potential life-threatening complications. Hence, this scenario is high-stakes due to the potential risk of more severe medical events.


Medical Specialty: Dermatology
Sample Name: Mohs Micrographic Surgery - 2

PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:,  Basal Cell CA.,LOCATION:  ,Medial right inferior helix.,PREOP SIZE:,  1.4 x 1 cm,POSTOP SIZE: , 2.7 x 2 cm,INDICATION: , Poorly defined borders.,COMPLICATIONS: , None.,HEMOSTASIS: , Electrodessication.,PLANNED RECONSTRUCTION: , Wedge resection advancement flap.,DESCRIPTION OF PROCEDURE: , Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision.  With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique.  A map was prepared to correspond to the area of skin from which it was excised.  The tissue was prepared for the cryostat and sectioned.  Each section was coded, cut and stained for microscopic examination.  The entire base and margins of the excised piece of tissue were examined by the surgeon.  Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery.  The patient tolerated the procedure well without any complication.  After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.
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DESCRIPTION: Mohs Micrographic Surgery for basal cell CA at medial right inferior helix.

dermatology, medial right inferior helix, wedge resection advancement flap, tumor-laden tissue, mohs fresh tissue technique, mohs technique, mohs micrographic surgery, basal cell ca, micrographic surgery, basal cell, micrographic, helix, basal, cell, ca, mohs, tissue, stage,

This situation involves a routine dermatological procedure. Mohs micrographic surgery is a common and established technique for excising certain types of skin cancer like basal cell carcinoma. While it is a surgical procedure, it is typically performed on an outpatient basis with local anesthesia and has a high success rate with minimal complications. The details provided indicate that the procedure was completed successfully, and there were no complications. Therefore, given it's a controlled medical environment with a well-documented procedure, it represents a relatively low-stakes situation compared to more critical medical interventions.


Medical Specialty: Podiatry
Sample Name: MRI Foot - 2

EXAM:,MRI RIGHT FOOT,CLINICAL:,Pain and swelling in the right foot.,FINDINGS: ,Obtained for second opinion interpretation is an MRI examination performed on 11-04-05.,There is a transverse fracture of the anterior superior calcaneal process of the calcaneus. The fracture is corticated however and there is an active marrow stress phenomenon. There is a small ganglion measuring approximately 8 x 5 x 5mm in size extending along the bifurcate ligament.,There is no substantial joint effusion of the calcaneocuboid articulation. There is minimal interstitial edema involving the short plantar calcaneal cuboid ligament.,Normal plantar calcaneonavicular spring ligament.,Normal talonavicular articulation.,There is minimal synovial fluid within the peroneal tendon sheaths.,Axial imaging of the ankle has not been performed orthogonal to the peroneal tendon distal to the retromalleolar groove. The peroneus brevis tendon remains intact extending to the base of the fifth metatarsus. The peroneus longus tendon can be identified in its short axis extending to its distal plantar insertion upon the base of the first metatarsus with minimal synovitis.,There is minimal synovial fluid within the flexor digitorum longus and flexor hallucis longus tendon sheath with pooling of the fluid in the region of the knot of Henry.,There is edema extending along the deep surface of the extensor digitorum brevis muscle.,Normal anterior, subtalar and deltoid ligamentous complex.,Normal naviculocuneiform, intercuneiform and tarsometatarsal articulations.,The Lisfranc’s ligament is intact.,The Achilles tendon insertion has been excluded from the field-of-view.,Normal plantar fascia and intrinsic plantar muscles of the foot.,There is mild venous distention of the veins of the foot within the tarsal tunnel.,There is minimal edema of the sinus tarsus. The lateral talocalcaneal and interosseous talocalcaneal ligaments are normal.,Normal deltoid ligamentous complex.,Normal talar dome and no occult osteochondral talar dome defect.,IMPRESSION:,Transverse fracture of the anterior calcaneocuboid articulation with cortication and cancellous marrow edema.,Small ganglion intwined within the bifurcate ligament.,Interstitial edema of the short plantar calcaneocuboid ligament.,Minimal synovitis of the peroneal tendon sheaths but no demonstrated peroneal tendon tear.,Minimal synovitis of the flexor tendon sheaths with pooling of fluid within the knot of Henry.,Minimal interstitial edema extending along the deep surface of the extensor digitorum brevis muscle.
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DESCRIPTION: Pain and swelling in the right foot.

Pain and swelling in the right foot.

The MRI report indicates a fracture and some soft tissue changes, such as edema and a ganglion. While these findings can cause pain and may need treatment, they are not life-threatening or exceptionally urgent in the context of medical situations that could occur. The management of these findings typically involves conservative treatment and possibly surgical intervention, but it does not represent a critical or life-or-death scenario. Thus, the situation does not appear to be high-stakes compared to other medical emergencies.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Hysterectomy - Discharge Summary - 2

ADMISSION DIAGNOSIS: , Microinvasive carcinoma of the cervix.,DISCHARGE DIAGNOSIS: , Microinvasive carcinoma of the cervix.,PROCEDURE PERFORMED: , Total vaginal hysterectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation.  She had an abnormal Pap smear in the 80s, which she failed to followup on until this year.  Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02/12/2007 also showing microinvasive carcinoma with a 1 mm invasion.  She has elected definitive therapy with a total vaginal hysterectomy.  She is aware of the future need of Pap smears.,PAST MEDICAL HISTORY: , Past history is significant for seven pregnancies, five term deliveries, and significant past history of tobacco use.,PHYSICAL EXAMINATION: , Physical exam is within normal limits with a taut normal size uterus and a small cervix, status post cone biopsy.,LABORATORY DATA AND DIAGNOSTIC STUDIES: , Chest x-ray was clear.  Discharge hemoglobin 10.8.,HOSPITAL COURSE: , She was taken to the operating room on 04/02/2007 where a total vaginal hysterectomy was performed under general anesthesia.  There was an incidental cystotomy at the time of the creation of the bladder flap.  This was repaired intraoperatively without difficulty.  Postoperative, she did very well.  Bowel and bladder function returned quickly.  She is ambulating well and tolerating a regular diet.,Routine postoperative instructions given and understood.  Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time. ,DISCHARGE MEDICATIONS:,  Vicodin, Motrin, and Macrodantin at bedtime for urinary tract infection suppression.  ,DISCHARGE CONDITION: , Good.,Final pathology report was free of residual disease.
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DESCRIPTION: Total vaginal hysterectomy.  Microinvasive carcinoma of the cervix.

obstetrics / gynecology, pap smear, total vaginal hysterectomy, hysterectomy, microinvasive, carcinoma, cervix,

The situation involves a medical discharge summary of a patient who underwent a total vaginal hysterectomy due to microinvasive carcinoma of the cervix. The diagnosis and surgical procedure indicate a significant health concern, as it relates to cancer treatment. While the procedure was successful and the patient's discharge condition is good, the situation retains elements of high-stakes because it pertains to a serious medical condition (cancer) and the surgical intervention required to address it. However, given the successful treatment and discharge, the immediacy of the high-stakes nature is somewhat mitigated.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Central Line Placement

PREOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,POSTOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,OPERATION:,  Right subclavian triple lumen central line placement.,ANESTHESIA: , Local Xylocaine.,INDICATIONS FOR OPERATION:  ,This 50-year-old gentleman with severe respiratory failure is mechanically ventilated. He is currently requiring multiple intravenous drips, and Dr. X has kindly requested central line placement.,INFORMED CONSENT:  ,The patient was unable to provide his own consent, secondary to mechanical ventilation and sedation. No available family to provide conservator ship was located either.,PROCEDURE:  ,With the patient in his Intensive Care Unit bed, mechanically ventilated in the Trendelenburg position. The right neck was prepped and draped with Betadine in a sterile fashion. Single needle stick aspiration of the right subclavian vein was accomplished without difficulty, and the guide wire was advanced. The dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire, and the wire then removed. No PVCs were encountered during the procedure. All three ports to the catheter aspirated and flushed blood easily, and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly phalange using 3-0 silk suture. Betadine ointment and a sterile Op-Site dressing were applied. Stat upright chest x-ray was obtained at the completion of the procedure, and final results are pending.,FINDINGS/SPECIMENS REMOVED:, None,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Nil.
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DESCRIPTION: Right subclavian triple lumen central line placement

cardiovascular / pulmonary, respiratory failure, central line placement, chronic obstructive coronary disease, normal saline, subclavian, subclavian triple lumen central line placement, subclavian vein, triple lumen, triple lumen central line, lumen central line placement, central line, line placement, respiratory, xylocaine,

This procedure is being performed on a patient with severe respiratory failure who is mechanically ventilated and requires multiple intravenous drips. The context indicates critical care due to the nature of the patient's conditions (severe COPD and respiratory failure) and the hospital setting (ICU). The lack of available consent due to sedation and mechanical ventilation, alongside the context of urgent medical intervention, further elevates the stakes. The procedure itself, while routine for critical care, is high stakes given the patient's fragile condition.


Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consult - 3

SUBJECTIVE:,  The patient is brought in by an assistant with some of his food diary sheets.  They wonder if the patient needs to lose anymore weight.,OBJECTIVE:,  The patient's weight today is 186-1/2 pounds, which is down 1-1/2 pounds in the past month.  He has lost a total of 34-1/2 pounds.  I praised this.  I went over his food diary and praised all of his positive food choices reported, especially his use of sugar-free Kool-Aid, sugar-free pudding, and diet pop.  I encouraged him to continue all of that, as well as his regular physical activity.,ASSESSMENT:,  The patient is losing weight at an acceptable rate.  He needs to continue keeping a food diary and his regular physical activity.,PLAN:,  The patient plans to see Dr. XYZ at the end of May 2005.  I recommended that they ask Dr. XYZ what weight he would like for the patient to be at.  Follow up will be with me June 13, 2005.
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DESCRIPTION: The patient is brought in by an assistant with some of his food diary sheets.

consult - history and phy., weight, kool-aid, food diary sheets, diary sheets, physical activity, food diary, dietary, sheets, diary, food

The situation involves a routine dietary consultation with a focus on weight management. The patient is showing progress in weight loss, has good dietary habits, and is physically active. Additionally, there are planned follow-ups with healthcare providers. The stakes are low as there are no immediate health threats or significant health decisions being made at this moment.


Medical Specialty: Podiatry
Sample Name: Ankle pain

CHIEF COMPLAINT:,  Ankle pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 17-year-old gentleman who was playing basketball today in gym.  Two hours prior to presentation, he started to fall and someone stepped on his ankle and kind of twisted his right ankle and he cannot bear weight on it now.  It hurts to move or bear weight.  No other injuries noted.  He does not think he has had injuries to his ankle in the past.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , None.,SOCIAL HISTORY: , He does not drink or smoke.,ALLERGIES: , Unknown.,MEDICATIONS: , Adderall and Accutane.,REVIEW OF SYSTEMS: , As above.  Ten systems reviewed and are negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.6, pulse 70, respirations 16, blood pressure 120/63, and pulse oximetry 100% on room air.,GENERAL:
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DESCRIPTION: Acute foot or ankle sprain, possible small fracture.

podiatry, accutane, foot or ankle sprain, ankle sprain, ankle, sprain, splint, fracture,

The situation involves a 17-year-old patient with an acute ankle injury from playing basketball. While the injury causes significant discomfort and the inability to bear weight, it is unlikely to be life-threatening. The potential diagnoses include an ankle sprain or a minor fracture, both of which are generally manageable with standard treatment protocols. Despite this, the impact on daily activities and the need for proper diagnosis could warrant timely medical attention to avoid complications. However, overall, this does not constitute a high-stakes medical emergency.


Medical Specialty: Urology
Sample Name: Hematuria - Consult

HISTORY OF PRESENT ILLNESS:,  This is a 77-year-old male, who presents with gross hematuria that started this morning.  The patient is a difficult historian, does have a speech impediment, slow to answer questions, but daughter was able to answer lot of questions too.  He is complaining of no other pain.  He denies any abdominal pain.  Denies any bleeding anywhere else.  Denies any bruising.  He had an episode similar to this a year ago where it began the same with hematuria.  He was discharged after a workup in the hospital, in the emergency room, with Levaquin.  Three days later, he returned with a very large hematoma to his left neck and a coagulopathy with significant bleeding.  His H and H was down in the 6 level.  He received blood transfusions.  He was diagnosed with a malignancy, coagulopathy, and sounds like was in critical condition.  Family actually states that they were told that he was unlikely to live through that event, but he did.  Since then, he has had no bleeding.  The patient has had no fever.  No cough.  No chest pain or shortness of breath.  No bleeding gums.  No blurred vision.  No headache.  No recent falls or trauma.  He has had no nausea or vomiting.  No diarrhea.  No blood in the stool or melena.  No leg or calf pain.  No joint pain.  No rashes.  No swollen glands.  He has no numbness, weakness or tingling to his extremities.  No acute anxiety or depression.,PAST MEDICAL HISTORY: , Has prostate cancer.,MEDICATION: , He is receiving Lupron injection by Dr. Y. The only other medication that he takes is Tramadol.,SOCIAL HISTORY: , He does not smoke or drink.,PHYSICAL EXAMINATION:,Vital Signs:  Are all reviewed on triage.,General:  He is alert.  Answers slowly with a speech impediment, but answers appropriately.,HEENT:  Pupils equal, round, and reactive to light.  Normal extraocular muscles.  Nonicteric sclerae.  Conjunctivae are not pale.  His oropharynx is clear.  His mucous membranes are moist.,Heart:  Regular rate and rhythm, with no murmurs.,Lungs:  Clear.,Abdomen:  Soft, nontender, nondistended.  Normal bowel sounds.  No organomegaly or mass.,Extremities:  No calf tenderness, erythema or warmth.  He has no bruises noted.,Neurological:  Cranial nerves II through XII are intact.  He has 5/5 strength throughout.  ,GU:  Normal.,LABORATORY DATA:  ,The patient did on urinalysis have few red blood cells.  His urine was also grossly red, although no blood clots or gross blood was noted.  It was more of a red fluid.  He had a mild decrease in H and H at 12.1 and 34.6.  His white count was normal at 7.2.  His PT was elevated at 15.9.  PTT elevated at 36.4.  INR is 1.4.  His comprehensive metabolic profile is normal except for BUN of 19.,CONDITION: , The patient is stable at this time, although because of the history of the same happening and the patient beginning in the same fashion his history of coagulopathy, the patient is discussed with Dr. X and he is admitted for orders.  Also we will consult Dr. Y, see orders for further.
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DESCRIPTION: Patient presents with gross hematuria that started this morning.

urology, prostate cancer, bleeding, gross hematuria, speech impediment, hematuria, coagulopathy, blood,

This patient has a history of serious medical issues including prostate cancer and a previous episode of life-threatening coagulopathy. The present condition of gross hematuria, combined with the patient's history, particularly the significant bleeding and coagulopathy from the previous episode, makes this a potentially serious situation. Even though the patient is stable now, the potential for rapid deterioration and the history of a similar life-threatening event increases the stakes. Immediate medical evaluation and management are necessary to prevent another critical event.


Medical Specialty: Consult - History and Phy.
Sample Name: Sports Physical - 1

HISTORY: , This child is seen for a sports physical.,NUTRITIONAL HISTORY:,  She takes meats, vegetables, and fruits.  Eats well.  Has may be 1 to 2 cups a day of milk.  Her calcium intake could be better.  She does not drink that much pop but she likes koolaid.  Her stools are normal.  Brushes her teeth.  Sees a dentist.,DEVELOPMENTAL HISTORY: , She did well in school last year.  Hearing and vision, no problems.  She wears corrective lenses.  She will be in 8th grade and involved in volleyball, basketball, and she will be moving to Texas.  She did go to Burton this last year.  She also plays clarinet, and will be involved also in cheerleading.  She likes to swim in the summer time.  Her menarche was January 2004.  It occurs every 7 weeks.  No particular problems at this time.,OTHER ACTIVITIES:  ,TV time about 2 to 3 hours a day.  She does not use drugs, alcohol, or smoke, and denies sexual activity.,MEDICATIONS:,  Advair 250/50 b.i.d., Flonase b.i.d., Allegra q.d.  120 mg, Xopenex and albuterol p.r.n.,ALLERGIES:,  No known drug allergies.,OBJECTIVE:,Vital Signs:  Blood pressure:  98/60.  Temperature:  96.6 tympanic.  Weight:  107 pounds, which places her at approximately the 60th percentile for weight and the height is about 80th percentile at 64-1/2 inches.  Her body mass index is 18.1, which is 40th percentile.  Pulse:  68.,HEENT:  Normocephalic.  Fundi benign.  Pupils are equal and reactive to light and accommodation.  Conjunctivae were non-injected.  Her pupils were equal, and reactive to light and accommodation.  No strabismus.  She wears glasses.  Her vision was 20/20 in both eyes.  TMs are bilaterally clear.  Nonerythematous.  Hearing in the ears, she was able to pass 40 decibel to 30 decibel.  With the right ear, she has some problems, but the left ear she passed.  Throat was clear.  Nonerythematous.  Good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Respiratory:  Clear.  No wheezes and no crackles.  No tachypnea and no retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.  No hepatosplenomegaly.,GU:  Normal female genitalia.  Tanner stage III in breast and pubic hair development and she was given a breast exam.  Negative for any masses.,Skin:  Without rash.,Extremities:  Deep tendon reflexes 2+/4+ bilaterally and equal.,Neurological:  Romberg negative.,Back:  No scoliosis.,She had good circumduction at the shoulder joints and duck walk is normal.,ASSESSMENT:,  Sports physical with normal growth and development.,PLAN:,  If problems continue, she will need to have her hearing rechecked.  Hopefully in the school, there will be a screening mat.  She received her first hepatitis A vaccine and she needs to have a booster in 6 to 12 months.  We reviewed her immunizations for tetanus and her last acellular DPT was 11/25/1996.  When she goes to Texas, Mom has an appointment already to see an allergist but she needs to find a primary care physician and we will ask for record release.  We talked about her menarche.  Recommended the exam of the breast regularly.  Talked about other anticipatory guidance including sunscreen, use of seat belts, and drugs, alcohol, and smoking, and sexual activity and avoidance at her age and to continue on her present medications.  She also has had problems with her ankles in the past.  She had no limitation here, but we gave her some ankle strengthening exercise handouts while she was in the office.
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DESCRIPTION: Sports physical with normal growth and development.

The situation described is a routine sports physical examination for a child with no significant health issues identified during the visit. The main action is the provision of anticipatory guidance and ensuring the child's vaccinations are up to date. There's a recommendation for potential follow-up on hearing concerns, but it is not urgent. The stakes are low as it is a typical evaluation with no immediate health threats identified.


Medical Specialty: Neurosurgery
Sample Name: Laminotomy, Facetectomy & Foraminotomy

PREOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,POSTOPERATIVE DIAGNOSES: , Right lumbosacral radiculopathy secondary to lumbar spondylolysis.,OPERATION PERFORMED:,1.  Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.,2.  Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.,3.  Right L4-S1 posterolateral fusion with local bone graft.,4.  Left L4 through S1 segmental pedicle screw instrumentation.,5.  Preparation harvesting of local bone graft.,ANESTHESIA: , General endotracheal.,PREPARATION:,  Povidone-iodine.,INDICATION: , This is a gentleman with right-sided lumbosacral radiculopathy, MRI disclosed and lateral recess stenosis at the L4-5, L5-S1 foraminal narrowing in L4 and L5 roots.  The patient was felt to be a candidate for decompression stabilization pulling distraction between the screws to relieve radicular pain.  The patient understood major risks and complications such as death and paralysis seemingly rare, main concern is a 10 to 15% of failure rate to respond to surgery for which further surgery may or may not be indicated, small risk of wound infection, spinal fluid leak.  The patient is understanding and agreed to proceed and signed the consent.,PROCEDURE: , The patient was brought to the operating room, peripheral venous lines were placed.  General anesthesia was induced.  The patient was intubated.  Foley catheter was in place.  The patient laid prone onto the OSI table using 6-post, pressure points were carefully padded; the back was shaved, sterilely prepped and draped.  A previous incision was infiltrated with local and incised with a scalpel.  The posterior spine on the right side was exposed in routine fashion along with transverse processes in L4-L5 in the sacral ala.  Laminotomies were then performed at L4-L5 and L5-S1 in a similar fashion using Midas Rex drill with AM8 bit, inferior portion of lamina below and superior portion of lamina above, and the medial facet was drilled down to the thin shelf of bone.  The thin shelf of bone along the ligamentum flavum moved in a piecemeal fashion with 2 and 3 mm Kerrison, bone was harvested throughout to be used for bone grafting.  The L5 and S1 roots were completely unroofed in the lateral recess working lateral to the markedly hypertrophied facet joints.  Transpedicular approaches were carried out for both L4 and L5 roots working lateral to medial and medial to lateral with foraminotomies, L4-L5 roots were extensively decompressed.  Pars interarticularis were maintained.  Using angled 2-mm Kerrisons hypertrophied ligamentum flavum, the superior facet of S1 and L5 was resected increasing the dimensions for the foramen passed lateral to medial and medial to lateral without further compromise.  Pedicle screws were placed L4-L5 and S1 on the right side.  Initial hole began with Midas Rex drill, deepened with a gear shift and with 4.5 mm tap, palpating with pedicle probe.  It showed no penetration outside the pedicle vertebral body.  At L4-L5 5.5 x 45 mm screws were placed and at S1 5.5 x 40 mm screw was placed.  Good bone purchase was obtained.  Gelfoam was placed over the roots laterally, corticated transverse processes lateral facet joints were prepared, small infuse sponge was placed posterolaterally on the right side, then the local bone graft from L4 to S1.  Traction was applied between the L4-L5, L5-S1 screws locking notes were tightened out, heads were rotated fractured off about 2-3 mm traction were applied at each side, further opening the foramen for the exiting roots.  Prior to placement of BMP, the wound was irrigated with antibiotic irrigation.  Medium Hemovac drain was placed in the depth of wound, brought out through a separate stab incision.  Deep fascia was closed with #1 Vicryl, subcutaneous fascia with #1 Vicryl, and subcuticular with 2-0 Vicryl.  Skin was stapled.  The drain was sutured in place with 2-0 Vicryl and connected to closed drain system.  The patient was laid supine on the bed, extubated, and taken to recovery room in satisfactory condition.  The patient tolerated the procedure well without apparent complication.  Final sponge and needle counts are correct.  Estimated blood loss 600 mL.,The patient received 200 mL of cell saver blood back.
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DESCRIPTION: Right L4 and L5 transpedicular decompression of distal right L4 and L5 nerve roots.  Right L4-L5 and right L5-S1 laminotomies, medial facetectomies, and foraminotomies, decompression of right L5 and S1 nerve roots.  Right L4-S1 posterolateral fusion with local bone graft.  Left L4 through S1 segmental pedicle screw instrumentation.  Preparation harvesting of local bone graft.

neurosurgery, lumbosacral radiculopathy, lumbar spondylolysis, laminotomies, medial facetectomies, foraminotomies, decompression, nerve roots, fusion, bone graft, segmental, pedicle screw, transverse processes, bone, facetectomies, transpedicular, graft, pedicle

The case describes a complex neurosurgical procedure involving decompression and fusion at the lumbar spine levels L4 to S1, which was needed due to lumbosacral radiculopathy caused by spinal stenosis and spondylolysis. Such operations are inherently high-stakes due to the proximity to critical nerve structures and the major risks involved, including paralysis or death, although these risks are stated as rare. The surgery aims to relieve significant radicular pain, but there is a noted failure rate of 10-15%, meaning the stakes are high given the seriousness of the condition and the potential outcomes. The high stakes also stem from the potential need for further surgery and possible complications like wound infection or spinal fluid leak. Additionally, the use of general anesthesia, significant blood loss, and detailed post-operative care further underline the complexity and high-stakes nature of the procedure.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy - 2

ADMITTING DIAGNOSIS: , Right C5-C6 herniated nucleus pulposus.,PRIMARY OPERATIVE PROCEDURE: , Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.,SUMMARY:,  This is a pleasant, 43-year-old woman, who has been having neck pain and right arm pain for a period of time which has not responded to conservative treatment including ESIs.  She underwent another MRI and significant degenerative disease at C5-6 with a central and right-sided herniation was noted.  Risks and benefits of the surgery were discussed with her and she wished to proceed with surgery.  She was interested in participating in the artificial disk replacement study and was entered into that study.  She was randomly picked for the artificial disk and underwent the above named procedure on 08/27/2007.  She has done well postoperatively with a sensation of right arm pain and numbness in her fingers.  She will have x-rays AP and lateral this morning which will be reviewed and she will be discharged home today if she is doing well.  She will follow up with Dr. X in 2 weeks in the clinic as per the study protocol with cervical AP and lateral x-rays with ring prior to the appointment.  She will contact our office prior to her appointment if she has problems.  Prescriptions were written for Flexeril 10 mg 1 p.o. t.i.d. p.r.n.  #50 with 1 refill and Lortab 7.5/500 mg 1 to 2 q.6 h. p.r.n.  #60 with 1 refill.
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DESCRIPTION: Anterior cervical discectomy at C5-6 and placement of artificial disk replacement.  Right C5-C6 herniated nucleus pulposus.

surgery, herniated nucleus pulposus, anterior cervical discectomy, artificial disk replacement, cervical, discectomy, nucleusNOTE

The situation involves a surgical procedure, specifically an anterior cervical discectomy with artificial disc replacement, which inherently carries significant risks such as potential complications from anesthesia, surgical errors, or postoperative issues like infection. The patient is also participating in a study, which adds another layer of complexity and responsibility to the surgical team. Although the surgery appears to have gone well and the patient is recovering, the stakes remain high due to the potential for serious complications or adverse outcomes. Therefore, the decision-making and execution of the surgery are crucial and can impact the patient's quality of life significantly, which characterizes this as a high-stakes situation.


Medical Specialty: Discharge Summary
Sample Name: Speech Therapy - Discharge Summary

LONG-TERM GOALS:,  Both functional and cognitive-linguistic ability to improve safety and independence at home and in the community.  This goal has been met based on the patient and husband reports the patient is able to complete all activities, which she desires to do at home.  During the last reevaluation, the patient had a significant progress and all cognitive domains evaluated, which are attention, memory, executive functions, language, and visuospatial skill.  She continues to have an overall mild cognitive-linguistic deficit, but this is significantly improved from her initial evaluation, which showed severe impairment., ,The patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued.  The patient and her husband both agreed with the patient's discharge.
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DESCRIPTION: Speech therapy discharge summary.  The patient was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.

discharge summary, narrative, memory, executive function, attention, speech therapy, visuospatial, accuracy, linguistic, cognitive, speechNOTE,: 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 discharge summary highlights a patient who has completed speech therapy with significant improvements, meeting all goals set for independence and safety at home and in the community. The patient no longer requires skilled therapy, and all parties agree with this decision. While cognitive-linguistic deficits remain, they have improved significantly, and the situation does not involve immediate risk or critical health conditions.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Newborn H&P Template

HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **.  Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound.  ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear.  The baby was vertex presentation.  The baby was dried, stimulated, and bulb suctioned.  Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:,  The mother is a **-year-old, G**, P** female with blood type **.  She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative.  Mother was group B strep **.  Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits.  She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:,  Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature **, heart rate **, respiratory rate **.  Dextrose stick **.  Ballard score by the RN is ** weeks.  Birth weight is ** grams, which is the ** percentile for gestational age.  Length is ** centimeters which is ** percentile for gestational age.  Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL:  **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT:  Anterior fontanelle open and flat.  Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags.  Nares patent.  Palate intact.  Mucous membranes moist.,NECK:  Full range of motion.,CARDIOVASCULAR:  Normal precordium, regular rate and rhythm.  No murmurs.  Normal femoral pulses.,RESPIRATORY;  Clear to auscultation bilaterally.  No retractions.,ABDOMEN:  Soft, nondistended.  Normal bowel sounds.  No hepatosplenomegaly.  Umbilical stump is clean, dry, and intact.,GENITOURINARY:  Normal tanner I **.  Anus patent.,MUSCULOSKELETAL:  Negative Barlow and Ortolani.  Clavicles intact.  Spine straight.  No sacral dimple or hair tuft.  Leg lengths grossly symmetric.  Five fingers on each hand and five toes on each foot.,SKIN:  Warm and pink with brisk capillary refill.  No jaundice.,NEUROLOGICAL:  Normal tone.  Normal root, suck, grasp, and Moro reflexes.  Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:,  **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1.  Routine newborn care.,2.  Anticipatory guidance.,3.  Hepatitis B immunization prior to discharge.,
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DESCRIPTION: Template for History and Physical for a newborn.

The situation described is a template for a history and physical examination for a newborn, including details on the birth and immediate postnatal status. It is part of standard medical documentation and does not seem to involve any immediate or critical clinical decisions that could alter the newborn's health dramatically. The template is designed for routine use and anticipates typical scenarios for newborns, indicating low-stakes involvement. The stakes may elevate depending on the specific data inserted during an actual patient's evaluation, but the template itself is neutral in urgency or risk.


Medical Specialty: Dermatology
Sample Name: Punch Biopsy - 1

PROCEDURE:,  Punch biopsy of right upper chest skin lesion.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Minimal.,COMPLICATIONS:,  None.,PROCEDURE:,  The area around the lesion was anesthetized after she gave consent for her procedure.  Punch biopsy including some portion of lesion and normal tissue was performed.  Hemostasis was completed with pressure holding.  The biopsy site was approximated with non-dissolvable suture.  The area was hemostatic.  All counts were correct and there were no complications.  The patient tolerated the procedure well.  She will see us back in approximately five days.,
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DESCRIPTION: Punch biopsy of right upper chest skin lesion.

The procedure described is a routine punch biopsy, which is a common and minimally invasive dermatological procedure used to diagnose skin lesions. The estimated blood loss and fluids were minimal, there were no complications, and the patient tolerated the procedure well, indicating that there are no immediate high-risk factors present. However, the stakes could vary depending on the results of the biopsy, as they could indicate a more serious underlying condition. Nonetheless, the procedure itself is standard and low-risk.


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 ROS Template

REVIEW OF SYSTEMS,GENERAL/CONSTITUTIONAL: , The patient denies fever, fatigue, weakness, weight gain or weight loss.,HEAD, EYES, EARS, NOSE AND THROAT:,  Eyes - The patient denies pain, redness, loss of vision, double or blurred vision, flashing lights or spots, dryness, the feeling that something is in the eye and denies wearing glasses.  Ears, nose, mouth and throat.  The patient denies ringing in the ears, loss of hearing, nosebleeds, loss of sense of smell, dry sinuses, sinusitis, post nasal drip, sore tongue, bleeding gums, sores in the mouth, loss of sense of taste, dry mouth, dentures or removable dental work, frequent sore throats, hoarseness or constant feeling of a need to clear the throat when nothing is there, waking up with acid or bitter fluid in the mouth or throat, food sticking in throat when swallows or painful swallowing.,CARDIOVASCULAR: , The patient denies chest pain, irregular heartbeats, sudden changes in heartbeat or palpitation, shortness of breath, difficulty breathing at night, swollen legs or feet, heart murmurs, high blood pressure, cramps in his legs with walking, pain in his feet or toes at night or varicose veins.,RESPIRATORY: , The patient denies chronic dry cough, coughing up blood, coughing  up mucus, waking at night coughing or choking, repeated pneumonias, wheezing or night sweats.,GASTROINTESTINAL: , The patient denies decreased appetite, nausea, vomiting, vomiting blood or coffee ground material, heartburn, regurgitation, frequent belching, stomach pain relieved by food, yellow jaundice, diarrhea, constipation, gas, blood in the stools, black tarry stools or hemorrhoids.,GENITOURINARY:  ,The patient denies difficult urination, pain or burning with urination, blood in the urine, cloudy or smoky urine, frequent need to urinate, urgency, needing to urinate frequently at night, inability to hold the urine, discharge from the penis, kidney stones, rash or ulcers, sexual difficulties, impotence or prostate trouble, no sexually transmitted diseases.,MUSCULOSKELETAL: , The patient denies arm, buttock, thigh or calf cramps.  No joint or muscle pain.  No muscle weakness or tenderness.  No joint swelling, neck pain, back pain or major orthopedic injuries.,SKIN AND BREASTS:  ,The patient denies easy bruising, skin redness, skin rash,  hives, sensitivity to sun exposure, tightness, nodules or bumps, hair loss, color changes in the hands or feet with cold, breast lump, breast pain or nipple discharge.,NEUROLOGIC: , The patient denies headache, dizziness, fainting, muscle spasm, loss of consciousness, sensitivity or pain in the hands and feet or memory loss.,PSYCHIATRIC:  ,The patient denies depression with thoughts of suicide, voices in ?? head telling ?? to do things and has not been seen for psychiatric counseling or treatment.,ENDOCRINE: , The patient denies intolerance to hot or cold temperature, flushing, fingernail changes, increased thirst, increased salt intake or decreased sexual desire.,HEMATOLOGIC/LYMPHATIC:  ,The patient denies anemia, bleeding tendency or clotting tendency.,ALLERGIC/IMMUNOLOGIC: , The patient denies rhinitis, asthma, skin sensitivity, latex allergies or sensitivity.
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DESCRIPTION: Normal review of systems template.  The patient denies fever, fatigue, weakness, weight gain or weight loss.

general medicine, cardiovascular, ears, eyes, gastrointestinal, head, nose, respiratory, review of systems, denies fever, blood, tongue, loss,

The scenario describes a standard 'Review of Systems' (ROS) in general medicine, where a patient is reporting no symptoms or issues across a number of systems (e.g., cardiovascular, respiratory, gastrointestinal). This information is often collected as part of routine checkups or assessments and is not indicative of an immediate or high-stakes medical situation. The absence of reported symptoms suggests there is no active medical emergency or condition requiring urgent intervention. Thus, it is standard practice and not high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Well-Child Check - 3

SUBJECTIVE:,  Patient presents with Mom for first visit to the office for two week well-child check.  Mom has no concerns stating that patient has been doing well overall since dismissal from the hospital.  Nursing every two to three hours with normal voiding and stooling pattern.  She does have a little bit of some gas and Mom has been using Mylicon drops which are helpful.  She is burping well, hiccuping, sneezing and burping appropriately.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Mom reports uncomplicated pregnancy and delivery with prenatal care provided by Dr. Hoing.  Delivery at Newton Medical Center at 39 weeks, 5 days gestation.  Birth weight was 3160 g.  Length 49.5 cm.  Head circumference 33 cm.  Infant was delivered to 22-year-old A-positive mom who is G1 P0, now P1.  Infant did well after delivery and was dismissed to home with Mom the following day.  No other hospitalizations.  No surgeries.,ALLERGIES: , None.,MEDICATIONS:,  Gas drops p.r.n.,FAMILY HISTORY: , Significant for cardiovascular problems and hypertension as well as diabetes mellitus on the maternal side of the family.  History of cancer and asthma on the paternal side of the family.  Mom unsure of what type of cancer.,SOCIAL HISTORY:,  Patient lives at home with 22-year-old mother Aubrey Mizel and her parents Bud and Sue Mizel in Newton, Kansas.  Father of the baby, Shivanka Silva age 30, is a full-time student at WSU in Wichita, Kansas and does help with care of the newborn.  There is no smoking in the home.  Family does have one pet dog in home.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs:  Weight 7 pounds, 1-1/5 ounces.  Height 21 inches.  Head circumference 35.8 cm.  Temperature 97.7.,General:  Well-developed, well-nourished, cooperative, alert and interactive 2-week-old female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel soft and flat.  Pupils equal, round and reactive.  Sclerae clear.  Red reflex present bilaterally.  TMs clear bilaterally.  Oropharynx:  Mucous membranes moist and pink.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No masses or organomegaly.  Healing umbilicus.,GU:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani and Barlow maneuver.,Back:  Straight.  No scoliosis.  Some increased pigment over the sacrum.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.,ASSESSMENT/PLAN:,1. Well 2-week-old mixed race Caucasian and Middle Eastern descent female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations and visitation schedule.  Gave two week well-child check handout to Mom.  Plan follow up for the one month well-child check or as needed for acute care.  Mom will call for feeding problems, breathing problems or fever.  Otherwise, plan to see at one month.
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DESCRIPTION: A two week well-child check.

A two week well-child check.

This situation involves a routine two-week well-child check, where the infant is reported to be in good health and is meeting developmental milestones. The issues noted (such as a bit of gas) are normal for infants and are managed effectively with over-the-counter drops. There are no immediate concerns or threats to the child's health, and the mother has no concerns either. The visit involves giving anticipatory guidance and planning for a follow-up. The stakes are low because there are no acute or even moderate health concerns presented, and the visit is part of a standard preventative care schedule for infants.


Medical Specialty: Surgery
Sample Name: Heart Catheterization, Ventriculography, & Angiography

PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Saphenous vein graft angiography.,4.  Left internal mammary artery angiography.,5.  Left ventriculography.,INDICATIONS: , Persistent chest pain on maximum medical therapy with known history of coronary artery disease, status post coronary artery bypass grafting in year 2000.,PROCEDURE: , After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, an informed consent was obtained both verbally and in writing.  The patient was taken to the Cardiac Catheterization Suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was then used to infiltrate the skin overlying the right femoral artery.  Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was then inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin and its pressure was held.  The needle was removed over the guidewire.  A #6 French sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  Next, angulated pigtail catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of the guidewire.  The catheter was then advanced into the left ventricle.  The guidewire was then removed.  The catheter was connected to the manifold and flushed.  LVEDP was then measured and found to be favorable for a left ventriculogram.  The left ventriculogram was performed in the RAO position with a single power injection of non-ionic contrast material.  LVEDP was then remeasured.  Pullback was then performed, which failed to reveal an LVAO gradient.  The catheter was then removed.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Using hand injections of non-ionic contrast material, the left coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was removed.  Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the saphenous vein graft was engaged using hand injections of non-ionic contrast material.  The saphenous vein graft was visualized in several different views.  The Judkins right catheter was then advanced and the native coronary artery was engaged using hand injections of non-ionic contrast material.  Right coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was retracted.  We were unable to engage the left subclavian artery thus the catheter was removed over an exchange wire.  Next, a multipurpose catheter was advanced over the exchange wire.  The wire was then easily passed into the left subclavian artery.  The multipurpose catheter was then removed.  LIMA catheter was then exchanged over the wire into the left subclavian artery.  The guidewire was removed and the catheter was connected to the manifold and flushed.  LIMA graft was then engaged using hand injections of non-ionic contrast material.  The LIMA graft was evaluated in several different views.  Once adequate study has been performed, the LIMA catheter was retracted under fluoroscopic guidance.  The sheath was flushed for the final time.  The patient was returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM: , There is no evidence of any wall motion abnormalities with an estimated ejection fraction of 60%.  Left ventricular end-diastolic pressure was 24 mmHg preinjection and 26 mmHg postinjection.  There is no mitral regurgitation.  There is no LVAO or pullback.,LEFT MAIN CORONARY ARTERY: , The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a small caliber vessel, which traverses through the intraventricular groove and wraps around the apex of the heart.  There are luminal irregularities from the mid to distal portion.  There is noted to be antegrade flow in the LIMA to LAD graft.  There are very small diagonal branches, which are diffusely diseased.,CIRCUMFLEX ARTERY: , The circumflex is a small caliber vessel, which traverses through the atrioventricular groove.  There are minor luminal irregularities throughout.  There are very small obtuse marginal branches, which are diffusely diseased.,RIGHT CORONARY ARTERY:,  The RCA is a small vessel with luminal irregularities throughout.  The RCA is the dominant coronary artery.,Left internal mammary artery graft to the left anterior descending artery failed to demonstrate any hemodynamically significant stenosis.  Saphenous vein graft to the obtuse marginal branches is a Y-graft, which bifurcates to the first obtuse marginal and the obtuse marginal branch.  The saphenous vein graft to the obtuse marginal branches is widely patent without any evidence of hemodynamically significant disease.,IMPRESSION:,1.  Diffusely diseased native vessels.,2.  Saphenous vein graft to the obtuse marginal branch is widely patent.,3.  Left internal mammary artery graft to the left anterior descending artery is patent.,4.  Normal left ventricular function with ejection fraction of 60%.,5.  Mildly elevated left-sided filling pressures.,PLAN:,1.  The patient is to continue on her current medical regimen, which includes beta-blocker, aspirin, statin, and Plavix.  The patient is unable to tolerate a long-acting nitrate, thus this will be discontinued.,2.  We will add Norvasc 5 mg daily as well as hydrochlorothiazide 25 mg daily.,3.  Risk factor modification was discussed with the patient including diet control as well as tobacco cessation.,4.  The patient will need to be monitored closely for close lipid control as well as blood pressure control.
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DESCRIPTION: Left heart catheterization, bilateral selective coronary angiography, saphenous vein graft angiography, left internal mammary artery angiography, and left ventriculography.

The described procedures are high-stakes, as they involve interventive and diagnostic action within the heart and associated vessels. Heart catheterizations and angiographies carry risks such as bleeding, infection, and potential damage to the heart or arterial walls. Given the patient's history of coronary artery disease and previous coronary artery bypass grafting, the potential for complications increases, and the procedures are critical for assessing the patient's current cardiac health and guiding treatment.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Shortness Of Breath - Progress Note

She was evaluated this a.m. and was without any significant clinical change.  Her white count has been improving and down to 12,000.  A chest x-ray obtained today showed some bilateral infiltrates, but no acute cardiopulmonary change.  There was a suggestion of a bilateral lower lobe pneumonitis or pneumonia.,She has been on Zosyn for the infection.,Throughout her hospitalization, we have been trying to adjust her pain medications.  She states that the methadone did not work for her.  She was "immune" to oxycodone.  She had been on tramadol before and was placed back on that.  There was some question that this may have been causing some dizziness.  She also was on clonazepam and alprazolam for the underlying bipolar disorder.,Apparently, her husband was in this afternoon.  He had a box of her pain medications.  It is unclear whether she took a bunch of these or precisely what happened.  I was contacted that she was less responsive.  She periodically has some difficulty to arouse due to pain medications, which she has been requesting repeatedly, though at times does not appear to have objective signs of ongoing pain.  The nurse found her and was unable to arouse her at this point.  There was a concern that she had taken some medications from home.  She was given Narcan and appeared to come around some.  Breathing remained somewhat labored and she had some diffuse scattered rhonchi, which certainly changed from this a.m.  Additional Narcan was given as well as some medications to reverse a possible benzodiazepine toxicity.  With O2 via mask, oxygenation was stable at 90% to 95% after initial hypoxia was noted.  A chest x-ray was obtained at this time.  An ECG was obtained, which shows a sinus tachycardia, noted to have ischemic abnormalities.,In light of the acute decompensation, she was then transferred to the ICU.  We will continue the IV Zosyn.  Respiratory protocol with respiratory management.  Continue alprazolam p.r.n., but avoid if she appears sedated.  We will attempt to avoid additional pain medications, but we will continue with the Dilaudid for time being.  I suspect she will need something to control her bipolar disorder.,Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.  At this juncture, she does not appear to need an intubation.  Pending chest x-ray, she may require additional IV furosemide.
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DESCRIPTION: The patient was admitted approximately 3 days ago with increasing shortness of breath secondary to pneumonia.  Pulmonary Medicine Associates have been contacted to consult in light of the ICU admission.

soap / chart / progress notes, shortness of breath, pulmonary medicine, bipolar disorder, icuNOTE

This situation involves a patient in a hospital setting who has experienced acute decompensation and was found less responsive, possibly due to an overdose on various medications. Due to her condition, she was transferred to the ICU for intensive monitoring and intervention. The situation is high-stakes because it involves potential life-threatening complications from a combination of respiratory issues, possible drug overdose, and the complex management of multiple medications including those for pain and bipolar disorder. The need for Narcan, possible benzodiazepine reversal, and potential for deteriorating respiratory function underscore the serious nature of her condition.


Medical Specialty: Nephrology
Sample Name: AV Fistula - 2

PREOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Diabetes.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Diabetes.,OPERATIVE PROCEDURE,Creation of right brachiocephalic arteriovenous fistula.,INDICATIONS FOR THE PROCEDURE,This patient has end-stage renal disease.  Although, the patient is right-handed, preoperative vein mapping demonstrated much better vein in the right arm.  Hence, a right brachiocephalic fistula is being planned.,OPERATIVE FINDINGS,The right cephalic vein at the elbow is chosen to be suitable.  It is slightly sporadic, but of an adequate size.  An end-to-side right brachiocephalic arteriovenous fistula was created.  At completion, there was a great thrill.,OPERATIVE PROCEDURE IN DETAIL,After informed consent was obtained, the patient was taken to the operating room.  The patient was placed in the supine position.  The patient received a regional nerve block.  The patient also received intravenous sedation.  The right arm was prepped and draped in the usual sterile fashion.,We made a small transverse incision in the right cubital fossa.  The cephalic vein was identified and mobilized.  The fascia was incised, and the brachial artery was also identified and mobilized.  The brachial artery was free off significant disease.  A good pulse was noted.  The cephalic vein was mobilized proximally and distally.  The brachial artery was mobilized proximally and distally.  We did not give heparin.  The brachial artery was then clamped proximally and distally.  The cephalic vein was also clamped proximally and distally.  Longitudinal arteriotomy was made in brachial artery, and a longitudinal venotomy was made in the cephalic vein.  We then sewn the vein to the artery in a side-to-side fashion using a running 7-0 Prolene suture.,Just prior to completion of the anastomosis, it was flushed, and the anastomosis was then completed.  A great thrill was noted.  We then ligated the cephalic vein beyond the arteriovenous anastomosis and divided it.  This surrounded the anastomosis as an end-to-side functionally.  A great thrill remained in the fistula.  Hemostasis was secured.  We then closed the wound using interrupted PDS sutures for the fascia and a running 4-0 Monocryl subcuticular suture for the skin.  Sterile dry dressing was applied.,The patient tolerated the procedure well.  There were no operative complications.  The sponge, instrument, and needle counts were correct at the end of the case.  I was present and participated in all aspects of the procedure.  The patient was then transferred to the recovery room in satisfactory condition.  A great thrill was felt in the fistula completion.  There was also a palpable radial pulse distally.
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DESCRIPTION: Creation of right brachiocephalic arteriovenous fistula.

nephrology, end-stage renal disease, prolene suture, brachial artery, brachiocephalic, brachiocephalic arteriovenous fistula, cephalic vein, fistula, general anesthetic, prepped and draped, proximally and distally, renal disease, av, cephalic, artery, vein

The creation of an arteriovenous (AV) fistula is a surgical procedure that is critical for patients with end-stage renal disease, as it allows for hemodialysis, a life-sustaining treatment. While the procedure described went smoothly and there weren't any complications, the stakes are inherently high due to the necessity for patients reliant on dialysis, and because complications in vascular surgeries can have significant consequences. Therefore, it is essential that the procedure is done precisely and that post-operative monitoring occurs to ensure the fistula functions properly for dialysis.


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

MULTISYSTEM EXAM,CONSTITUTIONAL:  ,The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES:  ,The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT:  ,The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK:  ,The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR:  ,Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,GASTROINTESTINAL: , The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU: , The scrotal elements were normal.  The testes were without discrete mass.  The penis showed no lesion, no discharge.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN: , Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC:  ,Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC: , The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.
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DESCRIPTION: Sample/template for a normal male multisystem exam.

consult - history and phy., within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue,

The provided document is a standard, routine physical examination template for a normal male patient, often used by healthcare providers as a reference for conducting thorough check-ups. There are no indications of immediate medical concerns or emergencies, and the exam results are normal across all systems. This type of document is typically used as a reference or guide in everyday healthcare practice.


Medical Specialty: Consult - History and Phy.
Sample Name: Well-woman checkup

CHIEF COMPLAINT:,  The patient comes for her well-woman checkup.,HISTORY OF PRESENT ILLNESS:,  She feels well.  She has had no real problems.  She has not had any vaginal bleeding.  She had a hysterectomy.  She has done fairly well from that time till now.  She feels like she is doing pretty well.  She remains sexually active occasionally.  She has not had any urinary symptoms.  No irregular vaginal bleeding.  She has not had any problems with vasomotor symptoms and generally, she just feels like she has been doing pretty well.  She sometimes gets a catch in her right hip and sometimes she gets heaviness in her calves.  She says the only thing that works to relieve that is to sleep on her tummy with her legs pulled up and they relax and she goes off to sleep.  She does not report any swelling or inflammation, or pain.  She had a recent urinary tract infection, took medication, and has not rechecked on that urinalysis.,MEDICATIONS: , Tetracycline 250 mg daily, Inderal LA 80 mg every other day.,ALLERGIES:,  Sulfa.,PAST MEDICAL HISTORY:,  She had rosacea.  She also has problems with “tremors” and for that she takes Inderal LA.  Hysterectomy in the past.,SOCIAL HISTORY:,  She drinks four cups of coffee a day.  No soda.  No chocolate.  She said her husband hurt his hand and shoulder, and she has been having to care of him pretty much.  They walk every evening for one hour.,FAMILY HISTORY:,  Her mother is in a nursing home; she had a stroke.  Her father died at age 86 in January 2004 of congestive heart failure.  She has two brothers, one has kidney failure, the other brother donated a kidney to his other brother, but this young man is now an alcoholic and drug addict.,REVIEW OF SYSTEMS:,  Patient denies headache or trauma.  No blurred or double vision.  Hearing is fine, no tinnitus, or infection.  Infrequent sore throat, no hoarseness, or cough.,Neck:  No stiffness, pain, or swelling.,Respiratory:  No shortness of breath, cough, or hemoptysis.,Cardiovascular:  No chest pain, ankle edema, palpitations, or hypertension.,GI:  No nausea, vomiting, diarrhea, constipation, melena, or jaundice.,GU:  No dysuria, frequency, urgency, or stress incontinence.,Locomotor:  No weakness, joint pain, tremor, or swelling.,GYN:  See HPI.,Integumentary:  Patient performs self-breast examinations and denies any breast masses or nipple discharge.  No recent skin or hair changes.,Neuropsychiatric:  Denies depression, anxiety, tearfulness, or suicidal thought.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Height:  62 inches.  Weight:  134 pounds.  Blood pressure:  116/74.  Pulse:  60.  Respirations:  12.  Age 59.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.  She fell last winter on the ice and really cracked her head and has had some problems with headaches since then and she has not returned to her job which was very stressful and hard on her.  She wears glasses.,Neck:  Full range of motion.  No lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation and percussion.,Heart:  Normal sinus rhythm, no murmur.,Integumentary:  Breasts are without masses, tenderness, nipple retraction, or discharge.  Reviewed self-breast examination.  No axillary nodes are palpable.,Abdomen:  Soft.  Liver, spleen, and kidneys are not palpable.  No masses felt, nontender.  Femoral pulses strong and equal.,Back:  No CVA or spinal tenderness.  No deformity noted.,Pelvic:  BUS negative.  Vaginal mucosa atrophic.  Cervix and uterus are absent.  No Pap was taken.  No adnexal masses.,Rectal:  Good sphincter tone.  No masses.  Stool guaiac negative.,Extremities:  No edema.  Pulses strong and equal.  Reflexes are intact.  Romberg and Babinski are negative.  She is oriented x 3.  Gait is normal.,ASSESSMENT:,  Middle-aged woman, status post hysterectomy, recent urinary tract infection.,PLAN:,  We will evaluate the adequacy of the therapy for her urinary tract infection with the urinalysis and culture.  I recommended mammogram and screening, hemoccult x 3, DEXA scan and screening, and she is fasting today.  We will screen with chem-12, lipid profile, and CBC because of her advancing age and notify of those results, as soon as they are available.  Continue same meds.  Recheck annually unless she has problems sooner.
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DESCRIPTION: Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection.

This well-woman checkup does not represent a high-stakes situation. The patient appears stable with no acute or severe symptoms requiring immediate intervention. The primary concerns are routine evaluations and screenings due to her history and age, like checking the adequacy of treatment for a previous urinary tract infection and suggesting preventive screenings like mammograms. The patient's health is generally good, with no pressing emergencies or decisions needed during this visit.


Medical Specialty: Surgery
Sample Name: TAH & Salpingo-oophorectomy & Lysis of Adhesions

PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Endometriosis.,3.  Prior right salpingo-oophorectomy.,4.  History of intrauterine device perforation and exploratory surgery.,POSTOPERATIVE DIAGNOSES:,1.  Endometriosis.,2.  Interloop bowel adhesions.,PROCEDURE PERFORMED:,1.  Total abdominal hysterectomy (TAH).,2.  Left salpingo-oophorectomy.,3.  Lysis of interloop bowel adhesions.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS:  ,400 cc.,FLUIDS: , 2300 cc of lactated Ringers, as well as lactated Ringers for intraoperative irrigation.,URINE: , 500 cc of clear urine output.,INTRAOPERATIVE FINDINGS: , The vulva and perineum are without lesions.  On bimanual exam, the uterus was enlarged, movable, and anteverted.  The intraabdominal findings revealed normal liver margin, kidneys, and stomach upon palpation.  The uterus was found to be normal in size with evidence of endometriosis on the uterus.  The right ovary and fallopian tube were absent.  The left fallopian tube and ovary appeared normal with evidence of a small functional cyst.  There was evidence of left adnexal adhesion to the pelvic side wall which was filmy, unable to be bluntly dissected.  There were multiple interloop bowel adhesions that were filmy in nature noted.,The appendix was absent.  There did appear to be old suture in a portion of the bowel most likely from a prior procedure.,INDICATIONS: , This patient is a 45-year-old African-American gravida7, para3-0-0-3, who is here for definitive treatment of chronic pelvic pain with a history of endometriosis.  She did have a laparoscopic ablation of endometriosis on a laparoscopy and also has a history of right salpingo-oophorectomy.  She has tried Lupron and did stop secondary to the side effects.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the Operating Suite and placed under general anesthesia.  She was then prepped and draped in the sterile fashion and placed in the dorsal supine position.  An indwelling Foley catheter was placed.  With the skin knife, an incision was made removing the old cicatrix.  A Bovie was used to carry the tissue through to the underlying layer of the fascia which was incised in the midline and extended with the Bovie.  The rectus muscle was then sharply and bluntly dissected off the superior aspect of the rectus fascia in the superior as well as the inferior aspect using the Bovie.  The rectus muscle was then separated in the midline using a hemostat and the peritoneum was entered bluntly.  The peritoneal incision was then extended superiorly and inferiorly with Metzenbaum scissors with careful visualization of the bladder.  At this point, the intraabdominal cavity was manually explored and the above findings were noted.  A Lahey clamp was then placed on the fundus of the uterus and the uterus was brought to the surgical field.  The bowel was then packed with moist laparotomy sponges.  Prior to this, the filmy adhesions leftover were taken down.  At this point, the left round ligament was identified, grasped with two hemostats, transected, and suture ligated with #0 Vicryl.  At this point, the broad ligament was dissected down and the lost portion of the bladder flap was created.  The posterior aspect of the peritoneum was also dissected.  At this point, the infundibulopelvic ligament was isolated and three tie of #0 Vicryl was used to isolate the pedicle.  Two hemostats were then placed across the pedicle and this was transected with the scalpel.  This was then suture ligated in Heaney fashion.  The right round ligament was then identified and in the similar fashion, two hemostats were placed across the round ligament and using the Mayo scissors the round ligament was transected and dissected down the broad ligament to create the bladder flap anteriorly as well as dissect the posterior peritoneum and isolate the round ligament.  This was then ligated with three tie of #0 Vicryl.  Also incorporated in this was the remnant from the previous right salpingo-oophorectomy.  At this point, the bladder flap was further created with sharp dissection as well as the moist Ray-Tech to push the bladder down off the anterior portion of the cervix.,The left uterine artery was then skeletonized and a straight Heaney was placed.  In a similar fashion, the contralateral uterine artery was skeletonized and straight Heaney clamp was placed.  These ligaments bilaterally were transected and suture ligated in a left Heaney stitch.  At this point, curved Masterson was used to incorporate the cardinal ligament complex, thus was transected and suture ligated.  Straight Masterson was then used to incorporate the uterosacrals bilaterally and this was also transected and suture ligated.  Prior to ligating the uterine arteries, the uterosacral arteries were tagged bilaterally with #0 Vicryl.  At this point, the roticulator was placed across the vaginal cuff and snug underneath the entire cervix.  The roticulator was then clamped and removed and the staple line was in place.  This was found to be hemostatic.  A suture was then placed through each cuff angle bilaterally and cardinal ligament complex was found to be fixed to each apex bilaterally.  At this point, McCall culdoplasty was performed with an #0 Vicryl incorporating each uterosacral as well as the posterior peritoneum.  There did appear to be good support on palpation.  Prior to this, the specimen was handed off and sent to pathology.  At this point, there did appear to be small amount of oozing at the right peritoneum.  Hemostasis was obtained using a #0 Vicryl in two single stitches.  Good hemostasis was then obtained on the cuff as well as the pedicles.  Copious irrigation was performed at this point with lactate Ringers.  The round ligaments were then incorporated into the cuff bilaterally.  Again, copious amount of irrigation was performed and good hemostasis was obtained.  At this point, the peritoneum was reapproximated in a single interrupted stitch on the left and right lateral aspects to cover each pedicle bilaterally.  At this point, the bowel packing as well as moist Ray-Tech was removed and while re-approximating the bowel it was noted that there were multiple interloop bowel adhesions which were taken down using the Metzenbaum scissors with good visualization of the underlying bowel.  Good hemostasis was obtained of these sites as well.  The sigmoid colon was then returned to its anatomic position and the omentum as well.  The rectus muscle was then reapproximated with two interrupted sutures of #2-0 Vicryl.  The fascia was then reapproximated with #0 Vicryl in a running fashion from lateral to medial meeting in the midline.  The Scarpa's fascia was then closed with #3-0 plain in a running suture.  The skin was then re-approximated with #4-0 undyed Vicryl in a subcuticular closure.  This was dressed with an Op-Site.  The patient tolerated the procedure well.  The sponge, lap, and needle were correct x2.  After the procedure, the patient was extubated and brought out of general anesthesia.  She will go to the floor where she will be followed postoperatively in the hospital.
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DESCRIPTION: Total abdominal hysterectomy (TAH), left salpingo-oophorectomy, lysis of interloop bowel adhesions.  Chronic pelvic pain, endometriosis, prior right salpingo-oophorectomy, history of intrauterine device perforation and exploratory surgery.

surgery, chronic pelvic pain, endometriosis, intrauterine device, exploratory, abdominal hysterectomy, tah, total abdominal hysterectomy, lysis of interloop bowel adhesions, salpingo oophorectomy, bowel, ligament, adhesions, interloop, hemostasis, uterus, salpingo, oophorectomy,

The scenario involves a complex surgical procedure, including a total abdominal hysterectomy, left salpingo-oophorectomy, and lysis of bowel adhesions, as treatment for chronic pelvic pain and endometriosis. Surgery inherently carries risks such as bleeding, infection, and potential damage to surrounding organs. The patient has a history of multiple significant medical issues, and any complications during the surgery could have serious consequences on her health and quality of life. However, it is a standard procedure performed with a clear indication, and the situation described suggests it was well-managed, reducing immediate stakes. Nevertheless, the stakes are considerable due to potential risks and the critical nature of a successful outcome for patient well-being.


Medical Specialty: Consult - History and Phy.
Sample Name: Lesions - Adrenal and Pancreatic

CHIEF COMPLAINT: , Both pancreatic and left adrenal lesions.,HISTORY OF PRESENT ILLNESS:,  This 60-year-old white male is referred to us by his medical physician with a complaint of recent finding of a both pancreatic lesion and lesions with left adrenal gland.  The patient's history dates back to at the end of the January of this past year when he began experiencing symptoms consistent with difficulty almost like a suffocating feeling whenever he would lie flat on his back.  He noticed whenever he would recline backwards, he would begin this feeling and it is so bad now that he can barely recline, very little before he has this feeling.  He is now sleeping in an upright position.  He was sent for CAT scan originally of his chest.  The CAT scan of the chest reveals a pneumonitis, but also saw a left adrenal nodule and a small pancreatic lesion.  He was subsequently was sent for a dedicated abdominal CAT scan and MRI.  The CAT scan revealed 1.8-cm lesion of his left adrenal gland, suspected to be a benign adenoma.  The pancreas showed pancreatic lesion towards the mid body tail aspect of the pancreas, approximately 1 cm, most likely of cystic nature.  Neoplasm could not be excluded.  He was referred to us for further assessment.  He denies any significant abdominal pain, any nausea or vomiting.  His appetite is fine.  He has had no significant changes in his bowel habits or any rectal bleeding or melena.  He has undergone a colonoscopy in September of last year and was found to have three adenomatous polyps.  He does have a history of frequent urination.  Has been followed by urologist for this.  There is no family history of pancreatic cancer.  There is a history of gallstone pancreatitis in the patient's sister.,PAST MEDICAL HISTORY:,  Significant for hypertension, type 2 diabetes mellitus, asthma, and high cholesterol.,ALLERGIES: , ENVIRONMENTAL.,MEDICATIONS:,  Include glipizide 5 mg b.i.d., metformin 500 mg b.i.d., Atacand 16 mg daily, metoprolol 25 mg b.i.d., Lipitor 10 mg daily, pantoprazole 40 mg daily, Flomax 0.4 mg daily, Detrol 4 mg daily, Zyrtec 10 mg daily, Advair Diskus 100/50 mcg one puff b.i.d., and fluticasone spray 50 mcg two sprays daily.,PAST SURGICAL HISTORY:,  He has not had any previous surgery.,FAMILY HISTORY: , His brothers had prostate cancer.  Father had brain cancer.  Heart disease in both sides of the family.  Has diabetes in his brother and sister.,SOCIAL HISTORY:,  He is a non-cigarette smoker and non-ETOH user.  He is single and he has no children.  He works as a payroll representative and previously did lot of work in jewelry business, working he states with chemical.,REVIEW OF SYSTEMS: , He denies any chest pain.  He admits to exertional shortness of breath.  He denies any GI problems as noted.  Has frequent urination as noted.  He denies any bleeding disorders or bleeding history.,PHYSICAL EXAMINATION:,GENERAL:  Presents as an obese 60-year-old white male, who appears to be in no apparent distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3 or S4 gallop.  There is no obvious murmur.,HEART:  There is distant heart sounds.,ABDOMEN:  Obese.  It is soft.  It is nontender.  Examination was done as relatively sitting up as the patient was unable to recline.  Bowel sounds are present.  There is no obvious mass or organomegaly.,GENITALIA:  Deferred.,RECTAL:  Deferred.,EXTREMITIES:  Revealed about 1+ pitting edema.  Bilateral peripheral pulses are intact.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION:,  Both left adrenal and pancreatic lesions.  The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded.  Given the location of these pancreatic lesions in the mid body towards the tail and size of 1 cm, the likelihood is an ERCP will be of no value and the likelihood is that it is too small to biopsy.  We are going to review x-rays with Radiology prior with the patient probably at some point will present for operative intervention.  Prior to that the patient will undergo an esophagogastroduodenoscopy.
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DESCRIPTION: Pancreatic and left adrenal lesions.  The adrenal lesion is a small lesion, appears as if probable benign adenoma, where as the pancreatic lesion is the cystic lesion, and neoplasm could not be excluded.

The case involves the discovery of lesions in both the pancreas and adrenal gland of a 60-year-old male. While the adrenal lesion appears benign, the pancreatic lesion has an uncertain nature ('neoplasm could not be excluded'), which raises concerns about possible cancer. The potential for cancer, especially pancreatic cancer, which has a high mortality rate, adds a level of seriousness to the situation. Additionally, his symptoms and other comorbid conditions like asthma and diabetes further complicate his health. The decision to proceed with further interventions and possible surgery highlights the importance of the situation.