Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Wound Check - Status Post APR

HISTORY OF PRESENT ILLNESS:,  Ms. Connor is a 50-year-old female who returns to clinic for a wound check.  The patient underwent an APR secondary to refractory ulcerative colitis.  Subsequently, she developed a wound infection, which has since healed.  On our most recent visit to our clinic, she has her perineal stitches removed and presents today for followup of her perineal wound.  She describes no drainage or erythema from her bottom.  She is having good ostomy output.  She does not describe any fevers, chills, nausea, or vomiting.  The patient does describe some intermittent pain beneath the upper portion of the incision as well as in the right lower quadrant below her ostomy.  She has been taking Percocet for this pain and it does work.  She has since run out has been trying extra strength Tylenol, which will occasionally help this intermittent pain.  She is requesting additional pain medications for this occasional abdominal pain, which she still experiences.,PHYSICAL EXAMINATION: , Temperature 95.8, pulse 68, blood pressure 132/73, and weight 159 pounds.  This is a pleasant female in no acute distress.  The patient's abdomen is soft, nontender, nondistended with a well-healed midline scar.  There is an ileostomy in the right hemiabdomen, which is pink, patent, productive, and protuberant.  There are no signs of masses or hernias over the patient's abdomen.,ASSESSMENT AND PLAN: , This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis.  Overall, her quality of life has significantly improved since she had her APR.  She is functioning well with her ileostomy.  She did have concerns or questions about her diet and we discussed the BRAT diet, which consisted of foods that would slow down the digestive tract such as bananas, rice, toast, cheese, and peanut butter.  I discussed the need to monitor her ileostomy output and preferential amount of daily output is 2 liters or less.  I have counseled her on refraining from soft drinks and fruit drinks.  I have also discussed with her that this diet is moreover a trial and error and that she may try certain foods that did not agree with her ileostomy, however others may and that this is something she will just have to perform trials with over the next several months until she finds what foods that she can and cannot eat with her ileostomy.  She also had questions about her occasional abdominal pain.  I told her that this was probably continue to improve as months went by and I gave her a refill of her Percocet for the continued occasional pain.  I told her that this would the last time I would refill the Percocet and if she has continued pain after she finishes this bottle then she would need to start ibuprofen or Tylenol if she had continued pain.  The patient then brought up some right hand and arm numbness, which has been there postsurgically and was thought to be from positioning during surgery.  This is all primarily gone away except for a little bit of numbness at the tip of the third digit as well as some occasional forearm muscle cramping.  I told her that I felt that this would continue to improve as it has done over the past two months since her surgery.  I told her to continue doing hand exercises as she has been doing and this seems to be working for her.  Overall, I think she has healed from her surgery and is doing very well.  Again, her quality of life is significantly improved.  She is happy with her performance.  We will see her back in six months just for a general routine checkup and see how she is doing at that time.
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DESCRIPTION: This is a pleasant 50-year-old female who has undergone an APR secondary to refractory ulcerative colitis.  Overall, her quality of life has significantly improved since she had her APR.  She is functioning well with her ileostomy.

soap / chart / progress notes, perineal wound, wound infection, wound, wound check, ulcerative colitis, apr, ileostomyNOTE

The situation involves a post-operative follow-up for a patient who underwent an abdominoperineal resection (APR) due to refractory ulcerative colitis. While this involves assessing her recovery and offers an opportunity to address any post-surgical complications and adjust pain management, it is a routine checkup rather than an immediate life-threatening situation. The patient is in no acute distress, her wound has healed, and she is adjusting well to her ileostomy, indicating stable postoperative progress. The discussion of pain management and dietary adjustments is part of routine postoperative care. Therefore, while important for the patient's comfort and ongoing recovery, the situation is not high-stakes in terms of immediate risk to life or severe medical intervention.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 20

SUBJECTIVE:,  This is an 11-year-old female who comes in for two different things.  1.  She was seen by the allergist.  No allergies present, so she stopped her Allegra, but she is still real congested and does a lot of snorting.  They do not notice a lot of snoring at night though, but she seems to be always like that.  2.  On her right great toe, she has got some redness and erythema.  Her skin is kind of peeling a little bit, but it has been like that for about a week and a half now.,PAST MEDICAL HISTORY:,  Otherwise reviewed and noted.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home.,REVIEW OF SYSTEMS:,  She has been having the redness of her right great toe, but also just a chronic nasal congestion and fullness.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed female, in no acute distress, afebrile.,HEENT:  Sclerae and conjunctivae clear.  Extraocular muscles intact.  TMs clear.  Nares patent.  A little bit of swelling of the turbinates on the left.  Oropharynx is essentially clear.  Mucous membranes are moist.,Neck:  No lymphadenopathy.,Chest:  Clear.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  She has got redness along the lateral portion of her right great toe, but no bleeding or oozing.  Some dryness of her skin.  Her toenails themselves are very short and even on her left foot and her left great toe the toenails are very short.,ASSESSMENT:,1.  History of congestion, possibly enlarged adenoids, or just her anatomy.,2.  Ingrown toenail, but slowly resolving on its own.,PLAN:,1.  For the congestion, we will have ENT evaluate.  Appointment has been made with Dr. XYZ for in a couple of days.,2.  I told her just Neosporin for her toe, letting the toenail grow out longer.  Call if there are problems.
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DESCRIPTION: 11-year-old female.  History of congestion, possibly enlarged adenoids.

consult - history and phy., enlarged adenoids, adenoids, oropharynx, congestion, toenails, toe,

The situation described involves medical concerns for an 11-year-old female, specifically nasal congestion possibly linked to enlarged adenoids, and an ingrown toenail. While these issues need medical attention, they are not immediately life-threatening and have clear plans for management (ENT evaluation and Neosporin application). Hence, the situation is not high-stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Phacoemulsification & Cataract Extraction

DIAGNOSIS:,  Nuclear sclerotic and cortical cataract, right eye.,OPERATION:,  Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.,PROCEDURE:,  The patient was taken to the operating room and placed on the table in the supine position.  Cardiac monitor and oxygen at 5 liters per minute were connected by the nursing staff.  Local anesthesia was obtained using 2% lidocaine, 0/75% Marcaine, 0.5 cc Wydase with 6 cc of this solution used in a paribulbar injection, followed by ten minutes of digital massage.  The patient was then prepped and draped in the usual sterile fashion for eye surgery.  With the Zeiss operating microscopy in position, a lid speculum was inserted and a 4-0 black silk bridal suture placed in the superior rectus muscle.  With Westcott scissors, a fornix-based conjunctival flap was made.  The surgical limbus was identified and hemostasis obtained with wet-field cautery.  With a 57-Beaver blade, a corneoscleral groove was made and shelved into clear cornea.  A stab incision was made at 2 o'clock with a 15-degree blade.  With a 3.0 mm keratome, the shelved groove was attended into the anterior chamber.  Viscoelastic was inserted into the anterior chamber and anterior capsulotomy was performed in a continuous-tear technique.  Hydrodissection was performed with Balanced Salt Solution.  Phacoemulsification was performed in a two-headed nuclear fracture technique.  The remaining cortical material was removed with irrigation and aspiration handpiece.  The posterior capsule remained intact and vacuumed with minimal suction.  The posterior chamber intraocular lens was obtained.  It was inspected, irrigated, inserted into the posterior chamber without difficulty.  Inspection revealed the intraocular lens to be in good position with intact capsule and well-approximated wound.  There was no aqueous leak even with digital pressure.  The conjunctiva was pulled back into position with wet-field cautery.  A subconjunctival injection with 20 mg Gatamycine and 0.5 cc Celestone was given.  Tobradex ointment was instilled into the eye, which was patched and shielded appropriately, after removing the lid speculum and bridle suture.  The patient tolerated the procedure well and was sent to the recovery room in good condition, to be followed in attending physician office the next day.
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DESCRIPTION: Phacoemulsification and extracapsular cataract extraction with intraocular lens implantation, right eye.

surgery, extracapsular cataract extraction, phacoemulsification, nuclear sclerotic, cortical cataract, extraction with intraocular lens, cataract extraction, intraocular lens, intraocular, extracapsular, implantation, conjunctival, cataract, chamberNOTE

Phacoemulsification and cataract extraction are common procedures in ophthalmic surgery, generally considered low-risk with high success rates, especially with experienced surgeons and standard cases. The detailed description mentions no complications and states that the patient tolerated the procedure well and is in good condition post-operatively. Although any surgery carries inherent risks, cataract surgeries are routine and generally low-stakes in terms of immediate patient life-threatening risks.


Medical Specialty: Surgery
Sample Name: I&D - Penoscrotal Abscess

PREOPERATIVE DIAGNOSIS: , Penoscrotal abscess.,POSTOPERATIVE DIAGNOSIS:,  Penoscrotal abscess.,OPERATION: , Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.,BRIEF HISTORY: , The patient is a 75-year-old male presented with penoscrotal abscess.  Options such as watchful waiting, drainage, and antibiotics were discussed.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, completely the infection turning into necrotizing fascitis, Fournier's gangrene were discussed.  The patient already had significant phimotic changes and disfigurement of the penis.  For further debridement the patient was told that his penis is not going to be viable, he may need a total or partial penectomy now or in the future.  Risks of decreased penile sensation, pain, Foley, other unexpected issues were discussed.  The patient understood all the complications and wanted to proceed with the procedure.,DETAIL OF THE OPERATION:  ,The patient was brought to the OR.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in the usual fashion.  Pictures were taken prior to starting the procedure for documentation.  The patient had an open sore on the right side of the penis measuring about 1 cm in size with pouring pus out using blunt dissection.  The penile area was opened up distally to allow the pus to come out.  The dissection around the proximal scrotum was done to make sure there are no other pus pockets.  The corporal body was intact, but the distal part of the corpora was completely eroded and had a fungating mass, which was biopsied and sent for permanent pathology analysis.,Urethra was identified at the distal tip, which was dilated and using 23-French cystoscope cystoscopy was done, which showed some urethral narrowing in the distal part of the urethra.  The rest of the bladder appeared normal.  The prostatic urethra was slightly enlarged.  There are no stones or tumors inside the bladder.  There were moderate trabeculations inside the bladder.  Otherwise, the bladder and the urethra appeared normal.  There was a significantly fungating mass involving the distal part of the urethra almost possibility to have including the fungating wart or fungating squamous cell carcinoma.  Again biopsies were sent for pathology analysis.  Prior to urine irrigation anaerobic aerobic cultures were sent, irrigation with over 2 L of fluid was performed.  After irrigation, packing was done with Kerlix.  The patient was brought to recovery in a stable condition.  Please note that 18-French Foley was kept in place.  Electrocautery was used at the end of the procedure to obtain hemostasis as much as possible, but there was fungating mass with slight bleeding packing was done and tight scrotal Kling was applied.  The patient was brought to Recovery in a stable condition after applying 0.5% Marcaine about 20 mL were injected around for local anesthesia.
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DESCRIPTION: Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.

surgery, i&d, penoscrotal, penile biopsy, cystoscopy, urethral dilation, incision and drainage, fungating mass, penoscrotal abscess, abscess, urethral,

This surgical case details a complex medical situation involving a 75-year-old male with a penoscrotal abscess and significant complications, including potential necrotizing fasciitis and the need for a penectomy. The presence of a fungating mass raises the possibility of squamous cell carcinoma, further compounding the stakes. The risks associated with the procedure, including potential for serious infection (Fournier's gangrene), and the need for extensive surgical intervention highlight the high-stakes nature of the situation, particularly given the patient's age and the severe nature of the conditions being treated.


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

HISTORY OF PRESENT ILLNESS: , The patient is a 44-year-old man who was seen for complaints of low back and right thigh pain.  He attributes this to an incident in which he was injured in 1994.  I do not have any paperwork authenticating his claim that there is an open claim.  Most recently he was working at Taco Bell, when he had a recurrence of back pain, and he was seen in our clinic on 04/12/05.  He rated pain of approximately 8/10 in severity., ,He took a Medrol Dosepak and states that his pain level has decreased to approximately 4-5/10.  He still localizes it to a band between L4 and the sacrum.  He initially had some right leg pain but states that this is minimal and intermittent at the present time.  His back history is significant for two laminectomies and a discectomy performed from 1990 to 1994.  The area of concern was L4-L5., ,The patient's MRI dated 10/18/04 showed multi-level degenerative changes, with facet involvement at L2-L3, L3-L4 and L5-S1.  There was no neural impingement.  He also had an MR myelogram, which showed severe stenosis at L3-L4, however it was qualified in that it may have been artifact, rather than a genuine finding., ,REVIEW OF SYSTEMS:,  Focal lower paralumbar pain, affecting both right and left sides, as well as intermittent right leg pain which appears to have improved significantly with the Medrol Dosepak.  He denies any recent illness.  He has no constitutional complaints such as fevers, chills or sweats.  HEENT: The patient denies any cephalgia, ocular, nasopharyngeal symptoms.  He has no dysphagia.  Cardiovascular: He denies any palpitations, chest pain, syncope or near-syncope.  Pulmonary: He denies any dyspnea or respiratory difficulties.  GI: The patient has no abdominal pain, nausea or vomiting.  GU: The patient denies any urinary frequency or dysuria. There is no gross hematuria.  Dermatologic: The patient notes no new onset of rash or other dermatological abnormalities.  Musculoskeletal: Denies any recent falls or near-falls.  He denies any abnormalities of endocrine, immunologic, hematologic, organ systems.  , ,MEDICATIONS: , Atenolol, Zestril, Vicodin., ,ALLERGIES:,  None., ,SOCIOECONOMIC STATUS:,  Lifting limitations of 5 pounds and limited stooping, bending and twisting., ,PHYSICAL EXAMINATION: , Vital signs:  Blood pressure 158/86, respiration 14, pulse 60, temperature 100.2.  He is sitting upright, alert and oriented and in no acute distress.  Skin is warm and dry.  Gross neurologic examination is normal.  ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes.  Neck: Full range of motion with no adenopathy or thyromegaly.  Cardiovascular: Regular rate and rhythm.  Lungs: Clear.  , ,On examination of the lumbar spine, he is minimally tender to palpation.  There is no overt muscular spasm.  His range of motion is estimated at 40 degrees of flexion and 15 degrees of extension.  Straight leg raises do not elicit any leg complaints on today's visit.  Lower extremity reflexes are symmetric., ,DIAGNOSIS: , Low back pain with a history of right leg pain.  The leg pain is no longer present.  His pain level has improved., ,PLAN:  ,1.  The patient will take another Medrol Dosepak.,2.  He can continue with physical therapy.,3.  He also continues with the same lifting restrictions.,4.  Follow up is within one week.
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DESCRIPTION: History of right leg pain.  Leg pain is no longer present.

The scenario describes a routine medical follow-up for a 44-year-old man experiencing low back pain with a history of right leg pain. The patient's symptoms have improved with medication and physical therapy. There are no indications of immediate severe complications or life-threatening conditions, and the patient's presentation during the exam was stable and without acute distress. His situation involves managing discomfort and monitoring for potential exacerbations of his condition. The stakes are not high because it pertains to ongoing management rather than an urgent or critical situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Ventricular Ectopy - Consult

REASON FOR CONSULTATION:,  Ventricular ectopy and coronary artery disease.,HISTORY OF PRESENT ILLNESS:  ,I am seeing the patient upon the request of Dr. Y.  The patient is a very well known to me.  He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.  The patient had presented to the hospital after having coughing episodes for about two weeks on and off, and seemed to have also given him some shortness of breath.  The patient was admitted and being treated for pneumonia, according to him.  The patient denies any chest pain, chest pressure, or heaviness.  Denies any palpitations, fluttering, or awareness of heart activity.  However, on monitor, he was noticed to have PVCs random.  He had run off three beats consecutive one time at 12:46 p.m. today.  The patient denied any awareness of that or syncope.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever or chills.,EYES:  No visual disturbances.,ENT:  No difficulty swallowing.,CARDIOVASCULAR:  Prior history of chest discomfort in 08/2009 with negative stress study.,RESPIRATORY:  Cough and shortness of breath.,MUSCULOSKELETAL:  Positive for arthritis and neck pain.,GU:  Unremarkable.,NEUROLOGIC:  Otherwise unremarkable.,ENDOCRINE:  Otherwise unremarkable.,HEMATOLOGIC:  Otherwise unremarkable.,ALLERGIC:  Otherwise unremarkable.,PAST MEDICAL HISTORY:,1.  Positive for coronary artery disease since 2002.,2.  History of peripheral vascular disease for over 10 years.,3.  COPD.,4.  Hypertension.,PAST SURGICAL HISTORY:,  Right fem-popliteal bypass about eight years ago, neck fusion in the remote past, stent-supported angioplasty to unknown vessel in the heart.,MEDICATIONS AT HOME:,1.  Aspirin 81 mg daily.,2.  Clopidogrel 75 mg daily.,3.  Allopurinol 100 mg daily.,4.  Levothyroxine 100 mcg a day.,5.  Lisinopril 10 mg a day.,6.  Metoprolol 25 mg a day.,7.  Atorvastatin 10 mg daily.,ALLERGIES: , THE PATIENT DOES HAVE ALLERGY TO MEDICATION.  HE SAID HE CANNOT TAKE ASPIRIN BECAUSE OF INTOLERANCE FOR HIS STOMACH AND STOMACH UPSET, BUT NO TRUE ALLERGY TO ASPIRIN.,FAMILY HISTORY:,  No history of premature coronary artery disease.  One daughter has early onset diabetes and one child has asthma.,SOCIAL HISTORY: , He is married and retired.  He has nine children, 25 grandchildren.  He smokes one pack per day.  He smoked 50 pack years and had no intention of quitting according to him.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature of 97, heart rate of 90, blood pressure of 187/105.,HEENT:  Normocephalic and atraumatic.  No thyromegaly or lymphadenopathy.,NECK:  Supple.,CARDIOVASCULAR:  Upstroke is normal.  Distal pulse symmetrical.  Heart regular with a normal S1 with normally split S2.  There is an S4 at the apex.,LUNGS:  With decreased air entry.  No wheezes.,ABDOMINAL:  Benign.  No masses.,EXTREMITIES:  No edema, cyanosis, or clubbing.,NEUROLOGIC:  Awake, alert, and oriented x3.  No focal deficits.,IMAGING STUDIES: , Echocardiogram on 08/26/2009, showed mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle, EF of 40%, mild mitral regurgitation, and diastolic dysfunction, grade 2.
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DESCRIPTION: Ventricular ectopy and coronary artery disease.   He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.

The patient has a complex cardiac history including coronary artery disease, peripheral vascular disease, and a recent episode of ventricular ectopy. Although the immediate presentation involves symptoms of a possible respiratory infection, the presence of ventricular ectopy and his risk factors elevate the stakes. These issues, if unaddressed, could potentially lead to severe cardiac events given his reduced ejection fraction and other complicating cardiac conditions. Therefore, the situation has significant medical implications.


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

PREOPERATIVE DIAGNOSIS:,  Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,POSTOPERATIVE DIAGNOSIS: , Cervical myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.,PROCEDURE PERFORMED:,1.  Anterior cervical discectomy, C4-C5 and C5-C6.,2.  Arthrodesis, C4-C5 and C5-C6.,3.  Partial corpectomy, C5.,4.  Machine bone allograft, C4-C5 and C5-C6.,5.  Placement of anterior cervical plate with a Zephyr C4 to C6.,6.  Fluoroscopic guidance.,7.  Microscopic dissection.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , 60 mL.,COMPLICATIONS: , None.,INDICATIONS:,  This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance.  He has also noted to have cord signal at the C4-C5 level secondary to a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6.  Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed.  He understood and wished to proceed.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in the supine position.  Preoperative antibiotics were given.  The patient was placed in the supine position with all pressure points noted and well padded.  The patient was prepped and draped in standard fashion.  An incision was made approximately above the level of the cricoid.  Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially.  We then placed needle into the disc spaces and was found to be at C5-C6.  Distracting pins were placed in the body of C4 and in to the body of C6.  The disc was then completely removed at C4-C5.  There was very significant compression of the cord.  This was carefully removed to avoid any type of pressure on the cord.  This was very severe and multiple free fragments were noted.  This was taken down to the level of ligamentum.  Both foramen were then also opened.  Other free fragments were also found behind the body of C5, part of the body of C5 was taken down to assure that all of these were removed.  The exact same procedure was done at C5-C6; however, if there were again free fragments noted, there was less not as severe compression at the C4-C5 area.  Again part of the body at C5 was removed to make sure that there was no additional constriction.  Both nerve roots were then widely decompressed.  Machine bone allograft was placed into the C4-C5 as well as C5-C6 and then a Zephyr plate was placed in the body of C4 and to the body of C6 with a metal pin placed into the body at C5.  Excellent purchase was obtained.  Fluoroscopy showed good placement and meticulous hemostasis was obtained.  Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin.  The patient tolerated the procedure well and went to recovery in good condition.
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DESCRIPTION: Anterior cervical discectomy, arthrodesis, partial corpectomy, Machine bone allograft, placement of anterior cervical plate with a Zephyr.
7.  Microscopic dissection.

neurosurgery, fluoroscopic guidance, microscopic dissectio, cervical plate, zephyr, corpectomy, arthrodesis, anterior cervical discectomy, machine bone allograft, cervical discectomy, bone allograft, disc herniations, anterior, cervical, discectomy,

The situation describes a surgical procedure for cervical myelopathy due to large disc herniations. The stakes are inherently high because neurosurgery involves operating on the spinal cord, which is critical for motor and sensory functions. Any errors during surgery can lead to serious, potentially life-altering complications such as paralysis or neurological deficits. Although the procedure described was completed without complications, the mere nature of the surgery and potential risks discussed make it high-stakes.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 23

SUBJECTIVE:,  Mom brings the patient in today for possible ear infection.  He is complaining of left ear pain today.  He was treated on 04/14/2004, with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today.  He has not had any fever but the congestion has continued to be very thick and purulent.  It has never really resolved.  He has a loose, productive-sounding cough but not consistently and not keeping him up at night.  No wheezing or shortness of breath.,PAST MEDICAL HISTORY:,  He has had some wheezing in the past but nothing recently.,FAMILY HISTORY: , All siblings are on antibiotics for ear infections and URIs.,OBJECTIVE:,General:  The patient is a 5-year-old male.  Alert and cooperative.  No acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, have distorted light reflexes but no erythema.  Gray in color.  Oropharynx pink and moist with a lot of postnasal discharge.  Nares are swollen and red.  Thick, purulent drainage.  Eyes are a little puffy.,Chest:  Respirations regular, nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry, pink.  Moist mucus membranes.  No rash.,ASSESSMENT:,  Ongoing purulent rhinitis.  Probable sinusitis and serous otitis.,PLAN:,  Change to Omnicef two teaspoons daily for 10 days.  Frequent saline in the nose.  Also, there was some redness around the nares with a little bit of yellow crusting.  It appeared to be the start of impetigo, so hold off on the Rhinocort for a few days and then restart.  Use a little Neosporin for now.
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DESCRIPTION: Patient in with mom for possible ear infection.

general medicine, ear infection, productive-sounding cough, purulent rhinitis, serous otitis, sinusitis, wheezing, ear, amoxicillin,

The situation involves a medical consultation for a child with recurring symptoms and possible sinusitis and ear infection. While it requires appropriate medical attention and treatment, it does not involve life-threatening conditions or require immediate critical interventions. The prescribed plan includes a change in antibiotics and observation. While important, it does not present high-stakes in the context of medical emergencies or severe conditions.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Posttransplant Lymphoproliferative Disorder

CHIEF COMPLAINT: , The patient is here for followup visit and chemotherapy.,DIAGNOSES:,1.  Posttransplant lymphoproliferative disorder.,2.  Chronic renal insufficiency.,3.  Squamous cell carcinoma of the skin.,4.  Anemia secondary to chronic renal insufficiency and chemotherapy.,5.  Hypertension.,HISTORY OF PRESENT ILLNESS: , A 51-year-old white male diagnosed with PTLD in latter half of 2007.  He presented with symptoms of increasing adenopathy, abdominal pain, weight loss, and anorexia.  He did not seek medical attention immediately.  He was finally hospitalized by the renal transplant service and underwent a lymph node biopsy in the groin, which showed diagnosis of large cell lymphoma.  He was discussed at the hematopathology conference.  Chemotherapy with rituximab plus cyclophosphamide, daunorubicin, vincristine, and prednisone was started.  First cycle of chemotherapy was complicated by sepsis despite growth factor support.  He also appeared to have become disoriented either secondary to sepsis or steroid therapy.,The patient has received 5 cycles of chemotherapy to date.  He did not keep his appointment for a PET scan after 3 cycles because he was not feeling well.  His therapy has been interrupted for infection related to squamous cell cancer, skin surgery as well as complaints of chest infection.,The patient is here for the sixth and final cycle of chemotherapy.  He states he feels well.  He denies any nausea, vomiting, cough, shortness of breath, chest pain or fatigue.  He denies any tingling or numbness in his fingers.  Review of systems is otherwise entirely negative.,Performance status on the ECOG scale is 1.,PHYSICAL EXAMINATION:,VITAL SIGNS:  He is afebrile.  Blood pressure 161/80, pulse 65, weight 71.5 kg, which is essentially unchanged from his prior visit.  There is mild pallor noted.  There is no icterus, adenopathy or petechiae noted.  CHEST:  Clear to auscultation.  CARDIOVASCULAR:  S1 and S2 normal with regular rate and rhythm.  Systolic flow murmur is best heard in the pulmonary area.  ABDOMEN:  Soft and nontender with no organomegaly.  Renal transplant is noted in the right lower quadrant with a scar present.  EXTREMITIES:  Reveal no edema.,LABORATORY DATA: , CBC from today shows white count of 9.6 with a normal differential, ANC of 7400, hemoglobin 8.9, hematocrit 26.5 with an MCV of 109, and platelet count of 220,000.,ASSESSMENT AND PLAN:,1.  Diffuse large B-cell lymphoma following transplantation.  The patient is to receive his sixth and final cycle of chemotherapy today.  PET scan has been ordered to be done within 2 weeks.  He will see me back for the visit in 3 weeks with CBC, CMP, and LDH.,2.  Chronic renal insufficiency.,3.  Anemia secondary to chronic renal failure and chemotherapy.  He is to continue on his regimen of growth factor support.,4.  Hypertension.  This is elevated today because he held his meds because he is getting rituximab other than that this is well controlled.  His CMP is pending from today.,5.  Squamous cell carcinoma of the skin.  The scalp is well healed.  He still has an open wound on the right posterior aspect of his trunk.  This has no active drainage, but it is yet to heal.  This probably will heal by secondary intention once chemotherapy is finished.  Prescription for prednisone as part of his chemotherapy has been given to him.
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DESCRIPTION: Posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma of the skin, anemia secondary to chronic renal insufficiency and chemotherapy, and hypertension.  The patient is here for followup visit and chemotherapy.

soap / chart / progress notes, anemia, chemotherapy, posttransplant lymphoproliferative disorder, squamous cell carcinoma, chronic renal insufficiency, renal insufficiency, adenopathy, lymphoproliferative,

This situation involves a patient with multiple serious medical conditions, including posttransplant lymphoproliferative disorder, chronic renal insufficiency, squamous cell carcinoma, anemia, and hypertension. The patient is receiving chemotherapy, which is inherently a high-stakes treatment due to potential severe side effects and complications, such as the sepsis mentioned in the history. While the patient appears stable at the moment, the ongoing need for chemotherapy and monitoring of multiple health issues contribute to the high-stakes nature of the situation. Decisions made during this followup could significantly impact the patient's health outcomes.


Medical Specialty: Urology
Sample Name: Prostate Adenocarcinoma

ADMISSION DIAGNOSIS:  ,Adenocarcinoma of the prostate.,HISTORY:,  The patient is a 71-year-old male whose personal physician, Dr. X identified a change in the patient's PSA from 7/2008 (4.2) to 4/2009 (10.5).  The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base.  The patient also had Gleason 6 in the right lobe, midportion, as well as the left apical portion.  He underwent a bone scan which was normal and cystoscopy which was normal and renal ultrasound that was normal.,SURGICAL HISTORY: , Appendectomy.,MEDICAL HISTORY:,  Atrial fibrillation.,MEDICATIONS:,  Coumadin and lisinopril.,SOCIAL HISTORY:  ,Smokes none.  Alcohol none.,ALLERGIES:,  NONE.,REVIEW OF SYSTEMS: , The patient relates no recent weight gain, weight loss, night sweats, fevers or chills.  Eyes:  No change in vision or diplopia.  Ears:  No tinnitus or vertigo.  Mouth:  No dysphagia.  Pulmonary:  No chronic cough or shortness of breath.  Cardiac:  No angina or palpitations.  GI:  No nausea, vomiting, diarrhea or constipation.  Musculoskeletal:  No arthritides or myalgias.  Hematopoietic:  No easy bleeding or bruising.  Skin:  No chronic ulcers or persistent itch.,PHYSICAL EXAMINATION:,GENERAL:  The patient is well developed and well nourished.,HEENT:  Head is normocephalic.  Eyes, pupils are equal.  Conjunctivae are pink.  Sclerae are anicteric.,NECK:  There is no adenopathy.,PULMONARY:  Respirations are unlabored.,HEART:  Regular rhythm.,ABDOMEN:  Liver, spleen, kidney, and bladder are not palpable.  There are no discernible masses.  There are no peritoneal signs.,GENITALIA:  The penis has no plaques.  Meatus is on the glans.  Scrotal skin is healthy.  Testicles are fair consistency.  Epididymides are nontender.,RECTAL:  The prostate is +1 to 2/4.  There are no areas that are suspicious for tumor.  Consistency is even.  Sidewalls are sharp.  Seminal vesicles are not palpable.,MUSCULOSKELETAL:  The upper and lower extremities are symmetric bilaterally.,NEUROLOGIC:  There are no gross focal neurologic abnormalities.,IMPRESSION:,1.  Adenocarcinoma of the prostate.,2.  Atrial fibrillation.,PLAN: , The patient's wife and I have discussed his treatment options, which include primarily radiation and surgery.  He has _________ surviving prostate cancer by Dr. Y.  He is aware of incontinency, both total and partial.  We discussed erectile dysfunction.  We have discussed bleeding, infection, injury to the rectum, injury to vessels and nerves, deep vein thrombosis, pulmonary embolus, MI, stroke, and death.  He had no questions at the conclusion of the conversation and he does know that in his age group, though a nerve-sparing procedure will be performed, preserving any erectile function is highly unlikely.  He had no questions at the conclusion of our last conversation.
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DESCRIPTION: Adenocarcinoma of the prostate.  The patient underwent a transrectal ultrasound and biopsy and was found to have a Gleason 3+4 for a score of 7, 20% of the tissue removed from the left base.

The case involves a diagnosis of prostate adenocarcinoma in a 71-year-old male. This is a significant diagnosis given the potential implications for the patient's health and quality of life. The Gleason score of 7 indicates a moderately aggressive cancer, which requires prompt and effective treatment to prevent progression and complications. Treatment options like surgery and radiation come with potential risks, including incontinence and erectile dysfunction, especially since it's noted that preserving erectile function is highly unlikely in his age group. All these factors, combined with potential complications and the necessity to manage the patient's existing conditions such as atrial fibrillation, elevate the stakes of medical decision-making in this scenario.


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

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

orthopedic, trigger thumb, trigger thumb release, tenosynovitis trigger, tenosynovitis, release, thumb, tourniquet, trigger,

The situation involves a surgical procedure for trigger thumb release, which is generally a routine and low-risk procedure in orthopedic surgery. It involves freeing a stenosing sheath to improve thumb mobility. While surgery always carries some level of risk, this particular procedure is considered low-stakes relative to other medical and orthopedic operations. There are no mentioned complications, which suggests the procedure went as expected.


Medical Specialty: Surgery
Sample Name: Vitrectomy - General Anesthesia

DESCRIPTION OF PROCEDURE: , After appropriate operative consent was obtained the patient was brought supine to the operating room and placed on the operating room table.  Induction of general anesthesia via endotracheal intubation was then accomplished without difficulty.  The patient's right eye was prepped and draped in sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a limited conjunctival peritomy performed at the limbus temporally and superonasally.  Infusion line was set up in the inferotemporal quadrant and two additional sclerotomies were made in the superonasal and superotemporal quadrants.  A lens ring was secured to the eye using 7-0 Vicryl suture.
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DESCRIPTION: Vitrectomy under general anesthesia

Vitrectomy under general anesthesia

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

The situation describes a surgical procedure involving a vitrectomy conducted under general anesthesia. Surgery, especially involving the eye, is typically a high-stakes situation due to the complexity and potential for serious complications. General anesthesia adds another layer of risk, requiring careful monitoring and management. The success of the procedure can significantly impact the patient's vision and overall health.


Medical Specialty: Surgery
Sample Name: Sling (SPARC Suburethral)

PREOPERATIVE DX: , Stress urinary incontinence.,POSTOPERATIVE DX: , Stress urinary incontinence.,OPERATIVE PROCEDURE: , SPARC suburethral sling.,ANESTHESIA: , General.,FINDINGS & INDICATIONS: , Outpatient evaluation was consistent with urethral hypermobility, stress urinary incontinence.  Intraoperatively, the bladder appeared normal with the exception of some minor trabeculations.  The ureteral orifices were normal bilaterally.,DESCRIPTION OF OPERATIVE PROCEDURE:,  This patient was brought to the operating room, a general anesthetic was administered.  She was placed in dorsal lithotomy position.  Her vulva, vagina, and perineum were prepped with Betadine scrubbed in solution.  She was draped in usual sterile fashion.  A Sims retractor was placed into the vagina and Foley catheter was inserted into the bladder.  Two Allis clamps were placed over the mid urethra.  This area was injected with 0.50% lidocaine containing 1:200,000 epinephrine solution.  Two areas suprapubically on either side of midline were injected with the same anesthetic solution.  The stab wound incisions were made in these locations and a sagittal incision was made over the mid urethra.  Metzenbaum scissors were used to dissect bilaterally to the level of the ischial pubic ramus.  The SPARC needles were then placed through the suprapubic incisions and then directed through the vaginal incision bilaterally.  The Foley catheter was removed.  A cystoscopy was performed using a 70-degree cystoscope.  There was noted to be no violation of the bladder.  The SPARC mesh was then snapped onto the needles, which were withdrawn through the stab wound incisions.  The mesh was snugged up against a Mayo scissor held under the mid urethra.  The overlying plastic sheaths were removed.  The mesh was cut below the surface of the skin.  The skin was closed with 4-0 Plain suture.  The vaginal vault was closed with a running 2-0 Vicryl stitch.  The blood loss was minimal.  The patient was awoken and she was brought to recovery in stable condition.
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DESCRIPTION: SPARC suburethral sling due to stress urinary incontinence.

surgery, stress urinary incontinence, foley catheter, metzenbaum scissor, sparc, sparc mesh, bladder, orifice, perineum, sling, suburethral, ureteral, urethral hypermobility, vagina, vaginal vault, vulva, cystoscopy, suburethral sling, stress urinary, urinary incontinence, incontinence

The operative procedure involves surgery to address stress urinary incontinence, which is a common condition that can significantly impact a patient's quality of life, but it is not life-threatening. The surgery itself is detailed, involving general anesthesia and various surgical techniques, but it is considered a routine procedure with minimal complications in most cases. The description indicates a stable outcome with minimal blood loss and the patient was stable post-op, further suggesting it's not high-stakes like urgent or life-saving surgeries.


Medical Specialty: Surgery
Sample Name: Nephrectomy - Radical

PREOPERATIVE DIAGNOSIS: , Right renal mass.,POSTOPERATIVE DIAGNOSIS: , Right renal mass.,PROCEDURE: , Right radical nephrectomy and assisted laparoscopic approach.,ANESTHESIA:  ,General.,PROCEDURE IN DETAIL:  ,The patient underwent general anesthesia with endotracheal intubation.  An orogastric was placed and a Foley catheter placed.  He was placed in a modified flank position with the hips rotated to 45 degrees.  Pillow was used to prevent any pressure points.  He was widely shaved, prepped, and draped.  A marking pen was used to delineate a site for the Pneumo sleeve in the right lower quadrant and for the trocar sites in the midline just above the umbilicus and halfway between the xiphoid and the umbilicus.  The incision was made through the premarked site through the skin and subcutaneous tissue.  The aponeurosis of the external oblique was incised in the direction of its fibers.  Muscle-splitting incision was made in the internal oblique and transversus abdominis.  The peritoneum was opened and the Pneumo sleeve was placed in the usual fashion being sure that no bowel was trapped inside the ring.  Then, abdominal insufflation was carried out through the Pneumo sleeve and the scope was passed through the Pneumo sleeve to visualize placement of the trocars in the other two positions.  Once this had been completed, the scope was placed in the usual port and dissection begun by taking down the white line of Toldt, so that the colon could be retracted medially.  This exposed the duodenum, which was gently swept off the inferior vena cava and dissection easily disclosed the takeoff of the right renal vein off the cava.  Next, attention was directed inferiorly and the ureter was divided between clips and the inferior tongue of Gerota fascia was taken down, so that the psoas muscle was exposed.  The attachments lateral to the kidney was taken down, so that the kidney could be flipped anteriorly and medially, and this helped in exposing the renal artery.  The renal artery had been previously noticed on the CT scan to branch early and so each branch was separately ligated and divided using the stapler device.  After the arteries had been divided, the renal vein was divided again using a stapling device.  The remaining attachments superior to the kidney were divided with the Harmonic scalpel and also utilized the stapler, and the specimen was removed.  Reexamination of the renal fossa at low pressures showed a minimal degree of oozing from the adrenal gland, which was controlled with Surgicel.  Next, the port sites were closed with 0 Vicryl utilizing the passer and doing it over the hand to prevent injury to the bowel and the right lower quadrant incision for the hand port was closed in the usual fashion.  The estimated blood loss was negligible.  There were no complications.  The patient tolerated the procedure well and left the operating room in satisfactory condition.
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DESCRIPTION: Right radical nephrectomy and assisted laparoscopic approach.

surgery, renal mass, foley catheter, gerota fascia, muscle-splitting incision, pneumo sleeve, endotracheal, laparoscopic, nephrectomy, orogastric, renal fossa, right lower quadrant, trocar, umbilicus, vena cava, renal, pneumo, radical,

The situation involves a radical nephrectomy, a major surgical procedure to remove a kidney due to conditions such as a renal mass which could be cancerous. The surgical details provided indicate the use of general anesthesia, control of vascular structures, and careful postoperative examination to ensure minimal complications. Given the complexity and potential life-impacting nature of the condition being addressed (e.g., cancer), this procedure is high-stakes due to the risks involved and its implications for the patient's health.


Medical Specialty: Surgery
Sample Name: Circumcision - Newborn

PROCEDURE: , Newborn circumcision.,INDICATIONS: , Parental preference.,ANESTHESIA:,  Dorsal penile nerve block.,DESCRIPTION OF PROCEDURE:,  The baby was prepared and draped in a sterile manner.  Lidocaine 1% 4 mL without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock.  The penile foreskin was removed using a XXX Gomco.  Hemostasis was achieved with minimal blood loss.  There was no sign of infection.  The baby tolerated the procedure well.  Vaseline was applied to the penis, and the baby was diapered by nursing staff.
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DESCRIPTION: Newborn circumcision.  The penile foreskin was removed using Gomco.

surgery, nerve block, newborn circumcision, foreskin, gomco, penis, circumcision, newborn, penile

The procedure described is a newborn circumcision, which is a routine and common surgical procedure with low risk when performed in a controlled medical environment. The situation is not considered high-stakes as it is a standard procedure with established protocols and low rates of complications when performed correctly.


Medical Specialty: General Medicine
Sample Name: Female ROS

FEMALE REVIEW OF SYSTEMS:,Constitutional:  Patient denies fevers, chills, sweats and weight changes.,Eyes:  Patient denies any visual symptoms.,Ears, Nose, and Throat:  No difficulties with hearing.  No symptoms of rhinitis or sore throat.,Cardiovascular:  Patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,Respiratory:  No dyspnea on exertion, no wheezing or cough.,GI:  No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,GU:  No dysuria, frequency or incontinence.  No difficulties with vaginal discharge.,Musculoskeletal:  No myalgias or arthralgias.,Breasts:  Patient performs self-breast examinations and has noticed no abnormalities or nipple discharge.,Neurologic:  No chronic headaches, no seizures.  Patient denies numbness, tingling or weakness.,Psychiatric:  Patient denies problems with mood disturbance.  No problems with anxiety.,Endocrine:  No excessive urination or excessive thirst.,Dermatologic:  Patient denies any rashes or skin changes.
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DESCRIPTION: Sample female review of systems.

Sample female review of systems.

general medicine, constitutional, breasts, cardiovascular, dermatologic, endocrine, female review of systems, musculoskeletal, neurologic, psychiatric, review of systems, respiratory, abdominal pain, chest pains, constipation, diarrhea, hematochezia, melena, nausea, nipple discharge, numbness, orthopnea, palpitations, paroxysmal nocturnal dyspnea, rashes, tingling, vomiting, weakness, wheezing, nose, systems,

The Female Review of Systems (ROS) provided is a comprehensive checklist used by healthcare providers to quickly assess various health areas of a patient. Since the patient denies any symptoms across multiple systems, the current situation does not present immediate health threats or conditions. The context is a standard interaction in primary care to rule out potential issues. This process is routine and not associated with high-risk or emergency conditions.


Medical Specialty: Consult - History and Phy.
Sample Name: Rotator cuff syndrome - H&P

CHIEF COMPLAINT:  ,This 18 year old male presents today with shoulder pain right.  Location:  He indicates the problem location is the right shoulder diffusely.  Quality:  Quality of the pain is described by the patient as aching, throbbing and tolerable.  Patient relates pain on a scale from 0 to 10 as 5/10.  Severity:  The severity has worsened over the past 3 months.  Timing (onset/frequency):  Onset was gradual and after pitching a baseball game.  Modifying Factors:  Patient's condition is aggravated by throwing.  He participates with difficulty in basketball.  Past conservative treatments include NSAID and muscle relaxant medications.,ALLERGIES: , No known medical allergies.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY:  ,Childhood Illnesses: (+) strep throat (+) mumps (+) chickenpox,PAST SURGICAL HISTORY:,  No previous surgeries.,FAMILY HISTORY:,  Patient admits a family history of arthritis associated with mother.,SOCIAL HISTORY: , Patient denies smoking, alcohol abuse, illicit drug use and STDs.,REVIEW OF SYSTEMS:,Musculoskeletal: (+) joint or musculoskeletal symptoms (+) stiffness in AM.,Psychiatric: (-) psychiatric or emotional difficulties.,Eyes: (-) visual disturbance or change.,Neurological: (-) neurological symptoms or problems Endocrine: (-) endocrine-related symptoms.,Allergic / Immunologic: (-) allergic or immunologic symptoms.,Ears, Nose, Mouth, Throat: (-) symptoms involving ear, nose, mouth, or throat.,Gastrointestinal: (-) GI symptoms.,Genitourinary: (-) GU symptoms.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Cardiovascular: (-) cardiovascular problems or chest symptoms.,Respiratory: (-)breathing difficulties, respiratory symptoms.,Physical Exam:  BP Standing:  116/68 Resp:  16 HR:  68 Temp:  98.1 Height:  5 ft.  11 in.  Weight:  165 lbs.  Patient is a 18 year old male who appears pleasant, in no apparent distress, his given age, well developed, well nourished and with good attention to hygiene and body habitus.  Oriented to person, place and time.  Right shoulder shows evidence of swelling and tenderness.  Radial pulses are 2 /4, bilateral.  Brachial pulses are 2 /4, bilateral.,Appearance:  Normal.,Tenderness:  Anterior - moderate, Biceps - none, Posterior - moderate and Subacromial - moderate right.,Range of Motion:  Right shoulder ROM shows decreased flexion, decreased extension, decreased adduction, decreased abduction, decreased internal rotation, decreased external rotation.  L shoulder normal.,Strength:  External rotation - fair.  Internal rotation - poor right.,AC Joint:  Pain with ABD and cross-chest - mild right.,Rotator Cuff:  Impingement - moderate.  Painful arc - moderate right.,Instability:  None.,TEST & X-RAY RESULTS:,  X-rays of the shoulder were performed.  X-ray of right shoulder reveals cuff arthropathy present.,IMPRESSION: , Rotator cuff syndrome, right.,PLAN: , Diagnosis of a rotator cuff tendinitis and shoulder impingement were discussed.  I noted that this is a very common condition resulting in significant difficulties with use of the arm.  Several treatment options and their potential benefits were described.  Nonsteroidal anti-inflammatories can be helpful but typically are slow acting.  Cortisone shots can be very effective and are quite safe.  Often more than one injection may be required.  Physical therapy can also be helpful, particularly if there is any loss of shoulder mobility or strength.  If these treatments fail to resolve symptoms, an MRI or shoulder arthrogram may be required to rule out a rotator cuff tear.  Injected shoulder joint and with Celestone Soluspan 1.0 cc .  Ordered x-rays of shoulder right.,PRESCRIPTIONS:,  Vioxx Dosage:  25 mg tablet Sig:  TID Dispense:  60 Refills:  0 Allow Generic:  Yes,PATIENT INSTRUCTIONS:,  Patient was instructed to restrict activity.  Patient was given instructions on RICE therapy.
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DESCRIPTION: Shoulder pain, right shoulder diffusely - Rotator cuff syndrome, right.

The situation involves a medical consultation for an 18-year-old male with rotator cuff syndrome. While painful and potentially impacting the patient’s quality of life and athletic activity, this condition is commonly managed effectively with treatments such as NSAIDs, cortisone injections, and physical therapy. Although the situation requires professional medical attention and management, it is not life-threatening or critical in nature. Therefore, it can be considered low to moderate stakes.

Furthermore, the patient is in otherwise good health with no significant medical history that would exacerbate his current condition into a high-stakes situation. The medical practitioner has a clear plan involving non-invasive treatments and possible diagnostics (MRI, shoulder arthrogram) if needed. These factors contribute to the assessment that the stakes are not high.


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

Medical Specialty: Radiology
Sample Name: Ultrasound OB - 6

GENERAL EVALUATION:,Fetal Cardiac Activity: Normal at 140 BPM,Fetal Position: Variable,Placenta: Posterior without evidence of placenta previa.,Uterus: Normal,Cervix:
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DESCRIPTION: Ultrasound - a 22-year-old pregnant female.

radiology, pregnant female, fetal anatomy, pregnant, placenta, gestational, ultrasound, fetal,

The situation involves a routine ultrasound for a pregnant woman, focusing on evaluating fetal cardiac activity, fetal position, and placenta location. The findings indicate normal cardiac activity and no evidence of placenta previa, which are good signs in a pregnancy. This is a routine check and not high-stakes unless specific abnormalities are detected, which is not indicated here.


Medical Specialty: Surgery
Sample Name: Granuloma Excision

PREOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,POSTOPERATIVE DIAGNOSIS: , Pyogenic granuloma, left lateral thigh.,ANESTHESIA:,  General.,PROCEDURE: , Excision of recurrent pyogenic granuloma.,INDICATIONS: , The patient is 12-year-old young lady, who has a hand-sized congenital vascular malformation on her left lateral thigh below the greater trochanter, which was described by her parents as a birthmark.  This congenital cutaneous vascular malformation faded substantially over the first years of her life and has regressed to a flat, slightly hyperpigmented lesion.  Although no isolated injury event can be recalled, the patient has developed a pyogenic granuloma next to the distal portion of this lesion on her mid thigh, and it has been treated with topical cautery in her primary care doctor's office, but with recurrence.  She is here today for excision.,OPERATIVE FINDINGS: , The patient had what appeared to be a classic pyogenic granuloma arising from this involuted vascular malformation.,DESCRIPTION OF OPERATION:  ,The patient came to the operating room, had an uneventful induction of general anesthesia.  We conducted a surgical time-out, reiterated her important and unique identifying information and confirmed that the excision of the left thigh pyogenic granuloma was the procedure planned for today.  Preparation and draping was __________ ensued with a chlorhexidine based prep solution.  The pyogenic granuloma was approximately 6 to 7 mm in greatest dimension and to remove it required creating an elliptical incision of about 1 to 1.2 cm.  This entire area was infiltrated with 0.25% Marcaine with dilute epinephrine to provide a wide local field block and then an elliptical incision was made with a #15 scalpel blade, excising the pyogenic granuloma, its base, and a small rim of surrounding normal skin.  Some of the abnormal vessels in the dermal and subdermal layer were cauterized with the needle-tip electrocautery pencil.  The wound was closed in layers with a deep dermal roll of 5-0 Monocryl stitches supplemented by 5-0 intradermal Monocryl and Steri-Strips for final skin closure.  The patient tolerated the procedure well.  This nodule was submitted to pathology for confirmation of its histology as a pyogenic granuloma.  Blood loss was less than 5 mL and there were no complications.
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DESCRIPTION: Pyogenic granuloma, left lateral thigh.   Excision of recurrent pyogenic granuloma.

surgery, trochanter, granuloma, pyogenic granuloma, vascular malformation, pyogenic, vascular, malformation, thigh,

The procedure described is a routine surgical excision of a pyogenic granuloma on a 12-year-old patient. It is performed under general anesthesia, which is common but not particularly high-risk for a simple excision. Pyogenic granulomas are generally benign and treatable growths, and the report indicates no complications, minimal blood loss, and a routine post-operative course. Given this, the procedure is not considered high-stakes compared to more complex or life-threatening surgeries.


Medical Specialty: Chiropractic
Sample Name: Wrist Pain

CHIEF COMPLAINT:,  Left wrist pain.,HISTORY OF PRESENT PROBLEM:,
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DESCRIPTION: Consultation for wrist pain.

Consultation for wrist pain.

chiropractic, wrist pain, scapholunate, tenderness to palpation, three views, traumatic wrist injury, ulnar styloid nonunion, ulnar styloid, wrist, union, soreness, styloid, ulnar,

The situation involves a consultation for wrist pain, which is typically not life-threatening but can affect quality of life and daily functioning. In a chiropractic context, it usually involves addressing musculoskeletal issues. While important, it is lower-stakes compared to situations involving severe or potentially life-threatening conditions.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 18

SUBJECTIVE:,  This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks.  Started off as a congestion but then he started coughing about a week ago.  Cough has gotten worsen.  Mother was also worried.  He had Pop Can just three days ago and she never found the top of that and was wondering if he had swallowed that, but his breathing has not gotten worse since that happened.  He is not running any fevers.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Fairly healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  The sister is in today with clinical sinusitis.  Mother and father have been healthy.,REVIEW OF SYSTEMS:,  He has been congested for about three weeks ago.  Coughing now but no fevers.  No vomiting.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed male in no acute distress, afebrile.,Vital Signs:  Weight:  22 pounds 6 ounces.,HEENT:  Sclerae and conjunctivae are clear.  Extraocular muscles are intact.  TMs are clear.  Nares are very congested.  Oropharynx has drainage in the back of the throat.  Mucous membranes are moist.  Mild erythema though.,Neck:  Some shotty lymphadenopathy.  Full range of motion.  Supple.,Chest:  Clear.  No crackles.  No wheezes.,Cardiovascular:  Regular rate and rhythm.  Normal S1, S2.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  Clear.  Tone is good.  Capillary refill less than 3 seconds.,RADIOLOGY:,  Chest x-ray:  No foreign body noted as well.  No signs of pneumonia.,ASSESSMENT:,  Clinical sinusitis and secondary cough.,PLAN:,  Amoxicillin a teaspoon twice daily for 10 days.  Plenty of fluids.  Tylenol and Motrin p.r.n., as well as oral decongestant and if coughing is not improving.
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DESCRIPTION: 1-year-old male who comes in with a cough and congestion.  Clinical sinusitis and secondary cough.

consult - history and phy., congestion, cough, sinusitis and secondary cough, cough and congestion, secondary cough, clinical sinusitis, male, sinusitis,

The situation involves a 1-year-old child with respiratory symptoms (cough and congestion) that have persisted for several weeks. However, the physical examination and radiology results do not indicate any acute distress or severe issues like pneumonia, and a possible foreign body ingestion has been ruled out on chest x-ray. The child is being prescribed antibiotics for sinusitis and additional medications for symptom management, indicating that medical professionals are taking appropriate steps. Although parental concern is noted, it seems to be reasonably controlled and addressed by medical examination and treatment. Given these elements, the situation doesn't appear to be life-threatening or critical.


Medical Specialty: Consult - History and Phy.
Sample Name: Hypertension & Cardiomyopathy

PROBLEMS LIST:,1.  Nonischemic cardiomyopathy.,2.  Branch vessel coronary artery disease.,3.  Congestive heart failure, NYHA Class III.,4.  History of nonsustained ventricular tachycardia.,5.  Hypertension.,6.  Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications.  However, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest.  He has history of orthopnea and PND.  He has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,REVIEW OF SYSTEMS: , Positive for right upper quadrant pain.  He has occasional nausea, but no vomiting.  His appetite has decreased.  No joint pain, TIA, seizure or syncope.  Other review of systems is unremarkable.,I reviewed his past medical history, past surgical history, and family history.,SOCIAL HISTORY: , He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,ALLERGIES: , He has no known drug allergies.,MEDICATIONS:,  I reviewed his medication list in the chart.  He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07.  HEENT:  Atraumatic and normocephalic.  No pallor, icterus or cyanosis.  NECK:  Supple.  Jugular venous distention 5 cm above the clavicle present.  No thyromegaly.  LUNGS:  Clear to auscultation.  No rales or rhonchi.  Pulse ox was 98% on room air.  CVS:  S1 and S2 present.  S3 and S4 present.  ABDOMEN:  Soft and nontender.  Liver is palpable 5 cm below the right subcostal margin.  EXTREMITIES:  No clubbing or cyanosis.  A 1+ edema present.,ASSESSMENT AND PLAN:,  The patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease.  Clinically, he is in NYHA Class III.  He has some volume overload and was not unfortunately taking Lasix as prescribed.  I have advised him to take Lasix 40 mg p.o. b.i.d.  I also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d.  I advised him to continue to take Toprol and lisinopril.  I have also added Aldactone 25 mg p.o. daily for survival advantage.  I reinforced the idea of not using cocaine.  He states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine.  I encouraged him to find a primary care provider.  He will come for a BMP check in one week.  I asked him to check his blood pressure and weight.  I discussed medication changes and gave him an updated list.  I have asked him to see a gastroenterologist for hepatitis C.  At this point, his Medicaid is pending.  He has no insurance and finds hard to find a primary care provider.  I will see him in one month.  He will have his fasting lipid profile, AST, and ALT checked in one week.
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DESCRIPTION: Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.

consult - history and phy., congestive heart failure, hypertension, cardiomyopathy, coronary artery disease, ventricular tachycardia, nonischemic cardiomyopathy, branch vessel, nyha class, nonischemic, tachycardia, orthopnea,

The patient's condition involves multiple severe health issues including nonischemic cardiomyopathy, coronary artery disease, congestive heart failure (Class III), history of ventricular tachycardia, and uncontrolled hypertension. The patient was recently hospitalized and is now non-compliant with prescribed medication, leading to exacerbation of symptoms. Additionally, there's a complexity added by social factors, such as lack of insurance and potential substance use, which can complicate management and adherence to medical advice. The situation is life-threatening and requires close monitoring and intervention to prevent potentially fatal outcomes.


Medical Specialty: Discharge Summary
Sample Name: Otitis Media - Discharge Summary

ADMITTING DIAGNOSES:,1.  Fever.,2.  Otitis media.,3.  Possible sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-month-old male who was seen in the office 1 day prior to admission.  He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes.  He has been taking Tylenol and Advil to help decrease the fevers, but the fever has continued to rise.  He was noted to have some increased workup of breathing and parents returned to the office on the day of admission.,PAST MEDICAL HISTORY: , Significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce.,PHYSICAL EXAMINATION: , On exam, he was moderately ill appearing and lethargic.  HEENT:  Atraumatic, normocephalic.  Pupils are equal, round, and reactive to light.  Tympanic membranes were red and yellow, and opaque bilaterally.  Nares were patent.  Oropharynx was slightly moist and pink.  Neck was soft and supple without masses.  Heart is regular rate and rhythm without murmurs.  Lungs showed increased workup of breathing, moderate tachypnea.  No rales, rhonchi or wheezes were noted.  Abdomen:  Soft, nontender, nondistended.  Active bowel sounds.  Neurologic exam showed good muscle strength, normal tone.  Cranial nerves II through XII are grossly intact.,LABORATORY FINDINGS: , He had electrolytes, BUN and creatinine, and glucose all of which were within normal limits.  White blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection.  Urinalysis was completely unremarkable.  Chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest.,HOSPITAL COURSE: , The patient was admitted to the hospital and allowed a clear liquid diet.  Activity is as tolerates.  CBC with differential, blood culture, electrolytes, BUN, and creatinine, glucose, UA, and urine culture all were ordered.  Chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia.  Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94%.  Gave D5 and quarter of normal saline at 45 mL per hour, which was just slightly above maintenance rate to help with hydration.  He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis, and I will add Tylenol and ibuprofen as needed for fevers.  Overnight, he did have his oxygen saturations drop and went into oxygen overnight.  His lungs remained clear, but because of the need for O2, we instituted albuterol aerosols every 6 hours to help maintain good lung function.  The nurses were instructed to attempt to wean O2 if possible and advance the diet.  He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient.  He did well the following evening with no further oxygen requirement.  He continued to spike fevers but last fever was around 13:45 on the previous day.  At the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees F. with clear lungs.  He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning.,CONDITION OF THE PATIENT AT DISCHARGE: , He was at 100% oxygen saturations on room air with no further dips at night.  He has become afebrile and was having no further increased work of breathing.,DISCHARGE DIAGNOSES:,1.  Bilateral otitis media.,2.  Fever.,PLAN:  ,Recommended discharge.  No restrictions in diet or activity.  He was continued Omnicef 125 mg/5 mL one teaspoon p.o. once daily and instructed to follow up with Dr. X, his primary doctor, on the following Tuesday.  Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy.
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DESCRIPTION: Fever, otitis media, and possible sepsis.

discharge summary, sepsis, cough, nasal congestion, rhinorrhea, oxygen saturations, otitis media, otitis, breathing, lungs, oropharynx, fever

The situation involves a 10-month-old infant admitted to the hospital with otitis media, fever, and possible sepsis. Infants are particularly vulnerable, and sepsis is a serious condition that can be life-threatening if not managed properly. The medical team monitored the child closely and intervened with antibiotics and supportive care, which ultimately stabilized his condition. Although the immediate risk to the child was mitigated, the initial concern of sepsis and the need for oxygen therapy indicate a high-stakes medical situation. The health and life of an infant were at risk, requiring careful and prompt medical attention. Therefore, while the discharge summary indicates stabilization, the initial circumstances were critical.


Medical Specialty: General Medicine
Sample Name: Normal Physical Exam Template - 2

GENERAL APPEARANCE: , This is a well-developed and well-nourished, ??,VITAL SIGNS: , Blood pressure ??, heart rate ?? and regular, respiratory rate ??, temperature is ?? degrees Fahrenheit.  Height is ?? feet ?? inches.  Weight is ?? pounds.  This yields a body mass index of ??.,HEAD, EYES, EARS, NOSE AND THROAT:,  The pupils were equal, round and reactive to light.  Extraocular movements are intact.  Sclera are nonicteric.  Ears, nose, mouth and throat - Externally the ears and nose are normal.  The mucous membranes are moist and midline.,NECK:  ,The neck is supple without masses.  No thyromegaly, no carotid bruits, no adenopathy.,LUNGS:  ,There is a normal respiratory effort.  Bilateral breath sounds are clear.  No wheezes or rales or rhonchi.,CARDIAC: , Normal cardiac impulse location.  S1 and S2 are normal.  No rubs, murmurs or gallops.  A regular rate and rhythm.  There are no abdominal aortic bruits.  The carotid, brachial, radial, femoral, popliteal and dorsalis pedis pulses are 2+ and equal bilaterally.,EXTREMITIES: , The extremities are without clubbing, cyanosis, or edema.,CHEST: , The chest examination is unremarkable.,BREASTS:  ,The breasts show no masses or tenderness.  No axillary adenopathy.,ABDOMEN:,  The abdomen is flat, soft, nontender, no organomegaly, no masses, normal bowel sounds are present.,RECTAL: , Examination was deferred.,LYMPHATIC: , No neck, axillary or groin adenopathy was noted.,SKIN EXAMINATION:,  Unremarkable.,MUSCULOSKELETAL EXAMINATION: , Grossly normal.,NEUROLOGIC: , The cranial nerves two through twelve are grossly intact.  Patellar and biceps reflexes are normal.,PSYCHIATRIC: , The patient is awake, alert and oriented times three.  Judgment and insight are good.  Affect is appropriate.
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DESCRIPTION: Normal physical exam template.  This is a well-developed and well-nourished.  The pupils were equal, round and reactive to light.  Extraocular movements are intact.

The provided text is a template for a normal physical examination. This kind of template is typically used for routine documentation during physical exams and does not contain any specific patient information or present any immediate health concerns. Routine physical exams are standard procedures that do not inherently involve high-stakes decisions unless abnormal or concerning findings are recorded, which is not the case here.


Medical Specialty: Dermatology
Sample Name: Acne - SOAP

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

Acne with folliculitis.

dermatology, acne with folliculitis, tazorac cream, acne, tazorac, cream, folliculitis,

The situation describes a dermatology case focusing on acne with folliculitis. While the patient is experiencing discomfort and is seeking further cosmetic and skin care options, the condition itself is not life-threatening. The treatment plan is standard and involves continuing antibiotics, topical treatment, and referral for cosmetic consultation. Given the patient's overall good health and the non-critical nature of acne and folliculitis, the stakes are not considered high.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy & Decompression - 1

PREOPERATIVE DIAGNOSES,1.  Herniated disc, C5-C6.,2.  Cervical spondylosis, C5-C6.,POSTOPERATIVE DIAGNOSES,1.  Herniated disc, C5-C6.,2.  Cervical spondylosis, C5-C6.,PROCEDURES,1.  Anterior cervical discectomy with decompression, C5-C6.,2.  Anterior cervical fusion, C5-C6.,3.  Anterior cervical instrumentation, C5-C6.,4.  Allograft C5-C6.,ANESTHESIA:  ,General endotracheal.,COMPLICATIONS:,  None.,PATIENT STATUS: , Taken to recovery room in stable condition.,INDICATIONS: , The patient is a 36-year-old female who has had severe, recalcitrant right upper extremity pain, numbness, tingling, shoulder pain, axial neck pain, and headaches for many months.  Nonoperative measures failed to relieve her symptoms and surgical intervention was requested.  We discussed reasonable risks, benefits, and alternatives of various treatment options.  Continuation of nonoperative care versus the risks associated with surgery were discussed.  She understood the risks including bleeding, nerve vessel damage, infection, hoarseness, dysphagia, adjacent segment degeneration, continued worsening pain, failed fusion, and potential need for further surgery.  Despite these risks, she felt that current symptoms will be best managed operatively.,SUMMARY OF SURGERY IN DETAIL: , Following informed consent and preoperative administration of antibiotics, the patient was brought to the operating suite.  General anesthetic was administered.  The patient was placed in the supine position.  All prominences and neurovascular structures were well accommodated.  The patient was noted to have pulse in this position.  Preoperative x-rays revealed appropriate levels for skin incision.  Ten pound inline traction was placed via Gardner-Wells tongs and shoulder roll was placed.  The patient was then prepped and draped in sterile fashion.  Standard oblique incision was made over the C6 vertebral body in the proximal nuchal skin crease.  Subcutaneous tissue was dissected down to the level of the omohyoid which was transected.  Blunt dissection was carried out with the trachea and the esophagus in the midline and the carotid sheath in its vital structures laterally.  This was taken down to the prevertebral fascia which was bluntly split.  Intraoperative x-ray was taken to ensure proper levels.  Longus colli was identified and reflected proximally 3 to 4 mm off the midline bilaterally so that the anterior cervical Trimline retractor could be placed underneath the longus colli, thus placing no new traction on the surrounding vital structures.  Inferior spondylosis was removed with high-speed bur.  A scalpel and curette was used to remove the disc.  Decompression was carried posterior to the posterior longitudinal ligament down to the uncovertebral joints bilaterally.  Disc herniation was removed from the right posterolateral aspect of the interspace.  High-speed bur was used to prepare the endplate down to good bleeding bone and preparation for fusion.  Curette and ball tip dissector was then passed out the foramen and along the ventral aspect of the dura.  No further evidence of compression was identified.  Hemostasis was achieved with thrombin-soaked Gelfoam.  Interspace was then distracted with Caspar pin distractions set gently.  Interspace was then gently retracted with the Caspar pin distraction set.  An 8-mm allograft was deemed in appropriate fit.  This was press fit with demineralized bone matrix and tamped firmly into position achieving excellent interference fit.  The graft was stable to pull-out forces.  Distraction and traction was then removed and anterior cervical instrumentation was completed using a DePuy Trimline anterior cervical plate with 14-mm self-drilling screws.  Plate and screws were then locked to the plate.  Final x-rays revealed proper positioning of the plate, excellent distraction in the disc space, and apposition of the endplates and allograft.  Wounds were copiously irrigated with normal saline.  Omohyoid was approximated with 3-0 Vicryl.  Running 3-0 Vicryl was used to close the platysma.  Subcuticular Monocryl and Steri-Strips were used to close the skin.  A deep drain was placed prior to wound closure.  The patient was then allowed to awake from general anesthetic and was taken to the recovery room in stable condition.  There were no intraoperative complications.  All needle and sponge counts were correct.  Intraoperative neurologic monitoring was used throughout the entirety of the case and was normal.
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DESCRIPTION: Anterior cervical discectomy with decompression, anterior cervical fusion, anterior cervical instrumentation, and Allograft C5-C6.

surgery, cervical spondylosis, cervical fusion, decompression, instrumentation, anterior cervical discectomy, anterior cervical, herniated disc, cervical discectomy, anterior, cervical, fusion, allograft, discectomy

The situation involves a detailed surgical procedure, specifically an anterior cervical discectomy and decompression at the C5-C6 level. This type of surgery, while routine in some surgical practices, involves significant risks such as nerve damage, bleeding, and potential complications which were all acknowledged and communicated to the patient. The outcome of the surgery can have life-altering impacts on the patient's quality of life, potentially relieving severe symptoms or leading to further complications if anything goes wrong. These factors inherently make it a high-stakes situation. Given the successful completion and stable postoperative condition of the patient, the immediate stakes are mitigated, but the inherent risk and potential for serious complications justify a higher stakes level.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Low-Transverse C-Section - 2

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2.  Protein S low.,3.  Oligohydramnios.,POSTOPERATIVE:,1.  Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.,2.  Protein S low.,3.  Oligohydramnios.,4.  Delivery of a viable female, weight 5 pound, 14 ounces.  Apgars of 9 and 9 at 1 and 5 minutes respectively and cord pH is 7.314.,OPERATION PERFORMED:,  Low transverse C-section.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS: , Foley.,ANESTHESIA: , Spinal with Duramorph.,HISTORY OF PRESENT ILLNESS:  ,This is a 21-year-old white female gravida 1, para 0, who had presented to the hospital at 37-3/7 weeks for induction.  The patient had oligohydramnios and also when placed on the monitor had nonreassuring fetal heart rate with late deceleration.  Due to the IUGR as well a decision for a C-section was made.,PROCEDURE: , The patient was taken to the operating room and placed in a seated position with standard spinal form of anesthesia administered by the Anesthesia Department.  The patient was then repositioned, prepped and draped in a slight left lateral tilt.  Once this was completed first knife was used to make a low transverse skin incision approximately two fingerbreadths above the pubic symphysis.  This was extended down to the level of the fascia.  The fascia was nicked in the center and extended in transverse fashion.  Edges of the fascia were grasped with Kocher and both blunt and sharp dissection both caudally and cephalic was completed consistent with the Pfannenstiel technique.  The abdominal rectus muscle was divided in the center, extended in vertical fashion and the peritoneum was entered at a high point and extended in vertical fashion.  Bladder blade was put in place and a bladder flap was created with the use of Metzenbaum and pickups and then bluntly dissected via cautery and reincorporated in the bladder blade.  Second knife was used to make a low transverse uterine incision with care being taken to avoid the presenting part of fetus.  Presenting part was vertex, the head was delivered, followed by the remaining portion of the body.  The mouth and nose were suctioned through bulb syringe and the cord was doubly clamped and cut and then the newborn handed off to waiting nursing personnel.  Cord pH blood and cord blood was obtained.  The placenta was delivered manually and the uterus was externalized and the lining was cleaned off any remaining placental fragments and blood and the incisional edges were reapproximated with 0-chromic and a continuous locking stitch with a second layer used to imbricate the first.  The bladder flap was re-peritonized with Gelfoam underneath and abdomen was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position.  The gutters were wiped clean of any remaining blood and fluid and the edges of the perineum grasped with hemostats and continuous locking stitches of 2-0 Vicryl was used to reapproximate the abdominal rectus muscle as well as the perineum.  This area was then irrigated.  Cautery was used for adequate hemostasis, corners of the fascia grasped with hemostats and continuous locking stitch of 1-Vicryl was started at both corners and overlapped in the center.  Subcutaneous tissue was irrigated with saline and reapproximated with 3-0 Vicryl.  Skin edges reapproximated with sterile staples.  Sterile dressing was applied.  The uterus was evacuated of any remaining clots vaginally.  The patient was taken to recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.
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DESCRIPTION: Intrauterine pregnancy at 37 plus weeks, nonreassuring fetal heart rate.

obstetrics / gynecology, apgars, low transverse c section, fetal heart rate, bladder blade, intrauterine pregnancy, intrauterine

This situation involves a C-section due to a nonreassuring fetal heart rate and oligohydramnios, both of which indicate potential distress for the fetus. The stakes are high because the well-being of both the mother and baby can be at risk. Managing fetal distress and ensuring a safe delivery are critical tasks for the healthcare team. This is compounded by the need for rapid decision-making and effective medical intervention to prevent complications. The outcome was successful, with the delivery of a healthy baby and stable condition of the mother, but the potential for serious consequences if not managed well makes it a high-stakes situation.


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

SUBJECTIVE:,  Mom brings patient in today because of sore throat starting last night.  Eyes have been very puffy.  He has taken some Benadryl when all of this congestion started but with a sudden onset just yesterday.  He has had low-grade fever and just felt very run down, appearing very tired.  He is still eating and drinking well, and his voice has been hoarse but no coughing.  No shortness of breath, vomiting, diarrhea or abdominal pain.,PAST MEDICAL HISTORY:,  Unremarkable.  There is no history of allergies.  He does have some history of some episodes of high blood pressure, and his weight is up about 14 pounds from the last year.,FAMILY HISTORY: , Noncontributory.  No one else at home is sick.,OBJECTIVE:,General:  A 13-year-old male appearing tired but in no acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, gray in color.  Good light reflex.  Oropharynx pink and moist.  No erythema or exudate.  Some drainage is seen in the posterior pharynx.  Nares:  Swollen, red.  No drainage seen.  No sinus tenderness.  Eyes are clear.,Chest:  Respirations are regular and nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry and pink, moist mucous membranes.  No rash.,LABORATORY:,  Strep test is negative.  Strep culture is negative.,RADIOLOGY:,  Water's View of the sinuses is negative for any sinusitis or acute infection.,ASSESSMENT:,  Upper respiratory infection.,PLAN:,  At this point just treat symptomatically.  I gave him some samples of Levall for the congestion and as an expectorant.  Push fluids and rest.  May use ibuprofen or Tylenol for discomfort.
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DESCRIPTION: Sore throat - Upper respiratory infection.

soap / chart / progress notes, soap, uri, upper respiratory infection, water's view, congestion, light reflex, sore throat, respiratory, strep, infection,

The situation described is a medical consultation for a 13-year-old male with symptoms consistent with an upper respiratory infection (URI). While the patient exhibits discomfort symptoms such as a sore throat, puffy eyes, and tiredness, the objective findings and lab results do not indicate a severe illness or immediate health threat. There is no evidence of strep throat or sinusitis, and the child is in no acute distress according to the objective examination. The plan of care involves symptomatic treatment and is quite routine for a URI, which is a common and generally low-stakes medical condition unless complications develop, which are not present here.


Medical Specialty: Radiology
Sample Name: MRI Brain -  Meningioma (Olfactory)

CC:, Progressive visual loss.,HX:, 76 y/o male suddenly became anosmic following shoulder surgery 13 years prior to this presentation. He continues to be anosmic, but has also recently noted decreased vision OD. He denies any headaches, weakness, numbness, weight loss, or nasal discharge.,MEDS:, none.,PMH:, 1) Diabetes Mellitus dx 1 year ago. 2) Benign Prostatic Hypertrophy, s/p TURP. 3) Right shoulder surgery (?DJD).,FHX:, noncontributory.,SHX:, Denies history of Tobacco/ETOH/illicit drug use.,EXAM:, BP132/66 HR78 RR16 36.0C,MS: A&O to person, place, and time. No other specifics given in Neurosurgery/Otolaryngology/Neuro-ophthalmology notes.,CN: Visual acuity has declined from 20/40 to 20/400, OD; 20/30, OS. No RAPD. EOM was full and smooth and without nystagmus. Goldmann visual fields revealed a central scotoma and enlarged blind spot OD and OS (OD worse) with a normal periphery. Intraocular pressures were 15/14 (OD/OS). There was moderate pallor of the disc, OD. Facial sensation was decreased on the right side (V1 distribution).,Motor/Sensory/Coord/Station/Gait: were all unremarkable.,Reflexes: 2/2 and symmetric throughout. Plantars were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, MRI Brain, 10/7/92, revealed: a large 6x5x6cm slightly heterogeneous, mostly isointense lesion on both T1 and T2 weighted images arising from the planum sphenoidale and olfactory groove. The mass extends approximately 3.6cm superior to the planum into both frontal regions with edema in both frontal lobes. The mass extends 2.5cm inferiorly involving the ethmoid sinuses with resultant obstruction of the sphenoid and frontal sinuses.,It also extends into the superomedial aspect of the right maxillary sinus. There is probable partial encasement of both internal carotid arteries just above the siphon. The optic nerves are difficult to visualize but there is also probable encasement of these structures as well. The mass enhances significantly with gadolinium contrast. These finds are consistent with Meningioma.,The patient underwent excision of this tumor by simultaneous bifrontal craniotomy and lateral rhinotomy following an intrasinus biopsy which confirmed the meningioma. Postoperatively, he lost visual acuity, OS, but this gradually returned to baseline. His 9/6/96 neuro-ophthalmology evaluation revealed visual acuity of 20/25-3 (OD) and 20/80-2 (OS). His visual fields continued to abnormal, but improved and stable when compared to 10/92. His anosmia never resolved.
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DESCRIPTION: MRI Brain - Olfactory groove meningioma.

radiology, mri brain, olfactory, groove, headaches, meningioma, nasal discharge, numbness, visual loss, weakness, weight loss, visual acuity, mri, brain, isointense, sinuses, visual,

The situation involves a detailed radiological medical case where a patient has a large brain meningioma causing significant symptoms like anosmia and vision loss. Surgical intervention was needed, and there were postoperative complications affecting vision. The case involves high-stakes medical decisions and procedures with potential life-altering outcomes for the patient's sensory functions and overall quality of life.


Medical Specialty: Consult - History and Phy.
Sample Name: H&P - Weakness

CHIEF COMPLAINT:, Right-sided weakness.,HISTORY OF PRESENT ILLNESS:, The patient was doing well until this morning when she was noted to have right-sided arm weakness with speech difficulties. She was subsequently sent to ABC Medical Center for evaluation and treatment. At ABC, the patient was seen by Dr. H including labs and a head CT which is currently pending. The patient has continued to have right-sided arm and hand weakness, and has difficulty expressing herself. She does seem to comprehend words. The daughter states the patient is in the Life Care Center, and she believes this started this morning. The patient denies headache, visual changes, chest pain and shortness of breath. These changes have been constant since onset this morning, have not improved or worsened, and the patient notes no modifying factors.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,MEDICATIONS:, Medications are taken from the paperwork from Life Care Center and include: Lortab 3-4 times a day for pain, Ativan 0.25 mg by mouth every 12 hours p.r.n. pain, Depakote ER 250 mg p.o. q nightly, Actos 15 mg p.o. t.i.d., Lantus 35 units subcu q nightly, Glipizide 10 mg p.o. q day, Lanoxin 0.125 mg p.o. q day, Lasix 40 mg p.o. q day, Lopressor 50 mg p.o. b.i.d., insulin sliding scale, Lunesta 1 mg p.o. q nightly, Sorbitol 15 mg p.o. q day, Zoloft 50 mg p.o. q nightly, Dulcolax as needed for constipation.,PAST MEDICAL HISTORY:, Significant for moderate to severe aortic stenosis, urinary tract infection, hypertension, chronic kidney disease (although her creatinine is near normal).,SOCIAL HISTORY:, The patient lives at Life Care Center. She does not smoke, drink or use intravenous drugs.,FAMILY HISTORY:, Negative for cerebrovascular accident or cardiac disease.,REVIEW OF SYSTEMS:, As in HPI. Patient and daughter also deny weight loss, fevers, chills, sweats, nausea, vomiting, abdominal pain. She has had some difficulty expressing herself, but seems to comprehend speech as above. The patient has had a history of chronic urinary tract infections and her drainage is similar to past episodes when she has had such infection.,PHYSICAL EXAMINATION:,VITAL SIGNS: The patient is currently with a temperature of 99.1, blood pressure 138/59, pulse 69, respirations 15. She is 95% on room air.,GENERAL: This is a pleasant elderly female who appears stated age, in mild distress.,HEENT: Oropharynx is dry.,NECK: Supple with no jugular venous distention or thyromegaly.,RESPIRATORY: Clear to auscultation. No wheezes, rubs or crackles.,CARDIOVASCULAR: A 4/6 systolic ejection murmur best heard at the 2nd right intercostal space with radiation to the carotids.,ABDOMEN: Soft. Normal bowel sounds.,EXTREMITIES: No clubbing, cyanosis or edema. She does have bilateral above knee amputations.,NEUROLOGIC: Strength 2/5 in her right hand, 4/5 in her left hand. She does have mild right facial droop and an expressive aphasia.,VASCULAR: The patient has good capillary refill in her fingertips.,LABORATORY DATA:, BUN 52, creatinine 1.3. Normal coags. Glucose 220. White blood cell count 10,800. Urinalysis has 608 white cells, 625 RBCs. Head CT is currently pending. EKG shows normal sinus rhythm with mild ST-depression and biphasic T-waves diffusely.,ASSESSMENT AND PLAN:,1. Right-sided weakness with an expressive aphasia, at this time concerning for a left-sided middle cerebral artery cerebrovascular accident/transient ischemic attach given the patient's serious vascular disease. At this point we will hydrate, treat her urinary tract infection, check an MRI, ultrasound of her carotids, and echocardiogram to reevaluate valvular and left ventricular function. Start antiplatelet therapy and ask Neuro to see the patient.,2. Urinary tract infection. Will treat with ceftriaxone, check urine culture data and adjust as needed.,3. Dehydration. Will hydrate with IV fluids and follow p.o. intake while holding diuretics.,4. Diabetes mellitus type 2 uncontrolled. Her sugar is 249. We will continue Lantus insulin and sliding scale coverage, and check hemoglobin A1c to gauge prior control.,5. Prophylaxis. Will institute low molecular weight heparin and follow activity levels.
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DESCRIPTION: Patient with right-sided arm weakness with speech difficulties, urinary tract infection, dehydration, and diabetes mellitus type 2

The situation involves a potential cerebrovascular accident, possibly a stroke, which requires immediate medical attention and evaluation. The presence of neurological symptoms like right-sided weakness and expressive aphasia in an elderly patient, combined with a history of serious vascular disease, increases the urgency of the situation. Strokes are high-stakes without timely intervention as they can lead to serious and permanent health consequences. Furthermore, the patient has other medical conditions like diabetes that need to be managed carefully. Therefore, this scenario is high-stakes.