Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 34

Chief Complaint:, Chronic abdominal pain.,History of Present Illness:, 23-year-old Hispanic male who presented for evaluation of chronic abdominal pain. Patient described the pain as dull, achy, constant and located at the epigastric area with some radiation to the back. There are also occasional episodes of stabbing epigastric pain unrelated to meals lasting only minutes. Patient noted that the pain started approximately six months prior to this presentation. He self medicated "with over the counter" antacids and obtained some relief so he did not seek medical attention at that time.,Two months prior to current presentation, he had worsening of his pain as well as occasional nausea and vomiting. At this time the patient was found to be H. pylori positive by serology and was treated with triple therapy for two weeks and continued on omeprazole without relief of his pain.,The patient felt he had experienced a twenty-pound weight loss since his symptoms began but he also admitted to poor appetite. He stated that he had two to three loose bowel movements a day but denied melena or bright red blood per rectum. Patient denied NSAID use, ethanol abuse or hematemesis. Position did not affect the quality of the pain. Patient denied fever or flushing. He stated he was a very active and healthy individual prior to these recent problems.,Past Medical History:, No significant past medical history.,Past Surgical History:, No prior surgeries.,Allergies:, No known drug allergies.,Medications:, Omeprazole 40 mg once a day. Denies herbal medications.,Family History:, Mother, father and siblings were alive and well.,Social History:, He is employed as a United States Marine officer, artillery repair specialist. He was a social drinker in the past but quit altogether two years ago. He never used tobacco products or illicit/intravenous drugs.,Physical Examination:, The patient was a thin male in no apparent distress. His oral temperature was 98.2 Fahrenheit, blood pressure was 114/67 mmHg, pulse rate of 91 beats per minute and regular, respiratory rate was 14 and his pulse oximetry on room air was 98%. Patient was 52 kg in weight and 173 cm height.,SKIN: No skin rashes, lesions or jaundice. He had one tattoo on each upper arm.,HEENT: Head was normocephalic and atraumatic. Pupils were equal, round and reactive. Anicteric sclerae. Tympanic membranes had a normal appearance. Normal funduscopic examination. Oral mucosa was moist and pink. Oral/pharynx was clear.,NECK: No lymphadenopathy. No carotid bruits. Trachea midline. Thyroid non-palpable. No jugular venous distension.,CHEST: Lungs were clear bilaterally with good air movement.,HEART: Regular rate and rhythm. Normal S1 and S2 with no murmurs, gallops or rubs. PMI was non-displaced.,ABDOMEN: Abdomen was flat. Normal active bowel sounds. Liver span percussed sixteen centimeters, six centimeters below R costal margin with irregular border that was mildly tender to palpation. Slightly tender to palpation in epigastric area. There was no splenomegaly. No abdominal masses were appreciated. No CVA tenderness was noted.,RECTAL: No perirectal lesions were found. Normal sphincter tone and no rectal masses. Prostate size was normal without nodules. Guaiac positive.,GENITALIA: Testes descended bilaterally, no penile lesions or discharge.,EXTREMITIES: No clubbing, cyanosis, or edema. No peripheral lymphadenopathy was noted.,NEUROLOGIC: Alert and oriented times three. Cranial nerves II to XII appeared intact. No muscle weakness or sensory deficits. DTRs equal and normal.,Radiology/Studies: 2 view CXR: Mild elevation right diaphragm.,CT of abdomen and pelvis: Too numerous to count bilobar liver masses up to about 8 cm. Extensive mass in the pancreatic body and tail, peripancreatic region and invading the anterior aspect of the left kidney. Question of vague splenic masses. No definite abnormality of the moderately distended gallbladder, bile ducts, right kidney, poorly seen adrenals, bowel or bladder. Evaluation of the retroperitoneum limited by paucity of fat.,Patient underwent several diagnostic procedures and soon after he was transferred to Houston Veterans Administration Medical Center to be near family and to continue work-up and treatment. At the HVAMC these diagnostic procedures were reviewed.
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DESCRIPTION: A male patient presented for evaluation of chronic abdominal pain.

The situation involves a patient with complex symptoms including chronic abdominal pain, significant weight loss, and numerous liver and pancreatic masses, which are potentially indicative of a serious underlying condition such as cancer. The diagnostic imaging findings are concerning, suggesting extensive metastatic disease. This requires urgent medical evaluation and management, possibly including invasive diagnostic and therapeutic interventions, making it a high-stakes medical situation.


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: Pediatric Rheumatology Consult

HISTORY:  ,We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic.  He was sent here with a chief complaint of joint pain in several joints for few months.  This is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he started to complain of pain in his fingers, elbows, and neck.  At this moment, this is better and is almost gone, but for several months, he was having pain to the point that he would cry at some point.  He is not a complainer according to his mom and he is a very active kid.  There is no history of previous illness to this or had gastrointestinal problems.  He has problems with allergies, especially seasonal allergies and he takes Claritin for it.  Other than that, he has not had any other problem.  Denies any swelling except for that doctor mentioned swelling on his elbow.  There is no history of rash, no stomach pain, no diarrhea, no fevers, no weight loss, no ulcers in his mouth except for canker sores.  No lymphadenopathy, no eye problems, and no urinary problems.,MEDICATIONS: , His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis.,ALLERGIES: , He has no allergies to any drugs.,BIRTH HISTORY:  ,Pregnancy and delivery with no complications.  He has no history of hospitalizations or surgeries.,FAMILY HISTORY: , Positive for arthritis in his grandmother.  No history of pediatric arthritis.  There is history of psoriasis in his dad.,SOCIAL HISTORY: , He lives with mom, dad, brother, sister, and everybody is healthy.  They live in Easton.  They have 4 dogs, 3 cats, 3 mules and no deer.  At school, he is in second grade and he is doing PE without any limitation.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Temperature is 98.7, pulse is 96, respiratory rate is 24, height is 118.1 cm, weight is 22.1 kg, and blood pressure is 61/44.,GENERAL:  He is alert, active, in no distress, very cooperative.,HEENT:  He has no facial rash.  No lymphadenopathy.  Oral mucosa is clear.  No tonsillitis.  His ear canals are clear and pupils are reactive to light and accommodation.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm and no murmur.,ABDOMEN:  Soft, nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation in any of his joints or active swelling today.  He has no tenderness either in any of his joints.  Muscle strength is 5/5 in proximal muscles.,LABORATORY DATA:,  Includes an arthritis panel.  It has normal uric acid, sedimentation rate of 2, rheumatoid factor of 6, and antinuclear antibody that is negative and C-reactive protein that is 7.1.  His mother stated that this was done while he was having symptoms.,ASSESSMENT AND PLAN: , This patient may have had reactive arthritis.  He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis.  I do not see any problems at this moment on his laboratories or on his physical examination.  This may have been related to recent episode of viral infection or infection of some sort.  Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints, I will be glad to see him back.,If you have any question on further assessment and plan, please do no hesitate to contact us.
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DESCRIPTION: A 7-year-old white male started to complain of pain in his fingers, elbows, and neck.  This patient may have had reactive arthritis.

consult - history and phy., rheumatology, pediatric, reactive arthritis, psoriatic arthritis, psoriasis, joints, swelling, arthritis,

The consultation describes a pediatric case with joint pain but no current signs of serious progression or complications. The symptoms have improved significantly, and tests do not indicate severe systemic issues. While the situation involves a young child with potentially distressing symptoms like joint pain that previously caused crying, the absence of serious lab findings and the improvement over time suggest that immediate high-stakes intervention is not necessary. Additionally, the specialist recommends only observation unless symptoms recur. Thus, this remains a manageable scenario with no immediate life-threatening implications.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Ophthalmology
Sample Name: Ophthalmology - Letter - 4

XYZ, M.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC.  The patient is being referred for evaluation of diabetic retinopathy.  The patient was just diagnosed with diabetes; however, he does not have any serious visual complaints at this time.,On examination, the patient is seeing 20/40 OD pinholing to 20/20.  The vision in the left eye is 20/20 uncorrected.  Applanation pressures are normal at 17 mmHg bilaterally.  Visual fields are full to count fingers OU and there is no relative afferent pupillary defect.  Slit lamp examination was within normal limits, other than trace to 1+ nuclear sclerosis OU.  On dilated examination, the patient shows a normal cup-to-disc ratio that is symmetric bilaterally.  The macula, vessels, and periphery are also within normal limits.,In conclusion, Mr. ABC does not show any evidence of diabetic retinopathy at this time.  We recommended him to have his eyes dilated once a year.  I have advised him to follow up with you for his regular check-ups.  Again, thank you for your kind referral of Mr. ABC and we should check on him once a year at this time.,Sincerely,,
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DESCRIPTION: The patient is being referred for evaluation of diabetic retinopathy.

ophthalmology, pupillary defect, cup-to-disc ratio, cup-to-disc, evaluation of diabetic retinopathy, referred for evaluation, diabetic retinopathy, visual, dilated, retinopathy, examination, diabetic,

The situation involves a routine ophthalmological evaluation for a patient recently diagnosed with diabetes to check for diabetic retinopathy. However, the findings are normal, and no immediate medical intervention is recommended. The stakes are relatively low as the patient currently does not exhibit any signs of diabetic retinopathy, and the recommendation is to continue with annual eye examinations. While monitoring for diabetic retinopathy is important for long-term eye health in diabetic patients, this particular assessment did not identify any urgent issues.


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

CONSTITUTIONAL:,  Normal; negative for fever, weight change, fatigue, or aching.,HEENT:,  Eyes normal; Negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects.  Ears normal; Negative for hearing or balance problems.  Nose normal; Negative for runny nose, sinus problems, or nosebleeds.  Mouth normal; Negative for dental problems, dentures, or bleeding gums.  Throat normal; Negative for hoarseness, difficulty swallowing, or sore throat.,CARDIOVASCULAR:,  Normal; Negative for angina, previous MI, irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation.,PULMONARY: , Normal; Negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema.,GASTROINTESTINAL: , Normal; Negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding.,GENITOURINARY:, Normal female OR male; Negative for incontinence, UTI, dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching.,SKIN: , Normal; Negative for rashes, keratoses, skin cancers, or acne.,MUSCULOSKELETAL: , Normal; Negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries.,NEUROLOGIC: , Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness.,PSYCHIATRIC: , Normal; Negative for anxiety, depression, or phobias.,ENDOCRINE:,  Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones.,HEMATOLOGIC/LYMPHATIC: , Normal; Negative for anemia, swollen glands, or blood disorders.,IMMUNOLOGIC: , Negative; Negative for steroids, chemotherapy, or cancer.,VASCULAR:,  Normal; Negative for varicose veins, blood clots, atherosclerosis, or leg ulcers.
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DESCRIPTION: Normal female review of systems template.  Negative for fever, weight change, fatigue, or aching.

consult - history and phy., cough, sputum, shortness of breath, fever, weight, fatigue, aching, nose, throat, swelling, disease, incontinence, bleeding, heartbeat, blood, joint,

The described situation involves a routine normal review of systems (ROS) for a female patient, which is a standard part of clinical practice. It systematically checks for symptoms across various body systems to ensure the patient's systems are functioning normally. As this document does not involve any acute or critical medical findings, and only reports normal health, it does not present high-stakes information usually associated with urgent medical issues.


Medical Specialty: Office Notes
Sample Name: Constipation - 1

Patient was informed by Dr. ABC that he does not need sleep study as per patient.,PHYSICAL EXAMINATION:,General:  Pleasant, brighter.,Vital signs:  117/78, 12, 56.,Abdomen:  Soft, nontender.  Bowel sounds normal.,ASSESSMENT AND PLAN:,1.  Constipation.  Milk of Magnesia 30 mL daily p.r.n., Dulcolax suppository twice a week p.r.n.,2.  CAD/angina.  See cardiologist this afternoon.,Call me if constipation not resolved by a.m., consider a Fleet enema then as discussed.,
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DESCRIPTION: Patient complains of constipation.  Has not had BM for two days.

office notes, constipation, bm, milk of magnesia, suppository, dulcolax, fleet enema,

The situation described is a routine medical office note documenting a common health issue (constipation) and a planned treatment. The stakes are relatively low because constipation, while uncomfortable, is typically not a severe condition and can be managed with over-the-counter treatments. The patient has a scheduled cardiology appointment, which indicates ongoing care for a potentially more serious condition (CAD/angina), but the immediate concern is about constipation. The plan includes easily accessible remedies and a clear call to action if constipation persists, minimizing risk.


Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consult - 2

SUBJECTIVE:,  The patient's assistant brings in her food diary sheets.  The patient says she stays active by walking at the mall.,OBJECTIVE:,  Weight today is 201 pounds, which is down 3 pounds in the past month.  She has lost a total of 24 pounds.  I praised this and encouraged her to continue.  I went over her food diary.  I praised her three-meal pattern and all of her positive food choices, especially the use of sugar-free Kool-Aid, sugar-free Jell-O, sugar-free lemonade, diet pop, as well as the variety of foods she is using in her three-meal pattern.  I encouraged her to continue all of this.,ASSESSMENT:,  The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.  She needs to continue all this.,PLAN:,  Followup is set for 06/13/05 to check the patient's weight, her food diary, and answer any questions.
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DESCRIPTION: The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.

consult - history and phy., food diary sheets, active, balanced diet, three-meal pattern, weight loss, sugar free, food diary, dietary, weight, meal, diary, sheets, food

The situation involves a dietary consultation where the patient is successfully losing weight and has been positively encouraged to continue her current habits. While weight management can have significant health implications, this particular instance indicates ongoing success, positive reinforcement, and a supportive plan without immediate high-risk factors. The meeting is routine follow-up to monitor progress rather than address urgent issues.


Medical Specialty: Orthopedic
Sample Name: Three Views - Ankle

EXAM: , Three views of the right ankle.,INDICATIONS:  ,Pain.,FINDINGS: , Three views of the right ankle are obtained.  There is no evidence of fractures or dislocations.  No significant degenerative changes or destructive osseous lesions of the ankle are noted.  There is a small plantar calcaneal spur.  There is no significant surrounding soft tissue swelling.,IMPRESSION:  ,Negative right ankle.
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DESCRIPTION: Pain.  Three views of the right ankle.  Three views of the right ankle are obtained.

orthopedic, three views, calcaneal, plantar, spur, osseous, ankle

The purpose of obtaining three views of the right ankle is to diagnose the cause of pain. The findings indicate no significant issues like fractures, dislocations, or substantial soft tissue swelling, hence ruling out serious conditions. The presence of a small plantar calcaneal spur is noted, but it is not life-threatening. Overall, the situation is related to diagnosing pain, with negative findings for severe conditions, making it relatively low-stakes.


Medical Specialty: Surgery
Sample Name: Laminectomy & Discectomy & Facetectomy

TITLE OF OPERATION: , Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.,INDICATIONS FOR SURGERY:  ,Please refer to medical record, but in short, the patient is a 43-year-old male known to me, status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.  Risks and benefits of surgery were explained in detail including risk of bleeding, infection, stroke, heart attack, paralysis, need for further surgery, hardware failure, persistent symptoms, and death.  This list was inclusive, but not exclusive.  An informed consent was obtained after all patient's questions were answered.,PREOPERATIVE DIAGNOSIS:  ,Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,POSTOPERATIVE DIAGNOSIS: , Severe lumbar spondylosis L5-S1, collapsed disk space, hypermobility, and herniated disk posteriorly.,ANESTHESIA: , General anesthesia and endotracheal tube intubation.,DISPOSITION: , The patient to PACU with stable vital signs.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room.  After adequate general anesthesia with endotracheal tube intubation was obtained, the patient was placed prone on the Jackson table.  Lumbar spine was shaved, prepped, and draped in the usual sterile fashion.  An incision was carried out from L4 to S1.  Hemostasis was obtained with bipolar and Bovie cauterization.  A Weitlaner was placed in the wound and a subperiosteal dissection was carried out identifying the lamina of L4, L5, and sacrum.  At this time, laminectomy was carried out of L5-S1.  Thecal sac was retracted rightward and the foramen was opened and unilateral medial facetectomy was carried out in the disk space.  At this time, the disk was entered with a #15 blade and bipolar.  The disk was entered with straight up and down-biting pituitaries, curettes, and the high speed drill and we were able to takedown calcified herniated disk.  We were able to reestablish the disk space, it was very difficult, required meticulous dissection and then drilling with a diamond bur in the disk space underneath the spinal canal, very carefully holding the spinal canal out of harm's way as well as the exiting nerve root.  Once this was done, we used rasps to remove more disk material anteriorly and under the midline to the left side and then we put in interbody graft of BMP 8 mm graft from Medtronic.  At this time, Dr. X will dictate the posterolateral fusion, pedicle screw fixation to L4 to S1 with compression and will dictate the closure of the wound.  There were no complications.
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DESCRIPTION: Revision laminectomy L5-S1, discectomy L5-S1, right medial facetectomy, preparation of disk space and arthrodesis with interbody graft with BMP.  Status post previous lumbar surgery for herniated disk with severe recurrence of axial back pain, failed conservative therapy.

surgery, revision laminectomy, discectomy, facetectomy, arthrodesis, lumbar spondylosis, hypermobility, collapsed disk space, medial facetectomy, interbody graft, herniated disk, interbody, laminectomy, disk, therapy, lumbar, herniated, space,

The described surgery involves multiple procedures on the lumbar spine: revision laminectomy, discectomy, and facetectomy, along with arthrodesis involving an interbody graft. This is a complex spinal surgery involving significant risks, such as paralysis, bleeding, infection, and even death. Additionally, the patient has a history of a previous lumbar surgery, which can complicate the current procedure. Given these factors, the situation is high-stakes, given the potential for serious complications and the essential nature of the spine. The need for informed consent and the detailed explanation of risks underline the procedure's seriousness.


Medical Specialty: Radiology
Sample Name: Nuclear Medicine Lymphatic Scan

EXAM:,  Nuclear medicine lymphatic scan.,REASON FOR EXAM: , Left breast cancer.,TECHNIQUE: , 1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations.  A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,FINDINGS:  ,There are two small foci of increased activity in the left axilla.  This is consistent with the sentinel lymph node.  No other areas of activity are visualized outside of the injection site and two axillary lymph nodes.,IMPRESSION:  ,Technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node.
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DESCRIPTION: Left breast cancer.  Nuclear medicine lymphatic scan.  A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.

radiology, technetium-99m, mci, biopsy, breast cancer, nuclear medicine, lymphatic scan, lymph node, nuclear, breast,

The situation involves performing a nuclear medicine lymphatic scan for a patient with left breast cancer. This type of scan is crucial for identifying the sentinel lymph nodes, which are the first nodes to which cancer cells are likely to spread from the primary tumor. The accuracy of this scan is important for staging cancer and planning treatment, which directly impacts patient outcomes. Given the implications for a serious condition like breast cancer, the situation is indeed high-stakes for the patient's health.


Medical Specialty: Hematology - Oncology
Sample Name: Axillary Dissection & Mass Excision

PREOPERATIVE DIAGNOSIS:,  Bilateral axillary masses, rule out recurrent Hodgkin's disease.,POSTOPERATIVE DIAGNOSIS:  ,Bilateral axillary masses, rule out recurrent Hodgkin's disease.,PROCEDURE PERFORMED:,1.  Left axillary dissection with incision and drainage of left axillary mass.,2.  Right axillary mass excision and incision and drainage.,ANESTHESIA: , LMA.,SPECIMENS:,  Left axillary mass with nodes and right axillary mass.,ESTIMATED BLOOD LOSS:  ,Less than 30 cc.,INDICATION: , This 56-year-old male presents to surgical office with history of bilateral axillary masses.  Upon evaluation, it was noted that the patient has draining bilateral masses with the left mass being approximately 8 cm in diameter upon palpation and the right being approximately 4 cm in diameter.  The patient had been continued on antibiotics preoperatively.  The patient with history of Hodgkin's lymphoma approximately 18 years ago and underwent therapy at that time and he was declared free of disease since that time.  Consent for possible recurrence of Hodgkin's lymphoma warranted exploration and excision of these masses.  The patient was explained the risks and benefits of the procedure and informed consent was obtained.,GROSS FINDINGS: , Upon dissection of the left axillary mass, the mass was removed in toto and noted to have a cavity within it consistent with an abscess.,No loose structures were identified and sent for frozen section, which upon intraoperative consultation with Pathology Department revealed no obvious evidence of lymphoma, however, the confirmed pathology report is pending at this time.  The right axillary mass was excised without difficulty without requiring full axillary dissection.,PROCEDURE: , The patient was placed in supine position after appropriate anesthesia was obtained and a sterile prep and drape complete.  A #10 blade scalpel was used to make an elliptical incision about the mass itself extending this incision further to aid in the mobilization of the mass.  Sharp dissection was utilized with Metzenbaum scissors about the mass to maintain the injury to the skin structure and upon showing out the mass, Bovie electrocautery was utilized adjacent to the wall structure to maintain hemostasis.  Identification of the axillary anatomy was made and care was made to avoid injury to nerve, vessel or musculature.  Once this mass was removed in toto, lymph node structures were as well delivered with this mass and sent to frozen section as well the specimen was sent to gram stain and culture.  Upon revaluation of the incisional site, it was noted to be hemostatic.  Warm lap sponge was then left in place at this site.  Next, attention was turned to the right axilla where a #10 blade scalpel was used to make a 4 cm incision about the mass including the cutaneous structures involved with the erythematous reaction.  This was as well removed in toto and sent to Pathology for gram stain and culture as well as pathologic evaluation.  This site was then made hemostatic as well with the aid of Bovie electrocautery and approximation of the deep dermal tissues after irrigation with warm saline was then done with #3-0 Vicryl suture followed by #4-0 Vicryl running subcuticular stitch.  Steri-Strips were applied.  Attention was returned back left axilla, which upon re-exploration was noted to be hemostatic and a #7 mm JP was then introduced making a skin stab inferior to the incision and bringing the end of the drain through this incision.  This was placed within the incision site, ________ drainage of the axillary potential space.  Approximation of the deep dermal tissues were then done with #3-0 Vicryl in an interrupted technique followed by #4-0 Vicryl with running subcuticular technique.  Steri-Strips and sterile dressings were applied.  JP bulb was then placed to suction and sterile dressings were applied to both axilla.  The patient tolerated the procedure well and sent to postanesthesia care unit in a stable condition.  He will be discharged to home upon ability of the patient to have pain tolerance with Vicodin 1-2 as needed every six hours for pain and continue on Keflex antibiotics until gram stain culture proves otherwise.
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DESCRIPTION: Left axillary dissection with incision and drainage of left axillary mass.  Right axillary mass excision and incision and drainage.   Bilateral axillary masses, rule out recurrent Hodgkin's disease.

hematology - oncology, incision and drainage, axillary mass excision, axillary dissection, hodgkin's disease, axillary mass, mass, incision, axillary,

The situation involves the surgical removal of axillary masses in a patient with a history of Hodgkin's lymphoma, which presents a potential for recurrence. Given the previous cancer history and current biopsy and pathology tests to rule out lymphoma recurrence, this is a medically significant scenario. The procedure, while routine for managing masses, carries stakes particularly because it involves assessing for cancer recurrence, which could dramatically influence the patient's prognosis and ongoing treatment needs. This makes it a relatively high-stakes situation. Additionally, proper postoperative follow-up is essential to manage any new findings from pathology reports. The potential implications for the patient's health and needed adjustments in medical care based on the outcomes underline the stakes involved.


Medical Specialty: Surgery
Sample Name: Total Knee Replacement - NexGen

PREOPERATIVE DIAGNOSIS: , Degenerative arthritis of left knee.,POSTOPERATIVE DIAGNOSIS:,  Degenerative arthritis of left knee.,PROCEDURE PERFORMED: , NexGen left total knee replacement.,ANESTHESIA: , Spinal.,TOURNIQUET TIME:  Approximately 66 minutes.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Approximately 50 cc.,COMPONENTS: , A NexGen stemmed tibial component size 5 was used, 10 mm cruciate retaining polyethylene surface, a NexGen cruciate retaining size E femoral component, and a size 38 9.5 mm thickness All-Poly Patella.,BRIEF HISTORY:,  The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.  She wishes to proceed with arthroplasty at this time.,PROCEDURE:  ,The patient was taken to the Operative Suite at ABCD General Hospital on 09/11/03.  She was placed on the operating table.  Department of Anesthesia administered a spinal anesthetic.  Once adequately anesthetized, the left lower extremity was prepped and draped in the usual sterile fashion.  An Esmarch was applied and a tourniquet was inflated to 325 mmHg on the left thigh.  A longitudinal incision was made over the anterior portion of the knee and this was taken down through the subcutaneous tissue to the level of the patella retinaculum.  A medial peripatellar arthrotomy was then made and taken down to the level of the tibial tubercle.  Care was then ensured that the patellar tendon was not violated.  The proximal tibia was then skeletonized both medially and laterally to the level of the axis through the joint line.  Again care was ensured that the patellar tendon was not avulsed from the insertion on the tibia.  The intramedullary canal was then opened using a drill and the anterior sizing guide was then placed.  Rongeur was used to take out any osteophytes and the size of approximately size E. At this point, the epicondyle axis guide was then inserted and aligned in a proper orientation.  The anterior cutting guide was then placed.  Care was checked for the amount of resection that the femur would be notched and the oscillating saw was used to cut the anterior portion of the femur.  After this was performed, this was removed and the distal femoral cutting guide was then placed.  The left knee placed in 5 degrees of valgus, guide was then placed, and a standard distal cut was then taken.  After the cuts were ensured further to be leveled and they were, and we proceeded to place the finishing guide size E and distal femur.  This was placed slightly in lateral position and secured in position with spring tense and head lift tense.  Once adequately secured and placed in the appropriate orientation, the alignment was again verified with the epicondyle axis and appeared to be externally rotated appropriately.  The chamfer cuts and anterior and posterior cuts were then made as well as the notch cut using the reciprocating and oscillating saws.  After this was performed, the guide was removed and all bony fragments were then removed.  Attention was then directed to the tibia.  The external tibial alignment guide was then placed and pinned to the proximal tibia in a proper position.  Care was ensured if it is was a varus or valgus and the appropriate.  The femur gauge was then used to provide us appropriate amount of bony resection.  This was then pinned and secured into place.  Ligament retractors were used to protect the collateral ligaments and the tip proximal tibial cut was then made.  This bony portion was then removed and remaining meniscal fragments were removed as well as the ACL till adequate exposure was obtained.  Trial components were then inserted into position and taken the range of motion and found to have good and full excellent range of motion stability.  The trial components were then removed.  The tibia was then stemmed in standard fashion after the tibial plate was placed in some degree of external rotation with appropriate alignment.  After it was stemmed and broached, these were removed and the patella was then incised, a size 41 patella reamer blade was then used and was taken down, a size 38 patella button was then placed intact.  Again the trial components were placed back into position.  Patella button was placed and the tracking was evaluated.  They tracked centrally with no touch technique.  Again, all components were now removed and the knee was then copiously irrigated and suctioned dry.  Once adequately suctioned dry, the tibial portion was cemented and packed into place.  Also excess cement was removed.  The femoral component was then cemented into position.  All excess cement was removed.  A size 12 poly was then inserted in trial to provide compression at cement adhered.  The patella was then cemented and held into place.  All components were held under compression until cement had adequately adhered all excess cement was then removed.  The knee was then taken through range of motion and size 12 felt to be slightly too big, this was removed and the size 10 trial was replaced, and again had excellent varus and valgus stability with full range of motion and felt to be the articulate surface of choice.  The knee was again copiously irrigated and suctioned dry.  One last check in the posterior aspect of the knee for any loose bony fragments or osteophytes was performed, there were none found and a final articulating surface was impacted and locked into place.  After this, the knee was taken again for final range of motion and found to have excellent position, stability, and good alignment of the components.  The knee was once again copiously irrigated, and the tourniquet was deflated.  Bovie cautery was used to cauterize the knee bleeding that was seen until good hemostasis obtained.  A drain was then placed deep to the retinaculum and the retinaculum repair was performed using #2-0 Ethibond and oversewn with a #1 Vicryl.  This was flexed and the repair was found held securely.  At this point, the knee was again copiously irrigated and suctioned dry.  The subcutaneous tissue was closed with #2-0 Vicryl, and the skin was approximated with skin staples.  Sterile dressing with Adaptic, 4x4s, ABDs, and Kerlix rolls was then applied.  The patient was then transferred back to the gurney in a supine position.,DISPOSITION: , The patient tolerated well with no complications, to PACU in satisfactory condition.
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DESCRIPTION: NexGen left total knee replacement.  Degenerative arthritis of left knee.  The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.

surgery, degenerative arthritis, nexgen stemmed tibial component, all-poly patella, nexgen cruciate, total knee replacement, patellar tendon, proximal tibia, epicondyle axis, bony fragments, patella button, tibial, knee, arthritis, nexgen, patella

This situation involves a surgical procedure, specifically a total knee replacement surgery. While the procedure described was completed successfully without complications, surgery in general carries inherent risks such as infection, blood clots, or adverse reactions to anesthesia. These risks, along with the importance of a successful outcome in restoring the patient's mobility and quality of life, means the situation is high-stakes in terms of both the patient's health and the surgical team's responsibilities.


Medical Specialty: Consult - History and Phy.
Sample Name: Gastric Bypass Discussion - 1

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

consult - history and phy., medifast, medifast dieting, hypertension, atrial fibrillation, hyperlipidemia, sleep apnea, morbid obesity, metabolic comorbidities, weight loss, supermorbid obesity, gastric bypass, bypass,

The situation involves a 55-year-old patient with morbid obesity (BMI of 69.7) discussing the possibility of undergoing gastric bypass surgery. This is a high-stakes situation due to the significant health risks associated with the surgery given the patient's severe comorbidities (hypertension, atrial fibrillation, hyperlipidemia, possible sleep apnea, and osteoarthritis) and history of smoking, which increases his risks of surgery complications such as DVT, PE, and cardiac issues. The decision to undergo such surgery carries significant potential health impacts, both positive and negative. The patient will need comprehensive preoperative preparation and long-term lifestyle changes, which adds to the seriousness of the situation.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 2

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

Sample progress note - Gen Med.

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

The provided situation describes a routine follow-up visit for a 78-year-old male patient with conditions like hypertension and hypercholesterolemia, common among elderly patients. There are no acute symptoms or emergency concerns in the report; the patient is doing well overall and is leading an active lifestyle. The care plan includes standard diagnostic tests, medication adjustments, and lifestyle recommendations. While managing chronic conditions is important, the scenario does not indicate imminent risk or life-threatening issues, thus categorizing it as low to moderate stakes.


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

CHIEF COMPLAINT:, Intractable nausea and vomiting.,HISTORY OF PRESENT ILLNESS:, This is a 43-year-old black female who was recently admitted and discharged yesterday for the same complaint. She has a long history of gastroparesis dating back to 2000, diagnosed by gastroscopy. She also has had multiple endoscopies revealing gastritis and esophagitis. She has been noted in the past multiple times to be medically noncompliant with her medication regimen. She also has very poorly controlled hypertension, diabetes mellitus and she also underwent a laparoscopic right adrenalectomy due to an adrenal adenoma in January, 2006. She presents to the emergency room today with elevated blood pressure and extreme nausea and vomiting. She was discharged on Reglan and high-dose PPI yesterday, and was instructed to take all of her medications as prescribed. She states that she has been compliant, but her symptoms have not been controlled. It should be noted that on her hospital admission she would have times where she would feel extremely sick to her stomach, and then soon after she would be witnessed going outside to smoke.,PAST MEDICAL HISTORY:,1. Diabetes mellitus (poorly controlled).,2. Hypertension (poorly controlled).,3. Chronic renal insufficiency.,4. Adrenal mass.,5. Obstructive sleep apnea.,6. Arthritis.,7. Hyperlipidemia.,PAST SURGICAL HISTORY:,1. Removal of ovarian cyst.,2. Hysterectomy.,3. Multiple EGDs with biopsies over the last six years. Her last EGD was in June, 2005, which showed esophagitis and gastritis.,4. Colonoscopy in June, 2005, showing diverticular disease.,5. Cardiac catheterization in February, 2002, showing normal coronary arteries and no evidence of renal artery stenosis.,6. Laparoscopic adrenalectomy in January, 2006.,MEDICATIONS:,1. Reglan 10 mg orally every 6 hours.,2. Nexium 20 mg orally twice a day.,3. Labetalol.,4. Hydralazine.,5. Clonidine.,6. Lantus 20 units at bedtime.,7. Humalog 30 units before meals.,8. Prozac 40 mg orally daily.,SOCIAL HISTORY:, She has a 27 pack year smoking history. She denies any alcohol use. She does have a history of chronic marijuana use.,FAMILY HISTORY:, Significant for diabetes and hypertension.,ALLERGIES:, NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:,HEENT: See has had headaches, and some dizziness. She denies any vision changes.,CARDIAC: She denies any chest pain or palpitations.,RESPIRATORY: She denies any shortness of breath.,GI: She has had persistent nausea and vomiting. She denies diarrhea, melena or hematemesis.,NEUROLOGICAL: She denies any neurological deficits.,All other systems were reviewed and were negative unless otherwise mentioned in HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure: 220/130. Heart rate: 113. Respiratory rate: 18. Temperature: 98.,GENERAL: This is a 43-year-old obese African-American female who appears in no acute distress. She has a depressed mood and flat affect, and does not answer questions elaborately. She will simply state that she does not feel well.,HEENT: Normocephalic, atraumatic, anicteric. PERRLA. EOMI. Mucous membranes moist. Oropharynx is clear.,NECK: Supple. No JVD. No lymphadenopathy.,LUNGS: Clear to auscultation bilaterally, nonlabored.,HEART: Regular rate and rhythm. S1 and S2. No murmurs, rubs, or gallops.
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DESCRIPTION: Intractable nausea and vomiting/history of diabetic gastroparesis/multiple endoscopies revealing gastritis and esophagitis.

The situation involves a 43-year-old female with a history of serious and chronic health conditions, including poorly controlled diabetes, hypertension, chronic renal insufficiency, and gastroparesis. She has been medically noncompliant in the past and is now presenting with intractable nausea and vomiting, as well as very high blood pressure, both of which require urgent medical intervention. Given the combination of poor compliance, potentially life-threatening hypertension, and complex medical history, this is a high-stakes situation. Failure to properly manage these conditions could result in severe health complications or even life-threatening consequences.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Telemetry Monitoring

DIAGNOSES PROBLEMS:,1.  Orthostatic hypotension.,2.  Bradycardia.,3.  Diabetes.,4.  Status post renal transplant secondary polycystic kidney disease in 1995.,5.  Hypertension.,6.  History of basal cell ganglia cerebrovascular event in 2004 with left residual.,7.  History of renal osteodystrophy.,8.  Iron deficiency anemia.,9.  Cataract status post cataract surgery.,10.  Chronic left lower extremity pain.,11.  Hyperlipidemia.,12.  Status post hysterectomy secondary to uterine fibroids.,PROCEDURES:,  Telemetry monitoring.,HISTORY FINDINGS HOSPITAL COURSE: , The patient was originally hospitalized on 04/26/07, secondary to dizziness and disequilibrium.  Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.  She was transferred briefly to Psychiatry, however, on the second day in Psychiatry, she became very orthostatic and was transferred acutely back to the medicine.  She briefly was on Cymbalta; however, this was discontinued when she was transferred back.  She was monitored back medicine for 24 hours and was given intravenous fluids and these were discontinued.  She was able to maintain her pressures then was able to ambulate without difficulty.  We had wanted to pursue workup for possible causes for autonomic dysfunction; however, the patient was not interested in remaining in the hospital anymore and left really against our recommendations.,DISCHARGE MEDICATIONS:,1.  CellCept - 500 mg twice a daily.,2.  Cyclosporine - 25 mg in the morning and 15 mg in the evening.,3.  Prednisone - 5 mg once daily.,4.  Hydralazine - 10 mg four times a day.,5.  Pantoprazole - 40 mg once daily.,6.  Glipizide - 5 mg every morning.,7.  Aspirin - 81 mg once daily.,FOLLOWUP CARE:  ,The patient is to follow up with Dr. X in about 1 week's time.
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DESCRIPTION: The patient was originally hospitalized secondary to dizziness and disequilibrium.  Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.

cardiovascular / pulmonary, orthostatic hypotension, bradycardia, basal cell ganglia cerebrovascular event, renal osteodystrophy, dizziness, disequilibrium, telemetry monitoring,

The patient's medical situation, which comprises multiple chronic and significant health issues including cardiovascular and renal conditions, makes it a high-stakes scenario. The conditions listed such as orthostatic hypotension, bradycardia, and status post renal transplant suggest a complex medical condition that requires careful monitoring and management. Despite being discharged against medical advice, the potential for serious complications remains, particularly due to the combination of cardiovascular, renal, and mental health issues. This requires the healthcare team to be vigilant, as the patient's return visit for follow-up indicates ongoing concern for her stability.


Medical Specialty: Consult - History and Phy.
Sample Name: Well-Child Check - 2

SUBJECTIVE:,  This 9-month-old Hispanic male comes in today for a 9-month well-child check.  They are visiting from Texas until the end of April 2004.  Mom says he has been doing well since last seen.  He is up-to-date on his immunizations per her report.  She notes that he has developed some bumps on his chest that have been there for about a week.  Two weeks ago he was diagnosed with left otitis media and was treated with antibiotics.  Mom says he has been doing fine since then.  She has no concerns about him.,PAST MEDICAL HISTORY:,  Significant for term vaginal delivery without complications.,MEDICATIONS: , None.,ALLERGIES:,  None.,SOCIAL HISTORY:,  Lives with parents.  There is no smoking in the household.,REVIEW OF SYSTEMS:,  Developmentally is appropriate.  No fevers.  No other rashes.  No cough or congestion.  No vomiting or diarrhea.  Eating normally.,OBJECTIVE:,  His weight is 16 pounds 9 ounces.  Height is 26-1/4 inches.  Head circumference is 44.75 cm.  Pulse is 124.  Respirations are 26.  Temperature is 98.1 degrees.  Generally, this is a well-developed, well-nourished, 9-month-old male, who is active, alert, and playful in no acute distress.,HEENT:  Normocephalic, atraumatic.  Anterior fontanel is soft and flat.  Tympanic membranes are clear bilaterally.  Conjunctivae are clear.  Pupils equal, round and reactive to light.  Nares without turbinate edema.  Oropharynx is nonerythematous.,NECK:  Supple, without lymphadenopathy, thyromegaly, carotid bruit, or JVD.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm, without murmur.,ABDOMEN:  Soft, nontender, nondistended, normoactive bowel sounds.  No masses or organomegaly to palpation.,GU:  Normal male external genitalia.  Uncircumcised penis.  Bilaterally descended testes.  Femoral pulses 2/4.,EXTREMITIES:  Moves all four extremities equally.  Minimal tibial torsion.,SKIN:  Without abnormalities other than five small molluscum contagiosum with umbilical herniation noted on chest.,ASSESSMENT/PLAN:,1.  Well-child check.  Is doing well.  Will recommend a followup well-child check at 1 year of age and immunizations at that time.  Discussed safety issues, including poisons, choking hazards, pet safety, appropriate nutrition with Mom.  She is given a parenting guide handout.,2.  Molluscum contagiosum.  Described the viral etiology of these.  Told her they are self limited, and we will continue to monitor at this time.,3.  Left otitis media, resolved.  Continue to monitor.  We will plan on following up in three months if they are still in the area, or p.r.n.
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DESCRIPTION: A 9-month well-child check.

A 9-month well-child check.

consult - history and phy., well-child check, otitis media, molluscum contagiosum, immunizations, developed, atraumatic, child,

The given situation describes a well-child checkup for a 9-month-old, which is a routine medical appointment to assess the child's growth and development. Although the presence of molluscum contagiosum and previous otitis media are noted, these conditions are not currently causing distress or severe health concerns, and the plan is to monitor them. The overall assessment indicates that the child is doing well and no urgent or severe issues are present. Therefore, this scenario is low-stakes as it involves standard monitoring and routine follow-up advice.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pulmonary Edema - Consult

HISTORY:  ,This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.  No confirmed prior history of heart attack, myocardial infarction, heart failure.  History dates back to about six months of intermittent shortness of breath, intermittent very slight edema with shortness of breath.  The blood pressure was up transiently last summer when this seemed to start and she was asked not to take Claritin-D, which she was taking for what she presumed was allergies.  She never had treated hypertension.  She said the blood pressure came down.  She is obviously very hypertensive this evening.  She has some mid scapular chest discomfort.  She has not had chest pain, however, during any of the other previous symptoms and spells.,CARDIAC RISKS:,  Does not smoke, lipids unknown.  Again, no blood pressure elevation, and she is not diabetic.,FAMILY HISTORY:,  Negative for coronary disease.  Dad died of lung cancer.,DRUG SENSITIVITIES:,  Penicillin.,CURRENT MEDICATIONS: , None.,SURGICAL HISTORY:,  Cholecystectomy and mastectomy for breast cancer in 1992, no recurrence.,SYSTEMS REVIEW: , Did not get headaches or blurred vision.  Did not suffer from asthma, bronchitis, wheeze, cough but short of breath as described above.  No reflux, abdominal distress.  No other types of indigestion, GI bleed.  GU:  Negative.  She is unaware of any kidney disease.  Did not have arthritis or gout.  No back pain or surgical joint treatment.  Did not have claudication, carotid disease, TIA.  All other systems are negative.,PHYSICAL FINDINGS,VITAL SIGNS:  Presenting blood pressure was 170/120 and her pulse at that time was 137.  Temperature was normal at 97, and she was obviously in major respiratory distress and hypoxemic.  Saturation of 86%.  Currently, blood pressure 120/70, heart rate is down to 100.,EYES:  No icterus or arcus.,DENTAL:  Good repair.,NECK:  Neck veins, cannot see JVD, at this point, carotids, no bruits, carotid pulse brisk.,LUNGS:  Fine and coarse rales, lower two thirds of chest.,HEART:  Diffuse cardiomegaly without a sustained lift, first and second heart sounds present, second is split.  There is loud third heart sound.  No murmur.,ABDOMEN:  Overweight, guess you would say obese, nontender, no liver enlargement, no bruits.,SKELETAL:  No acute joints.,EXTREMITIES:  Good pulses.  No edema.,NEUROLOGICALLY:  No focal weakness.,MENTAL STATUS:  Clear.,DIAGNOSTIC DATA: , 12-lead ECG, left bundle-branch block.,LABORATORY DATA:,  All pending.,RADIOGRAPHIC DATA: , Chest x-ray, pulmonary edema, cardiomegaly.,IMPRESSION,1.  Acute pulmonary edema.,2.  Physical findings of dilated left ventricle.,3.  Left bundle-branch block.,4.  Breast cancer in 1992.,PLAN:  ,Admit.  Aggressive heart failure management.  Get echo.  Start ACE and Coreg.  Diuresis of course underway.
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DESCRIPTION: This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.   No confirmed prior history of heart attack, myocardial infarction, heart failure.

The situation involves a 61-year-old patient presenting with acute symptoms that indicate a severe cardiovascular condition, specifically pulmonary edema. This condition can be potentially life-threatening and requires urgent medical intervention. The plan involves aggressive heart failure management, indicating the seriousness of the condition. Additionally, the presence of physical findings such as dilated left ventricle and left bundle-branch block further increases the medical complexity and risk. Given the acute nature and the potential for complications, this case can be considered high-stakes in the context of medical urgency and patient safety.


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

Medical Specialty: Radiology
Sample Name: Bilateral Mammogram

EXAM:,  Mammographic screening FFDM,HISTORY: , 40-year-old female who is on oral contraceptive pills.  She has no present symptomatic complaints.  No prior history of breast surgery nor family history of breast CA.,TECHNIQUE: , Standard CC and MLO views of the breasts.,COMPARISON: , This is the patient's baseline study.,FINDINGS: , The breasts are composed of moderately to significantly dense fibroglandular tissue.  The overlying skin is unremarkable.,There are a tiny cluster of calcifications in the right breast, near the central position associated with 11:30 on a clock.,There are benign-appearing calcifications in both breasts as well as unremarkable axillary lymph nodes.,There are no spiculated masses or architectural distortion.,IMPRESSION:,  Tiny cluster of calcifications at the 11:30 position of the right breast.  Recommend additional views; spot magnification in the MLO and CC views of the right breast.,BIRADS Classification 0 - Incomplete,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD Second Look Software Version 7.2 was utilized.
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DESCRIPTION: Bilateral Mammogram, (abnormal) additional views requested

radiology, ffdm, mammographic screening, tiny cluster of calcifications, bilateral mammogram, additional views, bilateral, mammogram, cluster, breasts, calcifications, mammography,

This situation involves a routine screening mammogram for a patient with no high-risk history for breast cancer. The findings indicate a need for additional imaging, which is not uncommon in radiology, especially when addressing dense breast tissue and calcifications. The BIRADS classification of 0 means more information is needed, not necessarily indicating an immediate high risk. While follow-up imaging is important for appropriate diagnosis, the lack of immediate clinical symptoms or high-risk family history suggests this is a low-stakes situation compared to others in medical practice.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 46

DIAGNOSES:,1.  Pneumonia.,2.  Crohn disease.,3.  Anasarca.,4.  Anemia.,CHIEF COMPLAINT: , I have a lot of swelling in my legs.,HISTORY:  ,The patient is a 41-year-old gentleman with a long history of Crohn disease.  He has been followed by Dr. ABC, his primary care doctor, but he states that he has had multiple gastroenterology doctors and has not seen one in the past year to 18 months.  He has been treated with multiple different medications for his Crohn disease and most recently has been taking pulses of steroids off and on when he felt like he was having symptoms consistent with crampy abdominal pain, increased diarrhea, and low-grade fevers.  This has helped in the past, but now he developed symptoms consistent with pneumonia and was admitted to the hospital.  He has been treated with IV antibiotics and is growing Streptococcus.  At this time, he seems relatively stable although slightly dyspneic.  Other symptoms include lower extremity edema, pain in his ankles and knees, and actually symptoms of edema in his entire body including his face and upper extremities.  At this time, he continues to have symptoms consistent with diarrhea and malabsorption.  He also has some episodes of nausea and vomiting at times.  He currently has a cough and symptoms of dyspnea.  Further review of systems was not otherwise contributory.,MEDICATIONS:,1.  Prednisone.,2.  Effexor.,3.  Folic acid.,4.  Norco for pain.,PAST MEDICAL HISTORY: , As mentioned above, but he also has anxiety and depression.,PAST SURGICAL HISTORY:,1.  Small bowel resections.,2.  Appendectomy.,3.  A vasectomy.,ALLERGIES:  ,He has no known drug allergies.,SOCIAL HISTORY:  ,He does smoke two packs of cigarettes per day.  He has no alcohol or drug use.  He is a painter.,FAMILY HISTORY:  ,Significant for his father who died of IPF and irritable bowel syndrome.,REVIEW OF SYSTEMS: , As mentioned in the history of present illness and further review of systems is not otherwise contributory.,PHYSICAL EXAMINATION:,GENERAL:  He is a thin appearing man in very mild respiratory distress when his oxygen is off.,VITAL SIGNS:  His respiratory rate is approximately 18 to 20, his blood pressure is 100/70, his pulse is 90 and regular, he is afebrile currently at 96, and weight is approximately 163 pounds.,HEENT:  Sclerae anicteric.  Conjunctivae normal.  Nasal and oropharynx are clear.,NECK:  Supple.  No jugular venous pressure distention is noted.  There is no adenopathy in the cervical, supraclavicular or axillary areas.,CHEST:  Reveals some crackles in the right chest, in the base, and in the upper lung fields.  His left is relatively clear with decreased breath sounds.,HEART:  Regular rate and rhythm.,ABDOMEN:  Slightly protuberant.  Bowel sounds are present.  He is slightly tender and it is diffuse.  There is no organomegaly and no ascites appreciable.,EXTREMITIES:  There is a mild scrotal edema and in his lower extremities he has 2 to 3+ edema at pretibial and lateral feet.,DERMATOLOGIC:  Shows thin skin.  No ecchymosis or petechiae.,LABORATORY STUDIES: , Laboratory studies are pertinent for a total protein of 3 and albumin of 1.3.  There is no M-spike observed.  His B12 is 500 with a folic acid of 11.  His white count is 21 with a hemoglobin of 10, and a platelet count 204,000.,IMPRESSION AT THIS TIME:,1.  Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.,2.  He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.,ASSESSMENT AND PLAN: , At this time, I believe evaluation of protein intake and dietary supplement will be most appropriate.  I believe that he needs a calorie count.  We will check on a sedimentation rate, C-reactive protein, LDH, prealbumin, thyroid, and iron studies in the morning with his laboratory studies that are already ordered.  I have recommended strongly to him that when he is out of the hospital, he return to the care of his gastroenterologist.  I will help in anyway that I can to improve the patient's laboratory abnormalities.  However, his lower extremity edema is primarily due to his marked hypoalbuminemia and I do not believe that diuretics will help him at this time.  I have explained this in detail to the patient and his family.  Everybody expresses understanding and all questions were answered.  At this time, follow him up during his hospital stay and plan to see him in the office as well.
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DESCRIPTION: Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.  He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.

The case involves a 41-year-old patient with several significant health issues, including pneumonia, severe Crohn disease, protein-losing enteropathy, severe malnutrition, anasarca, and associated anemia with leukocytosis. Crohn disease exacerbates his underlying conditions and contributes to other complications like severe malnutrition and edema. Given these multiple, interconnected serious health issues, this situation is high-stakes because it requires immediate and comprehensive medical management to prevent further deterioration of the patient's health. The presence of pneumonia on top of severe malnutrition and other chronic conditions increases the risk of complications, which makes the situation critical.


Medical Specialty: Surgery
Sample Name: Flex Sig

MEDICATIONS:,  None.,DESCRIPTION OF THE PROCEDURE:,  After informed consent was obtained, the patient was placed in the left lateral decubitus position and the Olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of *** cm to the proximal descending colon and then slowly withdrawn.  The mucosa appeared normal.  Retroflex examination of the rectum was normal.
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DESCRIPTION: Flexible Sigmoidoscopy.

Flexible Sigmoidoscopy.

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

This scenario describes the performance of a flexible sigmoidoscopy procedure, which is a routine medical diagnostic procedure used to examine the lower part of the colon. From the description, the procedure went normally with findings indicating normal mucosa and rectum. While medical procedures can carry inherent risks, flexible sigmoidoscopies generally have low risk and are routine when performed by trained professionals. The situation does not suggest complications, urgency, or critical conditions that raise the stakes considerably.


Medical Specialty: Dermatology
Sample Name: Poison Ivy - SOAP

SUBJECTIVE:,  He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing.  He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackman; it looked like it was Depo-Medrol 80 mg.  He said that it worked fairly well, although it seemed to still take awhile to get rid of it.  He has been using over-the-counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back.,OBJECTIVE:,Vitals:  Temperature is 99.2.  His weight is 207 pounds.,Skin:  Examination reveals a raised, maculopapular rash in kind of a linear pattern over his arms, legs and chest area which are consistent with a poison ivy or a poison oak.,ASSESSMENT AND ,PLAN:,  Poison ivy.  Plan would be Solu-Medrol 125 mg IM X 1.  Continue over-the-counter Benadryl or Rx allergy medicine that he was given the last time he was here, which is a one-a-day allergy medicine; he can not exactly remember what it is, which would also be fine rather than the over-the-counter Benadryl if he would like to use that instead.
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DESCRIPTION: Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.

dermatology, poison ivy, steroid injection, depo-medrol, maculopapular rash, poison oak, maculopapular, chest, ivy, poison

The described situation involves a dermatological reaction to poison ivy, which is generally not life-threatening, although it can be uncomfortable and bothersome. The patient has a history of such reactions and is receiving treatment in the form of a steroid injection and ongoing medication, which are standard treatments for this condition. This suggests the condition is manageable and not of high urgency, given the absence of severe symptoms such as difficulty breathing or widespread systemic issues.


Medical Specialty: Consult - History and Phy.
Sample Name: Glioblastoma Multiforme - Consult

REASON FOR CONSULTATION: , We were asked to see the patient in regards to a brain tumor.,HISTORY OF PRESENT ILLNESS: ,She was initially diagnosed in September of this year with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis.  She was seen by Dr. X in our group.  Because of her living arrangement, she elected to have treatment through the hospital radiation department and oncology department.  Details of her treatment are not available at the time of this dictation.  Her family has a packet of Temodar 100-mg pills.  She is admitted now with increasing confusion.  A CT shows increase in size of the lesions compared to the preoperative scan.  We are asked to comment on her treatment at this point.  She herself is confused and is unable to provide further history.  ,PAST MEDICAL HISTORY: , From her old chart:  No known past medical history prior to the diagnosis.,SOCIAL HISTORY:  ,She was living alone and is now living in assisted living.  ,MEDICATIONS,1.  Dilantin 300 mg daily.,2.  Haloperidol 1 mg h.s.,3.  Dexamethasone 4 mg q.i.d. ,4.  Docusate 100 mg b.i.d.,5.  Pen-VK 500 mg daily.,6.  Ibuprofen 600 mg daily.,7.  Zantac 150 mg twice a day.,8.  Temodar 100 mg daily.,9.  Magic Mouthwash daily.,10.  Tylenol #3 as needed.,REVIEW OF SYSTEMS,:  Unable.,PHYSICAL EXAMINATION,GENERAL:  Elderly woman, confused.  ,HEENT:  Normal conjunctivae.  Ears and nose normal.  Mouth normal.,NECK:  Supple.,CHEST: Clear.,HEART:  Normal.,ABDOMEN: Soft, positive bowel sounds.,NEUROLOGIC:  Alert, cranial nerves intact.  Left arm slightly weak.  Left leg slightly weak.,IMPRESSION AND PLAN:,  Glioblastoma multiforme, uncertain as to where she is in cancer treatment.  Given the number of pills in the patient's family's hands, it sounds like she has only been treated recently and therefore it is not surprising that she is showing increased problems related to increased size of the tumor.  We will have to talk with Dr. Y in the Clinic to get a better handle on her treatment regimen.  At this point, I will hold Temodar today and consider restarting it tomorrow if we can get her treatment plan clarified.
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DESCRIPTION: Asked to see the patient in regards to a brain tumor.  She was initially diagnosed with a glioblastoma multiforme.  She presented with several lesions in her brain and a biopsy confirmed the diagnosis.

This situation involves a patient with glioblastoma multiforme, a highly aggressive and malignant form of brain tumor. The stakes are high because the condition is life-threatening and requires immediate and accurate treatment decisions. The patient is currently experiencing increased confusion due to tumor progression, indicating a potential worsening of her condition. There is an urgent need to clarify her treatment plan with another doctor, Dr. Y, to determine the next steps in managing her care, including the use of Temodar, a chemotherapy medication. The high-stakes nature is further emphasized by the patient's confusion and the need for coordinated and timely intervention to address her deteriorating neurological status.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 22

PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES:,  The patient is a 56-year-old female.  She was referred for a screening colonoscopy.  The patient has bowel movements every other day.  There is no blood in the stool, no abdominal pain.  She has hypertension, dyslipidemia, and gastroesophageal reflux disease.  She has had cesarean section twice in the past.  Physical examination is unremarkable.  There is no family history of colon cancer.,POSTOPERATIVE DIAGNOSIS: , Diverticulosis.,PROCEDURE IN DETAIL: , Procedure and possible complications were explained to the patient.  Ample opportunity was provided to her to ask questions.  Informed consent was obtained.  She was placed in left lateral position.  Inspection of perianal area was normal.  Digital exam of the rectum was normal.,Video Olympus colonoscope was introduced into the rectum.  The sigmoid colon is very tortuous.  The instrument was advanced to the cecum after placing the patient in a supine position.  The patient was well prepared and a good examination was possible.  The cecum was identified by the ileocecal valve and the appendiceal orifice.  Images were taken.  The instrument was then gradually withdrawn while examining the colon again in a circumferential manner.  Few diverticula were encountered in the sigmoid and descending colon.  Retroflex view of the rectum was unremarkable.  No polyps or malignancy was identified.,After obtaining images, the air was suctioned.  Instrument was withdrawn from the patient.  The patient tolerated the procedure well.  There were no complications.,SUMMARY OF FINDINGS:  ,Colonoscopy was performed to cecum and demonstrates the following:,1.  Mild-to-moderate diverticulosis.,2.  ,RECOMMENDATION:,1.  The patient was provided information on diverticulosis including dietary advice.,2.  She was advised repeat colonoscopy after 10 years.
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DESCRIPTION: Mild-to-moderate diverticulosis.  She was referred for a screening colonoscopy.  There is no family history of colon cancer.  No evidence of polyps or malignancy.

surgery, screening colonoscopy, colon cancer, colonoscopy, polyps, malignancy, sigmoid, rectum, cecum, diverticulosis

The situation involves a routine screening colonoscopy, where mild-to-moderate diverticulosis was discovered, but no polyps or malignancy were found. The patient was given dietary advice and advised to have another colonoscopy in 10 years. This indicates that the findings were not urgent or life-threatening. The procedure was straightforward, with no complications noted, and the recommendation for a 10-year follow-up suggests low immediate concern. While medical procedures inherently carry some risk, this specific scenario is relatively low-stakes in terms of urgency and severity.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 28

HISTORY OF PRESENT ILLNESS: , The patient is an 85-year-old male who was brought in by EMS with a complaint of a decreased level of consciousness.  The patient apparently lives with his wife and was found to have a decreased status since the last one day.  The patient actually was seen in the emergency room the night before for injuries of the face and for possible elderly abuse.  When the Adult Protective Services actually went to the patient's house, he was found to be having decreased consciousness for a whole day by his wife.  Actually the night before, he fell off his wheelchair and had lacerations on the face.  As per his wife, she states that the patient was given an entire mg of Xanax rather than 0.125 mg of Xanax, and that is why he has had decreased mental status since then.  The patient's wife is not able to give a history.  The patient has not been getting Sinemet and his other home medications in the last 2 days.  ,PAST MEDICAL HISTORY:  ,Parkinson disease.,MEDICATIONS:,  Requip, Neurontin, Sinemet, Ambien, and Xanax.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.,PHYSICAL EXAMINATION:,GENERAL:
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DESCRIPTION: The patient brought in by EMS with a complaint of a decreased level of consciousness.

general medicine, level of consciousness, parkinson disease, altered mental status, dehydration, elderly abuse, decreased level of consciousness, ems, parkinson, consciousness, xanax, sinemet, decreased,

The situation involves an elderly patient with a decreased level of consciousness and possible medication mismanagement, which could be indicative of elder abuse or neglect. Additionally, the patient has Parkinson's disease and is missing critical medication, which may worsen his condition. The history also includes recent facial injuries. This combination of factors makes it a high-stakes situation because it involves immediate healthcare concerns, potential legal and ethical implications, and the need for urgent intervention to ensure the patient's safety.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CT Chest

TECHNIQUE: , Sequential axial CT images were obtained from the base of the brain to the upper abdomen following the uneventful administration of 100cc Optiray 350 intravenous contrast.,FINDINGS: , The heart size is normal and there is no pericardial effusion.  The aorta and great vessels are normal in caliber.  The central pulmonary arteries are patent with no evidence of embolus.  There is no significant mediastinal, hilar, or axillary lymphadenopathy.  The trachea and mainstem bronchi are patent.  The esophagus is normal in course and caliber.  The lungs are clear with no infiltrates, effusions, or masses.  There is no pneumothorax.  Scans through the upper abdomen are unremarkable.  The osseous structures in the chest are intact.  ,IMPRESSION: , No acute abnormalities.
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DESCRIPTION: Common CT Chest template

Common CT Chest template

cardiovascular / pulmonary, sequential axial ct images, optiray, pericardial effusion, mediastinal, hilar, axillary, lymphadenopathy, ct chest, upper abdomenNOTE

The CT Chest report describes a routine imaging examination with normal findings and no acute abnormalities. This scenario does not involve any immediate health crises or decisions requiring urgent intervention, making it low-stakes in nature. There is no mention of any critical condition or impending health risk based on the imaging results.


Medical Specialty: General Medicine
Sample Name: HIV Followup - 1

PROBLEM LIST:,1.  HIV stable.,2.  Hepatitis C chronic.,3.  History of depression, stable off meds.,4.  Hypertension, moderately controlled.,CHIEF COMPLAINT: , The patient comes for a routine followup appointment.,HISTORY OF PRESENTING ILLNESS: , This is a 34-year-old African American female who comes today for routine followup.  She has no acute complaints.  She reports that she has a muscle sprain on her upper back from lifting.  The patient is a housekeeper by profession.  It does not impede her work in anyway.  She just reports that it gives her some trouble sleeping at night, pain on 1 to 10 scale was about 2 and at worse it is 3 to 4 but relieved with over-the-counter medication.  No other associated complaints.  No neurological deficits or other specific problems.  The patient denies any symptoms associated with opportunistic infection.,PAST MEDICAL HISTORY:,1.  Significant for HIV.,2.  Hepatitis.,3.  Depression.,4.  Hypertension.,CURRENT MEDICATIONS:,1.  She is on Trizivir 1 tablet p.o. b.i.d.,2.  Ibuprofen over-the-counter p.r.n.,MEDICATION COMPLIANCE: , The patient is 100% compliant with her meds.  She reports she does not miss any doses.,ALLERGIES: , She has no known drug allergies.,DRUG INTOLERANCE:  ,There is no known drug intolerance in the past.,NUTRITIONAL STATUS: , The patient eats regular diet and eats 3 meals a day.,REVIEW OF SYSTEMS: , Noncontributory except as mentioned in the HPI.,LABORATORY DATA: , Most recent labs from 11/07.,RADIOLOGICAL DATA:,  She has had no recent radiological procedures.,IMMUNIZATIONS: , Up-to-date.,SEXUAL HISTORY: , She has had no recent STDs and she is not currently sexually active.  PPD status was negative in the past.  PPD will be placed again today.,Treatment adherence counseling was performed by both nursing staff and myself.  Again, the patient is a 100% compliant with her meds.  Last dental exam was in 11/07, where she had 2 teeth extracted.  Last Pap smear was 1 year ago was negative.  The patient has not had mammogram yet, as she is not of the age where she would start screening mammogram.  She has no family history of breast cancer.,MENTAL HEALTH AND SUBSTANCE ABUSE: , The patient has a history of depression.  No history of substance abuse.,ADVANCED DIRECTIVE: , Unknown.,PHYSICAL EXAMINATION:,GENERAL:  This is a thinly built female, not in acute distress.  VITAL SIGNS:  Temperature 36.5, blood pressure 132/89, pulse of 82, and weight of 104 pounds.  HEAD AND NECK:  Reveals bilaterally reactive pupils.  Supple neck.  No thrush.  No adenopathy.  HEART:  Heart sounds S1 and S2 regular.  No murmur.  LUNGS:  Clear bilaterally to auscultation.  ABDOMEN:  Soft and nontender with good bowel sounds.  NEUROLOGIC:  She is alert and oriented x3 with no focal neurological deficit.  EXTREMITIES:  Peripheral pulses are felt bilaterally.  She has no pitting pedal edema, clubbing or cyanosis.  GU:  Examination of external genitalia is unremarkable.  There are no lesions.,LABORATORY DATA: , From 11/07 shows hemoglobin and hematocrit of 16 and 46.  Creatinine of 0.6.  LFTs within normal limits.  Viral load of less than 48 and CD4 count of 918.,ASSESSMENT:,1.  Human immunodeficiency virus, stable on Trizivir.,2.  Hepatitis C with stable transaminases.,3.  History of depression, stable off meds.
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DESCRIPTION: Human immunodeficiency virus, stable on Trizivir.  Hepatitis C with stable transaminases.  History of depression, stable off meds.   Hypertension, moderately controlled on meds.

The situation involves a routine follow-up appointment for a patient with several chronic but stable medical conditions, including HIV, Hepatitis C, depression, and hypertension. The patient is compliant with her medications, and there are no acute issues or complaints other than a mild muscle sprain managed with over-the-counter medication. The patient's HIV and Hepatitis C are stable, as are her depression and hypertension, suggesting well-managed health conditions. Therefore, this situation is relatively low-stakes compared to emergency or acute medical situations.


Medical Specialty: Surgery
Sample Name: Direct Laryngoscopy

PREOPERATIVE DIAGNOSIS:,  Subglottic stenosis.,POSTOPERATIVE DIAGNOSIS: , Subglottic stenosis.,OPERATIVE PROCEDURES: , Direct laryngoscopy and bronchoscopy.,ANESTHESIA:,  General inhalation.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and placed supine on the operative table.  General inhalational anesthesia was administered through the patient's tracheotomy tube.  The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway.  There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds.  The stoma showed some suprastomal fibroma.  The remaining tracheobronchial passages were clear.  The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties.  Bleeding was negligible.  There were no untoward complications.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.
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DESCRIPTION: Direct laryngoscopy and bronchoscopy.

Direct laryngoscopy and bronchoscopy.

surgery, laryngoscopy and bronchoscopy, direct laryngoscopy, subglottic stenosis, bronchoscopy, laryngoscopy, subglottic, stenosis,

This procedure involves a direct laryngoscopy and bronchoscopy to address subglottic stenosis, a significant narrowing of the airway just below the vocal cords. The situation is high-stakes due to the location and potential implications of the condition, which can lead to airway obstruction. Surgery involving the airway carries inherent risks, although there were no complications in this case. However, such an operation remains critical as it concerns a patient's ability to breathe. Successful management of airway stenosis is crucial to prevent life-threatening situations. Given these factors, the stakes involved are high, warranting careful attention to detail and precise execution by the surgical team.


Medical Specialty: Orthopedic
Sample Name: MRI Spine - Epidural Lipoma

CC:, Progressive lower extremity weakness.,HX: ,This 54 y/o RHF presented on 7/3/93 with a 2 month history of lower extremity weakness. She was admitted to a local hospital on 5/3/93 for a 3 day h/o of progressive BLE weakness associated with incontinence and BLE numbness. There was little symptom of upper extremity weakness at that time, according to the patient. Her evaluation was notable for a bilateral L1 sensory level and 4/4 strength in BLE. A T-L-S Spine MRI revealed a T4-6 lipomatosis with anterior displacement of the cord without cord compression. CSF analysis yielded: opening pressure of 14cm H20, protein 88, glucose 78, 3 lymphocytes and 160 RBC, no oligoclonal bands or elevated IgG index, and negative cytology. Bone marrow biopsy was negative. B12, Folate, and Ferritin levels were normal. CRP 5.2 (elevated). ANA was positive at 1:5,120 in speckled pattern. Her hospital course was complicated by deep venous thrombosis, which recurred after heparin was stopped to do the bone marrow biopsy. She was subsequently placed on Coumadin. EMG/NCV testing revealed " lumbosacral polyradiculopathy with axonal degeneration and nerve conduction block." She was diagnosed with atypical Guillain-Barre vs. polyradiculopathy and received a single course of Decadron; and no plasmapheresis or IV IgG. She was discharged home o 6/8/93.,She subsequently did not improve and after awaking from a nap on her couch the day of presentation, 7/3/93, she found she was paralyzed from the waist down. There was associated mild upper lumbar back pain without radiation. She had had no bowel movement or urination since that time. She had no recent trauma, fever, chills, changes in vision, dysphagia or upper extremity deficit.,MEDS:, Coumadin 7.5mg qd, Zoloft 50mg qd, Lithium 300mg bid.,PMH:, 1) Bi-polar Affective Disorder, dx 1979 2) C-section.,FHX:, Unremarkable.,SHX:, Denied Tobacco/ETOH/illicit drug use.,EXAM: ,BP118/64, HR103, RR18, Afebrile.,MS: ,A&O to person, place, time. Speech fluent without dysarthria. Lucid thought processes.,CN: ,Unremarkable.,MOTOR:, 5/5 strength in BUE. Plegic in BLE. Flaccid muscle tone.,SENSORY:, L1 sensory level (bilaterally) to PP and TEMP, without sacral sparing. Proprioception was lost in both feet.,CORD: ,Normal in BUE.,Reflexes were 2+/2+ in BUE. They were not elicited in BLE. Plantar responses were equivocal, bilaterally.,RECTAL: ,Poor rectal tone. stool guaiac negative. She had no perirectal sensation.,COURSE:, CRP 8.8 and ESR 76. FVC 2.17L. WBC 1.5 (150 bands, 555 neutrophils, 440 lymphocytes and 330 monocytes), Hct 33%, Hgb 11.0, Plt 220K, MCV 88, GS normal except for slightly low total protein (8.0). LFT were normal. Creatinine 1.0. PT and PTT were normal. ABCG 7.46/25/79/96% O2Sat. UA notable for 1+ proteinuria. EKG normal.,MRI L-spine, 7/3/93, revealed an area of abnormally increased T2 signal extending from T12 through L5. This area causes anterior displacement of the spinal cord and nerve roots. The cauda equina are pushed up against the posterior L1 vertebral body. There bilaterally pulmonary effusions. There is also abnormally increased T2 signal in the center of the spinal cord extending from the mid thoracic level through the conus. In addition, the Fila Terminale appear thickened. There is increased signal in the T3 vertebral body suggestion a hemangioma. The findings were felt consistent with a large epidural lipoma displacing the spinal cord anteriorly. there also appeared spinal cord swelling and increased signal within the spinal cord which suggests an intramedullary process.,CSF analysis revealed: protein 1,342, glucose 43, RBC 4,900, WBC 9. C3 and C$ complement levels were 94 and 18 respectively (normal) Anticardiolipin antibodies were negative. Serum Beta-2 microglobulin was elevated at 2.4 and 3.7 in the CSF and Serum, respectively. It was felt the patient had either a transverse myelitis associated with SLE vs. partial cord infarction related to lupus vasculopathy or hypercoagulable state. She was place on IV Decadron. Rheumatology felt that a diagnosis of SLE was likely. Pulmonary effusion analysis was consistent with an exudate. She was treated with plasma exchange and place on Cytoxan.,On 7/22/93 she developed fever with associated proptosis and sudden loss of vision, OD. MRI Brain, 7/22/93, revealed a 5mm thick area of intermediate signal adjacent to the posterior aspect of the right globe, possibly representing hematoma. Ophthalmology felt she had a central retinal vein occlusion; and it was surgically decompressed.,She was placed on prednisone on 8/11/93 and Cytoxan was started on 8/16/93. She developed a headache with meningismus on 8/20/93. CSF analysis revealed: protein 1,002, glucose2, WBC 8,925 (majority were neutrophils). Sinus CT scan negative. She was placed on IV Antibiotics for presumed bacterial meningitis. Cultures were subsequently negative. She spontaneously recovered. 8/25/93, cisternal tap CSF analysis revealed: protein 126, glucose 35, WBC 144 (neutrophils), RBC 95, Cultures negative, cytology negative. MRI Brain scan revealed diffuse leptomeningeal enhancement in both brain and spinal canal.,DSDNA negative. She developed leukopenia in 9/93, and she was switched from Cytoxan to Imuran. Her LFT's rose and the Imuran was stopped and she was placed back on prednisone.,She went on to have numerous deep venous thrombosis while on Coumadin. This required numerous hospital admissions for heparinization. Anticardiolipin antibodies and Protein C and S testing was negative.
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DESCRIPTION: MRI Spine - T12-L5 epidural lipoma and thoracic spinal cord infarction vs. transverse myelitis.

The situation involves a complex medical case with significant health implications. The patient is experiencing paralysis, potential complications from spinal cord issues, and involvement of multiple organ systems, which may be related to a likely diagnosis of Systemic Lupus Erythematosus (SLE). The patient's condition has led to multiple serious symptoms, including paralysis and vision loss, requiring intensive investigation and treatment involving steroids, antibiotics, Cytoxan, Prednisone, and plasma exchange. Given the serious nature of the symptoms, the impact on the patient's quality of life, and the involvement of multiple specialists for diagnosis and management, the situation is high-stakes. The patient's life and long-term health outcomes are significantly affected by the decisions and treatments being made.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Aortobifemoral Bypass - 1

PREOPERATIVE DIAGNOSIS,1.  Aortoiliac occlusive disease bilaterally.,2.  Dementia.,POSTOPERATIVE DIAGNOSIS,1.  Aortoiliac occlusive disease bilaterally.,2.  Dementia.,OPERATION: , Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.,ANESTHESIA:,  General endotracheal,ESTIMATED BLOOD LOSS: , 300 cc,INTRAVENOUS FLUIDS: , 1200 cc of crystalloid,URINE OUTPUT: , 250 cc,OPERATION IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Note that previously the patient was found to have some baseline dementia, although slight.  The patient was seen and evaluated by the neurology team, who cleared the patient for surgery.  The patient was taken to the operating room and general endotracheal anesthesia was administered.  The abdomen was prepped and draped in the standard surgical fashion.  We first began our dissection by using a #10-blade scalpel to incise the skin over the femoral artery in the groin bilaterally.  Dissection was carried down to the level of the femoral vessels using Bovie electrocautery.  The common femoral, superficial femoral, and profunda femoris arteries were encircled and dissected out peripherally.  Vessel loops were placed around the aforementioned arteries.  After doing so, we turned our attention to beginning our abdominal dissection.  We used a #10-blade scalpel to make a midline laparotomy incision.  Dissection was carried down to the level of the fascia using Bovie electrocautery.  The abdomen was opened and an Omni retractor was positioned.  The aorta was dissected out in the abdomen.  The left femoral vein was identified.  There was a nicely clampable portion of aorta visible.  We, as mentioned, placed our Omni retractor and then turned our attention to performing our anastomosis.  Full-dose heparin was given.  Next, vascular clamps were applied to the iliac vessels as well as to the proximal aorta just below the renal vessels.  A #11-blade scalpel was used to make an arteriotomy in the aorta, which was lengthened both proximally and distally using Potts scissors.  We then beveled our proximal graft and constructed an end graft-to-side artery anastomosis using 3-0 Prolene in a running fashion.  Upon completion of our anastomosis, we flushed our graft and noted there was no evidence of a leak from the newly constructed anastomosis.  We then created our tunnels over the iliac vessels.  We pulled the distal limbs over our ABF graft into the groin.  We then proceeded to perform our right anastomosis first.  We applied vascular clamps on the proximal common femoral, profunda, and superficial femoral arteries.  We incised the common femoral artery and lengthened our arteriotomy in the vessel both proximally and distally.  We then footed the graft down onto the common femoral artery to the level of the SFA and constructed our anastomosis using 6-0 Prolene in a running fashion.  Upon completion of our anastomosis, we flushed the common femoral, SFA, and profunda femoris arteries.  We then removed our clamp.  We opened the limb more proximally in the abdomen on the right side.  We then turned our attention to the left side and similarly placed our vascular clamps.  We used a #11-blade scalpel to make an arteriotomy in the vessel.  We then lengthened our arteriotomy both proximally and distally again onto the SFA.  We constructed a footed end graft-to-side artery anastomosis using 6-0 Prolene in a running fashion.  Upon completion of our anastomosis, we opened our clamps.  There was no noticeable leak from the newly constructed anastomosis.  We checked our proximal graft to aortic anastomosis, which was noted to be in good condition.  We then gave full-dose protamine.  We closed the peritoneum over the graft with 4-0 Vicryl in a running fashion.  The abdomen was closed with #1 nylon in a running fashion.  The skin was closed with subcuticular 4-0 Monocryl in a running subcuticular fashion.  The instrument and sponge count was correct at end of case.  Patient tolerated the procedure well and was transferred to the intensive care unit in good condition.
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DESCRIPTION: Dementia and aortoiliac occlusive disease bilaterally.  Aortobifemoral bypass surgery utilizing a bifurcated Hemashield graft.

cardiovascular / pulmonary, bifurcated, hemashield graft, aortoiliac occlusive disease, aortobifemoral bypass, vascular clamps, common femoral, graft, femoral, anastomosis, aortobifemoral, aortoiliac, proximal, arteriotomy, bypass, artery, endotracheal, vessels,

The situation involves a major vascular surgical procedure, the aortobifemoral bypass, which is high-stakes due to its complexity, the potential for significant blood loss, and the vital nature of the arteries involved. Moreover, the patient having dementia adds another layer of complexity, increasing the stakes due to the possible impact on the patient's overall health and recovery process. The surgery requires careful postoperative monitoring, as it can have life-altering consequences if complications arise. Additionally, this procedure involves clearing the patient through neurologic evaluation, indicating its seriousness. However, the procedure described was completed successfully with the patient in good condition postoperatively, which slightly mitigates the immediate high-stakes concern.