Medical Specialty: General Medicine
Sample Name: Foreign Body - Fingernail

HISTORY OF PRESENT ILLNESS:,  Patient is a 72-year-old white male complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p.m. yesterday.  He attempted to remove it with tweezers at home, but was unsuccessful.  He is requesting we attempt to remove this for him.,The patient believes it has been over 10 years since his last tetanus shot, but states he has been allergic to previous immunizations primarily with "horse serum."  Consequently, he has declined to update his tetanus immunization.,MEDICATIONS: , He is currently on several medications, a list of which is attached to the chart, and was reviewed.  He is not on any blood thinners.,ALLERGIES: , HE IS ALLERGIC ONLY TO TETANUS SERUM.,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife.  ,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp and vital signs are all within normal limits.,GENERAL:  The patient is a pleasant elderly white male who is sitting on the stretcher in no acute distress.,EXTREMITIES:  Exam of the left fifth finger shows a 5- to 6-mm splinter lodged beneath the medial aspect of the nail plate.  It does not protrude beyond the end of the nail plate.  There is no active bleeding.  There is no edema or erythema of the digit tip.  Flexion and extension of the DIP joint is intact.  The remainder of the hand is unremarkable.,TREATMENT: , I did attempt to grasp the end of the splinter with splinter forceps, but it is brittle and continues to break off.  In order to better grasp the splinter, will require penetration beneath the nail plate, which the patient cannot tolerate due to pain.  Consequently, the base of the digit tip was prepped with Betadine, and just distal to the DIP joint, a digital block was applied with 1% lidocaine with complete analgesia of the digit tip.  I was able to grasp the splinter and remove this.  No further foreign body was seen beneath the nail plate and the area was cleansed and dressed with bacitracin and bandage.,ASSESSMENT: , Foreign body of the left fifth fingernail (wooden splinter).,PLAN: , Patient was urged to clean the area b.i.d. with soap and water and to dress with bacitracin and a Band-Aid.  If he notes increasing redness, pain, or swelling, he was urged to return for re-evaluation.
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DESCRIPTION: Foreign body of the left fifth fingernail (wooden splinter).  He attempted to remove it with tweezers at home, but was unsuccessful.  He is requesting we attempt to remove this for him.

general medicine, horse serum, wooden splinter, foreign body, nail plate, grasp, fingernail, splinter,

The situation involves the removal of a wooden splinter from a fingernail, which is a common minor injury. The main medical concern is the patient's allergic reaction to tetanus serum, leading to not updating his immunizations. This can be a concern if the splinter causes an infection or if the patient had other complications, but currently, the wound is clean and no signs of infection are present. The situation has been resolved with standard medical procedures, and instructions were given for monitoring the injury. While there is a slight risk due to the patient's allergic history, the overall situation is low-stakes as the injury is minor and effectively treated.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 43

HISTORY:,  A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis.  The patient was status post coronary artery bypass surgery aortic valve repair at Shadyside Hospital.  The patient subsequently developed CVA.  She also developed thrombosis of the right arm, which ultimately required right hand amputation.  She was stabilized and eventually transferred to HealthSouth for further management.,PHYSICAL EXAMINATION:,Vital Signs:  Pulse of 90 and blood pressure 150/70.,Heart:  Sounds were heard, grade 2/6 systolic murmur at the precordium.,Chest:  Clinically clear.,Abdomen:  Some suprapubic tenderness.  Evidence of right lower arm amputation.,The patient was started on Prevacid 30 mg daily, levothyroxine 75 mcg a day, Toprol 25 mg twice a day, Zofran 4 mg q.6 h, Coumadin dose at 5 mg and was adjusted.  She was given a pain control using Vicodin and Percocet, amiodarone 200 mg a day, Lexapro 20 mg a day, Plavix 75 mg a day, fenofibrate 145 mg, Lasix 20 mg IV twice a day, Lantus 50 units at bedtime and Humalog 10 units a.c. and sliding scale insulin coverage.  Wound care to the right heel was supervised by Dr. X.  The patient initially was fed through NG tube, which was eventually discontinued.  Physical therapy was ordered.  The patient continued to do well.  She was progressively ambulated.  Her meds were continuously adjusted.  The patient's insulin was eventually changed from Lantus to Levemir 25 units twice a day.  Dr. Y also followed the patient closely for left heel ulcer.,LABORATORY DATA: , The latest cultures from left heel are pending.  Her electrolytes revealed sodium of 135 and potassium of 3.2.  Her potassium was switched to K-Dur 40 mEq twice a day.  Her blood chemistries are otherwise closely monitored.  INRs were obtained and were therapeutic.  Throughout her hospitalization, multiple cultures were also obtained.  Urine cultures grew Klebsiella.  She was treated with appropriate antibiotics.  Her detailed blood work is as in the chart.  Detailed radiological studies are as in the chart.  The patient made a steady progress and eventually plans were made to transfer the patient to ABC furthermore aggressive rehabilitation.,FINAL DIAGNOSES:,1.  Atherosclerotic heart disease, status post coronary artery bypass graft.,2.  Valvular heart disease, status post aortic valve replacement.,3.  Right arm arterial thrombosis, status post amputation right lower arm.,4.  Hypothyroidism.,5.  Uncontrolled diabetes mellitus, type 2.,6.  Urinary tract infection.,7.  Hypokalemia.,8.  Heparin-induced thrombocytopenia.,9.  Peripheral vascular occlusive disease.,10.  Paroxysmal atrial fibrillation.,11.  Hyperlipidemia.,12.  Depression.,13.  Carotid stenosis.
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DESCRIPTION: A 69-year-old female with past history of type II diabetes, atherosclerotic heart disease, hypertension, carotid stenosis.

consult - history and phy., arterial thrombosis, valvular heart disease, atherosclerotic heart disease, type ii diabetes, hypertension, carotid stenosis, heart disease, diabetes, carotid, stenosis, bypass, amputation, heart, atherosclerotic,

This situation involves a comprehensive medical evaluation of a 69-year-old female patient with multiple complex medical conditions, including past and recent serious health issues such as coronary artery disease, valvular heart disease, and complications leading to a limb amputation. The patient's condition requires careful medication management and rehabilitation. The stakes are high due to the complexity of her health conditions, the need for precise medical management, and the potential for serious complications, such as further cardiovascular events, infection risks, and managing her diabetes and other comorbidities appropriately. Effective treatment and rehabilitation are crucial for her quality of life and survival.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: ENT - Otolaryngology
Sample Name: Tonsillectomy - 1

PREOPERATIVE DIAGNOSIS:,  Chronic tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis.,PROCEDURE:  ,Tonsillectomy.,DESCRIPTION OF PROCEDURE: , Under general orotracheal anesthesia, a Crowe-Davis mouth gag was inserted and suspended.  Tonsils were removed by electrocautery dissection and the tonsillar beds were injected with Marcaine 0.25% plain.  A catheter was inserted in the nose and brought out from mouth.  The throat was irrigated with saline.  There was no further bleeding.  The patient was awakened and extubated and moved to the recovery room in satisfactory condition.
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DESCRIPTION: Tonsillectomy.  Chronic tonsillitis.

Tonsillectomy.  Chronic tonsillitis.

ent - otolaryngology, crowe-davis, mouth gag, chronic tonsillitis, tonsillitis, anesthesia, tonsillectomy

The procedure described is a tonsillectomy, which is a common and routine surgical procedure performed to remove the tonsils, typically due to chronic tonsillitis. While any surgical procedure requires careful consideration and can carry risks, a tonsillectomy is generally considered to be low to moderate risk and is routinely performed. The description indicates no complications during the procedure, and the patient was reported to awaken in satisfactory condition, further supporting the classification of this as a low-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lobectomy - VATS

PREOPERATIVE DIAGNOSIS:,  Right middle lobe lung cancer.,POSTOPERATIVE DIAGNOSIS: , Right middle lobe lung cancer.,PROCEDURES PERFORMED:,1.  VATS right middle lobectomy.,2.  Fiberoptic bronchoscopy thus before and after the procedure.,3.  Mediastinal lymph node sampling including levels 4R and 7.,4.  Tube thoracostomy x2 including a 19-French Blake and a 32-French chest tube.,5.  Multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.,ANESTHESIA:  ,General endotracheal anesthesia with double-lumen endotracheal tube.,DISPOSITION OF SPECIMENS: , To pathology both for frozen and permanent analysis.,FINDINGS:,  The right middle lobe tumor was adherent to the anterior chest wall.  The adhesion was taken down, and the entire pleural surface along the edge of the adhesion was sent for pathologic analysis.  The final frozen pathology on this entire area returned as negative for tumor.  Additional chest wall abnormalities were biopsied and sent for pathologic analysis, and these all returned separately as negative for tumor and only fibrotic tissue.  Several other biopsies were taken and sent for permanent analysis of the chest wall.  All of the biopsy sites were additionally marked with Hemoclips.  The right middle lobe lesion was accompanied with distal pneumonitis and otherwise no direct involvement of the right upper lobe or right lower lobe.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,CONDITION OF THE PATIENT AFTER SURGERY: , Stable.,HISTORY OF PROCEDURE:,  This patient is well known to our service.  He was admitted the night before surgery and given hemodialysis and had close blood sugar monitoring in control.  The patient was subsequently taken to the operating room on April 4, 2007, was given general anesthesia and was endotracheally intubated without incident.  Although, he had markedly difficult airway, the patient had fiberoptic bronchoscopy performed all the way down to the level of the subsegmental bronchi.  No abnormalities were noted in the entire tracheobronchial tree, and based on this, the decision was made to proceed with the surgery.  The patient was kept in the supine position, and the single-lumen endotracheal tube was removed and a double-lumen tube was placed.  Following this, the patient was placed into the left lateral decubitus position with the right side up and all pressure points were padded.  Sterile DuraPrep preparation on the right chest was placed.  A sterile drape around that was also placed.  The table was flexed to open up the intercostal spaces.  A second bronchoscopy was performed to confirm placement of the double-lumen endotracheal tube.  Marcaine was infused into all incision areas prior to making an incision.  The incisions for the VATS right middle lobectomy included a small 1-cm incision for the auscultatory incision approximately 4 cm inferior to the inferior tip of the scapula.  The camera port was in the posterior axillary line in the eighth intercostal space through which a 5-mm 30-degree scope was used.  Third incision was an anterior port, which was approximately 2 cm inferior to the inframammary crease and the midclavicular line in the anterior sixth intercostal space, and the third incision was a utility port, which was a 4 cm long incision, which was approximately one rib space below the superior pulmonary vein.  All of these incisions were eventually created during the procedure.  The initial incision was the camera port through which, under direct visualization, an additional small 5-mm port was created just inferior to the anterior port.  These two ports were used to identify the chest wall lesions, which were initially thought to be metastatic lesions.  Multiple biopsies of the chest wall lesions were taken, and the decision was made to also insert the auscultatory incision port.  Through these three incisions, the initial working of the diagnostic portion of the chest wall lesion was performed.  Multiple biopsies were taken of the entire chest wall offers and specimens came back as negative.  The right middle lobe was noted to be adherent to the anterior chest wall.  This area was taken down and the entire pleural surface along this area was taken down and sent for frozen pathologic analysis.  This also returned as negative with only fibrotic tissue and a few lymphocytes within the fibrotic tissue, but no tumor cells.  Based on this, the decision was made to not proceed with chest wall resection and continue with right middle lobectomy.  Following this, the anterior port was increased in size and the utility port was made and meticulous dissection from an anterior to posterior direction was performed.  The middle lobe branch of the right superior pulmonary vein was initially dissected and stapled with vascular load 45-mm EndoGIA stapler.  Following division of the right superior pulmonary vein, the right middle lobe bronchus was easily identified.  Initially, this was thought to be the main right middle lobe bronchus, but in fact it was the medial branch of the right middle lobe bronchus.  This was encircled and divided with a blue load stapler with a 45-mm EndoGIA.  Following division of this, the pulmonary artery was easily identified.  Two branches of the pulmonary artery were noted to be going into the right middle lobe.  These were individually divided with a vascular load after encircling with a right angle clamp.  The vascular staple load completely divided these arterial branches successfully from the main pulmonary artery trunk, and following this, an additional branch of the bronchus was noted to be going to the right middle lobe.  A fiberoptic bronchoscopy was performed intraoperatively and confirmed that this was in fact the lateral branch of the right middle lobe bronchus.  This was divided with a blue load stapler 45 mm EndoGIA.  Following division of this, the minor and major fissures were completed along the edges of the right middle lobe separating the right upper lobe from the right middle lobe as well as the right middle lobe from the right lower lobe.  Following complete division of the fissure, the lobe was put into an EndoGIA bag and taken out through the utility port.  Following removal of the right middle lobe, a meticulous lymph node dissection sampling was performed excising the lymph node package in the 4R area as well as the 7 lymph node package.  Node station 8 or 9 nodes were easily identified, therefore none were taken.  The patient was allowed to ventilate under water on the right lung with no obvious air leaking noted.  A 19-French Blake was placed into the posterior apical position and a 32-French chest tube was placed in the anteroapical position.  Following this, the patient's lung was allowed to reexpand fully, and the patient was checked for air leaking once again.  Following this, all the ports were closed with 2-0 Vicryl suture used for the deeper tissue, and 3-0 Vicryl suture was used to reapproximate the subcutaneous tissue and 4-0 Monocryl suture was used to close the skin in a running subcuticular fashion.  The patient tolerated the procedure well, was extubated in the operating room and taken to the recovery room in stable condition.
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DESCRIPTION: VATS right middle lobectomy, fiberoptic bronchoscopy, mediastinal lymph node sampling, tube thoracostomy x2, multiple chest wall biopsies and excision of margin on anterior chest wall adjacent to adherent tumor.

cardiovascular / pulmonary, middle lobe, endogia, fiberoptic, mediastinal lymph node, vats, bronchoscopy, chest tube, chest wall, endotracheal tube, endotracheally, lobectomy, lung cancer, pneumonitis, sampling, thoracostomy, utility port, lumen endotracheal tube, superior pulmonary vein, chest wall lesions, anterior chest wall, middle lobectomy, fiberoptic bronchoscopy, anterior chest, lymph node, node, port, chest, bronchus, tumor, pulmonary, incision,

The document describes a complex surgical procedure (Video-Assisted Thoracoscopic Surgery - VATS) for a patient with right middle lobe lung cancer. This involves a right middle lobectomy along with bronchoscopy, lymph node sampling, and multiple biopsies. Such a surgery is critical given the nature of cancer treatment and potential complications related to the patient's condition and airway difficulties. Given that the procedure involved multiple incisions, delicate surgical maneuvers, and thorough pathology to confirm the absence of malignant cells, it indicates high-stakes to ensure successful removal of the cancer while preserving patient stability. Furthermore, the patient’s status post-surgery needs to ensure stability not just immediately after but also in the follow-up care to monitor for complications such as infection or recurrence.


Medical Specialty: Nephrology
Sample Name: Clogged AV Shunt - Consult

REASON FOR CONSULTATION: , Clogged AV shunt.,HISTORY OF PRESENT ILLNESS:,  This is a 32-year-old African-American male who came to ABCD General Hospital with the above chief complaint.  The patient complains of fatigue, nausea, vomiting and fever.  The patient states that the shunt was placed in February, although according to medical records it was placed in April and it has been periodically clogging since its placement.  The patient had dialysis today, which is Saturday, for approximately one hour before the shunt no longer worked.  The patient had been seen in the Emergency Room yesterday, 08/29/03, by Dr. X for the same problem.  At that time, Dr. X felt that the patient should use the AV fistula during dialysis and after the fistula is able to be used, the PermCath on the right subclavian should be removed.  As mentioned above, he had dialysis today and they were unable to use AV fistula as well as the PermCath read "did not work".  The patient has had dialysis since January secondary to hypertension-induced renal failure.  He takes dialysis Monday, Wednesday, and Friday at the ABCD Dialysis Center.  He also was seen at XYZ and he had an apparent thrombectomy with reversal done a few days ago.  The patient's history at this point is a little sketchy; however, he states that he left AMA.  All other systems are reviewed and are negative.,PAST MEDICAL HISTORY: , Significant for heart attack, chronic renal failure with dialysis, CHF, hypertension, and PermCath.,PAST SURGICAL HISTORY: , AV fistula on the left arm and a PermCath.,ALLERGIES: , Penicillin.,MEDICATIONS: , Include metoprolol 100 mg two tablets b.i.d., Tylenol #3, Accupril 20 mg q.d., digoxin, Renocaps, aspirin, and Combivent.,SOCIAL HISTORY: , Half pack of tobacco x3 years.  No alcohol, occasional marijuana, and no IV drug use.  He lives alone, single and no children.,PHYSICAL EXAMINATION: , Vital signs:  In Emergency Room, temperature 98.2, pulse 83, respirations 20, blood pressure 146/84 and 99% on room air.  General:  This is an alert and oriented African-American male x3 and in no acute distress.  The patient is extremely lethargic and had to be aroused multiple times to answer questions.  Mucous membranes are moist.  HEENT:  Head is normocephalic and atraumatic.  There is no scleral icterus noted.  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.  Cardiovascular:  Shows a heart rate that is regular with a laterally displaced point of maximum intensity.  There is no murmur, gallop, or rub noted.  Lungs:  Clear to auscultation bilaterally.  No wheeze, rhonchi or rales.  Abdomen:  Soft, nontender and nondistended.  Bowel sounds are present.  Extremities:  Show left forearm with an incision that is well healed from a left AV fistula.  There is a distal thrill palpable and there is some tenderness over the incisional area.  There is no erythema or pus noted.  Other extremities show peripheral pulses present and no edema.,LABORATORY VALUES: , Sodium 139, potassium 3.9, chloride 92, CO2 33, BUN 36, creatinine 9.2, and glucose 131.  Digoxin 0.6, white count is 5.8, hemoglobin 11.7, hematocrit 34.9 and platelets are 252.,IMPRESSION:,1.  Nonfunctional AV fistula.,2.  End-stage renal disease.,3.  Hypertension.,4.  Status post MI.,5.  Clogged PermCath.,PLAN:,1.  Give the patient TPA to the shunt, PermCath in both feet.,2.  To board for Tuesday for shunt repair if needed.,3.  To dialyze as soon as possible.,4.  To review previous operative report.,5.  The patient will be contacted in the morning and told whether to go to dialysis or not.
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DESCRIPTION: Clogged AV shunt.  The patient complains of fatigue, nausea, vomiting and fever.

This situation involves a patient with multiple serious health issues, including a clogged AV shunt, end-stage renal disease, hypertension, and a history of myocardial infarction. The patient's access for dialysis is compromised, which is a critical concern because it directly affects the management of his end-stage renal disease. Dialysis is necessary to prevent life-threatening complications due to kidney failure. Furthermore, the patient presents symptoms like fatigue, nausea, vomiting, and fever, which indicate potential complications such as infection. The stakes are high as the patient's condition requires prompt and effective intervention to maintain dialysis access and prevent further deterioration of health.


Medical Specialty: Neurosurgery
Sample Name: Anterior Lumbar Fusion

PREOPERATIVE DIAGNOSIS: , Severe low back pain.,POSTOPERATIVE DIAGNOSIS: , Severe low back pain.,OPERATIONS PERFORMED: , Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 mL.,DRAINS:,  None.,COMPLICATIONS: , None.,PATHOLOGICAL FINDINGS:,  Dr. X made the approach and once we were at the L5-S1 disk space, we removed the disk and we placed a 13-mm PEEK vertebral spacer filled with a core of bone taken from the L5 vertebral body.  This was filled with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  At L4-L5, we used a 13-mm PEEK vertebral spacer with structural autograft and BMP, and then we placed a two-level 87-mm Integra sacral plate with 28 x 6-mm screws, two each at L4 and L5 and 36 x 6-mm screws at S1.,OPERATION IN DETAIL:,  The patient was placed under general endotracheal anesthesia.  The abdomen was prepped and draped in the usual fashion.  Dr. X made the approach, and once the L5-S1 disk space was identified, we incised this with a knife and then removed a large core of bone taking rotating cutters.  I was able to remove additional disk space and score the vertebral bodies.  The rest of the disk removal was done with the curette, scraping the endplates.  I tried various sized spacers, and at this point, we exposed the L5 body and took a dowel from the body and filled the hole with a 15 x 20-mm Chronos VerteFill tricalcium phosphate plug.  Half of this was used to fill the spacer at L5-S1, BMP was placed in the spacer as well and then it was tapped into place.  We then moved the vessels over the opposite way approaching the L4-L5 disk space laterally, and the disk was removed in a similar fashion and we also used a 13-mm PEEK vertebral spacer, but this is the variety that we could put in from one side.  This was filled with bone and BMP as well.  Once this was done, we were able to place an 87-mm Integra sacral plate down over the three vertebral bodies and place these screws.  Following this, bleeding points were controlled and Dr. X proceeded with the closure of the abdomen.,SUMMARY: , This is a 51-year-old man who reports 15-year history of low back pain and intermittent bilateral leg pain and achiness.  He has tried multiple conservative treatments including physical therapy, epidural steroid injections, etc.  MRI scan shows a very degenerated disk at L5-S1, less so at L3-L4 and L4-L5.  A discogram was positive with the lower 3 levels, but he has pain, which starts below the iliac crest and I feel that the L3-L4 disk is probably that symptomatic.  An anterior lumbar interbody fusion was suggested.  Procedure, risks, and complications were explained.
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DESCRIPTION: Anterior lumbar fusion, L4-L5, L5-S1, PEEK vertebral spacer, structural autograft from L5 vertebral body, BMP and anterior plate.  Severe low back pain.

neurosurgery, peek vertebral spacer, autograft, anterior lumbar fusion, lumbar fusion, vertebral body, vertebral spacer, vertebral, spacer, anterior, lumbar, fusion,

The situation involves a detailed surgical procedure for anterior lumbar fusion on a patient suffering from severe low back pain. Surgeries, particularly neurosurgery procedures like spinal fusion, are generally high-stakes due to the complexity, risk of complications, and potential impacts on a patient's mobility and quality of life. Although this specific procedure went smoothly without complications, the inherent risks involved in neurosurgery make this a high-stakes situation.


Medical Specialty: Surgery
Sample Name: Excision - Soft Tissue Mass

PREOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,POSTOPERATIVE DIAGNOSIS: , Right flank subcutaneous mass.,PROCEDURE PERFORMED: , Excision of soft tissue mass on the right flank.,ANESTHESIA: , Sedation with local.,INDICATIONS FOR PROCEDURE:,  This 54-year-old male was evaluated in the office with a large right flank mass.  He would like to have this removed.,DESCRIPTION OF PROCEDURE:,  Consent was obtained after all risks and benefits were described.  The patient was brought back into the operating room.  The aforementioned anesthesia was given.  Once the patient was properly anesthetized, the area was prepped and draped in the sterile fashion.  With the area properly prepped and draped, a needle was used to localize the area directly above the mass on the patient's right flank.  Then a #10 blade scalpel was used to make the incision approximately 4 cm to 5 cm in length just above the mass.  The incision was extended down using electrocautery.  The excision then had a Allis clamp placed on it and was retracted using sharp dissection and electrocautery was used to dissect the mass off the muscle.  The mass was sent off to Pathology for investigation.  Hemostasis maintained with electrocautery and then the subcutaneous fascia was closed using a #3-0 Vicryl suture in interrupted fashion and the skin was reapproximated using a #4-0 undyed Vicryl suture in a running subcuticular fashion.  The patient's wound was cleaned.  Steri-Strips were placed and sterile dressings were placed on top of this.  The patient tolerated the procedure well and will reevaluate in the office in one week's time.
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DESCRIPTION: Excision of soft tissue mass on the right flank.  This 54-year-old male was evaluated in the office with a large right flank mass.  He would like to have this removed.

surgery, electrocautery, soft tissue mass, subcutaneous, excision

The situation involves a surgical procedure to excise a soft tissue mass on a patient's right flank. Given that it is a planned and common surgical procedure with local anesthesia and sedation, where the mass will be sent for pathology, this can be regarded as a relatively routine medical procedure with standard risks associated with surgery. While there is always a degree of seriousness in any surgical procedure due to anesthesia involvement and potential complications, this specific scenario does not involve life-threatening or highly complex issues, thus making it low-stakes in the context of surgical procedures.


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

EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.
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DESCRIPTION: Sample normal ear, nose, mouth, and throat exam.

consult - history and phy., erythema, tympanic, mouth, throat, ears, mucosa, noseNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The text describes a normal ear, nose, and throat (ENT) examination with no abnormalities found. It appears to be a routine medical assessment with the purpose of documenting normal findings in ENT physical exams. This situation carries low stakes as it doesn't indicate any medical emergencies or abnormalities that require immediate attention or intervention.


Medical Specialty: Discharge Summary
Sample Name: Neonatal Discharge Summary - 1

ADMITTING DIAGNOSES:,  Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.,HISTORY OF PRESENTING ILLNESS: , The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.  Baby was born at ABCD Hospital at 1333 on 07/14/2006.  Mother is a 20-year-old gravida 1, para 0 female who received prenatal care.  Prenatal course was complicated by low amniotic fluid index and hypertension.  She was evaluated for evolving preeclampsia and had a C-section secondary to the nonreassuring fetal status.  Baby delivered operatively, Apgar scores were 8 and 9 initially taken to level 2 satellite nursery and arrangements were to transfer to Children's Hospital.  Infant was transferred to Children's Hospital for higher level of care, stayed at Children's Hospital for approximately 2 weeks, and was transferred back to ABCD where he stayed until he was discharged on 08/16/2006.,HOSPITAL COURSE: , At the time of transfer to ABCD, these were the following issues.,FEEDING AND NUTRITION: , Baby was on TPN and p.o. feeds had been started and were advanced 1 ml q.6h.  Baby was tolerating p.o. feeds of expressed breast milk and baby began to experience some abdominal distention.  The p.o. feeds were held and IV D10 water was given.  Baby was started on Mylicon drops and glycerin suppositories.  Abdominal ultrasound showed gaseous distention without signs of obstruction.  OG tube was passed.  Baby improved after couple of days when p.o. feedings were restarted.  Baby was also given Reglan.  At the time of discharge, baby was tolerating p.o. feeds well of BM fortified with 22-cal NeoSure.  Feeding amounts at the time of discharge was between 35 to 50 mL per feed and weight was 1797 grams.,RESPIRATIONS: , At the time of admission, baby was not having any apnea spells, no bradycardia or desaturations, was saturating well on room air and continued to do well on room air until the time of discharge.,HYPOGLYCEMIA: , Baby began to experience hypoglycemic episodes on 07/24/2006.  Blood glucose level was as low as 46.  D10 was given initially as bolus.  Baby continued to experience hypoglycemic episodes.  Diazoxide was started 5 mg/kg per os every 8 hours and fingersticks were done to monitor blood glucose level.  The baby improved with diazoxide, hypoglycemic issues resolved and then began again.  Diazoxide was discontinued, but the hypoglycemic issues restarted.  The Diazoxide was restarted again.  Blood glucose level stabilized and then diazoxide was weaned off until daily dose of 6 mg/kg and then the diazoxide was discontinued.  At the time of discharge, blood glucose levels were not being stable for 24 hours.,CARDIOVASCULAR: , Infant was hemodynamically stable on admission from Madera.  Infant has a closed PDA.  Infant had two cardiac echograms done.  The lab showing normal antegrade flow across the right coronary artery as well as the left main and left anterior descending coronary artery, then the circumflex coronary artery.,CNS:,  Infant had a head ultrasound done to rule out intracranial abnormalities and intracranial hemorrhage.  The ultrasound was negative for intracranial hemorrhage.,INFECTIOUS DISEASE:,  The patient had been on antibiotics during the stay at Madera.  At the time of admission to the ABCD, the patient was not on any antibiotics and his clinically condition has remained stable.,HEMATOLOGY: , The patient is status post phototherapy at Madera and was started on iron.,OPHTHALMOLOGY: ,  Exam on 07/17/2006 showed immature retina.  The patient is to get followup exam after discharge.,DISCHARGE DIAGNOSIS: , Stable ex-32-weeks preemie.,DISCHARGE INSTRUCTIONS: , The patient has been educated on CPR measures.  Followup appointment has been made at Kid's Care.  Calcium challenge has been done.  The patient's parents are comfortable with feeding.  The patient has been discharged on NeoSure and expressed breast milk.,
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DESCRIPTION: Respiratory distress syndrome, intrauterine growth restriction, thrombocytopenia, hypoglycemia, retinal immaturity.  The baby is an ex-32 weeks small for gestational age infant with birth weight 1102.

discharge summary, delivered, preeclampsia, immaturity, intrauterine, prenatal, coronary artery, blood glucose, discharge, baby, coronary, intracranial, hypoglycemia, hypoglycemic, infant,

The discharge summary provided is for a neonatal patient with multiple serious medical conditions, including respiratory distress syndrome, hypoglycemia, and other complications related to prematurity. Although the baby is being discharged, he requires ongoing medical care and monitoring, which is indicative of a high-stakes situation. The health of a premature infant can be fragile, and the stakes are high in ensuring a successful transition to outpatient care. The discharge includes instructions for follow-up care, which is crucial for the baby's continued health and management of potential complications. Therefore, the stakes are significant due to the critical nature of the infant's health and the need for vigilant follow-up by caregivers and medical professionals.


Medical Specialty: Consult - History and Phy.
Sample Name: Cardiac Consultation - 1

CHIEF REASON FOR CONSULTATION:,  Evaluate recurrent episodes of uncomfortable feeling in the left upper arm at rest, as well as during exertion for the last one month.,HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female complains of having pain and discomfort in the left upper arm, especially when she walks and after heavy meals.  This lasts anywhere from a few hours and is not associated with shortness of breath, palpitations, dizziness, or syncope.  Patient does not get any chest pain or choking in the neck or pain in the back.  Patient denies history of hypertension, diabetes mellitus, enlarged heart, heart murmur, history suggestive of previous myocardial infarction, or acute rheumatic polyarthritis during childhood.  Her exercise tolerance is one to two blocks for shortness of breath and easy fatigability.,MEDICATIONS:,  Patient does not take any specific medications.,PAST HISTORY:,  The patient underwent hysterectomy in 1986.,FAMILY HISTORY:,  The patient is married, has four children who are doing fine.  Family history is positive for hypertension, congestive heart failure, obesity, cancer, and cerebrovascular accident.,SOCIAL HISTORY:, The patient smokes one pack of cigarettes per day and takes drinks on social occasions.
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DESCRIPTION: To evaluate recurrent episodes of uncomfortable feeling in arm at rest, as well as during exertion.

This medical scenario describes a consultation for a patient experiencing discomfort in the left upper arm possibly related to cardiac issues. The symptoms reported include discomfort during exertion and after meals, with a noteworthy family history of hypertension and heart disease, alongside the patient's smoking habit. These factors could potentially indicate underlying cardiac conditions. Given the role of these symptoms in indicating serious health concerns such as heart disease, the situation has significant importance for diagnosing and potentially preventing serious health events, like myocardial infarction or other cardiovascular diseases.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pneumoconiosis

HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  The patient also has a positive history of smoking in the past.  At the present time, he is admitted for continued,management of respiratory depression with other medical complications.  The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  In addition, he also developed cardiac complications including atrial fibrillation.  The patient was evaluated by the cardiologist as well as the pulmonary service and Urology.  He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  He subsequently underwent cardiac arrest and he was resuscitated at that time.  He was intubated and placed on mechanical ventilatory support.  Subsequent weaning was unsuccessful.  He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1.  Albuterol.,2.  Pacerone.,3.  Theophylline,4.  Lovenox.,5.  Atrovent.,6.  Insulin.,7.  Lantus.,8.  Zestril.,9.  Magnesium oxide.,10.  Lopressor.,11.  Zegerid.,12.  Tylenol as needed.,ALLERGIES:,  PENICILLIN.,PAST MEDICAL HISTORY:,1.  History of coal miner's disease.,2.  History of COPD.,3.  History of atrial fibrillation.,4.  History of coronary artery disease.,5.  History of coronary artery stent placement.,6.  History of gastric obstruction.,7.  History of prostate cancer.,8.  History of chronic diarrhea.,9.  History of pernicious anemia.,10.  History of radiation proctitis.,11.  History of anxiety.,12.  History of ureteral stone.,13.  History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker.  No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated.  Rapidly moving his upper extremities.  No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General:  The patient is currently agitated with some level of distress.  He has rapid respiratory rate.  He is responsive to verbal commands by looking at the eyes.,Vital Signs:  As per the monitors are stable.,Extremities:  Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas.  There is also edema of the forearm extending up to the mid upper arm area.  Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1.  Ulceration of bilateral upper extremities.,2.  Cellulitis of upper extremities.,3.  Lymphedema of upper extremities.,4.  Other noninfectious disorders of lymphatic channels.,5.  Ventilatory-dependent respiratory failure.
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DESCRIPTION: Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.

The situation involves a 91-year-old male with a complicated medical history, including pneumoconiosis, cardiac issues, and a dependency on ventilatory support. The patient has also experienced cardiac arrest and requires mechanical ventilation with unsuccessful weaning, indicating a critical and potentially volatile health condition. The presence of multiple comorbidities, including COPD, coronary artery disease, and ongoing respiratory depression, further elevates the stakes. Given the age and complexity of the medical issues involved, this situation represents a high-stakes scenario where any change in health status could have significant consequences.


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

REVIEW OF SYSTEMS,GENERAL:  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY:  Negative rash, negative jaundice.,HEMATOPOIETIC:  Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC:  Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS:  Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  Negative postnasal drip, negative sore throat.,CARDIOVASCULAR:  Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL:  Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY:  Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.  **No history of OB/GYN problems.,MUSCULOSKELETAL:  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC:  See psychiatric evaluation.,ENDOCRINE:  No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.
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DESCRIPTION: Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.

consult - history and phy., respiratory, gastrointestinal, integumentary, hematopoietic, night sweats, negative allergies, negative weakness, neurologic, throat, weakness

The situation described is a review of systems, which is a standard procedure in medical history taking. The template indicates that the patient doesn't have any symptoms across multiple systems. Since the patient doesn't exhibit any notable symptoms or abnormalities, and this is part of routine documentation—or template creation for efficiency—rather than an urgent medical incident, it is not a high-stakes situation. This is routine and non-critical data entry that aids in efficient medical assessment but is not indicative of an immediate risk to patient health.


Medical Specialty: Gastroenterology
Sample Name: Gastroscopy - 2

PROCEDURE:,  Gastroscopy.,PREOPERATIVE DIAGNOSIS:,  Dysphagia and globus.,POSTOPERATIVE DIAGNOSIS: , Normal.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach, and then through the gastrojejunal anastomosis into the efferent jejunal loop.  The preparation was good and all surfaces were well seen.  The hypopharynx was normal with no evidence of inflammation.  The esophagus had a normal contour and normal mucosa throughout with no sign of stricturing or inflammation or exudate.  The GE junction was located at 39 cm from the incisors and appeared normal with no evidence of reflux, damage, or Barrett's.  Below this there was a small gastric pouch measuring 6 cm with intact mucosa and no retained food.  The gastrojejunal anastomosis was patent measuring about 12 mm, with no inflammation or ulceration.  Beyond this there was a side-to-side gastrojejunal anastomosis with a short afferent blind end and a normal efferent end with no sign of obstruction or inflammation.  The scope was withdrawn and the patient was sent to recovery room.  She tolerated the procedure well.,FINAL DIAGNOSES:,1.  Normal post-gastric bypass anatomy.,2.  No evidence of inflammation or narrowing to explain her symptoms.
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DESCRIPTION: Gastroscopy.  Dysphagia and globus.  No evidence of inflammation or narrowing to explain her symptoms.

gastroenterology, olympus gastroscope, gastric pouch, gastrojejunal anastomosis, dysphagia, globus, esophagus, mucosa, gastric, gastroscopy, gastrojejunal, inflammation

The procedure described is a gastroscopy, which is a diagnostic procedure to view the stomach and esophagus. In this specific case, the findings were normal, and there were no complications or unexpected outcomes reported during or after the procedure. While the patient's symptoms (dysphagia and globus sensation) are uncomfortable, the gastroscopy itself revealed no immediate issues, suggesting there are no critical findings that require urgent intervention. Therefore, while it is important for the patient's ongoing care, there is no immediate high-stakes concern as there were no adverse findings.


Medical Specialty: Diets and Nutritions
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.

diets and nutritions, food diary sheets, active, balanced diet, three-meal pattern, weight loss, sugar free, food diary, dietary, weight, meal, diary, sheets, food

The situation described involves monitoring a patient's progress in a weight loss program. While maintaining a healthy weight can significantly impact an individual's overall health and wellbeing, the scenario provided is routine and does not imply any immediate risk to the patient's life or long-term health. This is a typical follow-up in dietary consultations, where the focus is on encouraging positive behaviors that are already in place.


Medical Specialty: Podiatry
Sample Name: Foot Pain

CHIEF COMPLAINT: , Foot pain.,HISTORY OF PRESENT ILLNESS: , This is a 17-year-old high school athlete who swims for the swimming team.  He was playing water polo with some of his teammates when he dropped a weight on the dorsal aspects of his feet.  He was barefoot at that time.  He had been in the pool practicing an hour prior to this injury.  Because of the contusions and abrasions to his feet, his athletic trainer brought in him to the urgent care.  He is able to bear weight; however, complains of pain in his toes.  The patient did have some avulsion of the skin across the second and third toes of the left foot with contusions across the second, third, and fourth toes and dorsum of the foot.  According to the patient, he was at his baseline state of health prior to this acute event.,PAST MEDICAL HISTORY: , Significant for attention deficit hyperactivity disorder.,PAST SURGICAL HISTORY:  ,Positive for wisdom tooth extraction.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,He does not use alcohol, tobacco or illicit drugs.  He plays water polo for the school team.,IMMUNIZATION HISTORY: , All immunizations are up-to-date for age.,REVIEW OF SYSTEMS: , The pertinent review of systems is as noted above; the remaining review of systems was reviewed and is noted to be negative.,PRESENT MEDICATIONS: , Provigil, Accutane and Rozerem.,ALLERGIES:  ,None.,PHYSICAL EXAMINATION:,GENERAL:  This is a pleasant white male in no acute distress.,VITAL SIGNS:  He is afebrile.  Vitals are stable and within normal limits.,HEENT:  Negative for acute evidence of trauma, injury or infection.,LUNGS:  Clear.,HEART:  Regular rate and rhythm with S1 and S2.,ABDOMEN:  Soft.,EXTREMITIES:  There are some abrasions across the dorsum of the right foot including the second, third and fourth toes.  There is some mild tenderness to palpation.  However, there are no clinical fractures.  Distal pulses are intact.  The left foot notes superficial avulsion lacerations to the third and fourth digit.  There are no subungual hematomas.  Range of motion is decreased secondary to pain.  No obvious fractures identified.,BACK EXAM:  Nontender.,NEUROLOGIC EXAM:  He is alert, awake and appropriate without deficit.,RADIOLOGY: , AP, lateral, and oblique views of the feet were conducted per Radiology, which were negative for acute fractures and significant soft tissue swelling or bony injuries.,On reevaluation, the patient was resting comfortably.  He was informed of the x-ray findings.  The patient was discharged in the care of his mother with a preliminary diagnosis of bilateral foot contusions with superficial avulsion lacerations, not requiring surgical repair.,DISCHARGE MEDICATIONS: , Darvocet.,The patient's condition at discharge was stable.  All medications, discharge instructions and follow-up appointments were reviewed with the patient/family prior to discharge.  The patient/family understood the instructions and was discharged without further incident.
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DESCRIPTION: Patient dropped a weight on the dorsal aspects of his feet.

The situation involves a teenage athlete who has sustained a non-life-threatening injury to his feet. The patient is stable, without fractures, and was discharged with minor treatment needed. The condition is painful and may impact his sports participation temporarily, but it is not considered a high-stakes medical emergency. The primary focus is on pain management and healing of the superficial wounds.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 17

CHIEF COMPLAINT:,  Fever.,HISTORY OF PRESENT ILLNESS:,  This is an 18-month-old white male here with his mother for complaint of intermittent fever for the past five days.  Mother states he just completed Amoxil several days ago for a sinus infection.  Patient does have a past history compatible with allergic rhinitis and he has been taking Zyrtec serum.  Mother states that his temperature usually elevates at night.  Two days his temperature was 102.6.  Mother has not taken it since, and in fact she states today he seems much better.  He is cutting an eye tooth that causes him to be drooling and sometimes fussy.  He has had no vomiting or diarrhea.  There has been no coughing.  Nose secretions are usually discolored in the morning, but clear throughout the rest of the day.  Appetite is fine.,PHYSICAL EXAMINATION:,General:  He is alert in no distress.,Vital Signs:  Afebrile.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  TMs are clear bilaterally.  Nares patent.  Clear secretions present.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular, no murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,Skin:  Normal turgor.,ASSESSMENT:,1.  Allergic rhinitis.,2.  Fever history.,3.  Sinusitis resolved.,4.  Teething.,PLAN:,  Mother has been advised to continue Zyrtec as directed daily.  Supportive care as needed.  Reassurance given and he is to return to the office as scheduled.
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DESCRIPTION: An 18-month-old white male here with his mother for complaint of intermittent fever for the past five days. - Allergic rhinitis, fever history, sinusitis resolved, and teething.

general medicine, sinusitis, fever, intermittent fever, allergic rhinitis, fever history, teething,

This scenario involves an 18-month-old child experiencing intermittent fever, which has a range of potential causes from benign to potentially serious. However, the child's condition appears to be stable and improving, with no distress signs and no significant complications identified during the examination. The fever itself is likely related to teething or a recent sinus infection, both common and typically non-serious conditions in children. Medical advice has been given for continued use of allergy medication. The child is also showing improvement and is afebrile during the examination. This suggests a generally low-risk situation, as immediate medical intervention does not appear necessary beyond supportive care and monitoring.


Medical Specialty: Radiology
Sample Name: Carotid Doppler Report

Grade II:  Atherosclerotic plaques are seen which appear to be causing 40-60% obstruction.,Grade III:  Atherosclerotic plaques are seen which appear to be causing greater than 60% obstruction.,Grade IV:  The vessel is not pulsating and the artery appears to be totally obstructed with no blood flow in it.,RIGHT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening with no increase in velocity and no evidence for any obstructive disease.  The internal carotid artery shows intimal thickening with some mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,LEFT CAROTID SYSTEM: , The common carotid artery and bulb area shows mild intimal thickening, but no increase in velocity and no evidence for any significant obstructive disease. the internal carotid artery shows some intimal thickening with mixed plaques, but no increase in velocity and no evidence for any significant obstructive disease.  The external carotid artery shows no disease.  The vertebral was present and was antegrade.,IMPRESSION:,  Bilateral atherosclerotic changes with no evidence for any significant obstructive disease.
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DESCRIPTION: Carotid Ultrasonic & Color Flow Imaging

Carotid Ultrasonic & Color Flow Imaging

radiology, atherosclerotic, atherosclerotic plaques, obstructive disease, carotid artery, carotid artery and bulb, common carotid artery, mild intimal thickening, external carotid artery, common carotid, internal carotid, external carotid, intimal thickening, carotid, intimal, plaques, artery,

The report describes a carotid Doppler scan with findings of mild atherosclerotic changes that do not result in significant obstruction of the carotid arteries. The impression indicates there is no significant obstructive disease, which suggests that the patient is not at immediate risk of a severe event like a stroke as a result of this scan. However, it is still important information for long-term cardiovascular risk management and monitoring by healthcare providers. The stakes are mainly related to ongoing monitoring and potential lifestyle or medical management changes rather than immediate high-risk intervention.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Psych Consult - Psychosis

IDENTIFYING DATA:,  Psychosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 28-year-old Samoan female who was her grandmother's caretaker.  Her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior.  She had lived with her parents and son, but parents removed son from the home, secondary to the patient's erratic behavior.  Recently, she was picked up by Kent Police Department "leaping on Highway 99.",PAST MEDICAL HISTORY: , PTSD, depression, and substance abuse.,PAST SURGICAL HISTORY:  ,Unknown.,ALLERGIES:,  Unknown.,MEDICATIONS: , Unknown.,REVIEW OF SYSTEMS: , Unable to obtain secondary to the patient being in seclusion.,OBJECTIVE:,  Vital signs that were previously taken revealed a blood pressure of 152/86, pulse of 106, respirations of 18, and temperature is 97.6 degrees Fahrenheit.  General appearance, HEENT, and history and physical examination was unable to be obtained today, as patient was put into seclusion.,LABORATORY DATA: , Laboratory reviewed reveals a BMP, slightly elevated glucose at 100.2.  Previous urine tox was positive for THC.  Urinalysis was negative, but did note positive UA wbc's.  CBC, slightly elevated leukocytosis at 12.0, normal range is 4 to 11.,ASSESSMENT AND PLAN:,AXIS I:  Psychosis.  Inpatient Psychiatric Team to follow.,AXIS II:  Deferred.,AXIS III:  We were unable to perform physical examination on the patient today secondary to her being in seclusion.  Laboratory was reviewed revealing leukocytosis, possibly secondary to a UTI.  We will wait until the patient is out of seclusion to perform examination.  Should she have some complaints of dysuria or any suprapubic pain, then we will begin on appropriate antimicrobial therapy.  We will followup with the patient should any new medical issues arise.
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DESCRIPTION: Patient with a history of PTSD, depression, and substance abuse.

consult - history and phy., ptsd, depression, psychosis, psychiatric, substance abuse, erratic behavior, behavior, axis,

The situation involves a patient experiencing severe psychosis following the death of a family member, compounded by a history of PTSD, depression, and substance abuse. These factors contribute to unstable and potentially dangerous behavior, such as leaping onto a highway, which is a significant safety risk to herself and possibly others. The patient has been placed in seclusion, indicating an acute psychiatric crisis requiring careful management and monitoring. This is a high-stakes situation because it concerns the urgent mental health and safety needs of the patient, requiring close medical supervision and intervention to mitigate risks.


Medical Specialty: Surgery
Sample Name: Vasectomy - 2

DIAGNOSIS:,  Desires vasectomy.,NAME OF OPERATION: , Vasectomy.,ANESTHESIA:,  General.,HISTORY: , Patient, 37, desires a vasectomy.,PROCEDURE: , Through a midline scrotal incision, the right vas was identified and separated from the surrounding tissues, clamped, transected, and tied off with a 4-0 chromic.  No bleeding was identified.,Through the same incision the left side was identified, transected, tied off, and dropped back into the wound.  Again no bleeding was noted.,The wound was closed with 4-0 Vicryl times two.  He tolerated the procedure well.  A sterile dressing was applied.  He was awakened and transferred to the recovery room in stable condition.
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DESCRIPTION: Normal vasectomy

Normal vasectomy

surgery, scrotal incision, right vas, bleeding, anesthesia, vasectomy

This situation involves a routine vasectomy procedure, which is considered a low-risk surgical operation. The procedure described went smoothly, with no bleeding and the patient being in stable condition post-operation. Although surgery typically carries some inherent risks, vasectomies are common and have a high success rate. Therefore, the stakes involved in this specific case are relatively low.


Medical Specialty: Letters
Sample Name: Cardiology - Letter

Please accept this letter of follow up on patient xxx xxx. He is now three months out from a left carotid angioplasty and stent placement. He was a part of a CapSure trial. He has done quite well, with no neurologic or cardiac event in the three months of follow up. He had a follow-up ultrasound performed today that shows the stent to be patent, with no evidence of significant recurrence.,Sincerely,,XYZ, MD,
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DESCRIPTION: Follow up update on patient with left carotid angioplasty and stent placement.

letters, capsure, cardiac event, ultrasound, carotid angioplasty, stent placement, letter, angioplastyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The scenario describes a standard follow-up letter concerning a patient who underwent cardiac procedures. The patient shows no significant recurrence and the procedure remains successful, indicating low immediate medical risk. Moreover, there is no urgent threat to the patient's health or life from this update. This is routine in medical practice, hence, it involves low-stakes.


Medical Specialty: Podiatry
Sample Name: Three Views - Foot

EXAM:  ,Three views of the right foot.,REASON FOR EXAM: , Right foot trauma.,FINDINGS: , Three views of the right foot were obtained.  There are no comparison studies.  There is no evidence of fractures or dislocations.  No significant degenerative changes or obstructive osseous lesions were identified.  There are no radiopaque foreign bodies.,IMPRESSION: , Negative right foot.
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DESCRIPTION: Right foot trauma.  Three views of the right foot.  Three views of the right foot were obtained.

podiatry, three views, radiopaque, fractures, foot trauma

The situation involves a diagnostic exam for right foot trauma in the field of podiatry. The examination revealed negative results for fractures, dislocations, and other significant issues. Since the findings are negative and there are no critical injuries or conditions identified, the scenario does not involve life-threatening situations. Therefore, it is not a high-stakes situation.


Medical Specialty: Discharge Summary
Sample Name: Renal Disease - Discharge Summary

ADMISSION DIAGNOSES:,1.  Syncope.,2.  End-stage renal disease requiring hemodialysis.,3.  Congestive heart failure.,4.  Hypertension.,DISCHARGE DIAGNOSES:,1.  Syncope.,2.  End-stage renal disease requiring hemodialysis.,3.  Congestive heart failure.,4.  Hypertension.,CONDITION ON DISCHARGE: , Stable.,PROCEDURE PERFORMED: , None.,HOSPITAL COURSE: , The patient is a 44-year-old African-American male who was diagnosed with end-stage renal disease requiring hemodialysis three times per week approximately four to five months ago.  He reports that over the past month, he has been feeling lightheaded when standing and has had three syncopal episodes during this time with return of consciousness after several minutes.  He reportedly had this even while seated and denied overt dizziness.  He reports this lightheadedness is made even worse when standing.  He has had these symptoms almost daily over the past month.  He does report some confusion when he awakens.  He reports that he loses consciousness for two to three minutes.  Denies any bowel or bladder loss, although he reports very little urine output secondary to his end-stage renal disease.  He denied any palpitations, warmth, or diaphoresis, which is indicative of vasovagal syncope.  There were no witnesses to his syncopal episodes.  He also denied any clonic activity and no history of seizures.  In the emergency room, the patient was given fluids and orthostatics were checked.  At that time, orthostatics were negative; however, due to the fact that fluid had been given before, it is impossible to rule out orthostatic hypotension.  The patient presented to the hospital on Coreg 12.5 mg b.i.d. and lisinopril 10 mg daily secondary to his hypertension, congestive heart failure with dilated cardiomyopathy and end-stage renal disease.  Regarding his syncopal episodes, he was admitted with likely orthostatic hypotension.  Cardiology was consulted and their recommendations were to reduce the lisinopril to 5 mg daily.  At that time, the Coreg had been held secondary to hypotension.  Cardiology also ordered a nuclear medicine myocardial perfusion stress test.  Regarding the end-stage renal disease, Nephrology was consulted as the patient was due for hemodialysis treatment the day following admission.  Nephrology was able to perform dialysis on the patient and Renal concurred that the presyncopal symptoms were likely due to decreased intravascular volume in the postdialytic time frame.  Renal agreed with decreasing his lisinopril to 5 mg daily and decreasing the Coreg to 6.25 mg b.i.d.  They reported that the Procrit should be continued.  As previously indicated regarding the dilated cardiomyopathy, Cardiology ordered a nuclear medicine stress test to be performed.  Also, regarding the patient's hypertension, he actually was noted to have hypotension on admission, and as previously stated, the Coreg was originally discontinued and then it was restarted at 6.25 mg b.i.d. and the patient tolerated this well.  The patient's hospital course remained uncomplicated until September 17, 2007, the day the nuclear medicine stress test was scheduled.  The patient stated that he was reluctant to proceed with the test and he was afraid of needles and the risks associated with the test although the procedure was explained to the patient and the risks of the procedure were quit low, the patient proceeded to discharge himself against medical advice.,DISCHARGE INSTRUCTIONS/MEDICATIONS:,The patient left AMA.  No specific discharge instructions and medications were given.  At the time of the patient leaving AMA, his medications were as follows:,1.  Aspirin 81 mg p.o. daily.,2.  Multivitamin, Nephrocaps one cap p.o. daily.,3.  Fosrenol 500 mg chewable t.i.d.,4.  Lisinopril 2.5 mg daily.,6.  Coreg 3.125 mg p.o. b.i.d.,7.  Procrit 10,000 units inject every Tuesday, Thursday, and Saturday.,8.  Heparin 5000 units q.8h. subcutaneous for DVT prophylaxis.
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DESCRIPTION: Syncope, end-stage renal disease requiring hemodialysis, congestive heart failure, and hypertension.

discharge summary, syncope, congestive heart failure, end-stage renal disease requiring hemodialysis, nuclear medicine, stress test, stage renal, renal disease, renal, disease, hemodialysis,

The presented discharge summary involves a patient with multiple serious medical conditions requiring careful management, including end-stage renal disease, congestive heart failure, and hypertension. The patient also signed out against medical advice (AMA), which can increase the risk of adverse outcomes since recommended follow-up care and testing (like the stress test) were not completed. Such situations have moderate to high stakes as they can impact the patient's health significantly, especially given their complex medical needs.


Medical Specialty: General Medicine
Sample Name: Post Thyroidectomy - Discharge Summary

ADMISSION DIAGNOSIS: , Symptomatic thyroid goiter.,DISCHARGE DIAGNOSIS:  ,Symptomatic thyroid goiter.,PROCEDURE PERFORMED DURING THIS HOSPITALIZATION: , Total thyroidectomy.,INDICATIONS FOR THE SURGERY:  ,Briefly, the patient is a 71-year-old female referred with increasingly symptomatic large nodular thyroid goiter.  She presented now after informed consent for the above procedure, understanding the inherent risks and complications and risk-benefit ratio.,HOSPITAL COURSE:  ,The patient underwent total thyroidectomy on 09/22/08, which she tolerated very well and remained stable in the postoperative period.  On postoperative day #1, she was tolerating her diet, began on thyroid hormone replacement, and remained afebrile with stable vital signs.  She required intravenous narcotics for pain control.  She was judged stable for discharge home on 09/25/08, tolerating a diet well, having no fever, stable vital signs, and good pain control.  The wound was clean and dry.  The drain was removed.  She was instructed to follow up in the surgical office within one week after discharge.  She was given prescription for Vicodin for pain and Synthroid thyroid hormone, and otherwise the appropriate wound care instructions per my routine wound care sheet.
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DESCRIPTION: Symptomatic thyroid goiter.  Total thyroidectomy.

general medicine, nodular, symptomatic thyroid goiter, thyroidectomy, goiter,

The situation involves a post-operative discharge summary for a patient who underwent a total thyroidectomy due to a symptomatic thyroid goiter. While surgical procedures and post-operative care inherently carry some risk, this case appears to be stable. The patient had a successful surgery, stable recovery, and the discharge plan seems routine with standard follow-up care and medication prescribed. There are no immediate or severe complications described. Hence, in the context of general medical operations and patient discharges, this situation is not high-stakes.


Medical Specialty: Lab Medicine - Pathology
Sample Name: Pathology - Prostate

SPECIMENS:,1.  Pelvis-right pelvic obturator node.,2.  Pelvis-left pelvic obturator node.,3.  Prostate.,POST-OPERATIVE DIAGNOSIS: , Adenocarcinoma of prostate, erectile dysfunction.,DIAGNOSTIC OPINION:,1.  Adenocarcinoma, Gleason score 9, with tumor extension to periprostatic tissue, margin involvement, and tumor invasion to seminal vesicle, prostate.,2.  No evidence of metastatic carcinoma, right pelvic obturator lymph node.,3.  Metastatic adenocarcinoma, left obturator lymph node; see description.,CLINICAL HISTORY: , None listed.,GROSS DESCRIPTION:,Specimen #1 labeled "right pelvic obturator lymph nodes" consists of two portions of adipose tissue measuring 2.5 x 1x 0.8 cm and 2.5 x 1x 0.5 cm.  There are two lymph nodes measuring 1 x 0.7 cm and 0.5 x 0.5 cm.  The entire specimen is cut into several portions and totally embedded.,Specimen #2 labeled "left pelvic obturation lymph nodes" consists of an adipose tissue measuring 4 x 2 x 1 cm.  There are two lymph nodes measuring 1.3 x 0.8 cm and 1 x 0.6 cm.  The entire specimen is cut into 1 cm.  The entire specimen is cut into several portions and totally embedded.,Specimen #3 labeled "prostate" consists of a prostate.  It measures 5 x 4.5 x 4 cm.  The external surface shows very small portion of seminal vesicles attached in both sides with tumor induration.  External surface also shows tumor induration especially in right side.  External surface is stained with green ink.  The cut surface shows diffuse tumor induration especially in right side.  The tumor appears to extend to excision margin.  Multiple representative sections are made.,MICROSCOPIC DESCRIPTION:,Section #1 reveals lymph node.  There is no evidence of metastatic carcinoma.,Section #2 reveals lymph node with tumor metastasis in section of large lymph node as well as section of small lymph node.,Section #3 reveals adenocarcinoma of prostate.  Gleason's score 9 (5+4).  The tumor shows extension to periprostatic tissue as well as margin involvement.  Seminal vesicle attached to prostate tissue shows tumor invasion.  Dr. XXX reviewed the above case.  His opinion agrees with the above diagnosis.,SUMMARY:,A.  Adenocarcinoma of prostate, Gleason's score 9, with both lobe involvement and seminal vesicle involvement (T3b).,B.  There is lymph node metastasis (N1).,C.  Distant metastasis cannot be assessed (MX).,D.  Excision margin is positive and there is tumor extension to periprostatic tissue.
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DESCRIPTION: Prostate adenocarcinoma and erectile dysfunction - Pathology report.

lab medicine - pathology, pelvic obturator node, erectile dysfunction, seminal vesicle, prostate, lymph node, specimen, section, adenocarcinoma of prostate, pelvic obturator, tumor, lymph, node, specimens, adenocarcinoma,

The pathology report indicates a serious case of prostate adenocarcinoma with a high Gleason score of 9, extension beyond the prostate, seminal vesicle involvement, and lymph node metastasis. These factors suggest an advanced stage of cancer, which generally requires urgent and comprehensive treatment. The patient's clinical outcome and quality of life can be heavily impacted by such a diagnosis, making it a high-stakes situation for medical professionals involved in the patient's care.


Medical Specialty: Dermatology
Sample Name: Facial Rhytids

HISTORY: , This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids.  In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds.,RECOMMENDATIONS: , I do believe a facelift procedure would be of maximum effect for the patient's areas of concern and a "quick lift" type procedure certainly would address these issues.  I went over risks and benefits with the patient along with the preoperative and postoperative care, and risks include but are not limited to bleeding, infection, discharge, scar formation, need for further surgery, facial nerve injury, numbness, asymmetry of face, problems with hypertrophic scarring, problems with dissatisfaction with anticipated results, and she states she will contact us later in the summer to possibly make arrangements for a quick lift through Memorial Medical Center.
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DESCRIPTION: Evaluation and recommendations regarding facial rhytids.

dermatology, quick lift, hypertrophic scarring, facial rhytids, mid face region, nasolabial folds, liftNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves a cosmetic procedure recommendation (facelift) for a 57-year-old patient to address facial wrinkles and fullness in certain facial areas. While the procedure does carry inherent surgical risks such as bleeding, infection, nerve injury, and dissatisfaction with results, these are standard risks associated with elective cosmetic surgeries. The procedure is elective, and the decision is primarily driven by personal aesthetic desires rather than a life-threatening medical condition. Therefore, while the decision is important to the patient's personal preferences and quality of life, it does not pose a high-stakes situation in terms of immediate health or life-risking consequences.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 22

SUBJECTIVE:,  This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion.  He does have significant allergies including ragweed.  The drainage has been clear.  He had a little bit of a headache yesterday.  He has had no fever.  No one else is ill at home currently.,CURRENT MEDICATIONS:,  Advair and Allegra.  He has been taking these regularly.  He is not sure the Allegra is working for him anymore.  He does think though better than Claritin.,PHYSICAL EXAM:,General:  Alert young man in no distress.,HEENT:  TMs clear and mobile.  Pharynx clear.  Mouth moist.  Nasal mucosa pale with clear discharge.,Neck:  Supple without adenopathy.,Heart:  Regular rate and rhythm without murmur.,Lungs:  Lungs clear, no tachypnea, wheezing, rales or retractions.,Abdomen:  Soft, nontender, without masses or splenomegaly.,ASSESSMENT:,  I think this is still his allergic rhinitis rather than a sinus infection.,PLAN:,  Change to Zyrtec 10 mg samples were given.  He is not using nasal spray, but he has some at home.  He should restart this.  Continue to watch his peak flows to make sure his asthma does not come under poor control.  Call if any further problems.
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DESCRIPTION: A 12-year-old young man with sinus congestion.

consult - history and phy., allergic rhinitis, sinus infection, sinus congestion, congestion, sinus

The situation involves a young patient experiencing sinus congestion likely due to allergies. The assessment suggests it's allergic rhinitis, not a sinus infection, and the plan involves changing allergy medication and monitoring, which are routine measures. The patient is currently stable, without signs of severe illness or acute distress. While monitoring his asthma is important, the stakes remain relatively low as the diagnosis and treatment plan are straightforward, and there is no indication of a life-threatening or severe condition.


Medical Specialty: General Medicine
Sample Name: Male Exam & ROS

GENERAL REVIEW OF SYSTEMS,General:  No fevers, chills, or sweats.  No weight loss or weight gain.,Cardiovascular:  No exertional chest pain, orthopnea, PND, or pedal edema.  No palpitations.,Neurologic:  No paresis, paresthesias, or syncope.,Eyes:  No double vision or blurred vision.,Ears:  No tinnitus or decreased auditory acuity.,ENT:  No allergy symptoms, such as rhinorrhea or sneezing.,GI:  No indigestion, heartburn, or diarrhea.  No blood in the stools or black stools.  No change in bowel habits.,GU:  No dysuria, hematuria, or pyuria.  No polyuria or nocturia.  Denies slow urinary stream.,Psych:  No symptoms of depression or anxiety.,Pulmonary:  No wheezing, cough, or sputum production.,Skin:  No skin lesions or nonhealing lesions.,Musculoskeletal:  No joint pain, bone pain, or back pain.  No erythema at the joints.,Endocrine:  No heat or cold intolerance.  No polydipsia.,Hematologic:  No easy bruising or easy bleeding.  No swollen lymph nodes.,PHYSICAL EXAM,Vital: Blood pressure today was *, heart rate *, respiratory rate *.,Ears:  TMs intact bilaterally.  Throat is clear without hyperemia.,Mouth:  Mucous membranes normal.  Tongue normal.,Neck:  Supple; carotids 2+ bilaterally without bruits; no lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation; no dullness to percussion.,Heart:  Revealed a regular rhythm, normal S1 and S2.  No murmurs, clicks or gallops.,Abdomen:  Soft to palpation without guarding or rebound.  No masses or hepatosplenomegaly palpable.  Bowel sounds are normoactive.,Extremities:  bilaterally symmetrical.  Peripheral pulses 2+ in all extremities.  No pedal edema.,Neurologic examination:  Essentially intact including cranial nerves II through XII intact bilaterally.  Deep tendon reflexes 2+ and symmetrical.,Genitalia:  Bilaterally descended testes without tenderness or masses.  No hernias palpable.  Rectal examination revealed normal sphincter tone, no rectal mass.  Prostate was *.  Stool was Hemoccult negative.
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DESCRIPTION: Sample male exam and review of systems.

Sample male exam and review of systems.

general medicine, male exam, cardiovascular, ent, ears, endocrine, extremities, genitalia, hemoccult, musculoskeletal, pulmonary, auditory acuity, blurred vision, heart rate, nocturia, pedal edema, percussion, polydipsia, rectal mass, regular rhythm, respiratory rate, review of systems, swollen lymph nodes, tinnitus, intact bilaterally, masses,

The situation described aligns with a routine medical examination and review of systems, which is typically low-stakes. It involves assessing a male patient's overall health status, without indicating any immediate or critical medical concerns. Given that no significant issues are reported in the examination, and the systems reviewed show no alarming symptoms, the level of urgency and risk appears to be minimal.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Aortogram - Leg claudication.

PREPROCEDURE DIAGNOSIS:,  Left leg claudication.,POSTPROCEDURE DIAGNOSIS: ,  Left leg claudication.,OPERATION PERFORMED: , Aortogram with bilateral, segmental lower extremity run off.,ANESTHESIA: , Conscious sedation.,INDICATION FOR PROCEDURE:  ,The patient presents with lower extremity claudication.  She is a 68-year-old woman, who is very fearful of the aforementioned procedures.  Risks and benefits of the procedure were explained to her to include bleeding, infection, arterial trauma requiring surgery, access issues and recurrence.  She appears to understand and agrees to proceed.,DESCRIPTION OF PROCEDURE: , The patient was taken to the Angio Suite, placed in a supine position.  After adequate conscious sedation, both groins were prepped with Chloraseptic prep.  Cloth towels and paper drapes were placed.  Local anesthesia was administered in the common femoral artery and using ultrasound guidance, the common femoral artery was accessed.  Guidewire was threaded followed by a ,4-French sheath.  Through the 4-French sheath a 4-French Omni flush catheter was placed.  The glidewire was removed and contrast administered to identify the level of the renal artery.  Using power injector an aortogram proceeded.,The catheter was then pulled down to the aortic bifurcation.  A timed run-off view of both legs was performed and due to a very abnormal and delayed run-off in the left, I opted to perform an angiogram of the left lower extremity with an isolated approach.  The catheter was pulled down to the aortic bifurcation and using a glidewire, I obtained access to the contralateral left external iliac artery.  The Omni flush catheter was advanced to the left distal external iliac artery.  The glidewire rather exchanged for an Amplatz stiff wire.  This was left in place and the 4-French sheath removed and replaced with a 6-French destination 45-cm sheath.  This was advanced into the proximal superficial femoral artery and an angiogram performed.  I identified a functionally occluded distal superficial femoral artery and after obtaining views of the run off made plans for angioplasty.,The patient was given 5000 units of heparin and this was allowed to circulate.  A glidewire was carefully advanced using Roadmapping techniques through the functionally occluded blood vessels.  A 4-mm x 4-cm angioplasty balloon was used to dilate the area in question.,Final views after dilatation revealed a dissection.  A search for a 5-mm stent was performed, but none of this was available.  For this reason, I used a 6-mm x 80-mm marked stent and placed this at the distal superficial femoral artery.  Post dilatation was performed with a 4-mm angioplasty balloon.  Further views of the left lower extremity showed irregular change in the popliteal artery.  No significant stenosis could be identified in the left popliteal artery and noninvasive scan.  For this reason, I chose not to treat any further areas in the left leg.,I then performed closure of the right femoral artery with a 6-French Angio-Seal device.  Attention was turned to the left femoral artery and local anesthesia administered.  Access was obtained with the ultrasound and the femoral artery identified.  Guidewire was threaded followed by a 4-French sheath.  This was immediately exchanged for the 6-French destination sheath after the glidewire was used to access the distal external iliac artery.  The glidewire was exchanged for the Amplatz stiff wire to place the destination sheath.  The destination was placed in the proximal superficial femoral artery and angiogram obtained.  Initial views had been obtained from the right femoral sheath before removal.,Views of the right superficial femoral artery demonstrated significant stenosis with accelerated velocities in the popliteal and superficial femoral artery.  For this reason, I performed the angioplasty of the superficial femoral artery using the 4-mm balloon.  A minimal dissection plane measuring less than 1 cm was identified at the proximal area of dilatation.  No further significant abnormality was identified.  To avoid placing a stent in the small vessel I left it alone and approached the popliteal artery.  A 3-mm balloon was chosen to dilate a 50 to 79% popliteal artery stenosis.  Reasonable use were obtained and possibly a 4-mm balloon could have been used.  However, due to her propensity for dissection I opted not to.  I then exchanged the glidewire for an O1 for Thruway guidewire using an exchange length.  This was placed into the left posterior tibial artery.  A 2-mm balloon was used to dilate the orifice of the posterior tibial artery.  I then moved the wire to the perineal artery and dilated the proximal aspect of this vessel.  Final images showed improved run-off to the right calf.  The destination sheath was pulled back into the left external iliac artery and an Angio-Seal deployed.,FINDINGS: , Aortogram demonstrates a dual right renal artery with the inferior renal artery supplying the lower one third of the right renal parenchyma.  No evidence of renal artery stenosis is noted bilaterally.  There is a single left renal artery.  The infrarenal aorta, both common iliac and the external iliac arteries are normal.  On the right, a superficial femoral artery is widely patent and normal proximally.  At the distal third of the thigh there is diffuse disease with moderate stenosis noted.  Moderate stenosis is also noted in the popliteal artery and single vessel run-off through the posterior tibial artery is noted.  The perineal artery is functionally occluded at the midcalf.  The dorsal pedal artery filled by collateral at the high ankle level.,On the left, the proximal superficial femoral artery is patent.  Again, at the distal third of the thigh, there is a functional occlusion of the superficial femoral artery with poor collateralization to the high popliteal artery.  This was successfully treated with angioplasty and a stent placement.  The popliteal artery is diffusely diseased without focal stenosis.  The tibioperoneal trunk is patent and the anterior tibial artery occluded at its orifice.,IMPRESSION,1.  Normal bilateral renal arteries with a small accessory right renal artery.,2.  Normal infrarenal aorta as well as normal bilateral common and external iliac arteries.,3.  The proximal right renal artery is normal with moderately severe stenosis in the superficial femoral popliteal and tibial arteries.  Successful angioplasty with reasonable results in the distal superficial femoral, popliteal and proximal posterior tibial artery as described.,4.  Normal proximal left superficial femoral artery with functional occlusion of the distal left superficial femoral artery successfully treated with angioplasty and stent placement.  Run-off to the left lower extremity is via a patent perineal and posterior tibial artery.
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DESCRIPTION: Aortogram with bilateral, segmental lower extremity run off.  Left leg claudication.  The patient presents with lower extremity claudication.

cardiovascular / pulmonary, claudication, extremity run off, angio suite, superficial femoral artery, popliteal, superficial, femoral, aortogram, artery, balloon, glidewire, angioplasty, stenosis, renal,

The procedure described involves complex cardiovascular interventions including an aortogram, angioplasty, and stent placement due to significant artery stenosis and occlusions. Given the patient's age and the risks mentioned (e.g., bleeding, infection, arterial trauma), this procedure is high-stakes as it directly impacts the patient's cardiovascular health and overall well-being. This type of medical procedure involves considerable risk requiring significant medical expertise and carries potential for complications, which can be life-threatening.


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

REASON FOR CONSULTATION:  ,Followup of seizures.,HISTORY OF PRESENT ILLNESS:,  This is a 47-year-old African-American female, well known to the neurology service, who has been referred to me for the first time evaluation of her left temporal lobe epilepsy that was diagnosed in August of 2002.  At that time, she had one generalized tonic-clonic seizure.  Apparently she had been having several events characterized by confusion and feeling unsteady lasting for approximately 60 seconds.  She said these events were very paroxysmal in the sense they suddenly came on and would abruptly stop.  She had two EEGs at that time, one on August 04, 2002 and second on November 01, 2002, both of which showed rare left anterior temporal sharp waves during drowsiness and sleep.  She also had an MRI done on September 05, 2002, with and without contrast that was negative.  Her diagnosis was confirmed by Dr. X at Johns Hopkins Hospital who reviewed her studies as well as examined the patient and felt that actually her history and findings were consistent with diagnosis of left temporal lobe epilepsy.  She was initially started on Trileptal, but had some problems with the medication subsequently Keppra, which she said made her feel bad and subsequently changed in 2003 to lamotrigine, which she has been taking since then.  She reports no seizures in the past several years.  She currently is without complaint.,In terms of seizure risk factors she denies head trauma, history of CNS infection, history of CVA, childhood seizures, febrile seizures.  There is no family history of seizures.,PAST MEDICAL HISTORY: , Significant only for hypertension and left temporal lobe epilepsy.,FAMILY HISTORY: , Remarkable only for hypertension in her father.  Her mother died in a motor vehicle accident.,SOCIAL HISTORY:  ,She works running a day care at home.  She has three children.  She is married.  She does not smoke, use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , Please see note in chart.  Only endorses weight gain and the history of seizures, as well as some minor headaches treated with over-the-counter medications.,CURRENT MEDICATIONS:  ,Lamotrigine 150 mg p.o. b.i.d., verapamil, and hydrochlorothiazide.,ALLERGIES: , Flagyl and aspirin.,PHYSICAL EXAMINATION: , Blood pressure is 138/88, heart rate is 76, respiratory rate is 18, and weight is 224 pounds, pain scale is none.,General Examination:  Please see note in chart, which is essentially unremarkable except mild obesity.,NEUROLOGICAL EXAMINATION: , Again, please see note in chart.  Mental status is normal, cranial nerves are intact, motor is normal bulk and tone throughout with no weakness appreciated in upper and lower extremities bilaterally.  There is no drift and there are no abnormalities to orbit.  Sensory examination, light touch, and temperature intact at all distal extremities.  Cerebellar examination, she has normal finger-to-nose, rapid alternating movements, heel-to-shin, and foot tap.,She rises easily from the chair.  She has normal step, stride, arm swing, toe, heel, and tandem.  Deep tendon reflexes are 2 and equal at biceps, brachioradialis, patella, and 1 at the ankles.,She was seen in the emergency room for chest pain one month ago.  CT of the head was performed, which I reviewed, dated September 07, 2006.  The findings were within the range of normal variation.  There is no evidence of bleeding, mass, lesions, or any evidence of atrophy.,IMPRESSION: , This is a pleasant 47-year-old African-American female with what appears to be cryptogenic left temporal lobe epilepsy that is very well controlled on her current dose of lamotrigine.,PLAN:,1.  Continue lamotrigine 150 mg p.o. b.i.d.,2.  I discussed with the patient the option of a trial of medications.  We need to repeat her EEG as well as her MRI prior to weaning her medications.  The patient wants to continue her lamotrigine at this time.  I concur.,3.  The patient will be following up with me in six months.,
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DESCRIPTION: Patient referred for evaluation of her left temporal lobe epilepsy.

The situation involves a follow-up consultation for a patient with a history of epilepsy, which has been controlled with medication. There are no immediate or acute medical emergencies indicated, and the patient reports no recent seizures or concerning symptoms. The consultation aims to monitor and possibly adjust the current medication. This situation primarily involves routine follow-up rather than acute or potentially life-threatening conditions.


Medical Specialty: Surgery
Sample Name: Left Orchiectomy & Right Orchidopexy

PREOPERATIVE DIAGNOSIS: , Left testicular torsion.,POSTOPERATIVE DIAGNOSES:  ,1.  Left testicular torsion.,2.  Left testicular abscess.,3.  Necrotic testes.,SURGERY:,  Left orchiectomy, scrotal exploration, right orchidopexy.,DRAINS:,  Penrose drain on the left hemiscrotum.,The patient was given vancomycin, Zosyn, and Levaquin preop.,BRIEF HISTORY:  ,The patient is a 49-year-old male who came into the emergency room with 2-week history of left testicular pain, scrotal swelling, elevated white count of 39,000.  The patient had significant scrotal swelling and pain.  Ultrasound revealed necrotic testicle.  Options such as watchful waiting and removal of the testicle were discussed.  Due to elevated white count, the patient was told that he must have the testicle removed due to the infection and possible early signs of urosepsis.  The risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, scrotal issues, other complications were discussed.  The patient was told about the morbidity and mortality of the procedure and wanted to proceed.,PROCEDURE IN DETAIL: , The patient was brought to the OR.  Anesthesia was applied.  The patient was prepped and draped in usual sterile fashion.  A midline scrotal incision was made.  There was very, very thick scrotal skin.  There was no necrotic skin.  As soon as the left hemiscrotum was entered, significant amount of pus poured out of the left hemiscrotum.  The testicle was completely filled with pus and had completely disintegrated with pus.  The pus just poured out of the left testicle.  The left testicle was completely removed.  Debridement was done of the scrotal wall to remove any necrotic tissue.  Over 2 L of antibiotic irrigation solution was used to irrigate the left hemiscrotum.  There was good tissue left after all the irrigation and debridement.  A Penrose drain was placed in the bottom of the left hemiscrotum.  I worried about the patient may have torsed and then the testicle became necrotic, so the plan was to pex the right testicle, plus the right side also appeared very abnormal.  So, the right hemiscrotum was opened.  The testicle had significant amount of swelling and scrotal wall was very thick.  The testicle appeared normal.  There was no pus coming out of the right hemiscrotum.  At this time, a decision was made to place 4-0 Prolene nonabsorbable stitches in 3 different quadrants to prevent it from torsion.  The hemiscrotum was closed using 2-0 Vicryl in interrupted stitches and the skin was closed using 2-0 PDS in horizontal mattress.  There was very minimal pus left behind and the skin was very healthy.  Decision was made to close it to help the patient heal better in the long run.  The patient was brought to the recovery in stable condition.
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DESCRIPTION: Left orchiectomy, scrotal exploration, right orchidopexy.

surgery, testicular abscess, necrotic testes, orchiectomy, scrotal exploration, orchidopexy, hemiscrotum, testicular torsion, penrose drain, scrotal swelling, scrotal wall, testicle, torsion

The situation involves emergency surgery due to left testicular torsion and abscess, potentially serious conditions that can lead to loss of the testicle and systemic infection (urosepsis) if not treated promptly. Surgical intervention in this context is necessary to prevent further complications and serious health outcomes. The preoperative and postoperative descriptions indicate a high-stakes situation due to the severity of the infection, risk of systemic complications, and the need for immediate surgical intervention to remove the necrotic testicle and prevent torsion of the right testicle.