Medical Specialty: Consult - History and Phy.
Sample Name: Renal Failure Evaluation

REASON FOR CONSULTATION:,  Renal failure evaluation for possible dialysis therapy.,HISTORY OF PRESENT ILLNESS:,  This is a 47-year-old gentleman, who works offshore as a cook, who about 4 days ago noted that he was having some swelling in his ankles and it progressively got worse over the past 3 to 4 days, until he was swelling all the way up to his mid thigh bilaterally.  He also felt like he could not make much urine, and his wife, who is a nurse instructed him to force fluids.  While he was there, he was drinking cranberry juice, some Powerade, but he also has a history of weightlifting and had been taking on a creatine protein drink on a daily basis for some time now.  He presented here with very decreased urine output until a Foley catheter was placed and about 500 mL was noted in his bladder.  He did have a CPK level of about 234 while his BUN and creatinine on admission were 109 and 6.9.  Despite IV hydration fluids, his potassium has gone up from 5.4 to 6.1.  He did not put out any significant urine and his weight was documented at 103 kg.  He was given a dose of Kayexalate.  His potassium came down to like about 5.9 and urine studies were ordered.  His urinalysis did show that he had microscopic hematuria and proteinuria and his protein-creatinine ratio was about 9 gm of protein consistent with nephrotic range proteinuria.  He did have a low albumin of 1.9.  He denied any nonsteroidal usage, any recreational drug abuse, and his urine drug screen was unremarkable, and he denied any history of hypertension or any other medical problems.  He has not had any blood work except for drug screens that are required by work and no work up by any primary care physician because he has not seen one for primary care.  He is very concerned because his mother and father were both on dialysis, which he thinks were due to diabetes and both parents have expired.  He denied any hemoptysis, gross hematuria, melena, hematochezia, hemoptysis, hematemesis, no seizures, no palpitations, no pruritus, no chest pain.  He did have a decrease in his appetite, which all started about Thursday.  We were asked to see this patient in consultation by Dr. X because of his renal failure and the need for possible dialysis therapy.  He was significantly hypertensive on admission with a blood pressure of 162/80.,PAST MEDICAL HISTORY: , Unremarkable.,PAST SURGICAL HISTORY: , Unremarkable.,FAMILY HISTORY: , Both mother and father were on dialysis of end-stage renal disease.,SOCIAL HISTORY: , He is married.  He does smoke despite understanding the risks associated with smoking a pack every 6 days.  Does not drink alcohol or use any recreational drug use.  He was on no prescribed medications.  He did have a fairly normal PSA of about 119 and I had ordered a renal ultrasound which showed fairly normal-sized kidneys and no evidence of hydronephrosis or mass, but it was consistent with increased echogenicity in the cortex, findings representative of medical renal disease.,PHYSICAL EXAMINATION:,Vital signs:  Blood pressure is 153/77, pulse 66, respiration 18, temperature 98.5.,General:  He was alert and oriented x 3, in no apparent distress, well-developed male.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light.  Extraocular muscles intact.,Neck:  Supple.  No JVD, adenopathy, or bruit.,Chest:  Clear to auscultation.,Heart:  Regular rate and rhythm without a rub.,Abdomen:  Soft, nontender, nondistended.  Positive bowel sounds.,Extremities:  Showed no clubbing, cyanosis.  He did have 2+ pretibial edema in both lower extremities.,Neurologic:  No gross focal findings.,Skin:  Showed no active skin lesions.,LABORATORY DATA: , Sodium 138, potassium 6.1, chloride 108, CO2 22, glucose 116, BUN 111, creatinine 7.29, estimated GFR 10 mL/minute.  Calcium 7.4 with an albumin of 1.9.  Mag normal at 2.2.  Urine culture negative at 12 hours.  His Random urine sodium was low at 12.  Random urine protein was 4756, and creatinine in the urine was 538.  Urine drug screen was unremarkable.  Troponin was within normal limits.  Phosphorus slightly elevated at 5.7.  CPK level was 234, white blood cells 6.5, hemoglobin 12.2, platelet count 188,000 with 75% segs.  PT 10.0, INR 1.0, PTT at 27.3.  B-natriuretic peptide 718.  Urinalysis showed 3+ protein, 4+ blood, negative nitrites, and trace leukocytes, 5 to 10 wbc's, greater than 100 rbc's, occasional fine granular casts, and moderate transitional cells.,IMPRESSION:,1.  Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.,2.  Hyperkalemia due to renal failure, slowly improving with Kayexalate.,3.  Microscopic hematuria with nephrotic range proteinuria, more consistent with a glomerulonephropathy nephritis.,4.  Hypertension.,PLAN: , I will give him Kayexalate 15 gm p.o. q.6h. x 2 more doses since he is responding and his potassium is already down to 5.2.  I will also recheck a urinalysis, consult the surgeon in the morning for temporary hemodialysis catheter placement, and consult case managers to start work on a transfer to ABCD Center per the patient and his wife's request, which will occur after his second dialysis treatment if he remains stable.  We will get a BMP, phosphorus, mag, CBC in the morning since he was given 80 mg of Lasix for fluid retention.  We will also give him 10 mg of Zaroxolyn p.o.  Discontinue all IV fluids.  Check an ANCA hepatitis profile, C3 and C4 complement levels along with CH 50 level.  I did discuss with the patient and his wife the need for kidney biopsy and they would like the kidney biopsy to be performed closer to home at Ochsner where his family is, since he only showed up here because of the nearest hospital located to his offshore job.  I do agree with getting him transferred once he is stable from his hyperkalemia and he starts his dialysis.,I appreciate consult.  I did discuss with him the importance of the kidney biopsies to direct treatment, finding the underlying etiology of his acute renal failure and to also give him prognostic factors of renal recovery.
---
DESCRIPTION: Renal failure evaluation for possible dialysis therapy.  Acute kidney injury of which etiology is unknown at this time, with progressive azotemia unresponsive to IV fluids.

The consultation involves a 47-year-old patient with acute kidney injury, progressive azotemia, severe hyperkalemia, and nephrotic syndrome, requiring evaluation for possible dialysis. The patient's condition is critical due to urgent electrolyte imbalances and kidney function impairment. Given the rapid deterioration and potential need for dialysis, this scenario is high-stakes as it involves immediate health risks and decisions impacting long-term outcomes.


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

Medical Specialty: Ophthalmology
Sample Name: Blepharoplasty - Quad

PREOPERATIVE DIAGNOSES:,1.  Blepharochalasia.,2.  Lower lid large primary and secondary bagging.,POSTOPERATIVE DIAGNOSES:,1.  Blepharochalasia.,2.  Lower lid large primary and secondary bagging.,PROCEDURE: , Quad blepharoplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Minimal.,CONDITION: , The patient did well.,PROCEDURE:  ,The patient had marks and measurements prior to surgery.  Additional marks and measurements were made at the time of surgery; these were again checked.  At this point, the area was injected with 0.5% lidocaine with 1:200,000 epinephrine.  Appropriate time waited for the anesthetic and epinephrine effect.,Beginning on the left upper lid, the skin excision was completed.  The muscle was opened, herniated, adipose tissue pad in the middle and medial aspect was brought forward, cross-clamped, excised, cauterized, and allowed to retract.  The eyes were kept irrigated and protected throughout the procedure.  Attention was turned to the opposite side.  Procedure was carried out in the similar manner.,At the completion, the wounds were then closed with a running 6-0 Prolene, skin adhesives, and Steri-Strips.  Attention was turned to the right lower lid.  A lash line incision was made.  A skin flap was elevated and the muscle was opened.  Large herniated adipose tissue pads were present in each of the three compartments.  They were individually elevated, cross-clamped, excised, cauterized, and allowed to retract.,At the completion, a gentle tension was placed on the facial skin and several millimeters of the skin excised.  Attention was turned to he opposite side.  The procedure was carried out as just described.  The contralateral side was reexamined and irrigated.  Hemostasis was good and it was closed with a running 6-0 Prolene.  The opposite side was closed in a similar manner.,Skin adhesives and Steri-Strips were applied.  The eyes were again irrigated and cool Swiss Eye compresses applied.  At the completion of the case, the patient was extubated in the operating room, breathing on her own, doing well, and transferred in good condition from operating room to recovering room.
---
DESCRIPTION: Quad blepharoplasty for blepharochalasia and lower lid large primary and secondary bagging.

ophthalmology, blepharochalasia, lower lid, swiss eye compresses, adipose tissue pad, bagging, blepharoplasty, lash line incision, quad blepharoplasty,

The described situation involves a quad blepharoplasty, an elective cosmetic surgical procedure to address eyelid concerns such as blepharochalasia and lower lid bagging. While it is a surgical intervention requiring general anesthesia, it is commonly performed and generally considered low-risk when appropriate measures are taken. The postoperative condition mentioned indicates the patient did well, and there was minimal blood loss, suggesting no immediate complications. However, as with any surgery involving anesthesia, there are inherent risks, but these are mitigated in a controlled medical environment, leading to the procedure being considered low to moderate stakes in terms of medical risk.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Arterial Imaging

INDICATIONS:,  Peripheral vascular disease with claudication.,RIGHT:,  ,1.  Normal arterial imaging of right lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic.,4.  Ankle brachial index is 0.96.,LEFT:,1.  Normal arterial imaging of left lower extremity.,2.  Peak systolic velocity is normal.,3.  Arterial waveform is triphasic throughout except in posterior tibial artery where it is biphasic.,4.  Ankle brachial index is 1.06.,IMPRESSION,:,Normal arterial imaging of both lower extremities.
---
DESCRIPTION: Arterial imaging of bilateral lower extremities.

cardiovascular / pulmonary, peripheral vascular disease, ankle brachial index, arterial waveform, peak systolic velocity, arterial imaging, biphasic, claudication, lower extremities, lower extremity, posterior tibial artery, triphasic, systolic velocity is normal, arterial waveform is triphasic, waveform is triphasic, normal arterial imaging, systolic velocity, brachial index, velocity, brachial, imaging, arterial,

The situation involves a standard diagnostic procedure, arterial imaging, which is used to assess vascular health. The results are mostly normal except for a slight variation in the left posterior tibial artery. However, such findings are not uncommon and may often not require immediate intervention. The findings suggest good overall vascular health, with ABI values within normal limits. This does not imply an immediate life-threatening situation. While important for long-term health planning, the situation isn't urgent or critical at present.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 7

EYES: , The conjunctivae are clear.  The lids are normal appearing without evidence of chalazion or hordeolum.  The pupils are round and reactive.  The irides are without any obvious lesions noted.  Funduscopic examination shows sharp disk margins.  There are no exudates or hemorrhages noted.  The vessels are normal appearing.,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.,NECK:,  The neck is nontender and supple.  The trachea is midline.  The thyroid is without any evidence of thyromegaly.  No obvious adenopathy is noted to the neck.,RESPIRATORY: , The patient has normal respiratory effort.  There is normal lung excursion.  Percussion of the chest is without any obvious dullness.  There is no tactile fremitus or egophony noted.  There is no tenderness to the chest wall or ribs.  There are no obvious abnormalities.  The lungs are clear to auscultation.  There are no wheezes, rales or rhonchi heard.  There are no obvious rubs noted.,CARDIOVASCULAR: , There is a normal PMI on palpation.  I do not hear any obvious abnormal sounds.  There are no obvious murmurs.  There are no rubs or gallops noted.  The carotid arteries are without bruit.  No obvious thrill is palpated. There is no evidence of enlarged abdominal aorta to palpation.  There is no abdominal mass to suggest enlargement of the aorta.  Good strong femoral pulses are palpated.  The pedal pulses are intact.  There is no obvious edema noted to the extremities.  There is no evidence of any varicosities or phlebitis noted.,GASTROINTESTINAL: , The abdomen is soft.  Bowel sounds are present in all quadrants.  There are no obvious masses.  There is no organomegaly, and no liver or spleen is palpable.  No obvious hernia is noted.  The perineum and anus are normal in appearance.  There is good sphincter tone and no obvious hemorrhoids are noted.  There are no masses.  On digital examination, there is no evidence of any tenderness to the rectal vault; no lesions are noted.  Stool is brown and guaiac negative.,GENITOURINARY (FEMALE): , The external genitalia is normal appearing with no obvious lesions, no evidence of any unusual rash.  The vagina is normal in appearance with normal-appearing mucosa.  The urethra is without any obvious lesions or discharge.  The cervix is normal in color with no obvious cervical discharge.  There are no obvious cervical lesions noted.  The uterus is nontender and small, and there is no evidence of any adnexal masses or tenderness.  The bladder is nontender to palpation.  It is not enlarged.,GENITOURINARY (MALE): , Normal scrotal contents are noted.  The testes are descended and nontender.  There are no masses and no swelling to the epididymis noted.  The penis is without any lesions.  There is no urethral discharge.  Digital examination of the prostate reveals a nontender, non-nodular prostate.,BREASTS:,  The breasts are normal in appearance.  There is no puckering noted.  There is no evidence of any nipple discharge.  There are no obvious masses palpable.  There is no axillary adenopathy.  The skin is normal appearing over the breasts.,LYMPHATICS: , There is no evidence of any adenopathy to the anterior cervical chain.  There is no evidence of submandibular nodes noted.  There are no supraclavicular nodes palpable.  The axillae are without any abnormal nodes.  No inguinal adenopathy is palpable.  No obvious epitrochlear nodes are noted.,MUSCULOSKELETAL/EXTREMITIES: , The patient has normal gait and station.  The patient has normal muscle strength and tone to all extremities.  There is no obvious evidence of any muscle atrophy.  The joints are all stable.  There is no evidence of any subluxation or laxity to any of the joints.  There is no evidence of any dislocation.  There is good range of motion of all extremities without any pain or tenderness to the joints or extremities.  There is no evidence of any contractures or crepitus.  There is no evidence of any joint effusions.  No obvious evidence of erythema overlying any of the joints is noted.  There is good range of motion at all joints.  There are normal-appearing digits.  There are no obvious lesions to any of the nails or nail beds.,SKIN:,  There is no obvious evidence of any rash.  There are no petechiae, pallor or cyanosis noted.  There are no unusual nodules or masses palpable.,NEUROLOGIC: , The cranial nerves II XII are tested and are intact.  Deep tendon reflexes are symmetrical bilaterally.  The toes are downgoing with normal Babinskis.  Sensation to light touch is intact and symmetrical.  Cerebellar testing reveals normal finger nose, heel shin.  Normal gait.  No ataxia.,PSYCHIATRIC:  ,The patient is oriented to person, place and time.  The patient is also oriented to situation.  Mood and affect are appropriate for the present situation.  The patient can remember 3 objects after 3 minutes without any difficulties.  Remote memory appears to be intact.  The patient seems to have normal judgment and insight into the situation.
---
DESCRIPTION: Most commonly used phrases in physical exam.

consult - history and phy., ears, nose, mouth, neck, respiratory, cardiovascular, eyes, gastrointestinal, genitourinary, breasts, lymphatics, musculoskeletal, extremities, skin, neurologic, psychiatric, normal appearing, physical exam, examination,

This scenario describes a routine and thorough physical examination across multiple systems of the body, noting the absence of any abnormalities or concerns. The language suggests it is a standard procedure for documenting a normal physical exam. As such, there are no indications of immediate health risks or urgent medical concerns. The stakes appear low because the primary goal is assessment without any pressing issues identified.


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

CHIEF COMPLAINT (1/1):  ,This 24 year-old female presents today complaining of itchy, red rash on feet.  Associated signs and symptoms:  Associated signs and symptoms include tingling, right.  Context:  Patient denies any previous history, related trauma or previous treatments for this condition.  Duration:  Condition has existed for 4 weeks.  Location:  She indicates the problem location is right great toe, right 2nd toe, right 3rd toe and right 4th toe.  Modifying factors:  Patient indicates ice improves condition.  Quality:  Quality of the itch is described by the patient as constant.  Severity:  Severity of condition is unbearable.  Timing (onset/frequency):  Onset was after leaving on sweaty socks.,ALLERGIES: , Patient admits allergies to adhesive tape resulting in severe rash.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY: , Childhood Illnesses: (+) chickenpox, (+) frequent ear infections.,PAST SURGICAL HISTORY:  ,Patient admits past surgical history of ear tubes.,SOCIAL HISTORY: , Patient admits alcohol use Drinking is described as social, Patient denies tobacco use, Patient denies illegal drug use, Patient denies STD history.,FAMILY HISTORY:,  Patient admits a family history of cataract associated with maternal grandmother,,headaches/migraines associated with maternal aunt.,REVIEW OF SYSTEMS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM: , BP Sitting:  110/64 Resp:  18 HR:  66 Temp:  98.6,Patient is a 24 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus.  Cardiovascular:  Skin temperature of the lower extremities is warm to cool, proximal to distal.,DP pulses palpable bilateral.,PT pulses palpable bilateral.,CFT immediate.,No edema observed.,Varicosities are not observed.  Skin:  Right great toe, right 2nd toe, right 3rd toe and right 4th toenail shows erythema and scaling.,Neurological:  Touch, pin, vibratory and proprioception sensations are normal.  Deep tendon reflexes normal.,Musculoskeletal:  Muscle strength is 5/5 for all groups tested.  Muscle tone is normal.  Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:,  No tests to report at this time,IMPRESSION: , Tinea pedis.,PLAN:  ,Obtained fungal culture of skin from right toes.  KOH prep performed revealed no visible microbes.,PRESCRIPTIONS:,  Lotrimin AF  Dosage:  1% cream  Sig:  apply qid  Dispense:  4oz tube Refills:  0  Allow Generic:  Yes
---
DESCRIPTION: Itchy red rash on feet - Tinea Pedis

Itchy red rash on feet - Tinea Pedis

The situation described involves a common dermatological condition, Tinea Pedis, or athlete's foot. It presents with symptoms such as itching and redness. While uncomfortable and potentially painful (described as 'unbearable' by the patient), this condition is treatable and typically not considered life-threatening or critical in a medical context. The treatment plan involves an over-the-counter topical antifungal medication. The patient has no significant medical history that complicates the situation. Therefore, while distressing for the patient, it does not qualify as high-stakes in the clinical sense.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pulmonary Function Test - 3

SPIROMETRY: , Spirometry reveals the FVC to be adequate.,FEV1 is also normal at 98% predicted and FVC is 90.5% predicted.  FEF25-75% is also within normal limits at 110% predicted.  FEV1/FVC ratio is within normal limits at 108% predicted.,After the use of bronchodilator, there is some improvement with 10%.  MVV is within normal limits.,LUNG VOLUMES:,  Shows total lung capacity to be normal.  RV as well as RV/TLC ratio they are within normal limits.,DIFFUSION CAPACITY:,  Shows that after correction for alveolar ventilation, is also normal.,Oxygen Saturation on Room Air:  98%.,FINAL INTERPRETATION:,  Pulmonary function test shows no evidence of obstructive or restrictive pulmonary disease.  There is some improvement after the use bronchodilator.  Diffusion capacity is within normal limits.  Oxygen saturation on room air is also normal.  Clinical correlation will be necessary in this case.
---
DESCRIPTION: Sample of Pulmonary Function Test

Sample of Pulmonary Function Test

cardiovascular / pulmonary, fvc, fev1, fev1/fvc ratio, fef, lung volumes, saturation on room air, pulmonary function test, pulmonary function, oxygen saturation, spirometry, bronchodilator, lung, diffusion, oxygen, saturation, pulmonary, capacity,

The scenario presented involves the interpretation of a pulmonary function test, which is routine in assessing lung function. The results indicate normal pulmonary function with some improvement after bronchodilator use and normal oxygen saturation, reducing immediate concern. While clinical correlation is recommended, the findings do not suggest an acute or critical medical issue. This makes the situation relatively low-stakes in nature, as there is no indication of disease or urgent need for intervention.


Medical Specialty: Surgery
Sample Name: YAG Laser Capsulotomy - 1

PREOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,POSTOPERATIVE DIAGNOSIS: , Secondary capsular membrane, right eye.,PROCEDURE PERFORMED: , YAG laser capsulotomy, right eye.,INDICATIONS: , This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.,PROCEDURE: , The patient was seated at the YAG laser, the pupil having been dilated with 1%  Mydriacyl, and Iopidine was instilled.  The Abraham capsulotomy lens was then positioned and applications of laser energy in the pattern indicated on the outpatient note were applied.  A total of
---
DESCRIPTION: This patient has undergone cataract surgery, and vision is reduced in the operated eye due to presence of a secondary capsular membrane.  The patient is being brought in for YAG capsular discission.

surgery, abraham capsulotomy, yag, yag laser capsulotomy, capsulotomy, laser, membrane, eye, capsular,

YAG laser capsulotomy is a common, routine outpatient procedure following cataract surgery to clear a secondary capsular membrane, which can obscure vision. While ensuring proper technique and care is important, the procedure itself is low-risk and typical in ophthalmic practice. Complications are rare and the stakes, in terms of potential harm, are not high compared to other surgical procedures.


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

SUBJECTIVE:,  This patient was seen in clinic for a school physical.,NUTRITIONAL HISTORY:,  She eats well, takes meats, vegetables, and fruits, but her calcium intake is limited.  She does not drink a whole lot of pop.  Her stools are normal.  Brushes her teeth, sees a dentist.,Developmental History:  Hearing and vision is okay.  She did well in school last year.  She will be going to move to Texas, will be going to Bowie High School.  She will be involved in cheerleading, track, volleyball, and basketball.  She will be also playing the clarinet and will be a freshman in that school.  Her menarche was 06/30/2004.,PAST MEDICAL HISTORY:,  She is still on medications for asthma.  She has a problem with her eye lately, this has been bothering her, and she also has had a rash in the left leg.  She had been pulling weeds on 06/25/2004 and then developed a rash on 06/27/2004.,Review of her immunizations, her last tetanus shot was 06/17/2003.,MEDICATIONS:  ,Advair 100/50 b.i.d., Allegra 60 mg b.i.d., Flonase q.d., Xopenex, Intal, and albuterol p.r.n.,ALLERGIES: , No known drug allergies.,OBJECTIVE:,Vital Signs:  Weight:  112 pounds about 40th percentile.  Height:  63-1/4 inches, also the 40th percentile.  Her body mass index was 19.7, 40th percentile.  Temperature:  97.7 tympanic.  Pulse:  80.  Blood pressure:  96/64.,HEENT:  Normocephalic.  Fundi benign.  Pupils equal and reactive to light and accommodation.  No strabismus.  Her vision was 20/20 in both eyes and each with contacts.  Hearing:  She passed that test.  Her TMs are bilaterally clear and nonerythematous.  Throat was clear.  Good mucous membrane moisture and good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Abdomen:  No hepatosplenomegaly.,Respiratory:  Clear.  No wheezes.  No crackles.  No tachypnea.  No retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.,GU:  Normal female genitalia.  Tanner stage 3, breast development and pubic hair development.  Examination of the breasts was negative for any masses or abnormalities or discharge from her areola.,Extremities:  She has good range of motion of upper and lower extremities.  Deep tendon reflexes were 2+/4+ bilaterally and equal.  Romberg negative.,Back:  No scoliosis.  She had good circumduction at shoulder joint and her duck walk was normal.,SKIN:  She did have some rash on the anterior left thigh region and also some on the right lower leg that had Kebner phenomenon and maculopapular vesicular eruption.  No honey crusting was noted on the skin.  She also had some mild rash on the anterior abdominal area near the panty line similar to that rash.  It was raised and blanch with pressure, it was slightly erythematous.,ASSESSMENT AND PLAN:,1.  Sports physical.,2.  The patient received her first hepatitis A vaccine.  She will get a booster in 6 to 12 months.  Prescription for Atarax 10 mg tablets one to two tablets p.o. q.4-6h. p.r.n. and a prescription for Elocon ointment to be applied topically, except for the face, once a day with a refill.  She will be following up with an allergist as soon as she gets to Texas and needs to find a primary care physician.  We talked about anticipatory guidance including breast exam, which we have reviewed with her today, seatbelt use, and sunscreen.  We talked about avoidance of drugs and alcohol and sexual activity.  Continue on her present medications and if her rash is not improved and goes to the neck or the face, she will need to be on PO steroid medication, but presently that was held and moved to treatment with Atarax and Elocon.  Also talked about cleaning her clothes and bedding in case she has any poison ivy oil that is harboring on any clothing.
---
DESCRIPTION: This patient was seen in clinic for a school physical.

consult - history and phy., school physical, calcium intake, hearing and vision, hepatitis a vaccine, booster, anticipatory guidance, developmental, percentile, physical, school, rash,

The situation described is a routine school physical examination. Although the patient has a few medical issues like a rash possibly from poison ivy and asthma, these are being managed with medications and follow-up care. The primary purpose of the visit is a standard check-up to ensure eligibility for school sports and activities. There is no indication of immediate life-threatening conditions or critical decisions needed at this moment. Therefore, while it involves ensuring the patient's health and readiness for physical activities, the stakes are relatively low compared to more urgent or severe medical situations.


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

REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.
---
DESCRIPTION: Sepsis.  The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.

The situation involves an 80-year-old patient with sepsis, a potentially life-threatening condition. The patient's underlying conditions, including a history of dementia, coronary artery disease, and a cerebrovascular accident, increase the risk of complications. The CT scan findings suggest an acute urinary obstruction, adding further complexity to the patient's condition. Sepsis, particularly in elderly patients with multiple comorbidities, is a high-stakes medical situation that requires immediate and thorough medical intervention.


Medical Specialty: Office Notes
Sample Name: Normal Male Exam Template - 3

PHYSICAL EXAMINATION,GENERAL: , The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative.  No dysarthria is noted.  No discomfort on presentation is noted.  ,HEAD: , Atraumatic, normocephalic. Pupils are equal, round and reactive to light.  Extraocular muscles are intact.  Sclerae are white without injection or icterus.  Fundi are without papilledema, hemorrhages or exudates with normal vessels.  ,EARS: , The ear canals are patent without edema, exudate or drainage.  Tympanic membranes are intact with a normal cone of light.  No bulging or erythema to indicate infection is present.  There is no hemotympanum.  Hearing is grossly intact.  ,NOSE:,  Without deformity, bleeding or discharge.  No septal hematoma is noted.  ,ORAL CAVITY:,  No swelling or abnormality to the lip or teeth.  Oral mucosa is pink and moist.  No swelling to the palate or pharynx.  Uvula is midline.  The pharynx is without exudate or erythema.  No edema is seen of the tonsils.  The airway is completely patent.  The voice is normal.  No stridor is heard.  ,NECK: , No signs of meningismus.  No Brudzinski or Kernig sign is present.  No adenopathy is noted.  No JVD is seen.  No bruits are auscultated.  Trachea is midline.  ,CHEST: , Symmetrical with equal breath sounds.  Equal excursion.  No hyperresonance or dullness to percussion is noted.  There is no tenderness on palpation of the chest.  ,LUNGS:  ,Clear to auscultation bilaterally.  No rales, rhonchi or wheezes are appreciated.  Good air movement is auscultated in all 4 lung fields.  ,HEART:,  Regular rate and rhythm.  No murmur.  No S3, S4 or rub is auscultated.  Point of maximal impulse is strong and in normal position.  Abdominal aorta is not palpable.  The carotid upstroke is normal.  ,ABDOMEN:  ,Soft, nontender and nondistended.  Normal bowel sounds are auscultated.  No organomegaly is appreciated.  No masses are palpated.  No tympany is noted on percussion.  No guarding, rigidity or rebound tenderness is seen on exam.  Murphy and McBurney sign is negative.  There is no Rovsing, obturator or psoas sign present.  No hepatosplenomegaly and no hernias are noted.  ,RECTAL:,  Normal tone.  No masses.  Soft, brown stool in the vault.  Guaiac negative.  ,GENITOURINARY:,  Penis is normal without lesion or urethral discharge.  Scrotum is without edema.  The testes are descended bilaterally.  No masses are palpated.  There is no tenderness.  ,EXTREMITIES: , No clubbing, cyanosis or edema.  Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal.  No deformity or signs of trauma.  All joints are stable without laxity.  There is good range of motion of all joints without tenderness or discomfort.  Homan sign is negative.  No atrophy or contractures are noted.  ,SKIN: , No rashes.  No jaundice.  Pink and warm with good turgor.  Good color.  No erythema or nodules noted.  No petechia, bulla or ecchymosis.  ,NEUROLOGIC: , Cranial nerves II through XII are grossly intact.  Muscle strength is graded 5/5 in the upper and lower extremities bilaterally.  Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally. Babinski is downgoing bilaterally.  Sensation is intact to light touch and vibration.  Gait is normal.  Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal.  There is no ataxia seen on gait testing.  Tone is normal.  No pronator drift is seen.  ,PSYCHIATRIC:  ,The patient is oriented x4.  Mood and affect are appropriate.  Memory is intact with good short- and long-term memory recall.  No dysarthria is noted.  Remote memory is intact.  Judgment and insight appear normal.,
---
DESCRIPTION: An example/template for a routine normal male physical exam.

The sample provided is a template for recording a normal male physical examination. It is comprehensive, covering all major systems, indicating that the patient is in good health with no abnormalities detected during the examination. As it is a template, it's meant for documentation purposes and does not pertain to a specific patient's urgent health situation or a critical medical decision-making scenario. Therefore, the stakes involved are quite low, as this pertains to routine documentation and template creation for physical exams.


Medical Specialty: Neurology
Sample Name: Video EEG - 2

IMPRESSION:  ,EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.
---
DESCRIPTION: EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.

neurology, ekg artifact, video monitoring, wakefulness, drowsiness, eegNOTE,: 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 EEG results indicated in both the impression and description show no signs of epileptogenic activity or focal issues. While EEG assessments can be important for diagnosing and managing conditions like epilepsy, the absence of abnormal activity in this case suggests no immediate concerns or diagnosis to follow up on. Therefore, the situation is not high-stakes as no actionable medical intervention is required based on this EEG assessment.


Medical Specialty: Neurosurgery
Sample Name: Shunt Revision - 3

PREOPERATIVE DIAGNOSIS:,  Blocked ventriculoperitoneal shunt.,POSTOPERATIVE DIAGNOSIS:,  Blocked ventriculoperitoneal shunt.,PROCEDURE: , Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end.,ANESTHESIA: , General.,HISTORY: , The patient is nonverbal.  He is almost 3 years old.  He presented with 2 months of irritability, vomiting, and increasing seizures.  CT scan was not conclusive, but shuntogram shows no flow through the shunt.,DESCRIPTION OF PROCEDURE: , After induction of general anesthesia, the patient was placed supine on the operating room table with his head turned to the left.  Scalp was clipped.  He was prepped on the head, neck, chest and abdomen with ChloraPrep.  Incisions were infiltrated with 0.5% Xylocaine with epinephrine 1:200,000.  He received oxacillin.,He was then reprepped and draped in a sterile manner.,The frontal incision was reopened and extended along the valve.  Subcutaneous sharp dissection with Bovie cautery was done to expose the shunt parts.  I separated the ventricular catheter from the valve, and this was a medium pressure small contour Medtronic valve.  There was some flow from the ventricular catheter, but not as much as I would expect.  I removed the right-angled clip with a curette and then pulled out the ventricular catheter, and there was gushing of CSF under high pressure.  So, I do believe that the catheter was obstructed, although inspection of the old catheter holes did not show any specific obstructions.  A new Codman BACTISEAL catheter was placed through the same hole.  I replaced it several times because I wanted to be sure it was in the cavity.  It entered easily and there was still just intermittent flow of CSF.  The catheter irrigated very well and seemed to be patent.,I tested the distal system with an irrigation filled feeding tube, and there was excellent flow through the distal valve and catheter.  So I did not think it was necessary to replace those at this time.  The new catheter was trimmed to a total length of 8 cm and attached to the proximal end of the valve.  The valve connection was secured to the pericranium with a #2-0 Ethibond suture.  The wound was irrigated with bacitracin irrigation.  The shunt pumped and refilled well.  The wound was then closed with #4-0 Vicryl interrupted galeal suture and Steri-Strips on the skin.  It was uncertain whether this will correct the problem or not, but we will continue to evaluate.  If his abdominal pressure is too high, then he may need a different valve.  This will be determined over time, but at this time, the shunt seemed to empty and refill easily.  The patient tolerated the procedure well.  No complications.  Sponge and needle counts were correct.  Blood loss was minimal.  None replaced.
---
DESCRIPTION: Ventriculoperitoneal shunt revision with replacement of ventricular catheter and flushing of the distal end.

neurosurgery, bactiseal, bactiseal catheter, codman bactiseal, blocked ventriculoperitoneal shunt, ventriculoperitoneal shunt revision, ventricular catheter, shunt revision, ventriculoperitoneal shunt, catheter, ventriculoperitoneal, ventricular, shunt

The situation involves a surgical procedure on a nearly 3-year-old who has a blocked ventriculoperitoneal shunt. The stakes are high because the procedure is essential to relieve symptoms that include irritability, vomiting, and seizures, potentially caused by intracranial pressure due to a shunt blockage. Any surgical procedure, especially in a young child, carries significant risk due to the need for general anesthesia and the possibility of surgical complications. Although the procedure went well, the outcome remains uncertain, as there may still be issues with the abdominal pressure, necessitating further interventions if the shunt does not function correctly. Errors could lead to severe consequences, such as neurological damage or life-threatening complications.


Medical Specialty: Surgery
Sample Name: Sebaceous Cyst Removal

PREOPERATIVE DIAGNOSIS:,  Infected sebaceous cyst, right neck.,POSTOPERATIVE DIAGNOSIS:,  Infected sebaceous cyst, right neck.,PROCEDURE: , The patient was electively taken to the operating room after obtaining an informed consent.  With a combination of intravenous sedation and local infiltration anesthesia, a time-out process was followed and then the patient was prepped and draped in the usual fashion.  The elliptical incision was performed around the draining tract.  Immediately we fell in to an abscess cavity with a lot of pus and necrotic tissue.  All the necrotic tissue was excised together with an ellipse of skin.  Hemostasis was achieved with a cautery.  The cavity was irrigated with normal saline.  At the end of procedure, there was a good size around cavity that was packed with iodoform gauze.  One skin suture was grazed for approximation.,A bulky dressing was applied.,The patient tolerated the procedure well.  Estimated blood loss was negligible and the patient was sent to Same Day Surgery for recovery.
---
DESCRIPTION: Removal of infected sebaceous cyst, right neck.

surgery, infected sebaceous cyst, necrotic tissue, sebaceous cyst, infected

The procedure described is a routine surgical removal of an infected sebaceous cyst on the patient's neck. While it involves an incision and removal of tissue, it is considered a minor surgery with low risk of significant complications. The details provided such as use of IV sedation and local anesthesia, negligible blood loss, and successful recovery indicate it is not high-stakes. It's a common surgical intervention where the patient is typically expected to recover well and quickly.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 5

PROCEDURE: , Colonoscopy.,INDICATIONS: , Hematochezia, Personal history of colonic polyps.,MEDICATIONS:,  Midazolam 2 mg IV, Fentanyl 100 mcg IV,PROCEDURE:,  A History and Physical has been performed, and patient medication allergies have been reviewed.  The patient's tolerance of previous anesthesia has been reviewed.  The risks and benefits of the procedure and the sedation options and risks were discussed with the patient.  All questions were answered and informed consent was obtained.  Mental Status Examination:  alert and oriented.  Airway Examination:  normal oropharyngeal airway and neck mobility.  Respiratory Examination:  clear to auscultation.  CV Examination:  RRR, no murmurs, no S3 or S4.  ASA Grade Assessment:  P1 A normal healthy patient.  After reviewing the risks and benefits, the patient was deemed in satisfactory condition to undergo the procedure.  The anesthesia plan was to use conscious sedation.  Immediately prior to administration of medications, the patient was re-assessed for adequacy to receive sedatives.  The heart rate, respiratory rate, oxygen saturations, blood pressure, adequacy of pulmonary ventilation, and response to care were monitored throughout the procedure.  The physical status of the patient was re-assessed after the procedure.  After I obtained informed consent, the scope was passed under direct vision.  Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously.  The colonoscope was introduced through the anus and advanced to the cecum, identified by appendiceal orifice & IC valve.  The quality of the prep was good.  The patient tolerated the procedure well.,FINDINGS:,1.  A sessile, non-bleeding polyp was found in the rectum.  The polyp was 5 mm in size.  Polypectomy was performed with a saline injection-lift technique using the snare.  Resection and retrieval were complete.  Estimated blood loss was minimal.,2.  One pedunculated, non-bleeding polyp was found in the sigmoid colon.  The polyp was 7 mm in size.  Polypectomy was performed with a hot forceps.  Resection and retrieval were complete.  Estimated blood loss was minimal.,3.  Multiple large-mouthed diverticula were found in the descending colon.,4.  Internal, non-bleeding, prolapsed with spontaneous reduction (grade II) hemorrhoids were found on retroflexion.,IMPRESSION:,1.  One 5 mm benign appearing polyp in the rectum.  Resected and retrieved.,2.  One 7 mm polyp in the sigmoid colon.  Resected and retrieved.,3.  Diverticulosis.,4.  Internal hemorrhoids were found.,RECOMMENDATION:,1.  High fiber diet.,2.  Await pathology results.,3.  Repeat colonoscopy for surveillance in 3 years.,4.  The findings and recommendations were discussed with the patient.,CPT CODE(S):,45385, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare,technique.,45384, 59, Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot,biopsy forceps or bipolar cautery.,45381, 59, Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance.,ICD9 CODE(S):,211.4, Benign neoplasm of rectum and anal canal.,211.3, Benign neoplasm of colon.,562.10, Diverticulosis of colon (without mention of hemorrhage).,455.2, Internal hemorrhoids with other complication,578.1, Blood in stool.,v12.72, Personal history of colonic polyps.
---
DESCRIPTION: Colonoscopy due to hematochezia and personal history of colonic polyps.

The colonoscopy procedure described, while invasive, is considered routine and low-risk in the context of modern gastroenterological practice, particularly for a normal healthy patient (ASA Grade P1). The findings, including small polyps, diverticulosis, and hemorrhoids, are also common and largely benign conditions that are managed with standard care protocol such as polypectomy. The recommendations and follow-up procedures (e.g., high fiber diet, pathology, and repeat colonoscopy in 3 years) indicate standard post-procedural care. Given these factors, the situation does not involve significant immediate risk to the patient's health or involve critical decision-making at this time.


Medical Specialty: Consult - History and Phy.
Sample Name: Well-Child Check - 7

SUBJECTIVE:,  This is a 1-month-old who comes in for a healthy checkup.  Mom says things are gone very well.  He is kind of acting like he has got a little bit of sore throat but no fevers.  He is still eating well.  He is up to 4 ounces every feeding.  He has not been spitting up.  Voiding and stooling well.,PAST MEDICAL HISTORY:,  Reviewed, very healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,DIETARY: , His formula fed on Enfamil Lipil.  Voiding and stooling well.  Growth chart reviewed with Mom.,DEVELOPMENTAL:,  He is starting to track with his eyes.  He is smiling a little bit, moving hands and feet symmetrically.,PHYSICAL EXAMINATION:,  In general well-developed, well-nourished male in no acute distress.,DERMATOLOGIC:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Anterior fontanel soft and flat.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes present bilaterally.  Does appear to have conjugate gaze.  Ears:  Tympanic membranes are pink to gray, translucent, neutral position, normal light reflex and mobility.  Nares are patent, pink mucosa, moist.  Oropharynx clear with pink mucosa, normal moisture.,NECK:  Supple without masses.,CHEST:  Clear to auscultation and percussion with easy respirations and no accessory muscle use.,CARDIOVASCULAR:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,ABDOMEN:  Soft, nontender, nondistended without hepatosplenomegaly.,GU EXAM:  Normal Tanner I male.  Testes descended bilaterally.  No hernias noted.,EXTREMITIES:  Pink and warm.  Moving all extremities well.  No subluxation of the hips and leg creases appear symmetric.,NEUROLOGIC:  Alert, otherwise nonfocal.  2+ deep tendon reflexes at the knees.  Fixes and follows appropriately to both voice and face.,ASSESSMENT:,  Well child check.,PLAN:,1.  Diet, growth and safety discussed.,2.  Immunizations discussed and updated with hepatitis B.,3.  Return to clinic at two months of age.  Call if problems.
---
DESCRIPTION: 1-month-old for a healthy checkup - Well child check

This scenario involves a routine well-child checkup for a 1-month-old baby. The main concern mentioned is a possible sore throat, but the child is feeding well and showing normal development. There are no urgent or severe symptoms present, and the encounter is a standard part of pediatric care to monitor growth and development. The stakes here are low because the child is overall healthy and the visit is preventive in nature.


Medical Specialty: Gastroenterology
Sample Name: Colon Cancer Screening

HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening.  The patient said that he occasionally gets some loose stools.  Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all.  He denies any hypertension, diabetes, or any other problems.  He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea.  Sometimes he gets some loose stools.  Occasionally there is some constipation.  Stools caliber has not changed.  There is no blood in stool or mucus in stool.  No weight loss.  Appetite is good.  No nausea, vomiting, or difficulty in swallowing.  Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3.  Vital signs: Weight is 214 pounds.  Blood pressure is 111/70.  Pulse is 69 per minute.  Respiratory rate is 18.  HEENT: Negative.  Neck: Supple.  There is no thyromegaly.  Cardiovascular: Both heart sounds are heard.  Rhythm is regular.  No murmur.  Lungs: Clear to percussion and auscultation.  Abdomen: Soft and nontender.  No masses felt.  Bowel sounds are heard.  Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy.  I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection.  The patient agreed for it.  We will proceed with it.  I also explained to the patient about conscious sedation.  He agreed for conscious sedation.
---
DESCRIPTION: Routine colorectal cancer screening.  He occasionally gets some loose stools.

gastroenterology, colon cancer screening, loose stools, colorectal, colonoscopy,

The scenario describes a routine procedure for colorectal cancer screening, which is often recommended for individuals over 50 years old. The patient has no major medical complaints and no family history of colon cancer. The described screening and procedure (colonoscopy) are standard preventive measures. While the patient has loose stools occasionally, this is not unusual and doesn't suggest an immediate risk. The stakes are relatively low as this is a preventative measure, and there are no signs of acute or severe issues.


Medical Specialty: Surgery
Sample Name: Vasectomy - 1

DESCRIPTION:,  The patient was placed in the supine position and was prepped and draped in the usual manner.  The left vas was grasped in between the fingers.  The skin and vas were anesthetized with local anesthesia.  The vas was grasped with an Allis clamp.  Skin was incised and the vas deferens was regrasped with another Allis clamp.  The sheath was incised with a scalpel and elevated using the iris scissors and clamps were used to ligate the vas deferens.  The portion in between the clamps was excised and the ends of the vas were clamped using hemoclips, two in the testicular side and one on the proximal side.  The incision was then inspected for hemostasis and closed with 3-0 chromic catgut interrupted fashion.,A similar procedure was carried out on the right side.  Dry sterile dressings were applied and the patient put on a scrotal supporter.  The procedure was then terminated.
---
DESCRIPTION: Normal vasectomy

Normal vasectomy

surgery, vasectomy, allis clamp, catgut, hemoclips, iris scissors, scrotal, scrotal supporter, testicular, vas, vas deferens, vas was grasped, deferens, clampsNOTE,: 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.

A vasectomy is a routine surgical procedure with a high success rate and generally low risk of severe complications. While any surgical procedure carries some level of risk, vasectomies are considered minor surgeries. They are typically done on an outpatient basis, meaning the patient can go home the same day. The stakes are relatively low, as the procedure is elective and not life-threatening. However, as with any medical procedure, it requires precision and proper execution to avoid complications, which is why it's not entirely without stakes.


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

Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Possible Spider Bite

SUBJECTIVE:,  This 47-year-old white female presents with concern about possible spider bite to the left side of her neck.  She is not aware of any specific injury.  She noticed a little tenderness and redness on her left posterior shoulder about two days ago.  It seems to be getting a little bit larger in size, and she saw some red streaks extending up her neck.  She has had no fever.  The area is very minimally tender, but not particularly so.,CURRENT MEDICATIONS:,  Generic Maxzide, Climara patch, multivitamin, Tums, Claritin, and vitamin C.,ALLERGIES:,  No known medicine allergies.,OBJECTIVE:,Vital Signs:  Weight is 150 pounds.  Blood pressure 122/82.,Extremities:  Examination of the left posterior shoulder near the neckline is an area of faint erythema which is 6 cm in diameter.  In the center is a tiny mark which could certainly be an insect or spider bite.  There is no eschar there, but just a tiny marking.  There are a couple of erythematous streaks extending towards the neck.,ASSESSMENT:,  Possible insect bite with lymphangitis.,PLAN:,1.  Duricef 1 g daily for seven days.,2.  Cold packs to the area.,3.  Discussed symptoms that were suggestive of the worsening, in which case she would need to call me.,4.  Incidentally, she has noticed a little bit of dryness and redness on her eyelids, particularly the upper ones’ and the lower lateral areas.  I suspect she has a mild contact dermatitis and suggested hydrocortisone 1% cream to be applied sparingly at bedtime only.
---
DESCRIPTION: A 47-year-old white female presents with concern about possible spider bite to the left side of her neck.

soap / chart / progress notes, spider bite, injury, tenderness, redness, insect bite, lymphangitis, streaks, spider, neck, bite,

The situation involves a possible insect or spider bite with mild symptoms of lymphangitis. While this does require attention and treatment, the plan includes a course of antibiotics and monitoring for worsening symptoms. As of now, there is no indication of severe symptoms like fever or significant pain that would categorize it as high-stakes medical emergency. It is a manageable condition under medical supervision.


Medical Specialty: Radiology
Sample Name: CT Brain - SAH

CC:, Headache,HX: ,This 16 y/o RHF was in good health, until 11:00PM, the evening of 11/27/87, when she suddenly awoke from sleep with severe headache. Her parents described her as holding her head between her hands. She had no prior history of severe headaches. 30 minutes later she felt nauseated and vomited. The vomiting continued every 30 minutes and she developed neck stiffness. At 2:00AM on 11/28/97, she got up to go to the bathroom and collapsed in her mother's arms. Her mother noted she appeared weak on the left side. Shortly after this she experienced fecal and urinary incontinence. She was taken to a local ER and transferred to UIHC.,PMH/FHX/SHX:, completely unremarkable FHx. Has boyfriend and is sexually active.,Denied drug/ETOH/Tobacco use.,MEDS:, Oral Contraceptive pill QD.,EXAM:, BP152/82 HR74 RR16 T36.9C,MS: Somnolent and difficult to keep awake. Prefer to lie on right side because of neck pain/stiffness. Answers appropriately though when questioned.,CN: No papilledema noted. Pupils 4/4 decreasing to 2/2. EOM Intact. Face: ?left facial weakness. The rest of the CN exam was unremarkable.,Motor: Upper extremities: 5/3 with left pronator drift. Lower extremities: 5/4 with LLE weakness evident throughout.,Coordination: left sided weakness evident.,Station: left pronator drift.,Gait: left hemiparesis.,Reflexes: 2/2 throughout. No clonus. Plantars were flexor bilaterally.,Gen Exam: unremarkable.,COURSE: ,The patient underwent emergent CT Brain. This revealed a perimesencephalic subarachnoid hemorrhage and contrast enhancing structures in the medial aspect of the parietotemporal region. She then underwent a 4-vessel cerebral angiogram. This study was unremarkable except for delayed transit of the contrast material through the vascular system of the brain and poor opacification of the straight sinus. This suggested straight sinus thromboses. MRI Brain was then done; this was unremarkable and did not show sign of central venous thrombosis. CBC/Blood Cx/ESR/PT/PTT/GS/CSF Cx/ANA were negative.,Lumbar puncture on 12/1/87 revealed an opening pressure of 55cmH20, RBC18550, WBC25, 18neutrophils, 7lymphocytes, Protein25mg/dl, Glucose47mg/dl, Cx negative.,The patient was assumed to have had a SAH secondary to central venous thrombosis due to oral contraceptive use. She recovered well, but returned to Neurology at age 32 for episodic blurred vision and lightheadedness. EEG was compatible with seizure tendency (right greater than left theta bursts from the mid-temporal regions), and she was recommended an anticonvulsant which she refused.
---
DESCRIPTION: CT Brain: Subarachnoid hemorrhage.

CT Brain: Subarachnoid hemorrhage.

radiology, ct, brain, sah, cerebral angiogram, blurred vision, lightheadedness, central venous thrombosis, subarachnoid hemorrhage, pronator drift, venous thrombosis, ct brain, subarachnoid, hemorrhage, pronator, venous, thrombosis, weakness,

The situation involves a 16-year-old patient who suddenly experienced a severe headache, nausea, vomiting, neck stiffness, and other neurological symptoms indicative of a subarachnoid hemorrhage (SAH). An SAH is a potentially life-threatening condition that requires immediate medical attention to prevent complications and improve outcomes. The situation was further complicated by the differential diagnosis of central venous thrombosis due to oral contraceptive use. This emergent medical situation involves complex diagnostic procedures (CT, MRI, angiogram) and significant medical history that suggests an acute neurological event. The outcome and long-term implications for the patient's neurological health and recovery are significant, making this a high-stakes medical scenario.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Tilt Table Test

FINDINGS:,1.  The patient's supine blood pressure was 153/88 with heart rate of 54 beats per minute.,2.  There was no significant change in heart rate or blood pressure on 80-degree tilt.,3.  No symptoms reported during the tilt study.,CONCLUSION: , Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome.
---
DESCRIPTION: Tilt table test.  Tilt table test is negative for any evidence of vasovagal, orthostasis or vasodepressor syndrome.

cardiovascular / pulmonary, blood pressure, tilt table test, vasovagal, vasodepressor, orthostasisNOTE

The situation involves the interpretation of a tilt table test in a cardiovascular and pulmonary specialty context. The findings indicate that the test results were negative for any evidence of vasovagal, orthostasis, or vasodepressor syndrome, and the patient did not experience any significant changes or symptoms. This suggests that the patient does not have these specific conditions, so there are no immediate risks or urgent issues to address. Thus, the stakes involved in this situation are relatively low since no immediate or critical concerns are present that require urgent intervention or decision-making.


Medical Specialty: Surgery
Sample Name: Coarctation of Aorta

HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%.  A bicuspid aortic valve was also seen without insufficiency or stenosis.  The patient underwent cardiac catheterization for balloon angioplasty for coarctation of the aorta.,PROCEDURE:  ,After sedation and general endotracheal anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a percutaneous technique a 4-French 8 cm long double lumen central venous catheter was inserted in the left femoral vein and sutured into place.  There was good blood return from both the ports.,Using a 4-French sheath a 4-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures out to the branch of pulmonary arteries.  The atrial septum was not probe patent.,Using a 4-French sheath a 4-French marker pigtail catheter was inserted into the left femoral artery and advanced retrograde to the descending aorta ,ascending aorta and left ventricle.  A descending aortogram demonstrated discrete coarctation of the aorta approximately 8 mm distal to the origin of the left subclavian artery.  The transverse arch measured 5 mm.  Isthmus measured 4.7 mm and coarctation measured 2.9 x 1.8 mm at the descending aorta level.  The diaphragm measured 5.6 mm.  The pigtail catheter was exchanged for a wedge catheter, which was then directed into the right innominate artery.  This catheter was exchanged over a wire for a Tyshak mini 6 x 2 cm balloon catheter which was advanced across the coarctation and inflated with complete disappearance of discrete waist.  Pressure pull-back following angioplasty, however, demonstrated a residual of 15-20 mmHg gradient.  Repeat angiogram showed mild improvement in degree of aortic narrowing.  The angioplasty was then performed using a Tyshak mini 7 x 2 cm balloon catheter with complete disappearance of mild waist.  The pigtail catheter was then reintroduced for a pressure pull-back measurement and final angiogram.,Flows were calculated by the Fick technique using an assumed oxygen consumption.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the pediatric intensive care unit in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was low due to mild systemic arterial desaturation and anemia.  There is no evidence of significant intracardiac shunt.  Further the heart was desaturated due to VQ mismatch.,Phasic right-sided pressures were normal as was the right pulmonary artery capillary wedge pressure with the A-wave similar to the normal left ventricular end-diastolic pressure of 12 mmHg.  Left ventricular systolic pressure was mildly increased with a 60 mmHg systolic gradient into the ascending aorta and a 29 mmHg systolic gradient on pressure pull-back to the descending aorta.  The calculated flows were mildly increased.  Vascular resistances were normal.  A cineangiogram with contrast injection in the descending aorta showed a normal left aortic arch with normal origins of the brachiocephalic vessels.  There is discrete juxtaductal coarctation of the aorta.  Flow within the intercostal arteries was retrograde.  Following balloon angioplasty of coarctation of the aorta, there was slight fall in the mixed venous saturation and an increase in systemic arterial saturation as the fall in left ventricular systolic pressure from 99 mmHg to 92 mmHg.  There remained a 4 mmHg systolic gradient into the ascending aorta and 9 mmHg systolic gradient pressure pull-back to the descending aorta.  The calculated systemic flow fell to normal values.  Final angiogram with injection in the descending aorta demonstrated improved caliber of coarctation of the aorta with mild intimal irregularity and a small left lateral filling defect consistent with a small intimal tear in the region of the ductus arteriosus.  There is brisk flow in the descending aorta and appropriate flow in the intercostal arteries.  The narrowest diameter of the aorta measured 4.9 x 4.2 mm.,DIAGNOSES:  ,1.  Juxtaductal coarctation of the aorta.,2.  Dilated cardiomyopathy.,3.  Bicuspid aortic valve.,4.  Patent foramen ovale.,INTERVENTION: , Balloon dilation of coarctation of the aorta.,MANAGEMENT: , The case will be discussed at combined Cardiology and Cardiothoracic Surgery Case Conference.  The patient will be allowed to recover from the current intervention with the hopes of complete left ventricular function recovery.  The patient will undoubtedly require formal coarctation of the aorta repair surgically in 4-6 months.  The further cardiologic care will be directed by Dr. X.
---
DESCRIPTION: Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale.

surgery, coarctation, juxtaductal, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale, catheter was inserted, mmhg systolic gradient, mmhg systolic, systolic gradient, descending aorta, catheterization, mmhg, ventricular, aorta, aortic, foramen,

The situation involves a 4-month-old infant diagnosed with severe cardiovascular issues, including coarctation of the aorta and dilated cardiomyopathy. The patient underwent a procedure for balloon angioplasty, and although the procedure was successful to a degree, the patient is expected to require additional surgery in the future. Such conditions and procedures for an infant are high-stakes due to the potential for severe complications or even mortality, the critical nature of the infrant's cardiovascular function, and the complexity involved in managing such young patients post-surgery and planning for further interventions.


Medical Specialty: Neurology
Sample Name: CT C-Spine

TECHNIQUE: , Sequential axial CT images were obtained through the cervical spine without contrast.  Additional high resolution coronal and sagittal reconstructed images were also obtained for better visualization of the osseous structures.  ,FINDINGS: , The cervical spine demonstrates normal alignment and mineralization with no evidence of fracture, dislocation, or spondylolisthesis.  The vertebral body heights and disc spaces are maintained.  The central canal is patent.  The pedicles and posterior elements are intact.  The paravertebral soft tissues are within normal limits.  The atlanto-dens interval and the dens are intact.  The visualized lung apices are clear.,IMPRESSION: , No acute abnormalities.
---
DESCRIPTION: Common CT C-Spine template

Common CT C-Spine template

neurology, sequential axial ct images, atlanto-dens interval, dens, ct c spine, cervical spineNOTE

The described situation involves the reading of a CT C-Spine scan, which is a routine radiological procedure to assess the cervical spine for any abnormalities. The findings indicate that everything is normal with no acute abnormalities. This is typically part of standard diagnostic practice in neurology or for trauma assessment, and the results fall within expected parameters. There are no severe implications for the patient since the scan is normal and no immediate action is required. As such, it is not a high-stakes situation.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Appendectomy - 5

PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS: , Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR OPERATION: , The patient is a 42-year-old female who presented with right lower quadrant pain.  She was evaluated and found to have a CT evidence of appendicitis.  She was subsequently consented for a laparoscopic appendectomy.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room, placed supine on the table.  The abdomen was prepared and draped in usual sterile fashion.  After the induction of satisfactory general endotracheal anesthesia, supraumbilical incision was made.  A Veress needle was inserted.  Abdomen was insufflated to 15 mmHg.  A 5-mm port and camera placed.  The abdomen was visually explored.  There were no obvious abnormalities.  A 15-mm port was placed in the suprapubic position in addition of 5 mm was placed in between the 1st two.  Blunt dissection was used to isolate the appendix.  Appendix was separated from surrounding structures.  A window was created between the appendix and the mesoappendix.  GIA stapler was tossed across it and fired.  Mesoappendix was then taken with 2 fires of the vascular load on the GIA stapler.  Appendix was placed in an Endobag and removed from the patient.  Right lower quadrant was copiously irrigated.  All irrigation fluids were removed.  Hemostasis was verified.  The 15-mm port was removed and the port site closed with 0-Vicryl in the Endoclose device.  All other ports were irrigated, infiltrated with 0.25% Marcaine and closed with 4-0 Vicryl subcuticular sutures.  Steri-Strips and sterile dressings were applied.  Overall, the patient tolerated this well, was awakened and returned to recovery in good condition.
---
DESCRIPTION: Laparoscopic appendectomy.  The patient is a 42-year-old female who presented with right lower quadrant pain.  She was evaluated and found to have a CT evidence of appendicitis.

gastroenterology, gia stapler, laparoscopic appendectomy, appendectomy, endotracheal, mesoappendix, laparoscopic, appendicitis, appendix

The situation describes a routine laparoscopic appendectomy performed on a patient diagnosed with appendicitis. This is a common surgical procedure with a high success rate and a low risk of complications when conducted by professionals. While surgery inherently carries some level of risk, a laparoscopic appendectomy is considered minimally invasive and is usually low-stakes relative to other medical procedures. The document indicates the procedure was uncomplicated and the patient tolerated it well, further suggesting a low-stakes scenario.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Toronto Porcine Valve Insertion

PREOPERATIVE DIAGNOSIS:,  Aortic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Aortic stenosis.,PROCEDURES PERFORMED,1.  Insertion of a **-mm Toronto stentless porcine valve.,2.  Cardiopulmonary bypass.,3.  Cold cardioplegia arrest of the heart.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  , 300 cc.,INTRAVENOUS FLUIDS:  , 1200 cc of crystalloid.,URINE OUTPUT:  , 250 cc.,AORTIC CROSS-CLAMP TIME: , **,CARDIOPULMONARY BYPASS TIME TOTAL: , **,PROCEDURE IN DETAIL:,  After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next the neck, chest and legs were prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make a midline median sternotomy incision.  Dissection was carried down to the left of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw.  The chest retractor was positioned.  Next, full-dose heparin was given.  The pericardium was opened.  Pericardial stay sutures were positioned.  After obtaining adequate ACT, we prepared to place the patient on cardiopulmonary bypass.  A 2-0 double pursestring of Ethibond suture was placed in the ascending aorta.  Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine.  Next a 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine.  A 4-0 U-stitch was placed in the right atrium.  A retrograde cardioplegia catheter was positioned at this site.  Next, scissors were used to dissect out the right upper pulmonary vein.  A 4-0 Prolene pursestring was placed in the right upper pulmonary vein.  Next, a right-angle sump was placed at this position.  We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit.  Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery.  The aorta was completely encircled.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  We then prepared to cross-clamp the aorta.  We went down on our flows and cross-clamped the aorta.  We backed up our flows.  We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart.  The patient had some aortic insufficiency so we elected, after initially arresting the heart, to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit.  Next, after obtaining complete diastolic arrest of the heart, we turned our attention to exposing the aortic valve, and 4-0 Tycron sutures were placed in the commissures.  In addition, a 2-0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view.  Next, scissors were used to excise the diseased aortic valve leaflets.  Care was taken to remove all the calcium from the aortic annulus.  We then sized up the aortic annulus which came out to be a **-mm stentless porcine Toronto valve.  We prepared the valve.  Next, we placed our proximal suture line of interrupted 4-0 Tycron sutures for the annulus.  We started with our individual commissural stitches.  They were connected to our valve sewing ring.  Next, we placed 5 interrupted 4-0 Tycron sutures in a subannular fashion at each commissural position.  After doing so, we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve.  The valve was lowered into place and all of the sutures were tied.  Next, we gave another round of cold blood antegrade and retrograde cardioplegia.  Next, we sewed our distal suture line.  We began with the left coronary cusp of the valve.  We ran a 5-0 RB needle up both sides of the valve.  Care was taken to avoid the left coronary ostia.  This procedure was repeated on the right cusp of the stentless porcine valve.  Again, care was taken to avoid any injury to the coronary ostia.  Lastly, we sewed our non-coronary cusp.  This was done without difficulty.  At this point we inspected our aortic valve.  There was good coaptation of the leaflets, and it was noted that both the left and the right coronary ostia were open.  We gave another round of cold blood antegrade and retrograde cardioplegia.  The antegrade portion was given in a direct ostial fashion once again.  We now turned our attention to closing the aorta.  A 4-0 Prolene double row of suture was used to close the aorta in a running fashion.  Just prior to closing, we de-aired the heart and gave a warm shot of antegrade and retrograde cardioplegia.  At this point, we removed our aortic cross-clamp.  The heart gradually regained its electromechanical activity.  We placed 2 atrial and 2 ventricular pacing wires.  We removed our aortic vent and oversewed that site with another 4-0 Prolene on an SH needle.  We removed our retrograde cardioplegia catheter.  We oversewed that site with a 5-0 Prolene.  By now, the heart was de-aired and resumed normal electromechanical activity.  We began to wean the patient from cardiopulmonary bypass.  We then removed our venous cannula and suture ligated that site with a #2 silk.  We then gave full-dose protamine.  After knowing that there was no evidence of a protamine reaction, we removed the aortic cannula.  We buttressed that site with a 4-0 Prolene on an SH needle.  We placed a mediastinal chest tube and brought it out through the skin.  We also placed 2 Blake drains, 1 in the left chest and 1 in the right chest, as the patient had some bilateral pleural effusions.  They were brought out through the skin.  The sternum was closed with #7 wires in an interrupted figure-of-eight fashion.  The fascia was closed with #1 Vicryl.  We closed the subcu tissue with 2-0 Vicryl and the skin with 4-0 PDS.
---
DESCRIPTION: Aortic stenosis.   Insertion of a Toronto stentless porcine valve, cardiopulmonary bypass, and cold cardioplegia arrest of the heart.

cardiovascular / pulmonary, cardioplegia, toronto stentless porcine valve, tycron sutures, coronary ostia, porcine valve, retrograde cardioplegia, cardiopulmonary bypass, sutures, valve, insertion, toronto, aortic, stentless, chest, coronary, porcine, cardiopulmonary, prolene, atrial, bypass, heart, aorta,

The procedure described in the report involves aortic stenosis treatment through the insertion of a porcine valve, requiring cardiopulmonary bypass and cardioplegia. This is a high-stakes situation because it involves major heart surgery with several critical phases such as the arrest and restart of the heart, bypass, and potential complications associated with anesthesia, bleeding, and infection. Furthermore, the successful replacement of the aortic valve is vital for the patient's survival and quality of life, indicating that the stakes are high.


Medical Specialty: Surgery
Sample Name: Total Abdominal Hysterectomy - 2

PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Pelvic pain.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Pelvic pain.,3.  Pelvic endometriosis.,PROCEDURE PERFORMED: ,Total abdominal hysterectomy.,ANESTHESIA: , General endotracheal and spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 200 cc.,FLUIDS:  ,2400 cc of crystalloids.,URINE OUTPUT: , 100 cc of clear urine.,INDICATIONS:,  This is a 40-year-old female gravida-0 with a history of longstanding enlarged fibroid uterus.  On ultrasound, the uterus measured 14 cm x 6.5 cm x 7.8 cm.  She had received two dosage of Lupron to help shrink the fibroid.  Her most recent Pap smear was normal.,FINDINGS: , On a manual exam, the uterus is enlarged approximately 14 to 16 weeks size with multiple fibroids palpated.  On laparotomy, the uterus did have multiple pedunculated fibroids, the largest being approximately 7 cm.  The bilateral tubes and ovaries appeared normal.,There was evidence of endometriosis on the posterior wall of the uterus as well as the bilateral infundibulopelvic ligament.  There was some adhesions of the bowel to the left ovary and infundibulopelvic ligament and as well as to the right infundibulopelvic ligament.,PROCEDURE:,  After consent was obtained, the patient was taken to the operating room where spinal anesthetic was first administered and then general anesthetic.  The patient was placed in the dorsal supine position and prepped and draped in normal sterile fashion.  A Pfannenstiel skin incision was made and carried to the underlying Mayo fashion using the second knife.  The fascia was incised in midline and the incision extended laterally using Mayo scissors.  The superior aspect of the fascial incision was grasped with Kocher clamps, tented up, and dissected off the underlying rectus muscle both bluntly and sharply with Mayo scissors.  Attention was then turned to the inferior aspect of the incision, which in a similar fashion was grasped with Kocher clamps, tented up and dissected off the underlying rectus muscles.  The rectus muscles were separated in the midline and the peritoneum was identified, grasped with hemostat, and entered sharply with Metzenbaum scissors.  This incision was extended superiorly and inferiorly with good visualization of the bladder.  The uterus was then brought up out of the incision.  The bowel adhesions were carefully taken down using Metzenbaum scissors.  Good hemostasis was noted at this point.  The self-retaining retractor was then placed.  The bladder blade was placed.  The bowel was gently packed with moist laparotomy sponges and held in place with the blade on the GYN extension.  The uterus was then grasped with a Lahey clamp and brought up out of the incision.  The left round ligament was identified and grasped with Allis clamp and tented up.  A hemostat was passed in the avascular area beneath the round ligament.  A suture #0 Vicryl was used to suture ligate the round ligament.  Two hemostats were placed across the round ligament proximal to the previously placed suture and the Mayo scissors were used to transect the round ligament.  An avascular area of the broad ligament was then identified and entered bluntly.  The suture of #0 Vicryl was then used to suture ligate the left uterovarian ligament.  Two straight Ochsner's were placed across the uterovarian ligament proximal to the previous suture.  The ligament was then transected and suture ligated with #0 Vicryl.  Attention was then turned to the right round ligament, which in a similar fashion was tented up with an Allis clamp.  An avascular area was entered beneath the round ligament using a hemostat and the round ligament was suture ligated and transected.  An avascular area of the broad ligament was then entered bluntly and the right uterovarian ligament was then suture ligated with #0 Vicryl.,Two straight Ochsner's were placed across the ligament proximal to previous suture.  This was then transected and suture ligated again with #0 Vicryl.  The left uterine peritoneum was then identified and grasped with Allis clamps.  The vesicouterine peritoneum was then transected and then entered using Metzenbaum scissors.  This incision was extended across the anterior portion of the uterus and the bladder flap was taken down.  It was sharply advanced with Metzenbaum scissors and then bluntly using a moist Ray-Tec.  The Ray-Tec was left in place at this point to ensure that the bladder was below the level of the cervix.  The bilateral uterine arteries then were skeletonized with Metzenbaum scissors and clamped bilaterally using straight Ochsner's.  Each were then transected and suture ligated with #0 Vicryl.  A curved Ochsner was then placed on either side of the cervix.  The tissue was transected using a long knife and suture ligated with #0 Vicryl.  Incidentally, prior to taking down the round ligaments, a pedunculated fibroid and the right fundal portion of the uterus was injected with Vasopressin and removed using a Bovie.  The cervix was then grasped with a Lahey clamp.  The cervicovaginal fascia was then taken down first using the long-handed knife and then a back handle of the knife to bring the fascia down below the level of the cervix.  A double-pointed scissors were used to enter the vaginal vault below the level of the cervix.  A straight Ochsner was placed on the vaginal vault.  The Jorgenson scissors were used to amputate the cervix and the uterus off of the underlying vaginal tissue.  The vaginal cuff was then reapproximated with #0 Vicryl in a running locked fashion and the pelvis was copiously irrigated.  There was a small area of bleeding noted on the underside of the bladder.  The bladder was tented up using an Allis clamp and a figure-of-eight suture of #3-0 Vicryl was placed with excellent hemostasis noted at this point.  The uterosacral ligaments were then incorporated into the vaginal cuff and the cuff was synched down.  A figure-of-eight suture of #0 Vicryl was placed in the midline of the vaginal cuff in attempt to incorporate the bilateral round ligament.  The round ligament was too short.  It would be a maximal amount of stretch to incorporate, therefore, only the left round ligament was incorporated into the vaginal cuff.  The bilateral adnexal areas were then re-peritonealized with #3-0 Vicryl in a running fashion.  The bladder flap was reapproximated to the vaginal cuff using one interrupted suture.  The pelvis was again irrigated at this point with excellent hemostasis noted.  Approximately 200 cc of saline with methylene blue was placed into the Foley to inflate the bladder.  There was no spillage of blue fluid into the abdomen.  The fluid again was allowed to drain.  All sponges were then removed and the bowel was allowed to return to its anatomical position.  The peritoneum was then reapproximated with #0 Vicryl in a running fashion.  The fascia was reapproximated also with #0 Vicryl in a running fashion.  The skin was then closed with staples.,A previously placed Betadine soaked Ray-Tec was removed from the patient's vagina and sponge stick was used to assess any bleeding in the vaginal vault.  There was no appreciable bleeding.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  The patient was taken to the recovery room in satisfactory condition.  She will be followed immediately postoperatively within the hospital.
---
DESCRIPTION: Total abdominal hysterectomy.  Enlarged fibroid uterus, pelvic pain, and pelvic endometriosis.  On laparotomy, the uterus did have multiple pedunculated fibroids.

surgery, pelvic pain, pelvic endometriosis, astramorph, total abdominal hysterectomy, enlarged fibroid, metzenbaum scissors, vaginal cuff, scissors, vaginal, uterus, ligament, hysterectomy, endometriosis, pedunculated, fibroids, infundibulopelvic, uterovarian, abdominal, laparotomy, peritoneum,

The described situation involves a total abdominal hysterectomy, a major surgical procedure to remove the uterus due to conditions such as fibroids, pelvic pain, and endometriosis. Surgery, especially one involving general anesthesia and potential significant blood loss, inherently carries high stakes due to the risks of complications and the need for precision in the execution. However, since the procedure was completed without complications and with all counts correct post-operation, it suggests proper management and reduced immediate risks. Any surgery with general anesthesia and significant tissue manipulation or removal carries considerable stakes but given the outcome described, these are managed effectively.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychosocial Eval - Donor

DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - "This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant.",When and how did subject of donation arise - "My mom and I talked about it together as a family.",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer:  "I would rather not go there.  Well, since we were talking, "I will tell you that my mother really does not understand.  She is very worried.  She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor.  I don't think my mom really understands, and I know that she really needs a kidney.  I think she is coming around to accepting.",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - "Well, my children are fine and my husband is very supportive.",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - "My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate.",How would your family and friends react if you decided not to be a donor - "I don't think that is going to happen.",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - "I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother.  I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup.",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - "That is my mother.",How your relationship with the recipient change if you donate your kidney - "I am not sure that it will change at all.  I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others.",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact.  I am away from my children and my husband a lot because of I travel with my job.  So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - "Yes, I have a very good understanding of the transplant process.  I work as a contract nursing all over the country.  I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process.",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - "Yes, I do understand all the risks.  I have had a long conversation with the coordinator and we have talked about these things.",Have you thought about how you might feel if the kidney is rejected - "I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine.  It is a part of the way I am managing my stress about this.",Do you have any doubts or concerns about donating - "No, I don't have any doubts or any concerns right now.  I just wish this headache would go away.,Do you understand that there will be pain after the transplant - "Of course, I do.",What are your expectations about your recuperation - "I am planning on staying with my mom for three months in the Houston area after the transplant.  We live outside of Tampa, Florida; so this will be an adventure for both of us.",Do you need to speak further to any of the transplant team members - "No, I have had a long talk with ABC.  I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - "I had a one cesarian section, and I also suffered from asthma as a child.  I am in otherwise good health.",Are you currently on any medication - "Yes, I am on Folic acid.",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - "No, I have not.  I have a good supportive system and a lot of people that I can talk to when I need to.",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - "No.",Any typical drinks you prefer - "I am a nondrinker.",What kinds of recreational drugs have you tried?  Have you used any recently - "None.",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS:  LENGTH OF TIME MARRIED:  "I live with my family, my husband, and my two children with good relationship.  We have been married for 29 years.",NAME OF SPOUSE/PARTNER:  "His name is Xyz.",AGE AND HEALTH OF SPOUSE/PARTNER:  He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter.  Our elder child has just finished college.",CHILDREN:  I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - "I will stay with a friend.  He lives in the Houston area.  I am staying with that friend right now, while I am here for my workup.",CURRENT OCCUPATION:,What is your current occupation - "I currently work on a contract basis as a nurse.  I go on assignments all over the country, and I work until the contract is over.  This allowed me to be flexible and the best candidate for donation to mom.",Do you have the support of your employer - "Absolutely.",PAID OFF TIME:,Paid leave - "None.",Disability coverage:  "None.",SUPPORTIVE ENVIRONMENT:,  "Yes."
---
DESCRIPTION: Psychosocial evaluation of kidney donor.  Questions - Answers

The situation involves a psychosocial evaluation for a potential kidney donor, which is inherently a high-stakes situation. Donating a kidney is a major medical procedure with significant risks and implications both for the donor and the recipient. Issues such as the donor's understanding of risks, the dynamics between the donor and recipient, and the emotional and psychological readiness of the donor are critical. The decision can have lasting impacts on the donor's health and the recipient's survival. While the donor appears well-informed and motivated, the stakes remain high due to the potential consequences of organ donation and surgery.