Medical Specialty: Letters
Sample Name: Chiropractic IME - 2

DATE OF INJURY : October 4, 2000,DATE OF EXAMINATION : September 5, 2003,EXAMINING PHYSICIAN : X Y, MD,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINT:  ,Aching and mid back pain.,HISTORY OF PRESENT INJURY: , Based upon the examinee's perspective: ,Mr. Abc is a 52-year-old self-employed, independent consultant for DEMILEE-USA. He is also a mechanical engineer. He reports that he was injured in a motor vehicle accident that occurred in October 4, 2000. At that time, he was employed as a purchasing agent for IBIKEN-USA. On the date of the motor vehicle accident, he was sitting in the right front passenger's seat, wearing seat and shoulder belt safety harnesses, in his 1996 or 1997 Volvo 850 Wagon automobile driven by his son. The vehicle was completely stopped and was "slammed from behind" by a van. The police officer, who responded to the accident, told Mr. Abc that the van was probably traveling at approximately 30 miles per hour at the time of impact.,During the impact, Mr. Abc was restrained in the seat and did not contact the interior surface of the vehicle. He experienced immediate mid back pain. He states that the Volvo automobile sustained approximately $4600 in damage.,He was transported by an ambulance, secured by a cervical collar and backboard to the emergency department. An x-ray of the whole spine was obtained, and he was evaluated by a physician's assistant. He was told that it would be "okay to walk." He was prescribed pain pills and told to return for reevaluation if he experienced increasing pain.,He returned to the Kaiser facility a few days later, and physical therapy was prescribed. Mr. Abc states that he was told that "these things can take a long time." He indicates that after one year he was no better. He then states that after two years he was no better and worried if the condition would never get better.,He indicates he saw an independent physician, a general practitioner, and an MRI was ordered. The MRI study was completed at ABCD Hospital. Subsequently, Mr. Abc returned and was evaluated by a physiatrist. The physiatrist reexamined the original thoracic spine x-rays that were taken on October 4, 2000, and stated that he did not know why the radiologist did not originally observe vertebral compression fractures. Mr. Abc believes that he was told by the physiatrist that it involved either T6-T7 or T7-T8.,Mr. Abc reports that the physiatrist told him that little could be done besides participation in core strengthening. Mr. Abc describes his current exercise regimen, consisting of cycling, and it was deemed to be adequate. He was told, however, by the physiatrist that he could also try a Pilates type of core exercise program.,The physiatrist ordered a bone scan, and Mr. Abc is unsure of the results. He does not have a formal follow up scheduled with Kaiser, and is awaiting re-contact by the physiatrist.,He denies any previous history of symptomatology or injuries involving his back.,CURRENT SYMPTOMS:  ,He reports that he has the same mid back pain that has been present since the original injury. It is located in the same area, the mid thoracic spine area. It is described as a pain and an ache and ranges from 3/10 to 6/10 in intensity, and the intensity varies, seeming to go in cycles. The pain has been staying constant.,When I asked whether or not the pain have improved, he stated that he was unable to determine whether or not he had experienced improvement. He indicates that there may be less pain, or conversely, that he may have developed more of a tolerance for the pain. He further states that "I can power through it." "I have learned how to manage the pain, using exercise, stretching, and diversion techniques." It is primary limitation with regards to the back pain involves prolonged sitting. After approximately two hours of sitting, he has required to get up and move around, which results in diminishment of the pain. He indicates that prior to the motor vehicle accident, he could sit for significantly longer periods of time, 10 to 12 hours on a regular basis, and up to 20 hours, continuously, on an occasional basis.,He has never experienced radiation of the pain from the mid thoracic spine, and he has never experienced radicular symptoms of radiation of pain into the extremities, numbness, tingling, or weakness.,Again, aggravating activities include prolonged sitting, greater than approximately two hours.,Alleviating activities include moving around, stretching, and exercising. Also, if he takes ibuprofen, it does seem to help with the back pain.,He is not currently taking medications regularly, but list that he takes occasional ibuprofen when the pain is too persistent.,He indicates that he received several physical therapy sessions for treatment, and was instructed in stretching and exercises. He has subsequently performed the prescribed stretching and exercises daily, for nearly three years.,With regards to recreational activities, he states that he has not limited his activities due to his back pain.,He denies bowel or bladder dysfunction.,FILES REVIEW:  ,October 4, 2000: An ambulance was dispatched to the scene of a motor vehicle accident on South and Partlow Road. The EMS crew arrived to find a 49-year-old male sitting in the front passenger seat of a vehicle that was damaged in a rear-end collision and appeared to have minimal damage. He was wearing a seatbelt and he denied loss of consciousness. He also denied a pertinent past medical history. They noted pain in the lower cervical area, mid thoracic and lumbar area. They placed him on a backboard and transported him to Medical Center.,October 4, 2000: He was seen in the emergency department of Medical Center. The provider is described as "unknown." The history from the patient was that he was the passenger in the front seat of a car that was stopped and rear-ended. He stated that he did not exit the car because of pain in his upper back. He reported he had been wearing the seatbelt and harness at that time. He denied a history of back or neck injuries. He was examined on a board and had a cervical collar in place. He was complaining of mid back pain. He denied extremity weakness. Sensory examination was intact. There was no tenderness with palpation or flexion in the neck. The back was a little tender in the upper thoracic spine area without visible deformity. There were no marks on the back. His x-ray was described as "no acute bony process." Listed visit diagnosis was a sprain-thoracic, and he was prescribed hydrocodone/acetaminophen tablets and Motrin 800 mg tablets.,October 4, 2000: During the visit, a Clinician's Report of Disability document was signed by Dr. M, authorizing time loss from October 4, 2000, through October 8, 2000. The document also advised no heavy lifting, pushing, pulling, or overhead work for two weeks. During this visit, a thoracic spine x-ray series, two views, was obtained and read by Dr. JR. The findings demonstrate no evidence of acute injury. No notable arthritic findings. The pedicles and paravertebral soft tissues appear unremarkable.,November 21, 2000: An outpatient progress note was completed at Kaiser, and the clinician of record was Dr. H. The history obtained documents that Mr. Abc continued to experience the same pain that he first noted after the accident, described as a discomfort in the mid thoracic spine area. It was non-radiating and described as a tightness. He also reported that he was hearing clicking noises that he had not previously heard. He denied loss of strength in the arms. The physical examination revealed good strength and normal deep tendon reflexes in the arms. There was minimal tenderness over T4 through T8, in an approximate area. The visit diagnosis listed was back pain. Also described in the assessment was residual pain from MVA, suspected bruised muscles. He was prescribed Motrin 800 mg tablets and an order was sent to physical therapy. Dr. N also documents that if the prescribed treatment measures were not effective, then he would suggest a referral to a physiatrist. Also, the doctor wanted him to discuss with physical therapy whether or not they thought that a chiropractor would be beneficial.,December 4, 2000: He was seen at Kaiser for a physical therapy visit by Philippe Justel, physical therapist. The history obtained from Mr. Abc is that he was not improving. Symptoms described were located in the mid back, centrally. The examination revealed mild tenderness, centrally at T3-T8, with very poor segmental mobility. The posture was described as rigid T/S in flexion. Range of motion was described as within normal limits, without pain at the cervical spine and thoracic spine. The plan listed included two visits per week for two weeks, for mobilization. It is also noted that the physical therapist would contact the MD regarding a referral to a chiropractor.,December 8, 2000: He was seen at Kaiser for a physical therapy visit by Mr. Justel. It was noted that the subjective category of the document revealed that there was no real change. It was noted that Mr. Abc tolerated the treatment well and that he was to see a chiropractor on Monday.,December 11, 2000: He presented to the Chiropractic Wellness Center. There is a form titled 'Chiropractic Case History,' and it documents that Mr. Abc was involved in a motor vehicle accident, in which he was rear-ended in October. He has had mid back pain since that time. The pain is worsened with sitting, especially at a computer. The pain decreases when he changes positions, and sometimes when he walks. Mr. Abc reports that he occasionally takes 800 mg doses of ibuprofen. He reported he went to physical therapy treatment on two occasions, which helped for a few hours only. He did report that he had a previous history of transitory low back pain.,During the visit, he completed a modified Oswestry Disability Questionnaire, and a WC/PI Subjective Complaint Form. He listed complaints of mid and low back pain of a sore and aching character. He rated the pain at grade 3-5/10, in intensity. He reported difficulty with sitting at a table, bending forward, or stooping. He reported that the pain was moderate and comes and goes.,During the visit at the Chiropractic Wellness Center, a spinal examination form was completed. It documents palpation tenderness in the cervical, thoracic, and lumbar spine area and also palpation tenderness present in the suboccipital area, scalenes, and trapezia. Active cervical range of motion measured with goniometry reveals pain and restriction in all planes. Active thoracic range of motion measured with inclinometry revealed pain and restriction in rotation bilaterally. Active lumbosacral range of motion measured with inclinometry reveals pain with lumbar extension, right lateral flexion, and left lateral flexion.,December 11, 2000: He received chiropractic manipulation treatment, and he was advised to return for further treatment at a frequency of twice a week.,December 13, 2000: He returned to the Chiropractic Wellness Center to see Joe Smith, DC, and it is documented that his middle back was better.,December 13, 2000: A personal injury patient history form is completed at the Chiropractic Wellness Center. Mr. Abc reported that on October 4, 2000, he was driving his 1996 Volvo 850 vehicle, wearing seat and shoulder belt safety harnesses, and completely stopped. He was rear-ended by a vehicle traveling at approximately 30 miles per hour. The impact threw him back into his seat, and he felt back pain and determined that it was not wise to move about. He reported approximate damage to his vehicle of $4800. He reported continuing mid and low back pain, of a dull and semi-intense nature. He reported that he was an export company manager for IBIKEN-USA, and that he missed two full days of work, and missed 10-plus partial days of work. He stated that he was treated initially after the motor vehicle accident at Kaiser and received painkillers and ibuprofen, which relieved the pain temporarily. He specifically denied ever experiencing similar symptoms.,December 26, 2000: A no-show was documented at the Chiropractic Wellness Center.,April 5, 2001: He received treatment at the Chiropractic Wellness Center. He reported that two weeks previously, his mid back pain had worsened.,April 12, 2001: He received chiropractic treatment at the Chiropractic Wellness Center.,April 16, 2001: He did not show up for his chiropractic treatment.,April 19, 2001: He did not show up for his chiropractic treatment.,April 26, 2001: He received chiropractic manipulation treatment at the Chiropractic Wellness Center. He reported that his mid back pain increased with sitting at the computer. At the conclusion of this visit, he was advised to return to the clinic as needed.,September 6, 2002: An MRI of the thoracic spine was completed at ABCD Hospital and read by Dr. RL, radiologist. Dr. D noted the presence of minor anterior compression of some mid thoracic vertebrae of indeterminate age, resulting in some increased kyphosis. Some of the mid thoracic discs demonstrate findings consistent with degenerative disc disease, without a significant posterior disc bulging or disc herniation. There are some vertebral end-plate abnormalities, consistent with small Schmorl's nodes, one on the superior aspect of T7, which is compressed anteriorly, and on the inferior aspect of T6.,May 12, 2003: He was seen at the Outpatient Clinic by Dr. L, internal medicine specialist. He was there for a health screening examination, and listed that his only complaints are for psoriasis and chronic mid back pain, which have been present since a 2000 motor vehicle accident. Mr. Abc reported that an outside MRI showed compression fractures in the thoracic spine. The history further documents that Mr. Abc is an avid skier and volunteers on the ski patrol. The physical examination revealed that he was a middle-aged Caucasian male in no acute distress. The diagnosis listed from this visit is back pain and psoriasis. Dr. L documented that he spent one hour in the examination room with the patient discussing what was realistic and reasonable with regard to screening testing. Dr. L also stated that since Mr. Abc was experiencing chronic back pain, he advised him to see a physiatrist for evaluation. He was instructed to bring the MRI to the visit with that practitioner.,June 10, 2003: He was seen at the Physiatry Clinic by Dr. R, physiatrist. The complaint listed is mid back pain. In the subjective portion of the chart note, Dr. R notes that Mr. Abc is involved in the import/export business, and that he is physically active in cycling, skiing, and gardening. He is referred by Dr. L because of persistent lower thoracic pain, following a motor vehicle accident, on October 4, 2000. Mr. Abc told Dr. R that he was the restrained passenger of a vehicle that was rear-ended at a moderate speed. He stated that he experienced immediate discomfort in his thoracic spine area without radiation. He further stated that thoracic spine x-rays were obtained at the Sunnyside Emergency Room and read as normal. It is noted that Mr. Abc was treated conservatively and then referred to physical therapy where he had a number of visits in late of 2002 and early 2003. No further chart entries were documented about the back problem until Mr. Abc complained to Dr. L that he still had ongoing thoracic spine pain during a visit the previous month. He obtained an MRI, out of pocket, at ABCD Hospital and stated that he paid $1100 for it. Dr. R asked to see the MRI and was told by Mr. Abc that he would have to reimburse or pay him $1100 first. He then told the doctor that the interpretation was that he had a T7 and T8 compression fracture. Mr. Abc reported his improvement at about 20%, compared to how he felt immediately after the accident. He described that his only symptoms are an aching pain that occurs after sitting for four to five hours. If he takes a break from sitting and walks around, his symptoms resolve. He is noted to be able to bike, ski, and be active in his garden without any symptoms at all. He denied upper extremity radicular symptoms. He denied lower extremity weakness or discoordination. He also denied bowel or bladder control or sensation issues. Dr. R noted that Mr. Abc was hostile about the Kaiser health plan and was quite uncommunicative, only reluctantly revealing his history. The physical examination revealed that he moved about the examination room without difficulty and exhibited normal lumbosacral range of motion. There was normal thoracic spine motion with good chest expansion. Neurovascular examination of the upper extremities was recorded as normal. There was no spasticity in the lower extremities. There was no tenderness to palpation or percussion up and down the thoracic spine. Dr. R reviewed the thoracic spine films and noted the presence of "a little compression of what appears to be T7 and T8 on the lateral view." Dr. R observed that this was not noted on the original x-ray interpretation. He further stated that the MRI, as noted above, was not available for review. Dr. R assessed that Mr. Abc was experiencing minimal thoracic spine complaints that probably related to the motor vehicle accident three years previously. The doctor further stated that "the patient's symptoms are so mild as to almost not warrant intervention." He discussed the need to make sure that Mr. Abc's workstation was ergonomic and that Mr. Abc could pursue core strengthening. He further recommended that Mr. Abc look into participation in a Pilates class. Mr. Abc was insistent, so Dr. R made plans to order a bone scan to further discriminate the etiology of his symptoms. He advised Mr. Abc that the bone scan results would probably not change treatment. As a result of this visit, Dr. R diagnosed thoracic spine pain (724.1) and ordered a bone scan study.
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DESCRIPTION: Chiropractic IME with old files review.  Detailed Thoracic Spine Examination.

The situation involves a Chiropractic Independent Medical Examination (IME) concerning a patient with longstanding mid-back pain from a motor vehicle accident. The detailed medical and diagnostic history indicates a non-life-threatening condition with demonstrated chronic pain management over several years. The examination output appears evaluative, not for immediate or acute intervention. Typically, such IMEs are used to assess the extent of injury for insurance or legal purposes, rather than direct medical treatment. This marks it as low-stakes in terms of direct health or life threat, though it holds moderate stakes for legal, insurance, or long-term health management aspects.


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

Medical Specialty: Surgery
Sample Name: Inguinal Hernia & Hydrocele Repair

PREOPERATIVE DIAGNOSIS:  ,Left communicating hydrocele.,POSTOPERATIVE DIAGNOSIS: , Left communicating hydrocele.,ANESTHESIA: , General.,PROCEDURE:  ,Left inguinal hernia and hydrocele repair.,INDICATIONS: , The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele.  The fluid size tends to fluctuate with time but has been relatively persistent for the past year.  I met with the patient's mom and also spoke with his father by phone in the past couple of months and explained the diagnosis of patent processus vaginalis for communicating hydrocele and talked to them about the surgical treatment and options.  All their questions have been answered and the patient is fit for operation today.,OPERATIVE FINDINGS:  ,The patient had a very thin patent processus vaginalis leading to a rather sizeable hydrocele sac in the left hemiscrotum.  We probably drained around 10 to 15 mL of fluid from the hydrocele sac.  The processus vaginalis was clearly seen back to the peritoneal reflection where a high ligation was successfully performed.  There were no other abnormalities noted in the inguinal scrotal region.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had an uneventful induction of inhalation anesthetic.  A peripheral IV was placed, and we conducted a surgical time-out to reiterate all of The patient's important identifying information and to confirm that we were indeed going to perform a left inguinal hernia and hydrocele repair.  After preparation and draping was done with chlorhexidine based prep solution, a local infiltration block as well as an ilioinguinal and iliohypogastric nerve block was performed with 0.25% Marcaine with dilute epinephrine.  A curvilinear incision was made low in the left inguinal area along one of prominent skin folds.  Soft tissue dissection was carried down through Scarpa's layer to the external oblique fascia, which was then opened to expose the underlying spermatic cord structures.  The processus vaginalis was dissected free from the spermatic cord structures, and the distal hydrocele sac was widely opened and drained of its fluid contents.  The processus vaginalis was cleared back to peritoneal reflection at the deep inguinal ring and a high ligation was performed there using both the transfixing and a mass ligature of 3-0 Vicryl.  After the excess hydrocele and processus vaginalis tissue was excised, the spermatic cord structures were replaced and the external oblique and Scarpa's layers were closed with interrupted 3-0 Vicryl sutures.  Subcuticular 5-0 Monocryl and Steri-Strips were used for the final skin closure.  The patient tolerated the operation well.  He was awakened and taken to the recovery room in good condition.  Blood loss was minimal.  No specimen was submitted.,
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DESCRIPTION: Left communicating hydrocele.  Left inguinal hernia and hydrocele repair.  The patient is a 5-year-old young man with fluid collection in the tunica vaginalis and peritesticular space on the left side consistent with a communicating hydrocele.

surgery, hydrocele, hydrocele repair, hernia, inguinal, fluid collection, tunica vaginalis, peritesticular space, hydrocele sac, spermatic cord, cord structures, inguinal hernia, communicating hydrocele, fluid, vaginalis

The situation involves a surgical procedure on a 5-year-old for a left communicating hydrocele and potential inguinal hernia repair, which are conditions that can cause discomfort and other issues if left untreated. However, such surgeries are relatively routine and commonly performed, especially in pediatric cases. With general anesthesia and the involvement of surgical techniques, there are some inherent risks, but these are typically low-stakes situations given the standard nature of the procedure. Moreover, the report indicates that the surgery was successful with minimal blood loss and no complications, further suggesting that the stakes are not particularly high.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Obstetrics / Gynecology
Sample Name: Breast Radiation Therapy Followup

DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1.  Glucosamine complex.,2.  Toprol XL.,3.  Alprazolam,4.  Hydrochlorothiazide.,5.  Dyazide.,6.  Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck.  She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area.  As such, I feel that we could safely re-treat the lower neck.  Her weight has increased to 189.5 from 185.2.  She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK:  On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area.  No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY:  Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected.  No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN:  Normal bowel sounds, no hepatomegaly.  No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress.  Thank you for having allowed me to participate in her care.
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DESCRIPTION: Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.

obstetrics / gynecology, carboplatin, taxol, radiation therapy, breast adenocarcinoma, beam radiotherapy, chest wall, radiotherapy, supraclavicular, lymphadenopathy, adenocarcinoma, breast,

The patient in question has stage IV breast adenocarcinoma with metastasis, indicating an advanced cancer diagnosis that requires ongoing treatment and followup. Managing advanced cancer involves complex decisions, such as treatment planning (including chemotherapy and potential radiotherapy), monitoring for side effects or disease progression, and addressing any quality of life concerns. This situation's high-stakes nature is influenced by the severe and potentially life-threatening nature of the disease, the need for precise coordination in treatment, and the emotional and physical burden on the patient. Stakes increase with management of metastatic cancer due to potential complications and necessary adjustments in treatment protocols.


Medical Specialty: Radiology
Sample Name: MRI Brain and Brainstem

CC:, Falling.,HX:, This 67y/o RHF was diagnosed with Parkinson's Disease in 9/1/95, by a local physician. For one year prior to the diagnosis, the patient experienced staggering gait, falls and episodes of lightheadedness. She also noticed that she was slowly "losing" her voice, and that her handwriting was becoming smaller and smaller. Two months prior to diagnosis, she began experienced bradykinesia, but denied any tremor. She noted no improvement on Sinemet, which was started in 9/95. At the time of presentation, 2/13/96, she continued to have problems with coordination and staggering gait. She felt weak in the morning and worse as the day progressed. She denied any fever, chills, nausea, vomiting, HA, change in vision, seizures or stroke like events, or problems with upper extremity coordination.,MEDS:, Sinemet CR 25/100 1tab TID, Lopressor 25mg qhs, Vitamin E 1tab TID, Premarin 1.25mg qd, Synthroid 0.75mg qd, Oxybutynin 2.5mg has, isocyamine 0.125mg qd.,PMH:, 1) Hysterectomy 1965. 2) Appendectomy 1950's. 3) Left CTR 1975 and Right CTR 1978. 4) Right oophorectomy 1949 for "tumor." 5) Bladder repair 1980 for unknown reason. 6) Hypothyroidism dx 4/94. 7) HTN since 1973.,FHX: ,Father died of MI, age 80. Mother died of MI, age73. Brother died of Brain tumor, age 9.,SHX: ,Retired employee of Champion Automotive Co.,Denies use of TOB/ETOH/Illicit drugs.,EXAM: ,BP (supine)182/113 HR (supine)94. BP (standing)161/91 HR (standing)79. RR16 36.4C.,MS: A&O to person, place and time. Speech fluent and without dysarthria. No comment regarding hypophonia.,CN: Pupils 5/5 decreasing to 2/2 on exposure to light. Disks flat. Remainder of CN exam unremarkable.,Motor: 5/5 strength throughout. NO tremor noted at rest or elicited upon movement or distraction,Sensory: Unremarkable PP/VIB testing.,Coord: Did not show sign of dysmetria, dyssynergia, or dysdiadochokinesia. There was mild decrement on finger tapping and clasping/unclasping hands (right worse than left).,Gait: Slow gait with difficulty turning on point. Difficulty initiating gait. There was reduced BUE swing on walking (right worse than left).,Station: 3-4step retropulsion.,Reflexes: 2/2 and symmetric throughout BUE and patellae. 1/1 Achilles. Plantar responses were flexor.,Gen Exam: Inremarkable. HEENT: unremarkable.,COURSE:, The patient continued Sinemet CR 25/100 1tab TID and was told to monitor orthostatic BP at home. The evaluating Neurologist became concerned that she may have Parkinsonism plus dysautonomia.,She was seen again on 5/28/96 and reported no improvement in her condition. In addition she complained of worsening lightheadedness upon standing and had an episode, 1 week prior to 5/28/96, in which she was at her kitchen table and became unable to move. There were no involuntary movements or alteration in sensorium/mental status. During the episode she recalled wanting to turn, but could not. Two weeks prior to 5/28/96 she had an episode of orthostatic syncope in which she struck her head during a fall. She discontinued Sinemet 5 days prior to 5/28/96 and felt better. She felt she was moving slower and that her micrographia had worsened. She had had recent difficulty rolling over in bed and has occasional falls when turning. She denied hypophonia, dysphagia or diplopia.,On EXAM: BP (supine)153/110 with HR 88. BP (standing)110/80 with HR 96. (+) Myerson's sign and mild hypomimia, but no hypophonia. There was normal blinking and EOM. Motor strength was full throughout. No resting tremor, but mild postural tremor present. No rigidity noted. Mild decrement on finger tapping noted. Reflexes were symmetric. No Babinski signs and no clonus. Gait was short stepped with mild anteroflexed posture. She was unable to turn on point. 3-4 step Retropulsion noted. The Parkinsonism had been unresponsive to Sinemet and she had autonomic dysfunction suggestive of Shy-Drager syndrome. It was recommended that she liberalize dietary salt use and lie with head of the bed elevate at 20-30 degrees at night. Indomethacin was suggested to improve BP in future.
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DESCRIPTION: MRI Brain and Brainstem - Falling (Multiple System Atrophy)

radiology, myerson's sign, falling, dysautonomia, mri brain and brainstem, brain and brainstem, mri brain, sinemet cr, mri, brainstem, ctr, tumor, retropulsion, parkinsonism, brain, lightheadedness, hypophonia, standing, sinemet,

This situation involves a complex medical assessment of a 67-year-old female patient with symptoms suggestive of Parkinson's disease and potential Multiple System Atrophy (MSA). The stakes are quite high due to the progressive and debilitating nature of the condition, the potential for injury due to falls, and the need for accurate diagnosis and management. The situation requires careful interpretation of neurological symptoms and appropriate adjustments in treatment to manage symptoms effectively and prevent further complications. However, it's less critical than immediate life-threatening situations.


Medical Specialty: Radiology
Sample Name: Transesophageal Echocardiogram - 6

HISTORY OF PRESENT ILLNESS: , I was kindly asked to see this patient for transesophageal echocardiogram performance by Dr. A and Neurology.  Please see also my cardiovascular consultation dictated separately.  But essentially, this is a pleasant 72-year-old woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry.  She has been recommended for a transesophageal echocardiogram for cardioembolic source of her CNS insult.,I discussed the procedure in detail with the patient as well as with her daughter, who was present at the patient's bedside with the patient's verbal consent.  I then performed a risk/benefit/alternative analysis with benefits being more definitive exclusion of intracardiac thrombus as well as assessment for intracardiac shunts; alternatives being transthoracic echo imaging, which she had already had, with an inherent false negativity for this indication as well as empiric medical management, which the patient was not interested in; risks including, but not limited to, and the patient was aware this was not an all-inclusive list, of oversedation from conscious sedation, risk of aspiration pneumonia from regurgitation of stomach contents, risk of oropharyngeal, esophageal, oral, tracheal, pulmonary and/or gastric perforation, hemorrhage, or tear.  The patient expressed understanding of this risk/benefit/alternative analysis, had the opportunity to ask questions, which I invited from her and her daughter, all of which were answered to their self-stated satisfaction.  The patient then stated in a clear competent and coherent fashion that she wished to go forward with the transesophageal echocardiogram.,PROCEDURE: , The appropriate time-out procedure was performed as per Medical Center protocol under my direct supervision with appropriate identification of the patient, position, physician, procedure documentation; there were no safety issues identified by staff nor myself.  She received 20 cc of viscous lidocaine for topical oral anesthetic effect.  She received a total of 4 mg of Versed and 100 micrograms of fentanyl utilizing titrated conscious sedation with continuous hemodynamic and oximetric monitoring with reasonable effect.  The multi-plane probe was passed using digital guidance for several passes, after an oral bite block had been put into place for protection of oral dentition.  This was placed into the posterior oropharynx and advanced into the esophagus, then advanced into the stomach and then rotated and withdrawn and removed with adequate imaging obtained throughout.  She was recovered as per the Medical Center conscious sedation protocol, and there were no apparent complications of the procedure.,FINDINGS: , Normal left ventricular size and systolic function.  LVEF of 60%.  Mild left atrial enlargement.  Normal right atrial size.  Normal right ventricular size and systolic function.  No left ventricular wall motion abnormalities identified.  The four pulmonary veins are identified.  The left atrial appendage is interrogated, including with Doppler and color flow, and while there is good to-and-fro motion seen, echo smoke is seen, and in fact, an intracardiac thrombus is identified and circumscribed at 1.83 cm in circumference at the base of the left atrial appendage.  No intracardiac vegetations nor endocarditis seen on any of the intracardiac valves.  The mitral valve is seen.  There is mild mitral regurgitation with two jets.  No mitral stenosis.  Four pulmonary veins were identified without reversible pulmonary venous flow.  There are three cusps of the aortic valve seen.  No aortic stenosis.  There is trace aortic insufficiency.  There is trace pulmonic insufficiency.  The pulmonary artery is seen and is within normal limits.  There is trace to mild tricuspid regurgitation.  Unable to estimate PA systolic pressure accurately; however, on the recent transthoracic echocardiogram (which I would direct the reader to) on January 5, 2010, RVSP was calculated at 40 mmHg on that study.  E wave velocity on average is 0.95 m/sec with a deceleration time of 232 milliseconds.  The proximal aorta is within normal limits, annulus 1.19 cm, sinuses of Valsalva 2.54 cm, ascending aorta 2.61 cm.  The intra-atrial septum is identified as are the SVC and IVC, and these are within normal limits.  The intra-atrial septum is interrogated with color flow as well as agitated D5W and there is no evidence of intracardiac shunting, including no atrial septal defect nor patent foramen ovale.  No pericardial effusion.  There is mild nonmobile descending aortic atherosclerosis seen.,IMPRESSION:,1.  Normal left ventricular size and systolic function.  Left ventricular ejection fraction visually estimated at 60% without regional wall motion abnormalities.,2.  Mild left atrial enlargement.,3.  Intracardiac thrombus identified at the base of the left atrial appendage.,4.  Mild mitral regurgitation with two jets.,5.  Mild nonmobile descending aortic atherosclerosis.,Compared to the transthoracic echocardiogram done previously, other than identification of the intracardiac thrombus, other findings appear quite similar.,These results have been discussed with Dr. A of inpatient Internal Medicine service as well as the patient, who was recovering from conscious sedation, and her daughter with the patient's verbal consent.
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DESCRIPTION: Transesophageal Echocardiogram.  A woman admitted to the hospital with a large right MCA CVA causing a left-sided neurological deficit incidentally found to have atrial fibrillation on telemetry.

radiology, echo, thrombus, intracardiac, cardiovascular, pulmonary veins, intracardiac thrombus, transesophageal echocardiogram, echocardiogram, atrial, mca, cva, transesophageal, pulmonary, ventricular, aortic

The situation involves a 72-year-old patient with a significant medical condition (large right MCA CVA and atrial fibrillation) requiring a transesophageal echocardiogram (TEE). The procedure aims to evaluate a potential cardioembolic source, which, if untreated, may lead to serious complications such as strokes or further neurological damage. Identifying an intracardiac thrombus significantly impacts treatment decisions (like anticoagulation therapy) to prevent future strokes. Hence, this is a high-stakes scenario as it involves critical diagnostic information that impacts the patient's health outcomes.


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

REASON FOR CONSULTATION:,  Thrombocytopenia.,HISTORY OF PRESENT ILLNESS:,  Mrs. XXX is a 17-year-old lady who is going to be 18 in about 3 weeks.  She has been referred for the further evaluation of her thrombocytopenia.  This thrombocytopenia was detected on a routine blood test performed on the 10th of June 2006.  Her hemoglobin was 13.3 with white count of 11.8 at that time.  Her lymphocyte count was 6.7.  The patient, subsequently, had a CBC repeated on the 10th at Hospital where her hemoglobin was 12.4 with a platelet count of 26,000.  She had a repeat of her CBC again on the 12th of June 2006 with hemoglobin of 14, white count of 11.6 with an increase in the number of lymphocytes.  Platelet count was 38.  Her rapid strep screen was negative but the infectious mononucleosis screen is positive.  The patient had a normal platelet count prior too and she is being evaluated for this low platelet count.,The patient gives a history of feeling generally unwell for a couple of days towards the end of May.  She was fine for a few days after that but then she had sore throat and fever 2-3 days subsequent to that.  The patient continues to have sore throat.,She denies any history of epistaxis.  Denies any history of gum bleeding.  The patient denies any history of petechiae.  She denies any history of abnormal bleeding.  Denies any history of nausea, vomiting, neck pain, or any headaches at the present time.,The patient was accompanied by her parents.,PAST MEDICAL HISTORY: , Asthma.,CURRENT MEDICATIONS: , Birth control pills, Albuterol, QVAR and Rhinocort.,DRUG ALLERGIES: , None.,PERSONAL HISTORY: , She lives with her parents.,SOCIAL HISTORY:,  Denies the use of alcohol or tobacco.,FAMILY HISTORY: , Noncontributory.,OCCUPATION: , The patient is currently in school.,REVIEW OF SYSTEMS:,Constitutional:  The history of fever about 2 weeks ago.,HEENT:  Complains of some difficulty in swallowing.,Cardiovascular:  Negative.,Respiratory:  Negative.,Gastrointestinal:  No nausea, vomiting, or abdominal pain.,Genitourinary:  No dysuria or hematuria.,Musculoskeletal:  Complains of generalized body aches.,Psychiatric:  No anxiety or depression.,Neurologic:  Complains of episode of headaches about 2-3 weeks ago.,PHYSICAL EXAMINATION:  ,She was not in any distress.  She appears her stated age.  Temperature 97.9.  Pulse 84.  Blood pressure was 110/60.  Weighs 162 pounds.  Height of 61 inches.  Lungs - Normal effort.  Clear.  No wheezing.  Heart - Rate and rhythm regular.  No S3, no S4.  Abdomen - Soft.  Bowel sounds are present.  No palpable hepatosplenomegaly.  Extremities - Without any edema, pallor, or cyanosis.  Neurological:  Alert and oriented x 3.  No focal deficit.  Lymph Nodes - No palpable lymphadenopathy in the neck or the axilla.  Skin examination reveals few petechiae along the lateral aspect of the left thigh but otherwise there were no ecchymotic patches.,DIAGNOSTIC DATA: , The patient's CBC results from before were reviewed.  Her CBC performed in the office today showed hemoglobin of 13.7, white count of 13.3, lymphocyte count of 7.6, and platelet count of 26,000.,IMPRESSION: , ITP, the patient has a normal platelet count.,PLAN:,1.  I had a long discussion with family regarding the treatment of ITP.  In view of the fact that the patient's platelet count is 26,000 and she is asymptomatic, we will continue to monitor the counts.,2.  An ultrasound of the abdomen will be performed tomorrow.,3.  I have given her a requisition to obtain some blood work tomorrow.
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DESCRIPTION: Consultation for evaluation of thrombocytopenia.

This consultation outlines a case of thrombocytopenia in a teenager with a diagnosis of Immune Thrombocytopenic Purpura (ITP). While this condition can be serious, the patient is currently asymptomatic, and the plan involves monitoring with further diagnostic evaluation. Given the platelet count of 26,000, which is below normal but not critically low, the situation is moderately concerning but not immediately life-threatening, especially since she is not experiencing symptoms like bleeding.


Medical Specialty: Surgery
Sample Name: ORIF & Closed Reduction

PREOPERATIVE DIAGNOSES: , Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,POSTOPERATIVE DIAGNOSES:,  Left elbow fracture dislocation with incarceration of the medial epicondyle with ulnar nerve paresthesias status post closed reduction, attempts 2, right radial shaft fracture with volar apex angulation.,PROCEDURES:  ,1.  Open reduction internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint.,2.  Closed reduction casting of the right forearm.,ANESTHESIA: , Surgery performed under general anesthesia.  Local anesthetic was 10 mL of 0.5% Marcaine.,TOURNIQUET TIME: , On the left was 29 minutes.,COMPLICATIONS:  ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,HISTORY AND PHYSICAL:  ,The patient is a 13-year-old right-hand dominant girl, who fell off a swing at school around 1:30 today.  The patient was initially seen at an outside facility and brought here by her father, given findings on x-ray, a closed reduction was attempted on the left elbow.  After the attempted reduction, the patient was noted to have an incarcerated medial epicondyle fracture as well as increasing ulnar paresthesias that were not present prior to the procedure.  Given this finding, the patient needed urgent open reduction and internal fixation to relieve the pressure on the ulnar nerve.  At that same time, the patient's mildly angulated radial shaft fracture will be reduced.  This was explained to the father.  The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for later hardware removal, and possible continuous nerve symptoms.  All questions were answered.  The father agreed to the above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  The left upper extremity was then prepped and draped in the standard surgical fashion.  Attempts to remove the incarcerated medial epicondyle with supination, valgus stress, and with extension were unsuccessful.  It was decided at this time that she would need open reduction.  The arm was wrapped in Esmarch prior to inflation of the tourniquet to 250 mmHg.  The Esmarch was then removed.  An incision was then made.  Care was taken to avoid any injury to the ulnar nerve.  The medial epicondyle fracture was found incarcerated into the anterior aspect of the joint.  This was easily removed.  The ulnar nerve was also identified, and appeared to be intact.  The medial epicondyle was then transfixed using a guidewire into its anatomic position with the outer cortex over drilled with a 3.2 drill bit, and subsequently a 44-mm 4.5 partially threaded cannulated screw was then placed with a washer to hold the medial epicondyle in place.  After fixation of the fragment, the ulnar nerve was visualized as it traveled around the medial epicondyle fracture with no signs of impingement.  The wound was then irrigated with normal saline and closed using 2-0 Vicryl and 4-0 Monocryl.  The wound was clean and dry, dressed with Steri-Strips and Xeroform.  The area was infiltrated with 0.5% Marcaine.  The patient was then placed in a long-arm posterior well-molded splint with 90 degrees of flexion and neutral rotation.  The tourniquet was released at 30 minutes prior to placement of the dressing, showed no significant bleeding.  Attention was then turned to right side, the arm was then manipulated and a well-molded long-arm cast placed.  The final position in the cast revealed a very small residual volar apex angulation, which is quite acceptable in this age.  The patient tolerated the procedure well, was subsequently extubated and taken to recovery in a stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized for pain control and neurovascular testing for the next 1 to 2 days.  The father was made aware of the intraoperative findings.  All questions answered.
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DESCRIPTION: Open reduction and internal fixation of the left medial epicondyle fracture with placement in a long-arm posterior well-molded splint and closed reduction casting of the right forearm.

surgery, orif, elbow fracture, dislocation, open reduction internal fixation, closed reduction, left medial epicondyle fracture, long-arm posterior well-molded splint, splint, radial shaft fracture, volar apex angulation, medial epicondyle fracture, medial epicondyle, internal fixation, epicondyle fracture, ulnar nerve, epicondyle, fracture, reduction, tourniquet, ulnar, nerve,

The scenario described involves a surgical procedure for a 13-year-old patient with a fracture dislocation in the left elbow and a fracture in the right forearm. The situation involves potential nerve damage (ulnar nerve paresthesias), which is considered serious. The surgery required general anesthesia and carried risks such as infection, bleeding, and potential long-term nerve issues. The fact that urgent surgery was needed to address the ulnar nerve pressure and the complex nature of treating an incarcerated medial epicondyle fracture indicate higher stakes. However, there were no complications during the surgery, and the patient was stable post-operation, which slightly mitigates the high-stakes nature.


Medical Specialty: Surgery
Sample Name: Transurethral Resection Of Bladder Tumor

PREOPERATIVE DIAGNOSIS: , Bladder tumor.,POSTOPERATIVE DIAGNOSIS: , Bladder tumor.,PROCEDURE PERFORMED: , Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Bladder tumor and specimen from base of bladder tumor.,DRAINS: , A 22-French 3-way Foley catheter, 30 mL balloon.,ESTIMATED BLOOD LOSS:,  Minimal.,INDICATIONS FOR PROCEDURE: , This is a 74-year-old male who presented with microscopic and an episode of gross hematuria.  He underwent an IVP, which demonstrated enlarged prostate and normal upper tracts.  Cystoscopy in the office demonstrated a 2.5- to 3-cm left lateral wall bladder tumor.  He is brought to the operating room for transurethral resection of that bladder tumor.,DESCRIPTION OF OPERATION: , After preoperative counseling of the patient and his wife, the patient was taken to the operating room and administered a spinal anesthetic.  He was placed in lithotomy position and prepped and draped in the usual fashion.  Using the visual obturator, the resectoscope was then inserted per urethra into the bladder.  The bladder was inspected confirming previous cystoscopic findings of a 2.5- to 3-cm left lateral wall bladder tumor away from the ureteral orifice.  Using the resectoscope loop, the tumor was then resected down to its base in a stepwise fashion.  Following completion of resection down to the base, the bladder was _______ free of tumor specimen.  The resectoscope was then reinserted and the base of the bladder tumor was then resected to get the base of the bladder tumor specimen, this was sent as a separate pathological specimen.  Hemostasis was assured with electrocautery.  The base of the tumor was then fulgurated again and into the periphery out in the normal mucosa surrounding the base of the bladder tumor.  Following completion of the fulguration, there was good hemostasis.  The remainder of the bladder was without evidence of significant abnormality.  Both ureteral orifices were visualized and noted to drain freely of clear urine.  The bladder was filled and the resectoscope was removed.  A 22-French 3-way Foley catheter was inserted per urethra into the bladder.  The balloon was inflated to 30 mL.  The catheter with sterile continuous irrigation and was noted to drain clear irrigant.  The patient was then removed from lithotomy position.  He was in stable condition.
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DESCRIPTION: Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.

surgery, turbt, bladder tumor, cystoscopic, resectoscope, hemostasis, foley catheter, tumor, bladder, lithotomy, transurethral, resection, hematuria,

The scenario represents a surgical procedure for a medium-sized bladder tumor, which involves transurethral resection (TURBT). This type of surgery is significant, as it concerns the removal of a tumor, requiring anesthesia and subsequent pathological analysis of the sample. While the procedure is common in urology, it is still a surgical operation and has inherent risks, particularly for an elderly patient. Therefore, the stakes are relatively high as it involves significant health implications and potential complications for the patient. However, the procedure described seems routine for this condition, and the postoperative condition is stable.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Facial Twitching

REASON FOR REFERRAL: , Facial twitching.,HISTORY OF PRESENT ILLNESS: , The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face.  She reports she is still having right posterior head pressure like sensations approximately one time per week.  These still are characterized by a tingling, pressure like sensation that often has a feeling as though water is running down on her hair.  This has also decreased in frequency occurring approximately one time per week and seems to respond to over-the-counter analgesics such as Aleve.  Lastly during conversation today, she brought again the problem of daydreaming at work and noted that she occasionally falls asleep when sitting in non-stimulating environments or in front of the television.  She states that she feels fatigued all the time and does not get good sleep.  She describes it as insomnia, but upon questioning she works from 4 till mid night and then gets home and cannot go to sleep for approximately two hours and wakes up reliably by 9.00 a.m. each morning and sleeps no more than five to six hours ever, but usually five hours.  Her sleep is relatively uninterrupted except for the need to get up and go to the bathroom.  She thinks she may snore, but she is not sure.  She does not recall any events of awakening and gasping for breath.,PAST MEDICAL HISTORY: , Please see my earlier notes in chart.,FAMILY HISTORY:  ,Please see my earlier notes in chart.,SOCIAL HISTORY: , Please see my earlier notes in charts.,REVIEW OF SYSTEMS:  ,Today, she mainly endorses the tingling sensation in the right posterior head often bilateral as well as a diagnosis of depression and persistent somewhat sad mood, poor sleep, and possible snoring; otherwise, the 10-system review is negative.,PHYSICAL EXAMINATION:,General Examination:  Unremarkable mainly for mild-to-moderate obesity with a weight of 258 pounds.  Otherwise, general examination is unremarkable.,NEUROLOGICAL EXAMINATION:  ,As before is nonfocal.  Please see note in chart for details.,PERTINENT FINDINGS: , Since the last evaluation, she has had an MRI performed, which was largely unremarkable except for a 1.2 cm lobular T2 hyperintense abnormality at the right clivus and petrous carotid canal, which does not enhance.  The nature of this lesion is unclear.  Certainly, this abnormality would not explain her left facial twitching and is unlikely to be involved with the right posterior sensory changes she experiences.,LABS: , She was supposed to have Lyme titers and thyroid tests as well as fasting glucose, which were not done; however, in light of her improvement these may not need to be performed at this time.,IMPRESSION:,1.  Left facial twitching-appears to be improving.  Most likely, this is a peripheral nerve injury related to her abscess as previously described.  In light of her negative MRI and clinical improvement, we discussed options and elected to just observe for now.,2.  Posterior pressure like headache, also appears to be improving.  The etiology is unclear, but as it responds nicely to nonsteroidal antiinflammatories and is decreasing, no further evaluation is needed.,3.  Probable circadian sleep disorder related to her nighttime work schedule and awakening at 9.00 a.m. with insufficient sleep.  There is also the possibility of consistent obstructive sleep apnea and if symptoms worsen then we should consider doing a sleep study.  For the time being, sleep hygiene measures were discussed with the patient including trying to sleep later at least till 10.00 a.m. or 10.30 to get a full-night sleep.  She is on vacation next week and is going to try to see if this will help.  We also discussed as before weight loss and exercise, which could be helpful.,4.  Right clivus and petrous lesion of unknown etiology.  We will repeat the MRI at four months to see for interval change.,5.  The patient voiced understanding of these plans and will be following up with me in five months.
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DESCRIPTION: The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face.

consult - history and phy., grimacing, headache, clivus and petrous, facial twitching, sleep, facial, twitching,

The situation involves a patient's health with symptoms that are concerning but not immediately life-threatening. The conditions include facial twitching potentially due to a peripheral nerve injury, a headache responding to over-the-counter medication, a circadian sleep disorder likely due to work schedule, and an MRI finding of unclear significance. The plan is patient observation and follow-up. MRI findings require monitoring but don't present immediate danger, while other conditions appear manageable. Thus, the stakes are not extremely high.


Medical Specialty: Urology
Sample Name: Laser Vaporization of Prostate

PREOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,SURGERY:  ,Cystopyelogram and laser vaporization of the prostate.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is a 67-year-old male with a history of TURP, presented to us with urgency, frequency, and dribbling.  The patient was started on alpha-blockers with some help, but had nocturia q.1h.  The patient was given anticholinergics with minimal to no help.  The patient had a cystoscopy done, which showed enlargement of the left lateral lobes of the prostate.  At this point, options were discussed such as watchful waiting and laser vaporization to open up the prostate to get a better stream.  Continuation of alpha-blockers and adding another anti-cholinergic at night to prevent bladder overactivity were discussed.  The patient was told that his symptoms may be related to the mild-to-moderate trabeculation in the bladder, which can cause poor compliance.,The patient understood and wanted to proceed with laser vaporization to see if it would help improve his stream, which in turn might help improve emptying of the bladder and might help his overactivity of the bladder.  The patient was told that he may need anticholinergics.  There could be increased risk of incontinence, stricture, erectile dysfunction, other complications and the consent was obtained.,PROCEDURE IN DETAIL:  ,The patient was brought to the OR and anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was given preoperative antibiotics.  The patient was prepped and draped in the usual sterile fashion.  A #23-French scope was inserted inside the urethra into the bladder under direct vision.  Bilateral pyelograms were normal.  The rest of the bladder appeared normal except for some moderate trabeculations throughout the bladder.  There was enlargement of the lateral lobes of the prostate.  The old TUR scar was visualized right at the bladder neck.  Using diode side-firing fiber, the lateral lobes were taken down.  The verumontanum, the external sphincter, and the ureteral openings were all intact at the end of the procedure.  Pictures were taken and were shown to the family.  At the end of the procedure, there was good hemostasis.  A total of about 15 to 20 minutes of lasering time was used.  A #22 3-way catheter was placed.  At the end of the procedure, the patient was brought to recovery in stable condition.  Plan was for removal of the Foley catheter in 48 hours and continuation of use of anticholinergics at night.
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DESCRIPTION: Cystopyelogram and laser vaporization of the prostate.

urology, laser vaporization of the prostate, cystopyelogram, benign prostatic hypertroph, benign prostatic hypertrophy, alpha blockers, laser vaporization, anticholinergics, laser, vaporization, prostate, bladder

The situation described involves a surgical procedure for benign prostatic hypertrophy, specifically laser vaporization of the prostate. While this is a common procedure and generally considered safe, it still involves several risks such as incontinence, stricture, erectile dysfunction, and other complications. Given the patient's age and medical history, this procedure is significant but not life-threatening. Therefore, it is not considered extremely high-stakes compared to other more critical or life-endangering surgeries.


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

REASON FOR THE CONSULT: , Sepsis, possible SBP.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse, who presented in the emergency room on 01/07/09 for ground-level fall secondary to weak knees.  He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month.  He ran out of prescription medications 1 month ago.  In the ER he was initially afebrile, but then spiked up to 101.3 with heart rate of 130, respiratory rate of 24.  White blood cell count was slightly low at 4 and platelet count was only 22,000.  Abdominal ultrasound showed mild-to-moderate ascites.  He was given 1 dose of Zosyn and then started on levofloxacin and Flagyl last night.  Dr. X was called early this morning due to hypotension, SBP in the 70s.  He then changed antibiotic regiment to vancomycin and doripenem.,PAST MEDICAL HISTORY: , Hepatitis C, cirrhosis, coronary artery disease, hyperlipidemia, chronic venous stasis, gastroesophageal reflux disease, history of exploratory laparotomy for stab wounds, chronic recurrent leg wounds, and hepatic encephalopathy.,SOCIAL HISTORY: , The patient is a former smoker, reportedly quit in 2007.  He used cocaine in the past, reportedly quit in 2005.  He also has a history of alcohol abuse, but apparently quit more than 10 years ago.,ALLERGIES:,  None known.,CURRENT MEDICATIONS: , Vancomycin, doripenem, thiamine, Protonix, potassium chloride p.r.n., magnesium p.r.n., Zofran. p.r.n., norepinephrine drip, and vitamin K.,REVIEW OF SYSTEMS: , Not obtainable as the patient is drowsy and confused.,PHYSICAL EXAMINATION:,CONSTITUTIONAL/VITAL SIGNS:  Heart rate 101, respiratory rate 17, blood pressure 92/48, temperature 97.5, and oxygen saturation 98% on 2 L nasal cannula.,GENERAL APPEARANCE:  The patient is drowsy.  Morbidly obese.  Height 5 feet 8 inches, body weight 182 kilos.,EYES:  Slightly pale conjunctivae, icteric sclerae.  Pupils equal, brisk reaction to light.,EARS, NOSE, MOUTH AND THROAT:  Intact gross hearing.  Moist oral mucosa.  No oral lesions.,NECK:  No palpable neck masses.  Thyroid is not enlarged on inspection.,RESPIRATORY:  Regular inspiratory effort.  No crackles or wheezes.,CARDIOVASCULAR:  Regular cardiac rhythm.  No rales or rubs.  Positive bipedal edema, 2+, right worse than left.,GASTROINTESTINAL:  Globular abdomen.  Soft.  No guarding, no rigidity.  Tender on palpation of n right upper quadrant and epigastric area.  Mildly tender on palpation of right upper quadrant and epigastric area.,LYMPHATIC:  No cervical lymphadenopathy.,SKIN:  Positive diffuse jaundice.  No palpable subcutaneous nodules.,PSYCHIATRIC:  Poor judgment and insight.,LABORATORY DATA: , White blood cell count from 01/08/09 is 9 with 68% neutrophils, 20% bands, H&H 9.7/28.2, platelet count 24,000.  INR 3.84, PTT more than 240.  BUN and creatinine 26.8/1.2.  AST 76, ALT 27, alkaline phosphatase 48, total bilirubin 17.85.  Total CK 1198.6, LDH 873.2.  Troponin 0.09, myoglobin 2792.  Urinalysis from 01/07/09 shows small leucocyte esterase, positive nitrites, 1 to 3 wbc's, 0 to 1 rbc's, 2+ bacteria.  Two sets of blood cultures from 01/07/09 still pending.,RADIOLOGY:,  Chest x-ray from 01/07/09 did not show any pathologic abnormalities of the heart, mediastinum, lung fields, bony or soft tissue structures.  Left knee x-rays on 01/07/09 showed advanced osteoarthritis.  Abdominal ultrasound on 01/07/09 showed mild-to-moderate ascites, mild prominence of the gallbladder with thickened ball and pericholecystic fluid.  Preliminary report of CAT scan of the abdomen showed changes consistent to liver cirrhosis and portal hypertension with mild ascites, splenomegaly, and dilated portal/splenic and superior mesenteric vein.  Appendix was not clearly seen, but there was no evidence of pericecal inflammation.,IMPRESSION:,1.  Septic shock.,2.  Possible urinary tract infection.,3.  Ascites, rule out spontaneous bacterial peritenonitis.,4.  Hyperbilirubinemia, consider cholangitis.,5.  Alcoholic liver disease.,6.  Thrombocytopenia.,7.  Hepatitis C.,8.  Cryoglobulinemia.,RECOMMENDATIONS:,1.  Continue with vancomycin and doripenem at this point.,2.  Agree with paracentesis.,3.  Send ascitic fluid for cell count, differential and cultures.,4.  Follow up with result of blood cultures.,5.  We will get urine culture from the specimen on admission.,6.  The patient needs hepatitis A vaccination.,Additional ID recommendations as appropriate upon followup.
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DESCRIPTION: Sepsis, possible SBP.  A 53-year-old Hispanic man with diabetes, morbid obesity, hepatitis C, cirrhosis, history of alcohol and cocaine abuse presented in the emergency room for ground-level fall secondary to weak knees.  He complained of bilateral knee pain, but also had other symptoms including hematuria and epigastric pain for at least a month.

The patient is in septic shock, a life-threatening condition requiring immediate medical attention. This situation involves multiple complex health issues: sepsis, liver disease with ascites possibly due to spontaneous bacterial peritonitis, and other complications like thrombocytopenia and potential infections. The patient's vital signs, lab results, and existing medical history indicate a high risk of rapid deterioration. The involvement of specialized treatment such as antibiotics and medical consultation underscores the critical nature of this situation.


Medical Specialty: Surgery
Sample Name: Intramedullary Nail Fixation

TITLE OF OPERATION: , Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail, 10 x 390 with a one 5-mm proximal locking screw and three 5-mm distal locking screws (CPT code is 27759) (the ICD-9 code again is 823.2 for a tibial shaft fracture).,INDICATION FOR SURGERY:  ,The patient is a 19-year-old male, who sustained a gunshot wound to the left tibia with a distal tibial shaft fracture.  The patient was admitted and splinted and had compartment checks.  The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves, or vital structures, nonunion or malunion, need for reoperation, compartment syndrome, and the risk of anesthesia.  The patient understood these risks and wished to proceed.,PREOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,POSTOP DIAGNOSIS: , Left tibial shaft fracture status post gunshot wound (CPT code 27759).,ANESTHESIA: , General endotracheal.,INTRAVENOUS FLUID:,  900.,ESTIMATED BLOOD LOSS:  ,100.,COMPLICATIONS:,  None.,DISPOSITION: , Stable to PACU.,PROCEDURE DETAIL:  ,The patient was met in the preoperative holding area and operative site was marked.  The patient was brought to the operating room and given preoperative antibiotics.  Left leg was then prepped and draped in the usual sterile fashion.  A midline incision was made in the center of the knee and was carried down sharply to the retinacular tissue.  The starting guidewire was used to localize the correct starting point, which is on the medial aspect of the lateral tibial eminence.  This was advanced and confirmed on the AP and lateral fluoroscopic images.  The opening reamer was then used and the ball-tip guidewire was passed.  The reduction was obtained over a large radiolucent triangle.  After passing the guidewire and achieving appropriate reduction, the flexible reamers were then sequentially passed, starting at 9 mm up to 11.5 mm reamer.  At this point, a 10 x 390 mm was passed without difficulty.  The guide was used to the proximal locking screw and the appropriate circle technique was used to the distal locking screws.  The final images were taken with fluoroscopy and a 15-mm end-cap was placed.  The wounds were then irrigated and closed with 2-0 Vicryl followed by staples to the distal screws and 0 Vicryl followed 2-0 Vicryl and staples to the proximal incision.  The patient was placed in a short leg, well-padded splint, was awakened and taken to recovery in good condition.,The plan will be nonweightbearing left lower extremity.  He will be placed in a short leg splint and should be transitioned to a short leg cast for the next 4 weeks.
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DESCRIPTION: Intramedullary nail fixation of the left tibia fracture with a Stryker T2 tibial nail.  Left tibial shaft fracture status post gunshot wound.

surgery, screw, stryker, tibia, intramedullary nail fixation, tibial shaft fracture, intramedullary, guidewire, nail, fracture, tibial

Intramedullary nail fixation for a tibial fracture, particularly following a gunshot wound, is a significant surgical procedure. This is because it involves realigning and stabilizing the bone using a metal rod, addressing potential complications from the gunshot wound, and the inherent risks associated with surgery and anesthesia. Although the procedure was performed with no complications and the patient is stable post-operation, it is high-stakes due to the potential for serious complications such as infection, bleeding, nonunion, and compartment syndrome, all of which were discussed preoperatively. The surgery needs to be done accurately to ensure proper healing and function of the limb, making it a medically high-stakes situation.


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.,
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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: Surgery
Sample Name: Tonsillectomy and Septoplasty

PREOPERATIVE DIAGNOSIS:,  Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate.,POSTOPERATIVE DIAGNOSIS:,  Obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum.,OPERATION:,  Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty.,ANESTHESIA:,  General anesthetics.,HISTORY: , This is a 51-year-old gentleman here with his wife.  She confirms the history of loud snoring at night with witnessed apnea.  The result of the sleep study was reviewed.  This showed moderate sleep apnea with significant desaturation.  The patient was unable to tolerate treatment with CPAP.  At the office, we observed large tonsils and elongation and thickening of the uvula as well as redundant soft tissue of the palate.  A tortuous appearance of the septum also was observed.  This morning, I talked to the patient and his wife about the findings.  I reviewed the CT images.  He has no history of sinus infections and does not recall a history of nasal trauma.  We discussed the removal of tonsils and uvula and soft palate tissue and the hope that this would help with his airway.  Depending on the findings of surgery, I explained that I might remove that bone spur that we are seeing within the nasal passage.  I will get the best look at it when he is asleep.  We discussed recovery as well.  He visited with Dr. XYZ about the anesthetic produce.,PROCEDURE:,:  General tracheal anesthetic was administered by Dr. XYZ and Mr. Radke.  Afrin drops were placed in both nostrils and a cottonoid soaked with Afrin was placed in each side of the nose.  A Crowe-Davis mouth gag was placed.  The tonsils were very large and touched the uvula.  The uvula was relatively long and very thick and there were redundant folds of soft palate mucosa and prominent posterior and anterior tonsillar pillars.  Also, there was a cryptic appearance of the tonsils but there was no acute redness or exudate.  Retraction of the soft palate permitted evaluation of the nasopharynx with the mirror and the choanae were patent and there was no adenoid tissue present.  A very crowded pharynx was appreciated.  The tonsils were first removed using electrodissection technique.  Hemostasis was achieved with the electrocautery and with sutures of 0 plain catgut.  The tonsil fossae were injected with 0.25% Marcaine with 1:200,000 epinephrine.  There already was more room in the pharynx, but the posterior pharyngeal wall was still obscured by the soft palate and uvula.  The uvula was grasped with the Alice clamp.  I palpated the posterior edge of the hard palate and calculated removal of about a third of the length of the soft palate.  We switched over from the Bayonet cautery to the blunt needle tip electrocautery.  The planned anterior soft palate incision was marked out with the electrocautery from the left anterior tonsillar pillar rising upwards and then extending horizontally across the soft palate to include all of the uvula and a portion of the soft palate, and the incision then extended across the midline and then inferiorly to meet the right anterior tonsillar pillar.  This incision was then deepened with the electrocautery on a cutting current.  The uvular artery just to the right of the midline was controlled with the suction electrocautery.  The posterior soft palate incision was made parallel to the anterior soft palate incision but was made leaving a longer length of mucosa to permit closure of the palatoplasty.  A portion of the redundant soft palate mucosa tissue also was included with the resection specimen and the tissue including the soft palate and uvula was included with the surgical specimen as the tonsils were sent to pathology.  The tonsil fossae were injected with 0.25% Marcaine with 1:200,000 epinephrine.  The soft palate was also injected with 0.25% Marcaine with 1:200,000 epinephrine.  The posterior tonsillar pillars were then brought forward to close to the anterior tonsillar pillars and these were sutured down to the tonsil bed with interrupted 0 plain catgut sutures.  The posterior soft palate mucosa was advanced forward and brought up to the anterior soft palate incision and closure of the soft palate wound was then accomplished with interrupted 3-0 chromic catgut sutures.  A much improved appearance of the oropharynx with a greatly improved airway was appreciated.  A moist tonsil sponge was placed into the nasopharynx and the mouth gag was removed.  I removed the cottonoids from both nostrils.  Speculum exam showed the inferior turbinates were large, the septum was tortuous and it angulated to the right and then sharply bent back to the left.  The septum was injected with 0.25% Marcaine with 1:200,000 epinephrine using a separate syringe and needle.  A #15 blade was used to make a left cheilion incision.,Mucoperichondrium and mucoperiosteum were elevated with the Cottle elevator.  When we reached the deflected portion of the vomer, this was separated from the septal cartilage with a Freer elevator.  The right-sided mucoperiosteum was elevated with the Freer elevator and then with Takahashi forceps and with the 4 mm osteotome, the deflected portion of the septal bone from the vomer was resected.  This tissue also was sent as a separate specimen to pathology.  The intraseptal space was irrigated with saline and suctioned.  The nasal septal mucosal flaps were then sutured together with a quilting suture of 4-0 plain catgut.  I observed no evidence of purulent secretion or polyp formation within the nostrils.  The inferior turbinates were then both outfractured using a knife handle, and now there was a much more patent nasal airway on both sides.  There was good support for the nasal tip and the dorsum and there was good hemostasis within the nose.  No packing was used in the nostrils.  Polysporin ointment was introduced into both nostrils.  The mouth gag was reintroduced and the pack removed from the nasopharynx.  The nose and throat were irrigated with saline and suctioned.  An orogastric tube was placed and a moderate amount of clear fluid suctioned from the stomach and this tube was removed.  Sponge and needle count were reported correct.  The mouth gag having been withdrawn, the patient was then awakened and returned to recovery room in a satisfactory condition.  He tolerated the operation excellently.  Estimated blood loss was about 15-20 cc.  In the recovery room, I observed that he was moving air well and I spoke with his wife about the findings of surgery.
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DESCRIPTION: Tonsillectomy, uvulopalatopharyngoplasty, and septoplasty for obstructive sleep apnea syndrome with hypertrophy of tonsils and of uvula and soft palate with deviation of nasal septum

surgery, obstructive sleep apnea syndrome, afrin drops, bayonet cautery, cpap, cottle elevator, crowe-davis, freer elevator, obstructive sleep apnea, tonsillectomy, hypertrophy, mouth gag, nasal, nasal passage, nasal septum, nasopharynx, nostrils, palate, pharynx, septal cartilage, septoplasty, sleep apnea, soft palate, tonsils, uvula, uvulopalatopharyngoplasty, hypertrophy of tonsils, anterior tonsillar pillars, soft palate incision, palate incision, tonsillar pillars, incision

The surgery described involves multiple procedures: tonsillectomy, uvulopalatopharyngoplasty, and septoplasty, which are performed to treat obstructive sleep apnea. These procedures, while commonly performed and generally considered low-risk, carry the inherent risks associated with surgeries requiring general anesthesia, such as infection, bleeding, and adverse reactions to anesthesia. The surgery is intended to address a significant health issue (sleep apnea) that affects the patient's quality of life and health, but the procedures themselves are routine with relatively low complication rates. Given these considerations, the situation involves a moderate level of stakes due to the medical intervention's complexity and the necessity of resolving the underlying condition.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych Consult - Depression - 2

REASON FOR CONSULT:,  Depression.,HPI:,  The patient is an 87-year-old white female admitted for low back pain status post hip fracture sustained a few days before Thanksgiving in 2006.  The patient was diagnosed and treated for a T9 compression fraction with vertebroplasty.  Soon after discharge, the patient was readmitted with severe mid low back pain and found to have a T8 compression fracture.  This was also treated with vertebroplasty.  The patient is now complaining of back pain that fluctuates at time, acknowledging her pain medication works but not all the time.  Her pain is in her upper back around her shoulder blades.  The patient says lying down with the heated pad lessens the pain and that any physical activity increases it.  MRI on January 29, 2007, was positive for possible meningioma to the left of anterior box.,The patient reports of many depressive symptoms, has lost all interest in things she used to do (playing cards, reading).  Has no energy to do things she likes, but does participate in physical therapy, cries often and what she believes for no reason.  Does not see any future for herself.  Reports not being able to concentrate on anything saying she gets distracted by thoughts of how she does not want to live anymore.  Admits to decreased appetite, feeling depressed, and always wanting to be alone.  Claims that before her initial hospitalization for her hip fracture, she was highly active, enjoyed living independently at Terrace.  Denies suicidal ideations and homicidal ideations, but that she did not mind dying, and denies any manic symptoms including decreased need to sleep, inflated self-worth, and impulsivity.  Denies auditory and visual hallucinations.  No paranoid, delusions, or other abnormalities of thought content.  Denies panic attacks, flashbacks, and other feelings of anxiety.  Does admit to feeling restless at times.  Is concerned with her physical appearance while in the hospital, i.e., her hair looking "awful.",PAST MEDICAL HISTORY:,  Hypertension, cataracts, hysterectomy, MI, osteoporosis, right total knee replacement in April 2004, hip fracture, and newly diagnosed diabetes.  No history of thyroid problems, seizures, strokes, or head injuries.,CURRENT MEDICATIONS:,  Norvasc 10 mg p.o. daily, aspirin 81 mg p.o. daily, Lipitor 20 mg p.o. daily, Klonopin 0.5 mg p.o. b.i.d., digoxin 0.125 mg p.o. daily, Lexapro 10 mg p.o. daily, TriCor 145 mg p.o. each bedtime, Lasix 20 mg p.o. daily, Ismo 20 mg p.o. daily, lidocaine patch, Zestril, Prinivil 40 mg p.o. daily, Lopressor 75 mg p.o. b.i.d., Starlix 120 mg p.o. t.i.d., Pamelor 25 mg p.o. each bedtime, polyethylene glycol 17 g p.o. every other day, potassium chloride 20 mEq p.o. t.i.d., Norco one tablet p.o. q.4h. p.r.n., Zofran 4 mg IV q.6h.,HOME MEDICATIONS:,  Unknown.,ALLERGIES:,  CODEINE (HALLUCINATIONS).,FAMILY MEDICAL HISTORY:,  Unremarkable.,PAST PSYCHIATRIC HISTORY:,  Unremarkable.  Never taken any psychiatric medications or have ever had a family member with psychiatric illness.,SOCIAL/DEVELOPMENTAL HISTORY:,  Unremarkable childhood.  Married for 40 plus years, widowed in 1981.  Worked as administrative assistant in UTMB Hospitals VP's office.  Two children.  Before admission, lived in the Terrace Independent Living Center.  Was happy and very active while living there.  Had friends in the Terrace and would not mind going back there after discharge.  Occasional glass of wine at dinner.  Denies ever using illicit drugs and tobacco.,MENTAL STATUS EXAM:,  The patient is an 87-year-old white female with appropriate appearance, wearing street clothes while lying in bed with her eyes tightly closed.  Slight decrease in motor activity.  Normal eye contact.  Speech, low volume and rate.  Good articulation and inflexion.  Normal concentration.  Mood, labile, tearful at times, depressed, then euthymic.  Affect, mood congruent, full range.  Thought process, logical and goal directed.  Thought content, no delusions, suicidal or homicidal ideations.  Perception, no auditory or visual hallucinations.  Sensorium, alert, and oriented x3.  Memory, fair.  Information and intelligence, average.  Judgment and insight, fair.,MINI MENTAL STATUS EXAM,:  A 28/30.  Could not remember two out of the three recalled words.,ASSESSMENT:,  The patient is an 87-year-old white female with recent history of hip fracture and two thoracic compression fractures.  The patient reports being high functioning prior to admission and says her depression symptoms have occurred while being in the hospital.,Axis I:  Major depression disorder.,Axis II:  Deferred.,Axis III:  Osteoporosis, hypertension, hip fracture, possible diabetes, meningioma, MI, and right total knee replacement.,Axis IV:  Lives independently at Terrace, difficulty walking, hospitalization.,Axis V:  45.,PLAN:,  Continue Lexapro 10 mg daily and Pamelor 25 mg each bedtime monitor for adverse effects of TCA and worsening of depressive symptoms.  Discussed about possible inpatient psychiatric care.,Thank you for the consultation.
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DESCRIPTION: Psychiatric Consultation of patient with major depression disorder.

The situation involves an 87-year-old patient with significant depressive symptoms but denies suicidal ideation. The main concerns are major depression following physical health issues, and some consideration for inpatient psychiatric care. While the patient's situation could potentially worsen, the current denial of suicidal ideation indicates it's not at the highest level of immediate risk. The stakes are moderate-high due to the patient's age, multiple medical comorbidities, and potential for deterioration.


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

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

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

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


Medical Specialty: Nephrology
Sample Name: CT-Guided Biopsy - Kidney

REASON FOR EXAM:  This 60-year-old female who was found to have a solid indeterminate mass involving the inferior pole of the right kidney was referred for percutaneous biopsy under CT guidance at the request of Dr. X.,PROCEDURE:  The procedure risks and possible complications including, but not limited to severe hemorrhage which could result in emergent surgery, were explained to the patient.  The patient understood.  All questions were answered, and informed consent was obtained.  With the patient in the prone position, noncontrasted CT localization images were obtained through the kidney.  Conscious sedation was utilized with the patient being monitored.  The patient was administered divided dose of Versed and fentanyl intravenously.,Following sterile preparation and local anesthesia to the posterior aspect of the right flank, an 18-gauge co-axial Temno-type needle was directed into the inferior pole right renal mass from the posterior oblique approach.  Two biopsy specimens were obtained and placed in 10% formalin solution.  CT documented needle placement.  Following the biopsy, there was active bleeding through the stylet, as well as a small hematoma about the inferior aspect of the right kidney posteriorly.  I placed several torpedo pledgets of Gelfoam through the co-axial sheath into the site of bleeding.  The bleeding stopped.  The co-axial sheath was then removed.  Bandage was applied.  Hemostasis was obtained.  The patient was placed in the supine position.  Postbiopsy CT images were then obtained.  The patient's hematoma appeared stable.  The patient was without complaints of pain or discomfort.  The patient was then sent to her room with plans of observing for approximately 4 hours and then to be discharged, as stable.  The patient was instructed to remain at bedrest for the remaining portions of the day at home and patient is to followup with Dr. Fieldstone for the results and follow-up care.,FINDINGS:  Initial noncontrasted CT localization images reveals the presence of an approximately 2.1 cm cortical mass involving the posterior aspect of the inferior pole of the right kidney.  Images obtained during the biopsy reveals the cutting portion of the biopsy needle to extend through the mass.  Images obtained following the biopsy reveals the development of a small hematoma posterior to the right kidney in its inferior pole adjacent to the mass.  There are small droplets of air within the hematoma.  No hydronephrosis is identified.,CONCLUSION:,1.  Percutaneous biopsy of inferior pole right renal mass under computed tomography guidance with specimen sent to laboratory in 10% formalin solution.,2.  Development of a small hematoma adjacent to the inferior pole of the right kidney with active bleeding through the biopsy needle stopped by tract embolization with Gelfoam pledgets.
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DESCRIPTION: CT-guided needle placement, CT-guided biopsy of right renal mass, and embolization of biopsy tract with gelfoam.

nephrology, embolization, ct localization, gelfoam pledgets, ct guided needle placement, ct guided biopsy, needle placement, renal mass, ct guided, inferior pole, ct, biopsy, hematoma, kidney, mass,

The situation involves an invasive medical procedure, a CT-guided kidney biopsy, which inherently carries risks including severe hemorrhage that could potentially require emergent surgery. Though the immediate situation was handled effectively with the use of Gelfoam to stop the bleeding, the potential for serious complications still exists, indicating high stakes. The patient’s response post-procedure was stable, which reduced the severity of the immediate stakes, but the procedure itself remains high risk by nature.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Chronic Otitis Media

CHIEF COMPLAINT:,  Chronic otitis media.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth.  There is also associated chronic nasal congestion.  There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection.  He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia.,ALLERGIES:,  None.,MEDICATIONS:,  None.,FAMILY HISTORY:,  Noncontributory.,MEDICAL HISTORY: , Mild reflux.,PREVIOUS SURGERIES:,  None.,SOCIAL HISTORY: , The patient is not in daycare.  There are no pets in the home.  There is no secondhand tobacco exposure.,PHYSICAL EXAMINATION: , Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present.  Left ear is still little bit black.  Nose, moderate inferior turbinate hypertrophy.  No polyps or purulence.  Oral cavity, oropharynx 2+ tonsils.  No exudates.  Neck, no nodes, masses or thyromegaly.  Lungs are clear to A&P.  Cardiac exam, regular rate and rhythm.  No murmurs.  Abdomen is soft and nontender.  Positive bowel sounds.,IMPRESSION: , Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation.,PLAN:,  The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia.
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DESCRIPTION: A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth.

consult - history and phy., chronic nasal congestion, tympanic membrane perforation, chronic otitis media, tube insertion, facemask anesthesia, otitis media, otitis, media,

The situation involves a medical procedure (myringotomy and tube insertion) for a 14-month-old with chronic otitis media. While this type of procedure is common and generally safe, any surgical procedure, especially under general anesthesia for a small child, can carry certain risks and anxiety for parents. The stakes are higher than a routine check-up but not extremely high given the standard nature of the procedure and the absence of severe complications in the patient's history.


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

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

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

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