Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 9

DISCHARGE DIAGNOSIS:,1.  Epigastric pain.  Questionable gastritis, questionable underlying myocardial ischemia.,2.  Congestive heart failure exacerbation.,3.  Small pericardial effusion with no tamponade.,4.  Hypothyroidism.,5.  Questionable subacute infarct versus neoplasm in the pons.,6.  History of coronary artery disease, status post angioplasty and stent.,7.  Hypokalemia.,CLINICAL RESUME: , This 83 year-old woman who presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months.  She has had extensive work up and had her gallbladder removed on April 22, 2007, and had an endoscopy, which had demonstrative gastric ulcer disease apparently about a year ago.  She has had abdominal CAT scan and gastric emptying studies which was normal.,A CT scan of the abdomen done on her May 9, 2007, which showed bilateral peripelvic renal cysts and a redundant sigmoid colon.  Otherwise unremarkable.  The patient follows with Dr. XYZ as an outpatient.  The patient had some worsening of her symptoms over the last few days and then came to the ER.  She was admitted.  Please refer to Dr. XYZ initial H&P for complete details.,HOSPITAL COURSE:,1.  Epigastric pain, nausea, and vomiting.  The patient was restituted with antiemetics and her symptoms improved.  It was not clear whether her nausea and abdominal pain were due to gastritis, peptic ulcer disease/gastric ischemia, or cardiac origin.  A brain MRI was also done which basically showed a tiny focus of abnormal enhancement in the pons, which could be subacute like infarct.  However, brain neoplasm could not be excluded.  Other workup including a CT angio did not show any evidence of acute pulmonary emboli.  It showed some moderate cardiomegaly with bilateral pleural effusions, and a small pericardial effusion.  The patient underwent Cardiolite stress test but finished only the resting studies, which was inconclusive.  She refused to complete the stress test.  She was seen by Dr. XYZ in consultation who recommended that the patient should have a small bowel follow through and eventually angiogram as an outpatient.,2.  Congestive heart failure exacerbation.  The patient was treated with ACE inhibitors, diuretics, Aldactone, and Lasix, and improved.  An echocardiogram done showed an ejection fraction of about 30% to 35%, mild water decrease in LV systolic function, with multiple segmental wall motion abnormalities, a small anterior pericardial effusion, but no electrocardiographic signs of cardiac tamponade.  There was some pseudo normal pattern of filling, mild MR and global hypokinesis of the LV.,3.  Small pericardial effusion.  The patient did not have any clinical or echocardiographic evidence of tamponade.,4.  Hypothyroidism.  TSH was quite elevated at 19.,5.  Questionable subacute infarct versus neoplasm in the pons on an MRI of the head.,6.  History of coronary artery disease/angioplasty and stents.,7.  Hyperkalemia.,8.  Patient was doing well.  She was back to her baseline and was refusing further workup and the patient was stable and it was felt she could be safely discharged home to have further testing done as an outpatient.,MEDICATIONS AND ADVICE ON DISCHARGE:,1.  She is to continue taking Coreg 12.5 mg p.o. b.i.d.,2.  Cozaar 50 mg p.o. daily.,3.  Aldactone 25 mg p.o. daily.,4.  Synthroid 0.075 mg p.o. daily.,5.  Carafate 1 gram p.o.  4 times a day.,6.  Claritin 10 mg p.o. daily.,7.  Lasix 20 mg p.o. daily.,8.  K-Dur 20 mEq p.o. daily.,9.  Prilosec 40 mg p.o. daily.,10.  Zofran 4 mg p.o. q.4-6 hourly p.r.n.,She is to follow up with her primary care physician, Dr. XYZ in 2 to 3 days' time.  She is to follow up with Dr. XYZ her cardiologist in 1 to 2 days' time.  She is to follow up with Dr. XYZ from GI as scheduled.  The patient was advised that she will need a small bowel follow through with angiogram which can be arranged by her gastroenterologist as an outpatient.  She was also advised that she would need a repeat MRI of her head in 2 to 3 months' time.  She will also need repeat echocardiogram done in one month for a pericardial effusion.  This can be arranged by her primary care physician.  Repeat TSH to be done in 6 weeks' time.,Over 35 minutes were spent in the patient discharged.
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DESCRIPTION: A woman presented to the ER with complaints of nausea, vomiting, and epigastric discomfort, ongoing for about 4 to 5 months.

The discharge summary indicates a complex medical case involving multiple diagnoses, including congestive heart failure exacerbation, potential myocardial ischemia, hypothyroidism, and a potential subacute brain infarct or neoplasm. While the patient is stable at discharge, the presence of significant medical conditions underlines potential high-stakes scenarios if not adequately monitored or managed. Proper follow-up care and testing are crucial, indicating that this case is moderately high-stakes, given the patient's age and the complexity of the conditions.


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Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 13

ADMITTING DIAGNOSES:,1.  Bradycardia.,2.  Dizziness.,3.  Diabetes.,4.  Hypertension.,5.  Abdominal pain.,DISCHARGE DIAGNOSIS:,  Sick sinus syndrome.  The rest of her past medical history remained the same.,PROCEDURES DONE: , Permanent pacemaker placement after temporary internal pacemaker.,HOSPITAL COURSE: , The patient was admitted to the intensive care unit.  Dr. X was consulted.  A temporary intracardiac pacemaker was placed.  Consultation was requested to Dr. Y. He considered the need to have a permanent pacemaker after reviewing electrocardiograms and telemetry readings.  The patient remained in sinus rhythm with severe bradycardias, but all of them one to one transmission.  This was considered to be a sick sinus syndrome.  Permanent pacemaker was placed on 09/05/2007 with right atrium appendage and right ventricular apex electrode placement.  This is a Medtronic pacemaker.  After this, the patient remained with pain in the left side of the chest in the upper area as expected, but well controlled.  Right femoral artery catheter was removed.  The patient remained with good pulses in the right lower extremity with no hematoma.  Other problem was the patient's blood pressure, which on 09/05/2007 was found at 180/90.  Medication was adjusted to benazepril 20 mg a day.  Norvasc 5 mg was added as well.  Her blood pressure has remained better, being today 144/74 and 129/76.,FINAL DIAGNOSES:  ,Sick sinus syndrome.  The rest of her past medical history remained without change, which are:,1.  Diabetes mellitus.,2.  History of peptic ulcer disease.,3.  Hypertension.,4.  Insomnia.,5.  Osteoarthritis.,PLAN: , The patient is discharged home to continue her previous home medications, which are:,1.  Actos 45 mg a day.,2.  Bisacodyl 10 mg p.o. daily p.r.n. constipation.,3.  Cosopt eye drops, 1 drop in each eye 2 times a day.,4.  Famotidine 20 mg 1 tablet p.o. b.i.d.,5.  Lotemax 0.5% eye drops, 1 drop in each eye 4 times a day.,6.  Lotensin (benazepril) increased to 20 mg a day.,7.  Triazolam 0.125 mg p.o. at bedtime.,8.  Milk of Magnesia suspension 30 mL daily for constipation.,9.  Tylenol No.  3, one to two tablets every 6 hours p.r.n. pain.,10.  Promethazine 25 mg IM every 6 hours p.r.n. nausea or vomiting.,11.  Tylenol 325 mg tablets every 4 to 6 hours as needed for pain.,12.  The patient will finish cefazolin 1 g IV every 6 hours, total 5 dosages after pacemaker placement.,DISCHARGE INSTRUCTIONS: , Follow up in the office in 10 days for staple removal.  Resume home activities as tolerated with no starch, sugar-free diet.
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DESCRIPTION: Bradycardia, dizziness, diabetes, hypertension, abdominal pain, and sick sinus syndrome.

The situation involves a patient who was admitted with several medical issues, notably bradycardia and sick sinus syndrome, requiring a pacemaker placement. These are serious medical conditions that necessitated intensive care and surgical intervention. The discharge summary indicates that the patient's condition was managed effectively, and they are being discharged with follow-up plans and medication adjustments in place. However, the potential for complications and the critical nature of the conditions make this a high-stakes medical situation, as it involves life-sustaining procedures and chronic condition management.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Discharge Summary
Sample Name: Death Summary - 2

FINAL DIAGNOSES:,1.  Cardiac arrest.,2.  Severe congestive heart failure.,3.  Acute on chronic respiratory failure.,4.  Osteoporosis.,5.  Depression.,HISTORY OF PRESENT ILLNESS: , This 92-year-old lady with history of depression and chronic low back pain, osteoporosis, and congestive heart failure, was diagnosed having pneumonia approximately for at least 10 days prior to admission.  In the ER, she was given oral antibiotics.  She also saw me few days before admission coming for a followup.  She was doing fairly well.  She was thought to have congestive heart failure and she was advised to continue with her diuretics.  For the last few days, the patient started to have anorexia, she did not eat well, and she did not drink well.  Her family could not take care of her.  So, she was brought to the emergency room, where she was found to have rapid heart rate with a sinus tachycardia around 112 to 130s.  The ________ was found to be dry.  She was given 1 L of IV fluids and she was subsequently admitted in the hospital for further management.,COURSE IN THE HOSPITAL: , The patient stayed in the telemetry.  The patient had significant shortness of breath secondary to congestive heart failure with bilateral basilar crackles.  She was continued on IV antibiotics and general IV hydration was started initially because of low blood pressure and low perfusion status.  On subsequently improved and stopped and Lasix was started; Dr. X, cardiologist was also placed.  The patient's family wanted her to be a DNR and DNI.  They were allowing us to treat her aggressively medically for pneumonia and congestive heart failure.  However, the patient became extremely weak, mostly unresponsive.  At this time, the patient's family wanted a Hospice consult, which was requested.  By the time the Hospice could evaluate her, the patient's condition got deteriorated, she went into more bradycardiac and hypertension and subsequently expired.  Please see the hospital notes for complete details.
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DESCRIPTION: Cardiac arrest, severe congestive heart failure, acute on chronic respiratory failure, osteoporosis, and depression.

discharge summary, bradycardiac, hypertension, hospice, congestive heart failure, cardiac arrest, respiratory failure,

The situation involves the death summary of a patient and the associated medical conditions and treatments leading up to the cardiac arrest and eventual death. This is inherently a high-stakes situation because it involves end-of-life care, sensitive communication with the family, decision-making around 'Do Not Resuscitate' (DNR) orders, and hospice care arrangements. These aspects require careful consideration of ethical, medical, and familial concerns, which are critical in the context of medical practice.


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

DISCHARGE DIAGNOSES:,1.  Advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.,2.  Respiratory failure secondary to above.,3.  Likely postobstructive pneumonia.,4.  Gastrointestinal bleed.,5.  Thrombocytopenia.,6.  Acute renal failure.,7.  Hyponatremia.,8.  Hypercalcemia, likely secondary to paraneoplastic syndrome from the non-small cell lung CA, possible metastases to the bones.,9.  Leukemoid reaction, likely secondary to malignancy.,10.  Elevated liver function tests.,HOSPITAL COURSE:,  This is a 53-year-old African American male patient of Dr. X who was admitted through the emergency room.  He has been having some right hip pain and cough.  The patient had a CT scan of the chest, which revealed a left pleural effusion, extensive mediastinal mass, left hilar adenopathy, causing complete obstruction of the left lower lobe and the lingula and the left pulmonary vein, and the multiple nodules on the right side of his chest.  These were all consistent with metastatic disease.  He was thus also a suspicion for osseous metastatic disease involving the right scapula with a left large pleural effusion.  The patient had severe shortness of breath, chest pain, a left-sided chest tube was inserted, and pleural effusion was positive for malignant cells.  The history of right hip pain could be secondary to metastatic disease.  The patient underwent bronchoscopy, which is positive for non-small cell lung CA.  The patient was seen by various consultants.  The patient underwent respiratory failure, requiring intubation, mechanical ventilatory support.  He was extubated, but had to be re-intubated because of respiratory failure.  Had a long discussion with the patient's wife and other family members.  The patient was seen by Dr. Y.  The patient was not in a condition to undergo any kind of chemotherapy, being on the ventilator.  The patient progressively got deteriorated.  The patient's family requested for DNR, withdrawal of the life support.  The patient was extubated, and he was pronounced expired on 08/21/08 at 01:40 hours.,I appreciate all consultants' input.
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DESCRIPTION: Death summary of patient with advanced non-small cell lung carcinoma with left malignant pleural effusion status post chest tube insertion status post chemical pleurodesis.

discharge summary, dnr, pronounced expired, extubated, death summary, lung carcinoma, pleural effusion,

The situation involves a summary of a patient's death due to advanced non-small cell lung carcinoma with several complications, including respiratory failure and other severe medical conditions. The document details the critical care process, family discussions regarding end-of-life decisions, and the eventual decision to withdraw life support. It is high-stakes because it pertains to a patient's end-of-life care, which involves critical decision-making by healthcare professionals and the patient's family.


Medical Specialty: Discharge Summary
Sample Name: CVA - Discharge Summary

DIAGNOSES ON ADMISSION,1.  Cerebrovascular accident (CVA) with right arm weakness.,2.  Bronchitis.,3.  Atherosclerotic cardiovascular disease.,4.  Hyperlipidemia.,5.  Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1.  Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2.  Old coronary infarct, anterior aspect of the right external capsule.,3.  Acute bronchitis with reactive airway disease.,4.  Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5.  Atherosclerotic cardiovascular disease.,6.  Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room.  Plavix was started  in addition to baby aspirin.  He was kept on oral Zithromax for his cough.  He was given Xopenex treatment, because of his respiratory distress.  Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid.  Dr. X saw him in consultation and recommended CT angiogram.  This showed no significant obstructive lesion other than what was known on the ultrasound.  Head MRI was done and revealed the above findings.  The patient was begun on PT and improved.  By discharge, he had much improved strength in his right arm.  He had no further progressions.  His cough improved with oral Zithromax and nebulizer treatments.  His platelets also improved as well.  By discharge, his platelets was up to 107,000.  His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential.  Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate.  Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1.  PT/INR on admission was 1.03, PTT 34.7.  At the time of discharge, the patient's cough was much improved.  His right arm weakness has much improved.  His lung examination has just occasional rhonchi.  He was changed to a metered dose inhaler with albuterol.  He is being discharged home.  An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation.  He will follow up in my office in 1 week.  He is to start PT and OT as an outpatient.  He is to avoid driving his car.  He is to notify, if further symptoms.  He has 2 more doses of Zithromax at home, he will complete.  His prognosis is good.
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DESCRIPTION: Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.  2.  Old coronary infarct, anterior aspect of the right external capsule.  Acute bronchitis with reactive airway disease.

discharge summary, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident

The situation involves a patient being discharged after a cerebrovascular accident (CVA), commonly known as a stroke, alongside several other significant health issues. Strokes are high-stakes medical events due to their potential to cause long-term disability and complications. The discharge summary indicates that the patient showed improvement during their hospital stay, but the complexity and potential severity of the conditions, such as thrombocytopenia, bronchitis, and cardiovascular disease, make the overall scenario high-stakes. The need for follow-up care, medication adherence, and physical therapy further highlights the importance of ongoing management to prevent deterioration or recurrence of acute events.


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

DISCHARGE DIAGNOSES:,1. Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe.,2. Hypertension.,3. Urinary tract infection.,4. Hypercholesterolemia.,PROCEDURES:,1. On 3/26/2006, portable chest, single view. Impression: atherosclerotic change in the aortic knob.,2. On 3/26/2006, chest, portable, single view. Impression: Mild tortuosity of the thoracic aorta, maybe secondary to hypertension; right lateral costophrenic angle is not evaluated due to positioning of the patient.,3. On March 27, 2006, swallowing study: Normal swallowing study with minimal penetration with thin liquids.,4. On March 26, 2006, head CT without contrast: 1) Air-fluid level in the right maxillary sinus suggestive of acute sinusitis; 2) A 1.8-cm oval, low density mass in the dependent portion of the left maxillary sinus is consistent with a retention cyst; 3) Mucoparietal cell thickening in the right maxillary sinus and ethmoid sinuses.,4. IV contrast CT scan of the head is unremarkable.,5. On 3/26/2006, MRI/MRA of the neck and brain, with and without contrast: 1) Changes consistent with an infarct involving the right basal ganglia and deep white matter of the left parietal lobe, as described above; 2) Diffuse smooth narrowing of the left middle cerebral artery that may be a congenital abnormality. Clinical correlation is necessary.,6. On March 27th, echocardiogram with bubble study. Impression: Normal left ventricular systolic function with estimated left ventricular ejection fraction of 55%. There is mild concentric left ventricular hypertrophy. The left atrial size is normal with a negative bubble study.,7. On March 27, 2006, carotid duplex ultrasound showed: 1) Grade 1 carotid stenosis on the right; 2) No evidence of carotid stenosis on the left.,HISTORY AND PHYSICAL: ,This is a 56-year-old white male with a history of hypertension for 15 years, untreated. The patient woke up at 7: 15 a.m. on March 26 with the sudden onset of right-sided weakness of his arm, hand, leg and foot and also with a right facial droop, right hand numbness on the dorsal side, left face numbness and slurred speech. The patient was brought by EMS to emergency room. The patient was normal before he went to bed the prior night. He was given aspirin in the ER. The CT of the brain without contrast did not show any changes. He could not have a CT with contrast because the machine was broken. He went ahead and had the MRI/MRA of the brain and neck, which showed infarct involving the right basal ganglia and deep white matter of the left parietal lobe. Also, there is diffuse smooth narrowing of the left middle cerebral artery.,The patient was admitted to the MICU.,HOSPITAL COURSE PER PROBLEM LIST:,1. Acute cerebrovascular accident: The patient was not a candidate for tissue plasminogen activator. A neurology consult was obtained from Dr. S. She agrees with our treatment for this patient. The patient was on aspirin 325 mg and also on Zocor 20 mg once a day. We also ordered fasting blood lipids, which showed cholesterol of 165, triglycerides 180, HDL cholesterol 22, LDL cholesterol 107. Dr. Farber agreed to treat the risk factors, to not treat blood pressure for the first two weeks of the stroke. We put the patient on p.r.n. labetalol only for systolic blood pressure greater than 200, diastolic blood pressure greater than 120. The patient's blood pressure has been stable and he did not need any blood pressure medications. His right leg kept improving with increased muscle strength and it was 4-5/5, however, his right upper extremity did not improve much and was 0-1/5. His slurred speech has been improved a little bit. The patient started PT, OT and speech therapy on the second day of hospitalization. The patient was transferred out to a regular floor on the same day of admission based on his stable neurologic exam. Also, we added Aggrenox for secondary stroke prevention, suggested by Dr. F. Echocardiogram was ordered and showed normal left ventricular function with bubble study that was negative. Carotid ultrasound only showed mild stenosis on the right side. EKG did not show any changes, so the patient will be transferred to Siskin Rehabilitation Hospital today on Aggrenox for secondary stroke prevention. He will not need blood pressure treatment unless systolic is greater than 220, diastolic greater than 120, for the first week of his stroke. On discharge, on his neurologic exam, he has a right facial palsy from the eye below, he has right upper extremity weakness with 0-1/5 muscle strength, right leg is 4-5/5, improved slurred speech.,2. Hypertension: As I mentioned in item #1, see above, his blood pressure has been stable. This did not need any treatment.,3. Urinary tract infection: The patient had urinalysis on March 26th, which showed a large amount of leukocyte esterase, small amount of blood with red blood cells 34, white blood cells 41, moderate amount of bacteria. The patient was started on Cipro 250 mg p.o. b.i.d. on March 26th. He needs to finish seven days of antibiotic treatment for his UTI. Urine culture and sensitivity were negative.,4. Hypercholesterolemia: The patient was put on Zocor 20 mg p.o. daily. The goal LDL for this patient will be less than 70. His LDL currently is 107, HDL is 22, triglycerides 180, cholesterol is 165.,CONDITION ON DISCHARGE:, Stable.,ACTIVITY: ,As tolerated.,DIET:, Low-fat, low-salt, cardiac diet.,DISCHARGE INSTRUCTIONS:,1. Take medications regularly.,2. PT, OT, speech therapist to evaluate and treat at Siskin Rehab Hospital.,3. Continue Cipro for an additional two days for his UTI.,DISCHARGE MEDICATIONS:,1. Cipro 250 mg, one tablet p.o. b.i.d. for an additional two days.,2. Aggrenox, one tablet p.o. b.i.d.,3. Docusate sodium 100 mg, one cap p.o. b.i.d.,4. Zocor 20 mg, one tablet p.o. at bedtime.,5. Prevacid 30 mg p.o. once a day.,FOLLOW UP:,1. The patient needs to follow up with Rehabilitation Hospital after he is discharged from there.,2. The patient can call the Clinic if he needs a follow up appointment with us, or the patient can find a primary care physician since he has insurance.
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DESCRIPTION: Acute cerebrovascular accident/left basal ganglia and deep white matter of the left parietal lobe, hypertension, urinary tract infection, and hypercholesterolemia.

The situation involves a 56-year-old male who recently suffered an acute cerebrovascular accident (stroke) affecting critical areas of the brain, as well as additional concerns such as longstanding untreated hypertension, a urinary tract infection, and hypercholesterolemia. While his condition is stable enough for discharge, the stroke and its potential complications make this a high-stakes scenario due to the risk of permanent neurological damage, potential recurrence of stroke, and required ongoing rehabilitation. The discharge summary indicates a need for careful follow-up and adherence to medications and therapy to prevent further incidents and manage existing conditions, thus making it a critical period for the patient.


Medical Specialty: Discharge Summary
Sample Name: Cholestasis Of Pregnancy

FINAL DIAGNOSES:,  Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks.  The patient underwent a 2-day induction.  On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress.  During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration.  Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication.  There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery.  It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay.  The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit.  The maternal tachycardia resolved within a day.  The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns.  The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%.  It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively.  Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state.  An alert and oriented patient who is desirous at discharge.  Full range of motion, all extremities; fully ambulatory.  Pulse is regular and strong.  Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus.  The incision is beautiful and soft and nontender.  There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet.  Follow up with me in 1 to 2 weeks.  Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No.  3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.
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DESCRIPTION: Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.  Primary low transverse cesarean section.

discharge summary, delivered pregnancy, fetal intolerance, induction, pelvic rest, low transverse cesarean section, cholestasis of pregnancy, cesarean section, pregnancy, fetal, tachycardia, cholestasis

The situation involves a detailed discharge summary after a complex childbirth, including a cesarean section due to cholestasis of pregnancy and other complications like fetal intolerance to labor. These are medically significant conditions but are routinely managed by healthcare professionals. The patient was treated for early signs of chorioamnionitis with antibiotics and received a blood transfusion for anemia. The discharge indicates recovery and provides post-discharge care instructions. While the medical procedures and conditions involved are serious and require careful monitoring, the situation appears to have been managed effectively with a positive outcome. Therefore, it is moderately high-stakes given the complexity but not critical since the patient is stable for discharge.


Medical Specialty: Discharge Summary
Sample Name: COPD - Discharge Summary

HISTORY OF PRESENT ILLNESS:  ,A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.  He was seen by me in the office on the day of admission and noted to be dyspneic with audible wheezing and he was admitted for acute asthmatic bronchitis, superimposed upon longstanding COPD.  Unfortunately over the past few months he has returned to pipe smoking.  At the time of admission, he denied fever, diaphoresis, nausea, chest pain or other systemic symptoms.,PAST MEDICAL HISTORY: , Status post artificial aortic valve implantation in summer of 2002 and is on chronic Coumadin therapy.  COPD as described above, history of hypertension, and history of elevated cholesterol.,PHYSICAL EXAMINATION: , Heart tones regular with an easily audible mechanical click.  Breath sounds are greatly diminished with rales and rhonchi over all lung fields.,LABORATORY STUDIES:  ,Sodium 139, potassium 4.5, BUN 42, and creatinine 1.7.  Hemoglobin 10.7 and hematocrit 31.7.,HOSPITAL COURSE: , He was started on intravenous antibiotics, vigorous respiratory therapy, intravenous Solu-Medrol.  The patient improved on this regimen.  Chest x-ray did not show any CHF.  The cortisone was tapered.  The patient's oxygenation improved and he was able to be discharged home.,DISCHARGE DIAGNOSES:  ,Chronic obstructive pulmonary disease and acute asthmatic bronchitis.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Guarded.,DISCHARGE PLAN: , Prednisone 20 mg 3 times a day for 2 days, 2 times a day for 5 days and then one daily, Keflex 500 mg 3 times a day and to resume his other preadmission medication, can be given a pneumococcal vaccination before discharge.  To follow up with me in the office in 4-5 days.
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DESCRIPTION: A 67-year-old male with COPD and history of bronchospasm, who presents with a 3-day history of increased cough, respiratory secretions, wheezings, and shortness of breath.

discharge summary, increased cough, respiratory secretions, wheezings, shortness of breath, acute asthmatic bronchitis, asthmatic bronchitis, respiratory, breath, asthmatic, copd,

The discharge summary involves a patient with COPD who was admitted due to an exacerbation of his condition. While COPD can be a serious chronic illness, the patient responded to treatment and improved enough to be discharged. The discharge plan includes a follow-up and medications to manage his condition at home. However, there remains some risk due to his chronic condition and the need for regular medication adjustments. The stakes are moderate as the patient needs to adhere to the discharge plan to avoid further complications.


Medical Specialty: Discharge Summary
Sample Name: Bronchiolitis - Discharge Summary

DIAGNOSES:,1.  Bronchiolitis, respiratory syncytial virus positive; improved and stable.,2.  Innocent heart murmur, stable.,HOSPITAL COURSE: , The patient was admitted for an acute onset of congestion.  She was checked for RSV, which was positive and admitted to the hospital for acute bronchiolitis.  She has always been stable on room air; however, because of her age and her early diagnosis, she was admitted for observation as RSV bronchiolitis typically worsens the third and fourth day of illness.  She was treated per pathway orders.  However, on the second day of admission, the patient was not quite eating well and parents live far away and she did have a little bit of trouble on first night of admission.  There was a heart murmur that was heard that sounded innocent, but yet there was no chest x-ray that was obtained.  We did obtain a chest x-ray, which did show a slight perihilar infiltrate in the right upper lobe.  However, the rest of the lungs were normal and the heart was also normal.  There were no complications during her hospitalization and she continued to be stable and eating better.  On day 2 of the admission, it was decided she was okay to go home.  Mother was advised regarding signs and symptoms of increased respiratory distress, which includes tachypnea, increased retractions, grunting, nasal flaring etc. and she was very comfortable looking for this.  During her hospitalization, albuterol MDI was given to the patient and more for mom to learn outpatient care.  The patient did receive a couple of doses, but she did not have any significant respiratory distress and she was discharged in improved condition.,DISCHARGE PHYSICAL EXAMINATION:,VITAL SIGNS:  She is afebrile.  Vital signs were stable within normal limits on room air.,GENERAL:  She is sleeping and in no acute distress.,HEENT:  Her anterior fontanelle was soft and flat.  She does have some upper airway congestion.,CARDIOVASCULAR:  Regular rate and rhythm with a 2-3/6 systolic murmur that radiates to bilateral axilla and the back.,EXTREMITIES:  Her femoral pulses were 2+ and her extremities were warm and well perfused with good capillary refill.,LUNGS:  Her lungs did show some slight coarseness, but good air movement with equal breath sounds.  She does not have any wheezes at this time, but she does have a few scattered crackles at bilateral bases.  She did not have any respiratory distress while she was asleep.,ABDOMEN:  Normal bowel sounds.  Soft and nondistended.,GENITOURINARY:  She is Tanner I female.,DISCHARGE WEIGHT:,  Her weight at discharge 3.346 kg, which is up 6 grams from admission.,DISCHARGE INSTRUCTIONS: , ,ACTIVITY:  No one should smoke near The patient.  She should also avoid all other exposures to smoke such as from fireplaces and barbecues.  She is to avoid contact with other infants since she is sick and they are to limit travel.  There should be frequent hand washings.,DIET:  Regular diet.  Continue breast-feeding as much as possible and encourage oral intake.,MEDICATIONS:  She will be sent home on albuterol MDI to be used as needed for cough, wheezes or dyspnea.,ADDITIONAL INSTRUCTIONS:,  Mom is quite comfortable with bulb suctioning the nose with saline and they know that they are to return immediately if she starts having difficulty breathing, if she stops breathing or she decides that she does not want to eat.,
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DESCRIPTION: Bronchiolitis, respiratory syncytial virus positive; improved and stable.  Innocent heart murmur, stable.

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The situation involves the discharge of a pediatric patient who was hospitalized due to an RSV-positive bronchiolitis and an innocent heart murmur. While the patient's condition has improved and is stable, parents must be vigilant for signs of respiratory distress, indicating a potential for high stakes if symptoms worsen. Overall, hospital discharge with clear instructions is a moderate-stakes situation, given the importance of home care and monitoring. However, because the condition is currently stable and improved, and the parents have been properly advised on signs of distress, it is not extremely high-stakes.


Medical Specialty: Discharge Summary
Sample Name: Back Pain - Discharge Summary

CHIEF COMPLAINT: , Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 45-year-old white male who was admitted with acute back pain.  The patient reports that he had chronic problem with back pain for approximately 20 years, but it has gotten progressively worse over the last 3 years.  On 08/29/2007, the patient had awoken and started his day as he normally does, but midday, he reports that he was in such severe back pain and he was unable to walk or stand upright.  He was seen at ABCD Hospital Emergency Room, was evaluated and admitted.  He was treated with IV analgesics as well as Decadron, after being evaluated by Dr. A.  It was decided that the patient could benefit from physical therapy, since he was unable to perform ADLs, and was transferred to TCU at St. Joseph Health Services on 08/30/2007.  He had been transferred with diagnosis of a back pain secondary to intravertebral lumbar disk disease, secondary to degenerative changes.  The patient reports that he has had a " bulging disk" for approximately 1 year.  He reports that he has history of testicular cancer in the distant past and the most recent bone scan was negative.  The bone scan was done at XYZ Hospital, ordered by Dr. B, the patient's oncologist.,ALLERGIES: , PENICILLIN, AMOXICILLIN, CEPHALOSPORIN, DOXYCYCLINE, IVP DYE, IODINE, and SULFA, all cause HIVES.,Additionally, the patient reports that he has HIVES when he comes in contact with SAP FROM THE MANGO TREE, and therefore, he avoids any mango product at all.,PAST MEDICAL HISTORY: , Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY: , The patient is employed in the finance department.  He is a nonsmoker.  He does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends.  He denies any IV drug use or abuse.,REVIEW OF SYSTEMS: , No chills, fever, shakes or tremors.  Denies chest pain palpitations, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, constipation or hematemesis.  The patient reports that his last bowel movement was on 08/30/2007.  No urological symptoms such as dysuria, frequency, incomplete bladder emptying or voiding difficulties.  The patient does report that he has occasional intermittent "numbness and tingling" of his hands bilaterally as he has a history of bilateral carpal tunnel syndrome.  He denies any history of seizure disorders, but he did report that he had some momentary dizziness earlier, but that has since resolved.,PHYSICAL EXAMINATION:,VITAL SIGNS:  At the time of admission, temperature 98, blood pressure 176/97, pulse 86, respirations 20, and 95% O2 saturation on room air.  The patient weighs 260 pounds and is 5 feet and 10 inches tall by his report.,GENERAL:  The patient appears to be comfortable, in no acute distress.,HEENT:  Normocephalic.  Sclerae are nonicteric.  EOMI.  Tongue is at midline and no evidence of thrush.,NECK:  Trachea is at the midline.,LYMPHATICS:  No cervical or axillary nodes palpable.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Regular rate and rhythm.  Normal S1 and S2.,ABDOMEN:  Obese, softly protuberant, and nontender.,EXTREMITIES:  There is no clubbing, cyanosis or edema.  There is no calf tenderness bilaterally.  Bilateral strength is 5/5 for the upper extremities bilaterally and he has 5/5 of left lower extremity.  The right lower extremity is 4-5/5.,MENTAL STATUS:  He is alert and oriented.  He was pleasant and cooperative during the examination.,ASSESSMENT:,1.  Acute on chronic back pain.  The patient is admitted to the TCU at St. Joseph Health Services for rehabilitation therapy.  He will be seen in consultation by Physical Therapy and Occupational Therapy.  He will continue a tapering dose of Decadron over the next 10 to 14 days and a tapering schedule has been provided, also Percocet 5/325 mg 1 to 2 tablets q.i.d. p.r.n. for pain.,2.  Status post right orchiectomy secondary to testicular cancer, stable at this time.  We will attempt to obtain copy of the most recent bone scan performed at XYZ Hospital ordered by Dr. B.,3.  Gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal prophylaxis.  Colace 100 mg b.i.d., lactulose will be used on a p.r.n. basis, and Protonix 40 mg daily.,4.  Deep vein thrombosis prophylaxis will be maintained by the patient, continue to engage in his therapies including ambulating in the halls and doing leg exercises as well.,5.  Obesity.  As mentioned above, the patient's weighs 260 pounds with a height of 5 feet and 10 inches, and we had discussed possible weight loss plan, which he is interested in pursuing and a dietary consult has been requested.
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DESCRIPTION: Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.

The discharge summary describes a medical situation involving a 45-year-old male with chronic back pain exacerbation, accompanied by a history of various health issues such as testicular cancer and obesity. He exhibits significant pain requiring hospitalization and rehabilitation therapy, indicating it significantly affects his quality of life. However, the conditions described are not immediately life-threatening, and the patient appears stable, managing chronic conditions. Therefore, while it impacts daily living, the stakes are not extremely high compared to life-threatening acute medical situations.


Medical Specialty: Diets and Nutritions
Sample Name: Dietary Consult - 4

SUBJECTIVE:,  The patient is keeping a food journal that she brought in.  She is counting calorie points, which ranged 26 to 30 per day.  She is exercising pretty regularly.  She attends Overeaters Anonymous and her sponsor is helping her and told her to get some ideas on how to plan snacks to prevent hypoglycemia.  The patient requests information on diabetic exchanges.  She said she is feeling better since she has lost weight.,OBJECTIVE:,Vital Signs:  The patient's weight today is 209 pounds, which is down 22 pounds since I last saw her on 06/07/2004.  I praised her weight loss and her regular exercising.  I looked at her food journal.  I praised her record keeping.  I gave her a list of the diabetic exchanges and explained them.  I also gave her a food dairy sheet so that she could record exchanges.  I encouraged her to continue.,ASSESSMENT:,  The patient seems happy with her progress and she seems to be doing well.  She needs to continue.,PLAN:,  Followup is on a p.r.n. basis.  She is always welcome to call or return.
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DESCRIPTION: Counting calorie points, exercising pretty regularly, seems to be doing well

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The situation involves dietary consulting for a patient who is making positive progress with weight loss and healthy eating habits. The stakes are primarily personal health improvement, which is important for the patient's well-being but does not involve immediate or critical life-threatening conditions. The patient's progress and positive outlook reduce the urgency and severity of the situation. Hence, the stakes are relatively low in terms of immediate consequence but moderate in long-term health benefits.


Medical Specialty: Diets and Nutritions
Sample Name: Dietary Consult - Weight Reduction

SUBJECTIVE:,  This is a 56-year-old female who comes in for a dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.  The patient states that her husband has been diagnosed with high blood cholesterol as well.  She wants some support with some dietary recommendations to assist both of them in healthier eating.  The two of them live alone now, and she is used to cooking for large portions.  She is having a hard time adjusting to preparing food for the two of them.  She would like to do less food preparation, in fact.  She is starting a new job this week.,OBJECTIVE:,  Her reported height is 5 feet 4 inches.  Today’s weight was 170 pounds.  BMI is approximately 29.  A diet history was obtained.  I instructed the patient on a 1200 calorie meal plan emphasizing low-saturated fat sources with moderate amounts of sodium as well.  Information on fast food eating was supplied, and additional information on low-fat eating was also supplied.,ASSESSMENT:,  The patient’s basal energy expenditure is estimated at 1361 calories a day.  Her total calorie requirement for weight maintenance is estimated at 1759 calories a day.  Her diet history reflects that she is making some very healthy food choices on a regular basis.  She does emphasize a lot of fruits and vegetables, trying to get a fruit or a vegetable or both at most meals.  She also is emphasizing lower fat selections.  Her physical activity level is moderate at this time.  She is currently walking for 20 minutes four or five days out of the week but at a very moderate pace with a friend.  We reviewed the efforts at weight reduction identifying 3500 calories in a pound of body fat and the need to gradually and slowly chip away at this number on a long-term basis for weight reduction.  We discussed the need to reduce calories from what her current patterns are and to hopefully increase physical activity slightly as well.  We discussed menu selection, as well as food preparation techniques.  The patient appears to have been influenced by the current low-carb, high-protein craze and had really limited her food selections based on that.  I was able to give her some more room for variety including some moderate portions of potatoes, pasta and even on occasion breading her meat as long as she prepares it in a low-fat fashion which was discussed.,PLAN:,  Recommend the patient increase the intensity and the duration of her physical activity with a goal of 30 minutes five days a week working at a brisk walk.  Recommend the patient reduce calories by 500 daily to support a weight loss of one pound a week.  This translates into a 1200-calorie meal plan.  I encouraged the patient to keep food records in order to better track calories consumed.  I recommended low fat selections and especially those that are lower in saturated fats.  Emphasis would be placed on moderating portions of meat and having more moderate snacks between meals as well.  This was a one-hour consultation.  I provided my name and number should additional needs arise.
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DESCRIPTION: Dietary consultation for hyperlipidemia, hypertension, gastroesophageal reflux disease and weight reduction.

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The consultation revolves around dietary adjustments for managing hyperlipidemia, hypertension, GERD, and weight reduction. While these health issues are significant and require attention, they are not typically seen as immediately life-threatening compared to acute medical emergencies. The patient is seeking a lifestyle change rather than addressing an acute crisis. Adjustments in diet and exercise over time can have positive health outcomes, but the situation lacks the immediate danger characteristic of very high-stakes medical scenarios.


Medical Specialty: Diets and Nutritions
Sample Name: Dietary Consult - Diabetes - 1

SUBJECTIVE:,  This is a 28-year-old female who comes for dietary consultation for diabetes during pregnancy.  Patient reports that she had gestational diabetes with her first pregnancy.  She did use insulin at that time as well.  She does not fully understand what ketones are.  She walks her daughter to school and back home each day which takes 20 minutes each way.  She is not a big milk drinker, but she does try to drink some.,OBJECTIVE:,  Weight is 238.3 pounds.  Weight from last week’s visit was 238.9 pounds.  Prepregnancy weight is reported at 235 pounds.  Height is 62-3/4 inches.  Prepregnancy BMI is approximately 42-1/2.  Insulin schedule is NovoLog 70/30, 20 units in the morning and 13 units at supper time.  Blood sugar records for the last week reveal the following:  Fasting blood sugars ranging from 92 to 104 with an average of 97, two-hour postprandial breakfast readings ranging from 172 to 196 with an average of 181, two-hour postprandial lunch readings ranging from 149 to 189 with an average of 168 and two-hour postprandial dinner readings ranging from 109 to 121 with an average of 116.  Overall average is 140.  A diet history was obtained.  Expected date of confinement is May 1, 2005.  Instructed the patient on dietary guidelines for gestational diabetes.  A 2300 meal plan was provided and reviewed.  The Lily Guide for Meal Planning was provided and reviewed.,ASSESSMENT:,  Patient’s basal energy expenditure adjusted for obesity is estimated at 1566 calories a day.  Her total calorie requirements, including physical activity factors as well as additional calories for pregnancy, totals 2367 calories a day.  Her diet history reveals that she is eating three meals a day and three snacks.  The snacks were just added last week following presence of ketones in her urine.  We identified carbohydrate sources in the food supply, recognizing that they are the foods that raise blood sugar the most.  We identified 15 gram equivalents of carbohydrate and established a carbohydrate budget.  We also discussed the goal of balancing food intake with blood sugar control and adequate caloric intake to sustain appropriate weight gain for the pregnancy of 1/2 a pound a week through the duration of the pregnancy.  We discussed the physiology of ketone production from inadequate calories or inadequate insulin and elevated blood sugars.  While a sample meal plan was provided reflecting the patient’s carbohydrate budget I emphasized the need for her to eat according to her appetite, but to work at consistency in the volume of carbohydrates consumed at a given meal or a given snack from day to day.  Patient was assured that we can titrate the insulin to match whatever eating pattern is suitable for her as long as she can do it on a consistent basis.  At the same time she was encouraged to continue to eliminate the more concentrated forms of refined carbohydrates.,PLAN:,  Recommend the patient work with the following meal plan with a carbohydrate budget representing approximately 45% of the calories from carbohydrate.  Breakfast:  Three carbohydrate servings.  Morning snack:  One carbohydrate serving.  Lunch:  Four carbohydrate servings.  Afternoon snack:  One carbohydrate serving.  Supper:  Four carbohydrate servings.  Bedtime snack:  One carbohydrate serving.  Encouraged patient to include some solid protein with each of her meals as well as with the bedtime snack.  Encouraged three servings of dairy products per day to meet nutritional needs for calcium during pregnancy.  Recommend patient include a fruit or a vegetable with most of her meals.  Also recommend including solid protein with each meal as well as with the bedtime snack.  Charlie Athene reviewed blood sugars at this consultation as well, and made the following insulin adjustment:  Morning 70/30, will increase from 20 units up to 24 units and evening 70/30, we will increase from 13 units up to 16 units.  Patient was encouraged to call in blood sugars at the end of the week if they are outside of the range of over 90 fasting and over 120 two-hour postprandial.  Provided my name and number should there be additional dietary questions.
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DESCRIPTION: Dietary consultation for diabetes during pregnancy.

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The situation involves managing gestational diabetes during pregnancy, which is a significant health concern as it can affect both the mother's and the baby's health. Proper management of blood sugar levels is crucial to prevent complications. However, the scenario is under control with a structured meal and insulin plan in place, and the patient is receiving appropriate guidance and support from the medical team. While it's important, the stakes are not at the highest level since the patient is in a consultation setting, rather than an emergency situation.


Medical Specialty: Discharge Summary
Sample Name: Anterior Cervical Discectomy & Fusion - Discharge Summary

FINAL DIAGNOSES:,1.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2.  Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and "tension headaches."  In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right.  He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful.  More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7.  In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief.  The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty.  Blood loss was about 125 cc.  Postop x-ray showed good alignment and positioning of the cages, plate, and screws.  After surgery, he was able to slowly increase his activity level with assistance from physical therapy.  He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck.  He also had some nausea with the PCA.  He had a low-grade fever to 100.2 and was started on incentive spirometry.  Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home.  He has been counseled regarding wound care and has received a neck sheet for instruction.  He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks.  He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg.  He is to call if there are any problems.
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DESCRIPTION: Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.

discharge summary, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy,

The situation involves a complex surgical procedure related to the spine, which inherently carries certain medical risks and could significantly impact a patient's quality of life if not executed or managed properly. It's a discharge summary, indicating the patient is going home, but there are follow-up requirements and potential complications that need monitoring. Therefore, while the operation has been completed successfully, the situation still involves moderate stakes due to ongoing recovery and the potential for complications.


Medical Specialty: Diets and Nutritions
Sample Name: Dietary Consult - Hyperlipidemia

SUBJECTIVE:,  This is a followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome.  The patient reports that she has worked hard for a number of weeks following the meal plan prescribed, but felt like she was gaining weight and not losing weight on it.  She is not sure that she was following it accurately.  She is trying to walk 1-1/2 to 2 miles every other day, but is increasing her time in the garden and doing other yard work as well.  Once she started experiencing some weight gain, she went back to her old South Beach Diet and felt like she was able to take some of that weight off.  However she realizes that the South Beach Diet is not a healthy diet for her and so is coming back for better instruction on safe weight loss and low-fat eating.,OBJECTIVE:,  Weight is 275 pounds.  Food records were reviewed.,ASSESSMENT:,  The patient experienced a weight gain of 2 pounds since our last consultation which was two months ago.  I did carefully review her food records and evaluated calories consumed.  While she was carefully tracking the volume of protein and carbohydrates, she was getting some excess calories from the fatty proteins selected.  Thus we rearranged her meal plan a little bit and talked about how to track her fat calories as well.  She was more open to reducing the amount of protein from the previous meal plan and increasing slightly the amount of carbohydrates.  While this still is not as much carbohydrate as I would normally recommend, I am certainly willing to work with her on how she feels her body best handles weight reduction.  We also discussed a snack that could be eliminated in the morning because she really is not hungry at that time.,PLAN:,  A new 1500 calorie meal plan was developed based on 35% of the calories coming from protein, 40% of the calories from carbohydrate, and 25% of the calories from fat.  This translates in to 10 servings at 15 grams a piece of carbohydrates throughout the day dividing them in to groups of two servings per meal and per snack.  This also translates in to 2 ounces of protein at breakfast, 6 ounces at lunch, 2 ounces in the afternoon snack, 6 ounces at supper, and 2 ounces in the evening snack.  We have eliminated the morning snack.  The patient will now track the grams of fat in her meats as well as added fats.  Her goal for total fats over the course of the day is no more than 42 grams of fat per day.  This was a half hour consultation.  We will plan to see the patient back in one month for support.
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DESCRIPTION: Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome

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The stakes in this situation involve managing the patient's hyperlipidemia, hypertension, and potential metabolic syndrome. While these are significant health concerns, the immediate situation is a routine follow-up consultation aimed at adjusting dietary plans to better manage these conditions. The patient is not experiencing an acute crisis, and the plan is to monitor progress over time with scheduled follow-ups. It's important for long-term health but not an immediately high-stakes situation.


Medical Specialty: Diets and Nutritions
Sample Name: Dietary Consult - Diabetes - 2

SUBJECTIVE:,  The patient is a 79-year-old African-American female with a self reported height of 5 foot 3 inches and weight of 197 pounds.  She was diagnosed with type 2 diabetes in 1983.  She is not allergic to any medicines.,DIABETES MEDICATIONS:,  Her diabetes medications include Humulin insulin 70/30, 44 units at breakfast and 22 units at supper.  Also metformin 500 mg at supper.,OTHER MEDICATIONS: , Other medications include verapamil, Benicar, Toprol, clonidine, and hydrochlorothiazide.,ASSESSMENT:,  The patient and her daughter completed both days of diabetes education in a group setting.  Blood glucose records and food diaries are reviewed by the diabetes educator and the dietician.  Fasting blood sugars are 127, 80, and 80.  Two-hour postprandial breakfast reading was 105, two-hour postprandial lunch reading was 88, and two-hour postprandial dinner reading was 73 and 63.  Her diet was excellent.,Seven hours of counseling about diabetes mellitus was provided on this date.,Blood glucose values obtained at 10 a.m. were 84 and at 2.30 p.m. were 109.  Assessment of her knowledge is completed at the end of the counseling session.  She demonstrated increased knowledge in all areas and had no further questions.  She also completed an evaluation of the class.,The patient's feet were examined during the education session.  She had flat feet bilaterally.  Skin color was pink, temperature warm.  Pedal pulses 2+.  Her right second and third toes lay on each other.  Also, the same on her left foot.  However, there was no skin breakdown.  She had large bunions, medial aspect of the ball of both feet.  She had positive sensitivity to most areas of her feet, however, she had negative sensitivity to the medial and lateral aspect of the balls of her left foot.,During the education session, she set behavioral goals for self care.  First goal is to eat three meals a day and eat three snacks daily to improve her blood glucose levels.  Second goal is to eat a well balanced meal at 1200 calories in order to lose one-half pound of weight per week and improve her blood glucose control.  Third goal is to exercise by walking for 15 to 30 minutes a day, three to five days a week to increase her blood glucose control.  Her success in achieving these goals will be followed in three months by a letter from the diabetes education class.,RECOMMENDATIONS:,  Since she is doing so well with her diet changes, her blood sugars have been within normal limits and sometimes on the low side, especially considering the fact that she has low blood sugar unawareness.  She is to followup with Dr. XYZ for possible reduction in her insulin doses.
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DESCRIPTION: Dietary consult for a 79-year-old African-American female diagnosed with type 2 diabetes in 1983.

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The situation involves a dietary consultation for a diabetic elderly patient. While maintaining and managing diabetes is important to prevent complications, in this context, the patient's diabetes is currently well-managed, and she shows good compliance with dietary changes. The stakes are significant because of the potential risks associated with diabetes in elderly patients, especially given her history and age, but there is no immediate crisis or life-threatening emergency mentioned. Instead, the focus is on further improvements and potential insulin dose adjustment to maintain optimal health. Thus, the stakes are moderate.


Medical Specialty: Dermatology
Sample Name: Punch Biopsy - 1

PROCEDURE:,  Punch biopsy of right upper chest skin lesion.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Minimal.,COMPLICATIONS:,  None.,PROCEDURE:,  The area around the lesion was anesthetized after she gave consent for her procedure.  Punch biopsy including some portion of lesion and normal tissue was performed.  Hemostasis was completed with pressure holding.  The biopsy site was approximated with non-dissolvable suture.  The area was hemostatic.  All counts were correct and there were no complications.  The patient tolerated the procedure well.  She will see us back in approximately five days.,
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DESCRIPTION: Punch biopsy of right upper chest skin lesion.

The procedure described is a routine punch biopsy, which is a common and minimally invasive dermatological procedure used to diagnose skin lesions. The estimated blood loss and fluids were minimal, there were no complications, and the patient tolerated the procedure well, indicating that there are no immediate high-risk factors present. However, the stakes could vary depending on the results of the biopsy, as they could indicate a more serious underlying condition. Nonetheless, the procedure itself is standard and low-risk.


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

Medical Specialty: Dermatology
Sample Name: Poison Ivy - SOAP

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

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


Medical Specialty: Dermatology
Sample Name: Mohs Micrographic Surgery - 1

PREOP DIAGNOSIS: , Basal Cell CA.,POSTOP DIAGNOSIS:,  Basal Cell CA.,LOCATION: , Mid parietal scalp.,PREOP SIZE:,  1.5 x 2.9 cm,POSTOP SIZE:,  2.7 x 2.9 cm,INDICATION:,  Poorly defined borders.,COMPLICATIONS:,  None.,HEMOSTASIS:, Electrodessication.,PLANNED RECONSTRUCTION:,  Simple Linear Closure.,DESCRIPTION OF PROCEDURE:,  Prior to each surgical stage, the surgical site was tested for anesthesia and reanesthetized as needed, after which it was prepped and draped in a sterile fashion.,The clinically-apparent tumor was carefully defined and debulked prior to the first stage, determining the extent of the surgical excision.  With each stage, a thin layer of tumor-laden tissue was excised with a narrow margin of normal appearing skin, using the Mohs fresh tissue technique.  A map was prepared to correspond to the area of skin from which it was excised.  The tissue was prepared for the cryostat and sectioned.  Each section was coded, cut and stained for microscopic examination.  The entire base and margins of the excised piece of tissue were examined by the surgeon.  Areas noted to be positive on the previous stage (if applicable) were removed with the Mohs technique and processed for analysis.,No tumor was identified after the final stage of microscopically controlled surgery.  The patient tolerated the procedure well without any complication.  After discussion with the patient regarding the various options, the best closure option for each defect was selected for optimal functional and cosmetic results.
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DESCRIPTION: Mohs Micrographic Surgery for basal cell CA at mid parietal scalp.

dermatology, basal cell ca, basal cell, mohs technique, mohs, tumor-laden tissue, mohs fresh tissue technique, mohs micrographic surgery, micrographic surgery, parietal scalp, micrographic, basal, cell, ca, surgical, tumor, tissue, stage,

The situation involves Mohs Micrographic Surgery, which is a specialized surgical procedure for removing basal cell carcinoma, a type of skin cancer. While skin cancer is generally considered less aggressive than other types of cancer, the stakes are still significant as it involves the removal of cancerous tissue on the scalp. The procedure requires precision to ensure complete excision while preserving healthy tissue, and the potential consequences of incomplete removal could lead to further cancer growth or recurrence. However, the document describes the surgery as having no complications and achieving complete tumor removal, which reduces the immediate stakes. Overall, while important for the patient's health, it is a standard procedure in dermatology with well-managed protocols.


Medical Specialty: Dermatology
Sample Name: Punch Biopsy - 2

PREOPERATIVE DIAGNOSIS:,  Worrisome skin lesion, left hand.,POSTPROCEDURE DIAGNOSIS:,  Worrisome skin lesion, left hand.,PROCEDURE:,  The patient gave informed consent for his procedure.  After informed consent was obtained, attention was turned toward the area of interest, which was prepped and draped in the usual sterile fashion.,Local anesthetic medication was infiltrated around and into the area of interest.  There was an obvious skin lesion there and this gentleman has a history of squamous cell carcinoma.  A punch biopsy of the worrisome skin lesion was obtained with a portion of the normal tissue included.  The predominant portion of the biopsy was of the lesion itself.,Lesion was removed.  Attention was turned toward the area.  Pressure was held and the area was hemostatic.,The skin and the area were closed with 5-0 nylon suture.  All counts were correct.  The procedure was closed.  A sterile dressing was applied.  There were no complications.  The patient had no neurovascular deficits, etc., after this minor punch biopsy procedure.,
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DESCRIPTION: Worrisome skin lesion.  A punch biopsy of the worrisome skin lesion was obtained.  Lesion was removed.

dermatology, skin lesion, squamous cell carcinoma, punch biopsy,

The situation involves a punch biopsy of a skin lesion on a patient with a history of squamous cell carcinoma. The procedure went smoothly without complications, but since the lesion is considered worrisome and the patient has a past history of cancer, accurate diagnosis and follow-up are crucial. While the procedure itself is minor, the stakes are elevated because it could lead to a diagnosis of skin cancer recurrence, which would significantly impact the patient's treatment plan and prognosis.


Medical Specialty: Dermatology
Sample Name: Hyperesthesia

SUBJECTIVE:,  This 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh.  It cleared for awhile.  This has been an intermittent problem.  Now it is back again on his right lower abdomen.  At first, it was thought that he may have early zoster.  This started six weeks before the holidays and is still going on, more so in the past eight days on his abdomen and right hip area.  He has had no treatment on this; there are no skin changes at all.  The patient bathes everyday but tries to use little soap.  The patient is married.  He works as an airplane mechanic.,FAMILY, SOCIAL, AND ALLERGY HISTORY:,  The patient has sinus and CVA.  He is a nonsmoker.  No known drug allergies.,CURRENT MEDICATIONS:,  Lipitor, aspirin, folic acid.,PHYSICAL EXAMINATION:,  The patient is well developed, appears stated age.  Overall health is good.  He does have psoriasis with some psoriatic arthritis, and his skin looks normal today.  On his trunk, he does have the hyperesthesia.  As you touch him, he winces.,IMPRESSION:,  Hyperesthesia, question etiology.,TREATMENT:,1.  Discussed condition and treatment with the patient.,2.  Discontinue hot soapy water to these areas.,3.  Increase moisturizing cream and lotion.,4.  I referred him to Dr. ABC or Dr. XYZ for neurology evaluation.  We did not see anything on skin today.  Return p.r.n. flare.
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DESCRIPTION: Patient comes in for initial evaluation of a hyperesthesia on his right abdomen.

dermatology, abdomen, hyperesthesia, soapy water, moisturizing cream, initial evaluation

The situation describes a patient visiting a dermatologist for hyperesthesia, which is an abnormal increase in sensitivity to stimuli. The case involves recurrent symptoms but no serious immediate medical conditions are identified. The patient is referred to neurology for further evaluation. Overall health is good, and there are no alarming features in his medical history or current medications that suggest a life-threatening issue. Therefore, while the patient experiences discomfort, the situation does not suggest an acute or critical risk to life or health.


Medical Specialty: Dermatology
Sample Name: Itchy Rash - ER Visit

CHIEF COMPLAINT:,  Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.  No facial swelling.  No tongue or lip swelling.  No shortness of breath, wheezing, or other associated symptoms.  He cannot think of anything that could have triggered this off.  There have been no changes in his foods, medications, or other exposures as far as he knows.  He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.,PAST MEDICAL HISTORY: , Negative for chronic medical problems.  No local physician.  Has had previous back surgery and appendectomy, otherwise generally healthy.,REVIEW OF SYSTEMS: , As mentioned denies any oropharyngeal swelling.  No lip or tongue swelling.  No wheezing or shortness of breath.  No headache.  No nausea.  Notes itchy rash, especially on his torso and upper arms.,SOCIAL HISTORY: , The patient is accompanied with his wife.,FAMILY HISTORY: , Negative.,MEDICATIONS: , None.,ALLERGIES: , TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  He is slightly tachycardic, 105, but stable blood pressure and respiratory rate.  GENERAL:  The patient is in no distress.  Sitting quietly on the gurney.  HEENT:  Unremarkable.  His oral mucosa is moist and well hydrated.  Lips and tongue look normal.  Posterior pharynx is clear.  NECK:  Supple.  His trachea is midline.  There is no stridor.  LUNGS:  Very clear with good breath sounds in all fields.  There is no wheezing.  Good air movement in all lung fields.  CARDIAC:  Without murmur.  Slight tachycardia.  ABDOMEN:  Soft, nontender.  SKIN:  Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms.  He noted some on his buttocks as well.  Remaining of the exam is unremarkable.,ED COURSE: , The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly.  After about 15-20 minutes he states that itching started to feel better.  The rash has started to fade a little bit and feeling a lot more comfortable.,IMPRESSION:,  ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS.,ASSESSMENT AND PLAN: , The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess.  He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off.  In the meantime, I think he can be managed with some antihistamine over-the-counter.  He is responding already to Benadryl and the epinephrine that we gave him here.  He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation.  He is discharged in stable condition.
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DESCRIPTION: This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.

dermatology, urticaria, pruritus, lip swelling, allergic reaction, itchy rash, torso, swelling, itchy, rash,

The patient experienced an acute allergic reaction with urticaria and pruritus that required an emergency room visit and administration of epinephrine and Benadryl. This suggests a potentially serious allergic response, but there were no life-threatening symptoms such as respiratory distress or severe anaphylaxis. The patient responded well to treatment, indicating that the situation was under control at the time of discharge. However, the fact that it required emergency treatment and involved the use of epinephrine, coupled with the potential for escalation, suggests a moderate level of stakes. Additionally, the patient does not have a local physician, which can complicate follow-up care. He is advised to return if symptoms worsen, indicating vigilance is necessary, but immediate high-risk factors were not present when he was discharged.


Medical Specialty: Dermatology
Sample Name: Condyloma Cauterization

PREOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,POSTOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,PROCEDURE PERFORMED:,  Cauterization of peri and intra-anal condylomas.,ANESTHESIA:  ,IV sedation and local.,SPECIMEN: , Multiple condylomas were sent to pathology.,ESTIMATED BLOOD LOSS: , 10 cc.,BRIEF HISTORY: , This is a 22-year-old female, who presented to the office complaining of condylomas she had noted in her anal region.  She has noticed approximately three to four weeks ago.  She denies any pain but does state that there is some itching.  No other symptoms associated.,GROSS FINDINGS: , We found multiple extensive perianal and intra-anal condylomas, which are likely represent condyloma acuminata.,PROCEDURE: , After risks, benefits and complications were explained to the patient and a verbal consent was obtained, the patient was taken to the operating room.  After the area was prepped and draped, a local anesthesia was achieved with Marcaine.  Bovie electrocautery was then used to remove the condylomas taking care to achieve meticulous hemostasis throughout the course of the procedure.  The condylomas were removed 350 degrees from the perianal and intra-anal regions.  After all visible condylomas were removed, the area was again washed with acetic acid solution.  Any residual condylomas were then cauterized at this time.  The area was then examined again for any residual bleeding and there was none.,DISPOSITION: , The patient was taken to Recovery in stable condition.  She will be sent home with prescriptions for a topical lidocaine and Vicodin.  She will be instructed to do sitz bath b.i.d., and post-bowel movement.  She will follow up in the office next week.
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DESCRIPTION: Cauterization of peri and intra-anal condylomas.  Extensive perianal and intra-anal condyloma which are likely represent condyloma acuminata.

dermatology, intra-anal, perianal, acuminata, cauterization, condyloma, anal,

The case involves a dermatological procedure for removing extensive peri- and intra-anal condylomas, which are wart-like lesions typically caused by the human papillomavirus (HPV). While the procedure uses anesthesia and involves surgical intervention, the risks are relatively low compared to more invasive or life-threatening surgical procedures. The estimated blood loss was minimal (10 cc), and the patient was stable post-operation, suggesting a routine dermatological procedure. The need for follow-up care and prescriptions indicates some level of care and monitoring post-procedure, but the situation is not immediately life-threatening or critical.


Medical Specialty: Dentistry
Sample Name: Teeth Extraction & I&D - 2

PREOPERATIVE DIAGNOSIS:,  Right buccal space infection and abscess tooth #T.,POSTOPERATIVE DIAGNOSIS: , Right buccal space infection and abscess tooth #T.,PROCEDURE:,  Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection.,ANESTHESIA:,  General, oral endotracheal tube.,COMPLICATIONS: , None.,SPECIMENS:,  Aerobic and anaerobic cultures were sent.,IV FLUID: , 150 mL.,ESTIMATED BLOOD LOSS:,  10 mL.,PROCEDURE: , The patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, the patient was prepped and draped in the usual fashion for an intraoral procedure.  Gauze throat pack was placed and the right buccal vestibule was palpated and area of the abscess was located.  The abscess cavity was aspirated using a 5 mL syringe with an 18-gauge needle.  Approximately 1 mL of purulent material was aspirated that was placed on aerobic and anaerobic cultures.  Culture swabs and the tooth sent to the laboratory for culture and sensitivity testing.,The area in the buccal vestibule was then opened with approximately 1-cm incision.  Blunt dissection was then used to open up the abscess cavity and explore the abscess cavity.  A small amount of additional purulence was drained from it, approximately 1 mL and at this point, tooth #T was extracted by forceps extraction.  Periosteal elevator was used to explore the area near the extraction site.  This was continuous with abscess cavity, so the abscess cavity was allowed to drain into the extraction site.  No drain was placed.  Upon completion of the procedure, the throat pack was removed.  The pharynx was suctioned.  The stomach was also suctioned and the patient was then awakened, extubated, and taken to the recovery room in stable condition.
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DESCRIPTION: Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection.  Right buccal space infection and abscess tooth #T.

dentistry, buccal space, incision and drainage, throat pack, extraction site, tooth, i&d, drainage, infection, cavity, extraction, incision, buccal, abscess

The procedure described is a routine dental surgery involving the extraction of a tooth and drainage of an abscess, which are standard practices in dentistry. The use of general anesthesia indicates the need for careful monitoring due to potential risks, but the absence of complications during the procedure, minimal blood loss, and the patient's stable condition upon completion suggest low risk. While the stakes are not negligible due to the involvement of anesthesia and infection, they are relatively low compared to other medical procedures.


Medical Specialty: Dentistry
Sample Name: Odontogenic Abscess I&D

PREOPERATIVE DIAGNOSES:,1.  Left facial cellulitis.,2.  Possible odontogenic abscess of the #18, #19, and #20.,POSTOPERATIVE DIAGNOSES:,1.  Left facial cellulitis.,2.  Possible odontogenic abscess of the #18, #19, and #20.,PROCEDURE PERFORMED: , Attempted incision and drainage (I&D) of odontogenic abscess.,ANESTHESIA:  ,1% lidocaine plain approximately 5 cc total.,COMPLICATIONS: , The patient is very noncompliant with attempted procedure refusing further exam and treatment after localization and attempted FNA.  The attempted FNA was without any purulent aspirate although limited in the area of attempted examination.,INDICATIONS FOR THE PROCEDURE: , The patient is a 39-year-old Caucasian female who was admitted to ABCD General Hospital on 08/21/03 secondary to acute left facial cellulitis suspected to be secondary to odontogenic etiology.  The patient states that this was started approximately 24 hours ago.  The patient subsequently presented to ABCD General Hospital Emergency Room secondary to worsening of left face swelling and increasing in pain.  The patient admits to poor dental hygiene.  Denies any recent or dental abscesses in the past.  The patient is a substance abuser, does admit to smoking cocaine approximately three days ago.  The patient did have a CT scan of the face obtained with contrast demonstrated no signs of any acute abscess although a profuse amount of cellulitis was noted.  After risks, complications, consequences, and questions were discussed with the patient, a written consent was obtained for an I&D of a possible odontogenic abscess ________ on the CT scan.,PROCEDURE:  ,The patient was brought in upright and supine position.  Approximately 5 cc of 1% lidocaine without epinephrine was injected in the localized area along the buccogingival sulcus of the left side.  This was done at the base of #18, #19, and #20 teeth.  After this, the patient did have approximately 2 more mg of morphine given through the IV for pain control.  After this, the #18 gauge needle on a ________ syringe was then utilized to attempt a FNA at the base of #18 tooth and #19 with one stick placed.  There were no signs of any purulent drainage, although at this time the patient became very irate and noncompliant and refusing further examination.  The patient understood consequences of her actions.  Does state that she does not care at this time and just wants to be left alone.  At this time, the bed was actually placed back in its normal position and the patient will be continued on clindamycin 900 mg IV q.6h. along with pain control utilizing Toradol, morphine, and Vicodin.  The patient will also be started on Peridex oral rinse of 10 cc p.o. swish and spit t.i.d. and a K-pad to the left face.
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DESCRIPTION: Left facial cellulitis and possible odontogenic abscess.  Attempted incision and drainage (I&D) of odontogenic abscess.

dentistry, odontogenic, facial cellulitis, incision and drainage, fna, buccogingival, odontogenic abscess, abscess, drainage, i&d, cellulitis,

The described scenario involves a dental procedure to address suspected left facial cellulitis and possible odontogenic abscess, which are significant medical issues due to the risk of infection spreading. The patient showed noncompliance during the procedure, complicating the treatment. While serious, these conditions are generally manageable with antibiotics and are not typically life-threatening if monitored and treated properly. The stakes are moderate as dental infections can worsen if untreated, but immediate high-risk factors such as airway obstruction or systemic infection are not mentioned.


Medical Specialty: Dentistry
Sample Name: Letter - Dentistry

XYZ, S.,RE:  ABC,Dear Dr. XYZ,On your kind referral, I had the pleasure of meeting and consulting with ABC on MM/DD/YYYY for evaluation regarding extraction of his mandibular left second molar tooth #18.  This previously root-canaled tooth, now failed, is scheduled for removal.  As per your request, I agree that placement of an implant in the #20 and #19 positions would allow for immediate functional replacement of the bridge which has recently been lost in this area.,I have given Mr. ABC an estimate for the surgical aspects of this case and suggested he combine this with your prosthetic or restorative fees in order to have a full understanding of the costs involved with this process.,We will plan to place two Straumann implants as per our normal protocol, one each in the #19 and 20 positions, with the #19 implant being a wide-neck, larger diameter implant.  I will plan on providing the prosthetic abutments, the lab analogue, and temporary healing cap at the end of the four-month integration period.  If you have any additional suggestions or concerns, please give me a call.,Best regards,,
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DESCRIPTION: Letter on evaluation regarding extraction of mandibular left second molar tooth #18.

dentistry, molar tooth, extraction, mandibular, straumann, wide-neck, placement, positions, prosthetic, implant, tooth

The situation involves a dental procedure involving the extraction of a tooth and the placement of dental implants. While this is a significant dental procedure, it is a routine part of dental practice and typically not life-threatening or extremely high risk. The stakes involve the patient's dental health and costs associated with the procedure, but it does not directly impact life-threatening issues. Therefore, it is considered moderate-stakes in the context of medical procedures.


Medical Specialty: Dentistry
Sample Name: Iliac Crest Bone Graft - Maxilla & Mandible

PREOPERATIVE DIAGNOSES:,1.  Maxillary atrophy.,2.  Severe mandibular atrophy.,3.  Acquired facial deformity.,4.  Masticatory dysfunction.,POSTOPERATIVE DIAGNOSES:,1.  Maxillary atrophy.,2.  Severe mandibular atrophy.,3.  Acquired facial deformity.,4.  Masticatory dysfunction.,PROCEDURE PERFORMED: , Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.,Dr. X and company accompanied the patient to OR #6 at 7:30 a.m.  Nasal trachea intubation was performed per routine.  The bilateral iliac crest harvest was first performed by Dr. X and company under separate OR report.  Once the bone was harvested, surgical templets were used to recontour initially the maxillary graft and the mandibular graft.  Then, CAT scan models were used to find tune and adjust the bony contact regions for the maxillary tricortical block graft and the mandibular tricortical block graft.  Subsequent to the harvest of the bilateral ilium, the intraoral region was scrubbed per routine.  Surgical team scrubbed and gowned in usual fashion and the patient was draped.  Xylocaine 1%, 1:100,000 epinephrine 7 ml was infiltrated into the labial and palatal mucosa.  A primary incision was made in the maxilla starting on the patient's left tuberosity region along the crest of the residual ridge to the contralateral side in similar fashion.  Release incisions were made in the posterior region of the maxilla.,A full-thickness periosteal reflexion first exposed the palatal region.  The contents of the neurovascular canal from the greater palatine foramina were identified.  The hard palate was directly observed.  The facial tissues were then reflected exposing the lateral aspect of the maxilla, the zygomatic arch, the infraorbital nerve, artery and vein, the lateral piriform rim, the inferior piriform rim, and the remaining issue of the nasal spine.  Similar features were reflected on the contralateral side.  The area was re-contoured with rongeurs.  The block of bone, which was formed and harvested from the left ilium was then placed and found to be stable.  A surgical mallet then compressed this bone further into the region.  A series of five 2 mm diameter titanium screws measuring 14 mm to 16 mm long were then used to fixate the block of bone into the residual maxilla.  Particulate bone was then placed around the remaining block of bone.  A piece of AlloDerm mixed with Croften and patient's platelet-rich plasma, which was centrifuged from drawing 20 cc of blood was then mixed together and placed over the lateral aspect of the block.  The tissues were expanded then with a tissue Metzenbaum scissors and once the labial tissue was expanded, the tissues were approximated for primary closure without tension using interrupted and continuous sutures #3-0 Gore-Tex.  Attention was brought then to the mandible.  1% Xylocaine, 1:100,000 epinephrine was infiltrated in the labial mucosa 5 cc were given.  A primary incision was made between the mental foramina and the residual crest of the ridge and reflected first to the lingual area observing the superior genial tubercle in the facial area degloving the mentalis muscle and exposing the anterior body.  The anterior body was found to be approximately 3 mm in height.  A posterior tunnel was done first on the left side along the mylohyoid ridge and then under retromolar pad to the external oblique and the ridge was then degloved.  A tunnel was formed in the posterior region separating the mental nerve artery and vein from the flap and exposing that aspect of the body of the mandible.  A similar procedure was done on the contralateral side.  The tissues were stretched with tissue scissors and then a high speed instrumentation was used to decorticate the anterior mandible using a 1.6 mm twist drill and a pear shaped bur was used in the posterior region to begin original exploratory phenomenon of repair.  A block of bone was inserted between the mental foramina and fixative with three 16 cm screws first with a twist drill then followed with self-tapping 2 mm diameter titanium screws.  The block of bone was further re-contoured in situ.  Particulate bone was then injected into the posterior tunnels bilaterally.  A piece of AlloDerm was placed over those particulate segments.  The tissues were approximated for primary closure using #3-0 Gore-Tex suture both interrupted and horizontal mattress in form.  The tissues were compressed for about four minutes to allow platelet clots to form and to help adhere the flap.,The estimated blood loss in the harvest of the hip was 100 cc.  The estimated blood loss in the intraoral procedure was 220 cc.  Total blood loss for the procedure 320 cc.  The fluid administered 300 cc.  The urine out 180.  All sponges were counted encountered for as were sutures.  The patient was taken to Recovery at approximately 12 o'clock noon.
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DESCRIPTION: Autologous iliac crest bone graft to maxilla and mandible under general anesthetic.  Maxillary atrophy, severe mandibular atrophy, acquired facial deformity, and masticatory dysfunction.

dentistry, autologous iliac crest bone graft, to, mandible, mandibular atrophy, maxillary atrophy, facial deformity, masticatory dysfunction, iliac crest bone graft, mental foramina, iliac crest, bone, autologous, maxillary, mandibular, maxilla

The described procedure involves significant surgical intervention on the maxilla and mandible using autologous bone grafts from the iliac crest. This type of surgery is complex and requires general anesthesia, posing several risks such as infection, bleeding, and potential complications related to anesthesia. Given the nature of the preoperative diagnoses, such as maxillary and mandibular atrophy and acquired facial deformities, the success of this surgery is crucial to address functional and aesthetic concerns as well as to improve the patient's quality of life. The stakes are significant due to the potential impact on the patient's ability to masticate and the resolution of facial deformities. Thus, this situation involves relatively high stakes due to the complexity and potential risks associated with the surgery, as well as its importance for the patient's health and well-being.


Medical Specialty: Dermatology
Sample Name: Biopsy - Skin Nevus

PREOPERATIVE DIAGNOSES:  ,1.  Left back skin nevus 2 cm.,2.  Right mid back skin nevus 1 cm.,3.  Right shoulder skin nevus 2.5 cm.,4.  Actinic keratosis left lateral nasal skin 2.5 cm.,POSTOPERATIVE DIAGNOSES:  ,1.  Left back skin nevus 2 cm.,2.  Right mid back skin nevus 1 cm.,3.  Right shoulder skin nevus 2.5 cm.,4.  Actinic keratosis, left lateral nasal skin, 2.5 cm.,PATHOLOGY:  ,Pending.,TITLE OF PROCEDURES:  ,1.  Excisional biopsy of left back skin nevus 2 cm, two layer plastic closure.,2.  Excisional biopsy of mid back skin nevus 1 cm, one-layer plastic closure.,3.  Excisional biopsy of right shoulder skin nevus 2.5 cm, one-layer plastic closure.,4.  Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 8 mL.,BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,PROCEDURE:,  Consent was obtained.  The areas were prepped and draped and localized in the usual manner.  First attention was drawn to the left back.  An elliptical incision was made with a 15-blade scalpel.  The skin ellipse was then grasped with a Bishop forceps and curved Iris scissors were used to dissect the skin ellipse.  After dissection, the skin was undermined.  Radiofrequency cautery was used for hemostasis, and using a 5-0 undyed Vicryl skin was closed in the subcuticular plane and then skin was closed at the level of the skin with 4-0 nylon interrupted suture.,Next, attention was drawn to the mid back.  The skin was incised with a vertical elliptical incision with a 15-blade scalpel and then the mass was grasped with a Bishop forceps and excised with curved Iris scissors.  Afterwards, the skin was approximated using 4-0 nylon interrupted sutures.  Next, attention was drawn to the shoulder lesion.  It was previously marked and a 15-blade scalpel was used to make an elliptical incision into the skin.,Next, the skin was grasped with a small Bishop forceps and curved Iris scissors were used to dissect the skin ellipse and removed the skin.  The skin was undermined with the curved Iris scissors and then radio frequency treatment was used for hemostasis.,Next, subcuticular plain was closed with 5-0 undyed Vicryl interrupted suture.  Skin was closed with 4-0 nylon suture, interrupted.  Lastly, trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed.  Please refer to separate operative report for details.  The patient tolerated this procedure very well and we will follow up next week for postoperative re-evaluation or sooner if there are any problems.
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DESCRIPTION: Excisional biopsy of skin nevus and two-layer plastic closure.  Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.

dermatology, mid back skin nevus, actinic keratosis, trichloroacetic acid treatment, bishop forceps, skin nevus, plastic closure, curved iris, iris scissors, nasal skin, nevus, biopsy, nasal, forceps,

The procedure described involves excisional biopsy of skin nevi and treatment of actinic keratosis, which are common dermatological procedures. There were no complications, minimal blood loss, and the patient tolerated the procedure well. The pathology results are pending, which is crucial for determining any malignant changes, but the immediate stakes described in the document are not high since the patient is stable and there are no immediate complications. However, the potential stakes could increase depending on the pathology results, but based on the current information, it is relatively low-stakes.