Medical Specialty: Pediatrics - Neonatal
Sample Name: A 5-month-old boy with cough

CHIEF COMPLAINT:,  A 5-month-old boy with cough.,HISTORY OF PRESENT ILLNESS:,  A 5-month-old boy brought by his parents because of 2 days of cough.  Mother took him when cough started 2 days go to Clinic where they told the mother he has viral infection and gave him Tylenol, but yesterday at night cough got worse and he also started having fever.  Mother did not measure it.,REVIEW OF SYSTEMS:,  No vomiting.  No diarrhea.  He had runny nose started with the cough two days ago.  No skin rash.  No cyanosis.  Pulling on his right ear.  Feeding, he is bottle-fed 2 ounces every 2 hours.  Mother states he urinates like 5 to 6 times a day, stools 1 time a day.  He is still feeding good to mom.,IMMUNIZATIONS: , He received first set of shot and due for the second set on 01/17/2008.,BIRTH HISTORY:,  He was premature at 33 weeks born at Hospital kept in NICU for 2 weeks for feeding problem as the mother said.  Mother had good prenatal care at 4 weeks for more than 12 visits.  No complications during pregnancy.  Rupture of membranes happened two days before the labor.  Mother received the antibiotics, but she is not sure, if she received steroids also or not.,FAMILY HISTORY: , No history of asthma or lung disease.,SOCIAL HISTORY: , Lives with parents and with two siblings, one 18-year-old and the other is 14-year-old in house, in Corrales.  They have animals, but outside the house and father smokes outside house.  No sick contacts as the mother said.,PAST MEDICAL HISTORY:,  No hospitalizations.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , No medications.,History of 2 previous ear infection, last one was in last November treated with ear drops, because there was pus coming from the right ear as the mother said.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 100.1, heart rate 184, respiratory rate 48.  Weight 7 kg.,GENERAL:  In no acute distress.,HEAD:  Normocephalic and atraumatic.  Open, soft, and flat anterior fontanelle.,NECK:  Supple.,NOSE:  Dry secretions.,EAR:  Right ear full of yellowish material most probably pus and necrotic tissue.  Tympanic membrane bilaterally visualized.,MOUTH:  No pharyngitis.  No ulcers.  Moist mucous membranes.,CHEST:  Bilateral audible breath sound.  No wheezes.  No palpitation.,HEART:  Regular rate and rhythm with no murmur.,ABDOMEN:  Soft, nontender, and nondistended.,GENITOURINARY:  Tanner I male with descended testes.,EXTREMITIES:  Capillary refill less than 2 seconds.,LABS:,  White blood cell 8.1, hemoglobin 10.5, hematocrit 30.9, and platelets 380,000.  CRP 6, segments 41, and bands 41.  RSV positive.  Chest x-ray evidenced bronchiolitis with hyperinflation and bronchial wall thickening in the central hilar region.  Subsegmental atelectasis in the right upper lobe and left lung base.,ASSESSMENT:,  A 5-month-old male with 2 days of cough and 1 day of fever.  Chest x-ray shows bronchiolitis with atelectasis, and RSV antigen is positive.,DIAGNOSES: , Respiratory syncytial virus bronchiolitis with right otitis externa.,PLAN: , Plan was to admit to bronchiolitis pathway, and ciprofloxacin for right otitis externa eardrops twice daily.,
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DESCRIPTION: A 5-month-old boy brought by his parents because of 2 days of cough.

In this scenario, a 5-month-old boy with a history of premature birth is presenting with respiratory syncytial virus (RSV) bronchiolitis and otitis externa. His medical evaluation shows signs of potential respiratory distress (tachycardia and tachypnea) and infections. Given the patient's age, prematurity, and the diagnosis of RSV bronchiolitis, which can lead to significant respiratory issues in infants, the situation is moderately high-stakes. RSV can cause severe symptoms in young infants and requires careful monitoring and potentially hospitalization, as suggested in the plan. Thus, this situation requires prompt and careful medical attention.


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

Medical Specialty: Gastroenterology
Sample Name: CT Abdomen & Pelvis - 3

EXAM: , CT of the abdomen and pelvis without contrast.,HISTORY: , Lower abdominal pain.,FINDINGS:,  Limited views of the lung bases demonstrate linear density most likely representing dependent atelectasis.  There is a 1.6 cm nodular density at the left posterior sulcus.,Noncontrast technique limits evaluation of the solid abdominal organs.  Cardiomegaly and atherosclerotic calcifications are seen.,Hepatomegaly is observed.  There is calcification within the right lobe of the liver likely related to granulomatous changes.  Subtle irregularity of the liver contour is noted, suggestive of cirrhosis.  There is splenomegaly seen.  There are two low-attenuation lesions seen in the posterior aspect of the spleen, which are incompletely characterized that may represent splenic cyst.  The pancreas appears atrophic.  There is a left renal nodule seen, which measures 1.9 cm with a Hounsfield unit density of approximately 29, which is indeterminate.,There is mild bilateral perinephric stranding.  There is an 8-mm fat density lesion in the anterior inner polar region of the left kidney, compatible in appearance with angiomyolipoma.  There is a 1-cm low-attenuation lesion in the upper pole of the right kidney, likely representing a cyst, but incompletely characterized on this examination.  Bilateral ureters appear normal in caliber along their visualized course.  The bladder is partially distended with urine, but otherwise unremarkable.,Postsurgical changes of hysterectomy are noted.  There are pelvic phlebolith seen.  There is a calcified soft tissue density lesion in the right pelvis, which may represent an ovary with calcification, as it appears continuous with the right gonadal vein.,Scattered colonic diverticula are observed.  The appendix is within normal limits.  The small bowel is unremarkable.  There is an anterior abdominal wall hernia noted containing herniated mesenteric fat.  The hernia neck measures approximately 2.7 cm.  There is stranding of the fat within the hernia sac.,There are extensive degenerative changes of the right hip noted with changes suggestive of avascular necrosis.  Degenerative changes of the spine are observed.,IMPRESSION:,1.  Anterior abdominal wall hernia with mesenteric fat-containing stranding, suggestive of incarcerated fat.,2.  Nodule in the left lower lobe, recommend follow up in 3 months.,3.  Indeterminate left adrenal nodule, could be further assessed with dedicated adrenal protocol CT or MRI.,4.  Hepatomegaly with changes suggestive of cirrhosis.  There is also splenomegaly observed.,5.  Low-attenuation lesions in the spleen may represent cyst, that are incompletely characterized on this examination.,6.  Fat density lesion in the left kidney, likely represents angiomyolipoma.,7.  Fat density soft tissue lesion in the region of the right adnexa, this contains calcifications and may represent an ovary or possibly dermoid cyst.
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DESCRIPTION: CT of the abdomen and pelvis without contrast.

gastroenterology, abdominal pain, cardiomegaly, atherosclerotic calcifications, hepatomegaly, perinephric stranding, low attenuation lesions, abdominal, calcifications, lesions, abdomen,

The CT scan reveals multiple findings that could potentially have significant medical implications, such as cirrhosis, a possible hernia with incarcerated fat, and various nodules that require follow-up. Some of these findings, like the suggestion of cirrhosis and the anterior abdominal wall hernia, might necessitate monitoring or intervention to prevent serious health complications. However, immediate life-threatening conditions are not apparent, as there is no mention of acute severe symptoms or critical findings that require urgent action. Thus, while the findings are serious and warrant attention, they are not extremely high-stakes life-threatening issues at this moment.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Neuropsychological Evaluation - 1

REASON FOR EVALUATION: , The patient is a 37-year-old white single male admitted to the hospital through the emergency room.  I had seen him the day before in my office and recommended him to go into the hospital.  He had just come from a trip to Taho in Nevada and he became homicidal while there.  He started having thoughts about killing his mother.  He became quite frightened by that thought and called me during the weekend we were able to see him on that Tuesday after talking to him.,HISTORY OF PRESENT ILLNESS: , This is a patient that has been suffering from a chronic psychotic condition now for a number of years.  He began to have symptoms when he was approximately 18 or 19 with auditory and visual hallucinations and paranoid delusions.  He was using drugs and smoking marijuana at that time has experimenting with LXV and another drugs too.  The patient has not used any drugs since age 25.  However, he has continued having intense and frequent psychotic bouts.  I have seen him now for approximately one year.  He has been quite refractory to treatment.  We tried different types of combination of medications, which have included Clozaril, Risperdal, lithium, and Depakote with partial response and usually temporary.  The patient has had starting with probably has had some temporary relief of the symptoms and they usually do not last more than a few days.  The dosages that we have used have been very high.  He has been on Clozaril 1200 mg combined with Risperdal up to 9 mg and lithium at a therapeutic level.  However, he has not responded.,He has delusions of antichrist.  He strongly believes that the dogs have a home in the neighborhood are communicating with him and criticizing him and he believes that all the people can communicate to him with telepathy including the animals.  He has paranoid delusions.  He also gets homicidal like prior to this admission.,PAST PSYCHIATRIC HISTORY:,  As mentioned before, this patient has been psychotic off and on for about 20 years now.  He has had years in which he did better on Clozaril and also his other medications.,With typical anti-psychotics, he has done well at times, but he eventually gets another psychotic bout.,PAST MEDICAL HISTORY: , He has a history of obesity and also of diabetes mellitus.  However, most recently, he has not been treated for diabetes since his last regular weight since he stopped taking Zyprexa.  The patient has chronic bronchitis.  He smokes cigarettes constantly up to 60 a day.,DRUG HISTORY:,  He stopped using drugs when he was 25.  He has got a lapse, but he was more than 10 years and he has been clean ever since then.  As mentioned before, he smokes cigarettes quite heavily and which has been a problem for his health since he also has chronic bronchitis.,PSYCHOSOCIAL STATUS: , The patient lives with his mother and has been staying with her for a few years now.  We have talked to her.  She is very supportive.  His only sister is also very supportive of him.  He has lived in the ABCD houses in the past.  He has done poorly in some of them.,MENTAL STATUS EXAMINATION:,  The patient appeared alert, oriented to time, place, and person.  His affect is flat.  He talked about auditory hallucinations, which are equivocal in nature.  He is not homicidal in the hospital as he was when he was at home.  His voice and speech are normal.  He believes in telepathy.  His memory appears intact and his intelligence is calculated as average.,INITIAL DIAGNOSES:,AXIS I:  Schizophrenia.,AXIS II:  Deferred.,AXIS III:  History of diabetes mellitus, obesity, and chronic bronchitis.,AXIS IV:  Moderate.,AXIS V:  GAF of 35 on admission.,INITIAL TREATMENT AND PLAN:,  Since, the patient has been on high dosages of medications, we will give him a holiday and a structured environment.  We will put him on benzodiazepines and make a decision anti-psychotic later.  We will make sure that he is safe and that he addresses his medical needs well.
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DESCRIPTION: Sample for Neuropsychological Evaluation

consult - history and phy., neuropsychological, gaf, schizophrenia, anti-psychotic, chronic psychotic condition, delusions, hallucination, homicidal, marijuana, psychological, psychotic, smokes cigarettes, smoking, neuropsychological evaluation, clozaril, bronchitis, axis,

The situation involves a patient with a severe, chronic mental health condition, schizophrenia, experiencing psychotic symptoms and expressing homicidal thoughts, which pose a significant risk to themselves and potentially to others. The patient's mental state requires hospitalization and adjustments in treatment to ensure safety and address medical needs effectively.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 13

PREOPERATIVE DIAGNOSIS: , History of polyps.,POSTOPERATIVE DIAGNOSES:,1.  Normal colonoscopy, left colonic diverticular disease.,2.  3+ benign prostatic hypertrophy.,PROCEDURE PERFORMED: , Total colonoscopy and photography.,GROSS FINDINGS: , This is a 74-year-old white male here for recheck colonoscopy for a history of polyps.  After signed informed consent, blood pressure monitoring, EKG monitoring, and pulse oximetry monitoring, he was brought to the Endoscopic Suite.  He was given 100 mg of Demerol, 3 mg of Versed IV push slowly.  Digital examination revealed a large prostate for which he is following up with his urologist.  No nodules.  3+ BPH.  Anorectal canal was within normal limits.  No stricture tumor or ulcer.  The Olympus CF 20L video endoscope was inserted per anus.  The anorectal canal was visualized, was normal.  The sigmoid, descending, splenic, and transverse showed scattered diverticula.  The hepatic, ascending, cecum, and ileocecal valve was visualized and was normal.  The colonoscope was removed.  The air was aspirated.  The patient was discharged with high-fiber, diverticular diet.  Recheck colonoscopy three years.
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DESCRIPTION: History of polyps.  Total colonoscopy and photography.  Normal colonoscopy, left colonic diverticular disease.  3+ benign prostatic hypertrophy.

surgery, digital examination, benign prostatic hypertrophy, anorectal canal, diverticular disease, photography, anorectal, colonoscopy,

The situation pertains to a routine medical procedure, specifically a follow-up colonoscopy in a 74-year-old male with a history of polyps. While the preoperative situation indicates a need for screening due to history, the result shows normal findings with benign conditions such as colonic diverticular disease and benign prostatic hypertrophy. It is important for the patient's health management, but it's not life-threatening or an emergency, which lowers its high-stakes nature. Overall, this would be considered routine follow-up care in a medical setting.


Medical Specialty: Ophthalmology
Sample Name: Tube Shunt - Ahmed Valve Implant

PREOPERATIVE DIAGNOSIS: ,Open angle glaucoma OX,POSTOPERATIVE DIAGNOSIS:, Open angle glaucoma OX,PROCEDURE:, Ahmed valve model S2 implant with pericardial reinforcement XXX eye,INDICATIONS: ,This is a XX-year-old (wo)man with glaucoma in the OX eye, uncontrolled by maximum tolerated medical therapy.,PROCEDURE: ,The risks and benefits of glaucoma surgery were discussed at length with the patient including bleeding, infection, reoperation, retinal detachment, diplopia, ptosis, loss of vision, and loss of the eye, corneal hemorrhage, hypotony, elevated pressure, worsening of glaucoma, and corneal edema. Informed consent was obtained. Patient received several sets of drops in his/her XXX eye including Ocuflox and Ocular. (S)He was taken to the operating room where monitored anesthetic care was initiated. Retrobulbar anesthesia was then administered to the XXX eye using a 50:50 mixture of 2% plain lidocaine and 0.05% Marcaine. The XXX eye was then prepped and draped in the usual sterile ophthalmic fashion. A speculum was placed on the eyelids and microscope was brought into position. A #7-0 Vicryl suture was passed through the superotemporal limbus and traction suture was placed at the superotemporal limbus and the eye was rotated infranasally so as to expose the superotemporal conjunctiva. At this point, smooth forceps and Westcott scissors were used to create a 100-degree superotemporal conjunctival peritomy, approximately 2 mm posterior to the superotemporal limbus. This was then dissected anteriorly to the limbus edge and then posteriorly. Steven scissors were then dissected in a superotemporal quadrant between the superior and lateral rectus muscles to provide good exposure. At this point, we primed the Ahmed valve with a #27 gauge cannula using BSS and it was noted to be patent. We then placed Ahmed valve in the superotemporal subconjunctival recess underneath the subtenon space and this was pushed posteriorly. We then measured with calipers so that it was positioned 9 mm posterior to the limbus. The Ahmed valve was then tacked down with #8-0 nylon suture through both fenestrations. We then applied light cautery to the superotemporal episcleral bed. We placed a paracentesis at the temporal position and inflated the anterior chamber with a small amount of Healon. We then used a #23 gauge needle and entered the superotemporal sclera, approximately 1 mm posterior to the limbus into the anterior chamber away from iris and away from cornea. We then trimmed the tube, beveled up in a 30 degree fashion with Vannas scissors, and introduced the tube through the #23 gauge tract into the anterior chamber so that approximately 2-3 mm of tube was extending into the anterior chamber. We burped some of the Healon out of the anterior chamber and filled it with BSS and we felt that the tube was in good position away from the lens, away from the cornea, and away from the iris. We then tacked down the tubes to the sclera with #8-0 Vicryl suture in a figure-of- eight fashion. The pericardium was soaked in gentamicin. We then folded the pericardium 1x1 cm piece onto itself and then placed it over the tube and this was tacked down in all four quadrants to the sclera with #8-0 nylon suture. At this point, we then re-approximated the conjunctiva to its original position and we closed it with an #8-0 Vicryl suture on a TG needle in a running fashion with interrupted locking bites. We then removed the traction suture. At the end of the case, the pupil was round, the chamber was deep, the tube appeared to be well positioned. The remaining portion of the Healon was burped out of the anterior chamber with BSS and the pressure was felt to be adequate. The speculum was removed. Ocuflox and Maxitrol ointment were placed over the eye. Then, an eye patch and shield were placed over the eye. The patient was awakened and taken to the recovery room in stable condition.
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DESCRIPTION: Tube Shunt  - Ahmed valve model S2 implant with pericardial reinforcement - Sample/Template.

ophthalmology, tube shunt, ahmed valve, healon, maxitrol ointment, ocuflox, open angle, anterior chamber, bleeding, conjunctival peritomy, cornea, corneal edema, corneal hemorrhage, diplopia, elevated pressure, glaucoma, hypotony, infection, loss of the eye, loss of vision, ophthalmic fashion, ptosis, reoperation, retinal detachment, sclera, superotemporal, worsening of glaucoma, ahmed valve model, superotemporal limbus, eye, ahmed, implant, bss, valve, limbus,

The procedure described involves surgery to implant an Ahmed valve for treating uncontrolled glaucoma. Glaucoma can lead to severe vision loss or blindness if untreated, making its management critical. The surgery itself carries risks including infection, bleeding, loss of vision, and loss of the eye which were discussed in the consent process. Because the stakes involve the potential for significant vision impairment or complications from surgery, this scenario is high-stakes in nature.


Medical Specialty: Surgery
Sample Name: Hypergranulation - Consult

CHIEF COMPLAINT:,  Non-healing surgical wound to the left posterior thigh.,HISTORY OF PRESENT ILLNESS: , This is a 49-year-old white male who sustained a traumatic injury to his left posterior thighthis past year while in ABCD.  He sustained an injury from the patellar from a boat while in the water.  He was air lifted actually up to XYZ Hospital and underwent extensive surgery.  He still has an external fixation on it for the healing fractures in the leg and has undergone grafting and full thickness skin grafting closure to a large defect in his left posterior thigh, which is nearly healed right in the gluteal fold on that left area.  In several areas right along the graft site and low in the leg, the patient has several areas of hypergranulation tissue.  He has some drainage from these areas.  There are no signs and symptoms of infection.  He is referred to us to help him get those areas under control.,PAST MEDICAL HISTORY:,  Essentially negative other than he has had C. difficile in the recent past.,ALLERGIES:,  None.,MEDICATIONS: , Include Cipro and Flagyl.,PAST SURGICAL HISTORY: , Significant for his trauma surgery noted above.,FAMILY HISTORY: , His maternal grandmother had pancreatic cancer.  Father had prostate cancer.  There is heart disease in the father and diabetes in the father.,SOCIAL HISTORY:,  He is a non-cigarette smoker and non-ETOH user.  He is divorced.  He has three children.  He has an attorney.,REVIEW OF SYSTEMS:,CARDIAC:  He denies any chest pain or shortness of breath.,GI:  As noted above.,GU:  As noted above.,ENDOCRINE:  He denies any bleeding disorders.,PHYSICAL EXAMINATION:,GENERAL:  He presents as a well-developed, well-nourished 49-year-old white male who appears to be in no significant distress.,HEENT:  Unremarkable.,NECK:  Supple.  There is no mass, adenopathy, or bruit.,CHEST:  Normal excursion.,LUNGS:  Clear to auscultation and percussion.,COR:  Regular.  There is no S3, S4, or gallop.  There is no murmur.,ABDOMEN:  Soft.  It is nontender.  There is no mass or organomegaly.,GU:  Unremarkable.,RECTAL:  Deferred.,EXTREMITIES:  His right lower extremity is unremarkable.  Peripheral pulse is good.  His left lower extremity is significant for the split thickness skin graft closure of a large defect in the posterior thigh, which is nearly healed.  The open areas that are noted above __________ hypergranulation tissue both on his gluteal folds on the left side.  There is one small area right essentially within the graft site, and there is one small area down lower on the calf area.  The patient has an external fixation on that comes out laterally on his left thigh.  Those pin sites look clean.,NEUROLOGIC:  Without focal deficits.  The patient is alert and oriented.,IMPRESSION: , Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.,PLAN:,  Plan would be for chemical cauterization of these areas.  Series of treatment with chemical cauterization till these are closed.
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DESCRIPTION: Non-healing surgical wound to the left posterior thigh. Several multiple areas of hypergranulation tissue on the left posterior leg associated with a sense of trauma to his right posterior leg.

The situation involves a non-healing surgical wound with hypergranulation tissue, which, while not immediately life-threatening, still requires careful management and could potentially lead to complications such as infection if not treated properly. The case involves a significant traumatic injury followed by extensive surgery, and the patient has already experienced prolonged recovery with an external fixation in place. While there are no current signs of infection, the stakes are moderate because of the potential for complications that require attention and treatment.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Consultation - 6

INDICATIONS: , Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.,HISTORY OF PRESENT ILLNESS:,  The patient is a 78-year-old white female with no prior cardiac history.  She sustained a mechanical fall with a subsequent left femoral neck fracture.  She was transferred to XYZ Hospital for definitive care.  In the emergency department of XYZ, the patient described six to seven seconds of sharp chest pain without radiation, without associated symptoms.  Electrocardiogram was obtained, which showed nonspecific ST-segment flattening in the high lateral leads I, aVL.  She also had a left axis deviation.  Serial troponins were obtained.  She has had four negative troponins since admission.  Due to age and chest pain history, a cardiology consultation was requested preoperatively.,At the time of my evaluation, the patient complained of left hip pain, but no chest pain, dyspnea, or symptomatic dysrhythmia.,PAST MEDICAL HISTORY:,1.  Mesothelioma.,2.  Recurrent urinary tract infections.,3.  Gastroesophageal reflux disease/gastritis.,4.  Osteopenia.,5.  Right sciatica.,6.  Hypothyroidism.,7.  Peripheral neuropathy.,8.  Fibromyalgia.,9.  Chart review also suggests she has atherosclerotic heart disease and pneumothorax.  The patient denies either of these.,PAST SURGICAL HISTORY:,1.  Tonsillectomy.,2.  Hysterectomy.,3.  Appendectomy.,4.  Thyroidectomy.,5.  Coccygectomy.,6.  Cystoscopies times several.,7.  Bladder neck resuspension.,8.  Multiple breast biopsies.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,MEDICATIONS:,  At the time of evaluation include, 1.  Cefazolin 1 g intravenous (IV).  2.  Morphine sulfate.  3.  Ondansetron p.r.n.,OUTPATIENT MEDICATIONS: , 1.  Robaxin.  2.  Detrol 4 mg q.h.s.  3.  Neurontin 300 mg p.o. t.i.d.  4.  Armour Thyroid 90 mg p.o. daily.  5.  Temazepam, dose unknown p.r.n.  6.  Chloral hydrate, dose unknown p.r.n.,FAMILY HISTORY: , Mother had myocardial infarction in her 40s, died of heart disease in her 60s, specifics not known.  She knows nothing of her father's history.  She has no siblings.  There is no other history of premature atherosclerotic heart disease in the family.,SOCIAL HISTORY: , The patient is married, lives with her husband.  She is a lifetime nonsmoker, nondrinker.  She has not been getting regular exercise for approximately two years due to chronic sciatic pain.,REVIEW OF SYSTEMS: ,GENERAL:  The patient is able to walk one block or less prior to the onset of significant leg pain.  She ever denies any cardiac symptoms with this degree of exertion.  She denies any dyspnea on exertion or chest pain with activities of daily living.  She does sleep on two to three pillows, but denies orthopnea or paroxysmal nocturnal dyspnea.  She does have chronic lower extremity edema.  Her husband states that she has had prior chest pain in the past, but this has always been attributed to gastritis.  She denies any palpitations or tachycardia.  She has remote history of presyncope, no true syncope.,HEMATOLOGIC:  Negative for bleeding diathesis or coagulopathy.,ONCOLOGIC:  Remarkable for past medical history.,PULMONARY:  Remarkable for childhood pneumonia times several.  No recurrent pneumonias, bronchitis, reactive airway disease as an adult.,GASTROINTESTINAL:  Remarkable for past medical history.,GENITOURINARY:  Remarkable for past medical history.,MUSCULOSKELETAL:  Remarkable for past medical history.,CENTRAL NERVOUS SYSTEM:  Negative for tic, tremor, transient ischemic attack (TIA), seizure, or stroke.,PSYCHIATRIC:  Remarkable for history of depression as an adolescent, she was hospitalized at State Mental Institution as a young woman.  No recurrence.,PHYSICAL EXAMINATION:,GENERAL:  This is a well-nourished, well-groomed elderly white female who is appropriate and articulate at the time of evaluation.,VITAL SIGNS:  She has had a low-grade temperature of 100.4 degrees Fahrenheit on 11/20/2006, currently 99.6.  Pulse ranges from 123 to 86 beats per minute.  Blood pressure ranges from 124/65 to 152/67 mmHg.  Oxygen saturation on 2 L nasal cannula was 94%.,HEENT:  Exam is benign.  Normocephalic and atraumatic.  Extraocular motions are intact.  Sclerae anicteric.  Conjunctivae noninjected.  She does have bilateral arcus senilis.  Oral mucosa is pink and moist.
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DESCRIPTION: Preoperative cardiac evaluation in the patient with chest pain in the setting of left hip fracture.

The situation involves a preoperative cardiac evaluation for a 78-year-old female with a hip fracture and a history of chest pain. The stakes are high due to the risk factors associated with surgical procedures in elderly patients, especially with the presence of chest pain, potential cardiac issues, and a need for surgery to address the hip fracture. Given her age, medical history, and the need for accurate assessment to prevent perioperative cardiac complications, this is a high-stakes medical situation.


Medical Specialty: Discharge Summary
Sample Name: Speech Therapy - Discharge Summary

LONG-TERM GOALS:,  Both functional and cognitive-linguistic ability to improve safety and independence at home and in the community.  This goal has been met based on the patient and husband reports the patient is able to complete all activities, which she desires to do at home.  During the last reevaluation, the patient had a significant progress and all cognitive domains evaluated, which are attention, memory, executive functions, language, and visuospatial skill.  She continues to have an overall mild cognitive-linguistic deficit, but this is significantly improved from her initial evaluation, which showed severe impairment., ,The patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued.  The patient and her husband both agreed with the patient's discharge.
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DESCRIPTION: Speech therapy discharge summary.  The patient was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.

discharge summary, narrative, memory, executive function, attention, speech therapy, visuospatial, accuracy, linguistic, cognitive, speechNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The discharge summary highlights a patient who has completed speech therapy with significant improvements, meeting all goals set for independence and safety at home and in the community. The patient no longer requires skilled therapy, and all parties agree with this decision. While cognitive-linguistic deficits remain, they have improved significantly, and the situation does not involve immediate risk or critical health conditions.


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

ADMISSION DIAGNOSES:,1.  Pyelonephritis.,2.  History of uterine cancer and ileal conduit urinary diversion.,3.  Hypertension.,4.  Renal insufficiency.,5.  Anemia.,DISCHARGE DIAGNOSES:,1.  Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit.,2.  Hypertension.,3.  Mild renal insufficiency.,4.  Anemia, which has been present chronically over the past year.,HOSPITAL COURSE:,  The patient was admitted with suspected pyelonephritis.  Renal was consulted.  It was thought that there was a thick mucous plug in the Foley in the ileal conduit that was irrigated by Dr. X.  Her symptoms responded to IV antibiotics and she remained clinically stable.  Klebsiella was isolated in this urine, which was sensitive to Bactrim and she was discharged on p.o.  Bactrim.  She was scheduled on 08/07/2007 for further surgery.  She is to follow up with Dr. Y in 7-10 days.  She also complained of right knee pain and the right knee showed no sign of effusion.  She was exquisitely tender to touch of the patellar tendon.  It was thought that this did not represent intraarticular process.  She was advised to use ibuprofen over-the-counter two to three tabs t.i.d.
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DESCRIPTION: Pyelonephritis likely secondary to mucous plugging of indwelling Foley in the ileal conduit, hypertension, mild renal insufficiency, and anemia, which has been present chronically over the past year.

discharge summary, uterine cancer, renal insufficiency, pyelonephritis, mucous plugging, ileal conduit

The discharge summary indicates a patient with multiple comorbidities, including pyelonephritis, hypertension, mild renal insufficiency, and a history of cancer with an ileal conduit urinary diversion. Although pyelonephritis is being treated and the patient's condition is stable, the combination of multiple chronic conditions, a planned surgery, and the specific challenges related to the patient's urinary diversion raise the stakes. The situation is significant for the patient's healthcare management but not critical at this moment, given the patient is stable and scheduled for follow-up.


Medical Specialty: Discharge Summary
Sample Name: Otitis Media - Discharge Summary

ADMITTING DIAGNOSES:,1.  Fever.,2.  Otitis media.,3.  Possible sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-month-old male who was seen in the office 1 day prior to admission.  He has had a 2-day history of fever that has gone up to as high as 103.6 degrees F. He has also had intermittent cough, nasal congestion, and rhinorrhea and no history of rashes.  He has been taking Tylenol and Advil to help decrease the fevers, but the fever has continued to rise.  He was noted to have some increased workup of breathing and parents returned to the office on the day of admission.,PAST MEDICAL HISTORY: , Significant for being born at 33 weeks' gestation with a birth weight of 5 pounds and 1 ounce.,PHYSICAL EXAMINATION: , On exam, he was moderately ill appearing and lethargic.  HEENT:  Atraumatic, normocephalic.  Pupils are equal, round, and reactive to light.  Tympanic membranes were red and yellow, and opaque bilaterally.  Nares were patent.  Oropharynx was slightly moist and pink.  Neck was soft and supple without masses.  Heart is regular rate and rhythm without murmurs.  Lungs showed increased workup of breathing, moderate tachypnea.  No rales, rhonchi or wheezes were noted.  Abdomen:  Soft, nontender, nondistended.  Active bowel sounds.  Neurologic exam showed good muscle strength, normal tone.  Cranial nerves II through XII are grossly intact.,LABORATORY FINDINGS: , He had electrolytes, BUN and creatinine, and glucose all of which were within normal limits.  White blood cell count was 8.6 with 61% neutrophils, 21% lymphocytes, 17% monocytes, suggestive of a viral infection.  Urinalysis was completely unremarkable.  Chest x-ray showed a suboptimal inspiration, but no evidence of an acute process in the chest.,HOSPITAL COURSE: , The patient was admitted to the hospital and allowed a clear liquid diet.  Activity is as tolerates.  CBC with differential, blood culture, electrolytes, BUN, and creatinine, glucose, UA, and urine culture all were ordered.  Chest x-ray was ordered as well with 2 views to evaluate for a possible pneumonia.  Pulse oximetry checks were ordered every shift and as needed with O2 ordered per nasal cannula if O2 saturations were less that 94%.  Gave D5 and quarter of normal saline at 45 mL per hour, which was just slightly above maintenance rate to help with hydration.  He was given ceftriaxone 500 mg IV once daily to treat otitis media and possible sepsis, and I will add Tylenol and ibuprofen as needed for fevers.  Overnight, he did have his oxygen saturations drop and went into oxygen overnight.  His lungs remained clear, but because of the need for O2, we instituted albuterol aerosols every 6 hours to help maintain good lung function.  The nurses were instructed to attempt to wean O2 if possible and advance the diet.  He was doing clear liquids well and so I saline locked to help to accommodate improve the mobility with the patient.  He did well the following evening with no further oxygen requirement.  He continued to spike fevers but last fever was around 13:45 on the previous day.  At the time of exam, he had 100% oxygen saturations on room air with temperature of 99.3 degrees F. with clear lungs.  He was given additional dose of Rocephin when it was felt that it would be appropriate for him to be discharged that morning.,CONDITION OF THE PATIENT AT DISCHARGE: , He was at 100% oxygen saturations on room air with no further dips at night.  He has become afebrile and was having no further increased work of breathing.,DISCHARGE DIAGNOSES:,1.  Bilateral otitis media.,2.  Fever.,PLAN:  ,Recommended discharge.  No restrictions in diet or activity.  He was continued Omnicef 125 mg/5 mL one teaspoon p.o. once daily and instructed to follow up with Dr. X, his primary doctor, on the following Tuesday.  Parents were instructed also to call if new symptoms occurred or he had return if difficulties with breathing or increased lethargy.
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DESCRIPTION: Fever, otitis media, and possible sepsis.

discharge summary, sepsis, cough, nasal congestion, rhinorrhea, oxygen saturations, otitis media, otitis, breathing, lungs, oropharynx, fever

The situation involves a 10-month-old infant admitted to the hospital with otitis media, fever, and possible sepsis. Infants are particularly vulnerable, and sepsis is a serious condition that can be life-threatening if not managed properly. The medical team monitored the child closely and intervened with antibiotics and supportive care, which ultimately stabilized his condition. Although the immediate risk to the child was mitigated, the initial concern of sepsis and the need for oxygen therapy indicate a high-stakes medical situation. The health and life of an infant were at risk, requiring careful and prompt medical attention. Therefore, while the discharge summary indicates stabilization, the initial circumstances were critical.


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

ADMISSION DIAGNOSES:,1.  Pneumonia, likely secondary to aspiration.,2.  Chronic obstructive pulmonary disease (COPD) exacerbation.,3.  Systemic inflammatory response syndrome.,4.  Hyperglycemia.,DISCHARGE DIAGNOSES:,1.  Aspiration pneumonia.,2.  Aspiration disorder in setting of severe chronic obstructive pulmonary disease.,3.  Chronic obstructive pulmonary disease (COPD) exacerbation.,4.  Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.,5.  Hypercapnia on admission secondary to chronic obstructive pulmonary disease.,6.  Systemic inflammatory response syndrome secondary to aspiration pneumonia.  No bacteria identified with blood cultures or sputum culture.,7.  Atrial fibrillation with episodic rapid ventricular rate, now rate control.,8.  Hyperglycemia secondary to poorly controlled type ii diabetes mellitus, insulin requiring.,9.  Benign essential hypertension, poorly controlled on admission, now well controlled on discharge.,10.  Aspiration disorder exacerbated by chronic obstructive pulmonary disease and acute respiratory failure.,11.  Hyperlipidemia.,12.  Acute renal failure on chronic renal failure on admission, now resolved.,HISTORY OF PRESENT ILLNESS:,  Briefly, this is 73-year-old white male with history of multiple hospital admissions for COPD exacerbation and pneumonia who presented to the emergency room on 04/23/08, complaining of severe shortness of breath.  The patient received 3 nebulizers at home without much improvement.  He was subsequently treated successfully with supplemental oxygen provided by normal nasal cannula initially and subsequently changed to BiPAP.,HOSPITAL COURSE:  ,The patient was admitted to the hospitalist service, treated with frequent small volume nebulizers, treated with IV Solu-Medrol and BiPAP support for COPD exacerbation.  The patient also noted with poorly controlled atrial fibrillation with a rate in the low 100s to mid 100s.  The patient subsequently received diltiazem, also received p.o. digoxin.  The patient subsequently responded well as well received IV antibiotics including Levaquin and Zosyn.  The patient made slow, but steady improvement over the course of his hospitalization.  The patient subsequently was able to be weaned off BiPAP during the day, but continued BiPAP at night and will continue with BiPAP if needed.  The patient may require a sleep study after discharge, but by the third day prior to discharge he was no longer utilizing BiPAP, was simply using supplemental O2 at night and was able to maintain appropriate and satisfactory O2 saturations on one-liter per minute supplemental O2 per nasal cannula.  The patient was able to participate with physical therapy, able to ambulate from his bed to the bathroom, and was able to tolerate a dysphagia 2 diet.  Note that speech therapy did provide a consultation during this hospitalization and his modified barium swallow was thought to be unremarkable and really related only to the patient's severe shortness of breath during meal time.  The patient's chest x-ray on admission revealed some mild vascular congestion and bilateral pleural effusions that appeared to be unchanged.  There was also more pronounced patchy alveolar opacity, which appeared to be, "mass like" in the right suprahilar region.  This subsequently resolved and the patient's infiltrate slowly improved over the course of his hospitalization.  On the day prior to discharge, the patient had a chest x-ray 2 views, which allowing for differences in technique revealed little change in the bibasilar infiltrates and atelectatic changes at the bases bilaterally.  This was compared with an examination performed 3 days prior.  The patient also had minimal bilateral effusions.  The patient will continue with clindamycin for the next 2 weeks after discharge.  Home health has been ordered and the case has been discussed in detail with Shaun Eagan, physician assistant at Eureka Community Health Center.  The patient was discharged as well on a dysphagia 2 diet, thin liquids are okay.  The patient discharged on the following medications.,DISCHARGE MEDICATIONS:,1.  Home oxygen 1 to 2 liters to maintain O2 saturations at 89 to 91% at all times.,2.  Ativan 1 mg p.o. t.i.d.,3.  Metformin 1000 mg p.o. b.i.d.,4.  Glucotrol 5 mg p.o. daily.,5.  Spiriva 1 puff b.i.d.,6.  Lantus 25 units subcu q.a.m.,7.  Cardizem CD 180 mg p.o. q.a.m.,8.  Advair 250/50 mcg, 1 puff b.i.d.  The patient is instructed to rinse with mouthwash after each use.,9.  Iron 325 mg p.o. b.i.d.,10.  Aspirin 325 mg p.o. daily.,11.  Lipitor 10 mg p.o. bedtime.,12.  Digoxin 0.25 mg p.o. daily.,13.  Lisinopril 20 mg p.o. q.a.m.,14.  DuoNeb every 4 hours for the next several weeks, then q.6 h. thereafter, dispensed 180 DuoNeb ampule's with one refill.,15.  Prednisone 40 mg p.o. q.a.m. x3 days followed by 30 mg p.o. q.a.m. x3 days, then followed by 20 mg p.o. q.a.m. x5 days, then 10 mg p.o. q.a.m. x14 days, then discontinue, #30 days supply given.  No refills.,16.  Clindamycin 300 mg p.o. q.i.d. x2 weeks, dispensed #64 with one refill.,The patient's aspiration pneumonia was discussed in detail.  He is agreeable to obtaining a chest x-ray PA and lateral after 2 weeks of treatment.  Note that this patient did not have community-acquired pneumonia.  His discharge diagnosis is aspiration pneumonia.  The patient will continue with a dysphagia 2 diet with thin liquids after discharge.  The patient discharged with home health.  A dietary and speech therapy evaluation has been ordered.  Speech therapy to treat for chronic dysphagia and aspiration in the setting of severe chronic obstructive pulmonary disease.,Total discharge time was greater than 30 minutes.
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DESCRIPTION: Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation.  Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.  Systemic inflammatory response syndrome secondary to aspiration pneumonia.  No bacteria identified with blood cultures or sputum culture.

The discharge summary describes a complex case with multiple serious medical conditions including aspiration pneumonia, COPD exacerbation, acute respiratory failure, and other comorbidities such as atrial fibrillation and diabetes. The patient is elderly and has a history of frequent hospital admissions, highlighting their vulnerability. The treatment plan involves a detailed regimen of medications and continued use of medical devices like BiPAP, along with home health services and dietary considerations. While the patient is stable enough for discharge, the complexity and potential for deterioration make this a high-stakes situation as it involves significant risk of readmission or complications if the condition is not managed properly post-discharge.


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

PRELIMINARY DIAGNOSES:,1.  Contusion of the frontal lobe of the brain.,2.  Closed head injury and history of fall.,3.  Headache, probably secondary to contusion.,FINAL DIAGNOSES:,1.  Contusion of the orbital surface of the frontal lobes bilaterally.,2.  Closed head injury.,3.  History of fall.,COURSE IN THE HOSPITAL: , This is a 29-year-old male, who fell at home.  He was seen in the emergency room due to headache.  CT of the brain revealed contusion of the frontal lobe near the falx.  The patient did not have any focal signs.  He was admitted to ABCD.  Neurology consultation was obtained.  Neuro checks were done.  The patient continued to remain stable, although he had some frontal headache.  He underwent an MRI to rule out extension of the contusion or the possibility of a bleed and the MRI of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure.  The patient remained clinically stable and his headache resolved.  He was discharged home on 11/6/2008.,PLAN: , Discharge the patient to home.,ACTIVITY:  ,As tolerated.,The patient has been advised to call if the headache is recurrent and Tylenol 650 mg 1 p.o. q.6 h. p.r.n. headache.  The patient has been advised to follow up with me as well as the neurologist in about 1 week.
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DESCRIPTION: Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.

discharge summary, interhemispheric, frontal lobe, head injury, brain, contusion

The situation involves a patient who has sustained brain contusions and a closed head injury from a fall. While the patient is stable and has been discharged, handling brain injuries requires careful monitoring for possible complications such as internal bleeding or worsening symptoms. However, the immediate risk seems low as the patient has been stable and is being managed with follow-up instructions and pain management. Thus, while it remains a serious condition, the immediate stakes are moderate due to the steps already taken in the hospital and the discharge with a plan for follow-up.


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

ADMISSION DIAGNOSES:,1.  Pneumonia, failed outpatient treatment.,2.  Hypoxia.,3.  Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1.  Atypical pneumonia, suspected viral.,2.  Hypoxia.,3.  Rheumatoid arthritis.,4.  Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.  She was seen on multiple occasions at Urgent Care and in her physician's office.  Initial x-ray showed some mild diffuse patchy infiltrates.  She was first started on Avelox, but had a reaction, switched to Augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin.  Her O2 saturations drifted downward.  They were less than 88% when active; at rest, varied between 88% and 92%.  Decision was made because of failed outpatient treatment of pneumonia.  Her medical history is significant for rheumatoid arthritis.  She is on 20 mg of methotrexate every week as well as Remicade every eight weeks.  Her last dose of Remicade was in the month of June.  Hospital course was relatively unremarkable.  CT scan was performed and no specific focal pathology was seen.  Dr. X, pulmonologist was consulted.  He also was uncertain as to the exact etiology, but viral etiology was most highly suspected.  Because of her loose stools, C. difficile toxin was ordered, although that is pending at the time of discharge.  She was continued on Rocephin IV and azithromycin.  Her fever broke 18 hours prior to discharge, and O2 saturations improved, as did her overall strength and clinical status.  She was instructed to finish azithromycin.  She has two pills left at home.  She is to follow up with Dr. X in two to three days.  Because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia.  She is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day).  We will consult her rheumatologist as to whether to continue her methotrexate, which we held this past Friday.  Methotrexate is known on some occasions to cause pneumonitis.
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DESCRIPTION: Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency.  This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.

discharge summary, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia,

The scenario involves an elderly patient with multiple health issues, including pneumonia, rheumatoid arthritis, and potential adrenal insufficiency. While the patient has shown improvement over the hospital stay, the combination of these conditions and her age places the discharge situation at a moderate to moderately high stakes level. There is a need for careful follow-up regarding her oxygen levels, continuation of medication, and consultation with specialists. The ramifications of poorly managed care could lead to health deterioration or hospital readmission, but the immediate discharge plan appears well-considered with scheduled follow-ups.


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

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

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

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


Medical Specialty: Discharge Summary
Sample Name: Laryngitis - Discharge

DIAGNOSIS: , Chronic laryngitis, hoarseness.,HISTORY:  ,The patient is a 68-year-old male, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.  The patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene.  The patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions.  The patient made great progress and he came in to discuss with an appointment on 12/23/08 stating that his voice had finally returned to "normal".,SHORT-TERM GOALS:,1.  To be independent with relaxation and stretching exercises and Lessac-Madsen Resonant Voice Therapy Protocol.,2.  He also met short-term goal therapy 3 and he is independent with resonant voice therapy tasks.,3.  We did not complete his __________ ratio during his last session; so, I am unsure if he had met his short-term goal number 2.,4.  To be referred for a videostroboscopy, but at this time, the patient is not in need of this evaluation.  However, in the future if hoarseness returns, it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy.,LONG-TERM GOALS:,1.  The patient did reach his long-term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty.,2.  The patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy.,The patient is discharged from my services at this time with a home program to continue to promote normal voicing.
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DESCRIPTION: Chronic laryngitis, hoarseness.  The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.

discharge summary, vocal hygiene, voice activities, hoarseness, skilled speech therapy, chronic laryngitis, voice therapy, resonant voice, videostroboscopy, laryngitis

This situation involves the discharge summary of a patient with chronic laryngitis who has successfully completed speech therapy and achieved the goals of returning to normal vocal function. While important for the patient's ongoing health and quality of life, this situation does not carry significant immediate risks or life-threatening consequences that would classify it as high-stakes. The patient has been discharged with a home program to maintain their progress, indicating resolution and low complexity of the current issue.


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

ADMISSION DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,DISCHARGE DIAGNOSES,1.  Neck pain with right upper extremity radiculopathy.,2.  Cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression C4-C5, C5-C6, and C6-C7.,2.  Arthrodesis with anterior interbody fusion C4-C5, C5-C6, and C6-C7.,3.  Spinal instrumentation C4 through C7.,4.  Implant.,5.  Allograft.,COMPLICATIONS:,  None.,COURSE ON ADMISSION: , This is the case of a very pleasant 41-year-old Caucasian female who was seen in clinic as an initial consultation on 09/13/07 complaining of intense neck pain radiating to the right shoulder blade to top of the right shoulder in to the right upper extremity to the patient's hand.  The patient's symptoms have been persistent and had gotten worse with subjective weakness of the right upper extremity since its onset for several weeks now.  The patient has been treated with medications, which has been unrelenting.  The patient had imaging studies that showed evidence of cervical spondylosis with herniated disk and stenosis at C4-C5, C5-C6 and C6-C7.  The patient underwent liver surgery and postoperatively her main issue was that of some degree of on and off right shoulder pain and some operative site soreness, which was treated well with IV morphine.  The patient has resolution of the pain down the arm, but she does have some tingling of the right thumb and right index finger.  The patient apparently is doing well with slight dysphagia, we treated her with Decadron and we will send her home with Medrol.  The patient will have continued pain medication coverage with Darvocet and Flexeril.  The patient will follow up with me as scheduled.  Instructions have been given.
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DESCRIPTION: Neck pain with right upper extremity radiculopathy and cervical spondylosis with herniated nucleus pulposus C4-C5, C5-C6, and C6-C7 with stenosis.

discharge summary, radiculopathy, cervical spondylosis, neck pain, anterior cervical discectomy, herniated nucleus pulposus, cervical, anterior, herniated,

The discharge summary details a medical case involving significant neck pain and conditions that warranted surgical intervention. While there were no complications and the patient is recovering well, the surgical nature of the treatment and ongoing symptoms suggest that the situation holds medical importance. However, the stakes are not life-threatening currently, as the patient is stable and showing signs of recovery. The high-stakes part is primarily related to ensuring proper recovery and management of residual symptoms, such as tingling and slight dysphagia.


Medical Specialty: Discharge Summary
Sample Name: Lap Chole - Discharge Summary

PROCEDURE:,  Laparoscopic cholecystectomy.,DISCHARGE DIAGNOSES:,1.  Acute cholecystitis.,2.  Status post laparoscopic cholecystectomy.,3.  End-stage renal disease on hemodialysis.,4.  Hyperlipidemia.,5.  Hypertension.,6.  Congestive heart failure.,7.  Skin lymphoma 5 years ago.,8.  Hypothyroidism.,HOSPITAL COURSE: , This is a 78-year-old female with past medical condition includes hypertension, end-stage renal disease, hyperlipidemia, hypothyroidism, and skin lymphoma who had a left AV fistula done about 3 days ago by Dr. X and the patient went later on home, but started having epigastric pain and right upper quadrant pain and mid abdominal pain, some nauseated feeling, and then she could not handle the pain, so came to the emergency room, brought by the family.  The patient's initial assessment, the patient's vital signs were stable, showed temperature 97.9, pulse was 106, and blood pressure was 156/85.  EKG was not available and ultrasound of the abdomen showed there is a renal cyst about 2 cm.  There is sludge in the gallbladder wall versus a stone in the gallbladder wall.  Thickening of the gallbladder wall with positive Murphy sign.  She has a history of cholecystitis.  Urine shows positive glucose, but negative for nitrite and creatinine was 7.1, sodium 131, potassium was 5.2, and lipase and amylase were normal.  So, the patient admitted to the Med/Surg floor initially and the patient was started on IV fluid as well as low-dose IV antibiotic and 2-D echocardiogram and EKG also was ordered.  The patient also had history of CHF in the past and recently had some workup done.  The patient does not remember initially.  Surgical consult also requested and blood culture and urine culture also ordered.  The same day, the patient was seen by Dr. Y and the patient should need cholecystectomy, but the patient also needs dialysis and also needs to be cleared by the cardiologist, so the patient later on seen by Dr. Z and cleared the patient for the surgery with moderate risk and the patient underwent laparoscopic cholecystectomy.  The patient also seen by nephrologist and underwent dialysis.  The patient's white count went down 6.1, afebrile.  On postop day #1, the patient started eating and also walking.  The patient also had chronic bronchitis.  The patient was later on feeling fine, discussed with surgery.  The patient was then able to discharge to home and follow with the surgeon in about 3-5 days.  Discharged home with Synthroid 0.5 mg 1 tablet p.o. daily, Plavix 75 mg p.o. daily, folic acid 1 mg p.o. daily, Diovan 80 mg p.o. daily, Renagel 2 tablets 800 mg p.o. twice a day, Lasix 40 mg p.o.  2 tablets twice a day, lovastatin 20 mg p.o. daily, Coreg 3.125 mg p.o. twice a day, nebulizer therapy every 3 hours as needed, also Phenergan 25 mg p.o. q.8 hours for nausea and vomiting, Pepcid 20 mg p.o. daily, Vicodin 1 tablet p.o. q.6 hours p.r.n. as needed, and Levaquin 250 mg p.o. every other day for the next 5 days.  The patient also had Premarin that she was taking, advised to discontinue because of increased risk of heart disease and stroke explained to the patient.  Discharged home.
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DESCRIPTION: Laparoscopic cholecystectomy.  Acute cholecystitis, status post laparoscopic cholecystectomy, end-stage renal disease on hemodialysis, hyperlipidemia, hypertension, congestive heart failure, skin lymphoma 5 years ago, and hypothyroidism.

discharge summary, end-stage renal disease, lymphoma, cholecystitis, congestive heart failure, skin lymphoma, gallbladder wall, laparoscopic cholecystectomy

The discharge summary describes a complex medical case of a 78-year-old woman who underwent a laparoscopic cholecystectomy. She has multiple serious chronic conditions including end-stage renal disease on hemodialysis, hypertension, congestive heart failure, and a history of skin lymphoma. Although she is currently stable and ready for discharge with medical follow-up, the complexity and interplay of her conditions make this a high-stakes situation in the medical context. Proper post-discharge care and follow-up are critical to avoid complications, leading to a relatively high-stakes scenario.


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

Medical Specialty: Discharge Summary
Sample Name: Knee Osteoarthrosis - Discharge Summary

PRINCIPAL DIAGNOSIS:,  Knee osteoarthrosis.,PRINCIPAL PROCEDURE: , Total knee arthroplasty.,HISTORY AND PHYSICAL:,  A 66-year-old female with knee osteoarthrosis.  Failed conservative management.  Risks and benefits of different treatment options were explained.  Informed consent was obtained.,PAST SURGICAL HISTORY: , Right knee surgery, cosmetic surgery, and carotid sinus surgery.,MEDICATIONS: , Mirapex, ibuprofen, and Ambien.,ALLERGIES: , QUESTIONABLE PENICILLIN ALLERGIES.,PHYSICAL EXAMINATION: , GENERAL:  Female who appears younger than her stated age.  Examination of her gait reveals she walks without assistive devices.,HEENT:  Normocephalic and atraumatic.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft.,EXTREMITIES:  Grossly neurovascularly intact.,HOSPITAL COURSE: , The patient was taken to the operating room (OR) on 03/15/2007.  She underwent right total knee arthroplasty.  She tolerated this well.  She was taken to the recovery room.  After uneventful recovery room course, she was brought to regular surgical floor.  Mechanical and chemical deep venous thrombosis (DVT) prophylaxis were initiated.  Routine postoperative antibiotics were administered.  Hemovac drain was discontinued on postoperative day #2.  Physical therapy was initiated.  Continuous passive motion (CPM) was also initiated.  She was able to spontaneously void.  She transferred to oral pain medication.  Incision remained clean, dry, and intact during the hospital course.  No pain with calf squeeze.  She was felt to be ready for discharge home on 03/19/2007.,DISPOSITION:  ,Discharged to home.,FOLLOW UP:,  Follow up with Dr. X in one week.  Prescriptions were written for Percocet and Coumadin.,INSTRUCTIONS: , Home physical therapy and PT and INR to be drawn at home for adjustment of Coumadin dosing.,
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DESCRIPTION: A 66-year-old female with knee osteoarthrosis who failed conservative management.

discharge summary, total knee arthroplasty, conservative management, knee arthroplasty, physical therapy, knee osteoarthrosis, arthroplasty, osteoarthrosis, knee,

The situation described is the discharge summary of a patient who underwent a total knee arthroplasty. Discharge summaries are crucial for ensuring continuity of care post-hospitalization, as they include information on the surgical procedure, hospital course, medications, allergies, and follow-up care necessary for patient recovery. While ensuring accurate transfer of information is very important, the direct stakes of this situation are moderate; it involves regular post-operative care and follow-up procedures. There is no immediate life-threatening situation described, such as complications during surgery or severe post-operative issues, which would suggest higher stakes.


Medical Specialty: Discharge Summary
Sample Name: Goldenhar Syndrome - Discharge Summary

ADMITTING DIAGNOSES,1.  Vomiting, probably secondary to gastroenteritis.,2.  Goldenhar syndrome.,3.  Severe gastroesophageal reflux.,4.  Past history of aspiration and aspiration pneumonia.,DISCHARGE DIAGNOSES,1.  Gastroenteritis versus bowel obstruction.,2.  Gastroesophageal reflux.,3.  Goldenhar syndrome.,4.  Anemia, probably iron deficiency.,HISTORY OF PRESENT ILLNESS:,  This is a 10-week-old female infant who has Goldenhar syndrome and has a gastrostomy tube in place and a J-tube in place.  She was noted to have vomiting approximately 18 to 24 hours prior to admission and was seen in the emergency department and then admitted.,Because of her Goldenhar syndrome and previous problems with aspiration, she is not fed my mouth, but does have a G-tube.  However, she has not been tolerating feedings through this prior to admission.,PHYSICAL EXAMINATION:,GENERAL:  At transfer to UNM on October 13, 2003 reveals a dysmorphic infant who is small and slightly cachectic.  Her left side of the face is deformed with microglia present, micrognathia present, and a moderate amount of torticollis.,VITAL SIGNS:  Presently, her temperature is 98, pulse 152, respirations 36, weight is 3.98 kg, pulse oximetry on room air is 95%.,HEENT:  Head is with anterior fontanelle open.  Eyes:  Red reflex elicited bilaterally.  Left ear is without an external ear canal and the right is not well visualized at this time.  Nose is presently without any discharge, and throat is nonerythematous.  NECK:  Neck with torticollis exhibited.,LUNGS:  Presently are clear to auscultation.,HEART:  Regular rate without murmur, click or gallop present.  ABDOMEN:  Moderately distended, but soft.  Bowel sounds are decreased, and there is a G-tube and a J-tube in place.  The skin surrounding the G-tube is moderately erythematous, but without any discharges present.  J-tube is with a dressing in place and well evaluated.,EXTREMITIES:  Grossly normal.  Hip defects are not checked at this time.,GENITALIA:  Normal female.,NEUROLOGIC:  The infant does have a suck reflex, feeding grasp-reflex, and a feeding Moro reflex.,SKIN:  Warm and dry and there is a macular area to the left ___ that is approximately 1 cm in length.,LABORATORY DATA: , WBC count on October 12, 2003 is 12,600 with 16 segs, 6 bands, 54 lymphocytes, 13% of which are noted to be reactive.  Hemoglobin is 10.4, hematocrit 30.8, and she has abnormal red blood cell morphology.  RDW is 13.1 and MCV is 91.  Sodium level is 138, potassium 5.4, chloride 103, CO2 23, BUN 7, creatinine 0.4, glucose 84, calcium 9.9, and at this dictation, the report on the abdominal flat plate is pending.,HOSPITAL COURSE:  ,The child was placed at bowel rest initially and then re-tried on full strength formula, but she did not tolerate.  She was again placed on bowel rest and her medications, Pepcid and Reglan, were given in an attempt to increase bowel motility.  Feedings were re-attempted with Pedialyte through the J-tube and these did not result in production of any stool and the child then began having vomiting again.  The vomitus was noted to be bilious in nature and with particulate matter present.,After consultation with Dr. X, it was determined the child probably needed further evaluation, and she had both of her drains placed to gravity and was kept n.p.o.  Her fluids have been D5 and 0.25 normal saline with 20 mEq/L of potassium chloride, which has run at her maintenance of 16 mL/h.,CONSULTATIONS: , With Dr. X and Dr. Y and the child is now ready for transport for continued diagnosis and treatment.  Her condition at discharge is stable.
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DESCRIPTION: Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.

The discharge summary involves a 10-week-old infant with multiple significant medical conditions, including Goldenhar syndrome, gastroesophageal reflux, and possible bowel obstruction. The patient's health is fragile, involving conditions that require careful medical management, such as a history of aspiration pneumonia and the need for tube feeds. The presence of these complex medical issues, combined with the young age of the patient and the potential need for further medical interventions, makes this situation relatively high-stakes as it involves crucial decision-making for the infant's ongoing health and stability.


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

CHIEF COMPLAINT:,  Falls at home.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety.  Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home.  They noted that she frequently came to the emergency room for "attention."  The patient denied any chest pain or pressure and no change to exercise tolerance.  The patient denied any loss of consciousness or incontinence.  She denies any seizure activity.  She states that she "tripped" at home.  Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating.  They stated that she has numerous medications at home, but they were not sure if she was taking them.  The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression.  The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL:  The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Negative.,NECK:  Supple.  Carotid upstrokes are 2+.,LUNGS:  Clear.,HEART:  Normal S1 and S2.  No gallops.  Rate is regular.,ABDOMEN:  Soft.  Positive bowel sounds.  Nontender.,EXTREMITIES:  No edema.  There is some ecchymosis noted to the left great toe.  The area is tender; however, metatarsal is nontender.,NEUROLOGICAL:  Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety.  Continue Paxil and Xanax use was recommended.  The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1.  Falls ,2.  Anxiety and depression.,3.  Hypertension.,4.  Hypercholesterolemia.,5.  Coronary artery disease.,6.  Osteoarthritis.,7.  Chronic obstructive pulmonary disease.,8.  Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation.
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DESCRIPTION: Falls at home.  Anxiety and depression.  The patient had been increasingly anxious and freely admitted that she was depressed at home.

The situation described in the discharge summary represents a moderate-stakes scenario. The patient is an elderly individual who experienced a fall at home, which can be a serious concern given the risk of injury in elderly patients. There are additional layers of complexity due to the patient's reported anxiety and depression, self-medicating behavior, and a multitude of chronic conditions, including hypertension, coronary artery disease, and chronic obstructive pulmonary disease (COPD). While the immediate physical health concerns appear stable as noted by the stable vital signs and other physical examination findings, the mental health aspects and risk of medication mismanagement increase the stakes. However, the patient has been discharged to a skilled nursing facility for further rehabilitation, which should help manage these risks. Overall, this is a concerning situation, but it is being actively managed through professional care.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - Respiratory Distress

ADMITTING DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,DISCHARGE DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,3.  Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of URI symptoms, then had an abrupt onset of cough and increased work of breathing.  Child was brought to Children's Hospital and received nebulized treatments in the ER and the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,He was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress.  He also received inhaled as well as systemic corticosteroids.  An x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading.  The patient was not started on any antibiotics and his fever resolved.  However, the CRP was relatively elevated at 6.7.  The CBC was normal with a white count of 9.6; however, the bands were 84%.  Given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and Zithromax.,He was taken off of continuous and he was not on room air all night.  In the morning, he still had some bilateral wheezing, but no tachypnea.,DISCHARGE PHYSICAL EXAMINATION: , ,GENERAL:  No acute distress, running around the room.,HEENT:  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly or masses.,CHEST:  Bilateral basilar wheezing.  No distress.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses.  Nontender to palpation.,GENITOURINARY:  Deferred.,EXTREMITIES:  Warm and well perfused.,DISCHARGE INSTRUCTIONS:,  As follows:,1.  Activity, regular.,2.  Diet is regular.,3.  Follow up with Dr. X in 2 days.,DISCHARGE MEDICATIONS:,1.  Xopenex MDI 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2.  QVAR 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3.  Amoxicillin 550 mg p.o. twice daily for 10 days.,4.  Zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,Total time for this discharge 37 minutes.
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DESCRIPTION: A 3-year-old abrupt onset of cough and increased work of breathing.

The discharge summary describes a situation where a 3-year-old child was treated for respiratory distress, reactive airways disease, and pneumonia. While respiratory issues in young children can be serious, the child has been stabilized and is being discharged with a comprehensive medication plan, indicating the immediate crisis has been managed. The discharge instructions are clear, and the patient is scheduled for a follow-up, which is a standard procedure. Although there is risk involved due to respiratory issues in a young child, the situation is not currently high-stakes as the child is being discharged with necessary care instructions.


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

ADMITTING DIAGNOSES:,  Left renal cell carcinoma, left renal cyst.,DISCHARGE DIAGNOSIS:,  Left renal cell carcinoma, left renal cyst.,SECONDARY DIAGNOSES:,1.  Chronic obstructive pulmonary disease.,2.  Coronary artery disease.,PROCEDURES: , Robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.,HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 70-year-old male who has been diagnosed with a left renal cell carcinoma with multiple renal cysts.  He has undergone MRI of the abdomen on June 18, 2008 revealing an enhancing mass of the upper pole of the left kidney consistent with his history of renal cell carcinoma.  Of note, there are no other enhancing solid masses seen on this MRI.  After discussion of multiple management strategies with the patient including:,1.  Left partial nephrectomy.,2.  Left radical nephrectomy.,3.  Left renal cyst decortication.  The patient is likely to undergo the latter procedure.,HOSPITAL COURSE:  ,The patient was admitted to undergo left renal cyst decortication as well as a cystoscopy.  Intraoperatively, approximately four enlarged renal cysts and six smaller renal cysts were initially removed.  The contents were aspirated and careful dissection of the cyst wall was performed.  Multiple specimens of the cyst wall were sent for pathology.  Approximately one liter of cystic fluid was drained during the procedure.  The renal bed was inspected for hemostasis, which appear to be adequate.  There were no complications with the procedure.  Single JP drain was left in place.  Additionally, the patient underwent flexible cystoscopy, which revealed no gross strictures or any other abnormalities in the penile nor prostatic urethra.  Furthermore, no gross lesions were encountered in the bladder.  The patient left OR with transfer to the PACU and subsequently to the hospital floor.,The patient's postoperative course was relatively uneventful.  His diet and activity were gradually advanced without complication.  On postoperative day #2, he was passing flatus and has had bowel movements.  His Jackson-Pratt drain was discontinued on postoperative day #3 that being the day of discharge.  His Foley catheter was removed on the morning of discharge and the patient subsequently passed the voiding trial without difficultly.  At the time of discharge, he was afebrile.  His vital signs indicated hemodynamic stability and he had no evidence of infection.  The patient was instructed to follow up with Dr. XYZ on 8/12/2008 at 1:50 p.m. and was given prescription for pain medications as well as laxative.,DISPOSITION: , To home.,DISCHARGE CONDITION:,  Good.,MEDICATIONS:  ,Please see attached medication list.,INSTRUCTIONS: , The patient was instructed to contact Dr. XYZ's office for fever greater than 101.5, intractable pain, nausea, vomiting, or any other concerns.,FOLLOWUP: , The patient will follow up with Dr. XYZ for a postoperative check on 08/12/2008 at 1:50 p.m. and he was made aware of this appointment.
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DESCRIPTION: Patient with left renal cell carcinoma, left renal cyst, had robotic-Assisted laparoscopic left renal cyst decortication and cystoscopy.

discharge summary, decortication, cystoscopy, pain, nausea, vomiting, renal cyst decortication, renal cell carcinoma, robotic assisted, renal cyst, renal, robotic, laparoscopic, nephrectomy, cysts, cell, carcinoma, discharge,

The situation describes the discharge summary of a patient who underwent a successful surgical procedure to address left renal cell carcinoma and left renal cyst. The patient had a smooth postoperative course with no complications reported, and they were discharged in good condition. This scenario is not high-stakes because the patient is stable, the procedure went as planned, and the follow-up is routine. The discharge instructions highlight precautions typical for postoperative care, indicating that any serious or high-risk concerns would be addressed promptly by contacting a medical professional.


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

PRINCIPAL DIAGNOSIS:,  Mesothelioma.,SECONDARY DIAGNOSES:,  Pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.,PROCEDURES,1.  On August 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy.,2.  On August 20, 2007, thoracentesis.,3.  On August 31, 2007, Port-A-Cath placement.,HISTORY AND PHYSICAL: , The patient is a 41-year-old Vietnamese female with a nonproductive cough that started last week.  She has had right-sided chest pain radiating to her back with fever starting yesterday.  She has a history of pericarditis and pericardectomy in May 2006 and developed cough with right-sided chest pain, and went to an urgent care center.  Chest x-ray revealed right-sided pleural effusion.,PAST MEDICAL HISTORY,1.  Pericardectomy.,2.  Pericarditis.,2.  Atrial fibrillation.,4.  RNCA with intracranial thrombolytic treatment.,5
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DESCRIPTION: Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.

The situation involves a discharge summary for a patient diagnosed with mesothelioma, a serious and life-threatening cancer. Additionally, the patient has multiple secondary diagnoses and has undergone several significant medical procedures. The patient's complex medical history, which includes conditions like atrial fibrillation and deep venous thrombosis, poses further risks. This complexity and the severe nature of the primary diagnosis make this a high-stakes situation, as any oversight could have severe consequences on the patient's health management plan.


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

DISCHARGE DIAGNOSES:,1.  End-stage renal disease, on hemodialysis.,2.  History of T9 vertebral fracture.,3.  Diskitis.,4.  Thrombocytopenia.,5.  Congestive heart failure with ejection fraction of approximately 30%.,6.  Diabetes, type 2.,7.  Protein malnourishment.,8.  History of anemia.,HISTORY AND HOSPITAL COURSE: , The patient is a 77-year-old white male who presented to Hospital of Bossier on April 14, 2008.  The patient was found to have lumbar diskitis and was going to require extensive antibiotic therapy, which was the cause of need for continued hospitalization.  He also needed to continue with dialysis and he needed to improve his rehabilitation.  The patient tolerated his medication well and he was going through rehab fairly well without any significant troubles.  He did have some bouts of issues with constipation on and off throughout his hospitalization, but this seemed to come under control with more aggressive management.  The patient had remained afebrile.  He did also have a bout with some episodic confusion problems, which appeared to be more of a sundowner-type of a problem, but this too cleared with his stay here at Promise.  On the day of discharge, on May 9, 2008, the patient was in good spirits, was very clear and lucid.  He denied any complaints of pain.  He did have some trouble with sleep at night at times, but I think this was mainly tied into the fact that he sleeps a lot during the day.  The patient has increased his appetite some and has been eating some.  His vital signs remain stable.  His blood pressure on discharge was 126/63, heart rate is 80, respiratory rate of 20 and temperature was 98.3.  PPD was negative.  An SMS form was filled out in plan for his discharge and he was sent with medications that he had been receiving while here at Promise.,The patient and his family understood our plan and agreed with it.  He thanked us for the care that he received at Promise and thought that they did a fantastic job taking care of him.  He did not have any acute questions as to where he was going and what the next step of his care would be, but we did discuss this at length prior to date of discharge.,
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DESCRIPTION: The patient is being discharged for continued hemodialysis and rehab.

discharge summary, end-stage renal disease, thrombocytopenia, anemia, hospitalization, hemodialysis and rehab, hemodialysis

The discharge summary presented describes a patient with multiple chronic and serious medical conditions, including end-stage renal disease, congestive heart failure, and a requirement for hemodialysis and rehabilitation. While these are serious health issues, the situation described in this summary does not indicate an immediate life-threatening emergency. The patient is being discharged with a clear plan for continued care and has shown improvements in appetite and stabilization of vital signs, suggesting they are in a stable condition upon discharge. Therefore, while it is crucial for the patient to follow through with the prescribed care and treatments, the immediate stakes of the discharge process are not extremely high.


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

PREOPERATIVE DIAGNOSIS: , Right pleural mass.,POSTOPERATIVE DIAGNOSIS: , Mesothelioma.,PROCEDURES PERFORMED:,1.  Flexible bronchoscopy.,2.  Mediastinoscopy.,3.  Right thoracotomy.,4.  Parietal pleural biopsy.,CONSULTS:,Consults obtained during this hospitalization included:,1.  Radiation Oncology.,2.  Pulmonary Medicine.,3.  Medical Oncology.,4.  Cancer Center Team consult.,5.  Massage therapy consult.,HOSPITAL COURSE:,  The patient's hospital course was unremarkable.  Her pain was well controlled with an epidural that was placed by Anesthesia.  At the time of discharge, the patient was ambulatory.  She was discharged with home oxygen available.  She was discharged with albuterol nebulizer treatments, treatments were to be q.i.d.  She was discharged with a prescription for Vicodin for pain control.  She is to follow up with Dr. X in the office in one week with a chest x-ray.  She is instructed not to lift, push or pull anything greater than 10 pounds.  She is instructed not to drive until after she sees us in the office and is off her pain medications.
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DESCRIPTION: A patient with preoperative diagnosis of right pleural mass and postoperative diagnosis of mesothelioma.

discharge summary, flexible bronchoscopy, mediastinoscopy, right thoracotomy, pleural biopsy, pleural mass, mesothelioma, oncology,

This situation involves the discharge of a patient who underwent significant surgical procedures, including a right thoracotomy and pleural biopsy, and has been diagnosed with mesothelioma, a serious and life-threatening condition. The correct management and follow-up of this patient are crucial for their recovery and optimizing their treatment for mesothelioma. Therefore, ensuring that all discharge instructions are followed carefully is vital. While the patient's hospital course was described as unremarkable, mesothelioma itself and the importance of correct post-operative care make it a relatively high-stakes situation.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - Hip Surgery

ADMITTING DIAGNOSIS:,  Posttraumatic AV in right femoral head.,DISCHARGE DIAGNOSIS:,  Posttraumatic AV in right femoral head.,SECONDARY DIAGNOSES PRIOR TO HOSPITALIZATION:,1.  Opioid use.,2.  Right hip surgery.,3.  Appendectomy.,4.  Gastroesophageal reflux disease.,5.  Hepatitis diagnosed by liver biopsy.,6.  Blood transfusion.,6.  Smoker.,7.  Trauma with multiple orthopedic procedures.,8.  Hip arthroscopy.,POSTOP COMORBIDITIES: , Postop acute blood loss anemia requiring transfusion and postop pain.,PROCEDURES DURING THIS HOSPITALIZATION:,  Right total hip arthroplasty and removal of hardware.,CONSULTS:,  Acute pain team consult.,DISPOSITION: , Home.,HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE:,  For details, please refer to clinic notes and OP notes.  In brief, the patient is a 47-year-old female with a posttraumatic AV in the right femoral head.  She came in consult with Dr. X who after reviewing the clinical and radiological findings recommended she undergo a right total hip arthroplasty and removal of old hardware.  After being explained the risks, benefits, alternative options, and possible outcomes of surgery, she was agreeable and consented to proceed and therefore on the day of her admission, she was sent to the operating room where she underwent a right total hip arthroplasty and removal of hardware without any complications.  She was then transferred to PACU for recovery and postop orthopedic floor for convalescence, physical therapy, and discharge planning.  DVT prophylaxis was initiated with Lovenox.  Postop pain was adequately managed with the aid of Acute Pain team.  Postop acute blood loss anemia was treated with blood transfusions to an adequate level of hemoglobin.  Physical therapy and occupational therapy were initiated and continued to work with her towards discharge clearance on the day of her discharge.,DISPOSITION:,  Home.  On the day of her discharge, she was afebrile, vital signs were stable.  She was in no acute distress.  Her right hip incision was clean, dry, and intact.  Extremity was warm and well perfused.  Compartments were soft.  Capillary refill less than two seconds.  Distal pulses were present.,PREDISCHARGE LABORATORY FINDINGS: , White count of 10.9, hemoglobin of 9.5, and BMP is pending.,DISCHARGE INSTRUCTIONS: , Continue diet as before.,ACTIVITY: , Weightbearing as tolerated in the right lower extremity as instructed.  Do not lift, drive, move furniture, do strenuous activity for six weeks.  Call Dr. X if there is increased temperature greater than 101.5, increased redness, swelling, drainage, increased pain that is not relieved by current pain regimen as per postop orthopedic discharge instruction sheet.,FOLLOW-UP APPOINTMENT:  Follow up with Dr. X in two weeks.
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DESCRIPTION: A 47-year-old female with a posttraumatic AV in the right femoral head.

The discharge summary is a routine document used after a surgical procedure to communicate the patient's condition and instructions for aftercare. While it contains important medical information, such documents are standard in hospital settings. The described surgery, a right total hip arthroplasty, and the complications like postop anemia, while serious, are common occurrences in medical practice. The stakes are moderate because ensuring the patient follows discharge instructions is important for recovery, but the situation lacks immediate life-threatening urgency.


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

ADMISSION DIAGNOSIS: , Symptomatic cholelithiasis.,DISCHARGE DIAGNOSIS:,  Symptomatic cholelithiasis.,SERVICE: , Surgery.,CONSULTS:,  None.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a 27-year-old woman who apparently presented with complaint of symptomatic cholelithiasis.  She was afebrile.  She was taken by Dr. X to the operating room.,HOSPITAL COURSE: , The patient underwent a procedure.  She tolerated without difficulty.  She had her pain controlled with p.o. pain medicine.  She was afebrile.  She is tolerating liquid diet.  It was felt that the patient is stable for discharge.  She did complain of bladder spasms when she urinated and she did say that she has a history of chronic UTIs.  We will check a UA and urine culture prior to discharge.  I will give her prescription for ciprofloxacin that she can take for 3 days presumptively and I have discharged her home with omeprazole and Colace to take over-the-counter for constipation and we will send her home with Percocet for pain.  Her labs were within normal limits.  She did have an elevated white blood cell count, but I believe this is just leukemoid reaction, but she is afebrile, and if she does have UTI, may also be related.  Her labs in terms of her bilirubin were within normal limits.  Her LFTs were slightly elevated, I do believe this is related to the cautery used on the liver bed.  They were 51 and 83 for the AST and ALT respectively.  I feel that she looks good for discharge.,DISCHARGE INSTRUCTIONS: , Clear liquid diet x48 hours and she can return to her Medifast, she may shower.  She needs to keep her wound clean and dry.  She is not to engage in any heavy lifting greater than 10 pounds x2 weeks.  No driving for 1 to 2 weeks.  She must be able to stop in an emergency and be off narcotic meds, no strenuous activity, but she needs to maintain mobility.  She can resume her medications per med rec sheets.,DISCHARGE MEDICATIONS: , As previously mentioned.,FOLLOWUP:,  We will follow up on both urinalysis and cultures.  She is instructed to follow up with Dr. X in 2 weeks.  She needs to call for any shortness of breath, temperature greater than 101.5, chest pain, intractable nausea, vomiting, and abdominal pain, any redness, swelling or foul smelling drainage from her wounds.
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DESCRIPTION: Patient with complaint of symptomatic cholelithiasis.

discharge summary, medifast, liquid diet, symptomatic cholelithiasis, symptomatic, cholelithiasis, discharge,

The discharge summary outlines a routine surgical procedure with post-operative care instructions. While there are some concerns, like possible UTI and elevated white blood cell counts, these are being monitored and treated. This is not a critically high-stakes situation as the patient is stable and the issues mentioned are not uncommon after such procedures. The detailed discharge instructions also help mitigate potential risks, lowering the stakes.