Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 7

CHIEF COMPLAINT:,  Right-sided facial droop and right-sided weakness.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old lady, a resident of a skilled nursing facility, with past medical history of a stroke and dementia with expressive aphasia, was found today with a right-sided facial droop, and was transferred to the emergency room for further evaluation.  While in the emergency room, she was found to having the right-sided upper extremity weakness and right-sided facial droop.  The CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident, will be admitted to monitor bed for observation and treatment and also she was recently diagnosed with urinary tract infection, which was resistant to all oral medications.,ALLERGIES: , SHE IS ALLERGIC TO PENICILLIN.,SOCIAL HISTORY: , She is a nondrinker and nonsmoker and currently lives at the skilled nursing facility.,FAMILY HISTORY: , Noncontributory.,PAST MEDICAL HISTORY:,1.  Cerebrovascular accident with expressive aphasia and lower extremity weakness.,2.  Abnormality of gait and wheelchair bound secondary to #1.,3.  Hypertension.,4.  Chronic obstructive pulmonary disease, on nasal oxygen.,5.  Anxiety disorder.,6.  Dementia.,PAST SURGICAL HISTORY: , Status post left mastectomy secondary to breast cancer and status post right knee replacement secondary to osteoarthritis.,REVIEW OF SYSTEMS: , Because of the patient's inability to communicate, is not obtainable, but apparently, she has urine incontinence and also stool incontinence, and is wheelchair bound.,PHYSICAL EXAMINATION:,GENERAL:  She is an 83-year-old patient, awake, and non-communicable lady, currently in bed, follows commands by closing and opening her eyes.,VITAL SIGNS:  Temperature is 99.6, pulse is 101, respirations 18, and blood pressure is in the 218/97.,HEENT:  Pupils are equal, round, and reactive to light.  External ocular muscles are intact.  Conjunctivae anicteric.  There is a slight right-sided facial droop.  Oropharynx is clear with the missing teeth on the upper and the lower part.  Tympanic membranes are clear.,NECK:  Supple.  There is no carotid bruit.  No cervical adenopathy.,CARDIAC:  Regular rate and rhythm with 2/6 systolic murmur, more at the apex.,LUNGS:  Clear to auscultation.,ABDOMEN:  Soft and no tenderness.  Bowel sound is present.,EXTREMITIES:  There is no pedal edema.  Both knees are passively extendable with about 10-15 degrees of fixed flexion deformity on both sides.,NEUROLOGIC:  There is right-sided slight facial droop.  She moves both upper extremities equally.  She has withdrawal of both lower extremities by touching her sole of the feet.,SKIN:  There is about 2 cm first turning to second-degree pressure ulcer on the right buttocks.,LABORATORY DATA: , The CT scan of the head shows brain atrophy with no acute events.  Sodium is 137, potassium 3.7, chloride 102, bicarbonate 24, BUN of 22, creatinine 0.5, and glucose of 92.  Total white blood cell count is 8.9000, hemoglobin 14.4, hematocrit 42.7, and the platelet count of 184,000.  The urinalysis was more than 100 white blood cells and 10-25 red blood cells.  Recent culture showed more than 100,000 colonies of E. coli, resistant to most of the tested medications except amikacin, nitrofurantoin, imipenem, and meropenem.,ASSESSMENT:,1.  Recent cerebrovascular accident with right-sided weakness.,2.  Hypertension.,3.  Dementia.,4.  Anxiety.,5.  Urinary tract infection.,6.  Abnormality of gait secondary to lower extremity weakness.,PLAN: , We will keep the patient NPO until a swallowing evaluation was done.  We will start her on IV Vasotec every 4 hours p.r.n. systolic blood pressure more than 170.  Neuro check every 4 hours for 24 hours.  We will start her on amikacin IV per pharmacy.  We will start her on Lovenox subcutaneously 40 mg every day and we will continue with the Ecotrin as swallowing evaluation was done.  Resume home medications, which basically include Aricept 10 mg p.o. daily, Diovan 160 mg p.o. daily, multivitamin, calcium with vitamin D, Ecotrin, and Tylenol p.r.n.  I will continue with the IV fluids at 75 mL an hour with a D5 normal saline at the range of 75 mL an hour and adding potassium 10 mEq per 1000 mL and I would follow the patient on daily basis.
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DESCRIPTION: Right-sided facial droop and right-sided weakness.  Recent cerebrovascular accident.  he CT scan of the head did not show any acute events with the impression of a new-onset cerebrovascular accident.

The patient's condition involves a suspected new cerebrovascular accident (stroke) with symptoms of right-sided facial droop and weakness, which can be life-threatening if not managed promptly. In addition, the patient has multiple comorbidities, such as dementia, chronic obstructive pulmonary disease, hypertension, and a resistant urinary tract infection. These complicate her medical situation further. The need for close monitoring, particularly with neuro checks and blood pressure management, highlights the urgency and potential seriousness of her condition. Based on these factors, this situation is high-stakes due to the immediate risk to the patient's health and the complexity of her care needs.


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

Medical Specialty: Neurosurgery
Sample Name: Hematoma Evacuation

PREOPERATIVE DIAGNOSIS: , Right temporal lobe intracerebral hemorrhage.,POSTOPERATIVE DIAGNOSES:,1.  Right temporal lobe intracerebral hemorrhage.,2.  Possible tumor versus inflammatory/infectious lesion versus vascular lesion, pending final pathology and microbiology.,PROCEDURES:,1.  Emergency right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.,2.  Biopsy of dura.,3.  Microscopic dissection using intraoperative microscope.,SPECIMENS: , Temporal lobe lesion and dura as well as specimen for microbiology for culture.,DRAINS:,  Medium Hemovac drain.,FINDINGS: , Vascular hemorrhagic lesion including inflamed dura and edematous brain with significant mass effect, and intracerebral hematoma with a history of significant headache, probable seizures, nausea, and vomiting.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Per Anesthesia.,FLUIDS: , One unit of packed red blood cells given intraoperatively.,The patient was brought to the operating room emergently.  This is considered as a life threatening admission with a hemorrhage in the temporal lobe extending into the frontal lobe and with significant mass effect.,The patient apparently became hemiplegic suddenly today.  She also had an episode of incoherence and loss of consciousness as well as loss of bowel/urine.,She was brought to Emergency Room where a CT of the brain showed that she had significant hemorrhage of the right temporal lobe extending into the external capsule and across into the frontal lobe.  There is significant mass effect.  There is mixed density in the parenchyma of the temporal lobe.,She was originally scheduled for elective craniotomy for biopsy of the temporal lobe to find out why she was having spontaneous hemorrhages.  However, this event triggered her family to bring her to the emergency room, and this is considered a life threatening admission now with a significant mass effect, and thus we will proceed directly today for evacuation of ICH as well as biopsy of the temporal lobe as well as the dura.,PROCEDURE IN DETAIL: , The patient was anesthetized by the anesthesiology team.  Appropriate central line as well as arterial line, Foley catheter, TED, and SCDs were placed.  The patient was positioned supine with a three-point Mayfield head pin holder.  Her scalp was prepped and draped in a sterile manner.  Her former incisional scar was barely and faintly noticed; however, through the same scalp scar, the same incision was made and extended slightly inferiorly.  The scalp was resected anteriorly.  The subdural scar was noted, and hemostasis was achieved using Bovie cautery.  The temporalis muscle was reflected along with the scalp in a subperiosteal manner, and the titanium plating system was then exposed.,The titanium plating system was then removed in its entirety.  The bone appeared to be quite fused in multiple points, and there were significant granulation tissue through the burr hole covers.,The granulation tissue was quite hemorrhagic, and hemostasis was achieved using bipolar cautery as well as Bovie cautery.,The bone flap was then removed using Leksell rongeur, and the underlying dura was inspected.  It was quite full.  The 4-0 sutures from the previous durotomy closure was inspected, and more of the inferior temporal bone was resected using high-speed drill in combination with Leksell rongeur.  The sphenoid wing was also resected using a high-speed drill as well as angled rongeur.,Hemostasis was achieved on the fresh bony edges using bone wax.  The dura pack-up stitches were noted around the periphery from the previous craniotomy.  This was left in place.,The microscope was then brought in to use for the remainder of the procedure until closure.  Using a #15 blade, a new durotomy was then made.  Then, the durotomy was carried out using Metzenbaum scissors, then reflected the dura anteriorly in a horseshoe manner, placed anteriorly, and this was done under the operating microscope.  The underlying brain was quite edematous.,Along the temporal lobe there was a stain of xanthochromia along the surface.  Thus a corticectomy was then accomplished using bipolar cautery, and the temporal lobe at this level and the middle temporal gyrus was entered.  The parenchyma of the brain did not appear normal.  It was quite vascular.  Furthermore, there was a hematoma mixed in with the brain itself.  Thus a core biopsy was then performed in the temporal tip.  The overlying dura was inspected and it was quite thickened, approximately 0.25 cm thick, and it was also highly vascular, and thus a big section of the dura was also trimmed using bipolar cautery followed by scissors, and several pieces of this vascularized dura was resected for pathology.  Furthermore, sample of the temporal lobe was cultured.,Hemostasis after evacuation of the intracerebral hematoma using controlled suction as well as significant biopsy of the overlying dura as well as intraparenchymal lesion was accomplished.  No attempt was made to enter into the sylvian fissure.  Once hemostasis was meticulously achieved, the brain was inspected.  It still was quite swollen, known that there was still hematoma in the parenchyma of the brain.  However, at this time it was felt that since there is no diagnosis made intraoperatively, we would need to stage this surgery further should it be needed once the diagnosis is confirmed.  DuraGen was then used for duraplasty because of the resected dura.  The bone flap was then repositioned using Lorenz plating system.  Then a medium Hemovac drain was placed in subdural space.  Temporalis muscle was approximated using 2-0 Vicryl.  The galea was then reapproximated using inverted 2-0 Vicryl.  The scalp was then reapproximated using staples.  The head was then dressed and wrapped in a sterile fashion.,She was witnessed to be extubated in the operating room postoperatively, and she followed commands briskly.  The pupils are 3 mm bilaterally reactive to light.  I accompanied her and transported her to the ICU where I signed out to the ICU attending.
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DESCRIPTION: Right side craniotomy for temporal lobe intracerebral hematoma evacuation and resection of temporal lobe lesion.  Biopsy of dura.

The situation involves a neurosurgical operation to evacuate a hematoma and perform a biopsy, which was performed as an emergency measure due to a life-threatening condition. The operation was necessary due to significant symptoms and rapid deterioration of the patient's neurological status, including hemiplegia, incoherence, and loss of consciousness. Neurosurgery is inherently high-stakes due to the delicate nature of brain operations and the severe potential consequences of intracerebral hemorrhage. The immediate threat to the patient's life and the potential for either a critical recovery or adverse outcome depending on the surgery and subsequent treatment results contribute to the high-stakes nature of this scenario.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Orthopedic
Sample Name: Physical Therapy - Low Back Pain

HISTORY OF PRESENT ILLNESS: , The patient is a 26-year-old female, referred to Physical Therapy for low back pain.  The patient has a history of traumatic injury to low back.  The patient stated initial injury occurred eight years ago, when she fell at a ABC Store.  The patient stated she received physical therapy, one to two visits and received modality treatment only, specifically electrical stimulation and heat pack per patient recollection.  The patient stated that she has had continuous low-back pain at varying degrees for the past eight years since that fall.  The patient gave birth in August 2008 and since the childbirth, has experienced low back pain.  The patient also states that she fell four to five days ago, while mopping her floor.  The patient stated that she landed on her tailbone and symptoms have increased since that fall.  The patient stated that her initial physician examination with Dr. X was on 01/10/09, and has a followup appointment on 02/10/09.,PAST MEDICAL HISTORY: , The patient denies high blood pressure, diabetes, heart disease, lung disease, thyroid, kidney, or bladder dysfunctions.  The patient stated that she quit smoking prior to her past childbirth and is currently not pregnant.  The patient has had a C-section and also an appendectomy.  The patient was involved in a motor vehicle accident four to five years ago and at that time, the patient did not require any physical therapy nor did she report any complaints of increased back pain following that accident.,MEDICATIONS: , Patient currently states she is taking:,1.  Vicodin 500 mg two times a day.,2.  Risperdal.,3.  Zoloft.,4.  Stool softeners.,5.  Prenatal pills.,DIAGNOSTIC IMAGERY:  ,The patient states she has not had an MRI performed on her lumbar spine.  The patient also states that Dr. X took x-rays two weeks ago, and no fractures were found at that time.  Per physician note, dated 12/10/08, Dr. X dictated that the x-ray showed an anterior grade 1 spondylolisthesis of L5 over S1, and requested Physical Therapy to evaluate and treat.,SUBJECTIVE:  ,The patient states that pain is constant in nature with a baseline of 6-7/10 with pain increasing to 10/10 during the night or in cold weather.  The patient states that pain is dramatically less, when the weather is warmer.  The patient also states that pain worsens as the day progresses, in that she also hard time getting out of bed in the morning.  The patient states that she does not sleep at night well and sleeps less than one hour at a time.,Aggravating factors include, sitting for periods greater than 20 minutes or lying supine on her back.  Easing factors include side lying position in she attempts to sleep.,OBJECTIVE: , AGE:  26 years old.  HEIGHT:  5 feet 2 inches.  WEIGHT:  The patient is an obese 26-year-old female.,ACTIVE RANGE OF MOTION: , Lumbar spine, flexion, lateral flexion and rotation all within functional limits without complaints of pain or soreness while performing them during evaluation.,PALPATION:  ,The patient complained of bilateral SI joint point tenderness.  The patient also complained of left greater trochanter hip point tenderness.  The patient also complained of bilateral paraspinal tenderness on cervical spine to lumbar spine.,STRENGTH:  ,RIGHT LOWER EXTREMITY:,Knee extension 5/5, hip flexion 5/5, knee flexion 4/5, internal and external hip rotation was 4/5.  With manual muscle testing of knee flexion, hip, internal and external rotation, the patient reports an increase in right SI joint pain to 8/10.,LEFT LOWER EXTREMITY:,Hip flexion 5/5, knee extension 5/5, knee flexion 4/5, hip internal and external rotation 4/5, with slight increase in pain level with manual muscle testing and resistance.  It must be noted that PT did not apply as much resistance during manual muscle testing, secondary to the 8/10 pain elicited during the right lower extremity.,NEUROLOGICAL:  ,The patient subjectively complains of numbness with tingling in her bilateral extremities when she sits longer than 25 minutes.  However, they subside when she stands.  The patient did complain of this numbness and tingling during the evaluation and the patient was seated for a period of 20 minutes.  Upon standing, the patient stated that the numbness and tingling subsides almost immediately.  The patient stated that Dr. X told her that he believes that during her past childbirth when the epidural was being administered that there was a possibility that a sensory nerve may have been also affected during the epidural less causing the numbness and tingling in her bilateral lower extremities.  The patient does not demonstrate any sensation deficits with gentle pressure to the lumbar spine and during manual muscle testing.,GAIT:  ,The patient ambulated out of the examination room, while carrying her baby in a car seat.,ASSESSMENT:  ,The patient is a 26-year-old overweight female, referred to Physical Therapy for low back pain.  The patient presents with lower extremity weakness, which may be contributing to her lumbosacral pain, in that she has poor lumbar stabilization with dynamic ADLs, transfers, and gait activity when fatigued.  At this time, the patient may benefit from skilled physical therapy to address her decreased strength and core stability in order to improve her ADL, transfer, and mobility skills.,PROGNOSIS: , The patient's prognosis for physical therapy is good for dictated goals.,SHORT-TERM GOALS TO BE ACHIEVED IN TWO WEEKS:,1.  The patient will be able to sit for greater than 25 minutes without complaints of paraesthesia or pain in her bilateral lower extremities or bilateral SI joints.,2.  The patient will increase bilateral hip internal and external rotation to 4/5 with SI joint pain less than or equal to 5/10.,3.  The patient will report 25% improvement in her functional and ADL activities.,4.  Pain will be less than 4/10 while performing __________ while at PT session.,LONG-TERM GOALS TO BE ACCOMPLISHED IN ONE MONTH:,1.  The patient will be independent with home exercise program.,2.  Bilateral hamstring, bilateral hip internal and external rotation strength to be 4+/5 with SI joint pain less than or equal to 2/10, while performing manual muscle test.,3.  The patient will report 60% improvement or greater in functional transfers in general ADL activity.,4.  The patient will be able to sit greater than or equal to 45 minutes without complaint of lumbosacral pain.,5.  The patient will be able to sleep greater than 2 hours without pain.,TREATMENT PLAN:,1.  Therapeutic exercises to increase lower extremity strength and assist with lumbar sacral stability.
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DESCRIPTION: The patient is a 26-year-old female, referred to Physical Therapy for low back pain.  The patient has a history of traumatic injury to low back.

The scenario involves a 26-year-old female patient experiencing chronic low back pain due to a traumatic injury that occurred in the past and aggravated by a recent fall. While the patient's condition affects her daily living activities and quality of life, it is not immediately life-threatening or indicative of a critical health situation. The pain and associated symptoms, such as numbness and tingling, are being assessed and managed through physical therapy, and the prognosis for improvement is positive. The situation is important for the patient's healthcare management, but it does not involve high-stakes decision-making, life-saving measures, or conditions that could rapidly deteriorate to a critical state.


Medical Specialty: Nephrology
Sample Name: Cysto & Double-J Stent Insersion

PREOPERATIVE DIAGNOSIS:,  Residual stone, status post right percutaneous nephrolithotomy.,POSTOPERATIVE DIAGNOSES: , Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.,ANESTHESIA:,  General via endotracheal tube.,BLOOD LOSS:,  Minimal.,DRAINS: , 16-French Foley, 6-French variable length double-J stent.,INTRAOPERATIVE COMPLICATIONS: , Unable to re-access the collecting system.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room and laid supine.  General anesthesia was accomplished.  A 16-French Foley was placed using aseptic technique.  The patient was then placed on the operating table prone.  His right flank was prepped and draped in a sterile fashion.  At this point, contrast was injected through his existing nephrostomy tube and there was no continuity with the collecting system and it was removed.  The 5-French Pollack catheter was used to pass a 0.38 super-stiff Amplatz wire.  The wire would not go down the ureter.  Multiple attempts were made using Pollack catheters and Cobra catheters and attempts were made to dilate the track, both with rigid dilator and the balloon dilator and access could not be obtained.  After multiple attempts, access was lost.  At this point, the tubes were left out of the kidney and sterile dressings were applied.  The patient was then placed on another operating table supine.  His genitalia were prepped and draped after removing his Foley catheter.  Flexible cystoscopy was performed and the right orifice identified, which was edematous and erythematous.  The wire was passed up to kidney and a 5-French Pollack catheter was then passed over to after the removing the scope.  The wire was removed.  Contrast injection with good placement in the collecting system.  The wire was replaced.  The Pollack catheter removed and 6-French variable length double-J stent was inserted using fluoroscopic guidance.  The wire was removed leaving the double-J stent in good position.  _______ 16-French Foley was reinserted and connected to close drains.,Procedure was terminated at this point and had been well tolerated.  The patient was awakened and taken to recovery room in satisfactory condition having tolerated the procedure well.
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DESCRIPTION: Residual stone status post right percutaneous nephrolithotomy, attempted second-look nephrolithotomy, cysto with insertion of 6-French variable length double-J stent.

nephrology, residual stone, percutaneous, cobra catheters, amplatz, double j stent, pollack catheter, cysto, catheter, nephrolithotomy, stent, french

The procedure described involves a surgical follow-up to address residual kidney stones after an initial nephrolithotomy. There were intraoperative complications as the healthcare team was unable to re-access the collecting system. Despite this, they managed to place a double-J stent correctly on a subsequent attempt. While there are risks associated with this type of surgery, including anesthesia and potential complications like infection or injury to surrounding tissues, the procedure was completed successfully in the end, and the patient was taken to recovery in satisfactory condition. This situation is important, as it involves managing the patient's current health condition and preventing further issues; however, it is not necessarily life-threatening, and the team is monitoring the patient post-operation. Given these factors, the situation is moderately high-stakes.


Medical Specialty: Orthopedic
Sample Name: Ulnar Nerve Transposition

PROCEDURE:,  Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve.  Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected.,Osborne's fascia was released, an ulnar neurolysis performed, and the ulnar nerve was mobilized.  Six cm of the medial intermuscular septum was excised, and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly.,The subcutaneous plane just superficial to the flexor-pronator mass was developed.  Meticulous hemostasis was maintained with bipolar electrocautery.  The nerve was transposed anteriorly, superficial to the flexor-pronator mass.  Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve.,A semicircular medially based flap of flexor-pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating.  The subcutaneous tissue and skin were closed with simple interrupted sutures.  Marcaine with epinephrine was injected into the wound.  The elbow was dressed and splinted.  The patient was awakened and sent to the recovery room in good condition, having tolerated the procedure well.
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DESCRIPTION: Subcutaneous ulnar nerve transposition.  A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve.

orthopedic, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve

The situation described involves a surgical procedure, specifically a subcutaneous ulnar nerve transposition, performed by an orthopedic specialist. While surgical procedures inherently carry certain risks and require precision, this particular type of surgery is considered relatively routine for trained surgeons. The document suggests that standard protocols were followed, and the patient was reported to have tolerated the procedure well. Therefore, while significant in terms of surgical care, it is not an emergency or life-threatening situation, assuming everything goes according to plan.


Medical Specialty: Dermatology
Sample Name: Wasp Sting - SOAP

SUBJECTIVE:,  He is a 29-year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.  He says that he has been stung by wasps before and had similar reactions.  He just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past.  He has had a lot of swelling, but no anaphylaxis-type reactions in the past; no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past; no racing heart beat or anxiety feeling, just a lot of localized swelling where the sting occurs.,OBJECTIVE:,Vitals:  His temperature is 98.4.  Respiratory rate is 18.  Weight is 250 pounds.,Extremities:  Examination of his right hand and forearm reveals that he has an apparent sting just around his wrist region on his right hand on the medial side as well as significant swelling in his hand and his right forearm; extending up to the elbow.  He says that it is really not painful or anything like that.  It is really not all that red and no signs of infection at this time.,ASSESSMENT:,  Wasp sting to the right wrist area.,PLAN:,1.  Solu-Medrol 125 mg IM X 1.,2.  Over-the-counter Benadryl, ice and elevation of that extremity.,3.  Follow up with Dr. XYZ if any further evaluation is needed.
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DESCRIPTION: Comes in complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.

dermatology, yellow jacket wasp, wasp sting, swelling, solu-medrol, lot of swelling, stung, sting, wasp,

The patient has experienced significant swelling from a wasp sting, which has been consistent in past reactions, but there are no signs of anaphylaxis or severe systemic reactions. The patient's vitals are stable, and the treatment plan involves standard measures like an IM steroid injection, antihistamine, and home care with follow-up. Without signs of life-threatening allergic reactions, the situation is not extremely high-stakes.


Medical Specialty: Orthopedic
Sample Name: MRI Cervical Spine - Chiropractic Specific

FINDINGS:,Normal foramen magnum.,Normal brainstem-cervical cord junction. There is no tonsillar ectopia. Normal clivus and craniovertebral junction. Normal anterior atlantoaxial articulation.,C2-3: There is disc desiccation but no loss of disc space height, disc displacement, endplate spondylosis or uncovertebral joint arthrosis. Normal central canal and intervertebral neural foramina.,C3-4: There is disc desiccation with a posterior central disc herniation of the protrusion type. The small posterior central disc protrusion measures 3 x 6mm (AP x transverse) in size and is producing ventral thecal sac flattening. CSF remains present surrounding the cord. The residual AP diameter of the central canal measures 9mm. There is minimal right-sided uncovertebral joint arthrosis but no substantial foraminal compromise.,C4-5: There is disc desiccation, slight loss of disc space height with a right posterior lateral pre-foraminal disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis. The disc osteophyte complex measures approximately 5mm in its AP dimension. There is minimal posterior annular bulging measuring approximately 2mm. The AP diameter of the central canal has been narrowed to 9mm. CSF remains present surrounding the cord. There is probable radicular impingement upon the exiting right C5 nerve root.,C5-6: There is disc desiccation, moderate loss of disc space height with a posterior central disc herniation of the protrusion type. The disc protrusion measures approximately 3 x 8mm (AP x transverse) in size. There is ventral thecal sac flattening with effacement of the circumferential CSF cleft. The residual AP diameter of the central canal has been narrowed to 7mm. Findings indicate a loss of the functional reserve of the central canal but there is no cord edema. There is bilateral uncovertebral and apophyseal joint arthrosis with moderate foraminal compromise.,C6-7: There is disc desiccation, mild loss of disc space height with 2mm of posterior annular bulging. There is bilateral uncovertebral and apophyseal joint arthrosis (left greater than right) with probable radicular impingement upon the bilateral exiting C7 nerve roots.,C7-T1, T1-2: There is disc desiccation with no disc displacement. Normal central canal and intervertebral neural foramina.,T3-4: There is disc desiccation with minimal 2mm posterior annular bulging but normal central canal and CSF surrounding the cord.,IMPRESSION:,Multilevel degenerative disc disease with uncovertebral joint arthrosis with foraminal compromise as described above.,C3-4 posterior central disc herniation of the protrusion type but no cord impingement.,C4-5 right posterior lateral disc osteophyte complex with right-sided uncovertebral and apophyseal joint arthrosis with probable radicular impingement upon the right C5 nerve root.,C5-6 degenerative disc disease with a posterior central disc herniation of the protrusion type producing borderline central canal stenosis with effacement of the circumferential CSF cleft indicating a limited functional reserve of the central canal.,C6-7 degenerative disc disease with annular bulging and osseous foraminal compromise with probable impingement upon the bilateral exiting C7 nerve roots.,T3-4 degenerative disc disease with posterior annular bulging.
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DESCRIPTION: MRI report Cervical Spine (Chiropractic Specific)

orthopedic, exiting c nerve roots, loss of disc space, posterior central disc herniation, herniation of the protrusion, uncovertebral and apophyseal joint, intervertebral neural foramina, ventral thecal sac, thecal sac flattening, disc osteophyte complex, disc space height, central disc herniation, apophyseal joint arthrosis, posterior annular bulging, degenerative disc disease, posterior central disc, csf cleft, osteophyte complex, radicular impingement, disc disease, central disc, annular bulging, disc desiccation, joint arthrosis, central canal, cervical, degenerative, csf, foraminal, bulging, impingement, protrusion, uncovertebral, arthrosis, canal

The MRI findings indicate multilevel degenerative disc disease with a range of issues, such as disc herniations, foraminal compromise, and probable nerve root impingement. These findings are clinically significant, as they can lead to pain, neurological deficits, and other complications if not managed properly. However, the situation is not immediately life-threatening, which would make it high-stakes. Instead, it is a manageable condition with appropriate medical interventions like physical therapy, chiropractic care, or possibly surgery. The stakes pertain more to risk of chronic pain or neurological impairment rather than an acute, critical condition.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Tracheostomy Tube Consult

HISTORY:  ,I had the pleasure of meeting and evaluating the patient today, referred for evaluation of tracheostomy tube placement and treatment recommendations.  As you are well aware, he is a pleasant 64-year-old gentleman who unfortunately is suffering from end-stage COPD, who required tracheostomy tube placement about three months ago when being treated for acute exacerbation of COPD and having difficulty coming off ventilatory support.  He now resides in an extended care facility with a capped tracheostomy tube, and he unfortunately states he has had not had to use the tracheostomy tube since his discharge and admission to the extended care facility.  He requires constant oxygen administration and has been having no problems with shortness of breath, worsening, requiring opening the tracheostomy tube site.  He states there has been some tenderness associated with the tracheostomy tube and difficulty with swallowing and he wishes to have it removed.  Apparently there is no history of any airway issues while sleeping or need for uncapping the tube and essentially the tube has just remained present for months capped in his neck.  No history of any previous tracheostomy tube insertion.,PAST MEDICAL HISTORY: , COPD, history of hypercarbic hypoxemia, history of coronary artery disease, history of previous myocardial infarction, and history of liver cirrhosis secondary to alcohol use.,PAST SURGICAL HISTORY:  ,Tonsillectomy, adenoidectomy, cholecystectomy, appendectomy, hernia repair, and tracheostomy.,FAMILY HISTORY:  ,Strong for heart disease, coronary artery disease, hypertension, diabetes mellitus, and cerebrovascular accident.,CURRENT MEDICATIONS:,  Prevacid, folic acid, aspirin, morphine sulfate, Pulmicort, Risperdal, Colace, clonazepam, Lotrisone, Roxanol, Ambien, Zolpidem tartrate, simethicone, Robitussin, and prednisone.,ALLERGIES: , Nitroglycerin.,SOCIAL HISTORY: , The patient has a 25-year-smoking history, which I believe is quite heavy and he has a significant alcohol use in the past.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Age 64, blood pressure is 110/78, pulse 96, and temperature is 98.6.,GENERAL:  The patient was examined in his wheelchair, resting comfortably, in no acute distress.,HEAD:  Normocephalic.  No masses or lesions noted.,FACE:  No facial tenderness or asymmetry noted.,EYES:  Pupils are equal, round and reactive to light and accommodation bilaterally.  Extraocular movements are intact bilaterally.,EARS:  The tympanic membranes are intact bilaterally with a good light reflex.  The external auditory canals are clear with no lesions or masses noted.  Weber and Rinne tests are within normal limits.,NOSE:  The nasal cavities are patent bilaterally.  The nasal septum is midline.  There are no nasal discharges.  No masses or lesions noted.,THROAT:  The oral mucosa appears healthy.  Dental hygiene is maintained well.  No oropharyngeal masses or lesions noted.  No postnasal drip noted.,NECK:  The patient has a stable-appearing tracheostomy tube site and the stoma appears to be without signs of infection.  The previous incision was vertical in nature and there is no hypertrophic scar formation.  No adenopathy noted.  No stridor noted.,NEUROLOGIC:  Cranial nerve VII intact bilaterally.  No signs of tremor.,LUNGS:  Diminished breath sounds in all four quadrants.  No wheezes noted.,HEART:  Regular rate and rhythm.,PROCEDURE: , Limited bronchoscopy and then fiberoptic laryngoscopy.,IMPRESSION:  ,1.  End-stage chronic obstructive pulmonary disease with a history of respiratory failure requiring mechanical ventilatory support with tracheostomy tube placement.,2.  Difficulty tolerating tracheostomy tubes secondary to swallow discomfort and neck irritation with no further need for tracheostomy tube over the past few months with the patient tolerating capped tracheostomy tube 24 hours a day.,3.  History of coronary artery disease.,4.  History of myocardial infarction.,5.  History of cirrhosis of liver.,RECOMMENDATIONS: , I discussed with the patient in detail after fiberoptic laryngoscopy and limited bronchoscopy was performed in the office whether or not to pull out the tracheostomy tube.  His vocal cords moved well, and I do not see any signs of granuloma or airway obstruction either in the supraglottic or subglottic region, and I felt he would tolerate the tube being removed with close monitoring by nursing at his extended care facility.  I did impress the fact that I believe he probably will have other events requiring airway support, which could include intubation, and if the intubation is prolonged a tracheostomy may be needed.  Creation of a long-term tracheostoma may be beneficial whereas the patient would not need such a long tracheostomy tube, and I informed the patient there are other options other than the tube he has at the present time.  The patient still wished to have the tube removed and he is aware he may need to have it replaced or he may have trouble with the area healing or scarring or he could end up having an emergent airway situation with the tube gone, but wishes to have it removed, and I did remove it today.  Dressing was applied and we will see him back next week to make sure everything is healing properly.
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DESCRIPTION: Patient referred for evaluation of tracheostomy tube placement and treatment recommendations.

The situation involves the evaluation and potential removal of a tracheostomy tube in a patient with end-stage COPD and other significant health issues. While the removal of a tracheostomy tube is a routine procedure when deemed safe, it requires careful consideration due to the patient's complex medical history and the possibility of requiring airway support again in the future. The decision also balances the patient's quality of life against medical risks. Given the possible severe consequences of removing the tube, such as the need for emergency intubation, this situation is moderately high-stakes in the context of patient safety and future respiratory health management.


Medical Specialty: Discharge Summary
Sample Name: ER Report - Chest Pain & Fever

CHIEF COMPLAINT: , Chest pain and fever.,HISTORY OF PRESENT ILLNESS: , This 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.  The patient noted since she began to feel poorly earlier on the day of admission, had an episode of substernal chest discomfort that was associated with nausea, dizziness, and sweating.  The patient does have a past medical history of diabetes and hypertension.  In addition, the patient complained of some neck and head discomfort for which she underwent a lumbar puncture in the emergency room; this was normal, causes turned out to be normal as well.  The patient denies nosebleed, visual changes, nausea, vomiting, diarrhea or changes in bowel habits.  She has not had any musculoskeletal or neurological deficits.  She denies any rashes or skin lesions.,PAST MEDICAL HISTORY:  ,Hypertension, diabetes, hyperlipidemia, particularly elevated triglycerides with a slightly elevated LDL at 81 with an new standard LDL of 74, diabetics with a bad family history for cardiovascular disease such as this patient does have, and postmenopausal hot flashes.,PAST SURGICAL HISTORY:  ,Cholecystectomy, appendectomy, oophorectomy.,FAMILY HISTORY: , Positive for coronary artery disease in her father and brother in their 40s.,SOCIAL HISTORY: , She is married and does not smoke or drink nor did she ever.,PHYSICAL EXAMINATION: , On admission, temperature 99.4 degrees F., blood pressure 137/60, pulse 90 and regular without ectopy, respiratory rate 20 without unusual respiratory effort.  In general, she is well developed, well nourished, oriented, and alert and in no apparent distress.  Head, ears, eyes, nose, and throat are unremarkable.  Neck is supple.  No neck vein distention is noted.  No bruits are heard.  Chest is clear to percussion and auscultation.  Heart has a regular rhythm and rate without murmurs or rubs or gallops.  Abdomen is soft, obese, and nontender.  Musculoskeletal is intact without deformity.  However, the patient did develop severe cramp behind her left knee during her treadmill testing.  Neurologic:  Cranial nerves are intact and she is nonfocal.  Skin is warm and dry without rash or lesions noted.,LABORATORY FINDINGS: , Glucose 162, BUN 14, creatinine 1.0, sodium 137, potassium 3.6, chloride 103, bicarbonate 23, protein 4.2.  Liver function panel is normal.  CK was 82.  MB fraction was 1.0.  Troponin was less than 0.1 on three occasions.  White count was 12,200 with a normal differential, hemoglobin was 12.1, platelet count 230,000.  Urinalysis showed positive nitrites, positive leukocyte esterase, 5 to 10 white cells per high power field, and 1+ bacteria rods.  Spinal fluid was clear with 11 red cells, glucose 75, protein 67, white count 0.  EKG was normal.,DIAGNOSES ON ADMISSION:,1.  Urinary tract infection.,2.  Chest pain of unclear etiology, rule out myocardial infarction.,3.  Neck and back pain of unclear etiology with a negative spinal tap.,4.  Hypertension.,5.  Diabetes type II, not treated with insulin.,6.  Hyperlipidemia treated with TriCor but not statins.,7.  Arthritis.,ADDITIONAL LABORATORY STUDIES:,  B-natriuretic peptide was 26.  Urine smear and culture negative on 24 and 48 hours.  Chest x-ray was negative.  Lipid panel - triglycerides 249, VLDL 49, HDL 33, LDL 81.,COURSE IN THE HOSPITAL: , The patient was placed on home medications.  This will be listed at the end of the discharge summary.  She was put on rule out acute myocardial infarction routine, and she did in fact rule out.  She had a stress test completed on the day of discharge which was normal, and she was discharged with a diagnoses of chest pain, acute myocardial infarction ruled out, urinary tract infection, fever secondary to UTI, diabetes mellitus type 2 non-insulin treated, hyperlipidemia with elevated triglycerides and an LDL elevated to 81 with new normal being less than 70.  She has a strong family history of early myocardial disease in the men in their 40s.,DISCHARGE MEDICATIONS:,1.  Enteric-coated aspirin 81 mg one daily.  This is new, as the patient was not taking aspirin at home.,2.  TriCor 48 mg one daily.,3.  Zantac 40 mg one daily.,4.  Lisinopril 20 mg one daily.,5.  Mobic 75 mg one daily for arthritis.,6.  Metformin 500 mg one daily.,7.  Macrodantin one two times a day for several more days.,8.  Zocor 20 mg one daily, which is a new addition.,9.  Effexor XR 37.5 mg one daily.,DIET: , ADA 1800-calorie diet.,ACTIVITY:,  As tolerated.  Continue water exercise five days a week.,DISPOSITION: , Recheck at Hospital with a regular physician there in 1 week.  Consider Byetta as an adjunct to her diabetic treatment and efforts to weight control.
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DESCRIPTION: A 48-year-old white married female presents in the emergency room after two days of increasing fever with recent diagnosis of urinary tract infection on outpatient treatment with nitrofurantoin.

The discharge summary describes a medical case where a 48-year-old female presented with chest pain and fever and was diagnosed with a urinary tract infection. The concern was acute chest pain, which necessitated ruling out a myocardial infarction—a potentially life-threatening condition. Although she was cleared of having a myocardial infarction and her other conditions like diabetes and hyperlipidemia were managed, the situation initially presented a potential high-stakes risk due to the possibility of heart-related issues compounded by her family history of heart disease. However, she was stabilized and discharged with prescribed medications and lifestyle recommendations, indicating resolution of the immediate high-stakes concern.


Medical Specialty: Surgery
Sample Name: Neuroma Excision

PREOPERATIVE DIAGNOSIS: , Morton's neuroma, third interspace, left foot.,POSTOPERATIVE DIAGNOSIS:,  Morton's neuroma, third interspace, left foot.,OPERATION PERFORMED: , Excision of neuroma, third interspace, left foot.,ANESTHESIA: , General (local was confirmed by surgeon).,HEMOSTASIS: , Ankle pneumatic tourniquet 225 mmHg.,TOURNIQUET TIME: , 18 minutes.  Electrocautery was necessary.,INJECTABLES: , 50:50 mixture of 0.5% Marcaine and 1% Xylocaine, both plain.  Also, 0.5 mL dexamethasone phosphate (4 mg/mL).,INDICATIONS: , Please see dictated H&P for specifics.,PROCEDURE:  ,After proper identification was made, the patient was brought to the operating room and placed on the table in supine position.  The patient was then placed under general anesthesia.  A local block was then injected into the third ray of the left foot.  The left foot was then prepped with chlorhexidine gluconate and then draped in the usual sterile technique.  The left foot was then exsanguinated with an Esmarch bandage and elevated and an ankle pneumatic tourniquet was then inflated.  Attention was then directed to the third interspace where a longitudinal incision was placed just proximal to the webspace.  The incision was deepened via sharp and blunt dissection with care taken to protect all vital structures.  Identification of the neuroma was made following plantar flexion of the digits.  It was grasped with a hemostat and it was dissected in toto and removed.  It was then sent to pathology.  The area was then flushed with copious amounts of sterile saline.  Closure was with 4-0 Vicryl in the subcutaneous tissue and then running subcuticular 4-0 nylon suture in the skin.  Steri-Strips were then placed over that area.  A sterile compressive dressing consisting of saline-soaked gauze, ABD, Kling, Coban was placed over the foot.  The tourniquet was then released.  Good flow was noted to return to all digits.  The patient did tolerate the procedure well.  He left the operating room with all vital signs stable and neurovascular status intact.  The patient went to the recovery.  The patient previously had been given both oral and written preoperative as well as postoperative instructions and a prescription for pain.  The patient will follow up with me in approximately 4 days for dressing change.
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DESCRIPTION: Excision of neuroma, third interspace, left foot.  Morton's neuroma, third interspace, left foot.

surgery, interspace, ankle pneumatic, pneumatic tourniquet, morton's neuroma, tourniquet, neuroma, foot, anesthesia,

The case describes a surgical procedure for excision of Morton's neuroma, which is a relatively routine and low-risk surgery commonly conducted for relief from nerve pain in the foot. Although general anesthesia was used, and the procedure is invasive, it is not considered high-stakes compared to more complex surgeries like cardiac or neurosurgery. The patient had a stable recovery post-operation, further indicating the low-stakes nature of the procedure. The level of stakes primarily arises from standard surgical risks and the need for precise technique to avoid nerve damage, but overall, these factors align with a moderate level of stakes commonly managed by surgical professionals.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization & Angiography - 1

CLINICAL INDICATION:  ,Normal stress test.,PROCEDURES PERFORMED:,1.  Left heart cath.,2.  Selective coronary angiography.,3.  LV gram.,4.  Right femoral arteriogram.,5.  Mynx closure device.,PROCEDURE IN DETAIL: , The patient was explained about all the risks, benefits, and alternatives of this procedure.  The patient agreed to proceed and informed consent was signed.,Both groins were prepped and draped in the usual sterile fashion.  After local anesthesia with 2% lidocaine, a 6-French sheath was inserted in the right femoral artery.  Left and right coronary angiography was performed using 6-French JL4 and 6-French 3DRC catheters.  Then, LV gram was performed using 6-French pigtail catheter.  Post LV gram, LV-to-aortic gradient was obtained.  Then, the right femoral arteriogram was performed.  Then, the Mynx closure device was used for hemostasis.  There were no complications.,HEMODYNAMICS: , LVEDP was 9.  There was no LV-to-aortic gradient.,CORONARY ANGIOGRAPHY:,1.  Left main is normal.  It bifurcates into LAD and left circumflex.,2.  Proximal LAD at the origin of big diagonal, there is 50% to 60% calcified lesion present.  Rest of the LAD free of disease.,3.  Left circumflex is a large vessel and with minor plaque.,4.  Right coronary is dominant and also has proximal 40% stenosis.,SUMMARY:,1.  Nonobstructive coronary artery disease, LAD proximal at the origin of big diagonal has 50% to 60% stenosis, which is calcified.,2.  RCA has 40% proximal stenosis.,3.  Normal LV systolic function with LV ejection fraction of 60%.,PLAN: , We will treat with medical therapy.  If the patient becomes symptomatic, we will repeat stress test.  If there is ischemic event, the patient will need surgery for the LAD lesion.  For the time being, we will continue with the medical therapy.,
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DESCRIPTION: Left heart cath, selective coronary angiography, LV gram, right femoral arteriogram, and Mynx closure device.  Normal stress test.

cardiovascular / pulmonary, selective coronary angiography, lv gram, femoral, mynx, heart cath, mynx closure device, heart catheterization, femoral arteriogram, stress test, coronary angiography, heart, arteriogram, catheterization, lad, coronary, angiography,

The situation involves a detailed cardiovascular procedure with indications of potential coronary artery disease. This procedure, including heart catheterization and angiography, is essential to diagnose and plan treatment for possibly life-threatening conditions. Although there were no complications during the procedure, the presence of calcified lesions and stenosis suggests a risk for future coronary events. The situation requires careful management and follow-up, indicating moderate stakes due to the possible progression to more serious conditions requiring surgery.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: D&C & Hysteroscopy Followup

PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Enlarged fibroid uterus.,3.  Hypermenorrhea.,4.  Intermenstrual spotting.,5.  Thickened endometrium per ultrasound of a 2 cm lining.,6.  Grade 1+ rectocele.,PROCEDURE PERFORMED:  ,D&C and hysteroscopy.,COMPLICATIONS: , None.,HISTORY: , The patient is a 48-year-old para 2, vaginal delivery.  She has heavy periods lasting 7 to 14 days with spotting in between her periods.  The patient's uterus is 12.2 x 6.2 x 5.3 cm.  Her endometrial thickness is 2 cm.  Her adnexa is within normal limits.  The patient and I had a long discussion.  Consent was reviewed in layman's terms.  The patient understood the foreseeable risks and complications, the alternative treatments and procedure itself and recovery.  Questions were answered.  The patient was taken back to the operative suite.  The patient underwent pelvic examination and then carefully placed in dorsal lithotomy position.  The patient had excellent femoral pulses and there was no excessive extension or hyperflexion of the lower extremities.  The patient's history is that she is at risk for development of condyloma.  The patient's husband was found to have a laryngeal papillomatosis.  She has had a laparotomy, which is an infraumbilical incision appendectomy, a laparoscopy, and bilateral tubal ligation.  Her uterus appears to be mobile by 12-week size.  There is a good descend.  There appears to be no adnexal abnormalities.  Uterus is 12-week sized and has fibroids, it is boggy and probably has a component of adenomyosis.  The patient's cervix was dilated without difficulty utilizing Circon ACMI hysteroscope with a 12-degree lens.  The patient underwent hysteroscopy.  The outflow valve was opened at all times.  The inflow valve was opened just to achieve appropriate distension.  The patient did have no evidence of trauma of the cervix.  No Trendelenburg as we were in room #9.  The patient also had the bag held two fingerbreadths above the level of the heart.  The patient was seen.  There is a 2 x 3 cm focal thickening of the posterior wall of the uterus' endometrial lining, a more of a polypoid nature.  The patient also has one in the fundal area.  The thickened tissue was removed via sharp curettage.  Therefore, we reinserted the hysteroscope.  It appeared that there was an appropriate curettage and that all areas of suspicion were indeed removed.  The patient's procedure was ended with specimen being obtained and sent to Department of Pathology.  We will follow her up in the office.
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DESCRIPTION: D&C and hysteroscopy.  Abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, and thickened endometrium per ultrasound of a 2 cm lining.
6.  Grade 1+ rectocele.

soap / chart / progress notes, pelvic examinatio, abnormal uterine bleeding, enlarged fibroid uterus, hypermenorrhea, intermenstrual spotting, thickened endometrium, intermenstrual, d&c, uterine, bleeding, fibroid, endometrium, hysteroscopy, uterus

The situation involves a follow-up on a medical procedure (D&C and hysteroscopy) for a patient with several preoperative and postoperative diagnoses. While these health issues, such as abnormal uterine bleeding and fibroid uterus, can be serious, the follow-up note mentions that the procedure had no complications and that the patient was prepped and the procedure executed effectively with specimens sent for pathology. This indicates a routine follow-up rather than an immediate life-threatening situation. Thus, while important for the patient's health management, it is not an extremely high-stakes scenario.


Medical Specialty: General Medicine
Sample Name: Motor Vehicle Accident

CHIEF COMPLAINT: , Motor vehicle accident.,HISTORY OF PRESENT ILLNESS: , This is a 32-year-old Hispanic female who presents to the emergency department today via ambulance.  The patient was brought by ambulance following a motor vehicle collision approximately 45 minutes ago.  The patient states that she was driving her vehicle at approximately 40 miles per hour.  The patient was driving a minivan.  The patient states that the car in front of her stopped too quickly and she rear-ended the vehicle ahead of her.  The patient states that she was wearing her seatbelt.  She was driving.  There were no other passengers in the van.  The patient states that she was restrained by the seatbelt and that her airbag deployed.  The patient denies hitting her head.  She states that she does have some mild pain on the left aspect of her neck.  The patient states that she believes she may have passed out shortly after the accident.  The patient states that she also has some pain low in her abdomen that she believes is likely due to the steering wheel or deployment on the airbag.  The patient denies any pain in her knees, ankles, or feet.  She denies any pain in her shoulders, elbows, and wrists.  The patient does state that she is somewhat painful throughout the bones of her pelvis as well.  The patient did not walk after this accident.  She was removed from her car and placed on a backboard and immobilized.  The patient denies any chest pain or difficulty breathing.  She denies any open lacerations or abrasions.  The patient has not had any headache, nausea or vomiting.  She has not felt feverish or chilled.  The patient does states that there is significant deformity to the front of the vehicle that she was driving, which again was a minivan.  There were no oblique vectors or force placed on this accident.  The patient had straight rear-ending of the vehicle in front of her.  The pain in her abdomen is most significant pain currently and she ranks it at 5 out of 10.  The patient states that her last menstrual cycle was at the end of May.  She does not believe that she could be pregnant.  She is taking oral birth control medications and also has an intrauterine device to prevent pregnancy as the patient is on Accutane.,PAST MEDICAL HISTORY:,  No significant medical history other than acne.,PAST SURGICAL HISTORY:,  None.,SOCIAL HABITS: ,  The patient denies tobacco, alcohol or illicit drug usage.,MEDICATIONS:,  Accutane.,ALLERGIES: , No known medical allergies.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  This is a Hispanic female who appears her stated age of 32 years.  She is well-nourished, well-developed, in no acute distress.  The patient is pleasant.  She is immobilized on a backboard and also her cervical spine is immobilized as well on a collar.  The patient is without capsular retractions, labored respirations or accessory muscle usage.  She responds well and spontaneously.,VITAL SIGNS:  Temperature 98.2 degrees Fahrenheit, blood pressure 129/84, pulse 75, respiratory rate 16, and pulse oximetry 97% on room air.,HEENT:  Head is normocephalic.  There is no crepitus.  No bony step-offs.  There are no lacerations on the scalp.  Sclerae are anicteric and noninjected.  Fundoscopic exam appears normal without papilledema.  External ocular movements are intact bilaterally without nystagmus or entrapment.  Nares are patent and free of mucoid discharge.  Mucous membranes are moist and free of exudate or lesions.,NECK:  Supple.  No thyromegaly.  No JVD.  No carotid bruits.  Trachea is midline.  There is no stridor.,HEART:  Regular rate and rhythm.  Clear S1 and S2.  No murmur, rub or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales, or rhonchi.,ABDOMEN:  Soft, nontender with the exception of mild-to-moderate tenderness in the bilateral lower pelvic quadrants.  There is no organomegaly here.  Positive bowel sounds are auscultated throughout.  There is no rigidity or guarding.  Negative CVA tenderness bilaterally.,EXTREMITIES:  No edema.  There are no bony abnormalities or deformities.,PERIPHERAL VASCULAR:  Capillary refill is less than two seconds in all extremities.  The patient does have intact dorsalis pedis and radial pulses bilaterally.,PSYCHIATRIC:  Alert and oriented to person, place, and time.  The patient recalls all events regarding the accident today.,NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally.  No focal deficits are appreciated.  The patient has equal and strong distal and proximal muscle group strength in all four extremities.  The patient has negative Romberg and negative pronator drift.,LYMPHATICS:  No appreciable adenopathy.,MUSCULOSKELETAL:  The patient does have pain free range of motion at the bilateral ankles, bilateral knees, bilateral hips, bilateral shoulders, bilateral elbows, and bilateral wrists.  There are no bony abnormalities identified.  The patient does have some mild tenderness over palpation of the bilateral iliac crests.,SKIN:  Warm, dry, and intact.  No lacerations.  There are no abrasions other than a small abrasion on the patient's abdomen just inferior to the umbilicus.  No lacerations and no sites of trauma or bleeding are identified.,DIAGNOSTIC STUDIES: , The patient does have multiple x-rays done.  There is an x-ray of the pelvis, which shows normal pelvis and right hip.  There is also a CT scan of the cervical spine that shows no evidence of acute traumatic bony injury of the cervical spine.  There is some prevertibral soft tissue swelling from C5 through C7.  This is nonspecific and could be due to prominence of upper esophageal sphincter.  The CT scan of the brain without contrast shows no evidence of acute intracranial injury.  There is some mucus in the left sphenoid sinus.  The patient also has emergent CT scan without contrast of the abdomen.  The initial studies show some dependent atelectasis in both lungs.  There is also some low density in the liver, which could be from artifact or overlying ribs; however, a CT scan with contrast is indicated.  A CT scan with contrast is obtained and this is found to be normal without bleeding or intraabdominal or pelvic abnormalities.  The patient has laboratory studies done as well.  CBC is within normal limits without anemia, thrombocytopenia or leukocytosis.  The patient has a urine pregnancy test, which is negative and urinalysis shows no blood and is normal.,EMERGENCY DEPARTMENT COURSE: , The patient was removed from the backboard within the first half hour of her emergency department stay.  The patient has no significant bony deformities or abnormalities.  The patient is given a dose of Tylenol here in the emergency department for treatment of her pain.  Her pain is controlled with medication and she is feeling more comfortable and removed from the backboard.  The patient's CT scans of the abdomen appeared normal.  She has no signs of bleeding.  I believe, she has just a contusion and abrasion to her abdomen from the seatbelt and likely from the airbag as well.  The patient is able to stand and walk through the emergency department without difficulty.  She has no abrasions or lacerations.,ASSESSMENT AND PLAN:,  Multiple contusions and abdominal pain, status post motor vehicle collision.  Plan is the patient does not appear to have any intraabdominal or pelvic abnormities following her CT scans.  She has normal scans of the brain and her C-spine as well.  The patient is in stable condition.  She will be discharged with instructions to return to the emergency department if her pain increases or if she has increasing abdominal pain, nausea or vomiting.  The patient is given a prescription for Vicodin and Flexeril to use it at home for her muscular pain.
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DESCRIPTION: Multiple contusions and abdominal pain, status post motor vehicle collision.

This scenario involves a 32-year-old woman who was in a motor vehicle accident and presents with abdominal pain and contusions. Although initially worrisome due to the potential for serious internal injuries, extensive diagnostic testing, including CT scans and x-rays, reveals no acute traumatic injuries or abnormalities. The patient is stable, has controlled pain, and is able to walk, which indicates that the situation has been managed effectively and no immediate life-threatening conditions are present. While it remains important to monitor for delayed complications, the immediate situation has been stabilized, making it medium-stakes rather than high-stakes.


Medical Specialty: Surgery
Sample Name: ORIF Wrist - Acumed Locking Plate

PREOPERATIVE DIAGNOSIS:  ,Closed displaced angulated fracture of the right distal radius.,POSTOPERATIVE DIAGNOSIS: , Closed displaced angulated fracture of the right distal radius.,PROCEDURE: , Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.,ANESTHESIA: , General laryngeal mask airway.,ESTIMATED BLOOD LOSS: , Minimal.,TOURNIQUET TIME: , 40 minutes.,COMPLICATIONS: , None.,The patient was taken to the postanesthesia care unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS:  ,The patient is a 23-year-old gentleman who was involved in a crush injury to his right wrist.  He was placed into a well-molded splint after reduction was performed in the emergency department.  Further x-rays showed further distal fragment dorsal angulation that progressively worsened and it was felt that surgical intervention was warranted.  All risks, benefits, expectations, and complications of the surgery were explained to the patient in detail, and he signed the informed consent for ORIF of the right wrist.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operative table.  The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well.  The right upper extremity had a well-padded tourniquet placed on the right arm, which was insufflated and maintained for 40 minutes at 250 mmHg pressure.  The right upper extremity was prepped and draped in a sterile fashion.  A 5-cm incision was made over the flexor carpi radialis of the right wrist.  The skin was incised down to the subcutaneous tissue, the deep tissue was retracted, blunt dissection was performed down to the pronator quadratus.  Sharp dissection was performed through the pronator quadratus after which a tissue elevator was used to elevate this tissue.  Next, a reduction was performed placing the distal fragment into appropriate alignment.  This was checked under fluoroscopy, and was noted to be adequately reduced and in appropriate position.  An Acumed Accu-lock plate was placed along the volar aspect of the distal radius.  This was checked under AP and lateral views with C-arm, noted to be in appropriate alignment.  A 3.5-mm cortical screw was placed through the proximal aspect of the plate, positioned it into position.  Two distal locking screws were placed along the plate itself.  The screws were checked under AP and lateral views noting the fracture fragment was well aligned and appropriately reduced with the 2 screws being placed into appropriate position with the appropriate length as well as not being intraarticular.  Four more screws were placed along the distal aspect of the plate and 2 more proximal along the plate.  All locking screws placed into position and had excellent purchase into the bone or had excellent fixation into the plate and maintained the alignment of the fracture.  AP and lateral views were taken of these screw placements again.  None of these screws were into the joint and all had appropriate length into the dorsal cortex.  Two more 3.5 fully threaded cortical screws were placed along the proximal aspect of the plate and had excellent bicortical purchase.  AP and lateral views were taken of the wrist once again showing that this was appropriate reduction of the fracture as well as appropriate placement of the screws.  Bicortical purchase was appreciated and no screws were placed into the joint.  The wound itself was copiously irrigated with saline and Kantrex after which the subcutaneous tissue was approximated with 2-0 Vicryl, and the skin was closed with running 4-0 nylon stitch; 10 mL of 0.5% Marcaine plain was injected into the wound site after which sterile dressing was placed as well as the volar splint.  The patient was awakened from general anesthetic, transferred to the hospital gurney and taken to the postanesthesia care unit in stable condition.  The patient tolerated the procedure well.
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DESCRIPTION: Open reduction and internal fixation (ORIF) of the right wrist using an Acumed locking plate.  Closed displaced angulated fracture of the right distal radius.

surgery, open reduction, angulated fracture, distal radius, acumed locking plate, internal fixation, tourniquet, acumed, orif, reduction, fracture, wrist

The description outlines a surgical procedure for a displaced angulated fracture of the right distal radius, which is managed through open reduction and internal fixation (ORIF) using an Acumed locking plate. While surgical procedures inherently involve some level of risk and complexity, this particular procedure appears to have been routine and completed without complications. The stakes are relatively high because surgery involves risks like infections, complications from anesthesia, and potential for long-term disability if not properly managed. However, the operation went smoothly with minimal blood loss and no complications reported, and the patient was stable post-surgery. The situation is moderately high-stakes given it involves surgery on a major joint that directly affects hand function, vital for quality of life, but it is not an emergency or life-threatening condition.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Endovascular Brachytherapy

ENDOVASCULAR BRACHYTHERAPY (EBT),The patient is to undergo a course of angioplasty for in-stent restenosis.  The radiotherapy will be planned using simulation films when the Novoste system catheter markers are placed on either side of the coronary artery injury site.  After this, a calculation will take place to determine the length of time at which the strontium sources will be left in place to deliver an adequate dose given the reference vessel diameter.  The rationale for this treatment is based on radiobiological principles that make this type of therapy more effective than blade atherectomy or laser atherectomy.  The does per fraction is individualized for each patient according to radiobiological principles and reference vessel diameter.  Given that this is a very high dose rate source and the chances of severe acute toxicity such as cardiac ischemia and machine malfunction are present, it is imperative that the patient be followed closely by myself and monitored for ST segment elevation and correct machine function.
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DESCRIPTION: Endovascular Brachytherapy (EBT)

Endovascular Brachytherapy (EBT)

cardiovascular / pulmonary, endovascular brachytherapy, ebt, angioplasty, stent, vessel, atherectomy, endovascular, brachytherapyNOTE,: 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 context describes a medical procedure involving endovascular brachytherapy for in-stent restenosis, which is a high-stakes situation due to the complexity and risks associated with the procedure. High-dose radiation and acute toxicity risk necessitate close monitoring and precise execution to avoid serious complications such as cardiac ischemia. Furthermore, machine malfunction poses a critical risk, emphasizing the need for careful oversight. These factors, combined with the necessity for individualized treatment plans, underscore the high-stakes nature of this medical scenario.


Medical Specialty: Surgery
Sample Name: Phenol Neurolysis & Botulinum Toxin Injection - 3

PROCEDURE CODES:  64640 times two, 64614 time two, 95873 times two, 29405 times two.,PREOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,POSTOPERATIVE DIAGNOSIS:  Spastic diplegic cerebral palsy, 343.0.,ANESTHESIA:  MAC.,COMPLICATIONS:  None.,DESCRIPTION OF TECHNIQUE:  Informed consent was obtained from the patient's mom.  The patient was brought to minor procedures and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.,The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse with active EMG stimulation.  Approximately 4 mL of 5% phenol was injected in this location bilaterally.  Phenol injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified with active EMG stimulation.  Approximately 50 units was injected in the rectus femoris bilaterally, 75 units in the medial hamstrings bilaterally and 100 units in the gastrocnemius soleus muscles bilaterally.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  After injections were performed, bilateral short leg fiberglass casts were applied.  The patient tolerated the procedure well and no complications were encountered.
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DESCRIPTION: Botulinum toxin injection bilateral rectus femoris, medial hamstrings, and gastrocnemius soleus muscles, phenol neurolysis of bilateral obturator nerves, application of bilateral short leg fiberglass casts.

surgery, botulinum toxin injection bilateral, toxin injection bilateral rectus, neurolysis of bilateral obturator, short leg fiberglass casts, muscles phenol neurolysis, botulinum toxin injection, gastrocnemius soleus muscles, short leg fiberglass, femoris medial, cerebral palsy, active emg, emg stimulation, phenol neurolysis, toxin injection, rectus femoris, gastrocnemius soleus, soleus muscles, obturator nerves, leg fiberglass, fiberglass casts, botulinum toxin, hamstrings, gastrocnemius, obturator, nerves, fiberglass, casts, muscles, botulinum, phenol, bilateral, injection, toxin

The procedure involves neurolysis and the injection of botulinum toxin in a patient with spastic diplegic cerebral palsy, which is a delicate and intricate process. It requires accuracy in locating and targeting specific nerves and muscles using EMG stimulation. However, it is a routine intervention for managing spasticity and was performed without complications. This suggests moderate stakes since it involves important medical interventions, but they are relatively well-known in medical practice. The successful completion without complications also indicates a lower level of risk. Therefore, the procedure is considered to be moderate-stakes.


Medical Specialty: Surgery
Sample Name: Pars Plana Vitrectomy & Lensectomy

TITLE OF OPERATION:,1.  Pars plana vitrectomy.,2.  Pars plana lensectomy.,3.  Exploration of exit wound.,4.  Closure of perforating corneal scleral laceration involving uveal tissue.,5.  Air-fluid exchange.,6.  C3F8 gas.,7.  Scleral buckling, right eye.,INDICATION FOR SURGERY: , The patient was hammering and a piece of metal entered his eye 1 day prior to the procedure giving him a traumatic cataract corneal laceration and the metallic intraocular foreign body was lodged in the posterior eye wall.  He undergoes repair of the open globe today.,PREOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,POSTOP DIAGNOSIS: , Perforating corneal scleral laceration involving uveal tissue with traumatic cataract and metallic foreign body lodged in the posterior eye wall, right eye.,ANESTHESIA:,  General.,SPECIMEN:,  None.,IMPLANTS:,1.  Style number XXX silicone band reference XXX , lot number XXX , exploration 11/13.,2.  Style number XXX Watzke sleeve reference XXX , lot number XXX , exploration 04/14.,PROCEDURE: , The risk, benefits, and alternatives to the procedure were reviewed with the patient and his wife.  All of their questions were answered.  Informed consent was signed.  The patient was brought into the operating room.  A surgical time-out was performed during which all members of the operating room staff agreed upon the patient's name, operation to be performed, and correct operative eye.  After administration of general anesthesia, the patient was intubated without incident.,The right eye was prepared and draped in the usual fashion for ophthalmic surgery.  A wire lid speculum was used to separate the eyelids of the left eye.  A 9 o'clock anterior chamber paracentesis was created with Supersharp blade and the anterior chamber was filled with Healon.  The clear corneal incision was superior to the visual axis and was closed with three interrupted 10-0 nylon sutures with the knots buried.  A standard three-port pars plana vitrectomy __________ was initiated by performing partial conjunctival peritomies in the superonasal, superotemporal, and inferotemporal quadrants with Westcott scissors.  Hemostasis was achieved with bipolar cautery.  A 7-0 Vicryl suture was preplaced in the mattress fashion, 3 mm posterior to the surgical limbus in the inferotemporal quadrant.  A microvitreoretinal blade was used to create a sclerotomy at this site and a 4-mm infusion cannula was introduced through the sclerotomy and tied in place with the aforementioned suture.  The presence of the tip of the cannula was confirmed to be within the vitreous cavity prior to initiation of posterior infusion.  Two additional sclerotomies were created superonasally and superotemporally, 3 mm posterior to the surgical limbus with microvitreoretinal blade.,The vitreous cutter was used to perform the pars plana lens actively preserving peripheral anterior capsule.  The pars plana vitrectomy was performed with the assistance of the BIOM non-contact lens indirect viewing system using the light pipe illuminator and the vitreous cutter.  The vitreous was trimmed to the vitreous base.  A posterior vitreous detachment was created and extended 360 degrees with the assistance of triamcinolone for staining.,The foreign body appeared to exit the posterior pole along the superotemporal arcade and apparently severed a branched retinal artery resulting in an area of macular ischemia with retinal whitening along its course.  The exit wound was explored.  No intraocular foreign body or mural foreign body was observed with the assistance of intraocular forceps.  The intraocular magnet was then inserted through the sclerotomy and no foreign body was again identified.,An air-fluid exchange was performed with the assistance of the soft-tip extrusion cannula and the retinal periphery was examined with scleral depression.  No retinal breaks or defects were noted in the periphery.  The plugs were placed in the sclerotomies and the conjunctival peritomy was extended at 360 degrees.  Each of the rectus muscles was isolated on a 2-0 silk suture and a #XXX band was threaded beneath each of the rectus muscle and fixed to itself in the inferonasal quadrant with the Watzke sleeve.  The buckle was sutured to the eye wall with 5-0 Mersilene sutures in each quadrant in a mattress fashion.  The buckle was trimmed and the height of the buckle was inspected internally and noted to be adequate.,Residual intraocular fluid was removed with a soft-tip extrusion cannula and the sclerotomies were closed with 7-0 Vicryl sutures.  A 12% concentration of C3F8 gas was flushed through the eye.  The infusion cannula was removed and the sclerotomy was closed with the preplaced 7-0 Vicryl suture.  All of the sclerotomies were noted to be airtight.  The intraocular pressure following injection of 0.05 mL each of vancomycin (0.5 mg) and ceftazidime (1 mg) were injected through the superotemporal pars plana, 30-gauge needles.,The conjunctiva was closed with 6-0 plain gut sutures with the knots buried.  Subconjunctival injections of Ancef and Decadron were delivered inferotemporally.  The lid speculum was removed.  Pred-G ointment and atropine solution were applied to the ocular surface.  The eye was patched and shielded, and the patient was returned to the recovery room in stable condition, having tolerated the procedure well.  There were no complications.,I was the attending surgeon, was present and scrubbed for the entirety of the procedure.
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DESCRIPTION: Pars plana vitrectomy, pars plana lensectomy, exploration of exit wound, closure of perforating corneal scleral laceration involving uveal tissue, air-fluid exchange, C3F8 gas, and scleral buckling, right eye.

The described situation involves a complex eye surgery addressing multiple serious conditions, including a perforating corneal scleral laceration, traumatic cataract, and an intraocular foreign body. These types of surgeries are high-stakes due to the risk of vision loss or other complications if the surgery is not successful. Additionally, it involves handling of vital ocular structures and the potential for significant patient impact post-surgery.


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

Medical Specialty: Bariatrics
Sample Name: Lipectomy - Abdomen/Thighs

PREOPERATIVE DIAGNOSIS: , Lipodystrophy of the abdomen and thighs.,POSTOPERATIVE DIAGNOSIS:,  Lipodystrophy of the abdomen and thighs.,OPERATION: , Suction-assisted lipectomy.,ANESTHESIA:,  General.,FINDINGS AND PROCEDURE:,  With the patient under satisfactory general endotracheal anesthesia, the entire abdomen, flanks, perineum, and thighs to the knees were prepped and draped circumferentially in sterile fashion.  After this had been completed, a #15 blade was used to make small stab wounds in the lateral hips, the pubic area, and upper edge of the umbilicus.  Through these small incisions, a cannula was used to infiltrate lactated Ringers with 1000 cc was infiltrated initially into the abdomen.  A 3 and 4-mm cannulas were then used to carry out the liposuction of the abdomen removing a total of 1100 cc of aspirate, which was mostly fat, little fluid, and blood.  Attention was then directed to the thighs both inner and outer.  A total of 1000 cc was infiltrated in both lateral thighs only about 50 cc in the medial thighs.  After this had been completed, 3 and 4-mm cannulas were used to suction 650 cc from each side, approximately 50 cc in the inner thigh and 600 on each lateral thigh.  The patient tolerated the procedure very well.  All of this aspirate was mostly fat with little fluid and very little blood.  Wounds were cleaned and steri-stripped and dressing of ABD pads and ***** was then applied.  The patient tolerated the procedure very well and was sent to the recovery room in good condition.
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DESCRIPTION: Suction-assisted lipectomy - lipodystrophy of the abdomen and thighs.

bariatrics, lipodystrophy, abd pads, suction-assisted lipectomy, abdomen, aspirate, lipectomy, perineum, steri-stripped, thighs, umbilicus, abdomen and thighs, abdomen/thighs,

The described situation involves a surgical procedure known as suction-assisted lipectomy, which is a form of liposuction used to remove excess fat from specific areas of the body. While this is a routine and common cosmetic surgical procedure, it involves general anesthesia and surgical interventions, which inherently have risks of complications such as infection, bleeding, or anesthesia-related issues. Although the procedure is elective and the patient tolerated it well without complications, surgeries carry potential risks that elevate the stakes. Additionally, the potential impact on the patient's health and well-being if complications were to arise adds to the stakes.


Medical Specialty: Surgery
Sample Name: Microsuspension Direct Laryngoscopy & Biopsy

PREOPERATIVE DIAGNOSES:,1.  Fullness in right base of the tongue.,2.  Chronic right ear otalgia.,POSTOPERATIVE DIAGNOSIS: , Pending pathology.,PROCEDURE PERFORMED: , Microsuspension direct laryngoscopy with biopsy.,ANESTHESIA: , General.,INDICATION:,  This is a 50-year-old female who presents to the office with a chief complaint of ear pain on the right side.  Exact etiology of her ear pain had not been identified.  A fiberoptic examination had been performed in the office.  Upon examination, she was noted to have fullness in the right base of her tongue.  She was counseled on the risks, benefits, and alternatives to surgery and consented to such.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Operative Suite where she was placed in supine position.  General endotracheal tube intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away where a shoulder roll was placed.  A tooth guard was then placed to protect the upper dentition.  The Dedo laryngoscope was then inserted into the oral cavity.  It was advanced on the right lateral pharyngeal wall until the epiglottis was brought into view.  At this point, it was advanced underneath the epiglottis until the vocal cords were seen.  At this point, it was suspended via the Lewy suspension arm from the Mayo stand.  At this point, the Zeiss microscope with a 400 mm lens was brought into the surgical field.  Inspection of the vocal cords underneath the microscope revealed them to be white and glistening without any mucosal abnormalities.  It should be mentioned that the right vocal cord did appear to be slightly more hyperemic, however, there were no mucosal abnormalities identified.  This was confirmed with a laryngeal probe as well as use of mirror evaluated in the subglottic portion as well as the ventricle.  At this point, the scope was desuspended and the microscope was removed.  The scope was withdrawn through the vallecular region.  Inspection of the vallecula revealed a fullness on the right side with a papillomatous type growth that appeared very friable.  Biopsies were obtained with straight-biting cup forceps.  Once hemostasis was achieved, the scope was advanced into the piriform sinuses.  Again in the right piriform sinus, there was noted to be studding along the right lateral wall of the piriform sinus.  Again, biopsies were performed and once hemostasis was achieved, the scope was further withdrawn down the lateral pharyngeal wall.  There were no mucosal abnormalities identified within the oropharynx.  The scope was then completely removed and a bimanual examination was performed.  No neck masses were identified.  At this point, the procedure was complete.  The mouth guard was removed and the patient was returned to Anesthesia for awakening and taken to the recovery room without incident.
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DESCRIPTION: Microsuspension direct laryngoscopy with biopsy.  Fullness in right base of the tongue and chronic right ear otalgia.

surgery, microsuspension, laryngoscopy, otalgia, ear pain, fiberoptic, dedo laryngoscope, epiglottis, direct laryngoscopy, piriform sinuses, tongue, microscope, mucosal, abnormalities, fullness, ear, scope

The situation involves a surgical procedure, which inherently carries certain risks and implications. However, the procedure was described as straightforward and concluded without incident. The stakes could be considered moderately high due to the potential implications of finding a malignancy and the diagnostic nature of the biopsy. Pending pathology results also introduce some uncertainty. Overall, while important, the procedure itself seems routine for the specialty, suggesting a moderate level of stakes rather than extremely high.


Medical Specialty: Surgery
Sample Name: Diagnostic Laparoscopy

TITLE OF OPERATION:,  Diagnostic laparoscopy.,INDICATION FOR SURGERY: , The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,PREOP DIAGNOSIS: , Possible ruptured ectopic pregnancy.,POSTOP DIAGNOSIS: , No evidence of ectopic pregnancy or ruptured ectopic pregnancy.,ANESTHESIA: , General endotracheal.,SPECIMEN: , Peritoneal fluid.,EBL: , Minimal.,FLUIDS:,  900 cubic centimeters crystalloids.,URINE OUTPUT: , 400 cubic centimeters.,FINDINGS: , Adhesed left ovary with dilated left fallopian tube, tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary, perihepatic lesions consistent with history of PID, approximately 1-200 cubic centimeters of more serous than sanguineous fluid.  No evidence of ectopic pregnancy.,COMPLICATIONS: , None.,PROCEDURE:,  After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered.  She was examined under anesthesia.  An 8-10 cm anteverted uterus was noted.  The patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion, a sponge on a sponge stick was used in the place of a HUMI in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy.  Attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus.  The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity.  Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water.  No peritoneum was obtained without difficulty using 4 liters of CO2 gas.  The 5-mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope.,The above-noted findings were visualized.  A 5-mm skin incision was made approximately one-third of the way from the ASI to the umbilicus at McBurney's point.  Under direct visualization, the trocar and sleeve were advanced without difficulty.  A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep.  The peritoneal fluid was aspirated and sent for culture and wash and cytology.  The abdomen and pelvis were surveyed with the above-noted findings.  No active bleeding was noted.  No evidence of ectopic pregnancy was noted.  The instruments were removed from the abdomen under good visualization with good hemostasis noted.  The sponge on a sponge stick was removed from the vagina.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.,The attending, Dr. X, was present and scrubbed for the entire procedure.
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DESCRIPTION: The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.

surgery, peritoneal fluid, sanguineous fluid, ruptured ectopic pregnancy, diagnostic laparoscopy, intrauterine pregnancy, ectopic pregnancy, trocar, ruptured, ectopic, tortuous, pregnancy,

The situation involves a surgical procedure to diagnose a possible ruptured ectopic pregnancy, which is considered a high-stakes medical situation. Ectopic pregnancies, if ruptured, can be life-threatening due to internal bleeding and require immediate medical intervention. Performing diagnostic laparoscopy in this context is crucial for accurately identifying the condition and ruling out any complications. While the surgery in this case revealed no evidence of an ectopic pregnancy, the initial indication was critical and potentially life-threatening.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: ORIF - Followup

REASON FOR VISIT:,  Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.,HISTORY OF PRESENT ILLNESS: , The patient is now approximately week status post removal of Ex-Fix from the right knee with an MUA following open reduction internal fixation of right tibial plateau fracture.  The patient states that this pain is well controlled.  He has had no fevers, chills or night sweats.  He has had some mild drainage from his pin sites.  He just started doing range of motion type exercises for his right knee.  He has had no numbness or tingling.,FINDINGS: , On exam, his pin sites had no erythema.  There is some mild drainage but they have been dressing with bacitracin, it looks like there may be part of the fluid noted.  The patient had 3/5 strength in the EHL, FHL.  He has intact sensation to light touch in a DP, SP, and tibial nerve distribution.,X-rays taken include three views of the right knee.  It demonstrate status post open reduction internal fixation of the right tibial plateau with excellent hardware placement and alignment.,ASSESSMENT: , Status post open reduction and internal fixation of right tibial plateau fracture with removal ex fix.,PLANS: , I gave the patient a prescription for aggressive range of motion of the right knee.  I would like to really work on this as he has not had much up to this time.  He should remain nonweightbearing.  I would like to have him return in 2 weeks' time to assess his knee range of motion.  He should not need x-rays at that time.
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DESCRIPTION: Followup visit status post removal of external fixator and status post open reduction internal fixation of right tibial plateau fracture.

soap / chart / progress notes, external fixator, open reduction internal fixation, tibial plateau fracture., ex fix, tibial plateau fracture, internal fixation, tibial plateau, orif,

The patient is in a follow-up stage after a serious orthopedic surgery (open reduction internal fixation of the tibial plateau), which involves significant recovery and rehabilitation. However, the patient's condition is currently stable, with pain well controlled and no signs of infection or complications. The main focus at this stage is the improvement of range of motion and the continuation of non-weight bearing status. While the overall situation is important for proper healing and long-term function, there are no immediate life-threatening issues at this moment.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 1

HISTORY OF PRESENT ILLNESS: ,This is the initial clinic visit for a 29-year-old man who is seen for new onset of right shoulder pain.  He states that this began approximately one week ago when he was lifting stacks of cardboard.  The motion that he describes is essentially picking up a stack of cardboard at his waist level, twisting to the right and delivering it at approximately waist level.  Sometimes he has to throw the stacks a little bit as well.  He states he felt a popping sensation on 06/30/04.  Since that time, he has had persistent shoulder pain with lifting activities.  He localizes the pain to the posterior and to a lesser extent the lateral aspect of the shoulder.  He has no upper extremity .  , ,REVIEW OF SYSTEMS: ,Focal lateral and posterior shoulder pain without a suggestion of any cervical radiculopathies.  He denies any chronic cardiac, pulmonary, GI, GU, neurologic, musculoskeletal, endocrine abnormalities.  , ,MEDICATIONS: , Claritin for allergic rhinitis.  , ,ALLERGIES: , None.  , ,PHYSICAL EXAMINATION:, Blood pressure 120/90, respirations 10, pulse 72, temperature 97.2.  He is sitting upright, alert and oriented, and in no acute distress.  Skin is warm and dry. Gross neurologic examination is normal.  ENT examination reveals normal oropharynx, nasopharynx, and tympanic membranes.  Neck: Full range of motion with no adenopathy or thyromegaly.  Cardiovascular:  Regular rate and rhythm.  Lungs:  Clear.  Abdomen: Soft.
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DESCRIPTION: Return to work & Fit for duty evaluation.

consult - history and phy., return to work, consult, fit for duty, cleared for work, muscular, paresthesias, shoulder, shoulder pain, strain, waist, x-rays, waist level, neurologic, abnormalities, impingement, examination,

The situation described involves a medical consultation for a 29-year-old man with new onset shoulder pain potentially related to a work-related activity, specifically lifting and twisting with cardboard stacks. While this situation involves assessing physical health, it is part of an initial clinic visit, likely aimed at diagnosing and treating a musculoskeletal injury. Such scenarios, while important for the individual's health and ability to work, are relatively routine in clinical practice for general medicine consultations. The stakes are not extremely high unless the diagnosis uncovers a more severe underlying condition or incapacitates the individual significantly, but there is no immediate indication of life-threatening or irreversible consequences from the information provided.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 23

SUBJECTIVE:,  Mom brings the patient in today for possible ear infection.  He is complaining of left ear pain today.  He was treated on 04/14/2004, with amoxicillin for left otitis and Mom said he did seem to get better but just started complaining of the left ear pain today.  He has not had any fever but the congestion has continued to be very thick and purulent.  It has never really resolved.  He has a loose, productive-sounding cough but not consistently and not keeping him up at night.  No wheezing or shortness of breath.,PAST MEDICAL HISTORY:,  He has had some wheezing in the past but nothing recently.,FAMILY HISTORY: , All siblings are on antibiotics for ear infections and URIs.,OBJECTIVE:,General:  The patient is a 5-year-old male.  Alert and cooperative.  No acute distress.,Neck:  Supple without adenopathy.,HEENT:  Ear canals clear.  TMs, bilaterally, have distorted light reflexes but no erythema.  Gray in color.  Oropharynx pink and moist with a lot of postnasal discharge.  Nares are swollen and red.  Thick, purulent drainage.  Eyes are a little puffy.,Chest:  Respirations regular, nonlabored.,Lungs:  Clear to auscultation throughout.,Heart:  Regular rhythm without murmur.,Skin:  Warm, dry, pink.  Moist mucus membranes.  No rash.,ASSESSMENT:,  Ongoing purulent rhinitis.  Probable sinusitis and serous otitis.,PLAN:,  Change to Omnicef two teaspoons daily for 10 days.  Frequent saline in the nose.  Also, there was some redness around the nares with a little bit of yellow crusting.  It appeared to be the start of impetigo, so hold off on the Rhinocort for a few days and then restart.  Use a little Neosporin for now.
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DESCRIPTION: Patient in with mom for possible ear infection.

general medicine, ear infection, productive-sounding cough, purulent rhinitis, serous otitis, sinusitis, wheezing, ear, amoxicillin,

The situation involves a medical consultation for a child with recurring symptoms and possible sinusitis and ear infection. While it requires appropriate medical attention and treatment, it does not involve life-threatening conditions or require immediate critical interventions. The prescribed plan includes a change in antibiotics and observation. While important, it does not present high-stakes in the context of medical emergencies or severe conditions.