Medical Specialty: Surgery
Sample Name: Full Mouth Dental Rehabilitation - 1

OPERATION PERFORMED:,  Full mouth dental rehabilitation in the operating room under general anesthesia.,PREOPERATIVE DIAGNOSES:  ,1.  Severe dental caries.,2.  Hemophilia.,POSTOPERATIVE DIAGNOSES:  ,1.  Severe dental caries.,2.  Hemophilia.,3.  Nonrestorable teeth.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY:  ,1 hour and 22 minutes.,BRIEF HISTORY:  ,The patient was first seen by me on 08/23/2007, who is 4-year-old with hemophilia, who received infusion on Tuesdays and Thursdays and he has a MediPort.  Mom reported history of high fever after surgery and he has one seizure previously.  He has history of trauma to his front teeth and physician put him on antibiotics.  He was only cooperative for having me do a visual examination on his anterior teeth.  Visual examination revealed severe dental caries and dental abscess from tooth #E and his maxillary anterior teeth needed to be extracted.  Due to his young age and hemophilia, I felt that he would be best served to be taken to the hospital operating room.,OTHER PREPARATION:  ,The child was brought to the Hospital Day Surgery accompanied by his mother.  There, I met with her and discussed the needs of the child, types of restoration to be performed, and the risks, and benefits of the treatment as well as the options and alternatives of the treatment.  After all her questions and concerns were addressed, she gave her informed consent to proceed with treatment.  The patient's history and physical examination was reviewed.  He was given factor for appropriately for his hemophilia prior to being taken back to the operating room.  Once he was cleared by Anesthesia, the child was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with an oral tube and the tube was stabilized.  The head was wrapped and IV was started.  The head and neck were draped with sterile towels and the body was covered with a lead apron and sterile sheath.  A moist continuous throat pack was placed beyond tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative clinical photographs were taken.  Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiograph.  After the radiographs were taken, the lead shield was removed.,Prophylaxis was then performed using a prophy cup and fluoridated prophy paste.  The patient's teeth were rinsed well.  The patient's oral cavity was suctioned clean.  Clinical and radiographic examination followed and areas of decay were noted.  During the restorative phase, these areas of decay were incidentally removed.  Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it.  Final caries removal was confirmed upon reaching hard, firm and sound dentin.,Teeth restored with composite ___________  bonded with a one-step bonding agent.  Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement.  Non-restorable primary teeth would be extracted.  The caries were extensive and invaded the pulp tissues, pulp therapy was initiated using ViscoStat and then IRM pulpotomies.  Teeth treated in such a manner would then be crowned with stainless steel crowns.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were then taken.  The continuous gauze throat pack was removed with continuous suction with visualization.  Topical fluoride was then placed on the teeth.  At the end of the procedure, the child was undraped, extubated, and awakened in the operating room, was taken to the recovery room, breathing spontaneously with stable vital signs.,FINDINGS: , This young patient presented with mild generalized marginal gingivitis, secondary to light generalized plaque accumulation and fair oral hygiene.  All primary teeth were present.  Dental carries were present on the following teeth:  Tooth B, OL caries, tooth C, M, L, S caries, tooth B, caries on all surfaces, tooth E caries on all surfaces, tooth F caries on all surfaces, tooth T caries on all surfaces, tooth H, lingual and facial caries, tooth I, caries on all surfaces, tooth L caries on all surfaces, and tooth S, all caries.  The remainder of his teeth and soft tissues were within normal limits.  The following restoration and procedures were performed.  Tooth B, OL amalgam, tooth C, M, L, S composite, tooth D, E, F, and G were extracted, tooth H, and L and separate F composite.  Tooth I is stainless steel crown, tooth L pulpotomy and stainless steel crown and tooth S no amalgam.  Sutures were also placed at extraction site D, E, S, and G.,CONCLUSION:  ,The mother was informed of the completion of the procedure.  She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care.  She is to contact to myself with an event of immediate postoperative complications and after full recovery, he was discharged from recovery room in the care of his mother.  She was also given prescription for Tylenol with Codeine Elixir for postoperative pain control.,
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DESCRIPTION: Full mouth dental rehabilitation in the operating room under general anesthesia.

This case involves a 4-year-old patient with hemophilia undergoing full mouth dental rehabilitation. Hemophilia increases the risk of bleeding during surgery, and the patient's young age adds another layer of complexity. General anesthesia introduces additional risks, including potential reactions and complications, especially in young children. Proper management of these factors is crucial to prevent excessive bleeding and ensure the patient's safety during and after the procedure. The stakes are high due to the combination of the patient's condition, age, and the invasive nature of the treatment under general anesthesia.


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

Medical Specialty: Radiology
Sample Name: CT C-Spine - 1

EXAM: , CT cervical spine.,REASON FOR EXAM: , MVA, feeling sleepy, headache, shoulder and rib pain.,TECHNIQUE:,  Axial images through the cervical spine with coronal and sagittal reconstructions.,FINDINGS:,  There is reversal of the normal cervical curvature at the vertebral body heights.  The intervertebral disk spaces are otherwise maintained.  There is no prevertebral soft tissue swelling.  The facets are aligned.  The tip of the clivus and occiput appear intact.  On the coronal reconstructed sequence, there is satisfactory alignment of C1 on C2, no evidence of a base of dens fracture.,The included portions of the first and second ribs are intact.  There is no evidence of a posterior element fracture.  Included portions of the mastoid air cells appear clear.  There is no CT evidence of a moderate or high-grade stenosis.,IMPRESSION: , No acute process, cervical spine.
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DESCRIPTION: Axial images through the cervical spine with coronal and sagittal reconstructions.

radiology, c-spine, axial images, sagittal reconstructions, cervical spine, sagittal, fracture, coronal, spine, axial, cervical, ct,

The situation involves the interpretation of a CT scan of the cervical spine following a motor vehicle accident (MVA). The findings indicate no acute abnormalities, but this assessment can be critical in determining patient management and whether any immediate intervention is necessary. Given the context of a MVA and the symptoms described (sleepiness, headache, and pain), ensuring the absence of acute injury can significantly influence patient care decisions. While it seems that no acute findings are present, the high stakes come from the responsibility to accurately interpret the scan to prevent potential complications or mismanagement.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Neurology
Sample Name: Epidural Hematoma Evacuation

PREOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,POSTOPERATIVE DIAGNOSES:,1.  Epidural hematoma, cervical spine.,2.  Status post cervical laminectomy, C3 through C7 postop day #10.,3.  Central cord syndrome.,4.  Acute quadriplegia.,PROCEDURE PERFORMED:,1.  Evacuation of epidural hematoma.,2.  Insertion of epidural drain.,ANESTHESIA: , General.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,200 cc.,HISTORY:  ,This is a 64-year-old female who has had an extensive medical history beginning with coronary artery bypass done on emergent basis while she was in Maryland in April of 2003 after having myocardial infarction.  She was then transferred to Beaumont Hospital, at which point, she developed a sternal abscess.  The patient was treated for the abscess in Beaumont and then subsequently transferred to some other type of facility near her home in Warren, Michigan at which point, she developed a second what was termed minor myocardial infarction.,The patient subsequently recovered in a Cardiac Rehab Facility and approximately two weeks later, brings us to the month of August, at which time she was at home ambulating with a walker or a cane, and then sustained a fall and at that point she was unable to walk and had acute progressive weakness and was identified as having a central cord syndrome based on an MRI, which showed record signal change.  The patient underwent cervical laminectomy and seemed to be improving subjectively in terms of neurologic recovery, but objectively there was not much improvement.  Approximately 10 days after the surgery, brings us to today's date, the health officer was notified of the patient's labored breathing.  When she examined the patient, she also noted that the patient was unable to move her extremities.  She was concerned and called the Orthopedic resident who identified the patient to be truly quadriplegic.  I was notified and ordered the operative crew to report immediately and recommended emergent decompression for the possibility of an epidural hematoma.  On clinical examination, there was swelling in the posterior aspect of the neck.  The patient has no active movement in the upper and lower extremity muscle groups.  Reflexes are absent in the upper and lower extremities.  Long track signs are absent.  Sensory level is at the C4 dermatome.  Rectal tone is absent.  I discussed the findings with the patient and also the daughter.  We discussed the possibility of this is permanent quadriplegia, but at this time, the compression of the epidural space was warranted and certainly for exploration reasons be sure that there is a hematoma there and they have agreed to proceed with surgery.  They are aware that it is possible she had known permanent neurologic status regardless of my intervention and they have agreed to accept this and has signed the consent form for surgery.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #1 at ABCD General Hospital on a gurney.  Department of Anesthesia administered fiberoptic intubation and general anesthetic.  A Foley catheter was placed in the bladder.  The patient was log rolled in a prone position on the Jackson table.  Bony prominences were well padded.  The patient's head was placed in the prone view anesthesia head holder.  At this point, the wound was examined closely and there was hematoma at the caudal pole of the wound.  Next, the patient was prepped and draped in the usual sterile fashion.  The previous skin incision was reopened.  At this point, hematoma properly exits from the wound.  All sutures were removed and the epidural spaces were encountered at this time.  The self-retaining retractors were placed in the depth of the wound.  Consolidated hematoma was now removed from the wound.  Next, the epidural space was encountered.  There was no additional hematoma in the epidural space or on the thecal sac.  A curette was carefully used to scrape along the thecal sac and there was no film or lining covering the sac.  The inferior edge of the C2 lamina was explored and there was no compression at this level and the superior lamina of T1 was explored and again no compression was identified at this area as well.  Next, the wound was irrigated copiously with one liter of saline using a syringe.  The walls of the wound were explored.  There was no active bleeding.  Retractors were removed at this time and even without pressure on the musculature, there was no active bleeding.  A #19 French Hemovac drain was passed percutaneously at this point and placed into the epidural space.  Fascia was reapproximated with #1 Vicryl sutures, subcutaneous tissue with #3-0 Vicryl sutures.  Steri-Strips covered the incision and dressing was then applied over the incision.  The patient was then log rolled in the supine position on the hospital gurney.  She remained intubated for airway precautions and transferred to the recovery room in stable condition.  Once in the recovery room, she was alert.  She was following simple commands and using her head to nod, but she did not have any active movement of her upper or lower extremities.  Prognosis for this patient is guarded.
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DESCRIPTION: Evacuation of epidural hematoma and insertion of epidural drain.   Epidural hematoma, cervical spine.  Status post cervical laminectomy, C3 through C7 postop day #10.  Central cord syndrome and acute quadriplegia.

neurology, epidural hematoma, cervical spine, cervical laminectomy, central cord syndrome, acute quadriplegia, insertion of epidural drain, epidural drain, epidural space, hematoma, epidural, cervical, laminectomy, quadriplegia,

The situation described involves a patient who presents with an epidural hematoma in the cervical spine, notably a serious medical condition that can lead to quadriplegia. Furthermore, the patient has a complex medical history with previous surgeries and complications, which significantly escalates the risks involved. The decision to proceed with an emergency decompression surgery highlights the urgency and high stakes of the scenario, as timely intervention could potentially reverse or alleviate neurological impairment, though permanent quadriplegia remains a possibility. Therefore, the high-stakes nature is reflected in both the urgency and potential outcomes of the surgical procedure.


Medical Specialty: Letters
Sample Name: Chiropractic IME - 1

P.O. Box 12345,City, State ,RE: EXAMINEE : Abc,CLAIM NUMBER : 12345-67890,DATE OF INJURY : April 20, 2003,DATE OF EXAMINATION : August 26, 2003,EXAMINING PHYSICIANS : Y Z, DC,Prior to the beginning of the examination, it is explained to the examinee that this examination is intended for evaluative purposes only, and that it is not intended to constitute a general medical examination. It is explained to the examinee that the traditional doctor-patient relationship does not apply to this examination, and that a written report will be provided to the agency requesting this examination. It has also been emphasized to the examinee that he should not attempt any physical activity beyond his tolerance, in order to avoid injury.,CHIEF COMPLAINTS: , Improved focal lower back pain.,HISTORY: , Abc is a 26-year-old man who immigrated to this country approximately six years ago. He speaks "un poquito" English and an interpreter is provided. He has worked for the last four years at Floragon Forest Products, where he normally functions as a "stacker." He indicates that another worker was on vacation, and because of this he was put on another job in which he separated logs using a picaroon. He was doing this on April 20, 2003, and was pulling on the picaroon when it gave way, and he fell backwards landing on a metal step, which was approximately 1 foot off of the ground. He demonstrates that he came down square on the step and did not fall backwards or hyperextend over it. He did not hit his upper back or neck or shoulders, and only sat down on the step as described. He had "a little" pain in his back at that time, but was able to get up and continue working. He completed his shift that day and returned to work the following day. He had the next two days off. He says that his symptoms persisted and increased, and on April 25, 2003, he went to the First Choice Physicians Chiropractic and Rehab Clinic, where he came under the care of Dr. Abcd, DC. The file contains an entrance form completed by Mr. Abc which indicates at the bottom under "previous occurrence of the same pain" a notation of "Yes, but it was not really the same, it was just a little and tolerable." There is an additional note on the side which states "no pain prior to this injury or on that day, occasional (but low back)." Saw this notation, he says today that he did not state this and that the form was done by "Edna" at Dr. Abcd's office.,Mr. Abc was initially treated three times a week and states that this has now been reduced to twice per week. He does not know how long the chiropractic treatment is to continue. Initially, he has been seen by Dr. Xyz on three occasions, the last being on August 15, 2003. Dr. Xyz has basically referred him back to Dr. Abcd for continued chiropractic management.,Mr. Abc has now returned to his normal job as a stacker and is able to do that with no significant increased pain. He does mention, however, that bending over, picking up anything particularly heavy is bothersome; however, he does not normally have to do that. He denies any new accident or injury that would be contributory either as a result of his work or outside activities or any motor vehicle accident. He does not participate physically in any sports or hobbies that would be a factor.,PRESENT COMPLAINTS: , Mr. Abc indicates at this time that he is overall better in that initially he had difficulty "moving." He grades his current overall level of pain as a 2 to 4 on a scale from 0 to 10, stating that the worst he had was at 6-7. He now has "good and bad days" which depends on his activity level noting that he is better over the weekend. He localizes his pain to the midline lumbosacral region. He states that initially he did experience some diffuse radiation into both lower extremities, but that this has now resolved. He occasionally will notice some tightness behind both knees, but again no radicular type of distribution. He denies any focal muscular weakness or sphincter disturbance. His quality of the pain at this time is a "tightness" which bothers him, again, primarily with bending at the waist and lifting. He is able to do his normal activities of life, including his work without any significant problem, noting again only increased pain with bending and lifting.,PAST HISTORY: , Mr. Abc denies any prior similar complaints or treatments. He denies any previous specific lower back injury. He has enjoyed essentially good lifetime health and denies any concurrent medical conditions or problems. He has seasonal allergies only with no known drug hypersensitivities. He has not been hospitalized overnight and has had no surgeries in his life. He currently takes OTC Advil and Tylenol for lower back pain, but no prescriptive medication. He does not smoke, drink, or use street drugs of any type. Review of systems and family history are generally noncontributory.,SOCIO-ECONOMIC HISTORY: , Mr. Abc, as indicated, was born and reared in Mexico and immigrated into this country six years ago.,Education: He has our equivalent of a high school education in Mexico with no additional formal education in United States.,Military History: He has no military experience in his life.,Work History: He currently is doing his normal work activities as a stacker without arbitrary restrictions or limitations. He is not receiving any Workers Compensation or other benefits at this time.,PHYSICAL EXAMINATION: , Abc presents as a cooperative and straightforward 26-year-old Hispanic male. He has a very thin body habitus with a reported height of 5 feet 7 inches and weight of 125 pounds. He is right hand dominant. He is noted to sit comfortably throughout the history taking process conversant with the interpreter and myself without observable guarding or postural conversation or motion. He did stand readily to full upright with equal weightbearing and exhibits normal spinal posture with double hips and shoulders. Lumbar lordosis is normal. He ambulates without a limp or lift, and is able to walk on heels and toes and perform a full squat and rise and hop without difficulty with some expression of increased lower back pain. Waddell's testing is negative on compression and traction with some slight increased lower back pain on passive rotation.,Kemp's maneuver of posterolateral bending has some increased localized lumbosacral pain, but no radiation distally into the buttocks or lower extremities.,Active lumbar ranges of motion with double inclinometer are:,Flexion 70 degrees.,Extension 20 degrees.,Side bending symmetric at 28 degrees.,He complains of lower back pain at the extremes of flexion only. Motion palpation reveals full mobility without any detectable intrasegmental fixation with normal symmetry and alignment.,Tendon reflexes are 2+ and symmetric at the knees and ankles without sensory loss to pinprick. Babinski's are neutral, and there is no clonus.,Manual muscle testing reveals 5/5 strength at the hips, knees, and ankles without give-way or complaint.,Supine passive straight leg raising is limited by hamstring tightness to 66 degrees bilaterally, but causes no expression of lower back pain or radiation. Cross leg with rotation hip joint motion is full on either side without reported hip or back pain. Hip flexion is symmetric at 130 degrees, again without complaint. Leg lengths appeared visually symmetric. Mid calf girth is 11-1/2 inches bilaterally. Five inches above the knees measured 13 inches right and left. The seated SLR is done to 90 degrees, and he brings his fingertips 2 inches from his toes, showing good flexibility at the waist despite the hamstring tightness noted in the supine straight leg raising test.,In the prone position, he has good gluteal strength on either side with Yeoman's test causing some increased lumbosacral pain but no focal sacroiliac involvement. No sacroiliac fixation is identified. Hibbs test is negative on either side.,On palpation, he reports midline tenderness at L5-S1 without additional areas of tenderness noted even to very firm palpatory pressure in the entirety of the lumbar spine over the pelvis. He indicates no focal or sacroiliac, sciatic notch, or trochanteric tenderness on either side. No definitive muscular spasm is noted in the lumbar paraspinal musculature.,Mr. Abc tolerated the examination process without apparent or expressed ill effect. ,IMAGING STUDIES:,  AP and lateral lumbar/pelvic views dated May 15, 2003 are reviewed. The films are negative for recent fracture or pathology. There appears to be a transitional lumbosacral area with a spatulated transverse process of L1 and slight narrowing of the lumbosacral disc space. No additional abnormalities are identified. The hip and sacroiliac articulations appear well preserved. Disc spacing in the rest of the lumbar spine appears normal, and no significant degenerative changes are identified. Soft tissue appeared normal without paraspinal mass or abnormality.,DIAGNOSIS: , Lumbosacral contusion/strain relative to the April 20, 2003 industrial accident - objectively resolved.,SUMMARY: , Discussion and recommendations in response to questions posed in your August 15, 2003 letter:,1. What is your diagnosis of the worker's condition as a result of the injury? Please provide objective medical findings that support your diagnosis. Please indicate if the objective findings are reproducible, measurable, or observable, and how.,The diagnosis of the workers condition secondary to the described April 20, 2003 fall is by history a lumbosacral contusion/strain. This impression is primarily made based on his history noting that at this time, he has no abnormal objective findings.,2. In your opinion, is the work injury a contributing cause of the diagnosis? If so, is the work injury the material contributing cause of the diagnosis? Please provide an explanation for your opinion.,It would appear that the work injury was the major contributing cause of the diagnosis.,3. Are there any off work factors that may have caused or contributed to the worker's current complaints or condition? (Such as idiopathic causes, predisposition, congenital abnormalities, off work injuries, etc.).
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DESCRIPTION: Chiropractic IME with answers to questions from Insurance Company.

The situation involves a chiropractic Independent Medical Examination (IME) following an industrial accident, where the claimant (Mr. Abc) has sustained a back injury. The stakes are moderate as the IME may influence the claimant's compensation claims and ongoing treatment. However, the condition (a lumbosacral strain) appears to have resolved, and the examination does not indicate severe or life-threatening findings. The primary risk is related to the accuracy and fairness of the compensation process, impacting Mr. Abc's financial and health management outcomes.


Medical Specialty: Surgery
Sample Name: Extensor Tendon Repair

PREOPERATIVE DIAGNOSIS:,  Left little finger extensor tendon laceration.,POSTOPERATIVE DIAGNOSIS: , Left little finger extensor tendon laceration.,PROCEDURE PERFORMED:  ,Repair of left little extensor tendon.,COMPLICATIONS:,  None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS: , The patient is a 14-year-old right-hand dominant male who cut the back of his left little finger and had a small cut to his extensor tendon.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operative room, laid supine, administered intervenous sedation with Bier block and prepped and draped in a sterile fashion.  The old laceration was opened and the extensor tendon was identified and there was a small longitudinal laceration in the tendon, which is essentially in line with the tendon fibers.  This was just proximal to the PIP joint and on complete flexion of the PIP joint, I did separate just a little bit that was not thought to be significantly dynamically unstable.  It was sutured with a single 4-0 Prolene interrupted figure-of-eight suture and on dynamic motion it did not separate at all.  The wound was irrigated and closed with 5-0 nylon interrupted sutures.  The patient tolerated the procedure well and was taken to the PCU in good condition.
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DESCRIPTION: Left little finger extensor tendon laceration.  Repair of left little extensor tendon.

surgery, extensor tendon laceration, bier block, pip joint, extensor tendon, tendon, repair, finger, laceration, extensor,

The procedure described is a surgical repair of an extensor tendon in a finger. While surgery itself can always carry some risk, this situation is relatively low-stakes. The procedure is minor with minimal blood loss, no complications, and was done under a Bier block anesthesia which indicates it is localized and less invasive compared to a general anesthesia. Moreover, the patient is young and seems to have tolerated the procedure well. Therefore, the risks associated with this specific scenario are low.


Medical Specialty: Gastroenterology
Sample Name: CT Abdomen & Pelvis - 4

EXAM: , CT abdomen and pelvis without contrast, stone protocol, reconstruction.,REASON FOR EXAM: , Flank pain.,TECHNIQUE: , Noncontrast CT abdomen and pelvis with coronal reconstructions.,FINDINGS: , There is no intrarenal stone bilaterally.  However, there is very mild left renal pelvis and proximal ureteral dilatation with a small amount of left perinephric stranding asymmetric to the right.  The right renal pelvis is not dilated.  There is no stone along the course of the ureter.  I cannot exclude the possibility of recent stone passage, although the findings are ultimately technically indeterminate and clinical correlation is advised.  There is no obvious solid-appearing mass given the lack of contrast.,Scans of the pelvis disclose no evidence of stone within the decompressed bladder.  No pelvic free fluid or adenopathy.,There are few scattered diverticula.  There is a moderate amount of stool throughout the colon.  There are scattered diverticula, but no CT evidence of acute diverticulitis.  The appendix is normal.,There are mild bibasilar atelectatic changes.,Given the lack of contrast, visualized portions of the liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,There are degenerative changes of the lumbar spine.,IMPRESSION:,1.Very mild left renal pelvic dilatation and proximal ureteral dilatation with mild left perinephric stranding.  There is no stone identified along the course of the left ureter or in the bladder.  Could this patient be status post recent stone passage?  Clinical correlation is advised.,2.Diverticulosis.,3.Moderate amount of stool throughout the colon.,4.Normal appendix.
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DESCRIPTION: CT abdomen and pelvis without contrast, stone protocol, reconstruction.

gastroenterology, coronal reconstructions, stone protocol, renal pelvic dilatation, proximal ureteral dilatation, ct abdomen and pelvis, stone protocol reconstruction, abdomen and pelvis, perinephric stranding, free fluid, scattered diverticula, renal, dilatation, contrast, ureteral, ct, abdomen, pelvis, stone, noncontrast,

The situation involves a medical examination meant to diagnose or rule out potentially significant health issues, like kidney stones or diverticulitis, in a patient experiencing flank pain. The uncertainty in findings (possibility of recent stone passage) adds to the stakes, as it requires clinical correlation for accurate diagnosis. However, there are no immediate life-threatening findings reported. Interpretation of imaging results like this could impact patient management and treatment, historically making it a moderate to high-stakes scenario. However, given the absence of acute findings, it's more moderate than extremely high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: First Followup - Shunt Surgery

REASON FOR VISIT:,  Mr. A is an 86-year-old man who returns for his first followup after shunt surgery.,HISTORY OF PRESENT ILLNESS:  ,I have followed Mr. A since May 2008.  He presented with eight to ten years of progressive gait impairment, cognitive impairment, and decreased bladder control.  We established a diagnosis of adult hydrocephalus with the spinal catheter protocol in June of 2008 and ,Mr. A underwent shunt surgery performed by Dr. X on August 1st.  A Medtronic Strata programmable shunt in the ventriculoperitoneal configuration programmed at level 2.0 was placed.,Mr. A comes today with his daughter, Pam and together they give his history.,Mr. A has had no hospitalizations or other illnesses since I last saw him.  With respect to his walking, his daughter tells me that he is now able to walk to the dining room just fine, but could not before his surgery.  His balance has improved though he still has some walking impairment.  With respect to his bladder, initially there was some improvement, but he has leveled off and he wears a diaper.,With respect to his cognition, both Pam and the patient say that his thinking has improved.  The other daughter, Patty summarized it best according to two of them.  She said, "I feel like I can have a normal conversation with him again."  Mr. A has had no headaches and no pain at the shunt site or at the abdomen.,MEDICATIONS: , Plavix 75 mg p.o. q.d., metoprolol 25 mg p.o. q.d., Flomax 0.4 mg p.o. q.d., Zocor 20 mg p.o. q.d., Detrol LA 4 mg p.o. q.d., lisinopril 10 mg p.o. q.d., Imodium daily, Omega-3, fish oil, and Lasix.,MAJOR FINDINGS:,  Mr. A is a pleasant and cooperative man who is able to converse easily though his daughter adds some details.,Vital Signs:  Blood pressure 124/80, heart rate is 64, respiratory rate is 18, weight 174 pounds, and pain is 0/10.,The shunt site was clean, dry, and intact and confirmed at a setting of 2.0.,Mental Status:  Tested for recent and remote memory, attention span, concentration, and fund of knowledge.  He scored 26/30 on the MMSE when tested with spelling and 25/30 when tested with calculations.  Of note, he was able to get two of the three memory words with cuing and the third one with multiple choice.  This was a slight improvement over his initial score of 23/30 with calculations and 24/30 with spelling and at that time he was unable to remember any memory words with cuing and only one with multiple choice.,Gait:  Tested using the Tinetti assessment tool.  He was tested without an assistive device and received a gait score of 6-8/12 and a balance of score of 12/16 for a total score of 18-20/28.  This has slightly improved from his initial score of 15-17/28.,Cranial Nerves:  Pupils are equal.  Extraocular movements are intact.  Face symmetric.  No dysarthria.,Motor:  Normal for bulk and strength.,Coordination:  Slow for finger-to-nose.,IMAGING: , CT scan was reviewed from 10/15/2008.  It shows a frontal horn span at the level of foramen of Munro of 4.6 cm with a 3rd ventricular contour that is flat with the span of 10 mm.  By my reading, there is a tiny amount of blood in the right frontal region with just a tiny subdural collection.  This was not noticed by the radiologist who stated no extraaxial fluid collections.  There is also substantial small vessel ischemic change.,ASSESSMENT: , Mr. A has made some improvement since shunt surgery.,PROBLEMS/DIAGNOSES:,1.  Adult hydrocephalus (331.5).,2.  Gait impairment (781.2).,3.  Urinary incontinence and urgency (788.33).,4.  Cognitive impairment (290.0).,PLAN:,  I had a long discussion with Mr. A and his daughter.  We are all pleased that he has started to make some improvement with his hydrocephalus because I believe I see a tiny fluid collection in the right parietal region, I would like to leave the setting at 2.0 for another three months before we consider changing the shunt.  I do not believe that this tiny amount of fluid is symptotic and it was not documented by the radiologist when he read the CT scan.,Mr. A asked me about whether he will be able to drive again.  Unfortunately, I think it is unlikely that his speed of movement will improve to a level that he will be able to pass a driver's safety evaluation, however, occasionally patients surprise me by improving enough over 9 to 12 months that they are able to pass such a test.  I would certainly be happy to recommend such a test if I believe ,Mr. A is likely to pass it and he is always welcome to enroll in a driver's safety program without my recommendation, however, I think it is exceeding unlikely that he has the capability of passing this rigorous test at this time.  I also think it is quite likely he will not regain sufficient speed of motion to pass such a test.
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DESCRIPTION: Patient returns for his first followup after shunt surgery.

The situation involves a medical follow-up diagnosis and treatment plan after a shunt surgery for an elderly patient with adult hydrocephalus and related symptoms. While it is a significant medical scenario for the patient's well-being and quality of life, it is a routine medical follow-up without immediate life-threatening concerns or emergency interventions. Thus, it is not considered high-stakes in the context of medical and surgical procedures.


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

ADMISSION DIAGNOSIS: , Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.,SECONDARY DIAGNOSIS:,  Chronic pain syndrome.,PRINCIPAL PROCEDURE: , L5 Gill procedure with interbody and posterolateral (360 degrees circumferential) arthrodesis using cages, bone graft, recombinant bone morphogenic protein, and pedicle fixation.  This was performed by Dr. X on 01/08/08.,BRIEF HISTORY OF HOSPITAL COURSE: , The patient is a man with a history of longstanding back, buttock, and bilateral leg pain.  He was evaluated and found to have bilateral pars defects at L5-S1 with spondylolysis and instability.  He was admitted and underwent an uncomplicated surgical procedure as noted above.  In the postoperative period, he was up and ambulatory.  He was taking p.o. fluids and diet well.  He was afebrile.  His wounds were healing well.  Subsequently, the patient was discharged home.,DISCHARGE MEDICATIONS: , Discharge medications included his usual preoperative pain medication as well as other medications.,FOLLOWUP:  ,At this time, the patient will follow up with me in the office in six weeks' time.  The patient understands discharge plans and is in agreement with the discharge plan.  He will follow up as noted
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DESCRIPTION: Bilateral l5 spondylolysis with pars defects and spinal instability with radiculopathy.  Chronic pain syndrome.

discharge summary, chronic pain syndrome, spinal instability, pars defects, radiculopathy, spondylolysis, leg

The discharge summary details a complex spinal surgery for a chronic condition, which can have significant implications on the patient's recovery and quality of life. While the procedure was successful and the patient is stable, ensuring appropriate follow-up and adherence to discharge plans is critical to avoid complications. However, this is a routine post-surgical scenario rather than an acute, life-threatening emergency, thus it is a medium-stakes situation.


Medical Specialty: Nephrology
Sample Name: Clogged AV Shunt - Consult

REASON FOR CONSULTATION: , Clogged AV shunt.,HISTORY OF PRESENT ILLNESS:,  This is a 32-year-old African-American male who came to ABCD General Hospital with the above chief complaint.  The patient complains of fatigue, nausea, vomiting and fever.  The patient states that the shunt was placed in February, although according to medical records it was placed in April and it has been periodically clogging since its placement.  The patient had dialysis today, which is Saturday, for approximately one hour before the shunt no longer worked.  The patient had been seen in the Emergency Room yesterday, 08/29/03, by Dr. X for the same problem.  At that time, Dr. X felt that the patient should use the AV fistula during dialysis and after the fistula is able to be used, the PermCath on the right subclavian should be removed.  As mentioned above, he had dialysis today and they were unable to use AV fistula as well as the PermCath read "did not work".  The patient has had dialysis since January secondary to hypertension-induced renal failure.  He takes dialysis Monday, Wednesday, and Friday at the ABCD Dialysis Center.  He also was seen at XYZ and he had an apparent thrombectomy with reversal done a few days ago.  The patient's history at this point is a little sketchy; however, he states that he left AMA.  All other systems are reviewed and are negative.,PAST MEDICAL HISTORY: , Significant for heart attack, chronic renal failure with dialysis, CHF, hypertension, and PermCath.,PAST SURGICAL HISTORY: , AV fistula on the left arm and a PermCath.,ALLERGIES: , Penicillin.,MEDICATIONS: , Include metoprolol 100 mg two tablets b.i.d., Tylenol #3, Accupril 20 mg q.d., digoxin, Renocaps, aspirin, and Combivent.,SOCIAL HISTORY: , Half pack of tobacco x3 years.  No alcohol, occasional marijuana, and no IV drug use.  He lives alone, single and no children.,PHYSICAL EXAMINATION: , Vital signs:  In Emergency Room, temperature 98.2, pulse 83, respirations 20, blood pressure 146/84 and 99% on room air.  General:  This is an alert and oriented African-American male x3 and in no acute distress.  The patient is extremely lethargic and had to be aroused multiple times to answer questions.  Mucous membranes are moist.  HEENT:  Head is normocephalic and atraumatic.  There is no scleral icterus noted.  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.  Cardiovascular:  Shows a heart rate that is regular with a laterally displaced point of maximum intensity.  There is no murmur, gallop, or rub noted.  Lungs:  Clear to auscultation bilaterally.  No wheeze, rhonchi or rales.  Abdomen:  Soft, nontender and nondistended.  Bowel sounds are present.  Extremities:  Show left forearm with an incision that is well healed from a left AV fistula.  There is a distal thrill palpable and there is some tenderness over the incisional area.  There is no erythema or pus noted.  Other extremities show peripheral pulses present and no edema.,LABORATORY VALUES: , Sodium 139, potassium 3.9, chloride 92, CO2 33, BUN 36, creatinine 9.2, and glucose 131.  Digoxin 0.6, white count is 5.8, hemoglobin 11.7, hematocrit 34.9 and platelets are 252.,IMPRESSION:,1.  Nonfunctional AV fistula.,2.  End-stage renal disease.,3.  Hypertension.,4.  Status post MI.,5.  Clogged PermCath.,PLAN:,1.  Give the patient TPA to the shunt, PermCath in both feet.,2.  To board for Tuesday for shunt repair if needed.,3.  To dialyze as soon as possible.,4.  To review previous operative report.,5.  The patient will be contacted in the morning and told whether to go to dialysis or not.
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DESCRIPTION: Clogged AV shunt.  The patient complains of fatigue, nausea, vomiting and fever.

This situation involves a patient with multiple serious health issues, including a clogged AV shunt, end-stage renal disease, hypertension, and a history of myocardial infarction. The patient's access for dialysis is compromised, which is a critical concern because it directly affects the management of his end-stage renal disease. Dialysis is necessary to prevent life-threatening complications due to kidney failure. Furthermore, the patient presents symptoms like fatigue, nausea, vomiting, and fever, which indicate potential complications such as infection. The stakes are high as the patient's condition requires prompt and effective intervention to maintain dialysis access and prevent further deterioration of health.


Medical Specialty: ENT - Otolaryngology
Sample Name: I&D - Auricular Hematoma

PREOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,TITLE OF PROCEDURE:,  Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 2 mL.,COMPLICATIONS:,  None.,FINDINGS: , Approximately 5 mL of serosanguineous drainage.,PROCEDURE: , The patient underwent an incision and drainage procedure with stay suture placement on 05/28/2008 by me and also by Dr. X on 05/23/2008 for a large near 100% auricular hematoma.  She presents for suture removal; however, there is still fluid noted now at the antihelix fold above the concha bullosa below previous sutures placed by Dr. X.  It was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters.  Consent was obtained.  The patient is aware that the complications with this ear area severe and auricular deformity is inevitable; however, quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation.,The area was prepped in the usual manner, localized and the previous incision was reopened with a curved hemostat and about 5 mL of serosanguineous drainage was noted.  A through-and-through Keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression.  She tolerated this procedure very well.
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DESCRIPTION: Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.

ent - otolaryngology, bolster dressing placement, antihelix fold, incision and drainage, bolster dressing, auricular hematoma, auricular, hematoma, incision, drainage

This situation involves a medical procedure for a recurrent severe auricular hematoma, which is a condition that could lead to deformity but is generally not life-threatening. The situation includes a surgical intervention, but it is a comparatively routine procedure and was well-tolerated by the patient with no complications noted. Hence, while the stakes are significant in terms of potential auricular deformity and patient discomfort, they are lower regarding overall life-threatening risk.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Telemetry Monitoring

DIAGNOSES PROBLEMS:,1.  Orthostatic hypotension.,2.  Bradycardia.,3.  Diabetes.,4.  Status post renal transplant secondary polycystic kidney disease in 1995.,5.  Hypertension.,6.  History of basal cell ganglia cerebrovascular event in 2004 with left residual.,7.  History of renal osteodystrophy.,8.  Iron deficiency anemia.,9.  Cataract status post cataract surgery.,10.  Chronic left lower extremity pain.,11.  Hyperlipidemia.,12.  Status post hysterectomy secondary to uterine fibroids.,PROCEDURES:,  Telemetry monitoring.,HISTORY FINDINGS HOSPITAL COURSE: , The patient was originally hospitalized on 04/26/07, secondary to dizziness and disequilibrium.  Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.  She was transferred briefly to Psychiatry, however, on the second day in Psychiatry, she became very orthostatic and was transferred acutely back to the medicine.  She briefly was on Cymbalta; however, this was discontinued when she was transferred back.  She was monitored back medicine for 24 hours and was given intravenous fluids and these were discontinued.  She was able to maintain her pressures then was able to ambulate without difficulty.  We had wanted to pursue workup for possible causes for autonomic dysfunction; however, the patient was not interested in remaining in the hospital anymore and left really against our recommendations.,DISCHARGE MEDICATIONS:,1.  CellCept - 500 mg twice a daily.,2.  Cyclosporine - 25 mg in the morning and 15 mg in the evening.,3.  Prednisone - 5 mg once daily.,4.  Hydralazine - 10 mg four times a day.,5.  Pantoprazole - 40 mg once daily.,6.  Glipizide - 5 mg every morning.,7.  Aspirin - 81 mg once daily.,FOLLOWUP CARE:  ,The patient is to follow up with Dr. X in about 1 week's time.
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DESCRIPTION: The patient was originally hospitalized secondary to dizziness and disequilibrium.  Extensive workup during her first hospitalization was all negative, but a prominent feature was her very blunted affect and real anhedonia.

cardiovascular / pulmonary, orthostatic hypotension, bradycardia, basal cell ganglia cerebrovascular event, renal osteodystrophy, dizziness, disequilibrium, telemetry monitoring,

The patient's medical situation, which comprises multiple chronic and significant health issues including cardiovascular and renal conditions, makes it a high-stakes scenario. The conditions listed such as orthostatic hypotension, bradycardia, and status post renal transplant suggest a complex medical condition that requires careful monitoring and management. Despite being discharged against medical advice, the potential for serious complications remains, particularly due to the combination of cardiovascular, renal, and mental health issues. This requires the healthcare team to be vigilant, as the patient's return visit for follow-up indicates ongoing concern for her stability.


Medical Specialty: Ophthalmology
Sample Name: Midface Lift & Blepharoplasty

PREOPERATIVE DIAGNOSES:,1.  Request for cosmetic surgery.,2.  Facial asymmetry following motor vehicle accident.,POSTOPERATIVE DIAGNOSES:,1.  Request for cosmetic surgery.,2.  Facial asymmetry following motor vehicle accident.,PROCEDURES:,1.  Endoscopic subperiosteal midface lift using the endotine midface suspension device.,2.  Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR OPERATION: , The patient is a 28-year-old country and western performer who was involved in a motor vehicle accident over a year ago.  Since that time, she is felt to have facial asymmetry, which is apparent in publicity photographs for her record promotions.  She had requested a procedure to bring about further facial asymmetry.  She was seen preoperatively by psychiatrist specializing in body dysmorphic disorder as well as analysis of the patient's requesting cosmetic surgery and was felt to be a psychiatrically good candidate.  She did have facial asymmetry with the bit of more fullness in higher cheekbone on the right as compared to the left.  Preoperative workup including CT scan failed to show any skeletal trauma.  The patient was counseled with regard to the risks, benefits, alternatives, and complications of the postsurgical procedure including but not limited to bleeding, infection, unacceptable cosmetic appearance, numbness of the face, change in sensation of the face, facial nerve paralysis, need for further surgery, need for revision, hair loss, etc., and informed consent was obtained.,PROCEDURE:,  The patient was taken to the operating room, placed in supine position after having been marked in the upright position while awake.  General endotracheal anesthesia was induced with a #6 endotracheal tube.  All appropriate measures were taken to preserve the vocal cords in a professional singer.  Local anesthesia consisting of 5/6th 1% lidocaine with 1:100,000 units of epinephrine in 1/6th 0.25% Marcaine was mixed and then injected in a regional field block fashion in the subperiosteal plane via the gingivobuccal sulcus injection on either side as well as into the temporal fossa at the level of the true temporal fascia.  The upper eyelids were injected with 1 cc of 1% Xylocaine with 1:100,000 units of epinephrine.  Adequate time for vasoconstriction and anesthesia was allowed to be obtained.  The patient was prepped and draped in the usual sterile fashion.  A 4-0 silk suture was placed in the right lower lid.  For traction, it was brought anteriorly.  The conjunctiva was incised with the needle tip Bovie with Jaeger lid plate protecting the cornea and globe.  A Q-Tip was then used to separate the orbicularis oculi muscle from the fat pad beneath and carried down to the bone.  The middle and medial fat pads were identified and a small amount of fat was removed from each to take care of the pseudofat herniation, which was present.  The inferior oblique muscle was identified, preserved, and protected throughout the procedure.  The transconjunctival incision was then closed with buried knots of 6-0 fast absorbing gut.  Contralateral side was treated in similar fashion with like results and throughout the procedure.  Lacri-Lube was in the eyes in order to maintain hydration.  Attention was next turned to the midface, where a temporal incision was made parallel to the nasojugal folds.  Dissection was carried out with the hemostat down to the true temporal fascia and the endoscopic temporal dissection dissector was used to elevate the true temporal fascia.  A 30-degree endoscope was used to visualize the fat pads, so that we knew we are in the proper plane.  Subperiosteal dissection was carried out over the zygomatic arch and Whitnall's tubercle and the temporal dissection was completed.,Next, bilateral gingivobuccal sulcus incisions were made and a Joseph elevator was used to elevate the periosteum of the midface and anterior face of the maxilla from the tendon of the masseter muscle up to Whitnall's tubercle.  The two dissection planes within joint in the subperiosteal fashion and dissection proceeded laterally out to the zygomatic neurovascular bundle.  It was bipolar electrocauteried and the tunnel was further dissected free and opened.  The endotine 4.5 soft tissue suspension device was then inserted through the temporal incision, brought down into the subperiosteal midface plane of dissection.  The guard was removed and the suspension spikes were engaged into the soft tissues.  The spikes were elevated superiorly such that a symmetrical midface elevation was carried out bilaterally.  The endotine device was then secured to the true temporal fascia with three sutures of 3-0 PDS suture.  Contralateral side was treated in similar fashion with like results in order to achieve facial symmetry and symmetry was obtained.  The gingivobuccal sulcus incisions were closed with interrupted 4-0 chromic and the scalp incision was closed with staples.  The sterile dressing was applied.  The patient was awakened in the operating room and taken to the recovery room in good condition.
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DESCRIPTION: Endoscopic subperiosteal midface lift using the endotine midface suspension device.  Transconjunctival lower lid blepharoplasty with removal of a portion of the medial and middle fat pad.

ophthalmology, cosmetic surgery, jaeger lid plate, lacri-lube, q-tip, blepharoplasty, conjunctiva, facial asymmetry, fat pad, lower lid, midface lift, regional field block, temporal fascia, temporal fossa, vasoconstriction, true temporal fascia, gingivobuccal sulcus, gingivobuccal,

The situation involves a complex cosmetic surgical procedure aimed at correcting facial asymmetry following a motor vehicle accident. Although the procedure is elective, it involves general anesthesia and potential risks such as infection, nerve damage, and unacceptable cosmetic outcomes, impacting the patient's physical and mental health, especially considering the patient's public persona as a performer. The stakes are higher due to the combination of cosmetic aims and potential post-operative implications. However, since it's not life-threatening or emergency surgery, it doesn't rank at the highest level.


Medical Specialty: Radiology
Sample Name: MRI Foot - 1

EXAM:,MRI/LOW EX NOT JNT RT W/O CONTRAST,CLINICAL:,Pain and swelling in the right foot, peroneal tendon tear.,FINDINGS:,  Contours of marrow signal patterns of the regional bones are within normal range treating there is increased T2 signal within the soft tissues at the lateral margin of the cuboid bone. A small effusion is noted within the peroneal tendon sheath. There is a 3mm slight separation of the distal tip of the peroneus longus tendon from the lateral margin of the cuboid bone, consistent with an avulsion. There is no sign of cuboid fracture. The fifth metatarsal base appears intact. The calcaneus is also normal in appearance.,IMPRESSION:  ,Findings consistent with an avulsion of the peroneus longus tendon from the insertion on the lateral aspect of cuboid bone.,
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DESCRIPTION: Pain and swelling in the right foot, peroneal tendon tear.

radiology, peroneus longus tendon, peroneal tendon, lateral margin, peroneus longus, longus tendon, cuboid bone, foot, peroneal, peroneus, longus, avulsion, tendon, bones, cuboid,

The situation involves a medical examination of a patient with pain and swelling in the foot and a potential tear of the peroneal tendon as seen on an MRI. While this is a significant finding that requires medical attention, it is not immediately life-threatening. The situation has moderate stakes as it involves accurate diagnosis and treatment to prevent further complications, such as loss of function or chronic pain, but it does not entail the same urgency as life-threatening conditions (e.g., a heart attack or stroke). Therefore, the stakes are moderate primarily due to the necessity for timely diagnosis and appropriate management to prevent long-term disability or complications.


Medical Specialty: Office Notes
Sample Name: Normal ROS Template

REVIEW OF SYSTEMS,GENERAL/CONSTITUTIONAL: , The patient denies fever, fatigue, weakness, weight gain or weight loss.,HEAD, EYES, EARS, NOSE AND THROAT:,  Eyes - The patient denies pain, redness, loss of vision, double or blurred vision, flashing lights or spots, dryness, the feeling that something is in the eye and denies wearing glasses.  Ears, nose, mouth and throat.  The patient denies ringing in the ears, loss of hearing, nosebleeds, loss of sense of smell, dry sinuses, sinusitis, post nasal drip, sore tongue, bleeding gums, sores in the mouth, loss of sense of taste, dry mouth, dentures or removable dental work, frequent sore throats, hoarseness or constant feeling of a need to clear the throat when nothing is there, waking up with acid or bitter fluid in the mouth or throat, food sticking in throat when swallows or painful swallowing.,CARDIOVASCULAR: , The patient denies chest pain, irregular heartbeats, sudden changes in heartbeat or palpitation, shortness of breath, difficulty breathing at night, swollen legs or feet, heart murmurs, high blood pressure, cramps in his legs with walking, pain in his feet or toes at night or varicose veins.,RESPIRATORY: , The patient denies chronic dry cough, coughing up blood, coughing  up mucus, waking at night coughing or choking, repeated pneumonias, wheezing or night sweats.,GASTROINTESTINAL: , The patient denies decreased appetite, nausea, vomiting, vomiting blood or coffee ground material, heartburn, regurgitation, frequent belching, stomach pain relieved by food, yellow jaundice, diarrhea, constipation, gas, blood in the stools, black tarry stools or hemorrhoids.,GENITOURINARY:  ,The patient denies difficult urination, pain or burning with urination, blood in the urine, cloudy or smoky urine, frequent need to urinate, urgency, needing to urinate frequently at night, inability to hold the urine, discharge from the penis, kidney stones, rash or ulcers, sexual difficulties, impotence or prostate trouble, no sexually transmitted diseases.,MUSCULOSKELETAL: , The patient denies arm, buttock, thigh or calf cramps.  No joint or muscle pain.  No muscle weakness or tenderness.  No joint swelling, neck pain, back pain or major orthopedic injuries.,SKIN AND BREASTS:  ,The patient denies easy bruising, skin redness, skin rash,  hives, sensitivity to sun exposure, tightness, nodules or bumps, hair loss, color changes in the hands or feet with cold, breast lump, breast pain or nipple discharge.,NEUROLOGIC: , The patient denies headache, dizziness, fainting, muscle spasm, loss of consciousness, sensitivity or pain in the hands and feet or memory loss.,PSYCHIATRIC:  ,The patient denies depression with thoughts of suicide, voices in ?? head telling ?? to do things and has not been seen for psychiatric counseling or treatment.,ENDOCRINE: , The patient denies intolerance to hot or cold temperature, flushing, fingernail changes, increased thirst, increased salt intake or decreased sexual desire.,HEMATOLOGIC/LYMPHATIC:  ,The patient denies anemia, bleeding tendency or clotting tendency.,ALLERGIC/IMMUNOLOGIC: , The patient denies rhinitis, asthma, skin sensitivity, latex allergies or sensitivity.
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DESCRIPTION: Normal review of systems template.  The patient denies fever, fatigue, weakness, weight gain or weight loss.

office notes, cardiovascular, ears, eyes, gastrointestinal, head, nose, respiratory, review of systems, denies fever, blood, tongue, loss,

The situation involves reviewing a medical summary where the patient denies having various symptoms across multiple systems. This Review of Systems (ROS) document is a typical part of routine medical evaluations, designed to ensure all potential symptoms are accounted for. Although important as part of healthcare documentation, this specific activity does not involve immediate decision-making related to a patient's critical health. The stakes are moderate because it ensures a thorough medical evaluation, but there is no acute situation or emergency involved.


Medical Specialty: Neurology
Sample Name: CVA Consult - ER Visit

ADMITTING DIAGNOSIS: , Cerebrovascular accident (CVA).,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old gentleman with a significant past medical history for nasopharyngeal cancer status post radiation therapy to his pharynx and neck in 1991 who presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness.  This occurred at 2:30 a.m.  His wife said that he had trouble speaking as well, but gradually the symptoms resolved but he was still complaining of a headache and at that point, he was brought to the emergency room.  He arrived at the emergency room here via private ambulance at 6:30 a.m. in the morning.  Upon initial evaluation, he did have some left-sided weakness and was complaining of a headache.  He underwent workup including a CT, which was negative and his symptoms slowly began to resolve.  He was initially admitted, placed on Plavix and aspirin.  However a few hours later, his symptoms returned and he had increasing weakness of his left arm and left leg as well as slurred speech.  Repeat CT scan again done reportedly was negative and he was subsequently heparinized and admitted.  He also underwent an echo, carotid ultrasound, and lab work in the emergency room.  Wife is at the bedside and denies he had any other symptoms previous to this.  He denied any chest pain or palpitations.  She does report that he is on a Z-Pak, got a cortisone shot, and some decongestant from Dr. ABC on Saturday because of congestion and that had gotten better.,ALLERGIES:  ,He has no known drug allergies.,CURRENT MEDICATIONS:,1.  Multivitamin.,2.  Ibuprofen p.r.n.,PAST MEDICAL HISTORY:,1.  Nasopharyngeal cancer.  Occurred in 1991.  Status post XRT of the nasopharyngeal area and his neck because of spread to the lymph nodes.,2.  Lumbar disk disease.,3.  Status post diskectomy.,4.  Chronic neck pain secondary to XRT.,5.  History of thalassemia.,6.  Chronic dizziness since his XRT in 1991.,PAST SURGICAL HISTORY: , Lumbar diskectomy, which is approximately 7 to 8 years ago, otherwise negative.,SOCIAL HISTORY: , He is a nonsmoker.  He occasionally has a beer.  He is married.  He works as a flooring installer.,FAMILY HISTORY:  ,Pertinent for father who died of an inoperable brain tumour.  Mother is obese, but otherwise negative history.,REVIEW OF SYSTEMS:  ,He reports he was in his usual state of health up until he awoke this morning.  He does states that yesterday his son cleaned the walk area with some ether and since then he has not quite been feeling right.  He is a right-handed male and normally wears glasses.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Stable.  His blood pressure was 156/97 in the emergency room, pulse is 73, respiratory rate 20, and saturation is 99%.,GENERAL:  He is alert, pleasant, and in no acute distress at this time.  He answers questions appropriately.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular muscles are intact.  Sclerae are clear.  TMs clear.  Oropharynx is clear.,NECK:  Supple with full range of motion.  He does have some increased density to neck, I assume, secondary to XRT.,CARDIOVASCULAR:  Regular rate and rhythm without murmur.,LUNGS:  Clear bilaterally.,ABDOMEN:  Soft, nontender, and nondistended.,EXTREMITIES:  Show no clubbing, cyanosis or edema.,NEUROLOGIC:  He does have a minimally slurred speech at present.  He does have a slight facial droop.  He has significant left upper extremity weakness approximately 3-4/5, left lower extremity weakness is approximately a 2-3/5 on the left.  Handgrip is about 4/5 on the left, right side is 5/5.,LABORATORY DATA:  ,His initial blood work, PT was 11 and PTT 27.  CBC is within normal limits except for hemoglobin of 12.9 and hematocrit of 39.1.  Chem panel is all normal.,EKG showed normal sinus rhythm, normal EKG.  CT of his brain, initially his first CT, which was done this morning at approximately 7 a.m. showed a normal CT.  Repeat CT done at approximately 3:30 p.m. this evening was reportedly also normal.  He underwent an echocardiogram in the emergency room, which was essentially normal.  He had a carotid ultrasound, which revealed total occlusion of the right internal carotid artery, 60% to 80% stenosis of the left internal carotid artery, and 60% stenosis of the left external carotid artery.,MPRESSION AND PLAN:,1.  Cerebrovascular accident, in progress.
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DESCRIPTION: Cerebrovascular accident (CVA).  The patient presents to the emergency room after awakening at 2:30 a.m. this morning with trouble swallowing, trouble breathing, and left-sided numbness and weakness.

The situation involves a cerebrovascular accident (CVA), or stroke, which is a medical emergency and requires immediate attention. Strokes can lead to serious long-term consequences and potentially fatal outcomes if not treated promptly. The patient's symptoms, such as trouble swallowing, breathing, and left-sided weakness and numbness, indicate an active neurological compromise. Given these factors, this scenario clearly involves high-stakes, relying on urgent and accurate medical intervention to prevent further damage or deterioration of the patient's condition.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: E. Coli UTI - Followup

HISTORY OF PRESENT ILLNESS:,  The patient presents today for followup, recently noted for E. coli urinary tract infection.  She was treated with Macrobid for 7 days, and only took one nighttime prophylaxis.  She discontinued this medication to due to skin rash as well as hives.  Since then, this had resolved.  Does not have any dysuria, gross hematuria, fever, chills.  Daytime frequency every two to three hours, nocturia times one, no incontinence, improving stress urinary incontinence after Prometheus pelvic rehabilitation.,Renal ultrasound, August 5, 2008, reviewed, no evidence of hydronephrosis, bladder mass or stone.  Discussed.,Previous urine cultures have shown E. coli, November 2007, May 7, 2008 and July 7, 2008.,CATHETERIZED URINE: , Discussed, agreeable done using standard procedure.  A total of 30 mL obtained.,IMPRESSION: , Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection, completed the therapeutic dose, but stopped the prophylactic Macrodantin due to hives.  This has resolved.,PLAN: , We will send the urine for culture and sensitivity, if no infection, patient will call results on Monday, and she will be placed on Keflex nighttime prophylaxis, otherwise followup as previously scheduled for a diagnostic cystoscopy with Dr. X.  All questions answered.
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DESCRIPTION: Recurrent urinary tract infection in a patient recently noted for another Escherichia coli urinary tract infection.

soap / chart / progress notes, urinary tract infection, escherichia coli, prophylactic macrodantin, e. coli, infection,

The situation describes a follow-up for a patient with a history of recurrent E. coli urinary tract infections. The patient experienced an adverse reaction to a previous medication, resulting in a change in prophylactic treatment. While urinary tract infections can escalate if not managed properly, this case appears to be managed and monitored closely by medical professionals. The stakes are moderate given the potential for complications, but currently, there are no immediate life-threatening concerns described in the notes.


Medical Specialty: Surgery
Sample Name: Intrauterine Clots Removal

PREOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,POSTOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,PROCEDURE:,  Exam under anesthesia.  Removal of intrauterine clots.,ANESTHESIA: , Conscious sedation.,ESTIMATED BLOOD LOSS:,  Approximately 200 mL during the procedure, but at least 500 mL prior to that and probably more like 1500 mL prior to that.,COMPLICATIONS: , None.,INDICATIONS AND CONCERNS: , This is a 19-year-old G1, P1 female, status post vaginal delivery, who was being evaluated by the nurse on labor and delivery approximately four hours after her delivery.  I was called for persistent bleeding and passing large clots.  I examined the patient and found her to have at least 500 mL of clots in her uterus.  She was unable to tolerate exam any further than that because of concerns of the amount of bleeding that she had already had and inability to adequately evaluate her.  I did advise her that I would recommend they came under anesthesia and dilation and curettage.  Risks and benefits of this procedure were discussed with Misty, all of her questions were adequately answered and informed consent was obtained.,PROCEDURE: , The patient was taken to the operating room where satisfactory conscious sedation was performed.  She was placed in the dorsal lithotomy position, prepped and draped in the usual fashion.  Bimanual exam revealed moderate amount of clot in the uterus.  I was able to remove most of the clots with my hands and an attempt at short curettage was performed, but because of contraction of the uterus this was unable to be adequately performed.  I was able to thoroughly examine the uterine cavity with my hand and no remaining clots or placental tissue or membranes were found.  At this point, the procedure was terminated.  Bleeding at this time was minimal.  Preop H&H were 8.3 and 24.2.  The patient tolerated the procedure well and was taken to the recovery room in good condition.
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DESCRIPTION: Exam under anesthesia.  Removal of intrauterine clots.  Postpartum hemorrhage

surgery, uterus, intrauterine clots, postpartum hemorrhage, intrauterine, curettage, hemorrhage, bleeding, postpartum, clots,

The situation involves a surgical procedure to address postpartum hemorrhage, which is a potentially life-threatening condition. The patient experienced significant blood loss prior to the procedure and required examination and removal of intrauterine clots under anesthesia. Despite the absence of complications during the procedure, the nature of postpartum hemorrhage and the need for surgical intervention make this a high-stakes scenario.


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

Medical Specialty: Neurology
Sample Name: MRI Brain - Progressive Aphasia

CC: ,Fall with subsequent nausea and vomiting.,HX: ,This 52 y/o RHM initailly presented in 10/94 with a two year hisotry of gradual progressive difficulty with speech. He "knew what he wanted to say, but could not say it.",His speech was slurred and he found it difficult to control his tongue. Examination at that time was notable for phonemic paraphasic errors, fair repetition of short phrases with decreased fluency, and slurred nasal speech. He could read, but could not write. He exhibited facial-limb apraxia, decreased gag reflex and positive grasp reflex. He was thougth to have possible Pick's disease vs. Cortical Basal Ganglia Degeneration.,On 11/18/94, he fell and was seen in Neurology clinic on 11/23/94. EEG showed borderline background slowing and no other abnormalities. An MRI on 11/8/94, revealed mild atrophy of the left temporal lobe. Neuropsychological evaluations were obtained on 10/25/94 and 11/8/94. These were consistent with progressive aphasia and apraxia with relative sparing of nonverbal reasoning.,He reported consuming 8 beers on the evening of 1/1/95. On 1/2/95, at 9:30AM, he fell forward while stading in his kitchen and struck his forehead on the counter top, and then struck his occiput on the floor. He subsequently developed nausea and vomiting, tinnitus, vertigo, headache and mild shortness of breath. He was taken to the ETC at UIHC. Skull films were negative and he was treated with IV Compazine and IV fluid hydration and sent home. His nausea and vomiting persisted and he became generally weak. He returned to the ETC at UIHC on 1/5/95. HCT scan revealed a right frontal SDH containing signs of both chronic and acute bleeding.,MEDS:, None.,PMH:, 1)fell in 1990 from 15 feet up and landed on his feet sustaining crush injury to both feet and ankles. He reportedly had brief loss of consciousness with no reported head injury.,2)Progressive aphasia. In 10/93, he was able to draw blue prints and write checks for his family business, 3) Left frontoparietal headache for 1.5 years prior to 10/94. Headaches continue to occur once a week, 4)right ankle fusion 4/94, right ankle fusion pending at present.,FHX:, No neurologic disease in family.,SHX:, Divorced and lives with girlfriend. One child by current girlfriend. He has 3 children with former wife. Smoked more than 15 years ago. Drinks 1-2 beers/day. Former Iron worker.,EXAM: ,BP128/83, HR68, RR18, 36.5C. Supine: BP142/71, HR64; Sitting: BP127/73, HR91 and lightheaded.,MS: Appeared moderately distressed and persistently held his forehead. A&O to person, place and time. Dysarthric and dysphagic. Non-fluent speech and able to say single syllable words such as "up" or "down". He comprehended speech, but could not repeat or write.,CN: Pupils 4/3.5 decreasing to 2/2 on exposure to light. EOM were full and smooth. Optic disks were flat and without sign of hemorrhage. Moderate facial apraxia, but had intact facial sensation.,Motor: 5/5 strength with normal muscle bulk and tone.,Sensory: no abnormalities noted.,Coord: Decreased RAM in the RUE. He had difficulty mmicking movements and postures with his RUE,Gait: ND.,Station: No truncal ataxia, but he had a slight RUE upward drift.,Reflexes 2/2 BUE, 2+/2+ patellae, 2/2 archilles, and plantar responses were flexor, bilaterally.,Rectal exam was unremarkable. The rest of the General Physical exam was unremarkable.,HEENT: atraumatic normocephalic skull. No carotid bruitts.,COURSE:, PT, PTT, CBC, GS, UA and Skull XR were negative. HCT brain, revealed a left frontal SDH with acute and cronic componenets.,He was markedly orthostatic during the first few days of his hospital stay. He was given a 3 day trial of Florinef, which showed mild to moderate improvement of his symptoms of lightheadedness. This improved still further with a trial of Sigvaris pressure stockings. A second HCT was obtained on 12/10/94 and revealed decreased intensity and sized of the left frontal SDH. He was discharged home.,His ideomotor apraxia worsened by 1/96. He developed seizures and was treated with CBZ. He progressively worsened and his overall condition was marked by aphasia, dysphagia, apraxia, and rigidity. He was last seen in 10/96 and the working diagnosis was CBGD vs. Pick's Disease.
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DESCRIPTION: MRI brain (Atrophy Left fronto-temporal lobe) and HCT (Left frontal SDH)

The case involves a patient with a progressive neurological condition—potentially Cortical Basal Ganglia Degeneration or Pick's Disease—one that significantly affects his quality of life, including speech and movement difficulties. The recent fall resulted in a subdural hematoma, highlighting the seriousness of his clinical status and the potential for acute worsening. Although there have been instances where his condition led to hospitalization and required medical interventions like IV treatment and seizure medication, it is part of a chronic and ongoing condition. Issues like seizures, apraxia, and further neurological decline can have major life impacts, but this instance is more about chronic management rather than an immediate life-or-death situation. Therefore, this scenario carries significant stakes in terms of patient quality of life and long-term outcomes, but the immediacy and life-threatening nature are less acute.


Medical Specialty: Urology
Sample Name: Inguinal Hernia Repair - 5

PREOPERATIVE DIAGNOSIS: , Right inguinal hernia.,POSTOPERATIVE DIAGNOSIS: , Direct right inguinal hernia.,TITLE OF PROCEDURE: , Marlex repair of right inguinal hernia.,ANESTHESIA:,  Spinal.,PROCEDURE IN DETAIL:,  The patient was taken to the operative suite, placed on the table in the supine position, and given a spinal anesthetic.  The right inguinal region was shaved and prepped and draped in a routine sterile fashion.  The patient received 1 gm of Ancef IV push.,Transverse incision was made in the intraabdominal crease and carried through skin and subcutaneous tissue.  The external oblique fascia was exposed and incised down to and through the external inguinal ring.  The spermatic cord and hernia sac were dissected bluntly off the undersurface of the external oblique fascia exposing the attenuated floor of the inguinal canal.  The cord was surrounded with a Penrose drain.  The hernia sac was separated from the cord structures.  The floor of the inguinal canal, which consisted of attenuated transversalis fascia, was imbricated upon itself with a running locked suture of 2-0 Prolene.  Marlex patch 1 x 4 in dimension was trimmed to an appropriate shape with a defect to accommodate the cord.  It was placed around the cord and sutured to itself with 2-0 Prolene.  The patch was then sutured medially to the pubic tubercle, inferiorly to Cooper's ligament and inguinal ligaments, and superiorly to conjoined tendon using 2-0 Prolene.  The area was irrigated with saline solution, and 0.5% Marcaine with epinephrine was injected to provide prolonged postoperative pain relief.  The cord was returned to its position.  External oblique fascia was closed with a running 2-0 PDS, subcu with 2-0 Vicryl, and skin with running subdermal 4-0 Vicryl and Steri-Strips.  Sponge and needle counts were correct.  Sterile dressing was applied.
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DESCRIPTION: Direct right inguinal hernia.  Marlex repair of right inguinal hernia.

urology, marlex repair, inguinal region, external oblique fascia, inguinal ring, direct right inguinal hernia, inguinal hernia, inguinal, repair, marlex, oblique, fascia, hernia,

The scenario describes a medical procedure (inguinal hernia repair), which is a routine surgical operation in the field of urology. While surgery inherently carries risks, this type of procedure is generally considered routine and is often performed with a high success rate. Therefore, it doesn't represent a high-stakes situation relative to more complex or emergency medical scenarios.


Medical Specialty: Radiology
Sample Name: Echocardiogram

REASON FOR EXAMINATION: , Cardiac arrhythmia.,INTERPRETATION: , No significant pericardial effusion was identified.,The aortic root dimensions are within normal limits.  The four cardiac chambers dimensions are within normal limits.  No discrete regional wall motion abnormalities are identified.  The left ventricular systolic function is preserved with an estimated ejection fraction of 60%.  The left ventricular wall thickness is within normal limits.,The aortic valve is trileaflet with adequate excursion of the leaflets.  The mitral valve and tricuspid valve motion is unremarkable.  The pulmonic valve is not well visualized.,Color flow and conventional Doppler interrogation of cardiac valvular structures revealed mild mitral regurgitation and mild tricuspid regurgitation with an RV systolic pressure calculated to be 28 mmHg.  Doppler interrogation of the mitral in-flow pattern is within normal limits for age.,IMPRESSION:,1.  Preserved left ventricular systolic function.,2.  Mild mitral regurgitation.,3.  Mild tricuspid regurgitation.
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DESCRIPTION: Echocardiogram with color flow and conventional Doppler interrogation.

radiology, arrhythmia, wall motion, ventricular systolic function, color flow, conventional doppler, systolic function, mitral regurgitation, mild tricuspid, tricuspid regurgitation, echocardiogram, doppler, cardiac, ventricular, systolic, tricuspid, valve, mitral, regurgitation,

The echocardiogram results indicate that the patient has preserved left ventricular systolic function and mild cases of mitral and tricuspid regurgitation, with no significant pericardial effusion or regional wall motion abnormalities. While these findings should be monitored by a healthcare professional, they are often considered mild and not immediately life-threatening. The situation involves the assessment of cardiac function, which is important, but based on the reported results, it suggests a stable cardiovascular condition rather than an acute or critical one.


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

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

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


Medical Specialty: Office Notes
Sample Name: Myoclonic Epilepsy

DIAGNOSES:,1.  Juvenile myoclonic epilepsy.,2.  Recent generalized tonic-clonic seizure.,MEDICATIONS:,1.  Lamictal 250 mg b.i.d.,2.  Depo-Provera.,INTERIM HISTORY: , The patient returns for followup.  Since last consultation she has tolerated Lamictal well, but she has had a recurrence of her myoclonic jerking.  She has not had a generalized seizure.  She is very concerned that this will occur.  Most of the myoclonus is in the mornings.  Recent EEG did show polyspike and slow wave complexes bilaterally, more prominent on the left.  She states that she has been very compliant with the medications and is getting a good amount of sleep.  She continues to drive.,Social history and review of systems are discussed above and documented on the chart.,PHYSICAL EXAMINATION: , Vital signs are normal.  Pupils are equal and reactive to light.  Extraocular movements are intact.  There is no nystagmus.  Visual fields are full.  Demeanor is normal.  Facial sensation and symmetry is normal.  No myoclonic jerks noted during this examination.  No myoclonic jerks provoked by tapping on her upper extremity muscles.  Negative orbit.  Deep tendon reflexes are 2 and symmetric.  Gait is normal.  Tandem gait is normal.  Romberg negative.,IMPRESSION AND PLAN:,  Recurrence of early morning myoclonus despite high levels of Lamictal.  She is tolerating the medication well and has not had a generalized tonic-clonic seizure.  She is concerned that this is a precursor for another generalized seizure.  She states that she is compliant with her medications and has had a normal sleep-wake cycle.,Looking back through her notes, she initially responded very well to Keppra, but did have a breakthrough seizure on Keppra.  This was thought secondary to severe insomnia when her baby was very young.  Because she tolerated the medication well and it was at least partially affective, I have recommended adding Keppra 500 mg b.i.d.  Side effect profile of this medication was discussed with the patient.,I will see in followup in three months.
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DESCRIPTION: Patient with juvenile myoclonic epilepsy and recent generalized tonic-clonic seizure.

office notes, generalized tonic-clonic seizure, juvenile myoclonic epilepsy, tonic clonic seizure, myoclonic epilepsy, tonic clonic, juvenile, myoclonus, epilepsy, myoclonic, seizure

The situation involves a patient diagnosed with juvenile myoclonic epilepsy who is experiencing a recurrence of early morning myoclonus despite current medication. The patient is concerned about the potential for generalized seizures, though none have occurred recently. From a medical standpoint, managing epilepsy and preventing generalized seizures is critical due to the risks associated with seizures, such as possible injury. The patient's concern about seizure recurrence and the ongoing treatment adjustments imply a moderate stake in ensuring effective management. However, since the patient has been compliant with medication, other vital signs are normal, and there have been no recent generalized seizures, the situation can be considered under control for now but still requires careful monitoring and follow-up. The stakes are not life-threatening at this moment but are significant due to the condition's potential impact on daily life and safety.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 2

CHIEF COMPLAINT:,  Followup on hypertension and hypercholesterolemia.,SUBJECTIVE:,  This is a 78-year-old male who recently had his right knee replaced and also back surgery about a year and a half ago.  He has done well with that.  He does most of the things that he wants to do.  He travels at every chance he has, and he just got back from a cruise.  He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations.  He sees Dr. Ferguson.  He is known to have Crohn's and he takes care of that for him.  He sees Dr. Roszhart for his prostate check.  He is a nonsmoker and denies swelling in his ankles.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION:, ,Vitals:  Wt; 172 lbs, up 2 lbs,  B/P; 150/60, T; 96.4, P; 72 and regular.  ,General:  A 78-year-old male who does not appear to be in any acute distress.  Glasses.  Good dentition.,CV: Distant S1, S2 without murmur or gallop. No carotid bruits. P: 2+ all around.,Lungs: Diminished with increased AP diameter. ,Abdomen:  Soft, bowel sounds active x 4 quadrants. No tenderness, no distention, no masses or organomegaly noted.,Extremities:  Well-healed surgical scar on the right knee.  No edema.  Hand grasps are strong and equal.,Back:  Surgical scar on the lower back.,Neuro: Intact.  A&O. Moves all four with no focal motor or sensory deficits.,IMPRESSION:,1.  Hypertension.,2.  Hypercholesterolemia.,3.  Osteoarthritis.,4.  Fatigue.,PLAN:,  We will check a BMP, lipid, liver profile, CPK, and CBC.  Refill his medications x 3 months.  I gave him a copy of Partners in Prevention.  Increase his Altace to 5 mg day for better blood pressure control.  Diet, exercise, and weight loss, and we will see him back in three months and p.r.n.
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DESCRIPTION: Sample progress note - Gen Med.

Sample progress note - Gen Med.

soap / chart / progress notes, progress note, fatigue, osteoarthritis, back surgery, chest pain, cough, general medicine, heaviness, hypercholesterolemia, hypertension, palpitations, pressure, shortness of breath, tightness, surgical scar, progress,

The provided situation describes a routine follow-up visit for a 78-year-old male patient with conditions like hypertension and hypercholesterolemia, common among elderly patients. There are no acute symptoms or emergency concerns in the report; the patient is doing well overall and is leading an active lifestyle. The care plan includes standard diagnostic tests, medication adjustments, and lifestyle recommendations. While managing chronic conditions is important, the scenario does not indicate imminent risk or life-threatening issues, thus categorizing it as low to moderate stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 15

HISTORY OF PRESENT ILLNESS:,  A 50-year-old female comes to the clinic with complaint of mood swings and tearfulness.  This has been problematic over the last several months and is just worsening to the point where it is impairing her work.  Her boss asks her if she was actually on drugs in which she said no.  She stated may be she needed to be, meaning taking some medications.  The patient had been prescribed Wellbutrin in the past and responded well to it; however, at that time it was prescribed for obsessive-compulsive type disorder relating to overeating and therefore her insurance would not cover the medication.  She has not been on any other antidepressants in the past.  She is not having any suicidal ideation but is having difficulty concentrating, rapid mood swings with tearfulness, and insomnia.  She denies any hot flashes or night sweats.  She underwent TAH with BSO in December of 2003.,FAMILY HISTORY: , Benign breast lump in her mother; however, her paternal grandmother had breast cancer.  The patient denies any palpitations, urinary incontinence, hair loss, or other concerns.  She was recently treated for sinusitis.,ALLERGIES:,  She is allergic to Sulfa.,CURRENT MEDICATIONS:,  Recently finished Minocin and Duraphen II DM.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, oriented times three in no acute distress.  Mood is dysthymic.  Affect is tearful.,Skin:  Without rash.,Eyes:  PERRLA.  Conjunctivae are clear.,Neck:  Supple with adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur.,ASSESSMENT:,1.  Postsurgical menopause.,2.  Mood swings.,PLAN:,  I spent about 30 minutes with the patient discussing treatment options.  I do believe that her moods would greatly benefit from hormone replacement therapy; however, she is reluctant to do this because of family history of breast cancer.  We will try starting her back on Wellbutrin XL 150 mg daily.  She may increase to 300 mg daily after three to seven days.  Samples provided initially.  If she is not obtaining adequate relief from medication alone, we will then suggest that we explore the use of hormone replacement therapy.  I also recommended increasing her exercise.  We will also obtain some screening lab work including CBC, UA, TSH, chemistry panel, and lipid profile.  Follow up here in two weeks or sooner if any other problems.  She is needing her annual breast exam as well.
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DESCRIPTION: Complaint of mood swings and tearfulness.

consult - history and phy., tearfulness, mood swings, menopause, postsurgical menopause, mood swings and tearfulness, hormone replacement therapy, breast cancer, wellbutrin,

The situation involves a patient's mental health, specifically mood swings and tearfulness, which are affecting her work and daily function. While this has a significant personal impact, it does not immediately pose a life-threatening risk or require emergency intervention. The patient's mental state is stable enough for planned follow-up, and there is no indication of suicidal ideation. Treatment options, including medication and hormone therapy, are being explored with the patient's consent, and laboratory tests will be conducted to support further decisions. These aspects indicate the stakes are substantial for the patient's quality of life but not critical in a life-or-death sense.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pacemaker Lead Placement & Rrevision.

PROCEDURE: , Right ventricular pacemaker lead placement and lead revision.,INDICATIONS:,  Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.,EQUIPMENT: , A new lead is a Medtronic model #12345, threshold sensing at 5.7, impedance of 1032, threshold of 0.3, atrial threshold is 0.3, 531, and sensing at 4.1.  The original chronic ventricular lead had a threshold of 3.5 and 6 on the can.,ESTIMATED BLOOD LOSS: , 5 mL.,PROCEDURE DESCRIPTION:  ,Conscious sedation with Versed and fentanyl over left subclavicular area with pacemaker pocket was anesthetized with local anesthetic with epinephrine.  The patient received a venogram documenting patency of the subclavian vein.  Skin incision with blunt and sharp dissection.  Electrocautery for hemostasis.  The pocket was opened and the pacemaker was removed from the pocket and disconnected from the leads.  The leads were sequentially checked.  Through the pocket a puncture of the vein with a thin wall needle was made and a long sheath was used to help carry it along the tortuosity of the proximal subclavian and innominate superior vena cava.  Ultimately, a ventricular lead was placed in apex of the right ventricle, secured to base pocket with 2-0 silk suture.  Pocket was irrigated with antibiotic solution.  The pocket was packed with bacitracin-soaked gauze.  This was removed during the case and then irrigated once again.  The generator was attached to the leads, placed in the pocket, secured with 2-0 silk suture and the pocket was closed with a three layer of 4-0 Monocryl.,CONCLUSION:  , Successful replacement of a right ventricular lead secondary to poor lead thresholds in a chronic lead and placement of the previous Vitatron pulse generator model # 12345.
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DESCRIPTION: Sinus bradycardia, sick-sinus syndrome, poor threshold on the ventricular lead and chronic lead.  Right ventricular pacemaker lead placement and lead revision.

cardiovascular / pulmonary, medtronic, atrial, subclavian, sick sinus syndrome, pacemaker lead placement, ventricular pacemaker, ventricular lead, lead, bradycardia, pacemaker, threshold, ventricular

This surgical procedure involves the placement and revision of a pacemaker lead, which is critical for patients with conditions like sinus bradycardia and sick-sinus syndrome. These conditions affect the heart's ability to maintain a proper rhythm, making the procedure essential to prevent serious complications such as arrhythmias or heart failure. The procedure is invasive, requires precision, and involves multiple steps, including sedation, effectively increasing its complexity. While not as immediately life-threatening as some other cardiac surgeries, any mistakes could lead to significant patient harm, heart function issues, or the need for additional medical intervention. Therefore, it holds a high impact on the patient's health and quality of life.