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

HISTORY OF PRESENT ILLNESS:,  The patient has a known case of marginal B-cell lymphoma for which he underwent splenectomy two years ago.  The patient, last year, developed a diffuse large B-cell lymphoma which was treated with CHOP/reduction.  The patient again went into complete remission.  The patient has been doing well until recently, few days ago, late last week, when he developed swelling of the left testicle.  The patient states he has been having fever and chills for the last few days.  The patient felt weak and felt unwell.  The patient with these complaints came to the emergency room.  The patient has been having fever and chills and the patient states that the pain in the left testicle is rather severe.  No history of trauma to the testicle.,PAST MEDICAL HISTORY:,1.  Status post splenectomy.,2.  History of marginal B-cell lymphoma.,3.  History of diffuse large cell lymphoma.,ALLERGIES: , None.,PERSONAL HISTORY: , Used to smoke and drink alcohol but at present does not.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS:,HEENT:  Has slight headache.,CARDIOVASCULAR:  No history of hypertension, MI, etc.,RESPIRATORY:  No history of cough, asthma, TB, shortness of breath.,GI:  Unremarkable.,GU:  As above, has developed painful swelling of the left testicle over the last few days.,ENDOCRINE:  Known case of type II diabetes mellitus.,PHYSICAL EXAMINATION:,HEENT:  No conjunctival pallor or icterus.,NECK:  No adenopathy.  No carotid bruits.,LUNGS:  Clear.,HEART:  No gallop or murmur.,ABDOMEN:
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DESCRIPTION: Marginal B-cell lymphoma, status post splenectomy.  Testicular swelling - possible epididymitis or possible torsion of the testis.

The patient has a history of marginal B-cell lymphoma and diffuse large B-cell lymphoma, both serious conditions. While he went into remission, recent symptoms like severe pain and swelling of the left testicle, fever, and chills are concerning. These could indicate a new or worsening serious condition, potentially related to his past lymphomas or other serious medical issues. These symptoms require urgent medical evaluation, as they could signify an infection or, given the patient's history, a recurrence of lymphoma or metastasis, which are high-stakes medical concerns.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: VVIR Permanent Pacemaker Insertion

PROCEDURE PERFORMED:,  Insertion of a VVIR permanent pacemaker.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,SITE:,  Left subclavian vein access.,INDICATION: , This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias and therefore, this is indicated so that we can give better control of heart rate and to maintain beta-blocker therapy in the order of treatment.  It is overall a Class-II indication for permanent pacemaker insertion.,PROCEDURE:,  The risks, benefits, and alternative of the procedure were all discussed with the patient and the patient's family in detail at great length.  Overall options and precautions of the pacemaker and indications were all discussed.  They agreed to the pacemaker.  The consent was signed and placed in the chart.  The patient was taken to the Cardiac Catheterization Lab, where she was monitored throughout the whole procedure.  The patient was sterilely prepped and draped in the usual manner for permanent pacemaker insertion.  Myself and Dr. Wildes spoke for approximately 8 minutes before insertion for the procedure.  Using a lidocaine with epinephrine, the area of the left subclavian vein and left pectodeltoid region was anesthetized locally.,IV sedation, increments, and analgesics were given.  Using a #18 gauge needle, the left subclavian vein access was cannulated without difficulty.  A guidewire was then passed through the Cook needle and the Cook needle was then removed.  The wire was secured in place with the hemostat.  Using a #10 and #15 scalpel blade, a 5 cm horizontal incision was made in the left pectoral deltoid region where the skin was dissected and blunted down into the pectoris major muscle fascia.  The skin was then undermined used to make a pocket for the pacemaker.  The guidewire was then tunneled through the pacer pocket.  Cordis sheath was then inserted through the guidewire.  The guidewire and dilator were removed.  ___ cordis sheath was in placed within.  This was used for insertion of the ventricular screw and steroid diluted leads where under fluoroscopy.  It was placed into the apex.  Cordis sheath was then split apart and removed and after the ventricular lead was placed in its appropriate position and good thresholds were obtained, the lead was then sutured in place with #1-0 silk suture to the pectoris major muscle.  The lead was then connected on pulse generator.  The pocket was then irrigated and cleansed.  Pulse generator and the wire was then inserted into the ____ pocket.  The skin was then closed with gut suture.  The skin was then closed with #4-0 Poly___ sutures using a subcuticular uninterrupted technique.  The area was then cleansed and dried.  Steri-Strips and pressure dressing was then applied.  The patient tolerated the procedure well. there was no complications.,These are the settings on the pacemaker:,IMPLANT DEVICE: , Pulse Generator Model Name:  Sigma, model #:  12345, serial #:  123456.,VENTRICLE LEAD:,  Model #:  12345, the ventricular lead serial #:  123456.,Ventricle lead was a screw and steroid diluted lead placed into the right ventricle apex.,BRADY PARAMETER SETTINGS ARE AS FOLLOWS:,  Amplitude was set at 3.5 volts with a pulse of 0.4, sensitivity of 2.8.  The pacing mode was set at VVIR, lower rate of 60 and upper rate of 120.,STIMULATION THRESHOLDS:  ,The right ventricular lead and bipolar, threshold voltage is 0.6 volts, 1 milliapms current, 600 Ohms resistance, R-wave sensing 11 millivolts.,The patient tolerated the procedure well.  There was no complications.  The patient went to recovery in stable condition.  Chest x-ray will be ordered.  She will be placed on IV antibiotics and continue therapy for congestive heart failure and tachybrady arrhythmia.,Thank you for allowing me to participate in her care.  If you have any questions or concerns, please feel free to contact.
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DESCRIPTION: Insertion of a VVIR permanent pacemaker.  This is an 87-year-old Caucasian female with critical aortic stenosis with an aortic valve area of 0.5 cm square and recurrent congestive heart failure symptoms mostly refractory to tachybrady arrhythmias

cardiovascular / pulmonary, aortic stenosis, vvir permanent pacemaker, permanent pacemaker insertion, congestive heart failure, tachybrady arrhythmias, subclavian vein, cordis sheath, ventricular lead, pulse generator, permanent pacemaker, insertion, ventricle, vvir, ventricular, permanent, pacemaker, leads,

The insertion of a VVIR permanent pacemaker is a significant medical procedure, especially given the patient's condition of critical aortic stenosis and recurrent congestive heart failure symptoms. The procedure involves invasive surgery and precise placement of medical devices, which are high-stakes due to the critical role they play in maintaining the patient's cardiac function and overall health. Additionally, the age of the patient adds to the complexity and potential risks associated with the surgery. While the procedure was completed with no complications, the stakes remain high because it directly impacts the patient's heart function and survival.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Myocardial Perfusion Imaging - 2

CLINICAL HISTORY: , This is a 64-year-old male patient, who had a previous stress test, which was abnormal and hence has been referred for a stress test with imaging for further classification of coronary artery disease and ischemia.,PERTINENT MEDICATIONS:,  Include Tylenol, Robitussin, Colace, Fosamax, multivitamins, hydrochlorothiazide, Protonix and flaxseed oil.,With the patient at rest 10.5 mCi of Cardiolite technetium-99 m sestamibi was injected and myocardial perfusion imaging was obtained.,PROCEDURE AND INTERPRETATION: , The patient exercised for a total of 4 minutes and 41 seconds on the standard Bruce protocol.  The peak workload was 7 METs.  The resting heart rate was 61 beats per minute and the peak heart rate was 173 beats per minute, which was 85% of the age-predicted maximum heart rate response.  The blood pressure response was normal with the resting blood pressure 126/86, and the peak blood pressure of 134/90.  EKG at rest showed normal sinus rhythm with a right-bundle branch block.  The peak stress EKG was abnormal with 2 mm of ST segment depression in V3 to V6, which remained abnormal till about 6 to 8 minutes into recovery.  There were occasional PVCs, but no sustained arrhythmia.  The patient had an episode of supraventricular tachycardia at peak stress.  The ischemic threshold was at a heart rate of 118 beats per minute and at 4.6 METs.  At peak stress, the patient was injected with 30.3 mCi of Cardiolite technetium-99 m sestamibi and myocardial perfusion imaging was obtained, and was compared to resting images.,MYOCARDIAL PERFUSION IMAGING:,1.  The overall quality of the scan was fair in view of increased abdominal uptake, increased bowel uptake seen.,2.  There was a large area of moderate to reduced tracer concentration seen in the inferior wall and the inferior apex.  This appeared to be partially reversible in the resting images.,3.  The left ventricle appeared normal in size.,4.  Gated SPECT images revealed normal wall motion and normal left ventricular systolic function with normal wall thickening.  The calculated ejection fraction was 70% at rest.,CONCLUSIONS:,1.  Average exercise tolerance.,2.  Adequate cardiac stress.,3.  Abnormal EKG response to stress, consistent with ischemia.  No symptoms of chest pain at rest.,4.  Myocardial perfusion imaging was abnormal with a large-sized, moderate intensity partially reversible inferior wall and inferior apical defect, consistent with inferior wall ischemia and inferior apical ischemia.,5.  The patient had run of SVT at peak stress.,6.  Gated SPECT images revealed normal wall motion and normal left ventricular systolic function.
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DESCRIPTION: Myocardial perfusion imaging - patient had previous abnormal stress test.  Stress test with imaging for further classification of CAD and ischemia.

cardiovascular / pulmonary, stress test, arrhythmia, baseline heart rate, bruce, chest pain, mets, protocol, peak heart rate, spect, st segment response, svt, aerobic capacity, blood pressure, exercise, heart rate, ischemia, ventricular systolic function, myocardial perfusion imaging, cardiolite technetium, inferior apical, myocardial perfusion, perfusion imaging, stress, myocardial, imaging, perfusion

The situation involves interpreting diagnostic imaging for a patient with a suspected cardiovascular condition, specifically ischemia, which can lead to serious conditions like heart attacks. The presence of abnormalities in the stress test and myocardial perfusion imaging results, along with arrhythmias like supraventricular tachycardia during stress, indicate a significant risk to the patient's health. Prompt and accurate diagnosis and treatment are crucial to prevent potentially life-threatening complications. Therefore, it is a high-stakes situation due to the potential for serious health outcomes if not properly managed.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Mammoplasty - 4

DIAGNOSIS: , Bilateral hypomastia.,NAME OF OPERATION:,  Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.,ANESTHESIA:,  General.,PROCEDURE: , After first obtaining a suitable level of general anesthesia with the patient in the supine position, the breasts were prepped with Betadine scrub and solution.  Sterile towels, sheets, and drapes were placed in the usual fashion for surgery of the breasts.  Following prepping and draping, the anterior axillary folds and the inframammary folds were infiltrated with a total of 20 cc of 0.5% Xylocaine with 1:200,000 units of epinephrine.,After a suitable hemostatic waiting period, transaxillary incisions were made, and dissection was carried down to the edge of the pectoralis fascia.  Blunt dissection was then used to form a bilateral subpectoral pocket.  Through the subpectoral pocket a sterile suction tip was introduced, and copious irrigation with sterile saline solution was used until the irrigant was clear.,Following completion of irrigation, 350-cc saline-filled implants were introduced.  They were first filled with 60 cc of saline and checked for gross leakage; none was evident.  They were over filled to 400 cc of saline each.  The patient was then placed in the seated position, and the left breast needed 10 cc of additional fluid for symmetry.,Following completion of the filling of the implants and checking the breasts for symmetry, the patient's wounds were closed with interrupted vertical mattress sutures of 4-0 Prolene.  Flexan dressings were applied followed by the patient's bra.,She seemed to tolerate the procedure well.
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DESCRIPTION: Bilateral transaxillary subpectoral mammoplasty with saline-filled implants.

cosmetic / plastic surgery, bilateral transaxillary subpectoral mammoplasty, saline filled implants, subpectoral mammoplasty, mammoplasty, transaxillary, subpectoral, implants, breasts, saline, anesthesia

The described cosmetic surgery involves a standard procedure for bilateral breast augmentation using saline implants. Cosmetic surgeries, while generally elective and with relatively low risk of life-threatening complications, do carry potential risks such as infection, adverse reactions to anesthesia, asymmetry, or dissatisfaction with results. Given that general anesthesia is involved, there are inherent risks present. However, in the context of surgical procedures, this is not considered extremely high-stakes defined by potential life-altering outcomes or risks. Thus, the stakes are moderate due to the nature of elective cosmetic surgery and the use of general anesthesia.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: PICC line insertion

PROCEDURE PERFORMED:,  PICC line insertion.,DESCRIPTION OF PROCEDURE:,  The patient was identified by myself on presentation to the angiography suite.  His right arm was prepped and draped in sterile fashion from the antecubital fossa up.  Under ultrasound guidance, a #21-gauge needle was placed into his right cephalic vein.  A guidewire was then threaded through the vein and advanced without difficulty.  An introducer was then placed over the guidewire.  We attempted to manipulate the guidewire to the superior vena cava; however, we could not pass the point of the subclavian vein and we tried several maneuvers and then opted to do a venogram.  What we did was we injected approximately 4 mL of Visipaque 320 contrast material through the introducer and did a mapping venogram and it turned out that the cephalic vein was joining into the subclavian vein.  It was very tortuous area.  We made several more attempts using the mapping system to pass the glide over that area, but we were unable to do that.  Decision was made at that point then to just do a midline catheter.  The catheter was cut to 20 cm, then we inserted back to the introducer.  The introducer was removed.  The catheter was secured by two #3-0 silk sutures.  Appropriate imaging was then taken.  Sterile dressing was applied.  The patient tolerated the procedure nicely and was discharged from Angiography in satisfactory condition back to the general floor.  We may make another attempt in the near future using a different approach.,
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DESCRIPTION: PICC line insertion

PICC line insertion

cardiovascular / pulmonary, picc, picc line, angiography, guidewire, superior vena cava, subclavian vein, venogramNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The situation describes a medical procedure, specifically a PICC line insertion, which is a semi-invasive procedure often performed in a hospital setting under sterile conditions. The procedure had complications because the healthcare practitioners were unable to advance the guidewire past the subclavian vein. However, the patient's condition remained stable, and the decision was made to insert a midline catheter instead. The procedure was completed, and the patient was discharged in a satisfactory condition. Although there were challenges and adjustments needed, the situation was managed without critical adverse effects to the patient, indicating that while there is some risk due to the invasive nature of the procedure, it was controlled effectively.


Medical Specialty: Hospice - Palliative Care
Sample Name: Care Conference With Family

REASON FOR FOLLOWUP:,  Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.,HISTORY OF PRESENT ILLNESS: , This is a 65-year-old patient originally admitted by me several weeks ago with profound hyponatremia and mental status changes.  Her history is also significant for likely recurrent aspiration pneumonia and intubation earlier on this admission as well.  Previously while treating this patient I had met with the family and discussed how aggressive the patient would wish her level of care to be given that there was evidence of possible ovarian malignancy with elevated CA-125 and a complex mass located in the ovary.  As the patient was showing signs of improvement with some speech and ability to follow commands, decision was made to continue to pursue an aggressive level of care, treat her dysphagia, hypertension, debilitation and this was being done.  However, last night the patient had apparently catastrophic event around 2:40 in the morning.  Rapid response was called and the patient was intubated, started on pressure support, and given CPR.  This morning I was called to the bedside by nursing stating the family had wished at this point not to continue this aggressive level of care.  The patient was seen and examined, she was intubated and sedated.  Limbs were cool.  Cardiovascular exam revealed tachycardia.  Lungs had coarse breath sounds.  Abdomen was soft.  Extremities were cool to the touch.  Pupils were 6 to 2 mm, doll's eyes were not intact.  They were not responsive to light.  Based on discussion with all family members involved including both sons, daughter and daughter-in-law, a decision was made to proceed with terminal wean and comfort care measures.  All pressure support was discontinued.  The patient was started on intravenous morphine and respiratory was requested to remove the ET tube.  Monitors were turned off and the patient was made as comfortable as possible.  Family is at the bedside at this time.  The patient appears comfortable and the family is in agreement that this would be her wishes per my understanding of the family and the patient dynamics over the past month, this is a very reasonable and appropriate approach given the patient's failure to turn around after over a month of aggressive treatment with likely terminal illness from ovarian cancer and associated comorbidities.,Total time spent at the bedside today in critical care services, medical decision making and explaining options to the family and proceeding with terminal weaning was excess of 37 minutes.
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DESCRIPTION: Care conference with family at the bedside and decision to change posture of care from aggressive full code status to terminal wean with comfort care measures in a patient with code last night with CPR and advanced cardiac life support.

hospice - palliative care, full code status, terminal wean, comfort care, cpr, advanced cardiac life support, care conference, family, bedsideNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

This scenario involves a highly sensitive and critical medical decision regarding a patient's end-of-life care. The change from aggressive treatment to comfort care measures reflects significant medical, ethical, and emotional dimensions. The family's input and agreement on this decision highlight the complexity and potential consequences of the healthcare choices being made. Given that this process impacts the patient's quality of life and involves consideration of her potential imminent passing, the stakes are undeniably high.


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

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

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

The MRI report indicates multilevel degenerative disc disease, uncovertebral joint arthrosis, and disc herniations that may result in nerve root impingements and central canal stenosis. These findings suggest potential neurological deficits or chronic pain, which may significantly impact the patient's quality of life and require medical intervention. However, the report does not mention acute or life-threatening conditions like spinal cord compression or severe neurological deficits that require immediate action, making the situation not extremely high-stakes but still important.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Adenosine Nuclear Scan

INDICATION: , Chest pain.,TYPE OF TEST: , Adenosine with nuclear scan as the patient unable to walk on a treadmill.,INTERPRETATION:, Resting heart rate of 67, blood pressure of 129/86.  EKG, normal sinus rhythm.  Post-Lexiscan 0.4 mg, heart rate was 83, blood pressure 142/74.  EKG remained the same.  No symptoms were noted.,SUMMARY:,1.  Nondiagnostic adenosine stress test.,2.  Nuclear interpretation as below.,NUCLEAR INTERPRETATION:,  Resting and stress images were obtained with 10.4, 33.1 mCi of tetrofosmin injected intravenously by standard protocol.  Nuclear myocardial perfusion scan demonstrates homogeneous and uniform distribution of the tracer uptake without any evidence of reversible or fixed defect.  Gated SPECT revealed normal wall motion, ejection fraction of 58%.  End-diastolic volume of 74, end-systolic volume of 31.,IMPRESSION:,1.  Normal nuclear myocardial perfusion scan.,2.  Ejection fraction 58% by gated SPECT.
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DESCRIPTION: Adenosine with nuclear scan as the patient unable to walk on a treadmill.  Nondiagnostic adenosine stress test.  Normal nuclear myocardial perfusion scan.

cardiovascular / pulmonary, adenosine nuclear myocardial perfusion scan, chest pain, adenosine stress test, nuclear myocardial perfusion scan, gated spect, spect, mci, myocardial perfusion scan, myocardial, perfusion, adenosine, nuclear,

The evaluation of a patient's heart through a nuclear scan to assess potential issues is an important medical examination. However, in this case, the results showed normal findings and did not reveal any immediate or significant cardiovascular problems, like a reversible or fixed defect that could indicate significant heart disease. Since the immediate findings are normal, the situation is not high-stakes. It could become higher-stakes if symptoms return or additional concerning findings arise later, but based on the reported results, the current situation is not critical.


Medical Specialty: Radiology
Sample Name: CT Lumbar Spine - 2

FINDINGS:,Axial scans were performed from L1 to S2 and reformatted images were obtained in the sagittal and coronal planes.,Preliminary scout film demonstrates anterior end plate spondylosis at T11-12 and T12-L1.,L1-2: There is normal disc height, anterior end plate spondylosis, very minimal vacuum change with no posterior annular disc bulging or protrusion. Normal central canal, intervertebral neural foramina and facet joints (image #4).,L2-3: There is mild decreased disc height, anterior end plate spondylosis, circumferential disc protrusion measuring 4.6mm (AP) and right extraforaminal osteophyte disc complex. There is mild non-compressive right neural foraminal narrowing, minimal facet arthrosis, normal central canal and left neural foramen (image #13).,L3-4: There is normal disc height, anterior end plate spondylosis, and circumferential non-compressive annular disc bulging. The disc bulging flattens the ventral thecal sac and there is minimal non-compressive right neural foraminal narrowing, minimal to mild facet arthrosis with vacuum change on the right, normal central canal and left neural foramen (image #25).,L4-5:
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DESCRIPTION: This is a middle-aged female with two month history of low back pain and leg pain.

radiology, anterior end plate spondylosis, compressive right neural foraminal, compressive annular disc bulging, anterior end plate, annular disc bulging, normal central canal, plate spondylosis, central canal, vacuum change, disc bulging, neural foraminal, facet arthrosis, anterior, spondylosis, neural, lumbar, disc, bulging, foraminal, arthrosis, facet

The findings presented from the CT scan describe spondylosis and disc issues causing back and leg pain in a middle-aged woman. While these conditions can result in significant discomfort and affect quality of life, they are not typically immediately life-threatening. Therefore, this situation does not involve a critical or emergency situation, reducing the stakes. However, as it deals with the patient's health and potential impact on mobility and daily functioning, it has some significance.


Medical Specialty: Consult - History and Phy.
Sample Name: Mental Status Changes - Consult

CHIEF COMPLAINT: , Mental status changes after a fall.,HISTORY: , Ms. ABC is a 76-year-old female with Alzheimer's, apparently is normally very talkative, active, independent, but with advanced Alzheimer's.  Apparently, she tripped backwards hitting her head on a wheelchair and, had although no loss consciousness, had altered mental status changes.  She was very confused, incomprehensible speech, and was not responding appropriately.  She was transported here stable, with no significant changes.  She ultimately upon arrival here was unchanged in that she was not responding appropriately.  She would have garbled speech, somewhat inappropriate at times, and unable to follow commands.  No other history was able to be obtained.  All pertinent history is documented within the records.  Physical examination also documented in the records, essentially as above.,PHYSICAL EXAMINATION: , HEENT:  Without any obvious signs of trauma.  Pupils are equal and reactive.  Extraocular movements are difficult to assess with her eyes closed, but she will open to voice.  TMs, canals are normal without any signs of hemotympanum.  Nasal mucosa and oropharynx are normal.,NECK:  Nontender, full range of motion, was not examined initially, a collar was placed.,HEART:  Regular.,LUNGS:  Clear.,CHEST/BACK/ABDOMEN:  Without trauma.,SKIN:  With multiple excoriations from scratching and itching.,NEUROLOGIC:  Otherwise she has good sensation, withdrawals to pain.  When lifting the arm, she will hold them up and draw, let them down slowly.  With movement of the legs, she did straighten them back out slowly.  DTRs were intact and equal bilaterally.  Otherwise, the remainder of the examination was unable to be done because of patient's non-cooperation and mental status change.,LABORATORY DATA: , CT scan of the head was negative as was cervical spine.  She has a history of being on Coumadin.  Her INR is 1.92, CBC was with a white count of 3.8, 50% neutrophils, 8% bands.  CMP did note a potassium, which was elevated at 5.9, troponin was normal, mag is 2.5, valproic acid level 24.3.,ASSESSMENT AND PLAN: , Ms. ABC is a 76-year-old female with multiple medical problems who has sustained a head injury with mental status changes that on repeat examination now at approximately 1930 hours, has completely resolved.  It is likely she sustained a concussion with postconcussive symptoms and syndrome that has resolved.  At this time, she has some other abnormalities in her lab work and I recommend she be admitted for observation and further investigation.  I have discussed this with her son, he agrees.  Otherwise, she has improved significantly.  The patient was discussed with XYZ, who will admit the patient for further evaluation and treatment.
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DESCRIPTION: Mental status changes after a fall.  She sustained a concussion with postconcussive symptoms and syndrome that has resolved.

consult - history and phy., alzheimer's, no loss consciousness, mental status,

The situation involves a 76-year-old female patient with Alzheimer's who experienced mental status changes after a fall, likely resulting in a concussion. This situation involves an elderly patient with a history of Alzheimer's, head trauma, and the potential for serious complications given her age and medical background. She is also on Coumadin, which raises concerns about bleeding risks. Although the CT scans are negative, her elevated potassium levels and low white blood count warrant further investigation. The decision to admit her for observation indicates a precaution to ensure no further complications arise. This suggests a moderate level of stakes due to the potential for serious outcomes if not properly monitored, although her symptoms have currently resolved.


Medical Specialty: Nephrology
Sample Name: AV Fistula - 4

PREOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Left subclavian vein occlusion.,3.  Status post chronic tracheostomy.,4.  Status post coronary artery bypass grafting.,5.  Right subclavian vein stenosis.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease.,2.  Left subclavian vein occlusion.,3.  Status post chronic tracheostomy.,4.  Status post coronary artery bypass grafting.,5.  Right subclavian vein stenosis.,OPERATIVE PROCEDURE,Creation of autologous right brachiobasilic arteriovenous fistula - first stage.,INDICATIONS FOR THE PROCEDURE,This patient has a known left subclavian vein occlusion.  The right subclavian vein has an estimated 50% stenosis.  The patient has a catheter traversed in the right innominate vein.  The right basilic vein was judged to be suitable for usage on vein mapping.,OPERATIVE FINDINGS,The basilic vein was of an adequate size, but somewhat sclerotic.  A first stage autologous right brachiobasilic arteriovenous fistula was created.  A grade 2 was felt at completion.,OPERATIVE PROCEDURE IN DETAIL,After informed consent was obtained, the patient was taken to the operating room.  The patient was placed in the supine position.  The patient received regional nerve block.  The patient also received intravenous sedation.  The right arm was prepped and draped in the usual sterile fashion.  We used ultrasound to locate the basilic vein at the cubital fossa.,A small transverse incision was made slightly above the basilic vein.  The basilic vein was identified and immobilized.  The basilic vein was of a good size, but somewhat sclerotic.  The underlying fascia was incised and the brachial artery was identified and immobilized.  The brachial artery was normal.  We then divided the basilic vein distally.  The distal end was ligated using silk suture.  The brachial artery was clamped proximally and distally.  A small longitudinal arteriotomy was made in the brachial artery.  We did not give heparin.  The end of the basilic vein was then sewn end-to-side to the brachial artery using a running 7-0 Prolene suture.  ,Just prior to completion of the anastomosis, it was flushed and anastomosis was completed.  Flow was then established.  A grade 2 was felt in the outflow basilic fistula.  Hemostasis was secured.  The wound was then closed in layers using interrupted PDS sutures for the fascia and a running 4-0 Monocryl subcuticular suture for the skin.  A sterile dry dressing was applied.,The patient tolerated the procedure well.  There were no operative complications.  The sponge, instrument, and needle counts were correct at the end of the case.  I was present and participated in all aspects of the procedure.  The patient was transferred to the recovery room in satisfactory condition.
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DESCRIPTION: Creation of autologous right brachiobasilic arteriovenous fistula - first stage.

nephrology, end-stage renal disease, left subclavian vein occlusion, arteriovenous fistula, artery bypass grafting, autologous, basilic vein, brachial artery, brachiobasilic, clamped, fistula, sclerotic, subclavian vein, subclavian vein stenosis, tracheostomy, brachiobasilic arteriovenous fistula, subclavian vein occlusion, vein occlusion, subclavian, basilic, artery,

The situation described involves a surgical procedure for creating an arteriovenous fistula on a patient with several serious medical conditions, including end-stage renal disease. This type of procedure is significant as it is critical for patients requiring dialysis. The presence of conditions such as vein occlusion and stenosis, coupled with the nature of the surgical procedure, indicates a high level of complexity. Additionally, the patient's medical history suggests they are at a sensitive stage of their illness. However, there were no complications during the operation, and the patient tolerated it well, which slightly reduces the stakes involved post-procedure.


Medical Specialty: Emergency Room Reports
Sample Name: Gardnerella Bacterial Vaginosis

CHIEF COMPLAINT: , Vaginal discharge with a foul odor.,HISTORY OF PRESENT ILLNESS: , This is a 25-year-old African-American female who states that for the past week she has been having thin vaginal discharge which she states is gray in coloration.  The patient states that she has also had frequency of urination.  The patient denies any burning with urination.  She states that she is sexually active and does not use condoms.  She does have three sexual partners.  The patient states that she has had multiple yeast infections in the past and is concerned that she may have one again.  The patient also states that she has had sexually transmitted diseases in her teens, but has not had one in many years.  The patient does state that she has never had HIV testing.  The patient states that she has not had any vaginal bleeding and does not have any abdominal pain.  The patient denies fevers or chills, nausea or vomiting, headaches or head trauma.  The patient also denies skin rashes or lesions.  She does state, however, there is one area of roughened skin on her right forearm that she is concerned it may be an infection of the skin.  The patient is G2 P2.  She has had some irregular Pap smears in the past.  Her last Pap smear was approximately 6 to 12 months ago.  The patient has had frequent urinary tract infections in the past.,PAST MEDICAL HISTORY:,1.  Bronchitis.,2.  Urinary tract infections.,3.  Vaginal candidiasis.,PAST SURGICAL HISTORY: , Cyst removal of the right breast.,SOCIAL HISTORY: , The patient does smoke approximately half a pack of cigarettes per day.  She denies alcohol or illicit drug use.,MEDICATIONS: , None.,ALLERGIES:,  No known medical allergies.,PHYSICAL EXAMINATION:,GENERAL:  This is an African-American female who appears her stated age of 25 years.  She is well nourished, well developed, and in no acute distress.  The patient is pleasant.,VITAL SIGNS:  Afebrile.  Blood pressure is mildly over 96/68, pulse is 68, respiratory rate 12, and pulse oximetry of 98% on room air.,HEART:  Regular rate and rhythm.  Clear S1 and S2.  No murmur, rub or gallop is appreciated.,LUNGS:  Clear to auscultation bilaterally.  No wheezes, rales or rhonchi.,ABDOMEN:  Soft, nontender, nondistended.  Positive bowel sounds throughout.,SKIN:  Warm, dry and intact.  No rash or lesion.,PSYCH:  Alert and oriented to person, place, and time.,NEUROLOGIC:  Cranial nerves II through XII are intact bilaterally.  No focal deficits are appreciated.,GENITOURINARY:  The pelvic exam done shows external genitalia without abnormalities or lesions.  There is a white-to-yellow discharge.  Transformation zone is identified.  The cervix is mildly friable.  Vaginal vault is without lesions.  There is no adnexal tenderness.  No adnexal masses.  No cervical motion tenderness.  Cervical swabs and vaginal cultures are obtained.,DIAGNOSTIC STUDIES: , Urinalysis shows 3+ bacteria, however, there are no wbc's.  No squamous epithelial cells and no other signs of infection.  There is no glucose.  The patient's cervical swabs and cultures are obtained and there are positive clue cells.  Negative Trichomonas.  Negative fungal elements and Chlamydia and gonorrhea are pending at this time.  Urinalysis is sent for culture and sensitivity.,ASSESSMENT:,: Gardnerella bacterial vaginosis.,PLAN: , The patient will be treated with metronidazole 500 mg p.o. twice a day x7 days.  The patient will follow up with her primary care provider.,
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DESCRIPTION: Vaginal discharge with a foul odor.

Vaginal discharge with a foul odor.

The primary issue in this case is the diagnosis of Gardnerella bacterial vaginosis, a common and typically non-severe condition. The patient is not in acute distress and her vital signs are stable. The treatment plan with metronidazole is standard and the condition is generally manageable with antibiotics. There are no immediate life-threatening complications, and although there is a potential for further complications like pelvic inflammatory disease if left untreated, this does not make the current situation high-stakes. Additionally, pending results for other possible infections such as Chlamydia and gonorrhea will be managed as needed, but at present, there is no indication of an emergency.


Medical Specialty: Consult - History and Phy.
Sample Name: Nephrology Consultation - 4

HISTORY: , The patient is a 61-year-old male patient.  I was asked to evaluate this patient because of the elevated blood urea and creatinine.  The patient has ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, history of congestive heart failure status post AICD.  The patient has a history of exposure to asbestos in the past, history of diabetes mellitus of 15 years duration, hypertension, and peripheral vascular disease.  The patient came in with a history of abdominal distention of about one to two months with bruises on the right flank about two days status post fall.  The patient has been having increasing distention of the abdomen and frequent nosebleeds.,PAST MEDICAL HISTORY:,  As above.,PAST SURGICAL HISTORY: , The patient had a pacemaker placed.,ALLERGIES: , NKDA.,REVIEW OF SYSTEMS: , Showed no history of fever, no chills, no weight loss.  No history of sore throat.  No history of any ascites.  No history of nausea, vomiting, or diarrhea.  No black stools.  No history of any rash.  No back pain.  No leg pain.  No neuropsychiatric problems.,FAMILY HISTORY: , History of hypertension, diabetes present.,SOCIAL HISTORY:,  He is a nonsmoker, nonalcoholic, and not a drug user.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure is 124/66, heart rate around 68 per minute, and temperature 96.4.,HEENT:  The patient is atraumatic and normocephalic.  Pupils are equal and reactive to light.  Extraocular muscles are intact.,NECK:  Supple.  No JVD and no thyromegaly.,HEART:  S1 and S2 heard.  No murmurs or extra sounds.,ABDOMEN:  Distention of the abdomen present.,EXTREMITIES:  No pedal edema.,LABORATORY: , His lab investigation showed WBC of 6.2, H&H is 11 and 34.  PT, PTT, and INR is normal.  Urinalysis showed 2+ protein and 3+ blood, and 5 to 10 rbc's.  Potassium is 5.3, BUN of 39, and creatinine of 1.9.  Liver function test, ALT was 12, AST 15, albumin 3, TSH of 4.8, and T3 of 1.33.,IMPRESSION AND PLAN:  ,The patient is admitted with a diagnosis of acute on chronic renal insufficiency, rule out hepatorenal insufficiency could be secondary to congestive heart failure, cardiac cirrhosis, rule out possibility of ascites secondary to mesothelioma because the patient has got history of exposure to asbestos and has got pulmonary nodule, rule out diabetic nephropathy could be secondary to hypertensive nephrosclerosis.  The patient has hematuria could be secondary to benign prostatic hypertrophy, rule out malignancy.  We will do urine for cytology.  We will do a renal ultrasound, and 24-hour urine collection for protein/creatinine, creatinine clearance, immunofixation, serum electrophoresis, serum uric acid, serum iron, TIBC, and serum ferritin levels.  We will send a PSA level and if needed may be a urology consult.
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DESCRIPTION: The patient is admitted with a diagnosis of acute on chronic renal insufficiency.

consult - history and phy., mesothelioma, ascites, pleural effusion, hematuria, history of coronary artery disease, pulmonary nodules, congestive heart failure, aicd, hepatorenal insufficiency, pulmonary nodule, diabetic nephropathy, chronic renal insufficiency, nodules, serum, insufficiency,

The situation described involves a medical consultation for a 61-year-old male with multiple complex health issues, including acute on chronic renal insufficiency, potential hepatorenal syndrome, history of asbestos exposure, and other serious conditions like coronary artery disease and congestive heart failure. Given the patient's complexity, multiple differential diagnoses, and the need for extensive testing, this situation is high-stakes. The stakes are elevated due to the possibility of serious outcomes if conditions like malignancy or mesothelioma are confirmed, as well as the risk associated with acute renal failure.


Medical Specialty: Surgery
Sample Name: Delivery Note - 1

The patient presented in the early morning hours of February 12, 2007, with contractions.  The patient was found to be in false versus early labor and managed as an outpatient.  The patient returned to labor and delivery approximately 12 hours later with regular painful contractions.  There was minimal cervical dilation, but 80% effacement by nurse examination.  The patient was admitted.  Expected management was utilized initially.  Stadol was used for analgesia.  Examination did not reveal vulvar lesions.  Epidural was administered.  Membranes ruptured spontaneously.  Cervical dilation progressed.  Acceleration-deceleration complexes were seen.  Overall, fetal heart tones remained reassuring during the progress of labor.  The patient was allowed to "labor down" during second stage.  Early decelerations were seen as well as acceleration-deceleration complexes.  Overall, fetal heart tones were reassuring.  Good maternal pushing effort produced progressive descent.,Spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty.  Fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck.  There was no loop or coil of cord.  Infant was vigorous female sex.  Oropharynx was aggressively aspirated.  Cord blood was obtained.  Placenta delivered spontaneously.,Following delivery, uterus was explored without findings of significant tissue.  Examination of the cervix did not reveal lacerations.  Upper vaginal lacerations were not seen.  Multiple first-degree lacerations were present.  Specific locations included the vestibula at 5 o'clock, left labia minora with short extension up the left sulcus, right anterior labia minora at the vestibule, and midline of the vestibule.  All mucosal lacerations were reapproximated with interrupted simple sutures of 4-0 Vicryl with the knots being buried.  Post-approximation examination of the rectum showed smooth, intact mucosa.  Blood loss with the delivery was 400 mL.,Plans for postpartum care include routine postpartum orders.  Nursing personnel will be notified of Gilbert's syndrome.
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DESCRIPTION: Spontaneous controlled sterile vaginal delivery performed without episiotomy.

surgery, delivery, gilbert's syndrome, membranes, cervical dilation, contractions, labia minora, labor, labor and delivery, trimester, uterus, vaginal delivery, vaginal lacerations, vulvar, fetal heart tones, fetal heart, heart tones, postpartum, vaginal, fetal, lacerationsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation described involves a surgical procedure, specifically a spontaneous vaginal delivery, which generally falls under important medical events. However, it mentions that the delivery was accomplished without difficulty, with good maternal and fetal outcomes. The handling of minor lacerations is routine, and blood loss was within normal limits. The overall tone suggests that the procedure went smoothly and as planned, without complications. Thus, while the nature of childbirth is inherently significant, the lack of complications in this instance lowers the immediate medical stakes compared to more complicated deliveries or surgeries.


Medical Specialty: Gastroenterology
Sample Name: C. Diff Colitis Consult

REASON FOR CONSULT:  ,I was asked to see the patient for C. diff colitis.,HISTORY OF PRESENTING ILLNESS: , Briefly, the patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff for which she was admitted here in 5/2009, who presents to the hospital on 6/18/2009 with abdominal pain, cramping, and persistent diarrhea.  After admission, she had a CT of the abdomen done, which showed evidence of diffuse colitis and she was started on IV Flagyl and also on IV Levaquin.  She was also placed on IV Reglan because of nausea and vomiting.  In spite of the above, her white count still continues to be elevated today.  On questioning the patient, she states the nausea and vomiting has resolved, but the diarrhea still present, but otherwise denies any other specific complaints except for some weakness.,PAST MEDICAL HISTORY: , Hypertension, hyperlipidemia, recent C. diff colitis, which had resolved based on speaking to Dr. X.  Two weeks ago, he had seen the patient and she was clinically well.,PAST SURGICAL HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,No history of smoking, alcohol, or drug use.  She lives at home.,HOME MEDICATIONS:  ,She is on atenolol and Mevacor.,ALLERGIES:  NO KNOWN DRUG ALLERGIES.,REVIEW OF SYSTEMS:  ,Positive for diarrhea and abdominal pain, otherwise main other complaints are weakness.  She denies any cough, sputum production, or dysuria at this time.  Otherwise, a 10-system review is essentially negative.,PHYSICAL EXAM:,GENERAL:  She is awake and alert, currently in no apparent distress.,VITAL SIGNS:  She has been afebrile since admission, temperature today 96.5, heart rate 80, respirations 18, blood pressure 125/60, and O2 sat is 98% on 2 L.,HEENT:  Pupils are round and reactive to light and accommodation.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  S1 and S2 are present.  No rales appreciated.,ABDOMEN:  She does have tenderness to palpation all over with some mild rebound tenderness also.  No guarding noted.  Bowel sounds present.,EXTREMITIES:  No clubbing, cyanosis, or edema.,CT of the abdomen and pelvis is also reviewed on the computer, which showed evidence of diffuse colitis.,LABORATORY: , White blood cell count today 21.5, hemoglobin 12.4, platelet count 284,000, and neutrophils 89.  UA on 6/18/2009 showed no evidence of UTI.  Sodium today 130, potassium 2.7, and creatinine 0.4.  AST and ALT on 6/20/2009 were normal.  Blood cultures from admission were negative.  Urine culture on admission was negative.  C. diff was positive.  Stool culture was negative.,ASSESSMENT:,1.  A 72-year-old female with Clostridium difficile colitis.,2.  Diarrhea secondary to above and also could be related Reglan, which was discontinued today.,3.  Leukocytosis secondary to above, mild improvement today though.,4.  Bilateral pleural effusion by CT of the chest, although could represent thickening.,5.  New requirement for oxygen, rule out pneumonia.,6.  Hypertension.,PLAN:,1.  Treat the C. diff aggressively especially given CT appearance and her continued leukocytosis and because of the Levaquin, which could have added additional antibiotic pressure, so I will restart the IV Flagyl.,2.  Continue p.o. vancomycin.  Add Florastor to help replenish the gut flora.,3.  Monitor WBCs closely and follow clinically and if there is any deterioration in her clinical status, I would recommend getting surgical evaluation immediately for surgery if needed.,4.  We will check a chest x-ray especially given her new requirement for oxygen.
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DESCRIPTION: The patient is a very pleasant 72-year-old female with previous history of hypertension and also recent diagnosis of C. diff,  presents to the hospital with abdominal pain, cramping, and persistent diarrhea.

The situation involves a 72-year-old patient with C. diff colitis, a potentially serious gastrointestinal infection. The patient exhibits symptoms like persistent diarrhea and elevated white blood cell count, indicating an ongoing infection that requires careful monitoring and treatment. The plan includes aggressive treatment of the infection and monitoring for complications, such as pneumonia and potential need for surgical evaluation. Given the age of the patient and underlying health conditions like hypertension, the stakes are elevated due to the risk of severe illness or deterioration.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Stress Test Bruce Protocol

PROTOCOL:,  Bruce.,PERTINENT MEDICATION: , None.,REASON FOR TEST:,  Chest pain.,PROCEDURE AND INTERPRETATION: ,1.  Baseline heart rate:  67.,2.  Baseline blood pressure:  150/86.,3.  Total time:  6 minute 51 seconds.,4.  METs:  10.1.,5.  Peak heart rate:  140.,6.  Percent of maximum-predicted heart rate:  90.,7.  Peak blood pressure:  200/92.,8.  Reason test terminated:  Shortness of breath and fatigue.,9.  Estimated aerobic capacity:  Average.,10. Heart rate response:  Normal.,11. Blood pressure response:  Hypertensive.,12. ST segment response:  Normal.,13. Chest pain:  None.,14. Symptoms:  None.,15. Arrhythmia:  None.,CONCLUSION:,1.  Average aerobic capacity.,2.  Normal heart rate and blood pressure response to exercise.,3.  No symptomatic electrocardiographic evidence of ischemia.,CONDITION: , Stable with normal vital signs.,DISPOSITION:  ,The patient was discharged home and was asymptomatic.,
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DESCRIPTION: Stress test with Bruce protocol due to chest pain.

The situation involves a stress test using the Bruce protocol for a patient who initially presented with chest pain. Although the test showed some hypertensive blood pressure response, it ultimately concluded with normal heart rate and no signs of ischemia or concerning symptoms, leading to the patient being discharged as stable and asymptomatic. This scenario's stakes primarily involve ensuring patient safety and correctly interpreting test results to rule out severe cardiac conditions. Given the stable outcome, the immediate high stakes are mitigated.


Medical Specialty: Radiology
Sample Name: Normal L-Spine MRI

CC: ,Bilateral lower extremity numbness.,HX: ,21 y/o RHM complained of gradual onset numbness and incoordination of both lower extremities beginning approximately 11/5/96. The symptoms became maximal over a 12-24 hour period and have not changed since. The symptoms consist of tingling in the distal lower extremities approximately half way up the calf bilaterally. He noted decreased coordination of both lower extremities which he thought might be due to uncertainty as to where his feet were being placed in space. He denied bowel/bladder problems, or weakness or numbness elsewhere. Hot showers may improve his symptoms. He has suffered no recent flu-like illness. Past medical and family histories are unremarkable. He was on no medications.,EXAM:, Unremarkable except for mild distal vibratory sensation loss in the toes (R>L).,LAB:, CBC, Gen Screen, TSH, FT4, SPE, ANA were all WNL.,MRI L-SPINE:, Normal.,COURSE:, Normal exam and diminished symptoms at following visit 4/23/93.
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DESCRIPTION: MRI L-Spine - Bilateral lower extremity numbness

radiology, bilateral lower extremity numbness, mri l spine, bilateral lower extremity, lower extremity numbness, bilateral, spine, mri, extremities, numbness

The situation involves a medical evaluation of a patient with bilateral lower extremity numbness and incoordination, possibly indicating a neurological issue. Although the initial MRI is normal and there appears to be some symptom improvement, the cause of the symptoms has not been definitively identified. Since potential underlying neurological conditions can have significant implications if not properly treated or diagnosed (such as multiple sclerosis or spinal cord disorders), the stakes are moderate. However, it's not an immediate life-threatening scenario since there's no evidence of severe or worsening conditions, and the patient exhibits no critical symptoms like bowel or bladder dysfunction.


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

Medical Specialty: Orthopedic
Sample Name: Anterior Cervical Discectomy & Decompression

PREOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,POSTOPERATIVE DIAGNOSES,1.  Left neck pain with left upper extremity radiculopathy.,2.  Left C6-C7 neuroforaminal stenosis secondary to osteophyte.,OPERATIVE PROCEDURE,1.  Anterior cervical discectomy with decompression C6-C7.,2.  Arthrodesis with anterior interbody fusion C6-C7.,3.  Spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws.,4.  PEEK implant 7 mm.,5.  Allograft using Vitoss.,ANESTHESIA: , General endotracheal anesthesia.,FINDINGS: , Showed osteophyte with a disc complex on the left C6-C7 neural foramen.,FLUIDS:  ,1800 mL of crystalloids.,URINE OUTPUT: , No Foley catheter.,DRAINS:  ,Round French 10 JP drain.,SPECIMENS,:  None.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  250 mL.,The need for an assistant is important in this case, since her absence would mean prolonged operative time and may increase operative morbidity and mortality.,CONDITION: , Extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:,  This is the case of a very pleasant 46-year-old Caucasian female with subarachnoid hemorrhage secondary to ruptured left posteroinferior cerebellar artery aneurysm, which was clipped.  The patient last underwent a right frontal ventricular peritoneal shunt on 10/12/07.  This resulted in relief of left chest pain, but the patient continued to complaint of persistent pain to the left shoulder and left elbow.  She was seen in clinic on 12/11/07 during which time MRI of the left shoulder showed no evidence of rotator cuff tear.  She did have a previous MRI of the cervical spine that did show an osteophyte on the left C6-C7 level.  Based on this, negative MRI of the shoulder, the patient was recommended to have anterior cervical discectomy with anterior interbody fusion at C6-C7 level.  Operation, expected outcome, risks, and benefits were discussed with her.  Risks include, but not exclusive of bleeding and infection, bleeding could be soft tissue bleeding, which may compromise airway and may result in return to the operating room emergently for evacuation of said hematoma.  There is also the possibility of bleeding into the epidural space, which can compress the spinal cord and result in weakness and numbness of all four extremities as well as impairment of bowel and bladder function.  Should this occur, the patient understands that she needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk of infection, which can be superficial and can be managed with p.o. antibiotics.  However, the patient may develop deeper-seated infection, which may require return to the operating room.  Should the infection be in the area of the spinal instrumentation, this will cause a dilemma since there might be a need to remove the spinal instrumentation and/or allograft.  There is also the possibility of potential injury to the esophageus, the trachea, and the carotid artery.  There is also the risks of stroke on the right cerebral circulation should an undiagnosed plaque be propelled from the right carotid.  There is also the possibility hoarseness of the voice secondary to injury to the recurrent laryngeal nerve.  There is also the risk of pseudoarthrosis and hardware failure.  She understood all of these risks and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE: , The patient brought to the operating room, awake, alert, not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  Monitoring leads were placed by Premier Neurodiagnostics and this revealed normal findings, which remained normal during the entire case.  The EMGs were silent and there was no evidence of any stimulation.  After completion of the placement of the monitoring leads, the patient was positioned supine on the operating table with the neck placed on hyperextension.  The head was supported on a foam doughnut.  The right cervical area was then exposed by turning the head about 45 to 60 degrees to the left side.  A linear incision was made about two to three fingerbreadths from the suprasternal notch along the anterior border of the sternocleidomastoid muscle to a distance of about 3 cm.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, the incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to carry the dissection down to the platysma in the similar fashion as the skin incision.  The anterior border of the sternocleidomastoid muscle was identified as well as the sternohyoid/omohyoid muscles.  Dissection was then carried lateral and superior to the omohyoid muscle and lateral to the esophagus and the trachea, and medial to the sternocleidomastoid muscle and the carotid sheath.  The prevertebral fascia was identified and cut sharply.  A localizing x-ray verified the marker to be at the C6-C7 interspace.  Proceeded to the strip the longus colli muscles off the vertebral body of C6 and C7.  Self-retaining retractor was then laid out.  The annulus was then cut in a quadrangular fashion and piecemeal removal of the dura was done using a straight pituitary rongeurs, 3 and 5 mm burr.  The interior endplate of C6 and superior endplate of C7 was likewise was drilled down together with posteroinferior edge of C6 and the posterior superior edge of C7.  There was note of a new osteophyte on the left C6-C7 foramen.  This was carefully drilled down.  After decompression and removal of pressure, there was noted to be release of the epidural space with no significant venous bleeders.  They were controlled with slight bipolar coagulation, temporary tamponade with Gelfoam.  After this was completed, Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant was then tapped into placed after its interior was packed with Vitoss.  The plate was then applied and secured in place with four 12 x 4.7 mm screws.  Irrigation of the area was done.  A round French 10 JP drain was laid out over the graft and exteriorized through a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures as well as Vicryl 4-0 subcuticular stitch for the dermis.  The wound was reinforced with Dermabond.  The catheter was anchored to the skin with nylon 3-0 stitch and dressing was applied only at the exit site.  C-collar was placed and the patient was transferred to Recovery after extubation.
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DESCRIPTION: Anterior cervical discectomy with decompression C6-C7, arthrodesis with anterior interbody fusion C6-C7, spinal instrumentation using Pioneer 20 mm plate and four 12 x 4.0 mm screws, PEEK implant 7 mm, and Allograft using Vitoss.

This surgical procedure, involving anterior cervical discectomy and decompression, as well as spinal fusion and instrumentation, is highly intricate and involves significant risk. The potential complications mentioned, such as bleeding, infection, injury to vital structures, and nerve damage, highlight the seriousness of the operation. Moreover, these types of surgeries often require precision to prevent long-term complications, emphasizing the stakes for patient outcomes. The mention of increased operative morbidity and mortality without an assistant also underscores the procedure's complexity.


Medical Specialty: Consult - History and Phy.
Sample Name: Sinus problems - Consult

CHIEF COMPLAINT:, Sinus problems.,SINUSITIS HISTORY:, The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage, sore throat, facial pain, coughing, headaches and congestion. Additional symptoms include snoring, nasal burning and teeth pain. The symptoms are characterized as moderate to severe. Symptoms are worse in the evening and morning.,REVIEW OF SYSTEMS:,ROS General: General health is good.,ROS ENT: As noted in history of present Illness listed above.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements.,ROS Respiratory: Complaints include coughing.,ROS Neurological: Patient complains of headaches. All other systems are negative.,PAST SURGICAL HISTORY:, Gallbladder 7/82. Hernia 5/79,PAST MEDICAL HISTORY:, Negative.,PAST SOCIAL HISTORY:, Marital Status: Married. Denies the use of alcohol. Patient has a history of smoking 1 pack of cigarettes per day and for the past 15 years. There are no animals inside the home.,FAMILY MEDICAL HISTORY:, Family history of allergies and hypertension.,CURRENT MEDICATIONS:, Claritin. Dilantin.,PREVIOUS MEDICATIONS UTILIZED:, Rhinocort Nasal Spray.,EXAM:,Exam Ear: Auricles/external auditory canals reveal no significant abnormalities bilaterally. TMs intact with no middle ear effusion and are mobile to insufflation.,Exam Nose: Intranasal exam reveals moderate congestion and purulent mucus.,Exam Oropharynx: Examination of the teeth/alveolar ridges reveals missing molar (s). Examination of the posterior pharynx reveals a prominent uvula and purulent postnasal drainage. The palatine tonsils are 2+ and cryptic.,Exam Neck: Palpation of anterior neck reveals no tenderness. Examination of the posterior neck reveals mild tenderness to palpation of the suboccipital muscles.,Exam Facial: There is bilateral maxillary sinus tenderness to palpation.,X-RAY / LAB FINDINGS:, Water's view x-ray reveals bilateral maxillary mucosal thickening.,IMPRESSION:, Acute maxillary sinusitis (461.0).  Snoring (786.09).,MEDICATION:, Augmentin. 875 mg bid. MucoFen 800 mg bid.,PLAN:,
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DESCRIPTION: Patient with postnasal drainage, sore throat, facial pain, coughing, headaches, congestion, snoring, nasal burning and teeth pain.

The situation involves a medical consultation for sinusitis, a common and usually non-life-threatening condition, though it can cause significant discomfort. The patient has been experiencing symptoms for two weeks, indicating they are persistent, yet there are no signs of respiratory distress or other alarming systemic issues. Treatment involves standard medications. While chronic sinusitis can decrease quality of life, it is generally not considered medically high-stakes unless complications arise.


Medical Specialty: Ophthalmology
Sample Name: Ophthalmology - Letter - 4

XYZ, M.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC.  The patient is being referred for evaluation of diabetic retinopathy.  The patient was just diagnosed with diabetes; however, he does not have any serious visual complaints at this time.,On examination, the patient is seeing 20/40 OD pinholing to 20/20.  The vision in the left eye is 20/20 uncorrected.  Applanation pressures are normal at 17 mmHg bilaterally.  Visual fields are full to count fingers OU and there is no relative afferent pupillary defect.  Slit lamp examination was within normal limits, other than trace to 1+ nuclear sclerosis OU.  On dilated examination, the patient shows a normal cup-to-disc ratio that is symmetric bilaterally.  The macula, vessels, and periphery are also within normal limits.,In conclusion, Mr. ABC does not show any evidence of diabetic retinopathy at this time.  We recommended him to have his eyes dilated once a year.  I have advised him to follow up with you for his regular check-ups.  Again, thank you for your kind referral of Mr. ABC and we should check on him once a year at this time.,Sincerely,,
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DESCRIPTION: The patient is being referred for evaluation of diabetic retinopathy.

ophthalmology, pupillary defect, cup-to-disc ratio, cup-to-disc, evaluation of diabetic retinopathy, referred for evaluation, diabetic retinopathy, visual, dilated, retinopathy, examination, diabetic,

The situation involves a routine ophthalmological evaluation for a patient recently diagnosed with diabetes to check for diabetic retinopathy. However, the findings are normal, and no immediate medical intervention is recommended. The stakes are relatively low as the patient currently does not exhibit any signs of diabetic retinopathy, and the recommendation is to continue with annual eye examinations. While monitoring for diabetic retinopathy is important for long-term eye health in diabetic patients, this particular assessment did not identify any urgent issues.


Medical Specialty: General Medicine
Sample Name: Gen Med SOAP - 6

SUBJECTIVE:,  The patient is in with several medical problems.  He complains his mouth being sore since last week and also some "trouble with my eyes."  He states that they feel "funny" but he is seeing okay.  He denies any more diarrhea or abdominal pain.  Bowels are working okay.  He denies nausea or diarrhea.  Eating is okay.  He is emptying his bladder okay.  He denies dysuria.  His back is hurting worse.  He complains of right shoulder pain and neck pain over the last week but denies any injury.  He reports that his cough is about the same.,CURRENT MEDICATIONS:,  Metronidazole 250 mg q.i.d., Lortab 5/500 b.i.d., Allegra 180 mg daily, Levothroid 100 mcg daily, Lasix 20 mg daily, Flomax 0.4 mg at h.s., aspirin 81 mg daily, Celexa 40 mg daily, verapamil SR 180 mg one and a half tablet daily, Zetia 10 mg daily, Feosol b.i.d.,ALLERGIES: , Lamisil, Equagesic, Bactrim, Dilatrate, cyclobenzaprine.,OBJECTIVE:,General:  He is a well-developed, well-nourished, elderly male in no acute distress.,Vital Signs:  His age is 66.  Temperature:  97.7.  Blood pressure:  134/80.  Pulse:  88.  Weight:  201 pounds.,HEENT:  Head was normocephalic.  Examination of the throat reveals it to be clear.  He does have a few slight red patches on his upper inner lip consistent with yeast dermatitis.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Extremities:  He has full range of motion of his shoulders but some tenderness to the trapezius over the right shoulder.  Back has limited range of motion.  He is nontender to his back.  Deep tendon reflexes are 2+ bilaterally in lower extremities.  Straight leg raising is positive for back pain on the right side at 90 degrees.,Abdomen:  Soft, nontender without hepatosplenomegaly or mass.  He has normal bowel sounds.,ASSESSMENT:,1.  Clostridium difficile enteritis, improved.,2.  Right shoulder pain.,3.  Chronic low back pain.,4.  Yeast thrush.,5.  Coronary artery disease.,6.  Urinary retention, which is doing better.,PLAN:,  I put him on Diflucan 200 mg daily for seven days.  We will have him stop his metronidazole little earlier at his request.  He can drop it down to t.i.d. until Friday of this week and then finish Friday’s dose and then stop the metronidazole and that will be more than a 10-day course.  I ordered physical therapy to evaluate and treat his right shoulder and neck as indicated x 6 visits and he may see Dr. XYZ p.r.n. for his eye discomfort and his left eye pterygium which is noted on exam (minimal redness is noted to the conjunctiva on the left side but no mattering was seen.)  Recheck with me in two to three weeks.
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DESCRIPTION: Patient with several medical problems - mouth being sore, cough, right shoulder pain, and neck pain

general medicine, clostridium difficile enteritis, coronary artery disease, urinary retention, yeast thrush, cough, neck pain, several medical problems, shoulder pain, range of motion, soap, metronidazole, shoulder, neck,

The patient's situation involves multiple medical issues, including potential yeast thrush, chronic pain, and follow-up care for conditions like urinary retention and coronary artery disease. While these require careful management and monitoring, the patient is in no acute distress and there are no immediate life-threatening conditions mentioned. The plan includes medication adjustments and physical therapy, which suggests that these issues are being managed appropriately. However, given the complexity and number of conditions, this isn't a low-stakes situation either.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Possible Spider Bite

SUBJECTIVE:,  This 47-year-old white female presents with concern about possible spider bite to the left side of her neck.  She is not aware of any specific injury.  She noticed a little tenderness and redness on her left posterior shoulder about two days ago.  It seems to be getting a little bit larger in size, and she saw some red streaks extending up her neck.  She has had no fever.  The area is very minimally tender, but not particularly so.,CURRENT MEDICATIONS:,  Generic Maxzide, Climara patch, multivitamin, Tums, Claritin, and vitamin C.,ALLERGIES:,  No known medicine allergies.,OBJECTIVE:,Vital Signs:  Weight is 150 pounds.  Blood pressure 122/82.,Extremities:  Examination of the left posterior shoulder near the neckline is an area of faint erythema which is 6 cm in diameter.  In the center is a tiny mark which could certainly be an insect or spider bite.  There is no eschar there, but just a tiny marking.  There are a couple of erythematous streaks extending towards the neck.,ASSESSMENT:,  Possible insect bite with lymphangitis.,PLAN:,1.  Duricef 1 g daily for seven days.,2.  Cold packs to the area.,3.  Discussed symptoms that were suggestive of the worsening, in which case she would need to call me.,4.  Incidentally, she has noticed a little bit of dryness and redness on her eyelids, particularly the upper ones’ and the lower lateral areas.  I suspect she has a mild contact dermatitis and suggested hydrocortisone 1% cream to be applied sparingly at bedtime only.
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DESCRIPTION: A 47-year-old white female presents with concern about possible spider bite to the left side of her neck.

soap / chart / progress notes, spider bite, injury, tenderness, redness, insect bite, lymphangitis, streaks, spider, neck, bite,

The situation involves a possible insect or spider bite with mild symptoms of lymphangitis. While this does require attention and treatment, the plan includes a course of antibiotics and monitoring for worsening symptoms. As of now, there is no indication of severe symptoms like fever or significant pain that would categorize it as high-stakes medical emergency. It is a manageable condition under medical supervision.


Medical Specialty: Consult - History and Phy.
Sample Name: Admission History & Physical - Nausea

CHIEF COMPLAINT: , Nausea.,PRESENT ILLNESS: , The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago.  He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back.  He feels like he was on it but has not done so.  He has overall malaise and a low-grade temperature of 100.3.  He denies any prior similar or lesser symptoms.  His last normal bowel movement was yesterday.  He denies any outright chills or blood per rectum.,PAST MEDICAL HISTORY: , Significant for hypertension and morbid obesity, now resolved.,PAST SURGICAL HISTORY: , Gastric bypass surgery in December 2007.,MEDICATIONS:  ,Multivitamins and calcium.,ALLERGIES: , None known.,FAMILY HISTORY:  ,Positive for diabetes mellitus in his father, who is now deceased.,SOCIAL HISTORY: , He denies tobacco or alcohol.  He has what sounds like a data entry computer job.,REVIEW OF SYSTEMS:  ,Otherwise negative.,PHYSICAL EXAMINATION:,  His temperature is 100.3, blood pressure 129/59, respirations 16, heart rate 84.  He is drowsy, but easily arousable and appropriate with conversation.  He is oriented to person, place, and situation.  He is normocephalic, atraumatic.  His sclerae are anicteric.  His mucous membranes are somewhat tacky.  His neck is supple and symmetric.  His respirations are unlabored and clear.  He has a regular rate and rhythm.  His abdomen is soft.  He has diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding.  He otherwise has no organomegaly, masses, or abdominal hernias evident.  His extremities are symmetrical with no edema.  His posterior tibial pulses are palpable and symmetric.  He is grossly nonfocal neurologically.,STUDIES:,  His white blood cell count is 8.4 with 79 segs.  His hematocrit is 41.  His electrolytes are normal.  His bilirubin is 2.8.  His AST 349, ALT 186, alk-phos 138 and lipase is normal at 239.,ASSESSMENT: , Choledocholithiasis, ? cholecystitis.,PLAN: , He will be admitted and placed on IV antibiotics.  We will get an ultrasound this morning.  He will need his gallbladder out, probably with intraoperative cholangiogram.  Hopefully, the stone will pass this way.  Due to his anatomy, an ERCP would prove quite difficult if not impossible unless laparoscopic assisted.  Dr. X will see him later this morning and discuss the plan further.  The patient understands.
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DESCRIPTION: Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.

consult - history and phy., gastric bypass surgery, nausea, choledocholithiasis, cholecystitis, ercp, gastric bypass, bypass surgery,

The patient exhibits symptoms such as nausea, right upper quadrant pain, and elevated liver enzymes indicating a high likelihood of choledocholithiasis (bile duct stones) and potential cholecystitis, which are serious conditions. The patient needs immediate medical intervention, possibly surgery, and has a complex medical history due to previous gastric bypass surgery that may complicate the treatment. Additionally, the inability to perform a simple ERCP due to anatomical changes means planning a more invasive and potentially riskier procedure. These factors contribute to a high-stakes situation in a medical setting.


Medical Specialty: Consult - History and Phy.
Sample Name: Pediatric Rheumatology Consult

HISTORY:  ,We had the pleasure of seeing the patient today in our Pediatric Rheumatology Clinic.  He was sent here with a chief complaint of joint pain in several joints for few months.  This is a 7-year-old white male who has no history of systemic disease, who until 2 months ago, was doing well and 2 months ago, he started to complain of pain in his fingers, elbows, and neck.  At this moment, this is better and is almost gone, but for several months, he was having pain to the point that he would cry at some point.  He is not a complainer according to his mom and he is a very active kid.  There is no history of previous illness to this or had gastrointestinal problems.  He has problems with allergies, especially seasonal allergies and he takes Claritin for it.  Other than that, he has not had any other problem.  Denies any swelling except for that doctor mentioned swelling on his elbow.  There is no history of rash, no stomach pain, no diarrhea, no fevers, no weight loss, no ulcers in his mouth except for canker sores.  No lymphadenopathy, no eye problems, and no urinary problems.,MEDICATIONS: , His medications consist only of Motrin only as needed and Claritin currently for seasonal allergies and rhinitis.,ALLERGIES: , He has no allergies to any drugs.,BIRTH HISTORY:  ,Pregnancy and delivery with no complications.  He has no history of hospitalizations or surgeries.,FAMILY HISTORY: , Positive for arthritis in his grandmother.  No history of pediatric arthritis.  There is history of psoriasis in his dad.,SOCIAL HISTORY: , He lives with mom, dad, brother, sister, and everybody is healthy.  They live in Easton.  They have 4 dogs, 3 cats, 3 mules and no deer.  At school, he is in second grade and he is doing PE without any limitation.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Temperature is 98.7, pulse is 96, respiratory rate is 24, height is 118.1 cm, weight is 22.1 kg, and blood pressure is 61/44.,GENERAL:  He is alert, active, in no distress, very cooperative.,HEENT:  He has no facial rash.  No lymphadenopathy.  Oral mucosa is clear.  No tonsillitis.  His ear canals are clear and pupils are reactive to light and accommodation.,CHEST:  Clear to auscultation.,HEART:  Regular rhythm and no murmur.,ABDOMEN:  Soft, nontender with no visceromegaly.,MUSCULOSKELETAL:  Shows no limitation in any of his joints or active swelling today.  He has no tenderness either in any of his joints.  Muscle strength is 5/5 in proximal muscles.,LABORATORY DATA:,  Includes an arthritis panel.  It has normal uric acid, sedimentation rate of 2, rheumatoid factor of 6, and antinuclear antibody that is negative and C-reactive protein that is 7.1.  His mother stated that this was done while he was having symptoms.,ASSESSMENT AND PLAN: , This patient may have had reactive arthritis.  He is seen frequently and the patient has family history of psoriatic arthritis or psoriasis.  I do not see any problems at this moment on his laboratories or on his physical examination.  This may have been related to recent episode of viral infection or infection of some sort.  Mother was oriented about the finding and my recommendation is to observe him and if there is any recurrence of the symptoms or persistence of swelling or limitation in any of his joints, I will be glad to see him back.,If you have any question on further assessment and plan, please do no hesitate to contact us.
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DESCRIPTION: A 7-year-old white male started to complain of pain in his fingers, elbows, and neck.  This patient may have had reactive arthritis.

consult - history and phy., rheumatology, pediatric, reactive arthritis, psoriatic arthritis, psoriasis, joints, swelling, arthritis,

The consultation describes a pediatric case with joint pain but no current signs of serious progression or complications. The symptoms have improved significantly, and tests do not indicate severe systemic issues. While the situation involves a young child with potentially distressing symptoms like joint pain that previously caused crying, the absence of serious lab findings and the improvement over time suggest that immediate high-stakes intervention is not necessary. Additionally, the specialist recommends only observation unless symptoms recur. Thus, this remains a manageable scenario with no immediate life-threatening implications.