Medical Specialty: Consult - History and Phy.
Sample Name: Normal Female Exam Template

MULTISYSTEM EXAM,CONSTITUTIONAL: , The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES: , The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT: , The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK: , The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR: , Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,BREASTS:  ,Breast inspection showed them to be symmetrical with no nipple discharge.  Palpation of the breasts and axilla revealed no obvious mass that I could appreciate.,GASTROINTESTINAL:  ,The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU:  ,The external genitalia appeared to be normal.  The pelvic exam revealed no adnexal masses.  The uterus appeared to be normal in size and there was no cervical motion tenderness.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN:,  Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC: , Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC:  ,The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.
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DESCRIPTION: Sample/template for a normal female multisystem exam

The provided text is a template for a normal female multisystem exam. It outlines the steps and observations typically recorded during such an examination when everything is normal. This is a generic, informational template and does not involve making any medical decisions or handling an urgent medical situation. Therefore, it does not represent a high-stakes scenario by itself.


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

Medical Specialty: Surgery
Sample Name: Endoscopy - 2

PREOPERATIVE DIAGNOSIS:,  Melena.,POSTOPERATIVE DIAGNOSIS:,  Solitary erosion over a fold at the GE junction, gastric side.,PREMEDICATIONS: , Versed 5 mg IV.,REPORTED PROCEDURE:,  The Olympus gastroscope was used.  The scope was placed in the upper esophagus under direct visit.  The esophageal mucosa was entirely normal.  There was no evidence of erosions or ulceration.  There was no evidence of varices.  The body and antrum of the stomach were normal.  They pylorus duodenum bulb and descending duodenum are normal.  There was no blood present within the stomach.,The scope was then brought back into the stomach and retroflexed in order to inspect the upper portion of the body of the stomach.  When this was done, a prominent fold was seen lying along side the GE junction along with gastric side and there was a solitary erosion over this fold.  The lesion was not bleeding.  If this fold were in any other location of the stomach, I would consider the fold, but at this location, one would have to consider that this would be an isolated gastric varix.  As such, the erosion may be more significant.  There was no bleeding.  Obviously, no manipulation of the lesion was undertaken.  The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Solitary erosion overlying a prominent fold at the gastroesophageal junction, gastric side – may simply be an erosion or may be an erosion over a varix.,2.  Otherwise unremarkable endoscopy - no evidence of a bleeding lesion of the stomach.,PLAN:,1.  Liver profile today.,2.  Being Nexium 40 mg a day.,3.  Scheduled colonoscopy for next week.
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DESCRIPTION: Melena and solitary erosion over a fold at the GE junction, gastric side.

surgery, ge junction, melena, olympus gastroscope, solitary erosion, descending duodenum, esophageal mucosa, esophagus, gastric side, pylorus duodenum bulb, stomach, liver profile, colonoscopy, ge junction gastric, junction gastric, endoscopy, duodenum, scope, solitary, junction, gastric, erosion,

The medical report describes an endoscopic procedure used to diagnose a solitary erosion over a fold at the gastroesophageal junction. This condition is associated with melena, which indicates gastrointestinal bleeding. Although the immediate findings did not reveal active bleeding or other significant complications, the presence of a solitary erosion over a potentially isolated gastric varix suggests close monitoring is needed. The stakes are moderate since potential complications like bleeding could arise if the condition worsens, particularly if the erosion is over a varix. The plan includes further diagnostics and starting medication, indicating proactive management. Overall, while urgent intervention isn't immediately necessary, the situation requires careful monitoring to prevent future high-risk developments.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Pain Management
Sample Name: Cervical Facet Joint Injection

CERVICAL FACET JOINT INJECTION WITH CONTRAST.,PREPROCEDURE PREPARATION:,  After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form. the patient was placed in the prone position and standard ASA monitors applied.  Intravenous access was established and IV sedation was used.  For further details of IV sedation and infusion, please refer to anesthesia notes.  Fluoroscopy was used to identify the appropriate anatomy and symptomatic facet joints.  The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure.,PROCEDURE DETAILS:,  The patient was laid supine.  Appropriate view of facet joints was achieved by placing pillow below the shoulder and turning the head.  The neck was aseptically prepared.  1% lidocaine was used for local infiltration and subsequently a 25-gauge spinal needle was passed down to the C4-5 facet joint under fluoroscopic control.  Positioning was checked and 0.2 mL of dye was injected.  Acceptable dye pattern was seen.  Subsequent 1 mL of a mixture of 0.5 mL of 1% lidocaine and 0.5 mL of Celestone was injected after aspiration and the patient was monitored.  Needle was removed and same procedure carried out on the other side.  Postprocedure, no complications were noted.
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DESCRIPTION: Cervical facet joint injection with contrast

pain management, injection, 1% lidocaine, asa monitors, cervical, cervical facet joint injection, celestone, facet joint, facet joint injection, fluoroscopy, iv sedation, facet joints, spinal needle, cervical facet joint, joint injection, joint, facetNOTE,: 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.

Cervical facet joint injections are standard medical procedures used for diagnostic and therapeutic purposes. While they involve patient consent, the use of sedation, and precise anatomical targeting, they are generally routine and well-practiced procedures in pain management clinics. The documentation highlights the procedural steps and patient monitoring, indicating a focus on safety and effectiveness. However, they are not typically considered high-stakes because they are common, and complications are rare with proper technique. The stakes would elevate if there were factors like severe patient reactions or atypical anatomy, neither of which is mentioned.


Medical Specialty: Consult - History and Phy.
Sample Name: Records Review - Epicondylitis

ALLOWED CONDITIONS:,  Lateral epicondylitis, right elbow,EMPLOYER:,  ABCD,REQUESTED ALLOWANCE:,  Carpal tunnel syndrome right.,Mr. XXXX is a 41-year-old male employed by ABCD as a car disassembler to make Hurst Limousines injured his right elbow on September 11, 2007, while stripping cars.  He does state he was employed for such company for the last five years.  His work includes lots of pulling, pushing, and working in weird angles.  He does state on the date of injury, he was not doing anything additional.,TREATMENT HISTORY: , Thereafter, he developed shooting pain about the right upper extremity into his hand from his elbow down to the hand.  Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.  He was initially seen by Dr. X on October 18, 2007, at the Occupational Health Facility.  He utilized a tennis elbow brace, but did continue to experience symptomatology into the middle, ring, and small finger.  He was placed on light duty for the next couple of months.  Mr. XXXX suffered another work injury to the right shoulder on October 11, 2007.  He did undergo arthroscopic rotator cuff repair by Dr. Y in December of 2007.  Thereafter, he continued to work in a light duty type of basis for the next few months.,An EMG and nerve conduction study was performed in December of 2008, which demonstrated evidence of carpal tunnel syndrome.  He was able to return to work doing more of a light duty type of position.,The injured worker has also seen Dr. Y once again subsequent to the EMG and nerve conduction study on December 3, 2008.  It was felt that the injured worker would benefit from decompression of the carpal tunnel and an ulnar nerve transposition.  The injured worker subsequently was placed in a no work status thereafter.,At the present time, the injured worker does complain of light tingling into the small, ring, and middle finger.  There are times when the whole hand becomes very numb.  He does not use and do any type of lifting with regards to the right hand secondary to the discomfort.  His pain does vary between a 4 on a scale of 1 to 10.  He denies any weakness.  He does not awaken at night with the symptomatology.  Doing his job is the only causation as related to the carpal tunnel syndrome and the cubital tunnel type symptoms.  He does state that he is right-handed.,In addition, he does note numbness and tingling as related to the left hand.  He has not had any type of EMG and nerve conduction study as related to the left upper extremity.,CURRENT MEDICATIONS: , None.,ALLERGIES:,  Zyrtec.,SURGERIES: , Left shoulder surgery.,SOCIAL HISTORY: , The injured worker denies tobacco or alcohol consumption.,PHYSICAL EXAMINATION:,  Healthy-appearing 41-year-old male, who is 5 feet 8 inches, weighs 205 pounds.  He does not appear to be in distress at this time.,On examination of the right upper extremity, one can appreciate no evidence of swelling, discoloration or ecchymosis.  The range of motion of the right wrist reveals flexion is 50 degrees, dorsiflexion 60 degrees, ulnar deviation 30 degrees, radial deviation 20 degrees.  Tinel's and Phalen's tests were positive.  Reverse Phalen's test was negative.  There is diminished sensation in distribution of the thumb, index, middle, and ring finger.  The intrinsic function did appear to be intact.  The injured worker does not demonstrate any evidence of difficulties as related to extension of the middle, ring, and index finger as related to the elbow.  The range of motion of the right elbow reveals flexion 140 degrees, extension 0 degrees, pronation and supination 80 degrees.  Tinel's test is negative as related to the elbow and the ulnar nerve.,There is noted to be satisfactory strength as related to major motor groups of the right upper extremity.,RECORDS REVIEW:  ,1.  First report of injury, difficulty as related to both hands.,2.  Number of notes of Occupational Health Clinic.  It was felt that the injured worker did indeed suffer from median nerve entrapment at the wrist and ulnar nerve entrapment at the right elbow with the associated right lateral epicondylitis.,3.  December 20, 2007, operative note of Dr. Y.  At which time, the injured worker underwent arthroscopic rotator cuff repair, subacromial decompression, partial synovectomy of the anterior compartment, limited debridement of the partial superior-sided subscapularis tear without evidence of subacromial impingement.,4.  November 17, 2008, EMG and nerve conduction study, which demonstrated moderate right median neuropathy plus carpal tunnel syndrome.,ASSESSMENT: , Please state your opinion for the following questions based upon your review of the enclosed medical records on January 23, 2009, examination of the claimant.,Please indicate whether the restriction given on December 3, 2008, is the result of the allowed condition of lateral epicondylitis.,It should be noted on physical examination that the symptomatology as related to the lateral epicondylitis have very much resolved as of January 23, 2009.  Resisted extension of the middle finger and wrist do not cause any pain about the lateral epicondylar region.  It also should be noted that really there is no significant weakness as related to the function of the right upper extremity.  Also noted is there is an absence of tenderness as related to the lateral epicondylar region.,QUESTION:  ,Has the claimant reached maximum medical improvement for the allowed conditions of lateral epicondylitis? Please explain.,ANSWER:  ,Based upon the examination on January 23, 2009, the injured worker has indeed reached maximum medical improvement as related to the diagnosis of lateral epicondylitis.  This is based upon review of the medical records, evidence-based medicine, and the Official Disability Guidelines.,QUESTION:  ,Please indicate whether the allowed condition of lateral epicondylitis has temporarily and totally disabled the claimant from December 8, 2008 through February 1, 2009, and continuing.  Please explain.,ANSWER:  ,There is insufficient medical evidence and it is my opinion to state that the allowed condition of lateral epicondylitis is not temporarily and totally disabling the claimant from December 8, 2008 through February 1, 2009, and continuing.  As mentioned the symptomatology referable to the lateral epicondylar region has very much resolved based upon the examination performed on January 23, 2009.,QUESTION:  ,If it is your opinion that the claimant is temporarily and totally disabled due to allowed condition of lateral epicondylitis, please indicate what treatment the claimant must undergo in order to achieve a plateau of maximum medical improvement.  Please also give an estimated time for maximum medical improvement.,ANSWER:  ,The injured worker has indeed reached maximum medical improvement as related to the elbow.  There is no question that the injured worker is not temporarily and totally disabled due to the allowed condition of lateral epicondylitis.  At the time of the exam, the injured worker has indeed reached maximum medical improvement as related to lateral epicondylitis as described previously.,QUESTION:  ,Is the claimant suffering from carpal tunnel syndrome, right?
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DESCRIPTION: Records review.  The patient developed shooting pain about the right upper extremity into his hand from his elbow down to the hand.  Any type of rotation and pulling muscle did cause numbness of the middle, ring, and small finger.

The situation described involves a review of medical records to assess the condition and status of a patient suffering from lateral epicondylitis and carpal tunnel syndrome. While medical assessments and treatment decisions are significant in a person's life, in this context, they relate to a routine medical evaluation of an injury, determining whether the condition has reached maximum medical improvement or if it caused temporary or total disability. Such evaluations are typical in occupational health cases, especially those involving workers' compensation claims. While important to the individual's health and employment, the stakes are moderate as there are no immediate life-threatening conditions or critical care situations involved.


Medical Specialty: Surgery
Sample Name: Craniotomy - Retrosigmoid

PREOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,POSTOPERATIVE DIAGNOSIS: , Left acoustic neuroma.,PROCEDURE PERFORMED: , Left retrosigmoid craniotomy and excision of acoustic neuroma.,ANESTHESIA:,  General.,OPERATIVE FINDINGS: , This patient had a 3-cm acoustic neuroma.  The tumor was incompletely excised leaving a remnant of the tumor along the cerebellopontine angle portion of the facial nerve.  The facial nerve was stimulated at the brainstem at 0.05 milliamperes at the conclusion of the dissections.,PROCEDURE IN DETAIL:  ,Following induction of adequate general anesthetic, the patient was positioned for surgery.  She was placed in a lateral position and her head was maintained with Mayfield pins.  The left periauricular area was shaved, prepped, and draped in the sterile fashion.  Transdermal electrodes for continuous facial nerve EMG monitoring were placed, and no response was verified.  The proposed incision was injected with 1% Xylocaine with epinephrine.  Next, T-shaped incision was made approximately 5 cm behind the postauricular crease.  The incision was undermined at the level of temporalis fascia, and the portion of the fascia was harvested for further use.,Incision was made along the inferior aspect of the temporalis muscle and then extended inferiorly over the mastoid tip.  Periosteal elevator was used to elevate periosteum in order to expose the mastoid and anterior aspect of the occipital bone.  Emissary veins posterior to the sigmoid sinus were controlled with electrocautery and bone wax.  Bergen retractors were used to maintain exposure.  Using a cutting bur with continuous suction and irrigation of craniotomy was performed.  The sigmoid sinus was identified anteriorly and the transverse sites were identified superiorly.  From these structures approximately 4 x 4 cm, a window of bone was removed.  Bone shavings were collected during the dissection and placed in Siloxane suspension for later use.  The bone flap was also left at the site for further use.  Dissection was extended along the inferior aspect of the sigmoid sinus to provide additional exposure of the skull base.  Bone wax was used to occlude air cells lateral to the sigmoid sinus.  There was extensively aerated temporal bone.  At this point, Dr. Trask entered the case in order to open the dura and expose the tumor.  The cerebellum was retracted away from the tumor, and the retractor was placed to help maintain exposure.  Once initial exposure was completed, attention was directed to the posterior aspect of the temporal bone.  The dura was excised from around the porous acusticus extending posteriorly along the bone.  Then, using diamond burs, the internal auditory canal was dissected out.  The bone was removed laterally for distance of approximately 8 mm.  There was considerable aeration around the internal auditory canal as well.  The dura was then incised over the internal auditory canal exposing the intracanalicular portion of the tumor.  The tumor extended all the way to the fundus such that initial exposure of the facial nerve around the tumor was difficult.  Therefore, Dr. Trask returned in order to further release the tumor from the brainstem and to debulk the central portions of the tumor.  With dissection, he released the tumor from the trigeminal nerve superiorly and elevated the tumor away from the dorsal brainstem.  The eighth nerve was identified and transected.  Tumor debulking allowed for retraction of the tumor capsule away from the brainstem.  The facial nerve was difficult to identify at the brainstem as well.  It was identified by using an electrical stimulator but dissection attempted at this time was the plane between the nerve and the tumor proximally but this was difficult to achieve.  Attention was then redirected to the internal auditory canal where this portion of the tumor was removed.  The superior and inferior vestibular nerves were evulsed laterally and dissection proceeded along the facial nerve to the porous acusticus.  At this point, plane of dissection was again indistinct.  The tumor had been released from the porous and could be rotated.  The tumor was further debulked and thinned, but could not crucially visualize the nerve on the anterior face of the tumor.  The nerve could be stimulated, but was quite splayed over the anterior face.  Further debulking of the tumor proceeded and additional attempts were made to establish point of dissection along the nerve, both proximally and distally.  However, the cerebellopontine angle portion of the nerve was not usually delineated.  However, the tumor was then thinned using CUSA down to fine sheath measuring only about 1 to 2 mm in thickness.  It was released from the brainstem ventrally.  The tumor was then cauterized with bipolar electrocautery.  The facial nerve was stimulated at the brainstem and stimulated easily at 0.05 milliamperes.  Overall, the remaining tumor volume would be of small percentage of the original volume.  At this point, Dr. Trask re-inspected the posterior fossa to ensure complete hemostasis.  The air cells around the internal auditory canal were packed off with muscle and bone wax.  A piece of fascia was then laid over the bone defect.  Next, the dura was closed with DuraGen and DuraSeal.  The bone flap and bone ***** were then placed in the bone defect.  Postauricular musculature was then reapproximated using interrupted 3-0 Vicryl sutures.  The skin was also closed using interrupted subdermal 3-0 Vicryl sutures.  Running 4-0 nylon suture was placed at the skin levels.  Sterile mastoid dressing was then placed.  The patient tolerated the procedure well and was transported to the PACU in a stable condition.  All counts were correct at the conclusion of the procedure.,ESTIMATED BLOOD LOSS:  ,100 mL.
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DESCRIPTION: Left retrosigmoid craniotomy and excision of acoustic neuroma.

surgery, neuroma, bergen retractors, emissary veins, mayfield pins, acoustic, acoustic neuroma, cerebellopontine, craniotomy, facial nerve, periauricular, retrosigmoid, retrosigmoid craniotomy, internal auditory canal, porous acusticus, sigmoid sinus, auditory canal, bone, brainstem, nerve, postauricular, tumor

The described procedure is a high-stakes situation because it involves brain surgery to remove an acoustic neuroma, which is a type of tumor in close proximity to critical structures such as the facial nerve and brainstem. The complexity of the surgery, the potential complications involved, such as nerve damage, and the high level of skill required to perform the operation without major complications make this a high-stakes situation. Additionally, the procedure involves general anesthesia, which adds another layer of risk.


Medical Specialty: Neurology
Sample Name: Video EEG - 2

IMPRESSION:  ,EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.
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DESCRIPTION: EEG during wakefulness, drowsiness, and sleep with synchronous video monitoring demonstrated no evidence of focal or epileptogenic activity.

neurology, ekg artifact, video monitoring, wakefulness, drowsiness, eegNOTE,: 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 EEG results indicated in both the impression and description show no signs of epileptogenic activity or focal issues. While EEG assessments can be important for diagnosing and managing conditions like epilepsy, the absence of abnormal activity in this case suggests no immediate concerns or diagnosis to follow up on. Therefore, the situation is not high-stakes as no actionable medical intervention is required based on this EEG assessment.


Medical Specialty: Gastroenterology
Sample Name: Hepatobiliary Scan

NUCLEAR MEDICINE HEPATOBILIARY SCAN,REASON FOR EXAM: , Right upper quadrant pain.,COMPARISONS:  ,CT of the abdomen dated 02/13/09 and ultrasound of the abdomen dated 02/13/09.,Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.,FINDINGS:,  Imaging obtained up to 30 minutes after the injection of radiopharmaceutical shows a normal hepatobiliary transfer time.  There is normal accumulation within the gallbladder.,After the injection of 2.1 mcg of intravenous cholecystic _______, the gallbladder ejection fraction at 30 minutes was calculated to be 32% (normal is greater than 35%).  The patient experienced 2/10 pain at 5 minutes after the injection of the radiopharmaceutical and the patient also complained of nausea.,IMPRESSION:,1.  Negative for acute cholecystitis or cystic duct obstruction.,2.  Gallbladder ejection fraction just under the lower limits of normal at 32% that can be seen with very mild chronic cholecystitis.
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DESCRIPTION: Right upper quadrant pain.  Nuclear medicine hepatobiliary scan.  Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.

gastroenterology, radiopharmaceutical, gallbladder ejection fraction, nuclear medicine hepatobiliary, hepatobiliary scan, quadrant, nuclear, technetium, choletec, ejection, fraction, cholecystitis, scan, abdomen, injection, gallbladder, hepatobiliary, medicine

The situation involves a medical scan meant to diagnose issues in the patient's hepatobiliary system, specifically the gallbladder. While the findings indicate some abnormalities, they are not immediately life-threatening and point towards mild chronic cholecystitis. The situation involves some risk, particularly if the condition worsens, but it is not emergent at the moment. Therefore, it is a moderate-stakes situation due to potential implications for the patient's health that might need follow-up or further management.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 4

SUBJECTIVE:,  The patient is in complaining of headaches and dizzy spells, as well as a new little rash on the medial right calf.  She describes her dizziness as both vertigo and lightheadedness.  She does not have a headache at present but has some intermittent headaches, neck pains, and generalized myalgias.  She has noticed a few more bruises on her legs.  No fever or chills with slight cough.  She has had more chest pains but not at present.  She does have a little bit of nausea but no vomiting or diarrhea.  She complains of some left shoulder tenderness and discomfort.  She reports her blood sugar today after lunch was 155.,CURRENT MEDICATIONS:,  She is currently on her nystatin ointment to her lips q.i.d. p.r.n.  She is still using a triamcinolone 0.1% cream t.i.d. to her left wrist rash and her Bactroban ointment t.i.d. p.r.n. to her bug bites on her legs.  Her other meds remain as per the dictation of 07/30/2004 with the exception of her Klonopin dose being 4 mg in a.m. and 6 mg at h.s. instead of what the psychiatrist had recommended which should be 6 mg and 8 mg.,ALLERGIES: , Sulfa, erythromycin, Macrodantin, and tramadol.,OBJECTIVE:,General:  She is a well-developed, well-nourished, obese female in no acute distress.,Vital Signs:  Her age is 55.  Temperature:  98.2.  Blood pressure:  110/70.  Pulse:  72.  Weight:  174 pounds.,HEENT:  Head was normocephalic.  Throat:  Clear.  TMs clear.,Neck:  Supple without adenopathy.,Lungs:  Clear.,Heart:  Regular rate and rhythm without murmur.,Abdomen:  Soft, nontender without hepatosplenomegaly or mass.,Extremities:  Trace of ankle edema but no calf tenderness x 2 in lower extremities is noted.  Her shoulders have full range of motion.  She has minimal tenderness to the left shoulder anteriorly.,Skin:  There is bit of an erythematous rash to the left wrist which seems to be clearing with triamcinolone and her rash around her lips seems to be clearing nicely with her nystatin.,ASSESSMENT:,1.  Headaches.,2.  Dizziness.,3.  Atypical chest pains.,4.  Chronic renal failure.,5.  Type II diabetes.,6.  Myalgias.,7.  Severe anxiety (affect is still quite anxious.),PLAN:,  I strongly encouraged her to increase her Klonopin to what the psychiatrist recommended, which should be 6 mg in the a.m. and 8 mg in the p.m.  I sent her to lab for CPK due to her myalgias and pro-time for monitoring her Coumadin.  Recheck in one week.  I think her dizziness is multifactorial and due to enlarged part of her anxiety.  I do note that she does have a few new bruises on her extremities, which is likely due to her Coumadin.
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DESCRIPTION: The patient is in complaining of headaches and dizzy spells.

soap / chart / progress notes, headaches and dizzy spells, chest pains, shoulder, progress, headaches,

The situation involves a patient with multiple symptoms and health conditions including headaches, dizziness, atypical chest pains, diabetes, and chronic renal failure, among others. While these symptoms could potentially indicate a more serious underlying issue, there is no immediate indication of an acute or life-threatening problem, as the patient is in no acute distress and the chest pain is not present at the time. The medical plan involves medication adjustments and monitoring, which suggests that the practitioner is taking appropriate steps to manage the conditions. Therefore, although it's a serious medical context, it does not appear to be an emergency or an extremely high-stakes situation.


Medical Specialty: Neurology
Sample Name: Neck & Lower Back Pain - Consult

CHIEF COMPLAINT:, Neck and lower back pain.,VEHICULAR TRAUMA HISTORY:, Date of incident: 1/15/2001. The patient was the driver of a small sports utility vehicle and was wearing a seatbelt. The patient’s vehicle was proceeding through an intersection and was struck by another vehicle from the left side and forced off the road into a utility pole. The other vehicle had reportedly been driven by a drunk driver and ran a traffic signal. Estimated impact speed was 80 m.p.h. The driver of the other vehicle was reportedly cited by police. The patient was transiently unconscious and came to the scene. There was immediate onset of headaches, neck and lower back pain. The patient was able to exit the vehicle and was subsequently transported by Rescue Squad to St. Thomas Memorial Hospital, evaluated in the emergency room and released.,NECK AND LOWER BACK PAIN HISTORY:, The patient relates the persistence of pain since the motor vehicle accident. Symptoms began immediately following the MVA. Because of persistent symptoms, the patient subsequently sought chiropractic treatment. Neck pain is described as severe. Neck pain remains localized and is non-radiating. There are no associated paresthesias. Back pain originates in the lumbar region and radiates down both lower extremities. Back pain is characterized as worse than the neck pain. There are no associated paresthesias.
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DESCRIPTION: Patient status post vehicular trauma.  Low Back syndrome and Cervicalgia.

The situation involves a patient experiencing long-term pain issues following a serious vehicular accident where the impact was significant enough for the patient to lose consciousness and experience immediate neck and back pain. The fact that this has persisted for years despite treatment attempts makes it significant because it impacts quality of life and may require ongoing medical evaluation and treatment. However, it is not immediately life-threatening, which keeps it from the highest level of urgency or stakes. In such consults, the stakes are moderate as diagnosis and management are critical for patient quality of life but do not typically imply immediate risk to life.


Medical Specialty: General Medicine
Sample Name: Medical Management Consult Request

CONSULT REQUEST FOR:, Medical management.,The patient has been in special procedures now for over 2 hours and I am unable to examine.,HISTORY OF PRESENT ILLNESS:, Obtained from Dr. A on an 81-year-old white female, who is right handed, who by history, had a large stroke to the right brain, causing left body findings, last night. She was unfortunately outside of the window for emergent treatment and had a negative CT scan of the head. Was started on protocol medication and that is similar to TPA, which is an investigational study.,During the evaluation she was found to be in atrial fibrillation on admission with hypertension that was treated with labetalol en route. Her heart rate was 130. She was brought down with Cardizem. She received the study drug in the night and about an hour later thought to have another large stroke effecting the opposite side of the brain, that the doctors and company think is probably cardioembolic and not related to the study drug, as TPA has no obvious known association with this.,At that time the patient became comatose and required emergent intubation and paralyzation. Her diastolic at that time rose up to 190, likely the result of the acute second stroke. She is currently in arteriogram and a clot has been extracted from the proximal left carotid, but there is still distal clot that they are working on. Dr. A has updated the family to her extremely guarded and critical prognosis.,At present, it is not known yet, we do not have the STAT echocardiogram, if she has a large clot in the heart or if she could have a patent foramen ovale clot in the legs that has been passed to the heart. Echo that is pending, and cannot be done till the patient is out of arteriogram, which is her lifesaving procedure right now.,REVIEW OF SYSTEMS:, Complete review of systems is unobtainable at present. From what I can tell, is that she is scheduled for an upcoming bladder distension surgery and I do not know if this is why she is off Coumadin for chronic AFib or what, at this point. Tremor for 3-4 years, diagnosed as early Parkinson's.,PAST MEDICAL HISTORY:, GERD, hypertension times 20 years, arthritis, Parkinson's, TIA, chronic atrial fibrillation, on Coumadin three years.,PAST SURGICAL HISTORY:, Cholecystectomy, TAH 33, gallstones, back surgery 1998, thoracotomy for unknown reason at present.,ALLERGIES:, MORPHINE, SULFAS (RASH), PROZAC.,MEDICATIONS AT HOME: Lanoxin 0.25 daily; Inderal LA 80 daily; MOBIC 7.5 daily; Robaxin 750 q.8; aspirin 80 one daily; acyclovir dose unknown daily; potassium, dose unknown; oxazepam 15 mg daily; aspirin 80 one daily; ibuprofen PRN; Darvocet-N 100 PRN.,SOCIAL HISTORY:, She does not drink or smoke. Lives in Fayetteville, Tennessee.,FAMILY HISTORY:, Mother died of cancer, unknown type. Dad died of an MI.,VACCINATION STATUS: Unknown.,PHYSICAL EXAMINATION:,VITAL SIGNS: On arrival were temperature 97.1, blood pressure 174/100, heart rate 100, 97%, respirations 15.,GENERAL: She was apparently alert and able to give history on arrival. Currently do not have any available vital signs or physical exam, as I cannot get to the patient.,LABORATORY: ,Reviewed and are remarkable for white count of 13 with 76 neutrophils. BMP is normal, except for a blood sugar of 157, hemoglobin A1c is pending. TSH 2.1, cholesterol 165, Digoxin 1.24, CPK 57. ABG 7.47/32/459 on 100%. Magnesium 1.5. ESR 9, coags normal.,EKG is pending my review.,Chest x-ray is read as mild cardiomegaly and atherosclerotic aorta.,Chest x-ray, shoulder films and CT scan of the head: I have reviewed. Chest x-ray has good ET tube placement. She has mild cardiomegaly. Some mild interstitial opacities consistent with OGD and minimal amount of atherosclerosis of the aorta.,CT scan of the head: I do not see any active bleeding.,X-rays of the shoulders appear intact to me and we are awaiting radiologies final approval on those.,ASSESSMENT/PLAN/PROBLEMS:,1. Large cardioembolic stroke initially to the right brain, with devastating effects, and now stroke into the left brain as well, with fluctuating mental status. Obviously she is in critical condition and stable with multiple strokes. One must also wonder if she could have a large clot burden below the heart and patent foramen ovale, etc. We need STAT records from her prior cardiologist and prior echocardiogram report to see exactly what are the details. I have ordered a STAT echo and to have the group that sees her read it, that if he has a large clot burdened in the heart or has distal clot with a PFO we may be able to better prognosticate at this point. Obviously, she cannot have any anticoagulants, except for the study drug, at present, which is her only chance and hopefully they will be able to retrieve most of the clot with emergency retrieval device as activated heroically, by Dr. A and interventional radiology.,2. Hypertension/atrial fibrillation: This will be a difficult management and the fact that she has been on a beta-blocker for Parkinson's, she may have withdrawal to the beta-blockers as we remove this. Given her atrial fibrillation, I do agree the safest agent right now is to use a Cardizem drip as needed and would use it for systolic greater than 160 to 180, or diastolics greater than 90 to 100. Also, would use it to control the atrial fibrillation. We would, however, be very cautious not to put her in heart block with the Digoxin and the beta-blocker on board. Weighing all risks and benefits, I think that given the fact that she has a beta-blocker on board and Digoxin, we would like to avoid the beta-blocker for vasospasm protection and will favor using calcium channel blocker for now. If, however, we run into trouble with this, I would prefer to switch her to Brevibloc or an Esmolol drip and see how she does, as she may withdraw from the beta-blocker. I will be watching this closely and managing the hypertension as I see fit at the moment, based on all factors. Will also ask cardiology if she has one that sees her here, to help guide this. Her Digoxin level is appropriate, as well as a TSH. I do not feel that we need to work this up further, other than the STAT echo and ultrasound of the leg.,3. Respiratory failure requiring ventilator: I have discussed this with Dr. Devlin, we do not feel the need to hyperventilate her at present. We will keep her comfortable on the breathing machine and try to keep her pH in a normal range, around 7.4, and her CO2 in the 30 to 40 range. If she has brain swelling, we will need to hyperventilate her to a pCO2 of 30 and a pH of 7.5, to optimize the cardiac arrhythmia potential of alkalosis weighed with the control of brain swelling.,4. Optimize electrolytes as you can.,5. Deep vein thrombosis prophylaxis for now, with thigh-high TED hose, possibly SCDs, although I do not have experience with the vampire/venom to know if we need to worry about DIC which the SCDs may worsen. Will follow daily CBCs for that.,6. Nutrition: Will go ahead and start a low dose of tube feeds and hope that she does survive.,I will defer all updates to the family for the next 24 to 48 hours to Dr. Devlin's expertise, given her unknown and fluctuating neurologic prognosis.,Thank you so much for allowing us to participate in her care. We will be happy to do all medication treatment until the point that I feel that I would need any help from critical care. I believe that we will be able to manage her fully at this point, for simplicity sake.
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DESCRIPTION: Patient with Hypertension, atrial fibrillation, large cardioembolic stroke initially to the right brain requesting medical management

The situation involves an elderly patient in critical condition due to multiple large strokes, atrial fibrillation, and significant cardiovascular risk factors. She is undergoing lifesaving procedures and her prognosis is extremely guarded. The patient's care involves complex management decisions regarding medication and treatment approaches, including investigational study drugs, beta-blocker withdrawal, and careful management of respiratory and cardiac functions. Her condition is unstable and requires urgent interventions and close monitoring, making the situation high-stakes due to the immediate risk to the patient's life and the complexity of medical management required.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychological Evaluation

COMPREHENSIVE CLINICAL PSYCHOLOGICAL EVALUATION,CURRENT MEDICATIONS:,  Nexium 4 mg 4 times per day, Propanolol 10 mg 4 times a day, Spironolactone 100 mg 3 times per day, Lactulose 60 cc's 3 times a day.,GENERAL OBSERVATIONS:  ,Mr. Abc, a 54-year-old black married male who was referred for a Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action.  Mr. Abc arrived five minutes late for his scheduled appointment.  He was accompanied to the office by his sister-in-law who drove him to the appt.  Mr. Abc currently does not receive Disability benefits.  This is the first time he has filed for Disability.  The Authorization form listed Mr. Abc's current complaints as "cirrhosis of the liver and mental issues."  Mr. Abc was well groomed and wore casual attire.  He looked older than his stated age.  The whites of his eyes were very jaundiced.  His posture was slightly stooped and his gait was slow.  He was winded after walking up the stairs.  Psychomotor activity was retarded.  Mr. Abc was cooperative throughout the interview.  Although he appeared to be answering most questions to the best of his ability, he appeared to be minimizing his emotional distress.  ,PRESENT ILLNESS: , Most information was provided by Mr. Abc who appeared to be a fairly reliable source.  His information was supplemented by review of his medical records.  Mr. Abc has applied for Federal Disability benefits believing that he qualifies based on his cirrhosis of the liver and his cognitive dysfunction.  Mr. Abc was diagnosed with cirrhosis in 1991.  His condition has worsened to the point that he is experiencing liver failure and is awaiting a liver transplant.  He stated that his main symptom is extreme fatigue.  He has no energy and is unable to engage in many activities.  Over the past year he was admitted to the hospital four times for confusion and bizarre behavior.  He stated that his sister-in-law and his wife told him that he had become violent and he fought with the Sherriff who was trying to take him to the hospital.  He has no memory of this.  Mr. Abc stated that he was hospitalized one time.  Actually he had begun having problems with confusion in July of 2004 and he has been treated four times since that time.  According to his medical records, he was found wandering outside of his home.  He was apparently delusional believing that a tree branch was a doorknob.  Mr. Abc also suffers from edema and swelling in his legs and his feet.  Mr. Abc attempted to return to work and found that he was unable to do his job due to the necessity of walking one-quarter mile from the front to the back of the plant.  He was unable to walk very far without becoming fatigued.  He had instances where he had passed out after becoming faint.  He had trouble at work sitting for very long because his feet swelled.  He was unable to lift the required 10 pounds of medication boxes.  When he found himself unable to do his regular job, he tried another job at the same plant but was unable to do that job.  He also became confused easily at work.  His doctor advised him to quit and then he did so in March of this year.  In addition to his cognitive symptoms, Mr. Abc has had some disturbance in mood as well.  He related that he feels very sad since he lost his job.  A lot of his self-esteem came from working.  He worries about financial problems.  His sleep has been disturbed.  He sleeps four to five hours a night with trouble falling asleep and frequent awakening in the middle of the night.  His appetite is fair.  ,PERSONAL, FAMILY AND SOCIAL HISTORY:,  Mr. Abc completed the 11th grade. He went on to get his GED in 1971.  He stated that he has never failed a grade and he has no history of a learning disability.  He received no special education services.  His grades were Bs and Cs. He stated that he was suspended from school one time for fighting but got along well in general. Mr. Abc is currently unemployed.  His last job was at Baxter Health Care where he worked for four years.  It was his longest place of employment.  He quit in March of 2005 because of fatigue and inability to perform the necessary job duties.  He denies that he was ever fired from a job and he reported good work relationships.  Mr. Abc has been married for two years. He has no prior marriages.  He has one daughter age 13.  He currently lives with his wife. Has been at his current address for four years.  ,HISTORY OF OTHER PERTINENT MEDICAL EVENTS: , Mr. Abc has cirrhosis of the liver, hepatitis C, hepatic encephalopathy, and gastroesophageal reflux disease, and hypertension. Surgeries include a cardiac catheterization in 2001, a liver biopsy in 2003.  Over the past year he has been hospitalized four times due to confusion and bizarre behaviors stemming from his liver failure.  ,DAILY ACTIVITIES AND FUNCTIONING:  ,Mr. Abc stated that he tries to do things but he has been severely restricted due to his extreme fatigue.  He enjoys reading and does it regularly.  He tries to help his wife with the household chores as he can.  He has washed dishes, cooked, mopped, dusted, vacuumed and has done laundry occasionally over the past month but not as much as he used to.  He stated that he used to mow the yard and do yard work but he can no longer do it because of his extreme fatigue.  He has given up driving all together and he no longer goes out alone.  He spends most days at home.  He enjoys going to church and he prays daily.  ,MENTAL HEALTH HISTORY: , Mr. Abc has never been diagnosed or treated for a mental health disorder.  He denied any history of mental health problems in his family.  He stated that he was evaluated one time earlier this year by a psychiatrist to determine his suitability for a liver transplant.  He was approved and he is now on the waiting list to receive a liver.  ,SUBSTANCE USE HISTORY:  ,Mr. Abc has a history of substance use beginning in his teenage years.  He has used alcohol, marijuana and cocaine.  He stated that he only used the marijuana and cocaine a few times when he was young but he continued using alcohol until recently.  His alcohol use became problematic and he was arrested for DWI three times.  He attended AA and the DART program.  Mr. Abc stated that he has been clean for eight years and five months.
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DESCRIPTION: Comprehensive Clinical Psychological Evaluation as part of a Disability Determination action.

This situation involves a comprehensive clinical psychological evaluation for Mr. Abc who is applying for disability benefits. The evaluation is significant due to Mr. Abc's severe medical conditions, including liver cirrhosis leading to liver failure, cognitive dysfunction, and other health problems. These impact his ability to work and function daily. The stakes are high due to the potential impact on Mr. Abc's financial situation, healthcare access, and quality of life if he qualifies for disability benefits. The stakes are further heightened by his urgent need for a liver transplant and his mental and physical health issues.


Medical Specialty: Chiropractic
Sample Name: Chiropractic Initial Evaluation - 2

SUBJECTIVE COMPLAINTS: ,Constant pain in the bilateral regions of the neck increased by forward movement rotating laterally, bending the neck. He also has pain and tightness in his low back increased on the left. His pain level is 7/10. He also states that since the accident, he has experienced tension headaches that began in the suboccipital region referring to the top of his head. He has also experienced anxiety and nervousness.,PHYSICAL EXAMINATION: ,Height is 5'10". Weight is 270 pounds.,Visual Evaluation: The patient has anterior head carriage with rounded shoulders. He does not seem to be in any extreme distress. He has slight antalgic head position to the right.,Dynamometer Testing (grip strength) in pounds: The patient is right hand dominant. Right hand 110, 105, and 98. Left hand 80, 70, and 85.,Neurological: Sensation was normal in the upper and lower extremities. Motor strength +5/5 bilaterally in the upper extremities. Reflexes: Upper extremities +2/2 bilaterally, lower extremities patellar +0/2 bilaterally, and S1 +2/2 bilaterally.,Cervical spine range of motion:,Flexion 50/50 with moderate discomfort on the left.,Extension 50/60 with moderate discomfort on the left.,Right lateral bending 40/45 with moderate discomfort on the left.,Left lateral bending 40/45 with moderate discomfort on the right.,Right rotation 70/80 with moderate pain in the left.,Left rotation 70/80 with moderate pain in the left.,Lumbosacral range of motion:,Flexion 60/60.,Extension 25/25.,Right lateral bending 25/25.,Left lateral bending 25/25 with pain in the left.,Right rotation 30/30 with moderate discomfort in the right.,Left rotation 30/30.,Orthopedic Tests: Axial compression negative with moderate pain bilaterally. Shoulder distraction negative with moderate pain bilaterally. Maigne's test negative bilaterally. Valsalva normal and swallow test normal. Heel walk normal. Toe walk normal. Sitting root normal. SLR normal. Patrick-Faber's normal. Iliac compression caused moderate pain in the left.,RADIOLOGY FINDINGS:, X-rays of the cervical and lumbar will be taken today.,DIAGNOSES:,1.  Cervical spine sprain/strain.,2.  Lumbar spine sprain/strain.,3.  Tension headaches.,CAUSATION:  ,The patient's symptoms appeared to have come on as a result of the motor vehicle accident consistent with the one described in this report. His history, subjective, and objective findings show evidence from a medical viewpoint that his condition is due to the current injury only and no contributing factors are present from preexisting conditions. The patient's condition is a result of a bony/soft tissue injury that has resulted in an undetermined impairment at this time.,PROGNOSIS: ,The likelihood of nearly complete symptomatic relief within 90 days is excellent.  The patient should reach maximum medical improvement in three or four months.,TREATMENT/PLAN: ,After completing an initial examination evaluation, I have selected the plan of treatment that should return this patient to a pre-injury status and minimize the possibility of future residuals. Treatment will consist of chiropractic manipulation, chiropractic physical therapy, and observation, decreasing in frequency as the patient's condition allows. I feel it is too early to determine whether this patient will have any residuals or permanent disability.
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DESCRIPTION: Chiropractic Evaluation for neck and low back pain following a car accident.

The situation described is a chiropractic evaluation following a car accident, which led to neck and low back pain with a pain level of 7/10, as well as tension headaches and anxiety. The patient's condition is not life-threatening, the prognosis is optimistic with expected improvement in 3-4 months, and the patient is not in extreme distress. While it involves a medical evaluation related to an accident, it doesn't indicate an immediate life-threatening situation or severe long-term disability. Therefore, this scenario does not qualify as high-stakes in the context of critical or emergency medical situations.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Bilateral Tubal Occlusion - Laparoscopic

PREOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE PERFORMED: , Laparoscopic bilateral tubal occlusion with Hulka clips.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:  ,None.,FINDINGS: , On bimanual exam, the uterus was found to be anteverted at approximately six weeks in size.  There were no adnexal masses appreciated.  The vulva and perineum appeared normal.  Laparoscopic findings revealed normal appearing uterus, fallopian tubes bilaterally as well as ovaries bilaterally.  There was a functional cyst on the left ovary.  There was filmy adhesion in the left pelvic sidewall.  There were two clear lesions consistent with endometriosis, one was on the right fallopian tube and the other one was in the cul-de-sac.  The uterosacrals and ovarian fossa as well as vesicouterine peritoneum were free of any endometriosis.  The liver was visualized and appeared normal.  The spleen was also visualized.,INDICATIONS: , This patient is a 34-year-old gravida 4, para-4-0-0-4 Caucasian female who desires permanent sterilization.  She recently had a spontaneous vaginal delivery in June and her family planning is complete.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed under general anesthesia.  She was then prepped and draped and placed in the dorsal lithotomy position.  A bimanual exam was performed and the above findings were noted.  Prior to beginning the procedure, her bladder was drained with a red Robinson catheter.  A weighted speculum was placed in the patient's posterior vagina and the 12 o' clock position of the cervix was grasped with a single-toothed tenaculum.  The cervix was dilated so that the uterine elevator could be placed.  Gloves were exchanged and attention was then turned to the anterior abdominal wall where the skin at the umbilicus was everted and using the towel clips, a 1 cm infraumbilical skin incision was made.  The Veress needle was then inserted and using sterile saline ______ the pelvic cavity.  The abdomen was then insufflated with appropriate volume and flow of CO2.  The #11 bladed trocar was then placed and intraabdominal placement was confirmed with the laparoscope.  A second skin incision was made approximately 2 cm above the pubic symphysis and under direct visualization, a 7 mm bladed trocar was placed without difficulty.  Using the Hulka clip applicator, the left fallopian tube was identified, followed out to its fimbriated end and the Hulka clip was then placed snugly against the uterus across the entire diameter of the fallopian tube.  A second Hulka clip was then placed across the entire diameter just proximal to this.  There was good hemostasis at the fallopian tube.  The right fallopian tube was then identified and followed out to its fimbriated end and the Hulka clip was placed. snugly against the uterus across the entire portion of the fallopian tube in a 90 degree angle.  A second Hulka clip was placed just distal to this again across the entire diameter.  Good hemostasis was obtained.  At this point, the abdomen was desufflated and after it was desufflated, the suprapubic port site was visualized and found to be hemostatic.  The laparoscope and remaining trocars were then removed with good visualization of the peritoneum and fascia and the laparoscope was removed.  The umbilical incision was then closed with two interrupted #4-0 undyed Vicryl.  The suprapubic incision was then closed with Steri-Strips.  The uterine elevator was removed and the single-toothed tenaculum site was found to be hemostatic.  The patient tolerated that procedure well.  The sponge, lap, and needle counts were correct x2.  She will follow up postoperatively for followup care.
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DESCRIPTION: Desires permanent sterilization.  Laparoscopic bilateral tubal occlusion with Hulka clips.

obstetrics / gynecology, laparoscopic bilateral tubal occlusion, bilateral tubal occlusion, hulka clips, fallopian tubes, anesthesia, laparoscope, endometriosis, laparoscopic, sterilization, fallopian, tubes, clips,

The procedure described is a laparoscopic bilateral tubal occlusion, a surgical technique for permanent sterilization. While this is a significant decision impacting the patient's reproductive capabilities, the procedure itself is routine and generally considered low-risk with minimal estimated blood loss and no complications reported. The patient has clearly expressed a desire for sterilization, indicating that this aligns with her personal and family planning goals. The operation seems to have been performed successfully without significant issues, suggesting it is not high-stakes in terms of immediate medical risk.


Medical Specialty: Office Notes
Sample Name: Normal Male Exam Template - 1

MALE PHYSICAL EXAMINATION,HEENT:  Pupils equal, round and reactive to light and accommodation.  Extraocular movements are intact.  Sclerae are anicteric.  TMs are clear bilaterally.  Oropharynx is clear without erythema or exudate.,NECK:  Supple without lymphadenopathy or thyromegaly.  Carotids are silent.  There is no jugular venous distention.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm without S3, S4.  No murmurs or rubs are appreciated.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No masses, hepatomegaly or splenomegaly are appreciated.,GU:  Normal **circumcised male.  No discharge or hernias.  No testicular masses.,RECTAL EXAM:  Normal rectal tone.  Prostate is smooth and not enlarged.  Stool is Hemoccult negative.,EXTREMITIES:  Reveal no clubbing, cyanosis, or edema.  Peripheral pulses are +2 and equal bilaterally in all four extremities.,JOINT EXAM:  Reveals no tenosynovitis.,NEUROLOGIC:  Cranial nerves II through XII are grossly intact.  Motor strength is 5/5 and equal in all four extremities.  Deep tendon reflexes are +2/4 and equal bilaterally.  Patient is alert and oriented times 3.,PSYCHIATRIC:  Grossly normal.,DERMATOLOGIC:  No lesions or rashes.
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DESCRIPTION: An example/template for a routine normal male physical exam.

office notes, male exam, physical exam, normal, normal male, physical, male, sclerae, extremities, intact, oropharynx

The situation describes a routine template for a normal male physical exam. This indicates regular, expected findings in a clinical setting. The template serves as a standard reference and does not seem to contain any urgent or high-risk scenarios. The stakes are relatively low as it is not dealing with any immediate critical medical issues or emergencies.


Medical Specialty: Office Notes
Sample Name: Normal Physical Exam Template

GENERAL: , Alert, well developed, in no acute distress.,MENTAL STATUS: , Judgment and insight appropriate for age.  Oriented to time, place and person.  No recent loss of memory.  Affect appropriate for age.,EYES:  ,Pupils are equal and reactive to light.  No hemorrhages or exudates.  Extraocular muscles intact.,EAR, NOSE AND THROAT: , Oropharynx clean, mucous membranes moist.  Ears and nose without masses, lesions or deformities.  Tympanic membranes clear bilaterally.  Trachea midline.  No lymph node swelling or tenderness.,RESPIRATORY:  ,Clear to auscultation and percussion.  No wheezing, rales or rhonchi.,CARDIOVASCULAR: , Heart sounds normal.  No thrills.  Regular rate and rhythm, no murmurs, rubs or gallops.,GASTROINTESTINAL: , Abdomen soft, nondistended.  No pulsatile mass, no flank tenderness or suprapubic tenderness.  No hepatosplenomegaly.,NEUROLOGIC: , Cranial nerves II-XII grossly intact.  No focal neurological deficits.  Deep tendon reflexes +2 bilaterally.  Babinski negative.  Moves all extremities spontaneously.  Sensation intact bilaterally.,SKIN: , No rashes or lesions.  No petechia.  No purpura.  Good turgor.  No edema.,MUSCULOSKELETAL: , No cyanosis or clubbing.  No gross deformities.  Capable of free range of motion without pain or crepitation.  No laxity, instability or dislocation.,BONE: , No misalignment, asymmetry, defect, tenderness or effusion.  Capable of from of joint above and below bone.,MUSCLE:  ,No crepitation, defect, tenderness, masses or swellings.  No loss of muscle tone or strength.,LYMPHATIC:,  Palpation of neck reveals no swelling or tenderness of neck nodes.  Palpation of groin reveals no swelling or tenderness of groin nodes.
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DESCRIPTION: An example of a physical exam

An example of a physical exam

office notes, mental status, ear, nose and throat, abdomen soft, nondistended, cranial nerves ii-xii grossly intact, physical exam,

The text provided is a template for a normal physical exam note, used by medical professionals to document patient examination findings. It is a standard and routine part of medical practice. While accurate documentation is important, it does not present an immediate high-stakes situation by itself as this is typically filled out when a patient is in a stable condition with normal findings. However, inaccuracies in medical documentation could lead to future issues if relied upon for clinical decision making. Thus, while maintaining accuracy is important, the stakes here are moderate and routine in nature.


Medical Specialty: Urology
Sample Name: Flexible Cystoscopy - Atrophic Vaginitis

PREOPERATIVE DIAGNOSIS:,  Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA.,POSTOPERATIVE DIAGNOSIS: , Normal cystoscopy with atrophic vaginitis.,PROCEDURE PERFORMED: , Flexible cystoscopy.,FINDINGS:,  Atrophic vaginitis.,PROCEDURE:  ,The patient was brought in to the procedure suite, prepped and draped in the dorsal lithotomy position.  The patient then had flexible scope placed through the urethral meatus and into the bladder.  Bladder was systematically scanned noting no suspicious areas of erythema, tumor or foreign body.  Significant atrophic vaginitis is noted.,IMPRESSION: , Atrophic vaginitis with overactive bladder with urge incontinence.,PLAN: , The patient will try VESIcare 5 mg with Estrace and follow up in approximately 4 weeks.
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DESCRIPTION: Recurring bladder infections with frequency and urge incontinence, not helped with Detrol LA.  Normal cystoscopy with atrophic vaginitis.

urology, urge incontinence, frequency, overactive bladder, vesicare, flexible cystoscopy, bladder infections, atrophic vaginitis, incontinence, cystoscopy, vaginitis,

The situation involves a medical procedure and a diagnosis related to recurring bladder infections, urge incontinence, and atrophic vaginitis. Although these conditions can affect quality of life, they are not immediately life-threatening. The procedure, flexible cystoscopy, is standard and the findings are not alarming. The plan includes trying new medication and follow-up, which suggests a manageable condition rather than an urgent or critical health crisis.


Medical Specialty: Consult - History and Phy.
Sample Name: Colon Cancer Screening

HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening.  The patient said that he occasionally gets some loose stools.  Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all.  He denies any hypertension, diabetes, or any other problems.  He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea.  Sometimes he gets some loose stools.  Occasionally there is some constipation.  Stools caliber has not changed.  There is no blood in stool or mucus in stool.  No weight loss.  Appetite is good.  No nausea, vomiting, or difficulty in swallowing.  Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3.  Vital signs: Weight is 214 pounds.  Blood pressure is 111/70.  Pulse is 69 per minute.  Respiratory rate is 18.  HEENT: Negative.  Neck: Supple.  There is no thyromegaly.  Cardiovascular: Both heart sounds are heard.  Rhythm is regular.  No murmur.  Lungs: Clear to percussion and auscultation.  Abdomen: Soft and nontender.  No masses felt.  Bowel sounds are heard.  Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy.  I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection.  The patient agreed for it.  We will proceed with it.  I also explained to the patient about conscious sedation.  He agreed for conscious sedation.
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DESCRIPTION: Routine colorectal cancer screening.  He occasionally gets some loose stools.

consult - history and phy., colon cancer screening, loose stools, colorectal, colonoscopy,

The situation involves a routine colon cancer screening for a 53-year-old patient. Screening for colon cancer at this age is standard practice and recommended as part of preventive healthcare. The absence of alarming symptoms or significant family history of colon cancer further reduces the urgency. The procedure, a colonoscopy, while medically significant, is routine and is not considered immediately life-threatening or high-risk under normal circumstances.


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

Medical Specialty: Neurosurgery
Sample Name: Wound Closure & Debridement - Hydrocephalus

TITLE OF OPERATION:,  A complex closure and debridement of wound.,INDICATION FOR SURGERY:,  The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.  There is no evidence of fevers.  CRP was normal.  Shunt CT were all normal.  The thought was he has insidious fistula versus tract where recommendation was for excision of this tract.,PREOP DIAGNOSIS: , Possible cerebrospinal fluid versus wound fistula.,POSTOP DIAGNOSIS: , Possible cerebrospinal fluid versus wound fistula.,PROCEDURE DETAIL: , The patient was brought to the operating room and willing to be inducted with a laryngeal mask airway, positioned supine and the right side was prepped and draped in the usual sterile fashion.  Next, working on the fistula, this was elliptically excised.  Once this was excised, this was followed down to the fistulous tract, which was completely removed.  There was no CSF drainage.  The catheter was visualized, although not adequately properly.  Once this was excised, it was irrigated and then closed in multiple layers using 3-0 Vicryl for the deep layers and 4-0 Caprosyn and Indermil with a dry sterile dressing applied.  The patient was reversed, extubated and transferred to the recovery room in stable condition.  Multiple cultures were sent as well as the tracts sent to Pathology.  All sponge and needle counts were correct.
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DESCRIPTION: A complex closure and debridement of wound.  The patient is a 26-year-old female with a long history of shunt and hydrocephalus presenting with a draining wound in the right upper quadrant, just below the costal margin that was lanced by General Surgery and resolved; however, it continued to drain.

neurosurgery, debridement of wound, shunt, costal margin, cerebrospinal fluid, cerebrospinal, closure, debridement, hydrocephalus, surgery, draining, fistula, wound,

The situation described involves neurosurgery for a patient with hydrocephalus and a history of shunt use. The surgery addresses a potentially insidious fistulous tract and involves excision and closure of this tract. Given the complexities of managing patients with hydrocephalus and the potential complications associated with cerebrospinal fluid leaks or infections, this surgical procedure could greatly impact the patient's health outcomes if not performed correctly. Thus, it involves high-stakes decision-making and precision in execution.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Myoview Perfusion Scan

INDICATIONS:,  Previously markedly abnormal dobutamine Myoview stress test and gated scan.,PROCEDURE DONE:,  Resting Myoview perfusion scan and gated myocardial scan.,MYOCARDIAL PERFUSION IMAGING:,  Resting myocardial perfusion SPECT imaging and gated scan were carried out with 32.6 mCi of Tc-99m Myoview.  Rest study was done and compared to previous dobutamine Myoview stress test done on Month DD, YYYY.  The lung heart ratio is 0.34.  There appears to be a moderate size inferoapical perfusion defect of moderate degree.  The gated myocardial scan revealed mild apical and distal inferoseptal hypokinesis with ejection fraction of 55%.,CONCLUSIONS:,  Study done at rest only revealed findings consistent with an inferior non-transmural scar of moderate size and moderate degree.  The left ventricular systolic function is markedly improved with much better regional wall motion of all left ventricular segments when compared to previous study done on Month DD, YYYY.  We cannot assess the presence of any reversible perfusion defects because no stress imaging was performed.
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DESCRIPTION: Resting Myoview perfusion scan and gated myocardial scan.  Findings consistent with an inferior non-transmural scar

cardiovascular / pulmonary, myoview perfusion scan, rest study, spect imaging, dobutamine myoview stress test, ejection fraction, gated myocardial scan, hypokinesis, ventricular systolic function, resting myoview perfusion scan, myoview stress test, resting myoview, myocardial perfusion, myoview perfusion, perfusion scan, myocardial scan, myocardial, myoview, perfusion

The Myoview Perfusion Scan provides important information about a patient's cardiac status, particularly involving potential perfusion defects and ventricular function. Although the scan shows an improved ventricular function and no stress testing was performed to identify reversible ischemia, the finding of a scar and hypokinesis implies some level of previous cardiac event or condition. This makes it important in a medical context, as it can impact treatment decisions for cardiovascular health. However, it does not indicate an immediate life-threatening situation at this time, given that it describes stable features and improvement in some aspects.


Medical Specialty: ENT - Otolaryngology
Sample Name: Chronic Otitis Media

CHIEF COMPLAINT:,  Chronic otitis media.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth.  There is also associated chronic nasal congestion.  There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection.  He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia.,ALLERGIES:,  None.,MEDICATIONS:,  None.,FAMILY HISTORY:,  Noncontributory.,MEDICAL HISTORY: , Mild reflux.,PREVIOUS SURGERIES:,  None.,SOCIAL HISTORY: , The patient is not in daycare.  There are no pets in the home.  There is no secondhand tobacco exposure.,PHYSICAL EXAMINATION: , Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present.  Left ear is still little bit black.  Nose, moderate inferior turbinate hypertrophy.  No polyps or purulence.  Oral cavity, oropharynx 2+ tonsils.  No exudates.  Neck, no nodes, masses or thyromegaly.  Lungs are clear to A&P.  Cardiac exam, regular rate and rhythm.  No murmurs.  Abdomen is soft and nontender.  Positive bowel sounds.,IMPRESSION: , Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation.,PLAN:,  The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia.
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DESCRIPTION: A 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth.

ent - otolaryngology, chronic nasal congestion, tympanic membrane perforation, chronic otitis media, tube insertion, facemask anesthesia, otitis media, otitis, media,

The case involves a young child with a history of chronic otitis media, which can cause significant medical issues if not adequately treated, such as hearing loss and speech development problems. Although there is an operative intervention planned, it is a relatively common procedure (myringotomy with tube insertion) and done under general anesthesia, which carries some risk especially in young children. However, given that the child is scheduled for a controlled procedure in a medical setting, the immediate situation is not life-threatening but does require timely medical intervention to improve quality of life and prevent further complications.


Medical Specialty: Surgery
Sample Name: Debridement - Shoulder

TITLE OF OPERATION:  ,1.  Incision and drainage with extensive debridement, left shoulder.,2.  Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).,3.  Implantation of antibiotic beads, left shoulder.,INDICATION FOR SURGERY: , The patient was seen multiple times preoperatively and found to have findings consistent with a chronic and indolent infections.  Risks and benefits have been discussed with him and his family at length including but not exclusive of continued infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, fractures, loss of bone, medical complications, surgical complications, transfusion related complications, etc.  The patient understood and wished to proceed.,PREOP DIAGNOSIS: , Presumed infection, left total shoulder arthroplasty.,POSTOP DIAGNOSES:  ,1.  Deep extensive infection, left total shoulder arthroplasty.,2.  Biceps tenosynovitis.,3.  Massive rotator cuff tear in left shoulder (full thickness subscapularis tendon rupture 3 cm x 4 cm; supraspinatus tendon rupture 3 cm x 3 cm; infraspinatus tear 2 cm x 2 cm).,DESCRIPTION OF PROCEDURE:  ,The patient was anesthetized in the supine position, a Foley catheter was placed in his bladder.  He was then placed Beach chair position and all bony prominences were well padded.  Pillows were placed around his knees to protect his sciatic nerve.  He was brought to the side of the table and secured with towels and tape.  The head was placed in neutral position with no lateral bending or extension to protect the brachioplexus from any stretch.  Left upper extremity was then prepped and draped in usual sterile fashion.  Unfortunately, preoperative antibiotics were given prior to the procedure.  This occurred due to lack of communication between the surgical staff and the anesthesia staff.  The patient's extremity, however, was prepped a second time with a chlorhexidine prep after he had been draped.  Also, Ioban bandages were placed securely to the skin to prevent any further introduction of infection into his shoulder.,Deltopectoral incision was then made.  The patient's had a cephalic vein, it was identified and protected throughout the case.  It was retracted laterally and once this has been completed, the deltopectoral interval was developed as carefully as possible.  The patient did have significant scar from this point on and did bleed from many surfaces throughout the case.  As a result, he was transfused 1 unit postoperatively.  He did not have any problems during the case except for one small drop of blood pressure.  However this was due primarily because of the extensive scarring of his proximal humerus.  He had scar between the anterior capsular structures and the conjoint tendon.  Also there was significant scar between the deltoid and the proximal humerus.  The deltoid was very carefully and tediously removed from the proximal humerus in order not to damage the axillary nerve.  Once the plane between the deltoid and underlying tissue was found, the proximal humerus was discovered to have a large defect, approximately 4 x 3.  This was covered by rimmed fibrous tissue which was fairly compressible, which felt to be purulent, however, when the needle was stuck into this area, there was no return of fluid.  As a result, this was finally opened and found to have fibrinous exudates which appeared to be old congealed, purulent material.  There was some suggestion of a synovitis type reaction also inside this cystic area.  This was all debrided but was found to track all the way into the proximal humerus from the lateral femoral component and also tracked posteriorly through and around the posterior cortex of the proximal humerus indicating that the infraspinatus probably had some tearing and detachment.  This later proved to be the case and infraspinatus did indeed have a tear 2 cm x 2 cm.  All of the mucinous material and fibrinous material was removed from the proximal humerus.  This was fairly extensive debridement.  All of this was sent to pathology and also sent for culture and sensitivity.  It should be noted that Gram stain became as multiple white blood cells but no organism seen.  The pathology came back as fibrinous material with multiple white cells, also with signs of chronic inflammation consistent with an infection.,Attention was then directed towards the anterior structures to gain access to the joint so that we could dislocate the prosthesis and remove it.  There was also cystic area in the anterior aspect of the shoulder which was fairly fibrinous.  This was also removed.  Once this was removed, though the capsule was found to be very thin, there was essentially no subscapularis tendon whatsoever.  It should also noted the patient's proximal humerus was subluxed superiorly so that there was no supraspinatus tendon present whatsoever.  As a result, the biceps tendon was finally identified just below the pectoralis tendon insertion.  The upper 1 or 2 cm of the pectoralis insertion was released in order to find the biceps.  It was tracked proximally and transverse ligament released.  The biceps tendon was flat and somewhat erythematous.  As a result, it released and tagged with an 0 Vicryl suture.  It was later tenodesed to the conjoint tendon using 2-0 Prolene sutures.  The joint was then entered and noted significant synovitis throughout the entire glenoid.  This was all very carefully removed using a rongeur and sharp dissection.,Next, the humeral component was removed and this was done by attempting to remove it with the slap hammer and device which comes with the Biomet set.  Unfortunately, this device would not hold the proximal humerus and we could not get the component to release.  As a result, bone contact of the metal proximally was released using a straight osteotome.  Once this was completed, another attempt was made to remove the prosthesis but this only resulted in fracture of the proximal humerus through the areas of erosion of the infection and once this has been completed, we abandoned use of that particular device and using a __________ , we were able to hit the prosthesis lip from beneath and essentially remove it.  There was no cement.  There was exudate within the canal which was removed using a curette.,Using fluoroscopy, sequential reamers were placed to a size of 11 distally down the shaft to remove the exudate.  This was also thoroughly irrigated with irrigation antibiotic, and impregnated irrigation to decrease any risk of infection.  It should be noted that the reaming was done fluoroscopically to make sure that there was no penetration of the canal at any point.,The attention was then directed to the glenoid.  The glenoid component was very carefully dissected free and found to be very loose.  It was essentially removed with digital dissection.  There was no remaining cement in the cavity itself.  The patient's glenoid was very carefully debrided.  The glenoid itself was found to be very cup shaped with significant amount of bone loss in the central portion of the canal itself.  This was debrided using rongeurs and curette until there was no purulent exudate present anywhere in the glenoid itself.,Next, the entire wound was irrigated thoroughly with 9 liters of antibiotic impregnated irrigation.  Rather than place a spacer, it was elected to use antiobiotic beads.  This was with antibiotic impregnated cement with one package with 3 gram of vancomycin.  These beads were then connected using Prolene and placed into the glenoid cavity itself, also some were placed in the greater tuberosity region.  These three did not have a Prolene attached to them.  The ones placed down the canal did have a Prolene used as did the ones placed in the cavity of the glenoid itself.,The biceps tendon was then tenodesed under tension to the conjoint tendon.  There was essentially no capsule left purely to close over the proximal humerus.  It was electively the proximal humerus.  A portion of bone intact because it did have some bleeding surfaces.  Deltopectoral was then closed with 0-Vicryl sutures, the deep subcutaneous tissues with 0-Vicryl sutures, superficial subcutaneous tissues with 2-0 Vicryl sutures.  Skin was closed with staples.  A sterile bandage was applied along with a cold therapy device and shoulder immobilizer.  The patient was sent to recovery room in stable and satisfactory condition.,It should be noted that __________ is being requested for this case.  This was a significantly scarred patient which required extra dissection and attention.  Even though this was a standard revision case due to infection, there was a significant more decision making and technical challenges in this case and this was present for typical revision case.  Similarly, this case took approximately 30 to 40% more length of time due to bleeding and the attention to hemostasis.  The blood loss and operative findings indicates that this case was at least 30 to 40% more challenging than a standard total shoulder or revision case.  This is being dictated for insurance purposes only and reflects no inherent difficulties with the case whatsoever.
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DESCRIPTION: Incision and drainage with extensive debridement, left shoulder.  Removal total shoulder arthroplasty (uncemented humeral Biomet component; cemented glenoid component).  Implantation of antibiotic beads, left shoulder.

surgery, incision and drainage, shoulder arthroplasty, extensive debridement, uncemented humeral, biomet, cemented, antibiotic beads, biceps tenosynovitis, rotator cuff tear, total shoulder arthroplasty, proximal humerus, vicryl sutures, glenoid, tendon, proximal, humerus, beads, shoulder, incision,

The surgical situation described here involves a complex shoulder surgery addressing a deep infection, rotator cuff tears, and removal of previous shoulder arthroplasty components. The procedure involves significant risks such as potential for ongoing infection, blood loss, damage to nerves or arteries, and complex repair work given the patient's significant scar tissue from previous surgeries. The stakes are high due to the potential for severe complications if the surgery does not go as planned, impacting the patient's mobility and quality of life. Furthermore, the technical difficulty and time requirement exceeding typical revision surgery underscore the significance.


Medical Specialty: Gastroenterology
Sample Name: Colon Cancer Screening

HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening.  The patient said that he occasionally gets some loose stools.  Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all.  He denies any hypertension, diabetes, or any other problems.  He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea.  Sometimes he gets some loose stools.  Occasionally there is some constipation.  Stools caliber has not changed.  There is no blood in stool or mucus in stool.  No weight loss.  Appetite is good.  No nausea, vomiting, or difficulty in swallowing.  Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3.  Vital signs: Weight is 214 pounds.  Blood pressure is 111/70.  Pulse is 69 per minute.  Respiratory rate is 18.  HEENT: Negative.  Neck: Supple.  There is no thyromegaly.  Cardiovascular: Both heart sounds are heard.  Rhythm is regular.  No murmur.  Lungs: Clear to percussion and auscultation.  Abdomen: Soft and nontender.  No masses felt.  Bowel sounds are heard.  Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy.  I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection.  The patient agreed for it.  We will proceed with it.  I also explained to the patient about conscious sedation.  He agreed for conscious sedation.
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DESCRIPTION: Routine colorectal cancer screening.  He occasionally gets some loose stools.

gastroenterology, colon cancer screening, loose stools, colorectal, colonoscopy,

The scenario describes a routine procedure for colorectal cancer screening, which is often recommended for individuals over 50 years old. The patient has no major medical complaints and no family history of colon cancer. The described screening and procedure (colonoscopy) are standard preventive measures. While the patient has loose stools occasionally, this is not unusual and doesn't suggest an immediate risk. The stakes are relatively low as this is a preventative measure, and there are no signs of acute or severe issues.


Medical Specialty: Surgery
Sample Name: Nasolabial Fold Elevation

PREOPERATIVE DIAGNOSIS:,  Left nasolabial fold scar deformity with effacement of alar crease.,POSTOPERATIVE DIAGNOSIS:,  Left nasolabial fold scar deformity with effacement of alar crease.,PROCEDURES PERFORMED:,1.  Left midface elevation with nasolabial fold elevation.,2.  Left nasolabial fold z-plasty and right symmetrization midface elevation.,ANESTHESIA: , General endotracheal intubation.,ESTIMATED BLOOD LOSS: , Less than 25 mL.,FLUIDS: , Crystalloid,CULTURES TAKEN: , None.,PATIENT'S CONDITION: , Stable.,IMPLANTS: , Coapt Endotine Midface B 4.5 bioabsorbable implants, reference #CFD0200197, lot #01447 used on the right and used on the left side.,IDENTIFICATION: , This patient is well known to the Stanford Plastic Surgery Service.  The patient is status post resection of the dorsal nasal sidewall skin cancer with nasolabial flap reconstruction with subsequent deformity.  In particular, the patient has had effacement of his alar crease with deepening of his nasolabial fold and notable asymmetry.  The patient was seen in consultation and felt to be a surgical candidate for improvement.  Risks and benefits of the operation were described to the patient in detail including, but not limited to bleeding, infection, scarring, possible damage to surrounding structures including neurovascular structures, need for revision of surgery, continued asymmetry, and anesthetic complication.  The patient understood these risks and benefits and consented to the operation.,PROCEDURE IN DETAIL: , The patient was taken to OR and placed supine on the operating table.  Dose of antibiotics was given to the patient.  Compression devices were placed on the lower extremities to prevent the knee embolic events.  The patient was turned to 180 degrees.  The ETT tube was secured and the area was then prepped and draped in usual sterile fashion.  A head wrap was then placed on the position and we then began our local.  Of note, the patient had previous incisions just lateral to his lateral canthus bilaterally and that were used for access.  Local consisting a 50:50 mix of 0.25% Marcaine with epinephrine and 1% lidocaine with epinephrine was then injected into the subperiosteal plane taking care to prevent injury to the infraorbital nerves.  This was done bilaterally.  We then marked the nasolabial fold and began with the elevation of the left midface.,We began with a lateral canthal-type incision extending out over his previous incision down to subcutaneous tissue.  We continued down to the lateral orbital rim until we identified periosteum.  We then pulled in a periosteal elevator and elevated the midface down over the zygoma elevating some lateral mesenteric attachments down over the buccal region until we felt we had reached pass the nasolabial folds medially.  Care was taken to preserve the infraorbital nerve and that was visualized after elevation.  We then released the periosteum distally and retracted up on the periosteum and noted improved contour of the nasolabial fold with increased bulk over the midface region over the zygoma.,We then used our Endotine Coapt device to engage the periosteum at the desired location and then elevated the midface and secured into position using the Coapt bioabsorbable screw.  After this was then carried out, we then clipped and cut as well as the end of the screw.  Satisfied with this, we then elevated the periosteum and secured it to reinforce our midface elevation to the lateral orbital rim and this was done using 3-0 Monocryl.  Several sutures were then used to anchor the orbicularis and deeper tissue to create additional symmetry.  Excess skin along the incision was then removed as well the skin from just lateral to the canthus.  Care was taken to leave the orbicularis muscle down.  We then continued closing our incision using absorbable plain gut 5-0 sutures for the subciliary-type incision and then continuing with interrupted 6-0 Prolenes lateral to the canthus.,We then turned our attention to performing the z-plasty portion of the case.  A z-plasty was designed along the previous scar where it was padding to the notable scar deformity and effacement of crease and the z-plasty was then designed to lengthen along the scar to improve the contour.  This was carried out using a 15 blade down to subcutaneous tissue.  The flaps were debulked slightly to reduce the amount of fullness and then transposed and sutured into place using chromic suture.  At this point, we then noted that he had improvement of the nasal fold but continued asymmetry with regards to improved bulk on the left side and less bulk on the right and it was felt that a symmetrization procedure was required to make more symmetry with the midface bilaterally and nasolabial folds bilaterally.  As such, we then carried out the dissection after injecting local as noted and we used a 15 blade scalpel to create our incision along the lateral canthus along its preexisting incision.  We carried this down to the lateral orbital rim again elevating the periosteum taking care to preserve infraorbital nerve.,At this point, we then released the periosteum distally just at the level of the nasolabial fold and placed our Endotine midface implant into the desired area and then elevated slightly just for symmetry only.  This was then secured in place using the bioabsorbable screw and then resected a very marginal amount of tissue just for removal of the dog ear deformity and closed the deeper layers of tissue using 3-0 PDS and then closing the extension to the subciliary area using 5-0 plain gut and then 6-0 Prolene lateral to the canthus.,At this point, we felt that we had achieved improved contour, improved symmetry, and decreased effacement of the nasolabial fold and alar crease.  Satisfied with our procedures, we then placed cool compresses on to the eyes.,The patient was then extubated and brought to the PACU in stable condition.,Dr. X was present and scrubbed for the entire case and actively participated during all key elements.  Dr. Y was available and participated in the portions of the case as well.
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DESCRIPTION: Left midface elevation with nasolabial fold elevation and nasolabial fold z-plasty and right symmetrization midface elevation.

The procedure involves cosmetic surgery for correcting facial deformities due to a previous nasolabial flap reconstruction. While surgery always carries some inherent risk, including potential for infection, scarring, and anesthesia complications, the stakes associated with this particular surgery seem to be relatively low from a life-threatening standpoint. The estimated blood loss is minimal, and the patient's condition was stable both pre- and post-operation. The primary goals appear to be aesthetic, aiming to improve symmetry and contour. Therefore, the situation does not involve immediately life-threatening conditions or complex emergency interventions.


Medical Specialty: Surgery
Sample Name: Phacoemulsification & Lens Implantation - 7

TITLE OF OPERATION: , Phacoemulsification with posterior chamber intraocular lens implant in the right eye.,INDICATION FOR SURGERY: , The patient is a 27-year-old male who sustained an open globe injury as a child.  He subsequently developed a retinal detachment in 2005 and now has silicone oil in the anterior chamber of the right eye as well as a dense cataract.  He is undergoing silicone oil removal as well as concurrent cataract extraction with lens implant in the right eye.,PREOP DIAGNOSIS:,1.  History of open globe to the right eye.,2.  History of retinal detachment status post repair in the right eye.,3.  Silicone oil in anterior chamber.,4.  Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,POSTOP DIAGNOSIS:,1.  History of open globe to the right eye.,2.  History of retinal detachment status post repair in the right eye.,3.  Silicone oil in anterior chamber.,4.  Dense silicone oil cataract in the right eye obscuring the view of the posterior pole.,ANESTHESIA: , General.,PROS DEV IMPLANT: , ABC Laboratories posterior chamber intraocular lens, 21.0 diopters, serial number 123456.,NARRATIVE: , Informed consent was obtained.  All questions were answered.  The patient was brought to preoperative holding area where the operative right eye was marked.  He was brought to the operating room and placed in the supine position.  EKG leads were placed.  General anesthesia was induced by the anesthesia service.  A time-out was called to confirm the procedure and operative eye.  The right operative eye was disinfected and draped in a standard fashion for eye surgery.  A lid speculum was placed.  The vitreoretinal team placed the infusion cannula after performing a peritomy.  At this point in the case, the patient was turned over to the cornea service with Mrs. Jun.  A paracentesis was made at the approximately 3 o'clock position.  Healon was placed into the anterior chamber.  The diamond keratome was used to make a vertical groove incision just inside the limbus at the 108-degree axis.  This incision was then shelved anteriorly and used to enter the anterior chamber.  The Utrata forceps were used to complete a continuous circular capsulorrhexis after incision of the capsule with the cystotome.  Hydrodissection was performed.  The lens nucleus was removed using phacoemulsification and irrigation and aspiration.  Lens cortex also was removed using irrigation and aspiration.  Viscoelastic was placed to inflate the capsular remnant.  The diamond knife was used to enlarge the phaco incision.  Intraocular lens was selected from preoperative calculations, placed in the injector system, and inserted into the capsule without difficulty.  The trailing haptic was placed using the Sheets forceps and the Barraquer sweep to push the IOL optic posteriorly as the trailing haptic was placed.  The anterior cornea wound was sutured along with the paracentesis after irrigation and aspiration was performed to remove remaining viscoelastic from the anterior chamber.  This was done without difficulty.  The anterior chamber was secured and watertight at the end of the procedure.  Intraocular pressure was satisfactory.  The patient tolerated the procedure well and then was turned over to the retina service in good condition.  They will dictate a separate note.
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DESCRIPTION: Phacoemulsification with posterior chamber intraocular lens implant in the right eye.

surgery, phacoemulsification, intraocular lens implant, posterior chamber, chamber, eye, intraocular, lens,

The situation involves a surgical procedure related to the eye, specifically phacoemulsification and lens implantation following an open globe injury, previous retinal detachment, and the presence of a dense cataract. While eye surgeries typically have a high degree of precision involved and certain risks, this procedure seems to be a planned operation with informed consent obtained and performed under general anesthesia. It involves coordination between different medical teams, indicating complexity. The stakes are significant since complications could impact the patient's vision. However, based on the detailed planning and standard procedural steps described, the surgery itself doesn't appear to be extraordinarily high-stakes compared to other surgeries. The risks are relatively controlled in a planned surgical environment.