Medical Specialty: Dentistry
Sample Name: I&D - Buccal Space Abscess

PREOPERATIVE DIAGNOSES,1.  Right buccal space abscess/cellulitis.,2.  Nonrestorable caries teeth #1, #29, and #32.,POSTOPERATIVE DIAGNOSES,1.  Right buccal space abscess/cellulitis.,2.  Nonrestorable caries teeth #1, #29, and #32.,PROCEDURE,1.  Incision and drainage of right buccal space abscess.,2.  Extraction of teeth #1, #29, and #32.,ANESTHESIA,GETA,EBL,20 mL.,IV FLUIDS,900 mL.,URINE OUTPUT,Not measured.,COMPLICATIONS,None.,SPECIMENS,1.  Aerobic culture was sent from the right buccal space abscess/cellulitis.,2.  Anaerobic culture from the same space was also obtained.,PROCEDURE IN DETAIL,The patient was identified in the appropriate holding area and transported to #13.  The patient was intubated by anesthesia orotracheally using a #7 ET tube.  The patient was induced in effective sleep using a propofol and gas inhalation anesthetics.  Following intubation, the patient's mouth was cleaned with chlorhexidine and a toothbrush following placement of a throat pack.  At that point, approximately 5 mL of 2% lidocaine with 1:20,000 epinephrine was injected for a right inferior alveolar block, as well as local infiltration in the right long buccal nerve area as well as the right cheek area.  Local infiltration also was done near the tooth #32.  At this point, a periosteal elevator was used to loosen up the gingival tissue of the teeth #1, #29, and #32; and all 3 teeth were extracted using simple extraction, using elevators and forceps.  In addition, the previous Penrose drain was removed by removing the suture, and the incision that was used for I&D on the previous day was extended laterally.  A hemostat was used to puncture through to the right buccal space.  Approximately, 2.5 to 3 mL of purulence was drained, and that was used for Gram stain and culture, as mentioned above.  Following copious irrigation of the area, following the extraction and following the incision and drainage, 2 quarter-inch Penrose drains were placed in the anterior as well as the posterior section of the incision into the buccal space.  At this point copious irrigation was done again, the throat pack was removed, and the procedure was ended.  Note that the patient was extubated without incident.  Dr. B was present for all critical aspects of patient care.
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DESCRIPTION: Incision and drainage of right buccal space abscess and teeth extraction.

dentistry, abscess, #7 et tube, aerobic culture, anaerobic culture, extraction of teeth, geta, alveolar block, buccal space, caries, cellulitis, copious irrigation, extraction, teeth, nonrestorable caries teeth, buccal space abscess, nonrestorable caries, caries teeth, throat pack, buccal,

The situation involves an incision and drainage of a buccal space abscess along with the extraction of nonrestorable teeth under general anesthesia. While the procedure is routine in oral surgery, it carries potential risks like infection, airway obstruction, and potential complications from anesthesia. The buccal space abscess can be serious if not treated promptly because it may lead to further complications, especially if it affects breathing or spreads. The detailed nature of the procedure and the lack of complications suggest proper management, indicating a medium-stakes scenario that requires attention but is not an emergency. Hence, while it is important, it's not extremely high-stakes compared to other medical emergencies.


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

Medical Specialty: Dentistry
Sample Name: Carious Teeth Extraction

PREOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth.,POSTOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32.,PROCEDURE: , Extraction of remaining teeth numbers 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and 32.,ANESTHESIA:,  General, oral endotracheal.,COMPLICATIONS: , None.,CONDITION:,  Stable to PACU.,PROCEDURE:  Patient was brought to the operating room, placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia, the patient was prepped and draped in the usual fashion for an intraoral procedure.  Gauze throat pack was placed and local anesthetic was administered in the upper and lower left quadrants and extraction of teeth was begun on the upper left quadrant teeth numbers 9, 10, 11, 12, 13, 14, 15, and 16 were removed with elevators and forceps extraction.  Moving to the lower quadrant on the left side, tooth numbers 17, 18, 19, 20, 21, 22, 23, and 24 were removed with elevators and routine forceps extraction.  The flaps were then closed with 3-0 gut sutures and upon completion of the two quadrants on the left side, the endotracheal tube was then relocated from the right side to the left side for access to the quadrants on the right.  Teeth numbers 2, 3, 4, 5, 7, and 8 were then removed with elevators and routine forceps extraction.  It was noted that tooth #6 was missing, could not be seen whether tooth #6 was palately impacted, but the tooth was not encountered.  On the lower right quadrant, teeth numbers 25, 26, 27, 28, 29, 30, and 31 were removed with elevators and routine forceps extraction.  Tooth #32 was partially bony impacted, but exposed, so it was removed by removing bone on buccal aspect with high-speed drill with a round bur.  Tooth was then luxated from the socket.  The flaps were then closed on both quadrants with 3-0 gut sutures.  The area was irrigated thoroughly with normal saline solution and a total of 8.5 mL of lidocaine 2% with 1:100, 000 epinephrine and 3.6 mL of bupivacaine 0.5% with epinephrine 1:200, 000.  Upon completion of the procedure, the throat pack was removed.  The pharynx was suctioned.  An oral gastric tube was passed and small amount of stomach contents were suctioned.  The patient was then extubated and taken to PACU in stable condition.
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DESCRIPTION: Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32. Extraction of teeth.

dentistry, intraoral procedure, partial bony impacted tooth, teeth extraction, forceps extraction, periodontal disease, carious teeth, periodontal, carious

The procedure described involves the extraction of all remaining teeth due to severe dental issues including carious teeth and periodontal disease. While extractions are common in dentistry, the extent of this procedure (involving all remaining teeth) and the use of general anesthesia raises the stakes. The presence of a partially bony impacted tooth and the involvement of systematic, oral surgery procedures increases complexity, necessitating careful monitoring of the patient's condition before, during, and after the surgery. However, there were no complications reported, and the patient was stable post-procedure. This suggests that while it is a significant surgery, it was conducted under controlled circumstances with a successful outcome.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Dentistry
Sample Name: Dental Restorations & Extractions

PREOPERATIVE DIAGNOSIS:,  Dental caries.,POSTOPERATIVE DIAGNOSIS: , Dental caries.,PROCEDURE: , Dental restorations and extractions.,CLINICAL HISTORY: , This 23-year-old male is a client of the ABC Center because of his disability, the nature of which is unclear to me at this time; however, he reportedly has several issues that qualify him as disabled.  He has had multiple severe carious lesions that warrant multiple extractions at this time.  It is also unclear to me as to how his prior or existing restorations were accomplished.  In any case, he has been cleared for the procedure today.  He has his history and physical in the chart.,PROCEDURE: , The patient was brought to the operating room at 11 o'clock and placed in the supine position.  Dr. X administered the general anesthetic, after which a throat pack was placed.  Available full mouth x-rays were reviewed.  These x-rays were taken at another location.  Teeth 2, 4, 10, 12, 13, 15, 18, 20, 27, and 31 were all in varying degrees of severe decay from complete destruction of the crowns to pulp exposures with periapical radiolucencies.  All of these aforementioned teeth were extracted using combinations of forceps and elevators.  Hemostasis in all of these sites was accomplished with direct pressure using gauze packs.  ,Tooth 5 had caries in the distal surface extending to the occlusal as well as another carious lesion in the buccal.  These carious lesions and his tooth were excavated, and the tooth was restored with amalgam involving these surfaces.  ,Tooth 6 had caries on the facial surface, which was excavated, and the tooth was restored with composite.  ,Tooth 7 had caries involving the distal surface.  ,Tooth 8 likewise had caries involving the distal surface, and both of these distal lesions extended into incisal area.  These carious lesions were excavated, and both of these teeth were restored with composite.  ,Tooth 9 had caries in a mesial surface and a buccal surface, which was excavated, and this tooth was restored with composite.  ,Tooth 28 caries in the mesial surface extending to the occlusal, which was excavated, and the tooth was restored with amalgam, and tooth 30 had carries in the buccal surface, which was excavated, and the tooth was restored with amalgam.  ,A prophylaxis was done, primarily using a rotating rubber cup and some minor scaling, and the mouth was irrigated and suctioned thoroughly.  The throat pack was removed, and the patient was awakened and brought to the recovery room in good condition at 1330 hours.  There was negligible blood loss.
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DESCRIPTION: Dental restorations and extractions.  Dental caries.  He has had multiple severe carious lesions that warrant multiple extractions at this time.

dentistry, extractions, multiple extractions, mesial surface, buccal surface, dental restorations, dental caries, distal surface, composite tooth, carious lesions, tooth, dental, caries

The situation involves a dental procedure for a patient with severe dental caries requiring multiple extractions and restorations under general anesthesia. While the procedures themselves are routine in dentistry, the need for general anesthesia and the patient's unclear disability status introduce some complexity. However, there appears to be no immediate life-threatening condition present, and the procedure was completed without complications or significant blood loss. Thus, while important, this scenario is not high-stakes when compared to more critical medical situations.


Medical Specialty: Dentistry
Sample Name: Dental Pain

CHIEF COMPLAINT:,  Dental pain.,HISTORY OF PRESENT ILLNESS:,  This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.  Presents now for evaluation.,PAST MEDICAL HISTORY: , Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease.  She has chronic pain in general and is followed by Dr. X.,REVIEW OF SYSTEMS: , Otherwise, unremarkable.  Has not noted any fever or chills.  However she, as mentioned, does note the dental discomfort with increasing swelling and pain.  Otherwise, unremarkable except as noted.,CURRENT MEDICATIONS: , Please see list.,ALLERGIES: , IODINE, FISH OIL, FLEXERIL, BETADINE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile, has stable and normal vital signs.  The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain.  HEENT:  Unremarkable.  I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region.  There is no neck adenopathy.  Oral mucosa is moist and well hydrated.  Dentition looks to be in reasonable condition.  However, she definitely is tender to percussion on the left lower first premolar.  I do not see any huge cavity or anything like that.  No real significant gingival swelling and there is no drainage noted.  None of the teeth are tender to percussion.,PROCEDURE:,  Dental nerve block.  Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia.  I have then written a prescription for penicillin and Vicodin for pain.,IMPRESSION: , ACUTE DENTAL ABSCESS.,ASSESSMENT AND PLAN:  ,The patient needs to follow up with the dentist for definitive treatment and care.  She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics.  However, outpatient followup should be adequate.  She is discharged in stable condition.
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DESCRIPTION: This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.

dentistry, dental pain, dental abscess, dental block, nerve block, mandible, swelling, dental,

The patient presents with an acute dental abscess, which, while often painful and requiring immediate attention, generally isn't life-threatening when managed promptly with appropriate antibiotics and pain relief. This case was managed with a nerve block, pain medication, and antibiotics, and the patient was discharged in stable condition. The situation requires dental follow-up, but it's unlikely to escalate into a life-threatening scenario if properly managed.


Medical Specialty: Dentistry
Sample Name: Closed Reduction - Mandible Fracture

PREOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,POSTOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,PROCEDURE:  ,Closed reduction of mandible fracture with MMF.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 2 L of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,HARDWARE: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,CONDITION:  ,The patient was extubated to PACU in good condition.,INDICATIONS FOR PROCEDURE: , The patient is a 17-year-old female who is 2 days status post an altercation in which she sustained multiple blows to the face.  She was worked up on Friday night, 2 days earlier at Hospital, was given palliative treatment and discharged and instructed to follow up as an outpatient with an oral surgeon and given a phone number to call.  The patient was worked up initially.  On initial exam, it was noted that the patient had a left V3 paresthesia.  She had a gross malocclusion.  On the facial CT and panoramic x-ray, it was noted to be a displaced left angle fracture and nondisplaced symphysis fracture.  Alternatives were discussed with the patient and it was determined she would benefit from being taken to the operating room under general anesthesia to have a closed reduction of her fractures.  Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and informed consent was obtained with the patient's mother.,DESCRIPTION OF PROCEDURE:, The patient was taken to the operating room #4 at Hospital and laid in a supine position on the operating room table.  Monitor was attached and general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics.  The patient was prepped and draped in the usual oromaxillofacial surgery fashion.,Surgeon approached the operating table in a sterile fashion.  Approximately 10 mL of 2% lidocaine with 1:100,000 epinephrine was injected into the oral vestibule in a nerve block fashion.  A moistened Ray-Tec sponge was placed in the posterior oropharynx and the mouth was prepped with Peridex mouthrinse, scrubbed with a toothbrush.  The Peridex was evacuated with Yankauer suction.  Erich arch bars were adapted to the maxilla from the first molar to the contralateral first molar and secured with 24-gauge surgical steel wire on the posterior teeth and 26-gauge surgical steel wire on the anterior teeth.  Same was done on the mandible.  The patient was then manipulated up in the maximum intercuspation and noted to be reproducible.  The throat pack was then removed.,The patient was remanipulated up to the maximum intercuspation and secured with interdental elastics.  At this point in time, the procedure was then determined to be over.,The patient was extubated and transferred to the PACU in good condition.
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DESCRIPTION: Bilateral open mandible fracture, open left angle and open symphysis fracture.  Closed reduction of mandible fracture with MMF.

dentistry, open symphysis fracture, closed reduction, mmf, endotracheal, pacu, bilateral open mandible fracture, symphysis fracture, mandible fracture, fracture, intubation, angle, mandible,

The procedure involves repairing a bilateral open mandible fracture, which, though a common dental surgery, involves general anesthesia and significant manipulation of the jaw. The stakes are moderately high due to the potential complications from fractures, the necessity for skilled surgical intervention, and the young age of the patient, which could influence healing. However, the procedure reported no complications, and both preoperative and postoperative statuses indicated the patient was in good condition, suggesting well-managed risks.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Rhytidectomy & Blepharoplasty

PREOPERATIVE DIAGNOSIS:,  Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION:  ,This is a 62-year-old female for the above-planned procedure.  She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied.  Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table.  Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen.  This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized.  Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty.  Markers were applied to both upper lids in symmetrical fashion.  The skin was excised from the right upper lid first followed by appropriate muscle resection.  Minimal fat removed from the medial upper portion of the eyelid.  Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture.  Attention was then turned to the lower lid.  A classic skin muscle flap was created accordingly.  Fat was resected from the middle, medial, and lateral quadrant.  The fat was allowed to open drain the arcus marginalis for appropriate contour.  Hemostasis was controlled with the pinpoint cautery accordingly.  Skin was redraped with a conservative amount resected.  Running closure with 7-0 nylon was accomplished without difficulty.  The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes.  Eye mass was likewise clamped.  Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure.  The right face was first operated.  It was injected with a 0.25% Marcaine 1:200,000 adrenaline.  A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula.  She had minimal subcutaneous extra fat as noted.  Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline.  The flap was elevated without difficulty with various facelift scissors.  Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision.  Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery.  The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication.  The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene.  The skin was draped appropriately and appropriate tissue was resected.  A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface.  Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon.  The hairline temporal incision was closed with running 5-0 nylon.  The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described.  Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly.  Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly.  Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure.  The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure.  She will be discharged in the morning.,Estimated blood loss was less than 75 cc.  No complications noted, and the patient tolerated the procedure well.
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DESCRIPTION: Cervical facial rhytidectomy.  Quadrilateral blepharoplasty.  Autologous fat injection to the upper lip - donor site, abdomen.

cosmetic / plastic surgery, ageing face, adaptic polysporin ointment, autologous fat injection, bovie cautery, kerlix wrap, smas plication, arcus marginalis, blepharoplasty, facelift, platysmal sling, quadrilateral, rhytidectomy, right upper lid, cervical facial rhytidectomy, pinpoint cautery, facial rhytidectomy, quadrilateral blepharoplasty, running nylon, autologous,

The scenario involves a complex cosmetic surgical procedure, which includes a cervical facial rhytidectomy, quadrilateral blepharoplasty, and autologous fat injection. While these procedures are generally elective and typically not life-threatening (given the stable postoperative condition of the patient), surgery always carries inherent risks such as infections, bleeding, or anesthesia complications. Additionally, the potential impact on a patient's facial appearance can have significant psychological and emotional effects if the outcome is unsatisfactory or if complications arise. However, given the detailed and comprehensive procedural notes indicating no complications and a stable postoperative condition, it seems the immediate stakes are moderate rather than extremely high.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Skin Graft

DIAGNOSIS:,  Stasis ulcers of the lower extremities,OPERATION:,  Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,INDICATIONS:,  This 84-year old female presented recently with large ulcers of the lower extremities.  These were representing on the order of 50% or more of the circumference of her lower leg.  They were in a distribution to be consistent with stasis ulcers.  They were granulating nicely and she was scheduled for surgery.,FINDINGS:,  Large ulcers of lower extremities with size as described above.  These are irregular in shape and posterior and laterally on the lower legs.  There was no evidence of infection.  The ultimate skin grafting was quite satisfactory.,PROCEDURE: , Having obtained adequate general endotracheal anesthesia, the patient was prepped from the pubis to the toes.  The legs were examined and the wounds were Pulsavaced bilaterally with 3 liters of saline with Bacitracin.  The wounds were then inspected and there was adequate hemostasis and there was only minimal fibrinous debris that needed to be removed.  Once this was accomplished, the skin was harvested from the right thigh at approximately 0.013 inch.  This was meshed 1:1.5 and then stapled into position on the wounds.  The wounds were then dressed with a fine mesh gauze that was stapled into position as well as Kerlix soaked in Sulfamylon solution.,She was then dressed in additional Kerlix, followed by Webril, and splints were fashioned in a spiral fashion that avoided foot drop and stabilized them, and at the same time did not put pressure across the heels.  The donor site was dressed with Op-Site.  The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.
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DESCRIPTION: Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.

cosmetic / plastic surgery, skin graft, lower extremities, split thickness skin grafting, skin grafting, kerlix, grafting, extremities, ulcers, leg,

The operation described is a split-thickness skin graft to treat stasis ulcers in an elderly patient. High-stakes elements include the patient's advanced age, which can increase surgical risks and complicate recovery. The procedure involves significant areas on both legs and requires careful management of wound care and potential complications such as infection or graft failure. However, there is no immediate life-threatening condition, and the surgery outcome was described as satisfactory with no evidence of infection. Thus, it's high-stakes due to the age and complexity but not the highest possible stakes as the patient tolerated the procedure well.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Flap revision

PREOPERATIVE DIAGNOSES,1.  Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2.  Bilateral breast asymmetry.,3.  Right breast macromastia.,4.  Right abdominal scar deformity.,5.  Left abdominal scar deformity.,6.  A 1.3 cm lesion right inferior breast.,7.  Lesion measuring 0.5 cm right inferior breast lateral.,POSTOPERATIVE DIAGNOSES,1.  Acquired absence of bilateral breast status post previous bilateral DIEP flap reconstruction.,2.  Bilateral breast asymmetry.,3.  Right breast macromastia.,4.  Right abdominal scar deformity.,5.  Left abdominal scar deformity.,6.  A 1.3 cm lesion right inferior breast.,7.  Lesion measuring 0.5 cm right inferior breast lateral.,PROCEDURES,1.  Left breast flap revision.,2.  Right breast flap revision.,3.  Right breast reduction mammoplasty.,4.  Right nipple reconstruction.,5.  Left abdominal scar deformity.,6.  Right abdominal scar deformity.,7.  Excision of right breast medial lesion enclosure.,8.  Excision of right breast lateral lesion enclosure.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,DRAINS:,  None.,SPECIMENS:,  Right breast skin and lesions x2.,COMPLICATIONS:, None.,INDICATIONS:,  This patient is a 54-year-old white female who presents for a revision of her previous bilateral breast reconstruction.  The patient had asymmetry as well as right breast hypertrophy, and therefore, the procedures named above were indicated.  The patient was informed about the possible risks and complications of the above procedures and gave an informed consent.,PROCEDURE:,  The patient was brought to the operating room, placed supine on the operative table.  After adequate endotracheal anesthesia was established and IV prophylactic antibiotics were given, the chest and abdomen were prepped and draped in standard surgical fashion.,Attention was first turned to the left breast where liposuction was performed laterally to allow for better contour and minimize the outer quadrant.  The incision was made for this and was then closed with 5-0 Prolene interrupted suture.,Attention was then turned to the right breast where liposuction was also performed to reduce the medial superior and lateral quadrants.  Once this was performed, the vertical reduction mammoplasty was outlined.  Prior to that, the nipple reconstruction was performed with a keyhole pattern flap.  The flap was elevated with 15-blade and hemostasis was then obtained with the Bovie.  The flap was then sutured onto itself and secured with 5-0 Prolene interrupted sutures.  Then the lateral and medial limbs were undermined to close the defect and this was performed with 3-0 Monocryl interrupted sutures.  Subsequently, the reduction mastectomy skin was then excised sharply and passed up the table marked and sent to Pathology. ,Hemostasis was then obtained with the Bovie and then undermining was performed in the medial, superior, and lateral skin to allow for closure of the reduction incisions.  Once this was performed, a 3-0 Monocryl interrupted sutures were used to close the inferior limb.  Subsequently 2-0 PDS continuous suture was then placed in the periareolar area to close the defect, with a diameter that equaled the new nipple areolar complex.  Once this was performed, the remaining incision was then closed with 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures.  Subsequently, the 2 lesions were excised, the larger one which was medial and the lateral one that was smaller that were excised sharply, passed up the table and sent to Pathology.  They were closed in 2 layers using 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the abdominal scars where liposuction and tumescent solution of diluted epinephrine were used to minimize the amount of excision that was required.  Subsequently the extra skin was excised sharply in an elliptical fashion on the right side measuring approximately 10 x 3 cm, this was the superior and inferior skin, was when undermined and closure was performed after hemostasis was obtained with 3-0 Monocryl followed by 4-0 Monocryl subcuticular suture.,Attention was then turned to the contralateral left side where there was a larger defect.  There was a larger excision required measuring approximately 15 x 3 cm.  The superior and inferior edges of skin were undermined and closed primarily using 3-0 Monocryl followed by 4-0 Monocryl subcuticular sutures.  Steri-Strips were placed on all incisions followed by surgical bra.,The patient tolerated the procedure well and was extubated without complications and transferred to the recovery room in stable condition.  All instruments, needle counts, and sponges were correct at the end of the case.
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DESCRIPTION: Breast flap revision, nipple reconstruction, reduction mammoplasty, breast medial lesion enclosure.

The situation involves a complex and extensive surgical procedure in the field of cosmetic/plastic surgery, addressing multiple issues such as breast asymmetry, macromastia, scar deformities, and lesions on a patient who has already undergone significant breast reconstruction. While the stakes are not life-threatening, the surgery's success is important for the patient's physical appearance and psychological well-being, as well as the correction of previous complications and improvements in symmetry. The procedures are intricate and require precision, indicating moderate stakes, particularly in terms of surgical outcomes and patient satisfaction. The absence of complications noted in the report reduces the immediate risk involved, but the overall impact of the surgery on the patient's appearance and health requires careful execution and follow-up.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Liposuction

PREOPERATIVE DIAGNOSES:,1.  Deformity, right breast reconstruction.,2.  Excess soft tissue, anterior abdomen and flank.,3.  Lipodystrophy of the abdomen.,POSTOPERATIVE DIAGNOSES:,1.  Deformity, right breast reconstruction.,2.  Excess soft tissue, anterior abdomen and flank.,3.  Lipodystrophy of the abdomen.,PROCEDURES:,1.  Revision, right breast reconstruction.,2.  Excision, soft tissue fullness of the lateral abdomen and flank.,3.  Liposuction of the supraumbilical abdomen.,ANESTHESIA: , General.,INDICATION FOR OPERATION:,  The patient is a 31-year-old white female who previously has undergone latissimus dorsi flap and implant, breast reconstruction.  She now had lateralization of the implant with loss of medial fullness for which she desired correction.  It was felt that mobilization of the implant medially would provide the patient significant improvement and this was discussed with the patient at length.  The patient also had a small dog ear in the flank area on the right from the latissimus flap harvest, which was to be corrected.  She had also had liposuction of the periumbilical and infraumbilical abdomen with desire to have great improvement superiorly, was felt to be a candidate for such.  The above-noted procedure was discussed with the patient in detail.  The risks, benefits and potential complications were discussed.  She was marked in the upright position and then taken to the operating room for the above-noted procedure.,OPERATIVE PROCEDURE: , The patient was taken to the operating room and placed in the supine position.  Following adequate induction of general LMA anesthesia, the chest and abdomen was prepped and draped in the usual sterile fashion.  The supraumbilical abdomen was then injected with a solution of 5% lidocaine with epinephrine, as was the dog ear.  At this time, the superior central scar was then excised, dissection continued through the subcutaneous tissue, the underlying latissimus muscle until the capsule of the implant was reached.  This was then opened.  The implant was removed and placed on the back table in antibiotic solution.  Using Bovie cautery, the medial capsule was released and undermining was then performed with release of the muscle to the level of the proposed medial projection of the breast.  The inframammary fold medially was secured with 2-0 PDS suture to create greater takeoff point at this level which in the upright position and using a sizer produced a good form.  The lateral pocket was diminished by series of 2-0 PDS suture to provide medialization of the implant.  The implant was then placed back into the submuscular pocket with much improved positioning and medial fullness.  With this completed, the implant was again removed, antibiotic irrigation was performed.  A drain was placed and brought out through a separate inferior stab wound incision and hemostasis was confirmed.  The implant was then replaced and the wound was then closed in layers using 2-0 PDS running suture on the muscle and 3-0 Monocryl Dermabond subcuticular sutures.  The 2.5 cm dog ear was then excised into and including the subcutaneous tissue, even contouring was achieved and this was closed with two layers using 3-0 Monocryl suture.  Using a #3 cannula, a superior umbilical incision, liposuction was carried out into the supraumbilical abdomen, removing approximately 40 to 50 mL of fat with improved supraumbilical contours.  This was closed with 6-0 Prolene suture.  The patient was placed in a compressive garment after treating the incision with Dermabond, Steri-Strips and antibiotic ointment around the drain site and umbilicus.  A Kerlix dressing and a surgical bra was placed to the chest area.  A compressive garment was placed.  The patient was then aroused from anesthesia, extubated, and taken to the recovery room in stable condition.  Sponge, needle, lap, instrument counts were all correct.  The patient tolerated the procedure well.  There were no complications.  The estimated blood loss was approximately 25 mL.
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DESCRIPTION: Liposuction of the supraumbilical abdomen, revision of right breast reconstruction, excision of soft tissue fullness of the lateral abdomen and flank.

cosmetic / plastic surgery, breast reconstruction, excess, lma anesthesia, lipodystrophy, liposuction, abdomen, drain site, flank, latissimus dorsi flap, soft tissue, supraumbilical, surgical bra, supraumbilical abdomen, reconstruction, breast, tissue, implant,

The scenario described involves a surgical procedure, which inherently carries a certain level of risk due to the involvement of anesthesia, potential for complications, and the need for postoperative recovery and monitoring. However, the procedure is elective cosmetic surgery, which typically poses lower stakes compared to life-saving surgeries. The patient's condition was stable post-operation, there were no complications, and the procedure was successfully executed which indicates that while there are risks and stakes involved, they are managed and not exceedingly high.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Breast Augmentation Consult

REASON FOR VISIT: , This is a cosmetic consultation.,HISTORY OF PRESENT ILLNESS:,  The patient is a very pleasant 34-year-old white female who is a nurse in the operating room.  She knows me through the operating room and has asked me to possibly perform cosmetic surgery on her.  She is very bright and well informed about cosmetic surgery.  She has recently had some neck surgery for a re-fusion of her neck and is currently on methadone for chronic pain regarding this.  Her current desires are that she obtain a breast augmentation and liposuction of her abdomen, and she came to me mostly because I offer transumbilical breast augmentation.  Her breasts are reportedly healthy without any significant problems.  Her weight is currently stable.,PAST MEDICAL AND SURGICAL HISTORY: ,  Negative.  Past surgical history is significant for a second anterior cervical fusion and diskectomy in 02/05 and in 09/06.  She has had no previous cosmetic or aesthetic surgery.,FAMILY HISTORY AND SOCIAL HISTORY:,  Significant for Huntington disease in her mother and diabetes in her father.  Her brother has an aneurysm.  She does occasionally smoke and has been trying to quit recently.  She is currently smoking about a pack a day.  She drinks about once a week.  She is currently a registered nurse, circulator, and scrub technician in the operating room at Hopkins.  She has no children.,REVIEW OF SYSTEMS:  ,A 12-system review is significant for some musculoskeletal pain, mostly around her neck and thoracic region.  She does have occasional rash on her chest and problems with sleep and anxiety that are related to her chronic pain.  She has considered difficult airway due to anterior cervical disk fusion and instability.  Her last mammogram was in 2000.  She has a size 38C breast.,MEDICATIONS: , Current medications are 5 mg of methadone three times a day and amitriptyline at night as needed.,ALLERGIES: , None.,FINDINGS: , On exam today, the patient has good posture, good physique, good skin tone.  She is tanned.  Her lower abdomen has some excess adiposity.  There is some mild laxity of the lower abdominal skin.  Her umbilicus is oval shaped and of adequate caliber for a transumbilical breast augmentation.  There was no piercing in that region.  Her breasts are C shaped.  They are not ptotic.  They have good symmetry with no evidence of tubular breast deformity.  She has no masses or lesions noted.  The nipples are of appropriate size and shape for a woman of her age.  Her scar on her neck from her anterior cervical disk fusion is well healed.  Hopefully, our scars would be similar to this.,IMPRESSION AND PLAN: , Hypomastia.  I think her general physique and body habitus would accommodate about 300 to 350 cubic centimeter implant nicely.  This would make her fill out her clothes much better, and I think transumbilical technique in her is a good option.  I have discussed with her the other treatment options, and she does not want scars around her breasts if at all possible.  I think her lower abdominal skin is of good tone.  I think suction lipectomy in this region would bring down her size and accentuate her waist nicely.  I am a little concerned about the lower abdominal skin laxity, and I will discuss with her further that in the near future if this continues to be a problem, she may need a mini tummy tuck.  I do think that a liposuction is a reasonable alternative and we could see how much skin tightening she gets after the adiposity is removed.  I will try to set this up in the near future.  I will try to set this up to get the instrumentation from the instrumentation rep for the transumbilical breast augmentation procedure.  Due to her neck issues, we may not be able to perform her surgery but I will check with Dr. X to see if she is comfortable giving her deep sedation and no general anesthetic with her neck being fused.
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DESCRIPTION: Hypomastia.   Patient wants breast augmentation and liposuction of her abdomen,

cosmetic / plastic surgery, breast augmentation and liposuction, liposuction of her abdomen, transumbilical breast augmentation, cosmetic surgery, abdominal skin, breast augmentation, augmentation, liposuction, cosmetic, transumbilical, breast,

The situation involves a cosmetic surgery consultation for breast augmentation and liposuction. While cosmetic surgeries can have implications, the stakes are not considered extremely high compared to situations involving life-threatening conditions. Factors such as the patient's existing health concerns, like neck surgery and medication for chronic pain, influence the complexity and consideration needed, but primarily it remains an elective, aesthetic procedure rather than critical or emergent healthcare.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Breast Reconstruction

REASON FOR CONSULTATION:,  Breast reconstruction post mastectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old lady, who had gone many years without a mammogram when she discovered a lump in her right breast early in February of this year.  She brought this to the attention of her primary care doctor and she soon underwent ultrasound and mammogram followed by needle biopsy, which revealed that there was breast cancer.  This apparently was positive in two separate locations within the suspicious area.  She also underwent MRI, which suggested that there was significant size to the area involved.  Her contralateral left breast appeared to be uninvolved.  She has had consultation with Dr. ABC and they are currently in place to perform a right mastectomy.,PAST MEDICAL HISTORY: , Positive for hypertension, which is controlled on medications.  She is a nonsmoker and engages in alcohol only moderately.,PAST SURGICAL HISTORY: , Surgical history includes uterine fibroids, some kind of cyst excision on her foot, and cataract surgery.,ALLERGIES: , None known.,MEDICATIONS: , Lipitor, ramipril, Lasix, and potassium.,PHYSICAL EXAMINATION: , On examination, the patient is a healthy looking 51-year-old lady, who is moderately overweight.  Breast exam reveals significant breast hypertrophy bilaterally with a double D breast size and significant shoulder grooving from her bra straps.  There are no any significant scars on the right breast as she has only undergone needle biopsy at this point.  Exam also reveals abdomen where there is moderate excessive fat, but what I consider a good morphology for a potential TRAM flap.,IMPRESSION:,  A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.  We discussed the breast reconstruction options in some detail including immediate versus delayed reconstruction and autologous tissue versus implant reconstruction.  I think for a lady of this physical size and breast morphology that the likelihood of getting a good result with a tissue expander reconstruction is rather slim.  A further complicating factor is the fact that she may well be undergoing radiation after her mastectomy.  I would think this would make a simple tissue expander reconstruction virtually beyond the balance of consideration.  I have occasionally gotten away with tissue expanders with reasonable results in irradiated patients when they are thinner and smaller breasted, but in a heavier lady with large breasts, I think it virtually deemed to failure.  We therefore, mostly confine our discussion to the relative merits of TRAM flap breast reconstruction and latissimus dorsi reconstruction with implant.  In either case, the contralateral breast reduction would be part of the overall plan., ,The patient understands that the TRAM flap although not much more lengthy of a procedure is a little comfortable recovery.  Since we are sacrificing a rectus abdominus muscle that can be more discomfort and difficulties in healing both due to it being a respiratory muscle and to its importance in sitting up and getting out of bed.  In any case, she does prefer this option in order to avoid the need for an implant.  We discussed pros and cons of the surgery, including the risks such as infection, bleeding, scarring, hernia, or bulging of the donor site, seroma of the abdomen, and fat necrosis or even the skin slough in the abdomen.  We also discussed some of the potential flap complications including partial or complete necrosis of the TRAM flap itself.,PLAN: , The patient is definitely interested in undergoing TRAM flap reconstruction.  At the moment, we are planning to do it as an immediate reconstruction at the time of the mastectomy.  For this reason, I have made arrangements to do initial vascular delay procedure within the next couple of days.  We may cancel this if the chance of postoperative irradiation is high.  If this is the case, I think we can do a better job on the reconstruction if we defer it.  The patient understands this and will proceed according to the recommendations from Dr. ABC and from the oncologist.
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DESCRIPTION: Breast reconstruction post mastectomy.  A 51-year-old lady for mastectomy on the right side, who is interested in the possibility of breast reconstruction.

cosmetic / plastic surgery, breast reconstruction, mastectomy, lump, breast, mammogram, needle biopsy, breast cancer, hypertrophy, tram flap, latissimus dorsi,

Breast reconstruction post-mastectomy involves significant medical decisions that are closely tied to the patient's cancer treatment plan and overall health. The procedure involves considerations of surgical risk, the patient's medical history, and potential future treatments like radiation. Given the context of breast cancer and surgery, this situation is high-stakes. The patient's life is not directly endangered by the reconstruction procedure itself, but the outcomes affect her physical and psychological well-being deeply, especially concerning body image after cancer.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Bilateral Orbital Frontozygomatic Craniotomy

PREOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,PROCEDURES PERFORMED: , ,1.  Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies.,2.  Bone grafts.,3.  Bilateral forehead reconstruction with autologous graft.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:,  None.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable, transferred to recovery room.,ESTIMATED BLOOD LOSS: , 300 mL.,CRYSTALLOIDS: , Packed red blood cells 440 mL, FFP 100 mL.,URINARY OUTPUT: , 160 mL.,INDICATIONS FOR PROCEDURE: , The patient is a 9-month-old baby with a history of trigonocephaly and metopic synostosis.  We have discussed locations, the nature of trigonocephaly's repair, metopic synostosis repair with bilateral fronto-orbital advancement, forehead reconstruction, and bone graft.  We have discussed risks and benefits.  Risks included, but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgeries, minimal possibility of death, the alternatives, devastating bleeding, anesthesia, death, dehiscence, infection.  The parents understand, decide to proceed with surgery.  Informed consent was obtained and we proceed with surgery.,DESCRIPTION OF PROCEDURE: , The patient was taken into the operating room, placed in the supine position.  General anesthetic was administered.  Prophylactic dose of antibiotic was given.  Lines were placed by Anesthesia and then the head of the bed was turned to 100 degrees.  The patient was once more positioned and padded in the usual manner.  The incision was marked with the help of a marking pen and local anesthetic was infiltrated after prepping the area one time, then the definitive prep and draping of the area was done.,The procedure began with an incision through the full-thickness of the skin into the subcutaneous tissue down to the subgaleal plane.  The subgaleal plane was developed and reflected anteriorly and slightly posteriorly.  Hemostasis achieved with electrocautery.  Raney clips were applied to both flaps to prevent significant bleeding.  Then, we proceed with craniotomy part and Dr. Y proceeded with this part of the procedure.  I assisted her and this will be described in a different operative report.  Then, the area corresponding to the C-shaped osteotomy was marked and then we proceed in conjunction with Dr. Y to develop these osteotomies with the help of the Midas by retracting the contents of the skull at the level of the anterior fossa as well as the orbital contents with the help of a ribbon retractor.  The osteotomies were done with the Midas and some irrigation.  There was an osteotomy done at the level of the frontozygomatic suture just posterior to the frontozygomatic suture and then these osteotomies continued down intraorbitally and lateral through the zygoma to the level of the intraorbital rim.  This was done on both sides.  Hemostasis achieved with bone wax and electrocautery.  Once the osteotomies were completed, __________ of the osteotomy sites allowed advancements.  On the left side, there was a minor fracture to the superior orbital rim that was plated.  The bone grafts were customized placing these at the level of the sphenoid bone in the posterior aspect of the orbital rim.  The temporalis muscle was advanced and attached to the orbital rim with holes that have been drilled with Midas and a 3-0 Vicryl interrupted stitches.  The forehead flaps were attached with the help of absorbable mesh.  The forehead portions were applied to the fronto-orbital advancement of fronto-orbital piece with the help of Synthes mesh and 3-mm screws.  Hemostasis was checked.  The flaps were retracted back into position.,The wound was closed with 3-0 Vicryl interrupted sutures, 4-0 Vicryl interrupted stitches, and 5-0 running fast absorbing gut.  Dressing was applied with Xeroform, bacitracin, and ABDs and a burn net.  The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition.  I was present and participated in all aspects of the procedure.  Sponge, needle, and instrument counts were completed at the end of the procedure.
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DESCRIPTION: Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.

cosmetic / plastic surgery, metopic synostosis, craniotomy, z-osteotomies, orbital advancement, bone grafts, frontozygomatic, forehead reconstruction, autologous graft, bilateral orbital frontozygomatic craniotomy, orbital, osteotomies, forehead,

The scenario describes a complex craniofacial surgical procedure performed on a 9-month-old baby, diagnosed with metopic synostosis with trigonocephaly. The stakes are high due to several factors: the patient's young age, the complexity and invasiveness of the procedure, the associated risks such as bleeding and the need for bone grafting, and the significant potential consequences of complication should anything go wrong during the surgery. Additionally, despite obtaining informed consent, there are risks like infection, need for future revisions, and even a minimal risk of death, all of which further elevate the stakes. However, since the surgery went without complications and the patient was stable post-operation, some lower risks were realized. Nevertheless, due to the inherent risks and criticality of the situation, it remains a high-stakes scenario.


Medical Specialty: Consult - History and Phy.
Sample Name: Well-woman checkup

CHIEF COMPLAINT:,  The patient comes for her well-woman checkup.,HISTORY OF PRESENT ILLNESS:,  She feels well.  She has had no real problems.  She has not had any vaginal bleeding.  She had a hysterectomy.  She has done fairly well from that time till now.  She feels like she is doing pretty well.  She remains sexually active occasionally.  She has not had any urinary symptoms.  No irregular vaginal bleeding.  She has not had any problems with vasomotor symptoms and generally, she just feels like she has been doing pretty well.  She sometimes gets a catch in her right hip and sometimes she gets heaviness in her calves.  She says the only thing that works to relieve that is to sleep on her tummy with her legs pulled up and they relax and she goes off to sleep.  She does not report any swelling or inflammation, or pain.  She had a recent urinary tract infection, took medication, and has not rechecked on that urinalysis.,MEDICATIONS: , Tetracycline 250 mg daily, Inderal LA 80 mg every other day.,ALLERGIES:,  Sulfa.,PAST MEDICAL HISTORY:,  She had rosacea.  She also has problems with “tremors” and for that she takes Inderal LA.  Hysterectomy in the past.,SOCIAL HISTORY:,  She drinks four cups of coffee a day.  No soda.  No chocolate.  She said her husband hurt his hand and shoulder, and she has been having to care of him pretty much.  They walk every evening for one hour.,FAMILY HISTORY:,  Her mother is in a nursing home; she had a stroke.  Her father died at age 86 in January 2004 of congestive heart failure.  She has two brothers, one has kidney failure, the other brother donated a kidney to his other brother, but this young man is now an alcoholic and drug addict.,REVIEW OF SYSTEMS:,  Patient denies headache or trauma.  No blurred or double vision.  Hearing is fine, no tinnitus, or infection.  Infrequent sore throat, no hoarseness, or cough.,Neck:  No stiffness, pain, or swelling.,Respiratory:  No shortness of breath, cough, or hemoptysis.,Cardiovascular:  No chest pain, ankle edema, palpitations, or hypertension.,GI:  No nausea, vomiting, diarrhea, constipation, melena, or jaundice.,GU:  No dysuria, frequency, urgency, or stress incontinence.,Locomotor:  No weakness, joint pain, tremor, or swelling.,GYN:  See HPI.,Integumentary:  Patient performs self-breast examinations and denies any breast masses or nipple discharge.  No recent skin or hair changes.,Neuropsychiatric:  Denies depression, anxiety, tearfulness, or suicidal thought.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Height:  62 inches.  Weight:  134 pounds.  Blood pressure:  116/74.  Pulse:  60.  Respirations:  12.  Age 59.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.  She fell last winter on the ice and really cracked her head and has had some problems with headaches since then and she has not returned to her job which was very stressful and hard on her.  She wears glasses.,Neck:  Full range of motion.  No lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation and percussion.,Heart:  Normal sinus rhythm, no murmur.,Integumentary:  Breasts are without masses, tenderness, nipple retraction, or discharge.  Reviewed self-breast examination.  No axillary nodes are palpable.,Abdomen:  Soft.  Liver, spleen, and kidneys are not palpable.  No masses felt, nontender.  Femoral pulses strong and equal.,Back:  No CVA or spinal tenderness.  No deformity noted.,Pelvic:  BUS negative.  Vaginal mucosa atrophic.  Cervix and uterus are absent.  No Pap was taken.  No adnexal masses.,Rectal:  Good sphincter tone.  No masses.  Stool guaiac negative.,Extremities:  No edema.  Pulses strong and equal.  Reflexes are intact.  Romberg and Babinski are negative.  She is oriented x 3.  Gait is normal.,ASSESSMENT:,  Middle-aged woman, status post hysterectomy, recent urinary tract infection.,PLAN:,  We will evaluate the adequacy of the therapy for her urinary tract infection with the urinalysis and culture.  I recommended mammogram and screening, hemoccult x 3, DEXA scan and screening, and she is fasting today.  We will screen with chem-12, lipid profile, and CBC because of her advancing age and notify of those results, as soon as they are available.  Continue same meds.  Recheck annually unless she has problems sooner.
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DESCRIPTION: Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection.

This well-woman checkup does not represent a high-stakes situation. The patient appears stable with no acute or severe symptoms requiring immediate intervention. The primary concerns are routine evaluations and screenings due to her history and age, like checking the adequacy of treatment for a previous urinary tract infection and suggesting preventive screenings like mammograms. The patient's health is generally good, with no pressing emergencies or decisions needed during this visit.


Medical Specialty: Consult - History and Phy.
Sample Name: Well-Child Check - 7

SUBJECTIVE:,  This is a 1-month-old who comes in for a healthy checkup.  Mom says things are gone very well.  He is kind of acting like he has got a little bit of sore throat but no fevers.  He is still eating well.  He is up to 4 ounces every feeding.  He has not been spitting up.  Voiding and stooling well.,PAST MEDICAL HISTORY:,  Reviewed, very healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,DIETARY: , His formula fed on Enfamil Lipil.  Voiding and stooling well.  Growth chart reviewed with Mom.,DEVELOPMENTAL:,  He is starting to track with his eyes.  He is smiling a little bit, moving hands and feet symmetrically.,PHYSICAL EXAMINATION:,  In general well-developed, well-nourished male in no acute distress.,DERMATOLOGIC:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Anterior fontanel soft and flat.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes present bilaterally.  Does appear to have conjugate gaze.  Ears:  Tympanic membranes are pink to gray, translucent, neutral position, normal light reflex and mobility.  Nares are patent, pink mucosa, moist.  Oropharynx clear with pink mucosa, normal moisture.,NECK:  Supple without masses.,CHEST:  Clear to auscultation and percussion with easy respirations and no accessory muscle use.,CARDIOVASCULAR:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,ABDOMEN:  Soft, nontender, nondistended without hepatosplenomegaly.,GU EXAM:  Normal Tanner I male.  Testes descended bilaterally.  No hernias noted.,EXTREMITIES:  Pink and warm.  Moving all extremities well.  No subluxation of the hips and leg creases appear symmetric.,NEUROLOGIC:  Alert, otherwise nonfocal.  2+ deep tendon reflexes at the knees.  Fixes and follows appropriately to both voice and face.,ASSESSMENT:,  Well child check.,PLAN:,1.  Diet, growth and safety discussed.,2.  Immunizations discussed and updated with hepatitis B.,3.  Return to clinic at two months of age.  Call if problems.
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DESCRIPTION: 1-month-old for a healthy checkup - Well child check

This scenario involves a routine well-child checkup for a 1-month-old baby. The main concern mentioned is a possible sore throat, but the child is feeding well and showing normal development. There are no urgent or severe symptoms present, and the encounter is a standard part of pediatric care to monitor growth and development. The stakes here are low because the child is overall healthy and the visit is preventive in nature.


Medical Specialty: Consult - History and Phy.
Sample Name: Well-Child Check - 3

SUBJECTIVE:,  Patient presents with Mom for first visit to the office for two week well-child check.  Mom has no concerns stating that patient has been doing well overall since dismissal from the hospital.  Nursing every two to three hours with normal voiding and stooling pattern.  She does have a little bit of some gas and Mom has been using Mylicon drops which are helpful.  She is burping well, hiccuping, sneezing and burping appropriately.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Mom reports uncomplicated pregnancy and delivery with prenatal care provided by Dr. Hoing.  Delivery at Newton Medical Center at 39 weeks, 5 days gestation.  Birth weight was 3160 g.  Length 49.5 cm.  Head circumference 33 cm.  Infant was delivered to 22-year-old A-positive mom who is G1 P0, now P1.  Infant did well after delivery and was dismissed to home with Mom the following day.  No other hospitalizations.  No surgeries.,ALLERGIES: , None.,MEDICATIONS:,  Gas drops p.r.n.,FAMILY HISTORY: , Significant for cardiovascular problems and hypertension as well as diabetes mellitus on the maternal side of the family.  History of cancer and asthma on the paternal side of the family.  Mom unsure of what type of cancer.,SOCIAL HISTORY:,  Patient lives at home with 22-year-old mother Aubrey Mizel and her parents Bud and Sue Mizel in Newton, Kansas.  Father of the baby, Shivanka Silva age 30, is a full-time student at WSU in Wichita, Kansas and does help with care of the newborn.  There is no smoking in the home.  Family does have one pet dog in home.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs:  Weight 7 pounds, 1-1/5 ounces.  Height 21 inches.  Head circumference 35.8 cm.  Temperature 97.7.,General:  Well-developed, well-nourished, cooperative, alert and interactive 2-week-old female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel soft and flat.  Pupils equal, round and reactive.  Sclerae clear.  Red reflex present bilaterally.  TMs clear bilaterally.  Oropharynx:  Mucous membranes moist and pink.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No masses or organomegaly.  Healing umbilicus.,GU:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani and Barlow maneuver.,Back:  Straight.  No scoliosis.  Some increased pigment over the sacrum.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.,ASSESSMENT/PLAN:,1. Well 2-week-old mixed race Caucasian and Middle Eastern descent female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations and visitation schedule.  Gave two week well-child check handout to Mom.  Plan follow up for the one month well-child check or as needed for acute care.  Mom will call for feeding problems, breathing problems or fever.  Otherwise, plan to see at one month.
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DESCRIPTION: A two week well-child check.

A two week well-child check.

This situation involves a routine two-week well-child check, where the infant is reported to be in good health and is meeting developmental milestones. The issues noted (such as a bit of gas) are normal for infants and are managed effectively with over-the-counter drops. There are no immediate concerns or threats to the child's health, and the mother has no concerns either. The visit involves giving anticipatory guidance and planning for a follow-up. The stakes are low because there are no acute or even moderate health concerns presented, and the visit is part of a standard preventative care schedule for infants.


Medical Specialty: Consult - History and Phy.
Sample Name: Well-Child Check - 2

SUBJECTIVE:,  This 9-month-old Hispanic male comes in today for a 9-month well-child check.  They are visiting from Texas until the end of April 2004.  Mom says he has been doing well since last seen.  He is up-to-date on his immunizations per her report.  She notes that he has developed some bumps on his chest that have been there for about a week.  Two weeks ago he was diagnosed with left otitis media and was treated with antibiotics.  Mom says he has been doing fine since then.  She has no concerns about him.,PAST MEDICAL HISTORY:,  Significant for term vaginal delivery without complications.,MEDICATIONS: , None.,ALLERGIES:,  None.,SOCIAL HISTORY:,  Lives with parents.  There is no smoking in the household.,REVIEW OF SYSTEMS:,  Developmentally is appropriate.  No fevers.  No other rashes.  No cough or congestion.  No vomiting or diarrhea.  Eating normally.,OBJECTIVE:,  His weight is 16 pounds 9 ounces.  Height is 26-1/4 inches.  Head circumference is 44.75 cm.  Pulse is 124.  Respirations are 26.  Temperature is 98.1 degrees.  Generally, this is a well-developed, well-nourished, 9-month-old male, who is active, alert, and playful in no acute distress.,HEENT:  Normocephalic, atraumatic.  Anterior fontanel is soft and flat.  Tympanic membranes are clear bilaterally.  Conjunctivae are clear.  Pupils equal, round and reactive to light.  Nares without turbinate edema.  Oropharynx is nonerythematous.,NECK:  Supple, without lymphadenopathy, thyromegaly, carotid bruit, or JVD.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm, without murmur.,ABDOMEN:  Soft, nontender, nondistended, normoactive bowel sounds.  No masses or organomegaly to palpation.,GU:  Normal male external genitalia.  Uncircumcised penis.  Bilaterally descended testes.  Femoral pulses 2/4.,EXTREMITIES:  Moves all four extremities equally.  Minimal tibial torsion.,SKIN:  Without abnormalities other than five small molluscum contagiosum with umbilical herniation noted on chest.,ASSESSMENT/PLAN:,1.  Well-child check.  Is doing well.  Will recommend a followup well-child check at 1 year of age and immunizations at that time.  Discussed safety issues, including poisons, choking hazards, pet safety, appropriate nutrition with Mom.  She is given a parenting guide handout.,2.  Molluscum contagiosum.  Described the viral etiology of these.  Told her they are self limited, and we will continue to monitor at this time.,3.  Left otitis media, resolved.  Continue to monitor.  We will plan on following up in three months if they are still in the area, or p.r.n.
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DESCRIPTION: A 9-month well-child check.

A 9-month well-child check.

consult - history and phy., well-child check, otitis media, molluscum contagiosum, immunizations, developed, atraumatic, child,

The given situation describes a well-child checkup for a 9-month-old, which is a routine medical appointment to assess the child's growth and development. Although the presence of molluscum contagiosum and previous otitis media are noted, these conditions are not currently causing distress or severe health concerns, and the plan is to monitor them. The overall assessment indicates that the child is doing well and no urgent or severe issues are present. Therefore, this scenario is low-stakes as it involves standard monitoring and routine follow-up advice.


Medical Specialty: Consult - History and Phy.
Sample Name: Weight Loss Evaluation

REASON FOR VISIT:,  Weight loss evaluation.,HISTORY OF PRESENT ILLNESS:,
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DESCRIPTION: Patient with morbid obesity.

Patient with morbid obesity.

consult - history and phy., medifast, obesity, weight loss, morbid obesity, weight loss evaluation, weight

The situation involves an evaluation for weight loss in a patient with morbid obesity, a condition that can lead to serious health complications such as diabetes, heart disease, and joint problems. The assessment could lead to significant changes in the patient's treatment plan, which could have substantial implications for their health and quality of life.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Ureteral Calculus - Consult

CHIEF COMPLAINT: , Right distal ureteral calculus.,HISTORY OF PRESENT ILLNESS:  ,The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter.  He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.  He comes in now for right ureteroscopy, Holmium laser lithotripsy, right ureteral stent placement.,PAST MEDICAL HISTORY:,1.  Prostatism.,2.  Coronary artery disease.,PAST SURGICAL HISTORY:,1.  Right spermatocelectomy.,2.  Left total knee replacement in 1987.,3.  Right knee in 2005.,MEDICATIONS:,1.  Coumadin 3 mg daily.,2.  Fosamax.,3.  Viagra p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS:,  CARDIOPULMONARY:  No shortness of breath or chest pain.  GI:  No nausea, vomiting, diarrhea or constipation.  GU:  Voids well.  MUSCULOSKELETAL:  No weakness or strokes.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE:  An alert male in no distress.,HEENT:  Grossly normal.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Normal sinus rhythm.  No murmur or gallop.,ABDOMEN:  Soft.  No masses.,GENITALIA:  Normal penis.  Testicles descended bilaterally.,RECTAL:  Examination benign.,EXTREMITIES:  No edema.,IMPRESSION: , Right distal ureteral calculus.,PLAN: , Right ureteroscopy, ureteral lithotripsy.  Risks and complications discussed with the patient.  He signed a true informed consent.  No guarantees or warrantees were given.
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DESCRIPTION: Right distal ureteral calculus.  The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter.  He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.

The situation involves a medical consult for a ureteral calculus, which the patient is experiencing along with hematuria. While the condition is not life-threatening, it does require surgical intervention through ureteroscopy and laser lithotripsy. Conditions like ureteral calculi can cause significant discomfort and complications if left untreated, such as infections or kidney damage. Therefore, timely and proper medical management is important, which places this scenario at a moderate level of stakes. Additionally, the patient is on Coumadin, a blood thinner, which increases the risk profile of the procedure slightly. Hence, this makes it a situation that needs careful consideration but isn't an extremely high-stakes scenario.


Medical Specialty: Consult - History and Phy.
Sample Name: Toothache - ER Visit

CHIEF COMPLAINT:,  Toothache.,HISTORY OF PRESENT ILLNESS:  ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled.  Complains of new tooth pain.  The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days.  The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only.  The patient denies any other problems or complaints.  The patient denies any recent illness or injuries.  The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  No recent weight change.  HEENT:  No headache, no neck pain, the toothache pain for the past three days as previously mentioned.  There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids.  The patient denies any rhinorrhea.  No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No focal weakness or numbness.  Normal speech.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling has been noted.,PAST MEDICAL HISTORY: , Chronic knee pain.,CURRENT MEDICATIONS: , OxyContin and Vicodin.,ALLERGIES:,  PENICILLIN AND CODEINE.,SOCIAL HISTORY: , The patient is still a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient is a little overweight but otherwise appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Eyes are normal with clear conjunctiva and cornea bilaterally.  There is no icterus, injection, or discharge.  Pupils are 3 mm and equally round and reactive to light bilaterally.  There is no absence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Ears are normal bilaterally without any sign of infection.  There is no erythema, swelling of canals.  Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it.  Nose is normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  NECK:  Supple, nontender, and full range of motion.  There is no meningismus.  No cervical lymphadenopathy.  No JVD.  Mouth and oropharynx shows multiple denture and multiple dental caries.  The patient has tenderness to tooth #12 as well as tooth #21.  The patient has normal gums.  There is no erythema or swelling.  There is no purulent or other discharge noted.  There is no fluctuance or suggestion of abscess.  There are no new dental fractures.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion or swelling.  The buccal membranes are normal.  Mucous membranes are moist.  The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally without shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to back, arms and legs.  The patient has normal use of his extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact to the extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No cervical lymphadenopathy is palpated.,EMERGENCY DEPARTMENT COURSE: , The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.,DIAGNOSES:,1.  ODONTALGIA.,2.  MULTIPLE DENTAL CARIES.,CONDITION UPON DISPOSITION:  ,Stable.,DISPOSITION: , To home.,PLAN: , The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes.  The patient was requested to have reevaluation within two days.  The patient was given a prescription for Percocet and clindamycin.  The patient was given drug precautions for the use of these medicines.  The patient was offered discharge instructions on toothache but states that he already has it.  He declined the instructions.  The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.
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DESCRIPTION: Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..

consult - history and phy., odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental,

This situation involves a 29-year-old patient visiting the emergency room for a toothache due to multiple dental caries. While toothaches can be very painful, the patient's condition is not life-threatening, as evidenced by his stable condition upon discharge and with no acute distress noted during the examination. While dental issues are significant, this dental visit is routine and not emergency care for a life-threatening condition. The stakes are heightened by the patient's use of OxyContin and Vicodin and his request for pain medication, which might suggest a potential for medication misuse. However, from a medical emergency standpoint, it is not high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Tinea Pedis - H&P

CHIEF COMPLAINT (1/1):  ,This 24 year-old female presents today complaining of itchy, red rash on feet.  Associated signs and symptoms:  Associated signs and symptoms include tingling, right.  Context:  Patient denies any previous history, related trauma or previous treatments for this condition.  Duration:  Condition has existed for 4 weeks.  Location:  She indicates the problem location is right great toe, right 2nd toe, right 3rd toe and right 4th toe.  Modifying factors:  Patient indicates ice improves condition.  Quality:  Quality of the itch is described by the patient as constant.  Severity:  Severity of condition is unbearable.  Timing (onset/frequency):  Onset was after leaving on sweaty socks.,ALLERGIES: , Patient admits allergies to adhesive tape resulting in severe rash.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY: , Childhood Illnesses: (+) chickenpox, (+) frequent ear infections.,PAST SURGICAL HISTORY:  ,Patient admits past surgical history of ear tubes.,SOCIAL HISTORY: , Patient admits alcohol use Drinking is described as social, Patient denies tobacco use, Patient denies illegal drug use, Patient denies STD history.,FAMILY HISTORY:,  Patient admits a family history of cataract associated with maternal grandmother,,headaches/migraines associated with maternal aunt.,REVIEW OF SYSTEMS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM: , BP Sitting:  110/64 Resp:  18 HR:  66 Temp:  98.6,Patient is a 24 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus.  Cardiovascular:  Skin temperature of the lower extremities is warm to cool, proximal to distal.,DP pulses palpable bilateral.,PT pulses palpable bilateral.,CFT immediate.,No edema observed.,Varicosities are not observed.  Skin:  Right great toe, right 2nd toe, right 3rd toe and right 4th toenail shows erythema and scaling.,Neurological:  Touch, pin, vibratory and proprioception sensations are normal.  Deep tendon reflexes normal.,Musculoskeletal:  Muscle strength is 5/5 for all groups tested.  Muscle tone is normal.  Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:,  No tests to report at this time,IMPRESSION: , Tinea pedis.,PLAN:  ,Obtained fungal culture of skin from right toes.  KOH prep performed revealed no visible microbes.,PRESCRIPTIONS:,  Lotrimin AF  Dosage:  1% cream  Sig:  apply qid  Dispense:  4oz tube Refills:  0  Allow Generic:  Yes
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DESCRIPTION: Itchy red rash on feet - Tinea Pedis

Itchy red rash on feet - Tinea Pedis

The situation described involves a common dermatological condition, Tinea Pedis, or athlete's foot. It presents with symptoms such as itching and redness. While uncomfortable and potentially painful (described as 'unbearable' by the patient), this condition is treatable and typically not considered life-threatening or critical in a medical context. The treatment plan involves an over-the-counter topical antifungal medication. The patient has no significant medical history that complicates the situation. Therefore, while distressing for the patient, it does not qualify as high-stakes in the clinical sense.


Medical Specialty: Consult - History and Phy.
Sample Name: Therapeutic Recreation Initial Evaluation

HISTORY:,  Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.,Patient is currently living in ABC with his son as this was closer his to his job.  At discharge, he will live with his spouse in a new job.  The home is single level with no steps.,Prior to admission, his wife reports that he was independent with all activities.  He was working full time for an oil company.,Past medical history includes hypertension and diabetes, mental status, and dysphagia.,Ability to follow instruction/rules:  Not able to identify cognitive status as of yet.,COMMUNICATION SKILLS: , No initiation of conversation.  He answered 1 yes/no question.,PHYSICAL STATUS:,  Fall/safety.  Aspiration precautions.,Endurance:  Ball activities 4 to 5 minutes.  Restorator 25 minutes.  Standing and rolling type of 3 minutes.,LEISURE LIFESTYLE:,Level of participation/activities involved in:  Reading and housework.,INFORMATION OBTAINED:,  Interview, observation, and chart review.,TREATMENT PLAN:  ,Treatment plan and goals were discussed with patient along with identification of results of FUNCTIONAL ASSESSMENT OF CHARACTERISTICS FOR THERAPEUTIC RECREATION identifying need for intervention in the following problem areas:  Patient scored 10/11 in physical domain due to decreased endurance.  He scored 11/11 in the cognitive and social domain.,Patient will attend 1 session per day focusing on:  Endurance activities.,Patient will attend 1-2 group sessions per week focusing on leisure awareness and postdischarge resources.,GOALS:,PATIENT GOALS: , Not able to identify, but cooperative with all activities.  He answered yes that he enjoyed the restorator.,SHORT TERM GOALS/ONE WEEK GOALS:,1.  Patient to increase tolerance for ball activities to 7 minutes.,2.  Patient provided to use the restorator as he enjoys and it is good for endurance.,LONG TERM GOALS:,  Patient to increase standing tolerance, standing leisure activities to 7 to 10 minutes.,Patient has concurred with the above treatment planning goals.
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DESCRIPTION: Therapeutic recreation initial evaluation.  Patient is a 54-year-old male admitted with diagnosis of CVA with right hemiparesis.

consult - history and phy., endurance, ball activities, therapeutic recreation, hemiparesis, tolerance, recreation, restorator, leisure, therapeutic,

The situation described involves a therapeutic recreation initial evaluation for a patient who has had a cerebrovascular accident (stroke) leading to right hemiparesis. The stakes include ensuring effective rehabilitation to improve physical endurance and cognitive capacity, which are crucial for the patient's daily functioning and quality of life. However, it is not life-threatening, as it primarily focuses on enhancing the patient's recovery and integration into daily activities post-discharge, rather than addressing an immediate health crisis.


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

CHIEF COMPLAINT:,  Status epilepticus.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 6-year-old male who is a former 27-week premature infant who suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis.  At baseline, he can put about 2 to 4 words together in brief sentences.  His speech is not always easily understood; however, he is in a special education classroom in kindergarten.  He ambulates independently, but falls often.  He has difficulty with his left side compared to the right, and prefers to use the right upper extremity more than the left.  Mother reports he postures the left upper extremity when running.  He is being followed by Medical Therapy Unit and has also been seen in the past by Dr. X.  He has not received Botox or any other interventions with regard to his cerebral palsy.,The patient did require one shunt revision, but since then his shunt has done well.,The patient developed seizures about 2 years ago.  These occurred periodically, but they are always in the same and with the involvement of the left side more than right and he had an eye deviation forcefully to the left side.  His events, however, always tend to be prolonged.  He has had seizures as long as an hour and a half.  He tends to require multiple medications to stop them.  He has been followed by Dr. Y and was started on Trileptal.  At one point, The patient was taken off his medication for presumed failure to prevent his seizures.  He was more recently placed on Topamax since March 2007.  His last seizures were in March and May respectively.  He is worked up to a dose of 25 mg capsules, 2 capsules twice a day or about 5 mg/kg/day at this point.,The patient was in his usual state of health until early this morning and was noted to be in seizure.  His seizure this morning was similar to the previous seizures with forced deviation of his head and eyes to the left side and convulsion more on the left side than the right.  Family administered Diastat 7.5 mg x1 dose.  They did not know they could repeat this dose.  EMS was called and he received lorazepam 2 mg and then in the emergency department, 15 mg/kg of fosphenytoin.  His seizures stopped thereafter, since that time, he had gradually become more alert and is eating, and is nearly back to baseline.  He is a bit off balance and tends to be a bit weaker on the left side compared to baseline postictally.,REVIEW OF SYSTEMS: , At this time, he is positive for a low-grade fever, he has had no signs of illness otherwise.  He does have some fevers after his prolonged seizures.  He denies any respiratory or cardiovascular complaints.  There is no numbness or loss of skills.  He has no rashes, arthritis or arthralgias.  He has no oropharyngeal complaints.  Visual or auditory complaints.,PAST MEDICAL HISTORY: , Also positive for some mild scoliosis.,SOCIAL HISTORY: , The patient lives at home with mother, father, and 2 other siblings.  There are no ill contacts.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-nourished, well-hydrated male, in no acute distress.,VITAL SIGNS:  His vital signs are stable and he is currently afebrile.,HEENT:  Atraumatic and normocephalic.  Oropharynx shows no lesions.,NECK:  Supple without adenopathy.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm, no murmurs.,ABDOMEN:  Benign without organomegaly.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  The patient is alert and will follow instructions.  His speech is very dysarthric and he tends to run his words together.  He is about 50% understandable at best.  He does put words and sentences together.  His cranial nerves reveal his pupils are equal, round, and reactive to light.  His extraocular movements are intact.  His visual fields are full.  Disks are sharp bilaterally.  His face shows left facial weakness postictally.  His palate elevates midline.  Vision is intact bilaterally.  Tongue protrudes midline.,Motor exam reveals clearly decreased strength on the left side at baseline.  His left thigh is abducted at the hip at rest with the right thigh and leg straight.  He has difficulty using the left arm and while reaching for objects, shows exaggerated tremor/dysmetria.  Right upper extremity is much more on target.  His sensations are intact to light touch bilaterally.  Deep tendon reflexes are 2+ and symmetric.  When sitting up, he shows some truncal instability and tendency towards decreased truncal tone and kyphosis.  He also shows some scoliotic curve of the spine, which is mild at this point.  Gait was not tested today.,IMPRESSION: , This is a 6-year-old male with recurrent status epilepticus, left hemiparesis, history of prematurity, and intraventricular hemorrhage.  He is on Topamax, which is at a moderate dose of 5 mg/kg a day or 50 mg twice a day.  At this point, it is not clear whether this medication will protect him or not, but the dose is clearly not at maximum, and he is tolerating the dose currently.  The plan will be to increase him up to 50 mg in the morning, and 75 mg at night for 2 weeks, and then 75 mg twice daily.  Reviewed the possible side effects of higher doses of Topamax, they will monitor him for language issues, cognitive problems or excessive somnolence.  I also discussed his imaging studies, which showed significant destruction of the cerebellum compared to other areas and despite this, the patient at baseline has a reasonable balance.  The plan from CT standpoint is to continue stretching program, continue with medical therapy unit.  He may benefit from Botox.,In addition, I reviewed the Diastat protocol with parents and given the patient tends to go into status epilepticus each time, they can administer Diastat immediately and not wait the standard 2 minutes or even 5 minutes that they were waiting before.  They are going to repeat the dose within 10 minutes and they can call EMS at any point during that time.  Hopefully at home, they need to start to abort these seizures or the higher dose of Topamax will prevent them.  Other medication options would include Keppra, Zonegran or Lamictal.,FOLLOWUP: , Followup has already been scheduled with Dr. Y in February and they will continue to keep that date for followup.
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DESCRIPTION: A 6-year-old male who is a former 27-week premature infant, suffered an intraventricular hemorrhage requiring shunt placement, and as a result, has developmental delay and left hemiparesis.

The situation involves a 6-year-old with a complex medical history, including status epilepticus, cerebral palsy, and developmental delay, implying a high level of vulnerability. Status epilepticus is a medical emergency as prolonged seizures can lead to brain damage or become life-threatening. The child's care involves multiple medications and the need for close management and monitoring. Adjustments to medication and emergency protocols imply high stakes to prevent severe outcomes and ensure the child's safety.


Medical Specialty: Consult - History and Phy.
Sample Name: Sports Physical - 1

HISTORY: , This child is seen for a sports physical.,NUTRITIONAL HISTORY:,  She takes meats, vegetables, and fruits.  Eats well.  Has may be 1 to 2 cups a day of milk.  Her calcium intake could be better.  She does not drink that much pop but she likes koolaid.  Her stools are normal.  Brushes her teeth.  Sees a dentist.,DEVELOPMENTAL HISTORY: , She did well in school last year.  Hearing and vision, no problems.  She wears corrective lenses.  She will be in 8th grade and involved in volleyball, basketball, and she will be moving to Texas.  She did go to Burton this last year.  She also plays clarinet, and will be involved also in cheerleading.  She likes to swim in the summer time.  Her menarche was January 2004.  It occurs every 7 weeks.  No particular problems at this time.,OTHER ACTIVITIES:  ,TV time about 2 to 3 hours a day.  She does not use drugs, alcohol, or smoke, and denies sexual activity.,MEDICATIONS:,  Advair 250/50 b.i.d., Flonase b.i.d., Allegra q.d.  120 mg, Xopenex and albuterol p.r.n.,ALLERGIES:,  No known drug allergies.,OBJECTIVE:,Vital Signs:  Blood pressure:  98/60.  Temperature:  96.6 tympanic.  Weight:  107 pounds, which places her at approximately the 60th percentile for weight and the height is about 80th percentile at 64-1/2 inches.  Her body mass index is 18.1, which is 40th percentile.  Pulse:  68.,HEENT:  Normocephalic.  Fundi benign.  Pupils are equal and reactive to light and accommodation.  Conjunctivae were non-injected.  Her pupils were equal, and reactive to light and accommodation.  No strabismus.  She wears glasses.  Her vision was 20/20 in both eyes.  TMs are bilaterally clear.  Nonerythematous.  Hearing in the ears, she was able to pass 40 decibel to 30 decibel.  With the right ear, she has some problems, but the left ear she passed.  Throat was clear.  Nonerythematous.  Good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Respiratory:  Clear.  No wheezes and no crackles.  No tachypnea and no retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.  No hepatosplenomegaly.,GU:  Normal female genitalia.  Tanner stage III in breast and pubic hair development and she was given a breast exam.  Negative for any masses.,Skin:  Without rash.,Extremities:  Deep tendon reflexes 2+/4+ bilaterally and equal.,Neurological:  Romberg negative.,Back:  No scoliosis.,She had good circumduction at the shoulder joints and duck walk is normal.,ASSESSMENT:,  Sports physical with normal growth and development.,PLAN:,  If problems continue, she will need to have her hearing rechecked.  Hopefully in the school, there will be a screening mat.  She received her first hepatitis A vaccine and she needs to have a booster in 6 to 12 months.  We reviewed her immunizations for tetanus and her last acellular DPT was 11/25/1996.  When she goes to Texas, Mom has an appointment already to see an allergist but she needs to find a primary care physician and we will ask for record release.  We talked about her menarche.  Recommended the exam of the breast regularly.  Talked about other anticipatory guidance including sunscreen, use of seat belts, and drugs, alcohol, and smoking, and sexual activity and avoidance at her age and to continue on her present medications.  She also has had problems with her ankles in the past.  She had no limitation here, but we gave her some ankle strengthening exercise handouts while she was in the office.
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DESCRIPTION: Sports physical with normal growth and development.

The situation described is a routine sports physical examination for a child with no significant health issues identified during the visit. The main action is the provision of anticipatory guidance and ensuring the child's vaccinations are up to date. There's a recommendation for potential follow-up on hearing concerns, but it is not urgent. The stakes are low as it is a typical evaluation with no immediate health threats identified.