Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 7

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

The situation describes an acute medical condition involving an elderly patient with a suspected new-onset cerebrovascular accident (stroke) and a urinary tract infection resistant to most oral medications. The patient's vital signs indicate potentially severe hypertension, and she has pre-existing conditions like dementia, COPD, and prior stroke history. Swift and competent medical intervention is necessary to manage the stroke symptoms and the infection, which might otherwise lead to severe complications or worsening of her condition. Given the patient's age, medical history, and current symptoms, this scenario is highly sensitive and potentially life-threatening, making it high-stakes.


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

Medical Specialty: Obstetrics / Gynecology
Sample Name: Preeclampsia

REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.  She is on multiple medications, unable to control the blood pressure.  From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath.  She complains of fatigue and tiredness.  The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery.  The patient is in intensive care unit.,CORONARY RISK FACTORS:,  History of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal.  No history of established coronary artery disease and family history noncontributory for coronary disease.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY:  ,No major surgery except for C-section.,MEDICATIONS:,  Presently on Cardizem and metoprolol were discontinued.  Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,ALLERGIES: , None.,PERSONAL HISTORY: , Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,  Hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  No congestive heart.  No arrhythmia.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis, or melena.,UROLOGIC:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.,LUNGS:  Clear.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.,LABORATORY DATA: , EKG shows sinus tachycardia with nonspecific ST-T changes.  Labs were noted.  BUN and creatinine within normal limits.,IMPRESSION:,1.  Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.,2.  No prior history of cardiac disease except for borderline gestational diabetes mellitus.,RECOMMENDATIONS:,1.  We will get an echocardiogram for assessment left ventricular function.,2.  The patient will start on labetalol and hydralazine to see how see fairs.,3.  Based on response to medication, we will make further adjustments.  Discussed with the patient regarding plan of care, fully understands and consents for the same.  All the questions answered in detail.
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DESCRIPTION: Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.  The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.

Preeclampsia is a serious condition, particularly after delivery, due to its potential complications such as seizures (eclampsia), stroke, or organ damage. Uncontrolled blood pressure post-cesarean section can lead to acute health crises for the mother. This requires careful management and monitoring to prevent severe outcomes. The situation is further exacerbated by the patient being treated with multiple medications, indicating the condition's severity. Additionally, monitoring is crucial due to potential complications with the heart and the recent delivery of a child with congenital anomalies. The stakes are high given these risks and the current critical condition of the patient in the ICU.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Salvage Cystectomy

PREOPERATIVE DIAGNOSES:,1.  Radiation cystitis.,2.  Refractory voiding dysfunction.,3.  Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,POSTOPERATIVE DIAGNOSES:,1.  Radiation cystitis.,2.  Refractory voiding dysfunction.,3.  Status post radical retropubic prostatectomy and subsequent salvage radiation therapy.,TITLE OF OPERATION: , Salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), Indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis.,ANESTHESIA: , General endotracheal with epidural.,INDICATIONS:  ,This patient is a 65-year-old white male who in 1998 had a radical prostatectomy.  He was initially dry without pads and then underwent salvage radiation therapy for rising PSA.  After that he began with episodes of incontinence as well as urinary retention requiring catheterization.  One year ago, he was unable to catheterize and was taken to the operative room and had cystoscopy.  He had retained staple removed and a diverticulum identified.  There were also bladder stones that were lasered and removed, and he had been incontinent ever since that time.  He wears 8 to 10 pads per day, and this has affected his quality of life significantly.  I took him to the operating room on January 16, 2008, and found diffuse radiation changes with a small capacity bladder and wide-open bladder neck.  We both felt that his lower urinary tract was not rehabilitatable and that a continent cutaneous diversion would solve the number of problems facing him.  I felt like if we could remove the bladder safely, then this would also provide a benefit.,FINDINGS: , At exploration, there were no gross lesions of the smaller or large bowel.  The bladder was predictably sucked into the pelvic sidewall both inferiorly and laterally.  The opened bladder, which we were able to remove completely, had a wide-open capacious diverticulum in its very distal segment.  Because of the previous radiation therapy and a dissection down to the pelvis, I elected to place an omental pedicle flap to provide additional blood supply for healing as well in the pelvis and also under the pubic bone which was exposed inferiorly due to previous surgery and treatment.,PROCEDURE IN DETAIL:  ,The patient was brought to the operative suite and after adequate general endotracheal and epidural anesthesia obtained, placed in the supine position, flexed over the anterosuperior iliac spine, and his abdomen and genitalia were sterilely prepped and draped in the usual fashion.  A nasogastric tube was placed as well as radial arterial line.  He was given intravenous antibiotics for prophylaxis.  A generous midline skin incision was made from the midepigastrium down to the symphysis pubis, deep into the rectus fascia, the rectus muscle separated in the midline, and exploration carried out with the findings described.  Moist wound towels and a Bookwalter retractor were placed for exposure.  We began by retracting the bowels by mobilizing the cecum and ascending colon and hepatic flexure and elevating the terminal ileum up to the second and third portion of the duodenum.  The ureter was identified as a crisis over the iliac vessels and dissected deep into pelvis and subsequently divided between clips.  An identical procedure was performed in the left side with similar findings and the bowels were packed cephalad.,We began then dissecting the bladder away from the pelvic side walls staying medial to both epigastric arteries.  This was quite challenging because of the previous radiation therapy and radical prostatectomy.  We essentially carved the bladder off of the pelvic sidewall inferiorly as best we could and then we were able to have enough freedom to identify the lateral pedicles, and these were taken between double clips approximately and clipped distally.  We then approached things posteriorly and carefully dissected between the __________ and posterior bladder.  There was some remnant seminal vesicle on the right as well as both remnant ejaculatory duct and we used this to dissect the longus safe plane anterior to the rectum.  We then entered the bladder anteriorly as distal as we could and remove the bladder and what we thought was a bladder neck and this appeared to end in a diverticulum.  We then peeled it off the remaining rectum and passed the specimen off the operative field.  Bladder was irrigated with warm sterile water and a meticulous inspection was made for hemostasis.,We then completely mobilized the omentum off of the proximal transverse colon.  This allowed a generous flap to be able to be laid into the pelvis without tension.,We then turned our attention to forming the Indiana pouch.  I completed the dissection of the right hepatic flexure and the proximal transverse colon and mobilized the omentum off of this portion of the colon.  The colon was divided proximal to the middle colic using a GIA-80 stapler.  I then divided the avascular plane of Treves along the terminal ileum and selected a point approximately 15 cm proximal to the ileocecal valve to divide the ileum.  The mesentery was then sealed with a LigaSure device and divided, and the bowel was divided with a GIA-60 stapler.  We then performed a side-to-side ileo-transverse colostomy using a GIA-80 stapler, closing the open end with a TA 60.  The angles were reinforced with silk sutures and the mesenteric closed with interrupted silk sutures.,We then removed the staple line along the terminal ileum, passed a 12-French Robinson catheter into the cecal segment, and plicated the ileum with 3 firings of the GIA-60 stapler.  The ileocecal valve was then reinforced with interrupted 3-0 silk sutures as described by Rowland, et al, and following this, passage of an 18-French Robinson catheter was associated with the characteristic "pop," indicating that we had adequately plicated the ileocecal valve.,As the patient had had a previous appendectomy, we made an opening in the cecum in the area of the previous appendectomy.  We then removed the distal staple line along the transverse colon and aligned the cecal end and the distal middle colic end with two 3-0 Vicryl sutures.  The bowel segment was then folded over on itself and the reservoir formed with 3 successive applications of the SGIA Polysorb-75.  Between the staple lines, Vicryl sutures were placed and the defects closed with 3-0 Vicryl suture ligatures.,We then turned our attention to forming the ileocolonic anastomosis.  The left ureter was mobilized and brought underneath the sigmoid mesentery and brought through the mesentery of the terminal ileum and an end-to-side anastomosis performed with an open technique using interrupted 4-0 Vicryl sutures, and this was stented with a Cook 8.4-French ureteral stent, and this was secured to the bowel lumen with a 5-0 chromic suture.  The right ureter was brought underneath the pouch and placed in a stented fashion with an identical anastomosis.  We then brought the stents out through a separate incision cephalad in the pouch and they were secured with a 2-0 chromic suture.  A 24-French Malecot catheter was placed through the cecum and secured with a chromic suture.  The staple lines were then buried with a running 3-0 Vicryl two-layer suture and the open end of the pouch closed with a TA 60 Polysorb suture.  The pouch was filled to 240 cc and noted to be watertight, and the ureteral anastomoses were intact.,We then made a final inspection for hemostasis.  The cecostomy tube was then brought out to the right lower quadrant and secured to the skin with silk sutures.  We then matured our stoma through the umbilicus.  We removed the plug of skin through the umbilicus and delivered the ileal segment through this.  A portion of the ileum was removed and healthy, well-vascularized tissue was matured with interrupted 3-0 chromic sutures.  We left an 18-French Robinson through the stomag and secured this to the skin with silk sutures.  The Malecot and stents were also secured in a similar fashion.,We matured the stoma to the umbilicus with interrupted chromic stitches.  The stitch was brought out to the right upper quadrant and the Malecot to the left lower quadrant.  A Large JP drain was placed in the pelvis dependent to the omentum pedicle flap as well as the Indiana pouch.,The rectus fascia was closed with a buried #2 Prolene running stitch, tying a new figure-of-eight proximally and distally and meeting in the middle and tying it underneath the fascia.  Subcutaneous tissue was irrigated with saline and skin was closed with surgical clips.  The estimated blood loss was 450 mL, and the patient received no packed red blood cells.  The final sponge and needle count were reported to be correct.  The patient was awakened and extubated, and taken on stretcher to the recovery room in satisfactory condition.
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DESCRIPTION: Salvage cystectomy (very difficult due to postradical prostatectomy and postradiation therapy to the pelvis), Indiana pouch continent cutaneous diversion, and omental pedicle flap to the pelvis.

surgery, radiation cystitis, voiding dysfunction, retropubic prostatectomy, salvage radiation therapy, salvage cystectomy, indiana pouch continent cutaneous diversion, omental pedicle flap, ligasure, gia, stapler, gia stapler, vicryl sutures, radiation therapy, silk sutures, bladder, therapy, sutures, endotracheal,

The situation involves a salvage cystectomy, a complex surgical procedure, particularly given the patient's medical history of radical prostatectomy and radiation therapy. The complexity of the surgery and its implications for the patient's quality of life make it a high-stakes situation. Additionally, surgeries involving organ removal and reconstruction, like forming an Indiana pouch, inherently carry significant risks, including complications related to anesthesia, infection, and recovery. The patient's history and surgical context indicate a high-risk scenario requiring careful consideration and skill. Therefore, this is a high-stakes situation given the potential impact on the patient's health and quality of life.


Medical Specialty: Letters
Sample Name: Cerebral Palsy - Letter

Doctor's Address,Dear Doctor:,This letter serves as an introduction to my patient, A, who will be seeing you in the near future.  He is a pleasant young man who has a diagnosis of bulbar cerebral palsy and hypotonia.  He has been treated by Dr. X through the pediatric neurology clinic.  He saw Dr. X recently and she noted that he was having difficulty with mouth breathing, which was contributing to some of his speech problems.  She also noted and confirmed that he has significant tonsillar hypertrophy.  The concern we have is whether he may benefit from surgery to remove his tonsils and improve his mouth breathing and his swallowing and speech.  Therefore, I ask for your opinion on this matter.,For his chronic allergic rhinitis symptoms, he is currently on Flonase two sprays to each nostril once a day.  He also has been taking Zyrtec 10 mg a day with only partial relief of the symptoms.  He does have an allergy to penicillin.,I appreciate your input on his care.  If you have any questions regarding, please feel free to call me through my office.  Otherwise, I look forward to hearing back from you regarding his evaluation.
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DESCRIPTION: Diagnosis of bulbar cerebral palsy and hypotonia.

letters, peech, swallowing, breathing, bulbar cerebral palsy, mouth breathing, cerebral palsy, hypotoniaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The content of the letter pertains to a medical condition and potential surgical intervention for a patient with cerebral palsy and associated symptoms. While the situation involves important healthcare decisions that can significantly impact the patient's quality of life, it is not life-threatening at this immediate stage. The patient's current challenges, such as speech and breathing issues due to tonsillar hypertrophy, are serious and require medical evaluation, but they do not imply an urgent or critical emergency. Therefore, while the stakes are notable in terms of improving the patient's health outcomes and quality of life, they are moderately high rather than extremely high.


Medical Specialty: Orthopedic
Sample Name: MRI T-Spine - 1

EXAM:  ,Thoracic Spine.,REASON FOR EXAM: , Injury.,INTERPRETATION: , The thoracic spine was examined in the AP, lateral and swimmer's projections.  There is mild chronic-appearing anterior wedging of what is believed to represent T11 and 12 vertebral bodies.  A mild amount of anterior osteophytic lipping is seen involving the thoracic spine.  There is a suggestion of generalized osteoporosis.  The intervertebral disc spaces appear generally well preserved.,The pedicles appear intact.,IMPRESSION:,1. Mild chronic-appearing anterior wedging of what is believed to represent the T11 and 12 vertebral bodies.,2. Mild degenerative changes of the thoracic spine.,3. Osteoporosis.
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DESCRIPTION: The thoracic spine was examined in the AP, lateral and swimmer's projections.

orthopedic, thoracic spine, swimmer's projections, osteoporosis, osteophytic lipping, anterior wedging, vertebral bodies, thoracic, spine,

This situation involves the interpretation of a medical imaging report for an orthopedic injury evaluation. It identifies mild chronic conditions and degenerative changes as well as osteoporosis, which are notable but not acutely life-threatening findings. The findings warrant ongoing clinical management and monitoring, but they do not represent immediate, high-risk emergencies that could compromise the patient's life or require urgent intervention.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 22

SUBJECTIVE:,  This is a 12-year-old young man who comes in with about 10 days worth of sinus congestion.  He does have significant allergies including ragweed.  The drainage has been clear.  He had a little bit of a headache yesterday.  He has had no fever.  No one else is ill at home currently.,CURRENT MEDICATIONS:,  Advair and Allegra.  He has been taking these regularly.  He is not sure the Allegra is working for him anymore.  He does think though better than Claritin.,PHYSICAL EXAM:,General:  Alert young man in no distress.,HEENT:  TMs clear and mobile.  Pharynx clear.  Mouth moist.  Nasal mucosa pale with clear discharge.,Neck:  Supple without adenopathy.,Heart:  Regular rate and rhythm without murmur.,Lungs:  Lungs clear, no tachypnea, wheezing, rales or retractions.,Abdomen:  Soft, nontender, without masses or splenomegaly.,ASSESSMENT:,  I think this is still his allergic rhinitis rather than a sinus infection.,PLAN:,  Change to Zyrtec 10 mg samples were given.  He is not using nasal spray, but he has some at home.  He should restart this.  Continue to watch his peak flows to make sure his asthma does not come under poor control.  Call if any further problems.
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DESCRIPTION: A 12-year-old young man with sinus congestion.

consult - history and phy., allergic rhinitis, sinus infection, sinus congestion, congestion, sinus

The situation involves a young patient experiencing sinus congestion likely due to allergies. The assessment suggests it's allergic rhinitis, not a sinus infection, and the plan involves changing allergy medication and monitoring, which are routine measures. The patient is currently stable, without signs of severe illness or acute distress. While monitoring his asthma is important, the stakes remain relatively low as the diagnosis and treatment plan are straightforward, and there is no indication of a life-threatening or severe condition.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lobectomy - Followup

HISTORY OF PRESENT ILLNESS: , The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer.  She returns for a routine surveillance visit.,She has undergone since her last visit an abdominopelvic CT, which shows an enlarging simple cyst of the left kidney.  She underwent barium swallow, which demonstrates a small sliding hiatal hernia with minimal reflux.  She has a minimal delayed emptying secondary tertiary contractions.  PA and lateral chest x-ray from the 11/23/09 was also reviewed, which demonstrates no lesions or infiltrates.  Review of systems, the patient continues to have periodic odynophagia and mid thoracic dysphagia.  This most likely is secondary to tertiary contractions with some delayed emptying.  She has also had increased size of the left calf without tenderness, which has not resolved over the past several months.  She has had a previous DVT in 1975 and 1985.  She denies weight loss, anorexia, fevers, chills, headaches, new aches or pains, cough, hemoptysis, shortness of breath at rest, or dyspnea on exertion.,MEDICATIONS: , Aspirin 81 mg p.o. q.d., Spiriva 10 mcg q.d., and albuterol p.r.n.,PHYSICAL EXAMINATION: , BP:  117/78.  RR:  18.  P:  93.,WT:  186 lbs.  RAS:  100%.,HEENT:  Mucous membranes are moist.  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIAC:  Regular rate and rhythm without murmurs.,EXTREMITIES:  No cyanosis, clubbing or edema.,NEURO:  Alert and oriented x3.  Cranial nerves II through XII intact.,ASSESSMENT: , The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.,PLAN:  ,She is to return to clinic in six months with a chest CT.  She was given a prescription for an ultrasound of the left lower extremity to rule out DVT.  She will be called with the results.  She was given a prescription for nifedipine 10 mg p.o. t.i.d. p.r.n. esophageal spasm.
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DESCRIPTION: The patient is a 65-year-old female who underwent left upper lobectomy for stage IA non-small cell lung cancer.  She returns for a routine surveillance visit.  The patient has no evidence of disease now status post left upper lobectomy for stage IA non-small cell lung cancer 13 months ago.

cardiovascular / pulmonary, non-small cell lung cancer, lobectomy, lung cancer, non-small cell, lung, cancer

The situation involves a follow-up after a significant surgery, a lobectomy for lung cancer, which inherently makes it a serious medical context. Moreover, the presence of multiple medical issues, such as an enlarging kidney cyst, hiatal hernia, delayed gastric emptying, and history of DVTs, adds complexity. However, the patient currently shows no evidence of cancer recurrence, and the follow-up plans are routine in nature (regular check-ups and monitoring for potential DVT). The patient's overall stability and the routine nature of the follow-up mitigate the immediate high-stakes nature, but the combination of past cancer and potential DVT risks implies a need for vigilance.


Medical Specialty: Neurology
Sample Name: CT Brain - Hemangioma

CC:, Horizontal diplopia.,HX: , This 67 y/oRHM first began experiencing horizontal binocular diplopia 25 years prior to presentation in the Neurology Clinic. The diplopia began acutely and continued intermittently for one year. During this time he was twice evaluated for myasthenia gravis (details of evaluation not known) and was told he probably did not have this disease. He received no treatment and the diplopia spontaneously resolved. He did well until one year prior to presentation when he experienced sudden onset horizontal binocular diplopia. The diplopia continues to occur daily and intermittently; and lasts for only a few minutes in duration. It resolves when he covers one eye. It is worse when looking at distant objects and objects off to either side of midline. There are no other symptoms associated with the diplopia.,PMH:, 1)4Vessel CABG and pacemaker placement, 4/84. 2)Hypercholesterolemia. 3)Bipolar Affective D/O.,FHX: ,HTN, Colon CA, and a daughter with unknown type of "dystonia.",SHX:, Denied Tobacco/ETOH/illicit drug use.,ROS:, no recent weight loss/fever/chills/night sweats/CP/SOB. He occasionally experiences bilateral lower extremity cramping (?claudication) after walking for prolonged periods.,MEDS: ,Lithium 300mg bid, Accupril 20mg bid, Cellufresh Ophthalmologic Tears, ASA 325mg qd.,EXAM:, BP216/108 HR72 RR14 Wt81.6kg T36.6C,MS: unremarkable.,CN: horizontal binocular diplopia on lateral gaze in both directions. No other CN deficits noted.,Motor: 5/5 full strength throughout with normal muscle bulk and tone.,Sensory: unremarkable.,Coord: mild "ataxia" of RAM (left > right),Station: no pronator drift or Romberg sign,Gait: unremarkable. Reflexes: 2/2 symmetric throughout. Plantars (bilateral dorsiflexion),STUDIES/COURSE:, Gen Screen: unremarkable. Brain CT revealed 1.0 x 1.5 cm area of calcific density within the medial two-thirds of the left cerebral peduncle. This shows no mass effect, but demonstrates mild contrast enhancement. There are patchy areas of low density in the periventricular white matter consistent with age related changes from microvascular disease. The midbrain findings are most suggestive of a hemangioma, though another consideration would be a low grade astrocytoma (this would likely show less enhancement). Metastatic lesions could show calcification but one would expect to see some degree of edema. The long standing clinical history suggest the former (i.e. hemangioma).,No surgical or neuroradiologic intervention was done and the patient was simply followed. He was lost to follow-up in 1993.
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DESCRIPTION: CT Brain: Midbrain hemangioma

CT Brain: Midbrain hemangioma

neurology, hemangioma, brain ct, ct brain, binocular diplopia, calcific density, diplopia, horizontal binocular diplopia, myasthenia gravis, horizontal binocular, midbrain, binocular, ct, horizontal,

The situation involves a 67-year-old patient with a complex medical history and neurological symptoms that include recurrent horizontal diplopia, potentially linked to a brain hemangioma. While the immediate stakes seem low given that no interventions were conducted and the patient was lost to follow-up, the presence of a brain hemangioma could become a serious issue if not monitored, especially given the patient's other health conditions. However, at this moment, there are no immediate life-threatening symptoms or conditions described that raise the stakes considerably.


Medical Specialty: Consult - History and Phy.
Sample Name: Psych Consult - Psychosis

IDENTIFYING DATA:,  Psychosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 28-year-old Samoan female who was her grandmother's caretaker.  Her grandmother unfortunately had passed away recently and then the patient had developed erratic behavior.  She had lived with her parents and son, but parents removed son from the home, secondary to the patient's erratic behavior.  Recently, she was picked up by Kent Police Department "leaping on Highway 99.",PAST MEDICAL HISTORY: , PTSD, depression, and substance abuse.,PAST SURGICAL HISTORY:  ,Unknown.,ALLERGIES:,  Unknown.,MEDICATIONS: , Unknown.,REVIEW OF SYSTEMS: , Unable to obtain secondary to the patient being in seclusion.,OBJECTIVE:,  Vital signs that were previously taken revealed a blood pressure of 152/86, pulse of 106, respirations of 18, and temperature is 97.6 degrees Fahrenheit.  General appearance, HEENT, and history and physical examination was unable to be obtained today, as patient was put into seclusion.,LABORATORY DATA: , Laboratory reviewed reveals a BMP, slightly elevated glucose at 100.2.  Previous urine tox was positive for THC.  Urinalysis was negative, but did note positive UA wbc's.  CBC, slightly elevated leukocytosis at 12.0, normal range is 4 to 11.,ASSESSMENT AND PLAN:,AXIS I:  Psychosis.  Inpatient Psychiatric Team to follow.,AXIS II:  Deferred.,AXIS III:  We were unable to perform physical examination on the patient today secondary to her being in seclusion.  Laboratory was reviewed revealing leukocytosis, possibly secondary to a UTI.  We will wait until the patient is out of seclusion to perform examination.  Should she have some complaints of dysuria or any suprapubic pain, then we will begin on appropriate antimicrobial therapy.  We will followup with the patient should any new medical issues arise.
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DESCRIPTION: Patient with a history of PTSD, depression, and substance abuse.

consult - history and phy., ptsd, depression, psychosis, psychiatric, substance abuse, erratic behavior, behavior, axis,

The situation involves a patient experiencing severe psychosis following the death of a family member, compounded by a history of PTSD, depression, and substance abuse. These factors contribute to unstable and potentially dangerous behavior, such as leaping onto a highway, which is a significant safety risk to herself and possibly others. The patient has been placed in seclusion, indicating an acute psychiatric crisis requiring careful management and monitoring. This is a high-stakes situation because it concerns the urgent mental health and safety needs of the patient, requiring close medical supervision and intervention to mitigate risks.


Medical Specialty: Surgery
Sample Name: Nephrectomy - Radical (Laparoscopic)

PREOPERATIVE DIAGNOSIS:,  Right renal mass.,POSTOP DIAGNOSIS: , Right renal mass.,PROCEDURE PERFORMED:,  Laparoscopic right radical nephrectomy.,ESTIMATED BLOOD LOSS:,  100 mL.,X-RAYS: , None.,SPECIMENS: , Right radical nephrectomy specimen.,COMPLICATIONS: , None.,ANESTHESIA:  ,General endotracheal.,DRAINS:,  16-French Foley catheter per urethra.,BRIEF HISTORY: , The patient is a 71-year-old woman recently diagnosed with 6.5 cm right upper pole renal mass.  This is an enhancing lesion suspicious for renal cell carcinoma versus oncocytoma.  I discussed a variety of options with her, and she opted to proceed with a laparoscopic right radical nephrectomy.  All questions were answered, and she wished to proceed with surgery as planned.,PROCEDURE IN DETAIL:,  After acquisition of appropriate written and informed consent and administration of perioperative antibiotics, the patient was taken to the operating room and placed supine on the operating table.  Note that, sequential compression devices were placed on both lower extremities and were activated per induction of anesthesia.  After institution of adequate general anesthetic via the endotracheal route, she was placed into the right anterior flank position with the right side elevated in a roll and the right arm across her chest.  All pressure points were carefully padded, and she was securely taped to the table to prevent shifting during the procedure.  Her abdomen was then prepped and draped in the standard surgical fashion after placing a 16-French Foley catheter per urethra to gravity drainage.  The abdomen was insufflated in the right outer quadrant.  Note that, the patient had had previous surgery which complicated accesses somewhat and that she had a previous hysterectomy.  The abdomen was insufflated into the right lateral abdomen with Veress needle to 50 mm of pressure without incident.  We then placed a 10/12 Visiport trocar approximately 7 cm lateral to the umbilicus.  Once this had entered into the peritoneal cavity without incident, the remaining trocars were all placed.  Under direct laparoscopic visualization, we placed three additional trocars; an 11-mm screw-type trocar in the umbilicus, a 6-mm screw-type trocar in the upper midline approximately 7 cm above the umbilicus, and 10/12 trocar in the lower midline about 7 cm below the umbilicus within and over the old hysterectomy scar.  There were some adhesions of omentum to the underside of that scar, and these were taken down sharply using laparoscopic scissors.,We began nephrectomy procedure by reflecting the right colon, by incising the white line of Toldt.  This exposed the retroperitoneum on the right side.  The duodenum was identified and reflected medially in a Kocher maneuver using sharp dissection only.  We then identified the ureter and gonadal vein in the retroperitoneum.  The gonadal vein was left down along the vena cava, and the plane underneath the ureter was elevated and this plane was carried up towards the renal hilum.  Sequential packets of tissue were taken using primarily the LigaSure Atlas device.  Once we got to the renal hilum, it became apparent that this patient had two sets of renal arteries and veins.  We proceeded then and skeletonized the structures into four individual packets.  We then proceeded to perform the upper pole dissection and developing the plane above the kidney and between the kidney and adrenal gland.  The adrenal was spared during this procedure.  There was no contiguous connection between the renal mass and a right adrenal gland.  This plane of dissection was taken down primarily using the LigaSure device.  We then sequentially took the four vessels going to the kidney initially taking two renal arteries with the endo GI stapler and then to renal veins again with endo GI stapler sequential flaring.  Once this was completed, the kidney was free except for its attachment to the ureter and lateral attachments.  The lateral attachments of the kidney were taken down using the LigaSure Atlas device, and then the ureter was doubly clipped and transected.  The kidney was then freed within the retroperitoneum.  A 50-mm EndoCatch bag was introduced through the lower most trocar site, and the kidney was placed into this bag for subsequent extraction.  We extended the lower most trocar site approximately 6 cm to facilitate extraction.  The kidney was removed and passed off the table as a specimen for pathology.  This was bivalved by pathology, and we reviewed the specimen.
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DESCRIPTION: Laparoscopic right radical nephrectomy due to right renal mass.

surgery, renal mass, carter-thomason, endocatch bag, foley catheter, gi stapler, laparoscopic, ligasure, toldt, laparoscopic scissors, nephrectomy, radical nephrectomy, screw-type trocar, umbilicus, upper pole, urethra, carter thomason closure device, laparoscopic right radical nephrectomy, carter thomason closure, carter thomason, renal hilum, kidney, abdomen, endotracheal, radical, oncocytoma, renal,

This surgical procedure involves the removal of a kidney due to a potentially malignant mass. It is a major surgery with significant risks, including bleeding, injury to surrounding organs, and postoperative complications. The health implications for the patient are significant, as the surgery is conducted to remove a potentially cancerous mass. The procedure requires precise surgical skills and careful management before, during, and after the surgery to ensure patient safety and a successful outcome. Given the potential cancer diagnosis and the nature of the surgery, the stakes are high.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Knee Pain

CHIEF COMPLAINT:,  Left knee pain.,SUBJECTIVE: , This is a 36-year-old white female who presents to the office today with a complaint of left knee pain.  She is approximately five days after a third Synvisc injection.  She states that the knee is 35% to 40 % better, but continues to have a constant pinching pain when she full weight bears, cannot handle having her knee in flexion, has decreased range of motion with extension.  Rates her pain in her knee as a 10/10.  She does alternate ice and heat.  She is using Tylenol No. 3 p.r.n. and ibuprofen OTC p.r.n. with minimal relief.,ALLERGIES,1.  PENICILLIN.,2.  KEFLEX.,3.  BACTRIM.,4.  SULFA.,5.  ACE BANDAGES.,MEDICATIONS,1.  Toprol.,2.  Xanax.,3.  Advair.,4.  Ventolin.,5.  Tylenol No.  3.,6.  Advil.,REVIEW OF SYSTEMS:,  Will be starting the Medifast diet, has discussed this with her PCP, who encouraged her to have gastric bypass, but the patient would like to try this Medifast diet first.  Other than this, denies any further problems with her eyes, ears, nose, throat, heart, lungs, GI, GU, musculoskeletal, nervous system, except what is noted above and below.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse 72, blood pressure 130/88, respirations 16, height 5 feet 6.5 inches.,GENERAL:  This is a 36-year-old white female who is A&O x3, in no apparent distress with a pleasant affect.  She is well developed, well nourished, appears her stated age.,EXTREMITIES:  Orthopedic evaluation of the left knee reveals there to be well-healed portholes.  She does have some medial joint line swelling.  Negative ballottement.  She has significant pain to palpation of the medial joint line, none of the lateral joint line.  She has no pain to palpation on the popliteal fossa.  Range of motion is approximately -5 degrees to 95 degrees of flexion.  It should be noted that she has extreme hyperextension on the right with 95+ degrees of flexion on the right.  She has a click with McMurray.  Negative anterior-posterior drawer.  No varus or valgus instability noted.  Positive patellar grind test.  Calf is soft and nontender.  Gait is stable and antalgic on the left.,ASSESSMENT,1.  Osteochondral defect, torn meniscus, left knee.,2.  Obesity.,PLAN: , I have encouraged the patient to work on weight reduction, as this will only benefit her knee.  I did discuss treatment options at length with the patient, but I think the best plan for her would be to work on weight reduction.  She questions whether she needs a total knee; I don't believe she needs total knee replacement.  She may, however, at some point need an arthroscopy.  I have encouraged her to start formal physical therapy and a home exercise program.  Will use ice or heat p.r.n.  I have given her refills on Tylenol No.  3, Flector patch, and Relafen not to be taken with any other anti-inflammatory.  She does have some abdominal discomfort with the anti-inflammatories, was started on Nexium 20 mg one p.o. daily.  She will follow up in our office in four weeks.  If she has not gotten any relief with formal physical therapy and the above-noted treatments, we will discuss with Dr. X whether she would benefit from another knee arthroscopy.  The patient shows a good understanding of this treatment plan and agrees.
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DESCRIPTION: Patient with complaint of left knee pain.  Patient is obese and will be starting Medifast Diet.

consult - history and phy., medifast, medifast diet, obesity, gastric bypass, knee pain, weight reduction, knee,

The situation involves a patient experiencing significant knee pain, with a clinical focus primarily on pain management and weight reduction to alleviate symptoms. While the patient's pain is severe (10/10), the treatment plan is non-urgent, involving lifestyle changes, physical therapy, and medication management. There is no immediate life-threatening condition or requirement for emergency intervention. The stakes are elevated due to the patient's severe pain and potential for surgical intervention if no improvements are made, but it is not a critical situation demanding immediate high-stakes decisions.


Medical Specialty: Discharge Summary
Sample Name: Multiple Medical Problems - Discharge Summary

ADMISSION DIAGNOSES:,1.  Seizure.,2.  Hypoglycemia.,3.  Anemia.,4.  Hypotension.,5.  Dyspnea.,6.  Edema.,DISCHARGE DIAGNOSES:,1.  Colon cancer, status post right hemicolectomy.,2.  Anemia.,3.  Hospital-acquired pneumonia.,4.  Hypertension.,5.  Congestive heart failure.,6.  Seizure disorder.,PROCEDURES PERFORMED:,1.  Colonoscopy.,2.  Right hemicolectomy.,HOSPITAL COURSE: , The patient is a 59-year-old female with multiple medical problems including diabetes mellitus requiring insulin for 26 years, previous MI and coronary artery disease, history of seizure disorder, GERD, bipolar disorder, and anemia.  She was admitted due to a seizure and myoclonic jerks as well as hypoglycemia and anemia.  Regarding the seizure disorder, Neurology was consulted.  Noncontrast CT of the head was negative.  Neurology felt that the only necessary intervention at that time would be to increase her Lamictal to 150 mg in the morning and 100 mg in the evening with gradual increase of the dosage until she was on 200 mg b.i.d.  Regarding the hypoglycemia, the patient has diabetic gastroparesis and was being fed on J-tube intermittent feedings throughout the night at the rate of 120 an hour.  Her insulin pump had a basal rate of roughly three at night during the feedings.  While in the hospital, the insulin pump rate was turned down to 1.5 and then subsequently decreased a few other times.  She seemed to tolerate the insulin pump rate well throughout her hospital course.  There were a few episodes of hypoglycemia as well as hyperglycemia, but the episode seem to be related to the patient's n.p.o. status and the changing rates of tube feedings throughout her hospital course.,At discharge, her endocrinologist was contacted.  It was decided to change her insulin pump rate to 3 units per hour from midnight till 6 a.m., from 0.8 units per hour from 6 a.m. until 8 a.m., and then at 0.2 units per hour from 8 a.m. until 6 p.m.  The insulin was to be NovoLog.  Regarding the anemia, the gastroenterologists were consulted regarding her positive Hemoccult stools.  A colonoscopy was performed, which found a mass at the right hepatic flexure.  General Surgery was then consulted and a right hemicolectomy was performed on the patient.  The patient tolerated the procedure well and tube feeds were slowly restarted following the procedure, and prior to discharge were back at her predischarge rates of 120 per hour.  Regarding the cancer itself, it was found that 1 out of 53 nodes were positive for cancer.  CT of the abdomen and pelvis revealed no metastasis, a CT of the chest revealed possible lung metastasis.  Later in hospital course, the patient developed a septic-like picture likely secondary to hospital-acquired pneumonia.  She was treated with Zosyn, Levaquin, and vancomycin, and tolerated the medications well.  Her symptoms decreased and serial chest x-rays were followed, which showed some resolution of the illness.  The patient was seen by the Infectious Disease specialist.  The Infectious Disease specialist recommended vancomycin to cover MRSA bacteria, which was found at the J-tube site.  At discharge, the patient was given three additional days of p.o. Levaquin 750 mg as well as three additional days of Bactrim DS every 12 hours.  The Bactrim was used to cover the MRSA at the J-tube site.  It was found that MRSA was sensitive to Bactrim.  Throughout her hospital course, the patient continued to receive Coreg 12.5 mg daily and Lasix 40 mg twice a day for her congestive heart failure, which remains stable.  She also received Lipitor for her high cholesterol.  Her seizure disorder remained stable and she was discharged on a dose of 100 mg in the morning and 150 mg at night.  The dosage increases can begin on an outpatient basis.,DISCHARGE INSTRUCTIONS/MEDICATIONS: , The patient was discharged to home.  She was told to shy away from strenuous activity.  Her discharge diet was to be her usual diet of isotonic fiber feeding through the J-tube at a rate of 120 per hour throughout the night.  The discharge medications were as follows:,1.  Coreg 12.5 mg p.o. b.i.d.,2.  Lipitor 10 mg p.o. at bedtime.,3.  Nitro-Dur patch 0.3 mg per hour one patch daily.,4.  Phenergan syrup 6.25 mg p.o. q.4h. p.r.n.,5.  Synthroid 0.175 mg p.o. daily.,6.  Zyrtec 10 mg p.o. daily.,7.  Lamictal 100 mg p.o. daily.,8.  Lamictal 150 mg p.o. at bedtime.,9.  Ferrous sulfate drops 325 mg, PEG tube b.i.d.,10.  Nexium 40 mg p.o. at breakfast.,11.  Neurontin 400 mg p.o. t.i.d.,12.  Lasix 40 mg p.o. b.i.d.,13.  Fentanyl 50 mcg patch transdermal q.72h.,14.  Calcium and vitamin D combination, calcium carbonate 500 mg/vitamin D 200 units one tab p.o. t.i.d.,15.  Bactrim DS 800mg/160 mg tablet one tablet q.12h. x3 days.,16.  Levaquin 750 mg one tablet p.o. x3 days.,The medications listed above, one listed as p.o. are to be administered via the J-tube.,FOLLOWUP:  ,The patient was instructed to see Dr. X in approximately five to seven days.  She was given a lab sheet to have a CBC with diff as well as a CMP to be drawn prior to her appointment with Dr. X.  She is instructed to follow up with Dr. Y if her condition changes regarding her colon cancer.  She was instructed to follow up with Dr. Z, her oncologist, regarding the positive lymph nodes.  We were unable to contact Dr. Z, but his telephone number was given to the patient and she was instructed to make a followup appointment.  She was also instructed to follow up with her endocrinologist, Dr. A, regarding any insulin pump adjustments, which were necessary and she was also instructed to follow up with Dr. B, her gastroenterologist, regarding any issues with her J-tube.,CONDITION ON DISCHARGE: , Stable.
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DESCRIPTION: Seizure, hypoglycemia, anemia, dyspnea, edema. colon cancer status post right hemicolectomy, hospital-acquired pneumonia,
and congestive heart failure.

This discharge summary involves a patient with a complex medical history and a variety of serious and chronic medical issues including colon cancer, seizure disorder, and congestive heart failure. Hospital-acquired pneumonia and a potential metastasis indicate high-risk health concerns that need close monitoring and follow-up. The need for a right hemicolectomy and cancer treatment adds urgency and gravity to the situation. The coordination among various specialists for ongoing care is crucial for the patient's prognosis. Given the combination of multiple serious conditions, recent surgical intervention, and the need for precise medication and dietary management, this situation presents as high-stakes for the patient's health outcomes.


Medical Specialty: Surgery
Sample Name: Uterine Suction Curettage

PREOPERATIVE DIAGNOSIS: , A 10-1/2 week pregnancy, spontaneous, incomplete abortion.,POSTOPERATIVE DIAGNOSIS:,  A 10-1/2 week pregnancy, spontaneous, incomplete abortion.,PROCEDURE: , Exam under anesthesia with uterine suction curettage.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,COMPLICATIONS:,  None.,DRAINS:,  None.,CONDITION:,  Stable.,INDICATIONS:  ,The patient is a 29-year-old gravida 5, para 1-0-3-1, with an LMP at 12/18/05.  The patient was estimated to be approximately 10-1/2 weeks so long in her pregnancy.  She began to have heavy vaginal bleeding and intense lower pelvic cramping.  She was seen in the emergency room where she was found to be hemodynamically stable.  On pelvic exam, her cervix was noted to be 1 to 2 cm dilated and approximately 90% effaced.  There were bulging membranes protruding through the dilated cervix.  These symptoms were consistent with the patient's prior experience of spontaneous miscarriages.  These findings were reviewed with her and options for treatment discussed.  She elected to proceed with an exam under anesthesia with uterine suction curettage.  The risks and benefits of the surgery were discussed with her and knowing these, she gave informed consent.,PROCEDURE:  ,The patient was taken to the operating room where she was placed in the seated position.  A spinal anesthetic was successfully administered.  She was then moved to a dorsal lithotomy position.  She was prepped and draped in the usual fashion for the procedure.  After adequate spinal level was confirmed, a bimanual exam was again performed.  This revealed the uterus to be anteverted to axial and approximately 10 to 11 weeks in size.  The previously noted cervical exam was confirmed.  The weighted vaginal speculum was then inserted and the vaginal vault flooded with povidone solution.  This solution was then removed approximately 10 minutes later with dry sterile gauze sponge.  The anterior cervical lip was then attached with a ring clamp.  The tissue and membranes protruding through the os were then gently grasped with a ring clamp and traction applied.  The tissue dislodged revealing fluid mixed with blood as well as an apparent 10-week fetus.  The placental tissue was then gently tractioned out as well.  A size 9 curved suction curette was then gently inserted through the dilated os and into the endometrial cavity.  With the vacuum tubing applied in rotary motion, a moderate amount of tissue consistent with products of conception was evacuated.  The sharp curette was then utilized to probe the endometrial surface.  A small amount of additional tissue was then felt in the posterior uterine wall.  This was curetted free.  A second pass was then made with a vacuum curette.  Again, the endometrial cavity was probed with a sharp curette and no significant additional tissue was encountered.  A final pass was then made with a suction curette.,The ring clamp was then removed from the anterior cervical lip.  There was only a small amount of bleeding following the curettage.  The weighted speculum was then removed as well.  The bimanual exam was repeated and good involution was noted.  The patient was taken down from the dorsal lithotomy position.  She was transferred to the recovery room in stable condition.  The sponge and instrument count was performed and found to be correct.  The specimen of products of conception and 10-week fetus were submitted to Pathology for further evaluation.  The estimated blood loss for the procedure is less than 10 mL.
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DESCRIPTION: Exam under anesthesia with uterine suction curettage.  A 10-1/2 week pregnancy, spontaneous, incomplete abortion.

surgery, spontaneous, incomplete abortion, uterine suction curettage, fetus, anterior cervical lip, spontaneous incomplete abortion, bimanual exam, ring clamp, suction curettage, uterine, curettage, suction

The situation involves a surgical procedure for an incomplete miscarriage. It requires medical intervention to prevent complications such as infection or excessive bleeding, as well as to ensure that all pregnancy tissue is removed from the uterus. While the procedure is generally routine and has low complications when performed correctly, it is still a surgery with potential risks. The stakes are moderate because the patient's well-being and physical health depend on the successful completion of this procedure.


Medical Specialty: Chiropractic
Sample Name: Foot pain Consultation

CHIEF COMPLAINT:, Left foot pain.,HISTORY:, XYZ is a basketball player for University of Houston who sustained an injury the day prior. They were traveling. He came down on another player's foot sustaining what he describes as an inversion injury. Swelling and pain onset immediately. He was taped but was able to continue playing He was examined by John Houston, the trainer, and had tenderness around the navicular so was asked to come over and see me for evaluation. He has been in a walking boot. He has been taped firmly. Pain with weightbearing activities. He is limping a bit. No significant foot injuries in the past. Most of his pain is located around the dorsal aspect of the hindfoot and midfoot. ,PHYSICAL EXAM:, He does have some swelling from the hindfoot out toward the midfoot. His arch is maintained. His motion at the ankle and subtalar joints is preserved. Forefoot motion is intact. He has pain with adduction and abduction across the hindfoot. Most of this discomfort is laterally. His motor strength is grossly intact. His sensation is intact, and his pulses are palpable and strong. His ankle is not tender. He has minimal to no tenderness over the ATFL. He has no medial tenderness along the deltoid or the medial malleolus. His anterior drawer is solid. His external rotation stress is not painful at the ankle. His tarsometatarsal joints, specifically 1, 2 and 3, are nontender. His maximal tenderness is located laterally along the calcaneocuboid joint and along the anterior process of the calcaneus. Some tenderness over the dorsolateral side of the talonavicular joint as well. The medial talonavicular joint is not tender.,RADIOGRAPHS:, Those done of his foot weightbearing show some changes over the dorsal aspect of the navicular that appear chronic. I don't see a definite fracture. The tarsometarsal joints are anatomically aligned. Radiographs of his ankle again show changes along the dorsal talonavicular joint but no other fractures identified. Review of an MR scan of the ankle dated 12/01/05 shows what looks like some changes along the lateral side of the calcaneocuboid joint with disruption of the lateral ligament and capsular area. Also some changes along the dorsal talonavicular joint. I don't see any significant marrow edema or definitive fracture line. ,IMPRESSION:,  Left Chopart joint sprain.,PLAN:,  I have spoken to XYZ about this. Continue with ice and boot for weightbearing activities. We will start him on a functional rehab program and progress him back to activities when his symptoms allow. He is clear on the prolonged duration of recovery for these hindfoot type injuries.
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DESCRIPTION: Consultation for left foot pain.

Consultation for left foot pain.

chiropractic, foot pain, calcaneocuboid joint, dorsal aspect, dorsal talonavicular joint, foot injuries, hindfoot, midfoot, rehab program, walking boot, weightbearing, talonavicular joint, dorsal, talonavicular, ankle, foot, tenderness

The situation involves an athlete with a foot injury, specifically a left Chopart joint sprain. While this is a significant concern for the athlete’s sports career and may impact their ability to play in the short term, it does not pose an immediate threat to life or long-term health. Treatment involves conservative management such as ice, a walking boot, and functional rehabilitation, which suggests the situation is not critical. However, for an athlete, such injuries can have implications on their performance and future prospects in sports, which slightly raises the stakes.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychosocial Eval - Donor

DONOR'S PERCEPTION OF RECIPIENT'S ILLNESS:,What is your understanding of the recipient's illness and why they need a kidney - "This kidney is for my mother who is on dialysis and my mother has been suffering long enough, and I want to relieve the suffering so that she is able to have a kidney transplant.",When and how did subject of donation arise - "My mom and I talked about it together as a family.",RECIPIENT'S REACTION TO OFFER:,What was the recipient's reaction to your offer:  "I would rather not go there.  Well, since we were talking, "I will tell you that my mother really does not understand.  She is very worried.  She is very afraid that something might happen to me, and she would feel terrible if I had any problems as a result of being a donor.  I don't think my mom really understands, and I know that she really needs a kidney.  I think she is coming around to accepting.",FAMILY'S REACTION TO OFFER:,What are your family feelings about your being a donor - "Well, my children are fine and my husband is very supportive.",CANDIDATE'S MOTIVATION TO DONATE:,How did you arrive at the decision to be a donor - "My brothers and sisters and I got together and we all decided since my schedule was the most flexible and I was used to traveling, I seem like to the best candidate.",How would your family and friends react if you decided not to be a donor - "I don't think that is going to happen.",CANDIDATE'S MOTIVATION TO DONATE:,How would you feel if you cannot be the donor for any reason - "I would feel very upset because I know that this is the best for my mother, and I want to do this very badly for my mother.  I am hoping my headache is away and my blood pressure comes down so that I will start to feel better during this workup.",CANDIDATE'S DESCRIPTION OF RELATIONSHIP WITH RECIPIENT:,What is your relationship to the recipient - "That is my mother.",How your relationship with the recipient change if you donate your kidney - "I am not sure that it will change at all.  I know that I will feel better about doing this for my mother, because my mother is always sacrificing and helping others.",With your being a donor affect any other relationships in your life - No, I don't think it will have that much of an impact.  I am away from my children and my husband a lot because of I travel with my job.  So I don't think being donor will really have that dramatic affect.,Do you have an understanding of the process of transplant - "Yes, I have a very good understanding of the transplant process.  I work as a contract nursing all over the country.  I am able to see patients doing different things in different places and so I feel like I have a very realistic perceptive on the process.",CANDIDATE'S UNDERSTANDING OF TRANSPLANTATION AND RISK OF REJECTION:,Do you understand the risk of rejection of your kidney by the recipient - "Yes, I do understand all the risks.  I have had a long conversation with the coordinator and we have talked about these things.",Have you thought about how you might feel if the kidney is rejected - "I guess, I am just sure that I won't be rejected and I am just sure that everything will be fine.  It is a part of the way I am managing my stress about this.",Do you have any doubts or concerns about donating - "No, I don't have any doubts or any concerns right now.  I just wish this headache would go away.,Do you understand that there will be pain after the transplant - "Of course, I do.",What are your expectations about your recuperation - "I am planning on staying with my mom for three months in the Houston area after the transplant.  We live outside of Tampa, Florida; so this will be an adventure for both of us.",Do you need to speak further to any of the transplant team members - "No, I have had a long talk with ABC.  I feel pretty comfortable about my conversation with her as well as my conversation with the Nephrologist.,MEDICAL HISTORY:,What previous illnesses or surgeries have you had - "I had a one cesarian section, and I also suffered from asthma as a child.  I am in otherwise good health.",Are you currently on any medication - "Yes, I am on Folic acid.",PSYCHIATRIC HISTORY:,Have you ever spoken with a counselor, therapist, or psychiatrist - "No, I have not.  I have a good supportive system and a lot of people that I can talk to when I need to.",ALCOHOL, NICOTINE, DRUG USE:,Do you smoke - "No.",Any typical drinks you prefer - "I am a nondrinker.",What kinds of recreational drugs have you tried?  Have you used any recently - "None.",FAMILY AND SUPPORT SYSTEMS:,MARITAL STATUS:  LENGTH OF TIME MARRIED:  "I live with my family, my husband, and my two children with good relationship.  We have been married for 29 years.",NAME OF SPOUSE/PARTNER:  "His name is Xyz.",AGE AND HEALTH OF SPOUSE/PARTNER:  He is in his 40s and he is healthy and lives outside of Tampo with our 6-year-old daughter.  Our elder child has just finished college.",CHILDREN:  I have two children; ages 28 and also 6.,POST-SURGICAL HOUSING PLAN:,With whom will you stay after discharge - "I will stay with a friend.  He lives in the Houston area.  I am staying with that friend right now, while I am here for my workup.",CURRENT OCCUPATION:,What is your current occupation - "I currently work on a contract basis as a nurse.  I go on assignments all over the country, and I work until the contract is over.  This allowed me to be flexible and the best candidate for donation to mom.",Do you have the support of your employer - "Absolutely.",PAID OFF TIME:,Paid leave - "None.",Disability coverage:  "None.",SUPPORTIVE ENVIRONMENT:,  "Yes."
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DESCRIPTION: Psychosocial evaluation of kidney donor.  Questions - Answers

The situation involves a psychosocial evaluation for a potential kidney donor, which is inherently a high-stakes situation. Donating a kidney is a major medical procedure with significant risks and implications both for the donor and the recipient. Issues such as the donor's understanding of risks, the dynamics between the donor and recipient, and the emotional and psychological readiness of the donor are critical. The decision can have lasting impacts on the donor's health and the recipient's survival. While the donor appears well-informed and motivated, the stakes remain high due to the potential consequences of organ donation and surgery.


Medical Specialty: Nephrology
Sample Name: Cystourethroscopy & Retrograde Pyelogram - 1

PREOPERATIVE DIAGNOSES:,1.  Right renal mass.,2.  Hematuria.,POSTOPERATIVE DIAGNOSES:,1.  Right renal mass.,2.  Right ureteropelvic junction obstruction.,PROCEDURES PERFORMED:,1.  Cystourethroscopy.,2.  Right retrograde pyelogram.,3.  Right ureteral pyeloscopy.,4.  Right renal biopsy.,5.  Right double-J 4.5 x 26 mm ureteral stent placement.,ANESTHESIA: , Sedation.,SPECIMEN: , Urine for cytology and culture sensitivity, right renal pelvis urine for cytology, and right upper pole biopsies.,INDICATION:,  The patient is a 74-year-old male who was initially seen in the office with hematuria.  He was then brought to the hospital for other medical problems and found to still have hematuria.  He has a CAT scan with abnormal appearing right kidney and it was felt that he will benefit from cystoscope evaluation.,PROCEDURE: ,After consent was obtained, the patient was brought to the operating room and placed in the supine position.  He was given IV sedation and placed in dorsal lithotomy position.  He was then prepped and draped in the standard fashion.  A #21 French cystoscope was then passed through his ureter on which patient was noted to have a hypospadias and passed through across the ends of the bladder.  The patient was noted to have mildly enlarged prostate, however, it was non-obstructing.,Upon visualization of the bladder, the patient was noted to have some tuberculation to the bladder.  There were no masses or any other abnormalities noted other than the tuberculation.  Attention was then turned to the right ureteral orifice and an open-end of the catheter was then passed into the right ureteral orifice.  A retrograde pyelogram was performed.  Upon visualization, there was no visualization of the upper collecting system on the right side.  At this point, a guidewire was then passed through the open-end of the ureteral catheter and the catheter was removed.  The bladder was drained and the cystoscope was removed.  The rigid ureteroscope was then passed into the bladder and into the right ureteral orifice with the assistance of a second glidewire.  The ureteroscope was taken all the way through the proximal ureter just below the UPJ and there were noted to be no gross abnormalities.  The ureteroscope was removed and an Amplatz wire then passed through the scope up into the collecting system along the side of the previous wire.  The ureteroscope was removed and a ureteral dilating sheath was passed over the Amplatz wire into the right ureter under fluoroscopic guidance.  The Amplatz wire was then removed and the flexible ureteroscope was passed through the sheath into the ureter.  The ureteroscope was passed up to the UPJ at which point there was noted to be difficulty entering the ureter due to UPJ obstruction.  The wire was then again passed through the flexible scope and the flexible scope was removed.  A balloon dilator was then passed over the wire and the UPJ was dilated with balloon dilation.  The dilator was then removed and again the cystoscope was passed back up into the right ureter and was able to enter the collecting system.  Upon visualization of the collecting system of the upper portion, there was noted to be papillary mass within the collecting system.  The ________ biopsy forceps were then passed through the scope and two biopsies were taken of the papillary mass.  Once this was done, the wire was left in place and the ureteroscope was removed.  The cystoscope was then placed back into the bladder and a 26 x 4.5 mm ureteral stent was passed over the wire under fluoroscopic and cystoscopic guidance into the right renal pelvis.  The stent was noted to be clear within the right renal pelvis as well as in the bladder.  The bladder was drained and the cystoscope was removed.  The patient tolerated the procedure well.  He will be transferred to the recovery room and back to his room.  It has been discussed with his primary physician that the patient will likely need a nephrectomy.  He will be scheduled for an echocardiogram tomorrow and then decision will be made where the patient will be stable for possible nephrectomy on Wednesday.
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DESCRIPTION: Cystourethroscopy, right retrograde pyelogram, right ureteral pyeloscopy, right renal biopsy, and right double-J 4.5 x 26 mm ureteral stent placement.  Right renal mass and ureteropelvic junction obstruction and hematuria.

nephrology, renal mass, hematuria, ureteropelvic junction obstruction, cystourethroscopy, retrograde, pyelogram, ureteral pyeloscopy, renal biopsy, double-j, ureteral stent placement, ureteropelvic junction, flexible scope, papillary mass, ureteral stent, renal pelvis, ureteral orifice, amplatz wire, retrograde pyelogram, ureteral, cystoscope, ureteroscope, renal, bladder

The medical procedure detailed involves multiple diagnostic and therapeutic interventions to address a right renal mass and ureteropelvic junction obstruction in a 74-year-old male with hematuria. The findings suggest potential renal malignancy, requiring immediate and precise medical intervention, namely a possible nephrectomy. The patient's advanced age and the complexity of his condition underline the high-stakes nature of the situation. Any delay or error in such a case could have significant health implications for the patient.


Medical Specialty: Radiology
Sample Name: Chest PA & Lateral

EXAM: , Chest PA & Lateral.,REASON FOR EXAM: , Shortness of breath, evaluate for pneumothorax versus left-sided effusion.,INTERPRETATION:  ,There has been interval development of a moderate left-sided pneumothorax with near complete collapse of the left upper lobe.  The lower lobe appears aerated.  There is stable, diffuse, bilateral interstitial thickening with no definite acute air space consolidation.  The heart and pulmonary vascularity are within normal limits.  Left-sided port is seen with Groshong tip at the SVC/RA junction.  No evidence for acute fracture, malalignment, or dislocation.,IMPRESSION:,1.  Interval development of moderate left-sided pneumothorax with corresponding left lung atelectasis.,2.  Rest of visualized exam nonacute/stable.,3.  Left central line appropriately situated and stable.,4.  Preliminary report was issued at time of dictation.  Dr. X was called for results.
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DESCRIPTION: Chest PA & Lateral to evaluate shortness of breath and pneumothorax versus left-sided effusion.

radiology, effusion, interstitial thickening, chest pa & lateral, shortness of breath, chest, pneumothorax,

The exam reveals a moderate left-sided pneumothorax with near complete collapse of the left upper lobe, which constitutes a serious and potentially life-threatening condition requiring prompt medical intervention, typically involving procedures to re-expand the lung. Combined with the initial symptoms of shortness of breath, this suggests a high-stakes scenario due to the immediate risk to the patient's breathing and overall health.


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

Medical Specialty: Neurosurgery
Sample Name: Lumbar Puncture

REASON FOR VISIT:  ,This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X. She is accompanied by her daughter.,HISTORY OF PRESENT ILLNESS:,  The patient' daughter tells me that over the last month the patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak.  She has not been having any headaches.  She has had a significant decrease in appetite.  She is known to have lung cancer, but Ms. Wilson does not know what kind.  According to her followup notes, it is presumed non-small cell lung cancer of the left upper lobe of the lung.  The last note I have to evaluate is from October 2008.  CT scan from 12/01/2009 shows atrophy and small vessel ischemic change, otherwise a normal head CT, no mass lesion.  I also reviewed the MRI from September 2009, which does not suggest normal pressure hydrocephalus and shows no mass lesion.,Blood tests from 11/18/2009 demonstrate platelet count at 132 and INR of 1.0.,MAJOR FINDINGS: , The patient is a pleasant and cooperative woman who answers the questions the best she can and has difficulty moving her left arm and hand.  She also has pain in her left arm and hand at a level of 8-9/10.,VITAL SIGNS: , Blood pressure 126/88, heart rate 70, respiratory rate 16, and weight 95 pounds.,I screened the patient with questions to determine whether it is likely she has abnormal CSF pressure and she does not have any of the signs that would suggest this, so we performed the procedure in the upright position.,PROCEDURE:,  Lumbar puncture, diagnostic (CPT 62270).,PREOPERATIVE DIAGNOSIS: , Possible CSF malignancy.,POSTOPERATIVE DIAGNOSIS:  ,To be determined after CSF evaluation.,PROCEDURE PERFORMED: , Lumbar puncture.,ANESTHESIA: , Local with 2% lidocaine at the L4-L5 level.,SPECIMEN REMOVED:  ,15 cc of clear CSF.,ESTIMATED BLOOD LOSS: , None.,DESCRIPTION OF THE PROCEDURE:  ,I explained the procedure, its rationale, risks, benefits, and alternatives to the patient and her daughter.  The patient' daughter remained present throughout the procedure.  The patient provided written consent and her daughter signed as witness to the consent.,I located the iliac crest and spinous processes before the procedure and determined the level I planned for the puncture.  During the procedure, I spoke constantly with the patient to explain what was happening and to warn when there might be pain or discomfort.  The skin was prepped with chlorhexidine solution with the patient seated on the chair leaning forward with her face resting on the exam table.  Using local anesthetic and aseptic technique, I inserted a 20-gauge spinal needle at the L4-L5 interspace and 15 cc of CSF was collected without difficulty.,The patient tolerated the procedure well.,ASSESSMENT:  ,White blood cells 1, red blood cells 54, glucose 59, protein 51, Gram stain negative, bacterial culture negative after three days, and remaining tests pending.
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DESCRIPTION: Possible CSF malignancy.  This is an 83-year-old woman referred for diagnostic lumbar puncture for possible malignancy by Dr. X.   The patient has gradually stopped walking even with her walker and her left arm has become gradually less functional.  She is not able to use the walker because her left arm is so weak.

The situation involves a diagnostic lumbar puncture procedure on an 83-year-old woman with known lung cancer and potential neurological impairments. The procedure is conducted to rule out or confirm possible CSF malignancy, which could significantly impact her cancer management and overall prognosis. The patient's deteriorating physical abilities and the potential for malignancy in the CSF present high stakes in terms of health outcomes and necessary medical interventions. Although the immediate procedure is low-risk, the implications of its findings are high-stakes due to the possible need for urgent oncological interventions or changes in treatment if malignancy is confirmed.


Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consult - 2

SUBJECTIVE:,  The patient's assistant brings in her food diary sheets.  The patient says she stays active by walking at the mall.,OBJECTIVE:,  Weight today is 201 pounds, which is down 3 pounds in the past month.  She has lost a total of 24 pounds.  I praised this and encouraged her to continue.  I went over her food diary.  I praised her three-meal pattern and all of her positive food choices, especially the use of sugar-free Kool-Aid, sugar-free Jell-O, sugar-free lemonade, diet pop, as well as the variety of foods she is using in her three-meal pattern.  I encouraged her to continue all of this.,ASSESSMENT:,  The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.  She needs to continue all this.,PLAN:,  Followup is set for 06/13/05 to check the patient's weight, her food diary, and answer any questions.
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DESCRIPTION: The patient has been successful with weight loss due to assistance from others in keeping a food diary, picking lower-calorie items, her three-meal pattern, getting a balanced diet, and all her physical activity.

consult - history and phy., food diary sheets, active, balanced diet, three-meal pattern, weight loss, sugar free, food diary, dietary, weight, meal, diary, sheets, food

The situation involves a dietary consultation where the patient is successfully losing weight and has been positively encouraged to continue her current habits. While weight management can have significant health implications, this particular instance indicates ongoing success, positive reinforcement, and a supportive plan without immediate high-risk factors. The meeting is routine follow-up to monitor progress rather than address urgent issues.


Medical Specialty: Gastroenterology
Sample Name: Colon Cancer Consult

REASON FOR CONSULTATION: , I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer.,HISTORY OF PRESENT ILLNESS:,  The patient presented to medical attention after she noticed mild abdominal cramping in February 2007.  At that time, she was pregnant and was unsure if her symptoms might have been due to the pregnancy.  Unfortunately, she had miscarriage at about seven weeks.  She again had abdominal cramping, severe, in late March 2007.  She underwent colonoscopy on 04/30/2007 by Dr. Y.  Of note, she is with a family history of early colon cancers and had her first colonoscopy at age 35 and no polyps were seen at that time.,On colonoscopy, she was found to have a near-obstructing lesion at the splenic flexure.  She was not able to have the scope passed past this lesion.  Pathology showed a colon cancer, although I do not have a copy of that report at this time.,She had surgical resection done yesterday.  The surgery was laparoscopic assisted with anastomosis.  At the time of surgery, lymph nodes were palpable.,Pathology showed colon adenocarcinoma, low grade, measuring 3.8 x 1.7 cm, circumferential and invading in to the subserosal mucosa greater than 5 mm, 13 lymph nodes were negative for metastasis.  There was no angiolymphatic invasion noted.  Radial margin was 0.1 mm.  Other margins were 5 and 6 mm.  Testing for microsatellite instability is still pending.,Staging has already been done with a CT scan of the chest, abdomen, and pelvis.  This showed a mass at the splenic flexure, mildly enlarged lymph nodes there, and no evidence of metastasis to liver, lungs, or other organs.  The degenerative changes were noted at L5-S1.  The ovaries were normal.  An intrauterine device (IUD) was present in the uterus.,REVIEW OF SYSTEMS:,  She has otherwise been feeling well.  She has not had fevers, night sweats, or noticed lymphadenopathy.  She has not had cough, shortness of breath, back pain, bone pain, blood in her stool, melena, or change in stool caliber.  She was eating well up until the time of her surgery.  She is up-to-date on mammography, which will be due again in June.  She has no history of pulmonary, cardiac, renal, hepatic, thyroid, or central nervous system (CNS) disease.,ALLERGIES: , PENICILLIN, WHICH CAUSED HIVES WHEN SHE WAS A CHILD.,MEDICATIONS PRIOR TO ADMISSION:,  None.,PAST MEDICAL HISTORY: , No significant medical problem.  She has had three miscarriages, all of them at about seven weeks.  She has no prior surgeries.,SOCIAL HISTORY:  ,She smoked cigarettes socially while in her 20s.  A pack of cigarettes would last for more than a week.  She does not smoke now.  She has two glasses of wine per day, both red and white wine.  She is married and has no children.  An IUD was recently placed.  She works as an esthetician.,FAMILY HISTORY:  ,Father died of stage IV colon cancer at age 45.  This occurred when the patient was young and she is not sure of the rest of the paternal family history.  She does believe that aunts and uncles on that side may have died early.  Her brother died of pancreas cancer at age 44.  Another brother is aged 52 and he had polyps on colonoscopy a couple of years ago.  Otherwise, he has no medical problem.  Mother is aged 82 and healthy.  She was recently diagnosed with hemochromatosis.,PHYSICAL EXAMINATION: , ,GENERAL:  She is in no acute distress.,VITAL SIGNS:  The patient is afebrile with a pulse of 78, respirations 16, blood pressure 124/70, and pulse oximetry is 93% on 3 L of oxygen by nasal cannula.,SKIN:  Warm and dry.  She has no jaundice.,LYMPHATICS:  No cervical or supraclavicular lymph nodes are palpable.,LUNGS:  There is no respiratory distress.,CARDIAC:  Regular rate.,ABDOMEN:  Soft and mildly tender.  Dressings are clean and dry.,EXTREMITIES:  No peripheral edema is noted.  Sequential compression devices (SCDs) are in place.,LABORATORY DATA:,  White blood count of 11.7, hemoglobin 12.8, hematocrit 37.8, platelets 408, differential shows left shift, MCV is 99.6.  Sodium is 136, potassium 4.1, bicarb 25, chloride 104, BUN 5, creatinine 0.7, and glucose is 133.  Calcium is 8.8 and magnesium is 1.8.,IMPRESSION AND PLAN: , Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  She does not have high-risk factors such as high grade or angiolymphatic invasion, and adequate number of lymph nodes were sampled.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.,A lengthy discussion was held with the patient regarding her diagnosis and prognosis.  Firstly, she has a good prognosis for being cured without adjuvant therapy.  I would consider her borderline for chemotherapy given her young age.  Referring to the database that had been online, she has a 13% chance of relapse in the next five years, and with aggressive chemotherapy (X-linked agammaglobulinemia (XLA) platinum-based), this would be reduced to an 8% risk of relapse with a 5% benefit.  Chemotherapy with 5-FU based regimen would have a smaller benefit of around 2.5%.,Plan was made to allow her to recuperate and then meet with her and her husband to discuss the pros and cons of adjuvant chemotherapy including what regimen she could consider including the side effects.  We did not review all that information today.,She has a family history of early colon cancer.  Her mother will be visiting in the weekend and plan is to obtain the rest of the paternal family history if we can.  Tumor is being tested for microsatellite instability and we will discuss this when those results are available.  She has one sibling and he is up-to-date on colonoscopy.  She does report multiple tubes of blood were drawn prior to her admission.  I will check with Dr. Y's office whether she has had a CEA and liver-associated enzymes assessed.  If not, those can be drawn tomorrow.
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DESCRIPTION: Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1.  Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.

The situation involves a patient with a newly diagnosed stage II colon cancer. Although the prognosis seems favorable with potential for cure without adjuvant therapy, it remains a serious health concern due to family history and a non-negligible risk of cancer recurrence. Deciding on adjuvant chemotherapy is crucial and involves weighing the risks and benefits. These factors, combined with the emotional impact of cancer diagnosis, suggest a moderately high-stakes scenario.


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

PROCEDURES: , Left heart catheterization, left ventriculography, and left and right coronary arteriography.,INDICATIONS: , Chest pain and non-Q-wave MI with elevation of troponin I only.,TECHNIQUE:  ,The patient was brought to the procedure room in satisfactory condition.  The right groin was prepped and draped in routine fashion.  An arterial sheath was inserted into the right femoral artery.,Left and right coronary arteries were studied with a 6FL4 and 6FR4 Judkins catheters respectively.  Cine coronary angiograms were done in multiple views.,Left heart catheterization was done using the 6-French pigtail catheter.  Appropriate pressures were obtained before and after the left ventriculogram, which was done in the RAO view.,At the end of the procedure, the femoral catheter was removed and Angio-Seal was applied without any complications.,FINDINGS:,1.  LV is normal in size and shape with good contractility, EF of 60%.,2.  LMCA normal.,3.  LAD has 20% to 30% stenosis at the origin.,4.  LCX is normal.,5.  RCA is dominant and normal.,RECOMMENDATIONS: , Medical management, diet, and exercise.  Aspirin 81 mg p.o. daily, p.r.n. nitroglycerin for chest pain.  Follow up in the clinic.
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DESCRIPTION: Chest pain and non-Q-wave MI with elevation of troponin I only.  Left heart catheterization, left ventriculography, and left and right coronary arteriography.

cardiovascular / pulmonary, arteriography, coronary arteriography, heart catheterization, ventriculography, angiograms

The situation involves a heart catheterization procedure performed due to chest pain and non-Q-wave myocardial infarction (MI) with elevated troponin I levels, which indicates heart muscle damage. While catheterization is a routine procedure for diagnosing and managing coronary artery disease, the reason for the procedure, MI, elevates the stakes as it involves heart health. The findings show some stenosis but not severe, as the patient is advised for medical management and not immediate surgical intervention.


Medical Specialty: Consult - History and Phy.
Sample Name: Airway Compromise & Foreign Body - ER Visit

HISTORY OF PRESENT ILLNESS:,  The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.,PAST MEDICAL HISTORY: , Significant for diabetes, hypertension, asthma, cholecystectomy, and total hysterectomy and cataract.,ALLERGIES:  ,No known drug allergies.,CURRENT MEDICATIONS: , Prevacid, Humulin, Diprivan, Proventil, Unasyn, and Solu-Medrol.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY: , Negative for illicit drugs, alcohol, and tobacco.,PHYSICAL EXAMINATION:  ,Please see the hospital chart.,LABORATORY DATA: , Please see the hospital chart.,HOSPITAL COURSE: , The patient was taken to the operating room by Dr. X who is covering for ENT and noted that she had airway compromise and a rather large fishbone noted and that was removed.  The patient was intubated and it was felt that she should be observed to see if the airway would improve upon which she could be extubated.  If not she would require tracheostomy.  The patient was treated with IV antibiotics and ventilatory support and at the time of this dictation, she has recently been taken to the operating room where it was felt that the airway sufficient and she was extubated.  She was doing well with good p.o.s, good airway, good voice, and desiring to be discharged home.  So, the patient is being prepared for discharge at this point.  We will have Dr. X evaluate her before she leaves to make sure I do not have any problem with her going home.  Dr. Y feels she could be discharged today and will have her return to see him in a week.
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DESCRIPTION: The patient is a 17-year-old female, who presents to the emergency room with foreign body and airway compromise and was taken to the operating room.  She was intubated and fishbone.

consult - history and phy., diabetes, hypertension, asthma, cholecystectomy, fishbone, foreign body, airway compromise, airway,

This situation involves a 17-year-old female presenting to the ER with airway compromise due to a foreign body (fishbone), which required surgical intervention. Airway compromise is a potentially life-threatening condition, especially if not addressed promptly, as it can lead to suffocation. The involvement of multiple specialists, the need for intubation, and observation for potential tracheostomy underscore the high-stakes nature of the situation. However, the successful removal of the foreign body, stabilization, and preparation for discharge reduce immediate risks. The stakes are high but have lowered due to effective medical intervention.


Medical Specialty: Radiology
Sample Name: CT Maxillofacial

EXAM:  ,CT maxillofacial for trauma.,FINDINGS: , CT examination of the maxillofacial bones was performed without contrast.  Coronal reconstructions were obtained for better anatomical localization.,There is normal appearance to the orbital rims.  The ethmoid, sphenoid, and frontal sinuses are clear.  There is polypoid mucosal thickening involving the floor of the maxillary sinuses bilaterally.  There is soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.  The nasal bones appear intact.  The zygomatic arches are intact.  The temporomandibular joints are intact and demonstrate no dislocations or significant degenerative changes.  The mandible and maxilla are intact.  There is soft tissue swelling seen involving the right cheek.,IMPRESSION:,1.  Mucosal thickening versus mucous retention cyst involving the maxillary sinuses bilaterally.  There is also soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.,2.  Mild soft tissue swelling about the right cheek.
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DESCRIPTION: CT maxillofacial for trauma.  CT examination of the maxillofacial bones was performed without contrast.  Coronal reconstructions were obtained for better anatomical localization.

radiology, ethmoid, sphenoid, frontal sinuses, mandible, maxilla, ct examination, maxillofacial bones, mucosal thickening, maxillary sinuses, ct, maxillofacial

The CT maxillofacial report is used to evaluate potential trauma to the facial bones. In this case, the report primarily indicates soft tissue changes and potential sinus issues rather than findings suggestive of acute fractures or life-threatening injuries. While these findings need to be considered by a medical professional, especially in the context of trauma, the lack of immediate life-threatening issues like severe fractures, suggests it is not extremely high-stakes.


Medical Specialty: Neurosurgery
Sample Name: Neuroplasty

PREOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:,  Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS:,  None.,SUMMARY:  ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details).  Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle.  After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle.  These needles were removed and the patient was discharged in stable condition.
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DESCRIPTION: Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.

neurosurgery, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural,

Neurosurgery is inherently a high-stakes medical specialty due to the complex anatomy and potential complications involved. This procedure involves operating around the spine and nerve roots, which could have significant consequences if not done correctly, such as paralysis or worsening pain. The need for precision in decompression and adhesiolysis in spinal surgery indicates a high-stakes situation. The use of fluoroscopic guidance and the administration of medication directly around the neural structures also suggest critical care. Despite the absence of complications in this particular case, the potential risks associated with this type of surgery make it high-stakes.