Medical Specialty: Consult - History and Phy.
Sample Name: Nephrology Consultation - 3

PAST MEDICAL/SURGICAL HISTORY: , Briefly, his past medical history is significant for hypertension of more than 5 years, asthma, and he has been on Advair and albuterol.  He was diagnosed with renal disease in 02/2008 and has since been on hemodialysis since 02/2008.  His past surgical history is only significant for left AV fistula on the wrist done in 04/2008.  He still has urine output.  He has no history of blood transfusion.,PERSONAL AND SOCIAL HISTORY: , He is a nonsmoker.  He denies any alcohol.  No illicit drugs.  He used to work as the custodian at the nursing home, but now on disability since 03/2008.  He is married with 2 sons, ages 5 and 17 years old.,FAMILY HISTORY:,  No similar illness in the family, except for hypertension in his one sister and his mom, who died at 61 years old of congestive heart failure.  His father is 67 years old, currently alive with asthma.  He also has one sister who has hypertension.  The rest of the 6 siblings are alive and well.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Singulair 10 mg once daily, Cardizem 365 mg once daily, Coreg 25 mg once daily, hydralazine 100 mg three times a day, Lanoxin 0.125 mg once daily, Crestor 10 mg once daily, lisinopril 10 mg once daily, Phoslo 3 tablets with meals, and Advair 250 mg inhaler b.i.d.,REVIEW OF SYSTEMS: , Significant only for asthma.  No history of chest pain normal MI.  He has hypertension.  He occasionally will develop colds especially with weather changes.  GI:  Negative.  GU:  Still making urine about 1-3 times per day.  Musculoskeletal:  Negative.  Skin:  He complains of dry skin.  Neurologic:  Negative.  Psychiatry:  Negative.  Endocrine:  Negative.  Hematology:  Negative.,PHYSICAL EXAMINATION: , A pleasant 41-year-old African-American male who stands 5 feet 6 inches and weighs about 193 pounds.  HEENT:  Anicteric sclera, pink conjunctiva, no cervical lymphadenopathy.  Chest:  Equal chest expansion.  Clear breath sounds.  Heart:  Distinct heart sounds, regular rhythm with no murmur.  Abdomen:  Soft, nontender, flabby, no organomegaly.  Extremities:  Poor peripheral pulses.  No cyanosis and no edema.,ASSESSMENT AND PLAN:,  This is a 49-year old African-American male who was diagnosed with end-stage renal disease secondary to hypertension.  He is on hemodialysis since 02/2008.  Overall, I think that he is a reasonable candidate for a kidney transplantation and should undergo a complete pretransplant workup with pulmonary clearance because of his chronic asthma.  Other than that, I think that he is a reasonable candidate for transplant.,I would like to thank you for allowing me to participate in the care of your patient.  Please feel free to contact me if there are any questions regarding his case.
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DESCRIPTION: Patient with end-stage renal disease secondary to hypertension, a reasonable candidate for a kidney transplantation.

consult - history and phy., kidney transplantation, pretransplant, transplant clinic, renal disease, secondary, kidney, hemodialysis, renal, asthma, transplantation, hypertension

The situation involves a patient with end-stage renal disease who is a candidate for kidney transplantation. This is high-stakes because the patient’s life quality and longevity may significantly improve with a successful transplant, but the process also involves serious surgical procedures, potential complications, and requires careful pre-transplant evaluations. The physician must make well-considered recommendations which will significantly impact the patient's health outcomes.


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

Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 15

FINAL DIAGNOSES:,1.  Gastroenteritis.,2.  Autism.,DIET ON DISCHARGE:,  Regular for age.,MEDICATIONS ON DISCHARGE: , Adderall and clonidine for attention deficit hyperactivity disorder.,ACTIVITY ON DISCHARGE: , As tolerated.,DISPOSITION ON DISCHARGE: , Follow up with Dr. X in ABC Office in 1 to 2 weeks.,HISTORY OF PRESENT ILLNESS: , This 10-and-4/12-year-old Caucasian female has autism and is enrolled at ABC School, and she takes Adderall and clonidine for her hyperactivity.  She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved.  She developed vomiting 3 days prior to admission, but did not have diarrhea.  She voided on the day of admission.  When she presented to the office, her weight was 124 pounds, which was approximately 10 pounds below previous weights and even had a weight of 151.5 pounds, 05/30/2007 and weight of 137.5 pounds, 09/11/2007 with mother giving no good explanation as to why she had lost all this weight.  She was admitted because of the persistent vomiting, but there was concern about the weight loss.,Physical examination on admission was unremarkable except for the obvious signs autistic spectrum disorder.,LABORATORY DATA:  ,Laboratory data included sedimentation rate of 12, magnesium level of 2.2, TSH of 2.63 with normal being 0.34 to 5.60, free T4 of 1.68 with normal being 0.58 to 1.64.  Chest x-ray and abdominal films were unremarkable.  Hemoglobin 14.5, hematocrit 43.5, platelet count 400,000, white blood count 11,800.  Urinalysis was negative for ketones.  Specific gravity 1.023, and negative for protein.  Sodium 137, potassium 3.4, chloride 103, CO2 20, BUN 21, creatinine 0.9, and anion gap 14, glucose 90, total protein 8.1, albumin 4.5, calcium 8.8, bilirubin 1.5, AST 26, ALT 16, alkaline phosphatase 118.  Thyroid peroxidase antibody studies are pending.,HOSPITAL COURSE:  ,The child was observed on IV fluids and advanced to clear liquids and then regular diet as tolerated.  On the second hospital day, mother was comfortable taking her to home.  Mother did not have a good explanation for the weight loss.  In the hospital, her weight was 124 pounds, her height 58 inches, temperature 98.0 degree F., pulse 123, respirations 18, blood pressure 148/94.  Follow up blood pressure were some of them were in the 125 to 70 range making us think her hypertension as labile and perhaps related to the excitement of the admission.,She seem quite happy and in no distress at the time of discharge.  We will follow up in the office and try to further evaluate her for the unexplained weight loss.  She has been taking the Adderall for at least a year, and the mother does not think the Adderall is the cause of the weight loss.  The free T4 is borderline high and probably bears repeating along with further studies for Graves disease as an outpatient.
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DESCRIPTION: Gastroenteritis and autism.  She developed constipation one week prior to admission and mother gave her MiraLax and her constipation improved.

discharge summary, gastroenteritis, autism, constipation, hyperactivity, blood pressure, weight loss, adderall

The discharge summary presents a medical situation involving a child with autism who was admitted due to gastroenteritis and concerning weight loss without an obvious cause. There are multiple factors, including persistent vomiting, unexplained weight loss, a known condition of autism, and medication management. The potential for underlying conditions such as Graves' disease that require further investigation increases the stakes. However, since the child is being discharged, appears stable, and has follow-up care planned, these factors moderate the immediate stakes. The stakes are moderate due to the need for careful monitoring and follow-up investigations to ensure the child's health stability.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Hematology - Oncology
Sample Name: Breast Radiation Therapy Followup

DIAGNOSIS: , Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.,She has been found more recently to have stage IV disease with metastatic deposits and recurrence involving the chest wall and lower left neck lymph nodes.,CURRENT MEDICATIONS,1.  Glucosamine complex.,2.  Toprol XL.,3.  Alprazolam,4.  Hydrochlorothiazide.,5.  Dyazide.,6.  Centrum.,Dr. X has given her some carboplatin and Taxol more recently and feels that she would benefit from electron beam radiotherapy to the left chest wall as well as the neck.  She previously received a total of 46.8 Gy in 26 fractions of external beam radiotherapy to the left supraclavicular area.  As such, I feel that we could safely re-treat the lower neck.  Her weight has increased to 189.5 from 185.2.  She does complain of some coughing and fatigue.,PHYSICAL EXAMINATION,NECK:  On physical examination palpable lymphadenopathy is present in the left lower neck and supraclavicular area.  No other cervical lymphadenopathy or supraclavicular lymphadenopathy is present.,RESPIRATORY:  Good air entry bilaterally. Examination of the chest wall reveals a small lesion where the chest wall recurrence was resected.  No lumps, bumps or evidence of disease involving the right breast is present.,ABDOMEN:  Normal bowel sounds, no hepatomegaly.  No tenderness on deep palpation. She has just started her last cycle of chemotherapy today, and she wishes to visit her daughter in Brooklyn, New York. After this she will return in approximately 3 to 4 weeks and begin her radiotherapy treatment at that time.,I look forward to keeping you informed of her progress.  Thank you for having allowed me to participate in her care.
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DESCRIPTION: Breast radiation therapy followup note. Left breast adenocarcinoma stage T3 N1b M0, stage IIIA.

hematology - oncology, carboplatin, taxol, radiation therapy, breast adenocarcinoma, beam radiotherapy, chest wall, radiotherapy, supraclavicular, lymphadenopathy, adenocarcinoma, breast,

The situation involves a patient with a serious medical condition, stage IV left breast adenocarcinoma with metastases. Treatment plans include chemotherapy and radiotherapy, both of which indicate ongoing, significant medical intervention. The patient's condition requires careful monitoring and effective treatment regimens to manage symptoms and attempt to control the disease's progression. While life-threatening, the medical team is actively managing the case, and there is a structured treatment plan in place, making it a high-stakes situation requiring close attention and critical decision-making from medical professionals.


Medical Specialty: Radiology
Sample Name: Lower Extremity Venous Doppler

LEFT LOWER EXTREMITY VENOUS DOPPLER ULTRASOUND,REASON FOR EXAM: , Status post delivery five weeks ago presenting with left calf pain.,INTERPRETATIONS: , There was normal flow, compression and augmentation within the right common femoral, superficial femoral and popliteal veins.  Lymph nodes within the left inguinal region measure up to 1 cm in short-axis.,IMPRESSION: , Lymph nodes within the left inguinal region measure up to 1 cm in short-axis, otherwise no evidence for left lower extremity venous thrombosis.
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DESCRIPTION: Left lower extremity venous Doppler ultrasound

radiology, popliteal veins, superficial femoral, common femoral, inguinal region, lymph nodes, venous doppler, lower extremity, lymph, inguinal, axis, doppler, extremity, venous,

The situation involves a medical diagnostic test, specifically a Doppler ultrasound, to evaluate for thrombosis in a patient post-delivery experiencing calf pain. While the result is negative for thrombosis, the context of evaluating for a potential blood clot post delivery—a condition that can lead to serious complications such as pulmonary embolism if missed—is significant, making it relatively high-stakes.


Medical Specialty: Urology
Sample Name: Cystopyelogram - 1

PREOPERATIVE DIAGNOSIS: , Gross hematuria.,POSTOPERATIVE DIAGNOSIS:  ,Gross hematuria.,OPERATIONS:  ,Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.,ANESTHESIA: , Spinal.,FINDINGS:  ,Significant amount of bladder clots measuring about 150 to 200 mL, two cupful of clots were removed.  There was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side.  The right ureteral opening was difficult to visualize, the left one was normal.,BRIEF HISTORY: , The patient is a 78-year-old male with history of gross hematuria and recurrent UTIs.  The patient had hematuria.  Cystoscopy revealed atypical biopsy.  The patient came in again with gross hematuria.  The first biopsy was done about a month ago.  The patient was to come back and have repeat biopsies done, but before that came into the hospital with gross hematuria.  The options of watchful waiting, removal of the clots and biopsies were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT and PE were discussed.  Morbidity and mortality of the procedure were discussed.  Consent was obtained from the daughter-in-law who has the power of attorney in Florida.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the dorsal lithotomy position.  The patient was prepped and draped in the usual sterile fashion.  The patient had been off of the Coumadin for about 4 days and INR had been reversed.  The patient has significant amount of clot upon entering the bladder.  There was a tight bladder neck contracture.  The prostate was not enlarged.  Using ACMI 24-French sheath, using Ellick irrigation about 2 cupful of clots were removed.  It took about half an hour to just remove the clots.  After removing the clots, using 24-French cutting loop resectoscope, tumor on the left upper wall near the dome or near the 2 o'clock position was resected.  This was lateral to the left ureteral opening.  The base was coagulated for hemostasis.  Same thing was done at 10 o'clock on the right side where there was some tumor that was visualized.  The back wall and the rest of the bladder appeared normal.  Using 8-French cone-tip catheter, left-sided pyelogram was normal.  The right-sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots.  The contrast did go up to what appeared to be the right ureteral opening, but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening.  A little bit of contrast went out, but the force was not made just to avoid any secondary stricture formation.  The patient did have CT with contrast, which showed that the kidneys were normal.  At this time, a #24 three-way irrigation was started.  The patient was brought to Recovery room in stable condition.
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DESCRIPTION: Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.

urology, clot evacuation, transurethral resection, bladder tumor, bladder neck, gross hematuria, bladder, cystopyelogram, hematuria, clots,

This medical situation involves a surgical procedure on a 78-year-old male patient experiencing gross hematuria, which is a significant symptom indicating potential serious underlying conditions such as cancer. The procedure includes clot evacuation and resection of suspected tumors, which are critical due to the patient’s age and the complexity of the condition. The risks discussed with the patient's power of attorney, such as anesthesia, bleeding, infection, and possible heart-related complications, underscore the seriousness of the surgery. Hence, the situation is high-stakes, particularly because it involves potential cancer management and the patient's overall frail health status.


Medical Specialty: Surgery
Sample Name: Fistulogram & Angioplasty

PREPROCEDURE DIAGNOSIS: , End-stage renal disease.,POSTPROCEDURE DIAGNOSIS: , End-stage renal disease.,PROCEDURES PERFORMED,1.  Left arm fistulogram.,2.  Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.,3.  Ultrasound-guided access of left upper arm brachiocephalic fistula.,ANESTHESIA:,  Sedation with local.,COMPLICATIONS:,  None.,CONDITION:,  Fair.,DISPOSITION:,  PACU.,ACCESS SITE:,  Left upper arm brachiocephalic fistula.,SHEATH SIZE: , 5 French.,CONTRAST TYPE: , JC PEG tube 70.,CONTRAST VOLUME: , 48 mL.,FLUOROSCOPY TIME: , 16 minutes.,INDICATION FOR PROCEDURE: , This is a 38-year-old female with a left upper arm brachiocephalic fistula which has been transposed.  The patient recently underwent a fistulogram with angioplasty at the proximal upper arm cephalic vein due to a stenosis detected on Duplex ultrasound.  The patient subsequently was noted to have poor flow to the fistula, and the fistula was difficult to palpate.  A repeat ultrasound was performed which demonstrated a high-grade stenosis involving the distal upper arm cephalic vein just distal to the brachial anastomosis.  The patient presents today for a left arm fistulogram with angioplasty.  The risks, benefits, and alternatives of the procedure were discussed with the patient and understands and in agreement to proceed.,PROCEDURE DETAILS:  ,The patient was brought to the angio suite and laid supine on the table.  After sedation was administered, the left arm was then prepped and draped in a standard surgical fashion.  Continuous pulse oximetry and cardiac monitoring were performed throughout the procedure.  The patient was given 1 g of IV Ancef prior to incision.,The left brachiocephalic fistula was visualized with bevel ultrasound.  The cephalic vein in the proximal upper arm region appeared to be of adequate caliber.  There was an area of stenosis at the proximal cephalic vein just distal to the brachial artery anastomosis.  The cephalic vein in the proximal forearm region was easily compressible.  The skin overlying the vessel was injected with 1% lidocaine solution.  A small incision was made with the #11 blade.  The cephalic vein then was cannulated with a 5 French micropuncture introducer sheath.  The sheath was advanced over the wire.  A fistulogram was performed which demonstrated a high-grade stenosis just distal to the brachial artery anastomosis.  The introducer sheath was then exchanged for a 5 French sheath over a 0.025 guide wire.  The sheath was aspirated and flushed with heparinized saline solution.  A 0.025 glidewire was then obtained and advanced, placed over the sheath and across the area of stenosis into the brachial artery.  A 5 French short Kumpe catheter was used to guide the wire into the distal brachial and radial artery.  After crossing the area of stenosis, a 5 x 20 mm standard angioplasty balloon was obtained and prepped from the back table.  This was placed over the glidewire into the area of stenosis and inflated to 14 mmHg pressure and then deflated.  The balloon was then removed over the wire and repeat fistulogram was performed which demonstrated significant improvement.  However, there is still a remainder of residual stenosis.  The 5-mm balloon was placed over the wire again and a repeat angioplasty was performed.  The balloon was then removed over the wire and a repeat angiogram was performed which demonstrated again an area of stenosis right at the anastomosis.  The glidewire was removed and a 0.014 guide wire was then obtained and placed through the sheath and across the brachial anastomosis and into the radial artery.  A 4 x 20 mm cutting balloon was obtained and prepped on the back table.  The 5 French sheath was then exchanged for a 6 French sheath.  The balloon was then placed over the 0.014 guide wire into the area of stenosis and then inflated to normal pressures at 8 mmHg.  The balloon was then deflated and removed over the wire.  A 5 mm x 20 mm balloon was obtained and prepped and placed over the wire into the area of stenosis and inflated to pressures of 14 mmHg.  A repeat fistulogram was performed after the removal of the balloon which demonstrated excellent results with no significant residual stenosis.  The patient actually had a nice palpable thrill at this point.  The fistulogram of the distal cephalic vein at the subclavian anastomosis was performed which demonstrated a mild area of stenosis.  The sheath was removed and blood pressure was held over the puncture site for approximately 10 minutes.,After hemostasis was achieved, the cephalic vein again was visualized with bevel ultrasound.  The proximal cephalic vein was then cannulated after injecting the skin overlying the vessel with a 1% lidocaine solution.  A 5 French micropuncture introducer sheath was then placed over the wire into the proximal cephalic vein.  A repeat fistulogram was performed which demonstrated an area of stenosis within the distal cephalic vein just prior to the subclavian vein confluence.  The 5 French introducer sheath was then exchanged for a 5 French sheath.  The 5 mm x 20 mm balloon was placed over a 0.035 glidewire across the area of stenosis.  The balloon was inflated to 14 mmHg.  The balloon was then deflated and a repeat fistulogram was performed through the sheath which demonstrated good results.  The sheath was then removed and blood pressure was held over the puncture site for approximately 10 minutes.  After adequate hemostasis was achieved, the area was cleansed in 2x2 and Tegaderm was applied.  The patient tolerated the procedure without any complications.  I was present for the entire case.  The sponge, instrument, and needle counts are correct at the end of the case.  The patient was subsequently taken to PACU in stable condition.,ANGIOGRAPHIC FINDINGS:,  The initial left arm brachiocephalic fistulogram demonstrated a stenosis at the brachial artery anastomosis and distally within the cephalic vein.  After standard balloon angioplasty, there was a mild improvement but some residual area of stenosis remained at the anastomosis.  Then postcutting balloon angioplasty, venogram demonstrated a significant improvement without any evidence of significant stenosis.,Fistulogram of the proximal cephalic vein demonstrated a stenosis just prior to the confluence with the left subclavian vein.  Postangioplasty demonstrated excellent results with the standard balloon.  There was no evidence of any contrast extravasation.,IMPRESSION,1.  High-grade stenosis involving the cephalic vein at the brachial artery anastomosis and distally.  Postcutting balloon and standard balloon angioplasty demonstrated excellent results without any evidence of contrast extravasation.,2.  A moderate grade stenosis within the distal cephalic vein just prior to the confluence to the left subclavian vein.  Poststandard balloon angioplasty demonstrated excellent results.  No evidence of contrast extravasation.
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DESCRIPTION: Left arm fistulogram.  Percutaneous transluminal angioplasty of the proximal and distal cephalic vein.  Ultrasound-guided access of left upper arm brachiocephalic fistula.

The described medical procedure involves a surgical intervention to address significant vascular stenosis in a patient with end-stage renal disease. Such procedures are critical because they ensure proper blood flow through the fistula, necessary for effective dialysis, which is vital for the patient's survival. While the procedure was performed without complications and the patient was stable post-procedure, the underlying medical condition and the necessity of the procedure make it high-stakes. If the angioplasty had not been successful or had serious complications, it could have had severe implications for the patient's ability to undergo dialysis effectively.


Medical Specialty: Radiology
Sample Name: CT Head, Facial Bones, Cervical Spine - 1

CT HEAD WITHOUT CONTRAST, CT FACIAL BONES WITHOUT CONTRAST, AND CT CERVICAL SPINE WITHOUT CONTRAST,REASON FOR EXAM: , Motor vehicle collision.,CT HEAD,TECHNIQUE: , Noncontrast axial CT images of the head were obtained without contrast.,FINDINGS: , There is no acute intracranial hemorrhage, mass effect, midline shift, or extra-axial fluid collection.  The ventricles and cortical sulci are normal in shape and configuration.  The gray/white matter junctions are well preserved.  No calvarial fracture is seen.,IMPRESSION:  ,Negative for acute intracranial disease.,CT FACIAL BONES WITHOUT CONTRAST,TECHNIQUE:  ,Noncontrast axial CT images of the facial bones were obtained with coronal reconstructions.,FINDINGS:,  There is no facial bone fracture.  The maxilla and mandible are intact.  The visualized paranasal sinuses are clear.  The temporomandibular joints are intact.  The nasal bone is intact.  The orbits are intact.  The extra-ocular muscles and orbital nerves are normal.  The orbital globes are normal.,IMPRESSION: , No evidence for a facial bone fracture.,CT CERVICAL SPINE WITHOUT CONTRAST,TECHNIQUE: , Noncontrast axial CT images of the cervical spine were obtained with sagittal and coronal reconstructions.,FINDINGS: , There is a normal lordosis of the cervical spine, no fracture or subluxation is seen.  The vertebral body heights are normal.  The intervertebral disk spaces are well preserved.  The atlanto-dens interval is normal.  No abnormal anterior cervical soft tissue swelling is seen.  There is no spinal compression deformity.,IMPRESSION: , Negative for a facial bone fracture.
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DESCRIPTION: Motor vehicle collision.  CT head without contrast, CT facial bones without contrast, and CT cervical spine without contrast.

radiology, intracranial disease, motor vehicle collision, orbital nerves, extra-ocular muscles, cervical spine, ct cervical spine, ct facial bones, ct head, axial ct images, facial bone fracture, facial bones, ct, noncontrast, intracranial, axial, spine, fracture, cervical, contrast, facial, bones,

The situation involves a radiological assessment following a motor vehicle collision. Such scenarios are typically high-stakes because they assess for potentially life-threatening conditions like intracranial hemorrhage, fractures, or spinal injuries. In this case, the findings were negative for acute intracranial disease, facial bone fractures, and cervical spine injuries, which is reassuring. However, given the nature of the incident and the potential consequences of missed injuries, I rate it as high-stakes.


Medical Specialty: Hematology - Oncology
Sample Name: Non-Small Cell Lung Cancer - Consult

REASON FOR CONSULTATION:,  New diagnosis of non-small cell lung cancer.,HISTORY OF PRESENT ILLNESS: , ABCD is a very nice 47-year-old gentleman without much past medical history who has now been diagnosed with a new non-small cell lung cancer stage IV metastatic disease.  We are consulted at this time to discuss further treatment options.,ABCD and his wife state that his history goes back to approximately 2-2-1/2 weeks ago when he developed some left-sided flank pain.  Initially, he did not think much of this and tried to go about doing work and everything else but the pain gradually worsened.  Eventually this prompted him to present to the emergency room.  A CT scan was done there, and he was found to have a large left adrenal mass worrisome for metastatic disease.  At that point, he was transferred to XYZ Hospital for further evaluation.  On admission on 12/19/08, a CT scan of the chest, abdomen, and pelvis was done for full staging purposes.  The CT scan of the chest showed an abnormal soft tissue mass in the right paratracheal region, extending into the precarinal region, the subcarinal region, and the right hilum.  This was causing some compression on the inferior aspect of the SVC and also some narrowing of the right upper lobe pulmonary artery.  There was an abnormal lymph node noted in the AP window and left hilar region.  There was another spiculated mass within the right upper lobe measuring 2.0 x 1.5 cm.  There was also an 8 mm non-calcified nodule noted in the posterior-inferior aspect of the left upper lobe suspicious for metastatic disease.  There were areas of atelectasis particularly in the right base.  There was also some mild ground glass opacity within the right upper lobe adjacent to the right hilum potentially representing focal area of pulmonary edema versus small infarction related to the right upper lobe pulmonary artery narrowing.  There was a small lucency adjacent to the medial aspect of the left upper lobe compatible with a small pneumothorax.  In the abdomen, there was a mass involved in the left adrenal gland as well as a nodule involving the right adrenal gland both of which appeared necrotic compatible with metastatic tumor.  All other structures appeared normal.  On 12/22/08, a CT-guided biopsy of the left adrenal mass was performed.  Pathology from this returned showing metastatic poorly differentiated non-small cell carcinoma.  At this point, we have been consulted to discuss further treatment options.,On further review, ABCD states that he has may be had a 20 pound weight loss over the last couple of months which he relates to anorexia or decreased appetite.  He has not ever had a chronic smoker's cough and still does not have a cough.  He has no sputum production or hemoptysis.  He and his wife are very anxious about this diagnosis.,PAST MEDICAL HISTORY: , He denies any history of heart disease, lung disease, kidney disease, liver disease, hepatitis major infection, seizure disorders or other problems.,PAST SURGICAL HISTORY: , He denies having any surgeries.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  At home he takes no medication except occasional aspirin or ibuprofen, recently for his flank pain.  He does take a multivitamin on occasion.,SOCIAL HISTORY:  He has about a 30-pack-a-year history of smoking.  He used to drink alcohol heavily and has a history of getting a DUI about a year-and-half ago resulting in him having his truck-driving license revoked.  Since that time he has worked with printing press.  He is married and has two children, both of whom are grown in their 20s, but are now living at home.,FAMILY HISTORY: , His mother died for alcohol-related complications.  He otherwise denies any history of cancers, bleeding disorders, clotting disorders, or other problems.,REVIEW OF SYSTEMS: , GENERAL/CONSTITUTIONAL:  He has lost about 20 pounds of weight as described above.  He also has a trouble with fatigue.  No lightheadedness or dizziness.  HEENT:  He denies any new or changing headache, change in vision, double vision, or loss of vision, ringing in his ears, loss of hearing in one year.  He does not take care of his teeth very well but currently he has no mouth, jaw, or teeth pain.  RESPIRATORY:  He has had some little bit of dyspnea on exertion but otherwise denies shortness of breath at rest.  No cough, congestion, wheezing, hemoptysis, and sputum production.  CVS:  He denies any chest pains, palpitations, PND, orthopnea, or swelling of his lower extremities.  GI:  He denies any odynophagia, dysphagia, heartburn on a regular basis, abdominal pain, abdominal swelling, diarrhea, blood in his stool, or black tarry stools.  He has been somewhat constipated recently.  GU:  He denies any burning with urination, kidney stones, blood in his urine, dysuria, difficulty getting his urine out or other problems.  MUSCULOSKELETAL:  He denies any new bony aches or pains including back pain, hip pain, and rib pain.  No muscle aches, no joint swelling, and no history of gout.  SKIN:  No rashes, no bruising, petechia, non-healing wounds, or ulcerations.  He has had no nail or hair changes.  HEM:  He denies any bloody nose, bleeding gums, easy bruising, easy bleeding, swollen lymphs or bumps.  ENDOCRINE:  He denies any tremor, shakiness, history of diabetes, thyroid problems, new or enlarging stretch marks, exophthalmos, insomnia, or tremors.  NEURO:  He denies any mental status changes, anxiety, confusion, depression, hallucinations, loss of feeling in her arm or leg, numbness or tingling in hands or feet, loss of balance, syncope, seizures, or loss of coordination.,PHYSICAL EXAMINATION,VITAL SIGNS:  His T-max is 98.8.  His pulse is 85, respirations 18, and blood pressure 126/80 saturating over 90% on room air.,GENERAL:  No acute distress, pleasant gentleman who appears stated age.,HEENT:  NC/AT.  Sclerae anicteric.  Conjunctiva clear.  Oropharynx is clear without erythema, exudate, or discharge.,NECK:  Supple.  Nontender.  No elevated JVP.  No carotid bruits.  No thyromegaly.  No thyroid nodules.  Carotids are 2+ and symmetric.,BACK:  Spine is straight.  No spinal tenderness.  No CVA tenderness.  No presacral edema.,CHEST:  Clear to auscultation and percussion bilaterally.  No wheezes, rales, or rhonchi.  Normal symmetric chest wall expansion with inspiration.,CVS:  Regular rate and rhythm.  No murmurs, gallops, or rubs.,ABDOMEN:  Soft, nontender, nondistended.  No hepatosplenomegaly.  No guarding or rebound.  No masses.  Normoactive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  No joint swelling.  Full range of motion.,SKIN:  No rashes, wounds, ulcerations, bruises, or petechia.,NEUROLOGIC:  Cranial nerves II through XII are intact.  He has intact sensation to light touch throughout.  He has 2+ deep tendon reflexes bilaterally in the biceps, triceps, brachioradialis, patellar and ankle reflexes.  He is alert and oriented x3.,LABORATORY DATA: , His white blood cell count is 9.4, hemoglobin 13.0, hematocrit 38%, and platelets 365,000.  The differential shows 73% neutrophils, 17% lymphocytes, 7.6% monocytes, 1.9% eosinophils, and 0.7% basophils.  Chemistry shows sodium 138, potassium 3.8, chloride 104, CO2 of 31, BUN 9, creatinine 1.0, glucose 104, calcium 12.3, alkaline phosphatase 104, AST 16, ALT 12, total protein 7.6, albumin 3.5, total bilirubin 0.5, ionized calcium 1.7.  His INR is 1.0 with the PT of 11.4 and a PTT of 31.3.,IMAGINING DATA:,  MRI of the brain on 12/23/08 - this shows some mild white matter disease, question of minimal pontine ischemic gliosis as well as a small incidental venous angioma in the left posterior frontal deep white matter.  There is no evidence of cerebral metastasis, hemorrhage, or acute infarction.,ASSESSMENT/PLAN: , ABCD is a very nice 47-year-old gentleman without much past medical history, who now presents with metastatic non-small cell lung cancer.  At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.  His wife particularly had a very hard time with this prognosis.  They preferred not to know the exact average as to how long someone lives with this disease.  I did offer chemotherapy as a way to treat this disease.  Chemotherapy has been associated both with palliation of symptoms as well as prolong survival.  At this point, he has an excellent functional status and I think he would tolerate chemotherapy quite well.,In terms of chemotherapy, I talked briefly about the side affects including but not limited to GI upset, diarrhea, nausea, vomiting, mucositis, fatigue, loss of appetite, low blood counts including the possible need for transfusion as well as the risk of infections, which in some rare cases can be fatal.  I would likely use carboplatin and gemcitabine.  This would be both medications given on day 1 with a dose of gemcitabine on day 8.  This cycle will be repeated after 1-week break so that the cycle lasts 21 days.  The goal will be to complete 6 cycles of this as long as he is responding and tolerating the medication.,In terms of staging Mr. ABCD'S had all the appropriate staging.  A PET-CT scan could be done, but at this point would not provide much mean full information beyond the CT scans that we have.,At this point, his biggest issue is pain and he is getting a pain consult to help control his pain.  He will be ready to be discharged from the hospital once his pain is under better control.  As this is the holiday weekend, I do not have a way of scheduling a followup appointment with them, but I did give he and his wife my card and instructed them to call on Monday.  At that point, we will get him in and I will also begin working on making arrangements for his chemotherapy.,Thank you very much for this interesting consult.
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DESCRIPTION: New diagnosis of non-small cell lung cancer stage IV metastatic disease.  At this point, he and his wife ask about whether this is curable disease and it was difficult to inform that this was not curable disease but would be treatable.

The situation described involves a 47-year-old patient with a new diagnosis of stage IV metastatic non-small cell lung cancer. Stage IV cancer is critical because it indicates that the cancer has spread to other parts of the body, which significantly worsens the prognosis and limits treatment options. This is a severe medical condition with a focus on palliative care and potentially extending life with treatments such as chemotherapy. The emotional and psychological impacts on the patient and family make it a high-stakes situation. The clinical decisions made during this consultation directly affect the patient's quality of life and overall survival timeframe.


Medical Specialty: General Medicine
Sample Name: HIV Followup - 1

PROBLEM LIST:,1.  HIV stable.,2.  Hepatitis C chronic.,3.  History of depression, stable off meds.,4.  Hypertension, moderately controlled.,CHIEF COMPLAINT: , The patient comes for a routine followup appointment.,HISTORY OF PRESENTING ILLNESS: , This is a 34-year-old African American female who comes today for routine followup.  She has no acute complaints.  She reports that she has a muscle sprain on her upper back from lifting.  The patient is a housekeeper by profession.  It does not impede her work in anyway.  She just reports that it gives her some trouble sleeping at night, pain on 1 to 10 scale was about 2 and at worse it is 3 to 4 but relieved with over-the-counter medication.  No other associated complaints.  No neurological deficits or other specific problems.  The patient denies any symptoms associated with opportunistic infection.,PAST MEDICAL HISTORY:,1.  Significant for HIV.,2.  Hepatitis.,3.  Depression.,4.  Hypertension.,CURRENT MEDICATIONS:,1.  She is on Trizivir 1 tablet p.o. b.i.d.,2.  Ibuprofen over-the-counter p.r.n.,MEDICATION COMPLIANCE: , The patient is 100% compliant with her meds.  She reports she does not miss any doses.,ALLERGIES: , She has no known drug allergies.,DRUG INTOLERANCE:  ,There is no known drug intolerance in the past.,NUTRITIONAL STATUS: , The patient eats regular diet and eats 3 meals a day.,REVIEW OF SYSTEMS: , Noncontributory except as mentioned in the HPI.,LABORATORY DATA: , Most recent labs from 11/07.,RADIOLOGICAL DATA:,  She has had no recent radiological procedures.,IMMUNIZATIONS: , Up-to-date.,SEXUAL HISTORY: , She has had no recent STDs and she is not currently sexually active.  PPD status was negative in the past.  PPD will be placed again today.,Treatment adherence counseling was performed by both nursing staff and myself.  Again, the patient is a 100% compliant with her meds.  Last dental exam was in 11/07, where she had 2 teeth extracted.  Last Pap smear was 1 year ago was negative.  The patient has not had mammogram yet, as she is not of the age where she would start screening mammogram.  She has no family history of breast cancer.,MENTAL HEALTH AND SUBSTANCE ABUSE: , The patient has a history of depression.  No history of substance abuse.,ADVANCED DIRECTIVE: , Unknown.,PHYSICAL EXAMINATION:,GENERAL:  This is a thinly built female, not in acute distress.  VITAL SIGNS:  Temperature 36.5, blood pressure 132/89, pulse of 82, and weight of 104 pounds.  HEAD AND NECK:  Reveals bilaterally reactive pupils.  Supple neck.  No thrush.  No adenopathy.  HEART:  Heart sounds S1 and S2 regular.  No murmur.  LUNGS:  Clear bilaterally to auscultation.  ABDOMEN:  Soft and nontender with good bowel sounds.  NEUROLOGIC:  She is alert and oriented x3 with no focal neurological deficit.  EXTREMITIES:  Peripheral pulses are felt bilaterally.  She has no pitting pedal edema, clubbing or cyanosis.  GU:  Examination of external genitalia is unremarkable.  There are no lesions.,LABORATORY DATA: , From 11/07 shows hemoglobin and hematocrit of 16 and 46.  Creatinine of 0.6.  LFTs within normal limits.  Viral load of less than 48 and CD4 count of 918.,ASSESSMENT:,1.  Human immunodeficiency virus, stable on Trizivir.,2.  Hepatitis C with stable transaminases.,3.  History of depression, stable off meds.
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DESCRIPTION: Human immunodeficiency virus, stable on Trizivir.  Hepatitis C with stable transaminases.  History of depression, stable off meds.   Hypertension, moderately controlled on meds.

The situation involves a routine follow-up appointment for a patient with several chronic but stable medical conditions, including HIV, Hepatitis C, depression, and hypertension. The patient is compliant with her medications, and there are no acute issues or complaints other than a mild muscle sprain managed with over-the-counter medication. The patient's HIV and Hepatitis C are stable, as are her depression and hypertension, suggesting well-managed health conditions. Therefore, this situation is relatively low-stakes compared to emergency or acute medical situations.


Medical Specialty: Orthopedic
Sample Name: Styloidectomy

PREOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.,POSTOPERATIVE DIAGNOSIS: , Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion; finding of volar radial wrist mass of bulging inflammatory tenosynovitis from the volar radial wrist joint rather than a true ganglion cyst; synovitis was debrided and removed.,PROCEDURE: , Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist.,ANESTHESIA:,  Axillary block plus IV sedation.,ESTIMATED BLOOD LOSS:,  Zero.,SPECIMENS,1.  Inflammatory synovitis from the volar radial wrist area.,2.  Inflammatory synovitis from the dorsal wrist area.,DRAINS:,  None.,PROCEDURE DETAIL: , Patient brought to the operating room.  After induction of IV sedation a right upper extremity axillary block anesthetic was performed by anesthesia staff.  Routine prep and drape was employed.  Patient received 1 gm of IV Ancef preoperatively.  Arm was exsanguinated by means of elevation of Esmarch elastic tourniquet.  Tourniquet inflated to 250 mmHg pressure.  Hand positioned palm up in a lead hand-holder.  A longitudinal zigzag incision over the volar radial wrist mass was made.  Skin was sharply incised.  Careful blunt dissection was used in the subcutaneous tissue.  Antebrachial fascia was bluntly dissected and incised to reveal the radial artery.  Radial artery was mobilized preserving its dorsal and palmar branches.  Small transverse concomitant vein branches were divided to facilitate mobilization of the radial artery.  Wrist mass was exposed by blunt dissection.  This appeared to be an inflammatory arthritic mass from the volar radial wrist capsule.  This was debrided down to the wrist capsule with visualization of the joint through a small capsular window.  After complete volar synovectomy the capsular window was closed with 4-0 Mersilene figure-of-eight suture.  Subcutaneous tissue was closed with 4-0 PDS and the skin was closed with a running subcuticular 4-0 Prolene.  Forearm was pronated and C-arm image intensifier was used to confirm localization of the radial styloid for marking of the skin incision.  An oblique incision overlying the radial styloid centered on the second extensor compartment was made.  Skin was sharply incised.  Blunt dissection was used in the subcutaneous tissue.  Care was taken to identify and protect the superficial radial nerve.  Blunt dissection was carried out in the extensor retinaculum.  This was incised longitudinally over the second extensor compartment.  EPL tendon was identified, mobilized and released to facilitate retraction and prevent injury.  The interval between the ECRL and the ECRB was developed down to bone.  Dorsal capsulotomy was made and local synovitis was identified.  This was debrided and sent as second pathologic specimen.  Articular surface of the scaphoid was identified and seen to be completely devoid of articular cartilage with hard, eburnated subchondral bone consistent with a SLAC pattern arthritis.  Radial styloid had extensive spurring and was exposed subperiosteally and osteotomized in a dorsal oblique fashion preserving the volar cortex as the attachment point of the deep volar carpal ligament layer.  Dorsally the styloidectomy was beveled smooth and contoured with a rongeur.  Final x-rays documenting the styloidectomy were obtained.  Local synovitis beneath the joint capsule was debrided.  Remnants of the scapholunate interosseous which was completely deteriorated were debrided.  The joint capsule was closed anatomically with 4-0 PDS and extensor retinaculum was closed with 4-0 PDS.  Subcutaneous tissues closed with 4-0 Vicryl.  Skin was closed with running subcuticular 4-0 Prolene.  Steri-Strips were applied to wound edge closure; 10 cc of 0.5% plain Marcaine was infiltrated into the areas of the surgical incisions and radial styloidectomy for postoperative analgesia.  A bulky gently compressive wrist and forearm bandage incorporating an EBI cooling pad were applied.  Tourniquet was deflated.  Good vascular color and capillary refill were seen to return to the tips of all digits.  Patient discharged to the ambulatory recovery area and from there discharged home.,DISCHARGE PRESCRIPTIONS:,1.  Keflex 500 mg tablets, #20, one PO q.6h. x 5 days.,2.  Vicodin, 40 tablets, one to two PO q.4h. p.r.n.,3.  Percocet, #20 tablets, one to two PO q.3-4h. p.r.n. severe pain.
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DESCRIPTION: Excision of volar radial wrist mass (inflammatory synovitis) and radial styloidectomy, right wrist.  Right wrist pain with an x-ray showing a scapholunate arthritic collapse pattern arthritis with osteophytic spurring of the radial styloid and a volar radial wrist mass suspected of being a volar radial ganglion.

orthopedic, osteophytic, spurring, ganglion, synovitis, volar radial wrist mass, excision, inflammatory synovitis, radial styloidectomy, inflammatory, styloidectomy, volar, wrist, radial, mass

The document describes a fairly routine orthopedic surgical procedure, specifically an excision of inflammatory synovitis and a radial styloidectomy. The stakes are moderate, as it involves managing arthritis and wrist pain rather than life-threatening conditions. While the procedure does require careful surgical technique to avoid complications such as nerve damage or infection, it does not involve critical systems like cardiothoracic or neurosurgery procedures, which would carry higher stakes. The risk profile remains moderate because surgical precision and effective pain management are essential for successful outcomes, but the immediate threat to life or severe long-term consequences is relatively low.


Medical Specialty: Orthopedic
Sample Name: Diskectomy & Fusion

PREOPERATIVE DIAGNOSIS: , Degenerative disk disease at L4-L5 and L5-S1.,POSTOPERATIVE DIAGNOSIS:,  Degenerative disk disease at L4-L5 and L5-S1.,PROCEDURE PERFORMED:  ,Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.,ANESTHESIA: , General.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , 150 mL.,PROCEDURE IN DETAIL:  ,Patient was prepped and draped in sterile fashion.  Left lower quadrant incision was performed and taken down to the preperitoneal space with the use of the Bovie, and then preperitoneal space was opened.  The iliac veins were carefully mobilized medially, and then the L4-L5 disk space was confirmed by fluoroscopy, and diskectomy fusion, which will be separately dictated by Dr. X, was performed after the adequate exposure was gained, and then after this L4-L5 disk space was fused and the L5-S1 disk space was carefully identified between the iliac vessels and the presacral veins and vessels were ligated with clips, disk was carefully exposed.  Diskectomy and fusion, which will be separately dictated by Dr. X, were performed.  Once this was completed, all hemostasis was confirmed.  The preperitoneal space was reduced.  X-ray confirmed adequate positioning and fusion.  Then the fascia was closed with #1 Vicryl sutures, and then the skin was closed in 2 layers, the first layer being 2-0 Vicryl subcutaneous tissues and then a 4-0 Monocryl subcuticular stitch, then dressed with Steri-Strips and 4 x 4's.  Then patient was placed in the prone position after vascular checks of the lower extremity confirmed patency of the arteries with warm bilateral lower extremities.
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DESCRIPTION: Degenerative disk disease at L4-L5 and L5-S1.  Anterior exposure diskectomy and fusion at L4-L5 and L5-S1.

orthopedic, anterior exposure, degenerative disk disease, disk disease, disk space, diskectomy, fusion,

The scenario described involves a surgical procedure known as diskectomy and fusion to treat degenerative disk disease, which can affect a patient's mobility and quality of life if not adequately addressed. Surgical interventions in spine health are generally considered to be of significant importance due to the complexities and potential risks involved, including the maintenance of spinal integrity and prevention of nerve damage. However, as the operation proceeded without complications, and the estimated blood loss was moderate, it falls into a moderate high-stakes situation. The potential for high impact on a patient's life quality and implications of possible complications during such procedures make it high-stakes, but the successful completion reduces its critical nature to some extent.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Cholecystectomy - 1

PROCEDURE:,:  After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table.  General endotracheal anesthesia was induced.  The patient was then prepped and draped in the usual sterile fashion.  An #11 blade scalpel was used to make a small infraumbilical skin incision in the midline.  The fascia was elevated between two Ochsner clamps and then incised.  A figure-of-eight stitch of 2-0 Vicryl was placed through the fascial edges.  The 11-mm port without the trocar engaged was then placed into the abdomen.  A pneumoperitoneum was established.  After an adequate pneumoperitoneum had been established, the laparoscope was inserted.  Three additional ports were placed all under direct vision.  An 11-mm port was placed in the epigastric area.  Two 5-mm ports were placed in the right upper quadrant.  The patient was placed in reverse Trendelenburg position and slightly rotated to the left.  The fundus of the gallbladder was retracted superiorly and laterally.  The infundibulum was retracted inferiorly and laterally.  Electrocautery was used to carefully begin dissection of the peritoneum down around the base of the gallbladder.  The triangle of Calot was carefully opened up.  The cystic duct was identified heading up into the base of the gallbladder.  The cystic artery was also identified within the triangle of Calot.  After the triangle of Calot had been carefully dissected, a clip was then placed high up on the cystic duct near its junction with the gallbladder.  The cystic artery was clipped twice proximally and once distally.  Scissors were then introduced and used to make a small ductotomy in the cystic duct, and the cystic artery was divided.  An intraoperative cholangiogram was obtained.  This revealed good flow through the cystic duct and into the common bile duct.  There was good flow into the duodenum without any filling defects.  The hepatic radicals were clearly visualized.  The cholangiocatheter was removed, and two clips were then placed distal to the ductotomy on the cystic duct.  The cystic duct was then divided using scissors.  The gallbladder was then removed up away from the liver bed using electrocautery.  The gallbladder was easily removed through the epigastric port site.  The liver bed was then irrigated and suctioned.  All dissection areas were inspected.  They were hemostatic.  There was not any bile leakage.  All clips were in place.  The right gutter up over the edge of the liver was likewise irrigated and suctioned until dry.  All ports were then removed under direct vision.  The abdominal cavity was allowed to deflate.  The fascia at the epigastric port site was closed with a stitch of 2-0 Vicryl.  The fascia at the umbilical port was closed by tying the previously placed stitch.  All skin incisions were then closed with subcuticular sutures of 4-0 Monocryl and 0.25% Marcaine with epinephrine was infiltrated into all port sites.  The patient tolerated the procedure well.  The patient is currently being aroused from general endotracheal anesthesia.  I was present during the entire case.
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DESCRIPTION: Laparoscopic cholecystectomy.

Laparoscopic cholecystectomy.

gastroenterology, laparoscopic, calot, ochsner clamps, additional ports, cholangiogram, cholecystectomy, cystic duct, duodenum, epigastric, fascia, gallbladder, infraumbilical skin incision, infundibulum, pneumoperitoneum, triangle of calot, laparoscopic cholecystectomy, liver bed, epigastric port, port site, cystic artery, triangle, port, duct, cysticNOTE,: 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 described situation is a detailed account of a laparoscopic cholecystectomy, a common surgical procedure to remove the gallbladder. While surgeries inherently carry some risks, laparoscopic cholecystectomy is a routine procedure with a high success rate and low complication risk when performed by experienced surgeons. The report indicates that the procedure was completed without complications and the patient is being aroused from anesthesia, which suggests a typical and successful outcome expected in such cases.


Medical Specialty: Radiology
Sample Name: MRI C-Spine - C5-6 Disk Herniation

CC:, Right shoulder pain.,HX: ,This 46 y/o RHF presented with a 4 month history of right neck and shoulder stiffness and pain. The symptoms progressively worsened over the 4 month course. 2 weeks prior to presentation she began to develop numbness in the first and second fingers of her right hand and RUE pain. The later was described as a throbbing pain. She also experienced numbness in both lower extremities and pain in the coccygeal region. The pains worsened at night and impaired sleep. She denied any visual change, bowel or bladder difficulties and symptoms involving the LUE. She occasionally experienced an electric shock like sensation shooting down her spine when flexing her neck (Lhermitte's phenomena). She denied any history of neck/back/head trauma.,She had been taking Naprosyn with little relief.,PMH: ,1) Catamenial Headaches. 2) Allergy to Macrodantin.,SHX/FHX:, Smokes 2ppd cigarettes.,EXAM: ,Vital signs were unremarkable.,CN: unremarkable.,Motor: full strength throughout. Normal tone and muscle bulk.,Sensory: No deficits on LT/PP/VIB/TEMP/PROP testing.,Coord/Gait/Station: Unremarkable.,Reflexes: 2/2 in BUE except 2+ at left biceps. 1+/1+BLE except an absent right ankle reflex.,Plantar responses were flexor bilaterally. Rectal exam: normal tone.,IMPRESSION:, C-spine lesion.,COURSE: ,MRI C-spine revealed a central C5-6 disk herniation with compression of the spinal cord at that level. EMG/NCV showed normal NCV, but 1+ sharps and fibrillations in the right biceps (C5-6), brachioradialis (C5-6), triceps (C7-8) and teres major; and 2+ sharps and fibrillations in the right pronator terres. There was increased insertional activity in all muscles tested on the right side. The findings were consistent with a C6-7 radiculopathy.,The patient subsequently underwent C5-6 laminectomy and her symptoms resolved.
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DESCRIPTION: MRI C-spine to evaluate right shoulder pain - C5-6 disk herniation.

radiology, shoulder pain, stiffness, numbness, lhermitte's phenomena, c-spine lesion, disk herniation, mri c spine, reflexes, biceps, mri, disk, shoulder, spine, herniation,

The situation involves a medical case where the patient's symptoms indicated potential nerve compression due to a C5-6 disk herniation, confirmed by MRI. The patient was experiencing progressively worsening symptoms, including pain and numbness, which were affecting daily life activities. The issue was serious enough to require surgical intervention (laminectomy), but it was not immediately life-threatening, as indicated by the stability of vital signs and the absence of severe neurological deficits or loss of bowel/bladder function. The stakes are moderate because the condition could lead to permanent nerve damage or disability if untreated, but it had a clear surgical treatment path that resolved the symptoms.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Consultation - 3

HISTORY OF PRESENT ILLNESS:, The patient is known to me secondary to atrial fibrillation with slow ventricular response, partially due to medications, at least when I first saw him in the office on 01/11/06. He is now 77 years old. He is being seen on the Seventh Floor. The patient is in Room 7607. The patient has a history of recent adenocarcinoma of the duodenum that was found to be inoperable, since it engulfed the porta hepatis. The workup began with GI bleeding. He was seen in my office on 01/11/06 for preop evaluation due to leg edema. A nonocclusive DVT was diagnosed in the proximal left superficial femoral vein. Both legs were edematous, and bilateral venous insufficiency was also present. An echocardiogram demonstrated an ejection fraction of 50%. The patient was admitted to the hospital and treated with a Greenfield filter since anticoagulant was contraindicated. Additional information on the echocardiogram, where a grossly dilated left atrium, moderately severely dilated right atrium. The rhythm was, as stated before, atrial fibrillation with slow atrioventricular conduction and an intraventricular conduction delay on the monitor strip. There was mild to moderate tricuspid regurgitation, mild pulmonic insufficiency. The ejection fraction was considered low normal, since it was estimated 50 to 54%. The patient received blood while in the hospital due to anemia. The leg edema improved while lying down, suggesting that the significant element of venous insufficiency was indeed present. The patient, who was diabetic, received consultation by Dr. R. He was also a chronic hypertensive and was treated for that with ACE inhibitors. The atrial fibrillation was slow, and no digitalis or beta blockers were recommended at the same time. As a matter of fact, they were discontinued. Now, the patient denied any shortness of breath or chest pain throughout this hospitalization, and cardiac nuclear studies performed earlier demonstrated no reversible ischemia.,ALLERGIES:, THE PATIENT HAS NO KNOWN DRUG ALLERGIES.,His diabetes was suspected to be complicated with neuropathy due to tingling in both feet. He received his immunizations with flu in 2005 but did not receive Pneumovax.,SOCIAL HISTORY:, The patient is married. He had 1 child who died at the age of 26 months of unknown etiology. He quit smoking 6 years ago but dips (smokeless) tobacco.,FAMILY HISTORY:, Mother had cancer, died at 70. Father died of unknown cause, and brother died of unknown cause.,FUNCTIONAL CAPACITY:, The patient is wheelchair bound at the time of his initial hospitalization. He is currently walking in the corridor with assistance. Nocturia twice to 3 times per night.,REVIEW OF SYSTEMS:,OPHTHALMOLOGIC: Uses glasses.,ENT: Complains of occasional sinusitis.,CARDIOVASCULAR: Hypertension and atrial fibrillation.,RESPIRATORY: Normal.,GI: Colon bleeding. The patient believes he had ulcers.,GENITOURINARY: Normal.,MUSCULOSKELETAL: Complains of arthritis and gout.,INTEGUMENTARY: Edema of ankles and joints.,NEUROLOGICAL: Tingling as per above. Denies any psychiatric problems.,ENDOCRINE: Diabetes, NIDDM.,HEMATOLOGIC AND LYMPHATIC: The patient does not use any aspirin or anticoagulants and is not of anemia.,LABORATORY:, Current EKG demonstrates atrial fibrillation with incomplete left bundle branch block pattern. Q waves are noticed in the inferior leads. Nonprogression of the R-wave from V1 to V4 with small R-waves in V5 and V6 are suggestive of an old anterior and inferior infarcts. Left ventilator hypertrophy and strain is suspected.,PHYSICAL EXAMINATION:,GENERAL: On exam, the patient is alert, oriented and cooperative. He is mildly pale. He is an elderly gentleman who is currently without diaphoresis, pallor, jaundice, plethora, or icterus.,VITAL SIGNS: Blood pressure is 159/69 with a respiratory rate of 20, pulse is 67 and irregularly irregular. Pulse oximetry is 100.,NECK: Without JVD, bruit, or thyromegaly. The neck is supple.,CHEST: Symmetric. There is no heave or retraction.,HEART: The heart sounds are irregular and no significant murmurs could be auscultated.,LUNGS: Clear to auscultation.,ABDOMEN: Exam was deferred.,LEGS: Without edema. Pulses: Dorsalis pedis pulse was palpated bilaterally.,MEDICATIONS:, Current medications include enalapril, low dose enoxaparin, Fentanyl patches. He is no longer on fluconazole. He is on a sliding scale as per Dr. Holden. He is on lansoprazole (Prevacid), Toradol, piperacillin/tazobactam, hydralazine p.r.n., Zofran, Dilaudid, Benadryl, and Lopressor p.r.n.,ASSESSMENT AND PLAN:, The patient is a very pleasant elderly gentleman with intractable/inoperable malignancy. His cardiac issues are chronic and most likely secondary to long term hypertension and diabetes. He has chronic atrial fibrillation. I do not envision a scenario whereby he will become a candidate for management of this arrhythmia beyond weight control. He is also not a candidate for anticoagulation, which is, in essence, a part and parcel of the weight control. Reason being is high likelihood for GI bleeding, especially given the diagnosis of invasive malignancy with involvement of multiple organs and lymph nodes. At this point, I agree with the notion of hospice care. If his atrioventricular conduction becomes excessive, occasional nondihydropyridine calcium channel blocker such as diltiazem or beta blockers would be appropriate; otherwise, I would keep him off those medications due to evidence of slow conduction in the presence of digitalis and beta blockers.
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DESCRIPTION: Patient with atrial fibrillation with slow ventricular response, partially due to medications.

The situation involves a 77-year-old patient with multiple comorbidities, including chronic atrial fibrillation, an inoperable malignancy, and potential gastrointestinal bleeding. The patient is not a candidate for anticoagulation due to the high risk of bleeding, and hospice care is suggested, indicating a focus on comfort rather than aggressive treatment. The complex medical issues and considerations of end-of-life care make this a high-stakes situation for the patient's quality of life and management decisions.


Medical Specialty: Urology
Sample Name: Hypospadias Repair & Chordee Release

PREOPERATIVE DIAGNOSIS:,  Penoscrotal hypospadias with chordee.,POSTOPERATIVE DIAGNOSIS: , Penoscrotal hypospadias with chordee.,PROCEDURE:,  Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.,ANESTHESIA: , General inhalation anesthetic with a caudal block.,FLUIDS RECEIVED: , 300 mL of crystalloids.,ESTIMATED BLOOD LOSS: , 15 mL.,SPECIMENS: , No tissue sent to Pathology.,TUBES AND DRAINS: , An 8-French Zaontz catheter.,INDICATIONS FOR OPERATION: , The patient is a 1-1/2-year-old boy with penoscrotal hypospadias; plan is for repair.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, where surgical consent, operative site and the patient's identification was verified.  Once he was anesthetized, a caudal block was placed.  IV antibiotic was given.  The dorsal hood was retracted and the patient was then sterilely prepped and draped.  A stay stitch of 4-0 Prolene was then placed in the glans for traction.  His urethra was calibrated, it was quite thin, to a 10-French with the straight sounds.  We then marked the coronal cuff and the urethral plate as well as the penile shaft skin with marking pen and incised the coronal cuff circumferentially and then around the urethral plate with the 15 blade knife and then degloved the penis with a curved tenotomy scissors.  Electrocautery was used for hemostasis.  The ventral chordee tissue was removed.  We then placed a vessel loop tourniquet around the base of the penis and using IV grade saline did an artificial erection test, which showed that he had a persistent chordee.  In the midline a 15 blade knife was used to incise Buck fascia after marking the area of chordee with the marking pen.  We then used a Heinecke-Mikulicz Nesbit tuck with 5-0 Prolene to straighten the penis.  Artificial erection again performed showed the penis was straight.  The knot was buried with figure-of-eight suture of 7-0 Vicryl in Buck fascia above it.  We then left the tourniquet in place and then after marking the urethral plate incised it and enlarged it with Beaver blade and a 15 blade.  We then elevated the glanular wings as well in the similar fashion.  An 8-French Zaontz catheter was then placed and the urethral plate was then closed over this with a distal interrupted sutures of 7-0 Vicryl and then a running subcuticular closure of 7-0 Vicryl to close the defect.  We then put the stay sutures in the inter-preputial skin with 7-0 Vicryl and then rotated a flap using the subcutaneous tissue after dissecting it down to the pubis at the base of the penile shaft on the dorsum using the curved iris scissors.  We buttonholed the flap and then placed it through the penis as a sleeve.  Interrupted sutures of 7-0 Vicryl then used to reapproximate and to tack this flap and place over the urethroplasty.  Once this was done, a two 5-0 Vicryl deep sutures were placed in the glans to rotate the glans and allow for hemostasis.  Interrupted sutures of 7-0 Vicryl were then used to create the neomeatus and horizontal mattress sutures of 7-0 Vicryl used to reconstitute the glans.  We then removed the excessive preputial skin and using tacking sutures of 6-0 chromic tacked the penile shaft skin to the coronal cuff and on the ventrum we dropped a portion of the skin down on the left side of the penis to reconstitute the penoscrotal junction using horizontal mattress sutures.  We then closed the ventral defect.  Once this was done, the stay suture in the glans was used to keep the Zaontz catheter to tack it into place.  We then used Surgicel, Dermabond, and Telfa dressing with Mastisol and an eye tape to keep the dressing in place.  IV Toradol was given at the end of the procedure.  The patient was in stable condition upon transfer to the recovery room.
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DESCRIPTION: Hypospadias repair (TIT and tissue flap relocation) and Nesbit tuck chordee release.

urology, tissue flap relocation, penoscrotal hypospadias, urethra, nesbit tuck chordee release, horizontal mattress sutures, hypospadias repair, chordee release, zaontz catheter, urethral plate, glans, hypospadias, penis, chordee,

The situation involves a surgical procedure on a 1.5-year-old child for penoscrotal hypospadias with chordee, conditions that affect the urethra and penile curvature respectively. While the procedure described did not encounter any complications and the estimated blood loss was low, the fact that it involves surgery under general anesthesia on a young child makes it higher stakes than a non-surgical situation. Surgical interventions commonly carry inherent risks, especially in pediatric patients. However, since the surgery proceeded as planned and no unexpected developments were reported, this is a routine medical scenario for specialists in this field.


Medical Specialty: Gastroenterology
Sample Name: Endoscopy Template

INDICATIONS:,  Dysphagia.,PREMEDICATION:,  Topical Cetacaine spray and Versed IV.,PROCEDURE:,:  The scope was passed into the esophagus under direct vision.  The esophageal mucosa was all unremarkable.  There was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis.  The scope was passed on down into the stomach.  The gastric mucosa was all examined including a retroflexed view of the fundus and there were no abnormalities seen.  The scope was then passed into the duodenum and the duodenal bulb and second and third portions of the duodenum were unremarkable.  The scope was again slowly withdrawn through the esophagus and no evidence of narrowing was present.  The scope was then withdrawn.,IMPRESSION:,  Normal upper GI endoscopy without any evidence of anatomical narrowing.
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DESCRIPTION: Normal upper GI endoscopy.

Normal upper GI endoscopy.

gastroenterology, dysphagia, cetacaine spray, esophagus, esophageal mucosa, duodenum, scope was passed, upper gi, gi endoscopy, gi, endoscopy, scope

The procedure described is a routine diagnostic endoscopy for examining the GI tract, specifically due to symptoms of dysphagia. The results were normal, indicating no abnormalities or concerns that require immediate attention or intervention. The stakes involved are low since there are no findings that necessitate urgent medical action or imply a severe health condition, and the report reassures that the patient's upper GI tract appears normal.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 5

CHIEF COMPLAINT: , Swelling of lips causing difficulty swallowing.,HISTORY OF PRESENT ILLNESS:, This patient is a 57-year old white Cuban woman with a long history of rheumatoid arthritis.  She has received methotrexate on a weekly basis as an outpatient for many years.  Approximately two weeks ago, she developed a respiratory infection for which she received antibiotics.  She developed some ulcerations of the mouth and was instructed to discontinue the methotrexate approximately ten days ago.  She showed some initial improvement, but over the last 3-5 days has had malaise, a low-grade fever, and severe oral ulcerations with difficulty in swallowing although she can drink liquids with less difficulty.  ,The patient denies any other problems at this point except for a flare of arthritis since discontinuing the methotrexate.  She has rather diffuse pain involving both large and small joints.  ,MEDICATIONS:, Prednisone 7.5 mg p.o. q.d., Premarin 0.125 mg p.o. q.d., and Dolobid 1000 mg p.o. q.d., recently discontinued because of questionable allergic reaction.  HCTZ 25 mg p.o. q.o.d., Oral calcium supplements.  In the past she has been on penicillin, azathioprine, and hydroxychloroquine, but she has not had Azulfidine, cyclophosphamide, or chlorambucil. ,ALLERGIES: ,None by history.  ,FAMILY/SOCIAL HISTORY:, Noncontributory.,PHYSICAL EXAMINATION:, This is a chronically ill appearing female, alert, oriented, and cooperative.  She moves with great difficulty because of fatigue and malaise.  Vital signs: Blood pressure 107/80, heart rate: 100 and regular, respirations 22.  HEENT: Normocephalic. No scalp lesions.  Dry eyes with conjuctival injections.  Mild exophthalmos.  Dry nasal mucosa.  Marked cracking and bleeding of her lips with erosion of the mucosa.  She has a large ulceration of the mucosa at the bite margin on the left.  She has some scattered ulcerations on her hard and soft palette.  Tonsils not enlarged.  No visible exudate.  She has difficulty opening her mouth because of pain.  SKIN: She has some mild ecchymoses on her skin and some erythema; she has patches but no obvious skin breakdown.  She has some fissuring in the buttocks crease.  PULMONARY: Clear to percussion in auscultation.  CARDIOVASCULAR: No murmurs or gallops noted.  ABDOMEN: Protuberant no organomegaly and positive bowel sounds.  NEUROLOGIC EXAM: Cranial nerves II through XII are grossly intact. Diffuse hyporeflexia.  MUSCULOSKELATAL: Erosive, destructive changes in the elbows, wrist and hands consistent with rheumatoid arthritis.  She also has bilateral total knee replacements with stovepipe legs and parimalleolar pitting adema 1+.  I feel no pulse distally in either leg.  ,PROBLEMS: ,1.  Swelling of lips and dysphagia with questionable early Stevens-Johnson syndrome.,2.  Rheumatoid Arthritis class 3, stage 4.,3.  Flare of arthritis after discontinuing methotrexate.,4.  Osteoporosis with compression fracture.,5.  Mild dehydration.,6.  Nephrolithiasis.,PLAN:, Patient is admitted for IV hydration and treatment of oral ulcerations.  We will obtain a dermatology consult.  IV leucovorin will be started, and the patient will be put on high-dose corticosteroids.
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DESCRIPTION: Patient with swelling of lips and dysphagia and Arthritis.

consult - history and phy., swelling, iv hydration, osteoporosis, swelling of lips, allergic reaction, arthritis, difficulty swallowing, leucovorin, low-grade fever, methotrexate, respiratory infection, rheumatoid arthritis, flare of arthritis, rheumatoid, mucosa, dysphagia,

The situation described involves a patient with multiple complex medical issues, including potential early Stevens-Johnson syndrome, a serious condition requiring urgent attention, particularly given the severe oral ulcerations and swelling that impact swallowing. This is compounded by a history of rheumatoid arthritis, recent flare due to medication discontinuation, potential dehydration, and other underlying health concerns like osteoporosis and nephrolithiasis. The admission for IV hydration and initiation of systemic treatments underscores the seriousness. Such a combination of acute and chronic conditions elevates the stakes of the medical situation.


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

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

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

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

The main finding is mild renal pelvis and proximal ureteral dilatation with perinephric stranding, which suggests a potential recent stone passage. However, no current stones are identified, and no immediate acute complications or severe findings are noted. The clinical scenario requires attention and correlation with symptoms but does not present immediate life-threatening conditions. However, nephrology cases often require careful monitoring due to potential complications of kidney function.


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

REASON FOR REFERRAL:  ,The patient was referred for a neuropsychological evaluation by Dr. X.  A comprehensive evaluation was requested to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.,BRIEF SUMMARY & IMPRESSIONS:,RELEVANT HISTORY:,Historical information was obtained from a review of available medical records and an interview with ,the patient.,The patient presented to Dr. X on August 05, 2008 as she had been recently hospitalized for prolonged episodes of syncope.  She was referred to Dr. X for diagnostic differentiation for possible seizures or other causes of syncope.  The patient reports an extensive neurological history.  Her mother used alcohol during her pregnancy with the patient.  In spite of exposure to alcohol in utero, the patient reported that she achieved "honors in school" and "looked smart."  She reported that she began to experience migraines at 11 years of age.  At 15 years of age, she reported that she was thought to have hydrocephalus.  She reported that she will frequently "bang her head against the wall" to relieve the pain.  The patient gave birth to her daughter at 17 years of age.  At 18 years of age, she received a spinal tap as a procedure to determine the cause of her severe headaches.  She reported, in 1995 to 1996 she experienced a severe head injury, as she was struck by a car as a pedestrian and "thrown two and a half city blocks."  The patient reported that she could recall before being hit, but could not recall the activities of that same day or the following day.  She reported that she had difficulty walking following this head injury, but received rehabilitation for approximately one month.  Her migraines became more severe following the head injury.  In 1998, she reportedly was experiencing episodes of syncope where she would experience a headache with photophobia, phonophobia, and flashing lights.  Following the syncope episode, she would experience some confusion.  These episodes reportedly were related to her donating plasma.,The patient also reported that her ex-husband stated that she frequently jerked and would shake in her sleep.  She reported that upon awakening, she would feel off balanced and somewhat confused.  These episodes diminished from 2002 to June 2008.  When making dinner, she suddenly dropped and hit the back of her head on refrigerator.  She reported that she was unconscious for five to six minutes.  A second episode occurred on July 20th when she lost consciousness for may be a full day.  She was admitted to Sinai Hospital and assessed by a neurologist.  Her EEG and head CT were considered to be completely normal.  She did not report any typical episodes during the time of her 36-hour EEG.  She reported that her last episode of syncope occurred prior to her being hospitalized.  She stated that she had an aura of her ears ringing, vision being darker and "tunnel vision" (vision goes smaller to a pinpoint), and she was "spazzing out" on the floor.  During these episodes, she reports that she cannot talk and has difficulty understanding.,The patient also reports that she has experienced some insomnia since she was 6 years old.  She reported that she was a heavy drinker until about 1998 or 1999 and that she would drink a gallon daily of Jack Daniel.  She stopped the use of alcohol and that time she experienced a suicide attempt.  In 2002, she was diagnosed with bipolar disorder and was started on medication.  At the time of the neuropsychological evaluation, she had stopped taking her medicine as she felt that she was now in remission and could manage her symptoms herself.  The patient's medical history is also significant for postpartum depression.,The patient reported that she has been experiencing difficulty with cognitive abilities of attention/concentration, spelling, tangential and slow thinking, poor sequencing memory for events, and variable verbal memory.  She reported that she sometimes has difficulty understanding what people say, specifically she has difficulty understanding jokes.  She finds that she often has difficulty with expressing her thoughts, as she is very tangential.  She experiences episodes of not recalling what she was speaking of or remembering what activities she was trying to perform.  She reported that she had a photographic memory for directions.  She said that she experienced a great deal of emotional lability, but in general her personality has become more subdued.  At the present time, her daughter has now moved on to college.  The patient is living with her biological mother.  Although she is going through divorce, she reported that it was not really stressful.  She reported that she spends her day driving other people around and trying to be helpful to them.,At the time of the neuropsychological evaluation, the patient's medication included Ativan, Imitrex, Levoxyl, vitamin B12, albuterol metered dose inhaler as needed, and Zofran as needed.  (It should be noted that The patient by the time of the feedback on September 19, 2008 had resumed taking her Trileptal for bipolar disorder.).  The patient's familial medical history is significant for alcohol abuse, diabetes, hypertension, and high cholesterol.,TESTS ADMINISTERED:,Clinical Interview,Cognistat,Mattis Dementia Rating Scale,Wechsler Adult Intelligence Scale - III (WAIS-III),Wechsler Abbreviated Scale of Intelligence (WASI),Selected Subtests from the Delis Kaplan Executive Function System (DKEFS),  Trail Making Test,  Verbal Fluency (Letter Fluency & Category Fluency),  Design Fluency,  Color-Word Interference Test,  Tower,Wisconsin Card Sorting Test (WCST),Stroop Test,Color Trails,Trails A & B,Test of Variables of Attention,Multilingual Aphasia Examination II,  Token Test,  Sentence Repetition,  Visual Naming,  Controlled Oral Word Association,  Spelling Test,  Aural Comprehension,  Reading Comprehension,Boston Naming Test-2 (BNT-2),Animal Naming Test,The Beery-Buktenica Developmental Test of Visual-Motor Integration (VMI),The Beery-Buktenica Developmental Test of Motor Coordination,The Beery-Buktenica Developmental Test of Visual Perception,Judgment Line Orientation,Grooved Pegboard,Purdue Pegboard,Finger Tapping Test,Rey Complex Figure,Wechsler Memory Scale -III (WMS-III),California Verbal Learning Test
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DESCRIPTION: A neuropsychological evaluation to assess neuropsychological factors, clarify areas of strength and weakness, and to assist in therapeutic program planning in light of episodes of syncope.

The case involves a patient with a complex medical history including episodes of syncope, potentially serious neurological issues, and a history of head trauma, substance abuse, and mental health disorders. This patient is undergoing a comprehensive neuropsychological evaluation which may influence future treatment plans and has significant implications for her quality of life. The potential for underlying seizure disorders or other serious neurological conditions increases the stakes of this evaluation. Therefore, any misdiagnosis or oversight could have serious consequences on the patient's health or treatment plan.


Medical Specialty: Surgery
Sample Name: Upper Endoscopy

PROCEDURE:,  Upper endoscopy with removal of food impaction.,HISTORY OF PRESENT ILLNESS: , A 92-year-old lady with history of dysphagia on and off for two years.  She comes in this morning with complaints of inability to swallow anything including her saliva.  This started almost a day earlier.  She was eating lunch and had beef stew and suddenly noticed inability to finish her meal and since then has not been able to eat anything.  She is on Coumadin and her INR is 2.5.,OPERATIVE NOTE: , Informed consent was obtained from patient.  The risks of aspiration, bleeding, perforation, infection, and serious risk including need for surgery and ICU stay particularly in view of food impaction for almost a day was discussed.  Daughter was also informed about the procedure and risks.  Conscious sedation initially was administered with Versed 2 mg and fentanyl 50 mcg.  The scope was advanced into the esophagus and showed liquid and solid particles from mid esophagus all the way to the distal esophagus.  There was a meat bolus in the distal esophagus.  This was visualized after clearing the liquid material and small particles of what appeared to be carrots.  The patient, however, was not tolerating the conscious sedation.  Hence, Dr. X was consulted and we continued the procedure with propofol sedation.,The scope was reintroduced into the esophagus after propofol sedation.  Initially a Roth net was used and some small amounts of soft food in the distal esophagus was removed with the Roth net.  Then, a snare was used to cut the meat bolus into pieces, as it was very soft.  Small pieces were grabbed with the snare and pulled out.  Thereafter, the residual soft meat bolus was passed into the stomach along with the scope, which was passed between the bolus and the esophageal wall carefully.  The patient had severe bruising and submucosal hemorrhage in the esophagus possibly due to longstanding bolus impaction and Coumadin therapy.  No active bleeding was seen.  There was a distal esophageal stricture, which caused slight resistance to the passage of the scope into the stomach.  As this area was extremely inflamed, a dilatation was not attempted.,IMPRESSION: , Distal esophageal stricture with food impaction.  Treated as described above.,RECOMMENDATIONS:,  IV Protonix 40 mg q.12h.  Clear liquid diet for 24 hours.  If the patient is stable, thereafter she may take soft pureed diet only until next endoscopy, which will be scheduled in three to four weeks.  She should take Prevacid SoluTab 30 mg b.i.d. on discharge.
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DESCRIPTION: Upper endoscopy with removal of food impaction.

surgery, dysphagia, removal of food impaction, distal esophagus, stomach, distal esophageal, esophageal stricture, upper endoscopy, food impaction, endoscopy, aspiration, sedation, bolus, impaction, esophagus,

The situation involves a medical procedure on a 92-year-old patient who has a history of dysphagia and is currently experiencing an acute inability to swallow, which has resulted in food impaction in the esophagus. The patient is on Coumadin, which increases the risk of bleeding during the procedure. The risks associated with the procedure include potential aspiration, perforation, infection, and bleeding due to the use of anticoagulants. These factors make it a high-stakes medical scenario, given the patient's advanced age, existing health risks, and potential complications during the procedure.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Appendectomy - 2

PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was prepped and draped in sterile fashion.  Infraumbilical incision was performed and taken down to the fascia.  The fascia was incised.  The peritoneal cavity was carefully entered.  Two other ports were placed in the right and left lower quadrants.  The appendix was readily identified, and the base of the appendix as well as the mesoappendix was divided with the Endo GIA stapler and brought out through the umbilical wound with the Endocatch bag.,All hemostasis was further reconfirmed.  No leakage of enteral contents was noted.  All trocars were removed under direct visualization.  The umbilical fascia was closed with interrupted 0 Vicryl sutures.  The skin was closed with 4-0 Monocryl subcuticular stitch and dressed with Steri-Strips and 4 x 4's.  The patient was extubated and taken to the recovery area in stable condition.  The patient tolerated the procedure well.
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DESCRIPTION: Appendicitis.  Laparoscopic appendectomy. Infraumbilical incision was performed and taken down to the fascia.  The fascia was incised.  The peritoneal cavity was carefully entered.  Two other ports were placed in the right and left lower quadrants.

gastroenterology, mesoappendix, endocatch, laparoscopic appendectomy, appendix, umbilical, laparoscopic, appendectomy, appendicitis, fascia, infraumbilical

The description provided outlines a laparoscopic appendectomy for appendicitis, a common surgical procedure. The details indicate the surgery was routine without complications, the blood loss was minimal, and the patient was stable postoperatively. While surgery inherently carries some risk, this particular case appears straightforward and successful, minimizing the stakes involved. However, considering it is a surgical procedure, it isn't completely devoid of risks, thus it's moderately high-stakes within the context of routine surgeries.


Medical Specialty: Urology
Sample Name: Urology Letter

Sample Address,RE:  Sample Patient,Wife's name:  Sample Name,Dear Sample Doctor:,Mr. Sample Patient was seen on Month DD, YYYY, describing a vasectomy 10 years ago and a failed vasectomy reversal done almost two years ago at the University of Michigan.  He has remained azoospermic postoperatively.  The operative note suggests the presence of some sperm and sperm head on the right side at the time of the vasectomy reversal.,He states that he is interested in sperm harvesting and cryopreservation prior to the next attempted ovulation induction for his wife.  Apparently, several attempts at induction have been tried and due to some anatomic abnormality, they have been unsuccessful.,At the time that he left the office, he was asking for cryopreservation.  At the time of sperm harvesting, I recently received a phone call suggesting that he does not want to do this at all unless his wife's ovulation has been confirmed and it appears then that he may be interested in a fresh specimen harvest.  I look forward to hearing from you regarding the actual plan so that we can arrange our procedure appropriately.  At his initial request, Month DD, YYYY was picked as the date for scheduled harvesting, although this may change if you require fresh specimen.,Thank you very much for the opportunity to have seen him.,Sample Doctor, M.D.
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DESCRIPTION: Vasectomy 10 years ago, failed.  Azoospermic.  Reversal two years ago.  Interested in sperm harvesting and cryopreservation

urology, letter, urology letter, azoospermic, cryopreservation, specimen harvest, sperm harvesting, vasectomy, vasectomy reversal, fresh specimen, reversal, sperm,

The scenario involves a patient dealing with infertility issues due to a failed vasectomy reversal. The stakes are moderately high because it involves family planning, emotional aspects, and potentially complicated medical procedures like sperm harvesting and cryopreservation. While there are important personal implications, it is not immediately life-threatening or an emergency. The outcome will have a significant impact on the patient's family life, but there is time to consider options and make informed decisions.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 5

GENERAL: , Well developed, well nourished, alert, in no acute distress.  GCS 50, nontoxic.,VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature * degrees F.  Pulse oximetry *%.,HEENT: , Eyes: Lids and conjunctiva.  No lesions.  Pupils equal, round, reactive to light and accommodation.  Irises symmetrical, undilated.  Funduscopic exam reveals no hemorrhages or discopathy.  Ears, Nose, Mouth, and throat:  External ears without lesions.  Nares patent.  Septum midline.  Tympanic membranes without erythema, bulging or retraction.  Canals without lesion.  Hearing is grossly intact.  Lips, teeth, gums, palate without lesion.  Posterior oropharynx:  No erythema.  No tonsillar enlargement, crypt formation or abscess.,NECK:  ,Supple and symmetric.  No masses. Thyroid midline, non enlarged.  No JVD.  Neck is nontender.  Full range of motion without pain.,RESPIRATORY: , Good respiratory effort.  Clear to auscultation.  Clear to percussion.  Chest:  Symmetrical rise and fall.  Symmetrical expansion.  No egophony or tactile fremitus.,CARDIOVASCULAR:,  Regular rate and rhythm.  No murmur, gallops, clicks, heaves or rub.  Cardiac palpation within normal limits.  Pulses equal at carotid.  Femoral and pedal pulses:  No peripheral edema.,GASTROINTESTINAL:  ,No tenderness or mass.  No hepatosplenomegaly.  No hernia.  Bowel sounds equal times four quadrants.  Abdomen is nondistended.  No rebound, guarding, rigidity or ecchymosis.,MUSCULOSKELETAL: , Normal gait and station.  No pathology to digits or nails.  Extremities move times four.  No tenderness or effusion.  Range of motion adequate.  Strength and tone equal bilaterally, stable.,BACK: , Nontender on midline.  Full range of motion with flexion, extension and sidebending.,SKIN:,  Inspection within normal limits.  Well hydrated.  No diaphoresis.  No obvious wound.,LYMPH:,  Cervical lymph nodes.  No lymphadenopathy.,NEUROLOGICAL:  ,Cranial nerves II-XII grossly intact.  DTRs symmetric 2 out of 4 bilateral upper and lower extremity, elbow, patella and ankle.  Motor strength 4/4 bilateral upper and lower extremity.  Straight leg raise is negative bilaterally.,PSYCHIATRIC: , Judgment and insight adequate.  Alert and oriented times three.  Memory and mood within normal limits.  No delusions, hallucinations.  No suicidal or homicidal ideation.
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DESCRIPTION: Normal Physical Exam Template.  Well developed, well nourished, alert, in no acute distress.

consult - history and phy., respiratory, abdomen, normal physical exam, pulses, tenderness, strength, lymph, extremity, midline, range, motion, lesions, symmetrical,

The situation described involves a routine physical exam using a standard template. The results indicate that the patient is in good health, with no acute distress or significant findings that would cause concern. As such, this scenario is typical in a clinical setting and does not involve any high-stakes decisions or immediate medical interventions.