Medical Specialty: Gastroenterology
Sample Name: Gastroscopy - 2

PROCEDURE:,  Gastroscopy.,PREOPERATIVE DIAGNOSIS:,  Dysphagia and globus.,POSTOPERATIVE DIAGNOSIS: , Normal.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach, and then through the gastrojejunal anastomosis into the efferent jejunal loop.  The preparation was good and all surfaces were well seen.  The hypopharynx was normal with no evidence of inflammation.  The esophagus had a normal contour and normal mucosa throughout with no sign of stricturing or inflammation or exudate.  The GE junction was located at 39 cm from the incisors and appeared normal with no evidence of reflux, damage, or Barrett's.  Below this there was a small gastric pouch measuring 6 cm with intact mucosa and no retained food.  The gastrojejunal anastomosis was patent measuring about 12 mm, with no inflammation or ulceration.  Beyond this there was a side-to-side gastrojejunal anastomosis with a short afferent blind end and a normal efferent end with no sign of obstruction or inflammation.  The scope was withdrawn and the patient was sent to recovery room.  She tolerated the procedure well.,FINAL DIAGNOSES:,1.  Normal post-gastric bypass anatomy.,2.  No evidence of inflammation or narrowing to explain her symptoms.
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DESCRIPTION: Gastroscopy.  Dysphagia and globus.  No evidence of inflammation or narrowing to explain her symptoms.

gastroenterology, olympus gastroscope, gastric pouch, gastrojejunal anastomosis, dysphagia, globus, esophagus, mucosa, gastric, gastroscopy, gastrojejunal, inflammation

The procedure described is a gastroscopy, which is a diagnostic procedure to view the stomach and esophagus. In this specific case, the findings were normal, and there were no complications or unexpected outcomes reported during or after the procedure. While the patient's symptoms (dysphagia and globus sensation) are uncomfortable, the gastroscopy itself revealed no immediate issues, suggesting there are no critical findings that require urgent intervention. Therefore, while it is important for the patient's ongoing care, there is no immediate high-stakes concern as there were no adverse findings.


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

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

PAST MEDICAL HISTORY:,  Unremarkable, except for diabetes and atherosclerotic vascular disease.,ALLERGIES:,  PENICILLIN.,CURRENT MEDICATIONS:,  Include Glucovance, Seroquel, Flomax, and Nexium.,PAST SURGICAL HISTORY: , Appendectomy and exploratory laparotomy.,FAMILY HISTORY: , Noncontributory.,SOCIAL HISTORY:  ,The patient is a non-smoker.  No alcohol abuse.  The patient is married with no children.,REVIEW OF SYSTEMS:,  Significant for an old CVA.,PHYSICAL EXAMINATION:,  The patient is an elderly male alert and cooperative.  Blood pressure 96/60 mmHg.  Respirations were 20.  Pulse 94.  Afebrile.  O2 was 94% on room air.  HEENT:  Normocephalic and atraumatic.  Pupils are reactive.  Oral mucosa is grossly normal.  Neck is supple.  Lungs:  Decreased breath sounds.  Disturbed breath sounds with poor exchange.  Heart:  Regular rhythm.  Abdomen:  Soft and nontender.  No organomegaly or masses.  Extremities:  No cyanosis, clubbing, or edema.,LABORATORY DATA: , Oropharyngeal evaluation done on 11/02/2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid.  Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses, which clear with liquid swallow and double-saliva swallow.,ASSESSMENT:,1.  Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration.,2.  Old CVA with left hemiparesis.,3.  Oropharyngeal dysphagia.,4.  Diabetes.,PLAN:,  At the present time, the patient is recommended to continue on a regular diet, continue speech pathology evaluation as well as perform double-swallow during meals with bolus sensation.  He may use Italian lemon ice during meals to help clear sinuses as well.  The patient will follow up with you.  If you need any further assistance, do not hesitate to call me.
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DESCRIPTION: Patient with complaints of significant coughing and wheezing.

consult - history and phy., pulmonary evaluation, cough, wheezing, congestion, coughing and wheezing, breath sounds, oropharyngeal dysphagia, pulmonary, breath, sounds, dysphagia, aspiration, sinuses, oropharyngeal, coughing, swallowing,

The situation involves a pulmonary consultation for an elderly patient with a complex medical history, including diabetes, atherosclerotic vascular disease, a previous stroke (CVA), oropharyngeal dysphagia, and a probable multifactorial cause of cough. However, the patient is stable during the physical exam, with BP, resp, and O2 levels within a manageable range. The plan involves continuation of current medications and therapies, without immediate interventions, indicating moderate concern. While significant, the patient is not in acute distress, and there is a plan in place for follow-up and management, keeping this above routine but not in the highest stakes category.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Orthopedic
Sample Name: Closed Reduction - 1

PREOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,INDICATIONS:,  Mr. ABC is a 10-year-old boy who suffered a fall resulting in a right distal both-bone forearm fracture.  Upon evaluation by Orthopedic Surgery team in the emergency department, it was determined that a closed reduction under conscious sedation and application of a splint was warranted.  This was discussed with the parents who expressed verbal and written consent.,PROCEDURE:,  Conscious sedation was achieved via propofol via the emergency department staff.  Afterwards, traction with re-creation of the injury pattern was utilized to achieve reduction of the patient's fracture.  This was confirmed with image intensifier.  Subsequently, the patient was placed into a splint.  The patient was aroused from conscious sedation and at this time it was noted that he had full sensation throughout radial, median, and ulnar nerve distributions and positive extensor pollicis longus, flexor pollicis longus, dorsal and palmar interossei.,DISPOSITION:  ,Post-reduction x-rays revealed good alignment in the AP x-rays.  The lateral x-rays also revealed adequate reduction.  At this time, we will allow the patient to be discharged home and have him follow up with Dr. XYZ in one week.
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DESCRIPTION: Right distal both-bone forearm fracture.  Closed reduction under conscious sedation and application of a splint was warranted.

orthopedic, closed reduction, distal both bone forearm, emergency department, pollicis longus, bone forearm, forearm fracture, conscious sedation, emergency, department, pollicis, longus, splint, distal, bone, forearm, conscious, sedation, fracture, reduction,

The situation involves a medical procedure (closed reduction of a forearm fracture) on a 10-year-old patient. While any medical procedure has inherent risks, this particular situation involves a relatively standard procedure with conscious sedation, which is considered safe and routine in the orthopedic setting. Additionally, the procedure was completed successfully with confirmation of good bone alignment, and the child was discharged with a scheduled follow-up, indicating a positive outcome. However, because the patient is a child and the procedure involves sedation, it still requires careful attention, making it higher stakes than non-medical scenarios, but it's not life-threatening or extremely complex.


Medical Specialty: Surgery
Sample Name: D&C & Laparoscopy - 2

PREOPERATIVE DIAGNOSIS: , Incidental right adnexal mass on ultrasound.,POSTOPERATIVE DIAGNOSES:,1.  Complex left ovarian cyst.,2.  Bilateral complex adnexae.,3.  Bilateral hydrosalpinx.,4.  Chronic pelvic inflammatory disease.,5.  Massive pelvic adhesions.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Enterolysis.,4.  Lysis of the pelvic adhesions.,5.  Left salpingo-oophorectomy.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,SPECIMENS: , Endometrial curettings and left ovarian mass.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,DRAINS:,  None.,FINDINGS: , On bimanual exam, the patient has a slightly enlarged, anteverted, freely mobile uterus with an enlarged left adnexa.  Laparoscopically, the patient has massive pelvic adhesions with completely obliterated posterior cul-de-sac and adnexa.,No adnexal structures were initially able to be visualized until after the lysis of adhesions.  Eventually we found a normal appearing right ovary, severely scarred right and left fallopian tubes, and a enlarged complex cystic left ovary.  There was a normal-appearing appendix and liver, and the vesicouterine junction appeared within normal limits.  There were significant adhesions from the small bowel to the bilateral adnexa in the posterior surface of the uterus.,PROCEDURE:  ,The patient was taken to the operating room where a general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  Next, a weighted speculum was placed in the vagina and anterior wall of the vagina was elevated with the uterine sound and the anterior lip of the cervix was grasped with a vulsellum tenaculum.  The uterus was then sounded to 12 cm.  The cervix was then serially dilated with Hank dilators to a size #20 Hank.  Next a Telfa pad was placed on the weighted speculum and a short curettage was performed obtaining a large amount of endometrial tissue.  Next, the uterine manipulator was placed in the cervix and attached to the anterior lip of the cervix.  At this point, the vulsellum tenaculum and weighted speculum were removed.  Next, attention was turned to the abdomen where an approximately 2 cm incision was made immediately inferior to the umbilicus.  The superior aspect of the umbilicus was grasped with a towel clamp and Veress needle was inserted through this incision.  Small amount of normal saline was injected into Veress needle and seemed to drop freely.  So, the Veress needle was connected to he CO2 gas, which was started at the lower setting.  It was seen to flow freely with a normal resistance so the gas was advanced to the higher setting.  The abdomen was then insufflated to an adequate distention.  Next, the Veress needle was removed and a size #11 step trocar was inserted.  Next, the introducer was removed from the trocar and the laparoscope was inserted through this port and the port was also connected to the CO2 gas.  At this point, the initial operative findings were seen.  Next, a size #5 step trocar was inserted approximately two fingerbreadths above the pubic symphysis in the midline.  This was done by making a 1 cm incision with the skin knife, introducing a Veress needle with Ethicon sheet, and the Veress needle was then removed and the #5 port was introduced under direct visualization.  A size #5 port was also placed approximately six fingerbreadths to the right of the umbilicus in a similar manner also under direct visualization.  A blunt probe was inserted suprapubically along with a grasper in the right upper quadrant.  These were used to see the above operative findings.  Next, a size #12 mm port was introduced approximately seven fingerbreadths to the left of the umbilicus under direct visualization.  Through this, a Harmonic scalpel was inserted.,The Harmonic scalpel along with the grasper was used to meticulously address the adhesions along the right adnexa in the posterior cul-de-sac.  Care was taken at all times to avoid the bowel and the ureters.  The fallopian tubes appeared massively scarred and completely obliterated from disease.  After the right adnexa had been freed to the point where we could visualize the ovary and the posterior cul-de-sac was clearing off then we could visualize the uterosacral ligaments.  Attention was turned to the left adnexa, which appeared to contain a cystic structure, but it was unclear at the beginning of the procedure what the structure was.  Adhesions were carefully taken down from the bowel to the left fallopian tube and ovary, and sidewall.  The adhesions were then carefully removed from the inferior aspect of the ovary also with the Harmonic scalpel.  At intermittent points throughout the procedure, the suction irrigator was used to irrigate and suck blood and irrigation out of the pelvis to watch for any bleeding.  At this point, the Harmonic scalpel was removed and another laparoscopic needle with a 60 cc syringe was inserted and this was used to aspirate approximately 30 cc of serosanguineous fluid from the cystic structure.  Next, the needle was removed and the ligature device was inserted.  This was used to clamp across the fallopian tube initially and then after the fallopian tube was ligated, the uterovarian ligament was clamped and ligated with the ligature device.  Next, the fallopian tube was removed from the ovary with the ligature device in approximately 3 clamping and ligations.  Then, the attention was turned to the inferior aspect of the ovary.  First the infundibulopelvic ligament was identified, clamped with a ligature device, and ligated.  Next, the ovary was bluntly dissected from the ovarian fossa with attention to the left ureter.  Next, the ligature device was used to clamp and ligate the broad ligament immediately inferior to the ovary across.  Then the ovary was completely bluntly dissected out of the ovarian fossa and completely separated from the pelvis.  This was grasped with a clamp.  The ligature device was removed from the #12 and a EndoCatch bag was inserted to the size #12 port.  The left ovary was placed in this EndoCatch bag, which was then removed along with the whole port from the left upper quadrant.  Next, the pelvis was copiously irrigated and suctioned of all blood and extra fluid.  At this point, the remaining two size #5 ports were removed under direct visualization.  The camera was removed and the abdomen was desufflated.  Next, an introducer was replaced on a #11 port.  The #11 port was removed.  Next, the fascia in the left upper quadrant port was identified and grasped with Ochsner clamps, tented up, and closed with a single interrupted suture of #0 Vicryl on a UR-6 needle.  Next, all skin incisions were closed with #4-0 undyed Vicryl in a subcuticular interrupted fashion.  The incisions were cleaned, injected with 0.25% Marcaine, and then adjusted with Steri-Strips and bandage appropriately.,The patient was taken from the operating room in stable condition and should be observed overnight in the hospital.
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DESCRIPTION: Dilation and curettage (D&C), laparoscopy, enterolysis, lysis of the pelvic adhesions, and left salpingo-oophorectomy.  Complex left ovarian cyst, bilateral complex adnexae, bilateral hydrosalpinx, chronic pelvic inflammatory disease, and massive pelvic adhesions.

This surgical procedure involves multiple complex and invasive operations including dilation and curettage (D&C), laparoscopy, enterolysis, lysis of pelvic adhesions, and left salpingo-oophorectomy. The preoperative and postoperative diagnoses indicate significant medical conditions such as complex ovarian cysts, chronic pelvic inflammatory disease, and massive pelvic adhesions. These conditions can impact reproductive and general health, and the procedures are major surgeries that require general anesthesia. While the surgery was completed without any complications, the nature and extent of the procedures, alongside the potential impact on the patient's health and quality of life, classify this as a high-stakes situation.


Medical Specialty: Radiology
Sample Name: Ultrasound OB - 3

GENERAL EVALUATION: ,Twin B,Fetal Cardiac Activity: Normal at 166 BPM,Fetal Lie: Longitudinal, to the maternal right.,Fetal Presentation: Cephalic.,Placenta: Fused, posterior placenta, Grade I to II.,Uterus: Normal,Cervix: Closed.,Adnexa: Not seen,Amniotic Fluid: AFI 5.5cm in a single AP pocket.,BIOMETRY:,BPD: 7.9cm consistent with 31weeks, 5 days gestation,HC: 31.1cm consistent with 33 weeks, 3 days gestation,AC: 30.0cm consistent with 34 weeks, 0 days gestation,FL:
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DESCRIPTION: A 37 year-old female with twin pregnancy with threatened premature labor.

The situation involves a 37-year-old female with a twin pregnancy, with one fetus showing potential signs of fetal growth restriction due to the low amniotic fluid index (AFI) and threatened premature labor. This scenario is high-stakes because twin pregnancies inherently carry more risks, and the complications of low AFI and threatened premature labor can significantly impact the health outcomes for both the mother and the fetuses. It requires careful monitoring and potentially immediate intervention to prevent adverse outcomes.


Medical Specialty: General Medicine
Sample Name: Discharge Summary - 12

CURRENT HISTORY:,  A 94-year-old female from the nursing home with several days of lethargy and anorexia.  She was found to have evidence of UTI.  She also has renal insufficiency and digitalis toxicity.  She is admitted for further treatment.,Past medical history, social history, family history, physical examination can be seen on the admission H&P.,LABORATORIES ON ADMISSION: , White count 11,700, hemoglobin 12.8, hematocrit 37.2, BUN 91, creatinine 2.2, sodium 131, potassium 5.1.  Digoxin level of 4.1.,HOSPITAL COURSE: , The patient was admitted and intravenous fluids and antibiotics were administered.  Blood cultures were negative.  Urine cultures were nondiagnostic.  Renal function improved with creatinine down to 1 at the time of discharge.  Digoxin was restarted at a lower dose.  Her condition improved and she is stabilized and transferred back to assisted living in good condition.,PRIMARY DIAGNOSES:,1.  Urinary tract infection.,2.  Volume depletion.,3.  Renal insufficiency.,4.  Digitalis toxicity.,SECONDARY DIAGNOSES:,1.  Aortic valve stenosis.,2.  Congestive heart failure.,3.  Hypertension.,4.  Chronic anemia.,5.  Degenerative joint disease.,6.  Gastroesophageal reflux disease.,PROCEDURES:,  None.,COMPLICATIONS: , None.,DISCHARGE CONDITION: , Improved and stable.,DISCHARGE PLAN:  ,Physical activity:  With assistance.  ,Diet:  No restriction.  ,Medications:  Lasix 40 mg daily, lisinopril 5 mg daily, digoxin 0.125 mg daily, Augmentin 875 mg 1 tablet twice a day for 1 week, Nexium 40 mg daily, Elavil 10 mg at bedtime, Detrol 2 mg twice a day, potassium 10 mEq daily and diclofenac 50 mg twice a day.  ,Follow up:  She will see Dr. X in the office as scheduled.
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DESCRIPTION: A 94-year-old female from the nursing home with several days of lethargy and anorexia.  She was found to have evidence of UTI and also has renal insufficiency and digitalis toxicity.

The situation described in the discharge summary involves a 94-year-old female patient from a nursing home. She has multiple medical issues including a urinary tract infection, renal insufficiency, and digitalis toxicity. The seriousness is elevated due to her age, the combination of acute and chronic conditions, and the initial risks involved with renal insufficiency and medication toxicity. However, the patient was treated, her condition improved, and she was discharged in stable condition. Given her complex medical history, careful monitoring post-discharge is necessary, but she is not currently in critical condition. Therefore, the stakes, while important and requiring follow-up, are not extremely high at the moment.


Medical Specialty: Ophthalmology
Sample Name: Diplopia

HISTORY OF PRESENT ILLNESS: , The patient is a 53-year-old right-handed gentleman who presents to the clinic for further evaluation of diplopia.  He states that he was in his usual state of health when he awoke one morning in January 2009.  He had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.  He was able to drive.  However, the next day he woke up and he had double vision again.  Over the next week, the double vision worsened in intensity and frequency and by the second week, it was severe.  He states that he called Sinai Hospital and spoke to a physician who recommended that he come in for evaluation.  He was seen by a primary care physician who sent him for an ophthalmologic evaluation.  He was seen and referred to the emergency department for an urgent MRI to evaluate for possible aneurysm.  The patient states that he had a normal MRI and was discharged to home.,For the next month, the double vision improved, although he currently still experiences constant diplopia.  Whereas in the past, when he would see two objects, they were very far apart in a horizontal plane; now they are much closer together.  He still does not drive.  He also is not working due to the double vision.  There is no temporal fluctuation to the double vision.  More recently, over the past month, he has developed right supraorbital pain.  It actually feels like there is pain under his right lid.  He denies any dysphagia, dysarthria, weakness, numbness, tingling, or any other neurological symptoms.,There is a neurology consultation in the computer system.  Dr. X saw the patient on February 2, 2009, when he was in the emergency department.  He underwent an MRI that showed a questionable 3 mm aneurysm of the medial left supraclinoid internal carotid artery, but there were no abnormalities on the right side.  MRV was negative and MRI of the brain with and without contrast was also negative.  He also had an MRI of the orbit with and without contrast that was normal.  His impression was that the patient should follow up for a possible evaluation of myasthenia gravis or other disorder.,At the time of the examination, it was documented that he had right lid ptosis.  He had left gaze diplopia.  The pupils were equal, round, and reactive to light.  His neurological examination was otherwise entirely normal.  According to Dr. X's note, the ophthalmologist who saw him thought that there was ptosis of the right eye as well as an abnormal pupil.  There was also right medial rectus as well as possibly other extraocular abnormalities.  I do not have the official ophthalmologic consultation available to me today.,PAST MEDICAL HISTORY: , The patient denies any previous past medical history.  He currently does not have a primary care physician as he is uninsured.,MEDICATIONS:,  He does not take any medications.,ALLERGIES: , He has no known drug allergies.,SOCIAL HISTORY: , The patient lives with his wife.  He was an IT software developer, but he has been out of work for several months.  He smokes less than a pack of cigarettes daily.  He denies alcohol or illicit drug use.,FAMILY HISTORY: , His mother died of a stroke in her 90s.  His father had colon cancer.  He is unaware of any family members with neurological disorders.,REVIEW OF SYSTEMS: , A complete review of systems was obtained and was negative except for as mentioned above.  This is documented in the handwritten notes from today's visit.,PHYSICAL EXAMINATION:,Vital Signs:  BP 124/76
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DESCRIPTION: He awoke one morning and had double vision.  He states when he closed each eye, the double vision dissipated.  The double vision entirely dissipated within one hour.   The next day he woke up and he had double vision again.

The situation is relatively high-stakes due to several factors. Diplopia can significantly impact the patient's quality of life, affecting his ability to work and drive. The initial suspicion of a 3 mm aneurysm adds a potential risk of a serious and possibly life-threatening condition. Although the MRI was negative for immediate alarming issues, the presence of diplopia, right lid ptosis, and associated symptoms warrant ongoing medical attention to rule out serious conditions like myasthenia gravis or other possible neurological disorders. Undertaking further evaluations and appropriately managing the patient's condition is crucial to prevent deterioration or complications.


Medical Specialty: Consult - History and Phy.
Sample Name: Foreign Body - Right Nose

CHIEF COMPLAINT:,  Questionable foreign body, right nose.  Belly and back pain.  ,SUBJECTIVE: , Mr. ABC is a 2-year-old boy, who is brought in by parents, stating that the child keeps complaining of belly and back pain.  This does not seem to be slowing him down.  They have not noticed any change in his urine or bowels.  They have not noted him to have any fevers or chills or any other illness.  They state he is otherwise acting normally.  He is eating and drinking well.  He has not had any other acute complaints, although they have noted a foul odor coming from his nose.  Apparently, he was seen here a few weeks ago for a foreign body in the right nose, which was apparently a piece of cotton; this was removed and placed on antibiotics.  His nose got better and then started to become malodorous again.  Mother restarted him on the remainder of the antibiotics and they are also stating that they think there is something still in there.  Otherwise, he has not had any runny nose, earache, no sore throat.  He has not had any cough, congestion.  He has been acting normally.  Eating and drinking okay.  No other significant complaints.  He has not had any pain with bowel movement or urination, nor have they noted him to be more frequently urinating, then again he is still on a diaper.,PAST MEDICAL HISTORY: , Otherwise negative.,ALLERGIES: , No allergies.,MEDICATIONS: , No medications other than recent amoxicillin.,SOCIAL HISTORY: , Parents do smoke around the house.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  He is afebrile.,GENERAL:  This is a well-nourished, well-developed 2-year-old little boy, who is appearing very healthy, normal for his stated age, pleasant, cooperative, in no acute distress, looks very healthy, afebrile and nontoxic in appearance.,HEENT:  TMs, canals are normal.  Left naris normal.  Right naris, there is some foul odor as well as questionable purulent drainage.  Examination of the nose, there was a foreign body noted, which was the appearance of a cotton ball in the right nose, that was obviously infected and malodorous.  This was removed and reexamination of the nose was done and there was absolutely no foreign body left behind or residual.  There was some erythema.  No other purulent drainage noted.  There was some bloody drainage.  This was suctioned and all mucous membranes were visualized and are negative.,NECK:  Without lymphadenopathy.  No other findings.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  His abdomen is entirely benign, soft, nontender, nondistended.  Bowel sounds active.  No organomegaly or mass noted.,BACK:  Without any findings.  Diaper area normal.,GU:  No rash or infections.  Skin is intact.,ED COURSE: , He also had a P-Bag placed, but did not have any urine.  Therefore, a straight catheter was done, which was done with ease without complication and there was no leukocytes noted within the urine.  There was a little bit of blood from catheterization but otherwise normal urine.  X-ray noted some stool within the vault.  Child is acting normally.  He is jumping up and down on the bed without any significant findings.,ASSESSMENT:,1.  Infected foreign body, right naris.,2.  Mild constipation.,PLAN:,  As far as the abdominal pain is concerned, they are to observe for any changes.  Return if worse, follow up with the primary care physician.  The right nose, I will place the child on amoxicillin 125 per 5 mL, 1 teaspoon t.i.d.  Return as needed and observe for more foreign bodies.  I suspect, the child had placed this cotton ball in his nose again after the first episode.
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DESCRIPTION: Questionable foreign body, right nose.  Belly and back pain.   Mild constipation.

The situation involves a young child with a history of placing a foreign body in his right nose that resulted in infection. While the issue of a foreign body in the nose and associated infection can be concerning, particularly considering possible complications like an infection spreading or respiratory issues, the child currently shows no severe symptoms, is stable, afebrile, and acting normally. The situation is being monitored with a plan to return if symptoms worsen. This does not indicate an immediate life-threatening situation, but it does require prompt attention to prevent complications. Additionally, mild constipation is noted but it does not warrant urgent medical intervention considering the symptoms and findings.


Medical Specialty: Surgery
Sample Name: Trigger Thumb Release - 1

PREOPERATIVE DIAGNOSIS:  ,Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:,  Right trigger thumb.,OPERATIONS PERFORMED:,  Trigger thumb release.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia applied by surgeon with local.,COMPLICATIONS:,
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DESCRIPTION: Trigger thumb release.  Right trigger thumb.  The A-1 pulley was divided along its radial border, completely freeing the stenosing tenosynovitis (trigger release).

surgery, trigger thumb, trigger thumb release, tenosynovitis trigger, tenosynovitis, release, thumb, tourniquet, trigger,

The procedure described is a common surgical intervention for trigger thumb, which is a condition that causes pain and difficulty in moving the thumb. While it is a surgical procedure, it is generally considered low-risk and routine for experienced surgeons. The description does not mention any complications, indicating that the operation likely went smoothly as planned. The use of local and regional anesthesia suggests a focus on patient comfort during what is typically a straightforward procedure.


Medical Specialty: Sleep Medicine
Sample Name: Electroencephalogram - 4

PROCEDURE:,  A 21-channel digital electroencephalogram was performed on a patient in the awake state.  Per the technician's notes, the patient is taking Depakene.,The recording consists of symmetric 9 Hz alpha activity.  Throughout the recording, repetitive episodes of bursts of 3 per second spike and wave activity are noted.  The episodes last from approximately1 to 7 seconds.  The episodes are exacerbated by hyperventilation.,IMPRESSION:,  Abnormal electroencephalogram with repetitive bursts of 3 per second spike and wave activity exacerbated by hyperventilation.  This activity could represent true petit mal epilepsy.  Clinical correlation is suggested.
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DESCRIPTION: A 21-channel digital electroencephalogram was performed on a patient in the awake state.

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

The situation involves interpreting an electroencephalogram (EEG) to potentially diagnose petit mal epilepsy, which is a form of epilepsy. While epilepsy is a serious condition that requires accurate diagnosis and appropriate treatment, this particular procedure and interpretation do not involve immediate life-threatening decisions. The stakes are significant as they impact the patient's health management and quality of life, but it is not exceedingly high-stakes compared to scenarios involving life-or-death emergencies.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Three-Week Postpartum Checkup

CHIEF COMPLAINT:,  The patient comes for three-week postpartum checkup, complaining of allergies.,HISTORY OF PRESENT ILLNESS:,  She is doing well postpartum.  She has had no headache.  She is breastfeeding and feels like her milk is adequate.  She has not had much bleeding.  She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish.  She has not yet had sexual intercourse.  She does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding.  She has not been particularly constipated but her husband says she is not eating her vegetables like she should.  Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears.,MEDICATIONS:,  Prenatal vitamins.,ALLERGIES:,  She thinks to Benadryl.,FAMILY HISTORY: , Mother is 50 and healthy.  Dad is 40 and healthy.  Half-sister, age 34, is healthy.  She has a sister who is age 10 who has some yeast infections.,PHYSICAL EXAMINATION:,VITALS:  Weight:  124 pounds.  Blood pressure 96/54.  Pulse:  72.  Respirations:  16.  LMP:  10/18/03.  Age:  39.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.  She has allergic rhinitis with clear nasal drainage, clear watery discharge from the eyes.,Abdomen:  Soft.  No masses.,Pelvic:  Uterus is involuting.,Rectal:  She has one external hemorrhoid which has inflamed.  Stool is guaiac negative and using anoscope, no other lesions are identified.,ASSESSMENT/PLAN:,  Satisfactory three-week postpartum course, seasonal allergies.  We will try Patanol eyedrops and Allegra 60 mg twice a day.  She was cautioned about the possibility that this may alter her milk supply.  She is to drink extra fluids and call if she has problems with that.  We will try ProctoFoam HC.  For the hemorrhoids, also increase the fiber in her diet.  That prescription was written, as well as one for Allegra and Patanol.  She additionally will be begin on Micronor because she would like to protect herself from pregnancy until her husband get scheduled in and has a vasectomy, which is their ultimate plan for birth control, and she anticipates that happening fairly soon.  She will call and return if she continues to have problems with allergies.  Meantime, rechecking in three weeks for her final six-week postpartum checkup.
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DESCRIPTION: The patient comes for three-week postpartum checkup, complaining of allergies.

soap / chart / progress notes, checkup, allergies, postpartum, complaining of allergies, seasonal allergies, postpartum checkup,

The situation involves a routine three-week postpartum checkup for a patient experiencing mild symptoms related to allergies and hemorrhoids. The patient is generally well postpartum, and there are no immediate critical health concerns. The recommendations made involve standard care adjustments and monitoring, which do not indicate high-stakes medical decision-making. The plan includes relatively common medications and an expected follow-up for normal postpartum care, which further suggests a low-stakes scenario.


Medical Specialty: Neurology
Sample Name: Craniotomy - Biparietal

PREOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,POSTOPERATIVE DIAGNOSES: , Multiple metastatic lesions to the brain, a subtentorial lesion on the left, greater than 3 cm, and an infratentorial lesion on the right, greater than 3 cm.,TITLE OF THE OPERATION:,1.  Biparietal craniotomy and excision of left parietooccipital metastasis from breast cancer.,2.  Insertion of left lateral ventriculostomy under Stealth stereotactic guidance.,3.  Right suboccipital craniectomy and excision of tumor.,4.  Microtechniques for all the above.,5.  Stealth stereotactic guidance for all of the above and intraoperative ultrasound.,INDICATIONS: , The patient is a 48-year-old woman with a diagnosis of breast cancer made five years ago.  A year ago, she was diagnosed with cranial metastases and underwent whole brain radiation.  She recently has deteriorated such that she came to my office, unable to ambulate in a wheelchair.  Metastatic workup does reveal multiple bone metastases, but no spinal cord compression.  She had a consult with Radiation-Oncology that decided they could radiate her metastases less than 3 cm with stereotactic radiosurgery, but the lesions greater than 3 cm needed to be removed.  Consequently, this operation is performed.,PROCEDURE IN DETAIL: , The patient underwent a planning MRI scan with Stealth protocol.  She was brought to the operating room with fiducial still on her scalp.  General endotracheal anesthesia was obtained.  She was placed on the Mayfield head holder and rolled into the prone position.  She was well padded, secured, and so forth.  The neck was flexed so as to expose the right suboccipital region as well as the left and right parietooccipital regions.  The posterior aspect of the calvarium was shaved and prepared in the usual manner with Betadine soak scrub followed by Betadine paint.  This was done only, of course, after fiducial were registered in planning and an excellent accuracy was obtained with the Stealth system.  Sterile drapes were applied and the accuracy of the system was confirmed.  A biparietal incision was performed.  A linear incision was chosen so as to increase her chances of successful wound healing and that she is status post whole brain radiation.  A biparietal craniotomy was carried out, carrying about 1 cm over toward the right side and about 4 cm over to the left side as guided by the Stealth stereotactic system.  The dura was opened and reflected back to the midline.  An inner hemispheric approach was used to reach the very large metastatic tumor.  This was very delicate removing the tumor and the co-surgeons switched off to spare one another during the more delicate parts of the operation to remove the tumor.  The tumor was wrapped around and included the choroidal vessels.  At least one choroidal vessel was sacrificed in order to obtain a gross total excision of the tumor on the parietal occipital region.  Bleeding was quite vigorous in some of the arteries and finally, however, was completely controlled.  Complete removal of the tumor was confirmed by intraoperative ultrasound.,Once the tumor had been removed and meticulous hemostasis was obtained, this wound was left opened and attention was turned to the right suboccipital area.  A linear incision was made just lateral to the greater occipital nerve.  Sharp dissection was carried down in the subcutaneous tissues and Bovie electrocautery was used to reach the skull.  A burr hole was placed down low using a craniotome.  A craniotomy was turned and then enlarged as a craniectomy to at least 4 cm in diameter.  It was carried caudally to the floor of the posterior fossa and rostrally to the transverse sinus.  Stealth and ultrasound were used to localize the very large tumor that was within the horizontal hemisphere of the cerebellum.  The ventriculostomy had been placed on the left side with the craniotomy and removal of the tumor, and this was draining CSF relieving pressure in the posterior fossa.  Upon opening the craniotomy in the parietal occipital region, the brain was noted to be extremely tight, thus necessitating placement of the ventriculostomy.,At the posterior fossa, a corticectomy was accomplished and the tumor was countered directly.  The tumor, as the one above, was removed, both piecemeal and with intraoperative Cavitron Ultrasonic Aspirator.  A gross total excision of this tumor was obtained as well.,I then explored underneath the cerebellum in hopes of finding another metastasis in the CP angle; however, this was just over the lower cranial nerves, and rather than risk paralysis of pharyngeal muscles and voice as well as possibly hearing loss, this lesion was left alone and to be radiated and that it is less than 3 cm in diameter.,Meticulous hemostasis was obtained for this wound as well.,The posterior fossa wound was then closed in layers.  The dura was closed with interrupted and running mattress of 4-0 Nurolon.  The dura was watertight, and it was covered with blue glue.  Gelfoam was placed over the dural closure.  Then, the muscle and fascia were closed in individual layers using #0 Ethibond.  Subcutaneous was closed with interrupted inverted 2-0 and 0 Vicryl, and the skin was closed with running locking 3-0 Nylon.,For the cranial incision, the ventriculostomy was brought out through a separate stab wound.  The bone flap was brought on to the field.  The dura was closed with running and interrupted 4-0 Nurolon.  At the beginning of the case, dural tack-ups had been made and these were still in place.  The sinuses, both the transverse sinus and sagittal sinus, were covered with thrombin-soaked Gelfoam to take care of any small bleeding areas in the sinuses.,Once the dura was closed, the bone flap was returned to the wound and held in place with the Lorenz microplates.  The wound was then closed in layers.  The galea was closed with multiple sutures of interrupted 2-0 Vicryl.  The skin was closed with a running locking 3-0 Nylon.,Estimated blood loss for the case was more than 1 L.  The patient received 2 units of packed red cells during the case as well as more than 1 L of Hespan and almost 3 L of crystalloid.,Nevertheless, her vitals remained stable throughout the case, and we hopefully helped her survival and her long-term neurologic status for this really nice lady.
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DESCRIPTION: Biparietal craniotomy, insertion of left lateral ventriculostomy, right suboccipital craniectomy and excision of tumor.

neurology, metastatic lesion, biparietal, mayfield head holder, microtechniques, stealth, craniotomy, excision, fiducial, infratentorial, parietooccipital, stereotactic, suboccipital, subtentorial, ventriculostomy, lesions to the brain, removal of the tumor, parietal occipital region, running locking nylon, biparietal craniotomy, posterior fossa, tumor, brain, dura, lesions,

The situation involves a complex and delicate surgical procedure on a patient with multiple brain metastases. Given the patient's advanced stage of cancer and the life-threatening nature of the condition, this procedure is critical to potentially extending the patient's life and alleviating neurological symptoms. Surgical procedures involving the brain are inherently high-stakes due to the risks of complications and the potential impact on the patient's quality of life and survival. Therefore, the stakes of this medical scenario are extremely high.


Medical Specialty: Surgery
Sample Name: Tracheostomy Change

PREOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Laryngeal edema.,POSTOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Laryngeal edema.,PROCEDURE PERFORMED: , Tracheostomy change.  A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.,INDICATIONS: , The patient is a 60-year-old Caucasian female who presented to ABCD General Hospital with exacerbation of COPD and CHF.  The patient had subsequently been taken to the operating room by Department of Otolaryngology and a direct laryngoscope was performed.  The patient was noted at that time to have transglottic edema.  Biopsies were taken.  At the time of surgery, it was decided that the patient required a tracheostomy for maintenance of continued ventilation and airway protection.  The patient is currently postop day #6 and appears to be unable to be weaned from ventilator at this time and may require prolonged ventricular support.  A decision was made to perform tracheostomy change.,DESCRIPTION OF PROCEDURE: , The patient was seen in the Intensive Care Unit.  The patient was placed in a supine position.  The neck was then extended.  The sutures that were previously in place in the #6 Shiley with proximal extension were removed.  The patient was preoxygenated to 100%.  After several minutes, the patient was noted to have a pulse oximetry of 100%.  The IV tubing that was supporting the patient's trache was then cut.  The tracheostomy tube was then suctioned.,The inner cannula was then removed from the tracheostomy and a nasogastric tube was placed down the lumen of the tracheostomy tube as a guidewire.  The tracheostomy tube was then removed over the nasogastric tube and the operative field was suctioned.  With the guidewire in place and with adequate visualization, a new #6 Shiley with proximal extension was then passed over the nasogastric tube guidewire and carefully inserted into the trachea.  The guidewire was then removed and the inner cannula was then placed into the tracheostomy.  The patient was then reconnected to the ventilator and was noted to have normal tidal volumes.  The patient had a tidal volume of 500 and was returning 500 cc to 510 cc.  The patient continued to saturate well with saturations 99%.  The patient appeared comfortable and her vital signs were stable.  A soft trache collar was then connected to the trachesotomy.  A drain sponge was then inserted underneath the new trache site.  The patient was observed for several minutes and was found to be in no distress and continued to maintain adequate saturations and continued to return normal tidal volumes.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well.  0.25% acetic acid soaks were ordered to the drain sponge every shift.
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DESCRIPTION: Tracheostomy change.  A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.  Ventilator-dependent respiratory failure and laryngeal edema.

surgery, shiley, proximal extension, ventilator-dependent, respiratory failure, laryngeal edema, tracheostomy, cannula, respiratory, laryngeal, nasogastric, edema, ventilator

The situation involves a tracheostomy change in a patient who is ventilator-dependent and has laryngeal edema. Tracheostomies are critical for patients who cannot breathe independently and need mechanical ventilation. Although this specific procedure involved changing an existing tracheostomy tube, which is a routine procedure, it is still associated with potential risks such as airway loss or complications during the change. The patient in question is also critically ill, requiring careful monitoring. However, the procedure description indicates that it went smoothly without any complications, suggesting a low incidence of immediate danger.


Medical Specialty: Surgery
Sample Name: Low-Transverse C-Section - 7

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 and 1/7th weeks.,2.  Previous cesarean section, refuses trial of labor.,3.  Fibroid uterus.,4.  Oligohydramnios.,5.  Nonreassuring fetal heart tones.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 39 and 1/7th weeks.,2.  Previous cesarean section, refuses trial of labor.,3.  Fibroid uterus.,4.  Oligohydramnios.,5.  Nonreassuring fetal heart tones.,PROCEDURE PERFORMED:,  Repeat low-transverse cesarean section via Pfannenstiel incision.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS:,  1200 cc.,FLUIDS:,  2700 cc.,URINE:,  400 cc clear at the end of the procedure.,DRAINS: , Foley catheter.,SPECIMENS:  ,Placenta, cord gases and cord blood.,INDICATIONS:  ,The patient is a G5 P1 Caucasian female at 39 and 1/7th weeks with a history of previous cesarean section for failure to progress and is scheduled cesarean section for later this day who presents to ABCD Hospital complaining of contractions.  She was found to not be in labor, but had nonreassuring heart tones with a subtle late decelerations and AFOF of approximately 40 mm.  A decision was made to take her for a C-section early.,FINDINGS: , The patient had an enlarged fibroid uterus with a large anterior fibroid with large varicosities, normal appearing tubes and ovaries bilaterally.  There was a live male infant in the ROA position with Apgars of 9 at 1 minute and 9 at 5 minutes and a weight of 5 lb 4 oz.,PROCEDURE: , Prior to the procedure, an informed consent was obtained.  The patient who previously been interested in a tubal ligation refused the tubal ligation prior to surgery.  She states that she and her husband are fully disgusted and that they changed their mind and they were adamant about this.  After informed consent was obtained, the patient was taken to the operating room where spinal anesthetic with Astramorph was administered.  She was then prepped and draped in the normal sterile fashion.  Once the anesthetic was tested, it was found to be inadequate and a general anesthetic was administered.  Once the general anesthetic was administered and the patient was asleep, the previous incision was removed with the skin knife and this incision was then carried through an underlying layer of fascia with a second knife.  The fascia was incised in the midline with a second knife.  This incision was then extended laterally in both directions with the Mayo scissors.  The superior aspect of this fascial incision was then dissected off to the underlying rectus muscle bluntly without using Ochsner clamps.  It was then dissected in the midline with Mayo scissors.  The inferior aspect of this incision was then addressed in a similar manner.  The rectus muscles were then separated in the midline with a hemostat.  The rectus muscles were separated further in the midline with Mayo scissors superiorly and inferiorly.  Next, the peritoneum was grasped with two hemostats, tented up and entered sharply with the Metzenbaum scissors.  This incision was extended inferiorly with the Metzenbaum scissors, being careful to avoid the bladder and the peritoneal incision was extended bluntly.  Next, the bladder blade was placed.  The vesicouterine peritoneum was identified, tenting up with Allis clamps and entered sharply with the Metzenbaum scissors.  This incision was extended laterally in both directions and a bladder flap was created digitally.  The bladder blade was then reinserted.  Next, the uterine incision was made with a second knife and the uterus was entered with the blunt end of the knife.  Next, the uterine incision was extended laterally in both directions with the banded scissors.  Next, the infant's head and body were delivered without difficulty.  There was multiple section on the abdomen.  The cord was clamped and cut.  Section of cord was collected for gases and the cord blood was collected.  Next, the placenta was manually extracted.  The uterus was exteriorized and cleared of all clots and debris.  The edges of the uterine incision were then identified with Allis _______ clamps.  The uterine incision was reapproximated with #0 chromic in a running locked fashion and a second layer of the same suture was used to obtain excellent hemostasis.  One figure-of-eight with #0 chromic was used in one area to prevent a questionable hematoma from expanding along the varicosity for the anterior fibroid.  After several minutes of observation, the hematoma was seem to be non-expanding.  The uterus was replaced in the abdomen.  The uterine incision was reexamined and seem to be continuing to be hemostatic.  The pelvic gutters were then cleared of all clots and debris.  The vesicouterine peritoneum was then reapproximated with #3-0 Vicryl in a running fashion.  The peritoneum was then closed with #0 Vicryl in a running fashion.  The rectus muscles reapproximated with #0 Vicryl in a single interrupted stitch.  The fascia was closed with #0 Vicryl in a running locked fashion and the skin was closed with staples.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x3.  The patient was then taken to Recovery in stable condition and she will be followed for immediate postoperative course in the hospital.
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DESCRIPTION: Repeat low-transverse cesarean section via Pfannenstiel incision.  Intrauterine pregnancy at 39 and 1/7th weeks.  Previous cesarean section, refuses trial of labor.  Fibroid uterus, oligohydramnios, and nonreassuring fetal heart tones.

The situation involves a surgical procedure, specifically a repeat low-transverse cesarean section, which inherently carries significant health risks and potential complications for both the mother and infant. Key factors include the patient's refusal of a trial of labor, previous cesarean, fibroid uterus, oligohydramnios, and nonreassuring fetal heart tones, which justify the decision for an early C-section. The stakes are high as the procedure directly impacts the safety and well-being of both mother and child. However, the surgery was completed without noted complications, reducing immediate high-stakes pressure.


Medical Specialty: Consult - History and Phy.
Sample Name: Barium Swallow Study & Speech Evaluation - 1

SUBJECTIVE: , The patient is a 60-year-old female, who complained of coughing during meals.  Her outpatient evaluation revealed a mild-to-moderate cognitive linguistic deficit, which was completed approximately 2 months ago.  The patient had a history of hypertension and TIA/stroke.  The patient denied history of heartburn and/or gastroesophageal reflux disorder.  A modified barium swallow study was ordered to objectively evaluate the patient's swallowing function and safety and to rule out aspiration.,OBJECTIVE: , Modified barium swallow study was performed in the Radiology Suite in cooperation with Dr. ABC.  The patient was seated upright in a video imaging chair throughout this assessment.  To evaluate the patient's swallowing function and safety, she was administered graduated amounts of liquid and food mixed with barium in the form of thin liquid (teaspoon x2, cup sip x2); nectar-thick liquid (teaspoon x2, cup sip x2); puree consistency (teaspoon x2); and solid food consistency (1/4 cracker x1).,ASSESSMENT,ORAL STAGE:,  Premature spillage to the level of the valleculae and pyriform sinuses with thin liquid.  Decreased tongue base retraction, which contributed to vallecular pooling after the swallow.,PHARYNGEAL STAGE: , No aspiration was observed during this evaluation.  Penetration was noted with cup sips of thin liquid only.  Trace residual on the valleculae and on tongue base with nectar-thick puree and solid consistencies.  The patient's hyolaryngeal elevation and anterior movement are within functional limits.  Epiglottic inversion is within functional limits.,CERVICAL ESOPHAGEAL STAGE:  ,The patient's upper esophageal sphincter opening is well coordinated with swallow and readily accepted the bolus.  Radiologist noted reduced peristaltic action of the constricted muscles in the esophagus, which may be contributing to the patient's complaint of globus sensation.,DIAGNOSTIC IMPRESSION:,  No aspiration was noted during this evaluation.  Penetration with cup sips of thin liquid.  The patient did cough during this evaluation, but that was noted related to aspiration or penetration.,PROGNOSTIC IMPRESSION: ,Based on this evaluation, the prognosis for swallowing and safety is good.,PLAN: , Based on this evaluation and following recommendations are being made:,1.  The patient to take small bite and small sips to help decrease the risk of aspiration and penetration.,2.  The patient should remain upright at a 90-degree angle for at least 45 minutes after meals to decrease the risk of aspiration and penetration as well as to reduce her globus sensation.,3.  The patient should be referred to a gastroenterologist for further evaluation of her esophageal function.,The patient does not need any skilled speech therapy for her swallowing abilities at this time, and she is discharged from my services.
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DESCRIPTION:

consult - history and phy., gastroesophageal reflux disorder, cognitive linguistic deficit, tia, stroke, swallowing function, swallow study, barium swallow study, globus sensation, esophageal, penetration

The situation is a medical evaluation of a patient's swallowing function and the safety of consuming different consistencies of food and liquids. It involves assessing the risk of aspiration, a serious condition where food or liquid enters the airway, which can lead to pneumonia or other complications. Given the patient's history of a stroke and the current findings of penetration with certain liquids, there is a moderate level of concern for her swallowing safety. However, the report indicates a good prognosis for the patient's swallowing ability, suggesting that the immediate risks are manageable. The situation is serious, but not extremely high-stakes due to the absence of aspiration and the positive prognosis.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Hysteroscopy & Endometrial Ablation

PREOPERATIVE DX:,1.  Menorrhagia,2.  Desires permanent sterilization.,POSTOPERATIVE DX:,1.  Menorrhagia,2.  Desires permanent sterilization.,OPERATIVE PROCEDURE:,  Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.,ANESTHESIA: , General with paracervical block.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS:,  On hysteroscopy, 100 ml deficit of lactated Ringer's via IV, 850 ml of lactated Ringer's.,COMPLICATIONS: , None.,PATHOLOGY: , None.,DISPOSITION:  ,Stable to recovery room.,FINDINGS:,  A nulliparous cervix without lesions.  Uterine cavity sounding to 10 cm, normal appearing tubal ostia bilaterally, fluffy endometrium, normal appearing cavity without obvious polyps or fibroids.,PROCEDURE: , The patient was taken to the operating room, where general anesthesia was found to be adequate.  She was prepped and draped in the usual sterile fashion.  A speculum was placed into the vagina.  The anterior lip of the cervix was grasped with a single-tooth tenaculum and a paracervical block was performed using 20 ml of 0.50% lidocaine with 1:200,000 of epinephrine.,The cervical vaginal junction at the 4 o'clock position was injected and 5 ml was instilled.  The block was performed at 8 o'clock as well with 5 ml at 10 and 2 o'clock.  The lidocaine was injected into the cervix.  The cervix was minimally dilated with #17 Hanks dilator.  The 5-mm 30-degree hysteroscope was then inserted under direct visualization using lactated Ringer's as a distention medium.  The uterine cavity was viewed and the above normal findings were noted.  The Essure tubal occlusion was then inserted through the operative port and the tip of the Essure device easily slid into the right ostia.  The coil was advanced and easily placed and the device withdrawn.  There were three coils into the uterine cavity after removal of the insertion device.  The device was removed and reloaded.  The advice was to advance under direct visualization and the tip was inserted into the left ostia.  This passed easily and the device was inserted.  It was removed easily and three coils again were into the uterine cavity.  The hysteroscope was then removed and the ThermaChoice ablation was performed.  The uterus was then sounded to 9.5 to 10 cm.  The ThermaChoice balloon was primed and pressure was drawn to a negative 150.  The device was then moistened and inserted into the uterine cavity and the balloon was slowly filled with 40 ml of D5W.  The pressure was brought up to 170 and the cycle was initiated.  A full cycle of eight minutes was performed.  At no time there was a significant loss of pressure from the catheter balloon.  After the cycle was complete, the balloon was deflated and withdrawn.  The tenaculum was withdrawn.  No bleeding was noted.  The patient was then awakened, transferred, and taken to the recovery room in satisfactory condition.
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DESCRIPTION: Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.

obstetrics / gynecology, menorrhagia, essure, hysteroscopy, thermachoice, uterine cavity, endometrial ablation, endometrium, fibroids, fluffy, lactated ringer, nulliparous, paracervical block, permanent sterilization, polyps, tubal occlusion, tubal ostia, lactated ringer's, ablation, uterine,

The procedure described involves a hysteroscopy, Essure tubal occlusion, and ThermaChoice endometrial ablation, which are performed to address menorrhagia and sterilization desires. While these are significant medical procedures, they are relatively routine in the field of gynecology and are generally considered low risk with minimal complications, as indicated by the absence of complications in this case. The estimated blood loss was minimal and the patient was stable post-operation. Thus, the situation is not life-threatening or extremely critical, making it moderately high-stakes at most.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 53

HISTORY OF PRESENT ILLNESS: , Goes back to yesterday, the patient went out for dinner with her boyfriend.  The patient after coming home all the family members had some episodes of diarrhea; it is unclear how many times the patient had diarrhea last night.  She was found down on the floor this morning, soiled her bowel movements.  Paramedics were called and the patient was brought to the emergency room.  The patient was in the emergency room noted to be in respiratory failure, was intubated.  The patient was in septic shock with metabolic acidosis and no blood pressure and very rapid heart rate with acute renal failure.  The patient was started on vasopressors.  The patient was started on IV fluids as well as IV antibiotic.  The CT of the abdomen showed ileus versus bowel distention without any actual bowel obstruction or perforation.  A General Surgery consultation was called who did not think the patient was a surgical candidate and needed an acute surgical procedure.  The patient underwent an ultrasound of the abdomen, which did not show any evidence of cholecystitis or cholelithiasis.  The patient was also noted to have acute rhabdomyolysis on the workup in the emergency room.,PAST MEDICAL HISTORY:  ,Significant for history of osteoporosis, hypertension, tobacco dependency, anxiety, neurosis, depression, peripheral arterial disease, peripheral neuropathy, and history of uterine cancer.,PAST SURGICAL HISTORY:  ,Significant for hysterectomy, bilateral femoropopliteal bypass surgeries as well as left eye cataract surgery and appendicectomy.,SOCIAL HISTORY: , She lives with her boyfriend.  The patient has a history of heavy tobacco and alcohol abuse for many years.,FAMILY HISTORY: , Not available at this current time.,REVIEW OF SYSTEMS: , As mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  She is intubated, obtunded, gangrenous ears with gangrenous fingertips.,VITAL SIGNS:  Blood pressure is absent, heart rate of 138 per minute, and the patient is on the ventilator.,HEENT:  Examination shows head is atraumatic, pupils are dilated and very, very sluggishly reacting to light.  No oropharyngeal lesions noted.,NECK:  Supple.  No JVD, distention or carotid bruit.  No lymphadenopathy.,LUNGS:  Bilateral crackles and bruits.,ABDOMEN:  Distended, unable to evaluate if this is tender.  No hepatosplenomegaly.  Bowel sounds are very hyperactive.,LOWER EXTREMITIES:  Show no edema.  Distal pulses are decreased.,OVERALL NEUROLOGICAL:  Examination cannot be assessed.,LABORATORY DATA: , The database was available at this point of time.  WBC count is elevated at 19,000 with the left shift, hemoglobin of 17.7, and hematocrit of 55.8 consistent with severe dehydration.  PT INR is prolonged at 1.7 and aPTT is prolonged at 60.  Sodium was 143, BUN of 36, and creatinine of 2.5.  The patient's blood gas shows pH of 7.05, pO2 of 99.6, and pCO2 of 99.6.  Bicarb is 16.5.,ASSESSMENT AND EVALUATION:,1.  Septicemia with septic shock.,2.  Metabolic acidosis.,3.  Respiratory failure.,4.  Anuria.,5.  Acute renal failure.,The patient has no blood pressure at this point in time.  The patient is on IV fluids.  The patient is on vasopressors due to ventilator support, bronchodilators as well as IV antibiotics.  Her overall prognosis is extremely poor.  This was discussed with the patient's niece who is at bedside and will become indicated with her daughter when she arrives who is on the plane right now from Iowa.  The patient will be maintained on these supports at this point in time, but prognosis is poor.
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DESCRIPTION: The patient is a 61-year-old lady who was found down at home and was admitted for respiratory failure, septic shock, acute renal failure as well as metabolic acidosis.

The situation involves a patient in critical condition with multiple life-threatening issues: septic shock, respiratory failure, metabolic acidosis, and acute renal failure. The patient is intubated, has no blood pressure without mechanical support, and the prognosis is described as extremely poor. This indicates a high-stakes medical emergency requiring immediate and intensive intervention. Given these factors, the stakes are extremely high for the patient's survival.


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

Medical Specialty: Radiology
Sample Name: Cardiolite Treadmill Stress Test

CARDIOLITE TREADMILL EXERCISE STRESS TEST,CLINICAL DATA:,  This is a 72-year-old female with history of diabetes mellitus, hypertension, and right bundle branch block.,PROCEDURE:,  The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.  There was a normal blood pressure response.  The patient did not complain of any symptoms during the test and other than the right bundle branch block that was present at rest, no other significant electrographic abnormalities were observed.,Myocardial perfusion imaging was performed at rest following the injection of 10 mCi Tc-99 Cardiolite.  At peak pharmacological effect, the patient was injected with 30 mCi Tc-99 Cardiolite.,Gating poststress tomographic imaging was performed 30 minutes after the stress.,FINDINGS:,1.  The overall quality of the study is fair.,2.  The left ventricular cavity appears to be normal on the rest and stress studies.,3.  SPECT images demonstrate fairly homogeneous tracer distribution throughout the myocardium with no overt evidences of fixed and/or reperfusion defect.,4.  The left ventricular ejection fraction was normal and estimated to be 78%.,IMPRESSION: , Myocardial perfusion imaging is normal.  Result of this test suggests low probability for significant coronary artery disease.
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DESCRIPTION: Cardiolite treadmill exercise stress test.  The patient was exercised on the treadmill to maximum tolerance achieving after 5 minutes a peak heart rate of 137 beats per minute with a workload of 2.3 METS.

radiology, peak heart rate, bundle branch block, perfusion imaging, stress test, mci, ventricular, cardiolite, treadmill,

The Cardiolite treadmill stress test is used to assess heart function and detect potential coronary artery disease, especially in a patient with risk factors like diabetes and hypertension. However, the findings indicate a normal myocardial perfusion with no significant defects, suggesting a low probability of coronary artery disease. Therefore, despite the patient's clinical history, the test results were reassuring, which reduces the stakes in this specific case.


Medical Specialty: Neurology
Sample Name: Sleep Study Interpretation

PROCEDURE:, Sleep study.,CLINICAL INFORMATION:, This patient is a 56-year-old gentleman who had symptoms of obstructive sleep apnea with snoring, hypertension. The test was done 01/24/06. The patient weighed 191 pounds, five feet, seven inches tall.,SLEEP QUESTIONNAIRE:, According to the patient's own estimate, the patient took about 15 minutes to fall asleep, slept for six and a half hours, did have some dreams. Did not wake up and the sleep was less refreshing. He was sleepy in the morning.,STUDY PROTOCOL:, An all night polysomnogram was recorded with a Compumedics E Series digital polysomnograph. After the scalp was prepared, Ag/AgCl electrodes were applied to the scalp according to the International 10-20 System. EEG was monitored from C4-A1, C3-A2, O2-A1 and O2-A1. EOG and EMG were continuously monitored by electrodes placed at the outer canthi and chin respectively. Nasal and oral airflow were monitored using a triple port Thermistor. Respiratory effort was measured by piezoelectric technology employing an abdominal and thoracic belt. Blood oxygen saturation was continuously monitored by pulse oximetry. Heart rate and rhythm were monitored by surface electrocardiography. Anterior tibialis EMG was studied by using surface mounted electrodes placed 5 cm apart on both legs. Body position and snoring level were also monitored.,TECHNICAL QUALITY OF STUDY:, Good.,ELECTROPHYSIOLOGIC MEASUREMENTS:, Total recording time 406 minutes, total sleep time 365 minutes, sleep latency 25.5 minutes, REM latency 49 minutes, _____ 90%, sleep latency measured 86%. _____ period was obtained. The patient spent 10% of the time awake in bed.,Stage I: 3.8,Stage II: 50.5,Stage III: 14%,Stage REM: 21.7%,The patient had relatively good sleep architecture, except for excessive waking.,RESPIRATORY MEASUREMENTS:, Total apnea/hypopnea 75, age index 12.3 per hour. REM age index 15 per hour. Total arousal 101, arousal index 15.6 per hour. Oxygen desaturation was down to 88%. Longest event 35 second hypopnea with an FiO2 of 94%. Total limb movements 92, PRM index 15.1 per hour. PRM arousal index 8.9 per hour.,ELECTROCARDIOGRAPHIC OBSERVATIONS:, Heart rate while asleep 60 to 64 per minute, while awake 70 to 78 per minute.,CONCLUSIONS:, Obstructive sleep apnea syndrome with moderately loud snoring and significant apnea/hypopnea index.,RECOMMENDATIONS:,AXIS B: Overnight polysomnography.,AXIS C: Hypertension.,The patient should return for nasal CPAP titration. Sleep apnea if not treated, may lead to chronic hypertension, which may have cardiovascular consequences. Excessive daytime sleepiness, dysfunction and memory loss may also occur.
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DESCRIPTION: Sleep study - patient with symptoms of obstructive sleep apnea with snoring.

neurology, sleep study, obstructive sleep apnea, snoring, hypertension, polysomnogram, compumedics, polysomnograph, ag/agcl electrodes, triple port thermistor, rem, latency, polysomnography, cpap titration, sleep latency, apnea, sleep, obstructive, index,

Interpreting a sleep study for obstructive sleep apnea is not typically considered high-stakes in the moment, as it is a diagnostic procedure used to determine the presence and severity of sleep apnea, which is a common yet serious condition. However, untreated sleep apnea can lead to significant health issues such as hypertension and cardiovascular problems. The urgency in this context involves deciding on the appropriate treatment to mitigate long-term health risks. Therefore, while the interpretation itself is not immediately life-threatening, the subsequent actions based on the interpretation bear significant long-term health implications.


Medical Specialty: Letters
Sample Name: Ortho - Letter - 2

XYZ, D.C.,60 Evergreen Place,Suite 902,East Orange, NJ  07018,Re:
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DESCRIPTION: Patient suffers from neck and lower back pain radiating into both arms and both legs with numbness, paraesthesia, and tingling in both arms.

letters, paraspinal musculature, palpable trigger points, trigger point injections, lumbar, region, paraspinal, musculature, injections, trigger,

The situation involves a medical case where a patient is experiencing significant symptoms that could indicate nerve or spinal issues. These symptoms might require prompt medical attention or intervention to prevent further complications, making accuracy and timeliness critical. However, the severity of the case isn't explicitly mentioned, meaning it could be chronic rather than acute. Given the potential seriousness of nerve or spine issues, the stakes are moderate to high.


Medical Specialty: Orthopedic
Sample Name: Austin Bunionectomy

TITLE OF OPERATION: , Austin bunionectomy with internal screw fixation, first metatarsal, left foot.,PREOPERATIVE DIAGNOSIS:,  Bunion deformity, left foot.,POSTOPERATIVE DIAGNOSIS: , Bunion deformity, left foot.,ANESTHESIA: , Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,HEMOSTASIS: , 45 minutes, left ankle tourniquet set at 250 mmHg.,ESTIMATED BLOOD LOSS:,  Less than 10 mL.,MATERIALS USED: , 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, as well as a 16-mm and an 18-mm partially threaded cannulated screw from the OsteoMed Screw Fixation System.,DESCRIPTION OF THE PROCEDURE:,  The patient was brought to the operating room and placed on the operating table in a supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's left foot to anesthetize the future surgical sites.  The left ankle was covered with cast padding and an 18-inch ankle tourniquet was placed around the left ankle and set at 250 mmHg.  The left foot was then prepped, scrubbed, and draped in normal sterile technique.  The left ankle tourniquet was inflated.  Attention was then directed on the dorsomedial aspect of the first left metatarsophalangeal joint where a 6-cm linear incision was placed directly over the first left metatarsophalangeal joint parallel and medial to the course of the extensor hallucis longus tendon to the left great toe.  The incision was deepened through subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first left metatarsophalangeal joint.  All the tendinous neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, the periosteal and capsular attachments were mobilized from the head of the first left metatarsal.  The conjoint tendon was identified on the lateral plantar aspect of the base of the proximal phalanx of the left great toe and transversally resected from its insertion.  A lateral capsulotomy was also performed at the level of the first left metatarsophalangeal joint.  The dorsomedial prominence of the first left metatarsal head was adequately exposed using sharp dissection and resected with the use of a sagittal saw.  The same saw was used to perform an Austin-type bunionectomy on the capital aspect of the first left metatarsal head with its apex distal and its base proximal on the shaft of the first left metatarsal.  The dorsal arm of the osteotomy was longer than the plantar arm in order to accommodate for the future internal fixation.  The capital fragment of the first left metatarsal was then transposed laterally and impacted on the shaft of the first left metatarsal.  Provisional fixation was achieved with two smooth wires that were inserted vertically to the dorsal osteotomy in a dorsal distal to plantar proximal direction.  The same wires were also used as guide wires for the insertion of a 16-mm and an 18-mm partially threaded screws from the 3.0 OsteoMed System upon insertion of the screws, which was accomplished using AO technique.  The wires were removed.  Fixation on the table was found to be excellent.  Reduction of the bunion deformity was also found to be excellent and position of the first left metatarsophalangeal joint was anatomical.  The remaining bony prominence from the shaft of the first left metatarsal was then resected with a sagittal saw.  The area was copiously flushed with saline.  The periosteal and capsular tissues were approximated with 2-0 and 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues.  The incision site was reinforced with Steri-Strips.  At this time, the patient's left ankle tourniquet was deflated.  The time was 45 minutes.  Immediate hyperemia was noted to the entire right lower extremity upon deflation of the cuff.  The patient's incision was covered with Xeroform, copious amounts of fluff and Kling, stockinette, and an Ace bandage.  The patient's left foot was then placed in a surgical shoe.  The patient was then transferred to the recovered room under the care of the anesthesia team with her vital signs stable and her vascular status at appropriate levels.  The patient was given pain medication and instructions on how to control her postoperative course.  The patient was discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X in one week's time for her first postoperative appointment.
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DESCRIPTION: Austin bunionectomy with internal screw fixation, first metatarsal, left foot.

orthopedic, internal screw fixation, first metatarsal, bunion deformity, osteomed, screw fixation system, subcutaneous tissues, metatarsal head, austin bunionectomy, screw fixation, ankle tourniquet, metatarsophalangeal joint, austin, tourniquet, metatarsophalangeal, bunionectomy, foot, metatarsal,

An Austin bunionectomy is a relatively common orthopedic surgical procedure used to correct bunion deformities of the foot. While it is a significant surgical procedure and requires skill to perform, it is not considered a high-risk operation when performed by a qualified surgeon in a controlled environment. The procedure description indicates no complications, minimal blood loss, and an effective postoperative protocol. The patient's vitals were stable post-surgery, and they were discharged with standard follow-up instructions. Given these factors, the stakes are moderate, as successful surgery impacts the patient's quality of life but does not typically carry high risks under normal circumstances.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult for Colostomy Reversal

CHIEF COMPLAINT: , "I want my colostomy reversed.",HISTORY OF PRESENT ILLNESS: , Mr. A is a pleasant 43-year-old African-American male who presents to our clinic for a colostomy reversal as well as repair of an incisional hernia.  The patient states that in November 2007, he presented to High Point Regional Hospital with sharp left lower quadrant pain and was emergently taken to Surgery where he woke up with a "bag."  According to some notes that were faxed to our office from the surgeon in High Point who performed his initial surgery, Dr. X, the patient had diverticulitis with perforated sigmoid colon, and underwent a sigmoid colectomy with end colostomy and Hartmann's pouch.  The patient was unaware of his diagnosis; therefore, we discussed that with him today in clinic.  The patient also complains of the development of an incisional hernia since his surgery in November.  He was seen back by Dr. X in April 2008 and hopes that Dr. X may reverse his colostomy and repair his hernia since he did his initial surgery, but because the patient has lost his job and has no insurance, he was referred to our clinic by Dr. X.  Currently, the patient does state that his hernia bothers him more so than his colostomy, and if it were not for the hernia then he may just refrain from having his colostomy reversed; however, the hernia has grown in size and causing him significant discomfort.  He feels that he always has to hold his hand over the hernia to prevent it from prolapsing and causing him even more discomfort.,PAST MEDICAL AND SURGICAL HISTORY:,1.  Gastroesophageal reflux disease.,2.  Question of hypertension.,3.  Status post sigmoid colectomy with end colostomy and Hartmann's pouch in November 2007 at High Point Regional.,4.  Status post cholecystectomy.,7.  Status post unknown foot surgery.,MEDICATIONS:,  None.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , The patient lives in Greensboro.  He smokes one pack of cigarettes a day and has done so for 15 years.  He denies any IV drug use and has an occasional alcohol.,FAMILY HISTORY:  ,Positive for diabetes, hypertension, and coronary artery disease.,REVIEW OF SYSTEMS: , Please see history of present illness; otherwise, the review of systems is negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 95.9, pulse 67, blood pressure 135/79, and weight 208 pounds.,GENERAL:  This is a pleasant African-American male appearing his stated age in no acute distress.,HEENT:  Normocephalic, atraumatic.  Pupils are equal, round, and reactive to light and accommodation.  Moist mucous membranes.  Extraocular movements intact.,NECK:  Supple, no JVD, and no lymphadenopathy.,CARDIOVASCULAR:  Regular rate and rhythm.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, and nondistended with a left lower quadrant stoma.  The stoma is pink, protuberant, and productive.  The patient also has a midline incisional hernia approximately 6 cm in diameter.  It is reducible.  Otherwise, there are no further hernias or masses noted.,EXTREMITIES:  No clubbing, cyanosis or edema.,ASSESSMENT AND PLAN:  ,This is a 43-year-old gentleman who underwent what sounds like a sigmoid colectomy with end colostomy and Hartmann's pouch in November of 2007 secondary to perforated colon from diverticulitis.  The patient presents for reversal of his colostomy as well as repair of his incisional hernia.  I have asked the patient to return to High Point Regional and get his medical records including the operative note and pathology results from his initial surgery so that I would have a better idea of what was done during his initial surgery.  He stated that he would try and do this and bring the records to our clinic on his next appointment.  I have also set him up for a barium enema to study the rectal stump.  He will return to us in two weeks at which time we will review his radiological studies and his medical records from the outside hospital and determine the best course of action from that point.  This was discussed with the patient as well as his sister and significant other in the clinic today.  They were in agreement with this plan.  We also called the social worker to come and help the patient get more ostomy appliances, as he stated that he had no more and he was having to reuse the existing ostomy bag.  To my understanding, his social worker, as well as the ostomy nurses were able to get him some assistance with this.,
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DESCRIPTION: Patient presents for a colostomy reversal as well as repair of an incisional hernia.

This consultation involves the decision to reverse a colostomy and repair an incisional hernia in a patient who has no health insurance. While the surgeries themselves are significant, especially since the patient is experiencing discomfort due to the hernia, the immediate situation is primarily about planning and consultations rather than an emergency procedure. The stakes are moderate because they concern the patient's quality of life and surgical outcomes but are not immediately life-threatening.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pulmonary Function Test - 2

HISTORY:,  Smoking history zero.,INDICATION: , Dyspnea with walking less than 100 yards.,PROCEDURE:,  FVC was 59%.  FEV1 was 61%.  FEV1/FVC ratio was 72%. The predicted was 70%.  The FEF 25/75% was 45%, improved from 1.41 to 2.04 with bronchodilator, which represents a 45% improvement.  SVC was 69%. Inspiratory capacity was 71%.  Expiratory residual volume was 61%.  The TGV was 94%.  Residual volume was 113% of its predicted.  Total lung capacity was 83%.  Diffusion capacity was diminished.,IMPRESSION:,1.  Moderate restrictive lung disease.,2.  Some reversible small airway obstruction with improvement with bronchodilator.,3.  Diffusion capacity is diminished, which might indicate extrapulmonary restrictive lung disease.,4.  Flow volume loop was consistent with the above and no upper airway obstruction.,
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DESCRIPTION: Pulmonary Function Test to evaluate dyspnea.

cardiovascular / pulmonary, pulmonary function test, diffusion capacity, dyspnea, fef, fev1, fev1/fvc ratio, fvc, flow volume loop, pft, svc, smoking history, airway obstruction, bronchodilator, extrapulmonary, residual volume, restrictive lung disease, walking, pulmonary function, lung disease, pulmonary, function, lung, capacity

The pulmonary function test results indicate moderate restrictive lung disease and reversible small airway obstruction, with diminished diffusion capacity. This could suggest possible extrapulmonary restrictive lung disease, which requires careful medical evaluation and intervention, potentially impacting the patient's quality of life significantly. These results are not immediately life-threatening but indicate a chronic condition that could lead to more serious health issues if not managed properly. Therefore, while it is serious, it is not an emergency unless accompanied by acute symptoms like severe dyspnea or hypoxemia, hence medium to high stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 13

SUBJECTIVE: , The patient states she is feeling a bit better.,OBJECTIVE:,VITAL SIGNS:  Temperature is 95.4.  Highest temperature recorded over the past 24 hours is 102.1.,CHEST:  Examination of the chest is clear to auscultation.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Benign.  Right renal angle is tender.  Bowel sounds are positive.,EXTREMITIES:  There is no swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.,LABORATORY DATA: , White count is down from 35,000 to 15.5.  Hemoglobin is 9.5, hematocrit is 30, and platelets are 269,000.  BUN is down to 22, creatinine is within normal limits.,ASSESSMENT AND PLAN:,1.  Sepsis due to urinary tract infection.  Urine culture shows Escherichia coli, resistant to Levaquin.  We changed to doripenem.,2.  Urinary tract infection, we will treat with doripenem, change Foley catheter,3.  Hypotension.  Resolved, continue intravenous fluids.,4.  Ischemic cardiomyopathy.  No evidence of decompensation, we with monitor.,5.  Diabetes type 2.  Uncontrolled.  Continue insulin sliding scale.,6.  Recent pulmonary embolism, INR is above therapeutic range, Coumadin is on hold, we will monitor.,7.  History of coronary artery disease.  Troponin indeterminate.  Cardiologist intends no further workup.  Continue medical treatment.  Most likely troponin is secondary to impaired clearance.
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DESCRIPTION: Sepsis due to urinary tract infection.

Sepsis due to urinary tract infection.

soap / chart / progress notes, sepsis, escherichia coli, urinary tract infection, doripenem, troponin, urinary, infection

The situation described involves a patient with multiple significant medical conditions, including sepsis due to a urinary tract infection, ischemic cardiomyopathy, recent pulmonary embolism, diabetes, and a history of coronary artery disease. The presence of sepsis, which can be life-threatening, suggests a higher-stakes scenario, especially given the recent change in antibiotics due to resistance. The patient's condition requires careful monitoring and appropriate treatment adjustments, indicating a serious medical situation.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy & Fusion - 1

PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus C2-C3.,2.  Spinal stenosis C3-C4.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus C2-C3.,2.  Spinal stenosis C3-C4.,PROCEDURES,1.  Anterior cervical discectomy, C3-C4, C2-C3.,2.  Anterior cervical fusion, C2-C3, C3-C4.,3.  Removal of old instrumentation, C4-C5.,4.  Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.,PROCEDURE IN DETAIL: , The patient was placed in the supine position.  The neck was prepped and draped in the usual fashion for anterior cervical discectomy.  A high incision was made to allow access to C2-C3.  Skin and subcutaneous tissue and the platysma were divided sharply exposing the carotid sheath which was retracted laterally and the trachea and esophagus were retracted medially.  This exposed the vertebral bodies of C2-C3 and C4-C5 which was bridged by a plate.  We placed in self-retaining retractors.  With the tooth beneath the blades, the longus colli muscles were dissected away from the vertebral bodies of C2, C3, C4, and C5.  After having done this, we used the all-purpose instrumentation to remove the instrumentation at C4-C5, we could see that fusion at C4-C5 was solid.,We next proceeded with the discectomy at C2-C3 and C3-C4 with disc removal.  In a similar fashion using a curette to clean up the disc space and the space was fairly widened, as well as drilling up the vertebral joints using high-speed cutting followed by diamond drill bit.  It was obvious that the C3-C4 neural foramina were almost totally obliterated due to the osteophytosis and foraminal stenosis.  With the operating microscope; however, we had good visualization of these nerve roots, and we were able to ___________ both at C2-C3 and C3-C4.  We then placed the ABC 55-mm plate from C2 down to C4.  These were secured with 16-mm titanium screws after excellent purchase.  We took an x-ray which showed excellent position of the plate, the screws, and the graft themselves.  The next step was to irrigate the wound copiously with saline and bacitracin solution and s Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and Steri-Strips used to close the skin.  Blood loss was about 50 mL.  No complication of the surgery.  Needle count, sponge count, cottonoid count was correct.,The operating microscope was used for the entirety for both visualization and magnification and illumination which was quite superb.  At the time of surgery, he had total collapse of the C2, C3, and C4 disc with osteophyte formation.  At both levels, he has high-grade spinal stenosis at these levels, especially foramen stenosis causing the compression, neck pain, headaches, and arm and shoulder pain.  He does have degenerative changes at C5-C6, C6-C7, C7-T1; however, they do not appear to be symptomatic, although x-rays show the disks to be partially collapsed at all levels with osteophyte formation beginning to form.
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DESCRIPTION: Anterior cervical discectomy and fusion, C2-C3, C3-C4.  Removal of old instrumentation, C4-C5.  Fusion C3-C4 and C2-C3 with instrumentation using ABC plates.

surgery, abc plates, osteophyte, cervical, discectomy, cervical fusion, herniated nucleus pulposus, anterior cervical discectomy, nucleus pulposus, vertebral bodies, osteophyte formation, spinal stenosis, cervical discectomy, anterior, instrumentation, vertebral, stenosis, fusion

The situation involves a detailed description of a surgical procedure, specifically an anterior cervical discectomy and fusion. This type of surgery is considered a major surgical procedure due to its complexity, potential risks, and the critical nature of the structures involved, such as the spinal cord and nerves. Any complications or errors during the procedure could have significant consequences for the patient's health, mobility, or quality of life. Additionally, the surgery involves removing old instrumentation, addressing spinal stenosis, and ensuring proper placement of new instrumentation, all of which require precision and carry inherent risks. Therefore, the scenario is high-stakes both for the immediate success of the procedure and for the long-term outcomes and safety of the patient.


Medical Specialty: Physical Medicine - Rehab
Sample Name: EMG/Nerve Conduction Study - 1

HISTORY: , The patient is a 52-year-old right-handed female with longstanding bilateral arm pain, which is predominantly in the medial aspect of her arms and hands as well as left hand numbness, worse at night and after doing repetitive work with her left hand.  She denies any weakness.  No significant neck pain, change in bowel or bladder symptoms, change in gait, or similar symptoms in the past.  She is on Lyrica for the pain, which has been somewhat successful.,Examination reveals positive Phalen's test on the left.  Remainder of her neurological examination is normal.,NERVE CONDUCTION STUDIES:  ,The left median motor distal latency is prolonged with normal evoked response amplitude and conduction velocity.  The left median sensory distal latency is prolonged with an attenuated evoked response amplitude.  The right median sensory distal latency is mildly prolonged with a mildly attenuated evoked response amplitude.  The right median motor distal latency and evoked response amplitude is normal.  Left ulnar motor and sensory and left radial sensory responses are normal.  Left median F-wave is normal.,NEEDLE EMG:,  Needle EMG was performed on the left arm, right first dorsal interosseous muscle, and bilateral cervical paraspinal muscles.  It revealed spontaneous activity in the left abductor pollicis brevis muscle.  There is increased insertional activity in the right first dorsal interosseous muscle.  Both interosseous muscles showed signs of reinnervation.  Left extensor digitorum communis muscle showed evidence of reduced recruitment.  Cervical paraspinal muscles were normal.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:  A left median neuropathy at the wrist consistent with carpal tunnel syndrome.  Electrical abnormalities are moderate-to-mild bilateral C8 radiculopathies.  This may be an incidental finding.,I have recommended MRI of the spine without contrast and report will be sent to Dr. XYZ.  She will follow up with Dr. XYZ with respect to treatment of the above conditions.
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DESCRIPTION: The patient with longstanding bilateral arm pain, which is predominantly in the medial aspect of arms and hands, as well as left hand numbness, worse at night and after doing repetitive work with left hand.

physical medicine - rehab, nerve conduction study, emg, neuropathy, median motor distal latency, median sensory distal latency, attenuated evoked response amplitude, emg/nerve conduction study, sensory distal latency, attenuated evoked response, dorsal interosseous muscle, cervical paraspinal muscles, emg/nerve conduction, conduction study, median motor, needle emg, distal latency, evoked response, emg/nerve, bilateral, evoked, conduction,

The scenario involves a patient experiencing symptoms likely related to carpal tunnel syndrome and possibly C8 radiculopathies. While these conditions can cause significant discomfort and may impact the patient's daily function, they do not typically pose an immediate threat to life or long-term disability if managed properly. The recommendation for an MRI and a follow-up with a specialist suggests that there is a plan for appropriate management. This is a routine situation encountered in physical medicine and rehabilitation, not an emergency or life-threatening condition.


Medical Specialty: Surgery
Sample Name: Gastrostomy

PREOPERATIVE DIAGNOSES:,1.  Feeding disorder.,2.  Down syndrome.,3.  Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1.  Feeding disorder.,2.  Down syndrome.,3.  Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS:  ,This 6-week-old female infant had been transferred to Children's Hospital because of Down syndrome and congenital heart disease.  She has not been able to feed well and in fact has to now be NG tube fed.  Her swallowing mechanism does not appear to be very functional, and therefore, it was felt that in order to aid in her home care that she would be better served with a gastrostomy.,OPERATIVE PROCEDURE:  ,After the induction of general anesthetic, the abdomen was prepped and draped in usual manner.  Transverse left upper quadrant incision was made and carried down through skin and subcutaneous tissue with sharp dissection.  The muscle was divided and the peritoneal cavity entered.  The greater curvature of the stomach was grasped with a Babcock clamp and brought into the operative field.  The site for gastrostomy was selected and a pursestring suture of #4-0 Nurolon placed in the gastric wall.  A 14-French 0.8 cm Mic-Key tubeless gastrostomy button was then placed into the stomach and the pursestring secured about the tube.  Following this, the stomach was returned to the abdominal cavity and the posterior fascia was closed using a #4-0 Nurolon affixing the stomach to the posterior fascia.  The anterior fascia was then closed with #3-0 Vicryl, subcutaneous tissue with the same, and the skin closed with #5-0 subcuticular Monocryl.  The balloon was inflated to the full 5 mL.  A sterile dressing was then applied and the child awakened and taken to the recovery room in satisfactory condition.,
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DESCRIPTION: Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.

surgery, feeding disorder, down syndrome, congenital heart disease, mic-key tubeless, nurolon, subcutaneous tissue, fascia, syndrome, stomach, gastrostomy

The situation involves a surgical procedure on a 6-week-old infant with multiple serious health conditions including Down syndrome, congenital heart disease, and a feeding disorder. Gastrostomies, especially in such young patients, carry significant risk due to their age, existing health issues, and the need for general anesthesia. The stakes are high because the operation carries risks of complications, and the infant's underlying conditions add further complexity. Ensuring this procedure is successful is crucial for the infant's ability to receive nutrition and improve quality of life.