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

DISCHARGE DIAGNOSES:,1.  Central nervous system lymphoma.,2.  Gram-negative bacteremia.,3.  Pancytopenia.,4.  Hypertension.,5.  Perianal rash.,6.  Diabetes mellitus.,7.  Hypoxia.,8.  Seizure prophylaxis.,9.  Acute kidney injury.,PROCEDURES DURING HOSPITALIZATION:,1.  Cycle five high-dose methotrexate.,2.  Rituxan weekly.,3.  Chest x-ray.,4.  Wound consult.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a pleasant 60-year-old Caucasian female who was diagnosed in April 2008 with diffuse large B-cell lymphoma after she developed visual saltation, changes, and confusion.  Further staging revealed borderline mediastinal pretracheal lymphadenopathy but was otherwise unremarkable.  She began high-dose methotrexate in mid May 2008; courses of methotrexate have been complicated by prolonged methotrexate levels, mental confusion, and mania.  During cycle three, repeat MRI showed interval worsening of disease, and Rituxan was added to her regimen.  Ms. ABC had a repeat MRI on July 24, 2008 prior to this admission, which showed significant improvement in her CNS disease.,HOSPITAL COURSE: , Ms. ABC was admitted to the Hematology B Service under attending Dr. Z.,1.  CNS lymphoma.  Upon admission, she was started on her Rituxan, which she tolerated well.  She was then hydrated with bicarbonate solution to a urine pH of 8.  She received methotrexate 5 g/m2.  24-hour creatinine was 0.9, 48-hour methotrexate level was elevated at 2.08.  This was likely secondary to the need to initiate treatment with antibiotics secondary to infection.  Her leucovorin was increased to 100 mg/m2.  72-hour methotrexate level was 0.58.  96-hour methotrexate was 0.16, and 19-hour was 0.08.  She continued additional four doses of oral leucovorin.  Her creatinine improved.  On day prior to discharge, she received her weekly dose of Rituxan.  She will return for Rituxan next week and then return for an appointment with Dr. X on August 18, 2008 with plans for admission for next cycle of methotrexate.,2.  Gram-negative bacteremia.  On the morning of June 27, 2008, Ms. ABC did spike a fever.  She was started on empiric antibiotics with cefepime and vancomycin.  Cultures were drawn peripherally and from the Port-A-Cath which both grew out Gram-negative rods within 12 hours.  After being initiated on IV antibiotics, she remained afebrile for the remainder of the hospitalization.  Both cultures eventually grew out Proteus mirabilis, which was pansensitive.  She had three additional blood cultures, which were all negative.  On the day prior to discharge, she was transitioned to oral Cipro and remained afebrile.  We had intended to send her home with oral antibiotics; however, by day of discharge, she was pancytopenic and it was decided that she should be discharged to complete a 14-day course of IV antibiotics with cefepime.  She will continue this with the assistance of home health services.  She was advised to follow neutropenic precautions and labs will be followed closely as an outpatient.  She understands if she develops a fever greater than 100.5, she should call to return immediately for admission.,3.  Pancytopenia.  On the day of discharge, the patient was pancytopenic with white count of 0.7, ANC of 500, hemoglobin 8.5, hematocrit 24.8, and platelet count 38, 000.  Her labs will be followed closely as an outpatient.  During the admission, we did obtain a HIT antibody, which was negative.  Heparin was held until this level was returned.  She was placed on Arixtra for prophylaxis against thrombus.  It is thought that her decreasing counts may be secondary to infection; however, if she continues to be pancytopenic, she will have a repeat bone marrow as an outpatient.,4.  Hypertension.  Blood pressure remained stable throughout the admission.  She will continue lisinopril daily.,5.  Perianal rash.  Upon admission, she was found to have worsening of a candidal rash in the perianal region.  A wound consult was obtained.  They recommended Aloe Vesta foam and Silver gel to the area topically.  She was also continued on Diflucan 200 mg daily.  She will complete a 10-day course.,6.  Diabetes mellitus.  At the time of admission, she was found to have hyperglycemia.  She was started on sliding scale insulin and eventually started on long-acting Lantus insulin.  She will be discharged with the regimen of Lantus 35 units at bedtime and continue the sliding scale as needed.,7.  Hypoxia.  She did have evidence of decreased saturations.  There was concern that she may have a pneumonia, which was treated with vancomycin for possible hospital acquired pneumonia; however, upon further review of the blood cultures improved, chest x-ray consistent with atelectasis and normal saturations that this was likely secondary to increased fluids associated with methotrexate and atelectasis from being confined to bed.,8.  Seizure prophylaxis.  She will continue Keppra twice daily.,9.  Acute kidney injury.  She did have a bump in the creatinine when methotrexate level was elevated.  This resolved by the time of discharge.  Creatinine on day of discharge is 0.9.  This will be followed as an outpatient.,DISPOSITION: , To home in stable condition with home health services.,DISCHARGE MEDICATIONS: , See separate sheet attached.,DIET:,  Neutropenic diabetic.,ACTIVITY: , Resume same activity.,FOLLOWUP: , With weekly lab work and plans for admission on August 18, 2008.  Ms. ABC was advised if she has any problems or concerns in the interim and needs to be seen sooner, she should call.
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DESCRIPTION: Diffuse Large B-cell Lymphoma

Diffuse Large B-cell Lymphoma

The discharge summary for Ms. ABC indicates she is dealing with multiple serious and potentially life-threatening health issues, including central nervous system lymphoma, gram-negative bacteremia, and pancytopenia. The complexity and severity of her conditions, along with the treatments requiring careful monitoring, make this situation high-stakes. Each condition on its own is serious, but together they increase the risk significantly, making the treatment and follow-up critical to her health outcomes.


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

Medical Specialty: ENT - Otolaryngology
Sample Name: Microsuspension Direct Laryngoscopy & Biopsy

PREOPERATIVE DIAGNOSES:,1.  Fullness in right base of the tongue.,2.  Chronic right ear otalgia.,POSTOPERATIVE DIAGNOSIS: , Pending pathology.,PROCEDURE PERFORMED: , Microsuspension direct laryngoscopy with biopsy.,ANESTHESIA: , General.,INDICATION:,  This is a 50-year-old female who presents to the office with a chief complaint of ear pain on the right side.  Exact etiology of her ear pain had not been identified.  A fiberoptic examination had been performed in the office.  Upon examination, she was noted to have fullness in the right base of her tongue.  She was counseled on the risks, benefits, and alternatives to surgery and consented to such.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Operative Suite where she was placed in supine position.  General endotracheal tube intubation was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away where a shoulder roll was placed.  A tooth guard was then placed to protect the upper dentition.  The Dedo laryngoscope was then inserted into the oral cavity.  It was advanced on the right lateral pharyngeal wall until the epiglottis was brought into view.  At this point, it was advanced underneath the epiglottis until the vocal cords were seen.  At this point, it was suspended via the Lewy suspension arm from the Mayo stand.  At this point, the Zeiss microscope with a 400 mm lens was brought into the surgical field.  Inspection of the vocal cords underneath the microscope revealed them to be white and glistening without any mucosal abnormalities.  It should be mentioned that the right vocal cord did appear to be slightly more hyperemic, however, there were no mucosal abnormalities identified.  This was confirmed with a laryngeal probe as well as use of mirror evaluated in the subglottic portion as well as the ventricle.  At this point, the scope was desuspended and the microscope was removed.  The scope was withdrawn through the vallecular region.  Inspection of the vallecula revealed a fullness on the right side with a papillomatous type growth that appeared very friable.  Biopsies were obtained with straight-biting cup forceps.  Once hemostasis was achieved, the scope was advanced into the piriform sinuses.  Again in the right piriform sinus, there was noted to be studding along the right lateral wall of the piriform sinus.  Again, biopsies were performed and once hemostasis was achieved, the scope was further withdrawn down the lateral pharyngeal wall.  There were no mucosal abnormalities identified within the oropharynx.  The scope was then completely removed and a bimanual examination was performed.  No neck masses were identified.  At this point, the procedure was complete.  The mouth guard was removed and the patient was returned to Anesthesia for awakening and taken to the recovery room without incident.
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DESCRIPTION: Microsuspension direct laryngoscopy with biopsy.  Fullness in right base of the tongue and chronic right ear otalgia.

ent - otolaryngology, microsuspension, laryngoscopy, otalgia, ear pain, fiberoptic, dedo laryngoscope, epiglottis, direct laryngoscopy, piriform sinuses, tongue, microscope, mucosal, abnormalities, fullness, ear, scope

The procedure described involves a microsuspension direct laryngoscopy and biopsy, which is a significant medical procedure requiring general anesthesia. It is being performed to investigate the cause of fullness at the base of the tongue and chronic right ear pain. The need for biopsy and pathology suggests concern for potentially serious conditions, such as cancer, at the base of the tongue. While awaiting pathology results is a high-stakes situation due to the potential for a serious diagnosis, the procedure itself went smoothly, and no immediate life-threatening complications were noted during surgery. Therefore, while the stakes are elevated due to the implications of the biopsy results, the current status post-procedure is stable.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 6

SUBJECTIVE:,  This 3-year-old male is brought by his mother with concerns about his eating.  He has become a very particular eater, and not eating very much in general.  However, her primary concern was he was vomiting sometimes after particular foods.  They had noted that when he would eat raw carrots, within 5 to 10 minutes he would complain that his stomach hurt and then vomit.  After this occurred several times, they stopped giving him carrots.  Last week, he ate some celery and the same thing happened.  They had not given him any of that since.  He eats other foods without any apparent pain or vomiting.  Bowel movements are normal.  He does have a history of reactive airway disease, intermittently.  He is not diagnosed with intrinsic asthma at this time and takes no medication regularly.,CURRENT MEDICATIONS:,  He is on no medications.,ALLERGIES: , He has no known medicine allergies.,OBJECTIVE:,Vital Signs:  Weight:  31.5 pounds, which is an increase of 2.5 pounds since May.  Temperature is 97.1.  He certainly appears in no distress.  He is quite interested in looking at his books.,Neck:  Supple without adenopathy.,Lungs:  Clear.,Cardiac:  Regular rate and rhythm without murmurs.,Abdomen:  Soft without organomegaly, masses, or tenderness.,ASSESSMENT:,  Report of vomiting and abdominal pain after eating raw carrots and celery.  Etiology of this is unknown.,PLAN:,  I talked with mother about this.  Certainly, it does not suggest any kind of an allergic reaction, nor obstruction.  At this time, they will simply avoid those foods.  In the future, they may certainly try those again and see how he tolerates those.  I did encourage a wide variety of fruits and vegetables in his diet as a general principle.  If worsening symptoms, she is welcome to contact me again for reevaluation.
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DESCRIPTION: A 3-year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general.

soap / chart / progress notes, eating, foods, vomiting, reactive airway disease, raw carrots, carrots,

The case involves a 3-year-old boy experiencing vomiting and abdominal pain after consuming specific foods such as raw carrots and celery. While concerning, the symptoms are limited to these foods, and there is no indication of a severe allergic reaction or obstruction. The child is otherwise healthy with normal bowel movements and has gained weight. The plan is to avoid these foods and monitor symptoms, which suggests a cautious but not urgent approach. The stakes are relatively low as long-term effects or immediate severe health risks seem unlikely based on the current information.


Medical Specialty: Neurosurgery
Sample Name: Pituitary Adenomectomy

PREOPERATIVE DIAGNOSIS: , Large and invasive recurrent pituitary adenoma.,POSTOPERATIVE DIAGNOSIS:,  Large and invasive recurrent pituitary adenoma.,OPERATION PERFORMED: , Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma, endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus, harvesting of dermal fascia abdominal fat graft, placement of abdominal fat graft into sella turcica, reconstruction of sellar floor using autologous nasal bone creating a cranioplasty of less than 5 cm, repair of nasal septal deviation, using the operating microscope and microdissection technique, and placement of lumbar subarachnoid catheter connected to reservoir for aspiration and infusion.,INDICATIONS FOR PROCEDURE: , This man has undergone one craniotomy and 2 previous transsphenoidal resections of his tumor, which is known to be an invasive pituitary adenoma.  He did not return for followup or radiotherapy as instructed, and the tumor has regrown.  For this reason, he is admitted for transsphenoidal reoperation with an attempt to remove as much tumor as possible.  The high-risk nature of the procedure and the fact that postoperative radiation is mandatory was made clear to him.  Many risks including CSF leak and blindness were discussed in detail.  After clear understanding of all the same, he elected to proceed ahead with surgery.,PROCEDURE:  ,The patient was placed on the operating table, and after adequate induction of general anesthesia, he was placed in the left lateral decubitus position.  Care was taken to pad all pressure points appropriately.  The back was prepped and draped in usual sterile manner.,A 14-gauge Tuohy needle was introduced into the lumbar subarachnoid space.  Clear and colorless CSF issued forth.  A catheter was inserted to a distance of 40 cm, and the needle was removed.  The catheter was then connected to a closed drainage system for aspiration and infusion.,This no-touch technique is now a standard of care for treatment of patients with large invasive adenomas.  Via injections through the lumbar drain, one increases intracranial pressure and produces gentle migration of the tumor.  This improves outcome and reduces complications by atraumatically dissecting the tumor away from the optic apparatus.,The patient was then placed supine, and the 3-point headrest was affixed.  He was placed in the semi-sitting position with the head turned to the right and a roll placed under the left shoulder.  Care was taken to pad all pressure points appropriately.  The fluoroscope C-arm unit was then positioned so as to afford an excellent view of the sella and sphenoid sinus in the lateral projection.  The metallic arm was then connected to the table for the use of the endoscope.  The oropharynx, nasopharynx, and abdominal areas were then prepped and draped in the usual sterile manner.,A transverse incision was made in the abdominal region, and several large pieces of fat were harvested for later use.  Hemostasis was obtained.  The wound was carefully closed in layers.,I then advanced a 0-degree endoscope up the left nostril.  The middle turbinate was identified and reflected laterally exposing the sphenoid sinus ostium.  Needle Bovie electrocautery was used to clear mucosa away from the ostium.  The perpendicular plate of the ethmoid had already been separated from the sphenoid.  I entered into the sphenoid.,There was a tremendous amount of dense fibrous scar tissue present, and I slowly and carefully worked through all this.  I identified a previous sellar opening and widely opened the bone, which had largely regrown out to the cavernous sinus laterally on the left, which was very well exposed, and the cavernous sinus on the right, which I exposed the very medial portion of.  The opening was wide until I had the horizontal portion of the floor to the tuberculum sella present.,The operating microscope was then utilized.  Working under magnification, I used hypophysectomy placed in the nostril.,The dura was then carefully opened in the midline, and I immediately encountered tissue consistent with pituitary adenoma.  A frozen section was obtained, which confirmed this diagnosis without malignant features.,Slowly and meticulously, I worked to remove the tumor.  I used the suction apparatus as well as the bipolar coagulating forceps and ring and cup curette to begin to dissect tumor free.  The tumor was moderately vascular and very fibrotic.,Slowly and carefully, I systematically entered the sellar contents until I could see the cavernous sinus wall on the left and on the right.  There appeared to be cavernous sinus invasion on the left.  It was consistent with what we saw on the MRI imaging.,The portion working into the suprasellar cistern was slowly dissected down by injecting saline into the lumbar subarachnoid catheter.  A large amount of this was removed.  There was a CSF leak, as the tumor was removed for the upper surface of it was very adherent to the arachnoid and could not be separated free.,Under high magnification, I actually worked up into this cavity and performed a very radical excision of tumor.  While there may be a small amount of tumor remaining, it appeared that a radical excision had been created with decompression of the optic apparatus.  In fact, I reinserted the endoscope and could see the optic chiasm well.,I reasoned that I had therefore achieved the goal with that is of a radical excision and decompression.  Attention was therefore turned to closure.,The wound was copiously irrigated with Bacitracin solution, and meticulous hemostasis was obtained.  I asked Anesthesiology to perform a Valsalva maneuver, and there was no evidence of bleeding.,Attention was turned to closure and reconstruction.  I placed a very large piece of fat in the sella to seal the leak and verified that there was no fat in the suprasellar cistern by using fluoroscopy and looking at the pattern of the air.  Using a polypropylene insert, I reconstructed the sellar floor with this implant making a nice tight sling and creating a cranioplasty of less than 5 cm.,DuraSeal was placed over this, and the sphenoid sinus was carefully packed with fat and DuraSeal.,I inspected the nasal passages and restored the septum precisely to the midline repairing a previous septal deviation.  The middle turbinates were then restored to their anatomic position.  There was no significant intranasal bleeding, and for this reason, an open nasal packing was required.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left to the recovery room in excellent condition.  The sponge and needle counts were reported as correct, and there were no intraoperative complications.,Specimens were sent to Pathology consisting of tumor.
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DESCRIPTION: Endoscopic-assisted transsphenoidal exploration and radical excision of pituitary adenoma.  Endoscopic exposure of sphenoid sinus with removal of tissue from within the sinus.

This scenario involves a neurosurgical procedure to remove a large and invasive recurrent pituitary adenoma. Neurosurgery, particularly involving the brain, is inherently high-stakes due to the potential complications and risks such as CSF leaks, damage to surrounding critical structures, and potential for significant outcomes like blindness or other neurological deficits. The complexity of the procedure, the fact that it's a reoperation, and the necessity for careful handling to avoid intraoperative complications, all contribute to its high-stakes nature. Postoperative radiation also indicates the gravity of the treatment and need for further intervention.


Medical Specialty: Radiology
Sample Name: CT Brain - SAH

CC:, Headache,HX: ,This 16 y/o RHF was in good health, until 11:00PM, the evening of 11/27/87, when she suddenly awoke from sleep with severe headache. Her parents described her as holding her head between her hands. She had no prior history of severe headaches. 30 minutes later she felt nauseated and vomited. The vomiting continued every 30 minutes and she developed neck stiffness. At 2:00AM on 11/28/97, she got up to go to the bathroom and collapsed in her mother's arms. Her mother noted she appeared weak on the left side. Shortly after this she experienced fecal and urinary incontinence. She was taken to a local ER and transferred to UIHC.,PMH/FHX/SHX:, completely unremarkable FHx. Has boyfriend and is sexually active.,Denied drug/ETOH/Tobacco use.,MEDS:, Oral Contraceptive pill QD.,EXAM:, BP152/82 HR74 RR16 T36.9C,MS: Somnolent and difficult to keep awake. Prefer to lie on right side because of neck pain/stiffness. Answers appropriately though when questioned.,CN: No papilledema noted. Pupils 4/4 decreasing to 2/2. EOM Intact. Face: ?left facial weakness. The rest of the CN exam was unremarkable.,Motor: Upper extremities: 5/3 with left pronator drift. Lower extremities: 5/4 with LLE weakness evident throughout.,Coordination: left sided weakness evident.,Station: left pronator drift.,Gait: left hemiparesis.,Reflexes: 2/2 throughout. No clonus. Plantars were flexor bilaterally.,Gen Exam: unremarkable.,COURSE: ,The patient underwent emergent CT Brain. This revealed a perimesencephalic subarachnoid hemorrhage and contrast enhancing structures in the medial aspect of the parietotemporal region. She then underwent a 4-vessel cerebral angiogram. This study was unremarkable except for delayed transit of the contrast material through the vascular system of the brain and poor opacification of the straight sinus. This suggested straight sinus thromboses. MRI Brain was then done; this was unremarkable and did not show sign of central venous thrombosis. CBC/Blood Cx/ESR/PT/PTT/GS/CSF Cx/ANA were negative.,Lumbar puncture on 12/1/87 revealed an opening pressure of 55cmH20, RBC18550, WBC25, 18neutrophils, 7lymphocytes, Protein25mg/dl, Glucose47mg/dl, Cx negative.,The patient was assumed to have had a SAH secondary to central venous thrombosis due to oral contraceptive use. She recovered well, but returned to Neurology at age 32 for episodic blurred vision and lightheadedness. EEG was compatible with seizure tendency (right greater than left theta bursts from the mid-temporal regions), and she was recommended an anticonvulsant which she refused.
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DESCRIPTION: CT Brain: Subarachnoid hemorrhage.

CT Brain: Subarachnoid hemorrhage.

radiology, ct, brain, sah, cerebral angiogram, blurred vision, lightheadedness, central venous thrombosis, subarachnoid hemorrhage, pronator drift, venous thrombosis, ct brain, subarachnoid, hemorrhage, pronator, venous, thrombosis, weakness,

The situation involves a 16-year-old patient who suddenly experienced a severe headache, nausea, vomiting, neck stiffness, and other neurological symptoms indicative of a subarachnoid hemorrhage (SAH). An SAH is a potentially life-threatening condition that requires immediate medical attention to prevent complications and improve outcomes. The situation was further complicated by the differential diagnosis of central venous thrombosis due to oral contraceptive use. This emergent medical situation involves complex diagnostic procedures (CT, MRI, angiogram) and significant medical history that suggests an acute neurological event. The outcome and long-term implications for the patient's neurological health and recovery are significant, making this a high-stakes medical scenario.


Medical Specialty: Neurology
Sample Name: MRI of Lumbar Spine w/o Contrast

EXAM: , MRI of lumbar spine without contrast.,HISTORY:,  A 24-year-old female with chronic back pain.,TECHNIQUE: , Noncontrast axial and sagittal images were acquired through the lumbar spine in varying degrees of fat and water weighting.,FINDINGS: , The visualized cord is normal in signal intensity and morphology with conus terminating in proper position.  Visualized osseous structures are normal in marrow signal intensity and morphology without evidence for fracture/contusion, compression deformity, or marrow replacement process.  There are no paraspinal masses.,Disc heights, signal, and vertebral body heights are maintained throughout the lumbar spine.,L5-S1:  Central canal, neural foramina are patent.,L4-L5:  Central canal, neural foramina are patent.,L3-L4:  Central canal, neural foramen is patent.,L2-L3:  Central canal, neural foramina are patent.,L1-L2:  Central canal, neural foramina are patent.,The visualized abdominal aorta is normal in caliber.  Incidental note has been made of multiple left-sided ovarian, probable physiologic follicular cysts.,IMPRESSION: , No acute disease in the lumbar spine.
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DESCRIPTION: MRI of lumbar spine without contrast to evaluate chronic back pain.

neurology, mri, central canal, noncontrast, abdominal aorta, axial, back pain, contrast, follicular cysts, images, lumbar spine, morphology, neural foramina, sagittal, signal intensity, without contrast, mri of lumbar spine, mri of lumbar, lumbar, foramina, neural, patent, spine

The situation describes a medical examination (MRI) of a patient with chronic back pain. The findings indicate no acute disease or abnormalities in the lumbar spine, and the main concern appears to be the chronic pain management rather than an immediate life-threatening condition. While chronic pain can significantly impact quality of life, this specific MRI result does not suggest a high-stakes medical emergency.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 41

SUBJECTIVE:,  The patient complains of backache, stomachache, and dysuria for the last two days.  Fever just started today and cough.  She has history of kidney stones less than a year ago and had a urinary tract infection at that time.  Her back started hurting last night.,PAST MEDICAL HISTORY:,  She denies sexual activities since two years ago.  Her last menstrual period was 06/01/2004.  Her periods have been irregular.  She started menarche at 10 years of age and she is still irregular and it runs in Mom’s side of the family.  Mom and maternal aunt have had total hysterectomies.  She also is diagnosed with abnormal valve has to be on SBE prophylaxis, sees Dr. XYZ Allen.  She avoids decongestants.  She is limited on her activity secondary to her heart condition.,MEDICATION:,  Cylert.,ALLERGIES: , No known drug allergies.,OBJECTIVE:,Vital Signs:  Blood pressure is 124/72.  Temperature 99.2.  Respirations 20 unlabored.  Weight:  137 pounds.,HEENT:  Normocephalic.  Conjunctivae noninjected.  No mattering noted.  Her TMs are bilaterally clear, nonerythematous.  Throat clear, good mucous membrane moisture, but she did have erythema and edema at her posterior soft palate.,Neck:  Supple.  Increased lymphadenopathy noted in the submandibular nodes, but no axillary nodes and no hepatosplenomegaly.,Respiratory:  Clear.  No wheezes, no crackles, no tachypnea, and no retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal, no murmur.,Abdomen:  Soft.  No organomegaly.  She did have exquisite tenderness to palpation of the left upper quadrant and flank area, but the spleen was not palpable.  She has no suprapubic tenderness.,Extremities:  She has good range of motion of upper and lower extremities.  Good ambulation.,Her UA was positive for 2+ leukocyte esterase, positive nitrites, 1+ protein, 2+ ketones, 4+ blood, greater than 50 white blood cells, 10-20 rbc’s, and 1+ bacteria.  Culture and sensitivity is pending.  Her Strep test is negative.  Culture is pending.,ASSESSMENT:,1.  Urinary dysuria.,2.  Left flank pain.,3.  Pharyngitis.,PLAN:,  A 1 g of Rocephin IM was given.  Call Dr. B's office tomorrow morning incase a second IM dose is needed.  If not then she will fill a prescription for Omnicef 300 mg capsule 1 p.o. b.i.d. for 10 days total and then we will await the culture and sensitivity results to see if this is appropriate drug.  Push fluids.  Await strep culture report.  Follow up with Dr. XYZ if no better or symptoms worsen.
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DESCRIPTION: Backache, stomachache, and dysuria for the last two days - Urinary dysuria, left flank pain, pharyngitis.

general medicine, backache, stomachache, dysuria, cylert, urinary dysuria, pharyngitis, culture and sensitivity, tenderness, urinary, infection,

The clinical scenario involves a patient presenting with symptoms suggestive of a urinary tract infection (UTI), which could potentially involve an upper UTI or pyelonephritis given the flank pain. The patient has a history of kidney stones, which could complicate or mimic the presentation of a UTI. Pharyngitis and possible infection indicated by increased lymphadenopathy are additional concerns. While these are significant medical issues that require attention and appropriate management, they are not acute conditions that typically result in life-threatening consequences within the immediate term if managed appropriately. Nevertheless, given the patient's previous complicated history (heart condition requiring SBE prophylaxis) and the potential for progression to more severe infection if not adequately treated, this situation is more critical than a simple UTI. Hence, it sits mid-range on the stakes scale.


Medical Specialty: Urology
Sample Name: Discharge Summary - Urology & Nephrology

ADMITTING DIAGNOSES:,  Solitary left kidney with obstruction, and hypertension, and chronic renal insufficiency.,DISCHARGE DIAGNOSES: , Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.,PROCEDURES: , Cystoscopy under anesthesia, ureteroscopy, an attempted tube placement, stent removal with retrograde pyelography, percutaneous tube placement, and nephrostomy by Radiology.,PERTINENT LABORATORIES: , Creatinine of 1.4.  During the hospitalization it was decreased to 0.8 and Pseudomonas urinary tract infection, positive culture sensitive to ceftazidime and ciprofloxacin.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 3-1/2-year-old boy with a solitary kidney, had a ureteropelvic junction repair performed by Dr. Y, in the past, unfortunately, it was thought still be obstructed.  A stent was placed approximately 6 weeks ago after urethroscopic placement with some difficulty.  Plan was to remove the stent.  At the time of removal, we were unable to place another tube within the collecting system, and the patient was admitted for percutaneous nephrostomy placement.  He has had no recent cold or flu.  He has problems with hypertension for which he is on enalapril at home in addition to his Macrodantin prophylaxis.,PAST MEDICAL HISTORY: , The patient has no known allergies.  Multiple urinary tract infection, solitary kidney, and previous surgeries as mentioned above.,REVIEW OF SYSTEMS:,  A 14-organ system review of systems is negative except for the history of present illness.  He also has history of being a 34-week preemie twin.,ALLERGIES: , No known allergies.,FAMILY HISTORY: , Unremarkable without any bleeding or anesthetic problems.,SOCIAL HISTORY: , The patient lives at home with his parents, 2 brothers, and a sister.,IMMUNIZATIONS:,  Up-to-date.,MEDICATIONS: , On admission was Macrodantin, hydralazine, and enalapril.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an active little boy.,HEENT:  The head and neck exam was grossly normal.  He had no oral, ocular, or nasal discharge.,LUNGS:  Exam was normal without wheezing.,HEART:  Without murmur or gallops.,ABDOMEN:  Soft, without mass or tenderness with a well-healed flank incision.,GU:  Uncircumcised male with bilaterally descended testes.,EXTREMITIES:  He has full range of motion in all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,BACK:  He has normal back.  Normal gait.,HOSPITAL COURSE: , The patient was admitted to the hospital after inability to place a ureteral stent via ureteroscopy and cystoscopy.  He was made NPO.  He had a fever at first time with elevated creatinine.  He was also evaluated and treated by Dr. X, for fluid management, hypertensive management, and gave him some hydralazine and Lasix to improve his urine output, in addition to manage his blood pressure.  Once the percutaneous tube was placed, we found that his urine culture grew Pseudomonas, so he was kept on Fortaz, and was switched over to ciprofloxacin without difficulty.  He, otherwise, did well with continuing decrease his creatinine at the time of discharge to home.,The patient was discharged home in stable condition with ciprofloxacin, enalapril, and recommendation for followup in Urology in 1 to 2 weeks for the surgical correction in 2 to 3 weeks of repeat pyeloplasty or possible ureterocalicostomy.  The patient had draining nephrostomy tube without difficulty.,
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DESCRIPTION: Solitary left kidney with obstruction and hypertension and chronic renal insufficiency, plus a Pseudomonas urinary tract infection.

This discharge summary describes a complex case involving a young child with a solitary kidney, obstruction, hypertension, and a recent hospital course complicated by a Pseudomonas urinary tract infection. The stakes are elevated due to the patient's age, the complexity of his medical condition (involving vital organs such as kidneys), and the potential life-altering consequences if the conditions are not managed properly. Additionally, the necessity for future surgical interventions and ongoing medical management further suggests the high-stakes nature of this case.


Medical Specialty: Ophthalmology
Sample Name: Cataract

CATARACT, is the loss of transparency of the lens of the eye.  It often appears like a window that is fogged with steam.,WHAT CAUSES CATARACT FORMATION?,*  Aging, the most common cause.,*  Family history.,*  Steroid use.,*  Injury to the eye.,*  Diabetes.,*  Previous eye surgery.,*  Long-term exposure to sunlight.,HOW DO I KNOW IF I HAVE A CATARACT?,*  The best way for early detection is regular eye examinations by your medical eye doctor. There are many causes of visual loss in addition to the cataract such as problems involving the optic nerve and retina.  If these other problems exist, cataract removal may not result in the return or improvement of vision.  Your eye doctor can tell you how much improvement in vision is likely.,DOES IT TAKE A LONG TIME FOR A CATARACT TO FORM?,Cataract development varies greatly between patients and is affected by the cause of the cataract.  Generally, cataracts progress gradually over many years.  Some people, especially diabetics and younger patients, may find that cataract formation progresses rapidly over a few months making it impossible to know exactly how long it will take for the cataract to develop. ,WHAT IS THE TREATMENT FOR CATARACTS?,The only way to remove a cataract is surgery.  If the symptoms are not restricting your activity, a change of glasses may alleviate the symptoms at this time.  No medications, exercise, optical devices or dietary supplements have been shown to stop the progression or prevent cataracts.,It is important to provide protection from excessive sunlight.  Making sure that the sunglasses you wear screen out ultraviolet (UV) light rays or your regular eyeglasses are coated with a clear, anti-UV coating will help prevent or slow the progression of cataracts.,HOW DO I KNOW IF I NEED SURGERY?,Surgery is considered when your vision is interfering with your daily activities.  It is important to evaluate if you can see to do your job and drive safely.  Can you read and watch TV in comfort? Are you able to cook, do your shopping and yard work or take your medications without difficulty? Depending on how you feel your vision is affecting your daily life, you and your eye doctor will decide together when it is the appropriate time to do surgery.,WHAT IS INVOLVED WITH CATARACT SURGERY?,This surgery is generally performed under local anesthesia on an outpatient basis.  With the assistance of a microscope, the cloudy lens is removed and replaced with a permanent intraocular lens implant.,Right after the surgery you should be able to immediately perform all your normal activities except for the most strenuous ones.  You will need to take eye drops as directed by your eye doctor.  Follow-up visits are necessary to make sure the surgical site is healing without problems.,This procedure is performed on over 1.4 million people each year in the United States alone, 95% without complications.  With this highly successful procedure, 90% of the time vision improves unless a problem also exists with the cornea, retina or optic nerve.  As with any surgery, a good result cannot be guaranteed.
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DESCRIPTION: A sample note on Cataract

A sample note on Cataract

ophthalmology, transparency, eye, sunlight, optic nerve, eye doctor, cataract, retina, lens, vision, surgery,

The situation described involves cataract, a common medical condition related to ophthalmology. While cataracts can significantly impact a patient's quality of life and require surgical intervention, the associated surgery is generally routine and has a high success rate. The potential complications are low, and it is generally not a life-threatening condition. Therefore, while it is important, it is not considered high-stakes in comparison to more urgent and critical medical situations.


Medical Specialty: General Medicine
Sample Name: Female ROS

FEMALE REVIEW OF SYSTEMS:,Constitutional:  Patient denies fevers, chills, sweats and weight changes.,Eyes:  Patient denies any visual symptoms.,Ears, Nose, and Throat:  No difficulties with hearing.  No symptoms of rhinitis or sore throat.,Cardiovascular:  Patient denies chest pains, palpitations, orthopnea and paroxysmal nocturnal dyspnea.,Respiratory:  No dyspnea on exertion, no wheezing or cough.,GI:  No nausea, vomiting, diarrhea, constipation, abdominal pain, hematochezia or melena.,GU:  No dysuria, frequency or incontinence.  No difficulties with vaginal discharge.,Musculoskeletal:  No myalgias or arthralgias.,Breasts:  Patient performs self-breast examinations and has noticed no abnormalities or nipple discharge.,Neurologic:  No chronic headaches, no seizures.  Patient denies numbness, tingling or weakness.,Psychiatric:  Patient denies problems with mood disturbance.  No problems with anxiety.,Endocrine:  No excessive urination or excessive thirst.,Dermatologic:  Patient denies any rashes or skin changes.
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DESCRIPTION: Sample female review of systems.

Sample female review of systems.

general medicine, constitutional, breasts, cardiovascular, dermatologic, endocrine, female review of systems, musculoskeletal, neurologic, psychiatric, review of systems, respiratory, abdominal pain, chest pains, constipation, diarrhea, hematochezia, melena, nausea, nipple discharge, numbness, orthopnea, palpitations, paroxysmal nocturnal dyspnea, rashes, tingling, vomiting, weakness, wheezing, nose, systems,

The Female Review of Systems (ROS) provided is a comprehensive checklist used by healthcare providers to quickly assess various health areas of a patient. Since the patient denies any symptoms across multiple systems, the current situation does not present immediate health threats or conditions. The context is a standard interaction in primary care to rule out potential issues. This process is routine and not associated with high-risk or emergency conditions.


Medical Specialty: Neurosurgery
Sample Name: Ventricular Drain Catheter Insertion

PREOPERATIVE DIAGNOSES:,  Increased intracranial pressure and cerebral edema due to severe brain injury.,POSTOPERATIVE DIAGNOSES: , Increased intracranial pressure and cerebral edema due to severe brain injury.,PROCEDURE:,  Burr hole and insertion of external ventricular drain catheter.,ANESTHESIA: , Just bedside sedation.,PROCEDURE: , Scalp was clipped.  He was prepped with ChloraPrep and Betadine.  Incisions are infiltrated with 1% Xylocaine with epinephrine 1:200000.  He did receive antibiotics post procedure.  He was draped in a sterile manner.,Incision made just to the right of the right mid pupillary line 10 cm behind the nasion.  A self-retaining retractor was placed.  Burr hole was drilled with the cranial twist drill.  The dura was punctured with a twist drill.  A brain needle was used to localize the ventricle that took 3 passes to localize the ventricle.  The pressure was initially high.  The CSF was clear and colorless.  The CSF drainage rapidly tapered off because of the brain swelling.  With two tries, the ventricular catheter was then able to be placed into the ventricle and then brought out through a separate stab wound, the depth of catheter is 7 cm from the outer table of the skull.  There was intermittent drainage of CSF after that.  The catheter was secured to the scalp with #2-0 silk suture and the incision was closed with Ethilon suture.  The patient tolerated the procedure well.  No complications.  Sponge and needle counts were correct.  Blood loss is minimal.  None replaced.
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DESCRIPTION: Burr hole and insertion of external ventricular drain catheter.

neurosurgery, intracranial pressure, cerebral edema, external ventricular drain catheter, ventricular drain catheter, brain injury, burr hole, ventricular, brain, catheter,

The insertion of an external ventricular drain catheter in a neurosurgery context is a high-stakes procedure. The stakes are high because it directly involves the brain, requires precision, and is performed to alleviate increased intracranial pressure and cerebral edema, which are critical conditions. Any complications or errors could lead to severe consequences for the patient, including worsening neurological conditions or even death. Although this particular report mentions no complications and that the patient tolerated the procedure well, the initial situation and procedure itself are inherently high stakes in the context of neurosurgery.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 31

CHIEF COMPLAINT:,  A 74-year-old female patient admitted here with altered mental status.,HISTORY OF PRESENT ILLNESS:,  The patient started the last 3-4 days to do poorly.  She was more confused, had garbled speech, significantly worse from her baseline.  She has also had decreased level of consciousness since yesterday.  She has had aphasia which is baseline but her aphasia has gotten significantly worse.  She eventually became unresponsive and paramedics were called.  Her blood sugar was found to be 40 because of poor p.o. intake.  She was given some D50 but that did not improve her mental status, and she was brought to the emergency department.  By the time she came to the emergency department, she started having some garbled speech.  She was able to express her husband's name and also recognize some family members, but she continued to be more somnolent when she was in the emergency department.  When seen on the floor, she is more awake, alert.,PAST MEDICAL HISTORY: , Significant for recurrent UTIs as she was recently to the hospital about 3 weeks ago for urinary tract infection.  She has chronic incontinence and bladder atony, for which eventually it was decided for the care of the patient to put a Foley catheter and leave it in place.  She has had right-sided CVA.  She has had atrial fibrillation status post pacemaker.  She is a type 2 diabetic with significant neuropathy.  She has also had significant pain on the right side from her stroke.  She has a history of hypothyroidism.  Past surgical history is significant for cholecystectomy, colon cancer surgery in 1998.  She has had a pacemaker placement.  ,REVIEW OF SYSTEMS:,GENERAL:  No recent fever, chills.  No recent weight loss.,PULMONARY:  No cough, chest congestion.,CARDIAC:  No chest pain, shortness of breath.,GI:  No abdominal pain, nausea, vomiting.  No constipation.  No bleeding per rectum or melena.,GENITOURINARY:  She has had frequent urinary tract infection but does not have any symptoms with it.  ENDOCRINE:  Unable to assess because of patient's bed-bound status.,MEDICATIONS:  ,Percocet 2 tablets 4 times a day, Neurontin 1 tablet b.i.d.  600 mg, Cipro recently started 500 b.i.d., Humulin N 30 units twice a day.  The patient had recently reduced that to 24 units.  MiraLax 1 scoop nightly, Avandia 4 mg b.i.d., Flexeril 1 tablet t.i.d., Synthroid 125 mcg daily, Coumadin 5 mg.  On the medical records, it shows she is also on ibuprofen, Lasix 40 mg b.i.d., Lipitor 20 mg nightly, Reglan t.i.d.  5 mg, Nystatin powder.  She is on oxygen chronically.,SOCIAL/FAMILY HISTORY: , She is married, lives with her husband, has 2 children that passed away and 4 surviving children.  No history of tobacco use.  No history of alcohol use.  Family history is noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  She is awake, alert, appears to be comfortable.,VITAL SIGNS:  Blood pressure 111/43, pulse 60 per minute, temperature 37.2.  Weight is 98 kg.  Urine output is so far 1000 mL.  Her intake has been fairly similar.  Blood sugars are 99 fasting this morning.  ,HEENT:  Moist mucous membranes.  No pallor,NECK:  Supple.  She has a rash on her neck.  ,HEART:  Regular rhythm, pacemaker could be palpated.,CHEST:  Clear to auscultation.,ABDOMEN:  Soft, obese, nontender.,EXTREMITIES:  Bilateral lower extremities edema present.  She is able to move the left side more efficiently than the right.  The power is about 5 x 5 on the left and about 3-4 x 5 on the right.  She has some mild aphasia.,DIAGNOSTIC STUDIES: , BUN 48, creatinine 2.8.  LFTs normal.  She is anemic with a hemoglobin of 9.6, hematocrit 29.  INR 1.1, pro time 14.  Urine done in the emergency department showed 20 white cells.  It was initially cloudy but on the floor it has cleared up.  Cultures from the one done today are pending.  The last culture done on August 20 showed guaiac negative status and prior to that she has had mixed cultures.  There is a question of her being allergic to Septra that was used for her last UTI.,IMPRESSION/PLAN:,1.  Cerebrovascular accident as evidenced by change in mental status and speech.  She seems to have recovered at this point.  We will continue Coumadin.  The patient's family is reluctant in discontinuing Coumadin but they do express the patient since has overall poor quality of life and had progressively declined over the last 6 years, the family has expressed the need for her to be on hospice and just continue comfort care at home.,2.  Recurrent urinary tract infection.  Will await culture at this time, continue Cipro.,3.  Diabetes with episode of hypoglycemia.  Monitor blood sugar closely, decrease the dose of Humulin N to 15 units twice a day since intake is poor.  At this point, there is no clear evidence of any benefit from Avandia but will continue that for now.,4.  Neuropathy, continue Neurontin 600 mg b.i.d., for pain continue the Percocet that she has been on.,5.  Hypothyroidism, continue Synthroid.,6.  Hyperlipidemia, continue Lipitor.,7.  The patient is not to be resuscitated.  Further management based on the hospital course.
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DESCRIPTION: Patient was confused, had garbled speech, significantly worse from her baseline, and had decreased level of consciousness.

The situation involves a 74-year-old female patient with several serious medical conditions, including altered mental status, likely related to a cerebrovascular accident, recurrent UTIs, diabetes with recent hypoglycemic episode, and an overall decline in health. The mention of hospice care and discussions about comfort care highlight the seriousness of her condition and the family's desire to focus on quality of life rather than aggressive treatment. This makes it a high-stakes situation as it involves significant medical decisions regarding the patient's end-of-life care.


Medical Specialty: Surgery
Sample Name: Total Knee Replacement - NexGen

PREOPERATIVE DIAGNOSIS: , Degenerative arthritis of left knee.,POSTOPERATIVE DIAGNOSIS:,  Degenerative arthritis of left knee.,PROCEDURE PERFORMED: , NexGen left total knee replacement.,ANESTHESIA: , Spinal.,TOURNIQUET TIME:  Approximately 66 minutes.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Approximately 50 cc.,COMPONENTS: , A NexGen stemmed tibial component size 5 was used, 10 mm cruciate retaining polyethylene surface, a NexGen cruciate retaining size E femoral component, and a size 38 9.5 mm thickness All-Poly Patella.,BRIEF HISTORY:,  The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.  She wishes to proceed with arthroplasty at this time.,PROCEDURE:  ,The patient was taken to the Operative Suite at ABCD General Hospital on 09/11/03.  She was placed on the operating table.  Department of Anesthesia administered a spinal anesthetic.  Once adequately anesthetized, the left lower extremity was prepped and draped in the usual sterile fashion.  An Esmarch was applied and a tourniquet was inflated to 325 mmHg on the left thigh.  A longitudinal incision was made over the anterior portion of the knee and this was taken down through the subcutaneous tissue to the level of the patella retinaculum.  A medial peripatellar arthrotomy was then made and taken down to the level of the tibial tubercle.  Care was then ensured that the patellar tendon was not violated.  The proximal tibia was then skeletonized both medially and laterally to the level of the axis through the joint line.  Again care was ensured that the patellar tendon was not avulsed from the insertion on the tibia.  The intramedullary canal was then opened using a drill and the anterior sizing guide was then placed.  Rongeur was used to take out any osteophytes and the size of approximately size E. At this point, the epicondyle axis guide was then inserted and aligned in a proper orientation.  The anterior cutting guide was then placed.  Care was checked for the amount of resection that the femur would be notched and the oscillating saw was used to cut the anterior portion of the femur.  After this was performed, this was removed and the distal femoral cutting guide was then placed.  The left knee placed in 5 degrees of valgus, guide was then placed, and a standard distal cut was then taken.  After the cuts were ensured further to be leveled and they were, and we proceeded to place the finishing guide size E and distal femur.  This was placed slightly in lateral position and secured in position with spring tense and head lift tense.  Once adequately secured and placed in the appropriate orientation, the alignment was again verified with the epicondyle axis and appeared to be externally rotated appropriately.  The chamfer cuts and anterior and posterior cuts were then made as well as the notch cut using the reciprocating and oscillating saws.  After this was performed, the guide was removed and all bony fragments were then removed.  Attention was then directed to the tibia.  The external tibial alignment guide was then placed and pinned to the proximal tibia in a proper position.  Care was ensured if it is was a varus or valgus and the appropriate.  The femur gauge was then used to provide us appropriate amount of bony resection.  This was then pinned and secured into place.  Ligament retractors were used to protect the collateral ligaments and the tip proximal tibial cut was then made.  This bony portion was then removed and remaining meniscal fragments were removed as well as the ACL till adequate exposure was obtained.  Trial components were then inserted into position and taken the range of motion and found to have good and full excellent range of motion stability.  The trial components were then removed.  The tibia was then stemmed in standard fashion after the tibial plate was placed in some degree of external rotation with appropriate alignment.  After it was stemmed and broached, these were removed and the patella was then incised, a size 41 patella reamer blade was then used and was taken down, a size 38 patella button was then placed intact.  Again the trial components were placed back into position.  Patella button was placed and the tracking was evaluated.  They tracked centrally with no touch technique.  Again, all components were now removed and the knee was then copiously irrigated and suctioned dry.  Once adequately suctioned dry, the tibial portion was cemented and packed into place.  Also excess cement was removed.  The femoral component was then cemented into position.  All excess cement was removed.  A size 12 poly was then inserted in trial to provide compression at cement adhered.  The patella was then cemented and held into place.  All components were held under compression until cement had adequately adhered all excess cement was then removed.  The knee was then taken through range of motion and size 12 felt to be slightly too big, this was removed and the size 10 trial was replaced, and again had excellent varus and valgus stability with full range of motion and felt to be the articulate surface of choice.  The knee was again copiously irrigated and suctioned dry.  One last check in the posterior aspect of the knee for any loose bony fragments or osteophytes was performed, there were none found and a final articulating surface was impacted and locked into place.  After this, the knee was taken again for final range of motion and found to have excellent position, stability, and good alignment of the components.  The knee was once again copiously irrigated, and the tourniquet was deflated.  Bovie cautery was used to cauterize the knee bleeding that was seen until good hemostasis obtained.  A drain was then placed deep to the retinaculum and the retinaculum repair was performed using #2-0 Ethibond and oversewn with a #1 Vicryl.  This was flexed and the repair was found held securely.  At this point, the knee was again copiously irrigated and suctioned dry.  The subcutaneous tissue was closed with #2-0 Vicryl, and the skin was approximated with skin staples.  Sterile dressing with Adaptic, 4x4s, ABDs, and Kerlix rolls was then applied.  The patient was then transferred back to the gurney in a supine position.,DISPOSITION: , The patient tolerated well with no complications, to PACU in satisfactory condition.
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DESCRIPTION: NexGen left total knee replacement.  Degenerative arthritis of left knee.  The patient is a 72-year-old female with a history of bilateral knee pain for years progressively worse and decreasing quality of life and ADLs.

surgery, degenerative arthritis, nexgen stemmed tibial component, all-poly patella, nexgen cruciate, total knee replacement, patellar tendon, proximal tibia, epicondyle axis, bony fragments, patella button, tibial, knee, arthritis, nexgen, patella

This situation involves a surgical procedure, specifically a total knee replacement surgery. While the procedure described was completed successfully without complications, surgery in general carries inherent risks such as infection, blood clots, or adverse reactions to anesthesia. These risks, along with the importance of a successful outcome in restoring the patient's mobility and quality of life, means the situation is high-stakes in terms of both the patient's health and the surgical team's responsibilities.


Medical Specialty: Surgery
Sample Name: Arthroscopic Meniscoplasty

PREOPERATIVE DIAGNOSES:,1.  Torn lateral meniscus, right knee.,2.  Chondromalacia of the patella, right knee.,POSTOPERATIVE DIAGNOSES:,1.  Torn lateral meniscus, right knee.,2.  Chondromalacia of the patella, right knee.,PROCEDURE PERFORMED:,1.  Arthroscopic lateral meniscoplasty.,2.  Patellar shaving of the right knee.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,TOTAL TOURNIQUET TIME:,  Zero.,GROSS FINDINGS: , A complex tear involving the lateral and posterior horns of the lateral meniscus and grade-II chondromalacia of the patella.,HISTORY OF PRESENT ILLNESS: , The patient is a 45-year-old Caucasian male presented to the office complaining of right knee pain.  He complained of pain on the medial aspect of his right knee after an injury at work, which he twisted his right knee.,PROCEDURE:  ,After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the operative surgeon, the patient, the Department of Anesthesia and the nursing staff.,The patient was then transferred to preoperative area to Operative Suite #2, placed on the operating table in supine position.  Department of Anesthesia administered general anesthetic to the patient.  All bony prominences were well padded at this time.  The right lower extremity was then properly positioned in a Johnson knee holder.  At this time, 1% lidocaine with epinephrine 20 cc was administered to the right knee intra-articularly under sterile conditions.  The right lower extremity was then sterilely prepped and draped in usual sterile fashion.  Next, after all bony soft tissue landmarks were identified, an inferolateral working portal was established by making a 1-cm transverse incision at the level of the joint line lateral to the patellar tendon.  The cannula and trocar were then inserted through this, putting the patellofemoral joint.  An arthroscopic camera was then inserted and the knee was sequentially examined including the patellofemoral joint, the medial and lateral gutters, medial lateral joints, and the femoral notch.  Upon viewing of the patellofemoral joint, there was noted to be grade-II chondromalacia changes of the patella.  There were no loose bodies noted in the either gutter.  Upon viewing of the medial compartment, there was no chondromalacia or meniscal tear was noted.  While in this area, attention was directed to establish the inferomedial instrument portal.  This was first done using a spinal needle for localization followed by 1-cm transverse incision at the joint line.  A probe was then inserted through this portal and the meniscus was further probed.  Again, there was noted to be no meniscal tear.  The knee was taken through range of motion and there was no chondromalacia.  Upon viewing of the femoral notch, there was noted to be intact ACL with negative drawer sign.  PCL was also noted to be intact.  Upon viewing of the lateral compartment, there was noted to be a large bucket-handle tear involving the lateral and posterior horns.  It was reduced from the place, however, involved the white and red white area was elected to excise the bucket-handle.  An arthroscopic scissor was then inserted and the two remaining attachments the posterior and lateral attachments were then clipped and a Schlesinger grasper was then used to remove the resected meniscus.  It was noted that the meniscus was followed out to the whole and the entire piece was taken out of the knee.  Pictures were taken both pre-meniscal resection and post-meniscal resection.  The arthroscopic shaver was then inserted into the medial portal and the remaining meniscus was contoured.  The lateral gutter was then examined and was noted to be no loose bodies and ______ was intact.  Next, attention was directed to the inner surface of the patella.  This was debrided using the 2.5 arthroscopic shaver.  It was noted to be quite smooth and postprocedure the patient was taken ________ well.  The knee was then copiously irrigated and suctioned dry and all instrumentation was removed.  20 cc of 0.25% Marcaine was then administered to each portal as well as intra-articularly.,Sterile dressing was then applied consisting of Adaptic, 4x4s, ABDs, and sterile Webril and a stockinette to the right lower extremity.  At this time, Department of Anesthesia reversed the anesthetic.  The patient was transferred back to the hospital gurney to the Postanesthesia Care Unit.  The patient tolerated the procedure and there were no complications.
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DESCRIPTION: Torn lateral meniscus and chondromalacia of the patella, right knee.  Arthroscopic lateral meniscoplasty and patellar shaving of the right knee.

surgery, patella, chondromalacia, lateral meniscus, complex tear, torn lateral meniscus, femoral notch, meniscal tear, bucket handle, meniscal resection, arthroscopic shaver, patellofemoral joint, arthroscopic, knee, torn, meniscoplasty, meniscal, joint, meniscus,

The described situation involves a surgical procedure to address a torn lateral meniscus and chondromalacia of the patella. While the procedure itself carries inherent risks related to anesthesia and surgery, it is a common orthopedic procedure with a high success rate and generally low complication risk for patients in good health. There were no complications mentioned during the surgery, and the patient tolerated the procedure well. Thus, while not trivial, the stakes are not extremely high compared to more complex or life-threatening surgeries.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Consult - Palpitations & Presyncope

HISTORY OF PRESENT ILLNESS: , The patient is a charming and delightful 46-year-old woman admitted with palpitations and presyncope.,The patient is active and a previously healthy young woman, who has had nine years of occasional palpitations.  Symptoms occur three to four times per year and follow no identifiable pattern.  She has put thought and effort in trying to identify precipitating factors or circumstances but has been unable to do so.  Symptoms can last for an hour or more and she feels as if her heart is going very rapidly but has never measured her heart rate.  The last two episodes, the most recent of which was yesterday, were associated with feeling of darkness descending as if a shade was being pulled down in front of her vision.  On neither occasion did she lose consciousness.,Yesterday, she had a modestly active morning taking a walk with her dogs and performing her normal routines.  While working on a computer, she had a spell.  Palpitations persisted for a short time thereafter as outlined in the hospital's admission note prompting her to seek evaluation at the hospital.  She was in sinus rhythm on arrival and has been asymptomatic since.,No history of exogenous substance abuse, alcohol abuse, or caffeine abuse.  She does have a couple of sodas and at least one to two coffees daily.  She is a nonsmoker.  She is a mother of two.  There is no family history of congenital heart disease.  She has had no history of thoracic trauma.  No symptoms to suggest thyroid disease.,No known history of diabetes, hypertension, or dyslipidemia.  Family history is negative for ischemic heart disease.,Remote history is significant for an ACL repair, complicated by contact urticaria from a neoprene cast.,No regular medications prior to admission.,The only allergy is the neoprene reaction outlined above.,PHYSICAL EXAMINATION: , Vital signs as charted.  Pupils are reactive.  Sclerae nonicteric.  Mucous membranes are moist.  Neck veins not distended.  No bruits.  Lungs are clear.  Cardiac exam is regular without murmurs, gallops, or rubs.  Abdomen is soft without guarding, rebound masses, or bruits.  Extremities well perfused.  No edema.  Strong and symmetrical distal pulses.,A 12-lead EKG shows sinus rhythm with normal axis and intervals.  No evidence of preexcitation.,LABORATORY STUDIES: , Unremarkable.  No evidence of myocardial injury.  Thyroid function is pending.,Two-dimensional echocardiogram shows no evidence of clinically significant structural or functional heart disease.,IMPRESSION/PLAN: , Episodic palpitations over a nine-year period.  Outpatient workup would be appropriate.  Event recorder should be obtained and the patient can be seen again in the office upon completion of that study.  Suppressive medication (beta-blocker or Cardizem) was discussed with the patient for symptomatic improvement, though this would be unlikely to be a curative therapy.  The patient expresses a preference to avoid medical therapy if possible.,Thank you for this consultation.  We will be happy to follow her both during this hospitalization and following discharge.  Caffeine avoidance was discussed as well.,ADDENDUM: , During her initial evaluation, a D-dimer was mildly elevated to 5.  CT scan showed no evidence of pulmonary embolus.  Lower extremity venous ultrasound is pending; however, in the absence of embolization to the pulmonary vasculature, this would be an unlikely cause of palpitations.  In addition, no progression over the nine-year period that she has been symptomatic suggests that this is an unlikely cause.,
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DESCRIPTION: The patient admitted with palpitations and presyncope.

cardiovascular / pulmonary, presyncope, palpitations, episodic palpitations, beta-blocker, ultrasound, palpitations and presyncope, sinus rhythm, heart disease, heart

The situation involves a 46-year-old woman experiencing episodic palpitations and presyncope over a nine-year period, now seeking evaluation in a hospital setting. While there are potential concerns about the heart and vascular issues given the symptoms, initial investigations have not revealed significant immediate threats to her cardiovascular health. The plan includes outpatient monitoring and the option of a suppressive medication. The stakes are related to the potential of untreated cardiac conditions and ensuring the underlying cause is identified and managed to avoid serious events in the future.


Medical Specialty: Consult - History and Phy.
Sample Name: Lightheadedness

HISTORY OF PRESENT ILLNESS:  ,The patient comes in today because of feeling lightheaded and difficulty keeping his balance.  He denies this as a spinning sensation that he had had in the past with vertigo.  He just describes as feeling very lightheaded.  It usually occurs with position changes such as when he stands up from the sitting position or stands up from a lying position.  It tends to ease when he sits down again, but does not totally resolve for another 15 to 30 minutes and he feels shaky and weak all over.  Lorazepam did not help this sensation.  His blood pressure has been up lately and his dose of metoprolol was increased.  They feel these symptoms have gotten worse since metoprolol was increased.,PAST MEDICAL HISTORY: , Detailed on our H&P form.  Positive for elevated cholesterol, diabetes, glaucoma, cataracts, hypertension, heart disease, vertigo, stroke in May of 2005, congestive heart failure, CABG, and cataract removed right eye.,CURRENT MEDICATIONS: , Detailed on the H&P form.,PHYSICAL EXAMINATION: , His blood pressure sitting down was 180/80 with a pulse rate of 56.  Standing up blood pressure was 160/80 with a pulse rate of 56.  His general exam and neurological exam were detailed on our H&P form.  Pertinent positives on his neurological exam were decreased sensation in his left face, and left arm and leg.,IMPRESSION AND PLAN:  ,This lightheaded, he exquisitely denies vertigo, the vertigo that he has had in the past.  He states this is more of a lightheaded type feeling.  He did have a mild blood pressure drop here in the office.  We are also concerned that bradycardia might be contributing to his feeling of lightheadedness.  We are going to suggest that he gets a Holter monitor and he should speak to his general practitioner as well as his cardiologist regarding the lightheaded feeling.,We will schedule him for the Holter monitor and refer him back to his cardiologist.
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DESCRIPTION: The patient comes in today because of feeling lightheaded and difficulty keeping his balance.

consult - history and phy., lightheaded feeling, feeling lightheaded, pulse rate, neurological exam, holter monitor, blood pressure, balance, vertigo, lightheadedness,

The situation described involves a patient with a history of serious cardiovascular conditions, including hypertension, heart disease, and a previous stroke. The patient is experiencing new and concerning symptoms of lightheadedness and difficulty maintaining balance, which could potentially indicate an issue with his medication or a new cardiovascular event. The presence of bradycardia, despite blood pressure management, adds complexity. These indicators make the situation potentially serious, requiring close monitoring and specialist referral. However, it's not emergent at this exact moment since the patient is being referred for further evaluation.


Medical Specialty: Neurology
Sample Name: MRI Brain & Cerebral Angiogram

CC:, Difficulty with word finding.,HX: ,This 27y/o RHF experienced sudden onset word finding difficulty and slurred speech on the evening of 2/19/96. She denied any associated dysphagia, diplopia, numbness or weakness of her extremities. She went to sleep with her symptoms on 2/19/96, and awoke with them on 2/20/96. She also awoke with a headache (HA) and mild neck stiffness. She took a shower and her HA and neck stiffness resolved. Throughout the day she continued to have difficulty with word finding and had worsening of her slurred speech. That evening, she began to experience numbness and weakness in the lower right face. She felt like there was a "rubber-band" wrapped around her tongue.,For 3 weeks prior to presentation, she experienced transient episodes of a "boomerang" shaped field cut in the left eye. The episodes were not associated with any other symptoms. One week prior to presentation, she went to a local ER for menorrhagia. She had just resumed taking oral birth control pills one week prior to the ER visit after having stopped their use for several months. Local evaluation included an unremarkable carotid duplex scan. However, a HCT with and without contrast reportedly revealed a left frontal gyriform enhancing lesion. An MRI brain scan on 2/20/96 revealed nonspecific white matter changes in the right periventricular region. EEG reportedly showed diffuse slowing. CRP was reportedly "too high" to calibrate.,MEDS:, Ortho-Novum 7-7-7 (started 2/3/96), and ASA (started 2/20/96).,PMH:, 1)ventral hernia repair 10 years ago, 2)mild "concussion" suffered during a MVA; without loss of consciousness, 5/93, 3) Anxiety disorder, 4) One childbirth.,FHX: ,She did not know her father and was not in contact with her mother.,SHX:, Lives with boyfriend. Smokes one pack of cigarettes every three days and has done so for 10 years. Consumes 6 bottles of beers, one day a week. Unemployed and formerly worked at an herbicide plant.,EXAM: ,BP150/79, HR77, RR22, 37.4C.,MS: A&O to person, place and time. Speech was dysarthric with mild decreased fluency marked by occasional phonemic paraphasic errors. Comprehension, naming and reading were intact. She was able to repeat, though her repetition was occasionally marked by phonemic paraphasic errors. She had no difficulty with calculation.,CN: VFFTC, Pupils 5/5 decreasing to 3/3. EOM intact. No papilledema or hemorrhages seen on fundoscopy. No RAPD or INO. There was right lower facial weakness. Facial sensation was intact, bilaterally. The rest of the CN exam was unremarkable.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,Sensory: No deficits.,Coord/Station/Gait: unremarkable.,Reflexes 2/2 throughout. Plantar responses were flexor, bilaterally.,Gen Exam: unremarkable.,COURSE:, CRP 1.2 (elevated), ESR 10, RF 20, ANA 1:40, ANCA <1:40, TSH 2.0, FT4 1.73, Anticardiolipin antibody IgM 10.8GPL units (normal <10.9), Anticardiolipin antibody IgG 14.8GPL (normal<22.9), SSA and SSB were normal. Urine beta-hCG pregnancy and drug screen were negative. EKG, CXR and UA were negative.,MRI brain, 2/21/96 revealed increased signal on T2 imaging in the periventricular white matter region of the right hemisphere. In addition, there were subtle T2 signal changes in the right frontal, right parietal, and left parietal regions as seen previously on her local MRI can. In addition, special FLAIR imaging showed increased signal in the right frontal region consistent with ischemia.,She underwent Cerebral Angiography on 2/22/96. This revealed decreased flow and vessel narrowing the candelabra branches of the RMCA supplying the right frontal lobe. These changes corresponded to the areas of ischemic changes seen on MRI. There was also segmental narrowing of the caliber of the vessels in the circle of Willis. There was a small aneurysm at the origin of the LPCA. There was narrowing in the supraclinoid portion of the RICA and the proximal M1 and A1 segments. The study was highly suggestive of vasculitis.,2/23/96, Neuro-ophthalmology evaluation revealed no evidence of retinal vasculitic change. Neuropsychologic testing the same day revealed slight impairment of complex attention only. She was started on Prednisone 60mg qd and Tagamet 400mg qhs.,On 2/26/96, she underwent a right frontal brain biopsy. Pathologic evaluation revealed evidence of focal necrosis (stroke/infarct), but no evidence of vasculitis. Immediately following the brain biopsy, while still in the recovery room, she experienced sudden onset right hemiparesis and transcortical motor type aphasia. Initial HCT was unremarkable. An EEG was consistent with a focal lesion in the left hemisphere. However, a 2/28/96 MRI brain scan revealed new increased signal on T2 weighted images in a gyriform pattern from the left precentral gyrus to the superior frontal gyrus. This was felt consistent with vasculitis.,She began q2month cycles of Cytoxan (1,575mg IV on 2/29/96. She became pregnant after her 4th cycle of Cytoxan, despite warnings to the contrary. After extensive discussions with OB/GYN it was recommended she abort the pregnancy. She underwent neuropsychologic testing which revealed no significant cognitive deficits. She later agreed to the abortion. She has undergone 9 cycles of Cytoxan ( one cycle every 2 months) as of 4/97. She had complained of one episode of paresthesias of the LUE in 1/97. MRI then showed no new signs ischemia.
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DESCRIPTION: MRI brain & Cerebral Angiogram: CNS Vasculitis with evidence of ischemic infarction in the right and left frontal lobes.

The situation involves a young patient with complex neurological symptoms and potential CNS vasculitis, requiring detailed diagnostic imaging, cerebral angiography, and aggressive treatment with medications like Prednisone and Cytoxan. The patient also experienced significant events like a brain biopsy leading to new neurological deficits, and a complicated decision regarding pregnancy termination due to the treatment regimen. These aspects, coupled with the potential for serious long-term neurological impacts, make this a high-stakes medical scenario.


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

Medical Specialty: Surgery
Sample Name: TAH & Salpingo-oophorectomy - 1

PREOPERATIVE DIAGNOSIS:  ,Persistent abnormal uterine bleeding after endometrial ablation.,POSTOPERATIVE DIAGNOSIS: , Persistent abnormal uterine bleeding after endometrial ablation.,PROCEDURE PERFORMED: , Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 250 cc.,FLUIDS:  ,1500 cc of crystalloids.,URINE: , 125 cc of clear urine at the end of the procedure.,FINDINGS: , On exam, under anesthesia, an obese female with an enlarged fibroid uterus freely movable on the pelvis.  Operative findings demonstrated the same with normal appearing tubes bilaterally.  The right ovary contained a right ovarian cyst.  The left ovary appeared to be within normal limits.  The peritoneal surfaces were noted to be within normal limits.  The bowel was also noted to be within normal limits.,INDICATIONS FOR THIS PROCEDURE: , The patient is a 44-year-old female who had an endometrial ablation done in May, which showed submucosal fibroids.  She had history of anemia and has been on iron therapy.  She started having bleeding three weeks ago with intermittent bouts of flooding.,She desired permanent and definitive therapy and therefore it was felt very appropriate to take the patient for a total abdominal hysterectomy.  The uterus, cervix, and right tube and ovary was sent to pathology for review.,PROCEDURE: , After informed consent was obtained, all questions were answered to the patient's satisfaction in layman's term.  She was taken to the operating room where a general anesthesia was obtained without any difficulty.  She was examined under anesthesia with noted findings above.  She was placed in a dorsal supine position and prepped and draped in the usual sterile fashion.  The Pfannenstiel skin incision was made with the first knife and was then carried down to the underlying layer of the fascia.  With the second knife, the fascia was excised in the midline and extended laterally with the Mayo scissors.  The superior aspect of the fascial incision was then tented up with the Ochsner clamps and the underlying rectus muscle was dissected off sharply as well as bluntly.  Attention was then turned to the inferior aspect of the fascial incision, which in a similar fashion was tented up and the underlying rectus muscle was dissected off sharply as well as bluntly.  The rectus muscle was then separated in the midline, the peritoneum was identified, entered bluntly and digitally.  Then the peritoneal incision was then extended superior and inferiorly with excellent visualization of the bladder.  The GYN Balfour was then placed.  A Lahey clamp was placed on the fundus of the uterus to pull the uterus into the operative field and the bowel was packed away with moist laparotomy sponges.  Attention was then turned to the round ligaments bilaterally, which were tented up with Allis clamps and then a hemostat was poked through the avascular portion underneath the round ligament and the #O-tie was passed through and then tied down.  Then the round ligament was transected and suture ligated and noted to be hemostatic.  The round ligaments were then skeletonized to create a window in the broad ligament.  The right infundibulopelvic ligament was isolated through the window created from the round ligaments and then the infundibular ligament on the right was loop tied and then doubly clamped with straight Ochsner clamps and then transected and suture ligated with a #0 Vicryl in a Heaney stitch fashion.  It was noted to be hemostatic.  Attention was then turned to the left side, in which the uterovarian vessel was isolated and then tied with an #O-tie and then doubly clamped with straight Ochsner clamps, transected and suture ligated with a #0 Vicryl in a Heaney stitch fashion and noted to be hemostatic.  The vesicouterine peritoneum was then identified, tented up with Allis clamps, and then the bladder flap was created sharply with a Russian and Metzenbaum scissors.  Then the bladder was deflected off of the underlying cervix with blunt dissection with a moist Ray-Tec sponge down to the level of the cervix.,The uterine vessels were skeletonized bilaterally and then clamped with straight Ochsner clamps and transected and suture ligated and noted to be hemostatic.  In the similar fashion, the broad ligament down to the level of the caudal ligament, the uterosacral ligaments was clamped with curved Ochsner clamps and transected and suture ligated, and noted to be hemostatic.  The second Lahey clamp was then placed on the cervix.  The cervix was tented up and the pubocervical vesical fascia was transected with a long knife and then the vagina was entered with a double pointed scissors poked through well protecting posteriorly with a large malleable.  The cuff was then outlined.  The vaginal cuff was grasped with a Ochsner clamp and then the cervix, uterus, and the right tube and ovary were transected using the Jorgenson scissors.  The cuff outlined with Ochsner clamps.  The cuff was then painted with a Betadine soaked Ray-Tec sponge and the sponge was placed over the vagina.  The vaginal cuff was then closed with a #0 Vicryl in a running locked fashion holding on to the beginning end on the right side as well as incorporating the ipsilateral cardinal ligaments into the cuff angles.  A long Allis was then used to grasp the mid portion of the cuff and a #0 Vicryl figure-of-eight stitch was placed in the mid portion of the cuff and tied down.  At this time, the abdomen was copiously irrigated with warm normal saline and noted to be hemostatic.  The suture that was used to close the cuff was then used to come back through the posterior peritoneum grabbing the uterosacral ligaments and the mid portion of the cuff, and then tied down to bring the cuff close and together.  Then, the right round ligament was pulled into the cuff and tied down with the #0 Vicryl that was used as a figure-of-eight stitch in the middle of the cuff.  The left round ligament was too small to reach the cuff.  The abdomen was then again copiously irrigated with warm normal saline and noted to be hemostatic.  The peritoneum was then re-peritonealized with a #3-0 Vicryl in a running fashion.  The GYN Balfour and all packing sponges were removed from the abdomen.  Then the abdomen was then once again copiously irrigated and the cuff and incision sites were once again reinspected and noted to be hemostatic.  The ______ was placed back into the hollow of the sacrum.  The omentum was then pulled over to top of the bowel and then the peritoneum was then closed with a #3-0 Vicryl in a running fashion and then the fascia was closed with #0 Vicryl in a running fashion.  The skin was closed with staples and dressing applied.  The patient was then examined at the end of the procedure.  The Betadine-soaked sponge was removed from the vagina.  The cuff was noted to be intact without bleeding and the patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2 and she was taken to the recovery in stable condition.  The patient will be followed throughout her hospital stay.
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DESCRIPTION: Total abdominal hysterectomy (TAH) with a right salpingo-oophorectomy.

surgery, tah, salpingo-oophorectomy, total abdominal hysterectomy, abnormal uterine bleeding, endometrial ablatio, ochsner clamps, round ligaments, clamps, ligaments, cuff, salpingo, oophorectomy, hysterectomy, uterine, ablation, tubes, abdominal, anesthesia,

The procedure described is a total abdominal hysterectomy with a right salpingo-oophorectomy. While the surgery involves significant removal of reproductive organs and can have profound implications on the patient's health and life, the report indicates that it was successfully completed without complications. The surgery itself is a common procedure in cases of persistent abnormal uterine bleeding and fibroids after other treatments have failed. Given the patient's history of anemia and desire for definitive therapy, the decision for surgery was justified. However, any surgical procedure carries inherent risks, including anesthesia, blood loss, and infection, which need to be considered. Therefore, it is an important medical procedure but not an emergency or life-threatening one under normal circumstances.


Medical Specialty: Surgery
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 3

NAME OF PROCEDURE: , Left heart catheterization with ventriculography, selective coronary angiography.,INDICATIONS: , Acute coronary syndrome.,TECHNIQUE OF PROCEDURE: , Standard Judkins, right groin.  Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.  ,ANTICOAGULATION:  ,The patient was on heparin at the time.,COMPLICATIONS: , None.,I reviewed with the patient the pros, cons, alternatives, risks of catheterization and sedation including myocardial infarction, stroke, death, damage to nerve, artery or vein in the leg, perforation of a cardiac chamber, dissection of an artery requiring countershock, infection, bleeding, ATN allergy, need for cardiac surgery.  All questions were answered, and the patient desired to proceed.,HEMODYNAMIC DATA:  ,Aortic pressure was in the physiologic range.  No significant gradient across the aortic valve.,ANGIOGRAPHIC DATA,1. Ventriculogram:  The left ventricle is of normal size and shape, normal wall motion, normal ejection fraction.,2. Right coronary artery:  Dominant.  There was insignificant disease in the system.,3. Left coronary:  Left main, left anterior descending and circumflex systems showed no significant disease.,CONCLUSIONS,1. Normal left ventricular systolic function.,2. Insignificant coronary disease.,PLAN: , Based upon this study, medical therapy is warranted.  Six-French Angio-Seal was used in the groin.
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DESCRIPTION: Left heart catheterization with ventriculography, selective coronary angiography.  Standard Judkins, right groin.  Catheters used were a 6 French pigtail, 6 French JL4, 6 French JR4.

surgery, standard judkins, french pigtail, selective coronary angiography, heart catheterization, ventriculography, catheterization, angiography,

The situation involves a heart catheterization procedure and addresses patients with acute coronary syndrome, which is inherently a high-stakes situation due to the severe potential outcomes related to heart conditions, including myocardial infarction, stroke, or death. However, the procedure was completed without complications, and the results indicated no significant coronary disease, reducing the immediate risk level. The patient was informed about the risks, and their condition following the procedure suggests that ongoing high-stakes decisions might be mitigated with medical therapy. Overall, while the stakes are inherently high because of the procedure and condition involved, the specific circumstances presented reduced the risk level somewhat.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Stress Test Dobutamine

INDICATIONS:,  Atrial fibrillation, coronary disease.,STRESS TECHNIQUE:, The patient was infused with dobutamine to a maximum heart rate of 142.  ECG exhibits atrial fibrillation.,IMAGE TECHNIQUE:,  The patient was injected with 5.2 millicuries of thallous chloride and subsequently imaged on the gated tomographic SPECT system.,IMAGE ANALYSIS:,  It should be noted that the images are limited slightly by the patient's obesity with a weight of 263 pounds.  There is normal LV myocardial perfusion.  The LV systolic ejection fraction is normal at 65%.  There is normal global and regional wall motion.,CONCLUSIONS:,1.  Basic rhythm of atrial fibrillation with no change during dobutamine stress, maximum heart rate of 142.,2.  Normal LV myocardial perfusion.,3.  Normal LV systolic ejection fraction of 65%.,4.  Normal global and regional wall motion.
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DESCRIPTION: Dobutamine stress test for atrial fibrillation.

cardiovascular / pulmonary, dobutamine stress test, atrial fibrillation, lv myocardial perfusion, lv systolic ejection fraction, coronary disease, dobutamine, ejection fraction, gated tomographic spect system, thallous chloride, wall motion, stress, fibrillation, atrial

The situation described involves conducting a dobutamine stress test on a patient with atrial fibrillation to assess cardiovascular conditions. Although these tests are important for diagnosing and managing heart conditions, the given results indicate normal myocardial perfusion and ejection fraction. The test did not reveal new or acute issues beyond the known atrial fibrillation. While the procedure requires careful monitoring, especially given the patient's weight and existing condition, the outcome is stable and does not indicate a high-risk medical scenario. Therefore, the stakes, in this case, are moderate as the test results were normal, indicating no immediate danger or life-threatening condition.


Medical Specialty: Surgery
Sample Name: Circumcision - Newborn

PROCEDURE: , Newborn circumcision.,INDICATIONS: , Parental preference.,ANESTHESIA:,  Dorsal penile nerve block.,DESCRIPTION OF PROCEDURE:,  The baby was prepared and draped in a sterile manner.  Lidocaine 1% 4 mL without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock.  The penile foreskin was removed using a XXX Gomco.  Hemostasis was achieved with minimal blood loss.  There was no sign of infection.  The baby tolerated the procedure well.  Vaseline was applied to the penis, and the baby was diapered by nursing staff.
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DESCRIPTION: Newborn circumcision.  The penile foreskin was removed using Gomco.

surgery, nerve block, newborn circumcision, foreskin, gomco, penis, circumcision, newborn, penile

The procedure described is a newborn circumcision, which is a routine and common surgical procedure with low risk when performed in a controlled medical environment. The situation is not considered high-stakes as it is a standard procedure with established protocols and low rates of complications when performed correctly.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Acne - SOAP

SUBJECTIVE:,  The patient is a 49-year-old white female, established patient to Dermatology, last seen in the office on 08/10/2004.  She comes in today for reevaluation of her acne plus she has had what she calls a rash for the past two months now on her chest, stomach, neck, and back.  On examination, this is a flaring of her acne with small folliculitis lesions.  The patient has been taking amoxicillin 500 mg b.i.d. and using Tazorac cream 0.1, and her face is doing well, but she has been out of her medicine now for three days also.  She has also been getting photofacials at Healing Waters and was wondering about what we could offer as far as cosmetic procedures and skin care products, etc.  The patient is married.  She is a secretary.,FAMILY, SOCIAL, AND ALLERGY HISTORY:,  She has hay fever, eczema, sinus, and hives.  She has no melanoma or skin cancers or psoriasis.  Her mother had oral cancer.  The patient is a nonsmoker.  No blood tests.  Had some sunburn in the past.  She is on benzoyl peroxide and Daypro.,CURRENT MEDICATIONS:,  Lexapro, Effexor, Ditropan, aspirin, vitamins.,PHYSICAL EXAMINATION:,  The patient is well developed, appears stated age.  Overall health is good.  She has a couple of acne lesions, one on her face and neck but there are a lot of small folliculitis-like lesions on her abdomen, chest, and back.,IMPRESSION:,  Acne with folliculitis.,TREATMENT:,1.  Discussed condition and treatment with the patient.,2.  Continue the amoxicillin 500 mg two at bedtime.,3.  Add Septra DS every morning with extra water.,4.  Continue the Tazorac cream 0.1; it is okay to use on back and chest also.,5.  Referred to ABC clinic for an aesthetic consult.  Return in two months for followup evaluation of her acne.
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DESCRIPTION: Acne with folliculitis.

Acne with folliculitis.

soap / chart / progress notes, acne with folliculitis, tazorac cream, acne, dermatology, tazorac, cream, folliculitis,

The situation involves a medical evaluation of a patient with acne and folliculitis, which are generally non-life-threatening skin conditions, especially in the context provided. The patient is stable and the treatment plan is aimed at improving dermatological conditions primarily for comfort and cosmetic reasons. It doesn't involve emergency care or critical health risks.


Medical Specialty: Neurology
Sample Name: Consult - Facial Twitching

REASON FOR REFERRAL: , Facial twitching.,HISTORY OF PRESENT ILLNESS: , The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face.  She reports she is still having right posterior head pressure like sensations approximately one time per week.  These still are characterized by a tingling, pressure like sensation that often has a feeling as though water is running down on her hair.  This has also decreased in frequency occurring approximately one time per week and seems to respond to over-the-counter analgesics such as Aleve.  Lastly during conversation today, she brought again the problem of daydreaming at work and noted that she occasionally falls asleep when sitting in non-stimulating environments or in front of the television.  She states that she feels fatigued all the time and does not get good sleep.  She describes it as insomnia, but upon questioning she works from 4 till mid night and then gets home and cannot go to sleep for approximately two hours and wakes up reliably by 9.00 a.m. each morning and sleeps no more than five to six hours ever, but usually five hours.  Her sleep is relatively uninterrupted except for the need to get up and go to the bathroom.  She thinks she may snore, but she is not sure.  She does not recall any events of awakening and gasping for breath.,PAST MEDICAL HISTORY: , Please see my earlier notes in chart.,FAMILY HISTORY:  ,Please see my earlier notes in chart.,SOCIAL HISTORY: , Please see my earlier notes in charts.,REVIEW OF SYSTEMS:  ,Today, she mainly endorses the tingling sensation in the right posterior head often bilateral as well as a diagnosis of depression and persistent somewhat sad mood, poor sleep, and possible snoring; otherwise, the 10-system review is negative.,PHYSICAL EXAMINATION:,General Examination:  Unremarkable mainly for mild-to-moderate obesity with a weight of 258 pounds.  Otherwise, general examination is unremarkable.,NEUROLOGICAL EXAMINATION:  ,As before is nonfocal.  Please see note in chart for details.,PERTINENT FINDINGS: , Since the last evaluation, she has had an MRI performed, which was largely unremarkable except for a 1.2 cm lobular T2 hyperintense abnormality at the right clivus and petrous carotid canal, which does not enhance.  The nature of this lesion is unclear.  Certainly, this abnormality would not explain her left facial twitching and is unlikely to be involved with the right posterior sensory changes she experiences.,LABS: , She was supposed to have Lyme titers and thyroid tests as well as fasting glucose, which were not done; however, in light of her improvement these may not need to be performed at this time.,IMPRESSION:,1.  Left facial twitching-appears to be improving.  Most likely, this is a peripheral nerve injury related to her abscess as previously described.  In light of her negative MRI and clinical improvement, we discussed options and elected to just observe for now.,2.  Posterior pressure like headache, also appears to be improving.  The etiology is unclear, but as it responds nicely to nonsteroidal antiinflammatories and is decreasing, no further evaluation is needed.,3.  Probable circadian sleep disorder related to her nighttime work schedule and awakening at 9.00 a.m. with insufficient sleep.  There is also the possibility of consistent obstructive sleep apnea and if symptoms worsen then we should consider doing a sleep study.  For the time being, sleep hygiene measures were discussed with the patient including trying to sleep later at least till 10.00 a.m. or 10.30 to get a full-night sleep.  She is on vacation next week and is going to try to see if this will help.  We also discussed as before weight loss and exercise, which could be helpful.,4.  Right clivus and petrous lesion of unknown etiology.  We will repeat the MRI at four months to see for interval change.,5.  The patient voiced understanding of these plans and will be following up with me in five months.
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DESCRIPTION: The patient had several episodes where she felt like her face was going to twitch, which she could suppress it with grimacing movements of her mouth and face.

neurology, grimacing, headache, clivus and petrous, facial twitching, sleep, facial, twitching,

The patient's symptoms, including facial twitching, posterior pressure-like headaches, sleep issues, and the presence of a lesion in the right clivus and petrous region, are not uncommon in neurological scenarios. The symptoms have shown improvement and are being managed conservatively with regular follow-ups, sleep hygiene advice, and a planned repeat MRI. The situation doesn't involve immediate life-threatening risk, as there is no indication of rapid deterioration or severe disease. It largely involves careful monitoring and symptom management.