Medical Specialty: Dentistry
Sample Name: Jaw Pain - ER Visit

CHIEF COMPLAINT: , Jaw pain.,HISTORY OF PRESENT ILLNESS:  ,This is a 58-year-old male who started out having toothache in the left lower side of the mouth that is now radiating into his jaw and towards his left ear.  Triage nurse reported that he does not believe it is his tooth because he has regular dental appointments, but has not seen a dentist since this new toothache began.  The patient denies any facial swelling.  No headache.  No swelling to the throat.  No sore throat.  No difficulty swallowing liquids or solids.  No neck pain.  No lymph node swelling.  The patient denies any fever or chills.  Denies any other problems or complaints.,REVIEW OF SYSTEMS:,  CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  HEENT:  No headache.  No neck pain.  No eye pain or vision change.  No rhinorrhea.  No sinus congestion, pressure, or pain.  No sore throat.  No throat swelling.  The patient does have the toothache on the left lower side that radiates towards his left ear as previously described.  The patient does not have ear pain or hearing change.  No pressure in the ear.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath.  GASTROINTESTINAL:  No nausea or vomiting.  No abdominal pain.  MUSCULOSKELETAL:  No back pain.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No speech change.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY:,  None.,CURRENT MEDICATIONS: , None.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient smokes marijuana.  The patient does not smoke cigarettes.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 98.2 oral, blood pressure is 168/84, pulse is 87, respirations 16, and oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed.  The patient appears to be healthy.  The patient is calm, comfortable in no acute distress, looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear cornea and conjunctivae bilaterally.  Nose, normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  Ears are normal without any sign of infection.  No erythema or swelling of the canals.  Tympanic membranes are intact and normal without any erythema, bulging, air fluid levels, or bubbles behind it.  MOUTH:  The patient has a dental fracture at tooth #18.  The patient states that the fracture is a couple of months old.  The patient does not have any obvious dental caries.  The gums are normal without any erythema, swelling, or evidence of infection.  There is no fluctuance or suggestion of abscess.  There is slight tenderness of the tooth #18.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion, or swelling.  Mucous membranes are moist.  Floor of the mouth is normal without any tenderness or swelling.  No suggestion of abscess.  There is no pre or post auricular lymphadenopathy either.  NECK:  Supple.  Nontender.  Full range of motion.  No meningismus.  No cervical lymphadenopathy.  No JVD.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to the back, arms, or legs.  The patient has normal use of the extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  No evidence of clinical intoxification.  HEMATOLOGIC/LYMPHATIC:  No lymphadenitis is palpated.,DIAGNOSES:,1.  ACUTE LEFT JAW PAIN.,2.  #18 DENTAL FRACTURE, WHICH IS AN ELLIS TYPE II FRACTURE.,3.  ELEVATED BLOOD PRESSURE.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  Home.,PLAN: , We will have the patient follow up with his dentist Dr. X in three to five days for reevaluation.  The patient was encouraged to take Motrin 400 mg q.6h. as needed for pain.  The patient was given prescription for Vicodin for any breakthrough or uncontrolled pain.  He was given precautions for drowsiness and driving with the use of this medication.  The patient was also given a prescription for pen V.  The patient was given discharge instructions on toothache and asked to return to emergency room should he have any worsening of his condition, develop any other problems or symptoms of concern.
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DESCRIPTION: Patient started out having toothache, now radiating into his jaw and towards his left ear.  Ellis type II dental fracture.

dentistry, jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema,

The case involves a 58-year-old male presenting with jaw pain stemming from a toothache. The pain radiates into the jaw and towards the ear, and a dental fracture (Ellis type II) is identified. While the symptoms are uncomfortable and possibly painful for the patient, there are no immediate life-threatening signs such as swelling, fever, difficulty swallowing, or breathing issues. The patient's vital signs are mostly normal, with slightly elevated blood pressure, but no other systemic issues are noted. The patient is discharged with pain management instructions and a follow-up with a dentist. Given the lack of severe or life-threatening symptoms, the situation does not appear to be high-stakes on a medical emergency scale.


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

Medical Specialty: Gastroenterology
Sample Name: Exploratory Laparotomy & Colon Resection

PREOPERATIVE DIAGNOSIS: , Colovesical fistula.,POSTOPERATIVE DIAGNOSES:,1.  Colovesical fistula.,2.  Intraperitoneal abscess.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Low anterior colon resection.,3.  Flexible colonoscopy.,4.  Transverse loop colostomy and JP placement.,ANESTHESIA: , General.,HISTORY:  ,This 74-year-old female who had a recent hip fracture and the patient was in rehab when she started having some stool coming out of the urethra.  The patient had retrograde cystogram, which revealed colovesical fistula.  Recommendation for a surgery was made.  The patient was explained the risks and benefits as well as the two sons and the daughter.  They understood that the patient can even die from this procedure.  All the three procedures were explained, without a colostomy, with Hartmann's colostomy, and with a transverse loop colostomy, and out of the three procedures, the patient's requested to have the loop colostomy and stated that the Hartmann's colostomy leaving the anastomosis with the risk of leaking.,PROCEDURE DETAILS: , The patient was taken to the operating room, prepped and draped in the sterile fashion and was given general anesthetic.  An incision was performed in the midline below the umbilicus to the pubis with a #10 blade Bard Parker.  Electrocautery was used for hemostasis down to the fascia.  The fascia was grasped with Ochsner's and then immediately the peritoneum was entered and the incision was carried cephalad and caudad with electrocautery.,Once within the peritoneum, adhesiolysis was performed to separate the small bowel from the attachment of the anterior abdominal wall.  At this point, immediately a small bowel was retracted cephalad.  The patient was taken to a slightly Trendelenburg position and the descending colon was seen.  The white line of Toldt was opened all the way down to the area of inflammation.  At this point, meticulous dissection was carried to separate the small bowel from the attachment to the abscess.  When the small bowel was completely freed of  abscess, bulk of the bladder was seen anteriorly to the uterus.  The abscess was cultured and sent it back to Bacteriology Department and immediately the opening into the bladder was visualized.  At this point, the entire sigmoid colon was separated posteriorly as well as laterally and it was all the way down to sigmoid down to the rectum.  At this point, decision to place a moist towel and retract old intestine superiorly as well as to place first self-retaining retractor in the abdominal cavity with a bladder blade was placed.  Immediately, a GIA was fired right across the descending colon and sigmoid colon junction and then with peons within the mesentery were placed all the way down to the rectosigmoid junction where a TA-55 balloon Roticulator was fired.  The specimen was cut with #10 blade Bard-Parker and sent it to Pathology.  Immediately copious amount of irrigation was used and the staple line in the descending colon was brought with Allis.  A pursestring device was fired.  The staple line was cut.  The dilators were used using #25 and #29, then _________ #29 EEA was placed and the suture was tied.  At this point, attention was directed down to the rectal stump where dilators #25 and #29 were passed from the anus into the rectum and then the #29 Ethicon GIA was introduced.  The spike came posteriorly through the staple line to avoid the inflammatory process anteriorly that was present in the area of the cul-de-sac as well as the uterine was present in this patient.  ,Immediately, the EEA was connected with a mushroom.  It was tied, fired, and a Doyen was placed above the anastomosis approximately four inches.  Fluid was placed within the _________ and immediately a colonoscope was introduced from the patient's anus insufflating air.  No air was seen evolving from the staple line.  All fluid was removed and pictures of the staple line were taken.  The scope was removed at this point.  The case was passed to Dr. X for repair of the vesicle fistula.  Dr. X did repair down the perforation of the bladder that was communicating with an abscess secondary to the perforated diverticulitis and the colon.  After this was performed, copious amount of irrigation was used again.  More lysis of adhesions were performed and decision to make a loop transverse colostomy was made to protect the anastomosis in a phase of a severe inflammatory process in the pelvis in the infected area.  The incision was performed in the right upper quadrant.,This incision was performed with cutting in the cautery, down into the fascia splitting the muscle and then the Penrose was passed under transverse colon, and was grasped on pulling the transverse colon at the level of the skin.  The wire was passed under the transverse colon.  It was left in place.  Moderate irrigation was used in the peritoneal cavity and in the right lower quadrant, a JP was placed in the pelvis posteriorly to the abscess cavity that was down on the pelvis.  At this point, immediately, yellow fluid was removed from the peritoneal cavity and the abdomen was closed with cephalad to caudad and caudad to cephalad with a loop PDS suture and then tied.  Electrocautery for hemostasis and the subcutaneous tissue.  Copious amount of irrigation was used.  The skin was approximated with staples.  At this point, immediately, the wound was covered with a moist towel and decision to mature the loop colostomy was made.  The colostomy was opened longitudinally and then matured with interrupted #3-0 Vicryl suture through the skin edge.  One it was completely matured, immediately the index finger was probed proximally and distally and both loops were completely opened.  As previously mentioned, the Penrose was removed and the Bard was secured with a #3-0 nylon suture.  The JP was secured with #3-0 nylon suture as well.  At this point, dressings were applied.  The patient tolerated the procedure well.  The stent from the left ureter was removed and the Foley was left in place.  The patient did tolerate the procedure well and will be followed up during the hospitalization.
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DESCRIPTION: Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement.  Colovesical fistula and intraperitoneal abscess.

gastroenterology, intraperitoneal abscess, colovesical fistula, low anterior colon resection, flexible colonoscopy, transverse loop colostomy, jp placement, exploratory laparotomy, colon resection, descending colon, transverse colon, colostomy, colon, laparotomy, aparotomy, fistula

This medical situation is high-stakes due to the complexity and severity of the conditions being treated. The patient is undergoing major surgery with significant risks, including the possibility of death, as indicated in the preoperative discussions. The procedure involves multiple complex surgical interventions: exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and creation of a colostomy, all in the context of a colovesical fistula and intraperitoneal abscess. The patient's advanced age and recent medical history, including a hip fracture, add to the complexity and risk. Moreover, the need for precise intraoperative decision-making, coordination among multiple surgical steps, and management of potential complications (such as infection and leakage) further elevate the stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Neurology
Sample Name: MRI T-Spine - Spinal Mets

CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:,  T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation.
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DESCRIPTION: MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.

The case involves a serious neurological condition where a patient presents with progressive motor and sensory deficits due to spinal cord compression from metastatic adenocarcinoma. This situation is high-stakes because it involves urgent medical intervention to prevent potentially irreversible neurological damage. The immediate actions include managing any underlying malignancy, relieving spinal cord compression, and addressing the potential life-threatening complications such as paralysis and bladder dysfunction. Furthermore, this scenario ultimately concerns the patient's prognosis, which is poor despite intervention. These factors collectively make it a high-stakes medical situation.


Medical Specialty: Urology
Sample Name: Circumcision - Child

PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion.  The area of the penis and scrotum were prepared with povidone iodine solution.  The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  A dorsal slit was made, and the prepuce was dissected away from the glans penis.  A ** Gomco clamp was properly placed for 5 minutes.  During this time, the foreskin was sharply excised using a #10 blade.  With removal of the clamp, there was a good cosmetic outcome and no bleeding.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.
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DESCRIPTION: Circumcision.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.

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

The procedure described is a circumcision on a child, which is a common and typically low-risk surgical procedure. Although any surgery can carry some risk, circumcision in infants is generally straightforward with a low likelihood of complications when performed by a trained professional. There is no indication of complications during or after the procedure in the provided description, and the child tolerated it well. Additionally, circumcision does not involve life-saving or critical health interventions, so it is considered low-stakes in terms of urgency and severity.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Complete Physical - Female

SUBJECTIVE:,  This is an 18-year-old white female who presents for complete physical, Pap, and breast exam and to have paperwork filled out for college.  She denies any problems at this time.  Her last Pap smear was 06/25/2003 and was normal.  She is requesting to switch from Ortho-Tri-Cyclen to Seasonale at this time.  We did discuss that she may have increased episodes of breakthrough bleeding.,PAST MEDICAL HISTORY:,  Fever blisters and allergic rhinitis.,MEDICATIONS: , Allegra 180 mg q.d., trazodone 50 mg p.r.n. q.h.s., and Ortho-Tri-Cyclen.,ALLERGIES:,  None.,SOCIAL HISTORY:,  Denies tobacco or drug use, rare alcohol use.  She is sexually active and has had one partner.,FAMILY HISTORY:  ,Positive for rheumatoid arthritis.,REVIEW OF SYSTEMS:,  HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional, and psychiatric all negative except for HPI.,OBJECTIVE:,Vital Signs:  Height 5 feet 6 inches.  Weight 153 pounds.  Blood pressure 106/72.  Pulse 68.  Respirations 12.  Temperature 97.5.  Last menstrual period 05/30/2004.,General:  She is a well-developed, well-nourished white female in no acute distress.,HEENT:  Tympanic membranes unremarkable.  Oropharynx nonerythematous.  Pupils equal, round, and reactive to light.  Extraocular muscles intact.,Neck:  Supple.  No lymphadenopathy and no thyromegaly.,Chest:  Clear to auscultation bilaterally.,CV:  Regular rate and rhythm without murmur.,Abdomen:  Positive bowel sounds.  Soft and nontender.  No hepatosplenomegaly.,Breasts:  No nipple discharge.  No lumps or masses palpated.  No dimpling of the skin.  No axillary lymph nodes palpated.  Self-breast exam discussed and encouraged.,Pelvic:  Normal female genitalia.  Normal vaginal rugation.  No cervical lesions.  No cervical motion tenderness.  No adnexal tenderness or masses palpated.,Extremities:  No cyanosis, clubbing, or edema.,Neurologic:  2+/4 DTRs in all extremities.  5/5 motor strength in all extremities.  Negative Romberg.,Musculoskeletal:  No abnormalities or laxity noted in any of her joints.,ASSESSMENT/PLAN:,1.  Complete physical, Pap, and breast exam completed.,2.  School physical form completed and returned to the patient.,3.  Hepatitis B second injection will be given today.,4.  Contraceptive surveillance.  We will put patient to Seasonale to start at the end of this cycle a pill.,5.  Allergic rhinitis.  Prescription was given for Allegra 180 mg q.d.  #30 carrying refills for her to take with her school Cowley County Community College.,6.  Insomnia.  Prescription for trazodone 50 mg p.r.n. q.h.s. was given for her to take with her to school.  She will follow up as needed.
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DESCRIPTION: An 18-year-old white female who presents for complete physical, Pap, and breast exam.

The situation involves a routine medical check-up for an 18-year-old female, including a complete physical, breast exam, Pap smear, and switching contraceptives. It also includes advice and prescription renewals. Although it deals with health and preventative care, it does not present any acute health issues or emergencies. It's a standard and low-stakes situation typical in outpatient care for health maintenance and disease prevention.


Medical Specialty: Radiology
Sample Name: Full-Field Digital Mammogram (FFDM) - 1

EXAM: , Digital screening mammogram.,HISTORY:,  51-year-old female presents for screening mammography.  Patient denies personal history of breast cancer.  Breast cancer was reported in her maternal aunt.,TECHNIQUE:,  Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy.  Comparison is made with the previous performed on mm/dd/yy. iCAD Second Look proprietary software was utilized.,FINDINGS:  ,The breasts demonstrate a mixture of adipose and fibroglandular elements.  Composition appears similar.  Multiple tiny punctate benign-appearing calcifications are visualized bilaterally.  No dominant mass, areas of architecture distortion, or malignant-type calcifications are seen.  Skin overlying both breasts is unremarkable.,IMPRESSION: , Stable and benign mammographic findings.  Continued yearly mammographic screening is recommended.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized.
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DESCRIPTION: Bilateral Screening Mammogram Full-Field Digital Mammography (FFDM) (Benign Findings)

radiology, mediolateral, craniocaudal, fibroglandular, bilateral screening mammogram, breast cancer, screening mammogram, mammographic, mammogram, breasts, screening, mammography

The scenario describes a routine mammogram screening with benign findings and a recommended follow-up for continued yearly screening. While monitoring for breast health is important, the findings are stable and benign, which indicates that there is no immediate health threat based on this information alone. Given the absence of suspicious findings and the recommendation simply to continue regular screenings, this situation is not high-stakes in the immediate sense. However, it's important to recognize the broader significance of continued screening in monitoring health, but the urgency in this case specifically is low.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Double Lumen Port Inserstion

PREOPERATIVE DIAGNOSIS:,  Metastatic glossal carcinoma, needing chemotherapy and a port.,POSTOPERATIVE DIAGNOSIS: , Metastatic glossal carcinoma, needing chemotherapy and a port.,PROCEDURES,1.  Open exploration of the left subclavian/axillary vein.,2.  Insertion of a double lumen port through the left femoral vein, radiological guidance.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was electively taken to the operating room, where he underwent a general anesthetic through his tracheostomy.  The left deltopectoral and cervical areas were prepped and draped in the usual fashion.  Local anesthetic was infiltrated in the area.  There was some evidence that surgical procedure had happened in the area nearby and also there was collateral venous circulation under the skin, which made us suspicious that may be __________, but at any rate I tried to cannulate it subcutaneously and I was unsuccessful.  Therefore, I proceeded to make an incision and was able to isolate the vein, which would look very sclerotic.  I tried to cannulate it, but I could not advance the wire.,At that moment, I decided that there was no way we are going to put a port though that area.  I packed the incision and we prepped and redraped the patient including both groins.  Local anesthetic was infiltrated and then the left femoral vein was percutaneously cannulated without any difficulty.  The introducer was placed and then a wire and then the catheter of the double lumen port, which had been trimmed to position it near the heart.  It was done with radiological guidance.  Again, I was able to position the catheter in the junction of inferior vena cava and right atrium.  The catheter was looked upwards and the double lumen port was inserted subcutaneously towards the iliac area.  The port had been aspirated satisfactorily and irrigated with heparin solution.  The drain incision was closed in layers including subcuticular suture with Monocryl.  Then, we went up to the left shoulder and closed that incision in layers.  Dressings were applied.,The patient tolerated the procedure well and was sent back to recovery room in satisfactory condition.
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DESCRIPTION: Insertion of a double lumen port through the left femoral vein, radiological guidance.  Open exploration of the left subclavian and axillary vein.  Metastatic glossal carcinoma, needing chemotherapy and a port.

cardiovascular / pulmonary, axillary, vein, subclavian, double lumen port, femoral vein, radiological guidance, glossal carcinoma, port, inserstion, femoral, radiological, metastatic, carcinoma, chemotherapy, anesthetic, catheter,

The procedure described involves the insertion of a double lumen port, which is necessary for administering chemotherapy to a patient with metastatic glossal carcinoma. This is a high-stakes situation due to several factors: it involves a patient with a serious and life-threatening condition (metastatic cancer), requires surgical intervention, and the insertion of a port is critical for ongoing chemotherapy treatment. However, it is a routine procedure for such medical needs, so while it is important, it does not involve emergency intervention. The complexity and the patient's underlying condition elevate the stakes but not to the maximum extent.


Medical Specialty: Office Notes
Sample Name: Normal Physical Exam Template - 4

GENERAL:  ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX.  Height XXX, weight XXX.,HEAD: , Normocephalic.  Negative lesions, negative masses.,EYES: , PERLA, EOMI.  Sclerae clear.  Negative icterus, negative conjunctivitis.,ENT:,  Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates.  Negative ear obstructions, negative exudates.  Negative inflammation in external auditory canals.  Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers.  No tattoos.,NECK:,  Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:,  Regular rate and rhythm.  Negative rubs, negative gallops, negative murmurs.,LUNGS:,  Clear to auscultation.  Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds.  Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing.  Pulses adequate bilaterally.,MUSCULOSKELETAL:,  Negative muscle atrophy, negative masses.  Strength adequate bilaterally.  Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact.  Negative gait disturbance.  Balance and coordination intact.  Negative Romberg, negative Babinski.  DTRs equal bilaterally.,GENITOURINARY:  ,Deferred.,
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DESCRIPTION: Normal physical exam template.  Normocephalic.  Negative lesions, negative masses.

The content provided is a normal physical exam template used for routine documentation of a patient's health status during a check-up. Such a template includes various vital signs and conditions of different body systems that are standardly recorded in medical assessments. The use of 'negative' throughout suggests no abnormalities. The template is a part of non-emergency medical documentation indicating general procedure rather than immediate medical decision-making situations. Therefore, it denotes routine and non-urgent monitoring, making the situation low-stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Tube Insertion in ER

PREOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.  This patient is obtunded, intubated, and septic.  This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion.  The site of insertion was anesthetized with 1% Xylocaine, and an incision was made.  Blunt dissection was carried out 2 intercostal spaces above the initial incision site.  The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly.  The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  10 mL,COMPLICATIONS:,  None.,SPONGE COUNT: , Correct x2.
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DESCRIPTION: Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.

cardiovascular / pulmonary, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion,

The situation involves an emergency medical procedure on a patient with serious conditions such as a spontaneous pneumothorax, respiratory failure, and sepsis. Chest tube insertion is critical and urgent as it addresses life-threatening issues like pneumothorax and respiratory failure. The patient's obtunded state and the lack of ability to obtain informed consent further underscore the high-stakes nature of this scenario. Successful management is crucial to stabilize the patient, implying significant consequences if not executed properly.


Medical Specialty: Surgery
Sample Name: Radical Hysterectomy

PREOPERATIVE DIAGNOSIS:,  Cervical adenocarcinoma, stage I.,POSTOPERATIVE DIAGNOSIS: , Cervical adenocarcinoma, stage I.,OPERATION PERFORMED:,  Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Uterus with attached parametrium and upper vagina, right and left pelvic and obturator lymph nodes.,INDICATIONS FOR PROCEDURE:,  The patient recently underwent a cone biopsy at which time invasive adenocarcinoma of the cervix was noted.  She was advised regarding treatment options including radical hysterectomy versus radiation and the former was recommended. ,FINDINGS: , During the examination under anesthesia, the cervix was noted to be healing well from recent cone biopsy and no nodularity was noted in the supporting ligaments.  During the exploratory laparotomy, there was no evidence of disease extension into the broad ligament or bladder flap.  There was no evidence of intraperitoneal spread or lymphadenopathy.  ,OPERATIVE PROCEDURE:  ,The patient was brought to the Operating Room with an IV in place.  Anesthetic was administered after which she was examined under anesthesia.  The vagina was then prepped and a Foley catheter was placed.  She was prepped and draped.  A Pfannenstiel incision was made three centimeters above the symphysis pubis.  The peritoneum was entered and the abdomen was explored with findings as noted.  The Bookwalter retractor was placed, and bowel was packed.  Clamps were placed on the broad ligament for traction.  The retroperitoneum was opened by incising lateral and parallel to the infundibulopelvic ligaments.  The round ligaments were isolated, divided and ligated.  The peritoneum overlying the vesicouterine fold was incised, and the bladder was mobilized using sharp dissection.  The pararectal and paravesical spaces were opened, and the broad ligament was palpated with no evidence of suspicious findings or disease extension.  The utero-ovarian ligaments were then isolated, divided and doubly ligated.  Tubes and ovaries were mobilized.  The ureters were dissected free from the medial leaf of the peritoneum.  When the crossover of the uterine artery was reached, and the artery was isolated at its origin, divided and ligated.  The uterine artery pedicle was dissected anteriorly over the ureter.  The ureter was tunneled through the broad ligament using right angle clamps for tunneling after which each pedicle was divided and ligated.  This was continued until the insertion point of the ureter into the bladder trigone.  The peritoneum across the cul-de-sac was divided, and the rectovaginal space was opened.  Clamps were placed on the uterosacral ligaments at their point of origin.  Tissues were divided and suture ligated.  Clamps were placed on the paravaginal tissues, which were then divided, and suture ligated.  The vagina was then clamped and divided at the junction between the middle and upper third.  The vaginal vault was closed with interrupted figure-of-eight stitches.  Excellent hemostasis was noted.,Retractors were repositioned in the retroperitoneum for the lymphadenectomy.  The borders of dissection included the bifurcation of the common iliac artery superiorly, the crossover of the deep circumflex iliac vein over the external iliac artery inferiorly, the psoas muscle laterally and the anterior division of the hypogastric artery medially.  The obturator nerves were carefully isolated and preserved bilaterally and served as the posterior border of dissection.  Ligaclips were applied where necessary.  After removal of the lymph node specimens, the pelvis was irrigated.  The ovaries were transposed above the pelvic brim using running stitches.  Packs and retractors were removed, and peritoneum was closed with a running stitch.  Subcutaneous tissues were irrigated, and fascia was closed with a running mass stitch using delayed absorbable suture.  Subcutaneous adipose was irrigated, and Scarpa's fascia was closed with a running stitch.  Skin was closed with a running subcuticular stitch.  Final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was awakened from the anesthetic and taken to the Post Anesthesia Care Unit in stable condition.
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DESCRIPTION: Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.

surgery, cervical adenocarcinoma, radical hysterectomy, exploratory laparotomy, bilateral ovarian transposition, lymphadenectomy, parametrium, cervix, pelvic and obturator lymphadenectomy, pelvic and obturator, obturator lymphadenectomy, laparotomy, ovarian, adenocarcinoma, radical, hysterectomy, pelvic, obturator, peritoneum, nodes, ligaments

The procedure described is a radical hysterectomy, which is a significant surgical intervention for cervical cancer. This type of surgery is performed when cervical cancer is diagnosed and involves removing the uterus, surrounding tissues, and often lymph nodes to ensure the cancer hasn't spread. Such a procedure carries potential risks and complications, including those associated with general anesthesia, major surgery, and potential impacts on fertility and hormonal balance due to ovarian transposition. The stakes are high because it involves treating a potentially life-threatening condition (cervical cancer), requires meticulous surgical technique to prevent complications, and has long-term health implications for the patient.


Medical Specialty: Radiology
Sample Name: CT-Guided Needle Placement Biopsy

EXAM: , CT of abdomen with and without contrast.  CT-guided needle placement biopsy.,HISTORY: , Left renal mass.,TECHNIQUE: , Pre and postcontrast enhanced images were acquired through the kidneys.,FINDINGS: , Comparison made to the prior MRI.  There is re-demonstration of multiple bilateral cystic renal lesions.  Several of these demonstrate high attenuation in the precontrast phase of the exam suggesting that they are hemorrhagic cysts.  There was however one cyst seen in the lower pole of the left kidney, which demonstrated apparent enhancement from 30 to 70 Hounsfield units post contrast administration.  This measured approximately 1.4 x 1.3 cm to the exophytic half of the lower pole.  No other enhancing renal masses were seen.  The visualized liver, spleen, pancreas, and adrenal glands were unremarkable.  There are changes of cholecystectomy.  Mild prominence of the common bile duct is likely secondary to cholecystectomy.  There is no abdominal lymphadenopathy, masses, fluid collection, or ascites.,Lung bases are clear.  No acute bony pathology was noted.,IMPRESSION: , Solitary apparently enhancing left renal mass in the lower pole as described.  Renal cell carcinoma cannot be excluded.,CT-GUIDED NEEDLE BIOPSY, LEFT KIDNEY MASS: , Following discussion of risks, benefits, and alternatives, the patient wished to proceed with CT-guided biopsy of left renal lesion.  The patient was placed in the decubitus position.  The region overlying the left renal mass of note was marked.  Area was prepped and draped in usual sterile fashion.  Local anesthesia was achieved with approximately 8 mL of 1% lidocaine with bicarbonate.  The Versed and fentanyl were given to achieve conscious sedation.  Utilizing an 18 x 15 gauge coaxial system, 3 core biopsies were obtained through the mass in question, and sent to pathology for analysis.  Following procedure, scans through the region demonstrate a small subcutaneous hematoma in the region of the superficial anesthesia.  No perinephric fluid/hematoma was identified.  The patient tolerated the procedure without immediate complications.,IMPRESSION: , Three core biopsies through the region of the left renal tumor as described.
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DESCRIPTION: CT of abdomen with and without contrast.  CT-guided needle placement biopsy.

radiology, ct, ct-guided, ct-guided biopsy, hounsfield units, mri, abdomen, biopsy, cholecystectomy, contrast, contrast administration, decubitus position, images, needle, postcontrast, renal lesions, renal mass, renal tumor, with and without, ct guided needle placement, ct of abdomen, needle placement, lower pole, ct guided, renal

The CT-guided needle placement biopsy for a suspected renal mass involves significant considerations due to the potential for diagnosing a serious condition like renal cell carcinoma. The findings and biopsy results could have significant implications for the patient's treatment path, including potential surgical intervention or other treatments. The procedure's invasive nature, involving sedation and risk of complications, also adds to the stakes. The decision-making process involved, along with the implications of the biopsy results, suggests that this is quite high-stakes.


Medical Specialty: Neurosurgery
Sample Name: Laminotomy & Microdissection

PREOPERATIVE DIAGNOSES:  ,1.  Fractured and retained lumbar subarachnoid spinal catheter.,2.  Pseudotumor cerebri (benign intracranial hypertension).,PROCEDURES:  ,1.  L1 laminotomy.,2.  Microdissection.,3.  Retrieval of foreign body (retained lumbar spinal catheter).,4.  Attempted insertion of new external lumbar drain.,5.  Fluoroscopy.,ANESTHESIA: , General.,HISTORY:  ,The patient had a lumbar subarachnoid drain placed yesterday.  All went well with the surgery.  The catheter stopped draining and on pulling back the catheter, it fractured and CT scan showed that the remaining fragment is deep to the lamina.  The patient continues to have right eye blindness and headaches, presumably from the pseudotumor cerebri.,DESCRIPTION OF PROCEDURE:  ,After induction of general anesthesia, the patient was placed prone on the operating room table resting on chest rolls.  Her face was resting in a pink foam headrest.  Extreme care was taken positioning her because she weighs 92 kg.  There was a lot of extra padding for her limbs and her limbs were positioned comfortably.  The arms were not hyperextended.  Great care was taken with positioning of the head and making sure there was no pressure on her eyes especially since she already has visual disturbance.  A Foley catheter was in place.  She received IV Cipro 400 mg because she is allergic to most antibiotics.,Fluoroscopy was used to locate the lower end of the fractured catheter and the skin was marked.  It was also marked where we would try to insert the new catheter at the L4 or L3 interspinous space.,The patient was then prepped and draped in a sterile manner.,A 7-cm incision was made over the L1 lamina.  The incision was carried down through the fascia all the way down to the spinous processes.  A self-retaining McCullough retractor was placed.  The laminae were quite deep.  The microscope was brought in and using the Midas Rex drill with the AM-8 bit and removing some of the spinous process of L1-L2 with double-action rongeurs, the laminotomy was then done using the drill and great care was taken and using a 2-mm rongeur, the last layer of lamina was removed exposing the epidural fat and dura.  The opening in the bone was 1.5 x 1.5 cm.,Occasionally, bipolar cautery was used for bleeding of epidural veins, but this cautery was kept to a minimum.,Under high magnification, the dura was opened with an 11 blade and microscissors.  At first, there was a linear incision vertically to the left of midline, and I then needed to make a horizontal incision more towards the right.  The upper aspect of the cauda equina was visualized and perhaps the lower end of the conus.  Microdissection under high magnification did not expose the catheter.  The fluoroscope was brought in 2 more times including getting a lateral view and the fluoroscope appeared to show that the catheter should be in this location.,I persisted with intensive microdissection and finally we could see the catheter deep to the nerves and I was able to pull it out with the microforceps.,The wound was irrigated with bacitracin irrigation.,At this point, I then attempted lumbar puncture by making a small incision with an 11 blade in the L4 interspinous space and then later in the L3 interspinous space and attempted to puncture the dural sac with the Tuohy needle.  Dr. Y also tried.  Despite using the fluoroscope and our best attempts, we were not able to convincingly puncture the lumbar subarachnoid space and so the attempted placement of the new lumbar catheter had to be abandoned.  It will be done at a later date.,I felt it was unsafe to place a new catheter at this existing laminotomy site because it was very high up near the conus.  The potential for complications involving her spinal cord was greater and we have already had a complication of the catheter now and I just did not think it was safe to put in this location.,Under high magnification, the dura was closed with #6-0 PDS interrupted sutures.,After the dura was closed, a piece of Gelfoam was placed over the dura.  The paraspinous muscles were closed with 0 Vicryl interrupted sutures.  The subcutaneous fascia was also closed with 0 Vicryl interrupted suture.  The subcutaneous layer was closed with #2-0 Vicryl interrupted suture and the skin with #4-0 Vicryl Rapide.  The 4-0 Vicryl Rapide sutures were also used at the lumbar puncture sites to close the skin.,The patient was then turned carefully on to her bed after sterile dressings were applied and then taken to the recovery room.  The patient tolerated procedure well.  No complications.  Sponge and needle counts correct.  Blood loss minimal, none replaced.  This procedure took 5 hours.  This case was also extremely difficult due to patient's size and the difficulty of locating the catheter deep to the cauda equina.
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DESCRIPTION: L1 laminotomy, microdissection, retrieval of foreign body (retained lumbar spinal catheter), attempted insertion of new external lumbar drain, and fluoroscopy.

neurosurgery, laminotomy, microdissection, lumbar spinal catheter, external lumbar drain, fluoroscopy, lumbar subarachnoid, spinal catheter, intracranial hypertension, vicryl interrupted sutures, lumbar, catheter,

The situation involves a complex neurosurgical procedure dealing with a fractured spinal catheter and a condition known as pseudotumor cerebri. The retrieval of a retained object near the spinal cord and decision-making about catheter placement involve high precision and inherent risks associated with neurosurgery. The stakes are high due to potential serious complications, such as damage to the spinal cord or further complications from the patient's existing condition. The procedure's complexity, the need for precise surgical interventions, and potential life-altering outcomes contribute to this being a high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Transthoracic Echocardiography

REASON FOR EXAM: , Coronary artery bypass surgery and aortic stenosis.,FINDINGS: , Transthoracic echocardiogram was performed of technically limited quality.  The left ventricle was normal in size and dimensions with normal LV function.  Ejection fraction was 50% to 55%.  Concentric hypertrophy noted with interventricular septum measuring 1.6 cm, posterior wall measuring 1.2 cm.  Left atrium is enlarged, measuring 4.42 cm.  Right-sided chambers are normal in size and dimensions.  Aortic root has normal diameter.,Mitral and tricuspid valve reveals annular calcification.  Fibrocalcific valve leaflets noted with adequate excursion.  Similar findings noted on the aortic valve as well with significantly adequate excursion of valve leaflets.  Atrial and ventricular septum are intact.  Pericardium is intact without any effusion.  No obvious intracardiac mass or thrombi noted.,Doppler study reveals mild-to-moderate mitral regurgitation.  Severe aortic stenosis with peak velocity of 2.76 with calculated ejection fraction 50% to 55% with severe aortic stenosis.  There is also mitral stenosis.,IMPRESSION:,1.  Concentric hypertrophy of the left ventricle with left ventricular function.,2.  Moderate mitral regurgitation.,3.  Severe aortic stenosis, severe.,RECOMMENDATIONS: , Transesophageal echocardiogram is clinically warranted to assess the aortic valve area.
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DESCRIPTION: Coronary artery bypass surgery and aortic stenosis.  Transthoracic echocardiogram was performed of technically limited quality.  Concentric hypertrophy of the left ventricle with left ventricular function.  Moderate mitral regurgitation.  Severe aortic stenosis, severe.

cardiovascular / pulmonary, coronary artery bypass surgery, aortic stenosis, annular calcification, tricuspid, mitral, regurgitation, severe aortic stenosis, concentric hypertrophy, mitral regurgitation, transthoracic, echocardiogram, hypertrophy, ventricular, valve, stenosis, aortic

The situation involves the cardiovascular health of a patient who has undergone coronary artery bypass surgery and has severe aortic stenosis, among other conditions. These conditions can be quite serious, potentially affecting the patient's quality of life and risk of further cardiovascular events. Therefore, clinical interpretation and treatment are high-stakes, as incorrect or delayed management could have significant implications for the patient's health.


Medical Specialty: Radiology
Sample Name: MRI Brain - Thrombus

CC: ,Motor vehicle-bicycle collision.,HX:, A 5 y/o boy admitted 10/17/92. He was struck while riding his bicycle by a motor vehicle traveling at a high rate of speed. First responders found him unconscious with left pupil 6 mm and unreactive and the right pupil 3 mm and reactive. He had bilateral decorticate posturing and was bleeding profusely from his nose and mouth. He was intubated and ventilated in the field, and then transferred to UIHC.,PMH/FHX/SHX:, unremarkable.,MEDS:, none,EXAM:, BP 127/91 HR69 RR30,MS: unconscious and intubated,Glasgow coma scale=4,CN: Pupils 6/6 fixed. Corneal reflex: trace OD, absent OS. Gag present on manipulation of endotracheal tube.,MOTOR/SENSORY: bilateral decorticate posturing to noxious stimulation (chest).,Reflexes: bilaterally.,Laceration of mid forehead exposing calvarium.,COURSE:, Emergent Brain CT scan revealed: Displaced fracture of left calvarium. Left frontoparietal intraparenchymal hemorrhage. Right ventricular collection of blood. Right cerebral intraparenchymal hemorrhage. Significant mass effect with deviation of the midline structures to right. The left ventricle was compressed with obliteration of the suprasellar cistern. Air within the soft tissues in the left infra temporal region. C-spine XR, Abdominal/Chest CT were unremarkable.,Patient was taken to the OR emergently and underwent bifrontal craniotomy, evacuation of a small epidural and subdural hematomas, and duraplasty. He was given mannitol enroute to the OR and hyperventilated during and after the procedure. Postoperatively he continued to manifest decerebrate posturing . On 11/16/92 he underwent VP shunting with little subsequent change in his neurological status. On 11/23/92 he underwent tracheostomy. On 12/11/92 he underwent bifrontal acrylic prosthesis implantation for repair of the bifrontal craniectomy. By the time of discharge, 1/14/93, he tracked relatively well OD, but had a CN3 palsy OS. He had relatively severe extensor rigidity in all extremities (R>L). His tracheotomy was closed prior to discharge. A 11/16/92 Brain MRI demonstrated infarction in the upper brain stem (particularly in the Pons), left cerebellum, right basil ganglia and thalamus.,He was initially treated for seizure prophylaxis with DPH, but developed neutropenia, so it was discontinued. He developed seizures within several months of discharge and was placed on VPA (Depakene). This decreased seizure frequency but his liver enzymes became elevated and he changed over to Tegretol. 10/8/93 Brain MRI (one year after MVA) revealed interval appearance of hydrocephalus, abnormal increased T2 signal (in the medulla, right pons, both basal ganglia, right frontal and left occipital regions), a small mid-brain, and a right subdural fluid collection. These findings were consistent with diffuse axonal injury of the white matter and gray matter contusion, and signs of a previous right subdural hematoma.,He was last seen 10/30/96 in the pediatric neurology clinic--age 9 years. He was averaging 2-3 seizures per day---characterized by extension of BUE with tremor and audible cry or laughter---on Tegretol and Diazepam. In addition he experiences 24-48hour periods of "startle response (myoclonic movement of the shoulders)" with or without stimulation every 6 weeks. He had limited communication skills (sparse speech). On exam he had disconjugate gaze, dilated/fixed left pupil, spastic quadriplegia.
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DESCRIPTION: MRI Brain: Thrombus in torcula of venous sinuses.

radiology, mri brain, brain mri, thrombus, intraparenchymal hemorrhage, motor vehicle, prophylaxis, sinuses, torcula venous sinuses, venous, brain thrombus, bilateral decorticate, decorticate posturing, subdural hematomas, subdural, mri, brain, torcula

This case involves a young child with a serious and complex history of traumatic brain injury following a severe accident. The child has undergone multiple surgical interventions, suffers from neurological impairments, and experiences frequent seizures. The presence of a thrombus in the venous sinuses on the MRI adds another layer of complexity and potential risk of further complications such as increased intracranial pressure or venous infarction. The child's overall condition is critical and any changes or complications could have significant life-altering consequences.


Medical Specialty: Surgery
Sample Name: Heart Catheterization & Ventriculogram

PROCEDURE PERFORMED:,1.  Right heart catheterization.,2.  Left heart catheterization.,3.  Left ventriculogram.,4.  Aortogram.,5.  Bilateral selective coronary angiography.,ANESTHESIA:,  1% lidocaine and IV sedation including Versed 1 mg.,INDICATION:,  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.  She has had atrial fibrillation and previous episodes of congestive heart failure.  She has dyspnea on exertion and occasionally orthopnea and paroxysmal nocturnal dyspnea.,PROCEDURE:,  After the risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient in detail, informed consent was obtained, both verbally and in writing.  The patient was taken to the Cardiac Catheterization Lab where the procedure was performed.  The right inguinal area was thoroughly cleansed with Betadine solution and the patient was draped in the usual manner.  1% lidocaine solution was used to anesthetize the right inguinal area.  Once adequate anesthesia had been attained, a thing wall Argon needle was used to cannulate the right femoral vein.  A guidewire was advanced into the lumen of the vein without resistance.  The needle was removed and the guidewire was secured to the sterile field.  The needle was flushed and then used to cannulate the right femoral artery.  A guidewire was advanced through the lumen of the needle without resistance.  A small nick was made in the skin and the needle was removed.  This pressure was held.  A #6 French arterial sheath was advanced over the guidewire without resistance.  The dilator and guidewire were removed.  FiO2 sample was obtained and the sheath was flushed.  An #8 French sheath was advanced over the guidewire into the femoral vein after which the dilator and guidewire were removed and the sheath was flushed.  A Swan-Ganz catheter was advanced through the venous sheath into a pulmonary capillary was positioned and the balloon was temporarily deflated.  An angulated pigtail catheter was advanced into the left ventricle under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to a manifold and flushed.  Left ventricular pressures were continuously measured and the balloon was re-inflated and pulmonary capillary wedge pressure was remeasured.  Using dual transducers together and the mitral valve radius was estimated.  The balloon was deflated and mixed venous sample was obtained.  Hemodynamics were measured.  The catheter was pulled back in to the pulmonary artery right ventricle and right atrium.  The right atrial sample was obtained and was negative for shunt.  The Swan-Ganz catheter was then removed and a left ventriculogram was performed in the RAO projection with a single power injection of non-ionic contrast material.  Pullback was then performed which revealed a minimal LV-AO gradient.  Since the patient had aortic insufficiency on her echocardiogram, an aortogram was performed in the LAO projection with a single power injection of non-ionic contrast material.  The pigtail catheter was then removed and a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was carefully engaged.  Using multiple hand injections of non-ionic contrast material, the left coronary system was evaluated in different views.  This catheter was then removed and a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the right coronary artery was then engaged and using hand injections of non-ionic contrast material, the right coronary system was evaluated in different views.  This catheter was removed.  The sheaths were flushed final time.  The patient was taken to the Postcatheterization Holding Area in stable condition.,FINDINGS:,HEMODYNAMICS: , Right atrial pressure 9 mmHg, right ventricular pressure is 53/14 mmHg, pulmonary artery pressure 62/33 mmHg with a mean of 46 mmHg.  Pulmonary capillary wedge pressure is 29 mmHg.  Left ventricular end diastolic pressure was 13 mmHg both pre and post left ventriculogram.  Cardiac index was 2.4 liters per minute/m2.  Cardiac output 4.0 liters per minute.  The mitral valve gradient was 24.5 and mitral valve area was calculated to be 0.67 cm2.  The aortic valve area is calculated to be 2.08 cm2.,LEFT VENTRICULOGRAM: , No segmental wall motion abnormalities were noted.  The left ventricle was somewhat hyperdynamic with an ejection fraction of 70%.  2+ to 3+ mitral regurgitation was noted.,AORTOGRAM: , There was 2+ to 3+ aortic insufficiency noted.  There was no evidence of aortic aneurysm or dissection.,LEFT MAIN CORONARY ARTERY: , This was a moderate caliber vessel and it is rather long.  It bifurcates into the LAD and left circumflex coronary artery.  No angiographically significant stenosis is noted.,LEFT ANTERIOR DESCENDING ARTERY:,  The LAD begins as a moderate caliber vessel ________ anteriorly in the intraventricular groove.  It tapers in its mid portion to become small caliber vessel.  Luminal irregularities are present, however, no angiographically significant stenosis is noted.,LEFT CIRCUMFLEX CORONARY ARTERY: , The left circumflex coronary artery begins as a moderate caliber vessel.  Small obtuse marginal branches are noted and this is the nondominant system.  Lumen irregularities are present throughout the circumflex system.  However no angiographically significant stenosis is noted.,RIGHT CORONARY ARTERY: , This is the moderate caliber vessel and it is the dominant system.  No angiographically significant stenosis is noted, however, mild luminal irregularities are noted throughout the vessel.,IMPRESSION:,1.  Nonobstructive coronary artery disease.,2.  Severe mitral stenosis.,3.  2+ to 3+ mitral regurgitation.,4.  2+ to 3+ aortic insufficiency.
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DESCRIPTION: Right and left heart catheterization, left ventriculogram, aortogram, and bilateral selective coronary angiography.  The patient is a 48-year-old female with severe mitral stenosis diagnosed by echocardiography, moderate aortic insufficiency and moderate to severe pulmonary hypertension who is being evaluated as a part of a preoperative workup for mitral and possible aortic valve repair or replacement.

The procedure described involves heart catheterization and various diagnostic assessments essential in the context of evaluating a patient with severe mitral stenosis and moderate aortic insufficiency for potential valve repair or replacement. These are serious cardiovascular issues that, if left unaddressed, could result in significant health risks, including heart failure. The procedure is critical in assessing the patient's condition to plan lifesaving interventions. Therefore, the stakes are high due to the potential impact on the patient's health and the invasive nature of the procedure.


Medical Specialty: Radiology
Sample Name: 2-D Echocardiogram - 3

2-D ECHOCARDIOGRAM,Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships.  Cardiac function is normal.  There is no significant chamber enlargement or hypertrophy.  There is no pericardial effusion or vegetations seen.  Doppler interrogation, including color flow imaging, reveals systemic venous return to the right atrium with normal tricuspid inflow.  Pulmonary outflow is normal at the valve.  Pulmonary venous return is to the left atrium.  The interatrial septum is intact.  Mitral inflow and ascending aorta flow are normal.  The aortic valve is trileaflet.  The coronary arteries appear to be normal in their origins.  The aortic arch is left-sided and patent with normal descending aorta pulsatility.
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DESCRIPTION: 2-D Echocardiogram

2-D Echocardiogram

radiology, 2-d echocardiogram, cardiac function, doppler, echocardiogram, multiple views, aortic valve, coronary arteries, descending aorta, great vessels, heart, hypertrophy, interatrial septum, intracardiac, pericardial effusion, tricuspid, vegetation, venous, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The echocardiogram report indicates normal cardiac anatomy and function with no abnormalities found. This suggests that the patient's heart condition is stable and not life-threatening. Consequently, this situation doesn't involve high-stakes medical decision-making or immediate intervention requirements.


Medical Specialty: Emergency Room Reports
Sample Name: Fall - ER Visit

HISTORY OF PRESENT ILLNESS:,  The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home.  The patient states that she was on the ladder on Saturday and she stepped down after the ladder.  Felt some pain in her left hip.  Subsequently fell injuring her left shoulder.  It's unclear how long she was on the floor.  She was taken by EMS to Hospital where she was noted radiographically to have a left proximal humerus fracture and a nondisplaced left hip fracture.  Orthopedics was consulted.  Given the nature of the injury and the unclear events, an extensive workup was performed including a head CT and CT of the abdomen, which identified no evidence of intracranial injury and renal calculi only.  She presently is complaining of pain to the left shoulder.  She states she also has pain to the hip with motion of the leg.  She denies any numbness or paresthesias.  She states prior to this, she was relatively active within her home.  She does care for her daughter who has a mess.  The patient denies any other injuries.  Denies back pain.,PREVIOUS MEDICAL HISTORY:,  Extensive including coronary artery disease, peripheral vascular disease, status post MI, history of COPD, diverticular disease, irritable bowel syndrome, GERD, PMR, depressive disorder, and hypertension.,PREVIOUS SURGICAL HISTORY:,  Includes a repair of a right intertrochanteric femur fracture.,ALLERGIES,1.  PENICILLIN.,2.  SULFA.,3.  ACE INHIBITOR.,PRESENT MEDICATIONS,1.  Lipitor 20 mg q.d.,2.  Metoprolol 25 mg b.i.d.,3.  Plavix 75 mg once a day.,4.  Aspirin 325 mg.,5.  Combivent Aerosol two puffs twice a day.,6.  Protonix 40 mg q.d.,7.  Fosamax 70 mg weekly.,8.  Multivitamins including calcium and vitamin D.,9.  Hydrocortisone.,10.  Nitroglycerin.,11.  Citalopram 20 mg q.d.,SOCIAL HISTORY:,  She denies alcohol or tobacco use.  She is the caretaker for her daughter, who is widowed and lives at home.,FAMILY HISTORY:,  Not obtainable.,REVIEW OF SYSTEMS: , Patient is hard of hearing.  She also has vision problems.  Denies headache syndrome.  Presently, denies chest pain or shortness of breath.  She denies abdominal pain.  Presently, she has left hip pain and left shoulder pain.  No urinary frequency or dysuria.  No skin lesions.  She does have swelling to both lower extremities for the last several weeks.  She denies endocrinopathies.  Psychiatric issues include chronic depression.,PHYSICAL EXAMINATION,GENERAL:  The patient is alert and responsive.,EXTREMITIES:  The left upper extremity, there is moderate swelling and ecchymosis to the brachial compartment.  She is diffusely tender over the proximal humerus.  She is unable to actively elevate her arm due to pain.  The neurovascular exam to the left upper extremity is otherwise intact with a 1+ radial pulse.  She does have chronic degenerative change to the MP and IP joints of both hands.  The left lower extremity, the thigh compartment is supple.  She has pain with log rolling tenderness over the greater trochanter.  The patient has pain with any attempt at hip flexion passively or actively.  The knee range of motion between 5 and 60 degrees with no point specific tenderness, no joint effusion, and an intact extensive mechanism.  She has 2 to 3+ bilateral pitting edema pretibially and pedally.  The patient has a weak motor response to the left lower extremity.  She has a 1+ dorsalis pedis pulse.  Her sensory examination is intact plantarly and dorsally on the foot.,RADIOGRAPHS:,  Left shoulder series was performed which identifies a three-part valgus-impacted left proximal humerus fracture with displacement of the greater tuberosity fragment approximately 1 cm.  There is no evidence of dislocation.  There was an AP pelvis as well as left hip series, which identify a nondisplaced valgus-impacted type 1 femoral neck fracture.  There is also evidence of severe degenerative disk disease with degenerative scoliosis of the LS spine.  There is evidence of previous surgical repair of the right proximal femur with an intact intramedullary nail.,LABORATORY STUDIES: , Patient's H&H is 13 and 38.7, white blood cell count is 6.9, and there are 198,000 platelets.  Electrolytes, sodium 137, potassium 4.1, chloride 102, CO2 is 27, BUN is 20, and creatinine 0.62.  Urinalysis, the urine is clear yellow, 0 to 2 white cells, and no bacteria.,ASSESSMENT,1.  This is an 88-year-old household ambulator with a walker, status post fall with injuries to left shoulder and left hip.  The left shoulder fracture is a valgus-impacted proximal humerus fracture and the left hip is a nondisplaced type 1 femoral neck fracture.,2.  Extensive medical history including coronary artery disease, peripheral vascular disease, and chronic obstructive pulmonary disease on Plavix.,PLAN:,  I have discussed this case with the emergency room physician as well as the patient.  Patient should be admitted to medical service for medical clearance for surgery of her left hip, which will include a percutaneous screw fixation.  Since the patient is on Plavix, I recommend that the Plavix be discontinued and should be placed on Lovenox 30 mg subcu q.d. which may be stopped 24 hours before the procedure.  She will need cardiology clearance, which would include an echo in advance of the procedure.  I have explained the nature of the injuries to the patient, the recommended surgical procedures, and the postop course and rehabilitation required thereafter.  She presently understands and agrees with the plan.
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DESCRIPTION: The patient is an 88-year-old white female, household ambulator with a walker, who presents to the emergency department this morning after incidental fall at home.

The situation involves an 88-year-old patient with multiple significant injuries resulting from a fall: a proximal humerus fracture and a nondisplaced hip fracture. The patient has a complex medical history, including coronary artery disease and COPD, and is on medication (Plavix) that complicates surgical interventions. Additionally, she requires cardiology clearance for surgery, indicating the complexity and potential risks involved. These factors classify it as a high-stakes medical scenario due to the patient's age, medical history, and the nature of the injuries, which could have life-altering consequences if not managed properly.


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

Medical Specialty: Obstetrics / Gynecology
Sample Name: Pathology - Ovarian Cyst

GROSS DESCRIPTION: ,  Specimen labeled "right ovarian cyst" is received fresh for frozen section.  It consists of a smooth-walled, clear fluid filled cyst measuring 13x12x7 cm and weighing 1351 grams with fluid.  Both surfaces of the wall are pink-tan, smooth and grossly unremarkable.  No firm or thick areas or papillary structures are noted on the cyst wall externally or internally.  After removal the fluid, the cyst weight 68 grams.  The fluid is transparent and slightly mucoid.  A frozen section is submitted.,DIAGNOSIS: , Benign cystic ovary.,
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DESCRIPTION: Specimen labeled "right ovarian cyst" is received fresh for frozen section.

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

The situation involves the analysis of a right ovarian cyst, which is a common occurrence in the field of Obstetrics and Gynecology. The gross description and the diagnosis indicated that the cyst is benign. While it is important for patient management and treatment planning, it is a routine procedure and the cyst being benign reduces the risk associated with the situation. Since the cyst is not malignant, the situation is not immediately life-threatening or urgent, reducing the overall stakes.


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

REASON FOR VISIT: , Kyphosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis.  The patient has a family history in a maternal aunt and grandfather of kyphosis.  She was noted by her parents to have round back posture.  They have previously seen another orthopedist who recommended observation at this time.  She is here for a second opinion in regards to kyphosis.  The patient denies any pain in her back or any numbness, tingling, or weakness in her upper or lower extremities.  No problems with her bowels or bladder.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Bilateral pinning of her ears.,SOCIAL HISTORY:  ,She is currently an eighth grader at Middle School and is interested in basketball.  She lives with both of her parents and has a 9-year-old brother.  She had menarche beginning in September.,FAMILY HISTORY:  ,Of kyphosis in great grandmother and second cousin.,REVIEW OF SYSTEMS: , She is in her usual state of health and is negative except otherwise as mentioned in the history of present illness.,MEDICATIONS: , She is currently on Zyrtec, Flonase, and Ceftin for an ear infection.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, she is alert, oriented, and in no acute distress standing 63 inches tall.  In regards to her back, her skin is intact with no rashes, lesions, and/or no dimpling or hair spots.  No cafe au lait spots.  She is not tender to palpation from her occiput to her sacrum.  There is no evidence of paraspinal muscle spasm.  On forward bending, there is a mild kyphosis.  She is not able to touch her toes indicating her hamstring tightness.  She has a full 5 out of 5 in all muscle groups.  Her lower extremities including iliopsoas, quadriceps, gastroc-soleus, tibialis anterior, and extensor hallucis longus.  Her sensation intact to light touch in L1 through L2 dermatomal distributions.  She has symmetric limb lengths as well bilaterally from both the coronal and sagittal planes.,X-rays today included PA and lateral sclerosis series.  She has approximately 46 degree kyphosis.,ASSESSMENT: , Kyphosis.,PLANS:  ,The patient's kyphosis is quite mild.  While this is likely in the upper limits of normal or just it is normal for an adolescent and still within normal range as would be expected return at home.  At this time, three options were discussed with the parents including observation, physical therapy, and bracing.  At this juncture, given that she has continued to grow, they are Risser 0.  She may benefit from continued observation with physical therapy, bracing would be a more aggressive option certainly that thing would be lost with following at this time.  As such, she was given a prescription for physical therapy for extension based strengthening exercises, flexibility range of motion exercises, postural training with no forward bending.  We will see her back in 3 months' time for repeat radiographs at that time including PA and lateral standing of scoliosis series.  Should she show evidence of continued progression of her kyphotic deformity, discussions of bracing would be held at time.  We will see her back in 3 months' time for repeat evaluation.
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DESCRIPTION: A 13-year-old new patientfor evaluation of thoracic kyphosis.   Family history of kyphosis in a maternal aunt and grandfather.  She was noted by her parents to have round back posture.

consult - history and phy., thoracic kyphosis, round back posture, physical therapy, kyphosis, patientfor, orthopedist,

The clinical situation involves a 13-year-old patient with mild thoracic kyphosis, a relatively common spinal condition in adolescents. While the condition requires monitoring and potential intervention, it is not currently causing significant symptoms or complications, as evidenced by the absence of pain or neurological symptoms. The current recommendations involve observation and physical therapy, which indicates a non-urgent approach. This situation is not life-threatening or requiring immediate intervention, making it lower stakes in the medical context.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Thyroid Mass Consult

REASON FOR CONSULTATION: , Thyroid mass diagnosed as papillary carcinoma.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 16-year-old young lady, who was referred from the Pediatric Endocrinology Department by Dr. X for evaluation and surgical recommendations regarding treatment of a mass in her thyroid, which has now been proven to be papillary carcinoma on fine needle aspiration biopsy.  The patient's parents relayed that they first noted a relatively small but noticeable mass in the middle portion of her thyroid gland about 2004.  An ultrasound examination had reportedly been done in the past and the mass is being observed.  When it began to enlarge recently, she was referred to the Pediatric Endocrinology Department and had an evaluation there.  The patient was referred for fine needle aspiration and the reports recently returned a diagnosis of papillary thyroid carcinoma.  The patient has not had any hoarseness, difficulty swallowing, or any symptoms of endocrine dysfunction.  She has no weight changes consistent with either hyper or hypothyroidism.  There is no family history of thyroid cancer in her family.  She has no notable discomfort with this lesion.  There have been no skin changes.  Historically, she does not have a history of any prior head and neck radiation or treatment of any unusual endocrinopathy.,PAST MEDICAL HISTORY:,  Essentially unremarkable.  The patient has never been hospitalized in the past for any major illnesses.  She has had no prior surgical procedures.,IMMUNIZATIONS: , Current and up to date.,ALLERGIES: , She has no known drug allergies.,CURRENT MEDICATIONS:  ,Currently taking no routine medications.  She describes her pain level currently as zero.,FAMILY HISTORY: , There is no significant family history, although the patient's father does note that his mother had a thyroid surgery at some point in life, but it was not known whether this was for cancer, but he suspects it might have been for goiter.  This was done in Tijuana.  His mom is from central portion of Mexico.  There is no family history of multiple endocrine neoplasia syndromes.,SOCIAL HISTORY:  ,The patient is a junior at Hoover High School.  She lives with her mom in Fresno.,REVIEW OF SYSTEMS: , A careful 12-system review was completely normal except for the problems related to the thyroid mass.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a 55.7 kg, nondysmorphic, quiet, and perhaps slightly apprehensive young lady, who was in no acute distress.  She was alert and oriented x3 and had an appropriate affect.,HEENT:  The head and neck examination is most significant.  There is mild amount of facial acne.  The patient's head, eyes, ears, nose, and throat appeared to be grossly normal.,NECK:  There is a slightly visible midline bulge in the region of the thyroid isthmus.  A firm nodule is present there, and there is also some nodularity in the right lobe of the thyroid.  This mass is relatively hard, slightly fixed, but not tethered to surrounding tissues, skin, or muscles that I can determine.  There are some shotty adenopathy in the area.  No supraclavicular nodes were noted.,CHEST:  Excursions are symmetric with good air entry.,LUNGS:  Clear.,CARDIOVASCULAR:  Normal.  There is no tachycardia or murmur noted.,ABDOMEN:  Benign.,EXTREMITIES:  Extremities are anatomically correct with full range of motion.,GENITOURINARY:  External genitourinary exam was deferred at this time and can be performed later during anesthesia.  This is same as too for her rectal examination.,SKIN:  There is no acute rash, purpura, or petechiae.,NEUROLOGIC:  Normal and no focal deficits.  Her voice is strong and clear.  There is no evidence of dysphonia or vocal cord malfunction.,DIAGNOSTIC STUDIES: , I reviewed laboratory data from the Diagnostics Lab, which included a mild abnormality in the AST at 11, which is slightly lower than the normal range.  T4 and TSH levels were recorded as normal.  Free thyroxine was normal, and the serum pregnancy test was negative.  There was no level of thyroglobulin recorded on this.  A urinalysis and comprehensive metabolic panel was unremarkable.  A chest x-ray was obtained, which I personally reviewed.  There is a diffuse pattern of tiny nodules in both lungs typical of miliary metastatic disease that is often seen in patients with metastatic thyroid carcinoma.,IMPRESSION/PLAN: , The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis and is unfortunate in that it generally means a more advanced stage of disease.  I spent approximately 30 minutes with the patient and her family today discussing the surgical aspects of the treatment of this disease.  During this time, we talked about performing a total thyroidectomy to eradicate as much of the native thyroid tissue and remove the primary source of the cancer in anticipation of radioactive iodine therapy.  We talked about sentinel node dissection, and we spent significant amount of time talking about the possibility of hypoparathyroidism if all four of the parathyroid glands were damaged during this operation.  We also discussed the recurrent laryngeal and external laryngeal branches of the nerve supplying the vocal cord function and how they cane be damaged during the thyroidectomy as well.  I answered as many of the family's questions as they could mount during this stressful time with this recent information supplied to them.  I also did talk to them about the chest x-ray pattern, which was complete __________ as the film was just on the day prior to my clinic visit.  This will have some impact on the postoperative adjunctive therapy.  The radiologist commented about the risk of pulmonary fibrosis and the use of radioactive iodine in this situation, but it seems likely that is going to be necessary to attempt to treat this disease in the patient's case.  I did discuss with them the possibility of having to take large doses of calcium and vitamin D in the event of hypoparathyroidism if that does happen, and we also talked about possibly sparing parathyroid tissue and reimplanting it in a muscle belly either in the neck or forearm if that becomes a necessity.  All of the family's questions have been answered.  This is a very anxious and anxiety provoking time in the family.  I have made every effort to get the patient under schedule within the next 48 hours to have this operation done.  We are tentatively planning on proceeding this upcoming Friday afternoon with total thyroidectomy.
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DESCRIPTION: Thyroid mass diagnosed as papillary carcinoma.  The patient is a 16-year-old young lady with a history of thyroid mass that is now biopsy proven as papillary.  The pattern of miliary metastatic lesions in the chest is consistent with this diagnosis.

The scenario involves a 16-year-old patient diagnosed with papillary thyroid carcinoma with evidence of metastatic lesions in the lungs. This condition is life-threatening and requires urgent surgical intervention in the form of a total thyroidectomy. The potential complications from surgery, such as damage to parathyroid glands and nerves affecting vocal cord function, add to the stakes. Such a diagnosis is highly significant, especially given the young age of the patient and the presence of metastatic disease, which complicates treatment and prognosis.


Medical Specialty: Surgery
Sample Name: Craniotomy - Frontotemporal - 1

PREOPERATIVE DIAGNOSIS:,  Acute left subdural hematoma.,POSTOPERATIVE DIAGNOSIS:,  Acute left subdural hematoma.,PROCEDURE:,  Left frontal temporal craniotomy for evacuation of acute subdural hematoma.,DESCRIPTION OF PROCEDURE: , This is a 76-year-old man who has a history of acute leukemia.  He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency.  He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury.  His CT imaging reveals an acute left subdural hematoma, which is hemispheric.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy.  The images were brought up on the electronic imaging and confirmed that this was a left-sided condition.  He was fixed in a three-point headrest.  His scalp was shaved and prepared with Betadine, iodine and alcohol.  We made a small curved incision over the temporal, parietal, frontal region.  The scalp was reflected.  A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created.  After completing the bur hole flap, the dura was opened and a gelatinous mass of subdural was peeled away from the brain.  The brain actually looked relatively relaxed; and after removal of the hematoma, the brain sort of slowly came back up.  We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline.  After we felt that we had an adequate decompression, the dura was reapproximated and we filled the subdural space with saline.  We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates.  The scalp was reapproximated, and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment.  Given that this actual skin looked good with apparent removal of about 80% of the subdural we elected to take patient to the Intensive Care Unit for further management.,I was present for the entire procedure and supervised this.  I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain.
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DESCRIPTION: Acute left subdural hematoma.  Left frontal temporal craniotomy for evacuation of acute subdural hematoma.  CT imaging reveals an acute left subdural hematoma, which is hemispheric.

surgery, subdural, hematoma, temporal craniotomy, craniotomy, subdural space, bur hole, subdural hematoma,

The situation involves a surgical procedure to relieve an acute left subdural hematoma in a 76-year-old patient with significant pre-existing medical conditions, including acute leukemia and thrombocytopenia. The patient's situation is complicated by his fall and the requirement for an emergency craniotomy, which is inherently a high-stakes surgical intervention due to the potential for severe neurological damage or death if untreated. Furthermore, the presence of leukemia and low platelet counts increase the risks associated with surgery and postoperative recovery, further elevating the stakes.


Medical Specialty: General Medicine
Sample Name: Fall & Laceration

CC:,  Fall and laceration.,HPI: , Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk.  He denies loss of consciousness but says he was dazed for a while after it happened.  He complains of pain over the chin and right forehead where he has abrasions.  He denies neck pain, back pain, extremity pain or pain in the abdomen.,PMH: , Hypertension.,MEDS:,  None.,ROS: , As above.  Otherwise negative.,PHYSICAL EXAM: , This is a gentleman in full C-spine precautions on a backboard brought by EMS.  He is in no apparent distress.  ,Vital Signs:  BP 165/95 HR 80 RR 12 Temp 98.4 SpO2 95% ,HEENT:  No palpable step offs, there is blood over the right fronto-parietal area where there is a small 1cm laceration and surrounding abrasion.  Also, 2 cm laceration over the base of the chin without communication to the oro-pharynx.  No other trauma noted.  No septal hematoma.  No other facial bony tenderness.  ,Neck:  Nontender ,Chest:  Breathing comfortably; equal breath sounds.  ,Heart:  Regular rhythm.,Abd:  Benign.,Ext:  No tenderness or deformity; pulses are equal throughout; good cap refill ,Neuro:  Awake and alert; slight slurring of speech and cognitive slowing consistent with alcohol; moves all extremities; cranial nerves normal.  ,COURSE IN THE ED:,  Patient arrived and was placed on monitors.  An IV had been placed in the field and labs were drawn.  X-rays of the C spine show no fracture and I've removed the C-collar.  The lacerations were explored and no foreign body found.  They were irrigated and closed with simple interrupted sutures.  Labs showed normal CBC, Chem-7, and U/A except there was moderate protein in the urine.  The blood alcohol returned at 0.146.  A banana bag is ordered and his care will be turned over to Dr. G for further evaluation and care.
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DESCRIPTION: Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.

general medicine, loss of consciousness, laceration, fall, course in the ed, placed on monitors, fell and struck, abrasions,

The situation involves a patient who has sustained a fall and facial lacerations. The patient's vital signs are stable, and there is no evidence of serious injury such as fractures. The patient has mild symptoms consistent with alcohol consumption, but there is no loss of consciousness or severe neurological impairment. The lacerations have been treated, and the overall clinical picture suggests low immediate danger to life or function. Thus, while medical attention is necessary, the situation is not imminently life-threatening or high-stakes.


Medical Specialty: Diets and Nutritions
Sample Name: Dietary Consult - Gestational Diabetes

SUBJECTIVE:,  This is a 38-year-old female who comes for dietary consultation for gestational diabetes.  Patient reports that she is scared to eat because of its impact on her blood sugars.  She is actually trying not to eat while she is working third shift at Wal-Mart.  Historically however, she likes to eat out with a high frequency.  She enjoys eating rice as part of her meals.  She is complaining of feeling fatigued and tired all the time because she works from 10 p.m. to 7 a.m. at Wal-Mart and has young children at home.  She sleeps two to four hours at a time throughout the day.  She has been testing for ketones first thing in the morning when she gets home from work.,OBJECTIVE:,  Today's weight:  155.5 pounds.  Weight from 10/07/04 was 156.7 pounds.  A diet history was obtained.  Blood sugar records for the last three days reveal the following:  fasting blood sugars 83, 84, 87, 77; two-hour postprandial breakfast 116, 107, 97; pre-lunch 85, 108, 77; two-hour postprandial lunch 86, 131, 100; pre-supper 78, 91, 100; two-hour postprandial supper 125, 121, 161; bedtime 104, 90 and 88.  I instructed the patient on dietary guidelines for gestational diabetes.  The Lily Guide for Meal Planning was provided and reviewed.  Additional information on gestational diabetes was applied.  A sample 2000-calorie meal plan was provided with a carbohydrate budget established.,ASSESSMENT:,  Patient's basal energy expenditure adjusted for obesity is estimated at 1336 calories a day.  Her total calorie requirements, including a physical activity factor as well as additional calories for pregnancy, totals to 2036 calories per day.  Her diet history reveals that she has somewhat irregular eating patterns.  In the last 24 hours when she was working at Wal-Mart, she ate at 5 a.m. but did not eat anything prior to that since starting work at 10 p.m.  We discussed the need for small frequent eating.  We identified carbohydrate as the food source that contributes to the blood glucose response.  We identified carbohydrate sources in the food supply, recognizing that they are all good for her.  The only carbohydrates she was asked to entirely avoid would be the concentrated forms of refined sugars.  In regard to use of her traditional foods of rice, I pulled out a one-third cup measuring cup to identify a 15-gram equivalent of rice.  We discussed the need for moderating the portion of carbohydrates consumed at one given time.  Emphasis was placed at eating with a high frequency with a goal of eating every two to four hours over the course of the day when she is awake.  Her weight loss was discouraged.  Patient was encouraged to eat more generously but with attention to the amount of carbohydrates consumed at a time.,PLAN:,  The meal plan provided has a carbohydrate content that represents 40 percent of a 2000-calorie meal plan.  The meal plan was devised to distribute her carbohydrates more evenly throughout the day.  The meal plan was meant to reflect an example for her eating, while the patient was encouraged to eat according to appetite and not to go without eating for long periods of time.  The meal plan is as follows:  breakfast 2 carbohydrate servings, snack 1 carbohydrate serving, lunch 2-3 carbohydrate servings, snack 1 carbohydrate serving, dinner 2-3 carbohydrate servings, bedtime snack 1-2 carbohydrate servings.  Recommend patient include a solid protein with each of her meals as well as with her snack that occurs before going to sleep.  Encouraged adequate rest.  Also recommend adequate calories to sustain weight gain of one-half to one pound per week.  If the meal plan reflected does not support slow gradual weight gain, then we will need to add more foods accordingly.  This was a one-hour consultation.  I provided my name and number should additional needs arise.
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DESCRIPTION: Dietary consultation for gestational diabetes.

diets and nutritions, blood sugars, fatigued, total calorie, carbohydrate content, consultation for gestational diabetes, dietary consultation, weight gain, gestational diabetes, carbohydrate servings, meal planning, meals, weight, carbohydrate, dietary, servings, planning

Gestational diabetes is a medical condition that affects pregnancy and can have serious implications for both the mother and the unborn child, including the risk of high blood sugar and its potential complications. The patient is experiencing anxiety about her diet, fatigue from a strenuous work and sleep schedule, and is trying to manage her condition through dietary adjustments. Managing gestational diabetes correctly is critical to prevent complications during pregnancy such as preeclampsia, preterm birth, or fetal overgrowth. Hence, this consultation holds considerable importance for the health of both the mother and child.


Medical Specialty: Office Notes
Sample Name: Ortho Office Visit

Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature.  Motor strength was 5/5 on the MRC scale.  Reflexes were 2+ and symmetrical.  Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal musculature bilaterally.,Palpable trigger points were noted on today's evaluation.  She is suffering from ongoing myofascitis.  Her treatment plan will consist of a series of trigger point injections, which were performed today.  She tolerated the procedure well.  I have asked her to ice the region intermittently for 15 minutes off and on x 3.  She will be followed in four weeks' time for repeat trigger point injections if indicated.,
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DESCRIPTION: The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints.

office notes, back pain, trigger point injections, paraspinal musculature, lumbar, paraspinal, musculature, palpable, injections, evaluation, triggerNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

This scenario involves a medical practitioner documenting a patient's condition and treatment plan for myofascitis, a condition causing muscle inflammation and pain. While the context is within a medical setting which inherently involves patient health, this specific situation appears to be routine management of a non-life-threatening condition. The evaluation and treatment do not indicate any immediate critical health risks. Thus, although patient care is important, the stakes involved in this particular office visit are not extremely high.