Medical Specialty: Neurology
Sample Name: Craniotomy - Temporal

PREOPERATIVE DIAGNOSIS:,  Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:,  Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1.  Left temporal craniotomy.,2.  Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoulder roll, and the head was turned to the right side.  The entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation.  Next, we made an inverted-U fashion base over the asterion over temporoparietal area of the skull.  A free flap was elevated after the scalp that was reflected using the burr hole and craniotome.  The bone flap was placed aside and soaked in the bacitracin solution.,The dura was then opened in an inverted-U fashion.  Using the Stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle.  We head through the vein of Labbe, and we made great care to preserve this.  We saw where the tumor almost made to the surface.  Here we made a small corticectomy using the Stealth for guidance.  We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid.  This was submitted to pathology.  We biopsied this very abnormal tissue and submitted it to pathology.  They gave us a frozen section diagnosis of glioblastoma multiforme.  With the operating microscope and Greenwood bipolar forceps, we then systematically debulked this tumor.  It was very vascular and we really continued to remove this tumor until all visible tumors was removed.  We appeared to get two gliotic planes circumferentially.  We could see it through the ventricle.  After removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal.  The bone flap was then replaced and sutured with the Lorenz titanium plate system.  The muscle fascia galea was closed with interrupted 2-0 Vicryl sutures.  Skin staples were used for skin closure.  The blood loss of the operation was about 200 cc.  There were no complications of the surgery per se.  The needle count, sponge count, and the cottonoid count were correct.,COMMENT:  ,Operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain.
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DESCRIPTION: Left temporal craniotomy and removal of brain tumor.

neurology, temporal lobe, brain tumor, lorenz titanium plate, burr hole, cortex, corticectomy, craniotome, craniotomy, frozen section, glioblastoma multiforme, temporal craniotomy, temporoparietal, ventricle, white matter, tumor, temporal, brain,

The scenario involves a craniotomy to remove a glioblastoma multiforme, a highly aggressive brain tumor. This type of surgery is inherently high-stakes due to several factors: the critical nature of the brain as an organ, the potential for complications during and after surgery, the need for precise and careful technique to minimize damage to surrounding brain tissue, and the significant implications of the diagnosis itself. The report mentions the successful removal of the visible tumor and no complications during the procedure, but the nature of the surgery and the diagnosis of glioblastoma inherently involve substantial risk and complexity.


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

Medical Specialty: Surgery
Sample Name: Knee Arthroplasty - Bilateral

PREOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,PROCEDURE PERFORMED: , Bilateral knee arthroplasty.,Please note this procedure was done by Dr. X for the left total knee and Dr. Y for the right total knee.  This operative note will discuss the right total knee arthroplasty.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,BLOOD LOSS: , Approximately 150 cc.,HISTORY:,  This is a 79-year-old female who has disabling bilateral knee degenerative arthritis.  She has been unresponsive to conservative measures.  All risks, complications, anticipated benefits, and postoperative course were discussed.  The patient has agreed to proceed with surgery as described below.,GROSS FINDINGS: , There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,SPECIFICATIONS: , The Zimmer NexGen total knee system was utilized.,PROCEDURE: , The patient was taken to the operating room #2 and placed in supine position on the operating room table.  She was administered spinal anesthetic by Dr. Z.,The tourniquet was placed about the proximal aspect of the right lower extremity.  The right lower extremity was then sterilely prepped and draped in the usual fashion.  An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg.  Longitudinal incision was made over the anterior aspect of the right knee.  Subcutaneous tissue was carefully dissected.  A medial parapatellar retinacular incision was made.  The patella was then everted and the above noted gross findings were appreciated.  A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place.  The appropriate cuts were made at the distal femur as well as with use of the chamfer guide.  The trial femoral component was then positioned in place and noted to have good fit.  Attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut.  The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments.  The remnants of the anterior cruciate ligament and menisci were resected.  The tibial trial was positioned in place.  Intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut.  The tibial holes were then drilled.  The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella.  The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness.  Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate.  The knee was placed through range of motion with the trial components marked and then the appropriate components obtained.  The tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed.  The femoral component was inserted with methylmethacrylate.  Any excessive methylmethacrylate and bony debris were removed from the joint.  Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm.  The methylmethacrylate was also used at the patella.  The prosthesis was positioned in place.  The patellar clamp held securely till the methylmethacrylate was firm.  After all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment.  This component was removed and revised to a stemmed component with better alignment and position.  The previous component removed, the methylmethacrylate was removed.  Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached.  The trial tibial stemmed component was positioned in place.  Knee was placed through range of motion and the tracking was better.  Actual component was then obtained, methyl methacrylate was placed within the tibia.  The stemmed tibial component was impacted into place with good fit.  The Poly was then positioned in place.  Knee held in full extension with compression longitudinally after methylmethacrylate was solidified.  The trial Poly was removed.  Wound was irrigated and the joint was inspected.  There was no debris.  Collateral ligaments and posterior cruciate ligaments remained intact.  Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component.  The tourniquet was deflated.  Hemostasis was satisfactory.  A drain was placed into the depths of the wound.  The medial retinacular incision was closed with one Ethibond suture in interrupted fashion.  The knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain.  The subcutaneous tissue was closed with #2-0 undyed Vicryl in interrupted fashion.  The skin was closed with surgical clips.  The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity.  At the completion of the procedure, distal pulses were intact.  Toes were pink, warm, with good capillary refill.  Distal neurovascular status was intact.  Postoperative x-ray demonstrated satisfactory alignment of the prosthesis.  Prognosis is good in this 79-year-old female with a significant degenerative arthritis.
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DESCRIPTION: Bilateral knee degenerative arthritis.  Bilateral knee arthroplasty.  The Zimmer NexGen total knee system was utilized.

surgery, patellofemoral, eburnation, osteophyte, articulation, tibial, femoral, bilateral knee arthroplasty, knee degenerative arthritis, zimmer nexgen, lower extremity, arthroplasty, patella, methylmethacrylate,

This situation describes a surgical procedure for bilateral knee arthroplasty, which is generally complex and can be high-stakes due to the potential risks and complications associated with surgery, especially in a 79-year-old patient. Although it was noted that there were no complications during the procedure, and the outcome was satisfactory, the surgery involves significant medical intervention, anesthesia, and careful postoperative monitoring for recovery, which are typical high-stakes factors in orthopedic surgeries.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Urology
Sample Name: Overactive Bladder

REASON FOR VISIT: , Overactive bladder with microscopic hematuria.,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old noted to have microscopic hematuria with overactive bladder.  Her cystoscopy performed was unremarkable.  She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night.  No gross hematuria, dysuria, pyuria, no other outlet obstructive and/or irritative voiding symptoms.  The patient had been previously on Ditropan and did not do nearly as well.  At this point, what we will try is a different medication.  Renal ultrasound is otherwise unremarkable, notes no evidence of any other disease.,IMPRESSION: , Overactive bladder with microscopic hematuria most likely some mild atrophic vaginitis is noted.  She has no other significant findings other than her overactive bladder, which had continued.  At this juncture what I would like to do is try a different anticholinergic medication.  She has never had any side effects from her medication.,PLAN: , The patient will discontinue Ditropan.  We will start Sanctura XR and we will follow up as scheduled.  Otherwise we will continue to follow her urinalysis over the next year or so.
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DESCRIPTION: Overactive bladder with microscopic hematuria.

urology, overactive bladder with microscopic hematuria, irritative voiding symptoms, anticholinergic, microscopic hematuria, overactive bladder, ditropan, microscopic, hematuria, bladder, overactive

The situation involves a patient with an overactive bladder and microscopic hematuria. While it requires medical attention and follow-up, it appears to be managed and monitored appropriately by the practitioner. There are no immediate life-threatening conditions noted, such as gross hematuria or obstructive symptoms, and there are no significant adverse effects from the medication. The situation involves a change in medication, which is part of regular treatment adjustments, not indicative of a crisis.


Medical Specialty: Obstetrics / Gynecology
Sample Name: TAH & Salpingooophorectomy

PREOPERATIVE DIAGNOSES:,1.  Cervical intraepithelial neoplasia grade-III status post conization with poor margins.,2.  Recurrent dysplasia.,3.  Unable to follow in office.,4.  Uterine procidentia grade II-III.,POSTOPERATIVE DIAGNOSES:,1.  Cervical intraepithelial neoplasia grade-III postconization.,2.  Poor margins.,3.  Recurrent dysplasia.,4.  Uterine procidentia grade II-III.,5.  Mild vaginal vault prolapse.,PROCEDURES PERFORMED:,1.  Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy.,2.  Uterosacral ligament vault suspension.,ANESTHESIA: , General and spinal with Astramorph for postoperative pain.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,FLUIDS:  ,2400 cc.,URINE: , 200 cc of clear urine output.,INDICATIONS:  ,This patient is a 57-year-old nulliparous female who desires definitive hysterectomy for history of cervical intraepithelial neoplasia after conization and found to have poor margins.,FINDINGS:  ,On bimanual examination, the uterus was found to be small.  There were no adnexal masses appreciated.  Intraabdominal findings revealed a small uterus approximately 2 cm in size.  The ovaries were atrophic consistent with menopause.  The liver margins and stomach were palpated and found to be normal.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the operating suite and administered a spinal anesthesia for postoperative pain control.  She was then placed in the dorsal lithotomy position and administered general anesthesia.  She was then prepped and draped in the sterile fashion and an indwelling Foley catheter was placed in her bladder.  At this point, the patient was evaluated for a possible vaginal hysterectomy.  She was nulliparous and the pelvis was narrow.  After the anesthesia was administered, the patient was repeatedly stooling and therefore because of these two reasons, the decision was made to do an abdominal hysterectomy.  After the patient was prepped and draped, a Pfannenstiel skin incision was made approximately 2 cm above the pubic symphysis.  The second scalpel was used to dissect out to the underlying layer of fascia.  The fascia was incised in the midline and extended laterally using the Mayo scissors.  The superior aspect of the rectus fascia was grasped with Ochsners, tented up and underlying layer of rectus muscle was dissected off bluntly as well as with Mayo scissors.  In a similar fashion, the inferior portion of the rectus fascia was tented up, dissected off bluntly as well as with Mayo scissors.  The rectus muscle was then separated bluntly in the midline and the peritoneum was identified and entered with the Metzenbaum.  The peritoneal incision was extended superiorly and inferiorly with good visualization of the bladder.  At this point, the above findings were noted and the GYN Balfour retractor was placed.  Moist laparotomy sponges were used to pack the bowel out of the operative field.  The bladder blade and the extension for the retractor were then placed.  An Allis was used on the uterus for retraction.  The round ligaments were then identified, clamped with two hemostats and transected and then suture ligated.  The anterior portion of the broad ligament was dissected along vesicouterine resection.  The bladder was then dissected off the anterior cervix and vagina without difficulty.  The infundibulopelvic ligaments on both sides were then doubly clamped using hemostats, transected and suture ligated with #0 Vicryl suture.  The uterine vessels on both sides were skeletonized and clamped with two hemostats and transected and suture ligated with #0 Vicryl.  Good hemostasis was assured.  The cardinal ligaments on both sides were clamped using a curved hemostat, transected and suture ligated with #0 Vicryl.  Good hemostasis was obtained.  Two hemostats were then placed just under the cervix meeting in the midline.  The uterus and cervix were then _______ off using a scalpel.  This was handed and sent to Pathology for evaluation.  Using #0 Vicryl suture, the right vaginal cuff angle was closed and affixed to the ipsilateral cardinal ligament.  A baseball stitch was then used to close the cuff to the midline.  The same was done to the left vaginal cuff angle, which was affixed to the ipsilateral and cardinal ligaments.  The baseball stitch was used to close the cuff to the midline.  The hemostats were removed and the cuff was closed and good hemostasis was noted.  The uterosacral ligaments were also transfixed to the cuff and brought out for good support by using a #0 Vicryl suture through each uterosacral ligament and incorporating this into the vaginal cuff.  The pelvis was then copiously irrigated with warm normal saline.  Good support and hemostasis was noted.  The bowel packing was then removed and the GYN Balfour retractor was moved.  The peritoneum was then repaired with #0 Vicryl in a running fashion.  The fascia was then closed using #0 Vicryl in a running fashion, marking the first stitch and first last stitch in a lateral to medial fashion.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular closure and an Op-Site was placed over this.  The patient was then brought out of general anesthesia and extubated.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She will follow up postoperatively as an inpatient.
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DESCRIPTION: Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension.  Cervical intraepithelial neoplasia grade-III postconization.  Recurrent dysplasia.  Uterine procidentia grade II-III.  Mild vaginal vault prolapse.

obstetrics / gynecology, cervical intraepithelial neoplasia, vaginal vault prolapse, uterosacral ligament vault suspension, total abdominal hysterectomy, bilateral salpingooophorectomy, abdominal hysterectomy, uterosacral ligament, recurrent dysplasia, uterine procidentia, suture ligated, abdominal, intraepithelial, tah, salpingooophorectomy, hysterectomy, ligament, hemostats, vaginal,

The situation involves a medical procedure, specifically a total abdominal hysterectomy with bilateral salpingooophorectomy, which is a significant surgical intervention. The patient has a complex medical history with cervical intraepithelial neoplasia Grade III, recurrent dysplasia, and uterine procidentia Grade II-III. The stakes are high as surgical interventions always carry potential risks, such as complications during surgery, recovery issues, and the severity of the pre-existing conditions. These factors make it a high-stakes scenario, as the outcome directly impacts the patient's health and recovery.


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

HISTORY:  ,This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.  No confirmed prior history of heart attack, myocardial infarction, heart failure.  History dates back to about six months of intermittent shortness of breath, intermittent very slight edema with shortness of breath.  The blood pressure was up transiently last summer when this seemed to start and she was asked not to take Claritin-D, which she was taking for what she presumed was allergies.  She never had treated hypertension.  She said the blood pressure came down.  She is obviously very hypertensive this evening.  She has some mid scapular chest discomfort.  She has not had chest pain, however, during any of the other previous symptoms and spells.,CARDIAC RISKS:,  Does not smoke, lipids unknown.  Again, no blood pressure elevation, and she is not diabetic.,FAMILY HISTORY:,  Negative for coronary disease.  Dad died of lung cancer.,DRUG SENSITIVITIES:,  Penicillin.,CURRENT MEDICATIONS: , None.,SURGICAL HISTORY:,  Cholecystectomy and mastectomy for breast cancer in 1992, no recurrence.,SYSTEMS REVIEW: , Did not get headaches or blurred vision.  Did not suffer from asthma, bronchitis, wheeze, cough but short of breath as described above.  No reflux, abdominal distress.  No other types of indigestion, GI bleed.  GU:  Negative.  She is unaware of any kidney disease.  Did not have arthritis or gout.  No back pain or surgical joint treatment.  Did not have claudication, carotid disease, TIA.  All other systems are negative.,PHYSICAL FINDINGS,VITAL SIGNS:  Presenting blood pressure was 170/120 and her pulse at that time was 137.  Temperature was normal at 97, and she was obviously in major respiratory distress and hypoxemic.  Saturation of 86%.  Currently, blood pressure 120/70, heart rate is down to 100.,EYES:  No icterus or arcus.,DENTAL:  Good repair.,NECK:  Neck veins, cannot see JVD, at this point, carotids, no bruits, carotid pulse brisk.,LUNGS:  Fine and coarse rales, lower two thirds of chest.,HEART:  Diffuse cardiomegaly without a sustained lift, first and second heart sounds present, second is split.  There is loud third heart sound.  No murmur.,ABDOMEN:  Overweight, guess you would say obese, nontender, no liver enlargement, no bruits.,SKELETAL:  No acute joints.,EXTREMITIES:  Good pulses.  No edema.,NEUROLOGICALLY:  No focal weakness.,MENTAL STATUS:  Clear.,DIAGNOSTIC DATA: , 12-lead ECG, left bundle-branch block.,LABORATORY DATA:,  All pending.,RADIOGRAPHIC DATA: , Chest x-ray, pulmonary edema, cardiomegaly.,IMPRESSION,1.  Acute pulmonary edema.,2.  Physical findings of dilated left ventricle.,3.  Left bundle-branch block.,4.  Breast cancer in 1992.,PLAN:  ,Admit.  Aggressive heart failure management.  Get echo.  Start ACE and Coreg.  Diuresis of course underway.
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DESCRIPTION: This 61-year-old retailer who presents with acute shortness of breath, hypertension, found to be in acute pulmonary edema.   No confirmed prior history of heart attack, myocardial infarction, heart failure.

The patient is presenting with acute pulmonary edema, a potentially life-threatening condition that requires immediate medical attention. The individual has high blood pressure, respiratory distress, and is hypoxemic, all of which are critical issues that need urgent intervention. This medical case involves complex parameters like possible heart failure and involves immediate and aggressive treatment plans, including hospitalization and possibly long-term heart management. These factors indicate a high risk to the patient's health if not managed promptly and effectively.


Medical Specialty: Ophthalmology
Sample Name: Rhytidectomy & Blepharoplasty

PREOPERATIVE DIAGNOSIS:,  Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION:  ,This is a 62-year-old female for the above-planned procedure.  She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied.  Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table.  Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen.  This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized.  Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty.  Markers were applied to both upper lids in symmetrical fashion.  The skin was excised from the right upper lid first followed by appropriate muscle resection.  Minimal fat removed from the medial upper portion of the eyelid.  Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture.  Attention was then turned to the lower lid.  A classic skin muscle flap was created accordingly.  Fat was resected from the middle, medial, and lateral quadrant.  The fat was allowed to open drain the arcus marginalis for appropriate contour.  Hemostasis was controlled with the pinpoint cautery accordingly.  Skin was redraped with a conservative amount resected.  Running closure with 7-0 nylon was accomplished without difficulty.  The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes.  Eye mass was likewise clamped.  Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure.  The right face was first operated.  It was injected with a 0.25% Marcaine 1:200,000 adrenaline.  A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula.  She had minimal subcutaneous extra fat as noted.  Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline.  The flap was elevated without difficulty with various facelift scissors.  Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision.  Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery.  The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication.  The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene.  The skin was draped appropriately and appropriate tissue was resected.  A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface.  Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon.  The hairline temporal incision was closed with running 5-0 nylon.  The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described.  Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly.  Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly.  Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure.  The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure.  She will be discharged in the morning.,Estimated blood loss was less than 75 cc.  No complications noted, and the patient tolerated the procedure well.
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DESCRIPTION: Cervical facial rhytidectomy.  Quadrilateral blepharoplasty.  Autologous fat injection to the upper lip - donor site, abdomen.

ophthalmology, ageing face, adaptic polysporin ointment, autologous fat injection, bovie cautery, kerlix wrap, smas plication, arcus marginalis, blepharoplasty, facelift, platysmal sling, quadrilateral, rhytidectomy, right upper lid, cervical facial rhytidectomy, pinpoint cautery, facial rhytidectomy, quadrilateral blepharoplasty, running nylon, autologous,

The procedures mentioned, such as cervical facial rhytidectomy and blepharoplasty, are cosmetic surgeries aimed at addressing signs of aging. These procedures, while requiring precision and expert execution, are generally considered elective and are performed for aesthetic purposes. They typically carry a lower risk profile compared to more urgent or life-saving surgeries. The document specifies that full informed consent was obtained, there were no complications, and the estimated blood loss was minimal, indicating the procedure proceeded smoothly. However, any surgical procedure involving anesthesia and incisions carries inherent risks, contributing slightly to the stakes.


Medical Specialty: Emergency Room Reports
Sample Name: Dental Pain

CHIEF COMPLAINT:,  Dental pain.,HISTORY OF PRESENT ILLNESS:,  This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.  Presents now for evaluation.,PAST MEDICAL HISTORY: , Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease.  She has chronic pain in general and is followed by Dr. X.,REVIEW OF SYSTEMS: , Otherwise, unremarkable.  Has not noted any fever or chills.  However she, as mentioned, does note the dental discomfort with increasing swelling and pain.  Otherwise, unremarkable except as noted.,CURRENT MEDICATIONS: , Please see list.,ALLERGIES: , IODINE, FISH OIL, FLEXERIL, BETADINE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile, has stable and normal vital signs.  The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain.  HEENT:  Unremarkable.  I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region.  There is no neck adenopathy.  Oral mucosa is moist and well hydrated.  Dentition looks to be in reasonable condition.  However, she definitely is tender to percussion on the left lower first premolar.  I do not see any huge cavity or anything like that.  No real significant gingival swelling and there is no drainage noted.  None of the teeth are tender to percussion.,PROCEDURE:,  Dental nerve block.  Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia.  I have then written a prescription for penicillin and Vicodin for pain.,IMPRESSION: , ACUTE DENTAL ABSCESS.,ASSESSMENT AND PLAN:  ,The patient needs to follow up with the dentist for definitive treatment and care.  She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics.  However, outpatient followup should be adequate.  She is discharged in stable condition.
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DESCRIPTION: This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.

emergency room reports, dental pain, dental abscess, dental block, nerve block, mandible, swelling, dental,

The situation involves a 27-year-old female with dental pain and swelling, diagnosed as an acute dental abscess. While painful and potentially concerning if an abscess worsens or leads to systemic infection, the patient is stable, has received initial treatment, and is discharged in stable condition with a plan for outpatient follow-up. This is not considered a high-stakes emergency situation as her vital signs are stable, and there's no evidence of systemic infection at this time.


Medical Specialty: Surgery
Sample Name: Arthrotomy & Subscapularis Tendon Repair

TITLE OF OPERATION:  ,1.  Arthrotomy, removal humeral head implant, right shoulder.,2.  Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.,3.  Debridement glenohumeral joint.,4.  Biopsy and culturing the right shoulder.,INDICATION FOR SURGERY: , The patient had done well after a previous total shoulder arthroplasty performed by Dr. X.  However, the patient was lifted with subsequent significant pain and apparent tearing of his subscapularis.  Risks and benefits of the procedure had been discussed with the patient at length including, but not exclusive of infection, nerve or artery damage, stiffness, loss of range of motion, incomplete relief of pain, incomplete return of function, continued instability, retearing of the tendon, need for revision of his arthroplasty, permanent nerve or artery damage, etc.  The patient understood and wished to proceed.,PREOP DIAGNOSIS:  ,1.  Torn subscapularis tendon, right shoulder.,2.  Right total shoulder arthroplasty (Biomet system).,POSTOP DIAGNOSIS:  ,1.  Torn subscapularis tendon, right shoulder.,2.  Right total shoulder arthroplasty (Biomet system).,3.  Diffuse synovitis, right shoulder.,PROCEDURE: , The patient was anesthetized in the supine position.  A Foley catheter was placed in his bladder.  He was then placed in a beach chair position.  He was brought to the side of the table and the torso secured with towels and tape.  His head was then placed in the neutral position with no lateral bending or extension.  It was secured with paper tape over his forehead.  Care was taken to stay off his auricular cartilages and his orbits.  Right upper extremity was then prepped and draped in the usual sterile fashion.  The patient was given antibiotics well before the beginning of the procedure to decrease any risk of infection.  Once he had been prepped and draped with the standard prep, he was prepped a second time with a chlorhexidine-type skin prep.  This was allowed to dry and the skin was then covered with Ioban bandages also to decrease his risk of infection.,Also, preoperatively, the patient had his pacemaker defibrillator function turned off as a result during this case.  Bipolar type cautery had to be used as opposed to monopolar cautery.,The patient's deltopectoral incision was then opened and extended proximally and distally.  The patient had significant amount of scar already in this interval.  Once we got down to the deltoid and pectoralis muscle, there was no apparent cephalic vein present, as a result the rotator cuff interval had to be developed through an area of scar.  This created a significant amount of bleeding.  As a result a very slow and meticulous dissection was performed to isolate his coracoid and then his proximal humerus.  Care was taken to stay above the pectoralis minor and the conjoint tendon.  The deltoid had already started to scar down the proximal humerus as a result a very significant amount of dissection had to be performed to release the deltoid from proximal humerus.  Similarly, the deltoid insertion had to be released approximately 50% of its width to allow us enough mobility of the proximal humerus to be able to visualize the joint or the component.  It was clear that the patient had an avulsion of the subscapularis tendon as the tissue on the anterior aspect of the shoulder was very thin.  The muscle component of the subscapularis could be located approximately 1 cm off the glenoid rim and approximately 3 cm off the lesser tuberosity.  The soft tissue in this area was significantly scarred down to the conjoint tendon, which had to be very meticulously released.  The brachial plexus was identified as was the axillary nerve.  Once this was completed, an arthrotomy was then made leaving some tissue attached to the lesser tuberosity in case it was needed for closure later.  This revealed sanguineous fluid inside the joint.  We did not feel it was infected based upon the fluid that came from the joint.  The sutures for the subscapularis repair were still located in the proximal humerus with no tearing through the bone, which was fortunate because in that we could use the bone later for securing the sutures.  The remaining sutures were seen to be retracted medially to an area of the subscapularis as mentioned previously.  Some more capsule had to be released off the inferior neck in order for us to gain exposure during the scarring.  This was done also very meticulously.  The upper one half of the latissimus dorsi tendon was also released.  Once this was completed, the humerus could be subluxed enough laterally that we could remove the head.  This was done with no difficulty.  Fortunately, the humeral component stayed intact.  There were some exudates beneath the humeral head, which were somewhat mucinous.  However, these do not really appear to be infected, however, we sent them to pathology for a frozen section.  This frozen section later returned as possible purulent material.  I discussed this personally with the pathologist at that point.  We told him that the procedure is only 3 weeks old, but he was concerned that there might be more white blood cells in the tissue than he would expect.  As a result, all the mucinous exudates were carefully removed.  We also performed a fairly extensive synovectomy of the joint primarily to gain vision of the components, but also we irrigated the joint throughout the case with antibiotic impregnated irrigation.  At that point, we also had sent portions of this mucinous material to pathology for a stat Gram stain.  This came back as no organisms seen.  We also sent portions for culture and sensitivity both aerobic and anaerobic.,Once this was completed, attention was then directed to the glenoid.  The patient had significant amount of scar already.  The subscapularis itself was significantly scarred down to the anterior rim.  As a result, the adhesions along the anterior edge were released using a knife.  Also adhesions in the subcoracoid space area were released very carefully and meticulously to prevent any injury to the brachial plexus.  Two long retractors were placed medially to protect the brachial plexus during all portions of suturing of the subscapularis.  The subscapularis was then tagged with multiple number 2 Tycron sutures.  Adhesions were released circumferentially and it was found that with the arm in internal rotation about neutral degrees, the subscapularis could reach the calcar region without tension.  As a result, seven number 2 Tycron sutures were placed from the bicipital groove all the way down to the inferior calcar region of the humerus.  These all had excellent security in bone.  Once the joint had been debrided and irrigated, the real humeral head was then placed back on the proximal humerus.  Care was taken to remove fluid off the Morse taper.  The head was then impacted.  It should be noted that we tried multiple head sizes to see if a smaller or larger head size might be more appropriate for this patient.  Unfortunately, any of the larger head sizes would overstep the joint and any smaller sizes would not give good coverage to the proximal humerus.  As a result, it was felt to place the offset head back on the humerus, we did insert a new component as opposed to using the old component.  The old component was given to the family postoperatively.,With the arm in internal rotation, the Tycron sutures were then placed through the subscapularis tendon in the usual horizontal mattress fashion.  Also, it should be noted that the rotator cuff interval had to be released as part of the exposure.  We started the repair by closing the rotator cuff interval.  Anterior and posterior translation was then performed and was found to be very stable.  The remaining sutures were then secured through the subscapularis tendon taking care to make sure that very substantial bites were obtained.  This was then reinforced with the more flimsy tissue laterally being sewn into the tissue around the bicipital tuberosity essentially provided us with a two-layer repair of the subscapularis tendon.  After the tendon had been repaired, there was no tension on repair until 0 degrees external rotation was reached with the arm to the side.  Similarly with the arm abducted 90 degrees, tension was on repair at 0 degrees of external rotation.  It should be noted that the wound was thoroughly irrigated throughout with antibiotic impregnated irrigation.  The rotator cuff interval was closed with multiple number 2 Tycron sutures.  It was reinforced with 0 Vicryl sutures.  Two Hemovac drains were then placed inferiorly at the deltoid.  The deltopectoral interval was then closed with 0 Vicryl sutures.  A third drain was placed in the subcutaneous tissues to prevent any infections or any fluid collections.  This was sewn into place with the drain pulled out superiorly.  Once all the sutures have been secured and the drain visualized throughout this part of the closure, the drain was pulled distally until it was completely covered.  There were no signs that it had been tagged or hung up by any sutures.,The superficial subcutaneous tissues were closed with interrupted with 2-0 Vicryl sutures.  Skin was closed with staples.  A sterile bandage was applied along with a cold therapy device and a shoulder immobilizer.  The patient was sent to the intensive care unit in stable and satisfactory condition.,Due to the significant amount of scar and bleeding in this patient, a 22 modifier is being requested for this case.  This was a very difficult revision case and was significantly increased in technical challenges and challenges in the dissection and exposure of this implant compared to a standard shoulder replacement.  Similarly, the repair of the subscapularis tendon presented significantly more challenges than that of a standard rotator cuff repair because of the implant.  This was being dictated for insurance purposes only and reflects no inherent difficulties with this case.  The complexity and the time involved in this case was approximately 30% greater than that of a standard shoulder replacement or of a rotator cuff repair.  This is being dictated to indicate this was a revision case with significant amount of scar and bleeding due to the patient's situation with his pacemaker.  This patient also had multiple medical concerns, which increased the complexity of this case including the necessity to place him in intensive care unit postoperatively for observation.
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DESCRIPTION: Arthrotomy, removal humeral head implant, right shoulder.  Repair of torn subscapularis tendon (rotator cuff tendon) acute tear.  Debridement glenohumeral joint.  Biopsy and culturing the right shoulder.

surgery, arthrotomy, repair of torn subscapularis tendon, glenohumeral joint, biomet system, arthroplasty, diffuse synovitis, proximal humerus, torn subscapularis tendon, subscapularis tendon, rotator cuff, humerus, sutures, tendon, head, shoulder, subscapularis, torn,

The situation involves a complex surgical procedure with significant risks and challenges. A revision surgery on the shoulder involving removal of a humeral head implant, repair of a torn subscapularis tendon, and additional interventions is inherently high-stakes due to the potential complications, such as nerve or artery damage, infection, and loss of function. The patient has a pacemaker, adding to the complexity due to the need for special precautions during surgery. The procedure's complexity is further increased by significant scar tissue, bleeding, and the need for intensive post-operative care. These factors elevate the stakes as they could have serious consequences for the patient's future health and functionality.


Medical Specialty: Radiology
Sample Name: MRI Ankle - 2

EXAM:,MRI OF THE RIGHT ANKLE,CLINICAL:,Pain.,FINDINGS:,The bone marrow demonstrates normal signal intensity. There is no evidence of bone contusion or fracture. There is no evidence of joint effusion. Tendinous structures surrounding the ankle joint are intact. No abnormal mass or fluid collection is seen surrounding the ankle joint.,IMPRESSION,: NORMAL MRI OF THE RIGHT ANKLE.
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DESCRIPTION: MRI right ankle.

MRI right ankle.

radiology, ankle joint, bone, mri, ankle

The MRI results indicate that the right ankle is normal, with no evidence of bone contusion, fracture, or other abnormalities such as joint effusion or mass. While the patient is experiencing pain, the findings do not point to an urgent or severe condition based on the imaging results. Given these factors, the situation is not high-stakes from a medical perspective.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Well-Child Check - 7

SUBJECTIVE:,  This is a 1-month-old who comes in for a healthy checkup.  Mom says things are gone very well.  He is kind of acting like he has got a little bit of sore throat but no fevers.  He is still eating well.  He is up to 4 ounces every feeding.  He has not been spitting up.  Voiding and stooling well.,PAST MEDICAL HISTORY:,  Reviewed, very healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,DIETARY: , His formula fed on Enfamil Lipil.  Voiding and stooling well.  Growth chart reviewed with Mom.,DEVELOPMENTAL:,  He is starting to track with his eyes.  He is smiling a little bit, moving hands and feet symmetrically.,PHYSICAL EXAMINATION:,  In general well-developed, well-nourished male in no acute distress.,DERMATOLOGIC:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Anterior fontanel soft and flat.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes present bilaterally.  Does appear to have conjugate gaze.  Ears:  Tympanic membranes are pink to gray, translucent, neutral position, normal light reflex and mobility.  Nares are patent, pink mucosa, moist.  Oropharynx clear with pink mucosa, normal moisture.,NECK:  Supple without masses.,CHEST:  Clear to auscultation and percussion with easy respirations and no accessory muscle use.,CARDIOVASCULAR:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,ABDOMEN:  Soft, nontender, nondistended without hepatosplenomegaly.,GU EXAM:  Normal Tanner I male.  Testes descended bilaterally.  No hernias noted.,EXTREMITIES:  Pink and warm.  Moving all extremities well.  No subluxation of the hips and leg creases appear symmetric.,NEUROLOGIC:  Alert, otherwise nonfocal.  2+ deep tendon reflexes at the knees.  Fixes and follows appropriately to both voice and face.,ASSESSMENT:,  Well child check.,PLAN:,1.  Diet, growth and safety discussed.,2.  Immunizations discussed and updated with hepatitis B.,3.  Return to clinic at two months of age.  Call if problems.
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DESCRIPTION: 1-month-old for a healthy checkup - Well child check

The situation describes a routine 1-month well-child checkup for a healthy infant, which is a standard pediatric practice. The child is showing normal developmental progress and has no pressing medical issues. Given the absence of acute distress or significant medical concerns, the stakes are low in terms of immediate health risks or decision-making required.


Medical Specialty: Surgery
Sample Name: Abdominal Exploration

PREOPERATIVE DIAGNOSES:  ,1.  Congenital chylous ascites and chylothorax.,2.  Rule out infradiaphragmatic lymphatic leak.,POSTOPERATIVE DIAGNOSES: , Diffuse intestinal and mesenteric lymphangiectasia.,ANESTHESIA: , General.,INDICATION:  ,The patient is an unfortunate 6-month-old baby boy, who has been hospitalized most of his life with recurrent chylothoraces and chylous ascites.  The patient has been treated somewhat successfully with TPN and voluntary restriction of enteral nutrition, but he had repeated chylothoraces.  Last week, Dr. X took the patient to the operating room in hopes that with thoracotomy, a thoracic duct leak could be found, which would be successfully closed surgically.  However at the time of his thoracotomy exploration what was discovered was a large amount of transdiaphragmatic transition of chylous ascites coming from the abdomen.  Dr. X opened the diaphragm and could literally see a fountain of chylous fluid exiting through the diaphragmatic hole.  This was closed, and we decided that perhaps an abdominal exploration as a last stage effort would allow us to find an area of lymphatic leak that could potentially help the patient from this dismal prognostic disease.  We met with his parents and talked to them about this, and he is here today for that attempt.,OPERATIVE FINDINGS:  ,The patient's abdomen was relatively soft, minimally distended.  Exploration through supraumbilical transverse incision immediately revealed a large amount of chylous ascites upon entering into the peritoneal cavity.  What we found which explains the chronic chylous ascites and chylothorax was a diffuse lymphangiectatic picture involving the small bowel mesentery approximately two thirds to three quarters of the distal small bowel including all of the ileum, the cecum, and the portion of the ascending colon.  It appeared that any attempt to resect this area would have been met with failure because of the extensive lymphatic dilatation all the way down towards the root of the supramesenteric artery.  There was about one quarter to one third of the jejunum that did not appear to be grossly involved, but I did not think that resection of three quarters of the patient's small bowel would be viable surgical option.  Instead, we opted to close his abdomen and refer for potential small intestine transplantation procedure in the future if he is a candidate for that.,The lymphatic abnormality was extensive.  They were linear dilated lymphatic channels on the serosal surface of the bowel in the mesentery.  They were small aneurysm-like pockets of chyle all along the course of the mesenteric structures and in the mesentery medially adjacent to the bowel as well.  No other major retroperitoneal structure or correctable structure was identified.  Both indirect inguinal hernias were wide open and could be palpated from an internal aspect as well.,DESCRIPTION OF OPERATION:  ,The patient was brought from the Pediatric Intensive Care Unit to the operating room within an endotracheal tube im place and with enteral feeds established at full flow to provide maximum fat content and maximum lymphatic flow.  We conducted a surgical time-out and reiterated all of the patient's important identifying information and confirmed the operative plan as described above.  Preparation and draping of his abdomen was done with chlorhexidine based prep solution and then we opened his peritoneal cavity through a transverse supraumbilical incision dividing both rectus muscles and all layers of the abdominal wall fascia.  As the peritoneal cavity was entered, we divided the umbilical vein ligamentum teres remnant between Vicryl ties, and we were able to readily identify a large amount of chylous ascites that had been previously described.  The bowel was eviscerated, and then with careful inspection, we were able to identify this extensive area of intestinal and mesenteric lymphangiectasia that was a source of the patient's chylous ascites.  The small bowel from the ligament of Treitz to the proximal to mid jejunum was largely unaffected, but did not appear that resection of 75% of the small intestine and colon would be a satisfactory tradeoff for The patient, but would likely render him with significant short bowel and nutritional and metabolic problems.  Furthermore, it might burn bridges necessary for consideration of intestinal transplantation in the future if that becomes an option.  We suctioned free all of the chylous accumulations, replaced the intestines to their peritoneal cavity, and then closed the patient's abdominal incision with 4-0 PDS on the posterior sheath and 3-0 PDS on the anterior rectus sheath.  Subcuticular 5-0 Monocryl and Steri-Strips were used for skin closure.,The patient tolerated the procedure well.  He lost minimal blood, but did lose approximately 100 mL of chylous fluid from the abdomen that was suctioned free as part of the chylous ascitic leak.  The patient was returned to the Pediatric Intensive Care Unit with his endotracheal tube in place and to consider the next stage of management, which might be an attempted additional type of feeding or referral to an Intestinal Transplantation Center to see if that is an option for the patient because he has no universally satisfactory medical or surgical treatment for this at this time.
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DESCRIPTION: Congenital chylous ascites and chylothorax and rule out infradiaphragmatic lymphatic leak.   Diffuse intestinal and mesenteric lymphangiectasia.

surgery, intestinal, mesenteric, lymphangiectasia, ascites, chylothorax, lymphatic leak, infradiaphragmatic, abdominal exploration, congenital chylous, mesenteric lymphangiectasia, peritoneal cavity, chylous, abdominal, congenital, abdomen, lymphatic

The scenario involves a complex surgical procedure on a six-month-old infant with a serious and rare medical condition, congenital chylous ascites, and chylothorax. The condition is life-threatening and has resulted in the patient being hospitalized for most of his life. The surgical intervention explored the possibility of correcting a significant lymphatic leak that affects the patient's quality of life and survival prospects. The stakes are high because the outcome impacts the infant's immediate health and future treatment options, such as the potential need for an intestinal transplant. Given the severity of the condition, the involvement of critical organs like the intestines and lymphatic system, and the potential life-long implications, this is a high-stakes situation.


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

ADMISSION DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Symptomatic fibroid uterus.,DISCHARGE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Symptomatic fibroid uterus.,4.  Extensive adenomyosis by pathological report.,OPERATION PERFORMED: , On 6/10/2009 total abdominal hysterectomy (TAH).,COMPLICATIONS:,  None.,BLOOD TRANSFUSIONS: , None.,INFECTIONS: , None.,SIGNIFICANT LAB AND X-RAY: , On admission hemoglobin and hematocrit was 10.5 and 32.8 respectively.  On discharge, hemoglobin and hematocrit 7.9 and 25.2.,HOSPITAL COURSE AND TREATMENT:  ,The patient was admitted to the surgical suite and taken to the operating room on 6/10/2009 where a total abdominal hysterectomy (TAH) with low intraoperative complication was performed.  The patient tolerated all procedures well.  On the 1st postoperative day, the patient was afebrile and all vital signs were stable.  On the 3rd postoperative day, the patient was ambulating with difficulty and tolerating clear liquid diet.  On the 4th postoperative day, the patient was complaining of pain in her back and abdomen as well as incisional wound tenderness.  On the 5th postoperative day, the patient was afebrile.  Vital signs were stable.  The patient was tolerating a diet and ambulating without difficulty.  The patient was desirous of going home.  The patient denied any abdominal pain or flank pain.  The patient had minimal incisional wound tenderness.  The patient was desirous of going home and was discharged home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:,  Regular diet, bedrest x1 week with slow return to normal activity over the ensuing 4 to 6 weeks, pelvic rest for 6 weeks.  Motrin 600 mg tablets 1 tablet p.o. q.8h. p.r.n. pain, Colace 100 mg tablets 1 tablet p.o. daily p.r.n. constipation and ferrous sulfate 60 mg tablets 1 tablet p.o. daily, and multiple vitamin 1 tablet p.o. daily.  The patient is to return on Wednesday 6/17/2009 for removal of staples.  The patient was given a full explanation of her clinical condition.  The patient was given full and complete postoperative and discharge instructions.  All her questions were answered.
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DESCRIPTION: Total abdominal hysterectomy (TAH).  Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and symptomatic fibroid uterus.

discharge summary, adenomyosis, total abdominal hysterectomy, fibroid uterus, postoperative day, hemoglobin, hematocrit, therapy, menometrorrhagia, anemia, fibroid, uterus, tah, hysterectomy, abdominal,

The situation involves a discharge summary for a patient who underwent a total abdominal hysterectomy (TAH). While this is a significant medical procedure, the document indicates that there were no complications, infections, or blood transfusions needed. The patient's condition was stable upon discharge, and they were given standard postoperative instructions. Despite low hemoglobin levels noted, this document appears administrative and routine for post-surgery care in a stable patient.


Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 7

SUBJECTIVE:,  The patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea.  Apparently, his brother had similar symptoms.  They had eaten some chicken and then ate some more of it the next day, and I could not quite understand what the problem was because there is a little bit of language barrier, although dad was trying very hard to explain to me what had happened.  But any way, after he and his brother got done eating with chicken, they both felt bad and have continued to feel bad.  The patient has had diarrhea five to six times a day for the last four days and then he had emesis pretty frequently three days ago and then has just had a couple of it each day in the last two days.  He has not had any emesis today.  He has urinated this morning.  His parents are both concerned because he had a fever of 103 last night.  Also, he ate half of a hamburger yesterday and he tried drinking some milk and that is when he had an emesis.  He has been drinking Pedialyte, Gatorade, white grape juice, and 7Up, otherwise he has not been eating anything.,MEDICATIONS:  ,None.,ALLERGIES:  ,He has no known drug allergies.,REVIEW OF SYSTEMS:,  Negative as far as sore throat, earache, or cough.,PHYSICAL EXAMINATION:,General:  He is awake and alert, no acute distress.,Vital Signs:  Blood pressure:  106/75.  Temperature:  99.  Pulse:  112.  Weight is 54 pounds.,HEENT:  His TMs are normal bilaterally.  Posterior pharynx is unremarkable.,Neck:  Without adenopathy or thyromegaly.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur.,Abdomen:  Benign.,Skin:  Turgor is intact.  His capillary refill is less than 3 seconds.,LABORATORY: , White blood cell count is 5.3 with 69 segs, 15 lymphs, and 13 monos.  His platelet count on his CBC is 215.,ASSESSMENT:,  Viral gastroenteritis.,PLAN:,  The parents did point out to me a rash that he had on his buttock.  There were some small almost pinpoint erythematous patches of papules that have a scab on them.  I did not see any evidence of petechiae.  Therefore, I just reassured them that this is a viral gastroenteritis.  I recommended that they stop giving him juice and just go with the Gatorade and water.  He is to stay away from milk products until his diarrhea and stomach upset have calmed down.  We talked about BRAT diet and slowly advancing his diet as he tolerates.  They have used some Kaopectate, which did not really help with the diarrhea.  Otherwise follow up as needed.
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DESCRIPTION: Patient with a three-day history of emesis and a four-day history of diarrhea

general medicine, diarrhea, emesis, history of, gastroenteritis, viral, brat diet, progress note,

The situation involves a 7-year-old child with symptoms of viral gastroenteritis, including diarrhea and vomiting. While dehydration is a concern, the child appears to be alert, with no severe signs of dehydration or systemic infection, given his vital signs and laboratory results. The rash observed is not concerning for a more serious condition. The management plan involves hydration and dietary adjustments, which are standard care measures. Therefore, while attention and care are required to avoid potential dehydration, the situation does not involve immediate life-threatening conditions, making it relatively low-stakes.


Medical Specialty: Speech - Language
Sample Name: Cognitive Linguistic Impairment - Discharge

DIAGNOSIS: , Cognitive linguistic impairment secondary to stroke.,NUMBER OF SESSIONS COMPLETED:,  5,HOSPITAL COURSE:  ,The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.  Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall.  The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities.  At this time, the patient has accomplished all 5 of her short-term therapy goals.  She is able to complete functional mass tasks with 100% accuracy independently.  She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently.,She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently.  She is able to state 15 items in a broad category within a minute and a half independently.  The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently.  The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home.  The patient is no longer in need of skilled speech therapy and is discharged from my services.  She did quite well in therapy and also agreed with this discharge.
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DESCRIPTION: Cognitive linguistic impairment secondary to stroke.  The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.

speech - language, stroke, linguistic deficits, speech therapy, skilled speech therapy, linguistic impairment, cognitive linguistic, cognitive, linguistic,

The situation described involves a discharge summary of a patient who has successfully completed speech therapy for cognitive linguistic impairment secondary to a stroke. The patient has met all short-term and long-term therapy goals, indicating that she has made significant progress in her recovery. She is now able to recall and process information independently and is ready to return to her teaching role and manage her independence and safety at home. The situation does not indicate any immediate risk or emergency, as therapy has been successfully completed, and the patient agrees with the discharge. Therefore, it is a routine discharge situation with no high-stake elements involved.


Medical Specialty: Hematology - Oncology
Sample Name: Hyperfractionation

HYPERFRACTIONATION,This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy.  The radiotherapy will be given in a hyperfractionated fraction (decreased dose per fraction but 2 fractions delivered daily separated by a period of at least 6 hours).  The rationale for this treatment is based on radiobiologic principles that make this type of therapy more effective in rapidly growing, previously irradiated or poorly oxygenated tumors.  The dose per fraction and the total dose are calculated by me, and this is individualized for each patient according to radiobiologic principles.,During the hyperfractionated radiotherapy, the chance of severe acute side effects is increased, so the patient will be followed more intensively for the development of any side effects and treatment instituted accordingly.
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DESCRIPTION: Hyperfractionation.  This patient is to undergo a course of hyperfractionated radiotherapy in the treatment of known malignancy.

hematology - oncology, irradiated, oxygenated, tumors, malignancy, radiobiologic, hyperfractionation, hyperfractionated, radiotherapyNOTE,: 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 described involves hyperfractionated radiotherapy, which is used to treat malignancies, particularly aggressive or hard-to-treat tumors. The procedure uses multiple fractions of radiation to potentially increase the effectiveness of treatment, but also increases the risk of severe acute side effects. Since the patient's treatment and well-being directly depend on the precise administration and monitoring of this therapy, any errors or oversight could negatively affect the treatment outcome or exacerbate side effects.


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

SUBJECTIVE:,  This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04.  She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema.  I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion.  She comes in today for reevaluation because she is flaring.  Her hands are very dry, they are cracked, she has been washing with soap.  She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin.  She has been wearing some gloves also apparently.  The patient is single.  She is unemployed.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has asthma, sinus, hives, and history of psoriasis.  No known drug allergies.,MEDICATIONS: , The patient is a nonsmoker.  No bad sunburns or blood pressure problems in the past.,CURRENT MEDICATIONS:,  Claritin and Zyrtec p.r.n.,PHYSICAL EXAMINATION:,  The patient has very dry, cracked hands bilaterally.,IMPRESSION:,  Hand dermatitis.,TREATMENT:,1.  Discussed further treatment with the patient and her interpreter.,2.  Apply Aristocort ointment 0.1% and equal part of Polysporin ointment t.i.d. and p.r.n. itch.,3.  Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion.,4.  Keflex 500 mg b.i.d. times two weeks with one refill.  Return in one month if not better; otherwise, on a p.r.n. basis and send Dr. XYZ a letter on this office visit.
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DESCRIPTION: Hand dermatitis.

Hand dermatitis.

soap / chart / progress notes, cetaphil cleansing lotion, hand dermatitis, aristocort, wash, ointment, hand, lotion, dermatitis

The scenario described is a routine follow-up visit for an established dermatological condition, hand dermatitis, which is not immediately life-threatening. While it affects the patient's quality of life, it does not present an urgent or high-risk medical situation at this point. The treatment plan involves common dermatological interventions and is handled on an outpatient basis with follow-up appointments, indicating it's being managed effectively as a chronic condition rather than an acute medical emergency.


Medical Specialty: Neurology
Sample Name: MRI Brain - Pilocytic Astrocytoma

CC:, Headache.,HX: ,The patient is an 8y/o RHM with a 2 year history of early morning headaches (3:00-6:00AM) intermittently relieved by vomiting only. He had been evaluated 2 years ago and an EEG was "normal" then, but no brain imaging was performed. His headaches progressively worsened, especially in the past two months prior to this presentation. For 2 weeks prior to his 1/25/93 evaluation at UIHC, he would awake screaming. His parent spoke with a local physician who thought this might be due to irritability secondary to pinworms and,Vermox was prescribed and arrangements were made for a neurologic evaluation. On the evening of 1/24/93 the patient awoke screaming and began to vomit. This was followed by a 10 min period of tonic-clonic type movements and postictal lethargy. He was taken to a local ER and a brain CT revealed an intracranial mass. He was given Decadron and Phenytoin and transferred to UIHC for further evaluation.,MEDS:, noted above.,PMH: ,1)Born at 37.5 weeks gestation by uncomplicated vaginal delivery to a G1P0 mother. Pregnancy complicated by vaginal bleeding at 7 months. Met developmental milestones without difficulty. 2) Frequent otitis media, now resolved. 3) Immunizations were "up to date.",FHX:, non-contributory.,SHX:, lives with biologic father and mother. No siblings. In 3rd grade (mainstream) and maintaining good marks in schools.,EXAM:, BP121/57mmHg HR103 RR16 36.9C,MS: Sleepy, but cooperative.,CN: EOM full and smooth. Advanced papilledema, OU. VFFTC. Pupils 4/4 decreasing to 2/2. Right lower facial weakness. Tongue midline upon protrusion. Corneal reflexes intact bilaterally.,Motor: 5/5 strength. Slightly increased muscle on right side.,Sensory. No deficit to PP/VIB noted.,Coord: normal FNF, HKS and RAM, bilaterally.,Station: Mild truncal ataxia. Tends to fall backward.,Reflexes: BUE 2+/2+, Patellar 3/3, Ankles 3+/3+ with 6 beats of nonsustained clonus bilaterally.,Gen exam: unremarkable.,COURSE:, The patient was continued on Dilantin 200mg qd and Decadron 5mg IV q6hrs. Brain MRI, 1/26/93, revealed a large mass lesion in the region of the left caudate nucleus and thalamus which was hyperintense on T2 weighted images. There were areas of cystic formation at its periphery. The mass appeared to enhance on post gadolinium images. there was associated white matter edema and compression of the left lateral ventricle, and midline shift to the right. There was no sign of uncal herniation. He underwent bilateral VP shunting on 1/26/93; and then, subtotal resection (left frontal craniotomy with excision of the left caudate and thalamus with creation of an opening in the septum pellucidum) on 1/28/93. He then received 5040cGy of radiation therapy in 28 fractions completed on 3/25/93. A 3/20/95 neuropsychological evaluation revealed low average intellect on the WISC-III. There were also signs of memory, attention, reading and spelling deficits; and mild right-sided motor incoordination and mood variability. He remained in mainstream classes at school, but his physical and cognitive performance began to deteriorate in 4/95. Neurosurgical evaluation in 4/95 noted increased right hemiplegia and right homonymous hemianopia. MRI revealed tumor progression and he was subsequently placed on Carboplatin/VP-16 (CG 9933 protocol chemotherapy, regimen A). He was last seen on 4/96 and was having difficulty in the 6th grade; he was also undergoing physical therapy for his right hemiplegia.
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DESCRIPTION: MRI Brain - Pilocytic Astrocytoma in thalamus and caudate.

neurology, mri brain, pilocytic astrocytoma, caudate, thalamus, headache, astrocytoma, hemiplegia, pilocytic, mri,

The case involves a young child with a serious medical condition, specifically a brain tumor (pilocytic astrocytoma) in critical regions of the brain, such as the thalamus and caudate. This has already led to severe symptoms and required extensive interventions including surgery, radiation, and chemotherapy. The situation affects the child's neurological functions and cognitive abilities, impacting his quality of life significantly. The stakes are high due to the potential for further neurological decline, risk of complications from treatments, and the overall impact on the child's development and future. Given the complexity and sensitivity of managing a brain tumor in a child, this situation is very high-stakes.


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

Medical Specialty: Neurosurgery
Sample Name: Decompressive Laminectomy

PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:,  T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click'X System using 6.5 mm diameter x 40 mm length T11 screws and L1 screws, 7 mm diameter x 45 mm length.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  400 mL, replaced 2 units of packed cells.,Preoperative hemoglobin was less than 10.,DRAINS:,  None.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , With the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the T12-L1 interspace.  An incision was made over the posterior spinous process of T10, T11, T12, L1, and L2.  A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10, T11, T12, L1, and L2.  An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator.  The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent.  Initially, on the patient's left side, pedicle screws were placed in T11 and L1.  The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle.  Placement confirmed with biplanar coaxial fluoroscopy.  The awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of T11.  A 40-mm Click'X screw, 6.5 mm diameter with rod holder was then threaded into the T11 vertebral body.,Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an AM-8 dissecting tool, AM attachment to the Midas Rex instrumentation.  The area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in L1.  Using a pedicle probe, the pedicle was then probed to the mid body of L1 and a 7-mm diameter 45-mm in length Click'X Synthes screw with rod holder was placed in the L1 vertebral body.,At this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient's ventral canal on the right side.  Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis.  The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur.  It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12.,At this point, a laminectomy was performed using 45-degree Kerrison rongeur, both 2 mm and 4 mm, and Leksell rongeur.  There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11-T12 interlaminar space.  Additionally, there was marked instability of the facets bilaterally at T12 and L1.  These facets were removed with 45-degree Kerrison rongeur and Leksell rongeur.  Bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree Kerrison rongeur until the thecal sac was completely decompressed.  The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors, and these nerve roots were noted to be completely free.  Hemostasis was controlled with bipolar coagulation.,At this point, a Frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the T11-T12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile.  A #4 Penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac.  Copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at T11 and L1 using the technique described for a left-sided pedicle screw placement.  The anatomic landmarks being the transverse process at T11, the inferior articulating facet, and the lateral aspect of the superior articular facet for T11 and at L1, the transverse process, the junction of the intra-articular process and the facet joint.,With the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed.  It was felt that distraction was not necessary.  A 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod.  The locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld.  Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11-T12 or T12-L1 with excellent positioning of the rods and screws.  A crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,It should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11, T12, and L1 with AM-8 dissecting tool, AM attachment as well as the lateral aspects of the facet joints.  This was done bilaterally prior to placement of the rods.,Following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters.  Gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 Vicryl suture.  The fascia was closed with interrupted 0 Vicryl suture, subcutaneous layer was closed with 2-0 Vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted Vicryl suture, and the skin approximated with staples.  The patient appeared to tolerate the procedure well without complications.
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DESCRIPTION: Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.

neurosurgery, facetectomies, decompression, posterolateral fusion, synthes click'x system, decompressive laminectomy, leksell rongeur, kerrison rongeur, transverse processes, thecal sac, nerve roots, pedicle screws, spinous process, pedicle, process, screws, rods, laminectomy, decompressive, spinous,

The situation involves a complex neurosurgical procedure addressing a T12 compression fracture with cauda equina syndrome and spinal cord compression, conditions that can have severe consequences if not properly managed. The described surgery, a decompressive laminectomy supplemented with spinal instrumentation, is a high-stakes operation given the potential impact on the patient's neural function and overall health. Any complications could result in significant neurological deficits or other serious health issues.


Medical Specialty: Consult - History and Phy.
Sample Name: Ischemic Cecum - Consult

REASON FOR CONSULTATION: , Pneumatosis coli in the cecum.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 87-year-old gentleman who was admitted on 10/27/07 with weakness and tiredness with aspiration pneumonia.  The patient is very difficult to obtain information from; however, he appears to be having frequent nausea and vomiting with an aspiration pneumonia and abdominal discomfort.  In addition, this hospitalization, he has undergone an upper endoscopy, which found a small ulcer after dropping his hematocrit and becoming anemic.  He had a CT scan on Friday, 11/02/07, which apparently showed pneumatosis and his cecum worrisome for ischemic colitis as well as bilateral hydronephrosis and multiple liver lesions, which could be metastatic disease versus cysts.  In discussions with the patient, he had multiple bowel movements yesterday and is currently passing flatus and has epigastric pain.,PAST MEDICAL HISTORY:  ,Obtained from the medical chart.  Chronic obstructive pulmonary disease, history of pneumonia, and aspiration pneumonia, osteoporosis, alcoholism, microcytic anemia.,MEDICATIONS: , Per his current medical chart.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient had a long history of smoking but quit many years ago.  He does have chronic alcohol use.,PHYSICAL EXAMINATION:,GENERAL:  A very thin white male who is dyspneic and having difficulty breathing at the moment.,VITAL SIGNS:  Afebrile.  Heart rate in the 100s to 120s at times with atrial fibrillation.  Respiratory rate is 17-20.  Blood pressure 130s-150s/60s-70s.,NECK:  Soft and supple, full range of motion.,HEART:  Regular.,ABDOMEN:  Distended with tenderness mainly in the upper abdomen but very difficult to localize due to his difficulty providing information.  He does appear to have tenderness but does not have rebound and does not have peritoneal signs.,DIAGNOSTICS: , A CT scan done on 11/02/07 shows pneumatosis in the cecum with an enlarged cecum filled with stool and air fluid levels with chronically dilated small bowel.,ASSESSMENT: , Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.,PLAN: , The patient appears to have pneumatosis from a CT scan 2 days ago.  Nothing was done about it at that time as the patient appeared to not be symptomatic, but he continues to have nausea and vomiting with abdominal pain, but the fact that pneumatosis was found 2 days ago and the patient has survived this long indicates this may be a benign process at the moment, and I would recommend getting a repeat CT scan to assess it further to see if there is worsening of pneumatosis versus resolution to further evaluate the liver lesions and make decisions regarding planning at that time.  The patient has frequent desaturations secondary to his aspiration pneumonia, and any surgical procedure or any surgical intervention would certainly require intubation, which would then necessitate long-term ventilator care as he is not someone who would be able to come off of a ventilator very well in his current state.  So we will look at the CT scan and make decisions based on the findings as far as that is concerned.
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DESCRIPTION: Pneumatosis coli in the cecum.  Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.

consult - history and phy., ischemic cecum, metastatic disease, bilateral hydronephrosis, chronic alcohol abuse, acute renal failure, copd, anemia, gastric ulcer, pneumatosis coli, cecum, aspiration pneumonia, aspiration, ischemic, atrial, metastatic, hydronephrosis, fibrillation, pneumatosis, pneumonia,

The situation involves a complex medical case with an elderly patient presenting multiple comorbidities, including possible ischemic cecum, metastatic disease, aspiration pneumonia, and cardiovascular issues. The stakes are high because failure to appropriately diagnose and manage the conditions can lead to serious or fatal outcomes. Interventions need to be carefully considered due to the patient's frail condition, age, and the presence of aspiration pneumonia, which complicates surgical options and recovery. There is a need for immediate and precise medical decision-making, especially considering potential systemic complications.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med SOAP - 3

S:,  XYZ is in today not feeling well for the last three days.  She is a bit sick with bodyaches.  She is coughing.  She has a sore throat, especially when she coughs.  Her cough is productive of green colored sputum.  She has had some chills.  No vomiting.  No diarrhea.  She is sleeping okay.  She does not feel like she needs anything for the cough.  She did call in yesterday, and got a refill of her Keflex.  She took two Keflex this morning and she is feeling a little bit better now.  She is tearful, just tired of feeling ran down.,O:,  Vital signs as per chart.  Respirations 15.  Exam:  Nontoxic.  No acute distress.  Alert and oriented.  HEENT:  TMs are clear bilaterally without erythema or bulging.  Clear external canals.  Clear tympanic.  Conjunctivae are clear.  Clear nasal mucosa.  Clear oropharynx with moist mucous membranes.  NECK is soft and supple without lymphadenopathy.  LUNGS are coarse with no severe rhonchi or wheezes.  HEART is regular rate and rhythm without murmur.  ABDOMEN is soft and nontender.,Chest x-ray reveals no obvious consolidation or infiltrates.  We will send the x-ray for over-read.,Influenza test is negative.  Rapid strep screen is negative.,A:,  Bronchitis/URI.,P: , ,1.  Motrin as needed for fever and discomfort.,2.  Push fluids.,3.  Continue on the Keflex.,4.  Follow up with Dr. ABC if symptoms persist or worsen, otherwise as needed.
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DESCRIPTION: General Medicine SOAP note.

General Medicine SOAP note.

soap / chart / progress notes, bodyaches, alert and oriented, no acute distress, soap, diarrhea, general medicine, lymphadenopathy, regular rate and rhythm, rhonchi, soft and nontender, supple, vomiting, wheezes, coughing, keflex, oriented,

The given situation involves a patient case that appears to deal with an upper respiratory infection, common bronchitis, or URI. The patient has already been prescribed antibiotics and is being managed with symptomatic treatment. No acute distress or life-threatening conditions are noted in the assessment, and the patient has clear directions for follow-up should symptoms persist or worsen. While all medical situations require some level of attention, this case does not carry immediate high-stakes elements, such as critical or rapidly deteriorating conditions.


Medical Specialty: Office Notes
Sample Name: Induction of Vaginal Delivery

DIAGNOSES,1.  Term pregnancy.,2.  Possible rupture of membranes, prolonged.,PROCEDURE:,  Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:,  The patient is a 20-year-old female, gravida 4, para 0, who presented to the office.  She had small amount of leaking since last night.  On exam, she was positive Nitrazine, no ferning was noted.  On ultrasound, her AFI was about 4.7 cm.  Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin.  Once she was in her regular pattern, we ruptured her bag of water; fluid was clear.  She went rapidly to completion over the next hour and a half.  She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation.  Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications.  The baby was vigorous, moving all extremities.  The cord was clamped and cut.  The baby was handed off to mom with nurse present.  Apgars were 8 and 9.  Placenta was delivered spontaneously, intact.  Three-vessel cord with no retained placenta.  Estimated blood loss was about 150 mL.  There were no tears.
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DESCRIPTION: Induction of vaginal delivery of viable male, Apgars 8 and 9.  Term pregnancy and oossible rupture of membranes, prolonged.

office notes, induction of vaginal delivery, vaginal delivery, viable male, pregnancy, placenta, vaginal, membranes, apgars

The scenario involves the induction of vaginal delivery, which can be considered high-stakes due to the potential risks involved in childbirth, both for the mother and the baby. Factors such as the possible rupture of membranes and the use of medication like Pitocin add complexity and potential risk. Despite this, the document indicates a positive outcome with no complications or tears and healthy Apgar scores for the newborn, which mitigates the stakes to some extent. However, the context of childbirth, especially with possible complications, inherently involves significant risk.


Medical Specialty: Radiology
Sample Name: Bilateral Carotid Angiography

PROCEDURE PERFORMED:,1.  Selective ascending aortic arch angiogram.,2.  Selective left common carotid artery angiogram.,3.  Selective right common carotid artery angiogram.,4.  Selective left subclavian artery angiogram.,5.  Right iliac angio with runoff.,6.  Bilateral cerebral angiograms were performed as well via right and left common carotid artery injections.,INDICATIONS FOR PROCEDURE: , TIA, aortic stenosis, postoperative procedure.  Moderate carotid artery stenosis.,ESTIMATED BLOOD LOSS:,  400 ml.,SPECIMENS REMOVED:,  Not applicable.,TECHNIQUE OF PROCEDURE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in postabsorptive and nonsedated state.  The right groin was prepped and draped in the usual sterile fashion.  Lidocaine 2% was used for infiltration anesthesia.  Using modified Seldinger technique, a 6-French sheath was placed into the right common femoral artery and vein without complication.  Using injection through the side port of the sheath, a right iliac angiogram with runoff was performed.  Following this, straight pigtail catheter was used to advance the aortic arch and aortic arch angiogram under digital subtraction was performed.  Following this, selective engagement in left common carotid artery, right common carotid artery, and left subclavian artery angiograms were performed with a V-Tech catheter over an 0.035-inch wire.,ANGIOGRAPHIC FINDINGS:,1.  Type 2 aortic arch.,2.  Left subclavian artery was patent.,3 Left vertebral artery was patent.,4.  Left internal carotid artery had a 40% to 50% lesion with ulceration, not treated and there was no cerebral cross over.,5.  Right common carotid artery had a 60% to 70% lesion which was heavily calcified and was not treated with the summed left-to-right cross over flow.,6.  Closure was with a 6-French Angio-Seal of the artery, and the venous sheath was sutured in.,PLAN:,  Continue aspirin, Plavix, and Coumadin to an INR of 2 with a carotid duplex followup.
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DESCRIPTION: Carotid artery angiograms.

Carotid artery angiograms.

radiology, aortic arch angiogram, carotid artery angiogram, artery was patent, common carotid artery, arch angiogram, subclavian artery, aortic arch, carotid artery, carotid, angiography, artery, angiograms, subclavian, catheterization, aortic, angiogram,

The procedure described is a complex and invasive angiographic examination involving critical arteries that supply the brain, such as the carotid and subclavian arteries. The context suggests that the stakes are significant, given the potential risk associated with procedural complications and the fact that the findings revealed a substantial lesion in the carotid artery, which can lead to severe outcomes like stroke. The high level of medical specialization required and the potential consequences of findings or complications elevate the stakes. Furthermore, there is an ongoing management plan involving anticoagulant medication, which also necessitates careful monitoring due to bleeding risks.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 52

CHIEF COMPLAINT: , Anxiety, alcohol abuse, and chest pain.,HISTORY OF PRESENT ILLNESS:,  This is a pleasant 40-year-old male with multiple medical problems, basically came to the hospital yesterday complaining of chest pain.  The patient states that he complained of this chest pain, which is reproducible, pleuritic in both chest radiating to the left back and the jaw, complaining of some cough, nausea, questionable shortness of breath.  The patient describes the pain as aching, sharp and alleviated with pain medications, not alleviated with any nitrates.  Aggravated by breathing, coughing, and palpation over the area.  The pain was 9/10 in the emergency room and he was given some pain medications in the ER and was basically admitted.  Labs were drawn, which were essentially, potassium was about 5.7 and digoxin level was drawn, which was about greater than 5.  The patient said that he missed 3 doses of digoxin in the last 3 days after being discharged from Anaheim Memorial and then took 3 tablets together.  The patient has a history prior digoxin overdose of the same nature.,MEDICATIONS:,  Digoxin 0.25 mg, metoprolol 50 mg, Naprosyn 500 mg, metformin 500 mg, lovastatin 40 mg, Klor-Con 20 mEq, Advair Diskus, questionable Coreg.,PAST MEDICAL HISTORY: , MI in the past and atrial fibrillation, he said that he has had one stent put in, but he is not sure.  The last cardiologist he saw was Dr. X and his primary doctor is Dr. Y.,SOCIAL HISTORY:,  History of alcohol use in the past.,He is basically requesting for more and more pain medications.  He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid.  His pain is tolerable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Stable.,GENERAL:  Alert and oriented x3, no apparent distress.,HEENT:  Extraocular muscles are intact.,CVS:  S1, S2 heard.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema or clubbing.,NEURO:  Grossly intact.  Tender to palpate over the left chest, no obvious erythema or redness, or abnormal exam is found.,EKG basically shows atrial fibrillation, rate controlled, nonspecific ST changes.,ASSESSMENT AND PLAN:,1.  This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse.  Now, he has had significant block with EKG changes as stated.  Continue to follow the patient clinically at this time.  The patient has been admitted to ICU and will be changed to DOU.,2.  Chronic chest pain with a history of myocardial infarction in the past, has been ruled out with negative cardiac enzymes.  The patient likely has opioid dependence and requesting more and more pain medications.  He is also bargaining for pain medications with me.  The patient was advised that he will develop more opioid dependence and I will stop the pain medications for now and give him only oral pain medications in the anticipation of the discharge in the next 1 or 2 days.  The patient was likely advised to also be seen by a pain specialist as an outpatient after being referred.  We will try to verify his pain medications from his primary doctor and his pharmacy.  The patient said that he has been on Dilaudid and Vicodin ES and Norco and all these medications in the past.
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DESCRIPTION: Anxiety, alcohol abuse, and chest pain.   This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse.  Now, he has had significant block with EKG changes as stated.

consult - history and phy., anxiety, alcohol abuse, chest pain, digoxin toxicity, digoxin overuse, atrial fibrillation, opioid dependence, toxicity, dilaudid,

The situation involves a 40-year-old male with multiple significant medical issues such as anxiety, alcohol abuse, chest pain, and notably, digoxin toxicity, which is a potentially life-threatening condition. He has a complex medical history including myocardial infarction and atrial fibrillation. Additionally, there are complications involving potential opioid dependence or abuse, as the patient is requesting stronger pain medications and has a history of alcohol use. The patient is currently admitted in ICU, indicating the seriousness of the condition. This situation is high-stakes due to the immediate potential risks to the patient's health posed by digoxin toxicity and the challenges linked to managing his medication needs safely, including addressing possible opioid dependence.