Medical Specialty: Obstetrics / Gynecology
Sample Name: Total Abdominal Hysterectomy - 1

PREOPERATIVE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Anemia.,3.  Symptomatic fibroid uterus.,POSTOPERATIVE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Anemia.,3.  Symptomatic fibroid uterus.,PROCEDURE: , Total abdominal hysterectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS: , 150 mL.,COMPLICATIONS: , None.,FINDING:  ,Large fibroid uterus.,PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the usual sterile fashion for an abdominal procedure.  A scalpel was used to make a Pfannenstiel skin incision, which was carried down sharply through the subcutaneous tissue to the fascia.  The fascia was nicked in the midline and incision was carried laterally bilaterally with curved Mayo scissors.  The fascia was then bluntly and sharply dissected free from the underlying rectus abdominis muscles.  The rectus abdominis muscles were then bluntly dissected in the midline and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel.  The peritoneum was then bluntly entered and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel.  The O'Connor-O'Sullivan instrument was then placed without difficulty.  The uterus was grasped with a thyroid clamp and the entire pelvis was then visualized without difficulty.  The GIA stapling instrument was then used to separate the infundibulopelvic ligament in a ligated fashion from the body of the uterus.  This was performed on the left infundibulopelvic ligament and the right infundibulopelvic ligament without difficulty.  Hemostasis was noted at this point of the procedure.  The bladder flap was then developed free from the uterus without difficulty.  Careful dissection of the uterus from the pedicle with the uterine arteries and cardinal ligaments was then performed using #1 chromic suture ligature in an interrupted fashion on the left and right side.  This was done without difficulty.  The uterine fundus was then separated from the uterine cervix without difficulty.  This specimen was sent to pathology for identification.  The cervix was then developed with careful dissection.  Jorgenson scissors were then used to remove the cervix from the vaginal cuff.  This was sent to pathology for identification.  Hemostasis was noted at this point of the procedure.  A #1 chromic suture ligature was then used in running fashion at the angles and along the cuff.  Hemostasis was again noted.  Figure-of-eight sutures were then used in an interrupted fashion to close the cuff.  Hemostasis was again noted.  The entire pelvis was washed.  Hemostasis was noted.  The peritoneum was then closed using 2-0 chromic suture ligature in running pursestring fashion.  The rectus abdominis muscles were approximated using #1 chromic suture ligature in an interrupted fashion.  The fascia was closed using 0 Vicryl in interlocking running fashion.  Foundation sutures were then placed in an interrupted fashion for further closing the fascia.  The skin was closed with staple gun.  Sponge and needle counts were noted to be correct x2 at the end of the procedure.  Instrument count was noted to be correct x2 at the end of the procedure.  Hemostasis was noted at each level of closure.  The patient tolerated the procedure well and went to recovery room in good condition.
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DESCRIPTION: Total abdominal hysterectomy..  Severe menometrorrhagia unresponsive to medical therapy, anemia, and symptomatic fibroid uterus.

obstetrics / gynecology, menometrorrhagia, fibroid, uterus, total abdominal hysterectomy, rectus abdominis muscles, fibroid uterus, suture ligature, therapy, hemostasis, anemia, abdominal,

The total abdominal hysterectomy is a major surgical procedure that involves the removal of the uterus and potentially the cervix, ovaries, and other surrounding tissues. The procedure is typically performed under general anesthesia and is used to address severe conditions such as menometrorrhagia, which is heavy and prolonged menstrual bleeding unresponsive to medical therapy, as well as fibroid-related symptoms and anemia. Although the procedure went well without complications in this case, it is high-stakes due to the inherent risks of major surgery, including potential for significant blood loss, infection, and other surgical complications. The successful outcome is reassuring, but the complexity and nature of the procedure justify its classification as high-stakes.


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

Medical Specialty: Neurology
Sample Name: MRI Brain - Toxoplasmosis

CC:, Lethargy.,HX:, This 28y/o RHM was admitted to a local hospital on 7/14/95 for marked lethargy. He had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. On the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. He denied fevers, chills, sweats, cough, CP, SOB or diarrhea. Upon evaluation locally, he had a temperature of 99.5F and appeared lethargic. He also had anisocoria with left pupil 0.5mm bigger than the right. There was also question of left facial weakness. An MRI was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. He was given 10mg of IV Decardron,100gm of IV Mannitol, intubated and hyperventilated and transferred to UIHC.,He was admitted to the Department of Medicine on 7/14/95, and transferred to the Department of Neurology on 7/17/95, after being extubated.,MEDS ON ADMISSION:, Bactrim DS qd, Diflucan 100mg qd, Acyclovir 400mg bid, Xanax, Stavudine 40mg bid, Rifabutin 300mg qd.,PMH:, 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) HIV/AIDS dx 1991. He was initially treated with AZT, then DDI. He developed chronic diarrhea and was switched to D4T in 1/95. However, he developed severe neuropathy and this was stopped 4/95. The diarrhea recured. He has Acyclovir resistant genital herpes and generalized psoriasis. He most recent CD4 count (within 1 month of admission) was 20.,FHX:, HTN and multiple malignancies of unknown type.,SHX:, Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years.,EXAM: ,7/14/95 (by Internal Medicine): BP134/80, HR118, RR16 on vent, 38.2C, Intubated.,MS: Somnolent, but opened eyes to loud voices and would follow most commands.,CN: Pupils 2.5/3.0 and "equally reactive to light." Mild horizontal nystagmus on rightward gaze. EOM were otherwise intact.,MOTOR: Moved 4 extremities well.,Sensory/Coord/Gait/Station/Reflexes: not done.,Gen EXAM: Penil ulcerations.,EXAM:, 7/17/96 (by Neurology): BP144/73, HR59, RR20, 36.0, extubated.,MS: Alert and mildly lethargic. Oriented to name only. Thought he was a local hospital and that it was 1/17/1994. Did not understand he had a brain lesion.,CN: Pupils 6/5.5 decreasing to 4/4 on exposure to light. EOM were full and smooth. No RAPD or light-near dissociation. papilledema (OU). Right lower facial weakness and intact facial sensation to PP testing. Gag-shrug and corneal responses were intact, bilaterally. Tongue midline.,MOTOR: Grade 5- strength on the right side.,Sensory: no loss of sensation on PP/VIB/PROP testing.,Coord: reduced speed and accuracy on right FNF and right HKS movements.,Station: RUE pronator drift.,Gait: not done.,Reflexes: 2+/2 throughout. Babinski sign present on right and absent on left.,Gen Exam: unremarkable except for the genital lesion noted by Internal medicine.,COURSE:, The outside MRI was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. The mass inhomogenously enhanced with gadolinium contrast.,The findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. He refused brain biopsy and was started on empiric treatment for toxoplasmosis. This consisted of Pyrimethamine 75mg qd and Sulfadiazine 2 g bid. He later became DNR and was transferred at his and his partner's request Back to a local hospital.,He never returned for follow-up.
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DESCRIPTION: MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV.

This situation involves a patient with AIDS who presents with neurological symptoms and a brain mass, which is possibly CNS lymphoma or toxoplasmosis. These conditions are severe and life-threatening, especially in a patient with a compromised immune system due to AIDS. Prompt and accurate diagnosis is crucial for appropriate management and treatment. The patient also has other complicating factors, such as a history of medication-resistant infections and severe neuropathy. The refusal of a brain biopsy and decision to start empiric treatment indicates high stakes in terms of life risk and treatment outcomes. Therefore, this situation requires urgent attention and expert medical care.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Lobectomy & Lymph Node Dissection

OPERATION,1.  Right upper lung lobectomy.,2.  Mediastinal lymph node dissection.,ANESTHESIA,1.  General endotracheal anesthesia with dual-lumen tube.,2.  Thoracic epidural.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room, and general endotracheal anesthesia was administered with a dual-lumen tube.  Next, the patient was placed in the left lateral decubitus position, and his right chest was prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make an incision in the skin approximately 1 fingerbreadth below the angle of the scapula.  Dissection was carried down in a muscle-sparing fashion using Bovie electrocautery.  The 5th rib was counted, and the 6th interspace was entered.  The lung was deflated.  We identified the major fissure.  We then began by freeing up the inferior pulmonary ligament, which was done with Bovie electrocautery.  Next, we used Bovie electrocautery to dissect the pleura off the lung.  The pulmonary artery branches to the right upper lobe of the lung were identified.  Of note was the fact that there was a visible, approximately 4 x 4-cm mass in the right upper lobe of the lung without any other metastatic disease palpable.  As mentioned, a combination of Bovie electrocautery and sharp dissection was used to identify the pulmonary artery branches to the right upper lobe of the lung.  Next, we began by ligating the pulmonary artery branches of the right upper lobe of the lung.  This was done with suture ligature in combination with clips.  After taking the pulmonary artery branches of the right upper lobe of the lung, we used a combination of blunt dissection and sharp dissection with Metzenbaum scissors to separate out the pulmonary vein branch of the right upper lobe of the lung.  This likewise was ligated with a 0 silk.  It was stick-tied with a 2-0 silk.  It was then divided.  Next we dissected out the bronchial branch to the right upper lobe of the lung.  A curved Glover was placed around the bronchus.  Next a TA-30 stapler was fired across the bronchus.  The bronchus was divided with a #10-blade scalpel.  The specimen was handed off.  We next performed a mediastinal lymph node dissection.  Clips were applied to the base of the feeding vessels to the lymph nodes.  We inspected for any signs of bleeding.  There was minimal bleeding.  We placed a #32-French anterior chest tube, and a #32-French posterior chest tube.  The rib space was closed with #2 Vicryl in an interrupted figure-of-eight fashion.  A flat Jackson-Pratt drain, #10 in size, was placed in the subcutaneous flap.  The muscle layer was closed with a combination of 2-0 Vicryl followed by 2-0 Vicryl, followed by 4-0 Monocryl in a running subcuticular fashion.  Sterile dressing was applied.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the PACU in good condition.
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DESCRIPTION: Right upper lung lobectomy.  Mediastinal lymph node dissection

surgery, mediastinal, thoracic, epidural, lymph node dissection, lymph node, artery branches, lobectomy, lung, anesthesia, bovie, electrocautery, lymph, pulmonary, branches

The operation described involves a lobectomy and lymph node dissection, which are surgical procedures typically performed to treat lung cancer or other serious conditions. This is high-stakes because it involves removing a portion of the lung and is significant surgery requiring general anesthesia, which carries inherent risks such as complications from anesthesia, bleeding, and infection. Additionally, the outcome of the surgery can significantly impact the patient's prognosis and quality of life, particularly if cancer is involved.


Medical Specialty: Surgery
Sample Name: Adenoidectomy - 1

PREOPERATIVE DIAGNOSIS: , Adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Adenoid hypertrophy.,PROCEDURE PERFORMED:  ,Adenoidectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia.  The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.  The nasopharynx was inspected with the laryngeal mirror.  Serial passages of the curettes were utilized to remove the nasopharyngeal tissue, following which the nasopharynx was packed with 2 cherry gauze sponges coated in a solution of 0.25% Neo-Synephrine and tannic acid powder.,Attention was then redirected to the oropharynx.  The McIvor was reopened, packs removed, and the bleeding was controlled with the suction Bovie unit.  The catheters were removed, and the nasal passages and oropharynx were suctioned free of debris.  The McIvor was then removed, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.
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DESCRIPTION: Adenoidectomy.  Adenoid hypertrophy.  The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.

surgery, palate, nasal passage, mcivor mouth gag, oral cavity, nasal, nasopharynx, oropharynx, hypertrophy, oral, cavity, mcivor, tongue, adenoidectomy

Adenoidectomy is considered a routine and standard surgical procedure, especially in pediatric cases, to remove enlarged adenoids causing issues like chronic infections or breathing difficulties. The description indicates the procedure was conducted without complications, with the patient tolerating it well. While any surgical procedure carries certain risks, this is generally considered low complexity and is routinely performed, which implies lower stakes compared to many other surgeries. However, since it is a surgical procedure under general anesthesia, it cannot be classified as having the lowest stakes.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Appendectomy - 4

PREOPERATIVE DIAGNOSIS:,  Acute appendicitis with perforation.,POSTOPERATIVE DIAGNOSIS:  ,Acute appendicitis with perforation.,ANESTHESIA:,  General.,PROCEDURE: , Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old little boy, who has been sick for several days and was seen in our Emergency Department yesterday where a diagnosis of possible constipation was made, but he was sent home with a prescription for polyethylene glycol but became more acutely ill and returned today with tachycardia, high fever and signs of peritonitis.  A CT scan of his abdomen showed evidence of appendicitis with perforation.  He was evaluated in the Emergency Department and placed on the appendicitis critical pathway for this acute appendicitis process.  He required several boluses of fluid for tachycardia and evidence of dehydration.,I met with Carlos' parents and talked to them about the diagnosis of appendicis and surgical risks, benefits, and alternative treatment options.  All their questions have been answered and they agree with the surgical plan.,OPERATIVE FINDINGS: , The patient had acute perforated appendicitis with diffuse suppurative peritonitis including multiple intraloop abscesses and purulent debris in all quadrants of the abdomen including the perihepatic and subphrenic recesses as well.,DESCRIPTION OF PROCEDURE: , The patient came to the operating room and had an uneventful induction of general anesthesia.  A Foley catheter was placed for decompression, and his abdomen was prepared and draped in a standard fashion.  A 0.25% Marcaine was infiltrated in the soft tissues around his umbilicus and in the suprapubic and left lower quadrant locations chosen for trocar insertion.  We conducted our surgical timeout and reiterated all of Carlos' unique and important identifying information and confirmed the diagnosis of appendicitis and planned laparoscopic appendectomy as the procedure.  A 1-cm vertical infraumbilical incision was made and an open technique was used to place a 12-mm Step trocar through the umbilical fascia.  CO2 was insufflated to a pressure of 15 mmHg and then two additional 5-mm working ports were placed in areas that had been previously anesthetized.,There was a lot of diffuse purulent debris and adhesions between the omentum and adjacent surfaces of the bowel and the parietal peritoneum.  After these were gently separated, we began to identify the appendix.  In the __________ due to the large amount of small bowel dilatation and distension, I used the hook cautery with the lowest intraperitoneal __________ profile to coagulate the mesoappendix.  The base of the appendix was then ligated with 2-0 PDS Endoloops, and the appendix was amputated and withdrawn through the umbilical port.  I spent the next 10 minutes irrigating purulent fluid and debris from the peritoneal cavity using 2 L of sterile crystalloid solution and a suction power irrigation system.  When this was complete, the CO2 was released one final time and as much of the fluid was drained from the peritoneal cavity as possible.  The umbilical fascia was closed with figure-of-eight suture of 0 Monocryl and the skin incisions were closed with subcuticular 5-0 Monocryl and Steri-Strips.  The patient tolerated the operation well.  He was awakened and taken to the recovery room in satisfactory condition.  His blood loss was less than 10 mL, and he received only crystalloid fluid during the procedure.
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DESCRIPTION: Acute appendicitis with perforation.  Laparoscopic appendectomy.   A CT scan of abdomen showed evidence of appendicitis with perforation.

gastroenterology, adhesions, peritoneum, purulent debris, umbilical fascia, peritoneal cavity, laparoscopic appendectomy, appendectomy, constipation, purulent, debris, umbilical, appendix, abdomen, laparoscopic, perforation, appendicitis,

The situation involves a 4-year-old child with acute perforated appendicitis, a serious medical condition requiring urgent surgical intervention. The stakes are high due to the patient's age, the risk of complications from peritonitis, and the need for quick surgical response to prevent further deterioration. The surgical procedure is critical for the patient's recovery, making this a high-stakes medical scenario.


Medical Specialty: Podiatry
Sample Name: Tinea Pedis - H&P

CHIEF COMPLAINT (1/1):  ,This 24 year-old female presents today complaining of itchy, red rash on feet.  Associated signs and symptoms:  Associated signs and symptoms include tingling, right.  Context:  Patient denies any previous history, related trauma or previous treatments for this condition.  Duration:  Condition has existed for 4 weeks.  Location:  She indicates the problem location is right great toe, right 2nd toe, right 3rd toe and right 4th toe.  Modifying factors:  Patient indicates ice improves condition.  Quality:  Quality of the itch is described by the patient as constant.  Severity:  Severity of condition is unbearable.  Timing (onset/frequency):  Onset was after leaving on sweaty socks.,ALLERGIES: , Patient admits allergies to adhesive tape resulting in severe rash.,MEDICATION HISTORY:,  None.,PAST MEDICAL HISTORY: , Childhood Illnesses: (+) chickenpox, (+) frequent ear infections.,PAST SURGICAL HISTORY:  ,Patient admits past surgical history of ear tubes.,SOCIAL HISTORY: , Patient admits alcohol use Drinking is described as social, Patient denies tobacco use, Patient denies illegal drug use, Patient denies STD history.,FAMILY HISTORY:,  Patient admits a family history of cataract associated with maternal grandmother,,headaches/migraines associated with maternal aunt.,REVIEW OF SYSTEMS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM: , BP Sitting:  110/64 Resp:  18 HR:  66 Temp:  98.6,Patient is a 24 year old female who appears well developed, well nourished and with good attention to hygiene and body habitus.  Cardiovascular:  Skin temperature of the lower extremities is warm to cool, proximal to distal.,DP pulses palpable bilateral.,PT pulses palpable bilateral.,CFT immediate.,No edema observed.,Varicosities are not observed.  Skin:  Right great toe, right 2nd toe, right 3rd toe and right 4th toenail shows erythema and scaling.,Neurological:  Touch, pin, vibratory and proprioception sensations are normal.  Deep tendon reflexes normal.,Musculoskeletal:  Muscle strength is 5/5 for all groups tested.  Muscle tone is normal.  Inspection and palpation of bones, joints and muscles is unremarkable.,TEST RESULTS:,  No tests to report at this time,IMPRESSION: , Tinea pedis.,PLAN:  ,Obtained fungal culture of skin from right toes.  KOH prep performed revealed no visible microbes.,PRESCRIPTIONS:,  Lotrimin AF  Dosage:  1% cream  Sig:  apply qid  Dispense:  4oz tube Refills:  0  Allow Generic:  Yes
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DESCRIPTION: Itchy red rash on feet - Tinea Pedis

Itchy red rash on feet - Tinea Pedis

The situation described involves a medical assessment of a condition known as Tinea Pedis, which is a common fungal infection also known as athlete's foot. It generally represents low-stakes from a medical perspective as it is not life-threatening and is a condition that can typically be treated effectively with antifungal medication. The patient presents with typical symptoms that are uncomfortable but not dangerous, and the planned treatment is standard for this condition. Therefore, while the condition causes discomfort, it does not pose a significant risk to the patient's overall health, making it a low-stakes medical scenario.


Medical Specialty: General Medicine
Sample Name: Insect Sting

HISTORY OF PRESENT ILLNESS:,  Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today.  He did not note any immediate reaction.  Since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath.  He denies any sensation of tongue swelling or difficulty swallowing.,The patient states he was stung approximately one month ago without any serious reaction.  He did windup taking Benadryl at that time.  He has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day.,ALLERGIES: , HE DOES HAVE MEDICATION INTOLERANCES TO SULFA DRUGS (HEADACHE), MORPHINE (NAUSEA AND VOMITING), AND TORADOL (ULCER).,SOCIAL HISTORY: , Patient is married and is a nonsmoker and lives with his wife, who is here with him.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp and vital signs are all within normal limits.,GENERAL:  In general, the patient is an elderly white male who is sitting on the stretcher in no acute distress.,HEENT:  Head is normocephalic and atraumatic.  The face shows no edema.  The tongue is not swollen and the airway is widely patent.,NECK:  No stridor.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,EXTREMITIES:  Upper extremities, there is some edema and erythema to the dorsum of the left hand in the region of the distal third to fifth metacarpals.  There was some slight edema of the fourth digit, on which he still is wearing his wedding band.  The right hand shows no reaction.  The right knee is not swollen either.,The left fourth digit was wrapped in a rubber tourniquet to express the edema and using some Surgilube, I was able to remove his wedding band without any difficulty.  Patient was given Claritin 10 mg orally for what appears to be a simple local reaction to an insect sting.  I did explain to him that his swelling and redness may progress over the next few days.,ASSESSMENT: , Local reaction secondary to insect sting.,PLAN: , The patient was reassured that this is not a serious reaction to an insect sting and he should not progress to such a reaction.  I did urge him to use Claritin 10 mg once daily until the redness and swelling has gone.  I did explain that the swelling may worsen over the next two to three days, it may produce a large local reaction, but that anti-histamines were still the mainstay of therapy for such a reaction.  If he is not improved in the next four days, follow up with his PCP for a re-exam.
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DESCRIPTION: Local reaction secondary to insect sting.  Patient was stung by a bee on his right hand, left hand, and right knee at approximately noon today.

general medicine, stung by a bee, local reaction, insect sting, reaction, insect, bee, knee, edema, sting, swelling, hand

The situation involves a medical encounter where a patient experienced a local reaction to bee stings. The patient's vital signs are normal and he does not have signs of a serious allergic reaction (anaphylaxis), such as difficulty breathing or swelling of the tongue. The assessment confirmed it's a local reaction with a plan involving standard antihistamine treatment. The situation is not life-threatening and has been managed appropriately with the recommendation for follow-up if symptoms persist.


Medical Specialty: Ophthalmology
Sample Name: Vitrectomy Opening

VITRECTOMY OPENING,The patient was brought to the operating room and appropriately identified.  General anesthesia was induced by the anesthesiologist.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.  A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants.  Hemostasis was maintained with wet-field cautery.  Calipers were set at XX mm and the mark was made XX mm posterior to the limbus in the inferotemporal quadrant.  A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark.  The MVR blade was used to make a sclerotomy between the preplaced sutures.  An 8-0 nylon suture was then preplaced for a later sclerotomy closure.  The infusion cannula was inspected and found to be in good working order.  The infusion cannula was placed into the vitreous cavity and secured with the preplaced suture.  The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.  Additional sclerotomies were made XX mm posterior to the limbus in the supranasal and supratemporal quadrants.
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DESCRIPTION: Vitrectomy opening.  A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants.

ophthalmology, westcott scissors, inferotemporal quadrants, conjunctival, peritomy, sclerotomy, vitrectomy, supranasal, supratemporal, cannula, inferotemporalNOTE,: 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 vitrectomy opening procedure described is a surgical operation involving the eye, which is generally considered high-stakes due to the precision required and the potential for significant impact on the patient's vision if complications occur. Any surgical procedure involving the eyes or within a delicate area like the eye is inherently high-stakes because of the critical nature of the organ involved. Errors can lead to loss of vision or other serious complications. Therefore, the stakes are quite high when performing such a procedure.


Medical Specialty: General Medicine
Sample Name: Normal Female ROS Template

CONSTITUTIONAL:,  Normal; negative for fever, weight change, fatigue, or aching.,HEENT:,  Eyes normal; Negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects.  Ears normal; Negative for hearing or balance problems.  Nose normal; Negative for runny nose, sinus problems, or nosebleeds.  Mouth normal; Negative for dental problems, dentures, or bleeding gums.  Throat normal; Negative for hoarseness, difficulty swallowing, or sore throat.,CARDIOVASCULAR:,  Normal; Negative for angina, previous MI, irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation.,PULMONARY: , Normal; Negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema.,GASTROINTESTINAL: , Normal; Negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding.,GENITOURINARY:, Normal female OR male; Negative for incontinence, UTI, dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching.,SKIN: , Normal; Negative for rashes, keratoses, skin cancers, or acne.,MUSCULOSKELETAL: , Normal; Negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries.,NEUROLOGIC: , Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness.,PSYCHIATRIC: , Normal; Negative for anxiety, depression, or phobias.,ENDOCRINE:,  Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones.,HEMATOLOGIC/LYMPHATIC: , Normal; Negative for anemia, swollen glands, or blood disorders.,IMMUNOLOGIC: , Negative; Negative for steroids, chemotherapy, or cancer.,VASCULAR:,  Normal; Negative for varicose veins, blood clots, atherosclerosis, or leg ulcers.
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DESCRIPTION: Normal female review of systems template.  Negative for fever, weight change, fatigue, or aching.

general medicine, cough, sputum, shortness of breath, fever, weight, fatigue, aching, nose, throat, swelling, disease, incontinence, bleeding, heartbeat, blood, joint,

The provided text is a template for a normal review of systems (ROS) for a female patient in general medicine, indicating no significant findings or abnormalities. It is a standard procedure used as part of routine check-ups and does not involve high-stakes medical decision-making. There are no acute issues or critical situations mentioned that would elevate the urgency or risk level.


Medical Specialty: Orthopedic
Sample Name: Dorsal Ganglion - Excision

PREOPERATIVE DIAGNOSIS:,  Dorsal ganglion, right wrist.,POSTOPERATIVE DIAGNOSIS:,  Dorsal ganglion, right wrist.,OPERATIONS PERFORMED:,  Excision dorsal ganglion, right wrist.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME:,  minutes.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated and the tourniquet was elevated to 290 mm/Hg.  A transverse incision was made over the dorsal ganglion.  Using blunt dissection the dorsal ulnar sensory nerve branches and radial sensory nerve branches were dissected and retracted out of the operative field.  The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field.  The ganglion was then further dissected to its origin from the dorsal distal scapholunate interosseus ligament and excised in toto.  Care was taken to protect ligament integrity.  Reactive synovium was then removed using soft tissue rongeur technique.  The wound was then infiltrated with 0.25% Marcaine.  The tendons were allowed to resume their normal anatomical position.  The skin was closed with 3-0 Prolene subcuticular stitch.  Sterile dressings were applied.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.
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DESCRIPTION: Excision dorsal ganglion, right wrist.   The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field.

orthopedic, excision dorsal ganglion, extensor tendon, extensor retinaculum, dorsal ganglion, retinaculum, ganglion

The procedure described is a surgical excision of a dorsal ganglion on the right wrist, which is typically a routine and low-risk operation in orthopedic practice. There are no indications of complications during the procedure, and the patient tolerated it well, highlighting that this procedure is considered low in complexity and risk. Moreover, the use of monitored anesthesia care with regional anesthesia suggests a standard level of caution for outpatient or minimally invasive procedures.


Medical Specialty: Surgery
Sample Name: Prostatectomy

PREOPERATIVE DIAGNOSIS:,  Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,PROCEDURE DONE: , Open radical retropubic prostatectomy with bilateral lymph node dissection.,INDICATIONS:,  This is a 66-year-old gentleman who had an elevated PSA of 5.  His previous PSAs were in the 1 range.  TRUS biopsy revealed 4+3 Gleason score prostate cancer with a large tumor burden.  After extensive counseling, the patient elected for retropubic radical prostatectomy.  Given his disease burden, it was advised that an open prostatectomy is probably the standard of care to ensure entire excision.  The patient consented and agreed to proceed forward.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room here.  Time out was taken to properly identify the patient and procedure going to be done.  General anesthesia was induced.  The patient was placed in the supine position.  The bed was flexed distant to the pubic area.  The patient's lower abdominal area, pubic area, and penile and scrotal area were clipped, and then scrubbed with Hibiclens soap for three minutes.  The patient was then prepped and draped in normal sterile fashion.  Foley catheter was inserted sterilely in the field.  Preoperative antibiotics were given within 30 minutes of skin incision.  A 10 cm lower abdominal incision was made from the symphysis pubis towards the umbilicus.  Dissection was taken down through Scarpa's fascia to the level of the anterior rectus sheath.  The rectus sheath was then incised and the muscle was split in the middle.  Space of rectus sheath was then entered.  The Bookwalter ring was then applied to the belly, and the bladder was then retracted to the right side, thus exposing the left obturator area.  The lymph node packet on the left side was then dissected.  This was done in a split and roll fashion with the flimsy tissue, and the left external iliac vein was incised, and the tissues were then rolled over the left external iliac vein.  Dissection was carried down from the left external iliac vein to the obturator nerve and up to the level of the pelvic sidewall.  The proximal extent of dissection was the left hypogastric artery to the level of the node of Cloquet distally.  Care was taken to avoid injury to the nerves.  An accessory obturator vein was noted and was ligated.  The same procedure was done on the right side with dissection of the right obturator lymph node packet, which was sent for pathologic evaluation.  The bladder subsequently was retracted cephalad.  The prostate was then defatted up to the level of the endopelvic fascia.  The endopelvic fascia was then incised bilaterally, and the incision was then taken to the level of the puboprostatic ligaments.  Vicryl stitch was then applied at the level of the bladder neck in order to control the bladder back bleeders.  A Babcock was then applied around the dorsal venous complex over the urethra and the K-wire was then passed between the dorsal vein complex and the urethra by passing by the aid of a right angle.  A 0-Vicryl stitch was then applied over the dorsal venous complex, which was then tied down and cinched to the symphysis pubis.  Using a knife on a long handle, the dorsal venous complex was then incised using the K-wire as a guide.  Following the incision of the dorsal venous complex, the anterior urethra was then incised, thus exposing the Foley catheter.  The 3-0 Monocryl sutures were then applied going outside in on the anterior aspect of the urethra.  The lateral edges of the urethra were also then incised, and two lateral stitches were also applied going outside end.  The catheter was then drawn back at the level of membranous urethra, and a final posterior stitch was applied going outside end.  The urethra was subsequently divided in its entirety.  A Foley catheter was then taken out and was inserted directly into the bladder through the prostatic apex.  The prostate was then entered cephalad, and the prostatic pedicles were then systematically taken down with the right angle clips and cut.  Please note that throughout the case, the patient was noted to have significant oozing and bleeding partially from the dorsal venous complex, pelvic veins, and extensive vascularity that was noted in the patient's pelvic fatty tissue.  Throughout the case, the bleeding was controlled with the aid of a clips, Vicryl sutures, silk sutures, and ties, direct pressure packing, and FloSeal.  Following the excision of the prostatic pedicles, the posterior dissection at this point was almost complete.  Please note that the dissection was relatively technically challenging due to extensive adhesions between the prostate and Denonvilliers' fascia.  The seminal vesicle on the left side was dissected in its entirety; however, the seminal vesicle on the right side was adherently stuck to the Denonvilliers' fascia, which prompted the excision of most of the right seminal vesicle with the exception of the tip.  Care was taken throughout the posterior dissection to preserve the integrity of the ureters.  The anterior bladder neck was then cut anteriorly, and the bladder neck was separated from the prostate.  Following the dissection, the 5-French feeding tubes were inserted bilaterally into the ureters thus insuring their integrity.  Following the dissection of the bladder from the prostate, the prostate at this point was mobile and was sent for pathological evaluation.  The bladder neck was then repaired using Vicryl in a tennis racquet fashion.  The rest of the mucosa was then everted.  The ureteral orifices and ureters were protected throughout the procedure.  At this point, the initial sutures that were applied into the urethra were then applied into the corresponding position on the bladder neck, and the bladder neck was then cinched down and tied down after a new Foley catheter was inserted through the penile meatus and into the bladder pulling the bladder in position.  Hemostasis was then adequately obtained.  FloSeal was applied to the pelvis.  The bladder was then irrigated.  It was draining pink urine.  The wound was copiously irrigated.  The fascia was then closed using a #1 looped PDS.  The skin wound was then irrigated, and the skin was closed with a 4-0 Monocryl in subcuticular fashion.  At this point, the procedure was terminated with no complications.  The patient was then extubated in the operating room and taken in stable condition to the PACU.  Please note that during the case about 3600 mL of blood was noted.  This was due to the persistent continuous oozing from vascular fatty tissue and pelvic veins as previously noted in the dictation.
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DESCRIPTION: Open radical retropubic prostatectomy with bilateral lymph node dissection.

surgery, bilateral lymph node dissection, retropubic prostatectomy, radical retropubic prostatectomy, gleason score, prostate cancer, trus, biopsy, bilateral lymph node, lymph node dissection, catheter was inserted, bilateral lymph, node dissection, vicryl stitch, prostatic pedicles, pelvic veins, external iliac, iliac vein, seminal vesicle, lymph node, foley catheter, dorsal venous, venous complex, bladder neck, dissection, prostatectomy, bladder, endopelvic, vicryl, catheter, vein, venous, fascia, dorsal, urethra,

The situation involves a complex surgical procedure to treat prostate cancer, which is inherently high-stakes due to the risks associated with surgery, particularly with notable blood loss and potential complications arising from the procedure. The Gleason score and cancer burden further emphasize the critical nature of ensuring successful removal and treatment. Surgical procedures like this carry potential life-altering consequences for the patient, thus adding to the stakes. Additionally, the technical challenges described, such as bleeding and adhesion issues, elevate the risk level.


Medical Specialty: Office Notes
Sample Name: Normal ROS Template - 2

GENERAL:,  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:,  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: , Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  ,Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: , Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:,  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: , Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: , Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.,MUSCULOSKELETAL:,  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: , See psychiatric evaluation.,ENDOCRINE: , No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.
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DESCRIPTION: Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.

office notes, nose and throat, cardiovascular, integumentary, negative weakness, neurologic, throat, psychiatric, weakness,

The given text is an office note detailing a normal review of systems (ROS) for a patient, where 'negative' is used to indicate the absence of various symptoms or medical history. It is a document used to record that the patient did not report any issues in these areas. This is a routine documentation process used by medical practitioners to track patient conditions. It is considered low-stakes because it involves documenting an absence of problems rather than urgent or risky health issues. The template appears to be standardized for efficiency rather than dealing with a critical health concern.


Medical Specialty: Hospice - Palliative Care
Sample Name: Hospice Visit - CA of Cervix

HISTORY OF PRESENT ILLNESS: , The patient is a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum, lung, which was diagnosed approximately two years ago.  There is a nodule in her lung, which was treated by excision in February of 2007 on the right side.  She had spread to her kidney.  She had right-sided nephrectomy and left-sided nephrostomy.  She also had invasion of the bladder.  Currently, all of her urine comes out through the renal nephrostomy.  She complains of burning vaginal pain, as well as chronic discharge, which has improved slightly recently.  She is not able to engage in intercourse because of the pain and bleeding.  She also has pain with bowel movements, as well as painful urgency.  The pain is at least 3-4/10 and is partially relieved with methadone rescues and interferes with her ability to sleep at night as she feels exhausted and tired.  She has some nausea and diminished appetite.  No hallucinations.  She is anxious frequently and this is helped with clonazepam, which she has taken chronically for her anxiety disorder and recently started Zyprexa.  She has occasional shortness of breath, which used to be helped with oxygen in the hospital.,PAST MEDICAL HISTORY:,  Peptic ulcer disease, hypertension.,REVIEW OF SYSTEMS:,  She has constipation with hard bowel movements.,MEDICATIONS:,  Norvasc 10 mg daily, isosorbide 60 mg every 24 hours, olanzapine at 2.5-5 mg in bedtime, clonazepam 1 mg every eight hours, Sorbitol 30 cc twice a day, Senna-S two tabs daily, methadone 60 mg every eight hours, and 30 mg every four hours p.r.n. pain.,ALLERGIES:,  She has no known allergies.,SOCIAL HISTORY: , The patient lives with her common law husband and her daughter.  Code Status: DNR.  Religion.  Catholic.  She has a past history of heroin use and was enrolled in MMTP program for 12 hours.  She reports feeling discouraged from her symptoms and pain.,PHYSICAL EXAMINATION: , Blood pressure 120/80, pulse 80, and respirations 14.  General Appearance:  Mildly obese woman.  PERRLA, 3 mm.  Oral mucosa moist without lesions.  Lungs:  Clear.  Heart:  RRR without murmurs.  Abdomen:  Somewhat distended, but soft and nontender.  There is firmness found in the low abdomen bilaterally.  There is erythema in the intertriginous area and vulva, as well as some serous discharge from the vagina.  Neurological Exam:  Cranial nerves II through XII are grossly intact.  There is normal tone.  Power is 5-/5.  DTRs nonreactive.  Sensation intact to fine touch.  Mental Status:  The patient is alert, fully oriented, normal speech, and thought process.  Normal affect.,ASSESSMENT AND PLAN: , ,1.  Carcinoma of the cervix metastatic to the retroperitoneum, bladder, and lung with irritable obstruction and gradual decline in the performance status.  Given this, her prognosis is likely to be limited to six months and she will benefit from home hospice care.,2.  Pain, which is a combination of somatic nociceptive pain due to the retroperitoneal invasion, as well as a neuropathic component from pelvic and nerve involvement by the surgery as well as radiation therapy and disease itself.  We are going to increase methadone to 70 mg every eight hours and continue 30 mg for breakthrough.  We will add pregabalin 50 mg three times a day and titrate the dose up as needed.,3.  Nausea and poor appetite.  We will start Megace 200 mg daily.,4.  Shortness of breath.  We will provide oxygen p.r.n.,5.  Candidal infection.  We will start clotrimazole 1% cream b.i.d.,6.  Constipation.  We will advance the bowel regimen to Sorbitol 30 cc three times a day and Senna-S three tabs twice a day.,7.  Psychosocial.  The patient is getting discouraged.  We will provide supportive counseling.,Length of the encounter was 80 minutes; more than half spent on exchange of information.,Thank you for the opportunity to participate in the care for this patient.
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DESCRIPTION: Hospice care for a 55-year-old woman with carcinoma of the cervix metastatic to retroperitoneum and lungs.

hospice - palliative care, hospice, carcinoma of the cervix, code status, length of the encounter, mmtp program, normal affect, shortness of breath, bladder, decline, exchange of information, hospice care, irritable obstruction, lung, nephrectomy, nephrostomy, performance status, poor appetite, prognosis is likely to be limited to, retroperitoneum, carcinoma, metastatic, cervix, lungs,

The situation involves the palliative care of a patient with advanced cancer with a prognosis of less than six months. Decisions regarding the management of her pain, psychological support, and treatment of physical symptoms like nausea and infections are critical. The psychological aspect is also paramount, given her discouraged state and history of substance use. Moreover, adjusting medications such as methadone and managing side effects are key to her quality of life. Her DNR status further emphasizes the terminal nature of her condition, making these consultations high-stakes because they significantly impact her remaining quality of life and health management.


Medical Specialty: Neurology
Sample Name: Neurologic Examination

NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented.  There is no evidence of cognitive or language dysfunction.  Cranial nerves:  Visual fields are full.  Funduscopic examination is normal.  Extraocular movements full.  Pupils equal, round,  react to light.  There is no evidence of nystagmus noted.  Fifth nerve function is normal.  There is no facial asymmetry noted.  Lower cranial nerves are normal.  ,Manual motor testing reveals good tone and bulk throughout.  There is no evidence of pronator drift or decreased fine finger movements.  Muscle strength is 5/5 throughout.  Deep tendon reflexes are 2+ throughout with downgoing toes.  Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk.  Finger-to-nose and heel-to-shin moves are normal.  Romberg sign negative.  I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.
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DESCRIPTION: Neurologic examination sample.

Neurologic examination sample.

neurology, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE

The neurologic examination shows a normal exam with no acute findings, and the noncontrast CT scan of the head shows no evidence of acute issues such as infarction or hemorrhage. Given the lack of concerning findings and the standard nature of the examination, this scenario is low-stakes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Physical Exam and Pap - 1

SUBJECTIVE:,  This 45-year-old gravida 3, para 2, SAB 1 white female presents for exam and Pap.  Last Pap was a year ago and normal.  LMP was 08/29/2004.  Her cycles are usually regular, although that one came about a week early.  Her husband has had a vasectomy.  Overall, she is feeling well.,Health history form was reviewed.  There has been no change in her personal history.  She notes that a brother who was treated 12 years ago for a brain tumor has had a recurrence and had surgery again.  Social history is unchanged.,HEALTH HABITS: , She states that for a while she was really exercising regularly and eating lots of fruits and vegetables.  Right now, she is not doing nearly as well.  She has perhaps two dairy servings daily, trying to cut down.  She is not exercising at all and fruit and vegetable intake varies.  She is a nonsmoker.  Last cholesterol was in 2003 and was normal.  She had a mammogram which was normal recently.  She is current on her tetanus update.,REVIEW OF SYSTEMS:,HEENT:  She feels as though she may have some allergies at night.  Most of her symptoms occur then, not during the day.  She will wake up with some congestion, sneezing, and then rhinorrhea.  Currently, she uses Tylenol Sinus.  Today, her symptoms are much better.  We did have rain this morning.,Respiratory and CV:  Negative.,GI:  She tends to have a little gas which is worse when she is eating more fruits and vegetables.  She had been somewhat constipated but that is better.,GU:  Negative.,Dermatologic:  She noticed an area of irritation on her right third finger on the ulnar side at the PIP joint.  It was very sensitive to water.  It seems to be slowly improving.,OBJECTIVE:,Vital Signs:  Her weight was 154 pounds, which is down 2 pounds.  Blood pressure 104/66.,General:  She is a well-developed, well-nourished, pleasant white female in no distress.,Neck:  Supple without adenopathy.  No thyromegaly or nodules palpable.,Lungs:  Clear to A&P.,Heart:  Regular rate and rhythm without murmurs.,Breasts:  Symmetrical without masses, nipple, or skin retraction, discharge, or axillary adenopathy.,Abdomen:  Soft without organomegaly, masses, or tenderness.,Pelvic:  Reveals no external lesions.  The cervix is parous.  Pap smear done.  Uterus is anteverted and normal in size, shape, and consistency, and nontender.  No adnexal enlargement.,Extremities:  Examination of her right third finger shows an area of eczematous dermatitis approximately 2 cm in length on the ulnar side.,ASSESSMENT:,1.  Normal GYN exam.,2.  Rhinitis, primarily in the mornings.  Vasomotor versus allergic.,3.  Eczematous dermatitis on right third finger.,PLAN:,1.  Discussed vasomotor rhinitis.  I suggested she try Ayr Nasal saline gel.  Another option would be a steroid spray and a sample of Nasonex is given to use two sprays in each nostril daily.,2.  Exam with Pap annually.,3.  Hydrocortisone cream to be applied to the area of eczematous dermatitis.,4.  Discussed nutrition and exercise.  I recommended at least five fruits and vegetables daily, no more than three dairy servings daily, and regular exercise at least three times a week.
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DESCRIPTION: A white female presents for exam and Pap.

The situation involves a routine physical exam and Pap smear for a 45-year-old woman who is reportedly in overall good health. The assessments indicate normal results apart from some manageable conditions like morning rhinitis and eczematous dermatitis on her finger, for which treatments have been suggested. There is no immediate risk to the patient's life, and the purpose of the visit appears to be mostly preventive. Thus, it is low-stakes medically.


Medical Specialty: Consult - History and Phy.
Sample Name: Gastrointestinal Bleed - ER Visit

ADMITTING DIAGNOSIS: , Gastrointestinal bleed.,HISTORY OF PRESENT ILLNESS:  ,Ms. XYZ is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell.  She states that she woke yesterday morning and at approximately 10:30 had a bowel movement.  She noticed it was very dark and smelly.  She said she felt okay.  She got up.  She proceeded to clean her house without any difficulty or problems and then at approximately 2 o'clock in the afternoon she went back to the bathroom at which point she had another large stool and had weak spell felt like she was going to pass out.  She is able to get to her phone, called EMS and when the EMS arrived they found her with some blood and some very dark stools.  She states that she was perfectly fine up until Monday when she had an incident where at the Southern University where she works where there was an altercation between a dorm resistant and a young male, which ensued.  She came to place her call, etc.  She said she noticed her stomach was hurting after that, continued to hurt and she took the day off on Tuesday and this happened yesterday.  She denies any nausea except for when she got weak.  She denies any vomiting or any other symptoms.,ALLERGIES:  ,She has no known drug allergies.,CURRENT MEDICATIONS:,1.  Lipitor, dose unknown.,2.  Paxil, dose unknown.,3.  Lasix, dose unknown.,4.  Toprol, dose unknown.,5.  Diphenhydramine p.r.n.,6.  Ibuprofen p.r.n.,7.  Daypro p.r.n.,PAST MEDICAL HISTORY:,1.  Non-insulin diabetes mellitus.,2.  History of congestive heart failure.,3.  History of hypertension.,4.  Depression.,5.  Arthritis.  She states she has not needed any medications and not taken ibuprofen or Daypro recently.,6.  Hyperlipidemia.,7.  Peptic ulcer disease diagnosed in 2005.,PAST SURGICAL HISTORY: , C-section and tonsillectomy.,FAMILY HISTORY: , Her mother had high blood pressure and coronary artery disease.,SOCIAL HISTORY:,  She is a nonsmoker.  She occasionally has a drink every few weeks.  She is divorced.  She has 2 sons.  She is houseparent at Southern University.,REVIEW OF SYSTEMS:  ,Negative for the last 24 to 48 hours as mentioned in her HPI.,PREVENTIVE CARE:  ,She had an EGD done in 09/05 at which point she was diagnosed with peptic ulcer disease and she also had a colonoscopy at that time which revealed two polyps in the transverse colon.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Currently was stable.  She is afebrile.,GENERAL:  She is alert, pleasant in no acute distress.  She does complain of some dizziness when she stands up.,HEENT:  Pupils equal, round and reactive to light.  Extraocular muscles intact.  Sclerae clear.  Oropharynx is clear.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR:  She is slightly tachycardic but otherwise normal.,LUNGS:  Clear bilaterally.,ABDOMEN:  Soft, nontender, and nondistended.  She has no hepatomegaly.,EXTREMITIES:  No clubbing, cyanosis, only trace edema.,LABORATORY DATA UPON ADMISSION:,  Her initial chem panel was within normal limits.  Her PT and PTT were normal.  Her initial hematocrit was 31.2 subsequently dropped to 26.9 and 25.6.  She is currently administered transfusion.  Platelet count was 125.  Her chem panel actually showed an elevated BUN of 16, creatinine of 1.7.  PT and PTT were normal.  Cardiac enzymes were negative and initial hemoglobin was 10.6 with hematocrit of 31.2 that subsequently fell to 25.6 and she is currently receiving blood.,IMPRESSION AND PLAN:,1.  Gastrointestinal bleed.
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DESCRIPTION: Gastrointestinal Bleed.  An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell.  She woke yesterday morning had a very dark and smelly bowel movement.

An 81-year-old patient presenting with black tarry stools and symptoms such as dizziness and weakness suggests gastrointestinal bleeding, which can lead to significant blood loss, anemia, and can be life-threatening if not treated promptly. The patient's hematocrit levels have dropped, indicating ongoing blood loss and requiring blood transfusion, which underscores the seriousness of the situation. Given her age and medical history, including peptic ulcer disease, congestive heart failure, and hypertension, the stakes are higher due to the potential for complications.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Neurologic Examination

NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented.  There is no evidence of cognitive or language dysfunction.  Cranial nerves:  Visual fields are full.  Funduscopic examination is normal.  Extraocular movements full.  Pupils equal, round,  react to light.  There is no evidence of nystagmus noted.  Fifth nerve function is normal.  There is no facial asymmetry noted.  Lower cranial nerves are normal.  ,Manual motor testing reveals good tone and bulk throughout.  There is no evidence of pronator drift or decreased fine finger movements.  Muscle strength is 5/5 throughout.  Deep tendon reflexes are 2+ throughout with downgoing toes.  Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk.  Finger-to-nose and heel-to-shin moves are normal.  Romberg sign negative.  I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.
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DESCRIPTION: Neurologic examination sample.

Neurologic examination sample.

soap / chart / progress notes, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE

The situation described involves a neurological examination which is routine for assessing the basic neurological function of a patient. The findings indicate that the patient currently has normal neurological functioning with no acute issues observed in the examination or CT scan. Although neurological examinations can be crucial in diagnosing serious conditions, this specific case shows no signs of abnormalities and does not suggest a high-risk scenario. Thus, it appears to be low-stakes in this context.


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

Medical Specialty: Neurosurgery
Sample Name: Frameless Stereotactic Radiosurgery

PREOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:,  CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM.  He was referred for stereotactic radiosurgery.  The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits.  The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment.  He was placed on the treatment table.  The Aquaplast mask was constructed.  Initial imaging was obtained by the CyberKnife system.  The patient was then transported over to the CT scanner at Stanford.  Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered.  Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices.  These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me.  I outlined the tumor volume.  Inverse treatment planning was used to generate the treatment plan for this patient.  This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator.  The maximum dose within this center of treatment volume was 23.81 Gy.  The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm.  The volume treated at the reference dose was 98%.  The coverage isodose line was 79%.  The conformality index was 1.74 and modified conformality index was 1.55.  The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite.  He was placed on the treatment table.  The Aquaplast mask was applied.  Initial imaging was used to bring the patient into optimal position.  The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin.  He tolerated the procedure well.  He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months.  The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note.
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DESCRIPTION: CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.

neurosurgery, ct-guided, occipital, cyberknife, frameless stereotactic radiosurgery, occipital arteriovenous malformation, conformality index, arteriovenous malformation, malformation, avm, arteriovenous,

This scenario involves the treatment of a right occipital arteriovenous malformation through CT-guided frameless stereotactic radiosurgery. This is a high-stakes scenario due to the critical and intricate nature of the condition being treated. Arteriovenous malformations (AVMs) are complex tangles of abnormal blood vessels where arteries connect directly to veins, causing potential hemorrhage or other serious complications. The procedure, while minimally invasive compared to open surgery, is intricate and requires precise execution and careful planning. The potential consequences of failure or complications such as headaches, seizures, visual loss, or neurological deficits, along with the risks of radiation necrosis further underscore the high-stakes nature. The absence of a qualified resident highlights a potential challenge in the level of support available during the procedure. The complex planning and execution involving a 30-year-old patient further add to the criticality.


Medical Specialty: Surgery
Sample Name: Thoracoscopy & Thoracotomy - Mesothelioma

PREOPERATIVE DIAGNOSIS: , Left mesothelioma, focal.,POSTOPERATIVE DIAGNOSIS: , Left pleural-based nodule.,PROCEDURES PERFORMED:,1.  Left thoracoscopy.,2.  Left mini thoracotomy with resection of left pleural-based mass.,FINDINGS:,  Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.,FLUIDS: , 800 mL of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS, TUBES, CATHETERS: , 24-French chest tube in the left thorax plus Foley catheter.,SPECIMENS: , Left pleural-based nodule.,INDICATION FOR OPERATION:  ,The patient is a 59-year-old female with previous history of follicular thyroid cancer, approximately 40 years ago, status post resection with recurrence in the 1980s, who had a left pleural-based mass identified on chest x-ray.  Preoperative evaluation included a CT scan, which showed focal mass.  CT and PET confirmed anterior lesion.  Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction.  In the outpatient setting, the patient was willing to proceed.,PROCEDURE PERFORMED IN DETAIL: , After informed consent was obtained, the patient identified correctly.  She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty.  She was sedated and intubated with double-lumen endotracheal tube without difficulty.  She was positioned with left side up.  Appropriate pressure points were padded.  The left chest was prepped and draped in the standard surgical fashion.  The skin incision was made in the posterior axillary line, approximately 7th intercostal space with #10 blade, taken down through tissues and Bovie electrocautery.,Pleura was entered.  There was good deflation of the left lung.  __________ port was placed, followed by the 0-degree 10-mm scope with appropriate patient positioning.  Posteriorly a pedunculated 2.5 x 3-cm pleural-based mass was identified on the anterior chest wall.  There were thin adhesions to the pleura, but no invasion of the chest wall that could be identified.  The tumor was very mobile and was on a pedunculated stalk, approximately 1.5 cm.  It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk.,Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion.  Camera was placed through this port.  Laparoscopic scissors were placed through the posterior port, but it was necessary to have another instrument to provide more tension than just gravity.  Therefore because of the need to bring the specimen through the chest wall, a small 3-cm thoracotomy was made, which incorporated the posterior port site.  This was taken down to the subcutaneous tissue with Bovie electrocautery.  Periosteal elevator was used to lift the intercostal muscle off.  The ribs were not spread.  Through this 3-cm incision, both the laparoscopic scissors as well as Prestige graspers could be placed.  Prestige graspers were used to pull the specimen from the chest wall.  Care was taken not to injure the capsule.  The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall.  Care was taken not to transect the stalk.  Specimen came off the chest wall very easily.  There was good hemostasis.,At this point, the EndoCatch bag was placed through the incision.  Specimen was placed in the bag and then removed from the field.  There was good hemostasis.  Camera was removed.  A 24-French chest tube was placed through the anterior port and secured with 2-0 silk suture.  The posterior port site was closed 1st with 2-0 Vicryl in a running fashion for the intercostal muscle layer, followed by 2-0 closure of the latissimus fascia as well as subdermal suture, 4-0 Monocryl was used for the skin, followed by Steri-Strips and sterile drapes.  The patient tolerated the procedure well, was extubated in the operating room and returned to the recovery room in stable condition.
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DESCRIPTION: Left mesothelioma, focal.  Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.

surgery, mini thoracotomy, pleural based mass, pleural based nodule, chest wall, mesothelioma focal, pleural, chest, thoracotomy, mesothelioma, laparoscopic, thoracoscopy,

The surgical procedure described involves a thoracotomy and thoracoscopy for the removal of a mass associated with mesothelioma, a type of cancer. The high-stakes nature of this procedure arises from the involvement of the thoracic cavity, the need for careful handling of complex anatomy, and the implications of cancer treatment. Although the patient appears to have had a relatively successful initial surgery with minimal complications, any surgical intervention in a cancer diagnosis scenario inherently carries significant risks related to patient outcomes, potential complications, and impact on the cancer treatment plan.


Medical Specialty: Orthopedic
Sample Name: MRI T-Spine

CC:, BLE weakness.,HX:, This 82y/o RHM was referred to the Neurology service by the Neurosurgery service for evaluation of acute onset paraplegia. He was in his usual state of health until 5:30PM on 4/6/95, when he developed sudden "pressure-like" epigastric discomfort associated with bilateral lower extremity weakness, SOB, lightheadedness and diaphoresis. He knelt down to the floor and "went to sleep." The Emergency Medical Service was alert and arrived within minutes, at which time he was easily aroused though unable to move or feel his lower extremities. No associated upper extremity or bulbar dysfunction was noted. He was taken to a local hospital where an INR was found to be 9.1. He was given vitamin K 15mg, and transferred to UIHC to rule out spinal epidural hemorrhage. An MRI scan of the T-spine was obtained and the preliminary reading was "normal." The Neurology service was then asked to evaluate the patient.,MEDS:, Coumadin 2mg qd, Digoxin 0.25mg qd, Prazosin 2mg qd.,PMH:, 1)HTN. 2)A-Fib on coumadin. 3)Peripheral vascular disease:s/p left Femoral-popliteal bypass (8/94) and graft thrombosis-thrombolisis (9/94). 4)Adenocarcinoma of the prostate: s/p TURP (1992).,FHX: ,unremarkable.,SHX:, Farmer, Married, no Tobacco/ETOH/illicit drug use.,EXAM:, BP165/60 HR86 RR18 34.2C SAO2 98% on room air.,MS: A&O to person, place, time. In no acute distress. Lucid.,CN: unremarkable.,MOTOR: 5/5 strength in BUE. Flaccid paraplegia in BLE,Sensory: T6 sensory level to LT/PP, bilaterally. Decreased vibratory sense in BLE in a stocking distribution, distally.,Coord: Intact FNF and RAM in BUE. Unable to do HKS.,Station: no pronator drift.,Gait: not done.,Reflexes: 2/2 BUE, Absent in BLE, plantar responses were flexor, bilaterally.,Rectal: decreased rectal tone.,GEN EXAM: No carotid bruitts. Lungs: bibasilar crackles. CV: Irregular rate and rhythm with soft diastolic murmur at the left sternal border. Abdomen: flat, soft, non-tender without bruitt or pulsatile mass. Distal pulses were strong in all extremities.,COURSE:, Hgb 12.6, Hct 40%, WBC 11.7, Plt 154k, INR 7.6, PTT 50, CK 41, the GS was normal. EKG showed A-Fib at 75BPM with competing junctional pacemaker, essentially unchanged from 9/12/94.,It was suspected that the patient sustained an anterior-cervico-thoracic spinal cord infarction with resultant paraplegia and T6 sensory level. A CXR was done in the ER prior to admission. This revealed cardiomegaly and a widened mediastinum. He returned from the x-ray suite and suddenly became unresponsive and went into cardiopulmonary arrest. Resuscitative measures failed. Pericardiocentesis was unremarkable. Autopsy revealed a massive aortic dissection extending from the aortic root to the origin of the iliac arteries with extensive pericardial hematoma. The dissection was seen in retrospect on the MRI T-spine.
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DESCRIPTION: MRI T-spine and CXR - Aortic Dissection.

orthopedic, mri, a&o, aortic dissection, cxr, irregular rate and rhythm, mri scan, neurology service, t-spine, carotid bruitts, epidural hemorrhage, mediastinum, paraplegia, person, place, stocking distribution, time, weakness, mri t spine, sensory level, neurology, spine,

The scenario involves a critical medical case of an 82-year-old patient who experienced sudden paraplegia and other symptoms leading to a cardiopulmonary arrest. The high INR levels, administration of vitamin K, and subsequent MRI reveal significant medical concerns, highlighting the potential for severe outcomes. Additionally, the retrospective finding of a massive aortic dissection illustrates the substantial diagnostic challenge and consequences. The situation was time-sensitive and life-threatening, demonstrating the high-stakes nature of the medical scenario.


Medical Specialty: Dermatology
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.

dermatology, cetaphil cleansing lotion, hand dermatitis, aristocort, wash, ointment, hand, lotion, dermatitis

While the patient's condition involves discomfort and requires attention to prevent worsening, hand dermatitis is a common dermatological condition. It typically does not pose a severe or immediate threat to the patient's health like acute or life-threatening conditions might. The situation involves managing symptoms and improving the patient's quality of life rather than addressing an urgent medical emergency. Thus, it is not considered high-stakes in a medical context.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Allergic Rhinitis

SUBJECTIVE:,  This 23-year-old white female presents with complaint of allergies.  She used to have allergies when she lived in Seattle but she thinks they are worse here.  In the past, she has tried Claritin, and Zyrtec.  Both worked for short time but then seemed to lose effectiveness.  She has used Allegra also.  She used that last summer and she began using it again two weeks ago.  It does not appear to be working very well.  She has used over-the-counter sprays but no prescription nasal sprays.  She does have asthma but doest not require daily medication for this and does not think it is flaring up.,MEDICATIONS: , Her only medication currently is Ortho Tri-Cyclen and the Allegra.,ALLERGIES: , She has no known medicine allergies.,OBJECTIVE:,Vitals:  Weight was 130 pounds and blood pressure 124/78.,HEENT:  Her throat was mildly erythematous without exudate.  Nasal mucosa was erythematous and swollen.  Only clear drainage was seen.  TMs were clear.,Neck:  Supple without adenopathy.,Lungs:  Clear.,ASSESSMENT:,  Allergic rhinitis.,PLAN:,1.  She will try Zyrtec instead of Allegra again.  Another option will be to use loratadine.  She does not think she has prescription coverage so that might be cheaper.,2.  Samples of Nasonex two sprays in each nostril given for three weeks.  A prescription was written as well.
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DESCRIPTION: A 23-year-old white female presents with complaint of allergies.

soap / chart / progress notes, allergic rhinitis, allergies, asthma, nasal sprays, rhinitis, nasal, erythematous, allegra, sprays, allergic,

The situation presented is a routine medical evaluation for a patient with allergic rhinitis. The patient has not shown severe symptoms or complications such as anaphylaxis or severe asthma attacks, and her treatment involves non-emergency measures such as trying different medications and nasal sprays. While the patient's condition affects quality of life, it does not pose an immediate threat to her health or life. Therefore, the situation is low-stakes in the context of potential medical emergencies.


Medical Specialty: Urology
Sample Name: Vasectomy - 4

PROCEDURE: , Elective male sterilization via bilateral vasectomy.,PREOPERATIVE DIAGNOSIS:  ,Fertile male with completed family.,POSTOPERATIVE DIAGNOSIS:,  Fertile male with completed family.,MEDICATIONS:  ,Anesthesia is local with conscious sedation.,COMPLICATIONS: , None.,BLOOD LOSS: , Minimal.,INDICATIONS:  ,This 34-year-old gentleman has come to the office requesting sterilization via bilateral vasectomy.  I discussed the indications and the need for procedure with the patient in detail, and he has given consent to proceed.  He has been given prophylactic antibiotics.,PROCEDURE NOTE: , Once satisfactory sedation have been obtained, the patient was placed in the supine position on the operating table.  Genitalia was shaved and then prepped with Betadine scrub and paint solution and were draped sterilely.  The procedure itself was started by grasping the right vas deferens in the scrotum, and bringing it up to the level of the skin.  The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath.  The vas was brought out of the incision carefully.  A 2-inch segment was isolated, and 1-inch segment was removed.  The free ends were cauterized and were tied with 2-0 silk sutures in such a fashion that the ends double back on themselves.  After securing hemostasis with a cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Attention was now turned to the left side.  The vas was grasped and brought up to the level of the skin.  The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath.  The vas was brought out of the incision carefully.  A 2-inch segment was isolated, and 1-inch segment was removed.  The free ends were cauterized and tied with 2-0 silk sutures in such a fashion that the ends double back on themselves.  After securing hemostasis with the cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Bacitracin ointment was applied as well as dry sterile dressing.  The patient was awakened and was returned to Recovery in satisfactory condition.
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DESCRIPTION: Fertile male with completed family.  Elective male sterilization via bilateral vasectomy.

urology, sterilization, vas, fertile male, bilateral vasectomy, vasectomy, cauterized,

The procedure described is an elective vasectomy, which is a commonly performed and low-risk outpatient procedure for male sterilization. The stakes in this situation are relatively low because it is non-emergency, the surgery is straightforward, and there is no indication of complications or significant blood loss. However, the decision is significant on a personal and emotional level for the patient, as it involves permanent fertility changes, but strictly from a medical risk standpoint, it remains low-stakes.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Infant Not Gaining Weight

CHIEF COMPLAINT:,  Not gaining weight.,HISTORY OF PRESENT ILLNESS:,  The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds.  The patient appeared to have failure-to-thrive. was only at her birth weight but when eating one may be possibly gaining 2 ounces every 3-4 hours, and was noted to have a murmur.  At this point, the Hospitalist Service was contacted for admission.  The patient was directly admitted to Children's Hospital Explore Ward.,In the explore ward, she was noted to be in mild respiratory distress and has some signs and symptoms of heart failure and had a prominent murmur, so an echo was done at bedside, which did show a moderately-sized patent ductus arteriosus and very small VSD and some mild signs and symptoms of congestive heart failure.  The patient was also seen by Dr. X of Cardiology Service and a plan was then obtained.,PAST MEDICAL/BIRTH HISTORY: , The patient was born at term repeat C-section to a 27-year-old G3, P2 African-American female.  Pregnancy was not complicated by hypertension, diabetes, drugs, alcohol abuse or smoking.  Birthweight was 7 pounds 4 ounces at Community Hospital.  The mother did have a repeat C-section.  There is no rupture of membranes or group B strep status.  The prenatal care began in the second month of pregnancy and was otherwise uncomplicated.  Mother denies any sexual transmitted diseases or other significant illness.  The patient was discharged home on day of life #3 without any complications.,ALLERGIES:,  No known drug allergies.,DIET: , The patient only takes Enfamil 20 calories, 1-3 ounces per history every 3-4 hours.,ELIMINATION: , The patient urinates 3-4 times a day and has a bowel movement 3-4 times a day.,FAMILY HISTORY/SOCIAL HISTORY: , The patient lives with the mother.  She has 2 older male siblings.  All were reported good health.  Family history is negative for any congenital heart disease, syndromes, hypertension, sickle cell anemia or sickle cell trait and no significant positive PPD contacts and history of second-hand smoke exposures.,REVIEW OF SYSTEMS:  ,GENERAL:  The patient has been reported to have normal activity and normal cry with no significant weight loss per mom's report, but conversely no significant weight gain.  Mother does not report that she sweats whenever she eats or has any episodes of cyanosis.  ,HEENT:  Denies any significant nasal congestion or cough.  ,RESPIRATORY:  Denies any difficulty breathing or wheezing.  ,CARDIOVASCULAR:  As per above.  GI:  No history of any persistent vomiting or diarrhea.  ,GU:  Denies any decreased urinary output.  ,MUSCULOSKELETAL:  Negative.  ,NEUROLOGICAL:  Negative.  ,SKIN:  Negative.,All other systems reviewed are negative.,PHYSICAL EXAMINATION:,GENERAL:  The patient is examined in her room, our next floor.  She is crying very vigorously, especially when I examined but she is consolable.,VITAL SIGNS:  Temperature currently is 96.3, heart rate 137, respirations 36, blood pressure 105/61 while crying.,HEENT:  Normocephalic.  The patient has a possible right temporoparietal bossing noted and slightly irregular shaped trapezoidal-shaped head.  The anterior fontanelle is soft and flat.  Pupils are equal, reactive to light and accommodation, but there is some mild hypertelorism.  There is also some mild posterior rotation of the ears.  Oropharynx, mucous membranes are pink and moist.  There is a slightly high arched palate.,NECK:  Significant for possible mild reddening of the neck.,LUNGS:  Significant for perihilar crackles.  Mild tachypnea is noted.  O2 saturations are currently 97% on room air.  There is mild intercostal retraction.,CARDIOVASCULAR:  Heart has regular rate and rhythm.  Peripheral pulses are only 1+.  Capillary refills less than 3-4 seconds.,EXTREMITIES:  Slightly cool to touch.  There is 2-3/6 systolic murmur along the left sternal border.  Does radiate to the axilla and to the back.,ABDOMEN:  Soft, slightly distended, but nontender.  The liver edge is palpable 4 cm below right costal margin.  The spleen tip is also palpable.,GU:  Normal female external genitalia is noted.,MUSCULOSKELETAL:  The patient has poor fat deposits in her extremities.  Strength is only 2/4.  She had normal number of fingers and toes.,SKIN:  Significant for slight mottling.  There are very poor subcutaneous fat deposits in her skin.,LABORATORY DATA: , The i-STAT only shows sodium 135, potassium on a heel stick was 6.3, hemoglobin and hematocrit are 14 and 41, and white count was 1.4.  CBG on i-STAT showed the pH of 7.34 with CO2 of 55, O2 sat of 51, CO2 of 29 with the base excess of 4.  Chest x-ray shows bilateral infiltrates and significant cardiomegaly consistent with congenital heart disease and mild congestive heart failure.,ASSESSMENT: , This is an almost 2-month-old presents with:,1.  Failure-to-thrive.,2.  Significant murmur and patent ductus arteriosus.,3.  Congestive heart failure.,PLAN:  ,At present, we are going to admit and monitor closely tonight.  We will get a chest x-ray and start Lasix at 1 mg/kg twice daily.  We will also get a CBC and check a blood culture and further workup as necessary.
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DESCRIPTION: A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.

The situation described involves a 1-month-26-day-old infant with failure-to-thrive, a significant murmur, patent ductus arteriosus (PDA), and mild congestive heart failure, all of which are serious medical conditions. The condition is compounded by symptoms indicating heart issues and a failure to gain weight, which are critical concerns in a newborn. The urgency is high as newborns can deteriorate rapidly if heart conditions are not addressed. The need for admission to a children's hospital and close monitoring further indicates the high-stakes nature of the situation. Therefore, considering the age of the patient and the medical issues at hand, this scenario is quite high-stakes as it requires immediate and careful medical intervention to ensure the infant's survival and health.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Peripheral Effusion - Consult

REASON FOR CONSULT: , Peripheral effusion on the CAT scan.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.  The patient had a visiting nurse for Christmas and started having abdominal pain, nausea and vomiting for which, she was admitted.  She had a CAT scan of the abdomen done, showed moderate pericardial effusion for which cardiology consult was requested.  She had an echo done, which shows moderate pericardial effusion with early tamponade.  The patient has underlying shortness of breath because of COPD, emphysema and chronic cough.  However, denies any dizziness, syncope, presyncope, palpitation.  Denies any prior history of coronary artery disease.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , At this time, she is on hydromorphone p.r.n., erythromycin, ceftriaxone, calcium carbonate, Ambien.  She is on oxygen and nebulizer.,PAST MEDICAL HISTORY: , History of COPD, emphysema, pneumonia, and lung cancer.,PAST SURGICAL HISTORY:  ,Hip surgery and resection of the lung cancer 10 years ago.,SOCIAL HISTORY:,  Still smokes, but less than before.  Drinks socially.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS: , Denies any syncope, presyncope, palpitations, shortness of breath, cough, nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable not in any distress.,VITAL SIGNS:  Blood pressure 121/79, Pulse rate 94, respiratory rate 19, and temperature 97.6.,HEENT:  Atraumatic and normocephalic.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Breath sounds vesicular.  Clear on auscultation.,HEART:  PMI could not be localized.  S2 and S2 regular.  No S3, no S4.  No murmur.,ABDOMEN:  Soft and nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,EKG shows normal sinus rhythm, low voltage.,LABORATORY DATA: , White cell count 7.3, hemoglobin 12.9, hematocrit 38.1, and platelet at 322,000.  Sodium 135, potassium 5, BUN 6, creatinine 1.2, glucose 71, alkaline phosphatase 263, total protein 5.3, lipase 414, and amylase 57.,DIAGNOSTIC STUDIES:,  Chest x-ray shows left upper lobe airspace disease consistent with pneumonia _______.  CT abdomen showed diffuse replacement of the _______ metastasis, hepatomegaly, perihepatic ascites, moderate pericardial effusion, small left _______ sigmoid diverticulosis.,ASSESSMENT:,1.  Moderate peripheral effusion with early tamponade, probably secondary to lung cancer.,2.  Lung cancer with metastasis most likely.,3.  Pneumonia.,4.  COPD.,PLAN: , We will get CT surgery consult for pericardial window.  Continue present medication.
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DESCRIPTION: Peripheral effusion on the CAT scan.  The patient is a 70-year-old Caucasian female with prior history of lung cancer, status post upper lobectomy.  She was recently diagnosed with recurrent pneumonia and does have a cancer on the CAT scan, lung cancer with metastasis.

The patient in this scenario has a significant medical history that includes lung cancer with metastasis, COPD, pneumonia, and a current pericardial effusion with early signs of tamponade. These conditions are serious, especially since cardiac tamponade can become life-threatening if not treated promptly. The decision to consult CT surgery for a pericardial window indicates that immediate medical intervention is necessary to prevent potential complications, such as respiratory distress or cardiac arrest. The complexity and acuity of the patient's conditions make this a high-stakes situation.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Hemivulvectomy

PREOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,OPERATION PERFORMED: , Radical anterior hemivulvectomy.  Posterior skinning vulvectomy.,SPECIMENS: , Radical anterior hemivulvectomy, posterior skinning vulvectomy.,INDICATIONS FOR PROCEDURE: , The patient has a history of vulvar melanoma first diagnosed in November of 1995.  She had a surgical resection at that time and recently noted recurrence of an irritated nodule around the clitoris.  Biopsy obtained by The patient confirmed recurrence.  In addition, biopsies on the posterior labia (left side) demonstrated melanoma in situ.,FINDINGS: , During the examination under anesthesia, the biopsy sites were visible and a slightly pigmented irregular area of epithelium was seen near the clitoris.  No other obvious lesions were seen.  The room was darkened and a Woods lamp was used to inspect the epithelium.  A marking pen was used to outline all pigmented areas, which included several patches on both the right and left labia.,PROCEDURE: , The patient was prepped and draped and a scalpel was used to incise the skin on the anterior portion of the specimen.  The radical anterior hemivulvectomy was designed so that a 1.5-2.0 cm margin would be obtained and the depth was carried to the fascia of the urogenital diaphragm.  Subcutaneous adipose was divided with electrocautery and the specimen was mobilized from the periosteum.  After removal of the radical anterior portion, the skin on the posterior labia and perineal body was mobilized.  Skin was incised with a scalpel and electrocautery was used to undermine.  After removal of the specimen, the wounds were closed primarily with subcutaneous interrupted stitches of 3-0 Vicryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was then taken to the Post Anesthesia Care Unit in stable condition.
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DESCRIPTION: Wide Local Excision of the Vulva.  Radical anterior hemivulvectomy.  Posterior skinning vulvectomy.

obstetrics / gynecology, vulvar melanoma, wide local excision, radical anterior hemivulvectomy, posterior skinning vulvectomy, vulvectomy, hemivulvectomy, melanoma, woods lamp, recurrent vulvar melanoma, anterior hemivulvectomy, vulvar, labia, radical, skinning,

The situation involves a surgical procedure for recurrent vulvar melanoma, a potentially life-threatening condition. The stakes are high due to the nature of cancer treatment, the history of recurrence, and the complexity of the surgical procedure needed to manage the disease effectively. The health outcomes can significantly impact the patient's quality of life and survival, making it a high-stakes scenario.


Medical Specialty: Consult - History and Phy.
Sample Name: Cut on Foot - ER Visit

CHIEF COMPLAINT:,  Cut on foot.,HISTORY OF PRESENT ILLNESS:,  This is a 32-year-old male who had a piece of glass fall on to his right foot today.  The patient was concerned because of the amount of bleeding that occurred with it.  The bleeding has been stopped and the patient does not have any pain.  The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort.  The patient denies any injuries to any other portion of his body.  He has not had any recent illness.  The patient has no other problems or complaints.,PAST MEDICAL HISTORY:,  Asthma.,CURRENT MEDICATION: , Albuterol.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16.  Oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well-nourished, well-developed, the patient appears to be healthy.  The patient is calm and comfortable in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear conjunctiva and cornea bilaterally.  NECK:  Supple with full range of motion.  CARDIOVASCULAR:  Peripheral pulse is +2 to the right foot.  Capillary refills less than two seconds to all the digits of the right foot.  RESPIRATIONS:  No shortness of breath.  MUSCULOSKELETAL:  The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot.  There is no palpable foreign body, no foreign body is visualized.  There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels.  It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home.  The patient does not have any tenderness to the foot.  The patient has full range of motion to all the joints, all the toes, as well as the ankles.  The patient ambulates well without any difficulty or discomfort.  There are no other injuries noted to the rest of the body.  SKIN:  The 4-mm partial thickness laceration to the right foot as previously described.  No other injuries are noted.  NEUROLOGIC:  Motor is 5/5 to all the muscle groups of the right lower extremity.  Sensory is intact to light touch to all the dermatomes of the right foot.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No active bleeding is occurring at this time.  No evidence of bruising is noted to the body.,EMERGENCY DEPARTMENT COURSE:,  The patient had antibiotic ointment and a bandage applied to his foot.,DIAGNOSES:,1.  A 4-MM LACERATION TO THE RIGHT FOOT.,2.  ACUTE RIGHT FOOT PAIN, NOW RESOLVED.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  To home.  The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection.  The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on.
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DESCRIPTION: Patient had a piece of glass fall on to his right foot.  A 4-mm laceration.  Acute foot pain, now resolved.   The patient was given discharge instructions on wound care.

consult - history and phy., foot pain, cut on foot, piece of glass, foreign body, active bleeding, foot, injuries, atraumatic, laceration, bleeding, body,

The situation described involves a relatively minor injury (4-mm laceration caused by a piece of glass), which has been treated and resolved. The patient is stable, with no active bleeding, intact foot function, and no significant complications identified in the examination. Despite potential concerns like retained glass or infection risk, the overall condition is managed with discharge and follow-up instructions, indicating low immediate medical risk.