Medical Specialty: Surgery
Sample Name: G-tube placement

PREOPERATIVE DIAGNOSIS:,  Neurologic devastation secondary to nonaccidental trauma.,POSTOPERATIVE DIAGNOSES: , Neurologic devastation secondary to nonaccidental trauma.,PROCEDURE: , Laparoscopic G-tube placement (14-French 1.2-cm MIC-Key).,INDICATIONS FOR PROCEDURE: , This patient is a 5-month-old baby boy who presented unfortunately because of nonaccidental trauma.  The patient suffered neurologic devastation.  In order to facilitate enteral feedings, the plan is to place a G-tube as the patient cannot take by mouth.  Consent was obtained by court order as the patient is a ward of the state.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's abdomen was prepped and draped in the usual sterile fashion.  An incision was made through the umbilicus.  Peritoneal cavity entered bluntly.  A 5-mm trocar was introduced.  Abdomen was insufflated with a 5-mm scope.  No obvious pathology noted.  We visualized the stomach.  We chose the spot in the left upper quadrant for future G-tube site.  I made a small incision on the skin there, put another 5-mm trocar at that site.  Using a Babcock, we grasped the stomach along the greater curvature site for further G-tube.  I pulled a knuckle of stomach through the incision and secured with 4-0 Vicryl.  I then used 3-0 Prolene sutures as tacking sutures on either side of the future G-tube site taking full-thickness abdominal wall through stomach and back out the abdominal wall.  I then pulled the knuckle of stomach back up through the incision, made a gastrotomy, and then put a 4-0 pursestring around the gastrotomy site, introduced the 14, 1.2- cm MIC-Key into the stomach.  The gastrotomy site insufflated with 5 mL of saline.  We then tied down the pursestring.  On the laparoscopy, the G-tube looked to be in good position.  I insufflated the stomach through the G-tube, which I did and removed air subsequently.  I then placed 2 x 2 underneath the G-tube and tied down tacking sutures around the G-tube itself, placed the G-tube to gravity, desufflated the abdomen, closed the umbilical port site fascia with 3-0 Vicryl, closed skin with 5-0 Monocryl, and dressed with bacitracin, 2 x 2, and Steri-Strips.  The patient was extubated in the operating room and taken back to recovery room.  The patient tolerated the procedure well.
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DESCRIPTION:

surgery, neurologic devastation, g-tube placement, mic-key, laparoscopic g-tube placement, babcock, g-tube site, gastrotomy, mic key, abdominal wall, gastrotomy site, nonaccidental trauma, tube, stomach,

The situation involves a surgical procedure on a 5-month-old infant who has suffered neurologic devastation due to nonaccidental trauma. The procedure, G-tube placement, is necessary for the patient's feeding as they cannot eat by mouth due to their condition. This is a high-stakes situation because: 1) it involves a very young patient, increasing the complexity and potential risks of surgery; 2) there's an emotional aspect due to the cause being nonaccidental trauma, implicating potential legal or social services involvement; and 3) the procedure, while generally routine, requires precision and care due to the patient's fragile state. The necessity of court-ordered consent indicates that the child's situation is under legal scrutiny, adding another layer of complexity and pressure. Given these factors, the stakes in terms of medical, legal, and ethical considerations are significantly high.


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

Medical Specialty: Office Notes
Sample Name: Normal Physical Exam Template - 7

EYES: , The conjunctivae are clear.  The lids are normal appearing without evidence of chalazion or hordeolum.  The pupils are round and reactive.  The irides are without any obvious lesions noted.  Funduscopic examination shows sharp disk margins.  There are no exudates or hemorrhages noted.  The vessels are normal appearing.,EARS, NOSE, MOUTH AND THROAT:,  The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.,NECK:,  The neck is nontender and supple.  The trachea is midline.  The thyroid is without any evidence of thyromegaly.  No obvious adenopathy is noted to the neck.,RESPIRATORY: , The patient has normal respiratory effort.  There is normal lung excursion.  Percussion of the chest is without any obvious dullness.  There is no tactile fremitus or egophony noted.  There is no tenderness to the chest wall or ribs.  There are no obvious abnormalities.  The lungs are clear to auscultation.  There are no wheezes, rales or rhonchi heard.  There are no obvious rubs noted.,CARDIOVASCULAR: , There is a normal PMI on palpation.  I do not hear any obvious abnormal sounds.  There are no obvious murmurs.  There are no rubs or gallops noted.  The carotid arteries are without bruit.  No obvious thrill is palpated. There is no evidence of enlarged abdominal aorta to palpation.  There is no abdominal mass to suggest enlargement of the aorta.  Good strong femoral pulses are palpated.  The pedal pulses are intact.  There is no obvious edema noted to the extremities.  There is no evidence of any varicosities or phlebitis noted.,GASTROINTESTINAL: , The abdomen is soft.  Bowel sounds are present in all quadrants.  There are no obvious masses.  There is no organomegaly, and no liver or spleen is palpable.  No obvious hernia is noted.  The perineum and anus are normal in appearance.  There is good sphincter tone and no obvious hemorrhoids are noted.  There are no masses.  On digital examination, there is no evidence of any tenderness to the rectal vault; no lesions are noted.  Stool is brown and guaiac negative.,GENITOURINARY (FEMALE): , The external genitalia is normal appearing with no obvious lesions, no evidence of any unusual rash.  The vagina is normal in appearance with normal-appearing mucosa.  The urethra is without any obvious lesions or discharge.  The cervix is normal in color with no obvious cervical discharge.  There are no obvious cervical lesions noted.  The uterus is nontender and small, and there is no evidence of any adnexal masses or tenderness.  The bladder is nontender to palpation.  It is not enlarged.,GENITOURINARY (MALE): , Normal scrotal contents are noted.  The testes are descended and nontender.  There are no masses and no swelling to the epididymis noted.  The penis is without any lesions.  There is no urethral discharge.  Digital examination of the prostate reveals a nontender, non-nodular prostate.,BREASTS:,  The breasts are normal in appearance.  There is no puckering noted.  There is no evidence of any nipple discharge.  There are no obvious masses palpable.  There is no axillary adenopathy.  The skin is normal appearing over the breasts.,LYMPHATICS: , There is no evidence of any adenopathy to the anterior cervical chain.  There is no evidence of submandibular nodes noted.  There are no supraclavicular nodes palpable.  The axillae are without any abnormal nodes.  No inguinal adenopathy is palpable.  No obvious epitrochlear nodes are noted.,MUSCULOSKELETAL/EXTREMITIES: , The patient has normal gait and station.  The patient has normal muscle strength and tone to all extremities.  There is no obvious evidence of any muscle atrophy.  The joints are all stable.  There is no evidence of any subluxation or laxity to any of the joints.  There is no evidence of any dislocation.  There is good range of motion of all extremities without any pain or tenderness to the joints or extremities.  There is no evidence of any contractures or crepitus.  There is no evidence of any joint effusions.  No obvious evidence of erythema overlying any of the joints is noted.  There is good range of motion at all joints.  There are normal-appearing digits.  There are no obvious lesions to any of the nails or nail beds.,SKIN:,  There is no obvious evidence of any rash.  There are no petechiae, pallor or cyanosis noted.  There are no unusual nodules or masses palpable.,NEUROLOGIC: , The cranial nerves II XII are tested and are intact.  Deep tendon reflexes are symmetrical bilaterally.  The toes are downgoing with normal Babinskis.  Sensation to light touch is intact and symmetrical.  Cerebellar testing reveals normal finger nose, heel shin.  Normal gait.  No ataxia.,PSYCHIATRIC:  ,The patient is oriented to person, place and time.  The patient is also oriented to situation.  Mood and affect are appropriate for the present situation.  The patient can remember 3 objects after 3 minutes without any difficulties.  Remote memory appears to be intact.  The patient seems to have normal judgment and insight into the situation.
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DESCRIPTION: Most commonly used phrases in physical exam.

office notes, ears, nose, mouth, neck, respiratory, cardiovascular, eyes, gastrointestinal, genitourinary, breasts, lymphatics, musculoskeletal, extremities, skin, neurologic, psychiatric, normal appearing, physical exam, examination,

The information provided is a normal physical exam template used in routine check-ups. It does not indicate the presence of any acute medical issues or emergencies. Such templates are typically used as documentation for standard physical assessments, indicating an absence of medical abnormalities. Therefore, the stakes involved are low, as the situation pertains to documenting expected normal findings rather than diagnosing or managing critical health conditions.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Radiology
Sample Name: MRI Brain - CO poisoning

CC:, Found down.,HX:, 54y/o RHF went to bed at 10 PM at her boyfriend's home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5:00PM on 1/16/96. She next remembered riding in the ambulance from a Hospital. Initial Carboxyhemoglobin level was 24% (normal < 1.5%) and ABG 7.41/30/370 with O2Sat 75% on 100%FiO2.,MEDS:, unknown anxiolytic, estrogen.,PMH:, PUD, ?stroke and memory difficulty in the past 1-2 years.,FHX:, unknown.,SHX:, divorced. unknown history of tobacco/ETOH/illicit drug use.,EXAM: ,BP126/91, HR86, RR 30, 37.1C.,MS:, Oriented to name only. Speech without dysarthria. 2/3 recall at 5minutes.,CN:, unremarkable.,MOTOR: ,full strength throughout with normal muscle tone and bulk.,SENSORY: ,unremarkable.,COORD/STATION:, unremarkable.,GAIT:, not tested on admission.,GEN EXAM:, notable for erythema of the face and chest.,COURSE:, She underwent a total of four dives under Hyperbaric Oxygen ( 2 dives on 1/17 and 2 dives on 1/18). Neuropsychologic assessment on 1/18/96 revealed marked cognitive impairments with defects in anterograde memory, praxis, associative fluency, attention, and speed of information processing. She was discharged home on 1/19/96 and returned on 2/11/96 after neurologic deterioration. She progressively developed more illogical behavior, anhedonia, anorexia and changes in sleep pattern. She became completely dependent and could not undergo repeat neuropsychologic assessment in 2/96. She was later transferred to another care facility against medical advice. The etiology for these changes became complicated by a newly discovered history of possible ETOH abuse and usual "anxiety" disorder.,MRI brain, 2/14/96, revealed increased T2 signal within the periventricular white matter, bilaterally. EEG showed diffuse slowing without epileptiform activity.
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DESCRIPTION: MRI Brain, Carbon Monoxide poisoning.

MRI Brain, Carbon Monoxide poisoning.

The situation involves a medical case of carbon monoxide poisoning, which is a potentially life-threatening condition requiring timely and appropriate treatment. The patient showed significant cognitive impairments after the poisoning incident and needed multiple hyperbaric oxygen therapy sessions. The ongoing neurological deterioration and her dependency highlight the high stakes, as the outcome significantly affects the patient's quality of life and long-term health. The complexity of care is further increased by comorbidities and possible substance abuse issues.


Medical Specialty: Consult - History and Phy.
Sample Name: Bariatric Consult - Surgical Weight Loss - 4

HISTORY OF PRESENT ILLNESS:,  Ms. A is a 55-year-old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.  The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Watchers, NutriSystem, Jenny Craig, TOPS, cabbage diet, grape fruit diet, Slim-Fast, Richard Simmons, as well as over-the-counter measures without any long-term sustainable weight loss.  At the time of presentation to the practice, she is 5 feet 6 inches tall with a weight of 285.4 pounds and a body mass index of 46.  She has obesity-related comorbidities, which includes hypertension and hypercholesterolemia.,PAST MEDICAL HISTORY:,  Significant for hypertension, for which the patient takes Norvasc and Lopressor for.  She also suffers from high cholesterol and is on lovastatin for this.  She has depression, for which she takes citalopram.  She also stated that she had a DVT in the past prior to her hysterectomy.  She also suffers from thyroid disease in the past though this is unclear, the nature of this.,PAST SURGICAL HISTORY: , Significant for cholecystectomy in 2008 for gallstones.  She also had a hysterectomy in 1994 secondary to hemorrhage.  The patient denies any other abdominal surgeries.,MEDICATIONS: , Norvasc 10 mg p.o. daily, Lopressor tartrate 50 mg p.o. b.i.d., lovastatin 10 mg p.o. at bedtime, citalopram 10 mg p.o. daily, aspirin 500 mg three times a day, which is currently stopped, vitamin D, Premarin 0.3 mg one tablet p.o. daily, currently stopped, omega-3 fatty acids, and vitamin D 50,000 units q. weekly.,ALLERGIES: , The patient denies allergies to medications and to latex.,SOCIAL HISTORY: , The patient is a homemaker.  She is married, with 2 children aged 22 and 28.  She is a lifelong nonsmoker and nondrinker.,FAMILY HISTORY:  ,Significant for high blood pressure and diabetes as well as cancer on her father side.  He did pass away from congestive heart failure.  Mother suffers from high blood pressure, cancer, and diabetes.  Her mother has passed away secondary to cancer.  She has two brothers one passed away from brain cancer.,REVIEW OF SYSTEMS: , Significant for ankle swelling.  The patient also wears glasses for vision and has dentures.  She does complain of shortness of breath with exertion.  She also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain.  The patient denies ulcerative colitis, Crohn disease, bleeding diathesis, liver disease, or kidney disease.  She denies chest pain, cardiac disease, cancer, and stroke.,PHYSICAL EXAMINATION:  ,The patient is a well-nourished, well-developed female, in no distress.  Eye Exam:  Pupils equal and reactive to light.  Extraocular motions are intact.  Neck Exam:  No cervical lymphadenopathy.  Midline trachea.  No carotid bruits.  Nonpalpable thyroid.  Neuro Exam:  Gross motor strength in the upper and lower extremities, equal bilaterally with no focal neuro deficits noted.  Lung Exam:  Clear breath sounds without rhonchi or wheezes.  Cardiac Exam:  Regular rate and rhythm without murmur or bruits.  Abdominal Exam:  Positive bowel sounds.  Soft, nontender, obese, and nondistended abdomen.  Lap cholecystectomy scars noted.  No obvious hernias.  No organomegaly appreciated.  Lower extremity Exam:  Edema 1+.  Dorsalis pedis pulses 2+.,ASSESSMENT:  ,The patient is a 55-year-old female with a body mass index of 46, suffering from obesity-related comorbidities including hypertension and hypercholesterolemia, who presents to the practice for consideration of gastric bypass surgery.  The patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity-related comorbidities.,PLAN: , In preparation for surgery, we will obtain the usual baseline laboratory values including baseline vitamin levels.  I recommended the patient undergo an upper GI series prior to surgery due to find her upper GI anatomy.  Also the patient will meet with the dietitian and psychologist as per her usual routine.  I have recommended approximately six to eight weeks of Medifast for the patient to obtain a 10% preoperative weight loss in preparation for surgery.
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DESCRIPTION: Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.

consult - history and phy., jenny craig, medifast, nutrisystem, richard simmons, slim-fast, tops, weight watchers, cabbage diet, grape fruit diet, roux-en-y, laparoscopic roux-en-y gastric bypass, weight loss modalities, surgical weight loss, body mass index, weight loss,

The situation involves a medical assessment for a major surgery, gastric bypass, which is typically considered a high-stakes procedure due to the potential risks and benefits involved, especially given the patient's comorbidities such as hypertension and hypercholesterolemia. The surgery can significantly affect her health outcomes and quality of life. Furthermore, the preparation phase entails psychological and dietary evaluations, which indicate the seriousness of the intervention. These factors make it a high-stakes situation.


Medical Specialty: Orthopedic
Sample Name: Anterior Cervical Discectomy

PREOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1.  Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2.  Bilateral C6 nerve root decompression.,3.  Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4.  Bilateral C5 nerve root decompression.,5.  Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6.  Bilateral C4 nerve root decompression.,7.  Harvesting of autologous bone from the vertebral bodies.,8.  Grafting of allograft bone for creation of arthrodesis.,9.  Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12.  Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6.  There was a herniated disk with cord compression and radiculopathy at C4-C5.  C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels.  Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives.  He clearly understands and has no further questions and requests that I proceed.,PROCEDURE:  ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease.  Dissection was carried down through the platysma musculature and the anterior spine was exposed.  The medial borders of the longus colli muscle were dissected free from their attachments to the spine.  Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained.  A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space.  The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies.  The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament.  The ligament was incised and the underlying dura was exposed.  I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen.  There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact.  However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right.  The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5.  I worked down through bony osteophytes and identified the posterior longitudinal ligament.  The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces.  The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen.  The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it.  Again the microscope was angled to the left side where similar decompression was achieved.  Central decompression was achieved here where there was a moderate amount of spinal cord compression.  This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space.  Here there were large osteophytes projecting posteriorly against the cord.  I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord.  This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord.  I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right.  The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis.  A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration.  Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis.  Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4.  Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge.  I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks.  The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described.  An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation.  Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate.  The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush.  The holes were drilled and the screws were placed.  Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6.  All eight screws had good purchase.  The locking screws were tightly applied.  An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure.  The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained.  A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct.  There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.
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DESCRIPTION: Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression.  Harvesting of autologous bone from the vertebral bodies.  Grafting of allograft bone for creation of arthrodesis.

This scenario describes a complex surgical procedure involving multiple levels of the cervical spine. An anterior cervical discectomy is a significant surgery aimed at addressing severe conditions such as cervical spondylosis with myelopathy and herniated discs, which can cause considerable pain and neurological deficits. The stakes are high due to the potential risks involved, including complications such as spinal cord and nerve root injury, infection, and issues with the graft or instrumentation. The stakes are elevated further considering the patient's age and medical history, including recent smoking cessation. The successful outcome directly impacts the patient's neurological function and quality of life.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Exploratory Laparotomy - 2

PREOPERATIVE DIAGNOSES,1.  Pelvic mass.,2.  Suspected right ovarian cyst.,POSTOPERATIVE DIAGNOSES,1.  Pelvic mass.,2.  Suspected right ovarian cyst.,PROCEDURES,1.  Exploratory laparotomy.,2.  Extensive lysis of adhesions.,3.  Right salpingo-oophorectomy.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , 200 mL,SPECIMENS:  ,Right tube and ovary.,COMPLICATIONS: , None.,FINDINGS: , Extensive adhesive disease with the omentum and bowel walling of the entire pelvis, which required more than 45 minutes of operating time in order to establish visualization and to clear the bowel and other important structures from the ovarian cyst, tube, and ovary in order to remove them.  The large and small bowels were completely enveloping a large right ovarian cystic mass.  Normal anatomy was difficult to see due to adhesions.  Cyst was ruptured incidentally intraoperatively with approximately 150 mL to 200 mL of turbid fluid.  Cyst wall, tube, and ovary were stripped away from the bowel.  Posterior peritoneum was also removed in order to completely remove the cyst wall ovary and tube.  There was excellent postoperative hemostasis.,PROCEDURE:  ,The patient was taken to the operating room, where general anesthesia was achieved without difficulty.  She was then placed in a dorsal supine position and prepped and draped in the usual sterile fashion.  A vertical midline incision was made from the umbilicus and extended to the symphysis pubis along the line of the patient's prior incision.  Incision was carried down carefully until the peritoneal cavity was reached.  Care was taken upon entry of the peritoneum to avoid injury of underlying structures.  At this point, the extensive adhesive disease was noted, again requiring greater than 45 minutes of dissection in order to visualize the intended anatomy for surgery.  The omentum was carefully stripped away from the patient's right side developing a window.  This was extended down along the inferior portion of the incision removing the omentum from its adhesions to the anterior peritoneum and what appears to be the vesicouterine peritoneum.  A large mass of bowel was noted to be adherent to itself causing a quite tortuous course.  Adhesiolysis was performed in order to free up the bowel in order to pack it out of the pelvis.  Excellent hemostasis was noted.  The bowel was then packed over of the pelvis allowing visualization of a matted mass of large and small bowel surrounding a large ovarian cyst.  Careful adhesive lysis and dissection enabled the colon to be separated from the posterior wall of the cyst.  Small bowel and portion of the colon were adherent anteriorly on the cyst and during the dissection of these to remove them from their attachment, the cyst was ruptured.  Large amount of turbid fluid was noted and was evacuated.  The cyst wall was then carefully placed under tension and stripped away from the patient's small and large bowel.  Once the bowel was freed, the remnants of round ligament was identified, elevated, and the peritoneum was incised opening the retroperitoneal space.,The retroperitoneal space was opened following the line of the ovarian vessels, which were identified and elevated and a window made inferior to the ovarian vessels, but superior to the course of the ureter.  This pedicle was doubly clamped, transected, and tied with a free tie of #2-0 Vicryl.  A suture ligature of #0 Vicryl was used to obtain hemostasis.  Excellent hemostasis was noted at this pedicle.  The posterior peritoneum and portion of the remaining broad ligament were carefully dissected and shelled out to remove the tube and ovary, which was still densely adherent to the peritoneum.  Care was taken at the side of the remnant of the uterine vessels.  However, a laceration of the uterine vessels did occur, which was clamped with a right-angle clamp, and carefully sutured ligated with excellent hemostasis noted.  Remainder of the specimen was then shelled out including portions of the posterior and sidewall peritoneum and removed.,The opposite tube and ovary were identified, were also matted behind a large amount of large bowel and completely enveloped and wrapped in the fallopian tube.  Minimal dissection was performed in order to ascertain and ensure that the ovary appeared completely normal.  It was then left in situ.  Hemostasis was achieved in the pelvis with the use of electrocautery.  The abdomen and pelvis were copiously irrigated with warm saline solution.  The peritoneal edges were inspected and found to have good hemostasis after the side of the uterine artery pedicle, and the ovarian vessel pedicle.  The areas of the bowel had previously been dissected and due to adhesive disease, it was carefully inspected and excellent hemostasis was noted.,All instruments and packs removed from the patient's abdomen.  The abdomen was closed with a running mattress closure of #0 PDS, beginning at the superior aspect of the incision, and extending inferiorly.  Excellent closure of the incision was noted.  The subcutaneous tissues were then copiously irrigated.  Hemostasis was achieved with the use of cautery.  Subcutaneous tissues were reapproximated to close the edge space with a several interrupted sutures of #0 plain gut suture.  The skin was closed with staples.,Incision was sterilely clean and dressed.  The patient was awakened from general anesthesia and taken to the recovery room in stable condition.  All counts were noted correct times three.
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DESCRIPTION: Exploratory laparotomy.  Extensive lysis of adhesions.  Right salpingo-oophorectomy.   Pelvic mass, suspected right ovarian cyst.

obstetrics / gynecology, pelvic mass, ovarian cyst, exploratory laparotomy, lysis of adhesions, salpingo-oophorectomy, cyst, bowel, adhesions, uterine, abdomen, pelvis, ovary, peritoneum, ovarian, hemostasis,

The situation described involves a complex surgical procedure that addresses significant health concerns, such as a pelvic mass and suspected ovarian cyst. The surgery included an exploratory laparotomy, extensive lysis of adhesions, and right salpingo-oophorectomy. These procedures indicate a high level of complexity and potential risk due to the presence of extensive adhesions and the need for careful dissection to avoid damaging important structures. Additionally, there was an incidental rupture of the cyst intraoperatively, requiring management of cyst fluid spillage into the abdomen. Despite a successful outcome and no complications noted, the stakes are high due to the potential for significant intraoperative and postoperative complications, the necessity of preserving reproductive health, and the implications for the patient's quality of life.


Medical Specialty: Surgery
Sample Name: Subclavian Central Venous Catheter Insertion

PREOPERATIVE DIAGNOSES:,1.  Need for intravenous access.,2.  Status post fall.,3.  Status post incision and drainage of left lower extremity.,POSTOPERATIVE DIAGNOSES:,1.  Need for intravenous access.,2.  Status post fall.,3.  Status post incision and drainage of left lower extremity.,PROCEDURE PERFORMED: , Insertion of right subclavian central venous catheter.,SECOND ANESTHESIA: , Approximately 10 cc of 1% lidocaine.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE:  ,The patient is a 74-year-old white female who presents to ABCD General Hospital after falling down flight of eleven stairs and sustained numerous injuries.  The patient went to OR today for an I&D of left lower extremity degloving injury.  Orthopedics was planning on taking the patient back for serial debridements and need for reliable IV access is requested.,PROCEDURE: , Informed consent was obtained by the patient and her daughter.  All risks and benefits of the procedure were explained and all questions were answered.  The patient was prepped and draped in the normal sterile fashion.  After landmarks were identified, approximately 5 cc of 1% lidocaine were injected into the skin and subcuticular tissues and the right neck posterior head of the sternocleidomastoid.  Locator needle was used to correctly cannulate the right internal jugular vein.  Multiple attempts were made and the right internal jugular vein was unable to be cannulized.,Therefore, we prepared for a right subclavian approach.  The angle of the clavicle was found and a #22 gauge needle was used to anesthetize approximately 5 cc of 1% lidocaine in skin and subcuticular tissues along with the periosteum of the clavicle.  A Cook catheter needle was then placed and ________ the clavicle in the orientation aimed toward the sternal notch.  The right subclavian vein was then accessed.  A guidewire was placed with a Cook needle and then the needle was subsequently removed and a #11 blade scalpel was used to nick the skin.  A dilator sheath was placed over the guidewire and subsequently removed.  The triple lumen catheter was then placed over the guidewire and advanced to 14 cm.  All ports aspirated and flushed.  Good blood return was noted and all ports were flushed well.  The triple lumen catheter was then secured at 14 cm using #0 silk suture.  A sterile dressing was then applied.  A stat portable chest x-ray was ordered to check line placement.  The patient tolerated the procedure well and there were no complications.
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DESCRIPTION: Insertion of right subclavian central venous catheter.   Need for intravenous access, status post fall, and status post incision and drainage of left lower extremity.

surgery, intravenous access, incision and drainage, subclavian central venous catheter, central venous catheter, lower extremity, venous, intravenous, lidocaine, subclavian, needle, catheter, insertion

The procedure involves the insertion of a central venous catheter, which is a high-stakes procedure due to the need for reliable intravenous access in a patient who has experienced a fall resulting in significant injury. The patient's situation is compounded by her age and the need for orthopedic procedures, increasing the stakes by necessitating central venous access for potentially ongoing treatments. Although the surgical procedure described was successfully completed without complications, central venous catheter insertion carries inherent risks such as infection, bleeding, and complications related to insertion. The context of the patient's injuries and the need for subsequent procedures adds to the critical nature of the situation.


Medical Specialty: Surgery
Sample Name: Total Hip Arthroplasty

PREOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,PROCEDURE PERFORMED:  ,Total hip arthroplasty on the left.,ANESTHESIA:  ,General.,BLOOD LOSS: , 800 cc.,The patient was positioned with the left hip exposed on the beanbag.,IMPLANT SPECIFICATION: , A 54 mm Trilogy cup with cluster holes 3 x 50 mm diameter with a appropriate liner, a 28 mm cobalt-chrome head with a zero neck length head, and a 12 mm porous proximal collared femoral component.,GROSS INTRAOPERATIVE FINDINGS:  ,Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes.  The patient also had a rent in the attachment of the hip abductors and a partial rent in the vastus lateralis.  This was revealed once we removed the trochanteric bursa.,HISTORY:  ,This is a 56-year-old obese female with a history of bilateral degenerative hip arthritis.  She underwent a right total hip arthroplasty by Dr. X in the year of 2000, and over the past three years, the symptoms in her left hip had increased tremendously especially in the past few months.,Because of the increased amount of pain as well as severe effect on her activities of daily living and uncontrollable pain with narcotic medication, the patient has elected to undergo the above-named procedure.  All risks as well complications were discussed with the patient including but not limited to infection, scar, dislocation, need for further surgery, risk of anesthesia, deep vein thrombosis, and implant failure.  The patient understood all these risks and was willing to continue further on with the procedure.,PROCEDURE: , The patient was wheeled back to the Operating Room #2 at ABCD General Hospital on 08/27/03.  The general anesthetic was first performed by the Department of Anesthesia.  The patient was then positioned with the left hip exposed on the beanbag in the lateral position.  Kidney rests were also used because of the patient's size.  An axillary roll was also inserted for comfort in addition to a Foley catheter, which was inserted by the OR nurse.  All her bony prominences were well padded.  At this time, the left hip and left lower extremity was then prepped and draped in the usual sterile fashion for this procedure.  At this time, an anterolateral approach was then performed, first incising through the skin in approximately 5 to 6 inches of subcutaneous fat.  The tensor fascia lata was then identified.  A self-retainer was then inserted to expose the operative field.  Bovie cautery was used for hemostasis.  At this time, a fresh blade was then used to incise the tensor fascia lata over the posterior one-third of the greater trochanter.  At this time, a blunt dissection was taken proximally.  The tensor fascia lata was occluded with a hip retractor.  At this time, after hemostasis was obtained, Bovie cautery was used to incise the proximal end of the vastus lateralis and removing the partial portion of the hip abductor, the gluteus medius.  At this time, a periosteal elevator was used to expose anterior hip capsule.  A ________ was then inserted over the femoral head purchasing of the acetabulum underneath the reflected head of the quadriceps muscle.  Once this was performed, Homan retractors were then inserted superiorly and inferiorly underneath the femoral neck.  At this time, a capsulotomy was then performed using a Bovie cautery and the capsulotomy was ________ and then edged over the acetabulum.  At this point, a large bone hook was then inserted over the neck and with gentle traction and external rotation, the femoral head was dislocated out of the acetabulum.  At this time, we had an exposure of the femoral head, which did reveal degenerative changes of the femoral head and once the acetabulum was visualized, we did see degenerative changes within the acetabulum as well as osteophyte formation around the rim of the acetabulum.  At this time, a femoral stem guide was then used to measure proximal femoral neck cut.  We made a cut approximately a fingerbreadth above the lesser trochanter.  At this time, with protection of the soft tissues an oscillating saw was used to make femoral neck cut.,The femoral head was then removed.  At this time, we removed the leg out of the bag and Homan retractors were then used to expose the acetabulum.  A long-handle knife was used to cut through the remainder of the capsule and remove the glenoid labrum around the rim of the acetabulum.  With better exposure of the acetabulum, we started reaming the acetabulum.  We started with a size #44 and progressively reamed to a size #50.  At the size #50 mm reamer, we obtained excellent bony bleeding with good remainder of bone stalk both anteriorly and posteriorly as well as superiorly within the acetabulum.  We then reamed up to size #52 in order to get bony bleeding around the rim as well as anterior and posterior within the acetabulum.  A size 54 mm Trilogy cup was then implanted with excellent approaches approximately 45 degrees of abduction and 10 to 15 degrees of anteversion dialed in.  Once the cup was impacted in place, we did visualize that the cup was well seated on to the internal portion of the acetabulum.  At this time, two screws were the placed within the superior table for better approaches securing the acetabular cup.  At this time, a plastic liner was then inserted for protection.  The leg was then placed back in the bag.  A Bennett retractor was used to retract the tensor fascia lata and femoral elevator was used to elevate the femur for better exposure and at this time, we began working on the femur.  A rongeur was used to lateralize over the greater trochanter.  A Box osteotome was used to remove the cancellous portion of the femoral neck.  A Charnley awl was then used to cannulate through the proximal femoral canal.  A power reamer was then used to ream the lateral aspect of the greater trochanter in order to provide maximal lateralization and prevent varus implantation of our stem.  At this time, we began broaching.  We started with a size #10 and progressively worked up to a size #12 mm broach.  Once the 12 mm broach was inserted in place, it was seated approximately 1 mm below the calcar.  A calcar reamer was then placed and the calcar was reamed smoothly.  A standard neck as well as a 28 mm plastic head was then placed and a trial reduction was then performed.  Once this was performed, the hip was taken to range of motion with external rotation, longitudinal traction as well as flexion and revealed good stability with no impingement or dislocation.  At this time, we removed 12 mm broach and proceeded with implanting our polyethylene liner within the acetabulum.  This was impacted and placed and checked to assure that it was well seated with no loosening.  Once this was performed, we then exposed the proximal femur one more time.  We copiously irrigated within the canal and then suctioned it dry.  At this time, a 12 mm porous proximal collared stem, a femoral component was then impacted in place.  Once it was well seated on the calcar, we double checked to assure that there was no evidence of calcar fractures, which there were none.  The 28 mm zero neck length cobalt-chrome femoral head was then impacted in place and the Morse taper assured that this was well fixed by ________.,Next, the hip was then reduced within the acetabulum and again we checked range of motion as well as ligamentous stability with gentle traction, external rotation, as well as hip flexion.  We were satisfied with components as well as the alignment of the components.  Copious irrigation was then used to irrigate the wound.  #1 Ethibond was then used to approximate the anterior hip capsule.  #1 Ethibond in interrupted fashion was used to approximate the vastus lateralis as well as the gluteus medius attachment over the partial gluteus medius attachment which was resected off the greater trochanter.  Next, a #1 Ethibond was then used to approximate the tensor fascia lata with figure-of-eight closure.  A tight closure was performed.  Since the patient did have a lot of subcutaneous fat, multiple #2-0 Vicryl sutures were then used to approximate the bed space and then #2-0 Vicryl for the subcutaneous skin.  Staples were then used for skin closure.  The patient's hip was then cleansed.  Sterile dressings consisting of Adaptic, 4 x 4, ABDs, and foam tape were then placed.  A drain was placed prior to wound closure for postoperative drainage.  After the dressing was applied, the patient was extubated safely and transferred to recovery in stable condition.  Prognosis is good.
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DESCRIPTION: Total hip arthroplasty on the left.  Left hip degenerative arthritis.  Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes.

surgery, degenerative arthritis, total hip arthroplasty, tensor fascia lata, vastus lateralis, gluteus medius, femoral neck, femoral head, head, femoral, acetabulum, hip, attachment, arthroplasty,

Total hip arthroplasty is a major surgical procedure dealing with severe degenerative arthritis. It involves significant risks such as infection, dislocation, and potential for further surgeries. The blood loss of 800 cc adds complexity, and the patient's history of uncontrollable pain emphasizes the impact on quality of life. These factors collectively indicate a high-stakes situation for the patient's health and well-being.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Well-woman checkup

CHIEF COMPLAINT:,  The patient comes for her well-woman checkup.,HISTORY OF PRESENT ILLNESS:,  She feels well.  She has had no real problems.  She has not had any vaginal bleeding.  She had a hysterectomy.  She has done fairly well from that time till now.  She feels like she is doing pretty well.  She remains sexually active occasionally.  She has not had any urinary symptoms.  No irregular vaginal bleeding.  She has not had any problems with vasomotor symptoms and generally, she just feels like she has been doing pretty well.  She sometimes gets a catch in her right hip and sometimes she gets heaviness in her calves.  She says the only thing that works to relieve that is to sleep on her tummy with her legs pulled up and they relax and she goes off to sleep.  She does not report any swelling or inflammation, or pain.  She had a recent urinary tract infection, took medication, and has not rechecked on that urinalysis.,MEDICATIONS: , Tetracycline 250 mg daily, Inderal LA 80 mg every other day.,ALLERGIES:,  Sulfa.,PAST MEDICAL HISTORY:,  She had rosacea.  She also has problems with “tremors” and for that she takes Inderal LA.  Hysterectomy in the past.,SOCIAL HISTORY:,  She drinks four cups of coffee a day.  No soda.  No chocolate.  She said her husband hurt his hand and shoulder, and she has been having to care of him pretty much.  They walk every evening for one hour.,FAMILY HISTORY:,  Her mother is in a nursing home; she had a stroke.  Her father died at age 86 in January 2004 of congestive heart failure.  She has two brothers, one has kidney failure, the other brother donated a kidney to his other brother, but this young man is now an alcoholic and drug addict.,REVIEW OF SYSTEMS:,  Patient denies headache or trauma.  No blurred or double vision.  Hearing is fine, no tinnitus, or infection.  Infrequent sore throat, no hoarseness, or cough.,Neck:  No stiffness, pain, or swelling.,Respiratory:  No shortness of breath, cough, or hemoptysis.,Cardiovascular:  No chest pain, ankle edema, palpitations, or hypertension.,GI:  No nausea, vomiting, diarrhea, constipation, melena, or jaundice.,GU:  No dysuria, frequency, urgency, or stress incontinence.,Locomotor:  No weakness, joint pain, tremor, or swelling.,GYN:  See HPI.,Integumentary:  Patient performs self-breast examinations and denies any breast masses or nipple discharge.  No recent skin or hair changes.,Neuropsychiatric:  Denies depression, anxiety, tearfulness, or suicidal thought.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Height:  62 inches.  Weight:  134 pounds.  Blood pressure:  116/74.  Pulse:  60.  Respirations:  12.  Age 59.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.  She fell last winter on the ice and really cracked her head and has had some problems with headaches since then and she has not returned to her job which was very stressful and hard on her.  She wears glasses.,Neck:  Full range of motion.  No lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation and percussion.,Heart:  Normal sinus rhythm, no murmur.,Integumentary:  Breasts are without masses, tenderness, nipple retraction, or discharge.  Reviewed self-breast examination.  No axillary nodes are palpable.,Abdomen:  Soft.  Liver, spleen, and kidneys are not palpable.  No masses felt, nontender.  Femoral pulses strong and equal.,Back:  No CVA or spinal tenderness.  No deformity noted.,Pelvic:  BUS negative.  Vaginal mucosa atrophic.  Cervix and uterus are absent.  No Pap was taken.  No adnexal masses.,Rectal:  Good sphincter tone.  No masses.  Stool guaiac negative.,Extremities:  No edema.  Pulses strong and equal.  Reflexes are intact.  Romberg and Babinski are negative.  She is oriented x 3.  Gait is normal.,ASSESSMENT:,  Middle-aged woman, status post hysterectomy, recent urinary tract infection.,PLAN:,  We will evaluate the adequacy of the therapy for her urinary tract infection with the urinalysis and culture.  I recommended mammogram and screening, hemoccult x 3, DEXA scan and screening, and she is fasting today.  We will screen with chem-12, lipid profile, and CBC because of her advancing age and notify of those results, as soon as they are available.  Continue same meds.  Recheck annually unless she has problems sooner.
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DESCRIPTION: Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection.

The situation describes a routine well-woman checkup for a middle-aged woman who is generally doing well and presents no immediate medical concerns. It includes standard evaluations and follow-up tests due to age-appropriate screenings. Although there are health maintenance needs, nothing in the description indicates an acute or life-threatening situation. The tasks described are typical in preventive care, with no urgent or critical issues involved.


Medical Specialty: Urology
Sample Name: Excretory Urogram - IVP

There is normal and symmetrical filling of the caliceal system.  Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally.  The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. The postvoid films demonstrate normal emptying of the collecting system, including the urinary bladder.,IMPRESSION:,  Negative intravenous urogram.,
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DESCRIPTION: Common Excretory Urogram - IVP template

Common Excretory Urogram - IVP template

urology, intravenous urogram, caliceal system, urinary bladder, excretory urogram, collecting systems, ivp, urogram, intravenousNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation described presents routine findings from an excretory urogram that show normal results in a urology context. There are no abnormalities or urgent medical issues identified, such as obstructions or defects that would require immediate attention. Therefore, it is low-stakes as there is no indication of a pressing medical problem.


Medical Specialty: Podiatry
Sample Name: Athlete's Foot

ATHLETE'S FOOT, TINEA PEDIS,, is a very common fungal skin infection of the foot.  It often first appears between the toes.  It can be a one-time occurrence or it can be chronic.  The fungus, known as Trichophyton, thrives under warm, damp conditions so people whose feet sweat a great deal are more susceptible.  It is easily transmitted in showers and pool walkways.  Those people with immunosuppressive conditions, such as diabetes mellitus, are also more susceptible to athlete's foot.,SIGNS AND SYMPTOMS:,*  Itchy feet.,*  White or red and soft scaling on feet, usually in between toes.,*  Small blisters may be present.,*  Bad foot odor.,*  Very rare involvement of hands and simultaneously (called an Id reaction).,TREATMENT:,*  Diagnosis is via symptoms or sometimes by examining skin scrapings under a microscope..  A bacterial infection may also be suspected in which case a skin culture will confirm this.,*  Try a non-prescription antifungal powder or cream available in drugstores; your doctor can prescribe a stronger topical antifungal medication if necessary.,*  Oral antibiotics may be prescribed for a possible bacterial infection.,*  Keep feet as dry as possible! Change socks twice a day if necessary and wear those made of natural fibers, such as cotton.  Go barefoot when you have a chance or wear sandals.  Dry thoroughly in between toes after swimming or bathing.,*  A special powder to absorb moisture on feet is also available in drugstores.  Ask the pharmacist about this.,*  Spray your shower at home with a 10% bleach solution after bathing.  This may help decrease the chance that other family members will be infected.,*  Wear sandals or thongs in public showers and around pools.,*  Keep in mind that it may take up to a month or more to get rid of your athlete's foot.  Be diligent in using the antifungal medication.  Unfortunately, recurrence of athlete's foot is common.  Luckily, the condition does not cause serious problems for the majority of people who have it.,*  Call the office if your athlete's foot spreads or worsens despite treatment.,PLANTAR FASCIAL STRETCHES,1.  Raise toes toward you while bending your ankle as high as you can.,2.  Hold this position for 15 seconds.,3.  Alternate doing this with the opposite foot 10 times.,4.  Perform this exercise 2- 3 times a day.,WOUND CARE INSTRUCTIONS,1.  Clean the area daily with soap and water.,2.  Every day apply a thin coat of polysporin ointment.,3.  Change the dressing daily and keep the area covered with an adhesive bandage until completely healed.,4.  Notify the office if you have any increasing wound pain or any evidence of infection.
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DESCRIPTION: A simple note on Athlete's foot, tinea pedis, a very common fungal skin infection of the foot.

podiatry, tinea pedis, infection, foot, athlete's foot, trichophyton, itchy, athlete's foot tinea pedis, fungal skin infection, fungal, athlete's,

Athlete's foot is a common and generally low-risk fungal infection. While it can be uncomfortable and inconvenient, it typically does not lead to serious health issues for the majority of people, and effective treatments are readily available. It can become more problematic for individuals with certain pre-existing conditions, such as diabetes, due to potential complications, but generally, it is not considered a high-stakes medical issue.


Medical Specialty: Surgery
Sample Name: Femoral Artery Cannulation & Aortogram

PREOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.,POSTOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.  Significant coronary artery disease, very severe PAD.,PROCEDURES PERFORMED:,1.  Right common femoral artery cannulation.,2.  Conscious sedation using IV Versed and IV fentanyl.,3.  Retrograde bilateral coronary angiography.,4.  Abdominal aortogram with pelvic runoff.,5.  Left external iliac angiogram with runoff to the patient's left foot.,6.  Left external iliac angiogram with runoff to the patient's right leg.,7.  Right common femoral artery angiogram runoff to the patient's right leg.,PROCEDURE IN DETAIL:,  The patient was taken to the cardiac catheterization laboratory after having a valid consent.  He was prepped and draped in the usual sterile fashion.,After local infiltration with 2% Xylocaine, the right common femoral artery was entered percutaneously and a 4-French sheath was placed over the artery.  The arterial sheath was flushed throughout the procedure.,Conscious sedation was obtained using IV Versed and IV fentanyl.,With the help of a Wholey wire, a 4-French 4-curve Judkins right coronary artery catheter was advanced into the ascending aorta.  The wire was removed, the catheter was flushed.  The catheter was engaged in the left main.  Injections were performed at the left main in different views.  The catheter was then exchanged for an RCA catheter, 4-French 4-curve which was advanced into the ascending aorta with the help of a J-wire.  The wire was removed, the catheter was flushed.  The catheter was engaged in the RCA.  Injections were performed at the RCA in different views.,The catheter was then exchanged for a 5-French Omniflush catheter, which was advanced into the abdominal aorta with the help of a regular J-wire.  The wire was removed.  The catheter was flushed.  Abdominal aortogram was then performed with runoff to the patient's pelvis.,The Omniflush catheter was then retracted into the aortic bifurcation.  Through the Omniflush catheter, a Glidewire was then advanced distally into the left SFA.  The Omniflush was then removed.  Through the wire, a Royal Flush catheter was then advanced into the left external iliac.  The wire was removed.  Left external iliac angiogram was performed with runoff to the patient's left foot _______ was then performed.  The catheter was then retracted into the left common iliac.  Angiograms were performed of the left common iliac with runoff to the patient's left groin.  The catheter was then positioned at the level of the right common iliac.  Angiogram of the right common iliac with runoff to the patient's right leg was then performed.  The catheter was then removed with the help of a J-wire.  The J-wire was left in the abdominal aorta.  Hand injection was performed of the right common femoral artery in 2 locations with runoff to the patient's right leg.,The wire was then removed.  The arterial sheath was then removed after being flushed.  Hemostasis was obtained using hand compression.,The patient tolerated the procedure well and had no complications.  At the end of the procedure, palpable right common femoral pulses were noted as well as 1+ right PT pulse.,Hemodynamic Findings:,  Aortic pressure 140/70.,ANGIOGRAPHIC FINDINGS: , Left main with calcification 25% to 40% lesion.,The left main is very short.,LAD with calcification 25% to 40% proximal lesion.,D1 has 25% lesion.  No in-stent restenosis was noted in D1.,D2 and D3 are very small with luminal irregularities.,Circumflex artery was diseased throughout the vessel.  The circumflex artery has an ostium of 60% to 75% lesion distally and the circumflex has a 75% lesion.,OM1 has 25% to 40% lesion.  These OMs are small with luminal irregularities.,RCA has 25% to 50% lesion, distally, the RCA has luminal irregularities.,Left ventriculography was not done.,ABDOMINAL AORTOGRAM:,  Right renal artery with luminal irregularities.  Left renal artery with luminal irregularities.  The abdominal aorta has 25% lesion.,Right common iliac has a 25% to 50% lesion as well as a distal 75% lesion.,The right external iliac has a proximal 75% lesion.,The distal part of the right external iliac as well as the right common femoral appears to be occlusive by the 5-French sheath.,The right SFA was visualized, although not very well.,Left common iliac with 25% to 50% lesion.  Left external iliac with 25% to 40% lesion.  Left common femoral with 25% to 40% lesion.  Left SFA with 25% lesion.  Left popliteal with wall luminal irregularities.,Three-vessel runoff is noted at the level of the left knee and at the level of the left ankle.,Conclusions:  Severe coronary artery disease.  Very severe peripheral arterial disease.,PLAN: , Because of the anatomic distribution of the coronary artery disease, for now we will continue medical treatment for CAD.  We will proceed with revascularization of the right external iliac as well as right common femoral.  Discontinue tobacco.
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DESCRIPTION: Right common femoral artery cannulation, cnscious sedation using IV Versed and IV fentanyl, retrograde bilateral coronary angiography, abdominal aortogram with pelvic runoff, left external iliac angiogram with runoff to the patient's left foot, left external iliac angiogram with runoff to the patient's right leg, right common femoral artery angiogram runoff to the patient's right leg.

The document describes a detailed and complex surgical procedure involving multiple cannulations and angiograms to address serious cardiovascular conditions. The patient has severe peripheral arterial disease and significant coronary artery disease, which are life-threatening conditions. The procedure involves direct interventions on major arteries and requires conscious sedation, indicating the need for precise, skilled execution and monitoring to avoid complications. While the patient tolerated the procedure well, the potential risks inherently associated with such surgeries make this a high-stakes situation.


Medical Specialty: Nephrology
Sample Name: Excretory Urogram - IVP

There is normal and symmetrical filling of the caliceal system.  Subsequent films demonstrate that the kidneys are of normal size and contour bilaterally.  The caliceal system and ureters are in their usual position and show no signs of obstruction or intraluminal defects. The postvoid films demonstrate normal emptying of the collecting system, including the urinary bladder.,IMPRESSION:,  Negative intravenous urogram.,
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DESCRIPTION: Common Excretory Urogram - IVP template

Common Excretory Urogram - IVP template

nephrology, intravenous urogram, caliceal system, urinary bladder, excretory urogram, collecting systems, ivp, urogram, intravenousNOTE,: 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 report provided is a standard medical imaging finding indicating a normal intravenous pyelogram (IVP) result. A negative IVP suggests that there are no abnormalities or concerning findings in the urinary tract, kidneys, or bladder. The context is within routine medical diagnostics, with no critical issues identified that would suggest an urgent or high-risk situation. This indicates a low-stakes scenario as the findings are normal and not indicative of any immediate health concerns.


Medical Specialty: Emergency Room Reports
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.

emergency room reports, foot pain, cut on foot, piece of glass, foreign body, active bleeding, foot, injuries, atraumatic, laceration, bleeding, body,

The situation presented involves a 32-year-old male who sustained a laceration on his right foot from a piece of glass without any immediate complications or severe pain. The cut resulted in initial bleeding, which has been controlled, and the patient is experiencing no pain or impairment in function. While there remains a minor risk of infection or the presence of a small piece of retained glass, the patient was sufficiently stable to be discharged with instructions for at-home care. The patient's condition does not appear life-threatening or in need of urgent intervention. Therefore, it is considered a low-stakes medical situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Well-Child Check - 4

SUBJECTIVE:,  The patient presents with Mom and Dad for her 1-year well child check.  The family has no concerns stating the patient has been doing well overall since the last visit taking in a well-balanced diet consisting of formula transitioning to whole milk, fruits, vegetables, proteins and grains.  Normal voiding and stooling pattern.  No concerns with hearing or vision.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction as well as speech and language development.  See Denver II form in the chart.,PAST MEDICAL HISTORY:,  Allergies:  None.  Medications:  Tylenol this morning in preparation for vaccines and a multivitamin daily.,FAMILY SOCIAL HISTORY:,  Unchanged since last checkup.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,  Weight 24 pounds 1 ounce.  Height 30 inches.  Head circumference 46.5 cm.  Temperature afebrile.,General:  A well-developed, well-nourished, cooperative, alert and interactive 1-year-old white female smiling, happy and drooling.,HEENT:  Atraumatic, normocephalic.  Anterior fontanel is closed.  Pupils equally round and reactive.  Sclerae are clear.  Red reflex present bilaterally.  Extraocular muscles intact.  TMs are clear bilaterally.  Oropharynx:  Mucous membranes are moist and pink.  Good dentition.  Drooling and chewing with teething behavior today.  Neck is supple.  No lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze.  No crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No mass.  No organomegaly.,Genitourinary:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.  Negative Ortolani and Barlow maneuver.,Back:  Straight.  No scoliosis.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.  Cranial nerves II through XII are grossly intact.,ASSESSMENT AND PLAN:,1.  Well 1-year-old white female.,2.  Anticipatory guidance.  Reviewed growth, diet development and safety issues as well as immunizations.  Will receive Pediarix and HIB today.  Discussed risks and benefits as well as possible side effects and symptomatic treatment.  Will also obtain a screening CBC and lead level today via fingerstick and call the family with results as they become available.  Gave 1-year well child checkup handout to Mom and Dad.,3.  Follow up for the 15-month well child check or as needed for acute care.
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DESCRIPTION: 1-year well child check.

1-year well child check.

consult - history and phy., well child check, denver ii, child check, checkup, check, child,

The situation described is a standard well-child checkup for a 1-year-old patient. The examination is routine, assessing growth, development, and overall health, and there are no concerns or red flags noted by the parents or healthcare provider. The plan includes routine vaccinations and screenings. Given this context, the stakes are low as there are no immediate health risks or emergencies present.


Medical Specialty: Consult - History and Phy.
Sample Name: Annual Health Maintenance Exam

HISTORY OF PRESENT ILLNESS:  ,This 59-year-old white male is seen for comprehensive annual health maintenance examination on 02/19/08, although this patient is in excellent overall health.  Medical problems include chronic tinnitus in the left ear with moderate hearing loss for many years without any recent change, dyslipidemia well controlled with niacin, history of hemorrhoids with occasional external bleeding, although no problems in the last 6 months, and also history of concha bullosa of the left nostril, followed by ENT associated with slight septal deviation.  There are no other medical problems.  He has no symptoms at this time and remains in excellent health.,PAST MEDICAL HISTORY: , Otherwise noncontributory.  There is no operation, serious illness or injury other than as noted above.,ALLERGIES: , There are no known allergies.,FAMILY HISTORY: , Father died of an MI at age 67 with COPD and was a heavy smoker.  His mother is 88, living and well, status post lung cancer resection.  Two brothers, living and well.  One sister died at age 20 months of pneumonia.,SOCIAL HISTORY:,  The patient is married.  Wife is living and well.  He jogs or does Cross Country track 5 times a week, and weight training twice weekly.  No smoking or significant alcohol intake.  He is a physician in allergy/immunology.,REVIEW OF SYSTEMS:,  Otherwise noncontributory.  He has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology.  No symptoms other than as described above.,PHYSICAL EXAMINATION:,GENERAL:  He appears alert, oriented, and in no acute distress with excellent cognitive function.  VITAL SIGNS:  His height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16.  SKIN:  Warm and dry.  There is no pallor, cyanosis or icterus.  HEENT:  Tympanic membranes benign.  The pharynx is benign.  Nasal mucosa is intact.  Pupils are round, regular, and equal, reacting equally to light and accommodation.  EOM intact.  Fundi reveal flat discs with clear margins.  Normal vasculature.  No hemorrhages, exudates or microaneurysms.  No thyroid enlargement.  There is no lymphadenopathy.  LUNGS:  Clear to percussion and auscultation.  Normal sinus rhythm.  No premature beat, murmur, S3 or S4.  Heart sounds are of good quality and intensity.  The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally.  ABDOMEN:  Benign without guarding, rigidity, tenderness, mass or organomegaly.  NEUROLOGIC:  Grossly intact.  EXTREMITIES:  Normal.  GU:  Genitalia normal.  There are no inguinal hernias.  There are mild hemorrhoids in the anal canal.  The prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality.  There is no rectal mass.  The stool is Hemoccult negative.,IMPRESSION:,1.  Comprehensive annual health maintenance examination.,2.  Dyslipidemia.,3.  Tinnitus, left ear.,4.  Hemorrhoids.,PLAN:,  At this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin E 400 units daily; and vitamin C 500 mg daily.  Consider adding lycopene, selenium, and flaxseed to his regimen.  All appropriate labs will be obtained today.  Followup fasting lipid profile and ALT in 6 months.
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DESCRIPTION: Comprehensive annual health maintenance examination, dyslipidemia, tinnitus in left ear, and hemorrhoids.

consult - history and phy., tinnitus, dyslipidemia, annual health maintenance, health, hemorrhoids, benign

The situation described is a routine annual health maintenance exam for a 59-year-old male in good overall health. While the patient has a few chronic conditions such as dyslipidemia, tinnitus, and a history of hemorrhoids, these are well-managed, and there are no new or worsening symptoms reported. Such evaluations are standard preventive measures and do not involve immediate or life-threatening concerns. Consequently, the stakes are relatively low, focused primarily on continued health maintenance and monitoring.


Medical Specialty: Psychiatry / Psychology
Sample Name: Huntington's Disease - Consult

CHIEF COMPLAINT: , "A lot has been thrown at me.",The patient is interviewed with husband in room.,HISTORY OF PRESENT ILLNESS: , This is a 69-year-old Caucasian woman with a history of Huntington disease, who presented to Hospital four days ago after an overdose of about 30 Haldol tablets 5 mg each and Tylenol tablet 325 mg each, 40 tablets.  She has been on the medical floor for monitoring and is medically stable and was transferred to the psychiatric floor today.  The patient states she had been thinking about suicide for a couple of weeks.  Felt that her Huntington disease had worsened and she wanted to spare her family and husband from trouble.  Reports she has been not socializing with her family because of her worsening depression.  Husband notes that on Monday after speaking to Dr. X, they had been advised to alternate the patient's Pamelor (nortriptyline) to every other day because the patient was reporting dry mouth.  They did as they have instructed and husband feels this may have had some factor on her worsening depression.  The patient decided to ingest the pills when her husband went to work on Friday.  She thought Friday would be a good day because there would be less medical people working so her chances of receiving medical care would be lessened.  Her husband left around 7 in the morning and returned around 11 and found her sleeping.  About 30 minutes after his arrival, he found the empty bottles and woke up the patient to bring her to the hospital.,She says she wishes she would have died, but is happy she is alive and is currently not suicidal because she notes her sons may be have to be tested for the Huntington gene.  She does not clearly explain how this has made her suicidality subside.,This is the third suicide attempt in the last two months for this patient.  About two months ago, the patient took an overdose of Tylenol and some other medication, which the husband and the patient are not able to recall.  She was taken to Southwest Memorial Hermann Hospital.  A few weeks ago, the patient tried to shoot herself and the gun was fired and there is a blow-hole in the floor.  Husband locked the gun after that and she was taken to Bellaire Hospital.  The patient has had three psychiatric admissions in the past two months, two to Southwest Memorial and one to Bellaire Hospital for 10 days.  She sees Dr. X once or twice weekly.  He started seeing her after her first suicide attempt.,The patient's husband and the patient state that until March 2009, the patient was independent, was driving herself around and was socially active.  Since then she has had worsening of her Huntington symptoms including short-term memory loss.  At present, the patient could not operate the microwave or operate her cell phone and her husband says that she is progressively more withdrawn, complains about anxiety, and complains about shortness of breath.  The patient notes that she has had depressive symptoms of quitting social life, the patient being withdrawn for the past few months and excessive worry about her Huntington disease.,The patient's mother passed away 25 years ago from Huntington's.  Her grandmother passed away 50 years ago and two brothers also passed away of Huntington's.  The patient has told her husband that she does not want to go that way.  The patient denies auditory or visual hallucinations, denies paranoid ideation.  The husband and the patient deny any history of manic or hypomanic symptoms in the past.,PAST PSYCHIATRIC HISTORY: , As per the HPI, this is her third suicide attempt in the last two months and started seeing Dr. X.  She has a remote history of being on Lexapro for depression.,MEDICATIONS: , Her medications on admission, alprazolam 0.5 mg p.o. b.i.d., Artane 2 mg p.o. b.i.d., Haldol 2.5 mg p.o. t.i.d., Norvasc 10 mg p.o. daily, nortriptyline 50 mg p.o. daily.  Husband has stated that the patient's chorea becomes better when she takes Haldol.  Alprazolam helps her with anxiety symptoms.,PAST MEDICAL HISTORY: , Huntington disease, symptoms of dementia and hypertension.  She has an upcoming appointment with the Neurologist.  Currently, does have a primary care physician and _______ having an outpatient psychiatrist, Dr. X, and her current Neurologist, Dr. Y.,ALLERGIES: , CODEINE AND KEFLEX.,FAMILY MEDICAL HISTORY:  ,Strong family history for Huntington disease as per the HPI.  Mother and grandmother died of Huntington disease.  Two young brothers also had Huntington disease.,FAMILY PSYCHIATRIC HISTORY: , The patient denies history of depression, bipolar, schizophrenia, or suicide attempts.,SOCIAL HISTORY:  ,The patient lives with her husband of 48 years.  She used to be employed as a registered nurse.  Her husband states that she does have a pattern of self-prescribing for minor illness, but does not think that she has ever taken muscle relaxants or sedative medications without prescriptions.  She rarely drinks socially.  She denies any illicit substance usage.  Her husband reportedly gives her medication daily.  Has been proactive in terms of seeking mental health care and medical care.  The patient and husband report that from March 2009, she has been relatively independent, more socially active.,MENTAL STATUS EXAM:  ,This is an elderly woman appearing stated age.  Alert and oriented x4 with poor eye contact.  Appears depressed, has psychomotor retardation, and some mild involuntary movements around her lips.  She is cooperative.  Her speech is of low volume and slow rate and rhythm.  Her mood is sad.  Her affect is constricted.  Her thought process is logical and goal-directed.  Her thought content is negative for current suicidal ideation.  No homicidal ideation.  No auditory or visual hallucinations.  No command auditory hallucinations.  No paranoia.  Insight and judgment are fair and intact.,LABORATORY DATA:,  A CT of the brain without contrast, without any definite evidence of acute intracranial abnormality.  U-tox positive for amphetamines and tricyclic antidepressants.  Acetaminophen level 206.7, alcohol level 0.  The patient had a leukocytosis with white blood cell of 15.51, initially TSH 1.67, T4 10.4.,ASSESSMENT: , This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.  She took 30 tablets of Haldol and 40 tablets of Tylenol.  At present, the patient is without suicidal ideation.  She reports that her worsening depression has coincided with her worsening Huntington disease.  She is more hopeful today, feels that she may be able to get help with her depression.,The patient was admitted four days ago to the medical floor and has subsequently been stabilized.  Her liver function tests are within normal limits.,AXIS I:  Major depressive disorder due to Huntington disease, severe.  Cognitive disorder, NOS.,AXIS II:  Deferred.,AXIS III:  Hypertension, Huntington disease, status post overdose.,AXIS IV:  Chronic medical illness.,AXIS V:  30.,PLAN,1.  Safety.  The patient would be admitted on a voluntary basis to Main-7 North.  She will be placed on every 15-minute checks with suicidal precautions.,2.  Primary psychiatric issues/medical issues.  The patient will be restarted as per written by the consult service for Prilosec 200 mg p.o. daily, nortriptyline 50 mg p.o. nightly, Haldol 2 mg p.o. q.8h., Artane 2 mg p.o. daily, Xanax 0.5 mg p.o. q.12h., fexofenadine 180 mg p.o. daily, Flonase 50 mcg two sprays b.i.d., amlodipine 10 mg p.o. daily, lorazepam 0.5 mg p.o. q.6h. p.r.n. anxiety and agitation.,3.  Substance abuse.  No acute concern for alcohol or benzo withdrawal.,4.  Psychosocial.  Team will update and involve family as necessary.,DISPOSITION: , The patient will be admitted for evaluation, observation, treatment.  She will participate in the milieu therapy with daily rounds, occupational therapy, and group therapy.  We will place occupational therapy consult and social work consults.
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DESCRIPTION: This is a 69-year-old white woman with Huntington disease, who presents with the third suicide attempt in the past two months.

The situation involves multiple recent suicide attempts by a patient with a severe chronic illness, Huntington's disease, which significantly affects her mental health. The patient has expressed suicidal ideation and has a strong family history of the disease, which exacerbates the psychological burden. The complexity of managing her psychiatric needs in conjunction with her medical condition makes this a high-stakes situation. Factors such as her prior attempts, the seriousness of the overdose, and her ongoing depressive symptoms underscore the critical nature of the medical and psychological interventions required to prevent further harm.


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

Medical Specialty: Surgery
Sample Name: Ganglion Excision

PREOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,POSTOPERATIVE DIAGNOSIS: , Ganglion of the left wrist.,OPERATION: , Excision of ganglion.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,OPERATION: , After a successful anesthetic, the patient was positioned on the operating table.  A tourniquet applied to the upper arm.  The extremity was prepped in a usual manner for a surgical procedure and draped off.  The superficial vessels were exsanguinated with an elastic wrap and the tourniquet was then inflated to the usual arm pressure.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.  By blunt and sharp dissection, it was dissected out from underneath the extensor tendons and the stalk appeared to arise from the distal radiocapitellar joint and the dorsal capsule was excised along with the ganglion and the specimen was removed and submitted.  The small superficial vessels were electrocoagulated and instilled after closing the skin with 4-0 Prolene, into the area was approximately 6 to 7 mL of 0.25 Marcaine with epinephrine.  A Jackson-Pratt drain was inserted and then after the tourniquet was released, it was kept deflated until at least 5 to 10 minutes had passed and then it was activated and then removed in the recovery room.  The dressings applied to the hand were that of Xeroform, 4x4s, ABD, Kerlix, and elastic wrap over a volar fiberglass splint.  The tourniquet was released.  Circulation returned to the fingers.  The patient then was allowed to awaken and left the operating room in good condition.
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DESCRIPTION: Excision of ganglion of the left wrist.  A curved incision was made over the presenting ganglion over the dorsal aspect of the wrist.

surgery, curved incision, superficial vessels, tourniquet, excision, dorsal, wrist, ganglion

The surgical procedure described is a ganglion excision, which is generally considered a routine and low-risk surgery typically performed to remove a nonmalignant cyst on the wrist. The operation is well-documented with proper precautions such as the use of a tourniquet, general anesthesia, and minimal blood loss. Post-operative recovery is straightforward, and the patient left the operating room in good condition. Thus, this scenario is not high-stakes compared to major surgeries involving critical organs or life-threatening conditions.


Medical Specialty: Emergency Room Reports
Sample Name: Difficulty Breathing - ER Visit

HISTORY:,  The patient is 14 months old, comes in with a chief complaint of difficulty breathing.  Difficulty breathing began last night.  He was taken to Emergency Department where he got some Xopenex, given a prescription for amoxicillin and discharged home.  They were home for about an hour when he began to get worse and they drove here to Children's Hospital.  He has a history of reactive airway disease.  He has been seen here twice in the last month on 10/04/2007 and 10/20/2007, both times with some wheezing.  He was diagnosed with pneumonia back on 06/12/2007 here in the Emergency Department but was not admitted at that time.  He has been on albuterol off and on over that period.  He has had fever overnight.  No vomiting, no diarrhea.  Increased work of breathing with retractions and audible wheezes noted and thus brought to the Emergency Department.  Normal urine output.  No rashes have been seen.,PAST MEDICAL HISTORY: , As noted above.  No hospitalizations, surgeries, allergies.,MEDICATIONS: , Xopenex.,IMMUNIZATIONS:,  Up-to-date.,BIRTH HISTORY:,  The child was full term, no complications, home with mom.  No surgeries.,FAMILY HISTORY: , Negative.,SOCIAL HISTORY: , No smokers or pets in the home.  No ill contacts, no travel, no change in living condition.,REVIEW OF SYSTEMS: , Ten are asked, all are negative, except as noted above.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temp 37.1, pulse 158, respiratory rate 48, 84% on room air indicating hypoxia.,GENERAL:  The child is awake, alert, in moderate respiratory distress.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements are intact.  The TMs are clear.  The nares show some dry secretions.  Audible congestion and wheezing is noted.  Mucous membranes are dry.  Throat is clear.  No oral lesions noted.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Show inspiratory and expiratory wheezes in all fields.  Audible wheezes are noted.  There are intercostal and subcostal retractions and suprasternal muscle use is noted.,HEART:  Shows tachycardia.  Regular rhythm.  Normal S1, S2.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding.  No rebound.  No hepatosplenomegaly.,EXTREMITIES:  Capillary refill is brisk.  Good distal pulses.,NEUROLOGIC:  Cranial nerves II through XII intact.  Moves all 4 extremities equally and normally.,HOSPITAL COURSE: , The child has an IV placed.  I felt the child was dehydrated on examination.  We gave 20 mL/kg bolus of normal saline over one hour.  The child was given Solu-Medrol 2 mg/kg IV.  He was initially started on unit dose albuterol and Atrovent but high-dose albuterol for continuous nebulization was ordered.,A portable chest x-ray was done showing significant peribronchial thickening bilaterally.  Normal heart size.  No evidence of pneumothorax.  No evidence of focal pneumonia.  After 3 unit dose of albuterol/Atrovent breathing treatments, there was much better air exchange bilaterally but still with inspiratory/expiratory wheezes and high-dose continuous albuterol was started at that time.  The child was monitored closely while on high-dose albuterol and slowly showed improvement resulting in only expiratory wheezes after one hour.  The child's pulse ox on breathing treatments with 100% oxygen was 100%.  Respiratory rate remained about 40 to 44 breaths per minute indicating tachypnea.  The child's color improved with oxygen therapy, and the capillary refill was always less than 2 seconds.,The child has failed outpatient therapy at this time.  After 90 minutes of continuous albuterol treatment, the child still has expiratory wheezes throughout.  After I removed the oxygen, the pulse ox was down at 91% indicating hypoxia.  The child has a normal level of alertness; however, has not had any vomiting here.  I spoke with Dr. X, on call for hospitalist service.  She has come down and evaluated the patient.  We both feel that since this child had two ER visits this last month, one previous ER visit within the last 5 hours, we should admit the child for continued albuterol treatments, IV steroids, and asthma teaching for the family.  The child is admitted in a stable condition.,DIFFERENTIAL DIAGNOSES:  ,Ruled out pneumothorax, pneumonia, bronchiolitis, croup.,TIME SPENT:  ,Critical care time outside billable procedures was 45 minutes with this patient.,IMPRESSION:  ,Status asthmaticus, hypoxia.,PLAN:  ,Admitted to Pediatrics.
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DESCRIPTION: The patient is 14 months old, comes in with a chief complaint of difficulty breathing.

The situation involves a 14-month-old child experiencing difficulty breathing and hypoxia, which are critical conditions requiring immediate medical attention. Considering the child's young age and the previous failure to respond adequately to outpatient treatment, the stakes are high. Timely intervention is crucial to prevent potential deterioration in the child's health. The decision to admit the child for continuous monitoring and treatment underscores the seriousness of the situation.


Medical Specialty: Office Notes
Sample Name: Normal Physical Exam Template - 1

GENERAL: , Vital signs and temperature as documented in nursing notes.  The patient appears stated age and is adequately developed.,EYES:,  Pupils are equal, round, reactive to light and accommodation.  Lids and conjunctivae reveal no gross abnormality.,ENT:  ,Hearing appears adequate.  No obvious asymmetry or deformity of the ears and nose.,NECK: , Trachea midline.  Symmetric with no obvious deformity or mass; no thyromegaly evident.,RESPIRATORY:,  The patient has normal and symmetric respiratory effort.  Lungs are clear to auscultation.,CARDIOVASCULAR: , S1, S2 without significant murmur.,ABDOMEN: , Abdomen is flat, soft, nontender.  Bowel sounds are active.  No masses or pulsations present.,EXTREMITIES: , Extremities reveal no remarkable dependent edema or varicosities.,MUSCULOSKELETAL:  ,The patient is ambulatory with normal and symmetric gait.  There is adequate range of motion without significant pain or deformity.,SKIN: , Essentially clear with no significant rash or lesions.  Adequate skin turgor.,NEUROLOGICAL: , No acute focal neurologic changes.,PSYCHIATRIC:,  Mental status, judgment and affect are grossly intact and normal for age.
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DESCRIPTION: An example normal physical exam

An example normal physical exam

office notes, vital signs, equal, round, reactive, normal physical exam, physical exam,

The situation is a documentation of a normal physical exam, presented as a template for medical office notes. This is a standard procedure in the healthcare field, useful for consistent recording and not indicative of any immediate medical emergencies. It provides a baseline for an uneventful checkup, where no high-stakes decisions or actions are required since the exam results do not suggest the presence of any urgent or serious conditions.


Medical Specialty: ENT - Otolaryngology
Sample Name: BMT - Bilateral Myringotomy Tubes

Parents often ask why the fluid cannot be drained without inserting a tube.  The need for the tube insertion is because the eardrum incision generally heals very rapidly (within a few days), which is not long enough for the swollen membranes in the middle ear to return to normal.  As soon as the eardrum heals, fluid will reaccumulate.  Tubes were first introduced because of this very problem.  There are many types of tubes, but all tubes serve the same function.  They keep the eardrum open, allow air to enter the middle ear space, and permit fluid in the middle ear to drain.  Most tubes will gradually be rejected by the ear and work their way out of the eardrum.  As they come out, the eardrum seals behind the tube.  Tubes will last four to six months in the eardrum before they come out.  Occasionally, the eardrum does not heal completely when the tube comes out.,The majority of children treated with tubes do not require further surgery.  They may have ear infections in the future, but most will clear up with medical treatment.  Some children are very prone to ear infections and have a tendency to accumulate fluid after each infection.  Children tend to outgrow this cycle by age 7 or 8.  In an ear, nose and throat specialty practice, this group comprises 10 to 15% of all children who have required tubes.  Occasionally the physician has to physically remove the tube from the ear drum.
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DESCRIPTION: A sample note on bilateral myringotomy tubes

ent - otolaryngology, eardrum, myringotomy, tubes, bilateral myringotomy tubes, myringotomy tubes, ear infections, middle ear, fluid, childrenNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation described involves a common medical procedure for children known as bilateral myringotomy with tube insertion to manage ear infections. This is generally a standard and routine procedure in ENT practices. While it involves surgery, it is often considered low-risk and highly effective for treating chronic ear infections or fluid accumulation. The description indicates that most cases do not require further surgery and complications are minimal. Thus, the overall situation presented is not high-stakes, especially given the commonality of the procedure and its wide acceptance as a treatment modality.