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Medical Specialty: Surgery
Sample Name: Cardiac Catheterization - 6

PRECATHETERIZATION DIAGNOSIS (ES):, Hypoplastic left heart, status post Norwood procedure and Glenn shunt.,POSTCATHETERIZATION DIAGNOSIS (ES):,1. Hypoplastic left heart.,A. Status post Norwood.,B. Status post Glenn.,2. Left pulmonary artery hypoplasia.,3. Diminished right ventricular systolic function.,4. Trivial neo-aortic stenosis.,5. Trivial coarctation.,6. Flow to right upper lobe more than left upper lobe from collaterals arising from branches of the aortic arch.,PROCEDURE (S):, Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.,I. PROCEDURES:, XXXXXX was brought to the catheterization lab and was anesthetized by anesthesia. He was intubated. His supplemental oxygen was weaned to 24%, on which all of his hemodynamics were obtained. The patient was prepped and draped in the routine sterile fashion, including both groins and the right neck. Xylocaine was administered in the right femoral area. A 6-French sheath was introduced into the right femoral vein percutaneously without complication. A 4-French sheath was introduced into the right femoral artery percutaneously without complication. A 4-French pigtail catheter was introduced and passed to the abdominal aorta.,Dr. Hayes, using the SiteRite device, introduced a 5-French sheath into the right internal jugular vein without complication.,A 5-French wedge catheter was introduced through the sheath in the right internal jugular vein and was passed to the left pulmonary artery and further to the left pulmonary capillary wedge position. This catheter would not pass to the right pulmonary artery. The wedge catheter was removed. A 5-French IMA catheter was then introduced and passed to the right pulmonary artery. After right pulmonary artery pressure was measured, this catheter was removed.,The 5 wedge catheter was advanced through the right femoral sheath and was passed to the following chambers or vessels: Inferior vena cava, right atrium, left atrium, and right ventricle.,The previously introduced 4 pigtail catheter was advanced to the ascending aorta. Simultaneous right ventricular and ascending aortic pressures were measured. A pullback from ascending aorta to descending aorta was then performed. Simultaneous measurements of right ventricular and descending aortic pressures were measured.,The wedge catheter was removed. A 5-French Berman catheter was advanced down the Glenn shunt to the right pulmonary artery, where a pullback from right pulmonary artery to Glenn shunt was performed. An injection was then performed using Omnipaque 16 mL at 8 mL per second with the Berman catheter positioned in the Glenn shunt. The 5-French Berman was removed.,A 6-French Berman was introduced through the right femoral vein sheath and was advanced to the right ventricle. A right ventriculogram was performed using Omnipaque 18 mL at 12 mL per second. The Berman catheter was pulled back to the inferior vena cava, where an inferior vena cavagram was performed using Omnipaque 10 mL at 8 mL per second.,The 4-French pigtail catheter was advanced to the ascending aorta and an ascending aortogram was performed using Omnipaque 16 mL at 12 mL per second.,Following the ascending angiograms, two kidneys and a bladder were noted. The catheters and sheaths were removed, and hemostasis was obtained by direct pressure. The estimated blood loss was less than 30 mL, and none was replaced. Heparin was administered following placement of all of the sheaths. Pulse oximetry saturation, pulse in the right foot, and EKG were monitored continuously.,II. PRESSURES:,A. Left pulmonary artery, mean of 11; left capillary wedge, mean of 9; main pulmonary artery, mean of 12; right pulmonary artery, mean of 10; descending aorta, 75/45, mean of 57; right atrium, A6 to 9, V6 to 8, mean 7; left atrium, mean 8; inferior vena cava, mean 7.,B. Ascending aorta, 65/35, with a simultaneous right ventricular pressure of 70/10; descending aorta, 60/35, with a right ventricular pressure of 72/10.,C. Pullbacks, left pulmonary artery to main pulmonary artery, mean of 11 to mean of 12; main pulmonary artery to Glenn, mean of 12 to mean of 13; right pulmonary artery to Glenn, mean of 12 to mean of 13; ascending aorta 68/35 to descending aorta 62/35.,INTERPRETATION:, Right and left pulmonary artery pressures are appropriate for this situation. There is a gradient of, at most, 2 mmHg on pullback from both the right and left pulmonary arteries to the Glenn shunt. The left atrial mean pressure is normal. Right ventricular end-diastolic pressure is, at most, slightly elevated. There is a trivial gradient between the right ventricle and ascending aorta consistent with trivial neo-aortic valve stenosis. There is a roughly 10-mm gradient between the right ventricle and descending aorta, consistent with additional coarctation of the aorta. On pullback from ascending to descending aorta, there is a 6-mmHg gradient between the two. Systemic blood pressure is normal.,III. OXIMETRY:, Superior vena cava 65, right pulmonary artery 67, left pulmonary artery 65, left atrium 96, right atrium 87, inferior vena cava 69, aorta 86, right ventricle 83.,INTERPRETATION:, Systemic arteriovenous oxygenation difference is normal, consistent with a normal cardiac output. Left atrial saturation is fairly normal, consistent with normal oxygenation in the lungs. The saturation falls passing from the left atrium to the right atrium and further to the right ventricle, consistent with mixing of pulmonary venous return and inferior vena cava return, as would be expected in this patient.,IV. SPECIAL PROCEDURE (S):, None done.,V. CALCULATIONS:,Please see the calculation sheet. Calculations were based upon an assumed oxygen consumption. The _____ saturation used was 67%, with a pulmonary artery saturation of 65%, a left atrial saturation of 96%, and an aortic saturation of 86%. Using the above information, the pulmonary to systemic flow ratio was 0.6. Systemic blood flow was 5.1 liters per minute per meter squared. Pulmonary blood flow was 3.2 liters per minute per meter squared. Systemic resistance was 9.8 Wood's units times meter squared, which is mildly diminished. Pulmonary resistance was 2.5 Wood's units times meter squared, which is in the normal range.,VI. ANGIOGRAPHY:, The injection to the Glenn shunt demonstrates a wide-open Glenn connection. The right pulmonary artery is widely patent, without stenosis. The proximal portion of the left pulmonary artery is significantly narrowed, but does open up near its branch point. The right pulmonary artery measures 6.5, the left pulmonary artery measures 3.0 mm. The aorta at the diaphragm on a later injection was 5.5 mm. There is a small collateral off the innominate vein passing to the left upper lobe. Flow to both upper lobes is diminished versus lower lung fields. There is normal return of the pulmonary veins from the right, with simultaneous filling of the left atrium and right atrium. There is normal return of the left lower pulmonary vein and left upper pulmonary vein. There is some reflux of dye into the inferior vena cava from the right atrium.,The right ventriculogram demonstrates a heavily pedunculated right ventricle with somewhat depressed right ventricular systolic function. The calculated ejection fraction from the LAO projection is only mildly diminished at 59%. There is no significant tricuspid regurgitation. The neo-aortic valve appears to open well with no stenosis. The ascending aorta is dilated. There is mild narrowing of the aorta at the isthmal area. On some projections, there appears to be a partial duplication of the aortic arch, probably secondary to this patient's style of Norwood reconstruction. There is some filling of the right upper and left upper lobes from collateral blood flow, with the left being more opacified than the right.,The inferior vena cavagram demonstrates normal return of the inferior vena cava to the right atrium.,The ascending aortogram demonstrates trivial aortic insufficiency, which is probably catheter-induced. The coronary arteries are poorly seen. Again, a portion of the aorta appears to be partially duplicated. There is faint opacification of the left upper lung from collateral blood flow. The above-mentioned narrowing of the aortic arch is again noted.
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DESCRIPTION: Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.

The scenario involves cardiac catheterization in a patient with a complex congenital heart condition (Hypoplastic Left Heart Syndrome) who has undergone significant surgical interventions (Norwood procedure and Glenn shunt). This procedure is crucial for assessing the heart's current function and any present complications, as it can provide essential data guiding future medical decisions and interventions. Any potential issues during the procedure, such as complications related to the heart pressure and blood saturation measurements, could have serious consequences for the patient's health. Therefore, the stakes are inherently high in this medical situation.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Osteophytectomy

PREOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,OPERATIVE PROCEDURE,1.  CPT code 63075:  Anterior cervical discectomy and osteophytectomy, C5-C6.,2.  CPT code 63076:  Anterior cervical discectomy and osteophytectomy, C6-C7, additional level.,3.  CPT code 22851:  Application of prosthetic interbody fusion device, C5-C6.,4.  CPT code 22851-59:  Application of prosthetic interbody fusion device, C6-C7, additional level.,5.  CPT code 22554-51:  Anterior cervical interbody arthrodesis, C5-C6.,6.  CPT code 22585:  Anterior cervical interbody arthrodesis, C6-C7, additional level.,7.  CPT code 22845:  Anterior cervical instrumentation, C5-C7.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:  ,Negligible.,DRAINS: , Small suction drain in the cervical wound.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:,  The patient was given intravenous antibiotic prophylaxis and thigh-high TED hoses were placed on the lower extremities while in the preanesthesia holding area.  The patient was transported to the operative suite and on to the operative table in the supine position.  General endotracheal anesthesia was induced.  The head was placed on a well-padded head holder.  The eyes and face were protected from pressure.  A well-padded roll was placed beneath the neck and shoulders to help preserve the cervical lordosis.  The arms were tucked and draped to the sides.  All bony prominences were well padded.  An x-ray was taken to confirm the correct level of the skin incision.  The anterior neck was then prepped and draped in the usual sterile fashion.,A straight transverse skin incision over the left side of the anterior neck was made and carried down sharply through the skin and subcutaneous tissues to the level of the platysma muscle, which was divided transversely using the electrocautery.  The superficial and deep layers of the deep cervical fascia were divided.  The midline structures were reflected to the right side.  Care was taken during the dissection to avoid injury to the recurrent laryngeal nerve and the usual anatomical location of that nerve was protected.  The carotid sheath was palpated and protected laterally.  An x-ray was taken to confirm the level of C5-C6 and C6-C7.,The longus colli muscle was dissected free bilaterally from C5 to C7 using blunt dissection.  Hemostasis was obtained using the electrocautery.  The blades of the cervical retractor were placed deep to the longus colli muscles bilaterally.  At C5-C6, the anterior longitudinal ligament was divided transversely.  Straight pituitary rongeurs and a curette were used to remove the contents of the disc space.  All cartilages were scraped off the inferior endplate of C5 and from the superior endplate of C6.  The disc resection was carried posteriorly to the posterior longitudinal ligament and laterally to the uncovertebral joints.  The posterior longitudinal ligament was resected using a 1 mm Kerrison rongeur.  Beginning in the midline and extending into both neural foramen, posterior osteophytes were removed using a 1 m and a 2 mm Kerrison rongeurs.  The patient was noted to have significant bony spondylosis causing canal and foraminal stenosis as well as a degenerative and protruding disc in agreement with preoperative diagnostic imaging studies.  Following completion of the discectomy and osteophytectomy, a blunt nerve hook was passed into the canal superiorly and inferiorly as well as in the both neural foramen to make sure that there were no extruded disc fragments and to make sure the bony decompression was complete.  A portion of the uncovertebral joint was resected bilaterally for additional nerve root decompression.  Both nerve roots were visualized and noted to be free of encroachment.  The same procedure was then carried out at C6-C7 with similar findings.  The only difference in the findings was that at C6-C7 on the left side, the patient was found to have an extruded disc fragment in the canal and extending into the left side neural foramen causing significant cord and nerve root encroachment.,In preparation for the arthrodesis, the endplates of C5, C6, and C7 were burred in a parallel fashion down to the level of bleeding bone using a high-speed cutting bur with irrigant solution for cooling.  The disc spaces were then measured to the nearest millimeter.  Attention was then turned toward preparation of the structural allograft, which consisted of two pieces of pre-machined corticocancellous bone.  The grafts were further shaped to fit the disc spaces exactly in a press-fit manner with approximately 1.5 mm of distraction at each disc space.  The grafts were shaped to be slightly lordotic to help preserve the cervical lordosis.  The grafts were impacted into the disc spaces.  There was complete bony apposition between the ends of the bone grafts and the vertebral bodies of C5, C6, and C7.  A blunt nerve hook was passed posterior to each bone graft to make sure that the bone grafts were in good position.  Anterior osteophytes were removed using a high-speed cutting bur with irrigant solution for cooling.  An appropriate length Synthes cervical plate was selected and bent slightly to conform to the patient's cervical lordosis.  The plate was held in the midline with provided instrumentation while a temporary fixation screw was applied at C6.  Screw holes were then drilled using the provided drill and drill guide taking care to avoid injury to neurovascular structures.  The plate was then rigidly fixed to the anterior spine using 14-mm cancellous screws followed by locking setscrews added to the head of each screw to prevent postoperative loosening of the plate and/or screws.,An x-ray was taken, which confirmed satisfactory postioning of the plate, screws, and bone grafts.,Blood loss was minimal.  The wound was irrigated with irrigant solution containing antibiotics.  The wound was inspected and judged to be dry.  The wound was closed over a suction drain placed in the deepest portion of the wound by reapproximating the platysma muscle with #4-0 Vicryl running suture, the subdermal and subcuticular layers with #4-0 Monocryl interrupted sutures, and the skin with Steri-Strips.  The sponge and needle count were correct.  A sterile dressing was applied to the wound.  The neck was placed in a cervical orthosis.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.
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DESCRIPTION: Anterior cervical discectomy and osteophytectomy.  Application of prosthetic interbody fusion device.  Anterior cervical interbody arthrodesis.  Anterior cervical instrumentation

The given medical scenario involves a complex neurosurgical procedure - an anterior cervical discectomy and osteophytectomy - which includes significant risks associated with operating close to the spinal cord. Such procedures require precision, as any error could lead to serious complications such as paralysis or nerve damage. Nevertheless, the described procedure went without complications, maintaining the critical safety measures. Although the surgery was successful, the inherent risks associated with this type of neurosurgery make the situation quite high-stakes.


Medical Specialty: Surgery
Sample Name: Laparoscopic Pyeloplasty

PREOPERATIVE DIAGNOSIS:  ,Right ureteropelvic junction obstruction.,POSTOPERATIVE DIAGNOSES:,1.  Right ureteropelvic junction obstruction.,2.  Severe intraabdominal adhesions.,3.  Retroperitoneal fibrosis.,PROCEDURES PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Attempted laparoscopic pyeloplasty.,3.  Open laparoscopic pyeloplasty.,ANESTHESIA:,  General.,INDICATION FOR PROCEDURE:  ,This is a 62-year-old female with a history of right ureteropelvic junction obstruction with chronic indwelling double-J ureteral stent.  The patient presents for laparoscopic pyeloplasty.,PROCEDURE: , After informed consent was obtained, the patient was taken to the operative suite and administered general anesthetic.  The patient was sterilely prepped and draped in the supine fashion after building up the right side of the OR table to aid in the patient's positioning for bowel retraction.  Hassan technique was performed for the initial trocar placement in the periumbilical region.  Abdominal insufflation was performed.  There were significant adhesions noted.  A second 12 mm port was placed in the right midclavicular line at the level of the umbilicus and a Harmonic scalpel was placed through this and adhesiolysis was performed for approximately two-and-half hours, also an additional port was placed 12 mm in the midline between the xiphoid process and the umbilicus, an additional 5 mm port in the right upper quadrant subcostal and midclavicular.  After adhesions were taken down, the ascending colon was mobilized by incising the white line of Toldt and mobilizing this medially.  The kidney was able to be palpated within Gerota's fascia.  The psoas muscle caudate to the inferior pole of the kidney was identified and the tissue overlying this was dissected to the level of the ureter.  The uterus was grasped with a Babcock through a trocar port and carried up to the level of the ureteropelvic junction obstruction.  The renal pelvis was also identified and dissected free.  There was significant fibrosis and scar tissue around the ureteropelvic junction obliterating the tissue planes.  We were unable to dissect through this mass of fibrotic tissue safely and therefore the decision was made to abort the laparoscopic procedure and perform the pyeloplasty open.  An incision was made from the right upper quadrant port extending towards the midline.  This was carried down through the subcutaneous tissue, anterior fascia, muscle layers, posterior fascia, and peritoneum.  A Bookwalter retractor was placed.  The renal pelvis and the ureter were again identified.  Fibrotic tissue was able to be dissected away at this time utilizing right angle clamps and Bovie cautery.  The tissue was sent down to Pathology for analysis.  Please note that upon entering the abdomen, all of the above which was taken down from the adhesions to the abdominal wall were carefully inspected and no evidence of bowel injury was noted.  Ureter was divided just distal to the ureteropelvic junction obstruction and stent was maintained in place.  The renal pelvis was then opened in a longitudinal manner and excessive pelvis was removed reducing the redundant tissue.  At this point, the indwelling double-J ureteral stent was removed.  At this time, the ureter was spatulated laterally and at the apex of this spatulation a #4-0 Vicryl suture was placed.  This was brought up to the deepened portion of the pyelotomy and cystic structures were approximated.  The back wall of the ureteropelvic anastomosis was then approximated with running #4-0 Vicryl suture.  At this point, a double-J stent was placed with a guidewire down into the bladder.  The anterior wall of the uteropelvic anastomosis was then closed again with a #4-0 running Vicryl suture.  Renal sinus fat was then placed around the anastomosis and sutured in place.  Please note in the inferior pole of the kidney, there was approximately 2 cm laceration which was identified during the dissection of the fibrotic tissue.  This was repaired with horizontal mattress sutures #2-0 Vicryl.  FloSeal was placed over this and the renal capsule was placed over this.  A good hemostasis was noted.  A #10 Blake drain was placed through one of the previous trocar sites and placed into the perirenal space away from the anastomosis.  The initial trocar incision was closed with #0 Vicryl suture.  The abdominal incision was also then closed with running #0 Vicryl suture incorporating all layers of muscle and fascia.  The Scarpa's fascia was then closed with interrupted #3-0 Vicryl suture.  The skin edges were then closed with staples.  Please note that all port sites were inspected prior to closing and hemostasis was noted at all sites and the fascia was noted to be reapproximated as these trocar sites were placed with the ________ obturator.  We placed the patient on IV antibiotics and pain medications.  We will obtain KUB and x-rays for stent placement.  Further recommendations to follow.
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DESCRIPTION: Laparoscopic lysis of adhesions, attempted laparoscopic pyeloplasty, and open laparoscopic pyeloplasty.  Right ureteropelvic junction obstruction, severe intraabdominal adhesions, and retroperitoneal fibrosis.

surgery, retroperitoneal, fibrosis, pyeloplasty, laparoscopic, lysis of adhesions, ureteropelvic junction obstruction, laparoscopic pyeloplasty, ureteropelvic junction, junction, ureteropelvic, intraabdominal, adhesions,

This surgical procedure involves complications like severe intraabdominal adhesions and retroperitoneal fibrosis, resulting in the transition from a laparoscopic to an open surgery. The patient's pre-existing conditions and the inability to safely proceed with the initial laparoscopic approach heighten the stakes, given the potential risks during open surgery, such as bleeding or organ damage. While the situation is managed by the surgical team, the inherent risks and need for an open surgery elevate the stakes.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy - 10

PREOPERATIVE DIAGNOSIS: , Nausea and vomiting and upper abdominal pain.,POST PROCEDURE DIAGNOSIS:  ,Normal upper endoscopy.,OPERATION: , Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.,ANESTHESIA:,  IV sedation 50 mg Demerol, 8 mg of Versed.,PROCEDURE: , The patient was taken to the endoscopy suite.  After adequate IV sedation with the above medications, hurricane was sprayed in the mouth as well as in the esophagus.  A bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus, stomach, and pylorus.  The first, second, and third portions of the duodenum were normal.  The scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for H. pylori.  The scope was retroflexed which showed a normal GE junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia.  The scope was withdrawn at the GE junction which was in a normal position with a normal transition zone.  The scope was then removed throughout the esophagus which was normal.  The patient tolerated the procedure well.,The plan is to obtain a HIDA scan as the right upper quadrant ultrasound appeared to be normal, although previous ultrasounds several years ago showed a gallstone.
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DESCRIPTION: Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.  Nausea and vomiting and upper abdominal pain.

gastroenterology, h. pylori, forceps, antral biopsies, ge junction, esophagogastroduodenoscopy, pylori, esophagus, antral,

The procedure described is an esophagogastroduodenoscopy (EGD), which is a common, minimally invasive diagnostic procedure to visually inspect the upper digestive system. Although it involves sedation and some risk, it is generally routine and not high-stakes, especially since the patient tolerated the procedure well and no immediate complications were noted. The findings were normal, which suggests low urgency in this scenario. The planned follow-up with a HIDA scan for further exploration also indicates routine follow-up care rather than an emergency or high-stakes situation.


Medical Specialty: General Medicine
Sample Name: Normal Male Exam Template - 2

MALE PHYSICAL EXAMINATION,Eye:  Eyelids normal color, no edema.  Conjunctivae with no erythema, foreign body, or lacerations.  Sclerae normal white color, no jaundice.  Cornea clear without lesions.  Pupils equally responsive to light.  Iris normal color, no lesions.  Anterior chamber clear.  Lacrimal ducts normal.  Fundi clear.,Ear:  External ear has no erythema, edema, or lesions.  Ear canal unobstructed without edema, discharge, or lesions.  Tympanic membranes clear with normal light reflex.  No middle ear effusions.,Nose:  External nose symmetrical.  No skin lesions.  Nares open and free of lesions.  Turbinates normal color, size and shape.  Mucus clear.  No internal lesions.,Throat:  No erythema or exudates.  Buccal mucosa clear.  Lips normal color without lesions.  Tongue normal shape and color without lesion.  Hard and soft palate normal color without lesions.  Teeth show no remarkable features.  No adenopathy.  Tonsils normal shape and size.  Uvula normal shape and color.,Neck:  Skin has no lesions.  Neck symmetrical.  No adenopathy, thyromegaly, or masses.  Normal range of motion, nontender.  Trachea midline.,Chest:  Symmetrical.  Clear to auscultation bilaterally.  No wheezing, rales or rhonchi.  Chest nontender.  Normal lung excursion.  No accessory muscle use.,Cardiovascular:  Heart has regular rate and rhythm with no S3 or S4.  Heart rate is normal.,Abdominal:  Soft, nontender, nondistended, bowel sounds present.  No hepatomegaly, splenomegaly, masses, or bruits.,Genital:  Penis normal shape without lesions.  Testicles normal shape and contour without tenderness.  Epididymides normal shape and contour without tenderness.  Rectum normal tone to sphincter.  Prostate normal shape and contour without nodules.  Stool hemoccult negative.  No external hemorrhoids.  No skin lesions.,Musculoskeletal:  Normal strength all muscle groups.  Normal range of motion all joints.  No joint effusions.  Joints normal shape and contour.  No muscle masses.,Foot:  No erythema.  No edema.  Normal range of motion all joints in the foot.  Nontender.  No pain with inversion, eversion, plantar or dorsiflexion.,Ankle:  Anterior and posterior drawer test negative.  No pain with inversion, eversion, dorsiflexion, or plantar flexion.  Collateral ligaments intact.  No joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.,Knee:  Normal range of motion.  No joint effusion, erythema, nontender.  Anterior and posterior drawer tests negative.  Lachman's test negative.  Collateral ligaments intact.  Bursas nontender without edema.,Wrist:  Normal range of motion.  No edema or effusion, nontender.  Negative Tinel and Phalen tests.  Normal strength all muscle groups.,Elbow:  Normal range of motion.  No joint effusion or erythema.  Normal strength all muscle groups.  Nontender.  Olecranon bursa flat and nontender, no edema.  Normal supination and pronation of forearm.  No crepitus.,Hip:  Negative swinging test.  Trochanteric bursa nontender.  Normal range of motion.  Normal strength all muscle groups.  No pain with eversion and inversion.  No crepitus.  Normal gait.,Psychiatric:  Alert and oriented times four.  No delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality.  Affect is appropriate.  No psychomotor slowing or agitation.  Eye contact is appropriate.
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DESCRIPTION: An example/template for a routine normal male physical exam.

general medicine, male exam, normal, physical exam, normal range of motion, male physical, nontender, lesions, dorsiflexion, sclerae, contour, muscle, erythema, joints, edema, shape,

The situation described is a routine physical examination with normal findings. It is a template for documenting a standard physical exam in general medicine, which is a typical part of regular healthcare maintenance. There are no signs of acute or emergent medical issues within the information provided. This setting is low-stakes as it primarily involves routine documentation and likely serves as a reference or template for practitioners.


Medical Specialty: Bariatrics
Sample Name: Laparoscopic Gastric Bypass

PREOPERATIVE DIAGNOSIS: , Morbid obesity.,POSTOPERATIVE DIAGNOSIS:  ,Morbid obesity.,PROCEDURE: , Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.,ANESTHESIA: , General with endotracheal intubation.,INDICATION FOR PROCEDURE: , This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.  She has been to our Bariatric Surgery Seminar, received some handouts, and signed the consent.  The risks and benefits of the procedure have been explained to the patient.,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  All pressure points were carefully padded.  She was given general anesthesia with endotracheal intubation.  SCD stockings were placed on both legs.  Foley catheter was placed for bladder decompression.  The abdomen was then prepped and draped in standard sterile surgical fashion.  Marcaine was then injected through umbilicus.  A small incision was made.  A Veress needle was introduced into the abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg.  A 12-mm VersaStep port was placed through the umbilicus.  I then placed a 5-mm port just anterior to the midaxillary line and just subcostal on the right side.  I placed another 5-mm port in the midclavicular line just subcostal on the right side, a few centimeters below and medial to that, I placed a 12-mm VersaStep port.  On the left side, just anterior to the midaxillary line and just subcostal, I placed a 5-mm port.  A few centimeters below and medial to that, I placed a 15-mm port.  I began by lifting up the omentum and identifying the transverse colon and lifting that up and thereby identifying my ligament of Treitz.  I ran the small bowel down approximately 40 cm and divided the small bowel with a white load GIA stapler.  I then divided the mesentery all the way down to the base of the mesentery with a LigaSure device.  I then ran the distal bowel down, approximately 100 cm, and at 100 cm, I made a hole at the antimesenteric portion of the Roux limb and a hole in the antimesenteric portion of the duodenogastric limb, and I passed a 45 white load stapler and fired a stapler creating a side-to-side anastomosis.  I reapproximated the edges of the defect.  I lifted it up and stapled across it with another white load stapler.  I then closed the mesenteric defect with interrupted Surgidac sutures.  I divided the omentum all the way down to the colon in order to create a passageway for my small bowel to go antecolic.  I then put the patient in reverse Trendelenburg.  I placed a liver retractor, identified, and dissected the angle of His.  I then dissected on the lesser curve, approximately 2.5 cm below the gastroesophageal junction, and got into a lesser space.  I fired transversely across the stomach with a 45 blue load stapler.  I then used two fires of the 60 blue load with SeamGuard to go up into my angle of His, thereby creating my gastric pouch.  I then made a hole at the base of the gastric pouch and had Anesthesia remove the bougie and place the OG tube connected to the anvil.  I pulled the anvil into place, and I then opened up my 15-mm port site and passed my EEA stapler.  I passed that in the end of my Roux limb and had the spike come out antimesenteric.  I joined the spike with the anvil and fired a stapler creating an end-to-side anastomosis, then divided across the redundant portion of my Roux limb with a white load GI stapler, and removed it with an Endocatch bag.  I put some additional 2-0 Vicryl sutures in the anastomosis for further security.  I then placed a bowel clamp across the bowel.  I went above and passed an EGD scope into the mouth down to the esophagus and into the gastric pouch.  I distended gastric pouch with air.  There was no air leak seen.  I could pass the scope easily through the anastomosis.  There was no bleeding seen through the scope.  We closed the 15-mm port site with interrupted 0 Vicryl suture utilizing Carter-Thomason.  I copiously irrigated out that incision with about 2 L of saline.  I then closed the skin of all incisions with running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.
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DESCRIPTION: Morbid obesity.  Laparoscopic antecolic antegastric Roux-en-Y gastric bypass with EEA anastomosis.  This is a 30-year-old female, who has been overweight for many years.  She has tried many different diets, but is unsuccessful.

bariatrics, gastric bypass, eea anastomosis, roux-en-y, antegastric, antecolic, morbid obesity, roux limb, gastric pouch, intubation, laparoscopic, bypass, roux, endotracheal, anastomosis, gastric

The situation described involves a laparoscopic gastric bypass surgery, which is a significant procedure with inherent risks and potential complications. It is used to treat morbid obesity when other weight-loss approaches have failed. The stakes are high because the surgery involves multiple steps, requires general anesthesia, and has a direct impact on the patient's long-term health and quality of life. Complications can include bleeding, infection, blood clots, gastrointestinal leaks, and long-term nutritional deficiencies. The patient's safety during and after the procedure is critical, making it a high-stakes situation.


Medical Specialty: Radiology
Sample Name: Myocardial Perfusion Imaging - 3

DIAGNOSIS:  ,Shortness of breath.  Fatigue and weakness.  Hypertension.  Hyperlipidemia.,INDICATION: , To evaluate for coronary artery disease.,
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DESCRIPTION: Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.

radiology, myocardial perfusion imaging, spect wall motion study at stress, rest and stress, perfusion study at rest, calculation of ejection fraction, normal left ventricular wall, spect wall motion study, ventricular wall motion, myocardial perfusion study, perfusion imaging, blood pressure, nonspecific st, ventricular wall, gated spect, spect wall, motion study, stress test, heart rate, ejection fraction, myocardial perfusion, technetium, tetrofosmin, ischemia, ekg, imaging, spect, heart, ventricular, mci, resting, perfusion, stress, myocardial,

The scenario involves the evaluation of a patient's potential coronary artery disease using myocardial perfusion imaging, which is a critical diagnostic tool. The diagnosis involves symptoms like shortness of breath, fatigue, and underlying conditions such as hypertension and hyperlipidemia, which can be indicative of serious health risks. The result of this imaging could influence significant clinical decisions, potentially involving treatment for heart disease, which could have substantial impacts on the patient's health and life. The high stakes are related to accurately diagnosing and managing heart disease, which is vital for the patient's wellbeing.


Medical Specialty: Consult - History and Phy.
Sample Name: T-Cell Lymphoma Consult

CHIEF COMPLAINT: , Newly diagnosed T-cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago.  He was originally treated with antibiotics as a possible tooth abscess.  Prior to this event, in March of 2010, he was treated for strep throat.  The pain at that time was on the right side.  About a month ago, he started having night sweats.  The patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked.  All these symptoms were preceded by overwhelming fatigue and exhaustion.  He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home.  With the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable.  He also reports occasional headaches with some stabbing and pain in his feet and legs.  He also complains of some left groin pain.,PAST MEDICAL HISTORY: , Significant for HIV diagnosed in 2000.  He also had mononucleosis at that time.  The patient reports being on anti-hepatitis viral therapy period that was very intense.  He took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells.  He reports no other history of transfusions.  He has history of spontaneous pneumothorax.  The first episode was 1989 on his right lung.  In 1990 he had a slow collapse of the left lung.  He reports no other history of pneumothoraces.  In 2003, he had shingles.  He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy.,FAMILY HISTORY: , Notable for his mother who is currently battling non-small cell lung cancer.  She is a nonsmoker.  His sister is Epstein-Barr virus positive.  The patient's mother also reports that she is Epstein-Barr virus positive.  His maternal grandfather died from complications from melanoma.  His mother also has diabetes.,SOCIAL HISTORY: , The patient is single.  He currently lives with his mother in house for several both in New York and here in Colorado.  His mother moved out to Colorado eight years ago and he has been out here for seven years.  He currently is self employed and does antiquing.  He has also worked as nurses' aide and worked in group home for the state of New York for the developmentally delayed.  He is homosexual, currently not sexually active.  He does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day.  He does not use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , As mentioned above his weight has been fairly stable.  Although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years.  He has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath.  He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck.  He has had fevers as well.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:
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DESCRIPTION: Newly diagnosed T-cell lymphoma.  The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago.

consult - history and phy., t-cell lymphoma, submandibular, tooth abscess, strep throat, submandibular region, lymphoma, neck,

The patient has been diagnosed with T-cell lymphoma, a type of cancer, which inherently makes this a high-stakes situation. The history of HIV and significant past medical issues such as a profound anemia history and spontaneous pneumothorax add complexity and severity. The patient is experiencing specific symptoms that align with systemic lymphoma symptoms, like night sweats and fatigue, which could indicate disease progression or complications. Considering the existing serious medical conditions, the implications of lymphoma, and the need for immediate and effective treatment and management, this case is high-stakes in terms of both health risk and treatment urgency.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Infected Toenails

S - ,This patient has reoccurring ingrown infected toenails.  He presents today for continued care.,O - ,On examination, the left great toenail is ingrown on the medial and lateral toenail border.  The right great toenail is ingrown on the lateral nail border only.  There is mild redness and granulation tissue growing on the borders of the toes.  One on the medial and one on the lateral aspect of the left great toe and one on the lateral aspect of the right great toe.  These lesions measure 0.5 cm in diameter each.  I really do not understand why this young man continues to develop ingrown nails and infections.,A - ,1.  Onychocryptosis.,
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DESCRIPTION: This patient has reoccurring ingrown infected toenails.

soap / chart / progress notes, infected toenails, onychocryptosis, benign lesions, toenail border, left great toe, neosporin ointment, hemostasis was achieved, ointment and absorbent, toenails, ingrown, lesions, benign, infected,

The scenario involves a medical consultation for patient with recurring ingrown infected toenails. This condition, known as onychocryptosis, while painful and potentially leading to infection, is generally not life-threatening if treated appropriately. However, it can cause significant discomfort and if left untreated, can lead to more serious infections. The scenario involves managing a chronic issue, but it does not indicate immediate life-threatening danger.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy & Fusion - 7

PREOPERATIVE DIAGNOSIS:,  C4-C5, C5-C6 stenosis.,PREOPERATIVE DIAGNOSIS: , C4-C5, C5-C6 stenosis.,PROCEDURE: , C4-C5, C5-C6 anterior cervical discectomy and fusion.,COMPLICATIONS: , None.,ANESTHESIA: , General.,INDICATIONS OF PROCEDURE: , The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms.  Her MRI showed stenosis at portion of C4 to C6.  I discussed the procedure as well as risks and complications.  She wishes to proceed with surgery.  Risks will include but are not limited to infection, hemorrhage, spinal fluid leak, worsened neurologic deficit, recurrent stenosis, requiring further surgery, difficulty with fusion requiring further surgery, long-term hoarseness of voice, difficulty swallowing, medical anesthesia risk.,PROCEDURE:  ,The patient was taken to the operating room on 10/02/2007.  She was intubated for anesthesia.  TEDS and boots as well as Foley catheter were placed.  She was placed in a supine position with her neck in neutral position.  Appropriate pads were also used.  The area was prepped and draped in usual sterile fashion.  Preoperative localization was taken.  _____ not changed.  Incision was made on the right side in transverse fashion over C5 vertebral body level.  This was made with a #10 blade knife and further taken down with pickups and scissors.  The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine.  Intraoperative x-ray was taken.  Longus colli muscles were retracted laterally.  Caspar retractors were used.  Intraoperative x-ray was taken.  I first turned by attention at C5-C6 interspace.  This was opened with #15 blade knife.  Disc material was taken out using pituitary as well as Kerrison rongeur.  Anterior aspects were taken down.  End plates were arthrodesed using curettes.  This was done under distraction.  Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur.  Bilateral foraminotomies were done.  At this point, I felt that there was a good decompression.  The foramen appeared to be opened.  Medtronic cage was then encountered and sent few millimeters.  This was packed with demineralized bone matrix.  The distraction was then taken down.  The cage appeared to be strong.  This procedure was then repeated at C4-C5.  A 42-mm AcuFix plate was then placed between C4 and C6.  This was carefully screwed and locked.  The instrumentation appeared to be strong.  Intraoperative x-ray was taken.  Irrigation was used.  Hemostasis was achieved.  The platysmas was closed with 3-0 Vicryl stitches.  The subcutaneous was closed with 4-0 Vicryl stitches.  The skin was closed with Steri-strips.  The area was clean and dry and dressed with Telfa and Tegaderm.  Soft cervical collar was placed for the patient.  She was extubated per anesthesia and brought to the recovery in stable condition.
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DESCRIPTION: C4-C5, C5-C6 anterior cervical discectomy and fusion.  The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms.  Her MRI showed stenosis at portion of C4 to C6.

surgery, anterior cervical discectomy, fusion, infection, hemorrhage, spinal fluid leak, anesthesia, foley catheter, teds, anterior cervical, cervical discectomy, anterior, cervical, discectomy, stenosis,

The situation involves a surgical procedure, specifically an anterior cervical discectomy and fusion, which is inherently high-stakes due to the complexity and risks involved. Surgical procedures always carry risks such as infection, hemorrhage, and complications from anesthesia, and in this case, potential spinal and neurological complications. The age of the patient (62) adds another layer of risk, and the procedure's potential impacts on the spinal cord make it critical. Surgery generally involves high-risk factors given the possible severe consequences of complications.


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

CHIEF COMPLAINT:,  Toothache.,HISTORY OF PRESENT ILLNESS:  ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled.  Complains of new tooth pain.  The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days.  The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only.  The patient denies any other problems or complaints.  The patient denies any recent illness or injuries.  The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  No recent weight change.  HEENT:  No headache, no neck pain, the toothache pain for the past three days as previously mentioned.  There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids.  The patient denies any rhinorrhea.  No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No focal weakness or numbness.  Normal speech.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling has been noted.,PAST MEDICAL HISTORY: , Chronic knee pain.,CURRENT MEDICATIONS: , OxyContin and Vicodin.,ALLERGIES:,  PENICILLIN AND CODEINE.,SOCIAL HISTORY: , The patient is still a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient is a little overweight but otherwise appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Eyes are normal with clear conjunctiva and cornea bilaterally.  There is no icterus, injection, or discharge.  Pupils are 3 mm and equally round and reactive to light bilaterally.  There is no absence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Ears are normal bilaterally without any sign of infection.  There is no erythema, swelling of canals.  Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it.  Nose is normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  NECK:  Supple, nontender, and full range of motion.  There is no meningismus.  No cervical lymphadenopathy.  No JVD.  Mouth and oropharynx shows multiple denture and multiple dental caries.  The patient has tenderness to tooth #12 as well as tooth #21.  The patient has normal gums.  There is no erythema or swelling.  There is no purulent or other discharge noted.  There is no fluctuance or suggestion of abscess.  There are no new dental fractures.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion or swelling.  The buccal membranes are normal.  Mucous membranes are moist.  The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally without shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to back, arms and legs.  The patient has normal use of his extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact to the extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No cervical lymphadenopathy is palpated.,EMERGENCY DEPARTMENT COURSE: , The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.,DIAGNOSES:,1.  ODONTALGIA.,2.  MULTIPLE DENTAL CARIES.,CONDITION UPON DISPOSITION:  ,Stable.,DISPOSITION: , To home.,PLAN: , The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes.  The patient was requested to have reevaluation within two days.  The patient was given a prescription for Percocet and clindamycin.  The patient was given drug precautions for the use of these medicines.  The patient was offered discharge instructions on toothache but states that he already has it.  He declined the instructions.  The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.
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DESCRIPTION: Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..

emergency room reports, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental,

The patient's condition, a toothache due to multiple dental caries, is typically considered non-life-threatening. Although he requires pain management and has issues with following up with dental care, he does not exhibit any signs of systemic infection or other acute problems commonly associated with high-stakes health issues. The emergency intervention involved basic pain relief and antibiotics, and he was sent home in stable condition. Therefore, this situation does not pose significant immediate risk to the patient's life or overall health in the short term.


Medical Specialty: Emergency Room Reports
Sample Name: Jaw Pain - ER Visit

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

emergency room reports, jaw pain, dental appointment, ellis type ii fracture, ellis type, dental fracture, toothache, tenderness, pressure, erythema,

The situation described doesn't indicate life-threatening symptoms such as chest pain, shortness of breath, or significant trauma. The patient's main issue is dental, involving a known tooth fracture, and the vital signs are relatively stable. While elevated blood pressure is noted, it is not at a critical level necessitating immediate intervention. The patient is discharged with clear follow-up instructions and pain management plan, indicating that the ER staff does not consider the condition to be urgent or life-threatening at this moment.


Medical Specialty: Hematology - Oncology
Sample Name: Sepsis - Consult

REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.
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DESCRIPTION: Sepsis.  The patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.

The situation involves a medical case with multiple serious components: advanced age, sepsis, potential urinary tract obstruction, and numerous comorbidities including heart disease and dementia. Sepsis is an acute and potentially life-threatening condition requiring immediate medical attention. The presence of bilateral hydronephrosis and hydroureter suggests serious concerns about kidney function. This high complexity and risk profile make it a high-stakes medical situation.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Hysterectomy - Laparoscopic Supracervical

PREOPERATIVE DIAGNOSES:,  Menorrhagia and dysmenorrhea.,POSTOPERATIVE DIAGNOSES: , Menorrhagia and dysmenorrhea.,PROCEDURE: , Laparoscopic supracervical hysterectomy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 100 mL.,FINDINGS: , An 8-10 cm anteverted uterus, right ovary with a 2 cm x 2 cm x 2 cm simple cyst containing straw colored fluid, a normal-appearing left ovary, and normal-appearing tubes bilaterally.,SPECIMENS:  ,Uterine fragments.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , The patient was brought to the OR where general endotracheal anesthesia was obtained without difficulty.  The patient was placed in dorsal lithotomy position.  Examination under anesthesia revealed an anteverted uterus and no adnexal masses.  The patient was prepped and draped in normal sterile fashion.  A Foley catheter was placed in the patient's bladder.  The patient's cervix was visualized with speculum.  A single-tooth tenaculum was placed on the anterior lip of the cervix.  A HUMI uterine manipulator was placed through the internal os of the cervix and the balloon was inflated.  The tenaculum and speculum were then removed from the vagina.  Attention was then turned to the patient's abdomen where a small infraumbilical incision was made with scalpel.  Veress needle was placed through this incision and the patient's abdomen was inflated to a pressure of 15 mmHg.  Veress needle was removed and then 5-mm trocar was placed through the umbilical incision.  Laparoscope was placed through this incision and the patient's abdominal contents were visualized.  A 2nd trocar incision was placed in the midline 2 cm above the symphysis pubis and a 5-mm trocar was placed through this incision on direct visualization for laparoscope.  A trocar incision was made in the right lower quadrant.  A 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  A ___ trocar incision was made in the left lower quadrant and a 2nd 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  The patient's abdominal and pelvic anatomy were again visualized with the assistance of a blunt probe.  The Gyrus cautery was used to cauterize and cut the right and left round ligaments.  The anterior leaf of the broad ligament was bluntly dissected and cauterized and cut in an inferior fashion towards lower uterine segment.  The right uteroovarian ligament was cauterized and cut using the Gyrus.  The uterine vessels were then bluntly dissected.  The Gyrus was then used to cauterize the right uterine vessels.  Gyrus was then used on the left side to cauterize and cut the left round ligament.  The anterior leaf of the broad ligament on the left side was bluntly dissected, cauterized, and cut.  Using the Gyrus, the left uteroovarian ligament was cauterized and cut and the left uterine vessels were then bluntly dissected.  The left uterine vessels were then cauterized and cut using the Gyrus.  At this point, as the uterine vessels had been cauterized on both sides, the uterine body exhibited blanching.  At this point, the Harmonic scalpel hook was used to amputate the uterine body from the cervix at the level just below the uterine vessels.  The HUMI manipulator was removed prior to amputation of the uterine body.  After the uterine body was detached from the cervical stump, morcellation of the uterine body was performed using the uterine morcellator.  The uterus was removed in a piecemeal fashion through the right lower quadrant trocar incision.  Once, all fragments of the uterus were removed from the abdominal cavity, the pelvis was irrigated.  The Harmonic scalpel was used to cauterize the remaining endocervical canal.  The cervical stump was also cauterized with the Harmonic scalpel and good hemostasis was noted at the cervical stump and also at the sites of all pedicles.  The Harmonic scalpel was then used to incise the right ovarian simple cyst.  The right ovarian cyst was then drained yielding straw-colored fluid.  The site of right ovarian cystotomy was noted to be hemostatic.  The pelvis was again inspected and noted to be hemostatic.  The ureters were identified on both sides and noted to be intact throughout the visualized course.  All instruments were then removed from the patient's abdomen and the abdomen was deflated.  The fascial defects at the 10-mm trocar sites were closed using figure-of-8 sutures of 0-Vicryl and skin incisions were closed with a 4-0 Vicryl in subcuticular fashion.  The cervix was then visualized with the speculum.  Good hemostasis at the site of tenaculum insertion was obtained using silver nitrate sticks.  All instruments were removed from the patient's vagina and the patient was placed in normal supine position.,Sponge, lap, needle, and instrument counts were correct x2.  The patient was awoken from anesthesia and then transferred to the recovery room in stable condition.
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DESCRIPTION: Laparoscopic supracervical hysterectomy.  Menorrhagia and dysmenorrhea.

obstetrics / gynecology, supracervical hysterectomy, incision, uterine, uteroovarian, hysterectomy, supracervical, menorrhagia, dysmenorrhea, cervical, laparoscopic, laparoscope, cervix, ligaments, trocar

The procedure described is a laparoscopic supracervical hysterectomy, which is a significant surgical intervention, typically indicated for severe or problematic symptoms such as menorrhagia (heavy menstrual bleeding) and dysmenorrhea (painful menstruation). The procedure involves general anesthesia, and while it is considered minimally invasive compared to open surgery, it still carries risks including bleeding, infection, or damage to surrounding organs. The detailed step-by-step description confirms the complexity and importance of the procedure, although no complications were reported, and the patient was stable post-operation. In a medical context, especially in surgery, the stakes are quite high because the outcome can significantly affect the patient's health and quality of life.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Transesophageal Echocardiogram - 2

REASON FOR EXAM: , Vegetation and bacteremia.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION: , The procedure and its complications were explained to the patient in detail and formal consent was obtained.  The patient was brought to special procedure unit.  His throat was anesthetized with lidocaine spray.  Subsequently, 2 mg of IV Versed was given for sedation.  The patient was positioned.  Probe was introduced without any difficulty.  The patient tolerated the procedure very well.  Probe was taken out.  No complications were noted.  Findings are as mentioned below.,FINDINGS:,1.  Left ventricle has normal size and dimensions with normal function.  Ejection fraction of 60%.,2.  Left atrium and right-sided chambers were of normal size and dimensions.,3.  Left atrial appendage is clean without any clot or smoke effect.,4.  Atrial septum is intact.  Bubble study was negative.,5.  Mitral valve is structurally normal.,6.  Aortic valve reveals echodensity suggestive of vegetation.,7.  Tricuspid valve was structurally normal.,8.  Doppler reveals moderate mitral regurgitation and moderate-to-severe aortic regurgitation.,9.  Aorta is benign.,IMPRESSION:,1.  Normal left ventricular size and function.,2.  Echodensity involving the aortic valve suggestive of endocarditis and vegetation.,3.  Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.
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DESCRIPTION: Transesophageal echocardiogram due to vegetation and bacteremia. Normal left ventricular size and function.  Echodensity involving the aortic valve suggestive of endocarditis and vegetation. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.

cardiovascular / pulmonary, ventricle, atrium, atrial, septum, mitral valv, aortic valve, tricuspid valve, doppler, ventricular size, transesophageal echocardiogram, severe aortic, bacteremia, transesophageal, echocardiogram, echodensity, vegetation, valve, aortic,

The situation involves a medical procedure (Transesophageal Echocardiogram) conducted to investigate potential endocarditis, which is a serious condition involving infection of the heart lining or valves. The findings note vegetation on the aortic valve, which indicates potential bacterial infection and implies significant implications for the patient's health, including moderate-to-severe aortic regurgitation. Given the serious nature of cardiac infections and potential for severe complications, this scenario involves high stakes for the patient's health outcomes.


Medical Specialty: Surgery
Sample Name: Phacoemulsification & Lens Implantation - 3

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,PROCEDURE:,  Phacoemulsification with intraocular lens placement, right eye.,ANESTHESIA: , Monitored anesthesia care,ESTIMATED BLOOD LOSS: , None,COMPLICATIONS:,  None,SPECIMENS:,  None,PROCEDURE IN DETAIL: , The patient had previously been examined in the clinic and was found to have a visually significant cataract in the right eye.  The patient had the risks and benefits of surgery discussed.  After discussion, the patient decided to proceed and the consent was signed.,On the day of surgery, the patient was taken from the holding area to the operating suite by the anesthesiologist and monitors were placed.  Following this, the patient was sterilely prepped and draped in the usual fashion.  After this, a lid speculum was placed, preservative-free lidocaine drops were placed, and the SuperSharp blade was used to make an anterior chamber paracentesis.  Preservative-free lidocaine was instilled into the anterior chamber, and then Viscoat was instilled into the eye.,The 3.0 diamond keratome was then used to make a clear corneal temporal incision.  Following this, the cystotome was used to make a continuous tear-type capsulotomy.  After this, BSS was used to hydrodissect and hydrodelineate the lens.  The phacoemulsification unit was used to remove the cataract.  The I&A unit was used to remove the residual cortical material.  Following this, Provisc was used to inflate the bag.  The lens, a model SA60AT of ABCD diopters, serial #1234, was inserted into the bag and rotated into position using the Lester pusher.,After this, the residual Provisc was removed.  Michol was instilled and then the corneal wound was hydrated with BSS, and the wound was found to be watertight.  The lid speculum was removed.  Acular and Vigamox drops were placed.  The patient tolerated the procedure well without complications and will be followed up in the office tomorrow.
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DESCRIPTION: Cataract, right eye.  Phacoemulsification with intraocular lens placement, right eye.

surgery, capsulotomy, diopters, intraocular lens placement, lid speculum, anterior chamber, phacoemulsification, lens, cataract, intraocular

Phacoemulsification with intraocular lens implantation is a common surgical procedure for treating cataracts and is generally considered to be low-risk with a high success rate, particularly without any noted complications or blood loss as described in this case. It is elective surgery, meaning it is not urgent or life-threatening, reducing the stakes. Patients are typically able to see better very soon after the procedure, which contributes to its characterization as a low-stakes surgery. However, as with any surgery, there are always inherent risks, even if minimal.


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

Medical Specialty: Surgery
Sample Name: Sacral Decubitus Debridement

PREOPERATIVE DIAGNOSIS:,  Stage IV necrotic sacral decubitus.,POSTOPERATIVE DIAGNOSIS:,  Stage IV necrotic sacral decubitus.,PROCEDURE PERFORMED:,  Debridement of stage IV necrotic sacral decubitus.,GROSS FINDINGS: , This is a 92-year-old African-American female who was brought into the office 48 hours earlier with a chief complaint of necrotic foul-smelling wound in the sacral region and upon examination was found to have absolutely necrosis of the fat and subcutaneous tissue in the sacral region approximately 15 cm x 15 cm.  A long discussion with the family ensued that it needs to be debrided and then cleaned and then if she cannot keep the stool out of the wound that she will probably need a diverting colostomy.,OPERATIVE PROCEDURE:  ,The patient was properly prepped and draped under local sedation.  A 0.25% Marcaine was injected circumferentially around the necrotic decubitus.  A wide excision and debridement of the necrotic decubitus taken down to the presacral fascia and all necrotic tissue was electrocauterized and removed.  All bleeding was cauterized with electrocautery and then a Kerlix stack was then placed and a pressure dressing applied.  The patient was sent to recovery in satisfactory condition.
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DESCRIPTION: Stage IV necrotic sacral decubitus.  Debridement of stage IV necrotic sacral decubitus.

surgery, diverting colostomy, sacral decubitus debridement, necrotic sacral decubitus, wound, tissue, debridement, sacral, decubitus, necrotic,

The situation involves a surgical procedure for a stage IV necrotic sacral decubitus, which is a severe pressure ulcer. These types of ulcers indicate extensive tissue damage and carry high risks of infection and other complications. The procedure involves significant medical intervention, and the potential use of a diverting colostomy if conditions like contamination with stool cannot be managed. The patient is also an elderly individual, which adds to the complexity and risk of the procedure. This makes it a high-stakes situation, as it has significant health implications for the patient.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Cataract Extraction - 2

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,TITLE OF OPERATION: , Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room where tetracaine drops were instilled in the eye.  The patient was then prepped and draped using standard procedure.  An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.,The eye was rotated downward and a crescent blade used to make an incision at the limbus.  This was then dissected forward approximately 1 mm, and then a keratome was used to enter the anterior chamber.  The anterior chamber was filled with 1% preservative-free lidocaine and the lidocaine was then replaced with Provisc.  A cystotome was used to make a continuous-tear capsulorrhexis, and then the capsular flap was removed with the Utrata forceps.  The lens nucleus was hydrodissected using BSS on a cannula and then removed using the phaco.  This was aided by cracking the lens nucleus with McPherson forceps.  The remaining cortex was removed from the eye with the I&A.  The capsular bag was then polished with the I&A on capsular bag.  The bag was inflated using viscoelastic and then the wound extended slightly with a keratome.  A folding posterior chamber lens was inserted and rotated into position using McPherson forceps.  The I&A was then placed in the eye again and the remaining viscoelastic removed.  The wound was checked for watertightness and found to be watertight.  TobraDex drops were instilled in the eye and a shield was placed over it.,The patient tolerated the procedure well and was brought to recovery in good condition.
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DESCRIPTION: Cataract, right eye.  Phacoemulsification with intraocular lens insertion, right eye.  The patient was then prepped and draped using standard procedure.  An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.

ophthalmology, tetracaine, intraocular lens, lid speculum, mcpherson forceps, capsular bag, eye, phacoemulsification, cataract, lens, intraocular,

The document describes a routine cataract surgery procedure known as phacoemulsification, which is a common and generally safe surgical procedure performed under local anesthesia. The patient tolerated the procedure well with no complications reported. Although any surgical procedure carries some level of risk, this is a standard operation with a high success rate and low complication rates, indicating it is not high-stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Circumcision Followup

REASON FOR VISIT: , Followup circumcision.,HISTORY OF PRESENT ILLNESS: , The patient had his circumcision performed on 09/16/2007 here at Children's Hospital.  The patient had a pretty significant phimosis and his operative course was smooth.  He did have a little bit of bleeding when he woke in recovery room, which required placement of some additional sutures, but after that, his recovery has been complete.  His mom did note that she had to him a couple of days of oral analgesics, but he seems to be back to normal and pain free now.  He is having no difficulty urinating, and his bowel function remains normal.,PHYSICAL EXAMINATION:  ,Today, The patient looks healthy and happy.  We examined his circumcision site.  His Monocryl sutures are still in place.  The healing is excellent, and there is only a mild amount of residual postoperative swelling.  There was one area where he had some recurrent adhesions at the coronal sulcus, and I gently lysed this today and applied antibiotic ointment showing this to mom had to especially lubricate this area until the healing is completed.,IMPRESSION: , Satisfactory course after circumcision for severe phimosis with no perioperative complications.,PLAN:  ,The patient came in followup for his routine care with Dr. X, but should not need any further routine surgical followup unless he develops any type of difficulty with this surgical wound.  If that does occur, we will be happy to see him back at any time.,
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DESCRIPTION: Followup circumcision.  The patient had a pretty significant phimosis and his operative course was smooth.  Satisfactory course after circumcision for severe phimosis with no perioperative complications.

soap / chart / progress notes, circumcision, adhesions, followup circumcision, sutures, phimosis,

The situation described is a follow-up visit after a circumcision, a routine surgical procedure. The original procedure was performed to address phimosis and appears to have healed well, with minor issues (like mild postoperative swelling and slight adhesions) that are being managed without complications. There are no indications of major issues or emergencies, reducing the immediate stakes involved. As such, the stakes here are lower, focused primarily on ensuring uneventful recovery and minor wound care.


Medical Specialty: Surgery
Sample Name: Lipoma Excision - 1

PREOPERATIVE DIAGNOSIS:,  Mass, left knee.,POSTOPERATIVE DIAGNOSIS: , Lipoma, left knee.,PROCEDURE PERFORMED: ,Excision of lipoma, left knee.,ANESTHESIA: , Local with sedation.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , A 4 cm mass of adipose tissue most likely representing a lipoma was found in the patient's anteromedial left knee.,HISTORY:,  The patient is a 35-year-old female with history of lump on her right knee for the past, what she reports to be six years.  She states it had grow in size over the last six months, rarely causes her any discomfort or pain, denies any neurovascular complaints of her right lower extremity.  She denies any other lumps or bumps on her body.  She wishes to have this removed for cosmetic reasons.,PROCEDURE: , After all potential risks, benefits, and complications of the procedure were discussed with the patient, informed consent was obtained.  She was transferred from the Preoperative Care Unit to Operating Suite #1.  She was transferred from the gurney to the operating table.  All bony prominences were well padded.  A well padded tourniquet was applied to her right thigh.  Anesthesia then administered some sedation, which she tolerated well.  Her right lower extremity was then sterilely prepped and draped in normal fashion.  Next, a rubber Esmarch was used to exsanguinate her right lower extremity.,Next, approximately 20 cc of 0.25% Marcaine with 1% lidocaine were used to locally anesthetize her anterior medial right knee in location of the mass.  Next, a #15 blade Bard-Parker scalpel was utilized to make an approximately 3 cm vertical incision over the soft tissue mass upon incising the skin and the subcutaneous tissue readily and there was the aforementioned fatty tissue mass.  This was easily excised with blunt dissection.  Examination of the wound then revealed a second piece of fatty tissue, which resembled a lipoma measuring approximately 1.5 cm x 2 cm.  This was then also excised utilizing Littler scissors.  Hemostasis was obtained.  The wound was then copiously irrigated after this all the underlying bone tissue was removed.  #2-0 Vicryl interrupted subcutaneous sutures were then placed and the skin was reapproximated utilizing #4-0 horizontal mattress nylon sutures.  Sterile dressings was applied of Adaptic, 4x4s, and Kerlix as well as an Ace wrap.  Sedation was reversed.  Tourniquet was deflated.  The patient was transferred from the operating table to the gurney and to the Postoperative Care Unit in stable condition.  Her prognosis for this is good.
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DESCRIPTION: Excision of lipoma, left knee.  A 4 cm mass of adipose tissue most likely representing a lipoma was found in the patient's anteromedial left knee.

surgery, excision of lipoma, adipose tissue, fatty tissue, lipoma, tissue, knee

The lipoma excision is a routine surgical procedure typically performed for cosmetic reasons or to relieve minor discomfort. The surgery involves minimal risk and was performed under local anesthesia with sedation. There were no complications during the procedure, and the patient is expected to have a good prognosis. While any surgical procedure carries some inherent risks, this situation is not characterized by life-threatening conditions or serious complications.


Medical Specialty: Neurology
Sample Name: Cervical Cord Lesion - Consult

HISTORY OF PRESENT ILLNESS:, This is a 58-year-old male who reports a six to eight-week history of balance problems with fatigue and weakness. He has had several falls recently. He apparently had pneumonia 10 days prior to the onset of the symptoms. He took a course of amoxicillin for this. He complained of increased symptoms with more and more difficulty with coordination. He fell at some point near the onset of the symptoms, but believes that his symptoms had occurred first. He fell from three to five feet and landed on his back. He began seeing a chiropractor approximately five days ago and had adjustments of the neck and lumbar spine, although he clearly had symptoms prior to this.,He has had mid and low back pain intermittently. He took a 10-day course of Cipro believing that he had a UTI. He denies, however, any bowel or bladder problems. There is no incontinence and he does not feel that he is having any difficulty voiding.,PAST SURGICAL HISTORY:, He has a history of surgery on the left kidney, when it was "rebuilt." He has had knee surgery, appendectomy and right inguinal hernia repair.,MEDICATIONS:, His only home medications had been Cipro and Aleve. However, he does take aspirin and several over the counter supplements including a multivitamin with iron, "natural" potassium, Starlix and the aspirin.,ALLERGIES:, HE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:, He smokes one-and-one-half-packs of cigarettes per day and drinks alcohol at least several days per week. He is employed in sales, which requires quite a bit of walking, but he is not doing any lifting. He had been a golfer in the past.,PAST MEDICAL HISTORY:, He has had documented cervical spondylosis, apparently with an evaluation over 15 years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS: Blood pressure 156/101, pulse was 88, respirations 18. He is afebrile.,MENTAL STATUS: He is alert.,CRANIAL NERVES: His pupils were reactive to light. He had a dense left cataract present. The right disk margin appears sharp. His eye movements were full. The face was symmetric. Pain and temperature sensation were intact over both sides of the face. The tongue was midline.,NECK: His neck was supple.,MUSCULOSKELETAL: He has intact strength and normal tone in the upper extremities. He had increased tone in both lower extremities. He had hip flexion of 4/5 on the left. He had intact strength on the right lower extremity, although had slight hammertoe deformity bilaterally.,NEUROLOGIC: His reflexes were 2+ in the upper extremities, 3+ at the knees and 1+ at the ankles. He withdrew to plantar stimulation on the left, but did not have a Babinski response clearly present. He had intact finger-to-nose testing. Marked impairment in heel-to-shin testing. He was able to sit unassisted. He stood with assistance, but had a markedly ataxic gait. On sensory exam, he had a slight distal gradient to pin and vibratory sense in both lower extremities, but also had a decrease in sensation to pin over the right lower extremity compared to the left.,CARDIOVASCULAR: He had no carotid bruits. His heart rhythm was regular.,BACK: There was no focal back pain present. He did have a slight sensory level at the upper T spine at approximately T3, both anteriorly and posteriorly.,RADIOLOGIC DATA:, MRI by my view showed essentially unremarkable T spine. The MRI of his C spine showed significant spondylosis in the mid and lower C spine with spondylolisthesis at C7-T1. There is an abnormal signal in the cord which begins at approximately this level, but descends approximately 2 cm. There is slight enhancement at the mid-portion of the lesion. This appears to be an intrinsic lesion to the cord, not clearly associated with mild to moderate spinal stenosis at the level of the spondylolisthesis.,LABORATORY: ,His initial labs were unremarkable.,IMPRESSION: ,Cervical cord lesion at the C7 to T2 level of unclear etiology. Consider a transverse myelitis, tumor, contusion or ischemic lesion.,PLAN:, Will check labs including sedimentation rate, MRI of the brain, chest x-ray. He will probably need a lumbar puncture. He also appears to have a mild peripheral neuropathy, which I suspect is an independent problem. We will request labs for this.
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DESCRIPTION: Patient reports a six to eight-week history of balance problems with later fatigue and weakness.

The situation involves a potential cervical cord lesion with unclear etiology, which is affecting the patient's motor control and possibly indicating serious underlying conditions such as transverse myelitis, tumor, contusion, or ischemic lesion. Given the neurological compromise, the potential for significant impact on mobility and quality of life, and the need for urgent diagnostic tests and interventions, it constitutes a high-stakes medical situation requiring prompt and thorough evaluation.


Medical Specialty: Urology
Sample Name: Vasectomy - 3

PREOPERATIVE DIAGNOSIS:,  Desire for sterility.,POSTOPERATIVE DIAGNOSIS:,  Desire for sterility.,OPERATIVE PROCEDURES: , Vasectomy.,DESCRIPTION OF PROCEDURE: , The patient was brought to the suite, where after oral sedation, the scrotum was prepped and draped.  Then, 1% lidocaine was used for anesthesia.  The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.  A segment about 3 cm in length was dissected out.  It was clipped proximally and distally, and then the ends were cauterized after excising the segment.  Minimal bleeding was encountered and the scrotal skin was closed with 3-0 chromic.  The identical procedure was performed on the contralateral side.  He tolerated it well.  He was discharged from the surgical center in good condition with Tylenol with Codeine for pain.  He will use other forms of birth control until he has confirmed azoospermia with two consecutive semen analyses in the month ahead.  Call if there are questions or problems prior to that time.
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DESCRIPTION: Desire for sterility.  Vasectomy.  The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.

urology, vas, contralateral, desire for sterility, scalpel, sterility, vasectomy

The situation involves a vasectomy procedure, which is generally a low-risk and common surgical procedure for male sterilization. The report suggests the procedure was performed without complications and the patient was discharged in good condition. Although any surgical procedure carries some risk, the stakes in this situation are relatively low as it is a routine procedure with a high success rate and minimal complications.


Medical Specialty: Radiology
Sample Name: MRI Head

EXAM:,  MRI Head W&WO Contrast.,REASON FOR EXAM:,  Dyspnea.,COMPARISON:,  None. ,TECHNIQUE:,  MRI of the head performed without and with 12 ml of IV gadolinium (Magnevist).  ,INTERPRETATION: , There are no abnormal/unexpected foci of contrast enhancement.  There are no diffusion weighted signal abnormalities.  There are minimal, predominantly periventricular, deep white matter patchy foci of FLAIR/T2 signal hyperintensity, the rest of the brain parenchyma appearing unremarkable in signal.  The ventricles and sulci are prominent, but proportionate.  Per T2 weighted sequence, there is no hyperdense vascularity.  There are no calvarial signal abnormalities.  There is no significant mastoid air cell fluid.  No significant sinus mucosal disease per MRI.,IMPRESSION:,1.  No abnormal/unexpected foci of contrast enhancement; specifically, no evidence for metastases or masses.  ,2.  No evidence for acute infarction. ,3.  Mild, scattered, patchy, chronic small vessel ischemic disease changes. ,4.  Diffuse cortical volume loss, consistent with patient's age. ,5.  Preliminary report was issued at the time of dictation.  ,
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DESCRIPTION: MRI Head W&WO Contrast.

MRI Head W&WO Contrast.

radiology, dyspnea, mri of the head, foci of contrast, patchy foci, white matter, w&wo contrast, mri head, mri

The MRI report for the head does not indicate any immediate or severe findings such as tumors, acute infarctions, or other critical pathologies. The findings described, like chronic small vessel ischemic disease and cortical volume loss, are common in aging populations and typically do not require urgent intervention. Therefore, while the examination is important for understanding the patient's neurological health, it does not present a high-stakes situation that demands immediate action.


Medical Specialty: Gastroenterology
Sample Name: Laparoscopic Cholecystectomy - 10

PREOPERATIVE DIAGNOSIS: , Biliary colic and biliary dyskinesia.,POSTOPERATIVE DIAGNOSIS:,  Biliary colic and biliary dyskinesia.,PROCEDURE PERFORMED:,  Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,DISPOSITION:  ,The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY:  ,This patient is a 42-year-old female who presented to Dr. X's office with complaints of upper abdominal and back pain, which was sudden onset for couple of weeks.  The patient is also diabetic.  The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.  The patient was then scheduled for laparoscopic cholecystectomy for biliary colic and biliary dyskinesia.,INTRAOPERATIVE FINDINGS: , The patient's abdomen was explored.  There was no evidence of any peritoneal studding or masses.  The abdomen was otherwise within normal limits.  The gallbladder was easily visualized.  There was an intrahepatic gallbladder.  There was no evidence of any inflammatory change.,PROCEDURE:,  After informed written consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought into the operating suite.,After general endotracheal intubation, the patient was prepped and draped in normal sterile fashion.  Next, an infraumbilical incision was made with a #10 scalpel.  The skin was elevated with towel clips and a Veress needle was inserted.  The abdomen was then insufflated to 15 mmHg of pressure.  The Veress needle was removed and a #10 blade trocar was inserted without difficulty.  The laparoscope was then inserted through this #10 port and the abdomen was explored.  There was no evidence of any peritoneal studding.  The peritoneum was smooth.  The gallbladder was intrahepatic somewhat.  No evidence of any inflammatory change.  There were no other abnormalities noted in the abdomen.  Next, attention was made to placing the epigastric #10 port, which again was placed under direct visualization without difficulty.  The two #5 ports were placed, one in the midclavicular and one in the anterior axillary line again in similar fashion under direct visualization.  The gallbladder was then grasped out at its fundus, elevated to patient's left shoulder.  Using a curved dissector, the cystic duct was identified and freed up circumferentially.  Next, an Endoclip was used to distal and proximal to the gallbladder, Endoshears were used in between to transect the cystic duct.  The cystic artery was transected in similar fashion.  Attention was next made in removing the gallbladder from the liver bed using electrobovie cautery and spatulated tip.  It was done without difficulty.  The gallbladder was then grasped via the epigastric port and removed without difficulty and sent to pathology.  Hemostasis was maintained using electrobovie cautery.  The liver bed was then copiously irrigated and aspirated.  All the fluid and air was then aspirated and then all ports were removed under direct visualization.  The two #10 ports were then closed in the fascia with #0 Vicryl and a UR6 needle.  The skin was closed with a running subcuticular #4-0 undyed Vicryl.  0.25% Marcaine was injected and Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and was transferred to Recovery in stable condition.
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DESCRIPTION: Laparoscopic cholecystectomy.  Biliary colic and biliary dyskinesia.  The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.

gastroenterology, electrobovie cautery, laparoscopic cholecystectomy, biliary colic, biliary dyskinesia, biliary, laparoscopic, cholecystectomy, colic, abdomen, dyskinesia, gallbladder

The situation describes a laparoscopic cholecystectomy, a common and typically low-risk surgical procedure to remove the gallbladder. While any surgical procedure inherently carries some degree of risk, this case did not present complications, and the patient was stable post-surgery. Therefore, this is considered a routine surgical procedure with manageable risk.


Medical Specialty: General Medicine
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

general medicine, vital signs, equal, round, reactive, normal physical exam, physical exam,

The situation involves a medical practitioner reviewing a template for a normal physical exam in general medicine. There are no indications of any acute medical issues or emergencies, as the template describes typical findings expected during a routine physical examination. This is a standard practice, with no immediate patient risks or critical decision-making involved.