Medical Specialty: Neurology
Sample Name: Astrocytoma

CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The "stroke" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.,PMH:, Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.,MEDS:, DPH and ASA,SHX/FHX:, 2-4 Beers/day. 1-2 packs of cigarettes per day.,EXAM:, BP 111/68, P 68BPM, 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally.,LAB:, Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.,Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.,CXR:, 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.,EEG:, 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect.,NEUROPSYCHOLOGICAL TESTING:, Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.,COURSE: ,Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed.
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DESCRIPTION: MRI - Right temporal lobe astrocytoma.

MRI - Right temporal lobe astrocytoma.

neurology, confusion, gfap, gfap staining, mri scan, astrocytoma, hippocampus, memory loss, palpitation, signal, stroke, temporal lobe, tongue-biting, tonic/clonic movement, weakness, increased t signal, mri brain, mri, temporal,

The situation involves the diagnosis and treatment of a brain tumor (Grade 2 Astrocytoma) in a 65-year-old patient. This is considered high-stakes due to the potential impact on the patient's neurological functions and overall prognosis. Brain tumors can have significant health implications, leading to cognitive decline, physical dysfunctions, and can be life-threatening. The need for surgery and radiation therapy further underscores the seriousness of the condition.


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

Medical Specialty: Surgery
Sample Name: Biceps Tendon Repair

PREOPERATIVE DIAGNOSIS: , Ruptured distal biceps tendon, right elbow.,POSTOPERATIVE DIAGNOSIS:,  Ruptured distal biceps tendon, right elbow.,PROCEDURE PERFORMED: , Repair of distal biceps tendon, right elbow.,PROCEDURE:  ,The patient was taken to OR, Room #2 and administered a general anesthetic.  The right upper extremity was then prepped and draped in the usual manner.  A sterile tourniquet was placed on the proximal aspect of the right upper extremity.  The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg.  Tourniquet time was 74 minutes.  A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin.  Hemostasis was achieved utilizing electrocautery.  Subcutaneous fat was separated and the skin flaps elevated.  The _________ was identified.  It was incised.  The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found.  There was some serosanguineous fluid from the previous rupture.  This area was suctioned clean.  The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface.  At this point, the #2 fiber wire was then passed through the tendon.  Two fiber wires were utilized in a Krackow-type suture.  Once this was completed, dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously.  The radial tuberosity was palpated.  Just ulnar to this, a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow.  A skin incision was made over this area.  Approximately two inches down to the skin and subcutaneous tissues, the fascia was split and the extensor muscle was also split.,A stat was then attached through the tip of that stat and passed back up through the antecubital fossa.  The tails of the fiber wire suture were grasped and pulled down through the second incision.  At this point, they were placed to the side.  Attention was directed at exposure of the radial tuberosity with a forearm fully pronated.  The tuberosity came into view.  The margins were cleared with periosteal elevator and sharp dissection.  Utilizing the power bur, a trough approximately 1.5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity.  Three small drill holes were then placed along the margin for passage of the suture.  The area was then copiously irrigated with gentamicin solution.  A #4-0 pullout wire was utilized to pass the sutures through the drill holes, one on each outer hole and two in the center hole.  The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated.  The suture was tied over the bone islands.  Both wounds were then copiously irrigated with gentamicin solution and suctioned dry.  Muscle fascia was closed with running #2-0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted #2-0 Vicryl and small staples.  The anterior incision was approximated with interrupted #2-0 Vicryl for Subq. and then skin was approximated with small staples.  Both wounds were infiltrated with a total of 30 cc of 0.25% Marcaine solution for postop analgesia.  A bulky fluff dressing was applied to the elbow, followed by application of a long-arm plaster splint maintaining the forearm in the supinated position.  Tourniquet was inflated prior to application of the splint.  Circulatory status returned to the extremity immediately.  The patient was awakened.  He was rather boisterous during his awakening, but care was taken to protect the right upper extremity.  He was then transferred to the recovery room in apparent satisfactory condition.
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DESCRIPTION: Ruptured distal biceps tendon, right elbow.  Repair of distal biceps tendon, right elbow.

surgery, ruptured distal biceps tendon, gentamicin solution, antecubital fossa, distal biceps, biceps tendon, tendon, tuberosity, biceps, elbow,

The situation involves a surgical procedure for repairing a ruptured distal biceps tendon. This is a specialized medical operation requiring precision and expertise, as it involves delicate handling of tendons, muscles, and bones, and the use of general anesthesia. The description indicates a systematic surgical process, outlining preoperative and postoperative considerations, as well as the technical steps involved in the procedure. Such surgeries are high-stakes due to the potential for significant impact on a patient's future mobility and function, the need for sterile technique to prevent infection, and the exacting nature of tendon repair. Additionally, general anesthesia introduces risks, further elevating the high-stakes nature of the situation.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Radiology
Sample Name: Astrocytoma

CC: ,Episodic confusion.,HX: ,This 65 y/o RHM reportedly suffered a stroke on 1/17/92. He presented locally at that time with complaint of episodic confusion and memory loss lasting several minutes per episode. The "stroke" was reportedly verified on MRI scan dated 1/17/92. He was subsequently placed on ASA and DPH. He admitted that there had been short periods (1-2 days duration) since then, during which he had forgotten to take his DPH. However, even when he had been taking his DPH regularly, he continued to experience the spells mentioned above. He denied any associated tonic/clonic movement, incontinence, tongue-biting, HA, visual change, SOB, palpitation, weakness or numbness. The episodes of confusion and memory loss last 1-2 minutes in duration, and have been occurring 2-3 times per week.,PMH:, Bilateral Hearing Loss of unknown etiology, S/P bilateral ear surgery many years ago.,MEDS:, DPH and ASA,SHX/FHX:, 2-4 Beers/day. 1-2 packs of cigarettes per day.,EXAM:, BP 111/68, P 68BPM, 36.8C. Alert and Oriented to person, place and time, 30/30 on mini-mental status test, Speech fluent and without dysarthria. CN: Left superior quandranopia only. Motor: 5/5 strength throughout. Sensory: unremarkable except for mild decreased vibration sense in feet. Coordination: unremarkable. Gait and station testing were unremarkable. He was able to tandem walk without difficulty. Reflexes: 2+ and symmetric throughout. Flexor plantar responses bilaterally.,LAB:, Gen Screen, CBC, PT, PTT all WNL. DPH 4.6mcg/ml.,Review of outside MRI Brain done 1/17/92 revealed decreased T1 and increased T2 signal in the Right temporal lobe involving the uncus and adjacent hippocampus. The area did not enhance with gadolinium contrast.,CXR:, 8/31/92: 5 x 6 mm spiculated opacity in apex right lung.,EEG:, 8/24/92: normal awake and asleep,MRI Brain with/without contrast: 8/31/92: Decreased T1 and increased T2 signal in the right temporal lobe. The lesion increased in size and enhances more greatly when compared to the 1/17/92 MRI exam. There is also edema surrounding the affected area and associated mass effect.,NEUROPSYCHOLOGICAL TESTING:, Low-average digit symbol substitution, mildly impaired verbal learning, and severely defective delayed recall. There was relative preservation of other cognitive functions. The findings were consistent with left mesiotemporal dysfunction.,COURSE: ,Patient underwent right temporal lobectomy on 9/16/92 following initial treatment with Decadron. Pathologic analysis was consistent with a Grade 2 astrocytoma. GFAP staining positive. Following surgery he underwent 5040 cGy radiation therapy in 28 fractions to the tumor bed.
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DESCRIPTION: MRI - Right temporal lobe astrocytoma.

MRI - Right temporal lobe astrocytoma.

radiology, confusion, gfap, gfap staining, mri scan, astrocytoma, hippocampus, memory loss, palpitation, signal, stroke, temporal lobe, tongue-biting, tonic/clonic movement, weakness, increased t signal, mri brain, mri, temporal,

The situation involves a detailed medical case of a patient with an astrocytoma, a type of brain tumor. The procedural history includes diagnosis and treatment, including surgery and radiation therapy, which are critical aspects of the patient's care pathway. This makes it a potentially high-stakes situation because the diagnosis and treatment of brain tumors involve significant risk, complex decision-making, and potential for serious outcomes. Given the nature of the medical condition (astrocytoma), the oncologic implications, and the interventions undertaken, the stakes are quite high.


Medical Specialty: Gastroenterology
Sample Name: Umbilical Hernia Repair - 1

PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:,  After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  The sac was cleared of overlying adherent tissue, and the fascial defect was delineated.  The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect.  The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures.  The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia.,The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The skin was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.
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DESCRIPTION: Umbilical hernia repair. A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.

gastroenterology, fascial defect, umbilical hernia repair, curvilinear umbilical, hernia sac, metzenbaum scissors, umbilical hernia, bovie electrocautery, electrocautery, hernia, incision, umbilical,

The situation involves a standard umbilical hernia repair, which is a common and relatively low-risk surgical procedure. The description indicates that the procedure went smoothly without any complications, and the patient was stable post-operation. While surgery always carries some level of risk, this particular procedure is routinely performed and is generally considered low-stakes in the context of surgeries.


Medical Specialty: Podiatry
Sample Name: Symes Amputation - Hallux

PREOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1.  Excision of mass, left second toe.,2.  Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot.  The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  The patient also has history of shave biopsy in the past.  The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  The foot was lowered to the operating table.  The stockinet was reflected and the foot was cleansed with wet and dry sponge.  A distal Syme's incision was planned over the distal aspect of the left hallux.  The incision was performed with a #10 blade and deepened with #15 down to the level of bone.  The dorsal skin flap was removed and dissected in toto off of the distal phalanx.  There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer.  Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  The area was inspected for any remaining suspicious tissues.  Any suspicious tissue was removed.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe.  There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  A linear incision was made just medial to the tissue mass.  The mass was then dissected from the overlying skin and off of the underlying capsule.  This tissue mass was hard, round, and pearly-gray in appearance.  It does not invade into any other surrounding tissues.  The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed.  The patient will be contacted immediately pending the results of pathology.  Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.
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DESCRIPTION: Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy.  Mass, left second toe.  Tumor.  Left hallux bone invasion of the distal phalanx.

podiatry, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux

The situation involves a surgical procedure for a rapidly growing mass suspected to be a tumor with bone invasion in the left toe of a patient. This is a significant and complex medical procedure, involving potential cancer diagnosis and the removal of part of the toe. Although not life-threatening in the immediate sense, the stakes are considerable due to the implications for the patient's health, quality of life, and the potential cancer diagnosis. There are also potential risks associated with the procedure, anesthesia, and recovery. These factors make it a relatively high-stakes medical situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Glioma - 2

CC:, Headache,HX: ,37 y/o RHF presented to her local physician with a one month history of intermittent predominantly left occipital headaches which were awakening her in the early morning hours. The headachese were dull to throbbing in character. She was initially treated with Parafon-forte for tension type headaches, but the pain did not resolve. She subsequently underwent HCT in early 12/90 which revealed a right frontal mass lesion.,PMH: ,1)s/p tonsillectomy. 2)s/p elective abortion.,FHX:, Mother with breast CA, MA with "bone cancer." AODM both sides of family.,SHX: ,Denied tobacco or illicit drug use. Rarely consumes ETOH. Married with 2 teenage children.,EXAM: ,VItal signs unremarkable.,MS: Alert and oriented to person, place, time. Lucid thought process per NSG note.,CN: unremarkable.,Motor: full strength with normal muscle bulk and tone.,Sensory: unremarkable.,Coordination: unremarkable.,Station/Gait: unremarkable.,Reflexes: unremarkable.,Gen. Exam: unremarkable.,COURSE:, MRI Brain: large solid and cystic right frontal lobe mass with a large amount of surrounding edema. There is apparent tumor extension into the corpus callosum across the midline. Tumor extension is also suggested in the anterior limb of the interanl capsule on the right. There is midline mass shift to the left with effacement of the anterior horn of the right lateral ventricle. The MRI findings are most consistent with glioblastoma.,The patient underwent right frontal lobectomy. The pathological diagnosis was xanthomatous astrocytoma. The literature at the time was not clear as to optimal treatment protocol. People have survived as long as 25 years after diagnosis with this type of tumor. XRT was deferred until 11/91 when an MRI and PET Scan suggested extension of the tumor. She then received 5580 cGy of XRT in divided segments. She developed olfactory auras shortly after lobectomy at was treated with PB with subsequent improvement. She was treated with BCNU chemotherapy protocol in 1992.
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DESCRIPTION: Headache.  Right frontal lobe glioma.

Headache.  Right frontal lobe glioma.

consult - history and phy., frontal lobe, tumor extension, glioma, headache, lobectomy, astrocytoma,

The situation involves a medical case with significant implications for the patient's health. The patient has been diagnosed with a right frontal lobe glioma, a serious condition. The medical decisions regarding surgical intervention and ongoing treatment (e.g., lobectomy, XRT, chemotherapy) have direct impacts on the patient’s quality of life and possibly their survival. Additionally, the complexity of the treatment decisions (e.g., choosing when to defer or administer treatment like XRT and chemotherapy) adds to the stakes, as these decisions need to be carefully considered to balance potential benefits and risks. Therefore, the stakes are high given the potential outcomes and implications of the treatment options.


Medical Specialty: ENT - Otolaryngology
Sample Name: Normal ENT Exam

EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.
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DESCRIPTION: Sample normal ear, nose, mouth, and throat exam.

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

This situation describes a standard and normal ear, nose, throat, and mouth examination, which is a routine part of otolaryngological assessment. There is no indication of any abnormalities or urgent findings. It's a typical descriptive section of a patient's chart with all normal findings, indicating low urgency and no immediate action needed.


Medical Specialty: General Medicine
Sample Name: Normal Physical Exam Template - 6

VITAL SIGNS:,  Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.,CONSTITUTIONAL: , Normal appearance for chronological age, does not appear chronically ill.,HEENT: , The pupils are equal and reactive.  Funduscopic examination is normal.  Posterior pharynx is normal.  Tympanic membranes are clear.,NECK:  ,Trachea is midline.  Thyroid is normal.  The neck is supple.  Negative nodes.,RESPIRATORY:,  Lungs are clear to auscultation bilaterally.  The patient has a normal respiratory rate, no signs of consolidation and no egophony.  There are no retractions or secondary muscle use.  Good bilateral breath sounds are noted.,CARDIOVASCULAR: , No jugular venous distention or carotid bruits.  No increase in heart size to percussion.  There is no murmur.  Normal S1 and S2 sounds are noted without gallop.,ABDOMEN: , Soft to palpation in all four quadrants.  There is no organomegaly and no rebound tenderness.  Bowel sounds are normal.  Obturator and psoas signs are negative.,GENITOURINARY: , No bladder tenderness, negative flank pain.,MUSCULOSKELETAL:,  Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.,NEUROLOGIC: , Normal Glasgow Coma Scale.  Cranial nerves II through XII appear grossly intact.  Normal motor and cerebellar tests.  Reflexes are normal.,HEME/LYMPH:  ,No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.,PSYCHIATRIC: , Normal with no overt depression or suicidal ideations.
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DESCRIPTION: Normal physical exam template.  Normal appearance for chronological age, does not appear chronically ill.

general medicine, jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds,

The situation involves evaluating a normal physical examination template for a general medicine practice. This is a routine task and is part of the standard procedure in medical practice, used primarily for documentation and developing familiarity with normal findings. It does not involve critical decision-making or direct patient intervention, but rather focuses on ensuring accurate record-keeping. Consequently, while accurate record-keeping is important, the stakes are very low given that the scenario describes a conclusion of normal findings, typical in many routine exams.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy & Fusion - 2

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,PROCEDURE: , Anterior cervical discectomy with fusion C5-C6.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion.  An incision was made from midline to the anterior border of the sternocleidomastoid in the right side.  Skin and subcutaneous tissue were divided sharply.  Trachea and esophagus were retracted medially.  Carotid sheath was retracted laterally.  Longus colli muscles were dissected away from the vertebral bodies of C5-C6.  We confirmed our position by taking intraoperative x-rays.  We then used the operating microscope and cleaned out the disk completely.  We then sized the interspace and then tapped in a #7 mm cortical cancellous graft.  We then used the DePuy Dynamic plate with 14-mm screws.  Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed in layers using 2-0 Vicryl for muscle and fascia.  The blood loss was less than 10-20 mL.  No complication.  Needle count, sponge count, and cottonoid count was correct.
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DESCRIPTION: Herniated nucleus pulposus, C5-C6, with spinal stenosis.  Anterior cervical discectomy with fusion C5-C6.

surgery, carotid sheath, jackson-pratt drain, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, herniated nucleus, nucleus pulposus, spinal stenosis, discectomy, fusion, herniated, nucleus, pulposus, spinal, stenosis, anterior

The situation involves a detailed description of an anterior cervical discectomy and fusion surgery, which is a significant surgical procedure on the cervical spine. Such surgeries carry inherent risks due to their proximity to the spinal cord and critical structures like the trachea and esophagus. Although the described surgery was seemingly routine and without complications, it involves high-stakes elements such as potential nerve damage, infection, or other surgical complications given its nature.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Lens Implantation

PREOPERATIVE DIAGNOSIS:,  Cataract, nuclear sclerotic, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, nuclear sclerotic, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with intraocular lens implantation, right eye.,ANESTHESIA: , Topical tetracaine, intracameral lidocaine, monitored anesthesia care.,IOL: , AMO Model SI40 NB, power *** diopters.,INDICATIONS FOR SURGERY: , This patient has been experiencing difficulty with eyesight regarding activities in their daily life.  There has been a progressive and gradual decline in the visual acuity.  By examination, this was found to be related to cataracts.  The risks, benefits, and alternatives (including observation or spectacles) were discussed in detail.  The patient accepted these risks and elected to proceed with cataract surgery.  All questions were answered and informed consent was obtained.,Questions were answered in personal conference with the patient to ensure that the patient had a good grasp of the operative goals, risks, and alternatives involved as well as the postoperative instructions.  A preoperative surgical history and physical examination was done to ensure that the patient was in optimal general health for cataract surgery.  To minimize and decrease the chance of bacterial infection, the patient was started on a course of antibiotic drops for two days prior to surgery.,DESCRIPTION OF PROCEDURE:  ,The patient was identified and the procedure was verified.  The pupil was dilated per protocol.  The patient was taken to the operating room and placed in a comfortable supine position.  The operative table was placed in Trendelenburg head-up tilt to decrease orbital congestion and posterior vitreous pressure.  The patient was prepped and draped in the usual ophthalmic sterile fashion.  The lids and periorbita were prepped with full-strength Betadine solution with care taken to concentrate on sterilizing the eyelid margins.  The conjunctival cul-de-sac was also prepped in dilute Betadine solution.  The fornices were also prepped.  The drape was done meticulously to ensure complete eyelash inclusion.,An eyelid speculum was placed to separate the eyelids.  A paracentesis site was made.  Intracameral preservative-free lidocaine was injected.  Amvisc Plus was then used to stabilize the anterior chamber.  A 3-mm diamond blade was then used to carefully construct a clear corneal incision in the temporal location.  A 25-gauge pre-bent cystotome was used to begin a capsulorrhexis.  The capsular flap was removed.  A 27-gauge blunt cannula was used for hydrodissection.  The lens was able to be freely rotated within the capsular bag.  Divide-and-conquer technique was used for phacoemulsification.  After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment.  Each of the four nuclear quadrants was phacoemulsified.  Aspiration was used to remove remaining cortex with the I/A handpiece.  Viscoelastic was used to re-inflate the capsular bag.  The intraocular lens was injected into the capsular bag.  The lens was then dialed into position.  The lens was well-centered and stable.  Viscoelastic was aspirated.  BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure along with stromal hydration.  A Weck-Cel sponge was used to check both incision sites for leaks and none were identified.  The incision sites remained well approximated and dry with a well-formed anterior chamber and well-centered intraocular lens.  The eyelid speculum was removed and the patient was cleaned free of Betadine.  Zymar and Pred Forte drops were applied.  A firm eye shield was taped over the operative eye.  The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed.  All questions were answered.  The discharge instructions were also reviewed with the patient by the discharging nurse.  The patient was comfortable and was discharged with followup in 24 hours.
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DESCRIPTION: Cataract, nuclear sclerotic, right eye.  Phacoemulsification with intraocular lens implantation, right eye.

ophthalmology, nuclear sclerotic, diopters, viscoelastic, capsulorrhexis, amvisc plus, lens implantation, intraocular lens, intraocular, topical, cataract, phacoemulsification, lens

The procedure described is a cataract surgery, which is a common and routine ophthalmic procedure. While any surgical procedure carries risks, cataract surgeries are generally low-risk with high success rates. This particular procedure appears to have been conducted without complications, and the patient tolerated it well. Postoperative instructions and follow-up care are standard practices to ensure recovery. Given that cataract surgeries are performed regularly and have a high rate of success, the situational stakes here are relatively low compared to other more complex or life-threatening surgeries.


Medical Specialty: General Medicine
Sample Name: Female Physical Exam - 1

FEMALE 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:  Labia majora normal shape without erythema or lesions.  Labia minora normal shape without erythema or lesions.  Clitoris normal shape and contour.  Vaginal mucosa normal color without lesions.  No significant discharge.  Cervix normal shape and parity without lesions.  Ovaries normal shape and contour.  No pelvic masses.  Uterus normal shape and contour.  No external hemorrhoids.,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: Sample female physical exam

Sample female physical exam

general medicine, physical examination, abdominal, anterior chamber, cardiovascular, chest, ear, ear canal, eye, eyelids, female, female physical examination, labia majora, labia minora, nares, neck symmetrical, vaginal mucosa, crepitus, ecchymosis, edema, erythema, joint effusion, normal range of motion, shape and contour, normal strength, joint effusions, normal color, nontender, lesions, effusions, muscle, joints,

The situation describes a detailed physical examination report of a female patient, which is a common routine in general medicine. The examination results are normal, indicating no medical emergency or significant health issues were observed. The stakes are relatively low as this is a standard procedure and is not dealing with an urgent or critical health condition.


Medical Specialty: Neurosurgery
Sample Name: Cystic Suprasellar Tumor Resection

TITLE OF OPERATION:,  Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,INDICATION FOR SURGERY: , She is a 3-year-old girl who is known to have a head injury and CT in 2005 was normal, presented with headache.  All endocrine labs were normal.  Surgery was recommended.,PREOP DIAGNOSIS: , Cystic suprasellar tumor.,POSTOP DIAGNOSIS:,  Cystic suprasellar tumor.,PROCEDURE DETAIL: , The patient was brought to operating room, underwent smooth induction of general endotracheal anesthesia, head was placed in the horseshoe head rest and positioned supine with head turned slightly towards left and slightly extended.  The patient was then prepped and draped in the usual sterile fashion.  With the assistance of fluoro and mapping the localization, the right nostril was infiltrated.  Dr. X will dictate the procedure of the approach.  Once the dura was visualized, there was a complex procedure secondary to the small nasal naris as well as the bony drilling that would necessitate significant drilling.  Once the operating microscope was in the field, at this point, the drilling was completed.  The dura was opened in cruciate fashion revealing normal pituitary, which was displaced and the cystic tumor.  This was then opened and using microsurgical technique with the curette suctioned and the pituitary calcifications were removed, several Valsalva maneuvers were performed without any evidence of CSF leak and trying to pull the tumor further down.  Once this was completed, there was no evidence of any bleeding.  The endoscope was then used to remove any residual fragments __________ with the arachnoid.  Once this was completely ensured, small piece of Duragel was placed and the closure will be dictated by Dr. X.  She was reversed, extubated, and transported to the ICU in stable condition.  Blood loss, minimal.  All sponge, needle counts were correct.
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DESCRIPTION: Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.

neurosurgery, microsurgical transnasal resection, cystic suprasellar tumor, transnasal resection, endoscopic, transnasal, microsurgical, suprasellar, cystic, tumor,

This is a complex surgical procedure in the field of neurosurgery, involving a 3-year-old patient with a cystic suprasellar tumor. The operation is highly specialized, requiring meticulous techniques to avoid complications such as CSF leaks or damage to surrounding structures. Given the patient's age, the location of the tumor, and the precision necessary for a successful outcome, the situation is high-stakes due to the potential impact on the patient's neurological function and overall health.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Difficulty Breathing - ER Visit

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

The situation described involves a 14-month-old patient with difficulty breathing, a history of reactive airway disease, and previous ER visits for similar issues. The child presented with severe respiratory distress, tachypnea, and hypoxia, necessitating high-dose albuterol and continuous monitoring. The patient did not respond adequately to outpatient treatment and required hospitalization for continued care and stabilization. This is a high-stakes situation due to the age of the child, the severity of respiratory symptoms, the risk of respiratory failure, and the need for intensive medical intervention to prevent further deterioration.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Decompression

PREOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Herniated nucleus pulposus, C5-C6.,2.  Herniated nucleus pulposus, C6-C7.,PROCEDURE PERFORMED,1.  Anterior cervical decompression, C5-C6.,2.  Anterior cervical decompression, C6-C7.,3.  Anterior spine instrumentation.,4.  Anterior cervical spine fusion, C5-C6.,5.  Anterior cervical spine fusion, C6-C7.,6.  Application of machined allograft at C5-C6.,7.  Application of machined allograft at C6-C7.,8.  Allograft, structural at C5-C6.,9.  Allograft, structural at C6-C7.,ANESTHESIA: , General.,PREOPERATIVE NOTE:  ,This patient is a 47-year-old male with chief complaint of severe neck pain and left upper extremity numbness and weakness.  Preoperative MRI scan showed evidence of herniated nucleus pulposus at C5-C6 and C6-C7 on the left.  The patient has failed epidural steroid injections.  Risks and benefits of the above procedure were discussed with the patient including bleeding, infection, muscle loss, nerve damage, paralysis, and death.,OPERATIVE REPORT: , The patient was taken to the OR and placed in the supine position.  After general endotracheal anesthesia was obtained, the patient's neck was sterilely prepped and draped in the usual fashion.  A horizontal incision was made on the left side of the neck at the level of the C6 vertebral body.  It was taken down through the subcutaneous tissues exposing the platysmus muscle.  The platysmus muscle was incised along the skin incision and the deep cervical fascia was bluntly dissected down to the anterior cervical spine.  An #18 gauge needle was placed in the C5-C6 interspace and the intraoperative x-ray confirmed that this was the appropriate level.  Next, the longus colli muscles were resected laterally on both the right and left side, and then a complete anterior cervical discectomy was performed.  The disk was very degenerated and brown in color.  There was an acute disk herniation through posterior longitudinal ligament.  The posterior longitudinal ligament was removed and a bilateral foraminotomy was performed.  Approximately, 5 mm of the nerve root on both the right and left side was visualized.  A ball-ended probe could be passed up the foramen.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates of C5 and C6 were prepared using a high-speed burr and a 6-mm lordotic machined allograft was malleted into place.  There was good bony apposition both proximally and distally.  Next, attention was placed at the C6-C7 level.  Again, the longus colli muscles were resected laterally and a complete anterior cervical discectomy at C6-C7 was performed.  The disk was degenerated and there was acute disk herniation in the posterior longitudinal ligament on the left.  The posterior longitudinal ligament was removed.  A bilateral foraminotomy was performed.  Approximately, 5 mm of the C7 nerve root was visualized on both sides.  A micro nerve hook was able to be passed up the foramen easily.  Bleeding was controlled with bipolar electrocautery and Surgiflo.  The end plates at C6-C7 were then prepared using a high-speed burr and then a 7-mm machined lordotic allograft was malleted into place.  There was good bony apposition, both proximally and distally.  Next, a 44-mm Blackstone low-profile anterior cervical plate was applied to the anterior cervical spine with six 14 mm screws.  Intraoperative x-ray confirmed appropriate positioning of the plate and the graft.  The wound was then copiously irrigated with normal saline and bacitracin.  There was no active bleeding upon closure of the wound.  A small drain was placed deep.  The platysmal muscle was closed with 3-0 Vicryl.  The skin was closed with #4-0 Monocryl.  Mastisol and Steri-Strips were applied.  The patient was monitored throughout the procedure with free-running EMGs and SSEPs and there were no untoward events.  The patient was awoken and taken to the recovery room in satisfactory condition.
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DESCRIPTION: Herniated nucleus pulposus.  Anterior cervical decompression, anterior spine instrumentation, anterior cervical spine fusion, and application of machined allograft.

surgery, herniated nucleus pulposus, anterior cervical decompression, spine fusion, cervical spine, allograft, anterior cervical spine, anterior, cervical,

This case concerns a surgical procedure to address a herniated cervical disc in a patient experiencing severe neck pain and numbness in the upper extremity. The surgery involves anterior cervical decompression, spinal fusion, and instrumentation, all of which are intricate and potentially risky due to the proximity to the spinal cord and critical nerves. The stakes are high due to the potential complications, which include bleeding, infection, paralysis, and even death, making it a high-stakes scenario in medical practice.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 14

HISTORY OF PRESENT ILLNESS:,  A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache.  Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved.  She is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay.  She continues to have some left-sided jaw pain.  Denies any headache, fever, cough, or sore throat.  She had used Cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that.  She has also had problems with sinusitis in the past and chronic left-sided headache.,FAMILY HISTORY:,  Reviewed and unchanged.,ALLERGIES: , To cephalexin.,CURRENT MEDICATIONS:,  Ibuprofen.,SOCIAL HISTORY:,  She is a nonsmoker.,REVIEW OF SYSTEMS:,  As above.  No nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, and in no acute distress.,Vital Signs:  Weight:  121 pounds.  Temperature:  97.9 degrees.,Skin:  Reveals scattered erythematous plaques with some mild lichenification on the nuchal region and behind the knees.,Eyes:  PERRLA.  Conjunctivae are clear.,Ears:  Left TM with some effusion.  Right TM is clear.  Canals are clear.  External auricles are nontender to manipulation.,Nose:  Nasal mucosa is pink and moist without discharge.,Throat:  Nonerythematous.  No tonsillar hypertrophy or exudate.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.  Respirations are regular and unlabored.,Heart:  Regular rate and rhythm at rate of 100 beats per minute.,ASSESSMENT:,1.  Serous otitis.,2.  Atopic dermatitis.,PLAN:,1.  Nasacort AQ two sprays each nostril daily.,2.  Duraphen II one b.i.d.,3.  Refills Cutivate cream 0.05% to apply to affected areas b.i.d.  Recheck p.r.n.
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DESCRIPTION: Complaint of left otalgia (serous otitis) and headache.  History of atopic dermatitis.

The situation presented here is a non-emergency medical consultation for relatively common and non-life-threatening conditions: serous otitis and atopic dermatitis. The patient is conscious, alert, in no acute distress, and her symptoms, while uncomfortable, are not indicative of an urgent or life-threatening issue. The plan includes routine treatments and follow-ups, and there are no signs of severe complications or risks involved. Consequently, this scenario would be considered low-stakes in a medical context.


Medical Specialty: Office Notes
Sample Name: Normal ROS Template - 1

REVIEW OF SYSTEMS,There was no weight loss, fevers, chills, sweats.  There is no blurring of the vision, itching, throat or neck pain, or neck fullness.  There is no vertigo or hoarseness or painful swallowing.  There is no chest pain, shortness of breath, paroxysmal nocturnal dyspnea, or chest pain with exertion.  There is no shortness of breath and no cough or hemoptysis.  No melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation or blood in the stools.  No dysuria, hematuria or excessive urination.  No muscle weakness or tenderness.  No new numbness or tingling.  No arthralgias or arthritis.  There are no rashes.  No excessive fatigability, loss of motor skills or sensation.  No changes in hair texture, change in skin color, excessive or decreased appetite.  No swollen lymph nodes or night sweats.  No headaches.  The rest of the review of systems is negative.
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DESCRIPTION: There was no weight loss, fevers, chills, sweats.  There is no blurring of the vision, itching, throat or neck pain, or neck fullness.  There is no vertigo or hoarseness or painful swallowing.

office notes, weight loss, fevers, chills, sweats, melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation, itching throat, neck fullness, painful swallowing, breath, loss, neckNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The information provided is part of a routine medical documentation for a 'Review of Systems', which is a systematic way to screen for any symptoms that the patient might have experienced. This specific documentation indicates that the patient is not experiencing any of the listed symptoms. As it is a routine process without any urgent symptoms detected, it is not high-stakes.


Medical Specialty: Surgery
Sample Name: Subxiphoid Pericardial Window

PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxiphoid pericardial window.,2. Transesophageal echocardiogram.,ANESTHESIA:, General endotracheal.,FINDINGS:, The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition.
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DESCRIPTION: Emergent subxiphoid pericardial window, transesophageal echocardiogram.

surgery, endocarditis, valve replacement, st. jude, echocardiogram, transesophageal, pericardium, blake drain, st jude mechanical valve, subxiphoid pericardial window, pericardial window, aortic valve, tamponade, subxiphoid, valve, pericardial, aortic

The situation involves an emergent surgical procedure due to pericardial tamponade, a condition that can rapidly become life-threatening if not treated promptly. The surgical intervention, which also required general anesthesia and was conducted in an emergency setting, underscores the high-stakes nature of the scenario. The fact that this was to address complications potentially stemming from a complex condition such as endocarditis and prior heart valve replacement increases the stakes further, given the critical nature of cardiac health interventions.


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

Medical Specialty: Surgery
Sample Name: Cardiac Catheterization - 5

PROCEDURE PERFORMED:,1. Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.,2. Right femoral selective angiogram.,3. Closure device the seal the femoral arteriotomy using an Angio-Seal.,INDICATIONS FOR PROCEDURE: ,The patient with known coronary atherosclerotic heart disease and multiple risk factors of coronary disease, who had her last coronary arteriogram performed in 2004. She has had complaints of progressive chest discomfort, and has ongoing risks including current smoking, diabetes, hypertension, hyperlipidemia to name a few. The decision was made to proceed on with percutaneous evaluation and possible intervention given her known disease and the possibility of disease progression.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, The patient was taken to cardiac catheterization lab where her procedure was performed. She was prepped and prepared on the table; after which, her right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery over a standard 0.035 guide wire. Coronary angiography and left ventricular measurement and angiography were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery. A 6-French JR4 diagnostic catheter to image the right groin and her artery and the saphenous vein graft conduit. Subsequently, a 6-French angled pigtail catheter was used to measure left ventricular pressures and to perform a power injection, a left ventriculogram at 8 mL per second for a total of 30 mL. At the conclusion of the diagnostic evaluation, the patient had selective arteriography of her right femoral artery, which showed the right femoral artery to be free of significant atherosclerotic plaque. Did have a normal bifurcation into the superficial femoral and profunda femoris arteries and to have an arteriotomy that was in the common femoral artery away from the bifurcation. As such, an initial attempt to advance a Perclose device failed to allow the device descend to _____ tract and into the appropriate position within the artery. As such, the Perclose was never deployed and was removed intact over the wire from the system. We then replaced this with a 6-French Angio-Seal which was used to seal the femoral arteriotomy with achievement of hemostasis. The patient was subsequently dispositioned back to the MAC Unit where she will complete her bedrest prior to her disposition to home.,HEMODYNAMIC DATA:, Opening aortic pressure 125/60, left ventricular pressure 108/4 with an end-diastolic pressure of 16. There was no significant gradient across the aortic valve on pullback from the left ventricle. Left ventricular ejection fraction was 55%. Mitral regurgitation was less than or equal to 1+. There was normal wall motion in the RAO projection.,CORONARY ANGIOGRAM:, The left main coronary artery had mild atherosclerotic plaque. The proximal LAD was 100% occluded. The left circumflex had mild diffuse atherosclerotic plaque. The obtuse marginal branch which operates as an OM-2 had a mid approximately 80% stenosis at a kink in the artery. This appears to be the area of a prior anastomosis, the saphenous vein graft to the OM. This is a very small-caliber vessel and is 1.5-mm in diameter at best. The right coronary artery is dominant. The native right coronary artery had mild proximal and mid atherosclerotic plaque. The distal right coronary artery has an approximate 40% stenosis. The posterior left ventricular branch has a proximal 50 to 60% stenosis. The proximal PDA has a 40 to 50% stenosis. The saphenous vein graft to the right PDA is widely patent. There was competitive flow noted between the native right coronary artery and the saphenous vein graft to the PDA. The runoff from the PDA is nice with the native proximal PDA and PLV disease as noted above. There is also some retrograde filling of the right coronary artery from the runoff of this graft. The saphenous vein graft to the left anterior descending is widely patent. The LAD beyond the distal anastomosis is a relatively small-caliber vessel. There is some retrograde filling that allows some filling into a more proximal diagonal branch. The saphenous vein graft to the obtuse marginal was known to be occluded from the prior study in 2004. Overall, this study does not look markedly different than the procedure performed in 2004.,CONCLUSION:, 100% proximal LAD mild left circumflex disease with an OM that is a small-caliber vessel with an 80% lesion at a kink that is no amenable to percutaneous intervention. The native right coronary artery has mild to moderate distal disease with moderate PLV and PDA disease. The saphenous vein graft to the OM is known to be 100% occluded. The saphenous vein graft to the PDA and the saphenous vein graft to the LAD are open. Normal left ventricular systolic function.,PLAN:, The plan will be for continued medical therapy and risk factor modification. Aggressive antihyperlipidemic and antihypertensive control. The patient's goal LDL will be at or below 70 with triglyceride level at or below 150, and it is very imperative that the patient stop smoking.,After her bedrest is complete, she will be dispositioned to home, after which, she will be following up with me in the office within 1 month. We will also plan to perform a carotid duplex Doppler ultrasound to evaluate her carotid bruits.
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DESCRIPTION: Left heart catheterization with coronary angiography, vein graft angiography and left ventricular pressure measurement and angiography.

surgery, catheterization, vein graft, angiography, angiogram, angio-seal, closure device, coronary atherosclerotic heart disease, saphenous vein graft, ventricular pressure, coronary artery, saphenous vein, atherosclerotic, coronary, artery, bifurcation, pda, ventricular, saphenous

Cardiac catheterization is a procedure performed on patients with coronary artery disease to evaluate the condition of their coronary arteries, heart chambers, and blood flow. In this particular case, the patient has a history of coronary artery disease, with significant existing conditions such as 100% occlusion of the proximal LAD and an 80% stenosis in a small-caliber obtuse marginal branch, amongst other cardiovascular issues. Although the immediate procedure here is diagnostic, not interventional, it is high-stakes due to the patient's underlying severe coronary conditions, which could result in significant complications if not properly managed. The stakes are also elevated by the patient's risk factors, including smoking and diabetes, and the necessity for precise medical decision-making. A slight complication or oversight could have serious consequences given the patient's cardiovascular state.


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

PREOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,POSTOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.  In addition to this, he had a large herniated disk at C3-C4 in the midline.,PROCEDURE: , Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.,PROCEDURE IN DETAIL: , The patient placed in the supine position, the neck was prepped and draped in the usual fashion.  Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4.  Skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially.  The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4-C5.  It appeared that the C5-C6 disk area had fused spontaneously.  We then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at C3-C4, C4-C5.,After placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at C3-C4, C4-C5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,Next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation.  We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments.  This was then removed with 2-mm Kerrison rongeur.  After we removed the posterior longitudinal ligament, we could see the dura pulsating nicely.  We did foraminotomies at C3-C4 as well as C4-C5 as well.  After having totally decompressed both the cord as well as the nerve roots of C3-C4, C4-C5, we proceeded to the next step, which was a fusion.,We sized two 8-mm cortical cancellous grafts and after distracting the bone at C3-C4, C4-C5, we gently tapped the grafts into place.  The distraction was removed and the grafts were now within.  We went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,We then placed a titanium ABC plate from C3-C5, secured it with 16-mm titanium screws.  X-rays showed good position of the screws end plate.,The next step was to place Jackson-Pratt drain to the vertebral fascia.  Meticulous hemostasis was obtained.  The wound was closed in layers using 2-0 Vicryl for the subcutaneous tissue.  Steri-Strips were used for skin closure.  Blood loss less than about 200 mL.  No complications of the surgery.  Needle counts, sponge count, and cottonoid count was correct.
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DESCRIPTION: Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.

neurosurgery, titanium plates fixation, bone black bone procedure, anterior cervical discectomy, titanium plates, cervical discectomy, spondylotic myelopathy, cord compression, cervical spondylosis, foraminotomies, cervical, anterior

The situation involves a detailed and complex neurosurgical procedure, Anterior Cervical Discectomy and Fusion (ACDF), addressing cervical spondylotic myelopathy and disc herniation. This is a high-stakes medical process as it involves decompression of the spinal cord and stabilization of the cervical spine, which if not performed correctly, can lead to significant neurological deficits or even be life-threatening. The precision required to avoid complications such as damage to nerve roots, excessive blood loss, or infection further elevates the stakes. Nevertheless, the description indicates that the procedure went smoothly with no complications.


Medical Specialty: Neurology
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.

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

The MRI report describes findings consistent with chronic small vessel ischemic disease and diffuse cortical volume loss, which are not immediately life-threatening conditions, especially as they are described as mild and consistent with the patient's age. There is no evidence of acute infarction, metastases, or other major neurological concerns that would indicate an immediate or life-threatening situation. While chronic conditions like ischemic changes can have serious long-term implications, the findings in this report suggest a more routine or low-immediacy scenario.


Medical Specialty: Neurology
Sample Name: EEG

DIAGNOSIS:,  Possible cerebrovascular accident.,DESCRIPTION: , The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages.  The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically.  A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session.  Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions.  Hyperventilation was not performed.  No epileptiform activity or any definite lateralizing findings were seen.,IMPRESSION: , Mildly abnormal study.  The findings are suggestive of a generalized cerebral disorder.  Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated.  Clinical correlation is recommended.
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DESCRIPTION: Possible cerebrovascular accident.  The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages.

neurology, scalp-to-scalp, scalp-to-vertex, montages, electrodes, amplitude, epileptiform activity, cerebrovascular accident, eegNOTE

The diagnosis of a possible cerebrovascular accident (CVA), or stroke, is inherently high-stakes because it involves potential brain damage and immediate health risks to the patient. The EEG findings in this case suggest a generalized cerebral disorder, and even though the study is mildly abnormal, the interpretation must be considered along with clinical symptoms. The presence of movement artifacts complicates the interpretation, possibly obscuring lateralizing signs that could help identify the affected brain area. Immediate and appropriate medical attention is crucial to confirm the diagnosis and manage patient care effectively, hence making this a high-stakes situation.


Medical Specialty: Discharge Summary
Sample Name: Cardio/Pulmo Discharge Summary

ADMISSION DIAGNOSIS:,1. Respiratory arrest.,2 . End-stage chronic obstructive pulmonary disease.,3. Coronary artery disease.,4. History of hypertension.,DISCHARGE DIAGNOSIS:,1. Status post-respiratory arrest.,2. Chronic obstructive pulmonary disease.,3. Congestive heart failure.,4. History of coronary artery disease.,5. History of hypertension.,SUMMARY:,  The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea.,ADMISSION PHYSICAL EXAMINATION:,GENERAL: Showed a well-developed, slightly obese man who was in extremis.,NECK: Supple, with no jugular venous distension.,HEART: Showed tachycardia without murmurs or gallops.,PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes.,EXTREMITIES: Free of edema.,HOSPITAL COURSE:,  The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a,significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an outpatient basis.,DIAGNOSTIC DATA:,  The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of 7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands.,DISPOSITION:,  The patient was discharged home.,DISCHARGE INSTRUCTIONS:,  His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250 mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch h.s., K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge.
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DESCRIPTION: A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.

discharge summary, ada diet, congestive heart failure, coronary artery disease, respiratory arrest, chest pain, chronic obstructive pulmonary disease, emergency room, hypertension, sputum, wheezing, respiratory distress, myocardial infarctions, respiratory failure, pulmonary disease, basilar rales, heart failure, infarctions, heart, wheezes, coronary, pulmonary, discharge, respiratory,

The patient in the discharge summary has multiple serious chronic health conditions, including end-stage COPD, coronary artery disease, recurrent myocardial infarctions, and congestive heart failure. The recent episode of respiratory arrest and requirement for intubation indicate the patient's life was in immediate danger during the hospital stay. While the patient was stabilized enough to be discharged, the combination of ongoing complex medical needs and the need for close follow-up make this situation relatively high-stakes. Managing these complex conditions inadequately could again lead to life-threatening situations.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych Consult - Pain Meds

REASON FOR CONSULTATION: , Management of pain medications.,HISTORY OF PRESENT ILLNESS: , This is a 60-year-old white male with history of coronary artery disease, status post CABG in 1985 with subsequent sternal dehiscence with rewiring in December 2005 and stent placement in LAD region in 2005, who developed sudden chest pain and was taken to San Jacinto via ambulance where he was diagnosed with acute MI and then went into atrial fibrillation.  An intraaortic balloon pump was placed for cardiogenic shock, and then he was transferred to the ABCD Hospital on October 22, 2006, for continued critical care.  He was in a state of cardiogenic shock and multiorgan system failure including respiratory failure and acute renal insufficiency when he was transferred.  He is currently on dialysis due to end-stage renal disease and has a tracheostomy.  He is receiving fentanyl since he has been here for back pain, leg pain, abdominal pain, and pain in the feet.  He states that he is currently in pain and the fentanyl only helps for about an hour or so before the pain resumes.  He currently rates his pain as 7 out of 10.  He denies a depressed mood or anxiety and states that he knows he is getting better.  He describes his sleep as erratic and states that he will sleep for 1 hour after giving fentanyl IV and then will wake up until he gets another fentanyl.  He has PEG for tube feeding.  He has weakness on left side of his body as well as both legs since his MI.  He has been switched from fentanyl IV q.2h. to the fentanyl patch today.  He also has been started on Seroquel 12.5 mg p.o. at bedtime and will receive his first dose on the evening of Monday, February 12, 2007.  He denies any other psychiatric symptoms including auditory or visual hallucinations or delusions.  His wife was present in the room and both him and his wife seemed to be offended by the suggestion of any psychiatric history or any psychiatric problems.,PAST MEDICAL HISTORY:,1.  DVT in December 2005.,2.  Three MI's (1996, 2005, and 2006).,3.  Diabetes for 5 years.,4.  Coronary artery disease for 10 years.,PAST SURGERIES:,1.  Appendectomy as a child.,2.  CABG x3, November 2005.,3.  Sternal rewiring, December 2005.,MEDICATIONS:,1.  Restoril 7.5 mg p.o. at bedtime p.r.n.,2.  Acetaminophen 650 mg p.o. q.6h. p.r.n. fever.,3.  Aspirin 81 mg p.o. daily.,4.  Bisacodyl suppository 10 mg per rectum daily.,5.  Erythropoietin injection 100 mcg subcutaneously every week at 5 p.m.,6.  Esomeprazole 40 mg IV q.12h.,7.  Fentanyl patch 25 mcg per hour.,8.  Transderm patch every 72 hours.,9.  Heparin IV.,10.  Lactulose 30 mL p.o. daily p.r.n. constipation.,11.  Metastron injection 4 mg IV q.6h. p.r.n. nausea.,12.  Seroquel 12 mg p.o. at bedtime.,13.  Saliva substitute 30 mL spray p.o. q.3h. p.r.n. dry mouth.,14.  Simethicone drops 80 mg per G-tube p.r.n. gas pain.,15.  Bactrim suspension p.o. daily.,16.  Insulin medium dose sliding scale.,17.  Albumin 25% IV p.r.n. hemodialysis.,18.  Ipratropium solution for nebulizer.,ALLERGIES:,  No known drug allergies.,PAST PSYCHIATRIC HISTORY:,  The patient denies any past psychiatric problems.  No medications.  He denies any outpatient visits or inpatient hospitalizations for psychiatric reasons.,SOCIAL HISTORY:,  He lives with his wife in New Jersey.  He has 2 children.  One son in Texas City and 1 daughter in Florida.  He is a master mechanic for a trucking company since 1968.  He retired in the May 2006.  The highest level of education that he received was 1 year in college.,Ethanol, tobacco, or drugs; he smoked 2 packs per day for 40 years, but quit in 1996.  He occasionally has a beer, but denies any continuous use of alcohol.  He denies any illicit drug use.,FAMILY HISTORY:,  Both parents died with myocardial infarctions.  He has 2 sisters and a brother with diabetes mellitus and coronary artery disease.  He denies any history of psychiatric problems in family.,MENTAL STATUS EXAMINATION:,  The patient was sitting in his bed in hospital gown with tracheostomy and receiving tube feeding.  The patient's appearance was appropriate with fair-to-good grooming and hygiene.  He had little-to-no psychomotor activity secondary to weakness post MI.  He had good eye contact.  His speech was of decreased rate volume and flexion secondary to tracheostomy.  The patient was cooperative.  He described his mood is not good in congruent stable and appropriate affect with decreased range.  His thought process is logical and goal directed.  His thought content was negative for delusions, phobias, obsessions, suicidal ideation, or homicidal ideation.  He denied any perceptional disturbances including any auditory or visual hallucinations.  He was alert and oriented x3.,Mini mental status exams not completed.,ASSESSMENT:,AXIS I:  Pain with physical symptoms and possibly psychological symptoms.,AXIS II:  Deferred.,AXIS III:  See above.
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DESCRIPTION: Psychiatric consultation for management of pain medications.

This case involves complex medical issues including multiple organ failures, a history of major heart problems, chronic pain management, and psychological assessment. The transition from IV to patch medication for pain and the introduction of an antipsychotic potentially indicate an attempt to better manage pain and its psychological impact or side effects without exacerbating the patient's delicate condition. Considering the patient's volatile state and multifaceted needs, decisions made here significantly affect his day-to-day living and overall recovery trajectory, making this a high-stakes scenario.


Medical Specialty: Gastroenterology
Sample Name: Proctitis & Proctocolitis

PRESENTATION: , A 16-year-old male presents to the emergency department (ED) with rectal bleeding and pain on defecation.,HISTORY:,  A 16-year-old African American male presents to the ED with a chief complaint of rectal bleeding and pain on defecation.  The patient states that he was well until about three days prior to presentation when he first started to experience some pain when defecating.  The following day he noted increasing pain and first noted blood on the surface of his stool.  The pain worsened on the subsequent day with increasing bleeding as well as some mucopurulent anal discharge.  The patient denies any previous history of rectal bleeding or pain.  He also denies any previous sexually transmitted diseases (STDs) and states that he was screened for HIV infection eight months ago and was negative.  The patient does state that he has not felt well for the past week.  He states that he had felt "feverish" on several occasions but has not taken his temperature.  He has also complained of some abdominal discomfort with nausea and diarrhea as well as generalized myalgias and fatigue.  He thinks he has lost a few pounds but has not been weighing himself to determine the exact amount of weight loss.,The patient states that he has been sexually active since age 13.  He admits to eight previous partners and states that he "usually" uses a condom.  On further questioning, the patient states that of his eight partners, three were female and five were male.  His most recent sexual partner was a 38-year-old man whom he has been with for the past six months.  He states that he has been tested for STDs in the past but states that he only gave urine and blood for the testing.  He is unaware of the HIV status of his partner but assumes that the partner is uninfected because he looks healthy.  The patient also admits to one episode of sexual abuse at the age of 8 by a friend of the family.  As the man was a member of the family's church, the patient never felt comfortable disclosing this to any of the adults in his life.  He is very concerned about disclosure of his sexual behavior to his family, as they have expressed very negative comments concerning men who have sex with men.  He is accessing care in the ED unaccompanied by an adult.,PHYSICAL EXAM: , Thin but non-toxic young man with clear discomfort.,Pulse = 105,RR = 23,BP = 120/62,HEENT:  Several areas of white plaque-like material on the buccal mucosa.,Neck:  Multiple anterior/posterior cervical nodes in both anterior and posterior chains- 1-2 cm in diameter.,Lungs:  Clear to auscultation.,Cardiac:  Quiet precordium.,Nl S1/S2 with a II/VI systolic murmur. ,Abdomen:  Soft without hepatosplenomegaly.,GU:  Tanner V male with no external penile lesions.,Lymph:  2-3 cm axillary nodes bilaterally.,1-2 cm epitrochlear nodes.,Multiple 1-2 cm inguinal nodes.,Rectal:  Extremely painful digital exam.,+ gross blood and mucous.,LABORATORY EVALUATION:,Hbg = 12.  5 gm/dL,Hct = 32%,WBC = 3.9 thou/µL,Platelets = 120,000 thou/µL,76% neutrophils,19% lymphocytes,1% eosinophils,4% monocytes,ALT = 82 U/L,AST= 90 U/L,Erythrocyte sedimentation rate = 90,Electrolytes = normal,Gram stain of anal swab:  numerous WBCs,DIFFERENTIAL DIAGNOSIS: , This patient is presenting with acute rectal pain with bleeding and anal discharge.  The patient also presents with some constitutional symptoms including fever, fatigue, abdominal discomfort, and adenopathy on physical examination.  The following are in the differential diagnosis:  Acute Proctitis and  Proctocolitis.,ACUTE HIV SEROCONVERSION: , This subject is sexually active and reports inconsistent condom use.  Gastrointestinal symptoms have recently been reported commonly in patients with a history of HIV seroconversion.  The rectal symptoms of bleeding and pain are not common with HIV, and an alternative diagnosis would be required.,PERIRECTAL ABSCESS: , A patient with a history of receptive anal intercourse is at risk for developing a perirectal abscess either from trauma or a concurrent STD.  The patient could experience more systemic symptoms with fever and malaise, as found with this patient.  However, the physical examination did not reveal the typical localized area of pain and edema.,DIAGNOSIS:  ,The subject had rectal cultures obtained, which were positive for Neisseria gonorrhoeae.  An HIV ELISA was positive, as was the RNA PCR.,DISCUSSION: , This patient demonstrates a number of key issues to consider when caring for an adolescent or young adult.  First, the patient utilized the emergency department for care as opposed to identifying a primary care provider.  Although not ideal in many circumstances, testing for HIV infection is crucial when there is suspicion, since many newly diagnosed patients identify earlier contacts with health care providers when HIV counseling and testing were not performed.  Second, this young man has had both male and female sexual partners.  As young people explore their sexuality, asking about partners in an open, nonjudgmental manner without applying labels is integral to helping the young person discuss their sexual behaviors.  Assuming heterosexuality is a major barrier to disclosure for many young people who have same-sex attractions.  Third, screening for STDs must take into account sexual behaviors.  Although urine-based screening has expanded testing of young people, it misses anal and pharyngeal infections.  If a young person is only having receptive oral or anal intercourse, urine screening is insufficient to rule out STDs.  Fourth, this young man had both localized and systemic symptoms.  As his anal symptoms were most suggestive of a current STD, performing an HIV test should be part of the standard evaluation.  In addition, as acute infection is on the differential diagnosis, PCR testing should also be considered.  The care provided to this young man included the following.  He was treated presumptively for proctitis with both IM ceftriaxone as well as oral doxycycline to treat N gonorrhoeae and C trachomatis.  Ceftriaxone was chosen due to the recent reports of resistant N gonorrhoeae.  At the time of the diagnosis, the young man was given the opportunity to meet with the case manager from the adolescent-specific HIV program.  The case manager linked this young man directly to care after providing brief counseling and support.  The case manager maintained contact with the young man until his first clinical visit four days later.  Over the subsequent three months, the young man had two sets of laboratory testing to stage his HIV infection.,Set #1 CD4 T-lymphocyte count = 225 cells/mm3, 15% ,Quantitative RNA PCR = 75,000 copies/mL
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DESCRIPTION: Patient presents to the emergency department (ED) with rectal bleeding and pain on defecation.

The situation involves a minor presenting to the emergency department alone with rectal bleeding, pain, and positive tests for Neisseria gonorrhoeae and HIV. It concerns both an acute medical condition (proctitis leading to potential complications) and a chronic life-altering diagnosis (HIV), requiring immediate medical intervention and a plan for ongoing care. Additionally, there are significant social implications due to the patient's age, lack of adult accompaniment, and fear of disclosure, which adds complexity. The medical, psychological, and social aspects make it high-stakes.


Medical Specialty: Dermatology
Sample Name: Acne Vulgaris - H&P

CHIEF COMPLAINT (1/1): , This 19 year old female presents today complaining of acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use.  Location:  She indicates the problem location is the chin, right temple and left temple locally.  Severity:  Severity of condition is worsening.,Menses:  Onset:  13 years old.  Interval:  22-27 days.  Duration:  4-6 days.  Flow:  light.  Complications:  none.,ALLERGIES: , Patient admits allergies to penicillin resulting in difficulty breathing.,MEDICATION HISTORY:,  Patient is currently taking Alesse-28, 20 mcg-0.10 mg tablet usage started on 08/07/2001 medication was prescribed by Obstetrician-Gynecologist A.,PAST MEDICAL HISTORY:,  Female Reproductive Hx: (+) birth control pill use, Childhood Illnesses: (+) chickenpox, (+) measles.,PAST SURGICAL HISTORY:,  No previous surgeries.,FAMILY HISTORY: , Patient admits a family history of anxiety, stress disorder associated with mother.,SOCIAL HISTORY:,  Patient admits caffeine use She consumes 3-5 servings per day, Patient admits alcohol use Drinking is described as social, Patient admits good diet habits, Patient admits exercising regularly, Patient denies STD history.,REVIEW OF SYSTEMS:,  Integumentary: (+) periodic reddening of face, (+) acne problems, Allergic /,Immunologic: (-) allergic or immunologic symptoms, Constitutional Symptoms: (-) constitutional symptoms,such as fever, headache, nausea, dizziness.,PHYSICAL EXAM:,  Patient is a 19 year old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.  Skin:  Examination of scalp shows no abnormalities.  Hair growth and distribution is normal.  Inspection of skin outside of affected area reveals no abnormalities.  Palpation of skin shows no abnormalities.  Inspection of eccrine and apocrine glands shows no evidence of hyperidrosis, chromidrosis or bromhidrosis.  Face shows keratotic papule.,IMPRESSION:,  Acne vulgaris.,PLAN:,  Recommended treatment is antibiotic therapy.  Patient received extensive counseling about acne.  She understands acne treatment is usually long-term.  Return to clinic in 4 week (s).,PATIENT INSTRUCTIONS:,  Patient received literature regarding acne vulgaris.  Discussed with the patient the prescription for Tetracycline and handed out information regarding the side effects and the proper method of ingestion.,PRESCRIPTIONS:,  Tetracycline  Dosage:  250 mg capsule  Sig:  BID  Dispense:  60  Refills:  0  Allow Generic:  Yes
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DESCRIPTION: Acne from continually washing area, frequent phone use so the receiver rubs on face and oral contraceptive use - Acne Vulgaris

The clinical scenario involves a common dermatological condition, acne vulgaris, in a 19-year-old female. While acne can affect quality of life, given its impact on self-esteem and mental health, the situation is medically routine and non-life-threatening. Treatment involves standard antibiotic therapy, and there are no immediate severe health risks. The patient's allergy to penicillin is noted, but tetracycline has been prescribed, which is unrelated to the allergy. Overall, this situation is not high-stakes from a medical perspective.


Medical Specialty: Emergency Room Reports
Sample Name: Sickle Cell Anemia - ER Visit

HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia.  He comes to the emergency room on his own with 3-day history of back pain.  He is on no medicines.  He does live with a room mate.  Appetite is decreased.  No diarrhea, vomiting.  Voiding well.  Bowels have been regular.  Denies any abdominal pain.  Complains of a slight headaches, but his main concern is back ache that extends from above the lower T-spine to the lumbosacral spine.  The patient is not sure of his immunizations.  The patient does have sickle cell and hemoglobin is followed in the Hematology Clinic.,ALLERGIES: , THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.,MEDICATIONS: , He was previously on folic acid.  None at the present time.,PAST SURGICAL HISTORY: , He has had no surgeries in the past.,FAMILY HISTORY: , Positive for diabetes, hypertension and cancer.,SOCIAL HISTORY: , He denies any smoking or drug usage.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute,  respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.,GENERAL:  He is alert, speaks in full sentences, he does not appear to be in distress.,HEENT:  Normal.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular.,ABDOMEN:  Soft.  He has pain over the mid to lower spine.,SKIN:  Color is normal.,EXTREMITIES:  He moves all extremities well.,NEUROLOGIC:  Age appropriate.,ER COURSE: , It was indicated to the patient that I will be drawing labs and giving him IV fluids.  Also that he will get morphine and Benadryl combination.  The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour.  CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4.  Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect.  The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m.  He received morphine 5 mg and Benadryl 25 mg.  I subsequently spoke to Dr. X and it was decided to admit the patient.,The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning.  He stated that he has a job interview in the morning.  The resident service did come to evaluate him.  The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration.  He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.,IMPRESSION:  ,Sickle cell crisis.,DIFFERENTIAL DIAGNOSIS: , Veno-occlusive crisis, and diskitis.
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DESCRIPTION: A 19-year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.

The situation involves a 19-year-old male with sickle cell anemia experiencing what could be a sickle cell crisis, characterized by severe back pain lasting for three days. Sickle cell crises can cause significant complications, including severe pain and organ damage, and require medical intervention. Although the patient wants to leave for a job interview, medical professionals have decided to admit him for pain management and IV hydration. This indicates the situation is urgent and potentially serious, given the nature of sickle cell anemia complications and the immediate medical response. Therefore, it is a high-stakes medical situation.