Medical Specialty: Neurology
Sample Name: CT Scan of Brain with Contrast

CC:, Confusion.,HX: , A 71 y/o RHM ,with a history of two strokes ( one in 11/90 and one in 11/91), had been in a stable state of health until 12/31/92 when he became confused, and displayed left-sided weakness and difficulty speaking. The symptoms resolved within hours and recurred the following day. He was then evaluated locally and HCT revealed an old right parietal stroke. Carotid duplex scan revealed a "high grade stenosis" of the RICA. Cerebral Angiogram revealed 90%RICA and 50%LICA stenosis. He was then transferred to UIHC Vascular Surgery for carotid endarterectomy. His confusion persisted and he was evaluated by Neurology on 1/8/93 and transferred to Neurology on 1/11/93.,PMH:, 1)cholecystectomy. 2)inguinal herniorrhaphies, bilaterally. 3)ETOH abuse: 3-10 beers/day. 4)Right parietal stroke 10/87 with residual left hemiparesis (Leg worse than arm). 5) 2nd stoke in distant past of unspecified type.,MEDS:, None on admission.,FHX:, Alzheimer's disease and stroke on paternal side of family.,SHX:, 50+pack-yr cigarette use.,ROS:, no weight loss. poor appetite/selective eater.,EXAM:, BP137/70 HR81 RR13 O2Sat 95% Afebrile.,MS: Oriented to city and month, but did not know date or hospital. Naming and verbal comprehension were intact. He could tell which direction Iowa City and Des Moines were from Clinton and remembered 2-3 objects in two minutes, but both with assistance only. Incorrectly spelled "world" backward, as "dlow.",CN: unremarkable except neglects left visual field to double simultaneous stimulation.,Motor: Deltoids 4+/4-, biceps 5-/4, triceps 5/4+, grip 4+/4+, HF4+/4-, HE 4+/4+, Hamstrings 5-/5-, AE 5-/5-, AF 5-/5-.,Sensory: intact PP/LT/Vib.,Coord: dysdiadochokinesis on RAM, bilaterally.,Station: dyssynergic RUE on FNF movement.,Gait: ND,Reflexes: 2+/2+ throughout BUE and at patellae. Absent at ankles. Right plantar was flexor; and Left plantar was equivocal.,COURSE:, CBC revealed normal Hgb, Hct, Plt and WBC, but Mean corpuscular volume was large at 103FL (normal 82-98). Urinalysis revealed 20+WBC. GS, TSH, FT4, VDRL, ANA and RF were unremarkable. He was treated for a UTI with amoxacillin. Vitamin B12 level was reduced at 139pg/ml (normal 232-1137). Schillings test was inconclusive dure to inability to complete a 24-hour urine collection. He was placed on empiric Vitamin B12 1000mcg IM qd x 7 days; then qMonth. He was also placed on Thiamine 100mg qd, Folate 1mg qd, and ASA 325mg qd. His ESR and CRP were elevated on admission, but fell as his UTI was treated.,EEG showed diffuse slowing and focal slowing in the theta-delta range in the right temporal area. HCT with contrast on 1/19/93 revealed a gyriform enhancing lesion in the left parietal lobe consistent with a new infarct; and an old right parietal hypodensity (infarct). His confusion was ascribed to the UTI in the face of old and new strokes and Vitamin B12 deficiency. He was lost to follow-up and did not undergo carotid endarterectomy.
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DESCRIPTION: Brain CT with contrast - Abnormal Gyriform enhancing lesion (stroke) in the left parietal region, not seen on non-contrast HCTs.

neurology, ct scan, abnormal gyriform enhancing lesion, brain ct, ct with contrast, carotid duplex scan, confusion, hct, difficulty speaking, left-sided weakness, non-contrast hct, parietal region, stroke, theta-delta, with contrast, gyriform enhancing lesion, gyriform enhancing, enhancing lesion, parietal stroke, carotid endarterectomy, ct, scan, gyriform, endarterectomy, contrast, hcts, brain, parietal,

The situation involves a 71-year-old patient with a complex medical history, including prior strokes, high-grade carotid artery stenosis, vitamin B12 deficiency, UTI, and possible cognitive impairment. The stakes are high due to the immediate risk of further strokes or complications from the carotid stenosis, which can be life-threatening. Additionally, the patient's confusion and recent symptomatic episodes suggest an ongoing or worsening neurological condition that requires careful management. The potential for mismanagement or failure to follow up, as evidenced by the patient being lost to follow-up and not receiving a planned carotid endarterectomy, further elevates the stakes.


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

Medical Specialty: Surgery
Sample Name: EGD Template - 3

without difficulty, into the upper GI tract.  The anatomy and mucosa of the esophagus, gastroesophageal junction, stomach, pylorus, and small bowel were all carefully inspected.  All structures were visually normal in appearance.  Biopsies of the distal duodenum, gastric antrum, and distal esophagus were taken and sent for pathological evaluation.  The endoscope and insufflated air were slowly removed from the upper GI tract.  A repeat look at the structures involved again showed no visible abnormalities, except for the biopsy sites.,The patient tolerated the procedure with excellent comfort and stable vital signs.  After a recovery period in the Endoscopy Suite, the patient is discharged to continue recovering in the family's care at home.  The family knows to follow up with me today if there are concerns about the patient's recovery,from the procedure.  They will follow up with me later this week for biopsy and CLO test results so that appropriate further diagnostic and therapeutic plans can be made.,
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DESCRIPTION: Common description of EGD.

Common description of EGD.

surgery, gastric antrum, distal duodenum, distal esophagus, esophagus, duodenum, clo test, upper gi tract, upper gi, gi tract, egd, endoscope, gi, tract, structures, distal, biopsyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves a medical procedure called an esophagogastroduodenoscopy (EGD), which is a standard diagnostic tool used in gastroenterology. While it is an invasive procedure, it is routine and generally low-risk, as indicated by the normal findings and the patient's stable condition post-procedure. The text reports that the patient tolerated the procedure well and was discharged with instructions for follow-up, suggesting a low likelihood of complications. However, the situation involves biopsies, which could reveal significant health issues requiring further intervention, but there is no immediate risk based on the provided information.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CVA - Discharge Summary

DIAGNOSES ON ADMISSION,1.  Cerebrovascular accident (CVA) with right arm weakness.,2.  Bronchitis.,3.  Atherosclerotic cardiovascular disease.,4.  Hyperlipidemia.,5.  Thrombocytopenia.,DIAGNOSES ON DISCHARGE,1.  Cerebrovascular accident with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.,2.  Old coronary infarct, anterior aspect of the right external capsule.,3.  Acute bronchitis with reactive airway disease.,4.  Thrombocytopenia most likely due to old coronary infarct, anterior aspect of the right external capsule.,5.  Atherosclerotic cardiovascular disease.,6.  Hyperlipidemia.,HOSPITAL COURSE: , The patient was admitted to the emergency room.  Plavix was started  in addition to baby aspirin.  He was kept on oral Zithromax for his cough.  He was given Xopenex treatment, because of his respiratory distress.  Carotid ultrasound was reviewed and revealed a 50 to 69% obstruction of left internal carotid.  Dr. X saw him in consultation and recommended CT angiogram.  This showed no significant obstructive lesion other than what was known on the ultrasound.  Head MRI was done and revealed the above findings.  The patient was begun on PT and improved.  By discharge, he had much improved strength in his right arm.  He had no further progressions.  His cough improved with oral Zithromax and nebulizer treatments.  His platelets also improved as well.  By discharge, his platelets was up to 107,000.  His H&H was stable at 41.7 and 14.6 and his white count was 4300 with a normal differential.  Chest x-ray revealed a mild elevated right hemidiaphragm, but no infiltrate.  Last chemistry panel on December 5, 2003, sodium 137, potassium 4.0, chloride 106, CO2 23, glucose 88, BUN 17, creatinine 0.7, calcium was 9.1.  PT/INR on admission was 1.03, PTT 34.7.  At the time of discharge, the patient's cough was much improved.  His right arm weakness has much improved.  His lung examination has just occasional rhonchi.  He was changed to a metered dose inhaler with albuterol.  He is being discharged home.  An echocardiogram revealed mild concentric LVH with normal left ventricular function with an EF of 57%, moderate left atrial enlargement and diastolic dysfunction with mild mitral regurgitation.  He will follow up in my office in 1 week.  He is to start PT and OT as an outpatient.  He is to avoid driving his car.  He is to notify, if further symptoms.  He has 2 more doses of Zithromax at home, he will complete.  His prognosis is good.
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DESCRIPTION: Cerebrovascular accident (CVA) with right arm weakness and MRI indicating acute/subacute infarct involving the left posterior parietal lobe without mass effect.  2.  Old coronary infarct, anterior aspect of the right external capsule.  Acute bronchitis with reactive airway disease.

cardiovascular / pulmonary, subacute infarct, atherosclerotic cardiovascular disease, cerebrovascular accident, coronary infarct, external capsule, cva, cerebrovascular, mri, bronchitis, cardiovascular, xopenex, atherosclerotic, accident

The discharge summary situation involves a patient who has experienced a cerebrovascular accident (CVA), old coronary infarct, acute bronchitis, and other significant health concerns. These are serious medical conditions that require careful management and follow-up. The document outlines a complex hospital course with various treatments and improvements, and stresses the need for outpatient physical therapy and the patient's prognosis. The stakes are high because managing and recovering from such conditions is critical to the patient's long-term health and preventing further complications.


Medical Specialty: Surgery
Sample Name: Pacemaker (Single Chamber)

SINGLE CHAMBER PACEMAKER IMPLANTATION,PREOPERATIVE DIAGNOSIS: , Mobitz type II block with AV dissociation and syncope.,POSTOPERATIVE DIAGNOSIS: , Mobitz type II block, status post single chamber pacemaker implantation, Boston Scientific Altrua 60, serial number 123456.,PROCEDURES:,1.  Left subclavian access under fluoroscopic guidance.,2.  Left subclavian venogram under fluoroscopic evaluation.,3.  Insertion of ventricular lead through left subclavian approach and ventricular lead is Boston Scientific Dextrose model 12345, serial number 123456.,4.  Insertion of single-chamber pacemaker implantation, Altrua, serial number 123456.,5.  Closure of the pocket after formation of pocket for pacemaker.,PROCEDURE IN DETAIL:  ,The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient was brought to the cath lab, draped and prepped in the usual sterile fashion, received 1.5 mg of versed and 25 mg of Benadryl for conscious sedation.,Access to the right subclavian was successful after the second attempt.  The first attempt accessed the left subclavian artery.  The needle was removed and manual compression applied for five minutes followed by re-accessing the subclavian vein successfully.  The J-wire was introduced into the left subclavian vein.,The anterior wall chest was anesthetized with lidocaine 2%, 2-inch incision using a #10 blade was used.,The pocket was formed using blunt dissection as he was using the Bovie cautery for hemostasis.  The patient went asystole during the procedure.  The transcutaneous pacer was used.  The patient was oxygenating well.  The patient had several compression applied by the nurse.  However, her own rhythm resolved spontaneously and the percutaneous pacer was kept on standby.,After that, the J-wire was tunneled into the pocket and then used to put the #7-French sheath into the left subclavian vein.  The lead from the Boston Scientific Dextrose model 12345, serial number 12345 was inserted through the left subclavian to the right atrium; however, it was difficult to really enter the right ventricle; and while the lead was in place, the side port of the sheath was used to inject 15 mL of contrast to assess the subclavian and the right atrium.  The findings were showing different anatomy, may be consistent with persistent left superior vena cava, and the angle to the right ventricle was different.  At that point, the lead stylet was reshaped and was able to cross the tricuspid valve in a position consistent with the mid septal place.,At that point, the lead was actively fixated.  The stylet was removed.  The R-wave measured at 40 millivolts.  The impedance was 580 and the threshold was 1.3 volt.  The numbers were accepted and because of the patient's fragility and the different anatomy noticed in the right atrium, concern about putting a second lead with re-access of the subclavian was high.  I decided to proceed with a single-chamber pacemaker as a backup system.,After that, the lead sleeve was used to actively fixate the lead in the anterior chest with two Ethibond sutures in the usual fashion.,The lead was attached to the pacemaker in the header.  The pacemaker was single-chamber pacemaker Altura 60, serial number 123456.  After that, the pacemaker was put in the pocket.  Pocket was irrigated with normal saline and was closed into two layers, deep interrupted #3-0 Vicryl and surface as continuous #4-0 Vicryl continuous.,The pacemaker was programmed as VVI 60, and with history is 10 to 50 beats per minute.  The lead position will be evaluated with chest x-ray.,No significant bleeding noticed.,CONCLUSION:  ,Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.  No significant bleed.
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DESCRIPTION: Single chamber pacemaker implantation.  Successful single-chamber pacemaker implantation with left subclavian approach and venogram to assess the subclavian access site and the right atrial or right ventricle with asystole that resolved spontaneously during the procedure.

surgery, mobitz, av dissociation, syncope, mobitz type ii block, boston scientific altrua, subclavian, venogram, ventricular, single chamber pacemaker implantation, single chamber pacemaker, pacemaker implantation, pacemaker, vein, chest, atrium, ventricle, atrial, implantation, chamber,

The situation described involves a surgical procedure to implant a single-chamber pacemaker. This is inherently a high-stakes scenario due to the complexity of the procedure, the risks involved, such as asystole (a potentially life-threatening condition where the heart stops beating) during the surgery, and the overall importance of the procedure in maintaining the patient's heart rhythm. The fact that the procedure was successful and that spontaneous resolution of asystole occurred during the procedure indicate that it was managed well, but the potential risks justify a high-stakes classification.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy - 7

PREOPERATIVE DIAGNOSIS:,  Positive peptic ulcer disease.,POSTOPERATIVE DIAGNOSIS:,  Gastritis.,PROCEDURE PERFORMED: , Esophagogastroduodenoscopy with photography and biopsy.,GROSS FINDINGS:,  The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.,Upon endoscopy, gastroesophageal junction was at 40 cm, no esophageal tumor, varices, strictures, masses, or no reflux esophagitis was noted.  Examination of the stomach reveals mild inflammation of the antrum of the stomach, no ulcers, erosions, tumors, or masses.  The profundus and the cardia of the stomach were unremarkable.  The pylorus was concentric.  The duodenal bulb and sweep with no inflammation, tumors, or masses.,OPERATIVE PROCEDURE: , The patient taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position.  She was given IV sedation using Demerol and Versed.  Olympus videoscope was inserted in the hypopharynx, upon deglutition passed into the esophagus.  Using air insufflation, the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep.  The above gross findings noted.  The panendoscope was withdrawn back from the stomach, deflected upon itself.  The lesser curve fundus and cardiac were well visualized.  Upon examination of these areas, panendoscope was returned to midline.  Photographs and biopsies were obtained of the antrum of the stomach.  Air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel.,Photographs and biopsies were obtained as appropriate.  The patient is sent to recovery room in stable condition.
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DESCRIPTION: Positive peptic ulcer disease.  Gastritis.  Esophagogastroduodenoscopy with photography and biopsy.   The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.

gastroenterology, antrum, esophageal tumor, varices, strictures, masses, duodenal bulb, peptic ulcer, duodenal, esophagus, esophagogastroduodenoscopy, panendoscope, peptic, inflammation, ulcer, disease, stomach

The procedure described is a diagnostic esophagogastroduodenoscopy, which is a routine and commonly performed procedure. The findings of gastritis and history of peptic ulcer disease are relatively standard diagnoses in gastroenterology. The procedure appears to have been conducted without complications, as the patient was sent to recovery in stable condition. Therefore, this situation is not high-stakes, as it involves standard medical practice without immediate life-threatening conditions or complications.


Medical Specialty: Radiology
Sample Name: CT Facial

TECHNIQUE: , Sequential axial CT images were obtained through the facial bones without contrast.  Additional high resolution coronal reconstructed images were also obtained for better visualization of the osseous structures.,FINDINGS:,  The osseous structures within the face are intact with no evidence of fracture or dislocation.  The visualized paranasal sinuses and mastoid air cells are clear.  The orbits and extra-ocular muscles are within normal limits.  The soft tissues are unremarkable.  ,IMPRESSION: , No acute abnormalities.
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DESCRIPTION: Common CT Facial template.

Common CT Facial template.

radiology, sequential axial ct image, ct facial, osseous structuresNOTE

The provided scenario involves the interpretation of a CT scan in radiology. The results indicate 'no acute abnormalities,' suggesting a routine examination with no immediate concerns. While the accurate reading of such images is crucial in healthcare, this particular result reflects a non-urgent situation with no immediate medical threat to the patient. Hence, this scenario is lower on the stakes scale compared to situations that involve critical or life-threatening findings.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Sports Physical - 1

HISTORY: , This child is seen for a sports physical.,NUTRITIONAL HISTORY:,  She takes meats, vegetables, and fruits.  Eats well.  Has may be 1 to 2 cups a day of milk.  Her calcium intake could be better.  She does not drink that much pop but she likes koolaid.  Her stools are normal.  Brushes her teeth.  Sees a dentist.,DEVELOPMENTAL HISTORY: , She did well in school last year.  Hearing and vision, no problems.  She wears corrective lenses.  She will be in 8th grade and involved in volleyball, basketball, and she will be moving to Texas.  She did go to Burton this last year.  She also plays clarinet, and will be involved also in cheerleading.  She likes to swim in the summer time.  Her menarche was January 2004.  It occurs every 7 weeks.  No particular problems at this time.,OTHER ACTIVITIES:  ,TV time about 2 to 3 hours a day.  She does not use drugs, alcohol, or smoke, and denies sexual activity.,MEDICATIONS:,  Advair 250/50 b.i.d., Flonase b.i.d., Allegra q.d.  120 mg, Xopenex and albuterol p.r.n.,ALLERGIES:,  No known drug allergies.,OBJECTIVE:,Vital Signs:  Blood pressure:  98/60.  Temperature:  96.6 tympanic.  Weight:  107 pounds, which places her at approximately the 60th percentile for weight and the height is about 80th percentile at 64-1/2 inches.  Her body mass index is 18.1, which is 40th percentile.  Pulse:  68.,HEENT:  Normocephalic.  Fundi benign.  Pupils are equal and reactive to light and accommodation.  Conjunctivae were non-injected.  Her pupils were equal, and reactive to light and accommodation.  No strabismus.  She wears glasses.  Her vision was 20/20 in both eyes.  TMs are bilaterally clear.  Nonerythematous.  Hearing in the ears, she was able to pass 40 decibel to 30 decibel.  With the right ear, she has some problems, but the left ear she passed.  Throat was clear.  Nonerythematous.  Good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Respiratory:  Clear.  No wheezes and no crackles.  No tachypnea and no retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.  No hepatosplenomegaly.,GU:  Normal female genitalia.  Tanner stage III in breast and pubic hair development and she was given a breast exam.  Negative for any masses.,Skin:  Without rash.,Extremities:  Deep tendon reflexes 2+/4+ bilaterally and equal.,Neurological:  Romberg negative.,Back:  No scoliosis.,She had good circumduction at the shoulder joints and duck walk is normal.,ASSESSMENT:,  Sports physical with normal growth and development.,PLAN:,  If problems continue, she will need to have her hearing rechecked.  Hopefully in the school, there will be a screening mat.  She received her first hepatitis A vaccine and she needs to have a booster in 6 to 12 months.  We reviewed her immunizations for tetanus and her last acellular DPT was 11/25/1996.  When she goes to Texas, Mom has an appointment already to see an allergist but she needs to find a primary care physician and we will ask for record release.  We talked about her menarche.  Recommended the exam of the breast regularly.  Talked about other anticipatory guidance including sunscreen, use of seat belts, and drugs, alcohol, and smoking, and sexual activity and avoidance at her age and to continue on her present medications.  She also has had problems with her ankles in the past.  She had no limitation here, but we gave her some ankle strengthening exercise handouts while she was in the office.
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DESCRIPTION: Sports physical with normal growth and development.

The situation described is a routine sports physical examination for a child transitioning to 8th grade, with a focus on overall health, growth, and development. Although there are recommendations for follow-up (e.g., hearing recheck and future vaccination), there are no immediate health concerns or life-threatening conditions mentioned. Everything seems routine, and the child's health status is generally normal. These factors suggest the stakes are low.


Medical Specialty: Surgery
Sample Name: Control of Parapharyngeal Hemorrhage

PREOPERATIVE DIAGNOSIS: , Postoperative hemorrhage.,POSTOPERATIVE DIAGNOSIS:,  Postoperative hemorrhage.,SURGICAL PROCEDURE:  ,Examination under anesthesia with control of right parapharyngeal space hemorrhage.,ANESTHESIA:  ,General endotracheal technique.,SURGICAL FINDINGS: , Right lower pole bleeder cauterized with electrocautery with good hemostasis.,INDICATIONS FOR SURGERY: , The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy.  Previously, in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty.  However, in the PACU after a coughing spell she began bleeding from the right oropharynx, and was taken back to the operative suite for control of hemorrhage.,DESCRIPTION OF SURGERY:  ,The patient was placed supine on the operating room table and general anesthetic was administered, once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage.  A Crowe-Davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized.  There was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa, this area was cauterized with suction cautery and irrigated.  There was no other bleeding noted.  The patient was repositioned and the mouth gag, the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined.  There was a small amount of oozing noted in the right tonsillar bed, and this was cauterized with suction cautery.  No other bleeding was noted and the patient was recovered from general anesthetic.  She was extubated and left the operating room in good condition to postoperative recovery room area.  Prior to extubation the patient's tonsillar fossa were injected with a 6 mL of 0.25% Marcaine with 1:100,000 adrenalin solution to facilitate postoperative analgesia and hemostasis.
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DESCRIPTION: Postoperative hemorrhage. Examination under anesthesia with control of right parapharyngeal space hemorrhage.  The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy.

surgery, obstructive adenotonsillar hypertrophy, tonsillar fossa, suction cautery, postoperative hemorrhage, parapharyngeal space, anesthesia, oropharynx, parapharyngeal, tonsillectomy, hemorrhage,

The situation involves a patient who experienced postoperative hemorrhage after a tonsillectomy with adenoidectomy, necessitating a return to surgery to control the bleeding. Hemorrhage in the parapharyngeal space is a potentially serious condition, as uncontrolled bleeding can lead to airway obstruction or significant blood loss. The surgery was performed under general anesthesia, indicating a serious approach to handle the complication. The stakes are considerably high since bleeding in this area could escalate to life-threatening if not controlled promptly.


Medical Specialty: Pediatrics - Neonatal
Sample Name: School Physical - 1

SUBJECTIVE:,  This patient was seen in clinic for a school physical.,NUTRITIONAL HISTORY:,  She eats well, takes meats, vegetables, and fruits, but her calcium intake is limited.  She does not drink a whole lot of pop.  Her stools are normal.  Brushes her teeth, sees a dentist.,Developmental History:  Hearing and vision is okay.  She did well in school last year.  She will be going to move to Texas, will be going to Bowie High School.  She will be involved in cheerleading, track, volleyball, and basketball.  She will be also playing the clarinet and will be a freshman in that school.  Her menarche was 06/30/2004.,PAST MEDICAL HISTORY:,  She is still on medications for asthma.  She has a problem with her eye lately, this has been bothering her, and she also has had a rash in the left leg.  She had been pulling weeds on 06/25/2004 and then developed a rash on 06/27/2004.,Review of her immunizations, her last tetanus shot was 06/17/2003.,MEDICATIONS:  ,Advair 100/50 b.i.d., Allegra 60 mg b.i.d., Flonase q.d., Xopenex, Intal, and albuterol p.r.n.,ALLERGIES: , No known drug allergies.,OBJECTIVE:,Vital Signs:  Weight:  112 pounds about 40th percentile.  Height:  63-1/4 inches, also the 40th percentile.  Her body mass index was 19.7, 40th percentile.  Temperature:  97.7 tympanic.  Pulse:  80.  Blood pressure:  96/64.,HEENT:  Normocephalic.  Fundi benign.  Pupils equal and reactive to light and accommodation.  No strabismus.  Her vision was 20/20 in both eyes and each with contacts.  Hearing:  She passed that test.  Her TMs are bilaterally clear and nonerythematous.  Throat was clear.  Good mucous membrane moisture and good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Abdomen:  No hepatosplenomegaly.,Respiratory:  Clear.  No wheezes.  No crackles.  No tachypnea.  No retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.,GU:  Normal female genitalia.  Tanner stage 3, breast development and pubic hair development.  Examination of the breasts was negative for any masses or abnormalities or discharge from her areola.,Extremities:  She has good range of motion of upper and lower extremities.  Deep tendon reflexes were 2+/4+ bilaterally and equal.  Romberg negative.,Back:  No scoliosis.  She had good circumduction at shoulder joint and her duck walk was normal.,SKIN:  She did have some rash on the anterior left thigh region and also some on the right lower leg that had Kebner phenomenon and maculopapular vesicular eruption.  No honey crusting was noted on the skin.  She also had some mild rash on the anterior abdominal area near the panty line similar to that rash.  It was raised and blanch with pressure, it was slightly erythematous.,ASSESSMENT AND PLAN:,1.  Sports physical.,2.  The patient received her first hepatitis A vaccine.  She will get a booster in 6 to 12 months.  Prescription for Atarax 10 mg tablets one to two tablets p.o. q.4-6h. p.r.n. and a prescription for Elocon ointment to be applied topically, except for the face, once a day with a refill.  She will be following up with an allergist as soon as she gets to Texas and needs to find a primary care physician.  We talked about anticipatory guidance including breast exam, which we have reviewed with her today, seatbelt use, and sunscreen.  We talked about avoidance of drugs and alcohol and sexual activity.  Continue on her present medications and if her rash is not improved and goes to the neck or the face, she will need to be on PO steroid medication, but presently that was held and moved to treatment with Atarax and Elocon.  Also talked about cleaning her clothes and bedding in case she has any poison ivy oil that is harboring on any clothing.
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DESCRIPTION: This patient was seen in clinic for a school physical.

pediatrics - neonatal, school physical, calcium intake, hearing and vision, hepatitis a vaccine, booster, anticipatory guidance, developmental, percentile, physical, school, rash,

The situation described is a standard comprehensive school physical for a pediatric patient who is about to move to a new state and enroll in a high school. The conditions and treatments discussed are typical for a pediatric patient and do not indicate any immediate medical emergency or life-threatening situation. The patient has asthma and a rash, which are being managed with prescribed medications. Although there are discussions regarding immunizations and ensuring follow-up in a new location, these are standard, non-critical healthcare practices. Therefore, the stakes, from a medical urgency perspective, are low.


Medical Specialty: General Medicine
Sample Name: Hypothermia - Discharge Summary

DIAGNOSIS AT ADMISSION: , Hypothermia.,DIAGNOSES ON DISCHARGE,1. Hypothermia.,2. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.,3. Organic brain syndrome.,4. Seizure disorder.,5. Adrenal insufficiency.,6. Hypothyroidism.,7. Anemia of chronic disease.,HOSPITAL COURSE:  ,The patient was admitted through the emergency room.  He was admitted to the Intensive Care Unit.  He was rewarmed and had blood, sputum, and urine cultures done.  He was placed on IV Rocephin.  His usual medications of Dilantin and Depakene were given.  The patient's hypertension was treated with fluid boluses.  The patient was empirically placed on Synthroid and hydrocortisone by Dr. X.  Blood work consisted of a chemistry panel that was unremarkable, except for decreased proteins.  H&H was stable at 33.3/10.9 and platelets of 80,000.  White blood cell counts were normal, differential was normal.  TSH was 3.41.  Free T4 was 0.9.  Dr. X felt this was consistent with secondary hypothyroidism and recommended Synthroid replacement.  A cortisol level was obtained prior to administration of hydrocortisone.  This was 10.9 and that was not a fasting level.  Dr. X felt because of his hypothyroidism and his hypothermia that he had secondary adrenal insufficiency and recommended hydrocortisone and Florinef.  The patient was eventually changed to prednisone 2.5 mg b.i.d. in addition to his Florinef 0.1 mg on Monday, Wednesday, and Friday.  The patient was started back on his tube feeds.  He tolerated these poorly with residuals.  Reglan was increased to 10 mg q.6 h. and erythromycin is being added.  The patient's temperature has been stable in the 94 to 95 range.  Other vital signs have been stable.  His urine output has been diminished.  An external jugular line was placed in the Intensive Care Unit.  The patient's legal guardian, Janet Sanchez in Albuquerque has requested he be transported there.  As per several physicians in Albuquerque and Dr. Y, an internist, we will accept him once we have a nursing home available to him.  He is being transported back to the nursing home today and discharge planners are working on getting him a nursing home in Albuquerque.  His prognosis is poor.
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DESCRIPTION: Hypothermia.  Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.  Organic brain syndrome.  Seizure disorder.  Adrenal insufficiency.  Hypothyroidism.  Anemia of chronic disease.

general medicine, sepsis, organic brain syndrome, seizure disorder, anemia of chronic disease, adrenal insufficiency, blood, cultures

The discharge summary for a patient with hypothermia includes several serious and chronic conditions: suspected infections, organic brain syndrome, seizure disorder, adrenal insufficiency, hypothyroidism, and anemia. The patient is in critical condition requiring ICU care and specific medication management. The summary indicates the complexity of managing multiple conditions and the poor prognosis only adds to the seriousness of the situation. Moreover, the involvement of legal guardians and the need for inter-hospital transport emphasize the high-stakes nature of the case.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy with Biopsies -2

PREOPERATIVE DIAGNOSIS: , Refractory dyspepsia.,POSTOPERATIVE DIAGNOSIS:,1.  Hiatal hernia.,2.  Reflux esophagitis.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with pseudo and esophageal biopsy.,ANESTHESIA:,  Conscious sedation with Demerol and Versed.,SPECIMEN: , Esophageal biopsy.,COMPLICATIONS: , None.,HISTORY:,  The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.  She has been on multiple medical regimens and continues with dyspeptic symptoms.,PROCEDURE: , After proper informed consent was obtained, the patient was brought to the endoscopy suite.  She was placed in the left lateral position and was given IV Demerol and Versed for sedation.  When adequate level of sedation achieved, the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated.  At the GE junction, a hiatal hernia was present.  There were mild inflammatory changes consistent with reflux esophagitis.  The scope was then passed into the stomach.  It was insufflated and the scope was coursed along the greater curvature to the antrum.  The pylorus was patent.  There was evidence of bile reflux in the antrum.  The duodenal bulb and sweep were examined and were without evidence of mass, ulceration, or inflammation.  The scope was then brought back into the antrum.,A retroflexion was attempted multiple times, however, the patient was having difficulty holding the air and adequate retroflexion view was not visualized.  The gastroscope was then slowly withdrawn.  There were no other abnormalities noted in the fundus or body.  Once again at the GE junction, esophageal biopsy was taken.  The scope was then completely withdrawn.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.  She will return to the General Medical Floor.  We will continue b.i.d proton-pump inhibitor therapy as well as dietary restrictions.  She should also attempt significant weight loss.
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DESCRIPTION: Esophagogastroduodenoscopy with pseudo and esophageal biopsy.  Hiatal hernia and reflux esophagitis. The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.

gastroenterology, refractory dyspepsia, hiatal hernia, reflux esophagitis, esophagogastroduodenoscopy, esophageal, pseudo, esophageal biopsy, ge junction, hiatal, hernia, esophagitis, antrum, gerd,

The situation involves a routine medical procedure known as an esophagogastroduodenoscopy (EGD), performed to examine upper digestive tract issues, such as refractory dyspepsia, hiatal hernia, and reflux esophagitis. The patient has a history of GERD and symptoms like hoarseness and chronic cough, which are chronic but not life-threatening in the immediate context. The procedure was completed without complications and the patient returned to stable condition. While medical procedures always carry some risk, this is a common and generally low-risk procedure that does not involve any immediate high-stake emergencies.


Medical Specialty: Surgery
Sample Name: Flexible Cystoscopy - BPH

PREOPERATIVE DIAGNOSIS: , Microscopic hematuria.,POSTOPERATIVE DIAGNOSIS:,  Microscopic hematuria with lateral lobe obstruction, mild.,PROCEDURE PERFORMED: , Flexible cystoscopy.,COMPLICATIONS: , None.,CONDITION: , Stable.,PROCEDURE: , The patient was placed in the supine position and sterilely prepped and draped in the usual fashion.  After 2% lidocaine was instilled, the anterior urethra is normal.  The prostatic urethra reveals mild lateral lobe obstruction.  There are no bladder tumors noted.,IMPRESSION:,  The patient has some mild benign prostatic hyperplasia.  At this point in time, we will continue with conservative observation.,PLAN: , The patient will follow up as needed.
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DESCRIPTION: Microscopic hematuria with lateral lobe obstruction, mild.

surgery, benign prostatic hyperplasia, urethra, lateral lobe obstruction, flexible cystoscopy, microscopic hematuria, cystoscopy, hematuria, obstruction,

The procedure described is a flexible cystoscopy, which is a routine diagnostic medical procedure used to examine the inside of the bladder and urethra. The patient's condition is stable and the findings show a mild obstruction due to benign prostatic hyperplasia (BPH), which is a common condition. There were no complications during the procedure and the plan is for conservative observation and follow-up as needed. Therefore, there is no immediate risk to the patient's health or life, making this a relatively low-stakes situation.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Belly Button Piercing

PROCEDURE:,  Belly button piercing for insertion of belly button ring.,DESCRIPTION OF PROCEDURE:,  The patient was prepped after informed consent was given of risk of infection and foreign body reaction.  The area was marked by the patient and then prepped.  The area was injected with 2% Xylocaine 1:100,000 epinephrine.,Then a #14-gauge needle was inserted above the belly button and inserted up to the skin just above the actual umbilical area and the ring was inserted into the #14-gauge needle and pulled through.  A small ball was placed over the end of the ring.  This terminated the procedure.,The patient tolerated the procedure well.  Postop instructions were given regarding maintenance.  Patient left the office in satisfactory condition.
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DESCRIPTION: Belly button piercing for insertion of belly button ring.

cosmetic / plastic surgery, belly button piercing, 2% xylocaine, belly button, postop instructions, the patient tolerated the procedure well, foreign body, gauge needle, needle, piercing, ring, satisfactory condition, umbilical, button piercing, belly, buttonNOTE

The procedure described is a belly button piercing, which is typically considered a low-risk cosmetic procedure. The stakes involved are low because the procedure is minimally invasive and generally performed without significant risk to the patient's health. Even though informed consent regarding risks like infection is given, these risks are minor compared to those associated with more invasive surgical procedures. The patient's tolerance of the procedure and satisfactory condition upon leaving further indicate low stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Ophthalmology Progress Note - 1

She is stable at this time and does not require any intervention at today's visit.  I have asked her to return in six months' for a followup dilated examination, but would be happy to see her sooner should you or she notice any changes in her vision.
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DESCRIPTION: Ophthalmology followup visit note.

Ophthalmology followup visit note.

soap / chart / progress notes, visual acuities, extraocular muscle, intraocular pressure, pupils, afferent, applanation, binocular, dilated fundus, left eye, lens, movements, ophthalmoscope, pigmentary, retina, retinal, right eye, ophthalmology, acuitiesNOTE,: 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 note indicates that the patient is stable and does not require any immediate intervention. The mention of a follow-up in six months suggests routine monitoring, with the option to return sooner if there are changes in her vision. This suggests that the situation is currently stable with low risk and typical follow-up care.


Medical Specialty: Surgery
Sample Name: Stenting

NAME OF PROCEDURE:,  Successful stenting of the left anterior descending.,DESCRIPTION OF PROCEDURE:,  Angina pectoris, tight lesion in left anterior descending.,TECHNIQUE OF PROCEDURE:,  Standard Judkins, right groin.,CATHETERS USED: , 6 French Judkins, right; wire, 14 BMW; balloon for predilatation, 25 x 15 CrossSail; stent 2.5 x 18 Cypher drug-eluting stent.,ANTICOAGULATION:  ,The patient was on aspirin and Plavix, received 3000 of heparin and was begun on Integrilin.,COMPLICATIONS: , None.,INFORMED CONSENT: , I reviewed with the patient the pros, cons, alternatives and risks of catheter and sedation exactly as I had done before during his diagnostic catheterization, plus I reviewed the risks of intervention including lack of success, need for emergency surgery, need for later restenosis and further procedures.,HEMODYNAMIC DATA: , The aortic pressure was in the physiologic range.,ANGIOGRAPHIC DATA: , Left coronary artery:  The left main coronary artery showed insignificant disease.  The left anterior descending showed fairly extensive calcification.  There was 90% stenosis in the proximal to midportion of the vessel.  Insignificant disease in the circumflex.,SUCCESSFUL STENTING: , A wire crossed the lesion.  We first predilated with a balloon, then advanced, deployed and post dilated the stent.  Final angiography showed 0% stenosis, no tears or thrombi, excellent intimal appearance.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure 160/88, temperature 98.6, pulse 83, respirations 30.  He is saturating at 96% on 4 L nonrebreather.,GENERAL:  The patient is a 74 year-old white male who is cooperative with the examination and alert and oriented x3.  The patient cannot speak and communicates through writing.,HEENT:  Very small moles on face.  However, pupils equal, round and regular and reactive to light and accommodation.  Extraocular movements are intact.  Oropharynx is moist.,NECK:  Supple.  Tracheostomy site is clean without blood or discharge.,HEART:  Regular rate and rhythm.  No gallop, murmur or rub.,CHEST:  Respirations congested.  Mild crackles in the left lower quadrant and left lower base.,ABDOMEN:  Soft, nontender and nondistended.  Positive bowel sounds.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  Cranial nerves II-XII grossly intact.  No focal deficit.,GENITALIA:  The patient does have a right scrotal swelling, very much larger than the other side, not reproducible and mobile to touch.,CONCLUSIONS,1. Successful stenting of the left anterior descending.  Initially, there was 90% stenosis.  After stenting with a drug-eluting stent, there was 0% residual.,2. Insignificant disease in the other coronaries.,PLAN:,  The patient will be treated with aspirin, Plavix, Integrilin, beta blockers and statins.  I have discussed this with him, and I have answered his questions.
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DESCRIPTION: Successful stenting of the left anterior descending.  Angina pectoris, tight lesion in left anterior descending.

The procedure described is a stenting process for the left anterior descending artery, which is a critical intervention given the initial 90% stenosis. Successful management of such cases is crucial as a failure can lead to significant patient morbidity or even mortality, such as myocardial infarction (heart attack). However, the procedure here was successful with no complications reported and the post-procedure condition of the patient seemed stable. The procedure involved necessary anticoagulation and showed no complications, suggesting good management of risks. Therefore, the stakes were high due to the critical nature of the artery being stented and potential consequences of failure, but the successful outcome and absence of complications are positive aspects.


Medical Specialty: Surgery
Sample Name: Release of A1 Pulley

PREOPERATIVE DIAGNOSIS: , Right trigger thumb.,POSTOPERATIVE DIAGNOSIS:,  Right trigger thumb.,SURGERY: , Release of A1 pulley, CPT code 26055.,ANESTHESIA:,  General LMA.,TOURNIQUET TIME:  ,9 minutes at 200 torr.,FINDINGS:,  The patient was found to have limitations to extension at the IP joint to the right thumb.  He was found to have full extension after release of A1 pulley.,INDICATIONS:,  The patient is 2-1/2-year-old.  He has a history of a trigger thumb.  This was evaluated in the office.  He was indicated for release of A1 pulley to allow for full excursion.  Risks and benefits including recurrence, infection, and problems with anesthesia were discussed at length with the family.  They wanted to proceed.,PROCEDURE:,  The patient was brought into the operating room and placed on the operating table in supine position.  General anesthesia was induced without incident.  He was given a weight-adjusted dose of antibiotics.  The right upper extremity was then prepped and draped in a standard fashion.  Limb was exsanguinated with an Esmarch bandage.  Tourniquet was raised to 200 torr.  Transverse incision was then made at the base of thumb.  The underlying soft tissues were carefully spread in line longitudinally.  The underlying tendon was then identified.  The accompanied A1 pulley was also identified.  This was incised longitudinally using #11 blade.  Inspection of the entire tendon then demonstrated good motion both in flexion and extension.  The leaflets of the pulley were easily identified.,The wound was then irrigated and closed.  The skin was closed using interrupted #4-0 Monocryl simple sutures.  The area was injected with 5 mL of 0.25% Marcaine.  The wound was dressed with Xeroform, dry sterile dressings, hand dressing, Kerlix, and Coban.  The patient was awakened from anesthesia and taken to the recovery room in good condition.  There were no complications.  All instrument, sponge, needle counts were correct at the end of case.,PLAN: , The patient will be discharged home.  He will return in 1-1/2 weeks for wound inspection.
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DESCRIPTION: The patient was found to have limitations to extension at the IP joint to the right thumb and he had full extension after release of A1 pulley.

surgery, a1 pulley, release of a1 pulley, trigger thumb, limitations to extension, ip joint

The described surgical procedure, 'Release of A1 Pulley' for a 2.5-year-old with a trigger thumb, is a routine and relatively minor surgical intervention. The procedure was performed without complications, and the patient was stable and recovering well post-operatively. Although surgical procedures generally carry some risk, this particular operation does not typically involve high-risk factors and is not life-threatening. The preoperative and postoperative diagnoses matched, indicating the procedure was straightforward and successful, further indicating lower stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lung adenocarcinoma Path Report

CLINICAL HISTORY:  ,Probable right upper lobe lung adenocarcinoma.,SPECIMEN: , Lung, right upper lobe resection.,GROSS DESCRIPTION:,  Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung".  It consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.cm.  The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable.  Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass.  This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum.  There is no necrosis or hemorrhage evident.  The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.,FINAL DIAGNOSIS:,  Right lung, upper lobe, lobectomy:  Bronchioloalveolar carcinoma, mucinous type,COMMENT:,  Right upper lobe, lobectomy.,Tumor type:  Bronchioloalveolar carcinoma, mucinous type.,Histologic grade:  Well differentiated.,Tumor size (greatest diameter):  3.6 cm.,Blood/lymphatic vessel invasion:  Absent.,Perineural invasion:  Absent.,Bronchial margin:  Negative.,Vascular margin:  Negative.,Inked surgical margin:  Negative.,Visceral pleura:  Not involved.,In situ carcinoma:  Absent.,Non-neoplastic lung:  Emphysema.,Hilar lymph nodes:  Number of positive lymph nodes:  0; Total number of lymph nodes:  1.,P53 immunohistochemical stain is negative in the tumor.
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DESCRIPTION: Probable right upper lobe lung adenocarcinoma.  Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung".

cardiovascular / pulmonary, bronchioloalveolar carcinoma, mucinous, mucoid mass, lymph nodes, upper lobe, visceral, bronchioloalveolar, carcinoma, lymph, pleural, margin, tumor, adenocarcinoma, specimen, lobe, lung,

The pathology report describes a case of lung adenocarcinoma, specifying detailed histological findings including the tumor type, size, and other characteristics. Given that this involves a patient diagnosed with cancer, decision-making about treatment paths (e.g., surgery, chemotherapy, radiation) can significantly affect patient outcomes. Although the tumor does not seem aggressive, as indicated by the well-differentiated nature, absence of invasion, and clear margins, cancer diagnoses generally have substantial implications for patient health and require careful clinical management.


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

Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Poison Ivy - SOAP

SUBJECTIVE:,  He is a 24-year-old male who said that he had gotten into some poison ivy this weekend while he was fishing.  He has had several cases of this in the past and he says that is usually takes quite awhile for him to get over it; he said that the last time he was here he got a steroid injection by Dr. Blackman; it looked like it was Depo-Medrol 80 mg.  He said that it worked fairly well, although it seemed to still take awhile to get rid of it.  He has been using over-the-counter Benadryl as well as cortisone cream on the areas of the rash and having a little bit of improvement, but this last weekend he must have gotten into some more poison ivy because he has got another outbreak along his chest, legs, arms and back.,OBJECTIVE:,Vitals:  Temperature is 99.2.  His weight is 207 pounds.,Skin:  Examination reveals a raised, maculopapular rash in kind of a linear pattern over his arms, legs and chest area which are consistent with a poison ivy or a poison oak.,ASSESSMENT AND ,PLAN:,  Poison ivy.  Plan would be Solu-Medrol 125 mg IM X 1.  Continue over-the-counter Benadryl or Rx allergy medicine that he was given the last time he was here, which is a one-a-day allergy medicine; he can not exactly remember what it is, which would also be fine rather than the over-the-counter Benadryl if he would like to use that instead.
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DESCRIPTION: Maculopapular rash in kind of a linear pattern over arms, legs, and chest area which are consistent with a poison ivy or a poison oak.

soap / chart / progress notes, poison ivy, steroid injection, depo-medrol, maculopapular rash, poison oak, maculopapular, chest, ivy, poison

The situation involves a common allergic reaction to poison ivy, which though uncomfortable and requiring treatment, seldom poses immediate life-threatening consequences. The patient's previous experiences with similar symptoms and the medical plan of using medications like Solu-Medrol and antihistamines suggest it is generally manageable with standard treatments. Given his stable vitals and the non-critical nature of the condition, this situation does not represent a high-stakes medical scenario.


Medical Specialty: Emergency Room Reports
Sample Name: High PT-INR - ER Visit

REASON FOR THE VISIT:,  Very high PT/INR.,HISTORY: , The patient is an 81-year-old lady whom I met last month when she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.  She did not want to have Coumadin started because she said that she has had it before and the INR has had been very difficult to regulate to the point that it was dangerous, but I convinced her to restart the Coumadin again.  I gave her the Coumadin as an outpatient and then the INR was found to be 12.  So, I told her to come to the emergency room to get vitamin K to reverse the anticoagulation.,PAST MEDICAL HISTORY:,1.  Congestive heart failure.,2.  Renal insufficiency.,3.  Coronary artery disease.,4.  Atrial fibrillation.,5.  COPD.,6.  Recent pneumonia.,7.  Bladder cancer.,8.  History of ruptured colon.,9.  Myocardial infarction.,10.  Hernia repair.,11.  Colon resection.,12.  Carpal tunnel repair.,13.  Knee surgery.,MEDICATIONS:,1.  Coumadin.,2.  Simvastatin.,3.  Nitrofurantoin.,4.  Celebrex.,5.  Digoxin.,6.  Levothyroxine.,7.  Vicodin.,8.  Triamterene and hydrochlorothiazide.,9.  Carvedilol.,SOCIAL HISTORY:  ,She does not smoke and she does not drink.,PHYSICAL EXAMINATION:,GENERAL:  Lady in no distress.,VITAL SIGNS:  Blood pressure 100/46, pulse of 75, respirations 12, and temperature 98.2.,HEENT:  Head is normal.,NECK:  Supple.,LUNGS:  Clear to auscultation and percussion.,HEART:  No S3, no S4, and no murmurs.,ABDOMEN:  Soft.,EXTREMITIES:  Lower extremities, no edema.,ASSESSMENT:,1.  Atrial fibrillation.,2.  Coagulopathy, induced by Coumadin.,PLAN: , Her INR at the office was 12.  I will repeat it, and if it is still elevated, I will give vitamin K 10 mg in 100 mL of D5W and then send her home and repeat the PT/INR next week.  I believe at this time that it is too risky to use Coumadin in her case because of her age and comorbidities, the multiple medications that she takes and it is very difficult to keep an adequate level of anticoagulation that is safe for her.  She is prone to a fall and this would be a big problem.  We will use one aspirin a day instead of the anticoagulation.  She is aware of the risk of stroke, but she is very scared of the anticoagulation with Coumadin and does not want to use the Coumadin at this time and I understand.  We will see her as an outpatient.
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DESCRIPTION: Very high PT-INR.  she came in with pneumonia and CHF.  She was noticed to be in atrial fibrillation, which is a chronic problem for her.

The situation describes an 81-year-old patient with a very high PT/INR due to Coumadin use, which poses a significant risk for bleeding complications. The patient has multiple comorbidities including congestive heart failure, atrial fibrillation, coronary artery disease, and a history of myocardial infarction, which heightens the complexity and risk of anticoagulation. The high INR and the decision to use vitamin K for reversal, as well as the shift from Coumadin to aspirin due to safety concerns, underscore the high-stakes nature due to the potential for life-threatening events such as bleeding or stroke.


Medical Specialty: General Medicine
Sample Name: Hyperthyroidism Following Pregnancy

HISTORY: , Patient is a 21-year-old white woman who presented with a chief complaint of chest pain.  She had been previously diagnosed with hyperthyroidism.  Upon admission, she had complaints of constant left sided chest pain that radiated to her left arm.  She had been experiencing palpitations and tachycardia.  She had no diaphoresis, no nausea, vomiting, or dyspnea.,She had a significant TSH of 0.004 and a free T4 of 19.3.  Normal ranges for TSH and free T4 are 0.5-4.7 µIU/mL and 0.8-1.8 ng/dL, respectively.  Her symptoms started four months into her pregnancy as tremors, hot flashes, agitation, and emotional inconsistency.  She gained 16 pounds during her pregnancy and has lost 80 pounds afterwards.  She complained of sweating, but has experienced no diarrhea and no change in appetite.  She was given isosorbide mononitrate and IV steroids in the ER.,FAMILY HISTORY:,  Diabetes, Hypertension, Father had a Coronary Artery Bypass Graph (CABG) at age 34.,SOCIAL HISTORY:,  She had a baby five months ago.  She smokes a half pack a day.  She denies alcohol and drug use.,MEDICATIONS:,  Citalopram 10mg once daily for depression; low dose tramadol PRN pain.,PHYSICAL EXAMINATION: , Temperature 98.4; Pulse 123; Respiratory Rate 16; Blood Pressure 143/74.,HEENT:  She has exophthalmos and could not close her lids completely.,Cardiovascular:  tachycardia.,Neurologic:  She had mild hyperreflexiveness.,LAB:,  All labs within normal limits with the exception of Sodium 133, Creatinine 0.2, TSH 0.004, Free T4 19.3 EKG showed sinus tachycardia with a rate of 122.  Urine pregnancy test was negative.,HOSPITAL COURSE: , After admission, she was given propranolol at 40mg daily and continued on telemetry.  On the 2nd day of treatment, the patient still complained of chest pain.  EKG again showed tachycardia.  Propranolol was increased from 40mg daily to 60mg twice daily., A I-123 thyroid uptake scan demonstrated an increased thyroid uptake of 90% at 4 hours and 94% at 24 hours.  The normal range for 4-hour uptake is 5-15% and 15-25% for 24-hour uptake.  Endocrine consult recommended radioactive I-131 for treatment of Graves disease.,Two days later she received 15.5mCi of I-131.  She was to return home after the iodine treatment.  She was instructed to avoid contact with her baby for the next week and to cease breast feeding.,ASSESSMENT / PLAN:,1. Treatment of hyperthyroidism.  Patient underwent radioactive iodine 131 ablation therapy.,2. Management of cardiac symptoms stemming from hyperthyroidism.  Patient was discharged on propranolol 60mg, one tablet twice daily.,3. Monitor patient for complications of I-131 therapy such as hypothyroidism.  She should return to Endocrine Clinic in six weeks to have thyroid function tests performed.  Long-term follow-up includes thyroid function tests at 6-12 month intervals.,4. Prevention of pregnancy for one year post I-131 therapy.  Patient was instructed to use 2 forms of birth control and was discharged an oral contraceptive, taken one tablet daily.,5. Monitor ocular health.  Patient was given methylcellulose ophthalmic, one drop in each eye daily.  She should follow up in 6 weeks with the Ophthalmology clinic.,6. Management of depression.  Patient will be continued on citalopram 10 mg.
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DESCRIPTION: Chief complaint of chest pain, previously diagnosed with hyperthyroidism.

general medicine, hyperthyroidism, diabetes, hypertension, hospital course, thyroid function, tachycardia, pregnancy,

The situation involves a young woman experiencing severe symptoms of hyperthyroidism following pregnancy, including chest pain and significant cardiac symptoms like tachycardia. The stakes are high because untreated or improperly managed hyperthyroidism can lead to serious complications, such as heart problems and thyroid storm, especially considering her age and recent pregnancy. She also has prescribed treatment that involves radioactive iodine and needs careful monitoring for potential complications such as hypothyroidism. Furthermore, the patient's need to avoid contact with her baby and to cease breastfeeding adds a social and emotional element to the health stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Physical Exam Template - 4

GENERAL:  ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX.  Height XXX, weight XXX.,HEAD: , Normocephalic.  Negative lesions, negative masses.,EYES: , PERLA, EOMI.  Sclerae clear.  Negative icterus, negative conjunctivitis.,ENT:,  Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates.  Negative ear obstructions, negative exudates.  Negative inflammation in external auditory canals.  Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers.  No tattoos.,NECK:,  Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:,  Regular rate and rhythm.  Negative rubs, negative gallops, negative murmurs.,LUNGS:,  Clear to auscultation.  Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds.  Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing.  Pulses adequate bilaterally.,MUSCULOSKELETAL:,  Negative muscle atrophy, negative masses.  Strength adequate bilaterally.  Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact.  Negative gait disturbance.  Balance and coordination intact.  Negative Romberg, negative Babinski.  DTRs equal bilaterally.,GENITOURINARY:  ,Deferred.,
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DESCRIPTION: Normal physical exam template.  Normocephalic.  Negative lesions, negative masses.

The provided situation involves a standardized template for documenting a normal physical exam. This documentation is routine and indicates that the patient does not present any immediate or concerning symptoms requiring urgent attention. As such, the stakes are low because the examination details a general, uneventful physical assessment with no identified medical concerns. The potential implications for patient health in this context are minimal, as all findings are within expected normal limits.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Lobectomy - Left Lower

OPERATION: , Left lower lobectomy.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  After general endotracheal anesthesia was induced, the appropriate monitoring devices were placed.  The patient was placed in the right lateral decubitus position.  The left chest and back were prepped and draped in a sterile fashion.  A right lateral thoracotomy incision was made.  Subcutaneous flaps were raised.  The anterior border of the latissimus dorsi was freed up, and the muscle was retracted posteriorly.  The posterior border of the pectoralis was freed up and it was retracted anteriorly.  The 5th intercostal space was entered.,The inferior pulmonary ligament was then taken down with electrocautery.  The major fissure was then taken down and arteries identified.  The artery was dissected free and it was divided with an Endo GIA stapler.  The vein was then dissected free and divided with an Endo GIA stapler.  The bronchus was then cleaned of all nodal tissue.  A TA-30 green loaded stapler was then placed across this, fired, and main bronchus divided distal to the stapler.,Then the lobe was removed and sent to pathology where margins were found to be free of tumor.  Level 9, level 13, level 11, and level 6 nodes were taken for permanent cell specimen.  Hemostasis noted.  Posterior 28-French and anterior 24-French chest tubes were placed.,The wounds were closed with #2 Vicryl.  A subcutaneous drain was placed.  Subcutaneous tissue was closed with running 3-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.
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DESCRIPTION: Left lower lobectomy.

Left lower lobectomy.

cardiovascular / pulmonary, lower lobectomy, electrocautery, endo gia stapler, subcutaneous drain, endotracheal, subcutaneous, lobectomy,

The document describes a left lower lobectomy, which is a surgical procedure to remove a lobe of the lung, typically due to conditions such as lung cancer or severe infection. Surgical procedures generally involve risks including bleeding, infection, and complications related to anesthesia. Given these aspects, and its impact on lung function and overall health, the operation can be considered high-stakes for the patient's well-being.


Medical Specialty: Neurology
Sample Name: Anaplastic Astrocytoma - Letter

XYZ,RE:  ABC,MEDICAL RECORD#:  123,Dear Dr. XYZ:,I saw ABC back in Neuro-Oncology Clinic today.  He comes in for an urgent visit because of increasing questions about what to do next for his anaplastic astrocytoma.,Within the last several days, he has seen you in clinic and once again discussed whether or not to undergo radiation for his left temporal lesion.  The patient has clearly been extremely ambivalent about this therapy for reasons that are not immediately apparent.  It is clear that his MRI is progressing and that it seems unlikely at this time that anything other than radiation would be particularly effective.  Despite repeatedly emphasizing this; however, the patient still is worried about potential long-term side effects from treatment that frankly seem unwarranted at this particular time.,After seeing you in clinic, he and his friend again wanted to discuss possible changes in the chemotherapy regimen.  They came in with a list of eight possible agents that they would like to be administered within the next two weeks.  They then wanted another MRI to be performed and they were hoping that with the use of this type of approach, they might be able to induce another remission from which he can once again be spared radiation.,From my view, I noticed a man whose language has deteriorated in the week since I last saw him.  This is very worrisome.  Today, for the first time, I felt that there was a definite right facial droop as well.  Therefore, there is no doubt that he is becoming symptomatic from his growing tumor.  It suggests that he is approaching the end of his compliance curve and that the things may rapidly deteriorate in the near future.,Emphasizing this once again, in addition, to recommending steroids I once again tried to convince him to undergo radiation.  Despite an hour, this again amazingly was not possible.  It is not that he does not want treatment, however.  Because I told him that I did not feel it was ethical to just put him on the radical regimen that him and his friend devised, we compromised and elected to go back to Temodar in a low dose daily type regimen.  We would plan on giving 75 mg/sq m everyday for 21 days out of 28 days.  In addition, we will stop thalidomide 100 mg/day.  If he tolerates this for one week, we then agree that we would institute another one of the medications that he listed for us.  At this stage, we are thinking of using Accutane at that point.,While I am very uncomfortable with this type of approach, I think as long as he is going to be monitored closely that we may be able to get away with this for at least a reasonable interval.  In the spirit of compromise, he again consented to be evaluated by radiation and this time, seemed more resigned to the fact that it was going to happen sooner than later.  I will look at this as a positive sign because I think radiation is the one therapy from which he can get a reasonable response in the long term.,I will keep you apprised of followups.  If you have any questions or if I could be of any further assistance, feel free to contact me.,Sincerely,
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DESCRIPTION: Patient seen in Neuro-Oncology Clinic because of increasing questions about what to do next for his anaplastic astrocytoma.

neurology, neuro oncology, anaplastic astrocytoma, anaplastic, oncology, radiation, astrocytoma

This situation involves a patient with anaplastic astrocytoma, a serious and progressive brain tumor. The patient exhibits symptoms indicating worsening condition (deteriorating language, right facial droop), which are concerning for the progression of the disease. The patient is hesitant to undergo radiation, which is suggested as the most effective treatment option at this stage. The alternative treatment plan is not ideal and relies heavily on monitoring and compromise, reflecting uncertainty about its effectiveness. Such medical decisions could significantly impact the patient's quality of life and survival, making this a high-stakes situation.


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Fusion - Discharge Summary

FINAL DIAGNOSES:,1.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2.  Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and "tension headaches."  In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right.  He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful.  More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7.  In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief.  The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty.  Blood loss was about 125 cc.  Postop x-ray showed good alignment and positioning of the cages, plate, and screws.  After surgery, he was able to slowly increase his activity level with assistance from physical therapy.  He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck.  He also had some nausea with the PCA.  He had a low-grade fever to 100.2 and was started on incentive spirometry.  Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home.  He has been counseled regarding wound care and has received a neck sheet for instruction.  He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks.  He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg.  He is to call if there are any problems.
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DESCRIPTION: Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.

neurosurgery, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy,

The discharge summary pertains to a complex neurosurgical procedure, and such medical scenarios usually have significant implications for the patient's health and quality of life. Any complications, such as post-operative infections or issues with the surgical site, can lead to severe outcomes. Additionally, the procedure involves the cervical spine, which is critical for many bodily functions, including movement and sensation. Managing this patient's post-operative care and recovery is crucial to ensure long-term health and mobility, hence making it a high-stakes situation.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Polycythemia Rubra Vera

CHIEF COMPLAINT: , Polycythemia rubra vera.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old female with a history of polycythemia vera.  She comes in to clinic today for followup.  She has not required phlebotomies for several months.  The patient comes to clinic unaccompanied.,CURRENT MEDICATIONS: , Levothyroxine 200 mcg q.d., Nexium 40 mg q.d., Celebrex 200 mg q.d., vitamin D3 2000 IU q.d., aspirin 81 mg q.d., selenium 200 mg q.d., Aricept 10 mg q.d., Skelaxin 800 mg q.d., ropinirole 1 mg q.d., vitamin E 1000 IU q.d., vitamin C 500 mg q.d., flaxseed oil 100 mg daily, fish oil 100 units q.d., Vicodin q.h.s., and stool softener q.d.,ALLERGIES:  ,Penicillin.,REVIEW OF SYSTEMS:  ,The patient's chief complaint is her weight.  She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key.  She has questions as to whether or not there would be any contra indications to her going on the diet.  Otherwise, she feels great.  She had family reunion in Iowa once in four days out there.  She continues to volunteer Hospital and is walking and enjoying her summer.  She denies any fevers, chills, or night sweats.  She has some mild constipation problem but has had under control.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:
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DESCRIPTION: Polycythemia rubra vera.  The patient is an 83-year-old female with a history of polycythemia vera.  She comes in to clinic today for followup.  She has not required phlebotomies for several months.

soap / chart / progress notes, polycythemia rubra vera, phlebotomy, hematocrit, polycythemia,

The patient is 83 years old with a history of polycythemia vera, but currently reports feeling well, not requiring recent phlebotomies, and has a stable routine. The chief concern mentioned is related to weight and dietary contraindications, not an acute or significantly high-risk health issue. While polycythemia vera is a chronic condition that requires monitoring, the current situation does not present any urgent or severe complications. Thus, it is not a high-stakes scenario.


Medical Specialty: Consult - History and Phy.
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.

consult - history and phy., 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 scenario revolves around a Review of Systems (ROS) in a medical context. This is a standard part of a medical history and physical examination used to identify symptoms and conditions. The description indicates a normal review with no alarming symptoms reported. Although the accuracy of such information is crucial for patient diagnosis, this particular situation involves a standard entry template showing no symptoms of concern. Therefore, it is considered routine and low-stakes.


Medical Specialty: Surgery
Sample Name: Vitrectomy - 1

PREOPERATIVE DIAGNOSIS: , Vitreous hemorrhage and retinal detachment, right eye.,POSTOPERATIVE DIAGNOSIS:,  Vitreous hemorrhage and retinal detachment, right eye.,NAME OF PROCEDURE: , Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.,ANESTHESIA: , Local with standby.,PROCEDURE:  ,The patient was brought to the operating room, and an equal mixture of Marcaine 0.5% and lidocaine 2% was injected in a retrobulbar fashion.  As soon as satisfactory anesthesia and akinesia had been achieved, the patient was prepped and draped in the usual manner for sterile ophthalmic surgery.  A wire lid speculum was inserted.  Three modified sclerotomies were selected at 9, 10, and 1 o'clock.  At the 9 o'clock position, the Accurus infusion line was put in place and tied with a preplaced #7-0 Vicryl suture.  The two superior sites at 10 and 1 were opened up where the operating microscope with the optical illuminating system was brought into position, and closed vitrectomy was begun.  Initially formed core vitrectomy was performed and formed anterior vitreous was removed.  After this was completed, attention was placed in the posterior segment.  Several broad areas of vitreoretinal traction were noted over the posterior pole out of the equator where the previously noted retinal tears were noted.  These were carefully lifted and dissected off the edges of the flap tears and trimmed to the ora serrata.  After all the vitreous had been removed and the membranes released, the retina was completely mobilized.  Total fluid-air exchange was carried out with complete settling of the retina.  Endolaser was applied around the margins of the retinal tears, and altogether several 100 applications were placed in the periphery.  Good reaction was achieved.  The eye was inspected with an indirect ophthalmoscope.  The retina was noted to be completely attached.  The instruments were removed from the eye.  The sclerotomy sites were closed with #7-0 Vicryl suture.  The infusion line was removed from the eye and tied with a #7-0 Vicryl suture.  The conjunctivae and Tenon's were closed with #6-0 plain gut suture.  A collagen shield soaked with Tobrex placed over the surface of the globe, and a pressure bandage was put in place.  The patient left the operating room in a good condition.
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DESCRIPTION: Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.

surgery, vitreous hemorrhage, retinal detachment, combined closed vitrectomy, vitrectomy, membrane peeling, fluid-air exchange, endolaser, vitrectomy with membrane peeling, membrane, peeling, hemorrhage, detachment, vicryl, eye, retinal,

The situation involves a surgical procedure for a vitreous hemorrhage and retinal detachment, which indicates a serious medical condition that requires precision and expertise to prevent potential vision loss. Retinal detachment, if untreated, can lead to permanent blindness. This makes the stakes fairly high since the outcome could significantly impact the patient's quality of life. However, because it was conducted under a controlled surgical environment, it is not at the highest possible stakes. Therefore, this scenario represents a high-stakes situation in the medical field.


Medical Specialty: Emergency Room Reports
Sample Name: Gastrointestinal Bleed - ER Visit

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

The situation involves an 81-year-old patient with a gastrointestinal bleed, which is a potentially life-threatening condition, especially considering the patient's advanced age and medical history, including ulcer disease and congestive heart failure. The dropping hematocrit and the need for a blood transfusion signify significant blood loss. These factors contribute to the high-stakes nature of the case since immediate medical intervention is crucial to prevent further deterioration and stabilize the patient.


Medical Specialty: Surgery
Sample Name: I&D - Gluteal Abscess

PREOPERATIVE DIAGNOSES,1.  Postoperative wound infection.,2.  Left gluteal abscess.,3.  Intraperitoneal pigtail catheter.,POSTOPERATIVE DIAGNOSES,1.  Postoperative wound infection.  There was an intraperitoneal foreign body.,2.  Left gluteal abscess.,3.  Intraperitoneal pigtail catheter.,PROCEDURES,1.  Incision and drainage (I&D) of gluteal abscess.,2.  Removal of pigtail catheter.,3.  Limited exploratory laparotomy with removal of foreign body and lysis of adhesions.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was transferred to the operating room where a time-out process was followed.  Under general endotracheal anesthesia, first of all the patient was positioned in the left lateral decubitus and the left gluteal area was prepped and draped in the usual fashion.  The opening of the abscess was probed and there was a tract of about 20 cm going subcutaneously upward.  I proceeded to enlarge the drainage area and to some degree unroofing the tract partially and then the area was débrided and then packed with iodoform gauze and a temporary dressing was applied.,Then, the patient was placed in a supine position, and I proceeded to remove the pigtail catheter after dividing it to undo its locking mechanism.  It came out without any difficulty.  Then, the colostomy was protected and draped apart, and the patient's abdomen was prepped and draped in the usual fashion.  My initial idea was to just drain and debride the wound infection, which had a sinus tract at lower end of the midline incision.  I initially probed the wound with a hemostat and this had at least 12 cm long tract and I proceeded to excise the badly scarred skin that was on top of it and then continued the dissection to the fascia and I realized that the sinus tract was going through the fascia into the abdomen.  Very carefully, I started dividing the fascia.  Of course, there were several small bowel loops adhered to the area.  The dissection was quite tedious for a while.  Initially, I thought that may be there was an enterocutaneous fistula in the area, but then I realized that the tissue that was interpreted as an intestinal mucosa was actually a very smooth __________ tissue that was walling the sinus tract.  I made a laparotomy of about 10 cm and I carefully dissected the bowel of the fascia.  There was an area at the bottom which looked like a foreign body and initially I thought there was a mesh that can be used to close the abdomen, but later on this substance floated out by self and it was an elongated strip, maybe about 6 cm, which we sent to Pathology for examination.  Initially, I have obtained a sample for culture and sensitivity for aerobic and anaerobic organisms.,I was very happy that we were not really dealing with enterocutaneous fistula.  The area was irrigated generously with saline and then we closed the fascia with number of interrupted figure-of-eight sutures of heavy PPS.  The subcutaneous tissue and the skin were left open and packed with Betadine-soaked sponges.,A dressing was applied.  A small dressing was applied to the area where we removed the pigtail catheter and also we went down to the gluteal area and put a formal dressing in that area.  The patient tolerated the procedure well.  Estimated blood loss was minimal, and he was sent to the ICU and also made acute care because of the need for a laparotomy, which we were not anticipating.
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DESCRIPTION: Incision and drainage (I&D) of gluteal abscess.  Removal of pigtail catheter.  Limited exploratory laparotomy with removal of foreign body and lysis of adhesions.

surgery, intraperitoneal pigtail catheter, postoperative wound infection, foreign body, intraperitoneal, exploratory laparotomy, enterocutaneous fistula, wound infection, sinus tract, gluteal abscess, pigtail catheter, i&d, abscess, laparotomy, fascia, pigtail, catheter, gluteal, incision, foreign

The situation described involves a surgical procedure which includes incision and drainage of a gluteal abscess, removal of a pigtail catheter, a limited exploratory laparotomy, and removal of a foreign body. These procedures are significant, involving anesthesia and exploratory surgery, which can have serious complications if not handled correctly. The patient requires monitoring in the ICU post-surgery, indicating the seriousness of the procedure. Although the patient tolerated the procedure well and the estimated blood loss was minimal, the stakes are still high due to the complexity and potential risks involved.