Medical Specialty: General Medicine
Sample Name: Normal Newborn H&P Template

HISTORY OF PRESENT ILLNESS: , This is a ** week gestational age ** delivered by ** at ** on **.  Gestational age was determined by last menstrual period and consistent with ** trimester ultrasound.  ** rupture of membranes occurred ** prior to delivery and amniotic fluid was clear.  The baby was vertex presentation.  The baby was dried, stimulated, and bulb suctioned.  Apgar scores of ** at one minute and ** at five minutes.,PAST MEDICAL HISTORY,MATERNAL HISTORY:,  The mother is a **-year-old, G**, P** female with blood type **.  She is rubella immune, hepatitis surface antigen negative, RPR nonreactive, HIV negative.  Mother was group B strep **.  Mother's past medical history is **.,PRENATAL CARE: , Mother began prenatal care in the ** trimester and had at least ** documented prenatal visits.  She did not smoke, drink alcohol, or use illicit drugs during pregnancy.,SURGICAL HISTORY: , **,MEDICATIONS:,  Medications taken during this pregnancy were **.,ALLERGIES: , **,FAMILY HISTORY: , **,SOCIAL HISTORY: , **,PHYSICAL EXAMINATION,VITAL SIGNS:  Temperature **, heart rate **, respiratory rate **.  Dextrose stick **.  Ballard score by the RN is ** weeks.  Birth weight is ** grams, which is the ** percentile for gestational age.  Length is ** centimeters which is ** percentile for gestational age.  Head circumference is ** centimeters which is ** percentile for gestational age.,GENERAL:  **Alert, active, nondysmorphic-appearing infant in no acute distress.,HEENT:  Anterior fontanelle open and flat.  Positive bilateral red reflexes.,Ears have normal shape and position with no pits or tags.  Nares patent.  Palate intact.  Mucous membranes moist.,NECK:  Full range of motion.,CARDIOVASCULAR:  Normal precordium, regular rate and rhythm.  No murmurs.  Normal femoral pulses.,RESPIRATORY;  Clear to auscultation bilaterally.  No retractions.,ABDOMEN:  Soft, nondistended.  Normal bowel sounds.  No hepatosplenomegaly.  Umbilical stump is clean, dry, and intact.,GENITOURINARY:  Normal tanner I **.  Anus patent.,MUSCULOSKELETAL:  Negative Barlow and Ortolani.  Clavicles intact.  Spine straight.  No sacral dimple or hair tuft.  Leg lengths grossly symmetric.  Five fingers on each hand and five toes on each foot.,SKIN:  Warm and pink with brisk capillary refill.  No jaundice.,NEUROLOGICAL:  Normal tone.  Normal root, suck, grasp, and Moro reflexes.  Moves all extremities equally.,DIAGNOSTIC STUDIES,LABORATORY DATA:,  **,ASSESSMENT: , Full term, appropriate for gestational age **.,PLAN:,1.  Routine newborn care.,2.  Anticipatory guidance.,3.  Hepatitis B immunization prior to discharge.,
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DESCRIPTION: Template for History and Physical for a newborn.

This is a template for conducting a routine History and Physical (H&P) examination for a newborn, generally taken by healthcare providers after childbirth. It covers various aspects like the birth process, maternal health, physical examination, and routine newborn care including immunization, without indicating immediate medical concerns or emergencies. The situation outlines standard procedure in a medical setting, typically involving no high-stakes decisions unless complications arise, which are not indicated here.


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

Medical Specialty: Orthopedic
Sample Name: Carpal Tunnel Release - 1

PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,TITLE OF THE PROCEDURE: , Right carpal tunnel release.,COMPLICATIONS:,  There were no complications during the procedure.,SPECIMEN:  ,The specimen was sent to pathology.,INSTRUMENTS: , All counts were correct at the end of the case and no complications were encountered.,INDICATIONS:  ,This is a 69-year-old female who have been complaining of right hand pain, which was steadily getting worse over a prolonged period of time.  The patient had tried nonoperative therapy, which did not assist the patient.  The patient had previous diagnosis of carpal tunnel and EMG showed compression of the right median nerve.  As a result of these findings, the patient was sent to my office presenting with this history and was carefully evaluated.  On initial evaluation, the patient had the symptomology of carpal tunnel syndrome.  The patient at the time had the risks, benefits, and alternatives thoroughly explained to her.  All questions were answered.  No guarantees were given.  The patient had agreed to the surgical procedure and the postoperative rehabilitation as needed.,DETAILS OF THE PROCEDURE:  ,The patient was brought to the operating room, placed supine on the operating room table, prepped and draped in the sterile fashion and was given sedation.  The patient was then given sedation.  Once this was complete, the area overlying the carpal ligament was carefully injected with 1% lidocaine with epinephrine.  The patient had this area carefully and thoroughly injected with approximately 10 mL of lidocaine with epinephrine and once this was complete, a 15-blade knife was then used to incise the skin opposite the radial aspect of the fourth ray.  Careful dissection under direct visualization was performed through the subcutaneous fat as well as through the palmar fascia.  A Weitlaner retractor was then used to retract the skin and careful dissection through the palmar fascia would then revealed the transverse carpal ligament.  This was then carefully incised using a 15-blade knife and once entry was again into the carpal canal, a Freer elevator was then inserted and under direct visualization, the carpal ligament was then released.  The transverse carpal ligament was carefully released first in the distal direction until palmar fat could be visualized and by palpation no further ligament could be felt.  The area was well hemostased with the 1% lidocaine with epinephrine and both proximal and distal dissection along the nerve was performed.  Visualization of the transverse carpal ligament was maintained with Weitlaner retractor as well as centric.  Both the centric and the Ragnell were used to retract both proximal and distal corners of the incision and the entirety of the area was under direct visualization at all times.  Palmar fascia was released both proximally and distally as well as the transverse carpal ligament.  Direct palpation of the carpal canal demonstrated a full and complete release.  Observation of the median nerve revealed an area of hyperemia in the distal two-thirds of the nerve, which demonstrated the likely area of compression.  Once this was complete, hemostasis was established using bipolar cautery and some small surface bleeders and irrigation of the area was performed and then the closure was achieved with 4-0 chromic suture in a horizontal mattress and interrupted stitch.  Xeroform was then applied to the incision.  A bulky dressing was then applied consisting of Kerlix and Ace wrap, and the patient was taken to the recovery room in stable condition without any complications.
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DESCRIPTION: Right carpal tunnel release.

Right carpal tunnel release.

orthopedic, carpal tunnel syndrome, ace wrap, emg, freer elevator, kerlix, weitlaner retractor, bulky dressing, carpal tunnel, carpal tunnel release, palmar fascia, subcutaneous fat, lidocaine with epinephrine, transverse carpal ligament, carpal ligament, carpal, tunnel, ligament,

The procedure described is a right carpal tunnel release, which is a common orthopedic surgery for treating carpal tunnel syndrome. While it is a surgical procedure, it is generally considered routine and low risk, with a low likelihood of complications when performed correctly. The document indicates that there were no complications during the surgery and the patient was stable post-operation. Therefore, while the procedure is important for the patient's quality of life, it does not typically involve high stakes comparable to more complex surgeries or life-threatening conditions.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Tonsillectomy & Adenoidectomy - 2

PREOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,OPERATION PERFORMED: , Tonsillectomy & adenoidectomy.,ANESTHESIA: , General endotracheal.,FINDINGS: , The tonsils were 3+ enlarged and cryptic.,DESCRIPTION OF OPERATION:,  Under general anesthesia with an endotracheal tube, the patient was placed in supine position.  A mouth gag was inserted and suspended from Mayo stand.  Red rubber catheter was placed through the nose and pulled up through the mouth with elevation of the palate.  The adenoid area was inspected.  The adenoids were small.  The left tonsil was grasped with a tonsil tenaculum.  The tonsil was removed with the Gold laser.  The apposite tonsil was removed in a similar manner.  Hemostasis was secured with electrocautery.  Both tonsillar fossae were injected with 0.25% Marcaine with adrenaline.  The patient tolerated the procedure well and left the operating room in good condition.
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DESCRIPTION: Tonsillectomy & adenoidectomy.  Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.

surgery, tonsil, gold laser, adenoids, chronic tonsillitis, adenoid hypertrophy, tonsillectomy, adenoidectomy, endotracheal, tonsillitis, symptomatic, hypertrophy

The described procedure, tonsillectomy and adenoidectomy, is a routine surgical procedure often performed to resolve chronic tonsillitis and airway obstruction issues. While surgery always carries some risk, this procedure is generally considered low-risk, especially since the patient tolerated the procedure well and left the operating room in good condition. There are no indications of complications or extraordinary circumstances.


Medical Specialty: Urology
Sample Name: Pyeloplasty - Robotic

PROCEDURES:,1.  Robotic-assisted pyeloplasty.,2.  Anterograde right ureteral stent placement.,3.  Transposition of anterior crossing vessels on the right.,4.  Nephrolithotomy.,DIAGNOSIS:,  Right ureteropelvic junction obstruction.,DRAINS:,1.  Jackson-Pratt drain times one from the right flank.,2.  Foley catheter times one.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS: , None.,SPECIMENS:,1.  Renal pelvis.,2.  Kidney stones.,INDICATIONS:  ,The patient is a 30-year-old Caucasian gentleman with history of hematuria subsequently found to have right renal stones and patulous right collecting system with notable two right crossing renal arteries.  Up on consideration of various modalities and therapy, the patient decided to undergo surgical therapy.,PROCEDURE IN DETAIL:  ,The patient was verified by armband and the procedure being robotic-assisted right pyeloplasty with nephrolithotomy was verified, and the procedure was carried out.  After institution of general endotracheal anesthesia and intravenous preoperative antibiotics, the patient was positioned into the right flank position with his right flank elevated.  Great care was taken to pad all pressure points and a right arm hanger was used.  The patient was flexed slightly, and a kidney rest was used.  Sequential compression devices were also placed.  Next, the patient was prepped and draped in normal sterile fashion with povidone-iodine.  Pneumoperitoneum was obtained by placing a Veress needle in the area of the umbilicus after it passed the water test.  A low pressure, high flow pneumoperitoneum was adequately obtained using CO2 gas.  Next, a 12-mm camera port was placed near the umbilicus.  The camera was inserted, and no bowel injury was seen.  Next, under direct vision flanking 8 mm camera ports, a 12 mm assist port, a 5 mm liver retraction port, and 5 mm assist port were placed.  The robot was docked and the instruments passed through respective checks.  Initial attention was directed to mobilizing the right colon from the abdominal wall totally medially.  Next, the right lateral duodenum was cauterized for further access to the right retroperitoneum.  At this point, the right kidney was in clear view, and the fascia was entered.  Initial attention was directed at careful dissection of the renal pelvis and proximal ureter which was done with a combination of electrocautery and blunt dissection.  It became readily apparent that there were two crossing vessels one in the medial inferior region of the kidney and another one in the most inferior portion of the lower pole.  These arteries were dissected carefully and vessel loops were applied.  Next, a small hole was then made in the renal pelvis using electrocautery and the contents of the renal pelvis were suctioned out.  The pyelotomy was extended so that the renal collecting system could be directly inspected.  Sequentially, each major calyx was inspected under direct vision and irrigated.  A total of four round kidney stones were extracted to be sent for analysis to being satisfied for the patient.  At this point, we directed our attention at the proximal right ureter which was dismembered from the remaining renal pelvis.  The proximal ureter was spatulated using cold scissors.  Next, redundant renal pelvis was excised using cold scissors and sent for permanent section.  We then identified the most inferior/dependent portion of the renal pelvis and placed a heel stitch at this for ureteral-renal pelvis anastomosis in a semi running fashion.  3-0 Monocryl sutures were used to re-anastomose the newly spatulated right ureter to the inferior portion of the renal pelvis.  Next, remainder of the pyelotomy was closed to itself also using 2-0 Monocryl sutures.  Before final stitches were placed, a 6x28 ureteral stent was placed anterograde.  This was accomplished by placing the stents over a guidewire, placing the guidewire under direct vision anterograde through the ureter.  This was done until the proximal end was in the renal pelvis, the guidewire was removed, and good proximal curl was verified by direct vision.  Then, the pyelotomy was completely closed again with 2-0 Monocryl sutures.  Next, attention was directed at transposition of the crossing renal artery by fixing it with Vicryl suture that would impinge less upon the renal pelvis.  Good pulsation was verified by direct vision proximal and distal to these pexy sutures.  Next, Gerota's fascia was reapproximated and closed with Vicryl sutures as was the right peritoneum.  Hemostasis appeared excellent at this point.  There was no obvious urine extravasation.  At this time, the procedure was terminated.  The robot was undocked.  Under direct visualization all 8 and 12 mm ports were closed at the level of the fascia with 0 Vicryl sutures in an interrupted fashion.  Then, all skin port sites were closed with 4-0 Monocryl in a subcuticular fashion and Dermabond and band-aids were applied over this.  Also, notably a Jackson-Pratt drain was placed in the area of the right kidney and additional right flank stab incision.  The patient tolerated the procedure well and no immediate perioperative complication was noted.,DISPOSITION: , The patient was discharged to Post Anesthesia Care Unit and subsequently to genitourinary floor to begin his recovery.
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DESCRIPTION: Right ureteropelvic junction obstruction.  Robotic-assisted pyeloplasty, anterograde right ureteral stent placement, transposition of anterior crossing vessels on the right, and nephrolithotomy.

urology, pyeloplasty, ureteral stent placement, nephrolithotomy, ureteropelvic junction obstruction, jackson-pratt drain, foley catheter, renal pelvis, kidney stones, monocryl sutures, pelvis, renal, ureteropelvic, sutures,

The described procedure involves a robotic-assisted pyeloplasty and nephrolithotomy which are complex surgical operations on the urinary tract, specifically addressing an obstruction and removing kidney stones. The procedure is invasive, requiring anesthesia and precision in handling the crossing renal vessels and re-anastomosis of the ureter. Given these details, this situation involves significant medical risks such as complications from anesthesia, potential damage to surrounding tissues or organs, and the need for precise surgical technique to ensure no long-term damage or complications like infection, bleeding, or further obstruction. Additionally, renal procedures have the risk of impacting kidney function if complications arise. However, the procedure went smoothly with minimal estimated blood loss and no immediate complications reported. While not life-threatening in the standard execution, the inherent nature of the surgery and potential for severe complications classify this as a high-stakes situation.


Medical Specialty: Urology
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.

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

The situation involves a medical procedure (flexible cystoscopy) to evaluate microscopic hematuria, with findings indicating mild benign prostatic hyperplasia. The procedure was completed without complications and the patient's condition is stable. The plan is to continue with conservative observation, indicating non-urgent follow-up care. Thus, the stakes are relatively low as there are no immediate serious health threats or invasive interventions required.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy - 5

MEDICATIONS:,1.  Versed intravenously.,2.  Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent, the patient was placed in the left lateral decubitus position and Cetacaine spray was applied to the posterior pharynx.  The patient was sedated with the above medications.  The Olympus video panendoscope was advanced under direct vision into the esophagus.  The esophagus was normal in appearance and configuration.  The gastroesophageal junction was normal.  The scope was advanced into the stomach, where the fundic pool was aspirated and the stomach was insufflated with air.  The gastric mucosa appeared normal.  The pylorus was normal.  The scope was advanced through the pylorus into the duodenal bulb, which was normal, then into the second part of the duodenum, which was normal as well.  The scope was pulled back into the stomach.  Retroflexed view showed a normal incisura, lesser curvature, cardia and fundus.  The scope was straightened out, the air removed and the scope withdrawn.  The patient tolerated the procedure well.  There were no apparent complications.,
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DESCRIPTION: Esophagogastroduodenoscopy.  The Olympus video panendoscope was advanced under direct vision into the esophagus.  The esophagus was normal in appearance and configuration.  The gastroesophageal junction was normal.

gastroenterology, duodenal bulb, gastric mucosa, olympus video, video panendoscope, gastroesophageal junction, esophagogastroduodenoscopy, gastroesophageal, pylorus, stomach, esophagus, scopeNOTE

The situation involves a routine medical procedure known as an esophagogastroduodenoscopy (EGD). This procedure is generally considered low-risk and is commonly performed to examine the lining of the esophagus, stomach, and the first part of the small intestine. The details provided indicate that the patient was sedated and the procedure was uneventful, with everything appearing normal and no complications encountered. While it is a medical procedure and inherently carries some level of risk, the fact that it's described as normal with no issues places it on the lower end of the high-stakes spectrum.


Medical Specialty: Hematology - Oncology
Sample Name: Intensity-Modulated Radiation Therapy

INTENSITY-MODULATED RADIATION THERAPY,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.  The treatment planning process requires at least 4 hours of physician time.  The technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures.  Sequential CT scans are obtained and transferred to the treatment planning software.  Extensive analysis occurs.  The target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected.  In addition, organs at risk are outlined.  Doses are selected both for targets, as well as for organs at risk.  Associated dose constraints are placed.  Inverse treatment planning is then performed in conjunction with the physics staff.  These are reviewed by the physician and ultimately performed only following approval by the physician.  Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk.  This is performed in hopes of minimizing associated complications.  The physician delineates the treatment type, number of fractions and total volume.  During the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance.  In addition, specific QA is performed by the physics staff under the physician's direction.,In view of the above, the special procedure code 77470 is deemed appropriate.
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DESCRIPTION: Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.

hematology - oncology, multiple beam arrangements, intensity modulated radiation therapyNOTE,: 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 use of Intensity-Modulated Radiation Therapy (IMRT) in hematology-oncology involves detailed planning and execution to target tumors while minimizing damage to surrounding tissues. Given its complexity and the critical nature of its application in treating cancer, it is definitely a high-stakes situation. The potential for significant impact on patient outcomes due to the precision required and the potential risks involved with misapplication make this scenario high-stakes. Furthermore, extensive physician intervention and monitoring are necessary, indicating the importance and seriousness of the procedure.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Female Exam Template - 2

VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE:,  Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT: , Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:,  Lungs are bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI nondisplaced.  Chest wall unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS:,  In the seated and supine position unremarkable.,ABDOMEN: , No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and no intraabdominal bruit auscultated.,EXTERNAL GENITALIA: , Normal for age.,RECTAL: , Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK:,  Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC:,  Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN: , Unremarkable for any premalignant or malignant condition with normal changes for age.
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DESCRIPTION: An example/template for a routine normal female physical exam.

consult - history and phy., heent, general appearance, hepatosplenomegaly, mass, tenderness, rebound, rigidity, pulse, bruit, adenopathy, chest, percussion, inspection, palpation, signs, tongue,

The provided situation is a template for a routine female physical exam, with no immediate health concerns or abnormalities noted. It serves as a documentation guide for medical practitioners and does not involve any urgent health decisions or high-risk implications. Therefore, it is low-stakes.


Medical Specialty: Surgery
Sample Name: Delivery Note - 5

DELIVERY NOTE: , This is a 30-year-old G7, P5 female at 39-4/7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away.  She was admitted and started on Pitocin.  Her cervix is 3 cm, 50% effaced and -2 station.  Artificial rupture of membrane was performed for clear fluid.  She did receive epidural anesthesia.  She progressed to complete and pushing.  She pushed to approximately one contraction and delivered a live-born female infant at 1524 hours.  Apgars were 8 at 1 minute and 9 at 5 minutes.  Placenta was delivered intact with three-vessel cord.  The cervix was visualized.  No lacerations were noted.  Perineum remained intact.  Estimated blood loss is 300 mL.  Complications were none.  Mother and baby remained in the birthing room in good condition.
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DESCRIPTION: Artificial rupture of membrane was performed for clear fluid.  She did receive epidural anesthesia.  She progressed to complete and pushing.

surgery, perineum, placenta, rupture of membrane, artificial rupture, cervix, delivery, inductionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation described in the delivery note involves a routine childbirth where the patient had previously large babies and lived far from the hospital, hence the induction. The birth process went smoothly with no noted complications, and both mother and baby were reported to be in good condition. There was no mention of any emergency situations or significant medical challenges, thus making it a low-stakes scenario in the context of surgical and obstetric practice.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 8

SUBJECTIVE:,  The patient comes in today for a comprehensive evaluation.  She is well-known to me.  I have seen her in the past multiple times.,PAST MEDICAL HISTORY/SOCIAL HISTORY/FAMILY HISTORY: , Noted and reviewed today.  They are on the health care flow sheet.  She has significant anxiety which has been under fair control recently.  She has a lot of stress associated with a son that has some challenges.  There is a family history of hypertension and strokes.,CURRENT MEDICATIONS:,  Currently taking Toprol and Avalide for hypertension and anxiety as I mentioned.,REVIEW OF SYSTEMS:,  Significant for occasional tiredness.  This is intermittent and currently not severe.  She is concerned about the possibly of glucose abnormalities such diabetes.  We will check a glucose, lipid profile and a Hemoccult test also and a mammogram.  Her review of systems is otherwise negative.,PHYSICAL EXAMINATION:,VITAL SIGNS:  As above.,GENERAL:  The patient is alert, oriented, in no acute distress.,HEENT:  PERRLA.  EOMI.  TMs clear bilaterally.  Nose and throat clear.,NECK:  Supple without adenopathy or thyromegaly.  Carotid pulses palpably normal without bruit.,CHEST:  No chest wall tenderness.,BREAST EXAM:  No asymmetry, skin changes, dominant masses, nipple discharge, or axillary adenopathy.,HEART:  Regular rate and rhythm without murmur, clicks, or rubs.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Soft, nontender, bowel sounds normoactive.  No masses or organomegaly.,GU:  External genitalia without lesions.  BUS normal.  Vulva and vagina show just mild atrophy without any lesions.  Her cervix and uterus are within normal limits.  Ovaries are not really palpable.  No pelvic masses are appreciated.,RECTAL:  Negative.,BREASTS:  No significant abnormalities.,EXTREMITIES:  Without clubbing, cyanosis, or edema.  Pulses within normal limits.,NEUROLOGIC:  Cranial nerves II-XII intact.  Strength, sensation, coordination, and reflexes all within normal limits.,SKIN:  Noted to be normal.  No subcutaneous masses noted.,LYMPH SYSTEM:  No lymphadenopathy.,ASSESSMENT:,  Generalized anxiety and hypertension, both under fair control.,PLAN:,  We will not make any changes in her medications.  I will have her check a lipid profile as mentioned, and I will call her with that.  Screening mammogram will be undertaken.  She declined a sigmoidoscopy at this time.  I look forward to seeing her back in a year and as needed.
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DESCRIPTION: Comprehensive Evaluation - Generalized anxiety and hypertension, both under fair control.

The patient's anxiety and hypertension are under fair control, and there is no indication of immediate life-threatening conditions in the current examination. Although there is concern about glucose levels and potential diabetes, these issues will be addressed through routine testing. The overall evaluation shows stable health with no urgent or critical interventions required at this time. The absence of severe symptoms or immediate medical threats indicates this is not a high-stakes situation.


Medical Specialty: Urology
Sample Name: Meatotomy Template

OPERATIVE NOTE:  ,The patient was taken to the operating room and was placed in the supine position on the operating room table.  A general inhalation anesthetic was administered.  The patient was prepped and draped in the usual sterile fashion.  The urethral meatus was calibrated with a small mosquito hemostat and was gently dilated.  Next a midline ventral type incision was made opening the meatus.  This was done after clamping the tissue to control bleeding.  The meatus was opened for about 3 mm.  Next the meatus was calibrated and easily calibrated from 8 to 12 French with bougie sounds.  Next the mucosal edges were everted and reapproximated to the glans skin edges with approximately five interrupted 6-0 Vicryl sutures.  The meatus still calibrated between 10 and 12 French.  Antibiotic ointment was applied.  The procedure was terminated.  The patient was awakened and returned to the recovery room in stable condition.
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DESCRIPTION: An example/template for meatotomy.

An example/template for meatotomy.

urology, urethral meatus, mosquito hemostat, meatus, mucosal edges, glans, meatotomyNOTE,: 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 document describes a standard surgical procedure known as meatotomy, often undertaken to address urethral stricture issues. While it involves surgery under general anesthesia and there are inherent risks such as infection or complications from anesthesia, it is considered a routine, minor procedure in urology with well-established protocols. The patient was reported to be stable post-operation, indicating a successful procedure without immediate complications. Thus, it presents as a low-risk, low-stakes situation within the context of urological surgeries.


Medical Specialty: General Medicine
Sample Name: Toothache - ER Visit

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

general medicine, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental,

The primary concern in this scenario is a toothache and dental pain, which, while uncomfortable, typically isn't immediately life-threatening. The patient has chronic dental issues but no significant systemic symptoms or signs of a severe infection, as indicated by the lack of fever, swelling, or abscess. Although he requested stronger pain medication, this is often a subjective measure of pain tolerance and management. The situation could escalate if untreated dental infections develop into systemic infections, but as of now, it remains relatively low-stakes. The patient has been stabilized and discharged with a follow-up plan.


Medical Specialty: Orthopedic
Sample Name: McBride Bunionectomy & Wedge Osteotomy

PREOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1.  Right McBride bunionectomy.,2.  Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle cuff.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in a supine position.  The right foot was prepared and draped in usual sterile manner.  Anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint.  Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg.  At this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made.  The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure.  The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection.  Using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp.  At this time, attention was directed to the first inner space using sharp and blunt dissection.  Dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments.  The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment.  At this time, the lateral release was stressed and was found to be complete.  The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw.  The area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted.  At this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length.  The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption.  At this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint.  At this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge.  The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3.0 x 22 mm.  The screw was placed following proper technique.  The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing.  A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy.  The packing of the cancellous bone was held in place with bone wax.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed.  At this time, a deep closure was achieved utilizing #2-0 Vicryl suture, subcuticular closure was achieved using #4-0 Vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion.  The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site.  At this time, the surgical site was postoperatively injected with 0.5 Marcaine plain as well as dexamethasone 4 mg primarily.  The surgical sites were then dressed with sterile Xeroform, sterile 4x4s, cascading, and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion.  The tourniquet was dropped and color and temperature of all digits returned to normal.  The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided.  The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.,
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DESCRIPTION: Right hallux abductovalgus deformity.  Right McBride bunionectomy.  Right basilar wedge osteotomy with OrthoPro screw fixation.

orthopedic, hallux, abductovalgus, bunionectomy, mcbride, basilar, wedge, osteotomy, orthopro, screw, fixation, wedge osteotomy

The procedure described involves an orthopedic surgery to correct a foot deformity, which is generally a routine and low-risk operation. It is not life-threatening and is performed to improve the patient's quality of life. However, it is important that the patient follows postoperative instructions to ensure proper healing. The stakes are low because there are no indications of complications or life-threatening scenarios in the information provided.


Medical Specialty: Discharge Summary
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.

discharge summary, sepsis, organic brain syndrome, seizure disorder, anemia of chronic disease, adrenal insufficiency, blood, cultures

The discharge summary involves multiple serious medical conditions including hypothermia, possible secondary adrenal insufficiency, secondary hypothyroidism, organic brain syndrome, and a seizure disorder. The patient's health is fragile, as noted by the transfer from ICU to a nursing home and a poor prognosis. Additionally, there is a need for coordination with multiple healthcare providers and facilities, indicating high complexity and high consequences if post-discharge care isn't properly managed.


Medical Specialty: Neurology
Sample Name: Electroencephalogram

DESCRIPTION OF RECORD:  ,This tracing was obtained utilizing 27 paste-on gold-plated surface disc electrodes placed according to the International 10-20 system.  Electrode impedances were measured and reported at less than 5 kilo-ohms each.,FINDINGS: , In general, the background rhythms are bilaterally symmetrical.  During the resting awake state they are composed of moderate amounts of low amplitude fast activity intermixed with moderate amounts of well-modulated 9-10 Hz alpha activity best seen posteriorly.  The alpha activity attenuates with eye opening.,During some portions of the tracing the patient enters a drowsy state in which the background rhythms are composed predominantly of moderate amounts of low amplitude fast activity intermixed with moderate amounts of low to medium amplitude polymorphic theta activity.,There is no evidence of focal slowing or paroxysmal activity.,IMPRESSION: , Normal awake and drowsy (stage I sleep) EEG for patient's age.
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DESCRIPTION: Normal awake and drowsy (stage I sleep) EEG for patient's age.

neurology, gold-plated surface disc electrodes, paroxysmal activity, eeg, drowsy stage, sleep eeg, stage, sleep, electrodes, awake, moderate, activity

The situation involves reviewing and interpreting the results of an electroencephalogram (EEG), which is a routine and standard procedure in neurology. The findings in this specific example indicate normal EEG results for both the awake and drowsy states, which suggests there are no immediate concerns or abnormal observations that would necessitate urgent or critical action. As such, the stakes are relatively low given that the interpretation confirms normal brain activity.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Well-Child Check - 4

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

1-year well child check.

pediatrics - neonatal, well child check, denver ii, child check, checkup, check, child,

The situation described is a standard 1-year well-child check in a pediatric setting. The assessment shows the child is developing normally with no immediate health concerns, and anticipatory guidance is given. While the child's health is always important, there are no acute or severe issues presented, such as a life-threatening condition or urgent medical need. Therefore, this scenario is routine and low-stakes in nature.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal Female Exam Template - 1

PHYSICAL EXAMINATION,GENERAL:  ,The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative.  No dysarthria is noted.  No discomfort on presentation is noted.,HEAD: , Atraumatic, normocephalic.  Pupils are equal, round and reactive to light.  Extraocular muscles are intact.  Sclerae are white without injection or icterus.  Fundi are without papilledema, hemorrhages or exudates with normal vessels.,EARS:  ,The ear canals are patent without edema, exudate or drainage.  Tympanic membranes are intact with a normal cone of light.  No bulging or erythema to indicate infection is present.  There is no hemotympanum.  Hearing is grossly intact.,NOSE: , Without deformity, bleeding or discharge.  No septal hematoma is noted.,ORAL CAVITY: , No swelling or abnormality to the lip or teeth.  Oral mucosa is pink and moist.  No swelling to the palate or pharynx.  Uvula is midline.  The pharynx is without exudate or erythema.  No edema is seen of the tonsils.  The airway is completely patent.  The voice is normal.  No stridor is heard.,NECK: , No signs of meningismus.  No Brudzinski or Kernig sign is present.  No adenopathy is noted.  No JVD is seen.  No bruits are auscultated.  Trachea is midline.,CHEST: , Symmetrical with equal breath sounds.  Equal excursion.  No hyperresonance or dullness to percussion is noted.  There is no tenderness on palpation of the chest.,LUNGS: , Clear to auscultation bilaterally.  No rales, rhonchi or wheezes are appreciated.  Good air movement is auscultated in all 4 lung fields.,HEART: , Regular rate and rhythm.  No murmur.  No S3, S4 or rub is auscultated.  Point of maximal impulse is strong and in normal position.  Abdominal aorta is not palpable.  The carotid upstroke is normal.,ABDOMEN: , Soft, nontender and nondistended.  Normal bowel sounds are auscultated.  No organomegaly is appreciated.  No masses are palpated.  No tympany is noted on percussion.  No guarding, rigidity or rebound tenderness is seen on exam.  Murphy and McBurney sign is negative.  There is no Rovsing, obturator or psoas sign present.  No hepatosplenomegaly and no hernias are noted.,RECTAL: , Normal tone.  No masses.  Soft, brown stool in the vault.  Guaiac negative.,GENITOURINARY: , External genitalia without erythema, exudate or discharge.  Vaginal vault is without discharge.  Cervix is of normal color without lesion.  The os is closed.  There is no bleeding noted.  Uterus is noted to be of normal size and nontender.  No cervical motion tenderness is seen.  No masses are palpated.  The adnexa are without masses or tenderness.,EXTREMITIES: , No clubbing, cyanosis or edema.  Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal.  No deformity or signs of trauma.  All joints are stable without laxity.  There is good range of motion of all joints without tenderness or discomfort.  Homan sign is negative.  No atrophy or contractures are noted.,SKIN: , No rashes.  No jaundice.  Pink and warm with good turgor.  Good color.  No erythema or nodules noted.  No petechia, bulla or ecchymosis.,NEUROLOGIC: , Cranial nerves II through XII are grossly intact.  Muscle strength is graded 5/5 in the upper and lower extremities bilaterally.  Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally.  Babinski is downgoing bilaterally.  Sensation is intact to light touch and vibration.  Gait is normal.  Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal.  There is no ataxia seen on gait testing.  Tone is normal.  No pronator drift is seen.,PSYCHIATRIC:  ,The patient is oriented x4.  Mood and affect are appropriate.  Memory is intact with good short- and long-term memory recall.  No dysarthria is noted.  Remote memory is intact.  Judgment and insight appear normal.
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DESCRIPTION: An example/template for a routine normal female physical exam.

The situation described is a routine physical examination template, which is a standard procedure in medical practice. It includes a comprehensive overview of a normal exam with findings that indicate the absence of abnormalities. Routine physical exams are low-stakes situations as they are part of regular health maintenance and do not involve emergency interventions, immediate health risks, or significant decision-making scenarios.


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

Medical Specialty: Surgery
Sample Name: Cardiac Catheterization - 10

EXAM: , Left Heart Catheterization,REASON FOR EXAM:,  Chest pain, coronary artery disease, prior bypass surgery.,INTERPRETATION: , The procedure and complications were explained to the patient in detail and formal consent was obtained.  The patient was brought to the cath lab.  The right groin was draped in the usual sterile manner.  Using modified Seldinger technique, a 6-French arterial sheath was introduced in the right common femoral artery.  A JL4 catheter was used to cannulate the left coronary arteries.  A JR4 catheter was used to cannulate the right coronary artery and also bypass grafts.  The same catheter was used to cannulate the vein graft and also LIMA.  I tried to attempt to cannulate other graft with Williams posterior catheter and also bypass catheter was unsuccessful.  A 6-French pigtail catheter was used to perform left ventriculography and pullback was done.  No gradient was noted.  Arterial sheath was removed.  Hemostasis was obtained with manual compression.  The patient tolerated the procedure very well without any complications.,FINDINGS:,1.  Native coronary arteries.  The left main is patent.  The left anterior descending artery is not clearly visualized.  The circumflex artery appears to be patent.  The proximal segment gives rise to small caliber obtuse marginal vessel.,2.  Right coronary artery is patent with mild distal and mid segment.  No evidence of focal stenosis or dominant system.,3.  Bypass graft LIMA to the left anterior descending artery patent throughout the body as well the anastomotic site.  There appears to be possible _______ graft to the diagonal 1 vessel.  The distal LAD wraps around the apex.  No stenosis following the anastomotic site noted.,4.  Vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel.,5.  No other bypass grafts are noted by left ventriculography and also aortic root shot.,6.  Left ventriculography with an ejection fraction of 60%.,IMPRESSION:,1.  Left coronary artery disease native.,2.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  _______ graft to the diagonal 1 vessel.,3.  Native right coronary artery is patent, mild disease.,RECOMMENDATIONS: , Medical treatment.
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DESCRIPTION: Left Heart Catheterization.  Chest pain, coronary artery disease, prior bypass surgery.  Left coronary artery disease native.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  Native right coronary artery is patent, mild disease.

surgery, chest pain, coronary artery disease, bypass surgery, heart catheterization, lima, lad, obtuse marginal vessel, vein graft, obtuse marginal, marginal vessel, coronary artery, catheterization, coronary, artery, obtuse, marginal, bypass, vessel, graft

The procedure described is a cardiac catheterization, which is a common but invasive medical procedure typically used to diagnose heart conditions such as coronary artery disease. The stakes are high because it involves direct intervention in the cardiovascular system, presenting risks like bleeding, infection, or even heart attack. The patient has a history of prior bypass surgery, indicating an existing high-risk cardiac profile. The outcome has significant implications for the patient's health status and future treatment options.


Medical Specialty: Surgery
Sample Name: Vasectomy

PREOPERATIVE DIAGNOSIS: , Voluntary sterility.,POSTOPERATIVE DIAGNOSIS: , Voluntary sterility.,OPERATIVE PROCEDURE:,  Bilateral vasectomy.,ANESTHESIA:,  Local.,INDICATIONS FOR PROCEDURE:  ,A gentleman who is here today requesting voluntary sterility.  Options were discussed for voluntary sterility and he has elected to proceed with a bilateral vasectomy.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, and after appropriately identifying the patient, the patient was prepped and draped in the standard surgical fashion and placed in a supine position on the OR table.  Then, 0.25% Marcaine without epinephrine was used to anesthetize the scrotal skin.  A small incision was made in the right hemiscrotum.  The vas deferens was grasped with a vas clamp.  Next, the vas deferens was skeletonized.  It was clipped proximally and distally twice.  The cut edges were fulgurated.  Meticulous hemostasis was maintained.  Then, 4-0 chromic was used to close the scrotal skin on the right hemiscrotum.  Next, the attention was turned to the left hemiscrotum, and after the left hemiscrotum was anesthetized appropriately, a small incision was made in the left hemiscrotum.  The vas deferens was isolated.  It was skeletonized.  It was clipped proximally and distally twice.  The cut edges were fulgurated.  Meticulous hemostasis was maintained.  Then, 4-0 chromic was used to close the scrotal skin.  A jockstrap and sterile dressing were applied at the end of the case.  Sponge, needle, and instruments counts were correct.
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DESCRIPTION: Voluntary sterility.  Bilateral vasectomy.  The vas deferens was grasped with a vas clamp.  Next, the vas deferens was skeletonized.  It was clipped proximally and distally twice.

surgery, hemiscrotum, bilateral vasectomy, voluntary sterility, vas deferens, vasectomy, skeletonized, scrotal, sterility, deferens

The situation involves a surgical procedure, specifically a bilateral vasectomy, which is a relatively common, straightforward outpatient surgery associated with low risk. Vasectomy is an elective procedure requested by the patient for voluntary sterility. The potential stakes include procedural risks like infection or bleeding, but these are generally low due to the nature of the procedure and are often well-managed with standard medical practices. There is no immediate life-threatening condition involved, and it is a routine surgical procedure for experienced practitioners. Therefore, it is not considered high-stakes in the medical field.


Medical Specialty: Ophthalmology
Sample Name: Cataract Extraction - 2

PREOPERATIVE DIAGNOSIS: , Cataract, left eye.,POSTOPERATIVE DIAGNOSIS:  ,Cataract, left eye.,PROCEDURE PERFORMED:  ,Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE: , After the induction of topical anesthesia with 4% Xylocaine drops, the left eye was prepped and draped in the usual fashion.  A speculum was inserted, and the microscope was moved into position.,A 3.2-mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o'clock position, and 0.1 cc of 1% Xylocaine without preservative was instilled into the anterior chamber.  It was then filled with viscoelastic.  A stab incision was made into the anterior chamber at the limbus at 5 o'clock position with a microblade.,A cystitome was used to make a capsulotomy, and the capsulorrhexis forceps were used to complete a circular capsulorrhexis.  The nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26-gauge cannula, and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision.  The irrigation-aspiration handpiece was used to systematically aspirate cortex 360 degrees.  The posterior capsule was vacuumed; it was clear and intact.,The capsular bag and the anterior chamber were filled with viscoelastic.  A model MA30AC lens, power 21.5 diopters, serial number 864414.095, was folded, grasped with the lens insertion forceps and inserted into the capsular bag.  The trailing loop was placed inside the bag.  The viscoelastic was removed with the irrigation-aspiration handpiece.  The lens centered well.  A single 10-0 nylon suture was placed to close the wound.  It was checked and ascertained to be watertight.  Decadron 0.25 cc, 0.25 cc of antibiotic and 0.25 cc of Xylocaine were injected subconjunctivally.  Dexacidin ointment was placed in the eye, and the procedure was terminated.,The procedure was well tolerated by the patient who was returned to the recovery room in good condition.
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DESCRIPTION: Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.

ophthalmology, anterior chamber, keratome, limbus, intraocular lens, cataract extraction, extracapsular, phacoemulsification, capsular, cataract, chamber, intraocular,

The described procedure is an extracapsular cataract extraction with phacoemulsification and implantation of an intraocular lens, which is a commonly performed and routine surgery in the field of ophthalmology. It is generally considered low to moderate risk with a high success rate. The document indicates that there were no complications and the patient tolerated the procedure well, which suggests it is a low-stakes situation. However, since it is still a surgical procedure on the eye, I will not rate it at the absolute lowest on the scale.


Medical Specialty: Office Notes
Sample Name: Post Dilation Instructions

The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult and sensitivity to light may increase. For a short time, wearing sunglasses may help.
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DESCRIPTION: Sample post dilation patient instructions.

office notes, dilation drops, eye dilation, sunglasses, blindness, eye examinations, dilation, eyesNOTE,: 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 given scenario pertains to routine post-dilation instructions after an eye examination. This is a very standard procedure that does not involve critical or high-risk factors. The potential risks, such as light sensitivity and difficulty reading, are mild and temporary, and the patient is advised to wear sunglasses for comfort. There is no immediate danger or severe consequence attached to not following the instructions beyond temporary discomfort.


Medical Specialty: Radiology
Sample Name: Barium Enema

EXAM: , Barium enema.,CLINICAL HISTORY: , A 4-year-old male with a history of encopresis and constipation.,TECHNIQUE:  ,A single frontal scout radiograph of the abdomen was performed.  A rectal tube was inserted in usual sterile fashion, and retrograde instillation of barium contrast was followed via spot fluoroscopic images.  A post-evacuation overhead radiograph of the abdomen was performed.,FINDINGS:,  The scout radiograph demonstrates a nonobstructive gastrointestinal pattern.  There are no suspicious calcifications seen or evidence of gross free intraperitoneal air.  The visualized lung bases and osseous structures are within normal limits.,The rectum and colon is of normal caliber throughout its course.  There is no evidence of obstruction, as contrast is seen to flow without difficulty into the right colon and cecum.  A small amount of contrast is seen to opacify small bowel loops on the post-evacuation image.  There is also opacification of a normal-appearing appendix documented.,IMPRESSION: , Normal barium enema.
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DESCRIPTION: Barium enema - history of encopresis and constipation.

radiology, encopresis and constipation, scout radiograph, post evacuation, barium enema, encopresis, constipation, evacuation, colon, radiograph, contrast, enema, barium,

The described situation is a routine diagnostic procedure (barium enema) for a common pediatric condition (encopresis and constipation). The findings indicate no abnormalities, suggesting no immediate medical concern. Although important in diagnosing potential issues, the current outcome shows nothing extraordinary threatening the child’s health.


Medical Specialty: Surgery
Sample Name: D&C & Laparoscopy

PREOPERATIVE DIAGNOSES:,1.  Hypermenorrhea.,2.  Pelvic pain.,3.  Infertility.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Infertility.,3.  Pelvic pain.,4.  Probable bilateral tubal occlusion.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Laparoscopy.,3.  Injection of indigo carmine dye.,GROSS FINDINGS: , The uterus was anteverted, firm, enlarged, irregular, and mobile.  The cervix is nulliparous without lesions.  Adnexal examination was negative for masses.,PROCEDURE:  ,The patient was placed in the lithotomy position, properly prepared and draped in sterile manner.  After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix was grasped with vulsellum tenaculum.  Uterus sounded to a depth of 10.5 cm.  Endocervical canal was progressively dilated with Hanks dilators to #20-French.  A medium-sized sharp curet was used to obtain a moderated amount of tissue upon curettage, which was taken from all uterine quadrants and sent to the pathologist for analysis.  A ________ syringe was then introduced into the uterine cavity to a depth of 9 cm and the balloon insufflated with 10 cc of air.  A 20 cc syringe filled with dilute indigo carmine dye was attached to the end of the ________ syringe to use to inject at the time of laparoscopy.,A small subumbilical incision was then made with insertion of the step dilating sheath with a Veress needle into the peritoneal cavity.  The peritoneal cavity was insufflated with 3 liters of carbondioxide and a 12 mm trocar inserted.  The laparoscope was then inserted through the trocar with visualization of the pelvic contents.  In steep Trendelenburg position, the uterus was visualized and aided by use of a Bierman needle to displace bowel from visualized areas.  The fallopian tubes appeared normal bilaterally with good visualization of a normal appearing fimbria.  The ovaries also appeared normal bilaterally.  The uterus was greatly enlarged and distorted with large fibroids in multiple areas and especially on the right coronal area.  An attempt was made to inject the indigo carmine dye and in fact a three syringes of 20 cc were injected without any visualization of intraperitoneal dye still.  Both fallopian tubes apparently were blocked.  The upper abdomen was visually explored and found to be normal as was the bowel and area of the right ileum.  The patient tolerated the procedure well.  Instruments were removed from the vaginal vault and the abdomen.  Trocar was removed and the carbondioxide allowed to escape and the subumbilical wound repaired with two #4-0 undyed Vicryl sutures.  Sterile dressing was applied to the wound and the patient was sent to the recovery area in satisfactory postoperative condition.
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DESCRIPTION: Enlarged fibroid uterus, infertility, pelvic pain, and probable bilateral tubal occlusion.  Dilatation and curettage and laparoscopy and injection of indigo carmine dye.

surgery, dilatation and curettage, laparoscopy, pelvic pain, infertility, enlarged fibroid uterus, tubal occlusion, indigo carmine dye, fibroid uterus, uterus infertility, peritoneal cavity, fallopian tubes, indigo carmine, endocervical, uterine, pelvic, curettage, uterus,

The situation involves a surgical procedure with significant implications for the patient's health, including addressing symptoms like hypermenorrhea, pelvic pain, and infertility. Despite being common, surgical procedures inherently carry higher stakes due to risks of complications, potential impact on the patient's fertility, and the patient's health concerns. The details of the surgery, including fibroid removal and tubal blockages, indicate serious considerations affecting the patient's quality of life. While the patient was stable post-operation, the high-stakes nature is due to the combination of complexity, potential consequences on fertility, and the underlying conditions being treated.


Medical Specialty: General Medicine
Sample Name: Annual Health Maintenance Exam

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

general medicine, tinnitus, dyslipidemia, annual health maintenance, health, hemorrhoids, benign

This scenario outlines a routine annual health maintenance examination for a generally healthy 59-year-old male. The patient's existing medical issues, such as controlled dyslipidemia, tinnitus, and hemorrhoids, are stable and not life-threatening. The examination does not reveal any new or acute health concerns, and the physician's plan involves continuing current medications and a follow-up in six months for routine lab tests. The stakes are low because there are no immediate or severe health threats requiring urgent intervention.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Hyperbilirubinemia - 4-day-old

HISTORY: , The patient is a 4-day-old being transferred here because of hyperbilirubinemia and some hypoxia.  Mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg%.  The patient was then sent to Hospital where she had some labs drawn and was noted to be hypoxic, but her oxygen came up with minimal supplemental oxygen.  She was also noted to have periodic breathing.  The patient is breast and bottle-fed and has been feeding well.  There has been no diarrhea or vomiting.  Voiding well.  Bowels have been regular.,According to the report from referring facility, because the patient had periodic breathing and was hypoxic, it was thought the patient was septic and she was given a dose of IM ampicillin.,The patient was born at 37 weeks' gestation to gravida 3, para 3 female by repeat C-section.  Birth weight was 8 pounds 6 ounces and the mother's antenatal other than was normal except for placenta previa.  The patient's mother apparently went into labor and then underwent a cesarean section.,FAMILY HISTORY: , Positive for asthma and diabetes and there is no exposure to second-hand smoke.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  The patient has a temperature of 36.8 rectally, pulse of 148 per minute, respirations 50 per minute, oxygen saturation is 96 on room air, but did go down to 90 and the patient was given 1 liter by nasal cannula.,GENERAL:  The patient is icteric, well hydrated.  Does have periodic breathing.  Color is pink and also icterus is noted, scleral and skin.,HEENT:  Normal.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular with a soft 3/6 murmur.  Femorals are well palpable.  Cap refill is immediate,ABDOMEN:  Soft, small, umbilical hernia is noted, which is reducible.,EXTERNAL GENITALIA:  Those of a female child.,SKIN:  Color icteric.  Nonspecific rash on the body, which is sparse.  The patient does have a cephalhematoma hematoma about 6 cm over the left occipitoparietal area.,EXTREMITIES:  The patient moves all extremities well.  Has a normal tone and a good suck.,EMERGENCY DEPARTMENT COURSE: , It was indicated to the parents that I would be repeating labs and also catheterize urine specimen.  Parents were made aware of the fact that child did have a murmur.  I spoke to Dr. X, who suggested doing an EKG, which was normal and since the patient will be admitted for hyperbilirubinemia, an echo could be done in the morning.  The case was discussed with Dr. Y and he will be admitting this child for hyperbilirubinemia.,CBC done showed a white count of 15,700, hemoglobin 18 gm%, hematocrit 50.6%, platelets 245,000, 10 bands, 44 segs, 34 lymphs, and 8 monos.  Chemistries done showed sodium of 142 mEq/L, potassium 4.5 mEq/L, chloride 104 mEq/L, CO2 28 mmol/L, glucose 75 mg%, BUN 8 mg%, creatinine 0.7 mg%, and calcium 8.0 mg%.  Total bilirubin was 25.4 mg, all of which was unconjugated.  CRP was 0.3 mg%.  Blood culture was drawn.  Catheterized urine specimen was normal.  Parents were kept abreast of what was going on all the time and the need for admission.  Phototherapy was instituted in the ER almost after the baby got to the emergency room.,IMPRESSION:,  Hyperbilirubinemia and heart murmur.,DIFFERENTIAL DIAGNOSES: , Considered breast milk, jaundice, ABO incompatibility, galactosemia, and ventricular septal defect.
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DESCRIPTION: 4-day-old with hyperbilirubinemia and heart murmur.

pediatrics - neonatal, hypoxia, periodic breathing, heart murmur, urine specimen, yellow, bilirubin, heart, murmur, hyperbilirubinemia,

The situation involves a 4-day-old neonate with significant hyperbilirubinemia (bilirubin level of 25.4 mg%), periodic breathing, hypoxia, and a heart murmur. Hyperbilirubinemia at this level in a newborn is concerning due to the risk of bilirubin encephalopathy (kernicterus), which can lead to permanent neurological damage. The presence of hypoxia and heart murmur could indicate underlying congenital or serious health issues. The need for phototherapy, possible investigations into the underlying cause of jaundice, and careful monitoring make this a serious and potentially high-stakes situation.


Medical Specialty: Radiology
Sample Name: Excretory Urogram - IVP

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

Common Excretory Urogram - IVP template

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

The situation is the interpretation of an excretory urogram, specifically noting that the findings are normal. The stakes of this situation are relatively low because the results indicate normal anatomy and function, with no signs of obstruction or defects. However, it's important to correctly interpret medical imaging to ensure that any pathology is not overlooked. Yet, given the nature of the report indicating negative findings, it does not involve immediate risk, critical conditions, or urgent treatment decisions.


Medical Specialty: Office Notes
Sample Name: Normal Physical Exam Template - 6

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

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

The provided template outlines a standard normal physical examination, reflecting a routine assessment any medical professional would conduct. This template is illustrative and does not represent an actual patient examination or indicate any potential medical emergency, critical decision-making, or legal ramifications. Therefore, the situation does not entail any high-stakes decisions; it is a routine and educational resource for documentation.


Medical Specialty: Surgery
Sample Name: Hardware Removal - Elbow

PREOPERATIVE DIAGNOSIS: , Retained hardware in left elbow.,POSTOPERATIVE DIAGNOSIS:,  Retained hardware in left elbow.,PROCEDURE: , Hardware removal in the left elbow.,ANESTHESIA: , Procedure done under general anesthesia.  The patient also received 4 mL of 0.25% Marcaine of local anesthetic.,TOURNIQUET:  ,There is no tourniquet time.,ESTIMATED BLOOD LOSS:  ,Minimal.,COMPLICATIONS:  ,No intraoperative complications.,HISTORY AND PHYSICAL:  ,The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture.  He underwent screw compression for the fracture in October 2007.  The fracture has subsequently healed and the patient presents for hardware removal.  The risks and benefits of surgery were discussed.  The risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion.  All questions were answered and the family agreed to the above plan.,PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in standard surgical fashion.  Using his previous incision, dissection was carried down through the screw.  A guide wire was placed inside the screw and the screw was removed without incident.  The patient had an extension lag of about 15 to 20 degrees.  Elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex.  The washer was also removed without incident.  Wound was then irrigated and closed using #2-0 Vicryl and #4-0 Monocryl.  Wound was injected with 0.25% Marcaine.  The wound was then dressed with Steri-Strips, Xeroform, 4 x4 and bias.  The patient tolerated the procedure well and subsequently taken to the recovery in stable condition.,DISCHARGE NOTE: , The patient will be discharged on date of surgery.  He is to follow up in one week's time for a wound check.  This can be done at his primary care physician's office.  The patient should keep his postop dressing for about 4 to 5 days.  He may then wet the wound, but not scrub it.  The patient may resume regular activities in about 2 weeks.  The patient was given Tylenol with Codeine 10 mL p.o. every 3 to 4 hours p.r.n.
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DESCRIPTION: Hardware removal in the left elbow.

Hardware removal in the left elbow.

surgery, retained hardware, hardware removal, tourniquet, elbow, hardware,

The procedure described is a routine hardware removal surgery, which, while involving anesthesia and surgical intervention, is generally considered low-risk and straightforward, especially in cases where the original fracture has healed well. The lack of complications during surgery further suggests that the situation is not high-stakes in medical terms. The follow-up care instructions and immediate discharge also support the perception that this is a low-stakes, routine procedure with expected outcomes.


Medical Specialty: Neurology
Sample Name: MRI T-Spine

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

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

The situation described involves a severe and acute medical emergency featuring an elderly patient with sudden onset paraplegia and aortic dissection leading to cardiopulmonary arrest. These conditions are life-threatening and require immediate medical intervention. The case also involves a significant medical decision process and evaluation to identify the correct diagnosis and appropriate treatment. Therefore, the stakes are extremely high as it involves significant risk to the patient's life and the decisions made directly impact patient outcomes.


Medical Specialty: ENT - Otolaryngology
Sample Name: Normal ENT Exam - 1

EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis.  There are no signs of acute trauma.  The nose is normal to palpation and inspection externally without evidence of acute trauma.  Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling.  The tympanic membranes are without disruption or infection.  Hearing intact bilaterally to normal level speech.  Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation.  The septum is without acute traumatic lesions or disruption.  The turbinates are without abnormal swelling.  There is no unusual rhinorrhea or bleeding.  ,LIPS/TEETH/GUMS:  ,The lips are without infection, mass lesion or traumatic lesions.  The teeth are intact without obvious signs of infection.  The gingivae are normal to palpation and inspection.  ,OROPHARYNX:  ,The oral mucosa is normal.  The salivary glands are without swelling.  The hard and soft palates are intact.  The tongue is without masses or swelling with normal movement.  The tonsils are without inflammation.  The posterior pharynx is without mass lesion with good patent oropharyngeal airway.
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DESCRIPTION: Sample normal ear, nose, mouth, and throat exam.

ent - otolaryngology, oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling,

The case described is a routine ear, nose, throat, and oral examination where the findings are normal and there are no signs of trauma or infection. This context is not associated with any acute or urgent medical needs, nor does it suggest life-threatening conditions. It is simply a documentation of a typical exam with standard findings, which does not involve any immediate risk or high-stakes decision-making.