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

NASAL EXAM: , The nose is grossly in the midline with no evidence of fractures or dislocations.  The nasal septum is roughly in the midline with pale boggy mucosa and moderately enlarged inferior turbinates.  There is no pus or polyps in the nose on anterior rhinoscopy.  The airway appears adequate.  No external valve prolapses are observed.,THROAT EXAM: , The oral cavity is clear.  The tongue is clear with no lesions noted and with good symmetrical movement.  The parotid and submaxillary ducts are producing clear mucus with no evidence of stones or infection.  Palate is clear.  The tonsils are not prominent.,No overt neoplasms in the mouth are noted.  Lips are clear.  The voice is adequate no deficits or hoarseness.  The saliva is clear.,EARS:  ,Canals are clear.  Eardrums are clear, moving on insufflation and swallowing.  No discharge is noted in the canals.  Hearing appears adequate in normal tonal conversations.,NECK EXAM: , Neck is supple with no palpable masses.  No lymphadenopathy.  The thyroid gland is not palpable.  The trachea is in the midline.  The parotid and submaxillary glands are not enlarged, are symmetrical and are not tender.  The neck movement is adequate.,GROSS NEUROLOGICAL EXAM: , Cranial nerves II-XII are intact.  Extraocular movements are full with no restrictions.  Patient is alert and responsive.,EYE EXAM: , Sclerae are clear.  Conjunctivae are clear.  Pupils respond symmetrically to light.  Extraocular movements are complete and full.
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DESCRIPTION: An example of normal ENT exam.

An example of normal ENT exam.

ent - otolaryngology, ent exam, boggy mucosa, inferior turbinates, nasal septum, nose, oral cavity, rhinoscopy, submaxillary ducts, tongue, neck, submaxillary, parotid, parotid and submaxillary, extraocular movements, ent, nasal

The examination detailed in the provided ENT report describes normal findings across all areas: nasal, throat, ear, neck, neurological, and eye exams. There are no signs of critical medical issues such as infections, growths, or functional abnormalities that would require urgent medical intervention. This type of examination is routine and indicates no immediate health risks for the patient. Consequently, the stakes are low as the examination results suggest good health with no need for immediate medical attention.


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Medical Specialty: Emergency Room Reports
Sample Name: Shone complex

HISTORY AND PHYSICAL:  ,The patient is a 13-year-old, who has a history of Shone complex and has a complete heart block.  He is on the pacemaker.  He had a coarctation of the aorta and that was repaired when he was an infant.  He was followed in our Cardiology Clinic here and has been doing well.  However last night, he was sleeping, and he states he felt as if he has having a dream, and there was thunder in this dream, which woke him up.  He then felt that his defibrillator was going off and this has continued and feels like his heart rate is not normal.  Thus, his dad put him in the car and transported him here.  He has been evaluated here.  He had some scar tissue at one point when the internal pacemaker was not working properly and had to have that replaced.  It was 2 a.m. when he woke, and again, he was brought here by private vehicle.  He was well prior to going to bed.  No cough, cold, runny nose, fever.  No trauma has been noted.,PAST MEDICAL HISTORY:,  Shone complex, pacemaker dependent.,MEDICATIONS: , He is on no medications at this time.,ALLERGIES:,  He has no allergies.,IMMUNIZATIONS:,  Up to date.,SOCIAL HISTORY: , He lives with his parents.,FAMILY HISTORY: , Negative.,REVIEW OF SYSTEM: , Twelve asked, all negative, except as noted above.,PHYSICAL EXAMINATION:,GENERAL:  This is an awake, alert male, who appears to be in mild distress.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular movements are intact.  His TMs are clear.  His nares are clear.  The mucous membranes are pink and moist.  Throat is clear.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Clear.,HEART:  Shows bradycardia at 53.  He has good distal pulses.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding, no rebound.  No rashes are seen.,HOSPITAL COURSE:,  Initial blood pressure is 164/90.  He was moved in room 1.  He was placed on nasal cannula.  Pulse ox was 100%, which is normal.  We placed him on a monitor.  We did an EKG; it has not appear to be capturing his pacemaker at this time.  Shortly after the patient's arrival, the Medtronic technician came and worked out his pacemaker.  Medtronic representative informed me that the lead that he has in place has been recalled because it has been prone to microfractures, oversensing, and automatic defibrillation.  As noted, he was transferred to room 1, placed on a monitor, pulse ox.  An IV was placed.  A standard blood work was sent.  A chest x-ray was done showing normal heart size, lead appeared to be in placed.  There was no evidence of pulmonary edema.  His pacemaker did not appear to be capturing.  We placed him on transthoracic leads.  However, it is difficult to get good placement with these because of the area where his pacemaker was placed.  The Medtronic technician initially turned off his defibrillation mode and turned down his sensor.  However, we could not get our transthoracic pacer to capture his heart.  When the Medtronic representative turned off the pacemaker, the heart rate seemed to drop into the 40s.  The patient appeared to be in pain.  We placed it back on a rate of 60 at that time.  He has remained in sinus bradycardia, but no evidence of ectopic beats.  No widening of his QRS complex.  I spoke with Cardiology.  Cardiology service has come in, has evaluated him at bedside with me.  Again, we turned up the transthoracic pacer, but it is again not seem to be picking up, and his heart rate is still going with the Medtronic's internal pacemaker.  So with the ICU physician on call, Dr. X, he has agreed with taking this young man to the ICU.,An hour after presentation here, the ICU was ready for bed.  I accompanied the patient up to the ICU.  He remained awake and alert.  Initially, he was complaining of a lot of chest pain.  Once the defibrillator was turned off, he had no more pain.  He was transported to the Pediatrics PICU and delivered in stable condition.,LABORATORY DATA: , CBC was normal.  Chem-20 was normal as well.,IMPRESSION:  ,Complete heart block with pacemaker malfunction.,PLAN:  ,He is admitted to the ICU.,TIME SEEN: , Critical care time outside billable procedures was 45 minutes with this patient.  I should note that a 12-lead EKG was done here showing sinus bradycardia, normal intervals otherwise.
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DESCRIPTION: Complete heart block with pacemaker malfunction and  a history of Shone complex.

The scenario is high-stakes because it involves a pediatric patient with a history of serious heart conditions, such as Shone complex and a complete heart block, who is experiencing a malfunction of his pacemaker. This situation can be life-threatening if not addressed promptly, especially given the patient's reliance on the pacemaker for maintaining an adequate heart rate. Immediate medical attention was required, and the decision to admit the patient to the ICU reflects the critical nature of the circumstance. The presence of a recalled pacemaker lead further adds to the severity of the situation.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Hematology - Oncology
Sample Name: Concomitant Chemoradiotherapy

CONCOMITANT CHEMORADIOTHERAPY FOR CURATIVE INTENT PATIENTS,This patient is receiving combined radiotherapy and chemotherapy in an effort to maximize the chance of control of this cancer.  The chemotherapy is given in addition to the radiotherapy, not only to act as a cytotoxic agent on its own, but also to potentiate and enhance the effect of radiotherapy on tumor cells.  It has been shown in the literature that this will maximize the chance of control.,During the course of the treatment, the patient's therapy must be closely monitored by the attending physician to be sure that the proper chemotherapy drugs are given at the proper time during the radiotherapy course.  It is also important to closely monitor the patient to know when treatment with either chemotherapy or radiotherapy needs to be held.  This combined treatment usually produces greater side effects than either treatment alone, and these need to be constantly monitored and treatment initiated on a timely basis to minimize these effects.  In accordance, this requires more frequency consultation and coordination with the medical oncologist.  Therefore, this becomes a very time intensive treatment and justifies CPT Code 77470.
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DESCRIPTION: Concomitant chemoradiotherapy for curative intent patients.

hematology - oncology, tumor cells, concomitant chemoradiotherapy, chemotherapy, radiotherapyNOTE,: 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.

Concomitant chemoradiotherapy for curative intent involves both chemotherapy and radiotherapy to maximize cancer control. There is a high level of complexity and risk due to the potentiating effects of combined treatments, which can result in greater side effects. Monitoring and adjusting treatment is crucial to prevent adverse effects and ensure efficacy, highlighting the high-stakes nature of the treatment. The focus is on curing potentially life-threatening cancer, adding to the high stakes involved.


Medical Specialty: Surgery
Sample Name: Phacoemulsification & Lens Implantation - 5

PREOPERATIVE DIAGNOSIS:,  Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,OPERATION PERFORMED: , Phacoemulsification with IOL, right eye.,ANESTHESIA:,  Topical with MAC.,COMPLICATIONS,:  None.,ESTIMATED BLOOD LOSS: , None.,PROCEDURE IN DETAIL:  After appropriate consent was obtained, the patient was brought to the operating room and then prepared and draped in the usual sterile fashion per Ophthalmology.  A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.  A 2.75-mm keratome then made a stab incision at the 2 o'clock position through which an anterior capsulorrhexis was performed using cystotome and Utrata.  BSS on blunt cannula, hydrodissector, and spun the nucleus after which phacoemulsification divided the nucleus in 3 quadrants each was subsequently cracked and removed through phacoemulsification I&A.  Healon was injected into the posterior capsule and a XXX lens was then placed with a shooter into the posterior capsule and rotated into position with I&A, which then removed all remaining cortex as well as viscoelastic material.  BSS on blunt cannula hydrated all wounds, which were noted to be free of leak and lid speculum was removed.  Under microscope, the anterior chamber being soft and well formed.  Pred Forte, Vigamox, and Iopidine were placed in the eye.  A shield was placed over the eye.  The patient was followed to recovery where he was noted to be in good condition.
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DESCRIPTION: Phacoemulsification with IOL, right eye.  Cataract, right eye.  A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.

surgery, lid speculum, lens, iol, viscoat, posterior, capsule, cataract, speculum, incision, phacoemulsification

The context describes a routine cataract surgery using phacoemulsification and lens implantation. Such procedures are common in ophthalmology and typically have low risk, especially considering there were no complications or blood loss mentioned. The presence of a detailed and uneventful procedural report further supports the low-stakes nature of this situation. However, as with any surgery, especially involving the eye, there is still a level of importance and risk, but it is significantly managed and low given the routine nature of the operation.


Medical Specialty: Surgery
Sample Name: D&C & Tubal Pregnancy Removal

PREOPERATIVE DIAGNOSIS: , Complex right lower quadrant mass with possible ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1.  Right ruptured tubal pregnancy.,2.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS:  ,Less than 100 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 25-year-old African-American female, gravida 7, para-1-0-5-1 with two prior spontaneous abortions with three terminations who presents with pelvic pain.  She does have a slowly increasing beta HCG starting at 500 to 849 and the max to 900.  Ultrasound showed a complex right lower quadrant mass with free fluid in the pelvis.  It was decided to perform a laparoscopy for the possibility of an ectopic pregnancy.,FINDINGS: , On bimanual exam, the uterus was approximately 10 weeks' in size, mobile, and anteverted.  There were no adnexal masses appreciated although there was some fullness in the right lower quadrant.  The cervical os appeared parous.,Laparoscopic findings revealed a right ectopic pregnancy, which was just distal to the right fallopian tube and attached to the fimbria as well as adherent to the right ovary.  There were some pelvic adhesions in the right abdominal wall as well.  The left fallopian tube and ovary and uterus appeared normal.  There was no evidence of endometriosis.  There was a small amount of blood in the posterior cul-de-sac.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped, placed under general anesthesia, and placed in the dorsal lithotomy position.  The bimanual exam was performed, which revealed the above findings.  A weighted speculum was placed in the patient's posterior vaginal vault and the 12 o' clock position of the cervix was grasped with the vulsellum tenaculum.  The cervix was then serially dilated using Hank dilators up to a #10.  A sharp curette was then introduced and curettage was performed obtaining a mild amount of tissue.  The tissue was sent to pathology for evaluation.  The uterine elevator was then placed in the patient's cervix.  Gloves were changed.  The attention was turned to the anterior abdominal wall where a 1 cm infraumbilical skin incision was made.  While tenting up the abdominal wall, the Veress needle was placed without difficulty.  The abdomen was then insufflated with appropriate volume and flow of CO2.  The #11 step trocar was then placed without difficulty in abdominal wall.  The placement was confirmed with a laparoscope.  It was then decided to put a #5 step trocar approximately 2 cm above the pubis symphysis in order to manipulate the pelvic contents.  The above findings were then noted.  Because the tubal pregnancy was adherent to the ovary, an additional port was placed in the right lateral aspect of the patient's abdomen.  A #12 step trocar port was placed under direct visualization.  Using a grasper, Nezhat-Dorsey suction irrigator, the mass was hydro-dissected off of the right ovary and further shelled away with graspers.  This was removed with the gallbladder grasper through the right lateral port site.  There was a small amount of oozing at the distal portion of the fimbria where the mass has been attached.  Partial salpingectomy was therefore performed.  This was done using the LigaSure.  The LigaSure was clamped across the portion of the tube including distal tube and ligated and transected.  Good hemostasis was obtained in all of the right adnexal structures.  The pelvis was then copiously suction irrigated.  The area again was then visualized and again found to be hemostatic.  The instruments were then removed from the patient's abdomen under direct visualization.  The abdomen was then desufflated and the #11 step trocar was removed.  The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips.  The uterine elevator was removed from the patient's vagina.,The patient tolerated the procedure well.  The sponge, lap, and needle count were correct x2.  She will follow up postoperatively as an outpatient.
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DESCRIPTION: Complex right lower quadrant mass with possible ectopic pregnancy.  Right ruptured tubal pregnancy and pelvic adhesions. Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy.

surgery, lower quadrant mass, tubal pregnancy, pelvic adhesions, laparoscopy, salpingectomy, ectopic pregnancy, abdominal wall, pregnancy,

The situation involves a surgical procedure to address a ruptured tubal pregnancy, which is a potentially life-threatening condition. Ectopic pregnancies, particularly those that rupture, can lead to significant internal bleeding and require prompt surgical intervention to ensure the patient's safety. The description indicates that the procedure was performed without complications, and the patient tolerated it well, which is an optimal outcome. However, the nature of the condition and the necessity of surgical intervention inherently make this a high-stakes medical situation.


Medical Specialty: Gastroenterology
Sample Name: Small Bowel Obstruction

CHIEF COMPLAINT:,  Patient AF is a 50-year-old hepatitis C positive African-American man presenting with a 2-day history of abdominal pain and distention with nausea and vomiting.,HISTORY OF PRESENT ILLNESS: , AF's symptoms began 2 days ago, and he has not passed gas or had any bowel movements.  He has not eaten anything, and has vomited 8 times.  AF reports 10/10 pain in the LLQ.,PAST MEDICAL HISTORY:,  AF's past medical history is significant for an abdominal injury during the Vietnam War which required surgery, and multiple episodes of small bowel obstruction and abdominal pain.  Other elements of his history include alcoholism, cocaine abuse, alcoholic hepatitis, hepatitis C positive, acute pancreatitis, chronic pancreatitis, appendicitis, liver hematoma/contusion, Hodgkin's Disease, constipation, diarrhea, paralytic ileus, anemia, multiple blood transfusions, chorioretinitis, pneumonia, and "crack chest pain" ,PAST SURGICAL HISTORY: , AF has had multiple abdominal surgeries, including Bill Roth Procedure Type 1 (partial gastrectomy) during Vietnam War, at least 2 exploratory laparotomies and enterolysis procedures (1993; 2000), and appendectomy,MEDICATIONS:,  None.,ALLERGIES:,  Iodine, IV contrast (anaphylaxis), and seafood/shellfish.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY:,  AF was born and raised in San Francisco.  His father was an alcoholic.  He currently lives with his sister, and does not work; he collects a pension.,HEALTH-RELATED BEHAVIORS:,  AF reports that he smokes 1 to 2 cigarettes per day, and drinks 40 ounces of beer per day.,REVIEW OF SYSTEMS: , Noncontributory, except that patient reports a 6 pound weight loss since his symptoms began, and reports multiple transfusions for anemia.,PHYSICAL EXAM:,Vital Signs:  T:  37.1
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DESCRIPTION: History of abdominal pain, obstipation, and distention with nausea and vomiting - paralytic ileus and mechanical obstruction.

The situation involves a patient with a history of small bowel obstruction who is currently experiencing severe symptoms such as abdominal pain (10/10 on pain scale), vomiting, and lack of bowel movements. Given the patient's medical history, including multiple previous obstructions and surgeries, along with the presence of a serious condition like hepatitis C and prior substance abuse, this presentation is likely to require urgent medical attention. The risk of complications, such as bowel perforation or ischemia, makes this a high-stakes situation.


Medical Specialty: Radiology
Sample Name: Renal Ultrasound - 1

EXAM: , Bilateral renal ultrasound.,CLINICAL INDICATION: , UTI.,TECHNIQUE: , Transverse and longitudinal sonograms of the kidneys were obtained.,FINDINGS:  ,The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm.  The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm.  There is no evidence for ,HYDRONEPHROSIS, or ,PERINEPHRIC ,fluid collections.  The bladder is of normal size and contour.  The bladder contains approximately 13 mL of urine after recent voiding.  This is a small postvoid residual.,IMPRESSION: , Normal renal ultrasound.  Small postvoid residual.
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DESCRIPTION: Bilateral renal ultrasound.

Bilateral renal ultrasound.

radiology, bilateral renal ultrasound, postvoid residual, renal ultrasound, residual, kidneys, renal, ultrasound,

The situation describes the findings of a bilateral renal ultrasound where no abnormalities were found, except for a small post-void residual volume of urine. This report appears to be routine and does not indicate any urgent or severe medical issues, as the kidneys and bladder are reported to be normal in size, echotexture, and there is no hydronephrosis or fluid collections. Therefore, from a medical perspective, this situation is typically low-stakes.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 14

PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES:  ,1. Normal operative site.  ,2. Mild diverticulosis of the sigmoid colon.  ,3. Hemorrhoids.,PROCEDURE:  ,Total colonoscopy.,PROCEDURE IN DETAIL:  ,The patient is a 60-year-old of Dr. ABC's being evaluated for the above.  The patient also apparently had an x-ray done at the Hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed.  She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push.  Digital rectal exam was done, unremarkable.  At that point, the Pentax video colonoscope was inserted.  The rectal vault appeared normal.  The sigmoid showed diverticula throughout, mild to moderate in nature.  The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized.  The scope was passed a short distance up the ileum, which appeared normal.  The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area.  The scope was then retroflexed, and anal verge visualized showed some hemorrhoids.  The scope was then removed.  The patient tolerated the procedure well.,RECOMMENDATIONS:  ,Repeat colonoscopy in three years.
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DESCRIPTION: Colonoscopy. History of colon polyps and partial colon resection, right colon.  Mild diverticulosis of the sigmoid colon.  Hemorrhoids.

gastroenterology, partial colon resection, diverticulosis, colon polyps, rectal vault, colonoscopy, polyps, hemorrhoids, sigmoid

This medical scenario describes a routine colonoscopy procedure for a patient with a history of colon polyps and partial colon resection. The findings were relatively mild, showing normal operative site, mild diverticulosis, and hemorrhoids, with no significant complications reported during the procedure. The follow-up recommendation is a standard protocol of repeating the colonoscopy in three years. While colonoscopy procedures can have serious implications, this particular case appears to be low-stakes as the patient tolerated the procedure well, and the findings do not indicate immediate or severe health risks.


Medical Specialty: Surgery
Sample Name: Phacoemulsification & Cataract Extraction - 1

PREOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,ANESTHESIA: , Topical/MAC.,PROCEDURE: , Phacoemulsification cataract extraction with intraocular lens implantation, left eye (Alcon AcrySof, SN60AT, 23.0 D, serial #***).,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY:  ,The patient is a 74-year-old woman with complaints of painless progressive loss of vision in her left eye.  She was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.,PROCEDURE IN DETAIL:  ,The patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart.  They were transported to the operative suite, accompanied by the anesthesia service, where appropriate cardiopulmonary monitoring was established.  MAC anesthesia was achieved, which was followed by topical anesthesia using 1% preservative-free tetracaine eye drops.  The patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed.,Two stab-incision paracenteses were made in the cornea using the MVR blade, and the anterior chamber was irrigated with 1% preservative-free lidocaine for intracameral anesthesia.  The anterior chamber was filled with viscoelastic and a shelved, temporal, clear corneal incision was made using the diamond groove knife and steel keratome.  A continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent-needle cystotome.  The lens nucleus was hydrodissected and hydrodelineated using balanced saline solution (BSS) on a Chang cannula until it rotated freely.,The phacoemulsification handpiece was introduced into the anterior chamber, and the lens nucleus was sculpted into 2 halves.  Each half was further subdivided with chopping and removed with phacoemulsification.  The remaining cortical material was removed with the irrigation and aspiration (I&A) handpiece.  The capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty.  The remaining viscoelastic was removed with the I&A handpiece, and the anterior chamber was filled to an appropriate intraocular pressure with BSS.  The corneal wounds were hydrated and verified to be water-tight.  Antibiotic ointment was placed, followed by a patch and shield.  The patient was transported to the PACU in good/stable condition.  There were no complications.  Followup is scheduled for tomorrow morning in the eye clinic.,A single interrupted 10-0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case.
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DESCRIPTION: Visually significant cataract, left eye.  Phacoemulsification cataract extraction with intraocular lens implantation, left eye.  The patient was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.

surgery, intraocular lens implantation, eye, intraocular lens, lens implantation, cataract extraction, cataract, intraocular, viscoelastic, handpiece, implantation, chamber, phacoemulsification, extraction, visually, anterior, lens

The situation described is a routine cataract surgery, which is generally considered to be a low-risk and common surgical procedure. Phacoemulsification is a standard approach for treating cataracts and is typically performed under local anesthesia, thus minimizing risk factors associated with general anesthesia. The absence of complications during the procedure, as stated, indicates a successful surgery. Although all surgeries carry some level of risk, in the context of surgical procedures, cataract extractions are considered low-stakes compared to many other types of surgeries.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Catheterization - 6

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

Cardiac catheterization is a complex and invasive procedure typically conducted to diagnose and sometimes treat conditions related to the heart and its surrounding structures. The patient has a hypoplastic left heart syndrome, which is a serious congenital heart defect requiring multiple surgeries including the Norwood procedure and Glenn shunt, as noted. The post-catheterization findings indicate several critical conditions like left pulmonary artery hypoplasia, diminished right ventricular systolic function, and trivial aortic stenosis, among others. These conditions, along with the patient's medical history, highlight the high stakes involved. Additionally, the interpretation of pressures and gradients can guide further treatment decisions, directly impacting the patient's life. Given the potential for complications and the necessity for ongoing medical management, this scenario represents a high-stakes situation for the medical team.


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

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

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

The situation described is a routine cataract surgery with phacoemulsification and lens implantation. Cataract surgeries are among the most common and generally low-risk procedures in ophthalmology. The documentation indicates that the procedure went as planned, with no blood loss or complications noted. The patient tolerated the procedure well and will have a follow-up appointment. Given its routine nature and the absence of complications, this situation is considered low-stakes in the context of medical procedures.


Medical Specialty: General Medicine
Sample Name: Ant Bait Exposure - ER Visit

CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it.  It had 11 mL of this fluid in it.  She spilled it on her, had it on her hands.  Parents were not sure whether she ingested any of it.  So, they brought her in for evaluation.  They did not note any symptoms of any type.,PAST MEDICAL HISTORY: , Negative.  Generally very healthy.,REVIEW OF SYSTEMS: , The child has not been having any coughing, gagging, vomiting, or other symptoms.  Acting perfectly normal.  Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes.  They did not witness that she ingested any, but did not see anything her mouth.,MEDICATIONS: , None.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  Stable vital signs and normal pulse oximetry.  GENERAL:  The child is very active, cheerful youngster, in no distress whatsoever.  HEENT:  Unremarkable.  Oral mucosa is clear, moist, and well hydrated.  I do not see any evidence of any sort of liquid on the face.  Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso.  Apparently, she had some on her hands that has been wiped off.,EMERGENCY DEPARTMENT COURSE:,  I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,IMPRESSION: , Exposure to ant bait.,PLAN: , At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely.  She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation.  So, the patient is discharged in stable condition.
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DESCRIPTION: Possible exposure to ant bait.  She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation.

general medicine, borax, vomiting, exposure to ant bait, ant bait, exposure, symptoms,

The scenario involves a 14-month-old child with possible exposure to ant bait containing Borax, but no symptoms or clear evidence of ingestion are present. After evaluation and consultation with Poison Control, the situation is deemed low risk and non-toxic due to the small quantity and lack of symptoms. The child is discharged with instructions to return if symptoms develop. While any potential ingestion by a child requires a precautionary approach, the details suggest low immediate risk to the child’s health.


Medical Specialty: Consult - History and Phy.
Sample Name: Infant Not Gaining Weight

CHIEF COMPLAINT:,  Not gaining weight.,HISTORY OF PRESENT ILLNESS:,  The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds.  The patient appeared to have failure-to-thrive. was only at her birth weight but when eating one may be possibly gaining 2 ounces every 3-4 hours, and was noted to have a murmur.  At this point, the Hospitalist Service was contacted for admission.  The patient was directly admitted to Children's Hospital Explore Ward.,In the explore ward, she was noted to be in mild respiratory distress and has some signs and symptoms of heart failure and had a prominent murmur, so an echo was done at bedside, which did show a moderately-sized patent ductus arteriosus and very small VSD and some mild signs and symptoms of congestive heart failure.  The patient was also seen by Dr. X of Cardiology Service and a plan was then obtained.,PAST MEDICAL/BIRTH HISTORY: , The patient was born at term repeat C-section to a 27-year-old G3, P2 African-American female.  Pregnancy was not complicated by hypertension, diabetes, drugs, alcohol abuse or smoking.  Birthweight was 7 pounds 4 ounces at Community Hospital.  The mother did have a repeat C-section.  There is no rupture of membranes or group B strep status.  The prenatal care began in the second month of pregnancy and was otherwise uncomplicated.  Mother denies any sexual transmitted diseases or other significant illness.  The patient was discharged home on day of life #3 without any complications.,ALLERGIES:,  No known drug allergies.,DIET: , The patient only takes Enfamil 20 calories, 1-3 ounces per history every 3-4 hours.,ELIMINATION: , The patient urinates 3-4 times a day and has a bowel movement 3-4 times a day.,FAMILY HISTORY/SOCIAL HISTORY: , The patient lives with the mother.  She has 2 older male siblings.  All were reported good health.  Family history is negative for any congenital heart disease, syndromes, hypertension, sickle cell anemia or sickle cell trait and no significant positive PPD contacts and history of second-hand smoke exposures.,REVIEW OF SYSTEMS:  ,GENERAL:  The patient has been reported to have normal activity and normal cry with no significant weight loss per mom's report, but conversely no significant weight gain.  Mother does not report that she sweats whenever she eats or has any episodes of cyanosis.  ,HEENT:  Denies any significant nasal congestion or cough.  ,RESPIRATORY:  Denies any difficulty breathing or wheezing.  ,CARDIOVASCULAR:  As per above.  GI:  No history of any persistent vomiting or diarrhea.  ,GU:  Denies any decreased urinary output.  ,MUSCULOSKELETAL:  Negative.  ,NEUROLOGICAL:  Negative.  ,SKIN:  Negative.,All other systems reviewed are negative.,PHYSICAL EXAMINATION:,GENERAL:  The patient is examined in her room, our next floor.  She is crying very vigorously, especially when I examined but she is consolable.,VITAL SIGNS:  Temperature currently is 96.3, heart rate 137, respirations 36, blood pressure 105/61 while crying.,HEENT:  Normocephalic.  The patient has a possible right temporoparietal bossing noted and slightly irregular shaped trapezoidal-shaped head.  The anterior fontanelle is soft and flat.  Pupils are equal, reactive to light and accommodation, but there is some mild hypertelorism.  There is also some mild posterior rotation of the ears.  Oropharynx, mucous membranes are pink and moist.  There is a slightly high arched palate.,NECK:  Significant for possible mild reddening of the neck.,LUNGS:  Significant for perihilar crackles.  Mild tachypnea is noted.  O2 saturations are currently 97% on room air.  There is mild intercostal retraction.,CARDIOVASCULAR:  Heart has regular rate and rhythm.  Peripheral pulses are only 1+.  Capillary refills less than 3-4 seconds.,EXTREMITIES:  Slightly cool to touch.  There is 2-3/6 systolic murmur along the left sternal border.  Does radiate to the axilla and to the back.,ABDOMEN:  Soft, slightly distended, but nontender.  The liver edge is palpable 4 cm below right costal margin.  The spleen tip is also palpable.,GU:  Normal female external genitalia is noted.,MUSCULOSKELETAL:  The patient has poor fat deposits in her extremities.  Strength is only 2/4.  She had normal number of fingers and toes.,SKIN:  Significant for slight mottling.  There are very poor subcutaneous fat deposits in her skin.,LABORATORY DATA: , The i-STAT only shows sodium 135, potassium on a heel stick was 6.3, hemoglobin and hematocrit are 14 and 41, and white count was 1.4.  CBG on i-STAT showed the pH of 7.34 with CO2 of 55, O2 sat of 51, CO2 of 29 with the base excess of 4.  Chest x-ray shows bilateral infiltrates and significant cardiomegaly consistent with congenital heart disease and mild congestive heart failure.,ASSESSMENT: , This is an almost 2-month-old presents with:,1.  Failure-to-thrive.,2.  Significant murmur and patent ductus arteriosus.,3.  Congestive heart failure.,PLAN:  ,At present, we are going to admit and monitor closely tonight.  We will get a chest x-ray and start Lasix at 1 mg/kg twice daily.  We will also get a CBC and check a blood culture and further workup as necessary.
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DESCRIPTION: A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.

This medical case involves a nearly 2-month-old infant presenting with serious health concerns including failure-to-thrive, a significant heart murmur, patent ductus arteriosus, and signs of congestive heart failure. These conditions are critical in an infant, especially given that she is at her birth weight and displays symptoms of heart failure, which can be life-threatening and require immediate medical intervention. The outlined plan includes hospitalization, close monitoring, medication, and further diagnostic work, illustrating the serious nature of the situation. As the patient's health could quickly deteriorate without appropriate medical care, this scenario is high-stakes.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 18

SUBJECTIVE:,  This is a 1-year-old male who comes in with a cough and congestion for the past two to three weeks.  Started off as a congestion but then he started coughing about a week ago.  Cough has gotten worsen.  Mother was also worried.  He had Pop Can just three days ago and she never found the top of that and was wondering if he had swallowed that, but his breathing has not gotten worse since that happened.  He is not running any fevers.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Fairly healthy.,CURRENT MEDICATIONS:,  None.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  The sister is in today with clinical sinusitis.  Mother and father have been healthy.,REVIEW OF SYSTEMS:,  He has been congested for about three weeks ago.  Coughing now but no fevers.  No vomiting.  Review of systems is otherwise negative.,PHYSICAL EXAMINATION:,General:  Well-developed male in no acute distress, afebrile.,Vital Signs:  Weight:  22 pounds 6 ounces.,HEENT:  Sclerae and conjunctivae are clear.  Extraocular muscles are intact.  TMs are clear.  Nares are very congested.  Oropharynx has drainage in the back of the throat.  Mucous membranes are moist.  Mild erythema though.,Neck:  Some shotty lymphadenopathy.  Full range of motion.  Supple.,Chest:  Clear.  No crackles.  No wheezes.,Cardiovascular:  Regular rate and rhythm.  Normal S1, S2.,Abdomen:  Positive bowel sounds and soft.,Dermatologic:  Clear.  Tone is good.  Capillary refill less than 3 seconds.,RADIOLOGY:,  Chest x-ray:  No foreign body noted as well.  No signs of pneumonia.,ASSESSMENT:,  Clinical sinusitis and secondary cough.,PLAN:,  Amoxicillin a teaspoon twice daily for 10 days.  Plenty of fluids.  Tylenol and Motrin p.r.n., as well as oral decongestant and if coughing is not improving.
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DESCRIPTION: 1-year-old male who comes in with a cough and congestion.  Clinical sinusitis and secondary cough.

general medicine, congestion, cough, sinusitis and secondary cough, cough and congestion, secondary cough, clinical sinusitis, male, sinusitis,

The situation involves a medical consultation for a 1-year-old child experiencing cough and congestion likely related to sinusitis. The mother expressed concern about a potential foreign body ingestion, but there is no evidence supporting this on the chest X-ray. The child is otherwise in no acute distress and afebrile, indicating stable health. The prescribed treatment is standard and non-emergent. Although the situation involves a very young child, which can increase concern, it is managed with routine care and does not indicate an immediate life-threatening condition.


Medical Specialty: Emergency Room Reports
Sample Name: Hydrocarbon Aspiration - ER Visit

SUBJECTIVE: , The patient is a 20-year-old Caucasian male admitted via ABCD Hospital Emergency Department for evaluation of hydrocarbon aspiration.  The patient ingested "tiki oil" (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting.  He was seen in the ABCD Hospital Emergency Department, toxic appearing with an abnormal chest x-ray demonstrating bilateral lower lobe infiltrates, greater on the right.  He had a temperature of 38.3 with tachycardia approximating 130.  White count was 59,300 with a marked left shift.  Arterial blood gases showed pH 7.48, pO2 79, and pCO2 35.  He was admitted for further medical management.,PAST MEDICAL HISTORY:,  Aplastic crisis during childhood requiring splenectomy and a cholecystectomy at age 9.,DRUG ALLERGIES: , NONE KNOWN.,CURRENT MEDICATIONS: , None.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,The patient works at a local Christmas tree farm.  He smokes cigarettes approximately one pack per day.,REVIEW OF SYSTEMS:,  Ten-system review significant for nausea, vomiting, fever, hemoptysis, and pleuritic chest pain.,PHYSICAL EXAMINATION,GENERAL:  A toxic-appearing 20-year-old Caucasian male, in mild respiratory distress.,VITAL SIGNS:  Blood pressure 122/74, pulse 130 and regular, respirations 24, temperature 38.3, and oxygen saturation 93%.,SKIN:  No rashes, petechiae or ecchymoses.,HEENT:  Within normal limits.  Pupils are equally round and reactive to light and accommodation.  Ears clean.  Throat clean.,NECK:  Supple without thyromegaly.  Lymph nodes are nonpalpable.,CHEST:  Decreased breath sounds bilaterally, greater on the right, at the right base.,CARDIAC:  No murmur or gallop rhythm.,ABDOMEN:  Mild direct diffuse tenderness without rebound.  No detectable masses, pulsations or organomegaly.,EXTREMITIES:  No edema.  Pulses are equal and full bilaterally.,NEUROLOGIC:  Nonfocal.,DATABASE: , Chest x-ray, bilateral lower lobe pneumonia, greater on the right.  EKG, sinus tachycardia, rate of 130, normal intervals, no ST changes.  Arterial blood gases on 2 L of oxygen, pH 7.48, pO2 79, and pCO2 35.,BLOOD STUDIES: , Hematocrit is 43, WBC 59,300 with a left shift, and platelet count 394,000.  Sodium is 130, potassium 3.8, chloride 97, bicarbonate 24, BUN 14, creatinine 0.8, random blood sugar 147, and calcium 9.4.,IMPRESSION,1.  Hydrocarbon aspiration.,2.  Bilateral pneumonia with pneumonitis secondary to aspiration.,3.  Asplenic patient.,PLAN,1.  ICU monitoring.,2.  O2 protocol.,3.  Hydration.,4.  Antiemetic therapy.,5.  Parenteral antibiotics.,6.  Prophylactic proton pump inhibitors.,The patient will need ICU monitoring and Pulmonary Medicine evaluation pending clinical course.,
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DESCRIPTION: The patient ingested tiki oil (kerosene, liquid paraffin, citronella oil) approximately two days prior to admission.  He subsequently developed progressive symptoms of dyspnea, pleuritic chest pain, hemoptysis with nausea and vomiting.

The situation involves a 20-year-old male with hydrocarbon aspiration leading to significant respiratory symptoms, including dyspnea, pleuritic chest pain, and hemoptysis. His vital signs and laboratory results show severe issues such as high white blood cell count indicating infection or inflammation, and his arterial blood gases suggest respiratory issues. The fact that he requires ICU monitoring indicates that the situation is critical and potentially life-threatening. Additionally, the patient's asplenic status due to prior splenectomy can increase his risk of severe infections. Hence, this is a high-stakes medical situation that requires immediate and intensive care.


Medical Specialty: Neurology
Sample Name: Epidural Fluid Collection

CC:, Fall/loss of consciousness.,HX: ,This 44y/o male fell 15-20feet from a construction site scaffold landing on his head on a cement sidewalk. He was transported directly from the scene, approximately one mile east of UIHC. The patient developed labored breathing and an EMT attempted to intubate the patient in the UIHC ER garage, but upon evaluation in the ER, was found to be in his esophagus and was immediately replaced into the trachea. Replacement of the ET tube required succinylcholine. The patient remained in a C-collar during the procedure. Once in the ER the patient had a 15min period of bradycardia.,MEDS: ,none prior to accident.,PMH:, No significant chronic or recent illness. s/p left knee arthroplasty. h/o hand fractures.,FHX:, Unremarkable.,SHX:, Married. Rare cigarette use/Occasional Marijuana use/Social ETOH use per wife.,EXAM:, BP156/79. HR 74 RR (Ambu Bag ventilation via ET tube) 34.7C 72-100% O2Sat.,MS: Unresponsive to verbal stimulation. No spontaneous verbalization.,CN: Does not open/close eyes to command or spontaneously. Pupils 9/7 and nonreactive.,Corneas -/+. Gag +/+. Oculocephalic and Oculovestibular reflexes not performed.,Motor: minimal spontaneous movement of the 4 extremities.,Sensory: withdraws LUE and BLE to noxious stimulation.,Coord/Station/Gait: Not tested.,Reflexes: 1-2+ and symmetric throughout. Babinski signs were present bilaterally.,HEENT: severe facial injury with brain parenchyma and blood from the right nostril. Severe soft tissue swelling about side of head.,Gen Exam: CV: RRR without murmur. Lungs: CTA. Abdomen: distended after ET tube misplacement.,COURSE: ,HCT upon arrival, 10/29/92, revealed: Extensive parenchymal contusions in right fronto-parietal area. Pronounced diffuse brain swelling seemingly obliterates the mesencephalic cistern and 4th ventricle. Considerable mass effect is exerted upon the right lateral ventricle, near totally obliterating its contour. Massive subcutaneous soft tissue swelling is present along the right anterolateral parietal area. There are extensive fractures of the following: two component horizontal fractures throughout the floor of the right middle cranial fossa which includes the squamous and petrous portions of the temporal bone, as well as the greater wing of the sphenoid. Comminuted fractures of the aqueous portion of the temporal bone and parietal bone is noted on the right. Extensive comminution of the right half of the frontal bone and marked displacement is seen. Comminuted fractures of the medial wall of the right orbit and ethmoidal air cells is seen with near total opacification of the air cells. The medial and lateral walls of the maxillary sinus are fractured and minimally displaced, as well as the medial wall of the left maxillary sinus. The right zygomatic bone is fractured at its articulation with the sphenoid bone and displaced posteriorly.,Portable chest, c-spine and abdominal XRays were unremarkable, but limited studies. Abdominal CT was unremarkable.,Hgb 10.4g/dl, Hct29%, WBC17.4k/mm3, Plt 190K. ABG:7.28/48/46 on admission. Glucose 131.,The patient was hyperventilated, Mannitol was administered (1g/kg), and the patient was given a Dilantin loading dose. He was taken to surgery immediately following the above studies to decompress the contused brain and remove bony fragments from multiple skull fractures. The patient remained in a persistent vegetative state at UIHC, and upon the request of this wife his feeding tube was discontinued. He later expired.
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DESCRIPTION: Fall/loss of consciousness.

Fall/loss of consciousness.

neurology, loss of consciousness, soft tissue swelling, medial wall, maxillary sinus, sphenoid, collection, tube, bone,

This case involves a serious traumatic brain injury resulting from a high fall, which led to extensive brain and skull injuries. The situation required immediate medical intervention, including surgery and life support measures, and ended in the patient's death. Given the life's threat posed by the injuries, and the subsequent decisions made about life-sustaining treatments, it is a high-stakes scenario involving critical and urgent medical decision-making.


Medical Specialty: Obstetrics / Gynecology
Sample Name: MRI Breast - 1

FINDINGS:,There are post biopsy changes seen in the retroareolar region, middle third aspect of the left breast at the post biopsy site.,There is abnormal enhancement seen in this location compatible with patient’s history of malignancy.,There is increased enhancement seen in the inferior aspect of the left breast at the 6:00 o’clock, N+5.5 cm position measuring 1.2 cm. Further work-up with ultrasound is indicated.,There are other multiple benign appearing enhancing masses seen in both the right and left breasts.,None of the remaining masses appear worrisome for malignancy based upon MRI criteria.,IMPRESSION:,  BIRADS CATEGORY M/5,There is a malignant appearing area of enhancement in the left breast which does correspond to the patient’s history of recent diagnosis of malignancy.,She has been scheduled to see a surgeon, as well as Medical Oncologist.,Dedicated ultrasonography of the inferior aspect of the left breast should be performed at the 6:00 o’clock, N+5.5 cm position for further evaluation of the mass. At that same time, ultrasonography of the remaining masses should also be performed.,Please note, however that the remaining masses have primarily benign features based upon MRI criteria. However, further evaluation with ultrasound should be performed.
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DESCRIPTION: Bilateral breast MRI with & without IV contrast.

obstetrics / gynecology, breast cancer, bilateral breast mri, bilateral breast, iv contrast, contrast, ultrasound, ultrasonography, malignancy, mri, benign, masses, breast

The situation involves a medical imaging report with findings that suggest malignancy in the breast, which corresponds to the patient's recent diagnosis of malignancy. The presence of a BIRADS CATEGORY M/5 is a high-risk indicator for breast cancer. Additionally, the patient is scheduled to see a surgeon and a medical oncologist, which indicates that immediate and precise medical action is needed. The potential for cancer and the need for further diagnostic procedures elevate the stakes considerably.


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

Medical Specialty: Radiology
Sample Name: Transesophageal Echocardiogram - 5

CLINICAL INDICATIONS: , MRSA bacteremia, rule out endocarditis.  The patient has aortic stenosis.,DESCRIPTION OF PROCEDURE: , The transesophageal echocardiogram was performed after getting verbal and a written consent signed.  Then a multiplane TEE probe was introduced into the upper esophagus, mid esophagus, lower esophagus, and stomach and multiple views were obtained.  There were no complications.  The patient's throat was numbed with Cetacaine spray and IV sedation was achieved with Versed and fentanyl.,FINDINGS:,1.  Aortic valve is thick and calcified, a severely restricted end opening and there is 0.6 x 8 mm vegetation attached to the right coronary cusp.  The peak velocity across the aortic valve was 4.6 m/sec and mean gradient was 53 mmHg and peak gradient 84 mmHg with calculated aortic valve area of 0.6 sq cm by planimetry.,2.  Mitral valve is calcified and thick.  No vegetation seen.  There is mild-to-moderate MR present.  There is mild AI present also.,3.  Tricuspid valve and pulmonary valve are structurally normal.,4.  There is a mild TR present.,5.  There is no clot seen in the left atrial appendage.  The velocity in the left atrial appendage was 0.6 m/sec.,6.  Intraatrial septum was intact.  There is no clot or mass seen.,7.  Normal LV and RV systolic function.,8.  There is thick raised calcified plaque seen in the thoracic aorta and arch.,SUMMARY:,1.  There is a 0.6 x 0.8 cm vegetation present in the aortic valve with severe aortic stenosis.  Calculated aortic valve area was 0.6 sq. cm.,2.  Normal LV systolic function.,
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DESCRIPTION: Transesophageal echocardiogram. MRSA bacteremia, rule out endocarditis.  The patient has aortic stenosis.

radiology, endocarditis, aortic stenosis, tee probe, mrsa bacteremia, transesophageal echocardiogram, aortic, echocardiogram, esophagus, vegetation, transesophageal

The transesophageal echocardiogram procedure in this context is conducted to rule out endocarditis in a patient with MRSA bacteremia and aortic stenosis. Both conditions are critical given their potential complications and mortality risks. MRSA bacteremia can lead to severe infections, and the presence of suspected endocarditis is particularly serious due to risks of further systemic complications. Additionally, the aortic stenosis, a significant finding, suggests an already compromised cardiac function, which increases the overall stakes of this medical evaluation.


Medical Specialty: Radiology
Sample Name: 2-D Echocardiogram - 4

DESCRIPTION:,1.  Normal cardiac chambers size.,2.  Normal left ventricular size.,3.  Normal LV systolic function.  Ejection fraction estimated around 60%.,4.  Aortic valve seen with good motion.,5.  Mitral valve seen with good motion.,6.  Tricuspid valve seen with good motion.,7.  No pericardial effusion or intracardiac masses.,DOPPLER:,1.  Trace mitral regurgitation.,2.  Trace tricuspid regurgitation.,IMPRESSION:,1.  Normal LV systolic function.,2.  Ejection fraction estimated around 60%.,
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DESCRIPTION: Echocardiogram and Doppler

Echocardiogram and Doppler

radiology, ejection fraction, lv systolic function, cardiac chambers, regurgitation, tricuspid, normal lv systolic function, normal lv systolic, ejection fraction estimated, normal lv, lv systolic, systolic function, function ejection, echocardiogram, doppler, lv, systolic, ejection, mitral, valve

The echocardiogram results indicate mostly normal findings, with normal cardiac chamber size and normal valve motions. The ejection fraction, a key indicator of heart health, is within the normal range at 60%. While there are mentions of trace mitral and tricuspid regurgitation, these are minimal findings that do not raise significant immediate concerns. In the context of radiology and cardiology, an echocardiogram report like this generally does not indicate a high-stakes situation unless the patient has additional risk factors or symptoms. Therefore, while any medical discussion can carry a degree of importance, this particular set of results suggests low urgency or risk based on the information provided.


Medical Specialty: Office Notes
Sample Name: Status Post T&A

SUBJECTIVE:,  A 6-year-old boy who underwent tonsillectomy and adenoidectomy two weeks ago.  Also, I cleaned out his maxillary sinuses.  Symptoms included loud snoring at night, sinus infections, throat infections, not sleeping well, and fatigue.  The surgery went well, and I had planned for him to stay overnight, but Mom reminds me that by about 8 p.m. the night nurse gotten him to take fluids well and we let him go home then that evening.  He finished up his Augmentin, by a day or two later he was off the Lortab.  Mom has not noticed any unusual voice change.  No swallowing difficulty except he does not like the taste of acidic foods such as tomato sauce.  He has not had any nasal discharge or ever had any bleeding.  He seems to be breathing better.,OBJECTIVE:,  Exam looks good.  The pharynx is well healed.  Tongue mobility is normal.  Voice sounds clear.  Nasal passages reveal no discharge or crusting.,RECOMMENDATION:,  I told Mom it is okay to use some ibuprofen in case his mouth or jaws are still sensitive.  He says it seems to hurt if he opens his mouth real wide such as when he brushes his teeth.  It is okay to chew gum and it is okay to eat crunchy foods such as potato chips.  The pathologist described the expected changes of chronic sinusitis and chronic hypertrophic tonsillitis and adenoiditis, and there were no atypical findings on the laboratories.,I am glad he has healed up well.  There are no other restrictions or limitations.  I told Mom, I had written to Dr. XYZ to let her know of the findings.  The child will continue his regular followup visits with his family doctor, and I told Mom I would be happy to see him anytime if needed.  He did very well after surgery and he seems to feel better and breathe a lot better after his throat and sinus procedure.
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DESCRIPTION: Underwent tonsillectomy and adenoidectomy two weeks ago.

office notes, tonsillectomy and adenoidectomy, tonsillectomy, adenoidectomy, maxillary, nasal, sinuses,

The situation involves a follow-up note for a common and routine surgical procedure (tonsillectomy and adenoidectomy) on a 6-year-old boy. The post-operative recovery appears normal without complications such as unusual voice changes, bleeding, or infection. This suggests that there are no immediate health threats or concerns that would categorize the situation as high-stakes. The recommendations provided are standard post-operative advice which does not indicate an urgent situation.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Well-Child Check - 2

SUBJECTIVE:,  This 9-month-old Hispanic male comes in today for a 9-month well-child check.  They are visiting from Texas until the end of April 2004.  Mom says he has been doing well since last seen.  He is up-to-date on his immunizations per her report.  She notes that he has developed some bumps on his chest that have been there for about a week.  Two weeks ago he was diagnosed with left otitis media and was treated with antibiotics.  Mom says he has been doing fine since then.  She has no concerns about him.,PAST MEDICAL HISTORY:,  Significant for term vaginal delivery without complications.,MEDICATIONS: , None.,ALLERGIES:,  None.,SOCIAL HISTORY:,  Lives with parents.  There is no smoking in the household.,REVIEW OF SYSTEMS:,  Developmentally is appropriate.  No fevers.  No other rashes.  No cough or congestion.  No vomiting or diarrhea.  Eating normally.,OBJECTIVE:,  His weight is 16 pounds 9 ounces.  Height is 26-1/4 inches.  Head circumference is 44.75 cm.  Pulse is 124.  Respirations are 26.  Temperature is 98.1 degrees.  Generally, this is a well-developed, well-nourished, 9-month-old male, who is active, alert, and playful in no acute distress.,HEENT:  Normocephalic, atraumatic.  Anterior fontanel is soft and flat.  Tympanic membranes are clear bilaterally.  Conjunctivae are clear.  Pupils equal, round and reactive to light.  Nares without turbinate edema.  Oropharynx is nonerythematous.,NECK:  Supple, without lymphadenopathy, thyromegaly, carotid bruit, or JVD.,CHEST:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm, without murmur.,ABDOMEN:  Soft, nontender, nondistended, normoactive bowel sounds.  No masses or organomegaly to palpation.,GU:  Normal male external genitalia.  Uncircumcised penis.  Bilaterally descended testes.  Femoral pulses 2/4.,EXTREMITIES:  Moves all four extremities equally.  Minimal tibial torsion.,SKIN:  Without abnormalities other than five small molluscum contagiosum with umbilical herniation noted on chest.,ASSESSMENT/PLAN:,1.  Well-child check.  Is doing well.  Will recommend a followup well-child check at 1 year of age and immunizations at that time.  Discussed safety issues, including poisons, choking hazards, pet safety, appropriate nutrition with Mom.  She is given a parenting guide handout.,2.  Molluscum contagiosum.  Described the viral etiology of these.  Told her they are self limited, and we will continue to monitor at this time.,3.  Left otitis media, resolved.  Continue to monitor.  We will plan on following up in three months if they are still in the area, or p.r.n.
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DESCRIPTION: A 9-month well-child check.

A 9-month well-child check.

pediatrics - neonatal, well-child check, otitis media, molluscum contagiosum, immunizations, developed, atraumatic, child,

The situation involves a routine 9-month well-child check for a pediatric patient, which generally has low stakes, as it mostly involves monitoring development and preventive care. Although there are minor health issues mentioned, such as molluscum contagiosum and resolved otitis media, these are common, non-urgent issues. The child's health appears stable and there are no immediate medical concerns or treatments required. Thus, the stakes are low in terms of urgency and potential negative outcomes if unaddressed.


Medical Specialty: Neurology
Sample Name: Rolandic Epilepsy

City, State,Dear Dr. Y:,I had the pleasure of seeing ABC today back in Neurology Clinic where he has been followed previously by Dr. Z.  His last visit was in June 2006, and he carries a diagnosis of benign rolandic epilepsy.  To review, his birth was unremarkable.  He is a second child born to a G3, P1 to 2 female.  He has had normal development, and is a bright child in 7th grade.  He began having seizures, however, at 9 years of age.  It is manifested typically as generalized tonic-clonic seizures upon awakening or falling into sleep.  He also had smaller spells with more focal convulsion and facial twitching.  His EEGs have shown a pattern consistent with benign rolandic epilepsy (central temporal sharp waves both of the right and left hemisphere).  Most recent EEG in May 2006 shows the same abnormalities.,ABC initially was placed on Tegretol, but developed symptoms of toxicity (hallucinations) on this medication, he was switched to Trileptal.  He has done very well taking 300 mg twice a day without any further seizures.  His last event was the day of his last EEG when he was sleep deprived and was off medication.  That was a convulsion lasting 5 minutes.  He has done well otherwise.  Parents deny that he has any problems with concentration.  He has not had any behavior issues.  He is an active child and participates in sports and some motocross activities.  He has one older sibling and he lives with his parents.  Father manages Turkey farm with foster farms.  Mother is an 8th grade teacher.,Family history is positive for a 3rd cousin, who has seizures, but the specific seizure type is not known.  There is no other relevant family history.,Review of systems is positive for right heel swelling and tenderness to palpation.  This is perhaps due to sports injury.  He has not sprained his ankle and does not have any specific acute injury around the time that this was noted.  He does also have some discomfort in the knees and ankles in the general sense with activities.  He has no rashes or any numbness, weakness or loss of skills.  He has no respiratory or cardiovascular complaints.  He has no nausea, vomiting, diarrhea or abdominal complaints.,Past medical history is otherwise unremarkable.,Other workup includes CT scan and MRI scan of the brain, which are both normal.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-nourished, well-hydrated male in no acute distress.  VITAL SIGNS:  His weight today is 80.6 pounds.  Height is 58-1/4 inches.  Blood pressure 113/66.  Head circumference 36.3 cm.  HEENT:  Atraumatic, normocephalic.  Oropharynx shows no lesions.  NECK:  Supple without adenopathy.  CHEST:  Clear auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs.  ABDOMEN:  Benign without organomegaly.  EXTREMITIES:  No clubbing, cyanosis or edema.  NEUROLOGIC:  The patient is alert and oriented.  His cognitive skills appear normal for his age.  His speech is fluent and goal-directed.  He follows instructions well.  His cranial nerves reveal his pupils equal, round, and reactive to light.  Extraocular movements are intact.  Visual fields are full.  Disks are sharp bilaterally.  Face moves symmetrically with normal sensation.  Palate elevates midline.  Tongue protrudes midline.  Hearing is intact bilaterally.  Motor exam reveals normal strength and tone.  Sensation intact to light touch and vibration.  His gait is nonataxic with normal heel-toe and tandem.  Finger-to-nose, finger-nose-finger, rapid altering movements are normal.  Deep tendon reflexes are 2+ and symmetric.,IMPRESSION:  ,This is an 11-year-old male with benign rolandic epilepsy, who is followed over the past 2 years in our clinic.  Most recent electroencephalogram still shows abnormalities, but it has not been done since May 2006.  The plan at this time is to repeat his electroencephalogram, follow his electroencephalogram annually until it reveres to normal.  At that time, he will be tapered off of medication.  I anticipate at some point in the near future, within about a year or so, he will actually be taken off medication.  For now, I will continue on Trileptal 300 mg twice a day, which is a low starting dose for him.  There is no indication that his dose needs to be increased.  Family understands the plan.  We will try to obtain an electroencephalogram in the near future in Modesto and followup is scheduled for 6 months.  Parents will contact us after the electroencephalogram is done so they can get the results.,Thank you very much for allowing me to access ABC for further management.
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DESCRIPTION: Diagnosis of benign rolandic epilepsy.

Diagnosis of benign rolandic epilepsy.

neurology, tonic-clonic seizures, benign rolandic epilepsy, rolandic epilepsy, epilepsy, seizures, electroencephalogram,

The situation involves a follow-up medical assessment for a child with benign rolandic epilepsy, which is a condition known to have a good prognosis and often resolves by adulthood. The child is currently stable on medication with a clearly outlined management plan. There are no immediate life-threatening issues or severe complications presented in the case notes. Therefore, it does not constitute a high-stakes situation from a clinical perspective. The presence of a treatment plan and lack of acute distress reduces the urgency and risk involved.


Medical Specialty: Consult - History and Phy.
Sample Name: Epidural Hematoma

CC:, Fall with questionable associated loss of consciousness.,HX: ,This 81 y/o RHM fell down 20 steps on the evening of admission, 1/10/93, while attempting to put his boots on at the top of the staircase. He was evaluated locally and was amnestic to the event at the time of examination. A HCT scan was obtained and he was transferred to UIHC, Neurosurgery.,MEDS:, Lasix 40mg qd, Zantac 150mg qd, Lanoxin 0.125mg qd, Capoten 2.5mg bid, Salsalate 750mg tid, ASA 325mg qd, "Ginsana" (Ginseng) 100mg bid.,PMH: ,1)Atrial fibrillation, 2)Right hemisphere stroke, 11/22/88, with associated left hemiparesis and amaurosis fugax. This was followed by a RCEA, 12/1/88 for 98% stenosis. The stroke symptoms/signs resolved. 3)DJD, 4)Right TKR 2-3 years ago, 5)venous stasis; with no h/o DVT, 6)former participant in NASCET, 7)TURP for BPH. No known allergies.,FHX:, Father died of an MI at unknown age, Mother died of complications of a dental procedure. He has one daughter who is healthy.,SHX:, Married. Part-time farmer. Denied tobacco/ETOH/illicit drug use.,EXAM: ,BP157/86, HR100 and irregular, RR20, 36.7C, 100%SaO2,MS: A&O to person, place, time. Speech fluent and without dysarthria.,CN: Pupils 3/3 decreasing to 2/2 on exposure to light. EOM intact. VFFTC. Optic disks were flat. Face was symmetric with symmetric movement. The remainder of the CN exam was unremarkable.,Motor: 5/5 strength throughout with normal muscle tone and bulk.,Sensory: unremarkable.,Coord: unremarkable.,Station/Gait: not mentioned in chart.,Reflexes: symmetric. Plantar responses were flexor, bilaterally.,Gen Exam: CV:IRRR without murmur. Lungs: CTA. Abdomen: NT, ND, NBS.,HEENT: abrasion over the right forehead.,Extremity: distal right leg edema/erythema (just above the ankle). tender to touch.,COURSE:, 1/10/93, (outside)HCT was reviewed, It revealed a left parietal epidural hematoma. GS, PT/PTT, UA, and CBC were unremarkable. RLE XR revealed a fracture of the right lateral malleolus for which he was casted. Repeat HCTs showed no change in the epidural hematoma and he was discharged home on DPH.
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DESCRIPTION: Fall with questionable associated loss of consciousness.  Left parietal epidural hematoma.

consult - history and phy., loss of consciousness, parietal epidural hematoma, parietal epidural, epidural hematoma, consciousness, epidural, hematoma,

The case involves an elderly patient who experienced a significant fall resulting in a left parietal epidural hematoma and a fracture. Epidural hematomas, particularly in elderly patients, can be serious due to the risk of increased intracranial pressure, potential for rapid neurological deterioration, and the patient's age and pre-existing conditions like atrial fibrillation and history of stroke. The situation requires careful monitoring and potentially urgent medical intervention to prevent serious outcomes, making it high-stakes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Physical Exam and Pap -2

SUBJECTIVE:,  The patient is a 68-year-old white female who presents for complete physical, Pap and breast exam.  Her last Pap smear was 05/02/2002.  Her only complaint is that she has had some occasional episodes of some midchest pain that seems to go to her back, usually occurs at rest.  Has awakened her at night on occasion and only last about 15 to 20 minutes.  Denies nausea, vomiting, diaphoresis or shortness of breath with it.  This has not happened in almost two months.  She had a normal EKG one year ago.  Otherwise, has been doing quite well.  Did quite well with her foot surgery with Dr. Clayton.,PAST MEDICAL HISTORY:,  Reactive airway disease; rheumatoid arthritis, recent surgery on her hands and feet; gravida 4, para 5, with one set of twins, all vaginal deliveries; iron deficiency anemia; osteoporosis; and hypothyroidism.,MEDICATIONS:,  Methotrexate 2.5 mg five weekly, Fosamax 70 mg weekly, folic acid daily, amitriptyline 15 mg daily, Synthroid 0.088 mg daily, calcium two in the morning and two at noon, multivitamin daily, baby aspirin daily and Colace one to three b.i.d.,ALLERGIES:,  None.,SOCIAL HISTORY:,  She is married.  Denies tobacco, alcohol and drug use.  She is not employed outside the home.,FAMILY HISTORY: , Unremarkable.,REVIEW OF SYSTEMS:,  HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional and psychiatric are all negative except for HPI.,OBJECTIVE:,Vital Signs:  Weight 146.  Blood pressure 100/64.  Pulse 80.  Respirations 16.  Temperature 97.7.,General:  She is a well-developed, well-nourished white female in no acute distress.,HEENT:  Grossly within normal limits.,Neck:  Supple.  No lymphadenopathy.  No thyromegaly.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Positive bowel sounds, soft and nontender.  No hepatosplenomegaly.,Breasts:  No nipple discharge.  No lumps or masses palpated.  No dimpling of the skin.  No axillary lymph nodes palpated.  Self-breast exam discussed and encouraged.,Pelvic:  Normal female genitalia.  Atrophic vaginal mucosa.  No cervical lesions.  No cervical motion tenderness.  No adnexal tenderness or masses palpated.,Rectal:  Normal sphincter tone.  No stool present in the vault.  No rectal masses palpated.,Extremities:  No cyanosis, clubbing or edema.  She does have obvious rheumatoid arthritis of her hands.,Neurologic:  Grossly intact.,ASSESSMENT/PLAN:,1.  Chest pain.  The patient will evaluate when it happens next; what she has been eating, what activities she has been performing.  She had normal ECG one year ago.  In fact this does not sound cardiac in nature.  We will not do further cardiac workup at this time.  Did discuss with her she may be having some GI reflux type symptoms.,2.  Hypothyroidism.  We will recheck TSH to make sure she is on the right amount of medication at this time, making adjustments as needed.,3.  Rheumatoid arthritis.  Continue her methotrexate as prescribed by Dr. Mortensen, and follow up with Dr. XYZ as needed.,4.  Osteoporosis.  It is time for her to have a repeat DEXA at this time and that will be scheduled.,5.  Health care maintenance, Pap smear was obtained today.  The patient will be scheduled for mammogram.
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DESCRIPTION: A white female who presents for complete physical, Pap and breast exam.

The situation described is not particularly high-stakes. The patient is undergoing routine exams (Pap smear, breast exam) and her main complaint, occasional chest pain, was assessed and not deemed cardiac in nature based on a previous normal EKG. Moreover, the chest pain has not occurred in two months. Her other conditions, such as hypothyroidism, rheumatoid arthritis, and osteoporosis, are being managed with medication and routine monitoring. The plan includes routine follow-ups and testing for ongoing health maintenance. There are no acute issues or immediate life-threatening conditions.


Medical Specialty: General Medicine
Sample Name: Normal ROS Template - 1

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

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

This scenario entails examining a patient's review of systems in general medicine, where no abnormal findings are reported. It highlights a routine check-up and documentation of a patient's health status without any indication of abnormalities. As it involves routine medical practice with no immediate crisis or complex decision-making, the stakes are relatively low.


Medical Specialty: Orthopedic
Sample Name: Anterior Cervical Discectomy & Fusion - 4

PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C3-4.,2.  Arthrodesis with anterior interbody fusion, C3-4.,3.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT:  ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  ,Less than 100 mL.,CONDITION:  ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:  ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop.  Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening.  About two days ago, he started noticing weakness on the left arm.  The patient also noted shuffling gait.  The patient presented to a family physician and was referred to Dr. X for further evaluation.  Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine.  MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes.  Based on these findings, I recommended decompression.  The patient was started on Decadron at 10 mg IV q.6h.  Operation, expected outcome, risks, and benefits were discussed with him.  Risks to include but not exclusive of bleeding and infection.  Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma.  The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function.  Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient.  There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics.  However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation.  This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed.  There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele.  This too can compromise airway and may require return to the operating room for repair of the dural tear.  There is also potential risk of injury to the esophagus, the trachea, as well as the carotid.  The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation.  The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  No monitoring leads were placed.  The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders.  Localizing x-ray verified the marker to be right at the C3-4 interspace.  Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion.  The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath.  The prevertebral fascia was identified.  Localizing x-ray verified another marker to be at the C3-4 interspace.  Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out.  There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur.  The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur.  The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4.  There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side.  By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed.  Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder.  With this completed, the Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant with its interior packed with Vitoss was then tapped into place.  An 18-mm plate was then screwed down with four 14 x 4.0 mm screws.  The area was irrigated with saline, with bacitracin solution.  Postoperative x-ray showed excellent placement of the graft and spinal instrumentation.  A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond.  The catheter was anchored to the skin with a nylon 3-0 stitch.  Dressing was placed only on the exit site of the drain.  C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities.
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DESCRIPTION: Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).

The situation described involves a surgical procedure for spinal cord compression due to cervical myelopathy. The stakes are high due to the complications and risks associated with spine surgery, including potential for paralysis, infection, damage to nearby organs, and anesthesia risks. Additionally, surgical intervention on the spine inherently carries significant risk due to the critical functions it supports in the body. Balancing these risks with the potential benefits makes this a high-stakes situation.


Medical Specialty: Gastroenterology
Sample Name: Flex Sig - 2

PROCEDURE IN DETAIL: , Following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal.  The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.  Withdrawal notes an otherwise normal descending, rectosigmoid and rectum.  Retroflexion noted no abnormality of the internal ring.  No hemorrhoids were noted.  Withdrawal from the patient terminated the procedure.
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DESCRIPTION: Flexible sigmoidoscopy.  The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.

gastroenterology, flexible sigmoidoscopy, flex sig, colonoscope, olympus video colonoscope, rectumNOTE,: 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 procedure described is a routine medical examination called a flexible sigmoidoscopy, used to examine the lower part of the colon and rectum. It seems to be a straightforward case where no abnormalities were found, which indicates it went normally. However, any medical procedure can have underlying risks, though in this situation, it appears to be low-risk as it's a part of standard medical care and no complications are mentioned.