Medical Specialty: General Medicine
Sample Name: Normal Physical Exam Template - 7

EYES: , The conjunctivae are clear.  The lids are normal appearing without evidence of chalazion or hordeolum.  The pupils are round and reactive.  The irides are without any obvious lesions noted.  Funduscopic examination shows sharp disk margins.  There are no exudates or hemorrhages noted.  The vessels are normal appearing.,EARS, NOSE, MOUTH AND THROAT:,  The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.,NECK:,  The neck is nontender and supple.  The trachea is midline.  The thyroid is without any evidence of thyromegaly.  No obvious adenopathy is noted to the neck.,RESPIRATORY: , The patient has normal respiratory effort.  There is normal lung excursion.  Percussion of the chest is without any obvious dullness.  There is no tactile fremitus or egophony noted.  There is no tenderness to the chest wall or ribs.  There are no obvious abnormalities.  The lungs are clear to auscultation.  There are no wheezes, rales or rhonchi heard.  There are no obvious rubs noted.,CARDIOVASCULAR: , There is a normal PMI on palpation.  I do not hear any obvious abnormal sounds.  There are no obvious murmurs.  There are no rubs or gallops noted.  The carotid arteries are without bruit.  No obvious thrill is palpated. There is no evidence of enlarged abdominal aorta to palpation.  There is no abdominal mass to suggest enlargement of the aorta.  Good strong femoral pulses are palpated.  The pedal pulses are intact.  There is no obvious edema noted to the extremities.  There is no evidence of any varicosities or phlebitis noted.,GASTROINTESTINAL: , The abdomen is soft.  Bowel sounds are present in all quadrants.  There are no obvious masses.  There is no organomegaly, and no liver or spleen is palpable.  No obvious hernia is noted.  The perineum and anus are normal in appearance.  There is good sphincter tone and no obvious hemorrhoids are noted.  There are no masses.  On digital examination, there is no evidence of any tenderness to the rectal vault; no lesions are noted.  Stool is brown and guaiac negative.,GENITOURINARY (FEMALE): , The external genitalia is normal appearing with no obvious lesions, no evidence of any unusual rash.  The vagina is normal in appearance with normal-appearing mucosa.  The urethra is without any obvious lesions or discharge.  The cervix is normal in color with no obvious cervical discharge.  There are no obvious cervical lesions noted.  The uterus is nontender and small, and there is no evidence of any adnexal masses or tenderness.  The bladder is nontender to palpation.  It is not enlarged.,GENITOURINARY (MALE): , Normal scrotal contents are noted.  The testes are descended and nontender.  There are no masses and no swelling to the epididymis noted.  The penis is without any lesions.  There is no urethral discharge.  Digital examination of the prostate reveals a nontender, non-nodular prostate.,BREASTS:,  The breasts are normal in appearance.  There is no puckering noted.  There is no evidence of any nipple discharge.  There are no obvious masses palpable.  There is no axillary adenopathy.  The skin is normal appearing over the breasts.,LYMPHATICS: , There is no evidence of any adenopathy to the anterior cervical chain.  There is no evidence of submandibular nodes noted.  There are no supraclavicular nodes palpable.  The axillae are without any abnormal nodes.  No inguinal adenopathy is palpable.  No obvious epitrochlear nodes are noted.,MUSCULOSKELETAL/EXTREMITIES: , The patient has normal gait and station.  The patient has normal muscle strength and tone to all extremities.  There is no obvious evidence of any muscle atrophy.  The joints are all stable.  There is no evidence of any subluxation or laxity to any of the joints.  There is no evidence of any dislocation.  There is good range of motion of all extremities without any pain or tenderness to the joints or extremities.  There is no evidence of any contractures or crepitus.  There is no evidence of any joint effusions.  No obvious evidence of erythema overlying any of the joints is noted.  There is good range of motion at all joints.  There are normal-appearing digits.  There are no obvious lesions to any of the nails or nail beds.,SKIN:,  There is no obvious evidence of any rash.  There are no petechiae, pallor or cyanosis noted.  There are no unusual nodules or masses palpable.,NEUROLOGIC: , The cranial nerves II XII are tested and are intact.  Deep tendon reflexes are symmetrical bilaterally.  The toes are downgoing with normal Babinskis.  Sensation to light touch is intact and symmetrical.  Cerebellar testing reveals normal finger nose, heel shin.  Normal gait.  No ataxia.,PSYCHIATRIC:  ,The patient is oriented to person, place and time.  The patient is also oriented to situation.  Mood and affect are appropriate for the present situation.  The patient can remember 3 objects after 3 minutes without any difficulties.  Remote memory appears to be intact.  The patient seems to have normal judgment and insight into the situation.
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DESCRIPTION: Most commonly used phrases in physical exam.

general medicine, ears, nose, mouth, neck, respiratory, cardiovascular, eyes, gastrointestinal, genitourinary, breasts, lymphatics, musculoskeletal, extremities, skin, neurologic, psychiatric, normal appearing, physical exam, examination,

The information provided is a comprehensive physical exam template. It describes a normal physical examination across various systems of the body, indicating that the focus is on documenting standard findings routinely used in medical practice. This is a common, standardized part of providing healthcare and is not inherently high-stakes unless linked to critical decision-making for a specific patient with acute conditions.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Pneumoconiosis

HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  The patient also has a positive history of smoking in the past.  At the present time, he is admitted for continued,management of respiratory depression with other medical complications.  The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  In addition, he also developed cardiac complications including atrial fibrillation.  The patient was evaluated by the cardiologist as well as the pulmonary service and Urology.  He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  He subsequently underwent cardiac arrest and he was resuscitated at that time.  He was intubated and placed on mechanical ventilatory support.  Subsequent weaning was unsuccessful.  He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1.  Albuterol.,2.  Pacerone.,3.  Theophylline,4.  Lovenox.,5.  Atrovent.,6.  Insulin.,7.  Lantus.,8.  Zestril.,9.  Magnesium oxide.,10.  Lopressor.,11.  Zegerid.,12.  Tylenol as needed.,ALLERGIES:,  PENICILLIN.,PAST MEDICAL HISTORY:,1.  History of coal miner's disease.,2.  History of COPD.,3.  History of atrial fibrillation.,4.  History of coronary artery disease.,5.  History of coronary artery stent placement.,6.  History of gastric obstruction.,7.  History of prostate cancer.,8.  History of chronic diarrhea.,9.  History of pernicious anemia.,10.  History of radiation proctitis.,11.  History of anxiety.,12.  History of ureteral stone.,13.  History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker.  No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated.  Rapidly moving his upper extremities.  No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General:  The patient is currently agitated with some level of distress.  He has rapid respiratory rate.  He is responsive to verbal commands by looking at the eyes.,Vital Signs:  As per the monitors are stable.,Extremities:  Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas.  There is also edema of the forearm extending up to the mid upper arm area.  Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1.  Ulceration of bilateral upper extremities.,2.  Cellulitis of upper extremities.,3.  Lymphedema of upper extremities.,4.  Other noninfectious disorders of lymphatic channels.,5.  Ventilatory-dependent respiratory failure.
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DESCRIPTION: Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.

The situation described involves a 91-year-old male patient with a complex and severe medical history, including pneumoconiosis, COPD, coronary artery disease, and recent complications such as cardiac arrest, ventilatory-dependent respiratory failure, and upper extremity lymphedema. The patient is experiencing respiratory depression and is dependent on mechanical ventilation, which indicates serious ongoing health issues. These factors contribute to the high-stakes nature of the situation, as the patient's life is at risk and requires careful management by the medical team.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: General Medicine
Sample Name: Trouble breathing

CHIEF COMPLAINT:, "Trouble breathing.",HISTORY OF PRESENT ILLNESS:, A 37-year-old German woman was brought to a Shock Room at the General Hospital with worsening shortness of breath and cough. Over the year preceding admission, the patient had begun to experience the insidious onset of shortness of breath. She had smoked one half pack of cigarettes per day for 20 years, but had quit smoking approximately 2 months prior to admission. Approximately 2 weeks prior to admission, she noted worsening shortness of breath and the development of a dry nonproductive cough. Approximately 1 week before admission, the shortness of breath became more severe and began to limit her activities. On the day of admission, her dyspnea had worsened to the point that she became markedly short of breath after walking a short distance, and she elected to seek medical attention. On arrival at the hospital, she was short of breath at rest and was having difficulty completing her sentences. She denied orthopnea, paroxysmal nocturnal dyspnea, swelling in her legs, chest pain, weight loss or gain, fever, chills, palpitations, and sick contacts. She denied any history of IVDA, tattoos, or high risk sexual behavior. She did report a distant history of pulmonary embolism in 1997 with recurrent venous thromboembolism in 1999 for which an IVC filter had been placed in Germany . She had been living in the United States for years, and had had no recent travel. She denied any occupational exposures. Before the onset of her shortness of breath she had been very active and had exercised regularly.,PAST MEDICAL HISTORY:,  Pulmonary embolism in 1997 which had been treated with thrombolysis in Germany. She reported that she had been on warfarin for 6 months after her diagnosis.  Recurrent venous thromboembolism in 1999 at which time an IVC filter had been placed.  Psoriasis.  She denied any history of miscarriage.,PAST SURGICAL HISTORY:,  IVC filter placement 1999.
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DESCRIPTION: Patient with worsening shortness of breath and cough.

The patient is experiencing significant and rapidly worsening shortness of breath, to the point of being short of breath at rest. Given her history of pulmonary embolism and recurrent venous thromboembolism, this could indicate a serious cardiopulmonary issue, possibly another pulmonary embolism or progression of underlying respiratory disease, which can be life-threatening. Immediate medical attention is warranted in such situations due to the potential for severe complications, including respiratory failure or death.


Medical Specialty: Surgery
Sample Name: Vasectomy - 4

PROCEDURE: , Elective male sterilization via bilateral vasectomy.,PREOPERATIVE DIAGNOSIS:  ,Fertile male with completed family.,POSTOPERATIVE DIAGNOSIS:,  Fertile male with completed family.,MEDICATIONS:  ,Anesthesia is local with conscious sedation.,COMPLICATIONS: , None.,BLOOD LOSS: , Minimal.,INDICATIONS:  ,This 34-year-old gentleman has come to the office requesting sterilization via bilateral vasectomy.  I discussed the indications and the need for procedure with the patient in detail, and he has given consent to proceed.  He has been given prophylactic antibiotics.,PROCEDURE NOTE: , Once satisfactory sedation have been obtained, the patient was placed in the supine position on the operating table.  Genitalia was shaved and then prepped with Betadine scrub and paint solution and were draped sterilely.  The procedure itself was started by grasping the right vas deferens in the scrotum, and bringing it up to the level of the skin.  The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath.  The vas was brought out of the incision carefully.  A 2-inch segment was isolated, and 1-inch segment was removed.  The free ends were cauterized and were tied with 2-0 silk sutures in such a fashion that the ends double back on themselves.  After securing hemostasis with a cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Attention was now turned to the left side.  The vas was grasped and brought up to the level of the skin.  The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath.  The vas was brought out of the incision carefully.  A 2-inch segment was isolated, and 1-inch segment was removed.  The free ends were cauterized and tied with 2-0 silk sutures in such a fashion that the ends double back on themselves.  After securing hemostasis with the cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Bacitracin ointment was applied as well as dry sterile dressing.  The patient was awakened and was returned to Recovery in satisfactory condition.
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DESCRIPTION: Fertile male with completed family.  Elective male sterilization via bilateral vasectomy.

surgery, sterilization, vas, fertile male, bilateral vasectomy, vasectomy, cauterized,

The procedure described is an elective vasectomy for sterilization purposes in a 34-year-old male with a completed family. The procedure is common, typically low-risk, and performed under local anesthesia with minimal complications and blood loss expected. Although it is a surgical procedure, it is elective and considered low-stakes compared to emergency or more complex surgeries. The stakes are higher if there were complications or if it were not elective, but given the information, there are none.


Medical Specialty: Consult - History and Phy.
Sample Name: Decreased Vision Consult

She has a past ocular history including cataract extraction with lens implants in both eyes in 2001 and 2003.  She also has a history of glaucoma diagnosed in 1990 and macular degeneration.  She has been followed in her home country and is here visiting family.  She had the above-mentioned observation and was brought in on an urgent basis today.,Her past medical history includes hypertension and hypercholesterolemia and hypothyroidism.,Her medications include V-optic 0.5% eye drops to both eyes twice a day and pilocarpine 2% OU three times a day.  She took both the drops this morning.  She also takes Eltroxin which is for hypothyroidism, Plendil for blood pressure, and pravastatin.,She is allergic to Cosopt.,She has a family history of blindness in her brother as well as glaucoma and hypertension.,Her visual acuity today at distance without correction are 20/25 in the right and count fingers at 3 feet in the left eye.  Manifest refraction showed no improvement in either eye.  The intraocular pressures by applanation were 7 on the right and 18 in the left eye.  Gonioscopy showed grade 4 open angles in both eyes.  Humphrey visual field testing done elsewhere showed diffuse reduction in sensitivity in both eyes.  The lids were normal OU.  She has mild dry eye OU.  The corneas are clear OU.  The anterior chamber is deep and quiet OU.  Irides appear normal.  The lenses show well centered posterior chamber intraocular lenses OU.,Dilated fundus exam shows clear vitreous OU.  The optic nerves are normal in size.  They both appear to have mild pallor.  The optic cups in both eyes are shallow.  The cup-to-disc ratio in the right eye is not overtly large, would estimated 0.5 to 0.6; however, she does have very thin rim tissue inferotemporally in the right eye.  In the left eye, the glaucoma appears to be more advanced to the larger cup-to-disc ratio and a thinner rim tissue.,The macula on the right shows drusen with focal areas of RPE atrophy.  I do not see any evidence of neovascularization such as subretinal fluid, lipid or hemorrhage.  She does have a punctate area of RPE atrophy which is just adjacent to the fovea of the right eye.  In the left eye, she has also several high-risk drusen, but no evidence of neovascularization.  The RPE in the left eye does appear to be more diffusely abnormal although these changes do appear somewhat mild.  I do not see any dense or focal areas of frank RPE atrophy or hypertrophy.,The peripheral retinas are attached in both eyes.,Ms. ABC has pseudophakia OU which is stable and she is doing well in this regard.  She has glaucoma which likely is worse in the left eye and also likely explains her poor vision in the left eye.  The intraocular pressure in the mid-to-high teens in the left eye is probably high for her.  She has allergic reaction to Cosopt.  I will recommend starting Xalatan OS nightly.  I think the intraocular pressure in the right eye is acceptable and is probably a stable pressure for her OD.  She will need followup in the next 1 or 2 months after returning home to Israel later this week after starting the new medication which is Xalatan.,Regarding the macular degeneration, she has had high-risk changes in both eyes.  The vision in the right eye is good, but she does have a very concerning area of RPE atrophy just adjacent to the fovea of the right eye.  I strongly recommend that she see a retina specialist before returning to Israel in order to fully discuss prophylactic measures to prevent worsening of her macular degeneration in the right eye.
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DESCRIPTION: One-week history of decreased vision in the left eye.  Past ocular history includes cataract extraction with lens implants in both eyes.

consult - history and phy., cataract extraction, lens implants, decreased vision, macular degeneration, intraocular pressures, rpe atrophy, eye, degeneration, glaucoma, macular, vision,

The situation involves a patient with complex ocular history and current issues that could potentially lead to severe vision loss if not managed properly. Conditions like glaucoma and macular degeneration are serious and require careful, ongoing monitoring and treatment. Additionally, there is a history of family blindness, adding a layer of genetic risk. Given that the patient needs to see a specialist soon before returning home, there are immediate logistical implications for her treatment plan. Therefore, the stakes are high because inadequate attention could lead to permanent vision impairment.


Medical Specialty: Consult - History and Phy.
Sample Name: Neurologic Consultation

REASON FOR CONSULTATION: , Neurologic consultation was requested by Dr. X to evaluate her seizure medication and lethargy.,HISTORY OF PRESENT ILLNESS: , The patient is well known to me.  She has symptomatic partial epilepsy secondary to a static encephalopathy, cerebral palsy, and shunted hydrocephalus related to prematurity.  She also has a history of factor V Leiden deficiency.  She was last seen at neurology clinic on 11/16/2007.  At that time, instructions were given to mom to maximize her Trileptal dose if seizures continue.  She did well on 2 mL twice a day without any sedation.  This past Friday, she had a 25-minute seizure reportedly.  This consisted of eye deviation, unresponsiveness, and posturing.  Diastat was used and which mom perceived was effective.  Her Trileptal dose was increased to 3 mL b.i.d. yesterday.,According to mom since her shunt revision on 12/18/2007, she has been sleepier than normal.  She appeared to be stable until this past Monday about six days ago, she became more lethargic and had episodes of vomiting and low-grade fevers.  According to mom, she had stopped vomiting since her hospitalization.  Reportedly, she was given a medication in the emergency room.  She still is lethargic, will not wake up spontaneously.  When she does awaken however, she is appropriate, and interacts with them.  She is able to eat well; however her overall p.o. intake has been diminished.  She has also been less feisty as her usual sounds.  She has been seizure free since her admission.,LABORATORY DATA: , Pertinent labs obtained here showed the following:  CRP is less than 0.3, CMP normal, and CBC within normal limits.  CSF cultures so far is negative.  Dr. Limon's note refers to a CSF, white blood cell count of 2, 1 RBC, glucose of 55, and protein of 64.  There are no imaging studies in the computer.  I believe that this may have been done at Kaweah Delta Hospital and reviewed by Dr. X, who indicated that there was no evidence of shunt malfunction or infection.,CURRENT MEDICATIONS: , Trileptal 180 mg b.i.d., lorazepam 1 mg p.r.n., acetaminophen, and azithromycin.,PHYSICAL EXAMINATION:,GENERAL:  The patient was asleep, but easily aroused.  There was a brief period of drowsiness, which she had some jerky limb movements, but not seizures.  She eventually started crying and became agitated.  She made attempts to sit by bending her neck forward.  Fully awake, she sucks her bottle eagerly.,HEENT:  She was obviously visually impaired.  Pupils were 3 mm, sluggishly reactive to light.,EXTREMITIES:  Bilateral lower extremity spasticity was noted.  There was increased flexor tone in the right upper extremity.  IV was noted on the left hand.,ASSESSMENT:  ,Seizure breakthrough due to intercurrent febrile illness.  Her lethargy could be secondary to a viral illness with some component of medication effect since her Trileptal dose was increased yesterday and these are probable explanations if indeed shunt malfunction has been excluded.,I concur with Dr. X's recommendations.  I do not recommend any changes in Trileptal for now.  I will be available while she remains hospitalized.,
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DESCRIPTION: Neurologic consultation was requested to evaluate her seizure medication and lethargy.

consult - history and phy., lethargy, encephalopathy, cerebral palsy, shunted hydrocephalus, seizure breakthrough, shunt malfunction, neurologic consultation, neurologic, seizure, trileptal

The situation described is a medical consultation for a patient with a history of epilepsy, cerebral palsy, and shunted hydrocephalus. The stakes are fairly high as it involves assessing the appropriateness of seizure medication amidst symptoms that could be due to complications like shunt malfunction or infection. Proper management is crucial to prevent potential life-threatening issues such as increased intracranial pressure if the shunt is malfunctioning or inappropriate seizure control worsening the patient's condition.


Medical Specialty: Surgery
Sample Name: Emergency C-section.

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Nonreassuring fetal heart tones with a prolonged deceleration.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Nonreassuring fetal heart tones with a prolonged deceleration.,PROCEDURE PERFORMED: , Emergency cesarean section.,ANESTHESIA:  ,General and endotracheal as well as local anesthesia.,ESTIMATED BLOOD LOSS: , 800 mL.,COMPLICATIONS: , None.,FINDINGS:  ,Female infant in cephalic presentation in OP position.  Normal uterus, tubes and ovaries are noted.  Weight was 6 pounds and 3 ounces, Apgars were 6 at 1 minute and 7 at 5 minutes, and 9 at 10 minutes.  Normal uterus, tubes and ovaries were noted.,INDICATIONS:  ,The patient is a 21-year-old Gravida 1, para 0 female who present to labor and delivery at term with spontaneous rupture of membranes noted at 5 a.m. on the day of delivery.  The patient was admitted and cervix was found to be 1 cm dilated.  Pitocin augmentation of labor was started.  The patient was admitted by her primary obstetrician Dr. Salisbury and was managed through the day by him at approximately 5 p.m. at change of shift care was assumed by me.  At this time, the patient was noted to have variable decelerations down to the 90s lasting approximately 1 minute with good return to baseline, good variability was noted as well as accelerations, variable deceleration despite position change was occurring with almost every contraction, but was lasting for 60 to 90 seconds at the longest.  Vaginal exam was done.  Cervix was noted to be 4 cm dilated.,At this time IPC was placed and amnioinfusion was started in hopes to relieve the variable declarations.  At 19:20 fetal heart tones was noted to go down to the 60s and remained down in the 60s for 3 minutes at which time the patient was transferred from Labor And Delivery Room to the operating room for an emergency cesarean section.  Clock in the operating room is noted to be 2 minutes faster then the time on trace view.  The OR delivery time was 19:36.  Delivery of this infant was performed in 14 minutes from the onset of the deceleration.  Upon arrival to the operating room, while prepping the patient for surgery and awaiting the arrival of the anesthesiologist, heart tones were noted to be in 60s and slowly came up to the 80s.  Following the transfer of the patient to the operating room bed and prep of the abdomen, the decision was made to begin the surgery under local anesthesia, 2% lidocaine was obtained for this purpose.,PROCEDURE NOTE: , The patient was taken to the operating room she was quickly prepped and draped in the dorsal supine position with a leftward tilt.  2% lidocaine was obtained and the skin was anesthetized using approximately 15 mL of 2% lidocaine.  As the incision site was being injected, the anesthesiologist arrived.  The procedure was started prior to the patient being put under general anesthesia.,A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia using the Scalpel using __________ technique.  The rectus muscles were separated in midline.  The peritoneum was bluntly dissected.  The bladder blade was inserted.  The uterus has been incised in the transverse fashion using the scalpel and extended using manual traction.  The infant was subsequently delivered.  Immediately following delivery of the infant.  The infant was noted to be crying with good tones.  The cord was clammed and cut.  The infant was subsequently transferred or handed to the nursery nurse.  The placenta was delivered manually intact with a three-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic sutures.  Hemostasis was visualized.  The uterus was returned to the abdomen.  The pelvis was copiously irrigated.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was reapproximated with 0 Vicryl suture.  The subcutaneous layer was closed with 2-0 plain gut.  The skin was closed in the subcuticular stitch using 4-0 Monocryl.  Steri-strips were applied.  Sponge, laps, and instrument counts were correct.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.
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DESCRIPTION: Emergency cesarean section.

Emergency cesarean section.

surgery, intrauterine pregnancy at term, prolonged deceleration, apgars, emergency cesarean section, fetal heart tones, intrauterine,

This situation involves an emergency cesarean section due to nonreassuring fetal heart tones, which indicates potential fetal distress. The speed and efficiency required in this scenario to ensure the health and safety of both the mother and the infant make it a high-stakes medical procedure. The successful delivery and stabilization of both mother and infant were crucial, and any delays or complications could have serious consequences.


Medical Specialty: Office Notes
Sample Name: Normal ROS Template - 3

HEENT:,  No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.,RESPIRATORY: , No shortness of breath, wheezing, dyspnea, pulmonary disease, tuberculosis or past pneumonias.,CARDIOVASCULAR: , No history of palpitations, irregular rhythm, chest pain, hypertension, hyperlipidemia, diaphoresis, congestive heart failure, heart catheterization, stress test or recent cardiac tests.,GASTROINTESTINAL:,  No history of rectal bleeding, appetite change, abdominal pain, hiatal hernia, ulcer, jaundice, change in bowel habits or liver problems, and no history of inflammatory bowel problems.,GENITOURINARY: , No dysuria, hematuria, frequency, incontinence or colic.,NERVOUS SYSTEM: , No gait problems, strokes, numbness or muscle weakness.,PSYCHIATRIC: , No history of emotional lability, depression or sleep disturbances.,ONCOLOGIC:,  No history of any cancer, change in moles or rashes.  No history of weight loss.  The patient has a good energy level.,ALLERGIC/LYMPH: , No history of systemic allergy, abnormal lymph nodes or swelling.,MUSCULOSKELETAL: , No fractures, motor weakness, arthritis or other joint pains.
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DESCRIPTION: Normal review of systems template.  No history of headaches, migraines, vertigo, syncope, visual loss, tinnitus, sinusitis, sore in the mouth, hoarseness, swelling or goiter.

office notes, review of systems, tinnitus, sinusitis, sore, mouth, hoarseness, goiter, heart, appetite, bowel, weakness, loss, swelling,

The provided information is a template for a 'Normal Review of Systems' (ROS) used in medical documentation. It lists systems and conditions in a clinical context, indicating there are no notable findings or medical history based on the categories mentioned. This situation is low-stakes because it represents a routine aspect of medical record-keeping rather than a critical decision-making point or a medical emergency.


Medical Specialty: General Medicine
Sample Name: Cut on Foot - ER Visit

CHIEF COMPLAINT:,  Cut on foot.,HISTORY OF PRESENT ILLNESS:,  This is a 32-year-old male who had a piece of glass fall on to his right foot today.  The patient was concerned because of the amount of bleeding that occurred with it.  The bleeding has been stopped and the patient does not have any pain.  The patient has normal use of his foot, there is no numbness or weakness, the patient is able to ambulate well without any discomfort.  The patient denies any injuries to any other portion of his body.  He has not had any recent illness.  The patient has no other problems or complaints.,PAST MEDICAL HISTORY:,  Asthma.,CURRENT MEDICATION: , Albuterol.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 98.8 oral, blood pressure 132/86, pulse is 76, and respirations 16.  Oxygen saturation is 100% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well-nourished, well-developed, the patient appears to be healthy.  The patient is calm and comfortable in no acute distress and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear conjunctiva and cornea bilaterally.  NECK:  Supple with full range of motion.  CARDIOVASCULAR:  Peripheral pulse is +2 to the right foot.  Capillary refills less than two seconds to all the digits of the right foot.  RESPIRATIONS:  No shortness of breath.  MUSCULOSKELETAL:  The patient has a 4-mm partial thickness laceration to the top of the right foot and about the area of the mid foot.  There is no palpable foreign body, no foreign body is visualized.  There is no active bleeding, there is no exposed deeper tissues and certainly no exposed tendons, bone, muscle, nerves, or vessels.  It appears that the laceration may have nicked a small varicose vein, which would have accounted for the heavier than usual bleeding that currently occurred at home.  The patient does not have any tenderness to the foot.  The patient has full range of motion to all the joints, all the toes, as well as the ankles.  The patient ambulates well without any difficulty or discomfort.  There are no other injuries noted to the rest of the body.  SKIN:  The 4-mm partial thickness laceration to the right foot as previously described.  No other injuries are noted.  NEUROLOGIC:  Motor is 5/5 to all the muscle groups of the right lower extremity.  Sensory is intact to light touch to all the dermatomes of the right foot.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No active bleeding is occurring at this time.  No evidence of bruising is noted to the body.,EMERGENCY DEPARTMENT COURSE:,  The patient had antibiotic ointment and a bandage applied to his foot.,DIAGNOSES:,1.  A 4-MM LACERATION TO THE RIGHT FOOT.,2.  ACUTE RIGHT FOOT PAIN, NOW RESOLVED.,CONDITION UPON DISPOSITION: , Stable.,DISPOSITION:,  To home.  The patient was given discharge instructions on wound care and asked to return to emergency room should he have any evidence or signs and symptoms of infection.  The patient was precautioned that there may still be a small piece of glass retained in the foot and that there is a possibility of infection or that the piece of glass may be extruded later on.
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DESCRIPTION: Patient had a piece of glass fall on to his right foot.  A 4-mm laceration.  Acute foot pain, now resolved.   The patient was given discharge instructions on wound care.

general medicine, foot pain, cut on foot, piece of glass, foreign body, active bleeding, foot, injuries, atraumatic, laceration, bleeding, body,

The situation described involves a 32-year-old male who sustained a 4-mm laceration from glass on his foot, leading to a brief emergency room visit. There was concern predominantly due to the bleeding. However, the bleeding was controlled, there were no signs of systemic infection or other complicating factors like foreign body retention that couldn't be managed at home with careful monitoring. The patient was stable, and the laceration was not associated with significant complications such as nerve or vascular damage. The condition was resolved enough to discharge the patient with instructions for self-care and follow-up if symptoms worsen. Generally, such cases are not considered high-stakes in emergency medicine unless there are complications or significant risk factors present, which are not indicated here.


Medical Specialty: Surgery
Sample Name: Punch Biopsy - 1

PROCEDURE:,  Punch biopsy of right upper chest skin lesion.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Minimal.,COMPLICATIONS:,  None.,PROCEDURE:,  The area around the lesion was anesthetized after she gave consent for her procedure.  Punch biopsy including some portion of lesion and normal tissue was performed.  Hemostasis was completed with pressure holding.  The biopsy site was approximated with non-dissolvable suture.  The area was hemostatic.  All counts were correct and there were no complications.  The patient tolerated the procedure well.  She will see us back in approximately five days.,
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DESCRIPTION: Punch biopsy of right upper chest skin lesion.

The described procedure is a punch biopsy, which is a minor and routine procedure generally associated with low risk. Minimal blood loss, minimal fluid involvement, absence of complications, and the patient tolerating the procedure well further indicate that it is not high-stakes. The follow-up arranged in five days also suggests routine care rather than urgent attention.


Medical Specialty: Office Notes
Sample Name: Normal ENT Exam - 1

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

office notes, oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling,

The information provided reflects a routine examination with normal findings. There are no indications of medical issues or emergencies. The stakes are low as it represents typical documentation of an exam with no adverse findings.


Medical Specialty: Orthopedic
Sample Name: Carpal Tunnel Release - 7

PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Right carpal tunnel syndrome.,PROCEDURE PERFORMED: , Right carpal tunnel release.,PROCEDURE NOTE:  ,The right upper extremity was prepped and draped in the usual fashion.  IV sedation was supplied by the anesthesiologist.  A local block using 6 cc of 0.5% Marcaine was used at the transverse wrist crease using a 25 gauge needle, superficial to the transverse carpal ligament.,The upper extremity was exsanguinated with a 6 inch ace wrap.,Tourniquet time was less than 10 minutes at 250 mmHg.,An incision was used in line with the third web space just to the ulnar side of the thenar crease.  It was carried sharply down to the transverse wrist crease.  The transverse carpal ligament was identified and released under direct vision.  Proximal to the transverse wrist crease it was released subcutaneously.  During the entire procedure care was taken to avoid injury to the median nerve proper, the recurrent median, the palmar cutaneous branch, the ulnar neurovascular bundle and the superficial palmar arch.  The nerve appeared to be mildly constricted.  Closure was routine with running 5-0 nylon.  A bulky hand dressing as well as a volar splint was applied and the patient was sent to the outpatient surgery area in good condition.
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DESCRIPTION: Right carpal tunnel syndrome.  Right carpal tunnel release.

orthopedic, superficial palmar arch, carpal tunnel release, carpal tunnel syndrome, transverse wrist crease, superficial, ligament,

The scenario describes a routine carpal tunnel release surgery, which is a common and relatively low-risk orthopedic procedure. The note outlines standard steps taken during the procedure, care to avoid nerve injury, and the use of local anesthesia with IV sedation. The terminology suggests that this is a regular surgical procedure with a pre-planned postoperative pathway. There are no unusual complications or high-risk factors mentioned. Considering that it is for carpal tunnel syndrome, which is a common and treatable condition, and that the patient is in good condition post-surgery, the stakes are not high.


Medical Specialty: Radiology
Sample Name: Coronary CT Angiography (CCTA) - 3

EXAM: , Coronary artery CTA with calcium scoring and cardiac function.,HISTORY: , Chest pain.,TECHNIQUE AND FINDINGS: , Coronary artery CTA was performed on a Siemens dual-source CT scanner.  Post-processing on a Vitrea workstation.  150 mL Ultravist 370 was utilized as the intravenous contrast agent.  Patient did receive nitroglycerin sublingually prior to the contrast.,HISTORY: , Significant for high cholesterol, overweight, chest pain, family history,Patient's total calcium score (Agatston) is 10. his places the patient just below the 75th percentile for age.,The LAD has a moderate area of stenosis in its midportion due to a focal calcified plaque.  The distal LAD was unreadable while the proximal was normal.  The mid and distal right coronary artery are not well delineated due to beam-hardening artifact.  The circumflex is diminutive in size along its proximal portion.  Distal is not readable.,Cardiac wall motion within normal limits.  No gross pulmonary artery abnormality however they are not well delineated.  A full report was placed on the patient's chart.  Report was saved to PACS.
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DESCRIPTION: Coronary Artery CTA with Calcium Scoring and Cardiac Function

radiology, coronary artery cta, calcium scoring, cardiac function, coronary artery, ct, scoring, lad, midportion, cta, calcium, cardiac, coronary, artery, angiography,

The report involves the interpretation of a coronary CT angiography, which is a critical diagnostic tool for evaluating coronary artery disease. This examination is essential for understanding the condition of the heart's arteries and requires precise interpretation since it can lead to significant medical decisions such as medication changes, surgical interventions, or further invasive diagnostic procedures. Furthermore, the findings indicate a moderate stenosis and issues with imaging clarity in certain areas, which can have ramifications on patient management. Overall, such assessments are high-stakes because inaccurate or delayed interpretation can significantly impact patient outcomes.


Medical Specialty: Consult - History and Phy.
Sample Name: Sports Physical - 3

SUBJECTIVE:,  This is a 12-year-old male who comes in for healthy checkups and sports physical.  No major concerns today.  He is little bit congested at times.  He has been told he is allergic to grasses.  They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports.  He has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Very healthy.,CURRENT MEDICATIONS:,  Claritin p.r.n.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home currently.,DIETARY:,  He is on whole milk and does a variety of foods.  Growth chart is reviewed with mother.  Voids and stools well.,DEVELOPMENTAL:,  He is in seventh grade and going out for cross-country and track.  He is supposed to be wearing glasses, is not today.  We did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother.  His hearing was normal today and no concerns with speech.,PHYSICAL EXAMINATION:,General:  A well-developed, well-nourished male in no acute distress.,Dermatologic:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes are present bilaterally.  Optic discs are sharp with normal vasculature.  Ears:  Tympanic membranes are gray, translucent with normal light reflex.  Nares are very congested.  Turbinates swollen and boggy.,Neck:  Supple without masses.,Chest:  Clear to auscultation and percussion, easy respirations.  No accessory muscle use.,Cardiovascular:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,Back:  Symmetric with no scoliosis or kyphosis noted.  Normal flexibility.  Femoral pulses 2+ and symmetric.,Abdomen:  Soft, nontender, nondistended without hepatosplenomegaly.,GU Exam:  Normal Tanner III male.  Testes descended bilaterally.  No abnormal rash, discharge, or scars.,Extremities:  Pink and warm.  Moves all extremities well with normal function and strength in the arms and legs.  Normal balance, station, and gait.  Normal speech.,Neurologic:  Nonfocal with normal speech, station, gait, and balance.,ASSESSMENT:,  Healthy Tanner III male, developing normally.,PLAN:,1.  Diet, growth, safety, drugs, violence, and social competence all discussed.,2.  Immunizations reviewed.,3.  We will place him on Clarinex 5 mg once daily, some Rhinocort-AQ nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4.  Return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n.
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DESCRIPTION: Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.

The situation involves a routine sports physical and health checkup for a 12-year-old male, with minor issues such as allergies and facial skin dryness. There are no immediate health threats or serious medical concerns, and the child is otherwise healthy and developing normally. The situation represents a low-stake, everyday medical assessment that does not require urgent intervention.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Myocardial Perfusion Imaging - 3

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

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

The diagnosis indicates symptoms and conditions such as shortness of breath, fatigue, hypertension, and hyperlipidemia, which are serious and suggestive of possible coronary artery disease. The myocardial perfusion imaging is used to assess blood flow to the heart, particularly evaluating for coronary artery disease, which can have significant health impacts. Therefore, the stakes are relatively high given the potential for severe cardiovascular issues.


Medical Specialty: Surgery
Sample Name: Fiberoptic Bronchoscopy - 1

PREOPERATIVE DIAGNOSIS:,1.  Hemoptysis.,2.  History of lung cancer.,POSTOPERATIVE DIAGNOSIS:,  Tumor occluding right middle lobe with friability.,PROCEDURE PERFORMED:,  Fiberoptic bronchoscopy, diagnostic.,LOCATION: , Endoscopy suite #4.,ANESTHESIA:,  General per Anesthesia Service.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain.  Due to her prior history, it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis.  She was brought to endoscopy suite #4 and informed consent was obtained.  ,PROCEDURE DETAILS:  ,The patient was placed in the supine position and intubated by the Anesthesia Service.  Intravenous sedation was given as per Anesthesia.  The fiberoptic scope was passed through the #8 endotracheal tube into the main trachea.  The right mainstem bronchus was examined.  The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted.  Upon examining the right middle lobe, there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe.,The clot was lavaged with normal saline and there was noted to be tumor behind this clot.  Tumor completely occluded both segments of the right middle lobe.  Scope was then passed to the subsegments of the right lower lobe, which were individually examined and noted to be grossly free of endobronchial lesions.  Scope was pulled back to the level of the midtrachea, passed into the left mainstem bronchus.  Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions.  The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions.  There were some secretions noted throughout the left lung.  The scope was retracted and passed again to the right mainstem bronchus.  The area of the right middle lobe was reexamined.  The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation.  It did not appear as if a scope or cannula could be passed distal to the tumor.  Due to continued oozing, 1 cc of epinephrine was applied topically with adequate hemostasis obtained.  The area was examined for approximately one minute for assurance of adequate hemostasis.  The scope was then retracted and the patient was sent to the recovery room in stable condition.  She will be extubated as per the Anesthesia Service.  Cytology and cultures were not sent due to the patient's known diagnosis.  Further recommendations are pending at this time.
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DESCRIPTION: Fiberoptic bronchoscopy, diagnostic.  Hemoptysis and history of lung cancer.  Tumor occluding right middle lobe with friability.

surgery, hemoptysis, lung cancer, tumor, fiberoptic, bronchoscopy, endoscopy suite, adequate hemostasis, fiberoptic bronchoscopy, endobronchial lesions, middle lobe, lobe,

The situation in question involves a medical procedure to investigate a patient with a history of lung cancer and acute hemoptysis. High-stakes factors include the presence of a tumor occluding the right middle lobe of the lung and associated bleeding (oozing) that was controlled using epinephrine. The detailed procedural report indicates the critical nature of the condition, though the immediate postoperative outcome was stable, which is encouraging but does not reduce the overall stakes given the underlying conditions. The potential consequences of the tumor and hemoptysis, including the risk of further bleeding, respiratory distress, and the implications for the patient's cancer treatment, elevate the stakes significantly. However, as the immediate situation post-procedure was managed and stable, there is some reduction in acute risk but substantial ongoing concern remains.


Medical Specialty: Surgery
Sample Name: Clear Corneal Temporal Incision

CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES),DESCRIPTION OF OPERATION: , Under satisfactory local anesthesia, the patient was appropriately prepped and draped.  A lid speculum was placed in the fissure of the right eye.,The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's 7:30 position and the anterior chamber re-formed using viscoelastic.  The primary incision was then made using a 3-mm diamond keratome at the surgeon's 5 o'clock position and additional viscoelastic injected into the anterior chamber as needed.  The capsulorrhexis was then performed in a standard circular tear fashion.  The nucleus was then separated from its cortical attachments by hydrodissection and emulsified in the capsular bag.  The residual cortex was then aspirated from the bag and the bag re-expanded using viscoelastic.  The posterior chamber intraocular lens was then inspected, irrigated, coated with Healon and folded, and then placed into the capsular bag under direct visualization.  The lens was noted to center well.  The residual viscoelastic was then removed from the eye and the eye re-formed using balanced salt solution.  The eye was then checked and found to be watertight; therefore, no suture was used.  The lid speculum and the drapes were then removed and the eye treated with Maxitrol ointment.,A shield was applied and the patient returned to the recovery room in good condition.
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DESCRIPTION: Clear corneal temporal incision (no stitches).  A lid speculum was placed in the fissure of the right eye.

surgery, clear corneal temporal incision, intraocular lens, corneal temporal incision, lid speculum, incision, temporal, chamber, corneal, viscoelastic, eyeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The situation described involves a common surgical procedure (clear corneal temporal incision for cataract surgery), performed under local anesthesia with standard precautions and techniques. Such procedures are routine for experienced ophthalmic surgeons and typically have a high success rate with low complication rates. The absence of stitches and post-operative good condition of the patient indicates a typically well-managed scenario. Though it involves surgery which always carries some risk, in the context of medical operations, it is relatively low-stakes compared to more complex or life-threatening surgeries.


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

Medical Specialty: Surgery
Sample Name: Knee Amputation

PREOPERATIVE DIAGNOSES:,1.  Left diabetic foot abscess and infection.,2.  Left calcaneus fracture with infection.,3.  Right first ray amputation.,POSTOP DIAGNOSES:,1.  Left diabetic foot abscess and infection.,2.  Left calcaneus fracture with infection.,3.  Right first ray amputation.,OPERATION AND PROCEDURE:,1.  Left below-the-knee amputation.,2.  Dressing change, right foot.,ANESTHESIA: , General.,BLOOD LOSS: , Less than 100 mL.,TOURNIQUET TIME:,  24 minutes on the left, 300 mmHg.,COMPLICATIONS:,  None.,DRAINS: , A one-eighth-inch Hemovac.,INDICATIONS FOR SURGERY: , The patient is a 62 years of age with diabetes.  He developed left heel abscess.  He had previous debridements, developed a calcaneal fracture and has now had several debridement with placement of the antibiotic beads.  After re-inspecting the wound last week, the plan was for possible debridement and he desired below-the-knee amputation.  We are going to change the dressing on the right side also.  The risks, benefits, and alternatives of surgery were discussed.  The risks of bleeding, infection, damage to nerves and blood vessels, persistent wound healing problems, and the need for future surgery.  He understood all the risks and desired operative treatment.,OPERATIVE PROCEDURE IN DETAIL: , After appropriate informed consent obtained, the patient was taken to the operating room and placed in the supine position.  General anesthesia induced.  Once adequate anesthesia had been achieved, cast padding placed on the left proximal thigh and tourniquet was applied.  The right leg was redressed.  I took the dressing down.  There was a small bit of central drainage, but it was healing nicely.  Adaptic and new sterile dressings were applied.,The left lower extremity was then prepped and draped in usual sterile fashion.,A transverse incision made about the mid shaft of the tibia.  A long posterior flap was created.  It was taken to the subcutaneous tissues with electrocautery.  Please note that tourniquet had been inflated after exsanguination of the limb.  Superficial peroneal nerve identified, clamped, and cut.  Anterior compartment was divided.  The anterior neurovascular bundle identified, clamped, and cut.  The plane was taken between the deep and superficial compartments.  The superficial compartment was reflected posteriorly.  Tibial nerve identified, clamped, and cut.  Tibial vessels identified, clamped, and cut.,Periosteum of the tibia elevated proximally along with the fibula.  The tibia was then cut with Gigli saw.  It was beveled anteriorly and smoothed down with a rasp.  The fibula was cut about a cm and a half proximal to this using a large bone cutter.  The remaining posterior compartment was divided.  The peroneal bundle identified, clamped, and cut.  The leg was then passed off of the field.  Each vascular bundle was then doubly ligated with 0 silk stick tie and 0 silk free tie.  The nerves were each pulled at length, injected with 0.25% Marcaine with epinephrine, cut, and later retracted proximally.  The tourniquet was released.  Good bleeding from the tissues and hemostasis obtained with electrocautery.  Copious irrigation performed using antibiotic-impregnated solution.  A one-eighth-inch Hemovac drain placed in the depth of wound adhering on the medial side.  A gastroc soleus fascia brought up and attached to the anterior fascia and periosteum with #1 Vicryl in an interrupted fashion.  The remaining fascia was closed with #1 Vicryl.  Subcutaneous tissues were then closed with 2-0 PDS suture using 2-0 Monocryl suture in interrupted fashion.  Skin closed with skin staples.  Xeroform gauze, 4 x 4, and a padded soft dressing applied.  He was placed in a well-padded anterior and posterior slab splint with the knee in extension.  He was then awakened, extubated, and taken to recovery in stable condition.  There were no immediate operative complications, and he tolerated the procedure well.
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DESCRIPTION: Left below-the-knee amputation.  Dressing change, right foot.

surgery, infection, adaptic, gigli saw, hemovac, abscess, amputation, below-the-knee amputation, calcaneus fracture, debridement, diabetic foot, ray amputation, tourniquet, transverse incision, knee amputation, knee, dressing, clamped,

The case involves a surgical procedure, specifically a left below-the-knee amputation, in a patient with complications from diabetes. Surgery inherently carries high stakes due to the potential for complications, the need for precision, and the significant impact on the patient's quality of life post-operation. The decision for amputation indicates a severe infection that was not manageable with less invasive methods. While the postoperative report indicates no complications, the seriousness of the procedure itself and the specialized care involved make it high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Not Feeling Well - ER Visit

CHIEF COMPLAINT:  ,The patient does not have any chief complaint.,HISTORY OF PRESENT ILLNESS:,  This is a 93-year-old female who called up her next-door neighbor to say that she was not feeling well.  The next-door neighbor came over and decided that she should go to the emergency room to be check out for her generalized complaint of not feeling well.  The neighbor suspects that this may have been due to the patient taking too many of her Tylenol PM, which the patient has been known to do.  The patient was a little somnolent early this morning and was found only to be oriented x1 with EMS upon their arrival to the patient's house.  The patient states that she just simply felt funny and does not give any more specific details than this.  The patient denies any pain at any time.  She did not have any shortness of breath.  No nausea or vomiting.  No generalized weakness.  The patient states that all that has gone away since arrival here in the hospital, that she feels at her usual self, is not sure why she is here in the hospital, and thinks she should go.  The patient's primary care physician, Dr. X reports that the patient spoke with him yesterday and had complained of shortness of breath, nausea, dizziness, as well as generalized weakness, but the patient states that all this has resolved.  The patient was actually seen here two days ago for those same symptoms and was found to have exacerbation of her COPD and CHF.  The patient was discharged home after evaluation in the emergency room.  The patient does use home O2.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  The patient had complained of generalized fatigue and weakness two days ago in the emergency room and yesterday to her primary care physician.  The patient denies having any other symptoms today.  The patient denies any fever or chills.  Has not had any recent weight change.  HEENT:  The patient denies any headache.  No neck pain.  No rhinorrhea.  No sinus congestion.  No sore throat.  No any vision or hearing change.  No eye or ear pain.  CARDIOVASCULAR:  The patient denies any chest pain.  RESPIRATIONS:  No shortness of breath.  No cough.  No wheeze.  The patient did report having shortness of breath and wheeze with her presentation to the emergency room two days ago and shortness of breath to her primary care physician yesterday, but the patient states that all this has resolved.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  No change in the bowel movements.  There has not been any diarrhea or constipation.  No melena or hematochezia.  GENITOURINARY:  No dysuria, hematuria, urgency, or frequency.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  No pain or abnormalities to any portion of the body.  SKIN:  No rashes or lesions.  NEUROLOGIC:  The patient reported dizziness to her primary care physician yesterday over the phone, but the patient denies having any problems with dizziness over the past few days.  The patient denies any dizziness at this time.  No syncope or no near-syncope.  The patient denies any focal weakness or numbness.  No speech change.  No difficulty with ambulation.  The patient has not had any vision or hearing change.  PSYCHIATRIC:  The patient denies any depression.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  COPD, CHF, hypertension, migraines, previous history of depression, anxiety, diverticulitis, and atrial fibrillation.,PAST SURGICAL HISTORY:,  Placement of pacemaker and hysterectomy.,CURRENT MEDICATIONS: , The patient takes Tylenol PM for insomnia, Lasix, Coumadin, Norvasc, Lanoxin, Diovan, atenolol, and folic acid.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient used to smoke, but quit approximately 30 years ago.  The patient denies any alcohol or drug use although her son reports that she has had a long history of this in the past and the patient has abused prescription medication in the past as well according to her son.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature 99.1 oral, blood pressure 139/65, pulse is 72, respirations 18, and oxygen saturation is 92% on room air and interpreted as low normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Head is atraumatic, normocephalic, and nontender.  Eyes are normal with clear sclerae and cornea bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Mouth and oropharynx are normal without any sign of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  No cervical lymphadenopathy.  No carotid artery or vertebral artery bruits.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  The patient does have +1 bilateral lower extremity edema.  RESPIRATIONS:  The patient has coarse breath sounds bilaterally, but no dyspnea.  Good air movement.  No wheeze.  No crackles.  The patient speaks in full sentences without any difficulty.  The patient does not exhibit any retractions, accessory muscle use or abdominal breathing.  GASTROINTESTINAL:  Abdomen is soft, nontender, and nondistended.  No rebound or guarding.  No hepatosplenomegaly.  Normal bowel sounds.  No bruits, no mass, no pulsatile mass, and no inguinal lymphadenopathy.  MUSCULOSKELETAL:  No abnormalities noted to the back, arms or legs.  SKIN:  No rashes or lesions.  NEUROLOGICAL:  Cranial nerves II through XII are intact.  Motor is 5/5 and equal to bilateral arms and legs.  Sensory is intact to light touch.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is awake, alert, and oriented x3 although the patient first stated that the year was 1908, but did manage to correct herself up on addressing this with her.  The patient has normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  There is no evidence of lymphadenopathy.,EMERGENCY DEPARTMENT TESTING: , EKG is a rate of 72 with evidence of a pacemaker that has good capture.  There is no evidence of acute cardiac disease on the EKG and there is no apparent change in the EKG from 03/17/08.  CBC has no specific abnormalities of issue.  Chemistry has a BUN of 46 and creatinine of 2.25, glucose is 135, and an estimated GFR is 20.  The rest of the values are normal and unremarkable.  LFTs are all within normal limits.  Cardiac enzymes are all within normal limits.  Digoxin level is therapeutic at 1.6.  Chest x-ray noted cardiomegaly and evidence of congestive heart failure, but no acute change from her chest x-ray done two days ago.  CAT scan of the head did not identify any acute abnormalities.  I spoke with the patient's primary care physician, Dr. X who stated that he would be able to follow up with the patient within the next day.  I spoke with the patient's neighbor who contacted the ambulance service who stated that the patient just reported not feeling well and appeared to be a little somnolent and confused at the time, but suspected that she may have taken too many of her Tylenol PM as she often has done in the past.  The neighbor is XYZ and he says that he checks on her three times a day every day.  ABC is the patient's son and although he lives out of town he calls and checks on her every day as well.  He states that he spoke to her yesterday.  She sounded fine, did not express any other problems that she had apparently been in contact with her primary care physician.  She sounded her usual self to him.  Mr. ABC also spoke to the patient while she was here in the emergency room and she appears to be her usual self and has her normal baseline mental status to him.  He states that he will be able to check on her tomorrow as well.  Although it is of some concern that there may be problems with development of some early dementia, the patient is adamant about not going to a nursing home and has been placed in a Nursing Home in the past, but Dr. Y states that she has managed to be discharged after two previous nursing home placements.  The patient does have Home Health that checks on her as well as housing care in between the two services they share visits every single day  by them as well as the neighbor who checks on her three times a day and her son who calls her each day as well.  The patient although she lives alone, does appear to have good followup and the patient is adamant that she wishes to return home.,DIAGNOSES,1.  EARLY DEMENTIA.,2.
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DESCRIPTION: A 93-year-old female called up her next-door neighbor to say that she was not feeling well.  The patient was given discharge instructions on dementia and congestive heart failure and asked to return to the emergency room should she have any new problems or symptoms of concern.

The situation involves a 93-year-old patient with several chronic health conditions, including COPD, CHF, and potential early dementia, who was taken to the ER after feeling unwell. The concern from the neighbor is that she might have taken too much Tylenol PM. Older patients, particularly those with multiple health issues, are at higher risk for serious complications from medication errors and sudden changes in health status. This patient has previously been in a nursing home, indicating the complexity of her health care needs. The stakes are high because of her age, the involvement of multiple chronic conditions, and potential medication misuse, which could lead to serious health risks.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Multiple Images of Skull (Pediatric)

EXAM:,  Skull, complete, five images,HISTORY:,  Plagiocephaly.,TECHNIQUE: , Multiple images of the skull were evaluated.  There are no priors for comparison.,FINDINGS: , Multiple images of the skull were evaluated and they reveal radiographic visualization of the cranial sutures without evidence of closure.  There is no evidence of any craniosynostosis.  There is no radiographic evidence of plagiocephaly.,IMPRESSION: , No evidence of craniosynostosis or radiographic characteristics for plagiocephaly.
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DESCRIPTION: Skull, complete, five images.

Skull, complete, five images.

pediatrics - neonatal, craniosynostosis, plagiocephaly, complete five images, multiple images, radiographic, images, skull,

The situation involves determining the presence of craniosynostosis or plagiocephaly in a pediatric patient. These conditions can have developmental implications, but the imaging results show no evidence of these conditions. Since the findings are normal and there are no concerning signs, the immediate situation has low stakes. However, considering that it involves a neonatal patient and potential developmental concerns, it slightly elevates the stakes compared to benign findings in adult imaging.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Consult/ER Report - OB/GYN

The patient states that she has abnormal menstrual periods and cannot remember the first day of her last normal menstrual period.  She states that she had spotting for three months daily until approximately two weeks ago, when she believes that she passed a fetus.  She states that upon removal of a tampon, she saw a tadpole like structure and believed it to be a fetus.  However, she states she did not know that she was pregnant at this time.  She denies any abdominal pain or vaginal bleeding.  She states that the pregnancy is unplanned; however, she would desire to continue the pregnancy.,PAST MEDICAL HISTORY:  Diabetes mellitus which resolved after weight loss associated with gastric bypass surgery.,PAST SURGICAL HISTORY:,1.  Gastric bypass.,2.  Bilateral carpal tunnel release.,3.  Laparoscopic cholecystectomy.,4.  Hernia repair after gastric bypass surgery.,5.  Thoracotomy.,6.  Knee surgery.,MEDICATIONS:,1.  Lexapro 10 mg daily.,2.  Tramadol 50 mg tablets two by mouth four times a day.,3.  Ambien 10 mg tablets one by mouth at bedtime.,ALLERGIES:  AMOXICILLIN CAUSES THROAT SWELLING.  AVELOX CAUSES IV SITE SWELLING.,SOCIAL HISTORY:  The patient denies tobacco, ethanol, or drug use.  She is currently separated from her partner who is the father of her 21-month-old daughter.  She currently lives with her parents in Greenville.  However, she was visiting the estranged boyfriend in Wilkesboro, this week.,GYN HISTORY:  The patient denies history of abnormal Pap smears or STDs.,OBSTETRICAL HISTORY:  Gravida 1 was a term spontaneous vaginal delivery, complicated only by increased blood pressures at the time of delivery.  Gravida 2 is current.,REVIEW OF SYSTEMS:  The 14-point review of systems was negative with the exception as noted in the HPI.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 134/45, pulse 130, respirations 28.  Oxygen saturation 100%.,GENERAL:  Patient lying quietly on a stretcher.  No acute distress.,HEENT:  Normocephalic, atraumatic.  Slightly dry mucous membranes.,CARDIOVASCULAR EXAM:  Regular rate and rhythm with tachycardia.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft, nontender, nondistended with positive bowel sounds.  No rebound or guarding.,SKIN:  Normal turgor.  No jaundice.  No rashes noted.,EXTREMITIES:  No clubbing, cyanosis, or edema.,NEUROLOGIC:  Cranial nerves II through XII grossly intact.,PSYCHIATRIC:  Flat affect.  Normal verbal response.,ASSESSMENT AND PLAN:  A 34-year-old Caucasian female, gravida 2 para 1-0-0-1, at unknown gestation who presents after suicide attempt.,1.  Given the substances taken, medications are unlikely to affect the development of the fetus.  There have been no reported human anomalies associated with Ambien or tramadol use.  There is, however, a 4% risk of congenital anomalies in the general population.,2.  Recommend quantitative HCG and transvaginal ultrasound for pregnancy dating.,3.  Recommend prenatal vitamins.,4.  The patient to follow up as an outpatient for routine prenatal care.,
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DESCRIPTION: A female with unknown gestational age who presents to the ED after a suicide attempt.

The situation is high-stakes due to multiple factors. Firstly, the patient is potentially pregnant, and there are concerns about the health and development of the fetus. The situation is further complicated by the fact that the patient has had a recent suicide attempt, which suggests that there might be significant mental health concerns that need urgent attention. Additionally, the patient's use of medications such as Ambien and tramadol could have implications for the fetus, even if the risk of anomalies is generally low according to the report. The patient's health and safety, both mental and physical, as well as the well-being of the fetus, make this a high-stakes situation requiring prompt and comprehensive medical and psychological intervention.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Cataract Extraction - 4

PREOPERATIVE DIAGNOSIS:  ,Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,PROCEDURE: , Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation.  ME 30, AC 25.0 diopter lens was used.,COMPLICATIONS:  ,None.,ANESTHESIA: , Local 2%, peribulbar lidocaine.,PROCEDURE NOTE:  ,Right eye was prepped and draped in the normal sterile fashion.  Lid speculum placed in his right eye.  Paracentesis made supratemporally.  Viscoat injected into the anterior chamber.  A 2.8 mm metal keratome blade was then used to fashion a clear corneal beveled incision temporally.  This was followed by circular capsulorrhexis and hydrodissection of the nucleus would be assessed.  Nuclear material removed via phacoemulsification.  Residual cortex removed via irrigation and aspiration.  The posterior capsule was clear and intact.  Capsular bag was then filled with Provisc solution.  The wound was enlarged to 3.5 mm with the keratoma.  The lens was folded in place into the capsular bag.  Residual Provisc was irrigated from the eye.  The wound was secured with one 10-0 nylon suture.  The lid speculum was removed.  One drop of 5% povidone-iodine prep was placed into the eye as well as a drop of Vigamox and TobraDex ointment.  He had a patch placed on it.  The patient was transported to the recovery room in stable condition.
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DESCRIPTION: Cataract extraction with phacoemulsification and posterior chamber intraocular lens implantation.  Cataract, right eye.

ophthalmology, provisc, intraocular lens implantation, intraocular lens, lens implantation, lid speculum, capsular bag, cataract extraction, phacoemulsification, cataract, intraocular

The procedure described is a common ophthalmic surgery to treat cataracts, known as phacoemulsification. This procedure typically has a high success rate and low complication risks when performed by experienced surgeons. While it is important for the patient, and any surgery carries inherent risks, this is considered a routine and low-stakes procedure within the field of ophthalmology when no complications are present and performed by competent medical professionals. The detailed description and absence of complications further indicate a typical scenario with expected outcomes.


Medical Specialty: Emergency Room Reports
Sample Name: Consult - ICU Management

REASON FOR CONSULTATION: , ICU management.,HISTORY OF PRESENT ILLNESS: , The patient is a 43-year-old gentleman who presented from an outside hospital with complaints of right upper quadrant pain in the abdomen, which revealed possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.  The patient was transferred to the ABCD Hospital where he had a weeklong course with progressive improvement in his status after aggressive care including intubation, fluid resuscitation, and watchful waiting.  The patient clinically improved; however, his white count remained elevated with the intermittent fevers prompting a CT scan.  Repeat CT scan showed a loculated area of ischemic bowel with perforation in the left upper abdomen.  The patient was taken emergently to the operating room last night by the General Surgery Service where proximal half of the jejunum was noted to be liquified with 3 perforations.  This section of small bowel was resected, and a wound VAC placed for damage control.  Plan was to return the patient to the Operating Room tomorrow for further exploration and possible re-anastomosis of the bowel.  The patient is currently intubated, sedated, and on pressors for septic shock and in the down ICU.,PAST MEDICAL HISTORY:,  Prior to coming into the hospital for this current episode, the patient had hypertension, diabetes, and GERD.,PAST SURGICAL HISTORY:,  Included a cardiac cath with no interventions taken.,HOME MEDICATIONS:,  Include Lantus insulin as well as oral hypoglycemics.,CURRENT MEDS:,  Include Levophed, Ativan, fentanyl drips, cefepime, Flagyl, fluconazole, and vancomycin.  Nexium, Synthroid, hydrocortisone, and Angiomax, which is currently on hold.,REVIEW OF SYSTEMS:,  Unable to be obtained secondary to the patient's intubated and sedated status.,ALLERGIES: , None.,FAMILY HISTORY:,  Includes diabetes on his father side of the family.  No other information is provided.,SOCIAL HISTORY:,  Includes tobacco use as well as alcohol use.,PHYSICAL EXAMINATION:,GENERAL: The patient is currently intubated and sedated on Levophed drip.,VITAL SIGNS: Temperature is 100.6, systolic is 110/60 with MAP of 80, and heart rate is 120, sinus rhythm.,NEUROLOGIC: Neurologically, he is sedated, on Ativan with fentanyl drip as well.  He does arouse with suctioning, but is unable to open his eyes to commands.,HEAD AND NECK EXAMINATION: His pupils are equal, round, reactive, and constricted.  He has no scleral icterus.  His mucous membranes are pink, but dry.  He has an EG tube, which is currently 24-cm at the lip.  He has a left-sided subclavian vein catheter, triple lumen.,NECK: His neck is without masses or lymphadenopathy or JVD.,CHEST: Chest has diminished breath sounds bilaterally.,ABDOMEN: Abdomen is soft, but distended with a wound VAC in place.  Groins demonstrate a left-sided femoral outline.,EXTREMITIES: His bilateral upper extremities are edematous as well as his bilateral lower extremities; however, his right is more than it is in the left.  His toes are cool, and pulses are not palpable.,LABORATORY EXAMINATION: , Laboratory examination reveals an ABG of 7.34, CO2 of 30, O2 of 108, base excess of -8, bicarb of 16.1, sodium of 144, potassium of 6.5, chloride of 122, CO2 18, BUN 43, creatinine 2.0, glucose 172, calcium 6.6, phosphorus 1.1, mag 1.8, albumin is 1.6, cortisone level random is 22.  After stimulation with cosyntropin, they were still 22 and then 21 at 30 and 60 minutes respectively.  LFTs are all normal.  Amylase and lipase are normal.  Triglycerides are 73, INR is 2.2, PTT is 48.3, white count 20.7, hemoglobin 9.6, and platelets of 211.  UA was done, which also shows a specific gravity of 1.047, 1+ protein, trace glucose, large amount of blood, and many bacteria.  Chest x-rays performed and show the tip of the EG tube at level of the carina with some right upper lobe congestion, but otherwise clear costophrenic angles.  Tip of the left subclavian vein catheter is appropriate, and there is no pneumothorax noted.,ASSESSMENT AND PLAN:,  This is a 43-year-old gentleman who is acutely ill, in critical condition with mesenteric ischemia secondary to visceral venous occlusion.  He is status post small bowel resection.  We plan to go back to operating room tomorrow for further debridement and possible closure.  Neurologically, the patient initially had question of encephalopathy while in the hospital secondary to slow awakening after previous intubation; however, he did clear eventually, and was able to follow commands.  I did not suspect any sort of pathologic abnormality of his neurologic status as he has further CT scan of his brain, which was normal.  Currently, we will keep him sedated and on fentanyl drip to ease pain and facilitate ventilation on the respirator.  We will form daily sedation holidays to assess his neurologic status and avoid over sedating with Ativan.,1.  Cardiovascular.  The patient currently is in septic shock requiring vasopressors maintained on MAP greater than 70.  We will continue to try to wean the vasopressin after continued volume loading, also place SvO2 catheter to assess his oxygen delivery and consumption given his state of shock.  Currently, his rhythm is of sinus tachycardia, I do not suspect AFib or any other arrhythmia at this time.  If he does not improve as expected with volume resuscitation and with resolution of his sepsis, we will obtain an echocardiogram to assess his cardiac function.  Once he is off the vasopressors, we will try low-dose beta blockade as tolerated to reduce his rate.,2.  Pulmonology.  Currently, the patient is on full vent support with a rate of 20, tidal volume of 550, pressure support of 10, PEEP of 6, and FiO2 of 60.  We will wean his FiO2 as tolerated to keep his saturation greater than 90% and wean his PEEP as tolerated to reduce preload compromise.  We will keep the head of bed elevated and start chlorhexidine as swish and swallow for VAP prevention.,3.  Gastrointestinal.  The patient has known mesenteric venous occlusion secondary to the thrombus formation at the portal vein as well as the SMV.  He is status post immediate resection of jejunum leaving a blind proximal jejunum and blind distal jejunum.  We will maintain NG tube as he has a blind stump there, and we will preclude any further administration of any meds through this NG tube.  I will keep him on GI prophylaxis as he is intubated.  We will currently hold his TPN as he is undergoing a large amount of volume changes as well as he is undergoing electrolyte changes.  He will have a long-term TPN after this acute episode.  His LFTs are all normal currently.  Once he is postop tomorrow, we will restart the Angiomax for his venous occlusion.,4.  Renal.  The patient currently is in the acute renal insufficiency with anuria and an increase in his creatinine as well as his potassium.  His critical hyperkalemia which is requiring dosing of dextrose insulin, bicarb, and calcium; we will recheck his potassium levels after this cocktail.  He currently is started to make more urine since being volume resuscitated with Hespan as well as bicarb drip.  Hopefully given his increased urine output, he will start to eliminate some potassium and will not need dialysis.  We will re-consult Nephrology at this time.,5.  Endocrine.  The patient has adrenal insufficiency based on lack of stem to cosyntropin.  We will start hydrocortisone 50 q.6h.,6.  Infectious Disease.  Currently, the patient is on broad-spectrum antibiotic prophylaxis imperially.  Given his bowel ischemia, we will continue these, and appreciate ID service's input.,7.  Hematology.  Hematologically, the patient has a hypercoagulable syndrome, also had HIT secondary to his heparin administration.  We will restart the Angiomax once he is back from the OR tomorrow.  Currently, his INR is 2.2.  Therefore, he should be covered at the moment.  Appreciate the Hematology's input in this matter.,Please note the total critical care time spent at the bedside excluding central line placement was 1 hour.
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DESCRIPTION: Consultation for ICU management for a patient with possible portal vein and superior mesenteric vein thrombus leading to mesenteric ischemia.

The described case involves a critically ill patient in the Intensive Care Unit (ICU) with life-threatening conditions such as mesenteric ischemia, septic shock, acute renal insufficiency, adrenal insufficiency, and a hypercoagulable syndrome. The patient requires continuous monitoring, aggressive management, and possible reoperation. Given the immediate risk to the patient's life and the complexity of their care, this is an extremely high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pulmonary Embolism

REASON FOR CONSULTATION: , Pulmonary embolism.,HISTORY:,  The patient is a 78-year-old lady who was admitted to the hospital yesterday with a syncopal episode that happened for the first time in her life.  The patient was walking in a store when she felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.  At that time, her daughter was with her.  No tonic-clonic movements.  No cyanosis.  The patient woke up on her own.  The patient currently feels fine, has mild shortness of breath upon exertion, but this is her usual for the last several years.  She cannot get up one flight of stairs, but feels short of breath.  She gets exerted and thinks to take a shower.  She does not have any chest pain, no fever or syncopal episodes.,PAST MEDICAL HISTORY,1.  Pulmonary embolism diagnosed one year ago.  At that time, she has had an IVC filter placed due to massive GI bleed from diverticulosis and gastric ulcers.  Paroxysmal atrial fibrillation and no anticoagulation due to history of GI bleed.,2.  Coronary artery disease status post CABG at that time.  She has had to stay in the ICU according to the daughter for 3 weeks due to again lower GI bleed.,3.  Mitral regurgitation.,4.  Gastroesophageal reflux disease.,5.  Hypertension.,6.  Hyperlipidemia.,7.  History of aortic aneurysm.,8.  History of renal artery stenosis.,9.  Peripheral vascular disease.,10.  Hypothyroidism.,PAST SURGICAL HISTORY,1.  CABG.,2.  Hysterectomy.,3.  IVC filter.,4.  Tonsillectomy.,5.  Adenoidectomy.,6.  Cosmetic surgery.,7.  Renal stent.,8.  Right femoral stent.,HOME MEDICATIONS,1.  Aspirin.,2.  Potassium.,3.  Lasix.,4.  Levothyroxine.,5.  Lisinopril.,6.  Pacerone.,7.  Protonix.,8.  Toprol.,9.  Vitamin B.,10.  Zetia.,11.  Zyrtec.,ALLERGIES:,  SULFA,SOCIAL HISTORY: , She used to be a smoker, not anymore.  She drinks 2 to 3 glasses of wine per week.  She is retired.,REVIEW OF SYSTEMS: , She has a history of snoring, choking for breath at night, and dry mouth in the morning.,PHYSICAL EXAMINATION,GENERAL APPEARANCE:  In no acute distress.,VITAL SIGNS:  Temperature 98.6, respirations 18, pulse 61, blood pressure 155/57, and oxygen saturation 93-98% on room air.,HEENT:  No lymph nodes or masses.,NECK:  No jugular venous distension.,LUNGS:  Clear to auscultation bilaterally.
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DESCRIPTION: Patient felt dizzy, had some cold sweats, mild shortness of breath, no chest pain, no nausea or vomiting, but mild diarrhea, and sat down and lost consciousness for a few seconds.

The situation involves a 78-year-old woman with a significant medical history, including a previous pulmonary embolism, coronary artery disease status post-CABG, and various other serious cardiovascular and systemic conditions. The patient experienced a syncopal episode with dizziness and mild shortness of breath, symptoms that can be associated with critical cardiovascular events. Given her complex medical history and the potential life-threatening nature of recurrent pulmonary embolism or cardiovascular compromise, this is considered high-stakes.


Medical Specialty: Emergency Room Reports
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.

emergency room reports, borax, vomiting, exposure to ant bait, ant bait, exposure, symptoms,

The situation involves a potential ingestion of a household product (ant bait) by a young child, which was not confirmed to have occurred. The child is not showing any symptoms and the ant bait is deemed nontoxic by Poison Control. The child has been evaluated in the emergency room and discharged with instructions for parents to monitor for symptoms. While the presence in the emergency room indicates some level of concern, the stable condition of the child and the nontoxic assessment make this a relatively low-stakes situation.


Medical Specialty: Office Notes
Sample Name: Normal Female Exam Template - 2

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

office notes, heent, general appearance, hepatosplenomegaly, mass, tenderness, rebound, rigidity, pulse, bruit, adenopathy, chest, percussion, inspection, palpation, signs, tongue,

The document provided is a template for a routine normal female physical exam. This template includes common metrics and assessments used during a physical check-up and does not indicate any urgent or critical medical issues. The sample contains standard observations expected in a healthy individual and serves as a guide for documenting similar routine examinations. Therefore, the stakes associated with this specific situation are low as it is not related to a current, immediate health concern but rather serves as a normal procedural reference.


Medical Specialty: Urology
Sample Name: Vasectomy

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

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

The procedure described is a bilateral vasectomy for voluntary sterility, a common and low-risk procedure. While all surgeries carry some level of risk, this is a routine outpatient procedure performed under local anesthesia with minimal risk of complications. The stakes can be considered low from a surgical risk perspective, as vasectomies are typically deemed safe and effective for male sterilization.