Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Fusion - 9

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,PROCEDURE:,  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.,FIRST ASSISTANT: , Nurse practitioner.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion for anterior discectomy and fusion.  An incision was made midline to the anterior body of the sternocleidomastoid at C5-C6 level.  The skin, subcutaneous tissue, and platysma muscle was divided exposing the carotid sheath, which was retracted laterally.  Trachea and esophagus were retracted medially.  After placing the self-retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at C5 and C6 and confirming our position with intraoperative x-rays, we then proceeded with the discectomy.,We then cleaned out the disc at C5-C6 after incising the annulus fibrosis.  We cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes, and the next step was to clean out the disc space totally.  With this having been done, we then turned our attention with the operating microscope to the osteophytes.  We drilled off the vertebral osteophytes at C5-C6, as well as the uncovertebral osteophytes.  This was removed along with the posterior longitudinal ligament.  After we had done this, the dural sac was opposed very nicely and both C6 nerve roots were thoroughly decompressed.  The next step after the decompression of the thecal sac and both C6 nerve roots was the fusion.  We observed that there was a ____________ in the posterior longitudinal ligament.  There was a free fragment disc, which had broken through the posterior longitudinal ligament just to the right of midline.,The next step was to obtain the bone from the back bone, using cortical cancellous graft 10 mm in size after we had estimated the size.  That was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor.,After we had tapped in the bone plug, we then removed the distraction and the bone plug was fitting nicely.,We then use the Aesculap cervical titanium instrumentation with the 16-mm screws.  After securing the C5-C6 disc with four screws and titanium plate, x-rays showed good alignment of the spine, good placement of the bone graft, and after x-rays showed excellent position of the bone graft and instrumentation, we then placed in a Jackson-Pratt drain in the prevertebral space brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and skin was closed with Steri-Strips.  Blood loss during the operation was less than 10 mL.  No complications of the surgery.  Needle count, sponge count, and cottonoid count were correct.,
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DESCRIPTION: Herniated nucleus pulposus C5-C6.  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.

neurosurgery, aesculap, titanium dynamic plating system, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, operating microscope, longitudinal ligament, discectomy, anterior, instrumentation, cervical, titanium

Anterior cervical discectomy and fusion (ACDF) is a common neurosurgical procedure used to alleviate spinal cord or nerve root pressure in the cervical spine due to herniation. Despite being routine, it involves significant structures such as the spinal cord and nerve roots, and it carries risks like spinal cord injury, nerve damage, or infection. These factors contribute to a high-stakes situation, as errors can lead to serious consequences for the patient, such as paralysis or chronic pain. Although the procedure here was described as without complications and with minimal blood loss, the inherent risks associated with neurosurgical operations make this a high-stakes situation.


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

Medical Specialty: General Medicine
Sample Name: Normal Male Exam Template

MULTISYSTEM EXAM,CONSTITUTIONAL:  ,The vital signs showed that the patient was afebrile; blood pressure and heart rate were within normal limits.  The patient appeared alert.,EYES:  ,The conjunctiva was clear.  The pupil was equal and reactive.  There was no ptosis.  The irides appeared normal.,EARS, NOSE AND THROAT:  ,The ears and the nose appeared normal in appearance.  Hearing was grossly intact.  The oropharynx showed that the mucosa was moist.  There was no lesion that I could see in the palate, tongue. tonsil or posterior pharynx.,NECK:  ,The neck was supple.  The thyroid gland was not enlarged by palpation.,RESPIRATORY:  ,The patient's respiratory effort was normal.  Auscultation of the lung showed it to be clear with good air movement.,CARDIOVASCULAR:  ,Auscultation of the heart revealed S1 and S2 with regular rate with no murmur noted.  The extremities showed no edema.,GASTROINTESTINAL: , The abdomen was soft, nontender with no rebound, no guarding, no enlarged liver or spleen.  Bowel sounds were present.,GU: , The scrotal elements were normal.  The testes were without discrete mass.  The penis showed no lesion, no discharge.,LYMPHATIC:  ,There was no appreciated node that I could feel in the groin or neck area.,MUSCULOSKELETAL:  ,The head and neck by inspection showed no obvious deformity.  Again, the extremities showed no obvious deformity.  Range of motion appeared to be normal for the upper and lower extremities.,SKIN: , Inspection of the skin and subcutaneous tissues appeared to be normal.  The skin was pink, warm and dry to touch.,NEUROLOGIC:  ,Deep tendon reflexes were symmetrical at the patellar area.  Sensation was grossly intact by touch.,PSYCHIATRIC: , The patient was oriented to time, place and person.  The patient's judgment and insight appeared to be normal.
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DESCRIPTION: Sample/template for a normal male multisystem exam.

general medicine, within normal limits, conjunctiva, eyes, ears, nose, throat, male, multisystem, heart, respiratory, auscultation, extremities, oropharynx, neck, tongue,

The situation involves the documentation of a standard physical exam for a patient in general medicine. It is a routine checkup with normal findings and no immediate concerns or abnormalities noted. Given the routine nature of the physical exam and absence of any critical issues, the stakes are quite low.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Urology
Sample Name: Circumcision - 7

PROCEDURE:,  Circumcision.,ANESTHESIA: , EMLA.,FINDINGS: , Normal penis.  The foreskin was normal in appearance and measured 1.6 cm.  There was no bleeding at the circumcision site.,PROCEDURE:,  Patient was placed on the circumcision restraint board.  EMLA had been applied approximately 90 minutes before.  A time-out was completed satisfactorily per protocol.  The area was prepped with Betadine.  The foreskin was grasped with sterile clamps and was dissected away from the corona and the glans penis with blunt dissection.  A Mogen clamp was applied to the cervix.  The excess foreskin was excised with the scalpel.  The clamp was removed.  At this point, the procedure was terminated.  Sterile Vaseline and gauze was applied to the glans penis.  There were no complications.  There was minimal blood loss.
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DESCRIPTION: Normal penis.  The foreskin was normal in appearance and measured 1.6 cm.  There was no bleeding at the circumcision site.

urology, mogen clamp, glans penis, emla, penis, foreskin, circumcision

The procedure described is a routine circumcision, which is generally considered a low-risk surgical procedure. The documentation specifies normal findings and no complications, indicating a typical outcome. Although all medical procedures have some level of risk, the stakes here are relatively low due to the routine nature of the operation and absence of any complications.


Medical Specialty: Radiology
Sample Name: Stress Test Adenosine Myoview

INDICATIONS:,  Ischemic cardiomyopathy, status post inferior wall myocardial infarction, status post left anterior descending PTCA and stenting.,PROCEDURE DONE:,  Adenosine Myoview stress test.,STRESS ECG RESULTS:,  The patient was stressed by intravenous adenosine, 140 mcg/kg/minute infused over four minutes.  The baseline resting electrocardiogram revealed an electronic pacemaker depolarizing the ventricles regularly at a rate of 70 beats per minute.  Underlying atrial fibrillation noted, very wide QRS complexes.  The heart rate remained unchanged at 70 beats per minute as the blood pressure decreased from 140/80 to 110/70 with adenosine infusion.
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DESCRIPTION: Stress test - Adenosine Myoview.  Ischemic cardiomyopathy.  Inferoseptal and apical transmural scar.

radiology, stress test, adenosine, adenosine myoview stress test, ischemic cardiomyopathy, spect, cardiomyopathy, electrocardiogram, myocardial infarction, stress test adenosine myoview, adenosine myoview stress, myoview stress test, ptca and stenting, myoview stress, transmural scar, adenosine infusion, septal motion, adenosine myoview, myocardial perfusion, hypokinesis, inferoseptal, ischemic, myocardial, myoview, perfusion, scan

The given radiology report describes a stress test performed on a patient with a history of ischemic cardiomyopathy and previous myocardial infarctions, which are serious cardiovascular conditions. The test is evaluating the heart's function and identifying any residual ischemia. This situation is high-stakes because improper evaluation or unnoticed abnormalities could have severe implications for the patient's health, including the risk of heart failure or future cardiac events.


Medical Specialty: Consult - History and Phy.
Sample Name: Acne Vulgaris - H&P

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

The situation involves a medical assessment and treatment of acne vulgaris for a 19-year-old female. Acne itself, while often distressing, is typically not a life-threatening or critical medical condition, especially in a controlled healthcare setting. The description reveals that the patient has been prescribed antibiotics after a proper examination, and she has been counseled on the treatment plan. Although the patient has an allergy to penicillin, the prescribed medication (Tetracycline) does not belong to the penicillin family, reducing immediate risk. As this is primarily a routine dermatological issue with a non-critical prescription treatment plan, it is not considered high-stakes.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 17

PREOPERATIVE DIAGNOSIS: , Colon polyps.,POSTOPERATIVE DIAGNOSES:,1.  Universal diverticulosis.,2.  Nonsurgical internal hemorrhoids.,PROCEDURE PERFORMED:, Total colonoscopy with photos.,ANESTHESIA:,  Demerol 100 mg IV with Versed 3 mg IV.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE:  ,The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.,PROCEDURE:,  Informed consent was obtained.  All risks and benefits of the procedure were explained and all questions were answered.  The patient was brought back to the Endoscopy Suite where he was connected to cardiopulmonary monitoring.  Demerol 100 mg IV and Versed 3 mg IV was given in a titrated fashion until appropriate anesthesia was obtained.  Upon appropriate anesthesia, a digital rectal exam was performed, which showed no masses.  The colonoscope was then placed into the anus and the air was insufflated.  The scope was then advanced under direct vision into the rectum, rectosigmoid colon, descending colon, transverse colon, ascending colon until it reached the cecum.  Upon entering the sigmoid colon and throughout the rest of the colon, there was noted diverticulosis.  After reaching the cecum, the scope was fully withdrawn visualizing all walls again noting universal diverticulosis.,Upon reaching the rectum, the scope was then retroflexed upon itself and there was noted to be nonsurgical internal hemorrhoids.  The scope was then subsequently removed.  The patient tolerated the procedure well and there were no complications.
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DESCRIPTION: Universal diverticulosis and nonsurgical internal hemorrhoids. Total colonoscopy with photos.  The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.

surgery, endoscopy, rectum, rectosigmoid colon, descending colon, transverse colon, ascending colon, total colonoscopy, colon polyps, colonoscopy, cecum, polyps, diverticulosis, hemorrhoids,

The context describes a routine medical procedure, specifically a colonoscopy, for a 62-year-old male with a history of colon polyps. The procedure was performed to inspect for complications and resulted in findings of universal diverticulosis and nonsurgical internal hemorrhoids. The process was executed without any complications, and it is described as having minimal estimated blood loss. Routine colonoscopies and related findings such as diverticulosis and hemorrhoids are common in older adults and typically managed on an outpatient basis without immediate high-stakes risks unless significant complications arise. In this case, there were none reported, indicating a relatively low-stakes situation.


Medical Specialty: Radiology
Sample Name: CT Stone Protocol

EXAM: , CT stone protocol.,REASON FOR EXAM:,  History of stones, rule out stones.,TECHNIQUE: , Noncontrast CT abdomen and pelvis per renal stone protocol.,FINDINGS: , Correlation is made with a prior examination dated 01/20/09.,Again identified are small intrarenal stones bilaterally.  These are unchanged.  There is no hydronephrosis or significant ureteral dilatation.  There is no stone along the expected course of the ureters or within the bladder.  There is a calcification in the low left pelvis not in line with ureter, this finding is stable and is compatible with a phlebolith.  There is no asymmetric renal enlargement or perinephric stranding.,The appendix is normal.  There is no evidence of a pericolonic inflammatory process or small bowel obstruction.,Scans through the pelvis disclose no free fluid or adenopathy.,Lung bases aside from very mild dependent atelectasis appear clear.,Given the lack of contrast, liver, spleen, adrenal glands, and the pancreas are grossly unremarkable.  The gallbladder is present.  There is no abdominal free fluid or pathologic adenopathy.,IMPRESSION:,1. Bilateral intrarenal stones, no obstruction.,2. Normal appendix.
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DESCRIPTION: Noncontrast CT abdomen and pelvis per renal stone protocol.

radiology, noncontrast ct, abdomen and pelvis, renal stone protocol, renal stone, intrarenal stones, stone protocol, ureteral, adenopathy, renal, ct, protocol, pelvis, intrarenal, stone, abdomen, noncontrast,

The situation involves interpreting a radiology report to assess the presence of kidney stones and potential complications. The findings indicate the presence of bilateral intrarenal stones but no obstruction or significant complications. While the information is important for patient management, the absence of obstruction or acute findings suggests that this is not an immediate high-stakes situation. The procedure and interpretation align with routine follow-up care for a patient with a history of kidney stones.


Medical Specialty: Surgery
Sample Name: Belly Button Piercing

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

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

This procedure is a cosmetic one and not medically necessary, usually performed in non-high-stakes environments. The potential complications, such as infection or foreign body reaction, are generally low-risk and manageable. As the patient tolerated the procedure well and left in satisfactory condition, it further suggests the situation does not have significant urgency or consequence.


Medical Specialty: Surgery
Sample Name: Low-Transverse C-Section - 3

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 33 weeks, twin gestation.,2.  Active preterm labor.,3.  Advanced dilation.,4.  Multiparity.,5.  Requested sterilization.,POSTOPERATIVE DIAGNOSIS:,1.  Intrauterine pregnancy at 33 weeks, twin gestation.,2.  Active preterm labor.,3.  Advanced dilation.,4.  Multiparity.,5.  Requested sterilization.,6.  Delivery of a viable female A weighing 4 pounds 7 ounces, Apgars were 8 and 9 at 1 and 5 minutes respectively and female B weighing 4 pounds 9 ounces, Apgars 6 and 7 at 1 and 5 minutes respectively.,7.  Uterine adhesions and omentum adhesions.,OPERATION PERFORMED: , Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS:,  Foley.,This is a 25-year-old white female gravida 3, para 2-0-0-2 with twin gestation at 33 weeks and previous C-section.  The patient presents to Labor and Delivery in active preterm labor and dilated approximately 4 to 6 cm.  The decision for C-section was made.,PROCEDURE:,  The patient was taken to the operating room and placed in a supine position with a slight left lateral tilt and she was then prepped and draped in usual fashion for a low transverse incision.  The patient was then given general anesthesia and once this was completed, first knife was used to make a low transverse incision extending down to the level of the fascia.  The fascia was nicked in the center and extended in a transverse fashion with the use of curved Mayo scissors.  The edges of the fascia were grasped with Kocher and both blunt and sharp dissection was then completed both caudally and cephalically.  The abdominal rectus muscle was divided in the center and extended in a vertical fashion.  Peritoneum was entered at a high point and extended in a vertical fashion as well.  The bladder blade was put in place.  The bladder flap was created with the use of Metzenbaum scissors and dissected away caudally.  The second knife was used to make a low transverse incision with care being taken to avoid the presenting part of the fetus.  The first fetus was vertex.  The fluid was clear.  The head was delivered followed by the remaining portion of the body.  The cord was doubly clamped and cut.  The newborn handed off to waiting pediatrician and nursery personnel.  The second fluid was ruptured.  It was the clear fluid as well.  The presenting part was brought down to be vertex.  The head was delivered followed by the rest of the body and the cord was doubly clamped and cut, and newborn handed off to waiting pediatrician in addition of the nursery personnel.  Cord pH blood and cord blood was obtained from both of the cords with careful identification of A and B. Once this was completed, the placenta was delivered and handed off for further inspection by Pathology.  At this time, it was noted at the uterus was adhered to the abdominal wall by approximately of 3 cm x 3 cm thick uterine adhesion and this was needed to be released by sharp dissection.  Then, there were multiple omental adhesions on the surface of the uterus itself.  This needed to be released as well as on the abdominal wall and then the uterus could be externalized.  The lining was wiped clean of any remaining blood and placental fragments and the edges of the uterus were grasped in four quadrants with Kocher and continuous locking stitch of 0 chromic was used to re-approximate the uterine incision, with the second layer used to imbricate the first.  The bladder flap was re-approximated with 3-0 Vicryl and Gelfoam underneath.  The right fallopian tube was grasped with a Babcock, it was doubly tied off with 0 chromic and the knuckle portion was then sharply incised and cauterized.  The same technique was completed on the left side with the knuckle portion cut off and cauterized as well.  The defect on the uterine surface was reinforced with 0 Vicryl in a baseball stitch to create adequate Hemostasis.  Interceed was placed over this area as well.  The abdominal cavity was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position.  The gutters were wiped clean of any remaining blood.  The edges of the peritoneum were grasped with hemostats and a continuous locking stitch was used to re-approximate abdominal rectus muscles as well as the peritoneal edges.  The abdominal rectus muscle was irrigated.  The corners of the fascia grasped with hemostats and continuous locking stitch of 0 Vicryl started on both corners and overlapped on the center.  The subcutaneous tissue was irrigated.  Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the subcutaneous tissue.  Skin edges were re-approximated with sterile staples.  Sterile dressing was applied.  Uterus was evacuated of any remaining blood vaginally.  The patient was taken to the recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.
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DESCRIPTION: Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.

surgery, intrauterine pregnancy, gestation, preterm labor, omentum adhesions, low transverse c section, uterine adhesions, intrauterine, adhesions, abdominal, uterus, uterine,

This case involves a surgical procedure, specifically a repeat low-transverse cesarean section, which includes the delivery of twins at 33 weeks, the management of uterine and omental adhesions, and a sterilization procedure via bilateral tubal ligation. The scenario is inherently high-stakes due to active preterm labor, advanced dilation, and the presence of surgical adhesions, which can complicate the procedure. Additionally, the patient is undergoing sterilization, which is a permanent decision. The stakes are high because both maternal and fetal health and safety are critical in this procedure, and the potential for complications exists given the circumstances outlined in the preoperative and postoperative diagnoses.


Medical Specialty: Emergency Room Reports
Sample Name: Ecstasy Ingestion - ER Visit

CHIEF COMPLAINT:,  "I took Ecstasy.",HISTORY OF PRESENT ILLNESS: , This is a 17-year-old female who went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.  The patient upon returning to home was energetic and agitated and shaking and had one episode of nonbloody, nonbilious emesis.  Mother called the EMS service when the patient vomited.  On arrival here, the patient states that she no longer has any nausea and that she feels just fine.  The patient states she feels wired but has no other problems or complaints.  The patient denies any pain.  The patient does not have any auditory of visual hallucinations.  The patient denies any depression or suicidal ideation.  The patient states that the alcohol and the Ecstasy was done purely as a recreational thing and not as an attempt to harm herself.  The patient denies any homicidal ideation.  The patient denies any recent illness or recent injuries.  The mother states that the daughter appears to be back to her usual self now.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No recent illness.  No fever or chills.  HEENT:  No headache.  No neck pain.  No vision change or hearing change.  No eye or ear pain.  No rhinorrhea.  No sore throat.  CARDIOVASCULAR:  No chest pain.  No palpitations or racing heart.  RESPIRATIONS:  No shortness of breath.  No cough.  GASTROINTESTINAL: One episode of nonbloody, nonbilious emesis this morning without any nausea since then.  The patient denies any abdominal pain.  No change in bowel movements.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No dizziness, syncope, or near syncope.  PSYCHIATRIC:  The patient denies any depression, suicidal ideation, homicidal ideation, auditory hallucinations or visual hallucinations.  ENDOCRINE:  No heat or cold intolerance.,PAST MEDICAL HISTORY:,  None.,PAST SURGICAL HISTORY: , Appendectomy when she was 9 years old.,CURRENT MEDICATIONS: , Birth control pills.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient denies smoking cigarettes.  The patient does drink alcohol and also uses illicit drugs.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Temperature is 98.8 oral, blood pressure 140/86, pulse is 79, respirations 16, oxygen saturation 100% on room air and is interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, and well developed, 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 cornea and conjunctiva bilaterally.  The patient does have dilated pupils of approximately 8 mm each and are equally round and reactive to light bilaterally.  No evidence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Nose is normal without rhinorrhea or audible congestion.  Ears are normal without any sign of infection.  Mouth and oropharynx are normal without any signs of infection.  Mucous membranes are moist.  NECK:  Supple and nontender.  Full range of motion.  There is no JVD.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +3 and bounding.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, normal and benign.  MUSCULOSKELETAL:  No abnormalities noted in back, arms, or legs.  The patient is normal use of her extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact in all extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  The patient does not have any smell of alcohol and does not exhibit any clinical intoxication.  The patient is quite pleasant, fully cooperative.  HEMATOLOGIC/LYMPHATIC: NO lymphadenitis is noted.  No bruising is noted.,DIAGNOSES:,1.  ECSTASY INGESTION.,2.  ALCOHOL INGESTION.,3.  VOMITING SECONDARY TO STIMULANT ABUSE.,CONDITION UPON DISPOSITION: , Stable disposition to home with her mother.,PLAN:,  I will have the patient followup with her physician at the ABC Clinic in two days for reevaluation.  The patient was advised to stop drinking alcohol, and taking Ecstasy as this is not only in the interest of her health, but was also illegal.  The patient is asked to return to the emergency room should she have any worsening of her condition, develop any other problems or symptoms of concern.
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DESCRIPTION: Patient went out partying last night and drank two mixed drinks last night and then over the course of the evening after midnight, the patient ended up taking a total of six Ecstasy tablets.

emergency room reports, nonbilious emesis, hallucinations, visual, auditory, ecstasy ingestion, suicidal ideation, homicidal ideation, ingestion, infection, alcohol, ecstasy,

The situation involves a 17-year-old taking a significant amount of Ecstasy along with alcohol, leading to a visit to the emergency room. While the patient appears stable and without serious acute symptoms at the time of examination, the ingestion of multiple substances poses a high risk of acute and long-term health issues. Ecstasy can lead to severe complications like dehydration, hyperthermia, or serotonin syndrome, particularly in large quantities. Additionally, legal and social implications are involved due to underage drinking and illegal drug use. These factors contribute to it being a high-stakes medical scenario.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 13

SUBJECTIVE:,  The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check.  She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.  Since her last visit she has been followed by Dr. Kumar.  Those issues are stable.  She has had no fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure.,PAST MEDICAL HISTORY:,  She has an intolerance to Prevacid.,CURRENT MEDICATIONS:,  Evista 60 daily, Levothroid 0.05 mg daily, Claritin 10 daily, Celebrex 200 daily, HCTZ 25 daily and amitriptyline p.r.n.,PAST SURGICAL HISTORY:,  Bilateral mastectomies, tonsillectomy, EGD, flex sig in 2001 and a heart cath.,FAMILY HISTORY: , Father passed away at 81; mother of multiple myeloma at 83.,SOCIAL HISTORY:,  She is married.  A 76-year-old who used to smoke a pack a day and quit in 1985.  She is retired.,REVIEW OF SYSTEMS:,  Essentially negative in HEENT, chest, cardiovascular, GI, GU, musculoskeletal, or neurologic.,OBJECTIVE:,  Temperature is 97.5 degrees.  Blood pressure is 168/70.  Pulse is 88.  Weight is 129 pounds.,GENERAL:  She is an elderly 76-year-old in no acute distress.,HEENT:  Atraumatic.  Extraocular muscles were intact.  Pupils equal, round and reactive to light and accommodation.  Tympanic membranes are clear, dry and intact.  Sinuses and throat are clear.  Neck is soft, supple.  No meningeal signs are present.  No thyromegaly is present.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, nontender.  Bowel sounds are positive.  No organomegaly or peritoneal signs are present.,EXTREMITIES:  Moving all extremities.  Peripheral pulses are normal.  No edema is present.,NEUROLOGIC:  Alert and oriented.  Cranial nerves II-XII grossly intact.  Strength 5+/5 globally.  Reflexes 2+/IV globally.  Romberg is negative.  There is no numbness, tingling, weakness or other neurologic deficit present.,BREASTS:  Surgically absent but there are no lumps, lesions, masses, discharge or adenopathy present.,BACK:  Straight.,SKIN:  Clear.,GENITALIA:  Deferred as she has been followed by Dr. XYZ many times this year.  She does have a history of some elevated cholesterol.,ASSESSMENT:,1.  Hypertension, suboptimal control.,2.  Hypothyroidism.,3.  Arthritis.,4.  Allergic rhinitis.,5.  History of kidney stones.,6.  Osteoporosis.,PLAN:,1.  CBC, complete metabolic profile, UA for hypertension.,2.  Chest x-ray for history of breast cancer.,3.  DEXA scan, full body for osteoporosis.,4.  Flex is up to date.,5.  Pneumovax has been given in the last five years.,6.  Lipid profile for elevated cholesterol.,7.  Refill meds.,8.  Follow up every three to six months for blood pressure check or sooner p.r.n. problems.
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DESCRIPTION: Consult for hypertension and a med check.  History of osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.

The situation involves a routine medical consultation for an elderly patient with multiple chronic conditions, including hypertension that is suboptimally controlled, but there are no signs of acute distress or immediate life-threatening complications. The objective findings and assessment indicate stability in the patient's conditions and a planned, systematic approach to monitoring and management. This does not constitute a high-stakes medical emergency as the primary focus is ongoing management of chronic conditions with scheduled follow-ups.


Medical Specialty: Hematology - Oncology
Sample Name: Neuroblastoma - Consult

REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.
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DESCRIPTION: The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.

The case involves an 11-month-old with neuroblastoma currently undergoing chemotherapy. Neuroblastoma, particularly in infants, is a serious and potentially life-threatening condition that requires careful and continuous medical management. The disease itself, along with the side effects of chemotherapy, can have significant impacts on the child's health. The management and treatment of this condition require careful monitoring to ensure the best possible outcomes. Additionally, the situation involves aspects such as immunosuppression and resolving neutropenia, which are critical components of the patient's care. Given the age of the patient and the severity of the condition, this is a high-stakes medical situation.


Medical Specialty: Endocrinology
Sample Name: Thyroidectomy

TITLE OF OPERATION:  ,Total thyroidectomy for goiter.,INDICATION FOR SURGERY:  ,This is a 41-year-old woman who notes that compressive thyroid goiter and symptoms related to such who wishes to undergo surgery.  Risks, benefits, alternatives of the procedures were discussed in great detail with the patient.  Risks include but were not limited to anesthesia, bleeding, infection, injury to nerve, vocal fold paralysis, hoarseness, low calcium, need for calcium supplementation, tumor recurrence, need for additional treatment, need for thyroid medication, cosmetic deformity, and other.  The patient understood all these issues and they wished to proceed.,PREOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,POSTOP DIAGNOSIS: , Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.,ANESTHESIA: , General endotracheal.,PROCEDURE DETAIL: , After identifying the patient, the patient was placed supine in a operating room table.  After establishing general anesthesia via oral endotracheal intubation with a 6 Nerve Integrity monitoring system endotracheal tube.  The eyes were then tacked with Tegaderm.  The Nerve Integrity monitoring system, endotracheal tube was confirmed to be working adequately.  Essentially a 7 cm incision was employed in the lower skin crease of the neck.  A 1% lidocaine with 1:100,000 epinephrine were given.  Shoulder roll was applied.  The patient prepped and draped in a sterile fashion.  A 15-blade was used to make the incision.  Subplatysmal flaps were raised to the thyroid notch and sternal respectively.  The strap muscles were separated in the midline.  As we then turned to the left side where the sternohyoid muscle was separated from the sternothyroid muscle there was a very dense and firm thyroid mass on the left side.  The sternothyroid muscle was transected horizontally.  Similar procedure was performed on the right side.,Attention was then turned to identify the trachea in the midline.  Veins in this area and the pretracheal region were ligated with a harmonic scalpel.  Subsequently, attention was turned to dissecting the capsule off of the left thyroid lobe.  Again this was very firm in nature.  The superior thyroid pole was dissected in the superior third artery, vein, and the individual vessels were ligated with a harmonic scalpel.  The inferior and superior parathyroid glands were protected.  Recurrent laryngeal nerve was identified in the tracheoesophageal groove.  This had arborized early as a course underneath the inferior thyroid artery to a very small tiny anterior motor branch.  This was followed superiorly.  The level of cricothyroid membrane upon complete visualization of the entire nerve, Berry's ligament was transected and the nerve protected and then the thyroid gland was dissected over the trachea.  A prominent pyramidal level was also appreciated and dissected as well.,Attention was then turned to the right side.  There was significant amount of thyroid tissue that was very firm.  Multiple nodules were appreciated.  In a similar fashion, the capsule was dissected.  The superior and inferior parathyroid glands protected and preserved.  The superior thyroid artery and vein were individually ligated with the harmonic scalpel and the inferior thyroid artery was then ligated close to the thyroid gland capsule.  Once the recurrent laryngeal nerve was identified again on this side, the nerve had arborized early prior to the coursing underneath the inferior thyroid artery.  The anterior motor branch was then very fine, almost filamentous and stimulated at 0.5 milliamps, completely dissected toward the cricothyroid membrane with complete visualization.  A small amount of tissue was left at the Berry's ligament as the remainder of thyroid level was dissected over the trachea.  The entire thyroid specimen was then removed, marked with a stitch upon the superior pole.  The wound was copiously irrigated, Valsalva maneuver was given, bleeding points controlled.  The parathyroid glands appeared to be viable.  Both the anterior motor branches that were tiny were stimulated at 5 milliamps and confirmed to be working with the Nerve Integrity monitoring system.,Attention was then turned to burying the Surgicel on the wound bed on both sides.  The strap muscles were reapproximated in the midline using a 3-0 Vicryl suture of the sternothyroid horizontal transection and the strap muscles in the midline were then reapproximated.  The 1/8th inch Hemovac drain was placed and secured with a 3-0 nylon.  The incision was then closed with interrupted 3-0 Vicryl and Indermil for the skin.  The patient has a history of keloid formation and approximately 1 cubic centimeter of 40 mg per cubic centimeter Kenalog was injected into the incisional line using a tuberculin syringe and 25-gauge needle.  The patient tolerated the procedure well, was extubated in the operating room table, and sent to postanesthesia care unit in a good condition.  Upon completion of the case, fiberoptic laryngoscopy revealed intact bilateral true vocal fold mobility.
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DESCRIPTION: Total thyroidectomy for goiter.  Multinodular thyroid goiter with compressive symptoms and bilateral dominant thyroid nodules proven to be benign by fine needle aspiration.

endocrinology, total thyroidectomy, goiter, multinodular thyroid goiter, multinodular, thyroid nodules, parathyroid glands, thyroid goiter, thyroid artery, thyroidectomy

A total thyroidectomy is a significant surgical procedure that involves removing the entire thyroid gland to treat a multinodular goiter, even though the nodules are benign. The potential risks associated with this surgery, including vocal fold paralysis, low calcium levels, and the need for lifelong thyroid medication, make it a relatively high-stakes situation. The thorough preparation and postoperative care detailed in the document also suggest the importance of preventing complications, emphasizing the serious nature of the procedure. While the patient tolerated the procedure well, and it was not an emergency surgery, the long-term implications and risks involved in the operation contribute to its high-stakes nature.


Medical Specialty: Ophthalmology
Sample Name: Blepharoplasty - Lower Lid

An orbital block was done.  An infraorbital block was also performed with a 25 gauge needle.  A skin muscle flap was elevated by sharp dissection down to the orbital rim area.  The herniated periorbital fat was removed by opening the orbital septum with sharp dissection using a 15 blade, teasing the periorbital fat out, cross clamping the fat and removing the fat with a scissor over the clamp.  The clamp was cauterized with needle cautery and then the clamp was scarped with a 15 blade.,The remaining fat was left to fall back into the orbit.  This was done in three compartments, the middle, medial and lateral compartments.  Fat was removed from all three compartments.  Then with the mouth open and the eyes in upward gaze, the lower skin muscle flap was redraped on the eyelids and tailored to fit exactly into place and then sutured into place with multiple 6-0 silk sutures.,Bleeding was minimal.  The patient tolerated the procedure well.
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DESCRIPTION: Lower lid blepharoplasty.

Lower lid blepharoplasty.

ophthalmology, lower lid, wydase, blepharoplasty, infraorbital block, muscle flap, orbital rim area, orbital septum, periorbital fat, subciliary incision, upward gaze, orbital, clampingNOTE,: 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 described situation involves a lower lid blepharoplasty, a surgical procedure generally considered routine in the field of ophthalmology or plastic surgery, particularly when performed by a trained and experienced surgeon. While all surgeries have inherent risks, this specific case mentions minimal bleeding and that the patient tolerated the procedure well, suggesting that there were no complications. Additionally, there is no immediate information indicating any critical or life-threatening scenarios during the procedure. Therefore, considering typical procedures, this does not qualify as a high-stakes situation.


Medical Specialty: Neurology
Sample Name: Electroencephalogram - 1

REPORT:,  The electroencephalogram shows background activity at about 9-10 cycle/second bilaterally.  Little activity in the beta range is noted.  Waves of 4-7 cycle/second of low amplitude were occasionally noted.  Abundant movements and technical artifacts are noted throughout this tracing.  Hyperventilation was not performed.  Photic stimulation reveals no important changes.,CLINICAL INTERPRETATION:,  The electroencephalogram is essentially normal.
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DESCRIPTION: Electroencephalogram (EEG).  Photic stimulation reveals no important changes.  Essentially normal.

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

The situation involves the analysis of an electroencephalogram (EEG) report, used to assess brain activity. The report indicates an essentially normal EEG with no significant abnormalities. This situation is typically not high-stakes because the normal findings suggest no immediate neurological concerns, and the absence of critical abnormalities means no urgent medical intervention is necessary. However, since this analysis pertains to neurological health, it cannot be rated too low-stakes.


Medical Specialty: Surgery
Sample Name: Thrombectomy

PREOPERATIVE DIAGNOSES:,1.  Thrombosed left forearm loop fistula graft.,2.  Chronic renal failure.,3.  Hyperkalemia.,POSTOPERATIVE DIAGNOSES:,1.  Thrombosed left forearm loop fistula graft.,2.  Chronic renal failure.,3.  Hyperkalemia.,PROCEDURE PERFORMED: , Thrombectomy of the left forearm loop graft.,ANESTHESIA: , Local with sedation.,ESTIMATED BLOOD LOSS: , Less than 5 cc.,COMPLICATIONS:, None.,OPERATIVE FINDINGS:,  The venous outflow was good.  There was stenosis in the mid-venous limb of the graft.,INDICATIONS: , The patient is an 81-year-old African-American female who presents with an occluded left forearm loop graft.  She was not able to have her dialysis as routine.  Her potassium was dramatically elevated at 7 the initial evening of anticipated surgery.  Both Surgery and Anesthesia thought this would be too risky to do.  Thus, she was given medications to decrease her potassium and a temporary hemodialysis catheter was placed in the femoral vein noted for her to have dialysis that night as well as this morning.  This morning her predialysis potassium was 6, and thus she was scheduled for surgery after her dialysis.,PROCEDURE: , The patient was taken to the operative suite and prepped and draped in the usual sterile fashion.  A transverse incision was made at the region of the venous anastomosis of the graft.  Further dissection was carried down to the catheter.  The vein appeared to be soft and without thrombus.  This outflow did not appear to be significantly impaired.  A transverse incision was made with a #11 blade on the venous limb of the graft near the anastomosis.  Next, a thrombectomy was done using a #4 Fogarty catheter.  Some of the clot and thrombus was removed from the venous limb.  The balloon did hang up in the multiple places along the venous limb signifying some degree of stenosis.  Once removing most of the clots from the venous limb prior to removing the plug, dilators were passed down the venous limb also indicating the area of stenosis.  At this point, we felt the patient would benefit from a curettage of the venous limb of the graft.  This was done and subsequent passes with the dilator and the balloon were then very easy and smooth following the curettage.  The Fogarty balloon was then passed beyond the clot and the plug.  The plug was visualized and inspected.  This also gave a good brisk bleeding from the graft.  The patient was heparinized and hep saline solution was injected into the venous limb and the angle vascular clamp was applied to the venous limb.  Attention was directed up to its anastomosis and the vein.  Fogarty balloon and thrombectomy was also performed well enough into this way.  There was good venous back bleeding following this.  The area was checked for any stenosis with the dilators and none was present.  Next, a #6-0 Prolene suture was used in a running fashion to close the graft.  Just prior to tying the suture, the graft was allowed to flush to move any debris or air.  The suture was also checked at that point for augmentation, which was good.  The suture was tied down and the wound was irrigated with antibiotic solution.  Next, a #3-0 Vicryl was used to approximate the subcutaneous tissues and a #4-0 undyed Vicryl was used in a running subcuticular fashion to approximate the skin edges.  Steri-Strips were applied and the patient was taken to recovery in stable condition.  She tolerated the procedure well.  She will be discharged from recovery when stable.  She is to resume her regular dialysis schedule and present for dialysis tomorrow.
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DESCRIPTION: Thrombosed left forearm loop fistula graft, chronic renal failure, and hyperkalemia.  Thrombectomy of the left forearm loop graft.  The venous outflow was good.  There was stenosis in the mid-venous limb of the graft.

surgery, thrombosed, hyperkalemia, thrombectomy, forearm loop graft, venous outflow, chronic renal failure, venous limb, loop graft, forearm loop, limb, forearm, graft, venous, anastomosis, stenosis,

The situation involves performing a surgical thrombectomy on an elderly patient with chronic renal failure and significant hyperkalemia, which initially presented a high potassium level making immediate surgery risky. Hyperkalemia is a potentially life-threatening condition if not managed promptly, especially in a patient needing regular dialysis. This makes the scenario high-stakes as both the condition and the treatment have critical implications on the patient's health. However, the procedure was completed successfully without complications, and the patient was stable post-operatively, which mitigates the immediate high-stakes nature of the situation.


Medical Specialty: Emergency Room Reports
Sample Name: Viral Syndrome - ER Visit

SUBJECTIVE:  ,This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum.  He says he does not feel short of breath.  He denies any fever or chills.,REVIEW OF SYSTEMS:,HEENT:  Denies any severe headache or sore throat.,CHEST:  No true pain.,GI:  No nausea, vomiting, or diarrhea.,PAST HISTORY:,  He states that he is on Coumadin because he had a cardioversion done two months ago for atrial fibrillation.  He also lists some other medications.  I do have his medications list.  He is on Pacerone, Zaroxolyn, albuterol inhaler, Neurontin, Lasix, and several other medicines.  Those are the predominant medicines.  He is not a diabetic.  The past history otherwise, he has had smoking history, but he quit several years ago and denies any COPD or emphysema.  No one else in the family is sick.,PHYSICAL EXAMINATION:,GENERAL:  The patient appears comfortable.  He did not appear to be in any respiratory distress.  He was alert.  I heard him cough once during the entire encounter.  He did not bring up any sputum at that time.,VITAL SIGNS:  His temperature is 98, pulse 71, respiratory rate 18, blood pressure 122/57, and pulse ox is 95% on room air.,HEENT:  Throat was normal.,RESPIRATORY:  He was breathing normally.  There was clear and equal breath sounds.  He was speaking in full sentences.  There was no accessory muscle use.,HEART:  Sounded regular.,SKIN:  Normal color, warm and dry.,NEUROLOGIC:  Neurologically he was alert.,IMPRESSION: , Viral syndrome, which we have been seeing in many cases throughout the week.  The patient asked me about antibiotics and I did not see a need to do this since he did not appear to have an infection other than viral given his normal temperature, normal pulse, normal respiratory rate, and near normal oxygen.  The patient being on Coumadin I explained to him that unless there was a solid reason to put him on antibiotics, he would be advised not to do so because antibiotics can alter the gut floor causing the INR to increase while on Coumadin which may cause serious bleeding.  The patient understands this.  I then asked him if the cough was annoying him, he said it was.  I offered him a cough syrup, which he agreed to take.  The patient was then discharged with Tussionex Pennkinetic a hydrocodone time-release cough syrup.  I told to check in three days, if the symptoms were not getting better.  The patient appeared to be content with this treatment and was discharged in approximately 30 to 45 minutes later.  His wife calls me very angry that I did not give him antibiotics.  I explained her exactly what I explained to him that they were not indicative at this time, and she became very upset saying that they came there specifically for antibiotics and I explained again that antibiotics are not indicated for viral infection and that I did not think he had a bacterial infection.,DIAGNOSIS: , Viral respiratory illness.
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DESCRIPTION: This 68-year-old man presents to the emergency department for three days of cough, claims that he has brought up some green and grayish sputum.  He says he does not feel short of breath.  He denies any fever or chills.

emergency room reports, sputum, short of breath, fever, chills, copd, emphysema, viral respiratory illness, green and grayish sputum, viral syndrome, respiratory rate, cough syrup, cough, antibiotics, inhaler,

The scenario involves a 68-year-old patient with a cough and some sputum production, but no other severe symptoms such as fever, shortness of breath, or respiratory distress. His vital signs are stable and there is a working diagnosis of a viral syndrome, for which antibiotics are not indicated. The patient's use of Coumadin adds a layer of complexity due to potential bleeding risks if antibiotics were prescribed unnecessarily, but this has been assessed and managed by the medical practitioner. The situation could escalate if not monitored, but the patient has been advised to return if symptoms persist or worsen. This mitigates the immediate high-stakes nature of the situation. It is primarily a common viral condition that has been appropriately addressed within the ER context, leading to a low-to-moderate stakes assessment due to the age and medication use of the patient.


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

Medical Specialty: Surgery
Sample Name: Colonoscopy - 14

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

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

The situation described is about a routine colonoscopy procedure for a patient with a medical history involving colon polyps and partial colon resection. The procedure itself was undertaken due to a previously spotted dark spot on an x-ray, but the current assessment found normal operative sites, mild diverticulosis, and hemorrhoids. The procedure was tolerated well by the patient, and a repeat colonoscopy was recommended in three years. Given the routine nature of the follow-up and lack of immediate critical findings, this scenario is not high-stakes.


Medical Specialty: Surgery
Sample Name: Aortobifemoral Bypass

PREOPERATIVE DIAGNOSIS:,  Aortoiliac occlusive disease.,POSTOPERATIVE DIAGNOSIS:, Aortoiliac occlusive disease.,PROCEDURE PERFORMED:, Aortobifemoral bypass.,OPERATIVE FINDINGS: , The patient was taken to the operating room.  The abdominal contents were within normal limits.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.,PROCEDURE: , The patient was taken to the operating room, placed in a supine position, and prepped and draped in the usual sterile manner with Betadine solution.  A longitudinal incision was made after a Betadine-coated drape was placed over the incisional area.  Longitudinal incision was made over each groin initially and carried down to the subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The common deep and superficial femoral arteries were exposed and then these incisions were covered with antibiotic soaked sponges.  Attention was then turned to the abdomen, where a longitudinal incision was made from the pubis xiphoid, carried down subcutaneous fat and fascia.  Hemostasis was obtained with electrocautery.  The abdomen was entered above the umbilicus and then this was extended with care inferiorly as the patient has undergone previous abdominal surgery.  Mild adhesions were lysed.  The omentum was freed.  The small and large intestine were run with no evidence of abnormalities.  The liver and gallbladder were within normal limits.  No abnormalities were noted.  At this point, the Bookwalter retractor was placed.  NG tube was placed in the stomach and placed on suction.  The intestines were gently packed intraabdominally and laterally.  The rest of the peritoneum was then opened.  The aorta was cleared, both proximally and distally.  The left iliac was completely occluded.  The right iliac was to be cleansed.  At this point, 5000 units of aqueous heparin was administered to allow take effect.  The aorta was then clamped below the renal arteries and opened in a longitudinal fashion.  A single lumbar was ligated with #3-0 Prolene.  The inferior mesenteric artery was occluded intraluminally and required no suture closure.  Care was taken to preserve collaterals.  The aorta was measured, and a 16 mm Gore-Tex graft was brought on the field and anastomosed to the proximal aorta using #3-0 Prolene in a running fashion.  Last stitch was tied.  Hemostasis was excellent.  The clamp was gradually removed and additional Prolene was placed in the right posterolateral aspect to obtain better hemostasis.  At this point, strong pulses were present within the graft.  The limbs were vented and irrigated.  Using bimanual technique, the retroperitoneal tunnels were developed immediately on top of the iliac arteries into the groin.  The grafts were then brought through these, care being taken to avoid twisting of the graft.  At this point, the right iliac was then ligated using #0 Vicryl and the clamp was removed.  Hemostasis was excellent.  The right common femoral artery was then clamped proximally and distally, opened with #11 blade extended with Potts scissors.  The graft was _____ and anastomosed to the artery using #5-0 Prolene in a continuous fashion with a stitch _______ running fashion.  Prior to tying the last stitch, the graft and artery were vented and the last stitch was tied.  Flow was initially restored proximally then distally with good results.  Attention was then turned to the left groin and the artery grafts were likewise exposed, cleared proximally and distally.  The artery was opened, extended with a Potts scissors and anastomosis was performed with #5-0 Prolene again with satisfactory hemostasis.  The last stitch was tied.  Strong pulses were present within the artery and graft itself.  At this point, 25 mg of protamine was administered.  The wounds were irrigated with antibiotic solution.  The groins were repacked.  Attention was then returned to the abdomen.  The retroperitoneal area and the anastomotic sites were checked for bleeding and none was present.  The shell of the aorta was closed over the proximal anastomosis and the retroperitoneum was then repaired over the remaining portions of the graft.  The intraabdominal contents were then allowed to resume their normal position.  There was no evidence of ischemia to the large or small bowel.  At this point, the omentum and stomach were repositioned.  The abdominal wall was closed in a running single layer fashion using #1 PDS.  The skin was closed with skin staples.  The groins were again irrigated, closed with #3-0 Vicryl and #4-0 undyed Vicryl and Steri-Strips.  The patient was then taken into the recovery room in satisfactory condition after tolerating the procedure well.  Sponges and instrument counts were correct.  Estimated blood loss 900 cc.
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DESCRIPTION: Aortoiliac occlusive disease.  Aortobifemoral bypass.  The aorta was of normal size and consistency consistent with arteriosclerosis.  A 16x8 mm Gore-Tex graft was placed without difficulty.  The femoral vessels were small somewhat thin and there was posterior packing, but satisfactory bypass was performed.

surgery, aorta, bypass, arteriosclerosis, abdominal contents, aortoiliac occlusive disease, gore tex graft, aortobifemoral bypass, longitudinal incision, aortobifemoral, hemostasis, artery, graft,

The aortobifemoral bypass is a major surgical procedure aimed at treating aortoiliac occlusive disease. This type of surgery is often necessary to restore adequate blood flow to the lower extremities in patients with severe arteriosclerosis. Given the complexity involved, such as handling the aorta and femoral arteries, the procedure carries significant risks, including bleeding, infection, and complications related to anesthesia. The nature of this type of surgery directly affects vital blood circulation, and the outcome can have profound impacts on the patient's overall health and mobility. Therefore, it is considered a high-stakes situation.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Total Abdominal Hysterectomy - Followup

POSTOPERATIVE DAY #1, TOTAL ABDOMINAL HYSTERECTOMY,SUBJECTIVE: , The patient is alert and oriented x3 and sitting up in bed.  The patient has been ambulating without difficulty.  The patient is still NPO.  The patient denies any new symptomatology from  6/10/2009.  The patient has complaints of incisional tenderness.  The patient was given a full explanation about her clinical condition and all her questions were answered.,OBJECTIVE:,VITAL SIGNS:  Afebrile now.  Other vital signs are stable.,GU:  Urinating through Foley catheter.,ABDOMEN:  Soft, negative rebound.,EXTREMITIES:  Without Homans, nontender.,BACK:  Without CVA tenderness.,GENITALIA:  Vagina, slight spotting.  Wound dry and intact.,ASSESSMENT:,  Normal postoperative course.,PLAN:,1.  Follow clinically.,2.  Continue present therapy.,3.  Ambulate with nursing assistance only.,
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DESCRIPTION: Postoperative day #1, total abdominal hysterectomy.  Normal postoperative course.

obstetrics / gynecology, postoperative course, total abdominal hysterectomy, postoperative

The situation involves a postoperative assessment following a total abdominal hysterectomy, a common surgical procedure in obstetrics and gynecology. The patient is stable, alert, and oriented, with no major complications reported. The vital signs are stable, and the assessment indicates a normal postoperative course. The plan includes continuation of present therapy and assisted ambulation. While there is some incisional tenderness and slight spotting, these are typical postoperative findings that are being monitored. Therefore, the stakes are relatively low as there are no alarming signs or complications.


Medical Specialty: Surgery
Sample Name: Vitrectomy

PREOPERATIVE DIAGNOSIS:,  Vitreous hemorrhage, right eye.,POSTOPERATIVE DIAGNOSIS: , Vitreous hemorrhage, right eye.,PROCEDURE:  ,Vitrectomy, right eye.,PROCEDURE IN DETAIL:  ,The patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia.  Initially, a 5 cc retrobulbar injection was performed with 2% Xylocaine during monitored anesthesia control.  A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.  MVR incisions were made 4 mm posterior to the limbus in the *** and *** o'clock meridians following which the infusion apparatus was positioned in the *** o'clock site and secured with a 5-0 Vicryl suture.  Then, under indirect ophthalmoscopic control, the vitrector was introduced through the *** o'clock site and a complete vitrectomy was performed.  All strands of significance were removed.  Tractional detachment foci were apparent posteriorly along the temporal arcades.  Next, endolaser coagulation was applied to ischemic sites and to neovascular foci under indirect ophthalmoscopic control.  Finally, an air exchange procedure was performed, also under indirect ophthalmoscopic control.  The intraocular pressure was within the normal range.  The globe was irrigated with a topical antibiotic.  The MVR incisions were closed with 7-0 Vicryl.  No further manipulations were necessary.  The conjunctiva was closed with 6-0 plain catgut.  An eye patch was applied and the patient was sent to the recovery area in good condition.
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DESCRIPTION: Vitreous hemorrhage, right eye.  Vitrectomy, right eye.  A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.

surgery, ophthalmoscopic, vitrectomy, endolaser, lancaster lid speculum, vitreous hemorrhage, vitreous, hemorrhage, conjunctiva

The described situation involves a surgical procedure known as a vitrectomy to treat a vitreous hemorrhage in the right eye. Surgical procedures, particularly those related to the eye, can be high-stakes due to the potential risk of complications such as vision loss, infection, bleeding, or other surgery-related issues. This procedure requires precision and skill to ensure successful outcomes for the patient. Given that the operation was conducted under local anesthesia and includes specific techniques like vitrectomy and endolaser coagulation, it underscores the importance of the procedure and the potential consequences if not performed correctly.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 4

PREOPERATIVE DIAGNOSIS:,  Diarrhea, suspected irritable bowel.,POSTOPERATIVE DIAGNOSIS:,  Normal colonoscopy., PREMEDICATIONS: , Versed 5 mg, Demerol 75 mg IV.,REPORTED PROCEDURE:,  The rectal exam revealed no external lesions.  The prostate was normal in size and consistency.,The colonoscope was inserted into the cecum with ease.  The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, sigmoid colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,  Normal colonoscopy - no evidence of inflammatory disease, polyp, or other neoplasm.  These findings are certainly consistent with irritable bowel syndrome.
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DESCRIPTION: Colonoscopy - Diarrhea, suspected irritable bowel

surgery, diarrhea, ascending colon, cecum, colonoscope, colonoscopy, descending colon, hepatic flexure, inflammatory disease, irritable bowel syndrome, irritable bowel., polyp, rectal exam, rectum, sigmoid colon, splenic flexure, transverse colon, normal colonoscopy, irritable bowel, flexure, irritable, bowel,

The situation involves a routine colonoscopy, which is a common procedure to investigate issues like diarrhea and irritable bowel syndrome. The postoperative diagnosis indicates a normal result without any complications such as inflammation, polyps, or neoplasms. Routine medical procedures with normal results generally do not carry high stakes. Furthermore, there is no indication of cancer or severe disease in the findings, which reduces the urgency or critical nature of the situation.


Medical Specialty: Orthopedic
Sample Name: Youngswick Osteotomy

TITLE OF OPERATION: , Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.,PREOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,POSTOPERATIVE DIAGNOSIS: , Hallux limitus deformity of the right foot.,ANESTHESIA:,  Monitored anesthesia care with 15 mL of 1:1 mixture of 0.5% Marcaine and 1% lidocaine plain.,ESTIMATED BLOOD LOSS:,  Less than 10 mL.,HEMOSTASIS:,  Right ankle tourniquet set at 250 mmHg for 35 minutes.,MATERIALS USED: , 3-0 Vicryl, 4-0 Vicryl, and two partially threaded cannulated screws from 3.0 OsteoMed System for internal fixation.,INJECTABLES:  ,Ancef 1 g IV 30 minutes preoperatively.,DESCRIPTION OF THE PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  After adequate sedation was achieved by the anesthesia team, the above-mentioned anesthetic mixture was infiltrated directly into the patient's right foot to anesthetize the future surgical site.  The right ankle was then covered with cast padding and an 18-inch ankle tourniquet was placed around the right ankle and set at 250 mmHg.  The right ankle tourniquet was then inflated.  The right foot was prepped, scrubbed, and draped in normal sterile technique.  Attention was then directed on the dorsal aspect of the first right metatarsophalangeal joint where a 6-cm linear incision was placed just parallel and medial to the course of the extensor hallucis longus to the right great toe.  The incision was deepened through the subcutaneous tissues.  All the bleeders were identified, cut, clamped, and cauterized.  The incision was deepened to the level of the capsule and the periosteum of the first right metatarsophalangeal joint.  All the tendinous and neurovascular structures were identified and retracted from the site to be preserved.  Using sharp and dull dissection, all the capsular and periosteal attachments were mobilized from the base of the proximal phalanx of the right great toe and head of the first right metatarsal.  Once the base of the proximal phalanx of the right great toe and the first right metatarsal head were adequately exposed, multiple osteophytes were encountered.  Gouty tophi were encountered both intraarticularly and periarticularly for the first right metatarsophalangeal joint, which were consistent with a medical history that is positive for gout for this patient.,Using sharp and dull dissection, all the ligamentous and soft tissue attachments were mobilized and the right first metatarsophalangeal joint was freed from all adhesions.  Using the sagittal saw, all the osteophytes were removed from the dorsal, medial, and lateral aspect of the first right metatarsal head as well as the dorsal, medial, and lateral aspect of the base of the proximal phalanx of the right great toe.  Although some improvement of the range of motion was encountered after the removal of the osteophytes, some tightness and restriction was still present.  The decision was thus made to perform a Youngswick-type osteotomy on the head of the first right metatarsal.  The osteotomy consistent of two dorsal cuts and a plantar cut in a V-pattern with the apex of the osteotomy distal and the base of the osteotomy proximal.  The two dorsal cuts were longer than the plantar cut in order to accommodate for the future internal fixation.  The wedge of bone that was formed between the two dorsal cuts was resected and passed off to Pathology for further examination.  The head of the first right metatarsal was then impacted on the shaft of the first right metatarsal and provisionally stabilized with two wires from the OsteoMed System.  The wires were inserted from a dorsal distal to plantar proximal direction through the dorsal osteotomy.  The wires were also used as guidewires for the insertion of two 16-mm proximally threaded cannulated screws from the OsteoMed System.  The 2 screws were inserted using AO technique.  Upon insertion of the screws, the two wires were removed.  Fixation of the osteotomy on the table was found to be excellent.  The area was copiously flushed with saline and range of motion was reevaluated and was found to be much improved from the preoperative levels without any significant restriction.  The cartilaginous surfaces on the base of the first right metatarsal and the base of the proximal phalanx were also fenestrated in order to induce some cartilaginous formation.  The capsule and periosteal tissues were then reapproximated with 3-0 Vicryl suture material, 4-0 Vicryl was used to approximate the subcutaneous tissues.  Steri-Strips were used to approximate and reinforce the skin edges.  At this time, the right ankle tourniquet was deflated.  Immediate hyperemia was noted in the entire right lower extremity upon deflation of the cuff.  The patient's surgical site was then covered with Xeroform, copious amounts of fluff and Kling, stockinette, and Ace bandage.  The patient's right foot was placed in a surgical shoe and the patient was then transferred to the recovery room under the care of the anesthesia team with her vital signs stable and neurovascular status at appropriate levels.  The patient was given instructions and education on how to continue caring for her right foot surgery at home.  The patient was also given pain medication instructions on how to control her postoperative pain.  The patient was eventually discharged from Hospital according to nursing protocol and was advised to follow up with Dr. X's office in one week's time for her first postoperative appointment.
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DESCRIPTION: Youngswick osteotomy with internal screw fixation of the first right metatarsophalangeal joint of the right foot.

orthopedic, hallux limitus deformity, metatarsophalangeal joint, plantar cut, youngswick osteotomy, dorsal cuts, ankle tourniquet, proximal phalanx, anesthesia, tourniquet, youngswick, phalanx, metatarsophalangeal, proximal, metatarsal, dorsal, osteotomy

The Youngswick osteotomy is a common orthopedic procedure for addressing issues such as hallux limitus deformity. While it involves surgery and standard surgical risks like infection and anesthesia-related issues, it is generally considered a routine and low-risk procedure. The description provided indicates that the surgery was performed without complications, with minimal blood loss, and the patient's vital signs and neurovascular status were stable post-operation. The post-operative care and follow-up instructions are standard for ensuring recovery. Therefore, while the stakes involve patient health, they are not considered critically high in this context.


Medical Specialty: Speech - Language
Sample Name: Laryngitis - Discharge

DIAGNOSIS: , Chronic laryngitis, hoarseness.,HISTORY:  ,The patient is a 68-year-old male, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.  The patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene.  The patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions.  The patient made great progress and he came in to discuss with an appointment on 12/23/08 stating that his voice had finally returned to "normal".,SHORT-TERM GOALS:,1.  To be independent with relaxation and stretching exercises and Lessac-Madsen Resonant Voice Therapy Protocol.,2.  He also met short-term goal therapy 3 and he is independent with resonant voice therapy tasks.,3.  We did not complete his __________ ratio during his last session; so, I am unsure if he had met his short-term goal number 2.,4.  To be referred for a videostroboscopy, but at this time, the patient is not in need of this evaluation.  However, in the future if hoarseness returns, it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy.,LONG-TERM GOALS:,1.  The patient did reach his long-term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty.,2.  The patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy.,The patient is discharged from my services at this time with a home program to continue to promote normal voicing.
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DESCRIPTION: Chronic laryngitis, hoarseness.  The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.

speech - language, vocal hygiene, voice activities, hoarseness, skilled speech therapy, chronic laryngitis, voice therapy, resonant voice, videostroboscopy, laryngitis

The patient has successfully completed speech therapy for chronic laryngitis and has regained normal voice function, leading to discharge from therapy. The situation involved is a routine, non-emergency medical procedure where the stakes were initially related to improving quality of life rather than life-threatening issues. The main concern about the patient's voice quality has been addressed and does not involve any immediate health risks.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pacemaker - DDDR

PROCEDURE PERFORMED:  ,DDDR permanent pacemaker.,INDICATION: , Tachybrady syndrome.,PROCEDURE:,  After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein.  Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  The needle was then removed over the guidewire and the guidewire was secured to the field.  A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen.  Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field.  Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area.  A #11-knife blade was used to make a deeper incision.  Hemostasis was made complete.  The edges of the incision were grasped and retracted.  Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane.  Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator.  Metzenbaum scissors were then used to dissect cephalad to expose the guide wires.  The guidewires were then pulled through the pacemaker pocket.  One guidewire was secured to the field.,A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance.  The guidewire and dilator were then removed.  Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.  The pacemaker lead was then placed in the appropriate position in the right ventricle.  Pacing and sensing thresholds were obtained.  The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________.  Pacing and sensing threshold were then reconfirmed.  Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen.  The guidewire and dilator were then removed.  Under fluoroscopic guidance, the atrial lead was passed into the right atrium.  The sheath was then turned away in standard fashion.  Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position.  Pacing and sensing thresholds were obtained.  The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________.  Sensing and pacing thresholds were then reconfirmed.  The leads were wiped free of blood and placed into the pacemaker generator.  The pacemaker generator leads were then placed into pocket with the leads posteriorly.  The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion.  A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch.  Steri-Strips overlaid.  A sterile gauge dressing was placed over the site.  The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.,PACEMAKER DATA (GENERATOR DATA):,Manufacturer:  Medtronics.,Model:  Sigma.,Model #:  1234.,Serial #:  123456789.,LEAD INFORMATION:,Right Atrial Lead:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,VENTRICULAR LEAD:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,PACING AND SENSING THRESHOLDS:,Right Atrial Bipolar Lead:  Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.,Ventricular Bipolar Lead:  Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.,PARAMETER SETTINGS:,  Pacing mode DDDR:  Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,IMPRESSION:,  Successful implantation of DDDR permanent pacemaker.,PLAN:,1.  The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2.  The patient will be placed on antibiotics for five days to avoid pacemaker infection.
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DESCRIPTION: DDDR permanent pacemaker.   Tachybrady syndrome.  A ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.

The procedure described is the implantation of a DDDR permanent pacemaker, which involves surgical intervention to address tachybrady syndrome. This condition involves irregular heart rhythms that can compromise the heart's ability to pump blood effectively. The procedure is high-stakes due to its complexity, the use of anesthesia, the need for precise placement of the pacemaker leads, and the potential risks associated with surgical interventions like infection, device failure, or procedural complications. Despite the procedural success reported, continuous monitoring and a course of antibiotics have been planned to mitigate post-procedural risks. The potential consequences of the procedure not being successful or encountering complications are significant and can affect the patient’s health critically, thus making it a high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: 2-D Echocardiogram - 3

2-D ECHOCARDIOGRAM,Multiple views of the heart and great vessels reveal normal intracardiac and great vessel relationships.  Cardiac function is normal.  There is no significant chamber enlargement or hypertrophy.  There is no pericardial effusion or vegetations seen.  Doppler interrogation, including color flow imaging, reveals systemic venous return to the right atrium with normal tricuspid inflow.  Pulmonary outflow is normal at the valve.  Pulmonary venous return is to the left atrium.  The interatrial septum is intact.  Mitral inflow and ascending aorta flow are normal.  The aortic valve is trileaflet.  The coronary arteries appear to be normal in their origins.  The aortic arch is left-sided and patent with normal descending aorta pulsatility.
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DESCRIPTION: 2-D Echocardiogram

2-D Echocardiogram

cardiovascular / pulmonary, 2-d echocardiogram, cardiac function, doppler, echocardiogram, multiple views, aortic valve, coronary arteries, descending aorta, great vessels, heart, hypertrophy, interatrial septum, intracardiac, pericardial effusion, tricuspid, vegetation, venous, pulmonaryNOTE,: 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 echocardiogram results indicate that all aspects of the patient's heart and surrounding vessels are normal. There are no signs of abnormalities, such as chamber enlargement, valve issues, or other conditions that might require immediate medical intervention. This suggests that there is currently no immediate health concern for the patient based on this test result.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: 2-D Echocardiogram - 4

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

Echocardiogram and Doppler

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

The echocardiogram results describe a generally normal cardiac function with terms like 'normal size' and 'good motion' for various heart valves. The presence of 'trace' mitral and tricuspid regurgitation suggests very minor issues that are often not considered serious unless they are more severe. The ejection fraction of 60% is within normal range, indicating good heart pumping efficiency. This suggests a very low-risk cardiac assessment, implying the situation is not high-stakes.


Medical Specialty: Surgery
Sample Name: Bilateral Myringotomies - 2

PREOPERATIVE DIAGNOSES: , Bilateral chronic otitis media,POSTOPERATIVE DIAGNOSES:,  Bilateral chronic otitis media,ANESTHESIA:,  General mask,NAME OF OPERATION:,  Bilateral Myringotomy with placement of PE tubes,PROCEDURE:,  The patient was taken to the operating room and placed in the supine position.  After adequate general inhalation anesthesia was obtained, the operating microscope with brought in for full use throughout the case.  First, the left and then the right tympanic membrane, was approached.  An anterior-inferior radial incision was made in the left tympanic membrane.  Suction revealed a substantial amount of mucopurulent drainage.  A Sheehy pressure equalization tube was placed in the myringotomy site.  Floxin drops were added.  The same procedure was repeated on the right side with similar findings noted of mucopurulent drainage.  The patient tolerated the procedure well and returned to the recovery room awake and in stable condition.
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DESCRIPTION: Bilateral Myringotomy with placement of PE tubes

surgery, placement of pe tubes, bilateral chronic otitis media, chronic otitis media, bilateral myringotomy, pe tubes, chronic otitis, otitis media, tympanic membrane, mucopurulent drainage, tympanic, membrane, mucopurulent, myringotomy, tubes,

The situation involves a surgical procedure known as bilateral myringotomy with the placement of pressure equalization (PE) tubes, which is generally a routine operation to treat chronic otitis media (ear infection). While it is a surgical procedure under general anesthesia, and any surgery carries inherent risks, it is considered one of the more common and straightforward ENT (ear, nose, and throat) surgeries, typically with low risk of complications. Given the nature of the procedure and the typical patient outcomes, this situation is not particularly high-stakes relative to other medical procedures, although it does require medical precision and appropriate post-operative care to prevent complications like infection.