Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Dobutamine Stress Test - 1

DOBUTAMINE STRESS ECHOCARDIOGRAM,REASON FOR EXAM: , Chest discomfort, evaluation for coronary artery disease.,PROCEDURE IN DETAIL: , The patient was brought to the cardiac center.  Cardiac images at rest were obtained in the parasternal long and short axis, apical four and apical two views followed by starting with a dobutamine drip in the usual fashion at 10 mcg/kg per minute for low dose, increased every 2 to 3 minutes by 10 mcg/kg per minute.  The patient maximized at 30 mcg/kg per minute.  Images were obtained at that level after adding 0.7 mg of atropine to reach maximal heart rate of 145.  Maximal images were obtained in the same windows of parasternal long and short axis, apical four and apical two windows.,Wall motion assessed at all levels as well as at recovery.,The patient got nauseated, had some mild shortness of breath.  No angina during the procedure and the maximal amount of dobutamine was 30 mcg/kg per minute.,The resting heart rate was 78 with the resting blood pressure 186/98.  Heart rate reduced by the vasodilator effects of dobutamine to 130/80.  Maximal heart rate achieved was 145, which is 85% of age-predicted heart rate.,The EKG at rest showed sinus rhythm with no ST-T wave depression suggestive of ischemia or injury.  Incomplete right bundle-branch block was seen.  The maximal stress test EKG showed sinus tachycardia.  There was subtle upsloping ST depression in III and aVF, which is a normal response to the tachycardia with dobutamine, but no significant depression suggestive of ischemia and no ST elevation seen.,No ventricular tachycardia or ventricular ectopy seen during the test.  The heart rate recovered in a normal fashion after using metoprolol 5 mg.,The heart images were somewhat suboptimal to evaluate because of obesity and some problems with the short axis windows mainly at peak exercise.,The EF at rest appeared to be normal at 55 to 60 with normal wall motion including anterior, anteroseptal, inferior, lateral, and septal walls at low dose.  All walls mentioned were augmented in a normal fashion.  At maximum dose, all walls were augmented on all views except for the short axis was foreshortened, was uncertain about the anterolateral wall at peak exercise; however, of the other views, the lateral wall was showing normal thickening and normal augmentation.  EF improved to about 70%.,The wall motion score was unchanged.,IMPRESSION:,1.  Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.,2.  Negative EKG criteria for ischemia.,3.  Normal augmentation at low and maximum stress test with some uncertainty about the anterolateral wall in peak exercise only on the short axis view.  This is considered the negative dobutamine stress echocardiogram test, medical management.
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DESCRIPTION: Dobutamine Stress Echocardiogram.  Chest discomfort, evaluation for coronary artery disease.  Maximal dobutamine stress echocardiogram test achieving more than 85% of age-predicted heart rate.  Negative EKG criteria for ischemia.

cardiovascular / pulmonary, chest discomfort, coronary artery disease, predicted heart rate, dobutamine stress echocardiogram, anterolateral wall, echocardiogram test, wall motion, stress echocardiogram, short axis, dobutamine stress, heart rate, dobutamine, stress, ekg, echocardiogram, artery, ischemia, heart

The situation involves a Dobutamine Stress Echocardiogram conducted to evaluate for coronary artery disease due to reported chest discomfort. This test is important because it helps assess heart function and detect potential coronary artery disease, which can be life-threatening. However, the test results were negative for ischemia, suggesting that no immediate critical issues were found. While the procedure itself and the chest discomfort preceding it do carry some level of risk, the outcome of the test indicates that at this moment, no immediate high-stakes decisions or interventions are needed. Therefore, it rates mid-level on the stakes scale.


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

Medical Specialty: Orthopedic
Sample Name: CT Lumbar Spine

EXAM:,  Noncontrast CT scan of the lumbar spine,REASON FOR EXAM: , Left lower extremity muscle spasm.,COMPARISONS: , None.,FINDINGS: , Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.,No abnormal paraspinal masses are identified.,There are sclerotic changes with anterior effusion of the sacroiliac joints bilaterally.,There is marked intervertebral disk space narrowing at the L5-S1 level with intervertebral disk vacuum phenomenon and advanced endplate degenerative changes.  Posterior disk osteophyte complex is present, most marked in the left paracentral to lateral region extending into the lateral recess on the left.  This most likely will affect the S1 nerve root on the left.  There are posterior hypertrophic changes extending into the neural foramina bilaterally inferiorly.  There is mild neural foraminal stenosis present.  Small amount of extruded disk vacuum phenomenon is present on the left in the region of the exiting nerve root.  There is facet sclerosis bilaterally.  Mild lateral recess stenosis just on the right, there is prominent anterior spondylosis.,At the L4-5 level, mild bilateral facet arthrosis is present.  There is broad based posterior annular disk bulging or protrusion, which mildly effaces the anterior aspect of the thecal sac and extends into the inferior aspect of the neural foramina bilaterally.  No moderate or high-grade central canal or neural foraminal stenosis is identified.,At the L3-4 level anterior spondylosis is present.  There are endplate degenerative changes with mild posterior annular disk bulging, but no evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the L2-3 level, there is mild bilateral ligamentum flavum hypertrophy.  Mild posterior annular disk bulging is present without evidence of moderate or high-grade central canal or neural foraminal stenosis.,At the T12-L1 and L1-2 levels, there is no evidence of herniated disk protrusion, central canal, or neural foraminal stenosis.,There is arteriosclerotic vascular calcification of the abdominal aorta and iliac arteries without evidence of aneurysm or dilatation.  No bony destructive changes or acute fractures are identified.,CONCLUSIONS:,1. Advanced degenerative disk disease at the L5-S1 level.,2. Probable chronic asymmetric herniated disk protrusion with peripheral calcification at the L5-S1 level, laterally in the left paracentral region extending into the lateral recess causing lateral recess stenosis.,3. Mild bilateral neural foraminal stenosis at the L5-S1 level.,4. Posterior disk bulging at the L2-3, L3-4, and L4-5 levels without evidence of moderate or high-grade central canal stenosis.,5. Facet arthrosis to the lower lumbar spine.,6. Arteriosclerotic vascular disease.
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DESCRIPTION: Noncontrast CT scan of the lumbar spine.  Left lower extremity muscle spasm.  Transaxial thin slice CT images of the lumbar spine were obtained with sagittal and coronal reconstructions on emergency basis, as requested.

orthopedic, noncontrast ct scan, lower extremity muscle spasm, neural foraminal stenosis, lumbar spine, spine, disk, lumbar, ct, intervertebral, canal, foraminal, noncontrast, stenosis,

The situation involves a non-contrast CT scan conducted on an emergency basis to diagnose issues related to a patient's left lower extremity muscle spasm. The findings indicate several concerning degenerative changes and possible nerve impingements at various levels of the lumbar spine, particularly at L5-S1. This could significantly impact the patient's mobility and quality of life. Although it requires medical intervention, possibly including surgical considerations, it is not immediately life-threatening. Thus, it is a high-stakes medical situation but isn't at the critical level that involves immediate life-saving actions.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Transesophageal Echocardiography Probe

INDICATIONS FOR PROCEDURE:,  Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl.,Procedures were done under general anesthesia.  The patient was already in the operating room under general anesthesia.  Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures.,PROCEDURE #1:,  Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #1: , The probe was well lubricated and with digital manipulation, was passed into the esophagus without resistance.  The probe was placed so that the larger diameter was in the anterior-posterior position during insertion.  The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography.  At the end, it was removed without trauma and there was no blood tingeing.  It is to be noted that approximately 30 minutes after removing the cannula, I inserted a 14-French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned.  There was no overt bleeding.,PROCEDURE #2: , Attempted and unsuccessful insertion of arterial venous lines.,DESCRIPTION OF PROCEDURE #2:,  Both groins were prepped and draped.  The patient was placed at 10 degrees head-up position.  A Cook 4-French double-lumen 8-cm catheter kit was opened.  Using the 21-gauge needle that comes with the kit, several attempts were made to insert central venous and then an arterial line in the left groin.  There were several successful punctures of these vessels, but I was unable to advance Seldinger wire.  After removal of the needles, the area was compressed digitally for approximately 5 minutes.  There was a small hematoma that was not growing.  Initially, the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds.  Using 1% lidocaine, I infiltrated the vessels of the groin both medial and lateral to the vascular sheath.  Further observation, the capillary refill and circulation of the left leg became more than adequate.  The O2 saturation monitor that was on the left toe functioned well throughout the procedures, from the beginning to the end.  At the end of the procedure, the circulation of the leg was intact.,
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DESCRIPTION: Insertion of transesophageal echocardiography probe and unsuccessful insertion of arterial venous lines.

cardiovascular / pulmonary, impending open heart surgery, ventricular septal defect, antibiotic prophylaxis, cefazolin, transesophageal echocardiography probe, arterial venous lines, groin, transesophageal echocardiography, echocardiography probe, insertion, transesophageal, arterial, venous, groins, echocardiography, probe

The situation involves a medical procedure on a 4-month-old infant who is about to undergo open heart surgery for a serious condition: closure of a ventricular septal defect. The use of transesophageal echocardiography is a critical component of surgical planning and safety for such procedures. Moreover, the difficulty encountered in inserting arterial venous lines, despite resolving without long-term harm, indicates the complexity and potential risk involved in the procedure. The patient's age and the condition being treated both contribute to the high-stakes nature of the situation, as cardiovascular and pulmonary procedures in very young children require careful monitoring and skill. Therefore, the scenario carries significant risks to the patient's health, but the situation did stabilize, reducing the urgency somewhat.


Medical Specialty: Surgery
Sample Name: Thoracoscopy/Thoracotomy

PREOPERATIVE DIAGNOSES:,  Empyema of the left chest and consolidation of the left lung.,POSTOPERATIVE DIAGNOSES:,  Empyema of the left chest, consolidation of the left lung, lung abscesses of the left upper lobe and left lower lobe.,OPERATIVE PROCEDURE: , Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.,ANESTHESIA:,  General.,FINDINGS: , The patient has a complex history, which goes back about four months ago when she started having respiratory symptoms and one week ago she was admitted to another hospital with hemoptysis and on her evaluation there which included two CAT scans of chest she was found to have marked consolidation of the left lung with a questionable lung abscess or cavity with hydropneumothorax.  There was also noted to be some mild infiltrates of the right lung.  The patient had a 30-year history of cigarette smoking.  A chest tube was placed at the other hospital, which produced some brownish fluid that had foul odor, actually what was thought to be a fecal-like odor.  Then an abdominal CT scan was done, which did not suggest any communication of the bowel into the pleural cavity or any other significant abnormalities in the abdomen on the abdominal CT.  The patient was started on antibiotics and was then taken to the operating room, where there was to be a thoracoscopy performed.  The patient had a flexible fiberoptic bronchoscopy that showed no endobronchial lesions, but there was bloody mucous in the left main stem bronchus and this was suctioned out.  This was suctioned out with the addition of the use of saline ***** in the bronchus.  Following the bronchoscopy, a double lumen tube was placed, but it was not possible to secure the double lumen to the place so we did not proceed with the thoracoscopy on that day.,The patient was transferred for continued evaluation and treatment.  Today, the double lumen tube was placed and there was some erythema of the mucosa noted in the airways in the bronchi and also remarkably bloody secretions were also noted.  These were suctioned, but it was enough to produce a temporary obstruction of the left mainstem bronchus.  Eventually, the double lumen tube was secured and an attempt at a left thoracoscopy was performed after the chest tube was removed and digital dissection was carried out through that.  The chest tube tract, which was about in the sixth or seventh intercostal space, but it was not possible to dissect enough down to get a acceptable visualization through this tract.  A second incision for thoracoscopy was made about on the sixth intercostal space in the midaxillary line and again some digital dissection was carried out but it was not enough to be able to achieve an opening or space for satisfactory inspection of the pleural cavity.  Therefore the chest was opened and remarkable findings included a very dense consolidation of the entire lung such that it was very hard and firm throughout.  Remarkably, the surface of the lower lobe laterally was not completely covered with a fibrotic line, but it was more the line anterior and posterior and more of it over the left upper lobe.  There were many pockets of purulent material, which had a gray-white appearance to it.  There was quite a bit of whitish fibrotic fibrinous deposit on the parietal pleura of the lung especially the upper lobe.  The adhesions were taken down and they were quite bloody in some areas indicating that the process had been present for some time.  There seemed to be an abscess that was about 3 cm in dimension, all the lateral basilar segment of the lower lobe near the area where the chest tube was placed.  Many cultures were taken from several areas.  The most remarkable finding was a large cavity, which was probably about 11 cm in dimension, containing grayish pus and also caseous-like material, it was thought to be perhaps necrotic lung tissue, perhaps a deposit related to tuberculosis in the cavity.,The apex of the lung was quite densely adhered to the parietal pleura there and the adhesions were quite thickened and firm.,PROCEDURE AND TECHNIQUE:,  With the patient lying with the right side down on the operating table the left chest was prepped and draped in sterile manner.  The chest tube had been removed and initially a blunt dissection was carried out through the old chest tube tract, but then it was necessary to enlarge it slightly in order to get the Thoracoport in place and this was done and as mentioned above we could not achieve the satisfactory visualization through this.  Therefore, the next incision for Thoracoport and thoracoscopy insertion through the port was over the sixth intercostal space and a little bit better visualization was achieved, but it was clear that we would be unable to complete the procedure by thoracoscopy.  Therefore posterolateral thoracotomy incision was made, entering the pleural space and what is probably the sixth intercostal space.  Quite a bit of blunt and sharp and electrocautery dissection was performed to take down adhesions to the set of the fibrinous deposit on the pleural cavity.  Specimens for culture were taken and specimens for permanent histology were taken and a frozen section of one of the most quite dense.  Suture ligatures of Prolene were required.  When the cavity was encountered it was due to some compression and dissection of some of the fibrinous deposit in the upper lobe laterally and anterior and this became identified as a very thin layer in one area over this abscess and when it was opened it was quite large and we unroofed it completely and there was bleeding down in the depths of the cavity, which appeared to be from pulmonary veins and these were sutured with a "tissue pledget" of what was probably intercostal nozzle and endothoracic fascia with Prolene sutures.,Also as the upper lobe was retracted in caudal direction the tissue was quite dense and the superior branch of the pulmonary artery on the left side was torn and for hemostasis a 14-French Foley catheter was passed into the area of the tear and the balloon was inflated, which helped establish hemostasis and suturing was carried out again with utilizing a small pledget what was probably intercostal muscle and endothoracic fascia and this was sutured in place and the Foley catheter was removed.  The patch was sutured onto the pulmonary artery tear.  A similar maneuver was utilized on the pulmonary vein bleeding site down deep in the cavity.  Also on the pulmonary artery repair some ***** material was used and also thrombin, Gelfoam and Surgicel.  After reasonably good hemostasis was established pleural cavity was irrigated with saline.  As mentioned, biopsies were taken from multiple sites on the pleura and on the edge and on the lung.  Then two #24 Blake chest tubes were placed, one through a stab wound above the incision anteriorly and one below and one in the inferior pleural space and tubes were brought out through stab wounds necked into the skin with 0 silk.  One was positioned posteriorly and the other anteriorly and in the cephalad direction of the apex.  These were later connected to water-seal suction at 40 cm of water with negative pressure.,Good hemostasis was observed.  Sponge count was reported as being correct.  Intercostal nerve blocks at probably the fifth, sixth, and seventh intercostal nerves was carried out.  Then the sixth rib had been broken and with retraction the fractured ends were resected and rongeur used to smooth out the end fragments of this rib.  Metallic clip was passed through the rib to facilitate passage of an intracostal suture, but the bone was partially fractured inferiorly and it was very difficult to get the suture out through the inner cortical table, so that pericostal sutures were used with #1 Vicryl.  The chest wall was closed with running #1 Vicryl and then 2-0 Vicryl subcutaneous and staples on the skin.  The chest tubes were connected to water-seal drainage with 40 cm of water negative pressure.  Sterile dressings were applied.  The patient tolerated the procedure well and was turned in the supine position where the double lumen endotracheal tube was switched out with single lumen.  The patient tolerated the procedure well and was taken to the intensive care unit in satisfactory condition.
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DESCRIPTION: Left thoracoscopy and left thoracotomy with declaudication and drainage of lung abscesses, and multiple biopsies of pleura and lung.

surgery, empyema, biopsies, bronchus, declaudication, endothoracic, hydropneumothorax, left lower lobe, left lung, left upper lobe, mainstem, pleura, thoracoscopy, thoracotomy, thoracotomy with declaudication, declaudication and drainage, double lumen tube, sixth intercostal space, lung abscesses, pleural cavity, intercostal space, upper lobe, double lumen, chest tube, cavity, tube, chest, lung, pulmonary, pleural, intercostal,

The described surgical procedure involves a thoracotomy and thoracoscopy for empyema, lung abscesses, and other severe lung conditions. Such procedures are invasive and come with significant risks, including bleeding and infection. The patient's complex history, marked by respiratory symptoms and previous hospitalizations, heightens the stakes. Additionally, any surgery on the lungs involving general anesthesia and lung manipulation is inherently high-stakes due to the potential complications and the critical nature of the respiratory system.


Medical Specialty: Office Notes
Sample Name: Normal Newborn H&P Template

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

The provided template is for documenting the history and physical examination of a newborn. While it involves critical medical information, this specific instance is routine and discusses a 'normal' newborn H&P. It's important to accurately fill out the form and ensure no health issues are missed, but the stakes are typical of standard healthcare documentation. However, mistakes could lead to misunderstanding the newborn's health status, impacting care.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Breast Calcifications - Preop Consult

REASON FOR HOSPITALIZATION:  ,Suspicious calcifications upper outer quadrant, left breast.,HISTORY OF PRESENT ILLNESS: , The patient is a 78-year-old woman who had undergone routine screening mammography on 06/04/08.  That study disclosed the presence of punctate calcifications that were felt to be in a cluster distribution in the left breast mound at the 2 o'clock position.  Additional imaging studies confirmed the suspicious nature of these calcifications.  The patient underwent a stereotactic core needle biopsy of the left breast 2 o'clock position on 06/17/08.  The final histologic diagnosis of the tissue removed during that procedure revealed focal fibrosis.  No calcifications could be identified in examination of the biopsy material including radiograph taken of the preserved tissue.,Two days post stereotactic core needle biopsy, however, the patient returned to the breast center with severe swelling and pain and mass in the left breast.  She underwent sonographic evaluation and was found to have a development of false aneurysm formation at the site of stereotactic core needle biopsy.  I was called to see the patient in the emergency consultation in the breast center.  At the same time, Dr. Y was consulted in Interventional Radiology.  Dr. Z and Dr. Y were able to identify the neck of the false aneurysm in the left breast mound and this was injected with ultrasound guidance with thrombin material.  This resulted in immediate occlusion of the false aneurysm.  The patient was seen in my office for followup appointment on 06/24/08.  At that time, the patient continued to have signs of a large hematoma and extensive ecchymosis, which resulted from the stereotactic core needle biopsy.  There was, however, no evidence of reforming of the false aneurysm.  There was no evidence of any pulsatile mass in the left breast mound or on the left chest wall.,I discussed the issues with the patient and her husband.  The underlying problem is that the suspicious calcifications, which had been identified on mammography had not been adequately sampled with the stereotactic core needle biopsy; therefore, the histologic diagnosis is not explanatory of the imaging findings.  For this reason, the patient was advised to have an excisional biopsy of this area with guidewire localization.  Since the breast mound was significantly disturbed from the stereotactic core needle biopsy, the decision was to postpone any surgical intervention for at least three to four months.  The patient now returns to undergo the excision of the left breast tissue with preoperative guidewire localization to identify the location of suspicious calcifications.,The patient has a history of prior stereotactic core needle biopsy of the left breast, which was performed on 01/27/04.  This revealed benign histologic findings.  The family history is positive involving a daughter who was diagnosed with breast cancer at the age of 40.  Other than her age, the patient has no other risk factors for development of breast cancer.  She is not receiving any hormone replacement therapy.  She has had five children with the first pregnancy occurring at the age of 24.  Other than her daughter, there are no other family members with breast cancer.  There are no family members with a history of ovarian cancer.,PAST MEDICAL HISTORY: , Other hospitalizations have occurred for issues with asthma and pneumonia.,PAST SURGICAL HISTORY: , Colon resection in 1990 and sinus surgeries in 1987, 1990 and 2005.,CURRENT MEDICATIONS:,1.  Plavix.,2.  Arava.,3.  Nexium.,4.  Fosamax.,5.  Advair.,6.  Singulair.,7.  Spiriva.,8.  Lexapro.,DRUG ALLERGIES:,  ASPIRIN, PENICILLIN, IODINE AND CODEINE.,FAMILY HISTORY:, Positive for heart disease, hypertension and cerebrovascular accidents.  Family history is positive for colon cancer affecting her father and a brother.  The patient has a daughter who was diagnosed with breast cancer at age 40.,SOCIAL HISTORY: , The patient does not smoke.  She does have an occasional alcoholic beverage.,REVIEW OF SYSTEMS:  ,The patient has multiple medical problems, for which she is under the care of Dr. X.  She has a history of chronic obstructive lung disease and a history of gastroesophageal reflux disease.  There is a history of anemia and there is a history of sciatica, which has been caused by arthritis.  The patient has had skin cancers, which have been treated with local excision.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an elderly aged female who is alert and in no distress.,HEENT:  Head, normocephalic.  Eyes, PERRL.  Sclerae are clear.  Mouth, no oral lesions.,NECK:  Supple without adenopathy.,HEART:  Regular sinus rhythm.,CHEST:  Fair air entry bilaterally.  No wheezes are noted on examination.,BREASTS:  Normal topography bilaterally.  There are no palpable abnormalities in either breast mound.  Nipple areolar complexes are normal.  Specifically, the left breast upper outer quadrant near the 2 o'clock position has no palpable masses.  The previous tissue changes from the stereotactic core needle biopsy have resolved.  Axillary examination normal bilaterally without suspicious lymphadenopathy or masses.,ABDOMEN:  Obese.  No masses.  Normal bowel sounds are present.,BACK:  No CVA tenderness.,EXTREMITIES:  No clubbing, cyanosis or edema.,ASSESSMENT:,1.  Left breast mound clustered calcifications, suspicious by imaging located in the upper outer quadrant at the 2 o'clock position.,2.  Prior stereotactic core needle biopsy of the left breast did not resolve the nature of the calcifications, this now requires excision of the tissue with preoperative guidewire localization.,3.  History of chronic obstructive lung disease and asthma, controlled with medications.,4.  History of gastroesophageal reflux disease, controlled with medications.,5.  History of transient ischemic attack managed with medications.,6.  History of osteopenia and osteoporosis, controlled with medications.,7.  History of anxiety controlled with medications.,PLAN: , Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.  This will be performed on an outpatient basis.
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DESCRIPTION: Suspicious calcifications upper outer quadrant, left breast.  Left breast excisional biopsy with preoperative guidewire localization and intraoperative specimen radiography.

The situation involves the medical management of suspicious breast calcifications with a history indicating familial breast cancer. The stakes are significant due to the potential of undiagnosed breast cancer and complications following previous procedures. Delayed treatment and precise diagnosis are crucial in such scenarios, indicating a moderately high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: H&P - Cardio (Angina)

CHIEF COMPLAINT (1/1):, This 62 year old female presents today for evaluation of angina.,Associated signs and symptoms: Associated signs and symptoms include chest pain, nausea, pain radiating to the arm and pain radiating to the jaw.,Context: The patient has had no previous treatments for this condition.,Duration: Condition has existed for 5 hours.,Quality: Quality of the pain is described by the patient as crushing.,Severity: Severity of condition is severe and unchanged.,Timing (onset/frequency): Onset was sudden and with exercise. Patient has the following coronary risk factors: smoking 1 packs/day for 40 years and elevated cholesterol for 5 years. Patient's elevated cholesterol is not being treated with medication. Menopause occurred at age 53.,ALLERGIES:, No known medical allergies.,MEDICATION HISTORY:, Patient is currently taking Estraderm 0.05 mg/day transdermal patch.,PMH:, Past medical history unremarkable.,PSH:, No previous surgeries.,SOCIAL HISTORY:, Patient admits tobacco use She relates a smoking history of 40 pack years.,FAMILY HISTORY:, Patient admits a family history of heart attack associated with father (deceased).,ROS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAMINATION:,General: Patient is a 62 year old female who appears pleasant, her given age, well developed,,oriented, well nourished, alert and moderately overweight.,Vital Signs: BP Sitting: 174/92 Resp: 28 HR: 88 Temp: 98.6 Height: 5 ft. 2 in. Weight: 150 lbs.,HEENT: Inspection of head and face shows head that is normocephalic, atraumatic, without any gross or neck masses. Ocular motility exam reveals muscles are intact. Pupil exam reveals round and equally reactive to light and accommodation. There is no conjunctival inflammation nor icterus. Inspection of nose reveals no abnormalities. Inspection of oral mucosa and tongue reveals no pallor or cyanosis. Inspection of the tongue reveals normal color, good motility and midline position. Examination of oropharynx reveals the uvula rises in the midline. Inspection of lips, teeth, gums, and palate reveals healthy teeth, healthy gums, no gingival,hypertrophy, no pyorrhea and no abnormalities.,Neck: Neck exam reveals neck supple and trachea that is midline, without adenopathy or crepitance palpable.,Thyroid examination reveals smooth and symmetric gland with no enlargement, tenderness or masses noted.,Carotid pulses are palpated bilaterally, are symmetric and no bruits auscultated over the carotid and vertebral arteries. Jugular veins examination reveals no distention or abnormal waves were noted. Neck lymph nodes are not noted.,Back: Examination of the back reveals no vertebral or costovertebral angle tenderness and no kyphosis or scoliosis noted.,Chest: Chest inspection reveals intercostal interspaces are not widened, no splinting, chest contours are normal and normal expansion. Chest palpation reveals no abnormal tactile fremitus.,Lungs: Chest percussion reveals resonance. Assessment of respiratory effort reveals even respirations without use of accessory muscles and diaphragmatic movement normal. Auscultation of lungs reveal diminished breath sounds bibasilar.,Heart: The apical impulse on heart palpation is located in the left border of cardiac dullness in the midclavicular line, in the left fourth intercostal space in the midclavicular line and no thrill noted. Heart auscultation reveals rhythm is regular, normal S1 and S2, no murmurs, gallop, rubs or clicks and no abnormal splitting of the second heart sound which moves normally with respiration. Right leg and left leg shows evidence of edema +6.,Abdomen: Abdomen soft, nontender, bowel sounds present x 4 without palpable masses. Palpation of liver reveals no abnormalities with respect to size, tenderness or masses. Palpation of spleen reveals no abnormalities with respect to size, tenderness or masses. Examination of abdominal aorta shows normal size without presence of systolic bruit.,Extremities: Right thumb and left thumb reveals clubbing.,Pulses: The femoral, popliteal, dorsalis, pedis and posterior tibial pulses in the lower extremities are equal and normal. The brachial, radial and ulnar pulses in the upper extremities are equal and normal. Examination of peripheral vascular system reveals varicosities absent, extremities warm to touch, edema present - pitting and pulses are full to palpation. Femoral pulses are 2 /4, bilateral. Pedal pulses are 2 /4, bilateral.,Neurological: Testing of cranial nerves reveals nerves intact. Oriented to person, place and time. Mood and affect normal and appropriate to situation.Deep tendon reflexes normal. Touch, pin, vibratory and proprioception sensations are normal. Babinski reflex is absent. Coordination is normal. Speech is not aphasic. Musculoskeletal: Muscle strength is 5/5 for all groups tested. Gait and station examination reveals midposition without abnormalities.,Skin: No skin rash, subcutaneous nodules, lesions or ulcers observed. Skin is warm and dry with normal turgor and there is no icterus.,Lymphatics: No lymphadenopathy noted.,IMPRESSION:, Angina pectoris, other and unspecified.,PLAN:, ,DIAGNOSTIC & LAB ORDERS:, Ordered serum creatine kinase isoenzymes (CK isoenzymes). Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report. The following cardiac risk factor modifications are recommended: quit smoking and reduce LDL cholesterol to below 120 mg/dl.,PATIENT INSTRUCTIONS:
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DESCRIPTION: H&P for a female with Angina pectoris.

H&P for a female with Angina pectoris.

The situation involves a 62-year-old female patient presenting with angina, which is considered a high-stakes medical condition. The patient is experiencing severe, crushing chest pain with radiation to the arm and jaw, which are common symptoms of potentially life-threatening cardiac events like myocardial infarction (heart attack). Additionally, she has multiple coronary risk factors, including a long history of smoking and elevated cholesterol. Given her family history of heart attacks and the acute nature of her symptoms, this scenario requires urgent and comprehensive evaluation to prevent severe cardiac events. These factors contribute to high-stakes involvement as prompt medical intervention is crucial.


Medical Specialty: ENT - Otolaryngology
Sample Name: Otitis Media

OTITIS MEDIA, is an infection of the middle ear space where the small bones and nerves of the ear connect to the eardrum on one side and the eustachian tube on the other.  The ear infection itself is not contagious but the respiratory infection preceding it is transmittable.  Otitis media is most often seen in infants and young children.  There are several causes including a viral or bacterial infection that spreads to the middle ear by way of the eustachian tubes, nasal allergy drainage blocking the sinuses or eustachian tubes, enlarged adenoids also blocking sinuses or eustachian tubes and eardrum rupture.  Many factors can increase the risk of an ear infection like recent upper respiratory tract illness, crowded living conditions, family history of ear infections, day care, smoking in household, altitude changes, cold weather and genetic factors.,SIGNS AND SYMPTOMS:,*  Irritability.,*  Ear pain, fullness, hearing loss.,*  Infants may pull on ear.,*  Fever.,*  Vomiting.,*  Discharge from ear.,*  Diarrhea.,TREATMENT:,*  Diagnosis is by physical exam and otoscopic exam.  Sometimes fluid from the ear is cultured.,*  Pain relievers, like acetaminophen (Tylenol).  Infant pain relievers are available.,*  Decongestant to relieve symptoms of upper respiratory tract infection.,*  Antibiotics when indicated for bacterial infection such as Amoxicillin or Zithromycin.  Finish ALL antibiotics as prescribed.  Do not stop the medication even if symptoms subside.,*  Avoid swimming until infection goes away.,*  Surgery is sometimes necessary to put in tubes through the eardrum to equalize pressure and drain fluids.,*  Surgery to remove adenoids if they are enlarged.,*  Reduce activity until symptoms subside.,Call doctor's office if symptoms do not improve within 2 days of treatment, and for convulsion, fever, ear swelling, dizziness, twitching facial muscles and severe headache.
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DESCRIPTION: A sample note on otitis media.

A sample note on otitis media.

ent - otolaryngology, ear, ear infection, otitis media, sinuses, drainage, ear pain, fullness, hearing loss, ear swelling, fever, bacterial infection, eustachian tubes, infection, eardrum, respiratory, otitis, media, eustachian, tubes,

Otitis Media is generally considered a common and treatable condition, especially in infants and young children. While it can cause discomfort and sometimes requires medical intervention, it is not typically life-threatening if managed appropriately. The complications, though possible, such as severe infection or hearing loss, are not the usual outcomes if treated properly. Therefore, while it requires prompt medical attention, it does not typically constitute a high-stakes medical emergency compared to other conditions.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Complete Physical - Female

SUBJECTIVE:,  This is an 18-year-old white female who presents for complete physical, Pap, and breast exam and to have paperwork filled out for college.  She denies any problems at this time.  Her last Pap smear was 06/25/2003 and was normal.  She is requesting to switch from Ortho-Tri-Cyclen to Seasonale at this time.  We did discuss that she may have increased episodes of breakthrough bleeding.,PAST MEDICAL HISTORY:,  Fever blisters and allergic rhinitis.,MEDICATIONS: , Allegra 180 mg q.d., trazodone 50 mg p.r.n. q.h.s., and Ortho-Tri-Cyclen.,ALLERGIES:,  None.,SOCIAL HISTORY:,  Denies tobacco or drug use, rare alcohol use.  She is sexually active and has had one partner.,FAMILY HISTORY:  ,Positive for rheumatoid arthritis.,REVIEW OF SYSTEMS:,  HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional, and psychiatric all negative except for HPI.,OBJECTIVE:,Vital Signs:  Height 5 feet 6 inches.  Weight 153 pounds.  Blood pressure 106/72.  Pulse 68.  Respirations 12.  Temperature 97.5.  Last menstrual period 05/30/2004.,General:  She is a well-developed, well-nourished white female in no acute distress.,HEENT:  Tympanic membranes unremarkable.  Oropharynx nonerythematous.  Pupils equal, round, and reactive to light.  Extraocular muscles intact.,Neck:  Supple.  No lymphadenopathy and no thyromegaly.,Chest:  Clear to auscultation bilaterally.,CV:  Regular rate and rhythm without murmur.,Abdomen:  Positive bowel sounds.  Soft and nontender.  No hepatosplenomegaly.,Breasts:  No nipple discharge.  No lumps or masses palpated.  No dimpling of the skin.  No axillary lymph nodes palpated.  Self-breast exam discussed and encouraged.,Pelvic:  Normal female genitalia.  Normal vaginal rugation.  No cervical lesions.  No cervical motion tenderness.  No adnexal tenderness or masses palpated.,Extremities:  No cyanosis, clubbing, or edema.,Neurologic:  2+/4 DTRs in all extremities.  5/5 motor strength in all extremities.  Negative Romberg.,Musculoskeletal:  No abnormalities or laxity noted in any of her joints.,ASSESSMENT/PLAN:,1.  Complete physical, Pap, and breast exam completed.,2.  School physical form completed and returned to the patient.,3.  Hepatitis B second injection will be given today.,4.  Contraceptive surveillance.  We will put patient to Seasonale to start at the end of this cycle a pill.,5.  Allergic rhinitis.  Prescription was given for Allegra 180 mg q.d.  #30 carrying refills for her to take with her school Cowley County Community College.,6.  Insomnia.  Prescription for trazodone 50 mg p.r.n. q.h.s. was given for her to take with her to school.  She will follow up as needed.
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DESCRIPTION: An 18-year-old white female who presents for complete physical, Pap, and breast exam.

The situation involves a routine medical check-up for an 18-year-old female, including a complete physical, breast exam, Pap smear, and switching contraceptives. It also includes advice and prescription renewals. Although it deals with health and preventative care, it does not present any acute health issues or emergencies. It's a standard and low-stakes situation typical in outpatient care for health maintenance and disease prevention.


Medical Specialty: Surgery
Sample Name: Myringotomy/Tube Insertion

PREOPERATIVE DIAGNOSES:,  Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,POSTOPERATIVE DIAGNOSES:,  Chronic otitis media with effusion, conductive hearing loss, and recurrent acute otitis media.,OPERATION: , Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.,ANESTHESIA:  ,General via facemask.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS: , None.,INDICATIONS:  ,The patient is a one-year-old with history of chronic and recurrent episodes of otitis media with persistent middle ear effusions resistant to medical therapy.,PROCEDURE: , The patient was brought to the operating room, was placed in supine position.  General anesthesia was begun via face mask technique.  Once an adequate level of anesthesia was obtained, the operating microscope was brought, positioned and visualized the right ear canal.  A small amount of wax was removed with a loop.  A 4-mm operating speculum was then introduced.  An anteroinferior quadrant radial myringotomy was then performed.  A large amount of mucoid middle ear effusion was aspirated from the middle ear cleft.  Reuter bobbin PE tube was then inserted, followed by Floxin otic drops and a cotton ball in the external meatus.  Head was then turned to the opposite side, where similar procedure was performed.  Once again, the middle ear cleft had a mucoid effusion.  A tube was inserted to an anteroinferior quadrant radial myringotomy.,Anesthesia was then reversed and the patient was transported to the recovery room having tolerated the procedure well with stable signs.
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DESCRIPTION: Bilateral myringotomies, insertion of PE tubes, and pharyngeal anesthesia.

surgery, bilateral myringotomies, insertion of pe tubes, chronic otitis media, conductive hearing loss, recurrent acute otitis media, reuter bobbin, radial myringotomy, ear cleft, pe tubes, middle ear, otitis media, effusion, otitis, media, ear, anesthesia

The situation described involves a routine surgical procedure known as a myringotomy with tube insertion, typically performed to treat chronic otitis media. This procedure is common, relatively straightforward, and generally low-risk, especially when no complications are reported, as in this case. The patient is a one-year-old child, and while any surgical procedure in young children warrants careful attention, the lack of estimated blood loss, complications, and the successful recovery suggest that this particular situation is not high-stakes. However, the involvement of general anesthesia and the age of the patient slightly elevate the stakes compared to minor procedures not requiring anesthesia.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 12

CHIEF COMPLAINT:,  Weak and shaky.,HISTORY OF PRESENT ILLNESS:,  The patient is a 75-year-old, Caucasian female who comes in today with complaint of feeling weak and shaky.  When questioned further, she described shortness of breath primarily with ambulation.  She denies chest pain.  She denies cough, hemoptysis, dyspnea, and wheeze.  She denies syncope, presyncope, or palpitations.  Her symptoms are fairly longstanding but have been worsening as of late.,PAST MEDICAL HISTORY:,  She has had a fairly extensive past medical history but is a somewhat poor historian and is unable to provide details about her history.  She states that she has underlying history of heart disease but is not able to elaborate to any significant extent.  She also has a history of hypertension and type II diabetes but is not currently taking any medication.  She has also had a history of pulmonary embolism approximately four years ago, hyperlipidemia, peptic ulcer disease, and recurrent urinary tract infections.  Surgeries include an appendectomy, cesarean section, cataracts, and hernia repair.,CURRENT MEDICATIONS:,  She is on two different medications, neither of which she can remember the name and why she is taking it.,ALLERGIES: , She has no known medical allergies.,FAMILY HISTORY:,  Remarkable for coronary artery disease, stroke, and congestive heart failure.,SOCIAL HISTORY:,  She is a widow, lives alone.  Denies any tobacco or alcohol use.,REVIEW OF SYSTEMS:,  Dyspnea on exertion.  No chest pain or tightness, fever, chills, sweats, cough, hemoptysis, or wheeze, or lower extremity swelling.,PHYSICAL EXAMINATION:,General:  She is alert but seems somewhat confused and is not able to provide specific details about her past history.,Vital Signs:  Blood pressure:  146/80.  Pulse:  68.  Weight:  147 pounds.,HEENT:  Unremarkable.,Neck:  Supple without JVD, adenopathy, or bruit.,Chest:  Clear to auscultation.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft.,Extremities:  No edema.,LABORATORY:,  O2 sat 100% at rest and with exertion.  Electrocardiogram was normal sinus rhythm.  Nonspecific S-T segment changes.  Chest x-ray pending.,ASSESSMENT/PLAN:,1.  Dyspnea on exertion, uncertain etiology.  Mother would be concerned about the possibility of coronary artery disease given the patient’s underlying risk factors.  We will have the patient sign a release of records so that we can review her previous history.  Consider setting up for a stress test.,2.  Hypertension, blood pressure is acceptable today.  I am not certain as to what, if the patient’s is on any antihypertensive agents.  We will need to have her call us what the names of her medications, so we can see exactly what she is taking.,3.  History of diabetes.  Again, not certain as to whether the patient is taking anything for this particular problem when she last had a hemoglobin A1C.  I have to obtain some further history and review records before proceeding with treatment recommendations.
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DESCRIPTION: Feeling weak and shaky - Dyspnea on exertion and history of diabetes

The situation involves a 75-year-old female with a complex medical history, presenting with significant symptoms including weakness, shakiness, and dyspnea on exertion. These symptoms, combined with her history of heart disease, diabetes, and a previous pulmonary embolism, necessitate careful evaluation to rule out serious underlying conditions like coronary artery disease. The patient also cannot recall her current medications, which complicates her management and increases the risk of adverse events or medication interactions. Moreover, her past medical history is inadequately detailed due to her inability to provide specifics, necessitating further investigation and coordination of care. These factors combined make it a high-stakes situation, as it could involve potential life-threatening cardiovascular issues or unmanaged chronic conditions without effective intervention.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psychiatric Consult

HISTORY OF PRESENT ILLNESS:  ,This is a 23-year-old married man who had an onset of aplastic anemia in December, underwent a bone marrow transplant in the end of March, has developed very severe graft-versus-host reaction.  Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.,The patient gives a significant history of behavioral problems from late adolescence until the onset of illness, states he had lot of trouble with law, he was convicted of assault, he was also arrested with small amount of cannabis, states he served one year incarcerated in ABCD that was about two years ago.  Gives an ongoing history of substance abuse until one year ago when he went into a drug rehabilitation program, he was discharged from that on 05/28/2006 and states he has been clean and sober since then.  Prior to going to rehabilitation, he was using intravenous heroin couple of times a week since age 17, which would have been over a period of about five years, reports heavy use of cannabis, smoking pot up to five times a day if he could.  He would drink up to half of a fifth of rum on a daily basis when available.,The patient is currently on Lexapro 10 mg in the morning and diazepam 10 mg at bedtime.  He complained of some depressive and some anxiety symptoms, but these do not appear to be out of proportion to his medical issues and, for this individual, the frustrations of his treatments.  He would have a limited support system here in Colorado.  He married in January and states that the marriage is not going particularly well, being young, sick, and hospitalized, has not helped his relationship with his new wife who apparently is expecting a child in July.  I would recommend some couples counseling as a part of their treatment here.,The patient was fairly drowsy during the interview and full past and developmental history was not obtained.  The patient's comment is that he grew up all over, that his parents had separated, that he lived with his mother, that he dropped out of school in eleventh grade, at that time was living in XYZ area because he did not like school.,PHYSICAL EXAMINATION:  ,GENERAL: , This is a cooperative man, speech is soft and difficult to understand.  There is no thought disorder and no hallucination.  He denies being suicidal, but does express at times feelings about giving up on his treatments and primarily complaints about feeling that he is treated like a child and confined in the hospital.,VITAL SIGNS: , Temperature 97.2, pulse 117, respirations 16, blood pressure 127/74, oxygen saturation 97%, and weight is 154 pounds.,PSYCHIATRY:,  There is no thought disorder, no paranoia, no delusions, and no psychotic symptoms.  Activities of daily living (ADLs) appear intact.  On formal testing, he is oriented to place.  He can give a reasonable recitation of his medical history.  He is oriented to the year, knows it is the 15th, but gave the month as June instead of May.  He can memorize four items, repeats three out of four at five minutes, gives the fourth through the category, which places short-term memory in normal limits.  He can do serial three subtractions accurately, can name objects appropriately.,LABORATORY DATA:,  Sodium of 135, BUN of 24, and glucose 119.  GGT of 355, ALT of 97, LDH of 703, and alk phos of 144.  FK506 is 28.8, which is elevated tacrolimus level.  Hematocrit 29% and white count is 7000.,DIAGNOSES:  ,AXIS I:,  Depressive disorder secondary to the underlying medical condition of graft-versus-host reaction.,AXIS II: , Personality disorder, not otherwise specified (NOS).,AXIS III: , History of polysubstance abuse, in remission.,RECOMMENDATIONS:  ,1.  This patient appears to retain the ability to make decisions on his own behalf.  I think he is mentally competent.  Unfortunately, his impulsive low frustration personality dynamics do not fit well with the demands and requirements for treatment of this chronic illness.  If the patient refuses treatment, he understands that the consequences of this would likely be hastened mortality and he does state that he does not want to die.,2.  The patient does complain of depressed mood, also of anxiety.  We did discuss medications.  He appeared somewhat sedated at the time of my interview.  I would recommend that we try Seroquel 25 mg twice daily on an as-needed basis to see if this diminishes anxiety.  I will have Dr. X followup with him.,Please feel free to contact me at digital pager if additional information is needed.,My overall recommendation would be that the patient be on some random urine drug screening, that he use cell phone if he goes off the unit, to be called back up when treatments are scheduled, and hopefully he will be agreeable to complying with this.
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DESCRIPTION: Psychiatric consultation has been requested as the patient has been noncompliant with treatment, leave the unit, does not return when requested, and it was unclear as to whether this is secondary to confusion or willful behavior.

psychiatry / psychology, noncompliant, confusion, graft versus host reaction, psychiatric consultation, willful behavior, cannabis,

This situation involves a young man with significant medical and psychiatric background who is noncompliant with a critical medical treatment following a bone marrow transplant. Noncompliance could result in severe health consequences, including hastened mortality. The patient has a complex history of substance abuse, legal troubles, and personality challenges, adding to the difficulty of adequately addressing his needs. The potential high-risk consequences of noncompliance in this medical context make this a high-stakes situation, warranting immediate attention to ensure proper engagement in treatment and minimize potential harm.


Medical Specialty: Neurology
Sample Name: MRI L-S Spine - Cauda Equina Syndrome

CC: ,Low Back Pain (LBP) with associated BLE weakness.,HX:, This 75y/o RHM presented with a 10 day h/o progressively worsening LBP. The LBP started on 12/3/95; began radiating down the RLE, on 12/6/95; then down the LLE, on 12/9/95. By 12/10/95, he found it difficult to walk. On 12/11/95, he drove himself to his local physician, but no diagnosis was rendered. He was given some NSAID and drove home. By the time he got home he had great difficulty walking due to LBP and weakness in BLE, but managed to feed his pets and himself. On 12/12/95 he went to see a local orthopedist, but on the way to his car he crumpled to the ground due to BLE weakness and LBP pain. He also had had BLE numbness since 12/11/95. He was evaluated locally and an L-S-Spine CT scan and L-S Spine X-rays were "negative." He was then referred to UIHC.,MEDS: ,SLNTC, Coumadin 4mg qd, Propranolol, Procardia XL, Altace, Zaroxolyn.,PMH: ,1) MI 11/9/78, 2) Cholecystectomy, 3) TURP for BPH 1980's, 4) HTN, 5) Amaurosis Fugax, OD, 8/95 (Mayo Clinic evaluation--TEE (-), but Carotid Doppler (+) but "non-surgical" so placed on Coumadin).,FHX:, Father died age 59 of valvular heart disease. Mother died of DM. Brother had CABG 8/95.,SHX:, retired school teacher. 0.5-1.0 pack cigarettes per day for 60 years.,EXAM:, BP130.56, HR68, RR16, Afebrile.,MS: A&O to person, place, time. Speech fluent without dysarthria. Lucid. Appeared uncomfortable.,CN: Unremarkable.,MOTOR: 5/5 strength in BUE. Lower extremity strength: Hip flexors & extensors 4-/4-, Hip abductors 3+/3+, Hip adductors 5/5, Knee flexors & extensors 4/4-, Ankle flexion 4-/4-, Tibialis Anterior 2/2-, Peronei 3-/3-. Mild atrophy in 4 extremities. Questionable fasciculations in BLE. Spasms illicited on striking quadriceps with reflex hammer (? percussion myotonia). No rigidity and essential normal muscle tone on passive motion.,SENSORY: Decreased vibratory sense in stocking distribution from toes to knees in BLE (worse on right). No sensory level. PP/LT/TEMP testing unremarkable.,COORD: Normal FNF-RAM. Slowed HKS due to weakness.,Station: No pronator drift. Romberg testing not done.,Gait: Unable to stand.,Reflexes: 2/2 BUE. 1/trace patellae, 0/0 Achilles. Plantar responses were flexor, bilaterally. Abdominal reflex was present in all four quadrants. Anal reflex was illicited from all four quadrants. No jaw jerk or palmomental reflexes illicited.,Rectal: normal rectal tone, guaiac negative stool.,GEN EXAM: Bilateral Carotid Bruits, No lymphadenopathy, right inguinal hernia, rhonchi and inspiratory wheeze in both lung fields.,COURSE: ,WBC 11.6, Hgb 13.4, Hct 38%, Plt 295. ESR 40 (normal 0-14), CRP 1.4 (normal <0.4), INR 1.5, PTT 35 (normal), Creatinine 2.1, CK 346. EKG normal. The differential diagnosis included Amyotrophy, Polymyositis, Epidural hematoma, Disc Herniation and Guillain-Barre syndrome. An MRI of the lumbar spine was obtained, 12/13/95. This revealed an L3-4 disc herniation extending inferiorly and behind the L4 vertebral body. This disc was located more on the right than on the left , compromised the right neural foramen, and narrowed the spinal canal. The patient underwent a L3-4 laminectomy and diskectomy and subsequently improved. He was never seen in follow-up at UIHC.
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DESCRIPTION: MRI L-S-Spine for Cauda Equina Syndrome secondary to L3-4 disc herniation - Low Back Pain (LBP) with associated BLE weakness.

neurology, ble weakness, carotid doppler, disc herniation, guillain-barre syndrome, amyotrophy, polymyositis, epidural hematoma, mri l s spine, cauda equina syndrome, flexors & extensors, cauda equina, herniation, cauda, equina, extensors, reflexes, mri, hip, flexors, weakness,

This scenario involves a neurological condition with urgent clinical implications. The patient exhibits symptoms consistent with cauda equina syndrome, a condition that requires prompt medical intervention due to the risk of severe complications, including permanent paralysis or loss of bowel and bladder control if not treated in a timely manner. The presence of a disc herniation compromising the neural foramen and narrowing the spinal canal supports the urgency. The situation calls for immediate surgical intervention, which was successfully carried out. This is a high-stakes medical situation due to its potential consequences on the patient's quality of life and the need for urgent intervention.


Medical Specialty: Radiology
Sample Name: MRI Brain - Pilocytic Astrocytoma

CC:, Headache.,HX: ,The patient is an 8y/o RHM with a 2 year history of early morning headaches (3:00-6:00AM) intermittently relieved by vomiting only. He had been evaluated 2 years ago and an EEG was "normal" then, but no brain imaging was performed. His headaches progressively worsened, especially in the past two months prior to this presentation. For 2 weeks prior to his 1/25/93 evaluation at UIHC, he would awake screaming. His parent spoke with a local physician who thought this might be due to irritability secondary to pinworms and,Vermox was prescribed and arrangements were made for a neurologic evaluation. On the evening of 1/24/93 the patient awoke screaming and began to vomit. This was followed by a 10 min period of tonic-clonic type movements and postictal lethargy. He was taken to a local ER and a brain CT revealed an intracranial mass. He was given Decadron and Phenytoin and transferred to UIHC for further evaluation.,MEDS:, noted above.,PMH: ,1)Born at 37.5 weeks gestation by uncomplicated vaginal delivery to a G1P0 mother. Pregnancy complicated by vaginal bleeding at 7 months. Met developmental milestones without difficulty. 2) Frequent otitis media, now resolved. 3) Immunizations were "up to date.",FHX:, non-contributory.,SHX:, lives with biologic father and mother. No siblings. In 3rd grade (mainstream) and maintaining good marks in schools.,EXAM:, BP121/57mmHg HR103 RR16 36.9C,MS: Sleepy, but cooperative.,CN: EOM full and smooth. Advanced papilledema, OU. VFFTC. Pupils 4/4 decreasing to 2/2. Right lower facial weakness. Tongue midline upon protrusion. Corneal reflexes intact bilaterally.,Motor: 5/5 strength. Slightly increased muscle on right side.,Sensory. No deficit to PP/VIB noted.,Coord: normal FNF, HKS and RAM, bilaterally.,Station: Mild truncal ataxia. Tends to fall backward.,Reflexes: BUE 2+/2+, Patellar 3/3, Ankles 3+/3+ with 6 beats of nonsustained clonus bilaterally.,Gen exam: unremarkable.,COURSE:, The patient was continued on Dilantin 200mg qd and Decadron 5mg IV q6hrs. Brain MRI, 1/26/93, revealed a large mass lesion in the region of the left caudate nucleus and thalamus which was hyperintense on T2 weighted images. There were areas of cystic formation at its periphery. The mass appeared to enhance on post gadolinium images. there was associated white matter edema and compression of the left lateral ventricle, and midline shift to the right. There was no sign of uncal herniation. He underwent bilateral VP shunting on 1/26/93; and then, subtotal resection (left frontal craniotomy with excision of the left caudate and thalamus with creation of an opening in the septum pellucidum) on 1/28/93. He then received 5040cGy of radiation therapy in 28 fractions completed on 3/25/93. A 3/20/95 neuropsychological evaluation revealed low average intellect on the WISC-III. There were also signs of memory, attention, reading and spelling deficits; and mild right-sided motor incoordination and mood variability. He remained in mainstream classes at school, but his physical and cognitive performance began to deteriorate in 4/95. Neurosurgical evaluation in 4/95 noted increased right hemiplegia and right homonymous hemianopia. MRI revealed tumor progression and he was subsequently placed on Carboplatin/VP-16 (CG 9933 protocol chemotherapy, regimen A). He was last seen on 4/96 and was having difficulty in the 6th grade; he was also undergoing physical therapy for his right hemiplegia.
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DESCRIPTION: MRI Brain - Pilocytic Astrocytoma in thalamus and caudate.

radiology, mri brain, pilocytic astrocytoma, caudate, thalamus, headache, astrocytoma, hemiplegia, pilocytic, mri,

The situation involves a young child with a brain tumor, specifically pilocytic astrocytoma, in a critical location affecting neurological functions and quality of life. This condition is life-threatening and requires immediate and specialized medical intervention, including surgery, radiation, and chemotherapy. The child's symptoms, like severe headaches, seizures, and neurological deficits, indicate a serious condition. Although pilocytic astrocytoma tends to be less aggressive than other forms of brain cancer, the tumor's location makes it a high-stakes situation due to the risk of severe complications, potential incapacitation, and the impact on the child's development and quality of life.


Medical Specialty: Bariatrics
Sample Name: Gastric Bypass Discussion - 2

HISTORY: , The patient is scheduled for laparoscopic gastric bypass.  The patient has been earlier seen by Dr. X, her physician.  She has been referred to us from Family Practice.  In short, she is a 33-year-old lady with a BMI of 43, otherwise healthy with unsuccessful nonsurgical methods of weight loss. ,She was on laparoscopic gastric bypass for weight loss. ,She meets the National Institute of Health Criteria.  She is very well educated and motivated and has no major medical contraindications for the procedure.,PHYSICAL EXAMINATION:,  On physical examination today, she weighs 216 pounds with a BMI of 43.5, pulse is 96, temperature is 97.6, blood pressure is 122/80.  Lungs are clear.  Abdomen is soft, nontender.  There is stigmata for morbid obesity.  She has cesarean section scars in the lower abdomen with no herniation. ,DISCUSSION: , I had a long talk with the patient about laparoscopic gastric bypass, possible open including risks, benefits, alternatives, need for long-term followup, need to adhere to dietary and exercise guidelines.  I also explained to her complications including rare cases of death secondary to DVT, PE, leak , peritonitis, sepsis, shock, multisystem organ failure, need for re-operation including for leak or bleeding, gastrostomy or jejunostomy for feeding, rare case of respiratory failure requiring mechanical ventilation, etc., with myocardial infarction, pneumonia, atelectasis in the postoperative period were also discussed. ,Short-term complications of gastric bypass including gastrojejunal stricture requiring endoscopic dilatation, marginal ulcer secondary to smoking or anti-inflammatory drug intake which can progress on to perforation or bleeding, small bowel obstruction secondary to internal hernia or adhesions, signs and symptoms of which were discussed.  The patient would alert us for earlier intervention.  Symptomatic gallstone formation secondary to rapid weight loss were also discussed.  How to avoid it by taking ursodiol were also discussed.  Long-term complications of gastric bypass including hair loss, excess skin, multivitamin and mineral deficiencies, protein-calorie malnutrition, weight regain, weight plateauing, need for major lifestyle and exercise and habit changes, avoiding pregnancy in the first two years, etc., were all stressed.  The patient understands.  She wants to go to surgery. ,In preparation of surgery, she will undergo very low-calorie diet through Medifast to decrease the size of the liver to make laparoscopic approach more successful and also to optimize her cardiopulmonary and metabolic comorbidities.  She will also see a psychologist, nutritionist, and exercise physiologist for a multidisciplinary effort for short and long-term success for weight loss surgery.  I will see her two weeks before the plan of surgery for further discussion and any other questions at that point of time.
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DESCRIPTION: Patient scheduled for laparoscopic gastric bypass.

bariatrics, medifast, laparoscopic gastric bypass, short-term complications, long-term complications, gastric bypass, complications of gastric bypass, weight loss,

The situation involves a medical procedure, specifically a laparoscopic gastric bypass, which inherently carries substantial risks. These risks include serious complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), leaks, peritonitis, sepsis, and others, including the very rare possibility of death. The need for a multidisciplinary approach, including psychological and nutritional counseling, underscores the intricacy and seriousness of preparing the patient for surgery. While the patient is in generally good health aside from morbid obesity and is educated about the procedure, the stakes remain high due to the nature of the surgery and its potential complications.


Medical Specialty: Dentistry
Sample Name: Teeth Extraction

PREOPERATIVE DIAGNOSES,1.  Basal cell nevus syndrome.,2.  Cystic lesion, left posterior mandible.,3.  Corrected dentition.,4.  Impacted teeth 1 and 16.,5.  Maxillary transverse hyperplasia.,POSTOPERATIVE DIAGNOSES,1.  Basal cell nevus syndrome.,2.  Cystic lesion, left posterior mandible.,3.  Corrected dentition.,4.  Impacted teeth 1 and 16.,5.  Maxillary transverse hyperplasia.,PROCEDURE,1.  Removal of cystic lesion, left posterior mandible.,2.  Removal of teeth numbers 4, 13, 20, and 29.,3.  Removal of teeth numbers 1 and 16.,4.  Modified Le Fort I osteotomy.,INDICATIONS FOR THE PROCEDURE:, The patient has undergone previous surgical treatment and had a diagnosis of basal cell nevus syndrome.  Currently our plan is to remove the impacted third molar teeth, to remove a cystic lesion left posterior mandible, to remove 4 second bicuspid teeth as requested by her orthodontist, and to weaken and her maxilla to allow expansion by a modified Le Fort osteotomy.,PROCEDURE IN DETAIL:, The patient was brought into the operating room, placed on the operating table in supine position.  Following treatment under adequate general anesthesia via the orotracheal route, the patient was prepped and draped in a manner consistent with intraoral surgical procedures.  The oral cavity was suctioned, was drained of fluid and a throat pack was placed.  General anesthesia nursing service was notified and which was removed at the end of the procedure.  Lidocaine 1% with epinephrine concentration in 1:100,000 was injected into the labial vestibule of the maxilla bilaterally as well as the lateral areas associated with the extractions sites in lower jaw and the left posterior mandible for a total of 11 mL.  A Bovie electrocautery was utilized to make a vestibular incision, beginning in the second molar region of the maxilla superior to the mucogingival junction extending to the area of the cuspid teeth.  Subperiosteal dissection revealed lateral aspect of the maxilla immediately posterior to the second molar tooth where the third molar tooth was identified and was bony crypt.  Following use of Cerebromaxillary osteotome, elevated, and underwent complete removal of the dental follicle.  Secondly, tooth number 4 was removed.  Tooth number 13 was removed, and the opposite third molar tooth was removed through an identical incision on the opposite side.  Surgeon then utilized a #15 saw to make a horizontal osteotomy through the lateral aspect of the maxilla from the target plates, anteriorly to the area of the buttress region cross the anterior maxilla to a point adjacent to the piriform rim, 5 mm superior to the nasal floor, bilaterally Cerebromaxillary osteotome utilized to separate the maxilla from the target placed posteriorly and a 5 mm Tessier osteotome through a vertical incision anteriorly between roots of teeth numbers 8 and 9.  This resulted in the alternate mobilization of the two halves of the maxilla, or to allow expansion.  These wounds were all irrigated with copious amounts of normal saline and with antibiotic containing solution, closed with 3-0 chromic suture in running fashion for watertight closure.  Attention was directed to the mandible where the left posterior mandible was approached through a lateral vestibular incision overlying the external oblique ridge and brought anteriorly in an old scar.  The surgeons utilized cautery osteotome to identify a cystic lesion associated with the left posterior mandible, which was approximately 1 cm in width and 2.5 to 3 cm in vertical dimension immediately adjacent to the neurovascular bundle.  This wound was then irrigated with copious amounts of normal saline and concentrated solution of clindamycin.  Closed primarily with a 3-0 Vicryl suture in running fashion for a watertight closure.  Teeth number 20 and 29 where removed and 3-0 chromic suture placed.  This concluded the procedure.  All cottonoids and other sponges, throat pack were removed.  No complications were encountered.  The aforementioned cystic lesion was sent with specimen no drains were placed.  The blood loss from this procedure was approximately 100 mL.,The patient was returned over the care of the anesthesia where she was extubated in the operating room, taken from the operating room to the recovery room with stable vital signs and spontaneous respirations.
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DESCRIPTION: Removal of cystic lesion, removal of teeth, modified Le Fort I osteotomy.

dentistry, nevus syndrome, basal cell, mandible, teeth, hyperplasia, cystic lesion, osteotomy, le fort, le fort osteotomy, orotracheal route, bony crypt, watertight, removal of cystic lesion, le fort i osteotomy, aspect of the maxilla, modified le fort, molar tooth, posterior mandible, maxillary, molar, tooth,

The procedure described involves a complex dental and oral surgery with multiple components, including extraction of impacted and other teeth, removal of a cystic lesion in the mandible, and performing a modified Le Fort I osteotomy. This involves significant surgical intervention in the craniofacial region. The stakes include potential complications such as nerve or vascular injury due to the proximity of neurovascular bundles, infection, significant blood loss, or issues related to anesthesia. While no complications were noted, the nature of the surgery makes this a higher stakes procedure compared to routine dental work due to the complexity and potential risks.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Deviated Septum Repair - Followup

CHIEF COMPLAINT: , Septal irritation.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old African-American female status post repair of septal deviation but unfortunately, ultimately ended with a large septal perforation.  The patient has been using saline nasal wash 2-3 times daily, however, she states that she still has discomfort in her nose with a "stretching" like pressure.  She says her nose is frequently dry and she occasionally has nosebleeds due to the dry nature of her nose.  She has no other complaints at this time.,PHYSICAL EXAM:,GENERAL:  This is a pleasant African-American female resting in the examination room chair in no apparent distress.,ENT:  External auditory canals are clear.  Tympanic membrane shows no perforation, is intact.,NOSE:  The patient has a slightly deviated right septum.  Septum has a large perforation in the anterior 2/3rd of the septum.  This appears to be well healed.  There is no sign of crusting in the nose.,ORAL CAVITY:  No lesions or sores.  Tonsils show no exudate or erythema.,NECK:  No cervical lymphadenopathy.,VITAL SIGNS:  Temperature 98 degrees Fahrenheit, pulse 77, respirations 18, blood pressure 130/73.,ASSESSMENT AND PLAN:  ,The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation.  At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.  At this time, I counseled the patient on the risks and benefits of surgery.  She will consider surgery but at this time, would like to continue using the saline nasal wash as well as occasional Bactroban to the nose if there is occasional irritation or crusting, which she will apply with the edge of a Q-tip.  We will see her back in 3 weeks and if the patient does not feel relieved from the Bactroban as well as saline nasal spray wash, we will consider setting the patient for surgery at that time.
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DESCRIPTION: The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation.  At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.

soap / chart / progress notes, saline nasal wash, deviated septum, saline nasal, septal perforation, nose, septum, septal, perforation

The situation involves a follow-up consultation for a patient who has undergone a procedure to repair a deviated septum but resulted in a complication (septal perforation). While the patient experiences discomfort and occasional nosebleeds, these symptoms are not life-threatening. The patient's condition is being managed with conservative measures like saline nasal wash and Bactroban, and there is no immediate need for surgery. Thus, although the situation involves medical follow-up and potential surgical intervention, it does not involve urgent or critical medical decisions that would classify it as high-stakes.


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

Medical Specialty: Emergency Room Reports
Sample Name: Abdominal Pain - Consult

CHIEF COMPLAINT:,  Abdominal pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 71-year-old female patient of Dr. X. The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.  She was seen 3 to 4 days ago at ABC ER and underwent evaluation and discharged and had a CT scan at that time and she was told it was "normal."  She was given oral antibiotics of Cipro and Flagyl.  She has had no nausea and vomiting, but has had persistent associated anorexia.  She is passing flatus, but had some obstipation symptoms with the last bowel movement two days ago.  She denies any bright red blood per rectum and no history of recent melena.  Her last colonoscopy was approximately 5 years ago with Dr. Y. She has had no definite fevers or chills and no history of jaundice.  The patient denies any significant recent weight loss.,PAST MEDICAL HISTORY:  ,Significant for history of atrial fibrillation, under good control and now in normal sinus rhythm and on metoprolol and also on Premarin hormone replacement.,PAST SURGICAL HISTORY: , Significant for cholecystectomy, appendectomy, and hysterectomy.  She has a long history of known grade 4 bladder prolapse and she has been seen in the past by Dr. Chip Winkel, I believe that he has not been re-consulted.,ALLERGIES: , SHE IS ALLERGIC OR SENSITIVE TO MACRODANTIN.,SOCIAL HISTORY: , She does not drink or smoke.,REVIEW OF SYSTEMS: , Otherwise negative for any recent febrile illnesses, chest pains or shortness of breath.,PHYSICAL EXAMINATION:,GENERAL:  The patient is an elderly thin white female, very pleasant, in no acute distress.,VITAL SIGNS:  Her temperature is 98.8 and vital signs are all stable, within normal limits.,HEENT:  Head is grossly atraumatic and normocephalic.  Sclerae are anicteric.  The conjunctivae are non-injected.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Generally nondistended and soft.  She is focally tender in the left lower quadrant to deep palpation with a palpable fullness or mass and focally tender, but no rebound tenderness.  There is no CVA or flank tenderness, although some very minimal left flank tenderness.,PELVIC:  Currently deferred, but has history of grade 4 urinary bladder prolapse.,EXTREMITIES:  Grossly and neurovascularly intact.,LABORATORY VALUES:  ,White blood cell count is 5.3, hemoglobin 12.8, and platelet count normal.  Alkaline phosphatase elevated at 184.  Liver function tests otherwise normal.  Electrolytes normal.  Glucose 134, BUN 4, and creatinine 0.7.,DIAGNOSTIC STUDIES:,  EKG shows normal sinus rhythm.,IMPRESSION AND PLAN: , A 71-year-old female with greater than one-week history of abdominal pain now more localized to the left lower quadrant.  Currently is a nonacute abdomen.  The working diagnosis would be sigmoid diverticulitis.  She does have a history in the distant past of sigmoid diverticulitis.  I would recommend a repeat stat CT scan of the abdomen and pelvis and keep the patient nothing by mouth.  The patient was seen 5 years ago by Dr. Y in Colorectal Surgery.  We will consult her also for evaluation.  The patient will need repeat colonoscopy in the near future and be kept nothing by mouth now empirically.  The case was discussed with the patient's primary care physician, Dr. X. Again, currently there is no indication for acute surgical intervention on today's date, although the patient will need close observation and further diagnostic workup.
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DESCRIPTION: The patient presented to the emergency room last evening with approximately 7- to 8-day history of abdominal pain which has been persistent.

The situation involves an elderly patient with a complex medical history experiencing persistent abdominal pain, a common but potentially serious symptom that could indicate conditions like diverticulitis, which can lead to complications if not properly managed. Although the patient's vital signs are stable and there is no indication for immediate surgery, the need for diagnostic imaging, consultation with specialists, and the potential for worsening condition make this a moderately high-stakes situation. This is especially true given the patient's age and medical history. Therefore, it requires careful monitoring and could escalate if her condition changes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchiolitis - 2-month-old

CHIEF COMPLAINT: , Increased work of breathing.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-month-old female with a 9-day history of illness.  Per mom's report, the illness started 9 days ago with a dry cough.  The patient was eating normal up until approximately three days ago.  Mom was using a vaporizer at night, which she feels to have helped.  The patient's cough gradually worsened and three days ago, the patient had a significant increasing cough.  At that time, the patient also had significant increasing congestion.  Two days ago the patient was taken to the primary care physician's office and the patient was given Xopenex 2 puffs every 4 to 6 hours for home regimen, but this per mom's report, did not help the patient's symptoms.  On Wednesday evening, the patient's congestion and work of breathing increased and the patient was gagging after feedings.  The patient was brought to Children's Hospital Emergency Room at which time the patient was evaluated.  A chest x-ray was obtained and was noted to be normal.  The patient's saturations were noted to be normal and the patient was discharged home.  Last night, the patient was having multiple episodes of emesis after feedings with coughing and today was noted to have decreasing activity.  The patient had a 101 temperature on Wednesday evening, but has had no true fevers.  The patient has had a mild decrease in urine output today and secondary to the persistent increased work of breathing, coughing, and posttussive emesis, the patient was brought to Children's Hospital for reevaluation.,REVIEW OF SYSTEMS: , The remainder of the review of system is otherwise negative, all systems being reviewed, outside of pertinent positives as stated above.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS:  ,As above.,IMMUNIZATIONS:,  None.,PAST MEDICAL HISTORY:  ,No hospitalizations.  No surgeries.,BIRTH HISTORY: , The patient was born to a G8, P2, A6 mom via normal spontaneous vaginal delivery.  Birth weight 6 pounds 12 ounces.  Mom stated she had a uterine infection during her pregnancy and at the time of delivery, but the patient was only in the hospital for 24 hours with mom after delivery.  The patient was full term and mom was noted to have gestational diabetes controlled with diet during her pregnancy.,FAMILY HISTORY: , Brother, mother, and father all have asthma.  Mom was noted to have gestational diabetes.,SOCIAL HISTORY: , The patient lives with mother, father, and a brother.  There is one bird.  There are smokers in the household.  There are sick contacts.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 97.7 and pulse is 181, but the patient is fussy.  Respiratory rate ranged between 36 and 44.  The patient is saturating 100% on one-half liter and 89% on room air.,GENERAL APPEARANCE:  Nontoxic child, but with increased work of breathing.  No respiratory distress.,HEENT:  Head is normocephalic and atraumatic.  Anterior fontanelle flat.  Pupils are equal, round, and reactive to light bilaterally.  Tympanic membranes are clear bilaterally.  Nares are congested.  Mucous membranes are moist without erythema.,NECK:  Supple.  No lymphadenopathy.,CHEST:  Exhibits symmetric expansion and retractions.,LUNGS:  The patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi.,CARDIOVASCULAR:  Heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder.,ABDOMEN:  Soft, nondistended, and nondistended.  Good bowel sounds noted in all 4 quadrants.,GU:  Normal female.  No discharge or erythema.,BACK:  Normal with a normal curvature.,EXTREMITIES:  A 2+ pulses in the bilateral upper lower extremities.  No evidence of clubbing, cyanosis, or edema.  Capillary refill less than 3 seconds.,LABORATORY DATA: , Labs in the emergency room include a CBC, which showed a white blood cell count of 20.8 with a hemoglobin of 10.7, hematocrit of 31.3 with platelet count of 715,000 with 40% neutrophils, 2 bands, and 70% monocytes.  A urinalysis obtained in the emergency room was noted to be negative.  CRP was noted to be 2.0.  The chest x-ray, reviewed by myself in the emergency room, showed no significant change from previous x-ray, but the patient does has some bronchial wall thickening.,ASSESSMENT AND PLAN: , This is a 2-month-old female who presents to Children's Hospital with examination consistent with bronchiolitis.  At this time, the patient will be placed on the bronchiolitis pathway providing this patient with aggressive suctioning and supplemental oxygen as needed.  Currently, at this time, I feel no respiratory treatments are indicated in this patient.  I hear no evidence of wheezing or reactive airway disease.  We will continue to monitor and reassess this patient closely for this as there is a strong family history of reactive airway disease; however, at this time, the patient will be monitored without any medications and the remainder of the clinical course will be determined by her presentation during the course of this illness.
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DESCRIPTION: 2-month-old female - increased work of breathing.

The situation involves a 2-month-old infant with respiratory distress due to bronchiolitis. Although the condition is common and the child is not currently in respiratory distress (with normal oxygen saturation on supplemental oxygen), the stakes are still significant due to the patient's young age and potential for rapid deterioration. The medical team is closely monitoring the patient, indicating awareness of these risks. Additionally, the involvement of family history of asthma and the presence of smokers in the household could complicate the child's recovery. Thus, while not life-threatening at the moment, the situation could escalate quickly without proper care, making it moderately high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Dental Pain

CHIEF COMPLAINT:,  Dental pain.,HISTORY OF PRESENT ILLNESS:,  This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.  Presents now for evaluation.,PAST MEDICAL HISTORY: , Remarkable for chronic back pain, neck pain from a previous cervical fusion, and degenerative disc disease.  She has chronic pain in general and is followed by Dr. X.,REVIEW OF SYSTEMS: , Otherwise, unremarkable.  Has not noted any fever or chills.  However she, as mentioned, does note the dental discomfort with increasing swelling and pain.  Otherwise, unremarkable except as noted.,CURRENT MEDICATIONS: , Please see list.,ALLERGIES: , IODINE, FISH OIL, FLEXERIL, BETADINE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile, has stable and normal vital signs.  The patient is sitting quietly on the gurney and does not look to be in significant distress, but she is complaining of dental pain.  HEENT:  Unremarkable.  I do not see any obvious facial swelling, but she is definitely tender all in the left mandible region.  There is no neck adenopathy.  Oral mucosa is moist and well hydrated.  Dentition looks to be in reasonable condition.  However, she definitely is tender to percussion on the left lower first premolar.  I do not see any huge cavity or anything like that.  No real significant gingival swelling and there is no drainage noted.  None of the teeth are tender to percussion.,PROCEDURE:,  Dental nerve block.  Using 0.5% Marcaine with epinephrine, I performed a left inferior alveolar nerve block along with an apical nerve block, which achieves good anesthesia.  I have then written a prescription for penicillin and Vicodin for pain.,IMPRESSION: , ACUTE DENTAL ABSCESS.,ASSESSMENT AND PLAN:  ,The patient needs to follow up with the dentist for definitive treatment and care.  She is treated symptomatically at this time for the pain with a dental block as well as empirically with antibiotics.  However, outpatient followup should be adequate.  She is discharged in stable condition.
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DESCRIPTION: This is a 27-year-old female who presents with a couple of days history of some dental pain.  She has had increasing swelling and pain to the left lower mandible area today.

consult - history and phy., dental pain, dental abscess, dental block, nerve block, mandible, swelling, dental,

The situation involves a dental abscess, which though potentially painful and uncomfortable, is typically not life-threatening if managed appropriately in the short term. The patient received a dental nerve block for pain relief and was prescribed antibiotics. The recommendation for outpatient follow-up with a dentist suggests that while it is important to address the underlying issue, the condition is not immediately critical. The patient is stable, with no signs of systemic infection (such as fever or chills) and normal vital signs, suggesting it is not an urgent or emergency situation.


Medical Specialty: Surgery
Sample Name: Open Cholecystectomy

PREOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS:,  Acute hemorrhagic cholecystitis.,PROCEDURE PERFORMED: , Open cholecystectomy.,ANESTHESIA: , Epidural with local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN:  ,Gallbladder.,BRIEF HISTORY:  ,The patient is a 73-year-old female who presented to ABCD General Hospital on 07/23/2003 secondary to a fall at home from which the patient suffered a right shoulder as well as hip fracture.  The patient subsequently went to the operating room on 07/25/2003 for a right hip hemiarthroplasty per the Orthopedics Department.  Subsequently, the patient was doing well postoperatively, however, the patient does have severe O2 and steroid-dependent COPD and at an extreme risk for any procedure.  The patient began developing abdominal pain over the course of the next several days and a consultation was requested on 08/07/2003 for surgical evaluation for upper abdominal pain.  During the evaluation, the patient was found to have an acute acalculous cholecystitis in which nonoperative management was opted for and on 08/08/03, the patient underwent a percutaneous cholecystostomy tube placement to drain the gallbladder.  The patient did well postdrainage.  The patient's laboratory values and biliary values returned to normal and the patient was planned for a removal of the tube with 48 hours of the tubing clamp.  However, once the tube was removed, the patient re-obstructed with recurrent symptoms and a second tube was needed to be placed; this was done on 08/16/2003.  A HIDA scan had been performed, which showed no cystic duct obstruction.  A tube cholecystogram was performed, which showed no cystic or common duct obstruction.  There was abnormal appearance of the gallbladder, however, the pathway was patent.  Thus after failure of two nonoperative management therapies, extensive discussions were made with the family and the patient's only option was to undergo a cholecystectomy.  Initial thoughts were to do a laparoscopic cholecystectomy, however, with the patient's severe COPD and risk for ventilator management, the options were an epidural and an open cholecystectomy under local was made and to be performed.,INTRAOPERATIVE FINDINGS:  ,The patient's gallbladder had some patchy and necrosis areas.  There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.  The patient also had no plane between the gallbladder and the liver bed.,OPERATIVE PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and discussed with the patient's family.  The patient was brought to the operating room after an epidural was performed per anesthesia.  Local anesthesia was given with 1% lidocaine.  A paramedian incision was made approximately 5 cm in length with a #15 blade scalpel.  Next, hemostasis was obtained using electro Bovie cautery.  Dissection was carried down transrectus in the midline to the posterior rectus fascia, which was grasped with hemostats and entered with a #10 blade scalpel.  Next, Metzenbaum scissors were used to extend the incision and the abdomen was entered .  The gallbladder was immediately visualized and brought up into view, grasped with two ring clamps elevating the biliary tree into view.  Dissection with a ______ was made to identify the cystic artery and cystic duct, which were both easily identified.  The cystic artery was clipped, two distal and one proximal to the gallbladder cutting between with Metzenbaum scissors.  The cystic duct was identified.  A silk tie #3-0 silk was placed one distal and one proximal with #3-0 silk and then cutting in between with a Metzenbaum scissors.  The gallbladder was then removed from the liver bed using electro Bovie cautery.  A plane was created.  The hemostasis was obtained using the electro Bovie cautery as well as some Surgicel.  The gallbladder was then removed as specimen, sent to pathology for frozen sections for diagnosis, of which the hemorrhagic cholecystitis was diagnosed on frozen sections.  Permanent sections are still pending.  The remainder of the fossa was hemostatic with the Surgicel and attention was next made to closing the abdomen.  The peritoneum as well as posterior rectus fascia was approximated with a running #0 Vicryl suture and then the anterior rectus fascia was closed in interrupted figure-of-eight #0 Vicryl sutures.  Skin staples were used on the skin and sterile dressings were applied and the patient was transferred to recovery in stable condition.
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DESCRIPTION: Acute acalculous cholecystitis.  Open cholecystectomy.  The patient's gallbladder had some patchy and necrosis areas.  There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder.

surgery, open cholecystectomy, hemorrhagic, gallbladder, serosal, liver bed, acute acalculous, acalculous cholecystitis, cystic duct, bovie cautery, rectus fascia, metzenbaum scissors, fascia, cholecystitis, cholecystectomy, cystic,

The situation involves a surgical procedure, specifically an open cholecystectomy, on a 73-year-old patient with severe comorbidities including steroid-dependent COPD. The patient had complications with nonoperative management of acute acalculous cholecystitis, necessitating surgical intervention. Surgery is inherently high-stakes due to the risks involved, and these are amplified considering the patient's age, underlying health conditions, and the history of attempted nonoperative management. Although the surgery was completed without complications, the high-stakes nature of the decision-making process and the procedure itself is evident.