Medical Specialty: General Medicine
Sample Name: Snoring

CHRONIC SNORING,Chronic snoring in children can be associated with obstructive sleep apnea or upper airway resistant syndrome.  Both conditions may lead to sleep fragmentation and/or intermittent oxygen desaturation, both of which have significant health implications including poor sleep quality and stress on the cardiovascular system.  Symptoms like daytime somnolence, fatigue, hyperactivity, behavior difficulty (i.e., ADHD) and decreased school performance have been reported with these conditions.  In addition, the most severe cases may be associated with right ventricular hypertrophy, pulmonary and/or systemic hypertension and even cor pulmonale.,In this patient, the risks for a sleep-disordered breathing include obesity and the tonsillar hypertrophy.  It is therefore indicated and medically necessary to perform a polysomnogram for further evaluation.  A two week sleep diary will be given to the parents to fill out daily before the polysomnogram is performed.
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DESCRIPTION: Chronic snoring in children

Chronic snoring in children

general medicine, snoring, chronic snoring, behavior difficulty, fatigue, hyperactivity, obstructive sleep apnea, oxygen, oxygen desaturation, polysomnogram, poor sleep quality, right ventricular hypertrophy, school performance, sleep fragmentation, somnolence, systemic hypertension, upper airway, upper airway resistant syndrome, snoring chronic, hypertrophy, sleepNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The scenario describes chronic snoring in children, which could potentially be associated with obstructive sleep apnea or other serious conditions like upper airway resistant syndrome. While these conditions do have significant health implications, including effects on cardiovascular health and cognitive function, in the majority of cases, they are treatable, and the situation is not immediately life-threatening. They require medical evaluation and proper management, such as a polysomnogram (sleep study) and potential surgical or medical interventions. The stakes are higher than routine conditions but lower than acute emergencies.


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

Medical Specialty: Surgery
Sample Name: Dental Restorations & Extractions

PREOPERATIVE DIAGNOSIS:,  Dental caries.,POSTOPERATIVE DIAGNOSIS: , Dental caries.,PROCEDURE: , Dental restorations and extractions.,CLINICAL HISTORY: , This 23-year-old male is a client of the ABC Center because of his disability, the nature of which is unclear to me at this time; however, he reportedly has several issues that qualify him as disabled.  He has had multiple severe carious lesions that warrant multiple extractions at this time.  It is also unclear to me as to how his prior or existing restorations were accomplished.  In any case, he has been cleared for the procedure today.  He has his history and physical in the chart.,PROCEDURE: , The patient was brought to the operating room at 11 o'clock and placed in the supine position.  Dr. X administered the general anesthetic, after which a throat pack was placed.  Available full mouth x-rays were reviewed.  These x-rays were taken at another location.  Teeth 2, 4, 10, 12, 13, 15, 18, 20, 27, and 31 were all in varying degrees of severe decay from complete destruction of the crowns to pulp exposures with periapical radiolucencies.  All of these aforementioned teeth were extracted using combinations of forceps and elevators.  Hemostasis in all of these sites was accomplished with direct pressure using gauze packs.  ,Tooth 5 had caries in the distal surface extending to the occlusal as well as another carious lesion in the buccal.  These carious lesions and his tooth were excavated, and the tooth was restored with amalgam involving these surfaces.  ,Tooth 6 had caries on the facial surface, which was excavated, and the tooth was restored with composite.  ,Tooth 7 had caries involving the distal surface.  ,Tooth 8 likewise had caries involving the distal surface, and both of these distal lesions extended into incisal area.  These carious lesions were excavated, and both of these teeth were restored with composite.  ,Tooth 9 had caries in a mesial surface and a buccal surface, which was excavated, and this tooth was restored with composite.  ,Tooth 28 caries in the mesial surface extending to the occlusal, which was excavated, and the tooth was restored with amalgam, and tooth 30 had carries in the buccal surface, which was excavated, and the tooth was restored with amalgam.  ,A prophylaxis was done, primarily using a rotating rubber cup and some minor scaling, and the mouth was irrigated and suctioned thoroughly.  The throat pack was removed, and the patient was awakened and brought to the recovery room in good condition at 1330 hours.  There was negligible blood loss.
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DESCRIPTION: Dental restorations and extractions.  Dental caries.  He has had multiple severe carious lesions that warrant multiple extractions at this time.

surgery, extractions, multiple extractions, mesial surface, buccal surface, dental restorations, dental caries, distal surface, composite tooth, carious lesions, tooth, dental, caries

The procedure described involves dental restorations and extractions under general anesthesia. While dental surgery can carry risks, this type of routine dental procedure is generally considered low to medium stakes, especially when conducted in a controlled medical environment with minimal complications. The patient was cleared for the procedure, experienced negligible blood loss, and was brought to recovery in good condition. Although general anesthesia adds some risk, the stakes are not extremely high in comparison to more invasive surgical procedures or those with significant potential for complications.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Polycythemia Rubra Vera

CHIEF COMPLAINT: , Polycythemia rubra vera.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old female with a history of polycythemia vera.  She comes in to clinic today for followup.  She has not required phlebotomies for several months.  The patient comes to clinic unaccompanied.,CURRENT MEDICATIONS: , Levothyroxine 200 mcg q.d., Nexium 40 mg q.d., Celebrex 200 mg q.d., vitamin D3 2000 IU q.d., aspirin 81 mg q.d., selenium 200 mg q.d., Aricept 10 mg q.d., Skelaxin 800 mg q.d., ropinirole 1 mg q.d., vitamin E 1000 IU q.d., vitamin C 500 mg q.d., flaxseed oil 100 mg daily, fish oil 100 units q.d., Vicodin q.h.s., and stool softener q.d.,ALLERGIES:  ,Penicillin.,REVIEW OF SYSTEMS:  ,The patient's chief complaint is her weight.  She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key.  She has questions as to whether or not there would be any contra indications to her going on the diet.  Otherwise, she feels great.  She had family reunion in Iowa once in four days out there.  She continues to volunteer Hospital and is walking and enjoying her summer.  She denies any fevers, chills, or night sweats.  She has some mild constipation problem but has had under control.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:
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DESCRIPTION: Polycythemia rubra vera.  The patient is an 83-year-old female with a history of polycythemia vera.  She comes in to clinic today for followup.  She has not required phlebotomies for several months.

soap / chart / progress notes, polycythemia rubra vera, phlebotomy, hematocrit, polycythemia,

The patient is 83 years old with a history of polycythemia vera, but currently reports feeling well, not requiring recent phlebotomies, and has a stable routine. The chief concern mentioned is related to weight and dietary contraindications, not an acute or significantly high-risk health issue. While polycythemia vera is a chronic condition that requires monitoring, the current situation does not present any urgent or severe complications. Thus, it is not a high-stakes scenario.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Mitral Valve Repair & Annuloplasty

OPERATIONS,1.  Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.,2.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.,3.  Posterior leaflet abscess resection.,ANESTHESIA:  ,General endotracheal anesthesia,TIMES:  ,Aortic cross-clamp time was ** minutes.  Cardiopulmonary bypass time total was ** minutes.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, the patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the patient's chest and legs were prepped and draped in standard surgical fashion.  A #10-blade scalpel was used to make a midline median sternotomy incision.  Dissection was carried down to the level of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw, and full-dose heparinization was given.  Next, the chest retractor was positioned.  The pericardium was opened with Bovie electrocautery and pericardial stay sutures were positioned.  We then prepared to place the patient on cardiopulmonary bypass.  A 2-0 Ethibond double pursestring was placed in the ascending aorta.  Through this was passed our aortic cannula and connected to the arterial side of the cardiopulmonary bypass machine.  Next, double cannulation with venous cannulas was instituted.  A 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our SEC cannula.  This was connected to the venous portion of the cardiopulmonary bypass machine in a Y-shaped circuit.  Next, a 3-0 Prolene pursestring was placed in the lower border of the right atrium.  Through this was passed our inferior vena cava cannula.  This was likewise connected to the Y connection of our venous cannula portion.  We then used a 4-0 U-stitch in the right atrium for our retrograde cardioplegia catheter, which was inserted.  Cardiopulmonary bypass was instituted.  Metzenbaum scissors were used to dissect out the SVC and IVC, which were subsequently encircled with umbilical tape.  Sondergaard's groove was taken down.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  This was connected appropriately as was the retrograde cardioplegia catheter.  Next, the aorta was cross-clamped, and antegrade and retrograde cardioplegia was infused so as to arrest the heart in diastole.  Next a #15-blade scalpel was used to open the left atrium.  The left atrium was decompressed with pump sucker.  Next, our self-retaining retractor was positioned so as to bring the mitral valve up into view.  Of note was the fact that the mitral valve P2 segment of the posterior leaflet had an abscess associated with it.  The borders of the P2 segment abscess were defined by using a right angle to define the chordae which were encircled with a 4-0 silk.  After doing so, the P2 segment of the posterior leaflet was excised with a #11-blade scalpel.  Given the laxity of the posterior leaflet, it was decided to reconstruct it with a 2-0 Ethibond pledgeted suture.  This was done so as to reconstruct the posterior annular portion.  Prior to doing so, care was taken to remove any debris and abscess-type material.  The pledgeted stitch was lowered into place and tied.  Next, the more anterior portion of the P2 segment was reconstructed by running a 4-0 Prolene stitch so as to reconstruct it.  This was done without difficulty.  The apposition of the anterior and posterior leaflet was confirmed by infusing solution into the left ventricle.  There was noted to be a small amount of central regurgitation.  It was felt that this would be corrected with our annuloplasty portion of the procedure.  Next, 2-0 non-pledgeted Ethibond sutures were placed in the posterior portion of the annulus from trigone to trigone in interrupted fashion.  Care was taken to go from trigone to trigone.  Prior to placing these sutures, the annulus was sized and noted to be a *** size for the Cosgrove-Galloway suture band ring from Medtronic.  After, as mentioned, we placed our interrupted sutures in the annulus, and they were passed through the CG suture band.  The suture band was lowered into position and tied in place.  We then tested our repair and noted that there was very mild regurgitation.  We subsequently removed our self-retaining retractor.  We closed our left atriotomy using 4-0 Prolene in a running fashion.  This was done without difficulty.  We de-aired the heart.  We then gave another round of antegrade and retrograde cardioplegia in warm fashion.  The aortic cross-clamp was removed, and the heart gradually resumed electromechanical activity.  We then removed our retrograde cardioplegia catheter from the coronary sinus and buttressed this site with a 5-0 Prolene.  We placed 2 ventricular and 2 atrial pacing leads which were brought out through the skin.  The patient was gradually weaned off cardiopulmonary bypass and our venous cannulas were removed.  We then gave full-dose protamine; and after noting that there was no evidence of a protamine reaction, we removed our aortic cannula.  This site was buttressed with a 4-0 Prolene on an SH needle.  The patient tolerated the procedure well.  We placed a mediastinal #32-French chest tube as well as a right chest Blake drain.  The mediastinum was inspected for any signs of bleeding.  There were none.  We closed the sternum with #7 sternal wires in interrupted figure-of-eight fashion.  The fascia was closed with a #1 Vicryl followed by a 2-0 Vicryl, followed by 3-0 Vicryl in a running subcuticular fashion.  The instrument and sponge count was correct at the end of the case.  The patient tolerated the procedure well and was transferred to the intensive care unit in good condition.
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DESCRIPTION: Mitral valve repair using a quadrangular resection of the P2 segment of the posterior leaflet.  Mitral valve posterior annuloplasty using a Cosgrove Galloway Medtronic fuser band.  Posterior leaflet abscess resection.

cardiovascular / pulmonary, mitral valve repair, mitral valve, abscess resection, leaflet abscess, cosgrove galloway medtronic, bovie electrocautery, cannulation, bypass, annuloplasty, cardioplegia, mitral,

The described procedure is a complex cardiac surgery involving mitral valve repair, annuloplasty, and abscess resection, which inherently carries significant risks. The need for cardiopulmonary bypass and general anesthesia adds to the complexity and potential complications, making this a high-stakes situation because it can directly affect the patient's life and health outcomes.


Medical Specialty: Letters
Sample Name: Gastroenterology - Letter

Sample Address,Re:  Mrs. Sample Patient,Dear Sample Doctor:,I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today.  Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermittent rectal bleeding.  The patient denies any weight loss, does have a good appetite, no nausea and no vomiting.,PAST MEDICAL HISTORY:,  Significant for hypertension and diabetes.,PAST SURGICAL HISTORY:,  The patient denies any past surgical history.,MEDICATIONS:,  The patient takes Cardizem CD 240-mg.  The patient also takes eye drops.,ALLERGIES:,  The patient denies any allergies.,SOCIAL HISTORY:,  The patient smokes about a pack a day for more than 25 years.  The patient drinks alcohol socially.,FAMILY HISTORY:,  Significant for hypertension and strokes.,REVIEW OF SYSTEMS:,  The patient does have a good appetite and no weight loss.  She does have intermittent rectal bleeding associated with irritation in the rectal area.  The patient denies any nausea, any vomiting, any night sweats, any fevers or any chills.,The patient denies any shortness of breath, any chest pain, any irregular heartbeat or chronic cough.,The patient is chronically constipated.,PHYSICAL EXAMINATION:,  This is a 48 year-old lady who is awake, alert and oriented x 3.  She does not seem to be in any acute distress.  Her vital signs are blood pressure is 130/70 with a heart rate of 75 and respirations of 16.  HEENT is normocephalic, atraumatic.  Sclerae are non-icteric.  Her neck is supple, no bruits, no lymph nodes.  Lungs are clear to auscultation bilaterally, no crackles, no rales and no wheezes.  The cardiovascular system has a regular rate and rhythm, no murmurs.  The abdomen is soft and non-tender.  Bowel sounds are positive and no organomegaly.  Extremities have no edema.,IMPRESSION:,  This is a 48-year-old female presenting with painless rectal bleeding not associated with any weight loss.  The patient is chronically constipated.,1.  Rule out colon cancer.,2.  Rule out colon polyps. ,3.  Rule out hemorrhoids, which is the most likely diagnosis.,RECOMMENDATIONS:,  Because of the patient's age, the patient will need to have a complete colonoscopy exam.,The patient will also need to have a CBC check and monitor.,The patient will be scheduled for the colonoscopy at Sample Hospital and the full report will be forwarded to your office.,Thank you very much for allowing me to participate in the care of your patient.,Sincerely yours,,Sample Doctor, MD
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DESCRIPTION: Female with intermittent rectal bleeding, not associated with any weight loss.  The patient is chronically constipated.

The situation involves a medical assessment for a patient with intermittent rectal bleeding and a family history of hypertension and strokes. The potential causes include colon cancer, polyps, and hemorrhoids. Hemorrhoids are likely given the symptoms, but colon cancer is a serious condition that must be ruled out. This medical scenario is significant because it involves ruling out a potentially life-threatening condition, which elevates the stakes.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 8

PROCEDURES PERFORMED:,  Colonoscopy.,INDICATIONS:,  Renewed symptoms likely consistent with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives.  Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications.  Vital signs were monitored by blood pressure, heart rate, and oxygen saturation.  Supplemental O2 given.  Specifics discussed.  Preprocedure physical exam performed.  Stable vital signs.  Lungs clear.  Cardiac exam showed regular rhythm.  Abdomen soft.  Her past history, her past workup, her past visitation with me for Inflammatory Bowel Disease, well responsive to sulfasalazine reviewed.  She currently has a flare and is not responding, therefore, likely may require steroid taper.  At the same token, her symptoms are mild.  She has rectal bleeding, essentially only some rusty stools.  There is not significant diarrhea, just some lower stools.  No significant pain.  Therefore, it is possible that we are just dealing with a hemorrhoidal bleed, therefore, colonoscopy now needed.  Past history reviewed.  Specifics of workup, need for followup, and similar discussed.  All questions answered.,A normal digital rectal examination was performed.  The PCF-160 AL was inserted into the anus and advanced to the cecum without difficulty, as identified by the ileocecal valve, cecal stump, and appendical orifice.  All mucosal aspects thoroughly inspected, including a retroflexed examination.  Withdrawal time was greater than six minutes.  Unfortunately, the terminal ileum could not be intubated despite multiple attempts.,Findings were those of a normal cecum, right colon, transverse colon, descending colon.  A small cecal polyp was noted, this was biopsy-removed, placed in bottle #1.  Random biopsies from the cecum obtained, bottle #2; random biopsies from the transverse colon obtained, as well as descending colon obtained, bottle #3.  There was an area of inflammation in the proximal sigmoid colon, which was biopsied, placed in bottle #4.  There was an area of relative sparing, with normal sigmoid lining, placed in bottle #5, randomly biopsied, and then inflammation again in the distal sigmoid colon and rectum biopsied, bottle #6, suggesting that we may be dealing with Crohn disease, given the relative sparing of the sigmoid colon and junk lesion.  Retroflexed showed hemorrhoidal disease.  Scope was then withdrawn, patient left in good condition.  ,IMPRESSION:,  Active flare of Inflammatory Bowel Disease, question of Crohn disease.,PLAN: , I will have the patient follow up with me, will follow up on histology, follow up on the polyps.  She will be put on a steroid taper and make an appointment and hopefully steroids alone will do the job.  If not, she may be started on immune suppressive medication, such as azathioprine, or similar.  All of this has been reviewed with the patient.  All questions answered.
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DESCRIPTION: Patient with active flare of Inflammatory Bowel Disease, not responsive to conventional therapy including sulfasalazine, cortisone, local therapy.

gastroenterology, sulfasalazine cortisone local therapy, inflammatory bowel disease, cortisone local, local therapy, crohn disease, sigmoid colon, bowel disease, colonoscopy, inflammatory, rectal, sulfasalazine, cecum, sigmoid, bowel, disease

The colonoscopy procedure itself involves moderate risks such as bleeding, infection, or bowel perforation. The situation entails diagnosing and managing an active flare of Inflammatory Bowel Disease, potentially Crohn's disease, which has not responded to conventional therapy. However, the patient's symptoms are currently mild, and the procedure was concluded with the patient in good condition. The procedure is crucial for correct diagnosis and effective treatment planning, especially if the disease progresses, which could significantly impact the patient's health. While it's important, the immediate risk isn't extreme as the patient is stable and has mild symptoms.


Medical Specialty: Surgery
Sample Name: Total Hip Arthroplasty

PREOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Left hip degenerative arthritis.,PROCEDURE PERFORMED:  ,Total hip arthroplasty on the left.,ANESTHESIA:  ,General.,BLOOD LOSS: , 800 cc.,The patient was positioned with the left hip exposed on the beanbag.,IMPLANT SPECIFICATION: , A 54 mm Trilogy cup with cluster holes 3 x 50 mm diameter with a appropriate liner, a 28 mm cobalt-chrome head with a zero neck length head, and a 12 mm porous proximal collared femoral component.,GROSS INTRAOPERATIVE FINDINGS:  ,Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes.  The patient also had a rent in the attachment of the hip abductors and a partial rent in the vastus lateralis.  This was revealed once we removed the trochanteric bursa.,HISTORY:  ,This is a 56-year-old obese female with a history of bilateral degenerative hip arthritis.  She underwent a right total hip arthroplasty by Dr. X in the year of 2000, and over the past three years, the symptoms in her left hip had increased tremendously especially in the past few months.,Because of the increased amount of pain as well as severe effect on her activities of daily living and uncontrollable pain with narcotic medication, the patient has elected to undergo the above-named procedure.  All risks as well complications were discussed with the patient including but not limited to infection, scar, dislocation, need for further surgery, risk of anesthesia, deep vein thrombosis, and implant failure.  The patient understood all these risks and was willing to continue further on with the procedure.,PROCEDURE: , The patient was wheeled back to the Operating Room #2 at ABCD General Hospital on 08/27/03.  The general anesthetic was first performed by the Department of Anesthesia.  The patient was then positioned with the left hip exposed on the beanbag in the lateral position.  Kidney rests were also used because of the patient's size.  An axillary roll was also inserted for comfort in addition to a Foley catheter, which was inserted by the OR nurse.  All her bony prominences were well padded.  At this time, the left hip and left lower extremity was then prepped and draped in the usual sterile fashion for this procedure.  At this time, an anterolateral approach was then performed, first incising through the skin in approximately 5 to 6 inches of subcutaneous fat.  The tensor fascia lata was then identified.  A self-retainer was then inserted to expose the operative field.  Bovie cautery was used for hemostasis.  At this time, a fresh blade was then used to incise the tensor fascia lata over the posterior one-third of the greater trochanter.  At this time, a blunt dissection was taken proximally.  The tensor fascia lata was occluded with a hip retractor.  At this time, after hemostasis was obtained, Bovie cautery was used to incise the proximal end of the vastus lateralis and removing the partial portion of the hip abductor, the gluteus medius.  At this time, a periosteal elevator was used to expose anterior hip capsule.  A ________ was then inserted over the femoral head purchasing of the acetabulum underneath the reflected head of the quadriceps muscle.  Once this was performed, Homan retractors were then inserted superiorly and inferiorly underneath the femoral neck.  At this time, a capsulotomy was then performed using a Bovie cautery and the capsulotomy was ________ and then edged over the acetabulum.  At this point, a large bone hook was then inserted over the neck and with gentle traction and external rotation, the femoral head was dislocated out of the acetabulum.  At this time, we had an exposure of the femoral head, which did reveal degenerative changes of the femoral head and once the acetabulum was visualized, we did see degenerative changes within the acetabulum as well as osteophyte formation around the rim of the acetabulum.  At this time, a femoral stem guide was then used to measure proximal femoral neck cut.  We made a cut approximately a fingerbreadth above the lesser trochanter.  At this time, with protection of the soft tissues an oscillating saw was used to make femoral neck cut.,The femoral head was then removed.  At this time, we removed the leg out of the bag and Homan retractors were then used to expose the acetabulum.  A long-handle knife was used to cut through the remainder of the capsule and remove the glenoid labrum around the rim of the acetabulum.  With better exposure of the acetabulum, we started reaming the acetabulum.  We started with a size #44 and progressively reamed to a size #50.  At the size #50 mm reamer, we obtained excellent bony bleeding with good remainder of bone stalk both anteriorly and posteriorly as well as superiorly within the acetabulum.  We then reamed up to size #52 in order to get bony bleeding around the rim as well as anterior and posterior within the acetabulum.  A size 54 mm Trilogy cup was then implanted with excellent approaches approximately 45 degrees of abduction and 10 to 15 degrees of anteversion dialed in.  Once the cup was impacted in place, we did visualize that the cup was well seated on to the internal portion of the acetabulum.  At this time, two screws were the placed within the superior table for better approaches securing the acetabular cup.  At this time, a plastic liner was then inserted for protection.  The leg was then placed back in the bag.  A Bennett retractor was used to retract the tensor fascia lata and femoral elevator was used to elevate the femur for better exposure and at this time, we began working on the femur.  A rongeur was used to lateralize over the greater trochanter.  A Box osteotome was used to remove the cancellous portion of the femoral neck.  A Charnley awl was then used to cannulate through the proximal femoral canal.  A power reamer was then used to ream the lateral aspect of the greater trochanter in order to provide maximal lateralization and prevent varus implantation of our stem.  At this time, we began broaching.  We started with a size #10 and progressively worked up to a size #12 mm broach.  Once the 12 mm broach was inserted in place, it was seated approximately 1 mm below the calcar.  A calcar reamer was then placed and the calcar was reamed smoothly.  A standard neck as well as a 28 mm plastic head was then placed and a trial reduction was then performed.  Once this was performed, the hip was taken to range of motion with external rotation, longitudinal traction as well as flexion and revealed good stability with no impingement or dislocation.  At this time, we removed 12 mm broach and proceeded with implanting our polyethylene liner within the acetabulum.  This was impacted and placed and checked to assure that it was well seated with no loosening.  Once this was performed, we then exposed the proximal femur one more time.  We copiously irrigated within the canal and then suctioned it dry.  At this time, a 12 mm porous proximal collared stem, a femoral component was then impacted in place.  Once it was well seated on the calcar, we double checked to assure that there was no evidence of calcar fractures, which there were none.  The 28 mm zero neck length cobalt-chrome femoral head was then impacted in place and the Morse taper assured that this was well fixed by ________.,Next, the hip was then reduced within the acetabulum and again we checked range of motion as well as ligamentous stability with gentle traction, external rotation, as well as hip flexion.  We were satisfied with components as well as the alignment of the components.  Copious irrigation was then used to irrigate the wound.  #1 Ethibond was then used to approximate the anterior hip capsule.  #1 Ethibond in interrupted fashion was used to approximate the vastus lateralis as well as the gluteus medius attachment over the partial gluteus medius attachment which was resected off the greater trochanter.  Next, a #1 Ethibond was then used to approximate the tensor fascia lata with figure-of-eight closure.  A tight closure was performed.  Since the patient did have a lot of subcutaneous fat, multiple #2-0 Vicryl sutures were then used to approximate the bed space and then #2-0 Vicryl for the subcutaneous skin.  Staples were then used for skin closure.  The patient's hip was then cleansed.  Sterile dressings consisting of Adaptic, 4 x 4, ABDs, and foam tape were then placed.  A drain was placed prior to wound closure for postoperative drainage.  After the dressing was applied, the patient was extubated safely and transferred to recovery in stable condition.  Prognosis is good.
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DESCRIPTION: Total hip arthroplasty on the left.  Left hip degenerative arthritis.  Severe degenerative changes within the femoral head as well as the acetabulum, anterior as well as posterior osteophytes.

surgery, degenerative arthritis, total hip arthroplasty, tensor fascia lata, vastus lateralis, gluteus medius, femoral neck, femoral head, head, femoral, acetabulum, hip, attachment, arthroplasty,

Total hip arthroplasty is a major surgical procedure dealing with severe degenerative arthritis. It involves significant risks such as infection, dislocation, and potential for further surgeries. The blood loss of 800 cc adds complexity, and the patient's history of uncontrollable pain emphasizes the impact on quality of life. These factors collectively indicate a high-stakes situation for the patient's health and well-being.


Medical Specialty: Neurology
Sample Name: Craniotomy - Burr Hole

PREOPERATIVE DIAGNOSIS: , Right chronic subdural hematoma.,POSTOPERATIVE DIAGNOSIS: ,Right chronic subdural hematoma.,TYPE OF OPERATION: , Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 100 cc.,OPERATIVE PROCEDURE:,  In preoperative identification, the patient was taken to the operating room and placed in supine position.  Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  Table was turned.  The right shoulder roll was placed.  The head was turned to the left and rested on a doughnut.  The scalp was shaved, and then prepped and draped in usual sterile fashion.  Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss.  The parietal boss incision was opened.  It was about an inch and a half in length.  It was carried down to the skull.  Self-retaining retractor was placed.  A bur hole was now fashioned with the perforator.  This was widened with a 2-mm Kerrison punch.  The dura was now coagulated with bipolar electrocautery.  It was opened in a cruciate-type fashion.  The dural edges were coagulated back to the bony edges.  There was egress of a large amount of liquid.  Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear.  A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision.  It was secured with a 3-0 nylon suture.  The area was closed with interrupted inverted 2-0 Vicryl sutures.  The skin was closed with staples.  Sterile dressing was applied.  The patient was subsequently returned back to anesthesia.  He was extubated in the operating room, and transported to PACU in satisfactory condition.
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DESCRIPTION: Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.

neurology, hematoma, burr hole, craniotomy, frontotemporal, frontotemporal craniotomy, subdural, subdural drain, subdural hematoma, subdural space

A craniotomy, specifically a burr hole craniotomy, is a significant neurosurgical procedure performed to evacuate a subdural hematoma. This type of surgery can be life-saving because subdural hematomas can lead to increased intracranial pressure, potentially causing brain damage or death if not treated promptly. The stakes are high as it involves critical brain functions, potential complications during surgery, and the need for precise execution to prevent long-term neurological deficits.


Medical Specialty: Letters
Sample Name: Suspected Seizure Activity

XYZ Street,City, State,Dear Dr. CD:,Thank you for seeing Mr. XYZ, a pleasant 19-year-old male who has seen you in 2005 for suspected seizure activity.  He comes to my office today continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.  He is requesting to come off the Dilantin at this point.  Upon reviewing your 2005 note there was some discrepancy as to the true nature of his episodes to the emergency room and there was consideration to reconsider medication use.  His physical exam, neurologically, is normal at this time.  His Dilantin level is slightly low at 12.5.,I will appreciate your evaluation and recommendation as to whether we need to continue the Dilantin at this time.  I understand this will probably entail repeating his EEG and so please coordinate this through Health Center.  I await your response and whether we should continue this medication.  If you require any laboratory, we use ABC Diagnostic and any further testing that is needed should be coordinated at Health Center prior to scheduling.
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DESCRIPTION: Patient continuing on Dilantin 300 mg daily and has been seizure episode free for the past 2 1/2 years.

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

The situation involves medical decision-making regarding a patient's seizure treatment. The stakes involve the potential for seizures if the medication is discontinued, which can have significant health impacts. However, the patient has been seizure-free for 2.5 years, and there is a plan to conduct further evaluation through EEG to guide the decision. This mitigates some risk, but it's still crucial to proceed carefully. This scenario is typical of ongoing medical management rather than an acute medical crisis.


Medical Specialty: Surgery
Sample Name: Hypospadias Repair & Chordee Release - 1

PREOPERATIVE DIAGNOSES: , Coronal hypospadias with chordee and asthma.,POSTOPERATIVE DIAGNOSES:,  Coronal hypospadias with chordee and asthma.,PROCEDURE: , Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).,ANESTHETIC: , General inhalational anesthetic with a caudal block.,FLUIDS RECEIVED:  ,300 mL of crystalloid.,ESTIMATED BLOOD LOSS:  ,20 mL.,TUBES/DRAINS:  ,An 8-French Zaontz catheter.,INDICATIONS FOR OPERATION:  ,The patient is a 17-month-old boy with hypospadias abnormality.  The plan is for repair.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, a caudal block was placed.  IV antibiotics were given.  He was then placed in the supine position.  The foreskin was retracted and cleansed.  He was then sterilely prepped and draped.  A stay stitch of 4-0 Prolene was then placed on the glans.  The urethra was calibrated with the lacrimal duct probes to an 8-French.  We then marked out the coronal cuff, the penile shaft skin as well as the glanular plate for future surgery with a marking pen.,We then used a 15-blade knife to circumscribe the penis around the coronal cuff.  We then degloved the penis using the curved tenotomy scissors, and electrocautery was used for hemostasis.  The patient had some splaying of the spongiosum tissue, which was also incised laterally and rotated to make a secondary flap.  Once the penis was degloved, and the excessive chordee tissue was released, we then placed a vessel loop tourniquet around the base of the penis and using IV grade saline injected the penis for an artifical erection.  He was still noted to have chordee, so a midline incision through the Buck fascia was made with a 15-blade knife and Heineke-Mikulicz closure using 5-0 Prolene was then used for the chordee Nesbit tuck.  We repeated the artificial erection and the penis was straight.  We then incised the urethral plate with an ophthalmic blade in the midline, and then elevated the glanular wings using a 15-blade knife to elevate and then incise them.  Using the curved iris scissors, we then also further mobilized the glanular wings.  The 8-French Zaontz was then placed while the tourniquet was still in place into the urethral plate.  The upper aspect of the distal meatus was then closed with an interrupted suture of 7-0 Vicryl, and then using a running subcuticular closure, we closed the urethral plates over the Zaontz catheter.  We then mobilized subcutaneous tissue from the penile shaft skin, and the inner perpetual skin on the dorsum, and then buttonholed the flap, placed it over the head of the penis, and then, used it to cover of the hypospadias repair with tacking sutures of 7-0 Vicryl.  We then rolled the spongiosum flap to cover the distal urethra that was also somewhat dysplastic; 7-0 Vicryl was used for that as well.  5-0 Vicryl was used to roll the glans with 2 deep sutures, and then, horizontal mattress sutures of 7-0 Vicryl were used to reconstitute the glans.  Interrupted sutures of 7-0 Vicryl were used to approximate the urethral meatus to the glans.  Once this was done, we then excised the excessive penile shaft skin, and used the interrupted sutures of 6-0 chromic to attach the penile shaft skin to the coronal cuff.  On the ventrum itself, we used horizontal mattress sutures to close the defect.,At the end of the procedure, the Zaontz catheter was sutured into place with a 4-0 Prolene suture, Dermabond tissue adhesive, and Surgicel was used as a dressing and a second layer of Telfa and clear eye tape was then used to tape it into place.  IV Toradol was given at the procedure.  The patient tolerated the procedure well and was in a stable condition upon transfer to the recovery room.
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DESCRIPTION: Hypospadias repair (TIP) with tissue flap relocation and chordee release (Nesbit tuck).

surgery, coronal hypospadias with chordee, coronal hypospadias, tissue flap relocation, nesbit tuck, hypospadias with chordee, horizontal mattress sutures, chordee release, zaontz catheter, coronal cuff, hypospadias repair, penile shaft, zaontz, glans, urethral, repair, coronal, hypospadias, penis, chordee,

The procedure described is a hypospadias repair with chordee release on a 17-month-old patient. Hypospadias repair is a common pediatric urological surgery, but given the young age of the patient and the complexity involved in the surgical correction (including use of general anesthetic and intricate surgical techniques), there is a moderate level of risk, primarily related to the anesthesia and potential complications from the surgery itself like infection, bleeding, or improper healing. Thus, while pediatric surgeries generally carry inherent risks due to the delicate nature of working with very young patients, it is not an emergent or life-threatening situation, which would categorize it as even higher stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Multiple Progress Notes

PROGRESS NOTES,4/16/01:,Patient in respiratory failure, on ventilator,Request airline placement,Airline tracing good,4/17/01:,S: Sedated, intubated in NAD,O: Lungs: Increased bibasilar crackles,A/P: Respiratory arrest, pneumonia, COPD exacerbation,Replete K+, continue IVABX, start TPN, decrease TV, review ABGs,4/18/01:,S: Sedated and intubated, one episode NSVT,O: ABGs: 7.38/67/86/97,4/19/01:,S: Sedated and intubated, scant blood material from NGT,A/P: 1) Respiratory arrest,2) Exacerbation COPD - gastro cath NG aspiration,4/20/01:,S: Intubated/sedated, w/ NAD,O: Pulmonary - Increase L. basilar inspiration,A/P: Pneumonia,Respiratory arrest,COPD exacerbation,New onset low grade fever,D/C NGT - suspect sensitivity,4/20/01:,O: Preliminary blood culture gram + cocci,Dr. A called w/ result, no orders left,Pt. afebrile, WBC increase to 20.2,ABGs improved from 4/20/01, pt. noted to have less secretions,Last night had 8 beat run V-Tach,4/21/01:,O: Chest x-rays reviewed - improvement in lower lobe infiltrate,Gram + cocci in blood,Sputum H. influen. gram neg.,4/22/01:,atient up in chair,Decrease ventilator support,Preliminary blood cultures - Staph coag neg 1 of 2,04/23/01:,S: Awake, alert in NAD,O: Temp 99.8,Blood cultures: Staph coag. Neg. 1 of 2,A/P: Pneumonia, respiratory arrest, COPD,Continue wearing tirals,4/24/01:,S: Awake and alert, +N, refused trach,If fails extubation, will allow for reintubation
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DESCRIPTION: Multiple Progress Notes for different dates in a patient with respiratory failure, on ventilator.

The situation involves a patient in respiratory failure on a ventilator in an intensive care setting, which is inherently high-stakes due to the critical nature of the condition. The progress notes describe medical management involving sedatives, intubation, blood cultures indicating infection, and complex decisions regarding ventilator and airway management, all requiring careful monitoring and timely medical intervention. Any misstep or delay can lead to significant deterioration or complications for the patient.


Medical Specialty: General Medicine
Sample Name: Tongue Swelling

REASON FOR ADMISSION: , A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.,PAST MEDICAL HISTORY:,1.  Diabetes type II.,2.  High blood pressure.,3.  High cholesterol.,4.  Acid reflux disease.,5.  Chronic back pain.,PAST SURGICAL HISTORY:,1.  Lap-Band done today.,2.  Right foot surgery.,MEDICATIONS:,1.  Percocet on a p.r.n. basis.,2.  Keflex 500 mg p.o. t.i.d.,3.  Clonidine 0.2 mg p.o. b.i.d.,4.  Prempro, dose is unknown.,5.  Diclofenac 75 mg p.o. daily.,6.  Enalapril 10 mg p.o. b.i.d.,7.  Amaryl 2 mg p.o. daily.,8.  Hydrochlorothiazide 25 mg p.o. daily.,9.  Glucophage 100 mg p.o. b.i.d.,10.  Nifedipine extended release 60 mg p.o. b.i.d.,11.  Omeprazole 20 mg p.o. daily.,12.  Zocor 20 mg p.o. at bedtime.,ALLERGIES: , No known allergies.,HISTORY OF PRESENT COMPLAINT: , This 54-year-old patient had had Lap-Band at Tempe St Luke this morning.  She woke up at home this evening with massive swelling of the left side of the tongue.  The patient therefore came to the emergency room for evaluation.  The patient was almost intubated on clinical grounds.  Anesthesia was called to see the patient and they decided to give a trial of conservative management of Decadron and racemic epinephrine.,REVIEW OF SYSTEMS:,GENERAL:  The patient denies any itching of the skin or urticaria.  She has not noticed any new rashes.  She denies fever, chill, or malaise.,HEENT:  The patient denies vision difficulty.,RESPIRATORY:  No cough or wheezing.,CARDIOVASCULAR:  No palpitations or syncopal episodes.,GASTROINTESTINAL:  The patient denies swallowing difficulty.,Rest of the review of systems not remarkable.,SOCIAL HISTORY:  ,The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  Obese 54-year-old lady, not in acute distress at this time.,VITAL SIGNS:  On arrival in the emergency room, blood pressure was 194/122, pulse was 94, respiratory rate of 20, and temperature was 96.6.  O2 saturation was 95% on room air.,HEAD AND NECK:  Face is symmetrical.  Tongue is still swollen, especially on the left side.  The floor of the mouth is also indurated.  There is no cervical lymphadenopathy.  There is no stridor.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  There is no swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.
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DESCRIPTION: A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.

The situation involves a 54-year-old patient with new-onset massive tongue swelling after a Lap-Band procedure. The swelling is severe enough that intubation was considered, indicating a potential airway compromise, which is a critical and urgent issue. Though conservative management with medications was chosen, the situation remains high-stakes because of the risk involved if the airway becomes obstructed. Moreover, the patient's hypertension during examination (blood pressure of 194/122) adds to the urgency of the situation as it presents an additional risk factor.


Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 7

SUBJECTIVE:,  The patient is a 7-year-old male who comes in today with a three-day history of emesis and a four-day history of diarrhea.  Apparently, his brother had similar symptoms.  They had eaten some chicken and then ate some more of it the next day, and I could not quite understand what the problem was because there is a little bit of language barrier, although dad was trying very hard to explain to me what had happened.  But any way, after he and his brother got done eating with chicken, they both felt bad and have continued to feel bad.  The patient has had diarrhea five to six times a day for the last four days and then he had emesis pretty frequently three days ago and then has just had a couple of it each day in the last two days.  He has not had any emesis today.  He has urinated this morning.  His parents are both concerned because he had a fever of 103 last night.  Also, he ate half of a hamburger yesterday and he tried drinking some milk and that is when he had an emesis.  He has been drinking Pedialyte, Gatorade, white grape juice, and 7Up, otherwise he has not been eating anything.,MEDICATIONS:  ,None.,ALLERGIES:  ,He has no known drug allergies.,REVIEW OF SYSTEMS:,  Negative as far as sore throat, earache, or cough.,PHYSICAL EXAMINATION:,General:  He is awake and alert, no acute distress.,Vital Signs:  Blood pressure:  106/75.  Temperature:  99.  Pulse:  112.  Weight is 54 pounds.,HEENT:  His TMs are normal bilaterally.  Posterior pharynx is unremarkable.,Neck:  Without adenopathy or thyromegaly.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur.,Abdomen:  Benign.,Skin:  Turgor is intact.  His capillary refill is less than 3 seconds.,LABORATORY: , White blood cell count is 5.3 with 69 segs, 15 lymphs, and 13 monos.  His platelet count on his CBC is 215.,ASSESSMENT:,  Viral gastroenteritis.,PLAN:,  The parents did point out to me a rash that he had on his buttock.  There were some small almost pinpoint erythematous patches of papules that have a scab on them.  I did not see any evidence of petechiae.  Therefore, I just reassured them that this is a viral gastroenteritis.  I recommended that they stop giving him juice and just go with the Gatorade and water.  He is to stay away from milk products until his diarrhea and stomach upset have calmed down.  We talked about BRAT diet and slowly advancing his diet as he tolerates.  They have used some Kaopectate, which did not really help with the diarrhea.  Otherwise follow up as needed.
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DESCRIPTION: Patient with a three-day history of emesis and a four-day history of diarrhea

general medicine, diarrhea, emesis, history of, gastroenteritis, viral, brat diet, progress note,

The situation involves a 7-year-old child with symptoms of viral gastroenteritis, including diarrhea and vomiting. While dehydration is a concern, the child appears to be alert, with no severe signs of dehydration or systemic infection, given his vital signs and laboratory results. The rash observed is not concerning for a more serious condition. The management plan involves hydration and dietary adjustments, which are standard care measures. Therefore, while attention and care are required to avoid potential dehydration, the situation does not involve immediate life-threatening conditions, making it relatively low-stakes.


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

EXAM:,  Echocardiogram.,INDICATION: , Aortic stenosis.,INTERPRETATION: , Transthoracic echocardiogram was performed of adequate technical quality.  Left ventricle reveals concentric hypertrophy with normal size and dimensions and normal function.  Ejection fraction is 60% without any obvious wall motion abnormality.  Left atrium and right side chambers are of normal size and dimensions.  Aortic root has normal diameter.,Mitral and tricuspid valves are structurally normal except for minimal annular calcification.  Valvular leaflet excursion is adequate.  Aortic valve reveals annular calcification.  Fibrocalcific valve leaflets with decreased excursion.  Atrial and ventricular septum are intact.  Pericardium is intact without any effusion.  No obvious intracardiac mass or thrombi noted.,Doppler reveals mild mitral regurgitation, mild-to-moderate tricuspid regurgitation.  Estimated pulmonary pressure of 48.  Systolic consistent with mild-to-moderate pulmonary hypertension.  Peak velocity across the aortic valve is 3.0 with a peak gradient of 37, mean gradient of 19, valve area calculated at 1.1 sq. cm consistent with moderate aortic stenosis.,IN SUMMARY:,1. Concentric hypertrophy of the left ventricle with normal function.,2. Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm.
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DESCRIPTION: Echocardiogram for aortic stenosis.  Transthoracic echocardiogram was performed of adequate technical quality.  Concentric hypertrophy of the left ventricle with normal function.  Doppler study as above, most pronounced being moderate aortic stenosis, valve area of 1.1 sq. cm

cardiovascular / pulmonary, moderate aortic stenosis, annular calcification, concentric hypertrophy, aortic stenosis, echocardiogram, stenosis, valve, aortic,

The echocardiogram findings reveal moderate aortic stenosis, which is a significant condition that can lead to severe health outcomes if not managed properly. Although the heart is currently functioning normally, the presence of moderate aortic stenosis, concentric hypertrophy, and pulmonary hypertension indicates that there is a risk of progression to more severe disease, which could lead to complications such as heart failure. Therefore, the situation requires careful monitoring and possibly intervention, making it relatively high-stakes.


Medical Specialty: General Medicine
Sample Name: Refractory Hypertension - Followup

PROBLEM LIST:,1.  Refractory hypertension, much improved.,2.  History of cardiac arrhythmia and history of pacemaker secondary to AV block.,3.  History of GI bleed in 1995.,4.  History of depression.,HISTORY OF PRESENT ILLNESS:,  This is a return visit to the renal clinic for this patient.  She is an 85-year-old woman with history as noted above.  Her last visit was approximately four months ago.  Since that time, the patient has been considerably more compliant with her antihypertensive medications and actually had a better blood pressure reading today than she had had for many visits previously.  She is not reporting any untoward side effect.  She is not having weakness, dizziness, lightheadedness, nausea, vomiting, constipation, diarrhea, abdominal pain, chest pain, shortness of breath or difficulty breathing.  She has no orthopnea.  Her exercise capacity is about the same.  The only problem she has is musculoskeletal and that pain in the right buttock, she thinks originating from her spine.  No history of extremity pain.,CURRENT MEDICATIONS:,1.  Triamterene/hydrochlorothiazide 37.5/25 mg.,2.  Norvasc 10 mg daily.,3.  Atenolol 50 mg a day.,4.  Atacand 32 mg a day.,5.  Cardura 4 mg a day.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.2, pulse 47, respirations 16, and blood pressure 157/56.  THORAX:  Revealed lungs that are clear, PA and lateral without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  S1 and S2 without murmur.  No S3.  I could not hear murmur today.  ABDOMEN:  Above plane, but nontender.  EXTREMITIES:  Revealed no edema.,ASSESSMENT:,  This is a return visit for this patient who has refractory hypertension.  This seems to be doing very well given her current blood pressure reading, at least much improved from what she had been previously.  We had discussed with her in the past beginning to see an internist at the senior center.  She apparently had an appointment scheduled and it was missed.  We are going to reschedule that today given her overall state of well-being and the fact that she has no evidence of GFR that is greater than 60%.,PLAN: , The plan will be for her to follow up at the senior center for her routine health care, and should the need arise for further management of blood pressure, a referral back to us.  In the meantime, we will discharge her from our practice.  Should there be confusion or difficulty getting in the senior center, we can always see her back in followup
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DESCRIPTION: Refractory hypertension, much improved, history of cardiac arrhythmia and history of pacemaker secondary to AV block, history of GI bleed, and history of depression.

general medicine, cardiac arrhythmia, av block, refractory hypertension, blood pressure, pacemaker, atenolol, arrhythmia

The situation involves follow-up care for an 85-year-old patient with a history of refractory hypertension, cardiac arrhythmia, pacemaker, and past medical conditions like GI bleed and depression. Although the patient's hypertension is currently stable, and no immediate critical conditions are reported, the scenario still involves managing a complex, elderly patient with potential risk factors such as history of GI bleed and cardiac issues. Transitioning her care to a senior center could be routine but must be monitored for continuity in care due to her age and medical history. Given the age and complexity, it is important but not exceedingly high-stakes.


Medical Specialty: Discharge Summary
Sample Name: Cardiac Transfer Summary

REASON FOR TRANSFER:,  Need for cardiac catheterization done at ABCD.,TRANSFER DIAGNOSES:,1.  Coronary artery disease.,2.  Chest pain.,3.  History of diabetes.,4.  History of hypertension.,5.  History of obesity.,6.  A 1.1 cm lesion in the medial aspect of the right parietal lobe.,7.  Deconditioning.,CONSULTATIONS: , Cardiology.,PROCEDURES:,1.  Echocardiogram.,2.  MRI of the brain.,3.  Lower extremity Duplex ultrasound.,HOSPITAL COURSE: , Please refer to my H&P for full details.  In brief, the patient is a  64-year-old male with history of diabetes, who presented with 6 hours of chest pressure.  He was brought in by a friend.  The friend states that the patient deteriorated over the last few weeks to the point that he is very short of breath with exertion.  He apparently underwent a cardiac workup 6 months ago that the patient states he barely passed.  His vital signs were stable on admission.  He was ruled out for myocardial infarction with troponin x2.  An echocardiogram showed concentric LVH with an EF of 62%.  I had Cardiology come to see the patient, who reviewed the records from Fountain Valley.  Based on his stress test in the past, Dr. X felt the patient needed to undergo a cardiac cath during his inpatient stay.,The patient on initial presentation complained of, what sounded like, amaurosis fugax.  I performed an MRI, which showed a 1 cm lesion in the right parietal lobe.  I was going to call Neurology at XYZ for evaluation.  However, secondary to his indication for transfer, this could be followed up at ABCD with Dr. Y.,The patient is now stable for transfer for cardiac cath.,Discharged to ABCD.,DISCHARGE CONDITION:,  Stable.,DISCHARGE MEDICATIONS:,1.  Aspirin 325 mg p.o. daily.,2.  Lovenox 40 mg p.o. daily.,3.  Regular Insulin sliding scale.,4.  Novolin 70/30, 15 units b.i.d.,5.  Metformin 500 mg p.o. daily.,6.  Protonix 40 mg p.o. daily.,DISCHARGE FOLLOWUP: , Followup to be arranged at ABCD after cardiac cath.
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DESCRIPTION: Need for cardiac catheterization.  Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity,  a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.

The case described involves a patient with multiple serious health conditions, including coronary artery disease, a lesion in the brain, and a requirement for cardiac catheterization. The patient needs to be transferred for specialized cardiac procedures which are critical for assessing and potentially treating their condition. The presence of a brain lesion adds complexity to the patient's overall health status, indicating a need for further evaluation by neurologists. Hence, the situation is high-stakes due to the potential risks involved with the patient's cardiac and neurological conditions.


Medical Specialty: Radiology
Sample Name: MRI Brain - Toxoplasmosis

CC:, Lethargy.,HX:, This 28y/o RHM was admitted to a local hospital on 7/14/95 for marked lethargy. He had been complaining of intermittent headaches and was noted to have subtle changes in personality for two weeks prior to 7/14/95. On the morning of 7/14/95, his partner found him markedly lethargic and complaingin of abdominal pain and vomiting. He denied fevers, chills, sweats, cough, CP, SOB or diarrhea. Upon evaluation locally, he had a temperature of 99.5F and appeared lethargic. He also had anisocoria with left pupil 0.5mm bigger than the right. There was also question of left facial weakness. An MRI was obtained and revealed a large left hemispheric mass lesion with surrounding edema and mass effect. He was given 10mg of IV Decardron,100gm of IV Mannitol, intubated and hyperventilated and transferred to UIHC.,He was admitted to the Department of Medicine on 7/14/95, and transferred to the Department of Neurology on 7/17/95, after being extubated.,MEDS ON ADMISSION:, Bactrim DS qd, Diflucan 100mg qd, Acyclovir 400mg bid, Xanax, Stavudine 40mg bid, Rifabutin 300mg qd.,PMH:, 1) surgical correction of pyoloric stenosis, age 1, 2)appendectomy, 3) HIV/AIDS dx 1991. He was initially treated with AZT, then DDI. He developed chronic diarrhea and was switched to D4T in 1/95. However, he developed severe neuropathy and this was stopped 4/95. The diarrhea recured. He has Acyclovir resistant genital herpes and generalized psoriasis. He most recent CD4 count (within 1 month of admission) was 20.,FHX:, HTN and multiple malignancies of unknown type.,SHX:, Homosexual, in monogamous relationship with an HIV infected partner for the past 3 years.,EXAM: ,7/14/95 (by Internal Medicine): BP134/80, HR118, RR16 on vent, 38.2C, Intubated.,MS: Somnolent, but opened eyes to loud voices and would follow most commands.,CN: Pupils 2.5/3.0 and "equally reactive to light." Mild horizontal nystagmus on rightward gaze. EOM were otherwise intact.,MOTOR: Moved 4 extremities well.,Sensory/Coord/Gait/Station/Reflexes: not done.,Gen EXAM: Penil ulcerations.,EXAM:, 7/17/96 (by Neurology): BP144/73, HR59, RR20, 36.0, extubated.,MS: Alert and mildly lethargic. Oriented to name only. Thought he was a local hospital and that it was 1/17/1994. Did not understand he had a brain lesion.,CN: Pupils 6/5.5 decreasing to 4/4 on exposure to light. EOM were full and smooth. No RAPD or light-near dissociation. papilledema (OU). Right lower facial weakness and intact facial sensation to PP testing. Gag-shrug and corneal responses were intact, bilaterally. Tongue midline.,MOTOR: Grade 5- strength on the right side.,Sensory: no loss of sensation on PP/VIB/PROP testing.,Coord: reduced speed and accuracy on right FNF and right HKS movements.,Station: RUE pronator drift.,Gait: not done.,Reflexes: 2+/2 throughout. Babinski sign present on right and absent on left.,Gen Exam: unremarkable except for the genital lesion noted by Internal medicine.,COURSE:, The outside MRI was reviewed and was notable for the left frontal/parietal mass lesion with surround edema. The mass inhomogenously enhanced with gadolinium contrast.,The findings were consistent most with lymphoma, though toxoplasmosis could not be excluded. He refused brain biopsy and was started on empiric treatment for toxoplasmosis. This consisted of Pyrimethamine 75mg qd and Sulfadiazine 2 g bid. He later became DNR and was transferred at his and his partner's request Back to a local hospital.,He never returned for follow-up.
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DESCRIPTION: MRI Brain: Probable CNS Lymphoma v/s toxoplasmosis in a patient with AIDS/HIV.

The scenario involves a medical diagnosis with serious implications, particularly focusing on potential brain lymphoma versus toxoplasmosis in a patient with AIDS. Both conditions are life-threatening, and the patient exhibits significant neurological symptoms, including lethargy and personality changes. Additionally, the patient's refusal for a brain biopsy limits diagnostic clarity, heightening the stakes in deciding on an empiric treatment strategy. The outcome critically impacts the patient's health and potentially their survival, making this a high-stakes medical scenario.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Hypertension - Progress Note

SUBJECTIVE:,  The patient is a 78-year-old female who returns for recheck.  She has hypertension.  She denies difficulty with chest pain, palpations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY / SURGERY / HOSPITALIZATIONS:,  Reviewed and unchanged from the dictation on 12/03/2003.,MEDICATIONS:  ,Atenolol 50 mg daily, Premarin 0.625 mg daily, calcium with vitamin D two to three pills daily, multivitamin daily, aspirin as needed, and TriViFlor 25 mg two pills daily.  She also has Elocon cream 0.1% and Synalar cream 0.01% that she uses as needed for rash.,ALLERGIES:  ,Benadryl, phenobarbitone, morphine, Lasix, and latex.,FAMILY HISTORY / PERSONAL HISTORY: , Reviewed.  Mother died from congestive heart failure.  Father died from myocardial infarction at the age of 56.  Family history is positive for ischemic cardiac disease.  Brother died from lymphoma.  She has one brother living who has had angioplasties x 2.  She has one brother with asthma.,PERSONAL HISTORY:,  Negative for use of alcohol or tobacco.,REVIEW OF SYSTEMS:,Bones and Joints:  She has had continued difficulty with lower back pain particularly with standing which usually radiates down her right leg.  She had been followed by Dr. Mills, but decided to see Dr. XYZ who referred to her Dr Isaac.  She underwent several tests.  She did have magnetic resonance angiography of the lower extremities and the aorta which were normal.  She had nerve conduction study that showed several peripheral polyneuropathy.  She reports that she has myelogram last week but has not got results of this.  She reports that the rest of her tests have been normal, but it seems that vertebrae shift when she stands and then pinches the nerve.  She is now seeing Dr. XYZ who comes to Hutchison from KU Medical Center, and she thinks that she probably will have surgery in the near future.,Genitourinary:  She has occasional nocturia.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  227.2 pounds.  Blood pressure:  144/72.  Pulse:  80.  Temperature:  97.5 degrees.,General Appearance:  She is an elderly female patient who is not in acute distress.,Mouth:  Posterior pharynx is clear.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1 and S2 without gallops or rubs.,Abdomen:  Without masses or tenderness to palpation.,Extremities:  Without edema.,IMPRESSION/PLAN:,1.  Hypertension.  She is advised to continue with the same medication.,2.  Syncope.  She previously had an episode of syncope around Thanksgiving.  She has not had a recurrence of this and her prior cardiac studies did not show arrhythmias.,3.  Spinal stenosis.  She still is being evaluated for this and possibly will have surgery in the near future.
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DESCRIPTION: Patient with hypertension, syncope, and spinal stenosis - for recheck.

cardiovascular / pulmonary, progress note, hypertension, spinal stenosis, syncope, spinal, stenosis, infarction, orthopnea,

This situation refers to a medical progress note for a 78-year-old female with a history of hypertension, syncope, and spinal stenosis. The stakes involved here pertain to the management and monitoring of hypertension and neurological symptoms potentially related to spinal stenosis. While hypertension and spinal stenosis can lead to significant health impacts if poorly managed, the progress notes indicate stable conditions (e.g., no recent syncope, hypertension under treatment). Though the patient's condition requires attention, it doesn't suggest an immediate life-threatening situation. The family history of cardiac issues adds a layer of consideration, but as the specifics provided indicate a relatively stable and managed situation currently, the stakes are moderate rather than high.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pacemaker Insertion

PREOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,POSTOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,OPERATIVE PROCEDURE:, Insertion of transvenous pacemaker.,ANESTHESIA:, Local,PROCEDURE AND GROSS FINDINGS:, The patient's chest was prepped with Betadine solution and a small amount of Lidocaine infiltrated.  In the left subclavian region, a subclavian stick was performed without difficulty, and a wire was inserted. Fluoroscopy confirmed the presence of the wire in the superior vena cava.  An introducer was then placed over the wire.  The wire was removed and replace by a ventricular lead that was seated under Fluoroscopy. Following calibration, the lead was attached to a pacemaker generator that was inserted in a subcutaneous pocket in the left subclavian area.  ,The subcutaneous tissues were irrigated and closed with Interrupted 4-O Vicryl, and the skin was closed with staples.  Sterile dressings were placed, and the patient was returned to the ICU in good condition.
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DESCRIPTION: Insertion of transvenous pacemaker for tachybrady syndrome

cardiovascular / pulmonary, insertion of transvenous pacemaker, fluoroscopy, tachybrady, tachybrady syndrome, chest, pacemaker, subclavian, subcutaneous, superior vena cava, syndrome, transvenous pacemaker, wire, insertion,

Pacemaker insertion is a significant medical procedure with potential risks and important consequences for the patient. The operation described involves careful planning and execution, and any complications could have serious implications for the patient's health given their underlying cardiac condition. While taccollegeybrady syndrome and pacemaker insertion are managed routinely, the high-stakes nature comes from potential complications or failures, which could be life-threatening.


Medical Specialty: Pain Management
Sample Name: Epidurogram

PREOPERATIVE DIAGNOSES:  ,1.  Right lower extremity radiculopathy with history of post laminectomy pain.,2.  Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:  ,1.  Right lower extremity radiculopathy with history of post laminectomy pain.,2.  Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED: , Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion.  The patient was given sedation and monitored.  Local anesthetic was used to insufflate the skin and paraspinal tissues and the L5 disk level on the right was noted to be completely collapsed with no way whatsoever to get a needle to the neural foramen of the L5 root.  The left side was quite open; however, that was not the side of her problem.  At this point using a oblique fluoroscopic projection and gun-barrel technique, a 22-gauge 3.5 inch spinal needle was placed at the superior articular process of L5 on the right, stepped off laterally and redirected medially into the intervertebral foramen to the L4 nerve root.  A second needle was taken and placed at the S1 nerve foramen using AP and lateral fluoroscopic views to confirm location.  After negative aspiration, 2 cc of Omnipaque 240 dye was injected through each needle.,There was a defect flowing in the medial epidural space at both sides.  There were no complications.
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DESCRIPTION: Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.

pain management, laminectomy, radiculopathy, nerve root entrapment, epidural fibrosis, nerve root, epidurogram, neural, epidural, foramen, nerve, needle

The situation described involves a medical procedure known as a transforaminal epidurogram for neural mapping, used in the context of diagnosing and treating nerve-related pain and complications post-surgery. The stakes are relatively high given the medical context, as complications or errors can lead to further neurological issues. However, the procedure is likely routine for the medical team, and it was performed without complications, which suggests that while important, the situation may not be considered extremely high-stakes from an overall risk perspective.


Medical Specialty: Orthopedic
Sample Name: Foreign Body Removal - Foot - 1

PREOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Irrigation debridement.,2.  Removal of foreign body of right foot.,ANESTHESIA:,  Spinal with sedation.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , Include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old Caucasian male with a history of uncontrolled diabetes mellitus.  The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot.  He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room.  He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics.  It was noted upon x-ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity.  After a long discussion held with the patient, it was elected to proceed with irrigation debridement and removal of the foreign body.,PROCEDURE: , After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the patient, operative surgeon, the Department of Anesthesia and nursing staff.  The patient was then transferred to preoperative area to Operative Suite #5 and placed on the operating table in supine position.  All bony prominences were well padded at this time.  The Department of Anesthesia was administered spinal anesthetic to the patient.  Once this anesthesia was obtained, the patient's right lower extremity was sterilely prepped and draped in the usual sterile fashion.  Upon viewing of the plantar aspect of the foot, there was noted to be a swollen ecchymotic area with a small hole in it, which purulent fluid was coming from.  At this time, after all bony and soft tissue landmarks were identified as well as the localization of the pus, a 2 cm longitudinal incision was made directly over this area, which was located between the second and third metatarsal heads.  Upon incising this, there was a foul smelling purulent fluid, which flowed from this region.  Aerobic and anaerobic cultures were taken as well as gram stain.  The area was explored and it ________ to the dorsum of the foot.  There was no obvious joint involvement.  After all loculations were broken, 3 liters antibiotic-impregnated fluid were pulse-evac through the wound.  The wound was again inspected with no more gross purulent or necrotic appearing tissue.  The wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s, floss, and Kerlix covered by an Ace bandage.  At this time, the Department of Anesthesia reversed the sedation.  The patient was transferred back to the hospital gurney to Postanesthesia Care Unit.  The patient tolerated the procedure well and there were no complications.,DISPOSITION:  ,The patient will be followed on a daily basis for possible repeat irrigation debridement.
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DESCRIPTION: Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot.  Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.

orthopedic, removal of foreign body, purulent material, metatarsal, cellulitis, abscess, kerlix, foreign body, foot, irrigation, debridement, purulent,

The situation described involves a surgical procedure on a patient with cellulitis, an abscess, and a foreign body in the foot. The patient also has a history of uncontrolled diabetes, which increases the risks of complications and slower healing. Although the procedure went well with no immediate complications, the underlying conditions (e.g., diabetes and infection) pose significant health risks if not managed properly. However, the situation is not immediately life-threatening, as indicated by the uneventful procedure and minimal blood loss. Nonetheless, careful postoperative monitoring is necessary due to the potential for complications given the patient's overall health status.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Foreskin - Followup

REASON FOR VISIT: , Follow up consultation, second opinion, foreskin.,HISTORY OF PRESENT ILLNESS: , A 2-week-old who at this point has otherwise been doing well.  He has a relatively unremarkable foreskin.  At this point in time, he otherwise seems to be doing reasonably well.  The question is about the foreskin.  He otherwise has no other significant issues.  Severity low, ongoing since birth two weeks.  Thank you for allowing me to see this patient in consultation.,PHYSICAL EXAMINATION:,  Male exam.  Normal and under the penis, report normal uncircumcised 2-week-old.  He has a slightly insertion on the penile shaft from the median raphe of the scrotum.,IMPRESSION: , Slightly high insertion of the median raphe.  I see no reason he cannot be circumcised as long as they are careful and do a very complete Gomco circumcision.  This kid should otherwise do reasonably well.,PLAN:  ,Follow up as needed.  But my other recommendation is that this kid as I went over with the mother may actually do somewhat better if he simply has a formal circumcision at one year of age, but may do well with a person who is very accomplished doing a Gomco circumcision.
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DESCRIPTION: Follow up consultation, second opinion, foreskin.

soap / chart / progress notes, formal circumcision, median raphe, penis, gomco circumcision, gomco, circumcision, foreskin,

The scenario involves a follow-up consultation for a 2-week-old child regarding their foreskin, seeking a second opinion. The situation is not critical as the foreskin condition is not severe and there is no immediate danger to the child’s health. The stakes involve deciding whether to perform a circumcision now or hold off until the child is older, which is more of a preference-oriented decision rather than an urgent medical need.


Medical Specialty: Surgery
Sample Name: Induction of Vaginal Delivery

DIAGNOSES,1.  Term pregnancy.,2.  Possible rupture of membranes, prolonged.,PROCEDURE:,  Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:,  The patient is a 20-year-old female, gravida 4, para 0, who presented to the office.  She had small amount of leaking since last night.  On exam, she was positive Nitrazine, no ferning was noted.  On ultrasound, her AFI was about 4.7 cm.  Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin.  Once she was in her regular pattern, we ruptured her bag of water; fluid was clear.  She went rapidly to completion over the next hour and a half.  She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation.  Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications.  The baby was vigorous, moving all extremities.  The cord was clamped and cut.  The baby was handed off to mom with nurse present.  Apgars were 8 and 9.  Placenta was delivered spontaneously, intact.  Three-vessel cord with no retained placenta.  Estimated blood loss was about 150 mL.  There were no tears.
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DESCRIPTION: Induction of vaginal delivery of viable male, Apgars 8 and 9.  Term pregnancy and oossible rupture of membranes, prolonged.

surgery, induction of vaginal delivery, vaginal delivery, viable male, pregnancy, placenta, vaginal, membranes, apgars

The situation involves medical details of a surgical procedure, specifically the induction of vaginal delivery. It describes a clinical scenario with a term pregnancy and possible prolonged rupture of membranes. The details provided indicate a successful delivery without complications, and the baby has good Apgar scores (8 and 9), signaling healthy immediate adaptation to life outside the womb. While childbirth always carries inherent risks, the description of the procedure suggests it went smoothly. As such, the stakes are moderate because while childbirth is significant, this particular case was managed well without complications.


Medical Specialty: Urology
Sample Name: Cystoscopy & Visual Urethrotomy

CYSTOSCOPY & VISUAL URETHROTOMY,OPERATIVE NOTE:,  The patient was placed in the dorsal lithotomy position and prepped and draped in the usual manner under satisfactory general anesthesia.  A Storz urethrotome sheath was inserted into the urethra under direct vision.  Visualization revealed a stricture in the bulbous urethra.  This was intubated with a 0.038 Teflon-coated guidewire, and using the straight cold urethrotomy knife, it was incised to 12:00 to allow free passage of the scope into the bladder.  Visualization revealed no other lesions in the bulbous or membranous urethra.  Prostatic urethra was normal for age.  No foreign bodies, tumors or stones were seen within the bladder.  Over the guidewire, a #16-French Foley catheter with a hole cut in the tip with a Cook cutter was threaded over the guidewire and inserted into the bladder and inflated with 10 mL of sterile water.,He was sent to the recovery room in stable condition.
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DESCRIPTION: Cystoscopy & Visual urethrotomy procedure

urology, cystoscopy, foley catheter, storz urethrotome sheath, teflon-coated guidewire, urethrotomy, bladder, bulbous urethra, dorsal lithotomy position, knife, membranous urethra, cystoscopy & visual urethrotomy, visual urethrotomyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves a medical procedure called cystoscopy and visual urethrotomy which is generally a routine and non-life-threatening procedure in urology. The procedure is completed under general anesthesia, and the patient was sent to the recovery room in stable condition with no complications reported. While medical procedures carry inherent risks, the documentation suggests that it was performed successfully without any issues, indicating low stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 8

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

This medical situation does not seem to involve an immediate threat to life or require urgent intervention. The patient's conditions are generalized anxiety and hypertension, both noted to be under fair control. The patient is under regular monitoring, and there are plans for standard tests and follow-up. There is no indication of acute or severe symptoms that require immediate medical intervention.


Medical Specialty: Neurology
Sample Name: Lobar Holoprosencephaly

CC: ,Delayed motor development.,HX:, This 21 month old male presented for delayed motor development, "jaw quivering" and "lazy eye." He was an 8 pound 10 ounce product of a full term, uncomplicated pregnancy-labor-spontaneous vaginal delivery to a G3P3 married white female mother. There had been no known toxic intrauterine exposures. He had no serious illnesses or hospitalizations since birth. He sat independently at 7 months, stood at 11 months, crawled at 16 months, but did not cruise until 18 months.,He currently cannot walk and easily falls. His gait is reportedly marked by left "intoeing." His upper extremity strength and coordination reportedly appear quite normal and he is able to feed himself, throw and transfer objects easily. He knows greater than 20 words and speaks two-word phrases.,No seizures or unusual behavior were reported except for "quivering" movement of his jaw. This has occurred since birth. In addition the parents have noted transient left exotropia.,PMH: ,As above.,FHX:, Many family members with "lazy eye." No other neurologic diseases declared.,9 and 5 year old sisters who are healthy.,SHX:, lives with parents and sisters.,EXAM:, BP83/67 HR122 36.4C Head circumference 48.0cm Weight 12.68kg (70%) Height 86.0cm (70%),MS: fairly cooperative.,CN: Minimal transient esotropia OS. Tremulous quivering of jaw--increased with crying. No obvious papilledema, though difficult to evaluate due to patient movement.,Motor: sat independently with normal posture and no truncal ataxia. symmetric and normal strength and muscle bulk throughout.,Sensory: withdrew to vibration.,Coordination: unremarkable in BUE.,Station: no truncal ataxia.,Gait: On attempting to walk, his right foot rotated laterally at almost 70degrees. Both lower extremities could rotate outward to 90degrees. There was marked passive eversion at the ankles as well.,Reflexes: 2+/2+ throughout.,Musculoskeletal: pes planovalgus bilaterally.,COURSE: ,CK normal. The parents decided to forego an MRI in 8/90. The patient returned 12/11/92 at age 4 years. He was ambulatory and able to run awkwardly. His general health had been good, but he showed signs developmental delay. Formal evaluation had tested his IQ at 87 at age 3.5 years. He was weakest on tasks requiring visual/motor integration and fine motor and visual discrimination skills. He was 6 months delayed in cognitive development at that time. On exam, age 4 years, he displayed mild right ankle laxity on eversion and inversion, but normal gait. The rest of the neurological exam was normal. Head circumference was 49.5cm (50%) and height and weight were in the 90th percentile. Fragile X analysis and karyotyping were unremarkable.
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DESCRIPTION: A 21-month-old male presented for delayed motor development, "jaw quivering" and "lazy eye."

neurology, delayed motor development, jaw quivering, head circumference, truncal ataxia, delayed motor, motor development, lazy eye, jaw, quivering, delayed, intrauterine,

The situation described involves a medical assessment of a 21-month-old child with developmental delays and potential neurological concerns, including possible lobar holoprosencephaly. While delays in motor development and symptoms like jaw quivering and lazy eye can be concerning and indicative of underlying conditions, the overall case seems to be managed conservatively at this point, with no immediate life-threatening symptoms reported and no specified emergencies. The condition mentioned, lobar holoprosencephaly, could have varying degrees of impact on the individual’s life, with appropriate management required over time. Given this context, while the stakes are certainly higher than routine health checks due to the neurological aspects and developmental concerns, they are not at the highest level, as there's no indication of acute risk or imminent harm. Thus, it is crucial to monitor the child's development and provide necessary interventions to support his growth.


Medical Specialty: Orthopedic
Sample Name: ORIF Mandibular Fracture & Dental Implant Removal

PREOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,POSTOPERATIVE DIAGNOSES: , Open, displaced, infected left atrophic mandibular fracture; failed dental implant.,PROCEDURE PERFORMED: , Open reduction and internal fixation (ORIF) of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.,ANESTHESIA: , General nasotracheal.,ESTIMATED BLOOD LOSS: , 125 mL.,FLUIDS GIVEN: , 1 L of crystalloids.,SPECIMEN: , Soft tissue from the fracture site sent for histologic diagnosis.,CULTURES: , Also sent for Gram stain, aerobic and anaerobic, culture and sensitivity.,INDICATIONS FOR THE PROCEDURE: , The patient is a 79-year-old male, who fell in his hometown, following an episode of syncope.  He sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in the above-mentioned fracture.  He was admitted to hospital in Harleton, Texas, where his initial evaluation showed the rib fractures have also showed a nodule on his right upper lobe as well as a mediastinal mass.  His mandible fracture was not noted initially.  The patient also has a history of prostate cancer and a renal cell carcinoma.  The patient at that point underwent a bronchoscopy with a biopsy of the mediastinal mass and the results of that biopsy are still pending.  The patient later saw a local oral surgeon.  He diagnosed his mandible fracture and advised him to seek treatment in Houston.  He presented to my office for evaluation on January 18, 2010, and he was found to have an extremely atrophic mandible with a fracture in the left parasymphysis region involving a failed dental implant, which had been placed approximately 15 years ago.  The patient had significant discomfort and could eat foods and drink fluids with difficulty.  Due to the nature of his fracture and the complex medical history, he was sent to the hospital for admission and following cardiac clearance, he was scheduled for surgery today.,PROCEDURE IN DETAIL: , The patient was taken to the operating room, and placed in a supine position.  Following a nasal intubation and induction of general anesthesia, the surgeon then scrubbed, gowned, and gloved in the normal sterile fashion.  The patient was then prepped and draped in a manner consistent with sterile procedures.  A marking pen was first used to outline the incision in the submental region and it was extended from the left mandibular body to the right mandibular body region, approximately 1.5 cm medial to the inferior border of the mandible.  A 1 mL of lidocaine 1% with 1:100,000 epinephrine was then infiltrated along the incision and then a 15-blade was used to incise through the skin and subcutaneous tissue.  A combination of sharp and blunt dissection was then used to carry the dissection superiorly to the inferior border of the mandible.  Electrocautery as well as 4.0 silk ties were used for hemostasis.  A 15-blade was then used to incise the periosteum along the inferior border of the mandible and it was reflected exposing the mandible as well as the fracture site.  The fracture site was slightly distracted allowing access to the dental implant within the bone and it was easily removed from the wound.  Cultures of this site were also obtained and then the granulation tissue from the wound was also curetted free of the wound and sent for a histologic diagnosis.  Manipulation of the mandible was then used to achieve an anatomic reduction and then an 11-hole Synthes reconstruction plate was then used to stand on the fracture site.  Since there was an area of weakness in the right parasymphysis region, in the location of another dental implant, the bone plate was extended posterior to that site.  When the plate was adapted to the mandible, it was then secured to the bone with 9 screws, each being 2 mm in diameter and each screw was placed bicortically.  All the screws were also locking screws.  Following placement of the screws, there was felt to be excellent stability of the fracture, so the wound was irrigated with a copious amount of normal saline.  The incision was closed in multiple layers with 4.0 Vicryl in the muscular and subcutaneous layers and 5.0 nylon in the skin.  A sterile dressing was then placed over the incision.  The patient tolerated the procedure well and was taken to the recovery room with spontaneous respirations and stable vital signs.  Estimated blood loss is 125 mL.
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DESCRIPTION: Open reduction and internal fixation of left atrophic mandibular fracture, removal of failed dental implant from the left mandible.  The patient fell following an episode of syncope and sustained a blunt trauma to his ribs resulting in multiple fractures and presumably also struck his mandible resulting in fracture.

orthopedic, atrophic mandibular fracture, dental implant, open reduction and internal fixation, orif, mandibular fracture, mandible, atrophic, mandibular, dental, implant,

The surgery described involves open reduction and internal fixation (ORIF) of a mandibular fracture, which is a procedure typically considered moderate to high-stakes in orthopedic and oral surgery. The patient is elderly with a complex medical history, including a history of syncope, prostate cancer, renal cell carcinoma, and a mediastinal mass under investigation. The operation involves general anesthesia, a significant aspect that increases the stakes due to potential complications from anesthesia, particularly in older patients with complex health histories. Additionally, the fragility of the mandible and the presence of an infection further complicate the case. The need for cardiac clearance prior to surgery highlights the potential risks involved. These factors collectively contribute to the high-stakes nature of the situation.