Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Stress Test Dobutamine Myoview

INDICATIONS:  ,Chest pain, hypertension, type II diabetes mellitus.,PROCEDURE DONE:,  Dobutamine Myoview stress test.,STRESS ECG RESULTS:,  The patient was stressed by dobutamine infusion at a rate of 10 mcg/kg/minute for three minutes, 20 mcg/kg/minute for three minutes, and 30 mcg/kg/minute for three additional minutes.  Atropine 0.25 mg was given intravenously eight minutes into the dobutamine infusion.  The resting electrocardiogram reveals a regular sinus rhythm with heart rate of 86 beats per minute, QS pattern in leads V1 and V2, and diffuse nonspecific T wave abnormality.  The heart rate increased from 86 beats per minute to 155 beats per minute, which is about 90% of the maximum predicted target heart rate.  The blood pressure increased from 130/80 to 160/70.  A maximum of 1 mm J-junctional depression was seen with fast up sloping ST segments during dobutamine infusion.  No ischemic ST segment changes were seen during dobutamine infusion or during the recovery process.,MYOCARDIAL PERFUSION IMAGING:,  Resting myocardial perfusion SPECT imaging was carried out with 10.9 mCi of Tc-99m Myoview.  Dobutamine infusion myocardial perfusion imaging and gated scan were carried out with 29.2 mCi of Tc-99m Myoview.  The lung heart ratio is 0.36.  Myocardial perfusion images were normal both at rest and with stress.  Gated myocardial scan revealed normal regional wall motion and ejection fraction of 67%.,CONCLUSIONS:,1.  Stress test is negative for dobutamine-induced myocardial ischemia.,2.  Normal left ventricular size, regional wall motion, and ejection fraction.
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DESCRIPTION: Chest pain, hypertension.  Stress test negative for dobutamine-induced myocardial ischemia.  Normal left ventricular size, regional wall motion, and ejection fraction.

cardiovascular / pulmonary, chest pain, dobutamine myoview, dobutamine myoview stress test, spect imaging, stress test, dobutamine infusion, ejection fraction, hypertension, myocardial ischemia, myocardial perfusion, ventricular size, wall motion, dobutamine, stress, myocardial, myoview, ischemia, ventricular, perfusion,

The situation involves a medical procedure, specifically a dobutamine stress test, which is used to assess cardiac function under stress. While the initial concern might relate to the patient's chest pain, hypertension, and type II diabetes mellitus, the conclusion of the test indicates normal results. The stress test is negative for dobutamine-induced myocardial ischemia, and myocardial perfusion images are normal. Although the procedure is significant due to the patient’s underlying conditions, the results are reassuring. Therefore, while the situation involves health assessments that relate to serious conditions, the outcome of this specific test is not indicative of immediate high-stakes concerns, as the results are normal.


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

Medical Specialty: Surgery
Sample Name: Pilon Fracture External Fixation

PREOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,POSTOP DIAGNOSES:,1.  Left pilon fracture.,2.  Left great toe proximal phalanx fracture.,OPERATION PERFORMED:,1.  External fixation of left pilon fracture.,2.  Closed reduction of left great toe, T1 fracture.,ANESTHESIA:  ,General.,BLOOD LOSS:  ,Less than 10 mL.,Needle, instrument, and sponge counts were done and correct.,DRAINS AND TUBES: , None.,SPECIMENS:,  None.,INDICATION FOR OPERATION:  ,The patient is a 58-year-old female who was involved in an auto versus a tree accident on 6/15/2009.  The patient suffered a fracture of a distal tibia and fibula as well as her great toe on the left side at that time.  The patient was evaluated by the emergency room and did undergo further evaluation due to loss of consciousness.  She underwent a provisional reduction and splinting in the emergency room followed by further evaluation for her heart and brain by the Medicine Service following this and she was appropriate for surgical intervention.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.  The patient had swollen lower extremities, however, compartments were soft and she had no sign of compartment syndrome.  Risks and benefits of procedure were discussed in detail with the patient and her husband.  All questions were answered, and consent was obtained.  The risks including damage to blood vessels and nerves with painful neuroma or numbness, limb altered function, loss of range of motion, need for further surgery, infection, complex regional pain syndrome and deep vein thrombosis were all discussed as potential risks of the surgery.,FINDINGS:,1.  There was a comminuted distal tibia fracture with a fibular shaft fracture.  Following traction, there was adequate coronal and sagittal alignment of the fracture fragments and based on the length of the fibula, the fracture fragments were out to length.,2.  The base of her proximal phalanx fracture was assessed and reduced with essentially no articular step-off and approximately 1-mm displacement.  As the reduction was stable with buddy taping, no pinning was performed.,3.  Her compartments were full, but not firm nor did she have any sign of compartment syndrome and no compartment releases were performed.,OPERATIVE REPORT IN DETAIL:  ,The patient was identified in the preoperative holding area.  The left leg was identified and marked at the surgical site of the patient.  She was then taken to the operating room where she was transferred to the operating room in the supine position, placed under general anesthesia by the anesthesiology team.  She received Ancef for antibiotic prophylaxis.  A time-out was then undertaken verifying the correct patient, extremity, visibility of preoperative markings, availability of equipment, and administration of preoperative antibiotics.  When all was verified by the surgeon, anesthesia and circulating personnel left lower extremity was prepped and draped in the usual fashion.  At this point, intraoperative fluoroscopy was used to identify the fracture site as well as the appropriate starting point both in the calcaneus for a transcalcaneal cross stent and in the proximal tibia with care taken to leave enough room for later plate fixation without contaminating the future operative site.  A single centrally threaded calcaneal cross tunnel was then placed across the calcaneus parallel to the joint surface followed by placement of 2 Schantz pins in the tibia and a frame type external fixator was then applied in traction with attempts to get the fracture fragments out to length, but not overly distract the fracture and restore coronal and sagittal alignment as much as able.  When this was adequate, the fixator apparatus was locked in place, and x-ray images were taken verifying correct placement of the hardware and adequate alignment of the fracture.  Attention was then turned to the left great toe, where a reduction of the proximal phalanx fracture was performed and buddy taping as this provided good stability and was least invasive.  X-rays were taken showing good reduction of the base of the proximal phalanx of the great toe fracture.  At this point, the pins were cut short and capped to protect the sharp ends.  The stab wounds for the Schantz pin and cross pin were covered with gauze with Betadine followed by dry gauze, and the patient was then awakened from anesthesia and transferred to the progressive care unit in stable condition.  Please note there was no break in sterile technique throughout the case.,PLAN:  ,The patient will require definitive surgical treatment in approximately 2 weeks when the soft tissues are amenable to plate and screw fixation with decreased risk of wound complication.  She will maintain her buddy taping in regards to her great toe fracture.
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DESCRIPTION: External fixation of left pilon fracture and closed reduction of left great toe, T1 fracture.  Due to the comminuted nature of her tibia fracture as well as soft tissue swelling, the patient is in need of a staged surgery with the 1st stage external fixation followed by open treatment and definitive plate and screw fixation.

surgery, phalanx fracture, schantz pins, toe fracture, tibia fracture, pilon fracture, external fixation, proximal phalanx, fracture, toe, pilon, phalanx, reduction, tibia, proximal, fixation,

The situation involves a surgical operation following traumatic injuries from an auto accident, including a staged surgery approach for a complex tibia fracture. Surgical procedures are inherently high-stakes due to the risks of complications such as nerve damage, infection, and potential need for additional surgeries. The patient's condition after a traumatic event and the nature of the staged surgical treatment contribute to the high-stakes nature of this case.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: General Medicine
Sample Name: Trouble breathing

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

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


Medical Specialty: Surgery
Sample Name: Hydrocelectomy - 1

PREOPERATIVE DIAGNOSES:,  Bladder cancer and left hydrocele.,POSTOPERATIVE DIAGNOSES: , Bladder cancer and left hydrocele.,OPERATION:  ,Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.,ANESTHESIA:,  Spinal.,ESTIMATED BLOOD LOSS:  ,Minimal.,FLUIDS:,  Crystalloid.,BRIEF HISTORY:  ,The patient is a 66-year-old male with history of smoking and hematuria, had bladder tumor, which was dissected.  He has received BCG.  The patient is doing well.  The patient was supposed to come to the OR for surveillance biopsy and pyelograms.  The patient had a large left hydrocele, which was increasingly getting worse and was making it very difficult for the patient to sit to void or put clothes on, etc.  Options such as watchful waiting, drainage in the office, and hydrocelectomy were discussed.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, infection in the scrotum, enlargement of the scrotum, recurrence, and pain were discussed.  The patient understood all the options and wanted to proceed with the procedure.,PROCEDURE IN DETAIL: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.,A transverse scrotal incision was made over the hydrocele sac and the hydrocele fluid was withdrawn.  The sac was turned upside down and sutures were placed.  Careful attention was made to ensure that the cord was open.  The testicle was in normal orientation throughout the entire procedure.  The testicle was placed back into the scrotal sac and was pexed with 4-0 Vicryl to the outside dartos to ensure that there was no risk of torsion.  Orchiopexy was done at 3 different locations.  Hemostasis was obtained using electrocautery.  The sac was closed using 4-0 Vicryl.  The sac was turned upside down so that when it heals, the fluid would not recollect.  The dartos was closed using 2-0 Vicryl and the skin was closed using 4-0 Monocryl and Dermabond was applied.  Incision measured about 2 cm in size.  Subsequently using ACMI cystoscope, a cystoscopy was performed.  The urethra appeared normal.  There was some scarring at the bulbar urethra, but the scope went in through that area very easily into the bladder.  There was a short prostatic fossa.  The bladder appeared normal.  There was some moderate trabeculation throughout the bladder, some inflammatory changes in the bag part, but nothing of much significance.  There were no papillary tumors or stones inside the bladder.  Bilateral pyelograms were obtained using 8-French cone-tip catheter, which appeared normal.  A cold cup biopsy of the bladder was done and was fulgurated for hemostasis.  The patient tolerated the procedure well.  The patient was brought to recovery at the end of the procedure after emptying the bladder.,The patient was given antibiotics and was told to take it easy.  No heavy lifting, pushing, or pulling.  Plan was to follow up in about 2 months.
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DESCRIPTION: Left hydrocelectomy, cystopyelogram, bladder biopsy, and fulguration for hemostasis.

surgery, hydrocele, fulguration, bladder biopsy, hydrocelectomy, cystopyelogram, cystopyelogram bladder, bladder cancer, bladder,

The situation involves a surgical procedure on a patient with bladder cancer and a problematic hydrocele. The surgery includes a hydrocelectomy, bladder biopsy, and fulguration for hemostasis. This type of surgery generally carries moderate risks associated with anesthesia, bleeding, infection, and recurrence of hydrocele. Although hydrocelectomy is a routine procedure, the patient's history of bladder cancer and other health factors (e.g., age, history of smoking) can increase complexity and stakes slightly. The stakes are moderate because the patient's quality of life and cancer monitoring are involved, but it is not life-threatening unless complications arise.


Medical Specialty: Surgery
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 8

PROCEDURES,1.  Left heart catheterization.,2.  Coronary angiography.,3.  Left ventriculogram.,PREPROCEDURE DIAGNOSIS:,  Atypical chest pain.,POSTPROCEDURE DIAGNOSES,1.  No angiographic evidence of coronary artery disease.,2.  Normal left ventricular systolic function.,3.  Normal left ventricular end diastolic pressure.,INDICATION:  ,The patient is a 58-year-old male with past medical history significant for polysubstance abuse, chronic tobacco abuse, chronic alcohol dependence with withdrawal, atrial flutter, history of ventricular tachycardia with AICD placement, and hepatitis C. The patient was admitted for atypical chest pain and scheduled for cardiac catheterization.,PROCEDURE IN DETAIL:,  After informed consent was signed by the patient, the patient was taken to the cardiac catheterization laboratory.  He was prepped and draped in the usual sterile manner.  The right inguinal area was anesthetized with 2% Xylocaine.  A 4-French sheath was inserted into the right femoral artery using the modified Seldinger technique.  JL4 and 3DRC catheters were used to cannulate the left and right coronary arteries respectively.  Coronary angiographies were performed.  These catheters were removed and exchanged for a 4-French pigtail catheter, which was positioned into the left ventricle.  Left ventriculography was performed.  The patient tolerated the procedure well.  At the end of the procedure, all catheters and sheaths were removed.  The patient was then transferred to telemetry in a stable condition.,HEMODYNAMIC DATA: , Hemodynamic data shows aortic pressures of 100/56 with mean of 70 mmHg and the LV 100/0 with LVEDP of 10 mmHg.,AORTIC VALVE:  ,There is no significant gradient across this valve noted.,LV GRAM: , A 10 mL of contrast were delivered for 3 seconds for a total of 30 mL.  Ejection fraction was calculated to be 69%.  There were no wall motion abnormalities noted.,ANGIOGRAM,LEFT MAIN CORONARY ARTERY: , Left main coronary artery is a moderate-caliber vessel free of disease and trifurcates.,LAD: , LAD is a long, tortuous vessel which wraps around the apex.  The LAD is small in caliber.  In addition, there is a long bifurcating small-caliber diagonal branch noted.  LAD and its branches are free of disease.,RAMUS INTERMEDIUS: , Ramus intermedius is a long small-caliber vessel free of disease.,LCX: , LCX is a nondominant small-caliber vessel with long bifurcating small-caliber distal OM branch.  LCX and its branches are free of disease.,RCA:,  RCA is a dominant small-caliber vessel with long small-caliber PDA branch.  RCA and its branches are free of disease.,IMPRESSION,1.  No angiographic evidence of coronary artery disease.,2.  Normal left ventricular systolic function.,3.  Normal left ventricular end diastolic pressure.,RECOMMENDATION: , Recommend to look for alternative causes of chest pain.
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DESCRIPTION: Left heart catheterization, coronary angiography, and left ventriculogram.  No angiographic evidence of coronary artery disease.  Normal left ventricular systolic function.  Normal left ventricular end diastolic pressure.

The described scenario involves a heart catheterization procedure to diagnose potential coronary artery disease in a 58-year-old male patient with significant risk factors. Although the procedure itself is invasive, it is routine and went smoothly. The results were normal, indicating no immediate life-threatening issues. While the procedure is critical for diagnosing serious conditions, and misjudgment could lead to serious consequences, the lack of findings reduces the immediate stakes. Therefore, while there is a degree of risk, it is managed within standard procedures, making it less high-stakes relative to other medical procedures with immediate and direct life-or-death outcomes.


Medical Specialty: General Medicine
Sample Name: Hypertension & Cardiomyopathy

PROBLEMS LIST:,1.  Nonischemic cardiomyopathy.,2.  Branch vessel coronary artery disease.,3.  Congestive heart failure, NYHA Class III.,4.  History of nonsustained ventricular tachycardia.,5.  Hypertension.,6.  Hepatitis C.,INTERVAL HISTORY: , The patient was recently hospitalized for CHF exacerbation and was discharged with increased medications.  However, he did not fill his prescriptions and came back with persistent shortness of breath on exertion and on rest.  He has history of orthopnea and PND.  He has gained a few pounds of weight but denied to have any palpitation, presyncope, or syncope.,REVIEW OF SYSTEMS: , Positive for right upper quadrant pain.  He has occasional nausea, but no vomiting.  His appetite has decreased.  No joint pain, TIA, seizure or syncope.  Other review of systems is unremarkable.,I reviewed his past medical history, past surgical history, and family history.,SOCIAL HISTORY: , He has quit smoking, but unfortunately was positive for cocaine during last hospital stay in 01/08.,ALLERGIES: , He has no known drug allergies.,MEDICATIONS:,  I reviewed his medication list in the chart.  He states he is compliant, but he was not taking the revised dose of medications as per discharge orders and prescription.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse 91 per minute and regular, blood pressure 151/102 in the right arm and 152/104 in the left arm, weight 172 pounds, which is about 6 pounds more than last visit in 11/07.  HEENT:  Atraumatic and normocephalic.  No pallor, icterus or cyanosis.  NECK:  Supple.  Jugular venous distention 5 cm above the clavicle present.  No thyromegaly.  LUNGS:  Clear to auscultation.  No rales or rhonchi.  Pulse ox was 98% on room air.  CVS:  S1 and S2 present.  S3 and S4 present.  ABDOMEN:  Soft and nontender.  Liver is palpable 5 cm below the right subcostal margin.  EXTREMITIES:  No clubbing or cyanosis.  A 1+ edema present.,ASSESSMENT AND PLAN:,  The patient has hypertension, nonischemic cardiomyopathy, and branch vessel coronary artery disease.  Clinically, he is in NYHA Class III.  He has some volume overload and was not unfortunately taking Lasix as prescribed.  I have advised him to take Lasix 40 mg p.o. b.i.d.  I also increased the dose of hydralazine from 75 mg t.i.d. to 100 mg t.i.d.  I advised him to continue to take Toprol and lisinopril.  I have also added Aldactone 25 mg p.o. daily for survival advantage.  I reinforced the idea of not using cocaine.  He states that it was a mistake, may be somebody mixed in his drink, but he has not intentionally taken any cocaine.  I encouraged him to find a primary care provider.  He will come for a BMP check in one week.  I asked him to check his blood pressure and weight.  I discussed medication changes and gave him an updated list.  I have asked him to see a gastroenterologist for hepatitis C.  At this point, his Medicaid is pending.  He has no insurance and finds hard to find a primary care provider.  I will see him in one month.  He will have his fasting lipid profile, AST, and ALT checked in one week.
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DESCRIPTION: Nonischemic cardiomyopathy, branch vessel coronary artery disease, congestive heart failure - NYHA Class III, history of nonsustained ventricular tachycardia, hypertension, and hepatitis C.

general medicine, congestive heart failure, hypertension, cardiomyopathy, coronary artery disease, ventricular tachycardia, nonischemic cardiomyopathy, branch vessel, nyha class, nonischemic, tachycardia, orthopnea,

The patient's situation involves multiple complex medical conditions including nonischemic cardiomyopathy, congestive heart failure (Class III), and hepatitis C, among others. The patient was recently hospitalized due to a CHF exacerbation and is non-compliant with medication adjustments due to not filling prescriptions. Furthermore, there is a social element of potential ongoing substance use and a lack of insurance which impacts the accessibility and continuity of care. All these factors contribute to a potentially life-threatening situation, especially given the significant cardiovascular and hepatic concerns. Therefore, the stakes are high both medically and socially.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - Urology

ADMITTING DIAGNOSES:,1. Hematuria.,2. Benign prostatic hyperplasia.,3. Osteoarthritis.,DISCHARGE DIAGNOSES:,1. Hematuria, resolved.,2. Benign prostatic hyperplasia.,3. Complex renal cyst versus renal cell carcinoma or other tumor.,4. Osteoarthritis.,HOSPITAL COURSE:, This is a 77-year-old African-American male who was previously well until he began having gross hematuria and clots passing through his urethra on the day of admission. He stated that he never had blood in his urine before, however, he does have a past history of BPH and he had a transurethral resection of prostate more than 10 years ago. He was admitted to a regular bed. Dr. G of Urology was consulted for evaluation of his hematuria. During the workup for this, he had a CT of the abdomen and pelvis with and without contrast with early and late-phase imaging for evaluation of the kidneys and collecting system. At that time, he was shown to have multiple bilateral renal cysts with one that did not meet classification as a simple cyst and ultrasound was recommended.,He had an ultrasound done of the cyst which showed a 2.1 x 2.7 cm mass arising from the right kidney which, again, did not fit ultrasound criteria for a simple cyst and they recommended further evaluation by an MRI as this could be a hemorrhagic cyst or a solid mass or tumor, so an MRI was scheduled on the day of discharge for further evaluation of this. The report was not back at discharge. The patient had a cystoscopy and transurethral resection of prostate as well with entire resection of the prostate gland. Pathology on this specimen showed multiple portions of prostatic tissue which was primarily fibromuscular, and he was diagnosed with nonprostatic hyperplasia. His urine slowly cleared. He tolerated a regular diet with no difficulties in his activities of daily living, and his Foley was removed on the day of discharge.,He was started on ciprofloxacin, Colace, and Lasix after the transurethral resection and continued these for a short course. He is asked to continue the Colace as an outpatient for stool softening for comfort.,DISCHARGE MEDICATIONS:, Colace 100 mg 1 b.i.d.,DISCHARGE FOLLOWUP PLANNING:, The patient is to follow up with his primary care physician at ABCD, Dr. B or Dr. J, the patient is unsure of which, in the next couple weeks. He is to follow up with Dr. G of  Urology in the next week by phone in regards to the patient's MRI and plans for a laparoscopic partial renal resection biopsy. This is scheduled for the week after discharge potentially by Dr. G, and the patient will discuss the exact time later this week. The patient is to return to the emergency room or to our clinic if he has worsening hematuria again or no urine output.
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DESCRIPTION: Discharge Summary of a patient with hematuria, benign prostatic hyperplasia, complex renal cyst versus renal cell carcinoma, and osteoarthritis.

discharge summary, bph, benign prostatic hyperplasia, hematuria, osteoarthritis, clots, cystoscopy, gross hematuria, kidney, renal cell carcinoma, renal cyst, simple cyst, prostatic hyperplasia, transurethral resection, discharge, summary, urology, transurethral, prostate, prostatic, hyperplasia, gross, benign, renal, cyst

The discharge summary describes a complex medical situation where a 77-year-old male with a history of benign prostatic hyperplasia experienced hematuria, which has been resolved during the hospital stay. However, an important potential diagnosis is a complex renal cyst versus renal cell carcinoma, for which further diagnostic evaluations (MRI and potential biopsy) are scheduled shortly after discharge. The potential risk of the cyst being a tumor makes the situation more critical than the resolved hematuria or osteoarthritis. The patient has clear follow-up instructions for treatment and monitoring, including returning to the emergency room if symptoms worsen. Given these considerations, the scenario has moderate to high stakes due to the possible presence of renal cell carcinoma.


Medical Specialty: Surgery
Sample Name: Cystourethroscopy & Urethral Dilation

PREOPERATIVE DIAGNOSIS:  ,Urinary hesitancy and weak stream.,POSTOPERATIVE DIAGNOSES:,1.  Urinary hesitancy and weak stream.,2.  Urethral narrowing.,3.  Mild posterior wall erythema.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Urethral dilation.,3.  Bladder biopsy and fulguration.,ANESTHESIA:  ,General.,SPECIMEN:  ,Urine culture sensitivity and cytology and bladder biopsy x1.,DISPOSITION: , To PACU in stable condition.,INDICATIONS AND FINDINGS:  ,This is a 76-year-old female with history of weak stream and history of intermittent catheterization secondary to hypotonic bladder in the past, last cystoscopy approximately two years ago.,FINDINGS AT TIME OF SURGERY:,  Cystourethroscopy revealed some mild narrowing of the urethra, which was easily dilated to #23 French.  A midureteral polyp was noted.  Cystoscopy revealed multiple cellules and mild trabeculation of the bladder.  Posterior wall revealed some mild erythema with some distorted architecture of the bladder mucosa.  No obvious raised bladder tumor was noted.  No foreign bodies were noted.  The ureteral orifices were noted on the trigone just proximal to the bladder neck.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to the operating room, general anesthesia was induced by the Department of Anesthesia.  The patient was prepped and draped in normal sterile fashion and urethral sounds used to dilate the urethra to accommodate #23 French cystoscope.  Cystoscopy was performed in its entirety with the above findings.  The small area of erythema on the posterior wall was biopsied using a flexible biopsy forceps and Bovie cautery was used to cauterize and fulgurate this area.  The bladder was drained, cystoscope was removed, scope was reinserted and bladder was again reexamined.  No evidence of active bleeding noted.  The bladder was drained, cystoscope was removed, and the patient was cleaned and sent to recovery room in stable condition to followup with Dr. X in two weeks.  She is given prescription for Levaquin and Pyridium and given discharge instructions.
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DESCRIPTION: Cystourethroscopy, urethral dilation, and bladder biopsy and fulguration.  Urinary hesitancy and weak stream, urethral narrowing, mild posterior wall erythema.

surgery, bladder biopsy, fulguration, urethral dilation, weak stream, bladder, cystoscopy, cystoscope, cystourethroscopy, biopsy, urethral,

The provided case involves a surgical procedure to address urinary issues in a 76-year-old patient. While any surgery has inherent risks, this is a relatively routine procedure involving urethral dilation and cystoscopy, which are standard interventions for urethral narrowing and diagnostic purposes like biopsy. The condition is not life-threatening, the patient was stable post-procedure, and there were no major complications reported during the surgery. However, surgery with general anesthesia and the patient's age add moderate risk factors.


Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consult - 1

SUBJECTIVE:,  His brother, although he is a vegetarian, has elevated cholesterol and he is on medication to lower it.  The patient started improving his diet when he received the letter explaining his lipids are elevated.  He is consuming less cappuccino, quiche, crescents, candy from vending machines, etc.  He has started packing his lunch three to four times per week instead of eating out so much.  He is exercising six to seven days per week by swimming, biking, running, lifting weights one and a half to two and a half hours each time.  He is in training for a triathlon.  He says he is already losing weight due to his efforts.,OBJECTIVE:,  Height:  6 foot 2 inches.  Weight:  204 pounds on 03/07/05.  Ideal body weight:  190 pounds, plus or minus ten percent.  He is 107 percent standard of midpoint ideal body weight.  BMI:  26.189.  A 48-year-old male.  Lab on 03/15/05:  Cholesterol:  251.  LDL:  166.  VLDL:  17.  HDL:  68.  Triglycerides:  87.  I explained to the patient the dietary guidelines to help improve his lipids.  I recommend a 26 to 51 to 77 fat grams per day for a 10 to 20 to 30 percent fat level of 2,300 calories since he is interested in losing weight.  I went over the printed information sheet on lowering your cholesterol and that was given to him along with a booklet on the same topic to read.  I encouraged him to continue as he is doing.,ASSESSMENT:,  Basal energy expenditure 1960 x 1.44 activity factor is approximately 2,800 calories.  His 24-hour recall shows he is making many positive changes already to lower his fat and cholesterol intake.  He needs to continue as he is doing.  He verbalized understanding and seemed receptive.,PLAN:,  The patient plans to recheck his lipids through Dr. XYZ  I gave him my phone number and he is to call me if he has any further questions regarding his diet.
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DESCRIPTION: Elevated cholesterol and is on medication to lower it.

consult - history and phy., vegetarian, lipids, cholesterol intake, elevated cholesterol, losing weight, body weight, dietary, cholesterol

This situation involves a patient with elevated cholesterol who is already taking steps to improve his condition through dietary changes and exercise. The patient's cholesterol levels are above normal, but he is actively managing his condition with a healthcare provider's guidance. While managing cholesterol is important for long-term health, the situation is currently stable, with no immediate life-threatening concerns. It is a medical concern with implications for long-term health, but it does not involve acute or immediate risks.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med SOAP - 4

S:,  ABC is in today for a followup of her atrial fibrillation.  They have misplaced the Cardizem.  She is not on this and her heart rate is up just a little bit today.  She does complain of feeling dizziness, some vertigo, some lightheadedness, and has attributed this to the Coumadin therapy.  She is very adamant that she wants to stop the Coumadin.  She is tired of blood draws.  We have had a difficult time getting her regulated.  No chest pains.  No shortness of breath.  She is moving around a little bit better.  Her arm does not hurt her.  Her back pain is improving as well.,O:,  Vital signs as per chart.  Respirations 15.  Exam:  Nontoxic.  No acute distress.  Alert and oriented.  HEENT:  TMs are clear bilaterally without erythema or bulging.  Clear external canals.  Clear tympanic.  Conjunctivae are clear.  Clear nasal mucosa.  Clear oropharynx with moist mucous membranes.  NECK is soft and supple.  LUNGS are clear to auscultation.  HEART is irregularly irregular, mildly tachycardic.  ABDOMEN is soft and nontender.  EXTREMITIES:  No cyanosis, no clubbing, no edema.,EKG shows atrial fibrillation with a heart rate of 104.,A:,1.
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DESCRIPTION: General Medicine SOAP note.

General Medicine SOAP note.

soap / chart / progress notes, soap, alert and oriented, no acute distress, no cyanosis, atrial fibrillation, blood draw, dizziness, general medicine, irregularly irregular, lightheadedness, no clubbing, no edema, shortness of breath, soft and nontender, vertigo, heart, fibrillation, coumadin, atrial,

The patient is experiencing atrial fibrillation, a condition that requires careful management to prevent potential complications such as stroke. The patient's request to stop Coumadin, a crucial medication for preventing blood clots in atrial fibrillation, increases the risk of a severe adverse event. The symptoms of dizziness and lightheadedness further indicate that the patient's condition needs prompt medical attention to ensure safety and effective management of their atrial fibrillation. While there are no immediate signs of distress, the potential for serious consequences if anticoagulation therapy is discontinued makes this a moderately high-stakes situation.


Medical Specialty: Cosmetic / Plastic Surgery
Sample Name: Hemangioma Debulking & Rhinoplasty

PREOPERATIVE DIAGNOSIS: , Hemangioma, nasal tip.,POSTOPERATIVE DIAGNOSIS:,  Hemangioma, nasal tip.,PROCEDURE PERFORMED:  ,1.  Debulking of hemangioma of the nasal tip through an open rhinoplasty approach.,2.  Rhinoplasty.,ESTIMATED BLOOD LOSS:  ,Minimal.,FINDINGS: , Large hemangioma involving the midline of the columella separated the lower lateral cartilages at a level of the columella and the nasal domes.,CONDITION:  ,Condition of the patient at end of the procedure stable, transferred to recovery room.,INDICATIONS FOR THE PROCEDURE: , The patient is a 2-year-old female with a history of a nasal tip hemangioma.  The hemangioma has involved at her upper tongue.  There has not been any change in the last 6 months.  We have discussed with the parents the situation and decided to proceed with the debulking of the nasal tip hemangioma.  They understand the nature of the incision, the nature of the surgery, and the possibility of future revision surgeries.  They understand the risk of bleeding, infection, dehiscence, scarring, need for future revision surgery, and minor asymmetry.  They wished to proceed with surgery.,Because of the procedure, informed consent is obtained.  The patient is taken to operating room and placed in the supine position.  General anesthetic is administrated to an oroendotracheal tube.  The face is prepped and draped in the usual manner.  The incision is designed to the lower aspect of the hemangioma, which corresponds to the columella and upper lip junction and then the remaining of the incision is designed as an open rhinoplasty with bilateral rim incisions.  The area is infiltrated with lidocaine with epinephrine.  We waited 7 minutes for the hemostatic effect and proceeded with the incision.  The incision was then done with a 15 C blade starting at the columella and then going laterally to the level of the rim and the double hook is placed at the level of the dome and the intracartilage incision is done through the mucosa, then extended laterally and upward to follow the lower lateral cartilage.  This is done in both sides.  Further incision is done.  A small tenotomy scissors is used and with the help of retraction of the lower lateral cartilage, the hemangioma is separated gently from the lower lateral cartilage on both sides and I proceeded to leave that the central part of the incision lifting up the entire columella to the level of the nasal tip.  The hemangioma is removed and is found to be involving the medial aspects of both medial crura.  This gently separated from the medial crura and from the soft tissue care is taken not to remove the entire hemangioma from the skin as the nose not to devascularize the distal columella portion.  Hemostasis is achieved with electrocautery.  Then, we proceed to place some interdomal stitches with the help of a 6-0 clear nylon and intercrural stitches are placed and then an interdomal stitch, a single one was placed.  The skin is redraped and the nose found to have satisfactory shape.  The columellar piece was tailored on the lateral aspect corresponding to rim incisions to match the newly created width of the columella.  Portions of skin and hemangioma are taken laterally on both sides of the columella distally.  The skin was closed with 6-0 mild chromic stitches, including the portion at the level of the columella and rim incisions medially.  The remaining of the internal incisions are closed with 5-0 chromic interrupted stitches.  The nose is irrigated and suctioned.  The patient tolerated the procedure without complications.  I was present and participated in all aspects of the procedure.  Sponge and instrument count were complete at the end of the procedure.
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DESCRIPTION: Debulking of hemangioma of the nasal tip through an open rhinoplasty approach and rhinoplasty.

cosmetic / plastic surgery, rhinoplasty approach, debulking of hemangioma, nasal domes, lower lateral cartilages, nasal tip, columella, hemangioma, debulking, cartilages, rhinoplasty, nasal,

This situation involves a cosmetic/plastic surgery procedure on a 2-year-old patient for the debulking of a nasal hemangioma. While the procedure is generally low-risk, it is still surgery on a very young child, which inherently carries significant anesthetic risks and requires careful management to avoid potential complications like bleeding or infection. Despite the cosmetic nature of the surgery, the age of the patient and the need for informed consent from the parents elevate the stakes of the situation. However, the procedure was performed successfully with minimal blood loss and the patient's condition was stable post-operation, which suggests that the immediate risk factors were well managed.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Laparoscopy - 3

PREOPERATIVE DIAGNOSIS: , Chronic pelvic pain, probably secondary to endometriosis.,POSTOPERATIVE DIAGNOSIS:,  Mild pelvic endometriosis.,PROCEDURE:,1.  Attempted laparoscopy.,2.  Open laparoscopy.,3.  Fulguration of endometrial implant.,ANESTHESIA: , General endotracheal.,BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS:  ,The patient is a 21-year-old single female with chronic recurrent pelvic pain unresponsive to both estrogen and progesterone-containing birth control pills, either cyclically or daily as well as progestational medication only, who had a negative GI workup recently including colonoscopy, and desired definitive operative evaluation and diagnosis prior to initiation of a 6-month course of Depo-Lupron.,PROCEDURE: , After an adequate plane of general anesthesia had been obtained, the patient was placed in a dorsal lithotomy position.  She was prepped and draped in the usual sterile fashion for pelviolabdominal surgery.  Bimanual examination revealed a mid position normal-sized uterus with benign adnexal area.,In the high lithotomy position, a weighted speculum was placed into the posterior vaginal wall.  The anterior lip of the cervix was grasped with a single-tooth tenaculum.  A Hulka tenaculum was placed transcervically.  The other instruments were removed.  A Foley catheter was placed transurethrally to drain the bladder intraoperatively.,In the low lithotomy position and in steep Trendelenburg, attention was turned to the infraumbilical region.  Here, a stab wound incision was made through which the 120 mm Veress needle was placed and approximately 3 L of carbon dioxide used to create a pneumoperitoneum.  The needle was removed, the incision minimally enlarged, and the #5 trocar and cannula were placed.  The trocar was removed and the scope placed confirming a preperitoneal insufflation.,The space was drained off the insufflated gas and 2 more attempts were made, which failed due to the patient's adiposity.  Attention was turned back to the vaginal area where in the high lithotomy position, attempts were made at a posterior vaginal apical insertion.  The Hulka tenaculum was removed, the posterior lip of the cervix grasped with a single-tooth tenaculum, and the long Allis clamp used to grasp the posterior fornix on which was placed traction.  The first short and subsequently 15 cm Veress needles were attempted to be placed, but after several passes, no good pneumoperitoneum could be established via this route also.  It was elected not to do a transcervical intentional uterine perforation, but to return to the umbilical area.  The 15 cm Veress needle was inserted several times, but again a pneumo was preperitoneal.,Finally, an open laparoscopic approach was undertaken.  The skin incision was expanded with a knife blade.  Blunt dissection was used to carry the dissection down to the fascia.  This was grasped with Kocher clamps, entered sharply and opened transversely.  Four 0 Vicryl sutures were placed as stay sutures and tagged with hemostats and needles were cutoff.  Dissection continued between the rectus muscle and finally the anterior peritoneum was reached, grasped, elevated, and entered.,At this juncture, the Hasson cannula was placed and tied snugly with the above stay sutures while the pneumoperitoneum was being created, a #10 scope was placed confirming the intraperitoneal positioning.,Under direct visualization, a suprapubic 5 mm cannula and manipulative probe were placed.  Clockwise inspection of the pelvis revealed a benign vesicouterine pouch, normal uterus and fundus, normal right tube and ovary.  In the cul-de-sac, there were 3 clusters of 3 to 5 carbon charred type endometrial implants and those more distally in the greatest depth had created puckering and tenting.  The left tube and ovary were normal.  There were no adhesions.  There was no evidence of acute pelvic inflammatory disease.,The Endoshears and subsequently cautery on a hook were placed and the implants fulgurated.  Pictures were taken for confirmation both before and after the burn.,The carbon chars were irrigated and aspirated.  The smoke plume was removed without difficulty.  Approximately 50 mL of irrigant was left in the pelvis.  Due to the difficulty in placing and maintaining the Hasson cannula, no attempts were made to view the upper abdominal quadrant, specifically the liver and gallbladder.,The suprapubic cannula was removed under direct visualization, the pneumo released, the scope removed, the stay sutures cut, and the Hasson cannula removed.  The residual sutures were then tied together to completely occlude the fascial opening so that there will be no future hernia at this site.  Finally, the skin incisions were approximated with 3-0 Dexon subcuticularly.  They had been preincisionally injected with bupivacaine to which the patient said she had no known allergies.  The vaginal instruments were removed.  All counts were correct.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.
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DESCRIPTION: Attempted laparoscopy, open laparoscopy and fulguration of endometrial implant.   Chronic pelvic pain, probably secondary to endometriosis.

obstetrics / gynecology, endometriosis, fulguration, endometrial, single tooth tenaculum, endometrial implant, hulka tenaculum, veress needle, hasson cannula, pneumoperitoneum, laparoscopy, cannula,

This situation involves a surgical procedure due to chronic pelvic pain and suspected endometriosis. While the procedure seems to have been complicated by the patient's adiposity, leading to an initial failed laparoscopy and requiring an open laparoscopy approach, there were no complications reported, and the procedure was eventually completed successfully. The patient's management in terms of preoperative and postoperative care is vital, but complications appear to have been avoided, and the patient was stable postoperatively. The stakes are moderate due to the necessity of the procedure being performed appropriately to manage the patient's long-term pain and health.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 46

DIAGNOSES:,1.  Pneumonia.,2.  Crohn disease.,3.  Anasarca.,4.  Anemia.,CHIEF COMPLAINT: , I have a lot of swelling in my legs.,HISTORY:  ,The patient is a 41-year-old gentleman with a long history of Crohn disease.  He has been followed by Dr. ABC, his primary care doctor, but he states that he has had multiple gastroenterology doctors and has not seen one in the past year to 18 months.  He has been treated with multiple different medications for his Crohn disease and most recently has been taking pulses of steroids off and on when he felt like he was having symptoms consistent with crampy abdominal pain, increased diarrhea, and low-grade fevers.  This has helped in the past, but now he developed symptoms consistent with pneumonia and was admitted to the hospital.  He has been treated with IV antibiotics and is growing Streptococcus.  At this time, he seems relatively stable although slightly dyspneic.  Other symptoms include lower extremity edema, pain in his ankles and knees, and actually symptoms of edema in his entire body including his face and upper extremities.  At this time, he continues to have symptoms consistent with diarrhea and malabsorption.  He also has some episodes of nausea and vomiting at times.  He currently has a cough and symptoms of dyspnea.  Further review of systems was not otherwise contributory.,MEDICATIONS:,1.  Prednisone.,2.  Effexor.,3.  Folic acid.,4.  Norco for pain.,PAST MEDICAL HISTORY: , As mentioned above, but he also has anxiety and depression.,PAST SURGICAL HISTORY:,1.  Small bowel resections.,2.  Appendectomy.,3.  A vasectomy.,ALLERGIES:  ,He has no known drug allergies.,SOCIAL HISTORY:  ,He does smoke two packs of cigarettes per day.  He has no alcohol or drug use.  He is a painter.,FAMILY HISTORY:  ,Significant for his father who died of IPF and irritable bowel syndrome.,REVIEW OF SYSTEMS: , As mentioned in the history of present illness and further review of systems is not otherwise contributory.,PHYSICAL EXAMINATION:,GENERAL:  He is a thin appearing man in very mild respiratory distress when his oxygen is off.,VITAL SIGNS:  His respiratory rate is approximately 18 to 20, his blood pressure is 100/70, his pulse is 90 and regular, he is afebrile currently at 96, and weight is approximately 163 pounds.,HEENT:  Sclerae anicteric.  Conjunctivae normal.  Nasal and oropharynx are clear.,NECK:  Supple.  No jugular venous pressure distention is noted.  There is no adenopathy in the cervical, supraclavicular or axillary areas.,CHEST:  Reveals some crackles in the right chest, in the base, and in the upper lung fields.  His left is relatively clear with decreased breath sounds.,HEART:  Regular rate and rhythm.,ABDOMEN:  Slightly protuberant.  Bowel sounds are present.  He is slightly tender and it is diffuse.  There is no organomegaly and no ascites appreciable.,EXTREMITIES:  There is a mild scrotal edema and in his lower extremities he has 2 to 3+ edema at pretibial and lateral feet.,DERMATOLOGIC:  Shows thin skin.  No ecchymosis or petechiae.,LABORATORY STUDIES: , Laboratory studies are pertinent for a total protein of 3 and albumin of 1.3.  There is no M-spike observed.  His B12 is 500 with a folic acid of 11.  His white count is 21 with a hemoglobin of 10, and a platelet count 204,000.,IMPRESSION AT THIS TIME:,1.  Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.,2.  He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.,ASSESSMENT AND PLAN: , At this time, I believe evaluation of protein intake and dietary supplement will be most appropriate.  I believe that he needs a calorie count.  We will check on a sedimentation rate, C-reactive protein, LDH, prealbumin, thyroid, and iron studies in the morning with his laboratory studies that are already ordered.  I have recommended strongly to him that when he is out of the hospital, he return to the care of his gastroenterologist.  I will help in anyway that I can to improve the patient's laboratory abnormalities.  However, his lower extremity edema is primarily due to his marked hypoalbuminemia and I do not believe that diuretics will help him at this time.  I have explained this in detail to the patient and his family.  Everybody expresses understanding and all questions were answered.  At this time, follow him up during his hospital stay and plan to see him in the office as well.
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DESCRIPTION: Pneumonia in the face of fairly severe Crohn disease with protein-losing enteropathy and severe malnutrition with anasarca.  He also has anemia and leukocytosis, which may be related to his Crohn disease as well as his underlying pneumonia.

The patient is dealing with multiple serious health issues including pneumonia, a severe case of Crohn's disease with associated malnutrition and anasarca (generalized swelling), and anemia. These conditions together significantly impact his health and quality of life, requiring close medical attention and management. The potential for complication is high, including risk from pneumonia, malabsorption due to Crohn's disease, and systemic impacts from malnutrition and possible infection. The stakes are heightened by the chronic nature of Crohn's disease, the acute infection, and the considerable systemic complications evident in this case, including marked hypoalbuminemia. These factors combined make the situation high-stakes.


Medical Specialty: General Medicine
Sample Name: Toothache - ER Visit

CHIEF COMPLAINT:,  Toothache.,HISTORY OF PRESENT ILLNESS:  ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled.  Complains of new tooth pain.  The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days.  The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only.  The patient denies any other problems or complaints.  The patient denies any recent illness or injuries.  The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  No recent weight change.  HEENT:  No headache, no neck pain, the toothache pain for the past three days as previously mentioned.  There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids.  The patient denies any rhinorrhea.  No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No focal weakness or numbness.  Normal speech.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling has been noted.,PAST MEDICAL HISTORY: , Chronic knee pain.,CURRENT MEDICATIONS: , OxyContin and Vicodin.,ALLERGIES:,  PENICILLIN AND CODEINE.,SOCIAL HISTORY: , The patient is still a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient is a little overweight but otherwise appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Eyes are normal with clear conjunctiva and cornea bilaterally.  There is no icterus, injection, or discharge.  Pupils are 3 mm and equally round and reactive to light bilaterally.  There is no absence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Ears are normal bilaterally without any sign of infection.  There is no erythema, swelling of canals.  Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it.  Nose is normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  NECK:  Supple, nontender, and full range of motion.  There is no meningismus.  No cervical lymphadenopathy.  No JVD.  Mouth and oropharynx shows multiple denture and multiple dental caries.  The patient has tenderness to tooth #12 as well as tooth #21.  The patient has normal gums.  There is no erythema or swelling.  There is no purulent or other discharge noted.  There is no fluctuance or suggestion of abscess.  There are no new dental fractures.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion or swelling.  The buccal membranes are normal.  Mucous membranes are moist.  The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally without shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to back, arms and legs.  The patient has normal use of his extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact to the extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No cervical lymphadenopathy is palpated.,EMERGENCY DEPARTMENT COURSE: , The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.,DIAGNOSES:,1.  ODONTALGIA.,2.  MULTIPLE DENTAL CARIES.,CONDITION UPON DISPOSITION:  ,Stable.,DISPOSITION: , To home.,PLAN: , The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes.  The patient was requested to have reevaluation within two days.  The patient was given a prescription for Percocet and clindamycin.  The patient was given drug precautions for the use of these medicines.  The patient was offered discharge instructions on toothache but states that he already has it.  He declined the instructions.  The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.
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DESCRIPTION: Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..

general medicine, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental,

The primary concern in this scenario is a toothache and dental pain, which, while uncomfortable, typically isn't immediately life-threatening. The patient has chronic dental issues but no significant systemic symptoms or signs of a severe infection, as indicated by the lack of fever, swelling, or abscess. Although he requested stronger pain medication, this is often a subjective measure of pain tolerance and management. The situation could escalate if untreated dental infections develop into systemic infections, but as of now, it remains relatively low-stakes. The patient has been stabilized and discharged with a follow-up plan.


Medical Specialty: Psychiatry / Psychology
Sample Name: Bipolar Affective Disorder - Consult

IDENTIFYING DATA:  ,The patient is a 35-year-old Caucasian female who speaks English.,CHIEF COMPLAINT:  ,The patient has a manic disorder, is presently psychotic with flight of ideas, believes, "I can fly," tangential speech, rapid pressured speech and behavior, impulsive behavior.  Last night, she tried to turn on the garbage disposal and put her hand in it, in the apartment shared by her husband.  She then turned on the oven and put her head in the oven and then tried to climb over the second storied  balcony.  All of these behaviors were interrupted by her husband who called 911.  He reports that she has not slept in 3 to 5 days and has not taken her meds in at least that time period.,HISTORY OF PRESENT ILLNESS:  ,The patient was treated most recently at ABCD Hospital and decompensated during that admission resulting in her 90-day LR being revoked.  After leaving ABCD approximately 01/25/2010, she stopped taking her Abilify and lithium.  Her husband states that he restrained her from jumping, "so she would not kill herself," and this was taken as a statement in his affidavit.  The patient was taken to X Hospital, medically cleared, given Ativan 2 mg p.o. and transferred on an involuntary status to XYZ Hospital.  She arrives here and is today pacing on the unit and in and out of the large TV room area.  She is friendly towards the patients although sometimes raises her voice and comes too close to other patients in a rapid manner.  She is highly tangential, delusional, and disorganized.  She refused to sign all admit papers and a considerable part of her immediate history is unknown.,PAST PSYCHIATRIC HISTORY:  ,The patient was last admitted to XYZ Hospital on January 14, 2009, and discharged on January 23, 2009.  Please see the excellent discharge summary of Dr. X regarding this admission for information, which the patient is unable to give at the present.  She is currently treated by Dr. Y.  She has been involuntarily detained at least 7 times and revoked at least 6 times.  She was on XYZ Inpatient in 2001 and in 01/2009.  She states that she "feels invincible" when she becomes manic and this is also the description given by her husband.,MEDICAL HISTORY:  ,The patient has a history of a herniated disc in 1999.,MEDICATIONS: , Current meds, which are her outpatient meds, which she is not taking at the moment are lithium 300 mg p.o.  AM and 600 mg p.o. q.p.m., Abilify 15 mg p.o. per day, Lyrica 100 mg p.o. per day, it is not clear if she is taking Geodon as the record is conflicting in this regard.  She is being given Vicodin, is not sure who the prescriber for that medication is and it is presumably due to her history of herniated disc.  Of note, she also has a history of abusing Vicodin.,ALLERGIES:  ,Said to be PENICILLIN, LAMICTAL, and ZYPREXA.,SOCIAL AND DEVELOPMENTAL HISTORY: , The patient lives with her husband.  There are no children.  She reportedly has a college education and has 2 brothers.,SUBSTANCE AND ALCOHOL HISTORY: , Per ABCD information, the patient has a history of abusing opiates, benzodiazepines, and Vicodin.  The X Hospital tox screen of last night was positive for opiates.  Her lithium level per last night at X Hospital was 0.42 mEq/L.  She smokes nicotine, the amount is not known although she has asked and received Nicorette gum.,LEGAL HISTORY: , She had a 90-day LR, which was revoked at ABCD Hospital, 12/ 25/2009, when she quickly deteriorated.,MENTAL STATUS EXAM:,ATTITUDE: ,The patient's attitude is agitated when asked questions, loud and evasive.,APPEARANCE:,  Disheveled and moderately well nourished.,PSYCHOMOTOR: , Restless with erratic sudden movements.,EPS:,  None.,AFFECT: , Hyperactive, hostile, and labile.,MOOD: , Her mood is agitated, suspicious, and angry.,SPEECH:  ,Circumstantial and sometimes intelligible when asked simple direct questions and at other points becomes completely tangential describing issues which are not real.,THOUGHT CONTENT: , Delusional, disorganized, psychotic, and paranoid.  Suicidal ideation, the patient refuses to answer the questions, but the record shows a past history of suicide attempt.,COGNITIVE ASSESSMENT:  ,The patient was said on her nursing admit to be oriented to place and person, but could not answer that question for me, and appeared to think that she may still be at ABCD Hospital.  Her recent, intermediate, and remote memory are impaired although there is a lack of cooperation in this testing.,JUDGMENT AND INSIGHT:,  Nil.  When asked, are there situations when you lose control, she refuses to answer.  When asked, are meds helpful, she refuses to answer.  She refuses to give her family information nor release of information to contact them.,ASSETS:,  The patient has an outpatient psychiatrist and she does better or is more stable when taking her medications.,LIMITATIONS:,  The patient goes off her medications routinely, behaves unsafely and in a potentially suicidal manner.,FORMULATION,:  The patient has bipolar affective disorder in a manic state at present.  She also may be depressed and is struggling with marital issues.,DIAGNOSES:
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DESCRIPTION: The patient has a manic disorder, is presently psychotic with flight of ideas, tangential speech, rapid pressured speech and behavior, impulsive behavior.   Bipolar affective disorder, manic state.  Rule out depression.

The situation involves a patient with bipolar affective disorder in a manic and potentially psychotic state, showing suicidal behavior. She has acted on dangerous impulses which could lead to self-harm or accidental death, and has a history of similar issues. The stakes are high due to immediate safety concerns for the patient and the need for urgent stabilization to prevent harm.


Medical Specialty: Orthopedic
Sample Name: Kyphoplasty & Vertebroplasty

PREOPERATIVE DIAGNOSES:,1.  Pathologic insufficiency.,2.  Fracture of the T8 vertebrae and T9 vertebrae.,POSTOPERATIVE DIAGNOSES:,1.  Pathologic insufficiency.,2.  Fracture of the T8 vertebra and T9 vertebra.,PROCEDURE PERFORMED:,1.  Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty.,2.  Vertebroplasties at T7 and T9 with insertion of prosthetic device.,ANESTHESIA: , Local with sedation.,SPECIMEN: , Bone from the T8 vertebra.,COMPLICATIONS:,  None.,SURGICAL INDICATIONS:,  The patient is an 80-year-old female who had previous history of compression fractures.  She had recently undergone an additional compression fracture of the T8 vertebrae.  She was in extreme pain.  This pain interfered with activities of daily living and was unimproved with conservative treatment modalities.  She is understanding the risks, benefits, and potential complications as well as all treatment alternatives.  The patient provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #2 where she was placed prone on the Jackson spinal table.  She was given sedative.  The thoracodorsal spine was then sterilely prepped and draped in the usual fashion.  Biplanar image intensification was utilized to localize the T8, T7, and T9 vertebrae.  Local anesthetic of 1% Marcaine with epinephrine and lidocaine were 50:50 mixed.,Approximately 7 cc was instilled on the left side.  This was directly over the posterior aspect of the pedicle on the left.  Once this was localized, the right side was localized as well.  Stab incisions were then created over the pedicles of T8 bilaterally.  Jamshidi needles were then placed percutaneously.  Their position was verified in both AP and lateral images.  They were advanced slowly under direct image intensification in biplanar fashion.  Once these were satisfactorily placed, the inner trocar was removed and a guidewire was inserted into the depths of the T7 vertebrae.  The Jamshidi needles were then removed.  A biopsy was then harvested with a biopsy trocar placed into the T8 vertebrae.  This bone was then removed and sent to the lab.  The injection cannulas were then placed over the guidewires and their position was verified in both AP and lateral images.  Once this was completed, a second Jamshidi needle was placed at the T7 vertebrae on the left at the entrance of the pedicle.  This was advanced under direct image intensification in a biplanar fashion.  Once this was deemed satisfactory, it was impacted.  The inner trocar was removed and a guidewire was then placed.  An injection cannula was then placed over the guidewire into the body of T7.  In a similar fashion, T9 was dressed on the left side as well.  A guidewire was then placed through the Jamshidi needle, which was verified in both AP and lateral images.  The cement injection cannula was then placed over this entering the T9 vertebrae body.  Attention was then turned to the kyphoplasty portion of the procedure at the T8 vertebrae.  The balloons were inserted bilaterally.  The balloons were then inflated under direct image intensification and pressurized to approximately 200 mmHg.  These were allowed to expand and reduce the fracture.  Once this was completed, the balloons were deflated and removed.  The inner cannulas of all four entrance holes were removed and approximately 1.5 cc of cement was injected in each of the cannulas.  This was done directly under image intensification.  Once this was completed, additional cement was injected into T9 as there was a larger vertebra.  The cement was allowed to cure.  The cannula was removed and final radiographs were obtained.  The stab incisions were then cleansed with water and antibiotic irrigation.  The wounds were then approximated with #4-0 Nylon in interrupted fashion.  Compression dressings were applied and fixed with tape.  She was aroused and moved to her inpatient bed.  She was moving all four extremities without deficit.  She had no significant pain.
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DESCRIPTION: Fracture reduction with insertion of prosthetic device at T8 with kyphoplasty.   Vertebroplasties at T7 and T9 with insertion of prosthetic device.   Fracture of the T8 vertebra and T9 vertebra.

orthopedic, pathologic insufficiency, vertebrae, fracture, fracture reduction, vertebroplasties, kyphoplasty, prosthetic device, jamshidi needles, insertion, prosthetic,

The described procedure is a surgical intervention involving kyphoplasty and vertebroplasty, targeting a patient with compression fractures causing extreme pain and impairment in daily activities. Although this type of surgery is often routine and performed frequently in orthopedic practice, it still carries inherent risks of complications and impacts the patient's quality of life significantly. These factors suggest it's moderate on the stakes scale, due to potential impacts on patient's mobility and pain management. However, the procedure being routine and the absence of any complications reduce the stakes considerably.


Medical Specialty: Bariatrics
Sample Name: Lap Band Adjustment

REASON FOR VISIT:,  Lap band adjustment.,HISTORY OF PRESENT ILLNESS:,  Ms. A is status post lap band placement back in 01/09 and she is here on a band adjustment.  Apparently, she had some problems previously with her adjustments and apparently she has been under a lot of stress.  She was in a car accident a couple of weeks ago and she has problems, she does not feel full.  She states that she is not really hungry but she does not feel full and she states that she is finding when she is hungry at night, having difficulty waiting until the morning and that she did mention that she had a candy bar and that seemed to make her feel better.,PHYSICAL EXAMINATION: , On exam, her temperature is 98, pulse 76, weight 197.7 pounds, blood pressure 102/72, BMI is 38.5, she has lost 3.8 pounds since her last visit.  She was alert and oriented in no apparent distress.  ,PROCEDURE:  ,I was able to access her port.  She does have an AP standard low profile.  I aspirated 6 mL, I did add 1 mL, so she has got approximately 7 mL in her band, she did tolerate water postprocedure.,ASSESSMENT:,  The patient is status post lap band adjustments, doing well, has a total of 7 mL within her band, tolerated water postprocedure.  She will come back in two weeks for another adjustment as needed.,
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DESCRIPTION: Patient status post lap band placement.

Patient status post lap band placement.

bariatrics, lap band adjustment, lap band placement, lap band,

The situation involves a routine medical procedure known as a lap band adjustment, which is a standard part of managing weight in patients who have undergone bariatric surgery. While the patient has experienced some stress and a recent car accident, these factors do not significantly increase stakes within the medical context provided, since the procedure was completed successfully without complication. Furthermore, there is no immediate risk to the patient's life or long-term health apparent in the scenario.


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

Medical Specialty: Dermatology
Sample Name: Cheek-Neck Facelift

PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis.  Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:,  Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825).  Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-old female who has progressive aging changes of the face and neck.  The patient demonstrates the deformities described above and has requested surgical correction.  The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient.  The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table.  An intravenous line was started and anesthesia was maintained throughout the case.  The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line.  A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline.  In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift.  The incision was marked in the submental crease for the submental lipectomy and liposuction.  The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine.  This provided local anesthesia and vasoconstriction.  The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery.  A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible.  4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly.  The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels.  Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area.  A similar procedure was performed with the 4 mm cannula cleaning the area.  Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle.  A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion.  5-0 plain catgut was used for closure in a running interlocking fashion.  The wound was cleaned at the end, dried, and Mastisol applied.  Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal.  A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region.  A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin.  The incision was made in the temporal area beveling parallel with the hair follicles.  (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid.  The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim.  At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible.  This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl.  Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS.  The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region.  When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected.  At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM.  The SMAS flap was then advanced posteriorly and superiorly.  The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum.  The excess SMAS was trimmed and excised from the portion anterior to the auricle.  The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained.  The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture.  The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period.  Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area.  The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion.  5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing.  The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut.  The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation.  Any small amount of fluid was expressed post-auricularly.  A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure.  A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas.  This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion.  The entire dressing complex was secured with a pre-formed elastic stretch wrap device.  All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well.  The patient left the operating room in satisfactory condition.  A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition.
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DESCRIPTION: Temporal cheek-neck facelift  and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides.

dermatology, neck skin ptosis, lipotosis, rhytides, facelift, submental suction assisted lipectomy, pre and post auricular, cheek neck facelift, auricular region, neck facelift, cheek neck, post auricular, auricular, incision, postoperative, cheek, submental, dissection, neck,

This case involves a significant surgical procedure that requires general anesthesia. A temporal cheek-neck facelift combined with submental suction assisted lipectomy is a complex operation with inherent risks such as infection, anesthesia complications, and potential nerve damage. The level of care and precision needed indicates the stakes are high, as these procedures have direct implications on the patient’s health, well-being, and appearance.


Medical Specialty: Orthopedic
Sample Name: Lateral Epicondylitis Release

PREOPERATIVE DIAGNOSIS:  ,Lateral epicondylitis.
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DESCRIPTION: Lateral release with lengthening of the ECRB tendon.  Lateral epicondylitis.

orthopedic, lateral release, ecrb tendon, ecrl, lateral epicondylitis, tourniquet, aponeurosis, epicondyle, antebrachial, epicondylitis, dissection, extensor, ecrb

The situation involves a surgical procedure for treating lateral epicondylitis, commonly known as tennis elbow. While surgery always carries some risks, this is generally considered a routine orthopedic procedure and not typically life-threatening. Therefore, this situation is not extremely high-stakes compared to more complex or life-threatening surgeries.


Medical Specialty: Orthopedic
Sample Name: Knee Arthroplasty - Discharge Summary

ADMISSION DIAGNOSIS:,  Painful right knee status post total knee arthroplasty many years ago.  The patient had gradual onset of worsening soreness and pain in this knee.  X-ray showed that the poly seems to be worn out significantly in this area.,DISCHARGE DIAGNOSIS:,  Status post poly exchange, right knee, total knee arthroplasty.,CONDITION ON DISCHARGE:,  Stable.,PROCEDURES PERFORMED:,  Poly exchange total knee, right.,CONSULTATIONS: , Anesthesia managed femoral nerve block on the patient.,HOSPITAL COURSE:  ,The patient was admitted with revision right total knee arthroplasty and replacement of patellar and tibial poly components.  The patient recovered well after this.  Working with PT, she was able to ambulate with minimal assistance.  Nerve block was removed by anesthesia.  The patient did well on oral pain medications.  The patient was discharged home.  She is actually going to home with her son who will be able to assist her and look after her for anything she might need.  The patient is comfortable with this, understands the therapy regimen, and is very satisfied after the procedure.,DISCHARGE INSTRUCTIONS AND MEDICATIONS: , The patient is to be discharged home to the care of the son.  Diet is regular.  Activity, weight bear as tolerated right lower extremity.  Continue to do physical therapy exercises.  The patient will be discharged home on Coumadin 4 mg a day as the INR was 1.9 on discharge with twice weekly lab checks.  Vicodin 5/500 mg take one to two tablets p.o. q.4-6h.  Resume home medications.  Call the office or return to the emergency room for any concerns including increased redness, swelling, drainage, fever, or any concerns regarding operation or site of incision.  The patient is to follow up with Dr. ABC in two weeks.
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DESCRIPTION: Painful right knee status post total knee arthroplasty many years ago.   Status post poly exchange, right knee, total knee arthroplasty.

orthopedic, painful right knee, total knee arthroplasty, poly exchange, femoral nerve block, patellar, tibial poly, knee arthroplasty, knee, arthroplasty,

The patient's condition following knee arthroplasty is stable, and they have recovered well enough to be discharged home. They have support from their son, are responding well to oral pain medications, and are comfortable with the therapy regimen. The instructions for follow-up are clear, and the patient has a support system in place. These factors collectively indicate that while medical procedures and recovery involve some level of risk, the situation is generally low-stakes given the patient's stability and supportive discharge plan.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Diabetes Mellitus - SOAP Note - 1

CHIEF COMPLAINT:  ,Followup diabetes mellitus, type 1., ,SUBJECTIVE:,  Patient is a 34-year-old male with significant diabetic neuropathy.  He has been off on insurance for over a year.  Has been using NPH and Regular insulin to maintain his blood sugars.  States that he is deathly afraid of having a low blood sugar due to motor vehicle accident he was in several years ago.  Reports that his blood sugar dropped too low which caused the accident.  Since this point in time, he has been unwilling to let his blood sugars fall within a normal range, for fear of hypoglycemia. Also reports that he regulates his blood sugars with how he feels, rarely checking his blood sugar with a glucometer., ,Reports that he has been worked up extensively at hospital and was seeing an Endocrinologist at one time.  Reports that he had some indications of kidney damage when first diagnosed.  His urine microalbumin today is 100.  His last hemoglobin A1C drawn at the end of December is 11.9.  Reports that at one point, he was on Lantus which worked well and he did not worry about his blood sugars dropping too low. While using Lantus, he was able to get his hemoglobin A1C down to 7.  His last CMP shows an elevated alkaline phosphatase level of 168. He denies alcohol or drug use and is a non smoker.  Reports he quit drinking 3 years ago. I have discussed with patient that it would be appropriate to do an SGGT and hepatic panel today.  Patient also has a history of gastroparesis and impotence.  Patient requests Nexium and Viagra, neither of which are covered under the Health Plan.  , ,Patient reports that he was in a scooter accident one week ago, fell off his scooter, hit his head.  Was not wearing a helmet.  Reports that he did not go to the emergency room and had a headache for several days after this incident.  Reports that an ambulance arrived at the scene and he was told he had a scalp laceration and to go into the emergency room.  Patient did not comply.  Reports that the headache has resolved.  Denies any dizziness, nausea, vomiting, or other neurological abnormalities., ,PHYSICAL EXAMINATION: , WD, WN.  Slender, 34-year-old white male.  VITAL SIGNS:  Blood sugar 145, blood pressure 120/88, heart rate 104, respirations 16.  Microalbumin 100. SKIN:  There appears to be 2 skin lacerations on the left parietal region of the scalp, each approximately 1 inch long.  No signs of infection.  Wound is closed with new granulation tissue.  Appears to be healing well.  HEENT:  Normocephalic.  PERRLA.  EOMI.  TMs pearly gray with landmarks present.  Nares patent.  Throat with no redness or swelling.  Nontender sinuses.  NECK:  Supple.  Full ROM.  No LAD. CARDIAC:
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DESCRIPTION: Followup diabetes mellitus, type 1.

Followup diabetes mellitus, type 1.

soap / chart / progress notes, diabetes mellitus, nph, regular insulin, sggt, diabetic neuropathy, dizziness, followup, glucometer, hypoglycemia, microalbumin, nausea, neurological, vomiting, mellitus type, blood sugars, blood, diabetes, mellitus, sugars

The situation involves a patient with diabetes mellitus type 1 and several complications, including fear of hypoglycemia affecting his insulin management, significant diabetic neuropathy, prior indications of kidney damage, elevated A1C levels, and recent injuries from a scooter accident without seeking immediate medical attention. Type 1 diabetes, especially with such a high A1C and poor management, can result in severe complications, including but not limited to cardiovascular disease, kidney failure, and nerve damage. These complications could lead to long-term health consequences or emergencies. Additionally, the patient's reluctance to address low blood sugar levels poses an acute risk. Moreover, there is potential for further health degradation if his head injury is not thoroughly evaluated, particularly since he experienced a scalp laceration and significant headaches after the accident.


Medical Specialty: Surgery
Sample Name: YAG Laser Capsulotomy

PREOPERATIVE DIAGNOSIS:,  Visually significant posterior capsule opacity, right eye.,POSTOPERATIVE DIAGNOSIS:,  Visually significant posterior capsule opacity, right eye.,OPERATIVE PROCEDURES:  ,YAG laser posterior capsulotomy, right eye.,ANESTHESIA: , Topical anesthesia using tetracaine ophthalmic drops.,INDICATIONS FOR SURGERY: , This patient was found to have a visually significant posterior capsule opacity in the right eye.  The patient has had a mild decrease in visual acuity, which has been a gradual change.  The posterior capsule opacity was felt to be related to the decline in vision.  The risks, benefits, and alternatives (including observation) were discussed.  I feel the patient had a good understanding of the proposed procedure and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified.  Pupil was dilated per protocol.  Patient was positioned at the YAG laser.  Then, *** of energy were used to perform a circular posterior laser capsulotomy through the visual axis.  A total of ** shots were used.  Total energy was **.  The patient tolerated the procedure well and there were no complications.  The lens remained well centered and stable.  Postoperative instructions were provided.  Alphagan P ophthalmic drops times two were instilled prior to his dismissal.,Post-laser intraocular pressure measured ** mmHg.  Postoperative instructions were provided and the patient had no further questions.
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DESCRIPTION: Visually significant posterior capsule opacity, right eye.  YAG laser posterior capsulotomy, right eye.

surgery, capsule opacity, yag, ophthalmic, yag laser posterior capsulotomy, capsulotomy, opacity, laser, visually, eye, anesthesia

The procedure described is a YAG laser capsulotomy, a common and generally low-risk outpatient procedure performed to treat posterior capsule opacity, which can occur after cataract surgery. While all surgical procedures carry some inherent risks, this type of surgery is routine, minimally invasive, and typically has a high success rate with few complications. The situation involves ensuring the patient's vision is corrected, but it does not typically pose a significant risk to the patient's life or overall health beyond the impact on vision. Therefore, it is not considered a high-stakes medical situation.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Lung Cancer Followup

CHIEF COMPLAINT:,1.  Extensive stage small cell lung cancer.,2.  Chemotherapy with carboplatin and etoposide.,3.  Left scapular pain status post CT scan of the thorax.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old female with extensive stage small cell lung cancer.  She is currently receiving treatment with carboplatin and etoposide.  She completed her fifth cycle on 08/12/10.  She has had ongoing back pain and was sent for a CT scan of the thorax.  She comes into clinic today accompanied by her daughters to review the results.,CURRENT MEDICATIONS: , Levothyroxine 88 mcg daily, Soriatane 25 mg daily, Timoptic 0.5% solution b.i.d., Vicodin 5/500 mg one to two tablets q.6 hours p.r.n.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:  ,The patient continues to have back pain some time she also take two pain pill.  She received platelet transfusion the other day and reported mild fever.  She denies any chills, night sweats, chest pain, or shortness of breath.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:
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DESCRIPTION: Extensive stage small cell lung cancer.  Chemotherapy with carboplatin and etoposide.  Left scapular pain status post CT scan of the thorax.

soap / chart / progress notes, small cell lung cancer, carboplatin, etoposide, pet/ct, pleural base, base mass, extensive stage, ct scan, lung cancer, lung, cancer,

The scenario involves a patient with extensive stage small cell lung cancer, a serious and life-threatening condition. The patient is undergoing chemotherapy, has experienced back pain, and requires a CT scan to evaluate potential issues. The involvement of a CT scan and discussion of results indicate that there may be significant changes in the patient's health status, which could impact treatment decisions and overall prognosis. This context makes the situation high-stakes as it pertains to the patient's health outcomes and treatment plan.


Medical Specialty: Urology
Sample Name: Testicular Pain

CHIEF COMPLAINT: , Testicular pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 4-year-old boy with a history of abrupt onset of left testicular pain at 11:30 this morning.  He was unable to walk and would not stand upright, and had fairly significant discomfort, so the parents checked his panel because of it.  Because of this, they took him to Emergency Department, at which time, he had no swelling noted initially, but very painful.  He had no voiding or stooling problems.  No nausea, vomiting or fever.  Family denies trauma or dysuria.  At that time, he was going to get an ultrasound done, but the mother said that all of sudden the patient stated the pain had resolved.  He has had hot chocolate this morning at 10:30 in the morning and water around 2:30 in the morning.  He has not had any pain since but states that he has had pain in the past, not as long and states there was a twisting sensation.  He has no recent cold or flu, although he had rhinorrhea about 3 weeks ago.  He is on no medications and he is here for evaluation.,PAST MEDICAL HISTORY:,  The patient has no known allergies.  He is term delivery via spontaneous vaginal delivery.  He has had no problems or hospitalizations with circumcision.,PAST SURGICAL HISTORY: , He has had no previous surgeries.,REVIEW OF SYSTEMS:,  All 14-point review of systems were negative except for the above left testicular pain and the history of possible upper respiratory infection about 2 to 3 weeks ago.,IMMUNIZATIONS: , Up-to-date.,FAMILY HISTORY: , The patient lives at home with both parents who are Spanish speaking.  He is not in school.,MEDICATIONS:,  He is on no medications.,PHYSICAL EXAMINATION:,VITAL SIGNS:  On physical exam, weight is 15.9 kg.,GENERAL:  The patient is a cooperative little boy.,HEENT:  Normal head and neck exam.  No oral or nasal discharge.,NECK:  Without masses.,CHEST:  Without masses.,LUNGS:  Clear.,CARDIAC:  Without murmurs or gallops.,ABDOMEN:  Soft.  No masses or tenderness.  His scrotum did not have any swelling at the present time.  There was only minimal discomfort with palpation at the left inguinal area, but no masses were noted.  No palpable nodules such as appendix testis and no swelling was noted and he had mild epididymal swelling only.  His left testis was slightly harder than the right, but this was not very significant.,EXTREMITIES:  He had full range of motion in all 4 extremities.,SKIN:  Warm, pink, and dry.,NEUROLOGIC:  Grossly intact.,LABORATORY DATA: , Ultrasound was obtained today showing no blood flow or poor blood flow on the left except for increased blood flow to the epididymis on the study done at about 1330 hours, and second one done around 1630 hours was normal flow, possible increased flow on the left.  This is personally reviewed by me.  The right was normal.  No masses were appreciated.  There was some mild change in echotexture on the left on the initial study, which had apparently resolved on the second, but may be due to the technical aspects of the study.,ASSESSMENT/PLAN: , The patient has a possibly torsion detorsion versus other acute testicular problem.  If the patient has indeed testicular torsion, there is an increased possibility that it may reoccur again, actually within the first 24 to 36 hours and as such is recommended doing a left scrotal exploration with possible detorsion of left testis, possible orchiectomy if the testis is markedly abnormal or nonviable, which probably is not the case, and bilateral testes fixation if the torsion is found.  I discussed the pre and postsurgical care with the parents.  Procedure itself with potential complications, risks, benefits, and alternatives of surgery including that the torsion could occur again, although it is less likely after the surgical fixation procedure.  The parents understand and wished to proceed.  We will schedule this later today emergently.
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DESCRIPTION: The patient has a possibly torsion detorsion versus other acute testicular problem.

The situation involves a young child with suspected testicular torsion, a medical emergency due to the risk of losing the testicle if not promptly addressed. The need for urgent surgical intervention indicates high stakes, as delays can lead to irreversible damage or loss of the testicle. The decision to perform surgery emergently demonstrates the critical nature of the condition.