Medical Specialty: Ophthalmology
Sample Name: Rhytidectomy & Blepharoplasty

PREOPERATIVE DIAGNOSIS:,  Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION:  ,This is a 62-year-old female for the above-planned procedure.  She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied.  Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table.  Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen.  This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized.  Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty.  Markers were applied to both upper lids in symmetrical fashion.  The skin was excised from the right upper lid first followed by appropriate muscle resection.  Minimal fat removed from the medial upper portion of the eyelid.  Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture.  Attention was then turned to the lower lid.  A classic skin muscle flap was created accordingly.  Fat was resected from the middle, medial, and lateral quadrant.  The fat was allowed to open drain the arcus marginalis for appropriate contour.  Hemostasis was controlled with the pinpoint cautery accordingly.  Skin was redraped with a conservative amount resected.  Running closure with 7-0 nylon was accomplished without difficulty.  The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes.  Eye mass was likewise clamped.  Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure.  The right face was first operated.  It was injected with a 0.25% Marcaine 1:200,000 adrenaline.  A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula.  She had minimal subcutaneous extra fat as noted.  Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline.  The flap was elevated without difficulty with various facelift scissors.  Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision.  Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery.  The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication.  The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene.  The skin was draped appropriately and appropriate tissue was resected.  A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface.  Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon.  The hairline temporal incision was closed with running 5-0 nylon.  The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described.  Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly.  Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly.  Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure.  The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure.  She will be discharged in the morning.,Estimated blood loss was less than 75 cc.  No complications noted, and the patient tolerated the procedure well.
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DESCRIPTION: Cervical facial rhytidectomy.  Quadrilateral blepharoplasty.  Autologous fat injection to the upper lip - donor site, abdomen.

ophthalmology, ageing face, adaptic polysporin ointment, autologous fat injection, bovie cautery, kerlix wrap, smas plication, arcus marginalis, blepharoplasty, facelift, platysmal sling, quadrilateral, rhytidectomy, right upper lid, cervical facial rhytidectomy, pinpoint cautery, facial rhytidectomy, quadrilateral blepharoplasty, running nylon, autologous,

The procedures mentioned, such as cervical facial rhytidectomy and blepharoplasty, are cosmetic surgeries aimed at addressing signs of aging. These procedures, while requiring precision and expert execution, are generally considered elective and are performed for aesthetic purposes. They typically carry a lower risk profile compared to more urgent or life-saving surgeries. The document specifies that full informed consent was obtained, there were no complications, and the estimated blood loss was minimal, indicating the procedure proceeded smoothly. However, any surgical procedure involving anesthesia and incisions carries inherent risks, contributing slightly to the stakes.


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

Medical Specialty: Ophthalmology
Sample Name: Post Dilation Instructions

The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult and sensitivity to light may increase. For a short time, wearing sunglasses may help.
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DESCRIPTION: Sample post dilation patient instructions.

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

Post dilation instructions relate to temporary effects after an eye examination, where patients may experience blurred vision and light sensitivity. These instructions are standard, with temporary mild discomfort that typically resolves within hours. This is routine for ophthalmology patients and not critical or life-threatening, thus the situation is low-stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification of Cataract

PREOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,POSTOPERATIVE DIAGNOSIS (ES):, Cataract, right eye.,PROCEDURE:, Right phacoemulsification of cataract with intraocular lens implantation.,DESCRIPTION OF THE OPERATION:, Under topical anesthesia with monitored anesthesia care, the patient was prepped, draped and positioned under the operating microscope. A lid speculum was applied to the right eye, and a stab incision into the anterior chamber was done close to the limbus at about the 1 o'clock position with a Superblade, and Xylocaine 1% preservative free 0.25 mL was injected into the anterior chamber, which was then followed by Healon to deepen the anterior chamber. Using a keratome, another stab incision was done close to the limbus at about the 9 o'clock position and with the Utrata forceps, anterior capsulorrhexis was performed, and the torn anterior capsule was totally removed. Hydrodissection and hydrodelineation were performed with the tuberculin syringe filled with BSS. The tip of the phaco unit was introduced into the anterior chamber, and anterior sculpting of the nucleus was performed until about more than two-thirds of the nucleus was removed. Using the phaco tip and the Drysdale hook, the nucleus was broken up into 4 pieces and then phacoemulsified.,The phaco tip was then exchanged for the aspiration/irrigation tip, and cortical materials were aspirated. Posterior capsule was polished with a curette polisher, and Healon was injected into the capsular bag. Using the Monarch intraocular lens inserter, the posterior chamber intraocular lens model SN60WF power +19.50 was placed into the inserter after applying some Healon, and the tip of the inserter was gently introduced through the cornea tunnel wound, into the capsular bag and then the intraocular lens was then inserted inferior haptic first into the back and the superior haptic was placed into the bag with the same instrument. Intraocular lens was then rotated about half a turn with a collar button hook. Healon was removed with the aspiration/irrigation tip, and balanced salt solution was injected through the side port to deepen the anterior chamber. It was found that there was no leakage of fluid through the cornea tunnel wound. For this reason, no suture was applied. Vigamox, Econopred and Nevanac eye drops were instilled and the eye was covered with a perforated shield. The patient tolerated the procedure well. There were no complications.
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DESCRIPTION: Right phacoemulsification of cataract with intraocular lens implantation - Cataract, right eye.

ophthalmology, cataract, implantation, intraocular, intraocular lens, lens implantation, phacoemulsification, capsular bag, capsule, intraocular lens implantation, cornea tunnel wound, phacoemulsification of cataract, cornea tunnel, anterior chamber, anesthesia, cornea, lens, chamber,

The described procedure is a cataract surgery using phacoemulsification with intraocular lens implantation. While cataract surgery is generally considered safe and routine with high success rates, it still carries some level of risk due to it being an invasive procedure performed on the eye, which is a delicate and essential organ. Any surgical procedure has inherent risks, such as infection or complications that could affect vision. Thus, while not extremely high-stakes compared to other surgeries (e.g., neurosurgery or heart surgery), it is still significant because of the potential impact on vision if something were to go wrong.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Lens Implantation - 5

PREOPERATIVE DIAGNOSIS:,  Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,OPERATION PERFORMED: , Phacoemulsification with IOL, right eye.,ANESTHESIA:,  Topical with MAC.,COMPLICATIONS,:  None.,ESTIMATED BLOOD LOSS: , None.,PROCEDURE IN DETAIL:  After appropriate consent was obtained, the patient was brought to the operating room and then prepared and draped in the usual sterile fashion per Ophthalmology.  A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.  A 2.75-mm keratome then made a stab incision at the 2 o'clock position through which an anterior capsulorrhexis was performed using cystotome and Utrata.  BSS on blunt cannula, hydrodissector, and spun the nucleus after which phacoemulsification divided the nucleus in 3 quadrants each was subsequently cracked and removed through phacoemulsification I&A.  Healon was injected into the posterior capsule and a XXX lens was then placed with a shooter into the posterior capsule and rotated into position with I&A, which then removed all remaining cortex as well as viscoelastic material.  BSS on blunt cannula hydrated all wounds, which were noted to be free of leak and lid speculum was removed.  Under microscope, the anterior chamber being soft and well formed.  Pred Forte, Vigamox, and Iopidine were placed in the eye.  A shield was placed over the eye.  The patient was followed to recovery where he was noted to be in good condition.
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DESCRIPTION: Phacoemulsification with IOL, right eye.  Cataract, right eye.  A lid speculum was placed in the right eye after which a supersharp was used to make a stab incision at the 4 o'clock position through which 2% preservative-free Xylocaine was injected followed by Viscoat.

ophthalmology, lid speculum, lens, iol, viscoat, posterior, capsule, cataract, speculum, incision, phacoemulsification

The situation described is a medical procedure involving cataract surgery with phacoemulsification, which is a common and generally low-risk ophthalmological procedure performed to restore vision. While important as it affects the patient's vision quality, it is routine and typically has a high success rate with minimal complications, as indicated by the lack of complications in this particular case. Therefore, while it requires skill and precision, it doesn't usually reach the highest levels of stakes compared to other medical operations such as neurosurgery or heart surgery.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Lens Implantation - 2

PROCEDURE PERFORMED: , Phacoemulsification with intraocular lens placement.,ANESTHESIA TYPE:  ,Topical.,COMPLICATIONS: , None.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrine eye drops.  Topical anesthetic drops were applied to the eye just prior to entering the operating room.  The eye was then prepped with a 5% Betadine solution injected in the usual sterile fashion.  A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade.  Lidocaine 1% preservative-free, 0.1 cc, was instilled into the anterior chamber through the clear corneal paracentesis site and this was followed with viscoelastic to fill the chamber.  A 2.8-mm keratome was used to create a self-sealing corneal incision temporally and then a bent capsulotomy needle was used to create an anterior capsular flap.  The Utrata forceps were used to complete a continuous tear capsulorrhexis, and hydrodissection and hydrodelineation of the nucleus was performed with BSS on a cannula.  Phacoemulsification in a quartering and cracking technique was used to remove the nucleus, and then the residual cortex was removed with the irrigation and aspiration unit.  Gentle vacuuming of the central posterior capsule was performed with the irrigation and aspiration unit.  The capsular bag was re-expanded with viscoelastic, and then the wound was opened to a 3.4-mm size to accommodate the intraocular lens insertion using an additional keratome blade.,The lens was folded, inserted into the capsular bag and then unfolded.  The trailing haptic was tucked underneath the anterior capsular rim.  The lens was shown to center very well.  The viscoelastic was removed with the irrigation and aspiration unit and one 10-0 nylon suture was placed across the incision after Miochol was injected into the anterior chamber to cause pupillary constriction.  The wound was shown to be watertight.  Therefore, TobraDex ointment was applied to the eye, an eye pad loosely applied, and a Fox shield taped firmly in place over the eye.,The patient tolerated the procedure well and left the operating room in good condition.
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DESCRIPTION: Phacoemulsification with intraocular lens placement.  A wire speculum was placed in the eye and then a clear corneal paracentesis site was made inferiorly with a 15-degree blade.

ophthalmology, keratome, phacoemulsification, cortex, tobradex, intraocular lens, aspiration unit, topical, chamber, viscoelastic, corneal, capsular, lens, intraocular, eye,

The procedure described is a routine cataract surgery involving phacoemulsification and lens implantation. Although it is an invasive surgical procedure, it is considered low-risk and is commonly performed with a high success rate and low complication occurrence. The report indicates no complications. Given the routine nature of this surgery and the absence of complications, the stakes, in terms of patient risk and potential for adverse outcomes, are relatively low compared to more complex or high-risk surgeries.


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

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

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

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


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Cataract Extraction - 1

PREOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,ANESTHESIA: , Topical/MAC.,PROCEDURE: , Phacoemulsification cataract extraction with intraocular lens implantation, left eye (Alcon AcrySof, SN60AT, 23.0 D, serial #***).,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY:  ,The patient is a 74-year-old woman with complaints of painless progressive loss of vision in her left eye.  She was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.,PROCEDURE IN DETAIL:  ,The patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart.  They were transported to the operative suite, accompanied by the anesthesia service, where appropriate cardiopulmonary monitoring was established.  MAC anesthesia was achieved, which was followed by topical anesthesia using 1% preservative-free tetracaine eye drops.  The patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed.,Two stab-incision paracenteses were made in the cornea using the MVR blade, and the anterior chamber was irrigated with 1% preservative-free lidocaine for intracameral anesthesia.  The anterior chamber was filled with viscoelastic and a shelved, temporal, clear corneal incision was made using the diamond groove knife and steel keratome.  A continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent-needle cystotome.  The lens nucleus was hydrodissected and hydrodelineated using balanced saline solution (BSS) on a Chang cannula until it rotated freely.,The phacoemulsification handpiece was introduced into the anterior chamber, and the lens nucleus was sculpted into 2 halves.  Each half was further subdivided with chopping and removed with phacoemulsification.  The remaining cortical material was removed with the irrigation and aspiration (I&A) handpiece.  The capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty.  The remaining viscoelastic was removed with the I&A handpiece, and the anterior chamber was filled to an appropriate intraocular pressure with BSS.  The corneal wounds were hydrated and verified to be water-tight.  Antibiotic ointment was placed, followed by a patch and shield.  The patient was transported to the PACU in good/stable condition.  There were no complications.  Followup is scheduled for tomorrow morning in the eye clinic.,A single interrupted 10-0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case.
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DESCRIPTION: Visually significant cataract, left eye.  Phacoemulsification cataract extraction with intraocular lens implantation, left eye.  The patient was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.

ophthalmology, intraocular lens implantation, eye, intraocular lens, lens implantation, cataract extraction, cataract, intraocular, viscoelastic, handpiece, implantation, surgery, chamber, phacoemulsification, extraction, visually, anterior, lens

The scenario describes a routine cataract surgery with no complications reported, and the patient was stable post-surgery. Cataract surgery is a common procedure with a high success rate and relatively low risk, especially in cases without complications like this one. The patient is scheduled for a follow-up, which indicates standard postoperative care. Although surgery always carries some risk, given the context of a highly routine and straightforward operation with no complications, the stakes in this particular situation are low relative to other medical procedures.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Lens Implantation - 1

PREOPERATIVE DIAGNOSIS:,  Visually significant nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with posterior chamber intraocular lens implantation, right eye.,ANESTHESIA:,  Monitored anesthesia care with retrobulbar block consisting of 2% lidocaine in an equal mixture with 0.75% Marcaine and Amphadase.,INDICATIONS FOR SURGERY:,  This patient has been experiencing difficulty with eyesight regarding activities of daily living.  There has been a progressive and gradual decline in the visual acuity.  The cataract was believed related to her decline in vision.  The risks, benefits, and alternatives (including with observation or spectacles) were discussed in detail.  The risks as explained included, but are not limited to pain, bleeding, infection, decreased or loss of vision/loss of eye, retinal detachment requiring further surgery, and possible consultation out of town, swelling of the back part of the eye/retina, need for prolonged eye drop use or injections, instability of the lens, and loss of corneal clarity necessitating long-term drop use or further surgery.  The possibility of needing intraocular lens exchange or incorrect lens power was discussed.  Anesthesia option and risks associated with anesthesia and retrobulbar anesthesia were discussed.  It was explained that some or all of these complications might arise at the time of or months to years after surgery.  The patient had a good understanding of the risks with the proposed, elective eye surgery.  The patient accepted these risks and elected to proceed with cataract surgery.  All questions were answered and informed consent was signed and placed in the chart.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified.  The pupil was dilated per protocol.  The patient was taken to the operating room and placed in the supine position.  After intravenous sedation, the retrobulbar block was injected followed by several minutes of digital massage.  No signs of orbital tenseness or retrobulbar hemorrhage were present.,The patient was prepped and draped in the usual ophthalmic sterile fashion.  An eyelid speculum was used to separate the eyelids.  A crescent blade was used to make a clear corneal temporally located incision.  A 1-mm Dual-Bevel blade was used to make a paracentesis site.  The anterior chamber was filled with viscoelastic (Viscoat).  The crescent blade was then used to make an approximate 2-mm long clear corneal tunnel through the temporal incision.  A 2.85-mm keratome blade was then used to penetrate into the anterior chamber through the temporal tunneled incision.  A 25-gauge pre-bent cystotome used to begin a capsulorrhexis.  The capsulorrhexis was completed with the Utrata forceps.  A 27-guage needle was used for hydrodissection and three full and complete fluid waves were noted.  The lens was able to be freely rotated within the capsular bag.  Divide-and-conquer ultrasound was used for phacoemulsification.  After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment.  Each of the four nuclear quadrants was phacoemulsified.  Aspiration was used to remove all remaining cortex.  Viscoelastic was used to re-inflate the capsular bag.  An AMO model SI40NB posterior chamber intraocular lens with power *** diopters and serial number *** was injected into the capsular bag.  The trailing haptic was placed with the Sinskey hook.  The lens was made well centered and stable.  Viscoelastic was aspirated.  BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure.  A Weck-Cel sponge was used to check both incision sites for leaks and none were identified.  The incision sites remained well approximated and dry with a well-formed anterior chamber and eccentric posterior chamber intraocular lens.  The eyelid speculum was removed and the patient was cleaned free of Betadine.  Vigamox and Econopred drops were applied.  A soft eye patch followed by a firm eye shield was taped over the operative eye.  The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed.  All questions were answered.  The discharge instructions were also reviewed with the patient by the discharging nurse.  The patient was comfortable and was discharged with followup in 24 hours.  Complications none.
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DESCRIPTION: Visually significant nuclear sclerotic cataract, right eye.  Phacoemulsification with posterior chamber intraocular lens implantation, right eye.

ophthalmology, retrobulbar block, posterior chamber intraocular lens, nuclear sclerotic cataract, cataract, lens implantation, posterior chamber, anterior chamber, intraocular lens, lens, eye, intraocular, anesthesia, phacoemulsification, retrobulbar,

The situation involves a common ophthalmological surgery, phacoemulsification with intraocular lens implantation, for treating cataracts. While the procedure is generally considered safe and routine with a high success rate, it still involves surgical risks such as infection, vision loss, or the need for additional surgeries. The informed consent process and detailed communication of risks highlight the importance of potential complications. Given these factors, the stakes are moderate, as the surgery addresses significant visual impairment but is relatively low-risk in a controlled environment.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Cataract Extraction - 5

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:  ,Cataract, right eye.,PROCEDURE PERFORMED:  ,Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation.  An Alcon MA30BA lens was used, * diopters, #*.,ANESTHESIA: ,Topical 4% lidocaine with 1% nonpreserved intracameral lidocaine.,COMPLICATIONS:, None.,PROCEDURE: , Prior to surgery, the patient was counseled as to the risks, benefits and alternatives of the procedure with risks including, but not limited to, bleeding, infection, loss of vision, loss of the eye, need for a second surgery, retinal detachment and retinal swelling.  The patient understood the risks clearly and wished to proceed.,The patient was brought into the operating suite after being given dilating drops.  Topical 4% lidocaine drops were used.  The patient was prepped and draped in the normal sterile fashion.  A lid speculum was placed into the right eye.  Paracentesis was made at the infratemporal quadrant.  This was followed by 1% nonpreservative lidocaine into the anterior chamber, roughly 250 microliters.  This was exchanged for Viscoat solution.  Next, a crescent blade was used to create a partial-thickness linear groove at the temporal limbus.  This was followed by a clear corneal bevel incision with a 3 mm metal keratome blade.  Circular capsulorrhexis was initiated with a cystitome and completed with Utrata forceps.  Balanced salt solution was used to hydrodissect the nucleus.  Nuclear material was removed via phacoemulsification with divide-and-conquer technique.  The residual cortex was removed via irrigation and aspiration.  The capsular bag was then filled with Provisc solution.  The wound was slightly enlarged.  The lens was folded and inserted into the capsular bag.,Residual Provisc solution was irrigated out of the eye.  The wound was stromally hydrated and noted to be completely self-sealing.,At the end of the case, the posterior capsule was intact.  The lens was well centered in the capsular bag.  The anterior chamber was deep.  The wound was self sealed and subconjunctival injections of Ancef, dexamethasone and lidocaine were given inferiorly.  Maxitrol ointment was placed into the eye.  The eye was patched with a shield.,The patient was transported to the recovery room in stable condition to follow up the following morning.
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DESCRIPTION: Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation.  An Alcon MA30BA lens was used.   A lid speculum was placed into the right eye.  Paracentesis was made at the infratemporal quadrant.

ophthalmology, alcon, phacoemulsification, cataract extraction, cataract, intraocular lens implantation, anterior chamber, provisc solution, capsular bag, topical, intraocular,

Cataract extraction via phacoemulsification is a common and generally low-risk ophthalmological procedure, especially for patients with a straightforward case like the one described (right eye cataract). The surgery was performed without complications, and the patient was stable post-operation. These factors contribute to the low-stakes nature of this situation. The potential risks involved, such as infection or vision loss, are standard for such procedures and are addressed during pre-surgery counseling. Given the detailed description and lack of complications, this scenario appears to be of lower risk than high-stakes surgical situations that could endanger life or lead to severe irreversible harm.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Cataract Extraction - 3

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:,  Cataract, right eye.,TITLE OF OPERATION:  ,Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Retrobulbar block.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room where retrobulbar anesthesia was induced.  The patient was then prepped and draped using standard procedure.  A wire lid speculum was inserted to keep the eye open and the eye rotated downward with a 0.12.  The anterior chamber was entered by making a small superior limbal incision with a crescent blade and then entering the anterior chamber with a keratome.  The chamber was then filled with viscoelastic and a continuous-tear capsulorrhexis performed.  The phacoemulsification was then instilled in the eye and a linear incision made in the lens.  The lens was then cracked with a McPherson forceps, and the remaining lens material removed with the phacoemulsification tip.  The remaining cortex was removed with an I&A.  The capsular bag was then inflated with viscoelastic and the wound extended slightly with the keratome.  The folding posterior chamber lens was then inserted in the capsular bag and rotated into position.  The remaining viscoelastic was removed from the eye with the I&A.  The wound was checked for watertightness and found to be watertight.  Tobramycin drops were instilled in the eye and a shield placed over it.  The patient tolerated the procedure well.
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DESCRIPTION: Cataract, right eye.  Phacoemulsification with intraocular lens insertion, right eye.  A wire lid speculum was inserted to keep the eye open and the eye rotated downward.

ophthalmology, tobramycin, limbal, lid speculum, intraocular lens, capsular bag, eye, phacoemulsification, lens, intraocular

This situation involves a cataract surgery, which is a common and generally low-risk procedure in ophthalmology with a high success rate. While it is surgical in nature, it's routinely performed and has standardized protocols. The documented operation went smoothly without complications, which further reduces the stakes. However, any surgical procedure carries some inherent risks, so it cannot be classified as extremely low-stakes.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification & Cataract Extraction - 2

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,TITLE OF OPERATION: , Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room where tetracaine drops were instilled in the eye.  The patient was then prepped and draped using standard procedure.  An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.,The eye was rotated downward and a crescent blade used to make an incision at the limbus.  This was then dissected forward approximately 1 mm, and then a keratome was used to enter the anterior chamber.  The anterior chamber was filled with 1% preservative-free lidocaine and the lidocaine was then replaced with Provisc.  A cystotome was used to make a continuous-tear capsulorrhexis, and then the capsular flap was removed with the Utrata forceps.  The lens nucleus was hydrodissected using BSS on a cannula and then removed using the phaco.  This was aided by cracking the lens nucleus with McPherson forceps.  The remaining cortex was removed from the eye with the I&A.  The capsular bag was then polished with the I&A on capsular bag.  The bag was inflated using viscoelastic and then the wound extended slightly with a keratome.  A folding posterior chamber lens was inserted and rotated into position using McPherson forceps.  The I&A was then placed in the eye again and the remaining viscoelastic removed.  The wound was checked for watertightness and found to be watertight.  TobraDex drops were instilled in the eye and a shield was placed over it.,The patient tolerated the procedure well and was brought to recovery in good condition.
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DESCRIPTION: Cataract, right eye.  Phacoemulsification with intraocular lens insertion, right eye.  The patient was then prepped and draped using standard procedure.  An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.

ophthalmology, tetracaine, intraocular lens, lid speculum, mcpherson forceps, capsular bag, eye, phacoemulsification, cataract, lens, intraocular,

The document describes a routine cataract surgery procedure known as phacoemulsification, which is a common and generally safe surgical procedure performed under local anesthesia. The patient tolerated the procedure well with no complications reported. Although any surgical procedure carries some level of risk, this is a standard operation with a high success rate and low complication rates, indicating it is not high-stakes.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification

PREOPERATIVE DIAGNOSIS:, Senile cataract OX,POSTOPERATIVE DIAGNOSIS: ,Senile cataract OX,PROCEDURE: ,Phacoemulsification with posterior chamber intraocular lens OX, model SN60AT (for Acrysof natural lens), XXX diopters.,INDICATIONS: ,This is a XX-year-old (wo)man with decreased vision OX.,PROCEDURE:, The risks and benefits of cataract surgery were discussed at length with the patient, including bleeding, infection, retinal detachment, re-operation, diplopia, ptosis, loss of vision, and loss of the eye. Informed consent was obtained. On the day of surgery, (s)he received several sets of drops in the XXX eye including 2.5% phenylephrine, 1% Mydriacyl, 1% Cyclogyl, Ocuflox and Acular. (S)he was taken to the operating room and sedated via IV sedation. 2% lidocaine jelly was placed in the XXX eye (or, retrobulbar anesthesia was performed using a 50/50 mixture of 2% lidocaine and 0.75% marcaine). The XXX eye was prepped using a 10% Betadine solution. (S)he was covered in sterile drapes leaving only the XXX eye exposed. A Lieberman lid speculum was placed to provide exposure. The Thornton fixation ring and a Superblade were used to create a paracentesis at approximately 2 (or 11 depending upon side and handedness, and assuming superior incision) o'clock. Then 1% lidocaine was injected through the paracentesis. After the nonpreserved lidocaine was injected, Viscoat was injected through the paracentesis to fill the anterior chamber. The Thornton fixation ring and a 2.75 mm keratome blade were used to create a two-step full-thickness clear corneal incision superiorly. The cystitome and Utrata forceps were used to create a continuous capsulorrhexis in the anterior lens capsule. BSS on a hydrodissection cannula was used to perform gentle hydrodissection. Phacoemulsification was then performed to remove the nucleus. I & A was performed to remove the remaining cortical material. Provisc was injected to fill the capsular bag and anterior chamber. A XXX diopter SN60AT (for Acrysof natural lens) intraocular lens was injected into the capsular bag. The Kuglen hook was used to rotate it into proper position in the capsular bag. I & A was performed to remove the remaining Viscoelastic material from the eye. BSS on the 30-gauge cannula was used to hydrate the wound. The wounds were checked and found to be watertight. The lid speculum and drapes were carefully removed. Several drops of Ocuflox were placed in the XXX eye. The eye was covered with an eye shield. The patient was taken to the recovery area in a good condition. There were no complications.
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DESCRIPTION: Phacoemulsification with posterior chamber intraocular lens - Sample/Template.

ophthalmology, phacoemulsification, acrysof, acrysof natural lens, acular, kuglen hook, ocuflox, provisc, sn60at, senile cataract, thornton fixation ring, bleeding, capsular bag, decreased vision, diopters, diplopia, infection, loss of the eye, loss of vision, ptosis, retinal detachment, lid speculum, thornton fixation, anterior chamber, intraocular lens, intraocular, chamber, lidocaine,

The situation involves a procedure known as phacoemulsification for the treatment of cataracts, which is a common ophthalmological surgery. While it is generally considered safe and routine, it is still a surgical procedure that carries potential risks such as infection, bleeding, and loss of vision, which were discussed with the patient. The risks involved demand competent handling and meticulous surgical practice, making it of moderate stakes for the surgeon and patient. Therefore, it is important but not usually life-threatening, although the outcome can significantly impact the patient's quality of life.


Medical Specialty: Ophthalmology
Sample Name: Optometry - Letter

RE:  Sample Patient,Dear Dr. Sample:,Sample Patient was seen at the Vision Rehabilitation Institute on Month DD, YYYY.  She is an 87-year-old woman with a history of macular degeneration, who admits to having PDT therapy within the last year.  She would like to get started with some vision therapy so that she may be able to perform her everyday household chores, as well as reading small print.  At this time, she uses a small handheld magnifier, which is providing her with only limited help.,A complete refractive work-up was performed today, in which we found a mild change in her distance correction, which allowed her the ability to see 20/70 in the right eye and 20/200 in the left eye.  With a pair of +4 reading glasses, she was able to read 0.5M print quite nicely.  I have loaned her a pair of +4 reading glasses at this time and we have started her with fine-detailed reading.  She will return to our office in a matter of two weeks and we will make a better determination on what near reading glasses to prescribe for her.  I think that she is an excellent candidate for low vision help.  I am sure that we can be of great help to her in the near future.,Thank you for allowing us to share in the care of your patient.,With best regards,,Sample Doctor, O.D.
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DESCRIPTION: Woman with a history of macular degeneration.  PDT therapy.  Some vision therapy.  Complete refractive work-up.

ophthalmology, optometry, letter, optometry letter, pdt therapy, distance correction, macular degeneration, reading glasses, vision therapy, complete refractive, macular, degeneration,

The situation involves an elderly patient with macular degeneration seeking vision therapy to improve her ability to perform daily tasks. While the clinical details are important, they represent routine follow-up care in an ophthalmology context, not an emergency or critical condition. The patient is being managed and evaluated for low vision aids, a common process for someone with her condition. Thus, the stakes are related primarily to the improvement in quality of life rather than immediate health risks.


Medical Specialty: Ophthalmology
Sample Name: Ophthalmology - Letter - 2

XYZ, O.D.,RE:  ABC,DOB:  MM/DD/YYYY,Dear Dr. XYZ:,Thank you for your kind referral for patient ABC.  Mr. ABC is being referred for evaluation of glaucoma.  The patient states he has no visual complaints.,On examination, the patient's visual acuity is 20/20 bilaterally.  The patient's visual fields are full to confrontation.  Extraocular muscles are intact.  There is no relative afferent pupillary defect and applanation pressures are 15 mmHg bilaterally.  On slit lamp examination, the patient has a normal anterior segment with 1+ nuclear sclerosis.  On dilated examination, the patient has a cup-to-disc ratio in the right eye of 0.4.  Macula, vessels, and periphery were within normal limits.  On the left eye, the patient has a cup-to-disc ratio of 0.3 and macula vessels and periphery are also within normal limits.  On gonioscopy, the patient shows deep anterior chamber angle OU and is open to the ciliary body band 360 degrees.,In conclusion, my initial impression is that Mr. ABC does not have glaucoma.  He has fairly symmetric and small cup-to-disc ratios OU.  His intraocular pressures were within normal limits in our office today.  I discussed at length with him the alternatives of observation versus continued work-up and testing.  He seemed to understand very well and went with my recommendation to continue observation for now.  We will take fundus photos of his optic nerves for future comparison, but I think given the lack of any strong findings suspicious for glaucoma, we will defer further testing at this time.,Should you have any specific questions or any other information that you think that I may not have included in this evaluation, please feel free to contact me.  I have recommended him to follow up with you for continued examination, continued check-ups, and should you find any other abnormal findings, I would be happy to address those again.,Again, thank you for your referral of Mr. ABC.,Sincerely,,
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DESCRIPTION: Patient being referred for evaluation of glaucoma.

ophthalmology, cup to disc ratio, referred for evaluation, cup to disc, disc ratio, macula vessels, pressures, eye, macula, vessels, visual, cup, disc, glaucoma, examination, intact,

The letter describes a medical examination in which a patient was referred for a potential case of glaucoma. The evaluation showed no current signs of glaucoma, and the doctor recommends observation instead of immediate intervention or treatment. While glaucoma is a serious condition that requires careful monitoring, the situation described does not involve immediate or critical medical intervention. The stakes include ensuring the patient is monitored effectively to prevent any potential future vision issues, but currently, there is no immediate health crisis present.


Medical Specialty: Ophthalmology
Sample Name: Eye Examination - H&P

CHIEF COMPLAINT:,  This 26-year-old male presents today for a complete eye examination.,ALLERGIES:,  Patient admits allergies to aspirin resulting in disorientation, GI upset.,MEDICATION HISTORY:,  Patient is currently taking amoxicillin-clavulanate 125 mg-31.25 mg tablet, chewable medication was prescribed by A. General Practitioner MD, Adrenocot 0.5 mg tablet medication was prescribed by A. General Practitioner MD, Vioxx 12.5 mg tablet (BID).,PMH: , Past medical history is unremarkable.,PAST SURGICAL HISTORY:,  Patient admits past surgical history of (+) appendectomy in 1989.,SOCIAL HISTORY:,  Patient denies alcohol use.  Patient denies illegal drug use.  Patient denies STD history.  Patient denies tobacco use.,FAMILY HISTORY:,  Unremarkable.,REVIEW OF SYSTEMS:,Eyes: (-) dry eyes (-) eye or vision problems (-) blurred vision.,Constitutional Symptoms: (-) constitutional symptoms such as fever, headache, nausea, dizziness.,Musculoskeletal: (-) joint or musculoskeletal symptoms.,EYE EXAM:,  Patient is a pleasant, 26-year-old male in no apparent distress who looks his given age, is well developed and nourished with good attention to hygiene and body habitus.,Pupils:  Pupil exam reveals round and equally reactive to light and accommodation.,Motility:  Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,Visual Fields:  Confrontation VF exam reveals full to finger confrontation O.U.,IOP:  IOP Method:  applanation tonometry OD:  10 mmHg Medications:  Alphagan; 0.2% Condition:  improving.,Keratometry:,OD:  K1 35.875K2 35.875,OS:  K1 35.875K2 41.875,Lids/Orbit:  Bilateral eyes reveal normal position without infection.  Bilateral eyelids reveals white and quiet.,Slit Lamp:  Corneal epithelium is intact with normal tear film and without stain.  Stroma is clear and avascular.  Corneal endothelium is smooth and of normal appearance.,Anterior Segment:  Bilateral anterior chambers reveal no cells or flare with deep chamber.,Lens:  Bilateral lenses reveals transparent lens that is in normal position.,Posterior Segment:  Posterior segment was dilated bilateral.  Bilateral retinas reveal normal color, contour, and cupping.,Retina:  Bilateral retinas reveals flat with normal vasculature out to the far periphery.  Bilateral retinas reveal normal reflex and color.,VISUAL ACUITY:,Visual acuity - uncorrected:  OD:  20/10 OS:  20/10 OU:  20/15.,REFRACTION:,Lenses - final:,OD:  +0.50 +1.50 X 125 Prism 1.75,OS:  +6.00 +3.50 X 125 Prism 4.00 BASE IN Fresnel,Add:  OD:  +1.00 OS:  +1.00,OU:  Far VA 20/25,TEST RESULTS:,  No tests to report at this time.,IMPRESSION:,  Eye and vision exam normal.,PLAN:,  Return to clinic in 12 month (s).,PATIENT INSTRUCTIONS:
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DESCRIPTION: Complete eye examination - Normal eye and vision exam.

The scenario described is a standard, routine eye examination with normal findings. The patient's eyes and vision are normal, and there are no acute issues, urgent medical needs, or complex medical management indicated. Routine follow-up is scheduled in 12 months, which is standard for a normal examination. The details provided indicate no immediate risks or high-stakes decisions involved in the current situation.


Medical Specialty: Ophthalmology
Sample Name: Ophthalmology Progress Note - 1

She is stable at this time and does not require any intervention at today's visit.  I have asked her to return in six months' for a followup dilated examination, but would be happy to see her sooner should you or she notice any changes in her vision.
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DESCRIPTION: Ophthalmology followup visit note.

Ophthalmology followup visit note.

ophthalmology, visual acuities, extraocular muscle, intraocular pressure, pupils, afferent, applanation, binocular, dilated fundus, left eye, lens, movements, ophthalmoscope, pigmentary, retina, retinal, right eye, acuitiesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The note indicates that the patient is stable and currently does not require any immediate medical intervention. The request for a follow-up in six months suggests that the situation is not urgent, but there is a contingency for an earlier visit if changes occur, which adds some level of importance. However, there is no indication of any immediate threat to the patient's health or vision based on this note.


Medical Specialty: Ophthalmology
Sample Name: Clear Corneal Temporal Incision

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

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

The scenario describes a common ophthalmic surgical procedure, specifically a cataract surgery utilizing a clear corneal temporal incision. This type of operation is routine and typically has a high rate of success with low complication risks. No sutures are required, indicating a minimally invasive approach. As such, this doesn't represent high-stakes for the medical team, but it does hold moderate importance to the patient due to the potential impact on their vision. While any surgery carries intrinsic risks, this procedure is considered standardized and safe within the field.


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

Medical Specialty: Ophthalmology
Sample Name: Connective Tissue Disorder

Her past medical history includes a presumed diagnosis of connective tissue disorder.  She has otherwise, good health.  She underwent a shoulder ligament repair for joint laxity.,She does not take any eye medications and she takes Seasonale systemically.  She is allergic to penicillin.,The visual acuity today, distance with her current prescription was 20/30 on the right and 20/20 on the left eye.  Over refraction on the right eye showed -0.50 sphere with acuity of 20/20 OD.  She is wearing -3.75 +1.50 x 060 on the right and -2.50 +0.25 x 140, OS.  Intraocular pressures are 13 OU and by applanation.  Confrontation, visual fields, extraocular movement, and pupils are normal in both eyes.  Gonioscopy showed normal anterior segment angle morphology in both eyes.  She does have some fine iris strength crossing the angle, but the angle is otherwise open 360 degrees in both eyes.,The lids were normal in both eyes.  Conjunctivae were quite, OU.  Cornea were clear in both eyes.  The anterior chamber is deep and quiet, OU.  She has clear lenses, which are in good position, OU.  Dilated fundus exam shows moderately optically clear vitreous, OU.  The optic nerves are normal in size.  The cup-to-disc ratios were approximately 0.4, OU.  The nerve fiber layers are excellent, OU.  The macula, vessels, and periphery were normal in both eyes.  No evidence of peripheral retinal degeneration is present in either eye.,Ms. ABC has optically clear vitreous.  She does not have any obvious risk factors for retinal detachment at present such as peripheral retinal degeneration and her anterior chamber angles are normal in both eyes.,She does have moderate myopia, however.,This combination of findings suggests and is consistent with her systemic connective tissue disorder such as a Stickler syndrome or a variant of Stickler syndrome.,I discussed with her the symptoms of retinal detachment and advised her to contact us immediately if they occur.  Otherwise, I can see her in 1 to 2 years.
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DESCRIPTION: She is sent for evaluation of ocular manifestations of systemic connective tissue disorders.  Denies any eye problems and history includes myopia with astigmatism.

ophthalmology, systemic connective tissue disorder, stickler syndrome, anterior chamber angles, retinal degeneration, connective tissue disorder, vitreous, degeneration, detachment, myopia, optically, astigmatism, eyes

The case involves a patient with a presumed connective tissue disorder, potential susceptibility to retinal detachment, but no current signs of it. The patient has been briefed on symptoms and advised on follow-ups. This makes it moderately significant due to the need for vigilance in monitoring potential retinal detachment, which can lead to vision impairment if not treated promptly. However, currently, there are no acute issues present.


Medical Specialty: Ophthalmology
Sample Name: Cataract Extraction - 2

PREOPERATIVE DIAGNOSIS: , Cataract, left eye.,POSTOPERATIVE DIAGNOSIS:  ,Cataract, left eye.,PROCEDURE PERFORMED:  ,Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE: , After the induction of topical anesthesia with 4% Xylocaine drops, the left eye was prepped and draped in the usual fashion.  A speculum was inserted, and the microscope was moved into position.,A 3.2-mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o'clock position, and 0.1 cc of 1% Xylocaine without preservative was instilled into the anterior chamber.  It was then filled with viscoelastic.  A stab incision was made into the anterior chamber at the limbus at 5 o'clock position with a microblade.,A cystitome was used to make a capsulotomy, and the capsulorrhexis forceps were used to complete a circular capsulorrhexis.  The nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26-gauge cannula, and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision.  The irrigation-aspiration handpiece was used to systematically aspirate cortex 360 degrees.  The posterior capsule was vacuumed; it was clear and intact.,The capsular bag and the anterior chamber were filled with viscoelastic.  A model MA30AC lens, power 21.5 diopters, serial number 864414.095, was folded, grasped with the lens insertion forceps and inserted into the capsular bag.  The trailing loop was placed inside the bag.  The viscoelastic was removed with the irrigation-aspiration handpiece.  The lens centered well.  A single 10-0 nylon suture was placed to close the wound.  It was checked and ascertained to be watertight.  Decadron 0.25 cc, 0.25 cc of antibiotic and 0.25 cc of Xylocaine were injected subconjunctivally.  Dexacidin ointment was placed in the eye, and the procedure was terminated.,The procedure was well tolerated by the patient who was returned to the recovery room in good condition.
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DESCRIPTION: Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.

ophthalmology, anterior chamber, keratome, limbus, intraocular lens, cataract extraction, extracapsular, phacoemulsification, capsular, cataract, chamber, intraocular,

The described procedure is an extracapsular cataract extraction with phacoemulsification and implantation of an intraocular lens, which is a commonly performed and routine surgery in the field of ophthalmology. It is generally considered low to moderate risk with a high success rate. The document indicates that there were no complications and the patient tolerated the procedure well, which suggests it is a low-stakes situation. However, since it is still a surgical procedure on the eye, I will not rate it at the absolute lowest on the scale.


Medical Specialty: Ophthalmology
Sample Name: Cataract - Second Opinion

SUBJECTIVE:  ,The patient seeks evaluation for a second opinion concerning cataract extraction.  She tells me cataract extraction has been recommended in each eye; however, she is nervous to have surgery.  Past ocular surgery history is significant for neurovascular age-related macular degeneration.  She states she has had laser four times to the macula on the right and two times to the left, she sees Dr. X for this.,OBJECTIVE: , On examination, visual acuity with correction measures 20/400 OU.  Manifest refraction does not improve this.  There is no afferent pupillary defect.  Visual fields are grossly full to hand motions.  Intraocular pressure measures 17 mm in each eye.  Slit-lamp examination is significant for clear corneas OU.  There is early nuclear sclerosis in both eyes.  There is a sheet like 1-2+ posterior subcapsular cataract on the left.  Dilated examination shows choroidal neovascularization with subretinal heme and blood in both eyes.,ASSESSMENT/PLAN:  ,Advanced neurovascular age-related macular degeneration OU, this is ultimately visually limiting.  Cataracts are present in both eyes.  I doubt cataract removal will help increase visual acuity; however, I did discuss with the patient, especially in the left, cataract surgery will help Dr. X better visualize the macula for future laser treatment so that her current vision can be maintained.  This information was conveyed with the use of a translator.,
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DESCRIPTION: The patient seeks evaluation for a second opinion concerning cataract extraction.

ophthalmology, advanced neurovascular age-related macular degeneration, neurovascular age, macular degeneration, visual acuity, cataract extraction, neurovascular, degeneration, visual, eyes, macular, cataract,

While the situation involves serious vision issues and a decision about cataract surgery, it is not immediately life-threatening. The patient's cataract extraction decision will primarily impact her quality of life and the management of her age-related macular degeneration. Additionally, the presence of a second opinion suggests careful consideration rather than urgency. However, any surgery carries some inherent risks, and vision is a critical aspect of daily living, making it moderately high-stakes.


Medical Specialty: Ophthalmology
Sample Name: Blepharoplasty - Direct Brow Repair

PREOPERATIVE DX:, Dermatochalasis, mechanical ptosis, brow ptosis.,POSTOPERATIVE DX:, Same,PROCEDURE:,: Upper lid blepharoplasty and direct brow lift,ANESTHESIA:, Local with sedation,INDICATIONS FOR SURGERY: , In the preoperative evaluation the patient was found to have visually significant and symptomatic dermatochalasis and brow ptosis causing mechanical ptosis and visual field obstruction.  Visual field testing showed *% superior hemifield loss on the right, and *% superior hemifield loss on the left.  These field losses resolved with upper eyelid taping which simulates the expected surgical correction.  Photodocumentation also showed the upper eyelids resting on the upper eyelashes, as well as a decrease in the effective superior marginal reflex distance.  The risks, benefits, limitations, alternatives, and expected improvement in symptoms and visual field loss were discussed in preoperative evaluation.,DESCRIPTION OF PROCEDURE:, On the day of surgery, the surgical site and procedure were verified by the physician with the patient.  An informed consent was signed and witnessed.  EMLA cream was applied to the eyelids and eyebrow region for 10 minutes to provide skin anesthesia.  Two drops of topical proparacaine eye drops were placed on the ocular surface.  The skin was cleaned with alcohol prep pads.  The patient received 3 to 4 mL of 2% Lidocaine with epinephrine and 0.5% Marcaine mixture to each upper lid.  5 to 6 mL of local were also given to the brow region along the entire length.  Pressure was applied over each site for 5 minutes.  The patient was then prepped and draped in the normal sterile fashion for oculoplastic surgery.,The desired amount of redundant brow tissue to be excised was carefully marked with a surgical marking pen on each side.  The contour of the outline was created to provide a greater temporal lift.  Care was taken to preserve a natural contour to the brow shape consistent with the patient’s desired features.  Using a #15 blade, the initial incision was placed just inside the superior most row of brow hairs, in parallel with the follicle growth orientation.  The incision extended in a nasal to temporal fashion with the nasal portion incision being carried down to muscle and becoming progressively shallower toward the tail of the incision line.  The dimensions of the redundant tissue measured * horizontally and * vertically.  The redundant tissue was removed sharply with Westcott scissors.  Hemostasis was maintained with hand held cautery and/or electrocautery.  The closure was carried out in multiple layers.  The deepest muscular/subcutaneous tissue was closed with 4-0 transparent nylon in a horizontal mattress fashion.  The intermediate layer was closed with 5-0 Vicryl similarly.  The skin was closed with 6-0 nylon in a running lock fashion.  Iced saline gauze pads were placed over the incision sites.  This completed the brow repair portion of the case.,Using a surgical marking pen, a vertical line was drawn from the superior punctum to the eyebrow.  An angled line was drawn from the ala of the nares to the lateral canthus edge and extending to the tail of the brow.  These lines served as the relative boundary for the horizontal length of the blepharoplasty incision.  The desired amount of redundant tissue to be excised was carefully pinched together with 0.5 forceps.  This tissue was outlined with a surgical marking pen.  Care was taken to avoid excessive skin removal near the brow region.  A surgical ruler was used to ensure symmetry.  The skin and superficial orbicularis were incised with a #15 blade on the first upper lid.  This layer was removed with Westcott scissors.,Hemostasis was achieved with high-temp hand held pen cautery.  The remaining orbicularis and septum were grasped superiorly and inferiorly on each side of the incision and tented upward.  The high temp cautery pen was then used to incise these layers in a horizontal fashion until preapeuronotic fat was identified.  * amount of central preaponeurotic fat was removed with cautery.  * amount of nasal fat pad was removed in the same fashion.  Care was taken to not disturb the levator aponeurosis.  A symmetric amount of fat was removed from each side.  Iced gauze saline was placed over the site and the entire procedure repeated on the fellow eyelid.  Skin hooks were placed on either side of the incision and the skin was closed in a continuous running fashion with 6-0 nylon.  Erythromycin ophthalmic ointment was placed over the incision site and on the ocular surface.  Saline gauze and cold packs were placed over the upper lids.  The patient was taken from the surgical suite in good condition.,DISCHARGE:,  In the recovery area the results of surgery were discussed with the patient and their family.  Specific instructions to resume all p.o. oral medications including anticoagulants/antiplatelets were given.  Written instructions and restrictions after eyelid surgery were reviewed with the patient and family member.  Instructions on antibiotic ointment use were reviewed.  The incision sites were checked prior to release.  The patient was released to home with a driver after vital signs were deemed stable.
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DESCRIPTION: Blepharoplasty with direct brow repair.

Blepharoplasty with direct brow repair.

ophthalmology, dermatochalasis, erythromycin ophthalmic, saline gauze, blepharoplasty, brow ptosis, cold packs, direct brow lift, follicle growth, hemifield loss, marginal reflex, mechanical ptosis, ocular surface, superficial orbicularis, visual field, surgical marking pen, direct brow, redundant tissue, incision sites, incision, brow, ptosis, surgical

The described procedure is a blepharoplasty with direct brow repair, which is primarily a cosmetic surgery but also has functional aspects due to the impact on the patient's visual field. The stakes are moderately high as it involves surgery on the eye area, which requires precision due to potential impacts on vision. However, this procedure is standard in ophthalmology with localized anesthesia and generally has a low complication rate, suggesting that it is not extremely high-stakes compared to other medical procedures. The postoperative care and instructions further indicate that this is a well-controlled and routine procedure in a specialized setting.


Medical Specialty: Ophthalmology
Sample Name: Blepharon & Entropion Repair

PREOPERATIVE DIAGNOSES:,1.  Entropion, left upper lid.,2.  Entropion and some blepharon, right lower lid.,TITLE OF OPERATION:,1.  Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.,2.  Repairs of blepharon, entropion, right lower lid with mucous membrane graft.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room and prepped and draped in the usual fashion.  The left upper lid and right lower lid were all infiltrated with 2% Xylocaine with Epinephrine.,The lid was then everted with special clips and the mucotome was then used to cut a large mucous membrane graft from the lower lid measuring 0.5 mm in thickness.  The graft was placed in saline and a 4 x 4 was placed over the lower lid.,Attention was then drawn to the left upper lid and the operating microscope was found to place.  An incision was made in the gray line nasally in the area of trichiasis and entropion, and the dissection was carried anterior to the tarsal plate and an elliptical piece of the anterior lamella was excised.  Bleeding was controlled with the wet-field cautery and the cryoprobe was then used with a temperature of -8 degree centigrade in the freeze-thaw-refreeze technique to treat the bed of the excised area.,Attention was then drawn to the right lower lid with the operating microscope and a large elliptical area of the internal aspect of the lid margin was excised with a super blade.  Some of the blepharon were dissected from the globe and bleeding was controlled with the wet-field cautery.  An elliptical piece of mucous membrane was then fashioned and placed into the defect in the lower lid and sutured with a running 6-0 chromic catgut suture anteriorly and posteriorly.,The graft was in good position and everything was satisfactory at the end of procedure.  Some antibiotic steroidal ointment was instilled in the right eye and a light pressure dressing was applied.  No patch was applied to the left eye.  The patient tolerated the procedure well and was sent to recovery room in good condition.
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DESCRIPTION: Repair of entropion, left upper lid, with excision of anterior lamella and cryotherapy.  Repairs of blepharon, entropion, right lower lid with mucous membrane graft.

ophthalmology, entropion, blepharon, catgut suture, cryoprobe, cryotherapy, freeze-thaw-refreeze, lamella, lid, lower lid, tarsal plate, trichiasis, upper lid, mucous membrane graft, anterior lamella, mucous membrane, membrane

The described surgical procedure involves an ophthalmological operation to correct entropion and blepharon, conditions that can significantly affect a patient's eye health and quality of life if left untreated. While these procedures can be routine for a specialized surgeon, they still carry the inherent risks associated with surgery, such as infection, bleeding, and reaction to anesthesia. Furthermore, the procedure requires precision to avoid complications or damage to the eye, which can lead to more severe issues. Nevertheless, the scenario does not involve an acute or life-threatening emergency, so it is not extremely high-stakes compared to other medical situations.


Medical Specialty: Office Notes
Sample Name: Right Hand Laceration

HISTORY: , The patient is a 19-year-old male who was involved in a fight approximately an hour prior to his ED presentation.  He punched a guy few times on the face, might be the mouth and then punched a drinking glass, breaking it and lacerating his right hand.  He has three lacerations on his right hand.  His wound was cleaned out thoroughly with tap water, and one of the navy corpsman tried to use Superglue and gauze to repair it.  However, it continues to bleed and he is here for evaluation.,PAST MEDICATION HISTORY:,  Significant for asthma and acne.,CURRENT MEDICATIONS: , Accutane and takes no other medications.,TETANUS STATUS: , Up-to-date.,SOCIAL HISTORY: , He is a nonsmoker.  He has been drinking alcohol today, but has no history of alcohol or drug abuse.,REVIEW OF SYSTEMS: , Otherwise well.  No febrile illness.  No motor or sensory complaints of any sort or paresthesias in the hand.,PHYSICAL EXAM:  ,GENERAL:  He is in no apparent distress.  He is alert and oriented x3.  Mental status is clear and appropriate.  VITALS SIGNS:  Temperature is 98.3, heart rate 100, respirations 18, blood pressure 161/98, oxygen saturation 99% on room air by pulse oximetry, which is normal.  EXTREMITIES:  Right hand, he has three lacerations all over the MCP joint of his right hand, irregular shaped over the fifth MCP and then over the fourth and third half wound, similarly the lacerations.  All total approximately 4 cm in length.  I see no foreign bodies, just capillary refills less than 2 seconds.  Radial pulses intact.  There is full range of motion with no gross deformities.  No significant amount of edema associated with these in the dorsum of the hand.,STUDIES: , X-rays shows no open fracture or bony abnormality.,EMERGENCY DEPARTMENT COURSE:  ,The patient was anesthetized with 1% Xylocaine.  Wounds were thoroughly irrigated with tap water with at least 2 liters.  They were repaired with simple sutures of 4-0 Ethilon, total of 17 sutures, 16 of which were simple, one is a horizontal mattress.  The patient was given Augmentin 875 mg p.o. due to the possibility of human bite wound.,ASSESSMENT: , RIGHT HAND LACERATIONS, SIMPLE X3, REPAIRED AS DESCRIBED.  NO SIGNS OF BONY ABNORMALITY OR FOREIGN BODY.,PLAN:  ,The patient will be given Augmentin 875 mg 1 p.o. b.i.d. for 7 days.  He will be given a prescription of Vicoprofen as he is unable to tolerate the Tylenol due to his Accutane.  He will take 1 p.o. every 6 hours or as needed, #12.  He will follow up for suture removal in 8 days.  Should he develop any signs of infection, he will come immediately here for reevaluation.  He is discharged in stable condition.,
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DESCRIPTION: Right hand laceration x3, repaired.

Right hand laceration x3, repaired.

office notes, accutane, hand laceration, laceration, hand,

The scenario involves a medical evaluation of a 19-year-old male who sustained lacerations to his right hand after a physical altercation. The patient's wounds have been properly cleaned, sutured, and he's been administered antibiotics due to the potential human bite. The situation seems well-managed as the patient is in stable condition and there are no fractures or foreign bodies present. Although there is some risk of infection that requires monitoring, the situation is typical for emergency department cases and the follow-up plan is straightforward.


Medical Specialty: Office Notes
Sample Name: Post Dilation Instructions

The effects of eye dilation drops will gradually decrease. It typically takes TWO to SIX HOURS for the effects to wear off. During this time, reading may be more difficult and sensitivity to light may increase. For a short time, wearing sunglasses may help.
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DESCRIPTION: Sample post dilation patient instructions.

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

The given scenario pertains to routine post-dilation instructions after an eye examination. This is a very standard procedure that does not involve critical or high-risk factors. The potential risks, such as light sensitivity and difficulty reading, are mild and temporary, and the patient is advised to wear sunglasses for comfort. There is no immediate danger or severe consequence attached to not following the instructions beyond temporary discomfort.


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

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

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

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


Medical Specialty: Office Notes
Sample Name: Normal ROS Template - 5

REVIEW OF SYSTEMS,GENERAL:  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY:  Negative rash, negative jaundice.,HEMATOPOIETIC:  Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC:  Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS:  Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  Negative postnasal drip, negative sore throat.,CARDIOVASCULAR:  Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL:  Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY:  Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.  **No history of OB/GYN problems.,MUSCULOSKELETAL:  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC:  See psychiatric evaluation.,ENDOCRINE:  No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.
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DESCRIPTION: Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.

office notes, respiratory, gastrointestinal, integumentary, hematopoietic, night sweats, negative allergies, negative weakness, neurologic, throat, weakness

The situation described is a normal review of systems (ROS) template used in medical office notes, indicating that all systems checked have negative findings (i.e., no problems reported). This suggests there are no immediate clinical concerns or high-stakes issues present in the patient evaluation. It is a routine documentation process rather than a critical medical intervention.


Medical Specialty: Office Notes
Sample Name: Ortho Office Visit

Her evaluation today reveals restriction in the range of motion of the cervical and lumbar region with tenderness and spasms of the paraspinal musculature.  Motor strength was 5/5 on the MRC scale.  Reflexes were 2+ and symmetrical.  Palpable trigger points were noted bilaterally in the trapezius and lumbar paraspinal musculature bilaterally.,Palpable trigger points were noted on today's evaluation.  She is suffering from ongoing myofascitis.  Her treatment plan will consist of a series of trigger point injections, which were performed today.  She tolerated the procedure well.  I have asked her to ice the region intermittently for 15 minutes off and on x 3.  She will be followed in four weeks' time for repeat trigger point injections if indicated.,
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DESCRIPTION: The patient continues to suffer from ongoing neck and lower back pain with no recent radicular complaints.

office notes, back pain, trigger point injections, paraspinal musculature, lumbar, paraspinal, musculature, palpable, injections, evaluation, triggerNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

This scenario involves a medical practitioner documenting a patient's condition and treatment plan for myofascitis, a condition causing muscle inflammation and pain. While the context is within a medical setting which inherently involves patient health, this specific situation appears to be routine management of a non-life-threatening condition. The evaluation and treatment do not indicate any immediate critical health risks. Thus, although patient care is important, the stakes involved in this particular office visit are not extremely high.


Medical Specialty: Office Notes
Sample Name: Normal ROS Template - 1

REVIEW OF SYSTEMS,There was no weight loss, fevers, chills, sweats.  There is no blurring of the vision, itching, throat or neck pain, or neck fullness.  There is no vertigo or hoarseness or painful swallowing.  There is no chest pain, shortness of breath, paroxysmal nocturnal dyspnea, or chest pain with exertion.  There is no shortness of breath and no cough or hemoptysis.  No melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation or blood in the stools.  No dysuria, hematuria or excessive urination.  No muscle weakness or tenderness.  No new numbness or tingling.  No arthralgias or arthritis.  There are no rashes.  No excessive fatigability, loss of motor skills or sensation.  No changes in hair texture, change in skin color, excessive or decreased appetite.  No swollen lymph nodes or night sweats.  No headaches.  The rest of the review of systems is negative.
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DESCRIPTION: There was no weight loss, fevers, chills, sweats.  There is no blurring of the vision, itching, throat or neck pain, or neck fullness.  There is no vertigo or hoarseness or painful swallowing.

office notes, weight loss, fevers, chills, sweats, melena, nausea, vomiting, dysphagia, abdominal pain, diarrhea, constipation, itching throat, neck fullness, painful swallowing, breath, loss, neckNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The information provided is part of a routine medical documentation for a 'Review of Systems', which is a systematic way to screen for any symptoms that the patient might have experienced. This specific documentation indicates that the patient is not experiencing any of the listed symptoms. As it is a routine process without any urgent symptoms detected, it is not high-stakes.


Medical Specialty: Office Notes
Sample Name: Normal ROS Template - 2

GENERAL:,  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY: , Negative rash, negative jaundice.,HEMATOPOIETIC: , Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC: , Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:,  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS: , Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  ,Negative postnasal drip, negative sore throat.,CARDIOVASCULAR: , Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:,  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL: , Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY: , Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.,MUSCULOSKELETAL:,  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC: , See psychiatric evaluation.,ENDOCRINE: , No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.
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DESCRIPTION: Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.

office notes, nose and throat, cardiovascular, integumentary, negative weakness, neurologic, throat, psychiatric, weakness,

The given text is an office note detailing a normal review of systems (ROS) for a patient, where 'negative' is used to indicate the absence of various symptoms or medical history. It is a document used to record that the patient did not report any issues in these areas. This is a routine documentation process used by medical practitioners to track patient conditions. It is considered low-stakes because it involves documenting an absence of problems rather than urgent or risky health issues. The template appears to be standardized for efficiency rather than dealing with a critical health concern.


Medical Specialty: Office Notes
Sample Name: Normal Physical Exam Template - 6

VITAL SIGNS:,  Reveal a blood pressure of *, temperature of *, respirations *, and pulse of *.,CONSTITUTIONAL: , Normal appearance for chronological age, does not appear chronically ill.,HEENT: , The pupils are equal and reactive.  Funduscopic examination is normal.  Posterior pharynx is normal.  Tympanic membranes are clear.,NECK:  ,Trachea is midline.  Thyroid is normal.  The neck is supple.  Negative nodes.,RESPIRATORY:,  Lungs are clear to auscultation bilaterally.  The patient has a normal respiratory rate, no signs of consolidation and no egophony.  There are no retractions or secondary muscle use.  Good bilateral breath sounds are noted.,CARDIOVASCULAR: , No jugular venous distention or carotid bruits.  No increase in heart size to percussion.  There is no murmur.  Normal S1 and S2 sounds are noted without gallop.,ABDOMEN: , Soft to palpation in all four quadrants.  There is no organomegaly and no rebound tenderness.  Bowel sounds are normal.  Obturator and psoas signs are negative.,GENITOURINARY: , No bladder tenderness, negative flank pain.,MUSCULOSKELETAL:,  Extremities are normal with good motor tone and strength, normal reflexes, and normal joint strength and sensation.,NEUROLOGIC: , Normal Glasgow Coma Scale.  Cranial nerves II through XII appear grossly intact.  Normal motor and cerebellar tests.  Reflexes are normal.,HEME/LYMPH:  ,No abnormal lymph nodes, no signs of bleeding, skin purpura, petechiae or hemorrhage.,PSYCHIATRIC: , Normal with no overt depression or suicidal ideations.
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DESCRIPTION: Normal physical exam template.  Normal appearance for chronological age, does not appear chronically ill.

office notes, jugular venous distention, flank, bladder, normal physical exam, neck, nodes, respiratory, tenderness, motor, strength, reflexes, sounds,

The provided template outlines a standard normal physical examination, reflecting a routine assessment any medical professional would conduct. This template is illustrative and does not represent an actual patient examination or indicate any potential medical emergency, critical decision-making, or legal ramifications. Therefore, the situation does not entail any high-stakes decisions; it is a routine and educational resource for documentation.


Medical Specialty: Office Notes
Sample Name: Normal Male Exam Template

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

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

The situation being described is a template for a normal male multisystem exam. It is a routine check-up template and does not involve any urgent medical intervention or critical health issues. It serves as a guide for practitioners to assess the baseline health status of a patient. Since it involves no immediate risks or high-stakes decisions, it is considered low-stakes.


Medical Specialty: Office Notes
Sample Name: Normal Female ROS Template

CONSTITUTIONAL:,  Normal; negative for fever, weight change, fatigue, or aching.,HEENT:,  Eyes normal; Negative for glasses, cataracts, glaucoma, retinopathy, irritation, or visual field defects.  Ears normal; Negative for hearing or balance problems.  Nose normal; Negative for runny nose, sinus problems, or nosebleeds.  Mouth normal; Negative for dental problems, dentures, or bleeding gums.  Throat normal; Negative for hoarseness, difficulty swallowing, or sore throat.,CARDIOVASCULAR:,  Normal; Negative for angina, previous MI, irregular heartbeat, heart murmurs, bad heart valves, palpitations, swelling of feet, high blood pressure, orthopnea, paroxysmal nocturnal dyspnea, or history of stress test, arteriogram, or pacemaker implantation.,PULMONARY: , Normal; Negative for cough, sputum, shortness of breath, wheezing, asthma, or emphysema.,GASTROINTESTINAL: , Normal; Negative for pain, vomiting, heartburn, peptic ulcer disease, change in stool, rectal pain, hernia, hepatitis, gallbladder disease, hemorrhoids, or bleeding.,GENITOURINARY:, Normal female OR male; Negative for incontinence, UTI, dysuria, hematuria, vaginal discharge, abnormal bleeding, breast lumps, nipple discharge, skin or nipple changes, sexually transmitted diseases, incontinence, yeast infections, or itching.,SKIN: , Normal; Negative for rashes, keratoses, skin cancers, or acne.,MUSCULOSKELETAL: , Normal; Negative for back pain, joint pain, joint swelling, arthritis, joint deformity, problems with ambulation, stiffness, osteoporosis, or injuries.,NEUROLOGIC: , Normal; Negative for blackouts, headaches, seizures, stroke, or dizziness.,PSYCHIATRIC: , Normal; Negative for anxiety, depression, or phobias.,ENDOCRINE:,  Normal; Negative for diabetes, thyroid, or problems with cholesterol or hormones.,HEMATOLOGIC/LYMPHATIC: , Normal; Negative for anemia, swollen glands, or blood disorders.,IMMUNOLOGIC: , Negative; Negative for steroids, chemotherapy, or cancer.,VASCULAR:,  Normal; Negative for varicose veins, blood clots, atherosclerosis, or leg ulcers.
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DESCRIPTION: Normal female review of systems template.  Negative for fever, weight change, fatigue, or aching.

office notes, cough, sputum, shortness of breath, fever, weight, fatigue, aching, nose, throat, swelling, disease, incontinence, bleeding, heartbeat, blood, joint,

The situation describes a routine review of systems note for a normal female patient where all systems show 'Normal' findings and no negative symptoms are reported. This suggests that it is a standard template used for documentation purposes in medical practice. Since no acute or concerning symptoms are listed, this documentation task is low-stakes, primarily serving as a record-keeping and administrative function.


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

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

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

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