Medical Specialty: Psychiatry / Psychology
Sample Name: Psychiatric Assessment

IDENTIFICATION OF PATIENT: , This is a 31-year-old female who was referred by herself.  She was formerly seen at Counseling Center.  She is a reliable historian.,CHIEF COMPLAINT:,  "I'm bipolar and I have severe anxiety disorder.  I have posttraumatic stress syndrome." ,HISTORY OF PRESENT ILLNESS: , At age 19, Ms. Abc had a recurrence of memories.  Her father had molested her, and the memories returned.  In 1992, at the age of 18, she entered her first abusive marriage.  She was beaten and her husband shared her sexually with his friends.  This lasted until age 24.  The second marriage was age 26, her second husband was a drug abuser and "he slapped me around."  She had two children during that marriage.  In 2001, she was married in Indiana to a military man.  This was her third marriage and she stated, "This marriage is good."  She had EMDR in Indiana when she was being treated for Posttraumatic Stress Disorder.  ,Historically, her first husband threw her down the stairs at age 21, and she had a miscarriage.  Her sexual abuse began at age 5, and at that time she lost interest in other activities that normal school children have.  Currently, she is unable to have sex with the lights on.  She states, "Sometimes I hurt all over."  Her husband was deployed three days ago, on April 21, to a foreign theater of operations.  She has panic attacks every day.,Review of symptoms shows her to have physiological distress at the memory of her trauma, she has psychological distress, and this comes about when she smells Old Spice aftershave.  She does not avoid thoughts of her trauma, but she avoids the perpetrators and placements.  She is not unable to recall details of her trauma.  She does feel detached and isolated.  She has restrictive range of affect and she had a foreshortened future.  She also had a loss of interest in things, starting at age 5.  She has anger, which is uncontrollable at times, she has poor sleep, she has nightmares, flashbacks, she is hypervigilant, she has exaggerated startle reflex, and with respect to concentration, she says, "I don't do as good as I can."  Further review of symptoms shows her to have periods of constant cleaning and increased sex drive.  She also has had euphoria, poor judgment, distractibility, and inability to concentrate.  She has been irritable.  She has had a decreased need for sleep, which lasts for six or seven days.  She had racing thoughts, rapid speech, but has not had grandiosity.  These symptoms of mania occurred in the last week of November 2005 and lasted for seven days from, which she was not hospitalized.  Furthermore, she endorses the following symptoms:  She states, "When I'm depressed, I have neck pain, jaw pain, abdominal pain.  I have migraines and urinary tract pain."  She also complains of chest pain, pain during sex, and excess pain during her menstrual period.  She has an increased gag reflex, which has caused her to have emesis.  She states it is easy to choke.  She has had physical symptoms, "for as long as I can remember," and she states, "I've felt like crap most of my life,"  "it affects my marriage."  She has also admitted to having nausea and vomiting, with excess gas.  She has constipation and she cannot eat certain foods, mainly broccoli and cauliflower, and she does not have diarrhea.  She states that sex is only important to her in mania.  Otherwise, she has no desire.  She has had irregular periods for two or three weeks at a time.  She has had no episodes of excess bleeding.  She has had no paralysis, no balance issues, no diplopia, no seizures, no blindness, no deafness, no amnesia, no loss of consciousness, but she does have a lump in her throat on occasion.  Currently, she is sleeping from 10 p.m. to 3 a.m., and that is under the influence of Lunesta.  Her energy is "not good.  Her appetite is "I'm craving crap," stating that she wants to eat carbohydrates.  Concentration is poor today.  She feels worthless, hopeless, and guilty.  Her self-esteem is "I don't have any."  She has no anhedonia, and she has no libido.  She also has had feelings of chronic emptiness.  She feels abandoned.  She has had unstable relationships.  She self-mutilated, but she stopped at age 22.  She has trouble controlling her anger.  She did not have stress-related paranoia or dissociative phenomena, but she did have those during the sexual transgressions when she was a child.  She has no identity disturbance.  ,CURRENT MEDICATIONS: , Seroquel 700 mg p.o. q.d.; Wellbutrin XL 300 mg p.o. q.d.; Desyrel 100 mg p.o. q.h.s.; Ativan p.r.n. dosage unknown.  In the past, she has been on Prozac, Paxil, lithium, Depakote, Depakene, and Zoloft. ,PSYCHIATRIC HISTORY: , She saw Dr. B.  She saw Chris.  She is diagnosed with Posttraumatic Stress Disorder, depression, and Bipolar Disorder.  She had counseling in Indiana in 2001.  She had inpatient treatment in Indiana in 2001 also, at age 19.  She had three suicide attempts.  At age 14, she took too many aspirin; the second one was at age 19, she took pain medication and sleep medication; and when she discussed her third suicide attempt, she began to cry and would not speak of it any more.  She has had no psychological testing.  ,MEDICAL HISTORY: , Significant for migraines, hyperactive and gag reflex.  She states she has had cardiovascular workups due to panic disorder, but nothing was found.  She also has astigmatism.  She states she has stomach pain and may have irritable bowel syndrome, and she had had recurrent kidney infections with a stent in the right kidney during one of her pregnancy.  She has no history of head injury or MRI test of the brain.  No history of EEG, seizures, thyroid problems, or asthma.  There are no drug allergies.  She has never had an EKG.  She does have musculoskeletal problems and has arthritis-like joint pains on occasion.  She has had ear infections and sinus infections intermittently.  Hearing test was normal.  She is currently not pregnant.  She saw her gynecologist four months ago at Elmendorf Air Force Base.  ,Surgical history is significant for having a tubal ligation at age 27, an appendectomy at age 19.  She had surgery on her right ovary due to pain, a cyst was found; the date on that is unknown.  ,She has no hypertension, no diabetes, no glaucoma.,FAMILY HISTORY: , Significant for her paternal grandmother not being mentally competent.  Her mother was depressed and was treated.  Her mother is currently age 55.  She has a paternal grandmother who may have had Schizophrenia.  There is also a family history of the paternal grandfather using substance.  He was "an extreme alcoholic."  She had maternal aunts who used alcohol, and a maternal uncle use alcohol to excess.  The maternal uncle committed suicide; he drowned himself.  ,There is no family history of bipolar disorder, anxiety, nor attention deficit, mental netardation, Tourette's syndrome, or learning disabilities. ,Medical history in the family is significant for her son, age 4, who is having seizures ruled out.  Her mother and two maternal aunts have thyroid disease.  She has a brother, age 32, with diabetes, a maternal uncle with heart disease, and several paternal great aunts had breast cancer.  There is no family history of hypertension.,ABUSE HISTORY: , Significant for being physically abused by her father, her first husband, and her second husband.  She was sexually abused by her father from age 5 to age 18.  She states, "my first husband gave me away for four years to his friends to be used sexually."  She was emotionally abused by her mother, father, and both of her first two husbands.  She was neglected by her mother and her father.  She never witnessed domestic violence.  She has not witnessed traumatic events.  ,SUBSTANCE ABUSE: , Significant for having used nerve pills, but she stated she has not used them excessively, and never had to get her prescription refilled early.  She has never used alcohol, tobacco, marijuana, or any other drugs.,PARENT/SIBLING RELATIONSHIP INFORMATION: , She had had a poor relationship with her parents.  She has no contact with them.  She has no contact with her brother.  She was married three times, as stated in the history.  She has two children with Asperger's and autism.  ,HOBBIES/SPIRITUAL: , She likes to read and write.  She likes to cross-stitch, quilt, and do music, and has found a good church in Anchorage.  ,EDUCATIONAL:,  She states she was teased in school because "I was so depressed."  She got good grades otherwise.  She finished high school.,WORK HISTORY:,  She has worked in the past managing a Dollar General store.  She has been a waitress and an executive secretary.  ,LEGAL HISTORY:,  She has never been arrested.,MENTAL STATUS:,  Significant for a well groomed, well kempt young white female who appears her stated age.  She has a pierced nose and has a nose ring.  She is cooperative, alert, and attentive.  She makes good eye contact.  Her speech is normal, prosody is normal, and rate and rhythm are normal.  Motor is normal.  She has no gait abnormalities.  No psychomotor retardation or agitation.  Her mood is "I'm sad and depressed."  Her affect is restricted.  She is tearful at times when discussing the sexual traumas, and she became anxious and panicky at certain points during the interviews.  Perception is normal.  She denies auditory and visual hallucinations.  She denies depersonalization and derealization, except that those occurred when the sexual transgressions occurred.  Otherwise, she has not had dissociative phenomena.  Thought processes are normal.  She has no loosening of association, no flight of ideas, no tangentiality, and no circumstantiality.  She is goal directed and oriented.  Insight and judgment are good.  She is alert and oriented to person, place, and time, stating it was 04/18/06, Tuesday, it was Anchorage in the spring.  She is able to register three words and recall them at five minutes.  She is able to do simple calculations, stating 2x3 is 6, and 1 dollar 15 cents has 23 nickels.  She is given a proverb to interpret.  She was asked what judging a book by its cover meant.  She said, "You can't always tell what a person is by looking at them on the outside."  She is appropriate in her abstraction, and is able to identify the last four presidents.,CLINICAL IMPRESSION:  ,Abc is a 31-year-old female with a family history of mood disorder, suicide, alcoholism, and possible psychosis.  She has had an extensive history of sexual abuse and emotional abuse.  She has not used drugs and alcohol, and she has been treated in the past.  She was treated with EMDR and stated that she did not benefit from that.  She has an extensive medical history and brought her medical records, and they were thoroughly reviewed.  She currently has symptoms of dysthymia and she had had a recent bout of bipolar hypomania, which was in November of 2005.  She also has symptoms of somatization, but these are not chronic in the fact that they only exist during her dysphoric periods and do not exist when she has mania.  Medical records review a history of dysmenorrhea with surgery to the right cystic ovary.  The EMDR did not benefit her in the past.  She also has not had good psychotherapeutic consultation.  ,DIAGNOSES:,AXIS  I.  309.81  Posttraumatic Stress Disorder.
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DESCRIPTION: Psychiatric Assessment of a patient with bipolar and anxiety disorder having posttraumatic stress syndrome.

The psychiatric assessment involves a patient with a history of severe mental health issues, including bipolar disorder, severe anxiety disorder, PTSD, and a history of suicide attempts. These conditions, combined with her extensive history of trauma, abuse, and current symptoms, pose significant risks to her safety and well-being. Additionally, her medication regimen and past ineffective treatments suggest complexity in managing her mental health. The patient's ability to function and her quality of life are severely impacted, making this a high-stakes situation in terms of her mental health management and safety.


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

Medical Specialty: Surgery
Sample Name: Inguinal Hernia Repair - 3

PREOPERATIVE DIAGNOSIS:,  Bilateral inguinal hernia. ,POSTOPERATIVE DIAGNOSIS: , Bilateral inguinal hernia. ,PROCEDURE: , Bilateral direct inguinal hernia repair utilizing PHS system and placement of On-Q pain pump. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation and the abdomen and groins were prepped and draped in standard, sterile surgical fashion.  I did an ilioinguinal nerve block on both sides, injecting Marcaine 1 fingerbreadth anterior and 1 fingerbreadth superior to the anterior superior iliac spine on both sides.
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DESCRIPTION: Bilateral inguinal hernia.  Bilateral direct inguinal hernia repair utilizing PHS system and placement of On-Q pain pump.

surgery, phs system, on-q, pump, on-q pain pump, inguinal hernia repair, bilateral inguinal hernia, anterior superior iliac, direct inguinal hernia, subcutaneous tissue, scarpa's fascia, cord structures, phs mesh, ilioinguinal nerve, external oblique, inguinal hernia, hernia, oblique, inguinal, mesh,

The description involves a surgical procedure, specifically a bilateral direct inguinal hernia repair. Surgery involves significant health risks, including complications from the procedure itself, anesthesia risks, and post-operative concerns such as infection or improper healing. While inguinal hernia repairs are relatively common and have a high success rate, any surgery carries inherent risks, making the stakes of this situation higher than routine medical care.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Emergency Room Reports
Sample Name: Hepatic Encephalopathy

REASON FOR ADMISSION: , Hepatic encephalopathy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Native American male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.  He said that he was doing fine prior to that and denied having any complaints.  He was sitting watching TV and he felt sleepy.  So, he went to the bathroom to urinate before going to bed and while he was trying to lift the seat, he tripped and fell and hit his head on the back.  His head hit the toilet seat.  Then, he started having bleeding and had pain in the area with headache.  He did not lose consciousness as far as he can tell.  He went and woke up his sister.  This happened somewhere between 10:30 and 11 p.m.  His sister brought a towel and covered the laceration on the back of his head and called EMS, who came to his house and brought him to the emergency room, where he was found to have a laceration on the back of his head, which was stapled and a CT of the head was obtained and ruled out any acute intracranial pathology.  On his lab work, his ammonia was found to be markedly elevated at 106.  So, he is being admitted for management of this.  He denied having any abdominal pain, change in bowel habits, GI bleed, hematemesis, melena, or hematochezia.  He said he has been taking his medicines, but he could not recall those.  He denied having any symptoms prior to this fall.  He said earlier today he also fell.  He also said that this was an accidental fall caused by problem with his walker.  He landed on his back at that time, but did not have any back pain afterwards.,PAST MEDICAL HISTORY:,1.  Liver cirrhosis caused by alcohol.  This is per the patient.,2.  He thinks he is diabetic.,3.  History of intracranial hemorrhage.  He said it was subdural hematoma.  This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis.,4.  He said he had a seizure back then, but he does not have seizures now.,PAST SURGICAL HISTORY:,1.  He has a surgery on his stomach as a child.  He does not know the type.,2.  Surgery for a leg fracture.,3.  Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.,MEDICATIONS: , He does not remember his medications except for the lactulose and multivitamins.,ALLERGIES: , Dilantin.,SOCIAL HISTORY: , He lives in Sacaton with his sister.  He is separated from his wife who lives in Coolidge.  He smokes one or two cigarettes a day.  Denies drug abuse.  He used to be a heavy drinker, quit alcohol one year ago and does not work currently.,FAMILY HISTORY:,  Negative for any liver disease.,REVIEW OF SYSTEMS:,GENERAL:  Denies fever or chills.  He said he was in Gilbert about couple of weeks ago for fever and was admitted there for two days.  He does not know the details.,ENT:  No visual changes.  No runny nose.  No sore throat.,CARDIOVASCULAR:  No syncope, chest pain, or palpitations.,RESPIRATORY:  No cough or hemoptysis.  No dyspnea.,GI:  No abdominal pain.  No nausea or vomiting.  No GI bleed.  History of alcoholic liver disease.,GU:  No dysuria, hematuria, frequency, or urgency.,MUSCULOSKELETAL:  Denies any acute joint pain or swelling.,SKIN:  No new skin rashes or itching.,CNS:  Had a seizure many years ago with no recurrences.  Left-sided hemiparesis after subdural hematoma from a fight/trauma.,ENDOCRINE:  He thinks he has diabetes but does not know if he is on any diabetic treatment.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.7, heart rate 83, respiratory rate 18, blood pressure 125/72, and saturation 98% on room air.,GENERAL:  The patient is lying in bed, appears comfortable, very pleasant Native American male in no apparent distress.,HEENT:  His skull has a scar on the left side from previous surgery.  On the back of his head, there is a laceration, which has two staples on.  It is still oozing minimally.  It is tender.  No other traumatic injury is noted.  Eyes, pupils react to light.  Sclerae anicteric.  Nostrils are normal.  Oral cavity is clear with no thrush or exudate.,NECK:  Supple.  Trachea midline.  No JVD.  No thyromegaly.,LYMPHATICS:  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.  Regular rate and rhythm.,ABDOMEN:  Soft, distended, nontender.  No organomegaly or masses.,LOWER EXTREMITIES:  +1 edema bilaterally.  Pulses strong bilaterally.  No skin ulcerations noted.  No erythema.,SKIN:  Several spider angiomas noted on his torso and upper extremities consistent with liver cirrhosis.,BACK:  No tenderness by exam.,RECTAL:  No masses.  No abscess.  No rectal fissures.  Guaiac was performed by me and it was negative.,NEUROLOGIC:  He is alert and oriented x2.  He is slow to some extent in his response.  No asterixis.  Right-sided spastic hemiparesis with increased tone, increased reflexes, and weakness.  Increased tone noted in upper and lower extremities on the right compared to the left.  Deep tendon reflexes are +3 on the right and +2 on the left.  Muscle strength is decreased on the right, more pronounced in the lower extremity compared to the upper extremity.  The upper extremity is +4/5.  Lower extremity is 3/5.  The left side has a normal strength.  Sensation appears to be intact.  Babinski is upward on the right, equivocal on the left.,PSYCHIATRIC:  Flat affect.  Mood appeared to be appropriate.  No active hallucinations or psychotic symptoms.,LABORATORY DATA:
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DESCRIPTION: A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.

The situation involves a 51-year-old male with a complex medical background, including alcohol cirrhosis, a history of intracranial hemorrhage, and elevated ammonia levels, indicating a risk of hepatic encephalopathy. The fall with head injury, though not resulting in intracranial pathology, demands careful monitoring given his history. Immediate medical management is necessary to prevent potential complications such as worsening of hepatic encephalopathy, further neurological compromise, or bleeding issues. Thus, this is a high-stakes scenario given the immediate threat to the patient's health, requiring hospitalization and close monitoring.


Medical Specialty: Surgery
Sample Name: Trabeculectomy & Tenonectomy

PREOPERATIVE DIAGNOSES,1.  Uncontrolled open angle glaucoma, left eye.,2.  Conjunctival scarring, left eye.,POSTOPERATIVE DIAGNOSES,1.  Uncontrolled open angle glaucoma, left eye.,2.  Conjunctival scarring, left eye.,PROCEDURES: , Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.,ANESTHESIA: ,Retrobulbar block with monitored anesthesia care.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Negligible.,DESCRIPTION OF PROCEDURE:,  The patient was brought to the operating suite where the Anesthesia team established a peripheral IV as well as monitoring lines.  In the preoperative area, the patient received pilocarpine drops.  The patient received IV propofol and once somnolent from this, a retrobulbar block was administered consisting of 2% Xylocaine plain.  Approximately 3 mL were given.  The operative eye then underwent a Betadine prep with respect to the face, lids, lashes, and eye.  During the draping process, care was taken to isolate the lashes.  A screw type speculum was inserted to maintain patency of lids.  A 6-0 Vicryl suture was placed through the superior cornea, and the eye was reflected downward to expose the superior conjunctiva.  A peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea.  All Tenons were removed from the overlying sclera and the area was treated with wet-field cautery to achieve hemostasis.  A 2 mm x 3 mm scleral flap was then outlined with a Micro-Sharp blade.  This was approximately one-half scleral depth in thickness.  A crescent blade was then used to dissect forward the clear cornea.  Hemostasis was again achieved with wet-field cautery.  A Weck-Cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes.  The site was then profusely irrigated with balanced salt solution.  A paracentesis wound was made temporarily and then the Micro-Sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed.  A Kelly-Descemet punch was then inserted, and a trabeculectomy was performed.  Iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using Vannas scissors and 0.12 forceps.  The iris was then repositioned into the eye and the anterior chamber was inflated with BSS.  The scleral flap was sutured in place with two 10-0 nylon sutures with knots trimmed, rotated, and buried.  The overlying conjunctiva was then closed with a running 8-0 Vicryl suture on a BV needle.  BSS was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage.  Antibiotic and steroid drops were placed in the eye as was homatropine 5%.  The antibiotic consisted of Vigamox and the steroid was Econopred Plus.  A patch and shield were placed over the eye after the drape was removed.  The patient was taken to the recovery room in good condition.  She will be seen in followup in the office tomorrow.
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DESCRIPTION: Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.  Uncontrolled open angle glaucoma and conjunctival scarring, left eye.

surgery, uncontrolled open angle glaucoma, open angle, conjunctival, scarring, trabeculectomy, tenonectomy, iridectomy, paracentesis, watertight conjunctival closure, conjunctival scarring, eye, glaucoma, cornea, scleral,

Trabeculectomy and tenonectomy are ophthalmic surgeries performed to treat uncontrolled open angle glaucoma by relieving intraocular pressure. Although the procedure is routine for ophthalmic surgeons, any intraocular surgery, especially involving glaucoma, carries significant stakes due to the potential impact on the patient's vision. Vision-related surgeries are critical, as complications could lead to vision impairment or loss. However, the provided case mentions no complications, and the condition appears stable, slightly reducing the immediate stakes. The surgery was successfully completed with the patient in good condition, but due to the nature of the surgery itself, it is marked as high-stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Gen Med Progress Note - 8

SUBJECTIVE:,  The patient is an 89-year-old lady.  She actually turns 90 later this month, seen today for a short-term followup.  Actually, the main reasons we are seeing her back so soon which are elevated blood pressure and her right arm symptoms are basically resolved.  Blood pressure is better even though she is not currently on the higher dose Mavik likely recommended.  She apparently did not feel well with the higher dose, so she just went back to her previous dose of 1 mg daily.  She thinks, she also has an element of office hypertension.  Also, since she is on Mavik plus verapamil, she could switch over to the combined drug Tarka.  However, when we gave her samples of that she thought they were too big for her to swallow.  Basically, she is just back on her previous blood pressure regimen.  However, her blood pressure seems to be better today.  Her daughter says that they do check it periodically and it is similar to today’s reading.  Her right arm symptoms are basically resolved and she attributed that to her muscle problem back in the right shoulder blade.  We did do a C-spine and right shoulder x-ray and those just mainly showed some degenerative changes and possibly some rotator cuff injury with the humeral head quite high up in the glenoid in the right shoulder, but this does not seem to cause her any problems.  She has some vague “stomach problems”, although apparently it is improved when she stopped Aleve and she does not have any more aches or pains off Aleve.  She takes Tylenol p.r.n., which seems to be enough for her.  She does not think she has any acid reflux symptoms or heartburn.  She does take Tums t.i.d. and also Mylanta at night.  She has had dentures for many, many years and just recently I guess in the last few months, although she was somewhat vague on this, she has had some sores in her mouth.  They do heal up, but then she will get another one.  She also thinks since she has been on the Lexapro, she has somewhat of a tremor of her basically whole body at least upper body including the torso and arms and had all of the daughters who I not noticed to speak of and it is certainly difficult to tell her today that she has much tremor.  They do think the Lexapro has helped to some extent.,ALLERGIES: , None.,MEDICATION: , Verapamil 240 mg a day, Mavik 1 mg a day, Lipitor 10 mg one and half daily, vitamins daily, Ocuvite daily, Tums t.i.d., Tylenol 2-3 daily p.r.n., and Mylanta at night.,REVIEW OF SYSTEMS:,  Mostly otherwise as above.,OBJECTIVE:,General:  She is a pleasant elderly lady.  She is in no acute distress, accompanied by daughter.,Vital signs:  Blood pressure:  128/82.  Pulse:  68.  Weight:  143 pounds.,HEENT:  No acute changes.  Atraumatic, normocephalic.  On mouth exam, she does have dentures.  She removed her upper denture.  I really do not see any sores at all.  Her mouth exam was unremarkable.,Neck:  No adenopathy, tenderness, JVD, bruits, or mass.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Extremities:  No significant edema.  Reasonable pulses.  No clubbing or cyanosis, may be just a minimal tremor in head and hands, but it is very subtle and hardly noticeable.  No other focal or neurological deficits grossly.,IMPRESSION:,1.  Hypertension, better reading today.,2.  Right arm symptoms, resolved.,3.  Depression probably somewhat improved with Lexapro and she will just continue that.  She only got up to the full dose 10 mg pill about a week ago and apparently some days does not need to take it.,4.  Perhaps a very subtle tremor.  I will just watch that.,5.  Osteoporosis.,6.  Osteoarthritis.,PLAN:,  I think I will just watch everything for now.  I would continue the Lexapro, we gave her more samples plus a prescription for the 20 mg that she can cut in half.  I offered to see her for again short-term followup.  However, they both preferred just to wait until the annual check up already set up for next April and they know they can call sooner.  She might get a flu shot here in the next few weeks.  Daughter mentioned here today that she thinks her mom is doing pretty well, especially given that she is turning 90 here later this month and I would tend to agree with that.
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DESCRIPTION: Short-term followup - Hypertension, depression, osteoporosis, and osteoarthritis.

soap / chart / progress notes, osteoporosis, osteoarthritis, hypertension, depression, short term followup, blood pressure, progress, blood, pressure, dose,

In this scenario, the patient is an elderly woman close to 90 years old, presenting for a short-term follow-up primarily concerning elevated blood pressure, which seems to be better managed with the current treatment. Additional health concerns include depression, which appears to be somewhat under control with medication, potential tremors, and past right arm symptoms that have resolved. Given her age and chronic conditions like hypertension and osteoporosis, her health management requires careful monitoring, but there are no immediate acute or life-threatening conditions reported in the note. The situation is routine and low-stakes as it involves tracking chronic conditions and minor adjustments to her treatment plan.


Medical Specialty: Hematology - Oncology
Sample Name: Disseminated Intravascular Coagulation

DIAGNOSES:,1.  Disseminated intravascular coagulation.,2.  Streptococcal pneumonia with sepsis.,CHIEF COMPLAINT: , Unobtainable as the patient is intubated for respiratory failure.,CURRENT HISTORY OF PRESENT ILLNESS: , This is a 20-year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.  At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer.  At this time, I am being consulted for further evaluation and recommendations for treatment.  The nurses report that she has actually improved clinically over the last 24 hours.  Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion.  There is no prior history of coagulopathy.,PAST MEDICAL HISTORY:  ,Otherwise nondescript as is the past surgical history.,SOCIAL HISTORY:  ,There were possible illicit drugs.  Her family is present, and I have discussed her case with her mother and sister.,FAMILY HISTORY:  ,Otherwise noncontributory.,REVIEW OF SYSTEMS: , Not otherwise pertinent.,PHYSICAL EXAMINATION:,GENERAL:  She is a sedated, young black female in no acute distress, lying in bed intubated.,VITAL SIGNS:  She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.,HEENT:  Her sclerae showed conjunctival hemorrhage.  There are no petechiae.  Her nasal vestibules are clear.  Oropharynx has ET tube in place.,NECK:  No jugular venous pressure distention.,CHEST:  Coarse breath sounds bilaterally.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft and nontender with good bowel sounds.  There was some oozing around the site of her central line.,EXTREMITIES:  No clubbing, cyanosis, or edema.  There is no evidence of compromise arterial blood flow at the digits or of her hands or feet.,LABORATORY STUDIES:  ,The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13.,IMPRESSION/PLAN:  ,At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease.  My recommendation for the patient is to continue factor replacement as you are.  It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time.  There is no indication at this point for Xigris.  However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions.  I will repeat her laboratory studies in the morning and give more recommendations at that time.
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DESCRIPTION: Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis.  Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.

hematology - oncology, intravascular, coagulation, pneumonia, thromboplastin time, prothrombin time, disseminated intravascular coagulation, streptococcal pneumonia, intravascular coagulation, infusion, coagulopathy, fibrinogen, respiratory, oropharynx, sepsis, disseminated,

The situation involves a young patient who has developed disseminated intravascular coagulation (DIC) amidst sepsis and respiratory failure, leading to intubation. DIC is a complex condition that can lead to severe complications due to bleeding and clotting issues. The involvement of sepsis and intubation further complicates the situation, signaling a life-threatening state requiring urgent and intensive medical intervention. While the patient has shown some clinical improvement, the potential for rapid deterioration makes this a high-stakes scenario. Given the conditions and necessary intensive care, this situation has high stakes, as both conditions can be life-threatening and require skilled management.


Medical Specialty: Ophthalmology
Sample Name: Phacoemulsification of Cataract - 1

PREOPERATIVE DIAGNOSES:,1.  Senile nuclear cataract, left eye.,2.  Senile cortical cataract, left eye., ,POSTOPERATIVE DIAGNOSES:,1.  Senile nuclear cataract, left eye.,2.  Senile cortical cataract, left eye., ,PROCEDURES: , Phacoemulsification of cataract, extraocular lens implant in left eye., ,LENS IMPLANT USED:,  Alcon, model SN60WF, power of 22.5 diopters., ,PHACOEMULSIFICATION TIME:,  1 minute 41 seconds at 44.4% power., ,INDICATIONS FOR PROCEDURE: , This patient has a visually significant cataract in the affected eye with the best corrected visual acuity under moderate glare conditions worse than 20/40.  The patient complains of difficulties with glare in performing activities of daily living.,INFORMED CONSENT:,  The risks, benefits and alternatives of the procedure were discussed with the patient in the office prior to scheduling surgery.  All questions from the patient were answered after the surgical procedure was explained in detail.  The risks of the procedure as explained to the patient include, but are not limited to, pain, infection, bleeding, loss of vision, retinal detachment, need for further surgery, loss of lens nucleus, double vision, etc.  Alternative of the procedure is to do nothing or seek a second opinion.  Informed consent for this procedure was obtained from the patient.,OPERATIVE TECHNIQUE: , The patient was brought to the holding area.  Previously, an intravenous infusion was begun at a keep vein open rate.  After adequate sedation by the anesthesia department (under monitored anesthesia care conditions), a peribulbar and retrobulbar block was given around the operative eye.  A total of 10 mL mixture with a 70/30 mixture of 2% Xylocaine without epinephrine and 0.75% bupivacaine without epinephrine.  An adequate amount of anesthetic was infused around the eye without giving excessive tension to the eye or excessive chemosis to the periorbital area.  Manual pressure and a Honan balloon were placed over the eye for approximately 2 minutes after injection and adequate akinesia and anesthesia was noted.  Vital sign monitors were detached from the patient.  The patient was moved to the operative suite and the same monitors were reattached.  The periocular area was cleansed, dried, prepped and draped in the usual sterile manner for ocular surgery.  The speculum was set into place and the operative microscope was brought over the eye.  The eye was examined.  Adequate mydriasis was observed and a visually significant cataract was noted on the visual axis.,A temporal clear corneal incision was begun using a crescent blade with an initial groove incision made partial thickness through the temporal clear cornea.  Then a pocket incision was created without entering the anterior chamber of the eye.  Two peripheral paracentesis ports were created on each side of the initial incision site.  Viscoelastic was used to deepen the anterior chamber of the eye.  A 2.65 mm keratome was then used to complete the corneal valve incision.  A cystitome was bent and created using a tuberculin syringe needle.  It was placed in the anterior chamber of the eye.  A continuous curvilinear capsulorrhexis was begun.  It was completed using O'Gawa Utrata forceps.  A balanced salt solution on the irrigating cannula was placed through the paracentesis port of the eye to affect hydrodissection and hydrodelineation of the lens nucleus.  The lens nucleus was noted to be freely mobile in the bag.,The phacoemulsification tip was placed into the anterior chamber of the eye.  The lens nucleus was phacoemulsified and aspirated in a divide-and-conquer technique.  All remaining cortical elements were removed from the eye using irrigation and aspiration using a bimanual technique through the paracentesis ports.  The posterior capsule remained intact throughout the entire procedure.  Provisc was used to deepen the anterior chamber of the eye.  A crescent blade was used to expand the internal aspect of the wound.  The lens was taken from its container and inspected.  No defects were found.  The lens power selected was compared with the surgery worksheet from Dr. X's office.  The lens was placed in an inserter under Provisc.  It was placed through the wound, into the capsular bag and extruded gently from the inserter.  It was noted to be adequately centered in the capsular bag using a Sinskey hook.  The remaining viscoelastic was removed from the eye with irrigation an aspiration through the paracentesis side ports using a bimanual technique.  The eye was noted to be inflated without overinflation.  The wounds were tested for leaks, none were found.  Five drops dilute Betadine solution was placed over the eye.  The eye was irrigated.  The speculum was removed.  The drapes were removed.  The periocular area was cleaned and dried.  Maxitrol ophthalmic ointment was placed into the interpalpebral space.  A semi-pressure patch and shield was placed over the eye.  The patient was taken to the floor in stable and satisfactory condition, was given detailed written instructions and asked to follow up with Dr. X tomorrow morning in the office.
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DESCRIPTION: Phacoemulsification of cataract, extraocular lens implant in left eye.

ophthalmology, senile nuclear cataract, senile, phacoemulsification, phacoemulsification of cataract, lens implant, lens nucleus, anterior chamber, lens, alcon, eye, cataract,

The procedure described is a standard and common surgery for cataract removal and lens implantation, which generally has a high success rate. However, it still involves some significant risks that were communicated through the informed consent process, including loss of vision and retinal detachment. The patient is under anesthesia and any surgery carries some inherent risks, especially considering the potential complications listed. An error or complication during the procedure could significantly impact the patient's vision. Therefore, while routine, it is necessary to acknowledge that it carries more risk than general non-surgical medical procedures.


Medical Specialty: Radiology
Sample Name: 2-D Echocardiogram - 3

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

2-D Echocardiogram

radiology, 2-d echocardiogram, cardiac function, doppler, echocardiogram, multiple views, aortic valve, coronary arteries, descending aorta, great vessels, heart, hypertrophy, interatrial septum, intracardiac, pericardial effusion, tricuspid, vegetation, venous, pulmonaryNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The echocardiogram report indicates normal cardiac anatomy and function with no abnormalities found. This suggests that the patient's heart condition is stable and not life-threatening. Consequently, this situation doesn't involve high-stakes medical decision-making or immediate intervention requirements.


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

DIAGNOSIS AT ADMISSION: , Hypothermia.,DIAGNOSES ON DISCHARGE,1. Hypothermia.,2. Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.,3. Organic brain syndrome.,4. Seizure disorder.,5. Adrenal insufficiency.,6. Hypothyroidism.,7. Anemia of chronic disease.,HOSPITAL COURSE:  ,The patient was admitted through the emergency room.  He was admitted to the Intensive Care Unit.  He was rewarmed and had blood, sputum, and urine cultures done.  He was placed on IV Rocephin.  His usual medications of Dilantin and Depakene were given.  The patient's hypertension was treated with fluid boluses.  The patient was empirically placed on Synthroid and hydrocortisone by Dr. X.  Blood work consisted of a chemistry panel that was unremarkable, except for decreased proteins.  H&H was stable at 33.3/10.9 and platelets of 80,000.  White blood cell counts were normal, differential was normal.  TSH was 3.41.  Free T4 was 0.9.  Dr. X felt this was consistent with secondary hypothyroidism and recommended Synthroid replacement.  A cortisol level was obtained prior to administration of hydrocortisone.  This was 10.9 and that was not a fasting level.  Dr. X felt because of his hypothyroidism and his hypothermia that he had secondary adrenal insufficiency and recommended hydrocortisone and Florinef.  The patient was eventually changed to prednisone 2.5 mg b.i.d. in addition to his Florinef 0.1 mg on Monday, Wednesday, and Friday.  The patient was started back on his tube feeds.  He tolerated these poorly with residuals.  Reglan was increased to 10 mg q.6 h. and erythromycin is being added.  The patient's temperature has been stable in the 94 to 95 range.  Other vital signs have been stable.  His urine output has been diminished.  An external jugular line was placed in the Intensive Care Unit.  The patient's legal guardian, Janet Sanchez in Albuquerque has requested he be transported there.  As per several physicians in Albuquerque and Dr. Y, an internist, we will accept him once we have a nursing home available to him.  He is being transported back to the nursing home today and discharge planners are working on getting him a nursing home in Albuquerque.  His prognosis is poor.
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DESCRIPTION: Hypothermia.  Rule out sepsis, was negative as blood cultures, sputum cultures, and urine cultures were negative.  Organic brain syndrome.  Seizure disorder.  Adrenal insufficiency.  Hypothyroidism.  Anemia of chronic disease.

discharge summary, sepsis, organic brain syndrome, seizure disorder, anemia of chronic disease, adrenal insufficiency, blood, cultures

The discharge summary involves multiple serious medical conditions including hypothermia, possible secondary adrenal insufficiency, secondary hypothyroidism, organic brain syndrome, and a seizure disorder. The patient's health is fragile, as noted by the transfer from ICU to a nursing home and a poor prognosis. Additionally, there is a need for coordination with multiple healthcare providers and facilities, indicating high complexity and high consequences if post-discharge care isn't properly managed.


Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 1

CHIEF COMPLAINT:,  Followup on diabetes mellitus, status post cerebrovascular accident.,SUBJECTIVE:,  This is a 70-year-old male who has no particular complaints other than he has just discomfort on his right side.  We have done EMG studies.  He has noticed it since his stroke about five years ago.  He has been to see a neurologist.  We have tried different medications and it just does not seem to help.  He checks his blood sugars at home two to three times a day.  He kind of adjusts his own insulin himself.  Re-evaluation of symptoms is essentially negative.  He has a past history of heavy tobacco and alcohol usage.,MEDICATIONS:, Refer to chart.,ALLERGIES:, Refer to chart.,PHYSICAL EXAMINATION: ,Vitals: Wt; 118 lbs, B/P; 108/72, T; 96.5, P; 80 and regular.  ,General:  A 70-year-old male who does not appear to be in acute distress but does look older than his stated age.  He has some missing dentition.,Skin:  Dry and flaky. ,CV:  Heart tones are okay, adequate carotid pulsations.  He has 2+ pedal pulse on the left and 1+ on the right.,Lungs: Diminished but clear.,Abdomen:  Scaphoid.,Rectal:  His prostate check was normal per Dr. Gill.,Neuro:  Sensation with monofilament testing is better on the left than it is on the right.,IMPRESSION:,1.  Diabetes mellitus.,2.  Neuropathy.,3.  Status post cerebrovascular accident.,PLAN:,  Refill his medications x 3 months.  We will check an A1c and BMP.  I have talked to him several times about a colonoscopy, which he has refused, and so we have been doing stools for occult blood.  We will check a PSA.  Continue with yearly eye exams, foot exams, Accu-Cheks, and we will see him in three months and p.r.n.
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DESCRIPTION: Sample progress note - Gen Med.

Sample progress note - Gen Med.

general medicine, diabetes mellitus, neuropathy, genernal medicine, post cerebrovascular accident, progerss note, post cerebrovascular, cerebrovascular accident, accident, cerebrovascular, neurologist, insulin,

The situation described involves a routine follow-up for a patient with a history of diabetes mellitus and a past cerebrovascular accident. While the patient has ongoing management needs and some risk factors like neuropathy and a history of heavy tobacco and alcohol use, the current visit is routine and not indicative of an acute or life-threatening situation where immediate action would impact patient safety or outcomes. Therefore, while it requires attention and continued management, it does not involve high-stakes decisions or interventions.


Medical Specialty: Gastroenterology
Sample Name: Esophagoscopy & Foreign Body Removal

PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:,  Esophageal foreign body, US penny.,PROCEDURE: , Esophagoscopy with foreign body removal.,ANESTHESIA: , General.,INDICATIONS: , The patient is a 17-month-old baby girl with biliary atresia, who had a delayed diagnosis and a late attempted Kasai portoenterostomy, which failed.  The patient has progressive cholestatic jaundice and is on the liver transplant list at ABCD.  The patient is fed by mouth and also with nasogastric enteral feeding supplements.  She has had an __________ cough and relatively disinterested in oral intake for the past month.  She was recently in the GI Clinic and an x-ray was ordered to check her tube placement and an incidental finding of a coin in the proximal esophagus was noted.  Based on the history, it is quite possible this coin has been there close to a month.  She is brought to the operating room now for attempted removal.  I met with the parents and talked to them at length about the procedure and the increased risk in a child with a coin that has been in for a prolonged period of time.  Hopefully, there will be no coin migration or significant irrigation that would require prolonged hospitalization.,OPERATIVE FINDINGS: , The patient had a penny lodged in the proximal esophagus in the typical location.  There was no evidence of external migration and surrounding irritation was noted, but did not appear to be excessive.  The coin actually came out with relative ease after which endoscopically identified.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had induction of general anesthesia.  She was slow to respond to the usual propofol and other inducing agents and may be has some difficulty with tolerance or __________ tolerance to these medications.  After her endotracheal tube was placed and securely taped to the left side of her mouth, I positioned the patient with a prominent shoulder roll and neck hyperextension and then used the laryngoscope to elevate the tiny glottic mechanism.  A rigid esophagoscope was then inserted into the proximal esophagus, and the scope was gradually advanced with the lumen directly in frontal view.  This was facilitated by the nasoenteric feeding tube that was in place, which I followed carefully until the edge of the coin could be seen.  At this location, there was quite a bit of surrounding mucosal inflammation, but the coin edge could be clearly seen and was secured with the coin grasping forceps.  I then withdrew the scope, forceps, and the coin as one unit, and it was easily retrieved.  The patient tolerated the procedure well.  There were no intraoperative complications.  There was only one single coin noted, and she was awakened and taken to the recovery room in good condition.
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DESCRIPTION: Esophageal foreign body, US penny.  Esophagoscopy with foreign body removal.  The patient had a penny lodged in the proximal esophagus in the typical location.

gastroenterology, portoenterostomy, foreign body removal, proximal esophagus, coin, esophagoscopy, esophageal, esophagus,

The case involves a 17-month-old baby girl with a US penny lodged in the esophagus, requiring esophagoscopy for removal. The child has a complex medical history with biliary atresia and is on the liver transplant list, indicating compromised health. Although removal of the coin was successful and without complications, the situation is high-stakes due to the potential risks involved in operating on a child with existing health conditions and due to the prolonged presence of the coin, which could have led to serious complications such as infection or inflammation. Furthermore, the general anesthesia and management of a pediatric patient in this scenario increase the stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Ventricular Ectopy - Consult

REASON FOR CONSULTATION:,  Ventricular ectopy and coronary artery disease.,HISTORY OF PRESENT ILLNESS:  ,I am seeing the patient upon the request of Dr. Y.  The patient is a very well known to me.  He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.  The patient had presented to the hospital after having coughing episodes for about two weeks on and off, and seemed to have also given him some shortness of breath.  The patient was admitted and being treated for pneumonia, according to him.  The patient denies any chest pain, chest pressure, or heaviness.  Denies any palpitations, fluttering, or awareness of heart activity.  However, on monitor, he was noticed to have PVCs random.  He had run off three beats consecutive one time at 12:46 p.m. today.  The patient denied any awareness of that or syncope.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever or chills.,EYES:  No visual disturbances.,ENT:  No difficulty swallowing.,CARDIOVASCULAR:  Prior history of chest discomfort in 08/2009 with negative stress study.,RESPIRATORY:  Cough and shortness of breath.,MUSCULOSKELETAL:  Positive for arthritis and neck pain.,GU:  Unremarkable.,NEUROLOGIC:  Otherwise unremarkable.,ENDOCRINE:  Otherwise unremarkable.,HEMATOLOGIC:  Otherwise unremarkable.,ALLERGIC:  Otherwise unremarkable.,PAST MEDICAL HISTORY:,1.  Positive for coronary artery disease since 2002.,2.  History of peripheral vascular disease for over 10 years.,3.  COPD.,4.  Hypertension.,PAST SURGICAL HISTORY:,  Right fem-popliteal bypass about eight years ago, neck fusion in the remote past, stent-supported angioplasty to unknown vessel in the heart.,MEDICATIONS AT HOME:,1.  Aspirin 81 mg daily.,2.  Clopidogrel 75 mg daily.,3.  Allopurinol 100 mg daily.,4.  Levothyroxine 100 mcg a day.,5.  Lisinopril 10 mg a day.,6.  Metoprolol 25 mg a day.,7.  Atorvastatin 10 mg daily.,ALLERGIES: , THE PATIENT DOES HAVE ALLERGY TO MEDICATION.  HE SAID HE CANNOT TAKE ASPIRIN BECAUSE OF INTOLERANCE FOR HIS STOMACH AND STOMACH UPSET, BUT NO TRUE ALLERGY TO ASPIRIN.,FAMILY HISTORY:,  No history of premature coronary artery disease.  One daughter has early onset diabetes and one child has asthma.,SOCIAL HISTORY: , He is married and retired.  He has nine children, 25 grandchildren.  He smokes one pack per day.  He smoked 50 pack years and had no intention of quitting according to him.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature of 97, heart rate of 90, blood pressure of 187/105.,HEENT:  Normocephalic and atraumatic.  No thyromegaly or lymphadenopathy.,NECK:  Supple.,CARDIOVASCULAR:  Upstroke is normal.  Distal pulse symmetrical.  Heart regular with a normal S1 with normally split S2.  There is an S4 at the apex.,LUNGS:  With decreased air entry.  No wheezes.,ABDOMINAL:  Benign.  No masses.,EXTREMITIES:  No edema, cyanosis, or clubbing.,NEUROLOGIC:  Awake, alert, and oriented x3.  No focal deficits.,IMAGING STUDIES: , Echocardiogram on 08/26/2009, showed mild biatrial enlargement, normal thickening of the left ventricle with mildly dilated ventricle, EF of 40%, mild mitral regurgitation, and diastolic dysfunction, grade 2.
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DESCRIPTION: Ventricular ectopy and coronary artery disease.   He is a 69-year-old gentleman with established history coronary artery disease and peripheral vascular disease with prior stent-supported angioplasty.

The patient has a complex medical history, including coronary artery disease, peripheral vascular disease, COPD, hypertension, and a recent episode of ventricular ectopy. These conditions, particularly coronary artery disease and ventricular ectopy, can pose serious risks to the patient's cardiovascular health. The patient is currently experiencing symptoms like cough and shortness of breath, which further complicate the situation. His high blood pressure readings indicate a risk for cardiovascular events. The combination of these factors results in a high-stakes situation, as any mismanagement can lead to serious complications such as arrhythmias or worsening of cardiovascular status.


Medical Specialty: Neurology
Sample Name: Hydrocephalus

REASON FOR VISIT: , Ms. ABC is a 67-year-old woman with adult hydrocephalus who returns to clinic for a routine evaluation.  She comes to clinic by herself.,HISTORY OF PRESENT ILLNESS:,  She has been followed for her hydrocephalus since 2002.  She also had an anterior cervical corpectomy and fusion from C3 though C5 in March 2007.  She was last seen by us in clinic in March 2008 and she was experiencing little bit of head fullness and ringing in the ears at that time; however, we decided to leave her shunt setting at 1.0.  We wanted her to followup with Dr. XYZ regarding the MRI of the cervical spine.  Today, she tells me that with respect to her bladder last week she had some episodes of urinary frequency, however, this week she is not experiencing the same type of episodes.  She reports no urgency, incontinence, and feels that she completely empties her bladder when she goes.  She does experience some leakage with coughing.  She wears the pad on a daily basis.  She does not think that her bladder has changed much since we saw her last.  With respect to her thinking and memory, she reports no problems at this time.  She reports no headaches at this time.  With respect to her walking and balance, she says that it feels worse.  In the beginning of May, she had a coughing spell and at that time she developed buttock pain, which travels down the legs.  She states that her leg often feel like elastic and she experiences a tingling radiculopathy.  She says that this tingling is constant and at times painful.  She feels that she is walking slower for this reason.  She does not use the cane at this time.  Most of the time, she is able to walk over uneven surfaces.  She is able to walk up and down stairs and has no trouble getting in and out of a car.,MEDICATIONS:,  Rhinocort 32 mg two sprays a day, Singulair 10 mg once a day, Xyzal 5 mg in the morning, Spiriva once a day, Advair twice a day, Prevacid 30 mg twice a day, Os-Cal 500 mg once a day, multivitamin once a day, and aspirin 81 mg a day.,MAJOR FINDINGS:,  On exam today, this is a pleasant 67-year-old woman who comes back from the clinic waiting area with little difficulty.  She is well developed, well nourished, and kempt.,The shunt site is clean, dry, and intact and confirmed at a setting of 1.0.,Mental Status:  Assessed and appears intact for orientation, recent and remote memory, attention span, concentration, language, and fund of knowledge.  Her Mini-Mental Status exam score was 26/30 when attention was tested with calculations and 30/30 when attention was tested with spelling.,Cranial Nerves:  Extraocular movements are somewhat inhibited.  She does not display any nystagmus at this time.  Facial movement, hearing, head turning, tongue, and palate movement are all intact.,Gait:  Assessed using the Tinetti assessment tool, which showed a balance score of 13/16 and a gait score of 11/12 for a total score of 24/28.,ASSESSMENT:,  Ms. ABC has been experiencing difficulty with walking over the past several months.,PROBLEMS/DIAGNOSES:,1.  Hydrocephalus.,2.  Cervical stenosis and retrolisthesis.,3.  Neuropathy in the legs.,PLAN: , Before we recommend anything more, we would like to get a hold of the notes from Dr. XYZ to try to come up with a concrete plan as to what we can do next for Ms. ABC.  We believe that her walking is most likely not being effected by the hydrocephalus.  We would like to see her back in clinic in two and a half months or so.  We also talked to her about having her obtain cane training so that she knows how to properly use her cane, which she states she does have one.  I suggested that she use the cane at her on discretion.
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DESCRIPTION: Woman with adult hydrocephalus, routine evaluation.

neurology, cervical stenosis, retrolisthesis, neuropathy, cervical corpectomy, adult hydrocephalus, cervical, hydrocephalus,

The situation involves a routine neurological evaluation of a woman with known adult hydrocephalus. While there are concerns about her walking and potential neuropathy in her legs, there are no immediate life-threatening conditions noted, and the patient is not experiencing acute distress. The visit is part of regular follow-ups to manage and monitor her condition. The current plan includes awaiting further notes to refine treatment, and patient management does not suggest an emergency or high-stakes scenario.


Medical Specialty: Orthopedic
Sample Name: Shoulder Hemi-resurfacing

PREOPERATIVE DIAGNOSIS: , Severe degenerative joint disease of the right shoulder.,POSTOPERATIVE DIAGNOSIS:,  Severe degenerative joint disease of the right shoulder.,PROCEDURE: , Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,COMPLICATIONS:,  None.  The patient was taken to Postanesthesia Care Unit in stable condition.  The patient tolerated the procedure well.,INDICATIONS: , The patient is a 55-year-old female who has had increased pain in to her right shoulder.  X-rays as well as an MRI showed a severe arthritic presentation of the humeral head with mild arthrosis of the glenoid.  She had an intact rotator cuff being at a young age and with potential of glenoid thus it was felt that a hemi-resurfacing was appropriate for her right shoulder focusing in the humeral head.  All risks, benefits, expectations and complications of surgery were explained to her in detail including nerve and vessel damage, infection, potential for hardware failure, the need for revision surgery with potential of some problems even with surgical intervention.  The patient still wanted to proceed forward with surgical intervention.  The patient did receive 1 g of Ancef preoperatively.,PROCEDURE: , The patient was taken to the operating suite, placed in supine position on the operating table.  The Department of anesthesia administered a general endotracheal anesthetic, which the patient tolerated well.  The patient was moved to a beach chair position.  All extremities were well padded.  Her head was well padded to the table.  Her right upper extremity was draped in sterile fashion.  A saber incision was made from the coracoid down to the axilla.  Skin was incised down to the subcutaneous tissue, the cephalic vein was retracted as well as all neurovascular structures were retracted in the case.  Dissecting through the deltopectoral groove, the subscapularis tendon was found as well as the bicipital tendon, 1 finger breadth medial to the bicipital tendon an incision was made.  Subscapularis tendon was released.  The humeral head was brought in to; there were large osteophytes that were removed with an osteotome.  The glenoid then was evaluated and noted to just have mild arthrosis, but there was no need for surgical intervention in this region.  A sizer was placed.  It was felt that size 5 was appropriate for this patient, after which the guide was used to place the stem and pin.  This was placed, after which a reamer was placed along the humeral head and reamed to a size 5.  All extra osteophytes were excised.  The supraspinatus and infraspinatus tendons were intact.  Next, the excess bone was removed and irrigated after which reaming of the central portion of the humeral head was performed of which a trial was placed and showed that there was adequate fit and appropriate fixation.  The arm had excellent range of motion.  There are no signs of gross dislocation.  Drill holes were made into the humeral head after which a size 5 Copeland hemi-resurfacing component was placed into the humeral head, kept down in appropriate position, had excellent fixation into the humeral head.  Excess bone that had been reamed was placed into the Copeland metal component, after which this was tapped into position.  After which the wound site was copiously irrigated with saline and antibiotics and the humeral head was reduced and taken through range of motion; had adequate range of motion, full internal and external rotation as well as forward flexion and abduction.  There was no gross sign of dislocation.  Wound site once again it was copiously irrigated with saline antibiotics.  The subscapularis tendon was approximated back into position with #2 Ethibond after which the bicipital tendon did have significant tear to it; therefore it was tenodesed in to the pectoralis major tendon.  After which, the wound site again was irrigated with saline antibiotics after which subcutaneous tissue was approximated with 2-0 Vicryl.  The skin was closed with staples.  A sterile dressing was placed.  The patient was awakened from general anesthetic and transferred to hospital gurney to the postanesthesia care unit in stable condition.
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DESCRIPTION: Right shoulder hemi-resurfacing using a size 5 Biomet Copeland humeral head component, noncemented.  Severe degenerative joint disease of the right shoulder.

orthopedic, degenerative joint disease, hemi-resurfacing, biomet copeland, shoulder hemi resurfacing, humeral, head, degenerative, glenoid, subscapularis, antibiotics, resurfacing, tendon, shoulder,

The situation involves a surgical procedure, which inherently carries certain risks. Factors like potential complications, anesthesia, and the patient's postoperative stability contribute to the stakes. Although this particular surgery was successful and the patient was stable afterwards, there are always risks involved with orthopedic surgeries, such as infection or hardware failure. Additionally, the patient's relief from severe joint disease also means a significant improvement in quality of life, raising the stakes for their personal outcome.


Medical Specialty: Orthopedic
Sample Name: Synovectomy - Partial

PREOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,OPERATION PERFORMED: , Arthroscopic irrigation and debridement of same with partial synovectomy.,ANESTHESIA:,  LMA.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,DRAINS:,  None.,INDICATIONS:,  The patient is an 81-year-old female, who is approximately 10 years status post total knee replacement performed in another state, who presented a couple of days ago to the office with worsening pain without injury and whose symptoms have been present for approximately a month following a possible urinary tract infection.  The patient' knee was aspirated in the office and cultures were positive for Escherichia coli.  She presents for operative therapy.,DESCRIPTION OF OPERATION: , After obtaining informed consent and the administration of antibiotics since her cultures had already been obtained, the patient was taken to the operating room and following satisfactory induction and the patient was placed on the table in supine position.  The left upper extremity was prepped and draped without a tourniquet.  The knee was injected with 30 mL of normal saline and standard arthroscopy portals were created.  The arthroscopy was inserted and a complete diagnostic was performed.  Arthroscopic pictures were taken throughout the procedure.  The knee was copiously irrigated with 9 L of irrigant.  A partial synovectomy was performed in all compartments.  Minimal amount of polyethylene wear was noted.  The total knee components were identified arthroscopically for future revision surgery.  The knee was then drained and the arthroscopic instruments were removed.  The portals were closed with 4-0 nylon and local anesthetic was injected.  A sterile dressing was applied and the patient was placed in a knee immobilizer, awakened from anesthesia and transported to the recovery room in stable condition and tolerated the procedure well.
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DESCRIPTION: Arthroscopic irrigation and debridement of same with partial synovectomy.  Septic left total knee arthroplasty.

orthopedic, total knee arthroplasty, arthroscopic irrigation, debridement, partial synovectomy, knee, arthroscopic, irrigation, arthroscopy, synovectomy,

The situation involves an 81-year-old female patient undergoing an orthopedic surgery (arthroscopic irrigation and debridement with partial synovectomy) due to septic left total knee arthroplasty. While the procedure itself is described as being performed without complications and with minimal blood loss, the severity of the pre-existing condition (septic joint) and the patient's age elevate the stakes. Sepsis in a prosthetic joint can lead to serious health repercussions if not appropriately managed. However, given that the procedure was successful and the patient was stable post-operation, the immediate scenario is not the most extreme in terms of high-stakes emergency situations that could occur in a medical context, but it is still significant.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Asperger Disorder

SUBJECTIVE:  ,School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom.  He appears confused and depressed at times.  Mother also indicates that preservative questioning had come down, but he started collecting old little toys that he did in the past.  He will attend social skills program in the summer.  ABCD indicated to me that they have identified two psychologists to refer him to for functional behavioral analysis.  There is lessening of tremoring in both hands since discontinuation of Zoloft.  He is now currently taking Abilify at 7.5 mg.,OBJECTIVE: , He came in less perseverative questioning, asked appropriate question about whether I talked to ABCD or not, greeted me with Japanese word to say hello, seemed less.,I also note that his tremors were less from the last time.,ASSESSMENT: , 299.8 Asperger disorder, 300.03 obsessive compulsive disorder.,PLAN:,  Decrease Abilify from 7.5 mg to 5 mg tablet one a day, no refills needed.  I am introducing slow Luvox 25 mg tablet one-half a.m. for OCD symptoms, if no side effects in one week we will to tablet one up to therapeutic level.,I also will call ABCD regarding the referral to psychologists for functional behavioral analysis.  Parents will call me in two weeks.  I will see him for medication review in four weeks.  Mother signed informed consent.  I reviewed side effects to observe including behavioral activation.,Abilify has been helpful in decreasing high emotional arousal.  Combination of medication and behavioral intervention is recommended.
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DESCRIPTION: School reports continuing difficulties with repetitive questioning, obsession with cleanness on a daily basis, concerned about his inability to relate this well in the classroom.   Asperger disorder.  Obsessive compulsive disorder.

soap / chart / progress notes, repetitive questioning, obsession with cleanness, inability to relate, obsessive compulsive disorder, functional behavioral analysis, asperger disorder, inability, asperger,

The situation described is related to a medical review and plan for a patient with Asperger Syndrome and OCD. The stakes involve managing a child's mental health with medication adjustments and behavioral interventions, which are critical but not immediately life-threatening. The potential for side effects and ensuring proper treatment makes it important, but it does not involve immediate physical danger or critical life-or-death scenarios.


Medical Specialty: Consult - History and Phy.
Sample Name: Cardiac Consultation - 4

REASON FOR CONSULTATION:,  Cardiac evaluation.,HISTORY: , This is a 42-year old Caucasian male with no previous history of hypertension, diabetes mellitus, rheumatic fever, rheumatic heart disease, or gout.  Patient used to take medicine for hyperlipidemia and then that was stopped.  He used to live in Canada and he moved to Houston four months ago.  He started complaining of right-sided upper chest pain, starts at the right neck and goes down to the right side.  It lasts around 10-15 minutes at times.  It is 5/10 in quality.  It is not associated with shortness of breath, nausea, vomiting, or sweating.  It is not also associated with food.  He denies exertional chest pain, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, or pedal edema.  No palpitations, syncope or presyncope.  He said he has been having little cough at night and he went to see an allergy doctor who prescribed several medications for him and told him that he has asthma.  No fever, chills, cough, hemoptysis, hematemesis or hematochezia.  His EKG shows normal sinus rhythm, normal EKG.,PAST MEDICAL HISTORY:,  Unremarkable, except for hyperlipidemia.,SOCIAL HISTORY: , He said he quit smoking 20 years ago and does not drink alcohol.,FAMILY HISTORY: , Positive for high blood pressure and heart disease.  His father died in his 50s with an acute myocardial infarction.,MEDICATION:,  Ranitidine 300 mg daily, Flonase 50 mcg nasal spray as needed, Allegra 100 mg daily, Advair 500/50 bid.,ALLERGIES:,  No known allergies.,REVIEW OF SYSTEMS:,  As mentioned above,EXAMINATION:,  This is a 42-year old male awake, alert, and oriented x3 in no acute distress.,Wt:  238
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DESCRIPTION: Patient with right-sided chest pain, borderline elevated high blood pressure, history of hyperlipidemia, and obesity.

The consultation describes a 42-year-old male with chest pain and a family history of heart disease, which could potentially indicate a serious cardiac condition such as coronary artery disease or other heart-related issues. These factors, combined with the patient's history of hyperlipidemia and obesity, make the situation quite serious, as heart-related conditions can sometimes lead to life-threatening events if not properly managed. Therefore, while the absence of acute distress or additional severe symptoms such as shortness of breath or palpitations suggests it might not be an immediate emergency, the presence of risk factors and symptoms warrant careful evaluation and monitoring.


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

Medical Specialty: Ophthalmology
Sample Name: Difficulty Distance Vision & Fine Print at Near

REASON FOR VISIT: , Mr. ABC is a 61-year-old Caucasian male who presents to us today as a new patient.  He states that he has difficulty with both his distance vision and also with fine print at near.,HISTORY OF PRESENT ILLNESS:,  Mr. ABC states that over the last year, he has had increasing difficulty with distance vision particularly when he is driving.  He is also having trouble when he is reading.  He does occasionally wear over-the-counter reading glasses, which do help with his near vision.,Past ocular history is significant for astigmatism for which he wore glasses since he was 18 years old.  However, Mr. ABC mentioned today that he has not worn his glasses for the last few years.,His past medical history is significant for hypertension, low serum testosterone level, hypercholesterolemia, GERD, depression, actinic keratoses, and a history of Pityrosporum folliculitis.,His family history is significant for diabetes in both parents.  He states that his mother is seen by Mrs. Goldberg, but he is not aware of her ocular history.  He has no known family history of glaucoma, age-related macular degeneration or hereditary blindness.,MEDICATIONS: , Wellbutrin XL 450 mg daily, Ritalin long-acting 60 mg daily, hydrochlorothiazide at an unknown dose, Vytorin at an unknown dose, and aspirin.,ALLERGIES: , No known drug allergies.,FINDINGS:,  Visual acuity today without correction was 20/20 -2 pinholing to 20/16 in the right eye, and 20/40 +2 pinholing to 20/16 in the left eye.  Near vision unaided was J2 in both eyes.,Manifest refraction today following pharmacological dilation was -0.50, +0.50 times 155 in the right eye revealing a vision of 20/16.  Manifest refraction was -1.00, +0.25 times 005 revealing a vision of 20/16 in the left eye.  The add was +2 in both eyes.  Visual fields are full to finger counting in both eyes.,Extraocular movements were within normal limits.  Intraocular pressure by applanation was 16 mmHg in the right eye and 18 mmHg in the left eye measured at 11.30 in the morning.,Examination of the anterior segment was unremarkable in both eyes except for mild nuclear sclerotic opacities in both eyes.,Dilated fundus examination of the right eye revealed a sharp and pink optic disc with a healthy rim and cup-to-disc ratio of 0.7; however, there was central excavation of the disc, but no disc hemorrhages were noted.  On examination of the macula, there were drusen scattered temporally.  Examination of the vasculature was normal.  Peripheral retinal examination was entirely normal.,On funduscopic examination of the left eye, there was a sharp and pink disc with a healthy rim, but with central excavation and a cup-to-disc ratio of 0.6.  Of note, there were no disc hemorrhages.  On examination of the macula, there was scattered tiny drusen centrally and superiorly.  Examination of the vasculature was entirely normal.  Peripheral fundus examination was unremarkable.,ASSESSMENT:,1.  Age-related macular degeneration category three (right greater than sign left).,2.  Glaucoma suspect based on disc appearance (increased cup-to-disc ratio and disc asymmetry).,3.  Presbyopia and astigmatism.,4.  Non-visually significant cataracts bilaterally.,PLANS:,1.  The above diagnoses and management plans each were discussed with the patient who expressed understanding.,2.  Commence Ocuvite PreserVision capulets one tablet twice a day by mouth for age-related macular degeneration.,3.  Humphrey visual field and disc photographs today for baseline documentation in view of glaucoma suspicion.,4.  Followup in Glaucoma Clinic arranged in 4 months' time with repeat Humphrey visual fields at this time for reevaluation and comparison.,5.  Follow up with Mrs. Braithwaite in the Comprehensive Eye Service Clinic for undilated refraction.,6.  We will follow up this gentleman in our clinic in 12 months' time; however, I have asked him to return to us soon should he develop any worsening ocular symptoms in the interim.
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DESCRIPTION: Difficulty with both distance vision and with fine print at near.

This case involves an elderly patient with degenerative eye conditions: age-related macular degeneration and potential glaucoma, both serious but common in older adults. The prescribed management plan aims to monitor progression and manage symptoms. While the visual problems affect quality of life, immediate severe consequences are unlikely if managed properly, making the situation moderately high-stakes.


Medical Specialty: Orthopedic
Sample Name: Youngswick Osteotomy

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

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

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


Medical Specialty: Emergency Room Reports
Sample Name: Leaking Nephrostomy Tube

CHIEF COMPLAINT:  ,Leaking nephrostomy tube.,HISTORY OF PRESENT ILLNESS: , This 61-year-old male was referred in today secondary to having urine leaked around the ostomy site for his right sided nephrostomy tube.  The leaking began this a.m.  The patient denies any pain, does not have fever and has no other problems or complaints.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.  The patient states he feels like his usual self and has no other problems or concerns.  The patient denies any fever or chills.  No nausea or vomiting.  No flank pain, no abdominal pain, no chest pain, no shortness of breath, no swelling to the legs.,REVIEW OF SYSTEMS: , Review of systems otherwise negative and noncontributory.,PAST MEDICAL HISTORY: , Metastatic prostate cancer, anemia, hypertension.,MEDICATIONS: , Medication reconciliation sheet has been reviewed on the nurses' note.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient is a nonsmoker.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 97.7 oral, blood pressure 150/85, pulse is 91, respirations 16, oxygen saturation 97% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished, well developed, appears to be healthy, calm, comfortable, no acute distress, looks well.  HEENT:  Eyes are normal with clear sclerae and cornea.  NECK:  Supple, full range of motion.  CARDIOVASCULAR:  Heart has regular rate and rhythm without murmur, rub or gallop.  Peripheral pulses are +2.  No dependent edema.  RESPIRATIONS:  Clear to auscultation bilaterally.  No shortness of breath.  No wheezes, rales or rhonchi.  Good air movement bilaterally.  GASTROINTESTINAL:  Abdomen is soft, nontender, nondistended.  No rebound or guarding.  Normal benign abdominal exam.  MUSCULOSKELETAL:  The patient has nontender back and flank.  No abnormalities noted to the back other than the bilateral nephrostomy tubes.  The nephrostomy tube left has no abnormalities, no sign of infection.  No leaking of urine, nontender, nephrostomy tube on the right has a damp dressing, which has a small amount of urine soaked into it.  There is no obvious active leak from the ostomy site.  No sign of infection.  No erythema, swelling or tenderness.  The collection bag is full of clear urine.  The patient has no abnormalities on his legs.  SKIN:  No rashes or lesions.  No sign of infection.  NEUROLOGIC:  Motor and sensory are intact to the extremities.  The patient has normal ambulation, normal speech.  PSYCHIATRIC:  Alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC AND LYMPHATIC:  No bleeding or bruising.,EMERGENCY DEPARTMENT COURSE:,  Reviewed the patient's admission record from one month ago when he was admitted for the placement of the nephrostomy tubes, both Dr. X and Dr. Y have been consulted and both had recommended nephrostomy tubes, there was not the name mentioned as to who placed the nephrostomy tubes.  There was no consultation dictated for this and no name was mentioned in the discharge summary, paged Dr. X as this was the only name that the patient could remember that might have been involved with the placement of the nephrostomy tubes.  Dr. A responded to the page and recommended __________ off a BMP and discussing it with Dr. B, the radiologist as he recalled that this was the physician who placed the nephrostomy tubes, paged Dr. X and received a call back from Dr. X.  Dr. X stated that he would have somebody get in touch with us about scheduling a time for which they will change out the nephrostomy tube to a larger and check a nephrogram at that time that came down and stated that they would do it at 10 a.m. tomorrow.  This was discussed with the patient and instructions to return to the hospital at 10 a.m. to have this tube changed out by Dr. X was explained and understood.,DIAGNOSES:,1.  WEAK NEPHROSTOMY SITE FOR THE RIGHT NEPHROSTOMY TUBE.,2.  PROSTATE CANCER, METASTATIC.,3.  URETERAL OBSTRUCTION.,The patient on discharge is stable and dispositioned to home.,PLAN: , We will have the patient return to the hospital tomorrow at 10 a.m. for the replacement of his right nephrostomy tube by Dr. X.  The patient was asked to return in the emergency room sooner if he should develop any new problems or concerns.
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DESCRIPTION: Urine leaked around the ostomy site for his right sided nephrostomy tube.  The patient had bilateral nephrostomy tubes placed one month ago secondary to his prostate cancer metastasizing and causing bilateral ureteral obstructions that were severe enough to cause acute renal failure.

emergency room reports, nephrostomy site, ureteral obstruction, leaking nephrostomy tube, acute renal failure, bilateral nephrostomy, ureteral obstructions, nephrostomy tube, tube, nephrostomy, ureteral, prostate, leaking, urine, tubes,

The situation involves a patient with metastatic prostate cancer who has a leaking nephrostomy tube, a medical device critical for urinary drainage. While the leak itself is not currently causing pain or infection, it is a significant concern because nephrostomy tubes are essential for preventing complications from obstructions in the urinary system, especially in the context of cancer. Immediate action to replace the tube is planned for the next day. While the current condition is stable, the stakes are elevated due to the underlying health conditions and the potential for rapid deterioration if the tube's functionality is compromised.


Medical Specialty: Hematology - Oncology
Sample Name: Symes Amputation - Hallux

PREOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux bone invasion of the distal phalanx.,POSTOPERATIVE DIAGNOSES:,1.  Mass, left second toe.,2.  Tumor.,3.  Left hallux with bone invasion of the distal phalanx.,PROCEDURE PERFORMED:,1.  Excision of mass, left second toe.,2.  Distal Syme's amputation, left hallux with excisional biopsy.,HISTORY: , This 47-year-old Caucasian male presents to ABCD General Hospital with a history of tissue mass on his left foot.  The patient states that the mass has been present for approximately two weeks and has been rapidly growing in size.  The patient also has history of shave biopsy in the past.  The patient does state that he desires surgical excision at this time.,PROCEDURE IN DETAIL:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported from the operating room and placed on the operating room table in the supine position with the safety belt across his lap.  Copious amount of Webril was placed around the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 6 cc mixed with 1% lidocaine plain with 0.5% Marcaine plain was injected in a digital block fashion at the base of the left hallux as well as the left second toe.,The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  Care was taken with the exsanguination to perform exsanguination below the level of the digits so as not to rupture the masses.  The foot was lowered to the operating table.  The stockinet was reflected and the foot was cleansed with wet and dry sponge.  A distal Syme's incision was planned over the distal aspect of the left hallux.  The incision was performed with a #10 blade and deepened with #15 down to the level of bone.  The dorsal skin flap was removed and dissected in toto off of the distal phalanx.  There was noted to be in growth of the soft tissue mass into the dorsal cortex with erosion in the dorsal cortex and exposure of cortical bone at the distal phalanx.  The tissue was sent to Pathology where Dr. Green stated that a frozen sample would be of less use for examining for cancer.  Dr. Green did state that he felt that there was an adequate incomplete excision of the soft tissue for specimen.  At this time, a sagittal saw was then used to resect all ends of bone of the distal phalanx.  The area was inspected for any remaining suspicious tissues.  Any suspicious tissue was removed.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon with a combination of simple and vertical mattress sutures.,Attention was then directed to the left second toe.  There was noted to be a dorsolateral mass over the dorsal distal aspect of the left second toe.  A linear incision was made just medial to the tissue mass.  The mass was then dissected from the overlying skin and off of the underlying capsule.  This tissue mass was hard, round, and pearly-gray in appearance.  It does not invade into any other surrounding tissues.  The area was then flushed with copious amounts of sterile saline and the skin was closed with #4-0 nylon.  Dressings consisted of Owen silk soaked in Betadine, 4x4s, Kling, Kerlix, and an Ace wrap.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription for Vicodin and instructed to follow up with Dr. Bonnani in his office as directed.  The patient will be contacted immediately pending the results of pathology.  Cultures obtained in the case were aerobic and anaerobic gram stain, Silver stain, and a CBC.
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DESCRIPTION: Excision of mass, left second toe and distal Symes amputation, left hallux with excisional biopsy.  Mass, left second toe.  Tumor.  Left hallux bone invasion of the distal phalanx.

hematology - oncology, distal phalanx, mass, tumor., hallux bone, phalanx, symes amputation, excisional biopsy, distal, amputation, invasion, toe, symes, incision, flushed, excision, tissue, hallux

The described situation involves a surgical procedure for a patient with a rapidly growing mass on their foot, including tumor excision and bone involvement, which are common in cases of potential malignancy. The potential presence of cancer significantly raises the stakes due to its implications for the patient's health, prognosis, and treatment plan. Additionally, the procedure involves critical decisions and coordination among medical professionals, highlighting its complexity and the importance of accuracy and thoroughness. The stakes are heightened due to the need for accurate pathology results to inform further treatment decisions.