Medical Specialty: General Medicine
Sample Name: Antibiotic Management Consult

REASON FOR CONSULTATION: , Antibiotic management for a right foot ulcer and possible osteomyelitis.,HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old Caucasian male with past medical history of diabetes mellitus.  He was doing fairly well until last week while mowing the lawn, he injured his right foot.  He presented to the Hospital Emergency Room.  Cultures taken from the wound on 06/25/2008, were reported positive for methicillin-sensitive Staphylococcus aureus (MSSA).  The patient was started on intravenous antibiotic therapy with Levaquin and later on that was changed to oral formulation.  The patient underwent debridement of the wound on 07/29/2008.  Apparently, MRI and a bone scan was performed at that facility, which was reported negative for osteomyelitis.  The patient was then referred to the wound care center at General Hospital.  From there, he has been admitted to Long-Term Acute Care Facility for wound care with wound VAC placement.  On exam, he has a lacerated wound on the plantar aspect of the right foot, which extends from the second metatarsal area to the fifth metatarsal area, closed with the area of the head of these bones.  The wound itself is deep and stage IV and with exam of her gloved finger in my opinion, the third metatarsal bone is palpable, which leads to the clinical diagnosis of osteomyelitis.  The patient has serosanguineous drainage in this wound and it tracks under the skin in all directions except distal.,PAST MEDICAL HISTORY: , Positive for:,1.  Diabetes mellitus.,2.  Osteomyelitis of the right fifth toe, which was treated with intravenous antibiotic therapy for 6 weeks about 5 years back.,FAMILY HISTORY: , Positive for mother passing away in her late 60s from heart attack, father had liver cancer, and passed away from that.  One of his children suffers from hypothyroidism, 2 grandchildren has cerebral palsy secondary to being prematurely born.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS: , Positive findings of the foot that have been mentioned above.  All other systems reviewed were negative.,PHYSICAL EXAMINATION:,General:  A 68-year-old Caucasian male who was not in any acute hemodynamic distress at present.,Vital Signs:  Show a maximum recorded temperature of 98, pulse is rating between 67 to 80 per minute, respiratory rate is 20 per minute, blood pressure is varying between 137/63 to 169/75.,HEENT:  Pupils equal, round, reactive to light.  Extraocular movements intact.  Head is normocephalic.  External ear exam is normal.,Neck:  Supple.  There is no palpable lymphadenopathy.,Cardiovascular:  Regular rate and rhythm of the heart without any appreciable murmur, rub or gallop.,Lungs:  Clear to auscultation and percussion bilaterally.,Abdomen:  Soft, nontender, and nondistended without any organomegaly and bowel sounds are positive.  There is no palpable lymphadenopathy in the inguinal and femoral area.,Extremities:  There is no cyanosis, clubbing or edema.  There is no peripheral stigmata of endocarditis.  On the plantar aspect of the distal part of the right foot, the patient has a lacerated wound, which extends from the second metatarsal area to the fifth metatarsal area.  Tracking under the skin is palpable with a gloved finger in all direction except the distal one.  On the proximal tracking, the area of the wound, the third metatarsal bone is palpable.  Therefore, clinically, the patient has diagnoses of osteomyelitis.,Central nervous system:  The patient is alert, oriented x3.  Cranial nerves II through XII are intact.  There is no focal deficit appreciated.,LABORATORY DATA:,  No laboratory or radiological data is available at present in the chart.,IMPRESSION/PLAN: , A 68-year-old Caucasian male with history of diabetes mellitus who had an accidental lawn mower-associated injury on the right foot.  He has undergone debridement on 07/29/2008.  Culture results from the debridement procedure are not available.  Wound cultures from 07/25/2008 showed methicillin-sensitive Staphylococcus aureus.,From the Infectious Disease point of view, the patient has the following problems, and I would recommend following treatments strategy.,1.  Right foot infected ulcer with clinical evidence of osteomyelitis.  Even if the MRI and bone scan are negative, the treatment should be guided with diagnosis on clinical counts in my opinion.  Cultures have been reported positive for methicillin-sensitive Staphylococcus aureus.  Therefore, I would discontinue the current antibiotic regimen of oral Levaquin, Zyvox, and intravenous Zosyn, and start the patient on intravenous Ancef 2 g q.8 h.  We will need to continue this treatment for 6 weeks for treatment of osteomyelitis and deep wound infection.  I would also recommend continuation of wound care and wound VAC placement that would start tomorrow.  We will get a PICC line placed to complete the 6-week course of intravenous antibiotic therapy.,2.  We would check labs including CBC with differential, chemistry 7 panel, LFTs, ESR, and C-reactive protein levels every Monday and chemistry 7 panel and CBC every Thursday for the duration of antibiotic therapy.,3.  I will continue to monitor wound healing 2 to 3 times a week.  Wound care will be managed by the wound care team at the Long-Term Acute Care Facility.,4.  The treatment plan was discussed in detail with the patient and his daughter who was visiting him when I saw him.,5.  Other medical problems will continue to be followed and treated by Dr. X's group during this hospitalization.,6.  I appreciate the opportunity of participating in this patient's care.  If you have any questions please feel free to call me at any time.  I will continue to follow the patient along with you for the next few days during this hospitalization.  We would also try to get the results of the deep wound cultures from 07/29/2008, MRI, and bone scan from Hospital.
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DESCRIPTION: Antibiotic management for a right foot ulcer and possible osteomyelitis.

The situation involves managing a 68-year-old male patient with diabetes and a serious foot ulcer potentially leading to osteomyelitis, a severe bone infection. Diabetes can complicate wound healing, increasing the risk of severe complications. The need for a long-term intravenous antibiotic regimen indicates a serious condition that requires meticulous management to prevent further deterioration. Given the clinical decisions and monitoring required, it qualifies as a high-stakes medical scenario.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Well-Child Check - 6

SUBJECTIVE:,  Patient presents with Mom and Dad for her 5-year 3-month well-child check.  Family has not concerns stating patient has been doing well overall since last visit.  Taking in a well-balanced diet consisting of milk and dairy products, fruits, vegetables, proteins and grains with minimal junk food and snack food.  No behavioral concerns.  Gets along well with peers as well as adults.  Is excited to start kindergarten this upcoming school year.  Does attend daycare.  Normal voiding and stooling pattern.  No concerns with hearing or vision.  Sees the dentist regularly.  Growth and development:  Denver II normal passing all developmental milestones per age in areas of fine motor, gross motor, personal and social interaction and speech and language development.  See Denver II form in the chart.,ALLERGIES:,  None.,MEDICATIONS: , None.,FAMILY SOCIAL HISTORY:,  Unchanged since last checkup.  Lives at home with mother, father and sibling.  No smoking in the home.,REVIEW OF SYSTEMS:,  As per HPI; otherwise negative.,OBJECTIVE:,Vital Signs:  Weight 43 pounds.  Height 42-1/4 inches.  Temperature 97.7.  Blood pressure 90/64.,General:  Well-developed, well-nourished, cooperative, alert and interactive 5-year -3month-old white female in no acute distress.,HEENT:  Atraumatic, normocephalic.  Pupils equal, round and reactive.  Sclerae clear.  Red reflex present bilaterally.  Extraocular muscles intact.  TMs clear bilaterally.  Oropharynx:  Mucous membranes moist and pink.  Good dentition.,Neck:  Supple, no lymphadenopathy.,Chest:  Clear to auscultation bilaterally.  No wheeze or crackles.  Good air exchange.,Cardiovascular:  Regular rate and rhythm.  No murmur.  Good pulses bilaterally.,Abdomen:  Soft, nontender.  Nondistended.  Positive bowel sounds.  No masses or organomegaly.,GU:  Tanner I female genitalia.  Femoral pulses equal bilaterally.  No rash.,Extremities:  Full range of motion.  No cyanosis, clubbing or edema.,Back:  Straight.  No scoliosis.,Integument:  Warm, dry and pink without lesions.,Neurological:  Alert.  Good muscle tone and strength.  Cranial nerves II-XII grossly intact.  DTRs 2+/4+ bilaterally.,ASSESSMENT/PLAN:,1. Well 5-year 3-month-old white female.,2. Anticipatory guidance for growth and diet development and safety issues as well as immunizations.  Will receive MMR, DTaP and IPV today.  Discussed risks and benefits as well as possible side effects and symptomatic treatment.  Gave 5-year well-child check handout to mom.  Completed school pre-participation physical.  Copy in the chart.  Completed vision and hearing screening.  Reviewed results with family.,3. Follow up in one year for next well-child check or as needed for acute care.
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DESCRIPTION: A 3-month well-child check.

A 3-month well-child check.

consult - history and phy., denver ii, child check, mom, diet, growth, denver, family, development, child, check,

The scenario is a routine well-child checkup for a healthy 5-year-old child, with no immediate medical concerns, allergies, or medications, and normal development and social history. The checkup is for monitoring growth, development, and administering routine vaccinations. These checkups are standard procedure in pediatrics, with low urgency or risk, and they do not imply any acute medical intervention is required. Therefore, the situation is not high-stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Physical Medicine - Rehab
Sample Name: Occupational Therapy Discharge Summary

DIAGNOSES: , Traumatic brain injury, cervical musculoskeletal strain.,DISCHARGE SUMMARY: , The patient was seen for evaluation on 12/11/06 followed by 2 treatment sessions.  Treatment consisted of neuromuscular reeducation including therapeutic exercise to improve range of motion, strength, and coordination; functional mobility training; self-care training; cognitive retraining; caregiver instruction; and home exercise program.  Goals were not achieved, as the patient was admitted to inpatient rehabilitation center.,RECOMMENDATIONS: , Discharged from OT this date, as the patient has been admitted to Inpatient Rehabilitation Center.,Thank you for this referral.
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DESCRIPTION: Occupational therapy discharge summary.  Traumatic brain injury, cervical musculoskeletal strain.

physical medicine - rehab, musculoskeletal strain, occupational therapy, traumatic, brain, cervical, musculoskeletal, rehabilitation,

The discharge summary indicates that the patient, who has sustained a traumatic brain injury and cervical musculoskeletal strain, is being discharged from occupational therapy because they were admitted to an inpatient rehabilitation center. While the transition to another care setting like inpatient rehab is serious and involves coordination, the situation described in the discharge summary itself is routine administrative documentation in a medical setting, and does not involve critical care or decision-making that directly impacts immediate patient safety. The stakes here are more about ensuring proper communication and continuity of care rather than immediate life-threatening consequences.


Medical Specialty: Surgery
Sample Name: Angiography & Catheterization

PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Left ventriculography.,4.  Right heart catheterization.,INDICATION: , Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery and vein.  Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin.  The pressure was held.  The needle was removed over the guidewire.  Next, a #6 French arterial sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was flushed.  Next, an angulated pigtail catheter was advanced to the level of the ascending aorta under the direct fluoroscopy visualization with the use of a guidewire.  The catheter was then guided into the left ventricle.  The guidewire and dilator were then removed.  The catheter was then flushed.  LVEDP was measured and found to be favorable for a left ventriculogram.  The left ventriculogram was performed in the RAO position with a single power injection of nonionic contrast material.  LVEDP was then remeasured.  Pullback was performed, which failed to reveal an LVAO gradient.  The catheter was then removed.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary was unable to be engaged with this catheter.  Thus it was removed over a guidewire.  Next, a Judkins left #5 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Left main coronary artery was then engaged.  Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views.  The catheter was then removed from the ostium of the left main coronary artery and was removed over a guidewire.  Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views.  The catheter was then removed from the ostium of the right coronary artery and then removed.  The sheath was then flushed.  Because the patient did have high left ventricular end-diastolic pressures, it was determined that the patient wound need a right heart catheterization.  Thus an #18 gauge Argon needle was used to cannulate the right femoral vein.  A steel guidewire was inserted through the needle into the vascular lumen.  The needle was removed over the guidewire.  Next, an #8 French venous sheath was advanced over the guidewire into lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  Next, a Swan-Ganz catheter was advanced to the level of 20 cm.  The balloon was inflated.  Under fluoroscopic visualization, the catheter was guided into the right atrium, right ventricle, and into the pulmonary artery wedge position.  Hemodynamics were measured along the way.  PA saturation, right atrial saturation, femoral artery saturation were all obtained.  Once adequate study has been performed, the catheter was then removed.  Both sheaths were flushed and found fine.  The patient was returned to the cardiac catheterization holding area in stable satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM:  ,There is no evidence of any wall motion abnormalities with estimated ejection fraction of 60%.  Left ventricular end-diastolic pressure was 38 mmHg preinjection and 40 mmHg postinjection.  There is no LVAO.  There is no mitral regurgitation.  There is a trileaflet aortic valve noted.,LEFT MAIN CORONARY ARTERY:  ,The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING: , The LAD is a moderate caliber vessel, which traverses through the intraventricular groove and reaches the apex of the heart.  There is a proximal 60% to 70% stenotic lesion.  There was also a mid 70% to 80% stenotic lesion at the takeoff of the first and second diagonal branches.,CIRCUMFLEX ARTERY:  ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove.  There is a mid 60% to 70% stenotic lesion followed by a second mid 90% stenotic lesion.  The first obtuse marginal branch is small and the second obtuse marginal branch is large without any evidence of critical disease.  The third obtuse marginal branch is also small.,RIGHT CORONARY ARTERY:  ,The RCA is a moderate caliber vessel with minor luminal irregularities throughout.  There is no evidence of any critical disease.  The right coronary artery is the dominant right coronary vessel.,RIGHT HEART FINDINGS:  ,Pulmonary artery pressure equals 61/23 with a mean of 44.  Pulmonary artery wedge pressure equals 32.  Right ventricle pressure equals 65/24.  The right atrial pressure equals to 22.  Cardiac output by Fick is 4.9.  Cardiac index by Fick is 2.3.  Hand calculated cardiac output equals 7.8.  Hand calculated cardiac index equals 3.7.  On 2 liters nasal cannula, pulmonary artery saturation equals 77.8%.  Femoral artery saturation equals 99.1%.  Pulse oximetry is 99%.  Right atrial saturation is 76.3%.  Systemic blood pressure is 166/58.  Body surface area equals 2.12.  Hemoglobin equals 12.6.,IMPRESSION:,1.  Two-vessel coronary artery disease with a complex left anterior descending arterial lesion as well as circumflex disease.,2.  Normal left ventricular function with an estimated ejection fraction of 60%.,3.  Biventricular overload.,4.  Moderate pulmonary hypertension.,5.  There is no evidence of shunt.,PLAN:,1.  The patient will be admitted for IV diuresis in light of the biventricular overload.,2.  The findings of the heart catheterization were discussed in detail with the patient and the patient's family.  There is some concern with the patient's two-vessel coronary artery disease in light of the patient's diabetic history.  We will obtain a surgical evaluation for the possibility of a coronary artery bypass grafting.,3.  The patient will remain on aggressive medical regimen including ACE inhibitor, aspirin, Plavix, and nitrate.,4.  The patient will need to undergo aggressive risk factor modification including weight loss and diet control.,5.  The patient will have an Internal Medicine evaluation regarding the patient's diabetic history.
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DESCRIPTION: Left heart catheterization, bilateral selective coronary angiography, left ventriculography, and right heart catheterization.  Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.

The situation described involves a detailed medical procedure relating to heart catheterization and angiography, with findings indicating significant coronary artery disease and other cardiovascular issues. This is inherently a high-stakes situation due to the potential risks associated with both the procedures and the conditions diagnosed. The identified stenotic lesions, especially in a patient with a history of diabetes, represent a serious health issue that requires careful management, including potential surgical intervention (coronary artery bypass grafting) and aggressive medical treatment. The stakes are high because unsuccessful management of the condition could lead to severe complications, including heart attack or other cardiovascular events.


Medical Specialty: Surgery
Sample Name: Cardiac Catheterization - 10

EXAM: , Left Heart Catheterization,REASON FOR EXAM:,  Chest pain, coronary artery disease, prior bypass surgery.,INTERPRETATION: , The procedure and complications were explained to the patient in detail and formal consent was obtained.  The patient was brought to the cath lab.  The right groin was draped in the usual sterile manner.  Using modified Seldinger technique, a 6-French arterial sheath was introduced in the right common femoral artery.  A JL4 catheter was used to cannulate the left coronary arteries.  A JR4 catheter was used to cannulate the right coronary artery and also bypass grafts.  The same catheter was used to cannulate the vein graft and also LIMA.  I tried to attempt to cannulate other graft with Williams posterior catheter and also bypass catheter was unsuccessful.  A 6-French pigtail catheter was used to perform left ventriculography and pullback was done.  No gradient was noted.  Arterial sheath was removed.  Hemostasis was obtained with manual compression.  The patient tolerated the procedure very well without any complications.,FINDINGS:,1.  Native coronary arteries.  The left main is patent.  The left anterior descending artery is not clearly visualized.  The circumflex artery appears to be patent.  The proximal segment gives rise to small caliber obtuse marginal vessel.,2.  Right coronary artery is patent with mild distal and mid segment.  No evidence of focal stenosis or dominant system.,3.  Bypass graft LIMA to the left anterior descending artery patent throughout the body as well the anastomotic site.  There appears to be possible _______ graft to the diagonal 1 vessel.  The distal LAD wraps around the apex.  No stenosis following the anastomotic site noted.,4.  Vein graft to what appears to be obtuse marginal vessel was patent with a small caliber obtuse marginal 1 vessel.,5.  No other bypass grafts are noted by left ventriculography and also aortic root shot.,6.  Left ventriculography with an ejection fraction of 60%.,IMPRESSION:,1.  Left coronary artery disease native.,2.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  _______ graft to the diagonal 1 vessel.,3.  Native right coronary artery is patent, mild disease.,RECOMMENDATIONS: , Medical treatment.
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DESCRIPTION: Left Heart Catheterization.  Chest pain, coronary artery disease, prior bypass surgery.  Left coronary artery disease native.  Patent vein graft with obtuse marginal vessel and also LIMA to LAD.  Native right coronary artery is patent, mild disease.

surgery, chest pain, coronary artery disease, bypass surgery, heart catheterization, lima, lad, obtuse marginal vessel, vein graft, obtuse marginal, marginal vessel, coronary artery, catheterization, coronary, artery, obtuse, marginal, bypass, vessel, graft

The procedure described is a cardiac catheterization, which is a common but invasive medical procedure typically used to diagnose heart conditions such as coronary artery disease. The stakes are high because it involves direct intervention in the cardiovascular system, presenting risks like bleeding, infection, or even heart attack. The patient has a history of prior bypass surgery, indicating an existing high-risk cardiac profile. The outcome has significant implications for the patient's health status and future treatment options.


Medical Specialty: Surgery
Sample Name: Stenting

NAME OF PROCEDURE:,  Successful stenting of the left anterior descending.,DESCRIPTION OF PROCEDURE:,  Angina pectoris, tight lesion in left anterior descending.,TECHNIQUE OF PROCEDURE:,  Standard Judkins, right groin.,CATHETERS USED: , 6 French Judkins, right; wire, 14 BMW; balloon for predilatation, 25 x 15 CrossSail; stent 2.5 x 18 Cypher drug-eluting stent.,ANTICOAGULATION:  ,The patient was on aspirin and Plavix, received 3000 of heparin and was begun on Integrilin.,COMPLICATIONS: , None.,INFORMED CONSENT: , I reviewed with the patient the pros, cons, alternatives and risks of catheter and sedation exactly as I had done before during his diagnostic catheterization, plus I reviewed the risks of intervention including lack of success, need for emergency surgery, need for later restenosis and further procedures.,HEMODYNAMIC DATA: , The aortic pressure was in the physiologic range.,ANGIOGRAPHIC DATA: , Left coronary artery:  The left main coronary artery showed insignificant disease.  The left anterior descending showed fairly extensive calcification.  There was 90% stenosis in the proximal to midportion of the vessel.  Insignificant disease in the circumflex.,SUCCESSFUL STENTING: , A wire crossed the lesion.  We first predilated with a balloon, then advanced, deployed and post dilated the stent.  Final angiography showed 0% stenosis, no tears or thrombi, excellent intimal appearance.,PHYSICAL EXAMINATION,VITAL SIGNS:  Blood pressure 160/88, temperature 98.6, pulse 83, respirations 30.  He is saturating at 96% on 4 L nonrebreather.,GENERAL:  The patient is a 74 year-old white male who is cooperative with the examination and alert and oriented x3.  The patient cannot speak and communicates through writing.,HEENT:  Very small moles on face.  However, pupils equal, round and regular and reactive to light and accommodation.  Extraocular movements are intact.  Oropharynx is moist.,NECK:  Supple.  Tracheostomy site is clean without blood or discharge.,HEART:  Regular rate and rhythm.  No gallop, murmur or rub.,CHEST:  Respirations congested.  Mild crackles in the left lower quadrant and left lower base.,ABDOMEN:  Soft, nontender and nondistended.  Positive bowel sounds.,EXTREMITIES:  No clubbing, cyanosis or edema.,NEUROLOGIC:  Cranial nerves II-XII grossly intact.  No focal deficit.,GENITALIA:  The patient does have a right scrotal swelling, very much larger than the other side, not reproducible and mobile to touch.,CONCLUSIONS,1. Successful stenting of the left anterior descending.  Initially, there was 90% stenosis.  After stenting with a drug-eluting stent, there was 0% residual.,2. Insignificant disease in the other coronaries.,PLAN:,  The patient will be treated with aspirin, Plavix, Integrilin, beta blockers and statins.  I have discussed this with him, and I have answered his questions.
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DESCRIPTION: Successful stenting of the left anterior descending.  Angina pectoris, tight lesion in left anterior descending.

The procedure described is a stenting process for the left anterior descending artery, which is a critical intervention given the initial 90% stenosis. Successful management of such cases is crucial as a failure can lead to significant patient morbidity or even mortality, such as myocardial infarction (heart attack). However, the procedure here was successful with no complications reported and the post-procedure condition of the patient seemed stable. The procedure involved necessary anticoagulation and showed no complications, suggesting good management of risks. Therefore, the stakes were high due to the critical nature of the artery being stented and potential consequences of failure, but the successful outcome and absence of complications are positive aspects.


Medical Specialty: Radiology
Sample Name: Conformal Simulation

CONFORMAL SIMULATION WITH COPLANAR BEAMS,This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated.  It allows us to highly focus the beam of radiation and shape the beam to the target volume, delivering a homogenous dosage through it while sparing the surrounding, more radiosensitive, normal tissues.  This will allow us to give the optimum chance of tumor control while minimizing the acute and long-term side effects.,A conformal simulation is a simulation which involves extended physician, therapist, and dosimetrist time and effort.  The patient is initially taken into a conventional simulator room, where appropriate markers are placed, and the patient is positioned and immobilized.  One then approximates the field sizes and arrangements (gantry angles, collimator angles, and number of fields).  Radiographs are taken, and these fields are marked on the patient's skin.  The patient is then transferred to the diagnostic facility and placed on a flat CT scan table.  Scans are then performed through the targeted area.  The CT scans are evaluated by the radiation oncologist, and the tumor volume, target volume, and critical structures are outlined on each slice of the CT scan.  The dosimetrist then evaluates each individual slice in the treatment planning computer with the appropriately marked structures.  This volume is then reconstructed in 3-dimensional space.  Utilizing the beam's-eye view features, the appropriate blocks are designed.  Multiplane computerized dosimetry is performed throughout the volume.  Field arrangements and blocking are modified as necessary to provide homogenous coverage of the target volume while minimizing the dose to normal structures.  Once all appropriate beam parameters and isodate distributions have been confirmed on the computer scan, each individual slice is then reviewed by the physician.  The beam's-eye view, block design, and appropriate volumes are also printed and reviewed by the physician.  Once these are approved, Cerrobend blocks will be custom fabricated.,If significant changes are made in the field arrangements from the original simulation, the patient is brought back to the simulator where the computer-designed fields are re-simulated.
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DESCRIPTION: Conformal simulation with coplanar beams.  This patient is undergoing a conformal simulation as the method to precisely define the area of disease which needs to be treated.

radiology, coplanar beams, ct scan, target volume, conformal simulation, beamsNOTE,: 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.,

Conformal simulations in radiology are critical for targeting tumors with radiation while minimizing exposure to healthy tissues. This process is essential for effective cancer treatment, affecting the patient's health outcomes. However, it doesn't involve immediate life-or-death stakes typical of emergency medical situations. The stakes are considered high due to the long-term implications of treatment success or failure, potential side effects, and the precision required in treatment planning.


Medical Specialty: Surgery
Sample Name: Vein Stripping

PREOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,POSTOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,PROCEDURES,1.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, right leg.,2.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, left leg.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was taken to the operating room where she underwent a general endotracheal anesthesia.  A time-out process was followed and antibiotics were given.,Then, both legs were prepped and draped in the usual fashion with the patient was in the supine position.  An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided.  Then, an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen.  A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities.  Then, a vein stripper was passed from the right calf up to the groin and the greater saphenous vein, which was divided, was stripped without any difficultly.  Several minutes of compression was used for hemostasis.  Then, the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do.,Then in the left thigh, a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side.  Also, an incision was made in the level of the knee and the saphenous vein was isolated there.  The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis.  Then, a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient's position would allow us.  Then, all incisions were closed in layers with Vicryl and staples.,Then, the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg.  The stab phlebectomies were performed with a hook and they were very satisfactory.  Hemostasis achieved with compression and then staples were applied to the skin.,Then, the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix, fluffs, and Ace bandages.,Estimated blood loss probably was about 150 mL.  The patient tolerated the procedure well and was sent to recovery room in satisfactory condition.  The patient is to be observed, so a decision will be made whether she needs to stay overnight or be able to go home.
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DESCRIPTION: Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.

surgery, chronic venous hypertension, varicosities, stab phlebectomies, greater saphenous vein stripping, lower extremities, vein stripping, saphenous vein, vein, incisions, hemostasis, stripping, branches, phlebectomies, thigh, calf, saphenous,

The procedure described is vein stripping and stab phlebectomies for chronic venous hypertension with varicosities. While it is a significant surgical procedure involving general anesthesia and multiple incisions, it is not typically considered life-threatening or highly complex compared to other surgical procedures such as cardiac surgery or neurosurgery. The procedure aims to alleviate pain and improve quality of life but generally has a predictable and controllable risk profile. The patient's post-operative condition is stated to be satisfactory, indicating a routine surgical event. Therefore, the stakes are not extremely high, but it does involve some level of risk as any surgical procedure does.


Medical Specialty: Gastroenterology
Sample Name: Epigastric Herniorrhaphy

PREOPERATIVE DIAGNOSIS: , Epigastric hernia.,POSTOPERATIVE DIAGNOSIS: , Epigastric hernia.,OPERATIONS:,  Epigastric herniorrhaphy.,ANESTHESIA: , General inhalation.,PROCEDURE: , Following attainment of satisfactory anesthesia, the patient's abdomen was prepped with Hibiclens and draped sterilely.  The hernia mass had been marked preoperatively.  This area was anesthetized with a mixture of Marcaine and Xylocaine.  A transverse incision was made over the hernia and dissection carried down to the entrapped fat.  Sharp dissection was carried around the fat down to the fascial edge.  The preperitoneal fat could not be reduced; therefore, it is trimmed away and the small fascial defect then closed with interrupted 0-Ethibond sutures.  The fascial edges were injected with the local anesthetic mixture.  Subcutaneous tissues were then closed with interrupted 4-0 Vicryl and skin edges closed with running subcuticular 4-0 Vicryl.  Steri-Strips and a sterile dressing were applied to complete the closure.  The patient was then awakened and taken to the PACU in satisfactory condition.,ESTIMATED BLOOD LOSS: , 10 mL.,SPONGE AND NEEDLE COUNT: , Reported as correct.,COMPLICATIONS: , None.
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DESCRIPTION: Epigastric herniorrhaphy.  Epigastric hernia.

gastroenterology, hibiclens, epigastric herniorrhaphy, epigastric hernia, herniorrhaphy,

The procedure described is a routine surgical repair of an epigastric hernia. While any surgery involves some level of risk, this type of procedure is fairly common and typically considered low to moderate in stakes. There were no complications during the surgery, estimated blood loss was minimal, and the patient was in satisfactory condition post-operation. Thus, the situation described does not present high stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Mantle Cell Lymphoma - Consult

CHIEF COMPLAINT:,  Newly diagnosed mantle cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a 47-year-old woman who presented with abdominal pain in September 2006.  On chest x-ray, she had a possible infiltrate and it was thought she might have pneumonia and she was treated with antibiotics and prednisone.  Symptoms improved temporarily, but did not completely resolve.  By the end of September, her pain had worsened and she was seen in the emergency room at ABC.  Chest x-ray was compatible with pleurisy and she was treated with Percocet.  Few days later, she was seen and given a prescription for Ultram because Percocet was causing nausea.  Eventually, she was seen by Dr. X and noted to have splenomegaly.  Repeat ultrasound was done and showed the spleen enlarged at 19 cm.  In retrospect, this was not changed in comparison to an ultrasound that was done in September.  She underwent positron emission tomography (PET) scanning, which showed diffuse hypermetabolic lymph nodes measuring 1 to 2 cm in diameter, as well as a hypermetabolic spleen that was enlarged.,The patient underwent lymph node biopsy on the right neck on 10/27/2006.  Pathology is consistent with mantle cell lymphoma.,On 10/31/2006, she had a bone marrow biopsy.  This does show involvement of bone marrow with lymphoma.,She was noted to have circulating lymphoma cells on peripheral smear as well.,Although CBC was normal, MCV was low and the ferritin was assessed and was low at 8, consistent with iron deficiency.,ALLERGIES:,  NONE.,MEDICATIONS:  ,1.  Estradiol/Prometrium.  ,2.  Ultram p.r.n.  ,3.  Baby aspirin.  ,4.  Lunesta for sleep.  ,5.  She has been started on iron supplements.,PAST MEDICAL HISTORY:  ,1.  Tubal ligation in 1986.,2.  Possible cyst removed from the left neck in 1991.,3.  Tonsillectomy.,4.  Migraines, which are rare.,SOCIAL HISTORY: , She does not smoke cigarettes and drinks alcohol only occasionally.  She is married and has two children, ages 24 and 20.  She works as a project administrator.,FAMILY HISTORY:  ,Father is deceased.  He had emphysema and colon cancer at age 68.  Mother has arrhythmia and hypertension.  Her sister has hypertension and her brother is healthy.,PHYSICAL EXAMINATION:  ,GENERAL:  She is in no acute distress.,VITAL SIGNS:  Her weight is 168 pounds, and she is afebrile with a normal blood pressure and pulse.,HEENT:  The oropharynx is benign.,SKIN:  The skin is warm and dry and shows no jaundice.,NECK:  There is shotty adenopathy in the neck.,CARDIAC:  Regular rate without murmur.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Soft and nontender and shows the spleen palpable about 10 cm below the right costal margin.,EXTREMITIES:  No peripheral edema is noted.,LABORATORY DATA: , CBC and chemistry panel are pending.  CBC was normal last week.  PT/INR was normal as well.,IMPRESSION:,  Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.  Toxicities have already been discussed with her including myelosuppression, mucositis, diarrhea, nausea, alopecia, the low risk for cardiac toxicity, bladder toxicity, neuropathy, constipation, etc.  Written materials were provided to her last week.,PLAN: , Plan will be to add Rituxan a little later in her course because she has circulating lymphoma cells.  She will be started on allopurinol today as well as hydration further to avoid the possibility of tumor lysis syndrome.,Plan will be to have her evaluated for bone marrow transplant in first remission.  I will have Dr. Y see her while she is in the hospital.,The patient is anxious, and will be given Ativan as needed.  We will discontinue aspirin for now, but continue estradiol/Prometrium.,Iron deficiency will be treated with oral iron supplements and we will follow her counts.  She may well have gastrointestinal (GI) involvement, which is not uncommon with mantle cell lymphoma.  After she undergoes remission, we will consider colonoscopy for biopsies prior to proceeding to transplant.
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DESCRIPTION: Newly diagnosed mantle cell lymphoma, admitted now to start chemotherapy.  She will start treatment with hyperfractionated cyclophosphamide, vincristine, doxorubicin, dexamethasone.

The situation involves a newly diagnosed case of mantle cell lymphoma, a type of cancer. The patient is about to start chemotherapy, a treatment with significant risks and toxicities. Decisions about treatment, potential bone marrow transplant, and managing side effects make this a high-stakes scenario. The immediacy of starting chemotherapy and the patient's anxiety also contribute to the high stakes, as they require careful consideration and management to ensure the best possible outcomes and patient safety.


Medical Specialty: Neurology
Sample Name: Vein Stripping

PREOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,POSTOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,PROCEDURES,1.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, right leg.,2.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, left leg.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was taken to the operating room where she underwent a general endotracheal anesthesia.  A time-out process was followed and antibiotics were given.,Then, both legs were prepped and draped in the usual fashion with the patient was in the supine position.  An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided.  Then, an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen.  A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities.  Then, a vein stripper was passed from the right calf up to the groin and the greater saphenous vein, which was divided, was stripped without any difficultly.  Several minutes of compression was used for hemostasis.  Then, the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do.,Then in the left thigh, a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side.  Also, an incision was made in the level of the knee and the saphenous vein was isolated there.  The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis.  Then, a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient's position would allow us.  Then, all incisions were closed in layers with Vicryl and staples.,Then, the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg.  The stab phlebectomies were performed with a hook and they were very satisfactory.  Hemostasis achieved with compression and then staples were applied to the skin.,Then, the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix, fluffs, and Ace bandages.,Estimated blood loss probably was about 150 mL.  The patient tolerated the procedure well and was sent to recovery room in satisfactory condition.  The patient is to be observed, so a decision will be made whether she needs to stay overnight or be able to go home.
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DESCRIPTION: Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.

neurology, chronic venous hypertension, varicosities, stab phlebectomies, greater saphenous vein stripping, lower extremities, vein stripping, saphenous vein, vein, incisions, hemostasis, stripping, branches, phlebectomies, thigh, calf, saphenous,

The procedure described involves surgical interventions for chronic venous hypertension with painful varicosities, involving both legs. Vein stripping and stab phlebectomies are relatively common vascular surgeries and typically not considered life-threatening. However, they require general anesthesia, meticulous surgical technique, and proper postoperative care to manage potential complications such as bleeding, infection, or deep vein thrombosis. The intraoperative progress was uneventful, and the patient's condition was stable post-surgery, indicating controlled risk. The decision for potential overnight observation further underscores its moderate stakes, ensuring patient safety is verified. Thus, while important and requiring surgical intervention and recovery, this situation is not extremely high-stakes compared to more critical or emergency procedures.


Medical Specialty: Neurosurgery
Sample Name: Craniotomy - Frontotemporal - 1

PREOPERATIVE DIAGNOSIS:,  Acute left subdural hematoma.,POSTOPERATIVE DIAGNOSIS:,  Acute left subdural hematoma.,PROCEDURE:,  Left frontal temporal craniotomy for evacuation of acute subdural hematoma.,DESCRIPTION OF PROCEDURE: , This is a 76-year-old man who has a history of acute leukemia.  He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency.  He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury.  His CT imaging reveals an acute left subdural hematoma, which is hemispheric.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy.  The images were brought up on the electronic imaging and confirmed that this was a left-sided condition.  He was fixed in a three-point headrest.  His scalp was shaved and prepared with Betadine, iodine and alcohol.  We made a small curved incision over the temporal, parietal, frontal region.  The scalp was reflected.  A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created.  After completing the bur hole flap, the dura was opened and a gelatinous mass of subdural was peeled away from the brain.  The brain actually looked relatively relaxed; and after removal of the hematoma, the brain sort of slowly came back up.  We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline.  After we felt that we had an adequate decompression, the dura was reapproximated and we filled the subdural space with saline.  We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates.  The scalp was reapproximated, and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment.  Given that this actual skin looked good with apparent removal of about 80% of the subdural we elected to take patient to the Intensive Care Unit for further management.,I was present for the entire procedure and supervised this.  I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain.
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DESCRIPTION: Acute left subdural hematoma.  Left frontal temporal craniotomy for evacuation of acute subdural hematoma.  CT imaging reveals an acute left subdural hematoma, which is hemispheric.

neurosurgery, subdural, hematoma, temporal craniotomy, craniotomy, subdural space, bur hole, subdural hematoma,

The situation involves a neurosurgical procedure for the evacuation of an acute subdural hematoma, a life-threatening condition that can lead to severe neurological deterioration or death if not treated urgently. The patient has additional risk factors such as thrombocytopenia due to acute leukemia, which increases the risk of hemorrhage during or after surgery. The decision-making and execution of the surgery are critical for the patient's survival and outcome, making this a high-stakes scenario.


Medical Specialty: Emergency Room Reports
Sample Name: Headache - Urgent Care Visit

CC: , Headache.,HPI: , This is a 15-year-old girl presenting with occipital headache for the last six hours.  She denies trauma.  She has been intermittently nauseated but has not vomited and has some photophobia.  Denies fever or change in vision.  She has no past history of headaches.  ,PMH: , None. ,MEDICATIONS:  ,Tylenol for pain.,ALLERGIES:,  None.,FAMILY HISTORY: , Grandmother died of cerebral aneurysm.  ,ROS:,  Negative.,PHYSICAL EXAM:  ,Vital Signs:  BP 102/60 P 70 RR 20 T 98.2 ,HEENT:  Throat is clear, nasopharynx clear, TMs clear, there is no lymphadenopathy, no tenderness to palpations, sinuses nontender. ,Neck:  Supple without meningismus. ,Chest:  Lungs clear; heart regular without murmur.,COURSE IN THE ED: , The patient was seen in the urgent care and examined.  At this time, her photophobia and nausea make migraine highly likely.  She is well appearing and we'll try Tylenol with codeine for her pain.  One day off school and follow up with her primary doctor.  ,IMPRESSION: , Migraine headache.  ,PLAN: , See above.
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DESCRIPTION: Migraine headache - The patient was seen in the urgent care.

emergency room reports, photophobia, nausea, migraine headache, tylenol, migraine, headache,

The case involves a 15-year-old girl experiencing a headache with symptoms suggestive of a migraine. While this condition can cause significant discomfort, the patient is stable, has no history of headaches, and shows no alarming emergency symptoms like altered consciousness, significant neurological deficits, or vital sign abnormalities. The situation has been managed in urgent care with appropriate follow-up plans, and although there is a family history of cerebral aneurysm, there's no immediate evidence indicating an acute condition. While monitoring and follow-up are important to rule out any serious underlying issues, the immediate risk level is not high-stakes.


Medical Specialty: Ophthalmology
Sample Name: Ahmed Shunt Placement

PROCEDURE IN DETAIL:  ,While in the holding area, the patient received a peripheral IV from the nursing staff.  In addition, pilocarpine 1% was placed into the operative eye, two times, separated by 10 minutes.  The patient was wheeled to the operating suite where the anesthesia team established peripheral monitoring lines.  Through the IV, the patient received IV sedation in the form of propofol and once somnolent from this, a retrobulbar block was administrated consisting of 2% Xylocaine plain.  Approximately 3 mL were administered.  The patient then underwent a Betadine prep with respect to the face, lens, lashes, and eye.  During the draping process, care was taken to isolate the lashes.  A Vicryl traction suture was placed through the superior cornea and the eye was reflected downward to expose the superior temporal conjunctiva.  Approximately 8 to 10 mm posterior to limbus, the conjunctiva was incised and dissected forward to the limbus.  Blunt dissection was carried out in the superotemporal quadrant.  Next, a 2 x 3-mm scleral flap was outlined that was one-half scleral depth in thickness.  This flap was cut forward to clear cornea using a crescent blade.  The Ahmed shunt was then primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures.  The knots were trimmed.  The tube was then cut to an appropriate length to enter the anterior chamber.  The anterior chamber was then entered after a paracentesis wound had been made temporally.  A trabeculectomy was done and then the tube was threaded through the trabeculectomy site.  The tube was sutured in place with a multi-wrapped 8-0 nylon suture.  The scleral flap was then sutured in place with two 10-0 nylon sutures.  The knots were trimmed, rotated and buried.  A scleral patch was then placed of an appropriate size over the two.  It was sutured in place with interrupted 8-0 nylon sutures.  The knots were trimmed.  The overlying conjunctiva was then closed with a running 8-0 Vicryl suture with a BV needle.  The anterior chamber was filled with Viscoat to keep it deep as the eye was somewhat soft.  A good flow was established with irrigation into the anterior chamber.  Homatropine, Econopred, and Vigamox drops were placed into the eye.  A patch and shield were placed over the eye after removing the draping and the speculum.  The patient tolerated the procedure well.  He was taken to the recovery in good condition.  He will be seen in followup in the office tomorrow.
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DESCRIPTION: The Ahmed shunt was primed and placed in the superior temporal quadrant and it was sutured in place with two 8-0 nylon sutures.  The knots were trimmed.

ophthalmology, cornea, ahmed shunt, nylon sutures, trabeculectomy, conjunctiva, chamberNOTE,: 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 Ahmed Shunt Placement is a surgical procedure typically used to treat glaucoma. It involves precision and carries some risk due to the nature of eye surgeries and the potential complications, such as infection, bleeding, or damage to the eye structure. The detailed steps highlight the careful preparation and execution required to ensure patient safety and successful outcomes. However, it is a routine procedure within ophthalmology for treating severe glaucoma, with the patient appearing to have tolerated it well without immediate complications. The stakes are moderate to high given the operation's complexity and the need for successful execution to avoid serious repercussions like vision loss.


Medical Specialty: Orthopedic
Sample Name: Hemilaminotomy & Foraminotomy

PRE AND POSTOPERATIVE DIAGNOSIS:,  Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR.  After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted.  At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position.  The patient's posterior cervical area was then prepped and draped in the usual sterile fashion.  At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine.  A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated.  After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken.  This showed the spinous process to be at the C4 level.  Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified.  After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken.  This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time.  At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina.  The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe.  This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur.  However, progress was limited because of thickness of the bone.  Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area.  After the bone had been thinned out, further bone was removed using the Kerrison rongeur.  At this point the nerve root was visually inspected and observed to be decompressed.  However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade.  Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery.  After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin.  Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches.  The subcutaneous layer was then reapproximated using 000 Dexon.  The skin was reapproximated using a running 000 nylon.  Sterile dressings were applied.  The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  minimal.
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DESCRIPTION: Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.

orthopedic, foraminotomy with medial facetectomy, facetectomy for microscopic decompression, decompression of nerve root, hemilaminotomy and foraminotomy, decompression of nerve, microscopic decompression, medial facetectomy, kerrison rongeur, nerve root, spinous processes, facetectomy, kerrison, hemilaminotomy, foraminotomy,

The situation involves a detailed description of a surgical procedure called hemilaminotomy and foraminotomy for treating cervical radiculopathy. This is a medical scenario where precise surgical intervention is necessary to relieve pressure on nerve roots to alleviate symptoms. The complexity of the procedure, the need for precision to avoid nerve damage, and the use of general anesthesia elevate the stakes compared to routine medical interactions. However, this type of surgery is relatively common in the field of orthopedic and neurosurgery, and these procedures are generally well-understood and routinely performed by experienced surgeons. Thus, while the stakes are higher compared to non-surgical interactions, they are not the highest due to the controlled surgical environment and expertise involved.


Medical Specialty: Nephrology
Sample Name: Renal Ultrasound - 1

EXAM: , Bilateral renal ultrasound.,CLINICAL INDICATION: , UTI.,TECHNIQUE: , Transverse and longitudinal sonograms of the kidneys were obtained.,FINDINGS:  ,The right kidney is of normal size and echotexture and measures 5.7 x 2.2 x 3.8 cm.  The left kidney is of normal size and echotexture and measures 6.2 x 2.8 x 3.0 cm.  There is no evidence for ,HYDRONEPHROSIS, or ,PERINEPHRIC ,fluid collections.  The bladder is of normal size and contour.  The bladder contains approximately 13 mL of urine after recent voiding.  This is a small postvoid residual.,IMPRESSION: , Normal renal ultrasound.  Small postvoid residual.
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DESCRIPTION: Bilateral renal ultrasound.

Bilateral renal ultrasound.

nephrology, bilateral renal ultrasound, postvoid residual, renal ultrasound, residual, kidneys, renal, ultrasound,

The situation involves the interpretation of a renal ultrasound to assess the kidney's condition based on a clinical indication of a UTI (Urinary Tract Infection). The results show normal kidneys and suggest a minor issue with a small postvoid residual. While interpreting medical imaging is important for patient care, this particular case shows normal findings, which indicates there is no immediate high-risk concern based on the ultrasound results. Therefore, it is not a high-stakes situation as it doesn't indicate a critical or life-threatening condition that requires urgent intervention.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Physical Therapy - Outpatient Rehab

SUMMARY:  ,The patient has attended physical therapy from 11/16/06 to 11/21/06.  The patient has 3 call and cancels and 3 no shows.  The patient has been sick for several weeks due to a cold as well as food poisoning, so has missed many appointments.,SUBJECTIVE:  ,The patient states pain still significant, primarily 1st seen in the morning.  The patient was evaluated 1st thing in the morning and did not take his pain medications, so objective findings may reflect that.  The patient states overall functionally he is improving where he is able to get out in the house and visit and do activities outside the house more.  The patient does feel like he is putting on more muscle girth as well.  The patient states he is doing well with his current home exercise program and feels like pool therapy is also helping as well.,OBJECTIVE: , Physical therapy has consisted of:,1.  Pool therapy incorporating endurance and general lower and upper extremity strengthening.,2.  Clinical setting incorporating core stabilization and general total body strengthening and muscle wasting.,3.  The patient has just begun this, so it is on a very beginners level at this time.,ASSESSMENT, DONE ON 12/21/06,STRENGTH,Activities
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DESCRIPTION: Outpatient rehabilitation physical therapy progress note.  A 52-year-old male referred to physical therapy secondary to chronic back pain, weakness, and debilitation secondary to chronic pain.

The scenario describes a patient's outpatient rehabilitation progress report. The stakes involve the patient's health and recovery, as well as their adherence to therapy, which impacts their treatment outcomes. While important for the individual's health, it does not involve life-threatening situations typically associated with high-stakes scenarios such as emergency medicine or surgery. However, the potential long-term impact on the patient's quality of life elevates the stakes slightly.


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

Medical Specialty: Dentistry
Sample Name: Teeth (full-mouth) Extraction

PREOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,POSTOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,PROCEDURE:, Full-mouth extraction of tooth #3,5,6, 7, 8, 9, 10, 11, 12, 13, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 31, and alveoloplasty in all four quadrants.,ANESTHESIA:,  Nasotracheal general anesthesia.,IV FLUIDS:, A 700 mL of crystalloid.,EBL:, Minimum.,URINE:, Not recorded.,COMPLICATIONS:, None.,CONDITION:, Good.,DISPOSITION:,  The patient was extubated in OR, transferred to PACU for recovery and will be transferred for 23-hour observation and discharged on subsequent day.,BRIEF HISTORY OF THE PATIENT:, Indicated the patient for surgery.  The patient is a 41-year-old white female with multiple grossly decaying nonrestorable teeth.  After discussing treatment options, she decided she will like to have extraction of remaining teeth with subsequent placement of upper and lower complete dentures.,PAST MEDICAL HISTORY:, Positive for a narcotic abuse, presently on methadone treatment, hepatitis C, and headaches.,PAST SURGICAL HISTORY:, C-section x2.,MEDICATIONS,Right now include:,1.  Methadone.,2.  Beta-blocker.,3.  Xanax.,4.  Norco.,5.  Clindamycin.,ALLERGIES:, THE PATIENT IS ALLERGIC TO PENICILLIN.,PROCEDURE IN DETAIL:, The patient was greeted in preoperative holding area, subsequently transferred to OR #17 where the patient was intubated with anesthesia staff present.  The patient was prepped and draped in sterile fashion.  Local anesthesia consisting of 1% lidocaine and 1:100,000 epinephrine, total 15 mL were injected into the maxillomandible.  Throat pack was placed in the mouth after a thorough suction.,A full-thickness mucoperiosteal flap was reflected from the upper right to the upper left, tooth number 3,5,6,7,8,9,10,11,12,13, and 14 and were elevated and delivered.  Extraction sites were thoroughly curettaged and irrigated.  Bony undercuts were removed then smoothed with rongeurs and bone saw.  After thorough irrigation, the postsurgical site closed in a running fashion with 3-0 chromic sutures.  Subsequently, a full-thickness mucoperiosteal flap was reflected in the mandible, tooth numbers 31, 28, 27, 26, 25, 24, 23, 22, 21, 20, and 19 were elevated and delivered with simple forceps extractions.  Bony undercuts were removed with rongeurs and smoothed with bone saw.,Extraction sites were thoroughly irrigated and curettaged.  Wound was closed in continuous fashion 3-0 chromic.  After adequate hematosis was achieved, 0.5% Marcaine and 1:200,000 epinephrine was injected in the maxillomandible thus to heal to aid in hematosis and pain control.  Total of 8 mL were used.  Throat pack was subsequently removed.  Orogastric tube was passed to suction out the stomach.,The patient was subsequently extubated in OR and transferred to PACU for recovery.  The patient would be placed in 23-hour observation.
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DESCRIPTION: Full-mouth extraction of teeth and alveoloplasty in all four quadrants.

This situation involves a full-mouth extraction and alveoloplasty, a significant dental surgical procedure, particularly given the patient's complex medical history, including narcotic abuse, hepatitis C, and medication use. The procedure requires general anesthesia and post-operative observation, which increases the stakes due to potential complications such as infection, bleeding, or anesthesia-related issues. Managing a patient with such a medical history also requires careful coordination and monitoring, which further adds to the stakes. However, since there are no recorded complications and the patient's condition post-operation is described as good, the situation is moderately high-stakes rather than the highest possible.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Consult - Coronary Artery Disease

REASON FOR CONSULTATION:,  Coronary artery disease (CAD), prior bypass surgery.,HISTORY OF PRESENT ILLNESS: , The patient is a 70-year-old gentleman who was admitted for management of fever.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.  No symptoms of chest pain or shortness of breath.,His history from cardiac standpoint as mentioned below.,CORONARY RISK FACTORS: , History of hypertension, history of diabetes mellitus, nonsmoker.  Cholesterol elevated.  History of established coronary artery disease in the family and family history positive.,FAMILY HISTORY: , Positive for coronary artery disease.,SURGICAL HISTORY: , Coronary artery bypass surgery and a prior angioplasty and prostate biopsies.,MEDICATIONS:,1.  Metformin.,2.  Prilosec.,3.  Folic acid.,4.  Flomax.,5.  Metoprolol.,6.  Crestor.,7.  Claritin.,ALLERGIES:,  DEMEROL, SULFA.,PERSONAL HISTORY: , He is married, nonsmoker, does not consume alcohol, and no history of recreational drug use.,PAST MEDICAL HISTORY:,  Significant for multiple knee surgeries, back surgery, and coronary artery bypass surgery with angioplasty, hypertension, hyperlipidemia, elevated PSA level, BPH with questionable cancer.  Symptoms of shortness of breath, fatigue, and tiredness.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills except for recent fever and rigors.,HEENT:  No history of cataract or glaucoma.,CARDIOVASCULAR:  As above.,RESPIRATORY:  Shortness of breath.  No pneumonia or valley fever.,GASTROINTESTINAL:  Nausea and vomiting.  No hematemesis or melena.,UROLOGICAL:  Frequency, urgency.,MUSCULOSKELETAL:  No muscle weakness.,SKIN:  None significant.,NEUROLOGICAL:  No TIA or CVA.  No seizure disorder.,PSYCHOLOGICAL:  No anxiety or depression.,ENDOCRINE:  As above.,HEMATOLOGICAL:  None significant.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 75, blood pressure 130/68, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic, normocephalic.,NECK:  Veins flat.  No significant carotid bruits.,LUNGS:  Air entry bilaterally fair.,HEART:  PMI displaced.  S1 and S2 regular.,ABDOMEN:  Soft, nontender.  Bowel sounds present.,EXTREMITIES:  No edema.  Pulses are palpable.  No clubbing or cyanosis.,CNS:  Benign.,EKG:
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DESCRIPTION: Coronary artery disease, prior bypass surgery.  The patient has history of elevated PSA and BPH.  He had a prior prostate biopsy and he recently had some procedure done, subsequently developed urinary tract infection, and presently on antibiotic.  From cardiac standpoint, the patient denies any significant symptom except for fatigue and tiredness.

This scenario involves a patient with coronary artery disease, prior bypass surgery, and several risk factors for heart problems, such as hypertension, diabetes, and hyperlipidemia. Although the patient is currently experiencing fatigue and tiredness, there are no symptoms of chest pain or significant shortness of breath. However, considering the patient's age, cardiac history, and multiple comorbidities, there remains a significant risk of cardiac issues, which could quickly escalate if any new symptoms develop. The patient's current medical situation requires close monitoring due to the potential for high-stakes consequences if it deteriorates.


Medical Specialty: Consult - History and Phy.
Sample Name: Ischemic Cecum - Consult

REASON FOR CONSULTATION: , Pneumatosis coli in the cecum.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 87-year-old gentleman who was admitted on 10/27/07 with weakness and tiredness with aspiration pneumonia.  The patient is very difficult to obtain information from; however, he appears to be having frequent nausea and vomiting with an aspiration pneumonia and abdominal discomfort.  In addition, this hospitalization, he has undergone an upper endoscopy, which found a small ulcer after dropping his hematocrit and becoming anemic.  He had a CT scan on Friday, 11/02/07, which apparently showed pneumatosis and his cecum worrisome for ischemic colitis as well as bilateral hydronephrosis and multiple liver lesions, which could be metastatic disease versus cysts.  In discussions with the patient, he had multiple bowel movements yesterday and is currently passing flatus and has epigastric pain.,PAST MEDICAL HISTORY:  ,Obtained from the medical chart.  Chronic obstructive pulmonary disease, history of pneumonia, and aspiration pneumonia, osteoporosis, alcoholism, microcytic anemia.,MEDICATIONS: , Per his current medical chart.,ALLERGIES: , NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY: , The patient had a long history of smoking but quit many years ago.  He does have chronic alcohol use.,PHYSICAL EXAMINATION:,GENERAL:  A very thin white male who is dyspneic and having difficulty breathing at the moment.,VITAL SIGNS:  Afebrile.  Heart rate in the 100s to 120s at times with atrial fibrillation.  Respiratory rate is 17-20.  Blood pressure 130s-150s/60s-70s.,NECK:  Soft and supple, full range of motion.,HEART:  Regular.,ABDOMEN:  Distended with tenderness mainly in the upper abdomen but very difficult to localize due to his difficulty providing information.  He does appear to have tenderness but does not have rebound and does not have peritoneal signs.,DIAGNOSTICS: , A CT scan done on 11/02/07 shows pneumatosis in the cecum with an enlarged cecum filled with stool and air fluid levels with chronically dilated small bowel.,ASSESSMENT: , Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.,PLAN: , The patient appears to have pneumatosis from a CT scan 2 days ago.  Nothing was done about it at that time as the patient appeared to not be symptomatic, but he continues to have nausea and vomiting with abdominal pain, but the fact that pneumatosis was found 2 days ago and the patient has survived this long indicates this may be a benign process at the moment, and I would recommend getting a repeat CT scan to assess it further to see if there is worsening of pneumatosis versus resolution to further evaluate the liver lesions and make decisions regarding planning at that time.  The patient has frequent desaturations secondary to his aspiration pneumonia, and any surgical procedure or any surgical intervention would certainly require intubation, which would then necessitate long-term ventilator care as he is not someone who would be able to come off of a ventilator very well in his current state.  So we will look at the CT scan and make decisions based on the findings as far as that is concerned.
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DESCRIPTION: Pneumatosis coli in the cecum.  Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.

consult - history and phy., ischemic cecum, metastatic disease, bilateral hydronephrosis, chronic alcohol abuse, acute renal failure, copd, anemia, gastric ulcer, pneumatosis coli, cecum, aspiration pneumonia, aspiration, ischemic, atrial, metastatic, hydronephrosis, fibrillation, pneumatosis, pneumonia,

The situation involves a complex medical case with an elderly patient presenting multiple comorbidities, including possible ischemic cecum, metastatic disease, aspiration pneumonia, and cardiovascular issues. The stakes are high because failure to appropriately diagnose and manage the conditions can lead to serious or fatal outcomes. Interventions need to be carefully considered due to the patient's frail condition, age, and the presence of aspiration pneumonia, which complicates surgical options and recovery. There is a need for immediate and precise medical decision-making, especially considering potential systemic complications.


Medical Specialty: IME-QME-Work Comp etc.
Sample Name: Permanent & Stationary Report

PRESENT COMPLAINTS: , The patient is reporting ongoing, chronic right-sided back pain, pain that radiates down her right leg intermittently.  She is having difficulty with bending and stooping maneuvers.  She cannot lift heavy objects.  She states she continues to have pain in her right neck and pain in her right upper extremity.  She has difficulty with pushing and pulling and lifting with her right arm.  She describes an intermittent tingling sensation in the volar aspect of her right hand.  She states she has diminished grip strength in her right hand because of wrist pain complaints.  She states that the Wellbutrin samples I had given her previously for depression seem to be helping.  Her affect appears appropriate.  She reports no suicidal ideation.  She states she continues to use Naprosyn as an anti-inflammatory, Biofreeze ointment over her neck and shoulder and back areas of complaints.  She also takes Imitrex occasionally for headache complaints related to her neck pain.  She also takes Flexeril occasionally for back spasms and Darvocet for pain.  She is asking for a refill on some of her medications today.  She is relating a VAS pain score regarding her lower back at a 6-7/10 and regarding her neck about 3/10, and regarding her right upper extremity about a 4/10., ,PHYSICAL EXAMINATION: , She is afebrile.  Blood pressure is 106/68, pulse of 64, respirations of 20.  Her physical exam is unchanged from 03/21/05.  Her orthopedic exam reveals full range of motion of the cervical spine.  Cervical compression test is negative.  Valsalva's maneuver is negative.  Hoffmann's sign is negative.  DTRs are +1 at the biceps, brachioradialis and trapezius bilaterally.  Her sensation is grossly intact to the upper extremity dermatomes.  Motor strength appears 5/5 strength in the upper extremity muscle groups tested.,Phalen's and Tinel's signs are negative at both wrists.  Passive range of motion of the right wrist is painful for her.  Passive range of motion of the left wrist is non painful.  Active range of motion of both wrists and hands are full.  She is right hand dominant.  Circumferential measurements were taken in her upper extremities.  She is 11" in the right biceps, 10 1/2" in the left biceps.  She is 9 3/4" in both right and left forearms.  Circumferential measurements were also taken of the lower extremities.  She is 21" at both the right and left thighs, 15" in both the right and left calves.  Jamar dynamometry was assessed on three tries in this right-hand-dominant individual.  She is 42/40/40 pounds on the right hand with good effort, and on the left is 60/62/60 pounds, suggesting a loss of at least 20% to 25% pre-injury grip strength in the right dominant hand.  , ,Examination of her lumbar trunk reveals decreased range of motion, flexion allowing her fingertips about 12" from touching the floor.  Lumbar extension is to 30 degrees.  The right SLR is limited to about 80 degrees, provoking back pain, with a positive Bragard's maneuver, causing pain to radiate to the back of the thigh.  The left SLR is to 90 degrees without back pain.  DTRs are +1 at the knees and ankles.  Toes are downgoing to plantar reflexes bilaterally.  Sensation is grossly intact in the lower extremity dermatomes.  Motor strength appears 5/5 strength in the lower extremity muscle groups tested., ,IMPRESSION: , (1)  Sprain/strain injury to the lumbosacral spine with lumbar disc herniation at L5-S1, with radicular symptoms in the right leg. (2)  Cervical sprain/strain with myofascial dysfunction. (3)  Thoracic sprain/strain with myofascial dysfunction. (4)  Probable chronic tendonitis of the right wrist.  She has negative nerve conduction studies of the right upper extremity. (5)  Intermittent headaches, possibly migraine component, possibly cervical tension cephalalgia-type headaches or cervicogenic headaches., ,TREATMENT / PROCEDURE: , I reviewed some neck and back exercises. , ,RX:, I dispensed Naprosyn 500 mg b.i.d. as an anti-inflammatory.  I refilled Darvocet N-100, one tablet q.4-6 hours prn pain, #60 tablets, and Flexeril 10 mg t.i.d. prn spasms, #90 tablets, and dispensed some Wellbutrin XL tablets, 150-mg XL tablet q.a.m., #30 tablets., ,PLAN / RECOMMENDATIONS:,  I told the patient to continue her medication course per above.  It seems to be helping with some of her pain complaints.  I told her I will pursue trying to get a lumbar epidural steroid injection authorized for her back and right leg symptoms.  I told her in my opinion I would declare her Permanent and Stationary as of today, on 04/18/05 with regards to her industrial injuries of 05/16/03 and 02/10/04.  , ,I understand her industrial injury of 05/16/03 is related to an injury at Home Depot where she worked as a credit manager.  She had a stack of screen doors fall, hitting her on the head, weighing about 60 pounds, knocking her to the ground.  She had onset of headaches and neck pain, and pain complaints about her right upper extremity.  She also has a second injury, dated 02/10/04, when apparently a co-worker was goofing around and apparently kicked her in the back accidentally, causing severe onset of back pain.  , ,FACTORS FOR DISABILITY:,OBJECTIVE:  ,1.  She exhibits decreased range of motion in the lumbar trunk.,2.  She has an abnormal MRI revealing a disc herniation at L5-S1.,3.  She exhibits diminished grip strength in the right arm and upper extremity., ,SUBJECTIVE: ,1.  Based on her headache complaints alone, would be considered occasional and minimal to slight at best. ,2.  With regards to her neck pain complaints, these would be considered occasional and slight at best. ,3.  Regarding her lower back pain complaints, would be considered frequent and slight at rest, with an increase to a moderate level of pain with repetitive bending and stooping and heavy lifting, and prolonged standing. ,4.  Regarding her right upper extremity and wrist pain complaints, these would be considered occasional and slight at rest, but increasing to slight to moderate with repetitive gripping, grasping, and torquing maneuvers of her right upper extremity. ,LOSS OF PRE-INJURY CAPACITY: , The patient advises that prior to her industrial dates of injury she was capable of repetitively bending and stooping and lifting at least 60 pounds.  She states she now has difficulty lifting more than 10 or 15 pounds without exacerbating back pain.  She has trouble trying to repetitively push or pull, torque, twist and lift with the right upper extremity, due to wrist pain, which she did not have prior to her industrial injury dates.  She also relates headaches, which she did not have prior to her industrial injury.  , ,WORK RESTRICTIONS AND DISABILITY: , I would find it reasonable to place some permanent restrictions on this patient.  It is my opinion she has a disability precluding heavy work, which contemplates the individual has lost approximately half of her pre-injury capacity for performing such activities as bending, stooping, lifting, pushing, pulling and climbing or other activities involving comparable physical effort.  The patient should probably no lift more than 15 to 20 pounds maximally.  She should probably not repetitively bend or stoop.  She should avoid repetitive pushing, pulling or torquing maneuvers, as well as gripping and grasping maneuvers of the right hand.  She should probably not lift more than 10 pounds repetitively with the right upper extremity.  I suspect that prior to her industrial she could lift repetitively and push, pull, torque and twist at least 20 to 25 pounds with the right upper extremity.  , ,CAUSATION AND APPORTIONMENT:, With regards to issues of causation, they appear appropriate to her industrial injuries and histories given per the 05/16/03 and the 02/10/04 injuries., ,With regards issues of apportionment, it is my opinion that 100% of her pain complaints are industrially related to her industrial injuries of 05/16/03 and 02/10/04.  There does not appear to be any apportionable issues here.
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DESCRIPTION: Work restrictions and disability evaluation

The situation involves a detailed medical evaluation of a patient for a Permanent & Stationary Report related to work injuries, focusing on her functional capacity, pain management, and work restrictions. While the medical conditions and the need for accurate assessments are important, they are not life-threatening. The situation mainly involves determining the patient's disability status and appropriate work restrictions, which are significant for her quality of life and work capacity but do not carry immediate life-or-death consequences. Therefore, the situation is important but not critically high-stakes.


Medical Specialty: Ophthalmology
Sample Name: Cataract Extraction Followup

Her past medical history includes insulin requiring diabetes mellitus for the past 28 years.  She also has a history of gastritis and currently is being evaluated for inflammatory bowel disease.  She is scheduled to see a gastroenterologist in the near future.  She is taking Econopred 8 times a day to the right eye and Nevanac, OD, three times a day.  She is allergic to penicillin.,The visual acuity today was 20/50, pinholing, no improvement in the right eye.  In the left eye, the visual acuity was 20/80, pinholing, no improvement.  The intraocular pressure was 14, OD and 9, OS.  Anterior segment exam shows normal lids, OU.  The conjunctiva is quiet in the right eye.  In the left eye, she has an area of sectoral scleral hyperemia superonasally in the left eye.  The cornea on the right eye shows a paracentral area of mild corneal edema.  In the left eye, cornea is clear.  Anterior chamber in the right eye shows trace cell.  In the left eye, the anterior chamber is deep and quiet.  She has a posterior chamber intraocular lens, well centered and in sulcus of the left eye.  The lens in the left eye shows 3+ nuclear sclerosis.  Vitreous is clear in both eyes.  The optic nerves appear healthy in color and normal in size with cup-to-disc ratio of approximately 0.48.  The maculae are flat in both eyes.  The retinal periphery is flat in both eyes.,Ms. ABC is recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.  She will continue her current drops.  In the left eye, she has an area of what appears to be sectoral scleritis.  I did a comprehensive review of systems today and she reports no changes in her pulmonary, dermatologic, neurologic, gastroenterologic or musculoskeletal systems.  She is, however, being evaluated for inflammatory bowel disease.  The mild scleritis in the left eye may be a manifestation of this.  We will notify her gastroenterologist of this possibility of scleritis and will start Ms. ABC on a course of indomethacin 25 mg by mouth two times a day.  I will see her again in one week.  She will check with her primary physician prior to starting the Indocin.
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DESCRIPTION: Patient  follows up for cataract extraction with lens implant 2 weeks ago.   Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.

ophthalmology, visual acuity, photophobia, lens implant, cataract extraction, eye, cataract, cornealNOTE,: 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 patient is recovering from cataract surgery and has ongoing medical issues, including diabetes and potential inflammatory bowel disease. She is experiencing mild scleritis, which could be linked to her gastrointestinal evaluation. While these conditions and post-surgical recovery need monitoring, there is no indication of an immediate life-threatening or extremely critical situation based on the information provided.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Bronchoscopy - Pediatric

FLEXIBLE BRONCHOSCOPY,The flexible bronchoscopy is performed under conscious sedation in the Pediatric Intensive Care Unit.  I explained to the parents that the possible risks include:  irritation of the nasal mucosa, which can be associated with some bleeding; risk of contamination of the lower airways by passage of the scope in the nasopharynx; respiratory depression from sedation; and a very small risk of pneumothorax.  A bronchoalveolar lavage may be obtained by injecting normal saline in one of the bronchi and suctioning the fluid back.  The sample will then be sent for testing.  The flexible bronchoscopy is mainly diagnostic, any therapeutic intervention, if deemed necessary, will be planned and will require a separate procedure.,The parents seem to understand, had the opportunity to ask questions and were satisfied with the information.  A booklet containing the description of the procedure and other information was provided.
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DESCRIPTION: Flexible Bronchoscopy (pediatric)

Flexible Bronchoscopy (pediatric)

pediatrics - neonatal, flexible bronchoscopy, pediatric intensive care unit, bleeding, bronchi, bronchoalveolar lavage, bronchoscopy, conscious sedation, nasal mucosa, nasopharynx, pneumothorax, respiratory, pediatric flexible bronchoscopyNOTE,: 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.

Flexible bronchoscopy, particularly in neonates and children, carries several potential risks due to the age and vulnerability of the patient population. It includes risks related to sedation and possible complications like pneumothorax, which could be life-threatening. Additionally, the setting is the Pediatric Intensive Care Unit, indicating the inherent high-stakes nature of the procedure due to the need for close monitoring and potential for serious complications. Given the nature of neonates and their sensitive health status, this qualifies as a high-stakes situation.


Medical Specialty: Consult - History and Phy.
Sample Name: GI Consultation - 3

PROBLEM:  ,Prescription evaluation for Crohn's disease., ,HISTORY: , This is a 46-year-old male who is here for a refill of Imuran.  He is taking it at a dose of 100 mg per day.  He is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years.  In fact, he had an episode three weeks ago in which he was seen at the emergency room after experiencing sudden onset of abdominal pain and vomiting. An x-ray was performed, which showed no signs of obstruction per his report.  He thinks that the inciting factor of this incident was too many grapes eaten the day before.  He has had similar symptoms suggestive of obstruction when eating oranges or other high-residue fruits in the past.  The patient's normal bowel pattern is loose stools and this is unchanged recently.  He has not had any rectal bleeding. He asks today about a rope-like vein on his anterior right arm that has been a little tender and enlarged after he was in the emergency room and they had difficulty with IV insertion.  He has not had any fever, red streaking up the arm, or enlargement of lymph nodes.  The tenderness has now completely resolved.  , ,He had a colonoscopy performed in August of 2003, by Dr. S.  An anastomotic stricture was found at the terminal ileum/cecum junction.  Dr. S recommended that if the patient experienced crampy abdominal pain or other symptoms of obstruction, that he may consider balloon dilation.  No active Crohn's disease was found during the colonoscopy.  , ,Earlier this year, he experienced a non-specific hepatitis with elevation of his liver function tests.  At that time he was taking a lot of Tylenol for migraine-type headaches.  Under Dr. S's recommendation, he stopped the Imuran for one month and reduced his dose of Tylenol.  Since that time his liver enzymes have normalized and he has restarted the Imuran with no problems.  , ,He also reports heartburn that is occurring on a slightly more frequent basis than it has in the past.  It used to occur once a week only, but has now increased in frequency to twice a week.  He takes over-the-counter H2 blockers as needed, as well as Tums.  He associates the onset of his symptoms with eating spicy Mexican food., ,PAST MEDICAL HISTORY: , Reviewed and unchanged.,ALLERGIES: , No known allergies to medications.,OPERATIONS: , Unchanged.,ILLNESSES: , Crohn's disease, vitamin B12 deficiency.,MEDICATIONS:,  Imuran, Nascobal, Vicodin p.r.n., ,REVIEW OF SYSTEMS: , Dated 08/04/04 is reviewed and noted.  Please see pertinent GI issues as discussed above.  Otherwise unremarkable., ,PHYSICAL EXAMINATION:  , GENERAL:  Pleasant male in no acute distress.  Well nourished and well developed. SKIN: indurated, cord-like superficial vein on the right anterior forearm, approx. 3 cm in length.  Non-tender to palpation. No erythema or red streaking.  No edema. LYMPH:  No epitrochlear or axillary lymph node enlargement or tenderness on the right side. , ,DATA REVIEWED: Labs from June 8th and July 19th reviewed.  Liver function tests normal with AST 14 and ALT 44.  WBCs were slightly low at 4.8.  Hemoglobin dropped slightly from 14.1 on 6/8 to 12.9 on 7/19. Hematocrit dropped slightly as well from 43.2 on 6/804 to 40.0 on 7/19/04.  These results were reviewed by Dr. S and lab results letter sent., ,IMPRESSION:  ,1. Crohn's disease, status post terminal ileum resection, on Imuran.  Intermittent symptoms of bowel obstruction.  Last episode three weeks ago.,2.  History of non-specific hepatitis while taking high doses of Tylenol.  Now resolved. ,2.  Increased frequency of reflux symptoms.,3.  Superficial thrombophlebitis, resolving. ,4.  Slightly low H&H., ,PLAN:  ,1.  We discussed Dr. S's recommendation that the patient undergo balloon dilation for recurrent bowel obstruction type symptoms.  The patient emphatically states that he does not want to consider dilation at this time.  The patient is strongly encouraged to call us when he does experience any obstructive symptoms, including abdominal pain, nausea, vomiting, or change in bowel habits.  He states understanding of this. Advised to maintain low residue diet to avoid obstructions. ,2.  Continue with liver panel and ABC every month per Dr. S's instructions.,3.  Continue Imuran 100 mg per day.,4.  Continue to minimize Tylenol use.  The patient is wondering if he can take another type of medication for migraines that is not Tylenol or antiinflammatories or aspirin.  Dr. S is consulted and agrees that Imitrex is an acceptable alternative for migraine headaches since he does not have advanced liver disease. The patient will make an appointment with his primary care provider to discuss this further. ,5.  Reviewed the importance of prophylactic treatment of reflux-type symptoms.  Encouraged the patient to take over-the-counter H2 blockers on a daily basis to prevent symptoms from occurring.  The patient will try this and if he remains symptomatic, then he will call our office and a prescription for Zantac 150 mg per day will be provided.  Reviewed the potential need for upper endoscopy should his symptoms continue or become more frequent.  He does not want to undergo any type of procedure such as that at this time.,6.
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DESCRIPTION: GI Consultation for Chrohn's disease.

GI Consultation for Chrohn's disease.

The situation involves managing a chronic condition, Crohn's disease, which can significantly affect the patient's quality of life, but it is not immediately life-threatening. The primary concerns are prescription management, recurring symptoms, and avoiding potential complications like bowel obstruction. While important, especially with the history of emergency room visits and surgical interventions, these factors do not indicate an immediate life-or-death scenario. However, any exacerbation can lead to high-stakes situations if not addressed timely, particularly with past severe symptoms and the patient's reluctance for certain procedures.