Medical Specialty: Neurosurgery
Sample Name: Brain Stimulator Electrode

PREOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,POSTOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,ANESTHESIA:,  MAC (monitored anesthesia care) with local anesthesia.,TITLE OF PROCEDURES:,1.  Left frontal craniotomy for placement of deep brain stimulator electrode.,2.  Right frontal craniotomy for placement of deep brain stimulator electrode.,3.  Microelectrode recording of deep brain structures.,4.  Stereotactic volumetric CT scan of head for target coordinate determination.,5.  Intraoperative programming and assessment of device.,INDICATIONS:  ,The patient is a 61-year-old woman with a history of dystonic tremor.  The movements have been refractory to aggressive medical measures, felt to be candidate for deep brain stimulation.  The procedure is discussed below.,I have discussed with the patient in great deal the risks, benefits, and alternatives.  She fully accepted and consented to the procedure.,PROCEDURE IN DETAIL:,  The patient was brought to the holding area and to the operating room in stable condition.  She was placed on the operating table in seated position.  Her head was shaved.  Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50:50 mixture of 0.5% Marcaine and 2% lidocaine in all planes.  IV antibiotics were administered as was the sedation.  She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken.  The images were then transported to the surgery planned work station where a 3-D reconstruction was performed and the target coordinates were then chosen.  Target coordinates chosen were 20 mm to the left of the AC-PC midpoint, 3 mm anterior to the AC-PC midpoint, and 4 mm below the AC-PC midpoint.  Each coordinate was then transported to the operating room as Leksell coordinates.,The patient was then placed on the operating table in a seated position once again.  Foley catheter was placed, and she was secured to the table using the Mayfield unit.  At this point then the patient's right frontal and left parietal bossings were cleaned, shaved, and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes.  Sterile drapes placed around the perimeter of the field.  This same scalp region was then anesthetized with same local anesthetic mixture.,A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings.  Bur holes were created on either side of the midline just behind the coronal suture.  Hemostasis was controlled using bipolar and Bovie, and self-retaining retractors had been placed in the field.  Using the drill, then two small grooves were cut in the frontal bone with a 5-mm cutting burs and Stryker drill.  The bur holes were then curetted free, the dura cauterized, and then opened in a cruciate manner on both sides with a #11 blade.  The cortical surface was then nicked with a #11 blade on both sides as well.  The Leksell arc with right-sided coordinate was dialed in, was then secured to the frame.  Microelectrode drive was secured to the arc.  Microelectrode recording was then performed.  The signatures of the cells were recognized.  Microelectrode unit was removed.  Deep brain stimulating electrode holding unit was mounted.  The DBS electrode was then loaded into target and intraoperative programming and testing was performed.  Using the screener box and standard parameters, the patient experienced some relief of symptoms on her left side.  This electrode was secured in position using bur-hole ring and cap system.,Attention was then turned to the left side, where left-sided coordinates were dialed into the system.  The microelectrode unit was then remounted.  Microelectrode recording was then undertaken.  After multiple passes, the microelectrode unit was removed.  Deep brain stimulator electrode holding unit was mounted at the desired trajectory.  The DBS electrode was loaded into target, and intraoperative programming and testing was performed once again using the screener box.  Using standard parameters, the patient experienced similar results on her right side.  This electrode was secured using bur-hole ring and cap system.  The arc was then removed.  A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel.,We then closed the electrode, replaced subgaleally.  Copious amounts of Betadine irrigation were used.  Hemostasis was controlled using the bipolar only.  Closure was instituted using 3-0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples.  Sterile dressings were applied.  The Leksell arc was then removed.,She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition.  All needle, sponge, cottonoid, and blade counts were correct x2 as verified by the nurses.
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DESCRIPTION: Frontal craniotomy for placement of deep brain stimulator electrode.  Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.

neurosurgery, dystonic, ac-pc, ct scan, dbs electrode, intraoperative programming, microelectrode, stereotactic, tremor, brain stimulator, craniotomy, device, dystonic tremor, electrode, frontal, screener box, target coordinate, volumetric, deep brain stimulator electrode, brain stimulator electrode, volumetric ct, stimulator, brain,

The situation outlined involves a neurosurgical procedure for the implantation of a deep brain stimulator in a patient with a dystonic tremor that is refractory to medical treatment. This type of procedure, while common in neurosurgery for movement disorders, is intrinsically high-stakes due to the complexity of brain surgery, the use of stereotactic techniques, and the need for precise placement of electrodes. Risks include potential neurological damage, bleeding, and infection, although these complications are minimized with meticulous technique. The procedure's success directly impacts the patient's quality of life by potentially alleviating tremors, making it significantly impactful. Given the nature of brain surgery, the stakes remain high despite the routine nature of these operations in specialized centers.


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

Medical Specialty: General Medicine
Sample Name: Elbow Pain - Consult

CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS:  ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain.  He also has pain in his left ankle, but he is able to walk normally.  He has had previous pain in his left knee.  He denies any passing out, any neck pain at this time even though he did get hit in the head.  He has no chest or abdominal pain.  Apparently, no knives or guns were involved.,PAST MEDICAL HISTORY: , He has had toe problems and left knee pain in the past.,REVIEW OF SYSTEMS: , No coughing, sputum production, dyspnea or chest pain.  No vomiting or abdominal pain.  No visual changes.  No neurologic deficits other than some numbness in his left hand.,SOCIAL HISTORY: , He is in Juvenile Hall for about 25 more days.  He is a nonsmoker.,ALLERGIES: , MORPHINE.,CURRENT MEDICATIONS:  ,Abilify.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  HEENT:  PERRLA.  EOMI.  Conjunctivae anicteric.  Skull is normocephalic.  He is not complaining of bruising.  HEENT:  TMs and canals are normal.  There is no Battle sign.  NECK:  Supple.  He has good range of motion.  Spinal processes are normal to palpation.  LUNGS:  Clear.  CARDIAC:  Regular rate.  No murmurs or rubs.  EXTREMITIES:  Left elbow is tender.  He does not wish to move it at all.  Shoulder and clavicle are within normal limits.  Wrist is normal to inspection.  He does have some pain to palpation.  Hand has good capillary refill.  He seems to have decreased sensation in all three dermatomes.  He has moderately good abduction of all fingers.  He has moderate opponens strength with his thumb.  He has very good extension of all of his fingers with good strength.,We did an x-ray of his elbow.  He has a spiral fracture of the distal one-third of the humerus, about 13 cm in length.  The proximal part looks like it is in good position.  The distal part has about 6 mm of displacement.  There is no significant angulation.  The joint itself appears to be intact.  The fracture line ends where it appears above the joint.  I do not see any extra blood in the joint.  I do not see any anterior or posterior Siegert sign.,I spoke with Dr. X.  He suggests we go ahead and splint him up and he will follow the patient up.  At this point, it does not seem like there needs to be any surgical revision.  The chance of a compartment syndrome seems very low at this time.,Using 4-inch Ortho-Glass and two assistants, we applied a posterior splint to immobilize his fingers, hand, and wrist all the way up to his elbow to well above the elbow.,He had much better comfort once this was applied.  There was good color to his fingers and again, much better comfort.,Once that was on, I took some 5-inch Ortho-Glass and put in extra reinforcement around the elbow so he would not be moving it, straightening it or breaking the fiberglass.,We then gave him a sling.,We gave him #2 Vicodin p.o. and #4 to go.  Gave him a prescription for #15 more and warned him to take it only at nighttime and use Tylenol or Motrin, and ice in the daytime.,I gave him the name and telephone number of Dr. X whom they can follow up with.  They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems.,DIAGNOSES:,1.  Fracture of the humerus, spiral.,2.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.,3.  Psychiatric disorder, unspecified.,DISPOSITION:  The patient will follow up as mentioned above.  They can return here anytime as needed.
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DESCRIPTION: Left elbow pain.  Fracture of the humerus, spiral.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.

The situation involves a 17-year-old male with a spiral fracture of the humerus due to an altercation, with potential nerve injuries to the radial and median nerves. While this is a significant medical condition requiring careful management, it appears to be under control with no immediate life-threatening elements or surgical intervention required. The healthcare provider has already performed appropriate immobilization, provided pain management, and set up follow-up care. The situation does not present a high risk of escalating into a more severe medical emergency such as compartment syndrome, according to the notes. The main focus is on recovery and monitoring, making it less high-stakes than scenarios involving immediate surgical needs or life-threatening injuries.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Supraclavicular Lymphadenopathy

On review of systems, the patient admits to hypertension and occasional heartburn.  She undergoes mammograms every six months, which have been negative for malignancy.  She denies fevers, chills, weight loss, fatigue, diabetes mellitus, thyroid disease, upper extremity trauma, night sweats, DVT, pulmonary embolism, anorexia, bone pain, headaches, seizures, angina, peripheral edema, claudication, orthopnea, PND, coronary artery disease, rheumatoid arthritis, rashes, upper extremity edema, cat scratches, cough, hemoptysis, shortness of breath, dyspnea at two flights of stairs, hoarseness, GI bleeding, change in bowel habits, dysphagia, ulcers, hematuria, or history of TB exposure.  She has had negative PPD.,PAST MEDICAL HISTORY:,  Hypertension.,PAST SURGICAL HISTORY:,  Right breast biopsy - benign.,SOCIAL HISTORY: , She was born and raised in Baltimore.  She has not performed farming or kept birds or cats.,Tobacco: None.,Ethanol: ,Drug Use: ,Occupation:  She is a registered nurse at Spring Grove Hospital.,Exposure: Negative to asbestos.,FAMILY HISTORY:,  Mother with breast cancer.,ALLERGIES: , Percocet and morphine causing temporary hypotension.,MEDICATIONS: , Caduet 10 mg p.o. q.d., Coreg CR 40 mg p.o. q.d., and Micardis HCT 80 mg/12.5 mg p.o. q.d.,PHYSICAL EXAMINATION: ,BP:  133/72
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DESCRIPTION: The patient was undergoing a routine physical examination and was found to have right supraclavicular lymphadenopathy.  She returned for followup examination and again was noted to have right supraclavicular lymphadenopathy.  She is now referred to the thoracic surgery clinic for evaluation.

The situation involves a patient with right supraclavicular lymphadenopathy noted during a routine examination, with a referral to thoracic surgery for evaluation. Supraclavicular lymphadenopathy can be associated with significant underlying conditions, including malignancies or infections like tuberculosis, although the latter is less likely considering the negative PPD and lack of TB exposure. While the patient's mammograms have been negative, her family history of breast cancer and the nature of the lymphadenopathy create a higher stakes scenario due to the potential for serious underlying conditions. The referral to thoracic surgery further highlights the importance of the situation, as it suggests the possibility of needing further diagnostic procedures, such as a biopsy, to rule out malignancy or other serious pathology.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy - 4

PROCEDURE: , Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,INDICATIONS FOR PROCEDURE: , A 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage.  Currently, he has a fistula from his anterior abdominal wall out.  It does not appear to connect to the gastrointestinal tract, but merely connect from the ventral surface of the rectus muscles out the abdominal wall.  CT scans show thickened terminal ileum, which suggest that we are dealing with Crohn's disease.  Endoscopy is being done to evaluate for Crohn's disease.,MEDICATIONS:  ,General anesthesia.,INSTRUMENT:,  Olympus GIF-160 and PCF-160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FINDINGS: , With the patient in the supine position, intubated under general anesthesia.  The endoscope was inserted without difficulty into the hypopharynx.  The scope was advanced down the esophagus, which had normal mucosal coloration and vascular pattern.  Lower esophageal sphincter was located at 40 cm from the central incisors.  It appeared normal and appeared to function normally.  The endoscope was advanced into the stomach, which was distended with excess air.  Rugal folds were flattened completely.  There were multiple superficial erosions scattered throughout the fundus, body, and antral portions consistent with Crohn's involvement of the stomach.  The endoscope was advanced through normal-appearing pyloric valve into the first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  Biopsies were obtained x2 in the second portion of the duodenum, antrum, body, and distal esophagus at 37 cm from the central incisors for histology.  Two additional biopsies were obtained in the antrum for CLO testing.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated that part of the procedure well.,The patient was turned and scope was changed for colonoscopy.  Prior to colonoscopy, it was noted that there was a perianal fistula at 7 o'clock.  The colonoscope was then inserted into the anal verge.  The colonic clean out was excellent.  The scope was advanced without difficulty to the cecum.  The cecal area had multiple ulcers with exudate.  The ileocecal valve was markedly distorted.  Biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending, transverse, descending, sigmoid, and rectum.  The colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon.  Biopsies were obtained in the cecum at 65 cm, transverse colon 50 cm, rectosigmoid 20 cm, and rectum at 5 cm.  No fistulas were noted in the colon.  Excess air was evacuated from the colon.  The scope was removed.  The patient tolerated the procedure well and was taken to recovery in satisfactory condition.,IMPRESSION: , Normal esophagus and duodenum.  There were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve.  All these findings are consistent with Crohn's disease.,PLAN:  ,Begin prednisone 30 mg p.o. daily.  Await PPD results and chest x-ray results, as well as cocci serology results.  If these are normal, then we would recommend Remicade 5 mg/kg IV infusion.  We would start Modulon 50 mL/h for 20 hours to reverse the malnutrition state of this boy.  Check CMP and phosphate every Monday, Wednesday, and Friday for receding syndrome noted by following potassium and phosphate.  We will discuss with Dr. X possibly repeating the CT fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula.  He will need an upper GI to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy.  If he has no stricture formation in the small bowel, we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with Crohn's in the small intestine that we cannot visualize with endoscopy.
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DESCRIPTION: Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.

gastroenterology, olympus gif-160, pcf-160, endoscopy, crohn's disease, aphthous ulcers, esophagogastroduodenoscopy, endoscope, esophagus, duodenum, mucosal, stomach, biopsies, colonoscopy

The situation involves a 17-year-old patient with severe gastrointestinal symptoms, suspected Crohn's disease, and a history of complex medical issues such as significant weight loss and past surgeries. The procedure described is both diagnostic and part of a treatment plan that might include biologic therapy with Remicade and nutritional support. The stakes are high as the patient's condition is complex and requires careful management to prevent complications, manage symptoms, and improve the patient's quality of life.


Medical Specialty: Surgery
Sample Name: AV Fistula - 1

PREOPERATIVE DIAGNOSIS,End-stage renal disease.,POSTOPERATIVE DIAGNOSIS,End-stage renal disease.,PROCEDURE,Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.,ANESTHESIA,General.,DESCRIPTION OF PROCEDURE,The patient was taken to the operating room where after induction of general anesthetic, the patient's arm was prepped and draped in a sterile fashion.  The IV catheter was inserted into the vein on the lower surface of the left forearm.  Venogram was performed, which demonstrated adequate appearance of the cephalic vein above the elbow.,Through a transverse incision, the cephalic vein and brachial artery were both exposed at the antecubital fossa.  The cephalic vein was divided, and the proximal end was anastomosed to the artery in an end-to-side fashion with a running 6-0 Prolene suture.,The clamps were removed establishing flow through the fistula.  Hemostasis was obtained.  The wound was closed in layers with PDS sutures.  Sterile dressing was applied.  The patient was taken to recovery room in stable condition.
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DESCRIPTION: Venogram of the left arm and creation of left brachiocephalic arteriovenous fistula.

surgery, end-stage renal disease, prolene suture, venogram, antecubital fossa, arteriovenous, arteriovenous fistula, brachiocephalic arteriovenous fistula, cephalic vein, fistula, prepped and draped, brachiocephalic, cephalic, vein

The creation of an arteriovenous (AV) fistula is a common surgical procedure for patients with end-stage renal disease who require hemodialysis. While it is a routine procedure, it is essential for the patient's prolonged health management as it provides the necessary vascular access for dialysis. The stakes are moderate due to the dependency of the patient's treatment on the successful creation of the fistula. Any complications could negatively impact the patient's ability to receive dialysis effectively, which is critical for their survival. However, general anesthesia and surgical risks raise the stakes, making it a moderate-risk procedure rather than a low-stakes scenario.


Medical Specialty: Nephrology
Sample Name: Nephrology Office Visit - 2

HISTORY OF PRESENT ILLNESS:,  This is a 79-year-old white male who presents for a nephrology followup for his chronic kidney disease secondary to nephrosclerosis and nonfunctioning right kidney.  His most recent BUN and creatinine on 04/04/06 are 40/2.0, which is stable.  He denies any chest pain or tightness in his chest.  He denies any shortness of breath, nausea, or vomiting.  He denies any change to his appetite.  He denies any fevers, chills, dysuria, or hematuria.  He does report his blood pressure being checked at the senior center and reporting that it is improved.  The patient has stage III chronic kidney disease. ,PAST MEDICAL HISTORY:,
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DESCRIPTION: Nephrology office visit for followup of CKD.

The patient is a 79-year-old male with stage III chronic kidney disease (CKD) due to nephrosclerosis and a nonfunctioning kidney. His lab results (BUN and creatinine) are stable, and he reports improved blood pressure. There are no acute symptoms such as chest pain or shortness of breath. Given the routine nature of the follow-up visit, stable lab indicators, and absence of acute symptoms, the situation does not appear to be high-stakes at the moment. However, managing CKD is still important as it can progress if not monitored effectively.


Medical Specialty: Orthopedic
Sample Name: Subperiosteal Abscess Debridement

PREOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,POSTOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,OPERATION:,  Repeat irrigation and debridement of above.,ANESTHESIA: , General.,BLOOD LOSS:,  Minimal.,FLUID: , Per anesthesia.,DRAINS: , Hemovac times two.,COMPLICATIONS: , None apparent.,SPECIMENS:,  To microbiology.,INDICATIONS: , She is a 10-year-old girl who has history of burns and has developed a subperiosteal abscess at her right distal femur.  I am bringing her back to the operating room for another exploration of this area and washout.  This will be the third procedure for this.  At the last time, there was gross purulence that was encountered.  Since that time, the patient has defervesced.  Her white count is slowly coming down.  Her C-reactive protein is slowly coming down.,PROCEDURE IN DETAIL:,  After informed consent was obtained, operative site marked, and after preoperative antibiotics were given, the patient was brought back to the operating room and placed supine on the operating table, where Anesthesia induced general anesthesia.  The patient's right lower extremity was prepped and draped in normal sterile fashion.  Surgical timeout occurred verifying the patient's identification, surgical site, surgical procedure, and administration of antibiotics.  The patient's previous incision sites had the sutures removed.  We bluntly dissected down through to the IT band.  These deep stitches were then removed.  We exposed the area of the subperiosteal abscess.  The tissue looked much better than at the last surgery.  We irrigated this area with three liters of saline containing bacitracin.  Next, we made our small medial window to assist with washout of the joint itself.  We put another three liters of saline containing bacitracin through the knee joint.  Lastly, we did another three liters into the area of the distal femur with three liters of plain saline.  We then placed two Hemovac drains, one in the metaphysis and one superficially.  We closed the deep fascia with #1 PDS.  Subcutaneous layers with 2-0 Monocryl and closed the skin with 2-0 nylon.  We placed a sterile dressing.  We then turned the case over to Dr. Petty for dressing change and skin graft.,PLAN:  ,Our plan will be to pull the drains in 48 hours.  We will then continue to watch the patient's fever curve and follow her white count to see how she is responding to the operative and medical therapies.,
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DESCRIPTION: Repeat irrigation and debridement of Right distal femoral subperiosteal abscess.

orthopedic, repeat irrigation and debridement, repeat irrigation, distal femur, distal femoral, femoral subperiosteal, subperiosteal abscess, hemovac, femur, debridement, irrigation, saline, anesthesia, distal, subperiosteal, abscess,

The situation involves a surgical procedure on a 10-year-old girl with a history of burns and a subperiosteal abscess at the right distal femur. This is the third procedure to address the issue, with the previous surgeries encountering gross purulence. Although the procedure described seems to have minimal complications and blood loss, it is inherently high-stakes due to the patient's young age, the history of multiple surgeries indicating persistent health issues, the involvement of general anesthesia, and the necessity to prevent further infection or complications. The stakes are heightened by the need to carefully monitor the patient's response postoperatively in terms of fever and inflammatory markers.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Colpocleisis

PREOPERATIVE DIAGNOSES: , Vault prolapse and rectocele.,POSTOPERATIVE DIAGNOSES:,  Vault prolapse and rectocele.,OPERATION: , Colpocleisis and rectocele repair.,ANESTHESIA:  ,Spinal.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT: , This is an 85-year-old female who presented to us with a vaginal mass.  On physical exam, the patient was found to have grade 3 rectocele and poor apical support, and history of hysterectomy.  The patient had good anterior support at the bladder.  Options were discussed such as watchful waiting, pessary, repair with and without mesh, and closing of the vagina (colpocleisis) were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, morbidity, and mortality of the procedure were discussed., ,Risk of infection and abscess formation were discussed.  The patient understood all the risks and benefits and wanted to proceed with the procedure.  Risk of retention and incontinence were discussed.  Consent was obtained through the family members.,DETAILS OF THE OR:,  The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient had a Foley catheter placed.  The posterior side of the rectocele was visualized with grade 3 rectocele and poor apical support.  A 1% lidocaine with epinephrine was applied for posterior hydrodissection, which was very difficult to do due to the significant scarring of the posterior part.  Attempts were made to lift the vaginal mucosa off of the rectum, which was very, very difficult to do at this point due to the patient's overall poor medical condition in terms of poor mobility and significant scarring.  Discussion was done with the family in the waiting area regarding simply closing the vagina and doing a colpocleisis since the patient is actually inactive.  Family agreed that she is not active and they rather not have any major invasive procedure especially in light of scarring and go ahead and perform the colpocleisis.  Oral consent was obtained from the family and her surgery was preceded.  The vaginal mucosa was denuded off using electrocautery and Metzenbaum scissors.  Using 0 Vicryl, 2 transverse longitudinal stitches were placed to bring the anterior and the posterior part of the vagina together and was started at the apex and was brought all the way out to the introitus.  The vaginal mucosa was pretty much completely closed off all the way up to the introitus.  Indigo carmine was given.  Cystoscopy revealed there was a good efflux of urine from both of the ureteral openings.  There was no injury to the bladder or kinking of the ureteral openings.  The bladder was normal.  Rectal exam was normal at the end of the colpocleisis repair.  There was good hemostasis., ,At the end of the procedure, Foley was removed and the patient was brought to recovery in a stable condition.
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DESCRIPTION: Colpocleisis and rectocele repair.

Colpocleisis and rectocele repair.

obstetrics / gynecology, vault prolapse, rectocele repair, rectocele, vaginal mass, metzenbaum scissors, ureteral openings, vaginal mucosa, colpocleisis, vaginal, infection,

The situation involves a surgical procedure for an 85-year-old female patient with multiple health considerations, including vault prolapse and rectocele, and a history of hysterectomy. The operation itself carries significant risks such as anesthesia complications, bleeding, infection, and mortality, particularly given the patient's advanced age and poor medical condition. Furthermore, informed consent was obtained from the family, highlighting the serious nature of the decision-making process. Despite a successful procedure with minimal complications, the stakes remain high due to the potential for postoperative complications and the initial complexity of the patient's condition.


Medical Specialty: Radiology
Sample Name: Ultrasound - Transvaginal

EXAM: , Transvaginal ultrasound.,HISTORY: , Pelvic pain.,FINDINGS: , The right ovary measures 1.6 x 3.4 x 2.0 cm.  There are several simple-appearing probable follicular cysts. There is no abnormal flow to suggest torsion on the right.  Left ovary is enlarged, demonstrating a 6.0 x 3.5 x 3.7 cm complex cystic mass of uncertain etiology.  This could represent a large hemorrhagic cyst versus abscess.  There is no evidence for left ovarian torsion.  There is a small amount of fluid in the cul-de-sac likely physiologic.,The uterus measures 7.7 x 5.0 cm.  The endometrial echo is normal at 6 mm.,IMPRESSION:,1.  No evidence for torsion.,2.  Large, complex cystic left ovarian mass as described.  This could represent a large hemorrhagic cyst; however, an abscess/neoplasm cannot be excluded.  Recommend either short interval followup versus laparoscopic evaluation given the large size and complex nature.
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DESCRIPTION: Transvaginal ultrasound to evaluate pelvic pain.

radiology, ultrasound, pelvic pain, transvaginal, cul-de-sac, cystic mass, echo, endometrial, flow, follicular cysts, hemorrhagic cyst, laparoscopic, neoplasm, ovarian, ovary, uterus, transvaginal ultrasound, complex cystic, torsion,

The situation involves a patient undergoing a transvaginal ultrasound due to pelvic pain and the finding of a large complex cystic ovarian mass. While no immediate emergency such as torsion is present, the differential diagnosis includes potential serious conditions such as a hemorrhagic cyst, abscess, or neoplasm. These findings necessitate further evaluation or intervention, making it a situation of significant concern due to the potential for serious underlying conditions requiring prompt diagnosis and treatment.


Medical Specialty: Consult - History and Phy.
Sample Name: Neurologic Examination

NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented.  There is no evidence of cognitive or language dysfunction.  Cranial nerves:  Visual fields are full.  Funduscopic examination is normal.  Extraocular movements full.  Pupils equal, round,  react to light.  There is no evidence of nystagmus noted.  Fifth nerve function is normal.  There is no facial asymmetry noted.  Lower cranial nerves are normal.  ,Manual motor testing reveals good tone and bulk throughout.  There is no evidence of pronator drift or decreased fine finger movements.  Muscle strength is 5/5 throughout.  Deep tendon reflexes are 2+ throughout with downgoing toes.  Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk.  Finger-to-nose and heel-to-shin moves are normal.  Romberg sign negative.  I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.
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DESCRIPTION: Neurologic examination sample.

Neurologic examination sample.

consult - history and phy., station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE

The neurological examination described is routine and indicates that the patient is functioning normally without any significant abnormalities or urgent issues. The findings suggest that the patient is neurologically stable, and a noncontrast CT scan of the head reveals no acute conditions like infarction or hemorrhage. Given that the patient is stable and there is no immediate threat to their health or well-being, the situation doesn't have high potential consequences typically associated with high-stakes situations.


Medical Specialty: Consult - History and Phy.
Sample Name: Normal ROS Template - 1

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

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

The scenario revolves around a Review of Systems (ROS) in a medical context. This is a standard part of a medical history and physical examination used to identify symptoms and conditions. The description indicates a normal review with no alarming symptoms reported. Although the accuracy of such information is crucial for patient diagnosis, this particular situation involves a standard entry template showing no symptoms of concern. Therefore, it is considered routine and low-stakes.


Medical Specialty: Chiropractic
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 described in the report involves a patient with chronic pain and physical limitations due to industrial accidents. While these injuries and their impact on the patient's life are significant, the 'high-stakes' level is considered moderate in a broader context. The report lays out ongoing management strategies, such as medication and potential treatments like steroid injections, but doesn't indicate immediate life-or-death decisions. The stakes are primarily related to long-term quality of life and work capability rather than an acute medical crisis.


Medical Specialty: Surgery
Sample Name: Arthroscopy, Meniscoplasty, & Chondroplasty

PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear, left knee.,POSTOPERATIVE DIAGNOSIS: , Chondromalacia of medial femoral condyle.,PROCEDURE PERFORMED:,1.  Arthroscopy of the left knee.,2.  Left arthroscopic medial meniscoplasty of medial femoral condyle.,3.  Chondroplasty of the left knee as well.,ESTIMATED BLOOD LOSS: , 80 cc.,TOTAL TOURNIQUET TIME: , 19 minutes.,DISPOSITION: , The patient was taken to PACU in stable condition.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 41-year-old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior MCL sprain.  He has had a positive symptomology of locking and pain since then.  He had no frank instability to it, however.,GROSS OPERATIVE FINDINGS: , We did find a tear to the medial meniscus as well as a large area of chondromalacia to the medial femoral condyle.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room.  The left lower extremity was prepped and draped in the usual sterile fashion.  Tourniquet was applied to the left thigh with adequate Webril padding, not inflated at this time.  After the left lower extremity had been prepped and draped in the usual sterile fashion, we applied an Esmarch tourniquet, exsanguinating the blood and inflated the tourniquet to 325 mmHg for a total of 19 minutes.  We established the lateral port of the knee with #11 blade scalpel.  We put in the arthroscopic trocar, instilled with water and inserted the camera.,On inspection of the patellofemoral joint, it was found to be quite smooth.  Pictures were taken there.  There was no evidence of chondromalacia, cracking, or fissuring of the articular cartilage.  The patella was well centered over the trochlear notch.  We then directed the arthroscope to the medial compartment of the knee.  It was felt that there was a tear to the medial meniscus.  We also saw large area of chondromalacia with grade-IV changes to bone over the medial femoral condyle.  This area was debrided with forceps and the arthroscopic shaver.  The cartilage was also smoothened over the medial femoral condyle.  This was curetted after the medial meniscus had been trimmed.  We looked into the notch.  We saw the ACL appeared stable, saw attachments to tibial as well as the femoral insertion with some evidence of laxity, wear and tear.  Attention then was taken to the lateral compartment with some evidence of tear to the lateral meniscus and the arterial surface of both the tibia as well as the femur were pristine in the lateral compartment.  All instruments were removed.  All loose cartilaginous pieces were suctioned from the knee and water was suctioned at the end.  We removed all instruments.  Marcaine was injected into the portal sites.  We placed a sterile dressing and stockinet on the left lower extremity.  He was transferred to the gurney and taken to PACU in stable condition.
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DESCRIPTION: Arthroscopy of the left knee, left arthroscopic medial meniscoplasty of medial femoral condyle, and chondroplasty of the left knee as well.  Chondromalacia of medial femoral condyle.   Medial meniscal tear, left knee.

surgery, medial meniscoplasty, arthroscopic, chondroplasty, arthroscopy, medial femoral condyle, medial meniscus, knee, meniscal, cartilage, meniscoplasty, meniscus, chondromalacia, condyle, femoral

The case described is a standard orthopedic surgical procedure involving arthroscopy, meniscoplasty, and chondroplasty for treating a medial meniscal tear and chondromalacia. While surgery in general carries a degree of risk, this does not involve life-or-death stakes. The procedure was completed with estimated small blood loss, short tourniquet time, and the patient was stable post-operation. Thus, it suggests lower high-stakes than major surgical operations or emergency situations.


Medical Specialty: Psychiatry / Psychology
Sample Name: Neuropsychological Evaluation - 5

PROBLEMS AND ISSUES:,1.  Headaches, nausea, and dizziness, consistent with a diagnosis of vestibular migraine, recommend amitriptyline for prophylactic treatment and Motrin for abortive treatment.,2.  Some degree of peripheral neuropathy, consistent with diabetic neuropathy, encouraged her to watch her diet and exercise daily.,HISTORY OF PRESENT ILLNESS: , The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.  I obtained and documented a full history and physical examination.  I reviewed the new patient questionnaire, which she completed prior to her arrival today.  I also reviewed the results of tests, which she had brought with her.,Briefly, she is a 60-year-old woman initially from Ukraine, who had headaches since age 25.  She recalls that in 1996 when her husband died her headaches became more frequent.  They were pulsating.  She was given papaverine, which was successful in reducing the severity of her symptoms.  After six months of taking papaverine, she no longer had any headaches.  In 2004, her headaches returned.  She also noted that she had "zig-zag lines" in her vision.  Sometimes she would not see things in her peripheral visions.  She had photophobia and dizziness, which was mostly lightheadedness.  On one occasion she almost had a syncope.  Again she has started taking Russian medications, which did help her.  The dizziness and headaches have become more frequent and now occur on average once to twice per week.  They last two hours since she takes papaverine, which stops the symptoms within 30 minutes.,PAST MEDICAL HISTORY: ,Her past medical history is significant for injury to her left shoulder, gastroesophageal reflux disorder, diabetes, anxiety, and osteoporosis.,MEDICATIONS:,  Her medications include hydrochlorothiazide, lisinopril, glipizide, metformin, vitamin D, Centrum multivitamin tablets, Actos, lorazepam as needed, Vytorin, and Celexa.,ALLERGIES: , She has no known drug allergies.,FAMILY HISTORY:  ,There is family history of migraine and diabetes in her siblings.,SOCIAL HISTORY: , She drinks alcohol occasionally.,REVIEW OF SYSTEMS: , Her review of systems was significant for headaches, pain in her left shoulder, sleeping problems and gastroesophageal reflex symptoms.  Remainder of her full 14-point review of system was unremarkable.,PHYSICAL EXAMINATION:,  On examination, the patient was pleasant.  She was able to speak English fairly well.  Her blood pressure was 130/84.  Heart rate was 80.  Respiratory rate was 16.  Her weight was 188 pounds.  Her pain score was 0/10.  Her general exam was completely unremarkable.  Her neurological examination showed subtle weakness in her left arm due to discomfort and pain.  She had reduced vibration sensation in her left ankle and to some degree in her right foot.  There was no ataxia.  She was able to walk normally.  Reflexes were 2+ throughout.,She had had a CT scan with constant, which per Dr. X's was unremarkable.  She reports that she had a brain MRI two years ago which was also unremarkable.,IMPRESSION AND PLAN:,  The patient is a delightful 60-year-old chemist from Ukraine who has had episodes of headaches with nausea, photophobia, and dizziness since her 20s.  She has had some immigration problems in recent months and has experienced increased frequency of her migraine symptoms.  Her diagnosis is consistent with vestibular migraine.  I do not see evidence of multiple sclerosis, Ménière's disease, or benign paroxysmal positional vertigo.,I talked to her in detail about the importance of following a migraine diet.  I gave her instructions including a list of foods times, which worsen migraine.  I reviewed this information for more than half the clinic visit.  I would like to start her on amitriptyline at a dose of 10 mg at time.  She will take Motrin at a dose of 800 mg as needed for her severe headaches.,She will make a diary of her migraine symptoms so that we can find any triggering food items, which worsen her symptoms.  I encouraged her to walk daily in order to improve her fitness, which helps to reduce migraine symptoms.
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DESCRIPTION: The patient comes in for a neurology consultation regarding her difficult headaches, tunnel vision, and dizziness.

psychiatry / psychology, nausea, dizziness, migraine, peripheral neuropathy, diabetic neuropathy, neuropathy, positional vertigo, photophobia and dizziness, neurology consultation, tunnel vision, vestibular migraine, migraine symptoms, headaches, photophobia, ataxia,

The scenario involves a neuropsychological evaluation of a 60-year-old woman with a history of migraines, diabetic neuropathy, and other health issues. While it's a medical situation requiring attention, it is routine and structured with a clear treatment plan, including the use of medications and lifestyle adjustments. The stakes involve managing symptoms and improving quality of life rather than addressing an immediate life-threatening condition. Thus, while important, it is not extremely high-stakes compared to scenarios involving acute emergencies like heart attack or stroke.


Medical Specialty: Urology
Sample Name: Vasectomy - 3

PREOPERATIVE DIAGNOSIS:,  Desire for sterility.,POSTOPERATIVE DIAGNOSIS:,  Desire for sterility.,OPERATIVE PROCEDURES: , Vasectomy.,DESCRIPTION OF PROCEDURE: , The patient was brought to the suite, where after oral sedation, the scrotum was prepped and draped.  Then, 1% lidocaine was used for anesthesia.  The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.  A segment about 3 cm in length was dissected out.  It was clipped proximally and distally, and then the ends were cauterized after excising the segment.  Minimal bleeding was encountered and the scrotal skin was closed with 3-0 chromic.  The identical procedure was performed on the contralateral side.  He tolerated it well.  He was discharged from the surgical center in good condition with Tylenol with Codeine for pain.  He will use other forms of birth control until he has confirmed azoospermia with two consecutive semen analyses in the month ahead.  Call if there are questions or problems prior to that time.
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DESCRIPTION: Desire for sterility.  Vasectomy.  The vas was identified, skin was incised, and no scalpel instruments were used to dissect out the vas.

urology, vas, contralateral, desire for sterility, scalpel, sterility, vasectomy

The situation involves a vasectomy procedure, which is generally a low-risk and common surgical procedure for male sterilization. The report suggests the procedure was performed without complications and the patient was discharged in good condition. Although any surgical procedure carries some risk, the stakes in this situation are relatively low as it is a routine procedure with a high success rate and minimal complications.


Medical Specialty: Orthopedic
Sample Name: ORIF, Closed Reduction, Screw Fixation, Etc.

TITLE OF OPERATION:,1.  Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture including skin, muscle, and bone using a Synthes 3.5 mm locking plate on the lateral malleolus and two Synthes 4.5 mm cannulated screws medial malleolus.,2.  Closed reduction and screw fixation of right femoral neck fracture using one striker Asnis 8.0 mm cannulated screw and two 6.5 mm cannulated screws.,3.  Retrograde femoral nail using a striker T2 retrograde nail 10 x 340 with a 10 mm INCAP and two 5 mm distal locking screws and two 5 mm proximal locking screws.,4.  Irrigation and debridement of right knee.,5.  Irrigation and debridement of right elbow abrasions.,PREOP DIAGNOSIS:,1.  Right open ankle fracture.,2.  Right femoral shaft fracture.,3.  Right femoral neck fracture.,4.  Right open knee.,5.  Right elbow abrasions.,POSTOP DIAGNOSIS:,1.  Right open ankle fracture.,2.  Right femoral shaft fracture.,3.  Right femoral neck fracture.,4.  Right open knee.,5.  Right elbow abrasions.,INTRAVENOUS FLUIDS: , 650 packed red blood cells.,TOURNIQUET TIME: , 2 hours.,URINE OUTPUT:  ,1600 cubic centimeters.,ESTIMATED BLOOD LOSS: , 250 cubic centimeters.,COMPLICATIONS:,  None.,PLAN:,  non-weightbearing right lower extremity, clindamycin x 48 hours.,OPERATIVE NARRATIVE:,  The patient is a 53-year-old female who is a pedestrian struck, in a motor vehicle accident and sustained numerous injuries.  She sustained a right open ankle fracture, right femur fracture, right femoral neck fracture, right open knee, and right elbow abrasions.  Given the emergent nature of the right femoral neck fracture and her young age as well as the open fracture, it was decided to proceed with an urgent operative intervention.  The risks of surgery were discussed in detail and the consents were signed.  The operative site was marked.  The patient was taken to the operating room where she was given preoperative clindamycin.  The patient had then general anesthetic performed by anesthesia.,A well-padded side tourniquet was placed.  Attention was turned to the right ankle first.  The large medical laceration was extended and the tissues were debrided.  All dirty of the all injured bone, muscle, and tissues were debrided.  Wound was then copiously irrigated with 8 liters of normal saline.  At this point, the medial malleolus fracture was identified and was reduced.  This was then fixed in with two 4.5 mm cannulated Synthes screws.,Next, the attention was turned to lateral malleolus.  Incision was made over the distal fibula.  It was carried down sharply through the skin in the subcutaneous issues.  Care was taken to preserve the superficial peroneal nerve.  The fracture was identified, and there was noted to be very comminuted distal fibula fracture.  The fracture was reduced and confirmed with fluoroscopy.  A 7 hole Synthes 3.5 mm locking plate was placed.  This was placed in a bridging fashion with three screws above and three screws below the fracture.  Appropriate reduction was confirmed under fluoroscopy.  A cotton test was performed, and the ankle did not open up.  Therefore, it was decided not to proceed with syndesmotic screw.,Next, the patient was then placed in the fracture table and all extremities were well padded.  All prominences were padded.  The right leg was then prepped and draped in usual sterile fashion.  A 2-cm incision was made just distal to the greater trochanter.  This was carried down sharply through the skin to the fascia.  The femur was identified.  The guidewire for a striker Asnis 6.5 mm screw was placed in the appropriate position.  The triangle guide was then used to ensure appropriate triangular formation of the remainder of the screws.  A reduction of the fracture was performed prior to placing all the guide wires.  A single 8 mm Asnis screw was placed inferiorly followed by two 6.5 mm screws superiorly.,Next, the abrasions on the right elbow were copiously irrigated.  The necrotic and dead tissue was removed.  The abrasions did not appear to enter the joints.  They were wrapped with Xeroform 4 x 4 x 4 Kerlix and Ace wrap.,Next, the lacerations of the anterior knee were connected and were extended in the midline.  They were carried down sharply to the skin and the retinacular issues to the joint.  The intercondylar notch was identified.  A guide wire for the striker T2 retrograde nail was placed and localized with fluoroscopy.  The opening reamer was used following the bolted guide wire was then passed.  The femur was then sequentially reamed using the flexible reamers.  A T2 retrograde nail 10 x 340 was then passed.  Two 5 mm distal locking screws and two 5 mm proximal locking screws were then placed.,Prior to reaming and passing the retrograde nail, the knee was copiously irrigated with 8 liters of normal saline.  Any dead tissues in the knee were identified and were debrided using rongeurs and curettes.,The patient was placed in the AO splints for the right ankle.  The wounds were dressed with Xeroform 4 x 4 x 4s and IO band.  The care was then transferred for the patient to Halstead Service.,The plan will be non-weightbearing right lower extremity and antibiotics for 48 hours.,Dr. X was present and scrubbed for the entirety of the procedure.
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DESCRIPTION: Open reduction internal fixation (ORIF) with irrigation and debridement of open fracture.  Closed reduction and screw fixation of right femoral neck fracture.  Retrograde femoral nail using a striker T2 retrograde nail.  Irrigation and debridement of knee and elbow abrasions.

The situation is high-stakes as it involves a complex surgical procedure following a severe traumatic event (a pedestrian struck by a vehicle). The operations are urgent and involve multiple fractures, including open fractures, which require extensive surgical intervention, such as open reduction internal fixation, retrograde femoral nailing, and careful irrigation and debridement to prevent complications such as infection. The patient’s condition, the need for precise surgical actions, and the potential for life-altering outcomes (e.g., loss of limb function, risk of infection) highlight the high-stakes nature of this medical situation.


Medical Specialty: Urology
Sample Name: Meatoplasty Template

OPERATIVE NOTE:  ,The patient was placed in the supine position under general anesthesia, and prepped and draped in the usual manner.  The penis was inspected.  The meatus was inspected and an incision was made in the dorsal portion of the meatus up towards the tip of the penis connecting this with the ventral urethral groove.  This was incised longitudinally and closed transversely with 5-0 chromic catgut sutures.  The meatus was calibrated and accepted the calibrating instrument without difficulty, and there was no stenosis.  An incision was made transversely below the meatus in a circumferential way around the shaft of the penis, bringing up the skin of the penis from the corpora.  The glans was undermined with sharp dissection and hemostasis was obtained with a Bovie.  Using a skin hook, the meatus was elevated ventrally and the glans flaps were reapproximated using 5-0 chromic catgut, creating a new ventral portion of the glans using the flaps of skin.  There was good viability of the skin.  The incision around the base of the penis was performed, separating the foreskin that was going to be removed from the coronal skin.  This was removed and hemostasis was obtained with a Bovie.  0.25% Marcaine was infiltrated at the base of the penis for post-op pain relief, and the coronal and penile skin was reanastomosed using 4-0 chromic catgut.  At the conclusion of the procedure, Vaseline gauze was wrapped around the penis.  There was good hemostasis and the patient was sent to the recovery room in stable condition.
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DESCRIPTION: An example/template for meatoplasty.

An example/template for meatoplasty.

urology, penis, meatus, urethral groove, corpora, glans, meatoplasty, bovie, chromic, catgut, hemostasisNOTE,: 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 operation described is a meatoplasty, a surgical procedure performed on the urinary meatus, usually involving fine and delicate tissue repair. The procedure requires precise surgical skills and is performed under general anesthesia, indicating that it is invasive but routine for trained surgeons. Although surgery itself can involve risks, the description suggests that this is a common and straightforward procedure without complications, such as severe blood loss or unexpected findings, as the patient was sent to recovery in stable condition. Considering this context, while the procedure carries some risk as any surgery does, it does not appear to involve immediate life-threatening stakes.


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

Medical Specialty: Obstetrics / Gynecology
Sample Name: Physical Exam and Pap - 1

SUBJECTIVE:,  This 45-year-old gravida 3, para 2, SAB 1 white female presents for exam and Pap.  Last Pap was a year ago and normal.  LMP was 08/29/2004.  Her cycles are usually regular, although that one came about a week early.  Her husband has had a vasectomy.  Overall, she is feeling well.,Health history form was reviewed.  There has been no change in her personal history.  She notes that a brother who was treated 12 years ago for a brain tumor has had a recurrence and had surgery again.  Social history is unchanged.,HEALTH HABITS: , She states that for a while she was really exercising regularly and eating lots of fruits and vegetables.  Right now, she is not doing nearly as well.  She has perhaps two dairy servings daily, trying to cut down.  She is not exercising at all and fruit and vegetable intake varies.  She is a nonsmoker.  Last cholesterol was in 2003 and was normal.  She had a mammogram which was normal recently.  She is current on her tetanus update.,REVIEW OF SYSTEMS:,HEENT:  She feels as though she may have some allergies at night.  Most of her symptoms occur then, not during the day.  She will wake up with some congestion, sneezing, and then rhinorrhea.  Currently, she uses Tylenol Sinus.  Today, her symptoms are much better.  We did have rain this morning.,Respiratory and CV:  Negative.,GI:  She tends to have a little gas which is worse when she is eating more fruits and vegetables.  She had been somewhat constipated but that is better.,GU:  Negative.,Dermatologic:  She noticed an area of irritation on her right third finger on the ulnar side at the PIP joint.  It was very sensitive to water.  It seems to be slowly improving.,OBJECTIVE:,Vital Signs:  Her weight was 154 pounds, which is down 2 pounds.  Blood pressure 104/66.,General:  She is a well-developed, well-nourished, pleasant white female in no distress.,Neck:  Supple without adenopathy.  No thyromegaly or nodules palpable.,Lungs:  Clear to A&P.,Heart:  Regular rate and rhythm without murmurs.,Breasts:  Symmetrical without masses, nipple, or skin retraction, discharge, or axillary adenopathy.,Abdomen:  Soft without organomegaly, masses, or tenderness.,Pelvic:  Reveals no external lesions.  The cervix is parous.  Pap smear done.  Uterus is anteverted and normal in size, shape, and consistency, and nontender.  No adnexal enlargement.,Extremities:  Examination of her right third finger shows an area of eczematous dermatitis approximately 2 cm in length on the ulnar side.,ASSESSMENT:,1.  Normal GYN exam.,2.  Rhinitis, primarily in the mornings.  Vasomotor versus allergic.,3.  Eczematous dermatitis on right third finger.,PLAN:,1.  Discussed vasomotor rhinitis.  I suggested she try Ayr Nasal saline gel.  Another option would be a steroid spray and a sample of Nasonex is given to use two sprays in each nostril daily.,2.  Exam with Pap annually.,3.  Hydrocortisone cream to be applied to the area of eczematous dermatitis.,4.  Discussed nutrition and exercise.  I recommended at least five fruits and vegetables daily, no more than three dairy servings daily, and regular exercise at least three times a week.
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DESCRIPTION: A white female presents for exam and Pap.

The situation involves a routine physical exam and Pap smear for a 45-year-old woman who is reportedly in overall good health. The assessments indicate normal results apart from some manageable conditions like morning rhinitis and eczematous dermatitis on her finger, for which treatments have been suggested. There is no immediate risk to the patient's life, and the purpose of the visit appears to be mostly preventive. Thus, it is low-stakes medically.


Medical Specialty: Surgery
Sample Name: Low-Transverse C-Section - 1

PREOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,POSTOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,OPERATION:,  Primary cesarean section by low-transverse incision.,ANESTHESIA:,  Epidural.,ESTIMATED BLOOD LOSS: , 450 mL.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS:  ,Foley catheter.,INDICATIONS: , The patient is a 39-year-old, G4, para 0-0-3-0, with an EDC of 03/08/2009.  The patient began having prodromal symptoms 2 to 3 days prior to presentation.  She was seen on 03/09/2007 and a nonstress test was performed.  This revealed some spontaneous variable-appearing decelerations.  She was given IV hydration.  A biophysical profile was obtained, which provided a score of 0/8 with only a 1 cm fluid pocket found.  Therefore, she was admitted for further fetal monitoring and evaluation.  She had changed her cervix from closed 2 days prior to presentation to 1 cm dilated.  She was having somewhat irregular contractions, but with stronger contractions, continued to have decelerations to 50 to 60 beats per minute.  Due to these findings, a scalp electrode was placed as well as an IUPC for an amnioinfusion.  This relieved the decelerations somewhat.  However, over a period of time with strong contractions, she still had bradycardia 40 to 50 beats per minute and developed a late component on the return of the decelerations.  Due to this finding, it was evident that the fetal state would not support labor in order to accomplish a vaginal delivery.  These findings were reviewed with the patient and recommendation was made for cesarean section delivery.  The risks and benefits of this surgery were reviewed, and knowing these facts, the patient gave informed consent.,PROCEDURE: , The patient was taken to the operating room where her epidural anesthesia was reinforced.  She was prepped and draped in the usual fashion for the procedure.  After adequate epidural level was confirmed, the scalp was utilized to make a transverse incision in the patient's lower abdominal wall.  This incision was carried down to the level of the fascia, which was also transversely incised.  After adequate hemostasis, the fascia was bluntly and sharply separated up from the underlying rectus muscle.  The rectus muscle was separated in midline exposing the peritoneum.  The peritoneum was carefully grasped and elevated with hemostats.  It was entered in an up and down fashion with Metzenbaum scissors.  The bladder blade was placed in the lower pole of the incision to protect the bladder.,The uterus was palpated and inspected.  A thin lower uterine segment was noted.  The vertex presentation was confirmed.  The scalp was then utilized to make a transverse or Kerr incision in the lower uterine wall.  Clear fluid was noted upon entering into the amniotic space.  At 05:27, a term viable female infant was delivered up through the incision.  She had spontaneous respirations.  She was given bulb suctioning for clear fluid.  Her cord was clamped and cut and she was delivered off the field to Dr. X who was attending.  The baby girl was subsequently signed Apgars of 8 at one minute and 9 at five minutes.  Her birth weight was found to be 5 pounds and 5 ounces.,The placenta was manually extracted from the endometrial cavity.  A ring clamp and two Allis clamps were placed around the margin of the uterine incision for hemostasis.  The uterus was delivered up into the operative field.  The endometrial cavity was swiped clean with a moist laparotomy pad.  The uterine incision was then closed in a two-layered fashion with 0 Vicryl suture, the first layer interlocking and the second layer imbricating.  Two additional stitches of 3-0 Vicryl suture were utilized for hemostasis.  The uterine incision was noted to be hemostatic upon closure.  The uterus was rotated forward, normal tubes and ovaries were noted on both sides.  The uterus was then returned to its normal position of the abdominal cavity.  The sponge and instrument count was performed for the first time at this point and found to be correct.  The pelvis and anterior uterine space was then irrigated with saline solution.  It was suctioned dry.  A final check of the uterine incision confirmed hemostasis.  The rectus muscle was stabilized across the midline with two simple stitches of 0 Vicryl suture.  The subcutaneous tissue was then exposed, and the fascia closed with two running lengths of 0 Vicryl suture, beginning in lateral margins and overlapping the midline.  The subcutaneous tissue was then irrigated and inspected.  No active bleeding was noted.  It was closed with a running length of 3-0 plain catgut suture.  The skin was then approximated with surgical steel staples.  The incision was infiltrated with a 0.5% solution of Marcaine local anesthetic.  The incision was cleansed and sterilely dressed.,The patient was transferred to the recovery room in stable condition.  The estimated blood loss through the procedure was 450 mL.  The sponge and instrument counts were performed two more times during closure and found to be correct each time.
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DESCRIPTION: Primary cesarean section by low-transverse incision.  Term pregnancy, nonreassuring fetal heart tracing.

surgery, low-transverse incision, edc, para, amnioinfusion, nonreassuring fetal heart tracing, primary cesarean section, fetal heart tracing, low transverse, term pregnancy, fetal heart, heart tracing, rectus muscle, uterine incision, vicryl suture, incision, transverse, fetal, suture, uterine,

The situation involves a surgical procedure, specifically a primary cesarean section, due to nonreassuring fetal heart tracing in a term pregnancy. This indicates potential fetal distress, which can pose significant risks to both the mother and the fetus if not addressed in a timely manner. While the procedure itself is routine, the context of fetal distress elevates the stakes, as timely intervention is crucial for ensuring the well-being of both the mother and the infant. The high-stakes nature is reinforced by the need for prompt decision-making and surgical intervention to prevent possible adverse outcomes.


Medical Specialty: Nephrology
Sample Name: CT Scan of Abdomen & Pelvis with Contrast

EXAM: , CT scan of the abdomen and pelvis with contrast.,REASON FOR EXAM: , Abdominal pain.,COMPARISON EXAM: , None.,TECHNIQUE: , Multiple axial images of the abdomen and pelvis were obtained.  5-mm slices were acquired after injection of 125 cc of Omnipaque IV.  In addition, oral ReadiCAT was given.  Reformatted sagittal and coronal images were obtained.,DISCUSSION:,  There are numerous subcentimeter nodules seen within the lung bases.  The largest measures up to 6 mm.  No hiatal hernia is identified.  Consider chest CT for further evaluation of the pulmonary nodules.  The liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys are within normal limits.  No dilated loops of bowel.  There are punctate foci of air seen within the nondependent portions of the peritoneal cavity as well as the anterior subcutaneous fat.  In addition, there is soft tissue stranding seen of the lower pelvis.  In addition, the uterus is not identified.  Correlate with history of recent surgery.  There is no free fluid or lymphadenopathy seen within the abdomen or pelvis.  The bladder is within normal limits for technique.,No acute bony abnormalities appreciated.  No suspicious osteoblastic or osteolytic lesions.,IMPRESSION:,1.  Postoperative changes seen within the pelvis without appreciable evidence for free fluid.,2.  Numerous subcentimeter nodules seen within the lung bases.  Consider chest CT for further characterization.
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DESCRIPTION: CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan.

nephrology, ct scan, abdominal pain, multiple axial images, abdomen and pelvis, adrenal glands, chest ct, coronal, gallbladder, kidneys, liver, lymphadenopathy, nodules, osteoblastic, osteolytic, pancreas, sagittal, spleen, with contrast, free fluid, ct, abdomen, pelvis,

In this scenario, a CT scan was performed to evaluate abdominal pain, and several findings were noted. The report mentions subcentimeter nodules in the lung bases and suggests a follow-up chest CT. There is also a suggestion of recent surgery due to postoperative changes in the pelvis. While these findings require careful follow-up and possibly further diagnostics, there is no immediate life-threatening condition mentioned, such as internal bleeding or organ failure. The stakes are moderate due to the potential need for further investigation of lung nodules and postoperative changes but nothing suggests an immediate high-risk situation.


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

DISCHARGE DIAGNOSES:  ,1.  Suspected mastoiditis ruled out.,2.  Right acute otitis media.,3.  Severe ear pain resolving.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.  The child has had very severe ear pain and blood draining from the right ear.  The child had a temperature maximum of 101.4 in the ER.  The patient was admitted and started on IV Unasyn, which he tolerated well and required Morphine and Vicodin for pain control.  In the first 12 hours after admission, the patient's pain decreased and also swelling of his cervical area decreased.  The patient was evaluated by Dr. X from the ENT while in house.  After reviewing the CT scan, it was felt that the CT scan was not consistent with mastoiditis.  The child was continued on IV fluid and narcotics for pain as well as Unasyn until the time of discharge.  At the time of discharge his pain is markedly decreased about 2/10 and swelling in the area has improved.  The patient is also able to take p.o. well.,DISCHARGE PHYSICAL EXAMINATION:,GENERAL:  The patient is alert, in no respiratory distress.,VITAL SIGNS:  His temperature is 97.6, heart rate 83, blood pressure 105/57, respiratory rate 16 on room air.,HEENT:  Right ear shows no redness.  The area behind his ear is nontender.  There is a large posterior chains node that is nontender and the swelling in this area has decreased markedly.,NECK:  Supple.,CHEST:  Clear breath sounds.,CARDIAC:  Normal S1, S2 without murmur.,ABDOMEN:  Soft.  There is no hepatosplenomegaly or tenderness.,SKIN:  Warm and well perfused.,DISCHARGE WEIGHT: , 38.7 kg.,DISCHARGE CONDITION: , Good.,DISCHARGE DIET:,  Regular as tolerated.,DISCHARGE MEDICATIONS:  ,1.  Ciprodex Otic Solution in the right ear twice daily.,2.  Augmentin 500 mg three times daily x10 days.,FOLLOW UP:  ,1.  Dr. Y in one week (ENT).,2.  The primary care physician in 2 to 3 days.,TIME SPENT: , Approximate discharge time is 28 minutes.
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DESCRIPTION: Suspected mastoiditis ruled out, right acute otitis media, and severe ear pain resolving.  The patient is an 11-year-old male who was admitted from the ER after a CT scan suggested that the child had mastoiditis.

The situation involves the discharge summary of an 11-year-old patient initially suspected of having mastoiditis but was later ruled out. His condition involves acute otitis media and has been on medications like Unasyn, Morphine, and Vicodin for pain management. The condition is resolving, with discharge instructions and follow-ups clearly outlined. While it is important to follow proper discharge procedures and medication protocols, the immediate situation described doesn't appear to involve life-threatening conditions since the patient's pain and symptoms are markedly improved and discharge was based on medical clearance. Therefore, it is not a high-stakes situation.


Medical Specialty: General Medicine
Sample Name: Gen Med SOAP - 9

SUBJECTIVE:  ,This patient presents to the office today for a checkup.  He has several things to go over and discuss.  First he is sick.  He has been sick for a month intermittently, but over the last couple of weeks it is worse.  He is having a lot of yellow phlegm when he coughs.  It feels likes it is in his chest.  He has been taking Allegra-D intermittently, but he is almost out and he needs a refill.  The second problem, his foot continues to breakout.  It seems like it was getting a lot better and now it is bad again.  He was diagnosed with tinea pedis previously, but he is about out of the Nizoral cream.  I see that he is starting to breakout again now that the weather is warmer and I think that is probably not a coincidence.  He works in the flint and it is really hot where he works and it has been quite humid lately.  The third problem is that he has a wart or a spot that he thinks is a wart on the right middle finger.  He is interested in getting that frozen today.  Apparently, he tells me I froze a previous wart on him in the past and it went away.  Next, he is interested in getting some blood test done.  He specifically mentions the blood test for his prostate, which I informed him is called the PSA.  He is 50 years old now.  He will also be getting his cholesterol checked again because he has a history of high cholesterol.  He made a big difference in his cholesterol by quitting smoking, but unfortunately after taking his social history today he tells me that he is back to smoking.  He says it is difficult to quit.  He tells me he did quit chewing tobacco.  I told him to keep trying to quit smoking.  ,REVIEW OF SYSTEMS:,  General:  With this illness he has had no problems with fever.  HEENT:  Some runny nose, more runny nose than congestion.  Respiratory:  Denies shortness of breath.  Skin:  He has a peeling skin on the bottom of his feet, mostly the right foot that he is talking about today.  At times it is itchy.,OBJECTIVE: , His weight is 238.4 pounds, blood pressure 128/74, temperature 97.8, pulse 80, and respirations 16.  General exam:  The patient is nontoxic and in no acute distress.  Ears:  Tympanic membranes pearly gray bilaterally.  Mouth:  No erythema, ulcers, vesicles, or exudate noted.  Neck is supple.  No lymphadenopathy.  Lungs:  Clear to auscultation.  No rales, rhonchi, or wheezing.  Cardiac:  Regular rate and rhythm without murmur.  Extremities:  No edema, cyanosis, or clubbing.  Skin exam:  I checked out the bottom of his right foot.  He has peeling skin visible consistent with tinea pedis.  On the anterior aspect of the right third finger there is a small little raised up area that I believe represents a wart.  The size of this wart is approximately 3 mm in diameter.,ASSESSMENT:  ,1.  Upper respiratory tract infection, persistent.,2.  Tinea pedis.,3.  Wart on the finger.,4.  Hyperlipidemia.,5.  Tobacco abuse.,PLAN: , The patient is getting a refill on Allegra-D.  I am giving him a refill on the Nizoral 2% cream that he should use to the foot area twice a day.  I gave him instructions on how to keep the foot clean and dry because I think the reason we are dealing with this persistent problem is the fact that his feet are hot and sweaty a lot because of his work.  His wart has been present for some time now and he would like to get it frozen.  I offered him the liquid nitrogen treatment and he did agree to it.  I used liquid nitrogen after a verbal consent was obtained from the patient to freeze the wart.  He tolerated the procedure very well.  I froze it once and I allowed for a 3 mm freeze zone.  I gave him verbal wound care instructions after the procedure.  Lastly, when he is fasting I am going to send him to the lab with a slip, which I gave him today for a basic metabolic profile, CBC, fasting lipid profile, and a screening PSA test.  Lastly, for the upper respiratory tract infection, I am giving him amoxicillin 500 mg three times a day for 10 days.
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DESCRIPTION: Upper respiratory tract infection, persistent.  Tinea pedis.  Wart on the finger.  Hyperlipidemia.  Tobacco abuse.

general medicine, hyperlipidemia, allegra-d, upper respiratory tract infection, tinea pedis wart, tobacco abuse, blood test, runny nose, peeling skin, tinea pedis, abuse, infection, wart,

The patient's condition seems to be stable and manageable with standard medical interventions. The issues such as persistent upper respiratory tract infection, tinea pedis, and a wart on the finger are common and generally low-risk if properly managed. The hyperlipidemia and tobacco abuse are concerns but are being addressed through medication and encouragement to quit smoking. The patient is not in acute distress, and the vital signs are within normal limits. Therefore, while the patient has multiple health issues, none are life-threatening or urgent, making this situation relatively low-stakes.


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

PREOPERATIVE DIAGNOSIS: , Left inguinal hernia.,POSTOPERATIVE DIAGNOSIS:, Left indirect inguinal hernia.,PROCEDURE PERFORMED:, Repair of left inguinal hernia indirect.,ANESTHESIA: , Spinal with local.,COMPLICATIONS:,  None.,DISPOSITION,:  The patient tolerated the procedure well, was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,BRIEF HISTORY: , The patient is a 60-year-old female that presented to Dr. X's office with complaints of a bulge in the left groin.  The patient states that she noticed there this bulge and pain for approximately six days prior to arrival.  Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have a left indirect inguinal hernia.,PROCEDURE: , After informed consent was obtained, risks and benefits of the procedure were explained to the patient.  The patient was brought to the operating suite.  After spinal anesthesia and sedation given, the patient was prepped and draped in normal sterile fashion.  In the area of the left inguinal region just superior to the left inguinal ligament tract, the skin was anesthetized with 0.25% Marcaine.  Next, a skin incision was made with a #10 blade scalpel.  Using Bovie electrocautery, dissection was carried down to Scarpa's fascia until the external oblique was noted.  Along the side of the external oblique in the direction of the external ring, incision was made on both sides of the external oblique and then grasped with a hemostat.  Next, the hernia and hernia sac was circumferentially grasped and elevated along with the round ligament.  Attention was next made to ligating the hernia sac at its base for removal.  The hernia sac was opened prior grasping with hemostats.  It was a sliding indirect hernia.  The bowel contents were returned to abdomen using a #0 Vicryl stick tie pursestring suture at its base.  The hernia sac was ligated and then cut above with the Metzenbaum scissors returning it to the abdomen.  This was then sutured at the apex of the repair down to the conjoint tendon.  Next, attention was made to completely removing the round ligament hernia sac which was again ligated at its base with an #0 Vicryl suture and removed as specimen.  Attention was next made to reapproximate it at floor with a modified ______ repair.  Using a #2-0 Ethibond suture in simple interrupted fashion, the conjoint tendon was approximated to the ilioinguinal ligament capturing a little bit of the floor of the transversalis fascia.  Once this was done, the external oblique was closed over, reapproximated again with a #2-0 Ethibond suture catching each hump in between each repair from the prior floor repair.  This was done in simple interrupted fashion as well.  Next Scarpa's fascia was reapproximated with #3-0 Vicryl suture.  The skin was closed with running subcuticular #4-0 undyed Vicryl suture.  Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure very well and he was transferred to Recovery in stable condition.  The patient had an abnormal chest x-ray in preop and is going for a CT of the chest in Recovery.
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DESCRIPTION: Repair of left inguinal hernia indirect.  The patient states that she noticed there this bulge and pain for approximately six days prior to arrival.  Upon examination in the office, the patient was found to have a left inguinal hernia consistent with tear, which was scheduled as an outpatient surgery.

surgery, bulge, groin, ethibond suture, vicryl suture, external oblique, inguinal hernia, hernia, inguinal, ligament, oblique, vicryl, indirect, sac, suture, repair,

The situation involves a surgical procedure to repair an indirect inguinal hernia. While surgery can carry risks, in this case, it was an outpatient procedure with no complications, and the patient was stable post-operation. The patient's condition was not life-threatening, and the surgery treated a common issue. Considering the patient was considered stable afterwards and the surgery was successfully completed without complications, it is not extremely high-stakes. However, it is still a significant medical procedure, hence not extremely low-stakes either.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Discharge Summary - Respiratory Distress

ADMITTING DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,DISCHARGE DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,3.  Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of URI symptoms, then had an abrupt onset of cough and increased work of breathing.  Child was brought to Children's Hospital and received nebulized treatments in the ER and the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,He was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress.  He also received inhaled as well as systemic corticosteroids.  An x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading.  The patient was not started on any antibiotics and his fever resolved.  However, the CRP was relatively elevated at 6.7.  The CBC was normal with a white count of 9.6; however, the bands were 84%.  Given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and Zithromax.,He was taken off of continuous and he was not on room air all night.  In the morning, he still had some bilateral wheezing, but no tachypnea.,DISCHARGE PHYSICAL EXAMINATION: , ,GENERAL:  No acute distress, running around the room.,HEENT:  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly or masses.,CHEST:  Bilateral basilar wheezing.  No distress.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses.  Nontender to palpation.,GENITOURINARY:  Deferred.,EXTREMITIES:  Warm and well perfused.,DISCHARGE INSTRUCTIONS:,  As follows:,1.  Activity, regular.,2.  Diet is regular.,3.  Follow up with Dr. X in 2 days.,DISCHARGE MEDICATIONS:,1.  Xopenex MDI 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2.  QVAR 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3.  Amoxicillin 550 mg p.o. twice daily for 10 days.,4.  Zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,Total time for this discharge 37 minutes.
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DESCRIPTION: A 3-year-old abrupt onset of cough and increased work of breathing.

The situation describes a medical case involving a 3-year-old boy with respiratory distress, pneumonia, and reactive airways disease. While the child is being discharged, the case remains somewhat critical due to the nature of the conditions and the age of the child. Immediate stakes are not critically high because the discharge indicates stability, but ongoing care with follow-up and medication is crucial. Infant respiratory issues can escalate quickly if not managed properly, so the case is moderately high-stakes.


Medical Specialty: Neurology
Sample Name: EMG/Nerve Conduction Study

HISTORY:,  The patient is a 52-year-old female with a past medical history of diet-controlled diabetes, diffuse arthritis, plantar fasciitis, and muscle cramps who presents with a few-month history of numbness in both big toes and up the lateral aspect of both calves.  Symptoms worsened considerable about a month ago.  This normally occurs after being on her feet for any length of time.  She was started on amitriptyline and this has significantly improved her symptoms.  She is almost asymptomatic at present.  She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs.  She has had no associated weakness.,On brief examination, straight leg raising is normal.  The patient is obese.  There is mild decreased vibration and light touch in distal lower extremities.  Strength is full and symmetric.  Deep tendon reflexes at the knees are 2+ and symmetric and absent at the ankles.,NERVE CONDUCTION STUDIES: , Bilateral sural sensory responses are absent.  Bilateral superficial sensory responses are present, but mildly reduced.  The right radial sensory response is normal.  The right common peroneal and tibial motor responses are normal.  Bilateral H-reflexes are absent.,NEEDLE EMG:,  Needle EMG was performed on the right leg and lumbosacral paraspinal muscles and the left tibialis posterior using a concentric disposable needle.  It revealed increased insertional activity in the right tibialis posterior muscle with signs of mild chronic denervation in bilateral peroneus longus muscles and the right tibialis posterior muscle.  Lumbar paraspinals were attempted, but were too painful to get a good assessment.,IMPRESSION:  ,This electrical study is abnormal.  It reveals the following:,1.  A very mild, purely sensory length-dependent peripheral neuropathy.,2.  Mild bilateral L5 nerve root irritation.  There is no evidence of active radiculopathy.,Based on the patient's history and exam, her new symptoms are consistent with mild bilateral L5 radiculopathies.  Symptoms have almost completely resolved over the last month since starting Elavil.  I would recommend MRI of the lumbosacral spine if symptoms return.  With respect to the mild neuropathy, this is probably related to her mild glucose intolerance/early diabetes.  However, I would recommend a workup for other causes to include the following:  Fasting blood sugar, HbA1c, ESR, RPR, TSH, B12, serum protein electrophoresis and Lyme titer.
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DESCRIPTION: History of numbness in both big toes and up the lateral aspect of both calves.  She dose complain of longstanding low back pain, but no pain that radiates from her back into her legs.  She has had no associated weakness.

neurology, nerve conduction studies, needle emg, numbness, tibialis posterior muscle, sensory responses, muscle, tibialis, toes

The case presented involves a 52-year-old female with symptoms likely related to mild sensory peripheral neuropathy and mild bilateral L5 radiculopathies. These symptoms have improved significantly with treatment, and the patient's condition is not currently characterized by severe or life-threatening issues. The recommendation is to conduct an MRI if symptoms reoccur, indicating that the situation would be monitored, but it is not immediately critical. The medical team also plans further diagnostic tests to determine the underlying cause of the neuropathy. Overall, the potential for deterioration exists, but the situation as described is currently stable and manageable.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 14

HISTORY OF PRESENT ILLNESS:,  A 49-year-old female with history of atopic dermatitis comes to the clinic with complaint of left otalgia and headache.  Symptoms started approximately three weeks ago and she was having difficulty hearing, although that has greatly improved.  She is having some left-sided sinus pressure and actually went to the dentist because her teeth were hurting; however, the teeth were okay.  She continues to have some left-sided jaw pain.  Denies any headache, fever, cough, or sore throat.  She had used Cutivate cream in the past for the atopic dermatitis with good results and is needing a refill of that.  She has also had problems with sinusitis in the past and chronic left-sided headache.,FAMILY HISTORY:,  Reviewed and unchanged.,ALLERGIES: , To cephalexin.,CURRENT MEDICATIONS:,  Ibuprofen.,SOCIAL HISTORY:,  She is a nonsmoker.,REVIEW OF SYSTEMS:,  As above.  No nausea, vomiting, or diarrhea.,PHYSICAL EXAMINATION:,General:  A well-developed and well-nourished female, conscious, alert, and in no acute distress.,Vital Signs:  Weight:  121 pounds.  Temperature:  97.9 degrees.,Skin:  Reveals scattered erythematous plaques with some mild lichenification on the nuchal region and behind the knees.,Eyes:  PERRLA.  Conjunctivae are clear.,Ears:  Left TM with some effusion.  Right TM is clear.  Canals are clear.  External auricles are nontender to manipulation.,Nose:  Nasal mucosa is pink and moist without discharge.,Throat:  Nonerythematous.  No tonsillar hypertrophy or exudate.,Neck:  Supple without adenopathy or thyromegaly.,Lungs:  Clear.  Respirations are regular and unlabored.,Heart:  Regular rate and rhythm at rate of 100 beats per minute.,ASSESSMENT:,1.  Serous otitis.,2.  Atopic dermatitis.,PLAN:,1.  Nasacort AQ two sprays each nostril daily.,2.  Duraphen II one b.i.d.,3.  Refills Cutivate cream 0.05% to apply to affected areas b.i.d.  Recheck p.r.n.
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DESCRIPTION: Complaint of left otalgia (serous otitis) and headache.  History of atopic dermatitis.

The situation presented here is a non-emergency medical consultation for relatively common and non-life-threatening conditions: serous otitis and atopic dermatitis. The patient is conscious, alert, in no acute distress, and her symptoms, while uncomfortable, are not indicative of an urgent or life-threatening issue. The plan includes routine treatments and follow-ups, and there are no signs of severe complications or risks involved. Consequently, this scenario would be considered low-stakes in a medical context.