Medical Specialty: Surgery
Sample Name: Excision - Hydradenitis

PREOPERATIVE DIAGNOSIS: , Bilateral hydradenitis, chronic.,POSTOPERATIVE DIAGNOSIS: , Bilateral hydradenitis, chronic.,NAME OF OPERATION: , Excision of bilateral chronic hydradenitis.,ANESTHESIA:,  Local.,FINDINGS: , This patient had previously had excision of hydradenitis.  However, she had residual disease in both axilla with chronic redraining of the cyst from hydradenitis.  This now is controlled and it was found to be suitable for excision.  There was an area in each axilla which needed to be excised.,PROCEDURE: , Under local infiltration and after routine prepping and draping, an elliptical incision was first made on the left side to encompass the area of chronic hydradenitis.  This wound was then irrigated with saline.  The deeper layers were closed using interrupted 3-0 Vicryl.  The skin was closed using interrupted 5-0 nylon.,Attention was then directed to the right side where a similar procedure was carried out encompassing the involved area with the closure being identical to the opposite side.  This appeared to encompass all of the active area of hydradenitis.,The needle counts were all correct.  No intraoperative complications were encountered.  Dressings were applied, and the patient was returned to the recovery room in satisfactory condition.
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DESCRIPTION: Excision of bilateral chronic hydradenitis.

surgery, hydradenitis, elliptical incision, bilateral hydradenitis, chronic hydradenitis, axilla, excision, chronic,

This situation describes a medical procedure involving the excision of bilateral chronic hydradenitis. It involves surgical intervention, which inherently carries some risk, but the procedure seems to be routine and uncomplicated as described, with local anesthesia being used. The postoperative condition was satisfactory, and no complications were encountered during the surgery. Therefore, while there is an element of risk due to it being a surgical procedure, it is managed and controlled, making it moderate in terms of stakes.


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

Medical Specialty: Nephrology
Sample Name: CT Abdomen & Pelvis - 7

REASON FOR EXAM: , Lower quadrant pain with nausea, vomiting, and diarrhea.,TECHNIQUE: , Noncontrast axial CT images of the abdomen and pelvis are obtained.,FINDINGS: , Please note evaluation of the abdominal organs is secondary to the lack of intravenous contrast material.,Gallstones are seen within the gallbladder lumen.  No abnormal pericholecystic fluid is seen.,The liver is normal in size and attenuation.,The spleen is normal in size and attenuation.,A 2.2 x 1.8 cm low attenuation cystic lesion appears to be originating off of the tail of the pancreas.  No pancreatic ductal dilatation is seen.  There is no abnormal adjacent stranding.  No suspected pancreatitis is seen.,The kidneys show no stone formation or hydronephrosis.,The large and small bowels are normal in course and caliber.  There is no evidence for obstruction.  The appendix appears within normal limits.,In the pelvis, the urinary bladder is unremarkable.  There is a 4.2 cm cystic lesion of the right adnexal region.  No free fluid, free air, or lymphadenopathy is detected.,There is left basilar atelectasis.,IMPRESSION:,1.  A 2.2 cm low attenuation lesion is seen at the pancreatic tail.  This is felt to be originating from the pancreas, a cystic pancreatic neoplasm must be considered and close interval followup versus biopsy is advised.  Additionally, when the patient's creatinine improves, a contrast-enhanced study utilizing pancreatic protocol is needed.  Alternatively, an MRI may be obtained.,2.  Cholelithiasis.,3.  Left basilar atelectasis.,4.  A 4.2 cm cystic lesion of the right adnexa, correlation with pelvic ultrasound is advised.
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DESCRIPTION: Lower quadrant pain with nausea, vomiting, and diarrhea.  CT abdomen without contrast and CT pelvis without contrast.  Noncontrast axial CT images of the abdomen and pelvis are obtained.

nephrology, ct abdomen, ct pelvis, neoplasm, lesion, attenuation, hydronephrosis, stone formation, ct images, cystic lesion, abdomen, cystic, pancreatic, ct, pelvis, intravenous, noncontrast

The situation involves a diagnostic imaging report which identifies several findings that require follow-up. Specifically, the potential for a cystic pancreatic neoplasm is a significant finding that may necessitate further invasive testing like a biopsy due to the risk of cancer. Additionally, the right adnexal cyst also calls for correlation with an ultrasound to rule out serious conditions like ovarian torsion or neoplasm. While not immediately life-threatening at this moment based on the information provided, the findings could indicate potentially serious underlying conditions, making it moderately high-stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Elevated BNP - Consult

REASON FOR REFERRAL: , Elevated BNP.,HISTORY OF PRESENT ILLNESS:,  The patient is a 95-year-old Caucasian male visiting from out of state, admitted because of the fall and could not get up and has a cough with dark color sputum, now admitted with pneumonia and a fall and the patient's BNP level was high, for which Cardiology consult was requested.  The patient denies any chest pain or shortness of breath.  Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,  At this time, he is on:,1.  Atrovent and albuterol nebulizers.,2.  Azithromycin.,3.  Potassium chloride 10 mEq p.o. daily.,4.  Furosemide 20 mg IV daily.,5.  Enoxaparin 40 mg daily.,6.  Lisinopril 10 mg p.o. daily.,7.  Ceftriaxone.,PAST MEDICAL HISTORY: , History of hypertension.,PAST SURGICAL HISTORY:,  History of abdominal surgery.,SOCIAL HISTORY: , He does not smoke.  Drinks occasionally.,FAMILY HISTORY:  ,Noncontributory.,REVIEW OF SYSTEMS: , Denies chest pain, PND, or orthopnea.  He has cough.  No fever.  No abdominal pain.  No syncope, near-syncope, or palpitation.  All other systems were reviewed.,PHYSICAL EXAMINATION:,GENERAL:  The patient is comfortable, not in distress.,VITAL SIGNS:  His blood pressure is 118/50, pulse rate 76, respiratory rate 18, and temperature 98.1.,HEENT:  Atraumatic, normocephalic.  Eyes PERRLA.,NECK:  Supple.  No JVD.  No carotid bruit.,CHEST:  Clear.,HEART:  S1 and S2, regular.  No S3.  No S4.  No murmur.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.,EXTREMITIES:  No cyanosis, clubbing, or edema.  Pulse 2+.,CNS:  Alert, awake, and oriented x3.,DIAGNOSTIC DATA:,  EKG shows sinus tachycardia, nonspecific ST-T changes, nonspecific intraventricular conduction delay.  CT chest shows bilateral pleural effusion, compressive atelectasis, pneumonic infiltrate noted in the right lower lobe.  Loculated pleural effusion in the left upper lobe.  No PE.  Chest x-ray shows bilateral lower lobe patchy opacities concerning for atelectasis or pneumonia.,LABORATORY DATA: , Sodium 139, potassium 4.1, BUN 26, creatinine 0.9, BNP 331, troponin less than 0.05.  White cell count 7.1, hemoglobin 11.5, hematocrit 35.2, platelet 195,000.,ASSESSMENT:,1.  Pneumonia.,2.  Diastolic heart failure, not contributing to his present problem.,3.  Hypertension, controlled.,4.  History of falls.,PLAN: , We will continue IV low-dose diuretics, continue lisinopril, continue IV antibiotics.  No further cardiac workup at this time.
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DESCRIPTION: Elevated BNP.  Diastolic heart failure, not contributing to his present problem. Chest x-ray and CAT scan shows possible pneumonia.  The patient denies any prior history of coronary artery disease but has a history of hypertension.

The situation involves a 95-year-old patient with multiple health issues including pneumonia, diastolic heart failure, and elevated BNP levels. While the patient's diastolic heart failure is not contributing to the current problems, the combination of pneumonia and a history of falls in an elderly patient can lead to serious complications. It is not critical at the moment as per the physician's plan and assessment, but it still involves significant health risks due to the patient’s age and complexity of symptoms.


Medical Specialty: Gastroenterology
Sample Name: EGD Template - 3

without difficulty, into the upper GI tract.  The anatomy and mucosa of the esophagus, gastroesophageal junction, stomach, pylorus, and small bowel were all carefully inspected.  All structures were visually normal in appearance.  Biopsies of the distal duodenum, gastric antrum, and distal esophagus were taken and sent for pathological evaluation.  The endoscope and insufflated air were slowly removed from the upper GI tract.  A repeat look at the structures involved again showed no visible abnormalities, except for the biopsy sites.,The patient tolerated the procedure with excellent comfort and stable vital signs.  After a recovery period in the Endoscopy Suite, the patient is discharged to continue recovering in the family's care at home.  The family knows to follow up with me today if there are concerns about the patient's recovery,from the procedure.  They will follow up with me later this week for biopsy and CLO test results so that appropriate further diagnostic and therapeutic plans can be made.,
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DESCRIPTION: Common description of EGD.

Common description of EGD.

gastroenterology, gastric antrum, distal duodenum, distal esophagus, esophagus, duodenum, clo test, upper gi tract, upper gi, gi tract, egd, endoscope, gi, tract, structures, distal, biopsyNOTE,: 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 situation involves a routine medical procedure, specifically an esophagogastroduodenoscopy (EGD). This involves inspection, biopsies, and patient recovery, which are standard aspects of such procedures. Although there are inherent risks in any medical procedure, this scenario describes a successful process with no complications observed and the patient recovering well. The stakes are moderate as it involves a medical diagnosis but given the described context, they aren't extremely high or life-threatening.


Medical Specialty: Surgery
Sample Name: Endotracheal Intubation

PROCEDURE: , Endotracheal intubation.,INDICATION: , Respiratory failure.,BRIEF HISTORY: , The patient is a 52-year-old male with metastatic osteogenic sarcoma.  He was admitted two days ago with small bowel obstruction.  He has been on Coumadin for previous PE and currently on heparin drip.  He became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness.  A code blue was called.  On my arrival, the patient's vital signs are stable.  His blood pressure is systolically in 140s and heart rate 80s.  He however has 0 respiratory effort and is unresponsive to even painful stimuli.  The patient was given etomidate 20 mg.,DESCRIPTION OF PROCEDURE:  ,The patient positioned appropriate equipment at the bedside, given 20 mg of etomidate and 100 mg of succinylcholine.  Mac-4 blade was used.  A 7.5 ET tube placed to 24th teeth.  There is good color change on the capnographer with bilateral breath sounds.  Following intubation, the patient's blood pressure began to drop.  He was given 2 L of bolus.  I started him on dopamine drip at 10 mcg.  Dr. X was at the bedside, who is the primary caregiver, he assumed the care of the patient, will be transferred to the ICU.  Chest x-ray will be reviewed and Pulmonary will be consulted.
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DESCRIPTION: Endotracheal intubation.  Respiratory failure.  The patient is a 52-year-old male with metastatic osteogenic sarcoma.  He was admitted two days ago with small bowel obstruction.

surgery, metastatic osteogenic sarcoma, respiratory failure, bowel obstruction, blood pressure, endotracheal intubation, endotracheal, sarcoma

Endotracheal intubation is generally a high-stakes procedure because it is performed in situations of acute respiratory failure, often in life-threatening scenarios. This particular case involves a patient with metastatic cancer, who has stopped breathing and is minimally responsive, indicating critical intervention is needed. The mention of a code blue being called, which is an emergency situation requiring immediate attention, further highlights the urgency and high-stakes nature of the situation.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Low-Transverse C-Section - 9

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy of 39 weeks.,2.  Herpes simplex virus, positive by history.,3.  Hepatitis C, positive by history with low elevation of transaminases.,4.  Cephalopelvic disproportion.,5.  Asynclitism.,6.  Postpartum macrosomia.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy of 39 weeks.,2.  Herpes simplex virus, positive by history.,3.  Hepatitis C, positive by history with low elevation of transaminases.,4.  Cephalopelvic disproportion.,5.  Asynclitism.,6.  Postpartum macrosomia.,7.  Delivery of viable 9 lb female neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , About 600 cc.,Baby is doing well.  The patient's uterus is intact, bladder is intact.,HISTORY: , The patient is an approximately 25-year-old Caucasian female with gravida-4, para-1-0-2-1.  The patient's last menstrual period was in December of 2002 with a foreseeable due date on 09/16/03 confirmed by ultrasound.,The patient has a history of herpes simplex virus to which there is no active prodromal and no evidence of lesions.  The patient has a history of IVDA and contracted hepatitis C with slightly elevated liver transaminases.  The patient had been seen through our office for prenatal care.  The patient is on Valtrex.  The patient was found to be 3 cm about 40%, 0 to 9 engaged.  Bag of waters was ruptured.  She was on Pitocin.  She was contracting appropriately for a couple of hours or so with appropriate ________.  There was no cervical change noted.  Most probably because there was a sink vertex and that the head was too large to descend into the pelvis.  The patient was advised of this and we recommended cesarean section.  She agreed.  We discussed the surgery, foreseeable risks and complications, alternative treatment, the procedure itself, and recovery in layman's terms.  The patient's questions were answered.  I personally made sure that she understood every aspect of the consent and that she was comfortable with the understanding of what would transpire.,PROCEDURE:  ,The patient was then taken back to operative suite.  She was given anesthetic and sterilely prepped and draped.  Pfannenstiel incision was used.  A second knife was used to carry the incision down to the anterior rectus fascia.  Anterior rectus fascia was incised in the midline and carried bilaterally and the fascia was lifted off the underlying musculature.  The rectus muscles were separated.  The patient's peritoneum tented up towards the umbilicus and we entered the abdominal cavity.  There was a very thin lower uterine segment.  There seemed to be quite a large baby.  The patient had a small nick in the uterus.  Following the blunt end of the bladder knife going through the innermost layer of the myometrium and into the endometrial cavity, clear amniotic fluid was obtained.  A blunt low transverse cervical incision was made.  Following this, we placed a ________ on the very large fetal head.  The head was delivered following which we were able to deliver a large baby girl, 9 lb, good at tone and cry.  The patient then underwent removal of the placenta after the cord blood and ABG were taken.  The patient's uterus was examined.  There appeared to be no retained products.  The patient's uterine incision was reapproximated and sutured with #0 Vicryl in a running non-interlocking fashion, the second imbricating over the first.  The patient's uterus was hemostatic.  Bladder flap was reapproximated with #0 Vicryl.  The patient then underwent an irrigation at every level of closure and the patient was quite hemostatic.  We reapproximated the rectus musculature with care being taken not to incorporate any underlying structures.  The patient had three interrupted sutures of this.  The fascia was reapproximated with two stitches of #0 Vicryl going from each apex towards the midline.  The Scarpa's fascia was reapproximated with #0 gut.  There was noted no fascial defects and the skin was closed with #0 Vicryl.,Prior to closing the abdominal cavity, the uterus appeared to be intact and bladder appeared to have clear urine and appeared to be intact.  The patient was hemostatic.  All counts were correct and the patient tolerated the procedure well.  We will see her back in recovery.
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DESCRIPTION: Primary low transverse cervical cesarean section.   Intrauterine pregnancy of 39 weeks, Herpes simplex virus positive by history, hepatitis C positive by history with low elevation of transaminases, cephalopelvic disproportion, asynclitism, postpartum macrosomia, and delivery of viable 9 lb female neonate.

obstetrics / gynecology, intrauterine pregnancy, herpes simplex virus, hepatitis c, cephalopelvic disproportion, asynclitism, postpartum, macrosomia, low transverse cervical cesarean section, rectus fascia, cesarean section, intrauterine, transaminases, herpes, uterus, fascia,

The scenario describes a cesarean section (C-section) delivery involving a woman with several complicating factors, such as herpes simplex virus, hepatitis C, and cephalopelvic disproportion. Despite these complexities, the procedure was completed without any complications or adverse outcomes for the mother or the newborn. The lack of complications in a medically-controlled environment and the successful delivery suggest a lower immediate high-stakes level compared to emergency situations or cases with complications. However, given the medical complexities and the necessity of surgical intervention, it is still a moderately high-stakes situation.


Medical Specialty: Radiology
Sample Name: Nuclear Cardiac Stress Report

NUCLEAR CARDIOLOGY/CARDIAC STRESS REPORT,INDICATION FOR STUDY: , Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.,PROCEDURE: , The patient was studied in the resting state following intravenous delivery of adenosine triphosphate at 140 mcg/kg/min delivered over a total of 4 minutes.  At completion of the second minute of infusion, the patient received technetium Cardiolite per protocol.  During this interval, the blood pressure 150/86 dropped to near 136/80 and returned to near 166/84 at completion.  No diagnostic electrocardiographic abnormalities were elaborated during this study.,REGIONAL MYOCARDIAL PERFUSION WITH ADENOSINE PROVOCATION: , Scintigraphic study reveals at this time multiple fixed defects in perfusion suggesting indeed multivessel coronary artery disease, yet no active ischemia at this time.  A fixed defect is seen in the high anterolateral segment.  A further fixed perfusion defect is seen in the inferoapical wall extending from close to the septum.  There is no evidence for active ischemia in either distribution.  Lateral wall moving towards the apex of the left ventricle is further involved from midway through the ventricle moving upward and into the high anterolateral vicinity.  When viewed from the vertical projection, the high septal wall is preserved with significant loss of the mid anteroapical wall moving to the apex and in a wraparound fashion in the inferoapical wall.  A limited segment of apical myocardium is still viable.,No gated wall motion study was obtained.,CONCLUSIONS:  ,Cardiolite perfusion findings support multivessel coronary artery disease and likely previous multivessel infarct as has been elaborated above.  There is no indication for active ischemia at this time.
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DESCRIPTION: Nuclear cardiac stress report.  Recurrent angina pectoris in a patient with documented ischemic heart disease and underlying ischemic cardiomyopathy.

radiology, angina pectoris, ischemic cardiomyopathy, myocardial perfusion, adenosine provocation, cardiolite perfusion, nuclear cardiac stress report, coronary artery disease, active ischemia, ischemic, angina,

The report is about a patient with recurrent angina pectoris and documented ischemic heart disease, which are serious cardiovascular conditions. The procedure conducted, a nuclear cardiac stress test, is used to evaluate the heart's condition and risk of future cardiac events. The findings indicate multivessel coronary artery disease and likely previous infarcts, although no active ischemia was observed at the time of the test. This information is crucial for managing the patient's treatment plan and could significantly impact their long-term health outcomes. Cardiovascular conditions can have severe implications if not properly managed, making this situation high-stakes in terms of the patient's health management.


Medical Specialty: Consult - History and Phy.
Sample Name: Pneumoconiosis

HISTORY OF PRESENT ILLNESS: , This is a 91-year-old male with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.  The patient also has a positive history of smoking in the past.  At the present time, he is admitted for continued,management of respiratory depression with other medical complications.  The patient was treated for multiple problems at Jefferson Hospital prior to coming here including abdominal discomfort due to a ureteral stone with resultant hydronephrosis and hydroureter.  In addition, he also developed cardiac complications including atrial fibrillation.  The patient was evaluated by the cardiologist as well as the pulmonary service and Urology.  He had a cystoscopy performed and a left ureteral stone was removed as well as insertion of a left ureteral stent on 07/23/2008.  He subsequently underwent cardiac arrest and he was resuscitated at that time.  He was intubated and placed on mechanical ventilatory support.  Subsequent weaning was unsuccessful.  He then had a tracheostomy placed.,CURRENT MEDICATIONS:,1.  Albuterol.,2.  Pacerone.,3.  Theophylline,4.  Lovenox.,5.  Atrovent.,6.  Insulin.,7.  Lantus.,8.  Zestril.,9.  Magnesium oxide.,10.  Lopressor.,11.  Zegerid.,12.  Tylenol as needed.,ALLERGIES:,  PENICILLIN.,PAST MEDICAL HISTORY:,1.  History of coal miner's disease.,2.  History of COPD.,3.  History of atrial fibrillation.,4.  History of coronary artery disease.,5.  History of coronary artery stent placement.,6.  History of gastric obstruction.,7.  History of prostate cancer.,8.  History of chronic diarrhea.,9.  History of pernicious anemia.,10.  History of radiation proctitis.,11.  History of anxiety.,12.  History of ureteral stone.,13.  History of hydronephrosis.,SOCIAL HISTORY: , The patient had been previously a smoker.  No other could be obtained because of tracheostomy presently.,FAMILY HISTORY: , Noncontributory to the present condition and review of his previous charts.,SYSTEMS REVIEW: , The patient currently is agitated.  Rapidly moving his upper extremities.  No other history regarding his systems could be elicited from the patient.,PHYSICAL EXAM:,General:  The patient is currently agitated with some level of distress.  He has rapid respiratory rate.  He is responsive to verbal commands by looking at the eyes.,Vital Signs:  As per the monitors are stable.,Extremities:  Inspection of the upper extremities reveals extreme xerosis of the skin with multiple areas of ecchymosis and skin tears some of them to the level of stage II especially over the dorsum of the hands and forearm areas.  There is also edema of the forearm extending up to the mid upper arm area.  Palpation of the upper extremities reveals fibrosis more prominent on the right forearm area with the maximum edema in the elbow area on the ulnar aspect.  There is also scabbing of some of the possibly from earlier skin tears in the upper side forearm area.,IMPRESSION:,1.  Ulceration of bilateral upper extremities.,2.  Cellulitis of upper extremities.,3.  Lymphedema of upper extremities.,4.  Other noninfectious disorders of lymphatic channels.,5.  Ventilatory-dependent respiratory failure.
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DESCRIPTION: Patient with a previous history of working in the coalmine and significant exposure to silica with resultant pneumoconiosis and fibrosis of the lung.

The situation described involves a 91-year-old male patient with a complex and severe medical history, including pneumoconiosis, COPD, coronary artery disease, and recent complications such as cardiac arrest, ventilatory-dependent respiratory failure, and upper extremity lymphedema. The patient is experiencing respiratory depression and is dependent on mechanical ventilation, which indicates serious ongoing health issues. These factors contribute to the high-stakes nature of the situation, as the patient's life is at risk and requires careful management by the medical team.


Medical Specialty: Orthopedic
Sample Name: Knee Arthroplasty - Bilateral

PREOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,POSTOPERATIVE DIAGNOSIS: , Bilateral knee degenerative arthritis.,PROCEDURE PERFORMED: , Bilateral knee arthroplasty.,Please note this procedure was done by Dr. X for the left total knee and Dr. Y for the right total knee.  This operative note will discuss the right total knee arthroplasty.,ANESTHESIA:  ,General.,COMPLICATIONS: , None.,BLOOD LOSS: , Approximately 150 cc.,HISTORY:,  This is a 79-year-old female who has disabling bilateral knee degenerative arthritis.  She has been unresponsive to conservative measures.  All risks, complications, anticipated benefits, and postoperative course were discussed.  The patient has agreed to proceed with surgery as described below.,GROSS FINDINGS: , There was noted to be eburnation and wear along the patellofemoral joint and femoral tibial articulation medially and laterally with osteophyte formation and sclerosis.,SPECIFICATIONS: , The Zimmer NexGen total knee system was utilized.,PROCEDURE: , The patient was taken to the operating room #2 and placed in supine position on the operating room table.  She was administered spinal anesthetic by Dr. Z.,The tourniquet was placed about the proximal aspect of the right lower extremity.  The right lower extremity was then sterilely prepped and draped in the usual fashion.  An Esmarch bandage was used to exsanguinate the right lower extremity and the tourniquet was inflated to 325 mmHg.  Longitudinal incision was made over the anterior aspect of the right knee.  Subcutaneous tissue was carefully dissected.  A medial parapatellar retinacular incision was made.  The patella was then everted and the above noted gross findings were appreciated.  A drill hole was placed in the distal aspect of the femur and the distal femoral cutting guides were positioned in place.  The appropriate cuts were made at the distal femur as well as with use of the chamfer guide.  The trial femoral component was then positioned in place and noted to have good fit.  Attention was then directed to proximal tibia, the external tibial alignment guide was positioned in place and the proximal tibial cut was made demonstrating satisfactory cut.  The medial and lateral collateral ligaments remained intact throughout the procedure as well as the posterior cruciate ligaments.  The remnants of the anterior cruciate ligament and menisci were resected.  The tibial trial was positioned in place.  Intraoperative radiographs were taken, demonstrating satisfactory alignment of the tibial cut.  The tibial holes were then drilled.  The patella was then addressed with the Bovie used to remove the soft tissue around the perimeter of the patella.  The patellar cutting guide was positioned in place and the posterior aspect of the patella was resected to the appropriate thickness.  Three drill holes were made within the patella after it was determined that 35 mm patella would be most appropriate.  The knee was placed through range of motion with the trial components marked and then the appropriate components obtained.  The tibial tray was inserted with cement, backed it into place, excess methylmethacrylate was removed.  The femoral component was inserted with methylmethacrylate.  Any excessive methylmethacrylate and bony debris were removed from the joint.  Trial Poly was positioned in place and the knee was held in full extension while the methylmethacrylate became firm.  The methylmethacrylate was also used at the patella.  The prosthesis was positioned in place.  The patellar clamp held securely till the methylmethacrylate was firm.  After all three components were in place, the knee was then again in placed range of motion and there appeared to be some torsion to the proximal tibial component and concerned regarding the alignment.  This component was removed and revised to a stemmed component with better alignment and position.  The previous component removed, the methylmethacrylate was removed.  Further irrigation was performed and then a stemmed template was positioned in place with the intramedullary alignment guide positioned and the tibia drilled and broached.  The trial tibial stemmed component was positioned in place.  Knee was placed through range of motion and the tracking was better.  Actual component was then obtained, methyl methacrylate was placed within the tibia.  The stemmed tibial component was impacted into place with good fit.  The Poly was then positioned in place.  Knee held in full extension with compression longitudinally after methylmethacrylate was solidified.  The trial Poly was removed.  Wound was irrigated and the joint was inspected.  There was no debris.  Collateral ligaments and posterior cruciate ligaments remained intact.  Soft tissue balancing was done and a 17 mm Poly was then inserted with the knee and tibial and femoral components with good tracking as well as the patellar component.  The tourniquet was deflated.  Hemostasis was satisfactory.  A drain was placed into the depths of the wound.  The medial retinacular incision was closed with one Ethibond suture in interrupted fashion.  The knee was placed through range of motion and there was no undue tissue tension, good patellar tracking, no excessive soft tissue laxity or constrain.  The subcutaneous tissue was closed with #2-0 undyed Vicryl in interrupted fashion.  The skin was closed with surgical clips.  The exterior of the wound was cleansed as well padded dressing ABDs and ace wrap over the right lower extremity.  At the completion of the procedure, distal pulses were intact.  Toes were pink, warm, with good capillary refill.  Distal neurovascular status was intact.  Postoperative x-ray demonstrated satisfactory alignment of the prosthesis.  Prognosis is good in this 79-year-old female with a significant degenerative arthritis.
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DESCRIPTION: Bilateral knee degenerative arthritis.  Bilateral knee arthroplasty.  The Zimmer NexGen total knee system was utilized.

orthopedic, patellofemoral, eburnation, osteophyte, articulation, tibial, femoral, bilateral knee arthroplasty, knee degenerative arthritis, zimmer nexgen, lower extremity, arthroplasty, patella, methylmethacrylate,

The procedure described is a bilateral knee arthroplasty, which is a significant orthopedic surgery aimed at replacing the knee joint to alleviate pain and improve function in patients with severe arthritis. While it is a routine procedure for experienced orthopedic surgeons, it carries considerable risks and requires careful intraoperative management, as reflected in the detailed procedural steps and attention to alignment and component fitting. Although the surgery in this case concluded without complications and with a good prognosis, the stakes are inherently high due to the potential for surgical complications and the patient's age (79 years old), which may affect recovery and postoperative care.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych Consult - Pain Meds

REASON FOR CONSULTATION: , Management of pain medications.,HISTORY OF PRESENT ILLNESS: , This is a 60-year-old white male with history of coronary artery disease, status post CABG in 1985 with subsequent sternal dehiscence with rewiring in December 2005 and stent placement in LAD region in 2005, who developed sudden chest pain and was taken to San Jacinto via ambulance where he was diagnosed with acute MI and then went into atrial fibrillation.  An intraaortic balloon pump was placed for cardiogenic shock, and then he was transferred to the ABCD Hospital on October 22, 2006, for continued critical care.  He was in a state of cardiogenic shock and multiorgan system failure including respiratory failure and acute renal insufficiency when he was transferred.  He is currently on dialysis due to end-stage renal disease and has a tracheostomy.  He is receiving fentanyl since he has been here for back pain, leg pain, abdominal pain, and pain in the feet.  He states that he is currently in pain and the fentanyl only helps for about an hour or so before the pain resumes.  He currently rates his pain as 7 out of 10.  He denies a depressed mood or anxiety and states that he knows he is getting better.  He describes his sleep as erratic and states that he will sleep for 1 hour after giving fentanyl IV and then will wake up until he gets another fentanyl.  He has PEG for tube feeding.  He has weakness on left side of his body as well as both legs since his MI.  He has been switched from fentanyl IV q.2h. to the fentanyl patch today.  He also has been started on Seroquel 12.5 mg p.o. at bedtime and will receive his first dose on the evening of Monday, February 12, 2007.  He denies any other psychiatric symptoms including auditory or visual hallucinations or delusions.  His wife was present in the room and both him and his wife seemed to be offended by the suggestion of any psychiatric history or any psychiatric problems.,PAST MEDICAL HISTORY:,1.  DVT in December 2005.,2.  Three MI's (1996, 2005, and 2006).,3.  Diabetes for 5 years.,4.  Coronary artery disease for 10 years.,PAST SURGERIES:,1.  Appendectomy as a child.,2.  CABG x3, November 2005.,3.  Sternal rewiring, December 2005.,MEDICATIONS:,1.  Restoril 7.5 mg p.o. at bedtime p.r.n.,2.  Acetaminophen 650 mg p.o. q.6h. p.r.n. fever.,3.  Aspirin 81 mg p.o. daily.,4.  Bisacodyl suppository 10 mg per rectum daily.,5.  Erythropoietin injection 100 mcg subcutaneously every week at 5 p.m.,6.  Esomeprazole 40 mg IV q.12h.,7.  Fentanyl patch 25 mcg per hour.,8.  Transderm patch every 72 hours.,9.  Heparin IV.,10.  Lactulose 30 mL p.o. daily p.r.n. constipation.,11.  Metastron injection 4 mg IV q.6h. p.r.n. nausea.,12.  Seroquel 12 mg p.o. at bedtime.,13.  Saliva substitute 30 mL spray p.o. q.3h. p.r.n. dry mouth.,14.  Simethicone drops 80 mg per G-tube p.r.n. gas pain.,15.  Bactrim suspension p.o. daily.,16.  Insulin medium dose sliding scale.,17.  Albumin 25% IV p.r.n. hemodialysis.,18.  Ipratropium solution for nebulizer.,ALLERGIES:,  No known drug allergies.,PAST PSYCHIATRIC HISTORY:,  The patient denies any past psychiatric problems.  No medications.  He denies any outpatient visits or inpatient hospitalizations for psychiatric reasons.,SOCIAL HISTORY:,  He lives with his wife in New Jersey.  He has 2 children.  One son in Texas City and 1 daughter in Florida.  He is a master mechanic for a trucking company since 1968.  He retired in the May 2006.  The highest level of education that he received was 1 year in college.,Ethanol, tobacco, or drugs; he smoked 2 packs per day for 40 years, but quit in 1996.  He occasionally has a beer, but denies any continuous use of alcohol.  He denies any illicit drug use.,FAMILY HISTORY:,  Both parents died with myocardial infarctions.  He has 2 sisters and a brother with diabetes mellitus and coronary artery disease.  He denies any history of psychiatric problems in family.,MENTAL STATUS EXAMINATION:,  The patient was sitting in his bed in hospital gown with tracheostomy and receiving tube feeding.  The patient's appearance was appropriate with fair-to-good grooming and hygiene.  He had little-to-no psychomotor activity secondary to weakness post MI.  He had good eye contact.  His speech was of decreased rate volume and flexion secondary to tracheostomy.  The patient was cooperative.  He described his mood is not good in congruent stable and appropriate affect with decreased range.  His thought process is logical and goal directed.  His thought content was negative for delusions, phobias, obsessions, suicidal ideation, or homicidal ideation.  He denied any perceptional disturbances including any auditory or visual hallucinations.  He was alert and oriented x3.,Mini mental status exams not completed.,ASSESSMENT:,AXIS I:  Pain with physical symptoms and possibly psychological symptoms.,AXIS II:  Deferred.,AXIS III:  See above.
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DESCRIPTION: Psychiatric consultation for management of pain medications.

This case involves complex medical issues including multiple organ failures, a history of major heart problems, chronic pain management, and psychological assessment. The transition from IV to patch medication for pain and the introduction of an antipsychotic potentially indicate an attempt to better manage pain and its psychological impact or side effects without exacerbating the patient's delicate condition. Considering the patient's volatile state and multifaceted needs, decisions made here significantly affect his day-to-day living and overall recovery trajectory, making this a high-stakes scenario.


Medical Specialty: Urology
Sample Name: Foul-Smelling Urine

CHIEF COMPLAINT:,  Foul-smelling urine and stomach pain after meals.,HISTORY OF PRESENT ILLNESS:,  Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time.  She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI.  This visit was in July 2010.,REVIEW OF SYSTEMS:,  HEENT:  No headaches.  No visual disturbances, no eye irritation.  No nose drainage or allergic symptoms.  No sore throat or masses.  Respiratory:  No shortness of breath.  No cough or wheeze.  No pain.  Cardiac:  No palpitations or pain.  Gastrointestinal:  Pain and cramping.  Denies nausea, vomiting, or diarrhea.  Has some regurgitation with gas after meals.  Genitourinary:  "Smelly" urine.  Musculoskeletal:  No swelling, pain, or numbness.,MEDICATION ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION:,General:  Unremarkable.,HEENT:  PERRLA.  Gaze conjugate.,Neck:  No nodes.  No thyromegaly.  No masses.,Lungs:  Clear.,Heart:  Regular rate without murmur.,Abdomen:  Soft, without organomegaly, without guarding or tenderness.,Back:  Straight.  No paraspinal spasm.,Extremities:  Full range of motion.  No edema.,Neurologic:  Cranial nerves II-XII intact.  Deep tendon reflexes 2+ bilaterally.,Skin:  Unremarkable.,LABORATORY STUDIES:,  Urinalysis was done, which showed blood due to her period and moderate leukocytes.,ASSESSMENT:,1.  UTI.,2.  GERD.,3.  Dysphagia.,4.  Contraception consult.,PLAN:,1.  Cipro 500 mg b.i.d. x five days.  Ordered BMP, CBC, and urinalysis with microscopy.,2.  Omeprazole 20 mg daily and famotidine 20 mg b.i.d.,3.  Prescriptions same as #2.  Also referred her for a barium swallow series to rule out a stricture.,4.  Ortho Tri-Cyclen Lo.,
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DESCRIPTION: Foul-smelling urine and stomach pain after meals.

The situation described involves ongoing symptoms related to both urinary and gastrointestinal systems, with a history spanning over a year. The patient has been receiving treatment for a urinary tract infection and gastrointestinal issues. While the condition is persistent and involves multiple systems, it doesn't seem to pose an immediate threat to life or require urgent intervention, as no life-threatening symptoms are present and the treatment plan is already in place. The stakes are moderate, given the potential complications from an untreated UTI or severe GERD, but it is not an emergency or life-threatening scenario.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Tube Removal

PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:,  None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage.  A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts, this necessitated to close the wounds with sutures.  The patient was agreeable to proceed.,OPERATIVE PROCEDURE:  ,The patient was prepped and draped at the bedside over both chest tube sites.  The pressures applied over the sites and the skin was closed with interrupted #3-0 Ethilon sutures.  The skin was then cleansed and Vaseline occlusive dressing was applied over the sites.  The same procedure was performed on the other side.  The chest tubes were removed on full inspiration.  Vital signs remained stable throughout the procedure.  The patient will remain in the intensive care unit for continued monitoring.,
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DESCRIPTION: Bilateral pleural effusion.  Removal of bilateral #32 French chest tubes with closure of wound.

cardiovascular / pulmonary, serous drainage, bilateral pleural effusion, pleural effusion, chest tubes, effusion, pleural, chest

The situation involves a medical procedure that is typically routine, such as the removal of chest tubes, especially since the patient remains stable throughout and there are no complications reported. While the patient is in intensive care and there is an ongoing need for monitoring, the procedure itself is not described as having any immediate high-risk factors. The stakes are moderate because any procedure involving the chest can have significant consequences, but in this context, the absence of complications and the controlled environment suggest a lower risk level.


Medical Specialty: Endocrinology
Sample Name: Total Thyroid Lumpectomy

PREOPERATIVE DIAGNOSIS:,  Left thyroid mass.,POSTOPERATIVE DIAGNOSIS:,  Left thyroid mass.,PROCEDURE PERFORMED:,  Left total thyroid lumpectomy.,ANESTHESIA,:  General endotracheal.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:,  None.,INDICATIONS FOR PROCEDURE:,  The patient is a 76-year-old Caucasian female with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.  The patient was then discussed the risks, complications, and consequences of a surgical procedure and a written consent was obtained.,PROCEDURE:  ,The patient is brought to the operative suite by Anesthesia.  The patient was placed on the operative table in supine position.  After this, the patient was placed under general endotracheal intubation anesthesia and the patient was then placed upon a shoulder roll.  After this, the skin incision was marked approximately two fingerbreadths above the sternal notch.  It was then localized with 1% lidocaine with epinephrine 1:1000 approximately 7 cc total.,After this, the patient was then prepped and draped in the usual sterile fashion and a #10 blade was then utilized to make a skin incision.  The subcutaneous tissue was then bluntly dissected utilizing a Ray-Tec sponge and a bear claw was then utilized to retract the upper incisional skin with counter retraction performed to allow a subplatysmal plane of skin flaps to be performed in superior and inferolateral directions.  After this, the midline was then identified and grasped on either side with a DeBakey forceps.  The raphe was noted and Bovie cauterization was utilized to cut down into this region.  The fine stats were utilized to further open this area with exposure and bisection of the sternothyroid muscle.  It was separated on the left side from the patient's sternothyroid muscle.  After this, the sternothyroid muscle was identified, grasped with the DeBakey forceps and infiltrated initially through its fascial plane with the Metzenbaum scissors.  Blunt dissection was then utilized to free the sternothyroid muscle from the thyroid gland in superior and inferior directions and laterally with the help of Kitners.  After this, the plane was rotated more anteriorly with the superior and inferior parathyroid glands identified.  The fat cap was noted to be attached on the superior parathyroid to the posterior aspect of the thyroid itself.  It was freed from the thyroid gland and reflected laterally and posteriorly.  The inferior parathyroid gland actually appeared to be attached also to the inferior aspect of the thyroid itself and was reflected laterally.  After this, the patient's thyroid gland was palpated noting a thyroid nodule in the posterior inferior aspect along with the calcification laterally.  The nodule appeared to be sort of rubbery in consistency and approximately 1 cm diameter.  As the gland was rotated more anteriorly, the recurrent laryngeal nerve on the left side was identified and further dissection along Berry's ligament on the medial aspect was performed.  The middle thyroid vein and inferior thyroid artery were both cauterized with a bipolar cautery and bisected.  After this, the gland was easily rotated anteriorly with further dissection carried up to the superior pole.  The superior pole was exposed with the help of a Richardson and Army-Navy retractors with cross-clamping and tying of the superior laryngeal artery and vein.  Further, the small bleeding vessels were identified and bipolared, and cut with the Metzenbaum scissors.  The superior pole was finally freed and the gland was rotated more anteriorly onto the anterior aspect of the trachea.  Berry's ligament was finally freed and the gland was cross-clamped on the opposing thyroid isthmus with a mosquito.  After this, the gland was cut with a Metzenbaum scissors and tied with a #3-0 undyed Vicryl tie.  The defect on the neck now was thoroughly irrigated with normal saline solution and further bleeding was controlled with bipolar cauterization.  Surgicel was then cut in small strips and three replaced in the lateral part of the neck.,The opposing side of the thyroid gland on the right was palpated with no noticeable nodules or masses.  The strap muscles were then reapproximated with #3-0 Vicryl on a SH, followed by reapproximation of the subcutaneous tissue with #4-0 Vicryl, followed by reapproximation of the skin by running subcuticular #5-0 Prolene and a #6-0 fast absorbing gut.  Mastisol, Steri-Strips, and bacitracin were placed followed by a sterile 4 x 4 dressing.  The patient was then turned back to Anesthesia, extubated in the operating room, and transferred to Recovery in stable condition.  The patient tolerated the procedure well and will be admitted to hospital for 23-hour observation and will be followed up in one week afterwards.
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DESCRIPTION: Left thyroid mass.  Left total thyroid lumpectomy.  The patient with a history of a left thyroid mass nodule that was confirmed with CT scan along with thyroid uptake scan, which demonstrated a hot nodule on the left anterior pole.

endocrinology, thyroid lumpectomy, thyroid uptake scan, thyroid mass nodule, total thyroid lumpectomy, parathyroid glands, berry's ligament, metzenbaum scissors, thyroid gland, thyroid mass, gland, thyroid, total,

The procedure described is a total thyroid lumpectomy, which involves the surgical removal of a thyroid nodule. This type of surgery generally has moderate stakes. While it is a common procedure and the risks are well-managed, it involves critical structures such as the recurrent laryngeal nerve, which, if damaged, could lead to significant complications for the patient. The situation doesn't involve an emergency or life-threatening circumstance as the patient is stable pre- and post-operation, but it requires high precision and expertise during surgery. Therefore, it is a moderate-stakes situation due to the potential risks involved with surgical precision.


Medical Specialty: Discharge Summary
Sample Name: Leiomyosarcoma

ADMITTING DIAGNOSES:,1.  Leiomyosarcoma.,2.  History of pulmonary embolism.,3.  History of subdural hematoma.,4.  Pancytopenia.,5.  History of pneumonia.,PROCEDURES DURING HOSPITALIZATION:,1.  Cycle six of CIVI-CAD (Cytoxan, Adriamycin, and DTIC) from 07/22/2008 to 07/29/2008.,2.  CTA, chest PE study showing no evidence for pulmonary embolism.,3.  Head CT showing no evidence of acute intracranial abnormalities.,4.  Sinus CT, normal mini-CT of the paranasal sinuses.,HISTORY OF PRESENT ILLNESS:  ,Ms. ABC is a pleasant 66-year-old Caucasian female who first palpated a mass in the left posterior arm in spring of 2007.  The mass increased in size and she was seen by her primary care physician and referred to orthopedic surgeon.  MRI showed inflammation and was thought to be secondary to rheumatoid arthritis.  The mass increased in size.  She eventually underwent a partial resection found to have pathologic grade 2 leiomyosarcoma, margins were impossible to assess, but were likely positive.  She was evaluated by Dr. X and Dr. Y and a decision was made to proceed with preoperative chemotherapy.  She began treatment with CIVI-CAD in December 2007.  Her course was complicated by pulmonary embolus, pneumonia, and subdural hematoma while on anticoagulation.  She eventually underwent surgical resection on May 1, 2008 with small area of residual disease, but otherwise clear margins.,HOSPITAL COURSE:,1.  Leiomyosarcoma, the patient was admitted to Hem/Onco B Service under attending Dr. XYZ for cycle six of continuous IV infusion Cytoxan, Adriamycin, and DTIC, which she tolerated well.,2.  History of pulmonary embolism.  Upon admission, the patient reported an approximate two-week history of dyspnea on exertion and some mild chest pain.  She underwent a CTA, which showed no evidence of pulmonary embolism and the patient was started on prophylactic doses of Lovenox at 40 mg a day.  She had no further complaints throughout the hospitalization with any shortness of breath or chest pain.,3.  History of subdural hematoma, also on admission the patient noted some mild intermittent headaches that were fleeting in nature, several a day that would resolve on their own.  Her headaches were not responding to pain medication and so on 07/24/2008, we obtained a head CT that showed no evidence of acute intracranial abnormalities.  The patient also had a history of sinusitis and so a sinus CT scan was obtained, which was normal.,4.  Pancytopenia.  On admission, the patient's white blood count was 3.4, hemoglobin 11.3, platelet count 82, and ANC of 2400.  The patient's counts were followed throughout admission.  She did not require transfusion of red blood cells or platelets; however, on 07/26/2008 her ANC did dip to 900 and she was placed on neutropenic diet.  At discharge her ANC is back up to 1100 and she is taken off neutropenic diet.  Her white blood cell count at discharge was 1.4 and her hemoglobin was 11.2 with a platelet count of 140.,5.  History of pneumonia.  During admission, the patient did not exhibit any signs or symptoms of pneumonia.,DISPOSITION: , Home in stable condition.,DIET: , Regular and less neutropenic.,ACTIVITY: , Resume same activity.,FOLLOWUP:  ,The patient will have lab work at Dr. XYZ on 08/05/2008 and she will also return to the cancer center on 08/12/2008 at 10:20 a.m.  The patient is also advised to monitor for any fevers greater than 100.5 and should she have any further problems in the meantime to please call in to be seen sooner.
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DESCRIPTION: Discharge summary of patient with leiomyosarcoma and history of pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia.

discharge summary, leiomyosarcoma, embolism, hematoma, pneumonia, acute intracranial abnormalities, white blood, platelet count, blood cells, neutropenic diet, subdural hematoma, pulmonary embolism, intracranial, pancytopenia, neutropenic, subdural, pulmonary,

The discharge summary involves a patient with leiomyosarcoma, a type of cancer, which is inherently a serious medical condition that requires careful management. The patient also has a history of significant complications such as pulmonary embolism, subdural hematoma, pancytopenia, and pneumonia, which add complexity to the management of her health. The patient has undergone chemotherapy and surgery, and while she is being discharged in stable condition, there are concerns about her white blood cell count and potential for neutropenia, requiring follow-up and monitoring. While the patient is stable at discharge, any recurrence of these serious conditions could rapidly become high-stakes due to their potential to deteriorate her health considerably. Thus, although she is currently stable, the potential for rapid changes in her condition makes this situation moderately high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Gastrointestinal Bleed - ER Visit

ADMITTING DIAGNOSIS: , Gastrointestinal bleed.,HISTORY OF PRESENT ILLNESS:  ,Ms. XYZ is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell.  She states that she woke yesterday morning and at approximately 10:30 had a bowel movement.  She noticed it was very dark and smelly.  She said she felt okay.  She got up.  She proceeded to clean her house without any difficulty or problems and then at approximately 2 o'clock in the afternoon she went back to the bathroom at which point she had another large stool and had weak spell felt like she was going to pass out.  She is able to get to her phone, called EMS and when the EMS arrived they found her with some blood and some very dark stools.  She states that she was perfectly fine up until Monday when she had an incident where at the Southern University where she works where there was an altercation between a dorm resistant and a young male, which ensued.  She came to place her call, etc.  She said she noticed her stomach was hurting after that, continued to hurt and she took the day off on Tuesday and this happened yesterday.  She denies any nausea except for when she got weak.  She denies any vomiting or any other symptoms.,ALLERGIES:  ,She has no known drug allergies.,CURRENT MEDICATIONS:,1.  Lipitor, dose unknown.,2.  Paxil, dose unknown.,3.  Lasix, dose unknown.,4.  Toprol, dose unknown.,5.  Diphenhydramine p.r.n.,6.  Ibuprofen p.r.n.,7.  Daypro p.r.n.,PAST MEDICAL HISTORY:,1.  Non-insulin diabetes mellitus.,2.  History of congestive heart failure.,3.  History of hypertension.,4.  Depression.,5.  Arthritis.  She states she has not needed any medications and not taken ibuprofen or Daypro recently.,6.  Hyperlipidemia.,7.  Peptic ulcer disease diagnosed in 2005.,PAST SURGICAL HISTORY: , C-section and tonsillectomy.,FAMILY HISTORY: , Her mother had high blood pressure and coronary artery disease.,SOCIAL HISTORY:,  She is a nonsmoker.  She occasionally has a drink every few weeks.  She is divorced.  She has 2 sons.  She is houseparent at Southern University.,REVIEW OF SYSTEMS:  ,Negative for the last 24 to 48 hours as mentioned in her HPI.,PREVENTIVE CARE:  ,She had an EGD done in 09/05 at which point she was diagnosed with peptic ulcer disease and she also had a colonoscopy at that time which revealed two polyps in the transverse colon.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Currently was stable.  She is afebrile.,GENERAL:  She is alert, pleasant in no acute distress.  She does complain of some dizziness when she stands up.,HEENT:  Pupils equal, round and reactive to light.  Extraocular muscles intact.  Sclerae clear.  Oropharynx is clear.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR:  She is slightly tachycardic but otherwise normal.,LUNGS:  Clear bilaterally.,ABDOMEN:  Soft, nontender, and nondistended.  She has no hepatomegaly.,EXTREMITIES:  No clubbing, cyanosis, only trace edema.,LABORATORY DATA UPON ADMISSION:,  Her initial chem panel was within normal limits.  Her PT and PTT were normal.  Her initial hematocrit was 31.2 subsequently dropped to 26.9 and 25.6.  She is currently administered transfusion.  Platelet count was 125.  Her chem panel actually showed an elevated BUN of 16, creatinine of 1.7.  PT and PTT were normal.  Cardiac enzymes were negative and initial hemoglobin was 10.6 with hematocrit of 31.2 that subsequently fell to 25.6 and she is currently receiving blood.,IMPRESSION AND PLAN:,1.  Gastrointestinal bleed.
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DESCRIPTION: Gastrointestinal Bleed.  An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell.  She woke yesterday morning had a very dark and smelly bowel movement.

An 81-year-old patient presenting with black tarry stools and symptoms such as dizziness and weakness suggests gastrointestinal bleeding, which can lead to significant blood loss, anemia, and can be life-threatening if not treated promptly. The patient's hematocrit levels have dropped, indicating ongoing blood loss and requiring blood transfusion, which underscores the seriousness of the situation. Given her age and medical history, including peptic ulcer disease, congestive heart failure, and hypertension, the stakes are higher due to the potential for complications.


Medical Specialty: Surgery
Sample Name: Control of Parapharyngeal Hemorrhage

PREOPERATIVE DIAGNOSIS: , Postoperative hemorrhage.,POSTOPERATIVE DIAGNOSIS:,  Postoperative hemorrhage.,SURGICAL PROCEDURE:  ,Examination under anesthesia with control of right parapharyngeal space hemorrhage.,ANESTHESIA:  ,General endotracheal technique.,SURGICAL FINDINGS: , Right lower pole bleeder cauterized with electrocautery with good hemostasis.,INDICATIONS FOR SURGERY: , The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy.  Previously, in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty.  However, in the PACU after a coughing spell she began bleeding from the right oropharynx, and was taken back to the operative suite for control of hemorrhage.,DESCRIPTION OF SURGERY:  ,The patient was placed supine on the operating room table and general anesthetic was administered, once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage.  A Crowe-Davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized.  There was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa, this area was cauterized with suction cautery and irrigated.  There was no other bleeding noted.  The patient was repositioned and the mouth gag, the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined.  There was a small amount of oozing noted in the right tonsillar bed, and this was cauterized with suction cautery.  No other bleeding was noted and the patient was recovered from general anesthetic.  She was extubated and left the operating room in good condition to postoperative recovery room area.  Prior to extubation the patient's tonsillar fossa were injected with a 6 mL of 0.25% Marcaine with 1:100,000 adrenalin solution to facilitate postoperative analgesia and hemostasis.
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DESCRIPTION: Postoperative hemorrhage. Examination under anesthesia with control of right parapharyngeal space hemorrhage.  The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy.

surgery, obstructive adenotonsillar hypertrophy, tonsillar fossa, suction cautery, postoperative hemorrhage, parapharyngeal space, anesthesia, oropharynx, parapharyngeal, tonsillectomy, hemorrhage,

The situation involves a patient who experienced postoperative hemorrhage after a tonsillectomy with adenoidectomy, necessitating a return to surgery to control the bleeding. Hemorrhage in the parapharyngeal space is a potentially serious condition, as uncontrolled bleeding can lead to airway obstruction or significant blood loss. The surgery was performed under general anesthesia, indicating a serious approach to handle the complication. The stakes are considerably high since bleeding in this area could escalate to life-threatening if not controlled promptly.


Medical Specialty: Letters
Sample Name: Ortho - Letter - 1

XYZ, D.C.,Re:  ABC,Dear Dr. XYZ:,I had the pleasure of seeing your patient, ABC, today MM/DD/YYYY in consultation.  He is an unfortunate 19-year-old right-handed male who was injured in a motor vehicle accident on MM/DD/YYYY, where he was the driver of an automobile, which was struck on the front passenger's side.  The patient sustained impact injuries to his neck and lower back.  There was no apparent head injury or loss of consciousness and he denied any posttraumatic seizures.  He was taken to Hospital, x-rays were taken, apparently which were negative and he was released.,At the present time, he complains of neck and lower back pain radiating into his right arm and right leg with weakness, numbness, paraesthesia, and tingling in his right arm and right leg.  He has had no difficulty with bowel or bladder function.  He does experience intermittent headaches associated with his neck pain with no other associated symptoms.,PAST HEALTH:,  He was injured in a prior motor vehicle accident on MM/DD/YYYY.  At the time of his most recent injuries, he was completely symptom free and under no active therapy.  There is no history of hypertension, diabetes, heart disease, neurological disorders, ulcers or tuberculosis.,SOCIAL HISTORY: , He denies tobacco or alcohol consumption.,ALLERGIES: , No known drug allergies.,CURRENT MEDICATIONS:  ,None.,FAMILY HISTORY: , Otherwise noncontributory.,FUNCTIONAL INQUIRY: , Otherwise noncontributory.,REVIEW OF DIAGNOSTIC STUDIES:,  Includes an MRI scan of the cervical spine dated MM/DD/YYYY which showed evidence for disc bulging at the C6-C7 level.  MRI scan of the lumbar spine on MM/DD/YYYY, showed evidence of a disc herniation at the L1-L2 level as well as a disc protrusion at the L2-L3 level with disc herniations at the L3-L4 and L4-L5 level and disc protrusion at the L5-S1 level.,PHYSICAL EXAMINATION: , Reveals an alert and oriented male with normal language function.  Vital Signs:  Blood pressure was 105/68 in the left arm sitting.  Heart rate was 70 and regular.  Height was 5 feet 8 inches.  Weight was 182 pounds.  Cranial nerve evaluation was unremarkable.  Pupils were equal and reactive.  Funduscopic evaluation was clear.  There was no evidence for nystagmus.  There was decreased range of motion noted in both the cervical and lumbar regions to a significant degree, with tenderness and spasm in the paraspinal musculature.  Straight leg raising was limited to 45 degrees on the right and 90 degrees on the left.  Motor strength was 5/5 on the MRC scale.  Reflexes were 2+ symmetrical and active.  No pathological responses were noted.  Sensory examination showed a diffuse decreased sensation to pinprick in the right upper extremity.  Cerebellar function was normal.  There was normal station and gait.  Chest and cardiovascular evaluations were unremarkable.  Heart sounds were normal.  There were no extra sounds or murmurs.  Palpable trigger points were noted in the right trapezius and right cervical and lumbar paraspinal musculature.,CLINICAL IMPRESSION: , Reveals a 19-year-old male suffering from a posttraumatic cervical and lumbar radiculopathy, secondary to traumatic injuries sustained in a motor vehicle accident on MM/DD/YYYY.  In view of the persistent radicular complaints associated with the weakness, numbness, paraesthesia, and tingling as well as the objective sensory loss noted on today's evaluation as well as the non-specific nature of the radiculopathy, I have scheduled him for an EMG study on his right upper and right lower extremity in two week's time to rule out any nerve root irritation versus any peripheral nerve entrapment or plexopathy as the cause of his symptoms.  Palpable trigger points were noted on today's evaluation.  He is suffering from ongoing myofascitis.  His treatment plan will consist of a series of trigger point injections to be initiated at his next follow up visit in two weeks' time.  I have encouraged him to continue with his ongoing treatment program under your care and supervision.  I will be following him in two weeks' time.  Once again, thank you kindly for allowing me to participate in this patient's care and management.,Yours sincerely,,
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DESCRIPTION: A 19-year-old right-handed male injured in a motor vehicle accident.

letters, numbness paraesthesia and tingling, paraesthesia and tingling, cervical and lumbar, motor vehicle accident, mri scan, disc protrusion, paraspinal musculature, letter, musculature, radiculopathy, nerve, trigger, vehicle, accident, cervical, lumbar, evaluation, disc, ortho,

The situation described involves a patient who has sustained significant injuries from a motor vehicle accident, resulting in ongoing medical issues such as cervical and lumbar radiculopathy. While these are serious medical concerns requiring further diagnostics and treatment, the immediate situation does not appear to involve life-threatening conditions or a critical emergency. There is a planned follow-up and treatment schedule. The stakes are primarily related to the patient's recovery and quality of life rather than an immediate life-or-death scenario.


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

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

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

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

The situation involves a standard medical procedure for repairing inguinal hernias, which is a common condition. While surgery does carry inherent risks, inguinal hernia repairs are typically routine and have a high success rate. The use of general anesthesia and specific surgical techniques, like the PHS system and nerve block, are well-established in medical practice, indicating it is a controlled and typical procedure. Therefore, it does not involve exceptionally high stakes as would be the case with more complex or emergency medical scenarios.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 52

CHIEF COMPLAINT: , Anxiety, alcohol abuse, and chest pain.,HISTORY OF PRESENT ILLNESS:,  This is a pleasant 40-year-old male with multiple medical problems, basically came to the hospital yesterday complaining of chest pain.  The patient states that he complained of this chest pain, which is reproducible, pleuritic in both chest radiating to the left back and the jaw, complaining of some cough, nausea, questionable shortness of breath.  The patient describes the pain as aching, sharp and alleviated with pain medications, not alleviated with any nitrates.  Aggravated by breathing, coughing, and palpation over the area.  The pain was 9/10 in the emergency room and he was given some pain medications in the ER and was basically admitted.  Labs were drawn, which were essentially, potassium was about 5.7 and digoxin level was drawn, which was about greater than 5.  The patient said that he missed 3 doses of digoxin in the last 3 days after being discharged from Anaheim Memorial and then took 3 tablets together.  The patient has a history prior digoxin overdose of the same nature.,MEDICATIONS:,  Digoxin 0.25 mg, metoprolol 50 mg, Naprosyn 500 mg, metformin 500 mg, lovastatin 40 mg, Klor-Con 20 mEq, Advair Diskus, questionable Coreg.,PAST MEDICAL HISTORY: , MI in the past and atrial fibrillation, he said that he has had one stent put in, but he is not sure.  The last cardiologist he saw was Dr. X and his primary doctor is Dr. Y.,SOCIAL HISTORY:,  History of alcohol use in the past.,He is basically requesting for more and more pain medications.  He states that he likes Dilaudid and would like to get the morphine changed to Dilaudid.  His pain is tolerable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Stable.,GENERAL:  Alert and oriented x3, no apparent distress.,HEENT:  Extraocular muscles are intact.,CVS:  S1, S2 heard.,CHEST:  Clear to auscultation bilaterally.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema or clubbing.,NEURO:  Grossly intact.  Tender to palpate over the left chest, no obvious erythema or redness, or abnormal exam is found.,EKG basically shows atrial fibrillation, rate controlled, nonspecific ST changes.,ASSESSMENT AND PLAN:,1.  This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse.  Now, he has had significant block with EKG changes as stated.  Continue to follow the patient clinically at this time.  The patient has been admitted to ICU and will be changed to DOU.,2.  Chronic chest pain with a history of myocardial infarction in the past, has been ruled out with negative cardiac enzymes.  The patient likely has opioid dependence and requesting more and more pain medications.  He is also bargaining for pain medications with me.  The patient was advised that he will develop more opioid dependence and I will stop the pain medications for now and give him only oral pain medications in the anticipation of the discharge in the next 1 or 2 days.  The patient was likely advised to also be seen by a pain specialist as an outpatient after being referred.  We will try to verify his pain medications from his primary doctor and his pharmacy.  The patient said that he has been on Dilaudid and Vicodin ES and Norco and all these medications in the past.
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DESCRIPTION: Anxiety, alcohol abuse, and chest pain.   This is a 40-year-old male with digoxin toxicity secondary to likely intentional digoxin overuse.  Now, he has had significant block with EKG changes as stated.

consult - history and phy., anxiety, alcohol abuse, chest pain, digoxin toxicity, digoxin overuse, atrial fibrillation, opioid dependence, toxicity, dilaudid,

The situation involves a 40-year-old male with multiple significant medical issues such as anxiety, alcohol abuse, chest pain, and notably, digoxin toxicity, which is a potentially life-threatening condition. He has a complex medical history including myocardial infarction and atrial fibrillation. Additionally, there are complications involving potential opioid dependence or abuse, as the patient is requesting stronger pain medications and has a history of alcohol use. The patient is currently admitted in ICU, indicating the seriousness of the condition. This situation is high-stakes due to the immediate potential risks to the patient's health posed by digoxin toxicity and the challenges linked to managing his medication needs safely, including addressing possible opioid dependence.


Medical Specialty: Orthopedic
Sample Name: Closed Reduction - 2

PREOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,PROCEDURE:,  Closed reduction with splint application with use of image intensifier.,INDICATIONS: , Mr. ABC is an 11-year-old boy who sustained a fall on 07/26/2008.  Evaluation in the emergency department revealed both-bone forearm fracture.  Considering the amount of angulation, it was determined that we should proceed with conscious sedation and closed reduction.  After discussion with parents, verbal and written consent was obtained.,DESCRIPTION OF PROCEDURE:  ,The patient was induced with propofol for conscious sedation via the emergency department staff.  After it was confirmed that appropriate sedation had been reached, a longitudinal traction in conjunction with re-creation of the injury maneuver was applied reducing the fracture.  Subsequently, this was confirmed with image intensification, a sugar-tong splint was applied and again reduction was confirmed with image intensifier.  The patient was aroused from anesthesia and tolerated the procedure well.  Post-reduction plain films revealed some anterior displacement of the distal fragment.  At this time, it was determined this fracture proved to be unstable.,DISPOSITION: , After review of the reduction films, it appears that there is some element of fracture causing displacement.  We will proceed to the operating room for open reduction and internal fixation versus closed reduction and percutaneous pinning as our operative schedule allows.,
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DESCRIPTION: Left distal both-bone forearm fracture.  Closed reduction with splint application with use of image intensifier.

orthopedic, closed reduction, reduction with splint application, distal both bone forearm, distal both bone, splint application, emergency department, conscious sedation, image intensifier, bone forearm, forearm fracture, reduction, emergency, department, conscious, displacement, splint, sedation, tong, distal, bone, image, intensifier, forearm, fracture

The situation involves a medical procedure for an 11-year-old boy who sustained a left distal both-bone forearm fracture. The preoperative and postoperative diagnoses are consistent, and the procedure involves a closed reduction with splint application, along with the use of an image intensifier. The procedure uses conscious sedation, which requires careful monitoring of the patient, especially since the initial reduction attempt shows some instability, and further surgical intervention is considered. While not life-threatening, this involves potential surgical intervention and management of a fracture, both of which involve moderate stakes as they affect the patient's recovery and long-term function.


Medical Specialty: Consult - History and Phy.
Sample Name: Urinary Retention

CHIEF COMPLAINT:,  Urinary retention.,HISTORY OF PRESENT ILLNESS: , This is a 66-year-old gentleman status post deceased donor kidney transplant in 12/07, who has had recurrent urinary retention issues since that time.  Most recently, he was hospitalized on 02/04/08 for acute renal insufficiency, which was probably secondary to dehydration.  He was seen by urology again at this visit for urinary retention.  He had been seen by urology during a previous hospitalization and he passed his voiding trial at the time of his stent removal on 01/22/08.  Cystoscopy showed at that time obstructive BPH.  He was started on Flomax at the time of discharge from the hospital.  During the most recent readmission on 02/04/08, he went back into urinary retention and he had had a Foley placed at the outside hospital.,REVIEW OF SYSTEMS:,  Positive for blurred vision, nasal congestion, and occasional constipation.  Denies chest pain, shortness of breath or any rashes or lesions.  All other systems were reviewed and found to be negative.,PAST MEDICAL HISTORY:,1.  End-stage renal disease, now status post deceased donor kidney transplant in 12/07.,2.  Hypertension.,3.  History of nephrolithiasis.,4.  Gout.,5.  BPH.,6.  DJD.,PAST SURGICAL HISTORY:,1.  Deceased donor kidney transplant in 12/07.,2.  Left forearm and left upper arm fistula placements.,FAMILY HISTORY:  ,Significant for mother with an unknown type of cancer, possibly colon cancer or lung and prostate problems on his father side of the family.  He does not know whether his father side of the family had any history of prostate cancer.,HOME MEDICATIONS:,1.  Norvasc.,2.  Toprol 50 mg.,3.  Clonidine 0.2 mg.,4.  Hydralazine.,5.  Flomax.,6.  Allopurinol.,7.  Sodium bicarbonate.,8.  Oxybutynin.,9.  Coumadin.,10.  Aspirin.,11.  Insulin 70/30.,12.  Omeprazole.,13.  Rapamune.,14.  CellCept.,15.  Prednisone.,16.  Ganciclovir.,17.  Nystatin swish and swallow.,18.  Dapsone.,19.  Finasteride.,ALLERGIES:,  No known drug allergies.,PHYSICAL EXAMINATION:,GENERAL:  This is a well-developed, well-nourished male, in no acute distress.  VITAL SIGNS:  Temperature 98, blood pressure 129/72, pulse 96, and weight 175.4 pounds.  LUNGS:  Clear to auscultation bilaterally.  CARDIOVASCULAR:  Regular rate and rhythm with a 3/6 systolic murmur.  ABDOMEN:  Right lower quadrant incision site scar well healed.  Nontender to palpation.  Liver and spleen not enlarged.  No hernias appreciated.  PENIS:  Normal male genitalia.  No lesions appreciated on the penis.  Previous DRE showed the prostate of approximately 40 grams and no nodules.  Foley in place and draining clear urine.,The patient underwent fill and pull study, in which his bladder tolerated 120 ml of sterile water passively filling his bladder.  He spontaneously voided without the Foley 110 mL.,ASSESSMENT AND PLAN:  ,This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since the kidney transplant in 12/07.  He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again.  We discussed with Mr. Barker that he has a urologist closer to his home and he lives approximately 3 hours away; however, he desires to continue follow up with the urology clinic at MCG and has been set up for followup in 6 weeks.  He was also given a prescription for 6 months of Flomax and Proscar.  He did not have a PSA drawn today as he had a catheter in place, therefore his PSA could be falsely elevated.  He will have PSA level drawn either just before his visit for followup.
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DESCRIPTION: This is a 66-year-old male with signs and symptoms of benign prostatic hypertrophy, who has had recurrent urinary retention since his kidney transplant.  He passed his fill and pull study and was thought to self-catheterize in the event that he does incur urinary retention again.

The situation involves a 66-year-old male patient with a history of a kidney transplant, benign prostatic hypertrophy, and recurrent urinary retention. While urinary retention and its complications can be serious, the patient is not in acute distress, and he has a management plan involving medications and self-catheterization. The presence of multiple medical conditions, including post-transplant status, adds complexity and risk, but the situation seems stable and managed. There is no immediate life-threatening condition; therefore, it is not classified as extremely high-stakes.


Medical Specialty: Orthopedic
Sample Name: Biceps Tendon Repair

PREOPERATIVE DIAGNOSIS: , Ruptured distal biceps tendon, right elbow.,POSTOPERATIVE DIAGNOSIS:,  Ruptured distal biceps tendon, right elbow.,PROCEDURE PERFORMED: , Repair of distal biceps tendon, right elbow.,PROCEDURE:  ,The patient was taken to OR, Room #2 and administered a general anesthetic.  The right upper extremity was then prepped and draped in the usual manner.  A sterile tourniquet was placed on the proximal aspect of the right upper extremity.  The extremity was then elevated and exsanguinated with an Esmarch bandage and tourniquet was inflated to 250 mmHg.  Tourniquet time was 74 minutes.  A curvilinear incision was made in the antecubital fossa of the right elbow down through the skin.  Hemostasis was achieved utilizing electrocautery.  Subcutaneous fat was separated and the skin flaps elevated.  The _________ was identified.  It was incised.  The finger was placed approximately up the anterior aspect of the arm and the distal aspect of the biceps tendon was found.  There was some serosanguineous fluid from the previous rupture.  This area was suctioned clean.  The biceps tendon ends were then placed over a sterile tongue blade and were then sharply cut approximately 5 mm to 7 mm from the tip to create a fresh surface.  At this point, the #2 fiber wire was then passed through the tendon.  Two fiber wires were utilized in a Krackow-type suture.  Once this was completed, dissection was taken digitally down into the antecubital fossa in the path where the biceps tendon had been previously.  The radial tuberosity was palpated.  Just ulnar to this, a curved hemostat was passed through the soft tissues and was used to tent the skin on the radial aspect of the elbow.  A skin incision was made over this area.  Approximately two inches down to the skin and subcutaneous tissues, the fascia was split and the extensor muscle was also split.,A stat was then attached through the tip of that stat and passed back up through the antecubital fossa.  The tails of the fiber wire suture were grasped and pulled down through the second incision.  At this point, they were placed to the side.  Attention was directed at exposure of the radial tuberosity with a forearm fully pronated.  The tuberosity came into view.  The margins were cleared with periosteal elevator and sharp dissection.  Utilizing the power bur, a trough approximately 1.5 cm wide x 7 mm to 8 mm high was placed in the radial tuberosity.  Three small drill holes were then placed along the margin for passage of the suture.  The area was then copiously irrigated with gentamicin solution.  A #4-0 pullout wire was utilized to pass the sutures through the drill holes, one on each outer hole and two in the center hole.  The elbow was flexed and the tendon was then pulled into the trough with the forearm supinated.  The suture was tied over the bone islands.  Both wounds were then copiously irrigated with gentamicin solution and suctioned dry.  Muscle fascia was closed with running #2-0 Vicryl suture on the lateral incision followed by closure of the skin with interrupted #2-0 Vicryl and small staples.  The anterior incision was approximated with interrupted #2-0 Vicryl for Subq. and then skin was approximated with small staples.  Both wounds were infiltrated with a total of 30 cc of 0.25% Marcaine solution for postop analgesia.  A bulky fluff dressing was applied to the elbow, followed by application of a long-arm plaster splint maintaining the forearm in the supinated position.  Tourniquet was inflated prior to application of the splint.  Circulatory status returned to the extremity immediately.  The patient was awakened.  He was rather boisterous during his awakening, but care was taken to protect the right upper extremity.  He was then transferred to the recovery room in apparent satisfactory condition.
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DESCRIPTION: Ruptured distal biceps tendon, right elbow.  Repair of distal biceps tendon, right elbow.

orthopedic, ruptured distal biceps tendon, gentamicin solution, antecubital fossa, distal biceps, biceps tendon, tendon, tuberosity, biceps, elbow,

The situation involves a surgical procedure to repair a ruptured distal biceps tendon, which is a routine orthopedic surgery but still involves general anesthesia, precise surgical technique, and postoperative care. While it's a standard procedure for orthopedic surgeons, it carries inherent risks associated with surgery and anesthesia, such as infection, poor healing, or complications during recovery. However, this is generally not life-threatening and is considered a regular part of orthopedic surgical practice, typically followed by a recovery period with physical therapy. Therefore, it's a medium-stakes situation since it requires competent execution but doesn't inherently involve life-threatening risks.


Medical Specialty: Emergency Room Reports
Sample Name: ER Report - URI

HISTORY OF PRESENT ILLNESS:,  The patient is a two-and-a-half-month-old male who has been sick for the past three to four days.  His mother has described congested sounds with cough and decreased appetite.  He has had no fever.  He has had no rhinorrhea.  Nobody else at home is currently ill.  He has no cigarette smoke exposure.  She brought him to the emergency room this morning after a bad coughing spell.  He did not have any apnea during this episode.,PAST MEDICAL HISTORY:,  Unremarkable.  He has had his two-month immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 99.1, oxygen saturations 98%, respirations by the nurse at 64, however, at my examination was much slower and regular in the 40s.,GENERAL:  Sleeping, easily aroused, smiling, and in no distress.,HEENT:  Soft anterior fontanelle.  TMs are normal.  Moist mucous membranes.,LUNGS:  Equal and clear.,CHEST:  Without retraction.,HEART:  Regular in rate and rhythm without murmur.,ABDOMEN:  Benign.,DIAGNOSTIC STUDIES:,  Chest x-ray ordered by ER physician is unremarkable, but to me also.,ASSESSMENT:,  Upper respiratory infection.,TREATMENT: , Use the bulb syringe and saline nose drops if there is any mucus in the anterior nares.  Smaller but more frequent feeds.  Discuss proper sleeping position.  Recheck if there is any fever or if he is no better in the next three days.
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DESCRIPTION: Patient in ER with upper respiratory infection

emergency room reports, er, uri, emergency room, upper respiratory infection, respiratory, sick, fever, chest,

The situation involves a two-and-a-half-month-old infant presenting with a suspected upper respiratory infection (URI) in the emergency room. While an infant's respiratory issues can be concerning, the provided details suggest mild symptoms: no fever, normal oxygen saturation, and vital signs within acceptable limits for his age. The treatment plan is non-invasive, focusing on supportive care and monitoring for symptom progression. Overall, the situation is not life-threatening at present.


Medical Specialty: Consult - History and Phy.
Sample Name: Bariatric Consult - Surgical Weight Loss - 4

HISTORY OF PRESENT ILLNESS:,  Ms. A is a 55-year-old female who presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.  The patient states that she has been overweight for approximately 35 years and has tried multiple weight loss modalities in the past including Weight Watchers, NutriSystem, Jenny Craig, TOPS, cabbage diet, grape fruit diet, Slim-Fast, Richard Simmons, as well as over-the-counter measures without any long-term sustainable weight loss.  At the time of presentation to the practice, she is 5 feet 6 inches tall with a weight of 285.4 pounds and a body mass index of 46.  She has obesity-related comorbidities, which includes hypertension and hypercholesterolemia.,PAST MEDICAL HISTORY:,  Significant for hypertension, for which the patient takes Norvasc and Lopressor for.  She also suffers from high cholesterol and is on lovastatin for this.  She has depression, for which she takes citalopram.  She also stated that she had a DVT in the past prior to her hysterectomy.  She also suffers from thyroid disease in the past though this is unclear, the nature of this.,PAST SURGICAL HISTORY: , Significant for cholecystectomy in 2008 for gallstones.  She also had a hysterectomy in 1994 secondary to hemorrhage.  The patient denies any other abdominal surgeries.,MEDICATIONS: , Norvasc 10 mg p.o. daily, Lopressor tartrate 50 mg p.o. b.i.d., lovastatin 10 mg p.o. at bedtime, citalopram 10 mg p.o. daily, aspirin 500 mg three times a day, which is currently stopped, vitamin D, Premarin 0.3 mg one tablet p.o. daily, currently stopped, omega-3 fatty acids, and vitamin D 50,000 units q. weekly.,ALLERGIES: , The patient denies allergies to medications and to latex.,SOCIAL HISTORY: , The patient is a homemaker.  She is married, with 2 children aged 22 and 28.  She is a lifelong nonsmoker and nondrinker.,FAMILY HISTORY:  ,Significant for high blood pressure and diabetes as well as cancer on her father side.  He did pass away from congestive heart failure.  Mother suffers from high blood pressure, cancer, and diabetes.  Her mother has passed away secondary to cancer.  She has two brothers one passed away from brain cancer.,REVIEW OF SYSTEMS: , Significant for ankle swelling.  The patient also wears glasses for vision and has dentures.  She does complain of shortness of breath with exertion.  She also suffers from hemorrhoids and frequent urination at night as well as weightbearing joint pain.  The patient denies ulcerative colitis, Crohn disease, bleeding diathesis, liver disease, or kidney disease.  She denies chest pain, cardiac disease, cancer, and stroke.,PHYSICAL EXAMINATION:  ,The patient is a well-nourished, well-developed female, in no distress.  Eye Exam:  Pupils equal and reactive to light.  Extraocular motions are intact.  Neck Exam:  No cervical lymphadenopathy.  Midline trachea.  No carotid bruits.  Nonpalpable thyroid.  Neuro Exam:  Gross motor strength in the upper and lower extremities, equal bilaterally with no focal neuro deficits noted.  Lung Exam:  Clear breath sounds without rhonchi or wheezes.  Cardiac Exam:  Regular rate and rhythm without murmur or bruits.  Abdominal Exam:  Positive bowel sounds.  Soft, nontender, obese, and nondistended abdomen.  Lap cholecystectomy scars noted.  No obvious hernias.  No organomegaly appreciated.  Lower extremity Exam:  Edema 1+.  Dorsalis pedis pulses 2+.,ASSESSMENT:  ,The patient is a 55-year-old female with a body mass index of 46, suffering from obesity-related comorbidities including hypertension and hypercholesterolemia, who presents to the practice for consideration of gastric bypass surgery.  The patient appears to be an excellent candidate for surgery and would benefit greatly from surgical weight loss in the management of her obesity-related comorbidities.,PLAN: , In preparation for surgery, we will obtain the usual baseline laboratory values including baseline vitamin levels.  I recommended the patient undergo an upper GI series prior to surgery due to find her upper GI anatomy.  Also the patient will meet with the dietitian and psychologist as per her usual routine.  I have recommended approximately six to eight weeks of Medifast for the patient to obtain a 10% preoperative weight loss in preparation for surgery.
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DESCRIPTION: Patient presented to the Bariatric Surgery Service for consideration of laparoscopic Roux-en-Y gastric bypass.

consult - history and phy., jenny craig, medifast, nutrisystem, richard simmons, slim-fast, tops, weight watchers, cabbage diet, grape fruit diet, roux-en-y, laparoscopic roux-en-y gastric bypass, weight loss modalities, surgical weight loss, body mass index, weight loss,

The situation involves a medical assessment for a major surgery, gastric bypass, which is typically considered a high-stakes procedure due to the potential risks and benefits involved, especially given the patient's comorbidities such as hypertension and hypercholesterolemia. The surgery can significantly affect her health outcomes and quality of life. Furthermore, the preparation phase entails psychological and dietary evaluations, which indicate the seriousness of the intervention. These factors make it a high-stakes situation.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pneumonia - Discharge Summary

ADMISSION DIAGNOSES:,1.  Pneumonia, failed outpatient treatment.,2.  Hypoxia.,3.  Rheumatoid arthritis.,DISCHARGE DIAGNOSES:,1.  Atypical pneumonia, suspected viral.,2.  Hypoxia.,3.  Rheumatoid arthritis.,4.  Suspected mild stress-induced adrenal insufficiency.,HOSPITAL COURSE: , This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.  She was seen on multiple occasions at Urgent Care and in her physician's office.  Initial x-ray showed some mild diffuse patchy infiltrates.  She was first started on Avelox, but had a reaction, switched to Augmentin, which caused loose stools, and then three days prior to admission was given daily 1 g Rocephin and started on azithromycin.  Her O2 saturations drifted downward.  They were less than 88% when active; at rest, varied between 88% and 92%.  Decision was made because of failed outpatient treatment of pneumonia.  Her medical history is significant for rheumatoid arthritis.  She is on 20 mg of methotrexate every week as well as Remicade every eight weeks.  Her last dose of Remicade was in the month of June.  Hospital course was relatively unremarkable.  CT scan was performed and no specific focal pathology was seen.  Dr. X, pulmonologist was consulted.  He also was uncertain as to the exact etiology, but viral etiology was most highly suspected.  Because of her loose stools, C. difficile toxin was ordered, although that is pending at the time of discharge.  She was continued on Rocephin IV and azithromycin.  Her fever broke 18 hours prior to discharge, and O2 saturations improved, as did her overall strength and clinical status.  She was instructed to finish azithromycin.  She has two pills left at home.  She is to follow up with Dr. X in two to three days.  Because she is on chronic prednisone therapy, it was suspected that she was mildly adrenal insufficient from the stress of her pneumonia.  She is to continue the increased dose of prednisone at 20 mg (up from 5 mg per day).  We will consult her rheumatologist as to whether to continue her methotrexate, which we held this past Friday.  Methotrexate is known on some occasions to cause pneumonitis.
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DESCRIPTION: Atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency.  This very independent 79-year old had struggled with cough, fevers, weakness, and chills for the week prior to admission.

cardiovascular / pulmonary, adrenal insufficiency, hypoxia, cough, fevers, weakness, chills, atypical pneumonia, loose stools, rheumatoid arthritis, azithromycin, arthritis, pneumonia,

The situation involves a 79-year-old patient with multiple diagnoses, including atypical pneumonia, hypoxia, rheumatoid arthritis, and suspected mild stress-induced adrenal insufficiency. The patient required hospitalization due to failed outpatient treatment, which indicates a certain level of severity. However, the hospital course was relatively unremarkable, and the patient's condition improved enough to allow discharge. The stakes are moderate due to the patient's age and medical complexity, but not extremely high given the improvement observed and the outlined follow-up care plan.


Medical Specialty: Neurology
Sample Name: EMG/Nerve Conduction Study - 2

HISTORY: , The patient is a 78-year-old right-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.  She was undergoing a spinal epidural injection about a month ago and had worsening of right low back pain, which radiates down into her buttocks and down to posterior aspect of her thigh into her knee.  This has required large amounts of opioid analgesics to control.  She has been basically bedridden because of this.  She was brought into hospital for further investigations.,PHYSICAL EXAMINATION: , On examination, she has positive straight leg rising on the right with severe shooting, radicular type pain with right leg movement.  Difficult to assess individual muscles, but strength is largely intact.  Sensory examination is symmetric.  Deep tendon reflexes reveal hyporeflexia in both patellae, which probably represents a cervical myelopathy from prior cord compression.  She has slightly decreased right versus left ankle reflexes.  The Babinski's are positive.  On nerve conduction studies, motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in lower extremities.,NEEDLE EMG: , Needle EMG was performed on the right leg and lumbosacral paraspinal muscles using a disposable concentric needle.  It reveals the spontaneous activity in right peroneus longus and gastrocnemius medialis muscles as well as the right lower lumbosacral paraspinal muscles.  There is evidence of denervation in right gastrocnemius medialis muscle.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  Inactive right S1 (L5) radiculopathy.,2.  There is no evidence of left lower extremity radiculopathy, peripheral neuropathy or entrapment neuropathy.,Results were discussed with the patient and she is scheduled for imaging studies in the next day.
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DESCRIPTION: A ight-handed inpatient with longstanding history of cervical spinal stenosis status post decompression, opioid dependence, who has had longstanding low back pain radiating into the right leg.

neurology, needle emg, radiculopathy, electrical study, emg, nerve conduction study, cervical spinal stenosis, lumbosacral paraspinal muscles, gastrocnemius medialis muscles, spinal stenosis, post decompression, lumbosacral paraspinal, paraspinal muscles, gastrocnemius medialis, medialis muscles, decompression, emg/nerve, conduction, cervical, spinal, needle, muscles,

The situation involves a 78-year-old patient with a complex medical history, including cervical spinal stenosis, opioid dependence, and severe low back and leg pain. The patient requires significant medical interventions and pain management, is bedridden, and is undergoing a series of diagnostic tests like EMG and imaging. These factors highlight a critical situation where there is a need for precise diagnosis and effective treatment to manage potentially debilitating neural and musculoskeletal conditions. The patient's quality of life and ability to function are significantly impacted, which raises the stakes of the situation.