Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: CyberKnife Treatment - Followup

HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer.  CyberKnife treatment was completed one month ago.  She is now being seen for her first post-CyberKnife treatment visit.,Since undergoing CyberKnife treatment, she has had low-level nausea without vomiting.  She continues to have pain with deep inspiration and resolving dysphagia.  She has no heartburn, cough, hemoptysis, rash, or palpable rib pain.,MEDICATIONS: , Dilantin 100 mg four times a day, phenobarbital 30 mg three times per day, levothyroxine 0.025 mg p.o. q. day, Tylenol with Codeine b.i.d., prednisone 5 mg p.r.n., citalopram 10 mg p.o. q. day, Spiriva q. day, Combivent inhaler p.r.n., omeprazole 20 mg p.o. q. day, Lidoderm patch every 12 hours, Naprosyn 375 mg p.o. b.i.d., oxaprozin 600 mg p.o. b.i.d., Megace 40 mg p.o. b.i.d., and Asacol p.r.n.,PHYSICAL EXAMINATION: , BP:  122/86.  Temp:  96.8.  HR:  79.  RR:  26.  RAS:  100%.,HEENT:  Normocephalic.  Pupils are equal and reactive to light and accommodation.  EOMs intact.,NECK:  Supple without masses or lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally,CARDIAC:  Regular rate and rhythm without rubs, murmurs, or gallops.,EXTREMITIES:  No cyanosis, clubbing or edema.,ASSESSMENT: , The patient has done well with CyberKnife treatment of a stage IA non-small cell lung cancer, right upper lobe, one month ago.,PLAN: , She is to return to clinic in three months with a PET CT.
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DESCRIPTION: The patient is a 61-year-old female who was treated with CyberKnife therapy to a right upper lobe stage IA non-small cell lung cancer.  CyberKnife treatment was completed one month ago.  She is now being seen for her first post-CyberKnife treatment visit.

soap / chart / progress notes, non-small cell lung cancer, cyberknife therapy, lung cancer, cell, lung, cancer, cyberknife,

This situation involves post-treatment follow-up for a patient who has undergone CyberKnife therapy for stage IA non-small cell lung cancer. It includes monitoring of symptoms and side effects to ensure proper recovery and management. Although the current assessment indicates that the patient is doing well, the follow-up and monitoring are vital to detect any complications early. However, since this is a routine follow-up visit and there are no immediate life-threatening issues reported, the stakes are moderate rather than high.


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

Medical Specialty: Surgery
Sample Name: Bilateral Myringotomies - 2

PREOPERATIVE DIAGNOSES: , Bilateral chronic otitis media,POSTOPERATIVE DIAGNOSES:,  Bilateral chronic otitis media,ANESTHESIA:,  General mask,NAME OF OPERATION:,  Bilateral Myringotomy with placement of PE tubes,PROCEDURE:,  The patient was taken to the operating room and placed in the supine position.  After adequate general inhalation anesthesia was obtained, the operating microscope with brought in for full use throughout the case.  First, the left and then the right tympanic membrane, was approached.  An anterior-inferior radial incision was made in the left tympanic membrane.  Suction revealed a substantial amount of mucopurulent drainage.  A Sheehy pressure equalization tube was placed in the myringotomy site.  Floxin drops were added.  The same procedure was repeated on the right side with similar findings noted of mucopurulent drainage.  The patient tolerated the procedure well and returned to the recovery room awake and in stable condition.
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DESCRIPTION: Bilateral Myringotomy with placement of PE tubes

surgery, placement of pe tubes, bilateral chronic otitis media, chronic otitis media, bilateral myringotomy, pe tubes, chronic otitis, otitis media, tympanic membrane, mucopurulent drainage, tympanic, membrane, mucopurulent, myringotomy, tubes,

The situation involves a surgical procedure known as bilateral myringotomy with the placement of pressure equalization (PE) tubes, which is generally a routine operation to treat chronic otitis media (ear infection). While it is a surgical procedure under general anesthesia, and any surgery carries inherent risks, it is considered one of the more common and straightforward ENT (ear, nose, and throat) surgeries, typically with low risk of complications. Given the nature of the procedure and the typical patient outcomes, this situation is not particularly high-stakes relative to other medical procedures, although it does require medical precision and appropriate post-operative care to prevent complications like infection.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Neurology
Sample Name: Wilson's Disease - Letter

Doctor's Address,Dear Doctor:,This letter is an introduction to my patient, A, who you will be seeing in the near future.  He is a pleasant gentleman with a history of Wilson's disease.  It has been treated with penicillamine.  He was diagnosed with this at age 14.  He was on his way to South Carolina for a trip when he developed shortness of breath, palpitations, and chest discomfort.  He went to the closest hospital that they were near in Randolph, North Carolina and he was found to be in atrial fibrillation with rapid rate.  He was admitted there and observed.  He converted to normal sinus rhythm spontaneously and so he required no further interventions.  He was started on Lopressor, which he has tolerated well.  An echocardiogram was performed, which revealed mild-to-moderate left atrial enlargement.  Normal ejection fraction.  No other significant valvular abnormality.  He reported to physicians there that he had cirrhosis related to his Wilson's disease.  Therefore hepatologist was consulted.  There was a recommendation to avoid Coumadin secondary to his questionable significant liver disease, therefore he was placed on aspirin 325 mg once a day.,In discussion with Mr. A and review of his chart that I have available, it is unclear as to the status of his liver disease, however, he has never had a liver biopsy, so his diagnosis of cirrhosis that they were concerned about in North Carolina is in doubt.  His LFTs have remained normal and his copper level has been undetectable on his current dose of penicillamine.,I would appreciate your input into the long term management of his anticoagulation and also any recommendations you would have about rhythm control.  He is in normal sinus rhythm as of my evaluation of him on 06/12/2008.  He is tolerating his metoprolol and aspirin without any difficulty.  I guess the big question remains is what level of risk that is entailed by placing him on Coumadin therapy due to his potentially paroxysmal atrial fibrillation and evidence of left atrial enlargement that would place him in increased risk of recurrent episodes.,I appreciate your input regarding this friendly gentleman.  His current medicines include penicillamine 250 mg p.o. four times a day, metoprolol 12.5 mg twice a day, and aspirin 325 mg a day.,If you have any questions regarding his care, please feel free to call me to discuss his case.  Otherwise, I will look forward to hearing back from you regarding his evaluation.  Thank you as always for your care of our patient.
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DESCRIPTION: A pleasant gentleman with a history of Wilson's disease who has been treated with penicillamine.

neurology, atrial enlargement, wilson's disease, penicillamine,

The situation involves the management of a patient with Wilson's disease who experienced an episode of atrial fibrillation, a condition that could lead to serious cardiovascular complications if not managed properly. The decision on anticoagulation therapy is crucial in preventing potential stroke or clot-related issues, especially considering the patient's liver disease history which complicates the use of blood thinners. The stakes are moderately high as improper management could lead to severe health consequences for the patient.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Laparoscopic Adrenalectomy

PREOPERATIVE DIAGNOSIS: , Left adrenal mass, 5.5 cm.,POSTOPERATIVE DIAGNOSES:,1.  Left adrenal mass, 5.5 cm.,2.  Intraabdominal adhesions.,PROCEDURE PERFORMED:,1.  Laparoscopic lysis of adhesions.,2.  Laparoscopic left adrenalectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:,  Less than 100 cc.,FLUIDS: , 3500 cc crystalloids.,DRAINS:,  None.,DISPOSITION:,  The patient was taken to recovery room in stable condition.  Sponge, needle, and instrument counts were correct per OR staff.,HISTORY:,  This is a 57-year-old female who was found to have a large left adrenal mass, approximately 5.5 cm in size.  She had undergone workup previously with my associate, Dr. X as well as by Endocrinology, and showed this to be a nonfunctioning mass.  Due to the size, the patient was advised to undergo an adrenalectomy and she chose the laparoscopic approach due to her multiple pulmonary comorbidities.,INTRAOPERATIVE FINDINGS: , Showed multiple intraabdominal adhesions in the anterior abdominal wall.  The spleen and liver were unremarkable.  The gallbladder was surgically absent.,There was large amount of omentum and bowel in the pelvis, therefore the gynecological organs were not visualized.  There was no evidence of peritoneal studding or masses.  The stomach was well decompressed as well as the bladder.,PROCEDURE DETAILS: , After informed consent was obtained from the patient, she was taken to the operating room and given general anesthesia.  She was placed on a bean bag and secured to the table.  The table was rotated to the right to allow gravity to aid in our retraction of the bowel.,Prep was performed.  Sterile drapes were applied.  Using the Hassan technique, we placed a primary laparoscopy port approximately 3 cm lateral to the umbilicus on the left.  Laparoscopy was performed with ___________.  At this point, we had a second trocar, which was 10 mm to 11 mm port.  Using the non-cutting trocar in the anterior axillary line and using Harmonic scalpel, we did massive lysis of adhesions from the anterior abdominal wall from the length of the prior abdominal incision, the entire length of the abdominal incision from the xiphoid process to the umbilicus.  The adhesions were taken down off the entire anterior abdominal wall.,At this point, secondary and tertiary ports were placed.  We had one near the midline in the subcostal region and to the left midline and one at the midclavicular line, which were also 10 and 11 ports using a non-cutting blade.,At this point, using the Harmonic scalpel, we opened the white line of Toldt on the left and reflected the colon medially, off the anterior aspect of the Gerota's fascia.  Blunt and sharp dissection was used to isolate the upper pole of the kidney, taking down some adhesions from the spleen.  The colon was further mobilized medially again using gravity to aid in our retraction.  After isolating the upper pole of the kidney using blunt and sharp dissection as well as the Harmonic scalpel, we were able to dissect the plane between the upper pole of the kidney and lower aspect of the adrenal gland.  We were able to isolate the adrenal vein, dumping into the renal vein, this was doubly clipped and transected.  There was also noted to be vascular structure of the upper pole, which was also doubly clipped and transected.  Using the Harmonic scalpel, we were able to continue free the remainder of the adrenal glands from its attachments medially, posteriorly, cephalad, and laterally.,At this point, using the EndoCatch bag, we removed the adrenal gland through the primary port in the periumbilical region and sent the flap for analysis.  Repeat laparoscopy showed no additional findings.  The bowel was unremarkable, no evidence of bowel injury, no evidence of any bleeding from the operative site.,The operative site was irrigated copiously with saline and reinspected and again there was no evidence of bleeding.  The abdominal cavity was desufflated and was reinspected.  There was no evidence of bleeding.,At this point, the camera was switched to one of the subcostal ports and the primary port in the periumbilical region was closed under direct vision using #0 Vicryl suture.  At this point, each of the other ports were removed and then with palpation of each of these ports, this indicated that the non-cutting ports did close and there was no evidence of fascial defects.,At this point, the procedure was terminated.  The abdominal cavity was desufflated as stated.  The patient was sent to Recovery in stable condition.  Postoperative orders were written.  The procedure was discussed with the patient's family at length.
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DESCRIPTION: Laparoscopic lysis of adhesions and Laparoscopic left adrenalectomy.  Left adrenal mass, 5.5 cm and intraabdominal adhesions.

The case involves a surgical procedure to remove a 5.5 cm adrenal mass through a laparoscopic adrenalectomy. The adrenal mass, though nonfunctioning, is sizable and can pose risks such as malignancy. Additionally, the patient has multiple pulmonary comorbidities, suggesting that both the surgery and anesthesia carry additional risks. Although no immediate postoperative complications are mentioned, the surgery's complexity, the patient's comorbid conditions, and the potential implications for her health make this a moderately high-stakes situation.


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

HISTORY:,  The patient is a 51-year-old female that was seen in consultation at the request of Dr. X on 06/04/2008 regarding chronic nasal congestion, difficulty with swallowing, and hearing loss.  The patient reports that she has been having history of recurrent sinus infection, averages about three times per year.  During the time that she gets the sinus infections, she has nasal congestion, nasal drainage, and also generally develops an ear infection as well.  The patient does note that she has been having hearing loss.  This is particular prominent in the right ear now for the past three to four years.  She does note popping after blowing the nose.  Occasionally, the hearing will improve and then it plugs back up again.  She seems to be plugged within the nasal passage, more on the right side than the left and this seems to be year round issue with her.  She tried Flonase nasal spray to see if this help with this and has been taking it, but has not seen a dramatic improvement.  She has had a history of swallowing issues and that again secondary to the persistent postnasal drainage.  She feels that she is having a hard time swallowing at times as well.  She has complained of a lump sensation in the throat that tends to come and go.  She denies any cough, no hemoptysis, no weight change.  No night sweats, fever or chills has been noted.  She is having at this time no complaints of tinnitus or vertigo.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:  ,ALLERGY/IMMUNOLOGIC:  History of seasonal allergies.  She also has severe allergy to penicillin and bee stings.,CARDIOVASCULAR:  Pertinent for hypercholesterolemia.,PULMONARY:  She has a history of cough, wheezing.,GASTROINTESTINAL:  Negative.,GENITOURINARY:  Negative.,NEUROLOGIC:  She has had a history of TIAs in the past.,VISUAL:  She does have history of vision change, wears glasses.,DERMATOLOGIC:  Negative.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  History of joint pain and bursitis.,CONSTITUTIONAL:  She has a history of chronic fatigue.,ENT:  She has had a history of cholesteatoma removal from the right middle ear and previous tympanoplasty with a progressive hearing loss in the right ear over the past few years according to the patient.,PSYCHOLOGIC:  History of anxiety, depression.,HEMATOLOGIC:  Easy bruising.,PAST SURGICAL HISTORY: , She has had right tympanoplasty in 1984.  She has had a left carotid endarterectomy, cholecystectomy, two C sections, hysterectomy, and appendectomy.,FAMILY HISTORY: , Mother, history of vaginal cancer and hypertension.  Brother, colon CA.  Father, hypertension.,CURRENT MEDICATIONS: , Aspirin 81 mg daily.  She takes vitamins one a day.  She is on Zocor, Desyrel, Flonase, and Xanax.  She also has been taking Chantix for smoking cessation.,ALLERGIES: , Penicillin causes throat swelling.  She also notes the bee sting allergy causes throat and tongue swelling.,SOCIAL HISTORY: , The patient is single.  She is unemployed at this time.  She is a smoker about a pack and a half for 38 years and notes rare alcohol use.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Her blood pressure 128/78, temperature is 98.6, pulse 80 and regular.,GENERAL:  The patient is an alert, cooperative, well-developed 51-year-old female.  She has a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  Right ear, the external ear is normal.  The ear canal is clean and dry.  The drum is intact.  She has got severe tympanosclerosis of the right tympanic membrane and Weber exam does lateralize to the right ear indicative of a conductive loss.  Left ear, the external ear is normal.  The ear canal is clean and dry.  The drum is intact and mobile with grossly normal hearing.  The audiogram does reveal normal hearing in the left ear.  She has got a mild conductive loss throughout all frequency ranges in the right ear with excellent discrimination scores noted bilaterally.  Tympanograms, there was no adequate seal obtained on the right side.  She has a normal type A tympanogram, left side.,NASAL:  Reveals a deviated nasal septum to the left, clear drainage, large inferior turbinates, no erythema.,ORAL:  Oral cavity is normal with good moisture.  Lips, teeth and gums are normal.  Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx.  Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords.  The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.,NECK:  The neck was examined with normal appearance.  Trachea in the midline.  The thyroid was normal, nontender, with no palpable masses or adenopathy noted.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,PROCEDURE: , Please note a fiberoptic laryngoscopy was also done at today's visit for further evaluation because of the patient's dysphagia and throat symptoms.  Findings do reveal moderately deviated nasal septum to the left, large inferior turbinates noted.  The nasopharynx does reveal moderate adenoid pad within this midline.  It is nonulcerated.  The larynx revealed both cords to be normal.  She does have mild lingual tonsillar hypertrophy as well.,IMPRESSION:  ,1.  Persistent dysphagia.  I think secondary most likely to the persistent postnasal drainage.,2.  Deviated nasal septum.,3.  Inferior turbinate hypertrophy.,4.  Chronic rhinitis.,5.  Conductive hearing loss, right ear with a history of cholesteatoma of the right ear.
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DESCRIPTION: Persistent dysphagia.  Deviated nasal septum.  Inferior turbinate hypertrophy.  Chronic rhinitis. Conductive hearing loss.  Tympanosclerosis.

The situation involves a comprehensive evaluation of a patient's ENT issues, including chronic nasal congestion, hearing loss, and swallowing difficulties. While these symptoms are discomforting and likely affect the patient's quality of life, they are not life-threatening in the immediate sense. The consultation aims to diagnose and plan treatment for symptoms that have been persistent but are not described as acute or immediately critical. The patient's past medical and surgical history, allergies, and family history add complexity but do not elevate the situation to a high-stakes emergency.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 3

PREOPERATIVE DIAGNOSIS:,  Prior history of neoplastic polyps.,POSTOPERATIVE DIAGNOSIS:,  Small rectal polyps/removed and fulgurated.,PREMEDICATIONS:,  Prior to the colonoscopy, the patient complained of a sever headache and she was concerned that she might become ill.  I asked the nurse to give her 25 mg of Demerol IV.,Following the IV Demerol, she had a nausea reaction.  She was then given 25 mg of Phenergan IV.  Following this, her headache and nausea completely resolved.  She was then given a total of 7.5 mg of Versed with adequate sedation.  Rectal exam revealed no external lesions.  Digital exam revealed no mass.,REPORTED PROCEDURE:,  The P160 colonoscope was used.  The scope was placed in the rectal ampulla and advanced to the cecum.  Navigation through the sigmoid colon was difficult.  Beginning at 30 cm was a very tight bend.  With gentle maneuvering, the scope passed through and then entered the cecum.  The cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, and descending colon were normal.  The sigmoid colon was likewise normal.  There were five very small (punctate) polyps in the rectum.  One was resected using the electrocautery snare and the other four were ablated using the snare and cautery.  There was no specimen because the polyps were so small.  The scope was retroflexed in the rectum and no further abnormality was seen, so the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Five small polyps as described, all fulgurated.,2.  Otherwise unremarkable colonoscopy.
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DESCRIPTION: Colonoscopy to evaluate prior history of neoplastic polyps.

gastroenterology, colonoscopy, demerol, phenergan, rectal exam, versed, ascending colon, cecum, colonoscope, descending colon, fulgurated, hepatic flexure, neoplastic, polyps, punctate, rectal ampulla, splenic flexure, transverse colon, scope

The situation involves a medical procedure where polyps were found and removed during a colonoscopy. While the removal of polyps can be routine, especially when they are small, the patient's prior history of neoplastic polyps potentially increases the risk of complications or future health issues. The patient's reaction to medications and the difficulty navigating the scope indicate some challenges during the procedure, but these were managed appropriately. Overall, the stakes are moderate given the potential implications of neoplastic polyps and immediate procedural considerations.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Thrombocytosis Followup

CHIEF COMPLAINT:,  Essential thrombocytosis.,HISTORY OF PRESENT ILLNESS: , This is an extremely pleasant 64-year-old gentleman who I am following for essential thrombocytosis.  He was first diagnosed when he first saw a hematologist on 07/09/07.  At that time, his platelet count was 1,240,000.  He was initially started on Hydrea 1000 mg q.d.  On 07/11/07, he underwent a bone marrow biopsy, which showed essential thrombocytosis.  He was positive for the JAK-2 mutation.  On 11/06/07, his platelets were noted to be 766,000.  His current Hydrea dose is now 1500 mg on Mondays and Fridays and 1000 mg on all other days.  He moved to ABCD in December 2009 in an attempt to improve his wife's rheumatoid arthritis.,Overall, he is doing well.  He has a good energy level, and his ECOG performance status is 0.  He denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS: , Hydrea 1500 mg on Mondays and Fridays and 1000 mg the other days of the week,  Flomax q.d., vitamin D q.d, saw palmetto q.d., aspirin 81 mg q.d., and vitamin C q.d.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:,  As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  He is status post an appendectomy.,2.  Status post a tonsillectomy and adenoidectomy.,3.  Status post bilateral cataract surgery.,4.  BPH.,SOCIAL HISTORY:  ,He has a history of tobacco use, which he quit at the age of 37.  He has one alcoholic drink per day.  He is married.  He is a retired lab manager.,FAMILY HISTORY:  ,There is no history of solid tumor or hematologic malignancies in his family.,PHYSICAL EXAM:,VIT:
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DESCRIPTION: Essential thrombocytosis.  He underwent a bone marrow biopsy, which showed essential thrombocytosis.  His CBC has been very stable.

The follow-up note describes a patient with essential thrombocytosis, a chronic condition characterized by an overproduction of platelets. The patient's condition appears to be well-managed with medication, and there are no immediate concerning symptoms such as fevers, chills, or night sweats. The situation does not indicate any urgent changes or new risks that need to be addressed immediately, suggesting it's not a high-stakes situation in the context of acute medical care. However, it does involve ongoing management of a hematologic condition, which requires monitoring.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Carotid Endarterectomy & Angioplasty.

PREOPERATIVE DIAGNOSIS:,  Critical left carotid stenosis.,POSTOPERATIVE DIAGNOSIS: , Critical left carotid stenosis.,PROCEDURE PERFORMED:,  Left carotid endarterectomy with endovascular patch angioplasty.,ANESTHESIA:,  Cervical block.,GROSS FINDINGS:  ,The patient is a 57-year-old black female with chronic renal failure.  She does have known critical carotid artery stenosis.  She wishes to undergo bilateral carotid endarterectomy, however, it was felt necessary by Dr. X to perform cardiac catheterization.  She was admitted to the hospital yesterday with chest pain.  She has been considered for coronary artery bypass grafting.  I have been asked to address the carotid stenosis, left being more severe, this was addressed first.  Intraoperatively, an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery.  The internal carotid artery is quite torturous.  The external carotid artery was occluded at its origin.  When the endarterectomy was performed, the external carotid artery back-bled nicely.  The internal carotid artery had good backflow bleeding noted.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite and placed in the supine position.  Then neck, shoulder, and chest wall were prepped and draped in appropriate manner.  Longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery.,Utilizing both blunt and sharp dissections, the common carotid artery, the internal carotid artery beyond the atherosclerotic back, the external carotid artery, and the superior thyroid artery were isolated and encircled with a umbilical tape.  During the dissection, facial veins were ligated with #4-0 silk ligature prior to dividing them.  Also during the dissection, ansa cervicalis, hypoglossal, and vagus nerve identified and preserved.  There was some inflammation above the carotid bulb, but this was not problematic.,The patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time.  The internal carotid artery is controlled with Heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with Heifitz clips.  The common carotid artery was controlled with profunda clamp.  The patient remained neurologically intact.  A longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery.  This was extended across the lobe on to the internal carotid artery.  An endarterectomy was then performed.  The ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline.  As mentioned before, the internal carotid artery is quite torturous.  This was shortened by imbricating the internal carotid artery with horizontal mattress stitches of #7-0 Prolene suture.,The wound was copiously irrigated, rather an endovascular patch was then brought on to the field.  This was cut to shape and length.  This was sutured in place with continuous running #6-0 Prolene suture.  The suture line began at both sites.  The suture was tied in the center along the anterior and posterior walls.  Prior to completing the closure, the common carotid artery was flushed.  The internal carotid artery permitted to back bleed.  The clamp was placed after completing the closure.  The clamp was placed at the origin of the internal carotid artery.  Flow was first directed into the external carotid artery then into the internal carotid artery.  The patient remained neurologically intact.  Topical ________ Gelfoam was utilized.  Of note, during the endarterectomy, the patient did receive an additional 7000 units of aqueous heparin.  The wound was copiously irrigated with antibiotic solution.  Sponge, needle, and all counts were correct.  All surgical sites were inspected.  Good hemostasis noted.  The incision was closed in layers with absorbable suture.  Stainless steel staples approximated skin.  Sterile dressings were applied.  The patient tolerated the procedure well, grossly neurologically intact.
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DESCRIPTION: Left carotid endarterectomy with endovascular patch angioplasty.  Critical left carotid stenosis.  The external carotid artery was occluded at its origin.  When the endarterectomy was performed, the external carotid artery back-bled nicely.  The internal carotid artery had good backflow bleeding noted.

cardiovascular / pulmonary, carotid stenosis, carotid endarterectomy, endovascular patch angioplasty, cervical block, carotid artery, common carotid artery, external carotid artery, endovascular patch, common carotid, external carotid, angioplasty, artery, endovascular, neurologically, carotid, stenosis, endarterectomy

The procedure described is a carotid endarterectomy with angioplasty, addressing critical carotid stenosis, which is a high-stakes surgical intervention. This type of surgery is performed to prevent stroke in patients with significant carotid artery stenosis, which itself poses a risk to the patient's neurological health. The stakes are high due to the potential complications associated with the procedure, such as stroke, nerve injury, myocardial infarction, and the patient's chronic renal failure, which adds complexity to perioperative management. Additionally, the patient's preoperative symptoms and the necessity for simultaneous cardiac evaluations and potential treatments like coronary artery bypass grafting elevate the stakes of the patient's overall health scenario.


Medical Specialty: Neurosurgery
Sample Name: Temporal Artery Biopsy

PREOPERATIVE DIAGNOSIS:,  Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS:  ,Rule out temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsy.,ANESTHESIA:,  Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:,  I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis.  I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way.  After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery.  The temporal artery was identified and was grossly normal on both sides.  Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult.  The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm.  They were sent as separate specimens, right and left labeled.  The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond.  She tolerated the procedure well.
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DESCRIPTION: Bilateral temporal artery biopsy.  Rule out temporal arteritis.

neurosurgery, headaches, bilateral temporal artery, temporal artery biopsy, temporal arteritis, temporal artery, temporal, biopsy, arteritis

The situation involves a medical procedure where a temporal artery biopsy is performed to rule out temporal arteritis. While a biopsy is an invasive procedure, it is generally not considered a highly risky or high-stakes operation compared to other neurosurgery procedures. Temporal arteritis can lead to serious complications such as vision loss if not treated, so diagnosing it is important, but the stakes in this specific context are related to diagnosis rather than immediate life-threatening conditions during the procedure.


Medical Specialty: Radiology
Sample Name: EMG/Nerve Conduction Study - 7

HISTORY: , The patient is a 34-year-old right-handed female who states her symptoms first started after a motor vehicle accident in September 2005.  She may have had a brief loss of consciousness at the time of the accident since shortly thereafter she had some blurred vision, which lasted about a week and then resolved.  Since that time she has had right low neck pain and left low back pain.  She has been extensively worked up and treated for this.  MRI of the C & T spine and LS spine has been normal.  She has improved significantly, but still complains of pain.  In June of this year she had different symptoms, which she feels are unrelated.  She had some chest pain and feeling of tightness in the left arm and leg and face.  By the next morning she had numbness around her lips on the left side and encompassing the whole left arm and leg.  Symptoms lasted for about two days and then resolved.  However, since that time she has had intermittent numbness in the left hand and leg.  The face numbness has completely resolved.  Symptoms are mild.  She denies any previous similar episodes.  She denies associated dizziness, vision changes incoordination, weakness, change in gait, or change in bowel or bladder function.  There is no associated headache.,Brief examination reveals normal motor examination with no pronator drift and no incoordination.  Normal gait.  Cranial nerves are intact.  Sensory examination reveals normal facial sensation.  She has normal and symmetrical light touch, temperature, and pinprick in the upper extremities.  In the lower extremities she has a feeling of dysesthesia in the lateral aspect of the left calf into the lateral aspect of the left foot.  In this area she has normal light touch and pinprick.  She describes it as a strange unusual sensation.,NERVE CONDUCTION STUDIES: , Motor and sensory distal latencies, evoked response amplitudes, conduction velocities, and F-waves are normal in the left arm and leg.,NEEDLE EMG: , Needle EMG was performed in the left leg, lumbosacral paraspinal, right tibialis anterior, and right upper thoracic paraspinal muscles using a disposable concentric needle.  It revealed normal insertional activity, no spontaneous activity, and normal motor unit action potential form in all muscles tested.,IMPRESSION: , This electrical study is normal.  There is no evidence for peripheral neuropathy, entrapment neuropathy, plexopathy, or lumbosacral radiculopathy.  EMG was also performed in the right upper thoracic paraspinal where she has experienced a lot of pain since the motor vehicle accident.  This was normal.,Based on her history of sudden onset of left face, arm, and leg weakness as well as a normal EMG and MRI of her spine I am concerned that she had a central event in June of this year.  Symptoms are now very mild, but I have ordered an MRI of the brain with and without contrast and MRA of the head and neck with contrast to further elucidate her symptoms.  Once she has the test done she will phone me and further management will be based on the results.
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DESCRIPTION: Patient had movor vehicle accirdent and may have had a brief loss of consciousness.  Shortly thereafter she had some blurred vision,  Since that time she has had right low neck pain and left low back pain.

radiology, nerve conduction studies, motor, sensory, distal latencies, evoked response, conduction velocities, needle emg, loss of consciousness, motor vehicle accident, thoracic paraspinal, needle, paraspinal, conduction,

The situation involves a patient who experienced significant symptoms such as numbness, weakness, and pain following a motor vehicle accident. While the initial EMG and MRI results are normal, there is a concern about a possible central nervous system event, which could be serious. The healthcare provider has ordered further diagnostic imaging to investigate the possibility of a central event like a stroke or transient ischemic attack. These potential diagnoses could have major implications for the patient's health and require urgent and effective medical intervention, making this situation relatively high-stakes.


Medical Specialty: Surgery
Sample Name: ORIF - 2

PREOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,POSTOPERATIVE DIAGNOSIS: , Severely comminuted fracture of the distal radius, left.,OPERATIVE PROCEDURE:  ,Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.,ANESTHESIA: , General endotracheal.,PREOPERATIVE INDICATIONS: , This is a 52-year-old patient of mine who I have repaired both shoulder rotator cuffs, the most recent one in the calendar year 2007.  While he was climbing a ladder recently in the immediate postop stage, he fell suffering the aforementioned heavily comminuted Frykman fracture.  This fracture had a fragment that extended in the distal radial ulnar joint, a die-punch fragment in the center of the radius.  The ulnar styloid and the radial styloid were off and there were severe dorsal comminutions.  He presented to my office the morning of April 3, 2007, having had a left reduction done elsewhere a day ago.  The reduction, although adequate, had allowed for the fragments to settle and I discussed with him the severity of the injury on a scale of 1-8, this was essentially an 8.  The best results have been either with external fixation or internal fixation, most recently volar plating of a locking variety has been popular, and I felt that this would be appropriate in his case.,Risks and benefits otherwise described were bleeding, infection, need to do operative revise or removal of hardware.  He is taking a job out of state in the next couple of months.  Hence I felt that even with close followup, this is a particularly difficult fracture as far as the morbidity of the injury proceeds.,OPERATIVE NOTE: , After adequate general endotracheal anesthesia was obtained, one gram of Ancef was given intravenously.  The left upper extremity was prepped and draped in supine position with the left hand in the arm table, magnification was used throughout.  The time out procedure was done to the satisfaction of all present that this was indeed the appropriate extremity on the appropriate patient.  A small C-arm was brought in to help guide the incision which was a volar curvilinear incision that included as part of this due to the fracture blisters eminent compartment syndrome and numbness in fingers.  A carpal tunnel release was done with the transverse carpal ligament being protected with a Freer elevator.  The usual amount of dissection of the pronator quadratus was necessary to view the distal radial fragment.  The pronator quadratus actually grasped several of the fragments itself which had to be dissected free from them, specifically the distal radial ulnar joint and die-punch fragment.  At this point, a locking Synthes distal radius plate from the modular handset was selected that had five articular screws as well as five locking shaft screws.  The ulnar styloid was not affixed in any portion of this repair.  The plate was viewed under the image intensification device, i.e., x-ray and the screws were placed in this order.  The most proximal shaft screw was placed to allow the remainder of the plate to form a buttress to then rearrange the fragments around the locking screws and a locking plate having been selected from the volar approach, a locking 12-mm screw through 16-mm screws were placed in the following order.  Most proximal on the radial shaft of the plate, then the radial styloid, i.e., the most distal and lateral screw, the next most proximal shaft screw followed by the distal radial ulnar joint screw.  Three screws were locking across the die-punch fragment.  The remaining two screws were placed into the radial shaft.  All of these were locking screws of 2 mm in diameter and as the construct was created, the relative motion of the intra-articular fragment in dorsal comminution all diminished greatly, although the exposure as well as the amount of reduction force used was substantial.  The tourniquet time was 1.5 hours.  At this point, the tourniquet was let down.  The entire construct was irrigated with copious amounts of bacitracin and normal saline.  Closure was affected with 0 Vicryl underneath the skin surface followed by 3-0 Prolene in interrupted sutures in the volar wound.  Several image intensification x-rays were taken at the conclusion of the case to check screw length.  Screw lengths were changed out during the case as needed based on the x-ray findings.  The wound was injected with Marcaine, lidocaine, Depo-Medrol, and Kantrex.  A very heavily padded fluffy cotton Jones-type dressing was applied with a volar splint.  Estimated blood loss was 10 mL.  There were no specimens.  Tourniquet time was 1.5 hours.
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DESCRIPTION: Open reduction and internal fixation, high grade Frykman VIII distal radius fracture.

surgery, distal radius, c-arm, depo-medrol, frykman, jones-type dressing, kantrex, marcaine, open reduction and internal fixation, die-punch, intra-articular, lidocaine, pronator quadratus, radial styloid, ulnar styloid, distal radial ulnar joint, radial ulnar joint, distal, screws, orif, fracture, radial

This surgical procedure involves open reduction and internal fixation for a complex, severely comminuted distal radius fracture, classified as Frykman VIII. This type of surgery inherently carries significant risks typical of orthopedic surgeries, such as bleeding, infection, and the potential need for later revision surgery. The complexity of the fracture, along with the patient's occupational situation, adds to the stakes, as the function of the wrist is critical for daily activities and the patient's upcoming job out of state. Moreover, the patient's history of falling and having a recent surgery further complicates the situation, making recovery and rehabilitation crucial.


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

REASON FOR VISIT: , Kyphosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis.  The patient has a family history in a maternal aunt and grandfather of kyphosis.  She was noted by her parents to have round back posture.  They have previously seen another orthopedist who recommended observation at this time.  She is here for a second opinion in regards to kyphosis.  The patient denies any pain in her back or any numbness, tingling, or weakness in her upper or lower extremities.  No problems with her bowels or bladder.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Bilateral pinning of her ears.,SOCIAL HISTORY:  ,She is currently an eighth grader at Middle School and is interested in basketball.  She lives with both of her parents and has a 9-year-old brother.  She had menarche beginning in September.,FAMILY HISTORY:  ,Of kyphosis in great grandmother and second cousin.,REVIEW OF SYSTEMS: , She is in her usual state of health and is negative except otherwise as mentioned in the history of present illness.,MEDICATIONS: , She is currently on Zyrtec, Flonase, and Ceftin for an ear infection.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, she is alert, oriented, and in no acute distress standing 63 inches tall.  In regards to her back, her skin is intact with no rashes, lesions, and/or no dimpling or hair spots.  No cafe au lait spots.  She is not tender to palpation from her occiput to her sacrum.  There is no evidence of paraspinal muscle spasm.  On forward bending, there is a mild kyphosis.  She is not able to touch her toes indicating her hamstring tightness.  She has a full 5 out of 5 in all muscle groups.  Her lower extremities including iliopsoas, quadriceps, gastroc-soleus, tibialis anterior, and extensor hallucis longus.  Her sensation intact to light touch in L1 through L2 dermatomal distributions.  She has symmetric limb lengths as well bilaterally from both the coronal and sagittal planes.,X-rays today included PA and lateral sclerosis series.  She has approximately 46 degree kyphosis.,ASSESSMENT: , Kyphosis.,PLANS:  ,The patient's kyphosis is quite mild.  While this is likely in the upper limits of normal or just it is normal for an adolescent and still within normal range as would be expected return at home.  At this time, three options were discussed with the parents including observation, physical therapy, and bracing.  At this juncture, given that she has continued to grow, they are Risser 0.  She may benefit from continued observation with physical therapy, bracing would be a more aggressive option certainly that thing would be lost with following at this time.  As such, she was given a prescription for physical therapy for extension based strengthening exercises, flexibility range of motion exercises, postural training with no forward bending.  We will see her back in 3 months' time for repeat radiographs at that time including PA and lateral standing of scoliosis series.  Should she show evidence of continued progression of her kyphotic deformity, discussions of bracing would be held at time.  We will see her back in 3 months' time for repeat evaluation.
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DESCRIPTION: A 13-year-old new patientfor evaluation of thoracic kyphosis.   Family history of kyphosis in a maternal aunt and grandfather.  She was noted by her parents to have round back posture.

consult - history and phy., thoracic kyphosis, round back posture, physical therapy, kyphosis, patientfor, orthopedist,

The clinical situation involves a 13-year-old patient with mild thoracic kyphosis, a relatively common spinal condition in adolescents. While the condition requires monitoring and potential intervention, it is not currently causing significant symptoms or complications, as evidenced by the absence of pain or neurological symptoms. The current recommendations involve observation and physical therapy, which indicates a non-urgent approach. This situation is not life-threatening or requiring immediate intervention, making it lower stakes in the medical context.


Medical Specialty: Surgery
Sample Name: Escharotomy

PREOPERATIVE DIAGNOSES:,  32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,POSTOPERATIVE DIAGNOSES: , 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,PROCEDURES  PERFORMED:,1.  Lateral escharotomy of right upper arm burn eschar.,2.  Medial escharotomy of left upper extremity burns and eschar.,ANESTHESIA:,  Propofol and Versed.,INDICATIONS FOR PROCEDURE: , The patient is a 72-year-old gentleman who was involved in a propane explosion where he sustained significant burns to his bilateral upper extremities, neck, and thorax.  The patient was transferred from outside facility and was found to have significant burns with impending compartment syndrome of the right upper extremity.  The patient had a _____ between his left and right upper extremity and very tight compartment of his right upper extremity.  It is felt the patient would need an escharotomy of his right upper extremity to maintain perfusion to his right arm and hand.,DESCRIPTION OF PROCEDURE:,  After appropriate time out was performed indicating the correct procedure, correct patient, and all parties involved, the patient's right upper extremity was placed in anatomical position.  An electrocautery device was readied and used to incise making make an incision on the lateral aspect of the patient's right upper extremity.  Starting just below the right humeral head, an incision was made through the burn eschar down to underlying subcutaneous tissue.  The incision was carried from the right humeral head down to just below the antecubital fossa on the right upper extremity.  All dermal bridging was taken down and was opened without any excessive bleeding.  Next, a medial incision was made starting at the axilla down to just below the medial epicondyle of the right upper extremity.  Again, the incision was carried through the entire of the eschar down to underlying subcutaneous tissue.  All bleeding was made hemostatic with electrocautery and all dermal abrasions were taken down.  At the completion of the procedure, the patient had improved right distal radial pulse and his compartment was much softer.  Silvadene cream was placed within the escharotomy incision and wrapped in Kerlix.  The patient tolerated the procedure well, and there were no adverse events during or after the procedure.
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DESCRIPTION: Lateral escharotomy of right upper arm burn eschar and medial escharotomy of left upper extremity burns and eschar.

surgery, lateral escharotomy, medial escharotomy, eschar, anterior thorax, underlying subcutaneous tissue, bilateral upper extremities, impending compartment syndrome, arm burn, extremity burns, humeral head, burn eschar, compartment syndrome, escharotomy, humeral, burns

The scenario involves a surgical procedure on a severely burned patient with an impending compartment syndrome, which is a serious and potentially life-threatening condition. Failure to correctly perform the escharotomy could result in permanent damage or loss of function in the affected limbs, and possibly other significant health complications. The patient's condition requires immediate and accurate surgical intervention, thus making it a high-stakes situation.


Medical Specialty: Neurology
Sample Name: Falls - Discharge Summary

CHIEF COMPLAINT:,  Falls at home.,HISTORY OF PRESENT ILLNESS:,  The patient is an 82-year-old female who fell at home and presented to the emergency room with increased anxiety.  Family members who are present state that the patient had been increasingly anxious and freely admitted that she was depressed at home.  They noted that she frequently came to the emergency room for "attention."  The patient denied any chest pain or pressure and no change to exercise tolerance.  The patient denied any loss of consciousness or incontinence.  She denies any seizure activity.  She states that she "tripped" at home.  Family states she frequently takes Darvocet for her anxiety and that makes her feel better, but they are afraid she is self medicating.  They stated that she has numerous medications at home, but they were not sure if she was taking them.  The patient been getting along for a number of years and has been doing well, but recently has been noting some decline primarily with regards to her depression.  The patient denied SI or HI.,PHYSICAL EXAMINATION:,GENERAL:  The patient is pleasant 82-year-old female in no acute distress.,VITAL SIGNS:  Stable.,HEENT:  Negative.,NECK:  Supple.  Carotid upstrokes are 2+.,LUNGS:  Clear.,HEART:  Normal S1 and S2.  No gallops.  Rate is regular.,ABDOMEN:  Soft.  Positive bowel sounds.  Nontender.,EXTREMITIES:  No edema.  There is some ecchymosis noted to the left great toe.  The area is tender; however, metatarsal is nontender.,NEUROLOGICAL:  Grossly nonfocal.,HOSPITAL COURSE: , A psychiatric evaluation was obtained due to the patient's increased depression and anxiety.  Continue Paxil and Xanax use was recommended.  The patient remained medically stable during her hospital stay and arrangements were made for discharge to a rehabilitation program given her recent falls.,DISCHARGE DIAGNOSES:,1.  Falls ,2.  Anxiety and depression.,3.  Hypertension.,4.  Hypercholesterolemia.,5.  Coronary artery disease.,6.  Osteoarthritis.,7.  Chronic obstructive pulmonary disease.,8.  Hypothyroidism.,CONDITION UPON DISCHARGE: , Stable.,DISCHARGE MEDICATIONS: , Tylenol 650 mg q.6h. p.r.n., Xanax 0.5 q.4h. p.r.n., Lasix 80 mg daily, Isordil 10 mg t.i.d., KCl 20 mEq b.i.d., lactulose 10 g daily, Cozaar 50 mg daily, Synthroid 75 mcg daily, Singulair 10 mg daily, Lumigan one drop both eyes at bed time, NitroQuick p.r.n., Pravachol 20 mg daily, Feldene 20 mg daily, Paxil 20 mg daily, Minipress 2 mg daily, Provera p.r.n., Advair 250/50 one puff b.i.d., Senokot one tablet b.i.d., Timoptic one drop OU daily, and verapamil 80 mg b.i.d.,ALLERGIES: , None.,ACTIVITY: , Per PT.,FOLLOW-UP: , The patient discharged to a skilled nursing facility for further rehabilitation.
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DESCRIPTION: Falls at home.  Anxiety and depression.  The patient had been increasingly anxious and freely admitted that she was depressed at home.

The situation involves an 82-year-old patient with a combination of falls, anxiety, depression, and a complex medical history involving multiple chronic conditions. The stakes are reasonably high due to the patient's age, the risk of further falls, potential self-medication, and mental health concerns. These elements suggest a need for careful monitoring and rehabilitation to prevent further deterioration. However, the immediate physical condition upon discharge is stable, and she is being moved to a skilled nursing facility for further care. This context slightly reduces the immediacy of the stakes, as she is under a structured care plan.


Medical Specialty: Surgery
Sample Name: Paracentesis

PREOPERATIVE DIAGNOSIS: , Abdominal mass.,POSTOPERATIVE DIAGNOSIS: , Abdominal mass.,PROCEDURE:,  Paracentesis.,DESCRIPTION OF PROCEDURE:  ,This 64-year-old female has stage II endometrial carcinoma, which had been resected before and treated with chemotherapy and radiation.  At the present time, the patient is under radiation treatment.  Two weeks ago or so, she developed a large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room.  We proceeded to admit the patient and drained a significant amount of clear fluid in the subsequent days.  The cytology of the fluid was negative and the culture was also negative.  Eventually, the patient was sent home with the pigtail shut off and the patient a week later underwent a repeat CAT scan of the abdomen and pelvis.,The CAT scan showed accumulation of the fluid and the mass almost achieving 80% of the previous size.  Therefore, I called the patient home and she came to the emergency department where the service was provided.  At that time, I proceeded to work on the pigtail catheter after obtaining an informed consent and preparing and draping the area in the usual fashion.  Unfortunately, the catheter was open.  I did not have a drainage system at that time.  So, I withdrew directly with a syringe 700 mL of clear fluid.  The system was connected to the draining bag, and the patient was instructed to keep a log and how to use equipment.  She was given an appointment to see me in the office next Monday, which is three days from now.
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DESCRIPTION: Paracentesis.  A large abdominal mass, which was cystic in nature and the radiologist inserted a pigtail catheter in the emergency room.

surgery, abdominal mass, clear fluid, cat scan, pigtail catheter, paracentesis,

The situation described involves a patient with previously treated stage II endometrial carcinoma experiencing complications and needing ongoing medical intervention. The procedure, paracentesis, was performed to manage a large cystic abdominal mass by draining fluid. While the procedure itself is fairly routine, the context of a cancer patient with recurrent fluid accumulation suggests potential underlying issues that could impact the patient's condition and treatment plan. It requires careful monitoring and follow-up to prevent complications and ensure appropriate management of her cancer-related symptoms, making it moderately high-stakes. However, it is not immediately life-threatening due to the negative results from cytology and culture, indicating that the fluid is not infected or malignant at the time.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 13

SUBJECTIVE:,  The patient is a 76-year-old white female who presents to the clinic today originally for hypertension and a med check.  She has a history of hypertension, osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.  Since her last visit she has been followed by Dr. Kumar.  Those issues are stable.  She has had no fever or chills, cough, congestion, nausea, vomiting, chest pain, chest pressure.,PAST MEDICAL HISTORY:,  She has an intolerance to Prevacid.,CURRENT MEDICATIONS:,  Evista 60 daily, Levothroid 0.05 mg daily, Claritin 10 daily, Celebrex 200 daily, HCTZ 25 daily and amitriptyline p.r.n.,PAST SURGICAL HISTORY:,  Bilateral mastectomies, tonsillectomy, EGD, flex sig in 2001 and a heart cath.,FAMILY HISTORY: , Father passed away at 81; mother of multiple myeloma at 83.,SOCIAL HISTORY:,  She is married.  A 76-year-old who used to smoke a pack a day and quit in 1985.  She is retired.,REVIEW OF SYSTEMS:,  Essentially negative in HEENT, chest, cardiovascular, GI, GU, musculoskeletal, or neurologic.,OBJECTIVE:,  Temperature is 97.5 degrees.  Blood pressure is 168/70.  Pulse is 88.  Weight is 129 pounds.,GENERAL:  She is an elderly 76-year-old in no acute distress.,HEENT:  Atraumatic.  Extraocular muscles were intact.  Pupils equal, round and reactive to light and accommodation.  Tympanic membranes are clear, dry and intact.  Sinuses and throat are clear.  Neck is soft, supple.  No meningeal signs are present.  No thyromegaly is present.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, nontender.  Bowel sounds are positive.  No organomegaly or peritoneal signs are present.,EXTREMITIES:  Moving all extremities.  Peripheral pulses are normal.  No edema is present.,NEUROLOGIC:  Alert and oriented.  Cranial nerves II-XII grossly intact.  Strength 5+/5 globally.  Reflexes 2+/IV globally.  Romberg is negative.  There is no numbness, tingling, weakness or other neurologic deficit present.,BREASTS:  Surgically absent but there are no lumps, lesions, masses, discharge or adenopathy present.,BACK:  Straight.,SKIN:  Clear.,GENITALIA:  Deferred as she has been followed by Dr. XYZ many times this year.  She does have a history of some elevated cholesterol.,ASSESSMENT:,1.  Hypertension, suboptimal control.,2.  Hypothyroidism.,3.  Arthritis.,4.  Allergic rhinitis.,5.  History of kidney stones.,6.  Osteoporosis.,PLAN:,1.  CBC, complete metabolic profile, UA for hypertension.,2.  Chest x-ray for history of breast cancer.,3.  DEXA scan, full body for osteoporosis.,4.  Flex is up to date.,5.  Pneumovax has been given in the last five years.,6.  Lipid profile for elevated cholesterol.,7.  Refill meds.,8.  Follow up every three to six months for blood pressure check or sooner p.r.n. problems.
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DESCRIPTION: Consult for hypertension and a med check.  History of osteoarthritis, osteoporosis, hypothyroidism, allergic rhinitis and kidney stones.

The situation involves a routine medical consultation for a patient with multiple chronic conditions, including hypertension, hypothyroidism, and osteoporosis. While the patient's hypertension is noted to be suboptimally controlled, there are no immediate life-threatening conditions or acute distress. The assessment and plan indicate standard follow-up procedures and tests to manage her chronic conditions. Therefore, while it is important for her ongoing health, it does not represent an urgent or dangerous high-stakes situation.


Medical Specialty: ENT - Otolaryngology
Sample Name: Consult - Enlarged Tonsils

HISTORY: , The patient is a 15-year-old female who was seen in consultation at the request of Dr. X on 05/15/2008 regarding enlarged tonsils.  The patient has been having difficult time with having two to three bouts of tonsillitis this year.  She does average about four bouts of tonsillitis per year for the past several years.  She notes that throat pain and fever with the actual infections.  She is having no difficulty with swallowing.  She does have loud snoring, though there have been no witnessed observed sleep apnea episodes.  She is a mouth breather at nighttime, however.  The patient does feel that she has a cold at today's visit.  She has had tonsil problems again for many years.  She does note a history of intermittent hoarseness as well.  This is particularly prominent with the current cold that she has had.  She had been seen by Dr. Y in Muskegon who had also recommended a tonsillectomy, but she reports she would like to get the surgery done here in the Ludington area as this is much closer to home.  For the two tonsillitis, she is on antibiotics again on an average about four times per year.  They do seem to help with the infections, but they tend to continue to recur.  The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.,REVIEW OF SYSTEMS:,ALLERGY/IMMUNOLOGIC:  Negative.,CARDIOVASCULAR:  Negative.,PULMONARY:  Negative.,GASTROINTESTINAL:  Negative.,GENITOURINARY:  Negative.,NEUROLOGIC:  Negative.,VISUAL:  Negative.,DERMATOLOGIC:  Negative.,ENDOCRINE:  Negative.,MUSCULOSKELETAL:  Negative.,CONSTITUTIONAL:  Negative.,PAST SURGICAL HISTORY: , Pertinent for previous cholecystectomy.,FAMILY HISTORY:,  No family history of bleeding disorder.  She does have a sister with a current ear infection.  There is a family history of cancer, diabetes, heart disease, and hypertension.,CURRENT MEDICATIONS: , None.,ALLERGIES: , She has no known drug allergies.,SOCIAL HISTORY: , The patient is single.  She is a student.  Denies tobacco or alcohol use.,PHYSICAL EXAMINATION: ,VITAL SIGNS:  Pulse is 80 and regular, temperature 98.4, weight is 184 pounds.,GENERAL:  The patient is an alert, cooperative, obese, 15-year-old female, with a normal-sounding voice and good memory.,HEAD & FACE:  Inspected with no scars, lesions or masses noted.  Sinuses palpated and are normal.  Salivary glands also palpated and are normal with no masses noted.  The patient also has full facial function.,CARDIOVASCULAR:  Heart regular rate and rhythm without murmur.,RESPIRATORY:  Lungs auscultated and noted to be clear to auscultation bilaterally with no wheezing or rubs and normal respiratory effort.,EYES:  Extraocular muscles were tested and within normal limits.,EARS:  The external ears are normal.  The ear canals are clean and dry.  The drums are intact and mobile.  Hearing is grossly normal.  Tuning fork examination with normal speech reception thresholds noted.,NASAL:  She has clear drainage, large inferior turbinates, no erythema.,ORAL:  Her tongue, lip, floor of mouth are noted to be normal.  Oropharynx does reveal very large tonsils measuring 3+/4+; they were exophytic.  Mirror examination of the larynx reveals some mild edema of the larynx at this time.  The nasopharynx could not be visualized on mirror exam today.,NECK:  Obese, supple.  Trachea is midline.  Thyroid is nonpalpable.,NEUROLOGIC:  Cranial nerves II through XII evaluated and noted to be normal.  Patient oriented times 3.,DERMATOLOGIC:  Evaluation reveals no masses or lesions.  Skin turgor is normal.,IMPRESSION: , ,1.  Chronic adenotonsillitis with adenotonsillar hypertrophy.,2.  Upper respiratory tract infection with mild acute laryngitis.,3.  Obesity.,RECOMMENDATIONS: , We are going to go ahead and proceed with an adenotonsillectomy.  All risks, benefits, and alternatives regarding the surgery have been reviewed in detail with the patient and her family.  This includes risk of bleeding, infection, scarring, regrowth of the adenotonsillar tissue, need for further surgery, persistent sore throat, voice changes, etc.  The parents are agreeable to the planned procedure, and we will schedule this accordingly at Memorial Medical Center here within the next few weeks.  We will make further recommendations afterwards.
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DESCRIPTION: Chronic adenotonsillitis with adenotonsillar hypertrophy.  Upper respiratory tract infection with mild acute laryngitis.

The situation involves a 15-year-old girl who has recurrent tonsillitis and significant tonsil enlargement that may affect her quality of life, such as causing loud snoring and potentially impacting her sleep. The decision to undergo adenotonsillectomy, while relatively common and routine, still involves surgical intervention with associated risks like bleeding and infection. However, it is not an emergency surgery, and the condition does not currently pose an immediate threat to her life. Given these considerations, this situation has moderate stakes due to the health implications and upcoming surgical procedure, but it's not life-threatening or extremely urgent.


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

Medical Specialty: Radiology
Sample Name: MRI Brain - Pontine Stroke

CC:, Left sided weakness.,HX:, 74 y/o RHF awoke from a nap at 11:00 AM on 11/22/92 and felt weak on her left side. She required support on that side to ambulate. In addition, she felt spoke as though she "was drunk." Nevertheless, she was able to comprehend what was being spoken around her. Her difficulty with speech completely resolved by 12:00 noon. She was brought to UIHC ETC at 8:30AM on 11/23/92 for evaluation.,MEDS:, none. ,ALLERGIES:,  ASA/ PCN both cause rash.,PMH:, 1)?HTN. 2)COPD. 3)h/o hepatitis (unknown type). 4)Macular degeneration.,SHX:, Widowed; lives alone. Denied ETOH/Tobacco/illicit drug use.,FHX:, unremarkable.,EXAM: , BP191/89 HR68 RR16 37.2C,MS: A & O to person, place and time. Speech fluent; without dysarthria. Intact naming, comprehension, and repetition.,CN: Central scotoma, OS (old). Mild upper lid ptosis, OD (old per picture). Lower left facial weakness.,Motor: Mild Left hemiparesis (4+ to 5- strength throughout affected side). No mention of muscle tone in chart.,Sensory: unremarkable.,Coord: impaired FNF and HKS movement secondary to weakness.,Station: Left pronator drift. No Romberg sign seen.,Gait: Left hemiparetic gait with decreased LUE swing.,Reflexes: 3/3+ biceps and triceps. 3/3+ patellae. 2/3+ ankles with 3-4beats of non-sustained ankle clonus on left. Plantars: Left babinski sign; and flexor on right.,General Exam: 2/6 SEM at left sternal border.,COURSE:, GS, CBC, PT, PTT, CK, ESR were within normal limits. ABC 7.4/46/63 on room air. EKG showed a sinus rhythm with right bundle branch block. MRI brain, 11/23/95, revealed a right pontine pyramidal tract infarction. She was treated with Ticlopidine 250mg bid. On 11/26/92, her left hemiparesis worsened. A HCT, 11/27/92, was unremarkable. The patient was treated with IV Heparin. This was discontinued the following day when her strength returned to that noted on 11/23/95. On 11/27/92, she developed angina and was ruled out for MI by serial EKG and cardiac enzyme studies. Carotid duplex showed 0-15% bilateral ICA stenosis and antegrade vertebral artery flow bilaterally. Transthoracic echocardiogram revealed aortic insufficiency only. Transesophageal echocardiogram revealed trivial mitral and tricuspid regurgitation, aortic valvular fibrosis. There was calcification and possible thrombus seen in the descending aorta. Cardiology did not feel the later was an indication for anticoagulation. She was discharged home on Isordil 20 tid, Metoprolol 25mg q12hours, and Ticlid 250mg bid.
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DESCRIPTION: Right pontine pyramidal tract infarct.

Right pontine pyramidal tract infarct.

radiology, mri brain, pontine stroke, difficulty with speech, hemiparesis, pontine pyramidal tract infarct, weakness, mri, brain, pyramidal, echocardiogram, pontine, infarct,

The situation involves the evaluation and management of a pontine stroke in an elderly patient with multiple medical comorbidities. This is a high-stakes scenario given the potential for significant morbidity associated with stroke, including paralysis, speech difficulties, and other neurological deficits. Immediate and precise medical intervention is crucial for minimizing long-term impacts on the patient's health and quality of life. Additionally, the patient's history of hypertension, COPD, and cardiovascular concerns heightens the stakes due to increased risk factors for complications.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 20

PREOPERATIVE DIAGNOSIS: , Screening. ,POSTOPERATIVE DIAGNOSIS:,  Tiny Polyps.,PROCEDURE PERFORMED:  , Colonoscopy.,PROCEDURE:  , The procedure, indications, and risks were explained to the patient, who understood and agreed.  He was sedated with Versed 3 mg, Demerol 25 mg during the examination.  ,A digital rectal exam was performed and the Pentax Video Colonoscope was advanced over the examiner's finger into the rectum.  It was passed to the level of the cecum.  The ileocecal valve was identified, as was the appendiceal orifice.  ,Slowly withdrawal through the colon revealed a small polyp in the transverse colon.  This was approximately 3 mm in size and was completely removed using multiple bites with cold biopsy forceps.  In addition, there was a 2 mm polyp versus lymphoid aggregate in the descending colon.  This was also removed using the cold biopsy forceps.  Further detail failed to reveal any other lesions with the exception of small hemorrhoids.  ,IMPRESSION:  , Tiny polyps.  ,PLAN:  , If adenomatous, repeat exam in five years.  Otherwise, repeat exam in 10 years.,
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DESCRIPTION: Screening colonoscopy.  Tiny polyps.   If adenomatous, repeat exam in five years.

surgery, pentax video colonoscope, biopsy forceps, tiny polyps, polyps, adenomatous, colonoscopy

The situation involves a routine medical diagnostic procedure—a colonoscopy—during which tiny polyps were found and removed. This is a common and low-risk procedure when managed correctly, and the follow-up plan is routine (repeating the exam in 5 or 10 years depending on the polyps' nature). There are no immediate risks or life-threatening conditions indicated in the report, reducing the stakes of the situation.


Medical Specialty: Gastroenterology
Sample Name: Viral Gastroenteritis

HISTORY OF PRESENT ILLNESS: , Patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank "lots of red wine."  She states after vomiting, she felt "fine through the night," but woke with more nausea and vomiting and diaphoresis.  She states she has vomited approximately 20 times today and has also had some slight diarrhea.  She denies any sore throat or cough.  She states no one else at home has been ill.  She has not taken anything for her symptoms.,MEDICATIONS: , Currently the patient is on fluoxetine for depression and Zyrtec for environmental allergies.,ALLERGIES: , SHE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:,  The patient is married and is a nonsmoker, and lives with her husband, who is here with her.,REVIEW OF SYSTEMS,Patient denies any fever or cough.  She notes no blood in her vomitus or stool.  The remainder of her review of systems is discussed and all are negative.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 37.6.  Other vital signs are all within normal limits.,GENERAL:  Patient is a healthy-appearing, middle-aged white female who is lying on the stretcher and appears only mildly ill.,HEENT:  Head is normocephalic and atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  NECK:  No enlarged anterior or posterior cervical lymph nodes.  There is no meningismus.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,ABDOMEN:  Active bowel sounds.  Soft without any focal tenderness on palpation.  There are no masses, guarding, or rebound noted.,SKIN:  No rash.,EXTREMITIES:  No cyanosis, clubbing, or edema.,LABORATORY DATA: , CBC shows a white count of 12.9 with an elevation in the neutrophil count on differential.  Hematocrit is 33.8, but the indices are normochromic and normocytic.  BMP is remarkable for a random glucose of 147.  All other values are unremarkable.  LFTs are normal.  Serum alcohol is less than 5.,TREATMENT: , Patient was given 2 L of normal saline wide open as well as Compazine 5 mg IV x2 doses with resolution of her nausea.  She was given two capsules of Imodium with some apple juice, which she was able to keep down.  The patient did feel well enough to be discharged home.,ASSESSMENT:,  Viral gastroenteritis.,PLAN: , Rx for Compazine 10 mg tabs, dispense five, sig. one p.o. q.8h. p.r.n. for any recurrent nausea.  She was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet.  Imodium for any diarrhea, but no dairy products until the diarrhea has gone for at least 24 hours.  If she is unimproved in the next two days, she was urged to follow up with her PCP back home.
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DESCRIPTION: Viral gastroenteritis.  Patient complaining of the onset of nausea and vomiting after she drank lots of red wine.  She denies any sore throat or cough.  She states no one else at home has been ill.

gastroenterology, nausea, vomiting, viral gastroenteritis, wine, gastroenteritis, ill,

The situation described involves a common medical condition, viral gastroenteritis, likely exacerbated by alcohol consumption. The patient has mild symptoms, no alarming signs, and was discharged in a stable condition with symptomatic treatment. While the symptoms are uncomfortable, they are not life-threatening, and the patient has clear follow-up instructions and management plan. Given the absence of severe complications or risk factors, the situation is not considered high-stakes.


Medical Specialty: Surgery
Sample Name: Esophagoscopy & Foreign Body Removal - 1

PRIMARY DIAGNOSIS:,  Esophageal foreign body, no associated comorbidities are noted.,PROCEDURE:,  Esophagoscopy with removal of foreign body.,CPT CODE: , 43215.,PRINCIPAL DIAGNOSIS:,  Esophageal foreign body, ICD-9 code 935.1.,DESCRIPTION OF PROCEDURE: , Under general anesthesia, flexible EGD was performed.  Esophagus was visualized.  The quarter was visualized at the aortic knob, was removed with grasper.  Estimated blood loss 0.  Intravenous fluids during time of procedure 100 mL.  No tissues.  No complications.  The patient tolerated the procedure well.  Dr. X Pipkin attending pediatric surgeon was present throughout the entire procedure.  The patient was transferred from OR to PACU in stable condition.
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DESCRIPTION: Esophagoscopy with removal of foreign body.   Esophageal foreign body, no associated comorbidities are noted.

surgery, esophagus, foreign body, esophagoscopy, esophageal,

This situation describes a surgical procedure to remove a foreign object from the esophagus. While the presence of a foreign body in the esophagus can be serious and potentially lead to complications, the description indicates a straightforward procedure with no complications, no associated comorbidities, and the patient was reported to be stable afterwards. The presence of the pediatric surgeon suggests appropriate medical oversight, reducing the stakes due to professional intervention. However, surgical procedures inherently carry some level of risk, making this a moderately high-stakes situation overall, as it involves a medical procedure under general anesthesia.


Medical Specialty: ENT - Otolaryngology
Sample Name: Progress Note - Supraglottitis

HISTORY: , A 59-year-old male presents in followup after being evaluated and treated as an in-patient by Dr. X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis, admitted on 05/23/2008, discharged on 05/24/2008.  Please refer to chart for history and physical and review of systems and medical record.,PROCEDURES PERFORMED:  ,Fiberoptic laryngoscopy identifying about 30% positive Muller maneuver.  No supraglottic edema; +2/4 tonsils with small tonsil cyst, mid tonsil, left.,IMPRESSION:  ,1.  Resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis.,2.  Possible obstructive sleep apnea; however, the patient describes no known history of this phenomenon.,3.  Hypercholesterolemia.,4.  History of anxiety.,5.  History of coronary artery disease.,6.  Hypertension.,RECOMMENDATIONS: , Recommend continuing on Augmentin and tapered prednisone as prescribed by Dr. X.  Cultures are still pending and follow up with Dr. X in the next few weeks for re-evaluation.  I did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this, but we will leave this open for him to talk with Dr. X on his followup, and he will pay more attention on his sleep pattern.
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DESCRIPTION: Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.

ent - otolaryngology, acute supraglottic edema, obstructive sleep apnea, acute supraglottitis, airway obstruction, parapharyngeal cellulitis, peritonsillar cellulitis, supraglottic edema, supraglottitis, tonsils, cellulitis

The situation involves a patient with a significant history of airway obstruction due to acute supraglottitis, which can be a life-threatening condition due to potential respiratory compromise. While the patient is currently managing with medication and is under follow-up care, the possibility of obstructive sleep apnea, coronary artery disease, and hypertension adds complexity and risk to the case. Additionally, cultures are still pending, and there might be new developments based on these results. Given these factors, the situation is higher stakes because monitoring and ongoing management are critical to prevent serious complications.


Medical Specialty: Urology
Sample Name: Circumcision - Infant

PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA:  ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents.  The risks are infection, hemorrhage, and meatal stenosis.  The benefits are ease of care and cleanliness and fewer urinary tract infections.  The parents understand this and have signed a permit.,FINDINGS: , The infant is without evidence of hypospadias or chordee prior to the procedure.,TECHNIQUE:  ,The infant was given a dorsal penile block with 1% lidocaine without epinephrine using a tuberculin syringe and 0.5 cc of lidocaine was delivered subcutaneously at 10:30 and at 1:30 o'clock at the dorsal base of the penis.,The infant was prepped then with Betadine and draped with a sterile towel in the usual manner.  Clamps were placed at 10 o'clock and 2 o'clock and the adhesions between the glans and mucosa were instrumentally lysed.  Dorsal hemostasis was established and a dorsal slit was made.  The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed.  The infant was fitted with a XX-cm Plastibell.  The foreskin was retracted around the Plastibell and circumferential hemostasis was established.  The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss.  Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis.
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DESCRIPTION: Circumcision.  Normal male phallus.   The infant is without evidence of hypospadias or chordee prior to the procedure.

urology, dorsal slit, hypospadias, chordee, epinephrine, hemorrhage, penis, adhesions, circumcision, phallus, lidocaine, foreskin, infant

The procedure being described is an infant circumcision, a common and routine surgical procedure. The risks associated (infection, hemorrhage, and meatal stenosis) are typically low, and the procedure is often performed for cultural, religious, or medical reasons. While it involves surgical intervention on an infant, which can be sensitive, the process is generally considered low-risk when performed by a qualified professional. The procedural details provided also suggest that the operation went smoothly, with minimal blood loss and successful application of the Plastibell, a device commonly used for this procedure.


Medical Specialty: Urology
Sample Name: Ureteral Calculus - Consult

CHIEF COMPLAINT: , Right distal ureteral calculus.,HISTORY OF PRESENT ILLNESS:  ,The patient had hematuria and a CT urogram at ABC Radiology on 01/04/07 showing a 1 cm non-obstructing calcification in the right distal ureter.  He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.  He comes in now for right ureteroscopy, Holmium laser lithotripsy, right ureteral stent placement.,PAST MEDICAL HISTORY:,1.  Prostatism.,2.  Coronary artery disease.,PAST SURGICAL HISTORY:,1.  Right spermatocelectomy.,2.  Left total knee replacement in 1987.,3.  Right knee in 2005.,MEDICATIONS:,1.  Coumadin 3 mg daily.,2.  Fosamax.,3.  Viagra p.r.n.,ALLERGIES: , NONE.,REVIEW OF SYSTEMS:,  CARDIOPULMONARY:  No shortness of breath or chest pain.  GI:  No nausea, vomiting, diarrhea or constipation.  GU:  Voids well.  MUSCULOSKELETAL:  No weakness or strokes.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL APPEARANCE:  An alert male in no distress.,HEENT:  Grossly normal.,NECK:  Supple.,LUNGS:  Clear.,HEART:  Normal sinus rhythm.  No murmur or gallop.,ABDOMEN:  Soft.  No masses.,GENITALIA:  Normal penis.  Testicles descended bilaterally.,RECTAL:  Examination benign.,EXTREMITIES:  No edema.,IMPRESSION: , Right distal ureteral calculus.,PLAN: , Right ureteroscopy, ureteral lithotripsy.  Risks and complications discussed with the patient.  He signed a true informed consent.  No guarantees or warrantees were given.
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DESCRIPTION: Right distal ureteral calculus.  The patient had hematuria and a CT urogram showing a 1 cm non-obstructing calcification in the right distal ureter.  He had a KUB also showing a teardrop shaped calcification apparently in the right lower ureter.

The patient is experiencing a ureteral calculus (kidney stone) which, while potentially painful, is not immediately life-threatening due to it being non-obstructing. The patient is set to undergo a ureteroscopy and lithotripsy, common and generally safe procedures to remove the stone. The patient also has other health considerations, such as coronary artery disease and medication use (Coumadin, which is important to manage during surgery due to bleeding risks), but these seem to be managed. The situation requires surgical intervention and carries routine surgical risks but is not considered extremely high-stakes in an immediate life-or-death sense.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Bell's Palsy

SUBJECTIVE:,  The patient is a 75-year-old female who comes in today with concerns of having a stroke.  She states she feels like she has something in her throat.  She started with some dizziness this morning and some left hand and left jaw numbness.  She said that she apparently had something about three weeks ago where she was dizzy and ended up falling down and she saw Dr. XYZ for that who gave her some Antivert.  She said that today though she woke up in the middle of the night and her left hand was numb and she was having numbness on the left side of her face, as well as the left side of her neck.  She said she had an earache a day or so ago.  She has not had any cold symptoms.,ALLERGIES:,  Demerol and codeine.,MEDICATIONS: , Lotensin, Lopid, metoprolol, and Darvocet.,REVIEW OF SYSTEMS:,  The patient says that she feels little bit nauseated at times.  She denies chest pain or shortness of breath and again feels like she has something in her throat.  She has been able to swallow liquids okay.  She said that she did brush her teeth this morning and did not have any fluid dripping out of her mouth.  She does say that she occasionally has numbness in her left hand prior to today.,PHYSICAL EXAMINATION:,General:  She is awake and alert, no acute distress.,Vital Signs:  Blood pressure:  175/86.  Temperature:  She is afebrile.  Pulse:  78.  Respiratory rate:  20.  O2 sat:  93% on room air.,HEENT:  Her TMs are normal bilaterally.  Posterior pharynx is unremarkable.  It should be noted that her uvula did not deviate and neither did her tongue.  When she smiles though she has some drooping of the left side of her face, as well as some mild nasolabial fold flattening.,Neck:  Without adenopathy or thyromegaly.  Carotids pulses are brisk without bruits.,Lungs:  Clear to auscultation.,Heart:  Regular rate and rhythm without murmur.,Extremities:  Her muscle strength is symmetrical and intact bilaterally.  DTRs are 2+/4+ bilaterally and muscle strength is intact in the upper extremities.  She has a positive Tinel’s sign on her left wrist.,Neurological:  I also took monofilament and she could sense it easily when testing her sensation on her face.,ASSESSMENT:,  Bell’s Palsy.,PLAN:,  We did get an EKG showed some ST segment changes anterolaterally.  The only EKG I have here is from 1998 and she actually had bypass in 1999, but there certainly does not appear to be anything acute on his EKG.  I assured her that it does not look like she has a stroke.  If she wants to prevent a stroke, obviously quitting her smoking would help.  It should be noted she also takes Synthroid and Zocor.  We are going to give her Valtrex 1 g t.i.d. for seven days and then if she starts noticing any other drooping or worsening of her symptoms on the left side of her face, she needs to come back, but I will not start her on steroids at this time, which she agreed with.
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DESCRIPTION: A 75-year-old female comes in with concerns of having a stroke.

soap / chart / progress notes, stroke, bell’s palsy, st segment changes, ekg, dizziness, numbness, dizzy, muscle strength, palsy, bell’s

The situation involves a 75-year-old female patient who presents with symptoms potentially indicative of a stroke or Bell's Palsy. Given her age and symptoms such as facial drooping and numbness, the concern for a stroke is significant. However, the physician assessed and diagnosed the condition as Bell's Palsy, which generally has a more favorable prognosis than a stroke. Although the immediate life-threatening risk has been addressed, the stakes remain relatively high due to the patient's age, initial stroke concerns, and possible complications if symptoms worsen.


Medical Specialty: Orthopedic
Sample Name: Hardware Removal - Elbow

PREOPERATIVE DIAGNOSIS: , Retained hardware in left elbow.,POSTOPERATIVE DIAGNOSIS:,  Retained hardware in left elbow.,PROCEDURE: , Hardware removal in the left elbow.,ANESTHESIA: , Procedure done under general anesthesia.  The patient also received 4 mL of 0.25% Marcaine of local anesthetic.,TOURNIQUET:  ,There is no tourniquet time.,ESTIMATED BLOOD LOSS:  ,Minimal.,COMPLICATIONS:  ,No intraoperative complications.,HISTORY AND PHYSICAL:  ,The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture.  He underwent screw compression for the fracture in October 2007.  The fracture has subsequently healed and the patient presents for hardware removal.  The risks and benefits of surgery were discussed.  The risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion.  All questions were answered and the family agreed to the above plan.,PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in standard surgical fashion.  Using his previous incision, dissection was carried down through the screw.  A guide wire was placed inside the screw and the screw was removed without incident.  The patient had an extension lag of about 15 to 20 degrees.  Elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex.  The washer was also removed without incident.  Wound was then irrigated and closed using #2-0 Vicryl and #4-0 Monocryl.  Wound was injected with 0.25% Marcaine.  The wound was then dressed with Steri-Strips, Xeroform, 4 x4 and bias.  The patient tolerated the procedure well and subsequently taken to the recovery in stable condition.,DISCHARGE NOTE: , The patient will be discharged on date of surgery.  He is to follow up in one week's time for a wound check.  This can be done at his primary care physician's office.  The patient should keep his postop dressing for about 4 to 5 days.  He may then wet the wound, but not scrub it.  The patient may resume regular activities in about 2 weeks.  The patient was given Tylenol with Codeine 10 mL p.o. every 3 to 4 hours p.r.n.
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DESCRIPTION: Hardware removal in the left elbow.

Hardware removal in the left elbow.

orthopedic, retained hardware, hardware removal, tourniquet, elbow, hardware,

The described procedure involves the removal of previously inserted hardware from the elbow of a young child. It is a routine orthopedic procedure that carries usual surgical risks such as anesthesia, infection, and potential complications related to movement or sensation. However, there were no complications during the surgery, estimated blood loss was minimal, and the patient is expected to recover and resume normal activities within a couple of weeks. Although all surgeries carry some level of risk, this scenario is more routine and not life-threatening.


Medical Specialty: General Medicine
Sample Name: H&P - Gen Med - 1

CHIEF COMPLAINT:, Diarrhea, vomiting, and abdominal pain.,HISTORY OF PRESENT ILLNESS:, The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. She was found by EMS sitting on the toilet having diarrhea, and apparently had also just vomited. Upon my questioning of the patient, she can confirm that she has been sick to her stomach and has vomited. She cannot tell me how many times. She is also unable to describe the vomitus. She also tells me that her belly has been hurting. I am unable to get any further history from the patient because, again, she is an extremely poor historian and very hard of hearing.,PAST MEDICAL HISTORY:, Per the ER documentation is hypertension, diverticulosis, blindness, and sciatica.,MEDICATIONS:, Lorazepam 0.5 mg, dosing interval is not noted; Tylenol PM; Klor-Con 10 mEq; Lexapro; calcium with vitamin D.,ALLERGIES:, SHE IS ALLERGIC TO PENICILLIN.,FAMILY HISTORY:, Unknown.,SOCIAL HISTORY:, Also unknown.,REVIEW OF SYSTEMS:, Unobtainable secondary to the patient's condition.,PHYSICAL EXAMINATION:,VITAL SIGNS: Pulse 80. Respiratory rate 18. Blood pressure 130/80. Temperature 97.6.,GENERAL: Elderly black female who is initially sleeping upon my evaluation, but is easily arousable.,NECK: No JVD. No thyromegaly.,EARS, NOSE, AND THROAT: Her oropharynx is dry. Her hearing is very diminished.,CARDIOVASCULAR: Regular rhythm. No lower extremity edema.,GI: Mild epigastric tenderness to palpation without guarding or rebound. Bowel sounds are normoactive.,RESPIRATORY: Clear to auscultation bilaterally with a normal effort.,SKIN: Warm, dry, no erythema.,NEUROLOGICAL: The patient attempts to answer questions when asked, but is very hard of hearing. She is seen to move all extremities spontaneously.,DIAGNOSTIC DATA:, White count 9.6, hemoglobin 15.9, hematocrit 48.2, platelet count 345, PTT 24, PT 13.3, INR 0.99, sodium 135, potassium 3.3, chloride 95, bicarb 20, BUN 54, creatinine 2.2, glucose 165, calcium 10.3, magnesium 2.5, total protein 8.2, albumin 3.8, AST 33, ALT 26, alkaline phosphatase 92. Cardiac isoenzymes negative x1. EKG shows sinus rhythm with a rate of 96 and a prolonged QT interval.,ASSESSMENT AND PLAN:,1. Pancreatitis. Will treat symptomatically with morphine and Zofran, and also IV fluids. Will keep NPO.,2. Diarrhea. Will check stool studies.,3. Volume depletion. IV fluids.,4. Hyperglycemia. It is unknown whether the patient is diabetic. I will treat her with sliding scale insulin.,5. Hypertension. If the patient takes blood pressure medications, it is not listed on the only medication listing that is available. I will prescribe clonidine as needed.,6. Renal failure. Her baseline is unknown. This is at least partly prerenal. Will replace volume with IV fluids and monitor her renal function.,7. Hypokalemia. Will replace per protocol.,8. Hypercalcemia. This is actually rather severe when adjusted for the patient's low albumin. Her true calcium level comes out to somewhere around 12. For now, I will just treat her with IV fluids and Lasix, and monitor her calcium level.,9. Protein gap. This, in combination with the calcium, may be suggestive of multiple myeloma. It is my understanding that the family is seeking hospice placement for the patient right now. I would have to discuss with the family before undertaking any workup for multiple myeloma or other malignancy.
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DESCRIPTION: An 85-year-old female with diarrhea, vomiting, and abdominal pain.

The situation involves an elderly patient presenting with multiple severe symptoms such as diarrhea, vomiting, abdominal pain, and potential pancreatitis. Her advanced age, hearing difficulties, and poor ability to provide a medical history increase the complexity of her care. Additionally, she has multiple concerning diagnostic findings, such as possible renal failure, hypercalcemia, and a protein gap that could suggest a serious underlying condition like multiple myeloma. The patient's baseline health status is unknown, adding to the uncertainty and potential risk. Given her age, the symptoms, the potential for multiple severe underlying conditions, and the need for immediate medical intervention, this is a high-stakes medical situation.


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

ADMISSION DIAGNOSIS: , Right tibial plateau fracture.,DISCHARGE DIAGNOSES: , Right tibial plateau fracture and also medial meniscus tear on the right side.,PROCEDURES PERFORMED:,  Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.,CONSULTATIONS: , To rehab, Dr. X and to Internal Medicine for management of multiple medical problems including hypothyroid, diabetes mellitus type 2, bronchitis, and congestive heart failure.,HOSPITAL COURSE: , The patient was admitted and consented for operation, and taken to the operating room for open reduction and internal fixation of right Schatzker III tibial plateau fracture and partial medial meniscectomy performed without incidence.  The patient seemed to be recovering well.  The patient spent the next several days on the floor, nonweightbearing with CPM machine in place, developed a brief period of dyspnea, which seems to have resolved and may have been a combination of bronchitis, thick secretions, and fluid overload.  The patient was given nebulizer treatment and Lasix increased the same to resolve the problem.  The patient was comfortable, stabilized, breathing well.  On day #12, was transferred to ABCD.,DISCHARGE INSTRUCTIONS: , The patient is to be transferred to ABCD after open reduction and internal fixation of right tibial plateau fracture and partial medial meniscectomy.,DIET:,  Regular.,ACTIVITY AND LIMITATIONS: , Nonweightbearing to the right lower extremity.  The patient is to continue CPM machine while in bed along with antiembolic stockings.  The patient will require nursing, physical therapy, occupational therapy, and social work consults.,DISCHARGE MEDICATIONS: , Resume home medications, but increase Lasix to 80 mg every morning, Lovenox 30 mg subcu daily x2 weeks, Vicodin 5/500 mg one to two every four to six hours p.r.n. pain, Combivent nebulizer every four hours while awake for difficulty breathing, Zithromax one week 250 mg daily, and guaifenesin long-acting one twice a day b.i.d.,FOLLOWUP: , Follow up with Dr. Y in 7 to 10 days in office.,CONDITION ON DISCHARGE:,  Stable.
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DESCRIPTION: Open reduction and internal fixation (ORIF) of right Schatzker III tibial plateau fracture with partial medial meniscectomy.

discharge summary, open reduction, internal fixation, schatzker iii tibial plateau fracture, meniscectomy, tibial plateau fracture, orif, schatzker, fixation, reduction, tibial, fracture, plateau,

The situation involves the completion of a surgical procedure and discharge planning for a patient with a serious fracture and other significant health conditions (including hypothyroidism, diabetes, bronchitis, and congestive heart failure). The discharge summary includes critical information about the patient's post-operative care, medications, and follow-up. Although the situation involves detailed medical management and coordination, it doesn’t represent an immediate life-threatening emergency, but incorrect handling could lead to complications or poor patient outcomes. Thus, it is important but not extremely urgent or life-critical in the immediate sense.