Medical Specialty: Consult - History and Phy.
Sample Name: Tongue Swelling

REASON FOR ADMISSION: , A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.,PAST MEDICAL HISTORY:,1.  Diabetes type II.,2.  High blood pressure.,3.  High cholesterol.,4.  Acid reflux disease.,5.  Chronic back pain.,PAST SURGICAL HISTORY:,1.  Lap-Band done today.,2.  Right foot surgery.,MEDICATIONS:,1.  Percocet on a p.r.n. basis.,2.  Keflex 500 mg p.o. t.i.d.,3.  Clonidine 0.2 mg p.o. b.i.d.,4.  Prempro, dose is unknown.,5.  Diclofenac 75 mg p.o. daily.,6.  Enalapril 10 mg p.o. b.i.d.,7.  Amaryl 2 mg p.o. daily.,8.  Hydrochlorothiazide 25 mg p.o. daily.,9.  Glucophage 100 mg p.o. b.i.d.,10.  Nifedipine extended release 60 mg p.o. b.i.d.,11.  Omeprazole 20 mg p.o. daily.,12.  Zocor 20 mg p.o. at bedtime.,ALLERGIES: , No known allergies.,HISTORY OF PRESENT COMPLAINT: , This 54-year-old patient had had Lap-Band at Tempe St Luke this morning.  She woke up at home this evening with massive swelling of the left side of the tongue.  The patient therefore came to the emergency room for evaluation.  The patient was almost intubated on clinical grounds.  Anesthesia was called to see the patient and they decided to give a trial of conservative management of Decadron and racemic epinephrine.,REVIEW OF SYSTEMS:,GENERAL:  The patient denies any itching of the skin or urticaria.  She has not noticed any new rashes.  She denies fever, chill, or malaise.,HEENT:  The patient denies vision difficulty.,RESPIRATORY:  No cough or wheezing.,CARDIOVASCULAR:  No palpitations or syncopal episodes.,GASTROINTESTINAL:  The patient denies swallowing difficulty.,Rest of the review of systems not remarkable.,SOCIAL HISTORY:  ,The patient does not smoke nor drink alcohol.,FAMILY HISTORY: , Noncontributory.,PHYSICAL EXAMINATION:,GENERAL:  Obese 54-year-old lady, not in acute distress at this time.,VITAL SIGNS:  On arrival in the emergency room, blood pressure was 194/122, pulse was 94, respiratory rate of 20, and temperature was 96.6.  O2 saturation was 95% on room air.,HEAD AND NECK:  Face is symmetrical.  Tongue is still swollen, especially on the left side.  The floor of the mouth is also indurated.  There is no cervical lymphadenopathy.  There is no stridor.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmurs appreciated.,ABDOMEN:  Benign.,EXTREMITIES:  There is no swelling.,NEUROLOGIC:  The patient is alert and oriented x3.  Examination is nonfocal.
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DESCRIPTION: A 54-year-old patient, here for evaluation of new-onset swelling of the tongue.

The patient has significant new-onset tongue swelling following a surgical procedure (Lap-Band), which is concerning due to the potential for airway obstruction. The decision not to intubate suggests that while the situation is serious, it is currently under control. There's also the use of medications like Decadron and racemic epinephrine, indicating ongoing monitoring and treatment. The potential for rapid deterioration makes this situation high-stakes from a clinical perspective.


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

Medical Specialty: Physical Medicine - Rehab
Sample Name: Hip Fracture - Rehab Consult

ADMISSION DIAGNOSIS: , Left hip fracture.,CHIEF COMPLAINT: , Diminished function, secondary to the above.,HISTORY: , This pleasant 70-year-old gentleman had a ground-level fall at home on 05/05/03 and was brought into ABCD Medical Center, evaluated by Dr. X and brought in for orthopedic stay.  He had left hip fracture identified on x-rays at that time.  Pain and inability to ambulate brought him in.  He was evaluated and then underwent medical consultation as well, where they found a history of resolving pneumonia, hypertension, chronic obstructive pulmonary disease, congestive heart failure, hypothyroidism, depression, anxiety, seizure and chronic renal failure, as well as anemia.  His medical issues are under good control.  The patient underwent left femoral neck fixation with hemiarthroplasty on that left side on 05/06/03.  The patient has had some medical issues including respiratory insufficiency, perioperative anemia, pneumonia, and hypertension.  Cardiology has followed closely, and the patient has responded well to medical treatment, as well as physical therapy and occupational therapy.  He is gradually tolerating more activities with less difficulties, made good progress and tolerated more consistent and more prolonged interventions.,PAST MEDICAL HISTORY: , Positive for congestive heart failure, chronic renal insufficiency, azotemia, hyperglycemia, coronary artery disease, history of paroxysmal atrial fibrillation.  Remote history of subdural hematoma precluding the use of Coumadin.  History of depression, panic attacks on Doxepin.  Perioperative anemia.  Swallowing difficulties.,ALLERGIES:,  Zyloprim, penicillin, Vioxx, NSAIDs.,CURRENT MEDICATIONS,1.  Heparin.,2.  Albuterol inhaler.,3.  Combivent.,4.  Aldactone.,5.  Doxepin.,6.  Xanax.,7.  Aspirin.,8.  Amiodarone.,9.  Tegretol.,10.  Synthroid.,11.  Colace.,SOCIAL HISTORY: , Lives in a 1-story home with 1 step down; wife is there.  Speech and language pathology following with current swallowing dysfunction.  He is minimum assist for activities of daily living, bed mobility.,REVIEW OF SYSTEMS:,  Currently negative for headache, nausea and vomiting, fevers, chills or shortness of breath or chest pain.,PHYSICAL EXAMINATION,HEENT:  Oropharynx clear.,CV:  Regular rate and rhythm without murmurs, rubs or gallops.,LUNGS:  Clear to auscultation bilaterally.,ABDOMEN:  Nontender, nondistended.  Bowel sounds positive.,EXTREMITIES:  Without clubbing, cyanosis, or edema.,NEUROLOGIC:  There are no focal motor or sensory losses to the lower extremities.  Bulk and tone normal in the lower extremities.  Wound site has healed well with staples out.,IMPRESSION ,1.  Status post left hip fracture and hemiarthroplasty.,2.  History of panic attack, anxiety, depression.,3.  Myocardial infarction with stent placement.,4.  Hypertension.,5.  Hypothyroidism.,6.  Subdural hematoma.,7.  Seizures.,8.  History of chronic obstructive pulmonary disease.  Recent respiratory insufficiency.,9.  Renal insufficiency.,10.  Recent pneumonia.,11.  O2 requiring.,12.  Perioperative anemia.,PLAN: , Rehab transfer as soon as medically cleared.
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DESCRIPTION: Status post left hip fracture and hemiarthroplasty.   Rehab transfer as soon as medically cleared.

The situation involves the rehabilitation care of a 70-year-old patient with a left hip fracture post-hemiarthroplasty, along with multiple comorbidities including congestive heart failure, COPD, and recent pneumonia. The stakes are moderate because the patient must successfully undergo rehabilitation to regain mobility and function, which can be crucial for independence and preventing further health decline. However, the patient is currently in a stable condition as per the medical assessment. This makes it a moderate high-stakes situation, considering the patient's age, complexity of medical history, and need for coordinated care.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Epidural Fluid Collection

CC:, Fall/loss of consciousness.,HX: ,This 44y/o male fell 15-20feet from a construction site scaffold landing on his head on a cement sidewalk. He was transported directly from the scene, approximately one mile east of UIHC. The patient developed labored breathing and an EMT attempted to intubate the patient in the UIHC ER garage, but upon evaluation in the ER, was found to be in his esophagus and was immediately replaced into the trachea. Replacement of the ET tube required succinylcholine. The patient remained in a C-collar during the procedure. Once in the ER the patient had a 15min period of bradycardia.,MEDS: ,none prior to accident.,PMH:, No significant chronic or recent illness. s/p left knee arthroplasty. h/o hand fractures.,FHX:, Unremarkable.,SHX:, Married. Rare cigarette use/Occasional Marijuana use/Social ETOH use per wife.,EXAM:, BP156/79. HR 74 RR (Ambu Bag ventilation via ET tube) 34.7C 72-100% O2Sat.,MS: Unresponsive to verbal stimulation. No spontaneous verbalization.,CN: Does not open/close eyes to command or spontaneously. Pupils 9/7 and nonreactive.,Corneas -/+. Gag +/+. Oculocephalic and Oculovestibular reflexes not performed.,Motor: minimal spontaneous movement of the 4 extremities.,Sensory: withdraws LUE and BLE to noxious stimulation.,Coord/Station/Gait: Not tested.,Reflexes: 1-2+ and symmetric throughout. Babinski signs were present bilaterally.,HEENT: severe facial injury with brain parenchyma and blood from the right nostril. Severe soft tissue swelling about side of head.,Gen Exam: CV: RRR without murmur. Lungs: CTA. Abdomen: distended after ET tube misplacement.,COURSE: ,HCT upon arrival, 10/29/92, revealed: Extensive parenchymal contusions in right fronto-parietal area. Pronounced diffuse brain swelling seemingly obliterates the mesencephalic cistern and 4th ventricle. Considerable mass effect is exerted upon the right lateral ventricle, near totally obliterating its contour. Massive subcutaneous soft tissue swelling is present along the right anterolateral parietal area. There are extensive fractures of the following: two component horizontal fractures throughout the floor of the right middle cranial fossa which includes the squamous and petrous portions of the temporal bone, as well as the greater wing of the sphenoid. Comminuted fractures of the aqueous portion of the temporal bone and parietal bone is noted on the right. Extensive comminution of the right half of the frontal bone and marked displacement is seen. Comminuted fractures of the medial wall of the right orbit and ethmoidal air cells is seen with near total opacification of the air cells. The medial and lateral walls of the maxillary sinus are fractured and minimally displaced, as well as the medial wall of the left maxillary sinus. The right zygomatic bone is fractured at its articulation with the sphenoid bone and displaced posteriorly.,Portable chest, c-spine and abdominal XRays were unremarkable, but limited studies. Abdominal CT was unremarkable.,Hgb 10.4g/dl, Hct29%, WBC17.4k/mm3, Plt 190K. ABG:7.28/48/46 on admission. Glucose 131.,The patient was hyperventilated, Mannitol was administered (1g/kg), and the patient was given a Dilantin loading dose. He was taken to surgery immediately following the above studies to decompress the contused brain and remove bony fragments from multiple skull fractures. The patient remained in a persistent vegetative state at UIHC, and upon the request of this wife his feeding tube was discontinued. He later expired.
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DESCRIPTION: Fall/loss of consciousness.

Fall/loss of consciousness.

consult - history and phy., loss of consciousness, soft tissue swelling, medial wall, maxillary sinus, sphenoid, collection, tube, bone,

This medical scenario involves a critical and life-threatening situation where a 44-year-old male suffered a severe fall resulting in head trauma, extensive skull fractures, brain contusions, and a persistent vegetative state. The high-stakes nature of this case is underscored by the need for immediate medical intervention, intubation, surgical decompression, and ultimately end-of-life decisions, reflecting the critical and urgent nature of the injuries and the care required.


Medical Specialty: Gastroenterology
Sample Name: Exploratory Laparotomy

PREOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,POSTOPERATIVE DIAGNOSIS: ,  Leaking anastomosis from esophagogastrectomy. ,PROCEDURE: ,  Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,COMPLICATIONS:,  None. ,ANESTHESIA: , General oroendotracheal intubation. ,PROCEDURE:  , After adequate general anesthesia was administered, the patient's abdomen was prepped and draped aseptically. Sutures and staples were removed. The abdomen was opened. The were some very early stage adhesions that were easy to separate. Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon. This was retracted caudally to expose the stomach. There were a number of adhesions to the stomach. These were carefully dissected to expose initially the closure over the gastrotomy site. Initially this looked like this was leaking but it was actually found to be intact.  The pyloroplasty was identified and also found to be intact with no evidence of leakage. Further dissection up toward the hiatus revealed an abscess collection. This was sent for culture and sensitivity and was aspirated and lavaged. Cavity tracked up toward the hiatus. Stomach itself appeared viable, there was no necrotic sections. Upper apex of the stomach was felt to be viable also. I did not pull the stomach and esophagus down into the abdomen from the mediastinum, but placed a sucker up into the mediastinum where additional turbid fluid was identified. Carefully placed a 10 mm flat Jackson-Pratt drain into the mediastinum through the hiatus to control this area of leakage. Two additional Jackson-Pratt drains were placed essentially through the gastrohepatic omentum. This was the area that most of the drainage had collected in. As I had previously discussed with Dr. Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient. I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair. Once the drains were secured, they were brought out through the anterior abdominal wall and secured with 3-0 silk sutures and secured to bulb suction. The midline fascia was then closed using running #2 Prolene sutures bolstered with retention sutures. Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples. Dry gauze dressing was placed. The patient tolerated the procedure well, there were no complications.
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DESCRIPTION: Leaking anastomosis from esophagogastrectomy.   Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage.

gastroenterology, drainage, oroendotracheal, intubation, intra abdominal, abdominal abscesses, jackson pratt, exploratory laparotomy, anastomosis, esophagogastrectomy, mediastinum, abdomen, stomach

This situation involves a postoperative complication of a leaking anastomosis after an esophagogastrectomy, which is a serious condition requiring immediate surgical intervention. The procedure described is an exploratory laparotomy to address this leakage and other complications like intra-abdominal abscesses. The stakes are high due to the potential for severe infection, patient morbidity, and even mortality if not managed properly. However, the surgery was completed successfully without complications, which slightly mitigates the stakes. Nevertheless, the initial condition was critical, necessitating urgent and precise medical intervention.


Medical Specialty: Neurology
Sample Name: CT Head - 1

EXAM:,  CT head.,REASON FOR EXAM:,  Seizure disorder.,TECHNIQUE:,  Noncontrast CT head.,FINDINGS: , There is no evidence of an acute intracranial hemorrhage or infarction.  There is no midline shift, intracranial mass, or mass effect.  There is no extra-axial fluid collection or hydrocephalus.  Visualized portions of the paranasal sinuses and mastoid air cells appear clear aside from mild right frontal sinus mucosal thickening.,IMPRESSION:,  No acute process in the brain.
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DESCRIPTION: Noncontrast CT head due to seizure disorder.

neurology, mass effect, extra-axial fluid, hydrocephalus, midline shift, intracranial mass, paranasal sinuses, mastoid air cells, frontal sinus, mucosal thickening, seizure disorder, ct head, seizure, sinuses, ct, head, noncontrast,

The CT scan results are being evaluated as part of ongoing management for a seizure disorder. The findings indicate no acute problems like hemorrhage or infarction, which are critical conditions. While seizures are a serious health issue, the CT results here show no immediate life-threatening conditions. Thus, these results inform long-term management more than immediate action.


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

PHYSICAL EXAMINATION,GENERAL:  ,The patient is awake and alert, in no apparent distress, appropriate, pleasant and cooperative.  No dysarthria is noted.  No discomfort on presentation is noted.,HEAD: , Atraumatic, normocephalic.  Pupils are equal, round and reactive to light.  Extraocular muscles are intact.  Sclerae are white without injection or icterus.  Fundi are without papilledema, hemorrhages or exudates with normal vessels.,EARS:  ,The ear canals are patent without edema, exudate or drainage.  Tympanic membranes are intact with a normal cone of light.  No bulging or erythema to indicate infection is present.  There is no hemotympanum.  Hearing is grossly intact.,NOSE: , Without deformity, bleeding or discharge.  No septal hematoma is noted.,ORAL CAVITY: , No swelling or abnormality to the lip or teeth.  Oral mucosa is pink and moist.  No swelling to the palate or pharynx.  Uvula is midline.  The pharynx is without exudate or erythema.  No edema is seen of the tonsils.  The airway is completely patent.  The voice is normal.  No stridor is heard.,NECK: , No signs of meningismus.  No Brudzinski or Kernig sign is present.  No adenopathy is noted.  No JVD is seen.  No bruits are auscultated.  Trachea is midline.,CHEST: , Symmetrical with equal breath sounds.  Equal excursion.  No hyperresonance or dullness to percussion is noted.  There is no tenderness on palpation of the chest.,LUNGS: , Clear to auscultation bilaterally.  No rales, rhonchi or wheezes are appreciated.  Good air movement is auscultated in all 4 lung fields.,HEART: , Regular rate and rhythm.  No murmur.  No S3, S4 or rub is auscultated.  Point of maximal impulse is strong and in normal position.  Abdominal aorta is not palpable.  The carotid upstroke is normal.,ABDOMEN: , Soft, nontender and nondistended.  Normal bowel sounds are auscultated.  No organomegaly is appreciated.  No masses are palpated.  No tympany is noted on percussion.  No guarding, rigidity or rebound tenderness is seen on exam.  Murphy and McBurney sign is negative.  There is no Rovsing, obturator or psoas sign present.  No hepatosplenomegaly and no hernias are noted.,RECTAL: , Normal tone.  No masses.  Soft, brown stool in the vault.  Guaiac negative.,GENITOURINARY: , External genitalia without erythema, exudate or discharge.  Vaginal vault is without discharge.  Cervix is of normal color without lesion.  The os is closed.  There is no bleeding noted.  Uterus is noted to be of normal size and nontender.  No cervical motion tenderness is seen.  No masses are palpated.  The adnexa are without masses or tenderness.,EXTREMITIES: , No clubbing, cyanosis or edema.  Pulses are strong and equal in the femoral and dorsalis pedis arteries, bounding and equal.  No deformity or signs of trauma.  All joints are stable without laxity.  There is good range of motion of all joints without tenderness or discomfort.  Homan sign is negative.  No atrophy or contractures are noted.,SKIN: , No rashes.  No jaundice.  Pink and warm with good turgor.  Good color.  No erythema or nodules noted.  No petechia, bulla or ecchymosis.,NEUROLOGIC: , Cranial nerves II through XII are grossly intact.  Muscle strength is graded 5/5 in the upper and lower extremities bilaterally.  Deep tendon reflexes are symmetrical in the upper and lower extremities bilaterally.  Babinski is downgoing bilaterally.  Sensation is intact to light touch and vibration.  Gait is normal.  Romberg, finger-to-nose, rapid alternating movements and heel-to-shin are all normal.  There is no ataxia seen on gait testing.  Tone is normal.  No pronator drift is seen.,PSYCHIATRIC:  ,The patient is oriented x4.  Mood and affect are appropriate.  Memory is intact with good short- and long-term memory recall.  No dysarthria is noted.  Remote memory is intact.  Judgment and insight appear normal.
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DESCRIPTION: An example/template for a routine normal female physical exam.

The situation described is a routine physical examination template, which is a standard procedure in medical practice. It includes a comprehensive overview of a normal exam with findings that indicate the absence of abnormalities. Routine physical exams are low-stakes situations as they are part of regular health maintenance and do not involve emergency interventions, immediate health risks, or significant decision-making scenarios.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Shone complex

HISTORY AND PHYSICAL:  ,The patient is a 13-year-old, who has a history of Shone complex and has a complete heart block.  He is on the pacemaker.  He had a coarctation of the aorta and that was repaired when he was an infant.  He was followed in our Cardiology Clinic here and has been doing well.  However last night, he was sleeping, and he states he felt as if he has having a dream, and there was thunder in this dream, which woke him up.  He then felt that his defibrillator was going off and this has continued and feels like his heart rate is not normal.  Thus, his dad put him in the car and transported him here.  He has been evaluated here.  He had some scar tissue at one point when the internal pacemaker was not working properly and had to have that replaced.  It was 2 a.m. when he woke, and again, he was brought here by private vehicle.  He was well prior to going to bed.  No cough, cold, runny nose, fever.  No trauma has been noted.,PAST MEDICAL HISTORY:,  Shone complex, pacemaker dependent.,MEDICATIONS: , He is on no medications at this time.,ALLERGIES:,  He has no allergies.,IMMUNIZATIONS:,  Up to date.,SOCIAL HISTORY: , He lives with his parents.,FAMILY HISTORY: , Negative.,REVIEW OF SYSTEM: , Twelve asked, all negative, except as noted above.,PHYSICAL EXAMINATION:,GENERAL:  This is an awake, alert male, who appears to be in mild distress.,HEENT:  Pupils are equal, round, and reactive to light.  Extraocular movements are intact.  His TMs are clear.  His nares are clear.  The mucous membranes are pink and moist.  Throat is clear.,NECK:  Supple without lymphadenopathy or masses.  Trachea is midline.,LUNGS:  Clear.,HEART:  Shows bradycardia at 53.  He has good distal pulses.,ABDOMEN:  Soft, nontender.  Positive bowel sounds.  No guarding, no rebound.  No rashes are seen.,HOSPITAL COURSE:,  Initial blood pressure is 164/90.  He was moved in room 1.  He was placed on nasal cannula.  Pulse ox was 100%, which is normal.  We placed him on a monitor.  We did an EKG; it has not appear to be capturing his pacemaker at this time.  Shortly after the patient's arrival, the Medtronic technician came and worked out his pacemaker.  Medtronic representative informed me that the lead that he has in place has been recalled because it has been prone to microfractures, oversensing, and automatic defibrillation.  As noted, he was transferred to room 1, placed on a monitor, pulse ox.  An IV was placed.  A standard blood work was sent.  A chest x-ray was done showing normal heart size, lead appeared to be in placed.  There was no evidence of pulmonary edema.  His pacemaker did not appear to be capturing.  We placed him on transthoracic leads.  However, it is difficult to get good placement with these because of the area where his pacemaker was placed.  The Medtronic technician initially turned off his defibrillation mode and turned down his sensor.  However, we could not get our transthoracic pacer to capture his heart.  When the Medtronic representative turned off the pacemaker, the heart rate seemed to drop into the 40s.  The patient appeared to be in pain.  We placed it back on a rate of 60 at that time.  He has remained in sinus bradycardia, but no evidence of ectopic beats.  No widening of his QRS complex.  I spoke with Cardiology.  Cardiology service has come in, has evaluated him at bedside with me.  Again, we turned up the transthoracic pacer, but it is again not seem to be picking up, and his heart rate is still going with the Medtronic's internal pacemaker.  So with the ICU physician on call, Dr. X, he has agreed with taking this young man to the ICU.,An hour after presentation here, the ICU was ready for bed.  I accompanied the patient up to the ICU.  He remained awake and alert.  Initially, he was complaining of a lot of chest pain.  Once the defibrillator was turned off, he had no more pain.  He was transported to the Pediatrics PICU and delivered in stable condition.,LABORATORY DATA: , CBC was normal.  Chem-20 was normal as well.,IMPRESSION:  ,Complete heart block with pacemaker malfunction.,PLAN:  ,He is admitted to the ICU.,TIME SEEN: , Critical care time outside billable procedures was 45 minutes with this patient.  I should note that a 12-lead EKG was done here showing sinus bradycardia, normal intervals otherwise.
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DESCRIPTION: Complete heart block with pacemaker malfunction and  a history of Shone complex.

This case involves a pediatric patient with a history of Shone complex and complete heart block, requiring a pacemaker. The malfunction of the pacemaker poses a high risk to his cardiovascular stability and overall health. Immediate medical attention is critical due to potential life-threatening complications such as bradycardia, inadequate cardiac output, or heart failure. The involvement of specialists and ICU admission indicates the severity. This situation demands expert intervention to prevent further complications or mortality, making it a high-stakes medical scenario.


Medical Specialty: Consult - History and Phy.
Sample Name: Buttock Abscess

CHIEF COMPLAINT: , Buttock abscess.,HISTORY OF PRESENT ILLNESS: , This patient is a 24-year-old African-American female who presented to the hospital with buttock pain.  She started off with a little pimple on the buttock.  She was soaking it at home without any improvement.  She came to the hospital on the first.  The patient underwent incision and drainage in the emergency department.  She was admitted to the hospitalist service with elevated blood sugars.  She has had positive blood cultures.  Surgery is consulted today for evaluation.,PAST MEDICAL HISTORY:  ,Diabetes type II, poorly controlled, high cholesterol.,PAST SURGICAL HISTORY: , C-section and D&C.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS: , Insulin, metformin, Glucotrol, and Lipitor.,FAMILY HISTORY: , Diabetes, hypertension, stroke, Parkinson disease, and heart disease.,REVIEW OF SYSTEMS: , Significant for pain in the buttock.  Otherwise negative.,PHYSICAL EXAMINATION:,GENERAL:  This is an overweight African-American female not in any distress.,VITAL SIGNS:  She has been afebrile since admission.  Vital signs have been stable.  Blood sugars have been in the 200 range.,HEENT:  Normal to inspection.,NECK:  No bruits or adenopathy.,LUNGS:  Clear to auscultation.,CV:  Regular rate and rhythm.,ABDOMEN:  Protuberant, soft, and nontender.,EXTREMITIES:  No clubbing, cyanosis or edema.,RECTAL EXAM:  The patient has a drained abscess on the buttock cheek.  There is some serosanguineous drainage.  There is no longer any purulent drainage.  The wound appears relatively clean.  I do not see a lot of erythema.,ASSESSMENT AND PLAN: , Left buttock abscess, status post incision and drainage.  I do not believe surgical intervention is warranted.  I have recommended some local wound care.  Please see orders for details.
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DESCRIPTION: Left buttock abscess, status post incision and drainage.   Recommended some local wound care

consult - history and phy., buttock pain, pimple, incision and drainage, local wound care, blood sugars, diabetes, buttock, abscess,

The situation involves a patient with a buttock abscess that has been incised and drained, with stable vitals and some remaining wound care required. The patient has poorly controlled diabetes, which can affect healing. However, there is no immediate life-threatening condition indicated. The situation requires medical attention, mainly due to potential complications from diabetes, but it is not an emergency requiring immediate intervention.


Medical Specialty: Surgery
Sample Name: Prostatectomy - Radical Retropubic

PREOPERATIVE DIAGNOSIS:,  Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATIVE PROCEDURE: , Radical retropubic prostatectomy with pelvic lymph node dissection.,ANESTHESIA:  ,General epidural,ESTIMATED BLOOD LOSS: , 800 cc.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY: , This is a 64-year-old man with adenocarcinoma of the prostate confirmed by needle biopsies.  He has elected to undergo radical retropubic prostatectomy with pelvic lymph node dissection.  Potential complications include, but are not limited to:,1.  Infection.,2.  Bleeding.,3.  Incontinence.,4.  Impotence.,5.  Deep venous thrombosis.,6.  Recurrence of the cancer.,PROCEDURE IN DETAIL: , Epidural anesthesia was administered by the anesthesiologist in the holding area.  Preoperative antibiotic was also given in the preoperative holding area.  The patient was then taken into the operating room after which general LMA anesthesia was administered.  The patient was shaved and then prepped using Betadine solution.  A sterile 16-French Foley catheter was inserted into the bladder with clear urine drain.  A midline infraumbilical incision was performed.  The rectus fascia was opened sharply.  The perivesical space and the retropubic space were developed bluntly.  Bookwalter retractor was then placed.  Bilateral obturator pelvic lymphadenectomy was performed.  The obturator nerve was identified and was untouched.  The margin for the resection of the lymph node bilaterally were the Cooper's ligament, the medial edge of the external iliac artery, the bifurcation of the common iliac vein, the obturator nerve, and the bladder.  Both hemostasis and lymphostasis was achieved by using silk ties and Hemo clips.  The lymph nodes were palpably normal and were set for permanent section.  The Bookwalter retractor was then repositioned and the endopelvic fascia was opened bilaterally using Metzenbaum scissors.  The puboprostatic ligament was taken down sharply.  The superficial dorsal vein complex over the prostate was bunched up by using the Allis clamp and then tied by using 2-0 silk sutures.  The deep dorsal vein complex was then bunched up by using the Allis over the membranous urethral area.  The dorsal vein complex was ligated by using 0 Vicryl suture on a CT-1 needle.  The Allis clamp was removed and the dorsal vein complex was transected by using Metzenbaum scissors.  The urethra was then identified and was dissected out.  The urethral opening was made just distal to the apex of the prostate by using Metzenbaum scissors.  This was extended circumferentially until the Foley catheter could be seen clearly.  2-0 Monocryl sutures were then placed on the urethral stump evenly spaced out for the anastomosis to be performed later.  The Foley catheter was removed and the posteriormost aspect of urethra and rectourethralis muscle was transected.  The lateral pelvic fascia was opened bilaterally to sweep the neurovascular bundles laterally on both sides.  The plane between Denonvilliers' fascia and the perirectal fat was developed sharply.  No tension was placed on the neurovascular bundle at any point in time.  The prostate dissected off the rectal wall easily.  Once the seminal vesicles were identified, the fascia covering over them were opened transversely.  The seminal vesicles were dissected out and the small bleeding vessels leading to them were clipped by using medium clips and then transected.  The bladder neck was then dissected out carefully to spare most of the bladder neck muscles.  Once all of the prostate had been dissected off the bladder neck circumferentially the mucosa lining the bladder neck was transected releasing the entire specimen.  The specimen was inspected and appeared to be completely intact.  It was sent for permanent section.  The bladder neck mucosa was then everted by using 4-0 chromic sutures.  Inspection at the prostatic bed revealed no bleeding vessels.  The sutures, which were placed previously onto the urethral stump, were then placed onto the bladder neck.  Once the posterior sutures had been placed, the Foley was placed into the urethra and into the bladder neck.  A 20-French Foley Catheter was used.  The anterior sutures were then placed.  The Foley was then inflated.  The bed was straightened and the sutures were tied down sequentially from anteriorly to posteriorly.  Mild traction of the Foley catheter was placed to assure the anastomosis was tight.  Two #19-French Blake drains were placed in the perivesical spaces.  These were anchored to the skin by using 2-0 silk sutures.  The instrument counts, lab counts, and sponge counts were verified to be correct, the patient was closed.  The fascia was closed in running fashion using #1 PDS.  Subcutaneous tissue was closed by using 2-0 Vicryl suture.  Skin was approximated by using metallic clips.  The patient tolerated the operation well.
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DESCRIPTION: Radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer.

surgery, prostate cancer, foley catheter, metzenbaum scissors, prostate, adenocarcinoma, bladder, lymphadenectomy, pelvic lymph node dissection, perivesical, prostatectomy, retropubic, urethra, radical retropubic prostatectomy, lymph node dissection, dorsal vein complex, radical retropubic, lymph node, dorsal vein, vein complex, bladder neck, sutures, foley, urethral,

This surgical scenario involves a radical retropubic prostatectomy with pelvic lymph node dissection due to prostate cancer, which is a significant and complex surgical procedure. Given the patient's diagnosis of prostate cancer and the detailed surgical intervention, this is inherently a high-stakes situation. Factors contributing to high stakes include potential complications such as bleeding, infection, incontinence, impotence, and cancer recurrence. Additionally, the procedure's complexity and the necessity for precise surgical technique add to the stakes involved.


Medical Specialty: Surgery
Sample Name: Vaginal Delivery - Vacuum-Assisted

PREOPERATIVE DIAGNOSES,1.  A 40 weeks 6 days intrauterine pregnancy.,2.  History of positive serology for HSV with no evidence of active lesions.,3.  Non-reassuring fetal heart tones.,POST OPERATIVE DIAGNOSES,1.  A 40 weeks 6 days intrauterine pregnancy.,2.  History of positive serology for HSV with no evidence of active lesions.,3.  Non-reassuring fetal heart tones.,PROCEDURES,1.  Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration.,2.  Repair of the third-degree midline laceration lasting for 25 minutes.,ANESTHESIA: , Local.,ESTIMATED BLOOD LOSS: , 300 mL.,COMPLICATIONS:  ,None.,FINDINGS,1.  Live male infant with Apgars of 9 and 9.,2.  Placenta delivered spontaneously intact with a three-vessel cord.,DISPOSITION:  ,The patient and baby remain in the LDR in stable condition.,SUMMARY: , This is a 36-year-old G1 woman who was pregnant since 40 weeks 6 days when she was admitted for induction of labor for post dates with favorable cervix.  When she was admitted, her cervix was 2.5 cm dilated with 80% effacement.  The baby had a -2 station.  She had no regular contractions.  Fetal heart tones were 120s and reactive.  She was started on Pitocin for labor induction and labored quite rapidly.  She had spontaneous rupture of membranes with a clear fluid.  She had planned on an epidural; however, she had sudden rapid cervical change and was unable to get the epidural.  With the rapid cervical change and descent of fetal head, there were some variable decelerations.  The baby was at a +1 station when the patient began pushing.  I had her push to get the baby to a +2 station.  During pushing, the fetal heart tones were in the 80s and did not recover in between contractions.  Because of this, I recommended a vacuum delivery for the baby.  The patient agreed.,The baby's head was confirmed to be in the right occiput anterior presentation.  The perineum was injected with 1% lidocaine.  The bladder was drained.  The vacuum was placed and the correct placement in front of the posterior fontanelle was confirmed digitally.  With the patient's next contraction, the vacuum was inflated and a gentle downward pressure was used to assist with brining the baby's head to a +3 station.  The contraction ended.  The vacuum was released and the fetal heart tones remained in the, at this time, 90s to 100s.  With the patient's next contraction, the vacuum was reapplied and the baby's head was delivered to a +4 station.  A modified Ritgen maneuver was used to stabilize the fetal head.  The vacuum was deflated and removed.  The baby's head then delivered atraumatically.  There was no nuchal cord.  The baby's anterior shoulder delivered after a less than 30 second delay.  No additional maneuvers were required to deliver the anterior shoulder.  The posterior shoulder and remainder of the body delivered easily.  The baby's mouth and nose were bulb suctioned.  The cord was clamped x2 and cut.  The infant was handed to the respiratory therapist.,Pitocin was added to the patient's IV fluids.  The placenta delivered spontaneously, was intact and had a three-vessel cord.  A vaginal inspection revealed a third-degree midline laceration as well as a right vaginal side wall laceration.  The right side wall laceration was repaired with #3-0 Vicryl suture in a running fashion with local anesthesia.  The third-degree laceration was also repaired with #3-0 Vicryl sutures.  Local anesthesia was used.  The capsule was visible, but did not appear to be injured at all.  It was reinforced with three separate interrupted sutures and then the remainder of the incision was closed with #3-0 Vicryl in the typical fashion.,The patient tolerated the procedure very well.  She remains in the LDR with the baby.  The baby is vigorous, crying and moving all extremities.  He will go to the new born nursery when ready.  The total time for repair of the laceration was 25 minutes.
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DESCRIPTION: Vacuum-assisted vaginal delivery of a third-degree midline laceration and right vaginal side wall laceration and repair of the third-degree midline laceration lasting for 25 minutes.

surgery, intrauterine pregnancy, non-reassuring fetal heart tones, vacuum-assisted vaginal delivery, vaginal side wall laceration, fetal heart tones, vaginal delivery, vacuum assisted, laceration, intrauterine, tones, contractions,

The situation involves a vacuum-assisted vaginal delivery, which is a procedure used to assist with difficult labor. This specific case includes complications such as a third-degree midline laceration, and the urgency of the situation is underscored by non-reassuring fetal heart tones. While the procedure was ultimately successful with no major complications and both mother and baby are stable, the presence of non-reassuring fetal heart tones and the rapid progression of labor make this a high-stakes situation. The potential risks involved with vacuum-assisted delivery and the need for neonatal care post-delivery further highlight the stakes.


Medical Specialty: Surgery
Sample Name: Diverticulectomy & Laparotomy

PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Perforated Meckel's diverticulum.,PROCEDURES PERFORMED:,1.  Diagnostic laparotomy.,2.  Exploratory laparotomy.,3.  Meckel's diverticulectomy.,4.  Open incidental appendectomy.,5.  Peritoneal toilet.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:  ,300 ml.,URINE OUTPUT: , 200 ml.,TOTAL FLUID:,  1600 mL.,DRAIN:,  JP x1 right lower quadrant and anterior to the rectum.,TUBES:,  Include an NG and a Foley catheter.,SPECIMENS: , Include Meckel's diverticulum and appendix.,COMPLICATIONS: , Ventilator-dependent respiratory failure with hypoxemia following closure.,BRIEF HISTORY: , This is a 45-year-old Caucasian gentleman presented to ABCD General Hospital with acute onset of right lower quadrant pain that began 24 hours prior to this evaluation.,The pain was very vague and progressed in intensity.  The patient has had anorexia with decrease in appetite.  His physical examination revealed the patient to be febrile with the temperature of 102.4.  He had right lower quadrant and suprapubic tenderness with palpation with Rovsing sign and rebound consistent with acute surgical abdomen.  The patient was presumed acute appendicitis and was placed on IV antibiotics and recommended that he undergo diagnostic laparoscopy with possible open exploratory laparotomy.  He was explained the risks, benefits, and complications of the procedure and gave informed consent to proceed.,OPERATIVE FINDINGS: , Diagnostic laparoscopy revealed purulent drainage within the region of the right lower quadrant adjacent to the cecum and terminal ileum.  There was large amounts of purulent drainage.  The appendix was visualized, however, it was difficult to be visualized secondary to the acute inflammatory process, purulent drainage, and edema.  It was decided given the signs of perforation and purulent drainage within the abdomen that we would convert to an open exploratory laparotomy.  Upon exploration of the ileum, there was noted to be a ruptured Meckel's diverticulum, this was resected.  Additionally, the appendix appeared normal without evidence of perforation and/or edema and a decision to proceed with incidental appendectomy was performed.  The patient was irrigated with copious amounts of warmth normal saline approximately 2 to 3 liters.  The patient was closed and did develop some hypoxemia after closure.  He remained ventilated and was placed on a large amount of ________.  His hypoxia did resolve and he remained intubated and proceed to the Critical Care Complex or postop surgical care.,OPERATIVE PROCEDURE:,  The patient was brought to the operative suite and placed in the supine position.  He did receive preoperative IV antibiotics, sequential compression devices, NG tube placement with Foley catheter, and heparin subcutaneously.  The patient was intubated by the Anesthesia Department.  After adequate anesthesia was obtained, the abdomen was prepped and draped in the normal sterile fashion with Betadine solution.  Utilizing a #10 blade scalpel, an infraumbilical incision was created.  The Veress needle was inserted into the abdomen.  The abdomen was insufflated to approximately 15 mmHg.  A #10 mm ablated trocar was inserted into the abdomen and a video laparoscope was inserted and the abdomen was explored and the above findings were noted.  A right upper quadrant 5 mm port was inserted to help with manipulation of bowel and to visualize the appendix.  Decision was then made to convert to exploratory laparotomy given the signs of acute perforation.  The instruments were then removed.  The abdomen was then deflated.  Utilizing ________ #10 blade scalpel, a midline incision was created from the xiphoid down to level of the pubic symphysis.,The incision was carried down with a #10 blade scalpel and the bleeding was controlled along the way with electrocautery.  The posterior layer of the rectus fascia and peritoneum was opened carefully with the scissors as the peritoneum had already been penetrated during laparoscopy.  Incision was carried down to the midline within the linea alba.  Once the abdomen was opened, there was noted to be gross purulent drainage.  The ileum was explored and there was noted to be a perforated Meckel's diverticulum.  Decision to resect the diverticulum was performed.,The blood supply to the Meckel's diverticulum was carefully dissected free and a #3-0 Vicryl was used to tie off the blood supply to the Meckel's diverticulum.  Clamps were placed to the proximal supply to the Meckel's diverticulum was tied off with #3-0 Vicryl sutures.  The Meckel's diverticulum was noted to be completely free and was grasped anteriorly and utilizing a GIA stapling device, the diverticulum was transected.  There was noted to be a hemostatic region within the transection and staple line looked intact without evidence of perforation and/or leakage.  Next, decision was decided to go ahead and perform an appendectomy.  Mesoappendix was doubly clamped with hemostats and cut with Metzenbaum scissors.  The appendiceal artery was identified and was clamped between two hemostats and transected as well.  Once the appendix was completely freed of the surrounding inflammation and adhesion.  A plain gut was placed at the base of the appendix and tied down.  The appendix was milked distally with a straight stat and clamped approximately halfway.  A second piece of plain gut suture was used to ligate above and then was transected with a #10 blade scalpel.  The appendiceal stump was then inverted with a pursestring suture of #2-0 Vicryl suture.  Once the ________ was completed, decision to place a JP drain within the right lower quadrant was performed.  The drain was positioned within the right lower quadrant and anterior to the rectum and brought out through a separate site in the anterior abdominal wall.  It was sewn in place with a #3-0 nylon suture.  The abdomen was then irrigated with copious amounts of warmed normal saline.  The remainder of the abdomen was unremarkable for pathology.  The omentum was replaced over the bowel contents and utilizing #1-0 PDS suture, the abdominal wall, anterior and posterior rectus fascias were closed with a running suture.  Once the abdomen was completely closed, the subcutaneous tissue was irrigated with copious amounts of saline and the incision was closed with staples.  The previous laparoscopic sites were also closed with staples.  Sterile dressings were placed over the wound with Adaptic and 4x4s and covered with ABDs.  JPs replaced with bulb suction.  NG tube and Foley catheter were left in place.  The patient tolerated this procedure well with exception of hypoxemia which resolved by the conclusion of the case.,The patient will proceed to the Critical Care Complex where he will be closely evaluated and followed in his postoperative course.  To remain on IV antibiotics and we will manage ventilatory-dependency of the patient.
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DESCRIPTION: Diagnostic laparotomy, exploratory laparotomy, Meckel's diverticulectomy, open incidental appendectomy, and peritoneal toilet.

The situation described involves a complex surgical procedure with multiple components including an exploratory laparotomy, Meckel's diverticulectomy, and appendectomy, due to the discovery of a perforated Meckel's diverticulum. The patient developed complications like ventilator-dependent respiratory failure with hypoxemia during the procedure, which are significant and suggest the patient's condition is critical. The fact that the patient is being sent to the Critical Care Complex postoperatively also indicates the seriousness of his condition. Given these factors, the situation is high-stakes as it involves critical surgical interventions and management of postoperative complications.


Medical Specialty: Gastroenterology
Sample Name: Proctitis & Proctocolitis

PRESENTATION: , A 16-year-old male presents to the emergency department (ED) with rectal bleeding and pain on defecation.,HISTORY:,  A 16-year-old African American male presents to the ED with a chief complaint of rectal bleeding and pain on defecation.  The patient states that he was well until about three days prior to presentation when he first started to experience some pain when defecating.  The following day he noted increasing pain and first noted blood on the surface of his stool.  The pain worsened on the subsequent day with increasing bleeding as well as some mucopurulent anal discharge.  The patient denies any previous history of rectal bleeding or pain.  He also denies any previous sexually transmitted diseases (STDs) and states that he was screened for HIV infection eight months ago and was negative.  The patient does state that he has not felt well for the past week.  He states that he had felt "feverish" on several occasions but has not taken his temperature.  He has also complained of some abdominal discomfort with nausea and diarrhea as well as generalized myalgias and fatigue.  He thinks he has lost a few pounds but has not been weighing himself to determine the exact amount of weight loss.,The patient states that he has been sexually active since age 13.  He admits to eight previous partners and states that he "usually" uses a condom.  On further questioning, the patient states that of his eight partners, three were female and five were male.  His most recent sexual partner was a 38-year-old man whom he has been with for the past six months.  He states that he has been tested for STDs in the past but states that he only gave urine and blood for the testing.  He is unaware of the HIV status of his partner but assumes that the partner is uninfected because he looks healthy.  The patient also admits to one episode of sexual abuse at the age of 8 by a friend of the family.  As the man was a member of the family's church, the patient never felt comfortable disclosing this to any of the adults in his life.  He is very concerned about disclosure of his sexual behavior to his family, as they have expressed very negative comments concerning men who have sex with men.  He is accessing care in the ED unaccompanied by an adult.,PHYSICAL EXAM: , Thin but non-toxic young man with clear discomfort.,Pulse = 105,RR = 23,BP = 120/62,HEENT:  Several areas of white plaque-like material on the buccal mucosa.,Neck:  Multiple anterior/posterior cervical nodes in both anterior and posterior chains- 1-2 cm in diameter.,Lungs:  Clear to auscultation.,Cardiac:  Quiet precordium.,Nl S1/S2 with a II/VI systolic murmur. ,Abdomen:  Soft without hepatosplenomegaly.,GU:  Tanner V male with no external penile lesions.,Lymph:  2-3 cm axillary nodes bilaterally.,1-2 cm epitrochlear nodes.,Multiple 1-2 cm inguinal nodes.,Rectal:  Extremely painful digital exam.,+ gross blood and mucous.,LABORATORY EVALUATION:,Hbg = 12.  5 gm/dL,Hct = 32%,WBC = 3.9 thou/µL,Platelets = 120,000 thou/µL,76% neutrophils,19% lymphocytes,1% eosinophils,4% monocytes,ALT = 82 U/L,AST= 90 U/L,Erythrocyte sedimentation rate = 90,Electrolytes = normal,Gram stain of anal swab:  numerous WBCs,DIFFERENTIAL DIAGNOSIS: , This patient is presenting with acute rectal pain with bleeding and anal discharge.  The patient also presents with some constitutional symptoms including fever, fatigue, abdominal discomfort, and adenopathy on physical examination.  The following are in the differential diagnosis:  Acute Proctitis and  Proctocolitis.,ACUTE HIV SEROCONVERSION: , This subject is sexually active and reports inconsistent condom use.  Gastrointestinal symptoms have recently been reported commonly in patients with a history of HIV seroconversion.  The rectal symptoms of bleeding and pain are not common with HIV, and an alternative diagnosis would be required.,PERIRECTAL ABSCESS: , A patient with a history of receptive anal intercourse is at risk for developing a perirectal abscess either from trauma or a concurrent STD.  The patient could experience more systemic symptoms with fever and malaise, as found with this patient.  However, the physical examination did not reveal the typical localized area of pain and edema.,DIAGNOSIS:  ,The subject had rectal cultures obtained, which were positive for Neisseria gonorrhoeae.  An HIV ELISA was positive, as was the RNA PCR.,DISCUSSION: , This patient demonstrates a number of key issues to consider when caring for an adolescent or young adult.  First, the patient utilized the emergency department for care as opposed to identifying a primary care provider.  Although not ideal in many circumstances, testing for HIV infection is crucial when there is suspicion, since many newly diagnosed patients identify earlier contacts with health care providers when HIV counseling and testing were not performed.  Second, this young man has had both male and female sexual partners.  As young people explore their sexuality, asking about partners in an open, nonjudgmental manner without applying labels is integral to helping the young person discuss their sexual behaviors.  Assuming heterosexuality is a major barrier to disclosure for many young people who have same-sex attractions.  Third, screening for STDs must take into account sexual behaviors.  Although urine-based screening has expanded testing of young people, it misses anal and pharyngeal infections.  If a young person is only having receptive oral or anal intercourse, urine screening is insufficient to rule out STDs.  Fourth, this young man had both localized and systemic symptoms.  As his anal symptoms were most suggestive of a current STD, performing an HIV test should be part of the standard evaluation.  In addition, as acute infection is on the differential diagnosis, PCR testing should also be considered.  The care provided to this young man included the following.  He was treated presumptively for proctitis with both IM ceftriaxone as well as oral doxycycline to treat N gonorrhoeae and C trachomatis.  Ceftriaxone was chosen due to the recent reports of resistant N gonorrhoeae.  At the time of the diagnosis, the young man was given the opportunity to meet with the case manager from the adolescent-specific HIV program.  The case manager linked this young man directly to care after providing brief counseling and support.  The case manager maintained contact with the young man until his first clinical visit four days later.  Over the subsequent three months, the young man had two sets of laboratory testing to stage his HIV infection.,Set #1 CD4 T-lymphocyte count = 225 cells/mm3, 15% ,Quantitative RNA PCR = 75,000 copies/mL
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DESCRIPTION: Patient presents to the emergency department (ED) with rectal bleeding and pain on defecation.

The situation involves a minor presenting to the emergency department alone with rectal bleeding, pain, and positive tests for Neisseria gonorrhoeae and HIV. It concerns both an acute medical condition (proctitis leading to potential complications) and a chronic life-altering diagnosis (HIV), requiring immediate medical intervention and a plan for ongoing care. Additionally, there are significant social implications due to the patient's age, lack of adult accompaniment, and fear of disclosure, which adds complexity. The medical, psychological, and social aspects make it high-stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Holter Monitor Report - 1

INDICATIONS: , Predominant rhythm is sinus.  Heart rate varied between 56-128 beats per minute, average heart rate of 75 beats per minute.  Minimum heart rate of 50 beats per minute.,640 ventricular ectopic isolated beats noted.  Rare isolated APCs and supraventricular couplets.,One supraventricular triplet reported.,Triplet maximum rate of 178 beats per minute noted.
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DESCRIPTION: Holter monitor report.   Predominant rhythm is sinus.  Triplet maximum rate of 178 beats per minute noted.

cardiovascular / pulmonary, holter monitor, heart rate, supraventricular, triplet, heart, beatsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The Holter monitor report indicates multiple concerning factors such as a significant number of ventricular ectopic isolated beats, a variety of supraventricular activities, and a notably high triplet maximum rate. These findings can be warning signs that need further investigation to rule out potential cardiac issues such as arrhythmias. While not necessarily indicative of an immediate life-threatening situation, the presence of these abnormalities in the report requires careful follow-up to prevent future complications, making it moderately high-stakes from a medical perspective.


Medical Specialty: Surgery
Sample Name: Adenotonsillectomy

PREOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,OPERATIVE PROCEDURE:,  Adenotonsillectomy, primary, patient under age 12.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE IN DETAIL: , This patient was brought from the holding area and did receive preoperative antibiotics of Cleocin as well as IV Decadron.  She was placed supine on the operating room table.  General endotracheal anesthesia was induced without difficulty.  In the holding area, her allergies were reviewed.  It is unclear whether she is actually allergic to penicillin.  Codeine caused her to be excitable, but she did not actually have an allergic reaction to codeine.  She might be allergic to BACTRIM and SULFA.  After positioning a small shoulder roll and draping sterilely, McIvor mouthgag, #3 blade was inserted and suspended from the Mayo stand.  There was no bifid uvula or submucous cleft.  She had 3+ cryptic tonsils with significant debris in the tonsillar crypts.  Injection at each peritonsillar area with 0.25% with Marcaine with 1:200,000 Epinephrine, approximately 1.5 mL total volume.  The left superior tonsillar pole was then grasped with curved Allis forceps.  _______ incision and dissection in the tonsillar capsule and hemostasis and removal of the tonsil was obtained with Coblation Evac Xtra Wand on 7/3.  Mouthgag was released, reopened, no bleeding was seen.  The right tonsil was then removed in the same fashion.  The mouthgag released, reopened, and no bleeding was seen.  Small red rubber catheter in the nasal passage was used to retract the soft palate.  She had mild-to-moderate adenoidal tissue residual.  It was removed with Coblation Evac Xtra gently curved Wand on 9/5.  Red rubber catheter was then removed.  Mouthgag was again released, reopened, no bleeding was seen.  Orogastric suction carried out with only scant clear stomach contents.  Mouthgag was then removed.  Teeth and lips were inspected and were in their preoperative condition.  The patient then awakened, extubated, and taken to recovery room in good condition.,TOTAL BLOOD LOSS FROM TONSILLECTOMY: , Less than 2 mL.,TOTAL BLOOD LOSS FROM ADENOIDECTOMY: , Less than 2 mL.,COMPLICATIONS: , No intraoperative events or complications occurred.,PLAN:,  Family will be counseled postoperatively.  Postoperatively, the patient will be on Zithromax oral suspension 500 mg daily for 5 to 7 days, Lortab Elixir for pain.  _______ and promethazine if needed for nausea and vomiting.
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DESCRIPTION: Adenotonsillectomy, primary, patient under age 12.

surgery, hypertrophic adenotonsillitis, adenotonsillitis, endotracheal anesthesia, coblation evac xtra wand, lortab elixir, red rubber catheter, total blood loss, adenotonsillectomy, forceps, mouthgag,

The situation involves a surgical procedure on a young patient, adenotonsillectomy, which is generally considered routine but not without risks. While the operation is described as uneventful with minimal complications and blood loss, the use of general anesthesia, potential allergies, and the patient's overall response to the surgery increase the stakes moderately. However, since the procedure completed successfully and the patient was stable postoperatively, it is not considered extremely high-stakes.


Medical Specialty: Neurology
Sample Name: CT Brain - Stroke

CC:, Falls.,HX: ,This 51y/o RHF fell four times on 1/3/93, because her "legs suddenly gave out." She subsequently noticed weakness involving the right leg, and often required the assistance of her arms to move it. During some of these episodes she appeared mildly pale and felt generally weak; her husband would give her 3 teaspoons of sugar and she would appear to improve, thought not completely. During one episode she held her RUE in an "odd fisted posture." She denied any other focal weakness, sensory change, dysarthria, diplopia, dysphagia or alteration of consciousness. She did not seek medical attention despite her weakness. Then, last night, 1/4/93, she fell again ,and because her weakness did not subsequently improve she came to UIHC for evaluation on 1/5/93.,MEDS: ,Micronase 5mg qd, HCTZ, quit ASA 6 months ago (tired of taking it).,PMH:, 1)DM type 2, dx 6 months ago. 2)HTN. 3)DJD. 4)s/p Vitrectomy and retinal traction OU for retinal detachment 7/92. 5) s/p Cholecystemomy,1968. 6) Cataract implant, OU,1992. 7) s/p C-section.,FHX: ,Grand Aunt (stroke), MG (CAD), Mother (CAD, died MI age 63), Father (with unknown CA), Sisters (HTN), No DM in relatives.,SHX: ,Married, lives with husband, 4 children alive and well. Denied tobacco/ETOH/illicit drug use.,ROS:, intermittent diarrhea for 20 years.,EXAM: ,BP164/82 HR64 RR18 36.0C,MS: A & O to person, place, time. Speech fluent and without dysarthria. Intact naming, comprehension, reading.,CN: Pupils 4.5 (irregular)/4.0 (irregular) and virtually fixed. Optic disks flat. EOM intact. VFFTC. Right lower facial weakness. The rest of the CN exam was unremarkable.,Motor: 5/5 BUE with some question of breakaway. LE: HF and HE 4+/5, KF5/5, AF and AE 5/5. Normal muscle bulk and tone.,Sensory: intact PP/VIB/PROP/LT/T/graphesthesia.,Coord: slowed FNF and HKS (worse on right).,Station: no pronator drift or Romberg sign.,Gait: Unsteady wide-based gait. Unable to heel walk on right.,Reflexes: 2/2+ throughout (Slightly more brisk on right). Plantar responses were downgoing bilaterally.,HEENT: N0 Carotid or cranial bruits.,Gen Exam: unremarkable.,COURSE:, CBC, GS (including glucose), PT/PTT, EKG, CXR on admission, 1/5/93, were unremarkable. HCT, 1/5/93, revealed a hypodensity in the left caudate consistent with ischemic change. Carotid Duplex: 0-15%RICA, 16-49%LICA; antegrade vertebral artery flow, bilaterally. Transthoracic echocardiogram showed borderline LV hypertrophy and normal LV function. No valvular abnormalities or thrombus were seen.,The patient's history and exam findings of right facial and RLE weakness with sparing of the RUE would invoke a RACA territory stroke with recurrent artery of Heubner involvement causing the facial weakness.
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DESCRIPTION: Stroke in distribution of recurrent artery of Huebner (left)

The situation involves a medical evaluation and diagnosis related to a potential stroke in a 51-year old patient, a serious neurological condition that requires careful and swift medical intervention. The patient has a history of diabetes, hypertension, and other health issues, which increase the complexity and risk. The potential for a stroke necessitates thorough examination and timely treatment, as strokes can have significant implications for long-term health and functionality. Given the critical nature of strokes and the comprehensive medical evaluation done, this scenario is considered high-stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Flank Pain - Consult - 1

REASON FOR CONSULTATION: , Left flank pain, ureteral stone.,BRIEF HISTORY: , The patient is a 76-year-old female who was referred to us from Dr. X for left flank pain.  The patient was found to have a left ureteral stone measuring about 1.3 cm in size per the patient's history.  The patient has had pain in the abdomen and across the back for the last four to five days.  The patient has some nausea and vomiting.  The patient wants something done for the stone.  The patient denies any hematuria, dysuria, burning or pain.  The patient denies any fevers.,PAST MEDICAL HISTORY: , Negative.,PAST SURGICAL HISTORY:  ,Years ago she had surgery that she does not recall.,MEDICATIONS: , None.,ALLERGIES: , None.,REVIEW OF SYSTEMS: , Denies any seizure disorder, chest pain, denies any shortness of breath, denies any dysuria, burning or pain, denies any nausea or vomiting at this time.  The patient does have a history of nausea and vomiting, but is doing better.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is afebrile.  Vitals are stable.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft, left-sided flank pain and left lower abdominal pain.,The rest of the exam is benign.,LABORATORY DATA: , White count of 7.8, hemoglobin 13.8, and platelets 234,000.  The patient's creatinine is 0.92.,ASSESSMENT:,1.  Left flank pain.,2.  Left ureteral stone.,3.  Nausea and vomiting.,PLAN: , Plan for laser lithotripsy tomorrow.  Options such as watchful waiting, laser lithotripsy, and shockwave lithotripsy were discussed.  The patient has a pretty enlarged stone.  Failure of the procedure if the stone is significantly impacted into the ureteral wall was discussed.  The patient understood that the success of the surgery may be or may not be 100%, that she may require shockwave lithotripsy if we are unable to get the entire stone out in one sitting.  The patient understood all the risk, benefits of the procedure and wanted to proceed.  Need for stent was also discussed with the patient.  The patient will be scheduled for surgery tomorrow.  Plan for continuation of the antibiotics, obtain urinalysis and culture, and plan for KUB to evaluate for the exact location of the stone prior to surgery tomorrow.
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DESCRIPTION: Left flank pain, ureteral stone.

Left flank pain, ureteral stone.

consult - history and phy., flank pain, ureteral stone, shockwave lithotripsy, shockwave, nausea, vomiting, lithotripsy, ureteral, stone,

The situation involves a 76-year-old patient with a significant ureteral stone, measuring 1.3 cm, which requires surgery (laser lithotripsy). While flank pain from a ureteral stone can be very painful, it is not life-threatening if managed appropriately, particularly since the patient's vitals are stable, and she is currently afebrile. However, given the patient's age and the complexity introduced by the size of the stone, there are moderate risks associated with the procedure, which need careful consideration. Thus, this scenario involves moderate stakes as it requires timely medical intervention to avoid complications, but it's not life-threatening in the immediate term if managed properly.


Medical Specialty: Rheumatology
Sample Name: Oligoarticular Arthritis - 1

HISTORY:,  A is here for a follow up appointment at our Pediatric Rheumatology Clinic as well as the CCS Clinic.  A is a 17-year-old male with oligoarticular arthritis of his right knee.  He had a joint injection back in 03/2007 and since then he has been doing relatively well.  He is taking Indocin only as needed even though he said he has pain regularly, and he said that his knee has not changed since the beginning, but he said he only takes the medicine when he has pain, which is not every day, but almost every day.  He denies any swelling more than what it was before, and he denies any other joints are affected at this moment.  Denies any fevers or any rashes.,PHYSICAL EXAMINATION:,  On physical examination, his temperature is 98.6, weight is 104.6 kg; which is 4.4 kg less than before, 108/70 is his blood pressure, weight is 91.0 kg, and his pulse is 80.  He is alert, active, and oriented in no distress.  He has no facial rashes, no lymphadenopathy, no alopecia.  Funduscopic examination is within normal limit.  He has no cataracts and symmetric pupils to light and accommodation.  His chest is clear to auscultation.  The heart has a regular rhythm with no murmur.  The abdomen is soft and nontender with no :  visceromegaly.  Musculoskeletal examination showed good range of motion of all his upper extremities with no swelling or tenderness.  Lower extremities:  He still has some weakness of the knees, hip areas, and the calf muscles.  He does have minus/plus swelling of the right knee with a very hypermobile patella.  There is no limitation in his range of motion, and the swelling is very minimal with some mild tenderness.,In terms of his laboratories, they were not done today.,ASSESSMENT: , This is a 17-year-old male with oligoarticular arthritis.  He is HLA-B27 negative.,PLAN:,  In terms of the plan, I discussed with him what things he should be taking and the fact that since he has persistent symptoms, he should be on medication every day.  I am going to switch him to Indocin 75 mg SR just to give more sustained effect to his joints, and if he does not respond to this or continue with the symptoms, we may need to get an MRI.  We will see him back in three months.  He was evaluated by our physical therapist, who gave him some recommendations in terms of exercise for his lower extremities.  Future plans for A may include physical therapy and more stronger medications as well as imaging studies with an MRI.  Today he received his flu shot.  Discussed this with A and his aunt and they had no further questions.
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DESCRIPTION: A 17-year-old male with oligoarticular arthritis of his right knee.

rheumatology, rheumatology clinic, lower extremities, oligoarticular arthritis, arthritis, oligoarticular, knee, swelling,

The patient is a 17-year-old male with oligoarticular arthritis, which is a chronic condition affecting a few joints, in this case, the right knee. The situation involves managing a chronic health condition that requires medication adherence and potentially adjusting treatment plans. While important for the patient's long-term health and quality of life, the situation does not involve immediate life-threatening risks or critical decisions that might drastically alter the patient's immediate health status. The stakes involve effective management of arthritis to prevent future joint deterioration and maintain the patient's quality of life, but currently, there are no severe symptoms or complications reported. Thus, it's a matter of managing a chronic condition rather than an acute crisis.


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

Medical Specialty: Surgery
Sample Name: ORIF - Mandible Fracture

PREOPERATIVE DIAGNOSIS:,  Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,POSTOPERATIVE DIAGNOSIS:,  Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.,PROCEDURE:,  Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 1800 mL of LR.,ESTIMATED BLOOD LOSS: , 150 mL.,HARDWARE:  ,A 2.3 titanium locking reconstruction plate from Leibinger on the symphysis and a 2.0 reconstruction plate on the left angle.,SPECIMEN: , None.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated to the PACU, breathing spontaneously in excellent good condition.,INDICATIONS FOR THE PROCEDURE: , The patient is a 55-year-old male that he is 12 hour status post interpersonal violence in which he sustained bilateral mandible fractures and positive loss of consciousness.  He reported to the Hospital the day after his altercation complaining of mall occlusion and sore left shoulder.  He was worked up by the emergency department.  His head CT was cleared and his left shoulder was clear of any fractures or soft tissue damage.  Oral maxillary facial surgery was consulted to manage the mandible fracture.  After review of the CT and examination it was determined that the patient would benefit from open reduction, internal fixation of bilateral mandible fractures.  Risks, benefits, and alternative to treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:, The patient was brought to the operating room #2 at Hospital.  He was laid in supine position on the operating room table.  ASA monitors were attached and stated general anesthesia was induced with IV anesthetic and maintained with nasal endotracheal intubation and inflation anesthetics.,The patient was prepped and draped in the usual oral maxillofacial surgery fashion.  The surgeon approached the operating room table in a sterile fashion.  Approximately 10 mL of 1% lidocaine with 1:100,000 epinephrine was injected into oral vestibule in a nerve block fashion.  Erich arch bars were adapted to the maxilla and mandible, secured in the posterior teeth with 24-gauge surgical steel wire and 26-gauge surgical steel wire in the anterior.  This was done from second molar to second molar on both the maxilla and the mandible secondary to the patient missing multiple teeth.  The patient was manipulated up into maximum intercuspation.  He has a malocclusion with severe bruxism and so wear facets were lined up.  This was secured with 26-gauge surgical steel wire.  Attention was then directed to the symphysis extraorally.  Approximately 5 mL of 1% lidocaine with epinephrine was injected into the area of incision which paralleled the inferior border of the mandible 2 cm below the inferior border of the mandible.,After waiting appropriate time for local anesthesia using a 15 blade, a skin and platysma incision was made.  Then using a series of blunt and sharp dissections, the dissection was carried to the inferior border of the mandible.  The periosteum was incised and reflected with the periosteal elevator.  The fracture was noted and it was displaced.  Manipulation of the segments and checking with the occlusion intraorally, the fracture was aligned.  This was secured with 7-hole 2.3 titanium locking reconstruction plate with bicortical screws.  The wound was then packed with moist Ray-Tec and attention was directed intraorally to the left angle fracture.  Approximately 5 mL of 1% lidocaine with 1:100,000 epinephrine was injected into the left vestibule.  After waiting appropriate time for local anesthesia to take effect, using Bovie electrocautery, a sagittal split incision was made and the fracture was identified.  It was noted that the fracture went through tooth #17 and this needed to be extracted.  Taking a round bur, a buckle trough was made and the tooth was elevated and removed both distal and mesial roots.  The fracture was then reduced and lateral superior border plate 2-0 4 whole with monocortical screws was placed.  The fracture was noted to be well reduced.  The wound was then irrigated with copious amount of sterile water.  The patient was released for excellent intercuspation.  He was then manipulated up into the occlusion easily.  Wound was then closed with running 3-0 chromic gut suture.  Attention was then directed extraorally.  This was irrigated with copious amount of sterile water and closed in a layer fashion with 3-0 Vicryl, 4-0 Vicryl, and 5-0 Prolene on skin.  Attention was then again directed into the mouth.  The throat pack was removed and orogastric tube was placed and stomach content was evacuated.  The patient was then manipulated back up to maximum intercuspation and secured with interdental elastics and a pressure dressing was applied to the extraoral incisions.  At this point, the procedure was then determined to be over.,The patient was extubated and breathing spontaneously, transported to the PACU in excellent condition.
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DESCRIPTION: Open left angle comminuted angle of mandible, 802.35, and open symphysis of mandible, 802.36.  Open reduction, internal fixation (ORIF) of bilateral mandible fractures with multiple approaches, CPT code 21470, and surgical extraction of teeth #17, CPT code 41899.

surgery, mandible, endotracheal, leibinger, pacu, oral maxillary facial surgery, maxillofacial, buckle, round bur, lidocaine with epinephrine, surgical steel wire, bilateral mandible fractures, mandible fracture, orif, symphysis, fracture,

The scenario describes a surgical procedure for repairing bilateral mandible fractures resulting from interpersonal violence, which required general anesthesia and careful surgical intervention. The stakes are moderately high given that maxillofacial surgery involves critical areas affecting the patient's ability to eat, speak, and breathe properly. However, the procedure was completed smoothly without complications, and the patient was in excellent condition post-surgery. Therefore, while the situation required skill and precision, it was not life-threatening, as evidenced by the absence of complications and the stable condition of the patient.


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

ADMISSION DIAGNOSES:,1.  Pneumonia, likely secondary to aspiration.,2.  Chronic obstructive pulmonary disease (COPD) exacerbation.,3.  Systemic inflammatory response syndrome.,4.  Hyperglycemia.,DISCHARGE DIAGNOSES:,1.  Aspiration pneumonia.,2.  Aspiration disorder in setting of severe chronic obstructive pulmonary disease.,3.  Chronic obstructive pulmonary disease (COPD) exacerbation.,4.  Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.,5.  Hypercapnia on admission secondary to chronic obstructive pulmonary disease.,6.  Systemic inflammatory response syndrome secondary to aspiration pneumonia.  No bacteria identified with blood cultures or sputum culture.,7.  Atrial fibrillation with episodic rapid ventricular rate, now rate control.,8.  Hyperglycemia secondary to poorly controlled type ii diabetes mellitus, insulin requiring.,9.  Benign essential hypertension, poorly controlled on admission, now well controlled on discharge.,10.  Aspiration disorder exacerbated by chronic obstructive pulmonary disease and acute respiratory failure.,11.  Hyperlipidemia.,12.  Acute renal failure on chronic renal failure on admission, now resolved.,HISTORY OF PRESENT ILLNESS:,  Briefly, this is 73-year-old white male with history of multiple hospital admissions for COPD exacerbation and pneumonia who presented to the emergency room on 04/23/08, complaining of severe shortness of breath.  The patient received 3 nebulizers at home without much improvement.  He was subsequently treated successfully with supplemental oxygen provided by normal nasal cannula initially and subsequently changed to BiPAP.,HOSPITAL COURSE:  ,The patient was admitted to the hospitalist service, treated with frequent small volume nebulizers, treated with IV Solu-Medrol and BiPAP support for COPD exacerbation.  The patient also noted with poorly controlled atrial fibrillation with a rate in the low 100s to mid 100s.  The patient subsequently received diltiazem, also received p.o. digoxin.  The patient subsequently responded well as well received IV antibiotics including Levaquin and Zosyn.  The patient made slow, but steady improvement over the course of his hospitalization.  The patient subsequently was able to be weaned off BiPAP during the day, but continued BiPAP at night and will continue with BiPAP if needed.  The patient may require a sleep study after discharge, but by the third day prior to discharge he was no longer utilizing BiPAP, was simply using supplemental O2 at night and was able to maintain appropriate and satisfactory O2 saturations on one-liter per minute supplemental O2 per nasal cannula.  The patient was able to participate with physical therapy, able to ambulate from his bed to the bathroom, and was able to tolerate a dysphagia 2 diet.  Note that speech therapy did provide a consultation during this hospitalization and his modified barium swallow was thought to be unremarkable and really related only to the patient's severe shortness of breath during meal time.  The patient's chest x-ray on admission revealed some mild vascular congestion and bilateral pleural effusions that appeared to be unchanged.  There was also more pronounced patchy alveolar opacity, which appeared to be, "mass like" in the right suprahilar region.  This subsequently resolved and the patient's infiltrate slowly improved over the course of his hospitalization.  On the day prior to discharge, the patient had a chest x-ray 2 views, which allowing for differences in technique revealed little change in the bibasilar infiltrates and atelectatic changes at the bases bilaterally.  This was compared with an examination performed 3 days prior.  The patient also had minimal bilateral effusions.  The patient will continue with clindamycin for the next 2 weeks after discharge.  Home health has been ordered and the case has been discussed in detail with Shaun Eagan, physician assistant at Eureka Community Health Center.  The patient was discharged as well on a dysphagia 2 diet, thin liquids are okay.  The patient discharged on the following medications.,DISCHARGE MEDICATIONS:,1.  Home oxygen 1 to 2 liters to maintain O2 saturations at 89 to 91% at all times.,2.  Ativan 1 mg p.o. t.i.d.,3.  Metformin 1000 mg p.o. b.i.d.,4.  Glucotrol 5 mg p.o. daily.,5.  Spiriva 1 puff b.i.d.,6.  Lantus 25 units subcu q.a.m.,7.  Cardizem CD 180 mg p.o. q.a.m.,8.  Advair 250/50 mcg, 1 puff b.i.d.  The patient is instructed to rinse with mouthwash after each use.,9.  Iron 325 mg p.o. b.i.d.,10.  Aspirin 325 mg p.o. daily.,11.  Lipitor 10 mg p.o. bedtime.,12.  Digoxin 0.25 mg p.o. daily.,13.  Lisinopril 20 mg p.o. q.a.m.,14.  DuoNeb every 4 hours for the next several weeks, then q.6 h. thereafter, dispensed 180 DuoNeb ampule's with one refill.,15.  Prednisone 40 mg p.o. q.a.m. x3 days followed by 30 mg p.o. q.a.m. x3 days, then followed by 20 mg p.o. q.a.m. x5 days, then 10 mg p.o. q.a.m. x14 days, then discontinue, #30 days supply given.  No refills.,16.  Clindamycin 300 mg p.o. q.i.d. x2 weeks, dispensed #64 with one refill.,The patient's aspiration pneumonia was discussed in detail.  He is agreeable to obtaining a chest x-ray PA and lateral after 2 weeks of treatment.  Note that this patient did not have community-acquired pneumonia.  His discharge diagnosis is aspiration pneumonia.  The patient will continue with a dysphagia 2 diet with thin liquids after discharge.  The patient discharged with home health.  A dietary and speech therapy evaluation has been ordered.  Speech therapy to treat for chronic dysphagia and aspiration in the setting of severe chronic obstructive pulmonary disease.,Total discharge time was greater than 30 minutes.
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DESCRIPTION: Aspiration pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation.  Acute respiratory on chronic respiratory failure secondary to chronic obstructive pulmonary disease exacerbation.  Systemic inflammatory response syndrome secondary to aspiration pneumonia.  No bacteria identified with blood cultures or sputum culture.

The discharge summary details a complex case involving multiple serious health issues, including aspiration pneumonia, COPD exacerbation, acute respiratory failure, systemic inflammatory response syndrome, atrial fibrillation, and chronic conditions such as diabetes and hypertension. The patient has been admitted multiple times, indicating chronic and potentially life-threatening health problems. Effective management and proper follow-up are crucial for this patient's well-being. Despite being discharged, the ongoing need for oxygen, BiPAP, various medications, and potential follow-up care highlight the seriousness and complexity of the case, making it high-stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: CT of Chest with Contrast

EXAM: , CT chest with contrast.,HISTORY: , Abnormal chest x-ray, which demonstrated a region of consolidation versus mass in the right upper lobe.,TECHNIQUE:  ,Post contrast-enhanced spiral images were obtained through the chest.,FINDINGS:  ,There are several, discrete, patchy air-space opacities in the right upper lobe, which have the appearance most compatible with infiltrates.  The remainder of the lung parenchyma is clear.  There is no pneumothorax or effusion.  The heart size and pulmonary vessels appear unremarkable.  There was no axillary, hilar or mediastinal lymphadenopathy.,Images of the upper abdomen are unremarkable.,Osseous windows are without acute pathology.,IMPRESSION: , Several discrete patchy air-space opacities in the right upper lobe, compatible with pneumonia.
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DESCRIPTION: CT of chest with contrast.  Abnormal chest x-ray demonstrating a region of consolidation versus mass in the right upper lobe.

cardiovascular / pulmonary, ct chest, air-space, axillary, chest x-ray, consolidation, contrast, contrast-enhanced, effusion, hilar, infiltrates, lung, lymphadenopathy, mass, mediastinal, parenchyma, patchy air-space, pneumonia, pneumothorax, right upper lobe, spiral images, with contrast, air space opacities, upper lobe, opacities, ct, lobe, chest

The situation describes a CT scan with findings that suggest pneumonia. While pneumonia can be serious, it is a common condition that is generally manageable with appropriate medical care. The report does not indicate any life-threatening findings such as a large mass or severe complications like pneumothorax or significant lymphadenopathy. Thus, while it requires medical attention, it is not immediately life-threatening based on the information provided.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Patent Ductus Arteriosus

HISTORY: , The patient is a 5-1/2-year-old, who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus.  An echocardiogram from 09/13/2007 demonstrated a 3.8-mm patent ductus arteriosus with restrictive left-to-right shunt.  There is mild left atrial chamber enlargement with an LA/AO ratio of 1.821.  An electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy.  The patient underwent cardiac catheterization for device closure of a ductus arteriosus.,PROCEDURE:  ,After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 5-French sheath, a 5-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries.  The atrial septum was not probe patent.,Using a 4-French sheath, a 4-French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  A descending aortogram demonstrated a small, type A patent ductus arteriosus with a small left-to-right angiographic shunt.  Minimal diameter was approximately 1.6 mm with ampulla diameter of 5.8 mm and length of 6.2 mm.  The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta.  This catheter exchanged over wire for a 5-French nit-occlude delivery catheter through which a nit-occlude 6/5 flex coil that was advanced and allowed to reconfigure the descending aorta.  Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery.  Once the stable device configuration was confirmed by fluoroscopy, device was released from the delivery catheter.  Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was normal with a slight increased saturation of the branch pulmonary arteries due to left-to-right shunt through the ductus arteriosus.  The left-sided heart was fully saturated.  The phasic right-sided and left-sided pressures were normal.  The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP:QS ratio of 1:1.  Vascular resistances were normal.  A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left-to-right angiographic shunt.  The branch pulmonary arteries appeared normal.  There is otherwise a normal left aortic arch.,Following coil embolization of the ductus arteriosus, there is no change in mixed venous saturation.  No evidence of residual left-to-right shunt.  There is no change in right-sided pressures.  There is a slight increase in the left-sided phasic pressures.  Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP:QS ratio of 1:1.  Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery.  There is a trace residual shunt through the center of coil mass.,INITIAL DIAGNOSES:, Patent ductus arteriosus.,SURGERIES (INTERVENTIONS):  ,Coil embolization of patent ductus arteriosus.,MANAGEMENT:  ,The case to be discussed at Combined Cardiology/Cardiothoracic Surgery case conference.  The patient will require a cardiologic followup in 6 months and 1 year's time including clinical evaluation and echocardiogram.  Further patient care be directed by Dr. X.,
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DESCRIPTION: Coil embolization of patent ductus arteriosus.

cardiovascular / pulmonary, cardiac murmur, coil embolization, cineangiograms, patent ductus arteriosus, pulmonary artery, patent ductus, descending aorta, ductus, arteriosus, catheterization

The situation involves a 5-year-old patient undergoing a procedure to address a patent ductus arteriosus, a heart defect that is not uncommon in children. While the procedure of coil embolization is routine and was performed without complications, the heart and vascular procedures inherently have higher stakes due to the critical nature of the systems involved, potential risks during and after the procedure, and the need for follow-up care to ensure no residual issues. The case also requires ongoing monitoring over a period of one year, suggesting moderate stakes but not the highest due to the lack of complications and the successful outcome so far.


Medical Specialty: General Medicine
Sample Name: Weight Loss Evaluation

REASON FOR VISIT:,  Weight loss evaluation.,HISTORY OF PRESENT ILLNESS:,
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DESCRIPTION: Patient with morbid obesity.

Patient with morbid obesity.

general medicine, medifast, obesity, weight loss, morbid obesity, weight loss evaluation, weight

This situation involves a medical evaluation for weight loss in a patient with morbid obesity. While obesity is a significant health concern, particularly when morbid, the scenario does not describe an acute or immediate life-threatening condition. However, obesity does relate to long-term health risks like heart disease, diabetes, and other serious health issues. The high-stakes nature depends on whether the weight loss evaluation reveals any pressing health concerns. As it stands, it is important but not immediately critical.


Medical Specialty: Emergency Room Reports
Sample Name: Proctitis & Proctocolitis

PRESENTATION: , A 16-year-old male presents to the emergency department (ED) with rectal bleeding and pain on defecation.,HISTORY:,  A 16-year-old African American male presents to the ED with a chief complaint of rectal bleeding and pain on defecation.  The patient states that he was well until about three days prior to presentation when he first started to experience some pain when defecating.  The following day he noted increasing pain and first noted blood on the surface of his stool.  The pain worsened on the subsequent day with increasing bleeding as well as some mucopurulent anal discharge.  The patient denies any previous history of rectal bleeding or pain.  He also denies any previous sexually transmitted diseases (STDs) and states that he was screened for HIV infection eight months ago and was negative.  The patient does state that he has not felt well for the past week.  He states that he had felt "feverish" on several occasions but has not taken his temperature.  He has also complained of some abdominal discomfort with nausea and diarrhea as well as generalized myalgias and fatigue.  He thinks he has lost a few pounds but has not been weighing himself to determine the exact amount of weight loss.,The patient states that he has been sexually active since age 13.  He admits to eight previous partners and states that he "usually" uses a condom.  On further questioning, the patient states that of his eight partners, three were female and five were male.  His most recent sexual partner was a 38-year-old man whom he has been with for the past six months.  He states that he has been tested for STDs in the past but states that he only gave urine and blood for the testing.  He is unaware of the HIV status of his partner but assumes that the partner is uninfected because he looks healthy.  The patient also admits to one episode of sexual abuse at the age of 8 by a friend of the family.  As the man was a member of the family's church, the patient never felt comfortable disclosing this to any of the adults in his life.  He is very concerned about disclosure of his sexual behavior to his family, as they have expressed very negative comments concerning men who have sex with men.  He is accessing care in the ED unaccompanied by an adult.,PHYSICAL EXAM: , Thin but non-toxic young man with clear discomfort.,Pulse = 105,RR = 23,BP = 120/62,HEENT:  Several areas of white plaque-like material on the buccal mucosa.,Neck:  Multiple anterior/posterior cervical nodes in both anterior and posterior chains- 1-2 cm in diameter.,Lungs:  Clear to auscultation.,Cardiac:  Quiet precordium.,Nl S1/S2 with a II/VI systolic murmur. ,Abdomen:  Soft without hepatosplenomegaly.,GU:  Tanner V male with no external penile lesions.,Lymph:  2-3 cm axillary nodes bilaterally.,1-2 cm epitrochlear nodes.,Multiple 1-2 cm inguinal nodes.,Rectal:  Extremely painful digital exam.,+ gross blood and mucous.,LABORATORY EVALUATION:,Hbg = 12.  5 gm/dL,Hct = 32%,WBC = 3.9 thou/µL,Platelets = 120,000 thou/µL,76% neutrophils,19% lymphocytes,1% eosinophils,4% monocytes,ALT = 82 U/L,AST= 90 U/L,Erythrocyte sedimentation rate = 90,Electrolytes = normal,Gram stain of anal swab:  numerous WBCs,DIFFERENTIAL DIAGNOSIS: , This patient is presenting with acute rectal pain with bleeding and anal discharge.  The patient also presents with some constitutional symptoms including fever, fatigue, abdominal discomfort, and adenopathy on physical examination.  The following are in the differential diagnosis:  Acute Proctitis and  Proctocolitis.,ACUTE HIV SEROCONVERSION: , This subject is sexually active and reports inconsistent condom use.  Gastrointestinal symptoms have recently been reported commonly in patients with a history of HIV seroconversion.  The rectal symptoms of bleeding and pain are not common with HIV, and an alternative diagnosis would be required.,PERIRECTAL ABSCESS: , A patient with a history of receptive anal intercourse is at risk for developing a perirectal abscess either from trauma or a concurrent STD.  The patient could experience more systemic symptoms with fever and malaise, as found with this patient.  However, the physical examination did not reveal the typical localized area of pain and edema.,DIAGNOSIS:  ,The subject had rectal cultures obtained, which were positive for Neisseria gonorrhoeae.  An HIV ELISA was positive, as was the RNA PCR.,DISCUSSION: , This patient demonstrates a number of key issues to consider when caring for an adolescent or young adult.  First, the patient utilized the emergency department for care as opposed to identifying a primary care provider.  Although not ideal in many circumstances, testing for HIV infection is crucial when there is suspicion, since many newly diagnosed patients identify earlier contacts with health care providers when HIV counseling and testing were not performed.  Second, this young man has had both male and female sexual partners.  As young people explore their sexuality, asking about partners in an open, nonjudgmental manner without applying labels is integral to helping the young person discuss their sexual behaviors.  Assuming heterosexuality is a major barrier to disclosure for many young people who have same-sex attractions.  Third, screening for STDs must take into account sexual behaviors.  Although urine-based screening has expanded testing of young people, it misses anal and pharyngeal infections.  If a young person is only having receptive oral or anal intercourse, urine screening is insufficient to rule out STDs.  Fourth, this young man had both localized and systemic symptoms.  As his anal symptoms were most suggestive of a current STD, performing an HIV test should be part of the standard evaluation.  In addition, as acute infection is on the differential diagnosis, PCR testing should also be considered.  The care provided to this young man included the following.  He was treated presumptively for proctitis with both IM ceftriaxone as well as oral doxycycline to treat N gonorrhoeae and C trachomatis.  Ceftriaxone was chosen due to the recent reports of resistant N gonorrhoeae.  At the time of the diagnosis, the young man was given the opportunity to meet with the case manager from the adolescent-specific HIV program.  The case manager linked this young man directly to care after providing brief counseling and support.  The case manager maintained contact with the young man until his first clinical visit four days later.  Over the subsequent three months, the young man had two sets of laboratory testing to stage his HIV infection.,Set #1 CD4 T-lymphocyte count = 225 cells/mm3, 15% ,Quantitative RNA PCR = 75,000 copies/mL
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DESCRIPTION: Patient presents to the emergency department (ED) with rectal bleeding and pain on defecation.

The situation involves a 16-year-old male presenting with rectal bleeding and acute pain, which are serious symptoms. Additionally, the patient is diagnosed with Neisseria gonorrhoeae and HIV, which are significant health conditions. Given the complexities of treating a young patient with potentially life-altering diagnoses and the psychosocial aspects of sexual history disclosure and family dynamics, this scenario is indeed high-stakes. It involves immediate medical treatment as well as long-term counseling and care for both gonorrhea and HIV, making timely and appropriate medical intervention crucial for the patient's health and wellbeing.