Medical Specialty: Pain Management
Sample Name: Cervical Epidural Steroid Injection

PROCEDURE:,  Cervical epidural steroid injection without fluoroscopy.,ANESTHESIA: , Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS: , None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the sitting position.  The posterior neck and upper back were prepped with Betadine.  Lidocaine 1.5% was used for skin wheal made between C7-T1 ________.  An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique and no cerebrospinal fluid or blood was noted.  After negative aspiration, a mixture of 5 cc preservative-free normal saline plus 160 mg Depo-Medrol was injected.  Neosporin and band-aid were applied over the site. The patient discharged to recovery room in stable condition.
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DESCRIPTION: Cervical epidural steroid injection without fluoroscopy.  An 18-gauge Tuohy needle was placed into the epidural space using loss of resistance technique.

pain management, epidural space, loss of resistance, cervical epidural steroid injection, fluoroscopy, lidocaine, steroid, epidural, cervical, injection,

The cervical epidural steroid injection is a common medical procedure in pain management, typically performed for conditions like neck pain, radiculopathy, or stenosis. While this procedure has potential risks, such as infection, bleeding, or nerve damage, it is generally considered safe and routine when performed by trained practitioners. The stakes are increased by not using fluoroscopy, which could potentially increase the risk of complications due to less precise needle placement. However, the procedure described was completed without any noted complications, suggesting its relative safety. Therefore, while some risk is present, the procedure doesn't represent extremely high-stakes in the broader context of medical procedures.


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

Medical Specialty: Surgery
Sample Name: I&D - Buccal Space Abscess

PREOPERATIVE DIAGNOSES,1.  Right buccal space abscess/cellulitis.,2.  Nonrestorable caries teeth #1, #29, and #32.,POSTOPERATIVE DIAGNOSES,1.  Right buccal space abscess/cellulitis.,2.  Nonrestorable caries teeth #1, #29, and #32.,PROCEDURE,1.  Incision and drainage of right buccal space abscess.,2.  Extraction of teeth #1, #29, and #32.,ANESTHESIA,GETA,EBL,20 mL.,IV FLUIDS,900 mL.,URINE OUTPUT,Not measured.,COMPLICATIONS,None.,SPECIMENS,1.  Aerobic culture was sent from the right buccal space abscess/cellulitis.,2.  Anaerobic culture from the same space was also obtained.,PROCEDURE IN DETAIL,The patient was identified in the appropriate holding area and transported to #13.  The patient was intubated by anesthesia orotracheally using a #7 ET tube.  The patient was induced in effective sleep using a propofol and gas inhalation anesthetics.  Following intubation, the patient's mouth was cleaned with chlorhexidine and a toothbrush following placement of a throat pack.  At that point, approximately 5 mL of 2% lidocaine with 1:20,000 epinephrine was injected for a right inferior alveolar block, as well as local infiltration in the right long buccal nerve area as well as the right cheek area.  Local infiltration also was done near the tooth #32.  At this point, a periosteal elevator was used to loosen up the gingival tissue of the teeth #1, #29, and #32; and all 3 teeth were extracted using simple extraction, using elevators and forceps.  In addition, the previous Penrose drain was removed by removing the suture, and the incision that was used for I&D on the previous day was extended laterally.  A hemostat was used to puncture through to the right buccal space.  Approximately, 2.5 to 3 mL of purulence was drained, and that was used for Gram stain and culture, as mentioned above.  Following copious irrigation of the area, following the extraction and following the incision and drainage, 2 quarter-inch Penrose drains were placed in the anterior as well as the posterior section of the incision into the buccal space.  At this point copious irrigation was done again, the throat pack was removed, and the procedure was ended.  Note that the patient was extubated without incident.  Dr. B was present for all critical aspects of patient care.
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DESCRIPTION: Incision and drainage of right buccal space abscess and teeth extraction.

surgery, abscess, #7 et tube, aerobic culture, anaerobic culture, extraction of teeth, geta, alveolar block, buccal space, caries, cellulitis, copious irrigation, extraction, teeth, nonrestorable caries teeth, buccal space abscess, nonrestorable caries, caries teeth, throat pack, buccal,

The situation involves a surgical procedure for an incision and drainage of a buccal space abscess, along with the extraction of nonrestorable teeth. Although described as a routine procedure with no complications reported, surgical interventions always carry inherent risks such as infection, bleeding, and reactions to anesthesia. The successful management of such a condition is necessary to prevent further complications, making it moderately high-stakes, particularly considering the involvement of an infection that could spread if not properly addressed.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Postop Medical Management

REASON FOR CONSULTATION: , Post-surgical medical management.,PROCEDURE DONE: , Right total knee replacement.,MEDICAL HISTORY:,1.  Arthritis of the right knee.,2.  Hypertension.,PAST SURGICAL HISTORY: , Hysterectomy, Cesarean section, left hip arthroplasty, and breast biopsy.,MEDICATIONS: , Hyzaar 12.5 mg p.o. daily, Femara 2.5 mg p.o. daily, Fosamax 70 mg p.o. every week, aspirin 81 mg p.o. daily, and vitamin.,ALLERGIES: , MORPHINE.,HISTORY OF PRESENT COMPLAINT: , This 84-year-old patient with history of arthritis underwent right total knee replacement yesterday.  The patient is admitted today to the surgical floor for postoperative management.  The patient tolerated the procedure well.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No fever, chills, or malaise.,ENT:  Unremarkable.,RESPIRATORY:  The patient denies shortness of breath, cough, or wheezing.,CARDIOVASCULAR:  No known heart problems.  No orthopnea, palpitations, syncopal episode, or pedal swelling.,GASTROINTESTINAL:  She denies nausea or vomiting.  No history of GI bleed.,GENITOURINARY:  No dysuria, no hematuria.,ENDOCRINE:  Negative for diabetes or thyroid problems.,NEUROLOGICAL:  No history of seizure or TIA.  Cognitive function is intact.,SOCIAL HISTORY:  ,The patient does not smoke.  She consumes alcohol moderately.,FAMILY HISTORY:  ,Positive for cancer.,PHYSICAL EXAMINATION:,GENERAL:  This is an 84-year-old lady who looks young for her age.,VITAL SIGNS:  Blood pressure of 138/53, pulse is 73, respiratory rate of 20, and O2 saturation is 95% on room air.  She is afebrile.,HEAD AND NECK:  Face is symmetrical.  Cranial nerves are intact.  No distended neck veins.  No palpable neck masses.,CHEST:  Clear to auscultation.  No wheezing.  No crepitations.,CARDIOVASCULAR:  First and second heart sounds were heard.  No murmur is appreciated.,ABDOMEN:  Soft and nontender.  Bowel sounds are positive.,EXTREMITIES:  There is no pedal swelling.,LABORATORY DATA:  ,Hemoglobin has dropped from 12.6 to 10.2.  Hematocrit is 30.  Glucose is 125.  BUN is 15.9, creatinine is 0.6, sodium is 134, and potassium is 3.8.,ASSESSMENT AND PLAN:,1.  Right knee arthritis status post right total knee replacement.  The patient tolerated the procedure well.,2.  Anemia due to stated operative blood loss, would not require transfusion at this point.,3.  Hypertension, under control.  Continue current home medications.,4.  Deep vein thrombosis risk, prophylaxis as per surgeon.,5.  Gastrointestinal prophylaxis.,6.  Debility.  Continue physical therapy and occupational therapy.
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DESCRIPTION: Post-surgical medical management; right total knee replacement.

The situation involves postoperative management of an 84-year-old patient after a right total knee replacement. While such cases are routine in surgical settings, they still require careful monitoring and management due to the patient's age, existing medical conditions like hypertension, a decrease in hemoglobin, and the risk of complications such as deep vein thrombosis. However, the situation is not critical as the patient tolerated the procedure well, and their vital signs are stable. Overall, while there are inherent risks, the situation does not appear to present immediate severe threats to the patient's health and is considered medium-stakes.


Medical Specialty: Radiology
Sample Name: MRI Brain - CO poisoning

CC:, Found down.,HX:, 54y/o RHF went to bed at 10 PM at her boyfriend's home on 1/16/96. She was found lethargic by her son the next morning. Three other individuals in the house were lethargic and complained of HA that same morning. Her last memory was talking to her granddaughter at 5:00PM on 1/16/96. She next remembered riding in the ambulance from a Hospital. Initial Carboxyhemoglobin level was 24% (normal < 1.5%) and ABG 7.41/30/370 with O2Sat 75% on 100%FiO2.,MEDS:, unknown anxiolytic, estrogen.,PMH:, PUD, ?stroke and memory difficulty in the past 1-2 years.,FHX:, unknown.,SHX:, divorced. unknown history of tobacco/ETOH/illicit drug use.,EXAM: ,BP126/91, HR86, RR 30, 37.1C.,MS:, Oriented to name only. Speech without dysarthria. 2/3 recall at 5minutes.,CN:, unremarkable.,MOTOR: ,full strength throughout with normal muscle tone and bulk.,SENSORY: ,unremarkable.,COORD/STATION:, unremarkable.,GAIT:, not tested on admission.,GEN EXAM:, notable for erythema of the face and chest.,COURSE:, She underwent a total of four dives under Hyperbaric Oxygen ( 2 dives on 1/17 and 2 dives on 1/18). Neuropsychologic assessment on 1/18/96 revealed marked cognitive impairments with defects in anterograde memory, praxis, associative fluency, attention, and speed of information processing. She was discharged home on 1/19/96 and returned on 2/11/96 after neurologic deterioration. She progressively developed more illogical behavior, anhedonia, anorexia and changes in sleep pattern. She became completely dependent and could not undergo repeat neuropsychologic assessment in 2/96. She was later transferred to another care facility against medical advice. The etiology for these changes became complicated by a newly discovered history of possible ETOH abuse and usual "anxiety" disorder.,MRI brain, 2/14/96, revealed increased T2 signal within the periventricular white matter, bilaterally. EEG showed diffuse slowing without epileptiform activity.
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DESCRIPTION: MRI Brain, Carbon Monoxide poisoning.

MRI Brain, Carbon Monoxide poisoning.

The situation involves a medical case of carbon monoxide poisoning, which is a potentially life-threatening condition requiring timely and appropriate treatment. The patient showed significant cognitive impairments after the poisoning incident and needed multiple hyperbaric oxygen therapy sessions. The ongoing neurological deterioration and her dependency highlight the high stakes, as the outcome significantly affects the patient's quality of life and long-term health. The complexity of care is further increased by comorbidities and possible substance abuse issues.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Evaluation of Allergies

HISTORY:,  A 55-year-old female presents self-referred for the possibility of evaluation and treatment of allergies, diminished taste, xerostomia, gastroesophageal reflux disease, possible food allergies, chronic GI irritability, asthma, and environmental inhalant allergies.  Please refer to chart for history and physical and review of systems and detailed medical history.,IMPRESSION:  ,1.  Chronic glossitis/xerostomia/probable environmental inhalant allergies/probable food allergies/history of asthma.,2.  History of fibromyalgia.,3.  History of peptic ulcer disease, history of gastritis, history of gastroesophageal disease.,4.  History of chronic fatigue.,5.  History of hypothyroidism.,6.  History of depression.,7.  History of dysphagia.,RECOMMENDATIONS: , RAST allergy testing was ordered for food allergy evaluation.  The patient had previous allergy testing done less than one year ago iby Dr. X, which was requested.  The patient will follow up after RAST allergy testing for further treatment recommendations.  At this point, no changes in her medication were prescribed until her followup visit.
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DESCRIPTION: Chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, and history of asthma.

soap / chart / progress notes, chronic glossitis, xerostomia, probable environmental inhalant allergies, probable food allergies, environmental inhalant allergies, rast allergy testing, rast, inhalant, food, allergy

The situation involves a comprehensive evaluation of a patient's potential allergies and various chronic conditions. This can significantly impact the patient's quality of life and potentially lead to more serious health issues if unmanaged. The stakes are moderate because the patient's current situation does not appear to be life-threatening, but requires careful attention to manage and treat the symptoms effectively. The recommendations for follow-up testing and the mention of various health issues like asthma and food allergies indicate the need for appropriate management but do not imply an immediate risk to life.


Medical Specialty: Speech - Language
Sample Name: Laryngitis - Discharge

DIAGNOSIS: , Chronic laryngitis, hoarseness.,HISTORY:  ,The patient is a 68-year-old male, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.  The patient attended initial evaluation plus 3 outpatient speech therapy sessions, which focused on training the patient to complete resonant voice activities and to improve his vocal hygiene.  The patient attended therapy one time a week and was given numerous home activities to do in between therapy sessions.  The patient made great progress and he came in to discuss with an appointment on 12/23/08 stating that his voice had finally returned to "normal".,SHORT-TERM GOALS:,1.  To be independent with relaxation and stretching exercises and Lessac-Madsen Resonant Voice Therapy Protocol.,2.  He also met short-term goal therapy 3 and he is independent with resonant voice therapy tasks.,3.  We did not complete his __________ ratio during his last session; so, I am unsure if he had met his short-term goal number 2.,4.  To be referred for a videostroboscopy, but at this time, the patient is not in need of this evaluation.  However, in the future if hoarseness returns, it is strongly recommended that he be referred for a videostroboscopy prior to returning to additional outpatient therapy.,LONG-TERM GOALS:,1.  The patient did reach his long-term goal of improved vocal quality to return to prior level of function and to utilize his voice in all settings without vocal hoarseness or difficulty.,2.  The patient appears very pleased with his return of his normal voice and feels that he no longer needs outpatient skilled speech therapy.,The patient is discharged from my services at this time with a home program to continue to promote normal voicing.
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DESCRIPTION: Chronic laryngitis, hoarseness.  The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to voicing difficulties.

speech - language, vocal hygiene, voice activities, hoarseness, skilled speech therapy, chronic laryngitis, voice therapy, resonant voice, videostroboscopy, laryngitis

The patient has successfully completed speech therapy for chronic laryngitis and has regained normal voice function, leading to discharge from therapy. The situation involved is a routine, non-emergency medical procedure where the stakes were initially related to improving quality of life rather than life-threatening issues. The main concern about the patient's voice quality has been addressed and does not involve any immediate health risks.


Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 51

CHIEF COMPLAINT: , Abdominal pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission.  He described the pain as 8/10 in severity and the intensity varied.  The symptoms persisted and he subsequently developed nausea and vomiting at 3 a.m. in the morning of admission.  The patient vomited twice and he states that he did note a temporary decrease in pain following his vomiting.  The patient was brought to the emergency room approximately 4 a.m. and evaluation including the CT scan, which revealed dilated loops of bowel without obvious obstruction.  The patient was subsequently admitted for possible obstruction.  The patient does have a history of previous small bowel obstruction approximately 20 times all but 2 required hospitalization, but all resolved with conservative measures (IV fluid, NG tube decompression, bowel rest.)  He has had previous abdominal surgeries including colon resection for colon CA and cholecystectomy as well as appendectomy.,PAST HISTORY: , Hypertension treated with Cozaar 100 mg daily and Norvasc 10 mg daily.  Esophageal reflux treated with Nexium 40 mg daily.  Allergic rhinitis treated with Allegra 180 mg daily.  Sleep disturbances, depression and anxiety treated with Paxil 25 mg daily, Advair 10 mg nightly and Ativan 1 mg nightly.  Glaucoma treated with Xalatan drops.  History of chronic bronchitis with no smoking history for which he uses p.r.n. Flovent and Serevent.,PREVIOUS SURGERIES:  ,Partial colon resection of colon carcinoma in 1961 with no recurrence, cholecystectomy 10 years ago, appendectomy, and glaucoma surgery.,FAMILY HISTORY: , Father died at age 85 of "old age," mother died at age 89 of "old age."  Brother died at age 92 of old age, 2 brothers died in their 70s of Parkinson disease.  Son is at age 58 and has a history of hypertension, hypercholesterolemia, rheumatoid arthritis, and glaucoma.,SOCIAL HISTORY:  ,The patient is widowed and a retired engineer.  He denies cigarettes smoking or alcohol intake.,REVIEW OF SYSTEMS: , Denies fevers or weight loss.  HEENT:  Denies headaches, visual abnormality, decreased hearing, tinnitus, rhinorrhea, epistaxis or sore throat.  Neck:  Denies neck stiffness, no pain or masses in the neck.  Respiratory:  Denies cough, sputum production, hemoptysis, wheezing or shortness of breath.  Cardiovascular:  Denies chest pain, angina pectoris, DOE, PND, orthopnea, edema or palpitation.  Gastrointestinal:  See history of the present illness.  Urinary:  Denies dysuria, frequency, urgency or hematuria.  Neuro:  Denies seizure, syncope, incoordination, hemiparesis or paresthesias.,PHYSICAL EXAMINATION:,GENERAL:  The patient is a well-developed, well-nourished elderly white male who is currently in no acute distress after receiving analgesics.,HEENT:  Atraumatic, normocephalic.  Eyes, EOMs full, PERRLA.  Fundi benign.  TMs normal.  Nose clear.  Throat benign.,NECK:  Supple with no adenopathy.  Carotid upstrokes normal with no bruits.  Thyroid is not enlarged.,LUNGS:  Clear to percussion and auscultation.,HEART:  Regular rate, normal S1 and S2 with no murmurs or gallops.  PMI is nondisplaced.,ABDOMEN:  Mildly distended with mild diffuse tenderness.  There is no rebound or guarding.  Bowel sounds are hypoactive.,EXTREMITIES:  No cyanosis, clubbing or edema.  Pulses are strong and intact throughout.,GENITALIA:  Atrophic male, no scrotal masses or tenderness.  Testicles are atrophic.  No hernia is noted.,RECTAL:  Unremarkable, prostate was not enlarged and there were no nodules or tenderness.,LAB DATA:,  WBC 12.1, hemoglobin and hematocrit 16.9/52.1, platelets 277,000.  Sodium 137, potassium 3.9, chloride 100, bicarbonate 26, BUN 27, creatinine 1.4, glucose 157, amylase 103, lipase 44.  Alkaline phosphatase, AST and ALT are all normal.  UA is negative.,Abdomen and pelvic CT showed mild stomach distention with multiple fluid-filled loops of bowel, no obvious obstruction noted.,IMPRESSION:,1.  Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.,2.  Hypertension.,3.  Esophageal reflux.,4.  Allergic rhinitis.,5.  Glaucoma.,PLAN: , The patient is admitted to the medical floor.  He has been kept NPO and will be given IV fluids.  He will also be given antiemetic medications with Zofran and an analgesic as necessary.  General surgery consultation was obtained.  Abdominal series x-ray will be done.
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DESCRIPTION: Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.  The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission.

The situation involves an 89-year-old male experiencing abdominal pain with a history of small bowel obstructions. While he has experienced and resolved similar episodes with conservative treatment in the past, the recurrence still presents a significant health concern given his age and medical history. Immediate medical attention is needed to rule out serious complications such as bowel obstruction. The situation is high-stakes due to the patient's advanced age, the potential severity of his symptoms, and the risk of requiring surgical intervention. This scenario involves acute medical care and decision-making, elevating the stakes.


Medical Specialty: General Medicine
Sample Name: Atrial Fibrillation - SOAP

SUBJECTIVE: , The patient states that she feels better.  She is on IV amiodarone, the dosage pattern is appropriate for ventricular tachycardia.  Researching the available records, I find only an EMS verbal statement that tachycardia of wide complex was seen.  There is no strip for me to review all available EKG tracings show a narrow complex atrial fibrillation pattern that is now converted to sinus rhythm.,The patient states that for a week, she has been home postoperative from aortic valve replacement on 12/01/08 at ABC Medical Center.  The aortic stenosis was secondary to a congenital bicuspid valve, by her description.  She states that her shortness of breath with exertion has been stable, but has yet to improve from its preoperative condition.  She has not had any decline in her postoperative period of her tolerance to exertion.,The patient had noted intermittent bursts of fast heart rate at home that had been increasing over the last several days.  Last night, she had a prolonged episode for which she contacted EMS.  Her medications at home had been uninterrupted and without change from those listed, being Toprol-XL 100 mg q.a.m., Dyazide 25/37.5 mg, Nexium 40 mg, all taken once a day.  She has been maintaining her Crestor and Zetia at 20 and 10 mg respectively.  She states that she has been taking her aspirin at 325 mg q.a.m.  She remains on Zyrtec 10 mg q.a.m.  Her only allergy is listed to latex.,OBJECTIVE:,VITAL SIGNS:  Temperature 36.1, heart rate 60, respirations 14, room air saturation 98%, and blood pressure 108/60.  The patient shows a normal sinus rhythm on the telemetry monitor with an occasional PAC.,GENERAL:  She is alert and in no apparent distress.,HEENT:  Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK:  Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:  Lungs are clear bilaterally to auscultation.  The incision is well healed and without evidence of significant cellulitis.,HEART:  Shows a regular rate and rhythm without murmur, gallop, heave, click, thrill or rub.  There is an occasional extra beat noted, which corresponds to a premature atrial contraction on the monitor.,ABDOMEN:  Soft and benign without hepatosplenomegaly, rebound, rigidity or guarding.,EXTREMITIES:  Show no evidence of DVT, acute arthritis, cellulitis or pedal edema.,NEUROLOGIC:  Nonfocal without lateralizing findings for cranial or peripheral nervous systems, strength, sensation, and cerebellar function.  Gait and station were not tested.,MENTAL STATUS:  Shows the patient to be alert, coherent with full capacity for decision making.,BACK:  Negative to inspection or percussion.,LABORATORY DATA: , Shows from 12/15/08 2100, hemoglobin 11.6, white count 12.9, and platelets 126,000.  INR 1.0.  Electrolytes are normal with exception potassium 3.3.  GFR is decreased at 50 with creatinine of 1.1.  Glucose was 119.  Magnesium was 2.3.  Phosphorus 3.8.  Calcium was slightly low at 7.8.  The patient has had ionized calcium checked at Munson that was normal at 4.5 prior to her discharge.  Troponin is negative x2 from 2100 and repeat at 07:32.  This morning, her BNP was 163 at admission.  Her admission chest x-ray was unremarkable and did not show evidence of cardiomegaly to suggest pericardial effusion.  Her current EKG tracing from 05:42 shows a sinus bradycardia with Wolff-Parkinson White Pattern, a rate of 58 beats per minute, and a corrected QT interval of 557 milliseconds.  Her PR interval was 0.12.,We received a call from Munson Medical Center that a bed had been arranged for the patient.  I contacted Dr. Varner and we reviewed the patient's managed to this point.  All combined impression is that the patient was likely to not have had actual ventricular tachycardia.  This is based on her EP study from October showing her to be non-inducible.  In addition, she had a cardiac catheterization that showed no evidence of coronary artery disease.  What is most likely that the patient has postoperative atrial fibrillation.  Her WPW may have degenerated into a ventricular tachycardia, but this is unlikely.  At this point, we will convert the patient from IV amiodarone to oral amiodarone and obtain an echocardiogram to verify that she does not have evidence of pericardial effusion in the postoperative period.  I will recheck her potassium, magnesium, calcium, and phosphorus at this point and make adjustments if indicated.  Dr. Varner will be making arrangements for an outpatient Holter monitor and further followup post-discharge.,IMPRESSION:,1.  Atrial fibrillation with rapid ventricular response.,2.  Wolff-Parkinson White Syndrome.,3.  Recent aortic valve replacement with bioprosthetic Medtronic valve.,4.  Hyperlipidemia.
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DESCRIPTION: Atrial fibrillation with rapid ventricular response, Wolff-Parkinson White Syndrome, recent aortic valve replacement with bioprosthetic Medtronic valve, and hyperlipidemia.

general medicine, ventricular tachycardia, wolff-parkinson white syndrome., ventricular response, medtronic valve, wolff parkinson white syndrome, aortic valve replacement, atrial fibrillation, atrial, aortic, tachycardia, fibrillation, ventricular, valve, medtronic,

The patient has a complex medical history with multiple cardiac issues including atrial fibrillation with a rapid ventricular response and Wolff-Parkinson White Syndrome, compounded by a recent aortic valve replacement. Although these conditions are being actively managed and the patient is currently stable, the possibility of serious complications such as another arrhythmia episode or issues related to the heart surgery makes this a high-stakes situation. The decision to switch from IV amiodarone to oral and monitor electrolytes closely indicates careful management is needed to prevent destabilization.


Medical Specialty: Urology
Sample Name: Cysto Stent Removal

PREOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,POSTOPERATIVE DIAGNOSIS: , Right lower pole renal stone and possibly infected stent.,OPERATION:,  Cysto stent removal.,ANESTHESIA:,  Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,MEDICATIONS: , The patient was on vancomycin and Levaquin was given x1 dose.  The patient was on vancomycin for the last 5 days.,BRIEF HISTORY:  ,The patient is a 53-year-old female who presented with Enterococcus urosepsis.  CT scan showed a lower pole stone with a stent in place.  The stent was placed about 2 months ago, but when patient came in with a possibly UPJ stone with fevers of unknown etiology.  The patient had a stent placed at that time due to the fevers, thinking that this was an urospetic stone.  There was some pus that came out.  The patient was cultured; actually it was negative at that time.  The patient subsequently was found to have lower extremity DVT and then was started on Coumadin.  The patient cannot be taken off Coumadin for the next 6 months due to the significant swelling and high risk for PE.  The repeat films were taken which showed the stone had migrated into the pole.,The stent was intact.  The patient subsequently developed recurrent UTIs and Enterococcus in the urine with fevers.  The patient was admitted for IV antibiotics since the patient could not really tolerate penicillin due to allergy and due to patient being on Coumadin, Cipro, and Levaquin where treatment was little bit more complicated.  Due to drug interaction, the patient was admitted for IV antibiotic treatment.  The thinking was that either the stone or the stent is infected, since the stone is pretty small in size, the stent is very likely possibility that it could have been infected and now it needs to be removed.  Since the stone is not obstructing, there is no reason to replace the stent at this time.  We are unable to do the ureteroscopy or the shock-wave lithotripsy when the patient is fully anticoagulated.  So, the best option at this time is to probably wait and perform the ureteroscopic laser lithotripsy when the patient is allowed to off her Coumadin, which would be probably about 4 months down the road.,Plan is to get rid of the stent and improve patient's urinary symptoms and to get rid of the infection and we will worry about the stone at later point.,DETAILS OF THE OR: , Consent had been obtained from the patient.  Risks, benefits, and options were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed.  The patient understood all the risks and benefits of removing the stent and wanted to proceed.  The patient was brought to the OR.  The patient was placed in dorsal lithotomy position.  The patient was given some IV pain meds.  The patient had received vancomycin and Levaquin preop.  Cystoscopy was performed using graspers.  The stent was removed without difficulty.  Plan was for repeat cultures and continuation of the IV antibiotics.
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DESCRIPTION: Right lower pole renal stone and possibly infected stent.  Cysto stent removal.

urology, infected stent, cysto stent removal, cysto stent, renal stone, lower pole, infected, stone, stent, cysto,

The case involves a procedure for the removal of a possibly infected stent in a patient with multiple medical concerns, such as a history of urosepsis, recurrent UTIs, DVT, and anticoagulation management. While the immediate procedure of stent removal is standard in urology and carries minimal blood loss with local anesthesia, the stakes are elevated due to the patient's complex medical history and ongoing risks, including managing anticoagulation and infection risk. However, the procedure itself is routine and intended to mitigate risks, making it important but not extremely high-stakes.


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

HISTORY OF PRESENT ILLNESS: , The patient presents today as a consultation from Dr. ABC's office regarding the above.  He was seen a few weeks ago for routine followup, and he was noted for microhematuria.  Due to his history of kidney stone, renal ultrasound as well as IVP was done.  He presents today for followup.  He denies any dysuria, gross hematuria or flank pain issues.  Last stone episode was over a year ago.  No history of smoking.  Daytime frequency 3 to 4 and nocturia 1 to 2, good stream, empties well with no incontinence.,Creatinine 1.0 on June 25, 2008, UA at that time was noted for 5-9 RBCs, renal ultrasound of 07/24/2008 revealed 6 mm left intrarenal stone, with no hydronephrosis.  IVP same day revealed a calcification over the left kidney, but without bilateral hydronephrosis.  The calcification previously noted on the ureter appears to be outside the course of the ureter.  Otherwise unremarkable.  This is discussed.,IMPRESSION:  ,1.  A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP.  The patient is asymptomatic.  We have discussed surgical intervention versus observation.  He indicates that this stone is not bothersome, prefers observation, need for hydration with a goal of making over 2 liters of urine within 24 hours is discussed.,2.  Microhematuria, we discussed possible etiologies of this, and the patient is agreeable to cystoscopy in the near future.  Urine sent for culture and sensitivity.,PLAN: , As above.  The patient will follow up for cystoscopy, urine sent for cytology, continue hydration.  Call if any concern.  The patient is seen and evaluated by myself.
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DESCRIPTION: A 6-mm left intrarenal stone, nonobstructing, by ultrasound and IVP.

consult - history and phy., intrarenal stone, ivp, ultrasound, microhematuria, hydration, kidney stone, renal ultrasound

The given medical scenario involves a patient with a nonobstructing kidney stone and microhematuria, which are relatively common urological issues. These conditions are not immediately life-threatening, especially since the patient is asymptomatic and prefers observational management over surgical intervention. The plan includes routine follow-up measures such as cystoscopy, urine culture, and maintaining hydration, which are standard for managing such conditions. However, the need for monitoring via cystoscopy indicates that while it's not an urgent situation, careful follow-up is necessary to prevent potential future complications.


Medical Specialty: Consult - History and Phy.
Sample Name: Sports Physical - 3

SUBJECTIVE:,  This is a 12-year-old male who comes in for healthy checkups and sports physical.  No major concerns today.  He is little bit congested at times.  He has been told he is allergic to grasses.  They have done over-the-counter Claritin and that seems to help but he is always sniffling mother reports.  He has also got some dryness on his face as far as the skin and was wondering what cream he could put on.,PAST MEDICAL HISTORY:,  Otherwise, reviewed.  Very healthy.,CURRENT MEDICATIONS:,  Claritin p.r.n.,ALLERGIES TO MEDICINES:,  None.,FAMILY SOCIAL HISTORY:,  Everyone else is healthy at home currently.,DIETARY:,  He is on whole milk and does a variety of foods.  Growth chart is reviewed with mother.  Voids and stools well.,DEVELOPMENTAL:,  He is in seventh grade and going out for cross-country and track.  He is supposed to be wearing glasses, is not today.  We did not test his vision because he recently saw the eye doctor though we did discuss the need for him to wear glasses with mother.  His hearing was normal today and no concerns with speech.,PHYSICAL EXAMINATION:,General:  A well-developed, well-nourished male in no acute distress.,Dermatologic:  Without rash or lesion.,HEENT:  Head normocephalic and atraumatic.  Eyes:  Pupils equal, round and reactive to light.  Extraocular movements intact.  Red reflexes are present bilaterally.  Optic discs are sharp with normal vasculature.  Ears:  Tympanic membranes are gray, translucent with normal light reflex.  Nares are very congested.  Turbinates swollen and boggy.,Neck:  Supple without masses.,Chest:  Clear to auscultation and percussion, easy respirations.  No accessory muscle use.,Cardiovascular:  Regular rate and rhythm without murmurs, rubs, heaves or gallops.,Back:  Symmetric with no scoliosis or kyphosis noted.  Normal flexibility.  Femoral pulses 2+ and symmetric.,Abdomen:  Soft, nontender, nondistended without hepatosplenomegaly.,GU Exam:  Normal Tanner III male.  Testes descended bilaterally.  No abnormal rash, discharge, or scars.,Extremities:  Pink and warm.  Moves all extremities well with normal function and strength in the arms and legs.  Normal balance, station, and gait.  Normal speech.,Neurologic:  Nonfocal with normal speech, station, gait, and balance.,ASSESSMENT:,  Healthy Tanner III male, developing normally.,PLAN:,1.  Diet, growth, safety, drugs, violence, and social competence all discussed.,2.  Immunizations reviewed.,3.  We will place him on Clarinex 5 mg once daily, some Rhinocort-AQ nasal spray one spray each nostril once daily and otherwise discussed the importance of him wearing glasses.,4.  Return to clinic p.r.n. and at two to three years for a physical, otherwise return p.r.n.
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DESCRIPTION: Healthy checkups and sports physical - 12 years old - Healthy Tanner III male, developing normally.

The situation involves a routine sports physical and health checkup for a 12-year-old male, with minor issues such as allergies and facial skin dryness. There are no immediate health threats or serious medical concerns, and the child is otherwise healthy and developing normally. The situation represents a low-stake, everyday medical assessment that does not require urgent intervention.


Medical Specialty: Emergency Room Reports
Sample Name: Ant Bait Exposure - ER Visit

CHIEF COMPLAINT: , Possible exposure to ant bait.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old child who apparently was near the sink, got into the childproof cabinet and pulled out ant bait that had Borax in it.  It had 11 mL of this fluid in it.  She spilled it on her, had it on her hands.  Parents were not sure whether she ingested any of it.  So, they brought her in for evaluation.  They did not note any symptoms of any type.,PAST MEDICAL HISTORY: , Negative.  Generally very healthy.,REVIEW OF SYSTEMS: , The child has not been having any coughing, gagging, vomiting, or other symptoms.  Acting perfectly normal.  Family mostly noted that she had spilled it on the ground around her, had it on her hands, and on her clothes.  They did not witness that she ingested any, but did not see anything her mouth.,MEDICATIONS: , None.,ALLERGIES: , NONE.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  Stable vital signs and normal pulse oximetry.  GENERAL:  The child is very active, cheerful youngster, in no distress whatsoever.  HEENT:  Unremarkable.  Oral mucosa is clear, moist, and well hydrated.  I do not see any evidence of any sort of liquid on the face.  Her clothing did have the substance on the clothes, but I did not see any evidence of anything on her torso.  Apparently, she had some on her hands that has been wiped off.,EMERGENCY DEPARTMENT COURSE:,  I discussed the case with Poison Control and apparently this is actually relatively small quantity and it is likely to be a nontoxic ingestion if she even ingested, which should does not appear likely to be the case.,IMPRESSION: , Exposure to ant bait.,PLAN: , At this point, it is fairly unlikely that this child ingested any significant amount, if at all, which seems unlikely.  She is not exhibiting any symptoms and I explained to the parents that if she develops any vomiting, she should be brought back for reevaluation.  So, the patient is discharged in stable condition.
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DESCRIPTION: Possible exposure to ant bait.  She is not exhibiting any symptoms and parents were explained that if she develops any vomiting, she should be brought back for reevaluation.

emergency room reports, borax, vomiting, exposure to ant bait, ant bait, exposure, symptoms,

The situation involves a potential ingestion of a household product (ant bait) by a young child, which was not confirmed to have occurred. The child is not showing any symptoms and the ant bait is deemed nontoxic by Poison Control. The child has been evaluated in the emergency room and discharged with instructions for parents to monitor for symptoms. While the presence in the emergency room indicates some level of concern, the stable condition of the child and the nontoxic assessment make this a relatively low-stakes situation.


Medical Specialty: Discharge Summary
Sample Name: Mullerian Adenosarcoma

PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma.  ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST:  Clear.  There is no heart murmur.,ABDOMEN:  Nontender.,PELVIC:  There is a large mass in the vagina.  ,HOSPITAL COURSE: , The patient went to surgery on the day of admission.  The postoperative course was marked by fever and ileus.  The patient regained bowel function.  She was discharged on the morning of the seventh postoperative day.,OPERATIONS: , July 25, 2006:  Total abdominal hysterectomy, bilateral salpingo-oophorectomy.,DISCHARGE CONDITION: , Stable.,  ,PLAN: , The patient will remain at rest initially with progressive ambulation thereafter.  She will avoid lifting, driving, stairs, or intercourse.  She will call me for fevers, drainage, bleeding, or pain.  Family history, social history, and psychosocial needs per the social worker.  The patient will follow up in my office in one week.,PATHOLOGY:,  Mullerian adenosarcoma.,MEDICATIONS:,  Percocet 5, #40, one q.3 h. p.r.n. pain.
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DESCRIPTION: Discharge summary of a patient presenting with a large mass aborted through the cervix.

discharge summary, cervix, fevers, drainage, bleeding, mullerian adenosarcoma, mullerian, adenosarcoma

The discharge summary for a patient with Mullerian adenosarcoma, who underwent surgery and had some postoperative complications such as fever and ileus, suggests a moderate-stakes situation. The principal diagnosis indicates a serious health condition, but the patient has been discharged in stable condition with a clear follow-up plan. As such, the stakes are primarily about ensuring proper recovery and monitoring for complications. Due to the nature of the condition, the initial diagnosis, and the mentioned possible complications, this situation is not at the highest level of urgency, but it requires careful follow-up to ensure successful recovery and management.


Medical Specialty: Hematology - Oncology
Sample Name: Conformal Simulation

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

hematology - oncology, coplanar beams, ct scan, target volume, conformal simulation, beamsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

This scenario describes a conformal simulation procedure in the context of radiation therapy for cancer treatment. It involves multiple stages including precise planning, simulation, and review to ensure effective treatment while minimizing damage to healthy tissues. These procedures are critical for patient safety and treatment efficacy, with direct implications on the patient's health outcomes, such as tumor control and minimizing side effects. Given the complexity and importance of accuracy in such procedures, it represents a high-stakes situation in a medical context.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Exercise Stress Test - 1

Informed written consent has been obtained from the patient.  I explained the procedure to her prior to initiation of such.  The appropriate time-out procedure as per Medical Center protocol was performed prior to the procedure being begun while the patient was actively participating with appropriate identification of the patient, procedure, physician, documentation, position.  There were no safety concerns noted by staff nor myself.,REST ECHO:,  EF 60%.  No wall motion abnormalities.  EKG shows normal sinus rhythm with mild ST depressions.  The patient exercised for 7 minutes 30 seconds on a standard Bruce protocol, exceeding target heart rate; no angina nor significant ECG changes seen.  Peak stress echo imaging shows EF of 75%, no regional wall motion abnormalities.  There was resting hypertension noted, systolic of approximately 152 mmHg with appropriate response of blood pressure to exercise.  No dysrhythmias noted.,IMPRESSION:,1.  Negative exercise ECG/echocardiogram stress evaluation for inducible ischemia in excess of target heart rate.,2.  Resting hypertension with appropriate response of blood pressure to exercise.,These results have been discussed with the patient.  Other management as per the hospital-based internal medicine service.,To be clear, there were no complications of this procedure.
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DESCRIPTION: A 44-year-old woman with a history of rheumatoid arthritis admitted to the hospital with chest pain.  MI has been ruled out.  She has been referred for an exercise echocardiogram.

cardiovascular / pulmonary, ecg/echocardiogram, exercise stress test, ecg, wall motion abnormalities, target heart rate, hypertension, echocardiogram

The situation involves interpreting results from an exercise stress test in a cardiovascular setting for a patient with history of chest pain. While the situation is important for patient care, it is not extremely high-stakes since the test results have already been generated and discussed with the patient, and there were no complications. The procedure is routine and results indicate no immediate health crisis. However, it is crucial for ensuring accurate diagnosis and management of any underlying conditions.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Endotracheal Intubation - 1

PROCEDURE PERFORMED: , Endotracheal intubation.,INDICATION FOR PROCEDURE:  ,The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  PCO2 was 29 and pO2 was 66 on the 15 liters.,NARRATIVE OF PROCEDURE: , The patient was given a total of 5 mg of Versed, 20 mg of etomidate, and 10 mg of vecuronium.  He was intubated in a single attempt.  Cords were well visualized, and a #8 endotracheal tube was passed using a curved blade.  Fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology, AFB, and fungal smear and culture.  A separate trap B was then lavaged for bacterial C&S and Gram stain and was sent for those purposes.  The patient tolerated the procedure well.
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DESCRIPTION: Endotracheal intubation.  The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  PCO2 was 29 and pO2 was 66 on the 15 liters.

cardiovascular / pulmonary, nonrebreather, respiratory distress, falling saturation, endotracheal intubation, lavage, breathingNOTE

Endotracheal intubation is a critical medical procedure often performed in emergency situations or when a patient is experiencing severe respiratory distress and requires immediate intervention to maintain airway patency. The patient's falling oxygen saturation and respiratory distress indicate a life-threatening condition that necessitates urgent action. The successful completion of the procedure is vital to ensure adequate oxygenation and ventilation, which are essential for patient survival. This context implies a high-stakes scenario given the potential for rapid deterioration of the patient's condition without proper intervention.


Medical Specialty: Neurology
Sample Name: MRI Brain and C-T Spine

CC:, Weakness.,HX:, This 30 y/o RHM was in good health until 7/93, when he began experiencing RUE weakness and neck pain. He was initially treated by a chiropractor and, after an unspecified length of time, developed atrophy and contractures of his right hand. He then went to a local neurosurgeon and a cervical spine CT scan, 9/25/92, revealed an intramedullary lesion at C2-3 and an extramedullary lesion at C6-7. He underwent a C6-T1 laminectomy with exploration and decompression of the spinal cord. His clinical condition improved over a 3 month post-operative period, and then progressively worsened. He developed left sided paresthesia and upper extremity weakness (right worse than left). He then developed ataxia, nausea, vomiting, and hyperreflexia. On 8/31/93, MRI C-spine showed diffuse enlargement of the cervical and thoracic spine and multiple enhancing nodules in the posterior fossa. On 9/1/93, he underwent suboccipital craniotomy with tumor excision, decompression, and biopsy which was consistent with hemangioblastoma. His symptoms stabilized and he underwent 5040 cGy in 28 fractions to his brain and 3600 cGy in 20 fractions to his cervical and thoracic spinal cord from 9/93 through 1/19/94.,He was evaluated in the NeuroOncology clinic on 10/26/95 for consideration of chemotherapy. He complained of progressive proximal weakness of all four extremities and dysphagia. He had difficulty putting on his shirt and raising his arms, and he had been having increasing difficulty with manual dexterity (e.g. unable to feed himself with utensils). He had difficulty going down stairs, but could climb stairs. He had no bowel or bladder incontinence or retention.,MEDS:, none.,PMH:, see above.,FHX:, Father with Von Hippel-Lindau Disease.,SHX:, retired truck driver. smokes 1-3 packs of cigarettes per day, but denied alcohol use. He is divorced and has two sons who are healthy. He lives with his mother.,ROS:, noncontributory.,EXAM:, Vital signs were unremarkable.,MS: A&O to person, place and time. Speech fluent and without dysarthria. Thought process lucid and appropriate.,CN: unremarkable exept for 4+/4+ strength of the trapezeii. No retinal hemangioblastoma were seen.,MOTOR: 4-/4- strength in proximal and distal upper extremities. There is diffuse atrophy and claw-hands, bilaterally. He is unable to manipulate hads to any great extent. 4+/4+ strength throughout BLE. There is also diffuse atrophy throughout the lower extremities though not as pronounced as in the upper extremities.,SENSORY: There was a right T3 and left T8 cord levels to PP on the posterior thorax. Decreased LT in throughout the 4 extremities.,COORD: difficult to assess due to weakness.,Station: BUE pronator drift.,Gait: stands without assistance, but can only manage to walk a few steps. Spastic gait.,Reflexes: Hyperreflexic on left (3+) and Hyporeflexic on right (1). Babinski signs were present bilaterally.,Gen exam: unremarkable.,COURSE: ,9/8/95, GS normal. By 11/14/95, he required NGT feeding due to dysphagia and aspiration risk confirmed on cookie swallow studies.MRI Brain, 2/19/96, revealed several lesions (hemangioblastoma) in the cerebellum and brain stem. There were postoperative changes and a cyst in the medulla.,On 10/25/96, he presented with a 1.5 week h/o numbness in BLE from the mid- thighs to his toes, and worsening BLE weakness. He developed decubitus ulcers on his buttocks. He also had had intermittent urinary retention for month, chronic SOB and dysphagia. He had been sitting all day long as he could not move well and had no daytime assistance. His exam findings were consistent with his complaints. He had had no episodes of diaphoresis, headache, or elevated blood pressures. An MRI of the C-T spine, 10/26/96, revealed a prominent cervicothoracic syrinx extending down to T10. There was evidence of prior cervical laminectomy of C6-T1 with expansion of the cord in the thecalsac at that region. Multiple intradural extra spinal nodular lesions (hyperintense on T2, isointense on T1, enhanced gadolinium) were seen in the cervical spine and cisterna magna. The largest of which measures 1.1 x 1.0 x 2.0cm. There are also several large ring enhancing lesions in cerebellum. The lesions were felt to be consistent with hemangioblastoma. No surgical or medical intervention was initiated. Visiting nursing was provided. He has since been followed by his local physician
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DESCRIPTION: MRI Brain & MRI C-T spine: Multiple hemangioblastoma in Von Hippel Lindau Disease.

This is a complex case involving multiple neurological issues, including hemangioblastoma due to Von Hippel-Lindau disease. The patient's symptoms and history indicate significant neurological impairments affecting daily living activities, which could potentially lead to more severe complications without proper management. The progression of symptoms such as weakness, dysphagia, and neurological deficits increase the stakes as they could deteriorate the patient's quality of life and potentially lead to life-threatening complications if not carefully monitored and managed. These factors contribute to a high-stakes situation both from a medical and quality of life perspective.


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

Medical Specialty: Orthopedic
Sample Name: MRI Knee - 1

EXAM:,MRI LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain.,FINDINGS:,Comparison is made with 10/13/05 radiographs.,There is a prominent suprapatellar effusion. Patient has increased signal within the medial collateral ligament as well as fluid around it, compatible with type 2 sprain. There is fluid around the lateral collateral ligament without increased signal within the ligament itself, compatible with type 1 sprain.,Medial and lateral menisci contain some minimal increased signal centrally that does not extend through an articular surface and findings are felt to represent minimal myxoid degeneration. No tear is seen. Anterior cruciate and posterior cruciate ligaments are intact. There is a bone bruise of medial patellar facet measuring approximately 8 x 5 mm. There is suggestion of some mild posterior aspect of the lateral tibial plateau. MR signal on the bone marrow is otherwise normal.,IMPRESSION:,Type 2 sprain in the medial collateral ligament and type sprain in the lateral collateral ligament.,Joint effusion and bone bruise with suggestion of some minimal overlying chondromalacia and medial patellar facet.
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DESCRIPTION: MRI left knee without contrast.

MRI left knee without contrast.

orthopedic, collateral ligament, mri, knee, collateral, sprain, medial, ligament,

The MRI findings indicate ligament sprains, a bone bruise, and some minimal degeneration, but these are typically not life-threatening conditions. In the context of orthopedic diagnostics, this pertains more to pain management and mobility rather than critical health risks. These conditions generally require standard treatment and monitoring, making it a moderate-stakes situation. Treatment should ensure quality of life and prevent future complications but isn't addressing an immediate life-threatening issue.


Medical Specialty: Urology
Sample Name: Elevated PSA - H&P

CHIEF COMPLAINT:, This 61-year-old male presents today with recent finding of abnormal serum PSA of 16 ng/ml. Associated signs and symptoms: Associated signs and symptoms include dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and urine stream is slow.  Timing (onset/frequency): Onset was 6 months ago. Patient denies fever and chills and denies flank pain.,ALLERGIES: ,Patient admits allergies to adhesive tape resulting in severe rash. Patient denies an allergy to anesthesia.,MEDICATION HISTORY:, Patient is not currently taking any medications.,PAST MEDICAL HISTORY:, Childhood Illnesses: (+) asthma, Cardiovascular Hx: (-) angina, Renal / Urinary Hx: (-) kidney problems.,PAST SURGICAL HISTORY:, Patient admits past surgical history of appendectomy in 1992.,SOCIAL HISTORY:, Patient admits alcohol use, Drinking is described as heavy, Patient denies illegal drug use, Patient denies STD history, Patient denies tobacco use.,FAMILY HISTORY:, Patient admits a family history of gout attacks associated with father.,REVIEW OF SYSTEMS:, Unremarkable with exception of chief complaint.,PHYSICAL EXAM: ,BP Sitting: 120/80 Resp: 20 HR: 72 Temp: 98.6,The patient is a pleasant, 61-year-old male in no apparent distress who looks his given age, is well-developed and nourished with good attention to hygiene and body habitus.,Neck: Neck is normal and symmetrical, without swelling or tenderness. Thyroid is smooth and symmetric with no enlargement, tenderness or masses noted.,Respiratory: Respirations are even without use of accessory muscles and no intercostal retractions noted. Breathing is not labored, diaphragmatic, or abdominal. Lungs clear to auscultation with no rales, rhonchi, wheezes, or rubs noted.,Cardiovascular: Normal S1 and S2 without murmurs, gallop, rubs or clicks.  Peripheral pulses full to palpation, no varicosities, extremities warm with no edema or tenderness.,Gastrointestinal: Abdominal organs, bladder, kidney: No abnormalities, without masses, tenderness, or rigidity. Hernia: absent; no inguinal, femoral, or ventral hernias noted. Liver and/or Spleen: no abnormalities, tenderness, or masses noted. Stool specimen not indicated.,Genitourinary: Anus and perineum: no abnormalities. No fissures, edema, dimples, or tenderness noted.,Scrotum: no abnormalities. No lesions, rash, or sebaceous cyst noted.,Epididymides: no abnormalities, masses, or spermatocele, without enlargement, induration, or tenderness.,Testes: symmetrical; no abnormalities, tenderness, hydrocele, or masses noted.,Urethral Meatus: no abnormalities; no hypospadias, lesions, polyps, or discharge noted.,Penis: no abnormalities; circumcised; no phimosis, Peyronie's, condylomata, or lumps noted.,Prostate: size 60 gr, RT>LT and firm.,Seminal Vesicles: no abnormalities; symmetrical; no tenderness, induration, or nodules noted.,Sphincter tone: no abnormalities; good tone; without hemorrhoids or masses.,Skin/Extremities: Skin is warm and dry with normal turgor and there is no icterus. No skin rash, subcutaneous nodules, lesions or ulcers observed.,Neurological/Psychiatric: Oriented to person, place and time. Mood and affect normal, appropriate to situation, without depression, anxiety, or agitation.,TEST RESULTS:, No tests to report at this time.,IMPRESSION: ,Elevated prostate specific antigen (PSA).,PLAN:, Cystoscopy in the office.,DIAGNOSTIC & LAB ORDERS:, Ordered serum creatinine. Urinalysis and C & S ordered using clean-catch specimen. Ordered free prostate specific antigen (PSA). Ordered ultrasound of prostate.,I have discussed the findings of this follow-up evaluation with the patient. The discussion included a complete verbal explanation of any changes in the examination results, diagnosis and current treatment plan. Discussed the possibility of a TURP surgical procedure; risks, complications, benefits, and alternative measures discussed. There are no activity restrictions . Instructed Ben to avoid caffeinated or alcoholic beverages and excessively spiced foods. Questions answered. If any questions should arise after returning home I have encouraged the patient to feel free to call the office at 327-8850.,PRESCRIPTIONS: , Proscar Dosage: 5 mg tablet Sig: once daily Dispense: 30 Refills: 0 Allow Generic: No,PATIENT INSTRUCTIONS:,  Patient completed benign prostatic hypertrophy questionnaire.
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DESCRIPTION: Abnormal serum PSA of 16 ng/ml, dribbling urine, inability to empty bladder, nocturia, urinary hesitancy and slow urine stream.

This situation involves a 61-year-old male patient with an elevated PSA level and associated urinary symptoms, which indicate potential issues with the prostate. The elevated PSA and the symptoms could suggest benign prostatic hyperplasia (BPH) or prostate cancer, though an elevated PSA is not solely indicative of cancer. The stakes here are moderate because while there is a possibility of serious conditions such as prostate cancer, further diagnostic tests and follow-ups have been planned, suggesting it is under control. Additionally, a TURP procedure has been discussed, indicating that the medical team is preparing for various potential outcomes. While important and concerning for the patient, medically, it does not immediately constitute a high-stakes situation since there is a clear plan for diagnosis and treatment.


Medical Specialty: Urology
Sample Name: Vasectomy - 4

PROCEDURE: , Elective male sterilization via bilateral vasectomy.,PREOPERATIVE DIAGNOSIS:  ,Fertile male with completed family.,POSTOPERATIVE DIAGNOSIS:,  Fertile male with completed family.,MEDICATIONS:  ,Anesthesia is local with conscious sedation.,COMPLICATIONS: , None.,BLOOD LOSS: , Minimal.,INDICATIONS:  ,This 34-year-old gentleman has come to the office requesting sterilization via bilateral vasectomy.  I discussed the indications and the need for procedure with the patient in detail, and he has given consent to proceed.  He has been given prophylactic antibiotics.,PROCEDURE NOTE: , Once satisfactory sedation have been obtained, the patient was placed in the supine position on the operating table.  Genitalia was shaved and then prepped with Betadine scrub and paint solution and were draped sterilely.  The procedure itself was started by grasping the right vas deferens in the scrotum, and bringing it up to the level of the skin.  The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath.  The vas was brought out of the incision carefully.  A 2-inch segment was isolated, and 1-inch segment was removed.  The free ends were cauterized and were tied with 2-0 silk sutures in such a fashion that the ends double back on themselves.  After securing hemostasis with a cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Attention was now turned to the left side.  The vas was grasped and brought up to the level of the skin.  The skin was infiltrated with 2% Xylocaine and punctured with a sharp hemostat to identify the vas beneath.  The vas was brought out of the incision carefully.  A 2-inch segment was isolated, and 1-inch segment was removed.  The free ends were cauterized and tied with 2-0 silk sutures in such a fashion that the ends double back on themselves.  After securing hemostasis with the cautery, the ends were allowed to drop back into the incision, which was also cauterized.,Bacitracin ointment was applied as well as dry sterile dressing.  The patient was awakened and was returned to Recovery in satisfactory condition.
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DESCRIPTION: Fertile male with completed family.  Elective male sterilization via bilateral vasectomy.

urology, sterilization, vas, fertile male, bilateral vasectomy, vasectomy, cauterized,

The procedure described is an elective vasectomy, which is a commonly performed and low-risk outpatient procedure for male sterilization. The stakes in this situation are relatively low because it is non-emergency, the surgery is straightforward, and there is no indication of complications or significant blood loss. However, the decision is significant on a personal and emotional level for the patient, as it involves permanent fertility changes, but strictly from a medical risk standpoint, it remains low-stakes.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 5

PREOPERATIVE DIAGNOSES,1.  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.,2.  Documented coronary artery disease with previous angioplasty and stent in the left anterior descending artery and circumflex artery, last procedure in 2005.,3.  Primary malignant ventricular arrhythmia and necessitated ventricular fibrillation.  He is intubated and ventilated.,POSTOPERATIVE DIAGNOSES:,  Acute coronary artery syndrome with ST segment elevation in anterior wall distribution.  Primary ventricular arrhythmia.  Occluded left anterior descending artery, successfully re-canalized with angioplasty and implantation of the drug-eluting stent.  Previously stented circumflex with mild stenosis and previously documented occlusion of the right coronary artery, well collateralized.,PROCEDURES:,  Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.,DESCRIPTION OF PROCEDURE:  ,The patient arrived from the emergency room intubated and ventilated.  He is hemodynamically stable on heparin and Integrilin bolus and infusion was initiated.  The right femoral area was prepped and draped in usual sterile fashion.  Lidocaine 2 mL was then filled locally.  The right femoral artery was cannulated with an 18-guage needle followed by a 6-French vascular sheath.  A guiding catheter XB 3.5 was advanced in manipulated to cannulate the left coronary artery and angiography was obtained.  A confirmed occlusion of the left anterior descending artery with minimal collaterals and also occlusion of the right coronary artery, which is well collateralized.  An angioplasty wire with present wire was advanced into the left anterior descending artery, and could cross the area of occlusion within the stent.  An angioplasty balloon measuring 2.0 x 15 was advanced and three inflations were obtained.  It successfully re-canalized the artery.  There is evidence of residual stenosis within the distal aspect of the previous stents.  A drug-eluting stent Xience 2.75 x 15 was advanced and positioned within the area of stenosis with its distal marker adjacent to bifurcation with a diagonal branch and was deployed at 12 and 18 atmospheres.  The intermittent result was improved.  An additional inflation was obtained more proximally.  His blood pressure fluctuated and dropped in the 70s, correlating with additional sedation.  There is patency of the left anterior descending artery and good antegrade flow.  The guiding catheter was replaced with a 5-French Judkins right catheter manipulated to cannulate the right coronary artery and selective angiography was obtained.  The catheter was then advanced into the left ventricle and pressure measurement was obtained including pullback across the aortic valve.  The right femoral vein was cannulated with an 18-guage needle followed by an 8-French vascular sheath.  A 8-French Swan-Ganz catheter was then advanced under fluoroscopic and hemodynamic control and pressure stenting was obtained from the right ventricle, pulmonary artery, and pulmonary capillary wedge position.  Cardiac catheter was determined by thermal dilution.  The procedure was then concluded, well tolerated and without complications.  The vascular sheath was in secured in place and the patient return to the coronary care unit for further monitoring.  Fluoroscopy time was 8.2 minutes.  Total amount of contrast was 113 mL.,HEMODYNAMICS:,  The patient remained in sinus rhythm with intermittent ventricular bigeminy post revascularization.  His initial blood pressure was 96/70 with a mean of 83 and the left ventricular pressure was 17 mmHg.  There was no gradient across the aortic valve.  Closing pressure was 97/68 with a mean of 82.,Right heart catheterization with right atrial pressure at 13, right ventricle 31/9, pulmonary artery 33/19 with a mean of 25, and capillary wedge pressure of 19.  Cardiac output was 5.87 by thermal dilution.,CORONARIES:,  On fluoroscopy, there was evidence of previous coronary stent in the left anterior descending artery and circumflex distribution.,A.  Left main coronary:  The left main coronary artery is of good caliber and has no evidence of obstructive lesions.,B.  Left anterior descending artery:  The left anterior descending artery was initially occluded within the previously stented proximal-to-mid segment.  There is minimal collateral flow.,C.  Circumflex:  Circumflex is a nondominant circulation.  It supplies a first obtuse marginal branch on good caliber.  There is an outline of the stent in the midportion, which has mild 30% stenosis.  The rest of the vessel has no significant obstructive lesions.  It also supplies significant collaterals supplying the occluded right coronary artery.,D.  Right coronary artery:  The right coronary artery is a weekly dominant circulation.  The vessel is occluded in intermittent portion and has a minimal collateral flow distally.,ANGIOPLASTY: , The left anterior descending artery was the site of re-canalization by angioplasty and implantation of a drug-eluting stent (Xience 15 mm length deployed at 2.9 mm) final result is good with patency of the left anterior descending artery, good antegrade flow and no evidence of dissection.  The stent was deployed proximal to the bifurcation with a second diagonal branch, which has remained patent.  There is a septal branch overlapped by the stent, which is also patent, although presenting a proximal stenosis.  The distal left anterior descending artery trifurcates with two diagonal branches and apical left anterior descending artery.  There is good antegrade flow and no evidence of distal embolization.,CONCLUSION: , Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution, complicated with primary ventricular malignant arrhythmia and required defibrillation along intubation and ventilatory support.,Previously documented coronary artery disease with remote angioplasty and stents in the left anterior descending artery and circumflex artery.,Acute coronary artery syndrome with ST-segment elevation in anterior wall distribution related to in-stent thrombosis of the left anterior descending artery, successfully re-canalized with angioplasty and a drug-eluting stent.  There is mild-to-moderate disease of the previously stented circumflex and clinic occlusion of the right coronary artery, well collateralized.,Right femoral arterial and venous vascular access.,RECOMMENDATION:,  Integrilin infusion is maintained until tomorrow.  He received aspirin and Plavix per nasogastric tube.  Titrated doses of beta-blockers and ACE inhibitors are initiated.  Additional revascularization therapy will be adjusted according to the clinical evaluation.
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DESCRIPTION: Left heart catheterization, selective bilateral coronary angiography and left ventriculography.  Revascularization of the left anterior descending with angioplasty and implantation of a drug-eluting stent.  Right heart catheterization and Swan-Ganz catheter placement for monitoring.

cardiovascular / pulmonary, ventricular arrhythmia, coronary artery syndrome, st segment elevation, heart catheterization, selective bilateral coronary angiography, ventriculography, catheterization, swan-ganz catheter, anterior descending artery, drug eluting stent, coronary artery, angioplasty, stent, coronary, anterior, angiography, artery, heart,

This medical situation involves an acute and critical cardiovascular condition requiring immediate intervention. The patient presented with acute coronary syndrome with ST segment elevation, a potentially life-threatening condition that can lead to cardiac arrest without prompt treatment. The procedure involved complex cardiac catheterization and revascularization techniques, including angioplasty and stent implantation to reopen blocked arteries, which is critical to patient survival and recovery. Given the severity of the condition and the requirement for intensive procedural intervention and monitoring, this scenario is high-stakes.


Medical Specialty: Chiropractic
Sample Name: Knee & Back Pain

REASON FOR EVALUATION:,
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DESCRIPTION: Evaluation for chronic pain program

Evaluation for chronic pain program

The situation involves evaluating a patient for a chronic pain program, specifically targeting knee and back pain. While chronic pain can significantly impact a patient's quality of life, the evaluation itself is part of routine diagnostic and planning processes in chiropractic care. There are no immediate life-threatening implications indicated, making it a moderate medical concern. The stakes are related to the effectiveness of treatment and patient quality of life improvement, not emergency or critical care.


Medical Specialty: Obstetrics / Gynecology
Sample Name: D&C & Laparoscopy - 1

PREOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Hypermenorrhea.,3.  Desire for future fertility.,4.  Failed conservative medical therapy.,POSTOPERATIVE DIAGNOSES:,1.  Chronic pelvic pain.,2.  Hypermenorrhea.,3.  Desire for future fertility.,4.  Failed conservative medical therapy.,5.  Possible adenomyosis.,6.  Left hydrosalpinx.,7.  Suspicion for endometriosis.,PROCEDURES PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Harmonic scalpel ablation of lesion which is suspicious for endometriosis.,ANESTHESIA: , General with endotracheal tube.,ESTIMATED BLOOD LOSS: , Less than 20 cc.,COMPLICATIONS:,  None.,INDICATIONS: , This is a 35-year-old Caucasian female gravida 1, para 0-0-1-0 with a history of spontaneous abortion.  This patient had approximately greater than ten years of chronic pelvic pain with dysmenorrhea which has significantly affected her activities of daily living.  Symptoms have not improved with prescription of oral contraceptives.,The patient has had one prior surgery for a left ovarian cystectomy done by laparoscopy in 1996.  The cyst was not diagnosed as an endometrioma.  The patient does desire future fertility; however, would like a definitive diagnosis.  Conservative medical therapy was offered i.e.  Lupron or repeat oral contraceptives, but declined.,FINDINGS:,  Bimanual exam reveals a small retroverted uterus which is easily mobile.  There were no adnexal masses.  The cervix was normal on palpation.  A fibrotic band was noted at the internal os during dilation.  On laparoscopic exam, the uterus was found to be small with mild spongy texture.  On palpation, the right ovary and adnexa were grossly normal with no evidence of endometriosis.  The left ovary was grossly normal.  The left fallopian tube had a mild hydrosalpinx present.  The left uterosacral ligament had three to four 1 mm to 2 mm lesions that were vesicular in nature consistent with endometriosis.  The vesicouterine reflection in the anterior aspect of the uterus were within normal limits as were the posterior cul-de-sac.  The liver appeared grossly normal.  There were no obvious pelvic adhesions.  The left internal inguinal ring is somewhat patent, however, there is no bowel or viscera protruding through it.,PROCEDURE:  ,The patient was seen in the preop suite.  History was reviewed and all questions were answered.  The patient was then taken to the operative suite where she was placed under general anesthesia with endotracheal tube.  She was placed in a dorsal lithotomy position in Allen stirrups.  She was prepped and draped in the normal sterile fashion.  Her bladder was drained with a red Robinson catheter producing approximately 100 cc of clear yellow urine.  A bimanual exam was performed by Dr. X, Dr. Y, and Dr. Z with above findings noted.  A sterile weighted speculum was placed in posterior aspect of the vagina and the anterior aspect of the cervix was grasped with vulsellum tenaculum.  There was an attempt to place the uterine sound through the external and internal cervical os, however, secondary to a fibrotic band at the internal os that was impossible.  A #9 dilator was allowed to remain in the cervix for minimal manipulation while attention was then turned to the abdomen.  An infraumbilical incision was made using skin scalpel.  The Veress needle was placed and CO2 was insufflated.  It was immediately noticed that the pressures were inconsistent with intraabdominal insufflation and the CO2 was discontinued and Veress needle was completely removed.  A second attempt placement of the Veress needle into the abdomen was successful and CO2 was insufflated approximately 3 liters with minimal intraabdominal pressure.  The #12 port was placed and the laparoscope was inserted.  Attention was then turned back to the uterus and with the assistance of current hemostat to bluntly dissect the fibrotic band of the internal os.,Successful sounding of the uterus showed an 8-cm uterus that was in a retroverted position.  The cervix was serially dilated using Hank dilators to allow for introduction of the sharp curette.  A curettage was then performed and specimen of the endometrium was sent for pathologic evaluation.  This procedure was performed under direct laparoscopic visualization.  Laparoscopic evaluation of the pelvis was performed and the above findings noted.  A second abdominal incision was performed suprapubically using a skin scalpel and the Veress needle was placed through the incision successfully under direct visualization.  A #5 port was then placed through the sheath and the uterine manipulator was used to complete visualization.  The manipulator was then removed and the Harmonic scalpel was placed through the #5 port.  The Harmonic scalpel was used then to ablate the 1 mm vesicular lesions on the left uterosacral ligament.  The lesions were suspect for endometriosis, however, they were not diagnostic of endometriosis.  There was also present a 3 mm to 5 mm submucosal uterine fibroid on the right lower uterine segment.  The Harmonic scalpel was removed from the abdomen as was the #5 port.  The incision was internally found to be hemostatic.  The laparoscope was then removed from the abdomen.  The abdomen was desufflated.  The introducer was then replaced into the #12 port and the #12 port was removed from the abdomen.  The uterine manipulator was removed from the uterus and the cervix was found to be hemostatic.  The weighted speculum was then removed.  The patient taken out of dorsal lithotomy position.  She was recovered from general anesthesia and taken to the postoperative suite for complete recovery.  The patient's discharge instructions will include a followup in one to two weeks in Dr. X's office for discussion of pathology.  Her family was notified of the findings.  She will be instructed not to have intercourse or use tampons or douche for the next two weeks.  The patient will be sent home with a prescription for Darvocet for pain.
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DESCRIPTION: Dilation and curettage (D&C), laparoscopy, and harmonic scalpel ablation of lesion which is suspicious for endometriosis.  Chronic pelvic pain, hypermenorrhea, desire for future fertility, failed conservative medical therapy, possible adenomyosis, left hydrosalpinx, and suspicion for endometriosis.

The situation involves a 35-year-old patient undergoing a combination of D&C, laparoscopy, and ablation for conditions including chronic pelvic pain, hypermenorrhea, and possible endometriosis. The patient has a strong desire for future fertility, which increases the stakes of this procedure. Additionally, she has not responded to conservative treatments and is looking for a definitive diagnosis, making the outcome of this procedure particularly important for her future reproductive plans. The procedure itself is complex, involving general anesthesia and several surgical steps, which inherently carries risk, although no immediate complications were noted. Given the complexity and the implications for the patient's fertility and quality of life, this is a high-stakes situation.


Medical Specialty: Obstetrics / Gynecology
Sample Name: OB/GYN Consultation - 1

PAST MEDICAL HX: , Significant for asthma, pneumonia, and depression.,PAST SURGICAL HX: , None.,MEDICATIONS:,  Prozac 20 mg q.d.  She desires to be on the NuvaRing.,ALLERGIES:,  Lactose intolerance.,SOCIAL HX: , She denies smoking or alcohol or drug use.,PE:,  VITALS: Stable.  Weight: 114 lb.  Height: 5 feet 2 inches.  GENERAL: Well-developed, well-nourished female in no apparent distress.  HEENT: Within normal limits. NECK: Supple without thyromegaly.  HEART: Regular rate and rhythm.  LUNGS: Clear to auscultation.  ABDOMEN: Soft and nontender.  There is no rebound or guarding.  No palpable masses and no peritoneal signs.  EXTREMITIES: Within normal limits.  SKIN: Warm and dry.  GU: External genitalia is without lesion.  Vaginal is clean without discharge.  Cervix appears normal; however, a colposcopy was performed using acetic acid, which showed a thick acetowhite ring around the cervical os and extending into the canal.  BIMANUAL: Reveals significant cervical motion tenderness and fundal tenderness.  She had no tenderness in her adnexa.  There are no palpable masses.,A:,  Although unlikely based on the patient's exam and pain, I have to consider subclinical pelvic inflammatory disease.  GC and chlamydia was sent and I treated her prophylactically with Rocephin 250 mg and azithromycin 1000 mg.  Repeat biopsies were not performed based on her colposcopy as well as her previous Pap and colposcopy by Dr. A.  A LEEP is a reasonable approach even in this 16-year-old.,P:,  We will schedule LEEP in the near future.  Even though she has already been exposed HPV Gardasil would still be beneficial in this patient to help prevent recurrence of low-grade lesions as well as high-grade lesions.  Now, we have her given her first shot.
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DESCRIPTION: Female referred for evaluation of an abnormal colposcopy, low-grade Pap with suspicious high-grade features.

obstetrics / gynecology, gravida, ecc, external genitalia, hpv, leep, pap, acetowhite, biopsies, blood with urination, cervical os, colposcopy, intraepithelial, right lower quadrant, squamous, suspicious, vaginal discharge, low grade pap, low grade,

The scenario involves a 16-year-old patient who is undergoing a consultation and treatment for an abnormal colposcopy and low-grade Pap smear with suspicious high-grade features. It discusses the possibility of subclinical pelvic inflammatory disease and the decision to perform a LEEP (Loop Electrosurgical Excision Procedure). Given the potential impact on future reproductive health, the age of the patient, and the necessity of a medical procedure, this situation carries a moderate-to-high level of stakes. Additionally, the patient's history of asthma and depression requires careful management of anesthesia and emotional support. The stakes are increased by the potential implications of HPV and future cervical health.


Medical Specialty: Surgery
Sample Name: Pelvic Laparotomy

PREOPERATIVE DIAGNOSIS: , Large left adnexal mass, 8 cm in diameter.,POSTOPERATIVE DIAGNOSIS: , Pelvic adhesions, 6 cm ovarian cyst.,PROCEDURES PERFORMED:  ,1.  Pelvic laparotomy.,2.  Lysis of pelvic adhesions.,3.  Left salpingooophorectomy with insertion of Pain-Buster Pain Management System by Dr. X.,GROSS FINDINGS:  ,There was a transabdominal mass palpable in the lower left quadrant.  An ultrasound suggestive with a mass of 8 cm, did not respond to suppression with norethindrone acetate and on repeat ultrasound following the medical treatment, the ovarian neoplasm persisted and did not decreased in size.,PROCEDURE:  ,Under general anesthesia, the patient was placed in lithotomy position, prepped and draped.  A low transverse incision was made down to and through to the rectus sheath.  The rectus sheath was put laterally.  The inferior epigastric arteries were identified bilaterally, doubly clamped and tied with #0 Vicryl sutures.  The rectus muscle was then split transversally and the peritoneum was split transversally as well.  The left adnexal mass was identified and large bowel was attached to the mass and Dr. Zuba from General Surgery dissected the large bowel adhesions and separated them from the adnexal mass.  The ureter was then traced and found to be free of the mass and free of the infundibulopelvic ligament.  The infundibulopelvic ligament was isolated, entered via blunt dissection.  A #0 Vicryl suture was put into place, doubly clamped with curved Heaney clamps, cut with curved Mayo scissors and #0 Vicryl fixation suture put into place.  Curved Heaney clamps were then used to remove the remaining portion of the ovary from its attachment to the uterus and then #0 Vicryl suture was put into place.  Pathology was called to evaluate the mass for potential malignancy and the pathology's verbal report at the time of surgery was that this was a benign lesion.  Irrigation was used.  Minimal blood loss at the time of surgery was noted.  Sigmoid colon was inspected in place in physiologic position of the cul-de-sac as well as small bowel omentum.  Instrument, needle, and sponge counts were called for and found to be correct.  The peritoneum was closed with #0 Vicryl continuous running locking suture.  The rectus sheath was closed with #0 Vicryl continuous running locking suture.  A DonJoy Pain-Buster Pain Management System was placed through the skin into the subcutaneous space and the skin was closed with staples.  Final instrument needle counts were called for and found to be correct.  The patient tolerated the procedure well with minimal blood loss and transferred to recovery area in satisfactory condition.
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DESCRIPTION: Pelvic laparotomy, lysis of pelvic adhesions, and left salpingooophorectomy with insertion of Pain-Buster Pain Management System.

surgery, lysis of pelvic adhesions, salpingooophorectomy, pain-buster pain management system, adnexal mass, pelvic laparotomy, pelvic adhesions, rectus sheath, vicryl sutures, adhesions, pelvic

This scenario involves a significant surgical procedure, pelvic laparotomy, which is performed to address an adnexal mass. Pelvic surgeries can be complex, with risks including infection, bleeding, and possible complications from anesthesia. Although the mass was found to be benign, the stakes are still relatively high due to the invasive nature of the procedure and the potential implications if something goes awry during or after the surgery. Thus, while there is no immediate life-threatening emergency, the situation still requires careful monitoring and competence from the surgical team.


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

CHIEF COMPLAINT: , Headache.,HISTORY OF PRESENT ILLNESS:,  This is a 16-year-old white female who presents here to the emergency department in a private auto with her mother for evaluation of headache.  She indicates intense constant right frontal headache, persistent since onset early on Monday, now more than 48 hours ago.  Indicates pressure type of discomfort with throbbing component.  It is as high as a 9 on a 0 to 10 scale of intensity.  She denies having had similar discomfort in the past.  Denies any trauma.,Review of systems:  No fever or chills.  No sinus congestion or nasal drainage.  No cough or cold symptoms.  No head trauma.  Mild nausea.  No vomiting or diarrhea.  Other systems reviewed and are negative.,PMH: , Acne.  Psychiatric history is unremarkable.,PSH: , Right knee surgery.,SH: , The patient is single.  Living at home.  No smoking or alcohol.,FH: , Noncontributory.,ALLERGIES:  ,No drug allergies.,MEDICATIONS: , Accutane and Ovcon.,PHYSICAL EXAMINATION:,VITALS:  Temperature of 97.8 degrees F., pulse of 80, respiratory rate of 16, and blood pressure is 131/96.,GENERAL:  This is a 16-year-old white female.  She is awake, alert, and oriented x3.  She does appear bit uncomfortable.,HEAD:  Normocephalic and atraumatic.,EYES:  The pupils were equal and reactive to light.  Extraocular movements are intact.,ENT:  TMs are clear.  Nose and throat are unremarkable.,NECK:  There is no evidence of nuchal rigidity.  She does, however, have notable tenderness and spasm of the right trapezius and rhomboid muscles when she extends up to the right paracervical muscles.  Palpation clearly causes having exacerbation of her discomfort.,CHEST:  Thorax is unremarkable.,GI:  Abdomen is nontender.,MUSCLES:  Extremities are unremarkable.,NEURO:  Cranial nerves II through XII are grossly intact.  Motor and sensory are grossly intact.  ,SKIN:  Skin is warm and dry.,ED COURSE:,  The patient was given IV Norflex 60 mg, Zofran 4 mg, and morphine sulfate 4 mg and with that has significant improvement in her discomfort.,DIAGNOSES:,1.  Muscle tension cephalgia.,2.  Right trapezius and rhomboid muscle spasm.,PLAN: , Scripts were given for Darvocet-N 100 one every 4 to 6 hours #15, Soma one 4 times a day #20.  She was instructed to apply warm compresses and perform gentle massage.  Follow up with regular provider as needed.  Return if any problems.
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DESCRIPTION: Muscle tension cephalgia.  Right trapezius and rhomboid muscle spasm.

The scenario involves a 16-year-old female presenting to the emergency department with intense headaches persisting for over 48 hours, rated 9 out of 10 in intensity, which is concerning but not immediately life-threatening. The patient's vitals are stable, and the diagnosis points towards muscle tension cephalgia and muscle spasm rather than a more serious condition such as meningitis or a brain hemorrhage. The situation demands attention and treatment to alleviate discomfort and rule out more severe conditions, but it does not involve immediate life or death decisions, making it moderate in stakes.


Medical Specialty: Consult - History and Phy.
Sample Name: Granulomatous Inflammation

CC:, Headache and diplopia.,HX:, This 39 y/o African American female began experiencing severe constant pressure pain type headaches beginning the last week of 8/95. The pain localized to bifronto-temporal regions of the head and did not radiate. There was no associated nausea, vomiting, photophobia or phonophobia. The HA's occurred daily; and throughout daylight hours. They diminished at bedtime, but occasionally awakened her in the morning.,Several days following the onset of her HA's, she began experiencing numbness and tingling about the right side of her face. These symptoms improved, but did not completely resolved.,Several days after the onset of facial paresthesias, she began to experience binocular horizontal diplopia. The diplopia resolved when covering either eye, and worsened upon looking toward the right. Coincidentally, she began veering toward the right when walking. She denied any weakness. She had had chronic unsteadiness for many years since developing juvenile rheumatoid arthritis. She was unsure whether her unsteadiness was due to poor depth perception in light of her diplopia.,The patient was admitted locally 9/2/95. HCT, 9/2/95 and Brain MRI with gadolinium, 9/3/95, were "unremarkable." Lumbar puncture (done locally),9/3/95: Opening pressure 27cm H20, CSF analysis ( protein 14.0, glucose 66, O WBC, 3 RBC, VDRL non-reactive, Lyme titer unremarkable, Myelin basic protein 1.0 (normal <4.0), and there was no evidence of oligoclonal bands. ESR=76. On 9/11/95 ESR=110. Acetylcholine receptor binding and blocking antibodies were negative. 9/4/95, ANA and RF were negative. 7/94, ANA and RF were negative, and ESR=60.,MEDS: ,Tylenol 500mg q5-6hrs. No known Allergies.,PMH:, 1)Juvenile Rheumatoid Arthritis diagnosed at age 10 years; now in remission. 2)Right #5 finger reattachment as child due to traumatic amputation.,FHX: ,Mother died age 42 of unknown type cancer. Father died age 62 of unknown type cancer. 4 sisters, one brother and 2 half-brothers. One of the half-brothers has asthma.,SHX: ,Single, lives with sister, and denies Tobacco/ETOH/illicit drug use.,EXAM:, BP141/84, HR99, RR14, 36.8C, Wt. 82kg Ht. 152.,MS: A&O to person, place, time. Speech fluent; without dysarthria. Mood euthymic with appropriate affect.,CN: Decreased abduction, OD. In neutral gaze, the right eye deviated slightly lateral of midline. In addition, she had mild proptosis, OD. The right eye was nontender to palpation during extraocular movement. Visual fields were full to confrontation. Optic disks appeared flat. Face was symmetric with full movement and sensation. Gag, shoulder shrug and corneal responses were intact, bilaterally. Tongue was midline with full ROM.,MOTOR: 5/5 strength throughout with normal muscle bulk and tone.,SENSORY: Unremarkable.,COORD: Unremarkable FNF/HKS/RAM.,STATION: Unremarkable. NO Romberg's sign or drift.,GAIT: Narrow based gait. Able to TT and HW without difficulty. Mild difficulty with TW.,REFLEXES: 2+/2+ Throughout all 4 extremities. Flexor plantar responses, bilaterally.,Musculoskeletal: Swan neck deformities of the #2 and #3 digits of both hands.,GEN EXAM: unremarkable, except for obvious sign of right finger reattachment (mentioned above).,COURSE: ,Repeat lumbar puncture yielded: Opening pressure 20.25cm H20, protein 22, glucose 62, 2RBC, 1WBC. CSF cytology, ACE, cultures (bacterial, fungal, AFB), gram stain, cryptococcal antigen, and VDRL were negative. Serum ACE, TSH, FT4 were unremarkable.,Neuroophthalmology confirmed her right CN6 palsy and proptosis (OD); and noted her complaint of paresthesias in the V1 and V2 distribution. They saw no evidence of papilledema. Visual field testing was unremarkable. MRI Brain/orbit/neck with gadolinium, 10/20/95, revealed abnormal enhancing signal in the right cavernous sinus and sinus mucosal thickening in both maxillary sinuses/ethmoid sinuses/frontal sinuses. CXR, 10/20/95, showed a lobulated mass arising from the right hilum. The mass appeared to obstruct the right middle lobe, causing partial collapse of this lobe. Chest CT with contrast, 10/23/95, revealed a 3.2x4.5x4.0cm mass in the right hilar region with impingement on the right lower bronchus. There appeared to be calcification as well as low attenuation regions within the mass. No lymphadenopathy was noted. She underwent bronchoscopy with bronchial brushing and transbronchial aspirate of the right lung on 10/24/95: no tumor cells were identified, GMS stains were negative and there was no evidence of viral changes, fungus or PCP by culture or molecular assay. She underwent right maxillary sinus biopsy and right middle lobe wedge resection and lymph node biopsy on 11/2/95: Caseating granulomatous inflammation with associated inflammatory pseudotumor was found in both sinus and lung biopsy specimens. No sign of cancer was found. Tissue cultures (bacterial, fungal, AFB) were negative times 3. The patients case was discussed at Head and Neck Oncology Tumor Board and a differential diagnosis of Sarcoidosis, Histoplasmosis, Wegener's Granulomatosis, were considered. Urine Histoplasmosis Antigen testing on 11/8/95 was 0.9units (normal<1.0): repeat testing on 12/13/95 was 0.8units. ANCA serum titers on 11/8/95 were <1:40 (normal). PPD testing was negative 11/95 (with positive candida and mumps controls).,The etiology of this patient's illness was not discovered. She was last seen 4/96 and her diplopia and right CN6 palsy had moderately improved.
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DESCRIPTION: Headache and diplopia.

Headache and diplopia.

The situation described is a complex medical case involving a 39-year-old woman with a history of headaches, diplopia, and neurological symptoms. Despite extensive testing, the diagnosis remains unclear, with differential diagnoses including serious conditions like Sarcoidosis, Histoplasmosis, and Wegener's Granulomatosis. This is high-stakes because the patient's condition involves potentially severe neurological and systemic symptoms, and there is uncertainty about the correct diagnosis and treatment, which may impact her quality of life and long-term health outcomes. The involvement of a tumor board signifies the complexity and seriousness of the case.