Medical Specialty: Surgery
Sample Name: Nipple Reconstruction

PREOPERATIVE DIAGNOSES,1.  Surgical absence of left nipple areola with personal history of breast cancer.,2.  Breast asymmetry.,POSTOPERATIVE DIAGNOSES,1.  Surgical absence of left nipple areola with personal history of breast cancer.,2.  Breast asymmetry.,PROCEDURE,1.  Left nipple areolar reconstruction utilizing a full-thickness skin graft from the left groin.,2.  Redo right mastopexy.,ANESTHESIA,General endotracheal.,COMPLICATIONS,None.,DESCRIPTION OF PROCEDURE IN DETAIL,The patient was brought to the operating room and placed on the table in the supine position and after suitable induction of general endotracheal anesthesia, the patient was placed in a frog-leg position and prepped and draped in usual fashion for the above-noted procedure.  The initial portion of the procedure was harvesting a full-thickness skin graft from the left groin region.  This was accomplished by ellipsing out a 42-mm diameter circle of skin just below the thigh, peroneal crease.  The defect was then closed with 3-0 Vicryl followed by 3-0 chromic suture in a running locked fashion.  The area was dressed with antibiotic ointment and then a Peri-Pad.  The patient's legs were brought out frog-leg back to the midline and sterile towels were placed over the opening in the drapes.  Surgical team's gloves were changed and then attention was turned to the planning of the left nipple flap.,A maltese cross pattern was employed with a 1-cm diameter nipple and a 42-mm diameter nipple areolar complex.  Once the maltese cross had been designed on the breast at the point where the nipple was to be placed, the areas of the portion of flap were de-epithelialized.  Then, when this had been completed, the dermis about the maltese cross was incised full thickness to allow mobilization of the flap to form the neonipple.  At this point, a Bovie electrocautery was used to control bleeding points and then 4-0 chromic suture was used to suture the arms of the flap together creating the nipple.  When this had been completed, the skin graft, which had been harvested from the left groin was brought onto the field where it was prepared by removing all subcutaneous tissue from the posterior aspect of the graft and carefully removing the hair follicles encountered within the graft.  At this point, the graft was sutured into position in the defect using 3-0 chromic in an interrupted fashion and then trimming the ellipse to an appropriate circle to fill the areola.  At this point, 4-0 chromic was used to run around the perimeter of the full-thickness skin graft and then at this point the nipple was delivered through a cruciate incision in the middle of the skin graft and then inset appropriately with 4-0 chromic.  The areolar skin graft was pie crusted.  Then, at this point, the area of areola was dressed with silicone gel sheeting.  A silo was placed over the neonipple with 3-0 nylon through the apex of the neonipple to support the nipple in an erect position.  Mastisol and Steri-Strips were then applied.,At this point, attention was turned to the right breast where a 2-cm wide ellipse transversely oriented and with its inferior most aspect just inferior to the transverse mastopexy incision line was made.  The skin was removed from the area and then a layered closure of 3-0 Vicryl followed by 3-0 PDS in a running subcuticular fashion was carried out.  When this had been completed, the Mastisol and Steri-Strips were applied to the transverse right breast incision.  Fluff dressings were applied to the right breast as well as the area around the silo on the left breast around the reconstructed nipple areola.  The patient was then placed in Surgi-Bra and then was taken from the operating room to the recovery room in good condition.
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DESCRIPTION: Nipple areolar reconstruction utilizing a full-thickness skin graft and mastopexy

surgery, nipple areola, breast asymmetry, general endotracheal, peri-pad, surgi-bra, breast cancer, frog-leg position, full-thickness skin graft, general endotracheal anesthesia, mastopexy, nipple areolar complex, nipple areolar reconstruction, nipple flap, prepped and draped, transverse mastopexy, areolar reconstruction, skin graft, graft, nipple, areolar, breast

The procedure described is a reconstructive surgery following breast cancer treatment, focusing on nipple areolar reconstruction and mastopexy. While these surgeries are typically elective and primarily aim to improve cosmetic appearance and psychological well-being, they follow serious medical conditions like breast cancer. However, in terms of immediate life-threatening risk during the surgery, the stakes are generally not high since there were no complications and this kind of reconstructive surgery is not typically associated with high mortality or severe morbidity. Therefore, while important for the patient's quality of life, the procedure itself does not carry high immediate stakes.


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

Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Breast Cancer Followup - 1

CHIEF COMPLAINT:,  Stage IIA right breast cancer.,HISTORY OF PRESENT ILLNESS:  ,This is an extremely pleasant 58-year-old woman, who I am following for her stage IIA right breast cancer.  She noticed a lump in the breast in November of 2007.  A mammogram was obtained dated 01/28/08, which showed a mass in the right breast.  On 02/10/08, she underwent an ultrasound-guided biopsy.  The pathology showed an infiltrating ductal carcinoma Nottingham grade II.  The tumor was ER positive, PR positive and HER-2/neu negative.  On 02/22/08, she underwent a lumpectomy and sentinel lymph node biopsy.  The pathology showed a 3.3 cm infiltrating ductal carcinoma grade I, one sentinel lymph node was negative.  Therefore it was a T2, N0, M0 stage IIA breast cancer.  Of note, at that time she was taking hormone replacement therapy and that was stopped.  She underwent radiation treatment ending in May 2008.  She then started on Arimidex, but unfortunately she did not tolerate the Arimidex and I changed her to Femara.  She also did not tolerate the Femara and I changed it to tamoxifen.  She did not tolerate the tamoxifen and therefore when I saw her on 11/23/09, she decided that she would take no further antiestrogen therapy.  She met with me again on 02/22/10, and decided she wants to rechallenge herself with tamoxifen.  When I saw her on 04/28/10, she was really doing quite well with tamoxifen.  She tells me 2 weeks after that visit, she developed toxicity from the tamoxifen and therefore stopped it herself.  She is not going take to any further tamoxifen.,Overall, she is feeling well.  She has a good energy level and her ECOG performance status is 0.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  No change in bowel or bladder habits.,CURRENT MEDICATIONS:,  Avapro 300 mg q.d., Pepcid q.d., Zyrtec p.r.n., and calcium q.d.,ALLERGIES:,  Sulfa, Betadine, and IV contrast.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  Asthma.,2.  Hypertension.,3.  GERD.,4.  Eczema.,5.  Status post three cesarean sections.,6.  Status post a hysterectomy in 1981 for fibroids.  They also removed one ovary.,7.  Status post a cholecystectomy in 1993.,8.  She has a history of a positive TB test.,9.  She is status post repair of ventral hernia in November 2008.,SOCIAL HISTORY: , She has no tobacco use.  Only occasional alcohol use.  She has no illicit drug use.  She has two grown children.  She is married.  She works as a social worker dealing with adult abuse and neglect issues.  Her husband is a high school chemistry teacher.,FAMILY HISTORY:  ,Her father had prostate cancer.  Her maternal uncle had Hodgkin's disease, melanoma, and prostate cancer.,PHYSICAL EXAM:,VIT:
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DESCRIPTION: Stage IIA right breast cancer.  The pathology showed an infiltrating ductal carcinoma Nottingham grade II.  The tumor was ER positive, PR positive and HER-2/neu negative.

The follow-up notes are related to a patient with stage IIA breast cancer, which is considered early-stage and generally has a good prognosis after appropriate treatment like surgery, radiation, and hormone therapy. However, the patient's intolerance to hormone therapy medications (Arimidex, Femara, and tamoxifen) complicates her management. Though the situation involves a serious health condition, it isn't immediately life-threatening based on the data provided. Current notes indicate the patient is generally feeling well with no acute symptoms indicating an urgent medical crisis. Hence, while serious and requiring careful management, the situation isn't extremely high-stakes.

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Medical Specialty: Surgery
Sample Name: Flex Sig - 2

PROCEDURE IN DETAIL: , Following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal.  The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.  Withdrawal notes an otherwise normal descending, rectosigmoid and rectum.  Retroflexion noted no abnormality of the internal ring.  No hemorrhoids were noted.  Withdrawal from the patient terminated the procedure.
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DESCRIPTION: Flexible sigmoidoscopy.  The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.

surgery, flexible sigmoidoscopy, flex sig, colonoscope, olympus video colonoscope, rectumNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The procedure described is a flexible sigmoidoscopy. This is a routine medical procedure typically used for screening and diagnostic purposes in the colon and rectum, particularly to look for signs of colorectal cancer or other abnormalities. While medical procedures always carry some level of risk, a flexible sigmoidoscopy is generally considered low-risk and routine. No complications or abnormal findings were noted, which further reduces the stakes of this situation. Therefore, this procedure is not considered high-stakes, as it does not involve immediate life-threatening conditions or urgent decision-making.


Medical Specialty: Urology
Sample Name: Brachytherapy

PREOPERATIVE DIAGNOSIS:,  Prostate cancer.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer.,OPERATIONS: , Brachytherapy, iodine-125 seed implantation, and cystoscopy.,ANESTHESIA:,  LMA.,ESTIMATED BLOOD LOSS: , Minimal.,Total number of seeds placed, 63.  Needles, 24.,BRIEF HISTORY OF THE PATIENT: , This is a 57-year-old male who was seen by us for elevated PSA.  The patient had a prostate biopsy with T2b disease, Gleason 6.  Options such as watchful waiting, robotic prostatectomy, seed implantation with and without radiation were discussed.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, incontinence, rectal dysfunction, voiding issues, burning pain, unexpected complications such as fistula, rectal injury, urgency, frequency, bladder issues, need for chronic Foley for six months, etc., were discussed.  The patient understood all the risks, benefits, and options, and wanted to proceed with the procedure.  The patient was told that there could be other unexpected complications.  The patient has history of urethral stricture.  The patient was told about the risk of worsening of the stricture with radiation.  Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the dorsal lithotomy position.  The patient had SCDs on.  The patient was given preop antibiotics.  The patient had done bowel prep the day before.  Transrectal ultrasound was performed.  The prostate was measured at about 32 gm.  The images were transmitted to the computer system for radiation oncologist to determine the dosing etc.  Based on the computer analysis, the grid was placed.  Careful attention was drawn to keep the grid away from the patient.  There was a centimeter distance between the skin and the grid.  Under ultrasound guidance, the needles were placed, first in the periphery of the prostate, a total of 63 seeds were placed throughout the prostate.  A total of 24 needles was used.  Careful attention was drawn to stay away from the urethra.  Under longitudinal ultrasound guidance, all the seeds were placed.  There were no seeds visualized in the bladder under ultrasound.  There was only one needle where the seeds kind of dragged as the needle was coming out on the left side and were dropped out of position.  Other than that, all the seeds were very well distributed throughout the prostate under fluoroscopy.  Please note that the Foley catheter was in place throughout the procedure.  Prior to the seed placement, the Foley was attempted to be placed, but we had to do it using a Glidewire to get the Foley in and we used a Councill-tip catheter.  The patient has had history of bulbar urethral stricture.  Pictures were taken of the strictures in the pre-seed placement cysto time frame.  We needed to do the cystoscopy and Glidewire to be able to get the Foley catheter in.  At the end of the procedure, again cystoscopy was done, the entire bladder was visualized.  The stricture was wide open.  The prostate was slightly enlarged.  The bladder appeared normal.  There was no sheath inside the urethra or in the bladder.  The cysto was done using 30-degree and 70-degree lens.  At the end of the procedure, a Glidewire was placed, and 18 Councill-tip catheter was placed.  The plan was for Foley to be left in place overnight since the patient has history of urethral strictures.  The patient is to follow up tomorrow to have the Foley removed.  The patient could also be shown to have it removed at home.,The patient was brought to Recovery in stable condition at the end of the procedure.  The patient tolerated the procedure well.
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DESCRIPTION: Brachytherapy, iodine-125 seed implantation, and cystoscopy.

urology, iodine-125 seed implantation, seed implantation, prostate cancer, cystoscopy, brachytherapy, councill tip catheter, brachytherapy iodine, ultrasound, catheter, urethral, prostate,

The situation involves a medical procedure for a 57-year-old male patient diagnosed with prostate cancer. The procedure includes brachytherapy with iodine-125 seed implantation and cystoscopy. While these procedures are considered standard treatment options for prostate cancer, they do carry significant risks, especially considering the patient’s history of urethral stricture and the potential for complications like infection, bleeding, and worsening of the stricture. Furthermore, the discussion of anesthesia risks, complications, and the need for careful placement of the seeds emphasizes the complexity and importance of the procedure. However, brachytherapy is a common and controlled treatment for prostate cancer, and the patient was reported to tolerate the procedure well, suggesting successful management. Thus, the stakes, while not minor, are not at the highest level either.


Medical Specialty: Surgery
Sample Name: TAH & Salpingo-oophorectomy

PREOPERATIVE DIAGNOSES:,1.  Hypermenorrhea.,2.  Uterine fibroids.,3.  Pelvic pain.,4.  Left adnexal mass.,5.  Pelvic adhesions.,POSTOPERATIVE DIAGNOSES:,1.  Hypermenorrhea.,2.  Uterine fibroids.,3.  Pelvic pain.,4.  Left adnexal mass.,5.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Total abdominal hysterectomy (TAH).,2.  Left salpingo-oophorectomy.,ANESTHESIA:,  General endotracheal.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,INDICATIONS: , The patient is a 47-year-old Caucasian female with complaints of hypermenorrhea and pelvic pain, noted to have a left ovarian mass 7 cm at the time of laparoscopy in July of 2003.  The patient with continued symptoms of pelvic pain and hypermenorrhea and desired definitive surgical treatment.,FINDINGS AT THE TIME OF SURGERY: , Uterus is anteverted and boggy with a very narrow introitus with a palpable left adnexal mass.,On laparotomy, the uterus was noted to be slightly enlarged with fibroid change as well as a hemorrhagic appearing left adnexal mass.  The bowel, omentum, and appendix had a normal appearance.,PROCEDURE: , The patient was taken to the operative suite where anesthesia was found to be adequate.  She was then prepared and draped in normal sterile fashion.  A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia with the second scalpel.  The fascia was then incised in the midline.  The fascial incision was then extended laterally with Mayo scissors.  The superior aspect of the fascial incision was grasped with Kochers with the underlying rectus muscle dissected off bluntly and sharply with Mayo scissors.  Attention was then turned to the inferior aspect of this incision, which in a similar fashion was tented up with the underlying rectus muscle and dissected off bluntly and sharply with Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum was identified, tented up with hemostats and entered sharply with Metzenbaum scissors.  The peritoneal incision was then extended superiorly and inferiorly with good visualization of the bladder.  The uterus and left adnexa were then palpated and brought out into the surgical field.  The fundus of the uterus was grasped with a Lahey clamp.  The GYN/Balfour retractor was placed.  The bladder blade was placed.  The bowel was packed away with moist laparotomy sponges and the extension through GYN/Balfour retractor was placed.  At this time, the patient's anatomy was surveyed and there was found to be a left hemorrhagic appearing adnexal mass.  Attention was first turned to the right round ligament, which was tented up with a Babcock and a small window was made beneath the round ligament with a hemostat.  It was then suture ligated with #0 Vicryl suture, transected with the broad ligament being skeletonized on both sides.  Next, the right ________ was isolated bluntly as the patient had a previous RSO.  This was then suture ligated with #0 Vicryl suture, doubly clamped with Kocher clamps, transected, and suture ligated with #0 Vicryl suture with a Heaney stitch.  Attention was then turned to the left round ligament, which was tented up with the Babcock.  Small window was made beneath it and the broad ligament with hemostat was then suture ligated with #0 Vicryl suture, transected, and skeletonized with the aid of Metzenbaums.  The left infundibulopelvic ligament was then bluntly isolated.  It was then suture ligated with #0 Vicryl suture, doubly clamped with Kocher clamps, and transected and suture ligated with #0 Vicryl suture with a Heaney stitch.  The bladder flap was then placed on tension with Allis clamps.  It was then dissected off of the lower uterine segment with the aid of Metzenbaum scissors and Russians.  It was then gently pushed off of lower uterine segment with the aid of a moist Ray-Tec.  The uterine arteries were then skeletonized bilaterally.,They were then clamped with straight Kocher clamps, transected, and suture ligated with #0 Vicryl suture.  The cardinal ligament and uterosacral complexes on both sides were then clamped with curved Kocher clamps.  These were then transected and suture ligated with #0 Vicryl suture.  The lower uterine segment was then grasped with Lahey clamps, at which time the cervix was already visible.  It was then entered with the last transection.  The cervix was grasped with a single-toothed tenaculum and the uterus, cervix, and left adnexa were amputated off the vagina with the aid of Jorgenson scissors.  The angles of the vaginal cuff were then grasped with Kocher clamps.  A Betadine-soaked Ray-Tec was then pushed into the vagina and the vaginal cuff was closed with #0 Vicryl suture in a running lock fashion with care taken to transect the ipsilateral cardinal ligament, at which time the suction tip was changed and copious suction irrigation was performed.  Good hemostasis was appreciated.  A figure-of-eight suture in the center of the vaginal cuff was placed with #0 Vicryl.  This was tagged for later use.  The uterosacrals on both sides were incorporated into the vaginal cuff with the aid of #0 Vicryl suture.  The round ligaments were then pulled into the vaginal cuff using the figure-of-eight suture placed in the center of the vaginal cuff and these were tied in place.  The pelvis was then again copiously suctioned irrigated and hemostasis was appreciated.  The peritoneal surfaces were then reapproximated with the aid of #3-0 Vicryl suture in a running fashion.  The GYN/Balfour retractor and bladder blade were then removed.  The bowel was then packed.  Again copious suction irrigation was performed with hemostasis appreciated.  The peritoneum was then reapproximated with #2-0 Vicryl suture in a running fashion.  The fascia was then reapproximated with #0 Vicryl suture in a running fashion.  The Scarpa's  fascia was then reapproximated with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a subcuticular fashion.  Steri-Strips were placed.  At the end of the procedure, the sponge that was pushed into the vagina previously was removed and hemostasis was appreciated vaginally.  The patient tolerated the procedure well and was taken to Recovery in stable condition.  Sponge, lap, and needle counts were correct x2.  Specimens include uterus, cervix, left fallopian tube, and ovary.
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DESCRIPTION: Total abdominal hysterectomy (TAH) and left salpingo-oophorectomy.  Hypermenorrhea, uterine fibroids, pelvic pain, left adnexal mass, and pelvic adhesions.

The situation describes a surgical procedure involving a total abdominal hysterectomy (TAH) and left salpingo-oophorectomy, typically performed to address conditions like hypermenorrhea, uterine fibroids, and adnexal masses. Surgery inherently involves significant risks, including anesthesia, bleeding, and potential complications during and after the procedure. The patient's condition, including pelvic pain and a left adnexal mass, prompts the necessity for surgery, indicating it's medically significant and deliberate. Despite the procedure being described as complicated, the fact that there were no complications and the patient tolerated it well suggests successful management of risks. Surgery on reproductive organs, especially involving potential malignancies, adds a layer of urgency and gravity, impacting both physical health and quality of life. Thus, this situation qualifies as high-stakes.


Medical Specialty: Surgery
Sample Name: Chest Tube Placement

PREOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,POSTOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,OPERATION: , Left chest tube placement.,IV SEDATION: , 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,PROCEDURE: , With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion.  A 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple.  The incision was made and deepened through the different layers to reach the intercostal space.  The pleura was entered on top of the underlying rib and finger digital palpation was performed.  Multiple loculations were encountered.  Break up of loculations was performed posteriorly and a chest tube was directed posteriorly.  Only a small amount of fluid was noted to come out initially.  This was sent for various studies.  Soft adhesions were encountered.  The plan was to obtain a chest x-ray and start Activase installation.
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DESCRIPTION: Left pleural effusion, parapneumonic, loculated.  Left chest tube placement.

surgery, activase, chest tube placement, pleural effusion, chest tube, lidocaine, infiltration, parapneumonic, loculated, pleural, chest,

The described procedure, chest tube placement, is an invasive medical procedure typically performed in a surgical or emergency setting to manage a pleural effusion, which is the accumulation of fluid in the pleural cavity. The insertion of a chest tube involves risks such as bleeding, infection, and damage to surrounding organs, making it a high-stakes situation. Additionally, the need for sedation and sterile techniques indicates the complexity and importance of precision in this procedure. Failure to properly manage a pleural effusion can lead to respiratory distress or infection worsening, thus emphasizing the stakes involved. However, this is a routine procedure for skilled professionals, which moderately reduces the stakes compared to a more complex or uncommon surgical intervention.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Chronic Kidney Disease Followup - 1

PROBLEMS LIST:,1.  Type 1 diabetes mellitus, insulin pump requiring.,2.  Chronic kidney disease, stage III.,3.  Sweet syndrome.,4.  Hypertension.,5.  Dyslipidemia.,6.  Osteoporosis.,7.  Anemia.,8.  A 25-hydroxy-vitamin D deficiency.,9.  Peripheral neuropathy manifested by insensate feet.,10.  Hypothyroidism.,11.  Diabetic retinopathy.,HISTORY OF PRESENT ILLNESS:,  This is a return visit to the renal clinic for the patient where she is followed up for diabetes and kidney disease management.  Her last visit to this clinic was approximately three months ago.  Since that time, the patient states that she has had some variability in her glucose control too largely to recent upper and lower respiratory illnesses.  She did not seek attention for these, and the symptoms have begun to subside on their own and in the meantime, she continues to have some difficulties with blood sugar management.  Her 14-day average is 191.  She had a high blood sugar this morning, which she attributed to a problem with her infusion set; however, in the clinic after an appropriate correction bolus, she subsequently became quite low.  She was treated appropriately with glucose and crackers, and her blood sugar came back up to over 100.  She was able to manage this completely on her own.  In the meantime, she is not having any other medical problems that have interfered with glucose control.  Her diet has been a little bit different in that she had been away visiting with her family for some period of time as well.,CURRENT MEDICATIONS:,1.  A number of topical creams for her rash.,2.  Hydroxyzine 25 mg 4 times a day.,3.  Claritin 5 mg a day.,4.  Fluoxetine 20 mg a day.,5.  Ergocalciferol 800 international units a day.,6.  Protonix 40 mg a day.,7.  Iron sulfate 1.2 cc every day.,8.  Actonel 35 mg once a week.,9.  Zantac 150 mg daily.,10.  Calcium carbonate 500 mg 3 times a day.,11.  NovoLog insulin via insulin pump about 30 units of insulin daily.,12.  Zocor 40 mg a day.,13.  Valsartan 80 mg daily.,14.  Amlodipine 5 mg a day.,15.  Plavix 75 mg a day.,16.  Aspirin 81 mg a day.,17.  Lasix 20 mg a day.,18.  Levothyroxine 75 micrograms a day.,REVIEW OF SYSTEMS: , Really not much change.  Her upper respiratory symptoms have resolved.  She is not describing fevers, chills, sweats, nausea, vomiting, constipation, diarrhea or abdominal pain.  She is not having any decreased appetite.  She is not having painful urination, any blood in the urine, frequency or hesitancy.  She is not having polyuria, polydipsia or polyphagia.  Her visual acuity has declined, but she does not appear to have any acute change.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 36.1, pulse 56, respirations 16, blood pressure 117/48, and weight is 109.7 pounds.  HEENT:  Examination found her to be atraumatic and normocephalic.  She has pupils that are equal, round, and reactive to light.  Extraocular muscles intact.  Sclerae and conjunctivae are clear.  The paranasal sinuses are nontender.  The nose is patent.  The external auditory canal and tympanic membranes are clear A.U.  Oral cavity and oropharynx examination is free of lesions.  The mucosus membranes are moist.  NECK:  Supple.  There is no lymphadenopathy.  There is no thyromegaly.  THORAX:  Reveals lungs that are clear, PA and lateral, without adventitious sounds.  CARDIOVASCULAR:  Demonstrated regular rate and rhythm.  EXTREMITIES:  Reveal no edema and is otherwise deferred.,ASSESSMENT AND PLAN: , This is a return visit to the renal clinic for the patient with history as noted above.  She has had variability in her glucose control, and the plan today is to continue her current regimen, which includes the following:  Basal rate, 12 a.m. 0.6 units per hour, 4 a.m. 0.7 units per hour, and 9 a.m. 0.6 units per hour.  Her target pre-meal is 120 and bedtime is 150.  Her insulin/carbohydrate ratio is 10 and her correction factor is 60.  We are not going to make any changes to her insulin pump settings at this time.  I have encouraged her to watch the number of processed high-calorie foods that she is consuming late at night.  She has agreed to try that and cut back on this a little bit.  I want to get fasting labs to include her standard labs for us today but include a fasting C-peptide and a hemoglobin A1C, so that we can make arrangements for her to get an upgraded insulin pump.  She states to me that she has been having some battery problems in the recent past, although she says the last time that she went four weeks without having to change batteries and that is about the appropriate amount of time.  Nonetheless, she is out of warranty and we will try to get her a new pump.,Plan to see the patient back here in approximately two months, and we will try to get the new pump through Medicare.
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DESCRIPTION: Type 1 diabetes mellitus, insulin pump requiring.  Chronic kidney disease, stage III.  Sweet syndrome, hypertension, and dyslipidemia.

The case presented involves a patient with multiple chronic health conditions including Type 1 diabetes managed with an insulin pump, chronic kidney disease stage III, hypertension, dyslipidemia, and other comorbidities. The stakes are moderate because managing these conditions requires regular monitoring and appropriate adjustments to treatment. Any significant mismanagement could lead to serious health complications, particularly with diabetes and kidney disease. However, the current situation appears to be under control with minor concerns that are being monitored and managed by healthcare professionals.


Medical Specialty: Orthopedic
Sample Name: Ankle Sprain - H&P

CHIEF COMPLAINT:,  Right ankle sprain.,HISTORY OF PRESENT ILLNESS: , This is a 56-year-old female who fell on November 26, 2007 at 11:30 a.m. while at work.  She did not recall the specifics of her injury but she thinks that her right foot inverted and subsequently noticed pain in the right ankle.  She describes no other injury at this time.,PAST MEDICAL HISTORY: , Hypertension and anxiety.,PAST SURGICAL HISTORY: , None.,MEDICATIONS: , She takes Lexapro and a blood pressure pill, but does not know anything more about the names and the doses.,ALLERGIES:,  No known drug allergies.,SOCIAL HISTORY: , The patient lives here locally.  She does not report any significant alcohol or illicit drug use.  She works full time.,FAMILY HISTORY:,  Noncontributory.,REVIEW OF SYSTEMS:,Pulm:  No cough, No wheezing, No shortness of breath,CV:  No chest pain or palpitations,GI:  No abdominal pain.  No nausea, vomiting, or diarrhea.,PHYSICAL EXAM:,GENERAL APPEARANCE:  No acute distress,VITAL SIGNS:  Temperature 97.8, blood pressure 122/74, heart rate 76, respirations 24, weight 250 lbs, O2 sat 95% on R.A.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.,CHEST:  Clear to auscultation bilaterally.,HEART:  Regular rate and rhythm.  No murmurs.,ABDOMEN:  Non-distended, nontender, normal active bowel sounds.,EXTREMITIES:  No Clubbing, No Cyanosis, No edema.,MUSCULOSKELETAL:  The spine is straight and there is no significant muscle spasm or tenderness there.  Both knees appear to be non-traumatic with no deformity or significant tenderness.  The right ankle has some swelling just below the right lateral malleolus and the dorsum of the foot is tender.  There is decreased range of motion and some mild ecchymosis noted around the ankle.,DIAGNOSTIC DATA: , X-ray of the right ankle reveals no acute fracture by my observation.  Radiologic interpretation is pending., ,IMPRESSION:,  Right ankle sprain.,PLAN:,1.  Motrin 800 mg t.i.d.,2.  Tylenol 1 gm q.i.d. as needed.,3.  Walking cast is prescribed.,4.  I told the patient to call back if any problems.  The next morning she called back complaining of worsening pain and I called in some Vicodin ES 1-2 p.o. q.  8 hours p.r.n. pain #60 with no refills.
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DESCRIPTION: History and Physical for right ankle sprain

The situation involves a medical evaluation of an ankle sprain, which is typically considered a routine and non-life-threatening orthopedic issue. The patient's condition is relatively stable, and there are no indications of acute emergency. Ankle sprains are common and can be managed effectively with proper treatment, such as pain management and immobilization with a walking cast. While pain management adjustments were necessary, the condition does not pose an immediate or serious risk to the patient's overall health, making it lower in stakes compared to life-threatening injuries or conditions.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Biventricular Cardioverter Defibrillator Implantation

REFERRAL INDICATION AND PREPROCEDURE DIAGNOSES,1.  Dilated cardiomyopathy.,2.  Ejection fraction less than 10%.,3.  Ventricular tachycardia.,4.  Bradycardia with likely high degree of pacing.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of biventricular automatic implantable cardioverter defibrillator.,2.  Fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator.,3.  Coronary sinus venogram for left ventricular lead placement.,4.  Defibrillation threshold testing x2.,FLUOROSCOPY TIME:  ,18.5 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Vancomycin 1 g (the patient was allergic to penicillin).,2.  Versed 10 mg.,3.  Fentanyl 100 mcg.,4.  Benadryl 50 mg.,CLINICAL HISTORY: , The patient is a pleasant 57-year-old gentleman with a dilated cardiomyopathy, an ejection fraction of 10%, been referred for AICD implantation because of his low ejection fraction and a non-sustained ventricular tachycardia.  He has underlying sinus bradycardia.  Therefore, will likely be pacing much of the time and would benefit from a biventricular pacing device.,RISKS AND BENEFITS:,  Risks, benefits, and alternatives to implantation of biventricular AICD and defibrillation threshold testing were discussed with the patient.  Risks including but not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, the need for urgent cardiovascular surgery, and death were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  After achieving appropriate anesthesia, a percutaneous access of the left axillary vein was performed under fluoroscopy with two separate sticks.  Guidewires were advanced down into the left axillary vein.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Hemostasis was achieved with electrocautery.  Lidocaine 1% (10 mL) was administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  Using the more lateral of the guidewires, a 7-French side-arm sheath was advanced into the left axillary vein.  The dilator was removed and another wire was advanced down into the sheath.  The sheath was then backed up over the top of the two wires.  One wire was pinned to the drape and using the alternate wire, a 9-French side-arm sheath was advanced down into the left axillary vein.  The dilator and wire were removed.  A defibrillation lead was then advanced down into the atrium.  The peel-away sheath was removed.  The lead was then passed across the tricuspid valve and positioned in the apical septal location.  The active fix screw was deployed.  Adequate pacing and sensing functions were established.  A 10-volt pacing was used temporarily and there was no diaphragmatic stimulation.  The suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  Using the wire that had been pinned to the drape, a 7-French side-arm sheath was advanced over this wire into the axillary vein.  The wire and dilator were removed.  An active pacing lead was then advanced down to the right atrium and the peel-away sheath was removed.  The lead was parked until a later time.  Using the separate access point, a 9-French side-arm sheath was advanced into the left axillary vein.  The dilator and wire were removed.  A curved outer sheath catheter as well as an inner catheter were advanced down into the area of the coronary sinus.  The coronary sinus was cannulated.  Inner catheter was removed and a balloon-tipped catheter was advanced into the coronary sinus.  A coronary sinus venogram was then performed.  It was noted that the most suitable location for lead placement was the middle cardiac vein.  This was cannulated and a passive lead was advanced over a Whisper EDS wire into a distal position.  Adequate pacing and sensing functions were established.  A 10-volt pacing was used temporarily.  There was no diaphragmatic stimulation.  The outer sheath was peeled away.  The 9 French sheath was then peeled away.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  At this point, the atrial lead was then positioned in the right atrial appendage using a preformed J-curved stylet.  The lead body was turned several times and the lead was affixed to the tissue.  Adequate pacing and sensing function were established.  A suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was then washed with antibiotic-impregnated saline.  Pulse generator was obtained and connected securely to the leads.  The leads were carefully wrapped behind the pulse generator and the entire system was placed in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  Sponge and needle counts were correct at the end of the procedure and no acute complications were noted.,The patient was sedated further and shock on T was performed on two separate occasions.  The device was allowed to detect the charge and defibrillate, establishing the entire workings of the ICD system.,DEVICE DATA,1.  Pulse generator, manufacturer Boston Scientific, model # N119, serial #12345.,2.  Right atrial lead, manufacturer Guidant, model #4470, serial #12345.,3.  Right ventricular lead, manufacturer Guidant, model #0185, serial #12345.,4.  Left ventricular lead, manufacturer Guidant, model #4549, serial #12345.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 705 ohms.  P-waves measured at 1.7 millivolts.  Pacing threshold 0.5 volt at 0.4 milliseconds.,2.  Right ventricular lead impedance 685 ohms.  R-waves measured 10.5 millivolts.  Pacing threshold 0.6 volt at 0.4 milliseconds.,3.  Left ventricular lead impedance 1098 ohms.  R-waves measured 5.2 millivolts.  Pacing threshold 1.4 volts at 0.4 milliseconds.,DEFIBRILLATION THRESHOLD TESTING,1.  Shock on T.  Charge time 2.9 seconds.  Energy delivered 17 joules, successful with lead impedance of 39 ohms.,2.  Shock on T.  Charge time 2.8 seconds.  Energy delivered 17 joules, successful with a type 2 break lead impedance of 38 ohms.,DEVICE SETTINGS,1.  A pacing DDD 60 to 120.,2.  VT-1 zone 165 beats per minute.  VT-2 zone 185 beats per minute.  VF zone 205 beats per minute.,CONCLUSIONS,1.  Successful implantation of a biventricular automatic implantable cardiovascular defibrillator,2.  Defibrillation threshold of less than or equal to 17.5 joules.,2.  No acute complications.,PLAN,1.  The patient will be taken back to his room for continued observation and dismissed to the discretion of the primary service.,2.  Chest x-ray to rule out pneumothorax and verified lead position.,3.  Device interrogation in the morning.,4.  Completion of the course of antibiotics.
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DESCRIPTION: Implantation of biventricular automatic implantable cardioverter defibrillator, fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator, coronary sinus venogram for left ventricular lead placement, and defibrillation threshold testing x2.

Biventricular cardioverter defibrillator implantation is a high-stakes medical procedure involving significant risks including bleeding, infection, cardiac perforation, and death. The patient's condition is critical, with a very low ejection fraction (less than 10%) and ventricular tachycardia, necessitating careful handling and monitoring. The procedure has been described thoroughly, and while it was successful without acute complications, the inherent risks and the patient's cardiac condition make this a high-stakes situation.


Medical Specialty: Consult - History and Phy.
Sample Name: Acute Inferior Myocardial Infarction

CHIEF COMPLAINT: , Chest pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 40-year-old white male who presents with a chief complaint of "chest pain".,The patient is diabetic and has a prior history of coronary artery disease.  The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent.  The severity of the pain has progressively increased.  He describes the pain as a sharp and heavy pain which radiates to his neck & left arm.  He ranks the pain a 7 on a scale of 1-10.  He admits some shortness of breath & diaphoresis.  He states that he has had nausea & 3 episodes of vomiting tonight.  He denies any fever or chills.  He admits prior episodes of similar pain prior to his PTCA in 1995.  He states the pain is somewhat worse with walking and seems to be relieved with rest.  There is no change in pain with positioning.  He states that he took 3 nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain.  The patient ranks his present pain a 4 on a scale of 1-10.  The most recent episode of pain has lasted one-hour.,The patient denies any history of recent surgery, head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.,REVIEW OF SYSTEMS:,  All other systems reviewed & are negative.,PAST MEDICAL HISTORY:,  Diabetes mellitus type II, hypertension, coronary artery disease, atrial fibrillation, status post PTCA in 1995 by Dr. ABC.,SOCIAL HISTORY: , Denies alcohol or drugs.  Smokes 2 packs of cigarettes per day.  Works as a banker.,FAMILY HISTORY: , Positive for coronary artery disease (father & brother).,MEDICATIONS: , Aspirin 81 milligrams QDay.  Humulin N. insulin 50 units in a.m.  HCTZ 50 mg QDay.  Nitroglycerin 1/150 sublingually PRN chest pain.,ALLERGIES: , Penicillin.,PHYSICAL EXAM: , The patient is a 40-year-old white male.,General:  The patient is moderately obese but he is otherwise well developed & well nourished.  He appears in moderate discomfort but there is no evidence of distress.  He is alert, and oriented to person place and circumstance.  There is no evidence of respiratory distress.  The patient ambulates
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DESCRIPTION: Patient presents with a chief complaint of chest pain admitted to Coronary Care Unit due to acute inferior myocardial infarction.

The patient is experiencing symptoms indicative of an acute inferior myocardial infarction, which is commonly known as a heart attack. Given the patient's history of coronary artery disease, diabetes, hypertension, and family history of heart issues, this situation is critical. Medical intervention is required urgently to prevent further cardiac damage or potential fatal outcome. Thus, the patient's condition is high-stakes due to the immediate threat to his life and the need for prompt medical treatment.


Medical Specialty: Radiology
Sample Name: Myocardial Perfusion Imaging - 3

DIAGNOSIS:  ,Shortness of breath.  Fatigue and weakness.  Hypertension.  Hyperlipidemia.,INDICATION: , To evaluate for coronary artery disease.,
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DESCRIPTION: Myocardial perfusion study at rest and stress, gated SPECT wall motion study at stress and calculation of ejection fraction.

radiology, myocardial perfusion imaging, spect wall motion study at stress, rest and stress, perfusion study at rest, calculation of ejection fraction, normal left ventricular wall, spect wall motion study, ventricular wall motion, myocardial perfusion study, perfusion imaging, blood pressure, nonspecific st, ventricular wall, gated spect, spect wall, motion study, stress test, heart rate, ejection fraction, myocardial perfusion, technetium, tetrofosmin, ischemia, ekg, imaging, spect, heart, ventricular, mci, resting, perfusion, stress, myocardial,

The scenario involves the evaluation of a patient's potential coronary artery disease using myocardial perfusion imaging, which is a critical diagnostic tool. The diagnosis involves symptoms like shortness of breath, fatigue, and underlying conditions such as hypertension and hyperlipidemia, which can be indicative of serious health risks. The result of this imaging could influence significant clinical decisions, potentially involving treatment for heart disease, which could have substantial impacts on the patient's health and life. The high stakes are related to accurately diagnosing and managing heart disease, which is vital for the patient's wellbeing.


Medical Specialty: Pediatrics - Neonatal
Sample Name: School Physical - 2

CHIEF COMPLAINT:,  Well-child check and school physical.,HISTORY OF PRESENT ILLNESS:,  This is a 9-year-old African-American male here with his mother for a well-child check.  Mother has no concerns at the time of the visit.  She states he had a pretty good school year.  He still has some fine motor issues, especially writing, but he is receiving help with that and math.  He continues to eat well.  He could do better with milk intake, but Mother states he does eat cheese and yogurt.  He brushes his teeth daily.  He has regular dental visits every six months.  Bowel movements are without problems.  He is having some behavior issues, and sometimes he tries to emulate his brother in some of his negative behaviors.,DEVELOPMENTAL ASSESSMENT:,  Social:  He has a sense of humor.  He knows his rules.  He does home chores.  Fine motor:  He is as mentioned before.  He can draw a person with six parts.  Language:  He can tell time.  He knows the days of the week.  He reads for pleasure.  Gross motor:  He plays active games.  He can ride a bicycle.,REVIEW OF SYSTEMS:,  He has had no fever and no vision problems.  He had an eye exam recently with Dr. Crum.  He has had some headaches which precipitated his vision exam.  No earache or sore throat.  No cough, shortness of breath or wheezing.  No stomachache, vomiting or diarrhea.  No dysuria, urgency or frequency.  No excessive bleeding or bruising.,MEDICATIONS:,  No daily medications.,ALLERGIES:,  Cefzil.,IMMUNIZATIONS:,  His immunizations are up to date.,PHYSICAL EXAMINATION:,General:  He is alert and in no distress, afebrile.,HEENT:  Normocephalic, atraumatic.  Pupils equal, round and react to light.  TMs are clear bilaterally.  Nares:  Patent.  Oropharynx is clear.,Neck:  Supple.,Lungs:  Clear to auscultation.,Heart:  Regular.  No murmur.,Abdomen:  Soft.  Positive bowel sounds.  No masses.  No hepatosplenomegaly.,GU:  Tanner III.,Extremities:  Symmetrical.  Femoral pulses 2+ bilaterally.  Full range of motion of all extremities.,Back:  No scoliosis.,Neurological:  Grossly intact.,Skin:  Normal turgor.  No rashes.,Hearing:  Grossly normal.,ASSESSMENT:,  Well child.,PLAN:,  Anticipatory guidance for age.  He is to return to the office in one year.
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DESCRIPTION: Well-child check and school physical.

Well-child check and school physical.

The given situation describes a routine well-child check-up for a 9-year-old boy who is generally in good health, with no significant medical issues or immediate concerns. The examination and review do not identify any urgent or severe medical conditions. Although there are some minor developmental concerns, such as fine motor issues and behavior problems, these are being addressed and do not constitute a high-stakes medical situation.


Medical Specialty: General Medicine
Sample Name: Buttock Abscess

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

general medicine, buttock pain, pimple, incision and drainage, local wound care, blood sugars, diabetes, buttock, abscess,

The patient is a 24-year-old female with a buttock abscess, a common condition, which was managed with incision and drainage. Although she has poorly controlled diabetes, a factor that can complicate infections, the vital signs are stable, there is no evidence of systemic infection, and positive blood cultures were mentioned which might indicate prior or ongoing systemic issues, possibly linked to poorly controlled diabetes. However, the immediate clinical situation with the abscess does not currently appear life-threatening. Furthermore, the surgical consultation concluded that no further surgical intervention is needed, just local wound care. This suggests that her current state is not critically high-risk, although close monitoring and proper diabetes management are necessary going forward.


Medical Specialty: Surgery
Sample Name: Cardiac Catheterization - 8

PROCEDURE PERFORMED:,1.  Right femoral artery access.,2.  Selective right and left coronary angiogram.,3.  Left heart catheterization.,4.  Left ventriculogram.,INDICATIONS FOR PROCEDURE:,  A 50-year-old lady with known history of coronary artery disease with previous stenting to the left anterior descending artery presents with symptoms of shortness of breath.  The resting echocardiogram showed a severe decrease in her left ventricular systolic function with a reported LVEF of 20% to 25%.  This was a sharp decline from a previous LVEF of 50% to 55%.  We therefore, decided to proceed with coronary angiography.,TECHNIQUE: , After obtaining informed consent, the patient was brought to the cardiac catheterization suite in post-absorptive and non-sedated state.  The right groin was prepped and draped in the usual sterile manner.  2% Lidocaine was used for infiltration anesthesia.  Using modified Seldinger technique, a 6-French sheath was introduced into the right femoral artery.  6-French JL4 and JR4 diagnostic catheters were used to perform the left and right coronary angiogram.  A 6-French pigtail catheter was used to perform the LV-gram in the RAO projection.,HEMODYNAMIC DATA: , LVEDP of 11.  There was no gradient across the aortic valve upon pullback.,ANGIOGRAPHIC FINDINGS:,1.  The left main coronary artery is a very short vessel and immediately bifurcates into the left anterior descending artery and the left circumflex coronary artery.,2.  The left main coronary artery is free of any disease.,3.  The left circumflex coronary artery which is a nondominant vessel gives off 2 marginal branches.  The first marginal branch is very small in caliber and runs a fairly long course and is free of any disease.,4.  The second marginal branch which is actually a continuation of the left circumflex coronary artery gives off several secondary branches.  One of its secondary branches which is a small caliber has an ostial 70% stenosis.,5.  The left anterior descending artery has a patent stent in the proximal LAD.  The second stent which is overlapping the junction of the mid and distal left anterior descending artery has mild late luminal loss.  There appears to be 30% narrowing involving the distal cuff segment of the stent in the distal left anterior descending artery.  The diagonal branches are free of any disease.,6.  The right coronary artery is a dominant vessel and has mild luminal irregularities.  Its midsegment has a focal area of 30% narrowing as well.  The rest of the right coronary artery is free of any disease.,7.  The LV-gram performed in the RAO projection shows well preserved left ventricular systolic function with an estimated LVEF of 55%.,RECOMMENDATION: , Continue with optimum medical therapy.  Because of the discrepancy between the left ventriculogram EF assessment and the echocardiographic EF assessment, I have discussed this matter with Dr. XYZ and we have decided to proceed with a repeat 2D echocardiogram.  The mild disease in the distal left anterior descending artery with mild in-stent re-stenosis should be managed medically with optimum control of hypertension and hypercholesterolemia.
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DESCRIPTION: Left heart cardiac catheterization.

Left heart cardiac catheterization.

surgery, heart catheterization, ventriculogram, femoral artery access, coronary angiogram, lvef, distal left anterior descending, circumflex coronary artery, anterior descending artery, femoral artery, systolic function, cardiac catheterization, circumflex coronary, anterior descending, coronary artery, coronary, artery, catheterization, descending

Cardiac catheterization and angiograms are invasive procedures performed to assess the state of coronary arteries, especially after significant changes in cardiac function indicating possible worsening heart disease. Given the patient's history of coronary artery disease, previous stenting, and a notable decrease in left ventricular ejection fraction (LVEF), the procedure's outcome has significant implications for her treatment and health prognosis. Therefore, the situation directly affects the patient's treatment plan and overall health, making it high-stakes.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 4

DATE OF ADMISSION: , MM/DD/YYYY.,DATE OF DISCHARGE: , MM/DD/YYYY.,ADMITTING DIAGNOSIS:, Peritoneal carcinomatosis from appendiceal primary.,DISCHARGE DIAGNOSIS:  , Peritoneal carcinomatosis from appendiceal primary.,SECONDARY DIAGNOSIS: , Diarrhea.,ATTENDING PHYSICIAN: , AB CD, M.D.,SERVICE: , General surgery C, Surgery Oncology.,CONSULTING SERVICES:,  Urology.,PROCEDURES DURING THIS HOSPITALIZATION:,  On MM/DD/YYYY, ,1.  Cystoscopy, bilaterally retrograde pyelograms, insertion of bilateral externalized ureteral stents.,2.  Exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, IPHC with mitomycin-C.,HOSPITAL COURSE: , The patient is a pleasant 56-year-old gentleman with no significant past medical history who after an extensive workup for peritoneal carcinomatosis from appendiceal primary was admitted on MM/DD/YYYY.  He was admitted to General Surgery C Service for a routine preoperative evaluation including baseline labs, bowel prep, urology consult for ureteral stent placement.  The patient was taken to the operative suite on MM/DD/YYYY and was first seen by Urology for a cystoscopy with bilateral ureteral stent placement.  Dr. XYZ performed an exploratory laparotomy, right hemicolectomy, cholecystectomy, splenectomy, omentectomy, and IPHC with mitomycin-C.  The procedure was without complications.  The patient was observed closely in the ICU for one day postoperatively for persistent tachycardia after extubation.  He was then transferred to the floor where he has done exceptionally well.,On postoperative day #2, the patient passed flatus and we were able to start a clear liquid diet.  We advanced him as tolerated to a regular health select diet by postoperative day #4.  His pain was well controlled throughout this hospitalization, initially with a PCA pump, which he very seldomly used.  He was then switched over to p.o. pain medicines and has required very little for adequate pain control.  By postoperative date #2, the patient had been out of bed and ambulating in the hallways.  The patient's only problem was with some mild diarrhea on postoperative days #3 and 4.  This was thought to be a result of his right hemicolectomy.  A C. diff toxin was sent and came back negative and he was started on Imodium to manage his diarrhea.  His post-splenectomy vaccines including pneumococcal, HiB, and meningococcal vaccines were administered during his hospitalization.,On the day of discharge, the patient was resting comfortably in the bed without complaints.  He had been afebrile throughout his hospitalization and his vital signs were stable.  Pertinent physical exam findings include that his abdomen was soft, nondistended and nontender with bowel sounds present throughout.  His midline incision is clean, dry, and intact and staples are in place.  He is just six days postop, he will go home with his staples in place and they will be removed on his follow-up appointment.,CONDITION AT DISCHARGE:  ,The patient was discharged in good and stable condition.,DISCHARGE MEDICATIONS:,1.  Multivitamins daily.,2.  Lovenox 40 mg in 0.4 mL solution inject subcutaneously once daily for 14 days.,3.  Vicodin 5/500 mg and take one tablet by mouth every four hours as needed for pain.,4.  Phenergan 12.5 mg tablets, take one tablet by mouth every six hours p.r.n. for nausea.,5.  Imodium A-D tablets take one tablet by mouth b.i.d. as needed for diarrhea.,DISCHARGE INSTRUCTIONS:,  The patient was instructed to contact us with any questions or concerns that may arise.  In addition, he was instructed to contact us, if he would have fevers greater than 101.4, chills, nausea or vomitting, continuing diarrhea, redness, drainage, or warmth around his incision site.  He will be seen in about one week's time in Dr. XYZ's clinic and his staples will be removed at that time.,FOLLOW-UP APPOINTMENT: , The patient will be seen by Dr. XYZ in clinic in one week's time.
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DESCRIPTION: Patient admitted after an extensive workup for peritoneal carcinomatosis from appendiceal primary.

The discharge summary describes the hospitalization of a patient with peritoneal carcinomatosis from appendiceal primary who underwent significant surgical procedures, including a right hemicolectomy, cholecystectomy, splenectomy, omentectomy, and IPHC with mitomycin-C. The situation is medically complex and involves potential complications from surgery and the management of peritoneal carcinomatosis, a serious condition. While the patient was discharged in stable condition, the underlying cancer and the need for continuous postoperative management indicate the situation has high medical stakes. However, since the patient was stable at discharge, it is not the most critical scenario.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Pulmonary - Followup Note

SUBJECTIVE:,  The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.  She was last seen in the Pulmonary Medicine Clinic in January 2004.  Since that time, her respiratory status has been quite good.  She has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort.  She denies any problems with cough or sputum production.  No fevers or chills.  Recently, she has had a bit more problems with fatigue.  For the most part, she has had no pulmonary limitations to her activity.,CURRENT MEDICATIONS:,  Synthroid 0.112 mg daily; Prilosec 20 mg daily; prednisone, she was 2.5 mg daily, but discontinued this on 06/16/2004; Plaquenil 200 mg b.i.d.; Imuran 100 mg daily; Advair one puff b.i.d.; Premarin 0.3 mg daily; Lipitor 10 mg Monday through Friday; Actonel 35 mg weekly; and aspirin 81 mg daily.  She is also on calcium, vitamin D, vitamin E, vitamin C and a multivitamin.,ALLERGIES:,  Penicillin and also intolerance to shellfish.,REVIEW OF SYSTEMS:,  Noncontributory except as outlined above.,EXAMINATION:,General:  The patient was in no acute distress.,Vital signs:  Blood pressure 122/60, pulse 72 and respiratory rate 16.,HEENT:  Nasal mucosa was mild-to-moderately erythematous and edematous.  Oropharynx was clear.,Neck:  Supple without palpable lymphadenopathy.,Chest:  Chest demonstrates decreased breath sounds, but clear.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Soft and nontender.,Extremities:  Without edema.  No skin lesions.,O2 saturation was checked at rest.  On room air it was 96% and on ambulation it varied between 94% and 96%.  Chest x-ray obtained today showed mild increased interstitial markings consistent with a history of lupus pneumonitis.  She has not had the previous chest x-ray with which to compare; however, I did compare the markings was less prominent when compared with previous CT scan.,ASSESSMENT:,1.  Lupus with mild pneumonitis.,2.  Respiratory status is stable.,3.  Increasing back and joint pain, possibly related to patient’s lupus, however, in fact may be related to recent discontinuation of prednisone.,PLAN:,  At this time, I have recommended to continue her current medications.  We would like to see her back in approximately four to five months, at which time I would like to recheck her pulmonary function test as well as check CAT scan.  At that point, it may be reasonable to consider weaning her Imuran if her pulmonary status is stable and the lupus appears to be under control.
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DESCRIPTION: Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.

cardiovascular / pulmonary, pulmonary medicine clinic, cat scan, lupus, respiratory status, chest x-ray, interstitial disease, lupus pneumonitis, pneumonitis, pulmonary function test, pulmonary status, respiratory difficulties, chest x ray, interstitial, respiratory, chest, pulmonary,

The situation involves a patient with interstitial lung disease secondary to lupus pneumonitis who is under regular follow-up. Although she recently experienced some back and joint pain which might be linked to her lupus or discontinuation of prednisone, her overall respiratory status seems stable at present. The primary actions are to monitor her status and potentially adjust her medication in future appointments. While lupus pneumonitis can be a serious condition, the information provided indicates stability and no immediate crisis, thus not making it an extremely high-stakes scenario in the immediate term.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiovascular - Letter

Dear Sample Doctor:,Thank you for referring Mr. Sample Patient for cardiac evaluation.  This is a 67-year-old, obese male who has a history of therapy-controlled hypertension, borderline diabetes, and obesity.  He has a family history of coronary heart disease but denies any symptoms of angina pectoris or effort intolerance.  Specifically, no chest discomfort of any kind, no dyspnea on exertion unless extreme exertion is performed, no orthopnea or PND.  He is known to have a mother with coronary heart disease.  He has never been a smoker.  He has never had a syncopal episode, MI, or CVA.  He had his gallbladder removed.  No bleeding tendencies.  No history of DVT or pulmonary embolism.  The patient is retired, rarely consumes alcohol and consumes coffee moderately.  He apparently has a sleep disorder, according to his wife (not in the office), the patient snores and stops breathing during sleep.  He is allergic to codeine and aspirin (angioedema).,Physical exam revealed a middle-aged man weighing 283 pounds for a height of 5 feet 11 inches.  His heart rate was 98 beats per minute and regular.  His blood pressure was 140/80 mmHg in the right arm in a sitting position and 150/80 mmHg in a standing position.  He is in no distress.  Venous pressure is normal.  Carotid pulsations are normal without bruits.  The lungs are clear.  Cardiac exam was normal.  The abdomen was obese and organomegaly was not palpated.  There were no pulsatile masses or bruits.  The femoral pulses were 3+ in character with a symmetrical distribution and dorsalis pedis and posterior tibiales were 3+ in character.  There was no peripheral edema.  ,He had a chemistry profile, which suggests diabetes mellitus with a fasting blood sugar of 136 mg/dl.  Renal function was normal.  His lipid profile showed a slight increase in triglycerides with normal total cholesterol and HDL and an acceptable range of LDL.  His sodium was a little bit increased.  His A1c hemoglobin was increased.  He had a spirometry, which was reported as normal.  ,He had a resting electrocardiogram on December 20, 2002, which was also normal.  He had a treadmill Cardiolite, which was performed only to stage 2 and was terminated by the supervising physician when the patient achieved 90% of the predicted maximum heart rate.  There were no symptoms or ischemia by EKG.  There was some suggestion of inferior wall ischemia with normal wall motion by Cardiolite imaging.,In summary, we have a 67-year-old gentleman with risk factors for coronary heart disease.  I am concerned with possible diabetes and a likely metabolic syndrome of this gentleman with truncal obesity, hypertension, possible insulin resistance, and some degree of fasting hyperglycemia, as well as slight triglyceride elevation.  He denies any symptoms of coronary heart disease, but he probably has some degree of coronary atherosclerosis, possibly affecting the inferior wall by functional testings.  ,In view of the absence of symptoms, medical therapy is indicated at the present time, with very aggressive risk factor modification.  I explained and discussed extensively with the patient, the benefits of regular exercise and a walking program was given to the patient.  He also should start aggressively losing weight.  I have requested additional testing today, which will include an apolipoprotein B, LPa lipoprotein, as well as homocystine, and cardio CRP to further assess his risk of atherosclerosis.  ,In terms of medication, I have changed his verapamil for a long acting beta-blocker, he should continue on an ACE inhibitor and his Plavix.  The patient is allergic to aspirin.  I also will probably start him on a statin, if any of the studies that I have recommended come back abnormal and furthermore, if he is confirmed to have diabetes.  Along this line, perhaps, we should consider obtaining the advice of an endocrinologist to decide whether this gentleman needs treatment for diabetes, which I believe he should.  This, however, I will leave entirely up to you to decide.  If indeed, he is considered to be a diabetic, a much more aggressive program should be entertained for reducing the risks of atherosclerosis in general, and coronary artery disease in particular.,I do not find an indication at this point in time to proceed with any further testing, such as coronary angiography, in the absence of symptoms.,If you have any further questions, please do not hesitate to let me know.,Thank you once again for this kind referral.,Sincerely,,Sample Doctor, M.D.
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DESCRIPTION: Male with a history of therapy-controlled hypertension, borderline diabetes, and obesity.  Risk factors for coronary heart disease.

cardiovascular / pulmonary, cardiovascular, letter, angioedema, beta-blocker, cardiac evaluation, chest discomfort, coronary heart disease, hypertension, metabolic syndrome, therapy-controlled hypertension, truncal obesity, controlled hypertension, borderline diabetes, risk factors, heart disease, intolerance, therapy, heart, atherosclerosis, diabetes, coronary, aspirin

The situation involves a patient with multiple risk factors for coronary heart disease, including obesity, hypertension, and possible metabolic syndrome. These factors place the patient at a high risk for developing more severe cardiovascular issues in the future. However, the patient currently lacks severe symptoms or immediate acute conditions that would raise the stakes further. Medical therapy and lifestyle changes are suggested as the appropriate course of action. There is a suggestion to consult an endocrinologist, indicating a longer-term management approach rather than an urgent, critical intervention. Given that the emphasis is on risk factor modification and the absence of immediate severe symptoms, the situation is of moderate stakes rather than extremely high stakes.


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

Medical Specialty: Radiology
Sample Name: Tun-L Catheter Placement

PREOPERATIVE DIAGNOSIS:,  Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy.,POSTOPERATIVE DIAGNOSIS:,  Same.,PROCEDURE:,1.  Nerve root decompression at L45 on the left side.,2.  Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.,3.  Interpretation of radiograph.,ANESTHESIA: , IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,INDICATION FOR PROCEDURE: , Severe and excruciating pain in the lumbar spine and lower extremity.  MRI shows disc pathology as well as facet arthrosis.,SUMMARY OF PROCEDURE: , The patient was admitted to the operating room, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels.  After the towels were places then sterile drapes were placed on top of that.,After which time the Epimed catheter was then placed, this was done by first repositioning the C-Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5, verifying the sacral hiatus.  The skin over the sacral hiatus was then injected with 1% Lidocaine and an #18-gauge needle was used for skin puncture.  The #18-gauge needle was inserted off of midline.  A #16-gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss-of-resistance technique the needle was placed.  Negative aspiration was carefully performed.  Omnipaque 240 dye was then injected through the #16-gauge RK needle.  The classical run off was noted.  A filling defect was noted @ L45 nerve root on the left side.  After which time 10 cc of 0.25% Marcaine/Triamcinolone (9/1 mixture) was then infused through the 16 R-K Needle.  Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique.,An Epimed Tun-L catheter was then inserted through the #16-gauage R-K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance.  As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized.  The tip of the catheter was noted to be @ L45 level on the left side.  After this the #16-gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side.  After this was successfully done, the catheter was then secured in place; this was done with Neosporin ointment, a Split 2x2, Op site and Hypofix tape.  The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected.  The classical run off was noted in the lumbar region.  Some lyses of adhesions were also visualized at this time with barbotage technique.  Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted.  Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect.  After which time negative aspiration was again performed through the Epimed® Tun-L catheter and then 10 cc of solution was then infused through the catheter, this was done over a 10-minute period with initial 3 cc test dose.  Approximately 3 minutes elapsed and then the remaining 7 cc were infused (Solution consisting of 8 cc of 0.25% Marcaine, 2 cc of Triamcinolone and 1 cc of Wydase.)  The catheter was then capped with a bacterial filter.  The patient was noted to have tolerated the procedure well without any complications.,Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed.  A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure.  This verified positive nerve root decompression.  The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side.  Positive myelogram without dural puncture was noted during this procedure; no sub-dural spread of Omnipaque 240 dye was noted.  This patient did not report any problems and reported pain reduction.
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DESCRIPTION: Nerve root decompression at L45 on the left side.  Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.  Interpretation of radiograph.

radiology, low back syndrome, low back pain, nerve root decompression, steroid solution, c-arm, epimed, tun l catheter, nerve root, negative aspiration, omnipaque dye, filling defect, nerve, root, catheter, adhesions, injection, needle,

The procedure involves decompression of a nerve root, placement of a catheter, and injection of medication, all under monitored anesthesia care. While the surgery addresses severe and excruciating pain due to disc pathology, the stakes are not in the higher range as it is a planned, minimally invasive procedure with no immediate life-threatening conditions reported. The main risks involve potential complications such as infection or bleeding, though none were reported. However, the procedure impacts the patient's quality of life significantly due to pain reduction.


Medical Specialty: Orthopedic
Sample Name: Arthroscopic Rotator Cuff Repair - 1

PREOPERATIVE DIAGNOSIS: , Rotated cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Rotated cuff tear, right shoulder.,2.  Glenoid labrum tear.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic glenoid labrum debridement.,2.  Subacromial decompression.,3.  Rotator cuff repair, right shoulder.,SPECIFICATIONS:,  Intraoperative procedure was done at Inpatient Operative Suite, room #1 at ABCD Hospital.  This was done under interscalene and subsequent general anesthetic in the modified beach chair position.,HISTORY AND GROSS FINDINGS: , The patient is a 48-year-old with male who has been suffering increasing right shoulder pain for a number of months prior to surgical intervention.  He was completely refractory to conservative outpatient therapy.  After discussing the alternative care as well as the advantages, disadvantages, risks, complications, and expectations, he elected to undergo the above stated procedure on this date.,Intraarticularly, the joint was observed.  There was noted to be a degenerative glenoid labrum tear.  The biceps complex was otherwise intact.  There were minimal degenerative changes at the glenohumeral joint.  Rotator cuff tear was appreciated on the inner surface.  Subacromially, the same was true.  This was an elliptical to V-type tear.  The patient has a grossly positive type III acromion.,OPERATIVE PROCEDURE: , The patient was laid supine on the operating table after receiving interscalene and then general anesthetic by the Anesthesia Department.  He was safely placed in modified beach chair position.  He was prepped and draped in the usual sterile manner.  Portals were created outside to end, posterior to anterior, and ultimately laterally in the typical fashion.  Upon complete diagnostic arthroscopy was carried out in the intraarticular aspect of the joint, a 4.2 meniscus shaver was placed anteriorly with the scope posteriorly.  Debridement was carried out to the glenoid labrum.  The biceps was probed and noted to be intact.  Undersurface of the rotator cuff was debrided with the shaver along with debridement of the subchondral region of the greater tuberosity attachment.,After this, instrumentation was removed.  The scope was placed subacromially and a lateral portal created.  Gross bursectomy was carried out in a stepwise fashion to the top part of the cuff as well as in the gutters.  An anterolateral portal was created.  Sutures were placed via express silk as well as other sutures with a #2 fiber wire.  With passing of the suture, they were tied with a slip-tight knot and then two half stitches.  There was excellent reduction of the tear.  Superolateral portal was then created.  A #1 Mitek suture anchor was then placed in the posterior cuff to bring this over to bleeding bone.  _______ suture was placed.  The implant was put into place.  The loop was grabbed and it was impacted in the previously drilled holes.  There was excellent reduction of the tear.,Trial range of motion was carried out and seemed to be satisfactory.,Prior to this, a subacromial decompression was accomplished after release of CA ligament with the vapor Bovie.  A 4.8 motorized barrel burr was utilized to sequentially take this down from the type III acromion to a flat type I acromion.,After all was done, copious irrigation was carried out throughout the joint.  Gross bursectomy lightly was carried out to remove all bony elements.  A pain buster catheter was placed through a separate portal and cut to length.  0.5% Marcaine was instilled after portals were closed with #4-0 nylon.  Adaptic, 4 x 4s, ABDs, and Elastoplast tape placed for dressing.  The patient was ultimately transferred to his cart and PACU in apparent satisfactory condition.  Expected surgical prognosis of this patient is fair.
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DESCRIPTION: Rotated cuff tear, right shoulder.  Glenoid labrum tear.  Arthroscopy with arthroscopic glenoid labrum debridement, subacromial decompression, and rotator cuff repair, right shoulder.

orthopedic, subacromial decompression, rotator cuff repair, arthroscopic glenoid labrum debridement, arthroscopy, glenoid labrum tear, glenoid labrum, cuff, tear, arthroscopic, subacromial, decompression, debridement, rotator, glenoid, labrum, shoulder,

The scenario involves a surgical procedure for a rotator cuff tear and a glenoid labrum tear. While it is a serious orthopedic surgery requiring technical skill and post-operative care, it is a procedure that is routinely performed by orthopedic surgeons. The patient has been properly diagnosed and likely consented to the surgery, understanding the risks and benefits. The situation does not imply urgent or life-threatening circumstances but rather routine surgical management of a common orthopedic condition. Therefore, it does not rate extremely high on a high-stakes scale.


Medical Specialty: Discharge Summary
Sample Name: Intrauterine Pregnancy - Discharge Summary

ADMITTING DIAGNOSIS:,  Intrauterine pregnancy at term with previous cesarean.,SECONDARY DIAGNOSIS: , Desired sterilization.,DISCHARGE DIAGNOSES,1.  Intrauterine pregnancy at term with previous cesarean.,2.  Desired sterilization.,3.  Status post repeat low transverse cesarean and bilateral tubal ligation.,HISTORY: , The patient is a 35-year-old gravida 2, para 1-0-0-1 with intrauterine pregnancy on 08/30/09.  Pregnancy was uncomplicated.  She opted for a scheduled elective C-section and sterilization without any trial of labor.  All routine screening labs were normal and she underwent a high-resolution ultrasound during pregnancy.,PAST MEDICAL HISTORY: , Significant for postpartum depression after her last baby as well as a cesarean.,ALLERGIES:,  SHE HAS SEASONAL ALLERGIES.,MEDICATIONS:,  She is taking vitamins and iron.,PHYSICAL EXAMINATION,GENERAL:  An alert gravid woman in no distress.,ABDOMEN:  Gravid, nontender, non-irritable, with an infant in the vertex presentation.  Estimated fetal weight was greater than 10 pounds.,HOSPITAL COURSE:  ,On the first hospital day, the patient went to the operating room where repeat low transverse cesarean and tubal ligation were performed under spinal anesthesia with delivery of a viable female infant weighing 7 pounds 10 ounces and Apgars of 9 and 9.  There was normal placenta, normal pelvic anatomy.  There was 600 cc estimated blood loss.  Patient recovered uneventfully from her anesthesia and surgery.  She was able to ambulate and void.  She tolerated regular diet.  She passed flatus.  She was breast-feeding.  Postoperative hematocrit was 31.  On the second postoperative day, the patient was discharged home in satisfactory condition.,DISCHARGE MEDICATIONS: , Motrin and Percocet for pain.  Paxil for postpartum depression.  She was instructed to do no lifting, straining, or driving, to put nothing in the vagina and to see me in two weeks or with signs of severe pain, heavy bleeding, fever, or other problems.
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DESCRIPTION: Intrauterine pregnancy at term with previous cesarean.   Desired sterilization.  Status post repeat low transverse cesarean and bilateral tubal ligation.

discharge summary, cesarean, bilateral tubal ligation, low transverse cesarean, intrauterine, gravida, sterilization, pregnancy,

The discharge summary describes a routine and uneventful hospital course for a patient who underwent a scheduled elective cesarean section and sterilization. There are no indications of complications during the procedure, and the patient was discharged in satisfactory condition. While the patient has past medical history of postpartum depression, it is being managed with medication. The situation presents standard postoperative instructions without signs of immediate critical health risks.


Medical Specialty: Dentistry
Sample Name: Toothache - ER Visit

CHIEF COMPLAINT:,  Toothache.,HISTORY OF PRESENT ILLNESS:  ,This is a 29-year-old male who has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled.  Complains of new tooth pain.  The patient states his current toothache is to both upper and lower teeth on the left side for approximately three days.  The patient states that he would have gone to see his regular dentist but he has missed so many appointments that they now do not allow him to schedule regular appointments, he has to be on standby appointments only.  The patient denies any other problems or complaints.  The patient denies any recent illness or injuries.  The patient does have OxyContin and Vicodin at home which he uses for his knee pain but he wants more pain medicines because he does not want to use up that medicine for his toothache when he wants to say this with me.,REVIEW OF SYSTEMS: , CONSTITUTIONAL:  No fever or chills.  No fatigue or weakness.  No recent weight change.  HEENT:  No headache, no neck pain, the toothache pain for the past three days as previously mentioned.  There is no throat swelling, no sore throat, no difficulty swallowing solids or liquids.  The patient denies any rhinorrhea.  No sinus congestion, pressure or pain, no ear pain, no hearing change, no eye pain or vision change.  CARDIOVASCULAR:  No chest pain.  RESPIRATIONS:  No shortness of breath or cough.  GASTROINTESTINAL:  No abdominal pain.  No nausea or vomiting.  GENITOURINARY:  No dysuria.  MUSCULOSKELETAL:  No back pain.  No muscle or joint aches.  SKIN:  No rashes or lesions.  NEUROLOGIC:  No vision or hearing change.  No focal weakness or numbness.  Normal speech.  HEMATOLOGIC/LYMPHATIC:  No lymph node swelling has been noted.,PAST MEDICAL HISTORY: , Chronic knee pain.,CURRENT MEDICATIONS: , OxyContin and Vicodin.,ALLERGIES:,  PENICILLIN AND CODEINE.,SOCIAL HISTORY: , The patient is still a smoker.,PHYSICAL EXAMINATION:,  VITAL SIGNS:  Temperature 97.9 oral, blood pressure is 146/83, pulse is 74, respirations 16, oxygen saturation 98% on room air and interpreted as normal.  CONSTITUTIONAL:  The patient is well nourished and well developed.  The patient is a little overweight but otherwise appears to be healthy.  The patient is calm, comfortable, in no acute distress, and looks well.  The patient is pleasant and cooperative.  HEENT:  Eyes are normal with clear conjunctiva and cornea bilaterally.  There is no icterus, injection, or discharge.  Pupils are 3 mm and equally round and reactive to light bilaterally.  There is no absence of light sensitivity or photophobia.  Extraocular motions are intact bilaterally.  Ears are normal bilaterally without any sign of infection.  There is no erythema, swelling of canals.  Tympanic membranes are intact without any erythema, bulging or fluid levels or bubbles behind it.  Nose is normal without rhinorrhea or audible congestion.  There is no tenderness over the sinuses.  NECK:  Supple, nontender, and full range of motion.  There is no meningismus.  No cervical lymphadenopathy.  No JVD.  Mouth and oropharynx shows multiple denture and multiple dental caries.  The patient has tenderness to tooth #12 as well as tooth #21.  The patient has normal gums.  There is no erythema or swelling.  There is no purulent or other discharge noted.  There is no fluctuance or suggestion of abscess.  There are no new dental fractures.  The oropharynx is normal without any sign of infection.  There is no erythema, exudate, lesion or swelling.  The buccal membranes are normal.  Mucous membranes are moist.  The floor of the mouth is normal without any abscess, suggestion of Ludwig's syndrome.  CARDIOVASCULAR:  Heart is regular rate and rhythm without murmur, rub, or gallop.  RESPIRATIONS:  Clear to auscultation bilaterally without shortness of breath.  GASTROINTESTINAL:  Abdomen is normal and nontender.  MUSCULOSKELETAL:  No abnormalities are noted to back, arms and legs.  The patient has normal use of his extremities.  SKIN:  No rashes or lesions.  NEUROLOGIC:  Cranial nerves II through XII are intact.  Motor and sensory are intact to the extremities.  The patient has normal speech and normal ambulation.  PSYCHIATRIC:  The patient is alert and oriented x4.  Normal mood and affect.  HEMATOLOGIC/LYMPHATIC:  No cervical lymphadenopathy is palpated.,EMERGENCY DEPARTMENT COURSE: , The patient did request a pain shot and the patient was given Dilaudid of 4 mg IM without any adverse reaction.,DIAGNOSES:,1.  ODONTALGIA.,2.  MULTIPLE DENTAL CARIES.,CONDITION UPON DISPOSITION:  ,Stable.,DISPOSITION: , To home.,PLAN: , The patient was given a list of local dental clinics that he can follow up with or he can choose to stay with his own dentist that he wishes.  The patient was requested to have reevaluation within two days.  The patient was given a prescription for Percocet and clindamycin.  The patient was given drug precautions for the use of these medicines.  The patient was offered discharge instructions on toothache but states that he already has it.  He declined the instructions.  The patient was asked to return to the emergency room, should he have any worsening of his condition or develop any other problems or symptoms of concern.
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DESCRIPTION: Patient has had multiple problems with his teeth due to extensive dental disease and has had many of his teeth pulled, now complains of new tooth pain to both upper and lower teeth on the left side for approximately three days..

dentistry, odontalgi, multiple dental caries, dentist, dental disease, extensive dental disease, teeth pulled, lower teeth, cervical lymphadenopathy, dental caries, toothache, erythema, swelling, teeth, dental,

The situation involves a patient with extensive dental disease experiencing a toothache severe enough to visit an emergency room. While dental pain can be quite distressing and impact one's quality of life, this particular case has been assessed as stable, and the patient has been sent home with a follow-up plan and pain management medications. There are no signs of a life-threatening condition or serious complications such as an abscess or systemic infection mentioned. The immediate treatment in the ER was successful, and the patient is encouraged to seek further dental care outside the emergency setting. This indicates that the situation is relatively manageable and not immediately life-threatening, though it does highlight a need for improved dental care access and continuity. Therefore, it is considered moderately low-stakes.


Medical Specialty: Ophthalmology
Sample Name: BCCa Excision - Lower Lid

PREOPERATIVE DIAGNOSIS: , Extremely large basal cell carcinoma, right lower lid.,POSTOPERATIVE DIAGNOSIS:,  Extremely large basal cell carcinoma, right lower lid.,TITLE OF OPERATION: , Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.,PROCEDURE: , The patient was brought into the operating room and prepped and draped in usual fashion.  Xylocaine 2% with epinephrine was injected beneath the conjunctiva and skin of the lower lid and also beneath the conjunctiva and skin of the upper lid.  A frontal nerve block was also given on the right upper lid.  The anesthetic agent was also injected in the right preauricular region which would provide a donor graft for the right lower lid defect.  The area was marked with a marking pen with margins of 3 to 4 mm, and a #15 Bard-Parker blade was used to make an incision at the nasal and temporal margins of the lesion.,The incision was carried inferiorly, and using a Steven scissors the normal skin, muscle, and conjunctiva was excised inferiorly.  The specimen was then marked and sent to pathology for frozen section.  Bleeding was controlled with a wet-field cautery, and the right upper lid was everted, and an incision was made 3 mm above the lid margin with the Bard-Parker blade in the entire length of the upper lid.  The incision reached the orbicularis, and Steven scissors were used to separate the tarsus from the underlying orbicularis.  Vertical cuts were made nasally and temporally, and a large dorsal conjunctival flap was fashioned with the conjunctiva attached superiorly.  It was placed into the defect in the lower lid and sutured with multiple interrupted 6-0 Vicryl sutures nasally, temporally, and inferiorly.,The defect in the skin was measured and an appropriate large preauricular graft was excised from the right preauricular region.  The defect was closed with interrupted 5-0 Prolene sutures, and the preauricular graft was sutured in place with multiple interrupted 6-0 silk sutures.  The upper border of the graft was attached to the upper lid after incision was made in the gray line with a Superblade, and the superior portion of the skin graft was sutured to the upper lid through the anterior lamella created by the razor blade incision.,Cryotherapy was then used to treat the nasal and temporal margins of the area of excision because of positive margins, and following this an antibiotic steroid ointment was instilled and a light pressure dressing was applied.  The patient tolerated the procedure well and was sent to recovery room in good condition.
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DESCRIPTION: Excision of large basal cell carcinoma, right lower lid, and repaired with used dorsal conjunctival flap in the upper lid and a large preauricular skin graft.

ophthalmology, basal cell carcinoma, cryotherapy, steven scissors, conjunctiva, conjunctival flap, frontal nerve block, frozen section, lower lid, orbicularis, skin graft, nasal and temporal margins, dorsal conjunctival flap, upper lid, basal, carcinoma, preauricular, incision, conjunctival,

This medical procedure involves the excision of a large basal cell carcinoma from the patient's right lower eyelid and reconstruction using a conjunctival flap and skin graft. The operation is delicate due to the location (near the eye) and the complexity of the reconstructive surgery involved. Basal cell carcinoma itself is typically not life-threatening, but the stakes are elevated because the cancer is 'extremely large' and located near crucial ocular structures, requiring precise surgical intervention to prevent functional or aesthetic complications. Additionally, the operation involves a multi-step process with nerve blocks, different types of sutures, and cryotherapy, indicating a significant level of complexity and precision. The risks associated with surgical complications in this sensitive area contribute to the high-stakes nature of the procedure.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Chest Tube Insertion in ER

PREOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.  This patient is obtunded, intubated, and septic.  This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion.  The site of insertion was anesthetized with 1% Xylocaine, and an incision was made.  Blunt dissection was carried out 2 intercostal spaces above the initial incision site.  The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly.  The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  10 mL,COMPLICATIONS:,  None.,SPONGE COUNT: , Correct x2.
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DESCRIPTION: Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.

cardiovascular / pulmonary, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion,

The situation involves an emergency medical procedure on a patient with serious conditions such as a spontaneous pneumothorax, respiratory failure, and sepsis. Chest tube insertion is critical and urgent as it addresses life-threatening issues like pneumothorax and respiratory failure. The patient's obtunded state and the lack of ability to obtain informed consent further underscore the high-stakes nature of this scenario. Successful management is crucial to stabilize the patient, implying significant consequences if not executed properly.


Medical Specialty: Consult - History and Phy.
Sample Name: Pain Management Consult - 2

HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing. The severity of the pain ranges from mild to severe. The pain is severe occasionally. It is present constantly. The pain is made worse by sitting, riding in a car, twisting and lifting. The pain is made better by rest. The patient's symptoms appear to be soft tissue (spine), myofascial (spine) and musculoskeletal (spine) in origin. Sleep alteration because of pain: positive and wakes up after getting to sleep nightly. Systemic signs/symptoms relevant or potentially relevant to the spine: none. Patient reports the following symptoms: depressed mood, loss of interest or pleasure in all or most activities, insomnia, inability to concentrate, fatigue and loss of energy.,WORK STATUS:,
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DESCRIPTION: Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.

The situation involves a detailed assessment of a patient experiencing significant and chronic pain due to a work injury. The patient's condition is affecting their sleep and emotional well-being, indicating a severe impact on their quality of life. This consult is likely crucial for determining an appropriate pain management strategy, which could have implications for the patient's recovery and work status. While not immediately life-threatening, the situation involves important considerations for the patient's health and work life, thus representing moderate to high stakes in the context of pain management and treatment planning.