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

Medical Specialty: Office Notes
Sample Name: Normal Female Exam Template - 1

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

The situation describes a template for a routine normal female physical exam. It provides a comprehensive yet standard checklist of observations that a medical practitioner might use during a general physical examination. There are no indicators of immediate or life-threatening conditions found in the information provided. This template would typically be used for documentation and reference during standard practice, so it lacks urgency or high-stakes elements. The stakes might be higher if there were abnormal findings or red flags that required immediate medical attention.


Medical Specialty: Office Notes
Sample Name: Normal Child Exam Template

CHILD PHYSICAL EXAMINATION,VITAL SIGNS:  Birth weight is ** grams, length **, occipitofrontal circumference **.  Character of cry was lusty.,GENERAL APPEARANCE:  Well.,BREATHING:  Unlabored.,SKIN:  Clear.  No cyanosis, pallor, or icterus.  Subcutaneous tissue is ample.,HEAD:  Normal.  Fontanelles are soft and flat.  Sutures are opposed.,EYES:  Normal with red reflex x2.,EARS:  Patent.  Normal pinnae, canals, TMs.,NOSE:  Patent nares.,MOUTH:  No cleft.,THROAT:  Clear.,NECK:  No masses.,CHEST:  Normal clavicles.,LUNGS:  Clear bilaterally.,HEART:  Regular rate and rhythm without murmur.,ABDOMEN:  Soft, flat.  No hepatosplenomegaly.  The cord is three vessel.,GENITALIA:  Normal ** genitalia **with testes descended bilaterally.,ANUS:  Patent.,SPINE:  Straight and without deformity.,EXTREMITIES:  Equal movements.,MUSCLE TONE:  Good.,REFLEXES:  Moro, grasp, and suck are normal.,HIPS:  No click or clunk.
---
DESCRIPTION: Normal child physical exam template.

Normal child physical exam template.

office notes, child physical examination, physical, genitalia, child,

The context provided is a template for a normal child physical exam, which is routinely used during check-ups to ensure a child's development is on track. While the document is important for maintaining and assessing child health, it's a standard procedure without any immediate high-risk implications. There is no indication of an emergency or critical situation from the provided text, which typically would involve specific concerning findings or the need for urgent intervention. Therefore, it suggests a low-stakes situation overall in terms of immediate medical risk or decision-making.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Office Notes
Sample Name: Normal Female Exam Template - 2

VITAL SIGNS: , Blood pressure *, pulse *, respirations *, temperature *.,GENERAL APPEARANCE:,  Alert and in no apparent distress, calm, cooperative, and communicative.,HEENT: , Eyes:  EOMI.  PERRLA.  Sclerae nonicteric.  No lesions of lids, lashes, brows, or conjunctivae noted.  Funduscopic examination unremarkable.  Ears:  Normal set, shape, TMs, canals and hearing.  Nose and Sinuses:  Negative.  Mouth, Tongue, Teeth, and Throat:  Negative except for dental work.,NECK: , Supple and pain free without bruit, JVD, adenopathy or thyroid abnormality.,CHEST:,  Lungs are bilaterally clear to auscultation and percussion.,HEART: , S1 and S2.  Regular rate and rhythm without murmur, heave, click, lift, thrill, rub, or gallop.  PMI nondisplaced.  Chest wall unremarkable to inspection and palpation.  No axillary or supraclavicular adenopathy detected.,BREASTS:,  In the seated and supine position unremarkable.,ABDOMEN: , No hepatosplenomegaly, mass, tenderness, rebound, rigidity, or guarding.  No widening of the aortic impulse and no intraabdominal bruit auscultated.,EXTERNAL GENITALIA: , Normal for age.,RECTAL: , Negative to 7 cm by gloved digital palpation with Hemoccult-negative stool.,EXTREMITIES: , Good distal pulse and perfusion without evidence of edema, cyanosis, clubbing, or deep venous thrombosis.  Nails of the hands and feet, and creases of the palms and soles are unremarkable.  Good active and passive range of motion of all major joints.,BACK:,  Normal to inspection and percussion.  Negative for spinous process tenderness or CVA tenderness.  Negative straight-leg raising, Kernig, and Brudzinski signs.,NEUROLOGIC:,  Nonfocal for cranial and peripheral nervous systems, strength, sensation, and cerebellar function.  Affect is normal.  Speech is clear and fluent.  Thought process is lucid and rational.  Gait and station are unremarkable.,SKIN: , Unremarkable for any premalignant or malignant condition with normal changes for age.
---
DESCRIPTION: An example/template for a routine normal female physical exam.

office notes, heent, general appearance, hepatosplenomegaly, mass, tenderness, rebound, rigidity, pulse, bruit, adenopathy, chest, percussion, inspection, palpation, signs, tongue,

The document provided is a template for a routine normal female physical exam. This template includes common metrics and assessments used during a physical check-up and does not indicate any urgent or critical medical issues. The sample contains standard observations expected in a healthy individual and serves as a guide for documenting similar routine examinations. Therefore, the stakes associated with this specific situation are low as it is not related to a current, immediate health concern but rather serves as a normal procedural reference.


Medical Specialty: Office Notes
Sample Name: Cardiology Office Visit - 2

HISTORY OF PRESENT ILLNESS:,  This 57-year-old black female was seen in my office on Month DD, YYYY for further evaluation and management of hypertension.  Patient has severe backache secondary to disc herniation.  Patient has seen an orthopedic doctor and is scheduled for surgery.  Patient also came to my office for surgical clearance.  Patient had cardiac cath approximately four years ago, which was essentially normal.  Patient is documented to have morbid obesity and obstructive sleep apnea syndrome.  Patient does not use a CPAP mask.  Her exercise tolerance is eight to ten feet for shortness of breath.  Patient also has two-pillow orthopnea.  She has intermittent pedal edema.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Blood pressure is 135/70.  Respirations 18 per minute.  Heart rate 70 beats per minute.  Weight 258 pounds.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good. ,NECK:  Supple.  JVP is flat.  Carotid upstroke is good. ,LUNGS:  Clear. ,CARDIOVASCULAR:  There is no murmur or gallop heard over the precordium. ,ABDOMEN:  Soft.  There is no hepatosplenomegaly. ,EXTREMITIES:  The patient has no pedal edema.  ,MEDICATIONS:  ,1.  BuSpar 50 mg daily.,2.  Diovan 320/12.5 daily.,3.  Lotrel 10/20 daily.,4.  Zetia 10 mg daily.,5.  Ambien 10 mg at bedtime.,6.  Fosamax 70 mg weekly.,DIAGNOSES:,1.  Controlled hypertension.,2.  Morbid obesity.,3.  Osteoarthritis.,4.  Obstructive sleep apnea syndrome.,5.  Normal coronary arteriogram.,6.  Severe backache.,PLAN:,1.  Echocardiogram, stress test.,2  Routine blood tests.,3.  Sleep apnea study.,4.  Patient will be seen again in my office in two weeks.
---
DESCRIPTION: Cardiology office visit sample note.

Cardiology office visit sample note.

In this scenario, a 57-year-old female with multiple chronic conditions including hypertension, obesity, and sleep apnea, is being evaluated for surgical clearance. While she is considered morbidly obese and experiences severe backache, the immediate medical evaluation indicates controlled hypertension and no critical findings on examination, suggesting lower immediate risk. The situation requires careful management, especially considering her upcoming surgery and sleep apnea. These factors contribute to moderate stakes because of the potential implications for her surgery and overall health.


Medical Specialty: Office Notes
Sample Name: Abnormal Stress Test

HISTORY OF PRESENT ILLNESS: , Mr. ABC is a 60-year-old gentleman who had a markedly abnormal stress test earlier today in my office with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.  He required 3 sublingual nitroglycerin in total (please see also admission history and physical for full details).,The patient underwent cardiac catheterization with myself today which showed mild-to-moderate left main distal disease of 30%, moderate proximal LAD with a severe mid-LAD lesion of 99%, and a mid-left circumflex lesion of 80% with normal LV function and some mild luminal irregularities in the right coronary artery with some moderate stenosis seen in the mid to distal right PDA.,I discussed these results with the patient, and he had been relating to me that he was having rest anginal symptoms, as well as nocturnal anginal symptoms, and especially given the severity of the mid left anterior descending lesion, with a markedly abnormal stress test, I felt he was best suited for transfer for PCI.  I discussed the case with Dr. X at Medical Center who has kindly accepted the patient in transfer.,CONDITION ON TRANSFER: , Stable but guarded.  The patient is pain-free at this time.,MEDICATIONS ON TRANSFER:,1.  Aspirin 325 mg once a day.,2.  Metoprolol 50 mg once a day, but we have had to hold it because of relative bradycardia which he apparently has a history of.,3.  Nexium 40 mg once a day.,4.  Zocor 40 mg once a day, and there is a fasting lipid profile pending at the time of this dictation.  I see that his LDL was 136 on May 3, 2002.,5.  Plavix 600 mg p.o. x1 which I am giving him tonight.,Other medical history is inclusive for obstructive sleep apnea for which he is unable to tolerate positive pressure ventilation, GERD, arthritis,DISPOSITION:  ,The patient and his wife have requested and are agreeable with transfer to Medical Center, and we are enclosing the CD ROM of his images.
---
DESCRIPTION: Patient had a markedly abnormal stress test with severe chest pain after 5 minutes of exercise on the standard Bruce with horizontal ST depressions and moderate apical ischemia on stress imaging only.

office notes, standard bruce, nitroglycerin, abnormal stress test, st depressions, anginal symptoms, stress test, lad, anginal, stress

The situation involves a 60-year-old patient experiencing severe chest pain after an abnormal stress test, indicative of significant cardiovascular issues. The cardiac catheterization results reveal severe blockages, including a 99% lesion in a critical artery, necessitating further intervention through Percutaneous Coronary Intervention (PCI). These factors collectively suggest a high risk for a potentially life-threatening cardiac event, hence it is high-stakes. The patient is stable but in a guarded condition, highlighting the urgency and critical nature of the situation.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Vaginal Delivery - Vacuum-Assisted

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

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

The situation involves a vacuum-assisted vaginal delivery, which is typically a high-stakes medical procedure due to the potential for complications for both the mother and the infant. There are several complicating factors mentioned, such as non-reassuring fetal heart tones, the need for rapid delivery, and a third-degree laceration. Although there were no complications reported post-operatively, the urgency and precision required in such deliveries, combined with the potential risks to both mother and child, make this scenario high-stakes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Well-woman checkup

CHIEF COMPLAINT:,  The patient comes for her well-woman checkup.,HISTORY OF PRESENT ILLNESS:,  She feels well.  She has had no real problems.  She has not had any vaginal bleeding.  She had a hysterectomy.  She has done fairly well from that time till now.  She feels like she is doing pretty well.  She remains sexually active occasionally.  She has not had any urinary symptoms.  No irregular vaginal bleeding.  She has not had any problems with vasomotor symptoms and generally, she just feels like she has been doing pretty well.  She sometimes gets a catch in her right hip and sometimes she gets heaviness in her calves.  She says the only thing that works to relieve that is to sleep on her tummy with her legs pulled up and they relax and she goes off to sleep.  She does not report any swelling or inflammation, or pain.  She had a recent urinary tract infection, took medication, and has not rechecked on that urinalysis.,MEDICATIONS: , Tetracycline 250 mg daily, Inderal LA 80 mg every other day.,ALLERGIES:,  Sulfa.,PAST MEDICAL HISTORY:,  She had rosacea.  She also has problems with “tremors” and for that she takes Inderal LA.  Hysterectomy in the past.,SOCIAL HISTORY:,  She drinks four cups of coffee a day.  No soda.  No chocolate.  She said her husband hurt his hand and shoulder, and she has been having to care of him pretty much.  They walk every evening for one hour.,FAMILY HISTORY:,  Her mother is in a nursing home; she had a stroke.  Her father died at age 86 in January 2004 of congestive heart failure.  She has two brothers, one has kidney failure, the other brother donated a kidney to his other brother, but this young man is now an alcoholic and drug addict.,REVIEW OF SYSTEMS:,  Patient denies headache or trauma.  No blurred or double vision.  Hearing is fine, no tinnitus, or infection.  Infrequent sore throat, no hoarseness, or cough.,Neck:  No stiffness, pain, or swelling.,Respiratory:  No shortness of breath, cough, or hemoptysis.,Cardiovascular:  No chest pain, ankle edema, palpitations, or hypertension.,GI:  No nausea, vomiting, diarrhea, constipation, melena, or jaundice.,GU:  No dysuria, frequency, urgency, or stress incontinence.,Locomotor:  No weakness, joint pain, tremor, or swelling.,GYN:  See HPI.,Integumentary:  Patient performs self-breast examinations and denies any breast masses or nipple discharge.  No recent skin or hair changes.,Neuropsychiatric:  Denies depression, anxiety, tearfulness, or suicidal thought.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Height:  62 inches.  Weight:  134 pounds.  Blood pressure:  116/74.  Pulse:  60.  Respirations:  12.  Age 59.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.  She fell last winter on the ice and really cracked her head and has had some problems with headaches since then and she has not returned to her job which was very stressful and hard on her.  She wears glasses.,Neck:  Full range of motion.  No lymphadenopathy or thyromegaly.,Chest:  Clear to auscultation and percussion.,Heart:  Normal sinus rhythm, no murmur.,Integumentary:  Breasts are without masses, tenderness, nipple retraction, or discharge.  Reviewed self-breast examination.  No axillary nodes are palpable.,Abdomen:  Soft.  Liver, spleen, and kidneys are not palpable.  No masses felt, nontender.  Femoral pulses strong and equal.,Back:  No CVA or spinal tenderness.  No deformity noted.,Pelvic:  BUS negative.  Vaginal mucosa atrophic.  Cervix and uterus are absent.  No Pap was taken.  No adnexal masses.,Rectal:  Good sphincter tone.  No masses.  Stool guaiac negative.,Extremities:  No edema.  Pulses strong and equal.  Reflexes are intact.  Romberg and Babinski are negative.  She is oriented x 3.  Gait is normal.,ASSESSMENT:,  Middle-aged woman, status post hysterectomy, recent urinary tract infection.,PLAN:,  We will evaluate the adequacy of the therapy for her urinary tract infection with the urinalysis and culture.  I recommended mammogram and screening, hemoccult x 3, DEXA scan and screening, and she is fasting today.  We will screen with chem-12, lipid profile, and CBC because of her advancing age and notify of those results, as soon as they are available.  Continue same meds.  Recheck annually unless she has problems sooner.
---
DESCRIPTION: Well-woman check up for a middle-aged woman, status post hysterectomy, recent urinary tract infection.

The situation describes a routine well-woman checkup for a middle-aged woman who is generally doing well and presents no immediate medical concerns. It includes standard evaluations and follow-up tests due to age-appropriate screenings. Although there are health maintenance needs, nothing in the description indicates an acute or life-threatening situation. The tasks described are typical in preventive care, with no urgent or critical issues involved.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Ultrasound OB - 8

REASON FOR EXAM: , Pregnant female with nausea, vomiting, and diarrhea.,FINDINGS: , The uterus measures 8.6 x 4.4 x 5.4 cm and contains a gestational sac with double decidual sac sign.  A yolk sac is visualized.  What appears to represent a crown-rump length measures 3.3 mm for an estimated sonographic age of 6 weeks 0 days and estimated date of delivery of 09/28/09.,Please note however that no fetal heart tones are seen.  However, fetal heart tones would be expected at this age.,The right ovary measures 3.1 x 1.6 x 2.3 cm.  The left ovary measures 3.3 x 1.9 x 3.5 cm.  No free fluid is detected.,IMPRESSION: , Single intrauterine pregnancy at 6 weeks 0 days with an estimated date of delivery of 09/28/09.  A live intrauterine pregnancy, however, could not be confirmed, as a sonographic fetal heart rate would be expected at this time.  A close interval followup in correlation with beta-hCG is necessary as findings may represent an inevitable abortion.
---
DESCRIPTION: Pregnant female with nausea, vomiting, and diarrhea.  OB ultrasound less than 14 weeks, transvaginal.

obstetrics / gynecology, intrauterine pregnancy, estimated date of delivery, nausea, vomiting, fetal heart tones, ovary measures, fetal heart, ultrasound, ob, ovary, pregnancy, sac, fetal, intrauterine

The ultrasound indicates an early-stage pregnancy where fetal heart tones are not detected, which could suggest an inevitable abortion. This is a critical situation for the patient as it involves the potential loss of the pregnancy, requiring immediate follow-up and further testing such as beta-hCG levels. The situation affects not only the immediate health of the patient but also requires sensitive handling and potentially emotionally significant outcomes.


Medical Specialty: Office Notes
Sample Name: Cardiology Office Visit - 1

HISTORY OF PRESENT ILLNESS:,  This 66-year-old white male was seen in my office on Month DD, YYYY.  Patient was recently discharged from Doctors Hospital at Parkway after he was treated for pneumonia.  Patient continues to have severe orthopnea, paroxysmal nocturnal dyspnea, cough with greenish expectoration.  His exercise tolerance is about two to three yards for shortness of breath.  The patient stopped taking Coumadin for reasons not very clear to him.  He was documented to have recent atrial fibrillation.  Patient has longstanding history of ischemic heart disease, end-stage LV systolic dysfunction, and is status post ICD implantation.  Fasting blood sugar this morning is 130.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  Blood pressure is 120/60.  Respirations 18 per minute.  Heart rate 75-85 beats per minute, irregular.  Weight 207 pounds.,HEENT:  Head normocephalic.  Eyes, no evidence of anemia or jaundice.  Oral hygiene is good. ,NECK:  Supple.  JVP is flat.  Carotid upstroke is good. ,LUNGS:  Severe inspiratory and expiratory wheezing heard throughout the lung fields.  Fine crepitations heard at the base of the lungs on both sides. ,CARDIOVASCULAR:  PMI felt in fifth left intercostal space 0.5-inch lateral to midclavicular line. First and second heart sounds are normal in character.  There is a II/VI systolic murmur best heard at the apex.,ABDOMEN:  Soft.  There is no hepatosplenomegaly.,EXTREMITIES:  Patient has 1+ pedal edema.,MEDICATIONS: , ,1.  Ambien 10 mg at bedtime p.r.n.,2.  Coumadin 7.5 mg daily.,3.  Diovan 320 mg daily.,4.  Lantus insulin 50 units in the morning.,5.  Lasix 80 mg daily.,6.  Novolin R p.r.n.,7.  Toprol XL 100 mg daily.,8.  Flovent 100 mcg twice a day.,DIAGNOSES:,1.  Atherosclerotic coronary vascular disease with old myocardial infarction.,2.  Moderate to severe LV systolic dysfunction.,3.  Diabetes mellitus.,4.  Diabetic nephropathy and renal failure.,5.  Status post ICD implantation.,6.  New onset of atrial fibrillation.,7.  Chronic Coumadin therapy.,PLAN:,1.  Continue present therapy.,2.  Patient will be seen again in my office in four weeks.
---
DESCRIPTION: Sample cardiology office visit note.

Sample cardiology office visit note.

The situation involves a patient with a complex medical history, including recent hospitalization for pneumonia, severe cardiac and pulmonary symptoms, and multiple chronic conditions such as ischemic heart disease, LV dysfunction, diabetes, and new-onset atrial fibrillation. The patient has also stopped taking Coumadin, a crucial medication for managing atrial fibrillation, with a high risk of thromboembolic events. Monitoring and adjusting his comprehensive treatment plan is essential to prevent potential life-threatening events. Given the patient's fragile health state and the combination of serious conditions, this presents a high-stakes medical situation.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Ultrasound OB - 2

FINDINGS:,By dates the patient is 8 weeks, 2 days.,There is a gestational sac within the endometrial cavity measuring 2.1cm consistent with 6 weeks 4 days. There is a fetal pole measuring 7mm consistent with 6 weeks 4 days. There was no fetal heart motion on Doppler or on color Doppler.,There is no fluid within the endometrial cavity.,There is a 2.8 x 1.2cm right adnexal cyst.,IMPRESSION:,Gestational sac with a fetal pole but no fetal heart motion consistent with fetal demise at 6 weeks 4 days. By dates the patient is 8 weeks, 2 days.,A preliminary report was called by the ultrasound technologist to the referring physician.
---
DESCRIPTION: A 34-year old female with no fetal heart motion noted on office scan.

obstetrics / gynecology, fetal heart motion, gestational sac, endometrial cavity, fetal pole, fetal heart, heart motion, gestational, fetal

The situation involves interpreting ultrasound results for a pregnant woman, where no fetal heart motion is detected, suggesting a possible fetal demise. This is a deeply emotional and potentially life-altering event for the patient, which requires sensitive communication and consideration of further medical evaluations or interventions. It involves significant emotional and medical implications.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Ultrasound OB - 1

EXAM: , OB Ultrasound.,HISTORY:,  A 29-year-old female requests for size and date of pregnancy.,FINDINGS: , A single live intrauterine gestation in the cephalic presentation, fetal heart rate is measured 147 beats per minute.  Placenta is located posteriorly, grade 0 without previa.  Cervical length is 4.2 cm.  There is normal amniotic fluid index of 12.2 cm.  There is a 4-chamber heart.  There is spontaneous body/limb motion.  The stomach, bladder, kidneys, cerebral ventricles, heel, spine, extremities, and umbilical cord are unremarkable.,BIOMETRIC DATA:,BPD = 7.77 cm = 31 weeks, 1 day,HC = 28.26 cm = 31 weeks, 1 day,AC = 26.63 cm = 30 weeks, 5 days,FL = 6.06 cm = 31 weeks, 4 days,Composite sonographic age 30 weeks 6 days plus minus 17 days.,ESTIMATED DATE OF DELIVERY: , Month DD, YYYY.,Estimated fetal weight is 3 pounds 11 ounces plus or minus 10 ounces.,IMPRESSION: , Single live intrauterine gestation without complications as described.
---
DESCRIPTION: OB Ultrasound - A 29-year-old female requests for size and date of pregnancy.

obstetrics / gynecology, ultrasound, ac, bpd, cervical length, estimated date of delivery, fl, hc, placenta, single live, amniotic fluid, bladder, cephalic, cephalic presentation, cerebral ventricles, extremities, fetal heart rate, fetal weight, gestation, heel, intrauterine, kidneys, pregnancy, previa, spine, stomach, umbilical cord, live intrauterine, intrauterine gestation

The ultrasound findings indicate a normal, healthy pregnancy without complications. The data shows normal fetal heart rate, normal amniotic fluid levels, and no signs of fetal anomalies or complications such as placenta previa. This particular ultrasound seems to be a routine check-up for determining size and date of pregnancy, which is low-risk given the findings. Therefore, the stakes involved are relatively low.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Ultrasound - Pelvis

EXAM: , Ultrasound of pelvis.,HISTORY:, Menorrhagia.,FINDINGS: , Uterus is enlarged measuring 11.0 x 7.5 x 11.0 cm.  It appears to be completely replaced by multiple ill-defined fibroids.  The endometrial echo complex was not visualized due to the contents of replacement of the uterus with fibroids.  The right ovary measures 3.9 x 1.9 x 2.3 cm.  The left ovary is not seen.  No complex cystic adnexal masses are identified.,IMPRESSION:  ,Essential replacement of the uterus by fibroids.  It is difficult to measure given their heterogenous and diffuse nature.  MRI of the pelvis could be performed for further evaluation to evaluate for possible uterine fibroid embolization.
---
DESCRIPTION: Ultrasound of pelvis - menorrhagia.

Ultrasound of pelvis - menorrhagia.

obstetrics / gynecology, pelvis, mri, menorrhagia, ultrasound, adnexa, echo complex, endometrial, fibroids, ovary, uterine fibroid, uterus, ultrasound of pelvis

The medical situation involves findings from an ultrasound on a patient experiencing menorrhagia, revealing the uterus primarily replaced by fibroids. The findings suggest considering further evaluation with an MRI, possibly for uterine fibroid embolization. While the findings could significantly affect the patient's quality of life and require medical intervention, they are not imminently life-threatening. Therefore, the stakes are moderate, addressing patient quality of life and potential further medical procedures.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Tubal Fulguration - Laparoscopic

A 1 cm infraumbilical skin incision was made.  Through this a Veress needle was inserted into the abdominal cavity.  The abdomen was filled with approximately 2 liters of CO2 gas.  The Veress needle was withdrawn.  A trocar sleeve was placed through the incision into the abdominal cavity.  The trocar was withdrawn and replaced with the laparoscope.  A 1 cm suprapubic skin incision was made.  Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope.  The trocar was withdrawn and replaced with a probe.,The patient was placed in Trendelenburg position, and the bowel was pushed out of the pelvis.  Upon visualization of the pelvis organs, the uterus, fallopian tubes and ovaries were all normal.  The probe was withdrawn and replaced with the bipolar cautery instrument.  The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus.  Electrical current was applied to the tube at this point and fulgurated.  The tube was then regrasped just distal to this and refulgurated.  It was then regrasped just distal to the lateral point and refulgurated again.  The same procedure was then carried out on the opposite tube.  The bipolar cautery instrument was withdrawn and replaced with the probe.  The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes.  The upper abdomen was visualized, and the liver surface was normal.  The gas was allowed to escape from the abdomen, and the instruments were removed.  The skin incisions were repaired.  The instruments were removed from the vagina.,There were no complications to the procedure.  Blood loss was minimal.  The patient went to the postanesthesia recovery room in stable condition.
---
DESCRIPTION: Laparoscopic tubal fulguration.

Laparoscopic tubal fulguration.

obstetrics / gynecology, tubal fulguration, cohen cannula, laparoscopic, trendelenburg position, veress needle, abdominal cavity, bipolar cautery, dorsal lithotomy, fallopian tubes, fimbriated ends, fulgurated, laparoscope, uterus, distal, trocar, tubesNOTE,: 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 described procedure is a laparoscopic tubal fulguration, which is a form of permanent birth control involving the coagulation (or burning) of the fallopian tubes. While the procedure itself is routine and generally low risk when performed by trained professionals, it is still a surgical intervention with the potential for serious complications such as bleeding, infection, or injury to adjacent organs. Considering this is a medical procedure, there is a level of inherent risk involved, which elevates the stakes compared to non-medical situations. However, no complications occurred during this particular procedure, and the patient is stable. Therefore, while it is not life-threatening or extremely high-stakes, it still requires skilled execution and thorough post-operative care.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Tubal Ligation - Postpartum

PREOPERATIVE DIAGNOSES:,  Multiparity requested sterilization and upper abdominal wall skin mass., ,POSTOPERATIVE DIAGNOSES:  ,Multiparity requested sterilization and upper abdominal wall skin mass.,OPERATION PERFORMED: , Postpartum tubal ligation and removal of upper abdominal skin wall mass.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,DRAINS: , None.,ANESTHESIA: , Spinal.,INDICATION: , This is a 35-year-old white female gravida 6, para 3, 0-3-3 who is status post delivery on 09/18/2007.  The patient was requesting postpartum tubal ligation and removal of a large mole at the junction of her abdomen and left lower rib cage at the skin level.,PROCEDURE IN DETAIL:,  The patient was taken to the operating room, placed in a seated position with spinal form of anesthesia administered by anesthesia department.  The patient was then repositioned in a supine position and then prepped and draped in the usual fashion for postpartum tubal ligation.  Subumbilical ridge was created using two Ellis and first knife was used to make a transverse incision.  The Ellis were removed and used to be grasped incisional edges and both blunt and sharp dissection down to the level of the fascia was then completed.  The fascia grasped with two Kocher's and then sharply incised and then peritoneum was entered with use of blunt dissection.  Two Army-Navy retractors were put in place and a vein retractor was used to grasp the left fallopian tube and then regrasped with Babcock's and followed to the fimbriated end.  A modified Pomeroy technique was completed with double tying of with 0 chromic, then upper portion was sharply incised and the cut fallopian tube edges were then cauterized.  Adequate hemostasis was noted.  This tube was placed back in its anatomic position.  The right fallopian tube was grasped followed to its fimbriated end and then regrasped with a Babcock and a modified Pomeroy technique was also completed on the right side, and upper portion was then sharply incised and the cut edges re-cauterized with adequate hemostasis and this was placed back in its anatomic position.  The peritoneum as well as fascia was reapproximated with 0-Vicryl.  The subcutaneous tissues reapproximated with 3-0 Vicryl and skin edges reapproximated with 4-0 Vicryl as well in a subcuticular stitch.  Pressure dressings were applied.  Marcaine 10 mL was used prior to making an incision.  Sterile dressing was applied.  The large mole-like lesion was grasped with Allis.  It was approximately 1 cm x 0.5 cm in size and an elliptical incision was made around the mass and cut edges were cauterized and 4-0 Vicryl was used to reapproximate the skin edges and pressure dressing was also applied.  Instrument count, needle count, and sponge counts were all correct, and the patient was taken to recovery room in stable condition.
---
DESCRIPTION: Postpartum tubal ligation and removal of upper abdominal skin wall mass.

obstetrics / gynecology, sterilization, fallopian tube, tubal ligation, postpartum

The situation involves a surgical procedure, namely a postpartum tubal ligation and removal of a skin mass. While surgical procedures generally carry a degree of risk, this particular case seems to have been performed without complications: the estimated blood loss was minimal, all counts were correct, and the patient was stable post-operation. There are no indications from the provided details that this was an emergency, nor that it involved any life-threatening circumstances beyond the routine risks associated with surgery. Therefore, this context contains moderate stakes, typical for an elective sterilization with concurrent simple mass removal.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Total Abdominal Hysterectomy - Followup

POSTOPERATIVE DAY #1, TOTAL ABDOMINAL HYSTERECTOMY,SUBJECTIVE: , The patient is alert and oriented x3 and sitting up in bed.  The patient has been ambulating without difficulty.  The patient is still NPO.  The patient denies any new symptomatology from  6/10/2009.  The patient has complaints of incisional tenderness.  The patient was given a full explanation about her clinical condition and all her questions were answered.,OBJECTIVE:,VITAL SIGNS:  Afebrile now.  Other vital signs are stable.,GU:  Urinating through Foley catheter.,ABDOMEN:  Soft, negative rebound.,EXTREMITIES:  Without Homans, nontender.,BACK:  Without CVA tenderness.,GENITALIA:  Vagina, slight spotting.  Wound dry and intact.,ASSESSMENT:,  Normal postoperative course.,PLAN:,1.  Follow clinically.,2.  Continue present therapy.,3.  Ambulate with nursing assistance only.,
---
DESCRIPTION: Postoperative day #1, total abdominal hysterectomy.  Normal postoperative course.

obstetrics / gynecology, postoperative course, total abdominal hysterectomy, postoperative

The situation involves a postoperative assessment following a total abdominal hysterectomy, a common surgical procedure in obstetrics and gynecology. The patient is stable, alert, and oriented, with no major complications reported. The vital signs are stable, and the assessment indicates a normal postoperative course. The plan includes continuation of present therapy and assisted ambulation. While there is some incisional tenderness and slight spotting, these are typical postoperative findings that are being monitored. Therefore, the stakes are relatively low as there are no alarming signs or complications.


Medical Specialty: Obstetrics / Gynecology
Sample Name: True Cut Needle Biopsy - Breast

PREOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,POSTOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,PROCEDURE PERFORMED: , True cut needle biopsy of the breast.,GROSS FINDINGS:  ,This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.  At this time, a true cut needle biopsy was performed.,PROCEDURE: , The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion.  The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine.  Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion.  Hemostasis was controlled with pressure.  The patient tolerated the procedure well, pending the results of biopsy.
---
DESCRIPTION: True cut needle biopsy of the breast.  This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.

obstetrics / gynecology, carcinoma, true cut needle biopsy, nipple, discharge, dimpling, puckering, breast,

The situation involves a medical procedure for a patient with a preoperative diagnosis of breast carcinoma, which is a serious condition. The procedure is a true cut needle biopsy, which is critical for confirming the presence and extent of cancer, guiding treatment decisions. Thus, it impacts the patient's treatment plan and potential outcome.


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

Medical Specialty: Obstetrics / Gynecology
Sample Name: Total Abdominal Hysterectomy - 1

PREOPERATIVE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Anemia.,3.  Symptomatic fibroid uterus.,POSTOPERATIVE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Anemia.,3.  Symptomatic fibroid uterus.,PROCEDURE: , Total abdominal hysterectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS: , 150 mL.,COMPLICATIONS: , None.,FINDING:  ,Large fibroid uterus.,PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the usual sterile fashion for an abdominal procedure.  A scalpel was used to make a Pfannenstiel skin incision, which was carried down sharply through the subcutaneous tissue to the fascia.  The fascia was nicked in the midline and incision was carried laterally bilaterally with curved Mayo scissors.  The fascia was then bluntly and sharply dissected free from the underlying rectus abdominis muscles.  The rectus abdominis muscles were then bluntly dissected in the midline and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel.  The peritoneum was then bluntly entered and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel.  The O'Connor-O'Sullivan instrument was then placed without difficulty.  The uterus was grasped with a thyroid clamp and the entire pelvis was then visualized without difficulty.  The GIA stapling instrument was then used to separate the infundibulopelvic ligament in a ligated fashion from the body of the uterus.  This was performed on the left infundibulopelvic ligament and the right infundibulopelvic ligament without difficulty.  Hemostasis was noted at this point of the procedure.  The bladder flap was then developed free from the uterus without difficulty.  Careful dissection of the uterus from the pedicle with the uterine arteries and cardinal ligaments was then performed using #1 chromic suture ligature in an interrupted fashion on the left and right side.  This was done without difficulty.  The uterine fundus was then separated from the uterine cervix without difficulty.  This specimen was sent to pathology for identification.  The cervix was then developed with careful dissection.  Jorgenson scissors were then used to remove the cervix from the vaginal cuff.  This was sent to pathology for identification.  Hemostasis was noted at this point of the procedure.  A #1 chromic suture ligature was then used in running fashion at the angles and along the cuff.  Hemostasis was again noted.  Figure-of-eight sutures were then used in an interrupted fashion to close the cuff.  Hemostasis was again noted.  The entire pelvis was washed.  Hemostasis was noted.  The peritoneum was then closed using 2-0 chromic suture ligature in running pursestring fashion.  The rectus abdominis muscles were approximated using #1 chromic suture ligature in an interrupted fashion.  The fascia was closed using 0 Vicryl in interlocking running fashion.  Foundation sutures were then placed in an interrupted fashion for further closing the fascia.  The skin was closed with staple gun.  Sponge and needle counts were noted to be correct x2 at the end of the procedure.  Instrument count was noted to be correct x2 at the end of the procedure.  Hemostasis was noted at each level of closure.  The patient tolerated the procedure well and went to recovery room in good condition.
---
DESCRIPTION: Total abdominal hysterectomy..  Severe menometrorrhagia unresponsive to medical therapy, anemia, and symptomatic fibroid uterus.

obstetrics / gynecology, menometrorrhagia, fibroid, uterus, total abdominal hysterectomy, rectus abdominis muscles, fibroid uterus, suture ligature, therapy, hemostasis, anemia, abdominal,

The total abdominal hysterectomy is a major surgical procedure that involves the removal of the uterus and potentially the cervix, ovaries, and other surrounding tissues. The procedure is typically performed under general anesthesia and is used to address severe conditions such as menometrorrhagia, which is heavy and prolonged menstrual bleeding unresponsive to medical therapy, as well as fibroid-related symptoms and anemia. Although the procedure went well without complications in this case, it is high-stakes due to the inherent risks of major surgery, including potential for significant blood loss, infection, and other surgical complications. The successful outcome is reassuring, but the complexity and nature of the procedure justify its classification as high-stakes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Suction, Dilation, & Curettage - 1

PREOPERATIVE DIAGNOSIS: ,Incomplete abortion.,POSTOPERATIVE DIAGNOSIS: ,Incomplete abortion.,PROCEDURE PERFORMED:, Suction dilation and curettage.,ANESTHESIA:  ,General and nonendotracheal by Dr. X.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,SPECIMENS: , Endometrial curettings.,DRAINS: , None.,FINDINGS:  ,On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina.  There was a large amount of tissue obtained on the procedure.,PROCEDURE:  ,The patient was taken to the operating room where a general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  Next, a weighted speculum was placed in the vagina.  The anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm, no cervical dilation was needed.  A size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed.  Two passes were made with the suction curettage.  Next, a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus.  After the procedure, the vulsellum tenaculum was removed.  The cervix was seemed to be hemostatic.  The weighted speculum was removed.  The patient was given 0.25 mg of Methergine IM approximately half-way through the procedure.  After the procedure, a second bimanual exam was performed and the patient's uterus had significantly decreased in size.  It is now approximately eight to ten-week size.  The patient was taken from the operating room in stable condition after she was cleaned.  She will be discharged on today.  She was given Methergine, Motrin, and doxycycline for her postoperative care.  She will follow-up in one week in the office.
---
DESCRIPTION: Suction dilation and curettage for incomplete abortion.  On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina.  There was a large amount of tissue obtained on the procedure.

obstetrics / gynecology, uterus, anteverted, dorsal lithotomy position, weighted speculum, mobile uterus, vulsellum tenaculum, bimanual exam, vagina, tenaculum, dilation, bimanual, cervix, suction, curettage,

The situation involves an obstetrics/gynecology procedure for treating an incomplete abortion through suction dilation and curettage. This is a common and necessary medical procedure to prevent complications like heavy bleeding or infection. The procedure is routine in obstetrics but should be handled with care and precision due to the potential risks involved with any surgical procedure, such as infection, excessive bleeding, or anesthesia-related issues. Additionally, the emotional implications for the patient must be considered. Hence, while the procedure itself is standard and typically safe, the potential for complications and the need for careful management make it moderately high-stakes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: TAH & Salpingooophorectomy

PREOPERATIVE DIAGNOSES:,1.  Cervical intraepithelial neoplasia grade-III status post conization with poor margins.,2.  Recurrent dysplasia.,3.  Unable to follow in office.,4.  Uterine procidentia grade II-III.,POSTOPERATIVE DIAGNOSES:,1.  Cervical intraepithelial neoplasia grade-III postconization.,2.  Poor margins.,3.  Recurrent dysplasia.,4.  Uterine procidentia grade II-III.,5.  Mild vaginal vault prolapse.,PROCEDURES PERFORMED:,1.  Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy.,2.  Uterosacral ligament vault suspension.,ANESTHESIA: , General and spinal with Astramorph for postoperative pain.,ESTIMATED BLOOD LOSS: , Less than 100 cc.,FLUIDS:  ,2400 cc.,URINE: , 200 cc of clear urine output.,INDICATIONS:  ,This patient is a 57-year-old nulliparous female who desires definitive hysterectomy for history of cervical intraepithelial neoplasia after conization and found to have poor margins.,FINDINGS:  ,On bimanual examination, the uterus was found to be small.  There were no adnexal masses appreciated.  Intraabdominal findings revealed a small uterus approximately 2 cm in size.  The ovaries were atrophic consistent with menopause.  The liver margins and stomach were palpated and found to be normal.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the operating suite and administered a spinal anesthesia for postoperative pain control.  She was then placed in the dorsal lithotomy position and administered general anesthesia.  She was then prepped and draped in the sterile fashion and an indwelling Foley catheter was placed in her bladder.  At this point, the patient was evaluated for a possible vaginal hysterectomy.  She was nulliparous and the pelvis was narrow.  After the anesthesia was administered, the patient was repeatedly stooling and therefore because of these two reasons, the decision was made to do an abdominal hysterectomy.  After the patient was prepped and draped, a Pfannenstiel skin incision was made approximately 2 cm above the pubic symphysis.  The second scalpel was used to dissect out to the underlying layer of fascia.  The fascia was incised in the midline and extended laterally using the Mayo scissors.  The superior aspect of the rectus fascia was grasped with Ochsners, tented up and underlying layer of rectus muscle was dissected off bluntly as well as with Mayo scissors.  In a similar fashion, the inferior portion of the rectus fascia was tented up, dissected off bluntly as well as with Mayo scissors.  The rectus muscle was then separated bluntly in the midline and the peritoneum was identified and entered with the Metzenbaum.  The peritoneal incision was extended superiorly and inferiorly with good visualization of the bladder.  At this point, the above findings were noted and the GYN Balfour retractor was placed.  Moist laparotomy sponges were used to pack the bowel out of the operative field.  The bladder blade and the extension for the retractor were then placed.  An Allis was used on the uterus for retraction.  The round ligaments were then identified, clamped with two hemostats and transected and then suture ligated.  The anterior portion of the broad ligament was dissected along vesicouterine resection.  The bladder was then dissected off the anterior cervix and vagina without difficulty.  The infundibulopelvic ligaments on both sides were then doubly clamped using hemostats, transected and suture ligated with #0 Vicryl suture.  The uterine vessels on both sides were skeletonized and clamped with two hemostats and transected and suture ligated with #0 Vicryl.  Good hemostasis was assured.  The cardinal ligaments on both sides were clamped using a curved hemostat, transected and suture ligated with #0 Vicryl.  Good hemostasis was obtained.  Two hemostats were then placed just under the cervix meeting in the midline.  The uterus and cervix were then _______ off using a scalpel.  This was handed and sent to Pathology for evaluation.  Using #0 Vicryl suture, the right vaginal cuff angle was closed and affixed to the ipsilateral cardinal ligament.  A baseball stitch was then used to close the cuff to the midline.  The same was done to the left vaginal cuff angle, which was affixed to the ipsilateral and cardinal ligaments.  The baseball stitch was used to close the cuff to the midline.  The hemostats were removed and the cuff was closed and good hemostasis was noted.  The uterosacral ligaments were also transfixed to the cuff and brought out for good support by using a #0 Vicryl suture through each uterosacral ligament and incorporating this into the vaginal cuff.  The pelvis was then copiously irrigated with warm normal saline.  Good support and hemostasis was noted.  The bowel packing was then removed and the GYN Balfour retractor was moved.  The peritoneum was then repaired with #0 Vicryl in a running fashion.  The fascia was then closed using #0 Vicryl in a running fashion, marking the first stitch and first last stitch in a lateral to medial fashion.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular closure and an Op-Site was placed over this.  The patient was then brought out of general anesthesia and extubated.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She will follow up postoperatively as an inpatient.
---
DESCRIPTION: Total abdominal hysterectomy (TAH) with bilateral salpingooophorectomy and uterosacral ligament vault suspension.  Cervical intraepithelial neoplasia grade-III postconization.  Recurrent dysplasia.  Uterine procidentia grade II-III.  Mild vaginal vault prolapse.

obstetrics / gynecology, cervical intraepithelial neoplasia, vaginal vault prolapse, uterosacral ligament vault suspension, total abdominal hysterectomy, bilateral salpingooophorectomy, abdominal hysterectomy, uterosacral ligament, recurrent dysplasia, uterine procidentia, suture ligated, abdominal, intraepithelial, tah, salpingooophorectomy, hysterectomy, ligament, hemostats, vaginal,

The situation involves a medical procedure, specifically a total abdominal hysterectomy with bilateral salpingooophorectomy, which is a significant surgical intervention. The patient has a complex medical history with cervical intraepithelial neoplasia Grade III, recurrent dysplasia, and uterine procidentia Grade II-III. The stakes are high as surgical interventions always carry potential risks, such as complications during surgery, recovery issues, and the severity of the pre-existing conditions. These factors make it a high-stakes scenario, as the outcome directly impacts the patient's health and recovery.


Medical Specialty: Obstetrics / Gynecology
Sample Name: TAH - Discharge Summary

ADMISSION DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Symptomatic fibroid uterus.,DISCHARGE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Symptomatic fibroid uterus.,4.  Extensive adenomyosis by pathological report.,OPERATION PERFORMED: , On 6/10/2009 total abdominal hysterectomy (TAH).,COMPLICATIONS:,  None.,BLOOD TRANSFUSIONS: , None.,INFECTIONS: , None.,SIGNIFICANT LAB AND X-RAY: , On admission hemoglobin and hematocrit was 10.5 and 32.8 respectively.  On discharge, hemoglobin and hematocrit 7.9 and 25.2.,HOSPITAL COURSE AND TREATMENT:  ,The patient was admitted to the surgical suite and taken to the operating room on 6/10/2009 where a total abdominal hysterectomy (TAH) with low intraoperative complication was performed.  The patient tolerated all procedures well.  On the 1st postoperative day, the patient was afebrile and all vital signs were stable.  On the 3rd postoperative day, the patient was ambulating with difficulty and tolerating clear liquid diet.  On the 4th postoperative day, the patient was complaining of pain in her back and abdomen as well as incisional wound tenderness.  On the 5th postoperative day, the patient was afebrile.  Vital signs were stable.  The patient was tolerating a diet and ambulating without difficulty.  The patient was desirous of going home.  The patient denied any abdominal pain or flank pain.  The patient had minimal incisional wound tenderness.  The patient was desirous of going home and was discharged home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:,  Regular diet, bedrest x1 week with slow return to normal activity over the ensuing 4 to 6 weeks, pelvic rest for 6 weeks.  Motrin 600 mg tablets 1 tablet p.o. q.8h. p.r.n. pain, Colace 100 mg tablets 1 tablet p.o. daily p.r.n. constipation and ferrous sulfate 60 mg tablets 1 tablet p.o. daily, and multiple vitamin 1 tablet p.o. daily.  The patient is to return on Wednesday 6/17/2009 for removal of staples.  The patient was given a full explanation of her clinical condition.  The patient was given full and complete postoperative and discharge instructions.  All her questions were answered.
---
DESCRIPTION: Total abdominal hysterectomy (TAH).  Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and symptomatic fibroid uterus.

obstetrics / gynecology, adenomyosis, total abdominal hysterectomy, fibroid uterus, postoperative day, hemoglobin, hematocrit, therapy, menometrorrhagia, anemia, fibroid, uterus, tah, hysterectomy, abdominal,

The situation involves a patient who underwent a total abdominal hysterectomy due to severe menometrorrhagia, severe anemia, and symptomatic fibroid uterus. Despite the severity of the conditions requiring surgery, the discharge summary indicates no complications, no blood transfusions, and no infections, which demonstrates a relatively positive outcome. Post-operative recovery seems to be progressing normally, based on the vitals and patient's discharge condition being stable. While this is a significant medical procedure with the potential for serious complications, the report reflects successful management and recovery. The patient is discharged with straightforward instructions, indicating no immediate high-risk issues post-surgery. Therefore, this situation doesn't seem to entail extremely high-stakes as the acute risks have been managed effectively.


Medical Specialty: Obstetrics / Gynecology
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.
---
DESCRIPTION: Total abdominal hysterectomy (TAH) and left salpingo-oophorectomy.  Hypermenorrhea, uterine fibroids, pelvic pain, left adnexal mass, and pelvic adhesions.

The procedure described is a total abdominal hysterectomy and left salpingo-oophorectomy, which are major surgeries typically performed to address significant health concerns such as hypermenorrhea, uterine fibroids, and ovarian masses. These conditions can cause substantial discomfort and affect quality of life, and the surgical procedure carries inherent risks due to the complexity and need for general anesthesia. However, the procedure was completed without complications, and the patient was stable post-operation. This context makes the stakes moderately high as it involves significant surgical intervention and potential impacts on the patient's health and well-being.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Spontaneous Vaginal Delivery

PREOPERATIVE DIAGNOSIS: , Term pregnancy at 40 and 3/7th weeks.,PROCEDURE PERFORMED: , Spontaneous vaginal delivery.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 36-year-old African-American female who is a G-2, P-2-0-0-2 with an EDC of 08/30/2003.  She is blood type AB -ve with antibody screen negative and is also rubella immune, VDRL nonreactive, hepatitis B surface antigen negative, and HIV nonreactive.  She does have a history of sickle cell trait.  She presented to Labor and Delivery Triage at 40 and 3/7th weeks gestation with complaint of contractions every ten minutes.  She also stated that she has lost her mucous plug.  She did have fetal movement, noted no leak of fluid, did have some spotting.  On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.  She was evaluated by sterile vaginal exam and was noted to be 4 cm dilated, 70% effaced, and -3 station.  This was a change from her last office exam, at which she was 1 cm to 2 cm dilated.,PROCEDURE DETAILS:,  The patient was admitted to Labor and Delivery for expected management of labor and AROM was performed and the amniotic fluid was noted to be meconium stained.  After her membranes were ruptured, contractions did increase to every two to three minutes as well as the intensity increased.  She was given Nubain for discomfort with good result.,She had a spontaneous vaginal delivery of a live born female at 11:37 with meconium stained fluid as noted from ROA position.  After controlled delivery of the head, tight nuchal cord was noted, which was quickly double clamped and cut and the shoulders and body were delivered without difficulty.  The infant was taken to the awaiting pediatrician.  Weight was 2870 gm, length was 51 cm.  The Apgars were 6 at 1 minute and 9 at 5 minutes.  There was initial neonatal depression, which was treated by positive pressure ventilation and the administration of Narcan.,Spontaneous delivery of an intact placenta with a three-vessel cord was noted at 11:45.  On examination, there were no noted perineal abrasions or lacerations.  On vaginal exam, there were no noted cervical or vaginal sidewall lacerations.  Estimated blood loss was less than 250 cc.  Mother and infant are in recovery doing well at this time.
---
DESCRIPTION: Spontaneous vaginal delivery.   Term pregnancy at 40 and 3/7th weeks.  On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.

obstetrics / gynecology, roa position, arom, labor and delivery, spontaneous vaginal delivery, term pregnancy, contracting, meconium, lacerations, pregnancy, contractions, vaginal,

The situation involves the delivery of a baby, which is inherently high-stakes due to the potential risks to both the mother and the newborn. This particular case includes some concerns, such as meconium-stained amniotic fluid, a tight nuchal cord, and initial neonatal depression requiring intervention. However, the delivery was ultimately successful, and both mother and baby are doing well. Nevertheless, childbirth often involves potential complications, making it a high-stakes scenario.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Radical Hysterectomy

PREOPERATIVE DIAGNOSIS:,  Cervical adenocarcinoma, stage I.,POSTOPERATIVE DIAGNOSIS: , Cervical adenocarcinoma, stage I.,OPERATION PERFORMED:,  Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Uterus with attached parametrium and upper vagina, right and left pelvic and obturator lymph nodes.,INDICATIONS FOR PROCEDURE:,  The patient recently underwent a cone biopsy at which time invasive adenocarcinoma of the cervix was noted.  She was advised regarding treatment options including radical hysterectomy versus radiation and the former was recommended. ,FINDINGS: , During the examination under anesthesia, the cervix was noted to be healing well from recent cone biopsy and no nodularity was noted in the supporting ligaments.  During the exploratory laparotomy, there was no evidence of disease extension into the broad ligament or bladder flap.  There was no evidence of intraperitoneal spread or lymphadenopathy.  ,OPERATIVE PROCEDURE:  ,The patient was brought to the Operating Room with an IV in place.  Anesthetic was administered after which she was examined under anesthesia.  The vagina was then prepped and a Foley catheter was placed.  She was prepped and draped.  A Pfannenstiel incision was made three centimeters above the symphysis pubis.  The peritoneum was entered and the abdomen was explored with findings as noted.  The Bookwalter retractor was placed, and bowel was packed.  Clamps were placed on the broad ligament for traction.  The retroperitoneum was opened by incising lateral and parallel to the infundibulopelvic ligaments.  The round ligaments were isolated, divided and ligated.  The peritoneum overlying the vesicouterine fold was incised, and the bladder was mobilized using sharp dissection.  The pararectal and paravesical spaces were opened, and the broad ligament was palpated with no evidence of suspicious findings or disease extension.  The utero-ovarian ligaments were then isolated, divided and doubly ligated.  Tubes and ovaries were mobilized.  The ureters were dissected free from the medial leaf of the peritoneum.  When the crossover of the uterine artery was reached, and the artery was isolated at its origin, divided and ligated.  The uterine artery pedicle was dissected anteriorly over the ureter.  The ureter was tunneled through the broad ligament using right angle clamps for tunneling after which each pedicle was divided and ligated.  This was continued until the insertion point of the ureter into the bladder trigone.  The peritoneum across the cul-de-sac was divided, and the rectovaginal space was opened.  Clamps were placed on the uterosacral ligaments at their point of origin.  Tissues were divided and suture ligated.  Clamps were placed on the paravaginal tissues, which were then divided, and suture ligated.  The vagina was then clamped and divided at the junction between the middle and upper third.  The vaginal vault was closed with interrupted figure-of-eight stitches.  Excellent hemostasis was noted.,Retractors were repositioned in the retroperitoneum for the lymphadenectomy.  The borders of dissection included the bifurcation of the common iliac artery superiorly, the crossover of the deep circumflex iliac vein over the external iliac artery inferiorly, the psoas muscle laterally and the anterior division of the hypogastric artery medially.  The obturator nerves were carefully isolated and preserved bilaterally and served as the posterior border of dissection.  Ligaclips were applied where necessary.  After removal of the lymph node specimens, the pelvis was irrigated.  The ovaries were transposed above the pelvic brim using running stitches.  Packs and retractors were removed, and peritoneum was closed with a running stitch.  Subcutaneous tissues were irrigated, and fascia was closed with a running mass stitch using delayed absorbable suture.  Subcutaneous adipose was irrigated, and Scarpa's fascia was closed with a running stitch.  Skin was closed with a running subcuticular stitch.  Final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was awakened from the anesthetic and taken to the Post Anesthesia Care Unit in stable condition.
---
DESCRIPTION: Exploratory laparotomy, radical hysterectomy, bilateral ovarian transposition, pelvic and obturator lymphadenectomy.

obstetrics / gynecology, cervical adenocarcinoma, radical hysterectomy, exploratory laparotomy, bilateral ovarian transposition, lymphadenectomy, parametrium, cervix, pelvic and obturator lymphadenectomy, pelvic and obturator, obturator lymphadenectomy, laparotomy, ovarian, adenocarcinoma, radical, hysterectomy, pelvic, obturator, peritoneum, nodes, ligaments

This medical procedure involves a radical hysterectomy to treat cervical adenocarcinoma, which is a serious condition requiring major surgical intervention. It is a high-stakes situation due to the complexity of the surgery, the risks involved such as potential complications during or after surgery, potential impact on the patient's life including fertility and hormonal changes, and the importance of successful cancer treatment. The stakes are elevated by the nature of the disease (cervical cancer) and the detailed and invasive nature of the procedure, which includes lymphadenectomy and ovarian transposition. Because this involves serious health implications and major surgery, it is considered to be high-stakes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Physical Exam and Pap -2

SUBJECTIVE:,  The patient is a 68-year-old white female who presents for complete physical, Pap and breast exam.  Her last Pap smear was 05/02/2002.  Her only complaint is that she has had some occasional episodes of some midchest pain that seems to go to her back, usually occurs at rest.  Has awakened her at night on occasion and only last about 15 to 20 minutes.  Denies nausea, vomiting, diaphoresis or shortness of breath with it.  This has not happened in almost two months.  She had a normal EKG one year ago.  Otherwise, has been doing quite well.  Did quite well with her foot surgery with Dr. Clayton.,PAST MEDICAL HISTORY:,  Reactive airway disease; rheumatoid arthritis, recent surgery on her hands and feet; gravida 4, para 5, with one set of twins, all vaginal deliveries; iron deficiency anemia; osteoporosis; and hypothyroidism.,MEDICATIONS:,  Methotrexate 2.5 mg five weekly, Fosamax 70 mg weekly, folic acid daily, amitriptyline 15 mg daily, Synthroid 0.088 mg daily, calcium two in the morning and two at noon, multivitamin daily, baby aspirin daily and Colace one to three b.i.d.,ALLERGIES:,  None.,SOCIAL HISTORY:,  She is married.  Denies tobacco, alcohol and drug use.  She is not employed outside the home.,FAMILY HISTORY: , Unremarkable.,REVIEW OF SYSTEMS:,  HEENT, pulmonary, cardiovascular, GI, GU, musculoskeletal, neurologic, dermatologic, constitutional and psychiatric are all negative except for HPI.,OBJECTIVE:,Vital Signs:  Weight 146.  Blood pressure 100/64.  Pulse 80.  Respirations 16.  Temperature 97.7.,General:  She is a well-developed, well-nourished white female in no acute distress.,HEENT:  Grossly within normal limits.,Neck:  Supple.  No lymphadenopathy.  No thyromegaly.,Chest:  Clear to auscultation bilaterally.,Cardiovascular:  Regular rate and rhythm.,Abdomen:  Positive bowel sounds, soft and nontender.  No hepatosplenomegaly.,Breasts:  No nipple discharge.  No lumps or masses palpated.  No dimpling of the skin.  No axillary lymph nodes palpated.  Self-breast exam discussed and encouraged.,Pelvic:  Normal female genitalia.  Atrophic vaginal mucosa.  No cervical lesions.  No cervical motion tenderness.  No adnexal tenderness or masses palpated.,Rectal:  Normal sphincter tone.  No stool present in the vault.  No rectal masses palpated.,Extremities:  No cyanosis, clubbing or edema.  She does have obvious rheumatoid arthritis of her hands.,Neurologic:  Grossly intact.,ASSESSMENT/PLAN:,1.  Chest pain.  The patient will evaluate when it happens next; what she has been eating, what activities she has been performing.  She had normal ECG one year ago.  In fact this does not sound cardiac in nature.  We will not do further cardiac workup at this time.  Did discuss with her she may be having some GI reflux type symptoms.,2.  Hypothyroidism.  We will recheck TSH to make sure she is on the right amount of medication at this time, making adjustments as needed.,3.  Rheumatoid arthritis.  Continue her methotrexate as prescribed by Dr. Mortensen, and follow up with Dr. XYZ as needed.,4.  Osteoporosis.  It is time for her to have a repeat DEXA at this time and that will be scheduled.,5.  Health care maintenance, Pap smear was obtained today.  The patient will be scheduled for mammogram.
---
DESCRIPTION: A white female who presents for complete physical, Pap and breast exam.

The situation described is not particularly high-stakes. The patient is undergoing routine exams (Pap smear, breast exam) and her main complaint, occasional chest pain, was assessed and not deemed cardiac in nature based on a previous normal EKG. Moreover, the chest pain has not occurred in two months. Her other conditions, such as hypothyroidism, rheumatoid arthritis, and osteoporosis, are being managed with medication and routine monitoring. The plan includes routine follow-ups and testing for ongoing health maintenance. There are no acute issues or immediate life-threatening conditions.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Pelvic Laparotomy

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

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

The situation described involves a surgical procedure in the field of obstetrics and gynecology, specifically a pelvic laparotomy, lysis of pelvic adhesions, and a salpingo-oophorectomy due to an ovarian mass that was suspected to be neoplastic. The stakes are relatively high due to the potential for complications in surgery, the initial concern for malignancy, and the necessity of removing an adnexal mass. Nonetheless, it appears that the outcome was favorable, with a benign diagnosis and minimal blood loss. Overall, while there are inherent risks and the matter is critical for the patient's health, the procedure itself is not uncommon in this field, making it moderately high-stakes rather than extremely high-stakes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: MRI Breast - 1

FINDINGS:,There are post biopsy changes seen in the retroareolar region, middle third aspect of the left breast at the post biopsy site.,There is abnormal enhancement seen in this location compatible with patient’s history of malignancy.,There is increased enhancement seen in the inferior aspect of the left breast at the 6:00 o’clock, N+5.5 cm position measuring 1.2 cm. Further work-up with ultrasound is indicated.,There are other multiple benign appearing enhancing masses seen in both the right and left breasts.,None of the remaining masses appear worrisome for malignancy based upon MRI criteria.,IMPRESSION:,  BIRADS CATEGORY M/5,There is a malignant appearing area of enhancement in the left breast which does correspond to the patient’s history of recent diagnosis of malignancy.,She has been scheduled to see a surgeon, as well as Medical Oncologist.,Dedicated ultrasonography of the inferior aspect of the left breast should be performed at the 6:00 o’clock, N+5.5 cm position for further evaluation of the mass. At that same time, ultrasonography of the remaining masses should also be performed.,Please note, however that the remaining masses have primarily benign features based upon MRI criteria. However, further evaluation with ultrasound should be performed.
---
DESCRIPTION: Bilateral breast MRI with & without IV contrast.

obstetrics / gynecology, breast cancer, bilateral breast mri, bilateral breast, iv contrast, contrast, ultrasound, ultrasonography, malignancy, mri, benign, masses, breast

The situation involves a medical imaging report with findings that suggest malignancy in the breast, which corresponds to the patient's recent diagnosis of malignancy. The presence of a BIRADS CATEGORY M/5 is a high-risk indicator for breast cancer. Additionally, the patient is scheduled to see a surgeon and a medical oncologist, which indicates that immediate and precise medical action is needed. The potential for cancer and the need for further diagnostic procedures elevate the stakes considerably.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Lysis of Pelvic Adhesions

PREOPERATIVE DIAGNOSIS: , Multiple pelvic adhesions.,POSTOPERATIVE DIAGNOSIS: , Multiple pelvic adhesions.,PROCEDURE PERFORMED: ,Lysis of pelvic adhesions.,ANESTHESIA: , General with local.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY: , The patient is a 32-year-old female who had an 8 cm left ovarian mass, which was evaluated by Dr. X.  She had a ultrasound, which demonstrated the same.  The mass was palpable on physical examination and was tender.  She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy.  During the surgery, there were multiple pelvic adhesions between the left ovarian cyst and the sigmoid colon.  These adhesions were taken down sharply with Metzenbaum scissors.,PROCEDURE: , A pelvic laparotomy had been performed by Dr. X.  Upon exploration of the abdomen, multiple pelvic adhesions were noted as previously stated.  A 6 cm left ovarian cyst was noted with adhesions to the sigmoid colon and mesentery.  These adhesions were taken down sharply with Metzenbaum scissors until the sigmoid colon was completely freed from the ovarian cyst.  The ureter had been identified and isolated prior to the adhesiolysis.  There was no evidence of bleeding.  The remainder of the case was performed by Dr. X and this will be found in a separate operative report.
---
DESCRIPTION: Lysis of pelvic adhesions.  The patient had an 8 cm left ovarian mass.   The mass was palpable on physical examination and was tender.  She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy.

obstetrics / gynecology, lysis of pelvic adhesions, pelvic adhesions, pelvic, adhesions, salpingooophorectomy, lysis, laparotomy, sigmoid, colon, mass, ovarian,

The procedure described involves an elective surgery, which typically implies a situation with some flexibility and planning rather than an emergency. Elective pelvic laparotomies are important and require expertise, especially when dealing with structures like the sigmoid colon and ureter, but they are not uncommon. The situation details that there were no complications, and there was no evidence of bleeding, which reduces the immediate severity. However, given the complexity of pelvic surgeries and the involvement of vital structures, some risk and significance are inherent, making it moderately high-stakes but not extremely so due to the elective nature and absence of complications.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Low-Transverse C-Section & BTL - 1

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 30 and 4/7th weeks.,2.  Previous cesarean section x2.,3.  Multiparity.,4.  Request for permanent sterilization.,POSTOPERATIVE DIAGNOSIS:,1.  Intrauterine pregnancy at 30 and 4/7th weeks.,2.  Previous cesarean section x2.,3.  Multiparity.,4.  Request for permanent sterilization.,5.  Breach presentation in the delivery of a liveborn female neonate.,PROCEDURES PERFORMED:,1.  Repeat low transverse cesarean section.,2.  Bilateral tubal ligation (BTL).,TUBES: , None.,DRAINS: , Foley to gravity.,ESTIMATED BLOOD LOSS: , 600 cc.,FLUIDS:,  200 cc of crystalloids.,URINE OUTPUT:,  300 cc of clear urine at the end of the procedure.,FINDINGS:,  Operative findings demonstrated a wire mesh through the anterior abdominal wall and the anterior fascia.  There were bowel adhesions noted through the anterior abdominal wall.  The uterus was noted to be within normal limits.  The tubes and ovaries bilaterally were noted to be within normal limits.  The baby was delivered from the right sacral anterior position without any difficulty.  Apgars 8 and 9.  Weight was 7.5 lb.,INDICATIONS FOR THIS PROCEDURE:  ,The patient is a 23-year-old G3 P 2-0-0-2 with reported 30 and 4/7th weeks' for a scheduled cesarean section secondary to repeat x2.  She had her first C-section because of congenial hip problems.  In her second C-section, baby was breached, therefore, she is scheduled for a third C-section.  The patient also requests sterilization.  Therefore, she requested a tubal ligation.,PROCEDURE: , After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where a spinal with Astramorph anesthesia was obtained without any difficulty.  She was placed in the dorsal supine position with a leftward tilt and prepped and draped in the usual sterile fashion.  A Pfannenstiel skin incision was made removing the old scar with a first knife and then carried down to the underlying layer of fascia with a second knife.  The fascia was excised in the midline extended laterally with the Mayo scissors.  The superior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply with the Metzenbaum scissors.  There was noted dense adhesions at this point as well as a wire mesh was noted.  The anterior aspect of the fascial incision was then tented up with Ochsner clamps and the underlying rectus muscle dissected off sharply as well as bluntly.  The rectus muscle superiorly was opened with a hemostat.  The peritoneum was identified and entered bluntly digitally.  The peritoneal incision was then extended superiorly up to the level of the mesh.  Then, inferiorly using the knife, the adhesions were taken down and the bladder was identified and the peritoneum incision extended inferiorly to the level of the bladder.  The bladder blade was inserted and vesicouterine peritoneum was identified and tented up with Allis clamps and bladder flap was created sharply with the Metzenbaum scissors digitally.  The bladder blade was then reinserted to protect the bladder and the uterine incision was made with a first knife and then extended laterally with the Bandage scissors.  The amniotic fluid was noted to be clear.  At this point, upon examining the intrauterine contents, the baby was noted to be breached.  The right foot was identified and then the baby was delivered from the double footling breach position without any difficulty.  The cord was clamped and the baby was then handed off to awaiting pediatricians.  The placenta cord gases were obtained and the placenta was then manually extracted from the uterus.  The uterus was exteriorized and cleared of all clots and debris.  Then, the uterine incision was then closed with #0 Vicryl in a double closure stitch fashion, first layer in locking stitch fashion and the second layer an imbricating layer.  Attention at this time was turned to the tubes bilaterally.,Both tubes were isolated and followed all the way to the fimbriated end and tented up with the Babcock clamp.  The hemostat was probed through the mesosalpinx in the avascular area and then a section of tube was clamped off with two hemostats and then transected with the Metzenbaum scissors.  The ends was then burned with the cautery and then using a #2-0 Vicryl suture tied down.  Both tube sections were noted to be hemostatic and the tubes were then sent to pathology for review.  The uterus was then replaced back into the abdomen.  The gutters were cleared of all clots and debris.  The uterine incision was then once again inspected and noted to be hemostatic.  The bladder flap was then replaced back into the uterus with #3-0 interrupted sutures.  The peritoneum was then closed with #3-0 Vicryl in a running fashion.  Then, the area at the fascia where the mesh had been cut and approximately 0.5 cm portion was repaired with #3-0 Vicryl in a simple stitch fashion.  The fascia was then closed with #0 Vicryl in a running fashion.  The subcutaneous layer and Scarpa's fascia were repaired with a #3-0 Vicryl.  Then, the skin edges were reapproximated using sterile clips.  The dressing was placed.  The uterus was then cleared of all clots and debris manually.  Then, the patient tolerated the procedure well.  Sponge, lap, and needle, counts were correct x2.  The patient was taken to recovery in sable condition.  She will be followed up throughout her hospital stay.
---
DESCRIPTION: Repeat low transverse cesarean section and bilateral tubal ligation (BTL).   Intrauterine pregnancy at 30 and 4/7th weeks, previous cesarean section x2, multiparity, request for permanent sterilization, and breach presentation in the delivery of a liveborn female neonate.

The situation involves a complex surgical procedure, a repeat cesarean section with bilateral tubal ligation, to address both an intrauterine pregnancy and a request for permanent sterilization, all occurring at preterm gestation of 30 and 4/7 weeks. The stakes are high due to multiple factors: the surgery occurs at an early gestational age, involves surgical risks associated with a C-section and sterilization, previous surgeries (with two prior C-sections), and the necessity to manage a breach presentation in the delivery. Moreover, there is a history of surgical complications (adhesions, mesh), increasing the procedure's complexity. The likelihood of surgical complications such as excessive bleeding, infection, and challenges associated with the surgical history (e.g., wire mesh, adhesions) presents potential high-stakes implications for the mother and the neonate's health. Successful outcomes can impact both the immediate and long-term health of both mother and child.