Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy

PREOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1.  Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2.  Bilateral C6 nerve root decompression.,3.  Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4.  Bilateral C5 nerve root decompression.,5.  Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6.  Bilateral C4 nerve root decompression.,7.  Harvesting of autologous bone from the vertebral bodies.,8.  Grafting of allograft bone for creation of arthrodesis.,9.  Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12.  Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6.  There was a herniated disk with cord compression and radiculopathy at C4-C5.  C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels.  Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives.  He clearly understands and has no further questions and requests that I proceed.,PROCEDURE:  ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease.  Dissection was carried down through the platysma musculature and the anterior spine was exposed.  The medial borders of the longus colli muscle were dissected free from their attachments to the spine.  Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained.  A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space.  The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies.  The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament.  The ligament was incised and the underlying dura was exposed.  I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen.  There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact.  However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right.  The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5.  I worked down through bony osteophytes and identified the posterior longitudinal ligament.  The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces.  The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen.  The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it.  Again the microscope was angled to the left side where similar decompression was achieved.  Central decompression was achieved here where there was a moderate amount of spinal cord compression.  This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space.  Here there were large osteophytes projecting posteriorly against the cord.  I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord.  This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord.  I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right.  The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis.  A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration.  Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis.  Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4.  Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge.  I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks.  The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described.  An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation.  Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate.  The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush.  The holes were drilled and the screws were placed.  Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6.  All eight screws had good purchase.  The locking screws were tightly applied.  An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure.  The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained.  A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct.  There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.
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DESCRIPTION: Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression.  Harvesting of autologous bone from the vertebral bodies.  Grafting of allograft bone for creation of arthrodesis.

The document describes an anterior cervical discectomy, a high-stakes surgical procedure that involves decompression of the spinal cord and nerve roots. Any operation involving the spinal cord is high-stakes due to potential complications, such as neurological damage or paralysis. Additionally, the procedure includes multiple levels of discectomy and fusion, adding complexity and risk. The stakes are further heightened by the patient's pre-existing conditions, such as cervical spondylosis with myelopathy, which increase the need for precision and caution. While the procedure is routine for spinal surgeons, it remains high-stakes due to the potential for severe outcomes if complications occur.


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

Medical Specialty: Surgery
Sample Name: Angiography & Catheterization - 1

INDICATION:,  Acute coronary syndrome.,CONSENT FORM: , The procedure of cardiac catheterization/PCI risks included but not restricted to death, myocardial infarction, cerebrovascular accident, emergent open heart surgery, bleeding, hematoma, limb loss, renal failure requiring dialysis, blood loss, infection had been explained to him.  He understands.  All questions answered and is willing to sign consent.,PROCEDURE PERFORMED:,  Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.,NARRATIVE: , The patient was brought to the cardiac catheterization laboratory in a fasting state.  Both groins were draped and sterilized in the usual fashion.  Local anesthesia was achieved with 2% lidocaine to the right groin area and a #6-French femoral sheath was inserted via modified Seldinger technique in the right common femoral artery.  Selective coronary angiography was performed with #6 French JL4 catheter for the left coronary system and a #6 French JR4 catheter of the right coronary artery.  Left ventricular catheterization and angiography was performed at the end of the procedure with a #6-French angle pigtail catheter.,FINDINGS,1.  Hemodynamics systemic blood pressure 140/70 mmHg.  LVEDP at the end of the procedure was 13 mmHg.,2.  The left main coronary artery is a large with mild diffuse disease in the distal third resulting in less than 20% angiographic stenosis at the take off of the left circumflex artery.  The left circumflex artery is a large caliber vessel with diffuse disease in the ostium of the proximal segment resulting in less than 30% angiographic stenosis.  The left circumflex artery gives rise to a high small obtuse marginal branch that has high moderate-to-severe ostium.  The rest of the left circumflex artery has mild diffuse disease and it gives rise to a second large obtuse marginal branch that bifurcates into an upper and lower trunk.,The LAD is calcified and diffusely disease in the proximal and mid portion.  There is mild nonobstructive disease in the proximal LAD resulting in less than 20% angiographic stenosis.,3.  The right coronary artery is dominant.  It is septal to be occluded in the mid portion.,The findings were discussed with the patient and she opted for PCI.  Angiomax bolus was started.  The ACT was checked.  It was higher in 300.  I have given the patient 600 mg of oral Plavix.,The right coronary artery was engaged using a #6-French JR4 guide catheter.  I was unable to cross through this lesion using a BMW wire and a 3.0x8 mm balloon support.  I was unable to cross with this lesion using a whisper wire.  I was unable to cross with this lesion using Cross-IT 100 wire.  I have also used second #6-French Amplatz right I guide catheter.  At one time, I have lost flow in the distal vessel.  The patient experienced severe chest pain, ST-segment elevation, bradycardia, and hypotension, which responded to intravenous fluids and atropine along with intravenous dopamine.,Dr. X was notified.,Eventually, an Asahi grand slam wire using the same 3.0 x 8 mm Voyager balloon support, I was able to cross into the distal vessel.  I have performed careful balloon angioplasty of the mid RCA.  I have given nitroglycerin under the nursing several times during the procedure.,I then performed arthrectomy using #5-French export catheter.,I performed more balloon predilation using a 3.0 x16 mm Voyager balloon.  I then deployed 4.0 x15 mm, excised, and across the mid RCA at 18 atmospheres with good angiographic result.  Proximal to the proximal edge of the stent, there was still some persistent haziness most likely just diseased artery/diffuse plaquing.  I decided to cover this segment using a second 4.0 x 15 mm, excised, and two stents were overlapped, the overlap was postdilated using the same stent delivery balloon at high pressure with excellent angiographic result.,Left ventricular catheterization was performed with #6-French angle pigtail catheter.  The left ventricle is rather smaller in size.  The mid inferior wall is minimally hypokinetic, ejection fraction is 70%.  There is no evidence of aortic wall stenosis or mitral regurgitation.,Femoral angiography revealed that the entry point was above the bifurcation of the right common femoral artery and I have performed this as Perclose hemostasis.,CONCLUSIONS,1.  Normal left ventricular size and function.  Ejection fraction is 65% to 70%.  No MR.,2.  Successful angioplasty and stenting of the subtotally closed mid RCA.  This was hard, organized thrombus, very difficult to penetrate.  I have deployed two overlapping 4.0 x15 mm excised and with excellent angiographic result.  The RCA is dominant.,3.  No moderate disease in the distal left main.  Moderate disease in the ostium of the left circumflex artery.  Mild disease in the proximal LAD.,PLAN: , Recommend smoking cessation.  Continue aspirin lifelong and continue Plavix for at least 12 months.
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DESCRIPTION: Selective coronary angiography of the right coronary artery, left main LAD, left circumflex artery, left ventricular catheterization, left ventricular angiography, angioplasty of totally occluded mid RCA, arthrectomy using 6-French catheter, stenting of the mid RCA, stenting of the proximal RCA, femoral angiography and Perclose hemostasis.

surgery, acute coronary syndrome, circumflex artery, ventricular catheterization, ventricular angiography, angioplasty, coronary artery, coronary angiography, arthrectomy, femoral angiography, perclose hemostasis, selective coronary angiography, angiographic stenosis, rca, coronary, catheterization, artery, angiography, hemostasis, wire, lad, femoral, angiographic, stenting, proximal,

This situation involves a surgical procedure that is high-stakes due to multiple factors. First, the patient's condition is acute coronary syndrome, a potentially life-threatening condition. The procedure of angiography, angioplasty, and stenting involves significant risks including death, myocardial infarction, stroke, and other serious complications. The narrative also describes an instance of procedural difficulty and the patient's adverse reaction, requiring immediate intervention. Finally, the procedure was ultimately successful, but the inherent risks and the complexity of the procedure make this a high-stakes situation.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Adenoidectomy - 1

PREOPERATIVE DIAGNOSIS: , Adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Adenoid hypertrophy.,PROCEDURE PERFORMED:  ,Adenoidectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia.  The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.  The nasopharynx was inspected with the laryngeal mirror.  Serial passages of the curettes were utilized to remove the nasopharyngeal tissue, following which the nasopharynx was packed with 2 cherry gauze sponges coated in a solution of 0.25% Neo-Synephrine and tannic acid powder.,Attention was then redirected to the oropharynx.  The McIvor was reopened, packs removed, and the bleeding was controlled with the suction Bovie unit.  The catheters were removed, and the nasal passages and oropharynx were suctioned free of debris.  The McIvor was then removed, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.
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DESCRIPTION: Adenoidectomy.  Adenoid hypertrophy.  The McIvor mouth gag was placed in the oral cavity and the tongue depressor applied.

surgery, palate, nasal passage, mcivor mouth gag, oral cavity, nasal, nasopharynx, oropharynx, hypertrophy, oral, cavity, mcivor, tongue, adenoidectomy

Adenoidectomy is considered a routine and standard surgical procedure, especially in pediatric cases, to remove enlarged adenoids causing issues like chronic infections or breathing difficulties. The description indicates the procedure was conducted without complications, with the patient tolerating it well. While any surgical procedure carries certain risks, this is generally considered low complexity and is routinely performed, which implies lower stakes compared to many other surgeries. However, since it is a surgical procedure under general anesthesia, it cannot be classified as having the lowest stakes.


Medical Specialty: Surgery
Sample Name: Adenocarcinoma & Mesothelioma

PREOPERATIVE DIAGNOSES,1.  Incomplete surgical staging of recent diagnosis of grade 1 endometrial adenocarcinoma and also low-grade mesothelioma of the ovary.,2.  Status post laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy.,POSTOPERATIVE DIAGNOSES,1.  Incomplete surgical staging of recent diagnosis of grade 1 endometrial adenocarcinoma and also low-grade mesothelioma of the ovary.,2.  Status post laparoscopic-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy.,OPERATIONS PERFORMED,1.  Robotic-assisted omentectomy.,2.  Robotic-assisted pelvic lymph node dissection.,3.  Attempted laparoscopy.,4.  Exploratory laparotomy with bilateral pelvic bilateral periaortic lymph node dissection with multiple biopsies.,ANESTHESIA:,  General/epidural anesthesia.,ESTIMATED BLOOD LOSS:,  200 mL.,COMPLICATIONS:,  None.,FINAL SPONGE AND NEEDLE COUNTS: , Correct, confirmed by x-ray JP drain x1.,INDICATIONS FOR SURGERY: , Mrs. A is a pleasant 66-year-old female who was diagnosed with an unsuspected grade 1 endometrial adenocarcinoma and low-grade mesothelioma of the ovary.  The patient is status post laparoscopic-assisted vaginal hysterectomy BSO.  The patient was referred to me by Dr. X.  Because of the incomplete staging, the patient was advised to undergo a robotic-assisted surgical staging.  Risks, benefits, and rationale of these procedures were reviewed.  The patient has understanding of these risks and wishes to proceed with the surgery as planned.,INTRAOPERATIVE FINDINGS,1.  No evidence of ascites.,2.  At the time of the exploratory laparotomy, the diaphragm was well palpated.  They were clear.  The low attachments were removed.  The lesser omentum was unremarkable.  The pancreas, spleen, and liver were unremarkable.  The gallbladder was unremarkable.  The stomach appeared grossly normal.  The small bowel was inspected from the ligament which starts to the ileocecal valve.  There is no evidence of disease.  Paracolic gutter and peritoneum was free.  The omentum was grossly normal.,3.  In the pelvis, uterus, tubes, and ovaries were absent.  There was no evidence seeding along the bladder, pelvic, cul-de-sac, and peritoneum.,4.  Retroperitoneally, pelvic lymph nodes were mostly normal; however, at the right aortic, there are nodes.  These nodes were extremely fibrotic and they were densely adherent to the anterior wall of the vena cava which precluded me from performing a robotic periaortic lymph node dissection.  There was some area that was suspicious right at the low right periaortic lymph node.  They were sent for frozen section and they came back as benign.  It is unclear to me why did the lymph nodes were quite fibrotic and firm, but we will wait for the pathology report.,PROCEDURE IN DETAIL: , The patient was given IV antibiotics prior to our incision site, sequential compression device was placed as part of the DVT prophylaxis.  I have requested an epidural catheter be placed for purpose of the periaortic lymph node dissection.  With this in mind, we proceeded as such.,We initially began with the robotic portion of the procedure.,A 1-cm supraumbilical incision made.  A Veress needle was inserted without difficulty.  Pneumoperitoneum was achieved to the abdominal pressure of 15 mmHg.  A 12mm trocar was inserted without difficulty.  After completion of this, a 12mm trocar was placed in the left lower quadrant 2 fingerbreadths medial to the anterior superior iliac spine under direct laparoscopic visualization.  After completion of this, a laparoscope was then placed in the left lower quadrant port to assist in the placement of the remainder of the da Vinci ports.  Two 8-mm ports were placed in the right upper quadrant 8 cm apart while one 8-mm port was placed in the left upper quadrant 8 cm apart.  After completion of this, the patient was placed in steep Trendelenburg position.  The robotic system was then docked and after docking the robotic system, the instrumentation was inserted under direct laparoscopic visualization to ensure that there was no injury to the abdominal contents.  Once this was completed, the robotic camera was then docked.  We then proceeded with our daVinci portion of the procedure.,I then proceeded now with the omentectomy.  The omentum was taken off the transverse colon with the harmonic scalpel.  The entire omentum was removed and placed in the pelvis.  After completion of this, I then proceeded now with the pelvic lymph node dissection.,An incision was made parallel along the peritoneum overlying the psoas muscle.  All the lymph node bearing tissues along the external iliac artery and vein were subsequently skeletonized off the vessels and resected.  The lymph node bearing tissues interposed between the external iliac vein and psoas muscle were mobilized into the obturator fossa and subsequently removed off the accessory obturator vein, artery and nerve.  In the process of removing the lymphoid tissues, the genitofemoral nerve along with the accessory obturator vein, obturator artery and nerve were all preserved.  The lymphoid tissues interposed between the external iliac vein and psoas muscle along with the common iliac vessels were also subsequently removed.  The lymph node bearing tissues bifurcating at the hypogastric and the external iliac vein were likewise removed in addition to the hypogastric lymph nodes.  All the lymph node tissues were placed in an Endobag and removed and submitted as pelvic nodes on the right side and subsequently the left side.  Boundaries of the pelvic nodal dissection distally were the external circumflex iliac vein, laterally the psoas muscle along with the obturator internus fascia, medially the superior vesical artery along with the ureter, and inferiorly below the obturator nerve.,At this point in time, we have attempted the periaortic lymph node dissection.  I did open up the peritoneum overlying the bifurcation of the aorta.  This peritoneum was incised up to the level of the duodenal recess.  It was at this point in time that the periaortic lymph node dissection was extremely difficult.  I was unable to get a tissue plane as the lymph nodes were apparently very fibrotic.  I was concerned that I would tear off the anterior wall of the cava in the process of trying to perform the right periaortic lymph node.  For this reason, I aborted the robotic procedure or in after nearly attempting for about an hour and a half for the periaortic lymph nodes.  Once this was unsuccessful, the robotic system was then dedocked.  I then placed additional ports.  A 5-mm port was placed in the suprapubic region, two fingerbreadths above.  A right lower quadrant 12-mm port was placed.  After completion of this, I had attempted to see whether we could do the remainder of the periaortic lymph node dissection via laparoscopically.  Despite an attempt for a nearly 35 minutes, I was not able to get adequate exposure.  The small bowel kept on falling in the operative field which precluded us to perform the procedure safely.  For this reason, I converted to an open procedure.,A midline incision was made from suprapubic bone and extended above the umbilicus.  The abdominal cavity was entered without injuring the bell.  After entering the abdomen, omentum was removed.  Ray-Tec sponges were removed.  We covered for the Ray-Tec sponges.  After completion of this, Thompson retractor was placed.  The patient was placed in C-Trendelenburg position.  The bowel was packed cephalad.  Retroperitoneum space was entered right and left ureters were identified.  I then meticulously resected the lymphoid-bearing tissues anterior and lateral to the cava.  This dissection was quite difficult as the lymph nodes were extremely fibrotic and adherent to the caval wall.  I was able to freed up these lymph nodes without injuring of the cava.  Likewise, the left periaortic lymph node dissection was carried out from the level of the bifurcation to 1 cm above the IMA.  All the periaortic lymph node dissection was then carried out.  After completion of this, I then took washings.  Random biopsies were obtained of the cul-de-sac and right and left pelvic side wall along with the right and left paracolic gutter.  After completion of this, the patient appears to have tolerated the procedure well.  There was no obvious gross disease.  The bowel was inspected meticulously to ensure that there was no evidence of injury.  Once this was completed, the bowel was placed back to its normal position.  Several film solutions were placed.  We counted for sponges, needles, and instruments.  Once this was counted for, the fascia was then closed with #2 Vicryl suture in a mass closure fashion.  The subcutaneous route was copiously irrigated with water.  The JP drain was brought to the right lower quadrant incision.  All the incision ports were then closed with 3-0 Monocryl suture.  Likewise, the midline incision was closed with 3-0 Monocryl sutures.,At the conclusion of the procedure, there was no obvious gross disease left.,
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DESCRIPTION: Grade 1 endometrial adenocarcinoma and low-grade mesothelioma of the ovary - Omentectomy, pelvic lymph node dissection, and laparoscopy.

The situation involves a complex surgical procedure aimed at achieving complete surgical staging for a patient with grade 1 endometrial adenocarcinoma and low-grade mesothelioma. The procedure is high-stakes due to several reasons: the surgical complexity, the need for complete cancer staging, the patient's health condition, and the potential impact on the patient's prognosis and treatment plan. The surgeon has to perform intricate procedures, such as omentectomy and lymph node dissection, which demand high precision to avoid complications. While the immediate medical risks during surgery were managed without reported complications, the outcome can significantly affect the patient's cancer treatment pathway and overall prognosis.


Medical Specialty: Surgery
Sample Name: Adenoidectomy

ADENOIDECTOMY,PROCEDURE:,  The patient was brought into the operating room suite, anesthesia administered via endotracheal tube.  Following this the patient was draped in standard fashion.  The Crowe-Davis mouth gag was inserted in the oral cavity.  The palate and tonsils were inspected, the palate was suspended with a red rubber catheter passed through the right nostril.  Following this, the mirror was used to visualize the adenoid pad and an adenoid curet was seated against the vomer.  The adenoid pad was removed without difficulty.  The nasopharynx was packed.  Following this, the nasopharynx was unpacked, several discrete bleeding sites were gently coagulated with electrocautery and the nasopharynx and oral cavity were irrigated.  The Crowe-Davis was released.,The patient tolerated the procedure without difficulty and was in stable condition on transfer to recovery.
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DESCRIPTION: Adenoidectomy procedure

Adenoidectomy procedure

surgery, adenoidectomy, crowe-davis, adenoid pad, electrocautery, endotracheal tube, gently coagulated, mouth gag, nasopharynx, oral cavity, red rubber catheter, vomer, palate, tonsilsNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

This scenario describes a surgical procedure, specifically an adenoidectomy. While surgical procedures inherently carry some level of risk due to factors like anesthesia, bleeding, and infection, adenoidectomy is generally considered a routine and low-risk surgery. It is often performed on children and is a common procedure with a high success rate and low rate of complications. Given that the procedure described was completed without any complications and the patient was stable upon transfer to recovery, the situation is not particularly high-stakes.


Medical Specialty: Surgery
Sample Name: Adenotonsillectomy - 2

POSTOPERATIVE DIAGNOSIS:  Adenotonsillitis with hypertrophy.,OPERATION PERFORMED:  Adenotonsillectomy.,ANESTHESIA:  General endotracheal.,INDICATIONS:  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated.,DESCRIPTION OF PROCEDURE:  The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, table was turned and shoulder roll was placed on the shoulders and face was draped in clean fashion.  A McIvor mouth gag was applied.  The tongue was retracted anteriorly and the McIvor was gently suspended from a Mayo stand.  A red rubber Robinson catheter was inserted through the left naris and the soft palate was retracted superiorly.  The adenoids were removed with suction electrocautery under mere visualization.  The left tonsil was grasped with a curved Allis forceps, retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The right tonsil was grasped in the similar fashion and retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The inferior, middle and superior pole vessels were further cauterized with suction electrocautery.  Copious saline irrigation of the oral cavity was then performed.  There was no further identifiable bleeding at the termination of the procedure.  The estimated blood loss was less than 10 mL.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.
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DESCRIPTION: Adenotonsillectomy.  Adenotonsillitis with hypertrophy.  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated.

surgery, hypertrophy, adenotonsillitis, tonsillar pillar, bovie electrocautery, adenotonsillectomyNOTE,: 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 routine adenotonsillectomy, which is a common surgery usually performed on children for conditions like adenotonsillitis with hypertrophy. The operation appears to have gone smoothly with no complications and minimal blood loss. While surgery always carries some inherent risk, this particular procedure is not generally considered high-stakes compared to more complex surgeries. The patient's condition was satisfactory post-operation, further indicating a successful and standard surgery.


Medical Specialty: Surgery
Sample Name: Adenotonsillectomy - 1

PREOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Recurrent tonsillitis.,PROCEDURE:  ,Adenotonsillectomy.,COMPLICATIONS:,  None.,PROCEDURE DETAILS:, The patient was brought to the operating room and, under general endotracheal anesthesia in supine position, the table turned and a McIvor mouthgag placed.  The adenoid bed was examined and was moderately hypertrophied.  Adenoid curettes were used to remove this tissue and packs placed.  Next, the right tonsil was grasped with a curved Allis and, using the gold laser, the anterior tonsillar pillar incised and, with this laser, dissection carried from the superior pole to the inferior pole and removed off the tonsillar muscular bed.  A similar procedure was performed on the contralateral tonsil.  Following meticulous hemostasis, saline was used to irrigate and no further bleeding noted.  The patient was then allowed to awaken and was brought to the recovery room in stable condition.
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DESCRIPTION: Adenotonsillectomy.  Recurrent tonsillitis.  The adenoid bed was examined and was moderately hypertrophied.  Adenoid curettes were used to remove this tissue and packs placed.

surgery, curved allis, tonsillitis, hypertrophied, curettes, tonsillar, adenoid, adenotonsillectomy,

The situation described involves a common surgical procedure known as adenotonsillectomy, typically performed to treat recurrent throat infections such as tonsillitis. This procedure is routinely performed in surgical settings and is generally considered low-risk, with a high success rate and minimal complications, as indicated in the description with no complications reported. Furthermore, the patient recovered with no issues and returned to stable condition, which implies a straightforward procedure without any high-stakes elements. However, as with any surgical procedure, there are inherent risks such as anesthesia and bleeding, but in the context provided, these are managed effectively, making it a standard and low-stakes medical scenario.


Medical Specialty: Surgery
Sample Name: AC Separation Revision & Hardware Removal

PREOPERATIVE DIAGNOSIS:,  Right AC separation.,POSTOPERATIVE DIAGNOSIS:,  Right AC separation.,PROCEDURES:,  Removal of the hardware and revision of right AC separation.,ANESTHESIA:,  General.,BLOOD LOSS:,  100 cc.,COMPLICATIONS:,  None.,FINDINGS: , Loose hardware with superior translation of the clavicle implants.,IMPLANTS: , Arthrex bioabsorbable tenodesis screws.,SUMMARY: , After informed consent was obtained and verified, the patient was brought to the operating room and placed supine on the operating table.  After uneventful general anesthesia was obtained, he was positioned in the beach chair and his right shoulder was sterilely prepped and draped in a normal fashion.  The incision was reopened and the hardware was removed without difficulty.  The AC joint was inspected and reduced.  An allograft was used to recreate the coracoacromial ligaments and then secured to decorticate with a bioabsorbable tenodesis screw and then to the clavicle.  And two separate areas that were split, one taken medially and one taken laterally, and then sewed together for further stability.  This provided good stability with no further superior translation of the clavicle as viewed under fluoroscopy.  The wound was copiously irrigated and the wound was closed in layers and a soft dressing was applied.  He was awakened from anesthesia and taken to recovery room in a stable condition.,Final needle and instrument counts were correct.
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DESCRIPTION: Removal of the hardware and revision of right AC separation.  Loose hardware with superior translation of the clavicle implants.  Arthrex bioabsorbable tenodesis screws.

surgery, loose hardware, superior translation, clavicle implants, ac separation, removal of the hardware, arthrex bioabsorbable tenodesis screws, bioabsorbable tenodesis, tenodesis screws, translation, implants, bioabsorbable, tenodesis, clavicle, separation, hardware

The procedure described is a surgical revision for a right AC (acromioclavicular) separation, which involved removing loose hardware and ensuring stability of the clavicle using bioabsorbable screws. Surgery inherently involves certain levels of risk, especially considering general anesthesia and possible complications from the procedure. However, this appears to be a routine procedure with no reported complications, minimal blood loss, and the patient was stable post-operation. In the context of surgical procedures, this is relatively low-stakes compared to surgeries involving life-threatening conditions.


Medical Specialty: Surgery
Sample Name: Abdominal Abscess I&D

PREOPERATIVE DIAGNOSIS: , Abdominal wall abscess.,POSTOPERATIVE DIAGNOSIS: , Abdominal wall abscess.,PROCEDURE: , Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.,ANESTHESIA: , LMA.,INDICATIONS: , Patient is a pleasant 60-year-old gentleman, who initially had a sigmoid colectomy for diverticular abscess, subsequently had a dehiscence with evisceration.  Came in approximately 36 hours ago with pain across his lower abdomen.  CT scan demonstrated presence of an abscess beneath the incision.  I recommended to the patient he undergo the above-named procedure.  Procedure, purpose, risks, expected benefits, potential complications, alternatives forms of therapy were discussed with him, and he was agreeable to surgery.,FINDINGS:,  The patient was found to have an abscess that went down to the level of the fascia.  The anterior layer of the fascia was fibrinous and some portions necrotic.  This was excisionally debrided using the Bovie cautery, and there were multiple pieces of suture within the wound and these were removed as well.,TECHNIQUE:  ,Patient was identified, then taken into the operating room, where after induction of appropriate anesthesia, his abdomen was prepped with Betadine solution and draped in a sterile fashion.  The wound opening where it was draining was explored using a curette.  The extent of the wound marked with a marking pen and using the Bovie cautery, the abscess was opened and drained.  I then noted that there was a significant amount of undermining.  These margins were marked with a marking pen, excised with Bovie cautery; the curette was used to remove the necrotic fascia.  The wound was irrigated; cultures sent prior to irrigation and after achievement of excellent hemostasis, the wound was packed with antibiotic-soaked gauze.  A dressing was applied.  The finished wound size was 9.0 x 5.3 x 5.2 cm in size.  Patient tolerated the procedure well.  Dressing was applied, and he was taken to recovery room in stable condition.
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DESCRIPTION: Incision and drainage (I&D) of abdominal abscess, excisional debridement of nonviable and viable skin, subcutaneous tissue and muscle, then removal of foreign body.

surgery, excisional debridement, subcutaneous tissue, abdominal wall abscess, foreign body, abdominal abscess, bovie cautery, abdominal, i&d, wound, incision, abscess,

This situation involves a surgical procedure that is necessary due to the presence of an abdominal wall abscess. The stakes are raised due to the patient's recent medical history, including a significant surgery (sigmoid colectomy) and complications like dehiscence and the formation of an abscess. Surgery inherently carries certain risks such as infection, bleeding, or complications from anesthesia. Additionally, postoperative outcomes depend on clear resolution of the infection and proper recovery without further complications. However, it's a relatively standard procedure for this type of condition, which reduces the stakes compared to more complex or urgent surgical interventions.


Medical Specialty: Speech - Language
Sample Name: Speech Therapy - Discharge Summary

LONG-TERM GOALS:,  Both functional and cognitive-linguistic ability to improve safety and independence at home and in the community.  This goal has been met based on the patient and husband reports the patient is able to complete all activities, which she desires to do at home.  During the last reevaluation, the patient had a significant progress and all cognitive domains evaluated, which are attention, memory, executive functions, language, and visuospatial skill.  She continues to have an overall mild cognitive-linguistic deficit, but this is significantly improved from her initial evaluation, which showed severe impairment., ,The patient does no longer need a skilled speech therapy because she has accomplished all of her goals and her progress has plateaued.  The patient and her husband both agreed with the patient's discharge.
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DESCRIPTION: Speech therapy discharge summary.  The patient was admitted for skilled speech therapy secondary to cognitive-linguistic deficits.

speech - language, narrative, memory, executive function, attention, speech therapy, visuospatial, accuracy, linguistic, cognitive, speechNOTE,: 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 situation described is a discharge summary for a patient who was receiving speech therapy. The patient has shown significant improvement in cognitive-linguistic abilities and no longer requires skilled speech therapy. While speech therapy and cognitive health are important factors for the patient's daily living and safety, in this context, it seems that the high stakes nature of a medical emergency or life-threatening situation is not present. The situation indicates resolution and positive outcomes, as the patient and her husband agree with the discharge. However, the situation holds moderate stakes because it involves the capacity for independent living and mental health.


Medical Specialty: Speech - Language
Sample Name: Cognitive Linguistic Impairment - Discharge

DIAGNOSIS: , Cognitive linguistic impairment secondary to stroke.,NUMBER OF SESSIONS COMPLETED:,  5,HOSPITAL COURSE:  ,The patient is a 73-year-old female who was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.  Based on the initial evaluation completed 12/29/08, the patient had mild difficulty with generative naming and auditory comprehension and recall.  The patient's skilled speech therapy was recommended for three times a week for 8 weeks to improve her overall cognitive linguistic abilities.  At this time, the patient has accomplished all 5 of her short-term therapy goals.  She is able to complete functional mass tasks with 100% accuracy independently.  She is able to listen to a narrative and recall the main idea plus at least five details after a 10 minute delay independently.,She is able to read a newspaper article and recall the main idea plus five details after a 15 minute delay independently.  She is able to state 15 items in a broad category within a minute and a half independently.  The patient is also able to complete deductive reasoning tasks to promote her mental flexibility with 100% accuracy independently.  The patient also met her long-term therapy goal of functional cognitive linguistic abilities to return to teaching and improve her independence and safety at home.  The patient is no longer in need of skilled speech therapy and is discharged from my services.  She did quite well in therapy and also agreed with this discharge.
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DESCRIPTION: Cognitive linguistic impairment secondary to stroke.  The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy secondary to cognitive linguistic deficits.

speech - language, stroke, linguistic deficits, speech therapy, skilled speech therapy, linguistic impairment, cognitive linguistic, cognitive, linguistic,

The situation described involves a discharge summary of a patient who has successfully completed speech therapy for cognitive linguistic impairment secondary to a stroke. The patient has met all short-term and long-term therapy goals, indicating that she has made significant progress in her recovery. She is now able to recall and process information independently and is ready to return to her teaching role and manage her independence and safety at home. The situation does not indicate any immediate risk or emergency, as therapy has been successfully completed, and the patient agrees with the discharge. Therefore, it is a routine discharge situation with no high-stake elements involved.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Tethered Cord Evaluation

REASON FOR VISIT: , The patient referred by Dr. X for evaluation of her possible tethered cord.,HISTORY OF PRESENT ILLNESS:,  Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.  The last surgery was in 03/95.  She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM.,Denies any new bowel or bladder dysfunction or increased sensory loss.  She had some patchy sensory loss from L4 to S1.,MEDICATIONS: , Singulair for occasional asthma.,FINDINGS: , She is awake, alert, and oriented x 3.  Pupils equal and reactive.  EOMs are full.  Motor is 5 out of 5.  She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus.  There is no evidence of clonus.  There is diminished sensation from L4 to S1, having proprioception.,ASSESSMENT AND PLAN: , Possible tethered cord.  I had a thorough discussion with the patient and her parents.  I have recommended a repeat MRI scan.  The prescription was given today.  MRI of the lumbar spine was just completed.  I would like to see her back in clinic.  We did discuss the possible symptoms of this tethering.
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DESCRIPTION: Evaluation of possible tethered cord.  She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.

soap / chart / progress notes, tethering, lipomyomeningocele repair, sensory loss, tethered cord, mri, cord, lipomyomeningocele,

The situation involves evaluating a 14-year-old with a history of spinal surgery for possible tethered cord syndrome, a serious neurological condition that can cause pain and worsen functioning. The evaluation results could lead to significant medical decisions or further interventions, but there's no immediate life-threatening emergency as current symptoms are manageable and being monitored with follow-up care and an MRI scan.


Medical Specialty: SOAP / Chart / Progress Notes
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.,
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DESCRIPTION: Postoperative day #1, total abdominal hysterectomy.  Normal postoperative course.

soap / chart / progress notes, postoperative course, total abdominal hysterectomy, postoperative

The provided situation is a routine follow-up note for a patient who has undergone a total abdominal hysterectomy. The patient is on postoperative day #1, experiencing normal symptoms and healing as expected. The note contains typical postoperative observations like vital signs, urination through a Foley catheter, and incisional tenderness, which are normal occurrences after such a surgery. The plan involves routine care, such as clinical follow-up, continuation of current therapy, and assisted ambulation. While any postoperative care has inherent risks, this situation does not indicate any complications or high-risk concerns and appears to be a standard part of recovery.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Thrombocytopenia - SOAP Note

SUBJECTIVE: , I am following the patient today for immune thrombocytopenia.  Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day.  Repeat on 01/16/07 revealed platelets up at 43.  No bleeding problems have been noted.  I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day.  The patient had been on 20 mg every other day at least for a while, and her platelets hovered at least above 20 or so.,PHYSICAL EXAMINATION: , Vitals:  As in chart.  The patient is alert, pleasant, and cooperative.  She is in no apparent distress.  The petechial areas on her legs have resolved.,ASSESSMENT AND PLAN: , Patient with improvement of her platelet count on burst of prednisone.  We will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day.  Basically thereafter, over time, I may try to sneak it back a little bit further.  She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D.  We will arrange to have a CBC drawn weekly.,
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DESCRIPTION: Patient with immune thrombocytopenia

Patient with immune thrombocytopenia

soap / chart / progress notes, platelets, platelet count, thrombocytopenia, prednisone,

The situation involves adjusting medication for a patient with immune thrombocytopenia, a condition that can lead to serious complications if not managed properly, such as bleeding. However, the patient is currently stable with improving platelet counts and no bleeding issues, making this scenario moderately critical but not immediately life-threatening. Regular monitoring and gradual adjustment of medication indicates a controlled management approach, which reduces the stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: SOAP - Substance Abuse

SUBJECTIVE: , This patient presents to the office today with his mom for checkup.  He used to live in the city.  He used to go to college down in the city.  He got addicted to drugs.  He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom.  He has a history of doing heroin.  He was injecting into his vein.  He was seeing a physician in the city.  They were prescribing methadone for some time.  He says that did help.  He was on 10 mg of methadone.  He was on it for three to four months.  He tried to wean down on the methadone a couple of different times, but failed.  He has been intermittently using heroin.  He says one of the big problems is that he lives in a household full of drug users and he could not get away from it.  All that changed now that he is living with his mom.  The last time he did heroin was about seven to eight days ago.  He has not had any methadone in about a week either.  He is coming in today specifically requesting methadone.  He also admits to being depressed.  He is sad a lot and down.  He does not have much energy.  He does not have the enthusiasm.  He denies any suicidal or homicidal ideations at the present time.  I questioned him on the symptoms of bipolar disorder and he does not seem to have those symptoms.  His past medical history is significant for no medical problems.  Surgical history, he voluntarily donated his left kidney.  Family and social history were reviewed per the nursing notes.  His allergies are no known drug allergies.  Medications, he takes no medications regularly.,OBJECTIVE: , His weight is 164 pounds, blood pressure 108/60, pulse 88, respirations 16, and temperature was not taken.  General:  He is nontoxic and in no acute distress.  Psychiatric:  Alert and oriented times 3.  Skin:  I examined his upper extremities.  He showed me his injection sites.  I can see marks, but they seem to be healing up nicely.  I do not see any evidence of cellulitis.  There is no evidence of necrotizing fasciitis.,ASSESSMENT: , Substance abuse.,PLAN: , I had a long talk with the patient and his mom.  I am not prescribing him any narcotics or controlled substances.  I am not in the practice of trading one addiction for another.  It has been one week without any sort of drugs at all.  I do not think he needs weaning.  I think right now it is mostly psychological, although there still could be some residual physical addiction.  However, once again I do not believe it to be necessary to prescribe him any sort of controlled substance at the present time.  I do believe that his depression needs to be treated.  I gave him fluoxetine 20 mg one tablet daily.  I discussed the side effects in detail.  I did also warn him that all antidepressant medications carry an increased risk of suicide.  If he should start to feel any of these symptoms, he should call #911 or go to the emergency room immediately.  If he has any problems or side effects, he was also directed to call me here at the office.  After-hours, he can go to the emergency room or call #911.  I am going to see him back in three weeks for the depression.  I gave him the name and phone number of Behavioral Health and I told him to call so that he can get into rehabilitation program or at least a support group.  We are unable to make a referral for him to do that.  He has to call on his own.  He has no insurance.  However, I think fluoxetine is very affordable.  He can get it for $4 per month at Wal-Mart.  His mom is going to keep an eye on him as well.  He is going to be staying there.  It sounds like he is looking for a job.
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DESCRIPTION: He got addicted to drugs.  He decided it would be a good idea to get away from the "bad crowd" and come up and live with his mom.

soap / chart / progress notes, addicted to drugs, substance abuse, abuse, heroin, methadone

The situation involves a patient with a history of heroin use, currently requesting methadone, and suffering from depression. The patient has no insurance but is living with his mother in a supportive environment. The visit reveals he has been drug-free for about a week. The physician is focusing on treating the depression with fluoxetine and encourages the patient to seek behavioral support. There are significant risks involved, such as relapse into heroin use or negative side effects from the depression treatment, potentially leading to suicidal ideation. While the depression and substance use history are serious concerns, the current situation under close supervision by family and healthcare providers doesn't constitute an immediate high-stakes emergency like an overdose or severe withdrawal symptoms. However, it remains important due to the complexity of substance abuse and mental health treatment.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: SOAP - Shortness of Breath

SUBJECTIVE: , The patient is admitted for shortness of breath, continues to do fairly well.  The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72.  The patient did undergo echocardiogram, which shows aortic stenosis, severe.  The patient does have an outside cardiologist.  I understand she was scheduled to undergo workup in this regard.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse of 78 and blood pressure 130/60.,LUNGS:  Clear.,HEART:  A soft systolic murmur in the aortic area.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.,IMPRESSION:,1.  Status shortness of breath responding well to medical management.,2.  Atrial fibrillation, chronic, on anticoagulation.,3.  Aortic stenosis.,RECOMMENDATIONS:,1.  Continue medications as above.,2.  The patient would like to follow with her cardiologist regarding aortic stenosis.  She may need a surgical intervention in this regard, which I explained to her.  The patient will be discharged home on medical management and she has an appointment to see her cardiologist in the next few days.,In the interim, if she changes her mind or if she has any concerns, I have requested to call me back.
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DESCRIPTION: The patient is admitted for shortness of breath, continues to do fairly well.  The patient has chronic atrial fibrillation, on anticoagulation, INR of 1.72.  The patient did undergo echocardiogram, which shows aortic stenosis, severe.  The patient does have an outside cardiologist.

soap / chart / progress notes, shortness of breath, medical management, atrial fibrillation, aortic stenosis, atrial, fibrillation, breath, stenosis, cardiologist, aortic, anticoagulation, inr,

The situation involves a medically significant condition, aortic stenosis, which may require surgical intervention, and the patient is currently admitted for shortness of breath. They have chronic atrial fibrillation, making accurate management critical due to the potential complications of both conditions. The condition and its management involve serious health implications. While the patient is doing fairly well currently, they need ongoing monitoring and coordination with their cardiologist. This scenario holds moderate to high stakes due to the potential for deterioration and the need for surgical decision-making.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: SOAP - Lung Mass

SUBJECTIVE:,  The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation.  The patient is doing fairly well.  This afternoon, she called me because heart rate was in the range of 120 to 140.  The patient is lying down.  She does have shortness of breath, but denies any other significant symptoms.,PAST MEDICAL HISTORY:,  History of mastectomy, chest tube placement, and atrial fibrillation; chronic.,MEDICATIONS:,1.  Cardizem, which is changed to 60 mg p.o. t.i.d.,2.  Digoxin 0.25 mg daily.,3.  Coumadin, adjusted dose.,4.  Clindamycin.,PHYSICAL EXAMINATION,VITAL SIGNS:  Pulse 122 and blood pressure 102/68.,LUNGS:  Air entry decreased.,HEART:  PMI is displaced.  S1 and S2 are irregular.,ABDOMEN:  Soft and nontender.,IMPRESSION:,1.  Pulmonary disorder with lung mass.,2.  Pleural effusion.,3.  Chronic uncontrolled atrial fibrillation secondary to pulmonary disorder.,RECOMMENDATIONS:,1.  From cardiac standpoint, follow with pulmonary treatment.,2.  The patient has an INR of 2.09.  She is on anticoagulation.  Atrial fibrillation is chronic with the rate increased.,Adjust the medications accordingly as above.
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DESCRIPTION: Pulmonary disorder with lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation secondary to pulmonary disorder. The patient is admitted for lung mass and also pleural effusion.  The patient had a chest tube placement, which has been taken out.  The patient has chronic atrial fibrillation, on anticoagulation.

soap / chart / progress notes, lung mass, pleural effusion, chest tube placement, chest tube, pulmonary disorder, atrial fibrillation, chest, anticoagulation, effusion, lung, pulmonary, atrial, fibrillation,

The medical situation involves multiple serious health issues such as a lung mass, pleural effusion, and chronic uncontrolled atrial fibrillation. These conditions are compounded by the patient's need for anticoagulation, which complicates the management of atrial fibrillation. The elevated heart rate and shortness of breath indicate that the patient is experiencing symptoms that could lead to further complications if not managed properly. Hence, it is a high-stakes situation requiring careful monitoring and treatment adjustments.


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

Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: SOAP - Numbness & Tingling

SUBJECTIVE: , This patient presents to the office today because of some problems with her right hand.  It has been going tingling and getting numb periodically over several weeks.  She just recently moved her keyboard down at work.  She is hoping that will help.  She is worried about carpal tunnel.  She does a lot of repetitive type activities.  It is worse at night.  If she sleeps on it a certain way, she will wake up and it will be tingling then she can usually shake out the tingling, but nonetheless it is very bothersome for her.  It involves mostly the middle finger, although, she says it also involves the first and second digits on the right hand.  She has some pain in her thumb as well.  She thinks that could be arthritis.,OBJECTIVE: , Weight 213.2 pounds, blood pressure 142/84, pulse 92, respirations 16.  General:  The patient is nontoxic and in no acute distress.  Musculoskeletal:  The right hand was examined.  It appears to be within normal limits and the appearance is similar to the left hand.  She has good and equal grip strength noted bilaterally.  She has negative Tinel's bilaterally.  She has a positive Phalen's test.  The fingers on the right hand are neurovascularly intact with a normal capillary refill.,ASSESSMENT:  ,Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  I suspect carpal tunnel syndrome.,PLAN:  ,The patient is going to use Anaprox double strength one pill every 12 hours with food as well as a cock-up wrist splint.  We are going to try this for two weeks and if the condition is still present, then we are going to proceed with EMG test at that time.  She is going to let me know.  While she is here, I am going to also get her the blood test she needs for her diabetes.  I am noting that her blood pressure is elevated, but improved from the last visit.  I also noticed that she has lost a lot of weight.  She is working on diet and exercise and she is doing a great job.  Right now for the blood pressure we are going to continue to observe as she carries forward additional measures in her diet and exercise to lose more weight and I expect the blood pressure will continue to improve.
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DESCRIPTION: Numbness and tingling in the right upper extremity, intermittent and related to the positioning of the wrist.  Carpal tunnel syndrome suspected.

soap / chart / progress notes, tinel's, phalen's, positioning of the wrist, numbness and tingling, carpal tunnel syndrome, carpal tunnel, numbness, tingling

The situation involves the assessment and management of numbness and tingling potentially due to carpal tunnel syndrome, which is generally a non-emergent medical issue. The proposed plan includes non-surgical interventions such as medication and a wrist splint, and follow-up with EMG testing only if symptoms persist. Although the patient has elevated blood pressure, it is improving with lifestyle changes, and there are no signs of immediate danger or acute distress. Thus, it is not a high-stakes medical situation.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: SOAP - Temporal Mass

SUBJECTIVE: , The patient is a 55-year-old African-American male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an MRI scan, which demonstrated right contrast-enhancing temporal mass.  Given the characteristics of this mass and his new onset seizures, it is significantly concerning for a high-grade glioma.  ,OBJECTIVE: , The patient is alert and oriented times three, GCS of 15.  Cranial nerves II to XII are grossly intact.  Motor exam demonstrates 5/5 strength in all four extremities.  Sensation is intact to light touch, pain, temperature, and proprioception.  Cerebellar exam is intact.  Gait is normal and tandem on heels and toes.  Speech is appropriate.  Judgment is intact.  Pupils are equal and reactive to light.,ASSESSMENT AND PLAN: , The patient is a 55-year-old African-American male with a new diagnosis of rim-enhancing right temporal mass.  Given the characteristics of the MRI scan, it is highly likely that he demonstrates high-grade glioma and concerning for glioblastoma multiforme.  We have discussed in length the possible benefits of biopsy, surgical resection, medical management, as well as chemotherapy, radiation treatments, and doing nothing.  Given the high probability that the mass represents a high-grade glioma, the patient, after weighing the risks and the benefits of surgery, has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high-grade glioma.  The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor.  He agrees that he will be n.p.o. after mid night on Wednesday night.  He is sent for preoperative assessment with the Anesthesiology tomorrow morning.  He has undergone vocational rehab assessment.
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DESCRIPTION: MRI demonstrated right contrast-enhancing temporal mass.

soap / chart / progress notes, new onset seizures, temporal mass, cerebellar exam, glioma, temporal, massNOTE

The situation involves a serious medical condition — a likely high-grade glioma or glioblastoma multiforme — which can have significant implications for the patient's prognosis and quality of life. The patient's management plan includes major medical interventions such as surgical biopsy, possible resection, chemotherapy, and radiation therapy. These interventions carry both high risk and potential benefits, and decisions regarding the course of treatment are critical and complex, reflecting a high-stakes medical scenario.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Sexual Dysfunction - Chart Note

SUBJECTIVE:,  The patient is a 33-year-old black male who comes in to the office today main complaint of sexual dysfunction.  Patient reports that he would like to try Cialis to see if it will improve his erectile performance.  Patient states that he did a quiz on-line at the Cialis web site and did not score in the normal range, so he thought he should come in.  Patient states that perhaps his desire has been slightly decreased, but that has not been the primary problem.  In discussing with me directly, patient primarily expresses that he would like to have his erections last longer.  However, looking at the quiz as he filled it out, he reported that much less than half the time was he able to get erections during sexual activity and only about half of the time he was able to maintain his erection after penetration.  However, he only reports that it is slightly difficult to maintain the erection until completion of intercourse.  Patient has no significant past medical history.  He has never had any previous testicular infections.  He denies any history of injuries to the groin and he has never been told that he has a hernia.,CURRENT MEDICATIONS:,  None.,ALLERGIES: , No drug allergies.,SOCIAL: , Only occasionally drinks alcohol and he is a nonsmoker.  He currently is working as a nurse aid, second shift, at a nursing home.  He states that he did not enroll in Wichita State this semester.  Stating he just was tired and wanted to take some time off.  He states he is in a relationship with one partner and denies any specific stress in the relationship.,OBJECTIVE:,General:  He appears in no distress.,Vital Signs:  Blood pressure:  With large cuff is 120/90.,Lungs:  Clear to auscultation.,Cardiovascular:  Normal S1-S2 without murmur.,Abdomen:  Soft, nontender.  Femoral pulses are 2+.,GU:  Testicles descended bilaterally.  No evidence of masses.  No evidence of inguinal hernias.,ASSESSMENT:,  Sexual dysfunction.,PLAN:,  We will check a free and total testosterone level as he does note some diminished desire.  He was given a sample of Cialis 10 mg with instructions on usage and a prescription for that if that is successful.  He will follow up here p.r.n.  Lastly, I did give him a blood pressure recording card, as his blood pressure is borderline today.  He will have that checked weekly at his workplace and follow up if they remain elevated.
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DESCRIPTION: A 33-year-old black male with main complaint of sexual dysfunction, would like to try Cialis.

soap / chart / progress notes, cialis, able to maintain, erectile, sexual activity, sexual dysfunction, blood pressure, maintain, dysfunction, erections, sexual

The situation involves a patient who is experiencing sexual dysfunction and is seeking medical evaluation and treatment with Cialis. While sexual dysfunction can significantly affect quality of life and relationships, in a medical context, it is generally considered low-stakes compared to conditions that pose immediate or serious health risks such as cardiovascular events or cancer. The patient's general health appears stable, with no alarming symptoms or past medical history. The plan includes standard diagnostic checks like testosterone level assessment and monitoring of borderline blood pressure. Therefore, the stakes of this situation are relatively low in the context of medical emergencies.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Recheck of ADHD Meds

SUBJECTIVE:,  This is a 6-year-old male who comes in rechecking his ADHD medicines.  We placed him on Adderall, first time he has been on a stimulant medication last month.  Mother said the next day, he had a wonderful improvement, and he has been doing very well with the medicine.  She has two concerns.  It seems like first thing in the morning after he takes the medicine and it seems like it takes a while for the medicine to kick in.  It wears off about 2 and they have problems in the evening with him.  He was initially having difficulty with his appetite but that seems to be coming back but it is more the problems early in the morning after he takes this medicine than in the afternoon when the thing wears off.  His teachers have seen a dramatic improvement and she did miss a dose this past weekend and said he was just horrible.  The patient even commented that he thought he needed his medication.,PAST HISTORY:,  Reviewed from appointment on 08/16/2004.,CURRENT MEDICATIONS:,  He is on Adderall XR 10 mg once daily.,ALLERGIES: , To medicines are none.,FAMILY AND SOCIAL HISTORY:,  Reviewed from appointment on 08/16/2004.,REVIEW OF SYSTEMS:,  He has been having problems as mentioned in the morning and later in the afternoon but he has been eating well, sleeping okay.  Review of systems is otherwise negative.,OBJECTIVE:,  Weight is 46.5 pounds, which is down just a little bit from his appointment last month.  He was 49 pounds, but otherwise, fairly well controlled, not all that active in the exam room.  Physical exam itself was deferred today because he has otherwise been very healthy.,ASSESSMENT:,  At this point is attention deficit hyperactivity disorder, doing fairly well with the Adderall.,PLAN:,  Discussed with mother two options.  Switch him to the Ritalin LA, which I think has better release of the medicine early in the morning or to increase his Adderall dose.  As far as the afternoon, if she really wanted him to be on the medication, we will do a small dose of the Adderall, which she would prefer.  So I have decided at this point to increase him to the Adderall XR 15 mg in the morning and then Adderall 5 mg in the afternoon.  Mother is to watch his diet.  We would like to recheck his weight if he is doing very well, in two months.  But if there are any problems, especially in the morning then we would do the Ritalin LA.  Mother understands and will call if there are problems.  Approximately 25 minutes spent with patient, all in discussion.
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DESCRIPTION: A 6-year-old male with attention deficit hyperactivity disorder, doing fairly well with the Adderall.

soap / chart / progress notes, adhd, attention deficit hyperactivity disorder, adderall xr, recheck, medicines, adderall,

The situation involves managing a 6-year-old patient's ADHD medication, with a focus on adjusting the dosage for better efficacy and tolerability. While medication management for ADHD is important for the child's wellbeing and daily functioning, it is not an emergency or life-threatening situation. The stakes are moderate because improper management can affect the child's quality of life and development. However, the options discussed, such as adjusting the current medication or switching to a different one, are standard procedures in ADHD management.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Pulmonary - Followup Note

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

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

The situation involves a follow-up for a patient with interstitial lung disease secondary to lupus pneumonitis. The patient presents with increasing back and joint pain, which may be related to lupus or recent changes in medication (prednisone discontinuation). Although the respiratory status is stable, the presence of an existing chronic condition (lupus pneumonitis) means there is potential for complications. The plan involves monitoring and potentially altering medication, indicating ongoing management is crucial. While not immediately life-threatening, the patient's complex medical condition and the need for careful monitoring make it moderately high-stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Q-Fever Endocarditis

HISTORY OF PRESENT ILLNESS: , This is a follow-up visit on this 16-year-old male who is currently receiving doxycycline 150 mg by mouth twice daily as well as hydroxychloroquine 200 mg by mouth three times a day for Q-fever endocarditis.  He is also taking digoxin, aspirin, warfarin, and furosemide.  Mother reports that he does have problems with 2-3 loose stools per day since September, but tolerates this relatively well.  This has not increased in frequency recently.,Mark recently underwent surgery at Children's Hospital and had on 10/15/2007, replacement of pulmonary homograft valve, resection of a pulmonary artery pseudoaneurysm, and insertion of Gore-Tex membrane pericardial substitute.  He tolerated this procedure well.  He has been doing well at home since that time.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature is 98.5, pulse 84, respirations 19, blood pressure 101/57, weight 77.7 kg, and height 159.9 cm.,GENERAL APPEARANCE:  Well-developed, well-nourished, slightly obese, slightly dysmorphic male in no obvious distress.,HEENT:  Remarkable for the badly degenerated left lower molar.  Funduscopic exam is unremarkable.,NECK:  Supple without adenopathy.,CHEST:  Clear including the sternal wound.,CARDIOVASCULAR:  A 3/6 systolic murmur heard best over the upper left sternal border.,ABDOMEN:  Soft.  He does have an enlarged spleen, however, given his obesity, I cannot accurately measure its size.,GU:  Deferred.,EXTREMITIES:  Examination of extremities reveals no embolic phenomenon.,SKIN:  Free of lesions.,NEUROLOGIC:  Grossly within normal limits.,LABORATORY DATA: , Doxycycline level obtained on 10/05/2007 as an outpatient was less than 0.5.  Hydroxychloroquine level obtained at that time was undetectable.  Of note is that doxycycline level obtained while in the hospital on 10/21/2007 was 6.5 mcg/mL.  Q-fever serology obtained on 10/05/2007 was positive for phase I antibodies in 1/2/6 and phase II antibodies at 1/128, which is an improvement over previous elevated titers.  Studies on the pulmonary valve tissue removed at surgery are pending.,IMPRESSION: , Q-fever endocarditis.,PLAN:  ,1.  Continue doxycycline and hydroxychloroquine.  I carefully questioned mother about compliance and concomitant use of dairy products while taking these medications.  She assures me that he is compliant with his medications.  We will however repeat his hydroxychloroquine and doxycycline levels.,2.  Repeat Q-fever serology.,3.  Comprehensive metabolic panel and CBC.,4.  Return to clinic in 4 weeks.,5.  Clotting times are being followed by Dr. X.
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DESCRIPTION: A 16-year-old male with Q-fever endocarditis.

soap / chart / progress notes, q-fever, q-fever endocarditis, endocarditis, doxycycline, fever,

This case involves a 16-year-old male with Q-fever endocarditis, which is being managed with a complex medication regimen and recent heart surgery. Endocarditis is a serious condition that can lead to life-threatening complications if not managed properly, especially when involving the heart valves as seen here. The stakes are increased by the need for careful monitoring of medication levels, potential side effects (like the loose stools mentioned), the patient's recent surgery, and the interaction with anticoagulant therapy monitored by clotting times. The patient's condition requires careful follow-up to prevent further complications, such as heart failure, embolic events, or surgical complications. While the situation is currently stable and managed, the high potential for serious complications makes this a high-stakes scenario.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Prostate Adenocarcinoma - 2

PHYSICAL EXAMINATION:,  This 71-year-old man went to his primary care physician for a routine physical.  His only complaints were nocturia times two and a gradual "slowing down" feeling.  The physical examination on 1/29 was within normal limits except for the digital rectal exam which revealed an asymmetric prostate gland with nodularity, R>L.  PSA was elevated.  The differential diagnosis for the visit was abnormal prostate, suggestive of CA.,IMAGING:  ,CT pelvis:  Irregular indentation of bladder.  Seminal vesicles enlarged.  Streaky densities in periprostatic fat consistent with transcapular spread to periprostatic plexus.  Impression:  prostatic malignancy with extracapsular extension and probable regional node metastasis.,Bone scan:  Negative for distant metastasis.,LABORATORY:,  PSA 32.1,PROCEDURES:,  Transrectal needle biopsy of prostate.  Pelvic lymphadenectomy and radical prostatectomy.,PATHOLOGY:  ,Prostate biopsy:  Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.,Lymphadenectomy and prostatectomy:  Frozen section of removed pelvic lymph nodes demonstrated metastatic adenocarcinoma in one lymph node in the right obturator fossa.  Therefore, the radical prostatectomy was canceled.  ,Final pathology diagnosis:  Pelvic lymphadenectomy; left obturator fossa, single negative lymph node.  Right obturator fossa; metastatic adenocarcinoma in 1/5 lymph nodes.  Largest involved node 1.5 cm.,TREATMENT: , Patient began external beam radiation therapy to the pelvis.
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DESCRIPTION: Moderate to poorly differentiated adenocarcinoma in the right lobe and poorly differentiated tubular adenocarcinoma in the left lobe of prostate.

soap / chart / progress notes, nocturia, asymmetric prostate gland, periprostatic, metastasis, poorly differentiated adenocarcinoma, differentiated adenocarcinoma, radical prostatectomy, metastatic adenocarcinoma, lymph nodes, prostatectomy, prostate, lymphadenectomy, adenocarcinoma

The patient's diagnosis indicates a serious and advanced medical condition, prostate adenocarcinoma, with evidence of extracapsular extension and regional metastasis. This situation involves significant decision-making regarding treatment options, such as the initially planned radical prostatectomy, which was canceled due to positive lymph nodes. The patient is undergoing external beam radiation therapy, which emphasizes the severity and potential impact on the patient's health and quality of life. The condition requires careful monitoring and management, making it a high-stakes medical situation.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Prostate Adenocarcinoma - 4

PHYSICAL EXAMINATION:,  Patient is a 46-year-old white male seen for annual physical exam and had an incidental PSA elevation of 4.0.  All other systems were normal.,PROCEDURES:  ,Sextant biopsy of the prostate.,Radical prostatectomy:  Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.,PATHOLOGY:,Prostate biopsy:  Right lobe, negative.  Left lobe, small focus of adenocarcinoma, Gleason's 3 + 3 in approximately 5% of the tissue.,Radical prostatectomy:  Negative lymph nodes.  Prostate gland showing moderately differentiated infiltrating adenocarcinoma, Gleason 3 + 2 extending to the apex involving both lobes of the prostate, mainly right.  Tumor overall involved less than 5% of the tissue.  Surgical margin was reported and involved at the apex.  The capsule and seminal vesicles were free.,DISCHARGE NOTE:,  Patient has made good post-op recovery other than mild urgency incontinence.  His post-op PSA is 0.1 mg/ml.
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DESCRIPTION: Prostate gland showing moderately differentiated infiltrating adenocarcinoma - Excised prostate including capsule, pelvic lymph nodes, seminal vesicles, and small portion of bladder neck.

soap / chart / progress notes, capsule, bladder neck, surgical margin, moderately differentiated infiltrating adenocarcinoma, pelvic lymph nodes, prostate gland, infiltrating adenocarcinoma, radical prostatectomy, seminal vesicles, gleason's, seminal, vesicles, adenocarcinoma, prostate,

This clinical scenario involves a patient diagnosed with prostate adenocarcinoma, confirmed through biopsy and radical prostatectomy. The stakes are moderate to high because cancer diagnosis and treatment significantly impact a patient's long-term health, quality of life, and survival. Although this case seems well-managed with a post-operative PSA of 0.1, indicating successful removal of prostate tissue, the involvement at the surgical margin suggests there might be a risk for residual disease. Ongoing monitoring and potentially further treatment could be necessary, highlighting the importance of follow-up care.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Prostate Adenocarcinoma - 1

HISTORY:,  This 75-year-old man was transferred from the nursing home where he lived to the hospital late at night on 4/11 through the Emergency Department in complete urinary obstruction.  After catheterization, the patient underwent cystoscopy on 4/13.  On 4/14 the patient underwent a transurethral resection of the prostate and was discharged back to the nursing home later that day with voiding improved.  Final diagnosis was adenocarcinoma of the prostate.  Because of his mental status and general debility, the patient's family declined additional treatment.,LABORATORY:,  None,PROCEDURES:,Cystoscopy:  Blockage of the urethra by a markedly enlarged prostate.,Transurethral resection of prostate:  45 grams of tissue were sent to the Pathology Department for analysis.,PATHOLOGY: , Well differentiated adenocarcinoma, microacinar type, in 1 of 25 chips of prostatic tissue.
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DESCRIPTION: Complete urinary obstruction, underwent a transurethral resection of the prostate - adenocarcinoma of the prostate.

soap / chart / progress notes, urinary obstruction, voiding, resection of the prostate, adenocarcinoma of the prostate, complete urinary obstruction, prostate adenocarcinoma, transurethral resection, cystoscopy, transurethral, resection, prostate, adenocarcinoma,

The situation involves a 75-year-old man diagnosed with prostate adenocarcinoma who is unable to receive further treatment due to mental status and general debility. The family declined additional treatment, which suggests that the patient's condition may be serious, but the decision to forgo further interventions indicates an acceptance of the risks. This is a significant medical situation, but the stakes for immediate action are limited given the family's decision.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Prostate Fossa Irradiation - Followup

HISTORY OF PRESENT ILLNESS: , The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma.  His urinary function had been stable until 2 days ago.  Over the past couple of days he has been waking every 1 to 1-1/2 hours and has had associated abdominal cramping, as well as a bit of sore throat (his wife has had a cold for about 2 weeks).  His libido remains intact (but he has not been sexually functional), but his erections have been dysfunctional.  The bowel function is stable with occasional irritative hemorrhoidal symptoms.  He has had no hematochezia.  The PSA has been slowly rising in recent months.  This month it reached 1.2.,PAIN ASSESSMENT: , Abdominal cramping in the past 2 days.  No more than 1 to 2 of 10 in intensity.,PERFORMANCE STATUS: , Karnofsky score 100.  He continues to work full-time.,NUTRITIONAL STATUS: , Appetite has been depressed over the past couple of days, and he has lost about 5 pounds.  (Per him, mostly this week.),PSYCHIATRIC: , Some stress regarding upcoming IRS audits of clients.,REVIEW OF SYSTEMS: , Otherwise noncontributory.,MEDICATIONS,1.  NyQuil.,2.  Timolol eye drops.,3.  Aspirin.,4.  Advil.,5.  Zinc.,PHYSICAL EXAMINATION,GENERAL:  Pleasant, well-developed, gentleman in no acute distress.  Weight is 197 pounds.,HEENT:  Sclerae and conjunctivae are clear.  Extraocular movement are intact.  Hearing is grossly intact.  The oral cavity is without thrush.  There is minor pharyngitis.,LYMPH NODES:  No palpable lymphadenopathy.,SKELETAL:  No focal skeletal tenderness.,LUNGS:  Clear to auscultation bilaterally.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft, nontender without palpable mass or organomegaly.,DIGITAL RECTAL EXAMINATION:  There are external hemorrhoids.  The prostate fossa is flat without suspicious nodularity.  There is no blood on the examining glove.,EXTREMITIES:  Without clubbing, cyanosis, or edema.,NEUROLOGIC:  Without focal deficit.,IMPRESSION:,  Concerning slow ongoing rise in PSA.,PLAN: , Discussed significance of this in detail with the patient.  He understands the probability that there may be residual cancer although the location is unknown.  For now there is no good evidence that early management affects the ultimate prognosis.  Accordingly, he is comfortable with careful monitoring, and I have asked him to return here in 3 months with an updated PSA.  I also suggested that he reestablish contact with Dr. X at his convenience.
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DESCRIPTION: The patient returns for followup evaluation 21 months after undergoing prostate fossa irradiation for recurrent Gleason 8 adenocarcinoma.    Concerning slow ongoing rise in PSA.

The situation involves a follow-up for a patient who previously underwent treatment for recurrent Gleason 8 adenocarcinoma, a high-grade prostate cancer. The concerning issue is the slow rise in PSA levels, which may indicate residual cancer. While the situation has potential implications for the patient's cancer prognosis, the current plan is to monitor carefully without immediate aggressive intervention. Therefore, while the stakes involve potential cancer recurrence, the immediate risk or action required is not critical or urgent, reflected in the decision for a 3-month follow-up.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Progress Note - Iron Deficiency Anemia

HISTORY OF PRESENT ILLNESS:,  The patient is a 55-year-old gentleman, a patient of Mrs. A, who was referred to me because the patient developed iron deficiency anemia and he had blood in his stool.  The patient also has chronic diarrhea.  His anemia was diagnosed months ago when he presented with unusual pruritus and he got a CBC.  At that time he was discovered to have hemoglobin of 9 and MCV 65.  The patient also had multiple episodes of dark blood and bright blood in the stool for the last 5 months on and off.  Last colonoscopy was performed by Dr. X in Las Cruces 3 years ago.  At that time the patient had polyps removed from the colon, all of them were hyperplastic in nature.  The patient also was diagnosed with lymphocytic colitis.  He was not treated for diarrhea for more than 3 years.,PAST MEDICAL HISTORY: , Includes chronic diarrhea as I mentioned before and chronic obstructive pulmonary disease secondary to heavy smoking.,MEDICATIONS: , Iron supplement.,ALLERGIES:  ,The patient has no known drug allergies.,FAMILY HISTORY:,  Includes coronary artery disease, hypertension.  Nobody in the family was diagnosed with any type of colon cancer or any type of other cancer.,SOCIAL HISTORY:,  The patient smoked 1-1/2 packs for more than 40 years.  He consumes 6 beers per day.  He denies any drug use.,REVIEW OF SYSTEMS: , The patient has no night sweats.  Good appetite.  Stable weight.  No chills, no fevers.  No visual problems.  No hearing problems.  The patient denies any difficulty swallowing, any nausea or vomiting, any burning sensation in the esophagus.  The patient has had chronic diarrhea for more than 3 years.  His stool is daily, 1-2 times per day and very loose.  He also admitted to have dark and bright blood in the stool on and off for more than 5 months.  Respiratory review of systems was significant for COPD.  The patient is not on oxygen and his COPD is mild.  He denies any neurological problems, psychiatric problems, endocrine problems, hematological problems, lymphatic problems, immunological problems, allergy problems.  The patient had recent episode of significant skin itching all over the body.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Weight 221 pounds.  Height 6 feet 1 inch.  Blood pressure 124/62, heart rate 87, temperature 98.4, saturation 98%.  Pain is 0/10.,GENERAL:  Well-developed, well-nourished, normal asthenic.  Good attention to grooming.,HEENT:  PERRLA.  EOM intact.  Oropharynx is clear of lesions.  Good dentition.,NECK:  Supple.  No lymphadenopathy.  No thyromegaly.,LUNGS:  Clear to auscultation and percussion bilaterally.  No wheezing, no rhonchi, no crackles.,CARDIOVASCULAR:  Regular rate and rhythm.  The patient had 2/6 systolic ejection murmur on aortic valve projected to carotid artery.  No rubs, no gallops.  No JVD.  Peripheral pulses 2+ in both radialis and both dorsalis pedis bilaterally.,ABDOMEN:  No masses, no tenderness.  No distention.  No hepatosplenomegaly.  Bowel sounds present.,RECTAL:  Good sphincter tone.  No palpable nodules.  No masses.  No blood.  Dark stool, the patient is taking iron.  Test was sent for occult blood test.,BACK:  No costovertebral tenderness bilaterally.,LYMPHATICS:  The patient had no neck, axial, groin or supraclavicular lymphadenopathy on exam.,MUSCULOSKELETAL:  The patient had good, stable gait.  No clubbing, no cyanosis, no pitting edema.  Full range of motion.  No joint deformities.,SKIN:  Clear of rashes and lesions.  No ulcers.,NEUROLOGICAL:  Cranial nerves II-XII within normal limits.  Deep tendon reflexes 2+ in both knees and both biceps.  Babinski negative bilaterally.  Good control of bowel and urinary bladder.  No local weakness.,PSYCHIATRIC:  The patient had good judgment and insight.  Oriented x4.  Good recent and remote memory.  Appropriate mood and affect.,ASSESSMENT & PLAN:  ,The patient is a 55-year-old gentleman with iron deficiency anemia, blood in the stool.  The patient needs evaluation for source of bleeding with a colonoscopy.  The patient was explained rationale, risks, benefits, and alternatives of the procedure.  He accepted the recommendation.  Colonoscopy scheduled.  The patient will need antibiotic prophylaxis prior to procedure because of valvular abnormality and we are not completely aware of what type of abnormality.  The patient had multiple tests from a previous examination.  One of the pathology reports from Dr. X from 2003 showed lymphocytic microscopic colitis, hyperplastic polyps.  Reviewed also multiple lab tests including CBC, CMP.  The patient had Coombs' test negative.  His reticulocyte count is 2.41.  His iron TIBC 514, serum iron 29, ferritin 7.  He had no liver function test abnormality.  PSA was in the normal range.  The patient had x-ray which showed pulmonary hyperinflation and emphysema.  The patient will be followed up with result of colonoscopy.
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DESCRIPTION: Patient developed iron deficiency anemia and had blood in his stool.

The patient is exhibiting serious symptoms indicative of a potentially severe condition. The presence of blood in the stool, coupled with chronic diarrhea, anemia, and a history of polyps and lymphocytic colitis, suggest the possibility of gastrointestinal bleeding or even a malignancy. Additionally, the patient's chronic obstructive pulmonary disease adds complexity to his health situation. While it is not a crisis requiring immediate emergency treatment, it requires thorough investigation and prompt action to prevent potential worsening of the condition. Given the need for a colonoscopy to identify the source of bleeding and the presence of anemia, this is a significant health concern that could have serious implications if not properly diagnosed and treated.