Medical Specialty: General Medicine
Sample Name: Normal Physical Exam Template - 4

GENERAL:  ,XXX,VITAL SIGNS: , Blood pressure XXX, pulse XXX, temperature XXX, respirations XXX.  Height XXX, weight XXX.,HEAD: , Normocephalic.  Negative lesions, negative masses.,EYES: , PERLA, EOMI.  Sclerae clear.  Negative icterus, negative conjunctivitis.,ENT:,  Negative nasal hemorrhages, negative nasal obstructions, negative nasal exudates.  Negative ear obstructions, negative exudates.  Negative inflammation in external auditory canals.  Negative throat inflammation or masses.,SKIN: , Negative rashes, negative masses, negative ulcers.  No tattoos.,NECK:,  Negative palpable lymphadenopathy, negative palpable thyromegaly, negative bruits.,HEART:,  Regular rate and rhythm.  Negative rubs, negative gallops, negative murmurs.,LUNGS:,  Clear to auscultation.  Negative rales, negative rhonchi, negative wheezing.,ABDOMEN: , Soft, nontender, adequate bowel sounds.  Negative palpable masses, negative hepatosplenomegaly, negative abdominal bruits.,EXTREMITIES: , Negative inflammation, negative tenderness, negative swelling, negative edema, negative cyanosis, negative clubbing.  Pulses adequate bilaterally.,MUSCULOSKELETAL:,  Negative muscle atrophy, negative masses.  Strength adequate bilaterally.  Negative movement restriction, negative joint crepitus, negative deformity.,NEUROLOGIC: , Cranial nerves I through XII intact.  Negative gait disturbance.  Balance and coordination intact.  Negative Romberg, negative Babinski.  DTRs equal bilaterally.,GENITOURINARY:  ,Deferred.,
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DESCRIPTION: Normal physical exam template.  Normocephalic.  Negative lesions, negative masses.

The provided text is a medical template for a normal physical exam and contains typical placeholder values for various sections such as vital signs, head, eyes, ENT, and more. This template is a standard document used by healthcare professionals to record the results of a patient’s routine physical examination. The stakes associated with this information are relatively low because the text represents a generic template without specific patient details, critical diagnoses, or time-sensitive information. It's a routine procedural document used for monitoring general health.


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

Medical Specialty: Discharge Summary
Sample Name: COPD & Bronchitis - Discharge Summary

DIAGNOSIS AT ADMISSION:,  Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.,DIAGNOSES AT DISCHARGE,1.  Chronic obstructive pulmonary disease exacerbation and acute bronchitis.,2.  Congestive heart failure.,3.  Atherosclerotic cardiovascular disease.,4.  Mild senile-type dementia.,5.  Hypothyroidism.,6.  Chronic oxygen dependent.,7.  Do not resuscitate/do not intubate.,HOSPITAL COURSE: , The patient was admitted from the office by Dr. X.  She was placed on the usual medications that included Synthroid 0.05 mg a day, enalapril 5 mg a day, Imdur 30 mg a day, Lanoxin 0.125 mg a day, aspirin 81 mg a day, albuterol and Atrovent nebulizers q.4 h., potassium chloride 10 mEq 2 tablets per day, Lasix 40 mg a day, Humibid L.A.  600 mg b.i.d.  She was placed on oral Levaquin after a load of 500 mg and 250 mg a day.  She was given oxygen, encouraged to eat, and suctioned as needed.,Laboratory data included a urinalysis that had 0-2 WBCs per high power field and urine culture was negative, blood cultures x2 were negative, TSH was 1.7, and chem-7, sodium 134, potassium 4.4, chloride 93, CO2 34, glucose 105, BUN 17, creatinine 0.9, and calcium 9.1.  Digoxin was 1.3.  White blood cell count was 6100 with a normal differential, H&H 37.4/12.1, platelets 335,000.  Chest x-ray was thought to have prominent interstitial lung changes without acute infiltrate.  There is a question if there is mild fluid overload.,The patient improved with the above regimen.  By discharge, her lungs fell back to her baseline.  She had no significant shortness of breath.  Her O2 saturations were stable.  Her vital signs were stable.,She is discharged home to follow up with me in a week and a half.,Her daughter has been spoken to by phone and she will notify me if she worsens or has problems.,PROGNOSIS:  ,Guarded.
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DESCRIPTION: Chronic obstructive pulmonary disease (COPD) exacerbation and acute bronchitis.

discharge summary, chronic obstructive pulmonary disease exacerbation, chronic obstructive pulmonary disease, pulmonary, copd, discharge, bronchitis,

The discharge summary indicates a patient with multiple chronic conditions and a new exacerbation of COPD. The inclusion of a prognosis labeled as 'guarded' and a 'do not resuscitate/do not intubate' order suggests a serious medical situation. While the patient is stable at discharge, the combination of multiple health issues, oxygen dependency, and a need for follow-up adds to the criticality. These factors potentially impact the patient's quality of life and require careful monitoring post-discharge, indicating medium to high stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Orthopedic
Sample Name: Bilateral Hip Pain

HISTORY OF PRESENT ILLNESS:  ,The patient is a 38-year-old woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration.  The patient states that she began with right hip pain getting steadily worse over the last 2 years and has now developed some pain in the left hip.  The pain is located laterally as well as anteriorly into the groin.  She states that the pain is present during activities such as walking, and she does get some painful popping and clicking in the right hip.  She is here for evaluation for the first time.  She sought no previous medical attention for this.,PAST MEDICAL HISTORY:  ,Significant for depression and reflux disease.,PAST SURGICAL HISTORY: , Cesarean section x 2.,CURRENT MEDICATIONS: , Listed in the chart and reviewed with the patient.,ALLERGIES:  ,The patient has no known drug allergies.,SOCIAL HISTORY:  ,The patient is married.  She is employed as an office manager.  She does smoke cigarettes, one pack per day for the last 20 years.  She consumes alcohol 3 to 5 drinks daily.  She uses no illicit drugs.  She exercises monthly mainly walking and low impact aerobics.  She also likes to play softball.,REVIEW OF SYSTEMS: , Significant for occasional indigestion and nausea as well as anxiety and depression.  The remainder of the systems negative.,PHYSICAL EXAMINATION: , The patient is 5 foot, 2 inches tall, weighs 155 pounds.  The patient ambulates independently without an assist device with normal stance and gait.  Inspection of the hips reveals normal contour and appearance and good symmetry.  The patient is able to do an active straight leg raise against gravity and against resistance bilaterally.  She has no significant trochanteric tenderness.  She does, however, have some tenderness in the groin bilaterally.  There is no crepitus present with passive or active range of motion of the hips.  She is grossly neurologically intact in the bilateral lower extremities.,DIAGNOSTIC DATA:,  X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip.  There are no acute findings.  No fractures or dislocations.  There are minimal degenerative changes noted in the joint.  There is, however, the suggestion of an exostosis on the superior femoral neck, which could be consistent with femoroacetabular impingement.,IMPRESSION: , Bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on x-rays and her clinical picture is also consistent with possible labral tear.,PLAN:,  After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy and especially concentrating on the labrum in the right hip.  We will get that done as soon as possible.  In the meantime, she is asked to moderate her activities.  She will follow up as soon as the MRIs are performed.
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DESCRIPTION: A woman presenting to our clinic for the first time for evaluation of hip pain, right greater than left, of greater than 2 years duration.  The pain is located laterally as well as anteriorly into the groin.

orthopedic, bilateral hip pain, femoroacetabular, impingement, hip,

The case involves a 38-year-old woman who has been experiencing bilateral hip pain for over two years, with possible femoroacetabular impingement or labral tear as suggested by the initial evaluation. Although the condition impacts her mobility and quality of life, especially given its duration, she has been living with the condition, indicating it may not be immediately life-threatening. However, her smoking and alcohol habits coupled with her existing depression could complicate both the diagnosis and potential treatment outcomes. Given these considerations, the stakes are moderate, primarily due to the potential for the condition to worsen without proper diagnosis and treatment, impacting her overall health and quality of life.


Medical Specialty: Chiropractic
Sample Name: Chiropractic Initial Evaluation - 1

HISTORY OF PRESENT COMPLAINT: ,Ms. Abc initially visited our office for the purpose of consultation and examination on December 1, 2004. Ms. Abc states that on November 16, 2004, she was in a parking lot, she was walking to her car, and stepped into a pothole. The patient reports that she fell backwards. The patient landed on her back and hit her head as well. The patient reports sudden, severe left ankle pain and low back pain as well as neck pain in the back of her head. The patient was unable to get up due to severe pain. The patient was afraid that she broke her left ankle. The patient eventually got up and went to her car. The patient went home and symptoms got worse. A few days later, the patient went to the hospital on November 21, 2004. The patient had x-rays of the lumbar spine, left ankle, and left foot. The patient was seen at Healthcare System. She was next seen by Rapid Rehabilitation on December 1, 2004.,
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DESCRIPTION: Chiropractic Evaluation - Patient with ankle, cervical, and thoracic sprain/strain.

The scenario involves the initial chiropractic evaluation of a patient who suffered an injury after falling into a pothole. The patient reports severe pain and was unable to get up initially, fearing a broken ankle. The situation requires careful assessment to rule out serious injuries and to guide the appropriate treatment. However, the case primarily concerns musculoskeletal issues, a common scope of chiropractic care, and does not appear to involve immediate life-threatening conditions or urgent surgical interventions, which would typically classify a situation as high-stakes.


Medical Specialty: Gastroenterology
Sample Name: Exploratory Laparotomy & Hernia Repair

PREOPERATIVE DIAGNOSIS:,1.  Acute bowel obstruction.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSIS:,1.  Acute small bowel obstruction.,2.  Incarcerated umbilical Hernia.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Release of small bowel obstruction.,3.  Repair of periumbilical hernia.,ANESTHESIA: , General with endotracheal intubation.,COMPLICATIONS:,  None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,HISTORY:  ,The patient is a 98-year-old female who presents from nursing home extended care facility with an incarcerated umbilical hernia, intractable nausea and vomiting and a bowel obstruction.  Upon seeing the patient and discussing in extent with the family, it was decided the patient needed to go to the operating room for this nonreducible umbilical hernia and bowel obstruction and the family agreed with surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have an incarcerated umbilical hernia.  There was a loop of small bowel incarcerated within the hernia sac.  It showed signs of ecchymosis, however no signs of any ischemia or necrosis.  It was easily reduced once opening the abdomen and the rest of the small bowel was ran without any other defects or abnormalities.,PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and the patient's family.  The patient was brought to the operating suite.  After general endotracheal intubation, prepped and draped in normal sterile fashion.  A midline incision was made around the umbilical hernia defect with a #10 blade scalpel.  Dissection was then carried down to the fascia.  Using a sharp dissection, an incision was made above the defect superior to the defect entering the fascia.  The abdomen was entered under direct visualization.  The small bowel that was entrapped within the hernia sac was easily reduced and observed and appeared to be ecchymotic, however, no signs of ischemia were noted or necrosis.  The remaining of the fascia was then extended using Metzenbaum scissors.  The hernia sac was removed using Mayo scissors and sent off as specimen.  Next, the bowel was run from the ligament of Treitz to the ileocecal valve with no evidence of any other abnormalities.  The small bowel was then milked down removing all the fluid.  The bowel was decompressed distal to the obstruction.  Once returning the abdominal contents to the abdomen, attention was next made in closing the abdomen and using #1 Vicryl suture in the figure-of-eight fashion the fascia was closed.  The umbilicus was then reapproximated to its anatomical position with a #1 Vicryl suture.  A #3-0 Vicryl suture was then used to reapproximate the deep dermal layers and skin staples were used on the skin.  Sterile dressings were applied.  The patient tolerated the procedure well and was transferred to recovery in stable condition.
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DESCRIPTION: Exploratory laparotomy, release of small bowel obstruction, and repair of periumbilical hernia.  Acute small bowel obstruction and incarcerated umbilical Hernia.

gastroenterology, endotracheal intubation, acute bowel obstruction, umbilical hernia, exploratory laparotomy, release of small bowel obstruction, repair of periumbilical hernia, incarcerated umbilical hernia, incarcerated, bowel, hernia, exploratory, laparotomy, abdomen, umbilical, obstruction,

The situation involves a surgical procedure performed on a 98-year-old patient with a potentially life-threatening condition, an acute bowel obstruction and an incarcerated umbilical hernia. Such conditions can lead to serious complications if not treated promptly, especially given the patient's advanced age and the potential for rapid deterioration. The surgery is necessary to prevent complications such as bowel ischemia or necrosis, which can be fatal. However, the procedure was completed successfully without complications, and the patient tolerated it well, which indicates that the immediate high-stakes element was managed effectively.


Medical Specialty: Emergency Room Reports
Sample Name: Fall & Laceration

CC:,  Fall and laceration.,HPI: , Mr. B is a 42-year-old man who was running to catch a taxi when he stumbled, fell and struck his face on the sidewalk.  He denies loss of consciousness but says he was dazed for a while after it happened.  He complains of pain over the chin and right forehead where he has abrasions.  He denies neck pain, back pain, extremity pain or pain in the abdomen.,PMH: , Hypertension.,MEDS:,  None.,ROS: , As above.  Otherwise negative.,PHYSICAL EXAM: , This is a gentleman in full C-spine precautions on a backboard brought by EMS.  He is in no apparent distress.  ,Vital Signs:  BP 165/95 HR 80 RR 12 Temp 98.4 SpO2 95% ,HEENT:  No palpable step offs, there is blood over the right fronto-parietal area where there is a small 1cm laceration and surrounding abrasion.  Also, 2 cm laceration over the base of the chin without communication to the oro-pharynx.  No other trauma noted.  No septal hematoma.  No other facial bony tenderness.  ,Neck:  Nontender ,Chest:  Breathing comfortably; equal breath sounds.  ,Heart:  Regular rhythm.,Abd:  Benign.,Ext:  No tenderness or deformity; pulses are equal throughout; good cap refill ,Neuro:  Awake and alert; slight slurring of speech and cognitive slowing consistent with alcohol; moves all extremities; cranial nerves normal.  ,COURSE IN THE ED:,  Patient arrived and was placed on monitors.  An IV had been placed in the field and labs were drawn.  X-rays of the C spine show no fracture and I've removed the C-collar.  The lacerations were explored and no foreign body found.  They were irrigated and closed with simple interrupted sutures.  Labs showed normal CBC, Chem-7, and U/A except there was moderate protein in the urine.  The blood alcohol returned at 0.146.  A banana bag is ordered and his care will be turned over to Dr. G for further evaluation and care.
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DESCRIPTION: Patient running to catch a taxi and stumbled, fell and struck his face on the sidewalk.

emergency room reports, loss of consciousness, laceration, fall, course in the ed, placed on monitors, fell and struck, abrasions,

The situation involves a middle-aged man who fell and sustained facial lacerations and abrasions while under the influence of alcohol. While his injuries do not appear to be life-threatening, the presence of a high blood alcohol level and slight cognitive impairment indicates a need for careful monitoring and treatment. There are no serious complications evident from the examination, such as loss of consciousness, neck or spine injury, but his hypertension and alcohol use complicate the situation slightly. Overall, while not the most critical emergency, it requires appropriate medical attention to prevent complications.


Medical Specialty: Orthopedic
Sample Name: McBride Bunionectomy & Wedge Osteotomy

PREOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,POSTOPERATIVE DIAGNOSIS:,  Right hallux abductovalgus deformity.,PROCEDURES PERFORMED:,1.  Right McBride bunionectomy.,2.  Right basilar wedge osteotomy with OrthoPro screw fixation.,ANESTHESIA: , Local with IV sedation.,HEMOSTASIS: , With pneumatic ankle cuff.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room and placed in a supine position.  The right foot was prepared and draped in usual sterile manner.  Anesthesia was achieved utilizing a 50:50 mixture of 2% lidocaine plain with 0.5 Marcaine plain infiltrated just proximal to the first metatarsocuneiform joint.  Hemostasis was achieved utilizing a pneumatic ankle Tourniquet placed above the right ankle and inflated to a pressure of 225 mmHg.  At this time, attention was directed to the dorsal aspect of the right first metatarsophalangeal joint where dorsal linear incision approximately 3 cm in length was made.  The incision was deepened within the same plain taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the underlying capsular structure once again taking care of the Bovie and retracted all superficial nerves and vessels as necessary.  The capsular incision following the same outline as the skin incision was made and carried down to the underlying bony structure.  The capsule was then freed from the underling bony structure utilizing sharp and blunt dissection.  Using a microsagittal saw, the medial and dorsal very prominent bony eminence were removed and the area was inspected for any remaining bony prominences following resection of bone and those noted were removed using a hand rasp.  At this time, attention was directed to the first inner space using sharp and blunt dissection.  Dissection was carried down to the underling level of the adductor hallucis tendon, which was isolated and freed from its phalangeal, sesamoidal, and metatarsal attachments.  The tendon was noted to lap the length and integrity for transfer and at this time was tenotomized taking out resection of approximately 0.5 cm to help prevent any re-fibrous attachment.  At this time, the lateral release was stressed and was found to be complete.  The extensor hallucis brevis tendon was then isolated using blunt dissection and was tenotomized as well taking out approximately 0.5-cm resection.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected for any bony prominences remaining and it was noted that the base of the proximal phalanx on the medial side due to the removal of the extensive buildup of the metatarsal head was going to be very prominent in nature and at this time was removed using a microsagittal saw.  The area was again copiously flushed and inspected for any abnormalities and/or prominences and none were noted.  At this time, attention was directed to the base of the first metatarsal where a second incision was made approximately 4 cm in length.  The incision was deepened within the same plain taking care of Bovie and retracted all superficial nerves and vessels as necessary.  The incision was then carried down to the level of the metatarsal and using sharp and blunt dissection periosteal capsule structures were freed from the base of the metatarsal and taking care to retract the long extensive tendon and any neurovascular structures to avoid any disruption.  At this time, there was a measurement made of 1 cm just distal to the metatarsocuneiform joint on the medial side and 2 cm distal to the metatarsocuneiform joint from the lateral aspect of the joint.  At this time, 0.5 cm was measured distal to that lateral measurement and using microsagittal saw, a wedge osteotomy was taken from the base with the apex of the osteotomy being medial, taking care to keep the medial cortex intact as a hinge.  The osteotomy site was feathered down until the osteotomy site could be closed with little tension on it and at this time using an OrthoPro screw 3.0 x 22 mm.  The screw was placed following proper technique.  The osteotomy site was found to be fixated with absolutely no movement and good stability upon manual testing.  A very tiny gap on the lateral aspect of the osteotomy site was found and this was filled in packing it with the cancellous bone that was left over from the wedge osteotomy.  The packing of the cancellous bone was held in place with bone wax.  The entire area was copiously flushed 3 times using a sterile saline solution and was inspected and tested again for any movement of the osteotomy site or any gapping and then removed.  At this time, a deep closure was achieved utilizing #2-0 Vicryl suture, subcuticular closure was achieved using #4-0 Vicryl suture, and skin repair was achieved at both surgical sites with #5-0 nylon suture in a running interlocking fashion.  The hallux was found to have excellent movement upon completion of the osteotomy and the second procedure of the McBride bunionectomy and the metatarsal was found to stay in excellent alignment with good stability at the proximal osteotomy site.  At this time, the surgical site was postoperatively injected with 0.5 Marcaine plain as well as dexamethasone 4 mg primarily.  The surgical sites were then dressed with sterile Xeroform, sterile 4x4s, cascading, and Kling with a final protective layer of fiberglass in a nonweightbearing cast fashion.  The tourniquet was dropped and color and temperature of all digits returned to normal.  The patient tolerated the anesthesia and the procedure well and left the operating room in stable condition.,The patient has been given written and verbal postoperative instructions and has been instructed to call if she has any questions, problems, or concerns at any time with the numbers provided.  The patient has also been warned a number of times the importance of elevation and no weightbearing on the surgical foot.,
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DESCRIPTION: Right hallux abductovalgus deformity.  Right McBride bunionectomy.  Right basilar wedge osteotomy with OrthoPro screw fixation.

orthopedic, hallux, abductovalgus, bunionectomy, mcbride, basilar, wedge, osteotomy, orthopro, screw, fixation, wedge osteotomy

The procedure described involves an orthopedic surgery to correct a foot deformity, which is generally a routine and low-risk operation. It is not life-threatening and is performed to improve the patient's quality of life. However, it is important that the patient follows postoperative instructions to ensure proper healing. The stakes are low because there are no indications of complications or life-threatening scenarios in the information provided.


Medical Specialty: General Medicine
Sample Name: Gen Med Progress Note - 12

SUBJECTIVE: , The patient was seen and examined.  He feels much better today, improved weakness and decreased muscular pain.  No other complaints.,PHYSICAL EXAMINATION:,GENERAL:  Not in acute distress, awake, alert and oriented x3.,VITAL SIGNS:  Blood pressure 147/68, heart rate 82, respiratory rate 20, temperature 97.7, O2 saturation 99% on 3 L.,HEENT:  NC/T, PERRLA, EOMI.,NECK:  Supple.,HEART: Regular rate and rhythm.,RESPIRATORY:  Clear bilateral.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses present bilateral.,LABORATORY DATA: , Total CK coming down 70,142 from 25,573, total CK is 200, troponin is 2.3 from 1.9 yesterday.,BNP, blood sugar 93, BUN of 55.7, creatinine 2.7, sodium 137, potassium 3.9, chloride 108, and CO2 of 22.,Liver function test, AST 704, ALT 298, alkaline phosphatase 67, total bilirubin 0.3.  CBC, WBC count 9.1, hemoglobin 9.9, hematocrit 29.2, and platelet count 204.  Blood cultures are still pending.,Ultrasound of abdomen, negative abdomen, both kidneys were echogenic, cortices suggesting chronic medical renal disease.  Doppler of lower extremities negative for DVT., ,ASSESSMENT AND PLAN:,1.  Rhabdomyolysis, most likely secondary to statins, gemfibrozil, discontinue it on admission.  Continue IV fluids.  We will monitor.,2.  Acute on chronic renal failure.  We will follow up with Nephrology recommendation.,3.  Anemia, drop in hemoglobin most likely hemodilutional.  Repeat CBC in a.m.,4.  Leukocytosis, improving.,5.  Elevated liver enzyme, most likely secondary to rhabdomyolysis.  The patient denies any abdominal pain and ultrasound is unremarkable.,6.  Hypertension.  Blood pressure controlled.,7.  Elevated cardiac enzyme, follow up with Cardiology recommendation.,8.  Obesity.,9.  Deep venous thrombosis prophylaxis.  Continue Lovenox 40 mg subcu daily.
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DESCRIPTION: Rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity.

general medicine, rhabdomyolysis, acute on chronic renal failure, anemia, leukocytosis, elevated liver enzyme, hypertension, elevated cardiac enzyme, obesity, cardiac enzyme, blood pressure,

The patient is experiencing several serious and potentially life-threatening medical conditions, including rhabdomyolysis, acute on chronic renal failure, elevated cardiac enzymes, and anemia. Additionally, there are risks associated with hypertension and obesity, which require careful monitoring and management. The situation requires close attention and potentially urgent intervention, particularly for the kidney and cardiac issues. These factors suggest a high-stakes situation, as improper management could lead to severe complications.


Medical Specialty: Neurology
Sample Name: Migraine without Aura - Consult

CHIEF COMPLAINT:, Headaches.,HEADACHE HISTORY:, The patient describes the gradual onset of a headache problem. The headache first began 2 months ago. The headaches are located behind both eyes. The pain is characterized as a sensation of pressure. The intensity is moderately severe, making normal activities difficult. Associated symptoms include sinus congestion and photophobia. The headache may be brought on by stress, lack of sleep and alcohol. The patient denies vomiting and jaw pain.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, ,No significant past surgical history.,FAMILY MEDICAL HISTORY:, ,There is a history of migraine in the family. The condition affects the patient’s brother and maternal grandfather.,ALLERGIES:, Codeine.,CURRENT MEDICATIONS:, See chart.,PERSONAL/SOCIAL HISTORY:, Marital status: Married. The patient smokes 1 pack of cigarettes per day.  Denies use of alcohol.,NEUROLOGIC DRUG HISTORY:, The patient has had no help with the headaches from over-the-counter analgesics.,REVIEW OF SYSTEMS:,ROS General: Generally healthy. Weight is stable.,ROS Head and Eyes: Patient has complaints of headaches. Vision can best be described as normal.,ROS Ears Nose and Throat: The patient notes some sinus congestion.,ROS Cardiovascular: The patient has no history of any cardiovascular problems and denies any present problems.,ROS Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,ROS Musculoskeletal: No muscle cramps, no joint back or limb pain. The patient denies any past or present problem related to the musculoskeletal system.,EXAM:,Exam General Appearance: The patient was alert and cooperative, and did not appear acutely or chronically ill.,Sex and Race: Male, Caucasian.,Exam Mental Status: Serial 7’s were performed normally. The patient was oriented with regard to time, place and situation.,Three out of three objects were readily recalled after several minutes. The patient correctly identified the president and past president. The patient could repeat 7 digits forward and 4 digits reversed without difficulty. The patient’s affect and emotional response was normal and appropriate. The patient related the clinical history in a coherent, organized fashion.,Exam Cranial Nerves: Sense of smell was intact.,Exam Neck: Neck range of motion was normal in all directions. There was no evidence of cervical muscle spasm.  No radicular symptoms were elicited by neck motions. Shoulder range of motion was normal bilaterally. There were no areas of tenderness. Tests of neurovascular compression were negative. There were no carotid bruits.,Exam Back: Back range of motion was normal in all directions.,Exam Sensory: Position and vibratory sense was normal.,Exam Reflexes: Active and symmetrical. There were no pathological reflexes.,Exam Coordination: The patient’s gait had no abnormal components. Tandem gait was performed normally.,Exam Musculoskeletal: Peripheral pulses palpably normal. There is no edema or significant varicosities.  No lesions identified.,IMPRESSION DIAGNOSIS: ,Migraine without aura (346.91),COMMENTS:, The patient has evolved into a chronic progressive course. Medications Prescribed: Therapeutic trial of Inderal 40mg - 1/2 tab b.i.d. x 1 week, then 1 tab. b.i.d. x 1 week then 1 tab t.i.d.,OTHER TREATMENT:, The patient was given a thorough explanation of the role of stress in migraine, and given a number of suggestions about implementing appropriate changes in lifestyle.,RATIONALE FOR TREATMENT PLAN:, The treatment plan chosen is the most effective and should result in the most beneficial outcome for the patient. There are no reasonable alternatives.,FOLLOW UP INSTRUCTIONS:
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DESCRIPTION: The patient with gradual onset of a headache problem, located behind both eyes.

The case presented is not immediately life-threatening. It describes a patient with a migraine without aura, which has developed over two months. Although the pain is moderately severe and affects the patient's daily activities, migraines are generally not considered to be high-stakes compared to conditions with more severe immediate health risks such as a stroke or a heart attack. The plan involves medication and lifestyle adjustments, which do not suggest a high level of urgency or complexity. Therefore, while the condition impacts the patient's quality of life, it does not pose an immediate or serious threat to life or function.


Medical Specialty: Surgery
Sample Name: Aortic Valve Replacement

DIAGNOSIS: , Aortic valve stenosis with coronary artery disease associated with congestive heart failure.  The patient has diabetes and is morbidly obese.,PROCEDURES: , Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.,ANESTHESIA: , General endotracheal,INCISION: , Median sternotomy,INDICATIONS: , The patient presented with severe congestive heart failure associated with the patient's severe diabetes.  The patient was found to have moderately stenotic aortic valve.  In addition, The patient had significant coronary artery disease consisting of a chronically occluded right coronary artery but a very important large obtuse marginal artery coming off as the main circumflex system.  The patient also has a left anterior descending artery which has moderate disease and this supplies quite a bit of collateral to the patient's right system.  It was decided to perform a valve replacement as well as coronary artery bypass grafting procedure.,FINDINGS: , The left ventricle is certainly hypertrophied· The aortic valve leaflet is calcified and a severe restrictive leaflet motion.  It is a tricuspid type of valve.  The coronary artery consists of a large left anterior descending artery which is associated with 60% stenosis but a large obtuse marginal artery which has a tight proximal stenosis.,The radial artery was used for the left anterior descending artery.  Flow was excellent.  Looking at the targets in the posterior descending artery territory, there did not appear to be any large branches.  On the angiogram these vessels appeared to be quite small.  Because this is a chronically occluded vessel and the patient has limited conduit due to the patient's massive obesity, attempt to bypass to this area was not undertaken.  The patient was brought to the operating room,PROCEDURE: , The patient was brought to the operating room and placed in supine position.  A median sternotomy incision was carried out and conduits were taken from the left arm as well as the right thigh.  The patient weighs nearly three hundred pounds.  There was concern as to taking down the left internal mammary artery.  Because the radial artery appeared to be a good conduit The patient would have arterial graft to the left anterior descending artery territory.  The patient was cannulated after the aorta and atrium were exposed and full heparinization.,The patient went on cardiopulmonary bypass and the aortic cross-clamp was applied Cardioplegia was delivered through the coronary sinuses in a retrograde manner.  The patient was cooled to 32 degrees.  Iced slush was applied to the heart.  The aortic valve was then exposed through the aortic root by transverse incision.  The valve leaflets were removed and the #23 St. Jude mechanical valve was secured into position by circumferential pledgeted sutures.  At this point, aortotomy was closed.,The first obtuse marginal artery was a very large target and the vein graft to this target indeed produced an excellent amount of flow.  Proximal anastomosis was then carried out to the foot of the aorta.  The left anterior descending artery does not have severe disease but is also a very good target and the radial artery was anastomosed to this target in an end-to-side manner.  The two proximal anastomoses were then carried out to the root of the aorta.,The patient came off cardiopulmonary bypass after aortic cross-clamp was released.  The patient was adequately warmed.  Protamine was given without adverse effect.  Sternal closure was then done using wires.  The subcutaneous layers were closed using Vicryl suture.  The skin was approximated using staples.
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DESCRIPTION: Aortic valve replacement using a mechanical valve and two-vessel coronary artery bypass grafting procedure using saphenous vein graft to the first obtuse marginal artery and left radial artery graft to the left anterior descending artery.

surgery, coronary artery bypass grafting, saphenous vein graft, radial artery graft, coronary artery disease, congestive heart failure, descending artery territory, aortic cross clamp, aortic valve replacement, coronary artery bypass, obtuse marginal artery, anterior descending artery, mechanical valve, artery bypass, bypass grafting, marginal artery, radial artery, aortic valve, coronary artery, anterior descending, descending artery, valve, artery, aortic, grafting,

The situation described is a complex cardiac surgical procedure involving multiple high-risk factors such as severe congestive heart failure, diabetes, and obesity. These factors significantly increase the surgical risks and complications potential, making this a high-stakes situation. The need for careful planning and execution due to these comorbidities, along with the significance of aortic valve replacement and coronary artery bypass grafting, further highlights the stakes involved.


Medical Specialty: Ophthalmology
Sample Name: Nasolacrimal Probing

PREOPERATIVE DIAGNOSES:,  Tearing, eyelash encrustation with probable tear duct obstruction bilateral.,POSTOPERATIVE DIAGNOSES:  ,1.  Distal nasolacrimal duct stenosis with obstruction, left eye.,2.  Distal nasolacrimal duct stenosis with obstruction, right eye.,OPERATIVE PROCEDURE: , Bilateral nasolacrimal probing.,ANESTHESIA: , Monitored anesthesia care along with mask sedation.,INDICATIONS FOR SURGERY: , This young infant is a 19-month-old who has had persistent tearing and mild eyelash encrustation of each eye for many months.  Conservative measures at home have failed to completely resolve the symptoms.  He has been placed on previous antibiotics treatment for presumed conjunctivitis.  Please refer to clinic note for more details.  Conservative measures at home have failed to resolve the symptoms.  A nasolacrimal probing was offered as an elective procedure.  Procedure as well as inherent risks, expected outcomes, benefits, and alternatives (including continued observation) were discussed with his mother prior to scheduling surgery.  Again, a description of procedure as well as diagram instruction was provided to mother and father in the morning of the procedure.  The risks as explained included, but were not limited to temporary bleeding, persistent symptoms, recurrence need for further procedure, possible need for future stent placement or repeat probing, and anesthesia risk were all discussed.  Also a rare possibility of errant passage of the nasolacrimal probe was discussed.  Preoperative evaluation and explanation include drying of the nasolacrimal system with an explanation expected outcome/result from surgery.  No guarantees were offered.  Informed consent was signed and placed on the chart.,DESCRIPTION OF PROCEDURE:  ,The patient was identified and the procedure was verified.  Procedure as well as inherent risks were again discussed with parents prior to the procedure.  After anesthesia was induced in the operating room, tetracaine drops were applied to each eye and the pressure of the eyes were checked with Tono-Pen.  The pressure on the right was 17 mmHg and on the left was 16 mmHg.,A punctal dilator was then used to dilate the left superior puncta.  A size 00 Bowman probe was used to navigate the superior puncta and canaliculus with traction of the eyelid temporally.  The probe was advanced until a firm stop of the lacrimal bone was felt.  The probe was rotated in a superior and medial fashion along the brow to allow for navigation through the nasolacrimal sac and duct.  A mild resistance was felt at the distal aspect of the nasolacrimal duct consistent with a location of the valve.  There was also some mild stenosis distally, but not felt significant.  The probe was used to navigate through this mild resistance.  A second Bowman probe was then placed through the left naris and metal on metal contact was felt confirming patency.  Both probes were removed.  The 00 Bowman probe was then used to navigate the inferior puncta canaliculus system.  Patency was confirmed.  The left upper lid was everted and inspected and was found to be normal.,Attention was then turned to the right side where the similar procedure through the right superior puncta was performed.  A punctal dilator was used to dilate the puncta followed by a size 00 Bowman probe.  Again on this side, a size 0 Bowman probe was unable to be placed initially to the superior puncta.  The probe was used to navigate the superior puncta, canaliculus, and then the probe was rotated superomedially and the probe was advanced.  Similar amount of distal stenosis and distal nasolacrimal duct obstruction was felt.  The mild resistance was over come at the approximate location of the valve.  Metal-on-metal feel confirmed patency through the right naris with a second metal probe.  At the completion of the procedure all probes were removed.  Awakened and taken to the postanesthesia recovery unit in good condition having tolerated the procedure well.,Postoperative instructions were provided to the parents by me, and the discharging nurse.  I did advised nasolacrimal massage for the next 7 to 10 days on each side two to three times daily.  Technique explained and demonstrated.  Erythromycin ointment to both eyes twice daily for three days.  Follow up was arranged and he may call with any further questions or concerns.
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DESCRIPTION: Bilateral nasolacrimal probing.   Tearing, eyelash encrustation with probable tear duct obstruction bilateral.  Distal nasolacrimal duct stenosis with obstruction, left and right eye

ophthalmology, tearing, eyelash encrustation, tear duct obstruction, nasolacrimal duct stenosis, nasolacrimal, bowman probe, distal nasolacrimal duct, nasolacrimal probing, nasolacrimal duct, superior puncta, probe, obstruction, eyelash, duct, punctal,

The situation involves a medical procedure for an infant with bilateral nasolacrimal duct obstruction, which is causing tearing and eyelash encrustation. The procedure, nasolacrimal probing, is commonly performed to alleviate symptoms but comes with some risks like temporary bleeding and anesthesia complications. Although the procedure is generally safe and the risks are low, it involves a 19-month-old child and anesthesia, both of which increase the stakes slightly due to the inherent vulnerabilities of pediatric patients and the need to avoid complications. However, this procedure is considered elective rather than urgent or life-threatening, further reducing the stakes.


Medical Specialty: Surgery
Sample Name: Vitrectomy - 3

DESCRIPTION OF OPERATION:,  The patient was brought to the operating room and appropriately identified.  Local anesthesia was obtained with a 50/50 mixture of 2% lidocaine and 0.75% bupivacaine given as a peribulbar block.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.,A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.  Calipers were set at 3.5 mm and a mark was made 3.5 mm posterior to the limbus in the inferotemporal quadrant.,A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark.  The MVR blade was used to make a sclerotomy between the pre-placed sutures.  An 8-0 nylon suture was then pre-placed for later sclerotomy closure.  The infusion cannula was inspected and found to be in good working order.  The infusion cannula was placed in the vitreous cavity and secured with the pre-placed sutures.  The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.,Additional sclerotomies were made 3.5 mm posterior to the limbus in the supranasal and supratemporal quadrants.  The light pipe and vitrectomy handpieces were then placed in the vitreous cavity and a vitrectomy was performed.  There was moderately severe vitreous hemorrhage, which was removed.  Once a view of the posterior pole could be obtained, there were some diabetic membranes emanating along the arcades.  These were dissected with curved scissors and judicious use of the vitrectomy cutter.  There was some bleeding from the inferotemporal frond.  This was managed by raising the intraocular pressure and using intraocular cautery.  The surgical view became cloudy and the corneal epithelium was removed with a beaver blade.  This improved the view.  There is an area suspicious for retinal break near where the severe traction was inferotemporally.  The Endo laser was used to treat in a panretinal scatter fashion to areas that had not received previous treatment.  The indirect ophthalmoscope was used to examine the retinal peripheral for 360 degrees and no tears, holes or dialyses were seen.  There was some residual hemorrhagic vitreous skirt seen.  The soft-tip cannula was then used to perform an air-fluid exchange.  Additional laser was placed around the suspicious area inferotemporally.  The sclerotomies were then closed with 8-0 nylon suture in an X-fashion, the infusion cannula was removed and it sclerotomy closed with the pre-existing 8-0 nylon suture.,The conjunctiva was closed with 6-0 plain gut.  A subconjunctival injection of Ancef and Decadron were given and a drop of atropine was instilled over the eye.  The lid speculum was removed.  Maxitrol ointment was instilled over the eye and the eye was patched.  The patient was brought to the recovery room in stable condition.
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DESCRIPTION: Vitrectomy. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.

surgery, conjunctival peritomy, westcott scissors, lid speculum, inferotemporal quadrants, inferotemporal, conjunctival, scissors, supranasal, supratemporal, sclerotomy, eye, vitreous, vitrectomy, infusion, cannulaNOTE

The description is of a vitrectomy, a surgical procedure involving the removal of the vitreous gel from the eye. It involves the use of specialized tools and techniques, such as sclerotomies and laser treatment, which require precision and skill. The stakes are high because it is a surgical eye procedure, where complications can lead to vision loss or other serious outcomes if not performed correctly. However, it appears to be a routine procedure for an experienced surgical team, with no immediate life-threatening conditions described.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardio/Pulmo Discharge Summary

ADMISSION DIAGNOSIS:,1. Respiratory arrest.,2 . End-stage chronic obstructive pulmonary disease.,3. Coronary artery disease.,4. History of hypertension.,DISCHARGE DIAGNOSIS:,1. Status post-respiratory arrest.,2. Chronic obstructive pulmonary disease.,3. Congestive heart failure.,4. History of coronary artery disease.,5. History of hypertension.,SUMMARY:,  The patient is a 49-year-old man who was admitted to the hospital in respiratory distress, and had to be intubated shortly after admission to the emergency room. The patient’s past history is notable for a history of coronary artery disease with prior myocardial infarctions in 1995 and 1999. The patient has recently been admitted to the hospital with pneumonia and respiratory failure. The patient has been smoking up until three to four months previously. On the day of admission, the patient had the sudden onset of severe dyspnea and called an ambulance. The patient denied any gradual increase in wheezing, any increase in cough, any increase in chest pain, any increase in sputum prior to the onset of his sudden dyspnea.,ADMISSION PHYSICAL EXAMINATION:,GENERAL: Showed a well-developed, slightly obese man who was in extremis.,NECK: Supple, with no jugular venous distension.,HEART: Showed tachycardia without murmurs or gallops.,PULMONARY: Status showed decreased breath sounds, but no clear-cut rales or wheezes.,EXTREMITIES: Free of edema.,HOSPITAL COURSE:,  The patient was admitted to the Special Care Unit and intubated. He received intravenous antibiotic therapy with Levaquin. He received intravenous diuretic therapy. He received hand-held bronchodilator therapy. The patient also was given intravenous steroid therapy with Solu-Medrol. The patient’s course was one of gradual improvement, and after approximately three days, the patient was extubated. He continued to be quite dyspneic, with wheezes as well as basilar rales. After pulmonary consultation was obtained, the pulmonary consultant felt that the patient’s overall clinical picture suggested that he had a,significant element of congestive heart failure. With this, the patient was placed on increased doses of Lisinopril and Digoxin, with improvement of his respiratory status. On the day of discharge, the patient had minimal basilar rales; his chest also showed minimal expiratory wheezes; he had no edema; his heart rate was regular; his abdomen was soft; and his neck veins were not distended. It was, therefore, felt that the patient was stable for further management on an outpatient basis.,DIAGNOSTIC DATA:,  The patient’s admission laboratory data was notable for his initial blood gas, which showed a pH of 7.02 with a pCO2 of 118 and a pO2 of 103. The patient’s electrocardiogram showed nonspecific ST-T wave changes. The patent’s CBC showed a white count of 24,000, with 56% neutrophils and 3% bands.,DISPOSITION:,  The patient was discharged home.,DISCHARGE INSTRUCTIONS:,  His diet was to be a 2 grams sodium, 1800 calorie ADA diet. His medications were to be Prednisone 20 mg twice per day, Theo-24 400 mg per day, Furosemide 40 mg 1-1/2 tabs p.o. per day; Acetazolamide 250 mg one p.o. per day, Lisinopril 20 mg. one p.o. twice per day, Digoxin 0.125 mg one p.o. q.d., nitroglycerin paste 1 inch h.s., K-Dur 60 mEq p.o. b.i.d. He was also to use a Ventolin inhaler every four hours as needed, and Azmacort four puffs twice per day. He was asked to return for follow-up with Dr. X in one to two weeks. Arrangements have been made for the patient to have an echocardiogram for further evaluation of his congestive heart failure later on the day of discharge.
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DESCRIPTION: A 49-year-old man with respiratory distress, history of coronary artery disease with prior myocardial infarctions, and recently admitted with pneumonia and respiratory failure.

cardiovascular / pulmonary, discharge summary, ada diet, congestive heart failure, coronary artery disease, respiratory arrest, chest pain, chronic obstructive pulmonary disease, emergency room, hypertension, sputum, wheezing, respiratory distress, myocardial infarctions, respiratory failure, pulmonary disease, basilar rales, heart failure, infarctions, heart, wheezes, coronary, pulmonary, discharge, respiratory,

This situation involves a discharge summary for a patient who was in critical condition due to respiratory arrest and has multiple severe chronic conditions, including end-stage chronic obstructive pulmonary disease and coronary artery disease. The patient's health status requires intensive monitoring and careful management, indicated by their complex medication regimen and necessary follow-up appointments. Any misstep in following the discharge instructions could lead to rapid deterioration of health or even life-threatening situations, given the severity of their conditions. Hence, this scenario is high-stakes due to the potential consequences of non-compliance or inadequate follow-up care.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Laparotomy & Myomectomy

PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Blood loss anemia.,PROCEDURE PERFORMED:,1.  Laparotomy.,2.  Myomectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS: , Less than a 100 cc.,URINE OUTPUT: , 110 cc, clear at the end of the procedure.,FLUIDS: , 500 cc during the procedure.,SPECIMENS: , Four uterine fibroids.,DRAINS:  ,Foley catheter to gravity.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses.  Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids, which is approximately 6+ cm and several small submucosal fibroids within the endometrium.  Both ovaries and tubes appeared within normal limits.,PROCEDURE: , The patient was taken to the operating room where she was prepped and draped in the normal sterile fashion in the dorsal supine position.  After the general anesthetic was found to be adequate, a Pfannenstiel skin incision was made with the first knife.  This was carried through the underlying layer of fascia with a second knife.  The fascia was incised in the midline with the second knife and the fascial incision was then extended laterally in both directions with the Mayo scissors.  The superior aspect of the fascial incision was then grasped with Ochsner clamps, tented up, and dissected off the underlying layer of rectus muscle bluntly.  It was then dissected in the middle with the Mayo scissors.  The inferior aspect of this incision was addressed in a similar manner.  The rectus muscles were separated in the midline bluntly.  The peritoneum was identified with hemostat clamps, tented up, and entered sharply with the Metzenbaum scissors.  The peritoneal incision was then extended superiorly and inferiorly with the Metzenbaum scissors and then extended bluntly.  Next, the uterus was grasped bluntly and removed from the abdomen.  The fundal fibroid was identified.  It was then injected with vasopressin, 20 units mixed in 30 cc of normal saline along the serosal surface and careful to aspirate to avoid any blood vessels.  15 cc was injected.  Next, the point tip was used with the cautery _______ cutting to cut the linear incision along the top of the _______ fibroid until fibroid fibers were seen.  The edges of the myometrium was grasped with Allis clamps, tented up, and a hemostat was used to bluntly dissect around the fibroid followed by blunt dissection with a finger.  The fibroid was easily and bluntly dissected out.  It was also grasped with Lahey clamp to prevent traction.  Once the blunt dissection of the large fibroid was complete, it was handed off to the scrub nurse.  The large fibroid traversed the whole myometrium down to the mucosal surface and the endometrial cavity was largely entered when this fibroid was removed.  At this point, several smaller fibroids were noticed along the endometrial surface of the uterus.  Three of these were removed just by bluntly grasping with the Lahey clamp and twisting, all three of these were approximately 1 cm to 2 cm in size.  These were also handed to the scrub tech.  Next, the uterine incision was then closed with first two interrupted layers of #0 chromic in an interrupted figure-of-eight fashion and then with a #0 Vicryl in a running baseball stitch.  The uterus was seen to be completely hemostatic after closure.  Next, a 3 x 4 inch piece of Interceed was placed over the incision and dampened with normal saline.  The uterus was then carefully returned to the abdomen and being careful not to disturb the Interceed.  Next, the greater omentum was replaced over the uterus.,The rectus muscles were then reapproximated with a single interrupted suture of #0 Vicryl in the midline.  Then the fascia was closed with #0 Vicryl in a running fashion.  Next, the Scarpa's fascia was closed with #3-0 plain gut in a running fashion and the skin was closed with #4-0 undyed Vicryl in a running subcuticular fashion.  The incision was then dressed with 0.5-inch Steri-Strips and bandaged appropriately.  After the patient was cleaned, she was taken to Recovery in stable condition and she will be followed for her immediate postoperative period during the hospital.
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DESCRIPTION: Laparotomy and myomectomy.   Enlarged fibroid uterus and blood loss anemia.  On bimanual exam, the patient has an enlarged, approximately 14-week sized uterus that is freely mobile and anteverted with no adnexal masses.  Surgically, the patient has an enlarged fibroid uterus with a large fundal/anterior fibroids.

obstetrics / gynecology, enlarged fibroid uterus, blood loss anemia, laparotomy, myomectomy, metzenbaum scissors, uterus, fibroid, rectus, fascia, scissors, fashion, clamps, enlarged, incision, bluntly,

The scenario involves a laparotomy and myomectomy for an enlarged fibroid uterus, which are surgical procedures that carry inherent risks like bleeding and infection. However, it was reported that the estimated blood loss was minimal, there were no complications, and the surgery was completed successfully with the patient in stable condition. While surgery is a serious procedure, the details provided suggest a routine case with no unexpected complications, indicating a moderate level of stakes typical for operations of this nature.


Medical Specialty: Surgery
Sample Name: Arthrotomy & I&D

PREOPERATIVE DIAGNOSIS: , Hemarthrosis, left knee, status post total knee replacement, rule out infection.,POSTOPERATIVE DIAGNOSIS: , Hemarthrosis, left knee, status post total knee replacement, rule out infection.,OPERATIONS:,1.  Arthrotomy, left total knee.,2.  Irrigation and debridement, left knee.,3.  Polyethylene exchange, left knee.,COMPLICATION: , None.,TOURNIQUET TIME:  ,58 minutes.,ESTIMATED BLOOD LOSS: , Minimal.,ANESTHESIA:  ,General.,INDICATIONS:  ,This patient underwent an uncomplicated left total knee replacement.  Postoperatively, unfortunately did not follow up with PT/INR blood test and he was taking Coumadin.  His INR was seemed to elevated and developed hemarthrosis.  Initially, it did look very benign, although over the last 24 hours it did become irritable and inflamed, and he therefore was indicated with the above-noted procedure.,This procedure as well as alternatives was discussed in length with the patient and he understood them well.  Risks and benefits were also discussed.  Risks such as bleeding, infection, damage to blood vessels, damage to nerve roots, need for further surgeries, chronic pain with range of motion, risk of continued discomfort, risk of need for further reconstructive procedures, risk of need for total knee revision, risk of blood clots, pulmonary embolism, myocardial infarction, and risk of death were discussed.  He understood them well.  All questions were answered and he signed consent for the procedure as described.,DESCRIPTION OF PROCEDURE: , The patient was placed on operating table and general anesthesia was achieved.  The left lower extremity was then prepped and draped in the usual sterile manner.  The leg was elevated and the tourniquet was inflated to 325 mmHg.  A longitudinal incision was then made and carried down through subcutaneous tissues.  This was made through the prior incision site.  There were some fatty necrotic tissues through the incision region and all necrotic tissue was debrided sharply on both sides of the incision site.  Medial and lateral flaps were then made.  The prior suture was identified, the suture removed and then a medial parapatellar arthrotomy was then performed.  Effusion within the knee was noted.  All hematoma was evacuated.  I then did flex the knee and removed the polyethylene.  Once the polyethylene was removed I did irrigate the knee with total of 9 liters of antibiotic solution.  Further debridement was performed of all inflamed tissue and thickened synovial tissue.  A 6 x 16-mm Stryker polyethylene was then snapped back in position.  The knee has excellent stability in all planes and I did perform a light manipulation to improve the flexion of the knee.  Further irrigation was performed on the all soft tissue in the knee with additional 3 liters of normal saline.  The knee was placed in a flexed position and the extensor mechanism was reapproximated using #2 Ethibond suture in a figure-of-eight manner.  The subcutaneous tissue was reapproximated in layers using #1 and 2-0 Vicryl sutures, and the skin was reapproximated using staples.  Prior to closure a Hemovac drain was inserted through a superolateral approach into the knee joint.,No complications were encountered throughout the procedure, and the patient tolerated the procedure well.  The patient was taken to recovery room in stable condition.
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DESCRIPTION: Hemarthrosis, left knee, status post total knee replacement, rule out infection.  Arthrotomy, irrigation and debridement, and polyethylene exchange, left knee.  No complications were encountered throughout the procedure.

The scenario described is a surgical procedure involving an arthrotomy, irrigation and debridement, and polyethylene exchange in a left knee that has undergone a total knee replacement. This is a significant surgical intervention, especially considering the patient developed hemarthrosis and had been on Coumadin, which affects blood clotting. While the procedure was successful with no complications, the potential risks were considerable due to the chance of infection, further bleeding, or the need for additional surgeries. The stakes are moderate to high because surgical procedures always carry risks, including the ones explicitly discussed with the patient. However, the surgery ended without complications and the patient was stable post-operation, mitigating some of the high-stakes elements.


Medical Specialty: Gastroenterology
Sample Name: Gastrointestinal Bleed - ER Visit

ADMITTING DIAGNOSIS: , Gastrointestinal bleed.,HISTORY OF PRESENT ILLNESS:  ,Ms. XYZ is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell.  She states that she woke yesterday morning and at approximately 10:30 had a bowel movement.  She noticed it was very dark and smelly.  She said she felt okay.  She got up.  She proceeded to clean her house without any difficulty or problems and then at approximately 2 o'clock in the afternoon she went back to the bathroom at which point she had another large stool and had weak spell felt like she was going to pass out.  She is able to get to her phone, called EMS and when the EMS arrived they found her with some blood and some very dark stools.  She states that she was perfectly fine up until Monday when she had an incident where at the Southern University where she works where there was an altercation between a dorm resistant and a young male, which ensued.  She came to place her call, etc.  She said she noticed her stomach was hurting after that, continued to hurt and she took the day off on Tuesday and this happened yesterday.  She denies any nausea except for when she got weak.  She denies any vomiting or any other symptoms.,ALLERGIES:  ,She has no known drug allergies.,CURRENT MEDICATIONS:,1.  Lipitor, dose unknown.,2.  Paxil, dose unknown.,3.  Lasix, dose unknown.,4.  Toprol, dose unknown.,5.  Diphenhydramine p.r.n.,6.  Ibuprofen p.r.n.,7.  Daypro p.r.n.,PAST MEDICAL HISTORY:,1.  Non-insulin diabetes mellitus.,2.  History of congestive heart failure.,3.  History of hypertension.,4.  Depression.,5.  Arthritis.  She states she has not needed any medications and not taken ibuprofen or Daypro recently.,6.  Hyperlipidemia.,7.  Peptic ulcer disease diagnosed in 2005.,PAST SURGICAL HISTORY: , C-section and tonsillectomy.,FAMILY HISTORY: , Her mother had high blood pressure and coronary artery disease.,SOCIAL HISTORY:,  She is a nonsmoker.  She occasionally has a drink every few weeks.  She is divorced.  She has 2 sons.  She is houseparent at Southern University.,REVIEW OF SYSTEMS:  ,Negative for the last 24 to 48 hours as mentioned in her HPI.,PREVENTIVE CARE:  ,She had an EGD done in 09/05 at which point she was diagnosed with peptic ulcer disease and she also had a colonoscopy at that time which revealed two polyps in the transverse colon.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Currently was stable.  She is afebrile.,GENERAL:  She is alert, pleasant in no acute distress.  She does complain of some dizziness when she stands up.,HEENT:  Pupils equal, round and reactive to light.  Extraocular muscles intact.  Sclerae clear.  Oropharynx is clear.,NECK:  Supple.  Full range of motion.,CARDIOVASCULAR:  She is slightly tachycardic but otherwise normal.,LUNGS:  Clear bilaterally.,ABDOMEN:  Soft, nontender, and nondistended.  She has no hepatomegaly.,EXTREMITIES:  No clubbing, cyanosis, only trace edema.,LABORATORY DATA UPON ADMISSION:,  Her initial chem panel was within normal limits.  Her PT and PTT were normal.  Her initial hematocrit was 31.2 subsequently dropped to 26.9 and 25.6.  She is currently administered transfusion.  Platelet count was 125.  Her chem panel actually showed an elevated BUN of 16, creatinine of 1.7.  PT and PTT were normal.  Cardiac enzymes were negative and initial hemoglobin was 10.6 with hematocrit of 31.2 that subsequently fell to 25.6 and she is currently receiving blood.,IMPRESSION AND PLAN:,1.  Gastrointestinal bleed.
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DESCRIPTION: Gastrointestinal Bleed.  An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell.  She woke yesterday morning had a very dark and smelly bowel movement.

The situation involves an 81-year-old patient with a gastrointestinal bleed presenting in the emergency room. This condition, particularly in an elderly individual with existing medical issues such as congestive heart failure and hypertension, is serious and potentially life-threatening. The patient has experienced significant blood loss, as evidenced by dropping hemoglobin and hematocrit levels, which has necessitated a blood transfusion. These factors contribute to the scenario being high-stakes, requiring immediate medical attention and careful management to prevent further complications or deterioration.


Medical Specialty: Consult - History and Phy.
Sample Name: Neuropsychological Evaluation - 3

REASON FOR REFERRAL:,  The patient is a 76-year-old Caucasian gentleman who works full-time as a tax attorney.  He was referred for a neuropsychological evaluation by Dr. X after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.,RELEVANT BACKGROUND INFORMATION: , Historical information was obtained from a review of available medical records and clinical interview with the patient.  A summary of pertinent information is presented below.  Please refer to the patient's medical chart for a more complete history.,HISTORY OF PRESENTING PROBLEM: , The patient was brought to the Hospital Emergency Department on 09/30/09 after experiencing an episode of confusion for which he has no recall the previous day.  He has no recollection of the event.  The following information is obtained from his medical record.  On 09/29/09, he reportedly went to a five-hour meeting and stated several times "I do not feel well" and looked "glazed."  He does not remember anything from midmorning until the middle of the night and when his wife came home, she found him in bed at 6 p.m., which is reportedly unusual.  She thought he was warm and had chills.  He later returned to his baseline.  He was seen by Dr. X in the hospital on 09/30/09 and reported to him at that time that he felt that he had returned entirely to baseline.  His neurological exam at that time was unremarkable aside from missing one of three items on recall for the Mini-Mental Status Examination.  Due to mild memory complaints from himself and his wife, he was referred for more extensive neuropsychological testing.  Note that reportedly when his wife found him in bed, he was shaking and feeling nauseated, somewhat clammy and kept saying that he could not remember anything and he was repeating himself, asking the same questions in an agitated way, so she brought him to the emergency room.  The patient had an episode two years ago of transient loss of memory during which he was staring blankly while sitting at his desk at work and the episode lasted approximately two hours.  He was hospitalized at Hospital at that time as well and evaluation included negative EEG, MRI showing mild atrophy, and a neurological consultation, which did not result in a specific diagnosis, but during this episode he was also reportedly nauseous.  He was also reportedly amnestic for this episode.,In 2004, he had a sense of a funny feeling in his neck and electrodes in his head and had an MRI at that time which showed some small vessel changes.,During this interview, the patient reported that other than a coworker noticing a few careless errors in his completion of some documents and his wife reporting some mild memory changes that he had not noticed any significant decline.  He thought that his memory abilities were similar to those of his peers of his same age.  When I asked about this episode, he said he had no recall of it at all and that he "felt fine the whole time."  He appeared to be somewhat questioning of the validity of reports that he was amnestic and confused at that time.  So, The patient reported some age related "memory lapses" such as going into a room and forgetting why, sometimes putting something down and forgetting where he had put it.  However, he reported that these were entirely within normal expectations and he denied any type of impairment in his ability to continue to work full-time as a tax attorney other than his wife and one coworker, he had not received any feedback from his children or friends of any problems.  He denied any missed appointments, any difficulty scheduling and maintaining appointments.  He does not have to recheck information for errors.  He is able to complete tasks in the same amount of time as he always has.  He reported that he has not made additional errors in tasks that he completed.  He said he does write everything down, but has always done things that way.  He reported that he works in a position that requires a high level of attentiveness and knowledge and that will become obvious very quickly if he was having difficulties or making mistakes.  He did report some age related changes in attention as well, although very mild and he thought these were normal and not more than he would expect for his age.  He remains completely independent in his ADLs.  He denied any difficulty with driving or maintaining any activities that he had always participated in.  He is also able to handle their finances.  He did report significant stress recently particularly in relation to his work environment.,PAST MEDICAL HISTORY:,  Includes coronary artery disease, status post CABG in 1991, radical prostate cancer, status post radical prostatectomy, nephrectomy for the same cancer, hypertension, lumbar surgery done twice previously, lumbar stenosis many years ago in the 1960s and 1970s, now followed by Dr. Y with another lumbar surgery scheduled to be done shortly after this evaluation, and hyperlipidemia.  Note that due to back pain, he had been taking Percocet daily prior to his hospitalization.,CURRENT MEDICATIONS: , Celebrex 200 mg, levothyroxine 0.025 mg, Vytorin 10/40 mg, lisinopril 10 mg, Coreg 10 mg, glucosamine with chondroitin, prostate 2.2, aspirin 81 mg, and laxative stimulant or stool softener.  Note that medical records say that he was supposed to be taking Lipitor 40 mg, but it is not clear if he was doing so and also there was no specific reason found for why he was taking the levothyroxine.,OTHER MEDICAL HISTORY: , Surgical history is significant for hernia repair in 2007 as well.  The patient reported drinking an occasional glass of wine approximately two days of the week.  He quit smoking cigarettes 25 to 30 years ago and he was diagnosed with cancer.  He denied any illicit drug use.  Please add that his prostatectomy was done in 1993 and nephrectomy in 1983 for carcinoma.  He also had right carpal tunnel surgery in 2005 and has cholelithiasis.  Upon discharge from the hospital, the patient's sleep deprived EEG was recommended.,MRI completed on 09/30/09 showed "mild cerebral and cerebellar atrophy with no significant interval change from a prior study dated June 15, 2007.  No evidence of acute intracranial processes identified.  CT scan was also unremarkable showing only mild cerebral and cerebellar atrophy.  EEG was negative.  Deferential diagnosis was transient global amnesia versus possible seizure disorder.  Note that he also reportedly has some hearing changes, but has not followed up with an evaluation for hearing aid.,FAMILY MEDICAL HISTORY:, Reportedly significant for TIAs in his mother, although the patient did not report this during our evaluation and so that she had no memory problems or dementia when she passed away of old age at the age of 85.  In addition, his father had a history of heart disease and passed away at the age of 75.  He has one sister with diabetes and thought his mom might have had diabetes as well.,SOCIAL HISTORY:,  The patient obtained a law degree from the University of Baltimore.  He did not complete his undergraduate degree from the University of Maryland because he was able to transfer his credits in order to attend law school at that time.  He reported that he did not obtain very good grades until he reached law school, at which point he graduated in the top 10 of his class and had no problem passing the Bar.  He thought that effort and motivation were important to his success in his school and he had not felt very motivated previously.  He reported that he repeated math classes "every year of school" and attended summer school every year due to that.  He has worked as a tax attorney for the past 48 years and reported having a thriving practice with clients all across the country.  He served also in the U.S.  Coast Guard between 1951 and 1953.  He has been married for the past 36 years to his wife, Linda, who is a homemaker.  They have four children and he reported having good relationship with them.  He described being very active.  He goes for dancing four to five times a week, swims daily, plays golf regularly and spends significant amounts of time socializing with friends.,PSYCHIATRIC HISTORY: , The patient denied any history of psychological or psychiatric treatment.  He reported that some stressors occasionally contribute to mildly low mood at this time, but that these are transient.,TASKS ADMINISTERED:,Clinical Interview,Adult History Questionnaire,Wechsler Test of Adult Reading (WTAR),Mini Mental Status Exam (MMSE),Cognistat Neurobehavioral Cognitive Status Examination,Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Form XX),Mattis Dementia Rating Scale, 2nd Edition (DRS-2),Neuropsychological Assessment Battery (NAB),Wechsler Adult Intelligence Scale, Third Edition (WAIS-III),Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV),Wechsler Abbreviated Scale of Intelligence (WASI),Test of Variables of Attention (TOVA),Auditory Consonant Trigrams (ACT),Paced Auditory Serial Addition Test (PASAT),Ruff 2 & 7 Selective Attention Test,Symbol Digit Modalities Test (SDMT),Multilingual Aphasia Examination, Second Edition (MAE-II), Token Test, Sentence Repetition, Visual Naming, Controlled Oral Word Association, Spelling Test, Aural Comprehension, Reading Comprehension,Boston Naming Test, Second Edition (BNT-2),Animal Naming Test
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DESCRIPTION: Patient was referred for a neuropsychological evaluation after a recent hospitalization for possible transient ischemic aphasia.  Two years ago, a similar prolonged confusional spell was reported as well.  A comprehensive evaluation was requested to assess current cognitive functioning and assist with diagnostic decisions and treatment planning.

The situation involves a 76-year-old man who has experienced episodes of confusion and memory loss, which could potentially indicate a serious underlying neurological or cognitive condition such as transient ischemic attacks (TIAs), seizures, or dementia. This has the potential to impact his ability to work as a tax attorney, his independence, and overall quality of life. The stakes are heightened due to his age and the potential severity of the conditions that are being evaluated. His work as a tax attorney is highly dependent on cognitive functioning, and any decline could have significant personal and professional consequences. However, at the current stage, it's mainly about diagnosing and understanding his condition, rather than immediate life-threatening stakes.


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

Medical Specialty: Neurology
Sample Name: Craniotomy - Frontotemporal - 1

PREOPERATIVE DIAGNOSIS:,  Acute left subdural hematoma.,POSTOPERATIVE DIAGNOSIS:,  Acute left subdural hematoma.,PROCEDURE:,  Left frontal temporal craniotomy for evacuation of acute subdural hematoma.,DESCRIPTION OF PROCEDURE: , This is a 76-year-old man who has a history of acute leukemia.  He is currently in the phase of his therapy where he has developed a profound thrombocytopenia and white cell deficiency.  He presents after a fall in the hospital in which he apparently struck his head and now has a progressive neurologic deterioration consistent with an intracerebral injury.  His CT imaging reveals an acute left subdural hematoma, which is hemispheric.,The patient was brought to the operating room, placed under satisfactory general endotracheal anesthesia.  He had previously been intubated and taken to the Intensive Care Unit and now is brought for emergency craniotomy.  The images were brought up on the electronic imaging and confirmed that this was a left-sided condition.  He was fixed in a three-point headrest.  His scalp was shaved and prepared with Betadine, iodine and alcohol.  We made a small curved incision over the temporal, parietal, frontal region.  The scalp was reflected.  A single bur hole was made at the frontoparietal junction and then a 4x6cm bur hole was created.  After completing the bur hole flap, the dura was opened and a gelatinous mass of subdural was peeled away from the brain.  The brain actually looked relatively relaxed; and after removal of the hematoma, the brain sort of slowly came back up.  We investigated the subdural space forward and backward as we could and yet careful not to disrupt any venous bleeding as we close to the midline.  After we felt that we had an adequate decompression, the dura was reapproximated and we filled the subdural space with saline.  We placed a small drain in the extra dural space and then replaced the bone flap and secured this with the bone plates.  The scalp was reapproximated, and the patient was awakened and taken to the CT scanner for a postoperative scan to ensure that there was no new hemorrhage or any other intracerebral pathology that warranted treatment.  Given that this actual skin looked good with apparent removal of about 80% of the subdural we elected to take patient to the Intensive Care Unit for further management.,I was present for the entire procedure and supervised this.  I confirmed prior to closing the skin that we had correct sponge and needle counts and the only foreign body was the drain.
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DESCRIPTION: Acute left subdural hematoma.  Left frontal temporal craniotomy for evacuation of acute subdural hematoma.  CT imaging reveals an acute left subdural hematoma, which is hemispheric.

neurology, subdural, hematoma, temporal craniotomy, craniotomy, subdural space, bur hole, subdural hematoma,

The situation describes an emergency neurosurgical procedure being performed on a 76-year-old man who suffered a fall, resulting in an acute left subdural hematoma. This is a high-stakes medical scenario because it involves life-threatening conditions such as significant brain injury and acute subdural hematoma, which require immediate surgical intervention. The patient's history of acute leukemia and associated thrombocytopenia complicates the situation further, increasing the risk of bleeding and postoperative complications. The urgency of the craniotomy and the need for ICU care post-surgery underscore the high stakes involved in ensuring the patient's survival and recovery.


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

HISTORY: , A 59-year-old male presents in followup after being evaluated and treated as an in-patient by Dr. X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis, admitted on 05/23/2008, discharged on 05/24/2008.  Please refer to chart for history and physical and review of systems and medical record.,PROCEDURES PERFORMED:  ,Fiberoptic laryngoscopy identifying about 30% positive Muller maneuver.  No supraglottic edema; +2/4 tonsils with small tonsil cyst, mid tonsil, left.,IMPRESSION:  ,1.  Resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis.,2.  Possible obstructive sleep apnea; however, the patient describes no known history of this phenomenon.,3.  Hypercholesterolemia.,4.  History of anxiety.,5.  History of coronary artery disease.,6.  Hypertension.,RECOMMENDATIONS: , Recommend continuing on Augmentin and tapered prednisone as prescribed by Dr. X.  Cultures are still pending and follow up with Dr. X in the next few weeks for re-evaluation.  I did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this, but we will leave this open for him to talk with Dr. X on his followup, and he will pay more attention on his sleep pattern.
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DESCRIPTION: Acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis.

soap / chart / progress notes, acute supraglottic edema, obstructive sleep apnea, acute supraglottitis, airway obstruction, parapharyngeal cellulitis, peritonsillar cellulitis, supraglottic edema, supraglottitis, tonsils, cellulitis

The situation involves a follow-up progress note for a patient who had a serious condition - acute supraglottitis with airway obstruction. Although the immediate high-risk situation seems managed, there's a potential risk if the condition exacerbates or if there is a new episode of airway obstruction. Additionally, the patient has other underlying conditions like coronary artery disease and hypertension, which can complicate health outcomes. The recommendations and follow-up appointments are critical to ensuring the patient's recovery and monitoring for any worsening conditions.


Medical Specialty: Orthopedic
Sample Name: Elbow Pain - Consult

CHIEF COMPLAINT: , Left elbow pain.,HISTORY OF PRESENT ILLNESS:  ,This 17-year-old male was fighting with some other kids in Juvenile Hall when he felt some pain in his left elbow, causing sudden pain.  He also has pain in his left ankle, but he is able to walk normally.  He has had previous pain in his left knee.  He denies any passing out, any neck pain at this time even though he did get hit in the head.  He has no chest or abdominal pain.  Apparently, no knives or guns were involved.,PAST MEDICAL HISTORY: , He has had toe problems and left knee pain in the past.,REVIEW OF SYSTEMS: , No coughing, sputum production, dyspnea or chest pain.  No vomiting or abdominal pain.  No visual changes.  No neurologic deficits other than some numbness in his left hand.,SOCIAL HISTORY: , He is in Juvenile Hall for about 25 more days.  He is a nonsmoker.,ALLERGIES: , MORPHINE.,CURRENT MEDICATIONS:  ,Abilify.,PHYSICAL EXAMINATION: , VITAL SIGNS:  Stable.  HEENT:  PERRLA.  EOMI.  Conjunctivae anicteric.  Skull is normocephalic.  He is not complaining of bruising.  HEENT:  TMs and canals are normal.  There is no Battle sign.  NECK:  Supple.  He has good range of motion.  Spinal processes are normal to palpation.  LUNGS:  Clear.  CARDIAC:  Regular rate.  No murmurs or rubs.  EXTREMITIES:  Left elbow is tender.  He does not wish to move it at all.  Shoulder and clavicle are within normal limits.  Wrist is normal to inspection.  He does have some pain to palpation.  Hand has good capillary refill.  He seems to have decreased sensation in all three dermatomes.  He has moderately good abduction of all fingers.  He has moderate opponens strength with his thumb.  He has very good extension of all of his fingers with good strength.,We did an x-ray of his elbow.  He has a spiral fracture of the distal one-third of the humerus, about 13 cm in length.  The proximal part looks like it is in good position.  The distal part has about 6 mm of displacement.  There is no significant angulation.  The joint itself appears to be intact.  The fracture line ends where it appears above the joint.  I do not see any extra blood in the joint.  I do not see any anterior or posterior Siegert sign.,I spoke with Dr. X.  He suggests we go ahead and splint him up and he will follow the patient up.  At this point, it does not seem like there needs to be any surgical revision.  The chance of a compartment syndrome seems very low at this time.,Using 4-inch Ortho-Glass and two assistants, we applied a posterior splint to immobilize his fingers, hand, and wrist all the way up to his elbow to well above the elbow.,He had much better comfort once this was applied.  There was good color to his fingers and again, much better comfort.,Once that was on, I took some 5-inch Ortho-Glass and put in extra reinforcement around the elbow so he would not be moving it, straightening it or breaking the fiberglass.,We then gave him a sling.,We gave him #2 Vicodin p.o. and #4 to go.  Gave him a prescription for #15 more and warned him to take it only at nighttime and use Tylenol or Motrin, and ice in the daytime.,I gave him the name and telephone number of Dr. X whom they can follow up with.  They were warned to come back here if he has increasing neurologic deficits in his hands or any new problems.,DIAGNOSES:,1.  Fracture of the humerus, spiral.,2.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.,3.  Psychiatric disorder, unspecified.,DISPOSITION:  The patient will follow up as mentioned above.  They can return here anytime as needed.
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DESCRIPTION: Left elbow pain.  Fracture of the humerus, spiral.  Possible nerve injuries to the radial and median nerve, possibly neurapraxia.

The patient has sustained a spiral fracture of the humerus with possible nerve injuries, which are significant injuries requiring careful evaluation and management. However, the immediate management plan involves non-surgical immobilization with a splint and follow-up, suggesting that the risk of severe complications or life-threatening situations is currently low. There is no immediate threat to life or limb, given the stable vital signs, intact joint, and good color to the fingers post-splinting. The situation requires careful follow-up to manage the fracture and potential nerve injuries, but as of now, it is not high-stakes.


Medical Specialty: Surgery
Sample Name: Circumcision & Chordee Release

PREOPERATIVE DIAGNOSES: , Phimosis and adhesions.,POSTOPERATIVE DIAGNOSES:  ,Phimosis and adhesions.,PROCEDURES PERFORMED: , Circumcision and release of ventral chordee.,ANESTHESIA:  ,Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.  The patient was given antibiotics preop.,BRIEF HISTORY: , This is a 43-year-old male who presented to us with significant phimosis, difficulty retracting the foreskin.  The patient had buried penis with significant obesity issues in the suprapubic area.  Options such as watchful waiting, continuation of slowly retracting the skin, applying betamethasone cream, and circumcision were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, and CVA risks were discussed.  The patient had discussed this issue with Dr Khan and had been approved to get off of the Plavix.  Consent had been obtained.  Risk of scarring, decrease in penile sensation, and unexpected complications were discussed.  The patient was told about removing the dressing tomorrow morning, okay to shower after 48 hours, etc.  Consent was obtained.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in supine position.  The patient was prepped and draped in usual sterile fashion.  Local MAC anesthesia was applied.  After draping, 17 mL of mixture of 0.25% Marcaine and 1% lidocaine plain were applied around the dorsal aspect of the penis for dorsal block.  The patient had significant phimosis and slight ventral chordee.  Using marking pen, the excess foreskin was marked off.  Using a knife, the ventral chordee was released.  The urethra was intact.  The excess foreskin was removed.  Hemostasis was obtained using electrocautery.  A 5-0 Monocryl stitches were used for 4 interrupted stitches and horizontal mattresses were done.  The patient tolerated the procedure well.  There was excellent hemostasis.  The penis was straight.  Vaseline gauze and Kerlix were applied.  The patient was brought to the recovery in stable condition.  Plan was for removal of the dressing tomorrow.  Okay to shower after 48 hours.
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DESCRIPTION: Circumcision and release of ventral chordee.

surgery, phimosis, adhesions, release of ventral chordee, ventral chordee, circumcision, penis, chordee, foreskin,

The situation involves a surgical procedure, which inherently carries certain risks. The patient is undergoing circumcision and release of ventral chordee, procedures that, while not considered major surgeries, still involve anesthesia, potential for bleeding, and other complications. The presence of additional factors, such as the patient's significant obesity, phimosis, and the cessation of anticoagulation therapy (Plavix), further elevates the stakes by adding complexity to the management and potential postoperative care. However, the preoperative diagnosis is not life-threatening, and the estimated blood loss was minimal, which suggests well-controlled procedures. Therefore, it's a moderately high-stakes situation resulting from the surgical context and patient-specific risk factors.


Medical Specialty: Neurology
Sample Name: MRI T-Spine - Spinal Mets

CC: ,BLE weakness and numbness.,HX:, This 59 y/o RHM was seen and released from an ER 1 week prior to this presentation for a 3 week history of progressive sensory and motor deficits in both lower extremities. He reported numbness beginning about his trunk and slowly progressing to involve his lower extremities over a 4 week period. On presentation, he felt numb from the nipple line down. In addition, he began experiencing progressive weakness in his lower extremities for the past week. He started using a cane 5 days before being seen and had been having difficulty walking and traversing stairs. He claimed he could not stand. He denied loss of bowel or bladder control. However, he had not had a bowel movement in 3 days and he had not urinated 24 hours. His lower extremities had been feeling cold for a day. He denied any associated back or neck pain. He has chronic shortness of breath, but felt it had become worse. He had also been experiencing lightheadedness upon standing more readily than usual for 2 days prior to presentation.,PMH:, 1)CAD with chronic CP, 2)NQWMI 1994, S/P Coronary Angioplasty, 3)COPD (previous FEV 11.48, and FVC 2.13), 4)Anxiety D/O, 5)DJD, 6)Developed confusion with metoprolol use, 7)HTN.,MEDS:, Benadryl, ECASA, Diltiazem, Isordil, Enalapril, Indomethacin, Terbutaline MDI, Ipratropium MDI, Folic Acid, Thiamine.,SHX:, 120pk-yr smoking, ETOH abuse in past, Retired Dock Hand,FHX: ,unremarkable except for ETOH abuse,EXAM:,  T98.2 96bpm 140/74mmHg R18,Thin cachetic male in moderate distress.,MS: A&O to person, place and time. Speech was fluent and without dysarthria. Comprehension, naming and reading were intact.,CN: unremarkable.,Motor: Full strength in both upper extremities.,HF HE HAdd HAbd KF KE AF AE,RLE 3 3 4 4 3 4 1 1,LLE 4 4 4+ 4+ 4+ 4 4 4,There was mild spastic muscle tone in the lower extremities. There was normal muscle bulk throughout.,SENSORY: Decreased PP in the LLE from the foot to nipple line, and in the RLE from the knee to nipple line. Decreased Temperature sensation from the feet to the umbilicus, bilaterally. No loss of Vibration or Proprioception. Decreased light touch from the feet to nipple line, bilaterally.,Gait: unable to walk. Stands with support only.,Station: no pronator drift or truncal ataxia.,Reflexes: 2+/2+ in BUE, 3+/3+ patellae, 0/1 ankles. Babinski signs were present, bilaterally. The abdominal reflexes were absent.,CV: RRR with a 2/6 systolic ejection murmur at the left sternal border. Lungs: CTA with mildly labored breathing. Abdomen: NT, ND, NBS, but bladder distended. Extremities were cool to touch. Peripheral pulses were intact and capillary refill was brisk. Rectal: decreased rectal tone and absent anal reflex. Right prostate nodule at the inferior pole.,COURSE: ,Admission Labs: FEV1=1.17, FVC 2.19, ABG 7.39/42/79 on room air. WBC 10/5, Hgb 13, Hct 39, Electrolytes were normal. PT & PTT were normal. Straight catheterization revealed a residual volume of 400cc of urine.,He underwent emergent T-spine MRI. This revealed a T3-4 vertebral body lesion which had invaded the spinal canal was compressing the spinal cord. He was treated with Decadron and underwent emergent spinal cord decompression on 5/7/95. He recovered some lower extremity strength following surgery. Pathological analysis of the tumor was consistent with adenocarcinoma. His primary tumor was not located despite chest-abdominal-pelvic CT scans, and a GI and GU workup which included cystoscopy and endoscopy. He received 3000cGy of XRT and died 5 months after presentation.
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DESCRIPTION: MRI T-spine: Metastatic Adenocarcinoma of the T3-T4 vertebrae and invading the spinal canal.

The case involves a serious neurological condition where a patient presents with progressive motor and sensory deficits due to spinal cord compression from metastatic adenocarcinoma. This situation is high-stakes because it involves urgent medical intervention to prevent potentially irreversible neurological damage. The immediate actions include managing any underlying malignancy, relieving spinal cord compression, and addressing the potential life-threatening complications such as paralysis and bladder dysfunction. Furthermore, this scenario ultimately concerns the patient's prognosis, which is poor despite intervention. These factors collectively make it a high-stakes medical situation.


Medical Specialty: Speech - Language
Sample Name: Speech Therapy - Discharge Summary - 2

The patient made some progress during therapy.  She accomplished two and a half out of her five short-term therapy goals.  We did complete an oral mechanism examination and clinical swallow evaluation, which showed her swallowing to be within functional limits.  The patient improved on her turn taking skills during conversation, and she was able to listen to a narrative and recall the main idea plus five details after a three-minute delay independently.  The patient continues to have difficulty with visual scanning in cancellation task, secondary to her significant left neglect.  She also did not accomplish her sustained attention goal, which required her to complete tasks greater than 80% accuracy for at least 15 minutes independently.  Thus she also continued to have difficulty with reading, comprehension, secondary to the significance of her left neglect.  The patient was initially authorized for 12 outpatient speech therapy sessions, but once again she only attended 9.  Her last session occurred on 01/09/09.  She has not made any additional followup sessions with me for over three weeks, so she is discharged from my services at this time.
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DESCRIPTION: The patient was referred for outpatient skilled speech therapy, secondary to right hemisphere disorder, status post stroke.  The patient attended nine outpatient skilled speech therapy sessions.

speech - language, outpatient speech therapy, swallow evaluation, swallowing, skilled speech therapy, hemisphere disorder, speech therapy, 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 involves evaluating a patient's progress in a speech therapy regimen following a stroke which affected the patient's right hemisphere. The discharge summary indicates some progress but also highlights ongoing challenges, particularly with visual scanning and sustained attention. However, the patient is not attending therapy as prescribed and hasn't scheduled further sessions, leading to a discharge from therapy services. The stakes here are medium because the patient's ability to improve language processing and comprehension can significantly affect daily functioning and quality of life, but it does not appear to be an immediate life-threatening situation.