Medical Specialty: General Medicine
Sample Name: Gen Med Consult - 54

HISTORY OF PRESENT ILLNESS: , The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend.  The patient has a long history of psychological disorders.  As per the patient, she also has a history of supraventricular tachycardia and coronary artery disease, for which the patient has had workup done in ABC Medical Center.  The patient was evaluated in the emergency room.  The initial cardiac workup was negative.  The patient was admitted to telemetry unit for further evaluation.  In the emergency room, the patient was also noted to have a strongly positive drug screen including methadone and morphine.  The patient's EKG in the emergency room was normal and the patient had some relief from her chest pain after she got some nitroglycerin.,PAST MEDICAL HISTORY: , As mentioned above is significant for history of seizure disorder, migraine headaches, coronary artery disease, CHF, apparently coronary stenting done, mitral valve prolapse, supraventricular tachycardia, pacemaker placement, colon cancer, and breast cancer.  None of the details of these are available.,PAST SURGICAL HISTORY: , Significant for history of lumpectomy on the left breast, breast augmentation surgery, cholecystectomy, cardiac ablation x3, left knee surgery as well as removal of half the pancreas.,CURRENT MEDICATIONS AT HOME: , Included Dilantin 400 mg daily, Klonopin 2 mg 3 times a day, Elavil 300 mg at night, nitroglycerin sublingual p.r.n., Thorazine 300 mg 3 times a day, Neurontin 800 mg 4 times a day, and Phenergan 25 mg as tolerated.,OB HISTORY: , Her last menstrual period was 6/3/2009.  The patient is admitting to having a recent abortion done.  She is not too sure whether the abortion was completed or not, has not had a followup with her OB/GYN.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY:  ,She lives with her boyfriend.  The patient has history of tobacco abuse as well as multiple illicit drug abuse.,REVIEW OF SYSTEMS:  As mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  She is alert, awake, and oriented.,VITAL SIGNS:  Her blood pressure is about 132/72, heart rate of about 87 per minute, respiratory rate of 16.,HEENT:  Shows head is atraumatic.  Pupils are round and reactive to light.  Extraocular muscles are intact.  No oropharyngeal lesions noted.,NECK:  Supple, no JV distention, no carotid bruits, and no lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,CARDIAC:  Reveals regular rate and rhythm.,ABDOMEN:  Soft, nontender, nondistended.  Bowel sounds are normally present.,LOWER EXTREMITIES:  Shows no edema.  Distal pulses are 2+.,NEUROLOGICAL:  Grossly nonfocal.,LABORATORY DATA: , The database that is available at this point of time, WBC count is normal, hemoglobin and hematocrit are normal.  Sodium, potassium, chloride, glucose, bicarbonate, BUN and creatinine, and liver function tests are normal.  The patient's 3 sets of cardiac enzymes including troponin-I, CPK-MB, and myoglobulin have been normal.  EKG is normal, sinus rhythm without any acute ST-T wave changes.  As mentioned before, the patient's toxicology screen was positive for morphine, methadone, and marijuana.  The patient also had a head CT done in the emergency room, which was fairly unremarkable.  The patient's beta-hCG level was marginally elevated at about 48.,ASSESSMENT AND EVALUATION:,1.  Chest pains, appear to be completely noncardiac.  The patient does seem to have a psychosomatic component to her chest pain.  There is no evidence of acute coronary syndrome or unstable angina at this point of time.,2.  Possible early pregnancy.  The patient's case was discussed with OB/GYN on-call over the phone.  Some of the medications have to be held secondary to potential danger.  The patient will follow up on an outpatient basis with her primary OB/GYN as well as PCP for the workup of her pregnancy as well as continuation of the pregnancy and prenatal visits.,3.  Migraine headaches for which the patient has been using her routine medications and the headaches seem to be under control.  Again, this is an outpatient diagnosis.  The patient will follow up with her PCP for control of migraine headache.,Overall prognosis is too soon to predict.,The plan is to discharge the patient home secondary to no evidence of acute coronary syndrome.
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DESCRIPTION: The patient is a 35-year-old lady who was admitted with chief complaints of chest pain, left-sided with severe chest tightness after having an emotional argument with her boyfriend.   The patient has a long history of psychological disorders.

The situation involves a 35-year-old patient with a complex medical history, including psychological disorders and a recent emotional distress-related admission due to chest pain. However, the cardiac workup was negative, indicating non-life-threatening conditions at present. Drug use and the possibility of early pregnancy add complications but the immediate medical crisis (potential cardiac issue) is ruled out. The stakes involve potential risks if conditions are not managed, but no immediate high-stakes medical threat is present.


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

Medical Specialty: Urology
Sample Name: Cystoscopy, Ureteropyelogram, & Ureteral Barbotage

PREOPERATIVE DIAGNOSES:,1.  Right hydronephrosis.,2.  Right flank pain.,3.  Atypical/dysplastic urine cytology.,POSTOPERATIVE DIAGNOSES:,1.  Right hydronephrosis.,2.  Right flank pain.,3.  Atypical/dysplastic urine cytology.,4.  Extrarenal pelvis on the right.,5.  No evidence of obstruction or ureteral/bladder lesions.,PROCEDURE PERFORMED:,1.  Cystoscopy.,2.  Bilateral retrograde ureteropyelograms.,3.  Right ureteral barbotage for urine cytology.,4.  Right ureterorenoscopy, diagnostic.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Urine and saline wash barbotage from right ureter through the ureteral catheter.,ESTIMATED BLOOD LOSS:  ,Minimal.,INDICATIONS FOR PROCEDURE: , This is a 70-year-old female who reports progressive intermittent right flank pain associated with significant discomfort and disability.  She presented to the emergency room where she was found to have significant hydronephrosis on the right without evidence of a stone.  She has some ureteral thickening in her distal right ureter.  She has persistent microscopic hematuria and her urine cytology and cytomolecular diagnosis significant for urothelial dysplasia with neoplasia-associated karyotypic profile.  She was brought to the operating room for further evaluation and treatment.,DESCRIPTION OF OPERATION: , After preoperative counseling, the patient was taken to the operating room and administered a spinal anesthesia.  She was placed in the lithotomy position, prepped and draped in the usual sterile fashion.  The 21-French cystoscope was inserted per urethra into the bladder.  The bladder was inspected and found to be without evidence of intravesical tumors, stones or mucosal abnormalities.  The right ureteral orifice was visualized and cannulated with an open-ended ureteral catheter.  This was gently advanced to the mid ureter.  Urine was collected for cytology.  Retrograde injection of saline through the ureteral catheter was then also used to enhance collection of the specimen.  This too was collected and sent for a pooled urine cytology as specimen from the right renal pelvis and ureter.  An 0.038 guidewire was then passed up through the open-ended ureteral catheter.  The open-ended ureteral catheter and cystoscope were removed, and over the guidewire the flexible ureteroscope was passed up to the level of the renal pelvis.  Using direct vision and fluoroscopy to confirm location, the entire renal pelvis and calyces were inspected.  The renal pelvis demonstrated an extrarenal pelvis, but no evidence of obstruction at the renal UPJ level.  There were no intrapelvic or calyceal stones.  The ureter demonstrated no significant mucosal abnormalities, no visible tumors, and no areas of apparent constriction on multiple passes of the ureteroscope through the ureter to evaluate.  The ureteroscope was then removed.  The cystoscope was reinserted.  Once again, retrograde injection of contrast through an open-ended ureteral catheter was undertaken in the right ureter and collecting system.  No evidence of extravasation or significant change in anatomy was visualized.  The left ureteral orifice was then visualized and cannulated with an open-ended ureteral catheter, and retrograde injection of contrast demonstrated a normal left ureter and collecting system.  The cystoscope was removed.  Foley catheter was inserted.  The patient was placed in the supine position and transferred to the recovery room in satisfactory condition.
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DESCRIPTION: Right hydronephrosis, right flank pain, atypical/dysplastic urine cytology, extrarenal pelvis on the right, no evidence of obstruction or ureteral/bladder lesions.  Cystoscopy, bilateral retrograde ureteropyelograms, right ureteral barbotage for urine cytology, and right ureterorenoscopy.

urology, hydronephrosis, ureteropyelogram, ureterorenoscopy, flank pain, renal pelvis, urine cytology, ureteral, cystoscopy, barbotage, cystoscope, retrograde, urine,

The procedure described, involving cystoscopy, ureteropyelograms, and ureteral barbotage, is aimed at diagnosing and potentially addressing issues related to right hydronephrosis and atypical urine cytology. While the conditions described are concerning, especially in the context of potential neoplasia, the procedure itself appears to have gone smoothly with minimal blood loss and no immediate complications. The mention of significant discomfort and disability from flank pain, associated with possible dysplasia, suggests moderate stakes, but the successful completion and diagnostics indicating no obstruction or lesions tempers the immediacy and severity. Thus, while important, the situation isn't critically or emergently high-stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: General Medicine
Sample Name: ER Report - URI

HISTORY OF PRESENT ILLNESS:,  The patient is a two-and-a-half-month-old male who has been sick for the past three to four days.  His mother has described congested sounds with cough and decreased appetite.  He has had no fever.  He has had no rhinorrhea.  Nobody else at home is currently ill.  He has no cigarette smoke exposure.  She brought him to the emergency room this morning after a bad coughing spell.  He did not have any apnea during this episode.,PAST MEDICAL HISTORY:,  Unremarkable.  He has had his two-month immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 99.1, oxygen saturations 98%, respirations by the nurse at 64, however, at my examination was much slower and regular in the 40s.,GENERAL:  Sleeping, easily aroused, smiling, and in no distress.,HEENT:  Soft anterior fontanelle.  TMs are normal.  Moist mucous membranes.,LUNGS:  Equal and clear.,CHEST:  Without retraction.,HEART:  Regular in rate and rhythm without murmur.,ABDOMEN:  Benign.,DIAGNOSTIC STUDIES:,  Chest x-ray ordered by ER physician is unremarkable, but to me also.,ASSESSMENT:,  Upper respiratory infection.,TREATMENT: , Use the bulb syringe and saline nose drops if there is any mucus in the anterior nares.  Smaller but more frequent feeds.  Discuss proper sleeping position.  Recheck if there is any fever or if he is no better in the next three days.
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DESCRIPTION: Patient in ER with upper respiratory infection

general medicine, er, uri, emergency room, upper respiratory infection, respiratory, sick, fever, chest,

The patient is a young infant with signs of an upper respiratory infection, but no fever or severe symptoms like apnea, and his vital signs are relatively stable. The chest x-ray is unremarkable and the recommended treatment is supportive care. The situation is concerning due to the patient's age, but does not appear to be life-threatening at this moment, therefore it is moderately low-stakes.


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

He has no voiding complaints and no history of sexually transmitted diseases.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Back surgery with a fusion of L5-S1.,MEDICATIONS: , He does take occasional Percocet for his back discomfort.,ALLERGIES:,  HE HAS NO ALLERGIES.,SOCIAL HISTORY:,  He is a smoker.  He takes rare alcohol.  His employment is that he does dynamite work and actually putting in the dynamite in large holes for destroying ground to that pipeline can be laid.  He travels to anywhere for his work.  He is married with one son.,FAMILY HISTORY: , Negative for prostate cancer, kidney cancer, bladder cancer, enlarged prostate or kidney disease.,REVIEW OF SYSTEMS:,  Negative for tremors, headaches, dizzy spells, numbness, tingling, feeling hot or cold, tired or sluggishness, abdominal pain, nausea or vomiting, indigestion, heartburn, fevers, chills, weight loss, wheezing, frequent cough, shortness of breath, chest pain, varicose veins, high blood pressure, skin rash, joint pain, ear infections, sore throat, sinus problems, hay fever, blood clotting problems, depressive affect or eye problems.,PHYSICAL EXAMINATION,GENERAL:  The patient is afebrile.  His vital signs are stable.  He is 177 pounds, 5 feet, 8 inches.  Blood pressure 144/66.  He is healthy appearing.  He is alert and oriented x 3.,HEART:  Regular rate and rhythm.,LUNGS:  Clear to auscultation.,ABDOMEN:  Soft and nontender.  His penis is circumcised.  He has a pedunculated cauliflower-like lesion on the dorsum of the penis at approximately 12 o'clock.  It is very obvious and apparent.  He also has a mildly raised brown lesion that the patient states has been there ever since he can remember and has not changed in size or caliber.  His testicles are descended bilaterally.  There are no masses.,ASSESSMENT AND PLAN: , This is likely molluscum contagiosum (genital warts) caused by HPV.  I did state to the patient that this is likely a viral infection that could have had a long incubation period.  It is not clear where this came from but it is most likely sexually transmitted.  He is instructed that he should use protected sex from this point on in order to try and limit the transmission.  Regarding the actual lesion itself, I did mention that we could apply a cream of Condylox, which could take up to a month to work.  I also offered him C02 laser therapy for the genital warts, which is an outpatient procedure.  The patient is very interested in something quick and effective such as a CO2 laser procedure.  I did state that the recurrence rate is significant and somewhere as high as 20% despite enucleating these lesions.  The patient understood this and still wished to proceed.  There is minimal risk otherwise except for those inherent in laser injury and accidental injury.  The patient understood and wished to proceed.
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DESCRIPTION: Likely molluscum contagiosum (genital warts) caused by HPV.  It is not clear where this came from but it is most likely sexually transmitted.

consult - history and phy., sexually transmitted, molluscum contagiosum, genital warts, hpv,

The situation involves a medical consultation about a case of genital warts likely caused by HPV. While HPV and genital warts are common and generally not life-threatening, the condition is significant for the patient's sexual health and emotional well-being. The proposed treatment options (application of a cream and CO2 laser therapy) are non-urgent and low-risk medical procedures. However, the information regarding the condition being sexually transmitted could impact the patient's relationships and lifestyle choices, adding a social dimension to the stakes. The medical decision to proceed with a CO2 laser procedure entails understanding potential recurrence and risk, but overall, the situation can be managed with appropriate care and precautions. Therefore, while having potential personal implications, the medical nature of the case is not high-stakes in terms of urgency or danger.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Dilatation & Curettage - D&C

PREOPERATIVE DIAGNOSIS: , Postmenopausal bleeding.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:  ,Fractional dilatation and curettage.,SPECIMENS: , Endocervical curettings, endometrial curettings.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding.  An office endometrial biopsy was unable to be performed secondary to a stenotic internal cervical os.,FINDINGS: , Examination under anesthesia revealed a retroverted, retroflexed uterus with fundal diameter of 6.5 cm.  The uterine cavity was smooth upon curettage.  Curettings were fairly copious.  Sounding depth was 8 cm.,PROCEDURE:,  The patient was brought to the Operating Room with an IV in place.  The patient was given a general anesthetic and was placed in the lithotomy position.  Examination under anesthesia was completed with findings as noted.  She was prepped and draped and a speculum was placed into the vagina.  ,Tenaculum was placed on the cervix.  The endocervical canal was curetted using a Kevorkian curette, and the sound was used to measure the overall depth of the uterus.  The endocervical canal was dilated without difficulty to a size 16 French dilator.  A small, sharp curette was passed into the uterine cavity and curettings were obtained.,After completion of the curettage, polyp forceps were passed into the uterine cavity.  No additional tissue was obtained.  Upon completion of the dilatation and curettage, minimum blood loss was noted.,The patient was awakened from her anesthetic, and taken to the post anesthesia care unit in stable condition.
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DESCRIPTION: Fractional dilatation and curettage

Fractional dilatation and curettage

obstetrics / gynecology, postmenopausal bleeding, endometrial, fractional dilatation, fractional dilatation and curettage, endocervical, dilatation and curettage, endocervical canal, uterine cavity, curetted, dilatation, curettings, curettage

The procedure described is a fractional dilatation and curettage (D&C), a common gynecological procedure performed to diagnose or treat certain uterine conditions. In this case, it is performed due to postmenopausal bleeding, which can be a symptom of serious conditions such as endometrial cancer but is also often due to benign problems. The preoperative inability to perform an office biopsy also highlights the necessity of the procedure to rule out or identify serious conditions. However, the process described seems routine, with the patient stable post-procedure and minimal blood loss indicating low immediate risk. While there is a potential for high-stakes outcomes depending on pathological findings, the procedure itself carries moderate risks typical of surgical interventions, primarily due to the patient's presentation and possible serious conditions it seeks to diagnose.


Medical Specialty: Surgery
Sample Name: Foreign Body Removal - Foot - 1

PREOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Cellulitis with associated abscess, right foot.,2.  Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Irrigation debridement.,2.  Removal of foreign body of right foot.,ANESTHESIA:,  Spinal with sedation.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,GROSS FINDINGS: , Include purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.,HISTORY OF PRESENT ILLNESS: , The patient is a 61-year-old Caucasian male with a history of uncontrolled diabetes mellitus.  The patient states that he was working in his garage over the past few days when he noticed some redness and edema in his right foot.  He notes some itching as well as increasing pain and redness in the right foot and presented to ABCD General Hospital Emergency Room.  He was evaluated by the Emergency Room staff as well as the medical team and the Department of Orthopedics.  It was noted upon x-ray a foreign body in his foot and he had significant amount of cellulitis as well ________ right lower extremity.  After a long discussion held with the patient, it was elected to proceed with irrigation debridement and removal of the foreign body.,PROCEDURE: , After all potential complications, risks, as well as anticipated benefits of the above-named procedures were discussed at length with the patient, informed consent was obtained.  The operative extremity was then confirmed with the patient, operative surgeon, the Department of Anesthesia and nursing staff.  The patient was then transferred to preoperative area to Operative Suite #5 and placed on the operating table in supine position.  All bony prominences were well padded at this time.  The Department of Anesthesia was administered spinal anesthetic to the patient.  Once this anesthesia was obtained, the patient's right lower extremity was sterilely prepped and draped in the usual sterile fashion.  Upon viewing of the plantar aspect of the foot, there was noted to be a swollen ecchymotic area with a small hole in it, which purulent fluid was coming from.  At this time, after all bony and soft tissue landmarks were identified as well as the localization of the pus, a 2 cm longitudinal incision was made directly over this area, which was located between the second and third metatarsal heads.  Upon incising this, there was a foul smelling purulent fluid, which flowed from this region.  Aerobic and anaerobic cultures were taken as well as gram stain.  The area was explored and it ________ to the dorsum of the foot.  There was no obvious joint involvement.  After all loculations were broken, 3 liters antibiotic-impregnated fluid were pulse-evac through the wound.  The wound was again inspected with no more gross purulent or necrotic appearing tissue.  The wound was then packed with an iodoform gauge and a sterile dressing was applied consisting of 4x4s, floss, and Kerlix covered by an Ace bandage.  At this time, the Department of Anesthesia reversed the sedation.  The patient was transferred back to the hospital gurney to Postanesthesia Care Unit.  The patient tolerated the procedure well and there were no complications.,DISPOSITION:  ,The patient will be followed on a daily basis for possible repeat irrigation debridement.
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DESCRIPTION: Cellulitis with associated abscess and foreign body, right foot. Irrigation debridement and removal of foreign body of right foot.  Purulent material from the abscess located in the plantar aspect of the foot between the third and fourth metatarsal heads.

surgery, removal of foreign body, purulent material, metatarsal, cellulitis, abscess, kerlix, foreign body, foot, irrigation, debridement, purulent,

The situation involves a surgical procedure on a patient with cellulitis, an abscess, and a foreign body in the foot. The patient has a history of uncontrolled diabetes, complicating infection management and wound healing. While the surgery involves routine removal of a foreign body and debridement with minimal estimated blood loss and no complications reported during the surgery, the underlying conditions such as diabetes and cellulitis make it moderately critical. Proper postoperative care and monitoring are required to prevent further complications like infection or necrosis, especially considering the patient's diabetes. Therefore, it is a moderately high-stakes situation in a surgical context.


Medical Specialty: Radiology
Sample Name: EMG/Nerve Conduction Study - 4

NERVE CONDUCTION STUDIES:,  Bilateral ulnar sensory responses are absent.  Bilateral median sensory distal latencies are prolonged with a severely attenuated evoked response amplitude.  The left radial sensory response is normal and robust.  Left sural response is absent.  Left median motor distal latency is prolonged with attenuated evoked response amplitude.  Conduction velocity across the forearm is mildly slowed.  Right median motor distal latency is prolonged with a normal evoked response amplitude and conduction velocity.  The left ulnar motor distal latency is prolonged with a severely attenuated evoked response amplitude both below and above the elbow.  Conduction velocities across the forearm and across the elbow are prolonged.  Conduction velocity proximal to the elbow is normal.  The right median motor distal latency is normal with normal evoked response amplitudes at the wrist with a normal evoked response amplitude at the wrist.  There is mild diminution of response around the elbow.  Conduction velocity slows across the elbow.  The left common peroneal motor distal latency evoked response amplitude is normal with slowed conduction velocity across the calf and across the fibula head.  F-waves are prolonged.,NEEDLE EMG: , Needle EMG was performed on the left arm and lumbosacral and cervical paraspinal muscles as well as middle thoracic muscles using a disposable concentric needle.  It revealed spontaneous activity in lower cervical paraspinals, left abductor pollicis brevis, and first dorsal interosseous muscles.  There were signs of chronic reinnervation in triceps, extensor digitorum communis, flexor pollicis longus as well first dorsal interosseous and abductor pollicis brevis muscles.,IMPRESSION: , This electrical study is abnormal.  It reveals the following:,1.  A sensory motor length-dependent neuropathy consistent with diabetes.,2.  A severe left ulnar neuropathy.  This is probably at the elbow, although definitive localization cannot be made.,3.  Moderate-to-severe left median neuropathy.  This is also probably at the carpal tunnel, although definitive localization cannot be made.,4.  Right ulnar neuropathy at the elbow, mild.,5.  Right median neuropathy at the wrist consistent with carpal tunnel syndrome, moderate.,6.  A left C8 radiculopathy (double crush syndrome).,7.  There is no evidence for thoracic radiculitis.,The patient has made very good response with respect to his abdominal pain since starting Neurontin.  He still has mild allodynia and is waiting for authorization to get insurance coverage for his Lidoderm patch.  He is still scheduled for MRI of C-spine and T-spine.  I will see him in followup after the above scans.
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DESCRIPTION: EMG/Nerve Conduction Study showing sensory motor length-dependent neuropathy consistent with diabetes, severe left ulnar neuropathy, and moderate-to-severe left median neuropathy,

radiology, emg, nerve conduction study, nerve conduction studies, needle emg, electrical study, neuropathy, ulnar neuropathy, median neuropathy, severely attenuated evoked response, normal evoked response amplitude, attenuated evoked response amplitude, median motor distal latency, motor distal latency, abductor pollicis, pollicis brevis, dorsal interosseous, carpal tunnel, conduction, emg/nerve, needle,

The situation involves the interpretation of complex medical tests, such as EMG and nerve conduction studies, which have identified several neuropathic conditions in the patient. The findings suggest multiple neuropathies and require further imaging (MRI) to localize issues accurately. The patient is also experiencing ongoing symptoms requiring medication management. This involves a coordinated medical effort and impacts patient care directly, thus it's relatively high-stakes for patient outcomes.


Medical Specialty: Surgery
Sample Name: Heart Catheterization & Angiography - 2

PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Left ventriculogram was not performed.,INDICATION: , Non-ST elevation MI.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery.  Once adequate anesthesia had been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin.  The pressure was held.  The needle was removed over the guidewire.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary artery was engaged.  Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views.  Once an adequate study had been performed, the catheter was removed from the ostium of the left main coronary artery and a steel guidewire was inserted through the catheter.  The catheter was then removed over the guidewire.,Next, a Judkins right #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to manifold and flushed.  The catheter did slip into the left ventricle.  During the rotation, the LVEDP was then measured.  The ostium of the right coronary artery was then engaged.  Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views.  Once adequate study has been performed, the catheter was then removed.  The sheath was lastly flushed for the final time.,FINDINGS:,LEFT MAIN CORONARY ARTERY: , The left main coronary artery is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING ARTERY: , The LAD is a moderate caliber vessel, which is subtotaled in its mid portion for approximately 1.5 cm to 1 cm with subsequent TIMI-I flow distally.  The distal portion was diffusely diseased.  The proximal portion otherwise shows minor luminal irregularities.  The first diagonal branch demonstrated minor luminal irregularities throughout.,CIRCUMFLEX ARTERY:  ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove.  There is a 60% proximal lesion and a 90% mid lesion prior to the takeoff of the first obtuse marginal branch.  The first obtuse marginal branch demonstrates minor luminal irregularities throughout.,RIGHT CORONARY ARTERY: , The RCA is a moderate caliber vessel, which demonstrates a 90% mid stenotic lesion.  The dominant coronary artery gives off the posterior descending artery and posterolateral artery.  The left ventricular end-diastolic pressure was approximately 22 mmHg.  It should be noted that during injection of the contrast agent that there was ST elevation in the inferior leads, which resolved after the injection was complete.,IMPRESSION:,1.  Three-vessel coronary artery disease involving a subtotaled left anterior descending artery with TIMI-I flow distally and 90% circumflex lesion and 90% right coronary artery lesion.,2.  Mildly elevated left-sided filling pressures.,PLAN:,1.  The patient will be transferred to Providence Hospital today for likely PCI of the mid LAD lesion with a surgical evaluation for a coronary artery bypass grafting.  These findings and plan were discussed in detail with the patient and the patient's family.  The patient is agreeable.,2.  The patient will be continued on aggressive medical therapy including beta-blocker, aspirin, ACE inhibitor, and statin therapy.  The patient will not be placed on Plavix secondary to the possibility for coronary bypass grafting.  In light of the patient's history of cranial aneurysmal bleed, the patient will be held off of Lovenox and Integrilin.
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DESCRIPTION: Left heart catheterization and bilateral selective coronary angiography. Left ventriculogram was not performed.

surgery, non-st elevation, coronary angiography, ventriculogram, heart catheterization, bypass grafting, catheterization, coronary, artery, angiography, luminal, branch, descending, circumflex, vessel, guidewire,

The procedure described is a heart catheterization and angiography, which are significant medical procedures commonly used to diagnose and treat heart conditions. The patient has a serious condition, indicated by a non-ST elevation myocardial infarction (MI) and significant coronary artery disease affecting multiple vessels. These conditions can lead to life-threatening complications if not treated appropriately. The plan involves potential PCI (Percutaneous Coronary Intervention) and surgical evaluation for a coronary artery bypass grafting, indicating the high stakes involved in managing the patient's condition to prevent more severe outcomes like heart attack or heart failure.


Medical Specialty: Dermatology
Sample Name: Excision - Skin Neoplasm

PREOPERATIVE DIAGNOSES:,1.  Enlarging nevus of the left upper cheek.,2.  Enlarging nevus 0.5 x 1 cm, left lower cheek.,3.  Enlarging superficial nevus 0.5 x 1 cm, right nasal ala.,TITLE OF PROCEDURES:,1.  Excision of left upper cheek skin neoplasm 0.5 x 1 cm with two layer closure.,2.  Excision of the left lower cheek skin neoplasm 0.5 x 1 cm with a two layer plastic closure.,3.  Shave excision of the right nasal ala 0.5 x 1 cm skin neoplasm.,ANESTHESIA:  ,Local.  I used a total of 5 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,COMPLICATIONS:,  None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  Risks including but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures have been all reviewed.  Each of these lesions appears to be benign nevi; however, they have been increasing in size.  The lesions involving the left upper and lower cheek appear to be deep.  These required standard excision with the smaller lesion of the right nasal ala being more superficial and amenable to a superficial shave excision.  Each of these lesions was marked.  The skin was cleaned with a sterile alcohol swab.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,Began first excision of the left upper cheek skin lesion.  This was excised with the 15-blade full thickness.  Once it was removed in its entirety, undermining was performed, and the wound was closed with 5-0 myochromic for the deep subcutaneous, 5-0 nylon interrupted for the skin.,The lesion of the lower cheek was removed in a similar manner.  Again, it was excised with a 15 blade with two layer plastic closure.  Both these lesions appear to be fairly deep nevi.,The right nasal ala nevus was superficially shaved using the radiofrequency wave unit.  Each of these lesions was sent as separate specimens.  The patient was discharged from my office in stable condition.  He had minimal blood loss.  The patient tolerated the procedure very well.  Postop care instructions were reviewed in detail.  We have scheduled a recheck in one week and we will make further recommendations at that time.
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DESCRIPTION: Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure.  Shave excision of the right nasal ala skin neoplasm.

dermatology, enlarging nevus, nevus, skin neoplasm, nasal ala, cheek skin neoplasm, shave excision, superficial, lesions, neoplasm, excision, cheek

The procedure described involves the removal of potentially benign skin lesions, which have been increasing in size. These types of procedures in dermatology are generally routine, especially when the lesions are assessed pre-operatively to be benign. The use of local anesthesia, minor blood loss, and absence of complications suggest it is a low-risk procedure. While there is always some level of importance due to possible changes in diagnosis upon pathological examination, the stakes are not very high in this context unless further analysis suggests malignancy or other complications.


Medical Specialty: Emergency Room Reports
Sample Name: Hyperbilirubinemia - 4-day-old

HISTORY: , The patient is a 4-day-old being transferred here because of hyperbilirubinemia and some hypoxia.  Mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg%.  The patient was then sent to Hospital where she had some labs drawn and was noted to be hypoxic, but her oxygen came up with minimal supplemental oxygen.  She was also noted to have periodic breathing.  The patient is breast and bottle-fed and has been feeding well.  There has been no diarrhea or vomiting.  Voiding well.  Bowels have been regular.,According to the report from referring facility, because the patient had periodic breathing and was hypoxic, it was thought the patient was septic and she was given a dose of IM ampicillin.,The patient was born at 37 weeks' gestation to gravida 3, para 3 female by repeat C-section.  Birth weight was 8 pounds 6 ounces and the mother's antenatal other than was normal except for placenta previa.  The patient's mother apparently went into labor and then underwent a cesarean section.,FAMILY HISTORY: , Positive for asthma and diabetes and there is no exposure to second-hand smoke.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  The patient has a temperature of 36.8 rectally, pulse of 148 per minute, respirations 50 per minute, oxygen saturation is 96 on room air, but did go down to 90 and the patient was given 1 liter by nasal cannula.,GENERAL:  The patient is icteric, well hydrated.  Does have periodic breathing.  Color is pink and also icterus is noted, scleral and skin.,HEENT:  Normal.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular with a soft 3/6 murmur.  Femorals are well palpable.  Cap refill is immediate,ABDOMEN:  Soft, small, umbilical hernia is noted, which is reducible.,EXTERNAL GENITALIA:  Those of a female child.,SKIN:  Color icteric.  Nonspecific rash on the body, which is sparse.  The patient does have a cephalhematoma hematoma about 6 cm over the left occipitoparietal area.,EXTREMITIES:  The patient moves all extremities well.  Has a normal tone and a good suck.,EMERGENCY DEPARTMENT COURSE: , It was indicated to the parents that I would be repeating labs and also catheterize urine specimen.  Parents were made aware of the fact that child did have a murmur.  I spoke to Dr. X, who suggested doing an EKG, which was normal and since the patient will be admitted for hyperbilirubinemia, an echo could be done in the morning.  The case was discussed with Dr. Y and he will be admitting this child for hyperbilirubinemia.,CBC done showed a white count of 15,700, hemoglobin 18 gm%, hematocrit 50.6%, platelets 245,000, 10 bands, 44 segs, 34 lymphs, and 8 monos.  Chemistries done showed sodium of 142 mEq/L, potassium 4.5 mEq/L, chloride 104 mEq/L, CO2 28 mmol/L, glucose 75 mg%, BUN 8 mg%, creatinine 0.7 mg%, and calcium 8.0 mg%.  Total bilirubin was 25.4 mg, all of which was unconjugated.  CRP was 0.3 mg%.  Blood culture was drawn.  Catheterized urine specimen was normal.  Parents were kept abreast of what was going on all the time and the need for admission.  Phototherapy was instituted in the ER almost after the baby got to the emergency room.,IMPRESSION:,  Hyperbilirubinemia and heart murmur.,DIFFERENTIAL DIAGNOSES: , Considered breast milk, jaundice, ABO incompatibility, galactosemia, and ventricular septal defect.
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DESCRIPTION: 4-day-old with hyperbilirubinemia and heart murmur.

emergency room reports, hypoxia, periodic breathing, heart murmur, urine specimen, yellow, bilirubin, heart, murmur, hyperbilirubinemia,

The situation described involves a 4-day-old infant with hyperbilirubinemia, hypoxia, periodic breathing, and a heart murmur, requiring immediate medical intervention including phototherapy and hospitalization. These conditions are potentially life-threatening for a newborn, making it a high-stakes medical scenario as they require prompt and effective treatment to prevent serious complications such as bilirubin encephalopathy or cardiac issues.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Heart Catheterization, Ventriculography, & Angiography - 4

NAME OF PROCEDURE,1.  Left heart catheterization with left ventriculography and selective coronary angiography.,2.  Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.,HISTORY: , This is a 58-year-old male who presented with atypical chest discomfort.  The patient had elevated troponins which were suggestive of a myocardial infarction.  The patient is suspected of having significant obstructive coronary artery disease, therefore he is undergoing cardiac catheterization.,PROCEDURE DETAILS: , Informed consent was given prior to the patient was brought to the catheterization laboratory.  The patient was brought to the catheterization laboratory in postabsorptive state.  The patient was prepped and draped in the usual sterile fashion, 2% Xylocaine solution was used to anesthetize the right femoral region.  Using modified Seldinger technique, a 6-French arterial sheath was placed.  Then, the patient had already been on heparin.  Then, a Judkins left 4 catheter was intubated into the left main coronary artery.  Several projections were obtained and the catheter was removed.  A 3DRC catheter was intubated into the right coronary artery.  Several projections were obtained and the catheter was removed.  Then, a 3DRC guiding catheter was intubated into the right coronary artery.  Then, a universal wire was advanced across the lesion into the distal right coronary artery.  Integrilin was given.  Then, a 3.0 x 12 Voyager balloon was inflated at 13 atmospheres for 30 seconds.  Then, a projection was obtained.  Then, a 3.0 x 15 Vision stent was placed into the distal right coronary artery.  The stent was deployed at 15 atmospheres for 25 seconds.  Post stent, the patient was given intracoronary nitroglycerin after one projection.  Then, there was an attempt to place the intervention wire across the third posterolateral branch which was partially obstructed and this was not successful.  Then, a pilot 150 wire was advanced across the lesion.  Then, attempt to place the 2.0 x 8 power saver across the lesion was performed.  However, it was felt that there was adequate flow and no further intervention needed to be performed.  Then, the stent delivery system was removed.  A pigtail catheter was placed into the left ventricle.  Hemodynamics followed by left ventriculography was performed.  Then, a pullback gradient was performed and the catheter was removed.  Then, the right femoral artery was visualized and using angiography and then an Angio-Seal was applied.  The patient was transferred back to his room in good condition.,FINDINGS,1.  Hemodynamics:  The opening aortic pressure was 116/61 with a mean of 64.  The opening left ventricular pressure was 112 with end-diastolic pressure of 23.  LV pressure on pullback was 106 with end-diastolic pressure of 21.  Aortic pressure was 111/67 with a mean of 87.  The closing pressure was 110/67.,2.  Left ventriculography:  The left ventricle was of normal cavity, size, and wall thickness.  There is a mild anterolateral hypokinesis and moderate inferior and inferoapical hypokinesis.  The overall systolic function appeared to be mildly reduced with ejection fraction between 40% and 45%.  The mitral valve had no significant prolapse or regurgitation.  The aortic valve appeared to be trileaflet and moved normally.,3.  Coronary angiography:  The left main is a normal-caliber vessel.  This bifurcates into the left anterior descending and circumflex arteries.  The left main is free of any significant obstructive coronary artery disease.  The left anterior descending is a large vessel that extends to the apex.  It gives off approximately 10 septal perforators and 5 diagonal branches.  The first diagonal branch was large.  The left anterior descending had mild irregularities, but no high-grade disease.  The left circumflex is a nondominant vessel, which gives rise to two obtuse marginal branches.  The two obtuse marginal branches are large.  There is a relatively small left atrial branch.  The left circumflex had a 50% stenosis after the first obtuse marginal branch.  The rest of the vessel is moderately irregular, but no high-grade disease.  The right coronary artery appears to be a dominant vessel, which gives rise to three right ventricular branches, four posterior lateral branches, two right atrial branches, and two small conus branches.  The right coronary artery had moderate disease in its proximal segment with multiple areas of plaquing but no high-grade disease.  However, distal between the second and third posterolateral branch, there is a 90% stenosis.  The rest of the vessels had mild irregularities, but no high-grade disease.  Then percutaneous transluminal coronary angioplasty of the right coronary artery resulted in a 20% residual stenosis.  Then, after stent placement there was 0% residual stenosis; however, there was partial occlusion of the third posterolateral branch.  Then, a wire was advanced through this and there was improvement of flow.  There is improvement from TIMI grade 2 to TIMI grade 3 flow.,CLINICAL IMPRESSION,1.  Successful percutaneous transluminal angioplasty and stent placement of the right coronary artery.,2.  Two-vessel coronary artery disease.,3.  Elevated left ventricular end-diastolic pressure.,4.  Mild anterolateral and moderate inferoapical hypokinesis.,RECOMMENDATIONS,1.  Integrilin.,2.  Bed rest.,3.  Risk factor modification.,4.  Thallium scintigraphy in approximately six weeks.
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DESCRIPTION: Left heart catheterization with left ventriculography and selective coronary angiography.  Percutaneous transluminal coronary angioplasty and stent placement of the right coronary artery.

cardiovascular / pulmonary, heart catheterization, ventriculography, selective coronary angiography., angioplasty, stent placement, transluminal, percutaneous, coronary artery, coronary angiography, coronary angioplasty, diastolic pressure, obtuse marginal, percutaneous transluminal, catheterization, artery, coronary, angiography

This medical procedure involves significant cardiovascular intervention, including left heart catheterization, ventriculography, angiography, and stent placement, due to symptoms indicative of myocardial infarction and significant coronary artery disease. The stakes are high given the potential for serious complications during these procedures, the underlying condition of the patient, and the need for precise execution of the treatment to prevent adverse outcomes. These procedures are typically carried out in patients with significant coronary artery disease, a condition that can lead to heart attacks or other severe outcomes if not properly managed. The details provided, including elevated troponins and substantial stenosis, further imply a critical situation requiring expert intervention.


Medical Specialty: Chiropractic
Sample Name: Chiropractic Progress Note

CHIEF COMPLAINT:  ,Hip pain.,HISTORY OF PRESENTING ILLNESS:  ,The patient is a very pleasant 41-year-old white female that is known to me previously from our work at the Pain Management Clinic, as well as from my residency training program, San Francisco. We have worked collaboratively for many years at the Pain Management Clinic and with her departure there, she has asked to establish with me for clinic pain management at my office.  She reports moderate to severe pain related to a complicated past medical history.  In essence, she was seen at a very young age at the clinic for bilateral knee and hip pain and diagnosed with bursitis at age 23.  She was given nonsteroidals at that time, which did help with this discomfort.  With time, however, this became inadequate and she was seen later in San Francisco in her mid 30s by Dr. V, an orthopedist who diagnosed retroverted hips at Hospital.  She was referred for rehabilitation and strengthening.  Most of this was focused on her SI joints.  At that time, although she had complained of foot discomfort, she was not treated for it.  This was in 1993 after which she and her new husband moved to the Boston area, where she lived from 1995-1996.  She was seen at the Pain Center by Dr. R with similar complaints of hip and knee pain.  She was seen by rheumatologists there and diagnosed with osteoarthritis as well as osteophytosis of the back.  Medications at that time were salicylate and Ultram.,When she returned to Portland in 1996, she was then working for Dr. B.  She was referred to a podiatrist by her local doctor who found several fractured sesamoid bones in her both feet, but this was later found not to be the case.  Subsequently, nuclear bone scans revealed osteoarthritis.  Orthotics were provided.  She was given Paxil and Tramadol and subsequently developed an unfortunate side effect of grand mal seizure.  During this workup of her seizure, imaging studies revealed a pericardial fluid-filled cyst adhered to her ventricle.  She has been advised not to undergo any corrective or reparative surgery as well as to limit her activities since.  She currently does not have an established cardiologist having just changed insurance plans.  She is establishing care with Dr. S, of Rheumatology for her ongoing care.  Up until today, her pain medications were being written by Dr. Y prior to establishing with Dr. L.,Pain management in town had been first provided by the office of Dr. F. Under his care, followup MRIs were done which showed ongoing degenerative disc disease, joint disease, and facet arthropathy in addition to previously described sacroiliitis.  A number of medications were attempted there, including fentanyl patches with Flonase from 25 mcg titrated upwards to 50 mcg, but this caused oversedation.  She then transferred her care to Ab Cd, FNP under the direction of Dr. K.  Her care there was satisfactory, but because of her work schedule, the patient found this burdensome as well as the guidelines set forth in terms of monthly meetings and routine urine screens.  Because of a previous commitment, she was unable to make one unscheduled request to their office in order to produce a random urine screen and was therefore discharged.,PAST MEDICAL HISTORY:  ,1.  Attention deficit disorder.,2.  TMJ arthropathy.,3.  Migraines.,4.  Osteoarthritis as described above.,PAST SURGICAL HISTORY:,1.  Cystectomies.,2.  Sinuses.,3.  Left ganglia of the head and subdermally in various locations.,4.  TMJ and bruxism.,FAMILY HISTORY:  ,The patient's father also suffered from bilateral hip osteoarthritis.,MEDICATIONS:,1.  Methadone 2.5 mg p.o. t.i.d.,2.  Norco 10/325 mg p.o. q.i.d.,3.  Tenormin 50 mg q.a.m.,4.  Skelaxin 800 mg b.i.d. to t.i.d. p.r.n.,5.  Wellbutrin SR 100 mg q.d.,6.  Naprosyn 500 mg one to two pills q.d. p.r.n.,ALLERGIES: , IV morphine causes hives.  Sulfa caused blisters and rash.,PHYSICAL EXAMINATION: , A well-developed, well-nourished white female in no acute distress, sitting comfortably and answering questions appropriately, making good eye contact, and no evidence of pain behavior.,VITAL SIGNS:  Blood pressure 110/72 with a pulse of 68.,HEENT:  Normocephalic.  Atraumatic.  Pupils are equal and reactive to light and accommodation.  Extraocular motions are intact.  No scleral icterus.  No nystagmus.  Tongue is midline.  Mucous membranes are moist without exudate.,NECK:  Free range of motion without thyromegaly.,CHEST:  Clear to auscultation without wheeze or rhonchi.,HEART:  Regular rate and rhythm without murmur, gallop, or rub.,ABDOMEN:  Soft, nontender.,MUSCULOSKELETAL:  There is musculoskeletal soreness and tenderness found at the ankles, feet, as well as the low back, particularly above the SI joints bilaterally.  Passive hip motion also elicits bilateral hip pain referred to the ipsilateral side.  Toe-heel walking is performed without difficulty.  Straight leg raises are negative.  Romberg's are negative.,NEUROLOGIC:  Grossly intact.  Intact reflexes in all extremities tested.  Romberg is negative and downgoing.,ASSESSMENT:,1. Osteoarthritis.,2. Chronic sacroiliitis.,3. Lumbar spondylosis.,4. Migraine.,5. TMJ arthropathy secondary to bruxism.,6. Mood disorder secondary to chronic pain.,7. Attention deficit disorder, currently untreated and self diagnosed.,RECOMMENDATIONS:,1. Agree with Rheumatology referral and review.  I would particularly be interested in the patient pursuing a bone density scan as well as thyroid and parathyroid studies.,2. Given the patient's previous sulfa allergies, we would recommend decreasing her Naprosyn usage.
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DESCRIPTION: Patient with hip pain, osteoarthritis, lumbar spondylosis, chronic sacroiliitis, etc.

The situation involves a complex case with a patient experiencing multiple chronic conditions, requiring careful management of their medical history and treatment plan. However, it does not present a life-threatening or emergency scenario. The stakes are moderate due to the patient's ongoing pain management needs, allergic reactions, and potential for side effects from medication, which necessitate careful monitoring and adjustment by a healthcare provider. It is important for the patient to establish care with new practitioners and manage her conditions effectively, but this situation doesn't suggest an immediate risk to life or acute deterioration.


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Screening Colonoscopy

HISTORY:,  A is a 55-year-old who I know well because I have been taking care of her husband.  She comes for discussion of a screening colonoscopy.  Her last colonoscopy was in 2002, and at that time she was told it was essentially normal.  Nonetheless, she has a strong family history of colon cancer, and it has been almost four to five years so she wants to have a repeat colonoscopy.  I told her that the interval was appropriate and that it made sense to do so.  She denies any significant weight change that she cannot explain.  She has had no hematochezia.  She denies any melena.  She says she has had no real change in her bowel habit but occasionally does have thin stools.,PAST MEDICAL HISTORY:,  On today's visit we reviewed her entire health history.  Surgically she has had a stomach operation for ulcer disease back in 1974, she says.  She does not know exactly what was done.  It was done at a hospital in California which she says no longer exists.  This makes it difficult to find out exactly what she had done.  She also had her gallbladder and appendix taken out in the 1970s at the same hospital.  Medically she has no significant problems and no true medical illnesses.  She does suffer from some mild gastroparesis, she says.,MEDICATIONS: , Reglan 10 mg once a day.,ALLERGIES: , She denies any allergies to medications but is sensitive to medications that cause her to have ulcers, she says.,SOCIAL HISTORY: , She still smokes one pack of cigarettes a day.  She was counseled to quit.  She occasionally uses alcohol.  She has never used illicit drugs.  She is married, is a housewife, and has four children.,FAMILY HISTORY: , Positive for diabetes and cancer.,REVIEW OF SYSTEMS: , Essentially as mentioned above.,PHYSICAL EXAMINATION:,GENERAL:  A is a healthy appearing female in no apparent distress.,VITAL SIGNS:  Her vital signs reveal a weight of 164 pounds, blood pressure 140/90, temperature of 97.6 degrees F.,HEENT:  No cervical bruits, thyromegaly, or masses.  She has no lymphadenopathy in the head and neck, supraclavicular, or axillary spaces bilaterally.,LUNGS:  Clear to auscultation bilaterally with no wheezes, rubs, or rhonchi.,HEART:  Regular rate and rhythm without murmur, rub, or gallop.,ABDOMEN:  Soft, nontender, nondistended.,EXTREMITIES:  No cyanosis, clubbing, or edema, with good pulses in the radial arteries bilaterally.,NEURO:  No focal deficits, is intact to soft touch in all four.,ASSESSMENT AND RECOMMENDATIONS: , In light of her history and physical, clearly the patient would be well served with an upper and lower endoscopy.  We do not know what the anatomy is, and if she did have an antrectomy, she needs to be checked for marginal ulcers.  She also complains of significant reflux and has not had an upper endoscopy in over five to six years as well.  I discussed the risks, benefits, and alternatives to upper and lower endoscopy, and these include over sedation, perforation, and dehydration, and she wants to proceed.,We will schedule her for an upper and lower endoscopy at her convenience.
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DESCRIPTION: Patient comes for discussion of a screening colonoscopy.

consult - history and phy., screening colonoscopy, colonoscopy, hematochezia, screening, endoscopy,

The situation involves a medical consultation for a screening colonoscopy in a patient with a significant family history of colon cancer. Any delay or oversight in screening could have serious health implications such as missed early detection of potentially life-threatening conditions like cancer. The patient has also been advised to undergo an upper endoscopy due to previous medical history and current symptoms indicating possible complications or conditions needing investigation. Ensuring the timely and proper execution of these procedures is crucial for her health, making this a relatively high-stakes situation.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Postop Parathyroid Exploration & Parathyroidectomy

SUMMARY:  ,This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia.  She has had an uneventful postoperative night.  She put out 1175 mL of urine since surgery.  Her incision looks good.  IV site and extremities are unremarkable.,LABORATORY DATA:  ,Her calcium level was 7.5 this morning.  She has been on three Tums orally b.i.d. and I am increasing three Tums orally q.i.d. before meals and at bedtime.,PLAN:,  I will heparin lock her IV, advance her diet, and ambulate her.  I have asked her to increase her prednisone when she goes home.  She will double her regular dose for the next five days.  I will advance her diet.  I will continue to monitor her calcium levels throughout the day.  If they stabilize, I am hopeful that she will be ready for discharge either later today or tomorrow.  She will be given Lortab Elixir 2 to 4 teaspoons orally every four hours p.r.n. pain, dispensed #240 mL with one refill.  Her final calcium dosage will be determined prior to discharge.  I will plan to see her back in the office on the 12/30/08, and she has been instructed to call or return sooner for any problems.
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DESCRIPTION: This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia.  She has had an uneventful postoperative night.

soap / chart / progress notes, parathyroid hyperplasia, parathyroid exploration, pth, hyperplasia, parathyroidectomy, parathyroidNOTE

The situation is medical in nature and involves postoperative care, which is often critical due to the potential for complications. However, the patient is recovering without major issues and is on track for discharge. Monitoring of calcium levels and adjustment of medication is important but is part of standard postoperative protocol. Hence, while it involves careful monitoring and management, it does not currently represent an extreme high-stakes situation unless complications arise.


Medical Specialty: Neurology
Sample Name: Craniotomy - Temporal

PREOPERATIVE DIAGNOSIS:,  Brain tumor left temporal lobe.,POSTOPERATIVE DIAGNOSIS:,  Brain tumor left temporal lobe - glioblastoma multiforme.,OPERATIVE PROCEDURE:,1.  Left temporal craniotomy.,2.  Removal of brain tumor.,OPERATING MICROSCOPE: , Stealth.,PROCEDURE: , The patient was placed in the supine position, shoulder roll, and the head was turned to the right side.  The entire left scalp was prepped and draped in the usual fashion after having being placed in 2-point skeletal fixation.  Next, we made an inverted-U fashion base over the asterion over temporoparietal area of the skull.  A free flap was elevated after the scalp that was reflected using the burr hole and craniotome.  The bone flap was placed aside and soaked in the bacitracin solution.,The dura was then opened in an inverted-U fashion.  Using the Stealth, we could see that this large cystic mass was just below the cortex in the white matter just anterior to the trigone of the ventricle.  We head through the vein of Labbe, and we made great care to preserve this.  We saw where the tumor almost made to the surface.  Here we made a small corticectomy using the Stealth for guidance.  We left small corticectomy entered large cavity with approximately 15 cc of yellowish necrotic liquid.  This was submitted to pathology.  We biopsied this very abnormal tissue and submitted it to pathology.  They gave us a frozen section diagnosis of glioblastoma multiforme.  With the operating microscope and Greenwood bipolar forceps, we then systematically debulked this tumor.  It was very vascular and we really continued to remove this tumor until all visible tumors was removed.  We appeared to get two gliotic planes circumferentially.  We could see it through the ventricle.  After removing all visible tumor grossly, we then irrigated this cavity multiple times and obtained meticulous hemostasis and then closed the dura primarily with 4-0 Nurolon sutures with the piece of DuraGen placed over this in order to increase our chances for a good watertight seal.  The bone flap was then replaced and sutured with the Lorenz titanium plate system.  The muscle fascia galea was closed with interrupted 2-0 Vicryl sutures.  Skin staples were used for skin closure.  The blood loss of the operation was about 200 cc.  There were no complications of the surgery per se.  The needle count, sponge count, and the cottonoid count were correct.,COMMENT:  ,Operating microscope was quite helpful in this; as we could use the light as well as the magnification to help us delineate the brain tumor - gliotic interface and while it was vague at sometimes we could I think clearly get a good cleavage plane in most instances so that we got a gross total removal of this very large and necrotic-looking tumor of the brain.
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DESCRIPTION: Left temporal craniotomy and removal of brain tumor.

neurology, temporal lobe, brain tumor, lorenz titanium plate, burr hole, cortex, corticectomy, craniotome, craniotomy, frozen section, glioblastoma multiforme, temporal craniotomy, temporoparietal, ventricle, white matter, tumor, temporal, brain,

The scenario involves a craniotomy to remove a glioblastoma multiforme, a highly aggressive brain tumor. This type of surgery is inherently high-stakes due to several factors: the critical nature of the brain as an organ, the potential for complications during and after surgery, the need for precise and careful technique to minimize damage to surrounding brain tissue, and the significant implications of the diagnosis itself. The report mentions the successful removal of the visible tumor and no complications during the procedure, but the nature of the surgery and the diagnosis of glioblastoma inherently involve substantial risk and complexity.


Medical Specialty: Gastroenterology
Sample Name: Hepatic Encephalopathy

REASON FOR ADMISSION: , Hepatic encephalopathy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Native American male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.  He said that he was doing fine prior to that and denied having any complaints.  He was sitting watching TV and he felt sleepy.  So, he went to the bathroom to urinate before going to bed and while he was trying to lift the seat, he tripped and fell and hit his head on the back.  His head hit the toilet seat.  Then, he started having bleeding and had pain in the area with headache.  He did not lose consciousness as far as he can tell.  He went and woke up his sister.  This happened somewhere between 10:30 and 11 p.m.  His sister brought a towel and covered the laceration on the back of his head and called EMS, who came to his house and brought him to the emergency room, where he was found to have a laceration on the back of his head, which was stapled and a CT of the head was obtained and ruled out any acute intracranial pathology.  On his lab work, his ammonia was found to be markedly elevated at 106.  So, he is being admitted for management of this.  He denied having any abdominal pain, change in bowel habits, GI bleed, hematemesis, melena, or hematochezia.  He said he has been taking his medicines, but he could not recall those.  He denied having any symptoms prior to this fall.  He said earlier today he also fell.  He also said that this was an accidental fall caused by problem with his walker.  He landed on his back at that time, but did not have any back pain afterwards.,PAST MEDICAL HISTORY:,1.  Liver cirrhosis caused by alcohol.  This is per the patient.,2.  He thinks he is diabetic.,3.  History of intracranial hemorrhage.  He said it was subdural hematoma.  This was traumatic and happened seven years ago leaving him with the right-sided hemiparesis.,4.  He said he had a seizure back then, but he does not have seizures now.,PAST SURGICAL HISTORY:,1.  He has a surgery on his stomach as a child.  He does not know the type.,2.  Surgery for a leg fracture.,3.  Craniotomy seven years ago for an intracranial hemorrhage/subdural hematoma.,MEDICATIONS: , He does not remember his medications except for the lactulose and multivitamins.,ALLERGIES: , Dilantin.,SOCIAL HISTORY: , He lives in Sacaton with his sister.  He is separated from his wife who lives in Coolidge.  He smokes one or two cigarettes a day.  Denies drug abuse.  He used to be a heavy drinker, quit alcohol one year ago and does not work currently.,FAMILY HISTORY:,  Negative for any liver disease.,REVIEW OF SYSTEMS:,GENERAL:  Denies fever or chills.  He said he was in Gilbert about couple of weeks ago for fever and was admitted there for two days.  He does not know the details.,ENT:  No visual changes.  No runny nose.  No sore throat.,CARDIOVASCULAR:  No syncope, chest pain, or palpitations.,RESPIRATORY:  No cough or hemoptysis.  No dyspnea.,GI:  No abdominal pain.  No nausea or vomiting.  No GI bleed.  History of alcoholic liver disease.,GU:  No dysuria, hematuria, frequency, or urgency.,MUSCULOSKELETAL:  Denies any acute joint pain or swelling.,SKIN:  No new skin rashes or itching.,CNS:  Had a seizure many years ago with no recurrences.  Left-sided hemiparesis after subdural hematoma from a fight/trauma.,ENDOCRINE:  He thinks he has diabetes but does not know if he is on any diabetic treatment.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 97.7, heart rate 83, respiratory rate 18, blood pressure 125/72, and saturation 98% on room air.,GENERAL:  The patient is lying in bed, appears comfortable, very pleasant Native American male in no apparent distress.,HEENT:  His skull has a scar on the left side from previous surgery.  On the back of his head, there is a laceration, which has two staples on.  It is still oozing minimally.  It is tender.  No other traumatic injury is noted.  Eyes, pupils react to light.  Sclerae anicteric.  Nostrils are normal.  Oral cavity is clear with no thrush or exudate.,NECK:  Supple.  Trachea midline.  No JVD.  No thyromegaly.,LYMPHATICS:  No cervical or supraclavicular lymphadenopathy.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Normal S1 and S2.  No murmurs or gallops.  Regular rate and rhythm.,ABDOMEN:  Soft, distended, nontender.  No organomegaly or masses.,LOWER EXTREMITIES:  +1 edema bilaterally.  Pulses strong bilaterally.  No skin ulcerations noted.  No erythema.,SKIN:  Several spider angiomas noted on his torso and upper extremities consistent with liver cirrhosis.,BACK:  No tenderness by exam.,RECTAL:  No masses.  No abscess.  No rectal fissures.  Guaiac was performed by me and it was negative.,NEUROLOGIC:  He is alert and oriented x2.  He is slow to some extent in his response.  No asterixis.  Right-sided spastic hemiparesis with increased tone, increased reflexes, and weakness.  Increased tone noted in upper and lower extremities on the right compared to the left.  Deep tendon reflexes are +3 on the right and +2 on the left.  Muscle strength is decreased on the right, more pronounced in the lower extremity compared to the upper extremity.  The upper extremity is +4/5.  Lower extremity is 3/5.  The left side has a normal strength.  Sensation appears to be intact.  Babinski is upward on the right, equivocal on the left.,PSYCHIATRIC:  Flat affect.  Mood appeared to be appropriate.  No active hallucinations or psychotic symptoms.,LABORATORY DATA:
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DESCRIPTION: A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.

The patient is experiencing several concerning medical issues including hepatic encephalopathy, a history of liver cirrhosis due to alcohol use, recent significant head trauma, and elevated ammonia levels. The combination of these factors increases the risk of severe complications, such as cerebral edema or worsening neurological function. The immediate hospitalization suggests the situation requires urgent and careful management to prevent potentially life-threatening consequences.


Medical Specialty: Surgery
Sample Name: Flexible Cystoscopy - BPH

PREOPERATIVE DIAGNOSIS: , Microscopic hematuria.,POSTOPERATIVE DIAGNOSIS:,  Microscopic hematuria with lateral lobe obstruction, mild.,PROCEDURE PERFORMED: , Flexible cystoscopy.,COMPLICATIONS: , None.,CONDITION: , Stable.,PROCEDURE: , The patient was placed in the supine position and sterilely prepped and draped in the usual fashion.  After 2% lidocaine was instilled, the anterior urethra is normal.  The prostatic urethra reveals mild lateral lobe obstruction.  There are no bladder tumors noted.,IMPRESSION:,  The patient has some mild benign prostatic hyperplasia.  At this point in time, we will continue with conservative observation.,PLAN: , The patient will follow up as needed.
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DESCRIPTION: Microscopic hematuria with lateral lobe obstruction, mild.

surgery, benign prostatic hyperplasia, urethra, lateral lobe obstruction, flexible cystoscopy, microscopic hematuria, cystoscopy, hematuria, obstruction,

The procedure described is a flexible cystoscopy, which is a routine diagnostic medical procedure used to examine the inside of the bladder and urethra. The patient's condition is stable and the findings show a mild obstruction due to benign prostatic hyperplasia (BPH), which is a common condition. There were no complications during the procedure and the plan is for conservative observation and follow-up as needed. Therefore, there is no immediate risk to the patient's health or life, making this a relatively low-stakes situation.


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

Medical Specialty: ENT - Otolaryngology
Sample Name: Nasal Septoplasty & Tonsillectomy

PREOPERATIVE DIAGNOSES,1.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2.  Tonsillitis with hypertrophy.,3.  Edema to the uvula and soft palate.,POSTOPERATIVE DIAGNOSES,1.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.,2.  Tonsillitis with hypertrophy.,3.  Edema to the uvula and soft palate.,OPERATION PERFORMED,1.  Nasal septoplasty.,2.  Bilateral submucous resection of the inferior turbinates.,3.  Tonsillectomy and resection of soft palate.,ANESTHESIA: , General endotracheal.,INDICATIONS: , Chris is a very nice 38-year-old male with nasal septal deviation and bilateral inferior turbinate hypertrophy causing nasal obstruction.  He also has persistent tonsillitis with hypertrophy and tonsillolith and halitosis.  He also has developed tremendous edema to his posterior palate and uvula, which is causing choking.  Correction of these mechanical abnormalities is indicated.,DESCRIPTION OF OPERATION:  ,The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the right and left nasal septal mucosa and right and left inferior turbinates were anesthetized with 1% lidocaine with 1:100,000 epinephrine using approximately 10 mL.  Afrin-soaked pledgets were placed in the nasal cavity bilaterally.  The face was prepped with pHisoHex and draped in a sterile fashion.  A hemitransfixion incision was performed on the left with a #15 blade and submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator.  Anterior to the septal deflection, the septal cartilage was incised and an opposite-sided submucoperichondrial and mucoperiosteal flap was raised with the Cottle elevator.  The deviated portion of the nasal septal cartilage and bone was removed with a Takahashi forceps, and a large inferior septal spur was removed with a V-chisel.  Once the septum was reduced in the midline, the hemitransfixion incision was closed with a 4-0 Vicryl in an interrupted fashion.  The right and left inferior turbinates were trimmed in a submucous fashion using straight and curved turbinate scissors under direct visualization with a 4 mm 0 degree Storz endoscope.  Hemostasis was acquired by using suction electrocautery.  The turbinates were then covered with bacitracin ointment after cauterizing them and bacitracin ointment soaked Doyle splints were placed in the right and left nares and secured anteriorly to the columella with a 3-0 nylon suture.  The table was then turned.  A shoulder roll placed under the shoulders and the face was draped in a clean fashion.  A McIvor mouth gag was applied.  The tongue was retracted and the McIvor was gently suspended from the Mayo stand.  The left tonsil was grasped with a curved Allis forceps, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole to inferior pole using a Bovie electrocautery in its entirety in a subcapsular fashion.  The right tonsil was grasped in a similar fashion, retracted medially, and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole to inferior pole using Bovie electrocautery in its entirety in a subcapsular fashion.  The inferior, middle, and superior pole vessels were further cauterized with suction electrocautery.  The extremely edematous portion of soft palate was resected using a right angle clamp and right angle scissor and was closed with 3-0 Vicryl in a figure-of-eight interrupted fashion.  Copious saline irrigation of the oral cavity was then performed.  There was no further identifiable bleeding at the termination of the procedure.  The estimated blood loss was less than 10 mL.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.
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DESCRIPTION: Nasal septoplasty, bilateral submucous resection of the inferior turbinates, and tonsillectomy and resection of soft palate.  Nasal septal deviation with bilateral inferior turbinate hypertrophy.  Tonsillitis with hypertrophy.  Edema to the uvula and soft palate.

ent - otolaryngology, nasal septal deviation, turbinate hypertrophy, nasal septoplasty, submucous resection, resection of soft palate, tonsillectomy, bilateral inferior turbinate, bovie electrocautery, nasal septal, inferior turbinates, turbinates, nasal, tonsillitis, electrocautery, hypertrophy,

The procedures described are common and routine in otolaryngology, typically not posing high immediate life-or-death risks, although any surgical operation under general anesthesia involves some level of risk. The situation involves corrective surgeries for conditions that, if left untreated, could lead to discomfort or further complications, particularly the airway obstructions. Given that the surgery went without complications and the patient was stable post-operation, the situation is not extremely high-stakes. It is crucial but not comparable to life-threatening emergencies.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Ischemic Cardiac Disease - Progress Note

HISTORY OF PRESENT ILLNESS:,  The patient is a 68-year-old man who returns for recheck.  He has a history of ischemic cardiac disease, he did see Dr. XYZ in February 2004 and had a thallium treadmill test.  He did walk for 8 minutes.  The scan showed some mild inferior wall scar and ejection fraction was well preserved.  He has not had difficulty with chest pain, palpitations, orthopnea, nocturnal dyspnea, or edema.,PAST MEDICAL HISTORY/SURGERIES/HOSPITALIZATIONS: , He had tonsillectomy at the age of 8.  He was hospitalized in 1996 with myocardial infarction and subsequently underwent cardiac catheterization and coronary artery bypass grafting procedure.  He did have LIMA to the LAD and had three saphenous vein grafts performed otherwise.,MEDICATIONS:,  Kerlone 10 mg 1/2 pill daily, gemfibrozil 600 mg twice daily, Crestor 80 mg 1/2 pill daily, aspirin 325 mg daily, vitamin E 400 units daily, and Citrucel one daily.,ALLERGIES: , None known.,FAMILY HISTORY:  ,Father died at the age of 84.  He had a prior history of cancer of the lung and ischemic cardiac disease.  Mother died in her 80s from congestive heart failure.  He has two brothers and six sisters living who remain in good health.,PERSONAL HISTORY:  ,Quit smoking in 1996.  He occasionally drinks alcoholic beverages.,REVIEW OF SYSTEMS:,Endocrine:  He has hypercholesterolemia treated with diet and medication.  He reports that he did lose 10 pounds this year.,Neurologic:  Denies any TIA symptoms.,Genitourinary:  He has occasional nocturia.  Denies any difficulty emptying his bladder.,Gastrointestinal:  He has a history of asymptomatic cholelithiasis.,PHYSICAL EXAMINATION:,Vital Signs:  Weight:  225 pounds.  Blood pressure:  130/82.  Pulse:  83.  Temperature:  96.4 degrees.,General Appearance:  He is a middle-aged man who is not in any acute distress.,HEENT:  Mouth:  The posterior pharynx is clear.,Neck:  Without adenopathy or thyromegaly.,Chest:  Lungs are resonant to percussion.  Auscultation reveals normal breath sounds.,Heart:  Normal S1, S2, without gallops or rubs.,Abdomen:  Without tenderness or masses.,Extremities:  Without edema.,IMPRESSION/PLAN:,1.  Ischemic cardiac disease.  This remains stable.  He will continue on the same medication.  He reports he has had some laboratory studies today.,2.  Hypercholesterolemia.  He will continue on the same medication.,3.  Facial tic.  We also discussed having difficulty with the facial tic at the left orbital region.  This occurs mainly when he is under stress.  He has apparently had numerous studies in the past and has seen several doctors in Wichita about this.  At one time was being considered for some type of operation.  His description, however, suggests that they were considering an operation for tic douloureux.  He does not have any pain with this tic and this is mainly a muscle spasm that causes his eye to close.  Repeat neurology evaluation was advised.  He will be scheduled to see Dr. XYZ in Newton on 09/15/2004.,4.  Immunization.  Addition of pneumococcal vaccination was discussed with him but had been decided by him at the end of the appointment.  We will have this discussed with him further when his laboratory results are back.
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DESCRIPTION: Patient with a history of ischemic cardiac disease and hypercholesterolemia.

The situation involves a 68-year-old patient with a history of ischemic cardiac disease and hypercholesterolemia. Although the conditions are stable and there's ongoing management, these are significant cardiovascular concerns that can have severe complications. The patient is under control with regular follow-ups and medication, but any potential change in their condition could have serious consequences, such as another myocardial infarction. Additionally, there is a recommendation for a repeat neurology evaluation for a facial tic, which though not currently debilitating, signals the need for further medical attention. Considering these factors, this patient scenario requires careful monitoring and can be considered moderately high-stakes.


Medical Specialty: Orthopedic
Sample Name: Back Pain - Discharge Summary

CHIEF COMPLAINT: , Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.,HISTORY OF PRESENT ILLNESS:,  The patient is a 45-year-old white male who was admitted with acute back pain.  The patient reports that he had chronic problem with back pain for approximately 20 years, but it has gotten progressively worse over the last 3 years.  On 08/29/2007, the patient had awoken and started his day as he normally does, but midday, he reports that he was in such severe back pain and he was unable to walk or stand upright.  He was seen at ABCD Hospital Emergency Room, was evaluated and admitted.  He was treated with IV analgesics as well as Decadron, after being evaluated by Dr. A.  It was decided that the patient could benefit from physical therapy, since he was unable to perform ADLs, and was transferred to TCU at St. Joseph Health Services on 08/30/2007.  He had been transferred with diagnosis of a back pain secondary to intravertebral lumbar disk disease, secondary to degenerative changes.  The patient reports that he has had a " bulging disk" for approximately 1 year.  He reports that he has history of testicular cancer in the distant past and the most recent bone scan was negative.  The bone scan was done at XYZ Hospital, ordered by Dr. B, the patient's oncologist.,ALLERGIES: , PENICILLIN, AMOXICILLIN, CEPHALOSPORIN, DOXYCYCLINE, IVP DYE, IODINE, and SULFA, all cause HIVES.,Additionally, the patient reports that he has HIVES when he comes in contact with SAP FROM THE MANGO TREE, and therefore, he avoids any mango product at all.,PAST MEDICAL HISTORY: , Status post right orchiectomy secondary to his testicular cancer 18 years ago approximately 1989, GERD, irritable bowel syndrome, seasonal asthma (fall and spring) triggered by postnasal drip, history of bilateral carpal tunnel syndrome, and status post excision of abdominal teratoma and incisional hernia.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY: , The patient is employed in the finance department.  He is a nonsmoker.  He does consume alcohol on the weekend as much as 3 to 4 alcoholic beverages per day on the weekends.  He denies any IV drug use or abuse.,REVIEW OF SYSTEMS: , No chills, fever, shakes or tremors.  Denies chest pain palpitations, hemoptysis, shortness of breath, nausea, vomiting, diarrhea, constipation or hematemesis.  The patient reports that his last bowel movement was on 08/30/2007.  No urological symptoms such as dysuria, frequency, incomplete bladder emptying or voiding difficulties.  The patient does report that he has occasional intermittent "numbness and tingling" of his hands bilaterally as he has a history of bilateral carpal tunnel syndrome.  He denies any history of seizure disorders, but he did report that he had some momentary dizziness earlier, but that has since resolved.,PHYSICAL EXAMINATION:,VITAL SIGNS:  At the time of admission, temperature 98, blood pressure 176/97, pulse 86, respirations 20, and 95% O2 saturation on room air.  The patient weighs 260 pounds and is 5 feet and 10 inches tall by his report.,GENERAL:  The patient appears to be comfortable, in no acute distress.,HEENT:  Normocephalic.  Sclerae are nonicteric.  EOMI.  Tongue is at midline and no evidence of thrush.,NECK:  Trachea is at the midline.,LYMPHATICS:  No cervical or axillary nodes palpable.,LUNGS:  Clear to auscultation bilaterally.,HEART:  Regular rate and rhythm.  Normal S1 and S2.,ABDOMEN:  Obese, softly protuberant, and nontender.,EXTREMITIES:  There is no clubbing, cyanosis or edema.  There is no calf tenderness bilaterally.  Bilateral strength is 5/5 for the upper extremities bilaterally and he has 5/5 of left lower extremity.  The right lower extremity is 4-5/5.,MENTAL STATUS:  He is alert and oriented.  He was pleasant and cooperative during the examination.,ASSESSMENT:,1.  Acute on chronic back pain.  The patient is admitted to the TCU at St. Joseph Health Services for rehabilitation therapy.  He will be seen in consultation by Physical Therapy and Occupational Therapy.  He will continue a tapering dose of Decadron over the next 10 to 14 days and a tapering schedule has been provided, also Percocet 5/325 mg 1 to 2 tablets q.i.d. p.r.n. for pain.,2.  Status post right orchiectomy secondary to testicular cancer, stable at this time.  We will attempt to obtain copy of the most recent bone scan performed at XYZ Hospital ordered by Dr. B.,3.  Gastroesophageal reflux disease, irritable bowel syndrome, and gastrointestinal prophylaxis.  Colace 100 mg b.i.d., lactulose will be used on a p.r.n. basis, and Protonix 40 mg daily.,4.  Deep vein thrombosis prophylaxis will be maintained by the patient, continue to engage in his therapies including ambulating in the halls and doing leg exercises as well.,5.  Obesity.  As mentioned above, the patient's weighs 260 pounds with a height of 5 feet and 10 inches, and we had discussed possible weight loss plan, which he is interested in pursuing and a dietary consult has been requested.
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DESCRIPTION: Decreased ability to perform daily living activities secondary to exacerbation of chronic back pain.

The situation, although concerning due to the patient's significant back pain and chronic conditions, is not immediately life-threatening or critical. The patient is undergoing rehabilitation therapy and the management plan includes physical and occupational therapy, medication adjustments, and a dietary consult for weight management. These are ongoing managements for chronic conditions which, while important for the patient's quality of life, do not constitute a high-stakes, emergency scenario. The patient's condition seems stable and under medical supervision, with a structured treatment plan in place.


Medical Specialty: Orthopedic
Sample Name: Pinning - Hip

PREOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,POSTOPERATIVE DIAGNOSIS: , Right acute on chronic slipped capital femoral epiphysis.,PROCEDURE: , Revision and in situ pinning of the right hip.,ANESTHESIA: , Surgery performed under general anesthesia.,COMPLICATIONS:  ,There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,LOCAL:  ,10 mL of 0.50% Marcaine local anesthetic.,HISTORY AND PHYSICAL: , The patient is a 13-year-old girl who presented in November with an acute on chronic right slipped capital femoral epiphysis.  She underwent in situ pinning.  The patient on followup; however, noted to have intraarticular protrusion of her screw.  This was not noted intraoperatively on previous fluoroscopic views.  Given this finding, I explained to the father and especially the mother that this can cause further joint damage and that the screw would need to be exchanged for a shorter one.  Risks and benefits of surgery were discussed.  Risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, failure to remove the screw, possible continued joint stiffness or damage.  All questions were answered and parents agreed to above plan.,PROCEDURE IN DETAIL: , The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A small bump was placed underneath her right buttock.  The right upper thigh was then prepped and draped in standard surgical fashion.  The upper aspect of the incision was reincised.  The dissection was carried down to the crew, which was easily found.  A guidewire was placed inside the screw with subsequent removal of the previous screw.  The previous screw measured 65 mm.  A 60 mm screw was then placed under direct visualization with fluoroscopy.  The hip was taken through full range of motion to check on the length of the screw, which demonstrated no intraarticular protrusion.  The guidewire was removed.  The wound was then irrigated and closed using 2-0 Vicryl in the fascial layer as well as the subcutaneous fat.  The skin was closed with 4-0 Monocryl.  The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, 4 x 4s, and tape.  The area was infiltrated with total 10 mL of 0.5% Marcaine local anesthetic.,POSTOPERATIVE PLAN: , The patient will be discharged on the day of surgery.  She should continue toe touch weightbearing on her leg.  The wound may be wet in approximately 5 days.  The patient should follow up in clinic in about 10 days.  The patient is given Vicodin for pain.  Intraoperative findings were relayed to the mother.
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DESCRIPTION: Revision and in situ pinning of the right hip.

orthopedic, guidewire, capital femoral epiphysis, intraarticular protrusion, femoral epiphysis, pinning, screw,

The procedure described involves a revision surgery due to a complication with the original in situ pinning where the screw had intraarticular protrusion, posing a risk of joint damage. Although there were no intraoperative complications and the procedure is relatively routine in orthopedic contexts, the stakes are higher than usual because this is a revision surgery in a 13-year-old, and there are significant potential risks including joint damage and possible future complications. However, the surgery itself is planned, no unexpected complications occurred, and the postoperative prognosis appears manageable, suggesting a moderate level of stakes.


Medical Specialty: Ophthalmology
Sample Name: Conjunctivitis

CONJUNCTIVITIS,, better known as Pink Eye, is an infection of the inside of your eyelid.  It is usually caused by allergies, bacteria, viruses, or chemicals.,WHAT ARE THE SIGNS AND SYMPTOMS?,1.  Red, irritated eye.,2.  Some burning and/or scratchy feeling.,3.  There may be a purulent (pus) or a mucous type discharge.,HOW IS IT TREATED?,It depends on what caused the Pink Eye.  It may or may not need medication for treatment.  If medication is given, follow the directions on the label.,TO PREVENT THE SPREAD OF THE INFECTION:,1.  Wash hands thoroughly before you use the medicine in your eyes.  After using the medicine in your eyes.  Every time you touch your eyes or face.,2.  Wash any clothing touched by infected eyes.,Clothes,Towels,Pillowcases,3.  Do not share make-up.  If the infection is caused by bacteria or a virus you must throw away your used make-up and buy new make-up.,4.  Do not touch the infected eye because the infection will spread to the good eye.  IMPORTANT!!!,5.  Pink Eye Spreads Very Easily!
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DESCRIPTION: A sample note on Conjunctivitis (Pink Eye).

ophthalmology, eyelid, infected eyes, pink eye, conjunctivitis, eyes, infection, eye

Conjunctivitis, or Pink Eye, while being a common and infectious condition, is typically not a life-threatening situation. It may cause discomfort and inconvenience, and it is highly contagious, which can lead to spread if not handled properly. However, the stakes remain low in terms of health impact, as it is generally treatable and not severe in terms of causing long-term damage or systemic illness. The primary concern is the spread of infection rather than serious health outcomes.


Medical Specialty: Consult - History and Phy.
Sample Name: Ear pain - Pediatric Consult

PRESENTATION: , Patient, 13 years old, comes to your office with his mother complaining about severe ear pain.  He awoke during the night with severe ear pain, and mom states that this is the third time this year he has had earaches.,HISTORY OF PRESENT ILLNESS:  ,Patient reports that he felt good after taking antibiotics with each earache episode and has recently started on the wrestling team.  Mom reports that patient has been afebrile with each of the earache episodes, and he has not had upper respiratory symptoms.  Patient denies any head trauma associated with wrestling practice.,BIRTH AND DEVELOPMENTAL HISTORY:,  Patient's mother reports a normal pregnancy with no complications, having received prenatal care from 12 weeks.  Vaginal delivery was uneventful with a normal perinatal course.  Patient sat alone at 6 months, crawled at 9 months, and walked at 13 months.  His verbal and motor developmental milestones were as expected.,FAMILY/SOCIAL HISTORY: , Patient lives with both parents and two siblings (brother - age 11 years, sister - age 15 years).  He reports enjoying school, remains active in scouts, and is very excited about being on the wresting team.  Mom reports that he has several friends, but she is concerned about the time required for the wrestling team.  Patient is in 8th grade this year and an A/B student.  Both siblings are healthy.  His Dad has hypertension and has frequent heartburn symptoms that he treats with over-the-counter (OTC) medications.  Mom is healthy and has asthma.,PAST MEDICAL HISTORY:  ,Patient has been seen in the clinic yearly for well child exams.  He has had no major illnesses or hospitalizations.  He had one emergency room visit 2 years ago for a knee laceration.  Patient has been healthy except for the past year when he had two episodes of otitis media not associated with respiratory infections.  He received antibiotic therapy (amoxicillin) for the otitis media and both episodes resolved without problems.  Patient's Mom states that he takes no prescribed medications or OTC medications, but he admits that he has been taking his dad's OTC Pepcid AE sometimes when he gets heartburn.  Upon further examination, he reports taking Pepcid when he eats pizza or Mexican food.  He does complain of sore throats sometimes and often feels burning in his throat when he goes to sleep at night after a late evening snack.,NUTRITIONAL HISTORY: , Patient eats cereal bars or pop tarts with milk for breakfast most days.  He takes his lunch (usually a sandwich and chips or yogurt and fruit) for lunch.  Mom or his sister cooks supper in the evening.  The family goes out to eat once or twice a week and he only gets "fast food" once or twice a week according to his Mom.  He says he eats "a lot" especially after a wrestling meet.,PHYSICAL EXAM:,Height/weight:  Patient weighs 109 pounds (60th percentile) and is 69 inches tall (93rd percentile).  He is following the growth pattern he established in infancy.,Vital signs:  BP 110/60, T 99.2, HR 70, R 16.,General:  Alert, cooperative but a bit shy.,Neuro:  DTRs symmetric, 2+, negative Romberg, able to perform simple calculations without difficulty, short-term memory intact.  He responds appropriately to verbal and visual cues, and movements are smooth and coordinated.,HEENT:  Normocephalic, PEERLA, red reflex present, optic disk and ocular vessels normal.  TMs deep red, dull, landmarks obscured, full bilaterally.  Post auricular and submandibular nodes on left are palpable and slightly tender.,Lungs:  CTA, breath sounds equal bilaterally, excursion and chest configuration normal.,Cardiac:  S1, S2 split, no murmurs, pulses equal bilaterally.,Abdomen:  Soft, rounded, reports no epigastric tenderness but states that heartburn begins in epigastric area and rises to throat.  Bowel sounds active in all quadrants.  No hepatosplenomegaly or tenderness.  No CVA tenderness.,Musculoskeletal:  Full range of motion, all extremities.  Spine straight, able to perform jumping jacks and duck walk without difficulty.,Genital:  Normal male, Tanner stage 4.  Rectal exam - small amount of soft stool, no fissures or masses.,LABS:  ,Stool negative for blood and H. pylori antigen.  Normal CBC and urinalysis.  A barium swallow and upper GI was scheduled for the following week.  It showed marked GE reflux.,ASSESSMENT: , The differential diagnoses for patient included (a) chronic otitis media/treatment failure, (b) peptic ulcer disease/gastritis, (c) gastro esophageal reflux disease (GERD) or carbonated beverage syndrome, (d) trauma.,CHRONIC OTITIS MEDIA. , Chronic otitis media due to a penicillin resistant organism would be the obvious diagnosis in this case.  It is rare for an adolescent to have otitis media with no precipitating factor (such as being on a swim team or otherwise exposed to unusual organisms or in an unusual environment).  It is certainly unusual for him to have three episodes in 1 year.,PEPTIC ULCER DISEASE.,  There were no symptoms of peptic ulcer disease, a negative H. pylori screen and lack of pain made this diagnosis less likely.  Trauma.  Trauma was a possibility, particularly since adolescent males frequently minimize symptoms especially if they might limit participation in a sport but patient maintained that he had not had an event where he struck his head or neck and that he always wore his helmet with ear padding.,GERD.,  The history of "heartburn" relieved by his father's medication was striking.  The positive study supported the diagnosis of GERD, which was severe and chronic enough to cause irritation of the mucosal surfaces exposed to the gastric juices and edema, inflammation in the inner ears.,PLAN:,  Patient and his Mom agreed to a trial of omeprazole 20 mg at bedtime for 2 weeks.  Patient was to keep a diary of any episodes of heartburn, including what foods seemed to aggravate it.  The clinician asked him to avoid using any antacid products in the meantime to gage the effectiveness of the medication.  He was also given a prescription for 10 days of Augmentin99 and a follow-up appointment for 2 weeks.  At his follow-up appointment he reported one episode after he ate a whole large pizza after wrestling practice but said it went away pretty quickly after he took his medication.  A 6-month follow up appointment was scheduled.
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DESCRIPTION: 13 years old complaining about severe ear pain - Chronic otitis media.

The scenario describes a pediatric patient experiencing recurring ear pain, diagnosed as chronic otitis media, with a consideration of possible gastroesophageal reflux disease (GERD) contributing to symptoms. The stakes here involve determining an accurate diagnosis and effective treatment to prevent potential complications, such as hearing loss or chronic infection. However, this appears to be a routine medical case for a pediatrician and not an emergency or life-threatening situation. The patient's condition is stable, and they are responsive to the treatment plan, reducing immediate high-stakes pressure.