Medical Specialty: General Medicine
Sample Name: Normal ROS Template - 5

REVIEW OF SYSTEMS,GENERAL:  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.,INTEGUMENTARY:  Negative rash, negative jaundice.,HEMATOPOIETIC:  Negative bleeding, negative lymph node enlargement, negative bruisability.,NEUROLOGIC:  Negative headaches, negative syncope, negative seizures, negative weakness, negative tremor.  No history of strokes, no history of other neurologic conditions.,EYES:  Negative visual changes, negative diplopia, negative scotomata, negative impaired vision.,EARS:  Negative tinnitus, negative vertigo, negative hearing impairment.,NOSE AND THROAT:  Negative postnasal drip, negative sore throat.,CARDIOVASCULAR:  Negative chest pain, negative dyspnea on exertion, negative palpations, negative edema.  No history of heart attack, no history of arrhythmias, no history of hypertension.,RESPIRATORY:  No history of shortness of breath, no history of asthma, no history of chronic obstructive pulmonary disease, no history of obstructive sleep apnea.,GASTROINTESTINAL:  Negative dysphagia, negative nausea, negative vomiting, negative hematemesis, negative abdominal pain.,GENITOURINARY:  Negative frequency, negative urgency, negative dysuria, negative incontinence.  No history of STDs.  **No history of OB/GYN problems.,MUSCULOSKELETAL:  Negative myalgia, negative joint pain, negative stiffness, negative weakness, negative back pain.,PSYCHIATRIC:  See psychiatric evaluation.,ENDOCRINE:  No history of diabetes mellitus, no history of thyroid problems, no history of endocrinologic abnormalities.
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DESCRIPTION: Normal review of systems template.  Negative weakness, negative fatigue, native malaise, negative chills, negative fever, negative night sweats, negative allergies.

general medicine, respiratory, gastrointestinal, integumentary, hematopoietic, night sweats, negative allergies, negative weakness, neurologic, throat, weakness

The situation involves a generalized review of systems (ROS) template within a medical context, indicating that it is a routine part of clinical documentation and assessment. There are no immediate medical concerns or emergencies highlighted in this template, as everything listed is 'negative', suggesting normal or baseline findings. Therefore, it reflects a standard evaluation process without suggesting actively life-threatening conditions or high-risk scenarios.


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

Medical Specialty: Consult - History and Phy.
Sample Name: Atrial Fibrillation Management

REASON FOR CONSULTATION: , Atrial fibrillation management.,HISTORY OF PRESENT ILLNESS: ,The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred by Dr. X for evaluation and management of atrial fibrillation.  The patient states that on Monday during routine Holt exam, it was detected by Dr. X that her heart was irregular on exam.  EKG obtained after that revealed atrial fibrillation, and subsequently the patient was started on Coumadin as well as having Toprol and referred for evaluation.  The patient states that for the last 3 years, she has had episodes of her heart racing.  It may last for minutes up to most 1 hour, and it will occasionally be related to eating a heavy meal or her caffeine or chocolate intake.  Denies dyspnea, diaphoresis, presyncope or syncope with the events, and she has had no episodes of chest pain.  They subsequently resolve on their own and do not limit her in anyway.  However, she states that for the last several years may be up to 7 years that she can recollect that she has been fatigued, and over the past couple of years, her symptoms have become more severe.  She said she can walk no more than 25 feet without becoming tired.  She states that she has to rest then her symptoms will go away, but she has been limited from that standpoint.  Denies peripheral edema, PND, orthopnea, abdominal pain, swelling, recent fever or chills.  She actually today has no complaints, and states that she has been compliant with her medications and has started taking her Coumadin as directed.,PAST MEDICAL HISTORY:,1.  Hypertension.,2.  Myocardial infarction in 2003.,3.  Left heart catheterization at University Hospital.,4.  Hypercholesterolemia.,5.  Arthritis.,6.  CVA in 2002 and in 2003 with right eye blindness.,PAST SURGICAL HISTORY:,1.  Left total knee replacement in 2002.,2.  Left lower quadrant abscess drainage in 12/07,FAMILY MEDICAL HISTORY: , Significant for lung and brain cancer.  There is no history that she is aware of cardiovascular disease in her family nor has any family member had sudden cardiac death.,SOCIAL HISTORY: , She is retired as a cook in a school cafeteria, where she worked for 34 years.  She retired 7 years ago because of low back pain.  She used to smoke 2-1/2 packs per day for 32 years, but quit in 1995.  Denies alcohol, and denies IV or illicit drug use.,ALLERGIES: , No known drug allergies.,MEDICATIONS:,1.  Coumadin 5 mg a day.,2.  Toprol-XL 50 mg a day.,3.  Aspirin 81 mg a day.,4.  Hydrochlorothiazide 25 mg a day.,5.  Plendil 10 mg daily.,6.  Lipitor 40 mg daily.,REVIEW OF SYSTEMS:  ,As above stating that following her stroke, she has right eye blindness, but she does have some minimal vision in her periphery.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure 138/66, pulse 96, and weight 229 pounds or 104 kg.  GENERAL:  A well-developed, well-nourished, middle-aged African American female in no acute distress.  NECK:  Supple.  No JVD.  No carotid bruits.  CARDIOVASCULAR:  Irregularly irregular rate and rhythm.  Normal S1 and S2.  No murmurs, gallops or rubs.  LUNGS:  Clear to auscultation bilaterally.  ABDOMEN:  Bowel sounds positive, soft, nontender, and nondistended.  No masses.  EXTREMITIES:  No clubbing, cyanosis or edema.  Pulses 2+ bilaterally.,LABORATORY DATA: , EKG today revealed atrial fibrillation with nonspecific lateral T-wave abnormalities and a rate of 94.,IMPRESSION:  ,The patient is a very pleasant 62-year-old African American female with atrial fibrillation of unknown duration with symptoms of paroxysmal episodes of palpitations, doing well today.,RECOMMENDATIONS:,1.  Her rate is suboptimally controlled, we will increase her Toprol-XL to 75 mg per day.,2.  We will obtain a transthoracic echocardiogram to evaluate her LV function as well as her valvular function.,3.  We will check a thyroid function panel.,4.  We will continue Coumadin as directed and to follow up with Dr. X for INR management.,5.  Given the patient's history of a stroke in her age and recurrent atrial fibrillation, the patient should be continued on Coumadin indefinitely.,6.  Depending upon the results of her transthoracic echocardiogram, the patient may benefit from repeat heart catheterization.  We will await results of transthoracic echocardiogram.,7.  We will arrange for the patient to wear a Holter monitor to monitor the rate controlled on a 24-hour period.  She will then return to the electrophysiology clinic in 1 month for followup visit with Dr. Y.,The patient was seen, discussed, and examined with Dr. Y in electrophysiology.
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DESCRIPTION: The patient is a very pleasant 62-year-old African American female with a history of hypertension, hypercholesterolemia, and CVA, referred for evaluation and management of atrial fibrillation.

The patient has a history of multiple serious medical conditions, including hypertension, myocardial infarction, and past strokes, along with new-onset atrial fibrillation. The consultation involves managing atrial fibrillation and assessing the potential need for further intervention, such as a repeat heart catheterization. Managing atrial fibrillation in a patient with such a complex medical history and a risk of stroke is critical to prevent more severe health complications. The stakes are high due to the potential for future strokes or heart issues if not managed properly, which makes the situation critical in terms of medical management.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Obstetrics / Gynecology
Sample Name: Tubal Sterilization & Coagulation

PROCEDURE:  ,Laparoscopic tubal sterilization, tubal coagulation.,PREOPERATIVE DIAGNOSIS: , Request tubal coagulation.,POSTOPERATIVE DIAGNOSIS: , Request tubal coagulation.,PROCEDURE:  ,Under general anesthesia, the patient was prepped and draped in the usual manner.  Manipulating probe placed on the cervix, changed gloves.  Small cervical stab incision was made, Veress needle was inserted without problem.  A 3 L of carbon dioxide was insufflated.  The incision was enlarged.  A 5-mm trocar placed through the incision without problem.  Laparoscope placed through the trocar.  Pelvic contents visualized.  A 2nd puncture was made 2 fingerbreadths above the symphysis pubis in the midline.  Under direct vision, the trocar was placed in the abdominal cavity.  Uterus, tubes, and ovaries were all normal.  There were no pelvic adhesions, no evidence of endometriosis.  Uterus was anteverted and the right adnexa was placed on a stretch.  The tube was grasped 1 cm from the cornual region, care being taken to have the bipolar forceps completely across the tube and the tube was coagulated using amp meter for total desiccation.  The tube was grasped again and the procedure was repeated for a separate coagulation, so that 1.5 cm of the tube was coagulated.  The structure was confirmed to be tube by looking at fimbriated end.  The left adnexa was then placed on a stretch and the procedure was repeated again grasping the tube 1 cm from the cornual region and coagulating it.  Under traction, the amp meter was grasped 3 more times so that a total of 1.5 cm of tube was coagulated again.  Tube was confirmed by fimbriated end.  Gas was lend out of the abdomen.  Both punctures repaired with 4-0 Vicryl and punctures were injected with 0.5% Marcaine 10 mL.  The patient went to the recovery room in good condition.
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DESCRIPTION: Laparoscopic tubal sterilization, tubal coagulation.

obstetrics / gynecology, cervix, cervical stab incision, laparoscopic tubal sterilization, tubal sterilization, tubal coagulation, sterilization, laparoscopic, endometriosis

Tubal sterilization is a common elective procedure in obstetrics and gynecology, often considered low-risk, especially when performed laparoscopically. While it is an important permanent contraceptive decision for the patient, the procedure itself is routine for trained medical personnel. Therefore, this situation is not high-stakes in terms of medical risk during the operation.


Medical Specialty: ENT - Otolaryngology
Sample Name: Normal ENT Exam

EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.
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DESCRIPTION: Sample normal ear, nose, mouth, and throat exam.

ent - otolaryngology, erythema, tympanic, mouth, throat, ears, mucosa, noseNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

This situation describes a standard and normal ear, nose, throat, and mouth examination, which is a routine part of otolaryngological assessment. There is no indication of any abnormalities or urgent findings. It's a typical descriptive section of a patient's chart with all normal findings, indicating low urgency and no immediate action needed.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 14

PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES:  ,1. Normal operative site.  ,2. Mild diverticulosis of the sigmoid colon.  ,3. Hemorrhoids.,PROCEDURE:  ,Total colonoscopy.,PROCEDURE IN DETAIL:  ,The patient is a 60-year-old of Dr. ABC's being evaluated for the above.  The patient also apparently had an x-ray done at the Hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed.  She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push.  Digital rectal exam was done, unremarkable.  At that point, the Pentax video colonoscope was inserted.  The rectal vault appeared normal.  The sigmoid showed diverticula throughout, mild to moderate in nature.  The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized.  The scope was passed a short distance up the ileum, which appeared normal.  The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area.  The scope was then retroflexed, and anal verge visualized showed some hemorrhoids.  The scope was then removed.  The patient tolerated the procedure well.,RECOMMENDATIONS:  ,Repeat colonoscopy in three years.
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DESCRIPTION: Colonoscopy. History of colon polyps and partial colon resection, right colon.  Mild diverticulosis of the sigmoid colon.  Hemorrhoids.

gastroenterology, partial colon resection, diverticulosis, colon polyps, rectal vault, colonoscopy, polyps, hemorrhoids, sigmoid

This medical scenario describes a routine colonoscopy procedure for a patient with a history of colon polyps and partial colon resection. The findings were relatively mild, showing normal operative site, mild diverticulosis, and hemorrhoids, with no significant complications reported during the procedure. The follow-up recommendation is a standard protocol of repeating the colonoscopy in three years. While colonoscopy procedures can have serious implications, this particular case appears to be low-stakes as the patient tolerated the procedure well, and the findings do not indicate immediate or severe health risks.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Transesophageal Echocardiogram - 2

REASON FOR EXAM: , Vegetation and bacteremia.,PROCEDURE: , Transesophageal echocardiogram.,INTERPRETATION: , The procedure and its complications were explained to the patient in detail and formal consent was obtained.  The patient was brought to special procedure unit.  His throat was anesthetized with lidocaine spray.  Subsequently, 2 mg of IV Versed was given for sedation.  The patient was positioned.  Probe was introduced without any difficulty.  The patient tolerated the procedure very well.  Probe was taken out.  No complications were noted.  Findings are as mentioned below.,FINDINGS:,1.  Left ventricle has normal size and dimensions with normal function.  Ejection fraction of 60%.,2.  Left atrium and right-sided chambers were of normal size and dimensions.,3.  Left atrial appendage is clean without any clot or smoke effect.,4.  Atrial septum is intact.  Bubble study was negative.,5.  Mitral valve is structurally normal.,6.  Aortic valve reveals echodensity suggestive of vegetation.,7.  Tricuspid valve was structurally normal.,8.  Doppler reveals moderate mitral regurgitation and moderate-to-severe aortic regurgitation.,9.  Aorta is benign.,IMPRESSION:,1.  Normal left ventricular size and function.,2.  Echodensity involving the aortic valve suggestive of endocarditis and vegetation.,3.  Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.
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DESCRIPTION: Transesophageal echocardiogram due to vegetation and bacteremia. Normal left ventricular size and function.  Echodensity involving the aortic valve suggestive of endocarditis and vegetation. Doppler study as above most pronounced being moderate-to-severe aortic insufficiency.

cardiovascular / pulmonary, ventricle, atrium, atrial, septum, mitral valv, aortic valve, tricuspid valve, doppler, ventricular size, transesophageal echocardiogram, severe aortic, bacteremia, transesophageal, echocardiogram, echodensity, vegetation, valve, aortic,

The situation involves a medical procedure (Transesophageal Echocardiogram) conducted to investigate potential endocarditis, which is a serious condition involving infection of the heart lining or valves. The findings note vegetation on the aortic valve, which indicates potential bacterial infection and implies significant implications for the patient's health, including moderate-to-severe aortic regurgitation. Given the serious nature of cardiac infections and potential for severe complications, this scenario involves high stakes for the patient's health outcomes.


Medical Specialty: Consult - History and Phy.
Sample Name: Viral Gastroenteritis

HISTORY OF PRESENT ILLNESS: , Patient is a 40-year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank "lots of red wine."  She states after vomiting, she felt "fine through the night," but woke with more nausea and vomiting and diaphoresis.  She states she has vomited approximately 20 times today and has also had some slight diarrhea.  She denies any sore throat or cough.  She states no one else at home has been ill.  She has not taken anything for her symptoms.,MEDICATIONS: , Currently the patient is on fluoxetine for depression and Zyrtec for environmental allergies.,ALLERGIES: , SHE HAS NO KNOWN DRUG ALLERGIES.,SOCIAL HISTORY:,  The patient is married and is a nonsmoker, and lives with her husband, who is here with her.,REVIEW OF SYSTEMS,Patient denies any fever or cough.  She notes no blood in her vomitus or stool.  The remainder of her review of systems is discussed and all are negative.,Nursing notes were reviewed with which I agree.,PHYSICAL EXAMINATION,VITAL SIGNS:  Temp is 37.6.  Other vital signs are all within normal limits.,GENERAL:  Patient is a healthy-appearing, middle-aged white female who is lying on the stretcher and appears only mildly ill.,HEENT:  Head is normocephalic and atraumatic.  Pharynx shows no erythema, tonsillar edema, or exudate.  NECK:  No enlarged anterior or posterior cervical lymph nodes.  There is no meningismus.,HEART:  Regular rate and rhythm without murmurs, rubs, or gallops.,LUNGS:  Clear without rales, rhonchi, or wheezes.,ABDOMEN:  Active bowel sounds.  Soft without any focal tenderness on palpation.  There are no masses, guarding, or rebound noted.,SKIN:  No rash.,EXTREMITIES:  No cyanosis, clubbing, or edema.,LABORATORY DATA: , CBC shows a white count of 12.9 with an elevation in the neutrophil count on differential.  Hematocrit is 33.8, but the indices are normochromic and normocytic.  BMP is remarkable for a random glucose of 147.  All other values are unremarkable.  LFTs are normal.  Serum alcohol is less than 5.,TREATMENT: , Patient was given 2 L of normal saline wide open as well as Compazine 5 mg IV x2 doses with resolution of her nausea.  She was given two capsules of Imodium with some apple juice, which she was able to keep down.  The patient did feel well enough to be discharged home.,ASSESSMENT:,  Viral gastroenteritis.,PLAN: , Rx for Compazine 10 mg tabs, dispense five, sig. one p.o. q.8h. p.r.n. for any recurrent nausea.  She was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet.  Imodium for any diarrhea, but no dairy products until the diarrhea has gone for at least 24 hours.  If she is unimproved in the next two days, she was urged to follow up with her PCP back home.
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DESCRIPTION: Viral gastroenteritis.  Patient complaining of the onset of nausea and vomiting after she drank lots of red wine.  She denies any sore throat or cough.  She states no one else at home has been ill.

consult - history and phy., nausea, vomiting, viral gastroenteritis, wine, gastroenteritis, ill,

The patient's condition is likely related to viral gastroenteritis possibly aggravated by excessive alcohol consumption. The situation was managed in a clinical setting with fluid rehydration and medication for symptom control. There are no indications of severe complications, and the patient was deemed well enough to be discharged with instructions for follow-up and symptomatic treatment. The condition, while uncomfortable, is generally self-limiting and not life-threatening or high-stakes unless there are complications, which are not currently evident.


Medical Specialty: Surgery
Sample Name: Vitrectomy

PREOPERATIVE DIAGNOSIS:,  Vitreous hemorrhage, right eye.,POSTOPERATIVE DIAGNOSIS: , Vitreous hemorrhage, right eye.,PROCEDURE:  ,Vitrectomy, right eye.,PROCEDURE IN DETAIL:  ,The patient was prepared and draped in the usual manner for a vitrectomy procedure under local anesthesia.  Initially, a 5 cc retrobulbar injection was performed with 2% Xylocaine during monitored anesthesia control.  A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.  MVR incisions were made 4 mm posterior to the limbus in the *** and *** o'clock meridians following which the infusion apparatus was positioned in the *** o'clock site and secured with a 5-0 Vicryl suture.  Then, under indirect ophthalmoscopic control, the vitrector was introduced through the *** o'clock site and a complete vitrectomy was performed.  All strands of significance were removed.  Tractional detachment foci were apparent posteriorly along the temporal arcades.  Next, endolaser coagulation was applied to ischemic sites and to neovascular foci under indirect ophthalmoscopic control.  Finally, an air exchange procedure was performed, also under indirect ophthalmoscopic control.  The intraocular pressure was within the normal range.  The globe was irrigated with a topical antibiotic.  The MVR incisions were closed with 7-0 Vicryl.  No further manipulations were necessary.  The conjunctiva was closed with 6-0 plain catgut.  An eye patch was applied and the patient was sent to the recovery area in good condition.
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DESCRIPTION: Vitreous hemorrhage, right eye.  Vitrectomy, right eye.  A Lancaster lid speculum was applied and the conjunctiva was opened 4 mm posterior to the limbus.

surgery, ophthalmoscopic, vitrectomy, endolaser, lancaster lid speculum, vitreous hemorrhage, vitreous, hemorrhage, conjunctiva

The described situation involves a surgical procedure known as a vitrectomy to treat a vitreous hemorrhage in the right eye. Surgical procedures, particularly those related to the eye, can be high-stakes due to the potential risk of complications such as vision loss, infection, bleeding, or other surgery-related issues. This procedure requires precision and skill to ensure successful outcomes for the patient. Given that the operation was conducted under local anesthesia and includes specific techniques like vitrectomy and endolaser coagulation, it underscores the importance of the procedure and the potential consequences if not performed correctly.


Medical Specialty: General Medicine
Sample Name: Discharge Summary - 2

ADMISSION DIAGNOSIS (ES):,1. Chronic obstructive pulmonary disease.,2. Pneumonia.,3. Congestive heart failure.,4. Diabetes mellitus.,5. Neuropathy.,6. Anxiety.,7. Hypothyroidism.,8. Depression.,9. Hypertension.,DISCHARGE DIAGNOSIS (ES):,1. Severe chronic obstructive pulmonary disease.,2. Diabetes mellitus.,3. Hypothyroidism.,4. Altered mental status, less somnolent, likely secondary to medications, resolved.,5. Lower gastrointestinal bleed.,6. Status post episode of atrial fibrillation.,7. Status post diverticular bleed.,DISCHARGE MEDICATIONS:,1. Albuterol inhaler q.i.d.,2. Xanax 1 mg t.i.d.,3. Cardizem CD 120 mg daily.,4. Colace 100 mg b.i.d.,5. Iron sulfate 325 mg b.i.d.,6. NPH 10 units subcutaneous b.i.d.,7. Atrovent inhaler q.i.d.,8. Statin oral suspension p.o. q.i.d., swish and spit.,9. Paxil 10 mg daily.,10. Prednisone 20 mg daily.,11. Darvocet Darvocet-N 100, one q.4h PRN pain.,12. Metamucil one pack b.i.d.,13. Synthroid 50 mcg daily.,14. Nexium 40 mg daily.,HOSPITAL COURSE:, The patient was a 66-year-old who presented with complaints of shortness of breath and was found to have acute COPD exacerbation. She had previously been at outlying hospital and had left AMA after 10 sets of BiPAP use. Here she was able to be kept off BiPAP later and slowly improved her exacerbation of COPD with the assistance of pulmonary. She was thought to have bronchitis as well and was treated with antibiotics. During hospitalization she developed acute lower GI bleed and was transferred to intensive care unit and transfused packed red blood cells. GI was consulted, performed endoscopy, revealing diverticular disease of the sigmoid colon, with this being the suspected cause of hemorrhage. Plavix is being held for at least 10 days. Lovenox held as well. No further signs of bleeding. The patient's respiratory status did slowly improve to baseline. She is discharged and given the above noted medications. Followup with Dr. Pesce, of diagnostic pulmonary, in the outpatient setting. She will also followup with Dr. Pesce, in the outpatient setting.
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DESCRIPTION: Patient with complaints of shortness of breath and was found to have acute COPD exacerbation.

The situation involves the discharge summary of a patient with multiple complex chronic conditions like COPD, heart failure, diabetes, and recent acute complications such as GI bleeding and atrial fibrillation. Management of such a patient involves careful coordination of medications and follow-up care which can significantly impact the patient's health outcomes. While this isn't an immediate life-threatening emergency, it is a high-stakes situation in terms of long-term health management and avoiding readmissions or complications.


Medical Specialty: Neurosurgery
Sample Name: Lumbar Laminectomy

PREOPERATIVE DIAGNOSIS: , Lumbar stenosis.,POSTOPERATIVE DIAGNOSES:,  Lumbar stenosis and cerebrospinal fluid fistula.,TITLE OF THE OPERATION,1.  Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques.,2.  Repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.,INDICATIONS:,  The patient is an 82-year-old woman who has about a four-month history now of urinary incontinence and numbness in her legs and hands, and difficulty ambulating.  She was evaluated with an MRI scan, which showed a very high-grade stenosis in her lumbar spine, and subsequent evaluation included a myelogram, which demonstrated cervical stenosis at C4-C5, C5-C6, and C6-C7 as well as a complete block of the contrast at L4-L5 and no contrast at L5-S1 either and stenosis at L3-L4 and all the way up, but worse at L3-L4, L4-L5, and L5-S1.  Yesterday, she underwent an anterior cervical discectomy and fusions C4-C5, C5-C6, C6-C7 and had some improvement of her symptoms and increased strength, even in the recovery room.  She was kept in the ICU because of her age and the need to bring her back to the operating room today for decompressive lumbar laminectomy.  The rationale for putting the surgery is close together that she is normally on Coumadin for atrial fibrillation, though she has been cardioverted.  She and her son understand the nature, indications, and risks of the surgery, and agreed to go ahead.,PROCEDURE: , The patient was brought from the Neuro ICU to the operating room, where general endotracheal anesthesia was obtained.  She was rolled in a prone position on the Wilson frame.  The back was prepared in the usual manner with Betadine soak, followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  Using the usual anatomical landmarks, linear midline incision was made presumed over L4-L5 and L5-S1.  Sharp dissection was carried down into subcutaneous tissue, then Bovie electrocautery was used to isolate the spinous processes.  A Kocher clamp was placed in the anterior spinous ligament and this turned out to be L5-S1.  The incision was extended rostrally and deep Gelpi's were inserted to expose the spinous processes and lamina of L3, L4, L5, and S1.  Using the Leksell rongeur, the spinous processes of L4 and L5 were removed completely, and the caudal part of L3.  A high-speed drill was then used to thin the caudal lamina of L3, all of the lamina of L4 and of L5.  Then using various Kerrison punches, I proceeded to perform a laminectomy.  Removing the L5 lamina, there was a dural band attached to the ligamentum flavum and this caused about a 3-mm tear in the dura.  There was CSF leak.  The lamina removal was continued, ligamentum flavum was removed to expose all the dura.  Then using 4-0 Nurolon suture, a running-locking suture was used to close the approximate 3-mm long dural fistula.  There was no CSF leak with Valsalva.,I then continued the laminectomy removing all of the lamina of L5 and of L4, removing the ligamentum flavum between L3-L4, L4-L5 and L5-S1.  Foraminotomies were accomplished bilaterally.  The caudal aspect of the lamina of L3 also was removed.  The dura came up quite nicely.  I explored out along the L4, L5, and S1 nerve roots after completing the foraminotomies, the roots were quite free.  Further more, the thecal sac came up quite nicely.  In order to ensure no CSF leak, we would follow the patient out of the operating room.  The dural closure was covered with a small piece of fat.  This was all then covered with DuraSeal glue.  Gelfoam was placed on top of this, then the muscle was closed with interrupted 0 Ethibond.  The lumbodorsal fascia was closed with multiple sutures of interrupted 0 Ethibond in a watertight fashion.  Scarpa's fascia was closed with a running 0 Vicryl, and finally the skin was closed with a running-locking 3-0 nylon.  The wound was blocked with 0.5% plain Marcaine.,ESTIMATED BLOOD LOSS:  Estimated blood loss for the case was about 100 mL.,SPONGE AND NEEDLE COUNTS:  Correct.,FINDINGS:  A very tight high-grade stenosis at L3-L4, L4-L5, and L5-S1.  There were adhesions between the dura and the ligamentum flavum owing to the severity and length of the stenosis.,The patient tolerated the procedure well with stable vitals throughout.
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DESCRIPTION: Lumbar laminectomy for decompression with foraminotomies L3-L4, L4-L5, L5-S1 microtechniques and repair of CSF fistula, microtechniques L5-S1, application of DuraSeal.  Lumbar stenosis and cerebrospinal fluid fistula.

neurosurgery, microtechniques, fistula, duraseal, foraminotomies, lumbar, stenosis, cerebrospinal, lumbar laminectomy, ligamentum flavum, csf, laminectomy, lamina,

The described scenario involves a complex neurosurgical procedure on an elderly patient with multiple pre-existing conditions, such as high-grade lumbar stenosis and cerebrospinal fluid fistula. The surgery includes lumbar laminectomy and repair of a CSF fistula, which are high-stakes due to the age of the patient, the need for precise surgical intervention, the potential for significant complications, and the possible impact on the patient's quality of life. The success of the procedure is critical for potentially relieving symptoms like urinary incontinence and difficulty ambulating. Additionally, the patient is on Coumadin for atrial fibrillation, which adds complexity regarding bleeding risks. Thus, this situation is high-stakes in a medical context because it involves life-altering decisions and potential risks related to patient health and recovery.


Medical Specialty: Surgery
Sample Name: Delivery Note - 5

DELIVERY NOTE: , This is a 30-year-old G7, P5 female at 39-4/7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away.  She was admitted and started on Pitocin.  Her cervix is 3 cm, 50% effaced and -2 station.  Artificial rupture of membrane was performed for clear fluid.  She did receive epidural anesthesia.  She progressed to complete and pushing.  She pushed to approximately one contraction and delivered a live-born female infant at 1524 hours.  Apgars were 8 at 1 minute and 9 at 5 minutes.  Placenta was delivered intact with three-vessel cord.  The cervix was visualized.  No lacerations were noted.  Perineum remained intact.  Estimated blood loss is 300 mL.  Complications were none.  Mother and baby remained in the birthing room in good condition.
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DESCRIPTION: Artificial rupture of membrane was performed for clear fluid.  She did receive epidural anesthesia.  She progressed to complete and pushing.

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

The situation described in the delivery note involves a routine childbirth where the patient had previously large babies and lived far from the hospital, hence the induction. The birth process went smoothly with no noted complications, and both mother and baby were reported to be in good condition. There was no mention of any emergency situations or significant medical challenges, thus making it a low-stakes scenario in the context of surgical and obstetric practice.


Medical Specialty: General Medicine
Sample Name: Female Physical Exam - 1

FEMALE PHYSICAL EXAMINATION,Eye:  Eyelids normal color, no edema.  Conjunctivae with no erythema, foreign body, or lacerations.  Sclerae normal white color, no jaundice.  Cornea clear without lesions.  Pupils equally responsive to light.  Iris normal color, no lesions.  Anterior chamber clear.  Lacrimal ducts normal.  Fundi clear.,Ear:  External ear has no erythema, edema, or lesions.  Ear canal unobstructed without edema, discharge, or lesions.  Tympanic membranes clear with normal light reflex.  No middle ear effusions.,Nose:  External nose symmetrical.  No skin lesions.  Nares open and free of lesions.  Turbinates normal color, size and shape.  Mucus clear.  No internal lesions.,Throat:  No erythema or exudates.  Buccal mucosa clear.  Lips normal color without lesions.  Tongue normal shape and color without lesion.  Hard and soft palate normal color without lesions.  Teeth show no remarkable features.  No adenopathy.  Tonsils normal shape and size.  Uvula normal shape and color.,Neck:  Skin has no lesions.  Neck symmetrical.  No adenopathy, thyromegaly, or masses.  Normal range of motion, nontender.  Trachea midline.,Chest:  Symmetrical.  Clear to auscultation bilaterally.  No wheezing, rales or rhonchi.  Chest nontender.  Normal lung excursion.  No accessory muscle use.,Cardiovascular:  Heart has regular rate and rhythm with no S3 or S4.  Heart rate is normal.,Abdominal:  Soft, nontender, nondistended, bowel sounds present.  No hepatomegaly, splenomegaly, masses, or bruits.,Genital:  Labia majora normal shape without erythema or lesions.  Labia minora normal shape without erythema or lesions.  Clitoris normal shape and contour.  Vaginal mucosa normal color without lesions.  No significant discharge.  Cervix normal shape and parity without lesions.  Ovaries normal shape and contour.  No pelvic masses.  Uterus normal shape and contour.  No external hemorrhoids.,Musculoskeletal:  Normal strength all muscle groups.  Normal range of motion all joints.  No joint effusions.  Joints normal shape and contour.  No muscle masses.,Foot:  No erythema.  No edema.  Normal range of motion all joints in the foot.  Nontender.  No pain with inversion, eversion, plantar or dorsiflexion.,Ankle:  Anterior and posterior drawer test negative.  No pain with inversion, eversion, dorsiflexion, or plantar flexion.  Collateral ligaments intact.  No joint effusion, erythema, edema, crepitus, ecchymosis, or tenderness.,Knee:  Normal range of motion.  No joint effusion, erythema, nontender.  Anterior and posterior drawer tests negative.  Lachman's test negative.  Collateral ligaments intact.  Bursas nontender without edema.,Wrist:  Normal range of motion.  No edema or effusion, nontender.  Negative Tinel and Phalen tests.  Normal strength all muscle groups.,Elbow:  Normal range of motion.  No joint effusion or erythema.  Normal strength all muscle groups.  Nontender.  Olecranon bursa flat and nontender, no edema.  Normal supination and pronation of forearm.  No crepitus.,Hip:  Negative swinging test.  Trochanteric bursa nontender.  Normal range of motion.  Normal strength all muscle groups.  No pain with eversion and inversion.  No crepitus.  Normal gait.,Psychiatric:  Alert and oriented times four.  No delusions or hallucinations, no loose associations, no flight of ideas, no tangentiality.  Affect is appropriate.  No psychomotor slowing or agitation.  Eye contact is appropriate.
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DESCRIPTION: Sample female physical exam

Sample female physical exam

general medicine, physical examination, abdominal, anterior chamber, cardiovascular, chest, ear, ear canal, eye, eyelids, female, female physical examination, labia majora, labia minora, nares, neck symmetrical, vaginal mucosa, crepitus, ecchymosis, edema, erythema, joint effusion, normal range of motion, shape and contour, normal strength, joint effusions, normal color, nontender, lesions, effusions, muscle, joints,

The situation describes a detailed physical examination report of a female patient, which is a common routine in general medicine. The examination results are normal, indicating no medical emergency or significant health issues were observed. The stakes are relatively low as this is a standard procedure and is not dealing with an urgent or critical health condition.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Cataract Extraction Followup

Her past medical history includes insulin requiring diabetes mellitus for the past 28 years.  She also has a history of gastritis and currently is being evaluated for inflammatory bowel disease.  She is scheduled to see a gastroenterologist in the near future.  She is taking Econopred 8 times a day to the right eye and Nevanac, OD, three times a day.  She is allergic to penicillin.,The visual acuity today was 20/50, pinholing, no improvement in the right eye.  In the left eye, the visual acuity was 20/80, pinholing, no improvement.  The intraocular pressure was 14, OD and 9, OS.  Anterior segment exam shows normal lids, OU.  The conjunctiva is quiet in the right eye.  In the left eye, she has an area of sectoral scleral hyperemia superonasally in the left eye.  The cornea on the right eye shows a paracentral area of mild corneal edema.  In the left eye, cornea is clear.  Anterior chamber in the right eye shows trace cell.  In the left eye, the anterior chamber is deep and quiet.  She has a posterior chamber intraocular lens, well centered and in sulcus of the left eye.  The lens in the left eye shows 3+ nuclear sclerosis.  Vitreous is clear in both eyes.  The optic nerves appear healthy in color and normal in size with cup-to-disc ratio of approximately 0.48.  The maculae are flat in both eyes.  The retinal periphery is flat in both eyes.,Ms. ABC is recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.  She will continue her current drops.  In the left eye, she has an area of what appears to be sectoral scleritis.  I did a comprehensive review of systems today and she reports no changes in her pulmonary, dermatologic, neurologic, gastroenterologic or musculoskeletal systems.  She is, however, being evaluated for inflammatory bowel disease.  The mild scleritis in the left eye may be a manifestation of this.  We will notify her gastroenterologist of this possibility of scleritis and will start Ms. ABC on a course of indomethacin 25 mg by mouth two times a day.  I will see her again in one week.  She will check with her primary physician prior to starting the Indocin.
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DESCRIPTION: Patient  follows up for cataract extraction with lens implant 2 weeks ago.   Recovering well from her cataract operation in the right eye with residual corneal swelling, which should resolve in the next 2 to 3 weeks.

soap / chart / progress notes, visual acuity, photophobia, lens implant, cataract extraction, eye, cataract, cornealNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

This situation involves a follow-up after cataract surgery. While cataract surgery and recovery can be important to a patient's vision and overall quality of life, this scenario does not immediately present as high-stakes. The patient's conditions, such as diabetes and possible inflammatory bowel disease, are ongoing concerns but are under management. The symptoms and findings reported here, such as residual corneal swelling and mild scleritis, seem expected in the post-operative period and are being monitored with scheduled follow-ups and adjustments in medication. The situation does not suggest immediate risk to life or major health deterioration.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Bronchoscopy - Fiberoptic

HISTORY OF PRESENT ILLNESS:,  A 67-year-old gentleman who presented to the emergency room with chest pain, cough, hemoptysis, shortness of breath, and recent 30-pound weight loss.  He had a CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.  There was also a question of liver metastases at that time.,OPERATION PERFORMED:,  Fiberoptic bronchoscopy with endobronchial biopsies.,The bronchoscope was passed into the airway and it was noted that there was a large, friable tumor blocking the bronchus intermedius on the right.  The tumor extended into the carina, involving the lingula and the left upper lobe, appearing malignant.  Approximately 15 biopsies were taken of the tumor.,Attention was then directed at the left upper lobe and lingula.  Epinephrine had already been instilled and multiple biopsies were taken of the lingula and the left upper lobe and placed in a separate container for histologic review.  Approximately eight biopsies were taken of the left upper lobe.
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DESCRIPTION: Fiberoptic bronchoscopy with endobronchial biopsies.  A CT scan done of the chest there which demonstrated bilateral hilar adenopathy with extension to the subcarinal space as well as a large 6-cm right hilar mass, consistent with a primary lung carcinoma.

cardiovascular / pulmonary, endobronchial, intermedius, fiberoptic bronchoscopy, lung carcinoma, bronchoscopy, fiberoptic, chest, tumor, lobeNOTE

This is a high-stakes situation because the patient is suspected to have lung carcinoma, which is a life-threatening condition. The bronchoscopy with biopsies is a critical procedure for diagnosis, determining the stage of cancer, and guiding treatment options. The potential for metastases, indicated by the questioning of liver involvement, further elevates the stakes, as this would significantly impact the patient's prognosis and treatment plan. The procedure and the biopsy results will directly influence the medical decisions and potential outcomes for the patient.


Medical Specialty: Neurosurgery
Sample Name: Cranial Vault Reconstruction

INDICATION FOR OPERATION:,  Right coronal synostosis with left frontal compensatory bossing causing plagiocephaly.,PREOPERATIVE DIAGNOSIS:,  Syndromic craniosynostosis.,POSTOPERATIVE DIAGNOSIS: , Syndromic craniosynostosis.,TITLE OF OPERATION: , Anterior cranial vault reconstruction with fronto-orbital bar advancement.,SPECIMENS: , None.,DRAINS: , One subgaleal drain exiting from the left posterior aspect of wound.,DESCRIPTION OF PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was started, the patient was placed on the operating table in supine position with the head held on a horseshoe-shaped headrest and the head was prepped and draped down the routine manner.  Here, the proposed scalp incision was infiltrated with 1% Xylocaine and then a zigzag scalp incision was made from one ear to the other ear, posterior to the coronal suture.  Scalp incision was reflected anteriorly and then the periosteum was taken off of the bone and then the temporalis muscles were reflected anterolaterally until the anterior cranial vault was exposed and then the periorbital rim, nasion and orbital part of the zygomatic arch were all dissected out as well as the pterion.  Using a craniotome, several bur holes were made; two on the either side of the midline posteriorly and then two posterolaterally.  The two posterior bur holes were then connected with a punch over the superior sagittal sinus and then the craniotome was used to fashion a flap first on the left and then on the right, going paramedian along the superior sagittal sinus in the midline and then curving over the fronto-orbital bar.  We then dissected superior sagittal sinus off of the inner table of the right bundle flap and then connected the right bundle flap going across the pterion on the right, which was abnormal.  The pterion on the right was then run short down after removing both bone flaps and then the dura was dissected off from the orbital roofs.  On the right, the orbital roof was jagged and abnormal and we had to repair a CSF leak from where the dura was punctured by the orbital roof.  The orbital rim was then dissected out and then using the saw and chisels, we were able to make the releasing cuts to free up the orbital rims, zygomatic arch and then remove the orbital bar going posteriorly and then the distal bar was split in the middle and then reapproximated with a bone graft in the middle to move the orbits out a little bit and the orbital bar was held together using absorbable plate.  It was then replaced and advanced and then relaxing, barrel-staving incisions were made in the bone flaps and the orbital rim and it was held on the right side with an absorbable plate to fix it in the proper position.  The bone flaps were then reapproximated using absorbable plates and screws, as well as #2-0 Vicryl to secure back into place.  Some of the places were also secured in the midline posteriorly, as well as off to the right where the bony defects were in place.  The periosteum was then brought over the skull and fastened in place and the temporalis muscles were tacked up to the periosteum.  The wounds were irrigated out.  A drain was left in posteriorly and then the wounds were closed in a routine manner using Vicryl for the galea and fast-absorbing gut for the skin followed by sterile dressings.  The patient tolerated the procedure well and did receive blood transfusions.
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DESCRIPTION: Anterior cranial vault reconstruction with fronto-orbital bar advancement.

neurosurgery, coronal synostosis, syndromic craniosynostosis, craniosynostosis, plagiocephaly, fronto-orbital bar, cranial vault reconstruction, cranial vault, orbital bar, orbital, cranial,

Cranial vault reconstruction is a complex and invasive neurosurgical procedure involving the correction of skull deformities, particularly in the context of syndromic craniosynostosis. It involves significant risks, including bleeding, infection, and potential neurological complications due to the proximity to the brain. The stakes are high as the surgery directly involves the brain and critical structures, and any complications can have severe consequences. The patient tolerated the procedure well in this case, but the inherent risks make this a high-stakes situation.


Medical Specialty: Surgery
Sample Name: Skin Graft

DIAGNOSIS:,  Stasis ulcers of the lower extremities,OPERATION:,  Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.,INDICATIONS:,  This 84-year old female presented recently with large ulcers of the lower extremities.  These were representing on the order of 50% or more of the circumference of her lower leg.  They were in a distribution to be consistent with stasis ulcers.  They were granulating nicely and she was scheduled for surgery.,FINDINGS:,  Large ulcers of lower extremities with size as described above.  These are irregular in shape and posterior and laterally on the lower legs.  There was no evidence of infection.  The ultimate skin grafting was quite satisfactory.,PROCEDURE: , Having obtained adequate general endotracheal anesthesia, the patient was prepped from the pubis to the toes.  The legs were examined and the wounds were Pulsavaced bilaterally with 3 liters of saline with Bacitracin.  The wounds were then inspected and there was adequate hemostasis and there was only minimal fibrinous debris that needed to be removed.  Once this was accomplished, the skin was harvested from the right thigh at approximately 0.013 inch.  This was meshed 1:1.5 and then stapled into position on the wounds.  The wounds were then dressed with a fine mesh gauze that was stapled into position as well as Kerlix soaked in Sulfamylon solution.,She was then dressed in additional Kerlix, followed by Webril, and splints were fashioned in a spiral fashion that avoided foot drop and stabilized them, and at the same time did not put pressure across the heels.  The donor site was dressed with Op-Site.  The patient tolerated the procedure well and returned to the recovery room in satisfactory condition.
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DESCRIPTION: Split-thickness skin grafting a total area of approximately 15 x 18 cm on the right leg and 15 x 15 cm on the left leg.

surgery, skin graft, lower extremities, split thickness skin grafting, skin grafting, kerlix, grafting, extremities, ulcers, leg,

The procedure described is a skin graft for stasis ulcers on an elderly patient. While surgery always carries inherent risks, this is a routine procedure with low immediate life-threatening risk, especially since the patient tolerated the procedure well and the grafting was satisfactory. The absence of infection and the fact that the patient returned to recovery in satisfactory condition suggest the situation is well-managed and controlled. However, the potential complications and the need for postoperative care in an elderly patient make it moderately significant.


Medical Specialty: Consult - History and Phy.
Sample Name: Infant Not Gaining Weight

CHIEF COMPLAINT:,  Not gaining weight.,HISTORY OF PRESENT ILLNESS:,  The patient is a 1-month-26-day-old African-American female in her normal state of health until today when she was taken to her primary care physician's office to establish care and to follow up on her feeds.  The patient appeared to have failure-to-thrive. was only at her birth weight but when eating one may be possibly gaining 2 ounces every 3-4 hours, and was noted to have a murmur.  At this point, the Hospitalist Service was contacted for admission.  The patient was directly admitted to Children's Hospital Explore Ward.,In the explore ward, she was noted to be in mild respiratory distress and has some signs and symptoms of heart failure and had a prominent murmur, so an echo was done at bedside, which did show a moderately-sized patent ductus arteriosus and very small VSD and some mild signs and symptoms of congestive heart failure.  The patient was also seen by Dr. X of Cardiology Service and a plan was then obtained.,PAST MEDICAL/BIRTH HISTORY: , The patient was born at term repeat C-section to a 27-year-old G3, P2 African-American female.  Pregnancy was not complicated by hypertension, diabetes, drugs, alcohol abuse or smoking.  Birthweight was 7 pounds 4 ounces at Community Hospital.  The mother did have a repeat C-section.  There is no rupture of membranes or group B strep status.  The prenatal care began in the second month of pregnancy and was otherwise uncomplicated.  Mother denies any sexual transmitted diseases or other significant illness.  The patient was discharged home on day of life #3 without any complications.,ALLERGIES:,  No known drug allergies.,DIET: , The patient only takes Enfamil 20 calories, 1-3 ounces per history every 3-4 hours.,ELIMINATION: , The patient urinates 3-4 times a day and has a bowel movement 3-4 times a day.,FAMILY HISTORY/SOCIAL HISTORY: , The patient lives with the mother.  She has 2 older male siblings.  All were reported good health.  Family history is negative for any congenital heart disease, syndromes, hypertension, sickle cell anemia or sickle cell trait and no significant positive PPD contacts and history of second-hand smoke exposures.,REVIEW OF SYSTEMS:  ,GENERAL:  The patient has been reported to have normal activity and normal cry with no significant weight loss per mom's report, but conversely no significant weight gain.  Mother does not report that she sweats whenever she eats or has any episodes of cyanosis.  ,HEENT:  Denies any significant nasal congestion or cough.  ,RESPIRATORY:  Denies any difficulty breathing or wheezing.  ,CARDIOVASCULAR:  As per above.  GI:  No history of any persistent vomiting or diarrhea.  ,GU:  Denies any decreased urinary output.  ,MUSCULOSKELETAL:  Negative.  ,NEUROLOGICAL:  Negative.  ,SKIN:  Negative.,All other systems reviewed are negative.,PHYSICAL EXAMINATION:,GENERAL:  The patient is examined in her room, our next floor.  She is crying very vigorously, especially when I examined but she is consolable.,VITAL SIGNS:  Temperature currently is 96.3, heart rate 137, respirations 36, blood pressure 105/61 while crying.,HEENT:  Normocephalic.  The patient has a possible right temporoparietal bossing noted and slightly irregular shaped trapezoidal-shaped head.  The anterior fontanelle is soft and flat.  Pupils are equal, reactive to light and accommodation, but there is some mild hypertelorism.  There is also some mild posterior rotation of the ears.  Oropharynx, mucous membranes are pink and moist.  There is a slightly high arched palate.,NECK:  Significant for possible mild reddening of the neck.,LUNGS:  Significant for perihilar crackles.  Mild tachypnea is noted.  O2 saturations are currently 97% on room air.  There is mild intercostal retraction.,CARDIOVASCULAR:  Heart has regular rate and rhythm.  Peripheral pulses are only 1+.  Capillary refills less than 3-4 seconds.,EXTREMITIES:  Slightly cool to touch.  There is 2-3/6 systolic murmur along the left sternal border.  Does radiate to the axilla and to the back.,ABDOMEN:  Soft, slightly distended, but nontender.  The liver edge is palpable 4 cm below right costal margin.  The spleen tip is also palpable.,GU:  Normal female external genitalia is noted.,MUSCULOSKELETAL:  The patient has poor fat deposits in her extremities.  Strength is only 2/4.  She had normal number of fingers and toes.,SKIN:  Significant for slight mottling.  There are very poor subcutaneous fat deposits in her skin.,LABORATORY DATA: , The i-STAT only shows sodium 135, potassium on a heel stick was 6.3, hemoglobin and hematocrit are 14 and 41, and white count was 1.4.  CBG on i-STAT showed the pH of 7.34 with CO2 of 55, O2 sat of 51, CO2 of 29 with the base excess of 4.  Chest x-ray shows bilateral infiltrates and significant cardiomegaly consistent with congenital heart disease and mild congestive heart failure.,ASSESSMENT: , This is an almost 2-month-old presents with:,1.  Failure-to-thrive.,2.  Significant murmur and patent ductus arteriosus.,3.  Congestive heart failure.,PLAN:  ,At present, we are going to admit and monitor closely tonight.  We will get a chest x-ray and start Lasix at 1 mg/kg twice daily.  We will also get a CBC and check a blood culture and further workup as necessary.
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DESCRIPTION: A 1-month-26-day-old with failure-to-thrive. was only at her birth weight, and was noted to have murmur.

This medical case involves a nearly 2-month-old infant presenting with serious health concerns including failure-to-thrive, a significant heart murmur, patent ductus arteriosus, and signs of congestive heart failure. These conditions are critical in an infant, especially given that she is at her birth weight and displays symptoms of heart failure, which can be life-threatening and require immediate medical intervention. The outlined plan includes hospitalization, close monitoring, medication, and further diagnostic work, illustrating the serious nature of the situation. As the patient's health could quickly deteriorate without appropriate medical care, this scenario is high-stakes.


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

Medical Specialty: Radiology
Sample Name: CT Brain: Subdural hematoma

CC:, Progressive unsteadiness following head trauma.,HX:,  A7 7 y/o male fell, as he was getting out of bed, and struck his head, 4 weeks prior to admission. He then began to experience progressive unsteadiness and gait instability for several days after the fall. He was then evaluated at a local ER and prescribed meclizine. This did not improve his symptoms, and over the past one week prior to admission began to develop left facial/LUE/LLE weakness. He was seen by a local MD on the 12/8/92 and underwent and MRI Brain scan. This showed a right subdural mass. He was then transferred to UIHC for further evaluation.,PMH:, 1)cardiac arrhythmia. 2)HTN. 3) excision of lip lesion 1 yr ago.,SHX/FHX:, Unremarkable. No h/o ETOH abuse.,MEDS:, Meclizine, Procardia XL.,EXAM:, Afebrile, BP132/74 HR72 RR16,MS: A & O x 3. Speech fluent. Comprehension, naming, repetition were intact.,CN: Left lower facial weakness only.,MOTOR: Left hemiparesis, 4+/5 throughout.,Sensory: intact PP/TEMP/LT/PROP/VIB,Coordination: ND,Station: left pronator drift.,Gait: left hemiparesis evident by decreased LUE swing and LLE drag.,Reflexes: 2/3 in UE; 2/2 LE; Right plantar downgoing; Left plantar equivocal.,Gen Exam: unremarkable.,COURSE:, Outside MRI revealed a loculated subdural hematoma extending throughout the frontotemporoparieto-occipital regions on the right. There was effacement of the right lateral ventricle. and a 0.5 cm leftward midline shift.,He underwent a HCT on admission, 12/8/92, which showed a right subdural hematoma. He then underwent emergent evacuation of this hematoma. He was discharged home 6 days after surgery.
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DESCRIPTION: CT of Brain - Subacute SDH.

CT of Brain - Subacute SDH.

radiology, ct brain, mri, sdh, subdural hematoma, gait instability, head trauma, hematoma, subacute, subdural, weakness, hemiparesis,

This situation involves a medical case where there was progressive neurological deterioration in a pediatric patient following head trauma and required emergent surgical intervention due to a subdural hematoma. The stakes are high because the condition posed an immediate threat to life and neurological function, necessitating rapid diagnosis and treatment to prevent further deterioration or potential long-term deficits.


Medical Specialty: Radiology
Sample Name: MRI Knee - 1

EXAM:,MRI LEFT KNEE WITHOUT CONTRAST,CLINICAL:,Left knee pain.,FINDINGS:,Comparison is made with 10/13/05 radiographs.,There is a prominent suprapatellar effusion. Patient has increased signal within the medial collateral ligament as well as fluid around it, compatible with type 2 sprain. There is fluid around the lateral collateral ligament without increased signal within the ligament itself, compatible with type 1 sprain.,Medial and lateral menisci contain some minimal increased signal centrally that does not extend through an articular surface and findings are felt to represent minimal myxoid degeneration. No tear is seen. Anterior cruciate and posterior cruciate ligaments are intact. There is a bone bruise of medial patellar facet measuring approximately 8 x 5 mm. There is suggestion of some mild posterior aspect of the lateral tibial plateau. MR signal on the bone marrow is otherwise normal.,IMPRESSION:,Type 2 sprain in the medial collateral ligament and type sprain in the lateral collateral ligament.,Joint effusion and bone bruise with suggestion of some minimal overlying chondromalacia and medial patellar facet.
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DESCRIPTION: MRI left knee without contrast.

MRI left knee without contrast.

radiology, collateral ligament, mri, knee, collateral, sprain, medial, ligament,

This MRI report does not indicate life-threatening conditions or immediate critical medical emergencies. The findings suggest sprains, minimal myxoid degeneration, and a bone bruise, which are painful and may require treatment or rehabilitation but are generally not high-stakes in terms of imminent danger. The high-stakes scenarios in radiology would include detecting highly urgent conditions like fractures, tumors, or signs of life-threatening diseases. The report findings are significant for diagnosis and treatment planning, but not immediately high-stakes since they do not pose an immediate threat to life or require urgent intervention.


Medical Specialty: Radiology
Sample Name: Moyamoya Disease

CC:, Confusion and slurred speech.,HX , (primarily obtained from boyfriend): This 31 y/o RHF experienced a "flu-like illness 6-8 weeks prior to presentation. 3-4 weeks prior to presentation, she was found "passed out" in bed, and when awoken appeared confused, and lethargic. She apparently recovered within 24 hours. For two weeks prior to presentation she demonstrated emotional lability, uncharacteristic of her ( outbursts of anger and inappropriate laughter). She left a stove on.,She began slurring her speech 2 days prior to admission. On the day of presentation she developed right facial weakness and began stumbling to the right. She denied any associated headache, nausea, vomiting, fever, chills, neck stiffness or visual change. There was no history of illicit drug/ETOH use or head trauma.,PMH:, Migraine Headache.,FHX: , Unremarkable.,SHX: ,Divorced. Lives with boyfriend. 3 children alive and well. Denied tobacco/illicit drug use. Rarely consumes ETOH.,ROS:, Irregular menses.,EXAM: ,BP118/66.  HR83. RR 20. T36.8C.,MS: Alert and oriented to name only. Perseverative thought processes. Utilized only one or two word answers/phrases. Non-fluent. Rarely followed commands. Impaired writing of name.,CN: Flattened right nasolabial fold only.,Motor: Mild weakness in RUE manifested by pronator drift. Other extremities were full strength.,Sensory: withdrew to noxious stimulation in all 4 extremities.,Coordination: difficult to assess.,Station: Right pronator drift.,Gait: unremarkable.,Reflexes: 2/2BUE, 3/3BLE, Plantars were flexor bilaterally.,General Exam: unremarkable.,INITIAL STUDIES:, CBC, GS, UA, PT, PTT, ESR, CRP, EKG were all unremarkable. Outside HCT showed hypodensities in the right putamen, left caudate, and at several subcortical locations (not specified).,COURSE: ,MRI Brian Scan, 2/11/92 revealed an old lacunar infarct in the right basal ganglia, edema within the head of the left caudate nucleus suggesting an acute ischemic event, and arterial enhancement of the left MCA distribution suggesting slow flow. The latter suggested a vasculopathy such as Moya Moya, or fibromuscular dysplasia. HIV, ANA, Anti-cardiolipin Antibody titer, Cardiac enzymes, TFTs, B12, and cholesterol studies were unremarkable.,She underwent a cerebral angiogram on 2/12/92. This revealed an occlusion of the left MCA just distal to its origin. The distal distribution of the left MCA filled on later films through collaterals from the left ACA. There was also an occlusion of the right MCA just distal to the temporal branch. Distal branches of the right MCA filled through collaterals from the right ACA. No other vascular abnormalities were noted. These findings were felt to be atypical but nevertheless suspicious of a large caliber vasculitis such as Moya Moya disease. She was subsequently given this diagnosis. Neuropsychologic testing revealed widespread cognitive dysfunction with particular impairment of language function. She had long latencies responding and understood only simple questions. Affect was blunted and there was distinct lack of concern regarding her condition. She was subsequently discharged home on no medications.,In 9/92 she was admitted for sudden onset right hemiparesis and mental status change. Exam revealed the hemiparesis and in addition she was found to have significant neck lymphadenopathy. OB/GYN exam including cervical biopsy, and abdominal/pelvic CT scanning revealed stage IV squamous cell cancer of the cervix. She died 9/24/92 of cervical cancer.
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DESCRIPTION: Cerebral Angiogram - moyamoya disease.

Cerebral Angiogram - moyamoya disease.

The case description involves a diagnosis of Moyamoya disease, a progressive cerebrovascular disorder that can lead to strokes or transient ischemic attacks (TIAs). The patient's symptoms mentioned, such as confusion, slurred speech, and motor weakness, were typical of these conditions. The situation could pose significant health risks if not managed properly, particularly due to the progressive and occlusive nature of the disease. Adding complexity is the fact that the patient was also diagnosed with stage IV cervical cancer, which is a life-threatening condition. The combination of these two serious health conditions significantly increases the stakes of the situation, as it involves high risks to the patient's health and life. Furthermore, the rapid progression to a terminal stage of cancer in a relatively short time underscores the high-stakes nature of this medical scenario.


Medical Specialty: ENT - Otolaryngology
Sample Name: Laryngoscopy

PREOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,POSTOPERATIVE DIAGNOSIS,Subglottic upper tracheal stenosis.,OPERATION PREFORMED,Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.,INDICATIONS FOR THE SURGERY,The patient is a 76-year-old white female with a history of subglottic upper tracheal stenosis.  She has had undergone multiple previous endoscopic procedures in the past; last procedure was in January 2007.  She returns with some increasing shortness of breath and dyspnea on exertion.  Endoscopic reevaluation is offered to her.  The patient has been considering laryngotracheal reconstruction; however, due to a recent death in the family, she has postponed this, but she has been having increasing symptoms.  An endoscopic treatment was offered to her.  Nature of the proposed procedure including risks and complications involving bleeding, infection, alteration of voice, speech, or swallowing, hoarseness changing permanently, recurrence of stenosis despite a surgical intervention, airway obstruction necessitating a tracheostomy now or in the future, cardiorespiratory, and anesthetic risks were all discussed in length.  The patient states she understood and wished to proceed.,DESCRIPTION OF THE OPERATION,The patient was taken to the operating room, placed on table in supine position.  Following adequate general anesthesia, the patient was prepared for endoscopy.  The top sliding laryngoscope was then inserted in the oral cavity, pharynx, and larynx examined. In the oral cavity, she had good dentition.  Tongue and buccal cavity mucosa were without ulcers, masses, or lesions.  The oropharynx was clear.  The larynx was then manually suspended.  Epiglottis area, epiglottic folds, false cords, true vocal folds with some mild edema, but otherwise, without ulcers, masses, or lesions, and the supraglottic and glottic airway were widely patent.  The larynx was manually suspended and a 5 x 30 pediatric rigid bronchoscope was passed through the vocal folds.  At the base of the subglottis, there was a narrowing and in the upper trachea, restenosis had occurred.  Moderate amount of mucoid secretions, these were suctioned, following which the area of stenosis was dilated.  Remainder of the bronchi was then examined.  The mid and distal trachea were widely patent.  Pale pink mucosa takeoff from mainstem bronchi were widely patent without ulcers, lesions, or evidence of scarring.  The scope was pulled back and removed and following this, a 6 x 30 pediatric rigid bronchoscope was passed through the larynx and further dilatation carried out.  Once this had been completed, dramatic improvement in the subglottic upper tracheal airway accomplished.  Instrumentation was removed and a #6 endotracheal tube, uncuffed, was placed to allow smooth emerge from anesthesia.  The patient tolerated the procedure well without complication.
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DESCRIPTION: Direct laryngoscopy, rigid bronchoscopy and dilation of subglottic upper tracheal stenosis.

ent - otolaryngology, stenosis, epiglottis, subglottic, bronchoscope, bronchoscopy, endoscopic, laryngoscopy, laryngotracheal reconstruction, larynx, oral cavity, pharynx, tracheal, true vocal folds, vocal, upper tracheal stenosis, subglottic upper tracheal, subglottic upper, upper tracheal, airway, cavity, patent,

This procedure involves direct laryngoscopy and bronchoscopy with dilation of subglottic tracheal stenosis, indicating a critical surgical intervention for a patient with serious airway obstruction issues. The condition involves stenosis, which can significantly disrupt breathing and is known to recur. Risks include airway obstruction, which may necessitate emergency measures like a tracheostomy. While this is not typically an emergency surgery, the condition's potential to rapidly become life-threatening underlines the inherently high-stakes nature of the operation. Furthermore, the patient's postponed larger reconstructive surgery due to personal reasons and recurrence of symptoms emphasizes the urgency and clinical significance of this procedure.


Medical Specialty: Nephrology
Sample Name: CT Abdomen & Pelvis

EXAM:,  CT Abdomen & Pelvis W&WO Contrast, ,REASON FOR EXAM: , Status post aortobiiliac graft repair. , ,TECHNIQUE: , 5 mm spiral thick spiral CT scanning was performed through the entire abdomen and pelvis utilizing intravenous dynamic bolus contrast enhancement.  No oral or rectal contrast was utilized.  Comparison is made with the prior CT abdomen and pelvis dated 10/20/05.  There has been no significant change in size of the abdominal aortic aneurysm centered roughly at the renal artery origin level which has dimensions of 3.7 cm transversely x 3.4 AP.  Just below this level is the top of the endoluminal graft repair with numerous surrounding surgical clips.  The size of the native aneurysm component at this level is stable at 5.5 cm in diameter with mural thrombus surrounding the enhancing endolumen.  There is no abnormal entrance of contrast agent into the mural thrombus to indicate an endoluminal leak.  Further distally, there is extension of the graft into both proximal common iliac arteries without evidence for endoluminal leak at this level either.  No exoluminal leakage is identified at any level.  There is no retroperitoneal hematoma present.  The findings are unchanged from the prior exam.  ,The liver, spleen, pancreas, adrenals and right kidney are unremarkable with moderate diffuse atrophy of the pancreas present.  There is advanced atrophy of the left kidney.  No hydronephrosis is present.  No acute findings are identified elsewhere in the abdomen. ,The lung bases are clear. ,Concerning the remainder of the pelvis, no acute pathology is identified.  There is prominent streak artifact from the left total hip replacement.  There is diffuse moderate sigmoid diverticulosis without evidence for diverticulitis.  The bladder grossly appears normal.  A hysterectomy has been performed.  ,IMPRESSION:,1.  No complications identified regarding endoluminal aortoiliac graft repair as described.  The findings are stable compared to the study of 10/20/04.  ,2.  Stable mild aneurysm of aortic aneurysm, centered roughly at renal artery level.  ,3.  No other acute findings noted. ,4.  Advanced left renal atrophy.
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DESCRIPTION: CT Abdomen & Pelvis W&WO Contrast

CT Abdomen & Pelvis W&WO Contrast

nephrology, aortobiiliac graft repair, renal atrophy, ct abdomen & pelvis, w&wo contrast, aortic aneurysm, renal artery, mural thrombus, endoluminal leak, ct abdomen, ct, contrast, pelvis, abdomen,

The CT report indicates a follow-up on an aortobiiliac graft repair, assessing for complications such as leaks or hematomas, neither of which are present. The report also mentions stable aneurysms and advanced left renal atrophy, conditions which must be monitored but do not indicate immediate critical care needs. The findings are stable, with no acute issues, suggesting the situation is not high-stakes.


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

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

discharge summary, adenomyosis, total abdominal hysterectomy, fibroid uterus, postoperative day, hemoglobin, hematocrit, therapy, menometrorrhagia, anemia, fibroid, uterus, tah, hysterectomy, abdominal,

The situation involves a discharge summary for a patient who underwent a total abdominal hysterectomy (TAH). While this is a significant medical procedure, the document indicates that there were no complications, infections, or blood transfusions needed. The patient's condition was stable upon discharge, and they were given standard postoperative instructions. Despite low hemoglobin levels noted, this document appears administrative and routine for post-surgery care in a stable patient.


Medical Specialty: Urology
Sample Name: Bilateral Vasovasostomy

Initially a small incision was made in the right superior hemiscrotum and the incision was carried down to the vas deferens.  This incision was carried down to the area of the previous vasectomy.  A towel clip was placed around this.  Next the scarred area was dissected free back to normal vas proximally and distally.  Approximately 4 cm of vas was freed up.  Next the vas was amputated above and below the scar tissue.  Fine hemostats were used to grasp the adventitial tissue on each side of the vas, both the proximal and distal ends.  Both ends were then dilated very carefully with lacrimal duct probes up to a #2 successfully.  After accomplishing this, fluid could be milked from the proximal vas which was encouraging.,Next the reanastomosis was performed.  Three 7-0 Prolene were used and full thickness bites were taken through the muscle layer of the vas deferens and into the lumen.  This was all done with 3.5 loupe magnification.  Next the vas ends were pulled together by tying the sutures.  A good reapproximation was noted.  Next in between each of these sutures two to three of the 7-0 Prolenes were used to reapproximate the muscularis layer further in an attempt to make this fluid-tight.,There was no tension on the anastomosis and the vas was delivered back into the right hemiscrotum.  The subcuticular layers were closed with a running 3-0 chromic and the skin was closed with three interrupted 3-0 chromic sutures.,Next an identical procedure was done on the left side.,The patient tolerated the procedure well and was awakened and returned to the recovery room in stable condition.  Antibiotic ointment, fluffs, and a scrotal support were placed.
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DESCRIPTION: Bilateral vasovasostomy surgery sample.

Bilateral vasovasostomy surgery sample.

urology, vasovasostomy, adventitial tissue, anastomosis, fluffs, hemiscrotum, loupe magnification, lumen, muscle layer, scrotal support, subcuticular, vas deferens, vas ends, bilateral vasovasostomy, chromic, suturesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Bilateral vasovasostomy is a surgical procedure to reverse a vasectomy, allowing for the possibility of restored fertility. While it is important for the patient's reproductive goals, it is an elective surgery that typically does not involve immediate life-threatening stakes. The procedure description indicates that the patient tolerated the surgery well and was in stable condition post-operatively, suggesting the operation went as planned and without complications. Thus, while important, it does not reach the high-stakes level of surgeries dealing with life-threatening conditions.


Medical Specialty: Surgery
Sample Name: Tonsillectomy & Adenoidectomy - 3

PREOPERATIVE DIAGNOSIS:,  Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,POSTOPERATIVE DIAGNOSIS: , Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,SURGICAL PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA: , General endotracheal technique.,SURGICAL FINDINGS:  ,A 4+/4+ cryptic and hypertrophic tonsils with 2+/3+ hypertrophic adenoid pads.,INDICATIONS: , We were requested to evaluate the patient for complaints of enlarged tonsils, which cause difficulty swallowing, recurrent pharyngitis, and sleep-induced respiratory disturbance.  She was evaluated and scheduled for an elective procedure.,DESCRIPTION OF SURGERY:  ,The patient was brought to the operative suite and placed supine on the operating room table.  General anesthetic was administered.  Once appropriate anesthetic findings were achieved, the patient was intubated and prepped and draped in the usual sterile manner for a tonsillectomy.  He was placed in semi-Rose ___ position and a Crowe Davis-type mouth gag was introduced into the oropharynx.  Under an operating headlight, the oropharynx was clearly visualized.  The right tonsil was grasped with the fossa triangularis and using electrocautery enucleation technique, was removed from its fossa.  This followed placing the patient in a suspension position using a McIvor-type mouth gag and a red rubber Robinson catheter via the right naris.  Once the right tonsil was removed, the left tonsil was removed in a similar manner, once again using a needle point Bovie dissection at 20 watts.  With the tonsils removed, it was possible to visualize the adenoid pads.  The oropharynx was irrigated and the adenoid pad evaluated with an indirect mirror technique.  The adenoid pad was greater than 2+/4 and hypertrophic.  It was removed with successive passes of electrocautery suction.  The tonsillar fossa was then once again hemostased with suction cautery, injected with 0.5% ropivacaine with 1:100,000 adrenal solution and then closed with 2-0 Monocryl on an SH needle.  The redundant soft tissue of the uvula was removed posteriorly and cauterized with electrocautery to prevent swelling of the uvula in the postoperative period.  The patient's oropharynx and nasopharynx were irrigated with copious amounts of normal saline contained with small amount of iodine, and she was recovered from her general endotracheal anesthetic.  She was extubated and left the operating room in good condition to the postoperative recovery room area.,Estimated blood loss was minimal.  There were no complications.  Specimens produced were right and left tonsils.  The adenoid pad was ablated with electrocautery.
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DESCRIPTION: Tonsillectomy and adenoidectomy.  Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.

surgery, obstructive adenotonsillar hypertrophy, pharyngitis, tonsillectomy, adenoidectomy, uvula, obstructive, adenotonsillar, hypertrophy, hypertrophic, fossa, tonsils, oropharynx, electrocautery, pads

The described situation is a routine tonsillectomy and adenoidectomy (T&A) for a condition that is relatively common, obstructive adenotonsillar hypertrophy. T&A procedures are considered relatively low-risk surgeries and are frequently performed, especially in children. In this specific case, the surgery went as planned with no complications, minimal estimated blood loss, and the patient left the operating room in good condition. Although any surgery involving general anesthesia carries certain risks, this is a standard, elective procedure known for its high success rate and minimal complications.


Medical Specialty: Consult - History and Phy.
Sample Name: Ankle Sprain - H&P

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

The situation involves a 56-year-old female with a right ankle sprain, which is a common injury often resulting from falling or twisting the ankle. The patient has some swelling, decreased range of motion, and mild ecchymosis, but no acute fracture is observed on the X-ray. The treatment plan includes pain management, a walking cast, and follow-up if necessary. Although the patient did report worsening pain the following day, leading to a prescription for stronger pain medication (Vicodin), the situation is not considered life-threatening. The stakes are moderate because appropriate pain management and follow-up are essential to ensure proper healing and to prevent complications, but it is not an emergency or life-and-death situation.


Medical Specialty: Orthopedic
Sample Name: de Quervain Release - Wrist

PREOPERATIVE DIAGNOSIS:,  Wrist de Quervain stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS: , Wrist de Quervain stenosing tenosynovitis.,TITLE OF PROCEDURES,1. de Quervain release.,2.  Fascial lengthening flap of the 1st dorsal compartment.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: , After MAC anesthesia and appropriate antibiotics were administered, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with an Esmarch and the tourniquet inflated to 250 mmHg.,I made a transverse incision just distal to the radial styloid.  Dissection was carried down directly to the 1st dorsal compartment with the superficial radial nerve identified and protected.  Meticulous hemostasis was maintained with bipolar electrocautery.,I dissected the sheath superficially free of any other structures, specifically the superficial radial nerve.  I then incised it under direct vision dorsal to its axis and incised it both proximally and distally.  The EPB subsheath was likewise released.,I irrigated the wound thoroughly.  In order to prevent tendon subluxation, I then back-cut both the dorsal and volar leafs of the sheath so that I could close them in an extended and lengthened position.  I did this with 3-0 Vicryl.  I then passed an instrument underneath to check and make sure that the sheath was not too tight.  I then irrigated it and closed the skin, and then I dressed and splinted the wrist appropriately.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.
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DESCRIPTION: Wrist de Quervain stenosing tenosynovitis.  de Quervain release.  Fascial lengthening flap of the 1st dorsal compartment.

orthopedic, de quervain, tenosynovitis, de quervain release, fascial lengthening flap, dorsal compartment, sheath, wrist, dorsal, tourniquet,

The described situation involves a surgical procedure for de Quervain release, which is a common orthopedic operation to relieve the symptoms of de Quervain's tenosynovitis. This type of procedure is generally considered routine with low risk to life or severe long-term consequences if performed correctly. Given that there were no complications, and it appears the surgery was successful with the patient sent to recovery in good condition, the stakes remain low. However, it is still a surgical procedure, so there is some inherent risk involved, albeit minor.


Medical Specialty: Radiology
Sample Name: EEG

DIAGNOSIS:,  Possible cerebrovascular accident.,DESCRIPTION: , The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages.  The background activity appears to consist of fairly organized somewhat pleomorphic low to occasional medium amplitude of 7-8 cycle per second activity and was seen mostly posteriorly bilaterally symmetrically.  A large amount of movement artifacts and electromyographic effects were noted intermixed throughout the recording session.  Transient periods of drowsiness occurred naturally producing irregular 5-7 cycle per second activity mostly over the anterior regions.  Hyperventilation was not performed.  No epileptiform activity or any definite lateralizing findings were seen.,IMPRESSION: , Mildly abnormal study.  The findings are suggestive of a generalized cerebral disorder.  Due to the abundant amount of movement artifacts, any lateralizing findings, if any cannot be well appreciated.  Clinical correlation is recommended.
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DESCRIPTION: Possible cerebrovascular accident.  The EEG was obtained using 21 electrodes placed in scalp-to-scalp and scalp-to-vertex montages.

radiology, scalp-to-scalp, scalp-to-vertex, montages, electrodes, amplitude, epileptiform activity, cerebrovascular accident, eegNOTE

The situation involves an EEG report indicating a possible cerebrovascular accident (stroke), which is a serious medical condition requiring further investigation and potentially urgent treatment. A stroke can lead to significant morbidity or mortality, so accurate diagnosis and management are critical. The recommendation for clinical correlation suggests it is important to follow up with further tests or assessments to confirm the diagnosis. Thus, the stakes are high as the findings could significantly impact patient care and outcomes.