Medical Specialty: General Medicine
Sample Name: Normal Physical Exam Template - 7

EYES: , The conjunctivae are clear.  The lids are normal appearing without evidence of chalazion or hordeolum.  The pupils are round and reactive.  The irides are without any obvious lesions noted.  Funduscopic examination shows sharp disk margins.  There are no exudates or hemorrhages noted.  The vessels are normal appearing.,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.,NECK:,  The neck is nontender and supple.  The trachea is midline.  The thyroid is without any evidence of thyromegaly.  No obvious adenopathy is noted to the neck.,RESPIRATORY: , The patient has normal respiratory effort.  There is normal lung excursion.  Percussion of the chest is without any obvious dullness.  There is no tactile fremitus or egophony noted.  There is no tenderness to the chest wall or ribs.  There are no obvious abnormalities.  The lungs are clear to auscultation.  There are no wheezes, rales or rhonchi heard.  There are no obvious rubs noted.,CARDIOVASCULAR: , There is a normal PMI on palpation.  I do not hear any obvious abnormal sounds.  There are no obvious murmurs.  There are no rubs or gallops noted.  The carotid arteries are without bruit.  No obvious thrill is palpated. There is no evidence of enlarged abdominal aorta to palpation.  There is no abdominal mass to suggest enlargement of the aorta.  Good strong femoral pulses are palpated.  The pedal pulses are intact.  There is no obvious edema noted to the extremities.  There is no evidence of any varicosities or phlebitis noted.,GASTROINTESTINAL: , The abdomen is soft.  Bowel sounds are present in all quadrants.  There are no obvious masses.  There is no organomegaly, and no liver or spleen is palpable.  No obvious hernia is noted.  The perineum and anus are normal in appearance.  There is good sphincter tone and no obvious hemorrhoids are noted.  There are no masses.  On digital examination, there is no evidence of any tenderness to the rectal vault; no lesions are noted.  Stool is brown and guaiac negative.,GENITOURINARY (FEMALE): , The external genitalia is normal appearing with no obvious lesions, no evidence of any unusual rash.  The vagina is normal in appearance with normal-appearing mucosa.  The urethra is without any obvious lesions or discharge.  The cervix is normal in color with no obvious cervical discharge.  There are no obvious cervical lesions noted.  The uterus is nontender and small, and there is no evidence of any adnexal masses or tenderness.  The bladder is nontender to palpation.  It is not enlarged.,GENITOURINARY (MALE): , Normal scrotal contents are noted.  The testes are descended and nontender.  There are no masses and no swelling to the epididymis noted.  The penis is without any lesions.  There is no urethral discharge.  Digital examination of the prostate reveals a nontender, non-nodular prostate.,BREASTS:,  The breasts are normal in appearance.  There is no puckering noted.  There is no evidence of any nipple discharge.  There are no obvious masses palpable.  There is no axillary adenopathy.  The skin is normal appearing over the breasts.,LYMPHATICS: , There is no evidence of any adenopathy to the anterior cervical chain.  There is no evidence of submandibular nodes noted.  There are no supraclavicular nodes palpable.  The axillae are without any abnormal nodes.  No inguinal adenopathy is palpable.  No obvious epitrochlear nodes are noted.,MUSCULOSKELETAL/EXTREMITIES: , The patient has normal gait and station.  The patient has normal muscle strength and tone to all extremities.  There is no obvious evidence of any muscle atrophy.  The joints are all stable.  There is no evidence of any subluxation or laxity to any of the joints.  There is no evidence of any dislocation.  There is good range of motion of all extremities without any pain or tenderness to the joints or extremities.  There is no evidence of any contractures or crepitus.  There is no evidence of any joint effusions.  No obvious evidence of erythema overlying any of the joints is noted.  There is good range of motion at all joints.  There are normal-appearing digits.  There are no obvious lesions to any of the nails or nail beds.,SKIN:,  There is no obvious evidence of any rash.  There are no petechiae, pallor or cyanosis noted.  There are no unusual nodules or masses palpable.,NEUROLOGIC: , The cranial nerves II XII are tested and are intact.  Deep tendon reflexes are symmetrical bilaterally.  The toes are downgoing with normal Babinskis.  Sensation to light touch is intact and symmetrical.  Cerebellar testing reveals normal finger nose, heel shin.  Normal gait.  No ataxia.,PSYCHIATRIC:  ,The patient is oriented to person, place and time.  The patient is also oriented to situation.  Mood and affect are appropriate for the present situation.  The patient can remember 3 objects after 3 minutes without any difficulties.  Remote memory appears to be intact.  The patient seems to have normal judgment and insight into the situation.
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DESCRIPTION: Most commonly used phrases in physical exam.

general medicine, ears, nose, mouth, neck, respiratory, cardiovascular, eyes, gastrointestinal, genitourinary, breasts, lymphatics, musculoskeletal, extremities, skin, neurologic, psychiatric, normal appearing, physical exam, examination,

The information provided is a comprehensive physical exam template. It describes a normal physical examination across various systems of the body, indicating that the focus is on documenting standard findings routinely used in medical practice. This is a common, standardized part of providing healthcare and is not inherently high-stakes unless linked to critical decision-making for a specific patient with acute conditions.


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

Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Angiography & Catheterization

PROCEDURES PERFORMED:,1.  Left heart catheterization.,2.  Bilateral selective coronary angiography.,3.  Left ventriculography.,4.  Right heart catheterization.,INDICATION: , Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to cardiac catheterization suite where the right femoral region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right femoral artery and vein.  Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right femoral artery.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  A small nick was then made in the skin.  The pressure was held.  The needle was removed over the guidewire.  Next, a #6 French arterial sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was flushed.  Next, an angulated pigtail catheter was advanced to the level of the ascending aorta under the direct fluoroscopy visualization with the use of a guidewire.  The catheter was then guided into the left ventricle.  The guidewire and dilator were then removed.  The catheter was then flushed.  LVEDP was measured and found to be favorable for a left ventriculogram.  The left ventriculogram was performed in the RAO position with a single power injection of nonionic contrast material.  LVEDP was then remeasured.  Pullback was performed, which failed to reveal an LVAO gradient.  The catheter was then removed.  Next, a Judkins left #4 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  The ostium of the left main coronary was unable to be engaged with this catheter.  Thus it was removed over a guidewire.  Next, a Judkins left #5 catheter was advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Left main coronary artery was then engaged.  Using hand injections of nonionic contrast material, the left coronary system was evaluated in several different views.  The catheter was then removed from the ostium of the left main coronary artery and was removed over a guidewire.  Next, a Judkins right #4 catheter was then advanced to the level of the ascending aorta under direct fluoroscopic visualization with the use of a guidewire.  The guidewire was removed.  The catheter was connected to the manifold and flushed.  Using hand injections of nonionic contrast material, the right coronary system was evaluated in several different views.  The catheter was then removed from the ostium of the right coronary artery and then removed.  The sheath was then flushed.  Because the patient did have high left ventricular end-diastolic pressures, it was determined that the patient wound need a right heart catheterization.  Thus an #18 gauge Argon needle was used to cannulate the right femoral vein.  A steel guidewire was inserted through the needle into the vascular lumen.  The needle was removed over the guidewire.  Next, an #8 French venous sheath was advanced over the guidewire into lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  Next, a Swan-Ganz catheter was advanced to the level of 20 cm.  The balloon was inflated.  Under fluoroscopic visualization, the catheter was guided into the right atrium, right ventricle, and into the pulmonary artery wedge position.  Hemodynamics were measured along the way.  PA saturation, right atrial saturation, femoral artery saturation were all obtained.  Once adequate study has been performed, the catheter was then removed.  Both sheaths were flushed and found fine.  The patient was returned to the cardiac catheterization holding area in stable satisfactory condition.,FINDINGS:,LEFT VENTRICULOGRAM:  ,There is no evidence of any wall motion abnormalities with estimated ejection fraction of 60%.  Left ventricular end-diastolic pressure was 38 mmHg preinjection and 40 mmHg postinjection.  There is no LVAO.  There is no mitral regurgitation.  There is a trileaflet aortic valve noted.,LEFT MAIN CORONARY ARTERY:  ,The left main is a moderate caliber vessel, which bifurcates into the left anterior descending and circumflex arteries.  There is no evidence of any hemodynamically significant stenosis.,LEFT ANTERIOR DESCENDING: , The LAD is a moderate caliber vessel, which traverses through the intraventricular groove and reaches the apex of the heart.  There is a proximal 60% to 70% stenotic lesion.  There was also a mid 70% to 80% stenotic lesion at the takeoff of the first and second diagonal branches.,CIRCUMFLEX ARTERY:  ,The circumflex is a moderate caliber vessel, which traverses through the atrioventricular groove.  There is a mid 60% to 70% stenotic lesion followed by a second mid 90% stenotic lesion.  The first obtuse marginal branch is small and the second obtuse marginal branch is large without any evidence of critical disease.  The third obtuse marginal branch is also small.,RIGHT CORONARY ARTERY:  ,The RCA is a moderate caliber vessel with minor luminal irregularities throughout.  There is no evidence of any critical disease.  The right coronary artery is the dominant right coronary vessel.,RIGHT HEART FINDINGS:  ,Pulmonary artery pressure equals 61/23 with a mean of 44.  Pulmonary artery wedge pressure equals 32.  Right ventricle pressure equals 65/24.  The right atrial pressure equals to 22.  Cardiac output by Fick is 4.9.  Cardiac index by Fick is 2.3.  Hand calculated cardiac output equals 7.8.  Hand calculated cardiac index equals 3.7.  On 2 liters nasal cannula, pulmonary artery saturation equals 77.8%.  Femoral artery saturation equals 99.1%.  Pulse oximetry is 99%.  Right atrial saturation is 76.3%.  Systemic blood pressure is 166/58.  Body surface area equals 2.12.  Hemoglobin equals 12.6.,IMPRESSION:,1.  Two-vessel coronary artery disease with a complex left anterior descending arterial lesion as well as circumflex disease.,2.  Normal left ventricular function with an estimated ejection fraction of 60%.,3.  Biventricular overload.,4.  Moderate pulmonary hypertension.,5.  There is no evidence of shunt.,PLAN:,1.  The patient will be admitted for IV diuresis in light of the biventricular overload.,2.  The findings of the heart catheterization were discussed in detail with the patient and the patient's family.  There is some concern with the patient's two-vessel coronary artery disease in light of the patient's diabetic history.  We will obtain a surgical evaluation for the possibility of a coronary artery bypass grafting.,3.  The patient will remain on aggressive medical regimen including ACE inhibitor, aspirin, Plavix, and nitrate.,4.  The patient will need to undergo aggressive risk factor modification including weight loss and diet control.,5.  The patient will have an Internal Medicine evaluation regarding the patient's diabetic history.
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DESCRIPTION: Left heart catheterization, bilateral selective coronary angiography, left ventriculography, and right heart catheterization.  Positive nuclear stress test involving reversible ischemia of the lateral wall and the anterior wall consistent with left anterior descending artery lesion.

The situation involves a patient undergoing complex cardiovascular procedures such as angiography and catheterization due to significant coronary artery disease and associated risk factors such as diabetes. The findings indicate two-vessel coronary artery disease with complex lesions, moderate pulmonary hypertension, and biventricular overload. The plan involves potential coronary artery bypass grafting surgery, which is a major surgical intervention. Managing such a condition with associated comorbidities, including diabetes, requires careful evaluation and treatment planning, making it a high-stakes situation due to the serious nature of cardiovascular disease and the potential consequences if not managed properly.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Vomiting & Nausea

CHIEF COMPLAINT:,  Vomiting and nausea.,HPI: , The patient is a 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.  She states she has it at least once a day.  It can be any time, but can also be postprandial.  She states she will vomit up some dark brown-to-green fluid.  There has been no hematemesis.  She states because of the nausea and vomiting, she has not been able to take much in the way of PO intake over the past week.  She states her appetite is poor.  The patient has lost 40 pounds of weight over the past 16 months.  She states for the past few days, she has been getting severe heartburn.  She used Tums over-the-counter and that did not help.  She denies having any dysphagia or odynophagia.  She is not having any abdominal pain.  She has no diarrhea, rectal bleeding, or melena.  She has had in the past, which was remote.  She did have some small amounts of rectal bleeding on the toilet tissue only if she passed a harder stool.  She has a history of chronic constipation for most of her life but she definitely has a bowel movement every 3 to 4 days and this is unchanged.  The patient states she has never had any endoscopy or barium studies of the GI tract.,The patient is anemic and her hemoglobin is 5.7 and she is thrombocytopenic with the platelet count of 34.  She states she has had these abnormalities since she has been diagnosed with breast cancer.  She states that she has metastatic breast cancer and that is in her rib cage and spine and she is getting hormonal chemotherapy for this and she is currently under the care of an oncologist.  The patient also has acute renal failure at this point.  The patient said she had a PET scan done about a week ago.,PAST MEDICAL HISTORY:,  Metastatic breast cancer to her rib cage and spine, hypothyroidism, anemia, thrombocytopenia, hypertension, Bells palsy, depression, uterine fibroids, hysterectomy, cholecystectomy, breast lumpectomy, and thyroidectomy.,ALLERGIES: , No known drug allergies.,MEDICINES:,  She is on Zofran, Protonix, fentanyl patch, Synthroid, Ativan, and Ambien.,SOCIAL HISTORY:  ,The patient is divorced and is a homemaker.  No smoking or alcohol.,FAMILY HISTORY:,  Negative for any colon cancer or polyps.  Her father died of mesothelioma, mother died of Hodgkin lymphoma.,SYSTEMS REVIEW: , No fevers, chills or sweats.  She has no chest pain, palpitations, coughing or wheezing.  She does get shortness of breath, no hematuria, dysuria, arthralgias, myalgias, rashes, jaundice, bleeding or clotting disorders.  The rest of the system review is negative as per the HPI.,PHYSICAL EXAM: , Temperature 98.4, blood pressure 95/63, heart rate 84, respiratory rate of 18, and weight is 108 kg.  GENERAL APPEARANCE:  The patient was comfortable in bed.  Skin exam is negative for any rashes or jaundice.  LYMPHATICS:  There is no palpable lymphadenopathy of the cervical or the supraclavicular area.  HEENT:  She has some mild ptosis of the right eye.  There is no icterus.  The patient's conjunctivae and sclerae are normal.  Pupils are equal, round, and reactive to light and accommodation.  No lesions of the oral mucosa or mucosa of the pharynx.  NECK:  Supple.  Carotids are 2+.  No thyromegaly, masses or adenopathy.  HEART:  Has regular rhythm.  Normal S1 and S2.  She has a 2/6 systolic ejection murmur.  No rubs or gallops.  Lungs are clear to percussion and auscultation.  Abdomen is obese, it may be mildly distended.  There is no increased tympany.  The patient does have hepatosplenomegaly.  There is no obvious evidence of ascites.  The abdomen is nontender, bowel sounds are present.  The extremities show some swelling and edema of the ankle regions bilaterally.  Legs are in SCDs.  No cyanosis or clubbing.  For the rectal exam, it shows brown stool that is very trace heme positive at most.  For the neuro exam, she is awake, alert, and oriented x3.  Memory intact.  No focal deficits.  Insight and judgment are intact.,X-RAY AND LABORATORY DATA:  ,She came in, white count 9.2, hemoglobin 7.2, hematocrit 22.2, MCV of 87, platelet count is 47,000.  Calcium is 8.1, sodium 134, potassium 5.3, chloride 102, bicarbonate 17, BUN of 69, creatinine of 5.2, albumin 2.2, ALT 28, bilirubin is 2.2, alkaline phosphatase is 359, AST is 96, and lipase is 30.  Today, her hemoglobin is 5.7, TSH is 1.1, platelet count is 34,000, alkaline phosphatase is 303, and bilirubin of 1.7.,IMPRESSION,1.  The patient has one week of nausea and vomiting with decreased p.o. intake as well as dehydration.  This could be on the basis of her renal failure.  She may have a viral gastritis.  The patient does have a lot of gastroesophageal reflux disease symptoms recently.  She could have peptic mucosal inflammation or peptic ulcer disease.,2.  The patient does have hepatosplenomegaly.  There is a possibility she could have liver metastasis from the breast cancer.,3.  She has anemia as well as thrombocytopenia.  The patient states this is chronic.,4.  A 40-pound weight loss.,5.  Metastatic breast cancer.,6.  Increased liver function tests.  Given her bone metastasis, the elevated alkaline phosphatase may be from this as opposed to underlying liver disease.,7.  Chronic constipation.,8.  Acute renal failure.,PLAN:  ,The patient will be on a clear liquid diet.  She will continue on the Zofran.  She will be on IV Protonix.  The patient is going to be transfused packed red blood cells and her hemoglobin and hematocrit will be monitored.  I obtained the result of the abdominal x-rays she had done through the ER.  The patient has a consult pending with the oncologist to see what her PET scan show.  There is a renal consult pending.  I am going to have her get a total abdominal ultrasound to see if there is any evidence of liver metastasis and also to assess her kidneys.  Her laboratory studies will be followed.  Based upon the patient's medical condition and including her laboratory studies including a platelet count, we talked about EGD versus upper GI workup per upper GI symptoms.  I discussed informed consent for EGD.  I discussed the indications, risks, benefits, and alternatives.  The risks reviewed included, but were not limited to an allergic reaction or side effect to medicines, cardiopulmonary complications, bleeding, infection, perforation, and needing to get admitted for antibiotics or blood transfusion or surgery.  The patient voices her understanding of the above.  She wants to think about what she wants to do.  Overall, this is a very ill patient with multiorgan involvement.
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DESCRIPTION: A 52-year-old female who said she has had 1 week of nausea and vomiting, which is moderate-to-severe.

The situation involves a 52-year-old female patient with a complex medical history, including metastatic breast cancer, acute renal failure, anemia, and thrombocytopenia. The current condition of nausea and vomiting is added to her existing critical health issues. This patient's situation is high-stakes due to the multiple severe health conditions requiring immediate and careful medical intervention to manage symptoms and potentially serious complications.


Medical Specialty: Surgery
Sample Name: Phacoemulsification & Cataract Extraction - 2

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract, right eye.,TITLE OF OPERATION: , Phacoemulsification with intraocular lens insertion, right eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,The patient was brought to the operating room where tetracaine drops were instilled in the eye.  The patient was then prepped and draped using standard procedure.  An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.,The eye was rotated downward and a crescent blade used to make an incision at the limbus.  This was then dissected forward approximately 1 mm, and then a keratome was used to enter the anterior chamber.  The anterior chamber was filled with 1% preservative-free lidocaine and the lidocaine was then replaced with Provisc.  A cystotome was used to make a continuous-tear capsulorrhexis, and then the capsular flap was removed with the Utrata forceps.  The lens nucleus was hydrodissected using BSS on a cannula and then removed using the phaco.  This was aided by cracking the lens nucleus with McPherson forceps.  The remaining cortex was removed from the eye with the I&A.  The capsular bag was then polished with the I&A on capsular bag.  The bag was inflated using viscoelastic and then the wound extended slightly with a keratome.  A folding posterior chamber lens was inserted and rotated into position using McPherson forceps.  The I&A was then placed in the eye again and the remaining viscoelastic removed.  The wound was checked for watertightness and found to be watertight.  TobraDex drops were instilled in the eye and a shield was placed over it.,The patient tolerated the procedure well and was brought to recovery in good condition.
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DESCRIPTION: Cataract, right eye.  Phacoemulsification with intraocular lens insertion, right eye.  The patient was then prepped and draped using standard procedure.  An additional drop of tetracaine was instilled in the eye, and then a lid speculum was inserted.

surgery, tetracaine, intraocular lens, lid speculum, mcpherson forceps, capsular bag, eye, phacoemulsification, cataract, lens, intraocular,

Phacoemulsification and cataract extraction is a common surgical procedure for treating cataracts, which involves the removal of the clouded lens and replacement with an artificial intraocular lens. While the procedure is generally considered routine and has a high success rate, it is still a surgical intervention on the eye, which carries inherent risks. The detailed report mentions no complications during the procedure and the patient tolerated it well. However, since any surgery inherently involves risk of complications, particularly when it involves vision, this can be considered moderate to high-stakes. Vision is a critically important sense, and surgery carries risks such as infection, bleeding, or vision loss, hence indicating a higher level of stakes.


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

MALE 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:  Penis normal shape without lesions.  Testicles normal shape and contour without tenderness.  Epididymides normal shape and contour without tenderness.  Rectum normal tone to sphincter.  Prostate normal shape and contour without nodules.  Stool hemoccult negative.  No external hemorrhoids.  No skin lesions.,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: An example/template for a routine normal male physical exam.

office notes, male exam, normal, physical exam, normal range of motion, male physical, nontender, lesions, dorsiflexion, sclerae, contour, muscle, erythema, joints, edema, shape,

The provided text is a comprehensive template for documenting a routine normal male physical exam. It outlines observations that typically indicate no immediate health concerns or abnormalities. This is a standardized procedure used by healthcare professionals to record findings during a standard check-up. As such, it involves no immediate decision-making or diagnoses that could have high-stakes implications unless abnormalities or acute conditions were documented, which is not the case in this scenario. Thus, it constitutes a low-stakes situation, typical of routine healthcare documentation.


Medical Specialty: Radiology
Sample Name: Coronary CT Angiography (CCTA) - 2

CARDIAC CT INCLUDING CORONARY CT ANGIOGRAPHY,PROCEDURE: , Breath hold cardiac CT was performed using a 64-channel CT scanner with a 0.5-second rotation time.  Contrast injection was timed using a 10 mL bolus of Ultravist 370 IV.  Then the patient received 75 mL of Ultravist 370 at a rate of 5 mL/sec.,Retrospective ECG gating was performed.  The patient received 0.4 milligrams of sublingual nitroglycerin prior to the to the scan.  The average heart rate was 62 beats/min.,The patient had no adverse reaction to the contrast.  Multiphase retrospective reconstructions were performed.  Small field of view cardiac and coronary images were analyzed on a 3D work station.  Multiplanar reformatted images and 3D volume rendering was performed by the attending physician for the purpose of defining coronary anatomy and determining the extent of coronary artery disease.,CORONARY CTA:,1.  The technical quality of the scan is adequate.,2.  The coronary ostia are in their normal position.  The coronary anatomy is right dominant.,3.  LEFT MAIN:  The left main coronary artery is patent without angiographic stenosis.,4.  LEFT ANTERIOR DESCENDING ARTERY:  The proximal aspect of the left anterior descending artery demonstrates a mixed plaque consisting of both calcified and noncalcified lesion which is less than 30% in stenosis severity.  Diagonal 1 and diagonal 2 branches of the left anterior descending artery demonstrate mild irregularities.,5.  The ramus intermedius is a small vessel with minor irregularities.,6.  LEFT CIRCUMFLEX:  The left circumflex and obtuse marginal 1 and obtuse marginal 2 branches of the vessel are patent without significant stenosis.,7.  RIGHT CORONARY ARTERY:  The right coronary artery is a large and dominant vessel.  It demonstrates within its mid-segment calcified atherosclerosis, less than 50% stenosis severity.  Left ventricular ejection fraction is calculated to be 69%.  There are no wall motion abnormalities.,8.  Coronary calcium score was calculated to be 79, indicating at least mild atherosclerosis within the coronary vessels.,ANCILLARY FINDINGS: , None.,FINAL IMPRESSION:,1.  Mild coronary artery disease with a preserved left ventricular ejection fraction of 69%.,2.  Recommendation is aggressive medical management consisting of aggressive lifestyle modifications and statin therapy.,Thank you for referring this patient to us.
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DESCRIPTION: CCTA with Cardiac Function/Calcium Scoring

radiology, coronary ct angiography, ventricular ejection fraction, anterior descending artery, coronary artery disease, coronary ct, ct angiography, cardiac ct, obtuse marginal, ventricular ejection, ejection fraction, coronary artery, artery, angiography, coronary, ccta, atherosclerosis, ventricular, beats/min, anterior, vessel, stenosis, ct, cardiac, disease,

The report indicates a mild coronary artery disease with a suggestion for aggressive management including lifestyle changes and statin therapy. Though the patient's left ventricular ejection fraction is preserved and stenosis severity is below critical levels, it involves the assessment of coronary artery health which can have serious implications if not monitored and managed properly. However, the current findings are not immediately life-threatening and recommend preventive measures for long-term health. Thus, it is a moderately high-stakes situation due to the potential future implications of coronary artery disease.


Medical Specialty: Neurology
Sample Name: CT Head - 2

REASON FOR CT SCAN: , The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan performed on January 16, 2008.  I changed the shunt setting from 1.5 to 2.0 on February 12, 2008 and his family obtained this repeat CT scan to determine whether his subdural effusions were improving.,CT scan from 03/11/2008 demonstrates frontal horn span at the level of foramen of Munro of 2.6 cm.  The 3rd ventricular contour which is flat with a 3rd ventricular span of 10 mm.  There is a single shunt, which enters on the right occipital side and ends in the left lateral ventricle.  He has symmetric bilateral subdurals that are less than 1 cm in breadth each, which is a reduction from the report from January 16, 2008, which states that he had a subdural hygroma, maximum size 1.3 cm on the right and 1.1 cm on the left.,ASSESSMENT: , The patient's subdural effusions are still noticeable, but they are improving at the setting of 2.0.,PLAN: , I would like to see the patient with a new head CT in about three months, at which time we can decide whether 2.0 is the appropriate setting for him to remain at or whether we can consider changing the shunt setting.
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DESCRIPTION: The patient is a 79-year-old man with adult hydrocephalus who was found to have large bilateral effusions on a CT scan.  The patient's subdural effusions are still noticeable, but they are improving.

neurology, ct scan, subdural, adult hydrocephalus, bilateral effusions, shunt setting, subdural effusions, hydrocephalus, ventricular, scan, ct,

The situation involves monitoring a medical condition related to adult hydrocephalus and the management of shunt settings to address subdural effusions. While this is important for the health and well-being of the patient, the immediate stakes are relatively moderate, as the CT scan indicates improvement, and the plan involves further monitoring. It is not a critical emergency, but requires careful ongoing management.


Medical Specialty: Urology
Sample Name: Bladder Tumor

CHIEF COMPLAINT:,  Recurrent bladder tumor.,HISTORY OF PRESENT ILLNESS: , The patient is a 79-year-old woman, the patient of Dr. X, who on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.  The patient underwent TUR of several transitional cell carcinomas of the bladder on the bladder neck in 2006.  This was followed by bladder instillation of BCG.  At this time, the patient denies any voiding symptoms or hematuria.  The patient opting for TUR and electrofulguration of the recurrent tumors.,ALLERGIES: , None known.,MEDICATIONS: , Atenolol 5 mg daily.,OPERATIONS: , Status post bilateral knee replacements and status post TUR of bladder tumors.,REVIEW OF SYSTEMS: , Other than some mild hypertension, the patient is in very, very good health.  No history of diabetes, shortness of breath or chest pain.,PHYSICAL EXAMINATION: , Well-developed and well-nourished woman, alert and oriented.  Her lungs are clear.  Heart, regular sinus rhythm.  Back, no CVA tenderness.  Abdomen, soft and nontender.  No palpable masses.,IMPRESSION: , Recurrent bladder tumors.,PLAN: , The patient to have CBC, chem-6, PT, PTT, EKG, and chest x-ray beforehand.
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DESCRIPTION: Recurrent bladder tumor.  The patient on recent followup cystoscopy for transitional cell carcinomas of the bladder neck was found to have a 5-cm area of papillomatosis just above the left ureteric orifice.

urology, bladder neck, voiding symptoms, hematuria, transitional cell carcinomas, ureteric orifice, bladder tumor, bladder, cystoscopy, papillomatosis, transitional, carcinomas, orifice,

The case involves a recurrent bladder tumor in a 79-year-old patient. Although she denies voiding symptoms or hematuria, the fact that it's a recurrence of transitional cell carcinomas and requires surgical intervention (TUR and electrofulguration) indicates a significant medical concern. Bladder tumors can potentially be life-threatening if not managed properly, which makes it relatively high-stakes. The necessary pre-procedure tests (CBC, chem-6, PT, PTT, EKG, and chest x-ray) also highlight the importance of careful management.


Medical Specialty: General Medicine
Sample Name: Discharge Summary - 17

FINAL DIAGNOSIS/REASON FOR ADMISSION:,1.  Acute right lobar pneumonia.,2.  Hypoxemia and hypotension secondary to acute right lobar pneumonia.,3.  Electrolyte abnormality with hyponatremia and hypokalemia - corrected.,4.  Elevated liver function tests, etiology undetermined.,5.  The patient has a history of moderate-to-severe dementia, Alzheimer's type.,6.  Anemia secondary to current illness and possible iron deficiency.,7.  Darkened mole on the scalp, status post skin biopsy, pending pathology report.,OPERATION AND PROCEDURE: , The patient underwent a scalp skin biopsy with pathology specimen obtained on 6/11/2009.  Dr. X performed the procedure, thoracentesis on 6/12/2009 both diagnostic and therapeutic.  Dr. Y's results pending.,DISPOSITION: , The patient discharged to long-term acute facility under the care of Dr. Z.,CONDITION ON DISCHARGE: , Clinically improved, however, requiring acute care.,CURRENT MEDICATIONS:  ,Include those on admission combined with IV Flagyl 500 mg every 8 hours and Levaquin 500 mg daily.,HOSPITAL SUMMARY: , This is one of several admissions for this 68-year-old female who over the initial 48 hours preceding admission had a complaint of low-grade fever, confusion, dizziness, and a nonproductive cough.  Her symptoms progressed and she presented to the emergency room at Brighton Gardens where a chest x-ray revealed evolving right lobar infiltrate.  She was started on antibiotics.  Infectious Disease was consulted.  She was initially begun on vancomycin.  Blood, sputum, and urine cultures were obtained; the results of which were negative for infection.  She was switched to IV Levaquin and received IV Flagyl for possible C. diff colitis as well as possible cholecystitis.  During her hospital stay, she initially was extremely relatively hypotensive with mild symptoms and she became dizzy with upright positioning.  Her systolic blood pressure was 60-70 mmHg despite rather aggressive IV fluid management up to 250 mL an hour.  She was seen in consultation by Dr. Y who monitored her fluid and pulmonary treatment.  Due to some elevated liver function tests, she was seen in consultation by Dr. X.  An ultrasound was negative; however, she did undergo CT scan of the chest and abdomen and there was a suspicion of fluid circling the gallbladder.  A HIDA scan was performed and revealed no evidence of gallbladder dysfunction.  Liver functions were monitored throughout her stay and while elevated, did reduce to approximately 1.5 times normal value.  She also was seen in consultation by Infectious Disease who followed her for several days and agreed with current management of antibiotics.  Over her week-stay, the patient was moderately hypoxemic with room air pulse oximetry of 90%.  She was placed on incentive spirometry and over the succeeding days, she did have improved pulmonary function.,LABORATORY TESTS: , Initially revealed a white count of 13,000, however, approximately 24 hours following admission her white count stabilized and in fact remained normal throughout her stay.  Blood cultures were negative at 5 days.  Sputum culture was negative.  Urine culture was negative and thoracentesis culture negative at 24 hours.  The patient did receive 2 units of packed red cells with the hemoglobin drop to 9 for cardiovascular support, as no evidence of GI bleeding was obtained.  Her most recent blood work on 6/14/2009 revealed a white count of 7000 and hemoglobin of 12.1 with a hematocrit of 36.8.  Her PT and PTT were normal.  Occult blood studies were negative for occult blood.  Hepatitis B antigen was negative.  Hepatitis A antibody IgM was negative.  Hepatitis B core IgM negative, and hepatitis C core antibody was negative.  At the time of discharge on 6/14/2009, sodium was 135, potassium was 3.7, calcium was 8.0, her ALT was 109, AST was 70, direct bilirubin was 0.2, LDH was 219, serum iron was 7, total iron unbound 183, and ferritin level was 267.,At the time of discharge, the patient had improved.  She complained of some back discomfort and lumbosacral back x-ray did reveal some evidence of mild degenerative disk disease with no obvious compression fracture acute noted and she will be followed by Dr. Z.
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DESCRIPTION: The patient underwent a scalp skin biopsy with pathology specimen obtained.   At the time of discharge, the patient had improved.

general medicine, pneumonia, hypoxemia, hypotension, electrolyte abnormality, anemia, scalp skin biopsy, liver function tests, lobar pneumonia, infectious disease, skin biopsy, white count, cultures

The discharge summary reflects on a complex medical case involving a patient with multiple significant health challenges, including acute right lobar pneumonia leading to hypoxemia and hypotension, electrolyte imbalances, elevated liver function tests, and a history of dementia. These conditions necessitate close monitoring and management, indicating a serious healthcare scenario. However, the patient showed clinical improvement by discharge, suggesting that while the situation involves many important medical decisions, it is not immediately life-threatening at this time given the improvement. The stakes remain high as ongoing care and monitoring will be critical due to her complex health needs, particularly considering the pending biopsy results which could alter treatment significantly.


Medical Specialty: Consult - History and Phy.
Sample Name: Abrasions & Lacerations - ER Visit

HISTORY OF PRESENT ILLNESS: , This is a 12-year-old male, who was admitted to the Emergency Department, who fell off his bicycle, not wearing a helmet, a few hours ago.  There was loss of consciousness.  The patient complains of neck pain.,CHRONIC/INACTIVE CONDITIONS:,  None.,PERSONAL/FAMILY/SOCIAL HISTORY/ILLNESSES:,  None.,PREVIOUS INJURIES: , Minor.,MEDICATIONS: , None.,PREVIOUS OPERATIONS: , None.,ALLERGIES:  ,NONE KNOWN.,FAMILY HISTORY: , Negative for heart disease, hypertension, obesity, diabetes, cancer or stroke.,SOCIAL HISTORY: , The patient is single.  He is a student.  He does not smoke, drink alcohol or consume drugs.,REVIEW OF SYSTEMS,CONSTITUTIONAL:  The patient denies weight loss/gain, fever, chills.,ENMT:  The patient denies headaches, nosebleeds, voice changes, blurry vision, changes in/loss of vision.,CV:  The patient denies chest pain, SOB supine, palpitations, edema, varicose veins, leg pains.,RESPIRATORY:  The patient denies SOB, wheezing, sputum production, bloody sputum, cough.,GI:  The patient denies heartburn, blood in stools, loss of appetite, abdominal pain, constipation.,GU:  The patient denies painful/burning urination, cloudy/dark urine, flank pain, groin pain.,MS:  The patient denies joint pain/stiffness, backaches, tendon/ligaments/muscle pains/strains, bone aches/pains, muscle weakness.,NEURO:  The patient had a loss of consciousness during the accident.  He does not recall the details of the accident.  Otherwise, negative for blackouts, seizures, loss of memory, hallucinations, weakness, numbness, tremors, paralysis.,PSYCH:  Negative for anxiety, irritability, apathy, depression, sleep disturbances, appetite disturbances, suicidal thoughts.,INTEGUMENTARY:  Negative for unusual hair loss/breakage, skin lesions/discoloration, unusual nail breakage/discoloration.,PHYSICAL EXAMINATION,CONSTITUTIONAL:  Blood pressure 150/75, pulse rate 80, respirations 18, temperature 37.4, saturation 97% on room air.  The patient shows moderate obesity.,NECK:  The neck is symmetric, the trachea is in the midline, and there are no masses.  No crepitus is palpated.  The thyroid is palpable, not enlarged, smooth, moves with swallowing, and has no palpable masses.,RESPIRATIONS:  Normal respiratory effort.  There is no intercostal retraction or action by the accessory muscles.  Normal breath sounds bilaterally with no rhonchi, wheezing or rubs.,CARDIOVASCULAR:  The PMI is palpable at the 5ICS in the MCL.  No thrills on palpation.  S1 and S2 are easily audible.  No audible S3, S4, murmur, click or rub.  Abdominal aorta is not palpable.  No audible abdominal bruits.  Femoral pulses are 3+ bilaterally, without audible bruits.  Extremities show no edema or varicosities.,GASTROINTESTINAL:  No palpable tenderness or masses.  Liver and spleen are percussed but not palpable under the costal margins.  No evidence for umbilical or groin herniae.,LYMPHATIC:  No nodes over 3 mm in the neck, axillae or groins.,MUSCULOSKELETAL:  Normal gait and station.  The patient is on a stretcher.  Symmetric muscle strength and normal tone, without signs of atrophy or abnormal movements.,SKIN:  There is a hematoma in the forehead and one in the occipital scalp, and there are abrasions in the upper extremities and abrasions on the knees.  No induration or subcutaneous nodules to palpation.,NEUROLOGIC:  Normal sensation by touch.  The patient moves all four extremities.,PSYCHIATRIC:  Oriented to time, place, and person.  Appropriate mood and affect.,LABORATORY DATA:  Reviewed chest x-ray, which is normal, right hand x-ray, which is normal, and an MRI of the head, which is normal.,DIAGNOSES,1.  Concussion.,2.  Facial abrasion.,3.  Scalp laceration.,4.  Knee abrasions.,PLANS/RECOMMENDATIONS:,  Admitted for observation.
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DESCRIPTION: A 12-year-old  fell off his bicycle, not wearing a helmet, a few hours ago.  There was loss of consciousness.  The patient complains of neck pain.

The patient's situation involves a 12-year-old male who fell off a bicycle without wearing a helmet, experienced loss of consciousness, and is complaining of neck pain. The loss of consciousness and neck pain present concerns for a potential concussion and possible cervical spine injury. However, the patient is now stable, oriented, and the imaging (MRI of the head) is normal, indicating no immediate life-threatening conditions. Given these details, the situation is moderately high-stakes due to the potential for serious complications, but the current condition is stable and under medical observation.


Medical Specialty: Neurology
Sample Name: Brain MRI - Pituitary Adenoma

CC:, Orthostatic lightheadedness.,HX:, This 76 y/o male complained of several months of generalized weakness and malaise, and a two week history of progressively worsening orthostatic dizziness. The dizziness worsened when moving into upright positions. In addition, he complained of intermittent throbbing holocranial headaches, which did not worsen with positional change, for the past several weeks. He had lost 40 pounds over the past year and denied any recent fever, SOB, cough, vomiting, diarrhea, hemoptysis, melena, hematochezia, bright red blood per rectum, polyuria, night sweats, visual changes, or syncopal episodes.,He had a 100+ pack-year history of tobacco use and continued to smoke 1 to 2 packs per day. He has a history of sinusitis.,EXAM:, BP 98/80 mmHg and pulse 64 BPM (supine); BP 70/palpable mmHG and pulse 84BPM (standing). RR 12, Afebrile. Appeared fatigued.,CN: unremarkable.,Motor and Sensory exam: unremarkable.,Coord: Slowed but otherwise unremarkable movements.,Reflexes: 2/2 and symmetric throughout all 4 extremities. Plantar responses were flexor, bilaterally.,The rest of the neurologic and general physical exam was unremarkable.,LAB:, Na 121 meq/L, K 4.2 meq/L, Cl 90 meq/L, CO2 20meq/L, BUN 12mg/DL, CR 1.0mg/DL, Glucose 99mg/DL, ESR 30mm/hr, CBC WNL with nl WBC differential, Urinalysis: SG 1.016 and otherwise WNL, TSH 2.8 IU/ML, FT4 0.9ng/DL, Urine Osmolality 246 MOSM/Kg (low), Urine Na 35 meq/L,,COURSE:, The patient was initially hydrated with IV normal saline and his orthostatic hypotension resolved, but returned within 24-48hrs. Further laboratory studies revealed: Aldosterone (serum)<2ng/DL (low), 30 minute Cortrosyn Stimulation test: pre 6.9ug/DL (borderline low), post 18.5ug/DL (normal stimulation rise), Prolactin 15.5ng/ML (no baseline given), FSH and LH were within normal limits for males. Testosterone 33ng/DL (wnl). Sinus XR series (done for history of headache) showed an abnormal sellar region with enlarged sella tursica and destruction of the posterior clinoids. There was also an abnormal calcification seen in the middle of the sellar region. A left maxillary sinus opacity with air-fluid level was seen. Goldman visual field testing was unremarkable. Brain CT and MRI revealed suprasellar mass most consistent with pituitary adenoma. He was treated with Fludrocortisone 0.05 mg BID and within 24hrs, despite discontinuation of IV fluids, remained hemodynamically stable and free of symptoms of orthostatic hypotension. His presumed pituitary adenoma continues to be managed with Fludrocortisone as of this writing (1/1997), though he has developed dementia felt secondary to cerebrovascular disease (stroke/TIA).
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DESCRIPTION: Brain CT and MRI - suprasellar mass (pituitary adenoma)

neurology, brain ct, goldman, mri, orthostatic, adenoma, generalized weakness, hypotension, lightheadedness, malaise, pituitary, sinus opacity, suprasellar mass, brain ct and mri, orthostatic hypotension, pituitary adenoma, brain, sinusitis, sellar,

The situation involves a 76-year-old male with a diagnosis of a pituitary adenoma, indicated by radiological findings and supported by symptoms and laboratory results. The case details multiple concerning symptoms such as progressive orthostatic hypotension, severe weight loss, and a history of heavy smoking, which elevate the stakes due to the risk of severe complications like adrenal insufficiency and other endocrine disorders. Furthermore, effective management is crucial to prevent potentially fatal outcomes such as adrenal crisis or serious neurological complications associated with pituitary adenomas. However, since the condition seems to have been stabilized with the treatment of Fludrocortisone, immediate stakes are moderately reduced though the potential for complications remains high.


Medical Specialty: Office Notes
Sample Name: Headache - Office Visit

She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and diabetic neuropathy.  She was referred to Dr. XYZ and will be seeing him on August 8, 2006.,She was also never referred to the endocrine clinic to deal with her poor diabetes control.  Her last hemoglobin A1c was 10.,PAST MEDICAL HISTORY:,  Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.,MEDICATIONS: , Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran.,PHYSICAL EXAMINATION:,  Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and weight was 226 pounds.  On general exam she has an area of tenderness on palpation in the left parietal region of her scalp.  Neurological exam is detailed on our H&P form.  Her neurological exam is within normal limits.,IMPRESSION AND PLAN:,  For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to maximize the Zonegran therapy.  If this is not effective, when she comes back on August 7, 2006 we will then consider other anticonvulsants such as Neurontin or Lyrica.  We also discussed with Ms. Hawkins the possibility of nerve block injection; however, at this point she is not interested.,She will be seeing Dr. XYZ for her neuropathies.,We made an appointment in endocrine clinic today for a counseling in terms of better diabetes control and she is responsible for trying to get her referral from her primary care physician to go for this consult.
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DESCRIPTION: The patient with continued problems with her headaches.

office notes, nerve conduction studies, emg, zonegran therapy, ulnar neuropathy, endocrine clinic, diabetes control, neurological exam, headache, zonegran

The situation described involves managing multiple, potentially serious medical conditions, including diabetes with poor control (indicated by high hemoglobin A1c levels), neuropathies, and headaches. However, the context provided is a routine office visit and follow-up consultation management rather than an emergency or immediate crisis. While these conditions are serious, they are being actively managed with a treatment plan in place. Therefore, the situation is not extraordinarily high-stakes in the immediate sense, although it is important for the patient's long-term health care management.


Medical Specialty: Surgery
Sample Name: Port-A-Cath Insertion

PROCEDURE PERFORMED: , Port-A-Cath insertion.,ANESTHESIA: , MAC.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Minimal.,PROCEDURE IN DETAIL:  ,Patient was prepped and draped in sterile fashion.  The left subclavian vein was cannulated with a wire.  Fluoroscopic confirmation of the wire in appropriate position was performed.  Then catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.  Once the catheter was advanced through the sheath, the sheath was peeled away.  Catheter was left in place, which was attached to hub, placed in the subcutaneous pocket, sewn in place with 2-0 silk sutures, and then all hemostasis was further reconfirmed.  No hemorrhage was identified.  The port was in appropriate position with fluoroscopic confirmation.  The wound was closed in 2 layers, the 1st layer being 3-0 Vicryl, the 2nd layer being 4-0 Monocryl subcuticular stitch.  Dressed with Steri-Strips and 4 x 4's.  Port was checked.  Had good blood return, flushed readily with heparinized saline.
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DESCRIPTION: Port-A-Cath insertion template.  Catheter was inserted after subcutaneous pocket was created, the sheath dilators were advanced, and the wire and dilator were removed.

surgery, hemostasis, port a cath insertion, fluoroscopic confirmation, cath insertion, insertion, fluoroscopic, subcutaneous, catheter, sheath, dilators, wire,

Port-A-Cath insertion is a common surgical procedure used to establish long-term venous access for patients, often required for chemotherapy or other regular infusions. While it is a routine procedure with a very low complication rate, it involves surgery and anesthesia, making it more serious than non-invasive procedures. However, the potential complications can generally be managed with appropriate care. Given that the procedure had no complications and minimal blood loss was reported, it is not considered highly critical for immediate risk but is important for the patient's long-term treatment plan.


Medical Specialty: Hematology - Oncology
Sample Name: Lung Cancer Followup

CHIEF COMPLAINT:,1.  Extensive stage small cell lung cancer.,2.  Chemotherapy with carboplatin and etoposide.,3.  Left scapular pain status post CT scan of the thorax.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old female with extensive stage small cell lung cancer.  She is currently receiving treatment with carboplatin and etoposide.  She completed her fifth cycle on 08/12/10.  She has had ongoing back pain and was sent for a CT scan of the thorax.  She comes into clinic today accompanied by her daughters to review the results.,CURRENT MEDICATIONS: , Levothyroxine 88 mcg daily, Soriatane 25 mg daily, Timoptic 0.5% solution b.i.d., Vicodin 5/500 mg one to two tablets q.6 hours p.r.n.,ALLERGIES: , No known drug allergies.,REVIEW OF SYSTEMS:  ,The patient continues to have back pain some time she also take two pain pill.  She received platelet transfusion the other day and reported mild fever.  She denies any chills, night sweats, chest pain, or shortness of breath.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:
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DESCRIPTION: Extensive stage small cell lung cancer.  Chemotherapy with carboplatin and etoposide.  Left scapular pain status post CT scan of the thorax.

hematology - oncology, small cell lung cancer, carboplatin, etoposide, pet/ct, pleural base, base mass, extensive stage, ct scan, lung cancer, lung, cancer,

The situation involves a patient with extensive stage small cell lung cancer, which is a serious and aggressive form of cancer. The patient's condition requires careful monitoring and management, including chemotherapy treatment and follow-up scans. The presence of back pain and the need to review CT scan results indicate that any progression of the disease or response to treatment needs to be assessed, which could significantly impact the patient's prognosis and treatment decisions. Coupled with a recent platelet transfusion and mild fever, this context adds complexity to the management due to potential risks like infection or treatment side effects. Therefore, this is a high-stakes scenario in a medical setting.


Medical Specialty: Chiropractic
Sample Name: Pain Management Consult - 2

HPI - WORKERS COMP:, The current problem began on or about 2/10/2000. The symptoms were sudden in onset. According to the patient, the current problem is a result of a work injury involving lifting approximately 40 pounds. Pain location (lower body): left hip. The patient describes the pain as dull, aching and stabbing. The severity of the pain ranges from mild to severe. The pain is severe occasionally. It is present constantly. The pain is made worse by sitting, riding in a car, twisting and lifting. The pain is made better by rest. The patient's symptoms appear to be soft tissue (spine), myofascial (spine) and musculoskeletal (spine) in origin. Sleep alteration because of pain: positive and wakes up after getting to sleep nightly. Systemic signs/symptoms relevant or potentially relevant to the spine: none. Patient reports the following symptoms: depressed mood, loss of interest or pleasure in all or most activities, insomnia, inability to concentrate, fatigue and loss of energy.,WORK STATUS:,
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DESCRIPTION: Entrapment of the Superior Gluteal Nerve in the aponeurosis of the Gluteus Medius-Left.

This situation involves a patient with chronic pain resulting from a work-related injury, which affects their ability to work and leads to psychological symptoms such as depression and insomnia. The stakes are somewhat high because this affects the patient's quality of life and work ability, and it could potentially lead to long-term disability if not managed properly. However, it is not an acutely life-threatening situation, which might rate higher on a high-stakes scale.


Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy - 8

PREOPERATIVE DIAGNOSIS:, Chronic abdominal pain and heme positive stool.,POSTOPERATIVE DIAGNOSES:,1.  Antral gastritis.,2.  Duodenal polyp.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with photos and antral biopsy.,ANESTHESIA: , Demerol and Versed.,DESCRIPTION OF PROCEDURE: , Consent was obtained after all risks and benefits were described.  The patient was brought back into the Endoscopy Suite.  The aforementioned anesthesia was given.  Once the patient was properly anesthetized, bite block was placed in the patient's mouth.  Then, the patient was given the aforementioned anesthesia.  Once he was properly anesthetized, the endoscope was placed in the patient's mouth that was brought down to the cricopharyngeus muscle into the esophagus and from the esophagus to his stomach.  The air was insufflated down.  The scope was passed down to the level of the antrum where there was some evidence of gastritis seen.  The scope was passed into the duodenum and then duodenal sweep where there was a polyp seen.  The scope was pulled back into the stomach in order to flex upon itself and straightened out.  Biopsies were taken for CLO and histology of the antrum.  The scope was pulled back.  The junction was visualized.  No other masses or lesions were seen.  The scope was removed.  The patient tolerated the procedure well.  We will recommend the patient be on some type of a H2 blocker.  Further recommendations to follow.
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DESCRIPTION: Chronic abdominal pain and heme positive stool, antral gastritis, and duodenal polyp.  Esophagogastroduodenoscopy with photos and antral biopsy.

gastroenterology, endoscopy, gastritis, clo, histology, antrum, heme positive stool, esophagogastroduodenoscopy, duodenal, polyp, antral,

The situation described involves a gastroenterological procedure (esophagogastroduodenoscopy) for a patient diagnosed with antral gastritis and a duodenal polyp. While the procedure involves anesthesia and carries some risk, it is a routine diagnostic assessment conducted to investigate chronic abdominal pain and heme positive stool. The presence of a duodenal polyp could indicate a potential for more serious conditions, but the stakes aren't extremely high unless further complications or severe disease are found from the biopsy results. Given the routine nature and the successful completion of the procedure, the immediate stakes are not very high, but further follow-up may have higher implications.


Medical Specialty: Hematology - Oncology
Sample Name: Intensity-Modulated Radiation Therapy

INTENSITY-MODULATED RADIATION THERAPY,Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.  The treatment planning process requires at least 4 hours of physician time.  The technology is appropriate in this patient's case due to the fact that the target volume is adjacent to significant radiosensitive structures.  Sequential CT scans are obtained and transferred to the treatment planning software.  Extensive analysis occurs.  The target volumes, including margins for uncertainty, patient movement and occult tumor extension are selected.  In addition, organs at risk are outlined.  Doses are selected both for targets, as well as for organs at risk.  Associated dose constraints are placed.  Inverse treatment planning is then performed in conjunction with the physics staff.  These are reviewed by the physician and ultimately performed only following approval by the physician.  Multiple beam arrangements may be tested for appropriateness and optimal dose delivery in order to maximize the chance of controlling disease, while minimizing exposure to organs at risk.  This is performed in hopes of minimizing associated complications.  The physician delineates the treatment type, number of fractions and total volume.  During the time of treatment, there is extensive physician intervention, monitoring the patient set up and tolerance.  In addition, specific QA is performed by the physics staff under the physician's direction.,In view of the above, the special procedure code 77470 is deemed appropriate.
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DESCRIPTION: Intensity-modulated radiation therapy is a complex set of procedures which requires appropriate positioning and immobilization typically with customized immobilization devices.

hematology - oncology, multiple beam arrangements, intensity modulated radiation therapyNOTE,: 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 use of Intensity-Modulated Radiation Therapy (IMRT) in hematology-oncology involves detailed planning and execution to target tumors while minimizing damage to surrounding tissues. Given its complexity and the critical nature of its application in treating cancer, it is definitely a high-stakes situation. The potential for significant impact on patient outcomes due to the precision required and the potential risks involved with misapplication make this scenario high-stakes. Furthermore, extensive physician intervention and monitoring are necessary, indicating the importance and seriousness of the procedure.


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

Medical Specialty: Neurology
Sample Name: Craniopharyngioma - Postop

REASON FOR VISIT:,  Postoperative visit for craniopharyngioma.,HISTORY OF PRESENT ILLNESS:,  Briefly, a 16-year-old right-handed boy who is in eleventh grade, who presents with some blurred vision and visual acuity difficulties, was found to have a suprasellar tumor.  He was brought to the operating room on 01/04/07, underwent a transsphenoidal resection of tumor.  Histology returned as craniopharyngioma.  There is some residual disease; however, the visual apparatus was decompressed.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.,MEDICATIONS: , Synthroid 100 mcg per day.,FINDINGS: , On exam, he is awake, alert and oriented x 3.  Pupils are equal and reactive.  EOMs are full.  His visual acuity is 20/25 in the right (improved from 20/200) and the left is 20/200 improved from 20/400.  He has a bitemporal hemianopsia, which is significantly improved and wider.  His motor is 5 out of 5.  There are no focal motor or sensory deficits.  The abdominal incision is well healed.  There is no evidence of erythema or collection.  The lumbar drain was also well healed.,The postoperative MRI demonstrates small residual disease.,Histology returned as craniopharyngioma.,ASSESSMENT: , Postoperative visit for craniopharyngioma with residual disease.,PLANS: , I have recommended that he call.  I discussed the options with our radiation oncologist, Dr. X. They will schedule the appointment to see him.  In addition, he probably will need an MRI prior to any treatment, to follow the residual disease.
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DESCRIPTION: Postoperative visit for craniopharyngioma with residual disease.  According to him, he is doing well, back at school without any difficulties.  He has some occasional headaches and tinnitus, but his vision is much improved.

neurology, visual acuity, blurred vision, tinnitus, headaches, residual disease, tumor, histology, craniopharyngioma,

The situation involves a postoperative evaluation for craniopharyngioma, a type of brain tumor, in a 16-year-old patient. While the initial surgery has improved his vision and removed part of the tumor, there is still residual disease that may require further treatment, such as radiation. The stakes are moderately high due to the potential impact on the patient's long-term health and quality of life if the residual disease progresses. However, the immediate condition of the patient is stable and improving, which somewhat lowers the stakes.


Medical Specialty: Surgery
Sample Name: Breast Excisional Biopsy

PREOPERATIVE DIAGNOSIS:,  Right breast mass with abnormal mammogram.,POSTOPERATIVE DIAGNOSIS:,  Right breast mass with abnormal mammogram.,PROCEDURE PERFORMED:,  Right breast excisional biopsy with needle-localization.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,SPECIMEN: , Right breast mass and confirmation by Radiology that the specimen was received with the mass was in the specimen.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,BRIEF HISTORY:  ,The patient is a 41-year-old female who presented to Dr. X's office with abnormal mammogram with a strong family history of breast cancer requesting needle-localized breast biopsy for nonpalpable breast mass.,PROCEDURE: , After informed consent, the risks and benefits of the procedure were explained to the patient.  The patient was brought into the operating suite.  After IV sedation was given, the patient was prepped and draped in normal sterile fashion.  A radial incision was made in the right lateral breast with a #10 blade scalpel.  The needle was brought into the field.  An Allis was used to grasp the breast mass and breast tissue using the #10 scalpel.  The mass was completely excised and sent out for specimen after confirmation by Radiology that the mass was in the specimen.,Hemostasis was then obtained with electrobovie cautery.  The skin was then closed with #4-0 Monocryl in a running subcuticular fashion.  Steri-Strips and sterile dressings were applied.  The patient tolerated the procedure well and was transferred to Recovery in stable condition.
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DESCRIPTION: Right breast excisional biopsy with needle-localization.  The patient is a 41-year-old female with abnormal mammogram with a strong family history of breast cancer requesting needle-localized breast biopsy for nonpalpable breast mass.

surgery, breast mass, mammogram, breast excisional biopsy, needle-localization, excisional biopsy, abnormal mammogram, breast, radiology, scalpel, excisional, biopsy, needle, specimen, mass

The situation involves a surgical procedure, specifically a breast excisional biopsy, which is a standard medical process but still carries inherent risks associated with surgery, including infection or reactions to anesthesia. Additionally, the patient has a strong family history of breast cancer, which adds emotional and diagnostic weight to the procedure. However, the surgery appears to have been successful with no complications, and the patient is stable post-operation. Therefore, while it is a significant situation for the patient, it is not life-threatening or critically emergent within the broader spectrum of medical procedures.


Medical Specialty: Orthopedic
Sample Name: Knee Osteoarthrosis - Discharge Summary

PRINCIPAL DIAGNOSIS:,  Knee osteoarthrosis.,PRINCIPAL PROCEDURE: , Total knee arthroplasty.,HISTORY AND PHYSICAL:,  A 66-year-old female with knee osteoarthrosis.  Failed conservative management.  Risks and benefits of different treatment options were explained.  Informed consent was obtained.,PAST SURGICAL HISTORY: , Right knee surgery, cosmetic surgery, and carotid sinus surgery.,MEDICATIONS: , Mirapex, ibuprofen, and Ambien.,ALLERGIES: , QUESTIONABLE PENICILLIN ALLERGIES.,PHYSICAL EXAMINATION: , GENERAL:  Female who appears younger than her stated age.  Examination of her gait reveals she walks without assistive devices.,HEENT:  Normocephalic and atraumatic.,CHEST:  Clear to auscultation.,CARDIOVASCULAR:  Regular rate and rhythm.,ABDOMEN:  Soft.,EXTREMITIES:  Grossly neurovascularly intact.,HOSPITAL COURSE: , The patient was taken to the operating room (OR) on 03/15/2007.  She underwent right total knee arthroplasty.  She tolerated this well.  She was taken to the recovery room.  After uneventful recovery room course, she was brought to regular surgical floor.  Mechanical and chemical deep venous thrombosis (DVT) prophylaxis were initiated.  Routine postoperative antibiotics were administered.  Hemovac drain was discontinued on postoperative day #2.  Physical therapy was initiated.  Continuous passive motion (CPM) was also initiated.  She was able to spontaneously void.  She transferred to oral pain medication.  Incision remained clean, dry, and intact during the hospital course.  No pain with calf squeeze.  She was felt to be ready for discharge home on 03/19/2007.,DISPOSITION:  ,Discharged to home.,FOLLOW UP:,  Follow up with Dr. X in one week.  Prescriptions were written for Percocet and Coumadin.,INSTRUCTIONS: , Home physical therapy and PT and INR to be drawn at home for adjustment of Coumadin dosing.,
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DESCRIPTION: A 66-year-old female with knee osteoarthrosis who failed conservative management.

orthopedic, total knee arthroplasty, conservative management, knee arthroplasty, physical therapy, knee osteoarthrosis, arthroplasty, osteoarthrosis, knee,

The scenario described involves a total knee arthroplasty, a common orthopedic surgery. While surgery always carries inherent risks, this is not considered one of the highest-stake surgical situations, especially with the described successful outcome and standard postoperative care. The follow-up and management plan post-discharge are in place, which is typical. The situation does not involve any immediate life-threatening issues or potential for severe complications, assuming proper adherence to discharge instructions and follow-up care.


Medical Specialty: Speech - Language
Sample Name: Speech Therapy - Discharge Summary - 1

HISTORY: , The patient is a 67-year-old female, was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.  At the onset of therapy, on 03/26/08, the patient was NPO with a G-tube and the initial speech and language evaluation revealed global aphasia with an aphasia quotient of 3.6/100 based on the Western Aphasia Battery.  Since the initial evaluation, the patient has attended 60 outpatient speech therapy sessions, which have focussed on her receptive communication, expressive language, multimodality communication skills, and swallowing function and safety.,SHORT-TERM GOALS:,1.  The patient met 3 out of 4 original short-term therapy goals, which were to complete a modified barium swallow study, which she did do and which revealed no aspiration.  At this time, the patient is eating and drinking and taking all medications by mouth; however, her G-tube is still present.  The patient was instructed to talk to the primary care physician about removal of her feeding tube.,2.  The patient will increase accuracy of yes-no responses to greater than 80% accuracy.  She did accomplish this goal.  The patient is also able to identify named objects with greater than 80% accuracy.,ADDITIONAL GOALS: , Following the completion of these goals, additional goals were established.  Based on reevaluation, the patient met 2 out of these 3 initial goals and she is currently able to read and understand simple sentences with greater than 90% accuracy independently and she is able to write 10 words related to basic wants and needs with greater than 80% accuracy independently.  The patient continues to have difficulty stating verbally, yes or no, to questions as well as accurately using head gestures and to respond to yes-no questions.  The patient continues to have marked difficulty with her expressive language abilities.  She is able to write simple words to help express her basic wants and needs.  She has made great strides; however, with her receptive communication, she is able to read words as well as short phrases and able to point to named objects and answer simple-to-moderate complex yes-no questions.  A reevaluation completed on 12/01/08, revealed an aphasia quotient of 26.4.  Once again, she made significant improvement and comprehension, but continues to have unintelligible speech.  An alternative communication device was discussed with the patient and her husband, but at this time, the patient does not want to utilize a communication device.  If, in the future, the patient continues to struggle with her expressive communication, an alternative augmented communication device would be a benefit to her.  Please reconsult at that time if and when the patient is ready to use a speech generating device.  The patient is discharged from my services at this time due to a plateau in her progress.  Numerous home activities were recommended to allow her to continue to make progress at home.
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DESCRIPTION: The patient was referred to Medical Center's Outpatient Rehabilitation Department for skilled speech therapy to improve her functional communication skills and swallowing function and safety.

speech - language, communication skills, g-tube, aphasia, language evaluation, western aphasia battery, skilled speech therapy, swallowing function, speech therapy, therapy, swallowing, aspiration, speech, communication,

This situation involves the discharge summary of a 67-year-old female patient who has been undergoing speech therapy for severe communication challenges following a diagnosis of global aphasia. While the therapy is crucial for improving quality of life, it is more of a routine summary marking the end of a therapy course due to a plateau in progress. The stakes here relate to the continuity of care and the patient's quality of life, which are important but do not involve immediate life-threatening situations or critical risks. The patient has shown significant improvement, and the therapy's effectiveness is well-documented. However, it does mention the potential use of alternative communication devices in the future, which could further enhance her abilities.


Medical Specialty: Psychiatry / Psychology
Sample Name: Psych Consult - Lethargy

REASON FOR CONSULTATION: , Lethargy.,HISTORY OF PRESENT ILLNESS:,  The patient is a 62-year-old white female with a past medical history of left frontal glioblastoma with subsequent craniotomy infection for PE, DVT, hyperlipidemia, and hypertension who is according to the patient's daughter expressing signs of depression.  Symptoms began on February 5, 2007, upon receiving the unexpected news, the patient would need three to four more days of chemotherapy and radiation therapy for her glioblastoma, described as a sudden onset of symptoms including hypersomnia (18 to 20 hours per day), drastic decrease in energy level, anhedonia, feelings of hopelessness and helplessness, psychomotor retardation, and past history of suicidal ideations.  The patient's appetite is unknown since she had been fed by NG tube after being diagnosed with neuromuscular oropharyngeal dysphagia.  Prior to receiving the news for needing more cancer therapy, the patient was described as being "fine," participating in physical therapy and talking regularly as she was looking forward to leaving the hospital.  Now, the patient has become angry, socially withdrawn, not wanting to see anyone including her own grandchildren, and not participating in physical therapy.  Has been on a daily dose of Lexapro since January 08, 2007, was increased from 10 mg to 20 mg on January 24, 2007, which is her current dose.  Has been on Provigil 100 mg b.i.d. since February 06, 2007, but has not noticed an impact.  Had been on Zyprexa 2.5 mg p.o. q.p.m. from December 20, 2006, to February 01, 2007, but has been discontinued.  Currently, the patient has not displayed any manic symptoms, auditory or visual hallucinations, or symptoms of anxiety.  Also, denies any homicidal ideations.,PAST PSYCHIATRIC HISTORY:,  Was prescribed Prozac for depression, felt during husband's successful battle with prostate cancer.  Never been diagnosed with psychiatric illness.  Displayed some psychotic symptoms, status post craniotomy while in ICU, treated with Zyprexa and Xanax during hospitalization in 2006.,PAST MEDICAL HISTORY:,  Craniotomy November 2006 with subsequent CSF infection of enterobacter, status post glioblastoma multiforme, PE, DVT, hypertension, SIADH, and IVC filter.  No history of thyroid problems, seizures, strokes, or traumatic head injuries.,HOME MEDICATIONS:,  Norvasc 5 mg daily, TriCor 145 mg daily, aspirin one tablet daily, Tylenol, and glucosamine chondroitin sulfate.,CURRENT MEDICATIONS:,  Norvasc 10 mg p.o. daily, Decadron injection 6 mg IV q.12h., Colace 100 mg liquid b.i.d., Cardura 2 mg p.o. daily, Lexapro 20 mg p.o. daily, Lopressor 50 mg p.o. q.12h., Flagyl 500 mg via PEG tube q.8h., modafinil 100 mg p.o. b.i.d., Lovenox 60 mg subcu q.12h., insulin sliding scale, Tylenol suppositories 650 mg rectal q.4h. p.r.n., and Ambien 5 mg p.o. q.h.s. p.r.n.,ALLERGIES:,  PHENYTOIN (STEVENS-JOHNSON SYNDROME), CODEINE, NOVOCAIN, UNKNOWN ALLERGY.,FAMILY MEDICAL HISTORY:,  Father had lung cancer, was smoker for 40 years.  Father's aunt have heart disease.,SOCIAL AND DEVELOPMENTAL HISTORY:,  Currently lives with husband of 40 years in League City, has a Masters in Education, is a retired reading specialist which she did it for 33 years.  Has one younger brother, one daughter.  Denies use of tobacco, alcohol and illicit drugs.  The child as per daughter was picked on and has a strained relationship with her mother, but they still are communicating.,MENTAL STATUS EXAMINATION:,  The patient is a 62-year-old white female, lying in hospital bed, with gown on, eyes closed, short shaven hair, and golf ball-sized indentation in the anterior fontanelle from craniotomy.  Psychomotor retardation, poor eye contact, speech low volume, slow rate, poor flexion, essentially unresponsive, and somnolent during interview.  Poor concentration, mood unknown (the patient did not respond to questions), affect flat, thought process logical and goal directed, thought content unable to assess from the patient but the patient's daughter denied delusions and homicidal ideations.  Positive for passive suicidal ideations and perceptions.  No auditory or visual hallucinations.  Sensorium stuporous, did not answer orientation questions.  Memory information, intelligence, judgment, and insight unknown.,Mini-Mental status examination unable to be performed.,ASSESSMENT:,  A 62-year-old white female status post craniotomy for glioblastoma multiforme with subsequent CNS infection and currently has been displaying symptoms of depression for the past seven days and hence was told she needed more chemotherapy and radiation therapy.,Axis I:  Depression, NOS.  Rule out depression secondary to general medical condition.,Axis II:  Deferred.,Axis III:  Craniotomy with subsequent CSF infection, PE, DVT, and hypertension.,Axis IV:  Hospitalization.,Axis V:  11.,PLAN:,  Continue Lexapro 20 mg p.o. daily.  Discontinue Provigil, begin Ritalin 5 mg p.o. q.a.m. and q. noon.,Thank you for the consultation.
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DESCRIPTION: Psychiatric consultation of patient with lethargy.

The situation is high-stakes due to the potential risk of suicide. The patient has a history of glioblastoma, recent major surgery, and current symptoms of severe depression with passive suicidal ideation, which requires immediate psychiatric intervention to prevent any progression to active suicidal behavior. Her emotional condition is worsened by the continuation of cancer treatment. The understanding of her mental state is crucial for her ongoing cancer treatment and overall prognosis.


Medical Specialty: General Medicine
Sample Name: Fall & Laceration

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

general medicine, loss of consciousness, laceration, fall, course in the ed, placed on monitors, fell and struck, abrasions,

The situation involves a patient who has sustained a fall and facial lacerations. The patient's vital signs are stable, and there is no evidence of serious injury such as fractures. The patient has mild symptoms consistent with alcohol consumption, but there is no loss of consciousness or severe neurological impairment. The lacerations have been treated, and the overall clinical picture suggests low immediate danger to life or function. Thus, while medical attention is necessary, the situation is not imminently life-threatening or high-stakes.


Medical Specialty: Surgery
Sample Name: Anterior Cervical Discectomy & Osteophytectomy

PREOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,OPERATIVE PROCEDURE,1.  CPT code 63075:  Anterior cervical discectomy and osteophytectomy, C5-C6.,2.  CPT code 63076:  Anterior cervical discectomy and osteophytectomy, C6-C7, additional level.,3.  CPT code 22851:  Application of prosthetic interbody fusion device, C5-C6.,4.  CPT code 22851-59:  Application of prosthetic interbody fusion device, C6-C7, additional level.,5.  CPT code 22554-51:  Anterior cervical interbody arthrodesis, C5-C6.,6.  CPT code 22585:  Anterior cervical interbody arthrodesis, C6-C7, additional level.,7.  CPT code 22845:  Anterior cervical instrumentation, C5-C7.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:  ,Negligible.,DRAINS: , Small suction drain in the cervical wound.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:,  The patient was given intravenous antibiotic prophylaxis and thigh-high TED hoses were placed on the lower extremities while in the preanesthesia holding area.  The patient was transported to the operative suite and on to the operative table in the supine position.  General endotracheal anesthesia was induced.  The head was placed on a well-padded head holder.  The eyes and face were protected from pressure.  A well-padded roll was placed beneath the neck and shoulders to help preserve the cervical lordosis.  The arms were tucked and draped to the sides.  All bony prominences were well padded.  An x-ray was taken to confirm the correct level of the skin incision.  The anterior neck was then prepped and draped in the usual sterile fashion.,A straight transverse skin incision over the left side of the anterior neck was made and carried down sharply through the skin and subcutaneous tissues to the level of the platysma muscle, which was divided transversely using the electrocautery.  The superficial and deep layers of the deep cervical fascia were divided.  The midline structures were reflected to the right side.  Care was taken during the dissection to avoid injury to the recurrent laryngeal nerve and the usual anatomical location of that nerve was protected.  The carotid sheath was palpated and protected laterally.  An x-ray was taken to confirm the level of C5-C6 and C6-C7.,The longus colli muscle was dissected free bilaterally from C5 to C7 using blunt dissection.  Hemostasis was obtained using the electrocautery.  The blades of the cervical retractor were placed deep to the longus colli muscles bilaterally.  At C5-C6, the anterior longitudinal ligament was divided transversely.  Straight pituitary rongeurs and a curette were used to remove the contents of the disc space.  All cartilages were scraped off the inferior endplate of C5 and from the superior endplate of C6.  The disc resection was carried posteriorly to the posterior longitudinal ligament and laterally to the uncovertebral joints.  The posterior longitudinal ligament was resected using a 1 mm Kerrison rongeur.  Beginning in the midline and extending into both neural foramen, posterior osteophytes were removed using a 1 m and a 2 mm Kerrison rongeurs.  The patient was noted to have significant bony spondylosis causing canal and foraminal stenosis as well as a degenerative and protruding disc in agreement with preoperative diagnostic imaging studies.  Following completion of the discectomy and osteophytectomy, a blunt nerve hook was passed into the canal superiorly and inferiorly as well as in the both neural foramen to make sure that there were no extruded disc fragments and to make sure the bony decompression was complete.  A portion of the uncovertebral joint was resected bilaterally for additional nerve root decompression.  Both nerve roots were visualized and noted to be free of encroachment.  The same procedure was then carried out at C6-C7 with similar findings.  The only difference in the findings was that at C6-C7 on the left side, the patient was found to have an extruded disc fragment in the canal and extending into the left side neural foramen causing significant cord and nerve root encroachment.,In preparation for the arthrodesis, the endplates of C5, C6, and C7 were burred in a parallel fashion down to the level of bleeding bone using a high-speed cutting bur with irrigant solution for cooling.  The disc spaces were then measured to the nearest millimeter.  Attention was then turned toward preparation of the structural allograft, which consisted of two pieces of pre-machined corticocancellous bone.  The grafts were further shaped to fit the disc spaces exactly in a press-fit manner with approximately 1.5 mm of distraction at each disc space.  The grafts were shaped to be slightly lordotic to help preserve the cervical lordosis.  The grafts were impacted into the disc spaces.  There was complete bony apposition between the ends of the bone grafts and the vertebral bodies of C5, C6, and C7.  A blunt nerve hook was passed posterior to each bone graft to make sure that the bone grafts were in good position.  Anterior osteophytes were removed using a high-speed cutting bur with irrigant solution for cooling.  An appropriate length Synthes cervical plate was selected and bent slightly to conform to the patient's cervical lordosis.  The plate was held in the midline with provided instrumentation while a temporary fixation screw was applied at C6.  Screw holes were then drilled using the provided drill and drill guide taking care to avoid injury to neurovascular structures.  The plate was then rigidly fixed to the anterior spine using 14-mm cancellous screws followed by locking setscrews added to the head of each screw to prevent postoperative loosening of the plate and/or screws.,An x-ray was taken, which confirmed satisfactory postioning of the plate, screws, and bone grafts.,Blood loss was minimal.  The wound was irrigated with irrigant solution containing antibiotics.  The wound was inspected and judged to be dry.  The wound was closed over a suction drain placed in the deepest portion of the wound by reapproximating the platysma muscle with #4-0 Vicryl running suture, the subdermal and subcuticular layers with #4-0 Monocryl interrupted sutures, and the skin with Steri-Strips.  The sponge and needle count were correct.  A sterile dressing was applied to the wound.  The neck was placed in a cervical orthosis.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.
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DESCRIPTION: Anterior cervical discectomy and osteophytectomy.  Application of prosthetic interbody fusion device.  Anterior cervical interbody arthrodesis.  Anterior cervical instrumentation

The procedure described is a complex spinal surgery involving the cervical spine, which is inherently high-stakes due to the critical anatomical structures involved, including the spinal cord and nerves. Complications in this type of surgery can lead to severe outcomes such as nerve damage, paralysis, or other significant neurological deficits. Despite the absence of immediate complications in this report, the overall situation is high-stakes because of the potential risks and the delicate nature of the structures involved.


Medical Specialty: Neurology
Sample Name: CT Brain - Aneurysm

CC:, Decreasing visual acuity.,HX: ,This 62 y/o RHF presented locally with a 2 month history of progressive loss of visual acuity, OD. She had a 2 year history of progressive loss of visual acuity, OS, and is now blind in that eye. She denied any other symptomatology. Denied HA.,PMH:, 1) depression. 2) Blind OS,MEDS:, None.,SHX/FHX: ,unremarkable for cancer, CAD, aneurysm, MS, stroke. No h/o Tobacco or ETOH use.,EXAM:, T36.0, BP121/85, HR 94, RR16,MS: Alert and oriented to person, place and time. Speech fluent and unremarkable.,CN: Pale optic disks, OU. Visual acuity: 20/70 (OD) and able to detect only shadow of hand movement (OS). Pupils were pharmacologically dilated earlier. The rest of the CN exam was unremarkable.,MOTOR: 5/5 throughout with normal bulk and tone.,Sensory: no deficits to LT/PP/VIB/PROP.,Coord: FNF-RAM-HKS intact bilaterally.,Station: No pronator drift. Gait: ND,Reflexes: 3/3 BUE, 2/2 BLE. Plantar responses were flexor bilaterally.,Gen Exam: unremarkable. No carotid/cranial bruits.,COURSE:, CT Brain showed large, enhancing 4 x 4 x 3 cm suprasellar-sellar mass without surrounding edema. Differential dx: included craniopharyngioma, pituitary adenoma, and aneurysm. MRI Brain findings were consistent with an aneurysm. The patient underwent 3 vessel cerebral angiogram on 12/29/92. This clearly revealed a supraclinoid giant aneurysm of the left internal carotid artery. Ten minutes following contrast injection the patient became aphasic and developed a right hemiparesis. Emergent HCT showed no evidence of hemorrhage or sign of infarct. Emergent carotid duplex showed no significant stenosis or clot. The patient was left with an expressive aphasia and right hemiparesis. SPECT scans were obtained on 1/7/93 and 2/24/93. They revealed hypoperfusion in the distribution of the left MCA and decreased left basal-ganglia perfusion which may represent in part a mass effect from the LICA aneurysm. She was discharged home and returned and underwent placement of a Selverstone Clamp on 3/9/93. The clamp was gradually and finally closed by 3/14/93. She did well, and returned home. On 3/20/93 she developed sudden confusion associated with worsening of her right hemiparesis and right expressive aphasia. A HCT then showed SAH around her aneurysm, which had thrombosed. She was place on Nimodipine. Her clinical status improved; then on 3/25/93 she rapidly deteriorated over a 2 hour period to the point of lethargy, complete expressive aphasia, and right hemiplegia. An emergent HCT demonstrated a left ACA and left MCA infarction. She required intubation and worsened as cerebral edema developed. She was pronounced brain dead. Her organs were donated for transplant.
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DESCRIPTION: CT Brain: Suprasellar aneurysm, pre and post bleed.

neurology, ct brain, hct, mri brain, suprasellar, suprasellar aneurysm, aneurysm, cerebral angiogram, craniopharyngioma, internal carotid artery, loss of visual acuity, pituitary adenoma, suprasellar-sellar mass, visual acuity, expressive aphasia, cerebral, ct, hemiparesis, aphasia, brain,

This situation involves a complex medical case requiring diagnosis and immediate medical interventions including surgeries and procedures due to a giant aneurysm, which at one point started affecting the patient's health critically. The patient experienced significant neurological deficits and rapidly deteriorated, ultimately resulting in brain death. The high-stakes nature is due to the critical and life-threatening condition, requiring precise and timely medical interventions to attempt to mitigate risks of serious brain injury or death. Even with interventions, the patient's condition declined leading to her death, showing the intricacies and high stakes involved in managing such a case.