Medical Specialty: Urology
Sample Name: Foreskin - Followup

REASON FOR VISIT: , Follow up consultation, second opinion, foreskin.,HISTORY OF PRESENT ILLNESS: , A 2-week-old who at this point has otherwise been doing well.  He has a relatively unremarkable foreskin.  At this point in time, he otherwise seems to be doing reasonably well.  The question is about the foreskin.  He otherwise has no other significant issues.  Severity low, ongoing since birth two weeks.  Thank you for allowing me to see this patient in consultation.,PHYSICAL EXAMINATION:,  Male exam.  Normal and under the penis, report normal uncircumcised 2-week-old.  He has a slightly insertion on the penile shaft from the median raphe of the scrotum.,IMPRESSION: , Slightly high insertion of the median raphe.  I see no reason he cannot be circumcised as long as they are careful and do a very complete Gomco circumcision.  This kid should otherwise do reasonably well.,PLAN:  ,Follow up as needed.  But my other recommendation is that this kid as I went over with the mother may actually do somewhat better if he simply has a formal circumcision at one year of age, but may do well with a person who is very accomplished doing a Gomco circumcision.
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DESCRIPTION: Follow up consultation, second opinion, foreskin.

urology, formal circumcision, median raphe, penis, gomco circumcision, gomco, circumcision, foreskin,

This situation involves a follow-up consultation for a routine examination of a foreskin in a 2-week-old infant. The primary concern is related to a slightly high insertion of the median raphe, but there are no significant health issues or severe complications mentioned. The recommendation includes a future circumcision, either now with caution or at one year of age. Given the patient's current condition is stable and non-urgent, the situation is low-stakes, with minimal immediate risk to the patient's health.


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

Medical Specialty: Surgery
Sample Name: EGD - 1

HISTORY OF PRESENT ILLNESS:,  Briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus.  He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture that may need to be dilated, or any other mucosal abnormality.,PROCEDURE PERFORMED: , EGD.,PREP: , Cetacaine spray, 100 mcg of fentanyl IV, and 5 mg of Versed IV.,FINDINGS:,  The tip of the endoscope was introduced into the esophagus, and the entire length of the esophagus was dotted with numerous, white, punctate lesions, suggestive of eosinophilic esophagitis.  There were come concentric rings present.  There was no erosion or flame hemorrhage, but there was some friability in the distal esophagus.  Biopsies throughout the entire length of the esophagus from 25-40 cm were obtained to look for eosinophilic esophagitis.  There was no stricture or Barrett mucosa.  The bony and the antrum of the stomach are normal without any acute peptic lesions.  Retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia.  There were no acute lesions and no evidence of ulcer, tumor, or polyp.  The pylorus was easily entered, and the first, second, and third portions of the duodenum are normal.  Adverse reactions:  None.,FINAL IMPRESSION:  ,Esophageal changes suggestive of eosinophilic esophagitis.  Biopsies throughout the length of the esophagus were obtained for microscopic analysis.  There was no evidence of stricture, Barrett, or other abnormalities in the upper GI tract.
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DESCRIPTION: Problems with dysphagia to solids and had food impacted in the lower esophagus.  Upper endoscopy to evaluate the esophagus.

surgery, length of the esophagus, food impacted, lower esophagus, upper endoscopy, entire length, eosinophilic esophagitis, egd, dysphagia, solids, impacted, endoscopy, mucosal, endoscope, biopsies, barrett, stomach, stricture, eosinophilic, esophagitis, esophagus,

The case involves a 17-year-old male undergoing an esophagogastroduodenoscopy (EGD) to investigate issues related to dysphagia and a recent food impaction in the esophagus. The potential diagnosis is eosinophilic esophagitis, which, while it can significantly impact a patient's quality of life, is not immediately life-threatening and does not require emergency intervention. The procedure was completed without adverse reactions, and there were no findings of stricture or other serious abnormalities. The results of the biopsy will further guide diagnosis and management, but the situation as described does not indicate a high-stakes emergency.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Psych Consult - Pain Meds

REASON FOR CONSULTATION: , Management of pain medications.,HISTORY OF PRESENT ILLNESS: , This is a 60-year-old white male with history of coronary artery disease, status post CABG in 1985 with subsequent sternal dehiscence with rewiring in December 2005 and stent placement in LAD region in 2005, who developed sudden chest pain and was taken to San Jacinto via ambulance where he was diagnosed with acute MI and then went into atrial fibrillation.  An intraaortic balloon pump was placed for cardiogenic shock, and then he was transferred to the ABCD Hospital on October 22, 2006, for continued critical care.  He was in a state of cardiogenic shock and multiorgan system failure including respiratory failure and acute renal insufficiency when he was transferred.  He is currently on dialysis due to end-stage renal disease and has a tracheostomy.  He is receiving fentanyl since he has been here for back pain, leg pain, abdominal pain, and pain in the feet.  He states that he is currently in pain and the fentanyl only helps for about an hour or so before the pain resumes.  He currently rates his pain as 7 out of 10.  He denies a depressed mood or anxiety and states that he knows he is getting better.  He describes his sleep as erratic and states that he will sleep for 1 hour after giving fentanyl IV and then will wake up until he gets another fentanyl.  He has PEG for tube feeding.  He has weakness on left side of his body as well as both legs since his MI.  He has been switched from fentanyl IV q.2h. to the fentanyl patch today.  He also has been started on Seroquel 12.5 mg p.o. at bedtime and will receive his first dose on the evening of Monday, February 12, 2007.  He denies any other psychiatric symptoms including auditory or visual hallucinations or delusions.  His wife was present in the room and both him and his wife seemed to be offended by the suggestion of any psychiatric history or any psychiatric problems.,PAST MEDICAL HISTORY:,1.  DVT in December 2005.,2.  Three MI's (1996, 2005, and 2006).,3.  Diabetes for 5 years.,4.  Coronary artery disease for 10 years.,PAST SURGERIES:,1.  Appendectomy as a child.,2.  CABG x3, November 2005.,3.  Sternal rewiring, December 2005.,MEDICATIONS:,1.  Restoril 7.5 mg p.o. at bedtime p.r.n.,2.  Acetaminophen 650 mg p.o. q.6h. p.r.n. fever.,3.  Aspirin 81 mg p.o. daily.,4.  Bisacodyl suppository 10 mg per rectum daily.,5.  Erythropoietin injection 100 mcg subcutaneously every week at 5 p.m.,6.  Esomeprazole 40 mg IV q.12h.,7.  Fentanyl patch 25 mcg per hour.,8.  Transderm patch every 72 hours.,9.  Heparin IV.,10.  Lactulose 30 mL p.o. daily p.r.n. constipation.,11.  Metastron injection 4 mg IV q.6h. p.r.n. nausea.,12.  Seroquel 12 mg p.o. at bedtime.,13.  Saliva substitute 30 mL spray p.o. q.3h. p.r.n. dry mouth.,14.  Simethicone drops 80 mg per G-tube p.r.n. gas pain.,15.  Bactrim suspension p.o. daily.,16.  Insulin medium dose sliding scale.,17.  Albumin 25% IV p.r.n. hemodialysis.,18.  Ipratropium solution for nebulizer.,ALLERGIES:,  No known drug allergies.,PAST PSYCHIATRIC HISTORY:,  The patient denies any past psychiatric problems.  No medications.  He denies any outpatient visits or inpatient hospitalizations for psychiatric reasons.,SOCIAL HISTORY:,  He lives with his wife in New Jersey.  He has 2 children.  One son in Texas City and 1 daughter in Florida.  He is a master mechanic for a trucking company since 1968.  He retired in the May 2006.  The highest level of education that he received was 1 year in college.,Ethanol, tobacco, or drugs; he smoked 2 packs per day for 40 years, but quit in 1996.  He occasionally has a beer, but denies any continuous use of alcohol.  He denies any illicit drug use.,FAMILY HISTORY:,  Both parents died with myocardial infarctions.  He has 2 sisters and a brother with diabetes mellitus and coronary artery disease.  He denies any history of psychiatric problems in family.,MENTAL STATUS EXAMINATION:,  The patient was sitting in his bed in hospital gown with tracheostomy and receiving tube feeding.  The patient's appearance was appropriate with fair-to-good grooming and hygiene.  He had little-to-no psychomotor activity secondary to weakness post MI.  He had good eye contact.  His speech was of decreased rate volume and flexion secondary to tracheostomy.  The patient was cooperative.  He described his mood is not good in congruent stable and appropriate affect with decreased range.  His thought process is logical and goal directed.  His thought content was negative for delusions, phobias, obsessions, suicidal ideation, or homicidal ideation.  He denied any perceptional disturbances including any auditory or visual hallucinations.  He was alert and oriented x3.,Mini mental status exams not completed.,ASSESSMENT:,AXIS I:  Pain with physical symptoms and possibly psychological symptoms.,AXIS II:  Deferred.,AXIS III:  See above.
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DESCRIPTION: Psychiatric consultation for management of pain medications.

The consultation involves a 60-year-old patient with a complex medical history of coronary artery disease, multiple myocardial infarctions, multiorgan failure, dialysis dependence, and several other ongoing issues. The patient's pain management is critical, especially considering the use of high-risk medications like fentanyl. The patient's pain is not adequately managed, and there is a transition to a fentanyl patch which requires careful monitoring. Additionally, psychiatric aspects may need to be considered as they could influence the management of the pain. The involvement of multiple organ systems, potential risks of inadequate pain management, and the need for coordinated care make this situation high-stakes.


Medical Specialty: ENT - Otolaryngology
Sample Name: BMT - Bilateral Myringotomy Tubes

Parents often ask why the fluid cannot be drained without inserting a tube.  The need for the tube insertion is because the eardrum incision generally heals very rapidly (within a few days), which is not long enough for the swollen membranes in the middle ear to return to normal.  As soon as the eardrum heals, fluid will reaccumulate.  Tubes were first introduced because of this very problem.  There are many types of tubes, but all tubes serve the same function.  They keep the eardrum open, allow air to enter the middle ear space, and permit fluid in the middle ear to drain.  Most tubes will gradually be rejected by the ear and work their way out of the eardrum.  As they come out, the eardrum seals behind the tube.  Tubes will last four to six months in the eardrum before they come out.  Occasionally, the eardrum does not heal completely when the tube comes out.,The majority of children treated with tubes do not require further surgery.  They may have ear infections in the future, but most will clear up with medical treatment.  Some children are very prone to ear infections and have a tendency to accumulate fluid after each infection.  Children tend to outgrow this cycle by age 7 or 8.  In an ear, nose and throat specialty practice, this group comprises 10 to 15% of all children who have required tubes.  Occasionally the physician has to physically remove the tube from the ear drum.
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DESCRIPTION: A sample note on bilateral myringotomy tubes

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

The situation described involves a common medical procedure for children known as bilateral myringotomy with tube insertion to manage ear infections. This is generally a standard and routine procedure in ENT practices. While it involves surgery, it is often considered low-risk and highly effective for treating chronic ear infections or fluid accumulation. The description indicates that most cases do not require further surgery and complications are minimal. Thus, the overall situation presented is not high-stakes, especially given the commonality of the procedure and its wide acceptance as a treatment modality.


Medical Specialty: Surgery
Sample Name: Abdominal Exploration

PREOPERATIVE DIAGNOSES:  ,1.  Congenital chylous ascites and chylothorax.,2.  Rule out infradiaphragmatic lymphatic leak.,POSTOPERATIVE DIAGNOSES: , Diffuse intestinal and mesenteric lymphangiectasia.,ANESTHESIA: , General.,INDICATION:  ,The patient is an unfortunate 6-month-old baby boy, who has been hospitalized most of his life with recurrent chylothoraces and chylous ascites.  The patient has been treated somewhat successfully with TPN and voluntary restriction of enteral nutrition, but he had repeated chylothoraces.  Last week, Dr. X took the patient to the operating room in hopes that with thoracotomy, a thoracic duct leak could be found, which would be successfully closed surgically.  However at the time of his thoracotomy exploration what was discovered was a large amount of transdiaphragmatic transition of chylous ascites coming from the abdomen.  Dr. X opened the diaphragm and could literally see a fountain of chylous fluid exiting through the diaphragmatic hole.  This was closed, and we decided that perhaps an abdominal exploration as a last stage effort would allow us to find an area of lymphatic leak that could potentially help the patient from this dismal prognostic disease.  We met with his parents and talked to them about this, and he is here today for that attempt.,OPERATIVE FINDINGS:  ,The patient's abdomen was relatively soft, minimally distended.  Exploration through supraumbilical transverse incision immediately revealed a large amount of chylous ascites upon entering into the peritoneal cavity.  What we found which explains the chronic chylous ascites and chylothorax was a diffuse lymphangiectatic picture involving the small bowel mesentery approximately two thirds to three quarters of the distal small bowel including all of the ileum, the cecum, and the portion of the ascending colon.  It appeared that any attempt to resect this area would have been met with failure because of the extensive lymphatic dilatation all the way down towards the root of the supramesenteric artery.  There was about one quarter to one third of the jejunum that did not appear to be grossly involved, but I did not think that resection of three quarters of the patient's small bowel would be viable surgical option.  Instead, we opted to close his abdomen and refer for potential small intestine transplantation procedure in the future if he is a candidate for that.,The lymphatic abnormality was extensive.  They were linear dilated lymphatic channels on the serosal surface of the bowel in the mesentery.  They were small aneurysm-like pockets of chyle all along the course of the mesenteric structures and in the mesentery medially adjacent to the bowel as well.  No other major retroperitoneal structure or correctable structure was identified.  Both indirect inguinal hernias were wide open and could be palpated from an internal aspect as well.,DESCRIPTION OF OPERATION:  ,The patient was brought from the Pediatric Intensive Care Unit to the operating room within an endotracheal tube im place and with enteral feeds established at full flow to provide maximum fat content and maximum lymphatic flow.  We conducted a surgical time-out and reiterated all of the patient's important identifying information and confirmed the operative plan as described above.  Preparation and draping of his abdomen was done with chlorhexidine based prep solution and then we opened his peritoneal cavity through a transverse supraumbilical incision dividing both rectus muscles and all layers of the abdominal wall fascia.  As the peritoneal cavity was entered, we divided the umbilical vein ligamentum teres remnant between Vicryl ties, and we were able to readily identify a large amount of chylous ascites that had been previously described.  The bowel was eviscerated, and then with careful inspection, we were able to identify this extensive area of intestinal and mesenteric lymphangiectasia that was a source of the patient's chylous ascites.  The small bowel from the ligament of Treitz to the proximal to mid jejunum was largely unaffected, but did not appear that resection of 75% of the small intestine and colon would be a satisfactory tradeoff for The patient, but would likely render him with significant short bowel and nutritional and metabolic problems.  Furthermore, it might burn bridges necessary for consideration of intestinal transplantation in the future if that becomes an option.  We suctioned free all of the chylous accumulations, replaced the intestines to their peritoneal cavity, and then closed the patient's abdominal incision with 4-0 PDS on the posterior sheath and 3-0 PDS on the anterior rectus sheath.  Subcuticular 5-0 Monocryl and Steri-Strips were used for skin closure.,The patient tolerated the procedure well.  He lost minimal blood, but did lose approximately 100 mL of chylous fluid from the abdomen that was suctioned free as part of the chylous ascitic leak.  The patient was returned to the Pediatric Intensive Care Unit with his endotracheal tube in place and to consider the next stage of management, which might be an attempted additional type of feeding or referral to an Intestinal Transplantation Center to see if that is an option for the patient because he has no universally satisfactory medical or surgical treatment for this at this time.
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DESCRIPTION: Congenital chylous ascites and chylothorax and rule out infradiaphragmatic lymphatic leak.   Diffuse intestinal and mesenteric lymphangiectasia.

surgery, intestinal, mesenteric, lymphangiectasia, ascites, chylothorax, lymphatic leak, infradiaphragmatic, abdominal exploration, congenital chylous, mesenteric lymphangiectasia, peritoneal cavity, chylous, abdominal, congenital, abdomen, lymphatic

The scenario involves a complex surgical procedure on a six-month-old infant with a serious and rare medical condition, congenital chylous ascites, and chylothorax. The condition is life-threatening and has resulted in the patient being hospitalized for most of his life. The surgical intervention explored the possibility of correcting a significant lymphatic leak that affects the patient's quality of life and survival prospects. The stakes are high because the outcome impacts the infant's immediate health and future treatment options, such as the potential need for an intestinal transplant. Given the severity of the condition, the involvement of critical organs like the intestines and lymphatic system, and the potential life-long implications, this is a high-stakes situation.


Medical Specialty: Hematology - Oncology
Sample Name: Discharge Summary - Mesothelioma - 1

PRINCIPAL DIAGNOSIS:,  Mesothelioma.,SECONDARY DIAGNOSES:,  Pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.,PROCEDURES,1.  On August 24, 2007, decortication of the lung with pleural biopsy and transpleural fluoroscopy.,2.  On August 20, 2007, thoracentesis.,3.  On August 31, 2007, Port-A-Cath placement.,HISTORY AND PHYSICAL: , The patient is a 41-year-old Vietnamese female with a nonproductive cough that started last week.  She has had right-sided chest pain radiating to her back with fever starting yesterday.  She has a history of pericarditis and pericardectomy in May 2006 and developed cough with right-sided chest pain, and went to an urgent care center.  Chest x-ray revealed right-sided pleural effusion.,PAST MEDICAL HISTORY,1.  Pericardectomy.,2.  Pericarditis.,2.  Atrial fibrillation.,4.  RNCA with intracranial thrombolytic treatment.,5
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DESCRIPTION: Mesothelioma, pleural effusion, atrial fibrillation, anemia, ascites, esophageal reflux, and history of deep venous thrombosis.

The situation described involves a discharge summary for a patient with several serious medical conditions, including mesothelioma, a form of cancer. Managing a cancer diagnosis alongside other conditions such as atrial fibrillation, deep venous thrombosis, and pleural effusion makes the stakes high due to the complexity and potential for severe health outcomes. Additionally, mesothelioma is usually a severe condition with a significant impact on the patient's quality of life and survival. The discharge summary suggests that the patient has undergone significant medical interventions, indicating a critical level of care. Moreover, this involves complex decision-making by healthcare professionals, adding to the high stakes of ensuring patient safety and appropriate follow-up care.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - 19

PRIMARY DISCHARGE DIAGNOSES:,1.  Urinary tract infection.,2.  Gastroenteritis with nausea and vomiting.,3.  Upper gastrointestinal bleed likely secondary to gastritis.,4.  Right hip osteoarthritic pain.,SECONDARY DISCHARGE DIAGNOSES:,1.  Hypertension.,2.  Gastroesophageal reflux disease.,3.  Chronic atrial fibrillation.,4.  Osteoporosis.,5.  Valvular heart disease.,HOSPITAL COURSE SUMMARY: , The patient is 93-year-old Caucasian female with a past medical history of hypertension, chronic atrial fibrillation, gastroesophageal reflux disease, osteoporosis and chronic right hip pain after total hip arthroplasty was admitted to our hospital for complaints of nausea and vomiting and urinary tract infection.  Over the course of her hospitalization, the patient was started on antibiotic regimen and proton pump inhibitors for an episode of coffee-ground emesis.  The patient was managed conservatively and was also provided with physical therapy for chronic right hip pain.,At the time of discharge, the patient continues to complain of right hip pain impairing ability to walk.  The patient denies any chest pain, nausea, vomiting, fever, chills, shortness of breath, abdominal pain or any urine or bowel problems.,PAST MEDICAL HISTORY: , Can be referred to the H&P dictated in the chart.,PAST SURGICAL HISTORY: , Can be referred to the H&P dictated in the chart.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  At the time of discharge temperature 36.6 degree Celsius, pulse rate of 77 per minute, respiratory rate 20 per minute, blood pressure 115/63, and oxygen saturation of 94% on room air.,GENERAL:  The patient is a thin built Caucasian female with no pallor, cyanosis or icterus.  She is alert and oriented x3.,HEENT:  No carotid bruits, JVD, lymphadenopathy or thyromegaly.  Pupils are equally reactive to light and accommodation.,BACK AND EXTREMITY:  Bilateral pitting edema and peripheral pulses are palpable.  The patient has right hip brace/immobilizer.,HEART:  Irregularly irregular heart rhythm, grade 2-3/6 systolic ejection murmur best heard over the aortic area and normal S1 and S2.,CHEST:  Auscultation revealed bibasilar crackles.,ABDOMEN:  Soft, nontender, no organomegaly and bowel sounds are present.,CNS:  Nonfocal.,LABORATORY STUDIES: , WBC 6.5, hemoglobin 12.5, hematocrit 38.9, platelet count 177,000, INR 1.2, sodium 141, potassium 3.6 and serum creatinine of 0.8.  Liver function tests were normal.  The patient's troponin was elevated at 0.05 at the time or presentation, but it trended down to 0.04 on the third set.  Urinalysis revealed trace protein, trace blood, and 10-20 WBCs.  Blood culture showed no growth till date.  Urine culture grew 50-100,000 colonies of Enterococcus susceptible to ampicillin and nitrofurantoin.,Chest x-ray showed enlarged heart with large intrathoracic hiatal hernia.  Lung parenchyma was otherwise clear.,Right hip x-ray showed that the prosthesis was in satisfactory position.  There was small gap between the cancellous bone and the long stem femoral component of the prosthesis, which is within normal limits.,DISCHARGE MEDICATIONS:,1.  Aspirin 81 mg orally once daily.,2.  Calcium with vitamin D two tablets orally once daily.,3.  Nexium 40 mg orally once daily.,4.  Multivitamins with minerals one capsule once daily.,5.  Zoloft 25 mg orally once daily.,6.  Norco 325/10 mg every 6-8 hours as needed for pain.,7.  Systane ophthalmic solution two drops in both eyes every two hours as needed.,8.  Herbal __________ by mouth everyday.,9.  Macrodantin 100 mg orally every six hours for seven days.,ALLERGIES:,  Penicillin.,PROGNOSIS: , Improved.,ASSESSMENT AND DISCHARGE PLAN:  ,The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.,PROBLEM #1:
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DESCRIPTION: The patient is a 93-year-old Caucasian female with a past medical history of chronic right hip pain, osteoporosis, hypertension, depression, and chronic atrial fibrillation admitted for evaluation and management of severe nausea and vomiting and urinary tract infection.

The situation involves a 93-year-old female with multiple health issues including a urinary tract infection, gastrointestinal problems, and osteoarthritic pain, alongside chronic conditions like atrial fibrillation and hypertension. While her case requires careful management due to her age and multiple diagnoses, this document is a discharge summary indicating she has been stabilized enough for discharge. The stakes involve ensuring appropriate follow-up care and management of chronic conditions, which are important but not critical compared to a life-threatening emergency. Her condition is improved, and there are no immediate signs of life-threatening issues listed upon discharge.


Medical Specialty: Surgery
Sample Name: Tubal Ligation - Postpartum

PREOPERATIVE DIAGNOSES:,  Multiparity requested sterilization and upper abdominal wall skin mass., ,POSTOPERATIVE DIAGNOSES:  ,Multiparity requested sterilization and upper abdominal wall skin mass.,OPERATION PERFORMED: , Postpartum tubal ligation and removal of upper abdominal skin wall mass.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,DRAINS: , None.,ANESTHESIA: , Spinal.,INDICATION: , This is a 35-year-old white female gravida 6, para 3, 0-3-3 who is status post delivery on 09/18/2007.  The patient was requesting postpartum tubal ligation and removal of a large mole at the junction of her abdomen and left lower rib cage at the skin level.,PROCEDURE IN DETAIL:,  The patient was taken to the operating room, placed in a seated position with spinal form of anesthesia administered by anesthesia department.  The patient was then repositioned in a supine position and then prepped and draped in the usual fashion for postpartum tubal ligation.  Subumbilical ridge was created using two Ellis and first knife was used to make a transverse incision.  The Ellis were removed and used to be grasped incisional edges and both blunt and sharp dissection down to the level of the fascia was then completed.  The fascia grasped with two Kocher's and then sharply incised and then peritoneum was entered with use of blunt dissection.  Two Army-Navy retractors were put in place and a vein retractor was used to grasp the left fallopian tube and then regrasped with Babcock's and followed to the fimbriated end.  A modified Pomeroy technique was completed with double tying of with 0 chromic, then upper portion was sharply incised and the cut fallopian tube edges were then cauterized.  Adequate hemostasis was noted.  This tube was placed back in its anatomic position.  The right fallopian tube was grasped followed to its fimbriated end and then regrasped with a Babcock and a modified Pomeroy technique was also completed on the right side, and upper portion was then sharply incised and the cut edges re-cauterized with adequate hemostasis and this was placed back in its anatomic position.  The peritoneum as well as fascia was reapproximated with 0-Vicryl.  The subcutaneous tissues reapproximated with 3-0 Vicryl and skin edges reapproximated with 4-0 Vicryl as well in a subcuticular stitch.  Pressure dressings were applied.  Marcaine 10 mL was used prior to making an incision.  Sterile dressing was applied.  The large mole-like lesion was grasped with Allis.  It was approximately 1 cm x 0.5 cm in size and an elliptical incision was made around the mass and cut edges were cauterized and 4-0 Vicryl was used to reapproximate the skin edges and pressure dressing was also applied.  Instrument count, needle count, and sponge counts were all correct, and the patient was taken to recovery room in stable condition.
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DESCRIPTION: Postpartum tubal ligation and removal of upper abdominal skin wall mass.

surgery, sterilization, fallopian tube, tubal ligation, postpartum

The situation described involves a surgical procedure post-childbirth, specifically a postpartum tubal ligation and removal of a skin mass. While this is a routine procedure with a low estimated blood loss and no drains, any surgery involves inherent risks, including those related to anesthesia and potential complications. However, given the low blood loss, stable post-operative condition, and the routine nature of the procedure, the stakes are relatively low. This is especially true since the patient is stable and there is no indication of immediate danger or complex medical conditions. Therefore, while important to perform correctly, this situation does not involve extremely high stakes compared to emergency or highly complex surgeries.


Medical Specialty: Dermatology
Sample Name: Excision - Actinic Neoplasm

PREOPERATIVE DIAGNOSES:,1.  Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2.  Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3.  A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4.  A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5.  A 1 cm x 1 cm actinic keratosis of the right mid cheek.,POSTOPERATIVE DIAGNOSES:,1.  Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2.  Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3.  A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4.  A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5.  A 1 cm x 1 cm actinic keratosis of the right mid cheek.,TITLE OF PROCEDURES:,1.  Excision of the left upper cheek actinic neoplasm defect measuring 1.5 cm x 1.8 cm with two-layer plastic closure.,2.  Excision of the left lower cheek upper neck, 1 cm x 1.5 cm skin neoplasm with two-layer plastic closure.,3.  Shave excision of the mid neck seborrheic keratosis that measured 1 cm x 1.5 cm.,4.  Shave excision of the right superior pinna auricular rim, 1 cm x 1.5 cm verrucous keratotic neoplasm.,5.  A 50% trichloroacetic acid treatment of the right mid cheek, 1 cm x 1 cm actinic neoplasm.,ANESTHESIA: , Local.  I used a total of 6 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS:,  Less than 30 mL.,COMPLICATIONS: , None.,COUNTS:  ,Sponge and needle counts were all correct.,PROCEDURE:,  The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  She is aware of risks include but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures, etc.  The areas of concern were marked with the marking pen.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,I began excising the left upper cheek and left lower cheek neck lesions as listed above.  These were excised with the #15 blade.  The left upper cheek lesion measures 1 cm x 1.5 cm, defect after excision is 1.5 cm x 1.8 cm.  A suture was placed at the 12 o'clock superior margin.  Clinically, this appears to be either actinic keratosis or possible basal cell carcinoma.  The healthy margin of healthy tissue around this lesion was removed.  Wide underminings were performed and the lesion was closed in a two-layered fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,The left upper neck lesion was also removed in the similar manner.  This is dark and black, appears to be either an intradermal nevus or pigmented seborrheic keratosis.  It was excised using a #15 blade down the subcutaneous tissue with the defect 1 cm x 1.5 cm.  After wide underminings were performed, a two-layer plastic closure was performed with 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,The lesion of the mid neck and the auricular rim were then shave excised for the upper dermal layer with the Ellman radiofrequency wave unit.  These appeared to be clinically seborrheic keratotic neoplasms.,Finally proceeded with the right cheek lesion, which was treated with the 50% TCA.  This was also an actinic keratosis.  It is new in onset, just within the last week.  Once a light frosting was obtained from the treatment site, bacitracin ointment was applied.  Postop care instructions have been reviewed in detail.  The patient is scheduled a recheck in one week for suture removal.  We will make further recommendations at that time.
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DESCRIPTION: Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures

The excision of skin neoplasms, particularly those suspected to be actinic keratosis or potential basal cell carcinoma, is a routine yet important dermatological procedure. While these lesions can sometimes evolve into more serious conditions, the immediate risk from the excision itself is relatively low due to the local anesthesia used, minimal blood loss, and absence of complications. The procedure is not life-threatening, and the patient's condition is stable. However, the stakes are slightly elevated due to the potential for recurrence or misdiagnosis, but these are typically manageable with follow-ups and further treatment if needed.


Medical Specialty: Consult - History and Phy.
Sample Name: Essential Tremor & Torticollis

REASON FOR CONSULT: , Essential tremor and torticollis.,HISTORY OF PRESENT ILLNESS: , This is a 62-year-old right-handed now left-handed white female with tremor since 5th grade.  She remembers that the tremors started in her right hand around that time subsequently later on in early 20s she was put on propranolol for the tremor and more recently within the last 10 years she has been put on primidone and clonazepam.  She thinks that her clonazepam is helping her a lot especially with anxiety and stress, and this makes the tremor better.  She has a lot of trouble with her writing because of tremor but does not report as much problem with other activities of daily living like drinking from a cup and doing her day-to-day activity.  Since around 6 to 7 years, she has had a head tremor, which is mainly "no- no" and occasional voice tremor also.  Additionally, the patient has been diagnosed with migraine headaches without aura, which are far and few apart.  She also has some stress incontinence.  Last MRI brain was done in 2001 reportedly normal.,CURRENT MEDICATIONS:,1.  Klonopin 0.5 mg twice a day.,2.  Primidone 100 mg b.i.d.,3.  Propranolol long-acting 80 mg once in the morning.,PAST MEDICAL HISTORY: , Essential tremor, cervical dystonia, endometriosis, migraine headaches without aura, left ear sensorineural deafness, and basal cell carcinoma resection on the nose.,PAST SURGICAL HISTORY: , L5-S1 lumbar laminectomy in 1975, exploratory laparotomy in 1967, tonsillectomy and adenoidectomy, and anal fissure surgery in 1975.,FAMILY HISTORY: , Both parents have ET and hypertension.  Maternal cousin with lupus.,SOCIAL HISTORY: , Denies any smoking or alcohol.  She is married since 44 years, has 3 children.  She used to work as a labor and delivery nurse up until early 2001 when she retired.,REVIEW OF SYSTEMS: , No fever, chills, nausea or vomiting.  No visual complaints.  She complains of hearing decreased on the left.  No chest pain or shortness of breath.  No constipation.  She does give a history of urge incontinence.  No rashes.  No depressive symptoms.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Blood pressure is 131/72, pulse is 50, and weight is 71.3 kg.  HEENT:  PERRLA.  EOMI.  CARDIOVASCULAR:  S1 and S2 normal.  Regular rate and rhythm.  She does have a rash over the right ankle with a prior basal cell carcinoma was resected.  NEUROLOGIC:  Alert and oriented x4.  Speech shows a voice tremor occasionally.  Language is intact.  Cranial nerves II through XII intact.  Motor examination showed 5/5 power in all extremities with minimal increased tone.  Sensory examination was intact to light touch.  Reflexes were brisk bilaterally, but they were equal and both toes were downgoing.  Her coordination showed minimal intentional component to bilateral finger-to-nose.  Gait was intact.  Lot of swing on Romberg's.  The patient did have a tremor both upper extremities, right more than left.  She did have a head tremor, which was no-no variety, and she had a minimal torticollis with her head twisted to the left.,ASSESSMENT AND PLAN: , This 62-year-old white female has essential tremor and mild torticollis.  Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible.  The patient did not wish to change any of her medication doses at this point.  We will go ahead and check MRI brain, and we will get the films later.  We will see her back in 3 months.  Also, the patient declined any possible Botox for the mild torticollis she has at this point.
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DESCRIPTION: This 62-year-old white female has essential tremor and mild torticollis.  Tremor not bothersome for most activities of daily living, but she does have a great difficulty writing, which is totally illegible.

consult - history and phy., clonazepam, difficulty writing, head tremor, voice tremor, migraine headaches, mri brain, essential tremor, torticollis, carcinoma,

The situation involves a medical consultation for a patient with essential tremor and mild torticollis. Although challenging, particularly with writing, her condition isn't life-threatening and doesn't severely impact most daily activities. The consultation seeks to manage and monitor her condition, not address an acute or critical health crisis.


Medical Specialty: Surgery
Sample Name: Nerve & Tendon Repair - Finger

PREOPERATIVE DIAGNOSIS:,  Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2.  25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.,PROCEDURE PERFORMED:,1.  Repair of nerve and tendon, right ring finger.,2.  Exploration of digital laceration.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,TOTAL TOURNIQUET TIME:  ,57 minutes.,COMPLICATIONS: , None.,DISPOSITION:  ,To PACU in stable condition.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.,GROSS OPERATIVE FINDINGS: , After wound exploration, it was found there was a 100% laceration to the ulnar digital neurovascular bundle.  The FDS had a partial ulnar slip laceration and the FDP had a 25% transverse laceration as well.  The radial neurovascular bundle was found to be completely intact.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room and placed in the supine position.  All bony prominences were adequately padded.  Tourniquet was placed on the right upper extremity after being packed with Webril, but not inflated at this time.  The right upper extremity was prepped and draped in the usual sterile fashion.  The hand was inspected.  Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx, which was approximated with nylon suture.  The sutures were removed and the wound was explored.  It was found that the ulnar digital neurovascular bundle was 100% transected.  The radial neurovascular bundle on the right ring finger was found to be completely intact.  We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25% laceration in a transverse fashion to the FDP.  We copiously irrigated the wound.  Repair was undertaken of the FDS with #3-0 undyed Ethibond suture.  The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact.  Attention during our repair at the flexor tendon, the A1 pulley was incised for better visualization as well as better tendon excursion after repair.  Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury.  The digital nerve was dissected proximally and distally to likely visualize the nerve.  The nerve was then approximated using microvascular technique with #8-0 nylon suture.  The hands were well approximated.  The nerve was not under undue tension.  The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture.  Sterile dressing was placed and a dorsal extension Box splint was placed.  The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition.  Overall prognosis is good.
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DESCRIPTION: Repair of nerve and tendon, right ring finger and exploration of digital laceration.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.

surgery, laceration, flexor tendon, volar laceration, digital laceration, ulnar slip, flexor digitorum, neurovascular bundle, nerve, injury, ring, finger, neurovascular, fds, bundle, tendon, repair, flexor, digital, ulnar,

The procedure described involves surgical repair of nerve and tendon injuries in the finger, which is a delicate operation due to the complexity of nerve and tendon anatomy. The stakes are moderate because while the procedure is performed under general anesthesia and requires precise surgical technique to ensure functional recovery, the patient was transferred in stable condition with a good prognosis and no reported complications. Additionally, the estimated blood loss was minimal, and nerves and tendons in the fingers, though crucial for function, are not typically life-threatening injuries. Therefore, the stakes relate more to the potential for impacting finger function and dexterity rather than being immediately life-threatening.


Medical Specialty: Surgery
Sample Name: Pleurodesis

PREOPERATIVE DIAGNOSIS:,  Large recurrent right pleural effusion.,POSTOPERATIVE DIAGNOSIS:,  Large recurrent right pleural effusion.,PROCEDURE:,1.  Conscious sedation.,2.  Chest tube talc pleurodesis of the right chest.,INDICATIONS: , The patient is a 65-year-old lady with a history of cirrhosis who has developed a recurrent large right pleural effusion.  Chest catheter had been placed previously, and she had been draining up to 1.5 liters of serous fluid a day.  Eventually, this has decreased and a talc pleurodesis is being done to see her pleural effusion does not recur.,SPECIMENS:,  None.,ESTIMATED BLOOD LOSS: , Zero.,NARRATIVE:,  After obtaining informed consent from the patient and her daughter, the patient was assessed and found to be in good condition and a good candidate for conscious sedation.  Vital signs were taken.  These were stable, so the patient was then given initially 0.5 mg of Versed and 2 mg of morphine IV.  After a couple of minutes, she was assessed and found to be awake but calm, so then the chest tube was clamped and then through the chest tube a solution of 120 mL of normal saline containing 5 g of talc and 40 mg of lidocaine were then put into her right chest taking care that no air would go in to create a pneumothorax.  She was then laid on her left lateral decubitus position for 5 minutes and then turned into the right lateral decubitus position for 5 minutes and then the chest tube was unclamped.  The patient was given additional 0.5 mg of Versed and 0.5 mg of Dilaudid IV achieving a state where the patient was comfortable but readily responsive.  The patient tolerated the procedure well.  She did complain of up to a 7/10 pain, but quickly this was brought under control.  The chest tube was unclamped.  Now, the patient will be left to rest and she will get a chest x-ray in the morning.
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DESCRIPTION: Chest tube talc pleurodesis of the right chest.

surgery, chest tube talc pleurodesis, lateral decubitus position, decubitus position, talc pleurodesis, pleural effusion, chest tube, chest, pleurodesis, talc, recurrent, pleural, effusion, tube

The situation involves a surgical procedure - pleurodesis, which is performed to prevent recurrent pleural effusion, commonly associated with conditions like cirrhosis in this patient. While it is not as high-risk as open surgery, it still involves potential complications such as infection, respiratory issues, or reaction to sedation. The patient also experienced significant pain during the procedure, indicating the potential for discomfort and complications. Therefore, this is a moderately high-stakes situation given the patient's underlying conditions and the procedure risks.


Medical Specialty: Podiatry
Sample Name: I&D & Foreign Body Removal

PREOPERATIVE DIAGNOSIS:,  Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Incision and drainage, right foot.,2.  Removal of foreign body, right foot.,HISTORY: , This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.,PROCEDURE:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on the operating table in a supine position with a safety strap across his lap.  General anesthesia was administered by the Department of Anesthesia.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The stockinette was reflected and the foot was cleansed with wet and dry sponge.  There was noted to be some remaining periwound erythema.  There was noted to be some mild crepitation about 2 cm proximal from the entry wound.  The entry wound was noted to be over the third metatarsal head dorsally.  Upon inspection of the wound, there was noted to be hard foreign filling substance deep within the wound.  The entry site from the foreign body was extended proximally approximately about 0.5 cm.  At this time, a large wooden foreign body was visualized and removed with a straight stat.,The area was carefully inspected for any remaining piece of foreign body.  Several small pieces were noted and they were removed.  The area was palpated and there was no more remaining foreign body noted.  At this time, the wound was inspected thoroughly.  There was noted to be an area along the third metatarsal head more distally that did probe to the bone.  There was no purulent drainage expressed.  Area was flushed with copious amounts of sterile saline.  Pulse lavage was performed with 3 liters of plain sterile saline.  Wound cultures were obtained, aerobic and aerobic.  The wound was then again inspected for any remaining foreign body or purulent drainage.  None was noticed.  The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s, ABDs, Kling, and Kerlix.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to the PACU with vital signs stable and vascular status intact.  The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry.  The patient had a postoperative pain prescription written for Tylenol, Elixir with codeine as needed.
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DESCRIPTION: Incision and drainage and removal of foreign body, right foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.

podiatry, incision and drainage, removal of foreign body, purulent drainage, foreign body, metatarsal head, orthopedic, metatarsal, i&d, incision, drainage, foot

The situation involves a 7-year-old undergoing a surgical procedure under general anesthesia to remove a foreign body from his foot. As it includes surgery, there are inherent risks such as infection, reaction to anesthesia, and potential complications. Additionally, the child had previous I&D but continued to have purulent drainage, indicating an ongoing issue that required surgical intervention. However, this type of procedure is relatively common and has a high success rate. The stakes are significant because there is a child's well-being involved and it is important to resolve the issue to prevent further complications, but it is not an emergency situation nor is it life-threatening if managed properly.


Medical Specialty: Discharge Summary
Sample Name: Discharge Summary - Gastric Bypass

ADMISSION DIAGNOSIS:,  Morbid obesity.  BMI is 51.,DISCHARGE DIAGNOSIS: , Morbid obesity.  BMI is 51.,PROCEDURE: , Laparoscopic gastric bypass.,SERVICE: , Surgery.,CONSULT: , Anesthesia and pain.,HISTORY OF PRESENT ILLNESS: , Ms. A is a 27-year-old woman, who suffered from morbid obesity for many years.  She has made multiple attempts at nonsurgical weight loss without success.  She underwent a preoperative workup and clearance for gastric bypass and was found to be an appropriate candidate.  She underwent her procedure.,HOSPITAL COURSE: , Ms. A underwent her procedure.  She tolerated without difficulty.  She was admitted to the floor post procedure.  Her postoperative course has been unremarkable.  On postoperative day 1, she was hemodynamically stable, afebrile, normal labs, and she was started on a clear liquid diet, which she has tolerated without difficulty.  She has ambulated and had no complaints.  Today, on postoperative day 2, the patient continues to do well.  Pain controlled with p.o. pain medicine, ambulating without difficulty, tolerating a liquid diet.  At this point, it is felt that she is stable for discharge.  Her drain was discontinued.,DISCHARGE INSTRUCTIONS:,  Liquid diet x1 week, then advance to pureed and soft as tolerated.  No heavy lifting, greater than 10 pounds x4 weeks.  The patient is instructed to not engage in any strenuous activity, but maintain mobility.  No driving for 1 to 2 weeks.  She must be able to stop in an emergency and be off narcotic pain medicine.  She may shower.  She needs to keep her wounds clean and dry.  She needs to follow up in my office in 1 week for postoperative evaluation.  She is instructed to call for any problems of shortness of breath, chest pain, calf pain, temperature greater than 101.5, any redness, swelling, or foul smelling drainage from her wounds, intractable nausea, vomiting, and abdominal pain.  She is instructed just to resume her discharge medications.,DISCHARGE MEDICATIONS:,  She was given a scripts for Lortab Elixir, Flexeril, ursodiol, and Colace.
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DESCRIPTION: Patient suffered from morbid obesity for many years and made multiple attempts at nonsurgical weight loss without success.

discharge summary, laparoscopic gastric bypass, gastric bypass, morbid obesity, liquid diet, bmi, discharge,

The discharge summary describes a patient who underwent a routine laparoscopic gastric bypass surgery due to morbid obesity. The procedure and postoperative course were uneventful, and the patient is stable at discharge. The discharge instructions are standard with no indication of complications or heightened risk. While there are important follow-up steps and potential complications to be aware of (common for surgical procedures), the present situation does not involve an immediate high-stakes critical medical decision. It's a typical routine post-surgery recovery situation, though it requires adherence to instructions for the patient's health and safety.


Medical Specialty: Surgery
Sample Name: Scleral Buckle Opening

SCLERAL BUCKLE OPENING,The patient was brought to the operating room and appropriately identified.  General anesthesia was induced by the anesthesiologist.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.  A 360-degree limbal conjunctival peritomy was created with Westcott scissors.  Curved tenotomy scissors were used to enter each of the intermuscular quadrants.  The inferior rectus muscle was isolated with a muscle hook, freed of its Tenon's attachment and tied with a 2-0 silk suture.  The 3 other rectus muscles were isolated in a similar fashion.  The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.
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DESCRIPTION: Scleral buckle opening.  The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.

surgery, tenotomy, scleral quadrants, scleral thinning, scleral buckle, staphylomaNOTE,: 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 scleral buckle opening is a surgical procedure related to retinal detachment, typically seen within ophthalmology. While it does require expertise and precision due to the proximity to vital structures like the retina, it is not considered among the riskiest surgeries. It's a well-established procedure with standard protocols aimed at reattaching the retina. General anesthesia is used, indicating some level of complexity and risk, but it's controlled and routine for surgeons specialized in this area. The stakes involved aren't life-threatening directly but could affect vision significantly, which is serious.


Medical Specialty: Lab Medicine - Pathology
Sample Name: Lung adenocarcinoma Path Report

CLINICAL HISTORY:  ,Probable right upper lobe lung adenocarcinoma.,SPECIMEN: , Lung, right upper lobe resection.,GROSS DESCRIPTION:,  Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung".  It consists of one lobectomy specimen measuring 16.1 x 10.6 x,4.5.cm.  The specimen is covered by a smooth, pink-tan and gray pleural surface which is largely unremarkable.  Sectioning reveals a round, ill-defined, firm, tan-gray mucoid mass.  This mass measures 3.6 x 3.3 x 2.7 cm and is located 3.7 cm from the closest surgical margin and 3.9 cm from the hilum.  There is no necrosis or hemorrhage evident.  The tumor grossly appears to abut, but not invade through, the visceral pleura, and the overlying pleura is puckered.,FINAL DIAGNOSIS:,  Right lung, upper lobe, lobectomy:  Bronchioloalveolar carcinoma, mucinous type,COMMENT:,  Right upper lobe, lobectomy.,Tumor type:  Bronchioloalveolar carcinoma, mucinous type.,Histologic grade:  Well differentiated.,Tumor size (greatest diameter):  3.6 cm.,Blood/lymphatic vessel invasion:  Absent.,Perineural invasion:  Absent.,Bronchial margin:  Negative.,Vascular margin:  Negative.,Inked surgical margin:  Negative.,Visceral pleura:  Not involved.,In situ carcinoma:  Absent.,Non-neoplastic lung:  Emphysema.,Hilar lymph nodes:  Number of positive lymph nodes:  0; Total number of lymph nodes:  1.,P53 immunohistochemical stain is negative in the tumor.
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DESCRIPTION: Probable right upper lobe lung adenocarcinoma.  Specimen is received fresh for frozen section, labeled with the patient's identification and "Right upper lobe lung".

lab medicine - pathology, bronchioloalveolar carcinoma, mucinous, mucoid mass, lymph nodes, upper lobe, visceral, bronchioloalveolar, carcinoma, lymph, pleural, margin, tumor, adenocarcinoma, specimen, lobe, lung,

The described pathology report is for lung adenocarcinoma, which is a serious medical condition. The stakes are elevated due to the potential implications on the patient's health, need for treatment decisions, and potential impact on prognosis. However, because the tumor is described as well differentiated with no lymph node involvement and negative surgical margins, the situation might have a more favorable outcome. This combination of factors places it moderately high on the stakes spectrum as it requires careful diagnosis and follow-up medical action.


Medical Specialty: Consult - History and Phy.
Sample Name: Dietary Consult - Hyperlipidemia

SUBJECTIVE:,  This is a followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome.  The patient reports that she has worked hard for a number of weeks following the meal plan prescribed, but felt like she was gaining weight and not losing weight on it.  She is not sure that she was following it accurately.  She is trying to walk 1-1/2 to 2 miles every other day, but is increasing her time in the garden and doing other yard work as well.  Once she started experiencing some weight gain, she went back to her old South Beach Diet and felt like she was able to take some of that weight off.  However she realizes that the South Beach Diet is not a healthy diet for her and so is coming back for better instruction on safe weight loss and low-fat eating.,OBJECTIVE:,  Weight is 275 pounds.  Food records were reviewed.,ASSESSMENT:,  The patient experienced a weight gain of 2 pounds since our last consultation which was two months ago.  I did carefully review her food records and evaluated calories consumed.  While she was carefully tracking the volume of protein and carbohydrates, she was getting some excess calories from the fatty proteins selected.  Thus we rearranged her meal plan a little bit and talked about how to track her fat calories as well.  She was more open to reducing the amount of protein from the previous meal plan and increasing slightly the amount of carbohydrates.  While this still is not as much carbohydrate as I would normally recommend, I am certainly willing to work with her on how she feels her body best handles weight reduction.  We also discussed a snack that could be eliminated in the morning because she really is not hungry at that time.,PLAN:,  A new 1500 calorie meal plan was developed based on 35% of the calories coming from protein, 40% of the calories from carbohydrate, and 25% of the calories from fat.  This translates in to 10 servings at 15 grams a piece of carbohydrates throughout the day dividing them in to groups of two servings per meal and per snack.  This also translates in to 2 ounces of protein at breakfast, 6 ounces at lunch, 2 ounces in the afternoon snack, 6 ounces at supper, and 2 ounces in the evening snack.  We have eliminated the morning snack.  The patient will now track the grams of fat in her meats as well as added fats.  Her goal for total fats over the course of the day is no more than 42 grams of fat per day.  This was a half hour consultation.  We will plan to see the patient back in one month for support.
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DESCRIPTION: Followup dietary consultation for hyperlipidemia, hypertension, and possible metabolic syndrome

consult - history and phy., hyperlipidemia, hypertension, metabolic syndrome, meal, food records, south beach diet, dietary consultation, meal plan, carbohydrates, snack, dietary, calories, weight

The situation involves a dietary consultation for managing hyperlipidemia, hypertension, and possible metabolic syndrome through dietary changes. While these conditions can have serious health implications if not managed properly, the consultation itself does not appear to be an emergency or in response to a critical health event. The patient is actively seeking guidance and has shown initiative in following prescribed plans and making changes. Although managing these conditions is important for long-term health, this particular consultation is focused on planning and adjustment rather than immediate, high-stakes action.


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

Medical Specialty: Hematology - Oncology
Sample Name: T-Cell Lymphoma Consult

CHIEF COMPLAINT: , Newly diagnosed T-cell lymphoma.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 40-year-old gentleman who reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago.  He was originally treated with antibiotics as a possible tooth abscess.  Prior to this event, in March of 2010, he was treated for strep throat.  The pain at that time was on the right side.  About a month ago, he started having night sweats.  The patient reports feeling hot, when he went to bed he fall asleep and would wake up soaked.  All these symptoms were preceded by overwhelming fatigue and exhaustion.  He reports being under significant amount of stress as he and his mom just recently moved from their house to a mobile home.  With the fatigue, he has had some mild chest pain and shortness of breath, and has also noted a decrease in his appetite, although he reports his weight has been stable.  He also reports occasional headaches with some stabbing and pain in his feet and legs.  He also complains of some left groin pain.,PAST MEDICAL HISTORY: , Significant for HIV diagnosed in 2000.  He also had mononucleosis at that time.  The patient reports being on anti-hepatitis viral therapy period that was very intense.  He took the meds for about six months, he reports stopping, and prior to 2002 at one point during his treatment, he was profoundly weak and found to have hemoglobin less than 4 and required three units of packed red blood cells.  He reports no other history of transfusions.  He has history of spontaneous pneumothorax.  The first episode was 1989 on his right lung.  In 1990 he had a slow collapse of the left lung.  He reports no other history of pneumothoraces.  In 2003, he had shingles.  He went through antiviral treatment at that time and he also reports another small outbreak in 2009 that he treated with topical therapy.,FAMILY HISTORY: , Notable for his mother who is currently battling non-small cell lung cancer.  She is a nonsmoker.  His sister is Epstein-Barr virus positive.  The patient's mother also reports that she is Epstein-Barr virus positive.  His maternal grandfather died from complications from melanoma.  His mother also has diabetes.,SOCIAL HISTORY: , The patient is single.  He currently lives with his mother in house for several both in New York and here in Colorado.  His mother moved out to Colorado eight years ago and he has been out here for seven years.  He currently is self employed and does antiquing.  He has also worked as nurses' aide and worked in group home for the state of New York for the developmentally delayed.  He is homosexual, currently not sexually active.  He does have smoking history as about a thirteen and a half pack year history of smoking, currently smoking about a quarter of a pack per day.  He does not use alcohol or illicit drugs.,REVIEW OF SYSTEMS: , As mentioned above his weight has been fairly stable.  Although, he suffered from obesity as a young teenager, but through a period of anorexia, but his weight has been stable now for about 20 years.  He has had night sweats, chest pain, and is also suffering from some depression as well as overwhelming fatigue, stabbing, short-lived headaches and occasional shortness of breath.  He has noted some stool irregularity with occasional loose stools and new onset of pain predominantly in left neck.  He has had fevers as well.  The rest of his review of systems is negative.,PHYSICAL EXAM:,VITALS:
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DESCRIPTION: Newly diagnosed T-cell lymphoma.  The patient reports swelling in his left submandibular region that occurred all of a sudden about a month and a half ago.

hematology - oncology, t-cell lymphoma, submandibular, tooth abscess, strep throat, submandibular region, lymphoma, neck,

This is a high-stakes situation because the patient has been newly diagnosed with T-cell lymphoma, a type of cancer that requires careful management and treatment. The patient's history of HIV, previous health complications, and family history of cancer add complexity to his current health status, indicating that immediate and thorough medical attention is crucial to determine the best course of action for treatment. Additionally, the presence of symptoms such as night sweats, fatigue, and reduced appetite as well as past serious medical issues increases the urgency and risks involved.


Medical Specialty: Surgery
Sample Name: AV Fistula - 5

PREOPERATIVE DIAGNOSES,1.  End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2.  Ischemic cardiomyopathy, ejection fraction 20%.,POSTOPERATIVE DIAGNOSES,1.  End-stage renal disease, hypertension, diabetes, need for chronic arteriovenous access.,2.  Ischemic cardiomyopathy, ejection fraction 20%.,OPERATION,Left forearm arteriovenous fistula between cephalic vein and radial artery.,INDICATION FOR SURGERY,This is a patient referred by Dr. Michael Campbell.  He is a 44-year-old African-American, who has end-stage renal disease and also ischemic cardiomyopathy.  This morning, he received coronary angiogram by Dr. A, which was reportedly normal, after which, he was brought to the operating room for an AV fistula.  All the advantages, disadvantages, risks, and benefits of the procedure were explained to him for which he had consented.,ANESTHESIA,Monitored anesthesia care.,DESCRIPTION OF PROCEDURE,The patient was identified, brought to the operating room, placed supine, and IV sedation given.  This was done under monitored anesthesia care.  He was prepped and draped in the usual sterile fashion.  He received local infiltration of 0.25% Marcaine with epinephrine in the region of the proposed incision.,Incision was about 2.5 cm long between the cephalic vein and the distal part of the forearm and the radial artery.  Incision was deepened down through the subcutaneous fascia.  The vein was identified, dissected for a good length, and then the artery was identified and dissected.  Heparin 5000 units was given.  The artery clamped proximally and distally, opened up in the middle.  It was found to have Monckeberg's arteriosclerosis of a moderate intensity.  The vein was of good caliber and size.,The vein was clipped distally, fashioned to size and shape, and arteriotomy created in the distal radial artery and end-to-side anastomosis was performed using 7-0 Prolene and bled prior to tying it down.  Thrill was immediately felt and heard.,The incision was closed in two layers and sterile dressing applied.
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DESCRIPTION: Left forearm arteriovenous fistula between cephalic vein and radial artery.

surgery, end-stage renal disease, av fistula, marcaine with epinephrine, monckeberg's, monitored anesthesia care, angiogram, arteriosclerosis, arteriovenous fistula, cephalic vein, ischemic cardiomyopathy, radial artery, subcutaneous fascia, arteriovenous, forearm, ischemic

The situation involves the surgical creation of an arteriovenous fistula (AV fistula) in a patient with end-stage renal disease, a condition requiring regular dialysis. The patient also has ischemic cardiomyopathy with a low ejection fraction, which increases surgical risk and complexity. This procedure is high-stakes because it significantly impacts the patient's ability to receive dialysis, which is life-sustaining. Additionally, the patient's cardiovascular condition adds to the surgical risk, making thorough planning and execution critical.


Medical Specialty: Hematology - Oncology
Sample Name: Anemia - Consult

DIAGNOSIS:,  Refractory anemia that is transfusion dependent.,CHIEF COMPLAINT: , I needed a blood transfusion.,HISTORY: , The patient is a 78-year-old gentleman with no substantial past medical history except for diabetes.  He denies any comorbid complications of the diabetes including kidney disease, heart disease, stroke, vision loss, or neuropathy.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.  He reports that he has no signs or symptom of bleeding and had a blood transfusion approximately two months ago and actually several weeks before that blood transfusion, he had a transfusion for anemia.  He has been placed on B12, oral iron, and Procrit.  At this time, we are asked to evaluate him for further causes and treatment for his anemia.  He denies any constitutional complaints except for fatigue, malaise, and some dyspnea.  He has no adenopathy that he reports.  No fevers, night sweats, bone pain, rash, arthralgias, or myalgias.,PAST MEDICAL HISTORY:  ,Diabetes.,PAST SURGICAL HISTORY:,  Hernia repair.,ALLERGIES: , He has no allergies.,MEDICATIONS: , Listed in the chart and include Coumadin, Lasix, metformin, folic acid, diltiazem, B12, Prevacid, and Feosol.,SOCIAL HISTORY: , He is a tobacco user.  He does not drink.  He lives alone, but has family and social support to look on him.,FAMILY HISTORY:,  Negative for blood or cancer disorders according to the patient.,PHYSICAL EXAMINATION:,GENERAL:  He is an elderly gentleman in no acute distress.  He is sitting up in bed eating his breakfast.  He is alert and oriented and answering questions appropriately.,VITAL SIGNS:  Blood pressure of 110/60, pulse of 99, respiratory rate of 14, and temperature of 97.4.  He is 69 inches tall and weighs 174 pounds.,HEENT:  Sclerae show mild arcus senilis in the right.  Left is clear.  Pupils are equally round and reactive to light.  Extraocular movements are intact.  Oropharynx is clear.,NECK:  Supple.  Trachea is midline.  No jugular venous pressure distention is noted.  No adenopathy in the cervical, supraclavicular, or axillary areas.,CHEST:  Clear.,HEART:  Regular rate and rhythm.,ABDOMEN:  Soft and nontender.  There may be some fullness in the left upper quadrant, although I do not appreciate a true spleen with inspiration.,EXTREMITIES:  No clubbing, but there is some edema, but no cyanosis.,NEUROLOGIC:  Noncontributory.,DERMATOLOGIC:  Noncontributory.,CARDIOVASCULAR:  Noncontributory.,IMPRESSION: , At this time is refractory anemia, which is transfusion dependent.  He is on B12, iron, folic acid, and Procrit.  There are no sign or symptom of blood loss and a recent esophagogastroduodenoscopy, which was negative.  His creatinine was 1.  My impression at this time is that he probably has an underlying myelodysplastic syndrome or bone marrow failure.  His creatinine on this hospitalization was up slightly to 1.6 and this may contribute to his anemia.,RECOMMENDATIONS:  ,At this time, my recommendation for the patient is that he undergoes further serologic evaluation with reticulocyte count, serum protein, and electrophoresis, LDH, B12, folate, erythropoietin level, and he should undergo a bone marrow aspiration and biopsy.  I have discussed the procedure in detail which the patient.  I have discussed the risks, benefits, and successes of that treatment and usefulness of the bone marrow and predicting his cause of refractory anemia and further therapeutic interventions, which might be beneficial to him.  He is willing to proceed with the studies I have described to him.  We will order an ultrasound of his abdomen because of the possible fullness of the spleen, and I will probably see him in follow up after this hospitalization.,As always, we greatly appreciate being able to participate in the care of your patient.  We appreciate the consultation of the patient.
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DESCRIPTION: Refractory anemia that is transfusion dependent.  At this time, he has been admitted for anemia with hemoglobin of 7.1 and requiring transfusion.

The situation involves a 78-year-old patient with refractory anemia that is transfusion-dependent, a condition that requires continuous medical attention and management. The anemia's refractoriness, along with the patient's age and existing medical condition (diabetes), makes this a high-stakes situation. Timely and precise diagnosis, possibly involving myelodysplastic syndromes or bone marrow failure, as well as subsequent management and treatment plans, are critical for the patient's quality of life and survival. While there is no immediate life-threatening emergency, the long-term implications of mismanagement or delayed diagnosis could severely impact the patient's health. Therefore, this consultation has significant importance in guiding the future care plan for the patient.


Medical Specialty: General Medicine
Sample Name: Patient with High Potassium

CHIEF COMPLAINT:, "My potassium is high",HISTORY OF PRESENT ILLNESS:, A 47-year-old Latin American man presented to the emergency room after being told to come in for a high potassium value drawn the previous day. He had gone to an outside clinic the day prior to presentation complaining of weakness and fatigue. Labs drawn there revealed a potassium of 7.0 and he was told to come here for further evaluation. At time of his assessment in the emergency room, he noted general malaise and fatigue for eight months. Over this same time period he had subjective fevers and chills, night sweats, and a twenty-pound weight loss. He described anorexia with occasional nausea and vomiting of non-bilious material along with a feeling of light-headedness that occurred shortly after standing from a sitting or lying position. He denied a productive cough but did note chronic left sided upper back pain located in the ribs that was worse with cough and better with massage. He denied orthopnea or paroxysmal nocturnal dyspnea but did become dyspneic after walking 2-3 blocks where before he had been able to jog 2-3 miles. He also noted that over the past year his left testicle had been getting progressively more swollen and painful. He had been seen for this at the onset of symptoms and given a course of antibiotics without improvement. Over the last several months there had been chronic drainage of yellowish material from this testicle. He denied trauma to this area. He denied diarrhea or constipation, changes in his urinary habits, rashes or skin changes, arthritis, arthralgias, abdominal pain, headache or visual changes.,PAST MEDICAL HISTORY:, None.,PAST SURGICAL HISTORY:, Mone.,MEDICATIONS:, Occasional acetaminophen.,ALLERGIES:, NKDA.,SOCIAL HISTORY:, He drank a 6 pack of beer per day for the past 30 years. He smoked a pack and a half of cigarettes per day for the past 35 years. He was currently unemployed but had worked as a mechanic and as a carpet layer in the past. He had been briefly incarcerated 5 years prior to admission. He denied intravenous drug use or unprotected sexual exposures.,FAMILY HISTORY:, There was a history of coronary artery disease and diabetes mellitus in the family.,PHYSICAL EXAM:,VITAL SIGNS - Temp 98.6° F, Respirations 16/minute Lying down - Blood pressure 109/70, pulse 70/minute Sitting - Blood pressure 78/65, pulse 79/minute Standing - Blood pressure 83/70, pulse 95/minute GENERAL: well developed, well nourished, no acute distress HEENT: Normocephalic, atraumatic. Sclerae anicteric. Oropharynx with hyperpigmented patches on the mucosa of the palate. No oral thrush. No lymphadenopathy. No jugular venous distension. No thyromegaly. Neck supple. LUNGS: Decreased intensity of breath sounds throughout without adventitious sounds. No dullness to percussion or changes in fremitus. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops, or rubs. Normal intensity of heart sounds. Normal peripheral pulses. ABDOMEN: Soft, non-tender, non-distended. Positive bowel sounds. No organomegaly. RECTAL: Normal sphincter tone. No masses. Normal prostate. Guaiac negative stool. GENITOURINARY: Left testicle indurated and painful to palpation with slight amount of pustular drainage expressible on anterior aspect. Right testicle normal. EXTREMITIES: Marked clubbing noted in fingers and toes. No cyanosis or edema. No rash or arthritis. LYMPHATICS: 1 x 1 cm mobile, firm, non-tender lymph node noted in left inguinal region. Otherwise no other palpable lymphadenopathy.,CHEST X-RAY:, Ill-defined reticular densities in both apices. No pleural effusions. Cardiomediastinal silhouette within normal range.,CHEST CT SCAN:, Multiple bilateral apical nodules/masses. Largest 3.2 x 1.6 cm in left apex. Several of these masses demonstrate spiculation. There is an associated 1 cm lymph node in the prevascular space as well as subcentimeter nodes in the pretracheal and subcarinal regions. There is a subcarinal node that demonstrates calcifications.,ABDOMINAL CT SCAN: ,Multiple hypodense lesions are noted throughout the liver. The right adrenal gland is full, measuring 1.0 x 2.3 cm. Otherwise the spleen, pancreas, left adrenal, and kidneys are free of gross mass. No significant lymphadenopathy or abnormal fluid collections are seen.,TESTICULAR ULTRASOUND: ,There is an enlarged irregular inhomogenous left epididymis with increased vascularity throughout the left epididymis and testis. There is a large septated hydrocele on the left. The right epididymis and testis is normal.,HOSPITAL COURSE:, The above-mentioned studies were obtained. Further laboratory tests and a diagnostic procedure were performed.
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DESCRIPTION: Patient in emergency room due to high potassium value.

general medicine, potassium is high, chest x-ray, chest ct scan, abdominal ct scan, testicular ultrasound, lymph node, ct scan, blood pressure, abdominal, multiple, subcarinal, epididymis, potassium, lymphadenopathy,

The situation described involves a patient with a critically high potassium level (7.0), which is a medical emergency due to the risk of cardiac arrhythmias and potential cardiac arrest. Additionally, the patient presents with symptoms and findings suggestive of possible underlying serious conditions, including malignancy or severe infections, given the weight loss, night sweats, clubbing, and swollen testicle with drainage. The multitude of diagnostic findings, including lung nodules, liver lesions, and testicular abnormalities, indicates the need for immediate and thorough medical evaluation. This is high-stakes due to the immediate risk to the patient's life and the complexity of his condition.


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

REASON FOR VISIT:,  The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma here for ongoing management of his disease and the visit is supervised by Dr. X.,HISTORY OF PRESENT ILLNESS: , The patient is an 11-month-old with neuroblastoma, which initially presented on the left when he was 6 weeks old and was completely resected.  It was felt to be stage 2.  It was not N-Myc amplified and had favorable Shimada histology.  In followup, he was found to have a second primary in his right adrenal gland, which was biopsied and also consistent with neuroblastoma with favorable Shimada histology.  He is now being treated with chemotherapy per protocol P9641 and not on study.  He last received chemotherapy on 05/21/07, with carboplatin, cyclophosphamide, and doxorubicin.  He received G-CSF daily after his chemotherapy due to neutropenia that delayed his second cycle.  In the interval since he was last seen, his mother reports that he had a couple of days of nasal congestion, but it is now improving.  He is not acted ill or had any fevers.  He has had somewhat diminished appetite, but it seems to be improving now.  He is peeing and pooping normally and has not had any diarrhea.  He did not have any appreciated nausea or vomiting.  He has been restarted on fluconazole due to having redeveloped thrush recently.,REVIEW OF SYSTEMS: , The following systems reviewed and negative per pathology except as noted above.  Eyes, ears, throat, cardiovascular, GI, genitourinary, musculoskeletal skin, and neurologic., PAST MEDICAL HISTORY:,  Reviewed as above and otherwise unchanged.,FAMILY HISTORY:,  Reviewed and unchanged.,SOCIAL HISTORY: , The patient's parents continued to undergo a separation and divorce.  The patient spends time with his father and his family during the first part of the week and with his mother during the second part of the week.,MEDICATIONS:  ,1.  Bactrim 32 mg by mouth twice a day on Friday, Saturday, and Sunday.,2.  G-CSF 50 mcg subcutaneously given daily in his thighs alternating with each dose.,3.  Fluconazole 37.5 mg daily.,4.  Zofran 1.5 mg every 6 hours as needed for nausea.,ALLERGIES: , No known drug allergies.,FINDINGS: , A detailed physical exam revealed a very active and intractable, well-nourished 11-month-old male with weight 10.5 kilos and height 76.8 cm.  Vital Signs:  Temperature is 35.3 degrees Celsius, pulse is 121 beats per minute, respiratory rate 32 breaths per minute, blood pressure 135/74 mmHg.  Eyes:  Conjunctivae are clear, nonicteric.  Pupils are equally round and reactive to light.  Extraocular muscle movements appear intact with no strabismus.  Ears:  TMs are clear bilaterally.  Oral Mucosa:  No thrush is appreciated.  No mucosal ulcerations or erythema.  Chest:  Port-a-Cath is nonerythematous and nontender to VP access port.  Respiratory:  Good aeration, clear to auscultation bilaterally.  Cardiovascular:  Regular rate, normal S1 and S2, no murmurs appreciated.  Abdomen is soft, nontender, and no organomegaly, unable to appreciate a right-sided abdominal mass or any other masses.  Skin:  No rashes.  Neurologic:  The patient walks without assistance, frequently falls on his bottom.,LABORATORY STUDIES: , CBC and comprehensive metabolic panel were obtained and they are significant for AST 51, white blood cell count 11,440, hemoglobin 10.9, and platelets 202,000 with ANC 2974.  Medical tests none.  Radiologic studies are none.,ASSESSMENT: , This patient's disease is life threatening, currently causing moderately severe side effects.,PROBLEMS DIAGNOSES:  ,1.  Neuroblastoma of the right adrenal gland with favorable Shimada histology.,2.  History of stage 2 left adrenal neuroblastoma, status post gross total resection.,3.  Immunosuppression.,4.  Mucosal candidiasis.,5.  Resolving neutropenia.,PROCEDURES AND IMMUNIZATIONS:,  None.,PLANS:  ,1.  Neuroblastoma.  The patient will return to the Pediatric Oncology Clinic on 06/13/07 to 06/15/07 for his third cycle of chemotherapy.  I will plan for restaging with CT of the abdomen prior to the cycle.,2.  Immunosuppression.  The patient will continue on his Bactrim twice a day on Thursday, Friday, and Saturday.  Additionally, we will tentatively plan to have him continue fluconazole since this is his second episode of thrush.,3.  Mucosal candidiasis.  We will continue fluconazole for thrush.  I am pleased that the clinical evidence of disease appears to have resolved.  For resolving neutropenia, I advised Gregory's mother about it is okay to discontinue the G-CSF at this time.  We will plan for him to resume G-CSF after his next chemotherapy and prescription has been sent to the patient's pharmacy.,PEDIATRIC ONCOLOGY ATTENDING: , I have reviewed the history of the patient.  This is an 11-month-old with neuroblastoma who received chemotherapy with carboplatin, cyclophosphamide, and doxorubicin on 05/21/07 for cycle 2 of POG-9641 due to his prior history of neutropenia, he has been on G-CSF.  His ANC is nicely recovered.  He will have a restaging CT prior to his next cycle of chemotherapy and then return for cycle 3 chemotherapy on 06/13/07 to 06/15/07.  He continues on fluconazole for recent history of thrush.  Plans are otherwise documented above.
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DESCRIPTION: The patient is an 11-month-old with a diagnosis of stage 2 neuroblastoma of the right adrenal gland with favorable Shimada histology and history of stage 2 left adrenal neuroblastoma, status post gross total resection.

This case involves an 11-month-old with stage 2 neuroblastoma, which is a serious and potentially life-threatening condition. The patient is currently undergoing chemotherapy, which inherently involves potential complications such as immunosuppression, mucosal candidiasis, and neutropenia. Although the condition appears to be managed well and is under regular observation, the stakes remain high due to the risk factors and the young age of the patient.


Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 2

PREOPERATIVE DIAGNOSES:,  Prior history of anemia, abdominal bloating.,POSTOPERATIVE DIAGNOSIS:,  External hemorrhoids, otherwise unremarkable colonoscopy.,PREMEDICATIONS:,  Versed 5 mg, Demerol 50 mg IV.,REPORT OF PROCEDURE:,  Digital rectal exam revealed external hemorrhoids.  The colonoscope was inserted into the rectal ampulla and advanced to the cecum.  The position of the scope within the cecum was verified by identification of the appendiceal orifice.  The cecum, the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen.  So the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Normal colonoscopy.,2.  External hemorrhoids.
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DESCRIPTION: Colonoscopy in a patient with prior history of anemia and abdominal bloating.

gastroenterology, colonoscopy, digital rectal exam, abdominal, anemia, ascending colon, bloating, cecum, colonoscope, descending colon, hemorrhoids, hepatic flexure, rectal ampulla, rectum, splenic flexure, transverse colon, external hemorrhoids, scope,

The situation involves a colonoscopy to investigate issues such as anemia and abdominal bloating, resulting in a diagnosis of external hemorrhoids and otherwise normal findings. While this medical procedure can be important for diagnosing or ruling out more serious conditions, the overall findings were positive and showed no serious abnormalities besides external hemorrhoids. Given these results, the stakes are not as high as if there had been significant discoveries like polyps or signs of cancerous growths.


Medical Specialty: Surgery
Sample Name: Fat Harvesting

PREOPERATIVE DIAGNOSIS: , Incompetent glottis.,POSTOPERATIVE DIAGNOSIS:,  Incompetent glottis.,OPERATION PERFORMED:,1.  Fat harvesting from the upper thigh.,2.  Micro-laryngoscopy.,3.  Fat injection thyroplasty.,FINDINGS AND PROCEDURE: , With the patient in the supine position under adequate general endotracheal anesthesia, the operative area was prepped and draped in a routine fashion.  A 1-cm incision was made in the upper thigh, and approximately 5 cc of fat was liposuctioned from the subcutaneous space.  After this had been accomplished, the wound was closed with an interrupted subcuticular suture of 4-0 chromic and a light compression dressing was applied.,Next, the fat was placed in a urine strainer and copiously washed using 100 cc of PhysioSol containing 100 units of regular insulin.  After this had been accomplished, it was placed in a 3-cc BD syringe and, thence, into the Stasney fat injector device.  Next, a Dedo laryngoscope was used to visualize the larynx, and approximately *** cc of fat was injected into the right TA muscle and *** cc of fat into the left TA muscle.,The patient tolerated the procedure well and was returned to the recovery room in satisfactory condition.  Estimated blood loss was negligible.
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DESCRIPTION: Incompetent glottis.  Fat harvesting from the upper thigh, micro-laryngoscopy, fat injection thyroplasty.

surgery, dedo laryngoscope, physiosol, micro laryngoscopy, fat injection, fat harvesting, incompetent glottis, laryngoscopy, thyroplasty, glottis, thigh

The procedure involves surgical intervention for an incompetent glottis, which suggests a significant medical condition affecting the patient's voice and possibly breathing. Although the surgery seems routine and the estimated blood loss is negligible, surgery inherently carries risk. However, since it is described as being tolerated well by the patient and doesn't indicate emergency or life-threatening situations, the situation is of moderate stakes.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Multiple Medical Problems

SUBJECTIVE:,  The patient was seen today by me at Nursing Home for her multiple medical problems.  The nurses report that she has been confused at times, having incontinent stool in the sink one time but generally she does not do that poorly.  She does have trouble walking which she attributes to weak legs.  She fell a couple of months ago.  Her eating has been fair.  She has been losing weight a little bit.  She denies diarrhea.  She does complain of feeling listless and unambitious and would like to try some Ensure.,CURRENT MEDICATIONS:,  Her meds are fairly extensive and include B12 1000 mg IM monthly, Digitek 250 p.o. every other day alternating with 125 mcg p.o. every other day, aspirin 81 mg daily, Theragran-M daily, Toprol XL 25 mg daily, vitamin B6 100 mg daily, Prevacid 30 mg daily, Oyster Shell calcium with D 500 mg t.i.d., Aricept 5 mg daily, Tylenol 650 mg q.4h. p.r.n., furosemide 20 mg daily p.r.n., and sublingual Nitro p.r.n., and alprazolam 0.25 mg p.r.n.,ALLERGIES:,  Sulfa and trimethoprim.,OBJECTIVE:,General:  She is a well-developed, well-nourished, elderly female in no acute distress.,Vital Signs:  Her age is 90.  Temperature is 98.5 degrees.  Blood pressure:  100/54.  Pulse:  60.  Respirations:  18.  Weight was 132.6 about a week ago, which is down one pound from couple of months ago.,HEENT:  Head was normocephalic.,Neck:  Supple.,Lungs:  Clear.,Heart:  Regular rate and rhythm.,Abdomen:  Soft, nontender without hepatosplenomegaly or mass.,Extremities:  No calf tenderness or significant ankle edema x 2 in the lower extremities is noted.,Mental Status Exam:  She was uncertain what season we are in.  She thought we were almost in winter.  She did know that today of the week was Friday.  She seemed to recognize me.,ASSESSMENT:,1.  Alzheimer’s dementia.,2.  Gradual weight loss.,3.  Fatigue.,4.  B12 deficiency.,5.  Osteoporosis.,6.  Hypertension.,PLAN:,  I ordered yearly digoxin levels.  Increased her Aricept to 10 mg daily.  She apparently does have intermittent atrial fibrillation as a reason for being on the digoxin.  We will plan to recheck her in a couple of months.  Ordered health supplement to be offered after each meal due to her weight loss.
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DESCRIPTION: Patient with multiple medical problems (Alzheimer’s dementia, gradual weight loss, fatigue, etc.)

soap / chart / progress notes, progress note, alzheimer’s dementia, b12 deficiency, fatigue, hypertension, osteoporosis, digoxin, incontinent stool, multiple medical problems, weak, weight loss, multiple, dementia, alzheimer’s, incontinent,

The situation involves an elderly patient with multiple medical conditions, including Alzheimer's dementia, gradual weight loss, and a complex medication regimen. While these medical issues are serious, they reflect a typical scenario in managing chronic conditions in a nursing home setting. The plan involves routine monitoring and adjustments in medication and supplements, indicating ongoing management rather than an immediate crisis. The patient's vitals are stable and she is in no acute distress, suggesting the situation is not currently high-stakes.


Medical Specialty: Surgery
Sample Name: Stamm Gastrostomy Tube Placement

PREOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,POSTOPERATIVE DIAGNOSES:,1. Squamous cell carcinoma of the head and neck.,2. Ethanol and alcohol abuse.,PROCEDURE:,1. Failed percutaneous endoscopic gastrostomy tube placement.,2. Open Stamm gastrotomy tube.,3. Lysis of adhesions.,4. Closure of incidental colotomy.,ANESTHESIA:, General endotracheal anesthesia.,IV FLUIDS:, Crystalloid 1400 ml.,ESTIMATED BLOOD LOSS:, Thirty ml.,DRAINS:, Gastrostomy tube was placed to Foley.,SPECIMENS:, None.,FINDINGS:, Stomach located high in the peritoneal cavity. Multiple adhesions around the stomach to the diaphragm and liver.,HISTORY: ,The patient is a 59-year-old black male who is indigent, an ethanol and tobacco abuse. He presented initially to the emergency room with throat and bleeding. Following evaluation by ENT and biopsy, it was determined to be squamous cell carcinoma of the right tonsil and soft palate, The patient is to undergo radiation therapy and possibly chemotherapy and will need prolonged enteral feeding with a bypass route from the mouth. The malignancy was not obstructing. Following obtaining informed consent for percutaneous endoscopic gastrostomy tube with possible conversion to open procedure, we elected to proceed following diagnosis of squamous cell carcinoma and election for radiation therapy.,DESCRIPTION OF PROCEDURE:, The patient was placed in the supine position and general endotracheal anesthesia was induced. Preoperatively, 1 gram of Ancef was given. The abdomen was prepped and draped in the usual sterile fashion. After anesthesia was achieved, an endoscope was placed down into the stomach, and no abnormalities were noted. The stomach was insufflated with air and the endoscope was positioned in the midportion and directed towards the anterior abdominal wall. With the room darkened and intensity turned up on the endoscope, a light reflex was noted on the skin of the abdominal wall in the left upper quadrant at approximately 2 fingerbreadths inferior from the most inferior rib. Finger pressure was applied to the light reflex with adequate indentation on the stomach wall on endoscopy. A 21-gauge 1-1/2 inch needle was initially placed at the margin of the light reflex, and this was done twice. Both times it was not visualized on the endoscopy. At this point, repositioning was made and, again, what was felt to be adequate light reflex was obtained, and the 14-gauge angio catheter was placed. Again, after two attempts, we were unable to visualize the needle in the stomach endoscopically. At this point, decision was made to convert the procedure to an open Stamm gastrostomy.,OPEN STAMM GASTROSTOMY: ,A short upper midline incision was made and deepened through the subcutaneous tissues. Hemostasis was achieved with electrocautery. The linea alba was identified and incised, and the peritoneal cavity was entered. The abdomen was explored. Adhesions were lysed with electrocautery under direct vision. The stomach was identified, and a location on the anterior wall near the greater curvature was selected. After lysis of adhesions was confirmed, we sufficiently moved the original chosen site without tension. A pursestring suture of #3-0 silk was placed on the interior surface of the stomach, and a second #3-0 pursestring silk stitch was placed exterior to that pursestring suture. An incision was then made at the location of the anterior wall which was near the greater curvature and was dissected down to the anterior abdominal wall. A Vanderbilt was used to pass through the abdominal wall in through the skin and then returned to the level of the skin and pulled the Bard feeding tube through the anterior wall into the field. An incision in the center of the pursestring suture on the anterior surface of the stomach was then made with electrocautery. The interior pursestring suture was sutured into place in such a manner as to inkwell the stomach around the catheter. The second outer concentric pursestring suture was then secured as well and tied to further inkwell the stomach. The stomach was then tacked to the anterior abdominal wall at the catheter entrance site with four #2-0 silk sutures in such a manner as to prevent leakage or torsion. The catheter was then secured to the skin with two #2-0 silk sutures. Hemostasis was checked and the peritoneal cavity was washed out and brought to the surgical field. Prior to the initiation of the gastrotomy, the bowel was run and at that time there was noted to be one incidental colotomy. This was oversewn with three #4-0 silk Lembert sutures. At the completion of the operation, the fascia was closed with #1 interrupted Vicryl suture, and the skin was closed with staples. The patient tolerated the procedure well and was taken to the postanesthesia care unit in stable condition.
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DESCRIPTION: Open Stamm gastrotomy tube, lysis of adhesions, and closure of incidental colotomy

The case involves a surgical procedure with a patient who has squamous cell carcinoma and a history of ethanol abuse. The patient requires a gastrostomy tube due to anticipated radiation therapy and the need for enteral feeding. The complexity of the procedure increased after a failed percutaneous attempt, necessitating an open surgical approach. Surgical risks are present due to the patient's cancer, history of substance abuse, and the complexity of the procedure (including managing adhesions and an incidental colotomy). Surgically, these factors can increase the potential for complications. While the procedure is routine for experienced surgeons, the context of cancer treatment and anticipated chemotherapy adds to the patient's vulnerability, making this a moderately high-stakes situation.