Medical Specialty: Pediatrics - Neonatal
Sample Name: Neonatal Consult

INFORMANT:,  Dad on phone.  Transferred from ABCD Memorial Hospital, rule out sepsis.,HISTORY:  ,This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease.  The patient had a fever of 100.1 on 09/13/2006 taken rectally, and mom being a nurse, took the baby to the hospital and he was admitted for rule out sepsis.  All the sepsis workup was done, CBC, UA, LP, and CMP, and since a murmur was noted 2/5, he also had an echo done.  The patient was put on ampicillin and cefotaxime.  Echo results came back and they showed patent foramen ovale/ASD with primary pulmonary stenosis and then considering severe congenital heart disease, he was transferred here on vancomycin, ampicillin, and cefotaxime.  The patient was n.p.o. when he came in.  He was on 3/4 L of oxygen.  According to the note, it conveyed that he had some subcostal retractions.  On arriving here, baby looks very healthy.  He has no subcostal retractions.  He is not requiring any oxygen and he is positive for urine and stool.  The stool is although green in color, and in the morning today, he spiked a fever of 100.1, but right now he is afebrile.  ED called that case is a direct admit.,REVIEW OF SYSTEMS:  ,The patient supposedly had fever, some weight loss, poor appetite.  The day he had fever, no rash, no ear pain, no congestion, no rhinorrhea, no throat pain, no neck pain, no visual changes, no conjunctivitis, no cough, no dyspnea, no vomiting, no diarrhea, and no dysuria.  According to mom, baby felt floppy on the day of fever and he also used to have stools every day 4 to 6 which is yellowish-to-green in color, but today the stool we noticed was green in color.  He usually has urine 4 to 5 a day, but the day he had fever, his urine also was low.  Mom gave baby some Pedialyte.,PAST MEDICAL HISTORY:,  None.,HOSPITALIZATIONS:,  Recent transfer from ABCD for the rule out sepsis and heart disease.,BIRTH HISTORY:  ,Born on 08/23/2006 at Memorial Hospital, NSVD, no complications.  Hospital stay 24 hours.  Breast-fed, no formula, no jaundice, 7 pounds 8 ounces.,FAMILY HISTORY:,  None.,SURGICAL HISTORY: , None.,SOCIAL HISTORY:  ,Lives with mom and dad.  Dad is a service manager at GMC; 4-year-old son, who is healthy; and 2 cats, 2 dogs, 3 chickens, 1 frog.  They usually visit to a ranch, but not recently.  No sick contact and no travel.,MEDICATIONS: , Has been on vancomycin, cefotaxime, and ampicillin.,ALLERGIES:,  No allergies.,DIET:,  Breast feeds q.2h.,IMMUNIZATIONS: , No immunizations.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Temperature 99, pulse 158, respiratory rate 68, blood pressure 87/48, oxygen 100% on room air.,MEASUREMENTS:  Weight 3.725 kg.,GENERAL:  Alert and comfortable and sleeping.,SKIN:  No rash.,HEENT:  Intact extraocular movements.  PERRLA.  No nasal discharge.  No nasal cannula, but no oxygen is flowing active, and anterior fontanelle is flat.,NECK:  Soft, nontender, supple.,CHEST:  CTAP.,GI:  Bowel sounds present.  Nontender, nondistended.,GU:  Bilaterally descended testes.,BACK:  Straight.,NEUROLOGIC:  Nonfocal.,EXTREMITIES:  No edema.  Bilateral pedal pulses present and upper arm pulses are also present.,LABORATORY DATA:,  As drawn on 09/13/2006 at ABCD showed WBC 4.2, hemoglobin 11.8, hematocrit 34.7, platelets 480,000.  Sodium 140, potassium 4.9, chloride 105, bicarbonate 28, BUN 7, creatinine 0.4, glucose 80, CRP 0.5.  Neutrophils 90, bands 7, lymphocytes 27, monocytes 12, and eosinophils 4.  Chest x-ray done on 09/13/2006 read as mild left upper lobe infiltrate, but as seen here, and discussed with Dr. X, we did not see any infiltrate and CBG was normal.  UA and LP results are pending.  Also pending are cultures for blood, LP, and urine.,ASSESSMENT AND PLAN: , This is a 3-week-old Caucasian baby boy admitted for rule out sepsis and congenital heart disease.,INFECTIOUS DISEASE/PULMONARY: , Afebrile with so far 20-hour blood cultures, LP and urine cultures are negative.  We will get all the results from ABCD and until then we will continue to rule out sepsis protocol and put the patient on ampicillin and cefotaxime.  The patient could be having fever due to mild gastroenteritis or urinary tract infection, so to rule out all these things we have to wait for all the results.,CVS: , He had a grade 2/5 murmur status post echo, which showed a patent foramen ovale, as well as primary pulmonary stenosis.  These are the normal findings in a newborn as discussed with Dr. Y, so we will just observe the patient.  He does not need any further workup.,GASTROINTESTINAL:
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DESCRIPTION: This is a 3-week-old, NSVD, Caucasian baby boy transferred from ABCD Memorial Hospital for rule out sepsis and possible congenital heart disease.

This situation involves a 3-week-old newborn who has been transferred to a hospital to rule out potentially severe conditions such as sepsis and congenital heart disease. Both conditions can be life-threatening, especially in a newborn. The patient has had multiple medical evaluations, including blood cultures and an echocardiogram, and is on multiple antibiotics. The assessment mentions the presence of a patent foramen ovale and pulmonary stenosis, which could be significant if not monitored carefully. Although the baby is currently stable, the potential severity of sepsis and congenital heart disease makes this a high-stakes situation. Early and accurate diagnosis and treatment are critical in preventing serious outcomes.


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

Medical Specialty: Pediatrics - Neonatal
Sample Name: Infant Not Gaining Weight

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

The situation described involves a 1-month-26-day-old infant with failure-to-thrive, a significant murmur, patent ductus arteriosus (PDA), and mild congestive heart failure, all of which are serious medical conditions. The condition is compounded by symptoms indicating heart issues and a failure to gain weight, which are critical concerns in a newborn. The urgency is high as newborns can deteriorate rapidly if heart conditions are not addressed. The need for admission to a children's hospital and close monitoring further indicates the high-stakes nature of the situation. Therefore, considering the age of the patient and the medical issues at hand, this scenario is quite high-stakes as it requires immediate and careful medical intervention to ensure the infant's survival and health.

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Medical Specialty: Pediatrics - Neonatal
Sample Name: Infantile Spasms

CHIEF COMPLAINT:,  Arm and leg jerking.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 10-day-old Caucasian female here for approximately 1 minute bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.  Mom denies any apnea, perioral cyanosis, or color changes.  These movements are without any back arching.  They mainly occur during sleep, so mom is unaware of any eye rolling.  Mom is able to wake the patient up during this periods and stop the patient's extremity movements.,Otherwise, this patient has been active, breast-feeding well, although she falls asleep at the breast.  She is currently taking in 15 to 20 minutes of breast milk every 2 to 3 hours.  She is having increased diapers up to 8 wet and 6 to 7 dirty-yellow stools per day.,REVIEW OF SYSTEMS:,  Negative fever, negative fussiness, tracks with her eyes, some sneezing and hiccups.  This patient has developed some upper airway congestion in the past day.  She has not had any vomiting or diarrhea.  Per mom, she does not spit up, and mom is also unable to notice any relationship between these movements and feeds.  This patient has not had any rashes.  Mom was notified by the nurses at birth that her temperature may be low of approximately 97.5 degrees Fahrenheit.  Otherwise, the above history of present illness and other review of systems negative.,BIRTH/PAST MEDICAL HISTORY: , The patient was an 8 pound 11 ounce baby, ex-41-weeker born via vaginal delivery without vacuum assist or forceps.  There were no complications during pregnancy such as diabetes or hypertension.  Prenatal care started at approximately 3 weeks, and mom maintained all visits.  She also denies any smoking, alcohol, or drug use during the pregnancy.  Mom was GBS status positive, but denies any other infections such as urinary tract infections.  She did not have any fever during labor and received inadequate intrapartum antibiotics prophylaxis.  After delivery, this patient did not receive antibiotics secondary to "borderline labs."  She was jaundiced after birth and received photo treatments.  Her discharge bilirubin level was approximately 11.  Mom and child stayed in the hospital for approximately 3-1/2 days.,Mom denies any history of sexually transmitted disease in her or dad.  She specifically denies any blistering, herpetic genital lesions.  She does have a history though of human papillomavirus warts (vaginal), removed 20 years ago.,PAST SURGICAL HISTORY:,  Negative.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , None.,SOCIAL HISTORY: , At home live mom, dad, and 18-, 16-, 14-, 12-year-old brothers, and a 3-year-old sister.  All the residents at home are sick currently with cold, cough, runny nose, except for mom.  At home also live 2 dogs and 2 outside cats.  Mom denies any recent travel history, especially during the recent holidays and no smoke exposures.,FAMILY HISTORY:,  Dad is with a stepdaughter with seizures starting at 14 years old, on medications currently.  The patient's 16-year-old brother has incessant nonsustained ventricular tachycardia.  The maternal grandmother is notable for hypertension and diabetes.  There are no other children in the family who see a specialist or no child death less than 1 year of age.,PHYSICAL EXAMINATION:
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DESCRIPTION: A 10-day-old Caucasian female with bilateral arm and leg jerks, which started at day of life 1 and have occurred 6 total times since then.

Infantile spasms can be a sign of a serious underlying neurological condition, such as epilepsy or a genetic disorder, and can impact brain development if not addressed promptly. The situation involves a 10-day-old infant with symptoms that commenced immediately after birth, which heightens the potential for serious underlying conditions. In such a young patient, early diagnosis and intervention are crucial, and the stakes are high in terms of ensuring proper neurological development and preventing long-term complications.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Hyperbilirubinemia - 4-day-old

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

pediatrics - neonatal, hypoxia, periodic breathing, heart murmur, urine specimen, yellow, bilirubin, heart, murmur, hyperbilirubinemia,

The situation involves a 4-day-old neonate with significant hyperbilirubinemia (bilirubin level of 25.4 mg%), periodic breathing, hypoxia, and a heart murmur. Hyperbilirubinemia at this level in a newborn is concerning due to the risk of bilirubin encephalopathy (kernicterus), which can lead to permanent neurological damage. The presence of hypoxia and heart murmur could indicate underlying congenital or serious health issues. The need for phototherapy, possible investigations into the underlying cause of jaundice, and careful monitoring make this a serious and potentially high-stakes situation.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Gagging - 3-year-old

HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging.  She was doing well until about 2 days ago, when she developed gagging.  No vomiting.  No fever.  She has history of constipation.  She normally passes stool every two days after giving an enema.  No rectal bleeding.  She was brought to the Hospital with some loose stool.  She was found to be dehydrated.  She was given IV fluid bolus, but then she started bleeding from G-tube site.  There was some fresh blood coming out of the G-tube site.  She was transferred to PICU.  She is hypertensive.  Intensivist Dr. X requested me to come and look at her, and do upper endoscopy to find the site of bleeding.,PAST MEDICAL HISTORY: , PEHO syndrome, infantile spasm, right above knee amputation, developmental delay, G-tube fundoplication.,PAST SURGICAL HISTORY: , G-tube fundoplication on 05/25/2007.  Right above knee amputation.,ALLERGIES:,  None.,DIET: , She is NPO now, but at home she is on PediaSure 4 ounces 3 times a day through G-tube, 12 ounces of water per day.,MEDICATIONS: , Albuterol, Pulmicort, MiraLax 17 g once a week, carnitine, phenobarbital, Depakene and Reglan.,FAMILY HISTORY:,  Positive for cancer.,PAST LABORATORY EVALUATION: , On 12/27/2007; WBC 9.3, hemoglobin 7.6, hematocrit 22.1, platelet 132,000.  KUB showed large stool with dilated small and large bowel loops.  Sodium 140, potassium 4.4, chloride 89, CO2 21, BUN 61, creatinine 2, AST 92 increased, ALT 62 increased, albumin 5.3, total bilirubin 0.1.  Earlier this morning, she had hemoglobin of 14.5, hematocrit 41.3, platelets 491,000.  PT 58 increased, INR 6.6 increased, PTT 75.9 increased.,PHYSICAL EXAMINATION:  ,VITAL SIGNS:  Temperature 99 degrees Fahrenheit, pulse 142 per minute, respirations 34 per minute, weight 8.6 kg.,GENERAL:  She is intubated.,HEENT:  Atraumatic.  She is intubated.,LUNGS:  Good air entry bilaterally.  No rales or wheezing.,ABDOMEN:  Distended.  Decreased bowel sounds.,GENITALIA:  Grossly normal female.,CNS:  She is sedated.,IMPRESSION: , A 3-year-old female patient with history of passage of blood through G-tube site with coagulopathy.  She has a history of G-tube fundoplication, developmental delay, PEHO syndrome, which is progressive encephalopathy optic atrophy.,PLAN:  ,Plan is to give vitamin K, FFP, blood transfusion.  Consider upper endoscopy.  Procedure and informed consent discussed with the family.
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DESCRIPTION: Pediatric Gastroenterology - History of gagging.

pediatrics - neonatal, g-tube, peho syndrome, tube site, gagging, constipation, endoscopy, peho, hemoglobin, hematocrit, intubated, bleeding, blood, fundoplication, tube,

The situation involves a 3-year-old patient with a complex medical history including PEHO syndrome, developmental delay, and previous surgical interventions. She presents with gagging, dehydration, bleeding from the G-tube site, and coagulopathy, which are serious medical concerns requiring intensive care evaluation and intervention. The plan involves potentially high-risk medical procedures and interventions such as vitamin K administration, FFP and blood transfusions, and possibly an upper endoscopy. Given the patient's young age, the complexity of her medical condition, and the presence of active bleeding and coagulopathy, this situation is indeed high-stakes.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Goldenhar Syndrome - Discharge Summary

ADMITTING DIAGNOSES,1.  Vomiting, probably secondary to gastroenteritis.,2.  Goldenhar syndrome.,3.  Severe gastroesophageal reflux.,4.  Past history of aspiration and aspiration pneumonia.,DISCHARGE DIAGNOSES,1.  Gastroenteritis versus bowel obstruction.,2.  Gastroesophageal reflux.,3.  Goldenhar syndrome.,4.  Anemia, probably iron deficiency.,HISTORY OF PRESENT ILLNESS:,  This is a 10-week-old female infant who has Goldenhar syndrome and has a gastrostomy tube in place and a J-tube in place.  She was noted to have vomiting approximately 18 to 24 hours prior to admission and was seen in the emergency department and then admitted.,Because of her Goldenhar syndrome and previous problems with aspiration, she is not fed my mouth, but does have a G-tube.  However, she has not been tolerating feedings through this prior to admission.,PHYSICAL EXAMINATION:,GENERAL:  At transfer to UNM on October 13, 2003 reveals a dysmorphic infant who is small and slightly cachectic.  Her left side of the face is deformed with microglia present, micrognathia present, and a moderate amount of torticollis.,VITAL SIGNS:  Presently, her temperature is 98, pulse 152, respirations 36, weight is 3.98 kg, pulse oximetry on room air is 95%.,HEENT:  Head is with anterior fontanelle open.  Eyes:  Red reflex elicited bilaterally.  Left ear is without an external ear canal and the right is not well visualized at this time.  Nose is presently without any discharge, and throat is nonerythematous.  NECK:  Neck with torticollis exhibited.,LUNGS:  Presently are clear to auscultation.,HEART:  Regular rate without murmur, click or gallop present.  ABDOMEN:  Moderately distended, but soft.  Bowel sounds are decreased, and there is a G-tube and a J-tube in place.  The skin surrounding the G-tube is moderately erythematous, but without any discharges present.  J-tube is with a dressing in place and well evaluated.,EXTREMITIES:  Grossly normal.  Hip defects are not checked at this time.,GENITALIA:  Normal female.,NEUROLOGIC:  The infant does have a suck reflex, feeding grasp-reflex, and a feeding Moro reflex.,SKIN:  Warm and dry and there is a macular area to the left ___ that is approximately 1 cm in length.,LABORATORY DATA: , WBC count on October 12, 2003 is 12,600 with 16 segs, 6 bands, 54 lymphocytes, 13% of which are noted to be reactive.  Hemoglobin is 10.4, hematocrit 30.8, and she has abnormal red blood cell morphology.  RDW is 13.1 and MCV is 91.  Sodium level is 138, potassium 5.4, chloride 103, CO2 23, BUN 7, creatinine 0.4, glucose 84, calcium 9.9, and at this dictation, the report on the abdominal flat plate is pending.,HOSPITAL COURSE:  ,The child was placed at bowel rest initially and then re-tried on full strength formula, but she did not tolerate.  She was again placed on bowel rest and her medications, Pepcid and Reglan, were given in an attempt to increase bowel motility.  Feedings were re-attempted with Pedialyte through the J-tube and these did not result in production of any stool and the child then began having vomiting again.  The vomitus was noted to be bilious in nature and with particulate matter present.,After consultation with Dr. X, it was determined the child probably needed further evaluation, and she had both of her drains placed to gravity and was kept n.p.o.  Her fluids have been D5 and 0.25 normal saline with 20 mEq/L of potassium chloride, which has run at her maintenance of 16 mL/h.,CONSULTATIONS: , With Dr. X and Dr. Y and the child is now ready for transport for continued diagnosis and treatment.  Her condition at discharge is stable.
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DESCRIPTION: Gastroenteritis versus bowel obstruction, gastroesophageal reflux, Goldenhar syndrome, and anemia, probably iron deficiency.

The situation involves a 10-week-old infant with multiple complex medical conditions, including Goldenhar syndrome, severe gastroesophageal reflux, and a history of aspiration. The child is being discharged in a stable condition but still requires intensive medical oversight and potential further evaluation and treatment. While the current condition is described as stable, the complexity of the medical issues and the necessity for ongoing care and monitoring make it a high-stakes medical situation. Any error in treatment or management could lead to severe complications for a vulnerable patient.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Ear pain - Pediatric Consult

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

The scenario involves a 13-year-old patient with recurring ear pain likely due to chronic otitis media, possibly resistant to penicillin, alongside significant symptoms suggestive of severe GERD. While concerning, the issues detailed do not imply immediate life-threatening conditions. The patient is under medical observation with a planned treatment and follow-up schedule. Though discomforting for the patient, these conditions are generally manageable with appropriate medical care and do not present imminent risks to life or long-term health if treated correctly. Therefore, the stakes are not extremely high.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Discharge Summary - Respiratory Distress

ADMITTING DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,DISCHARGE DIAGNOSES:,1.  Respiratory distress.,2.  Reactive airways disease.,3.  Pneumonia.,HISTORY OF PRESENT ILLNESS: , The patient is a 3-year-old boy previously healthy who has never had a history of asthma or reactive airways disease who presented with a 36-hour presentation of URI symptoms, then had an abrupt onset of cough and increased work of breathing.  Child was brought to Children's Hospital and received nebulized treatments in the ER and the Hospitalist Service was contacted regarding admission.  The patient was seen and admitted through the emergency room.,He was placed on the hospitalist system and was started on continuous nebulized albuterol secondary to his respiratory distress.  He also received inhaled as well as systemic corticosteroids.  An x-ray was without infiltrate on initial review by the hospitalist, but there was a right upper lobe infiltrate versus atelectasis per the official radiology reading.  The patient was not started on any antibiotics and his fever resolved.  However, the CRP was relatively elevated at 6.7.  The CBC was normal with a white count of 9.6; however, the bands were 84%.  Given these results, which she is to treat the pneumonia as bacterial and discharge the child with amoxicillin and Zithromax.,He was taken off of continuous and he was not on room air all night.  In the morning, he still had some bilateral wheezing, but no tachypnea.,DISCHARGE PHYSICAL EXAMINATION: , ,GENERAL:  No acute distress, running around the room.,HEENT:  Oropharynx moist and clear.,NECK:  Supple without lymphadenopathy, thyromegaly or masses.,CHEST:  Bilateral basilar wheezing.  No distress.,CARDIOVASCULAR:  Regular rate and rhythm.  No murmurs noted.  Well perfused peripherally.,ABDOMEN:  Bowel sounds present.  The abdomen is soft.  There is no hepatosplenomegaly, no masses.  Nontender to palpation.,GENITOURINARY:  Deferred.,EXTREMITIES:  Warm and well perfused.,DISCHARGE INSTRUCTIONS:,  As follows:,1.  Activity, regular.,2.  Diet is regular.,3.  Follow up with Dr. X in 2 days.,DISCHARGE MEDICATIONS:,1.  Xopenex MDI 2 puffs every 4 hours for 2 days and then as needed for cough or wheeze.,2.  QVAR 40, 2 puffs twice daily until otherwise instructed by the primary care provider.,3.  Amoxicillin 550 mg p.o. twice daily for 10 days.,4.  Zithromax 150 mg p.o. on day 1, then 75 mg p.o. daily for 4 more days.,Total time for this discharge 37 minutes.
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DESCRIPTION: A 3-year-old abrupt onset of cough and increased work of breathing.

The situation involves a pediatric patient with respiratory distress and reactive airways disease who was treated and then discharged with medications. While the condition is serious, the patient is described as stable without acute distress, indicating that the immediate life-threatening risk has been managed. The discharge summary and follow-up plan seem thorough, which suggests a well-handled case, reducing the stakes. However, given the age of the patient and the initial symptoms, it's still relatively high-stakes when not well-managed.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Circumcision - Child

PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion.  The area of the penis and scrotum were prepared with povidone iodine solution.  The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  A dorsal slit was made, and the prepuce was dissected away from the glans penis.  A ** Gomco clamp was properly placed for 5 minutes.  During this time, the foreskin was sharply excised using a #10 blade.  With removal of the clamp, there was a good cosmetic outcome and no bleeding.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.
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DESCRIPTION: Circumcision.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.

pediatrics - neonatal, circumstraint, dorsal slit, gomco clamp, circumcision, childNOTE,: 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 circumcision of a neonate is a common and generally low-risk procedure, particularly when performed in a controlled environment by an experienced practitioner. The documentation indicates that the procedure was uneventful, with no complications such as bleeding and a good cosmetic outcome. While proper aftercare and monitoring are essential, the stakes associated with the procedure itself are not considered high. However, because it involves a surgical procedure on a neonate, it naturally carries some importance, but it is routine and well-practiced in pediatrics.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Broviac Catheter Placement

PREOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,ANESTHESIA:,  General.,PROCEDURE:,  Placement of left subclavian 4-French Broviac catheter.,INDICATIONS:  ,The patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas.  The patient needs prolonged IV antibiotic therapy, but attempt at a PICC line failed.  She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement.  I met with the patient's mom.  With the help of a Spanish interpreter, I explained the technique for Broviac placement.  We discussed the surgical risks and alternatives, most of which have been exhausted.  All their questions have been answered, and the patient is fit for operation today.,DESCRIPTION OF OPERATION:  ,The patient came to the operating room and had an uneventful induction of general anesthesia.  We conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the Broviac catheter.  Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed.  A flexible guidewire was inserted into the central location and then a 4-French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins.  The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines.  The peel-away sheath was passed over the guidewire and then the 4-French catheter was deployed through the peel-away sheath.  There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava.  The catheter insertion site was closed with one buried 5-0 Monocryl stitch and the same 5-0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred.  Heparinized saline solution was used to flush the line.  A sterile occlusive dressing was applied, and the line was prepared for immediate use.  The patient was transported to the recovery room in good condition.  There were no intraoperative complications, and her blood loss was between 5 and 10 mL during the line placement portion of the procedure.
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DESCRIPTION: Lumbar osteomyelitis and need for durable central intravenous access.  Placement of left subclavian 4-French Broviac catheter.

pediatrics - neonatal, lumbar osteomyelitis, central intravenous access, subclavian, osteomyelitis, broviac catheter, catheter, toddler, intravenous,

The situation involves the placement of a Broviac catheter in a toddler who has lumbar osteomyelitis, requiring prolonged IV antibiotic therapy. It is high-stakes because the child is receiving treatment for a significant infection, and the procedure is necessary after other options like a PICC line failed. The procedure involves general anesthesia and has associated risks, especially in a pediatric population. However, the surgery is common and the procedure went well with no complications, which slightly lowers the stakes compared to more emergent or high-risk surgeries.


Medical Specialty: Pediatrics - Neonatal
Sample Name: 1-year-old Exam - H&P

CHIEF COMPLAINT:,  This 1-year-old female presents today for a health maintenance exam.  Patient was accompanied by mother.,The child eats 3 meals a day plus 2 snacks and is off the bottle.  She sleeps through the night.  She takes morning and afternoon naps.  Mother is concerned about child's red, matted eye and not walking completely alone yet.  Immunizations need to be updated at today's visit.,DEVELOPMENTAL MILESTONES:,  1 year developmental milestones reached:  bangs blocks together, drinks from cup, eating finger foods, feeds self, gives toys on request, imitates vocalizations, looks for dropped or hidden objects, points to desired objects, pulls to stand and cruises, releases cube into cup after demonstration, says "mama" and "dada" with meaning, says one or two other words, tries to build tower of 2 cubes and waves bye.,ALLERGIES:,  No known medical allergies.,MEDICATIONS:,  None.,PMH: , Past medical history is unremarkable.,PSH: , No previous surgeries.,FAMILY HISTORY:,  Patient admits a family history of cancer associated with maternal aunt, hypertension associated with paternal grandfather.,SOCIAL HISTORY:,  She lives at home with parents.  Patient admits being in daycare.,REVIEW OF SYSTEMS:,  No change since last visit,PHYSICAL EXAM:,  Temp:  97.6 Height:  0 ft.  31 in.  Weight:  28 lbs.  BMI:  20,Growth Chart Entry:  Weight:  28 lbs 0 ozs Height:  0 ft 31 in Head Circumference:  18.50 in Patient is a 1 year-old female who appears in no apparent distress, well developed and well nourished.,Inspection of head and face shows anterior fontanel normal, posterior fontanel normal and head is normocephalic and atraumatic.,Eyes:  Fundoscopic exam reveals red reflex is present bilaterally.,Alignment is normal.,Sclera is white bilaterally.,Left inferior palpebral conjunctiva reveals conjunctivitis.,Ocular motility exam reveals gross orthotropia with full ductions and versions bilateral.,ENT:  Pinna:  normal.,Otoscopic examination reveals no abnormalities of external auditory canals and tympanic membranes.,Inspection of nose reveals no abnormalities and nares that are normal.,Nasal mucosa moist, pink, and without mass or exudate with no abnormalities of the septum and turbinates noted.,Inspection of lips, gums, and palate reveals no abnormalities.,Examination of oropharynx reveals no abnormalities and tissues pink and moist.,Neck:  Neck exam reveals no masses.,Respiratory:  Assessment of respiratory effort reveals even and nonlabored respirations.  Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals rate is regular, rhythm is regular and no murmurs, gallop, rubs or clicks.  Femoral pulses are 2 /4, bilateral.,Abdomen:  Abdomen soft, nontender, bowel sounds present x 4 without palpable masses.  Palpation of liver reveals no abnormalities.  Palpation of spleen reveals no abnormalities.,Genitourinary:  Examination of anus and perineum shows no abnormalities.,Musculoskeletal:  Inspection and palpation of bones, joints and muscles is unremarkable.,Muscle tone is normal.,Skin:  Skin is not pale, jaundice, or cyanotic.  Skin turgor, hydration, and texture is good.  Palpation of skin shows no abnormalities.,Neurologic/Psychiatric:  Moves all extremities.,TEST & X-RAY RESULTS:,  Hb:  12 g/dl.,IMPRESSION:,  Routine well child care.  Acute conjunctivitis.,PLAN:
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DESCRIPTION: Health maintenance exam for 1-year-old female.

The situation involves a routine health maintenance exam for a 1-year-old child with concerns about developmental milestones and acute conjunctivitis. The medical setting is concerned with ensuring the child's health and development, which is important but a standard part of pediatric care. The child's condition (conjunctivitis) is generally a mild and common issue that can be treated easily. The stakes are not high in terms of immediate life-threatening risks or severe health impacts.


Medical Specialty: Pain Management
Sample Name: Tun-L Catheter Placement

PREOPERATIVE DIAGNOSIS:,  Low Back Syndrome - Low back pain with left greater than right lower extremity radiculopathy.,POSTOPERATIVE DIAGNOSIS:,  Same.,PROCEDURE:,1.  Nerve root decompression at L45 on the left side.,2.  Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.,3.  Interpretation of radiograph.,ANESTHESIA: , IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,INDICATION FOR PROCEDURE: , Severe and excruciating pain in the lumbar spine and lower extremity.  MRI shows disc pathology as well as facet arthrosis.,SUMMARY OF PROCEDURE: , The patient was admitted to the operating room, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral region was prepped and draped in sterile fashion with Betadine and four sterile towels.  After the towels were places then sterile drapes were placed on top of that.,After which time the Epimed catheter was then placed, this was done by first repositioning the C-Arm to visualize the lumbar spine and the vertebral bodies were then counted beginning at L5, verifying the sacral hiatus.  The skin over the sacral hiatus was then injected with 1% Lidocaine and an #18-gauge needle was used for skin puncture.  The #18-gauge needle was inserted off of midline.  A #16-gauge RK needle was then placed into the skin puncture and using the paramedian approach and loss-of-resistance technique the needle was placed.  Negative aspiration was carefully performed.  Omnipaque 240 dye was then injected through the #16-gauge RK needle.  The classical run off was noted.  A filling defect was noted @ L45 nerve root on the left side.  After which time 10 cc of 0.25% Marcaine/Triamcinolone (9/1 mixture) was then infused through the 16 R-K Needle.  Some additional lyses of adhesions were visualized as the local anesthetic displaced the Omnipaque 240 dye using this barbotage technique.,An Epimed Tun-L catheter was then inserted through the #16-gauage R-K needle and threaded up to the L45 interspace under continuous fluoroscopic guidance.  As the catheter was threaded up under continuous fluoroscopic visualization lyses of adhesions were visualized.  The tip of the catheter was noted to be @ L45 level on the left side.  After this the #16-gauge RK needle was then removed under fluoroscopic guidance verifying that the tip of the catheter did not migrate from the L45 nerve root region on the left side.  After this was successfully done, the catheter was then secured in place; this was done with Neosporin ointment, a Split 2x2, Op site and Hypofix tape.  The catheter was then checked with negative aspiration and the Omnipaque 240 dye was then injected.  The classical run off was noted in the lumbar region.  Some lyses of adhesions were also visualized at this time with barbotage technique.  Good dye spread was noted to extend one level above and one level below the L45 nerve root and bilateral spread was noted.  Nerve root decompression was visualized as dye spread into the nerve root whereas prior this was a filling defect.  After which time negative aspiration was again performed through the Epimed® Tun-L catheter and then 10 cc of solution was then infused through the catheter, this was done over a 10-minute period with initial 3 cc test dose.  Approximately 3 minutes elapsed and then the remaining 7 cc were infused (Solution consisting of 8 cc of 0.25% Marcaine, 2 cc of Triamcinolone and 1 cc of Wydase.)  The catheter was then capped with a bacterial filter.  The patient was noted to have tolerated the procedure well without any complications.,Interpretation of radiograph revealed nerve root adhesions present with lysis of these adhesions as the procedure was performed.  A filling defect was seen at the L45 nerve root and this filling defect being significant of fibrosis and adhesions in this region was noted to be lysed with the insertion of the catheter as well as the barbotage procedure.  This verified positive nerve root decompression.  The tip of the Epimed Tun L catheter was noted to be at L45 level on the left side.  Positive myelogram without dural puncture was noted during this procedure; no sub-dural spread of Omnipaque 240 dye was noted.  This patient did not report any problems and reported pain reduction.
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DESCRIPTION: Nerve root decompression at L45 on the left side.  Tun-L catheter placement with injection of steroid solution and Marcaine at L45 nerve roots left.  Interpretation of radiograph.

pain management, low back syndrome, low back pain, nerve root decompression, steroid solution, c-arm, epimed, tun l catheter, nerve root, negative aspiration, omnipaque dye, filling defect, nerve, root, catheter, adhesions, injection, needle,

The procedure described involves the insertion of a Tun-L catheter for nerve root decompression, guided by radiographic imaging, to address severe low back and radicular pain. This is a specialized medical procedure in pain management, which, while generally routine, still carries risks such as infection, bleeding, or nerve damage. The patient's severe and excruciating pain indicates significant discomfort and potential impact on their quality of life, making the procedure necessary but not life-saving. The stakes are moderately high because the procedure aims to alleviate severe pain and improve quality of life, but it is not immediately life-threatening.


Medical Specialty: Pain Management
Sample Name: Superior Gluteal Nerve Block

PRE-OPERATIVE DIAGNOSIS:, Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.,POST-OPERATIVE DIAGNOSIS:, Same,PROCEDURE:, Superior Gluteal Nerve Block, Left.,After verbal informed consent, whereby the patient is made aware of the risks of the procedure, the patient was placed in the standing position with the arms flaccid by the side. Alcohol was used to prep the skin 3 times, and a 27-gauge needle was advanced deep to the attachment of the Gluteus Medius Muscle near its attachment on the PSIS. The needle entered the plane between the Gluteus Medius and Gluteus Maximus Muscle, in close proximity to the Superior Gluteal Nerve. Aspiration was negative, and the mixture was easily injected. Aseptic technique was observed at all times, and there were no complications noted.,INJECTATE INCLUDED:,Methyl Prednisolone (DepoMedrol): 20 mg,Ketorolac (Toradol): 6 mg,Sarapin: 1 cc,Bupivacaine (Marcaine): Q.S.  2 cc.,The procedures, above were performed for diagnostic, as well as therapeutic purposes. This treatment plan is medically necessary to decrease pain and suffering, increase activities of daily living and improve sleep.,ZUNG SELF-RATING DEPRESSION SCALE© (SDS) RESULTS:, The patient scored as 'mildly depressed.,NOTE:, The pain was gone post procedure, consistent with the diagnosis, as well as with adequacy of medication placement.
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DESCRIPTION: Superior Gluteal Nerve Block, Left - Superior Gluteal Neuralgia/Neurapraxia-impingement Syndrome.

pain management, neurapraxia, impingement syndrome, neuralgia, superior gluteal, superior gluteal nerve block, gluteus medius muscle, gluteus maximus muscle, gluteus medius, nerve block, gluteal nerve, block, gluteus, nerve, gluteal

The procedure involves administering a nerve block to alleviate pain, which is a routine and common practice in pain management. While it is a medical procedure, it's considered minimally invasive with a low risk of complications when performed properly. The stakes primarily involve ensuring proper pain management for the patient, rather than life-threatening concerns.


Medical Specialty: Pain Management
Sample Name: Radiofrequency Ablation

PROCEDURE: , Bilateral L5, S1, S2, and S3 radiofrequency ablation.,INDICATION: , Sacroiliac joint pain.,INFORMED CONSENT: , The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,PROCEDURE: , Oxygen saturation and vital signs were monitored continuously throughout the procedure.  The patient remained awake throughout the procedure in order to interact and give feedback.  The x-ray technician was supervised and instructed to operate the fluoroscopy machine.,The patient was placed in a prone position on the treatment table with a pillow under the chest and head rotated.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.,With fluoroscopy, a 20 gauge 10-mm bent Teflon coated needle was gently guided into the groove between the SAP and the sacrum for the dorsal ramus of L5 and the lateral border of the posterior sacral foramen, for the lateral branches of S1, S2, and S3.  Also, fluoroscopic views were used to ensure proper needle placement.,The following technique was used to confirm correct placement.  Motor stimulation was applied at 2 Hz with 1 millisecond duration.  No extremity movement was noted at less than 2 volts.  Following this, the needle trocar was removed and a syringe containing 1% lidocaine was attached.  At each level, after syringe aspiration with no blood return, 0.5 mL of 1% lidocaine was injected to anesthetize the lateral branch and the surrounding tissue.  After completion, a lesion was created at that level with a temperature of 80 degrees for 90 seconds.,All injected medications were preservative free.  Sterile technique was used throughout the procedure.,ADDITIONAL DETAILS:  ,None.,COMPLICATIONS: , None.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made at PM&R Spine Clinic in approximately one to two weeks.
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DESCRIPTION: Bilateral L5, S1, S2, and S3 radiofrequency ablation for sacroiliac joint pain.  Fluoroscopy was used to identify the bony landmarks of the sacrum and the sacroiliac joints and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.

pain management, sacroiliac joint pain, sacroiliac, teflon coated needle, fluoroscopy, needle placement, radiofrequency ablation, ablation, tissue, lidocaine, needle,

Radiofrequency ablation for sacroiliac joint pain is a common and generally low-risk procedure within the realm of pain management. While there are potential risks involved, including infection, bleeding, allergic reactions, and nerve injuries, these are standard risks associated with minimally invasive procedures, and the chance of them occurring is low. The procedure is performed under controlled conditions with continuous monitoring of vital signs, and the patient is given explicit instructions for post-procedure care along with warning signs for which to seek immediate help. Overall, the stakes are relatively low given the routine nature and established safety protocols of this procedure.


Medical Specialty: Pain Management
Sample Name: Stellate Ganglion Block

PREOPERATIVE DIAGNOSIS:,  Complex Regional Pain Syndrome, right upper extremity.,POSTOPERATIVE DIAGNOSIS:,  Same.,OPERATION:,
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DESCRIPTION: Complex regional pain syndrome, right upper extremity.  Stellate ganglion block.

pain management, chassaignac's tubercle, horner's sign, stellate ganglion block, sheath, vertebral, stellate, ganglion, cervical, block,

Stellate ganglion block is a procedure used to manage pain, specifically for conditions like Complex Regional Pain Syndrome (CRPS), which can be debilitating. While the procedure itself is commonly performed and generally considered safe, it can have significant effects on the patient's quality of life. Additionally, it requires skill to perform correctly, and there are risks to consider, such as infection, nerve damage, or complications from anesthesia. Therefore, the stakes are moderately high due to the potential impact on the patient's well-being and the need for precision in the procedure.


Medical Specialty: Pain Management
Sample Name: Sacral Alar Notch Injection

PROCEDURE:,  Right sacral alar notch and sacroiliac joint/posterior rami injections with fluoroscopy.,ANESTHESIA:,  Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS:  ,None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the operating room with intravenous line in place and intravenous sedation was given.  The patient was in the prone position.  The back was prepped with Betadine.  Under fluoroscopy, the right sacral alar notch was identified and after placement of a 22-gauge, 3-1/2 inch spinal needle in to the notch, negative aspiration was performed and 5 cc of 0.5% Marcaine plus 20 mg of Depo-Medrol was injected.  The needle was then placed in to the right sacroiliac joint (distal third) and the same local anesthetic mixture was injected.  This was repeated for the right sacral alar notch and the right sacroiliac joint (distal third).  The needle was withdrawn.  The above was repeated for the posterior primary rami branch at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injection and coagulation as above.,There were no complications.  Needles removed.  Band-aids were applied over the puncture sites.  The patient was discharged to operating room recovery in stable condition.
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DESCRIPTION: Right sacral alar notch and sacroiliac joint/posterior rami injections with/without fluoroscopy.

pain management, fluoroscopy, sacroiliac joint, sacral alar notch, posterior rami, sacroiliac, alar, sacral, notch,

This procedure, while involving injections into specific areas in the spine with fluoroscopy guidance, is relatively routine in pain management for diagnosis or treatment of sacroiliac joint pain. Complications are noted as none, indicating it went successfully. Although any procedure around the spine requires precision to avoid complications, the stakes are not considered to be as high as major surgeries like spinal fusions or operations involving vital organs. The patient was discharged in stable condition, further indicating the procedure's routine nature and lower-risk profile.


Medical Specialty: Pain Management
Sample Name: Medial Branch Rhizotomy

PROCEDURE: , Medial branch rhizotomy, lumbosacral.,INFORMED CONSENT:,  The risks, benefits and alternatives of the procedure were discussed with the patient.  The patient was given opportunity to ask questions regarding the procedure, its indications and the associated risks.,The risk of the procedure discussed include infection, bleeding, allergic reaction, dural puncture, headache, nerve injuries, spinal cord injury, and cardiovascular and CNS side effects with possible of vascular entry of medications.  I also informed the patient of potential side effects or reactions to the medications potentially used during the procedure including sedatives, narcotics, nonionic contrast agents, anesthetics, and corticosteroids.,The patient was informed both verbally and in writing.  The patient understood the informed consent and desired to have the procedure performed.,SEDATION: , The patient was given conscious sedation and monitored throughout the procedure.  Oxygenation was given.  The patient's oxygenation and vital signs were closely followed to ensure the safety of the administration of the drugs.,PROCEDURE:  ,The patient remained awake throughout the procedure in order to interact and give feedback.  The x-ray technician was supervised and instructed to operate the fluoroscopy machine.  The patient was placed in the prone position on the treatment table with a pillow under the abdomen to reduce the natural lumbar lordosis.  The skin over and surrounding the treatment area was cleaned with Betadine.  The area was covered with sterile drapes, leaving a small window opening for needle placement.  Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.  With fluoroscopy, a Teflon coated needle, ***, was gently guided into the region of the Medial Branch nerves from the Dorsal Ramus of ***.  Specifically, each needle tip was inserted to the bone at the groove between the transverse process and superior articular process on lumbar vertebra, or for sacral vertebrae at the lateral-superior border of the posterior sacral foramen.  Needle localization was confirmed with AP and lateral radiographs.,The following technique was used to confirm placement at the Medial Branch nerves.  Sensory stimulation was applied to each level at 50 Hz; paresthesias were noted at,*** volts.  Motor stimulation was applied at 2 Hz with 1 millisecond duration; corresponding paraspinal muscle twitching without extremity movement was noted at *** volts.,Following this, the needle Trocar was removed and a syringe containing 1% lidocaine was attached.  At each level, after syringe aspiration with no blood return, 1cc 1% lidocaine was injected to anesthetize the Medial Branch nerve and surrounding tissue.  After completion of each nerve block a lesion was created at that level with a temperature of 85 degrees Celsius for 90 seconds.  All injected medications were preservative free.  Sterile technique was used throughout the procedure.,COMPLICATIONS:,  None.  No complications.,The patient tolerated the procedure well and was sent to the recovery room in good condition.,DISCUSSION: , Post-procedure vital signs and oximetry were stable.  The patient was discharged with instructions to ice the injection site as needed for 15-20 minutes as frequently as twice per hour for the next day and to avoid aggressive activities for 1 day.  The patient was told to resume all medications.  The patient was told to be in relative rest for 1 day but then could resume all normal activities.,The patient was instructed to seek immediate medical attention for shortness of breath, chest pain, fever, chills, increased pain, weakness, sensory or motor changes, or changes in bowel or bladder function.,Follow up appointment was made in approximately 1 week.
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DESCRIPTION: Medial branch rhizotomy, lumbosacral.  Fluoroscopy was used to identify the boney landmarks of the spine and the planned needle approach.  The skin, subcutaneous tissue, and muscle within the planned approach were anesthetized with 1% Lidocaine.

pain management, lumbosacral, medial branch rhizotomy, medial branch nerves, rhizotomy, fluoroscopy,

The procedure described is a medical intervention, specifically a medial branch rhizotomy, which involves significant elements of risk and is performed under careful preparation and observation. This type of procedure requires informed consent due to potential complications, such as infection, bleeding, and nerve injuries. Although the report mentions no complications and successful completion, the inherent risks involved in operating close to the spine and nerves, the use of conscious sedation, and the need for precise needle placement contribute to a high-stakes nature. Therefore, while complications did not occur in this instance, the potential seriousness of the procedure itself justifies a high-stakes categorization.


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

Medical Specialty: Pain Management
Sample Name: Lumbar Epidural Steroid Injection

PROCEDURE:,  Lumbar epidural steroid injection without fluoroscopy.,ANESTHESIA:,  Local sedation.,VITAL SIGNS:,  See nurse's records.,COMPLICATIONS:,  None.,DETAILS OF PROCEDURE:,  INT was placed.  The patient was in the sitting position and the back was prepped with Betadine.  Lidocaine 1.5% was used for skin wheal made between __________.  A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted.  After negative aspiration, a mixture of 10 cc of preservative free normal saline and 160 mg of preservative free Depo-Medrol was injected.  Neosporin and a band-aid were applied over the puncture site.  The patient was then placed in supine position.  The patient was discharged to the recovery room in stable condition.
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DESCRIPTION: Lumbar epidural steroid injection without fluoroscopy.  A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted.

pain management, neosporin, band-aid, epidural space, lumbar epidural steroid injection, loss of resistance, tuohy needle, fluoroscopy, cerebrospinal, lumbar, epidural, injection,

The situation involves a lumbar epidural steroid injection, a common procedure in pain management. While it was performed without fluoroscopy, which increases the risk of misplacement, it was completed without complications and the patient was discharged in stable condition. The stakes are moderately high due to the potential for serious complications if the procedure is not performed correctly, but in this case, it was uneventful and standard precautions were followed.


Medical Specialty: Pain Management
Sample Name: Lumbar Sympathetic Block

PROCEDURE:,  Bilateral lumbar sympathetic block.,ANESTHESIA: , Local sedation.,VITAL SIGNS:,  See nurse's notes.,COMPLICATIONS:,  None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the prone position and the back prepped with Betadine.  The patient was given sedation and monitored.  Xylocaine 1.5% for skin wheal 6 cm lateral and slightly inferior to the bilateral L2 transverse process was made.  A 20-gauge, 15 cm LSB needle was then directed using AP and lateral fluoroscopic guidance until the tip of the needle was just inside the lateral aspect of the vertebral body and on the lateral projection, it was noted to be along the anterior vertebral body, at the junction of the upper two thirds, lower one third of the body.  After negative aspiration 3 cc of Omnipaque dye was injected showing linear spread along the body.  After negative aspiration 18 cc of 0.25% Marcaine was injected.  Attention was then directed to the L3 level with the tip of the needle guided to the junction of the upper one third, lower two third of L3.  At this point, after confirmation of the linear spread of dye along the anterior portion of the body, negative aspiration was performed and 18 cc of 0.25% Marcaine was injected.  Neosporin and band-aids were applied over the sites.  The patient was taken to the outpatient recovery room in stable condition.
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DESCRIPTION: Bilateral lumbar sympathetic block.  The patient was in the prone position and the back prepped with Betadine.  The patient was given sedation and monitored.

pain management, transverse process, fluoroscopic guidance, lateral projection, lumbar sympathetic block, vertebral body, sympathetic, betadine, needle, aspiration, lumbar,

Performing a bilateral lumbar sympathetic block is considered an invasive medical procedure, which involves precision and carries certain risks such as infection, bleeding, nerve damage, or adverse reactions to the anesthesia. Although 'complications' are stated as none, any such procedure inherently involves some level of risk, especially considering the involvement of nerves in the lumbar region. The fact that this was done under sedation and with imaging guidance further highlights its delicacy. It does not reach the highest stakes like open-heart surgery, but it is also far from low risk and typically requires careful handling and monitoring.


Medical Specialty: Pain Management
Sample Name: Lumbar Facet Injections

PREOPERATIVE DIAGNOSIS:,  Lumbar spondylosis.,POSTOPERATIVE DIAGNOSIS:,  Lumbar spondylosis.,OPERATION PERFORMED:,  Lumbar facet injections done under fluoroscopic control.,ANESTHESIA:,  Local and IV.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE:  ,After proper consent was obtained, the patient was taken to the fluoroscopy suite and placed in a prone position on a fluoroscopy table with abdominal rolls in place.  The skin was prepped and draped in a sterile classical fashion.  The patient was monitored with blood pressure cuff, electrocardiogram, and pulse oximeter.  The patient was given oxygen, intravenous sedation and analgesics as needed.  The facets were identified and marked under fluoroscopic control by rotating the C-arm obliquely, laterally and caudocranial as needed for optimal visualization of the facet joint's "Scottie dog" and the opening of the facet.,After each facet joint was identified and marked, local anesthesia was infiltrated subcutaneously and deep over each of the identified facets.  A 22-gauge spinal needle was then utilized to cannulate the facet joint under fluoroscopic control utilizing a gun barrel technique.  After negative aspiration, 0.25 - 0.5 cc of Omnipaque 240 contrast media was injected into the facet as an arthrogram to visualize the joint and the capsule.  After another negative aspiration, 1cc of a 10cc solution of Marcaine 0.5% and 100 milligrams of methyl prednisolone acetate was injected into each facet.  The patient tolerated the procedure well without apparent difficulty or complication unless otherwise noted.
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DESCRIPTION: Lumbar facet injections done under fluoroscopic control.  Lumbar spondylosis.

pain management, fluoroscopic control, c-arm, lumbar facet injections, lumbar spondylosis, fluoroscopy, spondylosis, fluoroscopic, lumbar, injections, facet

The procedure described involves medical intervention using injections for pain management in patients with lumbar spondylosis. While this type of procedure is generally routine and considered relatively safe with low risk for complications, it still involves the use of fluoroscopy and precise injection techniques, which require skill and experience. Given the medical context and the potential for patient discomfort or minor adverse effects, it could be seen as moderate stakes. The lack of complications and standard nature of the procedure suggest it is not high-stakes.


Medical Specialty: Pain Management
Sample Name: Lumbar Epidural Steroid Injection - 1

OPERATION:,  Lumbar epidural steroid injection, intralaminar approach, seated position.,ANESTHESIA:,
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DESCRIPTION: Lumbar epidural steroid injection, intralaminar approach, seated position.  An 18-gauge Tuohy needle was then placed in the epidural space utilizing a midline intralaminar approach with loss of resistance technique and a saline-filled syringe.

pain management, loss of resistance technique, methylprednisolone acetate, lumbar epidural steroid injection, epidural steroid injection, tuohy needle, steroid injection, epidural space, intralaminar approach, injection, intralaminar, saline, epidural

The procedure described is a standard lumbar epidural steroid injection used for pain management, typically a routine outpatient procedure. It involves administering medication in the epidural space to decrease inflammation and alleviate pain. While this procedure is common and generally safe, it is invasive and involves risks such as bleeding, infection, or nerve damage, which could potentially have serious consequences if complications arise. Therefore, it involves moderate risk but is not typically high-stakes unless complications occur.


Medical Specialty: Pain Management
Sample Name: Lower Extremity Pain

REASON FOR REFERRAL:,  Evaluation for right L4 selective nerve root block.,CHIEF COMPLAINT:,
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DESCRIPTION: Evaluation for right L4 selective nerve root block.

The referral is for evaluating a patient for a right L4 selective nerve root block, which is a targeted procedure used for diagnosing and managing pain stemming from nerve root irritation or injury. While this is a medical procedure, it does not inherently indicate a life-threatening or critically urgent situation. It is typically part of a planned approach to manage chronic pain conditions. Therefore, this scenario is likely medium-stakes in the context of medical procedures, focusing on improving the patient's quality of life.


Medical Specialty: Pain Management
Sample Name: Knee Injection - 2

INDICATIONS FOR PROCEDURE: , The patient was here for joint injection.  She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee, although she has complaints of arthralgias in multiple joints.  What bother her the most is the joint swelling of her left knee that has been for several months.  She has been taking Naprosyn on her last visit.  She was feeling better but still has significant symptoms especially when she was active.  After evaluation in the clinic, she decided to have a joint injection as it was discussed before.  I discussed the side effects and the complications with the parents and the patient and the possibility of doing it in the clinic, but she decided that she did not want to do it in the clinic and she wanted to be sedated for this.,DESCRIPTION OF PROCEDURE: , So under aseptic technique and under general anesthesia, 20 mg of Aristospan were injected on the left knee.  No fluid was obtained.  Her swelling was about 1+.  No complications.  No bleeding was observed, and the patient tolerated the procedure without any complications or side effects.  After that she went to the recovery room where is going to be discharged with her parents and see her back in the clinic for re-evaluation in a few weeks after the procedure.  If the patient has any problems overnight, she is going to call us.  If she had any fevers or strange swelling, she is to call us for advice.  We will see her in the clinic as scheduled.
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DESCRIPTION: She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee, although she has complaints of arthralgias in multiple joints.  Under general anesthesia, 20 mg of Aristospan were injected on the left knee.

pain management, arthralgias, aristospan, pauciarticular arthritis, joint injection, injection, swelling, arthritis, joints, kneeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves a medical procedure on a 14-year-old patient with arthritis. While the use of general anesthesia and potential complications such as infection or adverse reaction to medication could pose risks, the procedure itself, a knee injection for arthritis, is relatively routine in a controlled environment. The presence of protocol for post-procedure recovery and instructions for potential complications mitigates risk. The decision to conduct the procedure under general anesthesia instead of in-clinic indicates a consideration of the patient's comfort rather than medical necessity. Therefore, while there are elements of risk, this does not qualify as extremely high-stakes.


Medical Specialty: Pain Management
Sample Name: Intercostal block - 1

PREPROCEDURE DIAGNOSIS:,  Chest pain secondary to fractured ribs, unmanageable with narcotics.,POSTPROCEDURE DIAGNOSIS:,  Chest pain secondary to fractured ribs, unmanageable with narcotics.,PROCEDURE: , Intercostal block from fourth to tenth intercostal spaces, left.,INDICATIONS: , I was requested by Dr. X to do an intercostal block on this lady who fell and has fractured ribs, whose chest pain is paralyzing and not responding well to increasing doses of narcotics.,PROCEDURE DETAIL:,  After obtaining an informed consent with the patient on her bedside, she was placed in the right decubitus position with the left side up.  The posterior left chest wall was prepped and draped in the usual fashion and then a mixture of 1% Xylocaine 20 mL and Marcaine 0.25% 20 mL were mixed together and the intercostal spaces from the fourth to the tenth ribs were anesthetized.  A total of 30 mL worth of solution was used.  I also injected some local anesthetic subcutaneously into an area of contusion in the left lumbar area.,The patient tolerated the procedure well.  She had no respiratory distress.  Immediately, the patient felt some relief from the pain.  Chest x-ray was ordered for the following day.
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DESCRIPTION: Intercostal block from fourth to tenth intercostal spaces, left.  Chest pain secondary to fractured ribs, unmanageable with narcotics.

pain management, xylocaine, marcaine, intercostal spaces, intercostal block, fractured ribs, intercostal, fractured, narcotics, chest,

The situation involves a medical procedure aimed at controlling severe chest pain due to fractured ribs. The pain was not manageable with narcotics, necessitating an intercostal block. While the procedure appears routine and was tolerated well by the patient, the context involves significant pain management for a patient who is not responding to standard narcotic treatment. Ensuring the procedure is performed safely and effectively is somewhat high-stakes, as it directly impacts the patient's quality of life and ability to breathe comfortably, particularly due to the location near the lungs and necessary respiratory function.


Medical Specialty: Pain Management
Sample Name: Hypogastric Plexus Block

NAME OF PROCEDURE:,  Hypogastric plexus block.,ANESTHESIA:,  Local.,PROCEDURE: , The patient was in the operating room in the prone position with the back prepped and draped in sterile fashion.  Local anesthesia was used to make a skin wheal 8-10 cm lateral to the L4 spinous process bilaterally from the midline.  Starting from the left side, a 20-gauge 6-inch needle was placed to the left L5-S1 facet level under AP fluoroscopic view.  On lateral view, the tip of the needle was at the inferior one-third of the LS vertebral body, anterior aspect.  Next 5 cc of Omnipaque dye was injection showing a linear spread along the anterior portion of L5 down the sacral promontory.  After negative aspiration 18 cc of 0.25% Marcaine plus 40 mg of Depo-Medrol was injection.  There were no complications.  The above sequence was repeated for the right side.  There were no complications.  The patient was discharged back to outpatient recovery in stable condition.
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DESCRIPTION: Standard hypogastric plexus block procedure note.

pain management, vertebral body, fluoroscopic view, omnipaque, hypogastric plexus blockNOTE

The hypogastric plexus block is a common pain management procedure, often used to relieve pelvic pain. It involves using a local anesthetic and fluoroscopic guidance to ensure accurate placement of the needle. The described procedure was completed successfully without complications, and the patient was stable post-procedure. While there are risks involved, such as infection, bleeding, or nerve damage, these are relatively rare. The procedure is routine in the context of pain management, and there were no reported complications in this case. Thus, it is not considered high-stakes for medical professionals who perform it regularly.


Medical Specialty: Pain Management
Sample Name: Epidural Steroid Injection - 2

PROCEDURE:  ,Caudal epidural steroid injection without fluoroscopy.,ANESTHESIA:,  Local sedation.,VITAL SIGNS: , See nurse's records.,PROCEDURE DETAILS: , INT was placed.  The patient was in the prone position.  The back was prepped with Betadine.  Lidocaine 1.5% was used to make a skin wheal over the sacral hiatus.  A 18-gauge Tuohy needle was then placed into the epidural space.  There were no complications from this (no blood or CSF).  After negative aspiration was performed, a mixture of 10 cc preservative free normal saline plus 160 mg preservative free Depo-Medrol was injected.  Neosporin and band-aid were applied over the puncture site.  The patient was then placed in supine position.  The patient was discharged to outpatient recovery in stable condition.
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DESCRIPTION: Caudal epidural steroid injection without fluoroscopy.

pain management, epidural space, epidural steroid injection, caudal epidural, caudal, fluoroscopy, steroid, epidural, injection

The procedure described is a standard caudal epidural steroid injection without fluoroscopy, which is relatively common in pain management for back pain relief. While it is a medical procedure with certain risks (such as infection or nerve damage), it is considered minimally invasive and low-risk, especially in the absence of complications like blood or CSF during the procedure. The lack of fluoroscopy can increase risk slightly due to less precise placement, but it is not considered high-stakes. Therefore, on the spectrum of medical procedures, this would be considered moderate to low-stakes.


Medical Specialty: Pain Management
Sample Name: Epidural Steroid Injection - 3

PROCEDURE NOTE:,  The patient was placed in a prone position.  The neck was sterilely prepped using a cervical prep set.  A lidocaine skin wheal was raised over the C5-6 interspace.  A 20-gauge Tuohy needle was used.  Loss of resistance was obtained using hanging drop technique.  This was followed by 2 mL of radiograph contrast material which showed spread of the dye into the epidural space.  A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were then infiltrated.  Following the infiltration, the patient noted warming of his arms and dramatic improvement of his symptoms.  He was observed for 30 minutes and discharged home in good condition.  There were no apparent complications to the procedure.
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DESCRIPTION: Epidural steroid injection.  A total of 5 mL containing 4 mL of 0.25% bupivacaine and 80 mg of methylprednisolone acetate were infiltrated.

pain management, methylprednisolone acetate, steroid, bupivacaine, methylprednisolone, acetate, epidural, injectionNOTE,: 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 procedure described is an epidural steroid injection, which is a routine and common procedure in pain management for certain conditions. Although it requires medical precision and has risks associated, such as infection or nerve damage, the document notes that the patient was observed with no apparent complications and that the procedure resulted in symptom improvement. This suggests a non-emergency, controlled medical environment with a typical patient monitoring process. Overall, the situation does not indicate extreme consequences if complications arise, which are usually manageable. Therefore, the stakes are moderate, reflecting the balance between procedure risks and their standard nature.


Medical Specialty: Pain Management
Sample Name: Cervical Selective Nerve Root Block

CERVICAL SELECTIVE NERVE ROOT BLOCK,PREPROCEDURE PREPARATION:,  After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form.  The patient was placed in the prone position and standard ASA monitors applied.  Intravenous access was established and IV sedation was used.  For further details of IV sedation and infusion, please refer to anesthesia notes.  The patient was able to respond appropriately throughout the procedure.  * Fluoroscopy was used to identify the appropriate anatomy.  The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure.,PROCEDURE DETAILS:,  The patient was laid supine.  Oblique placement was achieved by placing pillow below the shoulder and turning the head.  The C# neural foramina was identified by counting down from the C2-3 foramen.  The external carotid artery was marked off by palpation.  The neck was aseptically prepared.  1% lidocaine was used for local infiltration and subsequently a 25-gauge spinal needle was passed down to the C# neural foramen under fluoroscopic control.  The posterior inferior edge of the foramen bone was contacted.  The needle was then redirected and slowly walked off the bone into the foramen by a few millimeters.  Care was taken to remain in the posterior inferior edge of the foramen.  Positioning was checked by AP view, in which the needle tip extended no further medially than the midpoint of the adjacent pedicle.  1 mL of contrast was used to confirm position under fluoroscopy after aspiration.  Acceptable dye pattern was seen.  Subsequent 1 mL of 1% lidocaine was injected after aspiration and the patient was monitored.  No adverse affects with 1% lidocaine were noted and subsequently 1 mL of Celestone was injected.  Compression bandage was applied to the neck and no complications were noted.,POSTPROCEDURE EVALUATION:,  After a 30-minute recovery period, during which no complications were noted, the patient was discharged home.  Pulse oximetry was carried out on room air in recovery and all oxygen saturations were above 95% with no respiratory distress observed.
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DESCRIPTION: Cervical Selective Nerve Root Block

Cervical Selective Nerve Root Block

pain management, nerve root block, 1% lidocaine, asa monitors, cervical selective nerve root block, fluoroscopy, iv sedation, nerve root, oblique, selective nerve root, carotid artery, foramen, neural foramina, edge of the foramen, selective nerve root block, cervical,

The situation involves performing a cervical selective nerve root block, which is a medical procedure requiring expertise, precise technique, and adherence to safety protocols due to potential risks like nerve damage or adverse reactions. However, it is a routine procedure in pain management with established protocols to mitigate risks. The stakes are moderate primarily due to potential complications but non-life-threatening if performed correctly with appropriate monitoring.


Medical Specialty: Pain Management
Sample Name: Caudal Epidural Steroid Injection

CAUDAL EPIDURAL STEROID INJECTION,PROCEDURE:,:,1.  Caudal epidural steroid injection with contrast.,2.  Utilization of fluoroscopy for confirmation of needle placement.,PREPROCEDURE PREPARATION:,  After being explained the risks and benefits of the procedure, the patient signed the standard informed consent form.  The patient was placed in the prone position and standard ASA monitors applied.  Intravenous access was established and IV sedation was used.  For further details of IV sedation and infusion, please refer to anesthesia notes.  Fluoroscopy was used to identify the appropriate anatomy.  The skin was prepped and draped in a sterile fashion and sterile technique was maintained throughout the procedure.,PROCEDURE DETAILS:,
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DESCRIPTION: Caudal epidural steroid injection

Caudal epidural steroid injection

pain management, steroid injection, 1% lidocaine, ap and lateral, asa monitors, caudal epidural steroid injection, epidural, fluoroscopy, ligament, needle placement, sacral hiatus, sacrococcygeal, caudal epidural, epidural steroid, caudal, steroid, injection,

Caudal epidural steroid injections are generally considered to be low to moderate risk procedures. They are commonly used in pain management to alleviate lower back pain and other related symptoms. The procedure involves some risks, such as infection, nerve damage, or bleeding, but these are relatively rare when performed by experienced practitioners. The use of fluoroscopy for confirming needle placement helps mitigate risks. Nonetheless, given its invasive nature and potential for complications, there is some degree of stakes involved. Therefore, it's not a trivial procedure, but it's also not extremely high-stakes compared to major surgeries or other high-risk medical procedures.


Medical Specialty: Pain Management
Sample Name: Depo-Medrol Injection

PROCEDURE: , Right L5-S1 intralaminar epidural steroid injection with 120 mg of Depo-Medrol under fluoroscopic guidance.,INDICATION: , The patient is a 51-year-old female with back pain referring into the right leg.,RISKS VERSUS BENEFITS: , The risks and benefits were discussed with the patient prior to the procedure.  She agrees to accept the risks and signs a written consent to proceed with the procedure.,DESCRIPTION OF PROCEDURE: , The patient was placed prone on the table.  The skin was thoroughly cleansed with Betadine swabs x3 and wiped off with a sterile gauze.  The subcutaneous intramuscular and interligamentous region was anesthetized with 4% lidocaine.,A 3-1/2-inch 20-gauge Tuohy catheter was directed under intermittent fluoroscopic guidance at the lamina.  Once the lamina was detected, the catheter was directed cephalad and medially and loss of resistance technique was used to determine the epidural space.,EPIDUROGRAM: , Omnipaque 300 1.5 mL was placed just to the right of the midline.  This was viewed on the AP and lateral projections.  It showed typical epidural spread pattern with good cephalad and caudad flow, and the flow was unrestricted.,Depo-Medrol 120 mg along with an additional bacteriostatic normal saline for a total of 60 mL injected solution was placed just to the right of the midline at L5-S1.,The patient tolerated the procedure well without procedural complications.  She will follow up with me in the office in the next few weeks to monitor her response to the injection.
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DESCRIPTION: Right L5-S1 intralaminar epidural steroid injection with 120 mg of Depo-Medrol under fluoroscopic guidance.  The patient is a 51-year-old female with back pain referring into the right leg.

pain management, epidural steroid injection, fluoroscopic guidance, depo medrol, injection

This is an interventional pain management procedure where a steroid is injected into the epidural space of the spine to manage back pain. There is a risk associated with the procedure, such as infection, bleeding, or nerve damage, which could lead to significant complications; however, these risks are generally low when performed by an experienced practitioner. The benefits include significant pain relief and improved quality of life for the patient. While it is a routine and common procedure, the stakes are elevated due to the anatomy involved and the potential consequences of complications.


Medical Specialty: Pain Management
Sample Name: Celiac Plexus Block

NAME OF PROCEDURE: , Celiac plexus block.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS:,  None.,PROCEDURE: , INT was placed.  The patient was in the prone position back prepped and draped in sterile fashion.  Then 1.5% of Lidocaine for skin wheal was made approximately 10 cm lateral to the L1-L2 vertebral junction.  A 20 gauge, 15 cm needle was then placed in a cephalad medial 45o direction; the tip of the needle was just inside the L1 vertebral body.  On lateral view, this was noted to be approximately 1.5-2.5 cm anterior to the vertebral body.  At this time, 3 cc of Omnipaque dye was injected to the opposite side where the same sequence was performed.  Following this, a mixture of 18 cc of 0.5% Marcaine was injected on each side Neosporin and band-aids was applied over the puncture sites.  The patient was taken to the outpatient recovery where blood pressure was monitored and fluids given as needed.  The patient was discharged to operating room recovery in stable condition.
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DESCRIPTION: Standard celiac plexus block procedure note.

pain management, omnipaque, vertebral body, puncture sites, celiac plexus block, celiac, plexus, block, vertebral

A celiac plexus block is a medical procedure often used to manage abdominal pain, sometimes associated with conditions like chronic pancreatitis or certain cancers. While the procedure itself is considered routine in pain management contexts, it involves the injection of an anesthetic near major blood vessels and organs and requires precision to avoid complications. Although this particular note mentions no complications and the patient was stable post-procedure, the potential for serious complications in such procedures generally means they are not low-stakes. However, since this situation describes a successful procedure with no listed complications, it is not at the highest levels of urgency or risk.