Medical Specialty: ENT - Otolaryngology
Sample Name: Adenotonsillectomy

PREOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic hypertrophic adenotonsillitis.,OPERATIVE PROCEDURE:,  Adenotonsillectomy, primary, patient under age 12.,ANESTHESIA: , General endotracheal anesthesia.,PROCEDURE IN DETAIL: , This patient was brought from the holding area and did receive preoperative antibiotics of Cleocin as well as IV Decadron.  She was placed supine on the operating room table.  General endotracheal anesthesia was induced without difficulty.  In the holding area, her allergies were reviewed.  It is unclear whether she is actually allergic to penicillin.  Codeine caused her to be excitable, but she did not actually have an allergic reaction to codeine.  She might be allergic to BACTRIM and SULFA.  After positioning a small shoulder roll and draping sterilely, McIvor mouthgag, #3 blade was inserted and suspended from the Mayo stand.  There was no bifid uvula or submucous cleft.  She had 3+ cryptic tonsils with significant debris in the tonsillar crypts.  Injection at each peritonsillar area with 0.25% with Marcaine with 1:200,000 Epinephrine, approximately 1.5 mL total volume.  The left superior tonsillar pole was then grasped with curved Allis forceps.  _______ incision and dissection in the tonsillar capsule and hemostasis and removal of the tonsil was obtained with Coblation Evac Xtra Wand on 7/3.  Mouthgag was released, reopened, no bleeding was seen.  The right tonsil was then removed in the same fashion.  The mouthgag released, reopened, and no bleeding was seen.  Small red rubber catheter in the nasal passage was used to retract the soft palate.  She had mild-to-moderate adenoidal tissue residual.  It was removed with Coblation Evac Xtra gently curved Wand on 9/5.  Red rubber catheter was then removed.  Mouthgag was again released, reopened, no bleeding was seen.  Orogastric suction carried out with only scant clear stomach contents.  Mouthgag was then removed.  Teeth and lips were inspected and were in their preoperative condition.  The patient then awakened, extubated, and taken to recovery room in good condition.,TOTAL BLOOD LOSS FROM TONSILLECTOMY: , Less than 2 mL.,TOTAL BLOOD LOSS FROM ADENOIDECTOMY: , Less than 2 mL.,COMPLICATIONS: , No intraoperative events or complications occurred.,PLAN:,  Family will be counseled postoperatively.  Postoperatively, the patient will be on Zithromax oral suspension 500 mg daily for 5 to 7 days, Lortab Elixir for pain.  _______ and promethazine if needed for nausea and vomiting.
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DESCRIPTION: Adenotonsillectomy, primary, patient under age 12.

ent - otolaryngology, hypertrophic adenotonsillitis, adenotonsillitis, endotracheal anesthesia, coblation evac xtra wand, lortab elixir, red rubber catheter, total blood loss, adenotonsillectomy, forceps, mouthgag,

The situation involves a routine adenotonsillectomy for a child, a common ENT procedure with minimal blood loss and no complications. The anesthesia was administered without issue, and the postoperative plan is straightforward. While there are always risks with surgery and anesthesia, the details indicate it was handled smoothly without complications. This context places the stakes around the typical level for routine surgical procedures in a controlled medical environment.


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

Medical Specialty: Pediatrics - Neonatal
Sample Name: Sports Physical - 1

HISTORY: , This child is seen for a sports physical.,NUTRITIONAL HISTORY:,  She takes meats, vegetables, and fruits.  Eats well.  Has may be 1 to 2 cups a day of milk.  Her calcium intake could be better.  She does not drink that much pop but she likes koolaid.  Her stools are normal.  Brushes her teeth.  Sees a dentist.,DEVELOPMENTAL HISTORY: , She did well in school last year.  Hearing and vision, no problems.  She wears corrective lenses.  She will be in 8th grade and involved in volleyball, basketball, and she will be moving to Texas.  She did go to Burton this last year.  She also plays clarinet, and will be involved also in cheerleading.  She likes to swim in the summer time.  Her menarche was January 2004.  It occurs every 7 weeks.  No particular problems at this time.,OTHER ACTIVITIES:  ,TV time about 2 to 3 hours a day.  She does not use drugs, alcohol, or smoke, and denies sexual activity.,MEDICATIONS:,  Advair 250/50 b.i.d., Flonase b.i.d., Allegra q.d.  120 mg, Xopenex and albuterol p.r.n.,ALLERGIES:,  No known drug allergies.,OBJECTIVE:,Vital Signs:  Blood pressure:  98/60.  Temperature:  96.6 tympanic.  Weight:  107 pounds, which places her at approximately the 60th percentile for weight and the height is about 80th percentile at 64-1/2 inches.  Her body mass index is 18.1, which is 40th percentile.  Pulse:  68.,HEENT:  Normocephalic.  Fundi benign.  Pupils are equal and reactive to light and accommodation.  Conjunctivae were non-injected.  Her pupils were equal, and reactive to light and accommodation.  No strabismus.  She wears glasses.  Her vision was 20/20 in both eyes.  TMs are bilaterally clear.  Nonerythematous.  Hearing in the ears, she was able to pass 40 decibel to 30 decibel.  With the right ear, she has some problems, but the left ear she passed.  Throat was clear.  Nonerythematous.  Good dentition.,Neck:  Supple.  Thyroid normal sized.  No increased lymphadenopathy in the submandibular nodes and no axillary nodes.,Respiratory:  Clear.  No wheezes and no crackles.  No tachypnea and no retractions.,Cardiovascular:  Regular rate and rhythm.  S1 and S2 normal.  No murmur.,Abdomen:  Soft.  No organomegaly and no masses.  No hepatosplenomegaly.,GU:  Normal female genitalia.  Tanner stage III in breast and pubic hair development and she was given a breast exam.  Negative for any masses.,Skin:  Without rash.,Extremities:  Deep tendon reflexes 2+/4+ bilaterally and equal.,Neurological:  Romberg negative.,Back:  No scoliosis.,She had good circumduction at the shoulder joints and duck walk is normal.,ASSESSMENT:,  Sports physical with normal growth and development.,PLAN:,  If problems continue, she will need to have her hearing rechecked.  Hopefully in the school, there will be a screening mat.  She received her first hepatitis A vaccine and she needs to have a booster in 6 to 12 months.  We reviewed her immunizations for tetanus and her last acellular DPT was 11/25/1996.  When she goes to Texas, Mom has an appointment already to see an allergist but she needs to find a primary care physician and we will ask for record release.  We talked about her menarche.  Recommended the exam of the breast regularly.  Talked about other anticipatory guidance including sunscreen, use of seat belts, and drugs, alcohol, and smoking, and sexual activity and avoidance at her age and to continue on her present medications.  She also has had problems with her ankles in the past.  She had no limitation here, but we gave her some ankle strengthening exercise handouts while she was in the office.
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DESCRIPTION: Sports physical with normal growth and development.

The situation described is a routine sports physical examination for a child transitioning to 8th grade, with a focus on overall health, growth, and development. Although there are recommendations for follow-up (e.g., hearing recheck and future vaccination), there are no immediate health concerns or life-threatening conditions mentioned. Everything seems routine, and the child's health status is generally normal. These factors suggest the stakes are low.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Consult - History and Phy.
Sample Name: Consult - Seizures - 1

CHIEF COMPLAINT: , Worsening seizures.,HISTORY OF PRESENT ILLNESS:  ,A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.  The patient stated she was in her normal state of well being when she was experiencing having frequent seizures.  She lives in assisted living.  She has been falling more frequently.  The patient was driving a scooter and apparently was hitting into the wall with unresponsiveness in association with this.  There was no head trauma, but apparently she was doing that many times and there was no responsiveness.  The patient has no memory of the event.  She is now back to her baseline.  She states her seizures are worse in the setting of stress, but it is not clear to her why this has occurred.  She is on Carbatrol 300 mg b.i.d. and she has been very compliant and without any problems.  The patient is admitted for EMU monitoring for the characterization of these episodes and for the possibility of complex partial epilepsy syndrome or better characterization of this current syndrome.,PAST MEDICAL HISTORY:  ,Include dyslipidemia and hypertension.,FAMILY HISTORY:  ,Positive for stroke and sleep apnea.,SOCIAL HISTORY: , No smoking or drinking.  No drugs.,MEDICATIONS AT HOME: , Include, Avapro, lisinopril, and dyslipidemia medication, she does not remember.,REVIEW OF SYSTEMS:,  The patient does complain of gasping for air, witnessed apneas, and dry mouth in the morning.  The patient also has excessive daytime sleepiness with EDS of 16.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Last blood pressure 130/85, respirations 20, and pulse 70.,GENERAL:  Normal.,NEUROLOGICAL:  As follows.  Right-handed female, normal orientation, normal recollection to 3 objects.  The patient has underlying MR. Speech, no aphasia, no dysarthria.  Cranial nerves, funduscopic intact without papilledema.  Pupils are equal, round, and reactive to light.  Extraocular movements intact.  No nystagmus.  Her mood is intact.  Symmetric face sensation.  Symmetric smile and forehead.  Intact hearing.  Symmetric palate elevation.  Symmetric shoulder shrug and tongue midline.  Motor 5/5 proximal and distal.  The patient does have limp on the right lower extremity.  Her Babinski is hyperactive on the left lower extremity, upgoing toes on the left.  Sensory, the patient does have sharp, soft touch, vibration intact and symmetric.  The patient has trouble with ambulation.  She does have ataxia and uses a walker to ambulate.  There is no bradykinesia.  Romberg is positive to the left.  Cerebellar, finger-nose-finger is intact.  Rapid alternating movements are intact.  Upper airway examination, the patient has a Friedman tongue position with 4 oropharyngeal crowding.  Neck more than 16 to 17 inches, BMI elevated above 33.  Head and neck circumference very high.,IMPRESSION:,1.  Cerebral palsy, worsening seizures.,2.  Hypertension.,3.  Dyslipidemia.,4.  Obstructive sleep apnea.,5.  Obesity.,RECOMMENDATIONS:,1.  Admission to the EMU, drop her Carbatrol 200 b.i.d., monitor for any epileptiform activity.  Initial time of admission is 3 nights and 3 days.,2.  Outpatient polysomnogram to evaluate for obstructive sleep apnea followed by depression if clinically indicated.  Continue her other medications.,3.  Consult Dr. X for hypertension, internal medicine management.,4.  I will follow this patient per EMU protocol.
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DESCRIPTION: Cerebral palsy, worsening seizures.  A pleasant 43-year-old female with past medical history of CP since birth, seizure disorder, complex partial seizure with secondary generalization and on top of generalized epilepsy, hypertension, dyslipidemia, and obesity.

The described scenario involves a 43-year-old female patient with a history of cerebral palsy, seizure disorders, and other health issues such as hypertension, dyslipidemia, and obesity. The primary concern is worsening seizures that have resulted in falls and episodes of unresponsiveness. The patient's condition is acute, thus requiring evaluation and monitoring in the Epilepsy Monitoring Unit (EMU). While the situation is not immediately life-threatening, it is high-stakes due to the risk of injury from seizures and the need for accurate diagnosis and management to prevent further deterioration and improve quality of life.


Medical Specialty: Neurology
Sample Name: MRI T-Spine

CC:, BLE weakness.,HX:, This 82y/o RHM was referred to the Neurology service by the Neurosurgery service for evaluation of acute onset paraplegia. He was in his usual state of health until 5:30PM on 4/6/95, when he developed sudden "pressure-like" epigastric discomfort associated with bilateral lower extremity weakness, SOB, lightheadedness and diaphoresis. He knelt down to the floor and "went to sleep." The Emergency Medical Service was alert and arrived within minutes, at which time he was easily aroused though unable to move or feel his lower extremities. No associated upper extremity or bulbar dysfunction was noted. He was taken to a local hospital where an INR was found to be 9.1. He was given vitamin K 15mg, and transferred to UIHC to rule out spinal epidural hemorrhage. An MRI scan of the T-spine was obtained and the preliminary reading was "normal." The Neurology service was then asked to evaluate the patient.,MEDS:, Coumadin 2mg qd, Digoxin 0.25mg qd, Prazosin 2mg qd.,PMH:, 1)HTN. 2)A-Fib on coumadin. 3)Peripheral vascular disease:s/p left Femoral-popliteal bypass (8/94) and graft thrombosis-thrombolisis (9/94). 4)Adenocarcinoma of the prostate: s/p TURP (1992).,FHX: ,unremarkable.,SHX:, Farmer, Married, no Tobacco/ETOH/illicit drug use.,EXAM:, BP165/60 HR86 RR18 34.2C SAO2 98% on room air.,MS: A&O to person, place, time. In no acute distress. Lucid.,CN: unremarkable.,MOTOR: 5/5 strength in BUE. Flaccid paraplegia in BLE,Sensory: T6 sensory level to LT/PP, bilaterally. Decreased vibratory sense in BLE in a stocking distribution, distally.,Coord: Intact FNF and RAM in BUE. Unable to do HKS.,Station: no pronator drift.,Gait: not done.,Reflexes: 2/2 BUE, Absent in BLE, plantar responses were flexor, bilaterally.,Rectal: decreased rectal tone.,GEN EXAM: No carotid bruitts. Lungs: bibasilar crackles. CV: Irregular rate and rhythm with soft diastolic murmur at the left sternal border. Abdomen: flat, soft, non-tender without bruitt or pulsatile mass. Distal pulses were strong in all extremities.,COURSE:, Hgb 12.6, Hct 40%, WBC 11.7, Plt 154k, INR 7.6, PTT 50, CK 41, the GS was normal. EKG showed A-Fib at 75BPM with competing junctional pacemaker, essentially unchanged from 9/12/94.,It was suspected that the patient sustained an anterior-cervico-thoracic spinal cord infarction with resultant paraplegia and T6 sensory level. A CXR was done in the ER prior to admission. This revealed cardiomegaly and a widened mediastinum. He returned from the x-ray suite and suddenly became unresponsive and went into cardiopulmonary arrest. Resuscitative measures failed. Pericardiocentesis was unremarkable. Autopsy revealed a massive aortic dissection extending from the aortic root to the origin of the iliac arteries with extensive pericardial hematoma. The dissection was seen in retrospect on the MRI T-spine.
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DESCRIPTION: MRI T-spine and CXR - Aortic Dissection.

neurology, mri, a&o, aortic dissection, cxr, irregular rate and rhythm, mri scan, neurology service, t-spine, carotid bruitts, epidural hemorrhage, mediastinum, paraplegia, person, place, stocking distribution, time, weakness, mri t spine, sensory level, spine,

The situation described involves a severe and acute medical emergency featuring an elderly patient with sudden onset paraplegia and aortic dissection leading to cardiopulmonary arrest. These conditions are life-threatening and require immediate medical intervention. The case also involves a significant medical decision process and evaluation to identify the correct diagnosis and appropriate treatment. Therefore, the stakes are extremely high as it involves significant risk to the patient's life and the decisions made directly impact patient outcomes.


Medical Specialty: Surgery
Sample Name: Prostatectomy

PREOPERATIVE DIAGNOSIS:,  Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer, Gleason score 4+3 with 85% burden and 8/12 cores positive.,PROCEDURE DONE: , Open radical retropubic prostatectomy with bilateral lymph node dissection.,INDICATIONS:,  This is a 66-year-old gentleman who had an elevated PSA of 5.  His previous PSAs were in the 1 range.  TRUS biopsy revealed 4+3 Gleason score prostate cancer with a large tumor burden.  After extensive counseling, the patient elected for retropubic radical prostatectomy.  Given his disease burden, it was advised that an open prostatectomy is probably the standard of care to ensure entire excision.  The patient consented and agreed to proceed forward.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room here.  Time out was taken to properly identify the patient and procedure going to be done.  General anesthesia was induced.  The patient was placed in the supine position.  The bed was flexed distant to the pubic area.  The patient's lower abdominal area, pubic area, and penile and scrotal area were clipped, and then scrubbed with Hibiclens soap for three minutes.  The patient was then prepped and draped in normal sterile fashion.  Foley catheter was inserted sterilely in the field.  Preoperative antibiotics were given within 30 minutes of skin incision.  A 10 cm lower abdominal incision was made from the symphysis pubis towards the umbilicus.  Dissection was taken down through Scarpa's fascia to the level of the anterior rectus sheath.  The rectus sheath was then incised and the muscle was split in the middle.  Space of rectus sheath was then entered.  The Bookwalter ring was then applied to the belly, and the bladder was then retracted to the right side, thus exposing the left obturator area.  The lymph node packet on the left side was then dissected.  This was done in a split and roll fashion with the flimsy tissue, and the left external iliac vein was incised, and the tissues were then rolled over the left external iliac vein.  Dissection was carried down from the left external iliac vein to the obturator nerve and up to the level of the pelvic sidewall.  The proximal extent of dissection was the left hypogastric artery to the level of the node of Cloquet distally.  Care was taken to avoid injury to the nerves.  An accessory obturator vein was noted and was ligated.  The same procedure was done on the right side with dissection of the right obturator lymph node packet, which was sent for pathologic evaluation.  The bladder subsequently was retracted cephalad.  The prostate was then defatted up to the level of the endopelvic fascia.  The endopelvic fascia was then incised bilaterally, and the incision was then taken to the level of the puboprostatic ligaments.  Vicryl stitch was then applied at the level of the bladder neck in order to control the bladder back bleeders.  A Babcock was then applied around the dorsal venous complex over the urethra and the K-wire was then passed between the dorsal vein complex and the urethra by passing by the aid of a right angle.  A 0-Vicryl stitch was then applied over the dorsal venous complex, which was then tied down and cinched to the symphysis pubis.  Using a knife on a long handle, the dorsal venous complex was then incised using the K-wire as a guide.  Following the incision of the dorsal venous complex, the anterior urethra was then incised, thus exposing the Foley catheter.  The 3-0 Monocryl sutures were then applied going outside in on the anterior aspect of the urethra.  The lateral edges of the urethra were also then incised, and two lateral stitches were also applied going outside end.  The catheter was then drawn back at the level of membranous urethra, and a final posterior stitch was applied going outside end.  The urethra was subsequently divided in its entirety.  A Foley catheter was then taken out and was inserted directly into the bladder through the prostatic apex.  The prostate was then entered cephalad, and the prostatic pedicles were then systematically taken down with the right angle clips and cut.  Please note that throughout the case, the patient was noted to have significant oozing and bleeding partially from the dorsal venous complex, pelvic veins, and extensive vascularity that was noted in the patient's pelvic fatty tissue.  Throughout the case, the bleeding was controlled with the aid of a clips, Vicryl sutures, silk sutures, and ties, direct pressure packing, and FloSeal.  Following the excision of the prostatic pedicles, the posterior dissection at this point was almost complete.  Please note that the dissection was relatively technically challenging due to extensive adhesions between the prostate and Denonvilliers' fascia.  The seminal vesicle on the left side was dissected in its entirety; however, the seminal vesicle on the right side was adherently stuck to the Denonvilliers' fascia, which prompted the excision of most of the right seminal vesicle with the exception of the tip.  Care was taken throughout the posterior dissection to preserve the integrity of the ureters.  The anterior bladder neck was then cut anteriorly, and the bladder neck was separated from the prostate.  Following the dissection, the 5-French feeding tubes were inserted bilaterally into the ureters thus insuring their integrity.  Following the dissection of the bladder from the prostate, the prostate at this point was mobile and was sent for pathological evaluation.  The bladder neck was then repaired using Vicryl in a tennis racquet fashion.  The rest of the mucosa was then everted.  The ureteral orifices and ureters were protected throughout the procedure.  At this point, the initial sutures that were applied into the urethra were then applied into the corresponding position on the bladder neck, and the bladder neck was then cinched down and tied down after a new Foley catheter was inserted through the penile meatus and into the bladder pulling the bladder in position.  Hemostasis was then adequately obtained.  FloSeal was applied to the pelvis.  The bladder was then irrigated.  It was draining pink urine.  The wound was copiously irrigated.  The fascia was then closed using a #1 looped PDS.  The skin wound was then irrigated, and the skin was closed with a 4-0 Monocryl in subcuticular fashion.  At this point, the procedure was terminated with no complications.  The patient was then extubated in the operating room and taken in stable condition to the PACU.  Please note that during the case about 3600 mL of blood was noted.  This was due to the persistent continuous oozing from vascular fatty tissue and pelvic veins as previously noted in the dictation.
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DESCRIPTION: Open radical retropubic prostatectomy with bilateral lymph node dissection.

surgery, bilateral lymph node dissection, retropubic prostatectomy, radical retropubic prostatectomy, gleason score, prostate cancer, trus, biopsy, bilateral lymph node, lymph node dissection, catheter was inserted, bilateral lymph, node dissection, vicryl stitch, prostatic pedicles, pelvic veins, external iliac, iliac vein, seminal vesicle, lymph node, foley catheter, dorsal venous, venous complex, bladder neck, dissection, prostatectomy, bladder, endopelvic, vicryl, catheter, vein, venous, fascia, dorsal, urethra,

The situation involves a complex surgical procedure to treat prostate cancer, which is inherently high-stakes due to the risks associated with surgery, particularly with notable blood loss and potential complications arising from the procedure. The Gleason score and cancer burden further emphasize the critical nature of ensuring successful removal and treatment. Surgical procedures like this carry potential life-altering consequences for the patient, thus adding to the stakes. Additionally, the technical challenges described, such as bleeding and adhesion issues, elevate the risk level.


Medical Specialty: Discharge Summary
Sample Name: Hip Surgery - Discharge Summar

CHIEF COMPLAINT:,  Decreased ability to perform daily living activity secondary to recent right hip surgery.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 51-year-old white female who is status post right total hip replacement performed on 08/27/2007 at ABCD Hospital by Dr. A.  The patient had an unremarkable postoperative course, except low-grade fever of 99 to 100 postoperatively.  She was admitted to the Transitional Care Unit on 08/30/2007 at XYZ Services.  Prior to her discharge from ABCD Hospital, she had received DVT prophylaxis utilizing Coumadin and Lovenox and the INR goal is 2.0 to 3.0.  She presents reporting that her last bowel movement was on 08/26/2007 prior to surgery.  Otherwise, she reports some intermittent right calf discomfort and some postoperative right hip pain.,ALLERGIES:,  No known drug allergies.,PAST MEDICAL HISTORY:,  Anxiety, depression, osteoarthritis, migraine headaches associated with menstrual cycle, history of sciatic pain in the distant past, history of herniated disc, and status post appendectomy.,MEDICATIONS:  ,Medications taken at home are Paxil, MOBIC, and Klonopin.,MEDICATIONS ON TRANSFER: , Celebrex, Coumadin, Colace, Fiorinal, oxycodone, Klonopin, and Paxil.,FAMILY HISTORY:,  Noncontributory.,SOCIAL HISTORY: , The patient is married.  She lives with her husband and is employed as a school nurse for the School Department.  She had quit smoking cigarettes some 25 years ago and is a nondrinker.,REVIEW OF SYSTEMS:,  As mentioned above.  She has a history of migraine headaches associated with her menstrual cycle.  She wears glasses and has a history of floaters.  She reports a low-grade temperature of 99 to 100 postoperatively, mild intermittent cough, scratchy throat, (the symptoms may be secondary to intubation during surgery), intermittent right calf pain, which was described as sharp, but momentary with a negative Homans sign.  The patient denies any cardiopulmonary symptoms such as chest pain, palpitation, pain in the upper neck and down to her arm, difficulty breathing, shortness of breath, or hemoptysis.  She denies any nausea, vomiting, or diarrhea, but reports as being constipated with the last bowel movement being on 08/26/2007 prior to surgery.  She denies urinary symptoms such as dysuria, urinary frequency, incomplete bladder emptying or voiding difficulties.  First day of her last menstrual cycle was 08/23/207 and she reports that she is most likely not pregnant since her husband had a vasectomy years ago.,PHYSICAL EXAMINATION:,VITAL SIGNS:  At the time of admission, temperature 97.7, blood pressure 108/52, heart rate 94, respirations 18, and 95% O2 saturation on room air.,GENERAL:  No acute distress at the time of exam.,HEENT:  Normocephalic.  Sclerae are nonicteric.  EOMI.  Dentition is in good repair.,NECK:  Trachea is at the midline.,LUNGS:  Clear to auscultation.,HEART:  Regular rate and rhythm.,ABDOMEN:  Bowel sounds are heard throughout.  Soft and nontender.,EXTREMITIES:  Right hip incision is clean, intact, and no drainage is noted.  There is diffuse edema, which extends distally.  There is no calf tenderness per se bilaterally and Homans sign is negative.  There is no pedal edema.,MENTAL STATUS:  Alert and oriented x3, pleasant and cooperative during the exam.,LABORATORY DATA: , Initial workup included chemistry panel, which was unremarkable with the exception of a fasting glucose of 122 and an anion gap that was slightly decreased at 6.  The BUN was normal at 8, creatinine was 0.9, INR was 1.49.  CBC, had a white count of 5.7, hemoglobin was 9.2, hematocrit was 26.6, and platelets were 318,000.,IMPRESSION:,1.  Status post right total hip replacement.  The patient is admitted to the TCU at XYZ's Health Services and will be seen in consultation by Physical Therapy and Occupational Therapy.,2.  Postoperative anemia, Feosol 325 mg one q.d.,3.  Pain management.  Oxycodone SR 20 mg b.i.d., and oxycodone IR 5 mg one to two tablets q.4h., p.r.n. pain.  Additionally, she will utilize ice to help decrease edema.,4.  Depression and anxiety, Paxil 40 mg daily, Klonopin 1 mg q.h.s.,5.  Osteoarthritis, Celebrex 200 mg b.i.d.,6.  GI prophylaxis, Protonix 40 mg b.i.d.  Dulcolax suppository and lactulose will be used as a p.r.n. basis and Colace 100 mg b.i.d.,7.  DVT prophylaxis will be maintained with Arixtra 2.5 mg subcutaneously daily until the INR is greater than 1.7 and Coumadin will be adjusted according to the INR.  She will continue on 5 mg every day.,8.  Right leg muscle spasm/calf pain is stable at this time and we will reevaluate on a regular basis.  Monitor for any possibility of DVT.
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DESCRIPTION: Decreased ability to perform daily living activity secondary to recent right hip surgery.

The discharge summary provided is for a patient recovering from hip surgery, detailing her medical history, current medications, and ongoing treatments. While the patient exhibits some postoperative concerns like pain, mild fever, and calf discomfort, she is generally stable with no acute distress or life-threatening conditions noted. The potential for complications like deep vein thrombosis (DVT) is being actively managed and monitored. Therefore, the focus is on routine postoperative care and recovery, which is important but not critical in the absence of severe complications.


Medical Specialty: Surgery
Sample Name: Colonoscopy - 6

INDICATIONS: , This is a 55-year-old female who is having a colonoscopy to screen for colon cancer.  There is no family history of colon cancer and there has been no blood in the stool.,PROCEDURE PERFORMED:  ,Colonoscopy.,PREP: , Fentanyl 100 mcg IV and 3 mg Versed IV.,PROCEDURE:,  The tip of the endoscope was introduced into the rectum.  Retroflexion of the tip of the endoscope failed to reveal any distal rectal lesions.  The rest of the colon through to the cecum was well visualized.  The cecal strap, ileocecal valve, and light reflex in the right lower quadrant were all identified.  There was no evidence of tumor, polyp, mass, ulceration, or other focus of inflammation.  Adverse reactions none.,IMPRESSION:,  Normal colonic mucosa through to the cecum.  There was no evidence of tumor or polyp.
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DESCRIPTION: Colonoscopy to screen for colon cancer

Colonoscopy to screen for colon cancer

surgery, versed iv, colon, tumor, polyp, mass, ulceration, focus of inflammation, tip of the endoscope, evidence of tumor, colon cancer, endoscope, cecum, cancer, colonoscopy,

The colonoscopy is part of routine cancer screening for a 55-year-old female, considered a preventive measure. There is no immediate medical concern such as blood in the stool or a family history indicating increased risk. The procedure successfully completed without any findings of concern, such as tumors or polyps. The stakes are not high, as this was a screening procedure with no adverse reactions or abnormalities detected.


Medical Specialty: Radiology
Sample Name: Transthoracic Echocardiography

REASON FOR EXAM: , Coronary artery bypass surgery and aortic stenosis.,FINDINGS: , Transthoracic echocardiogram was performed of technically limited quality.  The left ventricle was normal in size and dimensions with normal LV function.  Ejection fraction was 50% to 55%.  Concentric hypertrophy noted with interventricular septum measuring 1.6 cm, posterior wall measuring 1.2 cm.  Left atrium is enlarged, measuring 4.42 cm.  Right-sided chambers are normal in size and dimensions.  Aortic root has normal diameter.,Mitral and tricuspid valve reveals annular calcification.  Fibrocalcific valve leaflets noted with adequate excursion.  Similar findings noted on the aortic valve as well with significantly adequate excursion of valve leaflets.  Atrial and ventricular septum are intact.  Pericardium is intact without any effusion.  No obvious intracardiac mass or thrombi noted.,Doppler study reveals mild-to-moderate mitral regurgitation.  Severe aortic stenosis with peak velocity of 2.76 with calculated ejection fraction 50% to 55% with severe aortic stenosis.  There is also mitral stenosis.,IMPRESSION:,1.  Concentric hypertrophy of the left ventricle with left ventricular function.,2.  Moderate mitral regurgitation.,3.  Severe aortic stenosis, severe.,RECOMMENDATIONS: , Transesophageal echocardiogram is clinically warranted to assess the aortic valve area.
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DESCRIPTION: Coronary artery bypass surgery and aortic stenosis.  Transthoracic echocardiogram was performed of technically limited quality.  Concentric hypertrophy of the left ventricle with left ventricular function.  Moderate mitral regurgitation.  Severe aortic stenosis, severe.

radiology, coronary artery bypass surgery, aortic stenosis, annular calcification, tricuspid, mitral, regurgitation, severe aortic stenosis, concentric hypertrophy, mitral regurgitation, transthoracic, echocardiogram, hypertrophy, ventricular, valve, stenosis, aortic

The situation involves a patient's cardiac health evaluation, specifically focusing on conditions such as aortic stenosis and mitral regurgitation. Aortic stenosis, characterized by severe stenosis in this case, and mitral regurgitation can lead to serious complications, including heart failure. The findings suggest the need for further detailed evaluation through a transesophageal echocardiogram, especially given the technically limited quality of the initial transthoracic echocardiogram. Given that the patient may require intervention to prevent potentially life-threatening outcomes, this scenario is high-stakes, especially in the context of pre-existing coronary artery disease and previous bypass surgery.


Medical Specialty: Nephrology
Sample Name: Indwelling Catheter Insertion

PREOPERATIVE DIAGNOSIS: , Chronic renal failure.,POSTOPERATIVE DIAGNOSIS:  ,Chronic renal failure.,PROCEDURE PERFORMED:,  Insertion of left femoral circle-C catheter.,ANESTHESIA: , 1% lidocaine.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,HISTORY: , The patient is a 36-year-old African-American male presented to ABCD General Hospital on 08/30/2003 for evaluation of elevated temperature.  He was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.  He did require a short-term of Levophed for hypotension.  He is felt to have an infected dialysis catheter, which was removed.  He was planned to undergo replacement of his Perm-A-Cath, dialysis catheter, however, this was not possible.  He will still require a dialysis and will require at least a temporary dialysis catheter until which time a long-term indwelling catheter can be established for dialysis.  He was explained the risks, benefits, and complications of the procedure previously.  He gave us informed consent to proceed.,OPERATIVE PROCEDURE: , The patient was placed in the supine position.  The left inguinal region was shaved.  His left groin was then prepped and draped in normal sterile fashion with Betadine solution.  Utilizing 1% lidocaine, the skin and subcutaneous tissue were anesthetized with 1% lidocaine.  Under direct aspiration technique, the left femoral vein was cannulated.  Next, utilizing an #18 gauge Cook needle, the left femoral vein was cannulated.  Sutures were removed, nonpulsatile flow was observed and a Seldinger guidewire was inserted within the catheter.  The needle was then removed.  Utilizing #11 blade scalpel, a small skin incision was made adjacent to the catheter.  Utilizing a #10 French dilator, the skin, subcutaneous tissue, and left femoral vein were dilated over the Seldinger guidewire.  Dilator was removed and a preflushed circle-C 8 inch catheter was inserted over the Seldinger guidewire.  The guidewire was retracted out from the blue distal port and grasped.  The catheter was then placed in the left femoral vessel _______.  This catheter was then fixed to the skin with #3-0 silk suture.  A mesenteric dressing was then placed over the catheter site.  The patient tolerated the procedure well.  He was turned to the upright position without difficulty.  He will undergo dialysis today per Nephrology.
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DESCRIPTION: Insertion of left femoral circle-C catheter (indwelling catheter).  Chronic renal failure.  The patient was discovered to have a MRSA bacteremia with elevated fever and had tenderness at the anterior chest wall where his Perm-A-Cath was situated.

nephrology, chronic renal failure, femoral circle-c catheter, indwelling catheter, catheter, insertion, seldinger, guidewire, indwelling, femoral, dialysis,

The procedure described involves the insertion of an indwelling catheter for a patient with chronic renal failure, who previously had a MRSA infection and experienced complications like hypotension requiring Levophed. This context inherently carries higher risks due to the patient's existing infection, potential for further complications, and reliance on dialysis for renal failure. However, this is also a routine procedure for nephrologists and the absence of complications during the insertion reduces immediate high-stakes concern. Still, managing this patient requires careful consideration due to the infection history and chronic condition, making it moderately high-stakes.


Medical Specialty: Surgery
Sample Name: Extraoral I&D

PREOPERATIVE DIAGNOSIS:,  Left masticator space infection secondary to necrotic tooth #17.,POSTOPERATIVE DIAGNOSIS: , Left masticator space infection secondary to necrotic tooth #17.,SURGICAL PROCEDURE:,  Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.,FLUIDS:  ,500 mL of crystalloid.,ESTIMATED BLOOD LOSS: , 60 mL.,SPECIMENS:,  Cultures and sensitivities, Aerobic and anaerobic were sent for micro studies.,DRAINS:,  One 0.25-inch Penrose placed in the medial aspect of the masticator space.,CONDITION: , Good, extubated, breathing spontaneously, to PACU.,INDICATIONS FOR PROCEDURE:  ,The patient is a 26-year-old Caucasian male with a 2-week history of a toothache and 5-day history of increasing swelling of his left submandibular region, presents to Clinic, complaining of difficulty swallowing and breathing.  Oral surgery was consulted to evaluate the patient.,After evaluation of the facial CT with tracheal deviation and abscess in the left muscular space, it was determined that the patient needed to be taken urgently to the operating room under general anesthesia and have the abscess incision and drainage and removal of tooth #17.  Risks, benefits, alternatives, treatments were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:,  The patient was transported to operating room #4 at Clinic.  He was laid supine on the operating room table.  ASA monitors were attached and general anesthesia was induced with IV anesthetics and maintained with oral endotracheal intubation and inhalation of anesthetics.  The patient was prepped and draped in the usual oral and maxillofacial surgery fashion.,The surgeon approached the operating room table in sterile fashion.  Approximately 2 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left submandibular area in the area of the incision.  After waiting appropriate time for local anesthesia to take effect, an 18-gauge needle was introduced into the left masticator space and approximately 5 mL of pus was removed.  This was sent for aerobic and anaerobic micro.  Using a 15-blade, a 2-cm incision was made in the left submandibular region, then a hemostat was introduced in blunt dissection into the medial border of the mandible was performed.  The left masticator space was thoroughly explored as well as the left submandibular space and submental space.  Pus was drained from this site.  Copious amounts of sterile fluid were irrigated into the site.,Attention was then directed intraorally where a moistened Ray-Tec sponge was placed in the posterior oropharynx to act as a throat pack.  Approximately 4 mL of 1% lidocaine with 1:100,000 epinephrine were injected into the left inferior alveolar nerve block.  Using a 15-blade, a full-thickness mucoperiosteal flap was developed around tooth #17.  The tooth was elevated and delivered, and the lingual area of tooth #17 was explored and more pus was expressed.  This pus was evacuated intraorally __________ suction.  The extraction site and the left masticator space were irrigated, and it was noted that the irrigation was communicating with extraoral incision in the neck.,A 0.25-inch Penrose drain was placed in the lingual aspect of the mandible extraorally through the neck and secured with 2-0 silk suture.  A tack stitch intraorally with 3-0 chromic suture was placed.  The throat pack was then removed.  An orogastric tube was placed and removed all other stomach contents and then removed.  At this point, the procedure was then determined to be over.  The patient was extubated, breathing spontaneously, and transported to PACU in good condition.
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DESCRIPTION: Left masticator space infection secondary to necrotic tooth #17.  Extraoral incision and drainage of facial space infection and extraction of necrotic tooth #17.

surgery, masticator space infection, extraoral, incision and drainage, ray-tec sponge, submandibular, space infection, necrotic tooth, masticator space, space, drainage, necrotic, incision, masticator, tooth,

This situation involves a surgical procedure to address a serious infection due to a necrotic tooth. The presence of symptoms such as difficulty swallowing and breathing, along with tracheal deviation, indicates the situation was potentially life-threatening if not addressed. The patient required urgent surgery under general anesthesia. The stakes are high because untreated infections like this can lead to serious complications, including airway obstruction or systemic infection (sepsis). Critical medical decisions were made urgently, illustrating the high-stakes nature of the situation.


Medical Specialty: Orthopedic
Sample Name: Kyphosis

REASON FOR VISIT: , Kyphosis.,HISTORY OF PRESENT ILLNESS: , The patient is a 13-year-old new patient is here for evaluation of thoracic kyphosis.  The patient has a family history in a maternal aunt and grandfather of kyphosis.  She was noted by her parents to have round back posture.  They have previously seen another orthopedist who recommended observation at this time.  She is here for a second opinion in regards to kyphosis.  The patient denies any pain in her back or any numbness, tingling, or weakness in her upper or lower extremities.  No problems with her bowels or bladder.,PAST MEDICAL HISTORY: , None.,PAST SURGICAL HISTORY: , Bilateral pinning of her ears.,SOCIAL HISTORY:  ,She is currently an eighth grader at Middle School and is interested in basketball.  She lives with both of her parents and has a 9-year-old brother.  She had menarche beginning in September.,FAMILY HISTORY:  ,Of kyphosis in great grandmother and second cousin.,REVIEW OF SYSTEMS: , She is in her usual state of health and is negative except otherwise as mentioned in the history of present illness.,MEDICATIONS: , She is currently on Zyrtec, Flonase, and Ceftin for an ear infection.,ALLERGIES: , No known drug allergies.,FINDINGS: , On physical exam, she is alert, oriented, and in no acute distress standing 63 inches tall.  In regards to her back, her skin is intact with no rashes, lesions, and/or no dimpling or hair spots.  No cafe au lait spots.  She is not tender to palpation from her occiput to her sacrum.  There is no evidence of paraspinal muscle spasm.  On forward bending, there is a mild kyphosis.  She is not able to touch her toes indicating her hamstring tightness.  She has a full 5 out of 5 in all muscle groups.  Her lower extremities including iliopsoas, quadriceps, gastroc-soleus, tibialis anterior, and extensor hallucis longus.  Her sensation intact to light touch in L1 through L2 dermatomal distributions.  She has symmetric limb lengths as well bilaterally from both the coronal and sagittal planes.,X-rays today included PA and lateral sclerosis series.  She has approximately 46 degree kyphosis.,ASSESSMENT: , Kyphosis.,PLANS:  ,The patient's kyphosis is quite mild.  While this is likely in the upper limits of normal or just it is normal for an adolescent and still within normal range as would be expected return at home.  At this time, three options were discussed with the parents including observation, physical therapy, and bracing.  At this juncture, given that she has continued to grow, they are Risser 0.  She may benefit from continued observation with physical therapy, bracing would be a more aggressive option certainly that thing would be lost with following at this time.  As such, she was given a prescription for physical therapy for extension based strengthening exercises, flexibility range of motion exercises, postural training with no forward bending.  We will see her back in 3 months' time for repeat radiographs at that time including PA and lateral standing of scoliosis series.  Should she show evidence of continued progression of her kyphotic deformity, discussions of bracing would be held at time.  We will see her back in 3 months' time for repeat evaluation.
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DESCRIPTION: A 13-year-old new patientfor evaluation of thoracic kyphosis.   Family history of kyphosis in a maternal aunt and grandfather.  She was noted by her parents to have round back posture.

orthopedic, thoracic kyphosis, round back posture, physical therapy, kyphosis, patientfor, orthopedist,

The situation involves a 13-year-old patient presenting with mild thoracic kyphosis. Although family history and potential for progression exist, the condition is currently deemed mild with options like observation and physical therapy advised. Given the condition's manageable nature and absence of severe symptoms, the stakes are not particularly high at this stage.


Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 9

SUBJECTIVE:,  The patient is well-known to me.  He comes in today for a comprehensive evaluation.  Really, again he borders on health crises with high blood pressure, diabetes, and obesity.  He states that he has reached a critical decision in the last week that he understands that he cannot continue with his health decisions as they have been made, specifically the lack of exercise, the obesity, the poor eating habits, etc.  He knows better and has been through some diabetes training.  In fact, interestingly enough, with his current medications which include the Lantus at 30 units along with Actos, glyburide, and metformin, he achieved ideal blood sugar control back in August 2004.  Since that time he has gone off of his regimen of appropriate eating, and has had sugars that are running on average too high at about 178 over the last 14 days.  He has had elevated blood pressure.  His other concerns include allergic symptoms.  He has had irritable bowel syndrome with some cramping.  He has had some rectal bleeding in recent days.  Also once he wakes up he has significant difficulty in getting back to sleep.  He has had no rectal pain, just the bleeding associated with that.,MEDICATIONS/ALLERGIES:,  As above.,PAST MEDICAL/SURGICAL HISTORY: , Reviewed and updated - see Health Summary Form for details.,FAMILY AND SOCIAL HISTORY:,  Reviewed and updated - see Health Summary Form for details.,REVIEW OF SYSTEMS:,  Constitutional, Eyes, ENT/Mouth, Cardiovascular, Respiratory, GI, GU, Musculoskeletal, Skin/Breasts, Neurologic, Psychiatric, Endocrine, Heme/Lymph, Allergies/Immune all negative with the following exceptions:  None.,PHYSICAL EXAMINATION:,VITAL SIGNS:  As above.,GENERAL:  The patient is alert, oriented, well-developed, obese male who is in no acute distress.,HEENT:  PERRLA.  EOMI.  TMs clear bilaterally.  Nose and throat clear.,NECK:  Supple without adenopathy or thyromegaly.  Carotid pulses palpably normal without bruit.,CHEST:  No chest wall tenderness or breast enlargement.,HEART:  Regular rate and rhythm without murmur, clicks, or rubs.,LUNGS:  Clear to auscultation and percussion.,ABDOMEN:  Significantly obese without any discernible organomegaly.  GU:  Normal male genitalia without testicular abnormalities, inguinal adenopathy, or hernia.,RECTAL:  Smooth, nonenlarged prostate with just some irritation around the rectum itself.  No hemorrhoids are noted.,EXTREMITIES:  Some slow healing over the tibia.  Without clubbing, cyanosis, or edema.  Peripheral pulses within normal limits.,NEUROLOGIC:  Cranial nerves II-XII intact.  Strength, sensation, coordination, and reflexes all within normal limits.,SKIN:  Noted to be normal.  No subcutaneous masses noted.,LYMPH SYSTEM:  No lymphadenopathy noted.,BACK:  He has pain in his back in general.,ASSESSMENT/PLAN:,1.  Diabetes and hypertension, both under less than appropriate control.  In fact, we discussed increasing the Lantus.  He appears genuine in his desire to embark on a substantial weight-lowering regime, and is going to do that through dietary control.  He knows what needs to be done with the absence of carbohydrates, and especially simple sugar.  He will also check a hemoglobin A1c, lipid profile, urine for microalbuminuria and a chem profile.  I will need to recheck him in a month to verify that his sugars and blood pressure have come into the ideal range.  He has allergic rhinitis for which Zyrtec can be used.,2.  He has irritable bowel syndrome.  We will use Metamucil for that which also should help stabilize the stools so that the irritation of the rectum is lessened.  For the bleeding I would like to obtain a sigmoidoscopy.  It is bright red blood.,3.  For his insomnia, I found there is very little in the way of medications that are going to fix that, however I have encouraged him in good sleep hygiene.  I will look forward to seeing him back in a month.  I will call him with the results of his lab.  His medications were made out.  We will use some Elocon cream for his seborrheic dermatitis of the face.  Zyrtec and Flonase for his allergic rhinitis.
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DESCRIPTION: Comprehensive Evaluation - Diabetes, hypertension, irritable bowel syndrome, and insomnia.

The medical situation described involves multiple chronic health conditions such as diabetes, hypertension, obesity, irritable bowel syndrome, and insomnia. These conditions are not currently well-controlled, putting the patient at potential risk for serious health complications if not managed properly. However, the patient is not in acute distress and is under ongoing medical supervision with a clear plan for treatment and follow-up, which reduces the immediacy of potential life-threatening outcomes. The discussion of lifestyle changes also reflects a proactive approach to health management. Thus, while the situation is concerning and requires careful management, it doesn't constitute an immediate high-stakes emergency.


Medical Specialty: SOAP / Chart / Progress Notes
Sample Name: Leg Pain & Bone Pain

CHIEF COMPLAINT:,  Leg pain.,HISTORY OF PRESENT ILLNESS:,  This is a 56-year-old female who has pain in her legs at nighttime and when she gets up it comes and goes, radiates from her buttocks to her legs, sometimes it is her ankle.  She has noticed it since she has been on Lipitor.  She has had some night sweats occasionally.  She has had a little bit of fever and nausea.  She has noticed her blood sugars have been low.  She has lost over 30 pounds after exercising doing water aerobics at Genesis in Wichita.  She has noticed her fasting blood sugars have been ranging from 100 to 120.  Blood sugars one and a half hours after meals have been 185.  She is coming in for a diabetic checkup in one month and wants lab prior to that time.  She has been eating more meat recently and has not been on a diet for cholesterol.,CURRENT MEDICATIONS:,  Include Lipitor 80 mg q.d. discontinued today, Vioxx 25 mg q.d., Maxzide 37/25 q.d., Protonix 40 mg q.d., hydroxyzine pamoate 50 mg at h.s., aspirin 81 mg q.d., Glucovance 1.25/250 b.i.d. decreased to one a day today, Monopril 20 mg q.d., estradiol one mg q.d., and glucosamine 1000 mg q.d.,ALLERGIES:,  Cipro, sulfa, Bactrim, and Demerol.,OBJECTIVE:,Vital Signs:  Weight is 248 pounds which is a 12-pound drop from January.  Blood pressure 120/70.  Pulse 68.,General:  This is a well-developed adult female, awake, alert, and in no acute distress.,HEENT:  Oropharynx and HEENT are within normal limits.,Lungs:  Clear.,Heart:  Regular rhythm and rate.,Abdomen:  Soft, nontender, and nondistended without organomegaly.,GU:  Palpation of femurs do not cause pain, rotation of hips do not cause pain, and compression of the hips do not cause pain.,Neurologic:  Deep tendon reflexes are normal.,Extremities:  Pulses in lower extremities are normal.  Straight leg lifts are normal.,ASSESSMENT/PLAN:,1.  Leg pain/bone pain, I am going to check her CMP.  I think this possibly is a side effect from Lipitor.  We will stop Lipitor, have her follow up in one month which she has already got planned for diabetes appointment and check symptoms at that time.  Certainly if her pain improves might consider something like Crestor, which is more water soluble, which may cause less adverse effects.  We will check her comprehensive metabolic panel to make sure the alkaline phosphatase is okay, may need an x-ray of back, hip, and legs at that time if symptoms are not gone.,2.  Hypercholesterolemia, this is somewhat bothersome as she is a diabetic.  Did discuss with her that we need to stick to the diet especially after going off of Lipitor.  We will see how she does with her bone pain/leg pain off of Lipitor.  If she has improvement may consider Crestor in one month.  I am going to check her lipid panel and a CMP.  Apparently, she is going to get this at a different site, Mapleridge in Wichita.,3.  Type II diabetes.  We will decrease her Glucovance because she is having frequent low blood sugars.  Her previous hemoglobin A1c was 5.6 so we will see if this improves her symptoms.  I am also going to check a hemoglobin A1c at Mapleridge in Wichita and have a followup here in one month for that diabetes appointment.
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DESCRIPTION: A female who has pain in her legs at nighttime that comes and goes, radiates from her buttocks to her legs, sometimes in her ankle.

soap / chart / progress notes, cmp, hypercholesterolemia, leg pain, type ii diabetes, ankle, blood sugars, bone pain, buttocks, pain, radiates from her buttocks, leg pain/bone, leg, sugars, weight,

The patient's situation indicates potential side effects from medication (Lipitor) leading to leg pain and other symptoms. She is also managing hypercholesterolemia and type II diabetes, both of which require careful monitoring and management. The need to discontinue Lipitor and monitor the patient's symptoms, along with her blood sugar levels and potential plans for alternative medications, add complexity. However, the patient is not in acute distress, and the physician has a detailed follow-up and adjustment plan. The stakes are moderately high because effective management is needed to prevent deterioration but she is in stable condition at present.


Medical Specialty: Podiatry
Sample Name: Right Foot Series

EXAM: , Right foot series.,REASON FOR EXAM:  ,Injury.,FINDINGS: , Three images of the right foot were obtained.  On the AP image only, there is a subtle lucency seen in the proximal right fourth metatarsal and a mild increased sclerosis in the proximal fifth metatarsal.  Also on a single image, there is a lucency seen in the lateral aspect of the calcaneus that is seen on the oblique image only.  Fractures in these bones cannot be completely excluded.  There is soft tissue swelling seen overlying the calcaneus within this region.,IMPRESSION: , Cannot exclude nondisplaced fractures in the lateral aspect of the calcaneus or at the base of the fourth and fifth metatarsals.  Recommend correlation with site of pain in addition to conservative management and followup imaging.  A phone call will be placed to the emergency room regarding these findings.
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DESCRIPTION: Right foot series after a foot injury.

Right foot series after a foot injury.

podiatry, sclerosis, calcaneus, metatarsal, foot series

The situation involves interpreting medical imaging findings that suggest possible nondisplaced fractures in the foot. There's a recommendation for patient management involving conservative treatment and follow-up, with communication to the emergency department. While important for the patient's foot health and recovery, it does not seem life-threatening or time-sensitive compared to other potential medical emergencies like a heart attack or severe head injury. Thus, it is moderate in stakes, primarily focusing on the appropriate management to prevent complications and ensure recovery.


Medical Specialty: Office Notes
Sample Name: Normal Physical Exam Template - 7

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

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

The information provided is a normal physical exam template used in routine check-ups. It does not indicate the presence of any acute medical issues or emergencies. Such templates are typically used as documentation for standard physical assessments, indicating an absence of medical abnormalities. Therefore, the stakes involved are low, as the situation pertains to documenting expected normal findings rather than diagnosing or managing critical health conditions.


Medical Specialty: Consult - History and Phy.
Sample Name: Lower Quadrant Pain

REASON:,  Right lower quadrant pain.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant 48-year-old female with an approximately 24-hour history of right lower quadrant pain, which she describes as being stabbed with a knife, radiating around her side to her right flank.  She states that is particularly bad when up and walking around, goes away when she is lying down.  She has no nausea or vomiting, no dysuria, no fever or chills, though she said she did feel warm.  She states that she feels a bit like she did when she had her gallbladder removed nine years ago.  Additionally, I should note that the patient is currently premenopausal with irregular menses, going anywhere from one to two months between cycles.  She has no abnormal vaginal discharge, and she is sexually active.,ALLERGIES:,  NO KNOWN DRUG ALLERGIES.,MEDICATIONS,1.  Hydrochlorothiazide 25 mg p.o. daily.,2.  Lisinopril 10 mg p.o. daily.,3.  Albuterol p.r.n.,PAST MEDICAL HISTORY:  ,Hypertension and seasonal asthma.,PAST SURGICAL HISTORY: , Left bilateral breast biopsy for benign disease.  Cholecystitis/cholecystectomy following tubal pregnancy 22 years ago.,FAMILY HISTORY: , Mother is alive and well.  Father with coronary artery disease.  She has siblings who have increased cholesterol.,SOCIAL HISTORY:  ,The patient does not smoke.  She quit 25 years ago.  She drinks one beer a day.  She works as a medical transcriptionist.,REVIEW OF SYSTEMS: , Positive for an umbilical hernia, but otherwise negative with the exception of what is noted above.,PHYSICAL EXAMINATION,GENERAL:  Reveals a morbidly obese female who is alert and oriented x3, pleasant and well groomed, and in mild discomfort.,VITAL SIGNS:  Her temperature is 38.7, pulse 113, respirations 18, and blood pressure 144/85.,HEENT:  Normocephalic and atraumatic.  Sclerae are without icterus.  Conjunctivae are not injected.,NECK:  Neck is supple.  Carotids 2+.  Trachea is midline.  Carotids are without bruits.,LYMPH NODES:  There is no cervical, supraclavicular, or occipital adenopathy.,LUNGS:  Clear to auscultation.,CARDIAC:  Regular rate and rhythm.,ABDOMEN:  Soft.  No hepatosplenomegaly.  She has a positive Rovsing sign and a positive obturator sign.  She is tender in the right lower quadrant with mild rebound and no guarding.,EXTREMITIES:  Reveal 2+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses.  She has only trace edema with varicosities around the bilateral ankles.,CNS:  Without gross neurologic deficits.,INTEGUMENTARY:  Skin integrity is excellent.,DIAGNOSTICS: , Urine, specific gravity is 1.010, blood is 50, leukocytes 1+, white blood cells 10 to 25, rbc's 2 to 5, and 2 to 5 squamous epithelial cells.  White blood cell count is 20,000 with 75 polys and 16 lymphs.  H&H is 13.7 and 39.7.  Total bilirubin 1.3, direct bilirubin 0.2, and alk phos 98.  Sodium 138, potassium 3.1, chloride 101, CO2 26, calcium 9.5, glucose 103, BUN 16, and creatinine 0.91.  Lipase is 19.  CAT scan is negative for acute appendicitis.  In fact, it mentions that the appendix is not discretely identified.  There are no focal inflammatory masses, abscess, ascites, or pneumoperitoneum.,IMPRESSION: , Abdominal pain right lower quadrant, etiology is unclear.,PLAN:,  Plan is to admit the patient.  Recheck the white blood cell count in the morning.  Re-examine her and further plan is pending, the results of that evaluation.
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DESCRIPTION: Abdominal pain right lower quadrant, radiating around her side to her right flank.  Etiology is unclear.

The patient exhibits symptoms that could be indicative of various potential medical conditions, some of which can be serious, such as appendicitis despite the negative CAT scan. Her elevated temperature, increased white blood cell count, and abdominal tenderness indicate an ongoing inflammatory process or infection, which requires careful monitoring and further investigation to determine the exact cause. Admitting the patient for further observation and tests is warranted. Although not the most urgent emergency medical condition, the potential for serious underlying issues makes this a moderate to high-stakes clinical situation.


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy

PREOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,POSTOPERATIVE DIAGNOSES,1.  Cervical spondylosis with myelopathy.,2.  Herniated cervical disk, C4-C5.,OPERATIONS PERFORMED,1.  Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord at C5-C6.,2.  Bilateral C6 nerve root decompression.,3.  Anterior cervical discectomy at C4-C5 with removal of herniated disk and osteophytes and decompression of spinal cord.,4.  Bilateral C5 nerve root decompression.,5.  Anterior cervical discectomy at C3-C4 with removal of herniated disk and osteophytes, and decompression of spinal cord.,6.  Bilateral C4 nerve root decompression.,7.  Harvesting of autologous bone from the vertebral bodies.,8.  Grafting of allograft bone for creation of arthrodesis.,9.  Creation of arthrodesis with allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C5-C6.,10.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C4-C5.,11.  Creation of additional arthrodesis using allograft bone and autologous bone from the vertebral bodies and bone morphogenetic protein at C3-C4.,12.  Placement of anterior spinal instrumentation from C3 to C6 using a Synthes Small Stature Plate, using the operating microscope and microdissection technique.,INDICATIONS FOR PROCEDURE: , This 62-year-old man has severe cervical spondylosis with myelopathy and cord compression at C5-C6.  There was a herniated disk with cord compression and radiculopathy at C4-C5.  C3-C4 was the source of neck pain as documented by facet injections.,A detailed discussion ensued with the patient as to the pros and cons of the surgery by two levels versus three levels.  Because of the severe component of the neck pain that has been relieved with facet injections, we elected to proceed ahead with anterior cervical discectomy and fusion at C3-C4, C4-C5, and C5-C6.,I explained the nature of this procedure in great detail including all risks and alternatives.  He clearly understands and has no further questions and requests that I proceed.,PROCEDURE:  ,The patient was placed on the operating room table and was intubated taking great care to keep the neck in a neutral position.  The methylprednisolone spinal cord protocol was instituted with bolus and continuous infusion dosages.,The left side of the neck was carefully prepped and draped in the usual sterile manner.,A transverse incision was made in the neck crease.  Dissection was carried down through the platysma musculature and the anterior spine was exposed.  The medial borders of the longus colli muscle were dissected free from their attachments to the spine.  Caspar self-retaining pins were placed into the bodies of C3, C4, C5, and C6 and x-ray localization was obtained.  A needle was placed in what was revealed to be the disk space at C4-C5 and an x-ray confirmed proper localization.,Self-retaining retractors were then placed in the wound, taking great care to keep the blades of the retractors underneath the longus colli muscles.,First I removed the large amount of anterior overhanging osteophytes at C5-C6 and distracted the space.  The high-speed cutting bur was used to drill back the osteophytes towards the posterior lips of the vertebral bodies.,An incision was then made at C4-C5 and the annulus was incised and a discectomy was performed back to the posterior lips of the vertebral bodies.,The retractors were then adjusted and again discectomy was performed at C3-C4 back to the posterior lips of the vertebral bodies.  The operating microscope was then utilized.,Working under magnification, I started at C3-C4 and began to work my way down to the posterior longitudinal ligament.  The ligament was incised and the underlying dura was exposed.  I worked out laterally towards the takeoff of the C4 nerve root and widely decompressed the nerve root edge of the foramen.  There were a large number of veins overlying the nerve root which were oozing and rather than remove these and produce tremendous amount of bleeding, I left them intact.  However, I could to palpate the nerve root along the pedicle into the foramen and widely decompressed it on the right.  The microscope was angled to the left side where similar decompression was achieved.,The retractors were readjusted and attention was turned to C4-C5.  I worked down through bony osteophytes and identified the posterior longitudinal ligament.  The ligament was incised; and as I worked to the right of the midline, I encountered herniated disk material which was removed in a number of large pieces.  The C5 root was exposed and then widely decompressed until I was flush with the pedicle and into the foramen.  The root had a somewhat high takeoff but I worked to expose the axilla and widely decompressed it.  Again the microscope was angled to the left side where similar decompression was achieved.  Central decompression was achieved here where there was a moderate amount of spinal cord compression.  This was removed by undercutting with 1 and 2-mm Cloward punches.,Attention was then turned to the C5-C6 space.  Here there were large osteophytes projecting posteriorly against the cord.  I slowly and carefully used the high-speed cutting diamond bur to drill these and then used 1 to 2-mm Cloward punches to widely decompress the spinal cord.  This necessitated undercutting the bodies of both C5 and C6 extensively, but I was then able to achieve a good decompression of the cord.  I exposed the C6 root and widely decompressed it until I was flush with the pedicle and into the foramen on the right.  The microscope was angled to the left side where a similar decompression was achieved.,Attention was then turned to creation of the arthrodesis.  A high-speed Cornerstone bur was used to decorticate the bodies of C5-C6, C4-C5 and C3-C4 to create a posterior shelf to prevent backwards graft migration.  Bone dust during the drilling was harvested for later use.,Attention was turned to creation of the arthrodesis.  Using the various Synthes sizers, I selected a 7-mm lordotic graft at C5-C6 and an 8-mm lordotic graft at C4-C5 and a 9-mm lordotic graft at C3-C4.  Each graft was filled with autologous bone from the vertebral bodies and bone morphogenetic protein soaked sponge.  I decided to use BMP in this case because there were three levels of fusion and because this patient has a very heavy history of smoking and having just recently discontinued for two weeks.  The BMP sponge and the ____________ bone were then packed in the center of the allograft.,Under distraction, the graft was placed at C3-C4, C4-C5, and C5-C6 as described.  An x-ray was obtained which showed good graft placement with preservation of the cervical lordosis.,Attention was turned to the placement of anterior spinal instrumentation.  Various sizes of Synthes plates were selected until I decided that a 54-mm plate was appropriate.  The plate had to be somewhat contoured and bent inferiorly and the vertebral bodies had to be drilled so that the plates would sit flush.  The holes were drilled and the screws were placed.  Eight screws were placed with two screws at C3, two screws at C4, two screws at C5, and two screws at C6.  All eight screws had good purchase.  The locking screws were tightly applied.  An x-ray was obtained which showed good placement of the graft, plate, and screws.,Attention was turned to closure.  The wound was copiously irrigated with Bacitracin solution and meticulous hemostasis was obtained.  A medium Hemovac drain was placed in the anterior vertebral body space and brought out through a separate stab incision in the skin.  The wound was then carefully closed in layers.  Sterile dressings were applied, and the operation was terminated.,The patient tolerated the procedure well and left for the recovery room in excellent condition.  The sponge and needle counts were reported as correct.  There were no intraoperative complications.,Specimens were sent to Pathology consisting of disk material and bone and soft tissue.
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DESCRIPTION: Anterior cervical discectomy and removal of herniated disk and osteophytes and decompression of spinal cord and bilateral nerve root decompression.  Harvesting of autologous bone from the vertebral bodies.  Grafting of allograft bone for creation of arthrodesis.

The situation involves a detailed neurosurgery procedure, which typically carries significant risks and implications for the patient's health. The potential complications can have serious consequences, making it a high-stakes scenario. The surgery addresses spinal cord compression and involves critical parts of the nervous system, using precision techniques and complex instrumentation. The success of this surgery directly affects the patient's quality of life, potentially preventing severe outcomes like paralysis or chronic pain. Thus, the stakes are high both in terms of patient safety and the skill required to perform the operation successfully.


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

Medical Specialty: Office Notes
Sample Name: Premature retina and vitreous

OCULAR FINDINGS: , Anterior chamber space:  Cornea, iris, lens, and pupils all unremarkable on gross examination in each eye.,Ocular adnexal spaces appear very good in each eye.,Cyclomydril x2 was used to dilate the pupil in each eye.,Medial spaces are clear and the periphery is still hazy in each eye.,Ocular disc space, normal size and shape with a pink color with clear margin in each eye.,Macular spaces are normal in appearance for the age in each eye.,Posterior pole.  No dilated blood vessels seen in each eye.,Periphery:  The peripheral retina is still hazy and retinopathy of prematurity cannot be ruled out at this time in each eye.,IMPRESSION:  ,Premature retina and vitreous, each eye.,PLAN:  ,Recheck in two weeks.,
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DESCRIPTION: Small office note on premature retina and vitreous.

office notes, eye ocular, premature retina, pupils, periphery, premature, vitreous, retina, eye,

The note pertains to a medical examination of a patient's eyes, specifically regarding retinopathy of prematurity, a condition typically affecting premature infants that can lead to vision problems. The stakes are relatively high because failing to diagnose or manage this condition can lead to complications or vision loss. However, currently, it is a follow-up plan with no immediate life-threatening issues, hence the stakes are moderate.


Medical Specialty: Pain Management
Sample Name: Plantar Fascia Injection

PROCEDURE:,:  Informed consent was obtained from the patient.  Special mention was made of the possibility of infection and necrosis of the heel pad.  The patient was placed in the supine position.  The tender area in the medial aspect of the heel was identified by palpation.  After proper preparation with antiseptic solution of the skin, a syringe containing 2 mL of 1% lidocaine was attached to 1.5" 27 gauge needle.  The needle was carefully advanced through the carefully identified point at a right angle to the skin, directly towards the central and medial aspect of the calcaneus.  The needle was advanced very slowly until the needle impinged on the bone, and then was withdrawn slowly.  The contents of the syringe were then gently injected.  Subsequently, the needle was left in place and a syringe containing 2 mL of 0.25% Marcaine and 1 mL of Depo-Medrol was attached to the needle and injected after aspiration at this site.  Subsequently the needle was removed.  Pressure was applied at the site of insertion and once it was made sure there was no bleeding taking place, a small bandage was applied.,POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers.  The patient has been asked to restrict the use of the * extremity for the next 24 hours.
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DESCRIPTION: Plantar Fascia Injection

Plantar Fascia Injection

pain management, plantar fascia injection, plantar fascia, calcaneus, heel pad, necrosis, depo-medrol, bandage, medial aspect, heel, syringe, injection, needleNOTE,: 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 a relatively common outpatient procedure for pain management that involves injecting medication into the plantar fascia. Although there are potential risks such as infection and necrosis as mentioned, these are uncommon when proper sterile techniques are used. The stakes for this procedure are not extremely high compared to more invasive surgeries, though any medical procedure involving injections does carry inherent risks. The mention of monitoring for signs of infection post-procedure is standard practice. Overall, due to the potential for complications, I would categorize this as a moderate-stakes situation.


Medical Specialty: Discharge Summary
Sample Name: CHF & Pleural Effusion - Discharge Summary

DIAGNOSIS AT ADMISSION: , Congestive heart failure (CHF) with left pleural effusion.,DIAGNOSES AT DISCHARGE,1.  Congestive heart failure (CHF) with pleural effusion.,2.  Hypertension.,3.  Prostate cancer.,4.  Leukocytosis.,5. Anemia of chronic disease.,HOSPITAL COURSE:  ,The patient was admitted to the emergency room by Dr. X. He has diuresed with IV Lasix.  He was placed on Prinivil, aspirin, oxybutynin, docusate, and Klor-Con.  Chest x-rays were followed.  He did have free flowing fluid in his left chest.  Radiology consultation was obtained for thoracentesis.  The patient was seen by Dr. Y. An echocardiogram was done.  This revealed an ejection fraction of 60% with diastolic dysfunction and periaortic stenosis with an opening of 1 cm3.  An adenosine sestamibi was done in March 2000, with a small fixed apical defect, but no ischemia.  Cardiac enzymes were negative.  Dr. Y recommended a beta-blocker with an ACE inhibitor; therefore, the lisinopril was discontinued.  The patient felt much better after the thoracentesis.  I do not have the details of this, i.e., the volumes.  No fluid was sent for routine studies.,LABORATORY AT DISCHARGE: , Sodium 134, potassium 4.2, chloride 99, CO2 26, glucose 182, BUN 17, and creatinine 1.0.  Glucose was elevated because of several doses of Solu-Medrol given to him because of bronchospams.  Magnesium was 1.8, calcium was 8.1.  Liver enzymes were unremarkable.  Cardiac enzymes were normal as mentioned.  PT/INR is 1.02, PTT 31.3, white blood cell count 15, 000 with a left shift.  This was presumed due to the corticosteroids.  H&H was 32.3/11.3 and platelets 352,000, and MCV was 99.  The patient's O2 saturations on room air were normal.,Vital signs were stable.,DISCHARGE MEDICATIONS: , He is being discharged home on Lasix 40 mg daily, potassium chloride 10 mEq daily, atenolol 25 mg daily, aspirin 5 grains daily, Ditropan 5 mg b.i.d., and Colace 100 mg b.i.d.,FOLLOWUP: , He will be followed in my office in 1 week.  He is to notify if recurrent fever or chills.,PROGNOSIS:  ,Guarded.
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DESCRIPTION: Congestive heart failure (CHF) with left pleural effusion.  Anemia of chronic disease.

discharge summary, prostate cancer, anemia of chronic disease, congestive heart failure, pleural effusion, thoracentesis, chf, anemia

This discharge summary involves a patient with multiple complex and serious health conditions, including congestive heart failure (CHF) with pleural effusion, hypertension, prostate cancer, leukocytosis, and anemia of chronic disease. These conditions require careful ongoing management and follow-up, and any oversight could potentially lead to severe health complications or deterioration. The prognosis is labeled as 'guarded,' indicating a cautious outlook on the patient's recovery. Therefore, the stakes are relatively high considering the potential health ramifications if not properly managed.


Medical Specialty: Pediatrics - Neonatal
Sample Name: Otitis Media - H&P

CHIEF COMPLAINT:,  This 3-year-old female presents today for evaluation of chronic ear infections bilateral.,ASSOCIATED SIGNS AND SYMPTOMS FOR OTITIS MEDIA: , Associated signs and symptoms include:  cough, fever, irritability and speech and language delay.  Duration (ENT):  Duration of symptom:  12 rounds of antibiotics for otitis media.  Quality of ear problems:  Quality of the pain is throbbing.,ALLERGIES: , No known medical allergies.,MEDICATIONS:,  None currently.,PMH:,  Past medical history is unremarkable.,PSH: , No previous surgeries.,SOCIAL HISTORY:,  Parent admits child is in a large daycare.,FAMILY HISTORY:,  Parent admits a family history of Alzheimer's disease associated with paternal grandmother.,ROS:,  Unremarkable with exception of chief complaint.,PHYSICAL EXAM:,  Temp:  99.6 Weight:  38 lbs.,Patient is a 3-year-old female who appears pleasant, in no apparent distress, her given age, well developed, well nourished and with good attention to hygiene and body habitus.,The child is accompanied by her mother who communicates well in English.,Head & Face:  Inspection of head and face shows no abnormalities.  Examination of salivary glands shows no abnormalities.  Facial strength is normal.,Eyes:  Pupil exam reveals PERRLA.,ENT:  Otoscopic examination reveals otitis media bilateral.,Hearing exam using tuning fork shows hearing to be diminished bilateral.,Inspection of left ear reveals drainage of a small amount.,Inspection of nasal mucosa, septum and turbinates reveals no abnormalities.,Frontal and maxillary sinuses all transilluminate well bilaterally.,Inspection of lips, teeth, gums, and palate reveals no gingival hypertrophy, no pyorrhea, healthy gums, healthy teeth and no abnormalities.,Inspection of the tongue reveals normal color, good motility and midline position.,Examination of oropharynx reveals no abnormalities.,Examination of nasopharynx reveals adenoid hypertrophy.,Neck:  Neck exam reveals no abnormalities.,Lymphatic:  No neck or supraclavicular lymphadenopathy noted.,Respiratory:  Chest inspection reveals chest configuration non-hyperinflated and symmetric expansion.  Auscultation of lungs reveal clear lung fields and no rubs noted.,Cardiovascular:  Heart auscultation reveals no murmurs, gallop, rubs or clicks.,Neurological/Psychiatric:  Testing of cranial nerves reveals no deficits.  Mood and affect normal and appropriate to situation.,TEST RESULTS:,  Audiometry test shows conductive hearing loss at 30 decibels and flat tympanogram.,IMPRESSION: , OM, suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.,PLAN:,  Patient scheduled for myringotomy and tubes, with adenoidectomy, using general anesthesia, as outpatient and scheduled for 08/07/2003.  Surgery will be performed at Children's Hospital.  Pre-operative consent form read and signed by parent.  Common risks and side effects of the procedure and anesthesia were mentioned.  Parent questions elicited and answered satisfactorily regarding planned procedure.  ,EDUCATIONAL MATERIAL PROVIDED: , Hospital preregistration, middle ear infection and myringtomy and tubes surgery.,PRESCRIPTIONS:,  Augmentin  Dosage:  400 mg-57 mg/5 ml powder for reconstitution  Sig:  One PO Q8h  Dispense:  1 Refills:  0  Allow Generic:  No
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DESCRIPTION: A 3-year-old female for evaluation of chronic ear infections bilateral - OM (otitis media), suppurative without spontaneous rupture.  Adenoid hyperplasia bilateral.

This case involves a 3-year-old patient with chronic otitis media requiring surgical intervention. While chronic ear infections can lead to hearing loss and speech delays, these are common pediatric conditions and generally treatable. The planned procedure, myringotomy with tubes and adenoidectomy, is routine and performed under general anesthesia, which does carry standard surgical risks. However, given the child's age and the need for surgery, it is a moderately high-stakes situation within pediatric care. The stakes are not extremely high as the condition is common and treatable, and the surgical procedure is routine and frequently successful.


Medical Specialty: Urology
Sample Name: Discharge Summary - Urology

ADMITTING DIAGNOSES:,1. Hematuria.,2. Benign prostatic hyperplasia.,3. Osteoarthritis.,DISCHARGE DIAGNOSES:,1. Hematuria, resolved.,2. Benign prostatic hyperplasia.,3. Complex renal cyst versus renal cell carcinoma or other tumor.,4. Osteoarthritis.,HOSPITAL COURSE:, This is a 77-year-old African-American male who was previously well until he began having gross hematuria and clots passing through his urethra on the day of admission. He stated that he never had blood in his urine before, however, he does have a past history of BPH and he had a transurethral resection of prostate more than 10 years ago. He was admitted to a regular bed. Dr. G of Urology was consulted for evaluation of his hematuria. During the workup for this, he had a CT of the abdomen and pelvis with and without contrast with early and late-phase imaging for evaluation of the kidneys and collecting system. At that time, he was shown to have multiple bilateral renal cysts with one that did not meet classification as a simple cyst and ultrasound was recommended.,He had an ultrasound done of the cyst which showed a 2.1 x 2.7 cm mass arising from the right kidney which, again, did not fit ultrasound criteria for a simple cyst and they recommended further evaluation by an MRI as this could be a hemorrhagic cyst or a solid mass or tumor, so an MRI was scheduled on the day of discharge for further evaluation of this. The report was not back at discharge. The patient had a cystoscopy and transurethral resection of prostate as well with entire resection of the prostate gland. Pathology on this specimen showed multiple portions of prostatic tissue which was primarily fibromuscular, and he was diagnosed with nonprostatic hyperplasia. His urine slowly cleared. He tolerated a regular diet with no difficulties in his activities of daily living, and his Foley was removed on the day of discharge.,He was started on ciprofloxacin, Colace, and Lasix after the transurethral resection and continued these for a short course. He is asked to continue the Colace as an outpatient for stool softening for comfort.,DISCHARGE MEDICATIONS:, Colace 100 mg 1 b.i.d.,DISCHARGE FOLLOWUP PLANNING:, The patient is to follow up with his primary care physician at ABCD, Dr. B or Dr. J, the patient is unsure of which, in the next couple weeks. He is to follow up with Dr. G of  Urology in the next week by phone in regards to the patient's MRI and plans for a laparoscopic partial renal resection biopsy. This is scheduled for the week after discharge potentially by Dr. G, and the patient will discuss the exact time later this week. The patient is to return to the emergency room or to our clinic if he has worsening hematuria again or no urine output.
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DESCRIPTION: Discharge Summary of a patient with hematuria, benign prostatic hyperplasia, complex renal cyst versus renal cell carcinoma, and osteoarthritis.

urology, discharge summary, bph, benign prostatic hyperplasia, hematuria, osteoarthritis, clots, cystoscopy, gross hematuria, kidney, renal cell carcinoma, renal cyst, simple cyst, prostatic hyperplasia, transurethral resection, discharge, summary, transurethral, prostate, prostatic, hyperplasia, gross, benign, renal, cyst

The situation involves the discharge of an elderly patient with multiple health conditions, including a potential renal cancer diagnosis. While the hematuria has resolved, the presence of a suspicious renal cyst that could indicate renal cell carcinoma requires further evaluation and potential surgical intervention. This adds significant stakes given the need for timely diagnosis and treatment of a possible malignancy. However, given the current resolution of immediate symptoms and a planned follow-up, the situation might not be critical but still holds substantial importance.


Medical Specialty: Cardiovascular / Pulmonary
Sample Name: Cardiac Transfer Summary

REASON FOR TRANSFER:,  Need for cardiac catheterization done at ABCD.,TRANSFER DIAGNOSES:,1.  Coronary artery disease.,2.  Chest pain.,3.  History of diabetes.,4.  History of hypertension.,5.  History of obesity.,6.  A 1.1 cm lesion in the medial aspect of the right parietal lobe.,7.  Deconditioning.,CONSULTATIONS: , Cardiology.,PROCEDURES:,1.  Echocardiogram.,2.  MRI of the brain.,3.  Lower extremity Duplex ultrasound.,HOSPITAL COURSE: , Please refer to my H&P for full details.  In brief, the patient is a  64-year-old male with history of diabetes, who presented with 6 hours of chest pressure.  He was brought in by a friend.  The friend states that the patient deteriorated over the last few weeks to the point that he is very short of breath with exertion.  He apparently underwent a cardiac workup 6 months ago that the patient states he barely passed.  His vital signs were stable on admission.  He was ruled out for myocardial infarction with troponin x2.  An echocardiogram showed concentric LVH with an EF of 62%.  I had Cardiology come to see the patient, who reviewed the records from Fountain Valley.  Based on his stress test in the past, Dr. X felt the patient needed to undergo a cardiac cath during his inpatient stay.,The patient on initial presentation complained of, what sounded like, amaurosis fugax.  I performed an MRI, which showed a 1 cm lesion in the right parietal lobe.  I was going to call Neurology at XYZ for evaluation.  However, secondary to his indication for transfer, this could be followed up at ABCD with Dr. Y.,The patient is now stable for transfer for cardiac cath.,Discharged to ABCD.,DISCHARGE CONDITION:,  Stable.,DISCHARGE MEDICATIONS:,1.  Aspirin 325 mg p.o. daily.,2.  Lovenox 40 mg p.o. daily.,3.  Regular Insulin sliding scale.,4.  Novolin 70/30, 15 units b.i.d.,5.  Metformin 500 mg p.o. daily.,6.  Protonix 40 mg p.o. daily.,DISCHARGE FOLLOWUP: , Followup to be arranged at ABCD after cardiac cath.
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DESCRIPTION: Need for cardiac catheterization.  Coronary artery disease, chest pain, history of diabetes, history of hypertension, history of obesity,  a 1.1 cm lesion in the medial aspect of the right parietal lobe, and deconditioning.

The situation involves the transfer of a patient with multiple serious health conditions, including coronary artery disease, chest pain, and a newly discovered lesion in the brain, for a critical procedure (cardiac catheterization). The patient's history of diabetes, hypertension, and obesity increases the complexity and potential risks involved. The need for timely intervention and accurate diagnosis makes this a high-stakes situation concerning the patient's health and treatment outcomes.