Medical Specialty: Surgery
Sample Name: Closed ORIF - Ankle

PREOPERATIVE DIAGNOSES:,1.  Trimalleolar ankle fracture.,2.  Dislocation right ankle.,POSTOPERATIVE DIAGNOSES:,1.  Trimalleolar ankle fracture.,2.  Dislocation right ankle.,PROCEDURE PERFORMED: , Closed open reduction and internal fixation of right ankle.,ANESTHESIA:  ,Spinal with sedation.,COMPLICATIONS:  ,None.,ESTIMATED BLOOD LOSS:  ,Minimal.,TOTAL TOURNIQUET TIME:  ,75 minutes at 325 mmHg.,COMPONENTS: , Synthes small fragment set was used including a 2.5 mm drill bed.  A six hole one-third tibial plate, one 12 mm 3.5 mm cortical screw fully threaded and two 16 mm 3.5 mm cortical fully-threaded screws.  There were two 20 mm 4.0 cancellous screws and one 18 mm 4.0 cancellous screw placed.  There were two 4.0 cancellous partially-threaded screws placed.,GROSS FINDINGS:  ,Include a comminuted fracture involving the lateral malleolus as well as a medial and posterior malleolus fracture as well.,HISTORY OF PRESENT ILLNESS: , The patient is an 87-year-old Caucasian female who presented to ABCD General Hospital Emergency Room complaining of right ankle pain status post a trip and fall.  The patient noted while walking with a walker, apparently tripped and fell.  The patient had significant comorbidities, seen and evaluated by the Emergency Room Department as well as Department of Orthopedics while in the Emergency Room.  At that time, a closed reduction was performed and she was placed in a Robert-Jones splint.  After complete medical workup and clearance, we elected to take her to the operating room for definitive care.,PROCEDURE:  ,After all potential complications and risks as well as risks and benefits of the above-mentioned procedure was discussed at length with the patient and family, informed consent was obtained.  The upper extremity was then confirmed with the operating surgeon, the patient, the nursing staff and Department of Anesthesia.  The patient was then transferred to preoperative area in the Operative Suite #3 and placed on the operating room table in supine position.  At this time, the Department of Anesthesia administered spinal anesthetic to the patient as well as sedation.  All bony prominences were well padded at this time.  A nonsterile tourniquet was placed on the right upper thigh of the patient.  This was then removed and the right lower extremity was sterilely prepped and draped in the usual sterile fashion.  The right lower extremity was then elevated and exsanguinated using Esmarch and tourniquet was then placed to 325 mmHg and kept up to a total of 75 minutes.  Next, after all bony and soft tissue landmarks were identified, a 6 cm longitudinal incision was made directly over this vestibule on the right ankle.  A sharp dissection was carefully taken down to the level of bone taking care to protect the neurovascular structures.  Once the bone was reached, the fractured site was identified.  The bony ends were then opened and divided of all hematoma as well as excess periosteum within the fracture site.  The wound was copiously irrigated and dried.  Next, the fracture was then reduced in anatomic position.  There was noted to be quite a bit of comminution as well as soft overall status of the bone.  It was held in place with reduction forceps.  A six hole one-third tubular Synthes plate was then selected for instrumentation.  It was contoured using ________ and placed on the lateral aspect of the distal fibula.  Next, the three most proximal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged and then a 3.5 mm fully threaded cortical screw was placed in each.  The most proximal was a 12 mm and the next two were 16 mm in length.  Next, the three most distal holes were sequentially drilled using a 2.5 mm drill bed, depth gauged, and a 4.0 cancellous screw was placed in each hole.  The most distal with a 20 mm and two most proximal were 18 mm in length.  Next the Xi-scan was used to visualize the hardware placement as well as the fracture reduction appeared to be in good anatomic position, all hardware was in good position.  There was no lateralization of the joints.  Attention was then directed towards the medial aspect of the ankle.  Again, after all bony and soft tissue landmarks were identified, a 4 cm longitudinal incision was made directly over the medial malleolus.  Again, the dissection was carefully taken down the level of the fracture site.  The retractors were then placed to protect all neurovascular structures.  Once the fracture site was identified, it was dried of all hematoma as well as excess periosteum.  The fracture site was then displaced and the ankle joint was visualized including the dome of the talus.  There appeared to be some minor degenerative changes of the talus, but no loose bodies.  Next, the wound was copiously irrigated and suctioned dry.  The medial malleolus was placed in reduced position and held in place with a 1.25 mm K-wire.  Next, the 2.5 mm drill bed was then used to sequentially drill holes to full depth and 4.0 cancellous screws were placed in each, each with a 45 mm in length.  These appeared to hold the fracture site securely in an anatomic position.  Again, Xi-scan was brought in to confirm placement of the screws.  They were in good overall position and there was no lateralization of the joint.  At this time, each wound was copiously irrigated and suctioned dry.  The wounds were then closed using #2-0 Vicryl suture in subcutaneous fashion followed by staples on the skin.  A sterile dressing was applied consistent with Adaptic, 4x4s, Kerlix, and Webril.  A Robert-Jones style splint was then placed on the right lower extremity.  This was covered by a 4-inch Depuy dressing.  At this time, the Department of Anesthesia reversed the sedation.  The patient was transferred back to the hospital gurney and to the Postanesthetic Care Unit.  The patient tolerated the procedure well.  There were no complications.
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DESCRIPTION: Trimalleolar ankle fracture and dislocation right ankle.  A comminuted fracture involving the lateral malleolus, as well as a medial and posterior malleolus fracture as well.  Closed open reduction and internal fixation of right ankle.

surgery, ankle fracture, dislocation, open reduction, internal fixation, orif, trimalleolar ankle fracture, cortical screw, cancellous screws, fracture site, fracture, ankle, malleolus,

This situation involves a surgical procedure on an 87-year-old patient with a trimalleolar ankle fracture and dislocation. Surgery inherently carries risks, especially in elderly patients with significant comorbidities. The successful performance of the surgery without complications is critical for the patient's recovery, mobility, and overall health. Therefore, it constitutes a high-stakes situation due to the potential impact on the patient's life and well-being.


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

Medical Specialty: Surgery
Sample Name: Clear Corneal Temporal Incision

CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES),DESCRIPTION OF OPERATION: , Under satisfactory local anesthesia, the patient was appropriately prepped and draped.  A lid speculum was placed in the fissure of the right eye.,The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's 7:30 position and the anterior chamber re-formed using viscoelastic.  The primary incision was then made using a 3-mm diamond keratome at the surgeon's 5 o'clock position and additional viscoelastic injected into the anterior chamber as needed.  The capsulorrhexis was then performed in a standard circular tear fashion.  The nucleus was then separated from its cortical attachments by hydrodissection and emulsified in the capsular bag.  The residual cortex was then aspirated from the bag and the bag re-expanded using viscoelastic.  The posterior chamber intraocular lens was then inspected, irrigated, coated with Healon and folded, and then placed into the capsular bag under direct visualization.  The lens was noted to center well.  The residual viscoelastic was then removed from the eye and the eye re-formed using balanced salt solution.  The eye was then checked and found to be watertight; therefore, no suture was used.  The lid speculum and the drapes were then removed and the eye treated with Maxitrol ointment.,A shield was applied and the patient returned to the recovery room in good condition.
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DESCRIPTION: Clear corneal temporal incision (no stitches).  A lid speculum was placed in the fissure of the right eye.

surgery, clear corneal temporal incision, intraocular lens, corneal temporal incision, lid speculum, incision, temporal, chamber, corneal, viscoelastic, eyeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The situation described involves a common surgical procedure (clear corneal temporal incision for cataract surgery), performed under local anesthesia with standard precautions and techniques. Such procedures are routine for experienced ophthalmic surgeons and typically have a high success rate with low complication rates. The absence of stitches and post-operative good condition of the patient indicates a typically well-managed scenario. Though it involves surgery which always carries some risk, in the context of medical operations, it is relatively low-stakes compared to more complex or life-threatening surgeries.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Closed Reduction - Mandible Fracture

PREOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,POSTOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,PROCEDURE:  ,Closed reduction of mandible fracture with MMF.,ANESTHESIA: , General anesthesia via nasal endotracheal intubation.,FLUIDS: , 2 L of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,HARDWARE: , None.,SPECIMENS: , None.,COMPLICATIONS: , None.,CONDITION:  ,The patient was extubated to PACU in good condition.,INDICATIONS FOR PROCEDURE: , The patient is a 17-year-old female who is 2 days status post an altercation in which she sustained multiple blows to the face.  She was worked up on Friday night, 2 days earlier at Hospital, was given palliative treatment and discharged and instructed to follow up as an outpatient with an oral surgeon and given a phone number to call.  The patient was worked up initially.  On initial exam, it was noted that the patient had a left V3 paresthesia.  She had a gross malocclusion.  On the facial CT and panoramic x-ray, it was noted to be a displaced left angle fracture and nondisplaced symphysis fracture.  Alternatives were discussed with the patient and it was determined she would benefit from being taken to the operating room under general anesthesia to have a closed reduction of her fractures.  Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and informed consent was obtained with the patient's mother.,DESCRIPTION OF PROCEDURE:, The patient was taken to the operating room #4 at Hospital and laid in a supine position on the operating room table.  Monitor was attached and general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics.  The patient was prepped and draped in the usual oromaxillofacial surgery fashion.,Surgeon approached the operating table in a sterile fashion.  Approximately 10 mL of 2% lidocaine with 1:100,000 epinephrine was injected into the oral vestibule in a nerve block fashion.  A moistened Ray-Tec sponge was placed in the posterior oropharynx and the mouth was prepped with Peridex mouthrinse, scrubbed with a toothbrush.  The Peridex was evacuated with Yankauer suction.  Erich arch bars were adapted to the maxilla from the first molar to the contralateral first molar and secured with 24-gauge surgical steel wire on the posterior teeth and 26-gauge surgical steel wire on the anterior teeth.  Same was done on the mandible.  The patient was then manipulated up in the maximum intercuspation and noted to be reproducible.  The throat pack was then removed.,The patient was remanipulated up to the maximum intercuspation and secured with interdental elastics.  At this point in time, the procedure was then determined to be over.,The patient was extubated and transferred to the PACU in good condition.
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DESCRIPTION: Bilateral open mandible fracture, open left angle and open symphysis fracture.  Closed reduction of mandible fracture with MMF.

surgery, open symphysis fracture, closed reduction, mmf, endotracheal, pacu, bilateral open mandible fracture, symphysis fracture, mandible fracture, fracture, intubation, angle, mandible,

The closed reduction procedure for a mandible fracture is certainly a significant medical procedure as it involves surgery under general anesthesia and is essential for correcting jaw alignment and preventing further complications. The patient's condition prior to the operation was serious, with malocclusion and nerve issues. However, the procedure itself is a routine one in oral and maxillofacial surgery, with minimal estimated blood loss and no reported complications in this case. The stakes are high because it's crucial for patient recovery and involves risks inherent to surgeries, but the condition was managed effectively as indicated by the successful outcome documented post-operation.


Medical Specialty: Surgery
Sample Name: Circumcision - Infant

PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA:  ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents.  The risks are infection, hemorrhage, and meatal stenosis.  The benefits are ease of care and cleanliness and fewer urinary tract infections.  The parents understand this and have signed a permit.,FINDINGS: , The infant is without evidence of hypospadias or chordee prior to the procedure.,TECHNIQUE:  ,The infant was given a dorsal penile block with 1% lidocaine without epinephrine using a tuberculin syringe and 0.5 cc of lidocaine was delivered subcutaneously at 10:30 and at 1:30 o'clock at the dorsal base of the penis.,The infant was prepped then with Betadine and draped with a sterile towel in the usual manner.  Clamps were placed at 10 o'clock and 2 o'clock and the adhesions between the glans and mucosa were instrumentally lysed.  Dorsal hemostasis was established and a dorsal slit was made.  The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed.  The infant was fitted with a XX-cm Plastibell.  The foreskin was retracted around the Plastibell and circumferential hemostasis was established.  The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss.  Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis.
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DESCRIPTION: Circumcision.  Normal male phallus.   The infant is without evidence of hypospadias or chordee prior to the procedure.

surgery, dorsal slit, hypospadias, chordee, epinephrine, hemorrhage, penis, adhesions, circumcision, phallus, lidocaine, foreskin, infant

The situation described is a routine infant circumcision, which is a common surgical procedure often performed on newborn males for cultural, religious, or medical reasons. While it involves surgery, it is generally considered low-risk, especially given the setting in a medical environment with anesthesia and proper surgical techniques. However, because it involves an infant, it requires careful consideration of potential risks such as infection and hemorrhage. These factors elevate the stakes slightly compared to a completely non-invasive procedure, but overall, the procedure is not considered high-stakes in a medical context.


Medical Specialty: Surgery
Sample Name: Circumcision - 6

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

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

This description outlines a standard circumcision procedure on a child, which is typically a routine surgical procedure. Although it involves surgery, circumcisions are generally low-risk and common. Informed consent indicates that the parents were fully aware and agreed to the procedure, and the document states there were no complications. Therefore, while all surgical procedures carry some risk, this instance does not present high-stakes given the routine nature and absence of complications.


Medical Specialty: Surgery
Sample Name: Circumcision - 3

CIRCUMCISION,After informed consent was obtained the baby was placed on the circumcision tray.  He was prepped in a sterile fashion times 3 with Betadine and then draped in a sterile fashion.  Then 0.2 mL of 1% lidocaine was injected at 10 and 2 o'clock.  A ring block was also done using another 0.3 mL of lidocaine.  Glucose water is also used for anesthesia.  After several minutes the curved clamp was attached at 9 o'clock with care being taken to avoid the meatus.  The blunt probe was then introduced again with care taken to avoid the meatus.  After initial adhesions were taken down the straight clamp was introduced to break down further adhesions.  Care was taken to avoid the frenulum.  The clamps where then repositioned at 12 and 6 o'clock.  The Mogen clamp was then applied with a dorsal tilt.  After the clamp was applied for 1 minute the foreskin was trimmed.  After an additional minute the clamp was removed and the final adhesions were taken down.  Patient tolerated the procedure well with minimal bleeding noted.  Patient to remain for 20 minutes after procedure to insure no further bleeding is noted.,Routine care discussed with the family.  Need to clean the area with just water initially and later with soap and water or diaper wipes once healed.
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DESCRIPTION: Circumcision procedure in a baby

Circumcision procedure in a baby

surgery, circumcision, 1% lidocaine, betadine, glucose water, adhesions, circumcision tray, diaper wipes, foreskin, frenulum, meatus, straight clamp, sterile fashion, clampNOTE,: 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 routine circumcision for a baby, which is a common surgical procedure. While it involves surgical skill and care must be taken to avoid complications, it is generally considered to be low-risk with minimal chances of complications if performed correctly. Since the procedure went well and the baby tolerated it with minimal bleeding, it suggests a successful outcome. However, it is still a surgical procedure on a newborn, which inherently carries a degree of seriousness.


Medical Specialty: Surgery
Sample Name: Circumcision - 1

CIRCUMCISION - OLDER PERSON,OPERATIVE NOTE:,  The patient was taken to the operating room and placed in the supine position on the operating table.  General endotracheal anesthesia was administered.  The patient was prepped and draped in the usual sterile fashion.  A 4-0 silk suture is used as a stay-stitch of the glans penis.  Next, incision line was marked circumferentially on the outer skin 3 mm below the corona.  The incision was then carried through the skin and subcutaneous tissues down to within a layer of * fascia.  Next, the foreskin was retracted.  Another circumferential incision was made 3 mm proximal to the corona.  The intervening foreskin was excised.  Meticulous hemostasis was obtained with electrocautery.  Next, the skin was reapproximated at the frenulum with a U stitch of 5-0 chromic followed by stitches at 12, 3, and 9 o'clock.  The stitches were placed equal distance among these to reapproximate all the skin edges.  Next, good cosmetic result was noted with no bleeding at the end of the procedure.  Vaseline gauze, Telfa, and Elastoplast dressing was applied.  The stay-stitch was removed and pressure held until bleeding stopped.  The patient tolerated the procedure well and was returned to the recovery room in stable condition.
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DESCRIPTION: Circumcision in an older person

Circumcision in an older person

surgery, circumcision, elastoplast, meticulous hemostasis, telfa, vaseline gauze, circumferential incision, corona, cosmetic result, endotracheal anesthesia, foreskin, glans penis, hemostasis, stay stitch, circumferentially, stitchNOTE,: 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.

Surgical procedures inherently involve some level of risk, particularly when general anesthesia is used, as it can lead to complications and requires careful monitoring. Additionally, while circumcision is a relatively common procedure, performing it on an older person may present additional challenges and risks due to potentially slower healing and the presence of other health issues. However, the procedure described was routine, with no complications reported, and the patient was stable afterward. Therefore, while it is certainly higher stakes than a non-medical situation, it does not involve life-or-death urgency typical of more complex surgeries.


Medical Specialty: Surgery
Sample Name: Cineangiography

PROCEDURES UNDERTAKEN,1.  Left coronary system cineangiography.,2.  Right coronary system cineangiography.,3.  Cineangiography of SVG to OM.,4.  Cineangiography of LIMA to LAD.,5.  Left ventriculogram.,6.  Aortogram.,7.  Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.,NARRATIVE:,  After all risks and benefits were explained to the patient, informed consent was obtained.  The patient was brought to the cardiac catheterization suite.  The right groin was prepped in the usual sterile fashion.  Right common femoral artery was cannulated using a modified Seldinger technique and a long 6-French AO sheath was introduced secondary to tortuous aorta.  Next, Judkins left catheter was used to engage the left coronary system.  Cineangiography was recorded in multiple views.  Next, Judkins right catheter was used to engage the right coronary system.  Cineangiography was recorded in multiple views.  Next, the Judkins right catheter was used to engage the SVG to OM.  Cineangiography was recorded.  Next, the Judkins right was advanced into the left subclavian and exchanged over a long exchange length J-wire for a 4-French left internal mammary artery which was used to engage the LIMA graft to LAD and cineangiography was recorded in multiple views.  Next, an angled pigtail catheter was advanced into the left ventricular cavity.  LV pressures were measured.  LV gram was done and a pullback gradient across the aortic valve was done and recorded.  Next, an aortogram was done and recorded.  At this point, I decided to proceed with percutaneous intervention of the left circumflex.  Therefore, AVA 3.5 guide was used to engage the left coronary artery.  Angiomax bolus and drip was started.  Universal wire was advanced past the lesion and a 2.5-balloon was advanced first to the proximal lesions and predilations were done at 14 atmospheres and then to the distal lesion and predilatation was done at 12 atmospheres.  Next, we attempted to advance a 3.0 x 12 stent to the distal lesion; however, we were unable to pass the stent.  Next, second dilatations were done again with the 2.5 balloon at 18 atmospheres; however, we are unable to break the lesion.  We next attempted a cutting balloon.  Again, we are unable to cross the lesion, therefore a buddy wire technique was used with a PT choice support wire.  Again, we were unable to cross the lesion with the stent.  We then try to cross with a noncompliant balloon, which we were unsuccessful.  We also try to cutting balloon again, we were unsuccessful.  Despite multiple dilatations, we were unable to cross anything beyond the noncompliant balloon across the lesion; therefore, finally the procedure was aborted.  Final images showed no evidence of dissection, perforation, or further complication.  The right groin was filled after taking an image to confirm sheath placement above the bifurcation with excellent results.  The patient tolerated the procedure very well without complications, was taken off the operating table and transferred back to cardiac telemetry floor.,DIAGNOSTIC FINDINGS,1.  The LV.  LVEDP was 4.  LVES is approximately 50%-55% with inferobasal hypokinesis.  No significant MR. No gradient across the aortic valve.,2.  Aortogram.  The ascending aorta shows no significant dilatation or evidence of dissection.  The valve shows no significant aortic insufficiencies.  The abdominal aorta and distal aorta shows significant tortuosities.,3.  The left main.  The left main coronary artery is a large caliber vessel, bifurcating the LAD and left circumflex with some mild distal disease of about 10%-20%.,4.  Left circumflex.  The left circumflex vessel is a large caliber vessel gives off a distal branching obtuse marginal branch.  The upper pole of the OM shows retrograde filling of the distal graft and also at that point approximately a 70%-80% stenosis.  The mid left circumflex is a high-grade 80% diffuse tortuous stenosis.,5.  LAD.  The LAD is a totally 100% occluded vessel.  The LIMA to LAD is patent with only a small-to-moderate caliber LAD.  There is a large diagonal branch coming off the proximal portion of the LAD and that proximal LAD showed some diffuse disease upwards of 60%-70%.  The diagonal shows proximal 80% stenosis.,6.  The right coronary artery:  The right coronary artery is 100% occluded.  There are retrograde collaterals from left to right to the distal PDA and PLV branches.  The SVG to OM is 100% occluded at its take off.  The SVG to PDA is not found; however, presumed 100% occluded given that there is collateral flow to the distal right.,7.  LIMA to LAD is widely patent.,ASSESSMENT AND PLAN: , Attempted intervention to the left circumflex system, only able to perform plano balloon angioplasty, unable to pass stents, noncompliant balloons or cutting balloon.  Final images showed some improvement, however, continued residual stenosis.  At this point, the patient will be transferred back to telemetry floor and monitored.  We can attempt future intervention or continue aggressive medical management.  The patient continues to have residual stenosis in the diagonal; however, due to the length of this procedure, I did not attempt intervention to that diagonal branch.  Possible consideration would be a stress test as an outpatient depending on where patient shows ischemia, focus on treatment to that lesion.
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DESCRIPTION: Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD.  Left ventriculogram and aortogram.  Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent.

surgery, coronary system cineangiography, svg to om, lima to lad, ventriculogram, aortogram, percutaneous intervention, circumflex, obtuse marginal branch, balloon angioplasty, coronary artery, balloon, cineangiography, lad,

The described scenario involves a complex cardiac procedure known as cineangiography and percutaneous coronary intervention (PCI). These procedures are critical in evaluating and treating coronary artery disease. The patient had a significant cardiac intervention attempt, which was not entirely successful due to difficulty with stent placement. This indicates a high-stakes situation because it relates directly to the patient's heart health and involves potential complications like worsening stenosis or ischemia. Medical decisions following the procedure (such as further intervention or aggressive medical management) will be crucial for the patient's health outcomes. However, the procedure was completed without complications and the patient was stable afterwards, so while high-stakes, it wasn't an emergency situation by conclusion.


Medical Specialty: Surgery
Sample Name: Cholecystectomy - Open

PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, None apparent.,ESTIMATED BLOOD LOSS:, 275 mL.,SPECIMENS:,1. Gallbladder.,2. Lymph node.,DRAINS:, One 19-French round Blake.,DESCRIPTION OF THE OPERATION:, After consent was obtained and the patient was properly identified, the patient was transported to the operating room and after induction of general endotracheal anesthesia, the patient was prepped and draped in a normal sterile fashion.,After infiltration with local, a vertical incision was made at the umbilicus and utilizing graspers, the underlying fascia was incised and was divided sharply. Dissecting further, the peritoneal cavity was entered. Once this done, a Hasson trocar was secured with #1 Vicryl and the abdomen was insufflated without difficulty. A camera was placed into the abdomen and there was noted to be omentum overlying the subhepatic space. A second trocar was placed in the standard fashion in the subxiphoid area; this was a 10/12 mm non-bladed trocar. Once this was done, a grasper was used to try and mobilize the omentum and a second grasper was added in the right costal margin; this was a 5-mm port placed, it was non-bladed and placed in the usual fashion under direct visualization without difficulty. A grasper was used to mobilize free the omentum which was acutely friable and after a significant time-consuming effort was made to mobilize the omentum, it was clear that the gallbladder was well incorporated by the omentum and it would be unsafe to proceed with a laparoscopy procedure and then the procedure was converted to open.,The trocars were removed and a right subcostal incision was made incorporating the 10/12 subxiphoid port. The subcutaneous space was divided with electrocautery, as well as the muscles and fascia. The Bookwalter retraction system was then set up and retractors were placed to provide exposure to the right subhepatic space. Then utilizing a right-angle and electrocautery, the omentum was freed from the gallbladder. An ensuing retrograde cholecystectomy was performed, in which, electrocautery and blunt dissection were used to mobilize the gallbladder from the gallbladder fossa; this was done down to the infundibulum. After meticulous dissection, the cystic artery was identified and it was ligated between 3-0 silks. Several other small ties were placed on smaller bleeding vessels and the cystic duct was identified, was skeletonized, and a 3-0 stick tie was placed on the proximal portion of it. After it was divided, the gallbladder was freed from the field.,Once this was done, the liver bed was inspected for hemostasis and this was achieved with electrocautery. Copious irrigation was also used. A 19-French Blake drain was placed in Morrison's pouch lateral to the gallbladder fossa and was secured in place with 2-0 nylon; this was a 19-French round Blake. Once this was done, the umbilical port was closed with #1 Vicryl in an interrupted fashion and then the wound was closed in two layers with #1 Vicryl in an interrupted fashion. The skin was closed with and absorbable stitch.,The patient was then awakened from anesthesia, extubated, and transported to the recovery room in stable condition.
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DESCRIPTION: Open cholecystectomy (attempted laparoscopic cholecystectomy).

surgery, cholelithiasis, cholecystitis, gangrenous, cholecystectomy, laparoscopic, gallbladder, blake, omentum, hasson, electrocautery, gallbladder fossa, endotracheal, subhepatic, french,

This scenario involves a surgical procedure, specifically an open cholecystectomy after a failed attempt at a laparoscopic approach due to complications with omental adhesions. The preoperative and postoperative diagnoses include acute perforated gangrenous cholecystitis, which is a serious and potentially life-threatening condition. The patient's condition requires surgical intervention and careful intraoperative and postoperative management to prevent further complications. While the surgery was completed without apparent complications, the initial condition and the conversion from laparoscopic to open surgery increase the stakes due to the complexity and risks involved. Therefore, the situation is high-stakes in a medical context.


Medical Specialty: Surgery
Sample Name: Cholecystectomy & Cholangiogram.

PREOPERATIVE DIAGNOSES:,1.  Cholelithiasis.,2.  Acute cholecystitis.,POSTOPERATIVE DIAGNOSES:,1.  Acute on chronic cholecystitis.,2.  Cholelithiasis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,ANESTHESIA: , General.,INDICATIONS: , This is a 38-year-old diabetic Hispanic female patient, with ongoing recurrent episodes of right upper quadrant pain, associated with nausea.  Ultrasound revealed cholelithiasis.  The patient also had somewhat thickened gallbladder wall.  The patient was admitted through emergency room last night with acute onset right upper quadrant pain.  Clinically, it was felt the patient had acute cholecystitis.  Laparoscopic cholecystectomy with cholangiogram was advised.  Procedure, indication, risk, and alternative were discussed with the patient in detail preoperatively and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was put in supine position on the operating table under satisfactory general anesthesia, and abdomen was prepped and draped.  A small transverse incision was made just above the umbilicus under local anesthesia.  Fascia was opened vertically.  Stay sutures were placed in the fascia.  Peritoneal cavity was carefully entered.  Hasson cannula was inserted and peritoneal cavity was insufflated with CO2.,Laparoscopic camera was inserted, and the patient was placed in reverse Trendelenburg, rotated to the left.  A 11-mm trocar was placed in the subxiphoid space and two 5-mm in the right subcostal region.  Examination at this time showed no free fluid, no acute inflammatory changes.  Liver was grossly normal.  Gallbladder was noted to be thickened.  Gallbladder wall with a stone stuck in the neck of the gallbladder and pericholecystic edema, consistent with acute cholecystitis.,The fundus of the gallbladder was retracted superiorly, and dissection was carried at the neck of the gallbladder where a cystic duct was identified and isolated.  It was clipped distally and using C-arm fluoroscopy, intraoperative cystic duct cholangiogram was done, which was interpreted as normal.  There was slight dilatation noted at the junction of the right and left hepatic duct, but no filling defects or any other pathology was noted.  It was presumed that this was probably a congenital anomaly.  The cystic duct was clipped twice proximally and divided beyond the clips.  Cystic artery was identified, isolated, clipped twice proximally, once distally, and divided.,The gallbladder was then removed from its bed using cautery dissection and subsequently delivered through the umbilical port.  Specimen was sent for histopathology.  Subhepatic and subdiaphragmatic spaces were irrigated with sterile saline solution.  Hemostasis was good.  Trocars were removed under direct vision and peritoneal cavity was evacuated with CO2.  Umbilical area fascia was closed with 0-Vicryl figure-of-eight sutures, required extra sutures to close the fascial defect.  Some difficulty was encountered closing the fascia initially because of the patient's significant amount of subcutaneous fat.  In the end, the repair appears to be quite satisfactory.  Rest of the incisions closed with 3-0 Vicryl for the subcutaneous tissues and staples for the skin.  Sterile dressing was applied.,The patient transferred to recovery room in stable condition.
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DESCRIPTION: Laparoscopic cholecystectomy with cholangiogram.

surgery, cholelithiasis, acute cholecystitis, laparoscopic, cholecystectomy, cholangiogram, laparoscopic cholecystectomy, gallbladder,

The situation involves a surgical procedure of a laparoscopic cholecystectomy with cholangiogram, on a patient who presented with acute cholecystitis. This procedure, while commonly performed and generally considered low-risk, is nevertheless a surgical intervention requiring general anesthesia. This means that it inherently carries risks such as infection, bleeding, and anesthesia complications. The presence of a congenital anomaly and the patient's diabetic condition add complexity, though these were acknowledged and managed. Overall, surgeries are high-stakes due to potential for complications, even if typically successful.


Medical Specialty: Surgery
Sample Name: Chest Tube Insertion in ER

PREOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.  This patient is obtunded, intubated, and septic.  This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion.  The site of insertion was anesthetized with 1% Xylocaine, and an incision was made.  Blunt dissection was carried out 2 intercostal spaces above the initial incision site.  The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly.  The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  10 mL,COMPLICATIONS:,  None.,SPONGE COUNT: , Correct x2.
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DESCRIPTION: Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma.

surgery, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion,

The scenario involves an emergent medical procedure, a chest tube insertion, to address serious conditions like a spontaneous pneumothorax, respiratory failure, and pneumonia with sepsis. The patient is obtunded, intubated, and septic, making the situation life-threatening. The critical nature of the medical conditions and the urgency of the intervention make this a high-stakes situation.


Medical Specialty: Surgery
Sample Name: Chest Tube Removal

PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:,  None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage.  A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts, this necessitated to close the wounds with sutures.  The patient was agreeable to proceed.,OPERATIVE PROCEDURE:  ,The patient was prepped and draped at the bedside over both chest tube sites.  The pressures applied over the sites and the skin was closed with interrupted #3-0 Ethilon sutures.  The skin was then cleansed and Vaseline occlusive dressing was applied over the sites.  The same procedure was performed on the other side.  The chest tubes were removed on full inspiration.  Vital signs remained stable throughout the procedure.  The patient will remain in the intensive care unit for continued monitoring.,
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DESCRIPTION: Bilateral pleural effusion.  Removal of bilateral #32 French chest tubes with closure of wound.

surgery, serous drainage, bilateral pleural effusion, pleural effusion, chest tubes, effusion, pleural, chest

The removal of chest tubes in a patient with bilateral pleural effusion is a procedure that inherently carries risk, given the patient's age and intensive care status. However, the procedure described was performed without complications and vital signs remained stable. The situation requires careful monitoring given the patient's overall condition, but the procedure itself was straightforward and without immediate complications. Therefore, while it is a critical medical procedure, the immediate stakes do not appear extremely high based on the provided information.


Medical Specialty: Surgery
Sample Name: Cesarean Section & BTL

PREOPERATIVE DIAGNOSES:,1.  Term pregnancy.,2.  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1.  Term pregnancy.,2.  Desires permanent sterilization.,PROCEDURE:,1.  Repeat low-transverse cesarean section.,2.  Bilateral tubal ligation.,3.  Extensive anterior abdominal wall/uterine/bladder adhesiolysis.,ANESTHESIA:,  Spinal/epidural with good effect.,FINDINGS:  ,Delivered vigorous male infant from cephalic presentation.  Apgars 9/9.  Birth weight 6 pounds 14 ounces.  Infant suctioned with a bulb upon delivery of the head and body.  Cord clamped and cut and infant passed to pediatric team present.  Complete placenta manually extracted intact with three vessel cord.  Extensive anterior abdominal wall adhesions with the anterior abdominal wall completely adhered to the anterior uterus throughout its entire length of the incision.  In addition, the bladder was involved in adhesion mass complex.  A window was developed surgically at the apical aspect of the incision enabling finger to pass to get behind the dense anterior abdominal wall adhesions.  These adhesions were surgically transected using Bovie cautery technique freeing up the anterior uterine attachment from the anterior abdominal wall.  Upon initial entry through the fibrous layer of the anterior abdominal wall _______ into the serosal and slightly muscular part of the anterior uterus due to the dense adhesion attachment that had occurred from previous surgeries.  Bilateral tubal ligation performed without difficulty via Parkland technique.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,URINE OUTPUT:  ,Per anesthesia records.  Urine cleared postoperatively.,IV FLUIDS:  ,Per anesthesia records.,The patient tolerated the procedure well and was taken to the recovery room in stable condition with stable vital signs.,OPERATIVE TECHNIQUE: , The patient was placed in a supine position after spinal/epidural anesthesia.  She was prepped and draped in the usual manner for repeat cesarean section.  A sharp knife was used to make a Pfannenstiel skin incision at the site of the previous scar.  This was carried through the subcutaneous tissue into the dense fibromuscular and fascial layer with a sharp knife.  This incision was extended laterally with Mayo scissors.  Dense fibromuscular layer was encountered from the patient's previous surgeries.  Upon entry, incision was entered into the serosal and partial muscular layer of the anterior uterus and there was no free area to enter into the peritoneal cavity due to dense fibromuscular adhesions of the entire uterus to the anterior abdominal wall at the length of the incision.  Fascia was previously separated superiorly and inferiorly from the muscular layer.  A surgical window was created at the apical aspect of the incision in the direction of the uterine fundus.  Finger was able to be passed and placed behind the dense adhesions between the uterus through anterior abdominal wall.  This adhesion complex was transacted via Bovie cautery its entire length circumferentially freeing the uterus from its attachment to anterior abdominal wall.  Inferiorly, difficulty was encountered with adhesion separation involving the bladder additionally to the uterus and the anterior abdominal wall.  These adhesions likewise were surgically transacted via sharp, blunt, and electrocautery dissection.  This was successfully done without anterior entry into the bladder.  Smooth pickups and Metzenbaum scissors were then used to do sharp dissection to separated the bladder from its attachment to the lower uterine segment enabling the vesicouterine peritoneal reflection for incision of the uterus.  The uterus was then incised using a sharp knife and low transverse incision.  This was extended with bandage scissors.  The infant was delivered easily from a cephalic presentation.  Bulb suction was done following delivery of the head and body.  The cord clamped and cut and the infant passed to pediatric team present.  Cord segment and cord blood was obtained.  Complete placenta manually extracted intact with three vessel cord.  Vigorous male infant, Apgars 9/9, weight 6 pounds 14 ounces.  Complete placenta with three vessels retrieved.  Uterus was exteriorized from the abdominal cavity.  Wet lap applied to the fundus and dry lap used to remove the remaining membranous tissue from the lining.  Pennington clamps placed at the uterine incision angles and the inferior incision lip.  A #1 chromic suture closed the uterus in running continuous interlocking closure.  Good hemostasis upon completion of the closure.  Laparotomy pads placed in the posterior cul-de-sac to remove any blood or clots.  The uterus was returned to the abdominal cavity, after using #1 chromic suture to close the anterior uterine incision, that was partial thickness through the serosal end of the muscular layer at midline adhesion.  This was closed with chromic suture in a running continuous interlocking closure with good hemostasis.  Attention was then focused on the bilateral tubal ligation.  Babcock clamp placed in the mid fallopian tube and elevated.  Cautery was used to make a window in the avascular segment of the mesosalpinx.  Proximal and distal #1 chromic suture ligation with mid fallopian tube transection performed.  The ligated proximal and distal stumps were then cauterized with Bovie cautery.  This tubal ligation procedure was done in a bilateral fashion.  Upon completion of tubal ligation, uterus was returned to the abdominal cavity.  Left and right gutters examined and found to be clean and dry.  Evaluation of the low uterine segment incision revealed continued hemostasis.  Oozing was encountered in the inferior bladder of dissection and 2-0 chromic suture in running continuous fashion, partial thickness of the bladder to control the oozing at this site was successfully done.  Interceed was then placed on the low uterine incision and the low anterior uterine aspect.  The midline rectus including peritoneum was re-approximated with simple interrupted chromic sutures.  Irrigation of the muscular layer with good hemostasis noted.  The fascia was closed with #1 Vicryl in a running continuous closure.  Subcutaneous tissue was irrigated, additional hemostasis with Bovie cautery.  The skin was closed with staples.
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DESCRIPTION: Repeat low-transverse cesarean section, bilateral tubal ligation (BTL), extensive anterior abdominal wall/uterine/bladder adhesiolysis.  Term pregnancy and desires permanent sterilization.

surgery, term pregnancy, sterilization, low-transverse cesarean section, bilateral tubal ligation, adhesiolysis, anterior uterus, abdominal cavity, cesarean section, chromic suture, tubal ligation, adhesions, uterus, abdominal, infant, anterior, cesarean, hemostasis, chromic, uterine,

The situation involves a repeat cesarean section (C-section) and a bilateral tubal ligation (BTL), both of which are surgical procedures with inherent risks. Additionally, the presence of extensive adhesions due to previous surgeries increases the complexity and risk of the operation. The surgical team must manage potential complications such as bleeding, injury to organs like the bladder, and ensure safe delivery of the infant. While C-sections and BTLs are relatively common procedures, the extensive adhesions elevate the stakes due to increased potential for complications. Furthermore, this is a high-profile medical procedure as it affects both the patient's and newborn's lives and health outcomes.


Medical Specialty: Surgery
Sample Name: Cemented Arthroplasty

PREOPERATIVE DIAGNOSIS: , Severe tricompartmental osteoarthritis, left knee with varus deformity.,POSTOPERATIVE DIAGNOSIS:,  Severe tricompartmental osteoarthritis, left knee with varus deformity.,PROCEDURE PERFORMED:  ,Left total knee cemented arthroplasty.,ANESTHESIA: , Spinal with Duramorph.,ESTIMATED BLOOD LOSS:  ,50 mL.,NEEDLE AND SPONGE COUNT:,  Correct.,SPECIMENS: , None.,TOURNIQUET TIME:  ,Approximately 77 minutes.,IMPLANTS USED:,1.  Zimmer NexGen posterior stabilized LPS-Flex GSF femoral component size D, left.,2.  All-poly patella, size 32/8.5 mm thickness.,3.  Prolong highly cross-linked polyethylene 12 mm.,4.  Stemmed tibial component, size 2.,5.  Palacos cement with antibiotics x2 batches.,INDICATION: , The patient is an 84-year-old female with significant endstage osteoarthritis of the left knee, who has had rapid progression with pain and disability.  Surgery was indicated to relieve her pain and improve her functional ability.  Goal objectives and the procedure were discussed with the patient.  Risks and benefits were explained.  No guarantees have been made or implied.  Informed consent was obtained.,DESCRIPTION OF THE PROCEDURE:  ,The patient was taken to the operating room and once an adequate spinal anesthesia with Duramorph was achieved, her left lower extremity was prepped and draped in a standard sterile fashion.  A nonsterile tourniquet was placed proximally in the thigh.  Antibiotics were infused prior to Foley catheter insertion.  Time-out procedure was called.,A straight longitudinal anterior midline incision was made.  Dissection was carried down sharply down the skin, subcutaneous tissue and the fascia.  Deep fascia was exposed.  The tourniquet was inflated at 300 mmHg prior to the skin incision.  A standard medial parapatellar approach was made.  The quadriceps tendon was incised approximately 1 cm from the vastus medialis insertion.  Incision was then carried down distally and distal arthrotomy was completed.  Patellar tendon was well protected.  Retinaculum and capsule was incised approximately 5 mm from the medial border of the patella for later repair.  The knee was exposed very well.  Significant tricompartmental osteoarthritis was noted.  The osteophytes were removed with a rongeur.  Anterior and posterior cruciate ligaments were excised.  Medial and lateral meniscectomies were performed.  Medial dissection was performed subperiosteally along the medial aspect of the proximal tibia to address the varus deformity.  The medial compartment was more affected than lateral.  Medial ligaments were tied.  Retropatellar fat pad was excised.  Osteophytes were removed.  Using a Cobb elevator, the medial soft tissue periosteum envelope was well reflected.,Attention was placed for the preparation of the femur.  The trochlear notch was ossified.  A rongeur was utilized to identify the notch and then using an intramedullary drill guide, a starting hole was created slightly anterior to the PCL attachment.  The anterior portal was 1 cm anterior to the PCL attachment.  The anterior femoral sizer was positioned keeping 3 degrees of external rotation.  Rotation was also verified using the transepicondylar axis and Whiteside line.  The pins were positioned in the appropriate holes.  Anterior femoral cut was performed after placing the cutting guide.  Now, the distal cutting guide was attached to the alignment and 5 degrees of valgus cut was planned.  A distal femoral cut was made which was satisfactory.  A sizer was positioned which was noted to be D.  The 5-in-1 cutting block size D was secured with spring pins over the resected bone.  Using an oscillating saw, cuts were made in a sequential manner such as anterior condyle, posterior condyle, anterior chamfer, and posterior chamfer.  Then using a reciprocating saw, intercondylar base notch cut and side cuts were made.  Following this, the cutting block for High-Flex knee was positioned taking 2 mm of additional posterior condyle.  Using a reciprocating saw, the side cuts were made and bony intercondylar notch cut was completed.  The bone with its attached soft tissue was removed.  Once the femoral preparation was completed, attention was placed for the preparation of the tibia.  The medial and the lateral collateral ligaments were well protected with a retractor.  The PCL retractor was positioned and the tibia was translated anteriorly.  Osteophytes were removed.  The extramedullary tibial alignment guide was affixed to the tibia and appropriate amount of external rotation was considered reference to the medial 1/3rd of the tibial tubercle.  Similarly, horseshoe alignment guide was positioned and the alignment guide was well aligned to the distal 1/3rd of the crest of the tibia as well as the 2nd toe.  Once the alignment was verified in a coronal plane, the tibial EM guide was well secured and then posterior slope was also aligned keeping the alignment rod parallel to the tibial crest.  A built-in 7-degree posterior slope was considered with instrumentation.  Now, the 2 mm stylus arm was positioned over the cutting block medially, which was the most affected site.  Tibial osteotomy was completed 90 degrees to the mechanical axis in the coronal plane.  The resected thickness of the bone was satisfactory taken 2 mm from the most affected site.  The resected surface shows some sclerotic bone medially.  Now, attention was placed for the removal of the posterior osteophytes from the femoral condyle.  Using curved osteotome, angle curette, and a rongeur, the posterior osteophytes were removed.  Now, attention was placed for confirming the flexion-extension gap balance using a 10 mm spacer block in extension and 12 mm in flexion.  Rectangular gap was achieved with appropriate soft tissue balance in both flexion and extension.  The 12 mm spacer block was satisfactory with good stability in flexion and extension.,Attention was now placed for completion of the tibia.  Size 2 tibial trial plate was positioned.  Appropriate external rotation was maintained with the help of the horseshoe alignment rod.  Reference to the tibial crest distally and 2nd toe was considered as before.  The midpoint of the trial tray was collinear with the medial 1/3rd of the tibial tubercle.  The rotation of tibial plate was satisfactory as required and the preparation of the tibia was completed with intramedullary drill followed by broach impactor.  At this point, trial femoral and tibial components were reduced using a 12 mm trial liner.  The range of motion and stability in both flexion and extension was satisfactory.  No further soft tissue release was indicated.  I was able to achieve 0 degrees of extension and complete flexion of the knee.,Attention was now placed for the preparation of the patella.  Using a patellar caliper, the thickness was measured to be 21.5 mm.  This gives an ideal resection of 8.5 mm keeping 13 mm of bone intact.  Reaming was initiated with a patellar reamer reaming up to 13 mm with the reaming alignment guide.  Using a caliper, the resected patella was measured, which was noted to be 13 mm.  A 32 sizer was noted to accommodate the resected surface very well.  Drilling was completed and trial 32 button was inserted without any difficulty.  The tracking was satisfactory.  There was no evidence of any subluxation or dislocation of the patella.  The trial components position was satisfactory.  The alignment and the rotation of all 3 components were satisfactory.  All the trial components were removed and the wound was thoroughly irrigated with Pulsavac lavage irrigation mechanical system.  The resected surfaces were dried with a sponge.  Two batches of Palacos cement were mixed.  The cementing was initiated starting with tibia followed by femur and patella.  Excess peripheral cement were removed with the curette and knife.  The knee was positioned in extension with a 12 mm trial liner.  Patellar clamp was placed after cementing the all-poly patella.  Once the cement was set hard and cured, tourniquet was deflated.  Hemostasis was achieved.  The trial 12 mm liner was replaced with definitive Prolong highly cross-linked polyethylene liner.  Range of motion and stability was verified at 0 degrees and flexion of 120 degrees.  Anterior-posterior drawer test was satisfactory.  Medial and lateral stability was satisfactory.  Patellar tracking was satisfactory.  The wound was thoroughly irrigated.  Hemostasis was achieved.  A local cocktail was injected, which included the mixture of 0.25% plain Marcaine, 30 mg of Toradol, and 4 mg of morphine.  The quadriceps mechanism and distal arthrotomy was repaired with #1 Vicryl in figure-of-8 fashion.  The subcutaneous closure was performed in layers using 2-0 Vicryl and 0 Vicryl followed by 2-0 Vicryl proximally.  The skin was approximated with staples.  Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias.  The patient was then transferred to the recovery room in a stable condition.  There were no intraoperative complications noted.  She tolerated the procedure very well.
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DESCRIPTION: Left total knee cemented arthroplasty.  Severe tricompartmental osteoarthritis, left knee with varus deformity.

The situation involves a surgical procedure, which inherently comes with high risks and significant consequences if not performed correctly. The detailed description outlines the complexity and critical nature of the surgery, including preparation, ligament preservation, alignment, bone cutting, and cementing of implants. Even though the procedure was completed successfully without complications, the stakes involved in such surgical operations are high due to potential risks such as infection, improper alignment which can lead to additional pain or the need for another surgery, and risks associated with anesthesia. Therefore, the stakes in this situation can be determined as relatively high.


Medical Specialty: Surgery
Sample Name: Central Line Insertion

PREOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,PROCEDURE:,  Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in the Trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty.  The triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline.  The catheter was fixed to the skin with sutures.  The dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter.
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DESCRIPTION: Central line insertion.  Empyema thoracis and need for intravenous antibiotics.

surgery, thoracis, intravenous, central line insertion, empyema, catheter,

The procedure described is a central line insertion, which is a common yet important medical procedure, especially in the context of treating conditions such as empyema thoracis. While it is considered a routine procedure for trained surgical personnel, it does carry risks such as infection, bleeding, and incorrect placement, which must be managed carefully. Additionally, the central line is crucial for administering intravenous antibiotics necessary for the patient's condition. Therefore, there are significant medical implications both in terms of the procedure itself and its necessity for treatment, making this a moderately high-stakes situation.


Medical Specialty: Surgery
Sample Name: Cauterization - Epistaxis

PREOPERATIVE DIAGNOSIS: , Epistaxis and chronic dysphonia.,POSTOPERATIVE DIAGNOSES:,1.  Atrophic dry nasal mucosa.,2.  Epistaxis.,3.  Atrophic laryngeal changes secondary to inhaled steroid use.,PROCEDURE PERFORMED:,1.  Cauterization of epistaxis, left nasal septum.,2.  Fiberoptic nasal laryngoscopy.,ANESTHESIA: , Neo-Synephrine with lidocaine nasal spray.,FINDINGS:,1.  Atrophic dry cracked nasal mucosa.,2.  Atrophic supraglottic and glottic changes likely secondary to inhaled steroids and recent endotracheal tube intubation.,INDICATIONS: , The patient is a 37-year-old African-American female who was admitted to ABCD General Hospital with a left wrist abscess.  The patient was taken to the operating room for incision and drainage.  Postoperatively, the patient was placed on nasal cannula oxygen and developed subsequent epistaxis.  Upon evaluating the patient, the patient complains of epistaxis from the left naris as well as some chronic dysphonia that had become exacerbated after surgery.  The patient does report of having endotracheal tube intubation during anesthesia.  The patient also gives a history of inhaled steroid use for her asthma.,The patient was extubated after surgery without difficulty, but continued to have some difficulty and the Department of Otolaryngology was asked to evaluate the patient regarding epistaxis and dysphonia.,PROCEDURE DETAILS:,  After the procedure was described, the patient was placed in the seated position.  The fiberoptic nasal laryngoscope was then inserted into the patient's left naris.  The nasal mucosal membranes were dry and atrophic throughout.  There was no evidence of any mass lesions.  The nasal laryngoscope was then advanced towards the posterior aspect of the nasal cavity.  There was no evidence of mass, ulceration, lesion, or obstruction.  The nasolaryngoscopy continued to be advanced into the oropharynx and the vallecula and the base of the tongue were evaluated and were without evidence of mass lesion or ulceration.,The fiberoptic scope was further advanced and visualization of the larynx revealed some atrophic, dry, supraglottic, and glottic changes.  There was no evidence of any local mass lesion, nodule, or ulcerations.  There was no evidence of any erythema.  Upon phonation, the vocal cords approximated completely and upon inspiration, the true vocal cords were abducted in a normal fashion and was symmetric.  The airway was stable and patent throughout the entire examination.  The nasal laryngoscope was then slowly withdrawn from the supraglottic region and the scope was further advanced into the oropharynx and nasopharynx.  The eustachian tube was completely visualized and was patent without obstruction.  The scope was then further removed without difficulty.  The patient tolerated the procedure well and remained in stable condition.,RECOMMENDATIONS AND PLAN: , The patient would benefit from Ocean nasal spray as well as bacitracin ointment applied to the anterior naris.  At this time, we were unable to discontinue the patient's inhaled steroids that she is using for her asthma.  If this becomes possible in the future, this may provide her some relief of her chronic dysphonia.  The patient is to follow up with Department of Otolaryngology after discharge from the hospital for further evaluation of these problems.
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DESCRIPTION: Cauterization of epistaxis, left nasal septum.  Fiberoptic nasal laryngoscopy.  Atrophic dry nasal mucosa.  Epistaxis.  Atrophic laryngeal changes secondary to inhaled steroid use.

surgery, laryngeal, inhaled steroid use, dry nasal mucosa, fiberoptic nasal laryngoscopy, nasal mucosa, atrophic, cauterization, mucosa, supraglottic, laryngoscope, fiberoptic, dysphonia, lesions, epistaxis,

The situation involves a medical procedure on a patient with chronic health issues exacerbated by recent surgical and medical conditions. Cauterization is necessary to manage active epistaxis (nosebleed) which can be a concerning, though not immediately life-threatening, condition unless it becomes severe. The need for fiberoptic nasal laryngoscopy suggests the epistaxis and related symptoms have some complexity, likely due to prior medical interventions and chronic conditions. However, while the examination reveals atrophic changes and requires follow-up, the postoperative findings indicate that the patient's airway is patent and stable, reducing the immediate risk. The follow-up care and inability to currently discontinue inhaled steroids for asthma management highlight ongoing medical attention is required, but without immediate life-threatening stakes involved.


Medical Specialty: Surgery
Sample Name: Catheter Placement

PROCEDURE PERFORMED: , Ultrasound-guided placement of multilumen central venous line, left femoral vein.,INDICATIONS:,  Need for venous access in a patient on a ventilator and on multiple IV drugs.,CONSENT: , Consent obtained from patient's sister.,PREOPERATIVE MEDICATIONS: , Local anesthesia with 1% plain lidocaine.,PROCEDURE IN DETAIL: , The ultrasound was used to localize the left femoral vein and to confirm it's patency and course.  The left inguinal area was then prepped and draped in a sterile manner.  The overlying soft tissues were anesthetized with 1% plain lidocaine.  Under direct ultrasound visualization, the femoral vein was cannulated without difficulty, and a guidewire advanced.  This was followed by a stab incision and the vein dilator in order to form a tract for the catheter itself.  Finally, the multilumen catheter itself was inserted over the guidewire.  Once the catheter was fully inserted, the guidewire was completely withdrawn.  Placement was confirmed by the withdrawal of dark venous blood from all ports; all ports were then flushed, the catheter sewn into place, and the dressing applied.  He tolerated the procedure very well, without complications.
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DESCRIPTION: Ultrasound-guided placement of multilumen central venous line, left femoral vein.

surgery, plain lidocaine, femoral vein, ultrasound, venous, femoral, guidewire, placement, vein, catheter, access,

The procedure described involves the placement of a central venous line, which is a critical and invasive procedure, particularly for patients who are on a ventilator and require multiple IV drugs. It demands precision due to the risks of misplacement, infection, or causing damage to the vein. Central venous line placement is crucial for the administration of medications and monitoring, especially in critically ill patients, making it a high-stakes situation in the medical field.


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Medical Specialty: Surgery
Sample Name: Cheek-Neck Facelift

PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis.  Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:,  Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825).  Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-year-old female who has progressive aging changes of the face and neck.  The patient demonstrates the deformities described above and has requested surgical correction.  The procedure, risks, limitations, and alternatives in this individual case have been very carefully discussed with the patient.  The patient has consented to surgery.,The patient was brought into the operating room and placed in the supine position on the operating table.  An intravenous line was started and anesthesia was maintained throughout the case.  The patient was monitored for cardiac, blood pressure, and oxygen saturation continuously.,The hair was prepared and secured with rubber bands and micropore tape along the incision line.  A marking pen had been used to outline the area of the incisions, which included the preauricular area to the level of the tragus, the post-tragal region, the post auricular region and into the hairline.  In addition, the incision was marked in the temporal area in the event of a temporal lift, then across the coronal scalp for the forehead lift.  The incision was marked in the submental crease for the submental lipectomy and liposuction.  The incision in the post auricular area extended up on the posterior aspect of the ear and ended near the occipital hairline.,The areas to be operated on were injected with 1% Lidocaine containing 1:100,000 Epinephrine.  This provided local anesthesia and vasoconstriction.  The total of Lidocaine used throughout the procedure was maintained at no more than 500mg.,SUBMENTAL SUCTION ASSISTED LIPECTOMY: , The incision was made, as previously outlined, in the submental crease in a transverse direction, through the skin and subcutaneous tissue, and hemostasis was obtained with bipolar cautery.  A Metzenbaum scissors was used to elevate the area in the submental region for about 2 or 3cm and making radial tunnels from the angle of the mandible all the way to the next angle of the mandible.  4mm liopsuction cannula was then introduced along these previously outlined tunnels into the jowl on both sides and down top the anterior border of the sternocleidomastoid laterally and just past the thyroid notch interiorly.  The tunnels were enlarged with a 6mm flat liposuction cannula.,Then with the Wells-Johnson liposuction machine 27-29 inches of underwater mercury suction was accomplished in all tunnels.  Care was taken not to turn the opening of the suction cannula up to the dermis, but it was rotated in and out taking a symmetrical amount of fat from each area.  A similar procedure was performed with the 4 mm cannula cleaning the area.  Bilateral areas were palpated for symmetry, and any remaining fat was then suctioned directly.,A triangular wedge of anterior platysma border was cauterized and excised at the cervical mental angle.  A plication stitch of 3-0 Vicryl was placed.,When a satisfactory visible result had been accomplished from the liposuction, the inferior flap was then advanced over anteriorly and the overlying skin excised in an incremental fashion.  5-0 plain catgut was used for closure in a running interlocking fashion.  The wound was cleaned at the end, dried, and Mastisol applied.  Then tan micropore tape was placed for support to the entire area.,FACE LIFT: , After waiting approximately 10-15 minutes for adequate vasoconstriction the post auricular incision was started at the earlobe and continued up on the posterior aspect of the ear for approximately 2cm just superior to the external auditory canal.  A gentle curve was then made, and again the incision was carried down to and into the posterior hairline paralleling the hair follicles and directed posteriorly towards the occipital region.  A preauricular incision was carried into the natural crease superior to the tragus, curved posterior to the tragus bilaterally then brought out inferiorly in the natural crease between the lobule and preauricular skin.  The incision was made in the temporal area beveling parallel with the hair follicles.  (The incision had been designed with curve underneath the sideburn in order to maintain the sideburn hair locations and then curved posteriorly.),The plane of dissection in the hairbearing area was kept deep to the roots of the hair follicles and superficial to the fascia of the temporalis muscle and sternocleidomastoid.  The dissection over the temporalis muscle was continued anteriorly towards the anterior hairline and underneath the frontalis to the supraorbital rim.  At the superior level of the zygoma and at the level of the sideburn, dissection was brought more superficially in order to avoid the nerves and vessels in the areas, specifically the frontalis branch of the facial nerve.,The facial flaps were then elevated with both blunt and sharp dissection with the Kahn facelift dissecting scissors in the post auricular region to pass the angle of the mandible.  This area of undermining was connected with an area of undermining starting with the temporal region extending in the preauricular area of the cheek out to the jowl.  Great care was taken to direct the plane of dissecting superficial to the parotid fascia or SMAS.  The entire dissection was carried in a radial fashion from the ear for approximately 4cm at the lateral canthal area to 8-10cm in the neck region.  When the areas of dissection had been connected carefully, hemostasis was obtained and all areas inspected.  At no point were muscle fibers or major vessels or nerves encountered in the dissection.,The SMAS was sharply incised in a semilunar fashion in front of the ear and in front of the anterior border of the SCM.  The SMAS flap was then advanced posteriorly and superiorly.  The SMAS was split at the level of the earlobe, and the inferior portion was sutured to the mastoid periosteum.  The excess SMAS was trimmed and excised from the portion anterior to the auricle.  The SMAS was then imbricated with 2-0 Surgidak interrupted sutures.,The area was then inspected for any bleeding points and careful hemostasis obtained.  The flaps were then rotated and advanced posteriorly and then superiorly, and incremental cuts were made and the suspension points in the pre and post auricular area were done with 2-0 Tycron suture.  The excess and redundant amount of skin were then excised and trimmed cautiously so as not to cause any downward pull on the ear lobule or any stretching of the scars in the healing period.  Skin closure was accomplished in the hairbearing areas with 5-0 Nylon in the preauricular tuft and 4-0 Nylon interrupted in the post auricular area.  The pre auricular area was closed first with 5-0 Dexon at the ear lobules, and 6-0 Nylon at the lobules, and 5-0 plain catgut in a running interlocking fashion.  5-0 Plain catgut was used in the post auricular area as well, leaving ample room for serosanguinous drainage into the dressing.  The post tragal incisin was closed with interrupted and running interlocking 5-0 plain catgut.  The exact similar procedure was repeated on the left side.,At the end of this procedure, all flaps were inspected for adequate capillary filling or any evidence of hematoma formation.  Any small amount of fluid was expressed post-auricularly.  A fully perforated bulb suction drain was placed under the flap and exited posterior to the hairline on each side prior to the suture closure.  A Bacitracin impregnated nonstick dressing was cut to conform to the pre and post auricular area and placed over the incision lines.,ABD padding over 4X4 gauze was used to cover the pre and post auricular areas.  This was wrapped around the head in a vertical circumferential fashion and anchored with white micropore tape in a non-constricting but secured fashion.  The entire dressing complex was secured with a pre-formed elastic stretch wrap device.  All branches of the facial nerve were checked and appeared to be functioning normally.,The procedures were completed without complication and tolerated well.  The patient left the operating room in satisfactory condition.  A follow-up appointment was scheduled, routine post-op medications prescribed, and post-op instructions given to the responsible party.,The patient was released to home in satisfactory condition.
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DESCRIPTION: Temporal cheek-neck facelift  and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides.

surgery, neck skin ptosis, lipotosis, rhytides, facelift, submental suction assisted lipectomy, pre and post auricular, cheek neck facelift, auricular region, neck facelift, cheek neck, post auricular, auricular, incision, postoperative, cheek, submental, dissection, neck,

The described surgical procedure, a temporal cheek-neck facelift with submental suction assisted lipectomy, is a significant and invasive cosmetic surgery that involves general anesthesia. While it is not life-threatening, the procedure carries risks associated with surgery and anesthesia. It also has implications for the patient's appearance, which is important given the potential impact on personal and psychological well-being. The medical practitioner must have detailed pre-operative discussions with the patient to address risks and manage expectations. Thus, while it is an elective cosmetic surgery, the stakes are moderately high due to the potential for complications and the significance of aesthetic outcomes.


Medical Specialty: Surgery
Sample Name: Cavernosaphenous Shunt - Priapism

PREOPERATIVE DIAGNOSIS:,  Refractory priapism.,POSTOPERATIVE DIAGNOSIS:,  Refractory priapism.,PROCEDURE PERFORMED: , Cavernosaphenous shunt.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS:  ,400 cc.,FLUIDS: , IV fluids 1600 crystalloids, one liter packed red blood cells.,INDICATIONS FOR PROCEDURE:  ,This is a 34-year-old African-American male who is known to our service with a history of recurrent priapism.  The patient presented with priapism x48 hours on this visit.  The patient underwent corporal aspiration and Winter's shunt both of which failed and then subsequently underwent _______ procedure.  The patient's priapism did return following this and he was scheduled for cavernosaphenous shunt.,PROCEDURE:,  Informed written consent was obtained.  The patient was taken to the operative suite and administered anesthetic.  The patient was sterilely prepped and draped in the supine fashion.  A #15 French Foley catheter was inserted under sterile conditions.  Incision was made in the left base of the penile shaft on the lateral aspect, approximately 3 cm in length.  Tissue was dissected down to the level of the corpora cavernosum and corpora spongiosum.  The fascia was incised in elliptical fashion for approximately 2 cm.  A #14 gauge Angiocath was inserted into the corpora cavernosum to the glans of the penis and the corpora was irrigated copiously until all of the old clotted blood was removed and fresher irrigation was noted.,Attention was then turned to the left groin and the superficial saphenous vein was harvested.  Due to incisions brought up into the initial incision after gauging enough length, this was then spatulated with Potts scissors for approximately 2 cm.  Vein was irrigated.  One branching vessel was noted to be leaking, this was tied off and repeat injection with heparinized saline showed no additional leaks.  Tunnel was then created from the superior most groin region to the incision in the penile shaft.  Saphenous vein was then passed through this tunnel with the aid of a hemostat.  Anastomosis was performed using #5-0 Prolene suture in a running fashion from proximal to distal.  There were no leaks noted.  There was good flow noted within the saphenous vein graft.  Penis was noted to be in a flaccid state.  All incisions were irrigated copiously and closed in several layers.  Sterile dressings were applied.  The patient was cleaned, transferred to recovery room in stable condition.,PLAN:  ,We will continue with antibiotics for pain control, maintain Foley catheter.  Further recommendations to follow.
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DESCRIPTION: Refractory priapism.  Cavernosaphenous shunt.   The patient presented with priapism x48 hours on this visit.  The patient underwent corporal aspiration and Winter's shunt both of which failed

surgery, corporal aspiration, winter's shunt, foley catheter, corpora cavernosum, refractory priapism, saphenous vein, cavernosaphenous shunt, corporal, priapism, aspiration

The described surgical procedure is addressing a case of refractory priapism, a condition where there is a persistent and often painful erection lasting more than four hours. This condition can be a medical emergency if not treated promptly, as it can lead to permanent erectile dysfunction due to the lack of blood flow to the penile tissue. The procedure described, cavernosaphenous shunt, is typically performed after less invasive measures have failed, signifying the seriousness of the case. While it may not involve life-threatening consequences directly like some cardiac or neurosurgeries, the stakes are significant given the potential for lasting impotence. Thus, it's more than a routine procedure.


Medical Specialty: Surgery
Sample Name: Cataract Extraction - 2

PREOPERATIVE DIAGNOSIS: , Cataract, left eye.,POSTOPERATIVE DIAGNOSIS:  ,Cataract, left eye.,PROCEDURE PERFORMED:  ,Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE: , After the induction of topical anesthesia with 4% Xylocaine drops, the left eye was prepped and draped in the usual fashion.  A speculum was inserted, and the microscope was moved into position.,A 3.2-mm incision was made in clear cornea at the limbus with a diamond keratome at the 3 o'clock position, and 0.1 cc of 1% Xylocaine without preservative was instilled into the anterior chamber.  It was then filled with viscoelastic.  A stab incision was made into the anterior chamber at the limbus at 5 o'clock position with a microblade.,A cystitome was used to make a capsulotomy, and the capsulorrhexis forceps were used to complete a circular capsulorrhexis.  The nucleus was hydrodelineated and hydrodissected with balanced salt solution on a 26-gauge cannula, and the phacoemulsifier was used to phacoemulsify the nucleus using a bimanual technique with the nucleus rotator inserted through the keratotomy incision.  The irrigation-aspiration handpiece was used to systematically aspirate cortex 360 degrees.  The posterior capsule was vacuumed; it was clear and intact.,The capsular bag and the anterior chamber were filled with viscoelastic.  A model MA30AC lens, power 21.5 diopters, serial number 864414.095, was folded, grasped with the lens insertion forceps and inserted into the capsular bag.  The trailing loop was placed inside the bag.  The viscoelastic was removed with the irrigation-aspiration handpiece.  The lens centered well.  A single 10-0 nylon suture was placed to close the wound.  It was checked and ascertained to be watertight.  Decadron 0.25 cc, 0.25 cc of antibiotic and 0.25 cc of Xylocaine were injected subconjunctivally.  Dexacidin ointment was placed in the eye, and the procedure was terminated.,The procedure was well tolerated by the patient who was returned to the recovery room in good condition.
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DESCRIPTION: Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.

surgery, anterior chamber, keratome, limbus, intraocular lens, cataract extraction, extracapsular, phacoemulsification, capsular, cataract, chamber, intraocular,

The procedure described is a cataract extraction surgery, which is a common and generally low-risk ophthalmic surgery. The document specifies that there were no complications, and the procedure was well-tolerated by the patient. While it is technically challenging and requires precision, it does not typically involve life-threatening stakes compared to other surgical procedures. The stakes involve ensuring vision restoration and avoiding complications like infection or lens dislocation, which are relatively rare with modern techniques and expertise.


Medical Specialty: Surgery
Sample Name: Carpal Tunnel Release - 8

PREOPERATIVE DIAGNOSES:,1.  Right carpal tunnel syndrome.,2.  Right index finger and middle fingers tenosynovitis.,POSTOPERATIVE DIAGNOSES:,1.  Right carpal tunnel syndrome.,2.  Right index finger and middle fingers tenosynovitis.,PROCEDURES PERFORMED:,1.  Right carpal tunnel release.,2.  Right index and middle fingers release A1 pulley.,TOURNIQUET TIME:  ,70 minutes.,BLOOD LOSS: , Minimal.,GROSS INTRAOPERATIVE FINDINGS:,1.  A compressed median nerve at the carpal tunnel, which was flattened.,2.  A stenosing tenosynovitis of the A1 pulley of the right index as well as middle fingers.  After the A1 pulley was released, there was evidence of some synovitis as well as some fraying of the flexor digitorum profundus as well as flexor digitorum superficialis tendons.,HISTORY:  ,This is a 78-year-old male who is complaining of right hand pain and numbness with decreased range of the middle index finger and right middle finger complaining of catching and locking.  The patient was diagnosed with carpal tunnel syndrome on bilateral hands the right being worse than the left.  He had positive EMG findings as well as clinical findings.  The patient did undergo an injection, which only provided him with temporary relief and is for this reason, he has consented to undergo the above-named procedure.,All risks as well as complications were discussed with the patient and consent was obtained.,PROCEDURE:  ,The patient was wheeled back to the operating room #1 at ABCD General Hospital on 08/29/03.  He was placed supine on the operating room table.  Next, a non-sterile tourniquet was placed on the right forearm, but not inflated.  At this time, 8 cc of 0.25% Marcaine with epinephrine was instilled into the carpal tunnel region of the volar aspect of the wrist for anesthesia.  In addition, an additional 2 cc were used on the superficial skin of the volar palm over the A1 pulley of the right index and right middle fingers.  At this time, the extremity was then prepped and draped in usual sterile fashion for this procedure.  First, we went for release of the carpal tunnel.  Approximately 2.5 cm incision was made over the volar aspect of the wrist over the carpal tunnel region.  First, dissection through the skin in the superficial fascia was performed with a self-retractor placed in addition to Ragnells retracting proximally and distally.  The palmaris brevis muscle was then identified and sharply transected.  At this time, we identified the transverse carpal tunnel ligament and a #15 blade was used to sharply and carefully release that fascia.  Once the fascia of the transverse carpal ligament was transected, the identification of the median nerve was visualized.  The resection of the ligament was taken both proximally and distally to assure complete release and it was checked thoroughly.  At this time, a neurolysis was performed and no evidence of space-occupying lesions were identified within the carpal tunnel.  At this time, copious irrigation was used to irrigate the wound.  The wound was suctioned dry.  At this time, we proceeded to the release of the A1 pulleys.  Approximately, a 1.5 cm incision was made over the A1 pulley in the volar aspect of the palm of the right index and right middle fingers.  First, we went for the index finger.  Once the skin incision was made, Metzenbaum scissor was used to longitudinally dissect the subcutaneous tissue and with Ragnell retractors we identified the A1 pulley.  A #15 blade was used to make a longitudinal slit along with A1 pulley and the Littler scissors were used to release the A1 pulley proximally as well as distally.  Once this was performed, a tendon hook was then used to wrap the tendon and release the tendons both proximally and distally and they were removed from the wound in order to check their integrity.  There was some evidence of synovitis in addition to some fraying of the both the profundus as well as superficialis tendons.  Once a thorough release was performed, copious irrigation was used to irrigate that wound.  In the similar fashion, a 1.5 cm incision was made over the volar aspect of the A1 pulley of the right middle finger.  A Littler scissor was used to bluntly dissect in the longitudinal fashion.  With the Ragnell retractors, we identified the A1 pulley of the right middle finger.,Using a #15 blade, the A1 pulley was scored with the #15 blade and the Litter scissor was used to complete the release of the A1 pulley distally and proximally.  We again placed the tendon hook around both the superficialis and the profundus tendons and they were extruded from the wound to check their integrity.  Again, there was evidence of some synovitis as well as fraying of both tendons.  The girth of both tendons and both wounds were within normal limits.  At this time, copious irrigation was used to irrigate the wound.  The patient was then asked to intraoperatively flex and extend his fingers and he was able to fully flex his fingers to make a close fit which he was not able to do preoperatively.  In addition, he was able to abduct his thumb indicating that the recurrent branch of the median nerve was intact.  At this time, #5-0 nylon was used to approximate in a vertical mattress type fashion both the carpal tunnel incision as well as the both A1 pulley incisions of the right middle finger and right index finger.  The wound closure took place after the tourniquet was released and hemostasis was obtained with Bovie cautery.  At this time, a short-arm splint was placed on the volar aspect of the wrist after it was wrapped in a sterile dressing consisting of Adaptic and Kerlix roll.  The patient was then carefully taken off of the operating room table to Recovery in stable condition.
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DESCRIPTION: Right carpal tunnel release and right index and middle fingers release A1 pulley.  Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis.

surgery, compressed median nerve, stenosing tenosynovitis, carpal tunnel release, carpal tunnel syndrome, middle fingers, carpal tunnel, littler scissors, median nerve, copious irrigation, volar aspect, tunnel, pulley, carpal, fingers, index, tourniquet, ligament, tenosynovitis, superficialis, tendons,

The procedure described is a surgical operation involving carpal tunnel release and the release of A1 pulleys in the fingers, which is a common treatment for conditions like carpal tunnel syndrome and tenosynovitis. While certainly important for the patient's health and quality of life, such surgeries are typically routine and low-risk for experienced surgical teams. The reported blood loss was minimal, and the operation was described as proceeding without complications. Moreover, the patient was stable post-operation and regained improved function immediately. Given this context and typical risk profiles associated with similar elective surgeries, this situation is not considered high-stakes in comparison to more critical surgeries, such as cardiac or brain surgeries that bear higher risk to a patient's life.


Medical Specialty: Surgery
Sample Name: Cartilage Loose Body Removal

PREOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,POSTOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,PROCEDURES:,  Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,ANESTHESIA: , General.,TOURNIQUET TIME:  ,Thirty-seven minutes.,MEDICATIONS: , The patient also received 30 mL of 0.5% Marcaine local anesthetic at the end of the case.,COMPLICATIONS: , No intraoperative complications.,DRAINS AND SPECIMENS: , None.,INTRAOPERATIVE FINDINGS: , The patient had a loose body that was found in the suprapatellar pouch upon entry of the camera.  This loose body was then subsequently removed.  It measured 24 x 14 mm.  This was actually the OCD lesion seen on the MRI that had come from the weightbearing surface of just the lateral posterior aspect of the medial femoral condyle,HISTORY AND PHYSICAL: , The patient is 13-year-old male with persistent left knee pain.  He was initially seen at Sierra Pacific Orthopedic Group where an MRI demonstrated unstable OCD lesion of the left knee.  The patient presented here for a second opinion.  Surgery was recommended grossly due to the instability of the fragment.  Risks and benefits of surgery were discussed.  The risks of surgery include risk of anesthesia, infection, bleeding, changes in sensation and motion extremity, failure to relieve pain or restore the articular cartilage, possible need for other surgical procedures, and possible early arthritis.  All questions were answered and parents agreed to the above plan.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient received Ancef preoperatively.  A nonsterile tourniquet was placed on the upper aspect of the patient's left thigh.  The extremity was then prepped and draped in standard surgical fashion.  The standard portals were marked on the skin.  The extremity was wrapped in Esmarch prior to inflation of tourniquet to 250 mmHg.  The portal incisions were then made by an #11 blade.  Camera was inserted into the lateral joint line.  There was a noted large cartilage loose body in the suprapatellar pouch.  This was subsequently removed with extension of the anterolateral portal.  Visualization of the rest of the knee revealed significant synovitis.  The patient had a large cartilage defect in the posterolateral aspect of the medial femoral condyle.  The remainder of the knee demonstrated no other significant cartilage lesions, loose bodies, plica or meniscal pathology.  ACL was also visualized to be intact in the intracondylar notch.,Attention was then turned back to the large defect.  The loose cartilage was debrided using a shaver.  Microfracture technique was then performed to 4 mm depth at 2 to 3 mm distances.  Tourniquet was released at the end of the case to ensure that there was fat and bleeding at the microfracture sites.  All instruments were then removed.  The portals were closed using #4-0 Monocryl.  A total of 30 mL of 0.5% Marcaine was injected into the knee.  Wounds were then cleaned and dried, and dressed in Steri-Strips, Xeroform, 4 x 4s, and bias.  The patient was then placed in a knee immobilizer.  The patient tolerated the procedure well.  The tourniquet was released at 37 minutes.  He was taken to recovery in stable condition.,POSTOPERATIVE PLAN: , The loose cartilage fragment was given to the family.  The intraoperative findings were relayed with intraoperative photos.  There was a large deficit in the weightbearing portion of medial femoral condyle.  His prognosis is guarded given the fact of the fragile lesion and location, but in advantages of his age and his rehab potential down the road, if the patient still has symptoms, he may be a candidate for osteochondral autograft, a procedure which is not performed at Children's or possible cartilaginous transplant.  All questions were answered.  The patient will follow up in 10 days, may wet the wound in 5 days.
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DESCRIPTION: Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.

surgery, knee arthroscopy, chondroplasty, medial femoral condyle, cartilage loose body, loose cartilage, knee, arthroscopy, tourniquet, microfracture, orthopedic, femoral, cartilage,

The procedure described involves surgical intervention on the knee of a 13-year-old patient for a condition diagnosed as osteochondritis dissecans. The stakes are relatively high because it involves surgery on a young patient, which carries inherent risks such as complications from anesthesia, infection, and potential impact on the patient's recovery and mobility. However, the procedure is routine for addressing this type of condition, there were no intraoperative complications, and the patient is expected to do well post-surgery. Therefore, while important, it is not as high-stakes as more invasive or complex surgeries. The guarded prognosis also indicates a need for careful follow-up, but not an immediate high-stakes situation.