Medical Specialty: Surgery
Sample Name: Phacoemulsification & Cataract Extraction - 5

PREOPERATIVE DIAGNOSIS: , Cataract, right eye.,POSTOPERATIVE DIAGNOSIS:  ,Cataract, right eye.,PROCEDURE PERFORMED:  ,Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation.  An Alcon MA30BA lens was used, * diopters, #*.,ANESTHESIA: ,Topical 4% lidocaine with 1% nonpreserved intracameral lidocaine.,COMPLICATIONS:, None.,PROCEDURE: , Prior to surgery, the patient was counseled as to the risks, benefits and alternatives of the procedure with risks including, but not limited to, bleeding, infection, loss of vision, loss of the eye, need for a second surgery, retinal detachment and retinal swelling.  The patient understood the risks clearly and wished to proceed.,The patient was brought into the operating suite after being given dilating drops.  Topical 4% lidocaine drops were used.  The patient was prepped and draped in the normal sterile fashion.  A lid speculum was placed into the right eye.  Paracentesis was made at the infratemporal quadrant.  This was followed by 1% nonpreservative lidocaine into the anterior chamber, roughly 250 microliters.  This was exchanged for Viscoat solution.  Next, a crescent blade was used to create a partial-thickness linear groove at the temporal limbus.  This was followed by a clear corneal bevel incision with a 3 mm metal keratome blade.  Circular capsulorrhexis was initiated with a cystitome and completed with Utrata forceps.  Balanced salt solution was used to hydrodissect the nucleus.  Nuclear material was removed via phacoemulsification with divide-and-conquer technique.  The residual cortex was removed via irrigation and aspiration.  The capsular bag was then filled with Provisc solution.  The wound was slightly enlarged.  The lens was folded and inserted into the capsular bag.,Residual Provisc solution was irrigated out of the eye.  The wound was stromally hydrated and noted to be completely self-sealing.,At the end of the case, the posterior capsule was intact.  The lens was well centered in the capsular bag.  The anterior chamber was deep.  The wound was self sealed and subconjunctival injections of Ancef, dexamethasone and lidocaine were given inferiorly.  Maxitrol ointment was placed into the eye.  The eye was patched with a shield.,The patient was transported to the recovery room in stable condition to follow up the following morning.
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DESCRIPTION: Cataract extraction via phacoemulsification with posterior chamber intraocular lens implantation.  An Alcon MA30BA lens was used.   A lid speculum was placed into the right eye.  Paracentesis was made at the infratemporal quadrant.

surgery, alcon, phacoemulsification, cataract extraction, cataract, intraocular lens implantation, anterior chamber, provisc solution, capsular bag, topical, intraocular,

The situation involved is a cataract surgery, which is a routine and common procedure in ophthalmology with a high success rate. Despite detailing potential serious risks like loss of vision or need for additional surgery, complications are rare. This specific case had no complications reported and the patient was stable post-operation. Given its routine nature and successful outcome, it is not extremely high-stakes, though it carries some inherent risks as all surgeries do.


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Medical Specialty: Surgery
Sample Name: Phacoemulsification & Lens Implantation - 1

PREOPERATIVE DIAGNOSIS:,  Visually significant nuclear sclerotic cataract, right eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant nuclear sclerotic cataract, right eye.,OPERATIVE PROCEDURES: , Phacoemulsification with posterior chamber intraocular lens implantation, right eye.,ANESTHESIA:,  Monitored anesthesia care with retrobulbar block consisting of 2% lidocaine in an equal mixture with 0.75% Marcaine and Amphadase.,INDICATIONS FOR SURGERY:,  This patient has been experiencing difficulty with eyesight regarding activities of daily living.  There has been a progressive and gradual decline in the visual acuity.  The cataract was believed related to her decline in vision.  The risks, benefits, and alternatives (including with observation or spectacles) were discussed in detail.  The risks as explained included, but are not limited to pain, bleeding, infection, decreased or loss of vision/loss of eye, retinal detachment requiring further surgery, and possible consultation out of town, swelling of the back part of the eye/retina, need for prolonged eye drop use or injections, instability of the lens, and loss of corneal clarity necessitating long-term drop use or further surgery.  The possibility of needing intraocular lens exchange or incorrect lens power was discussed.  Anesthesia option and risks associated with anesthesia and retrobulbar anesthesia were discussed.  It was explained that some or all of these complications might arise at the time of or months to years after surgery.  The patient had a good understanding of the risks with the proposed, elective eye surgery.  The patient accepted these risks and elected to proceed with cataract surgery.  All questions were answered and informed consent was signed and placed in the chart.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified.  The pupil was dilated per protocol.  The patient was taken to the operating room and placed in the supine position.  After intravenous sedation, the retrobulbar block was injected followed by several minutes of digital massage.  No signs of orbital tenseness or retrobulbar hemorrhage were present.,The patient was prepped and draped in the usual ophthalmic sterile fashion.  An eyelid speculum was used to separate the eyelids.  A crescent blade was used to make a clear corneal temporally located incision.  A 1-mm Dual-Bevel blade was used to make a paracentesis site.  The anterior chamber was filled with viscoelastic (Viscoat).  The crescent blade was then used to make an approximate 2-mm long clear corneal tunnel through the temporal incision.  A 2.85-mm keratome blade was then used to penetrate into the anterior chamber through the temporal tunneled incision.  A 25-gauge pre-bent cystotome used to begin a capsulorrhexis.  The capsulorrhexis was completed with the Utrata forceps.  A 27-guage needle was used for hydrodissection and three full and complete fluid waves were noted.  The lens was able to be freely rotated within the capsular bag.  Divide-and-conquer ultrasound was used for phacoemulsification.  After four sculpted grooves were made, a bimanual approach with the phacoemulsification tip and Koch spatula was used to separate and crack each grooved segment.  Each of the four nuclear quadrants was phacoemulsified.  Aspiration was used to remove all remaining cortex.  Viscoelastic was used to re-inflate the capsular bag.  An AMO model SI40NB posterior chamber intraocular lens with power *** diopters and serial number *** was injected into the capsular bag.  The trailing haptic was placed with the Sinskey hook.  The lens was made well centered and stable.  Viscoelastic was aspirated.  BSS was used to re-inflate the anterior chamber to an adequate estimated intraocular pressure.  A Weck-Cel sponge was used to check both incision sites for leaks and none were identified.  The incision sites remained well approximated and dry with a well-formed anterior chamber and eccentric posterior chamber intraocular lens.  The eyelid speculum was removed and the patient was cleaned free of Betadine.  Vigamox and Econopred drops were applied.  A soft eye patch followed by a firm eye shield was taped over the operative eye.  The patient was then taken to the Postanesthesia Recovery Unit in good condition having tolerated the procedure well.,Discharge instructions regarding activity restrictions, eye drop use, eye shield/patch wearing, and driving restrictions were discussed.  All questions were answered.  The discharge instructions were also reviewed with the patient by the discharging nurse.  The patient was comfortable and was discharged with followup in 24 hours.  Complications none.
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DESCRIPTION: Visually significant nuclear sclerotic cataract, right eye.  Phacoemulsification with posterior chamber intraocular lens implantation, right eye.

surgery, retrobulbar block, posterior chamber intraocular lens, nuclear sclerotic cataract, cataract, lens implantation, posterior chamber, anterior chamber, intraocular lens, lens, eye, intraocular, anesthesia, phacoemulsification, retrobulbar,

Cataract surgery, specifically phacoemulsification with lens implantation, is a common procedure and generally considered low-risk with a high success rate. However, it involves the eye, a vital organ, and any surgery carries inherent risks including pain, infection, or further complications that can affect vision. The stakes, while not life-threatening, are significant because the outcome directly affects the patient's quality of life. Since vision is crucial for daily activities, the procedure has moderate stakes in terms of the impact on the patient's well-being. Given that the surgery went smoothly with no complications reported and the patient was discharged in good condition, this further limits the high-stakes element of the situation.

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Medical Specialty: Surgery
Sample Name: Phacoemulsification & Cataract Extraction - 1

PREOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,POSTOPERATIVE DIAGNOSIS: , Visually significant cataract, left eye.,ANESTHESIA: , Topical/MAC.,PROCEDURE: , Phacoemulsification cataract extraction with intraocular lens implantation, left eye (Alcon AcrySof, SN60AT, 23.0 D, serial #***).,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY:  ,The patient is a 74-year-old woman with complaints of painless progressive loss of vision in her left eye.  She was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.,PROCEDURE IN DETAIL:  ,The patient was verified in the preoperative holding area and the informed consent was reviewed and verified to be on the chart.  They were transported to the operative suite, accompanied by the anesthesia service, where appropriate cardiopulmonary monitoring was established.  MAC anesthesia was achieved, which was followed by topical anesthesia using 1% preservative-free tetracaine eye drops.  The patient was prepped and draped in the usual fashion for sterile ophthalmic surgery and a lid speculum was placed.,Two stab-incision paracenteses were made in the cornea using the MVR blade, and the anterior chamber was irrigated with 1% preservative-free lidocaine for intracameral anesthesia.  The anterior chamber was filled with viscoelastic and a shelved, temporal, clear corneal incision was made using the diamond groove knife and steel keratome.  A continuous curvilinear capsulorrhexis was made in the anterior capsule using the bent-needle cystotome.  The lens nucleus was hydrodissected and hydrodelineated using balanced saline solution (BSS) on a Chang cannula until it rotated freely.,The phacoemulsification handpiece was introduced into the anterior chamber, and the lens nucleus was sculpted into 2 halves.  Each half was further subdivided with chopping and removed with phacoemulsification.  The remaining cortical material was removed with the irrigation and aspiration (I&A) handpiece.  The capsular bag was inflated with viscoelastic and the intraocular lens was injected into the capsule without difficulty.  The remaining viscoelastic was removed with the I&A handpiece, and the anterior chamber was filled to an appropriate intraocular pressure with BSS.  The corneal wounds were hydrated and verified to be water-tight.  Antibiotic ointment was placed, followed by a patch and shield.  The patient was transported to the PACU in good/stable condition.  There were no complications.  Followup is scheduled for tomorrow morning in the eye clinic.,A single interrupted 10-0 nylon suture was placed through the inferotemporal paracentesis to ensure that it was watertight at the end of the case.
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DESCRIPTION: Visually significant cataract, left eye.  Phacoemulsification cataract extraction with intraocular lens implantation, left eye.  The patient was found to have a visually-significant cataract and, after discussion of the risks, benefits and alternatives to surgery, she elected to proceed with cataract extraction and lens implantation in this eye in efforts to improve her vision.

surgery, intraocular lens implantation, eye, intraocular lens, lens implantation, cataract extraction, cataract, intraocular, viscoelastic, handpiece, implantation, chamber, phacoemulsification, extraction, visually, anterior, lens

The situation described is a routine cataract surgery, which is generally considered to be a low-risk and common surgical procedure. Phacoemulsification is a standard approach for treating cataracts and is typically performed under local anesthesia, thus minimizing risk factors associated with general anesthesia. The absence of complications during the procedure, as stated, indicates a successful surgery. Although all surgeries carry some level of risk, in the context of surgical procedures, cataract extractions are considered low-stakes compared to many other types of surgeries.


Medical Specialty: Surgery
Sample Name: Permacath Placement

PROCEDURE:,  Permacath placement.,INDICATION: , Renal failure.,IMPRESSION: , Status post successful placement of a #4-French Permacath dialysis catheter.,DISCUSSION:,  After informed consent was obtained at the request of Dr. Xyz, Permacath placement was performed.,The right neck and anterior chest were sterilely cleansed and draped.  Lidocaine 1% buffered with sodium bicarbonate was used as a local anesthetic.  Using ultrasound guidance, a micropuncture needle was advanced into the internal jugular vein.  The wire was then advanced with fluoroscopic guidance.  A dilator was placed.  An incision was then made at the puncture site for approximately 1 cm in the neck.  A 1 cm incision was also made in the anterior chest.  The catheter was tunneled subcutaneously from the incision on the anterior chest, out the incision of the neck.  Following this, over the wire, the tract into the internal jugular vein was dilated and a peel-away sheath was placed.  The catheter was then advanced through the peel-away sheath.  The peel-away sheath was removed.  The catheter was examined under fluoroscopic imaging and was in satisfactory position.  Both ports were aspirated and flushed easily.  Following this, the incision on the neck was closed with 2 #3-0 silk sutures.  The incision on the anterior chest was also closed 2 #3-0 silk sutures.,The patient tolerated the procedure well.  No complications occurred during or immediately after the procedure.  The patient was returned to her room in satisfactory condition.
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DESCRIPTION: Permacath placement - renal failure.

Permacath placement - renal failure.

surgery, permacath placement, permacath, renal failure, anterior chest, catheter, dialysis, fluoroscopic, fluoroscopic guidance, internal jugular vein, micropuncture, needle, sheath, sutures, ultrasound guidance, internal jugular, jugular vein, placement,

The procedure described is a surgical procedure related to placing a Permacath for dialysis in a patient with renal failure. While the procedure is a routine one for experienced surgeons and was completed without complications, it is still considered an invasive procedure. The catheter is essential for the patient's dialysis treatment, making it critical to their ongoing health and management of renal failure. Any surgical procedure carries inherent risks, though the anticipations of complications are usually low in experienced hands, and successful execution is crucial for patient health.


Medical Specialty: Surgery
Sample Name: Phacoemulsification

PREOPERATIVE DIAGNOSIS:, Senile cataract OX,POSTOPERATIVE DIAGNOSIS: ,Senile cataract OX,PROCEDURE: ,Phacoemulsification with posterior chamber intraocular lens OX, model SN60AT (for Acrysof natural lens), XXX diopters.,INDICATIONS: ,This is a XX-year-old (wo)man with decreased vision OX.,PROCEDURE:, The risks and benefits of cataract surgery were discussed at length with the patient, including bleeding, infection, retinal detachment, re-operation, diplopia, ptosis, loss of vision, and loss of the eye. Informed consent was obtained. On the day of surgery, (s)he received several sets of drops in the XXX eye including 2.5% phenylephrine, 1% Mydriacyl, 1% Cyclogyl, Ocuflox and Acular. (S)he was taken to the operating room and sedated via IV sedation. 2% lidocaine jelly was placed in the XXX eye (or, retrobulbar anesthesia was performed using a 50/50 mixture of 2% lidocaine and 0.75% marcaine). The XXX eye was prepped using a 10% Betadine solution. (S)he was covered in sterile drapes leaving only the XXX eye exposed. A Lieberman lid speculum was placed to provide exposure. The Thornton fixation ring and a Superblade were used to create a paracentesis at approximately 2 (or 11 depending upon side and handedness, and assuming superior incision) o'clock. Then 1% lidocaine was injected through the paracentesis. After the nonpreserved lidocaine was injected, Viscoat was injected through the paracentesis to fill the anterior chamber. The Thornton fixation ring and a 2.75 mm keratome blade were used to create a two-step full-thickness clear corneal incision superiorly. The cystitome and Utrata forceps were used to create a continuous capsulorrhexis in the anterior lens capsule. BSS on a hydrodissection cannula was used to perform gentle hydrodissection. Phacoemulsification was then performed to remove the nucleus. I & A was performed to remove the remaining cortical material. Provisc was injected to fill the capsular bag and anterior chamber. A XXX diopter SN60AT (for Acrysof natural lens) intraocular lens was injected into the capsular bag. The Kuglen hook was used to rotate it into proper position in the capsular bag. I & A was performed to remove the remaining Viscoelastic material from the eye. BSS on the 30-gauge cannula was used to hydrate the wound. The wounds were checked and found to be watertight. The lid speculum and drapes were carefully removed. Several drops of Ocuflox were placed in the XXX eye. The eye was covered with an eye shield. The patient was taken to the recovery area in a good condition. There were no complications.
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DESCRIPTION: Phacoemulsification with posterior chamber intraocular lens - Sample/Template.

surgery, phacoemulsification, acrysof, acrysof natural lens, acular, kuglen hook, ocuflox, provisc, sn60at, senile cataract, thornton fixation ring, bleeding, capsular bag, decreased vision, diopters, diplopia, infection, loss of the eye, loss of vision, ptosis, retinal detachment, lid speculum, thornton fixation, anterior chamber, intraocular lens, intraocular, chamber, lidocaine,

The situation involves a phacoemulsification surgery, a common procedure to remove cataracts and replace the cloudy lens with a clear artificial one. Although routine, it still carries potential risks such as bleeding, infection, retinal detachment, or the loss of vision, making it more significant than low-stakes scenarios. However, given the patient's good condition post-surgery and the procedure's routine nature, it is less critical compared to life-threatening surgeries.


Medical Specialty: Surgery
Sample Name: Penile Skin Bridges Excision

PREOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,POSTOPERATIVE DIAGNOSIS: , Penile skin bridges after circumcision.,PROCEDURE:  ,Excision of penile skin bridges about 2 cm in size.,ABNORMAL FINDINGS:  ,Same as above.,ANESTHESIA:  ,General inhalation anesthetic with caudal block.,FLUIDS RECEIVED: , 300 mL of crystalloids.,ESTIMATED BLOOD LOSS: , Less than 5 mL.,SPECIMENS: , No tissue sent to Pathology.,TUBES AND DRAINS:,  No tubes or drains were used.,COUNT: , Sponge and needle counts were correct x2.,INDICATIONS FOR OPERATION:  ,The patient is a 2-1/2-year-old boy with a history of newborn circumcision who developed multiple skin bridges after circumcision causing curvature with erection.  Plan is for repair.,DESCRIPTION OF PROCEDURE: , The patient is taken to the operating room, where surgical consent, operative site, and the patient's identification was verified.  Once he was anesthetized, the caudal block was placed and IV antibiotics were given.  He was then placed in a supine position and sterilely prepped and draped.  Once he was prepped and draped, we used a straight mosquito clamp and went under the bridges and crushed them, and then excised them with a curved iris and curved tenotomy scissors.  We removed the excessive skin on the shaft skin and on the glans itself.  We then on the ventrum excised the bridge and did a Heinecke-Mikulicz closure with interrupted figure-of-eight and interrupted suture of 5-0 chromic.  Electrocautery was used for hemostasis.  Once this was done, we then used Dermabond tissue adhesive and Surgicel to prevent the bridges from returning again.  IV Toradol was given at the end of procedure.  The patient tolerated the procedure well, was in stable condition upon transfer to the recovery room.
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DESCRIPTION: Excision of penile skin bridges about 2 cm in size.

surgery, heinecke-mikulicz, penile skin bridges, caudal block, penile skin, skin bridges, excision, circumcision, penile,

The surgical procedure involves a 2-1/2-year-old boy who developed penile skin bridges post-circumcision, which were causing curvature with erection. While it's a delicate surgery due to the patient's young age and the sensitive nature of the procedure, it is elective and focused on correcting a non-life-threatening issue. The procedure details indicate a low estimated blood loss, no abnormal findings beyond the bridges themselves, and a successful outcome with the patient tolerating the procedure well. Therefore, the stakes, while important for the patient's future quality of life, are relatively low compared to emergency or life-saving surgeries.


Medical Specialty: Surgery
Sample Name: Patent Ductus Arteriosus

HISTORY: , The patient is a 5-1/2-year-old, who recently presented with a cardiac murmur diagnosed due to a patent ductus arteriosus.  An echocardiogram from 09/13/2007 demonstrated a 3.8-mm patent ductus arteriosus with restrictive left-to-right shunt.  There is mild left atrial chamber enlargement with an LA/AO ratio of 1.821.  An electrocardiogram demonstrated normal sinus rhythm with possible left atrial enlargement and left ventricular hypertrophy.  The patient underwent cardiac catheterization for device closure of a ductus arteriosus.,PROCEDURE:  ,After sedation and local Xylocaine anesthesia, the patient was prepped and draped.  Cardiac catheterization was performed as outlined in the attached continuation sheets.  Vascular entry was by percutaneous technique, and the patient was heparinized.  Monitoring during the procedure included continuous surface ECG, continuous pulse oximetry, and cycled cuff blood pressures, in addition to intravascular pressures.,Using a 5-French sheath, a 5-French wedge catheter was inserted into the right femoral vein and advanced through the right heart structures up to the branch pulmonary arteries.  The atrial septum was not probe patent.,Using a 4-French sheath, a 4-French marker pigtail catheter was inserted into the right femoral artery advanced retrograde to the descending aorta, ascending aorta, and left ventricle.  A descending aortogram demonstrated a small, type A patent ductus arteriosus with a small left-to-right angiographic shunt.  Minimal diameter was approximately 1.6 mm with ampulla diameter of 5.8 mm and length of 6.2 mm.  The wedge catheter could be directed from the main pulmonary artery across the ductus arteriosus to the descending aorta.  This catheter exchanged over wire for a 5-French nit-occlude delivery catheter through which a nit-occlude 6/5 flex coil that was advanced and allowed to reconfigure the descending aorta.  Entire system was then brought into the ductal ampulla or one loop of coil was delivered in the main pulmonary artery.  Once the stable device configuration was confirmed by fluoroscopy, device was released from the delivery catheter.  Hemodynamic measurements and angiogram in the descending aorta were then repeated approximately 10 minutes following device implantation.,Flows were calculated by the Fick technique using a measured assumed oxygen consumption and contents derived from Radiometer Hemoximeter saturations and hemoglobin capacity.,Cineangiograms were obtained with injection in the descending aorta.,After angiography, two normal-appearing renal collecting systems were visualized.  The catheters and sheaths were removed and topical pressure applied for hemostasis.  The patient was returned to the recovery room in satisfactory condition.  There were no complications.,DISCUSSION: , Oxygen consumption was assumed to be normal.  Mixed venous saturation was normal with a slight increased saturation of the branch pulmonary arteries due to left-to-right shunt through the ductus arteriosus.  The left-sided heart was fully saturated.  The phasic right-sided and left-sided pressures were normal.  The calculated systemic flow was normal and pulmonary flow was slightly increased with a QP:QS ratio of 1:1.  Vascular resistances were normal.  A cineangiogram with contrast injection in the descending aorta showed a small conical shaped ductus arteriosus with a small left-to-right angiographic shunt.  The branch pulmonary arteries appeared normal.  There is otherwise a normal left aortic arch.,Following coil embolization of the ductus arteriosus, there is no change in mixed venous saturation.  No evidence of residual left-to-right shunt.  There is no change in right-sided pressures.  There is a slight increase in the left-sided phasic pressures.  Calculated systemic flow was unchanged from the resting state and pulmonary flow was similar with a QP:QS ratio of 1:1.  Final angiogram with injection in the descending aorta showed a majority of coil mass to be within the ductal ampulla with minimal protrusion in the descending aorta as well as the coil in the main pulmonary artery.  There is a trace residual shunt through the center of coil mass.,INITIAL DIAGNOSES:, Patent ductus arteriosus.,SURGERIES (INTERVENTIONS):  ,Coil embolization of patent ductus arteriosus.,MANAGEMENT:  ,The case to be discussed at Combined Cardiology/Cardiothoracic Surgery case conference.  The patient will require a cardiologic followup in 6 months and 1 year's time including clinical evaluation and echocardiogram.  Further patient care be directed by Dr. X.,
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DESCRIPTION: Coil embolization of patent ductus arteriosus.

surgery, cardiac murmur, coil embolization, cineangiograms, patent ductus arteriosus, pulmonary artery, patent ductus, descending aorta, ductus, arteriosus, catheterization

The case involves a 5-1/2-year-old child with a patent ductus arteriosus, a condition which if left untreated can lead to serious complications such as heart failure or pulmonary hypertension. The procedure described is an interventional cardiac catheterization to correct this issue, which is a significant and complex medical intervention. Although the procedure was completed without complications, it is still a high-stakes scenario given the child's age, the potential for long-term complications if untreated, and the involvement of multiple specialists and follow-up care. The stakes are mitigated by the successful completion of the procedure and the clear plan for follow-up, but remain high due to the nature of the condition and the patient's age.


Medical Specialty: Surgery
Sample Name: Patellar Tendon & Retinaculum Repair

PREOPERATIVE DIAGNOSIS:  , Patellar tendon retinaculum ruptures, right knee.,POSTOPERATIVE DIAGNOSIS: , Patellar tendon retinaculum ruptures, right knee.,PROCEDURE PERFORMED: , Patellar tendon and medial and lateral retinaculum repair, right knee.,SPECIFICATIONS:  ,Intraoperative procedure done at Inpatient Operative Suite, room #2 of ABCD Hospital.  This was done under subarachnoid block anesthetic in supine position.,HISTORY AND GROSS FINDINGS: , The patient is a 45-year-old African-American male who suffered acute rupture of his patellar tendon diagnosed both by exam as well as x-ray the evening before surgical intervention.  He did this while playing basketball.,He had a massive deficit at the inferior pole of his patella on exam.  Once opened, he had complete rupture of this patellar tendon as well as a complete rupture of his medial lateral retinaculum.  Minimal cartilaginous pieces were at the patellar tendon.  He had grade II changes to his femoral sulcus as well as grade I-II changes to the undersurface of the patella.,OPERATIVE PROCEDURE: , The patient was laid supine on the operative table receiving a subarachnoid block anesthetic by Anesthesia Department.  A thigh high tourniquet was placed.  He is prepped and draped in the usual sterile manner.  Limb was elevated, exsanguinated and tourniquet placed at 325 mmHg for approximately 30 to 40 minutes.  Straight incision is carried down through skin and subcutaneous tissue anteriorly.  Hemostasis was controlled via electrocoagulation.  Patellar tendon was isolated along with the patella itself.,A 6 mm Dacron tape x2 was placed with a modified Kessler tendon stitch with a single limb both medially and laterally and a central limb with subsequent shared tape.  The inferior pole was freshened up.  Drill bit was utilized to make holes x3 longitudinally across the patella and the limbs strutted up through the patella with a suture passer.  This was tied over the bony bridge superiorly.  There was excellent reduction of the tendon to the patella.  Interrupted running #1-Vicryl suture was utilized for over silk.  A running #2-0 Vicryl for synovial closure medial and laterally as well as #1-Vicryl medial and lateral retinaculum.  There was excellent repair.  Copious irrigation was carried out.  Tourniquet was dropped and hemostasis controlled via electrocoagulation.  Interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and skin staples were placed through the skin.  Adaptic, 4 x 4s, ABDs, and sterile Webril were placed for compression dressing.  Digits were warm and no brawny pulses present at the end of the case.  The patient's leg was placed in a Don-Joy brace 0 to 20 degrees of flexion.  He will leave this until seen in the office.,Expected surgical prognosis on this patient is fair.
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DESCRIPTION: Patellar tendon and medial and lateral retinaculum repair, right knee.   Patellar tendon retinaculum ruptures, right knee.

surgery, subarachnoid, patellar tendon retinaculum, tendon, patellar, tourniquet, knee, ruptures, retinaculum

The situation involves a surgical procedure to repair a ruptured patellar tendon and retinaculum in the right knee, which although not life-threatening, is crucial for the patient's mobility and quality of life. The successful execution of this surgery can significantly impact the patient's future physical abilities and recovery. The complexity of the surgery, involving tendon repair and ensuring proper technique to avoid complications, makes it a relatively high-stakes situation but not at the most extreme level since it doesn't directly threaten the patient's life.


Medical Specialty: Surgery
Sample Name: Paraphimosis

PREOPERATIVE DIAGNOSIS: , Phimosis.,POSTOPERATIVE DIAGNOSIS: , Phimosis.,PROCEDURE: , Reduction of paraphimosis.,ANESTHESIA:  ,General inhalation anesthetic with 0.25% Marcaine, penile block and ring block about 20 mL given.,FLUIDS RECEIVED: , 100 mL.,SPECIMENS:,  No tissues sent to pathology.,COUNTS: , Sponge and needle counts were not necessary.,TUBES/DRAINS: , No tubes or drains were used.,FINDINGS: , Paraphimosis with moderate swelling.,INDICATIONS FOR OPERATION: , The patient is a 15-year-old boy who had acute alcohol intoxication had his foreskin retracted with a Foley catheter placed at another institution.  When they removed the catheter they forgot to reduce the foreskin and he developed paraphimosis.  The plan is for reduction.,DESCRIPTION OF OPERATION: , The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, with manual pressure and mobilization of the shaft skin we were able to reduce the paraphimosis.  Using Betadine and alcohol cleanse, we then did a dorsal penile block and a ring block by surgeon with 0.25% Marcaine, 20 mL were given.  He did quite well after the procedure and was transferred to the recovery room in stable condition.
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DESCRIPTION: Reduction of paraphimosis.

Reduction of paraphimosis.

surgery, dorsal penile block, reduction of paraphimosis, penile block, phimosis, paraphimosis,

The situation involves a 15-year-old boy with paraphimosis that required surgical intervention to correct. Although paraphimosis can be quite painful and, if left untreated, may lead to serious complications such as tissue damage, the condition in this scenario was identified and addressed in a timely manner. The procedure described, while important, is fairly routine and was performed successfully without complications, making it unlikely to have high-stakes risk. The patient was in stable condition after the procedure, which further suggests the situation was managed effectively without high immediate risk to the patient's health beyond the discomfort and urgency associated with paraphimosis.


Medical Specialty: Surgery
Sample Name: Pacemaker - DDDR

PROCEDURE PERFORMED:  ,DDDR permanent pacemaker.,INDICATION: , Tachybrady syndrome.,PROCEDURE:,  After all risks, benefits, and alternatives of the procedure were explained in detail to the patient, informed consent was obtained both verbally and in writing.  The patient was taken to the Cardiac Catheterization Suite where the right subclavian region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the left subclavian vein.  Once adequate anesthesia had been obtained, a thin-walled #18-gauze Argon needle was used to cannulate the left subclavian vein.  A steel guidewire was inserted through the needle into the vascular lumen without resistance.  The needle was then removed over the guidewire and the guidewire was secured to the field.  A second #18 gauze Argon needle was used to cannulate the left subclavian vein and once again a steel guidewire was inserted through the needle into the vascular lumen.  Likewise, the needle was removed over the guidewire and the guidewire was then secured to the field.  Next, a #15-knife blade was used to make a 1 to 1.5 inch linear incision over the area.  A #11-knife blade was used to make a deeper incision.  Hemostasis was made complete.  The edges of the incision were grasped and retracted.  Using Metzenbaum scissors, dissection was carried down to the pectoralis muscle fascial plane.  Digital blunt dissection was used to make a pacemaker pocket large enough to accommodate the pacemaker generator.  Metzenbaum scissors were then used to dissect cephalad to expose the guide wires.  The guidewires were then pulled through the pacemaker pocket.  One guidewire was secured to the field.,A bloodless introducer sheath was then advanced over a guidewire into the vascular lumen under fluoroscopic guidance.  The guidewire and dilator were then removed.  Next, a ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.  The pacemaker lead was then placed in the appropriate position in the right ventricle.  Pacing and sensing thresholds were obtained.  The lead was sewn at the pectoralis muscle plane using #2-0 silk suture in an interrupted stitch fashion around the ________.  Pacing and sensing threshold were then reconfirmed.  Next, a second bloodless introducer sheath was advanced over the second guidewire into the vascular lumen.  The guidewire and dilator were then removed.  Under fluoroscopic guidance, the atrial lead was passed into the right atrium.  The sheath was then turned away in standard fashion.  Using fluoroscopic guidance, the atrial lead was then placed in the appropriate position.  Pacing and sensing thresholds were obtained.  The lead was sewn to the pectoralis muscle facial plane utilizing #2-0 silk suture around the ________.  Sensing and pacing thresholds were then reconfirmed.  The leads were wiped free of blood and placed into the pacemaker generator.  The pacemaker generator leads were then placed into pocket with the leads posteriorly.  The deep tissues were closed utilizing #2-0 Chromic suture in an interrupted stitch fashion.  A #4-0 undyed Vicryl was then used to close the subcutaneous tissue in a continuous subcuticular stitch.  Steri-Strips overlaid.  A sterile gauge dressing was placed over the site.  The patient tolerated the procedure well and was transferred to the Cardiac Catheterization Room in stable and satisfactory condition.,PACEMAKER DATA (GENERATOR DATA):,Manufacturer:  Medtronics.,Model:  Sigma.,Model #:  1234.,Serial #:  123456789.,LEAD INFORMATION:,Right Atrial Lead:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,VENTRICULAR LEAD:,Manufacturer:  Medtronics.,Model #:  1234.,Serial #:  123456789.,PACING AND SENSING THRESHOLDS:,Right Atrial Bipolar Lead:  Pulse width 0.50 milliseconds, impedance 518 ohms, P-wave sensing 2.2 millivolts, polarity is bipolar.,Ventricular Bipolar Lead:  Pulse width 0.50 milliseconds, voltage 0.7 volts, current 1.5 milliamps, impedance 655 ohms, R-wave sensing 9.7 millivolts, polarity is bipolar.,PARAMETER SETTINGS:,  Pacing mode DDDR:  Mode switch is on, low rate 60, upper 120, ________ is 33.0 milliseconds.,IMPRESSION:,  Successful implantation of DDDR permanent pacemaker.,PLAN:,1.  The patient will be monitored on telemetry for 24 hours to ensure adequate pacemaker function.,2.  The patient will be placed on antibiotics for five days to avoid pacemaker infection.
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DESCRIPTION: DDDR permanent pacemaker.   Tachybrady syndrome.  A ventricular pacemaker lead was advanced through the sheath and into the vascular lumen and under fluoroscopic guidance guided down into the right atrium.

The situation involves the surgical implantation of a DDDR permanent pacemaker into a patient with tachybrady syndrome, which is a clinical condition characterized by episodes of alternating bradycardia and tachycardia. The procedure is critical as it addresses potentially life-threatening arrhythmias, ensuring the patient maintains a stable heart rhythm. The success of the procedure and the condition of the leads and generator are pivotal for the patient's cardiac function post-operation. Additionally, there is a risk of infections and other complications. Thus, this surgical procedure has significant implications for the patient's immediate and long-term health, making it a high-stakes situation.


Medical Specialty: Surgery
Sample Name: Pacemaker Insertion

PREOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,POSTOPERATIVE DIAGNOSIS:, Tachybrady syndrome.,OPERATIVE PROCEDURE:, Insertion of transvenous pacemaker.,ANESTHESIA:, Local,PROCEDURE AND GROSS FINDINGS:, The patient's chest was prepped with Betadine solution and a small amount of Lidocaine infiltrated.  In the left subclavian region, a subclavian stick was performed without difficulty, and a wire was inserted. Fluoroscopy confirmed the presence of the wire in the superior vena cava.  An introducer was then placed over the wire.  The wire was removed and replace by a ventricular lead that was seated under Fluoroscopy. Following calibration, the lead was attached to a pacemaker generator that was inserted in a subcutaneous pocket in the left subclavian area.  ,The subcutaneous tissues were irrigated and closed with Interrupted 4-O Vicryl, and the skin was closed with staples.  Sterile dressings were placed, and the patient was returned to the ICU in good condition.
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DESCRIPTION: Insertion of transvenous pacemaker for tachybrady syndrome

surgery, insertion of transvenous pacemaker, fluoroscopy, tachybrady, tachybrady syndrome, chest, pacemaker, subclavian, subcutaneous, superior vena cava, syndrome, transvenous pacemaker, wire, insertion,

The procedure described is the insertion of a transvenous pacemaker, which is a common surgical intervention for managing tachybrady syndrome, a condition where the heart alternates between fast and slow rhythms. While the surgery itself is routine and when described as successful with the patient returning to the ICU in good condition, the stakes are still high as it involves the heart, requires precise placement under fluoroscopy, and involves potential risks such as infection or improper lead placement. However, this type of surgery is generally well-practiced and monitored in the medical field, decreasing the stakes compared to more experimental or emergency surgeries.


Medical Specialty: Surgery
Sample Name: Pacemaker Interrogation

PROCEDURE NOTE: , Pacemaker ICD interrogation.,HISTORY OF PRESENT ILLNESS: , The patient is a 67-year-old gentleman who was admitted to the hospital.  He has had ICD pacemaker implantation.  This is a St. Jude Medical model current DRRS, 12345 pacemaker.,DIAGNOSIS: , Severe nonischemic cardiomyopathy with prior ventricular tachycardia.,FINDINGS: , The patient is a DDD mode base rate of 60, max tracking rate of 110 beats per minute, atrial lead is set at 2.5 volts with a pulse width of 0.5 msec, ventricular lead set at 2.5 volts with a pulse width of 0.5 msec.  Interrogation of the pacemaker shows that atrial capture is at 0.75 volts at 0.5 msec, ventricular capture 0.5 volts at 0.5 msec, sensing in the atrium is 5.34 to 5.8 millivolts, R sensing is 12-12.0 millivolts, atrial lead impendence 590 ohms, ventricular lead impendence 750 ohms.  The defibrillator portion is set at VT1 at 139 beats per minute with SVT discrimination on therapy is monitor only.  VT2 detection criteria is 169 beats per minute with SVT discrimination on therapy of ATP times 3 followed by 25 joules, followed by 36 joules, followed by 36 joules times 2.  VF detection criteria set at 187 beats per minute with therapy of 25 joules, followed by 36 joules times 5.  The patient is in normal sinus rhythm.,IMPRESSION:  ,Normally functioning pacemaker ICD post implant day number 1.
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DESCRIPTION: Pacemaker ICD interrogation.  Severe nonischemic cardiomyopathy with prior ventricular tachycardia.

surgery, cardiomyopathy, ventricular, tachycardia, pacemaker icd interrogation, millivolts, impendence, interrogation, pacemaker,

The situation involves the interrogation of a pacemaker ICD in a patient with severe nonischemic cardiomyopathy and a history of ventricular tachycardia. Given the patient's condition and reliance on the pacemaker ICD to prevent potentially life-threatening arrhythmias, this scenario is high-stakes. Proper functioning of the device is crucial to the patient's safety and health. The consequence of an oversight or malfunction can be severe, potentially resulting in life-threatening situations.


Medical Specialty: Surgery
Sample Name: Pacemaker (Single Chamber) - 1

REFERRAL INDICATION,1.  Tachybrady syndrome.,2.  Chronic atrial fibrillation.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of a single-chamber pacemaker.,2.  Fluoroscopic guidance for implantation of single-chamber pacemaker.,FLUOROSCOPY TIME:  ,1.2 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Ancef 1 g.,2.  Benadryl 50 mg.,3.  Versed 3 mg.,4.  Fentanyl 150 mcg.,CLINICAL HISTORY: , The patient is a pleasant 73-year-old female with chronic atrial fibrillation.  She has been found to have tachybrady syndrome, has been referred for pacemaker implantation.,RISKS AND BENEFITS: , Risks, benefits, and alternatives of implantation of a single-chamber pacemaker were discussed with the patient.  The patient agreed both verbally and via written consent.  Risks that were discussed included but were not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, need for urgent cardiovascular surgery, and death were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in a fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  Percutaneous access of the left axillary vein was then performed.  A wire was then advanced in the left axillary vein using fluoroscopy.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Lidocaine 1% (10 mL) was then administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  Using the previously placed guidewire, a 7-French sidearm sheath was advanced over the wire into the vein.  The dilator and wire were removed.  An active pacing lead was then advanced down in the right atrium.  The peel-away sheath was removed.  Lead was passed across the tricuspid valve and positioned in an apical septal location.  This was an active fixed lead and the screw was deployed.  Adequate pacing and sensing function were established.  The suture sleeve was then advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was washed with antibiotic-impregnated saline.  A pulse generator was obtained and connected securely to the lead.  The lead was then carefully wrapped behind the pulse generator, and the entire system was placed in the pocket.  Pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  No acute complications were noted.,DEVICE DATA,1.  Pulse generator, manufacturer St. Jude model 12345, serial #123456.,2.  Right ventricular lead, manufacturer St. Jude model 12345, serial #ABCD123456.,MEASURED INTRAOPERATIVE DATA:,  Right ventricular lead impedance 630 ohms.  R wave measures 17.5 mV.  Pacing threshold of 0.8 V at 0.5 msec.,DEVICE SETTINGS: , VVI 70 to 120.,CONCLUSIONS,1.  Successful implantation of the single-chamber pacemaker with adequate pacing and sensing function.,2.  No acute complications.,PLAN,1.  The patient will be admitted for overnight observation and dismissed at the discretion of primary service.,2.  Chest x-ray to rule out pneumothorax and verify lead position.,3.  Completion of course of antibiotics.,4.  Device interrogation in the morning.,5.  Home dismissal instructions provided in a written format.,6.  Wound check in 7 to 10 days.,7.  Enrollment in Device Clinic.
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DESCRIPTION: Implantation of a single-chamber pacemaker.  Fluoroscopic guidance for implantation of single-chamber pacemaker.

The scenario involves the implantation of a single-chamber pacemaker, a significant medical procedure with inherent risks such as bleeding, infection, cardiac perforation, and even death, despite being described as having no acute complications. The procedure requires skillful execution and monitoring post-operation is crucial to ensure patient safety. The patient's background of chronic atrial fibrillation and tachybrady syndrome implies a complex medical condition being treated. The stakes are high due to the invasive nature of the procedure, potential complications, and the serious underlying health issues of the patient.


Medical Specialty: Surgery
Sample Name: Osteotomy & Bunionectomy - 1

PREOPERATIVE DIAGNOSES:,1.  Plantar flex third metatarsal, right foot.,2.  Talus bunion, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Plantar flex third metatarsal, right foot.,2.  Talus bunion, right foot.,PROCEDURE PERFORMED:,1.  Third metatarsal osteotomy, right foot.,2.  Talus bunionectomy, right foot.,3.  Application of short-leg cast, right foot.,ANESTHESIA: , TIVA/local.,HISTORY:  ,This 31-year-old female presents to ABCD Preoperative Holding Area after keeping herself n.p.o., since mid night for surgery on her painful right third plantar flex metatarsal.  In addition, she complains of a painful right talus bunion to the right foot.  She has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief.  At this time she desires to attempt a surgical correction.  The risks versus benefits of the procedure have been explained to the patient by Dr. X and the consent is available on the chart for review.,PROCEDURE IN DETAIL:  ,After IV was established by the Department Of Anesthesia, the patient was taken to the operating room via cart.  She was placed on the operating table in supine position and a safety strap was placed across her waist for retraction.  Next, copious amounts of Webril were applied around the right ankle and a pneumatic ankle tourniquet was applied.,Next, after adequate IV sedation was administered by the Department Of Anesthesia, a total of 10 cc mixture of 4.5 cc of 1% lidocaine/4.5 cc of 0.5% Marcaine/1 cc of Kenalog was injected into the right foot in an infiltrative type block.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  Next, the foot was lowered in the operative field and attention was directed to the dorsal third metatarsal area.  There was a plantar hyperkeratotic lesion and a plantar flex palpable third metatarsal head.  A previous cicatrix was noted with slight hypertrophic scarring.  Using a #10 blade, a lazy S-type incision was created over the dorsal aspect of the third metatarsal, approximately 3.5 cm in length.  Two semi-elliptical converging incisions were made over the hypertrophic scar and it was removed and passed off as a specimen.  Next, the #15 blade was used to deepen the incision down to the subcutaneous tissue.  Any small traversing veins were ligated with electrocautery.  Next, a combination of blunt and sharp dissection were used to undermine the long extensor tendon, which was tacked down with a moderate amount of fibrosis and fibrotic scar tissue.  Next, the extensor tendon was retracted laterally and the deep fascia over the metatarsals was identified.  A linear incision down to bone was made with a #15 blade to the capsuloperiosteal tissues.  Next, the capsuloperiosteal tissues were elevated using a sharp dissection with a #15 blade, off of the third metatarsal.  McGlamry elevator was carefully inserted around the head of the metatarsal and freed and all the plantar adhesions were freed.  A moderate amount of plantar adhesions were encountered.  The third toe was plantar flex and the third metatarsal was delivered into the wound.  Next, a V-shaped osteotomy with an apex distally was created using a sagittal saw.  The metatarsal head was allowed to float.  The wound was flushed with copious amounts of sterile saline.  #3-0 Vicryl was used to close the capsuloperiosteal tissues, which kept the metatarsal head contained.  Next, #4-0 Vicryl was used to close the subcutaneous layer in a simple interrupted suture technique.  Next, #4-0 nylon was used to close the skin in a simple interrupted technique.,Attention was directed to the right fifth metatarsal.  There was a large palpable hypertrophic prominence, which is the area of maximal pain, which the patient complained of preoperatively.  A #10 blade was used to make a 3 cm incision through the skin.  Next, a #15 blade was used to deepen the incision through the subcutaneous tissue.  Next, the medial and lateral aspects were undermined.  The abductor tendon was identified and retracted.  A capsuloperiosteal incision was made with a #15 blade in a linear fashion down to the bone.  The capsuloperiosteal tissues were elevated off the bone with a Freer elevator and a #15 blade.,Next, the sagittal saw was used to resect the large hypertrophic dorsal exostosis.  A reciprocating rasp was used to smooth all bony prominences.  The wound was flushed with copious amount of sterile saline.  #3-0 Vicryl was used to close the capsuloperiosteal tissues.  #4-0 Vicryl was used to close subcutaneous layer with a simple interrupted suture.  Next, #4-0 nylon was used to close the skin in a simple interrupted technique.  Next, attention was directed to the plantar aspect of the third metatarsal where a bursal sac was felt to be palpated under the plantar flex third metatarsal head.  A #15 blade was used to make a small linear incision under the third metatarsal head.  The incision was deepened through the dermal layer and curved hemostats and Metzenbaum scissors were used to undermine the skin from the underlying bursa.  The wound was flushed and two simple interrupted sutures with #4-0 nylon were applied.,Standard postoperative dressing was applied consisting of Xeroform, 4x4s, Kerlix, Kling, and Coban.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to the digits.,A sterile stockinet was placed on the toes just below the knee.  Copious amounts of Webril were placed on all bony prominences.  3 inch and 4 inch fiberglass cast tape was used to create a below the knee well-padded, well-moulded cast.  One was able to insert two fingers to the distal and proximal aspects of the _cast.  The capillary refill time to the digits was less than three seconds after cast application.  The patient tolerated the above anesthesia and procedures without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  She was given standard postoperative instructions to rest, ice and elevate her right foot.  She was counseled on smoking cessation.  She was given Vicoprofen #30 1 p.o. q.4-6h p.r.n., pain.  She was given Keflex #30 1 p.o. t.i.d.  She is to follow up with Dr. X on Monday.  She is to be full weightbearing with a cast boot.  She was given emergency contact numbers to call us if problem arises.
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DESCRIPTION: Plantar flex third metatarsal and talus bunion, right foot.  Third metatarsal osteotomy, talus bunionectomy, and application of short-leg cast, right foot.  Patient has tried conservative methods such as wide shoes and serial debridement and accommodative padding, all of which provided inadequate relief.  At this time she desires to attempt a surgical correction.

surgery, plantar flex, talus bunion, talus bunionectomy, metatarsal osteotomy, osteotomy, short-leg cast, hypertrophic scarring, subcutaneous tissue, sharp dissection, linear incision, foot talus, pneumatic ankle, capsuloperiosteal tissues, plantar, foot, metatarsal, capsuloperiosteal, bunionectomy

This scenario involves a surgical procedure, which inherently carries moderate stakes due to the risk of complications, the need for anesthesia, and potential impacts on the patient's mobility and recovery. The procedure has been properly prepared for, and no complications were noted during or immediately after surgery; however, surgeries involve significant medical procedures and post-operative care which classify them as moderately high-stakes situations. Therefore, it is important to ensure careful monitoring post-surgery to address any emerging issues promptly.


Medical Specialty: Surgery
Sample Name: ORIF & Cervical Fusion

PREOPERATIVE DIAGNOSIS: , Fracture dislocation, C2.,POSTOPERATIVE DIAGNOSIS:  ,Fracture dislocation, C2.,OPERATION PERFORMED,1.  Open reduction and internal fixation (ORIF) of comminuted C2 fracture.,2.  Posterior spinal instrumentation C1-C3, using Synthes system.,3.  Posterior cervical fusion C1-C3.,4.  Insertion of morselized allograft at C1to C3.,ANESTHESIA:,  GETA.,ESTIMATED BLOOD LOSS:,  100 mL.,COMPLICATIONS: , None.,DRAINS: , Hemovac x1.,Spinal cord monitoring is stable throughout the entire case.,DISPOSITION:,  Vital signs are stable, extubated and taken back to the ICU in a satisfactory and stable condition.,INDICATIONS FOR OPERATION:,  The patient is a middle-aged female, who has had a significantly displaced C2 comminuted fracture.  This is secondary to a motor vehicle accident and it was translated appropriately 1 cm.  Risks and benefits have been conferred with the patient as well as the family, they wish to proceed.  The patient was taken to the operating room for a C1-C3 posterior cervical fusion, instrumentation, open reduction and internal fixation.,OPERATION IN DETAIL: , After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #5.  The patient was placed in the usual supine position and intubated and under general anesthesia without any difficulties.  Spinal cord monitoring was induced.  No changes were seen from the beginning to the end of the case.,Mayfield tongues were placed appropriately.  This was placed in line with the pinna of the ear as well as a cm above the tip of the earlobes.  The patient was subsequently rolled onto the fluoroscopic OSI table in the usual prone position with chest rolls.  The patient's Mayfield tongue was fixated in the usual standard fashion.  The patient was subsequently prepped and draped in the usual sterile fashion.  Midline incision was extended from the base of the skull down to the C4 spinous process.  Full thickness skin fascia developed.  The fascia was incised at midline and the posterior elements at C1, C2, C3, as well as the inferior aspect of the occiput was exposed.  Intraoperative x-ray confirmed the level to be C2.,Translaminar screws were placed at C2 bilaterally.  Trajectory was completed with a hand drill and sounded in all four quadrants to make sure there was no violation of pedicles and once this was done, two 3.5 mm translaminar screws were placed bilaterally at C2.  Good placement was seen both in the AP and lateral planes using fluoroscopy.  Facet screws were then placed at C3.  Using standard technique of Magerl, starting in the inferomedial quadrant 14 mm trajectories in the 25-degree caudad-cephalad direction as well as 25 degrees in the medial lateral direction was made.  This was subsequently sounded in all four quadrants to make sure that there is no elevation of the trajectory.  A 14 x 3.5 mm screws were then placed appropriately.  Lateral masteries at C1 endplate were placed appropriately.  The medial and lateral borders were demarcated with a Penfield.  The great occipital nerve was retracted out the way.  Starting point was made with a high-speed power bur and midline and lateral mass bilaterally.  Using a 20-degree caudad-cephalad trajectory as well as 10-degree lateral-to-medial direction, the trajectory was completed in 8 mm increments, this was subsequently sounded in all four quadrants to make sure that there was no violation of the pedicle wall of the trajectory.  Once this was done, 24 x 3.5 mm smooth Schanz screws were placed appropriately.  Precontoured titanium rods were then placed between the screws at the C1, C2, C3 and casts were placed appropriately.  Once this was done, all end caps were appropriately torqued.  This completed the open reduction and internal fixation of the C2 fracture, which showed perfect alignment.  It must be noted that the reduction was partially performed on the table using lateral fluoroscopy prior to the instrumentation, almost reducing the posterior vertebral margin of the odontoid fracture with the base of the C2 access.  Once the screws were torqued bilaterally, good alignment was seen both in the AP and lateral planes using fluoroscopy, this completed instrumentation as well as open reduction and internal fixation of C2.  The cervical fusion was completed by decorticating the posterior elements of C1, C2, and C3.  Once this was done, the morselized allograft 30 mL of cortical cancellous bone chips with 10 mL of demineralized bone matrix was placed over the decorticated elements.  The fascia was closed using interrupted #1 Vicryl suture figure-of-8.  Superficial drain was placed appropriately.  Good alignment of the instrumentation as well as of the fracture was seen both in the AP and lateral planes.  The subcutaneous tissues were closed using a #2-0 Vicryl suture.  The dermal edges were approximated using staples.  The wound was then dressed sterilely using Bacitracin ointment, Xeroform, 4x4s, and tape, and the drain was connected appropriately.  The patient was subsequently released with a Mayfield contraption and rolled on to the stretcher in the usual supine position.  Mayfield tongues were subsequently released.  No significant bleeding was appreciated.  The patient was subsequently extubated uneventfully and taken back to the recovery room in satisfactory and stable condition.  No complications arose.
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DESCRIPTION: Open reduction and internal fixation (ORIF) of comminuted C2 fracture.  Posterior spinal instrumentation C1-C3, using Synthes system.  Posterior cervical fusion C1-C3.  Insertion of morselized allograft at C1to C3.

surgery, fracture dislocation, spinal instrumentatio, comminuted, fracture, morselized, allograft, vicryl suture, mayfield tongues, cervical fusion, internal fixation, orif, cervical, fusion, fixation, spinal, reduction, instrumentation,

The situation involves a complex surgical procedure for treating a fracture dislocation at the C2 vertebra, which is a critical part of the spine. This procedure, including open reduction and internal fixation (ORIF) and posterior cervical fusion, carries significant risks and is essential for stabilizing the patient's spinal column to prevent potential neurological damage or other serious complications. Given the detailed nature of the surgery and its importance for the patient’s recovery and quality of life, this is a high-stakes medical scenario. The successful outcome indicated by no complications and stable postoperative condition reduces the immediate risk, but the inherent risks of such an operation still classify it as high-stakes.


Medical Specialty: Surgery
Sample Name: Orchiopexy & Herniorrhaphy

OPERATIVE NOTE:,  The patient was taken to the operating room and placed in the supine position on the operating room table.  The patient was prepped and draped in usual sterile fashion.  An incision was made in the groin crease overlying the internal ring.  This incision was about 1.5 cm in length.  The incision was carried down through the Scarpa's layer to the level of the external oblique.  This was opened along the direction of its fibers and carried down along the external spermatic fascia.  The cremasteric fascia was then incised and the internal spermatic fascia was grasped and pulled free.  A hernia sac was identified and the testicle was located.  Next the internal spermatic fascia was incised and the hernia sac was dissected free inside the internal ring.  This was performed by incising the transversalis fascia circumferentially.  The hernia sac was ligated with a 3-0 silk suture high and divided and was noted to retract into the abdominal cavity.  Care was taken not to injure the testicular vessels.  Next the abnormal attachments of the testicle were dissected free distally with care not to injure any long loop vas and these were divided beneath the testicle for a fair distance.  The lateral attachments tethering the cord vessels were freed from the sidewalls in the retroperitoneum high.  This gave excellent length and very adequate length to bring the testicle down into the anterior superior hemiscrotum.  The testicle was viable.  This was wrapped in a moist sponge.,Next a hemostat was passed down through the inguinal canal down into the scrotum.  A small 1 cm incision was made in the anterior superior scrotal wall.  Dissection was carried down through the dartos layer.  A subdartos pouch was formed with blunt dissection.  The hemostat was then pushed against the tissues and this tissue was divided.  The hemostat was then passed through the incision.  A Crile hemostat was passed back up into the inguinal canal.  The distal attachments of the sac were grasped and pulled down without twisting these structures through the incision.  The neck was then closed with a 4-0 Vicryl suture that was not too tight, but tight enough to prevent retraction of the testicle.  The testicle was then tucked down in its proper orientation into the subdartos pouch and the subcuticular tissue was closed with a running 4-0 chromic and the skin was closed with a running 6-0 subcuticular chromic suture.  Benzoin and a Steri-Strip were placed.  Next the transversus abdominis arch was reapproximated to the iliopubic tract over the top of the cord vessels to tighten up the ring slightly.  This was done with 2 to 3 interrupted 3-0 silk sutures.  The external oblique was then closed with interrupted 3-0 silk suture.  The Scarpa's layer was closed with a running 4-0 chromic and the skin was then closed with a running 4-0 Vicryl intracuticular stitch.  Benzoin and Steri-Strip were applied.  The testicle was in good position in the dependent portion of the hemiscrotum and the patient had a caudal block, was awakened, and was returned to the recovery room in stable condition.
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DESCRIPTION: Orchiopexy & inguinal herniorrhaphy.

Orchiopexy & inguinal herniorrhaphy.

surgery, orchiopexy, benzoin, crile hemostat, scarpa's layer, caudal block, cremasteric fascia, groin crease, hemiscrotum, iliopubic tract, inguinal canal, inguinal herniorrhaphy, intracuticular stitch, retroperitoneum, spermatic fascia, testicle, hernia sac, inguinal, incisionNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The situation involves detailed surgical procedures, specifically orchiopexy and herniorrhaphy. These are significant surgeries with potential implications for the patient's future health and fertility. The surgical details emphasize precision and care, highlighting the potential risks if not performed correctly. The stakes include ensuring the reproductive functionality and avoiding complications such as infection or improper healing. Hence, while not immediately life-threatening, the stakes are moderately high due to long-term implications and the complexity of the procedure.


Medical Specialty: Surgery
Sample Name: ORIF - 1

PREOPERATIVE DIAGNOSES:,1.  Displaced intraarticular fracture, right distal radius.,2.  Right carpal tunnel syndrome.,PREOPERATIVE DIAGNOSES:,1.  Displaced intraarticular fracture, right distal radius.,2.  Right carpal tunnel syndrome.,OPERATIONS PERFORMED:,1.  Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture.,2.  Right carpal tunnel release.,ANESTHESIA: , General.,CLINICAL SUMMARY: , The patient is a 37-year-old right-hand dominant Hispanic female who sustained a severe fracture to the right wrist approximately one week ago.  This was an intraarticular four-part fracture that was displaced dorsally.  In addition, the patient previously undergone a carpal tunnel release, but had symptoms of carpal tunnel preop.  She is admitted for reconstructive operation.  The symptoms of carpal tunnel were present preop and worsened after the injury.,OPERATION:,  The patient was brought from the ambulatory care unit and placed on the operating table in a supine position and administered general anesthetic by Anesthesia.  Once adequate anesthesia had been obtained, the right upper extremity was prepped and draped in the usual sterile manner.  Tourniquet was placed around the right upper extremity.  The upper extremity was then elevated and exsanguinated using an Esmarch dressing.  The tourniquet was elevated to 250 mmHg.  The entire operation was performed with 4.5 loop magnification.  At this time an approximately 8 cm longitudinal incision was then made overlying the right flexor carpi radialis tendon from the flexion crease to the wrist proximally.  This was carried down to the flexor carpi radialis, which was then retracted ulnarly.  The floor of the flexor carpi radialis was then incised exposing the flexor pronator muscles.  The flexor pollicis longus was retracted ulnarly and the pronator quadratus was longitudinally incised 1 cm from its origin.  It was then elevated off of the fracture site exposing the fracture site, which was dorsally displaced.  This was an intraarticular four-part fracture.  Under image control, the two volar pieces and dorsal pieces were then carefully manipulated and reduced.  Then, 2.06 two-inch K-wires were drilled radial into the volar ulnar fragment and then a second K-wire was then drilled from the dorsal radial to the dorsal ulnar piece.  A third K-wire was then drilled from the volar radial to the dorsal ulnar piece.  The fracture was then manipulated.  The fracture ends were copiously irrigated with normal saline and curetted and then the fracture was reduced in the usual fashion by recreating the defect and distracting it.  Further K-wires were then placed through the radial styloid into the proximal fragment.  A Hand Innovations DVR plate of regular size for the right wrist was then fashioned over and placed over the distal radius and secured with two K-wires.  At this time, the distal screws were then placed.  The distal screws were the small screws.  These were non-locking screws, all eight screws were placed.  They were placed in the usual fashion by drilling with a small drill bit removing the small introducers and then using its depth.  Again, these were 18-20 mm screws.  After placing three of the screws it was necessary to remove the K-wires.  There was excellent reduction of the fragments and the fracture; excellent reduction of the intraarticular component and the fracture.  After the distal screws were placed, the fracture was reduced and held in place with K-wires, which were replaced and the proximal screws were drilled with the drill guide and the larger drill bit.  The screws were then placed.  These were 12 mm screws.  They were placed 4 in number.  The K-wires were then removed.  Finally, a 3 cm intrathenar incision was made beginning 1 cm distal to the flexor crease of the wrist.  This was carried down to the transverse carpal ligament, which was divided throughout the length of the incision, upon entering the carpal canal, the median nerve was found to be adherent to the undersurface of the structure.  It was dissected free from the structure out to its trifurcation.  The motor branches seen entering the thenar fascia and obstructed.  The nerve was then retracted dorsally and the patient had a great deal of scar tissue in the area of the volar flexion crease to the wrist where she had a previous incision that extended from the volar flexion crease of the wrist overlying the palmaris longus proximally for 1 cm.  In this area, careful dissection was performed in order to move the nerve from the surrounding structures and the most proximal aspect of the transverse carpal ligament, the more proximally located volar carpal ligament was then divided 5 cm into the distal forearm on the ulnar side of the palmaris longus tendon.  Incisions were then copiously irrigated with normal saline.  Homeostasis was maintained with electrocautery.  The pronator quadratus was closed with 3-0 Vicryl and the above skin incisions were closed proximally with 4-0 nylon and palmar incision with 5-0 nylon in the horizontal mattress fashion.  A large bulky dressing was then applied with a volar short-arm splint maintaining the wrist in neutral position.  The tourniquet was let down.  The fingers were immediately pink.  The patient was awakened and taken to the recovery room in good condition.  There were no operative complications.  The patient tolerated the procedure well.
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DESCRIPTION: Open reduction and internal fixation of right distal radius fracture - intraarticular four piece fracture and right carpal tunnel release.

surgery, intraarticular fracture, esmarch, k-wires, open reduction and internal fixation, tourniquet, carpal tunnel release, carpal tunnel syndrome, flexor carpi radialis, flexor pronator muscles, intraarticular, right distal radius, transverse carpal ligament, volar flexion crease, pronator quadratus, flexor carpi, carpi radialis, flexion crease, carpal ligament, carpal tunnel, carpal, volar

The described situation involves a complex surgical procedure addressing a displaced intraarticular fracture and carpal tunnel syndrome in a patient. Surgery, particularly one involving open reduction and internal fixation of a fracture and nerve release, carries inherent risks including complications from anesthesia, potential for infection, nerve damage, and the requirement for a precise and careful operative technique. These factors contribute to it being classified as a high-stakes scenario, given the potential impact on the patient's recovery and limb function.


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

Medical Specialty: Surgery
Sample Name: Orchiopexy & Hernia Repair

PREOPERATIVE DIAGNOSIS: , Left undescended testis.,POSTOPERATIVE DIAGNOSIS:,  Left undescended testis plus left inguinal hernia.,PROCEDURES:,  Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.,ABNORMAL FINDINGS:,  A high left undescended testis with a type III epididymal attachment along with vas.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS RECEIVED:  ,1100 mL of crystalloid.,TUBES/DRAINS: , No tubes or drains were used.,COUNTS:,  Sponge and needle counts were correct x2.,SPECIMENS,:  No tissues sent to Pathology.,ANESTHESIA:,  General inhalational anesthetic.,INDICATIONS FOR OPERATION: , The patient is an 11-1/2-year-old boy with an undescended testis on the left.  The plan is for repair.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room, where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, he was then placed in a supine position, and sterilely prepped and draped.  A superior curvilinear scrotal incision was then made in the left hemiscrotum with a 15-blade knife and further extended with electrocautery into the subcutaneous tissue.  We then used the curved cryoclamp to dissect into the scrotal space and found the tunica vaginalis and dissected this up to the external ring.  We were able to dissect all the way up to the ring, but were unable to get the testis delivered.  We then made a left inguinal incision with a 15-blade knife, further extending with electrocautery through Scarpa fascia down to the external oblique fascia.  The testis again was not visualized in the external ring, so we brought the sac up from the scrotum into the inguinal incision and then incised the external oblique fascia with a 15-blade knife further extending with Metzenbaum scissors.  The testis itself was quite high up in the upper canal.  We then dissected the gubernacular structures off of the testis, and also, then opened the sac, and dissected the sac off and found that he had a communicating hernia hydrocele and dissected the sac off with curved and straight mosquitos and a straight Joseph scissors.  Once this was dissected off and up towards the internal ring, it was twisted upon itself and suture ligated with an 0 Vicryl suture.  We then dissected the lateral spermatic fascia, and then, using blunt dissection, dissected in the retroperitoneal space to get more cord length.  We also dissected the sac from the peritoneal reflection up into the abdomen once it had been tied off.  We then found that we had an adequate amount of cord length to get the testis in the mid-to-low scrotum.  The patient was found to have a type III epididymal attachment with a long looping vas, and we brought the testis into the scrotum in the proper orientation and tacked it to mid-to-low scrotum with a 4-0 chromic stay stitch.  The upper aspect of the subdartos pouch was closed with a 4-0 chromic pursestring suture.  The testis was then placed into the scrotum in the proper orientation.  We then placed the local anesthetic, and the ilioinguinal nerve block, and placed a small amount in both incisional areas as well.  We then closed the external oblique fascia with a running suture of 0-Vicryl ensuring that the ilioinguinal nerve and cord structures were not bottom closure.  The Scarpa fascia was closed with a 4-0 chromic suture, and the skin was closed with a 4-0 Rapide subcuticular closure.  Dermabond tissue adhesive was placed on the both incisions, and IV Toradol was given at the end of the procedure.  The patient tolerated the procedure well, was in a stable condition upon transfer to the recovery room.
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DESCRIPTION: Left inguinal hernia repair, left orchiopexy with 0.25% Marcaine, ilioinguinal nerve block and wound block at 0.5% Marcaine plain.

surgery, inguinal hernia repair, ilioinguinal nerve block, external oblique fascia, hernia repair, epididymal attachment, external ring, inguinal incision, scarpa fascia, cord length, inguinal hernia, nerve block, ilioinguinal nerve, undescended testis, testis, inguinal, fascia, hernia, dissected,

The situation involves a surgical procedure for a pediatric patient with a left undescended testis and an inguinal hernia. While the surgery itself, described as an orchiopexy and hernia repair, is a routine pediatric surgical operation, there are always inherent risks associated with general anesthesia and possible complications during or after the surgery. However, the description indicates that the procedure went smoothly, with minimal blood loss, no abnormal intraoperative events, and a stable post-operative recovery. Despite the procedure's complexity and the patient's age, which increases the stakes somewhat, it is not an emergency or a life-threatening condition. Thus, while it requires professional expertise and careful execution, it does not represent an extremely high-stakes situation.


Medical Specialty: Surgery
Sample Name: Odontogenic Abscess I&D

PREOPERATIVE DIAGNOSES:,1.  Left facial cellulitis.,2.  Possible odontogenic abscess of the #18, #19, and #20.,POSTOPERATIVE DIAGNOSES:,1.  Left facial cellulitis.,2.  Possible odontogenic abscess of the #18, #19, and #20.,PROCEDURE PERFORMED: , Attempted incision and drainage (I&D) of odontogenic abscess.,ANESTHESIA:  ,1% lidocaine plain approximately 5 cc total.,COMPLICATIONS: , The patient is very noncompliant with attempted procedure refusing further exam and treatment after localization and attempted FNA.  The attempted FNA was without any purulent aspirate although limited in the area of attempted examination.,INDICATIONS FOR THE PROCEDURE: , The patient is a 39-year-old Caucasian female who was admitted to ABCD General Hospital on 08/21/03 secondary to acute left facial cellulitis suspected to be secondary to odontogenic etiology.  The patient states that this was started approximately 24 hours ago.  The patient subsequently presented to ABCD General Hospital Emergency Room secondary to worsening of left face swelling and increasing in pain.  The patient admits to poor dental hygiene.  Denies any recent or dental abscesses in the past.  The patient is a substance abuser, does admit to smoking cocaine approximately three days ago.  The patient did have a CT scan of the face obtained with contrast demonstrated no signs of any acute abscess although a profuse amount of cellulitis was noted.  After risks, complications, consequences, and questions were discussed with the patient, a written consent was obtained for an I&D of a possible odontogenic abscess ________ on the CT scan.,PROCEDURE:  ,The patient was brought in upright and supine position.  Approximately 5 cc of 1% lidocaine without epinephrine was injected in the localized area along the buccogingival sulcus of the left side.  This was done at the base of #18, #19, and #20 teeth.  After this, the patient did have approximately 2 more mg of morphine given through the IV for pain control.  After this, the #18 gauge needle on a ________ syringe was then utilized to attempt a FNA at the base of #18 tooth and #19 with one stick placed.  There were no signs of any purulent drainage, although at this time the patient became very irate and noncompliant and refusing further examination.  The patient understood consequences of her actions.  Does state that she does not care at this time and just wants to be left alone.  At this time, the bed was actually placed back in its normal position and the patient will be continued on clindamycin 900 mg IV q.6h. along with pain control utilizing Toradol, morphine, and Vicodin.  The patient will also be started on Peridex oral rinse of 10 cc p.o. swish and spit t.i.d. and a K-pad to the left face.
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DESCRIPTION: Left facial cellulitis and possible odontogenic abscess.  Attempted incision and drainage (I&D) of odontogenic abscess.

surgery, odontogenic, facial cellulitis, incision and drainage, fna, buccogingival, odontogenic abscess, abscess, drainage, i&d, cellulitis,

The situation involves a medical procedure (attempted incision and drainage of an odontogenic abscess) that was crucial to address an infection causing left facial cellulitis. Infections involving the face can become serious rapidly, especially if they involve the structures near the face or progress into deeper tissues, potentially leading to more severe systemic infections or complications. The patient's refusal to comply with the procedure and treatment adds complexity and risk to the management of her condition. Therefore, it is high-stakes as it involves immediate decisions regarding the patient's health and future treatment options in light of noncompliance.


Medical Specialty: Surgery
Sample Name: Ommaya reservoir

TITLE OF OPERATION: , Right frontal side-inlet Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy.  Recommendation was for an Ommaya reservoir.  Risks and benefits have been explained.  They agreed to proceed.,PREOP DIAGNOSIS: , Leukemic meningitis.,POSTOP DIAGNOSIS:  ,Leukemic meningitis.,PROCEDURE DETAIL: , The patient was brought to the operating room, underwent induction of laryngeal mask airway, positioned supine on a horseshoe headrest.  The right frontal region was prepped and draped in the usual sterile fashion.  Next, a curvilinear incision was made just anterior to the coronal suture 7 cm from the middle pupillary line.  Once this was completed, a burr hole was then created with a high-speed burr.  The dura was then coagulated and opened.  The Ommaya reservoir catheter was inserted up to 6.5 cm.  There was good flow.  This was connected to the side inlet, flat-bottom Ommaya and this was then placed in a subcutaneous pocket posterior to the incision.  This was then cut and __________.  It was then tapped percutaneously with 4 cubic centimeters and sent for routine studies.  Wound was then irrigated copiously with __________ irrigation, closed using 3-0 Vicryl for the deep layers and 4-0 Caprosyn for the skin.  The connection was made with a 3-0 silk suture and was a right-angle intermediate to hold the catheter in place.
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DESCRIPTION: Leukemic meningitis.   Right frontal side-inlet Ommaya reservoir.  The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy.

surgery, caprosyn, leukemic meningitis, ommaya reservoir, leukemia, meningeal, intrathecal, chemotherapy, leukemic, meningitis, ommaya,

The procedure described is a neurosurgical operation to implant an Ommaya reservoir, which is crucial for administering intrathecal chemotherapy to treat leukemic meningitis. This is a significant medical procedure due to its direct involvement with the central nervous system and the seriousness of the underlying condition, leukemia with meningeal involvement. Surgical procedures always carry inherent risks, and the correct placement and functioning of the reservoir is critical for treatment efficacy. Therefore, the stakes are high due to the potential impact on the patient’s treatment outcome and overall health.


Medical Specialty: Surgery
Sample Name: Orchiopexy

PREOPERATIVE DIAGNOSIS:,  Ectopic left testis.,POSTOPERATIVE DIAGNOSIS: , Ectopic left testis.,PROCEDURE PERFORMED: , Left orchiopexy.,ANESTHESIA: , General.  The patient did receive Ancef.,INDICATIONS AND CONSENT: , This is a 16-year-old African-American male who had an ectopic left testis that severed approximately one-and-a-half years ago.  The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.  The risks, benefits, and alternatives of the proposed procedure were discussed with the patient.  Informed consent was on the chart at the time of procedure.,PROCEDURE DETAILS:  ,The patient did receive Ancef antibiotics prior to the procedure.  He was then wheeled to the operative suite where a general anesthetic was administered.  He was prepped and draped in the usual sterile fashion and shaved in the area of the intended procedure.  Next, with a #15 blade scalpel, an oblique skin incision was made over the spermatic cord region.  The fascia was then dissected down both bluntly and sharply and hemostasis was maintained with Bovie electrocautery.  The fascia of the external oblique, creating the external ring was then encountered and that was grasped in two areas with hemostats and sized with Metzenbaum scissors.  This was then continued to open the external ring and was then carried cephalad to further open the external ring, exposing the spermatic cord.  With this accomplished, the testis was then identified.  It was located over the left pubic tubercle region and soft tissue was then meticulously dissected and cared to avoid all vascular and testicular structures.,The cord length was then achieved by applying some tension to the testis and further dissecting any of the fascial adhesions along the spermatic cord.  Once again, meticulous care was maintained not to involve any neurovascular or contents of the testis or vas deferens.  Weitlaner retractor was placed to provide further exposure.  There was a small vein encountered posterior to the testis and this was then hemostated into place and cut with Metzenbaum scissors and doubly ligated with #3-0 Vicryl.  Again hemostasis was maintained with ligation and Bovie electrocautery with adequate mobilization of the spermatic cord and testis.  Next, bluntly a tunnel was created through the subcutaneous tissue into the left empty scrotal compartment.  This was taken down to approximately the two-thirds length of the left scrotal compartment.  Once this tunnel has been created, a #15 blade scalpel was then used to make transverse incision.  A skin incision through the scrotal skin and once again the skin edges were grasped with Allis forceps and the dartos was then entered with the Bovie electrocautery exposing the scrotal compartment.  Once this was achieved, the apices of the dartos were then grasped with hemostats and supra-dartos pouch was then created using the Iris scissors.  A dartos pouch was created between the skin and the supra-dartos, both cephalad and caudad to the level of the scrotal incision.  A hemostat was then placed from inferior to superior through the created tunnel and the testis was pulled through the created supra-dartos pouch ensuring that anatomic position was in place, maintaining the epididymis posterolateral without any rotation of the cord.  With this accomplished, #3-0 Prolene was then used to tack both the medial and lateral aspects of the testis to the remaining dartos into the tunica vaginalis.  The sutures were then tied creating the orchiopexy.  The remaining body of the testicle was then tucked into the supra-dartos pouch and the skin was then approximated with #4-0 undyed Monocryl in a horizontal mattress fashion interrupted sutures.  Once again hemostasis was maintained with Bovie electrocautery.  Finally the attention was made towards the inguinal incision and this was then copiously irrigated and any remaining bleeders were then fulgurated with Bovie electrocautery to make sure to avoid any neurovascular spermatic structures.  External ring was then recreated and grasped on each side with hemostats and approximated with #3-0 Vicryl in a running fashion cephalad to caudad.  Once this was created, the created ring was inspected and there was adequate room for the cord.  There appeared to be no evidence of compression.  Finally, subcutaneous layer with sutures of #4-0 interrupted chromic was placed and then the skin was then closed with #4-0 undyed Vicryl in a running subcuticular fashion.  The patient had been injected with bupivacaine prior to closing the skin.  Finally, the patient was cleansed.,The scrotal support was placed and plan will the for the patient to take Keflex one tablet q.i.d. x7 days as well as Tylenol #3 for severe pain and Motrin for moderate pain as well as applying ice packs to scrotum.  He will follow up with Dr. X in 10 to 14 days.  Appointment will be made.
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DESCRIPTION: Left orchiopexy.  Ectopic left testis.   The patient did have an MRI, which confirmed ectopic testis located near the pubic tubercle.

surgery, pubic tubercle, ectopic testis, ectopic left testis, metzenbaum scissors, dartos pouch, bovie electrocautery, testis, orchiopexy, ectopic, scrotal, cord, dartos,

The procedure described is a surgical one, specifically a left orchiopexy involving the relocation of an ectopic testis. Surgery, in general, carries inherent risks, including those associated with anesthesia and potential complications from the procedure itself, such as bleeding, infection, or damage to surrounding structures. However, this particular procedure is fairly routine and not typically considered life-threatening or among the most complex surgical operations. Given that this is a planned, corrective surgery with standard risks and post-operative care, it doesn't reach the level of extremely high-stakes surgeries like those involving critical organs or emergency interventions.


Medical Specialty: Surgery
Sample Name: Olecranon Bursa - Excision

PREOPERATIVE DIAGNOSIS: , Acute infected olecranon bursitis, left elbow.,POSTOPERATIVE DIAGNOSIS: , Infection, left olecranon bursitis.,PROCEDURE PERFORMED:,1.  Incision and drainage, left elbow.,2.  Excision of the olecranon bursa, left elbow.,ANESTHESIA: , Local with sedation.,COMPLICATIONS: , None.,NEEDLE AND SPONGE COUNT: , Correct.,SPECIMENS: , Excised bursa and culture specimens sent to the microbiology.,INDICATION:  ,The patient is a 77-year-old male who presented with 10-day history of pain on the left elbow with an open wound and drainage purulent pus followed by serous drainage.  He was then scheduled for I&D and excision of the bursa.  Risks and benefits were discussed.  No guarantees were made or implied.,PROCEDURE: , The patient was brought to the operating room and once an adequate sedation was achieved, the left elbow was injected with 0.25% plain Marcaine.  The left upper extremity was prepped and draped in standard sterile fashion.  On examination of the left elbow, there was presence of thickening of the bursal sac.  There was a couple of millimeter opening of skin breakdown from where the serous drainage was noted.  An incision was made midline of the olecranon bursa with an elliptical incision around the open wound, which was excised with skin.  The incision was carried proximally and distally.  The olecranon bursa was significantly thickened and scarred.  Excision of the olecranon bursa was performed.  There was significant evidence of thickening of the bursa with some evidence of adhesions.  Satisfactory olecranon bursectomy was performed.  The wound margins were debrided.  The wound was thoroughly irrigated with Pulsavac irrigation lavage system mixed with antibiotic solution.  There was no evidence of a loose body.  There was no bleeding or drainage.  After completion of the bursectomy and I&D, the skin margins, which were excised were approximated with 2-0 nylon in horizontal mattress fashion.  The open area of the skin, which was excised was left _________ and was dressed with 0.25-inch iodoform packing.  Sterile dressings were placed including Xeroform, 4x4, ABD, and Bias.  The patient tolerated the procedure very well.  He was then extubated and transferred to the recovery room in a stable condition.  There were no intraoperative complications noticed.
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DESCRIPTION: Incision and drainage and excision of the olecranon bursa, left elbow.  Acute infected olecranon bursitis, left elbow.

surgery, incision and drainage, infected olecranon, olecranon bursitis, olecranon bursa, olecranon, wound, excision, drainage, elbow, bursa

The situation involves a surgical procedure on a 77-year-old patient with acute infected olecranon bursitis. While the surgery is specialized and requires precision, it appears to have been routine for such a condition with no complications recorded, and the patient tolerated the procedure well. The stakes are moderate given the patient's age and the nature of the infection, but the absence of complications and the stability noted post-operation reduce the overall severity. Surgical procedures always carry inherent risks, but given this context, they are on the lower to moderate spectrum because it's a localized issue rather than a systemic life-threatening one.


Medical Specialty: Surgery
Sample Name: Open Plantar Fasciotomy

PREOPERATIVE DIAGNOSIS: , Chronic plantar fasciitis, right foot.,POSTOPERATIVE DIAGNOSIS:,  Chronic plantar fasciitis, right foot.,PROCEDURE: , Open plantar fasciotomy, right foot.,ANESTHESIA: , Local infiltrate with IV sedation.,INDICATIONS FOR SURGERY:,  The patient has had a longstanding history of foot problems.  The foot problem has been progressive in nature and has not been responsive to conservative care despite multiple attempts at conservative care.  The preoperative discussion with the patient including alternative treatment options, the procedure itself was explained, and risk factors such as infection, swelling, scar tissue, numbness, continued pain, recurrence, falling arch, digital contracture, and the postoperative management were discussed.  The patient has been advised, although no guarantee for success could be given, most of the patients have improved function and less pain.  All questions were thoroughly answered.  The patient requested for surgical repair since the problem has reached a point to interfere with normal daily activities.  The purpose of the surgery is to alleviate the pain and discomfort.,DETAILS OF THE PROCEDURE:  ,The patient was given 1 g Ancef for antibiotic prophylaxis 30 minutes prior to the procedure.  The patient was brought to the operating room and placed in the supine position.  Following a light IV sedation, a posterior tibial nerve block and local infiltrate of the operative site was performed with 10 mL, and a 1:1 mixture of 1% lidocaine with epinephrine, and 0.25% Marcaine was affected.  The lower extremity was prepped and draped in the usual sterile manner.  Balance anesthesia was obtained.,PROCEDURE:, Plantar fasciotomy, right foot.  The plantar medial tubercle of the calcaneus was palpated and a vertical oblique incision, 2 cm in length with the distal aspect overlying the calcaneal tubercle was affected. Blunt dissection was carried out to expose the deep fascia overlying the abductor hallucis muscle belly and the medial plantar fascial band.  A periosteal elevator did advance laterally across the inferior aspect of the medial and central plantar fascial bands, creating a small and narrow soft tissue tunnel.  Utilizing a Metzenbaum scissor, transection of the medial two-third of the plantar fascia band began at the junction of the deep fascia of the abductor hallucis muscle belly and medial plantar fascial band, extending to the lateral two-thirds of the band.  The lateral plantar fascial band was left intact.  Visualization and finger probe confirmed adequate transection.  The surgical site was flushed with normal saline irrigation.,The deep layer was closed with 3-0 Vicryl and the skin edges coapted with combination of 1 horizontal mattress and simples.  The dressing consisted of Adaptic, 4 x 4, conforming bandages, and an ACE wrap to provide mild compression.  The patient tolerated the procedure and anesthesia well, and left the operating room to recovery room in good postoperative condition with vital signs stable and arterial perfusion intact.  A walker boot was dispensed and applied.  The patient will be allowed to be full weightbearing to tolerance, in the boot to encourage physiological lengthening of the release of plantar fascial band.,The next office visit will be in 4 days.  The patient was given prescriptions for Keflex 500 mg 1 p.o. three times a day x10 days and Lortab 5 mg #40, 1 to 2 p.o. q.4-6 h. p.r.n. pain, 2 refills, along with written and oral home instructions.  After a short recuperative period, the patient was discharged home with vital signs stable and in no acute distress.
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DESCRIPTION: Chronic plantar fasciitis, right foot.  Open plantar fasciotomy, right foot.

surgery, plantar fascial band, plantar fasciitis, plantar fasciotomy, plantar fascial, anesthesia, plantar, fascia, fasciotomy, fascial, band, foot,

The described medical scenario involves a surgical procedure called open plantar fasciotomy to address chronic plantar fasciitis. While the patient has been experiencing significant pain and the issue affects daily activities, the surgery itself is a common and well-understood procedure with low to moderate risks given the use of local anesthesia and sedation. Despite being a surgery, it is not life-threatening, and the patient was stable post-operatively. Therefore, the situation is not high-stakes, particularly in comparison to more complex or emergency surgical procedures.