Medical Specialty: Surgery
Sample Name: Spinal Manipulation

PREOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,POSTOPERATIVE DIAGNOSIS: , Sacro-iliitis (720.2), lumbo-sacral segmental dysfunction (739.3), thoraco-lumbar segmental dysfunction (739.2), associated with myalgia/fibromyositis (729.1).,ANESTHESIA: , Conscious Sedation.,INFORMED CONSENT: , After adequate explanation of the medical surgical and procedural options, this patient has decided to proceed with the recommended spinal Manipulation under Anesthesia (MUA).  The patient has been informed that more than one procedure may be necessary to achieve the satisfactory results.,INDICATION:,  This patient has failed extended conservative care of condition/dysfunction by means of aggressive physical medical and pharmacological intervention.,COMMENTS: , This patient understands the essence of the diagnosis and the reasons for the MUA- The associated risks of the procedure, including anesthesia complications, fracture, vascular accidents, disc herniation and post-procedure discomfort, were thoroughly discussed with the patient.  Alternatives to the procedure, including the course of the condition without MUA, were discussed.  The patient understands the chances of success from undergoing MUA and that no guarantees are made or implied regarding outcome.  The patient has given both verbal and written informed consent for the listed procedure.,PROCEDURE IN DETAIL: , The patient was draped in the appropriate gowning and accompanied to the operative area.  Following their sacral block injection, they were asked to lie supine on the operative table and they were placed on the appropriate monitors for this procedure.  When the patient and I were ready, the anesthesiologist administered the appropriate medications to assist the patient into the twilight sedation using medication which allows the stretching, mobilization, and adjustments necessary for the completion of the outcome I desired.,THORACIC SPINE: , With the patient in the supine position on the operative table, the upper extremities were flexed at the elbow and crossed over the patient's chest to achieve maximum traction to the patient's thoracic spine.  The first assistant held the patient's arms in the proper position and assisted in rolling the patient for the adjusting procedure.  With the help of the first assist, the patient was rolled to their right side, selection was made for the contact point and the patient was rolled back over the doctor's hand.  The elastic barrier of resistance was found, and a low velocity thrust was achieved using a specific closed reduction anterior to posterior/superior manipulative procedure.  The procedure was completed at the level of TI-TI2.  Cavitation was achieved.,LUMBAR SPINE/SACRO-ILIAC JOINTS:,  With the patient supine on the procedure table, the primary physician addressed the patient's lower extremities which were elevated alternatively in a straight leg raising manner to approximately 90 degrees from the horizontal.  Linear force was used to increase the hip flexion gradually during this maneuver.  Simultaneously, the first assist physician applied a myofascial release technique to the calf and posterior thigh musculature.  Each lower extremity was independently bent at the knee and tractioned cephalad in a neutral sagittal plane, lateral oblique cephalad traction, and medial oblique cephalad traction maneuver.  The primary physician then approximated the opposite single knee from his position from neutral to medial slightly beyond the elastic barrier of resistance. (a piriformis myofascial release was accomplished at this time).  This was repeated with the opposite lower extremity.  Following this, a Patrick-Fabere maneuver was performed up to and slightly beyond the elastic barrier of resistance.,With the assisting physician stabling the pelvis and femoral head (as necessary), the primary physician extended the right lower extremity in the sagittal plane, and while applying controlled traction gradually stretched the para-articular holding elements of the right hip by means gradually describing an approximately 30-35 degree horizontal arc.  The lower extremity was then tractioned, and straight caudal and internal rotation was accomplished.  Using traction, the lower extremity was gradually stretched into a horizontal arch to approximately 30 degrees.  This procedure was then repeated using external rotation to stretch the para-articular holding elements of the hips bilaterally.  These procedures were then repeated on the opposite lower extremity.,By approximating the patient's knees to the abdomen in a knee-chest fashion (ankles crossed), the lumbo-pelvic musculature was stretched in the sagittal plane, by both the primary and first assist, contacting the base of the sacrum and raising the lower torso cephalad, resulting in passive flexion of the entire lumbar spine and its holding elements beyond the elastic barrier of resistance
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DESCRIPTION: Spinal Manipulation under Anesthesia - Sacro-iliitis, lumbo-sacral segmental dysfunction, thoraco-lumbar segmental dysfunction, associated with myalgia/fibromyositis.

surgery, fibromyositis, myalgia, segmental dysfunction, sacro-iliitis, spinal manipulation under anesthesia, lumbar segmental dysfunction, informed consent, iliac joints, spinal manipulation, sacro iliitis, lower extremity, spinal, mua, cephalad, dysfunction, segmental, lumbar,

Spinal manipulation under anesthesia (MUA) for sacroiliitis and segmental dysfunctions is a high-stakes procedure. It involves sedation and complex manipulative techniques to address musculoskeletal issues that have not responded to conservative treatments. The procedure carries risks such as anesthesia complications, fractures, vascular accidents, and disc herniation. Thorough informed consent was obtained, highlighting its seriousness. While not emergency surgery, its invasive nature, sedation, and potential complications warrant a high-stakes evaluation.


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

Medical Specialty: Surgery
Sample Name: Spermatocelectomy

PREOPERATIVE DIAGNOSIS:,  Right spermatocele.,POSTOPERATIVE DIAGNOSIS:  ,Right spermatocele.,OPERATIONS PERFORMED:,1.  Right spermatocelectomy.,2.  Right orchidopexy.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY OF THE PATIENT:  ,The patient is a 77-year-old male who comes to the office with a large right spermatocele.  The patient says it does bother him on and off, has occasional pain and discomfort with it, has difficulty with putting clothes on etc. and wanted to remove.  Options such as watchful waiting, removal of the spermatocele or needle drainage were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, risk of infection, scrotal pain, and testicular pain were discussed.  The patient was told that his scrotum may enlarge in the postoperative period for about a month and it will settle down.  The patient was told about the risk of recurrence of spermatocele.  The patient understood all the risks, benefits, and options and wanted to proceed with removal.,DETAILS OF THE PROCEDURE:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient's scrotal area was shaved, prepped, and draped in the usual sterile fashion.  A midline scrotal incision was made measuring about 2 cm in size.  The incision was carried through the dartos through the scrotal sac and the spermatocele was identified.  All the layers of the spermatocele were removed.  Clear layer was visualized, was taken all the way up to the base, the base was tied.  Entire spermatocele sac was removed.  After removing the entire spermatocele sac, hemostasis was obtained.  The testicle was not in normal orientation.  The testis and epididymis was removed, which is a small appendage on the superior aspect of the testicle.  The testicle was placed in a normal orientation.  Careful attention was drawn not to twist the cord.  Orchidopexy was done to allow the testes to stay stable in the postoperative period using 4-0 Vicryl and was tied at 3 different locations.  Absorbable sutures were used, so that the patient does not feel the sutures in the postoperative period.  The dartos was closed using 2-0 Vicryl in running locking fashion.  There was excellent hemostasis.  The skin was closed using 4-0 Monocryl.  Dermabond was applied.  The patient tolerated the procedure well.  The patient was brought to the recovery room in stable condition.
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DESCRIPTION: Spermatocelectomy and orchidopexy

Spermatocelectomy and orchidopexy

surgery, orchidopexy, spermatocele, spermatocelectomy, scrotal

The procedure described is a surgical intervention (spermatocelectomy and orchidopexy) on a 77-year-old male patient. Although the surgery requires precision and carries risks such as bleeding, infection, and anesthetic complications, these are fairly routine risks associated with most surgeries. Since the spermatocele has been causing discomfort, the surgery aims to improve the patient's quality of life. In a surgical context, it is not considered extremely high-stakes as it does not involve life-threatening conditions or immediate critical care circumstances. However, the patient’s age and the potential risks of complications in surgery add moderate stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Spinal fluid evaluation

HISTORY:  ,This 15-day-old female presents to Children's Hospital and transferred from Hospital Emergency Department for further evaluation.  Information is obtained in discussion with the mother and the grandmother in review of previous medical records.  This patient had the onset on the day of presentation of a jelly-like red-brown stool started on Tuesday morning.  Then, the patient was noted to vomit after feeds.  The patient was evaluated at Hospital with further evaluation with laboratory data showing a white blood cell count elevated at 22.2; hemoglobin 14.1; sodium 138; potassium 7.2, possibly hemolyzed; chloride 107; CO2 23; BUN 17; creatinine 1.2; and glucose of 50, which was repeated and found to be stable in that range.  The patient underwent a barium enema, which was read by the radiologist as negative.  The patient was transferred to Children's Hospital for further evaluation after being given doses of ampicillin, cefotaxime, and Rocephin.,PAST MEDICAL HISTORY: , Further, the patient was born in Hospital.  Birth weight was 6 pounds 4 ounces.  There was maternal hypertension.  Mother denies group B strep or herpes.  Otherwise, no past medical history.,IMMUNIZATIONS: , None today.,MEDICATIONS: , Thrush medicine identified as nystatin.,ALLERGIES: , Denied.,PAST SURGICAL HISTORY: , Denied.,SOCIAL HISTORY:  ,Here with mother and grandmother, lives at home.  There is no smoking at home.,FAMILY HISTORY: , None noted exposures.,REVIEW OF SYSTEMS:  ,The patient is fed Enfamil, bottle-fed.  Has had decreased feeding, has had vomiting, has had diarrhea, otherwise negative on the 10 plus systems reviewed.,PHYSICAL EXAMINATION:,VITAL SIGNS/GENERAL:  On physical examination, the initial temperature 97.5, pulse 140, respirations 48 on this 2 kg 15-day-old female who is small, well-developed female, age appropriate.,HEENT: Head is atraumatic and normocephalic with a soft and flat anterior fontanelle.  Pupils are equal, round, and reactive to light.  Grossly conjugate.  Bilateral red reflex appreciated bilaterally.  Clear TMs, nose, and oropharynx.  There is a kind of abundant thrush and white patches on the tongue.,NECK:  Supple, full, painless, and nontender range of motion.,CHEST:  Clear to auscultation, equal, and stable.,HEART:  Regular without rubs or murmurs, and femoral pulses are appreciated bilaterally.,ABDOMEN:  Soft and nontender.  No hepatosplenomegaly or masses.,GENITALIA:  Female genitalia is present on a visual examination.,SKIN:  No significant bruising, lesions, or rash.,EXTREMITIES:  Moves all extremities, and nontender.  No deformity.,NEUROLOGICALLY:  Eyes open, moves all extremities, grossly age appropriate.,MEDICAL DECISION MAKING: , The differential entertained on this patient includes upper respiratory infection, gastroenteritis, urinary tract infection, dehydration, acidosis, and viral syndrome.  The patient is evaluated in the emergency department laboratory data, which shows a white blood cell count of 13.1, hemoglobin 14.0, platelets 267,000, 7 stabs, 68 segs, 15 lymphs, and 9 monos.  Serum electrolytes not normal.  Sodium 138, potassium 5.0, chloride 107, CO2 acidotic at 18, glucose normal at 88, and BUN markedly elevated at 22 as is the creatinine of 1.4.  AST and ALT were elevated as well at 412 and 180 respectively.  A cath urinalysis showing no signs of infection.  Spinal fluid evaluation, please see procedure note below.  White count 0, red count 2060.  Gram stain negative.,PROCEDURE NOTE: , After discussion of the risks, benefits, and indications, and obtaining informed consent with the family and their agreement to proceed, this patient was placed in the left lateral position and using aseptic Betadine preparation, sterile draping, and sterile technique pursued throughout, this patient's L4- L5 interspace was anesthetized with the 1% lidocaine solution following the above sterile preparation, entered with a 22-gauge styletted spinal needle of approximately 0.5 mL clear CSF, they were very slow to obtain.  The fluid was obtained, the needle was removed, and sterile bandage was placed.  The fluid was sent to laboratory for further evaluation (aunt and grandmother) were present throughout the period of time during this procedure and the procedure was tolerated well.  An i-STAT initially obtained showed somewhat of an acidosis with a base excess of -12.  A repeat i-STAT after a bolus of normal saline and a second bolus of normal saline, her maintenance rate of D5 half showed a base excess of -11, which is slowly improving, but not very fast.  Based on the above having this patient consulted to the Hospitalist Service at 2326 hours of request, this patient was consulted to PICU with the plan that the patient need to have continued IV fluids.  Showing signs of dehydration, a third bolus of normal saline was provided, twice maintenance D5 half was continued.  The patient was admitted to the Hospitalist Service for continued IV fluids.  The patient maintains to have clear lungs, has been feeding well here in the department, took virtually a whole small bottle of the appropriate formula.  She has not had any vomiting, is burping.  The patient is admitted for continued close observation and rehydration due to the working diagnoses of gastroenteritis, metabolic acidosis, and dehydration.  Critical care time on this patient is less than 30 minutes, exclusive, otherwise time has been spent evaluating this patient according to this patient's care and admission to the Hospitalist Service.
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DESCRIPTION: Consult and Spinal fluid evaluation in a 15-day-old

The situation involves a 15-day-old infant presenting with concerning symptoms such as vomiting, jelly-like red-brown stool, metabolic acidosis, and dehydration, requiring spinal fluid evaluation and a PICU consultation. These indicate potential severe medical issues, especially due to the age of the patient, thus raising the stakes for immediate and precise medical intervention to prevent life-threatening complications and manage the underlying condition effectively.


Medical Specialty: Surgery
Sample Name: Shunt Revision - 2

PREOPERATIVE DIAGNOSIS: , Shunt malfunction.,POSTOPERATIVE DIAGNOSIS: , Partial proximal obstruction, patent distal system.,TITLE OF OPERATION: , Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.,SPECIMENS:  ,None.,COMPLICATIONS:,  None.,ANESTHESIA:,  General.,SKIN PREPARATION:  ,Chloraprep.,INDICATIONS FOR OPERATION: , Headaches, irritability, slight increase in ventricle size.  Preoperatively patient improved with Diamox.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE: , After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the supine position with the head rotated towards the left.  The right frontal area and right retroauricular area was shaved and then the head, neck, chest and abdomen were prepped and draped out in the routine manner.  The old scalp incision was opened with a Colorado needle tip and the old catheter was identified as we took the Colorado needle tip over the existing ventricular catheter, right over the sleeve on top of it and when that was entered, the CSF poured out around the ventricular catheter.  The ventricular catheter was then disconnected from the reservoir and endoscopically explored.  We saw it was blocked up proximally.  The catheter was a little adherent and required some freeing up with coagulation and on twisting of the ventricular catheter, I was able to free up the ventricular catheter, and endoscopically inserted a new Bactiseal ventricular catheter.  The catheter went down to the septum and I could see both the right and left lateral ventricles and elected to pass it into the right lateral ventricle.  It irrigated out well.  There was minimal amount of bleeding, but not significant.  The distal catheter system was tested.  There was good distal run off.  Therefore, a linear skin incision was made in the retroauricular area.  Tunneling was performed between the two incisions and a ProGAV valve set to an opening pressure of 10 with a 1-5 shunt assist was brought through the subgaleal tissue, connected to the distal catheter and a flushing reservoir was interposed between the burr hole site ventricular catheter and the ProGAV valve.  All connections were secured with 2-0 Ethibond sutures.  Careful attention was made to make sure that the ProGAV was in the right orientation.  The wounds were irrigated out with Bacitracin, closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well.  He was awakened, extubated and taken to recovery room in satisfactory condition.
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DESCRIPTION: Endoscopic proximal and distal shunt revision with removal of old valve and insertion of new.

surgery, chloraprep, distal shunt revision, colorado needle tip, colorado needle, progav valve, shunt revision, ventricular catheter, catheter, shunt, ventricular,

The situation described involves a surgical procedure to revise a shunt, which is necessary for the management of cerebrospinal fluid (CSF) drainage and pressure regulation in the brain. Shunt revisions are crucial for preventing potentially life-threatening complications such as increased intracranial pressure, infections, and brain damage due to shunt malfunction. The procedure involves anesthesia, surgical intervention, and careful handling of brain structures, all of which carry inherent risks. Although the procedure went well with no reported complications, the inherent nature of surgical interventions and the potential consequences of shunt malfunction elevate the stakes significantly.


Medical Specialty: Surgery
Sample Name: Shunt Revision - 1

PREOPERATIVE DIAGNOSIS: , Shunt malfunction.  The patient with a ventriculoatrial shunt.,POSTOPERATIVE DIAGNOSIS:,  Shunt malfunction.  The patient with a ventriculoatrial shunt.,ANESTHESIA: , General endotracheal tube anesthesia.,INDICATIONS FOR OPERATION: , Headaches, fluid accumulating along shunt tract.,FINDINGS: , Partial proximal shunt obstruction.,TITLE OF OPERATION:,  Endoscopic proximal shunt revision.,SPECIMENS: , None.,COMPLICATIONS:,  None.,DEVICES: , Portnoy ventricular catheter.,OPERATIVE PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was administered, the patient positioned on the operating table in supine position with the right frontal area shaved and the head was prepped and draped in a routine manner.  The old right frontal scalp incision was reopened in a curvilinear manner, and the Bactiseal ventricular catheter was identified as it went into the right frontal horn.  The distal end of the VA shunt was flushed and tested with heparinized saline, found to be patent, and it was then clamped.  Endoscopically, the proximal end was explored and we found debris within the lumen, and then we were able to freely move the catheter around.  We could see along the tract that the tip of the catheter had gone into the surrounding tissue and appeared to have prongs or extensions in the tract, which were going into the catheter consistent with partial proximal obstruction.  A Portnoy ventricular catheter was endoscopically introduced and then the endoscope was bend so that the catheter tip did not go into the same location where it was before, but would take a gentle curve going into the right lateral ventricle.  It flushed in quite well, was left at about 6.5 cm to 7 cm and connected to the existing straight connector and secured with 2-0 Ethibond sutures.  The wounds were irrigated out with Bacitracin and closed in a routine manner using two 3-0 Vicryl for the galea and a 4-0 running Monocryl for the scalp followed by Mastisol and Steri-Strips.  The patient was awakened and extubated having tolerated the procedure well without complications.  It should be noted that the when we were irrigating through the ventricular catheter, fluid easily came out around the catheter indicating that the patient had partial proximal obstruction so that we could probably flow around the old shunt tract and perhaps this was leading to some of the symptomatology or findings of fluid along the chest.
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DESCRIPTION: Endoscopic proximal shunt revision.

Endoscopic proximal shunt revision.

surgery, ventriculoatrial shunt, endoscopic proximal shunt revision, endoscopic proximal shunt, portnoy ventricular catheter, shunt malfunction, shunt revision, ventricular catheter, shunt, endoscopic, ventricular, proximal, catheter,

The situation involves a surgical procedure, specifically an endoscopic proximal shunt revision for a patient with shunt malfunction causing headaches and fluid accumulation. Surgery inherently carries risks, especially involving the brain, due to the critical nature of the structures involved and the potential for life-threatening complications if not managed properly. Although there were no complications in this particular procedure, the stakes remain high due to possible severe outcomes if the shunt malfunction had not been addressed. Additionally, the patient's symptoms indicate that the malfunction was already impacting their health significantly, further emphasizing the importance of the procedure.


Medical Specialty: Surgery
Sample Name: Sigmoidoscopy - 1

PROCEDURE: , Sigmoidoscopy.,INDICATIONS:,  Performed for evaluation of anemia, gastrointestinal Bleeding.,MEDICATIONS: , Fentanyl (Sublazine) 0.1 mg IV Versed (midazolam) 1 mg IV,BIOPSIES: , No BRUSHINGS:,PROCEDURE:,  A history and physical examination were performed.  The procedure, indications, potential complications (bleeding, perforation, infection, adverse medication reaction), and alternative available were explained to the patient who appeared to understand and indicated this.  Opportunity for questions was provided and informed consent obtained.  After placing the patient in the left lateral decubitus position, the sigmoidoscope was inserted into the rectum and under direct visualization advanced to 25 cm.  Careful inspection was made as the sigmoidoscope was withdrawn.  The quality of the prep was good.  The procedure was stopped due to patient discomfort.  The patient otherwise tolerated the procedure well.  There were no complications.,FINDINGS: , Was unable to pass scope beyond 25 cm because of stricture vs very short bends secondary to multiple previous surgeries.  Retroflexed examination of the rectum revealed small hemorrhoids.  External hemorrhoids were found.  Other than the findings noted above, the visualized colonic segments were normal.,IMPRESSION: , Internal hemorrhoids  External hemorrhoids  Unable to pass scope beyond 25 cm due either to stricture or very sharp bend secondary to multiple surgeries.  Unsuccessful Sigmoidoscopy.  Otherwise Normal Sigmoidoscopy to 25 cm.  External hemorrhoids were found.
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DESCRIPTION: Sigmoidoscopy performed for evaluation of anemia, gastrointestinal Bleeding.

surgery, gastrointestinal bleeding, gastrointestinal, sigmoidoscope, rectum, anemia, bleeding, sigmoidoscopy, hemorrhoids,

Sigmoidoscopy is a routine medical procedure used to evaluate the colon and rectum for various conditions like anemia or gastrointestinal bleeding. While it can be important for diagnosing underlying medical issues, this specific situation does not involve life-threatening circumstances immediately or have urgent implications like a major surgery or a cardiac event. Given the procedure was stopped due to patient discomfort, but there were no complications noted aside from the inability to progress beyond 25 cm, the stakes of this particular instance appear relatively low.


Medical Specialty: Surgery
Sample Name: Scrotal Exploration

PREOPERATIVE DIAGNOSIS: , Left testicular torsion, possibly detorsion.,POSTOPERATIVE DIAGNOSIS: , Left testicular torsion, possibly detorsion.,PROCEDURE: , Left scrotal exploration with detorsion.  Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.,ANESTHETIC:,  A 0.25% Marcaine local wound insufflation per surgeon, 15 mL of Toradol.,FINDINGS:,  Congestion in the left testis and cord with a bell-clapper deformity on the right small appendix testes bilaterally.  No testis necrosis.,ESTIMATED BLOOD LOSS:,  5 mL.,FLUIDS RECEIVED: , 300 mL of crystalloid.,TUBES AND DRAINS:,  None.,SPECIMENS: , No tissues sent to pathology.,COUNTS:,  Sponges and needle counts were correct x2.,INDICATIONS OF OPERATION: , The patient is a 4-year-old boy with abrupt onset of left testicular pain.  He has had a history of similar onset.  Apparently, he had no full on one ultrasound and full on a second ultrasound, but because of possible torsion, detorsion, or incomplete detorsion, I recommended an exploration.,DESCRIPTION OF OPERATION:,  The patient was taken to the operating room, where surgical consent, operative site, and patient identification was verified.  Once he was anesthetized, he was placed in supine position and sterilely prepped and draped.  Superior scrotal incisions were then made with 15-blade knife and further extended up to the subcutaneous tissue and dartos fascia with electrocautery.  Electrocautery was used for hemostasis.  The subdartos pouch was created with curved tenotomy scissors.  The tunica vaginalis was then delivered, incised, and testis was delivered.  The testis itself with a bell-clapper deformity.  There was no actual torsion at the present time, there was some modest congestion and, however, the vasculature was markedly congested down the cord.  The penis fascia was cauterized and subdartos pouch was created.  The upper aspect of fascia was then closed with pursestring suture of 4-0 chromic.  The testis was then placed into the scrotum in a proper orientation.  No tacking sutures within the testis itself were used.  The tunica vaginalis; however, was wrapped perfectly behind the back of the testis.  A similar procedure was performed on the right side.  Again, an appendix testis was cauterized.  No torsion was seen.  He also had a bell-clapper deformity and similar dartos pouch was created and the testis was placed in the scrotum in the proper orientation and the upper aspect closed with #4-0 chromic suture.  The local anesthetic was then used for both as cord block, as well as a local wound insufflation bilaterally with 0.25% Marcaine.  The scrotal wall was then closed with subcuticular closure of #4-0 chromic.  Dermabond tissue adhesive was then used.  The patient tolerated the procedure well.  He was given IV Toradol and was taken to the recovery room in stable condition.
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DESCRIPTION: Left scrotal exploration with detorsion.  Already, de-torsed bilateral testes fixation and bilateral appendix testes cautery.

surgery, de-torsed bilateral testes, testes fixation, bell clapper deformity, testicular torsion, subdartos pouch, tunica vaginalis, scrotal exploration, appendix testes, scrotal, testes, torsion, detorsion, insufflation, testis,

The situation involves a 4-year-old patient undergoing surgery due to testicular torsion, a condition that can lead to loss of the testicle if not treated promptly. However, the surgery is described to have been successful with no testicular necrosis, minimal estimated blood loss, and the patient was stable post-operation. This indicates the acute high-stakes nature of testicular torsion due to the risk of testicular loss, but the execution and outcome of the procedure suggest it was well managed.


Medical Specialty: Surgery
Sample Name: Scleral Buckle Opening - Local Anesthesia

PROCEDURE IN DETAIL:,  After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table.  After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty.  The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus.  The 4 rectus muscles were looped and isolated using 2-0 silk suture.  The retinal periphery was then inspected via indirect ophthalmoscopy.,
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DESCRIPTION: Scleral buckle opening under local anesthesia.

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

The situation involves a surgical procedure, specifically a 'Scleral Buckle Opening,' which is typically done to treat retinal detachment. This type of surgery, while often successful, involves critical steps and anesthesia, indicating a higher potential risk if complications arise. While the use of local anesthesia and sedation suggests it's less risky than more invasive surgeries, the involvement of the eye makes it delicate. Due to the potential impact on vision if complications occur, the stakes, while not extreme, are certainly significant.


Medical Specialty: Surgery
Sample Name: Selective Coronary Angiography & Angioplasty

PREOPERATIVE DIAGNOSIS AND INDICATIONS:,  Acute non-ST-elevation MI.,POSTOPERATIVE DIAGNOSIS AND SUMMARY:,  The patient presented with an acute non-ST-elevation MI.  Despite medical therapy, she continued to have intermittent angina.  Angiography demonstrated the severe LAD as the culprit lesion.  This was treated as noted above with angioplasty alone as the stent could not be safely advanced.  She has residual lesions of 75% in the proximal right coronary and 60% proximal circumflex, and the other residual LAD lesions as noted above.  She will be continued on her medical therapy.  At age 90, she is not a good candidate for aortic valve replacement and coronary bypass grafting.,PROCEDURE PERFORMED: , Selective coronary angiography, coronary angioplasty.,PROCEDURE IN DETAIL:,  After informed consent was obtained, the patient was taken to the cath lab, placed on the table in the supine position.  The area of the right femoral artery was prepped and draped in a sterile fashion.  Using the percutaneous technique, a 6-French sheath was placed in the right femoral artery under fluoroscopic guidance.  With the guidewire in place, a 5-French JL-4 catheter was used to selectively angiogram the left coronary system.  The catheter was removed.  The sheath flushed.  The 5-French 3DRC catheter was then used to selectively angiogram the right coronary artery.  The cath removed, the sheath flushed.,It was decided that intervention was needed in the severe lesions in the LAD, which appeared to be the culprit lesions for the non-ST elevation-MI.  The patient was given a bolus of heparin and an ACT of approximately 50 seconds was obtained, we rebolused and the ACT was slightly lower.  We repeated the level and it was slightly higher.  We administered 500 more units of heparin and then proceeded with an ACT of approximately 270 seconds prior to the 500 units of heparin IV.  Additionally, the patient had been given 300 mg of Plavix orally during the procedure and Integrilin IV bolus and then maintenance drip was started.,A 6-French CLS 3.5 left coronary guide catheter was used to cannulate the left main and HEW guidewire was positioned in the distal LAD and another HEW guidewire in the relatively large third diagonal.  An Apex 2.5 x 15 mm balloon was positioned in the distal portion of the mid LAD stenosis and inflated to 6 atmospheres for 15 seconds and then deflated.  Angiography was then performed, demonstrated marked improvement in the stenosis and this image was used for sizing the last of the needed stent.  The balloon was pulled more proximally and then inflated again at 6 atmospheres for approximately 20 seconds, with the proximal end of the balloon positioned distal to the origin of the third diagonal so as to not compromise the ostium.  The balloon was inflated and removed, repeat angiography performed.  We attempted to advance a Driver 2.5 x 24 mm bare metal stent, but I could not advance it beyond the proximal LAD, where there was significant calcification.  The stent was removed.  Attempts to advance the same 2.5 x 15 mm Apex balloon that was previously used were unsuccessful.  It was removed, a new Apex 2.5 x 15 mm balloon was then positioned in the proximal LAD and inflated to 6 atmospheres for 15 seconds and then deflated and advanced slightly with the distal tip of the balloon proximal to the third diagonal ostium and it was inflated to 6 atmospheres for 15 seconds and then deflated and removed.  Repeat angiography demonstrated no evidence of dissection.  One more attempt was made to advance the Driver 2.5 x 24 mm bare metal stent, but again I could not advance it beyond the calcified plaque in the proximal LAD and this was despite the presence of the buddy wire in the diagonal.  I felt that further attempts in this calcified vessel in a 90-year-old with severe aortic stenosis and severe aortic insufficiency would likely result in complications of dissection, so the stent was removed.  The guidewires and guide cath were removed.  The sheath flushed and sutured into position.  The patient moved to ICU in stable condition with no chest discomfort at all.,CONTRAST: , Isovue-370, 120 mL.,FLUORO TIME: , 9.4 minutes.,ESTIMATED BLOOD LOSS: , 30 mL.,HEMODYNAMICS:,  Aorta 185/54.,Left ventriculography was not performed.  I did not make an attempt to cross this severely stenotic aortic valve.,The left main is a large vessel, giving rise to LAD and circumflex vessels.  The left main has no significant disease other than calcification in the walls.,The LAD is a moderate-to-large vessel, giving rise to small diagonals and then a moderate-to-large third diagonal, and then a small fourth diagonal.  The LAD has significant calcification proximally.  There is a 50% stenosis between the first and second diagonals that we treated with angioplasty alone in an attempt to be able to advance the stent.  This resulted in a 30% residual, mostly eccentric calcified plaque.  Following this, there was a 50% stenosis in the LAD just after the takeoff of the third diagonal.  This was not ballooned.  Beyond this is an 80% stenosis prior to the fourth diagonal and then a 99% stenosis after the fourth diagonal.  These 2 lesions were dilated with 10% residual prior to the fourth diagonal and 25% residual distal to the fourth diagonal.  As noted above, this area was not stented because I could not safely advance the stent.  Note, there was also a 50% stenosis at the origin of the moderate-to-large third diagonal that did not change with angioplasty.,The circumflex is a large, nondominant vessel consisting of a large obtuse marginal with multiple branches.  The proximal circumflex has an eccentric 60% stenosis prior to the takeoff of the obtuse marginal.  The remainder of the vessel was without significant disease.,The right coronary was a large, dominant vessel giving rise to a large posterior descending artery and small-to-moderate first posterolateral, small second posterolateral, and a small-to-moderate third posterolateral branch.  The right coronary has an eccentric smooth 75% stenosis beginning about a centimeter after the origin of the vessel and prior to the acute marginal branch.  The remainder of the right coronary and its branches were without significant disease.
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DESCRIPTION: Selective coronary angiography, coronary angioplasty.  Acute non-ST-elevation MI.

surgery, non-st-elevation mi, selective coronary angiography, coronary angioplasty, calcified plaque, coronary angiography, st elevation, stenosis, lad, coronary, selective, angiography, angioplasty, balloon, vessel, stent,

The situation involves a 90-year-old patient undergoing a complex coronary angiography and angioplasty due to an acute non-ST-elevation myocardial infarction (MI), a serious cardiac condition. Given the patient's age, severe calcification, and underlying health issues (including severe aortic stenosis and insufficiency), the procedure carries significant risks. These complications are not trivial and could lead to severe consequences if not managed properly, making this a high-stakes scenario.


Medical Specialty: Surgery
Sample Name: Septoplasty

PREOPERATIVE DIAGNOSES:,1.  Nasal septal deviation.,2.  Bilateral internal nasal valve collapse.,3.  Bilateral external nasal valve collapse.,POSTOPERATIVE DIAGNOSES:,1.  Nasal septal deviation.,2.  Bilateral internal nasal valve collapse.,3.  Bilateral external nasal valve collapse.,PROCEDURES:,1.  Revision septoplasty.,2.  Repair of internal nasal valve collapse using auricular cartilage.,3.  Repair of bilateral external nasal valve collapse using auricular cartilage.,4.  Harvest of right auricular cartilage.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Approximately 20 mL.,IV FLUIDS: , Include a liter of crystalloid fluid.,URINE OUTPUT: , None.,FINDINGS: , Include that of significantly deviated septum with postoperative changes and a significant septal spur along the floor.  There is also evidence of bilateral internal as well as external nasal valve collapse.,INDICATIONS:  ,The patient is a pleasant 49-year-old gentleman who had undergone a previous septorhinoplasty after significant trauma in his 20s.  He now presents with significant upper airway resistance and nasal obstruction and is unable to tolerate a CPAP machine.  Therefore, for repair of the above-mentioned deformities including the internal and external nasal valve collapse as well as straightening of the deviated septum, the risks and benefits of the procedure were discussed with him included but not limited to bleeding, infection, septal perforation, need for further surgeries, external deformity, and he desired to proceed with surgery.,DESCRIPTION OF THE PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and laid supine upon the OR table.  After the induction of general endotracheal anesthesia, the nose was decongested using Afrin-soaked pledgets followed by the injection of % lidocaine with 1:100,000 epinephrine in the submucoperichondrial planes bilaterally.  Examination revealed significant deviation of the nasal septum and the bony cartilaginous junction as well as the large septal spur along the floor.  The caudal septum appeared to be now in adequate position.  There was evidence that there had been a previous caudal septal graft on the right nares and it was decided to leave this in place.  Following the evaluation of the nose, a hemitransfixion incision was made on the left revealing a large septal spur consisting primarily down on the floor of the left nostril creating nearly a picture of the vestibular stenosis on the side.  Very carefully, the mucoperichondrial flaps were elevated over this, and it was excised using an osteotome taking care to preserve the 1.5 cm dorsal and caudal strap of the nasal septum and keep it attached to the nasal spine.  Very carefully, the bony cartilaginous junction was identified and a small piece of the bone, where the spur was, was carefully removed.  Following this, it was noted that the cartilaginous region was satisfactory in quantity as well as quality to perform adequate grafting procedures.  Therefore, attention was turned to harvesting the right-sided auricular cartilage, which was done after the region had adequately been prepped and draped in a sterile fashion.  Postauricular incision using a #15 blade, the area of the submucoperichondrial plane was elevated in order to preserve the nice lining and identifiable portion of the cartilage taking care to preserve the ridge of the helix at all times.  This was very carefully harvested.  This area had been injected previously with 1% lidocaine and 1:100,000 epinephrine.  Following this, the cartilage was removed.  It was placed in saline, noted to be fashioned in the bilateral spreader graft and alar rim graft as well as a small piece of crush which was used to be placed along the top of the dorsal irregularity.  The spreader grafts were sutured in place using submucoperichondrial pockets.  After an external septorhinoplasty approach had been performed and reflection of the skin and soft tissue envelope had been performed, adequately revealing straight septum with significant narrowing with what appeared to be detached perhaps from his ipsilateral cartilages rather from his previous surgery.  These were secured in place in the pockets using a 5-0 PDS suture in a mattress fashion in two places.  Following this, attention was turned to placing the alar rim grafts where pockets were created along the caudal aspect of the lower lateral cartilage and just along the alar margin.  Subsequently, the alar rim grafts were placed and extended all the way to the piriform aperture.  This was sutured in place using a 5-0 self-absorbing gut suture.  The lower lateral cartilage has had some inherent asymmetry.  This may have been related to his previous surgery with some asymmetry of the dome; however, this was left in place as he did not desire any changes in the tip region, and there was adequate support.  An endodermal suture was placed just to reenforce the region using a 5-0 PDS suture.  Following all this, the area was closed using a mattress 4-0 plain gut on a Keith needle followed by the application of ***** 5-0 fast-absorbing gut to close the hemitransfixion incision.  Very carefully, the skin and subcutaneous tissue envelopes were reflected.  The curvilinear incision was closed using a Vicryl followed by interrupted 6-0 Prolene sutures.  The marginal incisions were then closed using 5-0 fast-absorbing gut.  Doyle splints were placed and secured down using a nylon suture.  They had ointment also placed on them.  Following this, nasopharynx was suctioned.  There were no further abnormalities noted and everything appeared to be in nice position.  Therefore, an external splint was placed after the application of Steri-Strips.  The patient tolerated the procedure well.  He was awakened in the operating room.  He was extubated and taken to the recovery room in stable condition.
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DESCRIPTION: Revision septoplasty, repair of internal nasal valve collapse using auricular cartilage, repair of bilateral external nasal valve collapse using auricular cartilage, harvest of right auricular cartilage.

surgery, nasal septal deviation, nasal septal, auricular cartilage, nasal, nasal obstruction, nasal valve, septoplasty, submucoperichondrial, upper airway, internal nasal valve, external nasal valve, hemitransfixion incision, revision septoplasty, septal spur, valve collapse, auricular, cartilage, collapse, septum, valve,

The surgical procedure described, a revision septoplasty combined with the repair of nasal valve collapse using auricular cartilage, involves significant surgical intervention under general anesthesia. While this isn't as high-stakes as some life-saving surgeries, it does carry risks typical of surgery, such as bleeding, infection, and possible need for further surgeries. However, it's primarily a corrective surgery addressing functional issues like airway resistance and nasal obstruction arising from previous trauma and surgeries. While important for quality of life and potentially improving breathing, it's not life-threatening. Thus, the stakes are moderate.


Medical Specialty: Surgery
Sample Name: Scarf Bunionectomy

PREOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,POSTOPERATIVE DIAGNOSIS: , Hallux abductovalgus deformity with bunion of the left foot.,PROCEDURE PERFORMED: , Scarf bunionectomy procedure of the first metatarsal of the left foot.,ANESTHESIA:,  IV sedation with local.,HISTORY: , This patient is a 55-year-old female who presents to ABCD preoperative holding area after keeping herself n.p.o., since mid night for surgery for her painful left bunion.  The patient has had increasing pain over time and is having difficulty ambulating and wearing shoes.  The patient has failed to conservative treatment and desires surgical correction at this time.  Risks versus benefits of the procedure have been explained in detail by Dr. X, and consent is available on the chart for review.,PROCEDURE IN DETAIL:,  After an IV established by the Department of Anesthesia, the patient was given preoperatively 600 mg of clindamycin intravenously.  The patient was then taken to the Operating Suite via cart and was placed on the operating table in a supine position and a safety strap was placed across her waist for protection.  Next, a pneumatic ankle tourniquet was applied over her left ankle with copious amounts of Webril for the patient's protection.  After adequate IV sedation was applied, the patient was given a local injection consisting of 17 cc of 4.5 cc 1% lidocaine plain, 4.5 cc of 0.5% Marcaine plain, and 1.0 cc of Solu-Medrol mixture in the standard Mayo block to the left foot.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was then elevated, the Esmarch was applied and the tourniquet was inflated to 250 mmHg.  The foot was then lowered to the operating field.,A sterile stockinet was reflected and the attention was directed to the first metatarsophalangeal joint of the left foot.  After sufficient anesthesia, using a #10 blade a linear incision was made approximately 5 to 6 cm in length over the first metatarsophalangeal joint dorsally, just near to the extensor hallucis longus tendon.  Then using a fresh #15 blade, this incision was deepened through the skin into the subcutaneous layer after all small traversing veins were ligated and cauterized with electrocautery.  A neurovascular bundle was identified and reflected medially.  Laterally the extensor hallucis longus tendon was identified and protected with retraction as well.  Care was then taken to undermine the medial and lateral margins of the first metatarsophalangeal joint carefully.  The first metatarsophalangeal joint capsule was then identified and using a #15 blade, a linear incision made down to the bone through the joint capsule.  The periosteum was reflected and elevated off of its bone and the metatarsal head as well as the base of the proximal phalanx to a small degree.  Noted was a large hypertrophic bone spur on the dorsal medial aspect of the first metatarsal head as well as some small osteophytes along the medial portion of the proximal phalanx.  Care was then taken to reflect and dissect the periosteum off of the shaft of the first metatarsal proximally into the proximal portion of the metatarsal close to the first metatarsocuneiform joint.  The bone cortex was noted to be intact and in good condition.  Following this, using a sagittal saw with a #138 blade, the attention was directed to the medial hypertrophic bone of the first metatarsal head.  In the sagittal plane with the blade angulated from dorsolateral to proximal medial, the medial eminence of bone was resected.  Plantarly it was noted that the tibial sesamoid groove was intact and the sesamoid apparatus was intact as well.  Following this bone cut, 0.45 K-wire was inserted from medial to lateral through the medial portion of the first metatarsal head directed in the dorsal third of the metatarsal head.  Then using the Reese osteotomy guide, the guide was directed from the distal portion of the metatarsal head proximally to the proximal portion of the first metatarsal.  A second 0.45 K-wire was inserted proximally as well.  Following this, using the sagittal saw with the #138 blade a transverse linear osteotomy cut was made through the first metatarsal from medial to lateral.  After reaching the distal as well as the proximal portions of the bone and ensuring that cortex was cut on both the medial as well as lateral side, the Reese osteotomy guide was removed and the dorsal and plantar incision cuts were made.  This began with the dorsal distal cut, which extended from medial to lateral with the dorsal portion of the blade angled proximally about five degrees through the dorsal third of the distal first metatarsal.  Following this, attention was directed proximally and an incision osteotomy cut through the bone was made, directed medially to laterally with the inferior portion of the blade angled distally to transect the cortex of the bone.  Following this, the distal portion of the osteotomy cut was freely movable and was able to be translocated medially.  The head was then slit medially several millimeters until it was noted to be in good position and no chopping was present in the medullary canal of the bone.  Following this, the bone was stabilized using a 0.45 K-wire distally as well as proximally directed from dorsal to planar direction.  Next using the normal AO manner, the distal cortex was drilled from dorsal to plantar with a 2.0 mm drill bit and then over drilled proximally with the cortex using a 2.7 mm drill bit.  The proximal cortex was then _________ and then the drill hole was measured and it was determined to be 18 mm in length from dorsal to plantar cortex.  Then using 2.7 mm tap, the thread holes were placed and using an 18 x 2.7 mm screw ___________ was achieved and good apposition of the bone and tightness were achieved.  Intramedullary sludge was noted to exit from the osteotomy cut.  Following this, attention was directed proximally and the 0.45 K-wire was removed and the holes were predrilled using a 2.0 mm screw then over-drilled using 2.7 mm screw and counter sucked.  Following this, the holes were measured, found to 20 mm in length and the drill hole was tapped using a 2.7 mm tap.  Following this, a 20 mm full threaded screw was inserted and tightened.  Good intramedullary sludge was noted and compression was achieved.  Attention was then directed to the distal screw where it was once again tightened and found to be in good position with good bite.  Following this, range of motion was performed on the first metatarsophalangeal joint and some lateral deviation of the hallux was noted.  Based on this, a lateral release was performed.  The extensor hallucis longus tendon was identified and was transected medially and a linear incision was placed down using a #15 blade into the first interspace.  The incision was then deepened with sharp and blunt dissection and using a curved hemostat, the transverse as well as the oblique fibers of the abductor hallucis tendon were identified and transected.  Care was taken to perform lateral release around the fibular sesamoid through these suspensory ligaments as well as the transverse metatarsal ligament and the collateral ligament.  Upon completion of this, the hallux was noted to be in a rectus position with good alignment.  The area was then flushed and irrigated with copious amounts of sterile saline.  After this, attention was directed back to the medial capsule and a medial capsulorrhaphy was performed and the capsule was closed using #3-0 Vicryl suture.  Subcutaneous tissues were closed using #3-0 and #4-0 Vicryl sutures to close in layers.  The skin was then reapproximated and closed using #5-0 Monocryl suture.  Following this, the incisions were dressed and bandaged in the normal manner using Owen silk, 4x4s, Kling, and Kerlix as well as Coban dressing.  The tourniquet was then dropped with a total tourniquet time of 99 minutes at 250 mmHg.  The patient followed the procedure and the anesthesia well and vascular status was intact as noted by immediate hyperemia to digits one through five of the left foot.  The patient was then transferred back to the cart and escorted on the cart to the Postanesthesia Care Unit.  Following this, the patient was given prescription for Vicoprofen total #20 to be taken one every six hours as necessary for moderate to severe pain.  The patient was also given prescription for clindamycin to be taken 300 mg four times a day.  The patient was given surgical shoe and was placed in a posterior sling.  The patient was given crutches and instructed to use them for ambulation.  The patient was instructed to keep her foot iced and elevated and to remain nonweightbearing over the weekend.  The patient will follow up with Dr. X on Tuesday morning at 11'o clock in his Livonia office.  The patient was concerned about any possible allergic reaction to medication and was placed on codeine and antibiotics due to that.  The patient has Dr. X's pager and will contact him over this weekend if she has any problems or complaints or return to Emergency Department if any difficulty should arise.  X-rays were taken and the patient was discharged home upon completion of this.
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DESCRIPTION: Scarf bunionectomy procedure of the first metatarsal of the left foot.  Hallux abductovalgus deformity with bunion of the left foot.

surgery, hallux abductovalgus deformity, scarf bunionectomy, metatarsal, bunion, hallux abductovalgus, metatarsophalangeal joint, dorsally, foot, bone, abductovalgus

The situation involves a surgical procedure: a scarf bunionectomy, performed to correct a hallux abductovalgus deformity with a bunion on a patient's foot. Surgical procedures inherently carry certain risks, such as infection, complications from anesthesia, and surgical errors, which makes them moderate to high-stakes events. The stakes in this case are also influenced by the patient's quality of life improvements post-surgery, as the patient was experiencing significant pain and difficulty in walking. However, this is not an emergency or life-threatening procedure, which keeps it from reaching the highest stakes level.


Medical Specialty: Surgery
Sample Name: Ruptured Globe Repair - Sclera and Limbus

PREOPERATIVE DIAGNOSIS: , Ruptured globe with uveal prolapse OX.,POSTOPERATIVE DIAGNOSIS:,  Ruptured globe with uveal prolapse OX.,PROCEDURE:  ,Repair of ruptured globe with repositing of uveal tissue OX.,ANESTHESIA: ,General,SPECIMENS:,  None.,COMPLICATIONS:,  None.,INDICATIONS: , This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE: ,  The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was carefully placed to provide exposure. A two-armed 7 mm scleral laceration was seen in the supranasal quadrant. The laceration involved the sclera and the limbus in this area. There was a small amount of iris tissue prolapsed in the wound. The Westcott scissors and 0.12 forceps were used to carefully dissect the conjunctiva away from the wound to provide exposure. A cyclodialysis spatula was used to carefully reposit the prolapsed iris tissue back into the anterior chamber. The anterior chamber remained formed and the iris tissue easily resumed its normal position. The pupil appeared round. An 8-0 nylon suture was used to close the scleral portion of the laceration. Three sutures were placed using the 8-0 nylon suture. Then 9-0 nylon suture was used to close the limbal portion of the wound. After the wound appeared closed, a Superblade was used to create a paracentesis at approximately 2 o'clock. BSS was injected through the paracentesis to fill the anterior chamber. The wound was checked and found to be watertight. No leaks were observed. An 8-0 Vicryl suture was used to reposition the conjunctiva and close the wound. Three 8-0 Vicryl sutures were placed in the conjunctiva. All scleral sutures were completely covered. The anterior chamber remained formed and the pupil remained round and appeared so at the end of the case. Subconjunctival injections of Ancef and dexamethasone were given at the end of the case as well as Tobradex ointment. The lid speculum was carefully removed. The drapes were carefully removed. Sterile saline was used to clean around the XXX eye as well as the rest of the face. The area was carefully dried and an eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia without difficulty. (S)he was taken to the recovery area in good condition. There were no complications.
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DESCRIPTION: Repair of ruptured globe with repositing of uveal tissue - Sample/Template.

surgery, ruptured globe, bss, subconjunctival, bleeding, conjunctiva, eye patch, infection, limbus, loss of the eye, loss of vision, re-operation, scleral laceration, supranasal quadrant, uveal prolapse, wire lid speculum, iris tissue, anterior chamber, laceration, iris, chamber, ruptured, globe, eye,

A surgery to repair a ruptured globe, which involves the repositioning of uveal tissue, is a complex and high-stakes medical procedure. The eye is a delicate and crucial organ, and any damage to the globe can result in serious consequences such as loss of vision or even loss of the eye. The preoperative and postoperative considerations, informed consent, and the potential risks of bleeding, infection, or further complications underscore the seriousness of the surgery. Successful outcomes are critical to preserving the patient’s vision and quality of life.


Medical Specialty: Surgery
Sample Name: Salpingooophorectomy - Laparoscopic

PREOPERATIVE DIAGNOSES:,1.  Right pelvic pain.,2.  Right ovarian mass.,POSTOPERATIVE DIAGNOSES:,1.  Right pelvic pain.,2.  Right ovarian mass.,3.  8 cm x 10 cm right ovarian cyst with ovarian torsion.,PROCEDURE PERFORMED:  ,Laparoscopic right salpingooophorectomy.,ANESTHESIA:  ,General with endotracheal tube.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,TUBES: , None.,DRAINS:,  None.,PATHOLOGY: , The right tube and ovary sent to pathology for review.,FINDINGS: , On exam under anesthesia, a normal-appearing vulva and vagina and normally palpated cervix, a uterus that was normal size, and a large right adnexal mass.  Laparoscopic findings demonstrated a 8 cm x 10 cm smooth right ovarian cyst that was noted to be torsed twice.  Otherwise, the uterus, left tube and ovary, bowel, liver margins, appendix, and gallbladder were noted all to be within normal limits.  There was no noted blood in the pelvis.,INDICATIONS FOR THIS PROCEDURE:,  The patient is a 26-year-old G1 P1 who presented to ABCD General Emergency Room with complaint of right lower quadrant pain since last night, which has been increasing in intensity.  The pain persisted despite multiple pain medications given in the Emergency Room.  The patient reports positive nausea and vomiting.  There was no vaginal bleeding or discharge.  There was no fevers or chills.  Her cultures done in the Emergency Room were pending.  The patient did have an ultrasound that demonstrated an 8 cm right ovarian cyst, questionable hemorrhagic.  The uterus and left ovary were within normal limits.  There was a positive flow noted to bilateral ovaries on ultrasound.  Therefore, it was felt appropriate to take the patient for a diagnostic laparoscopy with a possible oophorectomy.,PROCEDURE:,  After informed consent was obtained, and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the operating room where general anesthesia was obtained without any difficulty.  She was placed in dorsal lithotomy position with the use of Allis strips and prepped and draped in the usual sterile fashion.  Her bladder was drained with a red Robinson catheter and she was examined under anesthesia and was noted to have the findings as above.  She was prepped and draped in the usual sterile fashion.  A weighted speculum was placed in the patient's vagina with excellent visualization of the cervix.  The cervix was grasped at 12 o'clock position with a single-toothed tenaculum and pulled into the operative field.  The uterus was then sounded to approximately 3.5 inches and then a uterine elevator was placed.  The vulsellum tenaculum was removed.  The weighted speculum was removed.  Attention was then turned to the abdomen where 1 cm infraumbilical incision was made in the infraumbilical fold.  The Veress step needle was then placed into the abdomen while the abdomen was being tented up with towel clamp.  The CO2 was then turned on with unoccluded flow and excellent pressures.  This was continued till a normal symmetrical pneumoperitoneum was obtained.  Then, a #11 mm step trocar and sleeve were placed into the infraumbilical port without any difficulty and placement was confirmed by laparoscope.  Laparoscopic findings are as noted above.  A suprapubic incision was made with the knife and then a #12 mm step trocar and sleeve were placed in the suprapubic region under direct visualization.  Then, a grasper was used to untorse the ovary.  Then, a #12 mm port was placed in the right flank region under direct visualization using a LigaSure vessel sealing system.  The right tube and ovary were amputated and noted to be hemostatic.  The EndoCatch bag was then placed through the suprapubic port and the ovary was placed into the bag.  The ovary was too large to fit completely into the bag.  Therefore, a laparoscopic needle with a 60 cc syringe was used to aspirate the contents of the ovary while it was still inside the bag.,There was approximately 200 cc of fluid aspirated from the cyst.  This was a clear yellow fluid.  Then, the bag was closed and the ovary was removed from the suprapubic port.  The suprapubic port did have to be extended somewhat to allow for the removal of the ovary.  The trocar and sleeve were then placed back into the port.  The abdomen was copiously irrigated with warm normal saline using the Nezhat-Dorsey suction irrigator and the incision site was noted to be hemostatic.  The pelvis was clear and clean.  ,Pictures were obtained.  The suprapubic port was then removed under direct visualization and then using a #0-vicyrl and UR6.  Two figure-of-eight sutures were placed in the fascia of suprapubic port and fascia was closed and the pneumoperitoneum was maintained after the sutures were placed.  Therefore, the peritoneal surface was noted to be hemostatic.  Therefore, the camera was removed.  All instruments were removed.  The abdomen was allowed to completely deflate and then the trocars were placed back through the sleeves of the right flank #12 port and the infraumbilical port and these were removed.  The infraumbilical port was examined and noted to have a small fascial defect which was repaired with #0-Vicryl and UR6.  The right flank area was palpated and there was no facial defect noted.  The skin was then closed with #4-0 undyed Vicryl in subcuticular fashion.  Dressings were changed.  The weighted speculum was removed from the patient's cervix.  The cervix noted to be hemostatic.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2 and the patient was taken to the Recovery in stable condition.
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DESCRIPTION: Laparoscopic right salpingooophorectomy.  Right pelvic pain and ovarian mass.  Right ovarian cyst with ovarian torsion.

The situation described involves a surgical procedure to address a right ovarian mass and torsion, which are serious medical conditions requiring prompt intervention to prevent complications such as tissue necrosis. Ovarian torsion is a potentially emergent condition because it can compromise blood flow to the ovary, causing severe pain and potentially leading to loss of ovarian function if not addressed quickly. Given that the procedure is surgical, under general anesthesia, and involves intra-abdominal intervention, it involves significant medical risks and considerations. However, the procedure was successfully completed with no complications reported, and the patient's recovery was described as stable.


Medical Specialty: Surgery
Sample Name: Ruptured Globe Repair - Posterior Sclera

PREOPERATIVE DIAGNOSIS: , Ruptured globe OX.,POSTOPERATIVE DIAGNOSIS:,  Ruptured globe OX.,PROCEDURE: , Repair of ruptured globe OX.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS: ,None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure.,Upon examination and dissection of the conjunctiva superiorly, a scleral rupture was found. The rupture extended approximately 15 mm in length superior to the cornea, approximately 2 mm from the limbus in a horizontal fashion. There was also a rupture at the limbus, near the middle of this laceration, causing the anterior chamber to be flat. There was a large blood clot filling the anterior chamber. An attempt was made to wash out the anterior chamber with BSS on a cannula. The BSS was injected through the limbal rupture, which communicated with the anterior chamber. The blood clot did not move. It was extremely adherent to the iris.,At that time, the rupture that involved the limbus from approximately 10:30 until 12 o'clock was closed using 1 suture of 10-0 nylon. The scleral laceration was then closed using 10 interrupted sutures with 9-0 Vicryl. At that time, the anterior chamber was formed and appeared to be fairly deep. The wounds were checked and found to be watertight. The knots were rotated posteriorly and the conjunctiva was draped up over the sutures and sewn into position at the limbus using four 7-0 Vicryl sutures, 2 nasally and 2 temporally. All suture knots were buried.  ,Gentamicin 0.5 cc was injected subconjunctivally. Then, the speculum was removed. The drapes were removed. Several drops of Ocuflox and Maxitrol ointment were placed in the XXX eye. An eye patch and shield were placed over the eye. The patient was awakened from general anesthesia without difficulty and taken to the recovery room in good condition.
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DESCRIPTION: Repair of ruptured globe involving posterior sclera - Sample/Template.

surgery, ruptured globe, ancef, bss, maxitrol ointment, ocuflox, anterior chamber, bleeding, conjunctiva, infection, limbus, loss of the eye, loss of vision, re-operation, scleral laceration, scleral rupture, wire lid speculum, repair of ruptured globe, ruptured, anterior, chamber, globe

The procedure described involves a surgical repair of a ruptured globe, which is a serious and potentially sight-threatening condition. The risks discussed, such as loss of vision or loss of the eye, indicate that the surgery carries significant consequences if not successful. Additionally, the mention of preparing the patient, using general anesthesia, and the detailed surgical steps reflect the complexity and critical nature of the operation. The outcome directly impacts the patient's vision and quality of life, making it a high-stakes situation.


Medical Specialty: Surgery
Sample Name: Rhytidectomy & Blepharoplasty

PREOPERATIVE DIAGNOSIS:,  Ageing face.,POSTOPERATIVE DIAGNOSIS: , Ageing face.,OPERATIVE PROCEDURE:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip.,OPERATIONS PERFORMED:,1.  Cervical facial rhytidectomy.,2.  Quadrilateral blepharoplasty.,3.  Autologous fat injection to the upper lip - donor site, abdomen.,INDICATION:  ,This is a 62-year-old female for the above-planned procedure.  She was seen in the preoperative holding area where the surgery was discussed accordingly and markings were applied.  Full informed consent noted and chemistries were on her chart and preoperative evaluation was negative.,PROCEDURE: , The patient was brought to the operative room under satisfaction, and she was placed supine on the OR table.  Administered general endotracheal anesthesia followed by sterile prep and drape at the patient's face and abdomen.  This included the neck accordingly.,Two platysmal sling application and operating headlight were utilized.  Hemostasis was controlled with the pinpoint cautery along with suction Bovie cautery.,The first procedure was performed was that of a quadrilateral blepharoplasty.  Markers were applied to both upper lids in symmetrical fashion.  The skin was excised from the right upper lid first followed by appropriate muscle resection.  Minimal fat removed from the medial upper portion of the eyelid.  Hemostasis was controlled with the quadrilateral tip needle; closure with a running 7-0 nylon suture.  Attention was then turned to the lower lid.  A classic skin muscle flap was created accordingly.  Fat was resected from the middle, medial, and lateral quadrant.  The fat was allowed to open drain the arcus marginalis for appropriate contour.  Hemostasis was controlled with the pinpoint cautery accordingly.  Skin was redraped with a conservative amount resected.  Running closure with 7-0 nylon was accomplished without difficulty.  The exact same procedure was repeated on the left upper and lower lid.,After completion of this portion of the procedure, the lag lid was again placed in the eyes.  Eye mass was likewise clamped.  Attention was turned to her face with plans for cervical facial rhytidectomy portion of the procedure.  The right face was first operated.  It was injected with a 0.25% Marcaine 1:200,000 adrenaline.  A submental incision was created followed by suction lipectomy and very minimal amounts of ***** in 3 mm and 2-mm suction cannula.  She had minimal subcutaneous extra fat as noted.  Attention was then turned to the incision which was in the temporal hairline in curvilinear fashion following the pretragal incision to the postauricular sulcus and into and along the post-occipital hairline.  The flap was elevated without difficulty with various facelift scissors.  Hemostasis was controlled again with a pinpoint cautery as well as suction Bovie cautery.,The exact same elevation of skin flap was accomplished on the left face followed by the anterosuperior submental space with approximately 4-cm incision.  Rectus plication in the midline with a running 4-0 Mersilene was followed by some transaction of the platysma above the hairline with coagulation, cutting, and cautery.  The submental incision was closed with a running 7-0 nylon over 5-0 Monocryl.,Attention was then turned to closure of the bilateral facelift incisions after appropriate SMAS plication.  The left side of face was first closed followed by interrupted SMAS plication utilizing 4-0 wide Mersilene.  The skin was draped appropriately and appropriate tissue was resected.  A 7-mm 9-0 French drain was utilized accordingly prior to closure of the skin with interrupted 4-0 Monocryl in the post-occipital region followed by running 5-0 nylon in the postauricular surface.  Preauricular interrupted 5-0 Monocryl was followed by running 7-0 nylon.  The hairline temporal incision was closed with running 5-0 nylon.  The exact same closure was accomplished on the right side of the face with a same size 7-mm French drain.,The patient's dressing consisted of Adaptic Polysporin ointment followed by Kerlix wrap with a 3-inch Ace.,The lips and mouth were sterilely prepped and draped accordingly after application of the head drape dressing as described.  Suction lipectomy was followed in the abdomen with sterile conditions were prepped and draped accordingly.  Approximately 2.5 to 3 cc of autologous fat was injected into the upper lip of the remaining cutaneous line with blunt tip dissector after having washed the fat with saline accordingly.  Tuberculin syringes were utilized on the injection utilizing a larger blunt tip needle for the actual injection procedure.  The incision site was closed with 7-0 nylon.,The patient tolerated the procedure well and was transferred to the recovery room in stable condition with Foley catheter in position.,The patient will be admitted for overnight short stay through the cosmetic package procedure.  She will be discharged in the morning.,Estimated blood loss was less than 75 cc.  No complications noted, and the patient tolerated the procedure well.
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DESCRIPTION: Cervical facial rhytidectomy.  Quadrilateral blepharoplasty.  Autologous fat injection to the upper lip - donor site, abdomen.

surgery, ageing face, adaptic polysporin ointment, autologous fat injection, bovie cautery, kerlix wrap, smas plication, arcus marginalis, blepharoplasty, facelift, platysmal sling, quadrilateral, rhytidectomy, right upper lid, cervical facial rhytidectomy, pinpoint cautery, facial rhytidectomy, quadrilateral blepharoplasty, running nylon, autologous,

The described surgical procedures, including rhytidectomy (facelift) and blepharoplasty (eyelid surgery), are cosmetic in nature. While any surgical procedure carries inherent risks, such as bleeding, infection, or complications from anesthesia, these specific procedures are routine for experienced surgeons and typically not life-threatening. The report indicates that the procedures were performed without complications and the patient was stable postoperatively. The surgery was elective and planned well in advance, which mitigates acute medical risks. Consequently, the situation involves moderate stakes, given the surgical nature and recovery aspects, but it's not extremely high-stakes like life-saving emergency surgeries.


Medical Specialty: Surgery
Sample Name: Right Shoulder Hemiarthroplasty

PREOPERATIVE DIAGNOSES:,1.  Right shoulder rotator cuff tear.,2.  Glenohumeral rotator cuff arthroscopy.,3.  Degenerative joint disease.,POSTOPERATIVE DIAGNOSES:,1.  Right shoulder rotator cuff tear.,2.  Glenohumeral rotator cuff arthroscopy.,3.  Degenerative joint disease.,PROCEDURE PERFORMED: ,Right shoulder hemiarthroplasty.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Approximately 125 cc.,COMPLICATIONS:,  None.,COMPONENTS: , A DePuy 10 mm global shoulder system stem was used cemented and a DePuy 44 x 21 mm articulating head was used.,BRIEF HISTORY:  ,The patient is an 82-year-old right-hand dominant female who presents for shoulder pain for many years now and affecting her daily living and function and pain is becoming unbearable failing conservative treatment.,PROCEDURE: , The patient was taken to the operative suite, placed on the operative field.  Department of Anesthesia administered general anesthetic.  Once adequately sedated, the patient was placed in the beach chair position.  Care was ensured that she was well positioned, adequately secured and padded.  At this point, the right upper extremity was then prepped and draped in the usual sterile fashion.  A deltopectoral approach was used and taken down to the skin with a #15 blade scalpel.,At this point, blunt dissection with Mayo scissors was used to come to the overlying subscapular tendon and bursal tissue.  Any perforating bleeders were cauterized with Bovie to obtain hemostasis.  Once the bursa was seen, it was removed with a Rongeur and subscapular tendon could be easily visualized.  At this point, the rotator cuff in the subacromial region was evaluated.  There was noted to be a large rotator cuff, which was irreparable.  There was eburnated bone on the greater tuberosity noted.  The articular surface could be visualized.  The biceps tendon was intact.  There was noted to be diffuse discolored synovium around this as well as some fraying of the tendon in the intraarticular surface.  The under surface of the acromion, it was felt there was mild ware on this as well.  At this point, the subscapular tendon was then taken off using Bovie cautery and Metzenbaum scissors that was tied with Metzenbaum suture.  It was separated from the capsule to have a two layered repair at closure.  The capsule was also reflected posterior.  At this point, the glenoid surface could be easily visualized.  It was evaluated and had good cartilage contact and appeared to be intact.  The humeral head was evaluated.  There was noted to be ware of the cartilage and eburnated bone particularly in the central portion of the humeral head.  At this point, decision was made to proceed with the arthroplasty, since the rotator cuff tear was irreparable and there was significant ware of the humoral head.  The arm was adequately positioned.  An oscillating saw was used to make the head articular cut.  This was done at the margin of the articular surface with the anatomic neck.  This was taken down to appropriate level until this articular surface was adequately removed.  At this point, the intramedullary canal and cancellous bone could be easily visualized.  The opening hand reamers were then used and this was advanced to a size #10.  Under direct visualization, this was performed easily.  At this point, the 10 x 10 proximal flange cutter was then inserted and impacted into place to cut grooves for the fins.  This was then removed.  A trial component was then impacted into place, which did fit well and trial heads were then sampled and it was felt that a size 44 x 21 mm head gave us the best fit and appeared adequately secured.  It did not appear overstuffed with evidence of excellent range of motion and no impingement.  At this point, the trial component was removed.  Wound was copiously irrigated and suctioned dry.  Cement was then placed with a cement gun into the canal and taken up to the level of the cut.  The prosthesis was then inserted into place and held under direct visualization.  All excess cement was removed and care was ensured that no cement was left in the posterior aspect of the joint itself.  This _______ cement was adequately hard at this point.  The final component of the head was impacted into place, secured on the Morris taper and checked, and this was reduced.,The final component was then taken through range of motion and found to have excellent stability and was satisfied with its position.  The wound was again copiously irrigated and suctioned dry.  At this point, the capsule was then reattached to its insertion site in the anterior portion.  Once adequately sutured with #1-Vicryl, attention was directed to the subscapular.  The subscapular was advanced superiorly and anchored not only to the biceps tendon region, but also to the top anterior portion of the greater tuberosity.  This was opened to allow some type of coverage points of the massive rotator cuff tear.  This was secured to the tissue and interosseous sutures with size #2 fiber wire.  After this was adequately secured, the wound was again copiously irrigated and suctioned dry.  The deltoid fascial split was then repaired using interrupted #2-0 Vicryl, subcutaneous tissue was then approximated using interrupted #24-0 Vicryl, skin was approximated using a running #4-0 Vicryl.  Steri-Strips and Adaptic, 4 x 4s, and ABDs were then applied.  The patient was then placed in a sling and transferred back to the gurney, reversed by Department of Anesthesia.,DISPOSITION: , The patient tolerated well and transferred to Postanesthesia Care Unit in satisfactory condition.
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DESCRIPTION: Right shoulder hemiarthroplasty.   Right shoulder rotator cuff tear.  Glenohumeral rotator cuff arthroscopy.  Degenerative joint disease.

surgery, glenohumeral rotator cuff, arthroscopy, degenerative joint disease, shoulder hemiarthroplasty, rotator, cuff, subscapular, shoulder,

The situation involves a surgical procedure, specifically a right shoulder hemiarthroplasty, performed due to significant joint issues and an irreparable rotator cuff tear. The stakes are relatively high due to the nature of surgery, the elderly age of the patient (82 years old), and the general anesthesia involved. The successful outcome of this procedure can significantly impact the patient's quality of life, reducing pain and improving shoulder function. However, the absence of complications and standard estimated blood loss suggest that the procedure went smoothly, which reduces the stakes slightly. Therefore, it is a moderately high-stakes situation overall.


Medical Specialty: Surgery
Sample Name: Rotator Cuff Repair

PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, left.,POSTOPERATIVE DIAGNOSES:,1.  Sixty-percent rotator cuff tear, joint side.,2.  Impingement syndrome.,ANESTHESIA: , General,NAME OF OPERATION:,1.  Arthroscopic subacromial decompression.,2.  Repair of rotator cuff through mini-arthrotomy.,FINDINGS AT OPERATION: , The patient's glenohumeral joint was completely clear, other than obvious tear of the rotator cuff.  The midportion of this appeared to be complete, but for the most part, this was about a 60% rupture of the tendon.  This was confirmed later when the bursal side was opened up.  Note, the patient also had abrasion of the coracoacromial ligament under the anterolateral edge of the acromion.  He did not have any acromioclavicular joint pain or acromioclavicular joint disease noted.,PROCEDURE:,  He was given an anesthetic, examined, prepped, and draped in a sterile fashion in a beach-chair position.  The shoulder was instilled with fluid from posteriorly, followed by the arthroscope.  The shoulder was instilled with fluid from posteriorly, followed by the arthroscope.  Arthroscopy was then carried out in standard fashion using a 30-degree Dionic scope.  With the scope in the posterior portal, the above findings were noted, and an anterior portal was established.  A curved shaver was placed for debridement of the tear.  I established this was about a 60-70% tear with a probable complete area of tear which was very small.  There were no problems at the biceps or the rest of the joint.  The subacromial space showed findings, as noted above, and a thorough subacromial decompression was carried out with a Bovie, rotary shaver, and bur.  I did not debride the acromioclavicular joint.  The lateral portal was then extended to a mini-arthrotomy, and subacromial space was entered by blunt dissection through the deltoid.  The area of weakness of the tendon was found, and was transversely cut, and findings were confirmed.  The diseased tissue was removed, and the greater tuberosity was abraded with a rongeur.  Tendon-to-tendon repair was then carried out with buried sutures of 2-0 Ethibond, giving a very nice repair.  The shoulder was carried through a range of motion.  I could see no evidence of impingement.  Copious irrigation was carried out.  The deltoid deep fascia was anatomically closed, as was the superficial fascia.  The subcutaneous tissue and skin were closed in layers.  A sterile dressing was applied.  The patient appeared to tolerate the procedure well.
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DESCRIPTION: Arthroscopic subacromial decompression and repair of rotator cuff through mini-arthrotomy.

surgery, rotator cuff tear, mini-arthrotomy, repair of rotator cuff, arthroscopic subacromial decompression, arthroscopic subacromial, cuff tear, subacromial space, subacromial decompression, mini arthrotomy, acromioclavicular joint, rotator cuff, arthroscopic, decompression, acromioclavicular, impingement, rotator, cuff,

The situation involves a surgical procedure for repairing a rotator cuff tear. Surgery inherently carries risks such as infection, bleeding, and adverse reactions to anesthesia, which makes it a high-stakes situation. Additionally, the outcome affects the patient's mobility and quality of life. The report suggests that the procedure involved a significant portion of the tendon but was managed well without complications. Despite that, the nature of surgery elevates its stakes.


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

Medical Specialty: Surgery
Sample Name: Revision Rhinoplasty.

PREOPERATIVE DIAGNOSIS: , Nasal deformity, status post rhinoplasty.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,  Revision rhinoplasty (CPT 30450).  Left conchal cartilage harvest (CPT 21235).,ANESTHESIA: , General.,INDICATIONS FOR THE PROCEDURE: , This patient is an otherwise healthy male who had a previous nasal fracture.  During his healing, perioperatively he did sustain a hockey puck to the nose resulting in a saddle-nose deformity with septal hematoma.  The patient healed status post rhinoplasty as a result but was left with a persistent saddle-nose dorsal defect.  The patient was consented for the above-stated procedure.  The risks, benefits, and alternatives were discussed.,DESCRIPTION OF PROCEDURE: ,The patient was prepped and draped in the usual sterile fashion.  The patient did have approximately 12 mL of Lidocaine with epinephrine 1% with 1:100,000 infiltrated into the nasal soft tissues.  In addition to this, cocaine pledgets were placed to assist with hemostasis.,At this point, attention was turned to the left ear.  Approximately 3 mL of 1% Lidocaine with 1:100,000 epinephrine was infiltrated into the subcutaneous tissues of the conchal bulb.  Betadine was utilized for preparation.  A 15 blade was used to incise along the posterior conchal area and a Freer elevator was utilized to lift the soft tissues off the conchal cartilage in a submucoperichondrial plane.  I then completed this along the posterior aspect of the conchal cartilage, was transected in the concha cavum and concha cymba, both were harvested.  These were placed aside in saline.  Hemostasis was obtained with bipolar electrocauterization.  Bovie electrocauterization was also employed as needed.  The entire length of the wound was then closed with 5-0 plain running locking suture.  The patient then had a Telfa placed both anterior and posterior to the conchal defect and placed in a sandwich dressing utilizing a 2-0 Prolene suture.  Antibiotic ointment was applied generously.,Next, attention was turned to opening and lifting the soft tissues of the nose.  A typical external columella inverted V gull-wing incision was placed on the columella and trailed into a marginal incision.  The soft tissues of the nose were then elevated using curved sharp scissors and Metzenbaums.  Soft tissues were elevated over the lower lateral cartilages, upper lateral cartilages onto the nasal dorsum.  At this point, attention was turned to osteotomies and examination of the external cartilages.,The patient did have very broad lower lateral cartilages leading to a bulbous tip.  The lower lateral cartilages were trimmed in a symmetrical fashion leaving at least 8 mm of lower lateral cartilage bilaterally along the lateral aspect.  Having completed this, the patient had medial and lateral osteotomies performed with a 2-mm osteotome.  These were done transmucosally after elevating the tract using a Cottle elevator.  Direct hemostasis pressure was applied to assist with bruising.,Next, attention was turned to tip mechanisms.  The patient had a series of double-dome sutures placed into the nasal tip.  Then, 5-0 Dexon was employed for intradomal suturing, 5-0 clear Prolene was used for interdomal suturing.  Having completed this, a 5-0 clear Prolene alar spanning suture was employed to narrow the superior tip area.,Next, attention was turned to dorsal augmentation.  A Gore-Tex small implant had been selected, previously incised.  This was taken to the back table and carved under sterile conditions.  The patient then had the implant placed into the super-tip area to assist with support of the nasal dorsum.  It was placed into a precise pocket and remained in the midline.,Next, attention was turned to performing a columella strut.  The cartilage from the concha was shaped into a strut and placed into a precision pocket between the medial footplate of the lower lateral cartilage.  This was fixed into position utilizing a 5-0 Dexon suture.,Having completed placement of all augmentation grafts, the patient was examined for hemostasis.  The external columella inverted gull-wing incision along the nasal tip was closed with a series of interrupted everting 6-0 black nylon sutures.  The entire marginal incisions for cosmetic rhinoplasty were closed utilizing a series of 5-0 plain interrupted sutures.,At the termination of the case, the ear was inspected and the position of the conchal cartilage harvest was hemostatic.  There was no evidence of hematoma, and the patient had a series of brown Steri-Strips and Aquaplast cast placed over the nasal dorsum.  The inner nasal area was then examined at the termination of the case and it seemed to be hemostatic as well.,The patient was transferred to the PACU in stable condition.  He was charged to home on antibiotics to prevent infection both from the left ear conchal cartilage harvest and also the Gore-Tex implant area.  He was asked to follow up in 4 days for removal of the bolster overlying the conchal cartilage harvest.
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DESCRIPTION: Revision rhinoplasty and left conchal cartilage harvest to correct nasal deformity.

surgery, nasal deformity, rhinoplasty, conchal cartilage harvest, conchal bulb, conchal, submucoperichondrial, gull-wing incision, gore-tex, gull wing incision, lower lateral cartilages, revision rhinoplasty, nasal dorsum, cartilage harvest, conchal cartilage, cartilage, nasal, deformity, hemostasis, columella, harvest, cartilages

The situation involves a surgery for a nasal deformity, which is significant and requires a surgical intervention, including general anesthesia and cartilage harvesting. While the procedure is not life-threatening and is typically considered elective, the surgical and postoperative considerations, along with the use of implants, indicate higher complexity. However, it does not involve imminent risk to the patient's life, but it is important due to the surgical complexities and potential complications associated with surgery and anesthesia, including infection or adverse reactions.


Medical Specialty: Surgery
Sample Name: Rhinectomy & Nasal Endoscopy

PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma, left nasal cavity.,POSTOPERATIVE DIAGNOSIS:,  Squamous cell carcinoma, left nasal cavity.,OPERATIONS PERFORMED:,1.  Nasal endoscopy.,2.  Partial rhinectomy.,ANESTHESIA:,  General endotracheal.,INDICATIONS: , This is an 81-year-old gentleman who underwent septorhinoplasty many years ago.  He also has a history of a skin lesion, which was removed from the nasal ala many years ago, the details of which he does not recall.  He has been complaining of tenderness and induration of his nasal tip for approximately two years and has been treated unsuccessfully for folliculitis and cellulitis of the nasal tip.  He was evaluated by Dr. A, who performed the septorhinoplasty, and underwent an intranasal biopsy, which showed histologic evidence of invasive squamous cell carcinoma.  The preoperative examination shows induration of the nasal tip without significant erythema.  There is focal tenderness just cephalad to the alar crease.  There is no lesion either externally or intranasally.,PROCEDURE AND FINDINGS: , The patient was taken to the operating room and placed in supine position.  Following induction of adequate general endotracheal anesthesia, the left nose was decongested with Afrin.  He was prepped and draped in standard fashion.  The left nasal cavity was examined by anterior rhinoscopy.  The septum was midline.  There was slight asymmetry of the nares.  No lesion was seen within the nasal cavity either in the area of the intercartilaginous area, which was biopsied by Dr. A, the septum, the lateral nasal wall, and the floor.  The 0-degree nasal endoscope was then used to examine the nasal cavity more completely.  No lesion was detectable.  A left intercartilaginous incision was made with a #15 blade since this was the area of previous biopsy by Dr. A.  The submucosal tissue was thickened diffusely, but there was no identifiable distinct or circumscribed lesion present.  Random biopsies of the submucosal tissue were taken and submitted to pathology for frozen section.  A diagnosis of diffuse invasive squamous cell carcinoma was rendered.  An alar incision was made with a #15 blade and the full-thickness incision was completed with the electrocautery.  The incision was carried more cephalad through the lower lateral cartilage up to the area of the upper lateral cartilage at the superior margin.  The full unit of the left nasal tip was excised completely and submitted to pathology after tagging and labeling it.  Frozen section examination again revealed diffuse squamous cell carcinoma throughout the soft tissues involving all margins.  Additional soft tissue was then taken from all margins tagging them for the pathologist.  The inferior margins were noted to be clear on the next frozen section report, but there was still disease present in the region of the upper lateral cartilage at its insertion with the nasal bone.  A Joseph elevator was used to elevate the periosteum off the maxillary process and off the inferior aspect of the nasal bone.  Additional soft tissue was taken in these regions along the superior margin.  The frozen section examination revealed persistent disease medially and additional soft tissue was taken and submitted to pathology.  Once all margins had been cleared histologically, additional soft tissue was taken from the entire wound.  A 5-mm chisel was used to take down the inferior aspect of the nasal bone and the medial-most aspect of the maxilla.  This was all submitted to pathology for routine permanent examination.  Xeroform gauze was then fashioned to cover the defect and was sutured along the periphery of the wound with interrupted 6-0 nylon suture to provide a barrier and moisture.  The anesthetic was then discontinued as the patient was extubated and transferred to the PACU in good condition having tolerated the procedure well.  Sponge and needle counts were correct.
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DESCRIPTION: Nasal endoscopy and partial rhinectomy due to squamous cell carcinoma, left nasal cavity.

surgery, nasal cavity, joseph elevator, squamous cell carcinoma, endoscopy, intranasally, maxilla, nasal ala, nasal tip, rhinectomy, septorhinoplasty, nasal endoscopy, lateral cartilage, frozen section, additional soft, squamous cell, cell carcinoma, nasal, cartilage, squamous, carcinoma, cavity, tissue

The situation involves a surgical procedure for an 81-year-old patient with a diagnosis of squamous cell carcinoma in the nasal cavity. Surgery, particularly when it involves cancer, is generally considered high-stakes due to the potential implications for the patient's health and life, including the risk of incomplete cancer removal or complications arising from the surgery. Effective treatment is necessary to prevent further morbidity or potential mortality. Therefore, this scenario carries significant importance and potential consequences.