Medical Specialty: Surgery
Sample Name: Nissen Fundoplication

PROCEDURE PERFORMED: , Nissen fundoplication.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained detailing the risks of infection, bleeding, esophageal perforation and death, the patient was brought to the operative suite and placed supine on the operating room table.  General endotracheal anesthesia was induced without incident.  The patient was then placed in a modified lithotomy position taking great care to pad all extremities.  TEDs and Venodynes were placed as prophylaxis against deep venous thrombosis.  Antibiotics were given for prophylaxis against surgical infection.,A 52-French bougie was placed in the proximal esophagus by Anesthesia, above the cardioesophageal junction.  A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process.  The fascia was then cleared of subcutaneous tissue using a tonsil clamp.  A 1-2 cm incision was then made in the fascia gaining entry into the abdominal cavity without incident.  Two sutures of 0 Vicryl were then placed superiorly and inferiorly in the fascia, and then tied to the special 12 mm Hasson trocar fitted with a funnel-shaped adaptor in order to occlude the fascial opening.  Pneumoperitoneum was then established using carbon dioxide insufflation to a steady state of pressure of 16 mmHg.  A 30-degree laparoscope was inserted through this port and used to guide the remaining trocars.,The remaining trocars were then placed into the abdomen taking care to make the incisions along Langer's line, spreading the subcutaneous tissue with a tonsil clamp, and confirming the entry site by depressing the abdominal wall prior to insertion of the trocar.  A total of 4 other 10/11 mm trocars were placed.  Under direct vision 1 was inserted in the right upper quadrant at the midclavicular line, at a right supraumbilical position; another at the left upper quadrant at the midclavicular line, at a left supraumbilical position; 1 under the right costal margin in the anterior axillary line; and another laterally under the left costal margin on the anterior axillary line.  All of the trocars were placed without difficulty.  The patient was then placed in reverse Trendelenburg position.,The triangular ligament was taken down sharply, and the left lobe of the liver was retracted superolaterally using a fan retractor placed through the right lateral cannula.  The gastrohepatic ligament was then identified and incised in an avascular plane.  The dissection was carried anteromedially onto the phrenoesophageal membrane.  The phrenoesophageal membrane was divided on the anterior aspect of the hiatal orifice.  This incision was extended to the right to allow identification of the right crus.  Then along the inner side of the crus, the right esophageal wall was freed by dissecting the cleavage plane.,The liberation of the posterior aspect of the esophagus was started by extending the dissection the length of the right diaphragmatic crus.  The pars flaccida of the lesser omentum was opened, preserving the hepatic branches of the vagus nerve.  This allowed free access to the crura, left and right, and the right posterior aspect of the esophagus, and the posterior vagus nerve.,Attention was next turned to the left anterolateral aspect of the esophagus.  At its left border, the left crus was identified.  The dissection plane between it and the left aspect of the esophagus was freed.  The gastrophrenic ligament was incised, beginning the mobilization of the gastric pouch.  By dissecting the intramediastinal portion of the esophagus, we elongated the intra-abdominal segment of the esophagus and reduced the hiatal hernia.,The next step consisted of mobilization of the gastric pouch.  This required ligation and division of the gastrosplenic ligament and several short gastric vessels using the harmonic scalpel.  This dissection started on the stomach at the point where the vessels of the greater curvature turned towards the spleen, away from the gastroepiploic arcade.  The esophagus was lifted by a Babcock inserted through the left upper quadrant port.  Careful dissection of the mesoesophagus and the left crus revealed a cleavage plane between the crus and the posterior gastric wall.  Confirmation of having opened the correct plane was obtained by visualizing the spleen behind the esophagus.  A one-half inch Penrose drain was inserted around the esophagus and sewn to itself in order to facilitate retraction of the distal esophagus.  The retroesophageal channel was enlarged to allow easy passage of the antireflux valve.,The 52-French bougie was then carefully lowered into the proximal stomach, and the hiatal orifice was repaired.  Two interrupted 0 silk sutures were placed in the diaphragmatic crura to close the orifice.,The last part of the operation consisted of the passage and fixation of the antireflux valve.  With anterior retraction on the esophagus using the Penrose drain, a Babcock was passed behind the esophagus, from right to left.  It was used to grab the gastric pouch to the left of the esophagus and to pull it behind, forming the wrap.  The,52-French bougie was used to calibrate the external ring.  Marcaine 0.5% was injected 1 fingerbreadth anterior to the anterior superior iliac spine and around the wound for postanesthetic pain control.  The skin incision was approximated with skin staples.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.
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DESCRIPTION: Nissen fundoplication.   A 2 cm midline incision was made at the junction of the upper two-thirds and lower one-third between the umbilicus and the xiphoid process.

surgery, umbilicus, insufflation, phrenoesophageal membrane, nissen fundoplication, gastric pouch, esophagus, penrose, antireflux, nissen, fundoplication, trocars, ligament,

The situation involves a surgical procedure, specifically a Nissen fundoplication, which is performed to treat gastroesophageal reflux disease (GERD). It details the steps of the surgery, including risks such as infection, bleeding, esophageal perforation, and death. Given the invasive nature, the requirement for general anesthesia, and the potential complications associated with the procedure, this is a high-stakes medical situation. Surgical procedures inherently carry significant risks, and patient outcomes can be critically affected by various factors during surgery.


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

Medical Specialty: Surgery
Sample Name: Nephrectomy - Transplant

PREOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,POSTOPERATIVE DIAGNOSIS: , Rejection of renal transplant.,OPERATIVE PROCEDURE: , Transplant nephrectomy.,DESCRIPTION OF PROCEDURE: , The patient has had rapid deterioration of her kidney function since her transplant at ABCD one year ago.  The patient was recently thought to have obstruction to the transplant and a stent was placed in to the transplant percutaneously, but the ureter was wide open and there was no evidence of obstruction.  Because the kidney was felt to be irretrievably lost and immunosuppression had been withdrawn, it was elected to go ahead and remove the kidney and hopes that her fever and toxic course could be arrested.,With the patient in the supine position, the previously placed nephrostomy tube was removed.  The patient then after adequate prepping and draping, and placing of a small roll under the right hip, underwent an incision in the direction of the transplant incision down through and through all muscle layers and into the preperitoneal space.  The kidney was encountered and kidney was dissected free of its attachments through the retroperitoneal space.  During the course of dissection, the iliac artery and vein were identified as was the native ureter and the patient's ilioinguinal nerve; all these were preserved.  The individual vessels in the kidney were identified, ligated, and incised, and the kidney was removed.  The ureter was encountered during the course of resection, but was not ligated.  The patient's retroperitoneal space was irrigated with antibiotic solution and #19 Blake drain was placed into the retroperitoneal space, and the patient returned to the recovery room in good condition.,ESTIMATED BLOOD LOSS:  900 mL.
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DESCRIPTION: Transplant nephrectomy after rejection of renal transplant

surgery, renal transplant, blake drain, rejection, iliac artery, ilioinguinal, immunosuppression, kidney function, nephrectomy, nephrostomy tube, retroperitoneal space, toxic, ureter, vein, transplant, renal, retroperitoneal, kidney,

The situation involves a transplant nephrectomy due to a rejected renal transplant. Surgeries related to organ transplants are high-stakes due to their complexity, the critical nature of the patient's condition, and potential complications such as significant blood loss, as seen with 900 mL estimated loss here. Rejection and removal of a transplanted organ can have serious implications on the patient’s health and future treatment options. This makes it a high-stakes situation within the medical field.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Neuromodulator

PREOPERATIVE DIAGNOSIS:,  Refractory urgency and frequency.,POSTOPERATIVE DIAGNOSIS: , Refractory urgency and frequency.,OPERATION: , Stage I and II neuromodulator.,ANESTHESIA: , Local MAC.,ESTIMATED BLOOD LOSS:,  Minimal.,FLUIDS: , Crystalloid.  The patient was given Ancef preop antibiotic.  Ancef irrigation was used throughout the procedure.,BRIEF HISTORY: , The patient is a 63-year-old female who presented to us with urgency and frequency on physical exam.  There was no evidence of cystocele or rectocele.  On urodyanamcis, the patient has significant overactivity of the bladder.  The patient was tried on over three to four different anticholinergic agents such as Detrol, Ditropan, Sanctura, and VESIcare for at least one month each.  The patient had pretty much failure from each of the procedure.  The patient had less than 20% improvement with anticholinergics.  Options such as continuously trying anticholinergics, continuation of the Kegel exercises, and trial of InterStim were discussed.  The patient was interested in the trial.  The patient had percutaneous InterStim trial in the office with over 70% to 80% improvement in her urgency, frequency, and urge incontinence.  The patient was significantly satisfied with the results and wanted to proceed with stage I and II neuromodulator.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, and PE were discussed.  Risk of failure of the procedure in the future was discussed.,Risk of lead migration that the treatment may or may not work in the long-term basis and data on the long term were not clear were discussed with the patient.  The patient understood and wanted to proceed with stage I and II neuromodulator.  Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR.  The patient was placed in prone position.  A pillow was placed underneath her pelvis area to slightly lift the pelvis up.  The patient was awake, was given some MAC anesthesia through the IV, but the patient was talking and understanding and was able to verbalize issues.  The patient's back was prepped and draped in the usual sterile fashion.  Lidocaine 1% was applied on the right side near the S3 foramen.  Under fluoroscopy, the needle placement was confirmed.  The patient felt stimulation in the vaginal area, which was tapping in nature.  The patient also had a pressure feeling in the vaginal area.  The patient had no back sensation or superficial sensation.  There was no sensation down the leg.  The patient did have __________, which turned in slide bellows response indicating the proper positioning of the needle.  A wire was placed.  The tract was dilated and lead was placed.  The patient felt tapping in the vaginal area, which is an indication that the lead is in its proper position.  Most of the leads had very low amplitude and stimulation.  Lead was tunneled under the skin and was brought out through an incision on the left upper buttocks.  Please note that the lidocaine was injected prior to the tunneling.  A pouch was created about 1 cm beneath the subcutaneous tissue over the muscle where the actual unit was connected to the lead.  Screws were turned and they were dropped.  Attention was made to ensure that the lead was all the way in into the InterStim.  Irrigation was performed after placing the main unit in the pouch.  Impedance was checked.  Irrigation was again performed with antibiotic irrigation solution.  The needle site was closed using 4-0 Monocryl.  The pouch was closed using 4-0 Vicryl and the subcutaneous tissue with 4-0 Monocryl.  Dermabond was applied.,The patient was brought to recovery in a stable condition.
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DESCRIPTION: Stage I and II neuromodulator.

Stage I and II neuromodulator.

surgery, refractory urgency, urgency, frequency, neuromodulator, subcutaneous tissue, interstim,

The operation described is a surgical procedure involving the insertion of a neuromodulator to address bladder overactivity. Surgery inherently carries some risk, particularly due to the potential complications such as infection, bleeding, and the risk of anesthesia-related issues mentioned in the data. However, the patient's situation primarily involves improving quality of life by managing symptoms that are not life-threatening. The stakes are elevated due to the invasive nature of the procedure and the potential impact on the patient’s quality of life, but as it is not a matter of life and death, and the patient is stable post-operation, it is not at the highest level of stakes.


Medical Specialty: Surgery
Sample Name: Nephrectomy

PREOPERATIVE DIAGNOSIS: , Left renal mass, left renal bleed.,POSTOPERATIVE DIAGNOSIS:  ,Left renal mass, left renal bleed.,PROCEDURE PERFORMED: , Left laparoscopic hand-assisted nephrectomy.,ANESTHESIA:,  General endotracheal.,EBL: , 100 mL.,The patient had a triple-lumen catheter A-line placed.,BRIEF HISTORY:,  The patient is a 54-year-old female with history of diabetic nephropathy, diabetes, hypertension, left BKA, who presented with abdominal pain with left renal bleed.  The patient was found to have a complex mass in the upper pole and the lower pole of the kidney.  MRI and CAT scan showed questionable renal mass, which could be malignant.  Initial plan was to let the patient stabilize for 2 weeks and perform the nephrectomy.  At this point, the patient was unable to go home.  The patient continually complained of pain.  The patient required about 3 to 4 units of blood transfusions prior.  The patient initially came in with hemoglobin less than 5.  The hemoglobin prior to surgery was 10.,Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, respiratory failure, morbidity and mortality of the procedure due to her low ejection fraction were discussed.  Cardiac clearance was obtained.  The patient was high risk, family and the patient knew about the risk.  The recommendation from the pulmonologist, cardiologist, and medical team was to get the kidney out at this point because the patient and the family stated that they would not do well at home without any intervention.  The patient and family understood all the risks and benefits in order to proceed with the surgery.,DETAILS OF THE PROCEDURE:,  The patient was brought to the OR.  Anesthesia was applied.  The patient had A-line triple-lumen catheter.  The patient was placed in left side up, right side down oblique position.  All the pressure points were well padded.  The right fistula was carefully padded completely around it.  Axilla was protected.  The fistula was checked throughout the procedure to ensure that it was stable.  The arms, ankles, knees, and joints were all padded with foam.  The patient was taped to the table using 2-inch wide tape.  OG and a Foley catheter were in place.  A supraumbilical incision was made about 6 cm in size and incision was carried through the subcutaneous tissue and through the fascia and peritoneum was entered sharply.  There were some adhesions where the omentum was into the umbilical hernia, which was completely stuck.  The omentum was released out of that just so we could obtain pneumoperitoneum.  Pneumoperitoneum was obtained after using GelPort.  Two 12-mm ports were placed in the left anterior axillary line, and mid clavicular line.  The colon was reflected medially.  Kidney was dissected laterally behind and inferiorly.  There was large hematoma visualized with significant amount of old blood, which was irrigated out.  Dissection was carried superiorly and the spleen was reflected medially.  The spleen and colon were all intact at the end of the procedure.  They were stable all throughout.  Using endovascular GIA stapler, all the medial and lateral dissection was carried through the stapler to ensure that the patient had minimal bleeding due to low cardiac reserve.  Hemostasis was obtained.  The renal vein and the renal artery were stapled and there was excellent hemostasis.,The dissection was carried lateral to the adrenal and medial to the right kidney.  The adrenal was preserved.  The entire kidney was removed through the hand port.  Irrigation was performed.  There was excellent hemostasis at the end of the nephrectomy.  Fibrin glue and Surgicel were applied just in case the patient had delayed DIC.  The colon was placed back and 12-mm ports were closed under direct palpation using 0 Vicryl.  The fascia was closed using loop #1 PDS in a running fashion and was tied in the middle.  Please note that prior to the fascial closure, the peritoneum was closed using 0 Vicryl in running fashion.  The subcuticular tissue was brought together using 4-0 Vicryl.  The skin was closed using 4-0 Monocryl.  Dermabond was applied.  The patient was brought to the recovery in a stable condition.
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DESCRIPTION: Left laparoscopic hand-assisted nephrectomy.

surgery, laparoscopic, nephrectomy, laparoscopic hand assisted nephrectomy, triple lumen catheter, lumen catheter, running fashion, renal mass, renal bleed, dissection, hemostasis, kidney, renal

The details provided describe a surgical procedure, specifically a left laparoscopic hand-assisted nephrectomy, performed on a patient with significant medical risks including a suspected malignant renal mass, a history of diabetic nephropathy, hypertension, and low hemoglobin levels requiring blood transfusions. The procedure involves general anesthesia and carries risks such as bleeding, infection, and potential respiratory or cardiac complications, especially given the patient's low ejection fraction. The situation is high-stakes due to the potential for severe complications and the importance of the surgery for the patient's health outcome. Given the complexity and significance of the procedure, alongside the detailed risk evaluation explained, this scenario is assigned a high-stakes rating.


Medical Specialty: Surgery
Sample Name: Needle Localized Excision - Breast Neoplasm

PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED:  ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS:  ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast.  After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity.  This too was excised.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room, placed in supine position in the operating table.  Intravenous sedation was administered by the Anesthesia Department.  The Kopans wire was trimmed to an appropriate length.  The patient was sterilely prepped and draped in the usual manner.  Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision.  A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire.  The wire was stabilized and brought to protrude through the incision.  Skin flaps were then generated with electrocautery.  A generous core tissue was grasped with Allis forceps and excised with electrocautery.  Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short.  The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along.  The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.,The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm.  On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen.  Hemostasis was obtained with electrocautery.  Good hemostasis was obtained.  The incision was closed in two layers.  The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl.  The second layer consisted of Steri-Strips on the epidermis.  A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied.  The patient tolerated the surgery well.
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DESCRIPTION: Nonpalpable neoplasm, right breast.  Needle localized wide excision of nonpalpable neoplasm, right breast.

surgery, neoplasm, needle localized wide excision, needle localized, nonpalpable neoplasm, needle, incision, electrocautery, excision, breast

This situation involves a surgical procedure for the excision of a breast neoplasm, which is a significant medical procedure due to the potential for cancer. The stakes are moderate to high as it deals with the removal of potentially malignant tissue, which could have serious health implications for the patient if not removed successfully. It also involves anesthesia and the need for careful surgical technique to avoid complications. The final diagnosis is deferred for pathology, indicating the potential cancerous nature of the tumor, adding to the stakes. However, the report indicates that the procedure was performed without complications, which somewhat moderates the immediacy of life-threatening outcomes.


Medical Specialty: Surgery
Sample Name: Myringotomy/Tube Insertion - 2

PREOPERATIVE DIAGNOSES:  ,Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,POSTOPERATIVE DIAGNOSES: , Tympanic membrane atelectasis and chronic eustachian tube dysfunction.,OPERATIVE PROCEDURE: , Bilateral myringotomies with insertion of Santa Barbara T-tube.,ANESTHESIA: , General mask.,FINDINGS:,  The patient is an 8-year-old white female with chronic eustachian tube dysfunction and TM atelectasis, was taken to the operating room for tubes.  At the time of surgery, she has had an extruding right Santa Barbara T-tube and severe left TM atelectasis with retraction.  There was a scant amount of fluid in both middle ear clefts.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed in supine position, and general mask anesthesia was established.  The right ear was draped in normal sterile fashion.  Cerumen was removed from the external canal.  The extruding Santa Barbara T-tube was identified and atraumatically removed.  A fresh Santa Barbara T-tube was atraumatically inserted and Ciloxan drops applied.,The attention was then directed to the left side where severe TM atelectasis was identified.  With a mask anesthetic, the eardrum elevated.  A radial incision was made in the inferior aspect of the tympanic membrane and middle ear fluid aspirated.  A Santa Barbara T-tube was then inserted without difficulty and 5 drops Ciloxan solution applied.  Anesthesia was then reversed and the patient taken to recovery room in satisfactory condition.
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DESCRIPTION: Bilateral myringotomies with insertion of Santa Barbara T-tube.

surgery, tympanic membrane, cerumen, ciloxan, santa barbara t-tube, tm atelectasis, atelectasis, eardrum, eustachian tube, eustachian tube dysfunction, middle ear, middle ear fluid, myringotomies, atelectasis and chronic eustachian, santa barbara t tube, myringotomies with insertion, chronic eustachian tube, barbara t tube, santa barbara, insertion, tube, tympanic

The procedure in question is a myringotomy with tube insertion, typically considered a routine and common surgical intervention for addressing recurrent ear infections or eustachian tube dysfunction, particularly in children. While any surgery under general anesthesia carries inherent risks, myringotomy with tube insertion is generally not high-stakes compared to more complex surgical procedures. The parents or guardians of the child must be informed and consent obtained, adding to the significance, but overall, it is not life-threatening or significantly complex. It is a standard procedure expected to alleviate the symptoms and has been conducted numerous times safely.


Medical Specialty: Surgery
Sample Name: Myringotomy/Tube Insertion - 1

PREOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,POSTOPERATIVE DIAGNOSIS: , Bilateral chronic serous otitis media.,OPERATION PERFORMED:,1.  Bilateral myringotomies.,2.  Insertion of Shepard grommet draining tubes.,ANESTHESIA: , General, by mask.,ESTIMATED BLOOD LOSS: , Less than 1 mL.,COMPLICATIONS:,  None.,FINDINGS:  ,The patient had a long history of persistent recurrent infections and was placed on antibiotics for the same.  At this point in time, he had a small amount of thick mucoid material in both middle ear spaces with middle ear mucosa somewhat inflamed, but no active acute infection at this point in time.,PROCEDURE:,  With the patient under adequate general anesthesia with the mask delivery of anesthesia, he had his ear canals cleaned utilizing an operating microscope and all foul cerumen had been removed from both sides.  Bilateral inferior radial myringotomies were performed, first on the right and then on the left.  Middle ear spaces were suctioned of small amount of thick mucoid material on both sides and then Shepard grommet draining tubes were inserted on either side.  Floxin drops were then instilled bilaterally to decrease any clotting within the tubes, and then cotton ball was placed in the external meatus bilaterally.  At this point, the patient was awakened and returned to the recovery room, satisfactory, with no difficulty encountered.
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DESCRIPTION: Bilateral myringotomies and insertion of Shepard grommet draining tubes.

surgery, serous otitis media, floxin drops, shepard grommet, cerumen, cotton ball, middle ear, mucoid, myringotomies, tubes, shepard grommet draining tubes, serous otitis, shepard, grommet, insertion

The situation describes a surgical procedure for chronic otitis media which is a relatively common issue and not considered highly risky. The procedure, myringotomy with tube insertion, is routine and performed under general anesthesia, with minimal blood loss and no complications reported. This indicates a low-stakes scenario typical for such procedures. Given these factors, the stakes are relatively low for this surgical intervention compared to more complex or risky surgeries.


Medical Specialty: Surgery
Sample Name: Myringotomy/Tube Insertion - 3

PREOPERATIVE DIAGNOSES: ,1.  Chronic eustachian tube dysfunction.,2.  Retained right pressure equalization tube.,3.  Retracted left tympanic membrane.,4.  Dizziness.,POSTOPERATIVE DIAGNOSES:,1.  Chronic eustachian tube dysfunction.,2.  Retained right pressure equalization tube.,3.  Retracted left tympanic membrane.,4.  Dizziness.,PROCEDURE:,1.  Removal of the old right pressure equalizing tube with placement of a tube.  Tube used was Santa Barbara.,2.  Myringotomy with placement of a left pressure equalizing tube.  The tube used was Santa Barbara.,ANESTHESIA:,  General.,INDICATION: , This is a 98-year-old female whom I have known for several years.  She has a marginal hearing.  With the additional conductive loss secondary to the retraction of the tympanic membrane, her hearing aid and function deteriorated significantly.  So, we have kept sets of tubes in her ears at all times.  The major problem is that she has got small ear canals and a very sensitive external auditory canal; therefore it cannot tolerate even the wax cleaning in the clinic awake.,The patient was seen in the OR and tubes were placed.  There were no significant findings.,PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, she was brought to the neurosensory OR, placed under general anesthesia.  Mask airway was used.  IV had already been started.,On the right side, we removed the old tube and then cleaned the cerumen and found that it was larger than the side of the tube in perfection or perforation in tympanic membrane in the anterior inferior quadrant.  In the same area, a small Santa Barbara tube was placed.  This T-tube was cut to 80% of its original length for comfort and then positioned to point straight out and treated.  Three drops of ciprofloxacin eyedrops was placed in the ear canal.,On the left side, the tympanic membrane adhered and it was retracted and has some myringosclerosis.  Anterior, inferior incision was made.  Tympanic membrane bounced back to neutral position.  A Santa Barbara tube was cut to the 80% of the original length and placed in the hole.  Ciprofloxacin drops were placed in the ear.  Procedure completed.,ESTIMATED BLOOD LOSS: , None.,COMPLICATION: , None.,SPECIMEN:,  None.,DISPOSITION:,  To PACU in a stable condition.
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DESCRIPTION: Removal of the old right pressure equalizing tube.  Myringotomy with placement of a left pressure equalizing tube.

The described situation is a routine surgical procedure performed on an elderly patient to address chronic ear conditions, including eustachian tube dysfunction and retracted tympanic membrane. While surgery always carries some risk, this particular procedure (myringotomy and tube insertion) is common, and the stakes are relatively low for surgical standards. The outcome was stable with no complications or blood loss reported, and the patient was safely transferred to the post-anesthesia care unit. The stakes could be considered moderate primarily due to the patient's age and existing health condition, but not particularly high given the routine nature of the procedure and absence of complications.


Medical Specialty: Surgery
Sample Name: Mumford Procedure & Acromioplasty

PREOPERATIVE DIAGNOSES:,1.  Partial rotator cuff tear with impingement syndrome.,2.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.,POSTOPERATIVE DIAGNOSES:,1.  Partial rotator cuff tear with impingement syndrome.,2.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic rotator cuff debridement.,2.  Anterior acromioplasty.,3.  Mumford procedure left shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operative Suite, Room #1 at ABCD General Hospital.  This was done in a modified beach chair position with interscalene and subsequent general anesthetic.,HISTORY AND GROSS FINDINGS: , This is a 38-year-old morbidly obese white male suffering increasing pain in his left shoulder for a number of months prior to surgical intervention.  He was refractory to conservative outpatient therapy.  He had injection of his AC joint, which removed symptoms but was not long lasting.  After discussing the alternatives of the care as well as advantages and disadvantages, risks, complications, and expectations, he elected to undergo the above-stated procedure on this date.,Intraarticular viewing of the joint revealed a partial rotator cuff tear on the supraspinatus insertion on the joint side.  All else was noted to be intact including the glenohumeral joint, the long head of the biceps, and the labrum.  The remainder of the rotator cuff observed was noted to be intact.  Subacromially, the patient was noted to have increased synovitis.  Degenerative changes were noted upon observation of the distal clavicle.,OPERATIVE PROCEDURE: , The patient was laid supine upon the operative table.  After receiving interscalene block anesthetic by Anesthesia Department, the patient was placed in modified beach chair position.  He was prepped and draped in the usual sterile manner.  Portals were created posteriorly and anteriorly from outside to in.  A full and complete diagnostic intraarticular arthroscopy was carried out.  Debridement was carried out through a 3.5 meniscal shaver to the 4.2 meniscal shaver to the undersurface of the partial tear of the rotator cuff.  Retrospectively it was approximately 25% of the generalized thickness.,Attention was then turned to the subacromial region.  The scope was directed subacromially.  A portal was created laterally.  Ultimately, the patient needed a general anesthetic once we were closer to the distal clavicle.  Gross bursectomy was carried out with a 4.2 meniscal shaver.  #18-gauge spinal needles have been placed to outline the anterior acromion prior to this.,It was difficult to control the patient's blood pressure with systolics ranging anywhere from 165 or 170 up to 200.  Because of this and difficulties with his anesthetic, it was elected to change to an open procedure.  Thus, the patient was anesthetized safely and secured.  An oblique incision was carried at the cross Langer's line across the outlet of the shoulder through the skin and subcutaneous tissue.  Hemostasis was controlled via electrocoagulation.  Flaps were created.  Anterior deltoid was reflected inferiorly.  Anterior acromioplasty was carried out with a saw then a Micro-Aire and then a beaver-tail rasp.  An excellent decompression was present.  CA ligament had been previously resected.  We then took the incision over the distal clavicle.  The end of the distal clavicle approximately 12 mm to 14 mm was isolated and removed with the Micro-Aire saw.  The beaver-tail rasp was utilized to smooth off the edges.  Pain buster catheter was placed deep to closure of the AC capsule and then to the deltoid with interrupted #1 Vicryl.  Transosseous sutures were placed across the acromion and the deltoid was elevated and closed with the same.  A superficial running #2-0 Vicryl suture was utilized for deltoid closure distally.  Interrupted #2-0 Vicryl was utilized to subcutaneous fat closure, running #4-0 subcuticular stitch for skin closure and Adaptic, 4x4s, ABDs, and Elastoplast tape placed for compression dressing.  0.25% Marcaine was flooded into the joint prior to the skin closure.  Pain buster catheter was hooked up.  The patient's arm was placed in arm sling.  He was safely transferred to the PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.
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DESCRIPTION: Arthroscopy with arthroscopic rotator cuff debridement, anterior acromioplasty, and Mumford procedure left shoulder.  Partial rotator cuff tear with impingement syndrome.  Degenerative osteoarthritis of acromioclavicular joint, left shoulder, rule out slap lesion.

surgery, slap lesion, acromioclavicular joint, impingement syndrome, mumford procedure, acromioplasty, arthroscopy, arthroscopic, arthroscopic rotator cuff debridement, anterior acromioplasty, rotator cuff tear, arthroscopic rotator, meniscal shaver, cuff tear, rotator cuff, debridement, osteoarthritis, acromioclavicular, clavicle, deltoid, rotator, cuff, shoulder, joint

The situation involves a surgical procedure on a shoulder, specifically addressing complications such as a partial rotator cuff tear, impingement syndrome, and degenerative osteoarthritis, which required detailed surgical intervention. While surgeries inherently carry risk, this particular procedure does not seem to involve life-threatening conditions. However, it is still significant due to the complexity of shoulder surgeries and the necessity for skilled execution for optimal outcomes. The stakes are moderate because the success of the surgery could affect the patient's quality of life, mobility, pain levels, and recovery process.


Medical Specialty: Surgery
Sample Name: Mini Laparotomy & Radical Retropubic Prostatectomy

PREOPERATIVE DIAGNOSIS:,  Adenocarcinoma of the prostate.,POSTOPERATIVE DIAGNOSIS:,  Adenocarcinoma of the prostate.,TITLE OF OPERATION:,  Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap.,ANESTHESIA: , General by intubation.,Informed consent was obtained for the procedure.  The patient understands the treatment options and wishes to proceed.  He accepts the risks to include bleeding requiring transfusion, infection, sepsis, incontinence, impotence, bladder neck constricture, heart attack, stroke, pulmonary emboli, phlebitis, injury to the bladder, rectum, or ureter, etcetera.,OPERATIVE PROCEDURE IN DETAIL: , The patient was taken to the Operating Room and placed in the supine position, prepped with Betadine solution and draped in the usual sterile fashion.  A 20- French Foley catheter was inserted into the penis and into the bladder and placed to dependent drainage.  The table was then placed in minimal flexed position.  A midline skin incision was then made from the umbilicus to the symphysis pubis.  It was carried down to the anterior rectus fascia into the pelvis proper.  Both obturator fossae were exposed.  Standard bilateral pelvic lymph node dissections were carried out.  The left side was approached first by myself.  The limits of my dissection were from the external iliac vein laterally to the obturator nerve medially, and from the bifurcation of the common iliac vein proximally to Cooper's ligament distally.  Meticulous lymphostasis and hemostasis was obtained using hemoclips and 2-0 silk ligatures.  The obturator nerve was visualized throughout and was not injured.  The right side was carried out by my assistant under my direct and constant supervision.  Again, the obturator nerve was visualized throughout and it was not injured.  Both packets were sent to Pathology where no evidence of carcinoma was found.,My attention was then directed to the prostate itself.  The  endopelvic fascia was opened bilaterally.  Using gentle dissection with a Kitner, I swept the levator muscles off the prostate and exposed the apical portion of the prostate.  A back bleeding control suture of 0 Vicryl was placed at the mid-prostate level.  A sternal wire was then placed behind the dorsal vein complex which was sharply transected.  The proximal and distal portions of this complex were then oversewn with 2-0 Vicryl in a running fashion.  When I was satisfied that hemostasis was complete, my attention was then turned to the neurovascular bundles.,The urethra was then sharply transected and six sutures of 2-0 Monocryl placed at the 1, 3, 5, 7, 9 and 11 o'clock positions.  The prostate was then lifted retrograde in the field and was swept from the anterior surface of the rectum and the posterior layer of Denonvilliers' fascia was incised distally, swept off the rectum and incorporated with the prostate specimen.  The lateral pedicles over the seminal vesicles were then mobilized, hemoclipped and transected.  The seminal vesicles themselves were then mobilized and hemostasis obtained using hemoclips.  Ampullae of the vas were mobilized, hemoclipped and transected.  The bladder neck was then developed using careful blunt and sharp dissection.  The prostate was then transected at the level of the bladder neck and sent for permanent specimen.  The bladder neck was reevaluated and the ureteral orifices were found to be placed well back from the edge.  The bladder neck was reconstructed in standard fashion.  It was closed using a running 2-0 Vicryl.  The mucosa was everted over the edge of the bladder neck using interrupted 3-0 Vicryl suture.  At the end of this portion of the case, the new bladder neck had a stoma-like appearance and would accommodate easily my small finger.  The field was then re-evaluated for hemostasis which was further obtained using hemoclips, Bovie apparatus and 3-0 chromic ligatures.  When I was satisfied that hemostasis was complete, the aforementioned Monocryl sutures were then placed at the corresponding positions in the bladder neck.  A new 20-French Foley catheter was brought in through the urethra into the bladder.  A safety suture of 0 Prolene was brought through the end of this and out through a separate stab wound in the bladder and through the left lateral quadrant.  The table was taken out of flexion and the bladder was then brought into approximation to the urethra and the Monocryl sutures were ligated.  The bladder was then copiously irrigated with sterile water and the anastomosis was found to be watertight.  The pelvis was also copiously irrigated with 2 liters of sterile water.  A 10-French Jackson-Pratt drain was placed in the pelvis and brought out through the right lower quadrant and sutured in place with a 2-0 silk ligature.,The wound was then closed in layers.  The muscle was closed with a running 0 chromic, the fascia with a running 1-0 Vicryl, the subcutaneous tissue with 3-0 plain, and the skin with a running 4-0 Vicryl subcuticular.  Steri-Strips were applied and a sterile dressing.,The patient was taken to the Recovery Room in good condition.  There were no complications.  Sponge and instrument counts were reported correct at the end of the case.
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DESCRIPTION: Mini-laparotomy radical retropubic prostatectomy with bilateral pelvic lymph node dissection with Cavermap.  Adenocarcinoma of the prostate.

surgery, mini-laparotomy, radical retropubic prostatectomy, pelvic lymph, pelvic lymph node dissection, cavermap, mini laparotomy, prostatectomy, bladder, intubation, adenocarcinoma, endopelvic, hemostasis, neck

This medical procedure involves a surgical operation for the removal of the prostate gland and nearby lymph nodes to treat prostate cancer, which is a serious medical condition. The risk factors associated with the surgery—such as bleeding, infection, sepsis, incontinence, impotence, and potential injury to nearby organs—indicate a high-stakes environment. The detailed post-operative report suggests a thorough and complex surgical process. Additionally, the operation involves the use of general anesthesia and a variety of surgical techniques to ensure the cancer is thoroughly removed, highlighting the procedure's complexity and necessity. Given these factors, the stakes are high due to the potential risks and the nature of cancer surgery.


Medical Specialty: Surgery
Sample Name: Mesothelioma - Port-A-Cath Insertion

PREOPERATIVE DIAGNOSIS: , Mesothelioma.,POSTOPERATIVE DIAGNOSIS:,  Mesothelioma.,OPERATIVE PROCEDURE: , Placement of Port-A-Cath, left subclavian vein with fluoroscopy.,ASSISTANT:,  None.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , The patient is a 74-year-old gentleman who underwent right thoracoscopy and was found to have biopsy-proven mesothelioma.  He was brought to the operating room now for Port-A-Cath placement for chemotherapy.  After informed consent was obtained with the patient, the patient was taken to the operating room, placed in supine position.  After induction of general endotracheal anesthesia, routine prep and drape of the left chest, left subclavian vein was cannulated with #18 gauze needle, and guidewire was inserted.  Needle was removed.  Small incision was made large enough to harbor the port.  Dilator and introducers were then placed over the guidewire.  Guidewire and dilator were removed, and a Port-A-Cath was introduced in the subclavian vein through the introducers.  Introducers were peeled away without difficulty.  He measured with fluoroscopy and cut to the appropriate length.  The tip of the catheter was noted to be at the junction of the superior vena cava and right atrium.  It was then connected to the hub of the port.  Port was then aspirated for patency and flushed with heparinized saline and summoned to the chest wall.  Wounds were then closed.  Needle count, sponge count, and instrument counts were all correct.
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DESCRIPTION: Biopsy-proven mesothelioma - Placement of Port-A-Cath, left subclavian vein with fluoroscopy.

surgery, biopsy-proven mesothelioma, placement of port-a-cath, port a cath, subclavian vein, fluoroscopy, mesothelioma,

Port-A-Cath insertion is generally a routine and low-risk procedure, commonly performed to facilitate chemotherapy treatments in patients with cancer, such as mesothelioma. The description provided indicates a standard procedure without any complications, suggesting it was performed as expected. Additionally, such procedures are typically not critical or life-threatening in the moment, leading to a lower high-stakes assessment. However, the patient's underlying condition, mesothelioma, is severe, which slightly raises the stakes. Overall, the focus here is on the procedure itself rather than the disease management.


Medical Specialty: Surgery
Sample Name: MediPort Placement

PREOPERATIVE DIAGNOSIS:,  Rhabdomyosarcoma of the left orbit.,POSTOPERATIVE DIAGNOSIS:,  Rhabdomyosarcoma of the left orbit.,PROCEDURE: , Left subclavian vein MediPort placement (7.5-French single-lumen).,INDICATIONS FOR PROCEDURE: , This patient is a 16-year-old girl, with newly diagnosed rhabdomyosarcoma of the left orbit.  The patient is being taken to the operating room for MediPort placement.  She needs chemotherapy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's neck, chest, and shoulders were prepped and draped in usual sterile fashion.  An incision was made on the left shoulder area.  The left subclavian vein was cannulated.  The wire was passed, which was in good position under fluoro, using Seldinger Technique.  Near wire incision site made a pocket above the fascia and sutured in a size 7.5-French single-lumen MediPort into the pocket in 4 places using 3-0 Nurolon.  I then sized the catheter under fluoro and placed introducer and dilator over the wire, removed the wire and dilator, placed the catheter through the introducer and removed the introducer.  The line tip was in good position under fluoro.  It withdrew and flushed well.  I then closed the incision using 4-0 Vicryl, 5-0 Monocryl for the skin, and dressed with Steri-Strips.  Accessed the ports with a 1-inch 20-gauge Huber needle, and it withdrew and flushed well with final heparin flush.  We secured this with Tegaderm.  The patient is then to undergo bilateral bone marrow biopsy and lumbar puncture by Oncology.
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DESCRIPTION: Rhabdomyosarcoma of the left orbit.  Left subclavian vein MediPort placement.  Needs chemotherapy.

surgery, rhabdomyosarcoma of the left orbit, single lumen, subclavian vein, mediport placement, chemotherapy, rhabdomyosarcoma, mediport,

The medical scenario involves the placement of a MediPort for a 16-year-old patient diagnosed with rhabdomyosarcoma in the left orbit. MediPort placement is a critical procedure in this context as it is essential for the administration of chemotherapy, which is pivotal in the treatment of cancer. The procedure, while routine in surgical practice, is high-stakes because it directly affects the patient's ability to receive timely chemotherapy, which is crucial for ameliorating the disease and improving the chances of recovery. Furthermore, the operation involves general anesthesia, which adds a layer of risk, particularly in pediatric patients.


Medical Specialty: Surgery
Sample Name: Mesothelioma - Thoracotomy & Lobectomy

PREOPERATIVE DIAGNOSIS:,  Right mesothelioma.,POSTOPERATIVE DIAGNOSIS: , Right lung mass invading diaphragm and liver.,FINDINGS: , Right lower lobe lung mass invading diaphragm and liver.,PROCEDURES:,1.  Right thoracotomy.,2.  Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,SPECIMENS: , Right lower lobectomy with en bloc resection of diaphragm and portion of liver.,BLOOD LOSS: , 600 mL.,FLUIDS: , Crystalloid 2.7 L and 1 unit packed red blood cells.,ANESTHESIA: , Double-lumen endotracheal tube.,CONDITION:,  Stable, extubated, to PACU.,PROCEDURE IN DETAIL:,  Briefly, this is a gentleman who was diagnosed with a B-cell lymphoma and then subsequently on workup noted to have a right-sided mass seeming to arise from the right diaphragm.  He was presented at Tumor Board where it was thought upon review that day that he had a right nodular malignant mesothelioma.  Thus, he was offered a right thoracotomy and excision of mass with possible reconstruction of the diaphragm.  He was explained the risks, benefits, and alternatives to this procedure.  He wished to proceed, so he was brought to the operating room.,An epidural catheter was placed.  He was put in a supine position where SCDs and Foley catheter were placed.  He was put under general endotracheal anesthesia with a double-lumen endotracheal tube.  He was given preoperative antibiotics, then he was placed in the left decubitus position, and the area was prepped and draped in the usual fashion.,A low thoracotomy in the 7th interspace was made using the skin knife and then Bovie cautery onto the middle of the rib and then with the Alexander instrument, the chest was entered.  Upon entering the chest, the chest wall retractor was inserted and the cavity inspected.  It appeared that the mass actually arose more from the right lower lobe and was involving the diaphragm.  He also had some marked lymphadenopathy.  With these findings, which were thought at that time to be more consistent with a bronchogenic carcinoma, we proceeded with the intent to perform a right lower lobectomy and en bloc diaphragmatic resection.  Thus, we mobilized the inferior pulmonary ligament and made our way around the hilum anteriorly and posteriorly.  We also worked to open the fissure and tried to identify the arteries going to the superior portion of the right lower lobe and basilar arteries as well as the artery going to the right middle lobe.  The posterior portion of the fissure ultimately divided with the single firing of a GIA stapler with a blue load and with the final portion being divided between 2-0 ties.  Once we had clearly delineated the arterial anatomy, we were able to pass a right angle around the artery going to the superior segment.  This was ligated in continuity with an additional stick tie in the proximal portion of 3-0 silk.  This was divided thus revealing a branched artery going to the basilar portion of the right lower lobe.  This was also ligated in continuity and actually doubly ligated.  Care was taken to preserve the artery to the right and middle lobe.,We then turned our attention once again to the hilum to dissect out the inferior pulmonary vein.  The superior pulmonary vein was visualized as well.  The right angle was passed around the inferior pulmonary vein, and this was ligated in continuity with 2-0 silk and a 3-0 stick tie.  Upon division of this portion, the specimen site had some bleeding, which was eventually controlled using several 3-0 silk sutures.  The bronchial anatomy was defined.  Next, we identified the bronchus going to the right lower lobe as well as the right middle lobe.  A TA-30 4.8 stapler was then closed.  The lung insufflated.  The right middle lobe and right upper lobe were noted to inflate well.  The stapler was fired, and the bronchus was cut with a 10-blade.,We then turned our attention to the diaphragm.  There was a small portion of the diaphragm of approximately 4 to 5 cm has involved with tumor, and we bovied around this with at least 1 cm margin.  Upon going through the diaphragm, it became clear that the tumor was also involving the dome of the liver, so after going around the diaphragm in its entirety, we proceeded to wedge out the portion of liver that was involved.  It seemed that it would be a mucoid shallow portion.  The Bovie was set to high cautery.  The capsule was entered, and then using Bovie cautery, we wedged out the remaining portion of the tumor with a margin of normal liver.  It did leave quite a shallow defect in the liver.  Hemostasis was achieved with Bovie cautery and gentle pressure.  The specimen was then taken off the table and sent to Pathology for permanent.  The area was inspected for hemostasis.  A 10-flat JP was placed in the abdomen at the portion of the wedge resection, and 0 Prolene was used to close the diaphragmatic defect, which was under very little tension.  A single 32 straight chest tube was also placed.  The lung was seen to expand.  We also noted that the incomplete fissure between the middle and upper lobes would prevent torsion of the right middle lobe.  Hemostasis was observed at the end of the case.  The chest tube was irrigated with sterile water, and there was no air leak observed from the bronchial stump.  The chest was then closed with Vicryl at the level of the intercostal muscles, staying above the ribs.  The 2-0 Vicryl was used for the latissimus dorsi layer and the subcutaneous layer, and 4-0 Monocryl was used to close the skin.  The patient was then brought to supine position, extubated, and brought to the recovery room in stable condition.,Dr. X was present for the entirety of the procedure, which was a right thoracotomy, right lower lobectomy with en bloc resection of diaphragm and a portion of liver.
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DESCRIPTION: Right nodular malignant mesothelioma.

Right nodular malignant mesothelioma.

surgery, double lumen endotracheal, en bloc resection, malignant mesothelioma, lung mass, endotracheal tube, chest tube, bovie cautery, en bloc, diaphragm, lobectomy, mesothelioma, thoracotomy,

This surgical case involves a right thoracotomy and lobectomy with significant procedures including the resection of parts of the diaphragm and liver due to malignant mesothelioma. The stakes are high in this situation because it involves complex surgery with potential for significant blood loss and impact on essential organs like the lungs, diaphragm, and liver. The patient's recovery and health depend on the success of the surgery and subsequent management. The case is further complicated by prior lymphoma diagnosis. Such surgeries are inherently high-stakes due to the potential for serious complications and the critical nature of the organs involved.


Medical Specialty: Surgery
Sample Name: Metastatic Lymphadenopathy & Thyroid Tissue Removal

TITLE OF OPERATION: , Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck.  Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side.  Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.,INDICATION FOR SURGERY: , The patient is a 37-year-old gentleman well known to me with a history of medullary thyroid cancer sporadic in nature having undergone surgery in 04/07 with final pathology revealing extrafocal, extrathyroidal extension, and extranodal extension in the soft tissues of his medullary thyroid cancer.  The patient had been followed for a period of time and underwent rapid development of a left and right infraclavicular lymphadenopathy and central neck lymphadenopathy also with imaging studies to suggest superior mediastinal disease.  Fine-needle aspiration of the left and right infraclavicular lymph nodes revealed persistent medullary thyroid cancer.  Risks, benefits, and alternatives of the procedures discussed with in detail and the patient elected to proceed with surgery as discussed.  The risks included, but not limited to anesthesia, bleeding, infection, injury to nerve, lip, tongue, shoulder, weakness, tongue numbness, droopy eyelid, tumor comes back, need for additional treatment, diaphragm weakness, pneumothorax, need for chest tube, others.  The patient understood all these issues and did wish to proceed.,PROCEDURE DETAIL:  ,After identifying the patient, the patient was placed supine on the operating room table.  The patient was intubated with a number 7 nerve integrity monitor system endotracheal tube.  The eyes were protected with Tegaderm.  The patient was rotated to 180 degrees towards the operating surgeon.  The Foley catheter was placed into the bladder with good return of urine.  Attention then was turned to securing the nerve integrity monitor system endotracheal tube and this was confirmed to be working adequately.  A previous apron incision was incorporated and advanced over onto the right side to the mastoid tip.  The incision then was planned around the old scar to be excised.  A 1% lidocaine with 1 to 100,000 epinephrine was injected.  A shoulder roll was applied.  The incision was made, the apron flap was raised to the level of the mandible and mastoid tip bilaterally all the way down to the clavicle and sternal notch inferiorly.  Attention was then turned to performing the level 1 dissection on the left.  Subsequently the marginal mandibular nerve was identified over the facial notch of the mandible.  The facial artery and vein were individually ligated and marginal mandibular nerve traced superiorly and perifascial lymph nodes freed from the marginal mandibular nerve.  Level 1A lymph nodes of the submental region were dissected off the mylohyoid and digastric.  The submandibular gland was appreciated and retracted laterally.  The mylohyoid muscle appreciated.  The lingual nerve was appreciated and the submandibular ganglion was ligated.  The hypoglossal nerve was appreciated and protected and digastric tunnel was then made posteriorly and the lymph nodes posterior along the marginal mandibular nerve and into the parotid gland were then dissected and incorporated into the specimen for histopathologic analysis.  The marginal mandibular nerve stimulated at the completion of this portion of the procedure.  Attention was then turned to incising the fascia along the clavicle on the left side.  Dissection then ensued along the floor of the neck palpating a very large bulky lymph node before the neck was identified.  The brachial plexus and phrenic nerve were identified.  The internal jugular vein identified and the mass was freed from the floor of the neck with careful dissection and suture ligation of vessels.  Attention was then turned to the central neck.  The strap muscles were appreciated in the midline.  There was a large firm mass measuring approximately 3 cm that appeared to be superior to the strap musculature.  A careful dissection with incorporation of a portion of the sternal hyoid muscle in this area for a margin was then performed.  Attention was then turned to identify the carotid artery and the internal jugular vein on the left side.  This was traced inferiorly, internal jugular vein to the brachiocephalic vein.  Palpation deep to this area into the mediastinum and up against the trachea revealed a 1.5 cm lymph node mass.  Subsequently this was carefully dissected preserving the brachiocephalic vein and also the integrity of the trachea and the carotid artery and these lymph nodes were removed in full and sent for histopathologic analysis.  Attention was then turned to the right neck dissection.  A posterior flap on the right was raised to the anterior border of the trapezius.  The accessory nerve was identified in the posterior triangle and traced superiorly and inferiorly.  Attention was then turned to identifying the submandibular gland.  A digastric tunnel was performed back to the sternocleidomastoid muscle.  The fascia overlying the sternocleidomastoid muscle on the right side was incised and the omohyoid muscle was appreciated.  The omohyoid muscle was retracted inferiorly.  Penrose drain was placed around the inferior aspect of the sternocleidomastoid muscle.  Subsequently the internal jugular vein was identified.  The external jugular vein ligated about 1 cm above the clavicle.  Palpation in this area and the infraclavicular region on the right revealed a firm irregular lymph node complex.  Dissection along the floor of the neck then was performed to allow for mobilization.  The transverse cervical artery and vein were individually ligated to allow full mobilization of this mass.  Tissue between the phrenic nerve and the internal jugular vein was clamped and suture ligated.  The tissue was then brought posteriorly from the trapezius muscle to the internal jugular vein and traced superiorly.  The cervical rootlets were transected after the contribution, so the phrenic nerve all the way superiorly to the skull base.  The hypoglossal nerve was identified and protected as the lymph node packet was dissected over the internal jugular vein.  The wound was copiously irrigated.  Valsalva maneuver was given.  No bleeding points identified.  The wound was then prepared for closure.  Two number 10 JPs were placed through the left supraclavicular fossa in the previous drain sites and secured with 3-0 nylon.  The wound was closed  with interrupted 3-0 Vicryl for platysma, subsequently a 4-0 running Biosyn for the skin, and Indermil.  The patient tolerated the procedure well, was extubated on the operating room table, and sent to the postanesthesia care unit in good condition.
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DESCRIPTION: Central neck reoperation with removal of residual metastatic lymphadenopathy and thyroid tissue in the central neck.   Left reoperative neck dissection levels 1 and the infraclavicular fossa on the left side.  Right levels 2 through 5 neck dissection and superior mediastinal dissection of lymph nodes and pretracheal dissection of lymph nodes in a previously operative field.

surgery, lymphadenopathy, thyroid, infraclavicular, fossa, lymph nodes, dissection, pretracheal, internal jugular vein, infraclavicular lymphadenopathy, metastatic lymphadenopathy, mandibular nerve, vein, nodes, neck, nerve, muscle, jugularNOTE

The scenario involves a complex surgical procedure for a patient with medullary thyroid cancer, including removal of metastatic lymph nodes and thyroid tissue. The surgery entails significant risks such as potential injury to nerves and adjacent structures, infection, and bleeding. Given the delicate nature of the neck region, and the history of medullary thyroid cancer which has metastasized, the operation has high stakes. Moreover, any complications could significantly affect the patient's quality of life, and the surgery is crucial for managing the patient's cancer effectively.


Medical Specialty: Surgery
Sample Name: Mediastinal Mass Resection

PREOPERATIVE DIAGNOSIS:,  Posterior mediastinal mass with possible neural foraminal involvement.,POSTOPERATIVE DIAGNOSIS: , Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).,OPERATION PERFORMED:,  Left thoracotomy with resection of posterior mediastinal mass.,INDICATIONS FOR PROCEDURE:  ,The patient is a 23-year-old woman who recently presented with a posterior mediastinal mass and on CT and MRI there were some evidence of potential widening of one of the neural foramina.  For this reason, Dr. X and I agreed to operate on this patient together.  Please note that two surgeons were required for this case due to the complexity of it.  The indications and risks of the procedure were explained and the patient gave her informed consent.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating suite and placed in the supine position.  General endotracheal anesthesia was given with a double lumen tube.  The patient was positioned for a left thoracotomy.  All pressure points were carefully padded.  The patient was prepped and draped in usual sterile fashion.  A muscle sparing incision was created several centimeters anterior to the tip of the scapula.  The serratus and latissimus muscles were retracted.  The intercostal space was opened.  We then created a thoracoscopy port inferiorly through which we placed a camera for lighting and for visualization.  Through our small anterior thoracotomy and with the video-assisted scope placed inferiorly we had good visualization of the posterior mediastinum mass.  This was in the upper portion of the mediastinum just posterior to the subclavian artery and aorta.  The lung was deflated and allowed to retract anteriorly.  With a combination of blunt and sharp dissection and with attention paid to hemostasis, we were able to completely resect the posterior mediastinal mass.  We began by opening the tumor and taking a very wide large biopsy.  This was sent for frozen section, which revealed a benign nerve sheath tumor.  Then, using the occluder device Dr. X was able to _____ the inferior portions of the mass.  This left the external surface of the mass much more malleable and easier to retract.  Using a bipolar cautery and endoscopic scissors we were then able to completely resect it.  Once the tumor was resected, it was then sent for permanent sections.  The entire hemithorax was copiously irrigated and hemostasis was complete.  In order to prevent any lymph leak, we used 2 cc of Evicel and sprayed this directly on to the raw surface of the pleural space.  A single chest tube was inserted through our thoracoscopy port and tunneled up one interspace.  The wounds were then closed in multiple layers.  A #2 Vicryl was used to approximate the ribs.  The muscles of the chest wall were allowed to return to their normal anatomic position.  A 19 Blake was placed in the subcutaneous tissues.  Subcutaneous tissues and skin were closed with running absorbable sutures.  The patient was then rolled in the supine position where she was awakened from general endotracheal anesthesia and taken to the recovery room in stable condition.
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DESCRIPTION: Posterior mediastinal mass with possible neural foraminal involvement (benign nerve sheath tumor by frozen section).  Left thoracotomy with resection of posterior mediastinal mass.

surgery, posterior mediastinal mass, neural foraminal, nerve sheath tumor, frozen section, thoracotomy, mediastinal mass, foraminal, neural, sheath, mediastinal,

The surgical procedure described involves the resection of a posterior mediastinal mass, which is a significant and complex surgery due to the location of the mass and its proximity to critical structures like the subclavian artery and aorta. The involvement of two surgeons underscores the complexity and potential risks involved, including the potential impact on neural foraminal structures. Such surgeries carry a high risk of complications, including bleeding, nerve damage, and postoperative issues, making the situation high-stakes for the patient's health and safety. Additionally, the need for careful dissection, intraoperative decision-making, and the use of frozen section pathology indicates the critical nature of ensuring a benign pathology and complete resection.


Medical Specialty: Surgery
Sample Name: Mediastinal Exploration & Right Atrium Repair

PREOPERATIVE DIAGNOSES:,1.  Cardiac tamponade.,2.  Status post mitral valve repair.,POSTOPERATIVE DIAGNOSES:,1.  Cardiac tamponade.,2.  Status post mitral valve repair.,PROCEDURE PERFORMED: , Mediastinal exploration with repair of right atrium.,ANESTHESIA: , General endotracheal.,INDICATIONS: , The patient had undergone mitral valve repair about seven days ago.  He had epicardial pacing wires removed at the bedside.  Shortly afterwards, he began to feel lightheaded and became pale and diaphoretic.  He was immediately rushed to the operating room for cardiac tamponade following removal of epicardial pacing wires.  He was transported immediately and emergently and remained awake and alert throughout the time period inspite of hypotension with the systolic pressure in the 60s-70s.,DETAILS OF PROCEDURE:  ,The patient was taken emergently to the operating room and placed supine on the operating room table.  His chest was prepped and draped prior to induction under general anesthesia.  Incision was made through the previous median sternotomy chest incision.  Wires were removed in the usual manner and the sternum was retracted.  There were large amounts of dark blood filling the mediastinal chest cavity.  Large amounts of clot were also removed from the pericardial well and chest.  Systematic exploration of the mediastinum and pericardial well revealed bleeding from the right atrial appendix at the site of the previous cannulation.  This was repaired with two horizontal mattress pledgeted #5-0 Prolene sutures.  An additional #0 silk tie was also placed around the base of the atrial appendage for further hemostasis.  No other sites of bleeding were identified.  The mediastinum was then irrigated with copious amounts of antibiotic saline solution.  Two chest tubes were then placed including an angled chest tube into the pericardial well on the inferior border of the heart, as well as straight mediastinal chest tube.  The sternum was then reapproximated with stainless steel wires in the usual manner and the subcutaneous tissue was closed in multiple layers with running Vicryl sutures.  The skin was then closed with a running subcuticular stitch.  The patient was then taken to the Intensive Care Unit in a critical but stable condition.
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DESCRIPTION: The patient had undergone mitral valve repair about seven days ago.

surgery, mitral valve repair, exploration, median sternotomy chest incision, pericardial, mediastinal exploration, pacing wires, cardiac tamponade, chest tubes, mitral valve, valve repair, mediastinal, mitral, wires, atrium, repair,

The situation involves an emergency surgical procedure to address a cardiac tamponade, a life-threatening condition where fluid accumulates around the heart, hindering its ability to pump blood effectively. The patient developed this condition following a recent mitral valve repair and subsequent removal of epicardial pacing wires, which led to hypotension and necessitated immediate mediastinal exploration and repair of the right atrium. The urgency and complexity of the situation, alongside the direct threat to the patient's life, categorize it as a high-stakes scenario. Such surgeries require immediate intervention to prevent deterioration or fatality, denoting a critical medical emergency.


Medical Specialty: Surgery
Sample Name: Medial Branch Rhizotomy

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

surgery, lumbosacral, medial branch rhizotomy, medial branch nerves, rhizotomy, fluoroscopy,

Medial branch rhizotomy is an invasive surgical procedure with the purpose of alleviating chronic back pain through targeting nerve branches. Because it involves (a) the use of anesthesia, requiring monitoring for potential side effects, (b) fluoroscopy for precise needle placement, and (c) potential significant risks such as spinal cord injury and nerve damage, the procedure should be considered moderately high-stakes. Although there were no complications in this case, the level of precision required and the potential consequences of errors make it higher-stakes than non-invasive procedures.


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

Medical Specialty: Surgery
Sample Name: Meatotomy Template

OPERATIVE NOTE:  ,The patient was taken to the operating room and was placed in the supine position on the operating room table.  A general inhalation anesthetic was administered.  The patient was prepped and draped in the usual sterile fashion.  The urethral meatus was calibrated with a small mosquito hemostat and was gently dilated.  Next a midline ventral type incision was made opening the meatus.  This was done after clamping the tissue to control bleeding.  The meatus was opened for about 3 mm.  Next the meatus was calibrated and easily calibrated from 8 to 12 French with bougie sounds.  Next the mucosal edges were everted and reapproximated to the glans skin edges with approximately five interrupted 6-0 Vicryl sutures.  The meatus still calibrated between 10 and 12 French.  Antibiotic ointment was applied.  The procedure was terminated.  The patient was awakened and returned to the recovery room in stable condition.
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DESCRIPTION: An example/template for meatotomy.

An example/template for meatotomy.

surgery, urethral meatus, mosquito hemostat, meatus, mucosal edges, glans, meatotomyNOTE,: 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 note for a meatotomy, which is a urological procedure. While any surgical procedure carries risks such as infection, bleeding, and anesthesia-related complications, this specific description indicates a routine operation without immediate complications. Additionally, the document is labeled as a 'template,' implying its use for educational or documentation purposes rather than the description of an active, urgent surgical situation. Therefore, the stakes appear to be moderate due to the medical context but not extremely high since it describes a standard procedure without complications.


Medical Specialty: Surgery
Sample Name: Lumpectomy & Lymph Node Biopsy

PREOPERATIVE DIAGNOSIS,Left breast ductal carcinoma in situ.,POSTOPERATIVE DIAGNOSIS,Left breast ductal carcinoma in situ.,PROCEDURES PERFORMED,1.  Sentinel lymph node biopsy.,2.  Ultrasound-guided lumpectomy with intraoperative ultrasound.,ANESTHESIA,General LMA anesthesia.,ESTIMATED BLOOD LOSS,Minimum.,IV FLUIDS,Per anesthesia record.,COMPLICATIONS,None.,FINDINGS,Clip well localized within the specimen.,INDICATION,This is a 65-year-old female who presents with abnormal mammogram who underwent stereotactic biopsy at an outside facility, which showed atypical ductal hyperplasia with central necrosis.  On reviewing this pathology, it is mostly likely DCIS.  The risks and benefits of the procedure were explained to the patient who appeared to understand and agreed to proceed.  The patient desired MammoSite Radiation Therapy; therefore, the sentinel lymph node biopsy was incorporated into the procedure.,PROCEDURE IN DETAIL,The patient was taken to the operating room, placed in supine position, and general LMA anesthesia was administered.  She was prepped and draped in the usual sterile fashion.  Prior to the procedure, she underwent nuclear medicine injection with technetium-99 and methylene blue.  Incision was made of the area of great uptake and the axilla and taken through the subcutaneous tissue with electric Bovie cautery.  Two sentinel lymph nodes were identified, one was blue and hot and the other was just hot.  These were sent to Pathology for touch prep.  Adequate hemostasis was obtained.  The wound was packed and attention was turned to the left breast.  Ultrasound was used to identify the marker and the mass within the breast and create an adequate anterior skin flap.  An elliptical incision was made roughly at approximately the 3 o'clock position secondary to subcutaneous tissues with electric Bovie cautery.  The mass was dissected off the surrounding tissue using Bovie cautery down to the level of the pectoralis fascia, which was incorporated within the specimen.  The specimen was completely removed and marked **** double deep, and a mini C-arm was used to confirm this.  The marker was well localized within the center of the specimen.  The fascia was then elevated off of the pectoralis muscle and closed loosely with the interrupted 2-0 Vicryl sutures to create a nice spherical cavity for the MammoSite radiation catheter.  The wound was then closed with a deep layer of interrupted 3-0 Vicryl followed by 3-0 Vicryl subcuticular stitch and 4-0 running Monocryl.  The axillary wound was closed with interrupted 3-0 Vicryl and a running 4-0 Monocryl.  Steri-Strips were applied.  The patient was awakened and extubated in the OR and taken to PACU in stable condition.  All counts were reported as correct.  I was present for the entire procedure.
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DESCRIPTION: Sentinel lymph node biopsy.  Ultrasound-guided lumpectomy with intraoperative ultrasound.

surgery, carcinoma in situ, dcis, lma, mammosite radiation therapy, monocryl, pacu, sentinel, steri-strips, central necrosis, ductal carcinoma, ductal hyperplasia, lumpectomy, lymph node biopsy, node biopsy, stereotactic biopsy, sentinel lymph node biopsy, electric bovie, lymph node, sentinel lymph, intraoperative, anesthesia, lymph, biopsy, ultrasound

The procedure described, involving a lumpectomy and sentinel lymph node biopsy, is a surgical intervention for breast cancer. While it is a common procedure, it is still significant due to the diagnosis of ductal carcinoma in situ (DCIS), a form of breast cancer. Surgery always carries certain risks, including anesthesia, bleeding, and infection risks, despite the patient's stable condition and no complications reported. The stakes are moderately high due to the nature of surgery and the cancer diagnosis, affecting the patient's immediate and long-term health outcomes.


Medical Specialty: Surgery
Sample Name: Lumbar Puncture - 2

PROCEDURE PERFORMED:,  Lumbar puncture.,The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form.  Alternatives were explained.  They agreed to proceed with the lumbar puncture.  Permit was signed and is on the chart.  The indication was to rule out toxoplasmosis or any other CNS infection. ,DESCRIPTION: , The area was prepped and draped in a sterile fashion.  Lidocaine 1% of 5 mL was applied to the L3-L4 spinal space after the area had been prepped with Betadine three times.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.  The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.,COMPLICATIONS:,  None.  The patient was resting comfortably and tolerated the procedure well.,ESTIMATED BLOOD LOSS: , None.,DISPOSITION: , The patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact.  Labs and cultures were sent for the usual in addition to some extra tests that had been ordered.,The opening pressure was 292, the closing pressure was 190.
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DESCRIPTION: Lumbar puncture.  A 20-gauge spinal needle was then inserted into the L3-L4 space.  Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.

surgery, spinal needle, lumbar puncture, lumbar, gauge, csf

The document describes a medical procedure, specifically a lumbar puncture, used to diagnose potential CNS infections like toxoplasmosis. While the procedure involves risks related to infection and is a medical procedure that can have serious implications, it is routine and commonly performed with minimal complications in a controlled environment. Given that no complications arose and the patient rested comfortably post-procedure, the situation is not extremely high-stakes compared to critical or emergency surgeries, but it involves significant medical considerations.


Medical Specialty: Surgery
Sample Name: Lumbar Puncture - 1

PROCEDURE: , Lumbar puncture with moderate sedation.,INDICATION: , The patient is a 2-year, 2-month-old little girl who presented to the hospital with severe anemia, hemoglobin 5.8, elevated total bilirubin consistent with hemolysis and weak positive direct Coombs test.  She was transfused with packed red blood cells.  Her hemolysis seemed to slow down.  She also on presentation had indications of urinary tract infection with urinalysis significant for 2+ leukocytes, positive nitrites, 3+ protein, 3+ blood, 25 to 100 white cells, 10 to 25 bacteria, 10 to 25 epithelial cells on clean catch specimen.  Culture subsequently grew out no organisms; however, the child had been pretreated with amoxicillin about x3 doses prior to presentation to the hospital.  She had a blood culture, which was also negative.  She was empirically started on presentation with the cefotaxime intravenously.  Her white count on presentation was significantly elevated at 20,800, subsequently increased to 24.7 and then decreased to 16.6 while on antibiotics.  After antibiotics were discontinued, she increased over the next 2 days to an elevated white count of 31,000 with significant bandemia, metamyelocytes and myelocytes present.  She also had three episodes of vomiting and thus she is being taken to the procedure room today for a lumbar puncture to rule out meningitis that may being inadvertently treated in treating her UTI.,I discussed with The patient's parents prior to the procedure the lumbar puncture and moderate sedation procedures.  The risks, benefits, alternatives, complications including, but not limited to bleeding, infection, respiratory depression.  Questions were answered to their satisfaction.  They would like to proceed.,PROCEDURE IN DETAIL: , After "time out" procedure was obtained, the child was given appropriate monitoring equipment including appropriate vital signs were obtained.  She was then given Versed 1 mg intravenously by myself.  She subsequently became sleepy, the respiratory monitors, end-tidal, cardiopulmonary and pulse oximetry were applied.  She was then given 20 mcg of fentanyl intravenously by myself.  She was placed in the left lateral decubitus position.  Dr. X cleansed the patient's back in a normal sterile fashion with Betadine solution.  She inserted a 22-gauge x 1.5-inch spinal needle in the patient's L3-L4 interspace that was carefully identified under my direct supervision.  Clear fluid was not obtained initially, needle was withdrawn intact.  The patient was slightly repositioned by the nurse and Dr. X reinserted the needle in the L3-L4 interspace position, the needle was able to obtain clear fluid, approximately 3 mL was obtained.  The stylette was replaced and the needle was withdrawn intact and bandage was applied.  Betadine solution was cleansed from the patient's back.,During the procedure, there were no untoward complications, the end-tidal CO2, pulse oximetry, and other vitals remained stable.  Of note, EMLA cream had also been applied prior procedure, this was removed prior to cleansing of the back.,Fluid will be sent for a routine cell count, Gram stain culture, protein, and glucose.,DISPOSITION: , The child returned to room on the medical floor in satisfactory condition.
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DESCRIPTION: Lumbar puncture with moderate sedation.

Lumbar puncture with moderate sedation.

surgery, moderate sedation, lumbar puncture, needle, lumbar,

A lumbar puncture, especially in a 2-year-old with potential meningitis, is a significant medical procedure. This is due to the need to rule out serious conditions like meningitis, which can be life-threatening if not diagnosed and managed promptly. The use of moderate sedation further implies the need for precise monitoring and careful handling to avoid complications. Given the complexity of the patient's condition, the underlying reasons for the procedure, and the potential complications discussed, this situation involves high stakes in ensuring a correct diagnosis and avoiding any procedural complications.


Medical Specialty: Surgery
Sample Name: Lumbar Discectomy - Microscopic

PREOPERATIVE DIAGNOSES:,1.  Extruded herniated disc, left L5-S1.,2.  Left S1 radiculopathy (acute).,3.  Morbid obesity.,POSTOPERATIVE DIAGNOSES:,1.  Extruded herniated disc, left L5-S1.,2.  Left S1 radiculopathy (acute).,3.  Morbid obesity.,PROCEDURE PERFORMED: , Microscopic lumbar discectomy, left L5-S1.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,50 cc.,HISTORY: , This is a 40-year-old female with severe intractable left leg pain from a large extruded herniated disc at L5-S1.  She has been dealing with these symptoms for greater than three months.  She comes to my office with severe pain, left my office and reported to the Emergency Room where she was admitted for pain control one day before surgery.  I have discussed the MRI findings with the patient and the potential risks and complications.  She was scheduled to go to surgery through my office, but because of her severe symptoms, she was unable to keep that appointment and reported right to the Emergency Room.  We discussed the diagnosis and the operative procedure in detail.  I have reviewed the potential risks and complications and she had agreed to proceed with the surgery.  Due to the patient's weight which exceeds 340 lb, there was some concern about her operative table being able to support her weight and also my standard microlumbar discectomy incision is not ________ in this situation just because of the enormous size of the patient's back and abdomen and I have discussed this with her.  She is aware that she will have a much larger incision than what is standard and has agreed to accept this.,OPERATIVE PROCEDURE:  ,The patient was taken to OR #5 at ABCD General Hospital.  While in the hospital gurney, Department of Anesthesia administered general anesthetic, endotracheal intubation was followed.  A Jackson table was prepared for the patient and was reinforced replacing struts under table to prevent the table from collapsing.  The table reportedly does have a limit of 500 lb, but the table has never been stressed above 275 lb.  Once the table was reinforced, the patient was carefully rolled in a prone position on the Jackson table with the bony prominences being well padded.  A marker was placed in from the back at this time and an x-ray was obtained for incision localization.  The back is now prepped and draped in the usual sterile fashion.  A midline incision was made over the L5-S1 disc space taking through subcutaneous tissue sharply with a #10 Bard-Parker scalpel.  The lumbar dorsal fascia was then encountered and incised to the left of midline.  In the subperiosteal fashion, the musculature was elevated off the lamina at L5 and S1 after facet joint, but not disturbing the capsule.  A second marker was now placed and an intraoperative x-ray confirms our location at the L5-S1 disc space.  The microscope was brought into the field at this point and the remainder of the procedure done with microscopic visualization and illumination.  A high speed drill was used to perform a laminotomy by removing small portion of the superior edge of the S1 lamina and the inferior edge of the L5 lamina.  Ligaments and fragments were encountered and removed at this time.  The epidural space was now encountered.  The S1 nerve root was now visualized and found to be displaced dorsally as a result of a large disc herniation while the nerve was carefully protected with a Penfield.  A small stab incision was made into the disc fragment and probably a large portion of disc extrudes from the opening.  This disc fragment was removed and the nerve root was much more supple, it was carefully retracted.  The nerve root was now retracted and using a series of downgoing curettes, additional disc material was removed from around the disc space and from behind the body of S1 and L5.  At this point, all disc fragments were removed from the epidural space.  Murphy ball was passed anterior to the thecal sac in the epidural space and there was no additional compression that I can identify.  The disc space was now encountered and loose disc fragments were removed from within the disc space.  The disc space was then irrigated.  The nerve root was then reassessed and found to be quite supple.  At this point, the Murphy ball was passed into the foramen of L5 and this was patent and also into the foramen of S1 by passing ventral and dorsal to the nerve root and there were no obstructions in the passage of the device.  At this point, the wound was irrigated copiously and suctioned dry.  Gelfoam was used to cover the epidural space.  The retractors were removed at this point.  The fascia was reapproximated with #1 Vicryl suture, subcutaneous tissue with #2-0 Vicryl suture and Steri-Strips for curved incision.  The patient was transferred to the hospital gurney in supine position and extubated by Anesthesia, subsequently transferred to Postanesthesia Care Unit in stable condition.
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DESCRIPTION: Microscopic lumbar discectomy, left L5-S1.   Extruded herniated disc, left L5-S1.  Left S1 radiculopathy (acute). Morbid obesity.

surgery, extruded herniated disc, radiculopathy, microscopic, lumbar, discectomy, lumbar discectomy, morbid obesity, herniated disc, epidural space, nerve root, disc space, space, intractable, lamina, epidural, incision, nerve, herniated,

The situation involves a surgical procedure, a lumbar discectomy, which inherently carries a significant level of risk as it involves the spinal area, potentially affecting the patient's nervous system and mobility if complications arise. Additionally, the patient's morbid obesity adds an element of complexity and risk to the surgery, as it poses challenges in handling and supporting the patient during the operation, as well as in conducting the procedure itself due to anatomical considerations. The stakes include both the successful removal of the herniated disc to alleviate severe pain and avoid neurological complications, as well as managing the anesthetic and operative risks associated with the patient's condition. Although the procedure was completed without complications and the patient was stable post-operation, the situation initially presented considerable high-stakes elements due to the patient's severe symptoms and specific challenges posed by the morbid obesity.