Medical Specialty: Surgery
Sample Name: Total Hip Arthroplasty - Revision

PREOPERATIVE DIAGNOSIS: , Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,POSTOPERATIVE DIAGNOSIS:,  Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.,PROCEDURES:,1.  Removal of antibiotic spacer.,2.  Revision total hip arthroplasty.,IMPLANTS,1.  Hold the Zimmer trabecular metal 50 mm acetabular shell with two 6.5 x 30 mm screws.,2.  Zimmer femoral component, 13.5 x 220 mm with a size AA femoral body.,3.  A 32-mm femoral head with a +0 neck length.,ANESTHESIA:  ,Regional.,ESTIMATED BLOOD LOSS: , 500 cc.,COMPLICATIONS:,  None.,DRAINS: , Hemovac times one and incisional VAC times one.,INDICATIONS:,  The patient is a 66-year-old female with a history of previous right bipolar hemiarthroplasty for trauma.  This subsequently became infected.  She has undergone removal of this prosthesis and placement of antibiotic spacer.  She currently presents for stage II reconstruction with removal of antibiotic spacer and placement of a revision total hip.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room by anesthesia personnel.  She was placed supine on the operating table.  A Foley catheter was inserted.  A formal time out was obtained in identifying the correct patient, operative site.  Preoperative antibiotics were held for intraoperative cultures.  The patient was placed into the lateral decubitus position with the right side up.  The previous surgical incision was identified.  The right lower extremity was prepped and draped in standard fashion.  The old surgical incision was reopened along its proximal extent.  Immediately encountered was a large amount of fibrous scar tissue.  Dissection was carried sharply down through this scar tissue.  Soft tissue plains were extremely difficult to visualize due to all the scarring.  There was no native tissue to orient oneself with.  We carried our dissection down through the scar tissue to what seemed to be a fascial layer.  We incised through the fascial layer down to some scarred gluteus maximus muscle and down over what was initially felt to be the greater trochanter.  Dissection was carried down through soft tissue and the distal located antibiotic spacer was exposed.  This was used as a landmark to orient remainder of the dissection.  The antibiotic spacer was exposed and followed distally to expose the proximal femur.  Dissection was continued posteriorly and proximally to expose the acetabulum.  A cobra retractor was able to be inserted across the superior aspect of the acetabulum to enhance exposure.  Once improved visualization was obtained, the antibiotic spacer was removed from the femur.  This allowed further improved visualization of the acetabulum.  The acetabulum was filled with soft tissue debris and scar tissue.  This was removed with sharp excision with a knife as well as with a rongeur and a Bovie.  Once soft tissue was removed, the acetabulum was reamed.  Reaming was started with a 46-mm reamer and carried up sequentially to prepare for 50-mm shell.  The 50 mm shell was trialed and had good stability and fit.  Attention was then turned to continue preparation of the femur.  The canal was then debrided with femoral canal curettes.  Some fibrous tissue was removed from the canal.  The length of the femoral stem was then checked with this canal curette in place.  Following x-rays, we prepared to begin reaming the femur.  This femur was reamed over a guide rod using flexible reaming rods.  The canal was reamed up to 13.5 mm distally in preparation for 14 mm stem.  The stem was selected and initially size A body was placed in trial.  The body was too tight proximally to fit.  The proximal canal was then reamed for a size AA body.  A longer stem with an anterior bow was selected and a size AA trial was assembled.  This fit nicely in the canal and had good fit and fill.  Intraoperative radiographs were obtained to determine component position.  Intraoperative radiographs revealed satisfactory length of the component past the distal of fractures in the femur.  The remainder of the trial was then assembled and the hip was relocated and trialed.  Initially, it was found to be unstable posteriorly.  We changed from a 10 degree lip liner to 20 degree lip liner.  Again, the hip was trialed and found to be unstable posteriorly.  This was due to reversion of the femoral component.  As we attempted to seat the prosthesis, the stent continued to attempt to turn in retroversion.  The stem was extracted and retrialed.  Improved stability was obtained and we decided to proceed with the real components.  A 20 degree liner was inserted into the acetabular shell.  The real femoral components were assembled and inserted into the femoral canal.  Again, the hip was trialed.  The components were found to be in relative retroversion.  The real components were then backed down and the neck was placed in the more anteversion and reinserted.  Again, the stem attempted to follow in the relative retroversion.  Along with this time, however, it was improved from previous attempts.  The femoral head trial was placed back on the components and the hip relocated.  It was taken to a range of motion and found to have improved stability compared to previous trialing.  Decision was made to accept the component position.  The real femoral head was selected and implanted.  The hip was then taken again to a range of motion.  It was stable at 90 degrees of flexion with 20 degrees of adduction and 40 degrees of internal rotation.  The patient reached full extension and had no instability anteriorly.,The wound was then irrigated again with pulsatile lavage.  Six liters of pulsatile lavage was used during the procedure.,The wound was then closed in a layered fashion.  A Hemovac drain was placed deep to the fascial layer.  The subcutaneous tissues were closed with #1 PDS, 2-0 PDS, and staples in the skin.  An incisional VAC was then placed over the wound as well.  Sponge and needle counts were correct at the close of the case.,DISPOSITION:,  The patient will be weightbearing as tolerated with posterior hip precautions.
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DESCRIPTION: Infected right hip bipolar arthroplasty, status post excision and placement of antibiotic spacer.  Removal of antibiotic spacer and revision total hip arthroplasty.

surgery, infected, bipolar arthroplasty, antibiotic spacer, revision, placement of antibiotic spacer, total hip arthroplasty, scar tissue, soft tissue, antibiotic, spacer, femoral, hip, arthroplasty, total, acetabulum, femur,

The scenario describes a surgical procedure involving a revision of a total hip arthroplasty due to infection. This situation inherently carries high stakes due to several reasons: infection management, the complexity associated with surgical revisions, potential complications during and after surgery, and the patient's recovery and mobility outcomes. These factors mean there are significant potential consequences for the patient's health and quality of life, making it a high-stakes situation. The absence of immediate complications during the procedure does not diminish the stakes due to the serious nature of managing infected joint replacements. Additionally, the risks associated with anesthesia, blood loss, and the technical challenges of the procedure add to the high-stakes nature. Given these considerations, it is important to recognize this as a critical medical intervention.


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

Medical Specialty: Surgery
Sample Name: Total Hip Replacement - 1

PROCEDURE:,  Total hip replacement.,PROCEDURE DESCRIPTION:,  The patient was bought to the operating room and placed in the supine position.  After induction of anesthesia, the patient was turned on the side and secured in the hip table.  An incision was made, centered over the greater trochanter.  Dissection was sharply carried down through the subcutaneous tissues.  The gluteus maximus was incised and split proximally.  The piriformis and external rotators were identified.  These were removed from their insertions on the greater trochanter as a sleeve with the hip capsule.  The hip was dislocated.  A femoral neck cut was made using the guidance of preoperative templating.  The femoral head was removed.  Extensive degenerative disease was found on the femoral head as well as in the acetabulum.,Baseline leg-length measurements were taken.  The femur was retracted anteriorly and a complete labrectomy was performed.  Reaming of the acetabulum was then performed until adequate bleeding subchondral bone was identified in the key areas.  The trial shell was placed and found to have an excellent fit.  The real shell was opened and impacted into position in the appropriate amount of anteversion and abduction.  Screws were placed by drilling into the pelvis, measuring, and placing the appropriate length screw.  Excellent purchase was obtained.  The trial liner was placed.,The femur was then flexed and internally rotated.  The extra trochanteric bone was removed, as was any leftover lateral soft tissue at the piriformis insertion.  An intramedullary hole was drilled into the femur to define the canal.  Reaming was performed until the appropriate size was reached.  The broaches were then used to prepare the femur with the appropriate amount of version.  Once the appropriate size broach was reached, it was used as a trial with head and neck placement.  Hip range-of-motion was checked in all planes, including flexion-internal rotation, the position of sleep, and extension-external rotation.  The hip was found to have excellent stability with the final chosen head-neck combination.  Leg length measurements were taken and found to be within acceptable range, given the necessity for stability.,The real stem was opened and impacted into position.  The real head was impacted atop the stem.  If cement was used, the canal was thoroughly washed and dried and plugged with a restrictor, and then the cement was injected and pressurized and the stem was implanted in the appropriate version.  Excess cement was removed from the edges of the component.  Range of motion and stability were once again checked and found to be excellent.  Adequate hemostasis was obtained.  Vigorous power irrigation was used to remove all debris from the joint prior to final reduction.,The arthrotomy and rotators were closed using #1 Ethibond through drill holes in the bone, recreating the posterior hip structural anatomy.  The gluteus maximus was repaired using 0 Ethibond and 0 Vicryl.  The subcutaneous tissues were closed after further irrigation with 2-0 Vicryl and Monocryl sutures.  The skin was closed with nylon.  Xeroform and a sterile dressing were applied followed by a cold pack and Ace wrap.  The patient was transferred to the recovery room in stable condition, having tolerated the procedure well.
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DESCRIPTION: Total hip replacement.  An incision was made, centered over the greater trochanter.  Dissection was sharply carried down through the subcutaneous tissues.

surgery, range-of-motion, hip, total hip replacement, gluteus maximus, femoral head, subcutaneous tissues, incision, ethibond, trochanter, subcutaneous, acetabulum, femur

Total hip replacement surgery is a major surgical procedure with potential risks and complications, including infection, blood clots, and implant failure. It requires precise execution to ensure the longevity and functionality of the implant and patient recovery. The impact on patient's mobility and quality of life post-surgery makes it a high-stakes procedure. Additionally, the narrative involves technical surgical details and indicates that the patient's condition was stable post-operation, which signifies a positive outcome but the stakes remain high due to the inherent risks of such a procedure.

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Medical Specialty: Surgery
Sample Name: Total Abdominal Hysterectomy - 3

PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Abnormal uterine bleeding.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Abnormal uterine bleeding.,PROCEDURE PERFORMED: , Total abdominal hysterectomy with a uterosacral vault suspension.,ANESTHESIA: , General with endotracheal tube as well as spinal with Astramorph.,ESTIMATED BLOOD LOSS: , 150 cc.,URINE OUTPUT:  ,250 cc of clear urine at the end of the procedure.,FLUIDS:,  2000 cc of crystalloids.,COMPLICATIONS: , None.,TUBES: , None.,DRAINS:  ,Foley to gravity.,PATHOLOGY: , Uterus, cervix, and multiple fibroids were sent to pathology for review.,FINDINGS:  ,On exam, under anesthesia, normal appearing vulva and vagina, a massively enlarged uterus approximately 20 weeks' in size with irregular contours suggestive of fibroids.,Operative findings demonstrated a large fibroid uterus with multiple subserosal and intramural fibroids as well as there were some filmy adnexal adhesions bilaterally.  The appendix was normal appearing.  The bowel and omentum were normal appearing.  There was no evidence of endometriosis.  Peritoneal surfaces and vesicouterine peritoneum as well as appendix and cul-de-sac were all free of any evidence of endometriosis.,PROCEDURE:,  After informed consent was obtained and all questions were answered to the patient's satisfaction in layman's terms, she was taken to the Operating Room where first a spinal anesthesia with Astramorph was obtained without any difficulty.  She then underwent a general anesthesia with endotracheal tube also without any difficulty.  She was then examined under anesthesia with noted findings as above.  The patient was then placed in dorsal supine position and prepped and draped in the usual sterile fashion..  A vertical skin incision was made 1 cm below the umbilicus extending down to 2 cm above the pubic symphysis.  This was made with a first knife and then carried down to the underlying layer of the fascia with the second knife.  Fascia was excised in the midline and extended superiorly and inferiorly with the Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum identified and entered bluntly.  The peritoneal incision was then extended superiorly and inferiorly with external visualization of the bladder.  The uterus was markedly evident upon entering the peritoneal cavity.  The uterus was then exteriorized and noted to have the findings as above.  At this point, approximately 10 cc of vasopressin 20 units and 30 cc was injected into the uterine fundus and multiple fibroids were removed by using the incision with the Bovie and then using a blunt and the sharp dissection and grasping with Lahey clamps.  Once the debulking of the uterus was felt appropriate to proceed with the hysterectomy, the uterus was then reapproximated with a few #0 Vicryl sutures in a figure-of-eight fashion.  The round ligaments were identified bilaterally and clamped with the hemostats and transacted with the Metzenbaum scissors.  The round ligaments were then bilaterally tied with the #0 tie and noted to be hemostatic.  The uterovarian vessels bilaterally were then isolated through a vascular window created from taking down the round ligaments.  The uterovarian vessels bilaterally were #0 tied and then doubly clamped with straight Ochsner clamps and transacted and suture tied with a Heaney hand stitch fashion, and both uterine and ovarian vessels were noted to be hemostatic.  At this time, the attention was then turned to the vesicouterine peritoneum, which was tented up with Allis clamps and the bladder flap was then created sharply with Russian pickups and the Metzenbaum scissors.  Then the bladder was bluntly dissected off the underlying cervix with a moist Ray-Tec sponge down to the level of the cervix.,At this point, the uterus was pulled on traction and the uterosacral ligaments were easily visualized.  Using #2-0 PDS suture, the suture was placed through both uterosacral ligaments distally with a backhand stitch fashion throwing the sutures from lateral to medial.  These sutures were then tagged and saved for later.  The uterine vessels were then identified bilaterally and skeletonized, then clamped with straight Ochsner clamps balancing off the cervix, and the uterine vessels were then transacted and suture ligated with #0 Vicryl and noted to be hemostatic.  In a similar fashion, the broad ligament down to the level of the cardinal ligaments was clamped with curved Ochsner and transacted and suture ligated and noted to be hemostatic.  At this point, the Lahey clamp was placed on the cervix and the cervix was tented up.  The pubocervical vesical fascia was transacted with long knife.  Then while protecting posteriorly, using the double-pointed scissors, the vagina was entered with double-pointed scissors at the level of the cervix and was grasped with a straight Ochsner clamp.  The uterus and cervix were then amputated using the Jorgenson scissors and the cuff was outlined with Ochsner clamps.  The cuff was then copiously painted with Betadine soaked sponge.  The Betadine-soaked sponge was placed in the patient's vagina.  Then the cuff was then closed with a #0 Vicryl in a running locked fashion to make sure to bring the ipsilateral cardinal ligaments into the vaginal cuff.  This was accomplished with one #0 Vicryl running stitch and then an Allis clamp was placed in the midsection portion of the cuff and tented up and a #0 Vicryl figure-of-eight was placed in the midsection portion of the cuff.  At this time, the uterosacral ligaments previously tagged needle was brought through the cardinal ligament and the uterosacral ligament on the ipsilateral side.  The needle was cut off and these were then tagged with the hemostats.  The cuff was then closed by taking the running suture and bringing back through the posterior peritoneum, grabbing part of the uterosacral and midsection portion of the posterior peritoneum of the uterosacral and then tying the cuff down to bunch and cuff together.  The suture in the midportion of the cuff was then used to tie down the round ligaments bilaterally to the cuff.  The abdomen was copiously irrigated with warm normal saline.  All areas were noted to be hemostatic.  Then the previously tagged uterosacral sutures were then tied bringing the vaginal cuff angles down to the uterosacral ligaments.  The abdomen was then once again copiously irrigated with warm normal saline.  All areas were noted to be hemostatic.  The sigmoid colon was replaced back into the hollow of the sacrum.  Then the omentum was pulled over the bowel.  After the myomectomy was performed, the GYN Balfour was placed into the patient's abdomen and the bowel was packed away with moist laparotomy sponges.  The GYN Balfour was then removed.  Packing sponges were removed and the fascia was then closed in an interrupted figure-of-eight fashion with #0 Vicryl.,Skin was closed with staples.  The patient tolerated the procedure well.  The sponge, lap, and needle counts were correct x2.  The sponge from the patient's vagina was removed and the vagina was noted to be hemostatic.  The patient would be followed throughout her hospital stay.
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DESCRIPTION: Total abdominal hysterectomy (TAH) with a uterosacral vault suspension.   Enlarged fibroid uterus and abnormal uterine bleeding.

The procedure described is a total abdominal hysterectomy, which is a major surgical operation involving the removal of the uterus. This type of surgery is typically performed under general anesthesia and involves significant surgical intervention with potential risks such as bleeding, infection, and complications related to anesthesia. While the procedure is commonly performed and complications are relatively low, the stakes are inherently high because it involves major surgery on a vital reproductive organ, requiring skilled surgical techniques and thorough post-operative care. Given the complexity of the operation and the nature of surgical intervention, especially due to the enlarged fibroid uterus, the situation can be considered high-stakes within the context of surgical operations.


Medical Specialty: Surgery
Sample Name: Toronto Porcine Valve Insertion

PREOPERATIVE DIAGNOSIS:,  Aortic stenosis.,POSTOPERATIVE DIAGNOSIS:  ,Aortic stenosis.,PROCEDURES PERFORMED,1.  Insertion of a **-mm Toronto stentless porcine valve.,2.  Cardiopulmonary bypass.,3.  Cold cardioplegia arrest of the heart.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  , 300 cc.,INTRAVENOUS FLUIDS:  , 1200 cc of crystalloid.,URINE OUTPUT:  , 250 cc.,AORTIC CROSS-CLAMP TIME: , **,CARDIOPULMONARY BYPASS TIME TOTAL: , **,PROCEDURE IN DETAIL:,  After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next the neck, chest and legs were prepped and draped in the standard surgical fashion.  We used a #10-blade scalpel to make a midline median sternotomy incision.  Dissection was carried down to the left of the sternum using Bovie electrocautery.  The sternum was opened with a sternal saw.  The chest retractor was positioned.  Next, full-dose heparin was given.  The pericardium was opened.  Pericardial stay sutures were positioned.  After obtaining adequate ACT, we prepared to place the patient on cardiopulmonary bypass.  A 2-0 double pursestring of Ethibond suture was placed in the ascending aorta.  Through this was passed an aortic cannula connected to the arterial side of the cardiopulmonary bypass machine.  Next a 3-0 Prolene pursestring was placed in the right atrial appendage.  Through this was passed our venous cannula connected to the venous portion of the cardiopulmonary bypass machine.  A 4-0 U-stitch was placed in the right atrium.  A retrograde cardioplegia catheter was positioned at this site.  Next, scissors were used to dissect out the right upper pulmonary vein.  A 4-0 Prolene pursestring was placed in the right upper pulmonary vein.  Next, a right-angle sump was placed at this position.  We then connected our retrograde cardioplegia catheter to the cardioplegia solution circuit.  Bovie electrocautery was used to dissect the interface between the aorta and pulmonary artery.  The aorta was completely encircled.  Next, an antegrade cardioplegia needle and associated sump were placed in the ascending aorta.  We then prepared to cross-clamp the aorta.  We went down on our flows and cross-clamped the aorta.  We backed up our flows.  We then gave antegrade and retrograde cold blood cardioplegia solution circuit so as to arrest the heart.  The patient had some aortic insufficiency so we elected, after initially arresting the heart, to open the aorta and transect it and then give direct ostial infusion of cardioplegia solution circuit.  Next, after obtaining complete diastolic arrest of the heart, we turned our attention to exposing the aortic valve, and 4-0 Tycron sutures were placed in the commissures.  In addition, a 2-0 Prolene suture was placed in the aortic wall so as to bring the aortic wall and root up into view.  Next, scissors were used to excise the diseased aortic valve leaflets.  Care was taken to remove all the calcium from the aortic annulus.  We then sized up the aortic annulus which came out to be a **-mm stentless porcine Toronto valve.  We prepared the valve.  Next, we placed our proximal suture line of interrupted 4-0 Tycron sutures for the annulus.  We started with our individual commissural stitches.  They were connected to our valve sewing ring.  Next, we placed 5 interrupted 4-0 Tycron sutures in a subannular fashion at each commissural position.  After doing so, we passed 1 end of the suture through the sewing portion of the Toronto stentless porcine valve.  The valve was lowered into place and all of the sutures were tied.  Next, we gave another round of cold blood antegrade and retrograde cardioplegia.  Next, we sewed our distal suture line.  We began with the left coronary cusp of the valve.  We ran a 5-0 RB needle up both sides of the valve.  Care was taken to avoid the left coronary ostia.  This procedure was repeated on the right cusp of the stentless porcine valve.  Again, care was taken to avoid any injury to the coronary ostia.  Lastly, we sewed our non-coronary cusp.  This was done without difficulty.  At this point we inspected our aortic valve.  There was good coaptation of the leaflets, and it was noted that both the left and the right coronary ostia were open.  We gave another round of cold blood antegrade and retrograde cardioplegia.  The antegrade portion was given in a direct ostial fashion once again.  We now turned our attention to closing the aorta.  A 4-0 Prolene double row of suture was used to close the aorta in a running fashion.  Just prior to closing, we de-aired the heart and gave a warm shot of antegrade and retrograde cardioplegia.  At this point, we removed our aortic cross-clamp.  The heart gradually regained its electromechanical activity.  We placed 2 atrial and 2 ventricular pacing wires.  We removed our aortic vent and oversewed that site with another 4-0 Prolene on an SH needle.  We removed our retrograde cardioplegia catheter.  We oversewed that site with a 5-0 Prolene.  By now, the heart was de-aired and resumed normal electromechanical activity.  We began to wean the patient from cardiopulmonary bypass.  We then removed our venous cannula and suture ligated that site with a #2 silk.  We then gave full-dose protamine.  After knowing that there was no evidence of a protamine reaction, we removed the aortic cannula.  We buttressed that site with a 4-0 Prolene on an SH needle.  We placed a mediastinal chest tube and brought it out through the skin.  We also placed 2 Blake drains, 1 in the left chest and 1 in the right chest, as the patient had some bilateral pleural effusions.  They were brought out through the skin.  The sternum was closed with #7 wires in an interrupted figure-of-eight fashion.  The fascia was closed with #1 Vicryl.  We closed the subcu tissue with 2-0 Vicryl and the skin with 4-0 PDS.
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DESCRIPTION: Aortic stenosis.   Insertion of a Toronto stentless porcine valve, cardiopulmonary bypass, and cold cardioplegia arrest of the heart.

surgery, cardioplegia, toronto stentless porcine valve, tycron sutures, coronary ostia, porcine valve, retrograde cardioplegia, cardiopulmonary bypass, sutures, valve, insertion, toronto, aortic, stentless, chest, coronary, porcine, cardiopulmonary, prolene, atrial, bypass, heart, aorta,

This scenario involves a major surgical procedure: the insertion of a Toronto stentless porcine valve to address aortic stenosis, using cardiopulmonary bypass and cold cardioplegia arrest. Such surgeries are complex and carry significant risks, including potential complications from the anesthesia, bleeding, and the heart stopping during the procedure. The success of this procedure is critical for the patient's health and survival, making it a high-stakes situation.


Medical Specialty: Surgery
Sample Name: Total Abdominal Hysterectomy - 1

PREOPERATIVE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Anemia.,3.  Symptomatic fibroid uterus.,POSTOPERATIVE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Anemia.,3.  Symptomatic fibroid uterus.,PROCEDURE: , Total abdominal hysterectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS: , 150 mL.,COMPLICATIONS: , None.,FINDING:  ,Large fibroid uterus.,PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the usual sterile fashion for an abdominal procedure.  A scalpel was used to make a Pfannenstiel skin incision, which was carried down sharply through the subcutaneous tissue to the fascia.  The fascia was nicked in the midline and incision was carried laterally bilaterally with curved Mayo scissors.  The fascia was then bluntly and sharply dissected free from the underlying rectus abdominis muscles.  The rectus abdominis muscles were then bluntly dissected in the midline and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel.  The peritoneum was then bluntly entered and this incision was carried forward inferiorly and superiorly with care taken to avoid bladder and bowel.  The O'Connor-O'Sullivan instrument was then placed without difficulty.  The uterus was grasped with a thyroid clamp and the entire pelvis was then visualized without difficulty.  The GIA stapling instrument was then used to separate the infundibulopelvic ligament in a ligated fashion from the body of the uterus.  This was performed on the left infundibulopelvic ligament and the right infundibulopelvic ligament without difficulty.  Hemostasis was noted at this point of the procedure.  The bladder flap was then developed free from the uterus without difficulty.  Careful dissection of the uterus from the pedicle with the uterine arteries and cardinal ligaments was then performed using #1 chromic suture ligature in an interrupted fashion on the left and right side.  This was done without difficulty.  The uterine fundus was then separated from the uterine cervix without difficulty.  This specimen was sent to pathology for identification.  The cervix was then developed with careful dissection.  Jorgenson scissors were then used to remove the cervix from the vaginal cuff.  This was sent to pathology for identification.  Hemostasis was noted at this point of the procedure.  A #1 chromic suture ligature was then used in running fashion at the angles and along the cuff.  Hemostasis was again noted.  Figure-of-eight sutures were then used in an interrupted fashion to close the cuff.  Hemostasis was again noted.  The entire pelvis was washed.  Hemostasis was noted.  The peritoneum was then closed using 2-0 chromic suture ligature in running pursestring fashion.  The rectus abdominis muscles were approximated using #1 chromic suture ligature in an interrupted fashion.  The fascia was closed using 0 Vicryl in interlocking running fashion.  Foundation sutures were then placed in an interrupted fashion for further closing the fascia.  The skin was closed with staple gun.  Sponge and needle counts were noted to be correct x2 at the end of the procedure.  Instrument count was noted to be correct x2 at the end of the procedure.  Hemostasis was noted at each level of closure.  The patient tolerated the procedure well and went to recovery room in good condition.
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DESCRIPTION: Total abdominal hysterectomy..  Severe menometrorrhagia unresponsive to medical therapy, anemia, and symptomatic fibroid uterus.

surgery, menometrorrhagia, fibroid, uterus, total abdominal hysterectomy, rectus abdominis muscles, fibroid uterus, suture ligature, therapy, hemostasis, anemia, abdominal,

The situation describes a surgical procedure - a total abdominal hysterectomy - which inherently carries significant risks and implications for the patient's health. The stakes are high as the surgery addresses severe menometrorrhagia, anemia, and a symptomatic fibroid uterus, conditions that significantly affect the patient's quality of life. Surgical procedures require careful precision to avoid complications, though none were reported in this case. The successful completion of the surgery without complications and the attention to hemostasis throughout the procedure indicate a well-executed surgery. However, the potential for significant complications or impacts on the patient's health status categorize this as a high-stakes situation.


Medical Specialty: Surgery
Sample Name: Tonsillectomy

PREOPERATIVE DIAGNOSIS: , Tonsillitis.,POSTOPERATIVE DIAGNOSIS:  ,Tonsillitis.,PROCEDURE PERFORMED:  ,Tonsillectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room and prepped and draped in the usual fashion.  After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll on the upper lip to provide soft palate retraction.  The nasopharynx was inspected with the laryngeal mirror.,Attention was then directed to the right tonsil.  The anterior tonsillar pillar was infiltrated with 1.5 cc of 1% Xylocaine with 1:100,000 epinephrine, as was the left tonsillar pillar.  The right tonsil was grasped with the tenaculum and retracted out of its fossa.  The anterior tonsillar pillar was incised with the #12 knife blade.  The plica semilunaris was incised with the Metzenbaum scissors.  Using the Metzenbaum scissors and the Fisher knife, the tonsil was dissected free of its fossa onto an inferior pedicle around which the tonsillar snare was placed and applied.  The tonsil was removed from the fossa and the fossa packed with a cherry gauze sponge as previously described.  By a similar procedure, the opposite tonsillectomy was performed and the fossa was packed.,Attention was re-directed to the right tonsil.  The pack was removed and bleeding was controlled with the suction Bovie unit.  Bleeding was then similarly controlled in the left tonsillar fossa and the nasopharynx after removal of the packs.  The catheters were then removed.  The nasal passages and oropharynx were suctioned free of debris.  The procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.
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DESCRIPTION: Tonsillectomy.   Tonsillitis.  McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.

surgery, tongue, palate, mcivor mouth gag, anterior tonsillar, metzenbaum scissors, oral cavity, tonsillar pillar, tonsillectomy, metzenbaum, tonsillitis, pillar, tonsillar, fossa

A tonsillectomy is a common surgical procedure, typically considered routine and low-risk. However, it does involve general anesthesia, which carries some risk, and the need for surgical precision to prevent complications such as excessive bleeding. The procedure is being discussed in a medical context, suggesting a professional and controlled environment. Although tonsillectomy is a significant event for the patient, it is likely not life-threatening under normal circumstances, given that the patient tolerated the procedure well. Therefore, the stakes for this surgery in this context appear to be moderate rather than extremely high.


Medical Specialty: Surgery
Sample Name: Tonsillectomy & Adenoidectomy

PREOPERATIVE DIAGNOSES:,  Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,POSTOPERATIVE DIAGNOSES:,  Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,OPERATIONS:,  Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.,ANESTHESIA:,  General.,HISTORY: , The patient is 5-1/2 years old.  She is here this morning with her Mom.  She has very large tonsils and she snores at night and gets up frequently at night and does not sleep well.  At the office we saw the tonsils were very big.  There was a rock in the right ear and it was very deep in the canal, near the drum.  We will remove the foreign body under the same anesthetic.,PROCEDURE:,:  Natalie was placed under general anesthetic by the orotracheal route of administration, under Dr. XYZ and Ms. B.  I looked into the left ear under the microscope, took out a little wax and observed a normal eardrum.  On the right side, I took out some impacted wax and removed the rock with a large suction.  It was actually resting on the surface of the drum but had not scarred or damaged the drum.  The drum was intact with no evidence of middle ear fluid.  The microscope was set aside.  Afrin drops were placed in both nostrils.  The neck was gently extended and the Crowe-Davis mouth gag inserted.  The tonsils and adenoids were very large.  The uvula was intact.  Adenoidectomy was performed using the adenoid curette with a tonsil sponge placed into the nasopharynx.  Tonsillectomy accomplished by sharp and blunt dissection.  Hemostasis achieved with electrocautery and the tonsils beds injected with 0.25% Marcaine with 1:200,000 epinephrine.  Sutures of zero plain catgut next were used to re-approximate the posterior to the anterior tonsillar pillars, suturing these down to the tonsillar beds.  Sponge is removed from the nasopharynx.  The suction electrocautery was used for pinpoint hemostasis on the adenoid bed.  We made sure the cautery tip did not come into the contact with the soft palate or the eustachian tube orifices.  The nose and throat were then irrigated with saline and suctioned.  Excellent hemostasis was observed.  An orogastric tube was placed.  The stomach found to be empty.  The tube was removed, as was the mouth gag.  Sponge and needle count were reported correct.  The child was then awakened and prepared for her to return to the recovery room.  She tolerated the operation excellently.
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DESCRIPTION: Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.

surgery, tonsillectomy, afrin drops, crowe-davis, hypertrophy, adenoid bed, adenoidectomy, adenoids, canal, catgut, dissection, drum, ear, foreign body, middle ear, mouth gag, nasopharynx, orotracheal, suction electrocautery, throat, tonsils, uvula, wax, tonsils and adenoids

The situation described is a surgical procedure involving a tonsillectomy, adenoidectomy, and the removal of a foreign body from a child's ear, all under general anesthesia. Although these types of surgeries are common and generally considered routine with low risk of serious complications, they are still surgical procedures requiring anesthesia on a young child, which can increase the stakes due to factors like anesthesia risks, potential bleeding, and postoperative recovery care. The presence of a foreign body near the eardrum also adds a layer of complexity. However, since the procedure was successful without complications, the stakes can be considered moderate.


Medical Specialty: Surgery
Sample Name: Thromboendarterectomy

OPERATIVE PROCEDURE,1.  Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.,2.  Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass,cold blood potassium cardioplegia, antegrade and retrograde, for myocardial protection, placement of temporary pacing wires.,DESCRIPTION:,  The patient was brought to the operating room, placed in supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring lines were placed.  The chest, abdomen and legs were prepped and draped in a sterile fashion.  The greater saphenous vein was harvested from the right upper leg through interrupted skin incisions and was prepared by ligating all branches with 4-0 silk and flushing with vein solution.  The leg was closed with running 3-0 Dexon subcu, and running 4-0 Dexon subcuticular on the skin, and later wrapped.  A median sternotomy incision was made and the left internal mammary artery was dissected free from its takeoff at the subclavian to its bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The sternum was closed.  A right carotid incision was made along the anterior border of the sternocleidomastoid muscle and carried down to and through the platysma.  The deep fascia was divided.  The facial vein was divided between clamps and tied with 2-0 silk.  The common carotid artery, takeoff of the external and internal carotid arteries were dissected free, with care taken to identify and preserve the hypoglossal and vagus nerves.  The common carotid artery was double-looped with umbilical tape, takeoff of the external was looped with a heavy silk, distal internal was double-looped with a heavy silk.  Shunts were prepared.  A patch was prepared.  Heparin 50 mg was given IV.  Clamp was placed on the beginning of the takeoff of the external and the proximal common carotid artery.  Distal internal was held with a forceps.  Internal carotid artery was opened with 11-blade.  Potts scissors were then used to extend the aortotomy through the lesion into good internal carotid artery beyond.  The shunt was placed and proximal and distal snares were tightened.  Endarterectomy was carried out under direct vision in the common carotid artery and the internal reaching a fine, feathery distal edge using eversion on the external.  All loose debris was removed and Dacron patch was then sutured in place with running 6-0 Prolene suture, removing the shunt just prior to completing the suture line.  Suture line was completed and the neck was packed.,The pericardium was opened.  A pericardial cradle was created.  The patient was heparinized for cardiopulmonary bypass, cannulated with a single aortic and single venous cannula.  A retrograde cardioplegia cannula was placed with a pursestring of 4-0 Prolene into the coronary sinus, and secured to a Rumel tourniquet.  An antegrade cardioplegia needle sump was placed in the ascending aorta and cardiopulmonary bypass was instituted.  The ascending aorta was cross-clamped and cold blood potassium cardioplegia was given antegrade, a total of 5 cc per kg.  This was followed sumping of the ascending aorta and retrograde cardioplegia, a total of 5 cc per kg to the coronary sinus.  The obtuse marginal 1 coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture.  The vein was cut to length.  Antegrade and retrograde cold blood potassium cardioplegia was given.  The obtuse marginal 2 was not felt to be suitable for bypass, therefore, the posterior descending of the right coronary was identified and opened, and an end-to-side anastomosis was then performed with running 7-0 Prolene suture to reverse autogenous saphenous vein.  The vein was cut to length.  The mammary was clipped distally, divided and spatulated for anastomosis.  Antegrade and retrograde cold blood potassium cardioplegia was given.  The anterior descending was identified and opened. the mammary was then sutured to this with running 8-0 Prolene suture.  Warm blood potassium cardioplegia was given, and the cross-clamp was removed.  A partial-occlusion clamp was placed.  Two aortotomies were made.  The veins were cut to fit these and sutured in place with running 5-0 Prolene suture.  The partial- occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Atrial and ventricular pacing wires were placed.  Ventilation was commenced.  The patient was fully warmed.  The patient was weaned from cardiopulmonary bypass and de-cannulated in a routine fashion.  Protamine was given.  Good hemostasis was noted.  A single mediastinal chest tube and bilateral pleural Blake drains were placed.  The sternum was closed with figure-of-eight stainless steel wire, the linea alba with figure-of-eight #1 Vicryl, the sternal fascia with running #1 Vicryl, the subcu with running 2-0 Dexon and the skin with a running 4-0 Dexon subcuticular stitch.
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DESCRIPTION: Thromboendarterectomy of right common, external, and internal carotid artery utilizing internal shunt and Dacron patch angioplasty closure.  Coronary artery bypass grafting x3 utilizing left internal mammary artery to left anterior descending, and reverse autogenous saphenous vein graft to the obtuse marginal, posterior descending branch of the right coronary artery.

surgery, cabg, thromboendarterectomy, carotid artery, coronary artery bypass, mammary, obtuse, papaverine-soaked, running prolene suture, cardiopulmonary bypass, internal carotid, running prolene, prolene suture, carotid, sutured, artery, prolene, coronary, bypass, veinNOTE

The surgery described involves thromboendarterectomy and coronary artery bypass grafting, which are complex and critical procedures often performed on patients with significant cardiovascular disease. These procedures carry substantial risks, including those related to anesthesia, surgical complications, and postoperative recovery. The use of cardiopulmonary bypass, shunts, and other advanced surgical techniques highlights the complexity and high stakes involved. The stakes are high because these surgeries are typically life-saving or life-extending for patients with severe conditions and have serious consequences if complications arise.


Medical Specialty: Surgery
Sample Name: Tongue Lesion Biopsy

PREOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,POSTOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,PROCEDURE PERFORMED:  ,Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.,ANESTHESIA: , General.,FINDINGS: , An ulceration in the right lateral base of tongue region.  This was completely excised.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS:,  None.,DRAINS:,  None.,CONDITION:,  Stable.,PROCEDURE:  ,The patient placed supine in position under general anesthesia.  First a Sweetheart gag was placed in the patient's mouth and the mouth was elevated.  The lesion in the tongue could be seen.  Then, it was injected with 1% lidocaine and 1:100,00 epinephrine.  After 5 minutes of waiting, then an elliptical incision was made around this mass with electrocautery and then it was sharply dissected off the muscular layer and removed in total.  Suction cautery was used for hemostasis.  Then, 3 simple interrupted #4-0 Vicryl sutures were used to close the wound and procedure was then terminated at that time.
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DESCRIPTION: Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.  Right lateral base of tongue lesion, probable cancer.

surgery, excisional biopsy, tongue lesion, mouth, biopsy,

This case involves a surgical procedure to excise a tongue lesion that is suspected to be cancerous. While the surgery itself is relatively minor and the risks appear low (no significant complications, minimal blood loss, and patient in stable condition), the potential diagnosis of cancer elevates the stakes significantly. The biopsy results could lead to further treatment and affect the patient's long-term health outcome. Therefore, while the immediate surgical procedure is low to moderate in stakes, the potential implications of a cancer diagnosis significantly increase the overall stakes of the situation.


Medical Specialty: Surgery
Sample Name: Thoracotomy & Esophageal Exploration

PREOPERATIVE DIAGNOSIS:  ,Esophageal rupture.,POSTOPERATIVE DIAGNOSIS:,  Esophageal rupture.,OPERATION PERFORMED,1.  Left thoracotomy with drainage of pleural fluid collection.,2.  Esophageal exploration and repair of esophageal perforation.,3.  Diagnostic laparoscopy and gastrostomy.,4.  Radiographic gastrostomy tube study with gastric contrast, interpretation.,ANESTHESIA: , General anesthesia.,INDICATIONS OF THE PROCEDURE: , The patient is a 47-year-old male with a history of chronic esophageal stricture who is admitted with food sticking and retching.  He has esophageal rupture on CT scan and comes now for a thoracotomy and gastrostomy.,DETAILS OF THE PROCEDURE: , After an extensive informed consent discussion process, the patient was brought to the operating room.  He was placed in a supine position on the operating table.  After induction of general anesthesia and placement of a double lumen endotracheal tube, he was turned and placed in a right lateral decubitus position on a beanbag with appropriate padding and axillary roll.  Left chest was prepped and draped in a usual sterile fashion.  After administration of intravenous antibiotics, a left thoracotomy incision was made, dissection was carried down to the subcutaneous tissues, muscle layers down to the fifth interspace.  The left lung was deflated and the pleural cavity entered.  The Finochietto retractor was used to help provide exposure.  The sixth rib was shingled in the posterior position and a careful expiration of the left pleural cavity was performed.,Immediately encountered was left pleural fluid including some purulent fluid.  Cultures of this were sampled and sent for microbiology analysis.  The left pleural space was then copiously irrigated.  A careful expiration demonstrated that the rupture appeared to be sealed.  There was crepitus within the mediastinal cavity.  The mediastinum was opened and explored and the esophagus was explored.  The tissues of the esophagus appeared to show some friability and an area of the rupture in the distal esophagus.  It was not possible to place any stitches in this tissue and instead a small intercostal flap was developed and placed to cover the area.  The area was copiously irrigated, this provided nice coverage and repair.  After final irrigation and inspection, two chest tubes were placed including a #36 French right angled tube at the diaphragm and a posterior straight #36 French.  These were secured at the left axillary line region at the skin level with #0-silk.,The intercostal sutures were used to close the chest wall with a #2 Vicryl sutures.  Muscle layers were closed with running #1 Vicryl sutures.  The wound was irrigated and the skin was closed with skin staples.,The patient was then turned and placed in a supine position.  A laparoscopic gastrostomy was performed and then a diagnostic laparoscopy performed.  A Veress needle was carefully inserted into the abdomen, pneumoperitoneum was established in the usual fashion, a bladeless 5-mm separator trocar was introduced.  The laparoscope was introduced.  A single additional left-sided separator trocar was introduced.  It was not possible to safely pass a nasogastric or orogastric tube, pass the stricture and perforation and so the nasogastric tube was left right at the level where there was some stricture or narrowing or resistance.  The stomach however did have some air insufflation and we were able to place our T-fasteners through the anterior abdominal wall and through the anterior gastric wall safely.  The skin incision was made and the gastric lumen was then accessed with the Seldinger technique.  Guide wire was introduced into the stomach lumen and series of dilators was then passed over the guide wire.  #18 French Gastrostomy was then passed into the stomach lumen and the balloon was inflated.  We confirmed that we were in the gastric lumen and the balloon was pulled up, creating apposition of the gastric wall and the anterior abdominal wall.  The T-fasteners were all crimped and secured into position.  As was in the plan, the gastrostomy was secured to the skin and into the tube.  Sterile dressing was applied.  Aspiration demonstrated gastric content.,Gastrostomy tube study, with interpretation.  Radiographic gastrostomy tube study with gastric contrast, with
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DESCRIPTION: Left thoracotomy with drainage of pleural fluid collection, esophageal exploration and repair of esophageal perforation, diagnostic laparoscopy and gastrostomy, and radiographic gastrostomy tube study with gastric contrast, interpretation.

surgery, esophageal rupture, thoracotomy, drainage of pleural fluid, esophageal perforation, esophageal exploration, laparoscopy, gastrostomy, pleural fluid, diagnostic laparoscopy, radiographic gastrostomy, gastric lumen, gastrostomy tube, gastric contrast, gastric, interpretation, abdominal, pleural, lumen, esophageal, tube,

The situation described involves a surgical intervention to address an esophageal rupture, which is a serious medical condition. Esophageal ruptures can lead to life-threatening complications, including severe infection or mediastinitis. The detailed account of the surgical procedure highlights the complexity and urgency of the operation, aimed at repairing the rupture and preventing further complications. The need for general anesthesia and the invasive nature of the thoracotomy further underscore the high-stakes nature of this procedure, as any complications could have significant repercussions on the patient's health.


Medical Specialty: Surgery
Sample Name: Thoracotomy & Bronchoscopy

PREOPERATIVE DIAGNOSIS:,  Empyema.,POSTOPERATIVE DIAGNOSIS: , Empyema.,PROCEDURE PERFORMED:,1.  Right thoracotomy, total decortication.,2.  Intraoperative bronchoscopy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  300 cc.,FLUIDS: , 2600 cc IV crystalloid.,URINE: , 300 cc intraoperatively.,INDICATIONS FOR PROCEDURE:  ,The patient is a 46-year-old Caucasian male who was admitted to ABCD Hospital since 08/14/03 with acute diagnosis of right pleural effusion.  A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion.  On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.  Decision was made to proceed with surgical intervention for a complete decortication and the patient understands the need for surgery and signed the preoperative informed consent.,OPERATIVE PROCEDURE: , The patient was taken to the operative suite and placed in the supine position under general anesthesia per Anesthesia Department.  Intraoperative bronchoscopy was performed by Dr. Y and evaluation of carina, left upper and lower lobes with segmental evidence of diffuse mucous, thick secretions which were thoroughly lavaged with sterile saline lavage.  Samples were obtained from both the left and the right subbronchiole segments for Gram stain cultures and ASP evaluation.  The right bronchus lower, middle, and upper were also examined and subsegmental bronchiole areas were thoroughly examined with no evidence of masses, lesions, or suspicious extrinsic compressions on the bronchi.  At this point, all mucous secretions were thoroughly irrigated and aspirated until the airways were clear.  Bronchoscope was then removed.  Vital signs remained stable throughout this portion of the procedure.  The patient was re-intubated by Anesthesia with a double lumen endotracheal tube.  At this point, the patient was repositioned in the left lateral decubitus position with protection of all pressure points and the table was extended in customary fashion.  At this point, the right chest was prepped and draped in the usual sterile fashion.  The chest tube was removed before prepping the patient and the prior thoracostomy site was cleansed thoroughly with Betadine.  The first port was placed through this incision intrathoracically.  A bronchoscope was placed for inspection of the intrathoracic cavity.  Pictures were taken.  There is extensive fibrinous exudate noted under parietal and visceral pleura, encompassing the lung surface, diaphragm, and the posterolateral aspect of the right thorax.  At this point, a second port site anteriorly was placed under direct visualization.  With the aid of the thoracoscopic view, a Yankauer resection device was placed in the thorax and blunt decortication was performed and aspiration of reminder of the pleural fluid.  Due to the gelatinous nature of the fibrinous exudate, there were areas of right upper lobe that adhered to the chest wall and the middle and lower lobes appeared entrapped.  Due to the extensive nature of the disease, decision was made to open the chest in a formal right thoracotomy fashion.  Incision was made.  The subcutaneous tissues were then electrocauterized down to the level of the latissimus dorsi, which was separated with electrocautery down to the anterior 6th rib space.  The chest cavity was entered with the right lung deflated per Anesthesia at our request.  Once the intrathoracic cavity was accessed, a thorough decortication was performed in meticulous systematic fashion starting with the right upper lobe, middle, and the right lower lobe.  With the expansion of the lung and reduction of the pleural surface fibrinous extubate, warm irrigation was used and the lungs allowed to re-expand.  There was no evidence of gross leakage or bleeding at the conclusion of surgery.,Full lung re-expansion was noted upon re-inflation of the lung.  Two #32 French thoracostomy tubes were placed, one anteriorly straight and one posteriorly on the diaphragmatic sulcus.  The chest tubes were secured in place with #0-silk sutures and placed on Pneumovac suction.  Next, the ribs were reapproximated with five interrupted CTX sutures and latissimus dorsi was then reapproximated with a running #2-0 Vicryl suture.  Next, subcutaneous skin was closed sequentially with a cosmetic layered subcutaneous closure.  Steri-Strips were applied along with sterile occlusive dressings.  The patient was awakened from anesthesia without difficulty and extubated in the operating room.  The chest tubes were maintained on Pleur-Evac suction for full re-expansion of the lung.  The patient was transported to the recovery with vital signs stable.  Stat portable chest x-ray is pending.  The patient will be admitted to the Intensive Care Unit for close monitoring overnight.
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DESCRIPTION: Empyema.  Right thoracotomy, total decortication and intraoperative bronchoscopy.  A thoracostomy tube was placed at the bedside with only partial resolution of the pleural effusion.  On CT scan evaluation, there is evidence of an entrapped right lower lobe with loculations.

surgery, empyema, total decortication, intraoperative bronchoscopy, intrathoracic cavity, fibrinous exudate, latissimus dorsi, chest tubes, pleural effusion, bronchoscopy, thoracostomy, thoracotomy, decortication, anesthesia, pleural,

The situation described involves a complex and invasive surgical procedure, which includes a thoracotomy with total decortication and bronchoscopy to treat empyema. Empyema is a serious condition that requires surgical intervention when not resolved with less invasive measures. The procedure involves significant health risks, general anesthesia, and the potential for complications, even though none occurred in this case. The need for ICU monitoring indicates the critical nature of the patient’s condition and the need for experienced medical personnel to handle such operations. The stakes involve the patient's health and survival, making it a high-stakes situation.


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

PREOPERATIVE DIAGNOSIS: , Left mesothelioma, focal.,POSTOPERATIVE DIAGNOSIS: , Left pleural-based nodule.,PROCEDURES PERFORMED:,1.  Left thoracoscopy.,2.  Left mini thoracotomy with resection of left pleural-based mass.,FINDINGS:,  Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.,FLUIDS: , 800 mL of crystalloid.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS, TUBES, CATHETERS: , 24-French chest tube in the left thorax plus Foley catheter.,SPECIMENS: , Left pleural-based nodule.,INDICATION FOR OPERATION:  ,The patient is a 59-year-old female with previous history of follicular thyroid cancer, approximately 40 years ago, status post resection with recurrence in the 1980s, who had a left pleural-based mass identified on chest x-ray.  Preoperative evaluation included a CT scan, which showed focal mass.  CT and PET confirmed anterior lesion.  Therefore the patient was seen in our thoracic tumor board where it was recommended to have resection performed with chest wall reconstruction.  In the outpatient setting, the patient was willing to proceed.,PROCEDURE PERFORMED IN DETAIL: , After informed consent was obtained, the patient identified correctly.  She was taken to the operating room where an epidural catheter was placed by Anesthesia without difficulty.  She was sedated and intubated with double-lumen endotracheal tube without difficulty.  She was positioned with left side up.  Appropriate pressure points were padded.  The left chest was prepped and draped in the standard surgical fashion.  The skin incision was made in the posterior axillary line, approximately 7th intercostal space with #10 blade, taken down through tissues and Bovie electrocautery.,Pleura was entered.  There was good deflation of the left lung.  __________ port was placed, followed by the 0-degree 10-mm scope with appropriate patient positioning.  Posteriorly a pedunculated 2.5 x 3-cm pleural-based mass was identified on the anterior chest wall.  There were thin adhesions to the pleura, but no invasion of the chest wall that could be identified.  The tumor was very mobile and was on a pedunculated stalk, approximately 1.5 cm.  It was felt that this could be resected without the need of chest wall reconstruction because of the narrow stalk.,Therefore a 2nd port was placed in the anterior axillary line approximately 8th intercostal space in the usual fashion.  Camera was placed through this port.  Laparoscopic scissors were placed through the posterior port, but it was necessary to have another instrument to provide more tension than just gravity.  Therefore because of the need to bring the specimen through the chest wall, a small 3-cm thoracotomy was made, which incorporated the posterior port site.  This was taken down to the subcutaneous tissue with Bovie electrocautery.  Periosteal elevator was used to lift the intercostal muscle off.  The ribs were not spread.  Through this 3-cm incision, both the laparoscopic scissors as well as Prestige graspers could be placed.  Prestige graspers were used to pull the specimen from the chest wall.  Care was taken not to injure the capsule.  The laparoscopic scissors on cautery were used to resect the parietal pleural off of the chest wall.  Care was taken not to transect the stalk.  Specimen came off the chest wall very easily.  There was good hemostasis.,At this point, the EndoCatch bag was placed through the incision.  Specimen was placed in the bag and then removed from the field.  There was good hemostasis.  Camera was removed.  A 24-French chest tube was placed through the anterior port and secured with 2-0 silk suture.  The posterior port site was closed 1st with 2-0 Vicryl in a running fashion for the intercostal muscle layer, followed by 2-0 closure of the latissimus fascia as well as subdermal suture, 4-0 Monocryl was used for the skin, followed by Steri-Strips and sterile drapes.  The patient tolerated the procedure well, was extubated in the operating room and returned to the recovery room in stable condition.
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DESCRIPTION: Left mesothelioma, focal.  Left anterior pleural-based nodule, which was on a thin pleural pedicle with no invasion into the chest wall.

surgery, mini thoracotomy, pleural based mass, pleural based nodule, chest wall, mesothelioma focal, pleural, chest, thoracotomy, mesothelioma, laparoscopic, thoracoscopy,

The surgical procedure described involves a thoracotomy and thoracoscopy for the removal of a mass associated with mesothelioma, a type of cancer. The high-stakes nature of this procedure arises from the involvement of the thoracic cavity, the need for careful handling of complex anatomy, and the implications of cancer treatment. Although the patient appears to have had a relatively successful initial surgery with minimal complications, any surgical intervention in a cancer diagnosis scenario inherently carries significant risks related to patient outcomes, potential complications, and impact on the cancer treatment plan.


Medical Specialty: Surgery
Sample Name: Thoracentesis - 1

PREOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,POSTOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,PROCEDURE:  ,Thoracentesis, left.,DESCRIPTION OF PROCEDURE: , The patient was brought to the recovery area of the operating room.  After obtaining the informed consent, the patient's posterior left chest wall was prepped and draped in usual fashion.  Xylocaine 1% was infiltrated above the seventh intercostal space in the midscapular line.  Initially, I tried to use the thoracentesis set after 1% Xylocaine had been infiltrated, but the needle of the system was just too short to reach the pleural cavity due to the patient's very thick chest wall.  Therefore, I had to use a #18 spinal needle, which I had to use almost in its entire length to reach the fluid.  From then on, I proceeded manually to withdraw 2000 mL of a light milky fluid.,The patient tolerated the procedure fairly well, but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle.  At that time, it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine.  At any rate, we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation.  We then thought that if she was doing fine, then we will send her home.,A chest x-ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure.,
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DESCRIPTION: Thoracentesis, left.   Malignant pleural effusion, left, with dyspnea.

surgery, malignant pleural effusion, chest wall, pleural effusion, dyspnea, thoracentesis, fluid, pleural,

Thoracentesis is a medical procedure involving the removal of fluid from the pleural space in the chest. The stakes are moderately high because it involves the potential for complications such as pneumothorax (collapsed lung) and infection. In this specific case, the procedure was challenging due to the patient's thick chest wall requiring a longer needle, and the patient experienced slight discomfort towards the end of the procedure but recovered well. The absence of complications like pneumothorax, as confirmed by a post-procedure chest x-ray, suggests that the procedure went smoothly overall. However, due to the nature of the condition being a malignant pleural effusion and the fact that the patient experienced some discomfort, it isn't without risk.


Medical Specialty: Surgery
Sample Name: Temporal Artery Biopsy - 1

PREOPERATIVE DIAGNOSIS:,  Headaches, question of temporal arteritis.,POSTOPERATIVE DIAGNOSIS:,  Headaches, question of temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was brought to the operating room where her right temporal area was prepped and draped in the usual fashion.  Xylocaine 1% was utilized and then an incision was made in front of the right ear and deepened anteriorly.  The temporal artery was found and exposed in an extension of about 2 cm.  The artery was proximally and distally ligated with 6-0 Prolene and also a side branch and a sample was sent for pathology.  Hemostasis achieved with a cautery and the incision was closed with a subcuticular suture of Monocryl.,Then, the patient was turned and her left temporal area was prepped and draped in the usual fashion.  A similar procedure was performed with 1% Xylocaine and exposed her temporal artery, which was excised in an extent to about 2 cm.  This was also proximally and distally ligated with 6-0 Prolene and also side branch.  Hemostasis was achieved with a cautery and the skin was closed with a subcuticular suture of Monocryl.,Dressings were applied to both areas.,The patient tolerated the procedure well.  Estimated blood loss was negligible, and the patient went back to Same Day Surgery for recovery.
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DESCRIPTION: Headaches, question of temporal arteritis.  Bilateral temporal artery biopsies.

surgery, temporal arteritis, temporal artery, temporal, artery, biopsies, hemostasis, subcuticular, headaches, arteritis,

The situation involves a surgical procedure to diagnose temporal arteritis, a serious condition due to inflammation that can lead to complications like vision loss. The procedure, while routine and minimally invasive, involves surgery and is directly connected to a critical health diagnosis. Hence, it carries moderate stakes due to the potential health implications and surgical risks.


Medical Specialty: Surgery
Sample Name: Teeth Extraction & I&D - 2

PREOPERATIVE DIAGNOSIS:,  Right buccal space infection and abscess tooth #T.,POSTOPERATIVE DIAGNOSIS: , Right buccal space infection and abscess tooth #T.,PROCEDURE:,  Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection.,ANESTHESIA:,  General, oral endotracheal tube.,COMPLICATIONS: , None.,SPECIMENS:,  Aerobic and anaerobic cultures were sent.,IV FLUID: , 150 mL.,ESTIMATED BLOOD LOSS:,  10 mL.,PROCEDURE: , The patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, the patient was prepped and draped in the usual fashion for an intraoral procedure.  Gauze throat pack was placed and the right buccal vestibule was palpated and area of the abscess was located.  The abscess cavity was aspirated using a 5 mL syringe with an 18-gauge needle.  Approximately 1 mL of purulent material was aspirated that was placed on aerobic and anaerobic cultures.  Culture swabs and the tooth sent to the laboratory for culture and sensitivity testing.,The area in the buccal vestibule was then opened with approximately 1-cm incision.  Blunt dissection was then used to open up the abscess cavity and explore the abscess cavity.  A small amount of additional purulence was drained from it, approximately 1 mL and at this point, tooth #T was extracted by forceps extraction.  Periosteal elevator was used to explore the area near the extraction site.  This was continuous with abscess cavity, so the abscess cavity was allowed to drain into the extraction site.  No drain was placed.  Upon completion of the procedure, the throat pack was removed.  The pharynx was suctioned.  The stomach was also suctioned and the patient was then awakened, extubated, and taken to the recovery room in stable condition.
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DESCRIPTION: Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection.  Right buccal space infection and abscess tooth #T.

surgery, buccal space, incision and drainage, throat pack, extraction site, tooth, i&d, drainage, infection, cavity, extraction, incision, buccal, abscess

The situation involves a surgical procedure for a dental abscess, which is relatively routine and appears to have been completed successfully without complications. While general anesthesia is involved, adding some level of risk, the procedure is standard for treating abscesses of this nature. The absence of complications and the patient's stable condition post-operation suggest it is not extremely high-stakes.


Medical Specialty: Surgery
Sample Name: Tarsectomy

PREOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,POSTOPERATIVE DIAGNOSES:,1.  Painful enlarged navicula, right foot.,2.  Osteochondroma of right fifth metatarsal.,PROCEDURE PERFORMED:,1.  Partial tarsectomy navicula, right foot.,2.  Partial metatarsectomy, right foot.,HISTORY:  ,This 41-year-old Caucasian female who presents to ABCD General Hospital with the above chief complaint.  The patient states that she has extreme pain over the navicular bone with shoe gear as well as history of multiple osteochondromas of unknown origin.  She states that she has been diagnosed with hereditary osteochondromas.  She has had previous dissection of osteochondromas in the past and currently has not been diagnosed in her feet as well as spine and back.  The patient desires surgical treatment at this time.,PROCEDURE:  ,An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on operating table in the supine position with a safety belt across her lap.  Copious amounts of Webril were placed on the left ankle followed by a blood pressure cuff.  After adequate sedation by the Department of Anesthesia, a total of 5 cc of 1:1 mixture of 1% lidocaine plain and 0.5% Marcaine plain were injected in the diamond block type fashion around the navicular bone as well as the fifth metatarsal.  Foot was then prepped and draped in the usual sterile orthopedic fashion.,Foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was then inflated to 250 mmHg.  The foot was lowered as well as the operating table.  The sterile stockinet was reflected and the foot was cleansed with wet and dry sponge.  Attention was then directed to the navicular region on the right foot.  The area was palpated until the bony prominence was noted.  A curvilinear incision was made over the area of bony prominence.  At that time, a total of 10 cc with addition of 1% additional lidocaine plain was injected into the surgical site.  The incision was then deepened with #15 blade.  All vessels encountered were ligated for hemostasis.  The dissection was carried down to the level of the capsule and periosteum.  A linear incision was made over the navicular bone obliquely from proximal dorsal to distal plantar over the navicular bone.  The periosteum and the capsule were then reflected from the navicular bone at this time.  A bony prominence was noted both medially and plantarly to the navicular bone.  An osteotome and mallet were then used to resect the enlarged portion of the navicular bone.  After resection with an osteotome there was noted to be a large plantar shelf.  The surrounding soft tissues were then freed from this plantar area.  Care was taken to protect the attachments of the posterior tibial tendon as much as possible.  Only minimal resection of its attachment to the fiber was performed in order to expose the bone.  Sagittal saw was then used to resect the remaining plantar medial prominent bone.  The area was then smoothed with reciprocating rasp until no sharp edges were noted.  The area was flushed with copious amount of sterile saline at which time there was noted to be a palpable ________ where the previous bony prominence had been noted.  The area was then again flushed with copious amounts of sterile saline and the capsule and periosteum were then reapproximated with #3-0 Vicryl.  The subcutaneous tissues were then reapproximated with #4-0 Vicryl to reduce tension from the incision and running #5-0 Vicryl subcuticular stitch was performed.,Attention was then directed to the fifth metatarsal.  There was noted to be a palpable bony prominence dorsally with fifth metatarsal head as well as radiographic evidence laterally of an osteochondroma at the neck of the fifth metatarsal.  Approximately 7 cm incision was made dorsolaterally over the fifth metatarsal.  The incision was then deepened with #15 blade.  Care was taken to preserve the extensor tendon.  The incision was then created over the capsule and periosteum of the fifth metatarsal head.  Capsule and periosteum were reflected both dorsally, laterally, and plantarly.  At that time, there was noted to be a visible osteochondroma on the plantar lateral aspect of the fifth metatarsal neck as well as on the dorsal aspect of the head of the fifth metatarsal.  A sagittal saw was used to resect both of these osteal prominences.,All remaining sharp edges were then smoothed with reciprocating rasp.  The area was inspected for the remaining bony prominences and none was noted.  The area was flushed with copious amounts of sterile saline.  The capsule and periosteum were then reapproximated with #3-0 Vicryl.  Subcutaneous closure was then performed with #4-0 Vicryl in order to reduce tension around the incision line.  Running #5-0 subcutaneous stitch was then performed.  Steri-Strips were applied to both surgical sites.  Dressings consisted of Adaptic, soaked in Betadine, 4x4s, Kling, Kerlix, and Coban.  The pneumatic ankle tourniquet was released and the hyperemic flush was noted to all five digits of the right foot.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transferred to the PACU with vital signs stable and vascular status intact.  The patient was given postoperative pain prescription and instructed to be partially weightbearing with crutches as tolerated.  The patient is to follow-up with Dr. X in his office as directed or sooner if any problems or questions arise.
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DESCRIPTION: Painful enlarged navicula, right foot.  Osteochondroma of right fifth metatarsal. Partial tarsectomy navicula and partial metatarsectomy, right foot.

surgery, navicula, metatarsal, osteochondroma, tarsectomy, metatarsectomy, painful enlarged navicula, navicular bone, foot, bony, capsule, periosteum, navicular, incision, bone

The situation involves a surgical procedure on a patient's foot to address painful bony growths. Surgery inherently carries risks such as infection, bleeding, and complications from anesthesia, making this a moderately high-stakes scenario. However, it is not emergent, but rather an elective procedure to improve the patient's quality of life by reducing pain. Given that the patient is stable post-operation and has clear follow-up instructions, the stakes are somewhat controlled.


Medical Specialty: Surgery
Sample Name: Teeth (full-mouth) Extraction

PREOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,POSTOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,PROCEDURE:, Full-mouth extraction of tooth #3,5,6, 7, 8, 9, 10, 11, 12, 13, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 31, and alveoloplasty in all four quadrants.,ANESTHESIA:,  Nasotracheal general anesthesia.,IV FLUIDS:, A 700 mL of crystalloid.,EBL:, Minimum.,URINE:, Not recorded.,COMPLICATIONS:, None.,CONDITION:, Good.,DISPOSITION:,  The patient was extubated in OR, transferred to PACU for recovery and will be transferred for 23-hour observation and discharged on subsequent day.,BRIEF HISTORY OF THE PATIENT:, Indicated the patient for surgery.  The patient is a 41-year-old white female with multiple grossly decaying nonrestorable teeth.  After discussing treatment options, she decided she will like to have extraction of remaining teeth with subsequent placement of upper and lower complete dentures.,PAST MEDICAL HISTORY:, Positive for a narcotic abuse, presently on methadone treatment, hepatitis C, and headaches.,PAST SURGICAL HISTORY:, C-section x2.,MEDICATIONS,Right now include:,1.  Methadone.,2.  Beta-blocker.,3.  Xanax.,4.  Norco.,5.  Clindamycin.,ALLERGIES:, THE PATIENT IS ALLERGIC TO PENICILLIN.,PROCEDURE IN DETAIL:, The patient was greeted in preoperative holding area, subsequently transferred to OR #17 where the patient was intubated with anesthesia staff present.  The patient was prepped and draped in sterile fashion.  Local anesthesia consisting of 1% lidocaine and 1:100,000 epinephrine, total 15 mL were injected into the maxillomandible.  Throat pack was placed in the mouth after a thorough suction.,A full-thickness mucoperiosteal flap was reflected from the upper right to the upper left, tooth number 3,5,6,7,8,9,10,11,12,13, and 14 and were elevated and delivered.  Extraction sites were thoroughly curettaged and irrigated.  Bony undercuts were removed then smoothed with rongeurs and bone saw.  After thorough irrigation, the postsurgical site closed in a running fashion with 3-0 chromic sutures.  Subsequently, a full-thickness mucoperiosteal flap was reflected in the mandible, tooth numbers 31, 28, 27, 26, 25, 24, 23, 22, 21, 20, and 19 were elevated and delivered with simple forceps extractions.  Bony undercuts were removed with rongeurs and smoothed with bone saw.,Extraction sites were thoroughly irrigated and curettaged.  Wound was closed in continuous fashion 3-0 chromic.  After adequate hematosis was achieved, 0.5% Marcaine and 1:200,000 epinephrine was injected in the maxillomandible thus to heal to aid in hematosis and pain control.  Total of 8 mL were used.  Throat pack was subsequently removed.  Orogastric tube was passed to suction out the stomach.,The patient was subsequently extubated in OR and transferred to PACU for recovery.  The patient would be placed in 23-hour observation.
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DESCRIPTION: Full-mouth extraction of teeth and alveoloplasty in all four quadrants.

The situation involves a full-mouth extraction surgery, which, while not extremely high-stakes like some emergency or life-threatening situations, still represents a significant surgical procedure with notable implications. The patient has complicating factors, such as a history of narcotic abuse, hepatitis C, and allergy to penicillin, which can increase the risk of complications during and after surgery. However, the procedure itself appears to have been completed without complications, and the patient is noted to be in good condition postoperatively. This mitigates the stakes somewhat but doesn't eliminate them entirely given the potential for post-operative issues and the need for effective pain management given the patient's medical history.


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

Medical Specialty: Surgery
Sample Name: Tailor Bunionectomy with Screw Fixation

PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus deformity, right foot.,2.  Tailor bunion deformity, right foot.,PROCEDURES PERFORMED:  ,Tailor bunionectomy, right foot, Weil-type with screw fixation.,ANESTHESIA: , Local with MAC, local consisting of 20 mL of 0.5% Marcaine plain.,HEMOSTASIS:,  Pneumatic ankle tourniquet at 200 mmHg.,INJECTABLES:,  A 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate.,MATERIAL: , A 2.4 x 14 mm, 2.4 x 16 mm, and 2.0 x 10 mm OsteoMed noncannulated screw.  A 2-0 Vicryl, 3-0 Vicryl, 4-0 Vicryl, and 5-0 nylon.,COMPLICATIONS: , None.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed on the operating table in the usual supine position.  At this time, a pneumatic ankle tourniquet was placed on the patient's right ankle for the purpose of maintaining hemostasis.  Number of the anesthesias was obtained and then induced mild sedation and local anesthetic as described above was infiltrated about the surgical site.  The right foot was then scrubbed, prepped, and draped in the usual aseptic manner.  An Esmarch bandage was then used to exsanguinate the patient's right foot, and the pneumatic ankle tourniquet inflated to 200 mmHg.  Attention was then directed to dorsal aspect of the first metatarsophalangeal joint where a linear longitudinal incision measuring approximately a 3.5 cm in length was made.  The incision was carried deep utilizing both sharp and blunt dissections.  All major neurovascular structures were avoided.  At this time, through the original skin incision, attention was directed to the first intermetatarsal space where utilizing both sharp and blunt dissection the deep transverse intermetatarsal ligament was identified.  This was then incised fully exposing the tendon and the abductor hallucis muscle.  This was then resected from his osseous attachments and a small tenotomy was performed.  At this time, a small lateral capsulotomy was also performed.  Lateral contractures were once again reevaluated and noted to be grossly reduced.,Attention was then directed to the dorsal aspect of the first metatarsal phalangeal joint where linear longitudinal and periosteal and capsular incisions were made following the first metatarsal joint and following the original shape of the skin incision.  The periosteal capsular layers were then reflected both medially and laterally from the head of the first metatarsal and a utilizing an oscillating bone saw, the head of the first metatarsal and medial eminence was resected and passed from the operative field.  A 0.045 inch K-wire was then driven across the first metatarsal head in order to act as an access dye.  The patient was then placed in the frog-leg position, and two osteotomy cuts were made, one from the access guide to the plantar proximal position and one from the access guide to the dorsal proximal position.  The dorsal arm was made longer than the plantar arm to accommodate for fixation.  At this time, the capital fragment was resected and shifted laterally into a more corrected position.  At this time, three portions of the 0.045-inch K-wire were placed across the osteotomy site in order to access temporary forms of fixation.  Two of the three of these K-wires were removed in sequence and following the standard AO technique two 3.4 x 15 mm and one 2.4 x 14 mm OsteoMed noncannulated screws were placed across the osteotomy site.  Compression was noted to be excellent.  All guide wires and 0.045-inch K-wires were then removed.  Utilizing an oscillating bone saw, the overhanging wedge of the bone on the medial side of the first metatarsal was resected and passed from the operating field.  The wound was then once again flushed with copious amounts of sterile normal saline.  At this time, utilizing both 2-0 and 3-0 Vicryl, the periosteal and capsular layers were then reapproximated.  At this time, the skin was then closed in layers utilizing 4-0 Vicryl and 4-0 nylon.  At this time, attention was directed to the dorsal aspect of the right fifth metatarsal where a linear longitudinal incision was made over the metatarsophalangeal joint just lateral to the extensor digitorum longus tension.  Incision was carried deep utilizing both sharp and blunt dissections and all major neurovascular structures were avoided.,A periosteal and capsular incision was then made on the lateral aspect of the extensor digitorum longus tendon and periosteum and capsular layers were then reflected medially and laterally from the head of the fifth metatarsal.  Utilizing an oscillating bone saw, the lateral eminence was resected and passed from the operative field.  Utilizing the sagittal saw, a Weil-type osteotomy was made at the fifth metatarsal head.  The head was then shifted medially into a more corrected position.  A 0.045-inch K-wire was then used as a temporary fixation, and a 2.0 x 10 mm OsteoMed noncannulated screw was placed across the osteotomy site.  This was noted to be in correct position and compression was noted to be excellent.  Utilizing a small bone rongeur, the overhanging wedge of the bone on the dorsal aspect of the fifth metatarsal was resected and passed from the operative field.  The wound was once again flushed with copious amounts of sterile normal saline.  The periosteal and capsular layers were reapproximated utilizing 3-0 Vicryl, and the skin was then closed utilizing 4-0 Vicryl and 4-0 nylon.  At this time, 10 mL of 0.5% Marcaine plain and 1 mL of dexamethasone phosphate were infiltrated about the surgical site.  The right foot was then dressed with Xeroform gauze, fluffs, Kling, and Ace wrap, all applied in mild compressive fashion.  The pneumatic ankle tourniquet was then deflated and a prompt hyperemic response was noted to all digits of the right foot.  The patient was then transported from the operating room to the recovery room with vital sings stable and neurovascular status grossly intact to the right foot.  After a brief period of postoperative monitoring, the patient was discharged to home with proper written and verbal discharge instructions, which included to keep dressing clean, dry, and intact and to follow up with Dr. A.  The patient is to be nonweightbearing to the right foot.  The patient was given a prescription for pain medications on nonsteroidal anti-inflammatory drugs and was educated on these.  The patient tolerated the procedure and anesthesia well.  Dr. A was present throughout the entire case.
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DESCRIPTION: Tailor bunionectomy, right foot, Weil-type with screw fixation.  Hallux abductovalgus deformity and tailor bunion deformity, right foot.

surgery, tailor bunionectomy, weil-type, screw fixation, hallux, abductovalgus, bunion, tailor, deformity, metatarsal, phalangeal, capsulotomy, abductor, hallucis,

The scenario describes a surgical procedure for addressing foot deformities, specifically a tailor bunionectomy with screw fixation. Despite being a common and generally low-risk foot surgery, it inherently involves risks associated with surgery and anesthesia. However, the procedure went smoothly with no complications, minimal blood loss, and the patient was discharged on the same day. The stakes are fairly moderate since it is a surgical intervention but the nature of this specific surgery does not typically involve life-threatening risks.


Medical Specialty: Surgery
Sample Name: Suction, Dilation, & Curettage - 1

PREOPERATIVE DIAGNOSIS: ,Incomplete abortion.,POSTOPERATIVE DIAGNOSIS: ,Incomplete abortion.,PROCEDURE PERFORMED:, Suction dilation and curettage.,ANESTHESIA:  ,General and nonendotracheal by Dr. X.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,SPECIMENS: , Endometrial curettings.,DRAINS: , None.,FINDINGS:  ,On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina.  There was a large amount of tissue obtained on the procedure.,PROCEDURE:  ,The patient was taken to the operating room where a general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  Next, a weighted speculum was placed in the vagina.  The anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm, no cervical dilation was needed.  A size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed.  Two passes were made with the suction curettage.  Next, a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus.  After the procedure, the vulsellum tenaculum was removed.  The cervix was seemed to be hemostatic.  The weighted speculum was removed.  The patient was given 0.25 mg of Methergine IM approximately half-way through the procedure.  After the procedure, a second bimanual exam was performed and the patient's uterus had significantly decreased in size.  It is now approximately eight to ten-week size.  The patient was taken from the operating room in stable condition after she was cleaned.  She will be discharged on today.  She was given Methergine, Motrin, and doxycycline for her postoperative care.  She will follow-up in one week in the office.
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DESCRIPTION: Suction dilation and curettage for incomplete abortion.  On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina.  There was a large amount of tissue obtained on the procedure.

surgery, uterus, anteverted, dorsal lithotomy position, weighted speculum, mobile uterus, vulsellum tenaculum, bimanual exam, vagina, tenaculum, dilation, bimanual, cervix, suction, curettage,

The procedure described is a suction dilation and curettage, which is typically performed following incomplete abortion. This is a significant medical procedure that requires surgical intervention and general anesthesia. While it is commonly performed and generally safe when executed by experienced practitioners, it addresses the serious condition of incomplete abortion, where remnants of the pregnancy can lead to significant complications like infection or heavy bleeding. Therefore, while it might be routine for medical practitioners, it still involves substantial medical risks, making it relatively high-stakes from the patient's perspective.


Medical Specialty: Surgery
Sample Name: Subxiphoid Pericardial Window

PREOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,POSTOPERATIVE DIAGNOSIS (ES):,1. Endocarditis.,2. Status post aortic valve replacement with St. Jude mechanical valve.,3. Pericardial tamponade.,PROCEDURE:,1. Emergent subxiphoid pericardial window.,2. Transesophageal echocardiogram.,ANESTHESIA:, General endotracheal.,FINDINGS:, The patient was noted to have 600 mL of dark bloody fluid around the pericardium. We could see the effusion resolve on echocardiogram. The aortic valve appeared to have good movement in the leaflets with no perivalvular leaks. There was no evidence of endocarditis. The mitral valve leaflets moved normally with some mild mitral insufficiency.,DESCRIPTION OF THE OPERATION:, The patient was brought to the operating room emergently. After adequate general endotracheal anesthesia, his chest was prepped and draped in the routine sterile fashion. A small incision was made at the bottom of the previous sternotomy incision. The subcutaneous sutures were removed. The dissection was carried down into the pericardial space. Blood was evacuated without any difficulty. Pericardial Blake drain was then placed. The fascia was then reclosed with interrupted Vicryl sutures. The subcutaneous tissues were closed with a running Monocryl suture. A subdermal PDS followed by a subcuticular Monocryl suture were all performed. The wound was closed with Dermabond dressing. The procedure was terminated at this point. The patient tolerated the procedure well and was returned back to the intensive care unit in stable condition.
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DESCRIPTION: Emergent subxiphoid pericardial window, transesophageal echocardiogram.

surgery, endocarditis, valve replacement, st. jude, echocardiogram, transesophageal, pericardium, blake drain, st jude mechanical valve, subxiphoid pericardial window, pericardial window, aortic valve, tamponade, subxiphoid, valve, pericardial, aortic

The situation involves an emergent surgical procedure due to pericardial tamponade, a condition that can rapidly become life-threatening if not treated promptly. The surgical intervention, which also required general anesthesia and was conducted in an emergency setting, underscores the high-stakes nature of the scenario. The fact that this was to address complications potentially stemming from a complex condition such as endocarditis and prior heart valve replacement increases the stakes further, given the critical nature of cardiac health interventions.


Medical Specialty: Surgery
Sample Name: Subperiosteal Abscess Debridement

PREOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,POSTOPERATIVE DIAGNOSIS: , Right distal femoral, subperiosteal abscess.,OPERATION:,  Repeat irrigation and debridement of above.,ANESTHESIA: , General.,BLOOD LOSS:,  Minimal.,FLUID: , Per anesthesia.,DRAINS: , Hemovac times two.,COMPLICATIONS: , None apparent.,SPECIMENS:,  To microbiology.,INDICATIONS: , She is a 10-year-old girl who has history of burns and has developed a subperiosteal abscess at her right distal femur.  I am bringing her back to the operating room for another exploration of this area and washout.  This will be the third procedure for this.  At the last time, there was gross purulence that was encountered.  Since that time, the patient has defervesced.  Her white count is slowly coming down.  Her C-reactive protein is slowly coming down.,PROCEDURE IN DETAIL:,  After informed consent was obtained, operative site marked, and after preoperative antibiotics were given, the patient was brought back to the operating room and placed supine on the operating table, where Anesthesia induced general anesthesia.  The patient's right lower extremity was prepped and draped in normal sterile fashion.  Surgical timeout occurred verifying the patient's identification, surgical site, surgical procedure, and administration of antibiotics.  The patient's previous incision sites had the sutures removed.  We bluntly dissected down through to the IT band.  These deep stitches were then removed.  We exposed the area of the subperiosteal abscess.  The tissue looked much better than at the last surgery.  We irrigated this area with three liters of saline containing bacitracin.  Next, we made our small medial window to assist with washout of the joint itself.  We put another three liters of saline containing bacitracin through the knee joint.  Lastly, we did another three liters into the area of the distal femur with three liters of plain saline.  We then placed two Hemovac drains, one in the metaphysis and one superficially.  We closed the deep fascia with #1 PDS.  Subcutaneous layers with 2-0 Monocryl and closed the skin with 2-0 nylon.  We placed a sterile dressing.  We then turned the case over to Dr. Petty for dressing change and skin graft.,PLAN:  ,Our plan will be to pull the drains in 48 hours.  We will then continue to watch the patient's fever curve and follow her white count to see how she is responding to the operative and medical therapies.,
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DESCRIPTION: Repeat irrigation and debridement of Right distal femoral subperiosteal abscess.

surgery, repeat irrigation and debridement, repeat irrigation, distal femur, distal femoral, femoral subperiosteal, subperiosteal abscess, hemovac, femur, debridement, irrigation, saline, anesthesia, distal, subperiosteal, abscess,

The situation involves a surgical procedure on a 10-year-old girl with a subperiosteal abscess, which is a potentially serious medical condition due to the risk of infection and the fact that it involves the bone. The procedure described is the third surgery for the condition, indicating ongoing complications and potential risk for the patient. While the immediate surgery had no apparent complications and involved minimal blood loss, the repeated need for surgery and the involvement of infection (as indicated by past purulence and monitoring of C-reactive protein and white blood cell count) elevate the stakes, though they are managed under controlled medical settings.