Medical Specialty: Surgery
Sample Name: Bunionectomy & Metatarsal Osteotomy

PREOPERATIVE DIAGNOSES:,1.  Bunion left foot.,2.  Hammertoe, left second toe.,POSTOPERATIVE DIAGNOSES:,1.  Bunion left foot.,2.  Hammertoe, left second toe.,PROCEDURE PERFORMED:,1.  Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left.,2.  Arthroplasty left second toe.,HISTORY:  ,This 39-year-old female presents to ABCD General Hospital with the above chief complaint.  The patient states that she has had bunion for many months.  It has been progressively getting more painful at this time.  The patient attempted conservative treatment including wider shoe gear without long-term relief of symptoms and desires surgical treatment.,PROCEDURE: , An IV was instituted by the Department of Anesthesia in the preop holding area.  The patient was transported to the operating room and placed on the operating table in the supine position with a safety belt across her lap.  Copious amount of Webril were placed around the left ankle followed by a blood pressure cuff.  After adequate sedation was achieved by the Department of Anesthesia, a total of 15 cc of 0.5% Marcaine plain was injected in a Mayo and digital block to the left foot.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The foot was elevated from the operating table and exsanguinated with an Esmarch bandage.  The pneumatic ankle tourniquet was inflated to 250 mmHg and the foot was lowered to the operating table.  The stockinette was reflected.  The foot was cleansed with wet and dry sponge.  Attention was then directed to the first metatarsophalangeal joint of the left foot.  An incision was created over this area approximately 6 cm in length.  The incision was deepened with a #15 blade.  All vessels encountered were ligated for hemostasis.  The skin and subcutaneous tissue was then dissected from the capsule.  Care was taken to preserve the neurovascular bundle.  Dorsal linear capsular incision was then created.  The capsule was then reflected from the head of the first metatarsal.  Attention was then directed to the first interspace where a lateral release was performed.  A combination of sharp and blunt dissection was performed until the abductor tendons were identified and transected.  A lateral capsulotomy was performed.  Attention was then directed back to the medial eminence where sagittal saw was used to resect the prominent medial eminence.  The incision was then extended proximally with further dissection down to the level of the bone.  Two 0.45 K-wires were then inserted as access guides for the SCARF osteotomy.  A standard SCARF osteotomy was then performed.  The head of the first metatarsal was then translocated laterally in order to reduce the first interspace in the metatarsal angle.  After adequate reduction of the bunion deformity was noted, the bone was temporarily fixated with a 0.45 K-wire.  A 3.0 x 12 mm screw was then inserted in the standard AO fashion with compression noted.  A second 3.0 x 14 mm screw was also inserted with tight compression noted.  The remaining prominent medial eminence medially was then resected with a sagittal saw.  Reciprocating rasps were then used to smooth any sharp bony edges.  The temporary fixation wires were then removed.  The screws were again checked for tightness, which was noted.  Attention was directed to the medial capsule where a medial capsulorrhaphy was performed.  A straight stat was used to assist in removing a portion of the capsule.  The capsule was then reapproximated with #2-0 Vicryl medially.  Dorsal capsule was then reapproximated with #3-0 Vicryl in a running fashion.  The subcutaneous closure was performed with #4-0 Vicryl followed by running subcuticular stitch with #5-0 Vicryl.  The skin was then closed with #4-0 nylon in a horizontal mattress type fashion.,Attention was then directed to the left second toe.  A dorsal linear incision was then created over the proximal phalangeal joint of the left second toe.  The incision was deepened with a #15 blade and the skin and subcutaneous tissue was dissected off the capsule to be aligned laterally.  An incision was made on either side of the extensor digitorum longus tendon.  A curved mosquito stat was then used to reflex the tendon laterally.  The joint was identified and the medial collateral ligamentous attachments were resected off the head of the proximal phalanx.  A sagittal saw was then used to resect the head of the proximal head.  The bone was then rolled and the lateral collateral attachments were transected and the bone was removed in toto.  The extensor digitorum longus tendon was inspected and noted to be intact.  Any sharp edges were then smoothed with reciprocating rasp.  The area was then flushed with copious amounts of sterile saline.  The skin was then reapproximated with #4-0 nylon.  Dressings consisted of Owen silk, 4x4s, Kling, Kerlix, and Coban.  Pneumatic ankle tourniquet was released and an immediate hyperemic flush was noted to all five digits of the left foot.  The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to PACU with vital signs stable and vascular status intact to the left foot.  The patient is to follow up with Dr. X in his clinic as directed.
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DESCRIPTION: Bunionectomy, SCARF type, with metatarsal osteotomy and internal screw fixation, left and arthroplasty left second toe.  Bunion left foot and hammertoe, left second toe.

surgery, hammertoe, osteotomy, internal screw fixation, scarf type, extensor digitorum, metatarsal osteotomy, foot, toe, metatarsal, bunionectomy,

The situation presented is a surgical procedure for a bunionectomy and a metatarsal osteotomy, which are considered routine orthopedic surgeries to treat foot deformities. While surgery always carries some risk, these are common procedures with well-established techniques and typically have a low risk of major complications. The document describes a planned and controlled surgical environment, suggesting standard protocols followed without any noted complications. The stakes are moderate given that the patient requires surgery to relieve pain and correct deformities but does not appear to be in a life-threatening condition. Based on this information, this scenario is not among the highest stakes in medical practice.


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

Medical Specialty: Surgery
Sample Name: Buccal Mucosal Lesion Excision

PREOPERATIVE DIAGNOSIS: , Left buccal mucosal verrucous squamous cell carcinoma.,POSTOPERATIVE DIAGNOSIS: , Left buccal mucosal verrucous squamous cell carcinoma.,PROCEDURE PERFORMED:,1.  Wide local excision of left buccal mucosal lesion with full thickness skin graft closure in the left supraclavicular region.,2.  Adjacent tissue transfer closure of the left supraclavicular grafting site.,ESTIMATED BLOOD LOSS: , Less than 30 cc.,COMPLICATIONS:, None.,INDICATIONS FOR PROCEDURE: , The patient is a 16-year-old Caucasian female with a history of left verrucous squamous cell carcinoma of the buccal mucosa, present for a number of months that was diagnosed in the office after two biopsies.  After risks, complications, consequences, and questions were addressed with the patient, medical clearance was obtained with the patient and a written consent was obtained.,PROCEDURE: , The patient was brought to operative suite by Anesthesia.  The patient was placed on the operative table in supine position.  After this, the patient was then placed under general endotracheal intubation anesthesia.  The operating bed was then turned 90 degrees away from anesthesia.  A shoulder roll was then placed followed by the patient's oral lesion being localized with 1% lidocaine with epinephrine 1:1000 approximately 5 cc total.  After this the patient was then prepped and draped in the usual sterile fashion including the left shoulder region.,After this sweetheart retractor along with a Minnesota retractor were utilized to lift the upper and lower lips along with tongue to gain access to this oral cavity lesion.  A #15 Bard Parker was then utilized to make an incision circumferentially around this lesion or mass with approximately a 1 cm margin.  The lesion was then grasped with a DeBakey forceps and grasped through in order to dissect this from the buccal mucosal sites with a #15 blade along with a curved sharp Joseph scissors.  After this the 12, 6, and 3 o'clock positions were marked with marking suture and the specimen was finally passed off the field.  It was sent to the frozen section's Pathology.  Hemostasis was maintained with bipolar cauterization.  Pathology called back into the room and verified that the regions from 12 to 3 and from 6 to 12 were still involved.  A second margin was obtained from the 6 o'clock position all the way to the 3 o'clock position with sutures again placed in the 12, 6, and 3 o'clock regions.  This was cut utilizing the #15 Bard-Parker and grasped with the DeBakey forceps.  It was passed off the field and sent to Pathology.  Pathology then called back into the room and verified that margins were clear.  After this the bipolar cauterization was then utilized to control a further bleeding.  After this the superior and inferior aspects of the defect were reapproximated with approximately one #4-0 Vicryl suture.  After this the left shoulder that was prepped previously was unveiled.  Surgical gloves were all changed and a 3 x 4 cm elliptical skin graft was taken from the left supraclavicular region.  First a #15 Bard-Parker was utilized to make an incision in the skin in elliptical fashion.  After this the skin was then grasped and a full thickness graft was taken with undermining performed by the #15 Bard-Parker.  After this the underlying subcutaneous tissue was then hemostatically controlled with bipolar cauterization.  After this the tissue was then reapproximated in multiple interrupted #4-0 undyed Vicryl followed by reapproximation of the skin with a #5-0 Prolene.  After this the skin graft was then defatted with a curved Joseph scissors.  It was then placed in the oral defect.  Circumferentially it was sutured down to the edge of the buccal mucosa with multiple interrupted #4-0 undyed Vicryl sutures.  It was then ________ with a #15 Bard-Parker and sutured in from the midportion of the multiple areas with multiple interrupted #4-0 undyed Vicryl.  After this the patient was then thoroughly cleaned and Mastisol Steri-Strips were then placed on the left shoulder defect along with the sterile dressing.  The patient was then turned back to the Anesthesia, extubated in the operating room and transferred to recovery room in stable condition.  The patient tolerated the procedure well and will be admitted to hospital for observation.
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DESCRIPTION: Wide local excision of left buccal mucosal lesion with full thickness skin graft closure in the left supraclavicular region and adjacent tissue transfer closure of the left supraclavicular grafting site

surgery, buccal mucosal verrucous squamous cell carcinoma, skin graft closure, supraclavicular, buccal mucosal lesion, squamous cell carcinoma, supraclavicular region, bard parker,

The situation involves a surgical procedure to excise a buccal mucosal lesion identified as verrucous squamous cell carcinoma in a 16-year-old patient. Surgery inherently carries significant risks and is of high importance, particularly when it involves cancer excision. The stakes are high due to the need for accurate removal to prevent recurrence and ensure clear margins. However, considering the patient was stable throughout the procedure and no complications were reported, the stakes aren't at the absolute highest end.

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Medical Specialty: Surgery
Sample Name: BTL & Salpingectomy

PREOPERATIVE DIAGNOSES:,1.  Pregnancy at 38 weeks and three days.,2.  Previous cesarean section x2.,3.  Refusing trial of labor.,4.  Multiparity, seeking family planning.,POSTOPERATIVE DIAGNOSES:,1.  Pregnancy at 38 weeks and three days.,2.  Previous cesarean section x2.,3.  Refusing trial of labor.,4.  Multiparity, seeking family planning.,5.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Repeat low transverse cervical cesarean section with delivery of a viable female neonate.,2.  Bilateral tubal ligation and partial salpingectomy.,3.  Lysis of adhesions.,ANESTHESIA: , Spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 800 cc.,FLUIDS: , 1800 cc of crystalloids.,URINE OUTPUT:,  600 cc of clear urine at the end of the procedure.,INDICATIONS:  ,This is a 36-year-old African-American female gravida 4, para-2-0-1-2, who presents for elective repeat cesarean section.  The patient has previous cesarean section x2 and refuses trial of labor.  The patient also requests a tubal ligation for permanent sterilization and family planning.,FINDINGS:,  A female infant in cephalic presentation in a ROP position.  Apgars of 9 and 9 at one and five minutes respectively.  Weight is 6 lb 2 oz and loose nuchal cord x1.  Normal uterus, tubes, and ovaries.,PROCEDURE:  ,After consent was obtained, the patient was taken to the operating room, where spinal anesthetic was found to be adequate.  The patient was placed in the dorsal supine position with a leftward tilt and prepped and draped in the normal sterile fashion.  The patient's previous Pfannenstiel scar incision was removed and the incision was carried through the underlying layer of fascia using the second knife.  The fascia was incised in the midline and the fascial incision was extended laterally using the second knife.  The rectus muscles were separated in the midline.  The peritoneum was identified, grasped with hemostats, and entered sharply with Metzenbaum scissors.  This incision was extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was then inserted and vesicouterine peritoneum was identified, grasped with an Allis clamp and entered sharply with Metzenbaum scissors.  This incision was extended laterally and the bladder flap created digitally.  The bladder blade was then reinserted and a small transverse incision was made along the lower uterine segment.  This incision was extended laterally manually.  The amniotic fluid was ruptured at this point with clear fluid obtained.  The infant's head was delivered atraumatically.  The nose and mouth were both suctioned on delivery.  The cord was doubly clamped and cut.  The infant was handed off to the awaiting pediatrician.  Cord gases and cord bloods were obtained and sent.  The placenta was then removed manually and the uterus exteriorized and cleared of all clots and debris.  The uterine incision was reapproximated with #0 chromic in a running lock fashion.  A second layer of the same suture was used with excellent hemostasis.  Attention was now turned to the right fallopian tube, which was grasped with the Babcock and avascular space below the tube was entered using a hemostat.  The tube was doubly clamped using hemostat and the portion between the clamps was removed using Metzenbaum scissors.  The ends of the tube were cauterized using the Bovie and they were then tied off with #2-0 Vicryl.  Attention was then turned to the left fallopian tube, which was grasped with the Babcock and avascular space beneath the tube was entered using a hemostat.  The tube was then doubly clamped with hemostat and the portion of tube between them was removed using the Metzenbaum scissors.  The ends of the tubes were cauterized and the tube was suture-ligated with #2-0 Vicryl.  There were some adhesions of the omentum to the bilateral adnexa.  These were carefully taken down using Metzenbaum scissors with excellent hemostasis noted.  The uterus was then returned to the abdomen and the bladder was cleared of all clots.  The uterine incision was reexamined and found to be hemostatic.  The fascia was then reapproximated with #0 Vicryl in a running fashion.  Several interrupted sutures of #3-0 chromic were placed in the subcutaneous tissue.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  The patient was taken to the recovery room in satisfactory condition.  She will be followed immediately postoperatively within the hospital.
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DESCRIPTION: Repeat low transverse cervical cesarean section with delivery of a viable female neonate.  Bilateral tubal ligation and partial salpingectomy.  Lysis of adhesions.

The situation described involves a repeat cesarean section, bilateral tubal ligation, and salpingectomy, all of which are common surgical procedures in obstetrics and gynecology. While the surgery itself is routine, it carries inherent risks due to anesthesia, blood loss, and the surgical process. The stakes are heightened by the context of surgery on a pregnant patient, which involves the safety of both the mother and the infant. Given that there were no reported complications and the procedure was elective with the informed consent of the patient, this particular case does not appear to be extremely high-stakes. However, considering the routine surgical risks and the context of childbirth, it is still relatively important.


Medical Specialty: Surgery
Sample Name: Broviac Catheter Placement

PREOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,POSTOPERATIVE DIAGNOSES:,1.  Lumbar osteomyelitis.,2.  Need for durable central intravenous access.,ANESTHESIA:,  General.,PROCEDURE:,  Placement of left subclavian 4-French Broviac catheter.,INDICATIONS:  ,The patient is a toddler admitted with a limp and back pain, who was eventually found on bone scan and septic workup to have probable osteomyelitis of the lumbar spine at disk areas.  The patient needs prolonged IV antibiotic therapy, but attempt at a PICC line failed.  She has exhausted most of her easy peripheral IV access routes and referral was made to the Pediatric Surgery Service for Broviac placement.  I met with the patient's mom.  With the help of a Spanish interpreter, I explained the technique for Broviac placement.  We discussed the surgical risks and alternatives, most of which have been exhausted.  All their questions have been answered, and the patient is fit for operation today.,DESCRIPTION OF OPERATION:  ,The patient came to the operating room and had an uneventful induction of general anesthesia.  We conducted a surgical time-out to reiterate all of the patient's important identifying information and to confirm that we were here to place the Broviac catheter.  Preparation and draping of her skin was performed with chlorhexidine based prep solution and then an infraclavicular approach to left subclavian vein was performed.  A flexible guidewire was inserted into the central location and then a 4-French Broviac catheter was tunneled through the subcutaneous tissues and exiting on the right anterolateral chest wall well below and lateral to the breast and pectoralis major margins.  The catheter was brought to the subclavian insertion site and trimmed so that the tip would lie at the junction of the superior vena cava and right atrium based on fluoroscopic guidelines.  The peel-away sheath was passed over the guidewire and then the 4-French catheter was deployed through the peel-away sheath.  There was easy blood return and fluoroscopic imaging showed initially the catheter had transited across the mediastinum up the opposite subclavian vein, then it was withdrawn and easily replaced in the superior vena cava.  The catheter insertion site was closed with one buried 5-0 Monocryl stitch and the same 5-0 Monocryl was used to tether the catheter at the exit site until fibrous ingrowth of the attached cuff has occurred.  Heparinized saline solution was used to flush the line.  A sterile occlusive dressing was applied, and the line was prepared for immediate use.  The patient was transported to the recovery room in good condition.  There were no intraoperative complications, and her blood loss was between 5 and 10 mL during the line placement portion of the procedure.
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DESCRIPTION: Lumbar osteomyelitis and need for durable central intravenous access.  Placement of left subclavian 4-French Broviac catheter.

surgery, lumbar osteomyelitis, central intravenous access, subclavian, osteomyelitis, broviac catheter, catheter, toddler, intravenous,

The procedure described involves the placement of a Broviac catheter in a toddler with lumbar osteomyelitis who requires prolonged IV antibiotic therapy. This is a high-stakes situation due to the patient's young age and the complexity of their medical condition. The need for central venous access and the failed attempt at a PICC line increase the stakes, as does the fact that many peripheral veins are exhausted. The risks associated with anesthesia and surgical complications, although minimal here as the operation went well, also contribute to the stakes. Moreover, effective intravenous access is critical for administering life-saving antibiotics given the seriousness of osteomyelitis.


Medical Specialty: Surgery
Sample Name: Bronchoscopy - 8

PREOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,POSTOPERATIVE DIAGNOSIS: , Persistent pneumonia, right upper lobe of the lung, possible mass.,PROCEDURE:,  Bronchoscopy with brush biopsies.,DESCRIPTION OF PROCEDURE: , After obtaining an informed consent, the patient was taken to the operating room where he underwent a general endotracheal anesthesia.  A time-out process had been followed and then the flexible bronchoscope was inserted through the endotracheal tube after 2 cc of 4% lidocaine had been infused into the endotracheal tube.  First the trachea and the carina had normal appearance.  The scope was passed into the left side and the bronchial system was found to be normal.  There were scars and mucoid secretions.  Then the scope was passed into the right side where brown secretions were obtained and collected in a trap to be sent for culture and sensitivity of aerobic and anaerobic fungi and TB.  First, the basal lobes were explored and found to be normal.  Then, the right upper lobe was selectively cannulated and no abnormalities were found except some secretions were aspirated.  Then, the bronchi going to the three segments were visualized and no abnormalities or mass were found.  Brush biopsy was obtained from one of the segments and sent to Pathology.,The procedure had to be interrupted several times because of the patient's desaturation, but after a few minutes of Ambu bagging, he recovered satisfactorily.,At the end, the patient tolerated the procedure well and was sent to the recovery room in satisfactory condition.,
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DESCRIPTION: Bronchoscopy with brush biopsies.  Persistent pneumonia, right upper lobe of the lung, possible mass.

surgery, persistent pneumonia, bronchoscopy, brush biopsies, endotracheal tube, biopsies, bronchial, abnormalities, pneumonia, secretions, endotracheal,

The procedure described is a bronchoscopy with brush biopsies to investigate persistent pneumonia and a possible mass in the right upper lobe of the lung. This situation is high-stakes due to the potential for finding a serious condition such as cancer, and the possibility of complications, as indicated by the patient's desaturation during the procedure. The stakes are further heightened by the need for precise pathological analysis for accurate diagnosis and subsequent treatment decisions.


Medical Specialty: Surgery
Sample Name: Bronchoscopy & Lobectomy

PREOPERATIVE DIAGNOSIS:  ,Carcinoma of the left upper lobe.,PROCEDURES PERFORMED:,1.  Bronchoscopy with aspiration.,2.  Left upper lobectomy.,PROCEDURE DETAILS:  ,With patient in supine position under general anesthesia with endotracheal tube in place, the flexible bronchoscope was then placed down through the endotracheal tube to examine the carina.  The carina was in the midline and sharp.  Moving directly to the right side, the right upper and middle lower lobes were examined and found to be free of obstructions.  Aspiration was carried out for backlog ________ examination.  We then moved to left side, left upper lobe.  There was a tumor mass located in the lingula of the left lobe and left lower lobe found free of obstruction.  No anatomic lesions were demonstrated.  The patient was prepared for left thoracotomy rotated to his right side with a double lumen endotracheal tube in place with an NG tube and a Foley catheter.  After proper position, utilizing Betadine solution, they were draped.  A posterolateral left thoracotomy incision was performed.  Hemostasis was secured with electrocoagulation.  The chest wall muscle was then divided over the sixth rib.  The periosteum of the sixth rib was then removed superiorly and the pleural cavity was entered carefully.  At this time, the mass was felt in the left upper lobe, which measures greater than 3 cm by palpation.  We examined the superior mediastinum.  No lymph nodes were demonstrated as well as in the anterior mediastinum.  Direction was then moved to the fascia where by utilizing sharp and blunt dissection, lingual artery was separated into the left upper lobe.  Casual dissection was carried out with superior segmental arteries and left lower lobe was examined.,Dissection was carried out around the pulmonary artery thus exposing the posterior artery to the left upper lobe.  Direction was carried out to the superior pulmonary vein and utilizing sharp and blunt dissection the entire superior pulmonary vein was separated from the surrounding tissue.  From the top side, the bronchus was then separated away from the pulmonary artery anteriorly, thus exposing the apical posterior artery, which was short.  Tumor mass was close to the artery at this time.  We then directed ourselves once again to the lingual artery which was doubly ligated and cut free.  The posterior artery of the superior branch was doubly ligated and cut free also.  At this time, the bronchus of the left upper lobe was encountered in the fissure on palpation to separate the upper lobe bronchus from lower lobe bronchus and the area was accomplished.  We then moved anteriorly to doubly ligate the pulmonary vein using #00 silk sutures for ligation and a transection #00 silk suture was used to fixate the vein.  Using sharp and blunt dissection, the bronchus through the left upper lobe was freed proximal.  Using the TA 50, the bronchus was then cut free allowing the lung to fall superiorly at which time direction was carried out to the pulmonary artery where the tumor was in close proximity at this time.  A Potts clamp arterial was then placed over the artery and shaving off the tumor and the apical posterior artery was then accomplished.  The anterior artery was seen in the clamp also and was separated and ligated and separated.  At this time, the entire tumor in the left upper lobe was then removed.  ,Direction was carried to the suture where #000 silk was used as a running suture over the pulmonary artery and was here doubly run and tied in place.  The clamp was then removed.  No bleeding was seen at this time.  Lymph nodes were then removed from the sump of the separation between the upper lobe and the lower lobe and sent for separate pathology.  We then carried out incision in the inferior pulmonary ligament up to the pulmonary vein allowing the lung to reexpand to its normal position.  At this time, two chest tubes #28 and #32 were placed anteriorly and posteriorly to fixate the skin using raw silk suture.  The chest cavity was then closed.  After reexamination, no bleeding was seen with three pericostal sutures of #1 chromic double strength.  A #2-0 Polydek was then used to close the chest wall muscle the anterior as well as latissimus dorsi #000 chromic subcutaneous tissue skin clips to the skin.  The chest tubes were attached to the Pleur-Evac drainage and placed on suction at this time.  The patient was extubated in the room without difficulty and sent to Recovery in satisfactory.
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DESCRIPTION: Bronchoscopy with aspiration and left upper lobectomy.  Carcinoma of the left upper lobe.

surgery, ng tube, chest tubes, endotracheal tube, pulmonary vein, artery, aspiration, lobectomy, bronchoscopy, tumor, vein, bronchus, pulmonary,

This case involves a surgical procedure of significant complexity and risks due to the diagnosis of carcinoma in the left upper lobe of the lung, requiring both bronchoscopy and lobectomy. Surgery, especially involving the lungs and the presence of cancer, carries inherent high stakes due to potential complications, the nature of the disease, and postoperative recovery concerns. Failure or complications during such a procedure could have severe consequences for the patient, potentially life-threatening. Therefore, the stakes in this context are quite high.


Medical Specialty: Surgery
Sample Name: Bronchoscopy - 4

PREOPERATIVE DIAGNOSIS:  ,Tracheal stenosis and metal stent complications.,POSTOPERATIVE DIAGNOSIS:  ,Tracheal stenosis and metal stent complications.,ANESTHESIA:  ,General endotracheal.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Subglottic stenosis down to 5 mm with mature cicatrix.,3.  Tracheal granulation tissue growing through the stents at the midway point of the stents.,5.  Three metallic stents in place in the proximal trachea.,6.  Distance from the true vocal cords to the proximal stent, 2 cm.,7.  Distance from the proximal stent to the distal stent, 3.5 cm.,8.  Distance from the distal stent to the carina, 8 cm.,9.  Distal airway is clear.,PROCEDURES:,1.  Rigid bronchoscopy with dilation.,2.  Excision of granulation tissue tumor.,3.  Application of mitomycin-C.,4.  Endobronchial ultrasound.,TECHNIQUE IN DETAIL:  ,After informed consent was obtained from the patient and her husband, she was brought to the operating theater after sequence induction was done.  She had a Dedo laryngoscope placed.  Her airways were inspected thoroughly with findings as described above.  She was intermittently ventilated with an endotracheal tube placed through the Dedo scope.  Her granulation tissue was biopsied and then removed with a microdebrider.  Her proximal trachea was dilated with a combination of balloon, Bougie, and rigid scopes.  She tolerated the procedure well, was extubated, and brought to the PACU.
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DESCRIPTION: Rigid bronchoscopy with dilation, excision of granulation tissue tumor, application of mitomycin-C, endobronchial ultrasound.

surgery, tracheal stenosis, dedo scope, bronchoscopy, cicatrix, dilation, endotracheal, granulation, metal stent, mitomycin-c, proximal trachea, vocal cords, endobronchial ultrasound, granulation tissue, proximal, tracheal, stent,

The situation involves a surgical procedure dealing with tracheal stenosis and metal stent complications, which are high-stakes due to the potential impact on the patient's airway and breathing. The procedure is complex, involving rigid bronchoscopy with dilation and excision of granulation tissue, which carries inherent risks related to airway management and potential postoperative complications. Thus, the potential consequences of errors or complications during the procedure could be severe, impacting the patient's health seriously.


Medical Specialty: Surgery
Sample Name: Bronchoscopy - 5

PREOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,POSTOPERATIVE DIAGNOSIS:,  Airway stenosis with self-expanding metallic stent complication.,PROCEDURES:,1.  Rigid bronchoscopy with removal of foreign body, prolonged procedure taking two hours to remove the stent piecemeal in a very difficult and trying situation.,2.  Excision of granulation tissue tumor.,3.  Bronchial dilation with a balloon bronchoplasty, right main bronchus.,4.  Argon plasma coagulation to control bleeding in the trachea.,5.  Placement of a tracheal and bilateral bronchial stents with a silicon wire stent.,ENDOSCOPIC FINDINGS:,1.  Normal true vocal cords.,2.  Proximal trachea with high-grade occlusion blocking approximately 90% of the trachea due to granulation tissue tumor and break down of metallic stent.,3.  Multiple stent fractures in the mid portion of the trachea with granulation tissue.,4.  High-grade obstruction of the right main bronchus by stent and granulation tissue.,5.  Left main bronchus was covered by the distal portion of the stent and was only being ventilated through the struts of the stent.,6.  All in all a high-grade terrible airway obstruction with involvement of the carina, left and right main stem bronchus, mid, distal, and proximal trachea.,TECHNIQUE IN DETAIL: , After informed consent was obtained from the patient, he was brought into the operating field.  A rapid sequence induction was done.  He was intubated with a rigid scope.  Jet ventilation technique was carried out using a rigid and flexible scope.  A thorough airway inspection was carried out with findings as described above.,Dr. D was present in the operating room and we conferred on operative strategy and agreed that the best of strategy would be to first dilate the right main bronchus, cauterize it to control bleeding and then piecemeal removed the stent from distal to proximal.  This is the technique that was carried out in a painstaking fashion removing bits of the stent piecemeal with finally getting all of the visible stent out of the airway.  It should be noted that Dr. Donovan and I felt that two of the metallic stents were probably in place but we cannot be sure because of the terrible anatomy and the fact that the stent pieces were coming out twisted metal in fragments.  Nevertheless, all the visible stent was removed, and the airway was much better after with the dilation of balloon and the rigid scope.  We took measurements and decided to place stents in the trachea, left and right main bronchus using a Dumon Y-stent.  It was measured 18 mm in tracheal diameter and 14 mm in bronchial diameter.  The right main stem stent was 2.25 cm in length, the left main stem stent was 3 cm in length and the tracheal portion was 9 cm in length.  After it was placed, excellent placement was achieved with the proximal end of the stent 3 cm below the true vocal cords.  The patient tolerated the procedure well and was brought to the recovery room extubated.
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DESCRIPTION: Rigid bronchoscopy, removal of foreign body, excision of granulation tissue tumor, bronchial dilation , Argon plasma coagulation, placement of a tracheal and bilateral bronchial stents.

surgery, airway, argon plasma coagulation, bronchial dilation, balloon bronchoplasty, bronchoscopy, bronchus, foreign body, granulation, metallic stent, stenosis, vocal cords, granulation tissue tumor, plasma coagulation, granulation tissue, tracheal, argon, stents, bronchial, metallic,

The situation described is high-stakes due to several factors. The patient's airway had a high-grade obstruction, blocking 90% of the trachea, which is life-threatening as it can severely impair breathing. The procedure involved complex and risky operations such as removing a stent piece by piece, excision of tissue, bronchial dilation, and controlling bleeding, all vital to ensuring the patient can breathe properly again. The involvement of multiple medical techniques highlights the complexity and critical nature of the scenario, emphasizing its high-stakes nature.


Medical Specialty: Surgery
Sample Name: Bronchoscopy

PREOPERATIVE DIAGNOSIS: , Atelectasis.,POSTOPERATIVE DIAGNOSIS: , Mucous plugging.,PROCEDURE PERFORMED: , Bronchoscopy.,ANESTHESIA: , Lidocaine topical 2%, Versed 3 mg IV.  Conscious sedation.,PROCEDURE: , At bedside, a bronchoscope was passed down the tracheostomy tube under monitoring.  The main carina was visualized.  The trachea was free of any secretions.  The right upper lobe, middle and lower lobes appeared to have some mucoid secretions but minimal and with some erythema.  Left mainstem appeared patent.  Left lower lobe had slight plugging in the left base, but much better that previous bronchoscopy findings.  The area was lavaged with some saline and cleared.  The patient tolerated the procedure well.
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DESCRIPTION: Bronchoscopy.  Atelectasis and mucous plugging.

The given scenario describes a bronchoscopy procedure performed to address mucous plugging in a patient with atelectasis. Bronchoscopy is a common procedure for such conditions, especially in patients with tracheostomy. While there are risks associated with any medical procedure, this seems to be a routine procedure conducted under conscious sedation. The patient tolerated it well, indicating no complications. Since this is a standard procedure with no reported complications, it does not appear to be high-stakes.


Medical Specialty: Surgery
Sample Name: Breast Biopsy

PROCEDURE PERFORMED: , Excisional breast biopsy with needle localization.,ANESTHESIA:,  General.,PROCEDURE: , After informed consent was obtained, the patient was brought to the radiology suite where needle localization was performed with mammographic guidance.  I reviewed the localizing films with the radiologist, and the patient was then brought to the operative suite and placed supine on the operating table.  General endotracheal anesthesia was induced without incident.  The patient was prepped and draped in the usual sterile manner.,The skin overlying the needle tip was incised in a curvilinear fashion.  Dissection down to the needle tip was performed using a combination of Metzenbaum scissors and Bovie electrocautery.  Every attempt was made to get approximately 1 cm of normal tissue around the lesion.  The wire was released and the lesion having been excised was removed from the wound and sent to Radiology for confirmation of excision.  The wound was copiously irrigated with sterile water, and hemostasis was obtained using Bovie electrocautery.  Once Radiology called and confirmed complete excision of the mass, the skin incision was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin and Steri-Strips were applied.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.
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DESCRIPTION: Excisional breast biopsy with needle localization.  The skin overlying the needle tip was incised in a curvilinear fashion.

surgery, curvilinear fashion, bovie electrocautery, breast biopsy, needle localization, needle tip, curvilinear, breast, biopsy, needle

The procedure described is an excisional breast biopsy with needle localization, which is a common surgical procedure to remove a suspicious area for further pathological examination. While it is a standard and relatively routine procedure, it involves general anesthesia and is performed to diagnose conditions that may include breast cancer. The outcome of the biopsy is significant as it can have a substantial impact on the patient's subsequent treatment and prognosis. Thus, although the surgical procedure itself is not high-risk, the stakes in terms of diagnosis and patient anxiety are higher.


Medical Specialty: Surgery
Sample Name: Breast Biopsy - 2

PREOPERATIVE DIAGNOSIS,Left breast mass.,POSTOPERATIVE DIAGNOSIS,Left breast mass.,PROCEDURE PERFORMED,Needle localization and left breast biopsy.,ANESTHESIA,General.,FLUIDS,1000 cc.,ESTIMATED BLOOD LOSS,Minimal.,DRAINS,None.,COMPLICATIONS,None.,SPECIMEN,Breast biopsy specimen with localizing needle.,FINDINGS,Breast tissue surrounding needle localization while no palpable mass.,HISTORY,The patient is a very pleasant 51-year-old African-American female who presented to the office with a mass in the left breast.  She was seen and evaluated.  On routine mammography, revealed a density in the left breast approximately at 4 o'clock position several centimeters lateral to the nipple complex.  She was readmitted for excisional biopsy.,Due to the nonpalpable nature of this lesion, the patient underwent first needle localization of the breast at the  Hospital and was taken to the operating room.,PROCEDURE IN DETAIL,After informed consent was obtained from the patient, the patient taken to the operating room and placed in the supine position on the operating table.  After appropriate general endotracheal anesthesia has been administered to the patient, the left breast was prepped and draped in a standard surgical fashion using Betadine solution.,The localization wire was cut at skin.  The patient had previously had a reduction mammoplasty in the lateral aspect of the transverse where an incision was re-incised to distance of about 4 cm.  The wire was entering the skin about 2 cm above the incision.  Superior skin flap was raised using electrocautery, and the needle localization wire was brought into the incision.  At this point, a core breast tissue of approximately 2 cm surrounding the needle was excised superiorly, inferiorly, medially, and laterally until the tissue specimen was well below the hook of the needle localization wire.,The breast specimen was then removed from breast, and silk sutures were used to mark the superior and lateral margins.  This specimen was then sent for mammography.  Pathologist called in the room to verify that the entire needle localization wire and hook were intact in the specimen.  At this point, the breast cavity was palpated and no other abnormalities were noted.  ,The wound was irrigated.  Bleeding points were easily controlled using electrocautery.  The wound was closed in two layers using 3-0 Vicryl and 4-0 Monocryl suture in a subcuticular fashion.  Benzoin, Steri-Strips, 2 x 2's, Tegaderm were placed.  The patient was aroused from anesthesia and transported to the recovery room in stable condition.  There were no complications.  All instrument, needle, and sponge counts were correct x2 at the end of the case.
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DESCRIPTION: Needle localization and left breast biopsy for left breast mass.

surgery, breast mass, needle localization, steri-strips, tegaderm, biopsy, breast biopsy, breast cavity, excisional biopsy, localization wire, room in stable condition, skin flap, specimen, needle localization wire, needle, breast, mammography, localization,

This situation is considered high-stakes due to the medical procedure involved. A breast biopsy is performed to diagnose the presence of cancerous cells, which directly impacts the patient's health outcomes and treatment plan. The stakes are further elevated by the use of general anesthesia, which carries its own risks, and the potential for discovering malignant tissue. Furthermore, the implications of the biopsy's findings can be significant for the patient's future healthcare decisions and quality of life.


Medical Specialty: Surgery
Sample Name: Breast Biopsy - 1

PREOPERATIVE DIAGNOSIS:,  Atypical ductal hyperplasia of left breast.,POSTOPERATIVE DIAGNOSIS: , Atypical ductal hyperplasia of left breast.,PROCEDURE: , Left excisional breast biopsy.,ANESTHESIA: , General.,INDICATIONS: , This is a 66-year-old female who has a history of a right lumpectomy for ductal carcinoma in situ in May 2001.  On recent mammogram, she was found to have calcifications in her left breast and a stereotactic biopsy revealed a typical ductal hyperplasia.  Excisional biopsy was, therefore, recommended.  Her family history was significant in her sister with breast cancer at the age of 34 and daughter at the age 38.,FINDINGS: , The area in question was excised.  See details below.  There was no gross evidence of malignancy.  Final evaluation will per the permanent sections.,PROCEDURE:,  Earlier today, the patient underwent a wire localization by Dr. A.  She was then taken to the operating room and placed in the supine position.  The left breast was prepped and draped in the usual sterile fashion.,A curvilinear incision was made in the upper outer quadrant to include a wire.  The skin was incised.  Hemostasis was achieved with cautery device where the breast tissue was excised around the wire.  The specimens were marked for the long stitch laterally and short stitch superiorly, and fair length superficially.  It was noted that the wire was fairly close to the superior deep aspect of the specimen.  I, therefore, excised a new superior deep margin.  This was performed with electrocautery device, the suture marks and new marks on the specimens.  The main specimen itself was sent for ***** and gross inspection.  The superior deep margin was soaked in Marcaine and the new margin was sent for permanent sections.,First, I went over to pathology and reviewed the specimen and radiograph with the radiologist Dr. A.  This revealed a clip in the tissue excised closer again to the superior deep edge of the tissue.  The specimens were then cut in serial fashion by Dr. Rust, the pathologist.  There was no gross evidence of malignancy.  As noted above, I previously excised the new superior deep margin and this was sent for permanent section.  ,The wound was thoroughly irrigated and hemostasis was carefully achieved.  The subdermal layer was closed with 4-0 PDS in simple interrupted fashion.  The skin was closed with 4-0 Monocryl in a running subcuticular fashion.  Steri-Strips and dressings were applied.  All sponge, needle, and instrument counts were correct.  The patient tolerated the procedure well and was taken to PACU in stable condition.,ESTIMATED BLOOD LOSS: , 5 mL.,COMPLICATIONS: , None.,DRAINS: , None.,SPECIMENS:,  Left breast tissue and new superior deep margin.
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DESCRIPTION: Left excisional breast biopsy due to atypical ductal hyperplasia of left breast.

surgery, breast, atypical ductal hyperplasia, breast biopsy, carcinoma in situ, excisional, hyperplasia, instrument counts, mammogram, needle, pathology, specimen, sponge, superior deep margin, ductal hyperplasia, deep margin, hemostasis, biopsy,

This surgical report is related to a breast biopsy procedure for a 66-year-old female with atypical ductal hyperplasia. While it was performed under general anesthesia and involves a previous history of ductal carcinoma in situ and family history of breast cancer, the procedure itself is routine in nature. There are no immediate complications noted, and the estimated blood loss is minimal. The stakes would be considered moderate due to the patient's cancer history and family history, which increases the importance of accurate diagnosis and potential treatment adjustments. However, the procedure was carried out without issues, thus lowering the immediate stakes.


Medical Specialty: Surgery
Sample Name: Brachytherapy

PREOPERATIVE DIAGNOSIS:,  Prostate cancer.,POSTOPERATIVE DIAGNOSIS:,  Prostate cancer.,OPERATIONS: , Brachytherapy, iodine-125 seed implantation, and cystoscopy.,ANESTHESIA:,  LMA.,ESTIMATED BLOOD LOSS: , Minimal.,Total number of seeds placed, 63.  Needles, 24.,BRIEF HISTORY OF THE PATIENT: , This is a 57-year-old male who was seen by us for elevated PSA.  The patient had a prostate biopsy with T2b disease, Gleason 6.  Options such as watchful waiting, robotic prostatectomy, seed implantation with and without radiation were discussed.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, incontinence, rectal dysfunction, voiding issues, burning pain, unexpected complications such as fistula, rectal injury, urgency, frequency, bladder issues, need for chronic Foley for six months, etc., were discussed.  The patient understood all the risks, benefits, and options, and wanted to proceed with the procedure.  The patient was told that there could be other unexpected complications.  The patient has history of urethral stricture.  The patient was told about the risk of worsening of the stricture with radiation.  Consent was obtained.,DETAILS OF THE OPERATION: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the dorsal lithotomy position.  The patient had SCDs on.  The patient was given preop antibiotics.  The patient had done bowel prep the day before.  Transrectal ultrasound was performed.  The prostate was measured at about 32 gm.  The images were transmitted to the computer system for radiation oncologist to determine the dosing etc.  Based on the computer analysis, the grid was placed.  Careful attention was drawn to keep the grid away from the patient.  There was a centimeter distance between the skin and the grid.  Under ultrasound guidance, the needles were placed, first in the periphery of the prostate, a total of 63 seeds were placed throughout the prostate.  A total of 24 needles was used.  Careful attention was drawn to stay away from the urethra.  Under longitudinal ultrasound guidance, all the seeds were placed.  There were no seeds visualized in the bladder under ultrasound.  There was only one needle where the seeds kind of dragged as the needle was coming out on the left side and were dropped out of position.  Other than that, all the seeds were very well distributed throughout the prostate under fluoroscopy.  Please note that the Foley catheter was in place throughout the procedure.  Prior to the seed placement, the Foley was attempted to be placed, but we had to do it using a Glidewire to get the Foley in and we used a Councill-tip catheter.  The patient has had history of bulbar urethral stricture.  Pictures were taken of the strictures in the pre-seed placement cysto time frame.  We needed to do the cystoscopy and Glidewire to be able to get the Foley catheter in.  At the end of the procedure, again cystoscopy was done, the entire bladder was visualized.  The stricture was wide open.  The prostate was slightly enlarged.  The bladder appeared normal.  There was no sheath inside the urethra or in the bladder.  The cysto was done using 30-degree and 70-degree lens.  At the end of the procedure, a Glidewire was placed, and 18 Councill-tip catheter was placed.  The plan was for Foley to be left in place overnight since the patient has history of urethral strictures.  The patient is to follow up tomorrow to have the Foley removed.  The patient could also be shown to have it removed at home.,The patient was brought to Recovery in stable condition at the end of the procedure.  The patient tolerated the procedure well.
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DESCRIPTION: Brachytherapy, iodine-125 seed implantation, and cystoscopy.

surgery, iodine-125 seed implantation, seed implantation, prostate cancer, cystoscopy, brachytherapy, councill tip catheter, brachytherapy iodine, ultrasound, catheter, urethral, prostate,

The situation described involves a surgical procedure for treating prostate cancer using brachytherapy with iodine-125 seed implantation. This type of procedure is typically considered high-stakes due to several factors: it involves anesthesia, has potential complications (e.g., infection, bleeding, urethral stricture worsening), and requires precise placement of radioactive seeds. Prostate cancer treatment decisions can significantly affect the patient's quality of life and long-term health outcomes; hence, informed consent and careful execution are critical. The presence of pre-existing conditions like urethral stricture adds complexity and potential risk to the procedure. Given the severity of the cancer diagnosis and the precision required in the procedure, this situation has substantial stakes for the patient's health.


Medical Specialty: Surgery
Sample Name: Bone Removal - Metatarsal Head

PREOPERATIVE DIAGNOSIS: , Tailor's bunion, right foot.,POSTOPERATIVE DIAGNOSIS:  ,Tailor's bunion, right foot.,PROCEDURE PERFORMED: , Removal of bone, right fifth metatarsal head.,ANESTHESIA:  ,TIVA/local.,HISTORY: , This 60-year-old male presents to ABCD Preoperative Holding Area after keeping himself n.p.o., since mid night for surgery on his painful right Tailor's bunion.  The patient has a history of chronic ulceration to the right foot which has been treated on an outpatient basis with conservative methods Dr. X.  At this time, he desires surgical correction as the ulcer has been refractory to conservative treatment.  Incidentally, the ulcer is noninfective and practically healed at this date.  The consent is available on the chart for review and Dr. X has discussed the risks versus benefits of this procedure to the patient in detail.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room, placed on the operating table in supine position and a safety strap was placed across his waist for his protection.  A pneumatic ankle tourniquet was applied about the right foot over copious amount of Webril for the patient's protection.  After adequate IV sedation was administered by the Department of Anesthesia, a total of 10 cc of 1:1 mixture of 1% lidocaine and 0.5% Marcaine plain were administered into the right fifth metatarsal using a Mayo type block technique.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 250 mmHg.  The foot was lowered in the operating field and a sterile stockinet was reflected.  The Betadine was cleansed with saline-soaked gauze and dried.  Anesthesia was tested with a one tooth pickup and found to be adequate.  A #10 blade was used to make 3.5 cm linear incision over the fifth metatarsophalangeal joint.  A #15 blade was used to deepen the incision to the subcutaneous layer.  Care was taken to retract the extensor digitorum longus tendon medially and the abductor digiti minimi tendon laterally.  Using a combination of sharp and blunt dissection, the medial and lateral edges of the wound were undermined down to the level of the capsule and deep fascia.  A linear capsular incision was made with a #15 blade down to the bone.  The capsular periosteal tissues were elevated off the bone with a #15 blade.  Metatarsal head was delivered into the wound.  There was hypertrophic exostosis noted laterally as well as a large bursa in the subcuteneous tissue layer.  The ulcer on the skin was approximately 2 x 2 mm, it was partial skin thickness and did not probe.  A sagittal saw was used to resect the hypertrophic lateral eminence.  The hypertrophic bone was split in half and one half was sent to Pathology and the other half was sent to Microbiology for culture and sensitivity.  Next, a reciprocating rasp was used to smoothen all bony surfaces.  The bone stock had an excellent healthy appearance and did not appear to be infected.  Copious amount of sterile gentamicin impregnated saline were used to flush the wound.  The capsuloperiosteal tissues were reapproximated with #3-0 Vicryl in simple interrupted technique.  The subcutaneous layer was closed with #4-0 Vicryl in simple interrupted technique.  Next, the skin was closed with #4-0 nylon in a horizontal mattress suture technique.  A standard postoperative dressing was applied consisting of Betadine-soaked Owen silk, 4x4s, Kerlix, and Kling.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted at the digits.  The patient tolerated the above anesthesia and procedure without complications.  He was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact to the right foot.  He was given a postop shoe and will be full weightbearing.  He has prescription already at home for hydrocodone and does not need to refill.  He is to follow up with Dr. X and was given emergency contact numbers.  He was discharged in stable condition.
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DESCRIPTION: Tailor's bunion, right foot.  Removal of bone, right fifth metatarsal head.

surgery, pneumatic ankle, metatarsal head, tailor's bunion, head, pneumatic, ulceration, metatarsal, bone

The surgical procedure described involves the removal of bone from the right fifth metatarsal head to address a Tailor's bunion. This type of surgery, while routine and relatively low-risk, still involves general surgical risks such as infection, anesthesia complications, and the need for a thorough postoperative care. The patient has a history of chronic ulceration, which slightly increases the stakes due to potential healing complications. However, the ulcer is described as healed and non-infectious. The procedure is not life-threatening, but it does require surgical precision and adequate postoperative monitoring to ensure no complications arise from the surgery itself. The stakes are moderate for ensuring the correction is successful and that recovery proceeds without incident, but it is not considered high-stakes in a surgical context.


Medical Specialty: Surgery
Sample Name: BMT & Adenoidectomy

PREOPERATIVE DIAGNOSIS: , Chronic otitis media.,POSTOPERATIVE DIAGNOSIS: , Chronic otitis media.,PROCEDURE PERFORMED: , Bilateral myringotomy tubes and adenoidectomy.,INDICATIONS FOR PROCEDURE:,  The patient is an 8-year-old child with history of recurrent otitis media.  The patient has had previous tube placement.  Tubes have since plugged and are no more functioning.  The patient has had recent recurrent otitis media.  Risks and benefits in terms of bleeding, anesthesia, and tympanic membrane perforation were discussed with the mother.  Mother wished to proceed with the surgery.,PROCEDURE IN DETAIL: , The patient was brought to the room, placed supine.  The patient was given general endotracheal anesthesia.  Starting on the left ear, under microscopic visualization, the ear was cleaned of wax.  A Bobbin tube was found stuck to the tympanic membrane.  This was removed.  After removing the tube the patient was found to have microperforation through which serous fluid was draining.  A fresh myringotomy was made in the anterior inferior quadrant.  More serous fluid was aspirated from middle ear space.  The new Bobbin tube was easily placed.  Floxin drops were placed in the ear.  In the right ear again under microscopic visualization, the ear was cleaned, the tube was removed off tympanic membrane.  There was no perforation seen; however, there was some granulation tissue on the surface of tympanic membrane.  A fresh myringotomy incision was made in the anterior inferior quadrant.  More serous fluid was drained out of middle ear space.  The tube was easily placed and Floxin drops were placed in the ear.  This completes tube portion of the surgery.  The patient was then turned and placed in the Rose position.  Shoulder roll was placed for neck extension.  Using a small McIvor mouth gag mouth was held open.  Using a rubber catheter the soft palate was retracted.  Under mirror visualization, the nasopharynx was examined.  The patient was found to have minimal adenoidal tissue.  This was removed using a suction Bovie.  The patient was then awakened from anesthesia, extubated and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge count correct.  Estimated blood loss none.
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DESCRIPTION: Bilateral myringotomy tubes and adenoidectomy.

surgery, chronic otitis media, bilateral myringotomy tubes, adenoidectomy, myringotomy tubes and adenoidectomy, middle ear space, bilateral myringotomy, bobbin tube, fresh myringotomy, serous fluid, otitis media, tympanic membrane, tubes, myringotomy, otitis, media, membrane,

The procedure described is a standard surgical intervention for an 8-year-old child experiencing recurrent otitis media. This type of surgery, involving the insertion of bilateral myringotomy tubes and adenoidectomy, is common and generally considered low-risk. The description provided indicates that the procedure was without complications, and no significant blood loss occurred. Although any surgical procedure involving anesthesia carries some inherent risks, in this case, these risks were discussed with the patient's mother, and she consented to the surgery. The context suggests a level of routine and expectation of success typical in such procedures, making the stakes not particularly high compared to more complex or emergency surgeries.


Medical Specialty: Surgery
Sample Name: Brain Stimulator Electrode

PREOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,POSTOPERATIVE DIAGNOSIS: , Tremor, dystonic form.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 100 mL.,ANESTHESIA:,  MAC (monitored anesthesia care) with local anesthesia.,TITLE OF PROCEDURES:,1.  Left frontal craniotomy for placement of deep brain stimulator electrode.,2.  Right frontal craniotomy for placement of deep brain stimulator electrode.,3.  Microelectrode recording of deep brain structures.,4.  Stereotactic volumetric CT scan of head for target coordinate determination.,5.  Intraoperative programming and assessment of device.,INDICATIONS:  ,The patient is a 61-year-old woman with a history of dystonic tremor.  The movements have been refractory to aggressive medical measures, felt to be candidate for deep brain stimulation.  The procedure is discussed below.,I have discussed with the patient in great deal the risks, benefits, and alternatives.  She fully accepted and consented to the procedure.,PROCEDURE IN DETAIL:,  The patient was brought to the holding area and to the operating room in stable condition.  She was placed on the operating table in seated position.  Her head was shaved.  Scalp was prepped with Betadine and a Leksell frame was mounted after anesthetizing the pin sites with a 50:50 mixture of 0.5% Marcaine and 2% lidocaine in all planes.  IV antibiotics were administered as was the sedation.  She was then transported to the CT scan and stereotactic volumetric CT scan of the head was undertaken.  The images were then transported to the surgery planned work station where a 3-D reconstruction was performed and the target coordinates were then chosen.  Target coordinates chosen were 20 mm to the left of the AC-PC midpoint, 3 mm anterior to the AC-PC midpoint, and 4 mm below the AC-PC midpoint.  Each coordinate was then transported to the operating room as Leksell coordinates.,The patient was then placed on the operating table in a seated position once again.  Foley catheter was placed, and she was secured to the table using the Mayfield unit.  At this point then the patient's right frontal and left parietal bossings were cleaned, shaved, and sterilized using Betadine soap and paint in scrubbing fashion for 10 minutes.  Sterile drapes placed around the perimeter of the field.  This same scalp region was then anesthetized with same local anesthetic mixture.,A bifrontal incision was made as well as curvilinear incision was made over the parietal bossings.  Bur holes were created on either side of the midline just behind the coronal suture.  Hemostasis was controlled using bipolar and Bovie, and self-retaining retractors had been placed in the field.  Using the drill, then two small grooves were cut in the frontal bone with a 5-mm cutting burs and Stryker drill.  The bur holes were then curetted free, the dura cauterized, and then opened in a cruciate manner on both sides with a #11 blade.  The cortical surface was then nicked with a #11 blade on both sides as well.  The Leksell arc with right-sided coordinate was dialed in, was then secured to the frame.  Microelectrode drive was secured to the arc.  Microelectrode recording was then performed.  The signatures of the cells were recognized.  Microelectrode unit was removed.  Deep brain stimulating electrode holding unit was mounted.  The DBS electrode was then loaded into target and intraoperative programming and testing was performed.  Using the screener box and standard parameters, the patient experienced some relief of symptoms on her left side.  This electrode was secured in position using bur-hole ring and cap system.,Attention was then turned to the left side, where left-sided coordinates were dialed into the system.  The microelectrode unit was then remounted.  Microelectrode recording was then undertaken.  After multiple passes, the microelectrode unit was removed.  Deep brain stimulator electrode holding unit was mounted at the desired trajectory.  The DBS electrode was loaded into target, and intraoperative programming and testing was performed once again using the screener box.  Using standard parameters, the patient experienced similar results on her right side.  This electrode was secured using bur-hole ring and cap system.  The arc was then removed.  A subgaleal tunnel was created between the two incisions whereby distal aspect of the electrodes led through this tunnel.,We then closed the electrode, replaced subgaleally.  Copious amounts of Betadine irrigation were used.  Hemostasis was controlled using the bipolar only.  Closure was instituted using 3-0 Vicryl in a simple interrupted fashion for the fascial layer followed by skin closure with staples.  Sterile dressings were applied.  The Leksell arc was then removed.,She was rotated into the supine position and transported to the recovery room in stable and satisfactory condition.  All needle, sponge, cottonoid, and blade counts were correct x2 as verified by the nurses.
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DESCRIPTION: Frontal craniotomy for placement of deep brain stimulator electrode.  Microelectrode recording of deep brain structures. Intraoperative programming and assessment of device.

surgery, dystonic, ac-pc, ct scan, dbs electrode, intraoperative programming, microelectrode, stereotactic, tremor, brain stimulator, craniotomy, device, dystonic tremor, electrode, frontal, screener box, target coordinate, volumetric, deep brain stimulator electrode, brain stimulator electrode, volumetric ct, stimulator, brain,

The procedure described involves a frontal craniotomy and the placement of deep brain stimulator electrodes, which are complex surgical interventions used to treat conditions like dystonic tremor. Such surgeries require precise execution and involve significant risks, including potential complications from the surgery itself, risks of infection, and the need for exact electrode placement to achieve the desired therapeutic effects. Although the specific case had no complications and estimated blood loss was low, this type of neurological surgery is inherently high-stakes due to the potential for severe consequences if something goes wrong. Every element of the monitoring and execution must be performed with precision to ensure patient safety and successful outcomes.


Medical Specialty: Surgery
Sample Name: Bone Impacted Tooth Removal

PREOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,POSTOPERATIVE DIAGNOSIS: , Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.,PROCEDURE:,  Removal of benign cyst and extraction of full bone impacted tooth #17.,ANESTHESIA:  ,General anesthesia with nasal endotracheal intubation.,SPECIMEN: , Cyst and section tooth #17.,ESTIMATED BLOOD LOSS:,  10 mL.,FLUIDS:,  1200 of Lactated Ringer's.,COMPLICATIONS: , None.,CONDITION: , The patient was extubated and transported to the PACU in good condition.  Breathing spontaneously.,INDICATION FOR PROCEDURE:  ,The patient is a 38-year-old Caucasian male who was referred to clinic to evaluate a cyst in his left mandible.  Preoperatively, a biopsy of the cyst was obtained and it was noted to be a benign dentigerous cyst.,After evaluation of the location of the cyst and the impacted wisdom tooth approximately the inferior border of the mandible, it was determined that the patient would benefit from removal of the cyst and removal of tooth #17 under general anesthesia in the operating room.  Risks, benefits, and alternatives of treatment were thoroughly discussed with the patient and consent was obtained.,DESCRIPTION OF PROCEDURE:,  The patient was taken to the operating room #1 at Hospital and laid in the supine fashion on the operating room table.  As stated, general anesthesia was induced with IV anesthetics and maintained with nasal endotracheal intubation and inhalation anesthetics.  The patient was prepped and draped in usual oro-maxillofacial surgery fashion.,Approximately, #6 mL of 2% lidocaine with 1:100,000 epinephrine was injected in the usual nerve block fashion.  After waiting appropriate time for local anesthesia to take effect, a moistened Ray-Tec sponge was placed in the posterior pharynx.  Peridex mouth rinse was used to prep the oral cavity.  This was removed with suction.,Using a #15 blade a sagittal split osteotomy incision was made along the left ramus.  A full-thickness mucoperiosteal flap was elevated and the crest of the bone was identified where the crown had super-erupted since the biopsy 6 weeks earlier.  Using a Hall drill, a buccal osteotomy was developed, the tooth was sectioned in half, fractured with an elevator and delivered in two pieces.  Using a double-ended curette, the remainder of the cystic lining was removed from the left mandible and sent to pathology with the tooth for review.,The area was irrigated with copious amounts of sterile water and closed with 3-0 chromic gut suture.  The throat pack was removed.  The procedure was then determined to be over, and the patient was extubated, breathing spontaneously, and transported to the PACU in good condition.
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DESCRIPTION: Dentigerous cyst, left mandible associated with full bone impacted wisdom tooth #17.  Removal of benign cyst and extraction of full bone impacted tooth #17.

surgery, dentigerous, wisdom tooth, extraction, bone impacted tooth, nasal endotracheal, dentigerous cyst, cyst, intubation, osteotomy, mandible,

The procedure involves surgical removal of a dentigerous cyst and an impacted tooth under general anesthesia. Although it is a standard surgical procedure with low estimated blood loss (10 mL) and no reported complications, general anesthesia and surgical intervention inherently carry certain risks. The stakes are moderate as the condition is not life-threatening but requires careful surgical procedure in the oromaxillofacial region.


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Medical Specialty: Surgery
Sample Name: Biopsy - Skin Nevus

PREOPERATIVE DIAGNOSES:  ,1.  Left back skin nevus 2 cm.,2.  Right mid back skin nevus 1 cm.,3.  Right shoulder skin nevus 2.5 cm.,4.  Actinic keratosis left lateral nasal skin 2.5 cm.,POSTOPERATIVE DIAGNOSES:  ,1.  Left back skin nevus 2 cm.,2.  Right mid back skin nevus 1 cm.,3.  Right shoulder skin nevus 2.5 cm.,4.  Actinic keratosis, left lateral nasal skin, 2.5 cm.,PATHOLOGY:  ,Pending.,TITLE OF PROCEDURES:  ,1.  Excisional biopsy of left back skin nevus 2 cm, two layer plastic closure.,2.  Excisional biopsy of mid back skin nevus 1 cm, one-layer plastic closure.,3.  Excisional biopsy of right shoulder skin nevus 2.5 cm, one-layer plastic closure.,4.  Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 8 mL.,BLOOD LOSS: , Minimal.,COMPLICATIONS:,  None.,PROCEDURE:,  Consent was obtained.  The areas were prepped and draped and localized in the usual manner.  First attention was drawn to the left back.  An elliptical incision was made with a 15-blade scalpel.  The skin ellipse was then grasped with a Bishop forceps and curved Iris scissors were used to dissect the skin ellipse.  After dissection, the skin was undermined.  Radiofrequency cautery was used for hemostasis, and using a 5-0 undyed Vicryl skin was closed in the subcuticular plane and then skin was closed at the level of the skin with 4-0 nylon interrupted suture.,Next, attention was drawn to the mid back.  The skin was incised with a vertical elliptical incision with a 15-blade scalpel and then the mass was grasped with a Bishop forceps and excised with curved Iris scissors.  Afterwards, the skin was approximated using 4-0 nylon interrupted sutures.  Next, attention was drawn to the shoulder lesion.  It was previously marked and a 15-blade scalpel was used to make an elliptical incision into the skin.,Next, the skin was grasped with a small Bishop forceps and curved Iris scissors were used to dissect the skin ellipse and removed the skin.  The skin was undermined with the curved Iris scissors and then radio frequency treatment was used for hemostasis.,Next, subcuticular plain was closed with 5-0 undyed Vicryl interrupted suture.  Skin was closed with 4-0 nylon suture, interrupted.  Lastly, trichloroacetic acid chemical peel treatment to the left lateral nasal skin was performed.  Please refer to separate operative report for details.  The patient tolerated this procedure very well and we will follow up next week for postoperative re-evaluation or sooner if there are any problems.
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DESCRIPTION: Excisional biopsy of skin nevus and two-layer plastic closure.  Trichloroacetic acid treatment to left lateral nasal skin 2.5 cm to treat actinic keratosis.

surgery, mid back skin nevus, actinic keratosis, trichloroacetic acid treatment, bishop forceps, skin nevus, plastic closure, curved iris, iris scissors, nasal skin, nevus, biopsy, nasal, forceps,

The situation described involves a surgical procedure, specifically the excisional biopsy of skin nevi and a chemical peel treatment for actinic keratosis. While these are routine dermatological and surgical interventions, they involve the removal of potentially suspicious skin lesions. The concern here is largely related to the pathology results which could identify malignant changes. Hence, while the procedure itself is not extremely high-stakes, the pending pathology result has important implications for the patient's health, particularly in regard to identifying skin cancer. However, the surgical procedures described seem to have been uncomplicated, with minimal blood loss and no immediate complications, indicating well-managed medical care. Therefore, the stakes are moderate as they revolve around the unknown pathology outcomes.


Medical Specialty: Surgery
Sample Name: Biventricular Cardioverter Defibrillator Implantation

REFERRAL INDICATION AND PREPROCEDURE DIAGNOSES,1.  Dilated cardiomyopathy.,2.  Ejection fraction less than 10%.,3.  Ventricular tachycardia.,4.  Bradycardia with likely high degree of pacing.,PROCEDURES PLANNED AND PERFORMED,1.  Implantation of biventricular automatic implantable cardioverter defibrillator.,2.  Fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator.,3.  Coronary sinus venogram for left ventricular lead placement.,4.  Defibrillation threshold testing x2.,FLUOROSCOPY TIME:  ,18.5 minutes.,MEDICATIONS AT THE TIME OF STUDY,1.  Vancomycin 1 g (the patient was allergic to penicillin).,2.  Versed 10 mg.,3.  Fentanyl 100 mcg.,4.  Benadryl 50 mg.,CLINICAL HISTORY: , The patient is a pleasant 57-year-old gentleman with a dilated cardiomyopathy, an ejection fraction of 10%, been referred for AICD implantation because of his low ejection fraction and a non-sustained ventricular tachycardia.  He has underlying sinus bradycardia.  Therefore, will likely be pacing much of the time and would benefit from a biventricular pacing device.,RISKS AND BENEFITS:,  Risks, benefits, and alternatives to implantation of biventricular AICD and defibrillation threshold testing were discussed with the patient.  Risks including but not limited to bleeding, infection, vascular injury, cardiac perforation, stroke, myocardial infarction, the need for urgent cardiovascular surgery, and death were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF PROCEDURE: , The patient was transported to the cardiac catheterization laboratory in the fasting state.  The region of the left deltopectoral groove was prepped and draped in the usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area.  After achieving appropriate anesthesia, a percutaneous access of the left axillary vein was performed under fluoroscopy with two separate sticks.  Guidewires were advanced down into the left axillary vein.  Following this, a 4-inch long transverse incision was made through the skin and subcutaneous tissue exposing the pectoral fascia and muscle beneath.  Hemostasis was achieved with electrocautery.  Lidocaine 1% (10 mL) was administered to the medial aspect of the incision and a pocket was fashioned in the medial direction.  Using the more lateral of the guidewires, a 7-French side-arm sheath was advanced into the left axillary vein.  The dilator was removed and another wire was advanced down into the sheath.  The sheath was then backed up over the top of the two wires.  One wire was pinned to the drape and using the alternate wire, a 9-French side-arm sheath was advanced down into the left axillary vein.  The dilator and wire were removed.  A defibrillation lead was then advanced down into the atrium.  The peel-away sheath was removed.  The lead was then passed across the tricuspid valve and positioned in the apical septal location.  The active fix screw was deployed.  Adequate pacing and sensing functions were established.  A 10-volt pacing was used temporarily and there was no diaphragmatic stimulation.  The suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  Using the wire that had been pinned to the drape, a 7-French side-arm sheath was advanced over this wire into the axillary vein.  The wire and dilator were removed.  An active pacing lead was then advanced down to the right atrium and the peel-away sheath was removed.  The lead was parked until a later time.  Using the separate access point, a 9-French side-arm sheath was advanced into the left axillary vein.  The dilator and wire were removed.  A curved outer sheath catheter as well as an inner catheter were advanced down into the area of the coronary sinus.  The coronary sinus was cannulated.  Inner catheter was removed and a balloon-tipped catheter was advanced into the coronary sinus.  A coronary sinus venogram was then performed.  It was noted that the most suitable location for lead placement was the middle cardiac vein.  This was cannulated and a passive lead was advanced over a Whisper EDS wire into a distal position.  Adequate pacing and sensing functions were established.  A 10-volt pacing was used temporarily.  There was no diaphragmatic stimulation.  The outer sheath was peeled away.  The 9 French sheath was then peeled away.  Suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  At this point, the atrial lead was then positioned in the right atrial appendage using a preformed J-curved stylet.  The lead body was turned several times and the lead was affixed to the tissue.  Adequate pacing and sensing function were established.  A suture sleeve was advanced to the entry point of the tissue and connected securely to the tissue.  The pocket was then washed with antibiotic-impregnated saline.  Pulse generator was obtained and connected securely to the leads.  The leads were carefully wrapped behind the pulse generator and the entire system was placed in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using a running mattress stitch.  Sponge and needle counts were correct at the end of the procedure and no acute complications were noted.,The patient was sedated further and shock on T was performed on two separate occasions.  The device was allowed to detect the charge and defibrillate, establishing the entire workings of the ICD system.,DEVICE DATA,1.  Pulse generator, manufacturer Boston Scientific, model # N119, serial #12345.,2.  Right atrial lead, manufacturer Guidant, model #4470, serial #12345.,3.  Right ventricular lead, manufacturer Guidant, model #0185, serial #12345.,4.  Left ventricular lead, manufacturer Guidant, model #4549, serial #12345.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 705 ohms.  P-waves measured at 1.7 millivolts.  Pacing threshold 0.5 volt at 0.4 milliseconds.,2.  Right ventricular lead impedance 685 ohms.  R-waves measured 10.5 millivolts.  Pacing threshold 0.6 volt at 0.4 milliseconds.,3.  Left ventricular lead impedance 1098 ohms.  R-waves measured 5.2 millivolts.  Pacing threshold 1.4 volts at 0.4 milliseconds.,DEFIBRILLATION THRESHOLD TESTING,1.  Shock on T.  Charge time 2.9 seconds.  Energy delivered 17 joules, successful with lead impedance of 39 ohms.,2.  Shock on T.  Charge time 2.8 seconds.  Energy delivered 17 joules, successful with a type 2 break lead impedance of 38 ohms.,DEVICE SETTINGS,1.  A pacing DDD 60 to 120.,2.  VT-1 zone 165 beats per minute.  VT-2 zone 185 beats per minute.  VF zone 205 beats per minute.,CONCLUSIONS,1.  Successful implantation of a biventricular automatic implantable cardiovascular defibrillator,2.  Defibrillation threshold of less than or equal to 17.5 joules.,2.  No acute complications.,PLAN,1.  The patient will be taken back to his room for continued observation and dismissed to the discretion of the primary service.,2.  Chest x-ray to rule out pneumothorax and verified lead position.,3.  Device interrogation in the morning.,4.  Completion of the course of antibiotics.
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DESCRIPTION: Implantation of biventricular automatic implantable cardioverter defibrillator, fluoroscopic guidance for lead implantation for biventricular automatic implantable cardioverter defibrillator, coronary sinus venogram for left ventricular lead placement, and defibrillation threshold testing x2.

The described procedure involves a surgical operation to implant a biventricular cardioverter defibrillator in a patient with severe cardiac conditions. This is inherently high-stakes due to the critical nature of the patient's health status—the presence of dilated cardiomyopathy, extremely low ejection fraction, ventricular tachycardia, and bradycardia. The surgery involves complex steps including lead placements and defibrillation threshold testing, all of which have substantial risks such as bleeding, infection, and potential need for emergency interventions or even death. The critical nature of the patient's conditions and the technical intricacies of the procedure make this a high-stakes scenario.


Medical Specialty: Surgery
Sample Name: Bilateral Vasovasostomy

Initially a small incision was made in the right superior hemiscrotum and the incision was carried down to the vas deferens.  This incision was carried down to the area of the previous vasectomy.  A towel clip was placed around this.  Next the scarred area was dissected free back to normal vas proximally and distally.  Approximately 4 cm of vas was freed up.  Next the vas was amputated above and below the scar tissue.  Fine hemostats were used to grasp the adventitial tissue on each side of the vas, both the proximal and distal ends.  Both ends were then dilated very carefully with lacrimal duct probes up to a #2 successfully.  After accomplishing this, fluid could be milked from the proximal vas which was encouraging.,Next the reanastomosis was performed.  Three 7-0 Prolene were used and full thickness bites were taken through the muscle layer of the vas deferens and into the lumen.  This was all done with 3.5 loupe magnification.  Next the vas ends were pulled together by tying the sutures.  A good reapproximation was noted.  Next in between each of these sutures two to three of the 7-0 Prolenes were used to reapproximate the muscularis layer further in an attempt to make this fluid-tight.,There was no tension on the anastomosis and the vas was delivered back into the right hemiscrotum.  The subcuticular layers were closed with a running 3-0 chromic and the skin was closed with three interrupted 3-0 chromic sutures.,Next an identical procedure was done on the left side.,The patient tolerated the procedure well and was awakened and returned to the recovery room in stable condition.  Antibiotic ointment, fluffs, and a scrotal support were placed.
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DESCRIPTION: Bilateral vasovasostomy surgery sample.

Bilateral vasovasostomy surgery sample.

surgery, vasovasostomy, adventitial tissue, anastomosis, fluffs, hemiscrotum, loupe magnification, lumen, muscle layer, scrotal support, subcuticular, vas deferens, vas ends, bilateral vasovasostomy, chromic, suturesNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

Bilateral vasovasostomy is a surgical procedure to reverse a vasectomy and restore fertility. The stakes are significant because the success of the procedure impacts the patient's ability to conceive. Additionally, surgical complications, though generally low in vasovasostomy, can have serious consequences for the patient, like infection or bleeding. However, the procedure itself is routinely performed by skilled surgeons, minimizing the risks involved.


Medical Specialty: Surgery
Sample Name: Bilateral Orbital Frontozygomatic Craniotomy

PREOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS: , Metopic synostosis with trigonocephaly.,PROCEDURES PERFORMED: , ,1.  Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies.,2.  Bone grafts.,3.  Bilateral forehead reconstruction with autologous graft.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS:,  None.,CONDITION OF THE PATIENT AT THE END OF THE PROCEDURE: , Stable, transferred to recovery room.,ESTIMATED BLOOD LOSS: , 300 mL.,CRYSTALLOIDS: , Packed red blood cells 440 mL, FFP 100 mL.,URINARY OUTPUT: , 160 mL.,INDICATIONS FOR PROCEDURE: , The patient is a 9-month-old baby with a history of trigonocephaly and metopic synostosis.  We have discussed locations, the nature of trigonocephaly's repair, metopic synostosis repair with bilateral fronto-orbital advancement, forehead reconstruction, and bone graft.  We have discussed risks and benefits.  Risks included, but not limited to risk of bleeding, infection, dehiscence, scarring, need for future revision surgeries, minimal possibility of death, the alternatives, devastating bleeding, anesthesia, death, dehiscence, infection.  The parents understand, decide to proceed with surgery.  Informed consent was obtained and we proceed with surgery.,DESCRIPTION OF PROCEDURE: , The patient was taken into the operating room, placed in the supine position.  General anesthetic was administered.  Prophylactic dose of antibiotic was given.  Lines were placed by Anesthesia and then the head of the bed was turned to 100 degrees.  The patient was once more positioned and padded in the usual manner.  The incision was marked with the help of a marking pen and local anesthetic was infiltrated after prepping the area one time, then the definitive prep and draping of the area was done.,The procedure began with an incision through the full-thickness of the skin into the subcutaneous tissue down to the subgaleal plane.  The subgaleal plane was developed and reflected anteriorly and slightly posteriorly.  Hemostasis achieved with electrocautery.  Raney clips were applied to both flaps to prevent significant bleeding.  Then, we proceed with craniotomy part and Dr. Y proceeded with this part of the procedure.  I assisted her and this will be described in a different operative report.  Then, the area corresponding to the C-shaped osteotomy was marked and then we proceed in conjunction with Dr. Y to develop these osteotomies with the help of the Midas by retracting the contents of the skull at the level of the anterior fossa as well as the orbital contents with the help of a ribbon retractor.  The osteotomies were done with the Midas and some irrigation.  There was an osteotomy done at the level of the frontozygomatic suture just posterior to the frontozygomatic suture and then these osteotomies continued down intraorbitally and lateral through the zygoma to the level of the intraorbital rim.  This was done on both sides.  Hemostasis achieved with bone wax and electrocautery.  Once the osteotomies were completed, __________ of the osteotomy sites allowed advancements.  On the left side, there was a minor fracture to the superior orbital rim that was plated.  The bone grafts were customized placing these at the level of the sphenoid bone in the posterior aspect of the orbital rim.  The temporalis muscle was advanced and attached to the orbital rim with holes that have been drilled with Midas and a 3-0 Vicryl interrupted stitches.  The forehead flaps were attached with the help of absorbable mesh.  The forehead portions were applied to the fronto-orbital advancement of fronto-orbital piece with the help of Synthes mesh and 3-mm screws.  Hemostasis was checked.  The flaps were retracted back into position.,The wound was closed with 3-0 Vicryl interrupted sutures, 4-0 Vicryl interrupted stitches, and 5-0 running fast absorbing gut.  Dressing was applied with Xeroform, bacitracin, and ABDs and a burn net.  The patient tolerated the procedure well without complications and was transferred to the recovery room in stable condition.  I was present and participated in all aspects of the procedure.  Sponge, needle, and instrument counts were completed at the end of the procedure.
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DESCRIPTION: Bilateral orbital frontozygomatic craniotomy with bilateral orbital advancement with Z-osteotomies and bilateral forehead reconstruction with autologous graft.

surgery, metopic synostosis, craniotomy, z-osteotomies, orbital advancement, bone grafts, frontozygomatic, forehead reconstruction, autologous graft, bilateral orbital frontozygomatic craniotomy, orbital, osteotomies, forehead,

The situation involves a complex and invasive surgical procedure on a 9-month-old infant with a serious condition (metopic synostosis with trigonocephaly). This type of surgery involves significant risks, including potential bleeding, infection, and the complexities of anesthesia, especially given the patient's age. Despite the procedure being completed without complications, the initial stakes are high due to the nature of the surgery, the vulnerability of the patient, and the potential for severe outcomes. Additionally, informed consent discussions mention serious risks including 'minimal possibility of death,' highlighting the high stakes involved.


Medical Specialty: Surgery
Sample Name: Bilateral Myringotomies

PREOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,FINAL DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,4.  Acute and chronic adenoiditis.,OPERATIONS PERFORMED,1.  Bilateral myringotomies.,2.  Placement of ventilating tubes.,3.  Nasal endoscopy.,4.  Adenoidectomy.,DESCRIPTION OF OPERATIONS: , The patient was brought to the operating room, endotracheal intubation carried out by Dr. X. Both sides of the patient's nose were then sprayed with Afrin.  Ears were inspected then with the operating microscope.  The anterior inferior quadrant myringotomy incisions were performed.  Then, a modest amount of serous and a trace of mucoid material encountered that was evacuated.  The middle ear mucosa looked remarkably clean.  Armstrong tubes were inserted.  Ciprodex drops were instilled.  Ciprodex will be planned for two postoperative days as well.  Nasal endoscopy was carried out, and evidence of acute purulent adenoiditis was evident in spite of the fact that clinically the patient has shown some modest improvement following cessation of all milk products.  The adenoids were shaved back, flushed with curette through a traditional transoral route with thick purulent material emanating from the crypts, and representative cultures were taken.  Additional adenoid tissue was shaved backwards with the RADenoid shaver.  Electrocautery was used to establish hemostasis, and repeat nasal endoscopy accomplished.  The patient still had residual evidence of inter choanal adenoid tissue, and video photos were taken.  That remaining material was resected, guided by the nasal endoscope using the RADenoid shaver to remove the material and flush with the posterior nasopharynx.  Electrocautery again used to establish hemostasis.  Bleeding was trivial.  Extensive irrigation accomplished.  No additional bleeding was evident.  The patient was awakened, extubated, taken to the recovery room in a stable condition.  Discharge anticipated later in the day on Augmentin 400 mg twice daily, Lortab or Tylenol p.r.n. for pain.  Office recheck would be anticipated if stable and doing well in approximately two weeks.  Parents were instructed to call, however, regarding the outcome of the culture on Monday next week to ensure adequate antibiotic coverage before cessation of the antibiotic.
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DESCRIPTION: Bilateral myringotomies, placement of ventilating tubes, nasal endoscopy, and adenoidectomy.

surgery, bilateral middle ear effusions, recurrent acute otitis media, chronic rhinitis, recurrent adenoiditis with adenoid hypertrophy, adenoiditis, bilateral myringotomies, ventilating tubes, nasal endoscopy, adenoidectomy, adenoid hypertrophy, myringotomies, otitis, media, hypertrophy, endoscopy, intubation, nasal,

The surgical procedures described involve bilateral myringotomies, placement of ventilating tubes, nasal endoscopy, and adenoidectomy, which, while significant, are considered standard otolaryngological surgeries often performed to manage conditions like recurrent acute otitis media and adenoid hypertrophy. Such procedures are indeed critical for the patient's well-being, but they are not inherently life-threatening and are performed routinely. The description suggests that the patient was stable post-operation, and discharge was planned the same day, indicating that the risk of severe complications is low. However, the need for surgical intervention in pediatric cases often carries additional considerations for recovery and ensuring no post-operative complications, particularly when it comes to monitoring for infection and ensuring proper antibiotic coverage.


Medical Specialty: Surgery
Sample Name: Bilateral Myringotomies - 1

PREOPERATIVE DIAGNOSES:,  OM, chronic, serous, simple or unspecified.  Adenoid hyperplasia.  Hypertrophy of tonsils.,POSTOPERATIVE DIAGNOSIS: , Same as preoperative diagnosis.,OPERATION: , Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.,ANESTHESIA:,  General.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,DRAINS: , None.,CONSENT:,  The procedure, benefits, and risks were discussed in detail preoperatively.  The parentsagreed to proceed after all questions were answered.,TECHNIQUE: , The patient was brought to the operating room and placed in the supine position.  After general mask anesthesia was adequately obtained, the right external auditory canal was cleaned out under the microscope.  Serous fluid was aspirated from the middle ear space.  An Armstrong grommet tube was placed down through the incision and rotated into place.  The opposite ear was then cleaned out under the microscope.  Serous fluid was aspirated from the middle ear space.  An Armstrong grommet tube was placed down through the incision and rotated into place.  Cortisporin suspension was placed in both ear canals.,Then the patient was intubated.  A Crowe-Davis mouth gag was placed into the mouth and extended and hung on the Mayo stand.  The red rubber catheter was placed down through the nose and brought out through the mouth to retract the palate.  The adenoid fossa was visualized with the mirror.  The adenoids were removed using the microdebrider.  Two adenoid packs were placed.  The packs were removed one by one.  Using mirror and suction bovie, adequate hemostasis was achieved.,The tonsils were quite large and cryptic.  The tenaculum was placed on the superior pole of the right tonsil.  Cheesy material came out from the crypts.  The tonsils were retracted medially.  The bovie electrocautery was used to make an incision in the right anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature.  The tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars.  All bleeders were cauterized as they were encountered.  The tenaculum was then placed on the superior pole of the left tonsil.  Cheesy material came out from the crypts.  The tonsils were retracted medially.  The bovie electrocautery was used to make an incision in the left anterior tonsillar pillar, and the plane was developed between the tonsil and the musculature.  The tonsil was completely dissected out of this plane, preserving both the anterior and posterior tonsillar pillars.  All bleeders were cauterized as they were encountered.  Both tonsil beds were then re-cauterized, paying particular attention to the inferior and superior poles.,The stomach was evacuated with the nasogastric tube.  The patient was then awakened in the operating room, extubated and taken to the recovery room in satisfactory condition.
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DESCRIPTION: Bilateral myringotomies with Armstrong grommet tubes, Adenoidectomy, and Tonsillectomy.

surgery, adenoid hyperplasia, om, adenoidectomy, tonsillectomy, auditory canal, serous fluid, crowe-davis mouth gag, tonsils, adenoidectomy and tonsillectomy, armstrong grommet tubes, bovie electrocautery, tonsillar pillar, bilateral myringotomies, armstrong, tubes, grommet, tonsillar, bilateral, myringotomies, tenaculum

The situation described involves a surgical procedure, which inherently carries certain risks due to the use of general anesthesia and surgical interventions. However, the specific procedures detailed—bilateral myringotomies, adenoidectomy, and tonsillectomy—are relatively routine, especially in pediatric care for conditions such as otitis media and hypertrophy of the tonsils and adenoids. The fact that there were no complications, minimal blood loss, and that the patient was moved to recovery in satisfactory condition further reduces the stakes. Therefore, while surgery is always a serious matter, this particular situation doesn't present high-stakes urgency or complexity.