Medical Specialty: Obstetrics / Gynecology
Sample Name: Low-Transverse C-Section - 5

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 38 weeks.,2.  Malpresentation.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 38 weeks.,2.  Malpresentation.,3.  Delivery of a viable male neonate.,PROCEDURE PERFORMED: , Primary low transverse cervical cesarean section.,ANESTHESIA: , Spinal with Astramorph.,ESTIMATED BLOOD LOSS: , 300 cc.,URINE OUTPUT:,  80 cc of clear urine.,FLUIDS: , 2000 cc of crystalloids.,COMPLICATIONS: , None.,FINDINGS: , A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g.  No nuchal cord.  No meconium.  Normal uterus, fallopian tubes, and ovaries.,INDICATIONS: , This patient is a 21-year-old gravida 3, para 1-0-1-1 Caucasian female who presented to Labor and Delivery in labor.  Her cervix did make some cervical chains.  She did progress to 75% and -2, however, there was a raised lobular area palpated on the fetal head.  However, on exam unable to delineate the facial structures, but definite fetal malpresentation.  The fetal heart tones did start and it continued to have variable decelerations with contractions overall are reassuring.  The contraction pattern was inadequate.  It was discussed with the patient's family that in light of the physical exam and with the fetal malpresentation that a cesarean section will be recommended.  All the questions were answered.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite and placed in the dorsal lithotomy position with a leftward tilt.  Prior to this, the spinal anesthesia was administered.  The patient was then prepped and draped.  A Pfannenstiel skin incision was made with the first scalpel and carried through to the underlying layer of fascia with the second scalpel.  The fascia was then incised in the midline and extended laterally using Mayo scissors.  The superior aspect of the rectus fascia was then grasped with Ochsners, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors.  The superior portion and inferior portion of the rectus fascia was identified, tented up and the underlying layer of rectus muscle was dissected up bluntly as well as with Mayo scissors.  The rectus muscle was then separated in the midline.  The peritoneum was then identified, tented up with hemostats and entered sharply with Metzenbaum scissors.  The peritoneum was then gently stretched.  The vesicouterine peritoneum was then identified, tented up with an Allis and the bladder flap was created bluntly as well as using Metzenbaum scissors.  The uterus was entered with the second scalpel and large transverse incision.  This was then extended in upward and lateral fashion bluntly.  The infant was then delivered atraumatically.  The nose and mouth were suctioned.  The cord was then clamped and cut.  The infant was handed off to the awaiting pediatrician.  The placenta was then manually extracted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was then repaired using #0 chromic in a running fashion marking a U stitch.  A second layer of the same suture was used in an imbricating fashion to obtain excellent hemostasis.  The uterus was then returned to the anatomical position.  The abdomen and the gutters were cleared of all clots.  Again, the incision was found to be hemostatic.  The rectus muscle was then reapproximated with #2-0 Vicryl in a single interrupted stitch.  The rectus fascia was then repaired with #0 Vicryl in a running fashion locking the first stitch and first last stitch in a lateral to medial fashion.  This was palpated and the patient was found to be without defect and intact.  The skin was then closed with staples.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She will be followed up as an inpatient with Dr. X.
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DESCRIPTION: Primary low transverse cervical cesarean section.  Intrauterine pregnancy at 38 weeks and malpresentation.  A viable male neonate in the left occiput transverse position with Apgars of 9 and 9 at 1 and 5 minutes respectively, weighing 3030 g.  No nuchal cord.  No meconium.  Normal uterus, fallopian tubes, and ovaries.

obstetrics / gynecology, low transverse cervical cesarean section, cesarean section, pregnancy, neonate, metzenbaum scissors, intrauterine pregnancy, rectus fascia, rectus muscle, intrauterine, peritoneum, malpresentation, transverse, astramorph,

The situation describes a primary low transverse cesarean section carried out due to fetal malpresentation at 38 weeks of intrauterine pregnancy. The procedure was necessary to ensure the safe delivery of a viable infant and the health of the mother. The operation was successful with no complications, and both the mother and the neonate were stable post-operation. Despite the absence of complications, any surgical procedure, particularly involving delivery and potential fetal distress, can be considered high-stakes due to the risks involved and the critical nature of delivery in obstetrics.


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Medical Specialty: Obstetrics / Gynecology
Sample Name: Low -Segment C-Section

PREOPERATIVE DIAGNOSIS:  ,Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,POSTOPERATIVE DIAGNOSIS: , Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,PROCEDURE: , Primary low segment cesarean section.  The patient was placed in the supine position under spinal anesthesia with a Foley catheter in place and she was prepped and draped in the usual manner.  A low abdominal transverse skin incision was constructed and carried down through the subcutaneous tissue through the anterior rectus fascia.  Bleeding points were snapped and coagulated along the way.  The fascia was opened transversally and was dissected sharply and bluntly from the underlying rectus muscles.  These were divided in the midline revealing the peritoneum, which was opened vertically.  The uterus was in mid position.  The bladder flap was incised elliptically and reflected caudad.  A low transverse hysterotomy incision was then constructed and extended bluntly.  Amniotomy revealed clear amniotic fluid.  A live born vigorous male infant was then delivered from the right occiput transverse position.  The infant breathed and cried spontaneously.  The nares and pharynx were suctioned.  The umbilical cord was clamped and divided and the infant was passed to the waiting neonatal team.  Cord blood samples were obtained.  The placenta was manually removed and the uterus was eventrated for closure.  The edges of the uterine incision were grasped with Pennington clamps and closure was carried out in standard two-layer technique using 0 Vicryl suture with the second layer imbricating the first.  Hemostasis was completed with an additional figure-of-eight suture of 0 Vicryl.  The cornual sac and gutters were irrigated.  The uterus was returned to the abdominal cavity.  The adnexa were inspected and were normal.  The abdomen was then closed in layers.  Fascia was closed with running 0 Vicryl sutures, subcutaneous tissue with running 3-0 plain Catgut, and skin with 3-0 Monocryl subcuticular suture and Steri-Strips.  Blood loss was estimated at 700 mL.  All counts were correct.,The patient tolerated the procedure well and left the operating room in excellent condition.
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DESCRIPTION: Primary low segment cesarean section.

Primary low segment cesarean section.

obstetrics / gynecology, nonreassuring fetal testing, anterior rectus fascia, pennington clamps, fetal testing, low segment, induction, suture,

The situation describes a cesarean section due to a pregnancy at 42 weeks with nonreassuring fetal testing and failed induction, meaning there is concern for the safety of the fetus and/or mother, thus requiring surgical intervention. A C-section is a major surgical procedure typically considered high-stakes due to the potential risks to both the mother and the newborn, such as surgical complications, bleeding, and infection. However, in this case, the procedure was completed successfully without complications, but the urgency of the situation still qualifies it as relatively high-stakes.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Obstetrics / Gynecology
Sample Name: Low-Transverse C-Section - 3

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at 33 weeks, twin gestation.,2.  Active preterm labor.,3.  Advanced dilation.,4.  Multiparity.,5.  Requested sterilization.,POSTOPERATIVE DIAGNOSIS:,1.  Intrauterine pregnancy at 33 weeks, twin gestation.,2.  Active preterm labor.,3.  Advanced dilation.,4.  Multiparity.,5.  Requested sterilization.,6.  Delivery of a viable female A weighing 4 pounds 7 ounces, Apgars were 8 and 9 at 1 and 5 minutes respectively and female B weighing 4 pounds 9 ounces, Apgars 6 and 7 at 1 and 5 minutes respectively.,7.  Uterine adhesions and omentum adhesions.,OPERATION PERFORMED: , Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,DRAINS:,  Foley.,This is a 25-year-old white female gravida 3, para 2-0-0-2 with twin gestation at 33 weeks and previous C-section.  The patient presents to Labor and Delivery in active preterm labor and dilated approximately 4 to 6 cm.  The decision for C-section was made.,PROCEDURE:,  The patient was taken to the operating room and placed in a supine position with a slight left lateral tilt and she was then prepped and draped in usual fashion for a low transverse incision.  The patient was then given general anesthesia and once this was completed, first knife was used to make a low transverse incision extending down to the level of the fascia.  The fascia was nicked in the center and extended in a transverse fashion with the use of curved Mayo scissors.  The edges of the fascia were grasped with Kocher and both blunt and sharp dissection was then completed both caudally and cephalically.  The abdominal rectus muscle was divided in the center and extended in a vertical fashion.  Peritoneum was entered at a high point and extended in a vertical fashion as well.  The bladder blade was put in place.  The bladder flap was created with the use of Metzenbaum scissors and dissected away caudally.  The second knife was used to make a low transverse incision with care being taken to avoid the presenting part of the fetus.  The first fetus was vertex.  The fluid was clear.  The head was delivered followed by the remaining portion of the body.  The cord was doubly clamped and cut.  The newborn handed off to waiting pediatrician and nursery personnel.  The second fluid was ruptured.  It was the clear fluid as well.  The presenting part was brought down to be vertex.  The head was delivered followed by the rest of the body and the cord was doubly clamped and cut, and newborn handed off to waiting pediatrician in addition of the nursery personnel.  Cord pH blood and cord blood was obtained from both of the cords with careful identification of A and B. Once this was completed, the placenta was delivered and handed off for further inspection by Pathology.  At this time, it was noted at the uterus was adhered to the abdominal wall by approximately of 3 cm x 3 cm thick uterine adhesion and this was needed to be released by sharp dissection.  Then, there were multiple omental adhesions on the surface of the uterus itself.  This needed to be released as well as on the abdominal wall and then the uterus could be externalized.  The lining was wiped clean of any remaining blood and placental fragments and the edges of the uterus were grasped in four quadrants with Kocher and continuous locking stitch of 0 chromic was used to re-approximate the uterine incision, with the second layer used to imbricate the first.  The bladder flap was re-approximated with 3-0 Vicryl and Gelfoam underneath.  The right fallopian tube was grasped with a Babcock, it was doubly tied off with 0 chromic and the knuckle portion was then sharply incised and cauterized.  The same technique was completed on the left side with the knuckle portion cut off and cauterized as well.  The defect on the uterine surface was reinforced with 0 Vicryl in a baseball stitch to create adequate Hemostasis.  Interceed was placed over this area as well.  The abdominal cavity was irrigated with copious amounts of saline and the uterus was placed back in its anatomical position.  The gutters were wiped clean of any remaining blood.  The edges of the peritoneum were grasped with hemostats and a continuous locking stitch was used to re-approximate abdominal rectus muscles as well as the peritoneal edges.  The abdominal rectus muscle was irrigated.  The corners of the fascia grasped with hemostats and continuous locking stitch of 0 Vicryl started on both corners and overlapped on the center.  The subcutaneous tissue was irrigated.  Cautery was used to create adequate hemostasis and 3-0 Vicryl was used to re-approximate the subcutaneous tissue.  Skin edges were re-approximated with sterile staples.  Sterile dressing was applied.  Uterus was evacuated of any remaining blood vaginally.  The patient was taken to the recovery room in stable condition.  Instrument count, needle count, and sponge counts were all correct.
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DESCRIPTION: Repeat low-transverse C-section, lysis of omental adhesions, lysis of uterine adhesions with repair of uterine defect, and bilateral tubal ligation.

obstetrics / gynecology, intrauterine pregnancy, gestation, preterm labor, omentum adhesions, low transverse c section, uterine adhesions, intrauterine, adhesions, abdominal, uterus, uterine,

This medical scenario involves a cesarean section for a woman in active preterm labor with twin gestation, which already presents increased risks compared to single pregnancies. The presence of uterine and omental adhesions adds complexity to the procedure. Additionally, the decision to perform bilateral tubal ligation adds another layer of importance, as it has long-term reproductive implications. While the operation seems to have proceeded without immediate complications, the stakes remain high due to the potential risks to the mother and infants related to preterm birth and surgical complications.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Left Lower Quadrant Pain - ER Visit

HISTORY OF PRESENT ILLNESS:,  The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.  She denies any leaking of fluid, vaginal bleeding, or uterine contractions.  She reports good fetal movement.  She denies any fevers, chills, or burning with urination.,REVIEW OF SYSTEMS: , Positive for back pain in her lower back only.  Her mother reports that she has been eating food without difficulty and that the current nausea and vomiting is much less than when she is not pregnant.  She continues to yell out for requesting pain medication and about how much "it hurts.",PAST MEDICAL HISTORY:,1.  Irritable bowel syndrome.,2.  Urinary tract infections times three.  The patient is unsure if pyelo is present or not.,PAST SURGICAL HISTORY:,  Denies.,ALLERGIES: , No known drug allergies.,MEDICATIONS: , Phenergan and Zofran twice a day.  Macrobid questionable.,GYN: , History of an abnormal Pap, group B within normal limits.  Denies any sexually transmitted diseases.,OB HISTORY: , G1 is a term spontaneous vaginal delivery without complications, now a 6-year-old.  G2 is current.  Gets her care at Lyndhurst.,SOCIAL HISTORY: , Denies tobacco and alcohol use.  She endorses marijuana use and a history of cocaine use five years ago.  Upon review of the Baptist lab systems, the patient has had multiple positive urine drug screens and as recently as February 2008 had a urine drug screen that was positive for benzodiazepines, barbiturates, opiates, and marijuana and as recently as 2005 with cocaine present as well.,PHYSICAL EXAM:,VITAL SIGNS:  Blood pressure 139/82, pulse 89, respirations 20, 98% on room air, 96 degrees Fahrenheit.  Fetal heart tones are 130s with moderate long-term variability.  No paper is available for the fetal heart monitor due to the misorder and audibly sounds reassuring.,GENERAL:  Appears sedated, trashing intermittently, and then falling asleep in mid sentence.,CARDIOVASCULAR:  Regular rate and rhythm.,PULMONARY:  Clear to auscultation bilaterally.,BACK:  Tender to palpation in her lower back bilaterally, but no CVA tenderness.,ABDOMEN:  Tender to palpation in left lower quadrant.  No guarding or rebound.  Normal bowel sounds.,EXTREMITIES:  Scar track marks from bilateral arms.,PELVIC:  External vaginal exam is closed, long, high, and posterior.  Stool was felt in the rectum.,LABS: , White count is 11.1, hemoglobin is 13.5, platelets are 279.  CMP is within normal limits with an AST of 17, ALT of 11, and creatinine of 0.6.  Urinalysis which is supposedly a cath specimen shows a specific gravity of 1.024, greater than 88 ketones, many bacteria, but no white blood cells or nitrites.,ASSESSMENT AND PLAN:  ,The patient is a 26-year-old gravida 2, para 1-0-0-1 at 28-1 weeks with left lower quadrant pain and likely constipation.  I spoke with Dr. X who is the physician on-call tonight, and he requests that she be transferred for continued fetal monitoring and further evaluation of this abdominal pain to Labor and Delivery.  Plans are made for transfer at this time.  This was discussed with Dr. Y who is in agreement with the plan.
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DESCRIPTION: The patient is a 26-year-old gravida 2, para 1-0-0-1, at 28-1/7 weeks who presents to the emergency room with left lower quadrant pain, reports no bowel movement in two weeks as well as nausea and vomiting for the last 24 hours or so.  She states that she has not voided in the last 24 hours as well due to pain.

The patient is pregnant (28 weeks gestation) and presents with abdominal pain, constipation, and a lack of urination, all of which can have serious implications for both maternal and fetal health. There is also a history of drug use, which could complicate the medical assessment and management. Immediate medical attention is warranted to ensure the well-being of both the mother and the fetus. The risks associated with untreated pain, potential infection, and lack of fetal monitoring increase the stakes. Additionally, the presence of tender lower back pain may suggest additional underlying complications that require prompt assessment.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Low-Transverse C-Section - 1

PREOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,POSTOPERATIVE DIAGNOSES: , Term pregnancy, nonreassuring fetal heart tracing.,OPERATION:,  Primary cesarean section by low-transverse incision.,ANESTHESIA:,  Epidural.,ESTIMATED BLOOD LOSS: , 450 mL.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS:  ,Foley catheter.,INDICATIONS: , The patient is a 39-year-old, G4, para 0-0-3-0, with an EDC of 03/08/2009.  The patient began having prodromal symptoms 2 to 3 days prior to presentation.  She was seen on 03/09/2007 and a nonstress test was performed.  This revealed some spontaneous variable-appearing decelerations.  She was given IV hydration.  A biophysical profile was obtained, which provided a score of 0/8 with only a 1 cm fluid pocket found.  Therefore, she was admitted for further fetal monitoring and evaluation.  She had changed her cervix from closed 2 days prior to presentation to 1 cm dilated.  She was having somewhat irregular contractions, but with stronger contractions, continued to have decelerations to 50 to 60 beats per minute.  Due to these findings, a scalp electrode was placed as well as an IUPC for an amnioinfusion.  This relieved the decelerations somewhat.  However, over a period of time with strong contractions, she still had bradycardia 40 to 50 beats per minute and developed a late component on the return of the decelerations.  Due to this finding, it was evident that the fetal state would not support labor in order to accomplish a vaginal delivery.  These findings were reviewed with the patient and recommendation was made for cesarean section delivery.  The risks and benefits of this surgery were reviewed, and knowing these facts, the patient gave informed consent.,PROCEDURE: , The patient was taken to the operating room where her epidural anesthesia was reinforced.  She was prepped and draped in the usual fashion for the procedure.  After adequate epidural level was confirmed, the scalp was utilized to make a transverse incision in the patient's lower abdominal wall.  This incision was carried down to the level of the fascia, which was also transversely incised.  After adequate hemostasis, the fascia was bluntly and sharply separated up from the underlying rectus muscle.  The rectus muscle was separated in midline exposing the peritoneum.  The peritoneum was carefully grasped and elevated with hemostats.  It was entered in an up and down fashion with Metzenbaum scissors.  The bladder blade was placed in the lower pole of the incision to protect the bladder.,The uterus was palpated and inspected.  A thin lower uterine segment was noted.  The vertex presentation was confirmed.  The scalp was then utilized to make a transverse or Kerr incision in the lower uterine wall.  Clear fluid was noted upon entering into the amniotic space.  At 05:27, a term viable female infant was delivered up through the incision.  She had spontaneous respirations.  She was given bulb suctioning for clear fluid.  Her cord was clamped and cut and she was delivered off the field to Dr. X who was attending.  The baby girl was subsequently signed Apgars of 8 at one minute and 9 at five minutes.  Her birth weight was found to be 5 pounds and 5 ounces.,The placenta was manually extracted from the endometrial cavity.  A ring clamp and two Allis clamps were placed around the margin of the uterine incision for hemostasis.  The uterus was delivered up into the operative field.  The endometrial cavity was swiped clean with a moist laparotomy pad.  The uterine incision was then closed in a two-layered fashion with 0 Vicryl suture, the first layer interlocking and the second layer imbricating.  Two additional stitches of 3-0 Vicryl suture were utilized for hemostasis.  The uterine incision was noted to be hemostatic upon closure.  The uterus was rotated forward, normal tubes and ovaries were noted on both sides.  The uterus was then returned to its normal position of the abdominal cavity.  The sponge and instrument count was performed for the first time at this point and found to be correct.  The pelvis and anterior uterine space was then irrigated with saline solution.  It was suctioned dry.  A final check of the uterine incision confirmed hemostasis.  The rectus muscle was stabilized across the midline with two simple stitches of 0 Vicryl suture.  The subcutaneous tissue was then exposed, and the fascia closed with two running lengths of 0 Vicryl suture, beginning in lateral margins and overlapping the midline.  The subcutaneous tissue was then irrigated and inspected.  No active bleeding was noted.  It was closed with a running length of 3-0 plain catgut suture.  The skin was then approximated with surgical steel staples.  The incision was infiltrated with a 0.5% solution of Marcaine local anesthetic.  The incision was cleansed and sterilely dressed.,The patient was transferred to the recovery room in stable condition.  The estimated blood loss through the procedure was 450 mL.  The sponge and instrument counts were performed two more times during closure and found to be correct each time.
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DESCRIPTION: Primary cesarean section by low-transverse incision.  Term pregnancy, nonreassuring fetal heart tracing.

obstetrics / gynecology, low-transverse incision, edc, para, amnioinfusion, nonreassuring fetal heart tracing, primary cesarean section, fetal heart tracing, low transverse, term pregnancy, fetal heart, heart tracing, rectus muscle, uterine incision, vicryl suture, incision, transverse, fetal, suture, uterine,

The case concerns an obstetric emergency where a primary cesarean section was necessary due to nonreassuring fetal heart tracing, which indicated potential fetal distress. Such situations are considered high-stakes because they involve immediate surgical intervention to prevent harm or fatal outcome to the fetus and possibly the mother. Although the procedure went without complications and both mother and newborn were stable post-procedure, the urgency and necessity for surgical intervention elevate the stakes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Laparoscopic Supracervical Hysterectomy.

PREOPERATIVE DIAGNOSIS,1.  Dysmenorrhea.,2.  Menorrhagia.,POSTOPERATIVE DIAGNOSIS,1.  Dysmenorrhea.,2.  Menorrhagia.,PROCEDURE:,  Laparoscopic supracervical hysterectomy.,ESTIMATED BLOOD LOSS:,  30 cc.,COMPLICATIONS:,  None.,INDICATIONS FOR SURGERY: , A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.  Please see clinic notes.  Risks of bleeding, infection, damage to other organs have been explained.  Informed consent was obtained.,OPERATIVE FINDINGS:,  Slightly enlarged but otherwise normal-appearing uterus.  Normal-appearing adnexa bilaterally.,OPERATIVE PROCEDURE IN DETAIL: , After administration of general anesthesia the patient was placed in dorsal lithotomy position, prepped and draped in the usual sterile fashion.  Uterine manipulator was inserted as well as a Foley catheter and this was then draped off from the remainder of the abdominal field.  A 5 mm incision was made umbilically after injecting 0.25% Marcaine; 0.25% Marcaine was injected in all the incisional sites.  Veress needle was inserted, position confirmed using the saline drop method.  After confirming an opening pressure of 4 mmHg of CO2 gas, approximately four liters was insufflated in the abdominal cavity.  Veress needle was removed and a 5 mm port placed and position confirmed using the laparoscope.  A 5 mm port was placed three fingerbreadths suprapubically and on the left and right side.  All these were placed under direct visualization.  Pelvic cavity was examined with findings as noted above.  The left utero-ovarian ligament was grasped and cauterized using the Gyrus.  Part of the superior aspect of the broad ligament was then cauterized as well.  Following this the anterior peritoneum over the bladder flap was incised and the bladder flap bluntly resected off the lower uterine segment.  The remainder of the broad and cardinal ligament was then cauterized and excised.  A similar procedure was performed on the right side.  The cardinal ligament was resected all the way down to 1 cm above the uterosacral ligament.  After assuring that the bladder was well out of the way of the operative field, bipolar cautery was used to incise the cervix at a level just above the uterosacral ligaments.  The area was irrigated extensively and cautery used to assure hemostasis.  A 15 mm probe was then placed on the right side and the uterine morcellator was used to remove the specimen and submitted to pathology for examination.  Hemostasis was again confirmed under low pressure.  Using Carter-Thomason the fascia was closed in the 15 mm port site with 0 Vicryl suture.  The accessory ports were removed and abdomen deflated and skin edges reapproximated with 5-0 Monocryl suture.  Instruments removed from vagina.  Patient returned to supine position, recalled from general anesthesia and transferred to recovery in satisfactory condition.  Sponge and needle counts correct at the conclusion of the case.  Estimated blood loss was 30 cc.  There were no complications.
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DESCRIPTION: Laparoscopic supracervical hysterectomy.  A female with a history of severe dysmenorrhea and menorrhagia unimproved with medical management.

obstetrics / gynecology, adnexa, uterus, laparoscopic supracervical hysterectomy, veress needle, bladder flap, cardinal ligament, uterine, cauterized, dysmenorrhea, menorrhagia,

The situation involves a laparoscopic supracervical hysterectomy, a surgical procedure, which inherently carries certain risks such as bleeding, infection, and potential damage to surrounding organs. While the specific case presented had no complications and minimal blood loss, surgeries generally have a significant impact on a patient's health and well-being. However, since this was a procedure without complications and for non-life-threatening conditions, the stakes are moderately high but not extreme. The procedure appears to have been completed successfully, with the patient transferred to recovery in satisfactory condition, which mitigates the stakes involved. The context around the procedure being elective rather than emergent also lessens the stakes somewhat.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Laparoscopic Hysterectomy

PREOPERATIVE DIAGNOSIS:,  Endometrial carcinoma.,POSTOPERATIVE DIAGNOSIS: , Endometrial carcinoma.,PROCEDURE PERFORMED:,  Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.,ANESTHESIA: , General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology; uterus with attached right tube and ovary; pelvic and paraaortic lymph node dissection; obturator lymph node dissection.,INDICATIONS FOR PROCEDURE: , The patient was recently found to have a grade II endometrial cancer.  She was counseled to undergo laparoscopic staging.,FINDINGS:,  During the laparoscopy, the uterus was noted to be upper limits of normal size, with a normal-appearing right fallopian tubes and ovaries.  No ascites was present.  On assessment of the upper abdomen, the stomach, diaphragm, liver, gallbladder, spleen, omentum, and peritoneal surfaces of the bowel, were all unremarkable in appearance.,PROCEDURE: , The patient was brought into the operating room with an intravenous line in placed, and anesthetic was administered.  She was placed in a low anterior lithotomy position using Allen stirrups.  The vaginal portion of the procedure included placement of a ZUMI uterine manipulator with a Koh colpotomy ring and a vaginal occluder balloon.,The laparoscopic port sites were anesthetized with intradermal injection of 0.25% Marcaine.  There were five ports placed, including a 3-mm left subcostal port, a 10-mm umbilical port, a 10-mm suprapubic port, and 5-mm right and left lower quadrant ports.  The Veress needle was placed through a small incision at the base of the umbilicus, and a pneumoperitoneum was insufflated without difficulty.  The 3-mm port was then placed in the left subcostal position without difficulty, and a 3-mm scope was placed.  There were no adhesions underlying the previous vertical midline scar.  The 10-mm port was placed in the umbilicus, and the laparoscope was inserted.  Remaining ports were placed under direct laparoscopic guidance.  Washings were obtained from the pelvis, and the abdomen was explored with the laparoscope, with findings as noted.,Attention was then turned to lymphadenectomy.  An incision in the retroperitoneum was made over the right common iliac artery, extending up the aorta to the retroperitoneal duodenum.  The lymph node bundle was elevated from the aorta and the anterior vena cava until the retroperitoneal duodenum had been reached.  Pedicles were sealed and divided with bipolar cutting forceps.  Excellent hemostasis was noted.  Boundaries of dissection included the ureters laterally, common ileac arteries at uterine crossover inferiorly, and the retroperitoneal duodenum superiorly with careful preservation of the inferior mesenteric artery.  Right and left pelvic retroperitoneal spaces were then opened by incising lateral and parallel to the infundibulopelvic ligament with the bipolar cutting forceps.  The retroperitoneal space was then opened and the lymph nodes were dissected, with boundaries of dissection being the bifurcation of the common iliac artery superiorly, psoas muscle laterally, inguinal ligament inferiorly, and the anterior division of the hypogastric artery medially.  The posterior boundary was the obturator nerve, which was carefully identified and preserved bilaterally.  The left common iliac lymph node was elevated and removed using the same technique.,Attention was then turned to the laparoscopic hysterectomy.  The right infundibulopelvic ligament was divided using the bipolar cutting forceps.  The mesovarium was skeletonized.  A bladder flap was mobilized by dividing the round ligaments using the bipolar cutting forceps, and the peritoneum on the vesicouterine fold was incised to mobilize the bladder.  Once the Koh colpotomy ring was skeletonized and in position, the uterine arteries were sealed using the bipolar forceps at the level of the colpotomy ring.  The vagina was transected using a monopolar hook (or bipolar spatula), resulting in separation of the uterus and attached tubes and ovaries.  The uterus, tubes, and ovaries were then delivered through the vagina, and the pneumo-occluder balloon was reinserted to maintain pneumoperitoneum.  The vaginal vault was closed with interrupted figure-of-eight stitches of 0-Vicryl using the Endo-Stitch device.  The abdomen was irrigated, and excellent hemostasis was noted.,The insufflation pressure was reduced, and no evidence of bleeding was seen.  The suprapubic port was then removed, and the fascia was closed with a Carter-Thomason device and 0-Vicryl suture.  The remaining ports were removed under direct laparoscopic guidance, and the pneumoperitoneum was released.  The umbilical port was removed using laparoscopic guidance.  The umbilical fascia was closed with an interrupted figure-of-eight stitch using 2-0 Vicryl.  The skin was closed with interrupted subcuticular stitches using 4-0 Monocryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was awakened and taken to the post anesthesia care unit in stable condition.
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DESCRIPTION: Total laparoscopic hysterectomy with laparoscopic staging, including paraaortic lymphadenectomy, bilateral pelvic and obturator lymphadenectomy, and washings.

obstetrics / gynecology, endometrial carcinoma, laparoscopic hysterectomy, total laparoscopic hysterectomy, laparoscopic staging, lymphadenectomy, pelvic, obturator, lymph node dissection, direct laparoscopic guidance, tubes and ovaries, bipolar cutting forceps, node dissection, koh colpotomy, iliac artery, infundibulopelvic ligament, laparoscopic guidance, retroperitoneal duodenum, lymph node, laparoscopic, hysterectomy, endometrial, pneumoperitoneum, washings, vaginal, retroperitoneal, forceps, bipolar,

The patient is undergoing a total laparoscopic hysterectomy for endometrial carcinoma, which is a potentially life-threatening condition. The procedure involves staging and lymphadenectomy, indicating a complex surgical intervention aimed at both removing cancerous tissue and determining the extent of the disease. Such surgeries carry significant risks due to the involvement of major blood vessels and organs in the abdomen. Errors or complications during the procedure can have severe consequences, impacting the patient's prognosis and recovery. Therefore, the situation is high-stakes, given the nature and purpose of the surgery.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Induction of Vaginal Delivery

DIAGNOSES,1.  Term pregnancy.,2.  Possible rupture of membranes, prolonged.,PROCEDURE:,  Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:,  The patient is a 20-year-old female, gravida 4, para 0, who presented to the office.  She had small amount of leaking since last night.  On exam, she was positive Nitrazine, no ferning was noted.  On ultrasound, her AFI was about 4.7 cm.  Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin.  Once she was in her regular pattern, we ruptured her bag of water; fluid was clear.  She went rapidly to completion over the next hour and a half.  She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation.  Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications.  The baby was vigorous, moving all extremities.  The cord was clamped and cut.  The baby was handed off to mom with nurse present.  Apgars were 8 and 9.  Placenta was delivered spontaneously, intact.  Three-vessel cord with no retained placenta.  Estimated blood loss was about 150 mL.  There were no tears.
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DESCRIPTION: Induction of vaginal delivery of viable male, Apgars 8 and 9.  Term pregnancy and oossible rupture of membranes, prolonged.

obstetrics / gynecology, induction of vaginal delivery, vaginal delivery, viable male, pregnancy, placenta, vaginal, membranes, apgars

The induction of labor and delivery involves certain risks and requires close medical supervision, which makes it a significant medical procedure. In this case, there were factors like a term pregnancy, possible rupture of membranes, and oligohydramnios which justified the induction. Furthermore, considering the mother's obstetric history as a gravida 4, para 0, where previous pregnancies did not result in live births may indicate additional emotional and psychological stakes. However, the delivery itself was uncomplicated, and both the mother and baby had favorable outcomes, as indicated by Apgar scores and lack of complications. Therefore, while medically significant, the situation described does not carry the highest possible stakes, particularly because of the positive outcome.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Hysterectomy (TAH - BSO)

PREOPERATIVE DIAGNOSIS: , Endometrial cancer.,POSTOPERATIVE DIAGNOSIS: , Same.,OPERATION PERFORMED:,  Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.,ANESTHESIA:,  General, endotracheal tube.,SPECIMENS: , Pelvic washings for cytology, uterus with attached tubes and ovaries, right and left pelvic lymph nodes, para-aortic nodes.,INDICATIONS FOR PROCEDURE: , The patient recently presented with postmenopausal bleeding and was found to have a Grade II endometrial carcinoma on biopsy.  She was counseled to undergo staging laparotomy.,FINDINGS:,  Examination under anesthesia revealed a small uterus with no nodularity.  During the laparotomy, the uterus was small, mobile, and did not show any evidence of extrauterine spread of disease.  Other abdominal viscera, including the diaphragm, liver, spleen, omentum, small and large bowel, and peritoneal surfaces, were palpably normal.  There was no evidence of residual neoplasm after removal of the uterus.  The uterus itself showed no serosal abnormalities and the tubes and ovaries were unremarkable in appearance.,PROCEDURE: , The patient was brought to the Operating Room with an IV in place.  Anesthesia was induced, after which she was examined, prepped and draped.,A vertical midline incision was made and fascia was divided.  The peritoneum was entered without difficulty and washings were obtained.  The abdomen was explored with findings as noted.  A Bookwalter retractor was placed and bowel was packed.  Clamps were placed on the broad ligament for traction.  The retroperitoneal spaces were opened by incising lateral and parallel to the infundibulopelvic ligament.  The round ligaments were isolated, divided, and ligated.  The peritoneum overlying the vesicouterine fold was incised to mobilize the bladder.,Retroperitoneal spaces were then opened, allowing exposure of pelvic vessels and ureters.  The infundibulopelvic ligaments were isolated, divided, and doubly ligated.  The uterine artery pedicles were skeletonized, clamped, divided, and suture ligated.  Additional pedicles were developed on each side of the cervix, after which tissue was divided and suture ligated.  When the base of the cervix was reached, the vagina was cross-clamped and divided, allowing removal of the uterus with attached tubes and ovaries.  Angle stitches of o-Vicryl were placed, incorporating the uterosacral ligaments and the vaginal vault was closed with interrupted figure-of-eight stitches.  The pelvis was irrigated and excellent hemostasis was noted.,Retractors were repositioned to allow exposure for lymphadenectomy.  Metzenbaum scissors were used to incise lymphatic tissues.  Borders of the pelvic node dissection included the common iliac bifurcation superiorly, the psoas muscle laterally, the cross-over of the deep circumflex iliac vein over the external iliac artery inferiorly, and the anterior division of the hypogastric artery medially.  The posterior border of dissection was the obturator nerve, which was carefully identified and preserved bilaterally.  Ligaclips were applied where necessary.  After the lymphadenectomy was performed bilaterally, excellent hemostasis was noted.,Retractors were again repositioned to allow exposure of para-aortic nodes.  Lymph node tissue was mobilized, Ligaclips were applied, and the tissue was excised.  The pelvis was again irrigated and excellent hemostasis was noted.  The bowel was run and no evidence of disease was seen.,All packs and retractors were removed and the abdominal wall was closed using a running Smead-Jones closure with #1 permanent monofilament suture.  Subcutaneous tissues were irrigated and a Jackson-Pratt drain was placed.  Scarpa's fascia was closed with a running stitch and skin was closed with a running subcuticular stitch.  The final sponge, needle and instrument counts were correct at the completion of the procedure. ,The patient was then awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.
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DESCRIPTION: Exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, right and left pelvic lymphadenectomy, common iliac lymphadenectomy, and endometrial cancer staging procedure.

obstetrics / gynecology, tah, bso, lymphadenectomy, endometrial, total abdominal hysterectomy, bilateral salpingo oophorectomy, tubes and ovaries, salpingo oophorectomy, lymph nodes, endometrial cancer, abdominal, hysterectomy, oophorectomy, hemostasis, retractors, washings, laparotomy, ligated, pelvic, uterus, nodes,

The scenario described involves a major surgical procedure, a total abdominal hysterectomy with bilateral salpingo-oophorectomy and lymphadenectomy for endometrial cancer staging. This is a high-stakes situation due to the nature of the surgery, the critical diagnoses involved, the need for precise surgical technique, and the potential impact on the patient's health and recovery. Successful staging and removal of cancerous tissue are crucial for the patient's prognosis. Additionally, the involvement of general anesthesia and the complexity of the procedure require significant medical expertise.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Hysterectomy & Salpingoophorectomy

PREOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,POSTOPERATIVE DIAGNOSES:,1.Stage IV endometriosis with severe pelvic pain.,2.Status post prior left salpingoophorectomy.,3.Severe adhesions.,TYPE OF ANESTHESIA: , General endotracheal tube.,TECHNICAL PROCEDURE: , Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.,INDICATION FOR PROCEDURE: , The patient is a 42-year-old parous female who had a longstanding history of severe endometriosis unresponsive to hormonal medical therapy and pain medication.  She had severe dyspareunia and chronic suprapelvic pain.  The patient had had a prior left salpingoophorectomy laparoscopically in 2004 for same disease process.  Now, she presented with a recurrent right ovarian endometrioma and severe pelvic pain.  She desired surgical treatment.  She accepted risk of a complete hysterectomy and salpingoophorectomy, risk of injury to underlying organs.  The risks, benefits, and alternatives were clearly discussed with the patient as documented in the medical record.,DESCRIPTION OF FINDINGS: , Absent left adnexa.  Right ovary about 6 cm with chocolate cyst and severely adherent to the right pelvic side wall, uterus, and colon.  Careful dissection to free right ovary and remove it although it is likely that some ovarian tissue remains behind.  Ureter visualized and palpated on right and appears normal.  Indigo carmine given IV with no leaks intraperitoneally noted.  Sigmoid colon dissected free from back of uterus and from cul-de-sac.  Bowel free of lacerations or denudation.  Upon inspection, right tube with hydrosalpinx, appendix absent.  Omental adhesions to ensure abdominal wall was lysed.,TECHNICAL PROCEDURE: , After informed consent was obtained, the patient was taken to the operating room where she underwent smooth induction of general anesthesia.  She was placed in a supine position with a transurethral Foley in place and compression stockings in place.  The abdomen and vagina were thoroughly prepped and draped in the usual sterile fashion.,A Pfannenstiel skin incision was made with the scalpel and carried down sharply to the underlying layer of fascia and peritoneum.  The peritoneum was bluntly entered and the incision extended caudally and cephaladly with good visualization of underlying organs.  Next, exploration of the abdominal and pelvic organs revealed the above noted findings.  The uterus was enlarged and probably contained adenomyosis.  There were dense adhesions, and a large right endometrioma with a chocolate cyst-like material contained within.  The sigmoid colon was densely adhered to the cul-de-sac into the posterior aspect of the uterus.  A Bookwalter retractor was placed into the incision, and the bowel was packed away with moist laparotomy sponges.  Next, a sharp and blunt dissection was used to free the extensive adhesions, and enterolysis was performed with very careful attention not to injure or denude the bowel.  Next, the left round ligament and cornual region was divided, transected, and suture-ligated with 0 Polysorb.  The anterior and posterior leafs of the broad ligament were dissected and opened anteriorly to the level of the bladder.  The uterine arteries were skeletonized on the left, and these were suture-clamped and transected with 0 Polysorb with good hemostasis noted.  Next, the bladder flap was developed anteriorly, and the bladder peritoneum was sharply and bluntly dissected off of the lower uterus.,On the right, a similar procedure was performed.  The right round ligament was suture-ligated with 0 Polysorb.  It was transected and divided with electrocautery.  The anterior and posterior leafs of the broad ligament were dissected and developed anteriorly and posteriorly, and this area was relatively avascular.  The left infundibulopelvic ligament was identified.  It was cross-clamped and transected, suture-ligated with 0 Polysorb with good hemostasis noted.  Next, the uterine arteries were skeletonized on the right.  They were transected and suture-ligated with 0 Polysorb.  The uterosacral ligaments were taken bilaterally and transected and suture-ligated with 0 Polysorb.  The cardinal ligaments were taken near their insertion into the cervical and uterine tissue.  Pedicles were sharply developed and suture-ligated with 0 Polysorb.  Next, the electrocautery was used to dissect the cervix anteriorly from the underlying vagina.  Once entry into the vagina was made, the cervix and uterus were amputated with Jorgensen scissors.  The vaginal cuff angles were suture-ligated with 0 Polysorb and transfixed to the ipsilateral, cardinal, and uterosacral ligaments for vaginal support.  The remainder of the vagina was closed with figure-of-eight sutures in an interrupted fashion with good hemostasis noted.,Next, the right ovarian tissue was densely adherent to the colon.  It was sharply and bluntly dissected, and most of the right ovary and endometrioma was removed and dissected off completely; however, there is a quite possibility that small remnants of ovarian tissue were left behind.  The right ureter was seen and palpated.  It did not appear to be dilated and had good peristalsis noted.  Next, the retractors were removed.  The laparotomy sponges were removed from the abdomen.  The rectus fascia was closed with 0 Polysorb in a continuous running fashion with 2 sutures meeting in the midline.  The subcutaneous tissue was closed with 0 plain gut in an interrupted fashion.  The skin was closed with 4-0 Polysorb in a subcuticular fashion.  A thin layer of Dermabond was placed.,The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x 2.  Cefoxitin 2 g was given preoperatively.,INTRAOPERATIVE COMPLICATIONS:,  None.,DESCRIPTION OF SPECIMEN: , Uterus and right adnexa.,ESTIMATED BLOOD LOSS: , 1000 mL.,POSTOPERATIVE CONDITION: , Stable.,
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DESCRIPTION: Total abdominal hysterectomy, right salpingoophorectomy, and extensive adhesiolysis and enterolysis.

The situation involves a major surgical procedure known as a total abdominal hysterectomy and right salpingoophorectomy, along with extensive adhesiolysis and enterolysis due to severe endometriosis. The stakes are high as this is a complex surgery associated with inherent risks, including injury to surrounding organs and significant blood loss (noted at 1000 mL in this case). Despite the patient tolerating the procedure well and no intraoperative complications reported, it remains a high-stakes surgical situation because of its complexity, the need for general anesthesia, the potential impact on the patient's quality of life, and the irreversible nature of the surgery. The patient's indication for surgery included severe pelvic pain and unresponsiveness to prior treatments, highlighting the necessity of the procedure.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Hemivulvectomy

PREOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,OPERATION PERFORMED: , Radical anterior hemivulvectomy.  Posterior skinning vulvectomy.,SPECIMENS: , Radical anterior hemivulvectomy, posterior skinning vulvectomy.,INDICATIONS FOR PROCEDURE: , The patient has a history of vulvar melanoma first diagnosed in November of 1995.  She had a surgical resection at that time and recently noted recurrence of an irritated nodule around the clitoris.  Biopsy obtained by The patient confirmed recurrence.  In addition, biopsies on the posterior labia (left side) demonstrated melanoma in situ.,FINDINGS: , During the examination under anesthesia, the biopsy sites were visible and a slightly pigmented irregular area of epithelium was seen near the clitoris.  No other obvious lesions were seen.  The room was darkened and a Woods lamp was used to inspect the epithelium.  A marking pen was used to outline all pigmented areas, which included several patches on both the right and left labia.,PROCEDURE: , The patient was prepped and draped and a scalpel was used to incise the skin on the anterior portion of the specimen.  The radical anterior hemivulvectomy was designed so that a 1.5-2.0 cm margin would be obtained and the depth was carried to the fascia of the urogenital diaphragm.  Subcutaneous adipose was divided with electrocautery and the specimen was mobilized from the periosteum.  After removal of the radical anterior portion, the skin on the posterior labia and perineal body was mobilized.  Skin was incised with a scalpel and electrocautery was used to undermine.  After removal of the specimen, the wounds were closed primarily with subcutaneous interrupted stitches of 3-0 Vicryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was then taken to the Post Anesthesia Care Unit in stable condition.
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DESCRIPTION: Wide Local Excision of the Vulva.  Radical anterior hemivulvectomy.  Posterior skinning vulvectomy.

obstetrics / gynecology, vulvar melanoma, wide local excision, radical anterior hemivulvectomy, posterior skinning vulvectomy, vulvectomy, hemivulvectomy, melanoma, woods lamp, recurrent vulvar melanoma, anterior hemivulvectomy, vulvar, labia, radical, skinning,

The situation involves a surgical procedure for recurrent vulvar melanoma, a potentially life-threatening condition. The stakes are high due to the nature of cancer treatment, the history of recurrence, and the complexity of the surgical procedure needed to manage the disease effectively. The health outcomes can significantly impact the patient's quality of life and survival, making it a high-stakes scenario.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Hysterectomy - Laparoscopic Supracervical

PREOPERATIVE DIAGNOSES:,  Menorrhagia and dysmenorrhea.,POSTOPERATIVE DIAGNOSES: , Menorrhagia and dysmenorrhea.,PROCEDURE: , Laparoscopic supracervical hysterectomy.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , 100 mL.,FINDINGS: , An 8-10 cm anteverted uterus, right ovary with a 2 cm x 2 cm x 2 cm simple cyst containing straw colored fluid, a normal-appearing left ovary, and normal-appearing tubes bilaterally.,SPECIMENS:  ,Uterine fragments.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL: , The patient was brought to the OR where general endotracheal anesthesia was obtained without difficulty.  The patient was placed in dorsal lithotomy position.  Examination under anesthesia revealed an anteverted uterus and no adnexal masses.  The patient was prepped and draped in normal sterile fashion.  A Foley catheter was placed in the patient's bladder.  The patient's cervix was visualized with speculum.  A single-tooth tenaculum was placed on the anterior lip of the cervix.  A HUMI uterine manipulator was placed through the internal os of the cervix and the balloon was inflated.  The tenaculum and speculum were then removed from the vagina.  Attention was then turned to the patient's abdomen where a small infraumbilical incision was made with scalpel.  Veress needle was placed through this incision and the patient's abdomen was inflated to a pressure of 15 mmHg.  Veress needle was removed and then 5-mm trocar was placed through the umbilical incision.  Laparoscope was placed through this incision and the patient's abdominal contents were visualized.  A 2nd trocar incision was placed in the midline 2 cm above the symphysis pubis and a 5-mm trocar was placed through this incision on direct visualization for laparoscope.  A trocar incision was made in the right lower quadrant.  A 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  A ___ trocar incision was made in the left lower quadrant and a 2nd 10-mm trocar was placed through this incision under direct visualization with the laparoscope.  The patient's abdominal and pelvic anatomy were again visualized with the assistance of a blunt probe.  The Gyrus cautery was used to cauterize and cut the right and left round ligaments.  The anterior leaf of the broad ligament was bluntly dissected and cauterized and cut in an inferior fashion towards lower uterine segment.  The right uteroovarian ligament was cauterized and cut using the Gyrus.  The uterine vessels were then bluntly dissected.  The Gyrus was then used to cauterize the right uterine vessels.  Gyrus was then used on the left side to cauterize and cut the left round ligament.  The anterior leaf of the broad ligament on the left side was bluntly dissected, cauterized, and cut.  Using the Gyrus, the left uteroovarian ligament was cauterized and cut and the left uterine vessels were then bluntly dissected.  The left uterine vessels were then cauterized and cut using the Gyrus.  At this point, as the uterine vessels had been cauterized on both sides, the uterine body exhibited blanching.  At this point, the Harmonic scalpel hook was used to amputate the uterine body from the cervix at the level just below the uterine vessels.  The HUMI manipulator was removed prior to amputation of the uterine body.  After the uterine body was detached from the cervical stump, morcellation of the uterine body was performed using the uterine morcellator.  The uterus was removed in a piecemeal fashion through the right lower quadrant trocar incision.  Once, all fragments of the uterus were removed from the abdominal cavity, the pelvis was irrigated.  The Harmonic scalpel was used to cauterize the remaining endocervical canal.  The cervical stump was also cauterized with the Harmonic scalpel and good hemostasis was noted at the cervical stump and also at the sites of all pedicles.  The Harmonic scalpel was then used to incise the right ovarian simple cyst.  The right ovarian cyst was then drained yielding straw-colored fluid.  The site of right ovarian cystotomy was noted to be hemostatic.  The pelvis was again inspected and noted to be hemostatic.  The ureters were identified on both sides and noted to be intact throughout the visualized course.  All instruments were then removed from the patient's abdomen and the abdomen was deflated.  The fascial defects at the 10-mm trocar sites were closed using figure-of-8 sutures of 0-Vicryl and skin incisions were closed with a 4-0 Vicryl in subcuticular fashion.  The cervix was then visualized with the speculum.  Good hemostasis at the site of tenaculum insertion was obtained using silver nitrate sticks.  All instruments were removed from the patient's vagina and the patient was placed in normal supine position.,Sponge, lap, needle, and instrument counts were correct x2.  The patient was awoken from anesthesia and then transferred to the recovery room in stable condition.
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DESCRIPTION: Laparoscopic supracervical hysterectomy.  Menorrhagia and dysmenorrhea.

obstetrics / gynecology, supracervical hysterectomy, incision, uterine, uteroovarian, hysterectomy, supracervical, menorrhagia, dysmenorrhea, cervical, laparoscopic, laparoscope, cervix, ligaments, trocar

The procedure described is a laparoscopic supracervical hysterectomy, which is a significant surgical intervention, typically indicated for severe or problematic symptoms such as menorrhagia (heavy menstrual bleeding) and dysmenorrhea (painful menstruation). The procedure involves general anesthesia, and while it is considered minimally invasive compared to open surgery, it still carries risks including bleeding, infection, or damage to surrounding organs. The detailed step-by-step description confirms the complexity and importance of the procedure, although no complications were reported, and the patient was stable post-operation. In a medical context, especially in surgery, the stakes are quite high because the outcome can significantly affect the patient's health and quality of life.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Full-Field Digital Mammogram (FFDM) - 1

EXAM: , Digital screening mammogram.,HISTORY:,  51-year-old female presents for screening mammography.  Patient denies personal history of breast cancer.  Breast cancer was reported in her maternal aunt.,TECHNIQUE:,  Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy.  Comparison is made with the previous performed on mm/dd/yy. iCAD Second Look proprietary software was utilized.,FINDINGS:  ,The breasts demonstrate a mixture of adipose and fibroglandular elements.  Composition appears similar.  Multiple tiny punctate benign-appearing calcifications are visualized bilaterally.  No dominant mass, areas of architecture distortion, or malignant-type calcifications are seen.  Skin overlying both breasts is unremarkable.,IMPRESSION: , Stable and benign mammographic findings.  Continued yearly mammographic screening is recommended.,BIRADS Classification 2 - Benign,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized.
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DESCRIPTION: Bilateral Screening Mammogram Full-Field Digital Mammography (FFDM) (Benign Findings)

obstetrics / gynecology, mediolateral, craniocaudal, fibroglandular, bilateral screening mammogram, breast cancer, screening mammogram, mammographic, mammogram, breasts, screening, mammography

The situation involves the interpretation of a mammogram, which is a routine diagnostic procedure for detecting breast cancer. The findings are benign, suggesting no immediate indication of malignancy, and the patient is recommended to continue regular screenings. While early detection of breast cancer can be critical, this specific case describes stable and benign findings with a BIRADS Classification 2. This indicates low suspicion of cancer, and therefore, the report does not present immediate high-stakes consequences. However, the nature of screening for serious conditions and the potential for false negatives do add some level of importance to the situation.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Emergency C-section.

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Nonreassuring fetal heart tones with a prolonged deceleration.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Nonreassuring fetal heart tones with a prolonged deceleration.,PROCEDURE PERFORMED: , Emergency cesarean section.,ANESTHESIA:  ,General and endotracheal as well as local anesthesia.,ESTIMATED BLOOD LOSS: , 800 mL.,COMPLICATIONS: , None.,FINDINGS:  ,Female infant in cephalic presentation in OP position.  Normal uterus, tubes and ovaries are noted.  Weight was 6 pounds and 3 ounces, Apgars were 6 at 1 minute and 7 at 5 minutes, and 9 at 10 minutes.  Normal uterus, tubes and ovaries were noted.,INDICATIONS:  ,The patient is a 21-year-old Gravida 1, para 0 female who present to labor and delivery at term with spontaneous rupture of membranes noted at 5 a.m. on the day of delivery.  The patient was admitted and cervix was found to be 1 cm dilated.  Pitocin augmentation of labor was started.  The patient was admitted by her primary obstetrician Dr. Salisbury and was managed through the day by him at approximately 5 p.m. at change of shift care was assumed by me.  At this time, the patient was noted to have variable decelerations down to the 90s lasting approximately 1 minute with good return to baseline, good variability was noted as well as accelerations, variable deceleration despite position change was occurring with almost every contraction, but was lasting for 60 to 90 seconds at the longest.  Vaginal exam was done.  Cervix was noted to be 4 cm dilated.,At this time IPC was placed and amnioinfusion was started in hopes to relieve the variable declarations.  At 19:20 fetal heart tones was noted to go down to the 60s and remained down in the 60s for 3 minutes at which time the patient was transferred from Labor And Delivery Room to the operating room for an emergency cesarean section.  Clock in the operating room is noted to be 2 minutes faster then the time on trace view.  The OR delivery time was 19:36.  Delivery of this infant was performed in 14 minutes from the onset of the deceleration.  Upon arrival to the operating room, while prepping the patient for surgery and awaiting the arrival of the anesthesiologist, heart tones were noted to be in 60s and slowly came up to the 80s.  Following the transfer of the patient to the operating room bed and prep of the abdomen, the decision was made to begin the surgery under local anesthesia, 2% lidocaine was obtained for this purpose.,PROCEDURE NOTE: , The patient was taken to the operating room she was quickly prepped and draped in the dorsal supine position with a leftward tilt.  2% lidocaine was obtained and the skin was anesthetized using approximately 15 mL of 2% lidocaine.  As the incision site was being injected, the anesthesiologist arrived.  The procedure was started prior to the patient being put under general anesthesia.,A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia using the Scalpel using __________ technique.  The rectus muscles were separated in midline.  The peritoneum was bluntly dissected.  The bladder blade was inserted.  The uterus has been incised in the transverse fashion using the scalpel and extended using manual traction.  The infant was subsequently delivered.  Immediately following delivery of the infant.  The infant was noted to be crying with good tones.  The cord was clammed and cut.  The infant was subsequently transferred or handed to the nursery nurse.  The placenta was delivered manually intact with a three-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic sutures.  Hemostasis was visualized.  The uterus was returned to the abdomen.  The pelvis was copiously irrigated.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was reapproximated with 0 Vicryl suture.  The subcutaneous layer was closed with 2-0 plain gut.  The skin was closed in the subcuticular stitch using 4-0 Monocryl.  Steri-strips were applied.  Sponge, laps, and instrument counts were correct.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.
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DESCRIPTION: Emergency cesarean section.

Emergency cesarean section.

obstetrics / gynecology, intrauterine pregnancy at term, prolonged deceleration, apgars, emergency cesarean section, fetal heart tones, intrauterine,

This scenario describes an emergency cesarean section due to nonreassuring fetal heart tones, which indicates a possible risk to both the mother and the infant. The procedure involves rapidly addressing potential fetal distress to prevent serious complications or life-threatening situations for the baby. While the procedure concluded without complications and both mother and child were stable, the initial situation was acute and required prompt surgical intervention, highlighting the high-stakes nature of this medical scenario.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Fetal Anatomical Survey

PAST MEDICAL HISTORY:  ,The patient denies any significant past medical history.,PAST SURGICAL HISTORY: , The patient denies any significant surgical history.,MEDICATIONS: , The patient takes no medications.,ALLERGIES: , No known drug allergies.,SOCIAL HISTORY: , She denies use of cigarettes, alcohol or drugs.,FAMILY HISTORY: , No family history of birth defects, mental retardation or any psychiatric history.,DETAILS: , I performed a transabdominal ultrasound today using a 4 MHz transducer.  There is a twin gestation in the vertex transverse lie with an anterior placenta and a normal amount of amniotic fluid surrounding both of the twins.  The fetal biometry of twin A is as follows.  The biparietal diameter is 4.9 cm consistent with 20 weeks and 5 days, head circumference 17.6 cm consistent with 20 weeks and 1 day, the abdominal circumference is 15.0 cm consistent with 20 weeks and 2 days, and femur length is 3.1 cm consistent with 19 weeks and 5 days, and the humeral length is 3.0 cm consistent with 20 weeks and 0 day.  The average gestational age by ultrasound is 20 weeks and 1 day and the estimated fetal weight is 353 g.  The following structures are seen as normal on the fetal anatomical survey, the shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insertion site, the bladder, the extremities, the genitalia, the cord, which appeared to have three vessels and the placenta.,Limited in views of baby A with a nasolabial region.,The following is the fetal biometry for twin B. The biparietal diameter is 4.7 cm consistent with 20 weeks and 2 days, head circumference 17.5 cm consistent with 20 weeks and 0 day, the abdominal circumference is 15.5 cm consistent with 20 weeks and 5 days, the femur length is 3.3 cm consistent with 20 weeks and 3 days, and the humeral length is 3.1 cm consistent with 20 weeks and 2 days, the average gestational age by ultrasound is 22 weeks and 2 days, and the estimated fetal weight is 384 g.  The following structures were seen as normal on the fetal anatomical survey.  The shape of the fetal head, the choroid plexuses, the cerebellum, nuchal fold thickness, the fetal spine and fetal face, the four-chamber view of the fetal heart, the outflow tracts of the fetal heart, the stomach, the kidneys, and cord insertion site, the bladder, the extremities, the genitalia, the cord, which appeared to have three vessels, and the placenta.  Limited on today's ultrasound the views of nasolabial region.,In summary, this is a twin gestation, which may well be monochorionic at 20 weeks and 1 day.  There is like gender and a single placenta.  One cannot determine with certainty whether or not this is a monochorionic or dichorionic gestation from the ultrasound today.,I sat with the patient and her husband and discussed alternative findings and the complications.  We focused our discussion today on the association of twin pregnancy with preterm delivery.  We discussed the fact that the average single intrauterine pregnancy delivers at 40 weeks' gestation while the average twin delivery occurs at 35 weeks' gestation.  We discussed the fact that 15% of twins deliver prior to 32 weeks' gestation.  These are the twins which we have the most concern regarding the long-term prospects of prematurity.  We discussed several etiologies of preterm delivery including preterm labor, incompetent cervix, premature rupture of the fetal membranes as well as early delivery from preeclampsia and growth restriction.  We discussed the use of serial transvaginal ultrasound to assess for early cervical change and the use of serial transabdominal ultrasound to assess for normal interval growth.  We discussed the need for frequent office visits to screen for preeclampsia.  We also discussed treatment options such as cervical cerclage, bedrest, tocolytic medications, and antenatal steroids.  I would recommend that the patient return in two weeks for further cervical assessment and assessment of fetal growth and well-being.,In closing, I do want to thank you very much for involving me in the care of your delightful patient.  I did review all of the above findings and recommendations with the patient today at the time of her visit.  Please do not hesitate to contact me if I could be of any further help to you.,Total visit time 40 minutes.
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DESCRIPTION: The patient is a 39-year-old gravida 3, para 2, who is now at 20 weeks and 2 days gestation.  This pregnancy is a twin gestation.  The patient presents for her fetal anatomical survey.

obstetrics / gynecology, vaginal delivery, transducer, transabdominal ultrasound, placenta, amniotic fluid, fetal anatomical survey, preterm delivery, twin gestation, gestation, infant, fetal, anatomical, delivery, ultrasound,

The situation involves a 39-year-old pregnant woman with a twin gestation, which introduces potential risks associated with preterm delivery and other complications typical for twin pregnancies such as monochorionic or dichorionic gestation uncertainties. While the current ultrasound findings show normal development, discussions about potential complications underline the high-stakes nature due to the elevated risks twins pose for preterm birth, and the consequent health risks for neonates. Such pregnancies require careful ongoing monitoring and management to mitigate risks, elevating the stakes significantly compared to a regular singleton pregnancy. Thus, the complexity and potential for complications make this a high-stakes situation.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Delivery Note - 9

DELIVERY NOTE:,  This G1, P0 with EDC 12/23/08 presented with SROM about 7.30 this morning.  Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho.  Exam upon arrival 2 to 3 cm, 100% effaced, -1 station and by report pool of fluid was positive for Nitrazine and positive ferning.,She required augmentation with Pitocin to achieve a good active phase.  She achieved complete cervical dilation at 1900  At this time, a bulging bag was noted, which ruptured and thick meconium was present.  At 1937 hours, she delivered a viable male infant, left occiput, anterior.  Mouth and nares suctioned well with a DeLee on the perineum.  No nuchal cord present.  Shoulders and body followed easily.  Infant re-suctioned with the bulb and cord clamped x2 and cut and was taken to the warmer where the RN and RT were in attendance.  Apgars 9 and 9.  Pitocin 15 units infused via pump protocol.  Placenta followed complete and intact with fundal massage and general traction on the cord.  Three vessels are noted.  She sustained a bilateral periurethral lax on the left side, this extended down to the labia minora, became a second degree in the inferior portion and did have some significant bleeding in this area.  Therefore, this was repaired with #3-0 Vicryl after 1% lidocaine infiltrated approximately 5 mL.  The remainder of the lacerations was not at all bleeding and no other lacerations present.  Fundus required bimanual massage in a couple of occasions for recurrent atony with several larger clots; however, as the Pitocin infused and massage continued, this improved significantly.  EBL was about 500 mL.  Bleeding appears much better; however, Cytotec 400 mcg was placed per rectum apparently prophylactically.  Mom and baby currently doing very well.
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DESCRIPTION: She required augmentation with Pitocin to achieve a good active phase.  She achieved complete cervical dilation.

obstetrics / gynecology, augmentation with pitocin, delivery, cervical, dilation, perineum, lacerations, pitocin, infantNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.

The situation described involves a labor and delivery process with certain complications, such as a thick meconium presence and bilateral periurethral lacerations requiring repair. Birth itself is inherently high-stakes due to potential risks to both mother and baby. The delivery went generally well, with a healthy infant delivered, but complications like bleeding and the need for augmentation with Pitocin and medications like Cytotec suggest that careful management was necessary. The successful intervention with Pitocin and the repair of lacerations averted more severe outcomes, reflecting a moderate to high-stakes situation due to the inherent risks involved and successful resolution.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Delivery Note - 8

DELIVERY NOTE: , The patient is a very pleasant 22-year-old primigravida with prenatal care with both Dr. X and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital.  The patient was admitted to labor and delivery on Tuesday, December 22, 2008 at 5:30 in the morning at 40 weeks and 1 day gestation for elective induction of labor since she lives a significant distance away from the hospital.  Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring.  At a later time, Pitocin was started.  The next day at about 9 o'clock in the morning, I checked her cervix and performed artifical rupture of membranes, which did reveal Meconium-stained amniotic fluid and so an intrauterine pressure catheter was placed and then MDL infusion started.  The patient did have labor epidural, which worked well.  It should be noted that the patient's recent vaginal culture for group B strep did come back negative for group B strep.  The patient went on to have a normal spontaneous vaginal delivery of a live-term male newborn with Apgar scores of 7 and 9 at 1 and 5 minutes respectively and a newborn weight of 7 pounds and 1.5 ounces at birth.  The intensive care nursery staff was present because of the presence of Meconium-stained amniotic fluid.  DeLee suctioning was performed at the perineum.  A second-degree midline episiotomy was repaired in layers in the usual fashion using 3-0 Vicryl.  The placenta was simply delivered and examined and found to be complete and bimanual vaginal exam was performed and revealed that the uterus was firm.,ESTIMATED BLOOD LOSS: , Approximately 300 mL.
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DESCRIPTION: Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring.  At a later time, Pitocin was started.

obstetrics / gynecology, amniotic fluid, contractions, pitocin, meconium, cervix, labor, vaginal, delivery, intravaginallyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The delivery note describes a situation involving labor and delivery with some complexities, such as elective induction of labor due to distance from the hospital, the use of Cytotec and Pitocin to induce labor, meconium-stained amniotic fluid, and the presence of an intensive care nursery staff. Although there were no severe complications, such as infection or severe hemorrhage, labor and delivery are generally high-stakes due to the potential risks to both the mother and newborn. The successful delivery with good Apgar scores, though, suggests that the high-risk factors were well managed.


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

Medical Specialty: Obstetrics / Gynecology
Sample Name: Delivery Note - 7

DELIVERY NOTE:,  The patient is a 29-year-old gravida 6, para 2-1-2-3, who has had an estimated date of delivery at 01/05/2009.  The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes at 2000 hours on 12/26/2008.  She was found to be positive for Nitrazine pull and fern.  At that time, she was not actually contracting.  She was Group B Streptococcus positive, however, was 5 cm dilated.  The patient was started on Group B Streptococcus prophylaxis with ampicillin.  She received a total of three doses throughout her labor.  Her pregnancy was complicated by scanty prenatal care.  She would frequently miss visits.  At 37 weeks, she claims that she had a suspicious bump on her left labia.  There was apparently no fluid or blistering of the lesion.  Therefore, it was not cultured by the provider; however, the patient was sent for serum HSV antibody levels, which she tested positive for both HSV1 and HSV2.  I performed a bright light exam and found no lesions anywhere on the vulva or in the vault as per sterile speculum exam and consulted with Dr. X, who agreed that since the patient seems to have no active lesion that she likely has had a primary outbreak in the past and it is safe to proceed with the vaginal delivery.  The patient requested an epidural anesthetic, which she received with very good relief.  She had IV Pitocin augmentation of labor and became completely dilated per my just routine exam just after 6 o'clock and was set up for delivery and the patient pushed very effectively for about one and a half contractions.  She delivered a viable female infant on 12/27/2008 at 0626 hours delivering over an intact perineum.  The baby delivered in the occiput anterior position.  The baby was delivered to the mother's abdomen where she was warm, dry, and stimulated.  The umbilical cord was doubly clamped and then cut.  The baby's Apgars were 8 and 9.  The placenta was delivered spontaneously intact.  There was a three-vessel cord with normal insertion.  The fundus was massaged to firm and Pitocin was administered through the IV per unit protocol.  The perineum was inspected and was found to be fully intact.  Estimated blood loss was approximately 400 mL.  The patient's blood type is A+.  She is rubella immune and as previously mentioned, GBS positive and she received three doses of ampicillin.
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DESCRIPTION: The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes.   She was found to be positive for Nitrazine pull and fern.  At that time, she was not actually contracting.

obstetrics / gynecology, nitrazine pull and fern, rupture of membranes, spontaneous, membranes, nitrazine, streptococcus, pitocin, perineum, hsv, laborNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves a delivery note for a gravida 6 patient with a history of scant prenatal care, Group B Streptococcus (GBS) positivity, and HSV1 and HSV2 antibodies. While there are several risk factors present, such as scant prenatal care, GBS, and HSV, the actual delivery process described was managed effectively with prophylaxis and careful monitoring. Despite these complexities, the delivery was completed without significant complications. Hence, while the circumstances do involve some level of risk inherent to childbirth, it is not an immediate high-stakes emergency as there were no apparent active complications during the delivery itself.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Delivery Note - 6

DELIVERY NOTE: , This is an 18-year-old, G2, P0 at 35-4/7th weeks by a stated EDC of 01/21/09.  The patient is a patient of Dr. X's.  Her pregnancy is complicated by preterm contractions.  She was on bedrest since her 34th week.  She also has a history of tobacco abuse with asthma.  She was admitted here and labor was confirmed with rupture of membranes.  She was initially 5, 70%, -1.  Her bag was ruptured, IUPC was placed.  She received an epidural for pain control and Pitocin augmentation was performed.  She progressed for several hours to complete and to push, then pushed for approximately 15 minutes to deliver a vigorous female infant from OA presentation.  Delivery of the head was manual assisted.  The shoulders and the rest of body then followed without difficulty.  Baby was bulb suctioned, had a vigorous cry.  Cord was clamped twice and cut and the infant was handed to the awaiting nursing team.  Placenta then delivered spontaneously and intact, was noted to have a three-vessel cord.  The inspection of the perineum revealed it to be intact.  There was a hymenal remnant/skin tag that was protruding from the vaginal introitus.  I discussed this with the patient.  She opted to have it removed.  This was performed and I put a single interrupted suture 3-0 Vicryl for hemostasis.  Further inspection revealed bilateral superficial labial lacerations that were hemostatic and required no repair.  Overall EBL is 300 mL.  Mom and baby are currently doing well.  Cord gases are being sent due to prematurity.,
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DESCRIPTION: Her pregnancy is complicated by preterm contractions.  She was on bedrest since her 34th week.  She was admitted here and labor was confirmed with rupture of membranes.

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

The situation described involves a preterm labor and delivery of a second pregnancy in an 18-year-old patient with a history of tobacco use and asthma, which adds complexity and potential risks to the medical case. The delivery was managed appropriately and both mother and baby are doing well, but factors such as preterm birth, maternal age, history of substance use, and underlying health conditions increase the stakes due to potential complications for both mother and infant. Given these considerations, this case can be classified as moderately high-stakes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Delivery Note - 2

Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete, and then as she began to push, there were additional decelerations of the baby's heart rate, which were suspicions of cord around the neck.  These were variable decelerations occurring late in the contraction phase.  The baby was in a +2 at a 3 station in an occiput anterior position, and so a low-forceps delivery was performed with Tucker forceps using gentle traction, and the baby was delivered with a single maternal pushing effort with retraction by the forceps.  The baby was a little bit depressed at birth because of the cord around the neck, and the cord had to be cut before the baby was delivered because of the tension, but she responded quickly to stimulus and was given an Apgar of 8 at 1 minute and 9 at 5 minutes.  The female infant seemed to weigh about 7.5 pounds, but has not been officially weighed yet.  Cord gases were sent and the placenta was sent to Pathology.  The cervix, the placenta, and the rectum all seemed to be intact.  The second-degree episiotomy was repaired with 2-O and 3-0 Vicryl.  Blood loss was about 400 mL.,Because of the hole in the dura, plan is to keep the patient horizontal through the day and a Foley catheter is left in place.  She is continuing to be attended to by the anesthesiologist who will manage the epidural catheter.  The baby's father was present for the delivery, as was one of the patient's sisters.  All are relieved and pleased with the good outcome.
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DESCRIPTION: Pitocin was started quickly to allow for delivery as quickly as possible.  Baby was delivered with a single maternal pushing effort with retraction by the forceps.

obstetrics / gynecology, labor, delivery, pitocin, tucker forceps, apnea, cerebrospinal fluid, contraction, epidural, episiotomy, fetal heart tones, baby was delivered, baby's heart rate, heart rate, catheter, placenta, cordNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves an emergency during a delivery where there were complications such as fetal heart rate decelerations and a suspicion of the umbilical cord being around the baby's neck. The use of Pitocin to expedite delivery and the eventual use of forceps to aid delivery indicate a high-stakes scenario to prevent potential harm to the newborn and the mother. The baby's initial depression at birth due to the umbilical cord issue and the need for emergency intervention elevate the stakes. However, the situation concludes with a positive outcome as both the baby and mother are stable, which slightly reduces the overall stakes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Delivery Note - 10

DELIVERY NOTE:  ,This is a 30-year-old G6, P5-0-0-5 with unknown LMP and no prenatal care, who came in complaining of contractions and active labor.  The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks.  The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.  Rupture of membranes occurred on 12/25/08 at 2008 hours via artificial rupture of membranes.  No meconium was noted.  Infant was delivered on 12/25/08 at 2154 hours.  Two doses of ampicillin was given prior to rupture of membranes.  GBS status unknown.  Intrapartum events, no prenatal care.  The patient had epidural for anesthesia.  No observed abnormalities were noted on initial newborn exam.  Apgar scores were 9 and 9 at one and five minutes respectively.  There was a nuchal cord x1, nonreducible, which was cut with two clamps and scissors prior to delivery of body of child.  Placenta was delivered spontaneously and was normal and intact.  There was a three-vessel cord.  Baby was bulb suctioned and then sent to newborn nursery.  Mother and baby were in stable condition.  EBL was approximately 500 mL, NSVD with postpartum hemorrhage.  No active bleeding was noted upon deliverance of the placenta.  Dr. X attended the delivery with second year resident, Dr. X. Upon deliverance of the placenta, the uterus was massaged and there was good tone.  Pitocin was started following deliverance of the placenta.  Baby delivered vertex from OA position.  Mother following delivery had a temperature of 100.7, denied any specific complaints and was stable following delivery.
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DESCRIPTION: The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks.  The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.

obstetrics / gynecology, spontaneous vaginal delivery, rupture of membranes, gestational age, vaginal delivery, intact perineum, prenatal care, gestational, placentaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation described is a medical delivery note for a patient with a high number of prior pregnancies (G6, P5) and no prenatal care, which inherently increases the risks. However, the delivery was vaginal with no significant complications such as excessive bleeding, and both mother and baby were stable post-delivery. The lack of prenatal care and unknown GBS status are concerning but were managed with ampicillin. Overall, the delivery outcome was positive with the baby having good Apgar scores.


Medical Specialty: Obstetrics / Gynecology
Sample Name: D&C & Tubal Pregnancy Removal

PREOPERATIVE DIAGNOSIS: , Complex right lower quadrant mass with possible ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1.  Right ruptured tubal pregnancy.,2.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS:  ,Less than 100 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 25-year-old African-American female, gravida 7, para-1-0-5-1 with two prior spontaneous abortions with three terminations who presents with pelvic pain.  She does have a slowly increasing beta HCG starting at 500 to 849 and the max to 900.  Ultrasound showed a complex right lower quadrant mass with free fluid in the pelvis.  It was decided to perform a laparoscopy for the possibility of an ectopic pregnancy.,FINDINGS: , On bimanual exam, the uterus was approximately 10 weeks' in size, mobile, and anteverted.  There were no adnexal masses appreciated although there was some fullness in the right lower quadrant.  The cervical os appeared parous.,Laparoscopic findings revealed a right ectopic pregnancy, which was just distal to the right fallopian tube and attached to the fimbria as well as adherent to the right ovary.  There were some pelvic adhesions in the right abdominal wall as well.  The left fallopian tube and ovary and uterus appeared normal.  There was no evidence of endometriosis.  There was a small amount of blood in the posterior cul-de-sac.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped, placed under general anesthesia, and placed in the dorsal lithotomy position.  The bimanual exam was performed, which revealed the above findings.  A weighted speculum was placed in the patient's posterior vaginal vault and the 12 o' clock position of the cervix was grasped with the vulsellum tenaculum.  The cervix was then serially dilated using Hank dilators up to a #10.  A sharp curette was then introduced and curettage was performed obtaining a mild amount of tissue.  The tissue was sent to pathology for evaluation.  The uterine elevator was then placed in the patient's cervix.  Gloves were changed.  The attention was turned to the anterior abdominal wall where a 1 cm infraumbilical skin incision was made.  While tenting up the abdominal wall, the Veress needle was placed without difficulty.  The abdomen was then insufflated with appropriate volume and flow of CO2.  The #11 step trocar was then placed without difficulty in abdominal wall.  The placement was confirmed with a laparoscope.  It was then decided to put a #5 step trocar approximately 2 cm above the pubis symphysis in order to manipulate the pelvic contents.  The above findings were then noted.  Because the tubal pregnancy was adherent to the ovary, an additional port was placed in the right lateral aspect of the patient's abdomen.  A #12 step trocar port was placed under direct visualization.  Using a grasper, Nezhat-Dorsey suction irrigator, the mass was hydro-dissected off of the right ovary and further shelled away with graspers.  This was removed with the gallbladder grasper through the right lateral port site.  There was a small amount of oozing at the distal portion of the fimbria where the mass has been attached.  Partial salpingectomy was therefore performed.  This was done using the LigaSure.  The LigaSure was clamped across the portion of the tube including distal tube and ligated and transected.  Good hemostasis was obtained in all of the right adnexal structures.  The pelvis was then copiously suction irrigated.  The area again was then visualized and again found to be hemostatic.  The instruments were then removed from the patient's abdomen under direct visualization.  The abdomen was then desufflated and the #11 step trocar was removed.  The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips.  The uterine elevator was removed from the patient's vagina.,The patient tolerated the procedure well.  The sponge, lap, and needle count were correct x2.  She will follow up postoperatively as an outpatient.
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DESCRIPTION: Complex right lower quadrant mass with possible ectopic pregnancy.  Right ruptured tubal pregnancy and pelvic adhesions. Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy.

obstetrics / gynecology, lower quadrant mass, tubal pregnancy, pelvic adhesions, laparoscopy, salpingectomy, ectopic pregnancy, abdominal wall, pregnancy,

The situation involves a surgical procedure to remove a ruptured ectopic pregnancy, a condition where a fertilized egg implants outside the uterus. Given the risk of significant internal bleeding and other complications, such situations are considered high-stakes due to the potential for rapid deterioration in the patient's condition. This procedure is critical to the patient's health and could be life-threatening if not promptly and correctly managed. However, the successful completion of the procedure and no complications reported decrease the immediate risk post-surgery, although it remains a significant medical event.