Medical Specialty: Surgery
Sample Name: Hardware Removal - Elbow

PREOPERATIVE DIAGNOSIS: , Retained hardware in left elbow.,POSTOPERATIVE DIAGNOSIS:,  Retained hardware in left elbow.,PROCEDURE: , Hardware removal in the left elbow.,ANESTHESIA: , Procedure done under general anesthesia.  The patient also received 4 mL of 0.25% Marcaine of local anesthetic.,TOURNIQUET:  ,There is no tourniquet time.,ESTIMATED BLOOD LOSS:  ,Minimal.,COMPLICATIONS:  ,No intraoperative complications.,HISTORY AND PHYSICAL:  ,The patient is a 5-year, 8-month-old male who presented to me direct from ED with distracted left lateral condyle fracture.  He underwent screw compression for the fracture in October 2007.  The fracture has subsequently healed and the patient presents for hardware removal.  The risks and benefits of surgery were discussed.  The risks of surgery include the risk of anesthesia, infection, bleeding, changes in sensation and motion of extremity, failure of removal of hardware, failure to relieve pain or improved range of motion.  All questions were answered and the family agreed to the above plan.,PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in standard surgical fashion.  Using his previous incision, dissection was carried down through the screw.  A guide wire was placed inside the screw and the screw was removed without incident.  The patient had an extension lag of about 15 to 20 degrees.  Elbow is manipulated and his arm was able to be extended to zero degrees dorsiflex.  The washer was also removed without incident.  Wound was then irrigated and closed using #2-0 Vicryl and #4-0 Monocryl.  Wound was injected with 0.25% Marcaine.  The wound was then dressed with Steri-Strips, Xeroform, 4 x4 and bias.  The patient tolerated the procedure well and subsequently taken to the recovery in stable condition.,DISCHARGE NOTE: , The patient will be discharged on date of surgery.  He is to follow up in one week's time for a wound check.  This can be done at his primary care physician's office.  The patient should keep his postop dressing for about 4 to 5 days.  He may then wet the wound, but not scrub it.  The patient may resume regular activities in about 2 weeks.  The patient was given Tylenol with Codeine 10 mL p.o. every 3 to 4 hours p.r.n.
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DESCRIPTION: Hardware removal in the left elbow.

Hardware removal in the left elbow.

surgery, retained hardware, hardware removal, tourniquet, elbow, hardware,

The procedure described is a routine hardware removal surgery, which, while involving anesthesia and surgical intervention, is generally considered low-risk and straightforward, especially in cases where the original fracture has healed well. The lack of complications during surgery further suggests that the situation is not high-stakes in medical terms. The follow-up care instructions and immediate discharge also support the perception that this is a low-stakes, routine procedure with expected outcomes.


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Medical Specialty: Surgery
Sample Name: Gastroscopy

PREOPERATIVE DIAGNOSES: , Dysphagia and esophageal spasm.,POSTOPERATIVE DIAGNOSES: , Esophagitis and esophageal stricture.,PROCEDURE:,  Gastroscopy.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum, to the third portion of the duodenum.  The hypopharynx was normal and the upper esophageal sphincter was unremarkable.  The esophageal contour was normal, with the gastroesophageal junction located at 38 cm from the incisors.  At this point, there were several linear erosions and a sense of stricturing at 38 cm.  Below this, there was a small hiatal hernia with the hiatus noted at 42 cm from the incisors.  The mucosa within the hernia was normal.  The gastric lumen was normal with normal mucosa throughout.  The pylorus was patent permitting passage of the scope into the duodenum, which was normal through the third portion.  During withdrawal of the scope, additional views were obtained of the cardia, confirming the presence of a small hiatal hernia.  It was decided to attempt dilation of the strictured area, so an 18-mm TTS balloon was placed across the stricture and inflated to the recommended diameter.  When the balloon was fully inflated, the lumen appeared to be larger than 18 mm diameter, suggesting that the stricture was in fact not a significant one.  No stretching of the mucosa took place.  The balloon was deflated and the scope was withdrawn.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Esophagitis.,2.  Minor stricture at the gastroesophageal junction.,3.  Hiatal hernia.,4.  Otherwise normal upper endoscopy to the transverse duodenum.,RECOMMENDATIONS:  ,Continue proton pump inhibitor therapy.
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DESCRIPTION: Esophagitis, minor stricture at the gastroesophageal junction, hiatal hernia.  Otherwise normal upper endoscopy to the transverse duodenum.

surgery, duodenum, esophagus, gastroscope, stomach, upper endoscopy, transverse duodenum, gastroesophageal junction, hiatal hernia, gastroscopy, endoscopy, esophagitis, gastroesophageal, hiatal, esophageal, hernia

The situation involves a surgical procedure, specifically a gastroscopy, which is inherently high-stakes due to the invasiveness and potential risks associated with any surgical intervention. However, the procedure was described as having no significant complications and the patient's condition was relatively stable post-procedure, with manageable findings such as a minor stricture and hiatal hernia. The recommendation for continuing proton pump inhibitor therapy also suggests a non-emergency status. Nonetheless, any surgical procedure carries inherent risks, making this scenario moderately high-stakes, especially given the pre-existing conditions of dysphagia and esophageal spasm.

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Medical Specialty: Surgery
Sample Name: Full Mouth Dental Rehabilitation - 2

OPERATION PERFORMED:,  Full mouth dental rehabilitation in the operative room under general anesthesia.,PREOPERATIVE DIAGNOSIS: , Severe dental caries.,POSTOPERATIVE DIAGNOSES:,1.  Severe dental caries.,2.  Non-restorable teeth.,COMPLICATIONS:,  None.,ESTIMATED BLOOD LOSS: , Minimal.,DURATION OF SURGERY: , 43 minutes.,BRIEF HISTORY:  ,The patient was first seen by me on 04/26/2007.  She had a history of open heart surgery at 11 months' of age.  She presented with severe anterior caries with most likely dental extractions needed.  Due to her young age, I felt that she would be best served in the safety of the hospital operating room.  After consultation with the mother, she agreed to have her treated in the safety of the hospital operating room at Children's Hospital.,OPERATIVE PREPARATION:  ,This child was brought to Hospital Day Surgery and is accompanied by her mother.  There I met with them and discussed the needs of the child, types of restorations to be performed, the risks and benefits of the treatment as well as the options and alternatives of the treatment.  After all their questions and concerns were addressed, I gave the informed consent to proceed with the treatment.  The patient's history and physical examination was reviewed.  Once she was cleared by Anesthesia and the child was taken back to the operating room.,OPERATIVE PROCEDURE:  ,The patient was placed on the surgical table in the usual supine position with all extremities protected.  Anesthesia was induced by mask.  The patient was then intubated with a nasal endotracheal tube and the tube was stabilized.  The head was wrapped and the eyes were taped shut for protection.  An angiocatheter was placed in the left hand and an IV was started.  The head and neck were draped with sterile towels, and the body was covered with a lead apron and sterile sheath.  A moist continuous throat pack was placed beyond the tonsillar pillars.  Plastic lip and cheek retractors were then placed.  Preoperative clinical photographs were taken.  Two posterior bitewing radiographs and two anterior periapical films were taken in the operating room with digital radiography.  After the radiographs were taken, the lead shield was removed.  Prophylaxis was then performed using prophy cup and fluoridated prophy paste.  The teeth were then rinsed well and the patient's oral cavity was suctioned clean.  Clinical and radiographic examinations followed and areas of decay were noted.  During the restorative phase, these areas of decay were entered into and removed.  Entry was made to the level of the dental-enamel junction and beyond as necessary to remove it.  Final caries was removed and was confirmed upon reaching hard, firm sounding dentin.  Teeth restored with amalgam had a dentin tubular seal placed prior to amalgam placement.  Non-restorable primary teeth would be extracted.,Upon conclusion of the restorative phase, the oral cavity was aspirated and found to be free of blood, mucus, and other debris.  The original treatment plan was verified with the actual treatment provided.  Postoperative clinical photographs were then taken.  The continuous gauze throat pack was removed with continuous suction with visualization.  Topical fluoride was then placed on the teeth.,At the end of the procedure, the child was undraped, extubated, and awakened in the operating room and taken to the recovery room breathing spontaneously with stable vital signs.,FINDINGS:  ,This young patient presented with mild generalized marginal gingivitis secondary to light generalized plaque accumulation and fair oral hygiene.  All primary teeth were present.  Dental caries were present on the following teeth:  Tooth D, E, F, and G caries on all surfaces; teeth J, lingual caries.  The remainder of her teeth and soft tissues were within normal limits.  The following restorations and procedures were performed:  Tooth D, E, F, and G were extracted and four sutures were placed one at each extraction site and tooth J lingual amalgam.,CONCLUSION:  ,The mother was informed of the completion of the procedure.  She was given a synopsis of the treatment provided as well as written and verbal instructions for postoperative care.  They will contact to my office in the event of immediate postoperative complications.  After full recovery, she was discharged from the recovery room in the care of her mother.
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DESCRIPTION: Full mouth dental rehabilitation in the operative room under general anesthesia.

surgery, full mouth dental rehabilitation, dental rehabilitation, full mouth, dental caries, non-restorable teeth, dental extractions, throat pack, oral cavity, restorative phase, primary teeth, dental, anesthesia, mouth, rehabilitation, prophylaxis, oral, amalgam, tooth,

This medical procedure involves full mouth dental rehabilitation under general anesthesia in a young child with a history of open heart surgery. The use of general anesthesia in a pediatric patient, particularly one with a complex medical history, introduces significant risk factors. However, the procedure itself was described as having minimal complications, with estimated blood loss being minimal, and the patient recovered without issue. The decision to conduct the procedure in a hospital setting underlines the consideration of safety, which underscores the seriousness of the situation. Despite the successful outcome, the anesthetic risks and the patient's medical history suggest that the situation carries moderate to high stakes due to the potential for complications, though in this specific case, no complications occurred.


Medical Specialty: Surgery
Sample Name: Gastroscopy - 1

PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum.  The hypopharynx was normal.  The esophagus had a normal upper esophageal sphincter, normal contour throughout, and a normal gastroesophageal junction viewed at 39 cm from the incisors.  There was no evidence of stricturing or extrinsic narrowing from her previous hiatal hernia repair.  There was no sign of reflux esophagitis.  On entering the gastric lumen, a large bezoar of undigested food was seen occupying much of the gastric fundus and body.  It had 2 to 3 mm diameter.  This was broken up using a scope into smaller pieces.  There was no retained gastric liquid.  The antrum appeared normal and the pylorus was patent.  The scope passed easily into the duodenum, which was normal through the second portion.  On withdrawal of the scope, additional views of the cardia were obtained, and there was no evidence of any tumor or narrowing.  The scope was withdrawn.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Normal postoperative hernia repair.,2.  Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.,3.  Otherwise normal upper endoscopy to the descending duodenum.,RECOMMENDATIONS:,1.  Continue proton pump inhibitors.,2.  Use Reglan 10 mg three to four times a day.
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DESCRIPTION: Dysphagia, possible stricture.  Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.

The situation involves a medical procedure, specifically a gastroscopy, with a preoperative concern for dysphagia and possible stricture, and a postoperative finding of gastroparesis. While this is a common and generally low-risk procedure in the field of surgery, it involves the management of potential complications like a bezoar, which could lead to more significant health issues if not managed properly. It also involves postoperative recommendations that could affect the patient's recovery and quality of life. Hence, it holds moderate stakes due to its impact on patient health and the need for proper follow-up care.


Medical Specialty: Surgery
Sample Name: Foreign Object Removal - Urethra

PREOPERATIVE DIAGNOSIS: , Prostate cancer.,POSTOPERATIVE DIAGNOSIS: , Prostate cancer.,OPERATION: , Cystoscopy and removal of foreign objects from the urethra.,BRACHYTHERAPY:,  Iodine 125.,ANESTHESIA: , General endotracheal.  The patient was given Levaquin 500 mg IV preoperatively.,Total seeds were 59.  Activity of 0.439, 30 seeds in the periphery with 10 needles and total of 8 seeds at the anterior of the fold, 4 needles.  Please note that the total needles placed on the top were actually 38 seeds and 22 seeds were returned back.,BRIEF HISTORY: , This is a 72-year-old male who presented to us with elevated PSA and prostate biopsy with Gleason 6 cancer on the right apex.  Options such as watchful waiting, brachytherapy, radical prostatectomy, cryotherapy, and external beam radiation were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE, incontinence, erectile dysfunction, urethral stricture, dysuria, burning pain, hematuria, future procedures, and failure of the procedure were all discussed.  The patient understood all the risks, benefits, and options and wanted to proceed with the procedure.  The patient wanted to wait until he came back from his summer vacations, so a one dose of Zoladex was given.  Prostate size measured about 15 g in the OR and about 22 g about two months ago.  Consent was obtained.,DETAILS OF THE OPERATION:  ,The patient was brought to the OR and anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient had a Foley catheter placed sterilely.  The scrotum was taped up using Ioban.  Transrectal ultrasound was done.  The prostate was measured 15 g.  Multiple images were taken.  A volume study was done.  This was given to the physicist, Dr. X was present who is radiation oncologist who helped with implanting of the seeds.  Total of 38 seeds were placed in the patient with 10 peripheral needles and then 4 internal needles.  Total of 30 seeds were placed in the periphery and total of 8 seeds were placed in the inside.  They were done directly under transrectal ultrasound vision.  The seeds were placed directly under ultrasound guidance.  There was a nice distribution of the seeds.  A couple of more seeds were placed on the right side due to the location of the prostate cancer.  Subsequently at the end of the procedure, fluoroscopy was done.  Couple of images were obtained.  Cystoscopy was done at the end of the procedure where a seed was visualized right in the urethra, which was grasped and pulled out using grasper, which was difficult to get the seed off of the spacers, which was actually pulled out.  There were no further seeds visualized in the bladder.  The bladder appeared normal.  At the end of the procedure, a Foley catheter was kept in place of 18 French and the patient was brought to recovery in stable condition.
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DESCRIPTION: Cystoscopy and removal of foreign objects from the urethra.

surgery, foreign objects, foley catheter, transrectal ultrasound, prostate cancer, cystoscopy, ultrasound, urethra, endotracheal, prostate

This surgical procedure involves multiple high-stakes elements: treating prostate cancer with brachytherapy and the removal of foreign objects from the urethra. The patient has cancer, which inherently presents a high-stakes scenario due to its serious nature. The use of anesthesia, risk of complications, and the potential impact on future health contribute to the stakes. However, the well-planned procedure, patient's informed consent, and stable post-operative condition slightly mitigate the stakes.


Medical Specialty: Surgery
Sample Name: Foreign Body Removal - Thigh

PREPROCEDURE DIAGNOSIS:,  Foreign body of the right thigh.,POSTOPERATIVE DIAGNOSIS: , Foreign body of the right thigh, sewing needle.,PROCEDURE:  ,Removal of foreign body of right thigh.,HISTORY:  ,This is a 71-year-old lady who has been referred because there is a mass in the right thigh.  The patient comes with an ultrasound and apparently was diagnosed with a blood clot.  On physical examination, blood pressure was 152/76 and temperature was 95.0.  The patient is 5 feet 1 inch and weighs 170.  On examination of her right thigh, there is a transverse area of ecchymosis in the upper third of the thigh.  There is a palpation of a very sharp object just under the skin.  The patient desires for this to be removed.,DESCRIPTION OF PROCEDURE: , After obtaining informed consent in our office, the area was prepped and draped in usual fashion.  Xylocaine 1% was infiltrated in the end of the object that was the sharpest and a small incision was made there and then I pushed the foreign body through partially and then grabbed it with a hemostat and took it out and it was a 1-1/2-inch sewing needle.,Compression was applied for a few minutes and then a Band-Aid was applied.,The patient was given a tetanus toxoid 0.5 cc IM shot injection and then she was dismissed with instructions of return if inflammatory signs develop.
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DESCRIPTION: Removal of foreign body of right thigh.  Foreign body of the right thigh, sewing needle.

surgery, removal of foreign body, sewing needle, foreign body

The procedure involves removing a foreign body, specifically a sewing needle, from the thigh of a 71-year-old patient. While any surgical procedure carries inherent risks, this one is relatively straightforward. It is not an emergency, as indicated by the pre-procedure preparation, including obtaining informed consent and the patient being dismissed with standard aftercare instructions. There are no immediate life-threatening conditions or complex medical issues resulting from the presence of the needle, aside from potential inflammation or infection which are standard risks manageable with proper care. Therefore, the situation is not high-stakes.


Medical Specialty: Surgery
Sample Name: Flexible Nasal Laryngoscopy

PREOPERATIVE DIAGNOSIS:  ,Oropharyngeal foreign body.,POSTOPERATIVE DIAGNOSES:,1.  Foreign body, left vallecula at the base of the tongue.,2.  Airway is patent and stable.,PROCEDURE PERFORMED: , Flexible nasal laryngoscopy.,ANESTHESIA:,  ______ with viscous lidocaine nasal spray.,INDICATIONS: , The patient is a 39-year-old Caucasian male who presented to ABCD General Hospital Emergency Department with acute onset of odynophagia and globus sensation.  The patient stated his symptoms began around mid night after returning home _________ ingesting some chicken.  The patient felt that he had ingested a chicken bone, tried to dislodge this with fluids and other solid foods as well as sticking his finger down his throat without success.  The patient subsequently was seen in the Emergency Department where it was discovered that the patient had a left vallecular foreign body.  Department of Otolaryngology was asked to consult for further evaluation and treatment of this foreign body.,PROCEDURE: , After verbal informed consent was obtained, the patient was placed in the upright position.  The fiberoptic nasal laryngoscope was inserted in the patient's right naris and then the left naris.  There was visualized some bilateral caudal spurring of the septum.  The turbinates were within normal limits.  There was some posterior nasoseptal deviation to the left.  The nasal laryngoscope was then inserted back into the right naris and it was advanced along the floor of the nasal cavity.  The nasal mucous membranes were pink and moist.  There was no evidence of mass, ulceration, lesion, or obstruction.,The scope was further advanced to the level of the nasopharynx where the eustachian tubes were visualized bilaterally.  There was evidence of some mild erythema in the right fossa Rosenmüller.  There was no evidence of mass lesion or ulceration in this area, however.  The eustachian tubes were patent without obstruction.  The scope was further advanced to the level of the oropharynx where the base of the tongue, vallecula, and epiglottis were visualized.  There was evidence of a 1.5 cm left vallecular white foreign body.  The rest of the oropharynx was without abnormality.  The epiglottis was within normal limits and was noted to be omega in shape.  There was no edema or erythema to the epiglottis.  The scope was then further advanced to the level of the hypopharynx to the level of the true vocal cords.  There was no evidence of erythema or edema of the posterior commissure, arytenoid cartilage, or superior surface of the vocal cords.  The laryngeal surface of the epiglottis was within normal limits.  There was no evidence of mass lesion or nodularity of the vocal cords.  The patient was asked to Valsalva and the piriform sinuses were observed without evidence of foreign body or mass lesion.  The patient did have complete glottic closure upon phonation and the airway was patent and stable throughout the exam.  The glottic aperture was completely patent with inspiration.  The anterior commissure, epiglottic folds, false vocal cords, and piriform sinuses were all within normal limits.  The scope was then removed without difficulty.  The patient tolerated the procedure well and remained in stable condition.,FINDINGS:,1.  A 1.5 cm white foreign body consistent with a chicken bone at the left vallecular region.  There is no evidence of supraglottic or piriform sinuses foreign body.,2.  Mild erythema of the right nasopharynx in the region of the fossa Rosenmüller.  No mass is appreciated at this time.,PLAN:,  The patient is to go to the operating room for direct laryngoscopy/microscopic suspension direct laryngoscopy for removal of foreign body under anesthesia this a.m.  Airway precautions were instituted.  The patient currently remained in stable condition.
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DESCRIPTION: Flexible nasal laryngoscopy.  Foreign body, left vallecula at the base of the tongue.   Airway is patent and stable.

surgery, oropharyngeal foreign body, flexible nasal laryngoscopy, nasal spray, foreign body, tongue, laryngoscopy, erythema, epiglottis, nasal, oropharyngeal

The situation involves a medical procedure to address a foreign body lodged in the oropharyngeal region of a patient. While the foreign body is currently causing discomfort and a sensation of obstruction (globus), the patient's airway is described as patent and stable, indicating no immediate life-threatening obstruction. However, the potential for airway compromise exists if the situation were to deteriorate. The planned surgical procedure to remove the foreign body under anesthesia shows the need for professional intervention, but the patient is currently stable, which suggests intermediate stakes rather than extremely high stakes.


Medical Specialty: Surgery
Sample Name: Flexible Bronchoscopy

PROCEDURE:, Flexible bronchoscopy.,PREOPERATIVE DIAGNOSIS (ES):, Chronic wheezing.,INDICATIONS FOR PROCEDURE:, Evaluate the airway.,DESCRIPTION OF PROCEDURE: ,This was done in the pediatric endoscopy suite with the aid of Anesthesia. The patient was sedated with sevoflurane and propofol. One mL of 1% lidocaine was used for airway anesthesia. The 2.8-mm flexible pediatric bronchoscope was passed through the left naris. The upper airway was visualized. The epiglottis, arytenoids, and vocal cords were all normal. The scope was passed below the cords. The subglottic space was normal. The patient had normal tracheal rings and a normal membranous portion of the trachea. There was noted to be slight deviation of the trachea to the right. At the carina, the right and left mainstem were evaluated. The right upper lobe, right middle lobe, and right lower lobe were all anatomically normal. The scope was wedged in the right middle lobe, 10 mL of saline was infused, 10 was returned. This was sent for cell count, cytology, lipid index, and quantitative bacterial cultures. The left side was then evaluated and there was noted to be the normal cardiac pulsations on the left. There was also noted to be some dynamic collapse of the left mainstem during the respiratory cycle. The left upper lobe and left lower lobe were normal. The scope was withdrawn. The patient tolerated the procedure well.,ENDOSCOPIC DIAGNOSIS:, Left mainstem bronchomalacia.
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DESCRIPTION: Flexible bronchoscopy  to evaluate the airway (chronic wheezing).

surgery, flexible bronchoscopy, airway, arytenoids, bronchomalacia, bronchoscopy, endoscopy suite, epiglottis, mainstem, subglottic, vocal cords, wheezing, chronic wheezing, tracheal, lobe,

The situation involves a flexible bronchoscopy, a procedure typically done to evaluate the airway, particularly in cases like chronic wheezing. Although it is a routine diagnostic or therapeutic procedure, it involves anesthesia and carries risks, especially in pediatric patients. The detection of left mainstem bronchomalacia could have implications for the patient's treatment plan. However, since the child tolerated the procedure well and no immediate life-threatening conditions were identified, it leans towards a moderate level of stakes.


Medical Specialty: Surgery
Sample Name: Flex Sig - 1

INDICATION:  , Rectal bleeding.,PREMEDICATION:, See procedure nurse NCS form.,PROCEDURE:  ,
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DESCRIPTION: Flexible sigmoidoscopy due to rectal bleeding.

surgery, rectal bleeding, digital rectal exam, pentax video, anal verge, angiodysplasia, colonic mucosa, diverticula, endoscope, flexible, flexible sigmoidoscopy, hemorrhoids, masses, polyps, rectum, sigmoidoscopy, sphincter tone, internal hemorrhoids, bleeding, rectal

The document contains information about a flexible sigmoidoscopy procedure performed due to rectal bleeding. While any medical procedure can have significant implications, in the scope of surgical practices, a flexible sigmoidoscopy is a common diagnostic procedure used to assess issues in the colon and rectum. It is minimally invasive, typically low-risk, and often performed as an outpatient procedure to identify or rule out serious conditions. The stakes increase if the bleeding is caused by a significant underlying condition, but as presented, it's a routine investigation rather than a high-stakes scenario.


Medical Specialty: Surgery
Sample Name: Facet Arthrogram & Injection

PREOPERATIVE DIAGNOSIS: , Low Back Syndrome - Low Back Pain.,POSTOPERATIVE DIAGNOSIS: , Same.,PROCEDURE:,1.  Bilateral facet Arthrogram at L34, L45, L5S1.,2.  Bilateral facet injections at L34, L45, L5S1.,3.  Interpretation of radiograph.,ANESTHESIA:  ,IV sedation with Versed and Fentanyl.,ESTIMATED BLOOD LOSS: , None.,COMPLICATIONS:  ,None.,INDICATION: , Pain in the lumbar spine secondary to facet arthrosis that was demonstrated by physical examination and verified with x-ray studies and imaging scans.,SUMMARY OF PROCEDURE: , The patient was admitted to the OR, consent was obtained and signed.  The patient was taken to the Operating room and was placed in the prone position.  Monitors were placed, including EKG, pulse oximeter and blood pressure monitoring.  Prior to sedation vitals signs were obtained and were continuously monitored throughout the procedure for amount of pain or changes in pain, EKG, respiration and heart rate and at intervals of three minutes for blood pressure.  After adequate IV sedation with Versed and Fentanyl the procedure was begun.,The lumbar sacral regions were prepped and draped in sterile fashion with Betadine prep and four sterile towels.,The facets in the lumbar regions were visualized with Fluoroscopy using an anterior posterior view.  A skin wheal was placed with 1% Lidocaine at the L34 facet region on the left.  Under fluoroscopic guidance a 22 gauge spinal needle was then placed into the L34 facet on the left side.  This was performed using the oblique view under fluoroscopy to the enable the view of the "Scotty Dog," After obtaining the "Scotty Dog" view the joints were easily seen.  Negative aspiration was carefully performed to verity that there was no venous, arterial or cerebral spinal fluid flow.  After negative aspiration was verified, 1/8th of a cc of Omnipaque 240 dye was then injected.  Negative aspiration was again performed and 1/2 cc of solution (Solution consisting of 9 cc of 0.5% Marcaine with 1 cc of Triamcinolone) was then injected into the joint.  The needle was then withdrawn out of the joint and 1.5 cc of this same solution was injected around the joint.  The 22-gauge needle was then removed.  Pressure was place over the puncture site for approximately one minute.  This exact same procedure was then repeated along the left-sided facets at L45, and L5S1.  This exact same procedure was then repeated on the right side.  At each level, vigilance was carried out during the aspiration of the needle to verify negative flow of blood or cerebral spinal fluid.,The patient was noted to have tolerated the procedure well without any complications.,Interpretation of the radiograph revealed placement of the 22-gauge spinal needles into the left-sided and right-sided facet joints at, L34, L45, and L5S1.  Visualizing the "Scotty Dog" technique under fluoroscopy facilitated this.  Dye spread into each joint space is visualized.  No venous or arterial run-off is noted.  No epidural run-off is noted.  The joints were noted to have chronic inflammatory changes noted characteristic of facet arthrosis.
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DESCRIPTION: Bilateral facet Arthrogram and injections at L34, L45, L5S1.  Interpretation of radiograph.  Low Back Syndrome - Low Back Pain.

surgery, low back syndrome, low back pain, facet injection, fluoroscopy, iv sedation, spinal fluid, facet arthrogram, aspiration, arthrogram, injection, facet,

The procedure described is a bilateral facet arthrogram and injection, which is a common and generally low-risk interventional pain management procedure performed to alleviate back pain caused by facet arthrosis. The lack of estimated blood loss, absence of complications, and use of moderate sedation (Versed and Fentanyl) suggest that while important for the patient's pain management, it is not an emergent or life-threatening procedure. Therefore, the stakes are not extremely high; however, it does involve surgical intervention and the use of anesthesia, which elevates the stakes slightly above very low-stakes situations.


Medical Specialty: Surgery
Sample Name: Femoral Artery Cannulation & Aortogram

PREOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.,POSTOPERATIVE DIAGNOSES: , Angina with severe claudication, coronary artery disease, hypertension, dyslipidemia, heavy tobacco abuse, and PAD.  Significant coronary artery disease, very severe PAD.,PROCEDURES PERFORMED:,1.  Right common femoral artery cannulation.,2.  Conscious sedation using IV Versed and IV fentanyl.,3.  Retrograde bilateral coronary angiography.,4.  Abdominal aortogram with pelvic runoff.,5.  Left external iliac angiogram with runoff to the patient's left foot.,6.  Left external iliac angiogram with runoff to the patient's right leg.,7.  Right common femoral artery angiogram runoff to the patient's right leg.,PROCEDURE IN DETAIL:,  The patient was taken to the cardiac catheterization laboratory after having a valid consent.  He was prepped and draped in the usual sterile fashion.,After local infiltration with 2% Xylocaine, the right common femoral artery was entered percutaneously and a 4-French sheath was placed over the artery.  The arterial sheath was flushed throughout the procedure.,Conscious sedation was obtained using IV Versed and IV fentanyl.,With the help of a Wholey wire, a 4-French 4-curve Judkins right coronary artery catheter was advanced into the ascending aorta.  The wire was removed, the catheter was flushed.  The catheter was engaged in the left main.  Injections were performed at the left main in different views.  The catheter was then exchanged for an RCA catheter, 4-French 4-curve which was advanced into the ascending aorta with the help of a J-wire.  The wire was removed, the catheter was flushed.  The catheter was engaged in the RCA.  Injections were performed at the RCA in different views.,The catheter was then exchanged for a 5-French Omniflush catheter, which was advanced into the abdominal aorta with the help of a regular J-wire.  The wire was removed.  The catheter was flushed.  Abdominal aortogram was then performed with runoff to the patient's pelvis.,The Omniflush catheter was then retracted into the aortic bifurcation.  Through the Omniflush catheter, a Glidewire was then advanced distally into the left SFA.  The Omniflush was then removed.  Through the wire, a Royal Flush catheter was then advanced into the left external iliac.  The wire was removed.  Left external iliac angiogram was performed with runoff to the patient's left foot _______ was then performed.  The catheter was then retracted into the left common iliac.  Angiograms were performed of the left common iliac with runoff to the patient's left groin.  The catheter was then positioned at the level of the right common iliac.  Angiogram of the right common iliac with runoff to the patient's right leg was then performed.  The catheter was then removed with the help of a J-wire.  The J-wire was left in the abdominal aorta.  Hand injection was performed of the right common femoral artery in 2 locations with runoff to the patient's right leg.,The wire was then removed.  The arterial sheath was then removed after being flushed.  Hemostasis was obtained using hand compression.,The patient tolerated the procedure well and had no complications.  At the end of the procedure, palpable right common femoral pulses were noted as well as 1+ right PT pulse.,Hemodynamic Findings:,  Aortic pressure 140/70.,ANGIOGRAPHIC FINDINGS: , Left main with calcification 25% to 40% lesion.,The left main is very short.,LAD with calcification 25% to 40% proximal lesion.,D1 has 25% lesion.  No in-stent restenosis was noted in D1.,D2 and D3 are very small with luminal irregularities.,Circumflex artery was diseased throughout the vessel.  The circumflex artery has an ostium of 60% to 75% lesion distally and the circumflex has a 75% lesion.,OM1 has 25% to 40% lesion.  These OMs are small with luminal irregularities.,RCA has 25% to 50% lesion, distally, the RCA has luminal irregularities.,Left ventriculography was not done.,ABDOMINAL AORTOGRAM:,  Right renal artery with luminal irregularities.  Left renal artery with luminal irregularities.  The abdominal aorta has 25% lesion.,Right common iliac has a 25% to 50% lesion as well as a distal 75% lesion.,The right external iliac has a proximal 75% lesion.,The distal part of the right external iliac as well as the right common femoral appears to be occlusive by the 5-French sheath.,The right SFA was visualized, although not very well.,Left common iliac with 25% to 50% lesion.  Left external iliac with 25% to 40% lesion.  Left common femoral with 25% to 40% lesion.  Left SFA with 25% lesion.  Left popliteal with wall luminal irregularities.,Three-vessel runoff is noted at the level of the left knee and at the level of the left ankle.,Conclusions:  Severe coronary artery disease.  Very severe peripheral arterial disease.,PLAN: , Because of the anatomic distribution of the coronary artery disease, for now we will continue medical treatment for CAD.  We will proceed with revascularization of the right external iliac as well as right common femoral.  Discontinue tobacco.
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DESCRIPTION: Right common femoral artery cannulation, cnscious sedation using IV Versed and IV fentanyl, retrograde bilateral coronary angiography, abdominal aortogram with pelvic runoff, left external iliac angiogram with runoff to the patient's left foot, left external iliac angiogram with runoff to the patient's right leg, right common femoral artery angiogram runoff to the patient's right leg.

The document describes a detailed and complex surgical procedure involving multiple cannulations and angiograms to address serious cardiovascular conditions. The patient has severe peripheral arterial disease and significant coronary artery disease, which are life-threatening conditions. The procedure involves direct interventions on major arteries and requires conscious sedation, indicating the need for precise, skilled execution and monitoring to avoid complications. While the patient tolerated the procedure well, the potential risks inherently associated with such surgeries make this a high-stakes situation.


Medical Specialty: Surgery
Sample Name: Fiberoptic Bronchoscopy - 1

PREOPERATIVE DIAGNOSIS:,1.  Hemoptysis.,2.  History of lung cancer.,POSTOPERATIVE DIAGNOSIS:,  Tumor occluding right middle lobe with friability.,PROCEDURE PERFORMED:,  Fiberoptic bronchoscopy, diagnostic.,LOCATION: , Endoscopy suite #4.,ANESTHESIA:,  General per Anesthesia Service.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE: , The patient presented to ABCD Hospital with a known history of lung cancer and acute hemoptysis with associated chest pain.  Due to her prior history, it was felt that she would benefit from diagnostic fiberoptic bronchoscopy to help determine the etiology of the hemoptysis.  She was brought to endoscopy suite #4 and informed consent was obtained.  ,PROCEDURE DETAILS:  ,The patient was placed in the supine position and intubated by the Anesthesia Service.  Intravenous sedation was given as per Anesthesia.  The fiberoptic scope was passed through the #8 endotracheal tube into the main trachea.  The right mainstem bronchus was examined.  The right upper lobe and subsegments appeared grossly within normal limits with no endobronchial lesions noted.  Upon examining the right middle lobe, there was a tumor noted occluding the lateral segment of the right middle lobe and a clot appreciated over the medial segment of the right middle lobe.,The clot was lavaged with normal saline and there was noted to be tumor behind this clot.  Tumor completely occluded both segments of the right middle lobe.  Scope was then passed to the subsegments of the right lower lobe, which were individually examined and noted to be grossly free of endobronchial lesions.  Scope was pulled back to the level of the midtrachea, passed into the left mainstem bronchus.  Left upper lobe and its subsegments were examined and noted to be grossly free of endobronchial lesions.  The lingula and left lower subsegments were all each individually examined and noted to be grossly free of endobronchial lesions.  There were some secretions noted throughout the left lung.  The scope was retracted and passed again to the right mainstem bronchus.  The area of the right middle lobe was reexamined.  The tumor was noted to be grossly friable with oozing noted from the tumor with minimal manipulation.  It did not appear as if a scope or cannula could be passed distal to the tumor.  Due to continued oozing, 1 cc of epinephrine was applied topically with adequate hemostasis obtained.  The area was examined for approximately one minute for assurance of adequate hemostasis.  The scope was then retracted and the patient was sent to the recovery room in stable condition.  She will be extubated as per the Anesthesia Service.  Cytology and cultures were not sent due to the patient's known diagnosis.  Further recommendations are pending at this time.
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DESCRIPTION: Fiberoptic bronchoscopy, diagnostic.  Hemoptysis and history of lung cancer.  Tumor occluding right middle lobe with friability.

surgery, hemoptysis, lung cancer, tumor, fiberoptic, bronchoscopy, endoscopy suite, adequate hemostasis, fiberoptic bronchoscopy, endobronchial lesions, middle lobe, lobe,

The situation in question involves a medical procedure to investigate a patient with a history of lung cancer and acute hemoptysis. High-stakes factors include the presence of a tumor occluding the right middle lobe of the lung and associated bleeding (oozing) that was controlled using epinephrine. The detailed procedural report indicates the critical nature of the condition, though the immediate postoperative outcome was stable, which is encouraging but does not reduce the overall stakes given the underlying conditions. The potential consequences of the tumor and hemoptysis, including the risk of further bleeding, respiratory distress, and the implications for the patient's cancer treatment, elevate the stakes significantly. However, as the immediate situation post-procedure was managed and stable, there is some reduction in acute risk but substantial ongoing concern remains.


Medical Specialty: Surgery
Sample Name: Exploratory Laparotomy & Hernia Repair

PREOPERATIVE DIAGNOSIS:,1.  Acute bowel obstruction.,2.  Umbilical hernia.,POSTOPERATIVE DIAGNOSIS:,1.  Acute small bowel obstruction.,2.  Incarcerated umbilical Hernia.,PROCEDURE PERFORMED:,1.  Exploratory laparotomy.,2.  Release of small bowel obstruction.,3.  Repair of periumbilical hernia.,ANESTHESIA: , General with endotracheal intubation.,COMPLICATIONS:,  None.,DISPOSITION: , The patient tolerated the procedure well and was transferred to recovery in stable condition.,SPECIMEN: , Hernia sac.,HISTORY:  ,The patient is a 98-year-old female who presents from nursing home extended care facility with an incarcerated umbilical hernia, intractable nausea and vomiting and a bowel obstruction.  Upon seeing the patient and discussing in extent with the family, it was decided the patient needed to go to the operating room for this nonreducible umbilical hernia and bowel obstruction and the family agreed with surgery.,INTRAOPERATIVE FINDINGS: , The patient was found to have an incarcerated umbilical hernia.  There was a loop of small bowel incarcerated within the hernia sac.  It showed signs of ecchymosis, however no signs of any ischemia or necrosis.  It was easily reduced once opening the abdomen and the rest of the small bowel was ran without any other defects or abnormalities.,PROCEDURE: , After informed written consent, risks and benefits of the procedure were explained to the patient and the patient's family.  The patient was brought to the operating suite.  After general endotracheal intubation, prepped and draped in normal sterile fashion.  A midline incision was made around the umbilical hernia defect with a #10 blade scalpel.  Dissection was then carried down to the fascia.  Using a sharp dissection, an incision was made above the defect superior to the defect entering the fascia.  The abdomen was entered under direct visualization.  The small bowel that was entrapped within the hernia sac was easily reduced and observed and appeared to be ecchymotic, however, no signs of ischemia were noted or necrosis.  The remaining of the fascia was then extended using Metzenbaum scissors.  The hernia sac was removed using Mayo scissors and sent off as specimen.  Next, the bowel was run from the ligament of Treitz to the ileocecal valve with no evidence of any other abnormalities.  The small bowel was then milked down removing all the fluid.  The bowel was decompressed distal to the obstruction.  Once returning the abdominal contents to the abdomen, attention was next made in closing the abdomen and using #1 Vicryl suture in the figure-of-eight fashion the fascia was closed.  The umbilicus was then reapproximated to its anatomical position with a #1 Vicryl suture.  A #3-0 Vicryl suture was then used to reapproximate the deep dermal layers and skin staples were used on the skin.  Sterile dressings were applied.  The patient tolerated the procedure well and was transferred to recovery in stable condition.
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DESCRIPTION: Exploratory laparotomy, release of small bowel obstruction, and repair of periumbilical hernia.  Acute small bowel obstruction and incarcerated umbilical Hernia.

surgery, endotracheal intubation, acute bowel obstruction, umbilical hernia, exploratory laparotomy, release of small bowel obstruction, repair of periumbilical hernia, incarcerated umbilical hernia, incarcerated, bowel, hernia, exploratory, laparotomy, abdomen, umbilical, obstruction,

The situation presented involves a surgical procedure on a 98-year-old patient for an acute small bowel obstruction and an incarcerated umbilical hernia. Although the procedure itself seemed to be routine without complications and the patient recovered well, the stakes are inherently higher due to the patient's advanced age and the acute nature of the medical condition. The potential for severe complications or outcomes is greater given the patient's frail health status and the critical nature of bowel obstructions, which can rapidly become life-threatening. Therefore, while the outcome was positive, the stakes involved in conducting surgery on a very elderly patient with these urgent diagnoses are high.


Medical Specialty: Surgery
Sample Name: Excision - Skin Neoplasm

PREOPERATIVE DIAGNOSES:,1.  Enlarging nevus of the left upper cheek.,2.  Enlarging nevus 0.5 x 1 cm, left lower cheek.,3.  Enlarging superficial nevus 0.5 x 1 cm, right nasal ala.,TITLE OF PROCEDURES:,1.  Excision of left upper cheek skin neoplasm 0.5 x 1 cm with two layer closure.,2.  Excision of the left lower cheek skin neoplasm 0.5 x 1 cm with a two layer plastic closure.,3.  Shave excision of the right nasal ala 0.5 x 1 cm skin neoplasm.,ANESTHESIA:  ,Local.  I used a total of 5 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,COMPLICATIONS:,  None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  Risks including but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures have been all reviewed.  Each of these lesions appears to be benign nevi; however, they have been increasing in size.  The lesions involving the left upper and lower cheek appear to be deep.  These required standard excision with the smaller lesion of the right nasal ala being more superficial and amenable to a superficial shave excision.  Each of these lesions was marked.  The skin was cleaned with a sterile alcohol swab.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,Began first excision of the left upper cheek skin lesion.  This was excised with the 15-blade full thickness.  Once it was removed in its entirety, undermining was performed, and the wound was closed with 5-0 myochromic for the deep subcutaneous, 5-0 nylon interrupted for the skin.,The lesion of the lower cheek was removed in a similar manner.  Again, it was excised with a 15 blade with two layer plastic closure.  Both these lesions appear to be fairly deep nevi.,The right nasal ala nevus was superficially shaved using the radiofrequency wave unit.  Each of these lesions was sent as separate specimens.  The patient was discharged from my office in stable condition.  He had minimal blood loss.  The patient tolerated the procedure very well.  Postop care instructions were reviewed in detail.  We have scheduled a recheck in one week and we will make further recommendations at that time.
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DESCRIPTION: Excision of left upper cheek skin neoplasm and left lower cheek skin neoplasm with two-layer closure.  Shave excision of the right nasal ala skin neoplasm.

surgery, enlarging nevus, nevus, skin neoplasm, nasal ala, cheek skin neoplasm, shave excision, superficial, lesions, neoplasm, excision, cheek

The situation involves a surgical procedure to remove potentially benign skin lesions. These are small neoplasms, likely benign, and the procedure is relatively straightforward, conducted under local anesthesia with minimal estimated blood loss and no complications. The patient is stable and the procedure involved routine excision techniques. While any surgery has some inherent risks, in the context of surgical procedures, this represents a low to moderate stakes situation.


Medical Specialty: Surgery
Sample Name: Excision of Squamous Cell Carcinoma

PREOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,POSTOPERATIVE DIAGNOSIS: , Squamous cell carcinoma on the right hand, incompletely excised.,NAME OF OPERATION: , Re-excision of squamous cell carcinoma site, right hand.,ANESTHESIA:,  Local with monitored anesthesia care.,INDICATIONS:,  Patient, 72,  status post excision of squamous cell carcinoma on the dorsum of the right hand at the base of the thumb.  The deep margin was positive.  Other margins were clear.  He was brought back for re-excision.,PROCEDURE:,  The patient was brought to the operating room and placed in the supine position.  He was given intravenous sedation.  The right hand was prepped and draped in the usual sterile fashion.  Three cubic centimeters of 1% Xylocaine mixed 50/50 with 0.5% Marcaine with epinephrine was instilled with local anesthetic around the site of the excision, and the site of the cancer was re-excised with an elliptical incision down to the extensor tendon sheath.  The tissue was passed off the field as a specimen.,The wound was irrigated with warm normal saline.  Hemostasis was assured with the electrocautery.  The wound was closed with running 3-0 nylon without complication.  The patient tolerated the procedure well and was taken to the recovery room in stable condition after a sterile dressing was applied.
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DESCRIPTION: Re-excision of squamous cell carcinoma site, right hand.

surgery, monitored anesthesia care, elliptical incision, squamous cell carcinoma site, squamous cell carcinoma, squamous cell, excision, squamous, carcinoma

The procedure described involves the re-excision of a squamous cell carcinoma on the patient's hand, which is a common procedure in surgical oncology. While it involves removing a potentially cancerous lesion, it is performed under local anesthesia and described as being relatively straightforward. The key risks would primarily relate to ensuring all cancerous cells are removed to prevent recurrence and managing potential surgical complications like infection or poor wound healing. However, the context provided suggests this is a routine follow-up surgical procedure with no immediate life-threatening concerns. Thus, while important, it is not an extremely high-stakes situation.


Medical Specialty: Surgery
Sample Name: Excision - Actinic Neoplasm

PREOPERATIVE DIAGNOSES:,1.  Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2.  Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3.  A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4.  A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5.  A 1 cm x 1 cm actinic keratosis of the right mid cheek.,POSTOPERATIVE DIAGNOSES:,1.  Enlarging skin neoplasm, actinic neoplasm, left upper cheek, measures 1 cm x 1.5 cm.,2.  Enlarging 0.5 cm x 1 cm nevus of the left lower cheek neck region.,3.  A 1 cm x 1 cm seborrheic keratosis of the mid neck.,4.  A 1 cm x 1.5 cm verrucous seborrheic keratosis of the right auricular rim.,5.  A 1 cm x 1 cm actinic keratosis of the right mid cheek.,TITLE OF PROCEDURES:,1.  Excision of the left upper cheek actinic neoplasm defect measuring 1.5 cm x 1.8 cm with two-layer plastic closure.,2.  Excision of the left lower cheek upper neck, 1 cm x 1.5 cm skin neoplasm with two-layer plastic closure.,3.  Shave excision of the mid neck seborrheic keratosis that measured 1 cm x 1.5 cm.,4.  Shave excision of the right superior pinna auricular rim, 1 cm x 1.5 cm verrucous keratotic neoplasm.,5.  A 50% trichloroacetic acid treatment of the right mid cheek, 1 cm x 1 cm actinic neoplasm.,ANESTHESIA: , Local.  I used a total of 6 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS:,  Less than 30 mL.,COMPLICATIONS: , None.,COUNTS:  ,Sponge and needle counts were all correct.,PROCEDURE:,  The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  She is aware of risks include but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures, etc.  The areas of concern were marked with the marking pen.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,I began excising the left upper cheek and left lower cheek neck lesions as listed above.  These were excised with the #15 blade.  The left upper cheek lesion measures 1 cm x 1.5 cm, defect after excision is 1.5 cm x 1.8 cm.  A suture was placed at the 12 o'clock superior margin.  Clinically, this appears to be either actinic keratosis or possible basal cell carcinoma.  The healthy margin of healthy tissue around this lesion was removed.  Wide underminings were performed and the lesion was closed in a two-layered fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,The left upper neck lesion was also removed in the similar manner.  This is dark and black, appears to be either an intradermal nevus or pigmented seborrheic keratosis.  It was excised using a #15 blade down the subcutaneous tissue with the defect 1 cm x 1.5 cm.  After wide underminings were performed, a two-layer plastic closure was performed with 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,The lesion of the mid neck and the auricular rim were then shave excised for the upper dermal layer with the Ellman radiofrequency wave unit.  These appeared to be clinically seborrheic keratotic neoplasms.,Finally proceeded with the right cheek lesion, which was treated with the 50% TCA.  This was also an actinic keratosis.  It is new in onset, just within the last week.  Once a light frosting was obtained from the treatment site, bacitracin ointment was applied.  Postop care instructions have been reviewed in detail.  The patient is scheduled a recheck in one week for suture removal.  We will make further recommendations at that time.
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DESCRIPTION: Excision of the left upper cheek actinic neoplasm and left lower cheek upper neck skin neoplasm with two-layer plastic closures

The situation involves multiple surgical excisions and treatments of skin lesions, including actinic keratoses, nevi, and seborrheic keratoses. While actinic keratosis can potentially lead to skin cancer, the procedures described are considered routine dermatological surgeries with local anesthesia, minimal blood loss, and no reported complications. The stakes are moderate due to potential malignancy and the necessity for precise surgical intervention, but the well-planned, straightforward procedures with correct counts indicate lower risk. However, there are still risks like infection, scarring, and the necessity for further procedures, which keep it from being very low stakes.


Medical Specialty: Surgery
Sample Name: Excision - Keratotic Neoplasm

PREOPERATIVE DIAGNOSES:,1.  Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2.  Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3.  Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,POSTOPERATIVE DIAGNOSES:,1.  Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2.  Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3.  Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,TITLE OF PROCEDURES:,1.  Excision of the left temple keratotic neoplasm, final defect 1.8 x 1.5 cm with two layer plastic closure.,2.  Excision of the left nasolabial fold defect 0.5 x 0.5 cm with single layer closure.,3.  Excision of the right temple keratotic neoplasm, final defect measuring 1.5 x 1.5 cm with two layer plastic closure.,ANESTHESIA: , Local using 3 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 30 mL.,COMPLICATIONS:,  None.,PROCEDURE: , The patient was evaluated preoperatively and noted to be in stable condition.  Informed consent was obtained from the patient.  All risks, benefits and alternatives regarding the surgery have been reviewed in detail with the patient.  This includes risks of bleeding, infection, scarring, recurrence of lesion, need for further procedures, etc.  Each of the areas was cleaned with a sterile alcohol swab.  Planned excision site was marked with a marking pen.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,We began first with excision of the left temple followed by the left nasolabial and right temple lesions.  The left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm.  However, it is somewhat deeper than the standard seborrheic keratosis.  The incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region.  Once this was removed, wide undermining was performed and the wound was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,Excision of left cheek was a keratotic nevus.  It was excised with a defect 0.5 x 0.5 cm.  It was closed in a single layer fashion 5-0 nylon.,The lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension.  Once it was excised full-thickness, the defect measure 1.5 x 1.5 cm.  Wide undermine was performed and it was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous, 5-0 nylon that was used to close skin.  Sterile dressing was applied afterwards.  The patient was discharged in stable condition.  Postop care instructions reviewed in detail.  She is scheduled with me in one week and we will make further recommendations at that time.
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DESCRIPTION: Excision of the left temple keratotic neoplasm and left nasolabial fold defect and right temple keratotic neoplasm.

surgery, keratotic lesion, keratotic neoplasm, seborrheic keratotic neoplasm, seborrheic, keratotic, neoplasm, nasolabial, two layer plastic closure, nasolabial fold, excision,

The situation involves a surgical procedure for excision of keratotic neoplasms on different areas of the face. While these types of surgeries generally carry some level of risk, the description indicates that the surgeries were conducted with local anesthesia, minimal blood loss, and no complications reported. Considering these aspects, the stakes are not extremely high because the procedure doesn't involve life-threatening conditions or emergencies. However, as with any surgical procedure, there are inherent risks such as infection or scarring, and the lesions need to be investigated further to rule out malignancy.


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

Medical Specialty: Surgery
Sample Name: Ethmoidectomy & Nasal Polypectomy

PROCEDURES PERFORMED:,1.  Functional endoscopic sinus surgery.,2.  Bilateral maxillary antrostomy.,3.  Bilateral total ethmoidectomy.,4.  Bilateral nasal polypectomy.,5.  Right middle turbinate reduction.,ANESTHESIA:,  General endotracheal tube.,BLOOD LOSS:,  Approximately 50 cc.,INDICATION: , This is a 48-year-old female with a history of chronic sinusitis as well as nasal polyposis that have been refractory to outpatient medical management.  She has underwent sinus surgery in the past approximately 12 years ago with the CT evaluation revealed evidence of chronic mucosal thickening within the maxillary and ethmoid sinuses as well as the presence of polyposis within the nasal cavities bilaterally.,PROCEDURE:  ,After all risks, benefits, and alternatives have been discussed with the patient in detail, informed consent was obtained.  The patient was brought to the operative suite where she was placed in supine position and general anesthesia was delivered by the Department of Anesthesia.  The patient was rotated 90 degrees away where cotton pledgets saturated with 4 cc of 10% cocaine solution were inserted into the nasal cavity.  The nasal septum, as well as the turbinates were then localized with a mixture of 1% lidocaine with 1:100,000 epinephrine solution.  The patient was then prepped and draped in the usual fashion.,Attention was directed first to the left nasal cavity.  A zero-degree sinus endoscope was inserted into the nasal cavity down to the level of the nasopharynx.  The initial examination revealed a gross polypoid disease emanating from the sphenoid sinuses as well as off the supreme turbinate.  There was also polypoid disease present within the left middle meatus.  Nasopharynx was visualized with a patent eustachian tube.  At this point, the XPS micro debrider was used to take down all the polyps emanating from the inferior surface of the left middle turbinate as well as from the supreme turbinate.  The ostium to the sphenoid sinus was visualized and was not entered.  At this point, the left middle turbinate was localized and then medialized with the use of a freer elevator.  A ball-tip probe was then used to localize the openings for the natural maxillary ostium.  Side-biting forceps were used to take down the uncinate process and was further taken down with the use of the microdebrider.  The opening of the maxillary sinus was visualized.  The posterior fontanelle was taken down with the use of straight line forceps.  It should be mentioned that tissue was very thick and polypoid with chronic inflammatory changes evident.  The maxillary sinus ostia was then suctioned with Olive-tip suction and maxillary wash was performed.  The remainder of the anterior ethmoid was then cleaned again removing excess polypoid tissue.  The basal lamella was visualized and the posterior ethmoid air cells were then entered with use of the microdebrider as the surgical assistant palpated the patient's eyes for any vibration.  All polypoid tissue was collected in the microdebrider and sent as a surgical specimen.  Once all polypoid tissue has been removed, the cocaine pledgets were reinserted into the ethmoid air cells for hemostatic purposes.  Attention was then directed to the right nasal cavity.  Again, a sinus endoscope was inserted.  Inspection revealed a grossly hypertrophied turbinate.  It was felt that this enlarged and polypoid turbinate was contributing the patient's symptoms.  Therefore, the turbinate was localized and a hemostat was used to crush the mid portion of the turbinate, which was then resected with use of side-biting scissors as well the Takahashi forceps.  Sinus endoscope was then inserted all the way down through the nasopharynx.  Again, the eustachian tube was visualized without any obstructing lesions or masses.  Upon retraction, there was again polypoid tissue noted within the ethmoid sinuses.  The ball-tip probe was again used to locate the right maxillary ostium.  The side-biting forceps was used further take down the uncinate process.  The maxillary ostium was then widened with use of a XPS microdebrider.  A maxillary sinus wash was then performed.  Now, the attention was directed to the ethmoid air cells.  It should be mentioned again that the tissue of the anterior ethmoid was very thickened and polypoid.  This was again taken down with the use of XPS microdebrider while the surgical assistant carefully palpated the patient's eye.,Once all polypoid tissue have been removed, some bleeding that was encountered was controlled with the use of suction cautery in a very conservative manner.  Once all bleeding has been controlled, all surgical instruments were removed and Merocel packing was placed in the bilateral nasal cavities with the intent to remove in the recovery room.  At this point, the procedure was felt to be complete.  The patient was awakened and taken to the recovery room without incident.
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DESCRIPTION: Functional endoscopic sinus surgery, bilateral maxillary antrostomy, bilateral total ethmoidectomy, bilateral nasal polypectomy, and right middle turbinate reduction.

surgery, endoscopic sinus surgery, maxillary antrostomy, ethmoidectomy, nasal polypectomy, turbinate reduction, sinus surgery, sinus endoscope, maxillary sinus, nasal cavity, polypoid tissue, sinus, maxillary, turbinate, polypoid, nasal, total, ostium, microdebrider,

This scenario involves a surgical procedure, specifically functional endoscopic sinus surgery (FESS) along with additional procedures such as bilateral maxillary antrostomy, bilateral ethmoidectomy, and nasal polypectomy. Surgery inherently carries risks including bleeding, infection, or adverse reactions to anesthesia. Despite being a routine procedure for treating chronic sinusitis and nasal polyposis, any endoscopic surgery near the sinuses can pose risks due to potential complications like damage to the optic nerve or brain if the surgery is not performed correctly. The use of general anesthesia and the patient's medical history of previous sinus surgeries also increase the complexity of the situation. However, this is not categorized as an emergency surgery, but it is non-trivial given potential risks and necessary skill level for successful outcomes.


Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy with Biopsies - 1

PROCEDURE: , Esophagogastroduodenoscopy with gastric biopsies.,INDICATION:,  Abdominal pain.,FINDINGS:,  Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.,MEDICATIONS: , Fentanyl 200 mcg and versed 6 mg.,SCOPE: , GIF-Q180.,PROCEDURE DETAIL: , Following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation and side effects of medications and alternatives were reviewed.  Questions were answered.  Pause preprocedure was performed.,Following titrated intravenous sedation the flexible video endoscope was introduced into the esophagus and advanced to the second portion of the duodenum without difficulty.  The esophagus appeared to have normal motility and mucosa.  Regular Z line was located at 44 cm from incisors.  No erosion or ulceration.  No esophagitis.,Upon entering the stomach gastric mucosa was examined in detail including retroflexed views of cardia and fundus.  There was pyloric channel and antral erythema, but no visible erosion or ulceration.  There was a 2 cm polypoid pyloric channel tissue which was suspicious for inflammatory polyp.  This was biopsied and was placed separately in bottle #2.  Random gastric biopsies from antrum, incisura and body were obtained and placed in separate jar, bottle #1.  No active ulceration was found.,Upon entering the duodenal bulb there was extensive erythema and mild erosions, less than 3 mm in length, in first portion of duodenum, duodenal bulb and junction of first and second part of the duodenum.  Postbulbar duodenum looked normal.,The patient was assessed upon completion of the procedure.  Okay to discharge once criteria met.,Follow up with primary care physician.,I met with patient afterward and discussed with him avoiding any nonsteroidal anti-inflammatory medication.  Await biopsy results.
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DESCRIPTION: Esophagogastroduodenoscopy with gastric biopsies.  Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.

surgery, gastric biopsies, duodenal erythema, inflammatory polyp, pyloric channel tissue, pyloric channel, esophagogastroduodenoscopy, pyloric, duodenal, duodenum, polypoid,

The situation described involves a medical procedure, esophagogastroduodenoscopy with biopsies, which is a routine diagnostic procedure performed to investigate causes of abdominal pain. While the procedure carries certain risks such as bleeding and perforation, these are typical for endoscopic procedures and are typically managed with well-established protocols. The situation does not describe any complications or urgent findings necessitating immediate intervention. The potential finding of an inflammatory polyp, while requiring follow-up, is not immediately life-threatening. Despite being of importance to the patient's ongoing care, the stakes are not considered extremely high compared to more critical medical situations.


Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy & Gastrostomy Tube Insertion

PREOPERATIVE DIAGNOSES:,1.  Neuromuscular dysphagia.,2.  Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSES:,1.  Neuromuscular dysphagia.,2.  Protein-calorie malnutrition.,PROCEDURES PERFORMED:,1.  Esophagogastroduodenoscopy with photo.,2.  Insertion of a percutaneous endoscopic gastrostomy tube.,ANESTHESIA:,  IV sedation and local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well without difficulty.,BRIEF HISTORY:  ,The patient is a 50-year-old African-American male who presented to ABCD General Hospital on 08/18/2003 secondary to right hemiparesis from a CVA.  The patient deteriorated with several CVAs and had became encephalopathic requiring a ventilator-dependency with respiratory failure.  The patient also had neuromuscular dysfunction.  After extended period of time, per the patient's family request and requested by the ICU staff, decision to place a feeding tube was decided and scheduled for today.,INTRAOPERATIVE FINDINGS: , The patient was found to have esophagitis as well as gastritis via EGD and was placed on Prevacid granules.,PROCEDURE: , After informed written consent, the risks and benefits of the procedure were explained to the patient and the patient's family.  First, the EGD was to be performed.,The Olympus endoscope was inserted through the mouth, oropharynx and into the esophagus.  Esophagitis was noted.  The scope was then passed through the esophagus into the stomach.  The cardia, fundus, body, and antrum of the stomach were visualized.  There was evidence of gastritis.  The scope was passed into the duodenal bulb and sweep via the pylorus and then removed from the duodenum retroflexing on itself in the stomach looking at the hiatus.  Next, attention was made to transilluminating the anterior abdominal wall for the PEG placement.  The skin was then anesthetized with 1% lidocaine.  The finder needle was then inserted under direct visualization.  The catheter was then grasped via the endoscope and the wire was pulled back up through the patient's mouth.  The Ponsky PEG tube was attached to the wire.  A skin nick was made with a #11 blade scalpel.  The wire was pulled back up through the abdominal wall point and Ponsky PEG back up through the abdominal wall and inserted into position.  The endoscope was then replaced confirming position.  Photograph was taken.  The Ponsky PEG tube was trimmed and the desired attachments were placed and the patient did tolerate the procedure well.  We will begin tube feeds later this afternoon.
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DESCRIPTION: Esophagogastroduodenoscopy with photo.  Insertion of a percutaneous endoscopic gastrostomy tube.  Neuromuscular dysphagia.  Protein-calorie malnutrition.

surgery, neuromuscular dysphagia, protein-calorie malnutrition, esophagogastroduodenoscopy, endoscopic, gastrostomy, percutaneous, gastrostomy tube, percutaneous endoscopic gastrostomy tube, protein calorie malnutrition, abdominal wall, dysphagia, stomach, abdominal, neuromuscular, tube,

The situation involves a medical procedure for a patient with multiple serious health conditions, including respiratory failure and the need for a gastrostomy tube for feeding. This suggests a high-stakes medical context as it involves critical decision-making for a vulnerable patient with numerous health complications.


Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy - 8

PREOPERATIVE DIAGNOSIS:, Chronic abdominal pain and heme positive stool.,POSTOPERATIVE DIAGNOSES:,1.  Antral gastritis.,2.  Duodenal polyp.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with photos and antral biopsy.,ANESTHESIA: , Demerol and Versed.,DESCRIPTION OF PROCEDURE: , Consent was obtained after all risks and benefits were described.  The patient was brought back into the Endoscopy Suite.  The aforementioned anesthesia was given.  Once the patient was properly anesthetized, bite block was placed in the patient's mouth.  Then, the patient was given the aforementioned anesthesia.  Once he was properly anesthetized, the endoscope was placed in the patient's mouth that was brought down to the cricopharyngeus muscle into the esophagus and from the esophagus to his stomach.  The air was insufflated down.  The scope was passed down to the level of the antrum where there was some evidence of gastritis seen.  The scope was passed into the duodenum and then duodenal sweep where there was a polyp seen.  The scope was pulled back into the stomach in order to flex upon itself and straightened out.  Biopsies were taken for CLO and histology of the antrum.  The scope was pulled back.  The junction was visualized.  No other masses or lesions were seen.  The scope was removed.  The patient tolerated the procedure well.  We will recommend the patient be on some type of a H2 blocker.  Further recommendations to follow.
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DESCRIPTION: Chronic abdominal pain and heme positive stool, antral gastritis, and duodenal polyp.  Esophagogastroduodenoscopy with photos and antral biopsy.

surgery, endoscopy, gastritis, clo, histology, antrum, heme positive stool, esophagogastroduodenoscopy, duodenal, polyp, antral,

The situation involves a medical procedure (esophagogastroduodenoscopy) that is diagnostic in nature, used to investigate symptoms such as chronic abdominal pain and heme positive stool. This suggests possible gastrointestinal issues like gastritis or polyps. While this procedure is routine and has diagnostic and therapeutic applications, it is not emergency surgery. However, given it involves anesthesia, potential diagnosis of serious conditions, and biopsy, it carries moderate stakes. It is important for patient management and follow-up treatment.


Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy - 6

PROCEDURE IN DETAIL: , Following premedication with Vistaril 50 mg and Atropine 0.4 mg IM, the patient received Versed 5.0 mg intravenously after Cetacaine spray to the posterior palate.  The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.  The upper, mid and lower portions of the esophagus; the lesser and greater curves of the stomach; anterior and posterior walls; body and antrum; pylorus; duodenal bulb; and duodenum were all normal.  No evidence of friability, ulceration or tumor mass was encountered.  The instrument was withdrawn to the antrum, and biopsies taken for CLO testing, and then the instrument removed.
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DESCRIPTION: Esophagogastroduodenoscopy.   The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.

surgery, cetacaine, pylorus, antrum, duodenum, upper esophagus, esophagogastroduodenoscopy, descending, esophagusNOTE,: 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 described procedure is an Esophagogastroduodenoscopy (EGD), which is a standard diagnostic procedure used to examine the lining of the esophagus, stomach, and the first part of the small intestine. While the procedure itself is common and often performed on an outpatient basis, it does involve sedation and carries some risks, such as perforation or bleeding, though these are uncommon. In this specific case, the procedure was unremarkable and no abnormalities were found, indicating it went smoothly. However, due to the involvement of sedation and the potential (albeit low) risks associated, it is still moderately high-stakes compared to many routine medical procedures.


Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy - 4

PROCEDURE: , Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,INDICATIONS FOR PROCEDURE: , A 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage.  Currently, he has a fistula from his anterior abdominal wall out.  It does not appear to connect to the gastrointestinal tract, but merely connect from the ventral surface of the rectus muscles out the abdominal wall.  CT scans show thickened terminal ileum, which suggest that we are dealing with Crohn's disease.  Endoscopy is being done to evaluate for Crohn's disease.,MEDICATIONS:  ,General anesthesia.,INSTRUMENT:,  Olympus GIF-160 and PCF-160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FINDINGS: , With the patient in the supine position, intubated under general anesthesia.  The endoscope was inserted without difficulty into the hypopharynx.  The scope was advanced down the esophagus, which had normal mucosal coloration and vascular pattern.  Lower esophageal sphincter was located at 40 cm from the central incisors.  It appeared normal and appeared to function normally.  The endoscope was advanced into the stomach, which was distended with excess air.  Rugal folds were flattened completely.  There were multiple superficial erosions scattered throughout the fundus, body, and antral portions consistent with Crohn's involvement of the stomach.  The endoscope was advanced through normal-appearing pyloric valve into the first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  Biopsies were obtained x2 in the second portion of the duodenum, antrum, body, and distal esophagus at 37 cm from the central incisors for histology.  Two additional biopsies were obtained in the antrum for CLO testing.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated that part of the procedure well.,The patient was turned and scope was changed for colonoscopy.  Prior to colonoscopy, it was noted that there was a perianal fistula at 7 o'clock.  The colonoscope was then inserted into the anal verge.  The colonic clean out was excellent.  The scope was advanced without difficulty to the cecum.  The cecal area had multiple ulcers with exudate.  The ileocecal valve was markedly distorted.  Biopsies were obtained x2 in the cecal area and then the scope was withdrawn through the ascending, transverse, descending, sigmoid, and rectum.  The colonic mucosa in these areas was well seen and there were a few scattered aphthous ulcers in the ascending and descending colon.  Biopsies were obtained in the cecum at 65 cm, transverse colon 50 cm, rectosigmoid 20 cm, and rectum at 5 cm.  No fistulas were noted in the colon.  Excess air was evacuated from the colon.  The scope was removed.  The patient tolerated the procedure well and was taken to recovery in satisfactory condition.,IMPRESSION: , Normal esophagus and duodenum.  There were multiple superficial erosions or aphthous ulcers in the stomach along with a very few scattered aphthous ulcers in the colon with marked cecal involvement with large ulcers and a very irregular ileocecal valve.  All these findings are consistent with Crohn's disease.,PLAN:  ,Begin prednisone 30 mg p.o. daily.  Await PPD results and chest x-ray results, as well as cocci serology results.  If these are normal, then we would recommend Remicade 5 mg/kg IV infusion.  We would start Modulon 50 mL/h for 20 hours to reverse the malnutrition state of this boy.  Check CMP and phosphate every Monday, Wednesday, and Friday for receding syndrome noted by following potassium and phosphate.  We will discuss with Dr. X possibly repeating the CT fistulogram if the findings on the previous ones are inconclusive as far as the noting whether we can rule in or out an enterocutaneous fistula.  He will need an upper GI to rule out small intestinal strictures and involvement of the small intestine that cannot be seen with upper and lower endoscopy.  If he has no stricture formation in the small bowel, we would then recommend a video endoscopy capsule to further evaluate any mucosal lesions consistent with Crohn's in the small intestine that we cannot visualize with endoscopy.
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DESCRIPTION: Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.

surgery, olympus gif-160, pcf-160, endoscopy, crohn's disease, aphthous ulcers, esophagogastroduodenoscopy, endoscope, esophagus, duodenum, mucosal, stomach, biopsies, colonoscopy

The situation describes a medical procedure involving esophagogastroduodenoscopy and colonoscopy with biopsy on a 17-year-old patient suspected of having Crohn's disease. This involves general anesthesia, biopsies, and the potential management of a complex condition with possible complications like malnutrition and fistula formation. These factors contribute to high stakes due to the potential impact on the patient's health and the need for careful diagnostics and treatment planning.


Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy - 2

PROCEDURE:,  Esophagogastroduodenoscopy with biopsy.,REASON FOR PROCEDURE:,  The child with history of irritability and diarrhea with gastroesophageal reflux.  Rule out reflux esophagitis, allergic enteritis, and ulcer disease, as well as celiac disease.  He has been on Prevacid 7.5 mg p.o. b.i.d. with suboptimal control of this irritability.,Consent history and physical examinations were performed.  The procedure, indications, alternatives available, and complications i.e. bleeding, perforation, infection, adverse medication reactions, possible need for blood transfusion, and surgery associated complication occur were discussed with the mother who understood and indicated this.  Opportunity for questions was provided and informed consent was obtained.,MEDICATIONS:  ,General anesthesia.,INSTRUMENT: , Olympus GIF-XQ 160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FINDINGS: , With the patient in the supine position intubated under general anesthesia, the endoscope was inserted without difficulty into the hypopharynx.  The proximal, mid, and distal esophagus had normal mucosal coloration and vascular pattern.  Lower esophageal sphincter appeared normal and was located at 25 cm from the central incisors.  A Z-line was identified within the lower esophageal sphincter.  The endoscope was advanced into the stomach, which was distended with excess air.  The rugal folds flattened completely.  The gastric mucosa was entirely normal.  No hiatal hernia was seen and the pyloric valve appeared normal.  The endoscope was advanced into first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  Ampule of Vater was identified and found to be normal.  Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  Additional two antral biopsies were obtained for CLO testing.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated the procedure well.  The patient was taken to recovery room in satisfactory condition.,IMPRESSION:,  Normal esophagus, stomach, and duodenum.,PLAN:,  Histologic evaluation and CLO testing.  Continue Prevacid 7.5 mg p.o. b.i.d.  I will contact the parents next week with biopsy results and further management plans will be discussed at that time.
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DESCRIPTION: Esophagogastroduodenoscopy with biopsy.

Esophagogastroduodenoscopy with biopsy.

surgery, olympus gif-xq 160, diarrhea, gastroesophageal, esophagitis, reflux, clo testing, esophagogastroduodenoscopy with biopsy, endoscope, esophagus, stomach, duodenum, esophagogastroduodenoscopy

The procedure described involves a minor surgical intervention under general anesthesia in a child, aimed at diagnosing potential gastrointestinal issues. While the procedure is routine in a medical setting and the patient tolerated it well with no immediate complications, it involves anesthesia and biopsy which carries certain risks like bleeding and infection. Furthermore, the results of the biopsies could lead to significant implications for the child's health management. Thus, it has a moderate level of stakes related to the surgical procedure and potential outcomes.


Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy

PROCEDURE:, Esophagogastroduodenoscopy with biopsy and snare polypectomy.,INDICATION FOR THE PROCEDURE:, Iron-deficiency anemia.,MEDICATIONS:, MAC.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration.,PROCEDURE:, After informed consent and appropriate sedation, the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum. The duodenal mucosa was completely normal. The pylorus was normal. In the stomach, there was evidence of diffuse atrophic-appearing nodular gastritis. Multiple biopsies were obtained. There also was a 1.5-cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum. There was mild ulceration on the tip of this polyp. It was decided to remove the polyp via snare polypectomy. Retroflexion was performed, and this revealed a small hiatal hernia in the distal esophagus. The Z-line was identified and was unremarkable. The esophageal mucosa was normal.,FINDINGS:,1. Hiatal hernia.,2. Diffuse nodular and atrophic appearing gastritis, biopsies taken.,3. A 1.5-cm polyp with ulceration along the greater curvature, removed.,RECOMMENDATIONS:,1. Follow up biopsies.,2. Continue PPI.,3. Hold Lovenox for 5 days.,4. Place SCDs.
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DESCRIPTION: Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia

surgery, esophagogastroduodenoscopy, iron-deficiency, iron-deficiency anemia, anemia, biopsy, endoscope, esophageal mucosa, esophagus, hiatal hernia, polypectomy, snare polypectomy, esophagogastroduodenoscopy with biopsy, iron deficiency anemia,

The procedure described is an Esophagogastroduodenoscopy with biopsy and snare polypectomy, which is a common diagnostic and therapeutic procedure. It involves minor surgical intervention, such as the removal of a polyp, as well as performing biopsies to diagnose the cause of iron-deficiency anemia. The risks, including medication reaction, bleeding, perforation, and aspiration, indicate that it is moderately high-stakes. However, the stakes in terms of immediate life-threatening circumstances are not extremely high as such procedures are routine in gastroenterology. While there are risks involved, they are well-known and typically manageable in a controlled medical setting.


Medical Specialty: Surgery
Sample Name: Epigastric Herniorrhaphy

PREOPERATIVE DIAGNOSIS: , Epigastric hernia.,POSTOPERATIVE DIAGNOSIS: , Epigastric hernia.,OPERATIONS:,  Epigastric herniorrhaphy.,ANESTHESIA: , General inhalation.,PROCEDURE: , Following attainment of satisfactory anesthesia, the patient's abdomen was prepped with Hibiclens and draped sterilely.  The hernia mass had been marked preoperatively.  This area was anesthetized with a mixture of Marcaine and Xylocaine.  A transverse incision was made over the hernia and dissection carried down to the entrapped fat.  Sharp dissection was carried around the fat down to the fascial edge.  The preperitoneal fat could not be reduced; therefore, it is trimmed away and the small fascial defect then closed with interrupted 0-Ethibond sutures.  The fascial edges were injected with the local anesthetic mixture.  Subcutaneous tissues were then closed with interrupted 4-0 Vicryl and skin edges closed with running subcuticular 4-0 Vicryl.  Steri-Strips and a sterile dressing were applied to complete the closure.  The patient was then awakened and taken to the PACU in satisfactory condition.,ESTIMATED BLOOD LOSS: , 10 mL.,SPONGE AND NEEDLE COUNT: , Reported as correct.,COMPLICATIONS: , None.
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DESCRIPTION: Epigastric herniorrhaphy.  Epigastric hernia.

surgery, hibiclens, epigastric herniorrhaphy, epigastric hernia, herniorrhaphy,

The situation involves a surgical procedure, specifically an epigastric herniorrhaphy. While surgeries inherently carry some risk, this operation appears to be standard and routine with no reported complications. The estimated blood loss was minimal, anesthesia was general but standard, and the procedure was completed without incident. Such factors suggest that, although there is always risk in surgical procedures, this particular situation does not represent a high-stakes scenario, especially since the patient was in satisfactory condition post-operation.


Medical Specialty: Surgery
Sample Name: Endovascular Abdominal Aortic Aneurysm Repair

PREOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,OPERATION PERFORMED:,  Endovascular abdominal aortic aneurysm repair.,FINDINGS: , The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.  A Gore exclusive device was used 3 pieces were used to effect the repair.  We had to place an iliac extender down in to right external iliac artery to manage the right common iliac artery aneurysm.  The right hypogastric artery had been previously coiled off.  Left common femoral artery was used for the _____ side.  We had small type 2 leak right underneath the take off the renal arteries, this was not felt to be type I leak and this was very delayed filling and it was felt that this was highly indicative of type 2 leak from a lumbar artery, which commonly come off in this area.  It was felt that this would seal after reversal of the anticoagulation given sufficient time.,PROCEDURE: , With the patient supine position under general anesthesia, the abdomen and lower extremities were prepped and draped in a sterile fashion.,Bilateral groin incisions were made, and the common femoral arteries were dissected out bilaterally.  The patient was then heparinized.,The 7-French sheaths were then placed retrograde bilaterally.,A stiff Amplatz wires were then placed up the right femoral artery and a stiff Amplatz were placed left side a calibrated catheter was placed up the right side.  The calibrated aortogram was the done.  We marked the renal arteries aortic bifurcation and bifurcation, common iliac arteries.  We then preceded placement of the main trunk, by replacing the 7 French sheath in the left groin area with 18-french sheath and then deployed the trunk body just below the take off renal arteries.,Once the main trunk has been deployed within wired _____ then deployed an iliac limb down in to the right common iliac artery.  As noted above, we then had to place an iliac extension, down in the external iliac artery to exclude the right common iliac artery and resume completely.,Following completion of the above all arteries were ballooned appropriately.  A completion angiogram was done which showed late small type 2 leak just under the take off renal arteries.  The area was ballooned aggressively.  It was felt that this would dissolve as discussed above.,Following completion of the above all wire sheaths etc., were removed from both groin areas.  Both femoral arteries were repaired by primary suture technique.  Flow was then reestablished to the lower extremities, and protamine was given to reverse the heparin.,Both surgical sites were then irrigated thoroughly.  Meticulous hemostasis was achieved.  Both wounds were then closed in a routine layered fashion.,Sterile antibiotic dressings were applied.  Sponge and needle counts were reported as correct.  The patient tolerated the procedure well the patient was taken to the recovery room in satisfactory condition.
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DESCRIPTION: The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.

surgery, gore, common iliac artery aneurysm, abdominal aortic aneurysm repair, abdominal aortic aneurysm, common iliac, aortic aneurysm, iliac artery, artery, aneurysm, iliac, abdominal, aortic, arteries,

Endovascular abdominal aortic aneurysm repair is a significant surgical procedure often performed to prevent the rupture of an aneurysm, which can be life-threatening. The procedure involves complex steps and careful monitoring to manage potential complications, such as leaks or issues arising from the aneurysm itself. The presence of leaks, use of specialized devices, and need for general anesthesia add to the stakes as they all hold potential serious implications for patient health if not managed properly. Given the complexity and potential risks involved, this scenario is high-stakes.


Medical Specialty: Surgery
Sample Name: Epidurogram

PREOPERATIVE DIAGNOSES:  ,1.  Right lower extremity radiculopathy with history of post laminectomy pain.,2.  Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:  ,1.  Right lower extremity radiculopathy with history of post laminectomy pain.,2.  Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED: , Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion.  The patient was given sedation and monitored.  Local anesthetic was used to insufflate the skin and paraspinal tissues and the L5 disk level on the right was noted to be completely collapsed with no way whatsoever to get a needle to the neural foramen of the L5 root.  The left side was quite open; however, that was not the side of her problem.  At this point using a oblique fluoroscopic projection and gun-barrel technique, a 22-gauge 3.5 inch spinal needle was placed at the superior articular process of L5 on the right, stepped off laterally and redirected medially into the intervertebral foramen to the L4 nerve root.  A second needle was taken and placed at the S1 nerve foramen using AP and lateral fluoroscopic views to confirm location.  After negative aspiration, 2 cc of Omnipaque 240 dye was injected through each needle.,There was a defect flowing in the medial epidural space at both sides.  There were no complications.
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DESCRIPTION: Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.

surgery, laminectomy, radiculopathy, nerve root entrapment, epidural fibrosis, nerve root, epidurogram, neural, epidural, foramen, nerve, needle

The procedure involves an epidurogram, which is a diagnostic imaging test to map nerve paths and diagnose conditions like radiculopathy and nerve root entrapment. While it involves precise placement of needles near nerve roots, which can have high-stakes implications if complications occur, the procedure was performed under local/IV sedation and had no recorded complications. This suggests that the immediate risk level was managed effectively. However, given it involves areas close to the spine and nerve roots, the stakes are relatively high if issues arise.