Medical Specialty: Surgery
Sample Name: Carpal Tunnel Release - Open

PREOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE:  ,Open carpal tunnel release.,COMPLICATIONS:  ,None.,PROCEDURE IN DETAIL:  ,After administering appropriate antibiotics and general anesthesia the Left upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray.  The dissection was carried down to the superficial aponeurosis, which was cut.  The distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the skin was repaired with 4-0 nylon interrupted stitches.,Marcaine with epinephrine was injected into the wound, which was then dressed and splinted.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.
---
DESCRIPTION: Carpal tunnel syndrome.  Open carpal tunnel release.  A longitudinal incision was made in line with the 4th ray.  The dissection was carried down to the superficial aponeurosis, which was cut.  The distal edge of the transverse carpal ligament was identified with a hemostat.

surgery, carpal ligament, carpal tunnel release, carpal tunnel syndrome, transverse carpal ligament, transverse, ligament, hemostat, tunnel, incision

The scenario describes a standard surgical procedure to relieve carpal tunnel syndrome, a common medical condition. The surgery itself is routine, with no complications reported, and the patient tolerated the procedure well, indicating a controlled and expected outcome. While all surgical procedures carry some level of risk and require precision, this particular surgery is generally considered low-risk with a high success rate. Therefore, the stakes are relatively low from a surgical standpoint.


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

Medical Specialty: Surgery
Sample Name: Carpal Tunnel Release - 9

PREOPERATIVE DIAGNOSIS:,  Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE:,  Right carpal tunnel release.,ANESTHESIA:,  Bier block to the right hand.,TOTAL TOURNIQUET TIME: , 20 minutes.,COMPLICATIONS: , None.,DISPOSITION: , Stable to PACU.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,GROSS OPERATIVE FINDINGS:,  We did find a compressed right median nerve upon entering the carpal tunnel, otherwise, the structures of the carpal canal are otherwise unremarkable.  No evidence of tumor was found.,BRIEF HISTORY OF PRESENT ILLNESS:  ,This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.,PROCEDURE: , The patient was taken to the operative room and placed in the supine position.  The patient underwent a Bier block by the Department of Anesthesia on the upper extremity.  The upper extremity was prepped and draped in usual sterile fashion and left free.  Attention was drawn then to the palm of the hand.  We did identify area of incision that we would make, which was located over the carpal tunnel.,Approximately, 1.5 cm incision was made using a #10 blade scalpel.  Dissection was carried through the skin and fascia over the palm down to the carpal tunnel taking care during dissection to avoid any branches of nerves.  Carpal tunnel was then entered and the rest of the transverse carpal ligament was incised sharply with a #10 scalpel.  We inspected the median nerve and found that it was flat and compressed from the transverse carpal ligament.  We found no evidence of tumor or space occupying lesion in the carpal tunnel.  We then irrigated copiously.  Tourniquet was taken down at that time and pressure was held.  There was no evidence of obvious bleeders.  We approximated the skin with nylon and placed a postoperative dressing with a volar splint.  The patient tolerated the procedure well.  She was placed back in the gurney and taken to PACU.
---
DESCRIPTION: Right carpal tunnel release.  Right carpal tunnel syndrome.  This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management.

surgery, carpal tunnel release, carpal tunnel syndrome, median nerve, bier block, carpal ligament, tunnel, carpal, transverse, median,

Carpal tunnel release surgery is a common procedure with generally low risk, especially when performed without complications as indicated in the report. The stakes are not extremely high given that the procedure is elective, and the patient is stable post-operation. However, as with any surgical procedure, there is inherent risk, particularly concerning nerve damage or infection, but these were not indicated here. Therefore, the stakes are moderate, primarily due to the surgical context rather than the specifics of the case which appears routine and successful.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Carpal Tunnel Release - 7

PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Right carpal tunnel syndrome.,PROCEDURE PERFORMED: , Right carpal tunnel release.,PROCEDURE NOTE:  ,The right upper extremity was prepped and draped in the usual fashion.  IV sedation was supplied by the anesthesiologist.  A local block using 6 cc of 0.5% Marcaine was used at the transverse wrist crease using a 25 gauge needle, superficial to the transverse carpal ligament.,The upper extremity was exsanguinated with a 6 inch ace wrap.,Tourniquet time was less than 10 minutes at 250 mmHg.,An incision was used in line with the third web space just to the ulnar side of the thenar crease.  It was carried sharply down to the transverse wrist crease.  The transverse carpal ligament was identified and released under direct vision.  Proximal to the transverse wrist crease it was released subcutaneously.  During the entire procedure care was taken to avoid injury to the median nerve proper, the recurrent median, the palmar cutaneous branch, the ulnar neurovascular bundle and the superficial palmar arch.  The nerve appeared to be mildly constricted.  Closure was routine with running 5-0 nylon.  A bulky hand dressing as well as a volar splint was applied and the patient was sent to the outpatient surgery area in good condition.
---
DESCRIPTION: Right carpal tunnel syndrome.  Right carpal tunnel release.

surgery, superficial palmar arch, carpal tunnel release, carpal tunnel syndrome, transverse wrist crease, superficial, ligament,

The procedure described is a carpal tunnel release surgery, which is commonly performed and generally considered routine with a high success rate, especially when complications are minimal as described. Although all surgeries carry risks, this procedure does not involve life-threatening conditions and appears to have been completed successfully without complications. The stakes are thus relatively low in this context, given the routine nature and standard outcomes associated with such a surgery.


Medical Specialty: Surgery
Sample Name: Carpal Tunnel Release - 5

PREOPERATIVE DIAGNOSIS:  ,Carpal tunnel syndrome, bilateral.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome, bilateral.,ANESTHESIA:,  General,NAME OF OPERATION: , Bilateral open carpal tunnel release.,FINDINGS AT OPERATION: , The patient had identical, very thick, transverse carpal ligaments, with dull synovium.,PROCEDURE:  ,Under satisfactory anesthesia, the patient was prepped and draped in a routine manner on both upper extremities.  The right upper extremity was exsanguinated, and the tourniquet inflated.  A curved incision was made at the the ulnar base, carried through the subcutaneous tissue and superficial fascia, down to the transverse carpal ligament.  This was divided under direct vision along its ulnar border, and wound closed with interrupted nylon.  The wound was injected, and a dry, sterile dressing was applied.  An identical procedure was done to the opposite side.  The patient left the operating room in satisfactory condition.
---
DESCRIPTION: Bilateral open carpal tunnel release.

Bilateral open carpal tunnel release.

surgery, bilateral open carpal tunnel, carpal tunnel syndrome, carpal tunnel release, carpal tunnel, release, tourniquet, bilateral, tunnel, carpal

The situation involves a surgical procedure for treating bilateral carpal tunnel syndrome. Surgical operations, while generally routine for experienced surgeons, inherently have risks such as complications from anesthesia, infection, or surgical errors. However, carpal tunnel release surgery is considered low-risk and commonly performed with a high success rate. Despite being standard, all surgeries require careful attention and carry some stakes due to their invasive nature and the need for precision.


Medical Specialty: Surgery
Sample Name: Carpal Tunnel Release - 3

PREOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome (354.0).,2.  Left ulnar nerve entrapment at the elbow (354.2).,POSTOPERATIVE DIAGNOSES:,1.  Left carpal tunnel syndrome (354.0).,2.  Left ulnar nerve entrapment at the elbow (354.2).,OPERATIONS PERFORMED:,1.  Left carpal tunnel release (64721).,2.  Left ulnar nerve anterior submuscular transposition at the elbow (64718).,3.  Lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve (25280).,ANESTHESIA: , General anesthesia with intubation.,INDICATIONS OF PROCEDURE: , This patient is insulin-dependant diabetic.  He is also has end-stage renal failure and has chronic hemodialysis.  Additionally, the patient has had prior heart transplantation.  He has been evaluated for ischemic problems to both lower extremities and also potentially to the left upper extremity.  However, it is our contention that this patient's prime problem of the left upper extremity is probably neuropathic ulcers from total lack of sensation along the ulnar border of the left little finger.  These started initially as unrecognized paper cuts.  Additionally, the patient appears to have a neurogenic pain affecting predominantly the areas innovated by the median nerve, but also to the little finger.  Finally, this patient does indeed have occlusive arterial disease to the left upper extremity in that he has a short segment radial artery occlusion and he does appear to have a narrowed segment in the ulnar artery, but the arteriogram shows distal perfusion down the ulnar border of the hand and into the little finger.  Thus, we have planned to proceed first with nerve entrapment releases and potentially at the later date do arterial reconstruction if deemed necessary.  Thirdly, this patient does have chronic distal ischemic problems with evidence of "ping-pong ball sign" due to fat atrophy at the finger tips and some periodic cracking and ulceration at the tips of the fingers.  However, this patient has no clinical sign at all of tissue necrosis at the finger tips at this time.,The patient has also previously had an arteriovenous shunt in the forearm, which has been deactivated within the last 3 weeks.  Thus, we planned to bring this patient to the operating room for left carpal tunnel release as well as anterior submuscular transposition of the ulnar nerve.  This patient had electro diagnostic studies performed, which showed severe involvement of both the ulnar nerve at the elbow and the medial nerve at the carpal tunnel.,DESCRIPTION OF PROCEDURE: , After general anesthesia being induced and the patient intubated, he is given intravenous Ancef.  The entire left upper extremity is prepped with Betadine all the way to the axilla and draped in a sterile fashion.  A sterile tourniquet and webril are placed higher on the arm.  The arm is then exsanguinated with Ace bandage and tourniquet inflated to 250 mmHg.  I started first at the carpal tunnel release and a longitudinal curvilinear incision is made parallel to the thenar crease and stopping short of the wrist flexion crease.  Dissection continued through subcutaneous tissue to the palmer aponeurosis, which is divided longitudinally from distal to proximal.  I next encountered the transverse carpal ligament, which in turn is also divided longitudinally from distal to proximal, and the proximal most division of the transverse carpal ligament is done under direct vision into the distal forearm.  Having confirmed a complete release of the transverse carpal ligament, I next evaluated the contents of the carpal tunnel.  The synovium was somewhat thickened, but not unduly so.  There was some erythema along the length of the median nerve, indicating chronic compression.  The motor branch of the median nerve was clearly identified.  The contents of the carpal canal were retracted in a radial direction and the floor of the canal evaluated and no other extrinsic compressive pathology was identified.  The wound was then irrigated with normal saline and wound edges were reapproximated with interrupted 5-0 nylon sutures.,I next turned my attention to the cubital tunnel problem and a longitudinal curvilinear incision is made on the medial aspect of the arm extending into the forearm with the incision passing directly between the olecranon and the medial epicondyle.  Dissection continues through fascia and then skin clamps are elevated to the level of the fascia on the flexor pronator muscle mass.  In the process of elevating this skin flap I elevated and deactivated shunt together with the skin flap.  I now gained access to the radial border of the flexor pronator muscle mass, dissected down the radial side, until I identified the median nerve.,I turned my attention back to the ulnar nerve and it is located immediately posterior to the medial intramuscular septum in the upper arm, and I dissected it all the way proximally until I encountered the location with ulnar the nerve passed from the anterior to the posterior compartments in the upper portion of the arm.  The entire medial intramuscular septum is now excised.  The ulnar nerve is mobilized between vessel loops and includes with it is accompanying vascular structures.  Larger penetrating vascular tributaries to the muscle ligated between hemoclips.  I continued to mobilize the nerve around the medial epicondyle and then took down the aponeurosis between the two heads of the flexor carpi ulnaris and continued to dissect the nerve between the FCU muscle fibers.  The nerve is now mobilized and I had retained the large muscular branches and dissected them out into the muscle and also proximally using microvascular surgical techniques.  In this way, the nerve was able to be mobilized between vessiloops and easily transposed anterior to the flexor pronator muscle mass in tension free manner.,I now made an oblique division of the entire flexor pronator muscle mass proximally in the forearm and the ulnar nerve was able to be transposed deep to the muscle in a nonkinking and tension-free manner.  Because of the oblique incision into the flexor pronator muscle mass the muscle edges were now able to slide on each other.  So that in effect a lengthening is performed.  Fascial repair is done with interrupted figure-of-eight 0-Ethibond sutures.  I now ranged the arm through the full range of flexion and extension at the elbow and there was no significant kinking on the nerve and there was a tension-free coverage of the muscle without any impingement on the nerve.  The entire arm is next wrapped with a Kerlix wrap and I released the tourniquet and after allowing the reactive hyperemia to subside, I then unwrap the arm and check for hemostasis.  Wound is copiously irrigated with normal saline and then a 15-French Round Blake drainage placed through a separate stab incision and laid along the length of the wound.  A layered wound closure is done with interrupted Vicryl subcutaneously, and a running subcuticular Monocryl to the skin.  A 0.25% plain Marcaine then used to infiltrate all the wound edges to help with post operative analgesia and dressings take the form of Adaptic impregnated Bacitracin ointment, followed by a well-fluffed gauze and a Kerlix dressing and confirming Kerlix and webril, and an above elbow sugar-tong splint is applied extending to the support of the wrist.  Fingers and femoral were free to move.  The splint is well padded with webril and is in turn held in place with Kerlix and Ace bandage.  Meanwhile the patient is awakened and extubated in the operating room and returned to the recovery room in good condition.  Sponge and needle counts reported as correct at the end of the procedure.
---
DESCRIPTION: Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve.

surgery, carpal tunnel syndrome, ace bandage, kerlix, carpal tunnel release, curvilinear incision, flexor pronator muscle, ping-pong ball sign, synovium, ulnar artery, ulnar nerve, ulnar nerve entrapment, pronator muscle mass, transverse carpal, carpal ligament, tunnel release, flexor pronator, pronator muscle, carpal tunnel, tunnel, carpal, nerve, pronator, forearm,

The procedure described involves surgical operations on a patient with several significant health conditions, including insulin-dependent diabetes, end-stage renal failure, and a history of heart transplantation. These factors contribute to the complexity and potential risks associated with the surgery. The presence of nerve compression and entrapment, compounded by the patient's chronic conditions, makes it crucial to address these issues surgically to prevent further complications. The procedure, while common, is performed under general anesthesia and involves precise surgical techniques, elevating the stakes involved. Furthermore, any complications could be potentially serious given the patient's health background.


Medical Specialty: Surgery
Sample Name: Carpal Ligament Release - 1

PREOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:,  Carpal tunnel syndrome.,PROCEDURE: , Endoscopic release of left transverse carpal ligament.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia provided by surgeon.  ,TOURNIQUET TIME: , 12 minutes.,OPERATIVE PROCEDURE IN DETAIL: , With the patient under adequate monitored anesthesia, the left upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated.  The tourniquet was elevated at 290 mmHg.  Construction lines were made on the left palm to identify the ring ray.  A transverse incision was made in the palm between FCR and FCU, one finger breadth proximal to the interval between the glabrous skin of the palm and normal forearm skin.  Blunt dissection exposed the antebrachial fascia.  Hemostasis was obtained with bipolar cautery.  A distal based window in the antebrachial fascia was then fashioned.  Care was taken to protect the underlying contents.  A synovial elevator was used to palpate the undersurface of the transverse carpal ligament, and synovium was elevated off this undersurface.,Hamate sounds were then used to palpate the Hood of Hamate.  The Agee Inside Job was then inserted into the proximal incision.  The transverse carpal ligament was easily visualized through the portal.  Using palmar pressure, transverse carpal ligament was held against the portal as the instrument was inserted down the transverse carpal ligament to the distal end.  The distal end of the transverse carpal ligament was then identified in the window.  The blade was then elevated, and the Agee Inside Job was withdrawn, dividing transverse carpal ligament under direct vision.  After complete division of transverse carpal ligament, the Agee Inside Job was reinserted.  Radial and ulnar edges of the transverse carpal ligament were identified and complete release was accomplished.  One cc of Celestone was then introduced into the carpal tunnel and irrigated free.  ,The wound was then closed with a running 3-0 Prolene subcuticular stitch.  Steri-strips were applied and a sterile dressing was applied over the Steri-strips.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.
---
DESCRIPTION: Endoscopic release of left transverse carpal ligament.

surgery, carpal tunnel syndrome, antebrachial fascia, carpal, ligament, palmar, synovium, tourniquet, transverse carpal ligament, transverse incision, agee inside job, transverse carpal, carpal ligament, carpal tunnel, antebrachial, release, endoscopic,

The scenario described is a surgical procedure focused on treating carpal tunnel syndrome through an endoscopic release of the transverse carpal ligament. While surgery inherently carries some risks, this particular procedure is common and typically low-risk, with a high success rate and minimal complications in comparison to other types of surgeries. It is a well-established, routine procedure usually performed in an outpatient setting. However, it's still a surgical situation, which elevates the stakes above the lowest level as it involves anesthesia and potential post-operative recovery issues.


Medical Specialty: Surgery
Sample Name: Carpal Tunnel Release

PROCEDURE PERFORMED: , Carpal tunnel release.,INDICATIONS FOR SURGERY: , Nerve conduction study tests diagnostic of carpal tunnel syndrome.  The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.,PROCEDURE:  ,The patient was brought to the operating room and, following a Bier block to the operative arm, the arm was prepped and draped in the usual manner.,Utilizing an incision that was laid out to extend not more distally than the thumb web space or proximally to a position short of crossing the most prominent base of the palm and in line with the longitudinal base of the thenar eminence in line with the fourth ray, the soft tissue dissection was carried down sharply through the skin and subcutaneous fat to the transverse carpal ligament.  It was identified at its distal edge.  Using a hemostat to probe the carpal tunnel, sharp dissection utilizing scalpel and iris scissors were used to release the carpal tunnel from a distal-to-proximal direction in its entirety.  The canal was probed with a small finger to verify no evidence of any bone prominences.  The nerve was examined for any irregularity.  There was slight hyperemia of the nerve and a slight hourglass deformity.  Following an irrigation, the skin was approximated using interrupted simple and horizontal mattress #5 nylon suture.  A sterile dressing was applied.,The patient was taken to the recovery room in satisfactory condition.,The time of the Bier block was 30 minutes.,COMPLICATIONS: , None noted.
---
DESCRIPTION: Carpal tunnel release.  Nerve conduction study tests diagnostic of carpal tunnel syndrome.  The patient failed to improve satisfactorily on conservative care, including anti-inflammatory medications and night splints.

surgery, carpal tunnel syndrome, carpal ligament, nerve conduction study, carpal tunnel release, bier block, carpal tunnel, tunnel, carpal,

Carpal tunnel release is a common surgical procedure generally considered low-risk. Although it involves precision and expertise from the surgeon, the procedure itself is routine, has a high success rate, and the patient was taken to the recovery room in satisfactory condition with no complications noted. The stakes involved are not as high as those in many other, more complex surgeries. However, as it is still a surgical procedure, it carries higher stakes than non-invasive treatments.


Medical Specialty: Surgery
Sample Name: Cardioversion - Direct Current - 1

PROCEDURE:  ,Direct-current cardioversion.,BRIEF HISTORY:  ,This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years.  He had a wide area of circumferential ablation done on November 9th for atrial fibrillation.  He did develop recurrent atrial fibrillation the day before yesterday and this is persistent.  Therefore, he came in for cardioversion today.  He is still within the first 4 to 6 weeks post ablation where we would attempt early cardioversion.,The patient was in the SDI unit, attached to noninvasive monitoring devices.  After Brevital was brought by the anesthesia service a single 150 joule synchronized biphasic shock using AP paddles did restore him to sinus rhythm in the 80s.  He tolerated it well.  He will be observed for couple hours and discharged home later today.  He will continue on his current medications.  He will follow back up in two to three weeks in the Atrial Fibrillation Clinic and then again in a couple months with myself.,CONCLUSIONS / FINAL DIAGNOSES: , Successful DC cardioversion of atrial fibrillation.
---
DESCRIPTION: Direct-current cardioversion.  This is a 53-year-old gentleman with history of paroxysmal atrial fibrillation for 3 years.  Successful DC cardioversion of atrial fibrillation.

surgery, direct-current cardioversion, circumferential ablation, paroxysmal atrial, dc cardioversion, direct current, atrial fibrillation, ablation, cardioversion,

This situation involves a direct-current cardioversion procedure on a patient with a history of paroxysmal atrial fibrillation. While this type of cardioversion is not considered a highly complex or high-risk procedure and the patient is expected to be discharged home the same day, it is still a medical procedure that involves stopping the heart briefly to restore normal rhythm. It is not as high-stakes as more invasive surgical procedures, however, any procedure on the heart has potential risks and requires careful monitoring, making it moderately high-stakes.


Medical Specialty: Surgery
Sample Name: Cardioversion - Unsuccessful

REASON FOR EXAM: , Atrial flutter/cardioversion.,PROCEDURE IN DETAIL: , The procedure was explained to the patient with risks and benefits.  The patient agreed and signed the consent form.  The patient received sedation prior to the cardioversion with a transesophageal echo as dictated earlier with a total of 50 mcg of fentanyl and 6 mg of Versed.  The pads were applied in the anterior-posterior approach.  The synchronized cardioversion with biphasic energy delivered at 150 J. First attempt was unsuccessful.  Second attempt at 200 J with anterior-posterior approach.  With biphasic synchronized energy delivered was also unsuccessful with degeneration of the atrial flutter into atrial fibrillation.,The patient was decided to be on wave control and amiodarone and reattempted cardioversion after anticoagulation for four to six weeks and because of the reduced LV function, the success of the rate without antiarrhythmic may be low.,IMPRESSION: , Unsuccessful direct current cardioversion with permanent atrial fibrillation.
---
DESCRIPTION: Cardioversion.  Unsuccessful direct current cardioversion with permanent atrial fibrillation.

surgery, atrial flutter, cardioversion, anterior-posterior, transesophageal, atrial fibrillation, flutter/cardioversion, fibrillation, atrial,

Cardioversion is a procedure that attempts to restore a normal heart rhythm in patients with certain types of arrhythmias, such as atrial flutter. Unsuccessful cardioversion means the patient remains in an abnormal rhythm, which carries risks including stroke or worsening heart function. Given these risks and the requirement for further treatment with medications like amiodarone and anticoagulation, this situation is of significant medical concern. The decision to delay further intervention for weeks while managing with medication adds complexity and potential risk, particularly due to the reduced left ventricular function described.


Medical Specialty: Surgery
Sample Name: Carotid Endarterectomy & Angioplasty.

PREOPERATIVE DIAGNOSIS:,  Critical left carotid stenosis.,POSTOPERATIVE DIAGNOSIS: , Critical left carotid stenosis.,PROCEDURE PERFORMED:,  Left carotid endarterectomy with endovascular patch angioplasty.,ANESTHESIA:,  Cervical block.,GROSS FINDINGS:  ,The patient is a 57-year-old black female with chronic renal failure.  She does have known critical carotid artery stenosis.  She wishes to undergo bilateral carotid endarterectomy, however, it was felt necessary by Dr. X to perform cardiac catheterization.  She was admitted to the hospital yesterday with chest pain.  She has been considered for coronary artery bypass grafting.  I have been asked to address the carotid stenosis, left being more severe, this was addressed first.  Intraoperatively, an atherosclerotic plaque was noted in the common carotid artery extending into the internal carotid artery.  The internal carotid artery is quite torturous.  The external carotid artery was occluded at its origin.  When the endarterectomy was performed, the external carotid artery back-bled nicely.  The internal carotid artery had good backflow bleeding noted.,OPERATIVE PROCEDURE: , The patient was taken to the OR suite and placed in the supine position.  Then neck, shoulder, and chest wall were prepped and draped in appropriate manner.  Longitudinal incision was created along the anterior border of the left sternocleidal mastoid muscle and this was taken through the subcutaneous tissue and platysmal muscle utilizing electrocautery.,Utilizing both blunt and sharp dissections, the common carotid artery, the internal carotid artery beyond the atherosclerotic back, the external carotid artery, and the superior thyroid artery were isolated and encircled with a umbilical tape.  During the dissection, facial veins were ligated with #4-0 silk ligature prior to dividing them.  Also during the dissection, ansa cervicalis, hypoglossal, and vagus nerve identified and preserved.  There was some inflammation above the carotid bulb, but this was not problematic.,The patient had been administered 5000 units of aqueous heparin after allowing adequate circulating time.  The internal carotid artery is controlled with Heifitz clip followed by the external carotid artery and the superior thyroid artery being controlled with Heifitz clips.  The common carotid artery was controlled with profunda clamp.  The patient remained neurologically intact.  A longitudinal arteriotomy was created along the posterior lateral border of the common carotid artery.  This was extended across the lobe on to the internal carotid artery.  An endarterectomy was then performed.  The ________ intima was cleared of all debris and the ________ was flushed with copious amounts of heparinized saline.  As mentioned before, the internal carotid artery is quite torturous.  This was shortened by imbricating the internal carotid artery with horizontal mattress stitches of #7-0 Prolene suture.,The wound was copiously irrigated, rather an endovascular patch was then brought on to the field.  This was cut to shape and length.  This was sutured in place with continuous running #6-0 Prolene suture.  The suture line began at both sites.  The suture was tied in the center along the anterior and posterior walls.  Prior to completing the closure, the common carotid artery was flushed.  The internal carotid artery permitted to back bleed.  The clamp was placed after completing the closure.  The clamp was placed at the origin of the internal carotid artery.  Flow was first directed into the external carotid artery then into the internal carotid artery.  The patient remained neurologically intact.  Topical ________ Gelfoam was utilized.  Of note, during the endarterectomy, the patient did receive an additional 7000 units of aqueous heparin.  The wound was copiously irrigated with antibiotic solution.  Sponge, needle, and all counts were correct.  All surgical sites were inspected.  Good hemostasis noted.  The incision was closed in layers with absorbable suture.  Stainless steel staples approximated skin.  Sterile dressings were applied.  The patient tolerated the procedure well, grossly neurologically intact.
---
DESCRIPTION: Left carotid endarterectomy with endovascular patch angioplasty.  Critical left carotid stenosis.  The external carotid artery was occluded at its origin.  When the endarterectomy was performed, the external carotid artery back-bled nicely.  The internal carotid artery had good backflow bleeding noted.

surgery, carotid stenosis, carotid endarterectomy, endovascular patch angioplasty, cervical block, carotid artery, common carotid artery, external carotid artery, endovascular patch, common carotid, external carotid, angioplasty, artery, endovascular, neurologically, carotid, stenosis, endarterectomy

The situation presented is highly technical and involves a surgical procedure addressing critical left carotid stenosis in a patient with chronic renal failure and chest pain. Carotid endarterectomy and angioplasty are significant surgical interventions aimed at preventing strokes by correcting artery stenosis. Given the patient's underlying conditions, such as critical arterial blockage and potential for coronary artery disease, this procedure is high-stakes, as it can prevent life-threatening events like stroke or cardiac incidents. Additionally, the complexity and invasiveness of the surgery increase its critical nature.


Medical Specialty: Surgery
Sample Name: Carious Teeth Extraction

PREOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth.,POSTOPERATIVE DIAGNOSIS: , Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32.,PROCEDURE: , Extraction of remaining teeth numbers 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, and 32.,ANESTHESIA:,  General, oral endotracheal.,COMPLICATIONS: , None.,CONDITION:,  Stable to PACU.,PROCEDURE:  Patient was brought to the operating room, placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia, the patient was prepped and draped in the usual fashion for an intraoral procedure.  Gauze throat pack was placed and local anesthetic was administered in the upper and lower left quadrants and extraction of teeth was begun on the upper left quadrant teeth numbers 9, 10, 11, 12, 13, 14, 15, and 16 were removed with elevators and forceps extraction.  Moving to the lower quadrant on the left side, tooth numbers 17, 18, 19, 20, 21, 22, 23, and 24 were removed with elevators and routine forceps extraction.  The flaps were then closed with 3-0 gut sutures and upon completion of the two quadrants on the left side, the endotracheal tube was then relocated from the right side to the left side for access to the quadrants on the right.  Teeth numbers 2, 3, 4, 5, 7, and 8 were then removed with elevators and routine forceps extraction.  It was noted that tooth #6 was missing, could not be seen whether tooth #6 was palately impacted, but the tooth was not encountered.  On the lower right quadrant, teeth numbers 25, 26, 27, 28, 29, 30, and 31 were removed with elevators and routine forceps extraction.  Tooth #32 was partially bony impacted, but exposed, so it was removed by removing bone on buccal aspect with high-speed drill with a round bur.  Tooth was then luxated from the socket.  The flaps were then closed on both quadrants with 3-0 gut sutures.  The area was irrigated thoroughly with normal saline solution and a total of 8.5 mL of lidocaine 2% with 1:100, 000 epinephrine and 3.6 mL of bupivacaine 0.5% with epinephrine 1:200, 000.  Upon completion of the procedure, the throat pack was removed.  The pharynx was suctioned.  An oral gastric tube was passed and small amount of stomach contents were suctioned.  The patient was then extubated and taken to PACU in stable condition.
---
DESCRIPTION: Carious teeth and periodontal disease affecting all remaining teeth and partial bony impacted tooth #32. Extraction of teeth.

surgery, intraoral procedure, partial bony impacted tooth, teeth extraction, forceps extraction, periodontal disease, carious teeth, periodontal, carious

The procedure described involves the extraction of multiple carious and periodontally affected teeth, as well as a partially bony impacted tooth. While it involves general anesthesia, which always carries some degree of risk, the procedure was completed without complications, and the patient's condition was stable post-operation. Extracting multiple teeth and managing impacted teeth are routine but significant dental procedures. The stakes are moderate, as the patient needs to be monitored closely for potential postoperative complications related to anesthesia or wound healing, but no immediate life-threatening risks were encountered during the surgery.


Medical Specialty: Surgery
Sample Name: Carpal Tunnel Release - 1

PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,TITLE OF THE PROCEDURE: , Right carpal tunnel release.,COMPLICATIONS:,  There were no complications during the procedure.,SPECIMEN:  ,The specimen was sent to pathology.,INSTRUMENTS: , All counts were correct at the end of the case and no complications were encountered.,INDICATIONS:  ,This is a 69-year-old female who have been complaining of right hand pain, which was steadily getting worse over a prolonged period of time.  The patient had tried nonoperative therapy, which did not assist the patient.  The patient had previous diagnosis of carpal tunnel and EMG showed compression of the right median nerve.  As a result of these findings, the patient was sent to my office presenting with this history and was carefully evaluated.  On initial evaluation, the patient had the symptomology of carpal tunnel syndrome.  The patient at the time had the risks, benefits, and alternatives thoroughly explained to her.  All questions were answered.  No guarantees were given.  The patient had agreed to the surgical procedure and the postoperative rehabilitation as needed.,DETAILS OF THE PROCEDURE:  ,The patient was brought to the operating room, placed supine on the operating room table, prepped and draped in the sterile fashion and was given sedation.  The patient was then given sedation.  Once this was complete, the area overlying the carpal ligament was carefully injected with 1% lidocaine with epinephrine.  The patient had this area carefully and thoroughly injected with approximately 10 mL of lidocaine with epinephrine and once this was complete, a 15-blade knife was then used to incise the skin opposite the radial aspect of the fourth ray.  Careful dissection under direct visualization was performed through the subcutaneous fat as well as through the palmar fascia.  A Weitlaner retractor was then used to retract the skin and careful dissection through the palmar fascia would then revealed the transverse carpal ligament.  This was then carefully incised using a 15-blade knife and once entry was again into the carpal canal, a Freer elevator was then inserted and under direct visualization, the carpal ligament was then released.  The transverse carpal ligament was carefully released first in the distal direction until palmar fat could be visualized and by palpation no further ligament could be felt.  The area was well hemostased with the 1% lidocaine with epinephrine and both proximal and distal dissection along the nerve was performed.  Visualization of the transverse carpal ligament was maintained with Weitlaner retractor as well as centric.  Both the centric and the Ragnell were used to retract both proximal and distal corners of the incision and the entirety of the area was under direct visualization at all times.  Palmar fascia was released both proximally and distally as well as the transverse carpal ligament.  Direct palpation of the carpal canal demonstrated a full and complete release.  Observation of the median nerve revealed an area of hyperemia in the distal two-thirds of the nerve, which demonstrated the likely area of compression.  Once this was complete, hemostasis was established using bipolar cautery and some small surface bleeders and irrigation of the area was performed and then the closure was achieved with 4-0 chromic suture in a horizontal mattress and interrupted stitch.  Xeroform was then applied to the incision.  A bulky dressing was then applied consisting of Kerlix and Ace wrap, and the patient was taken to the recovery room in stable condition without any complications.
---
DESCRIPTION: Right carpal tunnel release.

Right carpal tunnel release.

surgery, carpal tunnel syndrome, ace wrap, emg, freer elevator, kerlix, weitlaner retractor, bulky dressing, carpal tunnel, carpal tunnel release, palmar fascia, subcutaneous fat, lidocaine with epinephrine, transverse carpal ligament, carpal ligament, carpal, tunnel, ligament,

The situation involves a surgical procedure for carpal tunnel release, which is generally considered a routine and low-risk surgery. The procedure was completed without complications, and the patient was in stable condition afterward. While all surgeries carry some degree of risk, this particular type is not considered high-stakes compared to other more invasive or emergency surgeries.


Medical Specialty: Surgery
Sample Name: Cardioversion

HISTORY: , The patient is an 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation who was admitted yesterday with the recurrence of such in a setting of hypokalemia, incomplete compliance with obstructive sleep apnea therapy with CPAP, chocolate/caffeine ingestion and significant mental stress.  Despite repletion of her electrolytes and maintenance with Diltiazem IV she has maintained atrial fibrillation.  I have discussed in detail with the patient regarding risks, benefits, and alternatives of the procedure.  After an in depth discussion of the procedure (please see my initial consultation for further details) I asked the patient this morning if she would like me to repeat that as that discussion had happened yesterday.  The patient declined.  I invited questions for her which she stated she had none and wanted to go forward with the cardioversion which seemed appropriate.,PROCEDURE NOTE: , The appropriate time-out procedure was performed as per Medical Center protocol including proper identification of the patient, physician, procedure, documentation, and there were no safety issues identified by myself nor the staff.  The patient participated actively in this.  She received a total of 4 mg of Versed then and 50 micrograms of fentanyl with utilizing titrated conscious sedation with good effect.  She was placed in the supine position and hands free patches had previously been placed in the AP position and she received one synchronized cardioversion attempt after Diltiazem drip had been turned off with successful resumption of normal sinus rhythm.  This was confirmed on 12 lead EKG.,IMPRESSION/PLAN: , Successful resumption of normal sinus rhythm from recurrent atrial fibrillation.  The patient's electrolytes are now normal and that will need close watching to avoid hypokalemia in the future, as well as she has been previously counseled for strict adherence to sleep apnea therapy with CPAP and perhaps repeat sleep evaluation would be appropriate to titrate her settings, as well as avoidance of caffeine ingestion including chocolate and minimization of mental stress.  She will be discharged on her usual robust AV nodal antiarrhythmic therapy with sotalol 80 mg p.o. b.i.d., metoprolol 50 mg p.o. b.i.d., Diltiazem CD 240 mg p.o. daily and digoxin 0.125 mg p.o. daily and to be clear she does have a permanent pacemaker implanted.  She will follow-up with her regular cardiologist, Dr. X, for whom I am covering this weekend.,This was all discussed in detail with the patient, as well as her granddaughter with the patient's verbal consent at the bedside.
---
DESCRIPTION: Cardioversion.  An 86-year-old woman with a history of aortic valve replacement in the past with paroxysmal atrial fibrillation

surgery, atrial fibrillation, aortic valve, paroxysmal, normal sinus rhythm, sinus rhythm, cpap, cardioversion, fibrillation, atrial,

The situation involves performing a cardioversion procedure on an 86-year-old woman with a complex medical history, including aortic valve replacement and paroxysmal atrial fibrillation. Cardioversion is a procedure that can have significant risks, particularly in elderly patients with multiple co-morbidities. The procedure was successful in restoring normal sinus rhythm, indicating the high stakes nature of the situation due to the patient's age, complex medical history, and the immediate risks associated with both the procedure and her condition. Appropriate discussions with the patient and her granddaughter about the risks and benefits further underscore the seriousness of the decision-making involved.


Medical Specialty: Surgery
Sample Name: Cardiac Catheterization - 6

PRECATHETERIZATION DIAGNOSIS (ES):, Hypoplastic left heart, status post Norwood procedure and Glenn shunt.,POSTCATHETERIZATION DIAGNOSIS (ES):,1. Hypoplastic left heart.,A. Status post Norwood.,B. Status post Glenn.,2. Left pulmonary artery hypoplasia.,3. Diminished right ventricular systolic function.,4. Trivial neo-aortic stenosis.,5. Trivial coarctation.,6. Flow to right upper lobe more than left upper lobe from collaterals arising from branches of the aortic arch.,PROCEDURE (S):, Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.,I. PROCEDURES:, XXXXXX was brought to the catheterization lab and was anesthetized by anesthesia. He was intubated. His supplemental oxygen was weaned to 24%, on which all of his hemodynamics were obtained. The patient was prepped and draped in the routine sterile fashion, including both groins and the right neck. Xylocaine was administered in the right femoral area. A 6-French sheath was introduced into the right femoral vein percutaneously without complication. A 4-French sheath was introduced into the right femoral artery percutaneously without complication. A 4-French pigtail catheter was introduced and passed to the abdominal aorta.,Dr. Hayes, using the SiteRite device, introduced a 5-French sheath into the right internal jugular vein without complication.,A 5-French wedge catheter was introduced through the sheath in the right internal jugular vein and was passed to the left pulmonary artery and further to the left pulmonary capillary wedge position. This catheter would not pass to the right pulmonary artery. The wedge catheter was removed. A 5-French IMA catheter was then introduced and passed to the right pulmonary artery. After right pulmonary artery pressure was measured, this catheter was removed.,The 5 wedge catheter was advanced through the right femoral sheath and was passed to the following chambers or vessels: Inferior vena cava, right atrium, left atrium, and right ventricle.,The previously introduced 4 pigtail catheter was advanced to the ascending aorta. Simultaneous right ventricular and ascending aortic pressures were measured. A pullback from ascending aorta to descending aorta was then performed. Simultaneous measurements of right ventricular and descending aortic pressures were measured.,The wedge catheter was removed. A 5-French Berman catheter was advanced down the Glenn shunt to the right pulmonary artery, where a pullback from right pulmonary artery to Glenn shunt was performed. An injection was then performed using Omnipaque 16 mL at 8 mL per second with the Berman catheter positioned in the Glenn shunt. The 5-French Berman was removed.,A 6-French Berman was introduced through the right femoral vein sheath and was advanced to the right ventricle. A right ventriculogram was performed using Omnipaque 18 mL at 12 mL per second. The Berman catheter was pulled back to the inferior vena cava, where an inferior vena cavagram was performed using Omnipaque 10 mL at 8 mL per second.,The 4-French pigtail catheter was advanced to the ascending aorta and an ascending aortogram was performed using Omnipaque 16 mL at 12 mL per second.,Following the ascending angiograms, two kidneys and a bladder were noted. The catheters and sheaths were removed, and hemostasis was obtained by direct pressure. The estimated blood loss was less than 30 mL, and none was replaced. Heparin was administered following placement of all of the sheaths. Pulse oximetry saturation, pulse in the right foot, and EKG were monitored continuously.,II. PRESSURES:,A. Left pulmonary artery, mean of 11; left capillary wedge, mean of 9; main pulmonary artery, mean of 12; right pulmonary artery, mean of 10; descending aorta, 75/45, mean of 57; right atrium, A6 to 9, V6 to 8, mean 7; left atrium, mean 8; inferior vena cava, mean 7.,B. Ascending aorta, 65/35, with a simultaneous right ventricular pressure of 70/10; descending aorta, 60/35, with a right ventricular pressure of 72/10.,C. Pullbacks, left pulmonary artery to main pulmonary artery, mean of 11 to mean of 12; main pulmonary artery to Glenn, mean of 12 to mean of 13; right pulmonary artery to Glenn, mean of 12 to mean of 13; ascending aorta 68/35 to descending aorta 62/35.,INTERPRETATION:, Right and left pulmonary artery pressures are appropriate for this situation. There is a gradient of, at most, 2 mmHg on pullback from both the right and left pulmonary arteries to the Glenn shunt. The left atrial mean pressure is normal. Right ventricular end-diastolic pressure is, at most, slightly elevated. There is a trivial gradient between the right ventricle and ascending aorta consistent with trivial neo-aortic valve stenosis. There is a roughly 10-mm gradient between the right ventricle and descending aorta, consistent with additional coarctation of the aorta. On pullback from ascending to descending aorta, there is a 6-mmHg gradient between the two. Systemic blood pressure is normal.,III. OXIMETRY:, Superior vena cava 65, right pulmonary artery 67, left pulmonary artery 65, left atrium 96, right atrium 87, inferior vena cava 69, aorta 86, right ventricle 83.,INTERPRETATION:, Systemic arteriovenous oxygenation difference is normal, consistent with a normal cardiac output. Left atrial saturation is fairly normal, consistent with normal oxygenation in the lungs. The saturation falls passing from the left atrium to the right atrium and further to the right ventricle, consistent with mixing of pulmonary venous return and inferior vena cava return, as would be expected in this patient.,IV. SPECIAL PROCEDURE (S):, None done.,V. CALCULATIONS:,Please see the calculation sheet. Calculations were based upon an assumed oxygen consumption. The _____ saturation used was 67%, with a pulmonary artery saturation of 65%, a left atrial saturation of 96%, and an aortic saturation of 86%. Using the above information, the pulmonary to systemic flow ratio was 0.6. Systemic blood flow was 5.1 liters per minute per meter squared. Pulmonary blood flow was 3.2 liters per minute per meter squared. Systemic resistance was 9.8 Wood's units times meter squared, which is mildly diminished. Pulmonary resistance was 2.5 Wood's units times meter squared, which is in the normal range.,VI. ANGIOGRAPHY:, The injection to the Glenn shunt demonstrates a wide-open Glenn connection. The right pulmonary artery is widely patent, without stenosis. The proximal portion of the left pulmonary artery is significantly narrowed, but does open up near its branch point. The right pulmonary artery measures 6.5, the left pulmonary artery measures 3.0 mm. The aorta at the diaphragm on a later injection was 5.5 mm. There is a small collateral off the innominate vein passing to the left upper lobe. Flow to both upper lobes is diminished versus lower lung fields. There is normal return of the pulmonary veins from the right, with simultaneous filling of the left atrium and right atrium. There is normal return of the left lower pulmonary vein and left upper pulmonary vein. There is some reflux of dye into the inferior vena cava from the right atrium.,The right ventriculogram demonstrates a heavily pedunculated right ventricle with somewhat depressed right ventricular systolic function. The calculated ejection fraction from the LAO projection is only mildly diminished at 59%. There is no significant tricuspid regurgitation. The neo-aortic valve appears to open well with no stenosis. The ascending aorta is dilated. There is mild narrowing of the aorta at the isthmal area. On some projections, there appears to be a partial duplication of the aortic arch, probably secondary to this patient's style of Norwood reconstruction. There is some filling of the right upper and left upper lobes from collateral blood flow, with the left being more opacified than the right.,The inferior vena cavagram demonstrates normal return of the inferior vena cava to the right atrium.,The ascending aortogram demonstrates trivial aortic insufficiency, which is probably catheter-induced. The coronary arteries are poorly seen. Again, a portion of the aorta appears to be partially duplicated. There is faint opacification of the left upper lung from collateral blood flow. The above-mentioned narrowing of the aortic arch is again noted.
---
DESCRIPTION: Right heart and left heart catheterization by way of right femoral artery, right femoral vein, and right internal jugular vein.

The scenario involves cardiac catheterization in a patient with a complex congenital heart condition (Hypoplastic Left Heart Syndrome) who has undergone significant surgical interventions (Norwood procedure and Glenn shunt). This procedure is crucial for assessing the heart's current function and any present complications, as it can provide essential data guiding future medical decisions and interventions. Any potential issues during the procedure, such as complications related to the heart pressure and blood saturation measurements, could have serious consequences for the patient's health. Therefore, the stakes are inherently high in this medical situation.


Medical Specialty: Surgery
Sample Name: Cardiac Catheterization - 7

INDICATIONS FOR PROCEDURE:, The patient has presented with crushing-type substernal chest pain, even in the face of a normal nuclear medicine study. She is here for catheterization.,APPROACH:, Right common femoral artery.,ANESTHESIA:, IV sedation per cardiac catheterization protocol. Local sedation with 1% Xylocaine.,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Less than 10 mL.,ESTIMATED CONTRAST:, Less than 150 mL.,PROCEDURES PERFORMED:, Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.,OPERATIVE TECHNIQUE:, The patient was brought to the cardiac catheterization lab in the usual fasting state. She was placed supine on the cardiac catheterization table and the right groin was prepped and draped in the usual sterile fashion. One percent Xylocaine was infiltrated into the right femoral vessels. Next, a #6 French sheath was then placed in the right common femoral artery by the modified Seldinger technique.,SELECTIVE CORONARY ARTERIOGRAPHY:, Next, right and left Judkins diagnostic catheters were advanced through their respective ostia and injected in multiple views.,LEFT VENTRICULOGRAM:, Next, a pigtail catheter was advanced across the aortic valve and left ventricular pressure recorded. Next, an LV-gram was then performed with a hand injection of 50 mL of contrast. Next, pull-back pressure was measured across the aortic valve.,AORTA ARCH ANGIOGRAM:, Next, aortic arch angiogram was then performed with injection of 50 mL of contrast at a rate of 20 mL/second to maximum pressure of 750 PSI performed in the 40-degree LAO view.,Next, right iliofemoral angiogram was performed in the 20-degree RAO view. Next Angio-Seal was applied successfully.,The patient left the cath lab without problems or issues.,DIAGNOSES:, Left ventricular end-diastolic pressure was 18 mmHg. There was no gradient across the aortic valve. The central aortic pressure was 160 mmHg.,LEFT VENTRICULOGRAM:, The left ventriculogram demonstrated normal LV systolic function with estimated ejection fraction greater than 50%.,AORTIC ARCH ANGIOGRAM: ,The aortic arch angiogram demonstrated normal aortic arch. No aortic regurgitation was seen.,SELECTIVE CORONARY ARTERIOGRAPHY:, The right coronary artery is large and dominant.,The left main is patent.,The left anterior descending is patent.,The left circumflex is patent.,IMPRESSION:, This study demonstrates normal coronary arteries in the presence of normal left ventricular systolic function. In addition, the aortic root is normal.
---
DESCRIPTION: Left heart catheterization, left ventriculogram, selective coronary arteriography, aortic arch angiogram, right iliofemoral angiogram, #6 French Angio-Seal placement.

Cardiac catheterization is a critical procedure involving the examination of heart function and coronary arteries, often used to diagnose or rule out heart disease. It is a high-stakes procedure, as it directly relates to the cardiovascular health of a patient, and any complications can be life-threatening. In this specific case, the procedure was performed on a patient experiencing crushing substernal chest pain, which is a potential symptom of serious heart issues such as myocardial infarction. The stakes are high given the potential for significant cardiac events and the need for precise diagnosis and intervention. Fortunately, no complications occurred, but the nature of the procedure and the symptoms presented affirm its high-stakes classification.


Medical Specialty: Surgery
Sample Name: Cardiac Catheterization - 12

PREOPERATIVE DIAGNOSIS: , Coronary artery disease.,POSTOPERATIVE DIAGNOSIS: , Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.,DESCRIPTION OF PROCEDURE:,LEFT HEART CATHETERIZATION WITH ANGIOGRAPHY AND MID ABDOMINAL AORTOGRAPHY:,Under local anesthesia with 2% lidocaine with premedication, a right groin preparation was done.  Using the percutaneous Seldinger technique via the right femoral artery, a left heart catheterization was performed.  Coronary arteriography was performed with 6-French performed coronary catheters.  We used a 6-French JR4 and JL4 catheters to take multiple cineangiograms of the right and left coronary arteries.  After using the JR4 6-French catheter, nitroglycerin was administered because of the possibility of ostial spasm, and following that, we used a 5-French JR4 catheter for additional cineangiograms of the right coronary artery.  A pigtail catheter was placed in the mid abdominal aorta and abdominal aortic injection was performed to rule out abdominal aortic aneurysm, as there was dense calcification in the mid abdominal aorta.,ANALYSIS OF PRESSURE DATA: , Left ventricular end-diastolic pressure was 5 mmHg.  On continuous tracing from the left ventricle to the ascending aorta, there is no gradient across the aortic valve.  The aortic pressures were normal.  Contours of intracardiac pressure were normal.,ANALYSIS OF ANGIOGRAMS:,  Selective cineangiograms were obtained with injection of contrast to the left ventricle, coronary arteries, and mid abdominal aorta.  A pigtail catheter was introduced into the left ventricle and ventriculogram performed in right anterior oblique position.  The mitral valve is competent and demonstrates normal mobility.  The left ventricular cavity is normal in size with excellent contractility.  Aneurysmal dilatation and/or dyskinesia absent.  The aortic valve is tricuspid and normal mobility.  The ascending aorta appeared normal.,Pigtail catheter was introduced in the mid abdominal aorta and placed just above the renal arteries.  An abdominal aortic injection was performed.  Under fluoroscopy, we see heavy dense calcification of the mid abdominal aorta between the renal artery and the bifurcation.  There was some difficulty initially with maneuvering the wire pass that area and it was felt that might be a tight stenosis.  The abdominal aortogram reveals wide patency of that area with mild intimal irregularity.  There is a normal left renal artery, normal right renal artery.  The celiac seems to be normal, but what I believe is the splenic artery seen initially at its origin is normal.  The common left iliac and common right iliac arteries are essentially normal in this area.,CORONARY ANATOMY:,  One notes ostial coronary calcification of the right coronary artery.  Cineangiogram obtained with 6-French JR4 and 5-French JR4 catheters.  Prior to the introduction of the 5-French JR4 nitroglycerin was administered sublingually.  The 6-French JR4 catheters appeared to a show an ostial lesion of over 50%.  There was backwash of dye into the aorta, although there is a fine funneling of the ostium towards the proximal right coronary artery.  In the proximal portion of the right coronary artery just into the Shepherd turn, there is a 50% smooth tapering of the right coronary artery in the proximal third.  Then the artery seems to have a little bit more normal size and it divides into a large posterior descending artery posterolateral branch vessel.  The distal portion of the vessel is free of disease.  The conus branch is seen arising right at the beginning part of the right coronary artery.  We then removed the 6-French catheter and following nitroglycerin and sublingually we placed a 5-French catheter and again finding a stenosis, may be less than 50%.  At the ostium of the right coronary artery, calcification again is identified.  Backwash of dye noted at the proximal lesion, looked about the same 50% along the proximal turn of the Shepherd turn area.,The left coronary artery is normal, although there is a rim of ostial calcification, but there is no tapering or stenosis.  It forms the left anterior descending artery, the ramus branch, and the circumflex artery.,The left anterior descending artery is a very large vessel, very tortuous in its proximal segment, very tortuous in its mid and distal segment.  There appears to be some mild stenosis of 10% in the proximal segment.  It gives off a large diagonal branch in the proximal portion of the left anterior descending artery and it is free of disease.  The remaining portion of the left anterior descending artery is free of disease.  Upon injection of the left coronary artery, we see what I believe is the dye enters probably directly into the left ventricle, but via fistula excluding the coronary sinus, and we get a ventriculogram performed.  I could not identify an isolated area, but it seems to be from the interventricular septal collaterals that this is taking place.,The ramus branch is normal and free of disease.,The left circumflex artery is a tortuous vessel over the lateral wall and terminating in the inferoposterior wall that is free of disease.,The patient has a predominantly right coronary system.  There is no _______ circulation connecting the right and left coronary systems.,The patient tolerated the procedure well.  The catheter was removed.  Hemostasis was achieved.  The patient was transferred to the recovery room in a stable condition.,IMPRESSION:,1.  Excellent left ventricular contractility with normal left ventricular cavity size.,2.  Calcification of the mid abdominal aorta with wide patency of all vessels.  The left and right renal arteries are normal.  The external iliac arteries are normal.,3.  Essentially normal left coronary artery with some type of interventricular septal to left ventricular fistula.,4.  Ostial stenosis of the right coronary artery that appears to be about 50% or greater.  The proximal right coronary artery has 50% stenosis as well.,5.  Coronary calcification is seen under fluoroscopy at the ostia of the left and right coronary arteries.,RECOMMENDATIONS:  ,The patient has heavy calcification of the coronary arteries and continued risk factor management is needed.  The ostial lesion of the right coronary artery may be severe.  It is at least 50%, but it could be worse.  Therefore, she will be evaluated for the possibility of an IVUS and/or _______ analysis of the proximal right coronary artery.  We will reevaluate her stress nuclear study as well.  Continue aggressive medical therapy.
---
DESCRIPTION: Cardiac catheterization.   Coronary artery disease plus intimal calcification in the mid abdominal aorta without significant stenosis.

surgery, intimal calcification, stenosis, coronary artery disease, mid abdominal aorta, coronary artery, cardiac catheterization, coronary arteries, descending artery, calcification, mid, proximal, aorta, catheterization, abdominal, cardiac, intimal, coronary, artery,

This situation involves a cardiac catheterization procedure, which is an invasive diagnostic process used to assess coronary artery disease and other heart-related conditions. The report indicates the presence of coronary artery disease with significant calcification and a potential stenosis that may be more than 50%, which could have serious implications for the patient's health. The patient will require further evaluation, potentially an intravascular ultrasound (IVUS), to better understand the severity of the stenosis, and a reevaluation of their stress nuclear study. Additionally, aggressive medical therapy and risk factor management are recommended. Given the nature of the findings and the potential risk to the patient's health without appropriate follow-up and treatment, this is a high-stakes situation within a medical context. Mistakes or delays in further diagnosis or treatment could lead to significant cardiovascular events for the patient.


Medical Specialty: Surgery
Sample Name: Cardiac Catheterization - 4

PROCEDURES PERFORMED:,1. Left heart catheterization with coronary angiography and left ventricular pressure measurement.,2. Left ventricular angiography was not performed.,3. Right posterior descending artery percutaneous transluminal coronary angioplasty followed by stenting.,4. Right femoral artery angiography.,5. Perclose to seal the right femoral arteriotomy.,INDICATIONS FOR PROCEDURE:, Patient presenting with a history of coronary artery disease in the past with coronary angiography in the early 1990s. The patient presented with what appeared to be a COPD exacerbation and had mildly positive cardiac enzyme markers suggestive of a non-ST elevation myocardial infarction. He was subsequently dispositioned to the cardiac catheterization lab for further evaluation.,DESCRIPTION OF PROCEDURE:, After informed consent was obtained, the patient was taken to the cardiac catheterization lab, where his procedure was performed. The patient was appropriately prepped and prepared on the table, after which his right groin was locally anesthetized with 1% lidocaine. Then, a 6-French sheath was inserted into the right femoral artery. Over a standard 0.035 guidewire, coronary angiography and left ventricular pressure measurements were performed using a 6-French JL4 diagnostic catheter to image the left coronary artery, a 6-French JR4 diagnostic catheter to image the right coronary artery, a 6-French angled pigtail catheter to measure left ventricular pressure. At the conclusion of the diagnostic study, the case was progressed to percutaneous coronary intervention, which will be described below. Subsequently, right femoral artery angiography was performed which showed right femoral artery which was free of significant atherosclerotic plaque, and an arteriotomy that was suitable for a closure device. Then, a Perclose was used to seal the right femoral arteriotomy.,HEMODYNAMIC DATA:, The opening aortic pressure was 91/63. The left ventricular pressure was 94/13 with an end-diastolic pressure of 24. Left ventricular ejection fraction was not assessed, as ventriculogram was not performed. The patient did have some elevated creatinine earlier in this hospital course which warranted limitation of contrast where possible.,CORONARY ANGIOGRAM:, The left main coronary artery was angiographically okay. The LAD had mild diffuse disease. There appeared to be distal tapering of the LAD. The left circumflex had mild diffuse disease. In the very distal aspect of the circumflex after OM-3 and OM-4 type branch, there was a long, severely diseased segment that appeared to be chronic and subtotal in one area. The runoff from this area appeared to be a very small PLOM type branch and continuation of a circ which did not appear to supply much territory, and there was not much to salvage by approaching this lesion. The right coronary artery had mild diffuse disease. The PLV branch was 100% occluded at its ostium at the crux. The PDA at the ostium had an 80% stenosis. The PDA was a fairly sizeable vessel with a long course. The right coronary is dominant.,CONCLUSION:, Mild diffuse coronary artery disease with severe distal left circumflex lesion with not much runoff beyond this lesion. This circumflex appears to be chronically diseased and has areas that appear to be subtotal. There is a 100% PLV branch which is also chronic and reported in his angiogram in the 1990s. There is an ostial 80% right PDA lesion. The plan is to proceed with percutaneous intervention to the right PDA.,The case was then progressed to percutaneous intervention of the right PDA. A 6-French JR4 guide catheter with side holes was selected and used to engage the right coronary artery ostium. The lesion was crossed with a long BMW 0.014 guidewire. Then, we ballooned the lesion with a 2.5 x 9 mm Maverick balloon. Subsequently, we stented the lesion with a 2.5 x 16 mm Taxus drug-eluting stent with a nice angiographic result. The patient tolerated the procedure very well, without complications.,ANGIOPLASTY CONCLUSION:, Successful percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.,RECOMMENDATIONS:, Aspirin indefinitely, and Plavix 75 mg p.o. daily for no less than six months. The patient will be dispositioned back to telemetry for further monitoring.,TOTAL MEDICATIONS DURING PROCEDURE:, Versed 1 mg and fentanyl 25 mcg for conscious sedation. Heparin 8400 units IV was given for anticoagulation. Ancef 1 g IV was given for closure device prophylaxis.,CONTRAST ADMINISTERED:, 200 mL.,FLUOROSCOPY TIME:, 12.4 minutes.
---
DESCRIPTION: Percutaneous intervention with drug-eluting stent placement to the ostium of the PDA.

surgery, coronary angiography, ventricular pressure, coronary angioplasty, french, pda, drug-eluting stent, coronary artery disease, cardiac catheterization lab, plv branch, cardiac catheterization, femoral artery, coronary artery, artery, coronary, angioplasty, angiogram, angiographically, arteriotomy, angiography, cardiac, circumflex, ostium, ventricular, femoral, percutaneous, catheterization,

The situation involves a cardiac procedure, specifically a percutaneous transluminal coronary angioplasty followed by stenting, which is inherently high-stakes because it directly involves the heart. This procedure is performed to relieve symptoms of heart disease, such as chest pain, and to improve survival in certain patients with heart attacks. Additionally, the patient has a complex coronary artery disease history with previous interventions and multiple high-grade stenoses, which increases the risk profile of the procedure. Furthermore, the procedure deals with important cardiac vessels and any complications can have severe consequences for the patient's health and survival, thus overall providing a high-stakes context.


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

Medical Specialty: Surgery
Sample Name: Cardiac Cath & Selective Coronary Angiography

PREOPERATIVE DIAGNOSIS: , Post infarct angina.,TYPE OF PROCEDURE: , Left cardiac catheterization with selective right and left coronary angiography.,PROCEDURE: , After informed consent was obtained, the patient was brought to the Cardiac Catheterization Laboratory, and the groin was prepped in the usual fashion.  Using 1% lidocaine, the right groin was infiltrated, and using the Seldinger technique, the right femoral artery was cannulated.  Through this, a moveable guidewire was then advance to the level of the diaphragm, and through it, a 6 French pigtail catheter was advanced under hemodynamic monitoring to the ascending aorta and inserted into the left ventricle.  Pressure measurements were obtained and cineangiograms in the RAO and LAO positions were then obtained.  Catheter was then withdrawn and a #6 French non-bleed-back sidearm sheath was then introduced, and through this, a 6 French Judkins left coronary catheter was then advanced under hemodynamic monitoring to the left coronary ostium, engaged.  Cineangiograms were obtained of the left coronary system.  This catheter was then exchanged for a Judkins right 4 coronary catheter of similar dimension and under hemodynamic monitoring again was advanced to the right coronary ostium, engaged.  Cineangiograms were obtained, and the catheter and sheath were then withdrawn.  The patient tolerated the procedure well and left the Cardiac Catheterization Laboratory in stable condition.  No evidence of hematoma formation or active bleeding.  ,COMPLICATIONS: , None.  ,TOTAL CONTRAST: , 110 cc of Hexabrix.  ,TOTAL FLUOROSCOPY TIME:  ,1.8 minutes.  ,MEDICATIONS: , Reglan 10 mg p.o., 5 mg p.o.  Valium, Benadryl 50 mg p.o. and heparin 3,000 units IV push.
---
DESCRIPTION: Left cardiac catheterization with selective right and left coronary angiography.   Post infarct angina.

surgery, selective, angiography, post infarct angina, engaged cineangiograms, coronary angiography, hemodynamic monitoring, cardiac catheterization, catheterization, cineangiograms, cardiac, coronary,

The sample details a cardiac catheterization procedure, which is a medically significant and moderately invasive diagnostic or therapeutic procedure. The stakes are considered high because it involves the heart and significant blood vessels, with potential risks such as bleeding, hematoma, or other complications despite its frequent and routine nature in the clinical setting. However, the presence of informed consent, stable condition of the patient post-procedure, and absence of complications in this case slightly lower the stakes compared to more complex or emergency surgical interventions.


Medical Specialty: Surgery
Sample Name: CABG - Redo

OPERATIVE PROCEDURE:,1.  Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.,2.  Placement of a right femoral intraaortic balloon pump.,DESCRIPTION: , The patient was brought to the operating room and placed in the supine position.  After adequate endotracheal anesthesia was induced, appropriate monitoring lines were placed.  Chest, abdomen an legs were prepped and draped in sterile fashion.  The femoral artery on the right was punctured and a guidewire was placed.  The track was dilated and intraaortic balloon pump was placed in the appropriate position, sewn in place and ballooning started.,The left greater saphenous vein was harvested from the groin to the knee and prepared by ligating all branches with 4-0 silk and flushed with vein solution.  The leg was closed with running 3-0 Dexon subcu and running 4-0 Dexon on the skin.,The old mediastinal incision was opened.  The wires were cut and removed.  The sternum was divided in the midline.  Retrosternal attachments were taken down.  The left internal mammary was dissected free from its takeoff at the left subclavian bifurcation at the diaphragm and surrounded with papaverine-soaked gauze.  The heart was dissected free of its adhesions.  The patient was fully heparinized and cannulated with a single aorta and single venous cannula.  Retrograde cardioplegia cannula was attempted to be placed, but could not be fitted into the coronary sinus safely, therefore, it was banded and oversewn with 5-0 Prolene.  An antegrade cardioplegia needle sump was placed and secured to the ascending aorta.  Cardiopulmonary bypass ensued.  The ascending aorta was cross clamped.  Cold-blood potassium cardioplegia was given antegrade, a total of 10 cc/kg.  It was followed by sumping the ascending aorta.  The obtuse marginal was identified and opened and an end-to-side anastomosis was performed with a running 7-0 Prolene suture.  The vein was cut to length.  Antegrade cardioplegia was given, a total of 200 cc.  The posterior descending branch of the right coronary artery was identified, opened and end-to-side anastomosis then performed with a running 7-0 Prolene suture.  The vein was cut to length.  Antegrade cardioplegia was given.  The mammary was clipped distally, divided and spatulated for anastomosis.  The anterior descending was identified, opened and end-to-side anastomosis then performed with running 8-0 Prolene suture and warm blood potassium cardioplegia was given.  The cross clamp was removed.  A partial-occlusion clamp was placed.  Aortotomies were made.  The vein was cut to fit these and sutured in place with running 5-0 Prolene suture.  The partial-occlusion clamp was removed.  All anastomoses were inspected and noted to be patent and dry.  Atrial and ventricular pacing wires were placed.  The patient was fully warmed and ventilation was commenced.  The patient was weaned from cardiopulmonary bypass, ventricular balloon pumping and inotropic support and weaned from cardiopulmonary bypass.  The patient was decannulated in routine fashion.  Protamine was given.  Good hemostasis was noted.  A single mediastinal chest tube and bilateral pleural Blake drains were placed.  The sternum was closed with figure-of-eight stainless steel wire.  The linea alba was closed with figure-of-eight of #1 Vicryl, the sternal fascia closed with running #1 Vicryl, the subcu closed with running 2-0 Dexon, skin with running 4-0 Dexon subcuticular stitch.  The patient tolerated the procedure well.
---
DESCRIPTION: Redo coronary bypass grafting x3, right and left internal mammary, left anterior descending, reverse autogenous saphenous vein graft to the obtuse marginal and posterior descending branch of the right coronary artery.  Total cardiopulmonary bypass, cold-blood potassium cardioplegia, antegrade for myocardial protection.  Placement of a right femoral intraaortic balloon pump.

surgery, coronary bypass grafting, internal mammary, cardiopulmonary, intraaortic, femoral artery, cabg, running prolene suture, intraaortic balloon, balloon pump, ascending aorta, prolene suture, cardiopulmonary bypass, potassium, aorta, anastomosis, prolene, coronary, cardioplegia, bypass,

The description outlines a complex surgical procedure: a redo coronary artery bypass grafting (CABG), which involves significant risk given that it is a repeat surgery. The stakes are inherently high due to the nature of cardiac surgery, the use of cardiopulmonary bypass, and potential complications that can arise from operating on the heart, especially with previous surgical interventions. Additionally, the placement of an intra-aortic balloon pump indicates the patient's condition and potential hemodynamic instability, adding to the urgency and complexity of the procedure. Therefore, the situation involves substantial risks and is high-stakes.


Medical Specialty: Surgery
Sample Name: Bunionectomy & Arthrodesis

PREOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammer toe, right foot, second, third, fourth and fifth toes.,3.  Tailor's bunionette, right foot.,4.  Degenerative joint disease, right first metatarsophalangeal joint.,5.  Rheumatoid arthritis.,6.  Contracted fourth right metatarsophalangeal joint.,POSTOPERATIVE DIAGNOSES:,1.  Hallux abductovalgus, right foot.,2.  Hammer toe, right foot, second, third, fourth and fifth toes.,3.  Tailor's bunionette, right foot.,4.  Degenerative joint disease, right first metatarsophalangeal joint.,5.  Rheumatoid arthritis.,6.  Contracted fourth right metatarsophalangeal joint.,PROCEDURES PERFORMED:,1.  Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.,2.  Arthrodesis, right second, third, and fourth toes with external rod fixation.,3.  Hammertoe repair, right fifth toe.,4.  Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.,5.  Modified Tailor's bunionectomy, right fifth metatarsal.,ANESTHESIA:,  TIVA/local.,HISTORY:,  This 51-year-old female presented to ABCD preoperative holding area after keeping herself NPO since mid night for surgery on her painful right foot bunion, hammer toes, and Tailor's bunion.  The patient has a long history of crippling severe rheumatoid arthritis.  She has pain with shoe gear and pain with every step.  She has tried multiple conservative measures under Dr. X's supervision consisting of wide shoe's and accommodative padding all which have provided inadequate relief.  At this time, she desires attempted surgical reconstruction/correction.  The consent is available on the chart for review and the risks versus benefits of this procedure have been discussed with patient in detail by Dr. X.,PROCEDURE IN DETAIL: , After IV was established by the Department of Anesthesia, the patient was taken to the operating room via cart and placed on the operating table in a supine position and a safety strap was placed across her waist for her protection.  Next, copious amounts of Webril were applied about the right ankle and a pneumatic ankle tourniquet was applied over the Webril.  Next, after adequate IV sedation was administered by the Department of Anesthesia, a total of 20 cc of 1:1 mixture of 0.5% Marcaine plain and 1% lidocaine were instilled into the right foot using a standard ankle block technique.  Next, the foot was prepped and draped in the usual aseptic fashion.  An Esmarch bandage was used to exsanguinate the foot and the pneumatic ankle tourniquet was elevated to 230 mmHg.  The foot was lowered in the operative field.  The sterile stockinette was reflected and attention was directed to the right first metatarsophalangeal joint.  The joint was found to be severely contracted with lateral deviation of the hallux with a slightly overlapping contracted second toe.  In addition, the range of motion was less than 5 degrees of the first ray.  There was medial pinch callus and callus on the plantar right second metatarsal.  Using a #10 blade, a linear incision over the first metatarsophalangeal joint was then created approximately 4 cm in length.  Next, a #15 blade was used to deepen the incision to the subcutaneous tissue all which was found to be very thin taking care to protect the medial neurovascular bundle and the lateral extensor hallucis longus tendon.  Any small vein traversing the operative site were clamped with hemostat and ligated with electrocautery.  Next, the medial and lateral wound margins were undermined with sharp dissection.  The joint capsule was then visualized.  Two apparent soft tissue masses probably consistent with rheumatoid nodules were found at the distal medial aspect of the first metatarsal capsule.  A dorsal linear incision to the capsular tissue down to bone was performed with a #15 blade.  The capsule and periosteal tissues were elevated sharply off the metatarsal head and the base of proximal  phalanx.,A large amount of hypertrophic synovium was encountered over the metatarsophalangeal joint.  In addition, multiple hypertrophic exostosis were found dorsally, medially, and laterally over the metatarsal.  Upon entering the joint, the base of the proximal phalanx was grossly deformed and the medial and lateral aspect were widely flared and encompassing the metatarsal head.  A sagittal saw was used to carefully remove the base of the proximal phalanx just distal to the metaphyseal flare.  Next, the bone was passed out as specimen.  The head of the metatarsal had evidence of erosion and eburnation.  The tibial sesamoid was practically absent, but was found to be a conglomeration of hypertrophic synovium and poorly differentiated appearing exostosis and bony tissue.  This was hindering the range of motion of the joint and was removed.  The fibular sesamoid was in the interspace.  A lateral release was performed in addition.  Next, the McGlamry elevators were inserted into the first metatarsal head and all of the plantar adhesions were freed.  The metatarsal head was remodeled with a sagittal saw and all of the medial eminence the dorsal and lateral hypertropic bone was removed and the metatarsal head was shaped into more acceptable contoured structure.  Next, the Biopro sizer was used and it was found that a median large implant would be the best fit for this patient's joint.  A small drill hole was made in the central aspect at the base of the proximal phalanx.  The trial sizer median large was placed in the joint and an excellent fit and increased range of motion was observed.,Next, the joint was flushed with copious amounts of saline.  A median large porous Biopro implant was inserted using the standard technique and was tapped with the mallet into position.  It had an excellent fit and the range of motion again was markedly increased from the preoperative level.  Next, the wound was again flushed with copious amounts of saline.  The flexor tendon was inspected and was found to be intact plantarly.  A #3-0 Vicryl was used to close the capsule in a running fashion.  A medial capsulorrhaphy performed and the toe assumed to more rectus position and the joint was more congruous.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  Next, the skin was closed with #5-0 Monocryl in a running subcuticular fashion.,Attention was directed to the right second toe, which was found to be markedly contracted and rigid in nature.  There was a clavus in the dorsal aspect of the head of the proximal phalanx noted.  A linear incision was made over the proximal phalanx approximately 2 cm in length.  The incision was deepened with #15 blade down to the subcutaneous tissue.  Next, the medial and lateral aspects of the wound were undermined with sharp dissection taking care to protect the neurovascular structures.,Next, after identifying the extensor expansion and long extensor tendon, a #15 blade was used to transect the tendon at the level of the joint.  The tendon was peeled off sharply, proximally, and distally.  The medial and lateral collateral ligaments were released and the head of the proximal phalanx was delivered into the wound.  The bone was found to be extremely soft in the toe joints and the head of the proximal phalanx was oddly shaped and the cartilage was eroded.  The base of the middle phalanx, however, had a normal-appearing cartilage.  A sagittal saw was used to transect the head of the proximal phalanx just proximal to metaphyseal flare.  Next, the base of the middle phalanx was also resected.  A 0.045 inch Kirschner wire was retrograded out at the end of the toe and then back through the residual proximal phalanx shaft.  The toe assumed a straight and markedly increased straight position.  An extensor hood resection was performed to assist in keeping the proximal phalanx plantar flexed.  The joint was flushed with copious amounts of saline.  A #3-0 Vicryl was used to reapproximate the tendon after arthrodesis.  A #4-0 nylon was used to close the skin with a combination of simple interrupted and horizontal mattress suture technique.  The wire was cut, capped, and bent in the usual fashion.,Attention was directed to the right third toe where an exact same procedure as performed in the second digit was repeated.  The same suture material was used and the same 0.045 Kirschner wire was used for external wire fixation.,Attention was directed to the right fourth toe with exact same procedure was repeated.  The same suture material was used.  However, a 0.062 Kirschner wire was used to fixate the arthrodesis site as the bone was very soft and a 0.045 Kirschner wire was attempted but was found to be slipping in the soft bone and was inadequately holding the arthrodesis site tight.  Next, attention was directed to the fifth digit, which was found to be contracted as well.  A linear incision was made over the proximal phalanx with a #10 blade approximately 2 cm in length.  A #15 blade was used to deepen the incision to the subcutaneous tissue down to the level of the long extensor tendon, which was identified and transected.  The medial and lateral collateral ligaments were transected and the head of the proximal phalanx was delivered into the wound.  A sagittal saw was used to resect the head of the proximal phalanx just proximal to metaphyseal flare.  The toe assumed to more rectus position.  The reciprocating rasp was used to smooth the all bony surfaces.  The joint was again flushed with saline.  Next, the long extensor tendon was reapproximated with #3-0 Vicryl in a simple interrupted technique.  The skin was closed with #4-0 nylon in a simple interrupted technique.,Next, attention was directed to the fifth metatarsal head, which was found to have a lateral exostosis and bursa under the skin.  A #10 blade was used to make a 2.5 cm dorsal incision over the fifth metatarsal head.  The incision was deepened with a #15 blade to the subcutaneous tissue.  Any small vein traversing subcutaneous layer were ligated with electrocautery.  Care was taken to avoid abductor digiti minimi tendon and extensor digitorum longus tendon respectively.  Next, the dorsal linear capsular incision was made down to the bone with a #15 blade.  The capsular and periosteal tissues were elevated off the bone with a #15 blade and the metatarsal head was delivered into the wound.  Hypertrophic bone was noted to be found dorsally and laterally as well as plantarly.  A sagittal saw was used to resect all hypertrophic bone.  A reciprocating rasp was used to smooth all bony surfaces.  Next, the wound was flushed with copious amounts of saline.  The capsular and periosteal tissues wee closed with #3-0 Vicryl in a simple interrupted technique.  Next, the subcutaneous layer was closed with #4-0 Vicryl in a simple interrupted technique.  A bursa which was found consisting of a white glistening hypertrophic synovium was removed and sent as specimen as was also found in two of the second and third digit in the above procedures.  The skin was closed with #5-0 Monocryl in a running subcuticular fashion.  The ______ was reinforced with horizontal mattress sutures with #5-0 Monocryl.  Attention was directed to the fourth metatarsophalangeal joint where the joint was found to be contracted and the proximal phalanx was still found to be elevated.  Therefore, a #15 blade was used to make a stab incision over the joint lateral to the extensor digitorum longus tendon.  The tendon was transected.  Next, a blade was inserted in the dorsal, medial, and lateral aspects of the metatarsophalangeal joint and tenotomy was performed.  Next, the proximal phalanx residual bone was plantar flexed and found to assume a more rectus position.  One #4-0 nylon suture was placed in the skin.,Mastisol tape was applied to the first metatarsal and fifth metatarsal postoperative wounds.  Betadine-soaked Owen silk was applied to all wounds.  Betadine-soaked 4 x 4 splints were applied to all toes.  The pneumatic ankle tourniquet was released and immediate hyperemic flush was noted to all digits.  All the wires have previously been bent and cut and all were capped.  A standard postoperative consisting of 4x4s, Kling, Kerlix, and Coban were applied.  The patient tolerated the above anesthesia and procedure without complications.  She was transported via cart to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  She was given prescription for Tylenol #3, #40 one to two p.o. q.4-6h. p.r.n. pain and Naprosyn 375 mg p.o. b.i.d. p.c.  She is to continue her rheumatoid arthritis drugs preoperatively prescribed by the rheumatologist.,She is to follow up with Dr. X in the office.  She was given emergency contact numbers and standard postoperative instructions.  She was given Darco OrthoWedge shoe and a pair of crutches.  She was discharged in stable condition.
---
DESCRIPTION: Bunionectomy, right foot with Biopro hemi implant, right first metatarsophalangeal joint.  Arthrodesis, right second, third, and fourth toes with external rod fixation.  Hammertoe repair, right fifth toe.  Extensor tenotomy and capsulotomy, right fourth metatarsophalangeal joint.  Modified Tailor's bunionectomy, right fifth metatarsal.

The surgical procedures described are complex and involve multiple interventions on the patient's foot due to significant deformities and complications associated with rheumatoid arthritis. These procedures, while common in orthopedic and podiatric surgery, carry significant risk due to the nature of surgery, especially in a patient with a chronic condition like rheumatoid arthritis. Risks include infection, improper healing, potential impact on mobility, and the overall recovery process. The stakes are high for the patient’s quality of life and physical function. However, in the context of surgery overall, while important, this does not reach the stakes of emergency or life-threatening surgeries.