Medical Specialty: Neurosurgery
Sample Name: Decompressive Laminectomy

PREOPERATIVE DIAGNOSIS: , T12 compression fracture with cauda equina syndrome and spinal cord compression.,POSTOPERATIVE DIAGNOSIS:,  T12 compression fracture with cauda equina syndrome and spinal cord compression.,OPERATION PERFORMED: , Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes Click'X System using 6.5 mm diameter x 40 mm length T11 screws and L1 screws, 7 mm diameter x 45 mm length.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  400 mL, replaced 2 units of packed cells.,Preoperative hemoglobin was less than 10.,DRAINS:,  None.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , With the patient prepped and draped in a routine fashion in the prone position on laminae support, an x-ray was taken and demonstrated a needle at the T12-L1 interspace.  An incision was made over the posterior spinous process of T10, T11, T12, L1, and L2.  A Weitlaner retractor was placed and cutting Bovie current was used to incise the fascia overlying the dorsal spinous process of T10, T11, T12, L1, and L2.  An additional muscular ligamentous attachment was dissected free bilaterally with cutting Bovie current osteotome and Cobb elevator.  The cerebellar retractors were placed in the wound and obvious deformation of the lamina particularly on the left side at T12 was apparent.  Initially, on the patient's left side, pedicle screws were placed in T11 and L1.  The inferior articular facet was removed at T11 and an awl placed at the proximal location of the pedicle.  Placement confirmed with biplanar coaxial fluoroscopy.  The awl was in appropriate location and using a pedicle finder under fluoroscopic control, the pedicle was probed to the mid portion of the body of T11.  A 40-mm Click'X screw, 6.5 mm diameter with rod holder was then threaded into the T11 vertebral body.,Attention was next turned to the L1 level on the left side and the junction of the transverse processes with the superior articular facet and intra-articular process was located using an AM-8 dissecting tool, AM attachment to the Midas Rex instrumentation.  The area was decorticated, an awl was placed, and under fluoroscopic biplanar imaging noted to be at the pedicle in L1.  Using a pedicle probe, the pedicle was then probed to the mid body of L1 and a 7-mm diameter 45-mm in length Click'X Synthes screw with rod holder was placed in the L1 vertebral body.,At this point, an elongated rod was placed on the left side for purposes of distraction should it be felt necessary in view of the MRI findings of significant compression on the patient's ventral canal on the right side.  Attention was next turned to the right side and it should be noted that the dissection above was carried out with operating room microscope and at this point, the intraspinous process ligament superior to the posterior spinous process at T12 was noted be completely disrupted on a traumatic basis.  The anteroposterior spinous process ligament superior to the T12 was incised with cutting Bovie current and the posterior spinous process at T12 removed with a Leksell rongeur.  It was necessary to remove portion of the posterior spinous process at T11 for a full visualization of the involved laminar fractures at T12.,At this point, a laminectomy was performed using 45-degree Kerrison rongeur, both 2 mm and 4 mm, and Leksell rongeur.  There was an epidural hematoma encountered to the midline and left side at the mid portion of the T12 laminectomy and this was extending superiorly to the T11-T12 interlaminar space.  Additionally, there was marked instability of the facets bilaterally at T12 and L1.  These facets were removed with 45-degree Kerrison rongeur and Leksell rongeur.  Bony compression both superiorly and laterally from fractured bony elements was removed with 45-degree Kerrison rongeur until the thecal sac was completely decompressed.  The exiting nerve roots at T11 and T12 were visualized and followed with Frazier dissectors, and these nerve roots were noted to be completely free.  Hemostasis was controlled with bipolar coagulation.,At this point, a Frazier dissector could be passed superiorly, inferiorly, medially, and laterally to the T11-T12 nerve roots bilaterally, and the thecal sac was noted to be decompressed both superiorly and inferiorly, and noted to be quite pulsatile.  A #4 Penfield was then used to probe the floor of the spinal canal, and no significant ventral compression remained on the thecal sac.  Copious antibiotic irrigation was used and at this point on the patient's right side, pedicle screws were placed at T11 and L1 using the technique described for a left-sided pedicle screw placement.  The anatomic landmarks being the transverse process at T11, the inferior articulating facet, and the lateral aspect of the superior articular facet for T11 and at L1, the transverse process, the junction of the intra-articular process and the facet joint.,With the screws placed on the left side, the elongated rod was removed from the patient's right side along with the locking caps, which had been placed.  It was felt that distraction was not necessary.  A 75-mm rod could be placed on the patient's left side with reattachment of the locking screw heads with the rod cap locker in place; however, it was necessary to cut a longer rod for the patient's right side with the screws slightly greater distance apart ultimately settling on a 90-mm rod.  The locking caps were placed on the right side and after all 4 locking caps were placed, the locking cap screws were tied to the cold weld.  Fluoroscopic examination demonstrated no evidence of asymmetry at the intervertebral space at T11-T12 or T12-L1 with excellent positioning of the rods and screws.  A crosslink approximately 60 mm in width was then placed between the right and left rods, and all 4 screws were tightened.,It should be noted that prior to the placement of the rods, the patient's autologous bone, which had been removed during laminectomy portion of the procedure and cleansed off soft tissue and morcellated was packed in the posterolateral space after decortication had been effected on the transverse processes at T11, T12, and L1 with AM-8 dissecting tool, AM attachment as well as the lateral aspects of the facet joints.  This was done bilaterally prior to placement of the rods.,Following placement of the rods as noted above, allograft bone chips were packed in addition on top of the patient's own allograft in these posterolateral gutters.  Gelfoam was used to cover the thecal sac and at this point, the wound was closed by approximating the deep muscle with 0 Vicryl suture.  The fascia was closed with interrupted 0 Vicryl suture, subcutaneous layer was closed with 2-0 Vicryl suture, subcuticular layer was closed with 2-0 inverted interrupted Vicryl suture, and the skin approximated with staples.  The patient appeared to tolerate the procedure well without complications.
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DESCRIPTION: Decompressive laminectomy at T12 with bilateral facetectomies, decompression of T11 and T12 nerve roots bilaterally with posterolateral fusion supplemented with allograft bone chips and pedicle screws and rods with crosslink Synthes ClickX System.

neurosurgery, facetectomies, decompression, posterolateral fusion, synthes click'x system, decompressive laminectomy, leksell rongeur, kerrison rongeur, transverse processes, thecal sac, nerve roots, pedicle screws, spinous process, pedicle, process, screws, rods, laminectomy, decompressive, spinous,

The situation involves a complex neurosurgical procedure addressing a T12 compression fracture with cauda equina syndrome and spinal cord compression, conditions that can have severe consequences if not properly managed. The described surgery, a decompressive laminectomy supplemented with spinal instrumentation, is a high-stakes operation given the potential impact on the patient's neural function and overall health. Any complications could result in significant neurological deficits or other serious health issues.


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

Medical Specialty: Neurosurgery
Sample Name: Cystic Suprasellar Tumor Resection

TITLE OF OPERATION:,  Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.,INDICATION FOR SURGERY: , She is a 3-year-old girl who is known to have a head injury and CT in 2005 was normal, presented with headache.  All endocrine labs were normal.  Surgery was recommended.,PREOP DIAGNOSIS: , Cystic suprasellar tumor.,POSTOP DIAGNOSIS:,  Cystic suprasellar tumor.,PROCEDURE DETAIL: , The patient was brought to operating room, underwent smooth induction of general endotracheal anesthesia, head was placed in the horseshoe head rest and positioned supine with head turned slightly towards left and slightly extended.  The patient was then prepped and draped in the usual sterile fashion.  With the assistance of fluoro and mapping the localization, the right nostril was infiltrated.  Dr. X will dictate the procedure of the approach.  Once the dura was visualized, there was a complex procedure secondary to the small nasal naris as well as the bony drilling that would necessitate significant drilling.  Once the operating microscope was in the field, at this point, the drilling was completed.  The dura was opened in cruciate fashion revealing normal pituitary, which was displaced and the cystic tumor.  This was then opened and using microsurgical technique with the curette suctioned and the pituitary calcifications were removed, several Valsalva maneuvers were performed without any evidence of CSF leak and trying to pull the tumor further down.  Once this was completed, there was no evidence of any bleeding.  The endoscope was then used to remove any residual fragments __________ with the arachnoid.  Once this was completely ensured, small piece of Duragel was placed and the closure will be dictated by Dr. X.  She was reversed, extubated, and transported to the ICU in stable condition.  Blood loss, minimal.  All sponge, needle counts were correct.
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DESCRIPTION: Endoscopic and microsurgical transnasal resection of cystic suprasellar tumor.

neurosurgery, microsurgical transnasal resection, cystic suprasellar tumor, transnasal resection, endoscopic, transnasal, microsurgical, suprasellar, cystic, tumor,

This is a complex surgical procedure in the field of neurosurgery, involving a 3-year-old patient with a cystic suprasellar tumor. The operation is highly specialized, requiring meticulous techniques to avoid complications such as CSF leaks or damage to surrounding structures. Given the patient's age, the location of the tumor, and the precision necessary for a successful outcome, the situation is high-stakes due to the potential impact on the patient's neurological function and overall health.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Neurosurgery
Sample Name: Craniotomy & Neuronavigation

PROCEDURES:,1.  Right frontal craniotomy with resection of right medial frontal brain tumor.,2.  Stereotactic image-guided neuronavigation for resection of tumor.,3.  Microdissection and micro-magnification for resection of brain tumor.,ANESTHESIA: , General via endotracheal tube.,INDICATIONS FOR THE PROCEDURE:  ,The patient is a 71-year-old female with a history of left-sided weakness and headaches.  She has a previous history of non-small cell carcinoma of the lung, treated 2 years ago.  An MRI was obtained which showed a large enhancing mass in the medial right frontal lobe consistent with a metastatic lesion or possible primary brain tumor.  After informed consent was obtained, the patient was brought to the operating room for surgery.,PREOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift.,POSTOPERATIVE DIAGNOSES: , Medial right frontal brain tumor with surrounding edema and mass effect and right to left brain shift, probable metastatic lung carcinoma.,DESCRIPTION OF THE PROCEDURE: , The patient was wheeled into the operating room and satisfactory general anesthesia was obtained via endotracheal tube.  She was positioned on the operating room table in the Sugita frame with the head secured.,Using the preoperative image-guided MRI, we carefully registered the fiducials and then obtained the stereotactic image-guided localization to guide us towards the tumor.  We marked external landmarks.  Then we shaved the head over the right medial frontal area.  This area was then sterilely prepped and draped.,Evoked potential monitoring and sensory potentials were carried out throughout the case and no changes were noted.,A horseshoe shaped flap was based on the right and then brought across to the midline.  This was opened and hemostasis obtained using Raney clips.  The skin flap was retracted medially.  Two burr holes were made and were carefully connected.  One was placed right over the sinus and we carefully then removed a rectangular shaped bone flap.  Hemostasis was obtained.  Using the neuronavigation, we identified where the tumor was.  The dura was then opened based on a horseshoe flap based on the medial sinus.  We retracted this medially and carefully identified the brain.  The brain surface was discolored and obviously irritated consistent with the tumor.,We used the stereotactic neuronavigation to identify the tumor margins.,Then we used a bipolar to coagulate a thin layer of brain over the tumor.  Subsequently, we entered the tumor.  The tumor itself was extremely hard.  Specimens were taken and send for frozen section analysis, which showed probable metastatic carcinoma.,We then carefully dissected around the tumor margins.,Using the microscope, we then brought microscopic magnification and dissection into the case.  We used paddies and carefully developed microdissection planes all around the margins of the tumor superiorly, medially, inferiorly, and laterally.,Then using the Cavitron, we cored out the central part of the tumor.  Then we collapsed the tumor on itself and removed it entirely.  In this fashion, microdissection and magnification resection of the tumor was carried out.  We resected the entire tumor.  Neuronavigation was used to confirm that no further tumor residual was remained.,Hemostasis was obtained using bipolar coagulation and Gelfoam.  We also lined the cavity with Surgicel.  The cavity was nicely dry and excellent hemostasis was obtained.,The dura was closed using multiple interrupted 4-0 Nurolon sutures in a watertight fashion.  Surgicel was placed over the dural closure.  The bone flap was repositioned and held in place using CranioFIX cranial fixators.  The galea was re-approximated and the skin was closed with staples.  The wound was dressed.  The patient was returned to the intensive care unit.  She was awake and moving extremities well.  No apparent complications were noted.  Needle and sponge counts were listed as correct at the end of the procedure.  Estimated intraoperative blood loss was approximately 150 mL and none was replaced.
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DESCRIPTION: Right frontal craniotomy with resection of right medial frontal brain tumor.  Stereotactic image-guided neuronavigation and  microdissection and micro-magnification for resection of brain tumor.

neurosurgery, stereotactic image-guided neuronavigation, micro-magnification, resection of brain tumor, frontal craniotomy, mass effect, brain shift, stereotactic image, brain tumor, brain, tumor, craniotomy, endotracheal, carcinoma, neuronavigation, microdissection,

The situation described involves a high-stakes medical procedure, namely a right frontal craniotomy with the resection of a right medial frontal brain tumor. This is a complex neurosurgical operation essential for treating a potentially life-threatening condition – a probable metastatic lung carcinoma in the brain. The stakes are high due to the risks associated with brain surgery, including potential complications, impact on the patient’s neurological function, and the necessity to remove the tumor effectively while minimizing damage to surrounding brain tissue. Additionally, the history of the patient's condition intensifies the critical nature of the procedure.


Medical Specialty: Neurosurgery
Sample Name: Craniotomy - Burr Hole

PREOPERATIVE DIAGNOSIS: , Right chronic subdural hematoma.,POSTOPERATIVE DIAGNOSIS: ,Right chronic subdural hematoma.,TYPE OF OPERATION: , Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , 100 cc.,OPERATIVE PROCEDURE:,  In preoperative identification, the patient was taken to the operating room and placed in supine position.  Following induction of satisfactory general endotracheal anesthesia, the patient was prepared for surgery.  Table was turned.  The right shoulder roll was placed.  The head was turned to the left and rested on a doughnut.  The scalp was shaved, and then prepped and draped in usual sterile fashion.  Incisions were marked along a putative right frontotemporal craniotomy frontally and over the parietal boss.  The parietal boss incision was opened.  It was about an inch and a half in length.  It was carried down to the skull.  Self-retaining retractor was placed.  A bur hole was now fashioned with the perforator.  This was widened with a 2-mm Kerrison punch.  The dura was now coagulated with bipolar electrocautery.  It was opened in a cruciate-type fashion.  The dural edges were coagulated back to the bony edges.  There was egress of a large amount of liquid.  Under pressure, we irrigated for quite sometime until irrigation was returning mostly clear.  A subdural drain was now inserted under direct vision into the subdural space and brought out through a separate stab incision.  It was secured with a 3-0 nylon suture.  The area was closed with interrupted inverted 2-0 Vicryl sutures.  The skin was closed with staples.  Sterile dressing was applied.  The patient was subsequently returned back to anesthesia.  He was extubated in the operating room, and transported to PACU in satisfactory condition.
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DESCRIPTION: Right burr hole craniotomy for evacuation of subdural hematoma and placement of subdural drain.

neurosurgery, hematoma, burr hole, craniotomy, frontotemporal, frontotemporal craniotomy, subdural, subdural drain, subdural hematoma, subdural space

The situation described is a neurosurgical procedure involving a craniotomy to evacuate a subdural hematoma, a condition that can lead to serious brain damage or death if not treated promptly. The procedure is highly invasive, involves significant medical risks, and requires the use of general anesthesia. It directly impacts the patient's health and safety, making it a high-stakes scenario. Neurosurgical procedures are typically complex and critical, given the vulnerability of the brain and potential consequences of any complications.


Medical Specialty: Neurosurgery
Sample Name: Craniotomy - Frontal Zygomatic

PREOPERATIVE DIAGNOSIS:,  Metopic synostosis with trigonocephaly.,POSTOPERATIVE DIAGNOSIS:,  Metopic synostosis with trigonocephaly.,PROCEDURES:  ,1.  Bilateral orbital frontal zygomatic craniotomy (skull base approach).,2.  Bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts.,3.  Bilateral forehead reconstruction with autologous graft.,4.  Advancement of the temporalis muscle bilaterally.,5.  Barrel-stave osteotomies of the parietal bones.,ANESTHESIA: , General.,PROCEDURE: , After induction of general anesthesia, the patient was placed supine on the operating room table with a roll under his shoulders and his head resting on a foam doughnut.  Scalp was clipped.  He was prepped with ChloraPrep.  Incision was infiltrated with 0.5% Xylocaine with epinephrine 1:200,000 and he received antibiotics and he was then reprepped and draped in a sterile manner.,A bicoronal zigzag incision was made and Raney clips used for hemostasis.  Subcutaneous flaps were developed and reflected anteriorly and slightly posteriorly.  These were subgaleal flaps.  Bipolar and Bovie cautery were used for hemostasis.  The craniectomy was outlined with methylene blue.  The pericranium was incised exposing the bone along the outline of the craniotomy.,Paired bur holes were drilled anteriorly and posteriorly straddling the metopic suture.  One was just above the nasion and the other was near the bregma.  Also bilateral pterional bur holes were drilled.  There was a little bit of bleeding from a tributary of the sagittal sinus anteriorly and so bone wax was used for hemostasis in all the bur holes.,The dura was separated with a #4 Penfield dissector and then the craniotomies were fashioned or cut.  I should say with the Midas Rex drill using the V5 bit and the footplate attachment, the bilateral craniotomies were cut and then the midline piece was elevated separately.  Great care was taken when removing the bone from the midline.  Bipolar cautery was used for bleeding points on the dura and especially over the sagittal sinus and the bleeding was controlled.,The wound was irrigated with bacitracin irrigation.,The next step was to perform the orbital osteotomies with careful protection of the orbital contents.  Osteotomies were made with the Midas Rex drill using the V5 bit in the orbital roof bilaterally.  This was a very thick and vertically oriented orbital roof on each side.  Midas Rex drill and osteotomes and mallet were used to cut these osteotomies using retractors to protect the orbital contents and the dura.  The osteotomies were carried down through the tripod of the orbit and down through the lateral orbital rim and all the way down to the inferior orbital rim using the osteotome and mallet.  Bone wax was used for hemostasis.  It was necessary to score the undersurface of the bone at the midline because it was so thick and pointed.  So we were not going to be able to effect the orbital advancement without scoring the bone and thinning it out a bit.  This was done with the Midas Rex drill using B5 bit.  Also, the marked ridge just above the nasion was burred down with the Midas Rex drill.  The osteotomies were also carried down through the zygoma.  At this point, with a gentle rocking motion and sustained pressure using the osteotomes, it was then possible to carefully advance the orbital rims bilaterally, first on the right and then on the left again using just a careful rocking motion against the remaining bone to gently bend the orbital rims outward bilaterally.,Dr. X cut the bone grafts from the bone flaps and I fashioned a shelf to secure the bone graft by burring a ledge on the internal surface of the superior orbital rim.  This created a shelf for the notched bone graft to lean against basically anteriorly.  The posterior notch of the bone graft was able to be braced by the ledge of orbital roof posteriorly.,The left medial orbital rim greenstick fractured a bit, but the bone graft appeared to stay in place.,Holes were then cut in the supraorbital rim for advancement of the temporalis muscle and then a Synthes mesh was placed anteriorly using absorbable screw hardware and attached the mesh where the forehead bone flaps turned around and recontoured to make a nice bilateral forehead for Isaac.,At this point the undersurface of the temporalis muscle was scored using the Bovie cautery to allow advancement of the muscle anteriorly and we sutured it to the supraorbital rims bilaterally with #3-0 Vicryl suture.  This helped fill-in the indentation left by the orbital advancement at the temporal region.,Also, I separated the undersurface of the dura from the bone bilaterally and cut multiple barrel-stave osteotomies in the parietal bones and then greenstick fractured these barrel-staves outward to create a more normal contour of the bone slightly posteriorly.,At this point, Gelfoam had been used to protect the dura over the sagittal sinus during this part of the procedure.,The wound was then irrigated with bacitracin irrigation.  Bleeding had been controlled during the procedure with Bovie and bipolar electrocautery, even so the blood loss was fairly significant adding up to about 300 or 400 mL and he received that much in packed cells and he also received a unit of fresh frozen plasma.,At this point, the reconstruction looked good.  The advancement was about 1 cm and we were pleased with the results.  The wound was irrigated and then the Gelfoam over the midline dura was left in place and the galea was then closed with #4-0 and some #3-0 Vicryl interrupted suture and #5-0 mild chromic on the skin.  The patient tolerated procedure well.  No complications.  Sponge and needle counts were correct.  Again, blood loss was bout 300 to 400 mL and he received 2 units of blood and some fresh frozen plasma.
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DESCRIPTION: Bilateral orbital frontal zygomatic craniotomy (skull base approach), bilateral orbital advancement with (C-shaped osteotomies down to the inferior orbital rim) with bilateral orbital advancement with bone grafts, bilateral forehead reconstruction with autologous graft.

neurosurgery, metopic synostosis, trigonocephaly, bilateral orbital frontal zygomatic craniotomy, skull base approach, orbital advancement, c-shaped osteotomies, forehead reconstruction, temporalis muscle, midas rex drill, frontal zygomatic, sagittal sinus, orbital roof, orbital rim, bone grafts, forehead, bone, orbital, craniotomy, osteotomies,

The situation involves a complex neurosurgical procedure, specifically a craniotomy and orbital advancement for a condition called metopic synostosis with trigonocephaly. This type of surgery is high-stakes due to the critical nature of the area being operated on (the skull and brain), the complexity of the procedure, and the potential risks involved such as significant blood loss, complications with anesthesia, and the need for precise surgical technique to avoid damaging critical structures. The outcome of the surgery can have significant implications for the patient's health and development, which further contributes to the high-stakes nature of the situation.


Medical Specialty: Neurosurgery
Sample Name: Craniotomy - Frontotemporal

PREOPERATIVE DIAGNOSIS:,  Right frontotemporal chronic subacute subdural hematoma.,POSTOPERATIVE DIAGNOSIS:,  Right frontotemporal chronic subacute subdural hematoma.,TITLE OF THE OPERATION: , Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.,ASSISTANT: , None.,INDICATIONS: , The patient is a 75-year-old man with a 6-week history of decline following a head injury.  He was rendered unconscious by the head injury.  He underwent an extensive syncopal workup in Mississippi.  This workup was negative.  The patient does indeed have a heart pacemaker.  The patient was admitted to ABCD three days ago and yesterday underwent a CT scan, which showed a large appearance of subdural hematoma.  There is a history of some bladder tumors and so a scan with contrast was obtained that showed some enhancement in the membranes.  I decided to perform a craniotomy rather than burr hole drainage because of the enhancing membranes and the history of a bladder tumor undefined as well as layering of the blood within the cavity.  The patient and the family understood the nature, indications, and risk of the surgery and agreed to go ahead.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where general and endotracheal anesthesia was obtained.  The head was turned over to the left side and was supported on a cushion.  There was a roll beneath the right shoulder.  The right calvarium was shaved and prepared in the usual manner with Betadine-soaked scrub followed by Betadine paint.  Markings were applied.  Sterile drapes were applied.  A linear incision was made more or less along the coronal suture extending from just above the ear up to near the midline.  Sharp dissection was carried down into subcutaneous tissue and Bovie electrocautery was used to divide the galea and the temporalis muscle and fascia.  Weitlaner retractors were inserted.  A single bur hole was placed underneath the temporalis muscle.  I placed the craniotomy a bit low in order to have better cosmesis.  A cookie cutter type craniotomy was then carried out in dimensions about 5 cm x 4 cm.  The bone was set aside.  The dura was clearly discolored and very tense.  The dura was opened in a cruciate fashion with a #15 blade.  There was immediate flow of a thin motor oil fluid under high pressure.  Literally the fluid shot out several inches with the first nick in the membranous cavity.  The dura was reflected back and biopsy of the membranes was taken and sent for permanent section.  The margins of the membrane were coagulated.  The microscope was brought in and it was apparent there were septations within the cavity and these septations were for the most part divided with bipolar electrocautery.  The wound was irrigated thoroughly and was inspected carefully for any sites of bleeding and there were none.  The dura was then closed in a watertight fashion using running locking 4-0 Nurolon.  Tack-up sutures had been placed at the beginning of the case and the bone flap was returned to the wound and fixed to the skull using the Lorenz plating system.  The wound was irrigated thoroughly once more and was closed in layers.  Muscle fascia and galea were closed in separate layers with interrupted inverted 2-0 Vicryl.  Finally, the skin was closed with running locking 3-0 nylon.,Estimated blood loss for the case was less than 30 mL.  Sponge and needle counts were correct.,FINDINGS: , Chronic subdural hematoma with multiple septations and thickened subdural membrane.,I might add that the arachnoid was not violated at all during this procedure.  Also, it was noted that there was no subarachnoid blood but only subdural blood.
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DESCRIPTION: Right frontotemporal craniotomy and evacuation of hematoma, biopsy of membranes, microtechniques.

neurosurgery, frontotemporal, weitlaner, calvarium, cookie cutter type, craniotomy, dura, frontotemporal craniotomy, galea, hematoma, subdural, subdural hematoma, syncopal, temporalis, subacute subdural hematoma, temporalis muscle,

The situation involves a neurosurgical procedure (craniotomy) on a 75-year-old patient with a chronic subdural hematoma. Situations involving neurosurgery are generally high-stakes due to the complexity of the procedures, the risks involved (including potential complications from the surgery itself), and the critical nature of brain health. Additionally, the patient's age and medical history, which includes a head injury rendering him unconscious, a pacemaker, and a history of bladder tumors, add to the risk factors. The procedure has significant implications for the patient's recovery and overall health, which elevates its stakes.


Medical Specialty: Neurosurgery
Sample Name: Bifrontal Cranioplasty

PREOPERATIVE DIAGNOSIS:,  Cranial defect greater than 10 cm in diameter in the frontal region.,POSTOPERATIVE DIAGNOSIS: , Cranial defect greater than 10 cm in diameter in the frontal region.,PROCEDURE: , Bifrontal cranioplasty.,ANESTHESIA:,  General endotracheal anesthesia.,ESTIMATED BLOOD LOSS: , Nil.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old gentleman, who has a history of prior chondrosarcoma that he had multiple resections for.  The most recent one which I performed quite a number of years ago that was complicated by a bone flap infection and he has had removal of his bone flap.  He has been without the bone flap for a number of years now but has finally decided that he wanted to proceed with a cranioplasty.  After discussing the risks, benefits, and alternatives of surgery, the decision was made to proceed with operative intervention in the form of a cranioplasty.  He had previously undergone a CT scan.  Premanufactured cranioplasty made for him that was sterile and ready to implant.,DESCRIPTION OF PROCEDURE: , After induction of adequate general endotracheal anesthesia, an appropriate time out was performed.  We identified the patient, the location of surgery, the appropriate surgical procedure, and the appropriate implant.  He was given intravenous antibiotics with ceftriaxone, vancomycin, and Flagyl appropriately for antibiotic prophylaxis and sequential compression devices were used for deep venous thromboembolism prophylaxis.  The scalp was prepped and draped in the usual sterile fashion.  A previous incision was reopened and the scalp flap was reflected forward.  We dissected off the dura and we were able to get a nice plane of dissection elevating the temporalis muscle along with the scalp flap.  We freed up the bony edges circumferentially, but except for the inferior frontal region where the vascularized pericranial graft took its vascular supply from we did not come across the base.  We did explore laterally and saw a little bit of the mesh on the lateral orbit.  Once we had the bony edges explored, we took the performed plate and secured it in a place with titanium plates and screws.  We had achieved good hemostasis.  The wound was closed in multiple layers in usual fashion over a Blake drain.  At the end of the procedure, all sponge and needle counts were correct.  A sterile dressing was applied to the incision.  The patient was transported to the recovery room in good condition after having tolerated the procedure well.  I was personally present and scrubbed and performed/supervised all key portions.
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DESCRIPTION: Bifrontal cranioplasty, cranial defect greater than 10 cm in diameter in the frontal region.

neurosurgery, cranial defect, frontal region, bifrontal cranioplasty, cranioplasty, chondrosarcoma, scalp flap, bony edges, bone flap, bifrontal, cranial, endotracheal, frontal,

The situation described involves a bifrontal cranioplasty, a neurosurgical procedure, which inherently comes with significant risks, such as infection, bleeding, or complications from anesthesia. This surgery is being done to repair a sizable cranial defect in a 66-year-old patient who has a history of prior surgeries and complications. The fact that this involves the frontal region of the skull adds to the complexity and importance of the procedure, implicating brain safety. While the estimated blood loss was nil and the patient was stable post-operation, any complications during such a procedure could have critical consequences for the patient's health. Thus, this scenario is high-stakes in terms of patient safety and outcomes.


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Osteophytectomy

PREOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,POSTOPERATIVE DIAGNOSES,1.  Cervical radiculopathy, C5-C6 and C6-C7.,2.  Symptomatic cervical spondylosis, C5-C6 and C6-C7.,3.  Symptomatic cervical stenosis, C5-C6 and C6-C7.,4.  Symptomatic cervical disc herniations, C5-C6 and C6-C7.,OPERATIVE PROCEDURE,1.  CPT code 63075:  Anterior cervical discectomy and osteophytectomy, C5-C6.,2.  CPT code 63076:  Anterior cervical discectomy and osteophytectomy, C6-C7, additional level.,3.  CPT code 22851:  Application of prosthetic interbody fusion device, C5-C6.,4.  CPT code 22851-59:  Application of prosthetic interbody fusion device, C6-C7, additional level.,5.  CPT code 22554-51:  Anterior cervical interbody arthrodesis, C5-C6.,6.  CPT code 22585:  Anterior cervical interbody arthrodesis, C6-C7, additional level.,7.  CPT code 22845:  Anterior cervical instrumentation, C5-C7.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS:  ,Negligible.,DRAINS: , Small suction drain in the cervical wound.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:,  The patient was given intravenous antibiotic prophylaxis and thigh-high TED hoses were placed on the lower extremities while in the preanesthesia holding area.  The patient was transported to the operative suite and on to the operative table in the supine position.  General endotracheal anesthesia was induced.  The head was placed on a well-padded head holder.  The eyes and face were protected from pressure.  A well-padded roll was placed beneath the neck and shoulders to help preserve the cervical lordosis.  The arms were tucked and draped to the sides.  All bony prominences were well padded.  An x-ray was taken to confirm the correct level of the skin incision.  The anterior neck was then prepped and draped in the usual sterile fashion.,A straight transverse skin incision over the left side of the anterior neck was made and carried down sharply through the skin and subcutaneous tissues to the level of the platysma muscle, which was divided transversely using the electrocautery.  The superficial and deep layers of the deep cervical fascia were divided.  The midline structures were reflected to the right side.  Care was taken during the dissection to avoid injury to the recurrent laryngeal nerve and the usual anatomical location of that nerve was protected.  The carotid sheath was palpated and protected laterally.  An x-ray was taken to confirm the level of C5-C6 and C6-C7.,The longus colli muscle was dissected free bilaterally from C5 to C7 using blunt dissection.  Hemostasis was obtained using the electrocautery.  The blades of the cervical retractor were placed deep to the longus colli muscles bilaterally.  At C5-C6, the anterior longitudinal ligament was divided transversely.  Straight pituitary rongeurs and a curette were used to remove the contents of the disc space.  All cartilages were scraped off the inferior endplate of C5 and from the superior endplate of C6.  The disc resection was carried posteriorly to the posterior longitudinal ligament and laterally to the uncovertebral joints.  The posterior longitudinal ligament was resected using a 1 mm Kerrison rongeur.  Beginning in the midline and extending into both neural foramen, posterior osteophytes were removed using a 1 m and a 2 mm Kerrison rongeurs.  The patient was noted to have significant bony spondylosis causing canal and foraminal stenosis as well as a degenerative and protruding disc in agreement with preoperative diagnostic imaging studies.  Following completion of the discectomy and osteophytectomy, a blunt nerve hook was passed into the canal superiorly and inferiorly as well as in the both neural foramen to make sure that there were no extruded disc fragments and to make sure the bony decompression was complete.  A portion of the uncovertebral joint was resected bilaterally for additional nerve root decompression.  Both nerve roots were visualized and noted to be free of encroachment.  The same procedure was then carried out at C6-C7 with similar findings.  The only difference in the findings was that at C6-C7 on the left side, the patient was found to have an extruded disc fragment in the canal and extending into the left side neural foramen causing significant cord and nerve root encroachment.,In preparation for the arthrodesis, the endplates of C5, C6, and C7 were burred in a parallel fashion down to the level of bleeding bone using a high-speed cutting bur with irrigant solution for cooling.  The disc spaces were then measured to the nearest millimeter.  Attention was then turned toward preparation of the structural allograft, which consisted of two pieces of pre-machined corticocancellous bone.  The grafts were further shaped to fit the disc spaces exactly in a press-fit manner with approximately 1.5 mm of distraction at each disc space.  The grafts were shaped to be slightly lordotic to help preserve the cervical lordosis.  The grafts were impacted into the disc spaces.  There was complete bony apposition between the ends of the bone grafts and the vertebral bodies of C5, C6, and C7.  A blunt nerve hook was passed posterior to each bone graft to make sure that the bone grafts were in good position.  Anterior osteophytes were removed using a high-speed cutting bur with irrigant solution for cooling.  An appropriate length Synthes cervical plate was selected and bent slightly to conform to the patient's cervical lordosis.  The plate was held in the midline with provided instrumentation while a temporary fixation screw was applied at C6.  Screw holes were then drilled using the provided drill and drill guide taking care to avoid injury to neurovascular structures.  The plate was then rigidly fixed to the anterior spine using 14-mm cancellous screws followed by locking setscrews added to the head of each screw to prevent postoperative loosening of the plate and/or screws.,An x-ray was taken, which confirmed satisfactory postioning of the plate, screws, and bone grafts.,Blood loss was minimal.  The wound was irrigated with irrigant solution containing antibiotics.  The wound was inspected and judged to be dry.  The wound was closed over a suction drain placed in the deepest portion of the wound by reapproximating the platysma muscle with #4-0 Vicryl running suture, the subdermal and subcuticular layers with #4-0 Monocryl interrupted sutures, and the skin with Steri-Strips.  The sponge and needle count were correct.  A sterile dressing was applied to the wound.  The neck was placed in a cervical orthosis.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.
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DESCRIPTION: Anterior cervical discectomy and osteophytectomy.  Application of prosthetic interbody fusion device.  Anterior cervical interbody arthrodesis.  Anterior cervical instrumentation

The given medical scenario involves a complex neurosurgical procedure - an anterior cervical discectomy and osteophytectomy - which includes significant risks associated with operating close to the spinal cord. Such procedures require precision, as any error could lead to serious complications such as paralysis or nerve damage. Nevertheless, the described procedure went without complications, maintaining the critical safety measures. Although the surgery was successful, the inherent risks associated with this type of neurosurgery make the situation quite high-stakes.


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Fusion - 9

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus C5-C6.,PROCEDURE:,  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.,FIRST ASSISTANT: , Nurse practitioner.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion for anterior discectomy and fusion.  An incision was made midline to the anterior body of the sternocleidomastoid at C5-C6 level.  The skin, subcutaneous tissue, and platysma muscle was divided exposing the carotid sheath, which was retracted laterally.  Trachea and esophagus were retracted medially.  After placing the self-retaining retractors with the longus colli muscles having been dissected away from the vertebral bodies at C5 and C6 and confirming our position with intraoperative x-rays, we then proceeded with the discectomy.,We then cleaned out the disc at C5-C6 after incising the annulus fibrosis.  We cleaned out the disc with a combination of angled and straight pituitary rongeurs and curettes, and the next step was to clean out the disc space totally.  With this having been done, we then turned our attention with the operating microscope to the osteophytes.  We drilled off the vertebral osteophytes at C5-C6, as well as the uncovertebral osteophytes.  This was removed along with the posterior longitudinal ligament.  After we had done this, the dural sac was opposed very nicely and both C6 nerve roots were thoroughly decompressed.  The next step after the decompression of the thecal sac and both C6 nerve roots was the fusion.  We observed that there was a ____________ in the posterior longitudinal ligament.  There was a free fragment disc, which had broken through the posterior longitudinal ligament just to the right of midline.,The next step was to obtain the bone from the back bone, using cortical cancellous graft 10 mm in size after we had estimated the size.  That was secured into place with distraction being applied on the vertebral bodies using vertebral body distractor.,After we had tapped in the bone plug, we then removed the distraction and the bone plug was fitting nicely.,We then use the Aesculap cervical titanium instrumentation with the 16-mm screws.  After securing the C5-C6 disc with four screws and titanium plate, x-rays showed good alignment of the spine, good placement of the bone graft, and after x-rays showed excellent position of the bone graft and instrumentation, we then placed in a Jackson-Pratt drain in the prevertebral space brought out through a separate incision.  The wound was closed with 2-0 Vicryl for subcutaneous tissues and skin was closed with Steri-Strips.  Blood loss during the operation was less than 10 mL.  No complications of the surgery.  Needle count, sponge count, and cottonoid count were correct.,
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DESCRIPTION: Herniated nucleus pulposus C5-C6.  Anterior cervical discectomy fusion C5-C6 followed by instrumentation C5-C6 with titanium dynamic plating system, Aesculap.  Operating microscope was used for both illumination and magnification.

neurosurgery, aesculap, titanium dynamic plating system, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, operating microscope, longitudinal ligament, discectomy, anterior, instrumentation, cervical, titanium

Anterior cervical discectomy and fusion (ACDF) is a common neurosurgical procedure used to alleviate spinal cord or nerve root pressure in the cervical spine due to herniation. Despite being routine, it involves significant structures such as the spinal cord and nerve roots, and it carries risks like spinal cord injury, nerve damage, or infection. These factors contribute to a high-stakes situation, as errors can lead to serious consequences for the patient, such as paralysis or chronic pain. Although the procedure here was described as without complications and with minimal blood loss, the inherent risks associated with neurosurgical operations make this a high-stakes situation.


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Fusion - 7

PREOPERATIVE DIAGNOSIS:,  C4-C5, C5-C6 stenosis.,PREOPERATIVE DIAGNOSIS: , C4-C5, C5-C6 stenosis.,PROCEDURE: , C4-C5, C5-C6 anterior cervical discectomy and fusion.,COMPLICATIONS: , None.,ANESTHESIA: , General.,INDICATIONS OF PROCEDURE: , The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms.  Her MRI showed stenosis at portion of C4 to C6.  I discussed the procedure as well as risks and complications.  She wishes to proceed with surgery.  Risks will include but are not limited to infection, hemorrhage, spinal fluid leak, worsened neurologic deficit, recurrent stenosis, requiring further surgery, difficulty with fusion requiring further surgery, long-term hoarseness of voice, difficulty swallowing, medical anesthesia risk.,PROCEDURE:  ,The patient was taken to the operating room on 10/02/2007.  She was intubated for anesthesia.  TEDS and boots as well as Foley catheter were placed.  She was placed in a supine position with her neck in neutral position.  Appropriate pads were also used.  The area was prepped and draped in usual sterile fashion.  Preoperative localization was taken.  _____ not changed.  Incision was made on the right side in transverse fashion over C5 vertebral body level.  This was made with a #10 blade knife and further taken down with pickups and scissors.  The plane between the esophagus and carotid artery was carefully dissected both bluntly and sharply down to the anterior aspect of the cervical spine.  Intraoperative x-ray was taken.  Longus colli muscles were retracted laterally.  Caspar retractors were used.  Intraoperative x-ray was taken.  I first turned by attention at C5-C6 interspace.  This was opened with #15 blade knife.  Disc material was taken out using pituitary as well as Kerrison rongeur.  Anterior aspects were taken down.  End plates were arthrodesed using curettes.  This was done under distraction.  Posterior longitudinal ligament was opened with a nerve hook and Kerrison rongeur.  Bilateral foraminotomies were done.  At this point, I felt that there was a good decompression.  The foramen appeared to be opened.  Medtronic cage was then encountered and sent few millimeters.  This was packed with demineralized bone matrix.  The distraction was then taken down.  The cage appeared to be strong.  This procedure was then repeated at C4-C5.  A 42-mm AcuFix plate was then placed between C4 and C6.  This was carefully screwed and locked.  The instrumentation appeared to be strong.  Intraoperative x-ray was taken.  Irrigation was used.  Hemostasis was achieved.  The platysmas was closed with 3-0 Vicryl stitches.  The subcutaneous was closed with 4-0 Vicryl stitches.  The skin was closed with Steri-strips.  The area was clean and dry and dressed with Telfa and Tegaderm.  Soft cervical collar was placed for the patient.  She was extubated per anesthesia and brought to the recovery in stable condition.
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DESCRIPTION: C4-C5, C5-C6 anterior cervical discectomy and fusion.  The patient is a 62-year-old female who presents with neck pain as well as upper extremity symptoms.  Her MRI showed stenosis at portion of C4 to C6.

neurosurgery, anterior cervical discectomy, fusion, infection, hemorrhage, spinal fluid leak, anesthesia, foley catheter, teds, anterior cervical, cervical discectomy, anterior, cervical, discectomy, stenosis,

The scenario involves a neurosurgical procedure, specifically an anterior cervical discectomy and fusion, which is a complex surgery of the spine. Given the nature of this procedure, it inherently involves high risks such as infection, bleeding, nerve damage, and potential complications from general anesthesia. Additionally, any error during the surgery could have significant repercussions on the patient's health, including worsened neurological conditions or the need for further surgeries. Therefore, the stakes in this context are quite high.


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Fusion - 2

PREOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,POSTOPERATIVE DIAGNOSIS: , Herniated nucleus pulposus, C5-C6, with spinal stenosis.,PROCEDURE: , Anterior cervical discectomy with fusion C5-C6.,PROCEDURE IN DETAIL: , The patient was placed in supine position.  The neck was prepped and draped in the usual fashion.  An incision was made from midline to the anterior border of the sternocleidomastoid in the right side.  Skin and subcutaneous tissue were divided sharply.  Trachea and esophagus were retracted medially.  Carotid sheath was retracted laterally.  Longus colli muscles were dissected away from the vertebral bodies of C5-C6.  We confirmed our position by taking intraoperative x-rays.  We then used the operating microscope and cleaned out the disk completely.  We then sized the interspace and then tapped in a #7 mm cortical cancellous graft.  We then used the DePuy Dynamic plate with 14-mm screws.  Jackson-Pratt drain was placed in the prevertebral space and brought out through a separate incision.  The wound was closed in layers using 2-0 Vicryl for muscle and fascia.  The blood loss was less than 10-20 mL.  No complication.  Needle count, sponge count, and cottonoid count was correct.
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DESCRIPTION: Herniated nucleus pulposus, C5-C6, with spinal stenosis.  Anterior cervical discectomy with fusion C5-C6.

neurosurgery, carotid sheath, jackson-pratt drain, anterior cervical discectomy, herniated nucleus pulposus, cervical discectomy, herniated nucleus, nucleus pulposus, spinal stenosis, discectomy, fusion, herniated, nucleus, pulposus, spinal, stenosis, anterior

The situation describes a surgical procedure known as an Anterior Cervical Discectomy and Fusion (ACDF), which is commonly performed in neurosurgery to address spinal complications, such as a herniated nucleus pulposus with spinal stenosis. While it is a routine and well-established procedure in the field, neurosurgery inherently involves significant risks due to the anatomical structures involved, including the spinal cord and nerves. Potential risks include nerve damage, spinal instability, and infection, among others. Therefore, performing this surgery correctly and safely is critical to the patient's outcome and overall well-being, making it a high-stakes situation.


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy & Fusion - 4

PREOPERATIVE DIAGNOSIS: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,POSTOPERATIVE DIAGNOSES: , Cervical myelopathy, C3-4, secondary to stenosis from herniated nucleus pulposus, C3-4.,OPERATIVE PROCEDURES,1.  Anterior cervical discectomy with decompression, C3-4.,2.  Arthrodesis with anterior interbody fusion, C3-4.,3.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).,4.  Implant using PEEK 7 mm.,5.  Allograft using Vitoss.,DRAINS: , Round French 10 JP drain.,FLUIDS: , 1800 mL of crystalloids.,URINE OUTPUT:  ,1000 mL.,SPECIMENS: , None.,COMPLICATIONS:  ,None.,ANESTHESIA: , General endotracheal anesthesia.,ESTIMATED BLOOD LOSS:  ,Less than 100 mL.,CONDITION:  ,To postanesthesia care unit extubated with stable vital signs.,INDICATIONS FOR THE OPERATION:  ,This is a case of a very pleasant 32-year-old Caucasian male who had been experiencing posterior neck discomfort and was shooting basketball last week, during which time he felt a pop.  Since then, the patient started complaining of acute right arm and right leg weakness, which had been progressively worsening.  About two days ago, he started noticing weakness on the left arm.  The patient also noted shuffling gait.  The patient presented to a family physician and was referred to Dr. X for further evaluation.  Dr. X could not attempt to this, so he called me at the office and the patient was sent to the emergency room, where an MRI of the brain was essentially unremarkable as well as MRI of the thoracic spine.  MRI of the cervical spine, however, revealed an acute disk herniation at C3-C4 with evidence of stenosis and cord changes.  Based on these findings, I recommended decompression.  The patient was started on Decadron at 10 mg IV q.6h.  Operation, expected outcome, risks, and benefits were discussed with him.  Risks to include but not exclusive of bleeding and infection.  Bleeding can be superficial, but can compromise airway, for which he has been told that he may be brought emergently back to the operating room for evacuation of said hematoma.  The hematoma could also be an epidural hematoma, which may compress the spinal cord and result in weakness of all four extremities, numbness of all four extremities, and impairment of bowel and bladder function.  Should this happen, he needs to be brought emergently back to the operating room for evacuation of said hematoma.  There is also the risk by removing the hematoma that he can deteriorate as far as neurological condition, but this hopefully with the steroid prep will be prevented or if present will only be transient.  There is also the possibility of infection, which can be superficial and treated with IV and p.o. antibiotics.  However, should the infection be extensive or be deep, he may require return to the operating room for debridement and irrigation.  This may pose a medical problem since in the presence of infection, the graft as well as spinal instrumentation may have to be removed.  There is also the possibility of dural tear with its attendant complaints of headache, nausea, vomiting, photophobia, as well as the development of pseudomeningocele.  This too can compromise airway and may require return to the operating room for repair of the dural tear.  There is also potential risk of injury to the esophagus, the trachea, as well as the carotid.  The patient can also have a stroke on the right cerebral circulation should the plaque be propelled into the right circulation.  The patient understood all these risks together with the risk associated with anesthesia and agreed to have the procedure performed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room, awake, alert and not in any form of distress.  After smooth induction and intubation, a Foley catheter was inserted.  No monitoring leads were placed.  The patient was then positioned supine on the operating table with the head supported on a foam doughnut and the neck placed on hyperextension with a shoulder roll under both shoulders.  Localizing x-ray verified the marker to be right at the C3-4 interspace.  Proceeded to mark an incision along the anterior border of the sternocleidomastoid with the central point at the area of the marker measuring about 3 cm in length.  The area was then prepped with DuraPrep.,After sterile drapes were laid out, an incision was made using a scalpel blade #10.  Wound edge bleeders were controlled with bipolar coagulation and a hot knife was utilized to cut the platysma in a similar fashion.  The anterior border of the sternocleidomastoid was identified and dissection was carried superior to and lateral to the esophagus and trachea, but medial to the carotid sheath.  The prevertebral fascia was identified.  Localizing x-ray verified another marker to be at the C3-4 interspace.  Proceeded to strip the longus colli muscles off the vertebral body of C3 and C4 and a self-retaining retractor was then laid out.  There was some degree of anterior osteophyte and this was carefully drilled down with a Midas 5-mm bur.  The disk was then cut through the annulus and removal of the disk was done with the use of the Midas 5-mm bur and later a 3-mm bur.  The inferior endplate of C3 and the superior endplate of C4 were likewise drilled out together with posterior inferior osteophyte at the C3 and the posterior superior osteophyte at C4.  There was note of a central disk herniation centrally, but more marked displacement of the cord on the left side.  By careful dissection of this disk, posterior longitudinal ligament was removed and pressure on the cord was removed.  Hemostasis of the epidural bleeders was done with a combination of bipolar coagulation, but we needed to put a small piece of Gelfoam on the patient's left because of profuse venous bleeder.  With this completed, the Valsalva maneuver showed no evidence of any CSF leakage.  A 7-mm implant with its interior packed with Vitoss was then tapped into place.  An 18-mm plate was then screwed down with four 14 x 4.0 mm screws.  The area was irrigated with saline, with bacitracin solution.  Postoperative x-ray showed excellent placement of the graft and spinal instrumentation.  A round French 10 JP drain was laid over the construct and exteriorized though a separate stab incision on the patient's right inferiorly.  The wound was then closed in layers with Vicryl 3-0 inverted interrupted sutures for the platysma, Vicryl 4-0 subcuticular stitch for the dermis and Dermabond.  The catheter was anchored to the skin with a nylon 3-0 stitch.  Dressing was placed only on the exit site of the drain.  C-collar was placed, and the patient was transferred to the recovery awake and moving all four extremities.
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DESCRIPTION: Anterior cervical discectomy with decompression and arthrodesis with anterior interbody fusion.  Spinal instrumentation using Pioneer 18-mm plate and four 14 x 4.3 mm screws (all titanium).

The situation involves a neurosurgical procedure, specifically an anterior cervical discectomy and fusion, which is a complex and delicate operation addressing cervical myelopathy. These surgeries inherently carry significant risk, including potential complications such as bleeding, infection, hematoma, neurological deterioration, dural tears, and injury to major structures like the esophagus, trachea, or carotid artery. The risks, although managed and discussed thoroughly, can lead to serious consequences if complications arise, making it a high-stakes scenario. Additionally, the procedure's success is critical for alleviating symptoms and preventing further neurological decline in the patient.


Medical Specialty: Neurosurgery
Sample Name: Anterior Cervical Discectomy - 4

PREOPERATIVE DIAGNOSIS: , Left cervical radiculopathy.,POSTOPERATIVE DIAGNOSIS:  ,Left cervical radiculopathy.,PROCEDURES PERFORMED:,1.  C5-C6 anterior cervical discectomy.,2.  Bone bank allograft.,3.  Anterior cervical plate.,TUBES AND DRAINS LEFT IN PLACE: , None.,COMPLICATIONS: , None.,SPECIMEN SENT TO PATHOLOGY: , None.,ANESTHESIA: , General endotracheal.,INDICATIONS: , This is a middle-aged man who presented to me with left arm pain.  He had multiple levels of disease, but clinically, it was C6 radiculopathy.  We tested him in the office and he had weakness referable to that nerve.  The procedure was done at that level.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room at which time an intravenous line was placed.  General endotracheal anesthesia was obtained.  He was positioned supine in the operative area and the right neck was prepared.,An incision was made and carried down to the ventral spine on the right in the usual manner.  An x-ray confirmed our location.,We were impressed by the degenerative change and the osteophyte overgrowth.,As we had excepted, the back of the disk space was largely closed off by osteophytes.  We patiently drilled through them to the posterior ligament.  We went through that until we saw the dura.,We carefully went to the patient's symptomatic, left side.  The C6 foramen was narrowed by uncovertebral joint overgrowth.  The foramen was open widely.,An allograft was placed.  An anterior Steffee plate was placed.  Closure was commenced.,The wound was closed in layers with Steri-Strips on the skin.  A dressing was applied.,It should be noted that the above operation was done also with microscopic magnification and illumination.
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DESCRIPTION: C5-C6 anterior cervical discectomy, bone bank allograft, and anterior cervical plate.   Left cervical radiculopathy.

neurosurgery, cervical radiculopathy, anterior cervical discectomy, bank allograft, cervical discectomy, anterior, cervical, foramen, discectomy, allograft, radiculopathy,

The situation describes a neurosurgical procedure—specifically, an anterior cervical discectomy with a bone bank allograft and cervical plating. Surgery, particularly neurosurgery, is inherently high-stakes due to the potential risks and the critical nature of the nervous system. Mistakes can lead to severe consequences, including paralysis or even death, underscoring the importance of precision and skill. Additionally, although the surgery described seems to have been performed without complications, the involvement of the spine and cervical nerves highlights its serious nature.


Medical Specialty: Neurology
Sample Name: Video EEG - 1

DATE OF EXAMINATION: , Start:  12/29/2008 at 1859 hours.  End:  12/30/2008 at 0728 hours.,TOTAL RECORDING TIME:,  12 hours, 29 minutes.,PATIENT HISTORY:,  This is a 46-year-old female with a history of events concerning for seizures.  The patient has a history of epilepsy and has also had non-epileptic events in the past.  Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.,VIDEO EEG DIAGNOSES,1.  Awake:  Normal.,2.  Sleep:  Activation of a single left temporal spike seen maximally at T3.,3.  Clinical events:  None.,DESCRIPTION:  ,Approximately 12 hours of continuous 21-channel digital video EEG monitoring was performed.  During the waking state, there is a 9-Hz dominant posterior rhythm.  The background of the record consists primarily of alpha frequency activity.  At times, during the waking portion of the record, there appears to be excessive faster frequency activity.  No activation procedures were performed.,Approximately four hours of intermittent sleep was obtained.  A single left temporal, T3, spike is seen in sleep.  Vertex waves and sleep spindles were present and symmetric.,The patient had no clinical events during the recording.,CLINICAL INTERPRETATION:  ,This is abnormal video EEG monitoring for a patient of this age due to the presence of a single left temporal spike seen during sleep.  The patient had no clinical events during the recording period.  Clinical correlation is required.
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DESCRIPTION: The patient has a history of epilepsy and has also had non-epileptic events in the past.  Video EEG monitoring is performed to assess whether it is epileptic seizures or non-epileptic events.

neurology, non-epileptic events, temporal spike, eeg monitoring, video eeg, epilepsy, frequency, eeg, epileptic,

The situation involves interpreting the results of a Video EEG on a patient with a history of epilepsy, which is a serious neurological condition. Understanding whether the patient's events are epileptic seizures or non-epileptic is crucial for determining the appropriate treatment and management strategies. While there are no clinical events recorded during the EEG, the presence of a left temporal spike in sleep suggests an abnormality that requires clinical correlation. This makes the situation moderately high-stakes because it could influence significant medical decisions and affect the patient's health outcomes.


Medical Specialty: Neurology
Sample Name: Ventriculostomy Placement

PROCEDURE: , Placement of left ventriculostomy via twist drill.,PREOPERATIVE DIAGNOSIS:,  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,POSTOPERATIVE DIAGNOSIS: , Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.,INDICATIONS FOR PROCEDURE:  ,The patient is a man with a history of massive intracranial hemorrhage and hydrocephalus with intraventricular hemorrhage.  His condition is felt to be critical.  In a desperate attempt to relieve increased intracranial pressure, we have proposed placing a ventriculostomy.  I have discussed this with patient's wife who agrees and asked that we proceed emergently.,After a sterile prep, drape, and shaving of the hair over the left frontal area, this area is infiltrated with local anesthetic.  Subsequently a 1 cm incision was made over Kocher's point.  Hemostasis was obtained.  Then a twist drill was made over this area.  Bones strips were irrigated away.  The dura was perforated with a spinal needle.,A Camino monitor was connected and zeroed.  This was then passed into the left lateral ventricle on the first pass.  Excellent aggressive very bloody CSF under pressure was noted.  This stopped, slowed, and some clots were noted.  This was irrigated and then CSF continued.  Initial opening pressures were 30, but soon arose to 80 or a 100.,The patient tolerated the procedure well.  The wound was stitched shut and the ventricular drain was then connected to a drainage bag.,Platelets and FFP as well as vitamin K have been administered and ordered simultaneously with the placement of this device to help prevent further clotting or bleeding.
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DESCRIPTION: Placement of left ventriculostomy via twist drill.  Massive intraventricular hemorrhage with hydrocephalus and increased intracranial pressure.

neurology, intraventricular hemorrhage, hydrocephalus, intracranial pressure, camino monitor, twist drill, ventriculostomy, hemorrhage, intracranial, pressure, intraventricular

The case involves a neurological emergency requiring a ventriculostomy due to a massive intraventricular hemorrhage and increased intracranial pressure. The patient's condition is critical, as evidenced by the need for an emergent procedure to alleviate life-threatening pressure. In such neurological emergencies, timely and precise intervention is crucial to prevent severe outcomes, including permanent damage or death.


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

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

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

Temporal artery biopsy is a diagnostic surgical procedure used to confirm or rule out temporal arteritis, a serious condition that can lead to complications such as vision loss if untreated. Although the procedure is relatively routine for surgeons and the patient tolerated it well with negligible blood loss, the stakes are tied to the underlying condition being investigated. Correct diagnosis and treatment of temporal arteritis are crucial to prevent serious complications. Therefore, the stakes are moderate to high due to the potential impact on the patient's health if untreated.


Medical Specialty: Neurology
Sample Name: Tethered Cord Evaluation

REASON FOR VISIT: , The patient referred by Dr. X for evaluation of her possible tethered cord.,HISTORY OF PRESENT ILLNESS:,  Briefly, she is a 14-year-old right handed female who is in 9th grade, who underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.  The last surgery was in 03/95.  She did well; however, in the past several months has had some leg pain in both legs out laterally, worsening at night and requiring Advil, Motrin as well as Tylenol PM.,Denies any new bowel or bladder dysfunction or increased sensory loss.  She had some patchy sensory loss from L4 to S1.,MEDICATIONS: , Singulair for occasional asthma.,FINDINGS: , She is awake, alert, and oriented x 3.  Pupils equal and reactive.  EOMs are full.  Motor is 5 out of 5.  She was able to toe and heel walk without any difficulties as well as tendon reflexes were 2 plus.  There is no evidence of clonus.  There is diminished sensation from L4 to S1, having proprioception.,ASSESSMENT AND PLAN: , Possible tethered cord.  I had a thorough discussion with the patient and her parents.  I have recommended a repeat MRI scan.  The prescription was given today.  MRI of the lumbar spine was just completed.  I would like to see her back in clinic.  We did discuss the possible symptoms of this tethering.
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DESCRIPTION: Evaluation of possible tethered cord.  She underwent a lipomyomeningocele repair at 3 days of age and then again at 3-1/2 years of age.

neurology, tethering, lipomyomeningocele repair, sensory loss, tethered cord, mri, cord, lipomyomeningocele,

The evaluation of a possible tethered cord in a pediatric neurology patient who has a history of multiple surgeries is inherently significant. A tethered cord can lead to neurological deficits if not managed appropriately. However, the current situation notes no new bowel or bladder dysfunctions or increased sensory loss, which are more critical symptoms. The repeated MRI and follow-up suggest a cautious but routine management approach at this stage. Given these factors, it’s a moderate-stakes situation due to the potential implications if the condition worsens.


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

Medical Specialty: Neurology
Sample Name: SOAP - Temporal Mass

SUBJECTIVE: , The patient is a 55-year-old African-American male that was last seen in clinic on 07/29/2008 with diagnosis of new onset seizures and an MRI scan, which demonstrated right contrast-enhancing temporal mass.  Given the characteristics of this mass and his new onset seizures, it is significantly concerning for a high-grade glioma.  ,OBJECTIVE: , The patient is alert and oriented times three, GCS of 15.  Cranial nerves II to XII are grossly intact.  Motor exam demonstrates 5/5 strength in all four extremities.  Sensation is intact to light touch, pain, temperature, and proprioception.  Cerebellar exam is intact.  Gait is normal and tandem on heels and toes.  Speech is appropriate.  Judgment is intact.  Pupils are equal and reactive to light.,ASSESSMENT AND PLAN: , The patient is a 55-year-old African-American male with a new diagnosis of rim-enhancing right temporal mass.  Given the characteristics of the MRI scan, it is highly likely that he demonstrates high-grade glioma and concerning for glioblastoma multiforme.  We have discussed in length the possible benefits of biopsy, surgical resection, medical management, as well as chemotherapy, radiation treatments, and doing nothing.  Given the high probability that the mass represents a high-grade glioma, the patient, after weighing the risks and the benefits of surgery, has agreed to undergo a surgical biopsy and resection of the mass as well as concomitant chemotherapy and radiation as the diagnosis demonstrates a high-grade glioma.  The patient has signed consent for his right temporal craniotomy for biopsy and likely resection of right temporal brain tumor.  He agrees that he will be n.p.o. after mid night on Wednesday night.  He is sent for preoperative assessment with the Anesthesiology tomorrow morning.  He has undergone vocational rehab assessment.
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DESCRIPTION: MRI demonstrated right contrast-enhancing temporal mass.

neurology, new onset seizures, temporal mass, cerebellar exam, glioma, temporal, massNOTE

The situation involves a diagnosis of a potentially life-threatening condition, a high-grade glioma, which is significantly concerning due to its aggressive nature. Decisions about treatment, including surgery, chemotherapy, and radiation, are high-stakes as they can significantly impact the patient's survival and quality of life. The patient has to evaluate complex information and choices, potentially life-altering treatments, which represent a very serious medical scenario.


Medical Specialty: Neurology
Sample Name: SAH, Contusion, Skull Fracture

CC: ,Headache.,HX:, This 51 y/o RHM was moving furniture several days prior to presentation when he struck his head (vertex) against a door panel. He then stepped back and struck his back on a trailer hitch. There was no associated LOC but he felt "dazed." He complained a HA since the accident. The following day he began experiencing episodic vertigo lasting several minutes with associated nausea and vomiting. He has been lying in bed most of the time since the accident. He also complained of transient left lower extremity weakness. The night before admission he went to his bedroom and his girlfriend heard a loud noise. She found him on the floor unable to speak or move his left side well. He was taken to a local ER. In the ER experienced a spell in which he stared to the right for approximately one minute. During this time he was unable to speak and did not seem to comprehend verbal questions. This resolved. ER staff noted decreased left sided movement and a left Babinski sign.,He was given valium 5 mg, and DPH 1.0g. A HCT was performed and he was transferred to UIHC.,PMH:, DM, Coronary Artery Disease, Left femoral neuropathy of unknown etiology. Multiple head trauma in past (?falls/fights).,MEDS:, unknown oral med for DM.,SHX:, 10+pack-year h/o Tobacco use; quit 2 years ago. 6-pack beer/week. No h/o illicit drug use.,FHX:, unknown.,EXAM: ,70BPM, BP144/83, 16RPM, 36.0C,MS: Alert and oriented to person, place, time. Fluent speech.,CN: left lower facial weakness with right gaze preference. Pupils 3/3 decreasing to 2/2 on exposure to light. Optic disks flat.,MOTOR: decreased spontaneous movement of left-sided extremities. 5/4 strength in both upper and lower extremities. Normal muscle tone and bulk.,SENSORY: withdrew equally to noxious stimulation in all four extremities. GAIT/STATION/COORDINATION: not tested.,The general physical exam was unremarkable.,During the exam the patient experienced a spell during which his head turned and eyes deviated to the leftward, and his right hand twitched. The entire spell lasted one minute.,During the episode he was verbally unresponsive. He appeared groggy and lethargic after the event.,HCT without contrast: 11/18/92: right frontal skull fracture with associated minimal epidural hematoma and small subdural hematoma, as well as some adjacent subarachnoid blood and brain contusion.,LABS:, CBC, GS, PT/PTT were all WNL.,COURSE:, The patient was diagnosed with a right frontal SAH/contusion and post traumatic seizures. DPH was continued and he was given a Librium taper for possible alcoholic withdrawal. A neurosurgical consult was obtained. He did not receive surgical intervention and was discharged 12/1/92. Neuropsychological testing on 11/25/92 revealed: poor orientation to time or place and poor attention. Anterograde verbal and visual memory was severely impaired. Speech became mildly dysarthric when fatigued. Defective word finding. Difficulty copying 2 of 3 three dimensional figures. Recent head injury as well as a history of ETOH abuse and multiple prior head injuries probably contribute to his deficits.
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DESCRIPTION: HCT: SAH, Contusion, Skull fracture

HCT: SAH, Contusion, Skull fracture

neurology, sah, contusion, skull fracture, headache, post traumatic seizures, lower extremity weakness, loud noise, hct, weakness, skull, hematoma, fracture,

The situation involves a serious neurological condition resulting from head trauma, including a subarachnoid hemorrhage (SAH), contusion, and skull fracture, leading to seizures and significant neurological deficits. These conditions are potentially life-threatening and have long-term implications for patient health. Medical intervention, medication management, and neurosurgical consultation were required. The stakes are high due to the possible severe impact on the patient's health, including further neurological damage or death if not properly managed.


Medical Specialty: Neurology
Sample Name: Pseudotumor Cerebri

REASON FOR VISIT:  ,The patient is a 38-year-old woman with pseudotumor cerebri without papilledema who comes in because of new onset of headaches.  She comes to clinic by herself.,HISTORY OF PRESENT ILLNESS: , Dr. X has cared for her since 2002.  She has a Codman-Hakim shunt set at 90 mmH2O.  She last saw us in clinic in January 2008 and at that time we recommended that she followup with Dr. Y for medical management of her chronic headaches.  We also recommended that the patient see a psychiatrist regarding her depression, which she stated that she would followup with that herself.  Today, the patient returns to clinic because of acute onset of headaches that she has had since her shunt was adjusted after an MRI on 04/18/08.  She states that since that time her headaches have been bad.  They woke her up at night.  She has not been able to sleep.  She has not had a good sleep cycle since that time.  She states that the pain is constant and is worse with coughing, straining, and sneezing as well as on standing up.  She states that they feel a little bit better when lying down.  Medication shave not helped her.  She has tried taking Imitrex as well as Motrin 800 mg twice a day, but she states it has not provided much relief.  The pain is generalized, but also noted to be quite intense in the frontal region of her head.  She also reports ringing in the ears and states that she just does not feel well.  She reports no nausea at this time.  She also states that she has been experiencing intermittent blurry vision and dimming lights as well.  She tells me that she has an appointment with Dr. Y tomorrow.  She reports no other complaints at this time.,MAJOR FINDINGS:,  On examination today, this is a pleasant 38-year-old woman who comes back from the clinic waiting area without difficulty.  She is well developed, well nourished, and kempt.,Vital Signs:  Blood pressure 153/86, pulse 63, and respiratory rate 16.,Cranial Nerves:  Intact for extraocular movements.  Facial movement, hearing, head turning, tongue, and palate movements are all intact.  I did not know any papilledema on exam bilaterally.,I examined her shut site, which is clean, dry, and intact.  She did have a small 3 mm to 4 mm round scab, which was noted farther down from her shunt reservoir.  It looks like there is a little bit of dry blood there.,ASSESSMENT:,  The patient appears to have had worsening headaches since shunt adjustment back after an MRI.,PROBLEMS/DIAGNOSES:,1.  Pseudotumor cerebri without papilledema.,2.  Migraine headaches.,PROCEDURES:,  I programmed her shunt to 90 mmH2O.,PLAN:,  It was noted that the patient began to have an acute onset of headache pain after her shunt adjustment approximately a week and a half ago.  I had programmed her shunt back to 90 mmH2O at that time and confirmed it with an x-ray.  However, the picture of the x-ray was not the most desirable picture.  Thus, I decided to reprogram the shunt back to 90 mmH2O today and have the patient return to Sinai for a skull x-ray to confirm the setting at 90.  In addition, she told me that she is scheduled to see Dr. Y tomorrow, so she should followup with him and also plan on contacting the Wilmer Eye Institute to setup an appointment.  She should followup with the Wilmer Eye Institute as she is complaining of blurry vision and dimming of the lights occasionally.,Total visit time was approximately 60 minutes and about 10 minutes of that time was spent in counseling the patient.
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DESCRIPTION: The patient with pseudotumor cerebri without papilledema, comes in because of new onset of headaches.

neurology, migraine headaches, pseudotumor cerebri without papilledema, onset of headaches, blurry vision, shunt adjustment, pseudotumor cerebri, headaches, pseudotumor, cerebri, papilledema

The situation involves a patient with pseudotumor cerebri experiencing acute headaches after a shunt adjustment. This condition can potentially lead to increased intracranial pressure which requires careful management. The stakes are heightened by the potential risk of complications such as vision impairment due to elevated pressure. The need to reprogram the shunt and confirm the settings further illustrates the importance of correctly managing the patient's condition to prevent further complications.


Medical Specialty: Neurology
Sample Name: Phenol Neurolysis & Botulinum Toxin Injection - 1

PROCEDURES PERFORMED:,  Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves.  Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.,PROCEDURE CODES: , 64640 times three, 64614 times four, 95873 times four.,PREOPERATIVE DIAGNOSIS: , Spastic quadriparesis secondary to traumatic brain injury, 907.0.,POSTOPERATIVE DIAGNOSIS:,  Spastic quadriparesis secondary to traumatic brain injury, 907.0.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,DESCRIPTION OF TECHNIQUE: , Informed consent was obtained from the patient's brother.  The patient was brought to the minor procedure area and sedated per their protocol.  The patient was positioned lying supine.  Skin overlying all areas injected was prepped with chlorhexidine.  The obturator nerves were identified lateral to the adductor longus tendon origin and below the femoral pulse using active EMG stimulation.  Approximately 7 mL was injected on the right side and 5 mL on the left side.  At all sites of phenol injections in this area injections were done at the site of maximum hip adduction contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.  The musculocutaneous nerve was identified in the left upper extremity above the brachial pulse using active EMG stimulation.  Approximately 5 mL of 5% phenol was injected in this location.  Injections in this area were done at the site of maximum elbow flexion contraction with least amount of stimulus.  Negative drawback for blood was done prior to each injection of phenol.,Muscles injected with botulinum toxin were identified using active EMG stimulation.  Approximately 150 units was injected in the knee extensors bilaterally, 100 units in the left pectoralis major, and 50 units in the left wrist flexors.  Total amount of botulinum toxin injected was 450 units diluted 25 units to 1 mL.  The patient tolerated the procedure well and no complications were encountered.
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DESCRIPTION: Phenol neurolysis left musculocutaneous nerve and bilateral obturator nerves.  Botulinum toxin injection left pectoralis major, left wrist flexors, and bilateral knee extensors.

neurology, spastic quadriparesis, emg stimulation, emg, botulinum toxin injection, traumatic brain, brain injury, phenol neurolysis, toxin injection, musculocutaneous nerve, obturator nerves, pectoralis major, wrist flexors, knee extensors, active emg, botulinum toxin, toxin, injection, stimulus, neurolysis, musculocutaneous, extensors, botulinum, phenol

The situation involves a medical procedure targeting spastic quadriparesis due to traumatic brain injury. Both phenol neurolysis and botulinum toxin injections are performed to manage muscle spasticity, which can significantly affect a patient's mobility and quality of life. While the procedure appears to have been performed without complications, it involves critical nerve areas and requires precision to avoid adverse effects. Thus, the stakes are relatively high given the potential impact on the patient's physical function and the precision required in the procedure.


Medical Specialty: Neurology
Sample Name: New Onset Seizure

REASON FOR CONSULTATION: , New-onset seizure.,HISTORY OF PRESENT ILLNESS: , The patient is a 2-1/2-year-old female with a history of known febrile seizures, who was placed on Keppra oral solution at 150 mg b.i.d. to help prevent febrile seizures.  Although this has been a very successful treatment in terms of her febrile seizure control, she is now having occasional brief periods of pauses and staring, where she becomes unresponsive, but does not lose her postural tone.  The typical spell according to dad last anywhere from 10 to 15 seconds, mom says 3 to 4 minutes, which likely means probably somewhere in the 30- to 40-second period of time.  Mom did note that an episode had happened outside of a store recently, was associated with some perioral cyanosis, but there has never been a convulsive activity noted.  There have been no recent changes in her Keppra dosing and she is currently only at 20 mg/kg per day, which is overall a low dose for her.,PAST MEDICAL HISTORY: , Born at 36 weeks' gestation by C-section delivery at 8 pounds 3 ounces.  She does have a history of febrile seizures and what parents reported an abdominal migraine, but on further questioning, it appears to be more of a food intolerance issue.,PAST SURGICAL HISTORY: , She has undergone no surgical procedures.,FAMILY MEDICAL HISTORY: , There is a strong history of epilepsy on the maternal side of family including mom with some nonconvulsive seizure during childhood and additional seizures in maternal great grandmother and a maternal great aunt.  There is no other significant neurological history on the paternal side of the family.,SOCIAL HISTORY: , Currently lives with her mom, dad, and two siblings.  She is at home full time and does not attend day care.,REVIEW OF SYSTEMS:  ,Clear review of 10 systems are taken and revealed no additional findings other than those mentioned in the history of present illness.,PHYSICAL EXAMINATION:,Vital Signs:  Weight was 15.6 kg.  She was afebrile.  Remainder of her vital signs were stable and within normal ranges for her age as per the medical record.,General:  She was awake, alert, and oriented.  She was in no acute distress, only slightly flustered when trying to place the EEG leads.,HEENT:  Showed normocephalic and atraumatic head.  Her conjunctivae were nonicteric and sclerae were clear.  Her eye movements were conjugate in nature.  Her tongue and mucous membranes were moist.,Neck:  Trachea appeared to be in the midline.,Chest:  Clear to auscultation bilaterally without crackles, wheezes or rhonchi.,Cardiovascular:  Showed a normal sinus rhythm without murmur.,Abdomen:  Showed soft, nontender, and nondistended, with good bowel sounds.  There was no hepatomegaly or splenomegaly, or other masses noted on examination.,Extremities:  Showed IV placement in the right upper extremity with appropriate restraints from the IV.  There was no evidence of clubbing, cyanosis or edema throughout.  She had no functional deformities in any of her peripheral limbs.,Neurological:  From neurological standpoint, her cranial nerves were grossly intact throughout.  Her strength was good in the bilateral upper and lower extremities without any distal to proximal variation.  Her overall resting tone was normal.  Sensory examination was grossly intact to light touch throughout the upper and lower extremities.  Reflexes were 1+ in bilateral patella.  Toes were downgoing bilaterally.  Coordination showed accurate striking ability and good rapid alternating movements.  Gait examination was deferred at this time due to EEG lead placement.,ASSESSMENT:,  A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.,RECOMMENDATIONS,1.  For now, we will go ahead and try to capture EEG as long as she tolerates it; however, if she would require sedation, I would defer the EEG until further adjustments to seizure medications are made and we will see her response to these medications.,2.  As per the above, I will increase her Keppra to 300 mg p.o. b.i.d. bringing her to a total daily dose of just under 40 mg/kg per day.  If further spells are noted, we may increase upwards again to around 4.5 to 5 mL each day.,3.  I do not feel like any specific imaging needs to be done at this time until we see her response to the medication and review her EEG findings.  EEG, hopefully, will be able to be reviewed first thing tomorrow morning; however, I would not delay discharge the patient to wait on the EEG results.  The patient has been discharged and we will contact the family as an outpatient.,4.  The patient will need followup arrangement with me in 5 to 6 weeks' time, so we may recheck and see how she is doing and arrange for further followup then.
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DESCRIPTION: A 2-1/2-year-old female with history of febrile seizures, now with concern for spells of unclear etiology, but somewhat concerning for partial complex seizures and to a slightly lesser extent nonconvulsive generalized seizures.

The patient is a young child with a history of febrile seizures and currently experiencing spells that might be indicative of partial complex seizures. While the situation is being managed through changes in medication (Keppra) and monitoring with EEG, the potential for development into more severe seizures exists. However, the stakes are moderated by a planned medical follow-up and no immediate life-threatening symptoms. This makes it a medium-stakes situation concerning ongoing management and observation for potential complications.


Medical Specialty: Neurology
Sample Name: Neurology - Discharge Summary

PRELIMINARY DIAGNOSES:,1.  Contusion of the frontal lobe of the brain.,2.  Closed head injury and history of fall.,3.  Headache, probably secondary to contusion.,FINAL DIAGNOSES:,1.  Contusion of the orbital surface of the frontal lobes bilaterally.,2.  Closed head injury.,3.  History of fall.,COURSE IN THE HOSPITAL: , This is a 29-year-old male, who fell at home.  He was seen in the emergency room due to headache.  CT of the brain revealed contusion of the frontal lobe near the falx.  The patient did not have any focal signs.  He was admitted to ABCD.  Neurology consultation was obtained.  Neuro checks were done.  The patient continued to remain stable, although he had some frontal headache.  He underwent an MRI to rule out extension of the contusion or the possibility of a bleed and the MRI of the brain without contrast revealed findings consistent with contusion of the orbital surface of the frontal lobes bilaterally near the interhemispheric fissure.  The patient remained clinically stable and his headache resolved.  He was discharged home on 11/6/2008.,PLAN: , Discharge the patient to home.,ACTIVITY:  ,As tolerated.,The patient has been advised to call if the headache is recurrent and Tylenol 650 mg 1 p.o. q.6 h. p.r.n. headache.  The patient has been advised to follow up with me as well as the neurologist in about 1 week.
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DESCRIPTION: Contusion of the frontal lobe of the brain, closed head injury and history of fall, and headache, probably secondary to contusion.

neurology, interhemispheric, frontal lobe, head injury, brain, contusion

The case involves a young patient with a brain contusion and closed head injury, but his condition was stable and improved during the hospital stay. Discharge instructions are clear, and the follow-ups are planned with neurologists. Although head injuries can escalate, the immediate condition does not imply an urgent high-risk status. Thus, it's a moderate-stakes situation related to potential but not immediate life-threats.


Medical Specialty: Neurology
Sample Name: Neurologic Examination

NEUROLOGICAL EXAMINATION: , At present the patient is awake, alert and fully oriented.  There is no evidence of cognitive or language dysfunction.  Cranial nerves:  Visual fields are full.  Funduscopic examination is normal.  Extraocular movements full.  Pupils equal, round,  react to light.  There is no evidence of nystagmus noted.  Fifth nerve function is normal.  There is no facial asymmetry noted.  Lower cranial nerves are normal.  ,Manual motor testing reveals good tone and bulk throughout.  There is no evidence of pronator drift or decreased fine finger movements.  Muscle strength is 5/5 throughout.  Deep tendon reflexes are 2+ throughout with downgoing toes.  Sensory examination is intact to all modalities including stereognosis, graphesthesia.,TESTING OF STATION AND GAIT:, The patient is able to walk toe-heel and tandem walk.  Finger-to-nose and heel-to-shin moves are normal.  Romberg sign negative.  I appreciate no carotid bruits or cardiac murmurs.,Noncontrast CT scan of the head shows no evidence of acute infarction, hemorrhage or extra-axial collection.
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DESCRIPTION: Neurologic examination sample.

Neurologic examination sample.

neurology, station, motor testing, nerve function, neurologic examination, cranial nerves, cranial, extraocular, movementsNOTE

The neurologic examination shows a normal exam with no acute findings, and the noncontrast CT scan of the head shows no evidence of acute issues such as infarction or hemorrhage. Given the lack of concerning findings and the standard nature of the examination, this scenario is low-stakes.