Medical Specialty: Orthopedic
Sample Name: Arthrotomy & Ostectomy & Capsular Mass Excision

PREOPERATIVE DIAGNOSIS:, Soft tissue mass, right knee.,POSTOPERATIVE DIAGNOSES:,1.  Soft tissue mass, right knee.,2.  Osteophyte lateral femoral condyle, right knee.,PROCEDURES PERFORMED:, Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee.,SPECIFICATION: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under a local and IV sedation via the Anesthesia Department.,HISTORY AND GROSS FINDINGS:,  This is a 37-year-old African-American male with a mass present at the posterolateral aspect of his right knee.  On aspiration, it was originally attempted to no avail.  There was a long-standing history of this including two different MRIs, one about a year ago and one very recently both of which did not delineate the mass present.  During aspiration previously, the patient had experienced neuritic type symptoms down his calf, which have mostly resolved by the time that this had occurred.  The patient continued to complain of pain and dysfunction to his calf.  This was discussed with him at length.  He wished this to be explored and the mass excised even though knowing the possibility that they would not change his pain pattern with the potential of reoccurrence as well as the potential of scar stiffness, swelling, and peroneal nerve palsy.  With this, he decided to proceed.,Upon observation preoperatively, the patient was noted to have a hard mass present to the posterolateral aspect of the right knee.  It was noted to be tender.  It was marked preoperatively prior to an anesthetic.  Upon dissection, the patient was noted to have significant thickening of the posterior capsule.  The posterolateral aspect of the knee above the posterolateral complex at the gastroc attachment to the lateral femoral condyle.  There was also noted to be prominence of the lateral femoral condyle ridge.  The bifurcation at the tibial and peroneal nerves were identified and no neuroma was present.,OPERATIVE PROCEDURE:  ,The patient was laid supine upon the operating table.  After receiving IV sedation, he was placed prone.  Thigh tourniquet was placed.  He was prepped and draped in the usual sterile manner.  A transverse incision was carried down across the crease with a mass had been palpated through skin and subcutaneous tissue after exsanguination of the limb and tourniquet utilized.  The nerve was identified and carefully retracted throughout the case.  Both nerves were identified and carefully retracted throughout the case.  There was noted to be no neuroma present.  This was taken down until the gastroc was split.  There was gross thickening of the joint capsule and after arthrotomy, a section of the capsule was excised.  The lateral femoral condyle was then osteophied.  We then smoothed off with a rongeur.  After this, we could not palpate any mass whatsoever placing pressure upon the area of the nerve.  Tourniquet was deflated.  It was checked again.  There was no excessive swelling.  Swanson drain was placed to the depth of the wound and interrupted #2-0 Vicryl was utilized for subcutaneous fat closure and #4-0 nylon was utilized for skin closure.  Adaptic, 4x4s, ABDs, and Webril were placed for compression dressing.  Digits were warm _______ pulses distally at the end of the case.  The tourniquet as stated has been deflated prior to closure and hemostasis was controlled.  Expected surgical prognosis on this patient is guarded.
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DESCRIPTION: Excision of capsular mass and arthrotomy with ostectomy of lateral femoral condyle, right knee.  Soft tissue mass and osteophyte lateral femoral condyle, right knee.

orthopedic, soft tissue mass, osteophyte, lateral femoral condyle, excision, capsular mass, arthrotomy, ostectomy, knee, soft tissue, femoral condyle, mass, subcutaneous, capsular, tourniquet, femoral, condyle,

The situation involves a surgical procedure, specifically an excision of a capsular mass and osteophyte removal in a patient's knee. While knee surgeries can have significant implications for the patient's mobility and quality of life, the procedure described is routine and was performed under local and IV sedation, which indicates a lower level of risk than more invasive surgeries. The stakes are moderate due to the potential for complications such as peroneal nerve palsy, scar stiffness, and swelling, but these are expected risks in orthopedic surgeries. The mention of a 'guarded' prognosis suggests some uncertainty in outcome, which adds to the stakes slightly.


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Medical Specialty: Orthopedic
Sample Name: Arthroscopy, Meniscoplasty, & Chondroplasty

PREOPERATIVE DIAGNOSIS:,  Medial meniscal tear, left knee.,POSTOPERATIVE DIAGNOSIS: , Chondromalacia of medial femoral condyle.,PROCEDURE PERFORMED:,1.  Arthroscopy of the left knee.,2.  Left arthroscopic medial meniscoplasty of medial femoral condyle.,3.  Chondroplasty of the left knee as well.,ESTIMATED BLOOD LOSS: , 80 cc.,TOTAL TOURNIQUET TIME: , 19 minutes.,DISPOSITION: , The patient was taken to PACU in stable condition.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 41-year-old male with left knee pain for approximately two years secondary to hockey injury where he did have a prior MCL sprain.  He has had a positive symptomology of locking and pain since then.  He had no frank instability to it, however.,GROSS OPERATIVE FINDINGS: , We did find a tear to the medial meniscus as well as a large area of chondromalacia to the medial femoral condyle.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room.  The left lower extremity was prepped and draped in the usual sterile fashion.  Tourniquet was applied to the left thigh with adequate Webril padding, not inflated at this time.  After the left lower extremity had been prepped and draped in the usual sterile fashion, we applied an Esmarch tourniquet, exsanguinating the blood and inflated the tourniquet to 325 mmHg for a total of 19 minutes.  We established the lateral port of the knee with #11 blade scalpel.  We put in the arthroscopic trocar, instilled with water and inserted the camera.,On inspection of the patellofemoral joint, it was found to be quite smooth.  Pictures were taken there.  There was no evidence of chondromalacia, cracking, or fissuring of the articular cartilage.  The patella was well centered over the trochlear notch.  We then directed the arthroscope to the medial compartment of the knee.  It was felt that there was a tear to the medial meniscus.  We also saw large area of chondromalacia with grade-IV changes to bone over the medial femoral condyle.  This area was debrided with forceps and the arthroscopic shaver.  The cartilage was also smoothened over the medial femoral condyle.  This was curetted after the medial meniscus had been trimmed.  We looked into the notch.  We saw the ACL appeared stable, saw attachments to tibial as well as the femoral insertion with some evidence of laxity, wear and tear.  Attention then was taken to the lateral compartment with some evidence of tear to the lateral meniscus and the arterial surface of both the tibia as well as the femur were pristine in the lateral compartment.  All instruments were removed.  All loose cartilaginous pieces were suctioned from the knee and water was suctioned at the end.  We removed all instruments.  Marcaine was injected into the portal sites.  We placed a sterile dressing and stockinet on the left lower extremity.  He was transferred to the gurney and taken to PACU in stable condition.
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DESCRIPTION: Arthroscopy of the left knee, left arthroscopic medial meniscoplasty of medial femoral condyle, and chondroplasty of the left knee as well.  Chondromalacia of medial femoral condyle.   Medial meniscal tear, left knee.

orthopedic, medial meniscoplasty, arthroscopic, chondroplasty, arthroscopy, medial femoral condyle, medial meniscus, knee, meniscal, cartilage, meniscoplasty, meniscus, chondromalacia, condyle, femoral

The situation involves a surgical procedure for a knee injury, specifically addressing a medial meniscal tear and chondromalacia. While surgeries inherently involve some level of risk, the patient was reported to be in stable condition post-operation, with estimated blood loss being relatively low and tourniquet time brief. These factors indicate it was a routine and controlled procedure. However, it is still a surgical intervention requiring precision and care. Given this, the scenario represents moderate stakes, not life-threatening but requiring surgical expertise and patient recovery monitoring.

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Medical Specialty: Orthopedic
Sample Name: Arthroscopy - Shoulder

PREOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,POSTOPERATIVE DIAGNOSIS: , Partial rotator cuff tear, left shoulder.,PROCEDURE PERFORMED:, Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.,ANESTHESIA:  ,Scalene block with general anesthesia.,ESTIMATED BLOOD LOSS: , 30 cc.,COMPLICATIONS: , None.,DISPOSITION:  ,The patient went to the PACU stable.,GROSS OPERATIVE FINDINGS: , There was no overt pathology of the biceps tendon.  There was some softening and loss of the articular cartilage over the glenoid.  The labrum was ________ attached permanently to the glenoid.  The biceps tendon was nonsubluxable.  Upon ranging of the shoulder in internal and external rotation showed no evidence of rotator cuff tear on the articular side.  Subacromial space did show excessive soft tissue causing some overstuffing of the subacromial space.  There was reconstitution of the bursa noted as well.,HISTORY OF PRESENT ILLNESS:,  This is a 51-year-old female had left shoulder pain of chronic nature who has had undergone prior rotator cuff debridement in May with partial pain relief and has had continued pain in the left shoulder.  MRI shows partial rotator cuff tear.,PROCEDURE: , The patient was taken to the operating room and placed in a beachchair position.  After all bony prominences were adequately padded, the head was placed in the headholder with no excessive extension in the neck on flexion.  The left extremity was prepped and draped in usual fashion.  The #18 gauge needles were inserted into the left shoulder to locate the AC joint, the lateral aspect of the acromion as well as the pass of the first trocar to enter the shoulder joint from the posterior aspect.  We took an #11 blade scalpel and made a small 1-cm skin incision posteriorly approximately 4-cm inferior and medial to the lateral port of the acromion.  A blunt trocar was used to bluntly cannulate the joint and we put the camera into the shoulder at that point of the joint and instilled sterile saline to distend the capsule and begin our arthroscopic assessment of the shoulder.  A second port was established superior to the biceps tendon anteriorly under direct arthroscopic visualization using #11 blade on the skin and inserted bluntly the trocar and the cannula.  The operative findings found intra-articularly were as described previously gross operative findings.  We did not see any evidence of acute pathology.  We then removed all the arthroscopic instruments as well as the trocars and tunneled subcutaneously into the subacromial space and reestablished the portal and camera and inflow with saline.  The subacromial space was examined and found to have excessive soft tissue and bursa that was in the subacromial space that we debrided using arthroscopic shaver after establishing a lateral portal.  All this was done and hemostasis was achieved.  The rotator cuff was examined from the bursal side and showed no evidence of tears.  There was some fraying out laterally near its attachment over the greater tuberosity, which was debrided with the arthroscopic shaver.  We removed all of our instruments and suctioned the subacromial space dry.  A #4-0 nylon was used on the three arthroscopic portal and on the skin we placed sterile dressing and the arm was placed in an arm sling.  She was placed back on the gurney, extubated and taken to the PACU in stable condition.
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DESCRIPTION: Partial rotator cuff tear, left shoulder.  Arthroscopy of the left shoulder with arthroscopic rotator cuff debridement, soft tissue decompression of the subacromial space of the left shoulder.

orthopedic, subacromial space, arthroscopic, biceps tendon, labrum, glenoid, cartilage, partial rotator cuff tear, rotator cuff tear, shoulder arthroscopy, rotator cuff, arthroscopy, shoulder, tissue, subacromial, rotator, cuff,

The described situation involves an orthopedic procedure - arthroscopy of the shoulder with rotator cuff debridement and soft tissue decompression. It is a routine surgical procedure typically used to treat shoulder pain in cases like partial rotator cuff tears. While all surgeries carry some level of risk, this procedure is commonly performed with a low incidence of complications, as indicated by the report (e.g., estimated blood loss is minimal, and no complications were noted). Therefore, this scenario is not considered extremely high-stakes, although it does carry typical surgical risks.


Medical Specialty: Orthopedic
Sample Name: Arthroscopic Rotator Cuff Repair

PROCEDURE: , Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.,PATIENT PROFILE:,  This is a 42-year-old female.  Refer to note in patient chart for documentation of history and physical.  Due to the nature of the patient's increasing pain, surgery is recommended.  The alternatives, risks and benefits of surgery were discussed with the patient.  The patient verbalized understanding of the risks as well as the alternatives to surgery.  The patient wished to proceed with operative intervention.  A signed and witnessed informed consent was placed on the chart.  Prior to initiation of the procedure, patient identification and proposed procedure were verified by the surgeon in the pre-op area, and the operative site was marked by the patient and verified by the surgeon.,PRE-OP DIAGNOSIS: , Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,POST-OP DIAGNOSIS:,  Acute complete tear of the supraspinatus, Shoulder impingement syndrome.,ANESTHESIA: , General - Endotracheal.,FINDINGS:,ACROMION:,1.  There was a medium-sized (5 - 10 mm) anterior acromial spur.,2.  The subacromial bursa was inflamed.,3.  The subacromial bursa was thickened.,4.  There was thickening of the coracoacromial ligament.,LIGAMENTS / CAPSULE: , Joint capsule within normal limits.,LABRUM: , The labrum is within normal limits.,ROTATOR CUFF: , Full thickness tear of the supraspinatus tendon, 5 mm anterior to posterior, by 10 mm medial to lateral.  Muscles and Tendons:  The biceps tendon is within normal limits.,JOINT:,  Normal appearance of the glenoid and humeral surfaces.,DESCRIPTION OF PROCEDURE:,PATIENT POSITIONING: , Following induction of anesthesia, the patient was placed in the beach-chair position on the standard operating table.  All body parts were well padded and protected to make sure there were no pressure points.  Subsequently, the surgical area was prepped and draped in the appropriate sterile fashion with Betadine.,INCISION TYPE:,1.  Scope Ports:  Anterior Portal.,2.  Scope Ports:  Posterior Portal.,3.  Scope Ports:  Accessory Anterior Portal.,INSTRUMENTS AND METHODS:,1.  The arthroscope and instruments were introduced into the shoulder joint through the arthroscopic portals.,2.  The subacromial space and bursa, biceps tendon, coracoacromial and glenohumeral ligaments, biceps tendon, rotator cuff, supraspinatus, subscapularis, infraspinatus, teres minor, capsulo-labral complex, capsule, glenoid labrum, humeral head, and glenoid, including the inner and outer surfaces of the rotator cuff, were visualized and probed.,3.  The subacromial bursa, subacromial soft tissues and frayed rotator cuff tissue were resected and debrided using a motorized resector and 4.5 Synovial Resector.,4.  The anterior portion of the acromion and acromial spur were resected with the 5.5 acromionizer burr.  Approximately 5 mm of bone was removed.  The coracoacromial ligament was released with the bony resection.  The shoulder joint was thoroughly irrigated.,5.  The edges of the cuff tissue were prepared, prior to the fixation, using the motorized resector.,6.  The supraspinatus tendon was reattached and sutured using the arthroscopic knot pusher and Mitek knotless anchor system and curved pointed suture passer and large bore cannula (to pass the sutures).  The repair was accomplished in a side-to-side and a tendon-to-bone fashion using three double loaded Mitek G IV suture anchors with 1 PDS suture.,7.  The repair was stable to palpation with the probe and watertight.,8.  The arthroscope and instruments were removed from the shoulder.,PATHOLOGY SPECIMEN: , No pathology specimens.,WOUND CLOSURE:,  The joint was thoroughly irrigated with 7 L of sterile saline.  The portal sites were infiltrated with 1% Xylocaine.  The skin was closed with 4-0 Vicryl using interrupted subcuticular technique.,DRAINS / DRESSING:,  Applied sterile dressing including gauze, iodoform gauze and Elastoplast.,SPONGE / INSTRUMENT / NEEDLE COUNTS:,  Final counts were correct.
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DESCRIPTION: Primary right shoulder arthroscopic rotator cuff repair with subacromial decompression.

The situation involves a surgical procedure, specifically an arthroscopic rotator cuff repair with subacromial decompression. Surgical interventions naturally carry higher stakes due to the potential risks and complications associated with anesthesia, the possibility of infection, and the need for a successful outcome to improve the patient's quality of life. Additionally, there is an acute complete tear of the supraspinatus and shoulder impingement syndrome, both of which require precise surgical intervention to repair. Although routine and often performed successfully, any surgery involves significant decision-making and precise execution, which increases the stakes.


Medical Specialty: Orthopedic
Sample Name: Arthroscopic SLAP lesion

PREOPERATIVE DIAGNOSIS: , Rotator cuff tear, right shoulder.,POSTOPERATIVE DIAGNOSIS: , Superior labrum anterior and posterior lesion (peel-back), right shoulder.,PROCEDURE PERFORMED:,1.  Arthroscopy with arthroscopic SLAP lesion.,2.  Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.,SPECIFICATIONS: , The entire operative procedure was done in Inpatient Operating Suite, room #1 at ABCD General Hospital.  This was done under a interscalene block anesthetic and subsequent general anesthetic in the modified beachchair position.,HISTORY AND GROSS FINDINGS:  ,This is a 54-year-old white female suffering an increasing right shoulder pain for a few months prior to surgical intervention.  She had an injury to her right shoulder when she fell off a bike.  She was diagnosed preoperatively with a rotated cuff tear.,Intra-articularly besides we noted a large SLAP lesion, superior and posterior to the attachment of the glenoid labrum from approximately 12:30 back to 10:30.  This acted as a peel-back type of mechanism and was displaced into the joint beyond the superior rim of the glenoid.  This was an obvious avulsion into subchondral bone with bone exposed.  The anterior aspect had degenerative changes, but did not have evidence of avulsion.  The subscapular was noted to be intact.  On the joint side of the supraspinatus, there was noted to be a laminated type of tearing to the rotated cuff to the anterior and mid-aspect of the supraspinatus attachment.,This was confirmed subacromially.  The patient had a type-I plus acromion in outlet view and thus it was elected to not perform a subacromial decompression, but soft tissue release of the CA ligament in a releasing resection type fashion.,OPERATIVE PROCEDURE: , The patient was placed supine upon the operative table after she was given interscalene and then general anesthesia by the Anesthesia Department.  She was safely placed in a modified beachchair position.  She was prepped and draped in the usual sterile manner.  The portals were created from outside the ends, posterior to the scope and anteriorly for an intraoperative portal and then laterally.  She had at least two other portals appropriate for both repair mechanisms described above.,Attention was then turned to the SLAP lesion.  The edges were debrided both on the bony side as well as soft tissue side.  We used the anterior portal to lift up the mechanism and created a superolateral portal through the rotator cuff and into the edge of the labrum.  Further debridement was carried out here.  A drill hole was made just on the articular surface superiorly for a knotless anchor.  A pull-through suture of #2 fiber wire was utilized with the ________.  This was pulled through.  It was tied to the leader suture of the knotless anchor.  This was pulled through and one limb of the anchor loop was grabbed and the anchor impacted with a mallet.  There was excellent fixation of the superior labrum.  It was noted to be solid and intact.  The anchor was placed safely in the bone.  There was no room for further knotless or other anchors.  After probing was carried out, hard copy Polaroid was obtained.,Attention was then turned to the articular side for the rotator cuff.  It was debrided.  Subchondral debridement was carried out to the tuberosity also.  Care was taken to go to the subchondral region but not beyond.  The bone was satisfactory.,Scope was then placed in the subacromial region.  Gross bursectomy was carried out with in the lateral portal.  This was done throughout as well as in the gutters anterolaterally and posteriorly.  Debridement was carried out further to the rotator cuff.  Two types of fixation were carried out, one with a superolateral portal a drill hole was made and anchor of the _knotless suture placed after PDS leader suture placed with a Caspari punch.  There was an excellent reduction of the tear posteriorly and then anteriorly.  Tendon to tendon repair was accomplished by placing a fiber wire across the tendon and tying sutured down through the anterolateral portal.  This was done with a sliding stitch and then two half stitches.  There was excellent reduction of the tear.,Attention was then turned to the CA ligament.  It was released along with periosteum and the undersurface of the anterior acromion.  The CA ligament was not only released but resected.  There was noted to be no evidence of significant spurring with only a mostly type-I acromion.  Thus, it was not elected to perform subacromial decompression for bone with soft tissue only.  A pain buster catheter was placed separately.  It was cut to length.  An interrupted #4-0 nylon was utilized for portal closure.  A 0.5% Marcaine was instilled subacromially.  Adaptic, 4x4s, ABDs, and Elastoplast tape placed for dressing.  The patient's arm was placed in a arm sling.  She was transferred to PACU in apparent satisfactory condition.  Expected surgical prognosis on this patient is fair.
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DESCRIPTION: Rotator cuff tear, right shoulder.  Superior labrum anterior and posterior lesion (peel-back), right shoulder.  Arthroscopy with arthroscopic SLAP lesion.  Repair of soft tissue subacromial decompression rotator cuff repair, right shoulder.

orthopedic, rotator cuff tear, shoulder, labrum, lesion, decompression, subacromial, arthroscopic slap lesion, slap lesion, rotator cuff, anterior, arthroscopy, arthroscopic, slap, cuff

The described scenario involves a surgical procedure for an orthopedic condition, specifically dealing with a SLAP lesion and a rotator cuff tear. While this is a routine orthopedic procedure, there are always inherent risks associated with surgery such as infection, anesthesia complications, or poor recovery. However, given the typical nature of the procedure and standard expected outcomes, it isn't classified as an extremely high-risk or high-stakes situation compared to other medical scenarios such as emergency surgeries or life-threatening conditions.


Medical Specialty: Orthopedic
Sample Name: Arthroplasty

PREOPERATIVE DIAGNOSES:,1.  Hammertoe deformity, left fifth digit.,2.  Ulceration of the left fifth digit plantolaterally.,POSTOPERATIVE DIAGNOSIS:,1.  Hammertoe deformity, left fifth toe.,2.  Ulceration of the left fifth digit plantolaterally.,PROCEDURE PERFORMED:,1.  Arthroplasty of the left fifth digit proximal interphalangeal joint laterally.,2.  Excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.,OPERATIVE PROCEDURE IN DETAIL: , The patient is a 38-year-old female with longstanding complaint of painful hammertoe deformity of her left fifth toe.  The patient had developed ulceration plantarly after being scheduled for removal of a plantar mass in the same area.  The patient elects for surgical removal of this ulceration and correction of her hammertoe deformity at this time.,After an IV was instituted by the Department of Anesthesia, the patient was escorted to the OR where the patient was placed on the Operating Room table in the supine position.  After adequate amount of IV sedation was administered by Anesthesia Department, the patient was given a digital block to the left fifth toe using 0.5% Marcaine plain with 1% lidocaine plain in 1:1 mixture totaling 6 cc.  Following this, the patient was draped and prepped in a normal sterile orthopedic manner.  An ankle tourniquet was placed on the left ankle and the left foot was elevated and Esmarch bandage applied to exsanguinate the foot.  The ankle tourniquet was then inflated to 230 mmHg and then was brought back down to the level of the table.  The stockinette was then cut and reflected and held in place using towel clamp.,The skin was then cleansed using the wet and dry Ray-Tec sponge and then the plantar lesion was outlined.  The lesion measured 1 cm in diameter at the level of the skin and a 3 cm elliptical incision line was drawn on the surface of the skin in the plantolateral aspect of the left fifth digit.  Then using a fresh #15 blade, skin incision was made.  Following this, the incision was then deepened using a fresh #15 blade down to the level of the subcutaneous tissue.  Using a combination of sharp and blunt dissection, the skin was reflected distally and proximally to the lesion.  The lesion appeared well encapsulated with fibrous tissue and through careful dissection using combination of sharp and drill instrumentation the ulceration was removed in its entirety.  The next further exploration was performed to ensure that no residual elements of the fibrous capsular tissue remained within.  The lesion extended from the level of the skin down to the periosteal tissue of the middle and distal phalanx, however, did not show any evidence of extending beyond the level of a periosteum.  Remaining tissues were inspected and appeared healthy.  The lesion was placed in the specimen container and sent to pathology for microanalysis as well as growth.  Attention was then directed to the proximal interphalangeal joint of the left fifth digit and using further dissection with a #15 blade, the periosteum was reflected off the lateral aspect of the proximal ________ median phalanx.  The capsule was also reflected to expose the prominent lateral osseous portion of this joint.  Using a sagittal saw and #139 blade, the lateral osseous prominence was resected.  This was removed in entirety.  Then using power-oscillating rasp, the sharp edges were smoothed and recontoured to the desirable anatomic condition.  Then the incision and wound was flushed using copious amounts of sterile saline with gentamycin.  Following this, the bone was inspected and appeared to be healthy with no evidence of involvement from the removed aforementioned lesion.,Following this, using #4-0 nylon in a combination of horizontal mattress and simple interrupted sutures, the lesion wound was closed and skin was approximated well without tension to the surface skin.  Following this, the incision site was dressed using Owen silk, 4x4s, Kling, and Coban in a normal fashion.  The tourniquet was then deflated and hyperemia was noted to return to digits one through five of the left foot.  The patient was then escorted from the operative table into the Postanesthesia Care Unit.  The patient tolerated the procedure and anesthesia well and was brought to the Postanesthesia Care Unit with vital signs stable and vascular status intact.  In the recovery, the patient was given a surgical shoe as well as given instructions for postoperative care to include rest ice and elevation as well as the patient was given prescription for Naprosyn 250 mg to be taken three times daily as well as Vicodin ES to be taken q.6h. as needed.,The patient will follow-up on Friday with Dr. X in office for further evaluation.  The patient was also given instructions as to signs of infection and to monitor her operative site.  The patient was instructed to keep daily dressings intact, clean, dry, and to not remove them.
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DESCRIPTION: Hammertoe deformity, left fifth digit and ulceration of the left fifth digit plantolaterally.  Arthroplasty of the left fifth digit proximal interphalangeal joint laterally and excision of plantar ulceration of the left fifth digit 3 cm x 1 cm in size.

orthopedic, hammertoe deformity, plantolaterall, ulceration, arthroplasty, plantar ulceration, interphalangeal, painful hammertoe, proximal interphalangeal joint, interphalangeal joint, digit, toe, blade, deformity, incision, hammertoe, lesion

The situation involves a routine surgical procedure addressing a hammertoe deformity and an associated ulcer. While important for the patient's health and comfort, it does not present immediate life-threatening risks, especially given the patient's overall stable condition during and after the surgery. Standard post-operative care instructions were provided, and there are no indications of complications during the procedure.


Medical Specialty: Orthopedic
Sample Name: Arthrodesis

PREOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,POSTOPERATIVE DIAGNOSIS: , Congenital myotonic muscular dystrophy with bilateral planovalgus feet.,PROCEDURE: , Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.,ANESTHESIA: , Surgery performed under general anesthesia.  The patient received 6 mL of 0.25% Marcaine local anesthetic on each side.,TOURNIQUET TIME:  ,Tourniquet time was 53 minutes on the left and 45 minutes on the right.,COMPLICATIONS: , There were no intraoperative complications.,DRAINS:,  None.,SPECIMENS: , None.,HARDWARE USED: , Staple 7/8 inch x1 on each side.,HISTORY AND PHYSICAL:  ,The patient is a 5-year-4-month-old male who presents for evaluation of feet.  He has been having significant feet pain with significant planovalgus deformity.  The patient was noted to have flexible vertical talus.  It was decided that the patient would benefit by subtalar arthrodesis, possible autograft, and Achilles lengthening.  This was explained to the mother in detail.  This is going to be a stabilizing measure and the patient will probably need additional surgery at a later day when his foot is more mature.  Risks of surgery include risks of anesthesia, infection, bleeding, changes in sensation and motion of the extremity, hardware failure, need for other surgical procedures, need to be nonweightbearing for some time.  All questions were answered and the mother agreed to the above plan.,PROCEDURE NOTE: , The patient was taken to the operating room, placed supine on the operating room, general anesthesia was administered.  The patient received Ancef preoperatively.  Bilateral nonsterile tourniquets were placed on each thigh.  A bump was placed underneath the left buttock.  Both the extremities were then prepped and draped in standard surgical fashion.  Attention was first turned towards the left side.  Intended incision was marked on the skin.  The ankle was taken through a range of motion with noted improvement in the reduction of the talocalcaneal alignment with the foot in plantar flexion on the lateral view.  The foot was wrapped in Esmarch prior to inflation of tourniquet to 200 mmHg.  Incision was then made over the left lateral aspect of the hind foot to expose the talocalcaneal joint.  The sinus tarsi was then identified using a U-shaped flap to tack muscles, and periosteum was retracted distally.  Once the foot was reduced a Steinman pin was used to hold it in position.  This position was first checked on the fluoroscopy.  The 7/8th inch staple was then placed across the sinus tarsi to maintain the reduction.  This was also checked with fluoroscopy.  The incision was then extended posteriorly to allow for visualization of the Achilles, which was Z-lengthened with the release of the lateral distal half.  This was sutured using 2-0 Ethibond and that was also oversewn.  The wound was irrigated with normal saline.  The periosteal flap was sutured over the staple using 2-0 Vicryl.  Skin was closed using 2-0 Vicryl interrupted and then with 4-0 Monocryl.  The area was injected with 6 mL of 0.25% Marcaine local anesthetic.  The wound was cleaned and dried, dressed with Steri-Strips, Xeroform, and 4 x 4s and Webril.  Tourniquet was released after 53 minutes.  The exact same procedure was repeated on the right side with no changes or complications.  Tourniquet time on the right side was 45 minutes.  The patient tolerated the procedure well.  Bilateral long-leg casts were then placed with the foot in neutral with some moulding of his medial plantar arch.  The patient was subsequently was taken to Recovery in stable condition.,POSTOPERATIVE PLAN: , The patient will be hospitalized overnight for pain as per parents' request.  The patient is to be strict nonweightbearing for at least 6 weeks.  He is to follow up in the next 10 days for a check.  We will plan of changing to short-leg casts in about 4 weeks postop.
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DESCRIPTION: Bilateral Crawford subtalar arthrodesis with open Achilles Z-lengthening and bilateral long-leg cast.

orthopedic, myotonic muscular dystrophy, muscular dystrophy, planovalgus feet, achilles z-lengthening, subtalar arthrodesis, bilateral crawford subtalar arthrodesis, bilateral long leg cast, sinus tarsi, leg casts, tourniquet time, arthrodesis, intraoperative, fluoroscopy, tourniquet, surgery, subtalar, achilles, anesthesia, planovalgus, foot, bilateral,

This situation involves a complex surgical procedure on a young child diagnosed with congenital myotonic muscular dystrophy, which adds to the patient's vulnerability and the complexity of care. Arthrodesis and Achilles lengthening are significant orthopedic surgeries with potential risks that include anesthesia-related issues, infection, and incomplete recovery. Although there were no intraoperative complications, the stakes remain high due to the patient's young age, potential pain management concerns, and the requirement for extensive postoperative care and follow-ups. Thus, even though the surgery was initially successful, the potential for complications and the necessity for further surgeries make this a relatively high-stakes situation.


Medical Specialty: Orthopedic
Sample Name: Anterior Cervical Discectomy & Fusion - 8

PROCEDURES PERFORMED: , C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.,ESTIMATED BLOOD LOSS: , 10 mL.,CLINICAL NOTE: , This is a 57-year-old gentleman with refractory neck pain with single-level degeneration of the cervical spine and there was also some arm pain.  We decided go ahead with anterior cervical discectomy at C5-C6 and fusion.  The risks of lack of pain relief, paralysis, hoarse voice, nerve injuries, and infection were explained and the patient agreed to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the operating room where a general endotracheal anesthesia was induced without complication.  The patient was placed in the slightly extended position with the neck and the head was restrained in a doughnut and the occiput was restrained by the doughnut.  He had tape placed over the shoulders during intraoperative x-rays and his elbows were well padded.  The tape was placed and his arms were well padded.  He was prepped and draped in a sterile fashion.  A linear incision was fashioned at the cricothyroid level from near the midline to over the sternocleidomastoid muscle.  We separated the platysma from the subcutaneous tissue and then opened the platysma along the medial border of the sternocleidomastoid muscle.  We then dissected sharply medial to carotid artery, which we palpated to the prevertebral region.  We placed Caspar retractors for medial and lateral exposure over the C5-C6 disc space, which we confirmed with the lateral cervical spine x-ray including 18-gauge needle in the disc space.  We then marked the disc space.  We then drilled off ventral osteophyte as well as osteophyte creating concavity within the disc space.  We then under magnification removed all the disc material, we could possibly see down to bleeding bone and both the endplates.  We took down posterior longitudinal ligament as well.  We incised the 6-mm cornerstone bone.  We placed a 6-mm parallel medium bone nicely into the disc space.  We then sized a 23-mm plate.  We inserted the screws nicely above and below.  We tightened down the lock-nuts.  We irrigated the wound.  We assured hemostasis using bone wax prior to placing the plate.  We then assured hemostasis once again.  We reapproximated the platysma using 3-0 Vicryl in a simple interrupted fashion.  The subcutaneous level was closed using 3-0 Vicryl in a simple buried fashion.  The skin was closed with 3-0 Monocryl in a running subcuticular stitch.  Steri-Strips were applied.  Dry sterile dressing with Telfa was applied over this.  We obtained an intraoperative x-ray to confirm the proper level and good position of both plates and screw construct on the lateral x-ray and the patient was transferred to the recovery room, moving all four extremities with stable vital signs.  I was present as a primary surgeon throughout the entire case.
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DESCRIPTION: C5-C6 anterior cervical discectomy, allograft fusion, and anterior plating.

orthopedic, allograft fusion, anterior cervical discectomy, neck pain, cervical spine, discectomy, fusion, sternocleidomastoid muscle, assured hemostasis, anterior cervical, cervical discectomy, disc space, cervical, anterior, allograft

The situation involves a surgical procedure, which is inherently high-stakes due to the potential for significant complications such as paralysis, nerve injuries, infection, and unsuccessful pain relief. The risks were clearly communicated to the patient, indicating the critical nature of the procedure. Despite the blood loss being minimal and the procedure seemingly successful as described, the stakes remain high due to the potential for serious outcomes. The successful completion and minimal complications do somewhat decrease the stakes after the fact, but given the inherent risks described, this remains a high-stakes situation.


Medical Specialty: Orthopedic
Sample Name: Anterior Cervical Discectomy & Fusion - Discharge Summary

FINAL DIAGNOSES:,1.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy.,2.  Moderate stenosis C5-6.,OPERATION: , On 06/25/07, anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.,This is a 60-year-old white male who was in the office on 05/01/07 because of neck pain with left radiculopathy and "tension headaches."  In the last year or so, he has had more and more difficulty and more recently has developed tingling and numbness into the fingers of the left hand greater than right.  He has some neck pain at times and has seen Dr. X for an epidural steroid injection, which was very helpful.  More recently he saw Dr. Y and went through some physical therapy without much relief.,Cervical MRI scan was obtained and revealed a large right-sided disc herniation at C4-5 with significant midline herniations at C5-6 and a large left HNP at C6-7.  In view of the multiple levels of pathology, I was not confident that anything short of surgical intervention would give him significant relief.  The procedure and its risk were fully discussed and he decided to proceed with the operation.,HOSPITAL COURSE: , Following admission, the procedure was carried out without difficulty.  Blood loss was about 125 cc.  Postop x-ray showed good alignment and positioning of the cages, plate, and screws.  After surgery, he was able to slowly increase his activity level with assistance from physical therapy.  He had some muscle spasm and soreness between the shoulder blades and into the back part of his neck.  He also had some nausea with the PCA.  He had a low-grade fever to 100.2 and was started on incentive spirometry.  Over the next 12 hours, his fever resolved and he was able to start getting up and around much more easily.,By 06/27/07, he was ready to go home.  He has been counseled regarding wound care and has received a neck sheet for instruction.  He will be seen in two weeks for wound check and for a followup evaluation/x-rays in about six weeks.  He has prescriptions for Lortab 7.5 mg and Robaxin 750 mg.  He is to call if there are any problems.
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DESCRIPTION: Anterior cervical discectomy and fusions C4-5, C5-6, C6-7 using Bengal cages and Slimlock plate C4 to C7; intraoperative x-ray.  Herniated nucleuses pulposus, C5-6 greater than C6-7, left greater than C4-5 right with left radiculopathy and moderate stenosis C5-6.

orthopedic, slimlock, herniated nucleuses pulposus, anterior cervical discectomy, bengal cages, anterior, herniated, cervical, radiculopathy, discectomy,

The situation involves a surgical intervention for a herniated disc and stenosis, which is a significant medical procedure, although the immediate clinical outcome post-surgery was positive. The patient required an anterior cervical discectomy and fusion, which is not a minor operation, but rather a complex and invasive procedure that can have serious implications if complications arise. The stakes are elevated due to the nature of spinal surgery, risk of complications, and potential impact on the patient's quality of life if not successful. Post-surgery care and follow-up are crucial for ensuring good recovery, but the fact that no serious complications are reported at discharge lowers the immediate urgency of the situation.


Medical Specialty: Orthopedic
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 described procedure, an anterior cervical discectomy with osteophytectomy, is a significant spinal surgery involving the cervical spine (neck area). It addresses serious conditions such as cervical radiculopathy, cervical spondylosis, stenosis, and disc herniations, which can cause severe symptoms, including pain, numbness, and weakness. The surgery aims to decompress the nerve roots and stabilize the spine, which are critical to the patient's quality of life and function. While the document notes that there were no complications and the estimated blood loss was negligible, thereby reducing some immediate risks, spinal surgeries inherently carry high stakes due to potential complications such as nerve damage, infection, or impacts on spinal stability. Additionally, the procedure involves handling critical neurovascular structures, adding to its complexity. These factors contribute to its high-stakes nature.


Medical Specialty: Orthopedic
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 described involves a surgical procedure for spinal cord compression due to cervical myelopathy. The stakes are high due to the complications and risks associated with spine surgery, including potential for paralysis, infection, damage to nearby organs, and anesthesia risks. Additionally, surgical intervention on the spine inherently carries significant risk due to the critical functions it supports in the body. Balancing these risks with the potential benefits makes this a high-stakes situation.


Medical Specialty: Orthopedic
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.

orthopedic, 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

An anterior cervical discectomy and fusion (ACDF) procedure, while common in orthopedic and neurosurgical practice, involves delicate structures such as the spinal cord and major blood vessels. The presence of a herniated nucleus pulposus causing spinal stenosis at C5-C6 means the patient likely has significant symptoms that can affect quality of life and even lead to more severe issues if untreated. The surgery itself is typically straightforward but does carry risks of complications, including nerve injury or infection. Thus, while not the highest level of surgical risk, it is certainly not a low-stakes procedure either.


Medical Specialty: Orthopedic
Sample Name: Anterior Cervical Discectomy & Fusion

PREOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.,POSTOPERATIVE DIAGNOSES:,  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.  In addition to this, he had a large herniated disk at C3-C4 in the midline.,PROCEDURE: , Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.,PROCEDURE IN DETAIL: , The patient placed in the supine position, the neck was prepped and draped in the usual fashion.  Incision was made in the midline the anterior border of the sternocleidomastoid at the level of C4.  Skin, subcutaneous tissue, and vertebral muscles divided longitudinally in the direction of the fibers and the trachea and esophagus was retracted medially.  The carotid sheath was retracted laterally after dissecting the longus colli muscle away from the vertebral osteophytes we could see very large osteophytes at C4-C5.  It appeared that the C5-C6 disk area had fused spontaneously.  We then confirmed that position by taking intraoperative x-rays and then proceeded to do discectomy and fusion at C3-C4, C4-C5.,After placing distraction screws and self-retaining retractors with the teeth beneath the bellies of the longus colli muscles, we then meticulously removed the disk at C3-C4, C4-C5 using the combination of angled strip, pituitary rongeurs, and curettes after we had incised the anulus fibrosus with #15 blade.,Next step was to totally decompress the spinal cord using the operating microscope and high-speed cutting followed by the diamond drill with constant irrigation.  We then drilled off the uncovertebral osteophytes and midline osteophytes as well as thinning out the posterior longitudinal ligaments.  This was then removed with 2-mm Kerrison rongeur.  After we removed the posterior longitudinal ligament, we could see the dura pulsating nicely.  We did foraminotomies at C3-C4 as well as C4-C5 as well.  After having totally decompressed both the cord as well as the nerve roots of C3-C4, C4-C5, we proceeded to the next step, which was a fusion.,We sized two 8-mm cortical cancellous grafts and after distracting the bone at C3-C4, C4-C5, we gently tapped the grafts into place.  The distraction was removed and the grafts were now within.  We went to the next step for the procedure, which was the instrumentation and stabilization of the fused area.,We then placed a titanium ABC plate from C3-C5, secured it with 16-mm titanium screws.  X-rays showed good position of the screws end plate.,The next step was to place Jackson-Pratt drain to the vertebral fascia.  Meticulous hemostasis was obtained.  The wound was closed in layers using 2-0 Vicryl for the subcutaneous tissue.  Steri-Strips were used for skin closure.  Blood loss less than about 200 mL.  No complications of the surgery.  Needle counts, sponge count, and cottonoid count was correct.
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DESCRIPTION: Anterior cervical discectomy fusion C3-C4 and C4-C5 using operating microscope and the ABC titanium plates fixation with bone black bone procedure.  Cervical spondylotic myelopathy with cord compression and cervical spondylosis.

orthopedic, titanium plates fixation, bone black bone procedure, anterior cervical discectomy, titanium plates, cervical discectomy, spondylotic myelopathy, cord compression, cervical spondylosis, foraminotomies, cervical, anterior

The situation described is a surgical procedure involving an anterior cervical discectomy and fusion for a patient with cervical spondylotic myelopathy due to cord compression. This condition is serious as it involves spinal cord compression, which can lead to severe neurological deficits if not treated. The surgery entails high precision and risks, including nerve or spinal cord injury, bleeding, or infection. Thus, the stakes are inherently high due to the potential life-altering complications and the complexity of the procedure.


Medical Specialty: Orthopedic
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.

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

The described situation involves a surgical procedure, specifically an anterior cervical discectomy, which is a significant and invasive operation aimed at relieving cervical radiculopathy. Surgical procedures inherently carry a level of risk such as potential complications, impacts on the patient's mobility or nerve function, anesthesia risks, and recovery outcomes. Although this particular report mentions no complications, the stakes are still substantial due to the potential implications on the patient's health and the need for precise surgical execution. However, since no complications occurred and it appears standard for orthopedic practice, it isn't on the extreme high end of stakes.


Medical Specialty: Orthopedic
Sample Name: Achilles Ruptured Tendon

CHIEF COMPLAINT:,  Achilles ruptured tendon.,HISTORY:,  Mr. XYZ is 41 years of age, who works for Chevron and lives in Angola.  He was playing basketball in Angola back last Wednesday, Month DD, YYYY, when he was driving toward the basket and felt a pop in his posterior leg.  He was seen locally and diagnosed with an Achilles tendon rupture.  He has been on crutches and has been nonweightbearing since that time.  He had no pain prior to his injury.  He has had some swelling that is mild.  He has just been on aspirin a day due to his traveling time.  Pain currently is minimal.,PAST MEDICAL HISTORY:,  Denies diabetes, cardiovascular disease, or pulmonary disease.,CURRENT MEDICATIONS:,  Malarone, which is an anti-malarial.,ALLERGIES:,  NKDA,SOCIAL HISTORY:,  He is a petroleum engineer for Chevron.  Drinks socially.  Does not use tobacco.,PHYSICAL EXAM:,  Pleasant gentleman in no acute distress.  He has some mild swelling on the right ankle and hindfoot.  He has motion that is increased into dorsiflexion.  He has good plantarflexion.  Good subtalar, Chopart and forefoot motion.  His motor function is intact although weak into plantarflexion.  Sensation is intact.  Pulses are strong.  In the prone position, he has diminished tension on the affected side.  There is some bruising around the posterior heel.  He has a palpable defect about 6-8 cm proximal to the insertion site that is tender for him.  Squeezing the calf causes no plantarflexion of the foot.,RADIOGRAPHS:,  Of his right ankle today show a preserved joint space.  I don't see any evidence of fracture noted.  Radiographs of the heel show no fracture noted with good alignment.,IMPRESSION:,  Right Achilles tendon rupture.,PLAN:,  I have gone over with Mr. XYZ the options available.  We have discussed the risks, benefits and alternatives to operative versus nonoperative treatment.  Based on his age and his activity level, I think his best option is for operative fixation.  We went over the risks of bleeding, infection, damage to nerves and blood vessels, rerupture of the tendon, weakness and the need for future surgery.  We have discussed doing this as an outpatient procedure.  He would be nonweightbearing in a splint for 10 days, nonweightbearing in a dynamic brace for 4 weeks, and then a walking boot for another six weeks with a lift until three months postop when we can get him into a shoe with a ¼" lift.  He understands a 6-9 month return to sports overall.  He will also need to be on some Lovenox for a week after surgery and then on an aspirin as he is going to travel back to Angola.  Today we will put him in a high tide boot that he will need at six weeks, and we will put him in a 1" lift also.  He can weight bear until surgery and we will have it set up this week.  His questions were all answered today.
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DESCRIPTION: Right Achilles tendon rupture.

Right Achilles tendon rupture.

orthopedic, achilles tendon rupture, alignment, crutches, joint space, nonweightbearing, plantarflexion, achilles ruptured tendon, achilles ruptured, ruptured tendon, achilles tendon, tendon rupture, achilles,

The situation involves a medical procedure for repairing a ruptured Achilles tendon, which while serious and requiring surgery, is a common orthopedic procedure with a well-established treatment protocol. The patient is in good health otherwise, with no complicating medical conditions, and the risks have been explained and understood. The procedure is planned as outpatient surgery, indicating it's manageable and not life-threatening. The stakes are moderate due to the medical nature and the recovery process, but it's not critical or complex requiring intensive care.


Medical Specialty: Ophthalmology
Sample Name: Vitrectomy - 1

PREOPERATIVE DIAGNOSIS: , Vitreous hemorrhage and retinal detachment, right eye.,POSTOPERATIVE DIAGNOSIS:,  Vitreous hemorrhage and retinal detachment, right eye.,NAME OF PROCEDURE: , Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.,ANESTHESIA: , Local with standby.,PROCEDURE:  ,The patient was brought to the operating room, and an equal mixture of Marcaine 0.5% and lidocaine 2% was injected in a retrobulbar fashion.  As soon as satisfactory anesthesia and akinesia had been achieved, the patient was prepped and draped in the usual manner for sterile ophthalmic surgery.  A wire lid speculum was inserted.  Three modified sclerotomies were selected at 9, 10, and 1 o'clock.  At the 9 o'clock position, the Accurus infusion line was put in place and tied with a preplaced #7-0 Vicryl suture.  The two superior sites at 10 and 1 were opened up where the operating microscope with the optical illuminating system was brought into position, and closed vitrectomy was begun.  Initially formed core vitrectomy was performed and formed anterior vitreous was removed.  After this was completed, attention was placed in the posterior segment.  Several broad areas of vitreoretinal traction were noted over the posterior pole out of the equator where the previously noted retinal tears were noted.  These were carefully lifted and dissected off the edges of the flap tears and trimmed to the ora serrata.  After all the vitreous had been removed and the membranes released, the retina was completely mobilized.  Total fluid-air exchange was carried out with complete settling of the retina.  Endolaser was applied around the margins of the retinal tears, and altogether several 100 applications were placed in the periphery.  Good reaction was achieved.  The eye was inspected with an indirect ophthalmoscope.  The retina was noted to be completely attached.  The instruments were removed from the eye.  The sclerotomy sites were closed with #7-0 Vicryl suture.  The infusion line was removed from the eye and tied with a #7-0 Vicryl suture.  The conjunctivae and Tenon's were closed with #6-0 plain gut suture.  A collagen shield soaked with Tobrex placed over the surface of the globe, and a pressure bandage was put in place.  The patient left the operating room in a good condition.
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DESCRIPTION: Combined closed vitrectomy with membrane peeling, fluid-air exchange, and endolaser, right eye.

ophthalmology, vitreous hemorrhage, retinal detachment, combined closed vitrectomy, vitrectomy, membrane peeling, fluid-air exchange, endolaser, vitrectomy with membrane peeling, membrane, peeling, hemorrhage, detachment, vicryl, eye, retinal,

This surgical procedure involves repairing a retinal detachment and managing a vitreous hemorrhage through a vitrectomy. Such a surgery, while commonly performed in ophthalmology, is delicate and crucial for preserving the patient's vision. Retinal detachment is a serious condition that can lead to blindness if not treated promptly and correctly. The stakes are high because the success of the procedure can significantly impact the patient's quality of life and vision. Therefore, the situation involves high-stakes due to the potential consequences of surgical errors or complications.


Medical Specialty: Ophthalmology
Sample Name: YAG Laser Capsulotomy

PREOPERATIVE DIAGNOSIS:,  Visually significant posterior capsule opacity, right eye.,POSTOPERATIVE DIAGNOSIS:,  Visually significant posterior capsule opacity, right eye.,OPERATIVE PROCEDURES:  ,YAG laser posterior capsulotomy, right eye.,ANESTHESIA: , Topical anesthesia using tetracaine ophthalmic drops.,INDICATIONS FOR SURGERY: , This patient was found to have a visually significant posterior capsule opacity in the right eye.  The patient has had a mild decrease in visual acuity, which has been a gradual change.  The posterior capsule opacity was felt to be related to the decline in vision.  The risks, benefits, and alternatives (including observation) were discussed.  I feel the patient had a good understanding of the proposed procedure and informed consent was obtained.,DESCRIPTION OF PROCEDURE: , The patient was identified and the procedure was verified.  Pupil was dilated per protocol.  Patient was positioned at the YAG laser.  Then, *** of energy were used to perform a circular posterior laser capsulotomy through the visual axis.  A total of ** shots were used.  Total energy was **.  The patient tolerated the procedure well and there were no complications.  The lens remained well centered and stable.  Postoperative instructions were provided.  Alphagan P ophthalmic drops times two were instilled prior to his dismissal.,Post-laser intraocular pressure measured ** mmHg.  Postoperative instructions were provided and the patient had no further questions.
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DESCRIPTION: Visually significant posterior capsule opacity, right eye.  YAG laser posterior capsulotomy, right eye.

ophthalmology, capsule opacity, yag, ophthalmic, yag laser posterior capsulotomy, capsulotomy, opacity, laser, visually, eye, anesthesia

The YAG laser capsulotomy procedure is common for treating posterior capsule opacity after cataract surgery. While the procedure is typically low-risk, it involves a laser and the patient's eye, requiring precision and care. Potential complications like increased intraocular pressure or retinal detachment, though rare, can affect vision. However, given that this is a routine and well-tolerated procedure with a straightforward recovery and low complication rate, the stakes are comparatively low in the context of medical procedures.


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

Medical Specialty: Ophthalmology
Sample Name: Vitrectomy - 3

DESCRIPTION OF OPERATION:,  The patient was brought to the operating room and appropriately identified.  Local anesthesia was obtained with a 50/50 mixture of 2% lidocaine and 0.75% bupivacaine given as a peribulbar block.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.,A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.  Calipers were set at 3.5 mm and a mark was made 3.5 mm posterior to the limbus in the inferotemporal quadrant.,A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark.  The MVR blade was used to make a sclerotomy between the pre-placed sutures.  An 8-0 nylon suture was then pre-placed for later sclerotomy closure.  The infusion cannula was inspected and found to be in good working order.  The infusion cannula was placed in the vitreous cavity and secured with the pre-placed sutures.  The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.,Additional sclerotomies were made 3.5 mm posterior to the limbus in the supranasal and supratemporal quadrants.  The light pipe and vitrectomy handpieces were then placed in the vitreous cavity and a vitrectomy was performed.  There was moderately severe vitreous hemorrhage, which was removed.  Once a view of the posterior pole could be obtained, there were some diabetic membranes emanating along the arcades.  These were dissected with curved scissors and judicious use of the vitrectomy cutter.  There was some bleeding from the inferotemporal frond.  This was managed by raising the intraocular pressure and using intraocular cautery.  The surgical view became cloudy and the corneal epithelium was removed with a beaver blade.  This improved the view.  There is an area suspicious for retinal break near where the severe traction was inferotemporally.  The Endo laser was used to treat in a panretinal scatter fashion to areas that had not received previous treatment.  The indirect ophthalmoscope was used to examine the retinal peripheral for 360 degrees and no tears, holes or dialyses were seen.  There was some residual hemorrhagic vitreous skirt seen.  The soft-tip cannula was then used to perform an air-fluid exchange.  Additional laser was placed around the suspicious area inferotemporally.  The sclerotomies were then closed with 8-0 nylon suture in an X-fashion, the infusion cannula was removed and it sclerotomy closed with the pre-existing 8-0 nylon suture.,The conjunctiva was closed with 6-0 plain gut.  A subconjunctival injection of Ancef and Decadron were given and a drop of atropine was instilled over the eye.  The lid speculum was removed.  Maxitrol ointment was instilled over the eye and the eye was patched.  The patient was brought to the recovery room in stable condition.
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DESCRIPTION: Vitrectomy. A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and, separately, the supratemporal and inferotemporal quadrants.

ophthalmology, conjunctival peritomy, westcott scissors, lid speculum, inferotemporal quadrants, inferotemporal, conjunctival, scissors, supranasal, supratemporal, sclerotomy, eye, vitreous, vitrectomy, infusion, cannulaNOTE

The situation involves a highly detailed description of a vitrectomy, which is a complex eye surgery often performed to remove the vitreous gel from the eye. This procedure can be high-risk due to the delicate structures involved, such as the retina. The risks can include retinal detachment, infection, and vision loss, which makes the context fairly high-stakes. While this is a routine operation for trained ophthalmic surgeons, the potential for serious complications makes the overall situation high-stakes.


Medical Specialty: Ophthalmology
Sample Name: Vitrectomy Opening

VITRECTOMY OPENING,The patient was brought to the operating room and appropriately identified.  General anesthesia was induced by the anesthesiologist.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.  A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants.  Hemostasis was maintained with wet-field cautery.  Calipers were set at XX mm and the mark was made XX mm posterior to the limbus in the inferotemporal quadrant.  A 5-0 nylon suture was passed through partial-thickness sclera on either side of this mark.  The MVR blade was used to make a sclerotomy between the preplaced sutures.  An 8-0 nylon suture was then preplaced for a later sclerotomy closure.  The infusion cannula was inspected and found to be in good working order.  The infusion cannula was placed into the vitreous cavity and secured with the preplaced suture.  The tip of the infusion cannula was directly visualized and found to be free of any overlying tissue and the infusion was turned on.  Additional sclerotomies were made XX mm posterior to the limbus in the supranasal and supratemporal quadrants.
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DESCRIPTION: Vitrectomy opening.  A limited conjunctival peritomy was created with Westcott scissors to expose the supranasal and separately the supratemporal and inferotemporal quadrants.

ophthalmology, westcott scissors, inferotemporal quadrants, conjunctival, peritomy, sclerotomy, vitrectomy, supranasal, supratemporal, cannula, inferotemporalNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The vitrectomy opening procedure described is a surgical operation involving the eye, which is generally considered high-stakes due to the precision required and the potential for significant impact on the patient's vision if complications occur. Any surgical procedure involving the eyes or within a delicate area like the eye is inherently high-stakes because of the critical nature of the organ involved. Errors can lead to loss of vision or other serious complications. Therefore, the stakes are quite high when performing such a procedure.


Medical Specialty: Ophthalmology
Sample Name: Scleral Buckle Opening - Local Anesthesia

PROCEDURE IN DETAIL:,  After appropriate operative consent was obtained, the patient was brought supine to the operating room and placed on the operating room table.  After intravenous sedation was administered a retrobulbar block consisting of 2% Xylocaine with 0.75% Marcaine and Wydase was administered to the right eye without difficulty.  The patient's right eye was prepped and draped in a sterile ophthalmic fashion and the procedure begun.  A wire lid speculum was inserted into the right eye and a 360-degree conjunctival peritomy was performed at the limbus.  The 4 rectus muscles were looped and isolated using 2-0 silk suture.  The retinal periphery was then inspected via indirect ophthalmoscopy.,
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DESCRIPTION: Scleral buckle opening under local anesthesia.

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

The procedure described is a scleral buckle surgery, which is commonly performed for retinal detachment. While it is a routine ophthalmic procedure and uses local anesthesia, it involves significant surgical manipulation of the eye. Any errors or complications can result in serious consequences, such as loss of vision, infection, or even blindness. However, it is a frequently performed and well-understood procedure among ophthalmic surgeries, reducing the overall risk level somewhat compared to more complex surgeries in other fields. Given these factors, it can be considered moderate to high-stakes.


Medical Specialty: Ophthalmology
Sample Name: Trabeculectomy & Tenonectomy

PREOPERATIVE DIAGNOSES,1.  Uncontrolled open angle glaucoma, left eye.,2.  Conjunctival scarring, left eye.,POSTOPERATIVE DIAGNOSES,1.  Uncontrolled open angle glaucoma, left eye.,2.  Conjunctival scarring, left eye.,PROCEDURES: , Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.,ANESTHESIA: ,Retrobulbar block with monitored anesthesia care.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Negligible.,DESCRIPTION OF PROCEDURE:,  The patient was brought to the operating suite where the Anesthesia team established a peripheral IV as well as monitoring lines.  In the preoperative area, the patient received pilocarpine drops.  The patient received IV propofol and once somnolent from this, a retrobulbar block was administered consisting of 2% Xylocaine plain.  Approximately 3 mL were given.  The operative eye then underwent a Betadine prep with respect to the face, lids, lashes, and eye.  During the draping process, care was taken to isolate the lashes.  A screw type speculum was inserted to maintain patency of lids.  A 6-0 Vicryl suture was placed through the superior cornea, and the eye was reflected downward to expose the superior conjunctiva.  A peritomy was performed approximately 8 to 10 mm posterior to the limbus and this flap was dissected forward to the cornea.  All Tenons were removed from the overlying sclera and the area was treated with wet-field cautery to achieve hemostasis.  A 2 mm x 3 mm scleral flap was then outlined with a Micro-Sharp blade.  This was approximately one-half scleral depth in thickness.  A crescent blade was then used to dissect forward the clear cornea.  Hemostasis was again achieved with wet-field cautery.  A Weck-Cel sponge tip soaked in mitomycin was then placed under the conjunctival and tenon flap and left there for two minutes.  The site was then profusely irrigated with balanced salt solution.  A paracentesis wound was made temporarily and then the Micro-Sharp blade was used to enter the anterior chamber at the anterior most margin of the trabeculectomy bed.  A Kelly-Descemet punch was then inserted, and a trabeculectomy was performed.  Iris was withdrawn through the trabeculectomy site and a peripheral iridectomy was performed using Vannas scissors and 0.12 forceps.  The iris was then repositioned into the eye and the anterior chamber was inflated with BSS.  The scleral flap was sutured in place with two 10-0 nylon sutures with knots trimmed, rotated, and buried.  The overlying conjunctiva was then closed with a running 8-0 Vicryl suture on a BV needle.  BSS was irrigated in the anterior chamber and the blood was noted to elevate nicely without leakage.  Antibiotic and steroid drops were placed in the eye as was homatropine 5%.  The antibiotic consisted of Vigamox and the steroid was Econopred Plus.  A patch and shield were placed over the eye after the drape was removed.  The patient was taken to the recovery room in good condition.  She will be seen in followup in the office tomorrow.
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DESCRIPTION: Short flap trabeculectomy with lysis of conjunctival scarring, tenonectomy, peripheral iridectomy, paracentesis, watertight conjunctival closure, and 0.5 mg/mL mitomycin x2 minutes, left eye.  Uncontrolled open angle glaucoma and conjunctival scarring, left eye.

ophthalmology, uncontrolled open angle glaucoma, open angle, conjunctival, scarring, trabeculectomy, tenonectomy, iridectomy, paracentesis, watertight conjunctival closure, conjunctival scarring, eye, glaucoma, cornea, scleral,

The situation involves a surgical procedure addressing uncontrolled open angle glaucoma and conjunctival scarring, which can have serious implications for the patient's vision if left untreated. The procedure itself is complex, involving multiple steps and requires precision from the medical team to ensure a successful outcome. Although the procedure reported no complications and negligible estimated blood loss, it's still a surgery on the eye, which is considered a critical organ. The stakes are high due to the potential impacts on vision, but immediate critical risks were minimized in this particular case.


Medical Specialty: Ophthalmology
Sample Name: Scleral Buckle Opening

SCLERAL BUCKLE OPENING,The patient was brought to the operating room and appropriately identified.  General anesthesia was induced by the anesthesiologist.  The patient was prepped and draped in the usual sterile fashion.  A lid speculum was used to provide exposure to the right eye.  A 360-degree limbal conjunctival peritomy was created with Westcott scissors.  Curved tenotomy scissors were used to enter each of the intermuscular quadrants.  The inferior rectus muscle was isolated with a muscle hook, freed of its Tenon's attachment and tied with a 2-0 silk suture.  The 3 other rectus muscles were isolated in a similar fashion.  The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.
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DESCRIPTION: Scleral buckle opening.  The 4 scleral quadrants were inspected and found to be free of scleral thinning or staphyloma.

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

The procedure described is an ophthalmic surgical procedure involving the scleral buckle, which is generally associated with treating retinal detachment. This type of surgery carries potential risks such as infection, bleeding, or retinal damage, making it a significant procedure. However, the specific excerpt appears to document a portion of the routine surgical steps rather than addressing a complication or immediate life-threatening situation. Nonetheless, any eye surgery that interacts with the sclera and involves rectus muscles is inherently high-stakes due to the possible impact on the patient's vision if complications arise.


Medical Specialty: Ophthalmology
Sample Name: Ruptured Globe Repair - Cornea

PREOPERATIVE DIAGNOSIS:,  Ruptured globe with full-thickness corneal laceration OX.,POSTOPERATIVE DIAGNOSIS: , Ruptured globe with full-thickness corneal laceration OX.,PROCEDURE:  ,Ruptured globe with full-thickness corneal laceration repair OX.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with a ruptured globe with full-thickness corneal laceration of the XXX eye.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, astigmatism, cataract, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient received IV antibiotics including Ancef and Levaeuin prior to surgery. The patient was brought to the operating room and placud in the supine position, where (s)he wad prepped and draped in the routine fashion. A wire lid speculum was placed to provide exposure and 0.12 forceps and a Superblade were used to create a paracentesis at approximately 11 o'clock. Viscoat was injected through the paracentesis to fill the anterior chamber. The Viscoat cannula was used to sweep the incarcerated iris tissue from the wound. More Viscoat was injected to deepen the anterior chamber. A 10-0 nylon suture was used to place four sutures to close the corneal laceration. BSS was then injected to fill the anterior chamber and a small leak was noted at the inferior end of the wound. A fifth 10-0 nylon suture was then placed. The wound was packed and found to be watertight. The sutures were rotated, the wound was again checked and found to be watertight. A small amount of Viscoat was, again, injected to deepen the anterior chamber and the wound was swept to be sure there was no incarcerated uveal tissue. Several drops were placed in the XXX eye including Ocuflox, Pred Forte, Timolol 0.5%, Alphagan and Trusopt. An eye patch and shield were taped over the XXX eye. The patient was awakened from general anesthesia. (S)he was taken to the recovery area in good condition. There were no complications.
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DESCRIPTION: Ruptured globe with full-thickness corneal laceration repair - Sample/Template.

ophthalmology, ruptured globe, alphagan, bss, ocuflox, pred forte, superblade, timolol, viscoat cannula, anterior chamber, astigmatism, bleeding, cataract, corneal laceration, full-thickness corneal laceration, infection, laceration repair, loss of the eye, loss of vision, paracentesis, re-operation, wire lid speculum, viscoat, corneal, laceration,

The situation involves a surgical procedure for repairing a ruptured globe with a full-thickness corneal laceration. Such a condition is critical because it could lead to severe complications like loss of vision or loss of the eye if not treated properly. The procedure requires skilled precision and carries substantial risks, including bleeding, infection, and other vision-threatening complications. Thus, it is a high-stakes situation as it directly impacts the patient's vision and quality of life.