Medical Specialty: Obstetrics / Gynecology
Sample Name: D&C & Laparoscopy

PREOPERATIVE DIAGNOSES:,1.  Hypermenorrhea.,2.  Pelvic pain.,3.  Infertility.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Infertility.,3.  Pelvic pain.,4.  Probable bilateral tubal occlusion.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Laparoscopy.,3.  Injection of indigo carmine dye.,GROSS FINDINGS: , The uterus was anteverted, firm, enlarged, irregular, and mobile.  The cervix is nulliparous without lesions.  Adnexal examination was negative for masses.,PROCEDURE:  ,The patient was placed in the lithotomy position, properly prepared and draped in sterile manner.  After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix was grasped with vulsellum tenaculum.  Uterus sounded to a depth of 10.5 cm.  Endocervical canal was progressively dilated with Hanks dilators to #20-French.  A medium-sized sharp curet was used to obtain a moderated amount of tissue upon curettage, which was taken from all uterine quadrants and sent to the pathologist for analysis.  A ________ syringe was then introduced into the uterine cavity to a depth of 9 cm and the balloon insufflated with 10 cc of air.  A 20 cc syringe filled with dilute indigo carmine dye was attached to the end of the ________ syringe to use to inject at the time of laparoscopy.,A small subumbilical incision was then made with insertion of the step dilating sheath with a Veress needle into the peritoneal cavity.  The peritoneal cavity was insufflated with 3 liters of carbondioxide and a 12 mm trocar inserted.  The laparoscope was then inserted through the trocar with visualization of the pelvic contents.  In steep Trendelenburg position, the uterus was visualized and aided by use of a Bierman needle to displace bowel from visualized areas.  The fallopian tubes appeared normal bilaterally with good visualization of a normal appearing fimbria.  The ovaries also appeared normal bilaterally.  The uterus was greatly enlarged and distorted with large fibroids in multiple areas and especially on the right coronal area.  An attempt was made to inject the indigo carmine dye and in fact a three syringes of 20 cc were injected without any visualization of intraperitoneal dye still.  Both fallopian tubes apparently were blocked.  The upper abdomen was visually explored and found to be normal as was the bowel and area of the right ileum.  The patient tolerated the procedure well.  Instruments were removed from the vaginal vault and the abdomen.  Trocar was removed and the carbondioxide allowed to escape and the subumbilical wound repaired with two #4-0 undyed Vicryl sutures.  Sterile dressing was applied to the wound and the patient was sent to the recovery area in satisfactory postoperative condition.
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DESCRIPTION: Enlarged fibroid uterus, infertility, pelvic pain, and probable bilateral tubal occlusion.  Dilatation and curettage and laparoscopy and injection of indigo carmine dye.

obstetrics / gynecology, dilatation and curettage, laparoscopy, pelvic pain, infertility, enlarged fibroid uterus, tubal occlusion, indigo carmine dye, fibroid uterus, uterus infertility, peritoneal cavity, fallopian tubes, indigo carmine, endocervical, uterine, pelvic, curettage, uterus,

The situation described is a medical procedure involving a D&C (dilation and curettage) and laparoscopy, addressing serious health concerns like enlarged fibroid uterus, infertility, and pelvic pain. These issues can severely impact a patient's quality of life and future fertility prospects. Additionally, the procedure's outcome could significantly influence the patient's treatment plan and future fertility options. However, it's a planned surgical procedure with a recovery plan, and not an immediate life-threatening emergency, hence it's high-stakes but not critical.


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

Medical Specialty: Obstetrics / Gynecology
Sample Name: D&C & Hysteroscopy

PREOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Hypermenorrhea.,POSTOPERATIVE DIAGNOSES:,1.  Enlarged fibroid uterus.,2.  Hypermenorrhea.,3.  Secondary anemia.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Hysteroscopy.,GROSS FINDINGS: , Uterus was anteverted, greatly enlarged, irregular and firm.  The cervix is patulous and nulliparous without lesions.  Adnexal examination was negative for masses.,PROCEDURE:  ,The patient was taken to the operating room where she was properly prepped and draped in sterile manner under general anesthesia.  After bimanual examination, the cervix was exposed with a weighted vaginal speculum and the anterior lip of the cervix grasped with a vulsellum tenaculum.  The uterus was sounded to a depth of 11 cm.  The endocervical canal was then progressively dilated with Hanks and Hegar dilators to a #10 Hegar.  The ACMI hysteroscope was then introduced into the uterine cavity using sterile saline solution as a distending media and with attached video camera.  The endometrial cavity was distended with fluids and the cavity visualized.  Multiple irregular areas of fibroid degeneration were noted throughout the cavity.  The coronal areas were visualized bilaterally with corresponding tubal ostia.  A moderate amount of proliferative appearing endometrium was noted.  There were no direct intraluminal lesions seen.  The patient tolerated the procedure well.  Several pictures were taken of the endometrial cavity and the hysteroscope removed from the cavity.,A large sharp curet was then used to obtain a moderate amount of tissue, which was the sent to pathologist for analysis.  The instrument was removed from the vaginal vault.  The patient was sent to recovery area in satisfactory postoperative condition.
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DESCRIPTION: Enlarged fibroid uterus, hypermenorrhea, and secondary anemia.  Dilatation and curettage and hysteroscopy.

obstetrics / gynecology, dilatation and curettage, hysteroscopy, anemia, enlarged fibroid uterus, endometrial cavity, hypermenorrhea, fibroid, uterus

The situation involves a surgical procedure related to obstetrics and gynecology, specifically for treating conditions like an enlarged fibroid uterus, hypermenorrhea, and secondary anemia. While it is a routine procedure for a trained medical team, it involves general anesthesia and surgical intervention, both of which carry inherent risks. Additionally, the outcomes can significantly impact the patient's quality of life, hence it is important to address these issues carefully. However, in the context of common surgical procedures, it is not extremely high-stakes unless there are complications.

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Medical Specialty: Obstetrics / Gynecology
Sample Name: D&C & Hysteroscopy - 1

PREOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Status post spontaneous vaginal delivery.,POSTOPERATIVE DIAGNOSES:,1.  Abnormal uterine bleeding.,2.  Status post spontaneous vaginal delivery.,PROCEDURE PERFORMED:,1.  Dilation and curettage (D&C).,2.  Hysteroscopy.,ANESTHESIA: , IV sedation with paracervical block.,ESTIMATED BLOOD LOSS:,  Less than 10 cc.,INDICATIONS:  ,This is a 17-year-old African-American female that presents 7 months status post spontaneous vaginal delivery without complications at that time.  The patient has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.,PROCEDURE:,  The patient was consented and seen in the preoperative suite.  She was taken to the operative suite, placed in a dorsal lithotomy position, and placed under IV sedation.  She was prepped and draped in the normal sterile fashion.  Her bladder was drained with the red Robinson catheter which produced approximately 100 cc of clear yellow urine.  A bimanual exam was done, was performed by Dr. X and Dr. Z.  The uterus was found to be anteverted, mobile, fully involuted to a pre-pregnancy stage.  The cervix and vagina were grossly normal with no obvious masses or deformities.  A weighted speculum was placed in the posterior aspect of the vagina and the anterior lip of the cervix was grasped with the vulsellum tenaculum.,The uterus was sounded to 8 cm.  The cervix was sterilely dilated with Hank dilator and then Hagar dilator.  At the time of blunt dilation, it was noticed that the dilator passed posteriorly with greater ease than it had previously.  The dilation was discontinued at that time because it was complete and the hysteroscope was placed into the uterus.  Under direct visualization, the ostia were within normal limits.  The endometrial lining was hyperplastic, however, there was no evidence of retained products or endometrial polyps.  The hyperplastic tissue did not appear to have calcification or other abnormalities.  There was a small area of the lower uterine segment posteriorly that was suspicious for endometrial perforation, however this area was hemostatic, no evidence of bowel involvement and was approximately 1 x 1 cm in nature.  The hysteroscope was removed and a sharp curette was placed intrauterine very carefully using a anterior wall for guidance.  Endometrial curettings were obtained and the posterior aspect suspicious for perforation was gently probed and seemed to have clamped down since the endometrial curetting.  The endometrial sampling was placed on Telfa pad and sent to Pathology for evaluation.  A rectal exam was performed at the end of the procedure which showed no hematoma formation in the posterior cul-de-sac.  There was a normal consistency of the cervix and the normal step-off.  The uterine curette was removed as well as the vulsellum tenaculum and the weighted speculum.  The cervix was found to be hemostatic.  The patient was taken off the dorsal lithotomy position and recovered from her IV sedation in the recovery room.  The patient will be sent home once stable from anesthesia.  She will be instructed to followup in the office in two weeks for discussion of the pathologic report of the endometrial curettings.  The patient is sent home on Tylenol #3 prescription as she is allergic to Motrin.  The patient is instructed to refrain from intercourse douching or using tampons for the next two weeks.  The patient is also instructed to contact us if she has any problems with further bleeding, fevers, or difficulty with urination.
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DESCRIPTION: Dilation and curettage (D&C) and hysteroscopy.  A female presents 7 months status post spontaneous vaginal delivery, has had abnormal uterine bleeding since her delivery with an ultrasound showing a 6 cm x 6 cm fundal mass suspicious either for retained products or endometrial polyp.

obstetrics / gynecology, dilation and curettage, hysteroscopy, abnormal uterine bleeding, spontaneous vaginal delivery, endometrial curettings, vaginal delivery, uterine bleeding, endometrial, d&c, cervix, vaginal, uterine, delivery,

The situation involves a surgical procedure (D&C and hysteroscopy) on a 17-year-old female experiencing abnormal uterine bleeding postpartum. This medical scenario carries inherent risks, such as potential complications during surgery, the suspected endometrial perforation observed, and the need for pathological analysis of endometrial tissue. While the procedure seems to have been completed without immediate complications, the implication of underlying pathology and the patient's young age place this situation at moderately high stakes. Ensuring the patient's safety, accurate pathological diagnosis, and appropriate follow-up care are critical elements here.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Cesarean Section & BTL

PREOPERATIVE DIAGNOSES:,1.  Term pregnancy.,2.  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1.  Term pregnancy.,2.  Desires permanent sterilization.,PROCEDURE:,1.  Repeat low-transverse cesarean section.,2.  Bilateral tubal ligation.,3.  Extensive anterior abdominal wall/uterine/bladder adhesiolysis.,ANESTHESIA:,  Spinal/epidural with good effect.,FINDINGS:  ,Delivered vigorous male infant from cephalic presentation.  Apgars 9/9.  Birth weight 6 pounds 14 ounces.  Infant suctioned with a bulb upon delivery of the head and body.  Cord clamped and cut and infant passed to pediatric team present.  Complete placenta manually extracted intact with three vessel cord.  Extensive anterior abdominal wall adhesions with the anterior abdominal wall completely adhered to the anterior uterus throughout its entire length of the incision.  In addition, the bladder was involved in adhesion mass complex.  A window was developed surgically at the apical aspect of the incision enabling finger to pass to get behind the dense anterior abdominal wall adhesions.  These adhesions were surgically transected using Bovie cautery technique freeing up the anterior uterine attachment from the anterior abdominal wall.  Upon initial entry through the fibrous layer of the anterior abdominal wall _______ into the serosal and slightly muscular part of the anterior uterus due to the dense adhesion attachment that had occurred from previous surgeries.  Bilateral tubal ligation performed without difficulty via Parkland technique.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,URINE OUTPUT:  ,Per anesthesia records.  Urine cleared postoperatively.,IV FLUIDS:  ,Per anesthesia records.,The patient tolerated the procedure well and was taken to the recovery room in stable condition with stable vital signs.,OPERATIVE TECHNIQUE: , The patient was placed in a supine position after spinal/epidural anesthesia.  She was prepped and draped in the usual manner for repeat cesarean section.  A sharp knife was used to make a Pfannenstiel skin incision at the site of the previous scar.  This was carried through the subcutaneous tissue into the dense fibromuscular and fascial layer with a sharp knife.  This incision was extended laterally with Mayo scissors.  Dense fibromuscular layer was encountered from the patient's previous surgeries.  Upon entry, incision was entered into the serosal and partial muscular layer of the anterior uterus and there was no free area to enter into the peritoneal cavity due to dense fibromuscular adhesions of the entire uterus to the anterior abdominal wall at the length of the incision.  Fascia was previously separated superiorly and inferiorly from the muscular layer.  A surgical window was created at the apical aspect of the incision in the direction of the uterine fundus.  Finger was able to be passed and placed behind the dense adhesions between the uterus through anterior abdominal wall.  This adhesion complex was transacted via Bovie cautery its entire length circumferentially freeing the uterus from its attachment to anterior abdominal wall.  Inferiorly, difficulty was encountered with adhesion separation involving the bladder additionally to the uterus and the anterior abdominal wall.  These adhesions likewise were surgically transacted via sharp, blunt, and electrocautery dissection.  This was successfully done without anterior entry into the bladder.  Smooth pickups and Metzenbaum scissors were then used to do sharp dissection to separated the bladder from its attachment to the lower uterine segment enabling the vesicouterine peritoneal reflection for incision of the uterus.  The uterus was then incised using a sharp knife and low transverse incision.  This was extended with bandage scissors.  The infant was delivered easily from a cephalic presentation.  Bulb suction was done following delivery of the head and body.  The cord clamped and cut and the infant passed to pediatric team present.  Cord segment and cord blood was obtained.  Complete placenta manually extracted intact with three vessel cord.  Vigorous male infant, Apgars 9/9, weight 6 pounds 14 ounces.  Complete placenta with three vessels retrieved.  Uterus was exteriorized from the abdominal cavity.  Wet lap applied to the fundus and dry lap used to remove the remaining membranous tissue from the lining.  Pennington clamps placed at the uterine incision angles and the inferior incision lip.  A #1 chromic suture closed the uterus in running continuous interlocking closure.  Good hemostasis upon completion of the closure.  Laparotomy pads placed in the posterior cul-de-sac to remove any blood or clots.  The uterus was returned to the abdominal cavity, after using #1 chromic suture to close the anterior uterine incision, that was partial thickness through the serosal end of the muscular layer at midline adhesion.  This was closed with chromic suture in a running continuous interlocking closure with good hemostasis.  Attention was then focused on the bilateral tubal ligation.  Babcock clamp placed in the mid fallopian tube and elevated.  Cautery was used to make a window in the avascular segment of the mesosalpinx.  Proximal and distal #1 chromic suture ligation with mid fallopian tube transection performed.  The ligated proximal and distal stumps were then cauterized with Bovie cautery.  This tubal ligation procedure was done in a bilateral fashion.  Upon completion of tubal ligation, uterus was returned to the abdominal cavity.  Left and right gutters examined and found to be clean and dry.  Evaluation of the low uterine segment incision revealed continued hemostasis.  Oozing was encountered in the inferior bladder of dissection and 2-0 chromic suture in running continuous fashion, partial thickness of the bladder to control the oozing at this site was successfully done.  Interceed was then placed on the low uterine incision and the low anterior uterine aspect.  The midline rectus including peritoneum was re-approximated with simple interrupted chromic sutures.  Irrigation of the muscular layer with good hemostasis noted.  The fascia was closed with #1 Vicryl in a running continuous closure.  Subcutaneous tissue was irrigated, additional hemostasis with Bovie cautery.  The skin was closed with staples.
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DESCRIPTION: Repeat low-transverse cesarean section, bilateral tubal ligation (BTL), extensive anterior abdominal wall/uterine/bladder adhesiolysis.  Term pregnancy and desires permanent sterilization.

obstetrics / gynecology, term pregnancy, sterilization, low-transverse cesarean section, bilateral tubal ligation, adhesiolysis, anterior uterus, abdominal cavity, cesarean section, chromic suture, tubal ligation, adhesions, uterus, abdominal, infant, anterior, cesarean, hemostasis, chromic, uterine,

The procedure described involves multiple high-risk aspects: a repeat cesarean section, bilateral tubal ligation, and significant adhesiolysis due to previous surgeries. The presence of extensive abdominal wall, uterine, and bladder adhesions increases the complexity and potential risks of the surgery. Additionally, the desire for permanent sterilization adds a significant personal and emotional component. Although the procedure was successful with no reported complications, the initial complexity and potential for serious intraoperative complications make this a high-stakes scenario.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Cholestasis Of Pregnancy

FINAL DIAGNOSES:,  Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.,PROCEDURE: , Included primary low transverse cesarean section.,SUMMARY: , This 32-year-old gravida 2 was induced for cholestasis of pregnancy at 38-1/2 weeks.  The patient underwent a 2-day induction.  On the second day, the patient continued to progress all the way to the point of 9.5 cm at which point, she failed to progress.  During the hour or two of evaluation at 9.5 cm, the patient was also noted to have some fetal tachycardia and an occasional late deceleration.  Secondary to these factors, the patient was brought to the operative suite for primary low transverse cesarean section, which she underwent without significant complication.  There was a slightly enlarged blood loss at approximately 1200 mL, and postoperatively, the patient was noted to have a very mild tachycardia coupled with 100.3 degrees Fahrenheit temperature right at delivery.  It was felt that this was a sign of very early chorioamnionitis and therapeutic antibiotics were given throughout her stay.  The patient received 72 hours of antibiotics with there never being a temperature above 100.3 degrees Fahrenheit.  The maternal tachycardia resolved within a day.  The patient did well throughout the 3-day stay progressing to full diet, regular bowel movements, normal urination patterns.  The patient did receive 2 units of packed red cells on Sunday when attended to by my partner secondary to a hematocrit of 20%.  It should be noted, however, that this was actually an expected result with the initial hematocrit of 32% preoperatively.  Therefore, there was anemia but not an unexplained anemia.,PHYSICAL EXAMINATION ON DISCHARGE: , Includes the stable vital signs, afebrile state.  An alert and oriented patient who is desirous at discharge.  Full range of motion, all extremities; fully ambulatory.  Pulse is regular and strong.  Lungs are clear and the abdomen is soft and nontender with minimal tympany and a nontender fundus.  The incision is beautiful and soft and nontender.  There is scant lochia and there is minimal edema.,LABORATORY STUDIES: , Include hematocrit of 27% and the last liver function tests was within normal limits 48 hours prior to discharge.,FOLLOWUP: , For the patient includes pelvic rest, regular diet.  Follow up with me in 1 to 2 weeks.  Motrin 800 mg p.o. q.8h. p.r.n. cramps, Tylenol No.  3 one p.o. q.4h. p.r.n. pain, prenatal vitamin one p.o. daily, and topical triple antibiotic to incision b.i.d. to q.i.d.
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DESCRIPTION: Delivered pregnancy, cholestasis of pregnancy, fetal intolerance to labor, failure to progress.  Primary low transverse cesarean section.

obstetrics / gynecology, delivered pregnancy, fetal intolerance, induction, pelvic rest, low transverse cesarean section, cholestasis of pregnancy, cesarean section, pregnancy, fetal, tachycardia, cholestasis

This scenario describes a medical situation involving a pregnant patient with cholestasis, a condition that can lead to significant complications for both the mother and the fetus. The patient experienced fetal intolerance to labor, failure to progress, and underwent a cesarean section with some complications, including increased blood loss and early signs of chorioamnionitis. Although the patient was managed effectively with antibiotics and blood transfusions, the potential for serious complications makes this a high-stakes situation.


Medical Specialty: Obstetrics / Gynecology
Sample Name: BTL & Salpingectomy

PREOPERATIVE DIAGNOSES:,1.  Pregnancy at 38 weeks and three days.,2.  Previous cesarean section x2.,3.  Refusing trial of labor.,4.  Multiparity, seeking family planning.,POSTOPERATIVE DIAGNOSES:,1.  Pregnancy at 38 weeks and three days.,2.  Previous cesarean section x2.,3.  Refusing trial of labor.,4.  Multiparity, seeking family planning.,5.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Repeat low transverse cervical cesarean section with delivery of a viable female neonate.,2.  Bilateral tubal ligation and partial salpingectomy.,3.  Lysis of adhesions.,ANESTHESIA: , Spinal with Astramorph.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , 800 cc.,FLUIDS: , 1800 cc of crystalloids.,URINE OUTPUT:,  600 cc of clear urine at the end of the procedure.,INDICATIONS:  ,This is a 36-year-old African-American female gravida 4, para-2-0-1-2, who presents for elective repeat cesarean section.  The patient has previous cesarean section x2 and refuses trial of labor.  The patient also requests a tubal ligation for permanent sterilization and family planning.,FINDINGS:,  A female infant in cephalic presentation in a ROP position.  Apgars of 9 and 9 at one and five minutes respectively.  Weight is 6 lb 2 oz and loose nuchal cord x1.  Normal uterus, tubes, and ovaries.,PROCEDURE:  ,After consent was obtained, the patient was taken to the operating room, where spinal anesthetic was found to be adequate.  The patient was placed in the dorsal supine position with a leftward tilt and prepped and draped in the normal sterile fashion.  The patient's previous Pfannenstiel scar incision was removed and the incision was carried through the underlying layer of fascia using the second knife.  The fascia was incised in the midline and the fascial incision was extended laterally using the second knife.  The rectus muscles were separated in the midline.  The peritoneum was identified, grasped with hemostats, and entered sharply with Metzenbaum scissors.  This incision was extended superiorly and inferiorly with good visualization of the bladder.  The bladder blade was then inserted and vesicouterine peritoneum was identified, grasped with an Allis clamp and entered sharply with Metzenbaum scissors.  This incision was extended laterally and the bladder flap created digitally.  The bladder blade was then reinserted and a small transverse incision was made along the lower uterine segment.  This incision was extended laterally manually.  The amniotic fluid was ruptured at this point with clear fluid obtained.  The infant's head was delivered atraumatically.  The nose and mouth were both suctioned on delivery.  The cord was doubly clamped and cut.  The infant was handed off to the awaiting pediatrician.  Cord gases and cord bloods were obtained and sent.  The placenta was then removed manually and the uterus exteriorized and cleared of all clots and debris.  The uterine incision was reapproximated with #0 chromic in a running lock fashion.  A second layer of the same suture was used with excellent hemostasis.  Attention was now turned to the right fallopian tube, which was grasped with the Babcock and avascular space below the tube was entered using a hemostat.  The tube was doubly clamped using hemostat and the portion between the clamps was removed using Metzenbaum scissors.  The ends of the tube were cauterized using the Bovie and they were then tied off with #2-0 Vicryl.  Attention was then turned to the left fallopian tube, which was grasped with the Babcock and avascular space beneath the tube was entered using a hemostat.  The tube was then doubly clamped with hemostat and the portion of tube between them was removed using the Metzenbaum scissors.  The ends of the tubes were cauterized and the tube was suture-ligated with #2-0 Vicryl.  There were some adhesions of the omentum to the bilateral adnexa.  These were carefully taken down using Metzenbaum scissors with excellent hemostasis noted.  The uterus was then returned to the abdomen and the bladder was cleared of all clots.  The uterine incision was reexamined and found to be hemostatic.  The fascia was then reapproximated with #0 Vicryl in a running fashion.  Several interrupted sutures of #3-0 chromic were placed in the subcutaneous tissue.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  The patient was taken to the recovery room in satisfactory condition.  She will be followed immediately postoperatively within the hospital.
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DESCRIPTION: Repeat low transverse cervical cesarean section with delivery of a viable female neonate.  Bilateral tubal ligation and partial salpingectomy.  Lysis of adhesions.

The situation involves a major surgical procedure, specifically a repeat cesarean section, which inherently carries a level of risk and urgency due to factors such as the patient's previous two cesarean sections and the fact that she is 38 weeks pregnant. Additional procedures performed include bilateral tubal ligation and lysis of adhesions. While the outcomes were favorable with no complications reported, the stakes are high due to the potential risks associated with surgery, anesthesia, and the well-being of both mother and infant. These considerations make it a high-stakes situation, though mitigated by the successful outcome.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Biophysical Profile - 1

HISTORY: , Advanced maternal age and hypertension.,FINDINGS:,  There is a single live intrauterine pregnancy with a vertex lie, posterior placenta, and adequate amniotic fluid.  The amniotic fluid index is 23.2 cm.  Estimated gestational age based on prior ultrasound is 36 weeks 4 four days with an estimated date of delivery of 03/28/08.  Based on fetal measurements obtained today, estimated fetal weight is 3249 plus or minus 396 g, 7 pounds 3 ounces plus or minus 14 ounces, which places the fetus in the 66th percentile for the estimated gestational age.  Fetal heart motion at a rate of 156 beats per minute is documented.  The cord Doppler ratio is normal at 2.2.  The biophysical profile score, assessing fetal breathing movement, gross body movement, fetal tone, and qualitative amniotic fluid volume is 8/8.,IMPRESSION:,1.  Single live intrauterine pregnancy in vertex presentation with an estimated gestational age of 36 weeks 4 days and established due date of 03/28/08.,2.  Biophysical profile (BPP) score 8/8.
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DESCRIPTION: Ultrasound BPP - Advanced maternal age and hypertension.

obstetrics / gynecology, ultrasound, bpp, maternal age, intrauterine pregnancy, biophysical profile, amniotic fluid, gestational age, amniotic, gestational, fetal,

The situation involves an obstetrics/gynecology context where the patient is of advanced maternal age and has hypertension, which are both risk factors that can complicate pregnancy. The biophysical profile score of 8/8 indicates no immediate fetal distress, as it is a perfect score. However, monitoring should continue particularly due to the maternal conditions mentioned, meaning the stakes are higher than a normal pregnancy scenario. This context is moderately high-stakes due to the potential for complications, but currently stable given the BPP score.


Medical Specialty: Neurosurgery
Sample Name: VP Shunt Placement

TITLE OF OPERATION: , Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 2-month-old infant, born premature with intraventricular hemorrhage and Ommaya reservoir recommendation for removal and replacement with a new VP shunt.,PREOP DIAGNOSIS: , Hydrocephalus.,POSTOP DIAGNOSIS: , Hydrocephalus.,PROCEDURE DETAIL: , The patient was brought to the operating room, underwent induction of general endotracheal airway, positioned supine, head turned towards left.  The right side prepped and draped in the usual sterile fashion.  Next, using a 15 blade scalpel, two incisions were made, one in the parietooccipital region and.  The second just lateral to the umbilicus.  Once this was clear, the Bactiseal catheter was then tunneled.  This was connected to a Strata valve.  The Strata valve was programmed to a setting of 1.01 and this was ensured.  The small burr hole was then created.  The area was then coagulated.  Once this was completed, new Bactiseal catheter was then inserted.  It was connected to the Strata valve.  There was good distal flow.  The distal end was then inserted into the peritoneal region via trocar.  Once this was insured, all the wounds were irrigated copiously and closed with 3-0 Vicryl and 4-0 Caprosyn as well as Indermil glue.  The right frontal incision was then opened.  The Ommaya reservoir identified and removed.  The wound was then also closed with an inverted 3-0 Vicryl and 4-0 Caprosyn.  Once all the wounds were completed, dry sterile dressings were applied.  The patient was then transported back to the ICU in stable condition intubated.  Blood loss minimal.  All sponge and needle counts were correct.
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DESCRIPTION: Placement of right new ventriculoperitoneal (VP) shunts Strata valve and to removal of right frontal Ommaya reservoir.

neurosurgery, ommaya reservoir, frontal, strata valve, intraventricular hemorrhage, vp shunt, ventriculoperitoneal, hydrocephalus,

The situation is high-stakes due to several factors. The patient is a 2-month-old infant born prematurely and requires neurosurgery to treat hydrocephalus, a condition which can have serious implications for brain development and function. The procedure involves the placement of a ventriculoperitoneal (VP) shunt to relieve pressure on the brain by diverting cerebrospinal fluid. Mistakes in such surgeries can lead to significant complications or even be life-threatening. Additionally, the complexity of neurosurgery and the vulnerable age of the patient contribute to making this scenario high-stakes.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Breast Ultrasound & Biopsy

EXAM:  ,Bilateral diagnostic mammogram, left breast ultrasound and biopsy.,HISTORY: , 30-year-old female presents for digital bilateral mammography secondary to a soft tissue lump palpated by the patient in the upper right shoulder.  The patient has a family history of breast cancer within her mother at age 58.  Patient denies personal history of breast cancer.,TECHNIQUE AND FINDINGS:  ,Craniocaudal and mediolateral oblique projections of bilateral breasts were obtained on mm/dd/yy.  An additional lateromedial projection of the right breast was obtained.  The breasts demonstrate heterogeneously-dense fibroglandular tissue.  Within the upper outer aspect of the left breast, there is evidence of a circumscribed density measuring approximately 1 cm x 0.7 cm in diameter.  No additional dominant mass, areas of architectural distortion, or malignant-type calcifications are seen.  Multiple additional benign-appearing calcifications are visualized bilaterally.  Skin overlying both breasts is unremarkable.,Bilateral breast ultrasound was subsequently performed, which demonstrated an ovoid mass measuring approximately 0.5 x 0.5 x 0.4 cm in diameter located within the anteromedial aspect of the left shoulder.  This mass demonstrates isoechoic echotexture to the adjacent muscle, with no evidence of internal color flow.  This may represent benign fibrous tissue or a lipoma.,Additional ultrasonographic imaging of the left breast demonstrates a complex circumscribed solid and cystic lesion with hypervascular properties at the 2 o'clock position, measuring 0.7 x 0.7 x 0.8 cm in diameter.  At this time, the lesion was determined to be amenable by ultrasound-guided core biopsy.,The risks and complications of the procedure were discussed with the patient for biopsy of the solid and cystic lesion of the 2 o'clock position of the left breast.  Informed consent was obtained.  The lesion was re-localized under ultrasound guidance.  The left breast was prepped and draped in the usual sterile fashion.  2% lidocaine was administered locally for anesthesia.  Additional lidocaine with epinephrine was administered around the distal aspect of the lesion.  A small skin nick was made.  Color Doppler surrounding the lesion demonstrates multiple vessels surrounding the lesion at all sides.  The lateral to medial approach was performed with an 11-gauge Mammotome device.  The device was advanced under ultrasound guidance, with the superior aspect of the lesion placed within the aperture.  Two core biopsies were obtained.  The third core biopsy demonstrated evidence of an expanding hypoechoic area surrounding the lesion, consistent with a rapidly-expanding hematoma.  Arterial blood was visualized exiting the access site.  A biopsy clip was attempted to be placed, however could not be performed secondary to the active hemorrhage.  Therefore, the Mammotome was removed, and direct pressure over the access site and biopsy location was applied for approximately 20 minutes until hemostasis was achieved.  Postprocedural imaging of the 2 o'clock position of the left breast demonstrates evidence of a hematoma measuring approximately 1.9 x 4.4 x 1.3 cm in diameter.  The left breast was re-cleansed with a ChloraPrep, and a pressure bandage and ice packing were applied to the left breast.  The patient was observed in the ultrasound department for the following 30 minutes without complaints.  The patient was subsequently discharged with information and instructions on utilizing the ice bandage.  The obtained specimens were sent to pathology for further analysis.,IMPRESSION:,1.  A mixed solid and cystic lesion at the 2 o'clock position of the left breast was accessed under ultrasound guidance utilizing a Mammotome core biopsy instrument, and multiple core biopsies were obtained.  Transient arterial hemorrhage was noted at the biopsy site, resulting in a localized 4 cm hematoma.  Pressure was applied until hemostasis was achieved.  The patient was monitored for approximately 30 minutes after the procedure, and was ultimately discharged in good condition.  The core biopsies were submitted to pathology for further analysis.,2.  Small isoechoic ovoid mass within the anteromedial aspect of the left shoulder does not demonstrate color flow, and likely represents fibrotic changes or a lipoma.,3.  Suspicious mammographic findings.  The circumscribed density measuring approximately 8 mm at the 2 o'clock position of the left breast was subsequently biopsied.  Further pathologic analysis is pending.,BIRADS Classification 4 - Suspicious findings.,MAMMOGRAPHY INFORMATION:,1.  A certain percentage of cancers, probably 10% to 15%, will not be identified by mammography.,2.  Lack of radiographic evidence of malignancy should not delay a biopsy if a clinically suspicious mass is present.,3.  These images were obtained with FDA-approved digital mammography equipment, and iCAD SecondLook Software Version 7.2 was utilized.
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DESCRIPTION: Diagnostic mammogram, full-field digital, ultrasound of the breast and mammotome core biopsy of the left breast.

obstetrics / gynecology, mammotome core biopsy, diagnostic mammogram, breast cancer, bilateral breasts, circumscribed density, ovoid mass, breast ultrasound, core biopsy, lesion, biopsy, breast, hematoma, mammotome, mammography, ultrasound,

The situation involves a breast ultrasound and biopsy being performed on a young woman with a palpable lump and a family history of breast cancer. The presentation of a suspicious finding in the breast requires a biopsy to rule out or confirm malignancy, which is high-stakes due to the potential implications for the patient's health. The biopsy procedure resulted in a complication (arterial hemorrhage and hematoma), elevating the stakes due to immediate concerns over patient safety and the need for careful management. The BIRADS classification indicates that the imaging findings are suspicious for malignancy, which further heightens the stakes as it necessitates careful follow-up and potentially significant medical intervention. The outcome of the pathology will have critical implications for her treatment and prognosis.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Abdominosacrocolpopexy

PREOPERATIVE DIAGNOSES:,1.  Vault prolapse.,2.  Enterocele.,PREOPERATIVE DIAGNOSES:,1.  Vault prolapse.,2.  Enterocele.,OPERATIONS:,1.  Abdominosacrocolpopexy.,2.  Enterocele repair.,3.  Cystoscopy.,4.  Lysis of adhesions.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS:,  Less than 100 mL.,SPECIMEN: , None.,BRIEF HISTORY:,  The patient is a 53-year-old female with history of hysterectomy presented with vaginal vault prolapse.  The patient had good support in the anterior vagina and in the posterior vagina but had significant apical prolapse.  Options such as watchful waiting, pessary, abdominal surgery, robotic sacrocolpopexy versus open sacrocolpopexy were discussed.,The patient already had multiple abdominal scars.  Risk of open surgery was little bit higher for the patient.  After discussing the options the patient wanted to proceed a Pfannenstiel incision and repair of the sacrocolpopexy.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, mesh erogenic exposure, complications with mesh were discussed.  The patient understood the risks of recurrence, etc, and wanted to proceed with the procedure.  The patient was told to perform no heavy lifting for 3 months, etc.  The patient was bowel prepped, preoperative antibiotics were given.,DETAILS OF THE OPERATION: , The patient was brought to the OR, anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A Pfannenstiel low abdominal incision was done at the old incision site.  The incision was carried through the subcutaneous tissue through the fascia and the fascia was lifted off the rectus abdominus muscle.  The muscle was split in the middle and peritoneum was entered using sharp mets.  There was no injury to the bowel upon entry.  There were significant adhesions which were unleashed.  All the adhesions in the sigmoid colon from the right lower quadrant and left lower quadrant were released, similarly colon was mobilized.  There was minimal space, everything was packed, Bookwalter placed then over the sacral bone.  The middle of the sacral bone was identified.  The right ureter was clearly identified and was lateral to where the posterior peritoneum was opened.  The ligament over the sacral or sacral __________ was easily identified, 0 Ethibond stitches were placed x3.  A 1 cm x 5 cm mesh was cut out.  This was a Prolene soft mesh which was tied at the sacral ligament.  The bladder was clearly off the vault area which was exposed, in the raw surface 0 Ethibond stitches were placed x3.  The mesh was attached.  The apex was clearly up enterocele sac was closed using 4-0 Vicryl without much difficulty.  The ureter was not involved at all in this process.  The peritoneum was closed over the mesh.  Please note that the peritoneum was opened and it was brought around and over the mesh so that the mesh would not be exposed to the bowel.  Prior to closure antibiotic irrigation was done using Ancef solution.  The mesh has been exposed in antibiotic solution prior to the usage.,After a through irrigation with L and half of antibiotic solution.  All the solution was removed.  Good hemostasis was obtained.  All the packing was removed.  Count was correct.  Rectus abdominus muscle was brought together using 4-0 Vicryl.  The fascia was closed using loop #1 PDS in running fascia from both sides and was tied in the middle.  Subcutaneous tissue was closed using 4-0 Vicryl and the skin was closed using 4-0 Monocryl in subcuticular fashion.  Cystoscopy was done at the end of the procedure.  Please note that the Foley was in place throughout the entire procedure which was placed thoroughly at the beginning of the procedure.  Cystoscopy was done and indigo carmine has been given.  There was good efflux of indigo carmine in both of the ureteral opening.  There was no injury to the rectum or the bladder.  The bladder appeared completely normal.  The rectal exam was done at the end of the procedure after the cystoscopy.  After the cysto was done, the scope was withdrawn, Foley was placed back.  The patient was brought to recovery in the stable condition.
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DESCRIPTION: Abdominosacrocolpopexy, enterocele repair, cystoscopy, and lysis of adhesions.

obstetrics / gynecology, enterocele repair, cystoscopy, lysis of adhesions, enterocele, ethibond stitches, indigo carmine, vault prolapse, sacrocolpopexy, peritoneum, abdominosacrocolpopexy,

The scenario involves a surgical procedure with inherent risks, such as anesthesia, bleeding, infection, and potential complications with mesh. The patient's history of multiple abdominal surgeries increases surgical risk. Though the procedure is planned and routine, the stakes are higher compared to non-surgical settings due to the nature of surgery, potential complications, and need for post-operative care.


Medical Specialty: Obstetrics / Gynecology
Sample Name: Biophysical Profile

CLINICAL HISTORY:,  Gravida 1, para 0 at 33 weeks 5 days by early dating.  The patient is developing gestational diabetes.,Transabdominal ultrasound examination demonstrated a single fetus and uterus in vertex presentation.  The placenta was posterior in position.  There was normal fetal breathing movement, gross body movement, and fetal tone, and the qualitative amniotic fluid volume was normal with an amniotic fluid index of 18.2 cm.,The following measurements were obtained:  Biparietal diameter 8.54 cm, head circumference 30.96 cm, abdominal circumference 29.17 cm, and femoral length 6.58 cm.  These values predict a fetal weight of 4 pounds 15 ounces plus or minus 12 ounces or at the 42nd percentile based on gestation.,CONCLUSION:,  Normal biophysical profile (BPP) with a score of 8 out of possible 8.  The fetus is size appropriate for gestation.
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DESCRIPTION: BPP of Gravida 1, para 0 at 33 weeks 5 days by early dating.  The patient is developing gestational diabetes.

obstetrics / gynecology, biophysical profile, gestational diabetes, amniotic fluid, bpp, gravida, para, diabetes, fetus, fetalNOTE

The clinical context involves a pregnancy where the patient has developed gestational diabetes. While gestational diabetes can lead to complications such as preeclampsia, macrosomia, or preterm birth, the biophysical profile (BPP) results are normal, indicating that there are currently no immediate concerns for fetal well-being. The fetus is also size appropriate for gestation, which suggests that the pregnancy is being well-managed despite the gestational diabetes. Thus, while the situation requires ongoing monitoring, especially due to the diabetes, it does not appear to be high-stakes based on the current information.


Medical Specialty: Neurosurgery
Sample Name: Vein Stripping

PREOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,POSTOPERATIVE DIAGNOSIS: , Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.,PROCEDURES,1.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, right leg.,2.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, left leg.,PROCEDURE DETAIL: , After obtaining the informed consent, the patient was taken to the operating room where she underwent a general endotracheal anesthesia.  A time-out process was followed and antibiotics were given.,Then, both legs were prepped and draped in the usual fashion with the patient was in the supine position.  An incision was made in the right groin and the greater saphenous vein at its junction with the femoral vein was dissected out and all branches were ligated and divided.  Then, an incision was made just below the knee where the greater saphenous vein was also found and connection to varices from the calf were seen.  A third incision was made in the distal third of the right thigh in the area where there was a communication with large branch varicosities.  Then, a vein stripper was passed from the right calf up to the groin and the greater saphenous vein, which was divided, was stripped without any difficultly.  Several minutes of compression was used for hemostasis.  Then, the exposed branch varicosities both in the lower third of the thigh and in the calf were dissected out and then many stabs were performed to do stab phlebectomies at the level of the thigh and the level of the calf as much as the position would allow us to do.,Then in the left thigh, a groin incision was made and the greater saphenous vein was dissected out in the same way as was on the other side.  Also, an incision was made in the level of the knee and the saphenous vein was isolated there.  The saphenous vein was stripped and a several minutes of local compression was performed for hemostasis.  Then, a number of stabs to perform phlebectomy were performed at the level of the calf to excise branch varicosities to the extent that the patient's position would allow us.  Then, all incisions were closed in layers with Vicryl and staples.,Then, the patient was placed in the prone position and the stab phlebectomies of the right thigh and calf and left thigh and calf were performed using 10 to 20 stabs in each leg.  The stab phlebectomies were performed with a hook and they were very satisfactory.  Hemostasis achieved with compression and then staples were applied to the skin.,Then, the patient was rolled onto a stretcher where both legs were wrapped with the Kerlix, fluffs, and Ace bandages.,Estimated blood loss probably was about 150 mL.  The patient tolerated the procedure well and was sent to recovery room in satisfactory condition.  The patient is to be observed, so a decision will be made whether she needs to stay overnight or be able to go home.
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DESCRIPTION: Chronic venous hypertension with painful varicosities, lower extremities, bilaterally.  Greater saphenous vein stripping and stab phlebectomies requiring 10 to 20 incisions, bilaterally.

neurosurgery, chronic venous hypertension, varicosities, stab phlebectomies, greater saphenous vein stripping, lower extremities, vein stripping, saphenous vein, vein, incisions, hemostasis, stripping, branches, phlebectomies, thigh, calf, saphenous,

The situation involves a medical procedure for chronic venous hypertension, requiring vein stripping and stab phlebectomies. While this is a surgical procedure and thus carries inherent risks associated with anesthesia and surgery, it is generally not considered high-risk like major cardiac or neurological surgeries. The estimated blood loss is relatively low, and the patient tolerated the procedure well, with an uneventful recovery outlined. Therefore, while there is some risk involved, it does not exemplify a high-stakes scenario in the context of surgical interventions.


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

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

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

A temporal artery biopsy is a procedure often performed to diagnose temporal arteritis, which is an inflammation of the temporal arteries that can lead to serious complications such as vision loss if left untreated. The stakes are moderate because while the procedure itself isn't classified as highly risky when performed by skilled physicians, the implications of the procedure and diagnosis carry potential for high impact on patient health. Ensuring an accurate diagnosis is crucial to prevent potential complications like blindness. However, the procedure described was completed successfully with minimal complications and was tolerated well by the patient.


Medical Specialty: Neurosurgery
Sample Name: Shunt Revision - 1

PREOPERATIVE DIAGNOSIS: , Shunt malfunction.  The patient with a ventriculoatrial shunt.,POSTOPERATIVE DIAGNOSIS:,  Shunt malfunction.  The patient with a ventriculoatrial shunt.,ANESTHESIA: , General endotracheal tube anesthesia.,INDICATIONS FOR OPERATION: , Headaches, fluid accumulating along shunt tract.,FINDINGS: , Partial proximal shunt obstruction.,TITLE OF OPERATION:,  Endoscopic proximal shunt revision.,SPECIMENS: , None.,COMPLICATIONS:,  None.,DEVICES: , Portnoy ventricular catheter.,OPERATIVE PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was administered, the patient positioned on the operating table in supine position with the right frontal area shaved and the head was prepped and draped in a routine manner.  The old right frontal scalp incision was reopened in a curvilinear manner, and the Bactiseal ventricular catheter was identified as it went into the right frontal horn.  The distal end of the VA shunt was flushed and tested with heparinized saline, found to be patent, and it was then clamped.  Endoscopically, the proximal end was explored and we found debris within the lumen, and then we were able to freely move the catheter around.  We could see along the tract that the tip of the catheter had gone into the surrounding tissue and appeared to have prongs or extensions in the tract, which were going into the catheter consistent with partial proximal obstruction.  A Portnoy ventricular catheter was endoscopically introduced and then the endoscope was bend so that the catheter tip did not go into the same location where it was before, but would take a gentle curve going into the right lateral ventricle.  It flushed in quite well, was left at about 6.5 cm to 7 cm and connected to the existing straight connector and secured with 2-0 Ethibond sutures.  The wounds were irrigated out with Bacitracin and closed in a routine manner using two 3-0 Vicryl for the galea and a 4-0 running Monocryl for the scalp followed by Mastisol and Steri-Strips.  The patient was awakened and extubated having tolerated the procedure well without complications.  It should be noted that the when we were irrigating through the ventricular catheter, fluid easily came out around the catheter indicating that the patient had partial proximal obstruction so that we could probably flow around the old shunt tract and perhaps this was leading to some of the symptomatology or findings of fluid along the chest.
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DESCRIPTION: Endoscopic proximal shunt revision.

Endoscopic proximal shunt revision.

neurosurgery, ventriculoatrial shunt, endoscopic proximal shunt revision, endoscopic proximal shunt, portnoy ventricular catheter, shunt malfunction, shunt revision, ventricular catheter, shunt, endoscopic, ventricular, proximal, catheter,

The scenario involves a neurosurgical procedure to address a shunt malfunction, which is a critical medical condition. Shunt malfunctions can lead to serious complications like increased intracranial pressure, headaches, and fluid accumulation. The procedure described, an endoscopic proximal shunt revision, requires precise surgical intervention, and even though it was performed successfully without complications, the nature of neurosurgery and the potential risks involved mark it as high-stakes. Ensuring proper function of the ventricular shunt is crucial for the patient's health and well-being.


Medical Specialty: Neurosurgery
Sample Name: Shunt Revision

TITLE OF OPERATION:,  Bilateral endoscopic proximal shunt revision and a distal shunt revision.,INDICATIONS FOR OPERATION:,  Headaches, full subtemporal site.,PREOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,POSTOPERATIVE DIAGNOSIS: , Slit ventricle syndrome.,FINDINGS:,  Coaptation of ventricles against proximal end of ventricular catheter.,ANESTHESIA: , General endotracheal tube anesthesia.,DEVICES: , A Codman Hakim programmable valve with Portnoy ventricular catheter, a 0/20 proGAV valve with a shunt assist of 20 cm dual right-angled connector, and a flushing reservoir.,BRIEF NARRATIVE OF OPERATIVE PROCEDURE:,  After satisfactory general endotracheal tube anesthesia was administered, the patient was positioned on the operating table in the prone position with the head held on a soft foam padding.  The occipital area was shaven bilaterally and then the areas of the prior scalp incisions were infiltrated with 0.25% Marcaine with 1:200,000 epinephrine after routine prepping and draping.  Both U-shaped scalp incisions were opened exposing both the left and the right ventricular catheters as well as the old low pressure reservoir, which might have been leading to the coaptation of the ventricles.  The patient also had a right subtemporal depression, which was full preoperatively.  The entire old apparatus was dissected out.  We then cut both the ventricular catheters and secured them with sutures so that __________ could be inserted.  They were both inspected.  No definite debris were seen.  After removing the ventricular catheters, the old tracts were inspected and we could see where there was coaptation of the ventricles against the ventricular catheter.  On the right side, we elected to insert the Portnoy ventricular catheter and on the left a new Bactiseal catheter was inserted underneath the corpus callosum in a different location.  The old valve was dissected out and the proGAV valve with a 2-0 shunt assist was inserted and secured with a 2-0 Ethibond suture.  The proGAV valve was then connected to a Bactiseal distal tubing, which was looped in a cephalad way and then curved towards the left burr hole site and then the Portnoy catheter on the right was secured with a right-angled sleeve and then interposed between it and the left burr hole site with a flushing reservoir.  All connections secured with 2-0 Ethibond suture and a small piece of Bactiseal tubing between the flushing reservoir and the connector, which secured the left Bactiseal tubing to the two other Bactiseal tubings one being the distal Bactiseal tubing going towards the proGAV valve, which was set to an opening pressure of 8 and the other one being the Bactiseal tubing, which was going towards the flushing reservoir.,All the wounds were irrigated out with bacitracin and then closed in a routine manner using Vicryl for the deep layers and Monocryl for the skin, followed by Mastisol and Steri-Strips.  The patient tolerated the procedure well without complications.  CSF was not sent off.
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DESCRIPTION: Bilateral endoscopic proximal shunt revision and a distal shunt revision.

neurosurgery, codman hakim, portnoy, slit ventricle syndrome, shunt revision, bilateral endoscopic proximal shunt, coaptation of the ventricles, portnoy ventricular catheter, ventricular catheter, progav valve, flushing reservoir, bactiseal tubing, shunt, ventricular, bactiseal

The described procedure involves a neurosurgical operation to address slit ventricle syndrome, a condition affecting patients with shunts used to treat hydrocephalus. Neurosurgery inherently carries high risks due to its complexity and the critical structures involved, such as the brain. This is a delicate operation, requiring precise manipulation to prevent serious complications like infection, bleeding, or neurological damage. The outcome can significantly impact the patient's health and quality of life. Therefore, the stakes are high in this situation, considering the possible consequences and the level of precision required.


Medical Specialty: Neurosurgery
Sample Name: Ommaya reservoir

TITLE OF OPERATION: , Right frontal side-inlet Ommaya reservoir.,INDICATION FOR SURGERY: , The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy.  Recommendation was for an Ommaya reservoir.  Risks and benefits have been explained.  They agreed to proceed.,PREOP DIAGNOSIS: , Leukemic meningitis.,POSTOP DIAGNOSIS:  ,Leukemic meningitis.,PROCEDURE DETAIL: , The patient was brought to the operating room, underwent induction of laryngeal mask airway, positioned supine on a horseshoe headrest.  The right frontal region was prepped and draped in the usual sterile fashion.  Next, a curvilinear incision was made just anterior to the coronal suture 7 cm from the middle pupillary line.  Once this was completed, a burr hole was then created with a high-speed burr.  The dura was then coagulated and opened.  The Ommaya reservoir catheter was inserted up to 6.5 cm.  There was good flow.  This was connected to the side inlet, flat-bottom Ommaya and this was then placed in a subcutaneous pocket posterior to the incision.  This was then cut and __________.  It was then tapped percutaneously with 4 cubic centimeters and sent for routine studies.  Wound was then irrigated copiously with __________ irrigation, closed using 3-0 Vicryl for the deep layers and 4-0 Caprosyn for the skin.  The connection was made with a 3-0 silk suture and was a right-angle intermediate to hold the catheter in place.
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DESCRIPTION: Leukemic meningitis.   Right frontal side-inlet Ommaya reservoir.  The patient is a 49-year-old gentleman with leukemia and meningeal involvement, who was undergoing intrathecal chemotherapy.

neurosurgery, caprosyn, leukemic meningitis, ommaya reservoir, leukemia, meningeal, intrathecal, chemotherapy, leukemic, meningitis, ommaya,

This situation involves a neurosurgical procedure to implant an Ommaya reservoir for a patient with leukemic meningitis, a condition that is potentially life-threatening. The surgery is significant as it involves the brain and there are critical risks involved, requiring precision and attention. The outcome could significantly affect the patient's medical treatment and overall prognosis related to leukemia treatment and management of meningitis. Therefore, due to the complex nature of neurosurgery and the patient's serious medical condition, the stakes are high.


Medical Specialty: Neurosurgery
Sample Name: Pituitary Tumor Resection

TITLE OF OPERATION: , Transnasal transsphenoidal approach in resection of pituitary tumor.,INDICATION FOR SURGERY: , The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.  She was started on Dostinex with increasing dosages.  The most recent MRI demonstrated an increased growth with hemorrhage.  This was then discontinued.  Most recent prolactin was at 70, although normalized, the recommendation was surgical resection given the size of the sellar lesion.  All the risks, benefits, and alternatives were explained in great detail via translator.,PREOP DIAGNOSIS: , Pituitary tumor.,POSTOP DIAGNOSIS: , Pituitary tumor.,PROCEDURE DETAIL:  ,The patient brought to the operating room, positioned on the horseshoe headrest in a neutral position supine.  The fluoroscope was then positioned.  The approach will be dictated by Dr. X. Once the operating microscope and the endoscope were then used to approach it through transnasal, this was complicated and complex secondary to the drilling within the sinus.  Once this was ensured, the tumor was identified, separated from the pituitary gland, it was isolated and then removed.  It appeared to be hemorrhagic and a necrotic pituitary, several sections were sent.  Once this was ensured and completed and hemostasis obtained, the wound was irrigated.  There might have been a small CSF leak with Valsalva, so the recommendation was for a reconstruction, Dr. X will dictate.  The fat graft was harvested from the left lower quadrant and closed primarily, this was soaked in fat and used to close the closure.  All sponge and needle counts were correct.  The patient was extubated and transported to the recovery room in stable condition.  Blood loss was minimal.
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DESCRIPTION: Transnasal transsphenoidal approach in resection of pituitary tumor.   The patient is a 17-year-old girl who presented with headaches and was found to have a prolactin of 200 and pituitary tumor.

neurosurgery, transnasal transsphenoidal approach, resection, pituitary tumor, transsphenoidal, transnasal, prolactin, tumor, pituitary,

The operation described is a neurosurgical procedure involving the resection of a pituitary tumor through a transnasal transsphenoidal approach. Such surgeries inherently carry significant risks, including potential damage to surrounding brain structures, risk of cerebrospinal fluid (CSF) leaks, and other intraoperative complications. Additionally, the patient's age and the presence of hemorrhage in the tumor add complexity and urgency, as it can affect neurological and endocrine function if not adequately addressed. The stakes are high due to the potential for postoperative complications affecting the patient's quality of life and the precision required during the surgery.


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

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

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

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

The procedure involves phenol neurolysis and botulinum toxin injections, both of which require precision and carry risks, such as nerve damage and adverse reactions. Given the involvement of multiple nerves and muscle groups, combined with the pre-existing spastic quadriparesis condition from a traumatic brain injury, there are significant potential consequences if complications were to arise. However, no complications were reported, and the procedure was performed under a controlled setting, indicating a successful execution. These factors combined make the stakes relatively high due to the critical nature of the nerves involved and the patient's existing condition.


Medical Specialty: Neurosurgery
Sample Name: Nerve & Tendon Repair - Finger

PREOPERATIVE DIAGNOSIS:,  Volar laceration to right ring finger with possible digital nerve injury with possible flexor tendon injury.,POSTOPERATIVE DIAGNOSES:,1.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis.,2.  25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.,PROCEDURE PERFORMED:,1.  Repair of nerve and tendon, right ring finger.,2.  Exploration of digital laceration.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , Less than 10 cc.,TOTAL TOURNIQUET TIME:  ,57 minutes.,COMPLICATIONS: , None.,DISPOSITION:  ,To PACU in stable condition.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 13-year-old male who had sustained a laceration from glass and had described numbness and tingling in his right ring finger.,GROSS OPERATIVE FINDINGS: , After wound exploration, it was found there was a 100% laceration to the ulnar digital neurovascular bundle.  The FDS had a partial ulnar slip laceration and the FDP had a 25% transverse laceration as well.  The radial neurovascular bundle was found to be completely intact.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room and placed in the supine position.  All bony prominences were adequately padded.  Tourniquet was placed on the right upper extremity after being packed with Webril, but not inflated at this time.  The right upper extremity was prepped and draped in the usual sterile fashion.  The hand was inspected.  Palmar surface revealed approximally 0.5 cm laceration at the base of the right ring finger at the base of proximal phalanx, which was approximated with nylon suture.  The sutures were removed and the wound was explored.  It was found that the ulnar digital neurovascular bundle was 100% transected.  The radial neurovascular bundle on the right ring finger was found to be completely intact.  We explored the flexor tendon and found that there was a partial laceration of the ulnar slip of the FDS and a 25% laceration in a transverse fashion to the FDP.  We copiously irrigated the wound.  Repair was undertaken of the FDS with #3-0 undyed Ethibond suture.  The laceration of the FDP was not felt that it need to repair due to majority of the substance in the FDP was still intact.  Attention during our repair at the flexor tendon, the A1 pulley was incised for better visualization as well as better tendon excursion after repair.  Attention was then drawn to the ulnar digital bundle which has been transected prior during the injury.  The digital nerve was dissected proximally and distally to likely visualize the nerve.  The nerve was then approximated using microvascular technique with #8-0 nylon suture.  The hands were well approximated.  The nerve was not under undue tension.  The wound was then copiously irrigated and the skin was closed with #4-0 nylon interrupted horizontal mattress alternating with simple suture.  Sterile dressing was placed and a dorsal extension Box splint was placed.  The patient was transferred off of the bed and placed back on a gurney and taken to PACU in stable condition.  Overall prognosis is good.
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DESCRIPTION: Repair of nerve and tendon, right ring finger and exploration of digital laceration.  Laceration to right ring finger with partial laceration to the ulnar slip of the FDS which is the flexor digitorum superficialis and 25% laceration to the flexor digitorum profundus of the right ring finger and laceration 100% of the ulnar digital nerve to the right ring finger.

neurosurgery, laceration, flexor tendon, volar laceration, digital laceration, ulnar slip, flexor digitorum, neurovascular bundle, nerve, injury, ring, finger, neurovascular, fds, bundle, tendon, repair, flexor, digital, ulnar,

The situation involves a surgical procedure on a 13-year-old male patient who has sustained significant nerve and tendon injuries to his right ring finger, likely affecting both sensation and motor function. This surgical intervention is critical to restore functionality and sensation in the finger, prevent further complications, and ensure the patient's quality of life. The procedure requires precision and expertise in neurosurgery, thus making it relatively high-stakes due to the potential for long-term impact on hand function if not performed correctly.


Medical Specialty: Neurosurgery
Sample Name: Laminectomy & Foraminotomy Revision

PREOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,POSTOPERATIVE DIAGNOSES:,1.  Recurrent spinal stenosis at L3-L4, L4-L5, and L5-S1.,2.  Spondylolisthesis, which is unstable at L4-L5.,3.  Recurrent herniated nucleus pulposus at L4-L5 bilaterally.,PROCEDURE PERFORMED:,1.  Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.,2.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.,3.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.,ANESTHESIA: , General via endotracheal tube.,ESTIMATED BLOOD LOSS:  ,Approximately 1000 cc.,CELL SAVER RETURNED:  ,Approximately 550 cc.,SPECIMENS: , None.,COMPLICATIONS: , None.,DRAIN: , 8-inch Hemovac.,SURGICAL INDICATIONS: , The patient is a 59-year-old male who had severe disabling low back pain.  He had previous lumbar laminectomy at L4-L5.  He was noted to have an isthmic spondylolisthesis.,Previous lumbar laminectomy exacerbated this condition and made it further unstable.  He is suffering from neurogenic claudication.  He was unresponsive to extensive conservative treatment.  He has understanding of the risks, benefits, potential complications, treatment alternatives and provided informed consent.,OPERATIVE TECHNIQUE: , The patient was taken to OR #5 where he was given general anesthetic by the Department of Anesthesia.  He was subsequently placed prone on the Jackson's spinal table with all bony prominences well padded.  His lumbar spine was then sterilely prepped and draped in the usual fashion.  A previous midline incision was extended from approximate level of L3 to S1.  This was in the midline.  Skin and subcutaneous tissue were debrided sharply.  Electrocautery provided hemostasis.  ,Electrocautery was utilized to dissect through subcutaneous tissue of lumbar fascia.  The lumbar fascia was identified and split in the midline.  Subperiosteal dissection was then carried out with electrocautery and ______ elevated from the suspected levels of L3-S1.  Once this was exposed, the transverse processes, a Kocher clamp was placed and a localizing cross-table x-ray confirmed the interspace between the spinous processes of L3-L4.  Once this was completed, a self-retaining retractor was then placed.  With palpation of the spinous processes, the L4 posterior elements were noted to be significantly loosened and unstable.  These were readily mobile with digital palpation.  A rongeur was then utilized to resect the spinous processes from the inferior half of L3 to the superior half of S1.  This bone was morcellized and placed on the back table for utilization for bone grafting.  The rongeur was also utilized to thin the laminas from the inferior half of L3 to superior half of S1.  Once this was undertaken, the unstable posterior elements of L4 were meticulously dissected free until wide decompression was obtained.  Additional decompression was extended from the level of the inferior half of L3 to the superior half of S1.  The microscope was utilized during this portion of procedure for visualization.  There was noted to be no changes during the decompression portion or throughout the remainder of the surgical procedure.  Once decompression was deemed satisfactory, the nerve roots were individually inspected and due to the unstable spondylolisthesis, there was noted to be tension on the L4 and L5 nerve roots crossing the disc space at L4-L5.  Once this was identified, foraminotomies were created to allow additional mobility.  The wound was then copiously irrigated with antibiotic solution and suctioned dry.  Working type screws, provisional titanium screws were then placed at L4-l5.  This was to allow distraction and reduction of the spondylolisthesis.  These were placed in the pedicles of L4 and L5 under direct intensification.  The position of the screws were visualized, both AP and lateral images.  They were deemed satisfactory.,Once this was completed, a provisional plate was applied to the screws and distraction applied across L4-L5.  This allowed for additional decompression of the L5 and L4 nerve roots.  Once this was completed, the L5 nerve root was traced and deemed satisfactory exiting neural foramen after additional dissection and discectomy were performed.  Utilizing a series of interbody spacers, a size 8 mm spacer was placed within the L4-L5 interval.  This was taken in sequence up to a 13 mm space.  This was then reduced to a 11 mm as it was much more anatomic in nature.  Once this was completed, the spacers were then placed on the left side and distraction obtained.  Once the distraction was obtained to 11 mm, the interbody shavers were utilized to decorticate the interbody portion of L4 and L5 bilaterally.  Once this was taken to 11 mm bilaterally, the wound was copiously irrigated with antibiotic solution and suction dried.  A 11 mm height x 9 mm width x 25 mm length carbon fiber cages were packed with local bone graft and Allograft.  There were impacted at the interspace of L4-L5 under direct image intensification.  Once these were deemed satisfactory, the wound was copiously irrigated with antibiotic solution and suction dried.  The provisional screws and plates were removed.  This allowed for additional compression along L4-L5 with the cage instrumentation.  Permanent screws were then placed at L4, L5, and S1 bilaterally.  This was performed under direct image intensification.  The position was verified in both AP and lateral images.  Once this was completed, the posterolateral gutters were decorticated with an AM2 Midas Rex burr down to bleeding subchondral bone.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The morcellized Allograft and local bone graft were mixed and packed copiously from the transverse processes of L4-S1 bilaterally.  A 0.25 inch titanium rod was contoured of appropriate length to span from L4-S1.  Appropriate cross connecters were applied and the construct was placed over the pedicle screws.  They were tightened and sequenced to allow additional posterior reduction of the L4 vertebra.  Once this was completed, final images in the image intensification unit were reviewed and were deemed satisfactory.  All connections were tightened and retightened in Torque 2 specifications.  The wound was then copiously irrigated with antibiotic solution and suction dried.  The dura was inspected and noted to be free of tension.  At the conclusion of the procedure, there was noted to be no changes on the SSEP, EMG, and neurophysiologic monitors.  An 8-inch Hemovac drain was placed exiting the wound.  The lumbar fascia was then approximated with #1 Vicryl in interrupted fashion, the subcutaneous tissue with #2-0 Vicryl interrupted fashion, surgical stainless steel clips were used to approximate the skin.  The remainder of the Hemovac was assembled.  Bulky compression dressing utilizing Adaptic, 4x4, and ABDs was then affixed to the lumbar spine with Microfoam tape.  He was turned and taken to the recovery room in apparent satisfactory condition.  Expected surgical prognosis remains guarded.
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DESCRIPTION: Microscopic-assisted revision of bilateral decompressive lumbar laminectomies and foraminotomies at the levels of L3-L4, L4-L5, and L5-S1.  Posterior spinal fusion at the level of L4-L5 and L5-S1 utilizing local bone graft, allograft and segmental instrumentation.  Posterior lumbar interbody arthrodesis utilizing cage instrumentation at L4-L5 with local bone graft and allograft.  All procedures were performed under SSEP, EMG, and neurophysiologic monitoring.

The described medical procedure is a complex and intricate neuro-surgical intervention involving revision surgeries at multiple levels of the lumbar spine, addressing conditions such as recurrent spinal stenosis, spondylolisthesis, and herniated nucleus pulposus. These are significant medical issues that can cause severe pain and disability. The surgery involves numerous high-risk components, including spinal fusion, use of allografts, and careful neurophysiological monitoring to avoid complications. Any errors or complications during the procedure could lead to serious consequences, including potential paralysis or other long-term impairments. Therefore, the stakes are very high both in terms of the complexity of the surgery and the potential impact on the patient's life.


Medical Specialty: Neurosurgery
Sample Name: Laminectomy & Facetectomy

PREOPERATIVE DIAGNOSIS:,  Dural tear, postoperative laminectomy, L4-L5.,POSTOPERATIVE DIAGNOSES,1.  Dural tear, postoperative laminectomy, L4-L5.,2.  Laterolisthesis, L4-L5.,3.  Spinal instability, L4-L5.,OPERATIONS PERFORMED,1.  Complete laminectomy, L4.,2.  Complete laminectomy plus facetectomy, L3-L4 level.,3.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.,4.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.,5.  Posterior spinal fusion, L4 to S1.,6.  Insertion of morselized autograft, L4 to S1.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 500 mL.,COMPLICATIONS: , None.,DRAINS:  ,Hemovac x1.,DISPOSITION: , Vital signs stable, taken to the recovery room in a satisfactory condition, extubated.,INDICATIONS FOR OPERATION: , The patient is a 48-year-old gentleman who has had a prior decompression several weeks ago.  He presented several days later with headaches as well as a draining wound.  He was subsequently taken back for a dural repair.  For the last 10 to 11 days, he has been okay except for the last two days he has had increasing headaches, has nausea, vomiting, as well as positional migraines.  He has fullness in the back of his wound.  The patient's risks and benefits have been conferred him due to the fact that he does have persistent spinal leak.  The patient was taken to the operating room for exploration of his wound with dural repair with possible stabilization pending what we find intraoperatively.,PROCEDURE IN DETAIL:,  After appropriate consent was obtained from the patient, the patient was wheeled back to the operating theater room #7.  The patient was placed in the usual supine position and intubated under general anesthesia without any difficulties.  The patient was given intraoperative antibiotics.  The patient was rolled onto the OSI table in usual prone position and prepped and draped in usual sterile fashion.,Initially, a midline incision was made from the cephalad to caudad level.  Full-thickness skin flaps were developed.  It was seen immediately that there was large amount of copious fluid emanating from the wound, clear-like fluid, which was the cerebrospinal fluid.  Cultures were taken, aerobic, anaerobic, AFB, fungal.  Once this was done, the paraspinal muscles were affected from the posterior elements.  It was seen that there were no facet complexes on the right side at L4-L5 and L5-S1.  It was seen that the spine was listhesed at L5 and that the dural sac was pinched at the L4-5 level from the listhesis.  Once this was done; however, the fluid emanating from the dura could not be seen appropriately.  Complete laminectomy at L4 was performed as well extending the L5 laminectomy more to the left.  Complete laminectomy at L3 was done.  Once this was done within the subarticular recess on the right side at the L4 pedicle level, a rent in the dura was seen.  Once this was appropriately cleaned, the dural edges were approximated using a running 6-0 Prolene suture.  A Valsalva confirmed no significant lead after the repair was made.  There was a significant laterolisthesis at L4-L5 and due to the fact that there were no facet complexes at L5-S1 and L4-L5 on the right side as well as there was a significant concavity on the right L4-L5 disk space which was demonstrated from intraoperative x-rays and compared to preoperative x-rays, it was decided from an instrumentation.  The lateral pedicle screws were placed at L4, L5, and S1 using the standard technique of Magerl.  After this the standard starting point was made.  Trajectory was completed with gearshift and sounded in all four quadrants to make sure there was no violation of the pedicle wall.  Once this was done, this was undertapped at 1 mm and resounded in all four quadrants to make sure that there was no violation of the pedicle wall.  The screws were subsequently placed.  Tricortical purchase was obtained at S1 ________ appropriate size screws.  Precontoured titanium rod was then appropriately planned and placed between the screws at L4, L5, and S1.  This was done on the right side first.  The screw was torqued at S1 appropriately and subsequently at L5.  Minimal compression was then placed between L5 and L4 to correct the concavity as well as laterolisthesis and the screw appropriately torqued at L4.  Neutral compression distraction was obtained on the left side.  Screws were torqued at L4, L5, and S1 appropriately.  Good placement was seen both in AP and lateral planes using fluoroscopy.  Laterolisthesis corrected appropriately at L4 and L5.,Posterior spinal fusion was completed by decorticating the posterior elements at L4-L5 and the sacral ala with a curette.  Once good bleeding subchondral bone was appreciated, the morselized bone from the laminectomy was morselized with corticocancellous bone chips together with demineralized bone matrix.  This was placed in the posterior lateral gutters.  DuraGen was then placed over the dural repair, and after this, fibrin glue was placed appropriately.  Deep retractors then removed from the confines of the wound.  Fascia was closed using interrupted Prolene running suture #1.  Once this was done, suprafascial drain was placed appropriately.  Subcutaneous tissues were opposed using a 2-0 Prolene suture.  The dermal edges were approximated using staples.  Wound was dressed sterilely using bacitracin ointment, Xeroform, 4 x 4's, and tape.  The drain was connected appropriately.  The patient was rolled on stretcher in usual supine position, extubated uneventfully, and taken back to the recovery room in a satisfactory stable condition.  No complications arose.
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DESCRIPTION: Complete laminectomy, L4. and facetectomy, L3-L4 level.  A dural repair, right sided, on the lateral sheath, subarticular recess at the L4 pedicle level.  Posterior spinal instrumentation, L4 to S1, using Synthes Pangea System.  Posterior spinal fusion, L4 to S1.  Insertion of morselized autograft, L4 to S1.

The situation involves a complex surgical procedure in the field of neurosurgery, specifically addressing issues like a dural tear, spinal instability, and laterolisthesis. The stakes are high due to the location of the surgery (spinal cord area), the potential for significant complications, and the necessity of precise repair and stabilization techniques. Furthermore, successful recovery is critical for the patient's quality of life and avoidance of further surgeries. Therefore, this procedure can have serious implications for the patient's neurological function and overall well-being, indicating a high-stakes situation.


Medical Specialty: Neurosurgery
Sample Name: Hemilaminotomy & Foraminotomy

PRE AND POSTOPERATIVE DIAGNOSIS:,  Left cervical radiculopathy at C5, C6,OPERATION: , Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.,After informed consent was obtained from the patient, he was taken to the OR.  After general anesthesia had been induced, Ted hose stockings and pneumatic compression stockings were placed on the patient and a Foley catheter was also inserted.  At this point, the patient's was placed in three point fixation with a Mayfield head holder and then the patient was placed on the operating table in a prone position.  The patient's posterior cervical area was then prepped and draped in the usual sterile fashion.  At this time the patient's incision site was infiltrated with 1 percent Lidocaine with epinephrine.  A scalpel was used to make an approximate 3 cm skin incision cephalad to the prominent C7 spinous processes, which could be palpated.  After dissection down to a spinous process using Bovie cautery, a clamp was placed on this spinous processes and cross table lateral x-ray was taken.  This showed the spinous process to be at the C4 level.  Therefore, further soft tissue dissection was carried out caudally to this level after the next spinous processes presumed to be C5 was identified.  After the muscle was dissected off the lamina laterally on the left side, self retaining retractors were placed and after hemostasis was achieved, a Penfield probe was placed in the interspace presumed to be C5-6 and another cross table lateral x-ray of the C spine was taken.  This film confirmed our position at C5-6 and therefore the operating microscope was brought onto the field at this time.  At the time the Kerrison rongeur was used to perform a hemilaminotomy by starting with the inferior margin of the superior lamina.  The superior margin of the inferior lamina of C6 was also taken with the Kerrison rongeur after the ligaments had been freed by using a Woodson probe.  This was then extended laterally to perform a medial facetectomy also using the Kerrison rongeur.  However, progress was limited because of thickness of the bone.  Therefore at this time the Midas-Rex drill, the AM8 bit was brought onto the field and this was used to thin out the bone around our laminotomy and medial facetectomy area.  After the bone had been thinned out, further bone was removed using the Kerrison rongeur.  At this point the nerve root was visually inspected and observed to be decompressed.  However, there was a layer of fibrous tissue overlying the exiting nerve root which was removed by placing a Woodson resector in a plane between the fibrous sheath and the nerve root and incising it with a 15 blade.  Hemostasis was then achieved by using Gelfoam as well as bipolar electrocautery.  After hemostasis was achieved, the surgical site was copiously irrigated with Bacitracin.  Closure was initiated by closing the muscle layer and the fascial layer with 0 Vicryl stitches.  The subcutaneous layer was then reapproximated using 000 Dexon.  The skin was reapproximated using a running 000 nylon.  Sterile dressings were applied.  The patient was then extubated in the OR and transferred to the Recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  minimal.
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DESCRIPTION: Left C5-6 hemilaminotomy and foraminotomy with medial facetectomy for microscopic decompression of nerve root.

neurosurgery, foraminotomy with medial facetectomy, facetectomy for microscopic decompression, decompression of nerve root, hemilaminotomy and foraminotomy, decompression of nerve, microscopic decompression, medial facetectomy, kerrison rongeur, nerve root, spinous processes, facetectomy, kerrison, hemilaminotomy, foraminotomy,

The situation involves a neurosurgery procedure, specifically a hemilaminotomy and foraminotomy, which are delicate operations performed on the spine to relieve nerve compression. These surgeries carry inherent risks such as nerve damage, infection, or complications from anesthesia, making them relatively high-stakes due to the critical nature of the spinal area being operated on. Successful execution of this surgery is crucial for the patient's neurological health and overall recovery.


Medical Specialty: Neurosurgery
Sample Name: Frameless Stereotactic Radiosurgery

PREOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,POSTOPERATIVE DIAGNOSIS:,  Right occipital arteriovenous malformation.,PROCEDURE PERFORMED:,  CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.,Please note no qualified resident was available to assist in the procedure.,INDICATION: , The patient is a 30-year-old male with a right occipital AVM.  He was referred for stereotactic radiosurgery.  The risks of the radiosurgical treatment were discussed with the patient including, but not limited to, failure to completely obliterate the AVM, need for additional therapy, radiation injury, radiation necrosis, headaches, seizures, visual loss, or other neurologic deficits.  The patient understands these risks and would like to proceed.,PROCEDURE IN DETAIL: , The patient arrived to Outpatient CyberKnife Suite one day prior to the treatment.  He was placed on the treatment table.  The Aquaplast mask was constructed.  Initial imaging was obtained by the CyberKnife system.  The patient was then transported over to the CT scanner at Stanford.  Under the supervision of Dr. X, 125 mL of Omnipaque 250 contrast was administered.  Dr. X then supervised the acquisition of 1.2-mm contiguous axial CT slices.  These images were uploaded over the hospital network to the treatment planning computer, and the patient was discharged home.,Treatment plan was then performed by me.  I outlined the tumor volume.  Inverse treatment planning was used to generate the treatment plan for this patient.  This resulted in a total dose of 20 Gy delivered to 84% isodose line using a 12.5 mm collimator.  The maximum dose within this center of treatment volume was 23.81 Gy.  The volume treated was 2.972 mL, and the treated lesion dimensions were 1.9 x 2.7 x 1.6 cm.  The volume treated at the reference dose was 98%.  The coverage isodose line was 79%.  The conformality index was 1.74 and modified conformality index was 1.55.  The treatment plan was reviewed by me and Dr. Y of Radiation Oncology, and the treatment plan was approved.,On the morning of May 14, 2004, the patient arrived at the Outpatient CyberKnife Suite.  He was placed on the treatment table.  The Aquaplast mask was applied.  Initial imaging was used to bring the patient into optimal position.  The patient underwent stereotactic radiosurgery to deliver the 20 Gy to the AVM margin.  He tolerated the procedure well.  He was given 8 mg of Decadron for prophylaxis and discharged home.,Followup will consist of an MRI scan in 6 months.  The patient will return to our clinic once that study is completed.,I was present and participated in the entire procedure on this patient consisting of CT-guided frameless stereotactic radiosurgery for the right occipital AVM.,Dr. X was present during the entire procedure and will be dictating his own operative note.
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DESCRIPTION: CT-guided frameless stereotactic radiosurgery for the right occipital arteriovenous malformation using dynamic tracking.

neurosurgery, ct-guided, occipital, cyberknife, frameless stereotactic radiosurgery, occipital arteriovenous malformation, conformality index, arteriovenous malformation, malformation, avm, arteriovenous,

This scenario involves the treatment of a right occipital arteriovenous malformation through CT-guided frameless stereotactic radiosurgery. This is a high-stakes scenario due to the critical and intricate nature of the condition being treated. Arteriovenous malformations (AVMs) are complex tangles of abnormal blood vessels where arteries connect directly to veins, causing potential hemorrhage or other serious complications. The procedure, while minimally invasive compared to open surgery, is intricate and requires precise execution and careful planning. The potential consequences of failure or complications such as headaches, seizures, visual loss, or neurological deficits, along with the risks of radiation necrosis further underscore the high-stakes nature. The absence of a qualified resident highlights a potential challenge in the level of support available during the procedure. The complex planning and execution involving a 30-year-old patient further add to the criticality.