Medical Specialty: Surgery
Sample Name: Endoscopy - 1

PROCEDURE:,  Upper endoscopy.,PREOPERATIVE DIAGNOSIS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,1.  GERD, biopsied.,2.  Distal esophageal reflux-induced stricture, dilated to 18 mm.,3.  Otherwise normal upper endoscopy.,MEDICATIONS: , Fentanyl 125 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 50-year-old white male with dysphagia, which has improved recently with Aciphex.,FINDINGS: , The patient was placed in the left lateral decubitus position and the above medications were administered.  The oropharynx was sprayed with Cetacaine.  The endoscope was passed, under direct visualization, into the esophagus.  The squamocolumnar junction was irregular and edematous.  Biopsies were obtained for histology.  There was a mild ring at the LES, which was dilated with a 15 to 18 mm balloon, with no resultant mucosal trauma.  The entire gastric mucosa was normal, including a retroflexed view of the fundus.  The entire duodenal mucosa was normal to the second portion.  The patient tolerated the procedure well without complication.,IMPRESSION:,1.  Gastroesophageal reflux disease, biopsied.,2.  Distal esophageal reflux-induced stricture, dilated to 18 mm.,3.  Otherwise normal upper endoscopy.,PLAN:,I will await the results of the biopsies.  The patient was told to continue maintenance Aciphex and anti-reflux precautions.  He will follow up with me on a p.r.n. basis.
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DESCRIPTION: Upper endoscopy, patient with dysphagia.

surgery, lateral decubitus position, gastroesophageal reflux disease, gerd, normal upper endoscopy, mucosa was normal, esophageal reflux, stricture dilated, upper endoscopy, distal, esophageal, aciphex, biopsies, dysphagia, endoscopy, reflux,

The procedure described is an endoscopy with biopsies to investigate dysphagia. The post-operative diagnosis includes GERD and a dilated esophageal stricture. While endoscopies involve some risk, this particular procedure appears routine with no complications reported. The stakes are moderate due to awaiting biopsy results, but the current situation does not present immediate high-stakes concerns.


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Medical Specialty: Surgery
Sample Name: Endoscopy - 3

PROCEDURES PERFORMED: , Endoscopy.,INDICATIONS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,  Esophageal ring and active reflux esophagitis.,PROCEDURE: , Informed consent was obtained prior to the procedure from the parents and patient.  The oral cavity is sprayed with lidocaine spray.  A bite block is placed.  Versed IV 5 mg and 100 mcg of IV fentanyl was given in cautious increments.  The GIF-160 diagnostic gastroscope used.  The patient was alert during the procedure.  The esophagus was intubated under direct visualization.  The scope was advanced toward the GE junction with active reflux esophagitis involving the distal one-third of the esophagus noted.  The stomach was unremarkable.  Retroflexed exam unremarkable.  Duodenum not intubated in order to minimize the time spent during the procedure.  The patient was alert although not combative.  A balloon was then inserted across the GE junction, 15 mm to 18 mm, and inflated to 3, 4.7, and 7 ATM, and left inflated at 18 mm for 45 seconds.  The balloon was then deflated.  The patient became uncomfortable and a good-size adequate distal esophageal tear was noted.  The scope and balloon were then withdrawn.  The patient left in good condition.,IMPRESSION: , Successful dilation of distal esophageal fracture in the setting of active reflux esophagitis albeit mild.,PLAN: , I will recommend that the patient be on lifelong proton pump inhibition and have repeat endoscopy performed as needed.  This has been discussed with the parents.  He was sent home with a prescription for omeprazole.
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DESCRIPTION: Patient with dysphagia.

Patient with dysphagia.

surgery, active reflux esophagitis, ge junction, distal esophageal, active reflux, reflux esophagitis, dysphagia, esophagus, scope, ge, junction, endoscopy, esophageal, reflux, esophagitis, distal, balloon

The situation involves a medical procedure—specifically an endoscopy with balloon dilation due to esophageal issues, including an esophageal ring and active reflux esophagitis. While the procedure was largely successful, there was a complication involving a tear in the esophagus, which is a serious concern in surgical contexts. Post-procedure, the patient was stable and sent home with a treatment plan. Overall, while surgical procedures carry inherent risks, this scenario does not involve immediate life-threatening stakes given the patient was discharged in good condition and with follow-up care. However, the complication and the need for lifelong medication elevate the stakes to a moderate level.

Filled in based on scale_labels and scale_label_confidence


Medical Specialty: Surgery
Sample Name: Elbow Manipulation

PREOPERATIVE DIAGNOSIS:,  Left elbow with retained hardware.,POSTOPERATIVE DIAGNOSIS: , Left elbow with retained hardware.,PROCEDURE: , ,1.  Left elbow manipulation.,2.  Hardware removal of left elbow.,ANESTHESIA:  ,Surgery was performed under general anesthesia.,COMPLICATIONS:,  There were no intraoperative complications.,DRAINS: , None.,SPECIMENS: , None.,INTRAOPERATIVE FINDING: , Preoperatively, the patient is 40 to 100 degrees range of motion with limited supination and pronation of about 20 degrees.  We increased his extension and flexion to about 20 to 120 degrees and the pronation and supination to about 40 degrees.,LOCAL ANESTHETIC:  ,10 mL of 0.25% Marcaine.,HISTORY AND PHYSICAL: , The patient is a 10-year-old right-hand dominant male, who threw himself off a quad on 10/10/2007.  The patient underwent open reduction and internal fixation of his left elbow fracture dislocation.  The patient also sustained a nondisplaced right glenoid neck fracture.  The patient's fracture has healed without incident, although he had significant postoperative stiffness for which he is undergoing physical therapy, as well as use of a Dynasplint.  The patient is neurologically intact distally.  Given the fact that his fracture has healed, surgery was recommended for hardware removal to decrease his irritation with elbow extension from the hardware.  Risks and benefits of the surgery were discussed.  The risks of surgery included the risk of anesthesia, infection, bleeding, changes in sensation and motion of the extremities, failure to remove hardware, failure to relieve pain, continued postoperative stiffness.  All questions were answered and the parents agreed to the above plan.,PROCEDURE:  ,The patient was taken to the operating room and placed supine on the operating table.  General anesthesia was then administered.  The patient's left upper extremity was then prepped and draped in a standard surgical fashion.  Using fluoroscopy, the patient's K-wire was located.  An incision was made over his previous scar.  A subcutaneous dissection then took place in the plane between the subcutaneous fat and muscles.  The K-wires were easily palpable.  A small incision was made into the triceps, which allowed for visualization of the two pins, which were removed without incident.  The wound was then irrigated.  The triceps split was now closed using #2-0 Vicryl.  The subcutaneous tissue was also closed using #2-0 Vicryl and the skin with #4-0 Monocryl.  The wound was clean and dry and dressed with Steri-Strips, Xeroform, and 4 x 4s, as well as bias.  A total of 10 mL of 0.25% Marcaine was injected into the incision, as well as the joint line.  At the beginning of the case, prior to removal of the hardware, the arm was taken through some strenuous manipulations with improvement of his extension to 20 degrees, flexion to 130 degrees and pronation supination to about 40 degrees.,DIAGNOSTIC IMPRESSION:  ,The postoperative films demonstrated no fracture, no retained hardware.  The patient tolerated the procedure well and was subsequently taken to the recovery room in stable condition.,POSTOPERATIVE PLAN: , The patient will restart physical therapy and Dynasplint in 3 days.  The patient is to follow up in 1 week's time for a wound check.  The patient was given Tylenol No.  3 for pain.
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DESCRIPTION: Left elbow manipulation and hardware removal of left elbow.

surgery, k-wires, dynasplint, elbow manipulation, hardware removal, retained hardware, elbow, hardware,

The situation involves a surgical procedure for a young patient, which includes manipulating the elbow and removing hardware. Though the surgery is common and was without complications, any surgery involving general anesthesia, especially in a young patient, inherently carries risks such as anesthesia complications, infection, or postoperative issues. These factors make it relatively high-stakes, albeit not extremely so, compared to more life-threatening surgeries or those with more immediate risks of severe outcomes.


Medical Specialty: Surgery
Sample Name: Emergency C-section.

PREOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Nonreassuring fetal heart tones with a prolonged deceleration.,POSTOPERATIVE DIAGNOSES:,1.  Intrauterine pregnancy at term.,2.  Nonreassuring fetal heart tones with a prolonged deceleration.,PROCEDURE PERFORMED: , Emergency cesarean section.,ANESTHESIA:  ,General and endotracheal as well as local anesthesia.,ESTIMATED BLOOD LOSS: , 800 mL.,COMPLICATIONS: , None.,FINDINGS:  ,Female infant in cephalic presentation in OP position.  Normal uterus, tubes and ovaries are noted.  Weight was 6 pounds and 3 ounces, Apgars were 6 at 1 minute and 7 at 5 minutes, and 9 at 10 minutes.  Normal uterus, tubes and ovaries were noted.,INDICATIONS:  ,The patient is a 21-year-old Gravida 1, para 0 female who present to labor and delivery at term with spontaneous rupture of membranes noted at 5 a.m. on the day of delivery.  The patient was admitted and cervix was found to be 1 cm dilated.  Pitocin augmentation of labor was started.  The patient was admitted by her primary obstetrician Dr. Salisbury and was managed through the day by him at approximately 5 p.m. at change of shift care was assumed by me.  At this time, the patient was noted to have variable decelerations down to the 90s lasting approximately 1 minute with good return to baseline, good variability was noted as well as accelerations, variable deceleration despite position change was occurring with almost every contraction, but was lasting for 60 to 90 seconds at the longest.  Vaginal exam was done.  Cervix was noted to be 4 cm dilated.,At this time IPC was placed and amnioinfusion was started in hopes to relieve the variable declarations.  At 19:20 fetal heart tones was noted to go down to the 60s and remained down in the 60s for 3 minutes at which time the patient was transferred from Labor And Delivery Room to the operating room for an emergency cesarean section.  Clock in the operating room is noted to be 2 minutes faster then the time on trace view.  The OR delivery time was 19:36.  Delivery of this infant was performed in 14 minutes from the onset of the deceleration.  Upon arrival to the operating room, while prepping the patient for surgery and awaiting the arrival of the anesthesiologist, heart tones were noted to be in 60s and slowly came up to the 80s.  Following the transfer of the patient to the operating room bed and prep of the abdomen, the decision was made to begin the surgery under local anesthesia, 2% lidocaine was obtained for this purpose.,PROCEDURE NOTE: , The patient was taken to the operating room she was quickly prepped and draped in the dorsal supine position with a leftward tilt.  2% lidocaine was obtained and the skin was anesthetized using approximately 15 mL of 2% lidocaine.  As the incision site was being injected, the anesthesiologist arrived.  The procedure was started prior to the patient being put under general anesthesia.,A Pfannenstiel skin incision was made with a scalpel and carried through the underlying layer of fascia using the Scalpel using __________ technique.  The rectus muscles were separated in midline.  The peritoneum was bluntly dissected.  The bladder blade was inserted.  The uterus has been incised in the transverse fashion using the scalpel and extended using manual traction.  The infant was subsequently delivered.  Immediately following delivery of the infant.  The infant was noted to be crying with good tones.  The cord was clammed and cut.  The infant was subsequently transferred or handed to the nursery nurse.  The placenta was delivered manually intact with a three-vessel cord noted.  The uterus was exteriorized and cleared of all clots and debris.  The uterine incision was repaired in 2 layers using 0 chromic sutures.  Hemostasis was visualized.  The uterus was returned to the abdomen.  The pelvis was copiously irrigated.  The rectus muscles were reapproximated in the midline using 3-0 Vicryl.  The fascia was reapproximated with 0 Vicryl suture.  The subcutaneous layer was closed with 2-0 plain gut.  The skin was closed in the subcuticular stitch using 4-0 Monocryl.  Steri-strips were applied.  Sponge, laps, and instrument counts were correct.  The patient was stable at the completion of the procedure and was subsequently transferred to the recovery room in stable condition.
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DESCRIPTION: Emergency cesarean section.

Emergency cesarean section.

surgery, intrauterine pregnancy at term, prolonged deceleration, apgars, emergency cesarean section, fetal heart tones, intrauterine,

This situation involves an emergency cesarean section due to nonreassuring fetal heart tones, which indicates potential fetal distress. The speed and efficiency required in this scenario to ensure the health and safety of both the mother and the infant make it a high-stakes medical procedure. The successful delivery and stabilization of both mother and infant were crucial, and any delays or complications could have serious consequences.


Medical Specialty: Surgery
Sample Name: EGD with Biopsy - 1

PROCEDURE PERFORMED: , EGD with biopsy.,INDICATION: , Mrs. ABC is a pleasant 45-year-old female with a history of severe diabetic gastroparesis, who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago.  She was admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.  A CT scan done yesterday revealed evidence of feeding tube remnant still seen within the stomach.  The endoscopy is done to confirm this and remove it, as well as determine if there are any other causes to account for her symptoms.  Physical examination done prior to the procedure was unremarkable, apart from upper abdominal tenderness.,MEDICATIONS: , Fentanyl 25 mcg, Versed 2 mg, 2% lidocaine spray to the pharynx.,INSTRUMENT: , GIF 160.,PROCEDURE REPORT:,  Informed consent was obtained from Mrs. ABC's sister, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications.  Consent was not obtained from Mrs. Morales due to her recent narcotic administration.  Conscious sedation was achieved with the patient lying in the left lateral decubitus position.  The endoscope was then passed through the mouth, into the esophagus, the stomach, where retroflexion was performed, and it was advanced into the second portion of the duodenum.,FINDINGS:,1.  ESOPHAGUS:  There was evidence of grade C esophagitis, with multiple white-based ulcers seen from the distal to the proximal esophagus, at 12 cm in length.  Multiple biopsies were obtained from this region and placed in jar #1.,2.  STOMACH:  Small hiatal hernia was noted within the cardia of the stomach.  There was an indentation/scar from the placement of the previous PEG tube and there was suture material noted within the body and antrum of the stomach.  The remainder of the stomach examination was normal.  There was no feeding tube remnant seen within the stomach.,3.  DUODENUM:  This was normal.,COMPLICATIONS:,  None.,ASSESSMENT:,1.  Grade C esophagitis seen within the distal, mid, and proximal esophagus.,2.  Small hiatal hernia.,3.  Evidence of scarring at the site of the previous feeding tube, as well as suture line material seen in the body and antrum of the stomach.,PLAN: , Followup results of the biopsies and will have radiology replace her gastrojejunal feeding tube.
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DESCRIPTION: Patient admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.

surgery, recurrent nausea and vomiting, egd with biopsy, nausea and vomiting, gastrojejunal feeding tube, feeding tube remnant, recurrent nausea, gej feeding, gastrojejunal feeding, proximal esophagus, hiatal hernia, feeding tube, egd, biopsy, nausea, vomiting, gej, gastrojejunal, duodenum, esophagitis, multiple, distal, biopsies, hiatal, hernia, antrum, esophagus, feeding, tube, stomach,

The situation involves a surgical procedure, EGD with biopsy, which is conducted to address complications related to the patient's feeding tube and associated symptoms of nausea and vomiting. The stakes are elevated due to the patient's medical history, the need for biopsy for diagnosis, and potential complications that were discussed (e.g., bleeding, infection). While there were no complications during the procedure, the assessment highlights significant findings such as grade C esophagitis and a hiatal hernia. Follow-up actions involve biopsy results and further intervention for feeding tube replacement. Such procedures are critical in providing accurate diagnoses and addressing underlying health issues, making them high-stakes for the patient's health and quality of life.


Medical Specialty: Surgery
Sample Name: EGD Template - 3

without difficulty, into the upper GI tract.  The anatomy and mucosa of the esophagus, gastroesophageal junction, stomach, pylorus, and small bowel were all carefully inspected.  All structures were visually normal in appearance.  Biopsies of the distal duodenum, gastric antrum, and distal esophagus were taken and sent for pathological evaluation.  The endoscope and insufflated air were slowly removed from the upper GI tract.  A repeat look at the structures involved again showed no visible abnormalities, except for the biopsy sites.,The patient tolerated the procedure with excellent comfort and stable vital signs.  After a recovery period in the Endoscopy Suite, the patient is discharged to continue recovering in the family's care at home.  The family knows to follow up with me today if there are concerns about the patient's recovery,from the procedure.  They will follow up with me later this week for biopsy and CLO test results so that appropriate further diagnostic and therapeutic plans can be made.,
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DESCRIPTION: Common description of EGD.

Common description of EGD.

surgery, gastric antrum, distal duodenum, distal esophagus, esophagus, duodenum, clo test, upper gi tract, upper gi, gi tract, egd, endoscope, gi, tract, structures, distal, biopsyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The situation involves a medical procedure called an esophagogastroduodenoscopy (EGD), which is a standard diagnostic tool used in gastroenterology. While it is an invasive procedure, it is routine and generally low-risk, as indicated by the normal findings and the patient's stable condition post-procedure. The text reports that the patient tolerated the procedure well and was discharged with instructions for follow-up, suggesting a low likelihood of complications. However, the situation involves biopsies, which could reveal significant health issues requiring further intervention, but there is no immediate risk based on the provided information.


Medical Specialty: Surgery
Sample Name: EGD - Colonoscopy - Polypectomy

PROCEDURES:,1.  Esophagogastroduodenoscopy.,2.  Colonoscopy with polypectomy.,PREOPERATIVE DIAGNOSES:,1.  History of esophageal cancer.,2.  History of colonic polyps.,POSTOPERATIVE FINDINGS:,1.  Intact surgical intervention for a history of esophageal cancer.,2.  Melanosis coli.,3.  Transverse colon polyps in the setting of surgical changes related to partial and transverse colectomy.,MEDICATIONS:,  Fentanyl 250 mcg and 9 mg of Versed.,INDICATIONS:,  The patient is a 55-year-old dentist presenting for surveillance upper endoscopy in the setting of a history of esophageal cancer with staging at T2N0M0.,He also has a history of adenomatous polyps and presents for surveillance of this process.,Informed consent was obtained after explanation of the procedures, as well as risk factors of bleeding, perforation, and adverse medication reaction.,ESOPHAGOGASTRODUODENOSCOPY:,  The patient was placed in the left lateral decubitus position and medicated with the above medications to achieve and maintain a conscious sedation.  Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.  The Olympus single-channel endoscope was passed under direct visualization, through the oral cavity, and advanced to the second portion of the duodenum.,FINDINGS:,1.  ESOPHAGUS:  Anatomy consistent with esophagectomy with colonic transposition.,2.  STOMACH:  Revealed colonic transposition with normal mucosa.,3.  DUODENUM:  Normal.,IMPRESSION: , Intact surgical intervention with esophagectomy colonic transposition.,COLONOSCOPY: , The patient was then turned and a colonic 140-series colonoscope was passed under direct visualization through the anal verge and advanced to the cecum as identified by the appendiceal orifice.  Circumferential visualization the colonic mucosa revealed the following:,1.  Cecum revealed melanosis coli.,2.  Ascending, melanosis coli.,3.  Transverse revealed two diminutive sessile polyps, excised by cold forceps technique and submitted to histology as specimen #1 with surgical changes consistent with partial colectomy related to the colonic transposition.,4.  Descending, melanosis coli.,5.  Sigmoid, melanosis coli.,6.  Rectum, melanosis coli.,IMPRESSION: , Diffuse melanosis coli with incidental finding of transverse colon polyps.,RECOMMENDATION: , Follow-up histology.  Continue fiber with avoidance of stimulant laxatives.
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DESCRIPTION: Esophagogastroduodenoscopy and colonoscopy with polypectomy

The described medical procedures—an esophagogastroduodenoscopy and a colonoscopy with polypectomy—are routine surveillance procedures for a patient with a history of esophageal cancer and colonic polyps. While invasive, these procedures are common in the management of such conditions, particularly for monitoring and preventing the progression of these diseases. The high-stakes element comes from the potential risks associated with anesthesia and the possibility of perforation or bleeding during the procedures. Additionally, the patient's history of esophageal cancer adds a layer of concern as it requires ongoing surveillance. However, given that the procedures were completed without complications and are standard practice, the situation does not appear to be at the highest level of criticality.


Medical Specialty: Surgery
Sample Name: Dual Chamber ICD Implantation

PROCEDURE:,1.  Implantation, dual chamber ICD.,2.  Fluoroscopy.,3.  Defibrillation threshold testing.,4.  Venography.,PROCEDURE NOTE: , After informed consent was obtained, the patient was taken to the operating room.  The patient was prepped and draped in a sterile fashion.  Using modified Seldinger technique, the left subclavian vein was attempted to be punctured but unsuccessfully.  Approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein.  Venogram was then performed.  Under fluoroscopy via modified Seldinger technique, the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava, then the right atrium and then into the inferior vena cava.  A second guidewire was placed in a similar fashion.  Approximately a 5 cm incision was made in the left upper anterior chest.  The skin and subcutaneous tissue was dissected out of the prepectoral fascia.  Both guide wires were brought into the pocket area.  A sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava.  The dilator and guidewire were removed.  A Fixation ventricular lead, under fluoroscopic guidance, was placed through the sheath into the superior vena cava, right atrium and then right ventricle.  Using straight and curved stylettes, it was placed in position and screwed into the right ventricular apex.  After pacing and sensing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscle with Ethibond suture.  A guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava.  The dilator and guidewire were removed.  An Active Fixation atrial lead was fluoroscopically passed through the sheath, into the superior vena cava and then the right atrium.  Using straight and J-shaped stylettes, it was placed in the appropriate position and screwed in the right atrial appendage area.  After significant pacing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscles with Ethibond suture.  The tract was flushed with saline solution.  A Medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with Ethibond suture.  Deep and superficial layers were closed with 3-0 Vicryl in a running fashion.  Steri-strips were placed over the incision.  Tegaderm was placed over the Steri-strips.  Pressure dressing was applied to the pocket area.
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DESCRIPTION: Dual Chamber ICD Implantation, fluoroscopy,  defibrillation threshold testing, venography.

surgery, venography, defibrillation threshold testing, venogram, dual chamber icd implantation, dual chamber icd, superior vena cava, seldinger technique, pectoral muscle, steri strips, dual chamber, ethibond suture, superior vena, vena cava, dual, chamber, icd, implantation, fluoroscopy, atrium, pectoral, vein, fluoroscopically, vena, cava, lead, guidewire,

The procedure described is a medical procedure involving the implantation of a dual chamber implantable cardioverter defibrillator (ICD), which is a significant surgical intervention. It requires precision and has a direct impact on the patient's cardiac health outcomes. Errors or complications can have serious consequences, including life-threatening arrhythmias or surgical complications. Hence, the stakes are relatively high because the procedure is critical for the patient's health and requires specialized skills and detailed attention to ensure patient safety.


Medical Specialty: Surgery
Sample Name: Dual Chamber Generator Replacement

REFERRAL INDICATIONS,1.  Pacemaker at ERI.,2.  History AV block.,PROCEDURES PLANNED AND PERFORMED:,  Dual chamber generator replacement.,FLUOROSCOPY TIME: , 0 minutes.,MEDICATION AT THE TIME OF STUDY,1.  Ancef 1 g.,2.  Versed 2 mg.,3.  Fentanyl 50 mcg.,CLINICAL HISTORY:  ,The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.,RISKS AND BENEFITS: , Risks, benefits, and alternatives to generator replacement have been discussed with the patient.  Risks including but not limited to bleeding, infection, vascular injury, and the need for pacemaker upgrade were discussed with the patient.  The patient agreed both verbally and via written consent.,DESCRIPTION OF OPERATION: , The patient was transported to the cardiac catheterization laboratory in a fasting state.  The region of the left dorsal pectoral groove was prepped and draped in a usual sterile manner.  Lidocaine 1% (20 mL) was administered to the area of the previous incision.  A transverse incision was made through the skin and subcutaneous tissue.  Hemostasis was achieved with electrocautery.  Using blunt dissection, pacemaker, and leads were removed from the pocket.  Leads were disconnected from the pulse generator and interrogated.  The pocket was washed with antibiotic impregnated saline.  The new pulse generator was obtained and connected securely to the leads and placed back in the pocket.  The pocket was then closed with 2-0, 3-0, and 4-0 Vicryl using running stitch.  Sponge and needle counts were correct at the end of the procedure.  No acute complications were noted.,DEVICE DATA,1.  Explanted pulse generator Medronic, product # KDR601, serial # ABCD1234.,2.  New pulse generator Medronic, product # ADDR01, serial # ABCD1234.,3.  Right atrial lead, product # 4068, serial # ABCD1234.,4.  Right atrial lead, product # 4068, serial # ABCD1234.,MEASURED INTRAOPERATIVE DATA,1.  Right atrial lead impedance 572 ohms.  P wave measure 3.7 mV, pacing threshold 1.5 volts at 0.5 msec.,2.  Right ventricular lead impedance 365 ohms.  No R waves to measure, pacing threshold 0.9 volts at 0.5 msec.,CONCLUSIONS,1.  Successful dual chamber generator replacement.,2.  No acute complications.,PLAN,1.  She will be monitored for 3 hours and then dismissed home.,2.  Resume all medications.  Ex-home dismissal instructions.,3.  Doxycycline 100 mg one p.o. twice daily for 7 days.,4.  Wound check in 7-10 days.,5.  Continue followup in device clinic.
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DESCRIPTION: Dual chamber generator replacement.  The patient is a pleasant patient who presented to the office, recently was found to be at ERI and she has been referred for generator replacement.

This medical procedure involves the replacement of a dual chamber pacemaker generator. While routine in cardiac surgery, it is considered high-stakes due to potential risks such as bleeding, infection, and complications with the cardiac rhythm, which were discussed with the patient. The successful functioning of the pacemaker is critical for the patient's heart function, especially given their history of AV block. The medical staff took precautions and no acute complications were noted, but the procedure remains high-stakes due to the importance of heart function and the potential for serious complications.


Medical Specialty: Surgery
Sample Name: Dorsal Ganglion - Excision

PREOPERATIVE DIAGNOSIS:,  Dorsal ganglion, right wrist.,POSTOPERATIVE DIAGNOSIS:,  Dorsal ganglion, right wrist.,OPERATIONS PERFORMED:,  Excision dorsal ganglion, right wrist.,ANESTHESIA:,  Monitored anesthesia care with regional anesthesia applied by surgeon.,TOURNIQUET TIME:,  minutes.,DESCRIPTION OF PROCEDURE: , With the patient under adequate anesthesia, the upper extremity was prepped and draped in a sterile manner.  The arm was exsanguinated and the tourniquet was elevated to 290 mm/Hg.  A transverse incision was made over the dorsal ganglion.  Using blunt dissection the dorsal ulnar sensory nerve branches and radial sensory nerve branches were dissected and retracted out of the operative field.  The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field.  The ganglion was then further dissected to its origin from the dorsal distal scapholunate interosseus ligament and excised in toto.  Care was taken to protect ligament integrity.  Reactive synovium was then removed using soft tissue rongeur technique.  The wound was then infiltrated with 0.25% Marcaine.  The tendons were allowed to resume their normal anatomical position.  The skin was closed with 3-0 Prolene subcuticular stitch.  Sterile dressings were applied.  The tourniquet was deflated.  The patient was awakened from anesthesia and returned to the recovery room in satisfactory condition having tolerated the procedure well.
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DESCRIPTION: Excision dorsal ganglion, right wrist.   The extensor retinaculum was then incised and the extensor tendon was dissected and retracted out of the operative field.

surgery, excision dorsal ganglion, extensor tendon, extensor retinaculum, dorsal ganglion, retinaculum, ganglion

The excision of a dorsal ganglion from the wrist, while requiring skilled surgical intervention, is a relatively routine and minor outpatient procedure. The risks involved are relatively low compared to more complex surgeries, and the description indicates that the procedure was completed successfully without complications. The stakes involved are primarily related to ensuring proper recovery and avoiding infection or nerve damage, but these are common considerations for many surgical procedures. Overall, the stakes are not extremely high given the routine nature of the surgery.


Medical Specialty: Surgery
Sample Name: Dupuytren Disease Excision

PREOPERATIVE DIAGNOSIS: , Right hand Dupuytren disease to the little finger.,POSTOPERATIVE DIAGNOSIS:  ,Right hand Dupuytren disease to the little finger.,PROCEDURE PERFORMED:  ,Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.,COMPLICATIONS:  ,None.,BLOOD LOSS: , Minimal.,ANESTHESIA: , Bier block.,INDICATIONS:  ,The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, laid supine, administered a bier block, and prepped and draped in the sterile fashion.  A zig-zag incision was made down the palmar surface of the little finger and under the palm up to the mid palm region.  Skin flaps were elevated carefully, dissecting Dupuytren contracture off the undersurface of the flaps.  Both neurovascular bundles were identified proximally in the hand and the Dupuytren disease fibrous band was divided proximally, which essentially returned to normal-appearing tissue.  The neurovascular bundles were then dissected distally resecting everything medial to the 2 neurovascular bundles and above the flexor tendon sheath all the way out to the PIP joint of the finger where the Dupuytren disease stopped.  The wound was irrigated.  The neurovascular bundles rechecked with no evidence of any injury and the neurovascular bundles were not significantly involved in the Dupuytren disease.  The incisions were closed with 5-0 nylon interrupted sutures.,The patient tolerated the procedure well and was taken to the PACU in good condition.
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DESCRIPTION: Excision of Dupuytren disease of the right hand extending out to the proximal interphalangeal joint of the little finger.  The patient is a 51-year-old male with left Dupuytren disease, which is causing contractions both at the metacarpophalangeal and the PIP joint as well as significant discomfort.

surgery, excision of dupuytren disease, proximal interphalangeal joint, dupuytren disease, bier block, pip joint, disease, dupuytren, contractions, metacarpophalangeal, neurovascular, bundles, interphalangeal, finger

The surgical excision of Dupuytren disease in the hand involves a detailed and skilled procedure to relieve finger contractures. It is important as it aims to restore hand function and alleviate discomfort. However, the stakes are not life-threatening since the procedure had no complications, minimal blood loss, and was well-tolerated by the patient. The use of anesthesia and potential nerve involvement does increase the stakes slightly, but the absence of significant complications keeps this scenario more routine rather than high-stakes.


Medical Specialty: Surgery
Sample Name: Dressing Change

PREOPERATIVE DIAGNOSIS: , Traumatic injury to bilateral upper extremities.,POSTOPERATIVE DIAGNOSIS: , Traumatic injury to bilateral upper extremities.,PROCEDURE: , Dressing change under anesthesia.,PREOPERATIVE INDICATIONS:  ,This 6 year old was involved in a traumatic accident.  She presents today for evaluation and dressing change.,OPERATIVE PROCEDURE IN DETAIL: , The patient was brought to the operating room under the care of Dr. X.  He called us intraoperatively to evaluate the hand that had previously been repaired.  We were involved to that extent.  After removing the bandages, we recognized that more of the tissue had healed than was initially expected.  She had good perfusion although the distal aspect of her left long finger.  This was better than expected.  For this reason, no debridement was done at this time.  Dressings were reapplied to include Xeroform and a splint.  General Surgery and Orthopedic then carried on the rest of the operation.
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DESCRIPTION: Traumatic injury to bilateral upper extremities.  Dressing change under anesthesia.  This 6 year old was involved in a traumatic accident.  She presents today for evaluation and dressing change.

surgery, bandages, traumatic injury, upper extremities, dressing change, traumatic, dressing, injury,

The situation involves a young child who suffered traumatic injuries to both upper extremities, requiring a surgical dressing change under anesthesia. While a dressing change might appear routine, the circumstances of a traumatic accident, involvement of multiple surgical specialties, and the use of anesthesia elevate the stakes. The involvement of anesthesia and potential need for further medical intervention indicate a moderate level of risk and importance in ensuring the child's injuries are properly evaluated and treated.


Medical Specialty: Surgery
Sample Name: Delivery Note - 9

DELIVERY NOTE:,  This G1, P0 with EDC 12/23/08 presented with SROM about 7.30 this morning.  Her prenatal care complicated by GBS screen positive and a transfer of care at 34 weeks from Idaho.  Exam upon arrival 2 to 3 cm, 100% effaced, -1 station and by report pool of fluid was positive for Nitrazine and positive ferning.,She required augmentation with Pitocin to achieve a good active phase.  She achieved complete cervical dilation at 1900  At this time, a bulging bag was noted, which ruptured and thick meconium was present.  At 1937 hours, she delivered a viable male infant, left occiput, anterior.  Mouth and nares suctioned well with a DeLee on the perineum.  No nuchal cord present.  Shoulders and body followed easily.  Infant re-suctioned with the bulb and cord clamped x2 and cut and was taken to the warmer where the RN and RT were in attendance.  Apgars 9 and 9.  Pitocin 15 units infused via pump protocol.  Placenta followed complete and intact with fundal massage and general traction on the cord.  Three vessels are noted.  She sustained a bilateral periurethral lax on the left side, this extended down to the labia minora, became a second degree in the inferior portion and did have some significant bleeding in this area.  Therefore, this was repaired with #3-0 Vicryl after 1% lidocaine infiltrated approximately 5 mL.  The remainder of the lacerations was not at all bleeding and no other lacerations present.  Fundus required bimanual massage in a couple of occasions for recurrent atony with several larger clots; however, as the Pitocin infused and massage continued, this improved significantly.  EBL was about 500 mL.  Bleeding appears much better; however, Cytotec 400 mcg was placed per rectum apparently prophylactically.  Mom and baby currently doing very well.
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DESCRIPTION: She required augmentation with Pitocin to achieve a good active phase.  She achieved complete cervical dilation.

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

This medical note describes a labor and delivery scenario involving a first-time mother with certain complications, such as a positive GBS screen, transfer of care, thick meconium during delivery, and significant bleeding from a laceration. Despite these issues, the delivery was completed safely, and both mother and baby were reported to be doing well. While childbirth inherently carries risks, the successful management of complications suggests effective handling of the situation. Nevertheless, given the potential for serious complications, this remains a moderately high-stakes situation typical of surgical specialties like obstetrics.


Medical Specialty: Surgery
Sample Name: Diabetic Foot Care

S - ,An 83-year-old diabetic female presents today stating that she would like diabetic foot care.,O - ,On examination, the lateral aspect of her left great toenail is deeply ingrown.  Her toenails are thick and opaque.  Vibratory sensation appears to be intact.  Dorsal pedal pulses are 1/4.  There is no hair growth seen on her toes, feet or lower legs.  Her feet are warm to the touch.  All of her toenails are hypertrophic, opaque, elongated and discolored.,A - ,1.  Onychocryptosis.,
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DESCRIPTION: An 83-year-old diabetic female presents today stating that she would like diabetic foot care.

surgery, onychocryptosis, onychomycosis, great toenail, diabetic foot care, diabetic foot, foot, toenail, ingrown, toenails, diabetic,

The situation involves diabetic foot care for an elderly patient with onychocryptosis (ingrown toenail), which can be significant due to her age and underlying diabetic condition. People with diabetes are at increased risk for foot complications, potentially leading to severe infections or even amputations if not properly managed. However, the immediate issue described (ingrown toenail) does not seem life-threatening but requires attention to prevent escalation. The cumulative risk associated with her age, diabetes, and current foot condition suggests moderate stakes.


Medical Specialty: Surgery
Sample Name: Diagnostic Laparoscopy - 1

PREOPERATIVE DIAGNOSIS: , Acute abdominal pain, rule out appendicitis versus other.,POSTOPERATIVE DIAGNOSIS:,  Acute pelvic inflammatory disease and periappendicitis.,PROCEDURE PERFORMED: , Diagnostic laparoscopy.,COMPLICATIONS:,  None.,CULTURES:,  Intra-abdominally are done.,HISTORY:  ,The patient is a 31-year-old African-American female patient who complains of sudden onset of pain and has seen in the Emergency Room.  The pain has started in the umbilical area and radiated to McBurney's point.  The patient appears to have a significant pain requiring surgical evaluation.  It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.  The patient was seen by Dr. Y at my request in the ER with me in attendance.  We went over the case.  He decided that she should go to the operating room for evaluation and to have appendix evaluated and probably removed.  The patient on ultrasound had a 0.9 cm ovarian cyst on the right side.  The patient's cyst was not completely simple and they are concerns over the possibility of an abnormality.  The patient states that she has had chlamydia in the past, but it was not a pelvic infection more vaginal infection.  The patient has had hospitalization for this.  The patient therefore signed informed in layman's terms with her understanding that perceivable risks and complications, the alternative treatment, the procedure itself and recovery.  All questions were answered.  ,PROCEDURE: ,The patient was seen in the Emergency Room.  In the Emergency Room, there is really no apparent vaginal discharge.  No odor or cervical motion tenderness.  Negative bladder sweep.  Adnexa were without abnormalities.  In the OR, we were able to perform pelvic examination showing a slightly enlarged fibroid uterus about 9 to 10-week size.  The patient had no adnexal fullness.  The patient then underwent an insertion of a uterine manipulator and Dr. X was in the case at that time and he started the laparoscopic process i.e., inserting the laparoscope.  We then observed under direct laparoscopic visualization with the aid of a camera that there was pus in and around the uterus.  The both fallopian tubes were seen.  There did not appear to be hydrosalpinx.  The ovaries were seen.  The left showed some adhesions into the ovarian fossa.  The cul-de-sac had a banded adhesions.  The patient on the right adnexa had a hemorrhagic ovarian cyst, where the cyst was only about a centimeter enlarged.  The ovary did not appear to have pus in it, but there was pus over the area of the bladder flap.  The patient's bowel was otherwise unremarkable.  The liver contained evidence of Fitz-Hugh-Curtis syndrome and prior PID.  The appendix was somewhat adherent into the retrocecal area and to the mid-quadrant abdominal sidewall on the right.  The case was then turned over to Dr. Y who was in the room at that time and Dr. X had left.  The patient's case was turned over to him.  Dr. Y was performed an appendectomy following which cultures and copious irrigation.  Dr. Y was then closed the case.  The patient was placed on antibiotics.  We await the results of the cultures and as well further ______ therapy.,PRIMARY DIAGNOSES:,1.  Periappendicitis.,2.  Pelvic inflammatory disease.,3.  Chronic adhesive disease.
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DESCRIPTION: Diagnostic laparoscopy.   Acute pelvic inflammatory disease and periappendicitis.  The patient appears to have a significant pain requiring surgical evaluation.  It did not appear that the pain was pelvic in nature, but more higher up in the abdomen, more towards the appendix.

surgery, periappendicitis, pelvic inflammatory disease, chronic adhesive disease, abdominal pain, appendicitis, diagnostic laparoscopy, laparoscopy, pelvic,

The situation involves diagnostic laparoscopy performed due to acute abdominal pain, with a suspicion of appendicitis. The outcome reveals pelvic inflammatory disease and periappendicitis, both of which are serious medical conditions requiring timely diagnosis and treatment. The procedure was necessary to prevent potential complications such as spread of infection or rupture. The high-stakes aspect of this situation lies in the critical nature of timely diagnosis and intervention in acute abdominal conditions to prevent adverse outcomes.


Medical Specialty: Surgery
Sample Name: Diagnostic Arthroscopy

PREOPERATIVE DIAGNOSIS:,  Torn rotator cuff, right shoulder.,POSTOPERATIVE DIAGNOSES:,1.  Torn rotator cuff, right shoulder.,2.  Subacromial spur with impingement syndrome, right shoulder.,PROCEDURE PERFORMED:,1.  Diagnostic arthroscopy with subacromial decompression.,2.  Open repair of rotator cuff using three Panalok suture anchors.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:  ,Approximately 200 cc.,INTRAOPERATIVE FINDINGS: , There was noted to be a full thickness tear to the supraspinatus tendon at the insertion of the greater tuberosity.  There is moderate amount of synovitis noted throughout the glenohumeral joint.  There is a small subacromial spur noted on the very anterolateral border of the acromion.,HISTORY: , This is a 62-year-old female who previously underwent a repair of rotator cuff.  She continued to have pain within the shoulder.  She had a repeat MRI performed, which confirmed the clinical diagnosis of re-tear of the rotator cuff.  She wished to proceed with a repair.  All risks and benefits of the surgery were discussed with her at length.  She was in agreement with the above treatment plan.,PROCEDURE: , On 08/21/03, she was taken to the Operative Room at ABCD General Hospital.  She was placed supine on the operating table.  General anesthesia was applied by the Anesthesiology Department.  She was placed in the modified beachchair position.  Her upper extremity was sterilely prepped and draped in usual fashion.  A stab incision was made in the posterior aspect of the glenohumeral joint.  A camera was placed in the joint and was insufflated with saline solution.  Intraoperative pictures were obtained and the above findings were noted.  A second port site was initiated anteriorly.  Through this a probe was placed and the intraarticular structures were palpated and found to be intact.  A tear of the inner surface of the rotator cuff was identified.  The camera was then taken to the subacromial space.  A straight lateral portal was also used and a shaver was placed into the subacromial space.  Further debridement of the anterolateral border of the acromion was performed to remove evidence of the subacromial spur, which had reformed.  The edges of the rotator cuff were then debrided.  The camera was then removed and the shoulder was suction and dried.  A lateral incision was made over the anterolateral border of the acromion.  Subcuticular tissues were carefully dissected.  Hemostasis was controlled with electrocautery.  The deltoid musculature was then incised and aligned with its fibers exposing the rotator cuff tear and the edges were further debrided using a rongeur.  A trough was then made in the greater tuberosity using the rongeur.  Two Panalok anchors were then placed within the trough and weaved through the suture and third Panalok anchor was placed medial to the trough and weaved through the rotator cuff.  The ends of the suture were tied down from the fixating the rotator cuff within the trough.  The rotator cuff was then further oversewed using the Panalok suture.  The wound was then copiously irrigated and it was then suction dried.  The deltoid muscle was reapproximated using #1 Vicryl.  A continuous infusion pump catheter was placed into the subacromial space to help with postoperative pain control.  The subcutaneous tissues were reapproximated with #2-0 Vicryl.  The skin was closed with #4-0 PDS running subcuticular stitch.  Sterile dressing was applied to the upper extremity.  She was then placed in a shoulder immobilizer.  She was transferred to the recovery room in apparent stable and satisfactory condition.  Prognosis for this patient was guarded.  She will begin pendulum exercises postoperative day #3.  She will follow back in the office in 10 to 14 days for reevaluation.  Physical therapy initiated approximately six weeks postoperatively.
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DESCRIPTION: Torn rotator cuff and subacromial spur with impingement syndrome, right shoulder.  Diagnostic arthroscopy with subacromial decompression and open repair of rotator cuff using three Panalok suture anchors.

surgery, subacromial decompression, panalok suture, repair of rotator cuff, torn rotator cuff, diagnostic arthroscopy, subacromial space, subacromial spur, arthroscopy, panalok, shoulder, subacromial,

The described situation involves a surgical procedure which inherently carries a certain level of risk due to the complexity of the operation and the use of general anesthesia. Repairing a torn rotator cuff through diagnostic arthroscopy and open repair is not an uncommon surgery, but it involves detailed intraoperative steps and careful postoperative care. The stakes are further highlighted by the patient's history of persistent pain and previous surgery failure, suggesting a more challenging clinical situation. Additionally, complications are possible, though none were noted in this procedure. While the procedure is performed in a controlled hospital environment by specialists, indicating a system for managing risks, it still represents a significant medical intervention with potential implications for the patient’s quality of life.


Medical Specialty: Surgery
Sample Name: Delivery Note - 8

DELIVERY NOTE: , The patient is a very pleasant 22-year-old primigravida with prenatal care with both Dr. X and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital.  The patient was admitted to labor and delivery on Tuesday, December 22, 2008 at 5:30 in the morning at 40 weeks and 1 day gestation for elective induction of labor since she lives a significant distance away from the hospital.  Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring.  At a later time, Pitocin was started.  The next day at about 9 o'clock in the morning, I checked her cervix and performed artifical rupture of membranes, which did reveal Meconium-stained amniotic fluid and so an intrauterine pressure catheter was placed and then MDL infusion started.  The patient did have labor epidural, which worked well.  It should be noted that the patient's recent vaginal culture for group B strep did come back negative for group B strep.  The patient went on to have a normal spontaneous vaginal delivery of a live-term male newborn with Apgar scores of 7 and 9 at 1 and 5 minutes respectively and a newborn weight of 7 pounds and 1.5 ounces at birth.  The intensive care nursery staff was present because of the presence of Meconium-stained amniotic fluid.  DeLee suctioning was performed at the perineum.  A second-degree midline episiotomy was repaired in layers in the usual fashion using 3-0 Vicryl.  The placenta was simply delivered and examined and found to be complete and bimanual vaginal exam was performed and revealed that the uterus was firm.,ESTIMATED BLOOD LOSS: , Approximately 300 mL.
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DESCRIPTION: Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring.  At a later time, Pitocin was started.

surgery, amniotic fluid, contractions, pitocin, meconium, cervix, labor, vaginal, delivery, intravaginallyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The described situation is a childbirth through an elective induction of labor, which typically carries certain risks, especially with the discovery of meconium-stained amniotic fluid and subsequent interventions. However, the overall description indicates that both the mother and newborn were managed appropriately, and the newborn's Apgar scores suggest a stable condition. While childbirth carries inherent risks, this delivery note does not describe any complications that were not managed successfully, which suggests a medium stakes situation.


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

Medical Specialty: Surgery
Sample Name: Delivery Note - 6

DELIVERY NOTE: , This is an 18-year-old, G2, P0 at 35-4/7th weeks by a stated EDC of 01/21/09.  The patient is a patient of Dr. X's.  Her pregnancy is complicated by preterm contractions.  She was on bedrest since her 34th week.  She also has a history of tobacco abuse with asthma.  She was admitted here and labor was confirmed with rupture of membranes.  She was initially 5, 70%, -1.  Her bag was ruptured, IUPC was placed.  She received an epidural for pain control and Pitocin augmentation was performed.  She progressed for several hours to complete and to push, then pushed for approximately 15 minutes to deliver a vigorous female infant from OA presentation.  Delivery of the head was manual assisted.  The shoulders and the rest of body then followed without difficulty.  Baby was bulb suctioned, had a vigorous cry.  Cord was clamped twice and cut and the infant was handed to the awaiting nursing team.  Placenta then delivered spontaneously and intact, was noted to have a three-vessel cord.  The inspection of the perineum revealed it to be intact.  There was a hymenal remnant/skin tag that was protruding from the vaginal introitus.  I discussed this with the patient.  She opted to have it removed.  This was performed and I put a single interrupted suture 3-0 Vicryl for hemostasis.  Further inspection revealed bilateral superficial labial lacerations that were hemostatic and required no repair.  Overall EBL is 300 mL.  Mom and baby are currently doing well.  Cord gases are being sent due to prematurity.,
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DESCRIPTION: Her pregnancy is complicated by preterm contractions.  She was on bedrest since her 34th week.  She was admitted here and labor was confirmed with rupture of membranes.

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

The situation involves the delivery of a preterm infant (35 weeks, 4 days) to an 18-year-old mother with preterm contractions and a history of tobacco use complicated by asthma. While the delivery appears to have been successful, there are several factors that classify this as a higher-stakes situation: the prematurity of the infant, the mother's young age and medical history, and the necessity for interventions like epidural and Pitocin augmentation. Additionally, cord gases are being sent due to prematurity which indicates a need for monitoring the newborn's condition closely. Although the delivery and initial assessments are positive, the potential for complications associated with prematurity and the mother's medical background makes it a sensitive and somewhat high-stakes scenario, albeit not at the highest end of the scale due to positive initial outcomes.


Medical Specialty: Surgery
Sample Name: Delivery Note - 3

DELIVERY NOTE: , On 12/23/08 at 0235 hours, a 23-year-old G1, P0, white female, GBS negative, under epidural anesthesia, delivered a viable female infant with Apgar scores of 7 and 9.  Points taken of for muscle tone and skin color.  Weight and length are unknown at this time.  Delivery was via spontaneous vaginal delivery.  Nuchal cord x1 were tight and reduced.  Infant was DeLee suctioned at perineum.  Cord clamped and cut and infant handed to the awaiting nurse in attendance.  Cord blood sent for analysis, intact.  Meconium stained placenta with three-vessel cord was delivered spontaneously at 0243 hours.  A 15 units of Pitocin was started after delivery of the placenta.  Uterus, cervix, and vagina were explored and a mediolateral episiotomy was repaired with a 3-0 Vicryl in a normal fashion.  Estimated blood loss was approximately 400 mL.  The patient was taken to the recovery room in stable condition.  Infant was taken to Newborn Nursery in stable condition.  The patient tolerated the procedure well.  The only intrapartum event that occurred was thick meconium.  Otherwise, there were no other complications.  The patient tolerated the procedure well.
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DESCRIPTION: Delivery was via spontaneous vaginal delivery.  Nuchal cord x1 were tight and reduced.  Infant was DeLee suctioned at perineum.

surgery, nuchal cord, spontaneous, nuchal, delee, delivered, meconium, placenta, vaginal, perineum, delivery, infantNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medical transcription sample reports may include some uncommon or unusual formats;this would be due to the preference of the dictating physician. All names and dates have beenchanged (or removed) to keep confidentiality. Any resemblance of any type of name or date orplace or anything else to real world is purely incidental.,

The given delivery note describes the birth of a child via spontaneous vaginal delivery, which included a nuchal cord that was tight but successfully reduced. The infant required suctioning but was subsequently cared for in a stable condition. Despite the thick meconium observed, both the mother and infant were stable post-delivery. This reflects a standard obstetric situation where potential complications were managed appropriately, leading to a stable outcome for both the newborn and the mother. There was no mention of ongoing distress or severe complications that remained unaddressed, indicating the situation was managed within the normal scope of a delivery scenario. Therefore, it is not considered extremely high-stakes, but it is associated with some level of risk typical of childbirth situations.


Medical Specialty: Surgery
Sample Name: Decompressive Laminectomy

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

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

This medical situation involves a complex surgical procedure to address significant spinal issues, including a T12 compression fracture with cauda equina syndrome and spinal cord compression. Such conditions can lead to severe neurological deficits if not managed properly. The procedure itself, a decompressive laminectomy with additional fixation techniques, is intricate and requires precision and expertise due to the potential for serious complications, including paralysis or worsened neurological function if errors occur. The stakes are high as failure to successfully perform the surgery could result in permanent injury, while success could significantly improve the patient's quality of life.


Medical Specialty: Surgery
Sample Name: D&C, Laparoscopy, & Salpingectomy

PREOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1.  Pelvic pain.,2.  Ectopic pregnancy.,3.  Hemoperitoneum.,PROCEDURES PERFORMED:,1.  Dilation and curettage (D&C).,2.  Laparoscopy.,3.  Right salpingectomy.,4.  Lysis of adhesions.,5.  Evacuation of hemoperitoneum.,ANESTHESIA: , General endotracheal.,ESTIMATED BLOOD LOSS: , Scant from the operation, however, there was approximately 2 liters of clotted and old blood in the abdomen.,SPECIMENS:,  Endometrial curettings and right fallopian tube.,COMPLICATIONS: , None.,FINDINGS: , On bimanual exam, the patient has a small anteverted uterus, it is freely mobile.  No adnexal masses, however, were appreciated on the bimanual exam.  Laparoscopically, the patient had numerous omental adhesions to the vesicouterine peritoneum in the fundus of the uterus.  There were also adhesions to the left fallopian tube and the right fallopian tube.  There was a copious amount of blood in the abdomen approximately 2 liters of clotted and unclotted blood.  There was some questionable gestational tissue ________ on the left sacrospinous ligament.  There was an apparent rupture and bleeding ectopic pregnancy in the isthmus portion of the right fallopian tube.,PROCEDURE:,  After an informed consent was obtained, the patient was taken to the operating room and the general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  A weighted speculum was then placed in the vagina.  The interior wall of vagina elevated with the uterine sound and the anterior lip of the cervix was grasped with the vulsellum tenaculum.  The cervix was then serially dilated with Hank dilators to a size #20 Hank and then a sharp curettage was performed obtaining a moderate amount of decidual appearing tissue and the tissue was then sent to pathology.  At this point, the uterine manipulator was placed in the cervix and attached to the anterior cervix and vulsellum tenaculum and weighted speculum were removed.  Next, attention was then turned to the abdomen.  The surgeons all are removed the dirty gloves in the previous portion of the case.  Next, a 2 cm incision was made immediately inferior to umbilicus.  The superior aspect of the umbilicus was grasped with a towel clamp and a Veress needle was inserted through this incision.  Next, a syringe was used to inject normal saline into the Veress needle.  The normal saline was seen to drop freely, so a Veress needle was connected to the CO2 gas which was started at its lowest setting.  The gas was seen to flow freely with normal resistance, so the CO2 gas was advanced to a higher setting.  The abdomen was insufflated to an adequate distension.  Once an adequate distention was reached, the CO2 gas was disconnected.  The Veress needle was removed and a size #11 step trocar was placed.  The introducer was removed and the trocar was connected to the CO2 gas and a camera was inserted.  Next, a 1 cm incision was made in the midline approximately two fingerbreadths below the pubic symphysis after transilluminating with the camera.  A Veress needle and a step sheath were inserted through this incision.  Next, the Veress needle was removed and a size #5 trocar was inserted under direct visualization.  Next a size #5 port was placed approximately five fingerbreadths to the left of the umbilicus in a similar fashion.  A size #12 port was placed in a similar fashion approximately six fingerbreadths to the right of the umbilicus and also under direct visualization.  The laparoscopic dissector was inserted through the suprapubic port and this was used to dissect the omental adhesions bluntly from the vesicouterine peritoneum and the bilateral fallopian tubes.  Next, the Dorsey suction irrigator was used to copiously irrigate the abdomen.  Approximate total of 3 liters of irrigation was used and the majority of all blood clots and free blood was removed from the abdomen.,Once the majority of blood was cleaned from the abdomen, the ectopic pregnancy was easily identified and the end of the fallopian tube was grasped with the grasper from the left upper quadrant and the LigaSure device was then inserted through the right upper quadrant with # 12 port.  Three bites with the LigaSure device were used to transect the mesosalpinx inferior to the fallopian tube and then transect the fallopian tube proximal to the ectopic pregnancy.  An EndoCatch bag was then placed to the size #12 port and this was used to remove the right fallopian tube and ectopic pregnancy.  This was then sent to the pathology.  Next, the right mesosalpinx and remains of the fallopian tube were examined again and they were seemed to be hemostatic.  The abdomen was further irrigated.  The liver was examined and appeared to be within normal limits.  At this point, the two size #5 ports and a size #12 port were removed under direct visualization.  The camera was then removed.  The CO2 gas was disconnected and the abdomen was desufflated.  The introducer was then replaced in a size #11 port and the whole port and introducer was removed as a single unit.  All laparoscopic incisions were closed with a #4-0 undyed Vicryl in a subcuticular interrupted fashion.  They were then steri-stripped and bandaged appropriately.  At the end of the procedure, the uterine manipulator was removed from the cervix and the patient was taken to Recovery in stable condition.  The patient tolerated the procedure well.  Sponge, lap, and needle counts were correct x2.  She was discharged home with a postoperative hemoglobin of 8.9.  She was given iron 325 mg to be taken twice a day for five months and Darvocet-N 100 mg to be taken every four to six hours for pain.  She will follow up within a week in the OB resident clinic.
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DESCRIPTION: Dilation and curettage (D&C), laparoscopy, right salpingectomy, lysis of adhesions, and evacuation of hemoperitoneum.  Pelvic pain, ectopic pregnancy, and hemoperitoneum.

surgery, pelvic pain, ectopic pregnancy, hemoperitoneum, d&c, dilation, laparoscopy, curettage, salpingectomy, lysis of adhesions, bimanual exam, veress needle, fallopian tube, umbilicus, cervix, ectopic, pregnancy, abdomen, tube,

The situation described involves a surgical procedure to address significant medical issues such as ectopic pregnancy and hemoperitoneum. These are potentially life-threatening conditions if not addressed quickly and appropriately. An ectopic pregnancy can lead to severe complications, including internal bleeding, which is evident from the substantial blood loss described during the procedure. Given the complexity and urgency of the situation, as well as the necessity of multiple surgical interventions, it is considered high-stakes. Successful intervention is critical for the patient's safety and recovery.


Medical Specialty: Surgery
Sample Name: D&C & Tubal Pregnancy Removal

PREOPERATIVE DIAGNOSIS: , Complex right lower quadrant mass with possible ectopic pregnancy.,POSTOPERATIVE DIAGNOSES:,1.  Right ruptured tubal pregnancy.,2.  Pelvic adhesions.,PROCEDURE PERFORMED:,1.  Dilatation and curettage.,2.  Laparoscopy with removal of tubal pregnancy and right partial salpingectomy.,ANESTHESIA:  ,General.,ESTIMATED BLOOD LOSS:  ,Less than 100 cc.,COMPLICATIONS: , None.,INDICATIONS: , The patient is a 25-year-old African-American female, gravida 7, para-1-0-5-1 with two prior spontaneous abortions with three terminations who presents with pelvic pain.  She does have a slowly increasing beta HCG starting at 500 to 849 and the max to 900.  Ultrasound showed a complex right lower quadrant mass with free fluid in the pelvis.  It was decided to perform a laparoscopy for the possibility of an ectopic pregnancy.,FINDINGS: , On bimanual exam, the uterus was approximately 10 weeks' in size, mobile, and anteverted.  There were no adnexal masses appreciated although there was some fullness in the right lower quadrant.  The cervical os appeared parous.,Laparoscopic findings revealed a right ectopic pregnancy, which was just distal to the right fallopian tube and attached to the fimbria as well as adherent to the right ovary.  There were some pelvic adhesions in the right abdominal wall as well.  The left fallopian tube and ovary and uterus appeared normal.  There was no evidence of endometriosis.  There was a small amount of blood in the posterior cul-de-sac.,PROCEDURE IN DETAIL: , After informed consent was obtained in layman's terms, the patient was taken back to the operating suite, prepped and draped, placed under general anesthesia, and placed in the dorsal lithotomy position.  The bimanual exam was performed, which revealed the above findings.  A weighted speculum was placed in the patient's posterior vaginal vault and the 12 o' clock position of the cervix was grasped with the vulsellum tenaculum.  The cervix was then serially dilated using Hank dilators up to a #10.  A sharp curette was then introduced and curettage was performed obtaining a mild amount of tissue.  The tissue was sent to pathology for evaluation.  The uterine elevator was then placed in the patient's cervix.  Gloves were changed.  The attention was turned to the anterior abdominal wall where a 1 cm infraumbilical skin incision was made.  While tenting up the abdominal wall, the Veress needle was placed without difficulty.  The abdomen was then insufflated with appropriate volume and flow of CO2.  The #11 step trocar was then placed without difficulty in abdominal wall.  The placement was confirmed with a laparoscope.  It was then decided to put a #5 step trocar approximately 2 cm above the pubis symphysis in order to manipulate the pelvic contents.  The above findings were then noted.  Because the tubal pregnancy was adherent to the ovary, an additional port was placed in the right lateral aspect of the patient's abdomen.  A #12 step trocar port was placed under direct visualization.  Using a grasper, Nezhat-Dorsey suction irrigator, the mass was hydro-dissected off of the right ovary and further shelled away with graspers.  This was removed with the gallbladder grasper through the right lateral port site.  There was a small amount of oozing at the distal portion of the fimbria where the mass has been attached.  Partial salpingectomy was therefore performed.  This was done using the LigaSure.  The LigaSure was clamped across the portion of the tube including distal tube and ligated and transected.  Good hemostasis was obtained in all of the right adnexal structures.  The pelvis was then copiously suction irrigated.  The area again was then visualized and again found to be hemostatic.  The instruments were then removed from the patient's abdomen under direct visualization.  The abdomen was then desufflated and the #11 step trocar was removed.  The incisions were then repaired with #4-0 undyed Vicryl and dressed with Steri-Strips.  The uterine elevator was removed from the patient's vagina.,The patient tolerated the procedure well.  The sponge, lap, and needle count were correct x2.  She will follow up postoperatively as an outpatient.
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DESCRIPTION: Complex right lower quadrant mass with possible ectopic pregnancy.  Right ruptured tubal pregnancy and pelvic adhesions. Dilatation and curettage and laparoscopy with removal of tubal pregnancy and right partial salpingectomy.

surgery, lower quadrant mass, tubal pregnancy, pelvic adhesions, laparoscopy, salpingectomy, ectopic pregnancy, abdominal wall, pregnancy,

The situation involves a surgical procedure to address a ruptured tubal pregnancy, which is a potentially life-threatening condition. Ectopic pregnancies, particularly those that rupture, can lead to significant internal bleeding and require prompt surgical intervention to ensure the patient's safety. The description indicates that the procedure was performed without complications, and the patient tolerated it well, which is an optimal outcome. However, the nature of the condition and the necessity of surgical intervention inherently make this a high-stakes medical situation.


Medical Specialty: Surgery
Sample Name: de Quervain Release - Carpal

PREOPERATIVE DIAGNOSIS,1.  Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS,1.  Carpal tunnel syndrome.,2. de Quervain's stenosing tenosynovitis.,TITLE OF PROCEDURE,1.  Carpal tunnel release.,2. de Quervain's release.,ANESTHESIA: , MAC,COMPLICATIONS: , None.,PROCEDURE IN DETAIL:  ,After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch and the tourniquet inflated to 250 mmHg.,A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.  The subcutaneous fat was dissected radially from 2-3 mm and the superficial aponeurosis cut on this side to leave a longer ulnar leaf.,The ulnar leaf of the cut superficial aponeurosis was dissected ulnarly, and the distal edge of the transverse carpal ligament was identified with a hemostat.  The hemostat was gently placed under the transverse carpal ligament to protect the contents of the carpal tunnel, and the ligament was cut on its ulnar side with a knife directly onto the hemostat.  The antebrachial fascia was cut proximally under direct vision with scissors.,After irrigating the wound with copious amounts of normal saline, the radial leaf of the cut transverse carpal ligament was repaired to the ulnar leaf of the cut superficial aponeurosis with 4-0 Vicryl.  Care was taken to avoid entrapping the motor branch of the median nerve in the suture.  A hemostat was placed under the repair to ensure that the median nerve was not compressed.  The skin was repaired with 5-0 nylon interrupted stitches.,The first dorsal compartment was addressed through a transverse incision at the level of the radial styloid tip.  Dissection was carried down with care taken to avoid and protect the superficial radial nerve branches.  I released the compartment in a separate subsheath for the EPB on the dorsal side.  Both ends of the sheath were released to lengthen them, and then these were repaired with 4-0 Vicryl.  It was checked to make sure that there was significant room remaining for the tendons.  This was done to prevent postoperative subluxation.,I then irrigated and closed the wounds in layers.  Marcaine with epinephrine was placed into all wounds, and dressings and splint were placed.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.
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DESCRIPTION: Carpal tunnel syndrome and de Quervain's stenosing tenosynovitis.  Carpal tunnel release and de Quervain's release.  A longitudinal incision was made in line with the 4th ray, from Kaplan's cardinal line proximally to 1 cm distal to the volar wrist crease.  The dissection was carried down to the superficial aponeurosis.

surgery, de quervain's release, carpal tunnel syndrome, tenosynovitis, carpal, incision, aponeurosis, tunnel, cut,

The procedure described is a surgical one involving carpal tunnel release and de Quervain's release, which are common surgical procedures to relieve pressure on nerves and tendons to alleviate symptoms such as pain and numbness. While this involves anesthesia and surgical intervention, which inherently carries some risk, these are generally considered standard, routine procedures with high success rates and low complication risks when performed by experienced surgeons. The description notes no complications during the surgery, and the procedure was well-tolerated by the patient, further mitigating the stakes involved.


Medical Specialty: Surgery
Sample Name: de Quervain Release - Wrist

PREOPERATIVE DIAGNOSIS:,  Wrist de Quervain stenosing tenosynovitis.,POSTOPERATIVE DIAGNOSIS: , Wrist de Quervain stenosing tenosynovitis.,TITLE OF PROCEDURES,1. de Quervain release.,2.  Fascial lengthening flap of the 1st dorsal compartment.,ANESTHESIA:,  MAC.,COMPLICATIONS: , None.,PROCEDURE IN DETAIL: , After MAC anesthesia and appropriate antibiotics were administered, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with an Esmarch and the tourniquet inflated to 250 mmHg.,I made a transverse incision just distal to the radial styloid.  Dissection was carried down directly to the 1st dorsal compartment with the superficial radial nerve identified and protected.  Meticulous hemostasis was maintained with bipolar electrocautery.,I dissected the sheath superficially free of any other structures, specifically the superficial radial nerve.  I then incised it under direct vision dorsal to its axis and incised it both proximally and distally.  The EPB subsheath was likewise released.,I irrigated the wound thoroughly.  In order to prevent tendon subluxation, I then back-cut both the dorsal and volar leafs of the sheath so that I could close them in an extended and lengthened position.  I did this with 3-0 Vicryl.  I then passed an instrument underneath to check and make sure that the sheath was not too tight.  I then irrigated it and closed the skin, and then I dressed and splinted the wrist appropriately.  The patient was sent to the recovery room in good condition, having tolerated the procedure well.
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DESCRIPTION: Wrist de Quervain stenosing tenosynovitis.  de Quervain release.  Fascial lengthening flap of the 1st dorsal compartment.

surgery, de quervain, tenosynovitis, de quervain release, fascial lengthening flap, dorsal compartment, sheath, wrist, dorsal, tourniquet,

The situation described involves a surgical procedure, which inherently carries certain risks and is more complex than non-surgical treatments. The procedure is invasive and requires precise execution to prevent complications such as nerve damage or tendon subluxation. However, it's a well-established and routine surgery in the field of hand surgery, typically done under monitored anesthesia care (MAC) and without significant complications if performed correctly, as indicated by the 'None' noted under complications. While surgery always carries some level of risk, this particular procedure is not among the highest-risk surgeries and is generally considered safe with a straightforward recovery, which places it in the mid-range in terms of high-stakes situations.


Medical Specialty: Surgery
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.

surgery, dilatation and curettage, hysteroscopy, anemia, enlarged fibroid uterus, endometrial cavity, hypermenorrhea, fibroid, uterus

The case involves a surgical procedure (Dilatation and Curettage and Hysteroscopy) necessary for treating conditions like an enlarged fibroid uterus, hypermenorrhea, and secondary anemia. While these conditions typically aren't life-threatening emergencies, they can have a significant impact on health and quality of life. Anesthesia and surgical procedures always carry some level of risk. However, the procedures described are generally routine and common in gynecology. The stakes are not extremely high in comparison to major surgical interventions, but they are not trivial either because it involves surgery and anesthesia.


Medical Specialty: Surgery
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.

surgery, 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 involves a surgical procedure with significant implications for the patient's health, including addressing symptoms like hypermenorrhea, pelvic pain, and infertility. Despite being common, surgical procedures inherently carry higher stakes due to risks of complications, potential impact on the patient's fertility, and the patient's health concerns. The details of the surgery, including fibroid removal and tubal blockages, indicate serious considerations affecting the patient's quality of life. While the patient was stable post-operation, the high-stakes nature is due to the combination of complexity, potential consequences on fertility, and the underlying conditions being treated.