falan42/nurse_detection huggingface dataset:
Pain Management Progress Note 

DIAGNOSES:,1.  Cervical dystonia.,2.  Post cervical laminectomy pain syndrome.,Ms. XYZ states that the pain has now shifted to the left side.  She has noticed a marked improvement on the right side, which was subject to a botulinum toxin injection about two weeks ago.  She did not have any side effects on the Botox injection and she feels that her activities of daily living are increased, but she is still on the oxycodone and methadone.  The patient's husband confirms the fact that she is doing a lot better, that she is more active, but there are still issues yet regarding anxiety, depression, and frustration regarding the pain in her neck.,PHYSICAL EXAMINATION:,  The patient is appropriate.  She is well dressed and oriented x3.  She still smells of some cigarette smoke.  Examination of the neck shows excellent reduction in muscle spasm on the right paraspinals, trapezius and splenius capitis muscles.  There are no trigger points felt and her range of motion of the neck is still somewhat guarded, but much improved.  On the left side, however, there is significant muscle spasm with tight bands involving the multifidus muscle with trigger point activity and a lot of tenderness and guarding.  This extends down into the trapezius muscle, but the splenius capitis seems to be not involved.,TREATMENT PLAN:,  After a long discussion with the patient and the husband, we have decided to go ahead and do botulinum toxin injection into the left multifidus/trapezius muscles.  A total of 400 units of Botox is anticipated.  The procedure is being scheduled.  The patient's medications are refilled.  She will continue to see Dr. Berry and continue her therapy with Mary Hotchkinson in Victoria.pain management, progress note, management, muscle
Mortons Neuroma Injection  

POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers.  The patient has been asked to restrict the use of the * extremity for the next 24 hours.pain management, injection, depo-medrol, morton's neuroma, gauge needle, inflammation, metatarsal ligament, metatarsal space, neuroma, redness, swelling, morton'sNOTE,: 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.,
Radiofrequency Thermocoagulation - 3 

PREOPERATIVE DIAGNOSIS:,  Cervical spondylosis.,POSTOPERATIVE DIAGNOSIS:,  Cervical spondylosis.,OPERATION PERFORMED:,  Radiofrequency thermocoagulation (RFTC), medial branch posterior sensory rami of cervical at ***.,SURGEON:,  Ralph Menard, M.D.,ANESTHESIA:,  Local and IV.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , After proper consent was obtained, the patient was taken to the fluoroscopy suite and placed on a fluoroscopy table in a prone position with a chest roll in place.  The neck was placed in a flexed position.  The patient was monitored with blood pressure cuff, EKG, and pulse oximetry and given oxygen via nasal cannula.  The patient was lightly sedated.  The skin was prepped and draped in a sterile classical fashion.,Under fluoroscopy control, the waists of the articular pillars were identified and marked.  Local anesthesia infiltrated subcutaneously and deep extending down toward these previously marked points.  Once the anesthesia was established, an insulated 10-cm, 22-gauge needle with a 5-mm non-insulated stimulating tip was placed in contact with the waists of the articular pillars at the affected levels that were previously mentioned.  This was done under direct fluoroscopic control utilizing a gun barrel technique with PA views initially for orientation and then a lateral view to determine the depth of the needle.  For C3 to C6 medial branch RFTC's, the needles are placed along the ventral aspect of a line that connects the greatest antero-posterior diameter of the articular pillar but remains dorsal to the foramen as seen on lateral imaging.  For a C7 medial branch RFTC, the needle tip is positioned more superiorly such that it overlies the superior articular process.  For a C8 medial branch RFTC, the needle is placed at the junction of the superior articulating facet and the base of the transverse process of T1.,Sensory stimulation was carried out at 50 Hz from 0 to 2.0 volts.  Stimulation was stopped once the maximum voltage was delivered or the patient either described a buzzing sensation indicating that it was a nonpainful nerve, or it caused replication of their concordant pain.  The stimulation was then changed to 2 Hz for motor stimulation and advanced up to 2.0 volts or until motor stimulation was found at that level.  If motor stimulation occurred, the needle was repositioned to abolish it but still cause concordant pain, or the RFTC was aborted at this level.,If the sensory stimulation caused concordant pain without motor stimulation, the area was then anesthetized with 1 cc of Marcaine 0.5% with 5 mg of methyl prednisolone acetate.  Once the anesthesia was established, a radiofrequency lesioning was then done at 65 degrees for 60 seconds.  The same procedure was carried out at all the affected levels.  The patient tolerated the procedure well without any difficulties or complications.pain management, rami, fluoroscopic control, radiofrequency thermocoagulation, cervical spondylosis, articular pillars, motor stimulation, medial branch, thermocoagulation, rftc, needle, cervical, stimulation
Sacral Alar Notch Injection 

PROCEDURE:,  Right sacral alar notch and sacroiliac joint/posterior rami injections with fluoroscopy.,ANESTHESIA:,  Local sedation.,VITAL SIGNS: , See nurse's notes.,COMPLICATIONS:  ,None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the operating room with intravenous line in place and intravenous sedation was given.  The patient was in the prone position.  The back was prepped with Betadine.  Under fluoroscopy, the right sacral alar notch was identified and after placement of a 22-gauge, 3-1/2 inch spinal needle in to the notch, negative aspiration was performed and 5 cc of 0.5% Marcaine plus 20 mg of Depo-Medrol was injected.  The needle was then placed in to the right sacroiliac joint (distal third) and the same local anesthetic mixture was injected.  This was repeated for the right sacral alar notch and the right sacroiliac joint (distal third).  The needle was withdrawn.  The above was repeated for the posterior primary rami branch at S2 and S3 by stimulating along the superior lateral wall of the foramen; then followed by steroid injection and coagulation as above.,There were no complications.  Needles removed.  Band-aids were applied over the puncture sites.  The patient was discharged to operating room recovery in stable condition.pain management, fluoroscopy, sacroiliac joint, sacral alar notch, posterior rami, sacroiliac, alar, sacral, notch,
Neuroplasty 

PREOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:,  ,1.  Recurrent intractable low back and left lower extremity pain with history of L4-L5 discectomy.,2.  Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED:,  Left L4-L5 transforaminal neuroplasty with nerve root decompression and lysis of adhesions followed by epidural steroid injection.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS:,  None.,SUMMARY:  ,The patient in the operating room, status post transforaminal epidurogram (see operative note for further details).  Using AP and lateral fluoroscopic views to confirm the needle location the superior most being in the left L4 neural foramen and the inferior most in the left L5 neural foramen, 375 units of Wydase was injected through each needle.  After two minutes, 3.5 cc of 0.5% Marcaine and 80 mg of Depo-Medrol was injected through each needle.  These needles were removed and the patient was discharged in stable condition.pain management, nerve root decompression, discectomy, epidural fibrosis, nerve root entrapment, transforaminal neuroplasty, neural foramen, nerve root, foramen, neuroplasty, transforaminal, needle, epidural,
Plantar Fascia Injection 

PROCEDURE:,:  Informed consent was obtained from the patient.  Special mention was made of the possibility of infection and necrosis of the heel pad.  The patient was placed in the supine position.  The tender area in the medial aspect of the heel was identified by palpation.  After proper preparation with antiseptic solution of the skin, a syringe containing 2 mL of 1% lidocaine was attached to 1.5" 27 gauge needle.  The needle was carefully advanced through the carefully identified point at a right angle to the skin, directly towards the central and medial aspect of the calcaneus.  The needle was advanced very slowly until the needle impinged on the bone, and then was withdrawn slowly.  The contents of the syringe were then gently injected.  Subsequently, the needle was left in place and a syringe containing 2 mL of 0.25% Marcaine and 1 mL of Depo-Medrol was attached to the needle and injected after aspiration at this site.  Subsequently the needle was removed.  Pressure was applied at the site of insertion and once it was made sure there was no bleeding taking place, a small bandage was applied.,POST PROCEDURE INSTRUCTIONS:, The patient has been asked to report to us any redness, swelling, inflammation, or fevers.  The patient has been asked to restrict the use of the * extremity for the next 24 hours.pain management, plantar fascia injection, plantar fascia, calcaneus, heel pad, necrosis, depo-medrol, bandage, medial aspect, heel, syringe, injection, needleNOTE,: 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.,
Lumbar Epidural Steroid Injection - 2 

PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE: , Lumbar epidural steroid injection, L5-S1.,ANESTHESIA: , Local.,SPECIAL EQUIPMENT: , Fluoroscopic unit.,DETAILS OF PROCEDURE: , The patient was taken to the Radiology Suite and was placed in the prone position where the entire back region was scrubbed, prepped, and draped in a sterile fashion with Betadine solution.  The lumbar area was then draped with sterile towels and sterile drapes.  The surgeon was gloved with sterile gloves and mask in order to create a sterile environment for the epidural injection.  The fluoroscopy x-ray unit was then brought into the sterile field for a PA x-ray visualization of the spine.  A Steinmann pin was then placed across the spine to localize the level of the planned injection.  Local infiltration using 0.5% preservative-free Xylocaine via a 25-gauge needle was then placed into the dermis and subcutaneous tissue.  A Tuohy needle was then oriented perpendicular to the skin and was then advanced through the dermis and subcutaneous tissues.  Continuous injection of 0.5% preservative-free Xylocaine was used during the advancement of the Tuohy needle into the deeper spinous tissues.  A solution of 80 mg of Depo-Medrol with 2 cc of 1% Xylocaine injectable and 5 cc of normal saline were then injected into the epidural space.pain management, back pain, lumbar epidural steroid injection, tuohy needle, steroid injection, subcutaneous, epidural, steroid, lumbar, sterile, injection
Lumbar Epidural Steroid Injection - 3 

PREOPERATIVE DIAGNOSIS:  ,Lumbar radiculopathy, 724.4.,POSTOPERATIVE DIAGNOSIS:,  Lumbar radiculopathy, 724.4.,PROCEDURE:,  Lumbar epidural steroid injection.,ANESTHESIOLOGIST:,  Monitored anesthesia care,INJECTATE USED:,  10 mL of 0.5% lidocaine and 80 mg of Depo-Medrol.,ESTIMATED BLOOD LOSS:,  None.,COMPLICATIONS:,  None.,DETAILS OF THE PROCEDURE:,  The patient arrived at the preoperative holding area where informed consent, stable vital signs, and intravenous access were obtained.  A thorough discussion of the potential risks, benefits, and complications was made prior to the procedure including potential for post-dural puncture headache and its associated treatment as well as potential for increased neurological dysfunction and/or nerve root injury, infection, bleeding and even death.  There were no known EKG, chest X-ray, or laboratory contraindications to the procedure.,The patient has presented with significant apprehension concerning the proposed procedure and is fearful of movement during the procedure producing further neurological injury.  Arrangements will be made to have an anesthesia care provider present to provide heavier sedation while in the prone position with optimal airway management for improved patient safety and comfort.,The L4-L5 interspace was identified fluoroscopically.  A left paramedian insertion was marked and after sedation was established by the anesthesia department the skin and subcutaneous tissue over the proposed insertion site was infiltrated with 3 millimeters of 0.5% Lidocaine initially through a #25-gauge 5/8-inch needle later a #22-gauge 1-1/2-inch needle.,A number #18-gauge Tuohy epidural needle was then inserted and advanced with fluoroscopic guidance until passing just superior to the lamina of L5.  Needle tip position was confirmed in the anterior posterior fluoroscopic view.  The epidural space was located with the loss of pulsation technique.  Aspiration of the syringe was negative for blood or cerebrospinal fluid.  One millimeter of 0.9% preservative was injected with good loss resistance noted.,DISCHARGE SUMMARY:,  Following the completion of this procedure, the patient underwent monitoring in the recovery room and was discharged, to be followed as an outpatient.pain management
Lumbar Discogram 

PREOPERATIVE DIAGNOSIS: , Low back pain.,POSTOPERATIVE DIAGNOSIS: , Low back pain.,PROCEDURE PERFORMED:,1.  Lumbar discogram L2-3.,2.  Lumbar discogram L3-4.,3.  Lumbar discogram L4-5.,4.  Lumbar discogram L5-S1.,ANESTHESIA:  ,IV sedation.,PROCEDURE IN DETAIL:  ,The patient was brought to the Radiology Suite and placed prone onto a radiolucent table.  The C-arm was brought into the operative field and AP, left right oblique and lateral fluoroscopic images of the L1-2 through L5-S1 levels were obtained.  We then proceeded to prepare the low back with a Betadine solution and draped sterile.  Using an oblique approach to the spine, the L5-S1 level was addressed using an oblique projection angled C-arm in order to allow for perpendicular penetration of the disc space.  A metallic marker was then placed laterally and a needle entrance point was determined.  A skin wheal was raised with 1% Xylocaine and an #18-gauge needle was advanced up to the level of the disc space using AP, oblique and lateral fluoroscopic projections.  A second needle, #22-gauge 6-inch needle was then introduced into the disc space and with AP and lateral fluoroscopic projections, was placed into the center of the nucleus.  We then proceeded to perform a similar placement of needles at the L4-5, L3-4 and L2-3 levels.,A solution of Isovue 300 with 1 gm of Ancef was then drawn into a 10 cc syringe and without informing the patient of our injecting, we then proceeded to inject the disc spaces sequentially.pain management, back pain, c-arm, fluoroscopic projections, disc space, lumbar discogram, fluoroscopic, needle,
Lumbar Epidural Steroid Injection 

PROCEDURE:,  Lumbar epidural steroid injection without fluoroscopy.,ANESTHESIA:,  Local sedation.,VITAL SIGNS:,  See nurse's records.,COMPLICATIONS:,  None.,DETAILS OF PROCEDURE:,  INT was placed.  The patient was in the sitting position and the back was prepped with Betadine.  Lidocaine 1.5% was used for skin wheal made between __________.  A 18-gauge Tuohy needle was placed into the epidural space, using loss of resistance technique, with no cerebrospinal fluid or blood noted.  After negative aspiration, a mixture of 10 cc of preservative free normal saline and 160 mg of preservative free Depo-Medrol was injected.  Neosporin and a band-aid were applied over the puncture site.  The patient was then placed in supine position.  The patient was discharged to the recovery room in stable condition.pain management, neosporin, band-aid, epidural space, lumbar epidural steroid injection, loss of resistance, tuohy needle, fluoroscopy, cerebrospinal, lumbar, epidural, injection,
Lumbar Sympathetic Block 

PROCEDURE:,  Bilateral lumbar sympathetic block.,ANESTHESIA: , Local sedation.,VITAL SIGNS:,  See nurse's notes.,COMPLICATIONS:,  None.,DETAILS OF PROCEDURE: , INT was placed.  The patient was in the prone position and the back prepped with Betadine.  The patient was given sedation and monitored.  Xylocaine 1.5% for skin wheal 6 cm lateral and slightly inferior to the bilateral L2 transverse process was made.  A 20-gauge, 15 cm LSB needle was then directed using AP and lateral fluoroscopic guidance until the tip of the needle was just inside the lateral aspect of the vertebral body and on the lateral projection, it was noted to be along the anterior vertebral body, at the junction of the upper two thirds, lower one third of the body.  After negative aspiration 3 cc of Omnipaque dye was injected showing linear spread along the body.  After negative aspiration 18 cc of 0.25% Marcaine was injected.  Attention was then directed to the L3 level with the tip of the needle guided to the junction of the upper one third, lower two third of L3.  At this point, after confirmation of the linear spread of dye along the anterior portion of the body, negative aspiration was performed and 18 cc of 0.25% Marcaine was injected.  Neosporin and band-aids were applied over the sites.  The patient was taken to the outpatient recovery room in stable condition.pain management, transverse process, fluoroscopic guidance, lateral projection, lumbar sympathetic block, vertebral body, sympathetic, betadine, needle, aspiration, lumbar,
Knee Injection - 1 

PROCEDURE: , Right knee joint steroid injection.,PREOPERATIVE DIAGNOSIS:,  Osteoarthritis of the right knee.,POSTOPERATIVE DIAGNOSIS:,  Osteoarthritis of the right knee.,PROCEDURE:  ,The patient was apprised of the risks and the benefits of the procedure and consented.  The patient's right knee was sterilely prepped with Betadine.  A 4 mg of dexamethasone was drawn up into a 5 mL syringe with a 3 mL of 1% lidocaine.  The patient was injected with a 1.5-inch 25-gauze needle at the medial aspect of his right flexed knee.  There were no complications.  The patient tolerated the procedure well.  There was minimal bleeding.  The patient was instructed to ice his knee upon leaving clinic and refrain from overuse over the next 3 days.  The patient was instructed to go to the emergency room with any usual pain, swelling, or redness occurred in the injected area.  The patient was given a followup appointment to evaluate response to the injection to his increased range of motion and reduction of pain.pain management, injection, knee joint, steroid injection, osteoarthritis, knee
Lumbar Facet Injections 

PREOPERATIVE DIAGNOSIS:,  Lumbar spondylosis.,POSTOPERATIVE DIAGNOSIS:,  Lumbar spondylosis.,OPERATION PERFORMED:,  Lumbar facet injections done under fluoroscopic control.,ANESTHESIA:,  Local and IV.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE:  ,After proper consent was obtained, the patient was taken to the fluoroscopy suite and placed in a prone position on a fluoroscopy table with abdominal rolls in place.  The skin was prepped and draped in a sterile classical fashion.  The patient was monitored with blood pressure cuff, electrocardiogram, and pulse oximeter.  The patient was given oxygen, intravenous sedation and analgesics as needed.  The facets were identified and marked under fluoroscopic control by rotating the C-arm obliquely, laterally and caudocranial as needed for optimal visualization of the facet joint's "Scottie dog" and the opening of the facet.,After each facet joint was identified and marked, local anesthesia was infiltrated subcutaneously and deep over each of the identified facets.  A 22-gauge spinal needle was then utilized to cannulate the facet joint under fluoroscopic control utilizing a gun barrel technique.  After negative aspiration, 0.25 - 0.5 cc of Omnipaque 240 contrast media was injected into the facet as an arthrogram to visualize the joint and the capsule.  After another negative aspiration, 1cc of a 10cc solution of Marcaine 0.5% and 100 milligrams of methyl prednisolone acetate was injected into each facet.  The patient tolerated the procedure well without apparent difficulty or complication unless otherwise noted.pain management, fluoroscopic control, c-arm, lumbar facet injections, lumbar spondylosis, fluoroscopy, spondylosis, fluoroscopic, lumbar, injections, facet
Lumbar Epidural Steroid Injection - 1 

OPERATION:,  Lumbar epidural steroid injection, intralaminar approach, seated position.,ANESTHESIA:,pain management, loss of resistance technique, methylprednisolone acetate, lumbar epidural steroid injection, epidural steroid injection, tuohy needle, steroid injection, epidural space, intralaminar approach, injection, intralaminar, saline, epidural
Knee Injection - 2 

INDICATIONS FOR PROCEDURE: , The patient was here for joint injection.  She is a 14-year-old Hispanic female with history of pauciarticular arthritis in particular arthritis of her left knee, although she has complaints of arthralgias in multiple joints.  What bother her the most is the joint swelling of her left knee that has been for several months.  She has been taking Naprosyn on her last visit.  She was feeling better but still has significant symptoms especially when she was active.  After evaluation in the clinic, she decided to have a joint injection as it was discussed before.  I discussed the side effects and the complications with the parents and the patient and the possibility of doing it in the clinic, but she decided that she did not want to do it in the clinic and she wanted to be sedated for this.,DESCRIPTION OF PROCEDURE: , So under aseptic technique and under general anesthesia, 20 mg of Aristospan were injected on the left knee.  No fluid was obtained.  Her swelling was about 1+.  No complications.  No bleeding was observed, and the patient tolerated the procedure without any complications or side effects.  After that she went to the recovery room where is going to be discharged with her parents and see her back in the clinic for re-evaluation in a few weeks after the procedure.  If the patient has any problems overnight, she is going to call us.  If she had any fevers or strange swelling, she is to call us for advice.  We will see her in the clinic as scheduled.pain management, arthralgias, aristospan, pauciarticular arthritis, joint injection, injection, swelling, arthritis, joints, kneeNOTE,: 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.,