falan42/nurse_detection huggingface dataset:
Cholecystostomy Tube Placement 

PREOPERATIVE DIAGNOSIS:,  Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,PROCEDURE:,  Placement of cholecystostomy tube under ultrasound guidance.,ANESTHESIA: , Xylocaine 1% With Epinephrine.,INDICATIONS: , Patient is a pleasant 75-year-old gentleman who is about one week status post an acute MI who also has acute cholecystitis.  Because it is not safe to take him to the operating room for general anesthetic, I recommended he undergo the above-named procedure.  Procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken to the Radiology suite, where the area of interest was identified using ultrasound and prepped with Betadine solution, draped in sterile fashion.  After infiltration with 1% Xylocaine and after multiple attempts, the gallbladder was finally cannulated by Dr. Kindred using the Cook 18-French needle.  The guidewire was then placed and via Seldinger technique, a 10-French pigtail catheter was placed within the gallbladder, secured using the Cook catheter method, and dressings were applied and patient was taken to recovery room in stable condition.surgery, under ultrasound guidance, cholecystostomy tube, acalculous cholecystitis, catheter, cholecystostomy, ultrasound, acalculous, cholecystitis
Circumcision - 2 

CIRCUMCISION - NEONATAL,PROCEDURE:,:  The procedure, risks and benefits were explained to the patient's mom, and a consent form was signed.  She is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future.  The infant was placed on the papoose board.  The external genitalia were prepped with Betadine.  A penile block was performed with a 30-gauge needle and 1.5 mL of Nesacaine without epinephrine.,Next, the foreskin was clamped at the 12 o'clock position back to the appropriate proximal extent of the circumcision on the dorsum of the penis.  The incision was made.  Next, all the adhesions of the inner preputial skin were broken down.  The appropriate size bell was obtained and placed over the glans penis.  The Gomco clamp was then configured, and the foreskin was pulled through the opening of the Gomco.  The bell was then placed and tightened down.  Prior to do this, the penis was viewed circumferentially, and there was no excess of skin gathered, particularly in the area of the ventrum.  A blade was used to incise circumferentially around the bell.  The bell was removed.  There was no significant bleeding, and a good cosmetic result was evident with the appropriate amount of skin removed.,Vaseline gauze was then placed.  The little boy was given back to his mom.,PLAN:,  They have a new baby checkup in the near future with their primary care physician.  I will see them back on a p.r.n. basis if there are any problems with the circumcision.surgery, neonatal, circumcision, gomco, gomco clamp, external genitalia, foreskin, glans, glans penis, infant, meatal stenosis, penile block, penis, preputial skin, circumferentially, infection, bell,
Circumcision 

PREOPERATIVE DIAGNOSIS:,  Phimosis.,POSTOPERATIVE DIAGNOSES:,  Phimosis.,OPERATIONS:,  Circumcision.,ANESTHESIA: , LMA.,EBL:,  Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , This is a 3-year-old male, who was referred to us from Dr. X's office with phimosis.  The patient had spraying of urine and ballooning of the foreskin with voiding.  The urine seemed to have collected underneath the foreskin and then would slowly drip out.  Options such as dorsal slit, circumcision, watchful waiting by gently pulling the foreskin back were discussed.  Risk of anesthesia, bleeding, infection, pain, scarring, and expected complications were discussed.  The patient's family understood all the complications and wanted to proceed with the procedure.  Consent was obtained using interpreter.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR and anesthesia was applied.  The patient was placed in supine position.  The patient was prepped and draped in usual sterile fashion.  All the penile adhesions were released prior to the prepping.  The extra foreskin was marked off, 1 x 3 Gamco clamp was used.  Hemostasis was obtained after removing the extra foreskin using the Gamco clamp.,Using 5-0 Monocryl, 4 quadrant stitches were placed and horizontal mattress suturing was done.  There was excellent hemostasis.  Dermabond was applied.  The patient was brought to recovery at the end of the procedure in stable condition.surgery, ballooning of the foreskin, spraying of urine, gamco clamp, spraying, ballooning, circumcision, urine, phimosis, foreskin
Chest Tube Placement 

PREOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,POSTOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,OPERATION: , Left chest tube placement.,IV SEDATION: , 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,PROCEDURE: , With the patient semi recumbent and supine the left anterolateral chest was prepped and draped in the usual sterile fashion.  A 1% lidocaine was liberally infiltrated into the skin, subcutaneous tissue, deep fascia and the anterior axillary line just below the level of the nipple.  The incision was made and deepened through the different layers to reach the intercostal space.  The pleura was entered on top of the underlying rib and finger digital palpation was performed.  Multiple loculations were encountered.  Break up of loculations was performed posteriorly and a chest tube was directed posteriorly.  Only a small amount of fluid was noted to come out initially.  This was sent for various studies.  Soft adhesions were encountered.  The plan was to obtain a chest x-ray and start Activase installation.surgery, activase, chest tube placement, pleural effusion, chest tube, lidocaine, infiltration, parapneumonic, loculated, pleural, chest,
Chest Closure 

PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation.  Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected to leave the chest open to facilitate postoperative management.  He is now taken back to the operative room for delayed primary chest closure.,PREOP DX: , Open chest status post modified stage 1 Norwood operation.,POSTOP DX:,  Open chest status post modified stage 1 Norwood operation.,ANESTHESIA: , General endotracheal.,COMPLICATIONS: , None.,FINDINGS:,  No evidence of intramediastinal purulence or hematoma.  He tolerated the procedure well.,DETAILS OF PROCEDURE: , The patient was brought to the operating room and placed on the operating table in the supine position.  Following general endotracheal anesthesia, the chest was prepped and draped in the usual sterile fashion.  The previously placed AlloDerm membrane was removed.  Mediastinal cultures were obtained, and the mediastinum was then profusely irrigated and suctioned.  Both cavities were also irrigated and suctioned.  The drains were flushed and repositioned.  Approximately 30 cubic centimeters of blood were drawn slowly from the right atrial line.  The sternum was then smeared with a vancomycin paste.  The proximal aspect of the 5 mm RV-PA conduit was marked with a small titanium clip at its inferior most aspect and with an additional one on its rightward inferior side.  The sternum was then closed with stainless steel wires followed by closure of subcutaneous tissues with interrupted monofilament stitches.  The skin was closed with interrupted nylon sutures and a sterile dressing was placed.  The peritoneal dialysis catheter, atrial and ventricular pacing wires were removed.  The patient was transferred to the pediatric intensive unit shortly thereafter in very stable condition.,I was the surgical attending present in the operating room and in charge of the surgical procedure throughout the entire length of the case.surgery, open chest, stage 1 norwood operation, hypoplastic left heart syndrome, delayed primary chest closure, chest closure, norwood operation
Chest Wall Mass Removal 

PREOPERATIVE DIAGNOSIS:,  Chest wall mass, left.,POSTOPERATIVE DIAGNOSIS: , Chest wall mass, left.,PROCEDURE:,  Removal of chest wall mass.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was brought to the operating room where he underwent a general endotracheal anesthetic.  The time-out process was followed and preoperative antibiotics were given.  The patient was in the supine position and was prepped and draped in the usual fashion.,The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected.  An incision was made directly on the mass and carried down to the ribs.  This is where the several chondral cartilages of the lower ribs meet.  So I believe they were isolated in 9th rib anteriorly and I was able to encircle it.  The medial area was __________.  There was no way to perform same procedure there, so what I did, I took an electric saw and proceeded to divide the calcified cartilages of the sternum and also the attachments to the lower ribs.  There was also a separate sharp growth of the mass growing superiorly.  Apparently, I was able to excise the mass and actually it was much larger than it was palpated externally.  This may be due to an extension towards the inside of his chest.  Hemostasis was revised.  The internal mammary was intact and there was no obvious penetration of the pleural cavity.  The specimen was sent to Pathology and then we proceeded to close the defect.  Obviously, the space between the ribs cannot be approximated.  So what we did was approximate the pectoralis major operative defect and then the soft tissues and the skin with subcuticular suture of Monocryl.,The patient tolerated the procedure well.  Estimated blood loss was minimal and he was sent to the recovery room in satisfactory condition.surgery, chest wall mass, local anesthetic, lower ribs, chest wall, mass, cartilages, wall, chest, ribs,
Chest Tube Insertion in ER 

PREOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1.  Right spontaneous pneumothorax secondary to barometric trauma.,2.  Respiratory failure.,3.  Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.  This patient is obtunded, intubated, and septic.  This is an emergent procedure with 2-physician emergency consent signed and on the chart.,PROCEDURE: , The patient's right chest was prepped and draped in sterile fashion.  The site of insertion was anesthetized with 1% Xylocaine, and an incision was made.  Blunt dissection was carried out 2 intercostal spaces above the initial incision site.  The chest wall was opened, and a 32-French chest tube was placed into the thoracic cavity, after examination with the finger, making sure that the thoracic cavity had been entered correctly.  The chest tube was placed.,A postoperative chest x-ray is pending at this time.,The patient tolerated the procedure well and was taken to the recovery room in stable condition.,ESTIMATED BLOOD LOSS:,  10 mL,COMPLICATIONS:,  None.,SPONGE COUNT: , Correct x2.surgery, spontaneous pneumothorax, barometric trauma, respiratory failure, sepsis, pneumonia, blunt dissection, chest wall, thoracic cavity, chest x-ray, chest tube insertion, chest tube, pneumothorax, tube, chest, insertion,
Chest Tube Insertion 

PREOPERATIVE DIAGNOSIS: , Right hemothorax.,POSTOPERATIVE DIAGNOSIS: , Right hemothorax.,PROCEDURE PERFORMED: , Insertion of a #32 French chest tube on the right hemithorax.,ANESTHESIA: , 1% Lidocaine and sedation.,INDICATIONS FOR PROCEDURE:,  This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.  The patient is to have an Infuse-A-Port insertion today.  Postoperatively from that, she started having a blood tinged pink frothy sputum.  Chest x-ray was obtained and showed evidence of a hemothorax on the right hand side, opposite side of the Infuse-A-Port and a wider mediastinum.  The decision was made to place a chest tube in the right hemithorax to allow for the patient to be stable for transfer out of the operating room.,DESCRIPTION OF PROCEDURE: , The area was prepped and draped in the sterile fashion.  The area was anesthetized with 1% Lidocaine solution.  The patient was given sedation.  A #10 blade scalpel was used to make an incision approximately 1.5 cm long.  Then a curved scissor was used to dissect down to the level of the rib.  A blunt peon was then used to again enter into the right hemithorax.  Immediately a blood tinged effusion was released.  The chest tube was placed and directed in a posterior and superior direction.  The chest tube was hooked up to the Pleur-evac device which was ________ tip suction.  The chest tube was tied in with a #0 silk suture in a U-stitch fashion.  It was sutured in place with sterile dressing and silk tape.  The patient tolerated this procedure well.  We will obtain a chest x-ray in postop to ensure proper placement and continue to follow the patient very closely.surgery, hemothorax, hemithorax, pleur-evac device, infuse-a-port insertion, chest tube, carcinoma
Chest Tube Removal 

PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:,  None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the intensive care unit for over a month with bilateral chest tubes for chronic draining pleural effusions with serous drainage.  A decision was made to proceed with removal of these chest tubes and because of the fistulous tracts, this necessitated to close the wounds with sutures.  The patient was agreeable to proceed.,OPERATIVE PROCEDURE:  ,The patient was prepped and draped at the bedside over both chest tube sites.  The pressures applied over the sites and the skin was closed with interrupted #3-0 Ethilon sutures.  The skin was then cleansed and Vaseline occlusive dressing was applied over the sites.  The same procedure was performed on the other side.  The chest tubes were removed on full inspiration.  Vital signs remained stable throughout the procedure.  The patient will remain in the intensive care unit for continued monitoring.,surgery, serous drainage, bilateral pleural effusion, pleural effusion, chest tubes, effusion, pleural, chest
Cesarean Section 

 Cesarean Section.  An incision was made as noted above in the findings and carried down through the subcutaneous tissue, muscular fascia and peritoneum. surgery, peritoneum, cesarean section, abdominal incision, subcutaneous tissue, bladder flap, incision, cesarean, fascia, flap, abdominalNOTE,: 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.,
Cecal Polyp Resection 

PREOPERATIVE DIAGNOSIS:,  Cecal polyp.,POSTOPERATIVE DIAGNOSIS: , Cecal polyp.,PROCEDURE: , Laparoscopic resection of cecal polyp.,COMPLICATIONS: , None., ,ANESTHESIA:  ,General oral endotracheal intubation.,PROCEDURE:,  After adequate general anesthesia was administered the patient's abdomen was prepped and draped aseptically.  Local anesthetic was infiltrated into the right upper quadrant where a small incision was made.  Blunt dissection was carried down to the fascia which was grasped with Kocher clamps.  A bladed 11-mm port was inserted without difficulty.  Pneumoperitoneum was obtained using C02.  Under direct vision 2 additional, non-bladed, 11-mm trocars were placed, one in the left lower quadrant and one in the right lower quadrant.  There was some adhesion noted to the anterior midline which was taken down using the harmonic scalpel.  The cecum was visualized and found to have tattoo located almost opposite the ileocecal valve.  This was in what appeared to be an appropriate location for removal of this using the Endo GIA stapler without impinging on the ileocecal valve or the appendiceal orifice.  The appendix was somewhat retrocecal in position but otherwise looked normal.  The patient was also found to have ink marks in the peritoneal cavity diffusely indicating possible extravasation of dye.  There was enough however in the wall to identify the location of the polyp.  The lesion was grasped with a Babcock clamp and an Endo GIA stapler used to fire across this transversely. The specimen was then removed through the 12-mm port and examined on the back table.  The lateral margin was found to be closely involved with the specimen so I did not feel that it was clear.  I therefore lifted the lateral apex of the previous staple line and created a new staple line extending more laterally around the colon.  This new staple line was then opened on the back table and examined.  There was some residual polypoid material noted but the margins this time appeared to be clear.  The peritoneal cavity was then lavaged with antibiotic solution.  There were a few small areas of bleeding along the staple line which were treated with pinpoint electrocautery.  The trocars were removed under direct vision.  No bleeding was noted.  The bladed trocar site was closed using a figure-of-eight O Vicryl suture.  All skin incisions were closed with running 4-0 Monocryl subcuticular sutures.  Mastisol and Steri-Strips were placed followed by sterile Tegaderm dressing.  The patient tolerated the procedure well without any complications.surgery, polyp, laparoscopic resection, blunt dissection, kocher clamps, ileocecal valve, gia stapler, peritoneal cavity, cecal polyp, infiltrated, anesthetic
Central Line Placement 

PREOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,POSTOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,OPERATION:,  Right subclavian triple lumen central line placement.,ANESTHESIA: , Local Xylocaine.,INDICATIONS FOR OPERATION:  ,This 50-year-old gentleman with severe respiratory failure is mechanically ventilated. He is currently requiring multiple intravenous drips, and Dr. X has kindly requested central line placement.,INFORMED CONSENT:  ,The patient was unable to provide his own consent, secondary to mechanical ventilation and sedation. No available family to provide conservator ship was located either.,PROCEDURE:  ,With the patient in his Intensive Care Unit bed, mechanically ventilated in the Trendelenburg position. The right neck was prepped and draped with Betadine in a sterile fashion. Single needle stick aspiration of the right subclavian vein was accomplished without difficulty, and the guide wire was advanced. The dilator was advanced over the wire. The triple lumen catheter was cannulated over the wire, and the wire then removed. No PVCs were encountered during the procedure. All three ports to the catheter aspirated and flushed blood easily, and they were all flushed with normal saline. The catheter was anchored to the chest wall with butterfly phalange using 3-0 silk suture. Betadine ointment and a sterile Op-Site dressing were applied. Stat upright chest x-ray was obtained at the completion of the procedure, and final results are pending.,FINDINGS/SPECIMENS REMOVED:, None,COMPLICATIONS:, None.,ESTIMATED BLOOD LOSS:, Nil.surgery, respiratory failure, central line placement, chronic obstructive coronary disease, normal saline, subclavian, subclavian triple lumen central line placement, subclavian vein, triple lumen, triple lumen central line, lumen central line placement, central line, line placement, respiratory, xylocaine,
Central Venous & Arterial  Line 

INDICATIONS FOR PROCEDURES: , Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.,The patient was already under general anesthesia in the operating room.  Antibiotic prophylaxis with cephazolin and gentamicin were already given.  A strict aseptic technique was used including use of gowns, mask, and gloves, etc.  The skin was cleansed with alcohol and then prepped with ChloraPrep solution.,PROCEDURE #1:,  Insertion of central venous line.,DESCRIPTION OF PROCEDURE #1: , Attention was directed to the right groin.  A Cook 4-French double-lumen 12-cm long central venous heparin-coated catheter kit was opened.  Using the 21-gauge needle that comes with this kit, the needle was inserted approximately 2 cm below the right inguinal ligament just medial to the pulsations of the femoral artery.  There was good venous blood return on the first try.  Using the Seldinger technique, the soft J-end of the wire was inserted through the needle without resistance approximately 15 cm.  It was then exchanged for a 5-French dilator followed by the 4-French double-lumen catheter and the wire was removed intact.  There was good blood return from both lumens, which were flushed with heparinized saline.  The catheter was sutured to the skin at three points with #4-0 silk for stabilization.,PROCEDURE #2:,  Insertion of arterial line.,DESCRIPTION OF PROCEDURE #2:,  Attention was directed to the left wrist, which was placed on wrist rest.  The Allen test was normal.  A Cook 2.5-French 5 cm long arterial catheter kit was opened.  A 22-gauge IV cannula was used to enter the artery, which was done on the first try with good pulsatile blood return.  Using the Seldinger technique, the catheter was exchanged for a 2.5-French catheter and the wire was removed intact.  There was pulsatile blood return and the catheter was flushed with heparinized saline solution.  It was sutured to the skin with #4-0 silk at three points for stabilization.,Both catheters functioned well throughout the procedure.  The distal circulation of the leg and the hand was intact immediately after insertion, approximately 20 minutes later, and at the end of the procedure.  There were no complications.,PROCEDURE #3: , Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #3: , The probe was inserted under direct vision because initially there was some resistance to insertion.  Under direct vision, using the #2 Miller blade, the upper esophageal opening was visualized and the probe was passed easily without resistance.  There was good visualization of the heart.  The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography.  The probe was removed at the end.  There was no trauma and there was no blood tingeing.,surgery, open-heart surgery, central venous line, arterial line, transesophageal echocardiography probe, glenn procedure, atrial septectomy, aseptic technique, pulsatile blood, central venous, blood return, arterial, central, probe, insertion, catheter
Central Line Insertion 

PREOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1.  Empyema thoracis.,2.  Need for intravenous antibiotics.,PROCEDURE:,  Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopectoral area was prepped and draped in the usual fashion.  Xylocaine 1% was infiltrated and with the patient in the Trendelenburg position, the left subclavian vein was subcutaneously cannulated without any difficulty.  The triple-lumen catheter was inserted and all ports were flushed out and were irrigated with normal saline.  The catheter was fixed to the skin with sutures.  The dressing was applied and then the chest x-ray was obtained which showed no complications of the procedure and good position of the catheter.surgery, thoracis, intravenous, central line insertion, empyema, catheter,