falan42/nurse_detection huggingface dataset:
Tonsillectomy & Adenoidectomy - 3 

PREOPERATIVE DIAGNOSIS:,  Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,POSTOPERATIVE DIAGNOSIS: , Obstructive adenotonsillar hypertrophy with chronic recurrent pharyngitis.,SURGICAL PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA: , General endotracheal technique.,SURGICAL FINDINGS:  ,A 4+/4+ cryptic and hypertrophic tonsils with 2+/3+ hypertrophic adenoid pads.,INDICATIONS: , We were requested to evaluate the patient for complaints of enlarged tonsils, which cause difficulty swallowing, recurrent pharyngitis, and sleep-induced respiratory disturbance.  She was evaluated and scheduled for an elective procedure.,DESCRIPTION OF SURGERY:  ,The patient was brought to the operative suite and placed supine on the operating room table.  General anesthetic was administered.  Once appropriate anesthetic findings were achieved, the patient was intubated and prepped and draped in the usual sterile manner for a tonsillectomy.  He was placed in semi-Rose ___ position and a Crowe Davis-type mouth gag was introduced into the oropharynx.  Under an operating headlight, the oropharynx was clearly visualized.  The right tonsil was grasped with the fossa triangularis and using electrocautery enucleation technique, was removed from its fossa.  This followed placing the patient in a suspension position using a McIvor-type mouth gag and a red rubber Robinson catheter via the right naris.  Once the right tonsil was removed, the left tonsil was removed in a similar manner, once again using a needle point Bovie dissection at 20 watts.  With the tonsils removed, it was possible to visualize the adenoid pads.  The oropharynx was irrigated and the adenoid pad evaluated with an indirect mirror technique.  The adenoid pad was greater than 2+/4 and hypertrophic.  It was removed with successive passes of electrocautery suction.  The tonsillar fossa was then once again hemostased with suction cautery, injected with 0.5% ropivacaine with 1:100,000 adrenal solution and then closed with 2-0 Monocryl on an SH needle.  The redundant soft tissue of the uvula was removed posteriorly and cauterized with electrocautery to prevent swelling of the uvula in the postoperative period.  The patient's oropharynx and nasopharynx were irrigated with copious amounts of normal saline contained with small amount of iodine, and she was recovered from her general endotracheal anesthetic.  She was extubated and left the operating room in good condition to the postoperative recovery room area.,Estimated blood loss was minimal.  There were no complications.  Specimens produced were right and left tonsils.  The adenoid pad was ablated with electrocautery.surgery, obstructive adenotonsillar hypertrophy, pharyngitis, tonsillectomy, adenoidectomy, uvula, obstructive, adenotonsillar, hypertrophy, hypertrophic, fossa, tonsils, oropharynx, electrocautery, pads
Tonsillectomy & Adenoidectomy - 1  

PROCEDURE PERFORMED: , Tonsillectomy and adenoidectomy.,ANESTHESIA:,  General endotracheal.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room and prepped and draped in the usual fashion after induction of general endotracheal anesthesia.  The McIvor mouth gag was placed in the oral cavity, and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,The nasopharynx was inspected with a laryngeal mirror.  The adenoid tissue was fulgurated with the suction Bovie set at 35.  The catheters and the dental gauze roll were then removed.  The anterior tonsillar pillars were infiltrated with 0.5% Marcaine and epinephrine.  Using the radiofrequency wand, the tonsils were ablated bilaterally.  If bleeding occurred, it was treated with the wand on coag mode using a coag mode of 3 and an ablation mode of 9.  The tonsillectomy was completed.,The nasopharynx and nasal passages were suctioned free of debris, and the procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.surgery, tongue, nasal passage, palate, mcivor mouth gag, gauze roll, nasopharynx, tonsillectomy, adenoidectomy,
Tonsillectomy - 1 

PREOPERATIVE DIAGNOSIS:,  Chronic tonsillitis.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis.,PROCEDURE:  ,Tonsillectomy.,DESCRIPTION OF PROCEDURE: , Under general orotracheal anesthesia, a Crowe-Davis mouth gag was inserted and suspended.  Tonsils were removed by electrocautery dissection and the tonsillar beds were injected with Marcaine 0.25% plain.  A catheter was inserted in the nose and brought out from mouth.  The throat was irrigated with saline.  There was no further bleeding.  The patient was awakened and extubated and moved to the recovery room in satisfactory condition.surgery, crowe-davis, mouth gag, chronic tonsillitis, tonsillitis, anesthesia, tonsillectomy
Tonsillectomy 

PREOPERATIVE DIAGNOSIS: , Tonsillitis.,POSTOPERATIVE DIAGNOSIS:  ,Tonsillitis.,PROCEDURE PERFORMED:  ,Tonsillectomy.,ANESTHESIA: , General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room and prepped and draped in the usual fashion.  After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll on the upper lip to provide soft palate retraction.  The nasopharynx was inspected with the laryngeal mirror.,Attention was then directed to the right tonsil.  The anterior tonsillar pillar was infiltrated with 1.5 cc of 1% Xylocaine with 1:100,000 epinephrine, as was the left tonsillar pillar.  The right tonsil was grasped with the tenaculum and retracted out of its fossa.  The anterior tonsillar pillar was incised with the #12 knife blade.  The plica semilunaris was incised with the Metzenbaum scissors.  Using the Metzenbaum scissors and the Fisher knife, the tonsil was dissected free of its fossa onto an inferior pedicle around which the tonsillar snare was placed and applied.  The tonsil was removed from the fossa and the fossa packed with a cherry gauze sponge as previously described.  By a similar procedure, the opposite tonsillectomy was performed and the fossa was packed.,Attention was re-directed to the right tonsil.  The pack was removed and bleeding was controlled with the suction Bovie unit.  Bleeding was then similarly controlled in the left tonsillar fossa and the nasopharynx after removal of the packs.  The catheters were then removed.  The nasal passages and oropharynx were suctioned free of debris.  The procedure was terminated.,The patient tolerated the procedure well and left the operating room in good condition.surgery, tongue, palate, mcivor mouth gag, anterior tonsillar, metzenbaum scissors, oral cavity, tonsillar pillar, tonsillectomy, metzenbaum, tonsillitis, pillar, tonsillar, fossa
Tonsillectomy & Adenoidectomy 

PREOPERATIVE DIAGNOSES:,  Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,POSTOPERATIVE DIAGNOSES:,  Hypertrophy of tonsils and adenoids, and also foreign body of right ear.,OPERATIONS:,  Tonsillectomy, adenoidectomy, and removal of foreign body (rock) from right ear.,ANESTHESIA:,  General.,HISTORY: , The patient is 5-1/2 years old.  She is here this morning with her Mom.  She has very large tonsils and she snores at night and gets up frequently at night and does not sleep well.  At the office we saw the tonsils were very big.  There was a rock in the right ear and it was very deep in the canal, near the drum.  We will remove the foreign body under the same anesthetic.,PROCEDURE:,:  Natalie was placed under general anesthetic by the orotracheal route of administration, under Dr. XYZ and Ms. B.  I looked into the left ear under the microscope, took out a little wax and observed a normal eardrum.  On the right side, I took out some impacted wax and removed the rock with a large suction.  It was actually resting on the surface of the drum but had not scarred or damaged the drum.  The drum was intact with no evidence of middle ear fluid.  The microscope was set aside.  Afrin drops were placed in both nostrils.  The neck was gently extended and the Crowe-Davis mouth gag inserted.  The tonsils and adenoids were very large.  The uvula was intact.  Adenoidectomy was performed using the adenoid curette with a tonsil sponge placed into the nasopharynx.  Tonsillectomy accomplished by sharp and blunt dissection.  Hemostasis achieved with electrocautery and the tonsils beds injected with 0.25% Marcaine with 1:200,000 epinephrine.  Sutures of zero plain catgut next were used to re-approximate the posterior to the anterior tonsillar pillars, suturing these down to the tonsillar beds.  Sponge is removed from the nasopharynx.  The suction electrocautery was used for pinpoint hemostasis on the adenoid bed.  We made sure the cautery tip did not come into the contact with the soft palate or the eustachian tube orifices.  The nose and throat were then irrigated with saline and suctioned.  Excellent hemostasis was observed.  An orogastric tube was placed.  The stomach found to be empty.  The tube was removed, as was the mouth gag.  Sponge and needle count were reported correct.  The child was then awakened and prepared for her to return to the recovery room.  She tolerated the operation excellently.surgery, tonsillectomy, afrin drops, crowe-davis, hypertrophy, adenoid bed, adenoidectomy, adenoids, canal, catgut, dissection, drum, ear, foreign body, middle ear, mouth gag, nasopharynx, orotracheal, suction electrocautery, throat, tonsils, uvula, wax, tonsils and adenoids
Tonsillectomy & Adenoidectomy - 2 

PREOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Chronic tonsillitis with symptomatic tonsil and adenoid hypertrophy.,OPERATION PERFORMED: , Tonsillectomy & adenoidectomy.,ANESTHESIA: , General endotracheal.,FINDINGS: , The tonsils were 3+ enlarged and cryptic.,DESCRIPTION OF OPERATION:,  Under general anesthesia with an endotracheal tube, the patient was placed in supine position.  A mouth gag was inserted and suspended from Mayo stand.  Red rubber catheter was placed through the nose and pulled up through the mouth with elevation of the palate.  The adenoid area was inspected.  The adenoids were small.  The left tonsil was grasped with a tonsil tenaculum.  The tonsil was removed with the Gold laser.  The apposite tonsil was removed in a similar manner.  Hemostasis was secured with electrocautery.  Both tonsillar fossae were injected with 0.25% Marcaine with adrenaline.  The patient tolerated the procedure well and left the operating room in good condition.surgery, tonsil, gold laser, adenoids, chronic tonsillitis, adenoid hypertrophy, tonsillectomy, adenoidectomy, endotracheal, tonsillitis, symptomatic, hypertrophy
Tongue Lesion Biopsy 

PREOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,POSTOPERATIVE DIAGNOSIS: , Right lateral base of tongue lesion, probable cancer.,PROCEDURE PERFORMED:  ,Excisional biopsy with primary closure of a 4 mm right lateral base of tongue lesion.,ANESTHESIA: , General.,FINDINGS: , An ulceration in the right lateral base of tongue region.  This was completely excised.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FLUIDS: , Crystalloid only.,COMPLICATIONS:,  None.,DRAINS:,  None.,CONDITION:,  Stable.,PROCEDURE:  ,The patient placed supine in position under general anesthesia.  First a Sweetheart gag was placed in the patient's mouth and the mouth was elevated.  The lesion in the tongue could be seen.  Then, it was injected with 1% lidocaine and 1:100,00 epinephrine.  After 5 minutes of waiting, then an elliptical incision was made around this mass with electrocautery and then it was sharply dissected off the muscular layer and removed in total.  Suction cautery was used for hemostasis.  Then, 3 simple interrupted #4-0 Vicryl sutures were used to close the wound and procedure was then terminated at that time.surgery, excisional biopsy, tongue lesion, mouth, biopsy,
Thrombectomy AV Shunt 

PREOPERATIVE DIAGNOSIS: , Thrombosed arteriovenous shunt left forearm.,POSTOPERATIVE DIAGNOSIS:  ,Thrombosed arteriovenous shunt, left forearm with venous anastomotic stenosis.,PROCEDURE:  ,Thrombectomy AV shunt, left forearm and patch angioplasty of the venous anastomosis.,ANESTHESIA: , Local.,SKIN PREP: , Betadine.,DRAINS: , None.,PROCEDURE TECHNIQUE:  ,The left arm was prepped and draped.  Xylocaine 1% was administered and a transverse antecubital incision was made over the venous limb of the graft, which was dissected out and encircled with a vessel loop.  The runoff vein was dissected out and encircled with the vessel loop as well.  A longitudinal incision was made over the venous anastomosis.  There was a narrowing in the area and slightly the incision was extended more proximally.  There was good back bleeding from the vein as well as bleeding from the more distal vein.  These were occluded with noncrushing DeBakey clamps and the patient was given 5000 units of heparin intravenously.  A #4 Fogarty was used to extract thrombus from the graft systematically until the arterial plug was removed and excellent inflow was established.  There was a narrowing in the mid portion of the venous limb of the graft, which was dilated with a #5 coronary dilator.  The Fogarty catheter was then passed up the vein, but no clot was obtained.  A patch PTFE material was fashioned and was sutured over the graftotomy with running 6-0 Gore-Tex suture.  Clamps were removed and flow established.  A thrill was easily palpable.  Hemostasis was achieved and the wound was irrigated and closed with 3-0 Vicryl subcutaneous suture followed by 4-0 nylon on the skin.  A sterile dressing was applied.  The patient was taken to the recovery room in satisfactory condition having tolerated the procedure well.  Sponge, instrument and needle counts were reported as correct.surgery, angioplasty, venous, anastomosis, patch angioplasty, av shunt, venous anastomosis, av, thrombectomy, thrombosed, arteriovenous, vein, forearm, shunt,
Temporal Artery Biopsy 

PREOPERATIVE DIAGNOSIS:,  Rule out temporal arteritis.,POSTOPERATIVE DIAGNOSIS:  ,Rule out temporal arteritis.,PROCEDURE:,  Bilateral temporal artery biopsy.,ANESTHESIA:,  Local anesthesia 1% Xylocaine with epinephrine.,INDICATIONS:,  I was consulted by Dr. X for this patient with bilateral temporal headaches to rule out temporal arteritis.  I explained fully the procedure to the patient.,PROCEDURE: , Both sides were done exactly the same way.  After 1% Xylocaine infiltration, a 2 to 3-cm incision was made over the temporal artery.  The temporal artery was identified and was grossly normal on both sides.  Proximal and distal were ligated with both of 3-0 silk suture and Hemoccult.  The specimen of temporal artery was taken from both sides measuring at least 2 to 3 cm.  They were sent as separate specimens, right and left labeled.  The wound was then closed with interrupted 3-0 Monocryl subcuticular sutures and Dermabond.  She tolerated the procedure well.surgery, headaches, bilateral temporal artery, temporal artery biopsy, temporal arteritis, temporal artery, temporal, biopsy, arteritis
Thoracentesis - 1 

PREOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,POSTOPERATIVE DIAGNOSIS: , Malignant pleural effusion, left, with dyspnea.,PROCEDURE:  ,Thoracentesis, left.,DESCRIPTION OF PROCEDURE: , The patient was brought to the recovery area of the operating room.  After obtaining the informed consent, the patient's posterior left chest wall was prepped and draped in usual fashion.  Xylocaine 1% was infiltrated above the seventh intercostal space in the midscapular line.  Initially, I tried to use the thoracentesis set after 1% Xylocaine had been infiltrated, but the needle of the system was just too short to reach the pleural cavity due to the patient's very thick chest wall.  Therefore, I had to use a #18 spinal needle, which I had to use almost in its entire length to reach the fluid.  From then on, I proceeded manually to withdraw 2000 mL of a light milky fluid.,The patient tolerated the procedure fairly well, but almost at the end of it she said that she was feeling like fainting and therefore we carefully withdrew the needle.  At that time, it was getting difficult to withdraw fluid anyway and we allowed her to lie down and after a few minutes the patient was feeling fine.  At any rate, we gave her bolus of 250 mL of normal saline and the patient returned to her room for additional hours of observation.  We then thought that if she was doing fine, then we will send her home.,A chest x-ray was performed after the procedure which showed a dramatic reduction of the amount of pleural fluid and then there was no pneumothorax or no other obvious complications of her procedure.,surgery, malignant pleural effusion, chest wall, pleural effusion, dyspnea, thoracentesis, fluid, pleural,
Tesio Hemodialysis Catheter Insertion 

OPERATION,1.  Insertion of a left subclavian Tesio hemodialysis catheter.,2.  Surgeon-interpreted fluoroscopy.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and MAC anesthesia was administered.  Next, the patient's chest and neck were prepped and draped in the standard surgical fashion.  Lidocaine 1% was used to infiltrate the skin in the region of the procedure.  Next a #18-gauge finder needle was used to locate the left subclavian vein.  After aspiration of venous blood, Seldinger technique was used to thread a J wire through the needle.  This process was repeated.  The 2 J wires and their distal tips were confirmed to be in adequate position with surgeon-interpreted fluoroscopy.  Next, the subcutaneous tunnel was created.  The distal tips of the individual Tesio hemodialysis catheters were pulled through to the level of the cuff.  A dilator and sheath were passed over the individual J wires.  The dilator and wire were removed, and the distal tip of the Tesio hemodialysis catheter was threaded through the sheath, which was simultaneously withdrawn.  The process was repeated.  Both distal tips were noted to be in good position.  The Tesio hemodialysis catheters were flushed and aspirated without difficulty.  The catheters were secured at the cuff level with a 2-0 nylon.  The skin was closed with 4-0 Monocryl.  Sterile dressing was applied.  The patient tolerated the procedure well and was transferred to the PACU in good condition.surgery, needle, tesio hemodialysis catheter, hemodialysis catheter, fluoroscopy, catheters, catheter, tesio, hemodialysisNOTE,: 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.
Temporal Artery Biopsy - 1 

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

PREOPERATIVE DIAGNOSIS:,  Right buccal space infection and abscess tooth #T.,POSTOPERATIVE DIAGNOSIS: , Right buccal space infection and abscess tooth #T.,PROCEDURE:,  Extraction of tooth #T and incision and drainage (I&D) of right buccal space infection.,ANESTHESIA:,  General, oral endotracheal tube.,COMPLICATIONS: , None.,SPECIMENS:,  Aerobic and anaerobic cultures were sent.,IV FLUID: , 150 mL.,ESTIMATED BLOOD LOSS:,  10 mL.,PROCEDURE: , The patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, the patient was prepped and draped in the usual fashion for an intraoral procedure.  Gauze throat pack was placed and the right buccal vestibule was palpated and area of the abscess was located.  The abscess cavity was aspirated using a 5 mL syringe with an 18-gauge needle.  Approximately 1 mL of purulent material was aspirated that was placed on aerobic and anaerobic cultures.  Culture swabs and the tooth sent to the laboratory for culture and sensitivity testing.,The area in the buccal vestibule was then opened with approximately 1-cm incision.  Blunt dissection was then used to open up the abscess cavity and explore the abscess cavity.  A small amount of additional purulence was drained from it, approximately 1 mL and at this point, tooth #T was extracted by forceps extraction.  Periosteal elevator was used to explore the area near the extraction site.  This was continuous with abscess cavity, so the abscess cavity was allowed to drain into the extraction site.  No drain was placed.  Upon completion of the procedure, the throat pack was removed.  The pharynx was suctioned.  The stomach was also suctioned and the patient was then awakened, extubated, and taken to the recovery room in stable condition.surgery, buccal space, incision and drainage, throat pack, extraction site, tooth, i&d, drainage, infection, cavity, extraction, incision, buccal, abscess