falan42/nurse_detection huggingface dataset:
Triple Lumen Catheter Insertion - 1 

PREOPERATIVE DIAGNOSIS: , Need for intravenous access.,POSTOPERATIVE DIAGNOSIS: , Need for intravenous access.,PROCEDURE PERFORMED:  ,Insertion of a right femoral triple lumen catheter.,ANESTHESIA: , Includes 4 cc of 1% lidocaine locally.,ESTIMATED BLOOD LOSS: , Minimum.,INDICATIONS:,  The patient is an 86-year-old Caucasian female who presented to ABCD General Hospital secondary to drainage of an old percutaneous endoscopic gastrostomy site.  The patient is also ventilator-dependent, respiratory failure with tracheostomy in place and dependent on parenteral nutrition secondary to dysphagia and also has history of protein-calorie malnutrition and the patient needs to receive total parenteral nutrition and therefore needs central venous access.,PROCEDURE:,  The patient's legal guardian was talked to.  All questions were answered and consent was obtained.  The patient was sterilely prepped and draped.  Approximately 4 cc of 1% lidocaine was injected into the inguinal site.  A strong femoral artery pulse was felt and triple lumen catheter Angiocath was inserted at 30-degree angle cephalad and aspirated until a dark venous blood was aspirated.  A guidewire was then placed through the needle.  The needle was then removed.  The skin was ________ at the base of the wire and a dilator was placed over the wire.  The triple lumen catheters were then flushed with bacteriostatic saline.  The dilator was then removed from the guidewire and a triple lumen catheter was then inserted over the guidewire with the guidewire held at all times.,The wire was then carefully removed.  Each port of the lumen catheter was aspirated with 10 cc syringe with normal saline till dark red blood was expressed and then flushed with bacteriostatic normal saline and repeated on the remaining two ports.  Each port was closed off and also kept off.  Straight needle suture was then used to suture the triple lumen catheter down to the skin.  Peristatic agent was then placed at the site of the lumen catheter insertion and a Tegaderm was then placed over the site.  The surgical site was then sterilely cleaned.  The patient tolerated the full procedure well.  There were no complications.  The nurse was then contacted to allow for access of the triple lumen catheter.surgery, intravenous access, catheter, femoral triple lumen catheter, triple lumen catheter, lumen, ventilator, respiratory, guidewire
Trigger Finger Release 

PROCEDURE: , Trigger finger release.,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 over the digit's A1 pulley.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The sheath was opened under direct vision with a scalpel, and then a scissor was used to release it under direct vision from the proximal extent of the A1 pulley to just proximal to the proximal digital crease.  Meticulous hemostasis was maintained with bipolar electrocautery.,The tendons were identified and atraumatically pulled to ensure that no triggering remained.  The patient then actively moved the digit, and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.surgery, a1 pulley, neurovascular bundles, trigger finger release, proximal digital, digital crease, trigger finger, trigger, finger, sheath, incision
Trigger Thumb Release 

PROCEDURE:  ,Trigger thumb release.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual sterile fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A transverse incision was made over the MPJ crease of the thumb.  Dissection was carried down to the flexor sheath with care taken to identify and protect the neurovascular bundles.  The flexor sheath was opened under direct vision with a scalpel, and then a scissor was used to release the A1 pulley under direct vision on the radial side, from its proximal extent to its distal extent at the junction of the proximal and middle thirds of the proximal phalanx.  Meticulous hemostasis was maintained with bipolar electrocautery.,The flexor pollicis longus tendon was identified and atraumatically pulled to ensure that no triggering remained.  The patient then actively moved the thumb and no triggering was noted.,After irrigating out the wound with copious amounts of sterile saline, the skin was closed with 5-0 nylon simple interrupted sutures.,The wound was dressed and the patient was sent to the recovery room in good condition, having tolerated the procedure well.surgery, neurovascular, a1 pulley, trigger thumb release, mpj crease, trigger thumb, flexor sheath, triggering, sheath, proximal, incision
Transesophageal Echocardiography Probe 

INDICATIONS FOR PROCEDURE:,  Impending open heart surgery for closure of ventricular septal defect in a 4-month-old girl.,Procedures were done under general anesthesia.  The patient was already in the operating room under general anesthesia.  Antibiotic prophylaxis with cefazolin and gentamicin was already given prior to beginning the procedures.,PROCEDURE #1:,  Insertion of transesophageal echocardiography probe.,DESCRIPTION OF PROCEDURE #1: , The probe was well lubricated and with digital manipulation, was passed into the esophagus without resistance.  The probe was placed so that the larger diameter was in the anterior-posterior position during insertion.  The probe was used by the pediatric cardiologist for preoperative and postoperative diagnostic echocardiography.  At the end, it was removed without trauma and there was no blood tingeing.  It is to be noted that approximately 30 minutes after removing the cannula, I inserted a 14-French suction tube to empty the stomach and there were a few mL of blood secretions that were suctioned.  There was no overt bleeding.,PROCEDURE #2: , Attempted and unsuccessful insertion of arterial venous lines.,DESCRIPTION OF PROCEDURE #2:,  Both groins were prepped and draped.  The patient was placed at 10 degrees head-up position.  A Cook 4-French double-lumen 8-cm catheter kit was opened.  Using the 21-gauge needle that comes with the kit, several attempts were made to insert central venous and then an arterial line in the left groin.  There were several successful punctures of these vessels, but I was unable to advance Seldinger wire.  After removal of the needles, the area was compressed digitally for approximately 5 minutes.  There was a small hematoma that was not growing.  Initially, the left leg was mildly mottled with prolonged capillary refill of approximately 3 seconds.  Using 1% lidocaine, I infiltrated the vessels of the groin both medial and lateral to the vascular sheath.  Further observation, the capillary refill and circulation of the left leg became more than adequate.  The O2 saturation monitor that was on the left toe functioned well throughout the procedures, from the beginning to the end.  At the end of the procedure, the circulation of the leg was intact.,surgery, impending open heart surgery, ventricular septal defect, antibiotic prophylaxis, cefazolin, transesophageal echocardiography probe, arterial venous lines, groin, transesophageal echocardiography, echocardiography probe, insertion, transesophageal, arterial, venous, groins, echocardiography, probe
Transurethral Resection Of Bladder Tumor  

PREOPERATIVE DIAGNOSIS: , Bladder tumor.,POSTOPERATIVE DIAGNOSIS: , Bladder tumor.,PROCEDURE PERFORMED: , Transurethral resection of a medium bladder tumor (TURBT), left lateral wall.,ANESTHESIA: , Spinal.,SPECIMEN TO PATHOLOGY: , Bladder tumor and specimen from base of bladder tumor.,DRAINS: , A 22-French 3-way Foley catheter, 30 mL balloon.,ESTIMATED BLOOD LOSS:,  Minimal.,INDICATIONS FOR PROCEDURE: , This is a 74-year-old male who presented with microscopic and an episode of gross hematuria.  He underwent an IVP, which demonstrated enlarged prostate and normal upper tracts.  Cystoscopy in the office demonstrated a 2.5- to 3-cm left lateral wall bladder tumor.  He is brought to the operating room for transurethral resection of that bladder tumor.,DESCRIPTION OF OPERATION: , After preoperative counseling of the patient and his wife, the patient was taken to the operating room and administered a spinal anesthetic.  He was placed in lithotomy position and prepped and draped in the usual fashion.  Using the visual obturator, the resectoscope was then inserted per urethra into the bladder.  The bladder was inspected confirming previous cystoscopic findings of a 2.5- to 3-cm left lateral wall bladder tumor away from the ureteral orifice.  Using the resectoscope loop, the tumor was then resected down to its base in a stepwise fashion.  Following completion of resection down to the base, the bladder was _______ free of tumor specimen.  The resectoscope was then reinserted and the base of the bladder tumor was then resected to get the base of the bladder tumor specimen, this was sent as a separate pathological specimen.  Hemostasis was assured with electrocautery.  The base of the tumor was then fulgurated again and into the periphery out in the normal mucosa surrounding the base of the bladder tumor.  Following completion of the fulguration, there was good hemostasis.  The remainder of the bladder was without evidence of significant abnormality.  Both ureteral orifices were visualized and noted to drain freely of clear urine.  The bladder was filled and the resectoscope was removed.  A 22-French 3-way Foley catheter was inserted per urethra into the bladder.  The balloon was inflated to 30 mL.  The catheter with sterile continuous irrigation and was noted to drain clear irrigant.  The patient was then removed from lithotomy position.  He was in stable condition.surgery, turbt, bladder tumor, cystoscopic, resectoscope, hemostasis, foley catheter, tumor, bladder, lithotomy, transurethral, resection, hematuria,
Tracheotomy - 1 

PREOPERATIVE DIAGNOSIS: , Respiratory failure.,POSTOPERATIVE DIAGNOSIS:  ,Respiratory failure.,OPERATIVE PROCEDURE: , Tracheotomy.,ANESTHESIA:  ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine on the operating table.  General inhalational anesthesia was administered through the patient's existing 4.0 endotracheal tube.  The neck was extended and secured with tape and incision in the midline of the neck approximately 2 fingerbreadths above the sternal notch was outlined.  The incision measured approximately 1 cm and was just below the palpable cricoid cartilage and first tracheal ring.  The incision area was infiltrated with 1% Xylocaine with epinephrine 1:100,000.  A #67 blade was used to perform the incision.  Electrocautery was used to remove excess fat tissue to expose the strap muscles.  The strap muscles were grasped and divided in the midline with a cutting electrocautery.  Sharp dissection was used to expose the anterior trachea and cricoid cartilage.  The thyroid isthmus was identified crossing just below the cricoid cartilage.  This was divided in the midline with electrocautery.  Blunt dissection was used to expose adequate cartilaginous rings.  A 4.0 silk was used for stay sutures to the midline of the cricoid.  Additional stay sutures were placed on each side of the third tracheal ring.  Thin DuoDerm was placed around the stoma.  The tracheal incision was performed with a #11 blade through the second, third, and fourth tracheal rings.  The cartilaginous edges were secured to the skin edges with interrupted #4-0 Monocryl.  A 4.5 PED tight-to-shaft cuffed Bivona tube was placed and secured with Velcro ties.  A flexible scope was passed through the tracheotomy tube.  The carina was visualized approximately 1.5 cm distal to the distal end of the tracheotomy tube.  Ventilation was confirmed.  There was good chest rise and no appreciable leak.  The procedure was terminated.  The patient was in stable condition.  Bleeding was negligible and she was transferred back to the Pediatric intensive care unit in stable condition.surgery, bivona tube, duoderm, tracheotomy tube, respiratory failure, cricoid cartilage, tracheotomy, tracheal,
Tracheostomy Change 

PREOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Laryngeal edema.,POSTOPERATIVE DIAGNOSES:,1.  Ventilator-dependent respiratory failure.,2.  Laryngeal edema.,PROCEDURE PERFORMED: , Tracheostomy change.  A #6 Shiley with proximal extension was changed to a #6 Shiley with proximal extension.,INDICATIONS: , The patient is a 60-year-old Caucasian female who presented to ABCD General Hospital with exacerbation of COPD and CHF.  The patient had subsequently been taken to the operating room by Department of Otolaryngology and a direct laryngoscope was performed.  The patient was noted at that time to have transglottic edema.  Biopsies were taken.  At the time of surgery, it was decided that the patient required a tracheostomy for maintenance of continued ventilation and airway protection.  The patient is currently postop day #6 and appears to be unable to be weaned from ventilator at this time and may require prolonged ventricular support.  A decision was made to perform tracheostomy change.,DESCRIPTION OF PROCEDURE: , The patient was seen in the Intensive Care Unit.  The patient was placed in a supine position.  The neck was then extended.  The sutures that were previously in place in the #6 Shiley with proximal extension were removed.  The patient was preoxygenated to 100%.  After several minutes, the patient was noted to have a pulse oximetry of 100%.  The IV tubing that was supporting the patient's trache was then cut.  The tracheostomy tube was then suctioned.,The inner cannula was then removed from the tracheostomy and a nasogastric tube was placed down the lumen of the tracheostomy tube as a guidewire.  The tracheostomy tube was then removed over the nasogastric tube and the operative field was suctioned.  With the guidewire in place and with adequate visualization, a new #6 Shiley with proximal extension was then passed over the nasogastric tube guidewire and carefully inserted into the trachea.  The guidewire was then removed and the inner cannula was then placed into the tracheostomy.  The patient was then reconnected to the ventilator and was noted to have normal tidal volumes.  The patient had a tidal volume of 500 and was returning 500 cc to 510 cc.  The patient continued to saturate well with saturations 99%.  The patient appeared comfortable and her vital signs were stable.  A soft trache collar was then connected to the trachesotomy.  A drain sponge was then inserted underneath the new trache site.  The patient was observed for several minutes and was found to be in no distress and continued to maintain adequate saturations and continued to return normal tidal volumes.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well.  0.25% acetic acid soaks were ordered to the drain sponge every shift.surgery, shiley, proximal extension, ventilator-dependent, respiratory failure, laryngeal edema, tracheostomy, cannula, respiratory, laryngeal, nasogastric, edema, ventilator
Total Knee Arthroplasty - Right 

PREOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,POSTOPERATIVE DIAGNOSIS (ES):, Osteoarthritis, right knee.,PROCEDURE:, Right total knee arthroplasty.,DESCRIPTION OF THE OPERATION:, The patient was brought to the Operating Room and after the successful placement of an epidural, as well as general anesthesia, administration 1 gm of Ancef preoperatively, the patient's right thigh, knee and leg were scrubbed, prepped and draped in the usual sterile fashion. The leg was exsanguinated by gravity and pneumatic tourniquet was inflated to 300 mmHg.,A straight anterior incision was carried down through the skin and subcutaneous tissue. Unilateral flaps were developed and a median retinacular parapatellar incision was made. The extensor mechanism was partially divided and the patella was everted. Some of the femoral bone spurs were resected using an osteotome and a rongeur. Ascending drill hole was made in the distal femur and the distal femoral cut, anterior and posterior and chamfer cuts were accomplished for a 67.5 femoral component.,At this point the ACL was resected. Some of the fat pad and synovium were resected, as well as both medial and lateral menisci. A posterior cruciate retractor was utilized, the tibia brought forward and a centering drill hole made in the tibia. The intramedullary guide was used for cutting the tibia. It was set at 8 mm. An additional 2 mm was resected because of a moderate defect medially.,A trial reduction was done with a 71 tibial baseplate. This was pinned and drilled and then trial reduction done with a 10-mm insert.,This gave good stability and a full range of motion.,The patella was measured with the calibers and 9 mm of bone was resected with an oscillating saw. A 34-mm component was drilled for.,A further trial reduction was done and two liters of pulse lavage were used to clean the bony surfaces. A packet of cement was hand mixed, pressurized with a spatula into the proximal tibia. Multiple drill holes were made on the medial side of the tibia where the bone was somewhat sclerotic. The tibia baseplate was secured and the patella was inserted, held with a clamp. The extraneous cement was removed. At this point the tibial baseplate was locked into place and the femoral component also seated solidly.,The knee was extended, held in this position for another 5-6 minutes until the cement was cured. Further extraneous cement was removed. The pneumatic tourniquet was released, hemostasis was obtained with electrocoagulation.,Retinaculum, quadriceps and extensor were repaired with multiple figure-of-eight #1 Vicryl sutures, the subcutaneous tissue with 2-0 and the skin with skin staples. A sterile, bulky compression dressing was placed. The patient was stable on operative release.surgery, osteoarthritis, arthroplasty, knee, patella, retinacular parapatellar, total knee arthroplasty, total knee, knee arthroplasty, baseplate, femoral, tibia,
Total Abdominal Hysterectomy 

 Total Abdominal Hysterectomy (TAH).  An incision was made into the abdomen down through the subcutaneous tissue, muscular fascia and peritoneum.  Once inside the abdominal cavity, a self-retaining retractor was placed to expose the pelvic cavity with 3 lap sponges. surgery, fundus, double-toothed tenaculum, muscular fascia, total abdominal hysterectomy, vicryl suture, abdominal, incision, hysterectomy, uterine, cavity, uterus, ligaments, peritoneum, vicrylNOTE,: 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.,
Tonsillectomy & Adenoidectomy - 4 

PREOPERATIVE DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,POSTOPERATIVE DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,FINAL DIAGNOSES,1.  Recurrent tonsillitis.,2.  Deeply cryptic hypertrophic tonsils with numerous tonsillolith.,3.  Residual adenoid hypertrophy and recurrent epistaxis.,OPERATION PERFORMED,1.  Tonsillectomy and adenoidectomy.,2.  Left superficial nasal cauterization.,DESCRIPTION OF OPERATION:,  The patient was brought to the operating room.  Endotracheal intubation carried out by Dr. X. The McIvor mouth gag was inserted and gently suspended.  Afrin was instilled in both sides of the nose and allowed to take effect for a period of time.  The hypertrophic tonsils were then removed by the suction and snare.  Deeply cryptic changes as expected were evident.  Bleeding was minimal and controlled with packing followed by electrocautery followed by extensive additional irrigation.  An inspection of the nasopharynx confirmed that the adenoids were in fact hypertrophic rubbery cryptic and obstructive.  They were shaved back, flushed with prevertebral fascia with curette.  Hemostasis established with packing followed by electrocautery.  In light of his history of recurring nosebleeds, both sides of the nose were carefully inspected.  A nasal endoscope was used to identify the plexus of bleeding, which was predominantly on the left mid portion of the septum that was controlled with broad superficial cauterization using a suction cautery device.  The bleeding was admittedly a bit of a annoyance.  An additional control was established by infiltrating slowly with a 1% Xylocaine with epinephrine around the perimeter of the bleeding site and then cauterizing the bleeding site itself.  No additional bleeding was then evident.  The oropharynx was reinspected, clots removed, the patient was extubated, taken to the recovery room in stable condition.  Discharge will be anticipated later in the day on Lortab plus amoxicillin plus Ponaris nose drops.  Office recheck anticipated if stable and doing well in three to four weeks.surgery, tonsillitis, cryptic hypertrophic tonsils, tonsillolith, nasal cauterization, adenoid hypertrophy, hypertrophic tonsils, adenoidectomy, nasal, cauterization, hypertrophy, epistaxis, tonsils, hypertrophic, intubation, tonsillectomy