falan42/nurse_detection huggingface dataset:
Wasp Sting - SOAP 

SUBJECTIVE:,  He is a 29-year-old white male who is a patient of Dr. XYZ and he comes in today complaining that he was stung by a Yellow Jacket Wasp yesterday and now has a lot of swelling in his right hand and right arm.  He says that he has been stung by wasps before and had similar reactions.  He just said that he wanted to catch it early before he has too bad of a severe reaction like he has had in the past.  He has had a lot of swelling, but no anaphylaxis-type reactions in the past; no shortness of breath or difficultly with his throat feeling like it is going to close up or anything like that in the past; no racing heart beat or anxiety feeling, just a lot of localized swelling where the sting occurs.,OBJECTIVE:,Vitals:  His temperature is 98.4.  Respiratory rate is 18.  Weight is 250 pounds.,Extremities:  Examination of his right hand and forearm reveals that he has an apparent sting just around his wrist region on his right hand on the medial side as well as significant swelling in his hand and his right forearm; extending up to the elbow.  He says that it is really not painful or anything like that.  It is really not all that red and no signs of infection at this time.,ASSESSMENT:,  Wasp sting to the right wrist area.,PLAN:,1.  Solu-Medrol 125 mg IM X 1.,2.  Over-the-counter Benadryl, ice and elevation of that extremity.,3.  Follow up with Dr. XYZ if any further evaluation is needed.dermatology, yellow jacket wasp, wasp sting, swelling, solu-medrol, lot of swelling, stung, sting, wasp,
Punch Biopsy - 2 

PREOPERATIVE DIAGNOSIS:,  Worrisome skin lesion, left hand.,POSTPROCEDURE DIAGNOSIS:,  Worrisome skin lesion, left hand.,PROCEDURE:,  The patient gave informed consent for his procedure.  After informed consent was obtained, attention was turned toward the area of interest, which was prepped and draped in the usual sterile fashion.,Local anesthetic medication was infiltrated around and into the area of interest.  There was an obvious skin lesion there and this gentleman has a history of squamous cell carcinoma.  A punch biopsy of the worrisome skin lesion was obtained with a portion of the normal tissue included.  The predominant portion of the biopsy was of the lesion itself.,Lesion was removed.  Attention was turned toward the area.  Pressure was held and the area was hemostatic.,The skin and the area were closed with 5-0 nylon suture.  All counts were correct.  The procedure was closed.  A sterile dressing was applied.  There were no complications.  The patient had no neurovascular deficits, etc., after this minor punch biopsy procedure.,dermatology, skin lesion, squamous cell carcinoma, punch biopsy,
Hyperesthesia 

SUBJECTIVE:,  This 49-year-old white male, established patient in dermatology, last seen in the office on 08/02/2002, comes in today for initial evaluation of a hyperesthesia on his right abdomen, then on his left abdomen, then on his left medial thigh.  It cleared for awhile.  This has been an intermittent problem.  Now it is back again on his right lower abdomen.  At first, it was thought that he may have early zoster.  This started six weeks before the holidays and is still going on, more so in the past eight days on his abdomen and right hip area.  He has had no treatment on this; there are no skin changes at all.  The patient bathes everyday but tries to use little soap.  The patient is married.  He works as an airplane mechanic.,FAMILY, SOCIAL, AND ALLERGY HISTORY:,  The patient has sinus and CVA.  He is a nonsmoker.  No known drug allergies.,CURRENT MEDICATIONS:,  Lipitor, aspirin, folic acid.,PHYSICAL EXAMINATION:,  The patient is well developed, appears stated age.  Overall health is good.  He does have psoriasis with some psoriatic arthritis, and his skin looks normal today.  On his trunk, he does have the hyperesthesia.  As you touch him, he winces.,IMPRESSION:,  Hyperesthesia, question etiology.,TREATMENT:,1.  Discussed condition and treatment with the patient.,2.  Discontinue hot soapy water to these areas.,3.  Increase moisturizing cream and lotion.,4.  I referred him to Dr. ABC or Dr. XYZ for neurology evaluation.  We did not see anything on skin today.  Return p.r.n. flare.dermatology, abdomen, hyperesthesia, soapy water, moisturizing cream, initial evaluation
I&D - Buttock Abscess 

PRINCIPAL DIAGNOSIS: , Buttock abscess, ICD code 682.5.,PROCEDURE PERFORMED:,  Incision and drainage (I&D) of buttock abscess.,CPT CODE: , 10061.,DESCRIPTION OF PROCEDURE:  ,Under general anesthesia, skin was prepped and draped in usual fashion.  Two incisions were made along the right buttock approximately 5 mm diameter.  Purulent material was drained and irrigated with copious amounts of saline flush.  A Penrose drain was placed.  Penrose drain was ultimately sutured forming a circular drain.  The patient's drain will be kept in place for a period of 1 week and to be taken as an outpatient basis.  Anesthesia, general endotracheal anesthesia.  Estimated blood loss approximately 5 mL.  Intravenous fluids 100 mL.  Tissue collected.  Purulent material from buttock abscess sent for usual cultures and chemistries.  Culture and sensitivity Gram stain.  A single Penrose drain was placed and left in the patient.  Dr. X attending surgeon was present throughout the entire procedure.dermatology, incision and drainage, purulent material, penrose drain, buttock abscess, i&d, drainage
Itchy Rash - ER Visit 

CHIEF COMPLAINT:,  Itchy rash.,HISTORY OF PRESENT ILLNESS: , This 34-year-old gentleman awoke this morning noting some itchiness to his back and then within very a short period of time realized that he had an itchy rash all over his torso and arms.  No facial swelling.  No tongue or lip swelling.  No shortness of breath, wheezing, or other associated symptoms.  He cannot think of anything that could have triggered this off.  There have been no changes in his foods, medications, or other exposures as far as he knows.  He states a couple of days ago he did work and was removing some insulation but does not remember feeling itchy that day.,PAST MEDICAL HISTORY: , Negative for chronic medical problems.  No local physician.  Has had previous back surgery and appendectomy, otherwise generally healthy.,REVIEW OF SYSTEMS: , As mentioned denies any oropharyngeal swelling.  No lip or tongue swelling.  No wheezing or shortness of breath.  No headache.  No nausea.  Notes itchy rash, especially on his torso and upper arms.,SOCIAL HISTORY: , The patient is accompanied with his wife.,FAMILY HISTORY: , Negative.,MEDICATIONS: , None.,ALLERGIES: , TORADOL, MORPHINE, PENICILLIN, AND AMPICILLIN.,PHYSICAL EXAMINATION: , VITAL SIGNS:  The patient was afebrile.  He is slightly tachycardic, 105, but stable blood pressure and respiratory rate.  GENERAL:  The patient is in no distress.  Sitting quietly on the gurney.  HEENT:  Unremarkable.  His oral mucosa is moist and well hydrated.  Lips and tongue look normal.  Posterior pharynx is clear.  NECK:  Supple.  His trachea is midline.  There is no stridor.  LUNGS:  Very clear with good breath sounds in all fields.  There is no wheezing.  Good air movement in all lung fields.  CARDIAC:  Without murmur.  Slight tachycardia.  ABDOMEN:  Soft, nontender.  SKIN:  Notable for a confluence erythematous, blanching rash on the torso as well as more of a blotchy papular, macular rash on the upper arms.  He noted some on his buttocks as well.  Remaining of the exam is unremarkable.,ED COURSE: , The patient was treated with epinephrine 1:1000, 0.3 mL subcutaneously along with 50 mg of Benadryl intramuscularly.  After about 15-20 minutes he states that itching started to feel better.  The rash has started to fade a little bit and feeling a lot more comfortable.,IMPRESSION:,  ACUTE ALLERGIC REACTION WITH URTICARIA AND PRURITUS.,ASSESSMENT AND PLAN: , The patient has what looks to be some type of allergic reaction, although the underlying cause is difficult to assess.  He will make sure he goes home to look around to see if there is in fact anything that changed recently that could have triggered this off.  In the meantime, I think he can be managed with some antihistamine over-the-counter.  He is responding already to Benadryl and the epinephrine that we gave him here.  He is told that if he develops any respiratory complaints, shortness of breath, wheezing, or tongue or lip swelling he will return immediately for evaluation.  He is discharged in stable condition.dermatology, urticaria, pruritus, lip swelling, allergic reaction, itchy rash, torso, swelling, itchy, rash,
Facial Rhytids 

HISTORY: , This 57-year-old female who presented today for evaluation and recommendations regarding facial rhytids.  In summary, the patient is a healthy 57-year-old female, nonsmoker with no history of skin disease, who has predominant fullness in the submandibular region and mid face region and prominent nasolabial folds.,RECOMMENDATIONS: , I do believe a facelift procedure would be of maximum effect for the patient's areas of concern and a "quick lift" type procedure certainly would address these issues.  I went over risks and benefits with the patient along with the preoperative and postoperative care, and risks include but are not limited to bleeding, infection, discharge, scar formation, need for further surgery, facial nerve injury, numbness, asymmetry of face, problems with hypertrophic scarring, problems with dissatisfaction with anticipated results, and she states she will contact us later in the summer to possibly make arrangements for a quick lift through Memorial Medical Center.dermatology, quick lift, hypertrophic scarring, facial rhytids, mid face region, nasolabial folds, liftNOTE,: 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.,
Excision - Skin Neoplasm  

PREOPERATIVE DIAGNOSES:,1.  Enlarging nevus of the left upper cheek.,2.  Enlarging nevus 0.5 x 1 cm, left lower cheek.,3.  Enlarging superficial nevus 0.5 x 1 cm, right nasal ala.,TITLE OF PROCEDURES:,1.  Excision of left upper cheek skin neoplasm 0.5 x 1 cm with two layer closure.,2.  Excision of the left lower cheek skin neoplasm 0.5 x 1 cm with a two layer plastic closure.,3.  Shave excision of the right nasal ala 0.5 x 1 cm skin neoplasm.,ANESTHESIA:  ,Local.  I used a total of 5 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 10 mL.,COMPLICATIONS:,  None.,PROCEDURE: , The patient was evaluated preop and noted to be in stable condition.  Chart and informed consent were all reviewed preop.  All risks, benefits, and alternatives regarding the procedure have been reviewed in detail with the patient.  Risks including but not limited to bleeding, infection, scarring, recurrence of the lesion, need for further procedures have been all reviewed.  Each of these lesions appears to be benign nevi; however, they have been increasing in size.  The lesions involving the left upper and lower cheek appear to be deep.  These required standard excision with the smaller lesion of the right nasal ala being more superficial and amenable to a superficial shave excision.  Each of these lesions was marked.  The skin was cleaned with a sterile alcohol swab.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,Began first excision of the left upper cheek skin lesion.  This was excised with the 15-blade full thickness.  Once it was removed in its entirety, undermining was performed, and the wound was closed with 5-0 myochromic for the deep subcutaneous, 5-0 nylon interrupted for the skin.,The lesion of the lower cheek was removed in a similar manner.  Again, it was excised with a 15 blade with two layer plastic closure.  Both these lesions appear to be fairly deep nevi.,The right nasal ala nevus was superficially shaved using the radiofrequency wave unit.  Each of these lesions was sent as separate specimens.  The patient was discharged from my office in stable condition.  He had minimal blood loss.  The patient tolerated the procedure very well.  Postop care instructions were reviewed in detail.  We have scheduled a recheck in one week and we will make further recommendations at that time.dermatology, enlarging nevus, nevus, skin neoplasm, nasal ala, cheek skin neoplasm, shave excision, superficial, lesions, neoplasm, excision, cheek
Excision - Keratotic Neoplasm 

PREOPERATIVE DIAGNOSES:,1.  Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2.  Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3.  Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,POSTOPERATIVE DIAGNOSES:,1.  Enlarging dark keratotic lesion of the left temple measuring 1 x 1 cm.,2.  Enlarging keratotic neoplasm of the left nasolabial fold measuring 0.5 x 0.5 cm.,3.  Enlarging seborrheic keratotic neoplasm of the right temple measuring 1 x 1 cm.,TITLE OF PROCEDURES:,1.  Excision of the left temple keratotic neoplasm, final defect 1.8 x 1.5 cm with two layer plastic closure.,2.  Excision of the left nasolabial fold defect 0.5 x 0.5 cm with single layer closure.,3.  Excision of the right temple keratotic neoplasm, final defect measuring 1.5 x 1.5 cm with two layer plastic closure.,ANESTHESIA: , Local using 3 mL of 1% lidocaine with 1:100,000 epinephrine.,ESTIMATED BLOOD LOSS: , Less than 30 mL.,COMPLICATIONS:,  None.,PROCEDURE: , The patient was evaluated preoperatively and noted to be in stable condition.  Informed consent was obtained from the patient.  All risks, benefits and alternatives regarding the surgery have been reviewed in detail with the patient.  This includes risks of bleeding, infection, scarring, recurrence of lesion, need for further procedures, etc.  Each of the areas was cleaned with a sterile alcohol swab.  Planned excision site was marked with a marking pen.  Local anesthetic was infiltrated.  Sterile prep and drape were then performed.,We began first with excision of the left temple followed by the left nasolabial and right temple lesions.  The left temple lesion is noted to be a dark black what appears to be a keratotic or possible seborrheic keratotic neoplasm.  However, it is somewhat deeper than the standard seborrheic keratosis.  The incision for removal of this lesion was placed within the relaxed skin tension line of the left temple region.  Once this was removed, wide undermining was performed and the wound was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous and 5-0 nylon for the skin.,Excision of left cheek was a keratotic nevus.  It was excised with a defect 0.5 x 0.5 cm.  It was closed in a single layer fashion 5-0 nylon.,The lesion of the right temple also dark black keratotic neoplasm was excised with the incision placed within the relaxed skin tension.  Once it was excised full-thickness, the defect measure 1.5 x 1.5 cm.  Wide undermine was performed and it was closed in a two layer fashion using 5-0 myochromic for the deep subcutaneous, 5-0 nylon that was used to close skin.  Sterile dressing was applied afterwards.  The patient was discharged in stable condition.  Postop care instructions reviewed in detail.  She is scheduled with me in one week and we will make further recommendations at that time.dermatology, keratotic lesion, keratotic neoplasm, seborrheic keratotic neoplasm, seborrheic, keratotic, neoplasm, nasolabial, two layer plastic closure, nasolabial fold, excision,
Dermatitis - SOAP 

SUBJECTIVE:,  This is a 29-year-old Vietnamese female, established patient of dermatology, last seen in our office on 07/13/04.  She comes in today as a referral from ABC, D.O. for a reevaluation of her hand eczema.  I have treated her with Aristocort cream, Cetaphil cream, increased moisturizing cream and lotion, and wash her hands in Cetaphil cleansing lotion.  She comes in today for reevaluation because she is flaring.  Her hands are very dry, they are cracked, she has been washing with soap.  She states that the Cetaphil cleansing lotion apparently is causing some burning and pain because of the fissures in her skin.  She has been wearing some gloves also apparently.  The patient is single.  She is unemployed.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has asthma, sinus, hives, and history of psoriasis.  No known drug allergies.,MEDICATIONS: , The patient is a nonsmoker.  No bad sunburns or blood pressure problems in the past.,CURRENT MEDICATIONS:,  Claritin and Zyrtec p.r.n.,PHYSICAL EXAMINATION:,  The patient has very dry, cracked hands bilaterally.,IMPRESSION:,  Hand dermatitis.,TREATMENT:,1.  Discussed further treatment with the patient and her interpreter.,2.  Apply Aristocort ointment 0.1% and equal part of Polysporin ointment t.i.d. and p.r.n. itch.,3.  Discontinue hot soapy water and wash her hands with Cetaphil cleansing lotion.,4.  Keflex 500 mg b.i.d. times two weeks with one refill.  Return in one month if not better; otherwise, on a p.r.n. basis and send Dr. XYZ a letter on this office visit.dermatology, cetaphil cleansing lotion, hand dermatitis, aristocort, wash, ointment, hand, lotion, dermatitis
Biopsy - Actinic Keratosis 

PREOPERATIVE DIAGNOSES:  ,1.  Left chest actinic keratosis, 2 cm.,2.  Left medial chest actinic keratosis, 1 cm.,3.  Left shoulder actinic keratosis, 1 cm.,POSTOPERATIVE DIAGNOSES:  ,1.  Left chest actinic keratosis, 2 cm.,2.  Left medial chest actinic keratosis, 1 cm.,3.  Left shoulder actinic keratosis, 1 cm.,TITLE OF PROCEDURES:  ,1.  Excisional biopsy of left chest 2 cm actinic keratosis.,2.  Two-layer plastic closure.,3.  Excisional biopsy of left chest medial actinic keratosis 1 cm with one-layer plastic closure.,4.  Excisional biopsy of left should skin nevus, 1 cm, one-layer plastic closure.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 6 mL.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS: , None.,PROCEDURE: , All areas were prepped, draped, and localized in the usual manner.  Afterwards, elliptical incisions were placed with a #15-blade scalpel and curved iris scissors and small bishop forceps were used for the dissection of the skin lesions.  After all were removed, they were closed with one-layer technique for the shoulder and medial lesion, and the larger left chest lesion was closed with two-layer closure using Monocryl 5-0 for subcuticular closure and 5-0 nylon for skin closure.  She tolerated this procedure very well, and postoperative care instructions were provided.  She will follow up next week for suture removal.  Of note, she had an episode of hemoptysis, which could not be explained prompting an emergency room visit, and I discussed if this continues we may wish to perform a fiberoptic laryngoscopy examination and possible further workup if a diagnosis cannot be made.dermatology, two-layer plastic closure, one-layer plastic closure, skin nevus, actinic keratosis, plastic closures, keratosis, actinic, biopsy, forceps, layer, closures, chest
Burn - Consult 

CHIEF COMPLAINT: , Burn, right arm.,HISTORY OF PRESENT ILLNESS: , This is a Workers' Compensation injury.  This patient, a 41 year-old male, was at a coffee shop, where he works as a cook, and hot oil splashed onto his arm, burning from the elbow to the wrist on the medial aspect.  He has had it cooled, and presents with his friend to the Emergency Department for care.,PAST MEDICAL HISTORY:  ,Noncontributory.,MEDICATIONS:  ,None.,ALLERGIES:  ,None.,PHYSICAL EXAMINATION: , GENERAL:  Well-developed, well-nourished 21-year-old male adult who is appropriate and cooperative.  His only injury is to the right upper extremity.  There are first and second degree burns on the right forearm, ranging from the elbow to the wrist.  Second degree areas with blistering are scattered through the medial aspect of the forearm.  There is no circumferential burn, and I see no areas of deeper burn.  The patient moves his hands well.  Pulses are good.  Circulation to the hand is fine.,FINAL DIAGNOSIS:,1.  First-degree and second-degree burns, right arm secondary to hot oil spill.,2.  Workers' Compensation industrial injury.,TREATMENT: , The wound is cooled and cleansed with soaking in antiseptic solution.  The patient was ordered Demerol 50 mg IM for pain, but he refused and did not want pain medication.  A burn dressing is applied with Neosporin ointment.  The patient is given Tylenol No. 3, tabs #4, to take home with him and take one or two every four hours p.r.n. for pain.  He is to return tomorrow for a dressing change.  Tetanus immunization is up to date.  Preprinted instructions are given.  Workers' Compensation first report and work status report are completed.,DISPOSITION: , Home.dermatology, burn, workers' compensation industrial injury, workers' compensation, degree
Atopic Eczema 

SUBJECTIVE:,  This 1+ year, black female, new patient in dermatology, sent in for consult from ABC Practice for initial evaluation of a lifelong history of atopic eczema.  The patient’s mom is from Tanzania.  The patient has been treated with Elidel cream b.i.d. for six months but apparently this has stopped working now and it seems to make her more dry and plus she has been using some Johnson's Baby Oil on her.  The patient is a well-developed baby.  Appears stated age.  Overall health is good.,FAMILY, SOCIAL, AND ALLERGY HISTORY: , The patient has eczema and a positive atopic family history.  No psoriasis.  No known drug allergies.,CURRENT MEDICATIONS:,  None.,PHYSICAL EXAMINATION:, The patient has eczematous changes today on her face, trunk, and extremities.,IMPRESSION:,  Atopic eczema.,TREATMENT:,1.  Discussed condition and treatment with Mom.,2.  Continue bathing twice a week.,3.  Discontinue hot soapy water.,4.  Discontinue Elidel for now.,5.  Add Aristocort cream 0.25%, Polysporin ointment, Aquaphor b.i.d. and p.r.n. itch.  We will see her in one month if not better otherwise on a p.r.n. basis.  Send a letter to ABC Practice program.dermatology, elidel cream, johnson's baby oil, polysporin ointment, atopic eczema, eczema, eczematous, hot soapy water, atopic, elidel,
Condyloma Cauterization 

PREOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,POSTOPERATIVE DIAGNOSIS: , Extensive perianal and intra-anal condyloma.,PROCEDURE PERFORMED:,  Cauterization of peri and intra-anal condylomas.,ANESTHESIA:  ,IV sedation and local.,SPECIMEN: , Multiple condylomas were sent to pathology.,ESTIMATED BLOOD LOSS: , 10 cc.,BRIEF HISTORY: , This is a 22-year-old female, who presented to the office complaining of condylomas she had noted in her anal region.  She has noticed approximately three to four weeks ago.  She denies any pain but does state that there is some itching.  No other symptoms associated.,GROSS FINDINGS: , We found multiple extensive perianal and intra-anal condylomas, which are likely represent condyloma acuminata.,PROCEDURE: , After risks, benefits and complications were explained to the patient and a verbal consent was obtained, the patient was taken to the operating room.  After the area was prepped and draped, a local anesthesia was achieved with Marcaine.  Bovie electrocautery was then used to remove the condylomas taking care to achieve meticulous hemostasis throughout the course of the procedure.  The condylomas were removed 350 degrees from the perianal and intra-anal regions.  After all visible condylomas were removed, the area was again washed with acetic acid solution.  Any residual condylomas were then cauterized at this time.  The area was then examined again for any residual bleeding and there was none.,DISPOSITION: , The patient was taken to Recovery in stable condition.  She will be sent home with prescriptions for a topical lidocaine and Vicodin.  She will be instructed to do sitz bath b.i.d., and post-bowel movement.  She will follow up in the office next week.dermatology, intra-anal, perianal, acuminata, cauterization, condyloma, anal,