falan42/nurse_detection huggingface dataset:
Laparoscopic Cholecystectomy - 7 

PREOPERATIVE DIAGNOSIS: , Cholecystitis and cholelithiasis.,POSTOPERATIVE DIAGNOSIS:  ,Cholecystitis and cholelithiasis.,TITLE OF PROCEDURE,1.  Laparoscopic cholecystectomy.,2.  Intraoperative cholangiogram.,ANESTHESIA:  ,General.,PROCEDURE IN DETAIL:  ,The patient was taken to the operative suite and placed in the supine position under general endotracheal anesthetic.  The patient received 1 gm of IV Ancef intravenously piggyback.  The abdomen was prepared and draped in routine sterile fashion.,A 1-cm incision was made at the umbilicus and a Veress needle was inserted.  Saline test was performed.  Satisfactory pneumoperitoneum was achieved by insufflation of CO2 to a pressure of 14 mmHg.  The Veress needle was removed.  A 10- to 11-mm cannula was inserted.  Inspection of the peritoneal cavity revealed a gallbladder that was soft and without adhesions to it.  It was largely mobile.  The liver had a normal appearance as did the peritoneal cavity.  A 5-mm cannula was inserted in the right upper quadrant anterior axillary line.  A second 5-mm cannula was inserted in the subcostal space.  A 10- to 11-mm cannula was inserted into the upper midline.,The gallbladder was reflected in a cephalad direction.  The gallbladder was punctured with the aspirating needle, and under C-arm fluoroscopy was filled with contrast, filling the intra- and extrahepatic biliary trees, which appeared normal.  Extra contrast was aspirated and the aspirating needle was removed.  The ampulla was grasped with a second grasper, opening the triangle of Calot.  The cystic duct was dissected and exposed at its junction with the ampulla, was controlled with a hemoclip, digitally controlled with two clips and divided.  This was done while the common duct was in full visualization.  The cystic artery was similarly controlled and divided.  The gallbladder was dissected from its bed and separated from the liver, brought to the outside through the upper midline cannula and removed.,The subhepatic and subphrenic spaces were irrigated thoroughly with saline solution.  There was oozing and bleeding from the lateral 5-mm cannula site, but this stopped spontaneously with removal of the cannula.  The subphrenic and subhepatic spaces were again irrigated thoroughly with saline until clear.  Hemostasis was excellent.  CO2 was evacuated and the camera removed.  The umbilical fascia was closed with 2-0 Vicryl, the subcu with 3-0 Vicryl, and the skin was closed with 4-0 nylon.  Sterile dressings were applied.  Sponge and needle counts were correct.gastroenterology, cholangiogram, cholecystitis, cholelithiasis, ancef, endotracheal, umbilicus, veress needle, c-arm fluoroscopy, intraoperative cholangiogram, laparoscopic cholecystectomy, laparoscopic, cholecystectomy, gallbladder, cannula,
Laparoscopic Cholecystectomy - 6 

PREOPERATIVE DIAGNOSIS:,  Cholelithiasis; possible choledocholithiasis.gastroenterology, choledocholithiasis, cholangiogram, co2 insufflation, umbilicus, common bile duct, bile duct, laparoscopic cholecystectomy, cystic duct, intraoperative, laparoscopic, cholecystectomy, cholelithiasis, endotracheal, gallbladder, cystic, duct,
Laparoscopic Appendectomy - 3 

PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis. ,PROCEDURE: , Laparoscopic appendectomy. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL:  ,The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  His abdomen was prepped and draped in a standard, sterile surgical fashion.  A Foley catheter was placed for bladder decompression.  Marcaine was injected into his umbilicus.  A small incision was made.  A Veress needle was introduced in his abdomen.  CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus.  A 5-mm port was then placed just to the right side of the umbilicus.  Another 5-mm port was placed just suprapubic in the midline.  Upon inspection of the cecum, I was able find an inflamed and indurated appendix.  I was able to clear the mesentery at the base of the appendix between the appendix and the cecum.  I fired a white load stapler across the appendix at its base and fired a grey load stapler across the mesentery, and thereby divided the mesentery and freed the appendix.  I put the appendix in an Endocatch bag and removed it through the umbilicus.  I irrigated out the abdomen.  I then closed the fascia of the umbilicus with interrupted 0 Vicryl suture utilizing Carter-Thomason and closed the skin of all incisions with a running Monocryl.  Sponge, instrument, and needle counts were correct at the end of the case.  The patient tolerated the procedure well without any complications.gastroenterology, foley catheter, co2 insufflation, endotracheal intubation, laparoscopic appendectomy, appendectomy, intubation, cecum, laparoscopic, appendicitis, endotracheal, abdomen, mesentery, umbilicus, appendix,
Laparoscopic Cholecystectomy - 2 

PREOPERATIVE DIAGNOSIS:,1.  Cholelithiasis.,2.  Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:,1.  Cholelithiasis.,2.  Chronic cholecystitis.,NAME OF OPERATION: , Laparoscopic cholecystectomy.,ANESTHESIA:,  General.,FINDINGS:,  The gallbladder was thickened and showed evidence of chronic cholecystitis.  There was a great deal of inflammatory reaction around the cystic duct.  The cystic duct was slightly larger.  There was a stone impacted in the cystic duct with the gallbladder.  The gallbladder contained numerous stones which were small.  With the stone impacted in the cystic duct, it was felt that probably none were within the common duct.  Other than rather marked obesity, no other significant findings were noted on limited exploration of the abdomen.,PROCEDURE:,  Under general anesthesia after routine prepping and draping, the abdomen was insufflated with the Veress needle, and the standard four trocars were inserted uneventfully.  Inspection was made for any entry problems, and none were encountered.,After limited exploration, the gallbladder was then retracted superiorly and laterally, and the cystic duct was dissected out.  This was done with some difficulty due to the fibrosis around the cystic duct, but care was taken to avoid injury to the duct and to the common duct.  In this manner, the cystic duct and cystic artery were dissected out.  Care was taken to be sure that the duct that was identified went into the gallbladder and was the cystic duct.  The cystic duct and cystic artery were then doubly clipped and divided, taking care to avoid injury to the common duct.  The gallbladder was then dissected free from the gallbladder bed.  Again, the gallbladder was somewhat adherent to the gallbladder bed due to previous inflammatory reaction.  The gallbladder was dissected free from the gallbladder bed utilizing the endo shears and the cautery to control bleeding.  The gallbladder was extracted through the operating trocar site, and the trocar was reinserted.  Inspection was made of the gallbladder bed.  One or two bleeding areas were fulgurated, and bleeding was well controlled.gastroenterology, cholelithiasis chronic, inflammatory reaction, cystic artery, laparoscopic cholecystectomy, common duct, chronic cholecystitis, gallbladder bed, cystic duct, cystic, gallbladder, duct, inflammatory
Laparoscopic Cholecystectomy 

The patient's abdomen was prepped and draped in the usual sterile fashion.  A subumbilical skin incision was made.  The Veress needle was inserted, and the patient's abdominal cavity was insufflated with moderate pressure all times.  A subumbilical trocar was inserted.  The camera was inserted in the panoramic view.  The abdomen demonstrated some inflammation around the gallbladder.  A 10-mm midepigastric trocar was inserted.  A. 2 mm and 5 mm trocars were inserted.  The most lateral trocar grasping forceps was inserted and grasped the fundus of the gallbladder and placed in tension at liver edge.,Using the dissector, the cystic duct was identified and double Hemoclips were invited well away from the cystic-common duct junction.  The cystic artery was identified and double Hemoclips applied.  The gallbladder was taken down from the liver bed using Endoshears and electrocautery.  Hemostasis was obtained.  The gallbladder was removed from the midepigastric trocar site without difficulty.  The trocars were removed and the skin incisions were reapproximated using 4-0 Monocryl.  Steri-Strips and sterile dressing were placed.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.gastroenterology, gallbladder, laparoscopic cholecystectomy, midepigastric trocar, double hemoclips, laparoscopic, cholecystectomy, midepigastric, trocars, hemoclips, trocarNOTE,: 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.,
Laparoscopic Cholecystectomy - 3 

PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis without cholelithiasis.,POSTOPERATIVE DIAGNOSIS:  ,Chronic cholecystitis without cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy.,BRIEF DESCRIPTION: , The patient was brought to the operating room and anesthesia was induced.  The abdomen was prepped and draped and ports were placed.  The gallbladder was grasped and retracted.  The cystic duct and cystic artery were circumferentially dissected and a critical view was obtained.  The cystic duct and cystic artery were then doubly clipped and divided and the gallbladder was dissected off the liver bed with electrocautery and placed in an endo catch bag.  The gallbladder fossa and clips were examined and looked good with no evidence of bleeding or bile leak.  The ports were removed under direct vision with good hemostasis.  The Hasson was removed.  The abdomen was desufflated.  The gallbladder in its endo catch bag was removed.  The ports were closed.  The patient tolerated the procedure well.  Please see full hospital dictation.gastroenterology, chronic cholecystitis without cholelithiasis, laparoscopic cholecystectomy, cystic duct, cystic artery, endo catch, chronic cholecystitis, laparoscopic, cholecystectomy, abdomen, cholecystitis, cholelithiasis, gallbladder, cystic
Laparoscopic Appendectomy - 5 

PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS: , Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR OPERATION: , The patient is a 42-year-old female who presented with right lower quadrant pain.  She was evaluated and found to have a CT evidence of appendicitis.  She was subsequently consented for a laparoscopic appendectomy.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was brought to the operating room, placed supine on the table.  The abdomen was prepared and draped in usual sterile fashion.  After the induction of satisfactory general endotracheal anesthesia, supraumbilical incision was made.  A Veress needle was inserted.  Abdomen was insufflated to 15 mmHg.  A 5-mm port and camera placed.  The abdomen was visually explored.  There were no obvious abnormalities.  A 15-mm port was placed in the suprapubic position in addition of 5 mm was placed in between the 1st two.  Blunt dissection was used to isolate the appendix.  Appendix was separated from surrounding structures.  A window was created between the appendix and the mesoappendix.  GIA stapler was tossed across it and fired.  Mesoappendix was then taken with 2 fires of the vascular load on the GIA stapler.  Appendix was placed in an Endobag and removed from the patient.  Right lower quadrant was copiously irrigated.  All irrigation fluids were removed.  Hemostasis was verified.  The 15-mm port was removed and the port site closed with 0-Vicryl in the Endoclose device.  All other ports were irrigated, infiltrated with 0.25% Marcaine and closed with 4-0 Vicryl subcuticular sutures.  Steri-Strips and sterile dressings were applied.  Overall, the patient tolerated this well, was awakened and returned to recovery in good condition.gastroenterology, gia stapler, laparoscopic appendectomy, appendectomy, endotracheal, mesoappendix, laparoscopic, appendicitis, appendix
Laparoscopic Appendectomy - 1 

PREOPERATIVE DIAGNOSIS:,  Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Ruptured appendicitis.,PROCEDURE:,  Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE:,  This patient is a 4-year-old boy with less than 24-hour history of apparent right lower quadrant abdominal pain associated with vomiting and fevers.  The patient has elevated white count on exam and CT scan consistent with acute appendicitis.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's abdomen was prepped and draped in usual sterile fashion.  A periumbilical incision was made.  The fascia was incised.  Peritoneal cavity entered bluntly.  A 10-mm trocar and scope was passed.  Peritoneal cavity was insufflated.  Five-mm ports placed in left lower and hypogastric areas.  On visualization of the right lower quadrant, appendix was visualized stuck against the right anterior abdominal wall, there is obvious site of perforation and leakage of content and pus.  We proceeded to take the mesoappendix down to the base, and once the base was free, we placed GIA stapler across the base, fired the stapler, removed the appendix through the periumbilical port site.  We irrigated and suctioned out the right lower and pelvic areas.  We then removed the ports under direct visualization, closed the periumbilical port site fascia with 0 Vicryl, all skin incisions with 5-0 Monocryl, and dressed with Steri-Strips.  The patient was extubated in the operating table and taken back to recovery room.  The patient tolerated the procedure well.gastroenterology, ruptured appendicitis, acute appendicitis, laparoscopic appendectomy, laparoscopic, ruptured, abdominal, peritoneal, periumbilical, appendicitis, appendectomy,
Laparoscopic Appendectomy - 2 

PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:,  Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Minimal.,PROCEDURE IN DETAIL: , The patient was prepped and draped in sterile fashion.  Infraumbilical incision was performed and taken down to the fascia.  The fascia was incised.  The peritoneal cavity was carefully entered.  Two other ports were placed in the right and left lower quadrants.  The appendix was readily identified, and the base of the appendix as well as the mesoappendix was divided with the Endo GIA stapler and brought out through the umbilical wound with the Endocatch bag.,All hemostasis was further reconfirmed.  No leakage of enteral contents was noted.  All trocars were removed under direct visualization.  The umbilical fascia was closed with interrupted 0 Vicryl sutures.  The skin was closed with 4-0 Monocryl subcuticular stitch and dressed with Steri-Strips and 4 x 4's.  The patient was extubated and taken to the recovery area in stable condition.  The patient tolerated the procedure well.gastroenterology, mesoappendix, endocatch, laparoscopic appendectomy, appendix, umbilical, laparoscopic, appendectomy, appendicitis, fascia, infraumbilical
Laparoscopic Appendectomy 

PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,OPERATIVE PROCEDURE:,  Laparoscopic appendectomy.,INTRAOPERATIVE FINDINGS: , Include inflamed, non-perforated appendix.,OPERATIVE NOTE:  ,The patient was seen by me in the preoperative holding area.  The risks of the procedure were explained.  She was taken to the operating room and given perioperative antibiotics prior to coming to the surgery.  General anesthesia was carried out without difficulty and a Foley catheter was inserted.  The left arm was tucked and the abdomen was prepped with Betadine and draped in sterile fashion.  A 5-mm blunt port was inserted infra-umbilically at the level of the umbilicus under direct vision of a 5-mm 0-degree laparoscope.  Once we were inside the abdominal cavity, CO2 was instilled to attain an adequate pneumoperitoneum.  A left lower quadrant 5-mm port was placed under direct vision and a 12-mm port in the suprapubic region.  The 5-mm scope was introduced at the umbilical port and the appendix was easily visualized.  The base of the cecum was acutely inflamed but not perforated.  I then was easily able to grasp the mesoappendix and create a window between the base of the mesoappendix and the base of the appendix.  The window is big enough to get an Endo GIA blue cartridge through it and fired across the base of the mesoappendix without difficulty.  I reloaded with a red vascular cartridge, came across the mesoappendix without difficulty.  I then placed the appendix in an Endobag and brought out through the suprapubic port without difficulty.  I reinserted the suprapubic port and irrigated out the right lower quadrant until dry.  One final inspection revealed no bleeding from the staple line.  We then removed all ports under direct vision, and there was no bleeding from the abdominal trocar sites.  The pneumoperitoneum was then deflated and the suprapubic fascial defect was closed with 0-Vicryl suture.  The skin incision was injected with 0.25% Marcaine and closed with 4-0 Monocryl suture.  Steri-strips and sterile dressings were applied.  No complications.  Minimal blood loss.  Specimen is the appendix.  Brought to the recovery room in stable condition.gastroenterology, appendix, endobag, laparoscopic appendectomy, acute appendicitis, appendectomy, umbilically, abdominal, pneumoperitoneum, laparoscopic, appendicitis, suprapubic, mesoappendix,
Ischial Ulcer Debridement 

PREOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,POSTOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,PROCEDURE PERFORMED:  ,Debridement left ischial ulcer.,ANESTHESIA: ,Local MAC.,INDICATIONS:,  This is a 27-year-old white male patient, with a history of spina bifida who underwent spinal surgery about two years ago and subsequently he has been paraplegic.  The patient has a nonhealing decubitus ulcer in the left ischial region, which is quite deep.  It appears to be right down to the bone.  MRI shows findings suggestive of osteomyelitis.  The patient is being brought to operating room for debridement of this ulcer.  Procedure, indication, and risks were explained to the patient.  Consent obtained.,PROCEDURE IN DETAIL: ,The patient was put in right lateral position and left buttock and ischial region was prepped and draped.  Examination at this time showed fair amount of chronic granulation tissue and scarred tissue circumferentially as well as the base of this decubitus ulcer.  This was sharply excised until bleeding and healthy tissue was obtained circumferentially as well as the base.  The ulcer does not appear to be going into the bone itself as there was a covering on the bone, which appears to be quite healthy, normal and bone itself appeared solid.,I did not rongeur the bone.  The deeper portion of the excised tissue was also sent for tissue cultures.  Hemostasis was achieved with cautery and the wound was irrigated with sterile saline solution and then packed with medicated Kerlix.  Sterile dressing was applied.  The patient transferred to recovery room in stable condition.gastroenterology, debridement, ischial ulcer, ischial region, osteomyelitis, paraplegia, spina bifida, decubitus ulcer
GI Consultation - 4 

CHIEF COMPLAINT:, Nausea and abdominal pain after eating.,GALL BLADDER HISTORY:, The patient is a 36 year old white female.  Patient's complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. The patient's symptoms have been present for 3 months. Complaints are relieved with lying on right side and antacids. Prior workup by referring physicians have included abdominal ultrasound positive for cholelithiasis without CBD obstruction. Laboratory studies that are elevated include total bilirubin and elevated WBC.,PAST MEDICAL HISTORY:, No significant past medical problems.,PAST SURGICAL HISTORY:, Diagnostic laparoscopic exam for pelvic pain/adhesions.,ALLERGIES:, No known drug allergies.,CURRENT MEDICATIONS:, No current medications.,OCCUPATIONAL /SOCIAL HISTORY:, Marital status: married. Patient states smoking history of 1 pack per day. Patient quit smoking 1 year ago. Admits to no history of using alcohol. States use of no illicit drugs.,FAMILY MEDICAL HISTORY:, There is no significant, contributory family medical history.,OB GYN HISTORY:, LMP: 5/15/1999. Gravida: 1. Para: 1.  Date of last pap smear: 1/15/1998.,REVIEW OF SYSTEMS:,Cardiovascular: Denies angina, MI history, dysrhythmias, palpitations, murmur, pedal edema, PND, orthopnea, TIA's, stroke, amaurosis fugax.,Pulmonary: Denies cough, hemoptysis, wheezing, dyspnea, bronchitis, emphysema, TB exposure or treatment.,Neurological: Patient admits to symptoms of seizures and ataxia.,Skin: Denies scaling, rashes, blisters, photosensitivity.,PHYSICAL EXAMINATION:,Appearance: Healthy appearing. Moderately overweight.,HEENT: Normocephalic. EOM's intact. PERRLA. Oral pharynx without lesions.,Neck: Neck mobile. Trachea is midline.,Lymphatic: No apparent cervical, supraclavicular, axillary or inguinal adenopathy.,Breast: Normal appearing breasts bilaterally, nipples everted.  No nipple discharge, skin changes.,Chest: Normal breath sounds heard bilaterally without rales or rhonchi.  No pleural rubs. No scars.,Cardiovascular: Regular heart rate and rhythm without murmur or gallop.,Abdominal: Bowel sounds are high pitched.,Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted. Range of motion is normal.,Skin: Normal color, temperature, turgor and elasticity; no significant skin lesions.,IMPRESSION DIAGNOSIS:  ,  Gall Bladder Disease. Abdominal Pain.,DISCUSSION:, Laparoscopic Cholecystectomy handout was given to the patient, reviewed with them and questions answered. The patient has given both verbal and written consent for the procedure.,PLAN:, We will proceed with Laparoscopic Cholecystectomy with intraoperative cholangiogram.,MEDICATIONS PRESCRIBED:,nan
Hepatobiliary Scan 

NUCLEAR MEDICINE HEPATOBILIARY SCAN,REASON FOR EXAM: , Right upper quadrant pain.,COMPARISONS:  ,CT of the abdomen dated 02/13/09 and ultrasound of the abdomen dated 02/13/09.,Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.,FINDINGS:,  Imaging obtained up to 30 minutes after the injection of radiopharmaceutical shows a normal hepatobiliary transfer time.  There is normal accumulation within the gallbladder.,After the injection of 2.1 mcg of intravenous cholecystic _______, the gallbladder ejection fraction at 30 minutes was calculated to be 32% (normal is greater than 35%).  The patient experienced 2/10 pain at 5 minutes after the injection of the radiopharmaceutical and the patient also complained of nausea.,IMPRESSION:,1.  Negative for acute cholecystitis or cystic duct obstruction.,2.  Gallbladder ejection fraction just under the lower limits of normal at 32% that can be seen with very mild chronic cholecystitis.gastroenterology, radiopharmaceutical, gallbladder ejection fraction, nuclear medicine hepatobiliary, hepatobiliary scan, quadrant, nuclear, technetium, choletec, ejection, fraction, cholecystitis, scan, abdomen, injection, gallbladder, hepatobiliary, medicine