falan42/nurse_detection huggingface dataset:
Cystoscopy 

PREOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,POSTOPERATIVE DIAGNOSIS: , Bilateral vesicoureteral reflux with right reflux nephropathy after Deflux injection.,PROCEDURE:,  Cystoscopy under anesthesia, bilateral HIT/STING with Deflux under general anesthetic.,ANESTHESIA: , General inhalational anesthetic.,FLUIDS RECEIVED: , 250 mL crystalloids.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,SPECIMENS:,  Urine sent for culture.,ABNORMAL FINDINGS:  ,Gaping ureteral orifices, right greater than left, with Deflux not in or near the ureteral orifices.  Right ureteral orifice was HIT with 1.5 mL of Deflux and left with 1.2 mL of Deflux.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 4-1/2-year-old boy with history of reflux nephropathy and voiding and bowel dysfunction.  He has had a STING procedure performed but continues to have reflux bilaterally.  Plan is for another injection.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room where surgical consent, operative site, and patient identification were verified.  Once he was anesthetized, IV antibiotics were given.  He was then placed in a lithotomy position with adequate padding of his arms and legs.  His urethra was calibrated to 12-French with a bougie a boule.  A 9.5-French cystoscope was used and the offset system was then used.  His urethra was normal without valves or strictures.  His bladder was fairly normal with minimal trabeculations but no cystitis noted.  Upon evaluation, the patient's right ureteral orifice was found to be remarkably gaping and the Deflux that was present was not in or near ureteral orifice but it was inferior to it below the trigone.  This was similarly found on the left side where the Deflux was not close to the orifice as well.  It was slightly more difficult because of the amount impacted upon our angle for injection.  We were able to ultimately get the Deflux to go ahead with HIT technique on the right into the ureter itself to inject a total of 1.5 mL to include the HIT technique as well as the ureteral orifice itself on the right and left sides and some on the uppermost aspect.  Once we injected this, we ran the irrigant over the orifice and it no longer fluttered and there was no bleeding.  Similar procedure was done on the left.  This was actually more difficult as the Deflux injection from before displaced the ureter slightly more laterally but again HIT technique was performed.  There was some mild bleeding and Deflux was used to stop this as well and again no evidence of fluttering of the ureteral orifice after injection.  At the end of the procedure, the irrigant was drained and 2% lidocaine jelly was instilled in the urethra.  The patient tolerated the procedure well and was in stable condition upon transfer to Recovery.  A low-dose of IV Toradol was given at the end of the procedure as well.urology, bilateral vesicoureteral reflux, deflux, sting procedure, hit technique, cystoscopy under anesthesia, hit/sting with deflux, vesicoureteral reflux, ureteral orifices, vesicoureteral, cystoscopy, urethra, hit/sting, ureteral,
Cystourethroscopy & TURP 

PREOPERATIVE DIAGNOSES:,1.  Benign prostatic hypertrophy.,2.  Urinary retention.,POSTOPERATIVE DIAGNOSES:,1.  Benign prostatic hypertrophy.,2.  Urinary retention.,PROCEDURE PERFORMED:,1.  Cystourethroscopy.,2.  Transurethral resection of prostate (TURP).,ANESTHESIA:  ,Spinal.,DRAIN: , A #24 French three-way Foley catheter.,SPECIMENS: , Prostatic resection chips.,ESTIMATED BLOOD LOSS:  ,150 cc.,DISPOSITION:  ,The patient was transferred to the PACU in stable condition.,INDICATIONS AND FINDINGS:  ,This is an 84-year-old male with history of BPH and subsequent urinary retention with failure of trial of void, scheduled for elective TURP procedure.,FINDINGS: , At the time of surgery, cystourethroscopy revealed trilobar enlargement of the prostate with prostatic varices of the median lobe.  Cystoscopy showed a few cellules of the bladder with no obvious bladder tumors noted.,DESCRIPTION OF PROCEDURE: , After informed consent was obtained, the patient was moved to operating room and spinal anesthesia was induced by the Department of Anesthesia.  The patient was prepped and draped in the normal sterile fashion and a #21 French cystoscope inserted into urethra and into the bladder.  Cystoscopy performed with the above findings.  Cystoscope was removed.  A #27 French resectoscope with a #26 cutting loop was inserted into the bladder.  Verumontanum was identified as a landmark and systematic transurethral resection of the prostate tissue was undertaken in an circumferential fashion with good resection of tissue completed.  ________ irrigator was used to evacuate the bladder of prostatic chips.  Resectoscope was then inserted and any residual chips were removed in piecemeal fashion with a resectoscope loop.  Any obvious bleeding from the prostatic fossa was controlled with electrocautery.  Resectoscope was removed.  A #24 French three-way Foley catheter inserted into the urethra and into the bladder.  Bladder was irrigated and connected to three-way irrigation.  The patient was cleaned and sent to recovery in stable condition to be admitted overnight for continuous bladder irrigation and postop monitoring.urology, urinary retention, cystourethroscopy, transurethral resection of prostate, foley catheter, bph, cystoscopy, bladder, benign prostatic hypertrophy, turp,
Cystopyelogram - 1 

PREOPERATIVE DIAGNOSIS: , Gross hematuria.,POSTOPERATIVE DIAGNOSIS:  ,Gross hematuria.,OPERATIONS:  ,Cystopyelogram, clot evacuation, transurethral resection of the bladder tumor x2 on the dome and on the left wall of the bladder.,ANESTHESIA: , Spinal.,FINDINGS:  ,Significant amount of bladder clots measuring about 150 to 200 mL, two cupful of clots were removed.  There was papillary tumor on the left wall right at the bladder neck and one on the right dome near the bladder neck on the right side.  The right ureteral opening was difficult to visualize, the left one was normal.,BRIEF HISTORY: , The patient is a 78-year-old male with history of gross hematuria and recurrent UTIs.  The patient had hematuria.  Cystoscopy revealed atypical biopsy.  The patient came in again with gross hematuria.  The first biopsy was done about a month ago.  The patient was to come back and have repeat biopsies done, but before that came into the hospital with gross hematuria.  The options of watchful waiting, removal of the clots and biopsies were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT and PE were discussed.  Morbidity and mortality of the procedure were discussed.  Consent was obtained from the daughter-in-law who has the power of attorney in Florida.,DESCRIPTION OF PROCEDURE:  ,The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in the dorsal lithotomy position.  The patient was prepped and draped in the usual sterile fashion.  The patient had been off of the Coumadin for about 4 days and INR had been reversed.  The patient has significant amount of clot upon entering the bladder.  There was a tight bladder neck contracture.  The prostate was not enlarged.  Using ACMI 24-French sheath, using Ellick irrigation about 2 cupful of clots were removed.  It took about half an hour to just remove the clots.  After removing the clots, using 24-French cutting loop resectoscope, tumor on the left upper wall near the dome or near the 2 o'clock position was resected.  This was lateral to the left ureteral opening.  The base was coagulated for hemostasis.  Same thing was done at 10 o'clock on the right side where there was some tumor that was visualized.  The back wall and the rest of the bladder appeared normal.  Using 8-French cone-tip catheter, left-sided pyelogram was normal.  The right-sided pyelogram was very difficult to obtain and there was some mucosal irritation from the clots.  The contrast did go up to what appeared to be the right ureteral opening, but the mucosa seemed to be very much irritated and it was very difficult to actually visualize the opening.  A little bit of contrast went out, but the force was not made just to avoid any secondary stricture formation.  The patient did have CT with contrast, which showed that the kidneys were normal.  At this time, a #24 three-way irrigation was started.  The patient was brought to Recovery room in stable condition.urology, clot evacuation, transurethral resection, bladder tumor, bladder neck, gross hematuria, bladder, cystopyelogram, hematuria, clots,
Cystoscopy & Bladder Biopsy 

PREOPERATIVE DIAGNOSIS:,  History of bladder tumor with abnormal cytology and areas of erythema.,POSTOPERATIVE DIAGNOSIS: , History of bladder tumor with abnormal cytology and areas of erythema.,PROCEDURE PERFORMED:,1.  Cystoscopy.,2.  Bladder biopsy with fulguration.,ANESTHESIA: , IV sedation with local.,SPECIMEN: , Urine cytology and right lateral wall biopsies.,PROCEDURE:,  After the consent was obtained, the patient was brought to the operating room and given IV sedation.  He was then placed in dorsal lithotomy position and prepped and draped in standard fashion.  A #21 French cystoscope was then used to visualized the entire urethra and bladder.  There was noted to be a narrowing of the proximal urethra, however, the scope was able to pass through.  The patient was noted to have a previously resected prostate.  On visualization of the bladder, the patient did have areas of erythema on the right as well as the left lateral walls, more significant on the right side.  The patient did have increased vascularity throughout the bladder.  The ________ two biopsies of the right lateral wall and those were sent for pathology.  The Bovie cautery was then used to cauterize the entire area of the biopsy as well as surrounding erythema.  Bovie was also utilized to cauterize the areas of erythema on the left lateral wall.  No further bleeding was identified.  The bladder was drained and the cystoscope was removed.  The patient tolerated the procedure well and was transferred to the recovery room.,He will have his defibrillator restarted and will followup with Dr. X in approximately two weeks for the result.  He will be discharged home with antibiotics as well as pain medications.  He is to restart his Coumadin not before Sunday.urology, bladder biopsy with fulguration, iv sedation, bladder biopsy, bladder tumor, abnormal cytology, bladder, cystoscopy, tumor, cytology, erythema,
Cystopyelogram 

PREOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,POSTOPERATIVE DIAGNOSIS: , Left distal ureteral stone.,PROCEDURE PERFORMED: , Cystopyelogram, left ureteroscopy, laser lithotripsy, stone basket extraction, stent exchange with a string attached.,ANESTHESIA:,  LMA.,EBL: , Minimal.,FLUIDS: , Crystalloid.  The patient was given antibiotics, 1 g of Ancef and the patient was on oral antibiotics at home.,BRIEF HISTORY: , The patient is a 61-year-old female with history of recurrent uroseptic stones.  The patient had stones x2, 1 was already removed, second one came down, had recurrent episode of sepsis, stent was placed.  Options were given such as watchful waiting, laser lithotripsy, shockwave lithotripsy etc.  Risks of anesthesia, bleeding, infection, pain, need for stent, and removal of the stent were discussed.  The patient understood and wanted to proceed with the procedure.,DETAILS OF THE PROCEDURE: , The patient was brought to the OR.  Anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in usual sterile fashion.  A 0.035 glidewire was placed in the left system.  Using graspers, left-sided stent was removed.  A semirigid ureteroscopy was done.  A stone was visualized in the mid to upper ureter.  Using laser, the stone was broken into 5 to 6 small pieces.  Using basket extraction, all the pieces were removed.  Ureteroscopy all the way up to the UPJ was done, which was negative.  There were no further stones.  Using pyelograms, the rest of the system appeared normal.  The entire ureter on the left side was open and patent.  There were no further stones.  Due to the edema and the surgery, plan was to leave the stent attached to the string and the patient was to pull the string in about 24 hours.  Over the 0.035 glidewire, a 26 double-J stent was placed.  There was a nice curl in the kidney and one in the bladder.  The patient tolerated the procedure well.  Please note that the string was kept in place and the patient was to remove the stent the next day.  The patient's family was instructed how to do so.  The patient had antibiotics and pain medications at home.  The patient was brought to recovery room in a stable condition.urology, laser lithotripsy, shockwave lithotripsy, double-j stent, distal ureteral stone, ureteral stone, basket extraction, cystopyelogram, laser, lithotripsy, stones, string, ureteroscopy, stone, stent,
Cystolithalopaxy 

PREOPERATIVE DIAGNOSES:,1.  Prostatism.,2.  Bladder calculus.,OPERATION:,  Holmium laser cystolithalopaxy.,POSTOPERATIVE DIAGNOSES:,1.  Prostatism.,2.  Bladder calculus.,ANESTHESIA:  ,General.,INDICATIONS:,  This is a 62-year-old male diabetic and urinary retention with apparent neurogenic bladder and intermittent self-catheterization, recent urinary tract infections.  The cystoscopy showed a large bladder calculus, short but obstructing prostate.  He comes in now for transurethral resection of his prostate and holmium laser cystolithotripsy.,He is a diabetic with obesity.,LABORATORY DATA:  ,Includes urinalysis showing white cells too much to count, 3-5 red cells, occasional bacteria.  He had a serum creatinine of 1.2, sodium 138, potassium 4.6, glucose 190, calcium 9.1.  Hematocrit 40.5, hemoglobin 13.8, white count 7,900.,PROCEDURE: , The patient was satisfactorily given general anesthesia.  Prepped and draped in the dorsal lithotomy position.  A 27-French Olympus rectoscope was passed via the urethra into the bladder.  The bladder, prostate, and urethra were inspected.  He had an obstructing prostate.  He had marked catheter reaction in his bladder.  He had a lot of villous changes, impossible to tell from frank tumor.  He had a huge bladder calculus.  It was white and round.,I used the holmium laser with the largest fiber through the continuous flow resectoscope and sheath, and broke up the stone, breaking up approximately 40 grams of stone.  There was still stone left at the end of the procedure.  Most of the chips that could be irrigated out of the bladder were irrigated out using Ellik.,Then the scope was removed and a 24-French 3-way Foley catheter was passed via the urethra into the bladder.,The plan is to probably discharge the patient in the morning and then we will get a KUB.  We will probably bring him back for a second stage cystolithotripsy, and ultimately do a TURP.  We broke up the stone for over an hour, and my judgment continuing with litholapaxy transurethrally over an hour begins to markedly increase the risk to the patient.urology, prostatism, holmium laser cystolithalopaxy, urinary tract infections, holmium laser, bladder calculus, bladder, cystolithalopaxy, diabetic, urethra, urinary, catheterization, stone, calculus, prostate,
Cystoscopy & Visual Urethrotomy 

CYSTOSCOPY & VISUAL URETHROTOMY,OPERATIVE NOTE:,  The patient was placed in the dorsal lithotomy position and prepped and draped in the usual manner under satisfactory general anesthesia.  A Storz urethrotome sheath was inserted into the urethra under direct vision.  Visualization revealed a stricture in the bulbous urethra.  This was intubated with a 0.038 Teflon-coated guidewire, and using the straight cold urethrotomy knife, it was incised to 12:00 to allow free passage of the scope into the bladder.  Visualization revealed no other lesions in the bulbous or membranous urethra.  Prostatic urethra was normal for age.  No foreign bodies, tumors or stones were seen within the bladder.  Over the guidewire, a #16-French Foley catheter with a hole cut in the tip with a Cook cutter was threaded over the guidewire and inserted into the bladder and inflated with 10 mL of sterile water.,He was sent to the recovery room in stable condition.urology, cystoscopy, foley catheter, storz urethrotome sheath, teflon-coated guidewire, urethrotomy, bladder, bulbous urethra, dorsal lithotomy position, knife, membranous urethra, cystoscopy & visual urethrotomy, visual urethrotomyNOTE,: 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.,
Circumcision - Newborn  

PROCEDURE: , Newborn circumcision.,INDICATIONS: , Parental preference.,ANESTHESIA:,  Dorsal penile nerve block.,DESCRIPTION OF PROCEDURE:,  The baby was prepared and draped in a sterile manner.  Lidocaine 1% 4 mL without epinephrine was instilled into the base of the penis at 2 o'clock and 10 o'clock.  The penile foreskin was removed using a XXX Gomco.  Hemostasis was achieved with minimal blood loss.  There was no sign of infection.  The baby tolerated the procedure well.  Vaseline was applied to the penis, and the baby was diapered by nursing staff.urology, nerve block, newborn circumcision, foreskin, gomco, penis, circumcision, newborn, penile
Circumcision - Infant 

PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA:  ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents.  The risks are infection, hemorrhage, and meatal stenosis.  The benefits are ease of care and cleanliness and fewer urinary tract infections.  The parents understand this and have signed a permit.,FINDINGS: , The infant is without evidence of hypospadias or chordee prior to the procedure.,TECHNIQUE:  ,The infant was given a dorsal penile block with 1% lidocaine without epinephrine using a tuberculin syringe and 0.5 cc of lidocaine was delivered subcutaneously at 10:30 and at 1:30 o'clock at the dorsal base of the penis.,The infant was prepped then with Betadine and draped with a sterile towel in the usual manner.  Clamps were placed at 10 o'clock and 2 o'clock and the adhesions between the glans and mucosa were instrumentally lysed.  Dorsal hemostasis was established and a dorsal slit was made.  The foreskin was fully retracted and remaining adhesions between the glans and mucosa were manually lysed.  The infant was fitted with a XX-cm Plastibell.  The foreskin was retracted around the Plastibell and circumferential hemostasis was established.  The excess foreskin was removed with scissors and the infant tolerated the procedure well with a minimum amount of blood loss.  Instructions for continuing care are to watch for any evidence of hemorrhage or urination and the parents are instructed in the care of the circumcised penis.urology, dorsal slit, hypospadias, chordee, epinephrine, hemorrhage, penis, adhesions, circumcision, phallus, lidocaine, foreskin, infant
Circumcision - Child  

PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion.  The area of the penis and scrotum were prepared with povidone iodine solution.  The area was draped with sterile drapes, and the remainder of the procedure was done with sterile procedure.  A dorsal penile block was done using 2 injections of 0.3 cc each, 1% plain lidocaine.  A dorsal slit was made, and the prepuce was dissected away from the glans penis.  A ** Gomco clamp was properly placed for 5 minutes.  During this time, the foreskin was sharply excised using a #10 blade.  With removal of the clamp, there was a good cosmetic outcome and no bleeding.  The child appeared to tolerate the procedure well.  Care instructions were given to the parents.urology, circumstraint, dorsal slit, gomco clamp, circumcision, childNOTE,: 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.,
Consult - Prostate Cancer 

CONSULT FOR PROSTATE CANCER,The patient returned for consultation for his newly diagnosed prostate cancer.  The options including radical prostatectomy with or without nerve sparing were discussed with him with the risks of bleeding, infection, rectal injury, impotence, and incontinence.  These were discussed at length.  Alternative therapies including radiation therapy; either radioactive seed placement, conformal radiation therapy, or the HDR radiation treatments were discussed with the risks of bladder, bowel, and rectal injury and possible impotence were discussed also.  There is a risk of rectal fistula.  Hormonal therapy is usually added to the radiation therapy options and this has the risk of osteoporosis, gynecomastia, hot flashes and impotency.  Potency may not recover after the hormone therapy has been completed.  Cryosurgery was discussed with the risks of urinary retention, stricture formation, incontinence and impotency.  There is a risk of rectal fistula.  He would need to have a suprapubic catheter for about two weeks and may need to learn self-intermittent catheterization if he cannot void adequately.  Prostate surgery to relieve obstruction and retention after radioactive seeds or cryosurgery has a higher risk of urinary incontinence.  Observation therapy was discussed with him in addition.  I answered all questions that were put to me and I think he understands the options that are available.  I spoke with the patient for over 60 minutes concerning these options.urology, prostate cancer, cryosurgery, hdr radiation, prostate surgery, bladder, bleeding, bowel, consultation, impotence, incontinence, infection, prostatectomy, radiation therapy, radical, rectal, rectal fistula, rectal injury, prostate cancer consult, cancer, radiation, prostateNOTE,: 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.,