falan42/nurse_detection huggingface dataset:
Tessio Catheter Insertion 

OPERATIONS/PROCEDURES,1.  Insertion of right internal jugular Tessio catheter.,2.  Placement of left wrist primary submental arteriovenous fistula.,PROCEDURE IN DETAIL: , The patient was brought to the operating room and placed in the supine position.  Adequate general endotracheal anesthesia was induced.  Appropriate monitoring lines were placed.  The right neck, chest and left arm were prepped and draped in a sterile fashion.  A small incision was made at the top of the anterior jugular triangle in the right neck.  Through this small incision, the right internal jugular vein was punctured and a guidewire was placed.  It was punctured a 2nd time, and a 2nd guidewire was placed.  The Tessio catheters were assembled.  They were measured for length.  Counter-incisions were made on the right chest.  They were then tunneled through these lateral chest wall incisions to the neck incision, burying the Dacron cuffs.  They were flushed with saline.  A suture was placed through the guidewire, and the guidewire and dilator were removed.  The arterial catheter was then placed through this, and the tear-away introducer was removed.  The catheter aspirated and bled easily.  It was flushed with saline and capped.  This was repeated with the venous line.  It also aspirated easily and was flushed with saline and capped.  The neck incision was closed with a 4-0 Tycron, and the catheters were sutured at the exit sites with 4-0 nylon.  Dressings were applied.  An incision was then made at the left wrist.  The basilic vein was dissected free, as was the radial artery.  Heparin was given, 50 mg.  The radial artery was clamped proximally and distally with a bulldog.  It was opened with a #11 blade and Potts scissors, and stay sutures of 5-0 Prolene were placed.  The vein was clipped distally, divided and spatulated for anastomosis.  It was sutured to the radial artery with a running 7-0 Prolene suture.  The clamps were removed.  Good flow was noted through the artery.  Protamine was given, and the wound was closed with interrupted 3-0 Dexon subcutaneous and a running 4-0 Dexon subcuticular on the skin.  The patient tolerated the procedure well.surgery, internal jugular tessio catheter, arteriovenous, fistula, submental, tunneled, tessio catheter, internal jugular, radial artery, tessio, jugular, artery, catheterNOTE,: 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.
Thoracentesis 

PREOPERATIVE DIAGNOSIS:,  Left pleural effusion.,POSTOPERATIVE DIAGNOSIS:,  Left hemothorax.,PROCEDURE: , Thoracentesis.,PROCEDURE IN DETAIL:,  After obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department.  His left back was prepped and draped in the usual fashion.  Xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 mL blood.  This blood was nonclotting and it was tested twice.  Halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s.  Therefore, we laid him off his right side while keeping the chest catheter in place.  At that time, I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.,Overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not.surgery, pleural effusion, hemothorax, thoracentesis, chest,
Teeth Extraction & I&D - 1 

PREOPERATIVE DIAGNOSES: , Carious teeth #2 and #19 and left mandibular dental abscess.,POSTOPERATIVE DIAGNOSES:,  Carious teeth #2 and #19 and left mandibular dental abscess.,PROCEDURES:,  Extraction of teeth #2 and #19 and incision and drainage of intraoral and extraoral of left mandibular dental abscess.,ANESTHESIA: , General, oral endotracheal.,COMPLICATIONS: , None.,DRAINS: , Penrose 0.25 inch intraoral and vestibule and extraoral.,CONDITION:,  Stable to PACU.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room, placed on the table in the supine position and after demonstration of an adequate plane of general anesthesia via the oral endotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  In addition, the extraoral area on the left neck was prepped with Betadine and draped accordingly.  Gauze throat pack was placed and local anesthetic was administered in the left lower quadrant, total of 3.4 mL of lidocaine 2% with 1:100,000 epinephrine and Marcaine 1.7 mL of 0.5% with 1:200,000 epinephrine.  An incision was made with #15 blade in the left submandibular area through the skin and blunt dissection was accomplished with curved mosquito hemostat to the inferior border of the mandible.  No purulent drainage was obtained.  The 0.25 inch Penrose drain was then placed in the extraoral incision and it was secured with 3-0 silk suture.  Moving to the intraoral area, periosteal elevator was used to elevate the periosteum from the buccal aspect of tooth #19.  The area did not drain any purulent material.  The carious tooth #19 was then extracted by elevator and forceps extraction.  After the tooth was removed, the 0.25 inch Penrose drain was placed in a subperiosteal fashion adjacent to the extraction site and secured with 3-0 silk suture.  The tube was then repositioned to the left side allowing access to the upper right quadrant where tooth #2 was then extracted by routine elevator and forceps extraction.  After the extraction, the throat pack was removed.  An orogastric tube was then placed by Dr. X, and stomach contents were suctioned.  The pharynx was then suctioned with the Yankauer suction.  The patient was awakened, extubated, and taken to the PACU in stable condition.surgery, yankauer suction, orogastric tube, carious teeth, penrose drain, forceps extraction, dental abscess, incision, elevator, mandibular, dental, abscess, teeth, intraoral, extraction, drainage,
Teeth Extraction & I&D 

PREOPERATIVE DIAGNOSES,1.  Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2.  Left mandibular vestibular abscess.,POSTOPERATIVE DIAGNOSES,1.  Carious teeth #2, #5, #12, #15, #18, #19, and #31.,2.  Left mandibular vestibular abscess.,PROCEDURE,1.  Extraction of teeth #2.  #5, #12, #15, #18, #19, #31.,2.  Incision and drainage (I&D) of left mandibular vestibular abscess adjacent to teeth #18 and #19.,ANESTHESIA:,  General nasotracheal.,COMPLICATIONS: , None.,DRAIN:,  Quarter-inch Penrose drain place in left mandibular vestibule adjacent to teeth #18 and #19, secured with 3-0 silk suture.,CONDITION:,  The patient was taken to the PACU in stable condition.,INDICATION:,  Patient is a 32-year-old female who was admitted yesterday 03/04/10 with left facial swelling and a number of carious teeth which were also abscessed particularly those on the lower left and this morning, the patient was brought to the operating room for extraction of the carious teeth and incision and drainage of left vestibular abscess.,DESCRIPTION OF PROCEDURE:,  Patient was brought to the operating room, placed on the table in a supine position, and after demonstration of an adequate plane of general anesthesia via the nasotracheal route, patient was prepped and draped in the usual fashion for an intraoral procedure.  A gauze throat pack was placed and local anesthetic was administered in all four quadrants, a total of 6.8 mL of lidocaine 2% with 1:100,000 epinephrine, and 3.6 mL of Marcaine 0.5% with 1:200,000 epinephrine.  The area in the left vestibular area adjacent to the teeth #18 and #19 was aspirated with 5 cc syringe with an 18-guage needle and approximately 1 mL of purulent material was aspirated.  This was placed on the culture medium in the aerobic and anaerobic culture tubes and the tubes were then sent to the lab.  An incision was then made in the left mandibular vestibule adjacent to teeth #18 and #19.  The area was bluntly dissected with a curved hemostat and a small amount of approximately 3 mL of purulent material was drained.  Penrose drain was then placed using a curved hemostat.  The drain was secured with 3-0 silk suture.  The extraction of the teeth was then begun on the left side removing teeth #12, #15, #18 and #19 with forceps extraction, then moving to the right side teeth #2, #5, and #31 were removed with forceps extraction uneventfully.  After completion of the procedure, the throat pack was removed, the pharynx was suctioned.  The anesthesiologist then placed an orogastric tube and suctioned approximately 10 cc of stomach contents with the nasogastric tube.  The nasogastric tube was then removed.  Patient was then extubated and taken to the PACU in stable condition.surgery, mandibular, vestibular, abscess, throat pack, purulent material, forceps extraction, nasogastric tube, carious teeth, incision, teeth, nasogastric, carious, extraction
Teeth (full-mouth) Extraction 

PREOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,POSTOPERATIVE DIAGNOSIS:, Nonrestorable teeth.,PROCEDURE:, Full-mouth extraction of tooth #3,5,6, 7, 8, 9, 10, 11, 12, 13, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 31, and alveoloplasty in all four quadrants.,ANESTHESIA:,  Nasotracheal general anesthesia.,IV FLUIDS:, A 700 mL of crystalloid.,EBL:, Minimum.,URINE:, Not recorded.,COMPLICATIONS:, None.,CONDITION:, Good.,DISPOSITION:,  The patient was extubated in OR, transferred to PACU for recovery and will be transferred for 23-hour observation and discharged on subsequent day.,BRIEF HISTORY OF THE PATIENT:, Indicated the patient for surgery.  The patient is a 41-year-old white female with multiple grossly decaying nonrestorable teeth.  After discussing treatment options, she decided she will like to have extraction of remaining teeth with subsequent placement of upper and lower complete dentures.,PAST MEDICAL HISTORY:, Positive for a narcotic abuse, presently on methadone treatment, hepatitis C, and headaches.,PAST SURGICAL HISTORY:, C-section x2.,MEDICATIONS,Right now include:,1.  Methadone.,2.  Beta-blocker.,3.  Xanax.,4.  Norco.,5.  Clindamycin.,ALLERGIES:, THE PATIENT IS ALLERGIC TO PENICILLIN.,PROCEDURE IN DETAIL:, The patient was greeted in preoperative holding area, subsequently transferred to OR #17 where the patient was intubated with anesthesia staff present.  The patient was prepped and draped in sterile fashion.  Local anesthesia consisting of 1% lidocaine and 1:100,000 epinephrine, total 15 mL were injected into the maxillomandible.  Throat pack was placed in the mouth after a thorough suction.,A full-thickness mucoperiosteal flap was reflected from the upper right to the upper left, tooth number 3,5,6,7,8,9,10,11,12,13, and 14 and were elevated and delivered.  Extraction sites were thoroughly curettaged and irrigated.  Bony undercuts were removed then smoothed with rongeurs and bone saw.  After thorough irrigation, the postsurgical site closed in a running fashion with 3-0 chromic sutures.  Subsequently, a full-thickness mucoperiosteal flap was reflected in the mandible, tooth numbers 31, 28, 27, 26, 25, 24, 23, 22, 21, 20, and 19 were elevated and delivered with simple forceps extractions.  Bony undercuts were removed with rongeurs and smoothed with bone saw.,Extraction sites were thoroughly irrigated and curettaged.  Wound was closed in continuous fashion 3-0 chromic.  After adequate hematosis was achieved, 0.5% Marcaine and 1:200,000 epinephrine was injected in the maxillomandible thus to heal to aid in hematosis and pain control.  Total of 8 mL were used.  Throat pack was subsequently removed.  Orogastric tube was passed to suction out the stomach.,The patient was subsequently extubated in OR and transferred to PACU for recovery.  The patient would be placed in 23-hour observation.nan
Synovectomy - Partial 

PREOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,POSTOPERATIVE DIAGNOSIS: , Septic left total knee arthroplasty.,OPERATION PERFORMED: , Arthroscopic irrigation and debridement of same with partial synovectomy.,ANESTHESIA:,  LMA.,ESTIMATED BLOOD LOSS:,  Minimal.,COMPLICATIONS: , None.,DRAINS:,  None.,INDICATIONS:,  The patient is an 81-year-old female, who is approximately 10 years status post total knee replacement performed in another state, who presented a couple of days ago to the office with worsening pain without injury and whose symptoms have been present for approximately a month following a possible urinary tract infection.  The patient' knee was aspirated in the office and cultures were positive for Escherichia coli.  She presents for operative therapy.,DESCRIPTION OF OPERATION: , After obtaining informed consent and the administration of antibiotics since her cultures had already been obtained, the patient was taken to the operating room and following satisfactory induction and the patient was placed on the table in supine position.  The left upper extremity was prepped and draped without a tourniquet.  The knee was injected with 30 mL of normal saline and standard arthroscopy portals were created.  The arthroscopy was inserted and a complete diagnostic was performed.  Arthroscopic pictures were taken throughout the procedure.  The knee was copiously irrigated with 9 L of irrigant.  A partial synovectomy was performed in all compartments.  Minimal amount of polyethylene wear was noted.  The total knee components were identified arthroscopically for future revision surgery.  The knee was then drained and the arthroscopic instruments were removed.  The portals were closed with 4-0 nylon and local anesthetic was injected.  A sterile dressing was applied and the patient was placed in a knee immobilizer, awakened from anesthesia and transported to the recovery room in stable condition and tolerated the procedure well.surgery, total knee arthroplasty, arthroscopic irrigation, debridement, partial synovectomy, knee, arthroscopic, irrigation, arthroscopy, synovectomy,
Suction, Dilation, & Curettage 

PREOPERATIVE DIAGNOSIS: , Missed abortion.,POSTOPERATIVE DIAGNOSIS:  ,Missed abortion.,PROCEDURE PERFORMED: , Suction, dilation, and curettage.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:,  50 mL.,COMPLICATIONS: , None.,FINDINGS: , Products of conception consistent with a 6-week intrauterine pregnancy.,INDICATIONS: , The patient is a 28-year-old gravida 4, para 3 female at 13 weeks by her last menstrual period and 6 weeks by an ultrasound today in the emergency room who presents with heavy bleeding starting today.  A workup done in the emergency room revealed a beta-quant level of 1931 and an ultrasound showing an intrauterine pregnancy with a crown-rump length consistent with a 6-week and 2-day pregnancy.  No heart tones were visible.  On examination in the emergency room, a moderate amount of bleeding was noted.,Additionally, the cervix was noted to be 1 cm dilated.  These findings were discussed with the patient and options including surgical management via dilation and curettage versus management with misoprostol versus expected management were discussed with the patient.  After discussion of these options, the patient opted for a suction, dilation, and curettage.  The patient was described to the patient in detail including risks of infection, bleeding, injury to surrounding organs including risk of perforation.  Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where spinal anesthesia was administered without difficulty.  The patient was prepped and draped in usual sterile fashion in lithotomy position.  A weighted speculum was placed.  The anterior lip of the cervix was grasped with a single tooth tenaculum.  At this time, a 7-mm suction curettage was advanced into the uterine cavity without difficulty and was used to suction contents of the uterus.  Following removal of the products of conception, a sharp curette was advanced into the uterine cavity and was used to scrape the four walls of the uterus until a gritty texture was noted.  At this time, the suction curette was advanced one additional time to suction any remaining products.  All instruments were removed.  Hemostasis was visualized.  The patient was stable at the completion of the procedure.  Sponge, lap, and instrument counts were correct.surgery, missed abortion, intrauterine pregnancy, dilation, curettage, suction, intrauterine
Surgical Closure of Gastrostomy 

PREOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,POSTOPERATIVE DIAGNOSIS: , Gastrostomy (gastrocutaneous fistula).,OPERATION PERFORMED: , Surgical closure of gastrostomy.,ANESTHESIA: , General.,INDICATIONS: , This 1-year-old child had a gastrostomy placed due to feeding difficulties.  Since then, he has reached a point where he is now eating completely by mouth and no longer needed the gastrostomy.  The tube was, therefore, removed, but the tract has not shown signs of spontaneous closure.  He, therefore, comes to the operating room today for surgical closure of his gastrostomy.,OPERATIVE PROCEDURE: , After the induction of general anesthetic, the abdomen was prepped and draped in the usual manner.  An elliptical incision was made around the gastrostomy site and carried down through skin and subcutaneous tissue with sharp dissection.  The tract and the stomach were freed.  Stay sutures were then placed on either side of the tract.  The tract was amputated.  The intervening stomach was then closed with interrupted #4-0 Lembert, Nurolon sutures.  The fascia was then closed over the stomach using #3-0 Vicryl sutures.  The skin was closed with #5-0 subcuticular Monocryl.  A dressing was applied, and the child was awakened and taken to the recovery room in satisfactory condition.surgery, gastrocutaneous fistula, nurolon, closure of gastrostomy, feeding difficulties, surgical closure, gastrostomy
Subxiphoid Pericardial Window - 1 

OPERATION: , Subxiphoid pericardial window.,ANESTHESIA: , General endotracheal anesthesia.,OPERATIVE PROCEDURE IN DETAIL:  ,After obtaining informed consent from the patient's family, including a thorough explanation of the risks and benefits of the aforementioned procedure, patient was taken to the operating room and general endotracheal anesthesia was administered.  Next, the neck and chest were prepped and draped in the standard surgical fashion.  A #10-blade scalpel was used to make an incision in the area of the xiphoid process.  Dissection was carried down to the level of the fascia using Bovie electrocautery.  The xiphoid process was elevated, and the diaphragmatic attachments to it were dissected free.  Next the pericardium was identified.,The pericardium was opened with Bovie electrocautery.  Upon entering the pericardium, serous fluid was expressed.  In total, ** cc of fluid was drained.  A pericardial biopsy was obtained.  The fluid was sent off for cytologic examination as well as for culture.  A #24 Blake chest drain was brought out through the skin and placed in the posterior pericardium.  The fascia was closed with #1 Vicryl followed by 2-0 Vicryl followed by 4-0 PDS in a running subcuticular fashion.  Sterile dressing was applied.surgery, xiphoid process, pericardium, subxiphoid pericardial window, endotracheal anesthesia, bovie electrocautery, subxiphoid pericardial, bovie, electrocautery, subxiphoid, window, pericardial,
Subxiphoid Pericardiotomy 

PREOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,POSTOPERATIVE DIAGNOSIS: , Symptomatic pericardial effusion.,PROCEDURE PERFORMED:,  Subxiphoid pericardiotomy.,ANESTHESIA:,  General via ET tube.,ESTIMATED BLOOD LOSS: , 50 cc.,FINDINGS:,  This is a 70-year-old black female who underwent a transhiatal esophagectomy in November of 2003.  She subsequently had repeat chest x-rays and CT scans and was found to have a moderate pericardial effusion.  She had the appropriate inflammatory workup for pericardial effusion, however, it was nondiagnostic.  Also, during that time, she had become significantly more short of breath.  A dobutamine stress echocardiogram was performed, which was negative with the exception of the pericardial effusions.  She had no tamponade physiology.,INDICATION FOR THE PROCEDURE: , For therapeutic and diagnostic management of this symptomatic pericardial effusion.  Risks, benefits, and alternative measures were discussed with the patient.  Consent was obtained for the above procedure.,PROCEDURE: , The patient was prepped and draped in the usual sterile fashion.  A 4 cm incision was created in the midline above the xiphoid.  Dissection was carried down through the fascia and the xiphoid was resected.  The sternum was retracted superiorly the pericardium was identified and pericardial fat was cleared off the pericardium.  An #0 silk suture was then placed into the pericardium with care taken not to enter the underlying heart.,This suture was used to retract the pericardium and the pericardium was nicked with #15 blade under direct visualization.  Serous fluid exited through the pericardium and was sent for culture, cytology, and cell count etc.  A section of pericardium was taken approximately 2 cm x 2 cm x 2 cm and was removed.  The heart was visualized and appeared to be contracting well with no evidence of injury to the heart.  The pericardium was then palpated.  There was no evidence of studding.  A right angle chest tube was then placed in the pericardium along the diaphragmatic of the pericardium and then brought out though a small skin incision in the epigastrium.  It was sewn into place with #0 silk suture.  There was some air leak of the left pleural cavity, so a right angle chest tube was placed in the left pleural cavity and brought out through a skin nick in the epigastrium.  It was sewn in the similar way to the other chest tube.  Once again, the area was inspected and found to be hemostatic and then closed with #0 Vicryl suture for fascial stitch, then #3-0 Vicryl suture in the subcutaneous fat, and then #4-0 undyed Vicryl in a running subcuticular fashion.  The patient tolerated the procedure well.  Chest tubes were placed on 20 cm of water suction.  The patient was taken to PACU in stable condition.surgery, subxiphoid pericardiotomy, symptomatic pericardial effusion, chest x-rays, echocardiogram, dobutamine, pleural cavity, chest tube, pericardial effusion, pericardium, inflammatory, subxiphoid, pericardiotomy, heart, chest, effusion, pericardial