falan42/nurse_detection huggingface dataset:
Lid Laceration Repair 

PREOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,POSTOPERATIVE DIAGNOSES:,1. XXX upper lid laceration.,2. XXX upper lid canalicular laceration.,PROCEDURES:,1. Repair of XXX upper lid laceration.,2. Repair of XXX upper lid canalicular laceration.,ANESTHESIA:, General,SPECIMENS:,  None.,COMPLICATIONS:, None.,INDICATIONS:, This is a XX-year-old (wo)man with XXX eye upper eyelid laceration involving the canaliculus.,PROCEDURE:, The risks and benefits of eye surgery were discussed at length with the patient, including bleeding, infection, re-operation, loss of vision, and loss of the eye. Informed consent was obtained. The patient was brought to the operating room and placed in the supine position, where (s)he was prepped and draped in the routine fashion for general ophthalmic plastic reconstructive surgery, once the appropriate cardiac and respiratory monitoring was placed on him/her, and once general endotracheal anesthetic had been administered. The patient then had the wound freshened up with Westcott scissors and cotton-tip applications. Hemostasis was achieved with a high-temp disposable cautery. Once this had been done, the proximal end of the XXX upper lid canalicular system was intubated with a Monoka tube on a Prolene. The proximal end was then found and this was intubated with the same tubing system. Then, two 6-0 Vicryl sutures were used to reapproximate the medial canthal tendon. Once this had been done, the skin was reapproximated with interrupted 6-0 Vicryl sutures and interrupted 6-0 plain gut sutures. To ensure that the punctum was in the correct position and in the Monoka tube was seated with a seater, and the tube was cut short. The patient's nose was suctioned of blood, and (s)he was awakened from general endotracheal anesthesia and did well. (S)he left the operating room in good condition.surgery, laceration, monoka tube, westcott scissors, bleeding, canalicular laceration, canthal tendon, cotton-tip, infection, lid, lid canalicular system, lid laceration, loss of the eye, loss of vision, ophthalmic plastic reconstructive surgery, re-operation, upper lid, lid laceration repair, laceration repair, lid canalicular, canalicular
Leaking ET tube 

ASSESSMENT:  ,The patient needed reintubation due to a leaking tube.  I explained to the patient the procedure that I was going to do and he nodded in seeming understanding of the procedure.,Using Versed and succinylcholine, we were able to sedate and paralyze him to perform the procedure.  His potassium this morning was normal.  Using an 8.5 ET tube under direct visualization, the tube was passed through the cords.  The patient tolerated the procedure extremely well.  Auscultation of the lungs revealed bilateral equal breath sounds.  Chest x-ray is pending.  CO2 monitor was positive.surgery, et tube, reintubated, postoperative, leakingNOTE,: 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.
Laser Vaporization of Prostate 

PREOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,POSTOPERATIVE DIAGNOSIS: , Benign prostatic hypertrophy.,SURGERY:  ,Cystopyelogram and laser vaporization of the prostate.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is a 67-year-old male with a history of TURP, presented to us with urgency, frequency, and dribbling.  The patient was started on alpha-blockers with some help, but had nocturia q.1h.  The patient was given anticholinergics with minimal to no help.  The patient had a cystoscopy done, which showed enlargement of the left lateral lobes of the prostate.  At this point, options were discussed such as watchful waiting and laser vaporization to open up the prostate to get a better stream.  Continuation of alpha-blockers and adding another anti-cholinergic at night to prevent bladder overactivity were discussed.  The patient was told that his symptoms may be related to the mild-to-moderate trabeculation in the bladder, which can cause poor compliance.,The patient understood and wanted to proceed with laser vaporization to see if it would help improve his stream, which in turn might help improve emptying of the bladder and might help his overactivity of the bladder.  The patient was told that he may need anticholinergics.  There could be increased risk of incontinence, stricture, erectile dysfunction, other complications and the consent was obtained.,PROCEDURE IN DETAIL:  ,The patient was brought to the OR and anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was given preoperative antibiotics.  The patient was prepped and draped in the usual sterile fashion.  A #23-French scope was inserted inside the urethra into the bladder under direct vision.  Bilateral pyelograms were normal.  The rest of the bladder appeared normal except for some moderate trabeculations throughout the bladder.  There was enlargement of the lateral lobes of the prostate.  The old TUR scar was visualized right at the bladder neck.  Using diode side-firing fiber, the lateral lobes were taken down.  The verumontanum, the external sphincter, and the ureteral openings were all intact at the end of the procedure.  Pictures were taken and were shown to the family.  At the end of the procedure, there was good hemostasis.  A total of about 15 to 20 minutes of lasering time was used.  A #22 3-way catheter was placed.  At the end of the procedure, the patient was brought to recovery in stable condition.  Plan was for removal of the Foley catheter in 48 hours and continuation of use of anticholinergics at night.surgery, laser vaporization of the prostate, cystopyelogram, benign prostatic hypertroph, benign prostatic hypertrophy, alpha blockers, laser vaporization, anticholinergics, laser, vaporization, prostate, bladder
Left Orchiectomy & Right Orchidopexy 

PREOPERATIVE DIAGNOSIS: , Left testicular torsion.,POSTOPERATIVE DIAGNOSES:  ,1.  Left testicular torsion.,2.  Left testicular abscess.,3.  Necrotic testes.,SURGERY:,  Left orchiectomy, scrotal exploration, right orchidopexy.,DRAINS:,  Penrose drain on the left hemiscrotum.,The patient was given vancomycin, Zosyn, and Levaquin preop.,BRIEF HISTORY:  ,The patient is a 49-year-old male who came into the emergency room with 2-week history of left testicular pain, scrotal swelling, elevated white count of 39,000.  The patient had significant scrotal swelling and pain.  Ultrasound revealed necrotic testicle.  Options such as watchful waiting and removal of the testicle were discussed.  Due to elevated white count, the patient was told that he must have the testicle removed due to the infection and possible early signs of urosepsis.  The risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, scrotal issues, other complications were discussed.  The patient was told about the morbidity and mortality of the procedure and wanted to proceed.,PROCEDURE IN DETAIL: , The patient was brought to the OR.  Anesthesia was applied.  The patient was prepped and draped in usual sterile fashion.  A midline scrotal incision was made.  There was very, very thick scrotal skin.  There was no necrotic skin.  As soon as the left hemiscrotum was entered, significant amount of pus poured out of the left hemiscrotum.  The testicle was completely filled with pus and had completely disintegrated with pus.  The pus just poured out of the left testicle.  The left testicle was completely removed.  Debridement was done of the scrotal wall to remove any necrotic tissue.  Over 2 L of antibiotic irrigation solution was used to irrigate the left hemiscrotum.  There was good tissue left after all the irrigation and debridement.  A Penrose drain was placed in the bottom of the left hemiscrotum.  I worried about the patient may have torsed and then the testicle became necrotic, so the plan was to pex the right testicle, plus the right side also appeared very abnormal.  So, the right hemiscrotum was opened.  The testicle had significant amount of swelling and scrotal wall was very thick.  The testicle appeared normal.  There was no pus coming out of the right hemiscrotum.  At this time, a decision was made to place 4-0 Prolene nonabsorbable stitches in 3 different quadrants to prevent it from torsion.  The hemiscrotum was closed using 2-0 Vicryl in interrupted stitches and the skin was closed using 2-0 PDS in horizontal mattress.  There was very minimal pus left behind and the skin was very healthy.  Decision was made to close it to help the patient heal better in the long run.  The patient was brought to the recovery in stable condition.surgery, testicular abscess, necrotic testes, orchiectomy, scrotal exploration, orchidopexy, hemiscrotum, testicular torsion, penrose drain, scrotal swelling, scrotal wall, testicle, torsion
Laser of Vulva 

PREOPERATIVE DIAGNOSIS: , Recurrent dysplasia of vulva.,POSTOPERATIVE DIAGNOSIS:,  Same.,OPERATION PERFORMED:,  Carbon dioxide laser photo-ablation.,ANESTHESIA: , General, laryngeal mask.,INDICATIONS FOR PROCEDURE: , The patient has a past history of recurrent vulvar dysplasia.  She has had multiple prior procedures for treatment.  She was counseled to undergo laser photo-ablation.,FINDINGS:,  Examination under anesthesia revealed several slightly raised and pigmented lesions, predominantly on the left labia and perianal regions.  After staining with acetic acid, several additional areas of acetowhite epithelium were seen on both sides and in the perianal region.,PROCEDURE:  ,The patient was brought to the operating room with an IV in place.  Anesthetic was administered, after which she was placed in the lithotomy position.  Examination under anesthesia was performed, after which she was prepped and draped.  Acetic acid was applied and marking pen was utilized to outline the extent of the dysplastic lesion.  The carbon dioxide laser was then used to ablate the lesion to the third surgical plane as defined Reid.  Setting was 25 watts using a 6 mm pattern size with the silk-touch hand piece in the paint mode.  Excellent hemostasis was noted and Bacitracin was applied prophylactically.  The patient was awakened from her anesthetic and taken to the Post Anesthesia Care Unit in stable condition.surgery, laser of vulva, recurrent dysplasia, carbon dioxide laser photo-ablation, recurrent dysplasia of vulva, dysplasia of vulva, carbon dioxide laser, photo ablation, carbon, dysplasia, laser, ablation,
LEEP 

DIAGNOSIS:,1.  Broad-based endocervical poly.,2.  Broad- based pigmented, raised nevus, right thigh.,OPERATION:,1.  LEEP procedure of endocervical polyp.,2.  Electrical excision of pigmented mole of inner right thigh.,FINDINGS: , There was a 1.5 x 1.5 cm broad-based pigmented nevus on the inner thigh that was excised with a wire loop.  Also, there was a butt-based, 1-cm long endocervical polyp off the posterior lip of the cervix slightly up in the canal.,PROCEDURE: , With the patient in the supine position, general anesthesia was administered.  The patient was put in the dorsal lithotomy position and prepped and draped for dilatation and curettage in a routine fashion.,An insulated posterior weighted retractor was put in.  Using the LEEP tenaculum, we were able to grasp the anterior lip of the cervix with a large wire loop at 35 cutting, 30 coagulation.  The endocervical polyp on the posterior lip of the cervix was excised.,Then changing from a 50 of coagulation and 5 cutting, the base of the polyp was electrocoagulated, which controlled all the bleeding.  The wire loop was attached, and the pigmented raised nevus on the inner thigh was excised with the wire loop.  Cautery of the base was done, and then it was closed with figure-of-eight 3-0 Vicryl sutures.  A band-aid was applied over this.,Rechecking the cervix, no bleeding was noted.  The patient was laid flat on the table, awakened, and moved to the recovery room bed and sent to the recovery room in satisfactory condition.surgery, endocervical polyp, pigmented mole, polyp, leep tenaculum, leep, cervix, endocervical, pigmented
Laparoscopy - 4 

PROCEDURE: , Laparoscopy with ablation of endometriosis.,DIAGNOSIS: , Endometriosis.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , None.,FINDINGS: , Allen-Masters window in the upper left portion of the cul-de-sac, bronze lesions of endometriosis in the central portion of the cul-de-sac as well as both the left uterosacral ligament, flame lesions of the right uterosacral ligament approximately 5 mL of blood tinged fluid in the cul-de-sac.  Normal tubes and ovaries, normal gallbladder, smooth liver edge.,PROCEDURE:  ,The patient was taken to the operating room and placed under general anesthesia.  She was put in the dorsal lithotomy position, and the perineum and abdomen were prepped and draped in a sterile manner.  Subumbilical area was injected with Marcaine, and a Veress needle was placed subumbilically through which approximately 2 L of CO2 were inflated.  Scalpel was used to make a subumbilical incision through which a 5-mm trocar was placed.  Laparoscope was inserted through the cannula and the pelvis was visualized.  Under direct visualization, two 5-mm trocars were placed in the right and left suprapubic midline.  Incision sites were transilluminated and injected with Marcaine prior to cutting.  Hulka manipulator was placed on the cervix.  Pelvis was inspected and blood tinged fluid was aspirated from the cul-de-sac.  The beginnings of an Allen-Masters window in the left side of the cul-de-sac were visualized along with bronze lesions of endometriosis.  Some more lesions were noted above the left uterosacral ligament.  Flame lesions were noted above the right uterosacral ligament.  Tubes and ovaries were normal bilaterally with the presence of a few small paratubal cysts on the left tube.  There was a somewhat leathery appearance to the ovaries.  The lesions of endometriosis were ablated with the argon beam coagulator, as was a region of the Allen-Masters window.  Pelvis was irrigated and all operative sites were hemostatic.  No other abnormalities were visualized and all instruments were moved under direct visualization.  Approximately 200 mL of fluid remained in the abdominal cavity.  All counts were correct and the skin incisions were closed with 2-0 Vicryl after all CO2 was allowed to escape.  The patient was taken to the recovery in stable condition.surgery, ablation of endometriosis, allen-masters window, uterosacral ligament, endometriosis, cul de sac, laparoscopy, lesions, ablation
Laparoscopy - 1 

 Laparoscopy.  The cervix was grasped with a single-tooth tenaculum.  The uterus was gently sounded and a manipulator was inserted for movement of the uterus throughout the case. surgery, uterus, cervix, vaginal, single tooth tenaculum, trocar sites, laparoscopy, bladder, laparoscopic, abdominal, cavity, trocar, toothNOTE,: 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.,Home
Laparoscopy - Drainage of Cyst 

PREOPERATIVE DIAGNOSIS:,  Ovarian cyst, persistent.,POSTOPERATIVE DIAGNOSIS: , Ovarian cyst.,ANESTHESIA:,  General,NAME OF OPERATION:,  Diagnostic laparoscopy and drainage of cyst.,PROCEDURE:,  The patient was taken to the operating room, prepped and draped in the usual manner, and adequate anesthesia was induced.  An infraumbilical incision was made, and Veress needle placed without difficulty.  Gas was entered into the abdomen at two liters.  The laparoscope was entered, and the abdomen was visualized.  The second puncture site was made, and the second trocar placed without difficulty.  The cyst was noted on the left, a 3-cm, ovarian cyst.  This was needled, and a hole cut in it with the scissors.  Hemostasis was intact.  Instruments were removed.  The patient was awakened and taken to the recovery room in good condition.surgery, ovarian cyst, infraumbilical incision, drainage of cyst, diagnostic laparoscopy, laparoscopy, drainage, ovarian,
Laparoscopy & Salpingo-oophorectomy 

PREOPERATIVE DIAGNOSIS:,  Left adnexal mass.,POSTOPERATIVE DIAGNOSIS:,  Left ovarian lesion.,PROCEDURE PERFORMED:  ,Laparoscopy with left salpingo-oophorectomy.,ANESTHESIA:,  General.,ESTIMATED BLOOD LOSS: , Less than 50 cc.,COMPLICATIONS:,  None.,FINDINGS:,  The labia and perineum were within normal limits.  The hymen was found to be intact.  Laparoscopic findings revealed a 4 cm left adnexal mass, which appeared fluid filled.  There were a few calcifications on the surface of the mass.  The right ovary and fallopian tube appeared normal.  There was no evidence of endometriosis.  The uterus appeared normal in size.  There were no pelvic adhesions noted.,INDICATIONS: , The patient is a 55-year-old gravida 0, para 0 Caucasian female who presents with a left adnexal mass on ultrasound which is 5.3 cm.  She does complain of minimal discomfort.  Bimanual exam was not able to be performed secondary to the vaginal stenosis and completely intact hymen.,PROCEDURE IN DETAIL: , After informed consent was obtained, the patient was taken back to the Operative Suite, prepped and draped, and placed in the dorsal lithotomy position.  A 1 cm skin incision was made in the infraumbilical vault.  While tenting up the abdominal wall, the Veress needle was inserted without difficulty and the abdomen was insufflated.  This was done using appropriate flow and volume of CO2.  The #11 step trocar was then placed without difficulty.  The above findings were confirmed.  A #12 mm port was then placed approximately 2 cm above the pubic symphysis under direct visualization.  Two additional ports were placed, one on the left lateral aspect of the abdominal wall and one on the right lateral aspect of the abdominal wall.  Both #12 step ports were done under direct visualization.  Using a grasper, the mass was tented up at the inferior pelvic ligament and the LigaSure was placed across this and several bites were taken with good visualization while ligating.  The left ovary was then placed in an Endocatch bag and removed through the suprapubic incision.  The skin was extended around this incision and the fascia was extended using the Mayo scissors.  The specimen was removed intact in the Endocatch bag through this site.  Prior to desufflation of the abdomen, the site where the left adnexa was removed was visualized to be hemostatic.  All the port sites were hemostatic as well.  The fascia of the suprapubic incision was then repaired using a running #0 Vicryl stitch on a UR6 needle.  The skin was then closed with #4-0 undyed Vicryl in a subcuticular fashion.  The remaining incisions were also closed with #4-0 undyed Vicryl in a running fashion after all instruments were removed and the abdomen was completely desufflated.  Steri-Strips were placed on each of the incisions.  The patient tolerated the procedure well.  Sponge, lap, and needle count were x2.  She will go home on Vicodin for pain and followup postoperatively in the office where we will review path report with her.surgery, salpingo-oophorectomy, ovarian lesion, adnexal mass, salpingo oophorectomy, abdominal wall, intact, adnexal, laparoscopy, mass,
Laparoscopy - 2 

 Laparoscopy.  An incision was made in the umbilicus, allowing us to insert a micro-laparoscopic trocar.  We then insufflated the abdomen with approximately 3 liters of carbon dioxide gas and inserted the micro-laparoscopic instrument.surgery, umbilicus, trocar, falope, laparoscopy, abdomen, suprapubic, laparoscopicNOTE,: 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 Gastric Bypass - 1 

PREOPERATIVE DIAGNOSIS: , Morbid obesity. ,POSTOPERATIVE DIAGNOSIS: , Morbid obesity. ,PROCEDURE:,  Laparoscopic Roux-en-Y gastric bypass, antecolic, antegastric with 25-mm EEA anastamosis, esophagogastroduodenoscopy. ,ANESTHESIA: , General with endotracheal intubation. ,INDICATIONS FOR PROCEDURE: , This is a 50-year-old male who has been overweight for many years and has tried multiple different weight loss diets and programs.  The patient has now begun to have comorbidities related to the obesity.  The patient has attended our bariatric seminar and met with our dietician and psychologist.  The patient has read through our comprehensive handout and understands the risks and benefits of bypass surgery as evidenced by the signing of our consent form.,PROCEDURE IN DETAIL: , The risks and benefits were explained to the patient.  Consent was obtained.  The patient was taken to the operating room and placed supine on the operating room table.  General anesthesia was administered with endotracheal intubation.  A Foley catheter was placed for bladder decompression.  All pressure points were carefully padded, and sequential compression devices were placed on the legs.  The abdomen was prepped and draped in standard, sterile, surgical fashion.  Marcaine was injected into the umbilicus.surgery, morbid obesity, roux-en-y, gastric bypass, antecolic, antegastric, anastamosis, esophagogastroduodenoscopy, eea, surgidac sutures, roux limb, port, stapler, laparoscopic, intubation