falan42/nurse_detection huggingface dataset:
Sickle Cell Anemia - ER Visit 

HISTORY OF PRESENT ILLNESS: , This is a 19-year-old known male with sickle cell anemia.  He comes to the emergency room on his own with 3-day history of back pain.  He is on no medicines.  He does live with a room mate.  Appetite is decreased.  No diarrhea, vomiting.  Voiding well.  Bowels have been regular.  Denies any abdominal pain.  Complains of a slight headaches, but his main concern is back ache that extends from above the lower T-spine to the lumbosacral spine.  The patient is not sure of his immunizations.  The patient does have sickle cell and hemoglobin is followed in the Hematology Clinic.,ALLERGIES: , THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.,MEDICATIONS: , He was previously on folic acid.  None at the present time.,PAST SURGICAL HISTORY: , He has had no surgeries in the past.,FAMILY HISTORY: , Positive for diabetes, hypertension and cancer.,SOCIAL HISTORY: , He denies any smoking or drug usage.,PHYSICAL EXAMINATION: , ,VITAL SIGNS:  On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute,  respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.,GENERAL:  He is alert, speaks in full sentences, he does not appear to be in distress.,HEENT:  Normal.,NECK:  Supple.,CHEST:  Clear.,HEART:  Regular.,ABDOMEN:  Soft.  He has pain over the mid to lower spine.,SKIN:  Color is normal.,EXTREMITIES:  He moves all extremities well.,NEUROLOGIC:  Age appropriate.,ER COURSE: , It was indicated to the patient that I will be drawing labs and giving him IV fluids.  Also that he will get morphine and Benadryl combination.  The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour.  CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4.  Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect.  The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m.  He received morphine 5 mg and Benadryl 25 mg.  I subsequently spoke to Dr. X and it was decided to admit the patient.,The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning.  He stated that he has a job interview in the morning.  The resident service did come to evaluate him.  The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration.  He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.,IMPRESSION:  ,Sickle cell crisis.,DIFFERENTIAL DIAGNOSIS: , Veno-occlusive crisis, and diskitis.nan
Prostate Brachytherapy 

PROSTATE BRACHYTHERAPY - PROSTATE I-125 IMPLANTATION,This patient will be treated to the prostate with ultrasound-guided I-125 seed implantation.  The original consultation and treatment planning will be separately performed.  At the time of the implantation, special coordination will be required.  Stepping ultrasound will be performed and utilized in the pre-planning process.  Some discrepancies are frequently identified, based on the positioning, edema, and/or change in the tumor since the pre-planning process.  Re-assessment is required at the time of surgery, evaluating the pre-plan and comparing to the stepping ultrasound.  Modifications will be made in real time to add or subtract needles and seeds as required.  This may be integrated with the loading of the seeds performed by the brachytherapist, as well as coordinated with the urologist, dosimetrist or physicist.,The brachytherapy must be customized to fit the individual's tumor and prostate.  Attention is given both preoperatively and intraoperatively to avoid overdosage of rectum and bladder.hematology - oncology, i-125 implantation, tumor, prostate, prostate brachytherapy, implantationNOTE,: 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.
Radical Mastectomy 

PREOPERATIVE DIAGNOSIS:,  Invasive carcinoma of left breast.,POSTOPERATIVE DIAGNOSIS:,  Invasive carcinoma of left breast.,OPERATION PERFORMED:,  Left modified radical mastectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR THE PROCEDURE:  ,The patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast.  The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy.  She is aware of the risks and complications of surgery, and wished to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room.  She underwent general endotracheal anesthetic.  The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well.  The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner.  The recent biopsy site was located in the upper and outer quadrant of left breast.  The plain incision was marked along the skin.  Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site.  The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia.  Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle.  The dissection was started medially and extended laterally towards the left axilla.  The breast was removed and then the axillary contents were dissected out.  Left axillary vein and artery were identified and preserved as well as the lung _____.  The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection.  Care was taken to avoid injury to any of the above mentioned neurovascular structures.  After the tissues were irrigated, we made sure there were no signs of bleeding.  Hemostasis had been achieved with Hemoclips.  Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps.  The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips.  The drains were sutured to the chest wall with 3-0 nylon sutures.  Dressing was applied and the procedure was completed.  The patient went to the recovery room in stable condition.hematology - oncology, invasive carcinoma, chest wall, neck, axilla, modified radical mastectomy, radical mastectomy, invasive, carcinoma, mastectomy
Sepsis - Consult 

REASON FOR ADMISSION: , Sepsis.,HISTORY OF PRESENT ILLNESS:  ,The patient is a pleasant but demented 80-year-old male, who lives in board and care, who presented with acute onset of abdominal pain.  In the emergency room, the patient was found to have a CT scan with dilated bladder with thick wall suggesting an outlet obstruction as well as bilateral hydronephrosis and hydroureter.  The patient is unable to provide further history.  The patient's son is at the bedside and confirmed his history.  The patient was given IV antibiotics in the emergency room.  He was also given some hydration.,PAST MEDICAL HISTORY:,1.  History of CAD.,2.  History of dementia.,3.  History of CVA.,4.  History of nephrolithiasis.,ALLERGIES: , NONE.,MEDICATIONS:,1.  Ambien.,2.  Milk of magnesia.,3.  Tylenol.,4.  Tramadol.,5.  Soma.,6.  Coumadin.,7.  Zoloft.,8.  Allopurinol.,9.  Digoxin.,10.  Namenda.,11.  Zocor.,12.  BuSpar.,13.  Detrol.,14.  Coreg.,15.  Colace.,16.  Calcium.,17.  Zantac.,18.  Lasix.,19.  Seroquel.,20.  Aldactone.,21.  Amoxicillin.,FAMILY HISTORY:  ,Noncontributory.,SOCIAL HISTORY: , The patient lives in a board and care.  No tobacco, alcohol or IV drug use.,REVIEW OF SYSTEMS: , As per the history of present illness, otherwise unremarkable.,PHYSICAL EXAMINATION:,VITAL SIGNS:  The patient is currently afebrile.  Pulse 52, respirations 20, blood pressure 104/41, and saturating 98% on room air.,GENERAL:  The patient is awake.  Not oriented x3, in no acute distress.,HEENT:  Pupils are equal, round, and reactive to light and accommodation.  Extraocular movements are intact.  Mucous membranes are dry.,NECK:  Supple.  No thyromegaly.  No jugular venous distention.,HEART:  Irregularly irregular, brady.,LUNGS:  Clear to auscultation bilaterally anteriorly.,ABDOMEN:  Positive normoactive bowel sounds.  Soft.  Tenderness in the suprapubic region without rebound.,EXTREMITIES:  No clubbing, cyanosis or edema in upper and lower extremities.nan
Nuclear Medicine Lymphatic Scan 

EXAM:,  Nuclear medicine lymphatic scan.,REASON FOR EXAM: , Left breast cancer.,TECHNIQUE: , 1.0 mCi of Technetium-99m sulfur colloid was injected within the dermis surrounding the left breast biopsy site at four locations.  A 16-hour left anterior oblique imaging was performed with and without shielding of the original injection site.,FINDINGS:  ,There are two small foci of increased activity in the left axilla.  This is consistent with the sentinel lymph node.  No other areas of activity are visualized outside of the injection site and two axillary lymph nodes.,IMPRESSION:  ,Technically successful lymph node injection with two areas of increased activity in the left axilla consistent with sentinel lymph node.hematology - oncology, technetium-99m, mci, biopsy, breast cancer, nuclear medicine, lymphatic scan, lymph node, nuclear, breast,
Polycythemia Rubra Vera 

CHIEF COMPLAINT: , Polycythemia rubra vera.,HISTORY OF PRESENT ILLNESS: , The patient is an 83-year-old female with a history of polycythemia vera.  She comes in to clinic today for followup.  She has not required phlebotomies for several months.  The patient comes to clinic unaccompanied.,CURRENT MEDICATIONS: , Levothyroxine 200 mcg q.d., Nexium 40 mg q.d., Celebrex 200 mg q.d., vitamin D3 2000 IU q.d., aspirin 81 mg q.d., selenium 200 mg q.d., Aricept 10 mg q.d., Skelaxin 800 mg q.d., ropinirole 1 mg q.d., vitamin E 1000 IU q.d., vitamin C 500 mg q.d., flaxseed oil 100 mg daily, fish oil 100 units q.d., Vicodin q.h.s., and stool softener q.d.,ALLERGIES:  ,Penicillin.,REVIEW OF SYSTEMS:  ,The patient's chief complaint is her weight.  She brings in a packet of information on HCZ Diovan and also metabolic assessment that was done at the key.  She has questions as to whether or not there would be any contra indications to her going on the diet.  Otherwise, she feels great.  She had family reunion in Iowa once in four days out there.  She continues to volunteer Hospital and is walking and enjoying her summer.  She denies any fevers, chills, or night sweats.  She has some mild constipation problem but has had under control.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:hematology - oncology, polycythemia rubra vera, phlebotomy, hematocrit, polycythemia,
Pilonidal Cyst Excision 

PREOPERATIVE DIAGNOSIS: , Pilonidal cyst with abscess formation.,POSTOPERATIVE DIAGNOSIS:,  Pilonidal cyst with abscess formation.,OPERATION: , Excision of infected pilonidal cyst.,PROCEDURE: , After obtaining informed consent, the patient underwent a spinal anesthetic and was placed in the prone position in the operating room.  A time-out process was followed.  Antibiotics were given and then the patient was prepped and draped in the usual fashion.  It appeared to me that the abscess had drained somewhat during the night, as it was much smaller than I was anticipating.  An elliptical excision of all infected tissues down to the coccyx was performed.  Hemostasis was achieved with a cautery.  The wound was irrigated with normal saline and it was packed open with iodoform gauze and an absorptive dressing.,The patient was sent to recovery room in satisfactory condition.  Estimated blood loss was minimal.  The patient tolerated the procedure well.hematology - oncology, hemostasis, excision, pilonidal cyst, cyst, abscess, infected,
Neck Dissection 

PREOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,POSTOPERATIVE DIAGNOSIS: , Metastatic papillary cancer, left neck.,OPERATION PERFORMED: , Left neck dissection.,ANESTHESIA:  ,General endotracheal.,INDICATIONS: , The patient is a very nice gentleman, who has had thyroid cancer, papillary cell type, removed with a total thyroidectomy and then subsequently recurrent disease was removed with a paratracheal dissection.  He now has evidence of lesion in the left mid neck and the left superior neck on ultrasound, which are suspicious for recurrent cancer.  Left neck dissection is indicated.,DESCRIPTION OF OPERATION: , The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, the table was then turned.  A shoulder roll placed under the shoulders and the face was placed in an extended fashion.  The left neck, chest, and face were prepped with Betadine and draped in a sterile fashion.  A hockey stick skin incision was performed, extending a previous incision line superiorly towards the mastoid cortex through skin, subcutaneous tissue and platysma with Bovie electrocautery on cut mode.  Subplatysmal superior and inferior flaps were raised.  The dissection was left lateral neck dissection encompassing zones 1, 2A, 2B, 3, and the superior portion of 4.  The sternocleidomastoid muscle was unwrapped at its fascial attachment and this was taken back posterior to the XI cranial nerve into the superior posterior most triangle of the neck.  This was carried forward off of the deep rooted muscles including the splenius capitis and anterior and middle scalenes taken medially off of these muscles including the fascia of the muscles, stripped from the carotid artery, the X cranial nerve, the internal jugular vein and then carried anteriorly to the lateral most extent of the dissection previously done by Dr. X in the paratracheal region.  The submandibular gland was removed as well.  The X, XI, and XII cranial nerves were preserved.  The internal jugular vein and carotid artery were preserved as well.  Copious irrigation of the wound bed showed no identifiable bleeding at the termination of the procedure.  There were two obviously positive nodes in this neck dissection.  One was left medial neck just lateral to the previous tracheal dissection and one was in the mid region of zone 2.  A #10 flat fluted Blake drain was placed through a separate stab incision and it was secured to the skin with a 2-0 silk ligature.  The wound was closed in layers using a 3-0 Vicryl in a buried knot interrupted fashion for the subcutaneous tissue and the skin was closed with staples.  A fluff and Kling pressure dressing was then applied.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.hematology - oncology, metastatic papillary cancer, thyroidectomy, thyroid cancer, papillary cell type, dissection, neck, metastatic, paratracheal, papillary, cancer
Needle Localized Excision - Breast Neoplasm 

PREOPERATIVE DIAGNOSIS: , Nonpalpable neoplasm, right breast.,POSTOPERATIVE DIAGNOSIS: , Deferred for Pathology.,PROCEDURE PERFORMED:  ,Needle localized wide excision of nonpalpable neoplasm, right breast.,SPECIMEN: , Mammography.,GROSS FINDINGS:  ,This 53-year-old Caucasian female who had a nonpalpable neoplasm detected by mammography in the right breast.  After excision of neoplasm, there was a separate 1 x 2 cm nodule palpated within the cavity.  This too was excised.,OPERATIVE PROCEDURE:  ,The patient was taken to the operating room, placed in supine position in the operating table.  Intravenous sedation was administered by the Anesthesia Department.  The Kopans wire was trimmed to an appropriate length.  The patient was sterilely prepped and draped in the usual manner.  Local anesthetic consisting of 1% lidocaine and 0.5% Marcaine was injected into the proposed line of incision.  A curvilinear circumareolar incision was then made with a #15 scalpel blade close to the wire.  The wire was stabilized and brought to protrude through the incision.  Skin flaps were then generated with electrocautery.  A generous core tissue was grasped with Allis forceps and excised with electrocautery.  Prior to complete excision, the superior margin was marked with a #2-0 Vicryl suture, which was tied and cut short.  The lateral margin was marked with a #2-0 Vicryl suture, which was tied and cut along.  The posterior margin was marked with a #2-0 Polydek suture, which was tied and cut.,The specimen was then completely excised and sent off the operative field as specimen where specimen mammography confirmed the excision of the mammographically detected neoplasm.  On palpation of the cavity, there was felt to be a second nodule further medial and this was grasped with an Allis forceps and excised with electrocautery and sent off the field as a separate specimen.  Hemostasis was obtained with electrocautery.  Good hemostasis was obtained.  The incision was closed in two layers.  The first layer consisting of a subcuticular inverted interrupted sutures of #4-0 undyed Vicryl.  The second layer consisted of Steri-Strips on the epidermis.  A pressure dressing of fluff, 4x4s, ABDs, and Elastic bandage was applied.  The patient tolerated the surgery well.hematology - oncology, neoplasm, needle localized wide excision, needle localized, nonpalpable neoplasm, needle, incision, electrocautery, excision, breast
Mullerian Adenosarcoma 

PRINCIPAL DIAGNOSIS: , Mullerian adenosarcoma.  ,HISTORY OF PRESENT ILLNESS: , The patient is a 56-year-old presenting with a large mass aborted through the cervix.,PHYSICAL EXAM:,CHEST:  Clear.  There is no heart murmur.,ABDOMEN:  Nontender.,PELVIC:  There is a large mass in the vagina.  ,HOSPITAL COURSE: , The patient went to surgery on the day of admission.  The postoperative course was marked by fever and ileus.  The patient regained bowel function.  She was discharged on the morning of the seventh postoperative day.,OPERATIONS: , July 25, 2006:  Total abdominal hysterectomy, bilateral salpingo-oophorectomy.,DISCHARGE CONDITION: , Stable.,  ,PLAN: , The patient will remain at rest initially with progressive ambulation thereafter.  She will avoid lifting, driving, stairs, or intercourse.  She will call me for fevers, drainage, bleeding, or pain.  Family history, social history, and psychosocial needs per the social worker.  The patient will follow up in my office in one week.,PATHOLOGY:,  Mullerian adenosarcoma.,MEDICATIONS:,  Percocet 5, #40, one q.3 h. p.r.n. pain.hematology - oncology, cervix, fevers, drainage, bleeding, mullerian adenosarcoma, mullerian, adenosarcoma
Mesothelioma - Port-A-Cath Insertion 

PREOPERATIVE DIAGNOSIS: , Mesothelioma.,POSTOPERATIVE DIAGNOSIS:,  Mesothelioma.,OPERATIVE PROCEDURE: , Placement of Port-A-Cath, left subclavian vein with fluoroscopy.,ASSISTANT:,  None.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:,  None.,DESCRIPTION OF PROCEDURE: , The patient is a 74-year-old gentleman who underwent right thoracoscopy and was found to have biopsy-proven mesothelioma.  He was brought to the operating room now for Port-A-Cath placement for chemotherapy.  After informed consent was obtained with the patient, the patient was taken to the operating room, placed in supine position.  After induction of general endotracheal anesthesia, routine prep and drape of the left chest, left subclavian vein was cannulated with #18 gauze needle, and guidewire was inserted.  Needle was removed.  Small incision was made large enough to harbor the port.  Dilator and introducers were then placed over the guidewire.  Guidewire and dilator were removed, and a Port-A-Cath was introduced in the subclavian vein through the introducers.  Introducers were peeled away without difficulty.  He measured with fluoroscopy and cut to the appropriate length.  The tip of the catheter was noted to be at the junction of the superior vena cava and right atrium.  It was then connected to the hub of the port.  Port was then aspirated for patency and flushed with heparinized saline and summoned to the chest wall.  Wounds were then closed.  Needle count, sponge count, and instrument counts were all correct.hematology - oncology, biopsy-proven mesothelioma, placement of port-a-cath, port a cath, subclavian vein, fluoroscopy, mesothelioma,
MediPort Placement 

PREOPERATIVE DIAGNOSIS:,  Rhabdomyosarcoma of the left orbit.,POSTOPERATIVE DIAGNOSIS:,  Rhabdomyosarcoma of the left orbit.,PROCEDURE: , Left subclavian vein MediPort placement (7.5-French single-lumen).,INDICATIONS FOR PROCEDURE: , This patient is a 16-year-old girl, with newly diagnosed rhabdomyosarcoma of the left orbit.  The patient is being taken to the operating room for MediPort placement.  She needs chemotherapy.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room, placed supine, put under general endotracheal anesthesia.  The patient's neck, chest, and shoulders were prepped and draped in usual sterile fashion.  An incision was made on the left shoulder area.  The left subclavian vein was cannulated.  The wire was passed, which was in good position under fluoro, using Seldinger Technique.  Near wire incision site made a pocket above the fascia and sutured in a size 7.5-French single-lumen MediPort into the pocket in 4 places using 3-0 Nurolon.  I then sized the catheter under fluoro and placed introducer and dilator over the wire, removed the wire and dilator, placed the catheter through the introducer and removed the introducer.  The line tip was in good position under fluoro.  It withdrew and flushed well.  I then closed the incision using 4-0 Vicryl, 5-0 Monocryl for the skin, and dressed with Steri-Strips.  Accessed the ports with a 1-inch 20-gauge Huber needle, and it withdrew and flushed well with final heparin flush.  We secured this with Tegaderm.  The patient is then to undergo bilateral bone marrow biopsy and lumbar puncture by Oncology.hematology - oncology, rhabdomyosarcoma of the left orbit, single lumen, subclavian vein, mediport placement, chemotherapy, rhabdomyosarcoma, mediport,
Marginal Zone Lymphoma 

CHIEF COMPLAINT: , Marginal zone lymphoma.,HISTORY OF PRESENT ILLNESS: , This is a very pleasant 46-year-old woman, who I am asked to see in consultation for a newly diagnosed marginal zone lymphoma (MALT-type lymphoma).  A mass was found in her right breast on physical examination.  On 07/19/10, she had a mammogram and ultrasound, which confirmed the right breast mass.  On 07/30/10, she underwent a biopsy, which showed a marginal zone lymphoma (MALT-type lymphoma).,Overall, she is doing well.  She has a good energy level and her ECOG performance status is 0.  She denies any fevers, chills, or night sweats.  No lymphadenopathy.  No nausea or vomiting.  She has normal bowel and bladder habits.  No melena or hematochezia.,CURRENT MEDICATIONS:  ,Macrobid 100 mg q.d.,ALLERGIES:  ,Sulfa, causes nausea and vomiting.,REVIEW OF SYSTEMS: , As per the HPI, otherwise negative.,PAST MEDICAL HISTORY:,1.  She is status post a left partial nephrectomy as a new born.,2.  In 2008 she had a right ankle fracture.,SOCIAL HISTORY: , She has a 20-pack year history of tobacco use.  She has rare alcohol use.  She has no illicit drug use.  She is in the process of getting divorced.  She has a 24-year-old son in the area and 22-year-old daughter.,FAMILY HISTORY:  ,Her mother had uterine cancer.  Her father had liver cancer.,PHYSICAL EXAM:,VIT:nan