falan42/nurse_detection huggingface dataset:
Deviated Septum Repair - Followup 

CHIEF COMPLAINT: , Septal irritation.,HISTORY OF PRESENT ILLNESS: , The patient is a 39-year-old African-American female status post repair of septal deviation but unfortunately, ultimately ended with a large septal perforation.  The patient has been using saline nasal wash 2-3 times daily, however, she states that she still has discomfort in her nose with a "stretching" like pressure.  She says her nose is frequently dry and she occasionally has nosebleeds due to the dry nature of her nose.  She has no other complaints at this time.,PHYSICAL EXAM:,GENERAL:  This is a pleasant African-American female resting in the examination room chair in no apparent distress.,ENT:  External auditory canals are clear.  Tympanic membrane shows no perforation, is intact.,NOSE:  The patient has a slightly deviated right septum.  Septum has a large perforation in the anterior 2/3rd of the septum.  This appears to be well healed.  There is no sign of crusting in the nose.,ORAL CAVITY:  No lesions or sores.  Tonsils show no exudate or erythema.,NECK:  No cervical lymphadenopathy.,VITAL SIGNS:  Temperature 98 degrees Fahrenheit, pulse 77, respirations 18, blood pressure 130/73.,ASSESSMENT AND PLAN:  ,The patient is a 40-year-old female with a past medical history of repair of deviated septum with complication of a septal perforation.  At this time, the patient states that her septal perforation bothers her as she feels that she has very dry air through her nose as well as occasional epistaxis.  At this time, I counseled the patient on the risks and benefits of surgery.  She will consider surgery but at this time, would like to continue using the saline nasal wash as well as occasional Bactroban to the nose if there is occasional irritation or crusting, which she will apply with the edge of a Q-tip.  We will see her back in 3 weeks and if the patient does not feel relieved from the Bactroban as well as saline nasal spray wash, we will consider setting the patient for surgery at that time.ent - otolaryngology, saline nasal wash, deviated septum, saline nasal, septal perforation, nose, septum, septal, perforation
CT Maxillofacial 

EXAM:  ,CT maxillofacial for trauma.,FINDINGS: , CT examination of the maxillofacial bones was performed without contrast.  Coronal reconstructions were obtained for better anatomical localization.,There is normal appearance to the orbital rims.  The ethmoid, sphenoid, and frontal sinuses are clear.  There is polypoid mucosal thickening involving the floor of the maxillary sinuses bilaterally.  There is soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.  The nasal bones appear intact.  The zygomatic arches are intact.  The temporomandibular joints are intact and demonstrate no dislocations or significant degenerative changes.  The mandible and maxilla are intact.  There is soft tissue swelling seen involving the right cheek.,IMPRESSION:,1.  Mucosal thickening versus mucous retention cyst involving the maxillary sinuses bilaterally.  There is also soft tissue or fluid opacification of the ostiomeatal complexes bilaterally.,2.  Mild soft tissue swelling about the right cheek.ent - otolaryngology, ethmoid, sphenoid, frontal sinuses, mandible, maxilla, ct examination, maxillofacial bones, mucosal thickening, maxillary sinuses, ct, maxillofacial
Control of Parapharyngeal Hemorrhage 

PREOPERATIVE DIAGNOSIS: , Postoperative hemorrhage.,POSTOPERATIVE DIAGNOSIS:,  Postoperative hemorrhage.,SURGICAL PROCEDURE:  ,Examination under anesthesia with control of right parapharyngeal space hemorrhage.,ANESTHESIA:  ,General endotracheal technique.,SURGICAL FINDINGS: , Right lower pole bleeder cauterized with electrocautery with good hemostasis.,INDICATIONS FOR SURGERY: , The patient is a 35-year-old female with a history of a chronic pharyngitis and obstructive adenotonsillar hypertrophy.  Previously, in the day she had undergone a tonsillectomy with adenoidectomy and was recovering without difficulty.  However, in the PACU after a coughing spell she began bleeding from the right oropharynx, and was taken back to the operative suite for control of hemorrhage.,DESCRIPTION OF SURGERY:  ,The patient was placed supine on the operating room table and general anesthetic was administered, once appropriate anesthetic findings achieved the patient was intubated and then prepped and draped in usual sterile manner for a parapharyngeal space hemorrhage.  A Crowe-Davis type mouth gag was introduced in the oropharynx and under operating headlight the oropharynx was clearly visualized.  There was a small bleeder present at the inferior mid pole of the right oropharynx in the tonsillar fossa, this area was cauterized with suction cautery and irrigated.  There was no other bleeding noted.  The patient was repositioned and the mouth gag, the tongue was rotated to the left side of the mouth and the right parapharyngeal space carefully examined.  There was a small amount of oozing noted in the right tonsillar bed, and this was cauterized with suction cautery.  No other bleeding was noted and the patient was recovered from general anesthetic.  She was extubated and left the operating room in good condition to postoperative recovery room area.  Prior to extubation the patient's tonsillar fossa were injected with a 6 mL of 0.25% Marcaine with 1:100,000 adrenalin solution to facilitate postoperative analgesia and hemostasis.ent - otolaryngology, obstructive adenotonsillar hypertrophy, tonsillar fossa, suction cautery, postoperative hemorrhage, parapharyngeal space, anesthesia, oropharynx, parapharyngeal, tonsillectomy, hemorrhage,
Chronic Otitis Media 

CHIEF COMPLAINT:,  Chronic otitis media.,HISTORY OF PRESENT ILLNESS:,  This is a 14-month-old with history of chronic recurrent episodes of otitis media, totalling 6 bouts, requiring antibiotics since birth.  There is also associated chronic nasal congestion.  There had been no bouts of spontaneous tympanic membrane perforation, but there had been elevations of temperature up to 102 during the acute infection.  He is being admitted at this time for myringotomy and tube insertion under general facemask anesthesia.,ALLERGIES:,  None.,MEDICATIONS:,  None.,FAMILY HISTORY:,  Noncontributory.,MEDICAL HISTORY: , Mild reflux.,PREVIOUS SURGERIES:,  None.,SOCIAL HISTORY: , The patient is not in daycare.  There are no pets in the home.  There is no secondhand tobacco exposure.,PHYSICAL EXAMINATION: , Examination of ears reveals retracted poorly mobile tympanic membranes on the right side with a middle ear effusion present.  Left ear is still little bit black.  Nose, moderate inferior turbinate hypertrophy.  No polyps or purulence.  Oral cavity, oropharynx 2+ tonsils.  No exudates.  Neck, no nodes, masses or thyromegaly.  Lungs are clear to A&P.  Cardiac exam, regular rate and rhythm.  No murmurs.  Abdomen is soft and nontender.  Positive bowel sounds.,IMPRESSION: , Chronic eustachian tube dysfunction, chronic otitis media with effusion, recurrent acute otitis media, and wax accumulation.,PLAN:,  The patient will be admitted to the operating room for myringotomy and tube insertion under general facemask anesthesia.ent - otolaryngology, chronic nasal congestion, tympanic membrane perforation, chronic otitis media, tube insertion, facemask anesthesia, otitis media, otitis, media,
Collar Tubes 

 Collar Tubes techniqueent - otolaryngology, ototopical drops, tympanic, membrane, ear canals, cerumen, collar tubes, incision, myringotomy, collar, tubes, anesthesiaNOTE,: 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.,
BMT & T&A 

PREOPERATIVE DIAGNOSES: , Chronic otitis media and tonsillar adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES:,  Chronic otitis media and tonsillar adenoid hypertrophy.,PROCEDURES:,  Bilateral myringotomy and tube placement, tonsillectomy and adenoidectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 3-1/2-year-old child with history of recurrent otitis media as well as snoring and chronic mouth breathing.  Risks and benefits of surgery including risk of bleeding, general anesthesia, tympanic membrane perforation as well as persistent recurrent otitis media were discussed with the patient and parents and informed consent was signed by the parents.,FINDINGS:  ,The patient was brought to the operating room, placed in supine position, given general endotracheal anesthesia.  The left ear was then draped in a clean fashion.  Under microscopic visualization, the ear canal was cleaned of the wax.  Myringotomy incision was made in the anterior inferior quadrant.  There was no fluid in the middle ear space.  A Micron Bobbin tube was easily placed.  Floxin drops were placed in the ear.  The same was performed on the right side with similar findings.  The patient was then turned to be placed in Rose position.  The patient draped in clean fashion.  A small McIvor mouth gag was used to hold open the oral cavity.  The soft palate was palpated.  There was no submucous cleft felt.  Using a 1:1 mixture of 1% Xylocaine with 1:100,000 epinephrine and 0.25% Marcaine, both tonsillar pillars and the fossae injected with approximately 7 mL total.  Using a curved Allis the right tonsil was grasped and pulled medially.  Tonsil was dissected off the tonsillar fossa using a Coblator.  The left tonsil was removed in the similar fashion.  Hemostasis then achieved in tonsillar fossa using the Coblator on coagulation setting.  The soft palate was then retracted using red rubber catheter.  Under mirror visualization, the patient was found to have enlarged adenoids.  The adenoids were removed using the Coblator.  Hemostasis was also achieved using the Coblator on coagulation setting.  The rubber catheter was then removed.  Reexamining the oropharynx, small bleeding points were cauterized with the Coblator.  Stomach contents were then aspirated with saline sump.  The patient was woken up from anesthesia, extubated and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge correct.  Estimated blood loss minimal.ent - otolaryngology, bilateral myringotomy, tube placement, tonsillectomy, adenoidectomy, micron bobbin, myringotomy and tube, tonsillectomy and adenoidectomy, chronic otitis media, tonsillar adenoid, tonsillar fossa, rubber catheter, otitis media, adenoids, myringotomy, otitis, media, tonsillar, coblator,
Cleft Repair - Soft Palate 

PREOPERATIVE DIAGNOSIS: , Cleft soft palate.,POSTOPERATIVE DIAGNOSIS: , Cleft soft palate.,PROCEDURES:,1.  Repair of cleft soft palate, CPT 42200.,2.  Excise accessory ear tag, right ear.,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , The patient was placed supine on the operating room table.  After anesthesia was administered, time out was taken to ensure correct patient, procedure, and site.  The face was prepped and draped in a sterile fashion.  The right ear tag was examined first.  This was a small piece of skin and cartilaginous material protruding just from the tragus.  The lesion was excised and injected with 0.25% bupivacaine with epinephrine and then excised using an elliptical-style incision.  Dissection was carried down the subcutaneous tissue to remove any cartilaginous attachment to the tragus.  After this was done, the wound was cauterized and then closed using interrupted 5-0 Monocryl.  Attention was then turned towards the palate.  The Dingman mouthgag was inserted and the palate was injected with 0.25% bupivacaine with epinephrine.  After giving this 5 minutes to take effect, the palate was incised along its margins.  The anterior oral mucosa was lifted off and held demonstrating the underlying levator muscle.  Muscle was freed up from its attachments at the junction of the hard palate and swept down so that it will be approximated across the midline.  The Z-plasties were then designed, so there would be opposing Z-plasties from the nasal mucosa compared to the oral mucosa.  The nasal mucosa was sutured first using interrupted 4-0 Vicryl.  Next, the muscle was reapproximated using interrupted 4-0 Vicryl with an attempt to overlap the muscle in the midline.  In addition, the remnant of the uvula tissue was found and was sutured in such a place that it would add some extra bulk to the nasal surface of the palate.  Following this, the oral layer of mucosa was repaired using an opposing Z-plasty compared to the nasal layer.  This was also sutured in place using interrupted 4-0 Vicryl.  The anterior and posterior open edges of the palatal were sewn together.  The patient tolerated the procedure well.  Suction of blood and mucus performed at the end of the case.  The patient tolerated the procedure well.,IMMEDIATE COMPLICATIONS: , None.,DISPOSITION:,  In satisfactory condition to recovery.ent - otolaryngology, repair, tragus, oral mucosa, nasal mucosa, ear tag, soft palate, palate, cleft, soft
BMT & Adenoidectomy 

PREOPERATIVE DIAGNOSIS: , Chronic otitis media.,POSTOPERATIVE DIAGNOSIS: , Chronic otitis media.,PROCEDURE PERFORMED: , Bilateral myringotomy tubes and adenoidectomy.,INDICATIONS FOR PROCEDURE:,  The patient is an 8-year-old child with history of recurrent otitis media.  The patient has had previous tube placement.  Tubes have since plugged and are no more functioning.  The patient has had recent recurrent otitis media.  Risks and benefits in terms of bleeding, anesthesia, and tympanic membrane perforation were discussed with the mother.  Mother wished to proceed with the surgery.,PROCEDURE IN DETAIL: , The patient was brought to the room, placed supine.  The patient was given general endotracheal anesthesia.  Starting on the left ear, under microscopic visualization, the ear was cleaned of wax.  A Bobbin tube was found stuck to the tympanic membrane.  This was removed.  After removing the tube the patient was found to have microperforation through which serous fluid was draining.  A fresh myringotomy was made in the anterior inferior quadrant.  More serous fluid was aspirated from middle ear space.  The new Bobbin tube was easily placed.  Floxin drops were placed in the ear.  In the right ear again under microscopic visualization, the ear was cleaned, the tube was removed off tympanic membrane.  There was no perforation seen; however, there was some granulation tissue on the surface of tympanic membrane.  A fresh myringotomy incision was made in the anterior inferior quadrant.  More serous fluid was drained out of middle ear space.  The tube was easily placed and Floxin drops were placed in the ear.  This completes tube portion of the surgery.  The patient was then turned and placed in the Rose position.  Shoulder roll was placed for neck extension.  Using a small McIvor mouth gag mouth was held open.  Using a rubber catheter the soft palate was retracted.  Under mirror visualization, the nasopharynx was examined.  The patient was found to have minimal adenoidal tissue.  This was removed using a suction Bovie.  The patient was then awakened from anesthesia, extubated and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge count correct.  Estimated blood loss none.ent - otolaryngology, chronic otitis media, bilateral myringotomy tubes, adenoidectomy, myringotomy tubes and adenoidectomy, middle ear space, bilateral myringotomy, bobbin tube, fresh myringotomy, serous fluid, otitis media, tympanic membrane, tubes, myringotomy, otitis, media, membrane,
Cancer of the nasopharynx 

DIAGNOSIS: , T1 N3 M0 cancer of the nasopharynx, status post radiation therapy with 2 cycles of high dose cisplatin with radiation, completed June, 2006; status post 2 cycles  carboplatin/5-FU given as adjuvant therapy, completed September, 2006; hearing loss related to chemotherapy and radiation; xerostomia; history of left upper extremity deep venous thrombosis.,PERFORMANCE STATUS:,  0.,INTERVAL HISTORY: , In the interim since his last visit he has done quite well.  He is working.  He did have an episode of upper respiratory infection and fever at the end of April which got better with antibiotics.  Overall when he compares his strength to six or eight months ago he notes that he feels much stronger.  He has no complaints other than mild xerostomia and treatment related hearing loss.,PHYSICAL EXAMINATION:,Vital Signs:  Height 65 inches, weight 150, pulse 76, blood pressure 112/74, temperature 95.4, respirations 18.,HEENT:  Extraocular muscles intact.  Sclerae not icteric.  Oral cavity free of exudate or ulceration.  Dry mouth noted.,Lymph:  No palpable adenopathy in cervical, supraclavicular or axillary areas.,Lungs:  Clear.,Cardiac:  Rhythm regular.,Abdomen:  Soft, nondistended.  Neither liver, spleen, nor other masses palpable.,Lower Extremities:  Without edema.,Neurologic:  Awake, alert, ambulatory, oriented, cognitively intact.,I reviewed the CT images and report of the study done on May 1.  This showed no evidence of metabolically active malignancy.,Most recent laboratory studies were performed last September and the TSH was normal.  I have asked him to repeat the TSH at the one year anniversary.,He is on no current medications.,In summary, this 57-year-old man presented with T1 N3 cancer of the nasopharynx and is now at 20 months post completion of all therapy.  He has made a good recovery.  We will continue to follow thyroid function and I have asked him to obtain a TSH at the one year anniversary in September and CBC in follow up.  We will see him in six months' time with a PET-CT.,He returns to the general care and direction of Dr. ABC.ent - otolaryngology, radiation therapy with cycles, cancer of the nasopharynx, status post radiation, cisplatin with radiation, radiation therapy, hearing loss, hearing, cisplatin, xerostomia, cancer, radiation, nasopharynx,
Bilateral Myringotomies 

PREOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,POSTOPERATIVE DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,FINAL DIAGNOSES,1.  Recurrent acute otitis media, bilateral middle ear effusions.,2.  Chronic rhinitis.,3.  Recurrent adenoiditis with adenoid hypertrophy.,4.  Acute and chronic adenoiditis.,OPERATIONS PERFORMED,1.  Bilateral myringotomies.,2.  Placement of ventilating tubes.,3.  Nasal endoscopy.,4.  Adenoidectomy.,DESCRIPTION OF OPERATIONS: , The patient was brought to the operating room, endotracheal intubation carried out by Dr. X. Both sides of the patient's nose were then sprayed with Afrin.  Ears were inspected then with the operating microscope.  The anterior inferior quadrant myringotomy incisions were performed.  Then, a modest amount of serous and a trace of mucoid material encountered that was evacuated.  The middle ear mucosa looked remarkably clean.  Armstrong tubes were inserted.  Ciprodex drops were instilled.  Ciprodex will be planned for two postoperative days as well.  Nasal endoscopy was carried out, and evidence of acute purulent adenoiditis was evident in spite of the fact that clinically the patient has shown some modest improvement following cessation of all milk products.  The adenoids were shaved back, flushed with curette through a traditional transoral route with thick purulent material emanating from the crypts, and representative cultures were taken.  Additional adenoid tissue was shaved backwards with the RADenoid shaver.  Electrocautery was used to establish hemostasis, and repeat nasal endoscopy accomplished.  The patient still had residual evidence of inter choanal adenoid tissue, and video photos were taken.  That remaining material was resected, guided by the nasal endoscope using the RADenoid shaver to remove the material and flush with the posterior nasopharynx.  Electrocautery again used to establish hemostasis.  Bleeding was trivial.  Extensive irrigation accomplished.  No additional bleeding was evident.  The patient was awakened, extubated, taken to the recovery room in a stable condition.  Discharge anticipated later in the day on Augmentin 400 mg twice daily, Lortab or Tylenol p.r.n. for pain.  Office recheck would be anticipated if stable and doing well in approximately two weeks.  Parents were instructed to call, however, regarding the outcome of the culture on Monday next week to ensure adequate antibiotic coverage before cessation of the antibiotic.ent - otolaryngology, bilateral middle ear effusions, recurrent acute otitis media, chronic rhinitis, recurrent adenoiditis with adenoid hypertrophy, adenoiditis, bilateral myringotomies, ventilating tubes, nasal endoscopy, adenoidectomy, adenoid hypertrophy, myringotomies, otitis, media, hypertrophy, endoscopy, intubation, nasal,
Adenotonsillectomy - 2 

POSTOPERATIVE DIAGNOSIS:  Adenotonsillitis with hypertrophy.,OPERATION PERFORMED:  Adenotonsillectomy.,ANESTHESIA:  General endotracheal.,INDICATIONS:  The patient is a very nice patient with adenotonsillitis with hypertrophy and obstructive symptoms.  Adenotonsillectomy is indicated.,DESCRIPTION OF PROCEDURE:  The patient was placed on the operating room table in the supine position.  After adequate general endotracheal anesthesia was administered, table was turned and shoulder roll was placed on the shoulders and face was draped in clean fashion.  A McIvor mouth gag was applied.  The tongue was retracted anteriorly and the McIvor was gently suspended from a Mayo stand.  A red rubber Robinson catheter was inserted through the left naris and the soft palate was retracted superiorly.  The adenoids were removed with suction electrocautery under mere visualization.  The left tonsil was grasped with a curved Allis forceps, retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The right tonsil was grasped in the similar fashion and retracted medially and the anterior tonsillar pillar was incised with Bovie electrocautery.  The tonsil was removed from the superior pole and inferior pole using Bovie electrocautery in its entirety in the subcapsular fashion.  The inferior, middle and superior pole vessels were further cauterized with suction electrocautery.  Copious saline irrigation of the oral cavity was then performed.  There was no further identifiable bleeding at the termination of the procedure.  The estimated blood loss was less than 10 mL.  The patient was extubated in the operating room, brought to the recovery room in satisfactory condition.  There were no intraoperative complications.ent - otolaryngology, hypertrophy, adenotonsillitis, tonsillar pillar, bovie electrocautery, adenotonsillectomyNOTE,: 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.