falan42/nurse_detection huggingface dataset:
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.obstetrics / gynecology, salpingo-oophorectomy, ovarian lesion, adnexal mass, salpingo oophorectomy, abdominal wall, intact, adnexal, laparoscopy, mass,
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.obstetrics / gynecology, ablation of endometriosis, allen-masters window, uterosacral ligament, endometriosis, cul de sac, laparoscopy, lesions, ablation
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.obstetrics / gynecology, 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.,
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. obstetrics / gynecology, 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.,
Intrauterine Clots Removal 

PREOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,POSTOPERATIVE DIAGNOSIS: , Postpartum hemorrhage.,PROCEDURE:,  Exam under anesthesia.  Removal of intrauterine clots.,ANESTHESIA: , Conscious sedation.,ESTIMATED BLOOD LOSS:,  Approximately 200 mL during the procedure, but at least 500 mL prior to that and probably more like 1500 mL prior to that.,COMPLICATIONS: , None.,INDICATIONS AND CONCERNS: , This is a 19-year-old G1, P1 female, status post vaginal delivery, who was being evaluated by the nurse on labor and delivery approximately four hours after her delivery.  I was called for persistent bleeding and passing large clots.  I examined the patient and found her to have at least 500 mL of clots in her uterus.  She was unable to tolerate exam any further than that because of concerns of the amount of bleeding that she had already had and inability to adequately evaluate her.  I did advise her that I would recommend they came under anesthesia and dilation and curettage.  Risks and benefits of this procedure were discussed with Misty, all of her questions were adequately answered and informed consent was obtained.,PROCEDURE: , The patient was taken to the operating room where satisfactory conscious sedation was performed.  She was placed in the dorsal lithotomy position, prepped and draped in the usual fashion.  Bimanual exam revealed moderate amount of clot in the uterus.  I was able to remove most of the clots with my hands and an attempt at short curettage was performed, but because of contraction of the uterus this was unable to be adequately performed.  I was able to thoroughly examine the uterine cavity with my hand and no remaining clots or placental tissue or membranes were found.  At this point, the procedure was terminated.  Bleeding at this time was minimal.  Preop H&H were 8.3 and 24.2.  The patient tolerated the procedure well and was taken to the recovery room in good condition.obstetrics / gynecology, uterus, intrauterine clots, postpartum hemorrhage, intrauterine, curettage, hemorrhage, bleeding, postpartum, clots,
Intrauterine Pregnancy - Discharge Summary 

ADMITTING DIAGNOSIS:,  Intrauterine pregnancy at term with previous cesarean.,SECONDARY DIAGNOSIS: , Desired sterilization.,DISCHARGE DIAGNOSES,1.  Intrauterine pregnancy at term with previous cesarean.,2.  Desired sterilization.,3.  Status post repeat low transverse cesarean and bilateral tubal ligation.,HISTORY: , The patient is a 35-year-old gravida 2, para 1-0-0-1 with intrauterine pregnancy on 08/30/09.  Pregnancy was uncomplicated.  She opted for a scheduled elective C-section and sterilization without any trial of labor.  All routine screening labs were normal and she underwent a high-resolution ultrasound during pregnancy.,PAST MEDICAL HISTORY: , Significant for postpartum depression after her last baby as well as a cesarean.,ALLERGIES:,  SHE HAS SEASONAL ALLERGIES.,MEDICATIONS:,  She is taking vitamins and iron.,PHYSICAL EXAMINATION,GENERAL:  An alert gravid woman in no distress.,ABDOMEN:  Gravid, nontender, non-irritable, with an infant in the vertex presentation.  Estimated fetal weight was greater than 10 pounds.,HOSPITAL COURSE:  ,On the first hospital day, the patient went to the operating room where repeat low transverse cesarean and tubal ligation were performed under spinal anesthesia with delivery of a viable female infant weighing 7 pounds 10 ounces and Apgars of 9 and 9.  There was normal placenta, normal pelvic anatomy.  There was 600 cc estimated blood loss.  Patient recovered uneventfully from her anesthesia and surgery.  She was able to ambulate and void.  She tolerated regular diet.  She passed flatus.  She was breast-feeding.  Postoperative hematocrit was 31.  On the second postoperative day, the patient was discharged home in satisfactory condition.,DISCHARGE MEDICATIONS: , Motrin and Percocet for pain.  Paxil for postpartum depression.  She was instructed to do no lifting, straining, or driving, to put nothing in the vagina and to see me in two weeks or with signs of severe pain, heavy bleeding, fever, or other problems.obstetrics / gynecology, cesarean, bilateral tubal ligation, low transverse cesarean, intrauterine, gravida, sterilization, pregnancy,
Induction of Vaginal Delivery 

DIAGNOSES,1.  Term pregnancy.,2.  Possible rupture of membranes, prolonged.,PROCEDURE:,  Induction of vaginal delivery of viable male, Apgars 8 and 9.,HOSPITAL COURSE:,  The patient is a 20-year-old female, gravida 4, para 0, who presented to the office.  She had small amount of leaking since last night.  On exam, she was positive Nitrazine, no ferning was noted.  On ultrasound, her AFI was about 4.7 cm.  Because of a variable cervix, oligohydramnios, and possible ruptured membranes, we recommended induction.,She was brought to the hospital and begun on Pitocin.  Once she was in her regular pattern, we ruptured her bag of water; fluid was clear.  She went rapidly to completion over the next hour and a half.  She then pushed for 2 hours delivering a viable male over an intact perineum in an OA presentation.  Upon delivery of the head, the anterior and posterior arms were delivered, and remainder of the baby without complications.  The baby was vigorous, moving all extremities.  The cord was clamped and cut.  The baby was handed off to mom with nurse present.  Apgars were 8 and 9.  Placenta was delivered spontaneously, intact.  Three-vessel cord with no retained placenta.  Estimated blood loss was about 150 mL.  There were no tears.obstetrics / gynecology, induction of vaginal delivery, vaginal delivery, viable male, pregnancy, placenta, vaginal, membranes, apgars
Hysteroscopy & Endometrial Ablation 

PREOPERATIVE DX:,1.  Menorrhagia,2.  Desires permanent sterilization.,POSTOPERATIVE DX:,1.  Menorrhagia,2.  Desires permanent sterilization.,OPERATIVE PROCEDURE:,  Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.,ANESTHESIA: , General with paracervical block.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS:,  On hysteroscopy, 100 ml deficit of lactated Ringer's via IV, 850 ml of lactated Ringer's.,COMPLICATIONS: , None.,PATHOLOGY: , None.,DISPOSITION:  ,Stable to recovery room.,FINDINGS:,  A nulliparous cervix without lesions.  Uterine cavity sounding to 10 cm, normal appearing tubal ostia bilaterally, fluffy endometrium, normal appearing cavity without obvious polyps or fibroids.,PROCEDURE: , The patient was taken to the operating room, where general anesthesia was found to be adequate.  She was prepped and draped in the usual sterile fashion.  A speculum was placed into the vagina.  The anterior lip of the cervix was grasped with a single-tooth tenaculum and a paracervical block was performed using 20 ml of 0.50% lidocaine with 1:200,000 of epinephrine.,The cervical vaginal junction at the 4 o'clock position was injected and 5 ml was instilled.  The block was performed at 8 o'clock as well with 5 ml at 10 and 2 o'clock.  The lidocaine was injected into the cervix.  The cervix was minimally dilated with #17 Hanks dilator.  The 5-mm 30-degree hysteroscope was then inserted under direct visualization using lactated Ringer's as a distention medium.  The uterine cavity was viewed and the above normal findings were noted.  The Essure tubal occlusion was then inserted through the operative port and the tip of the Essure device easily slid into the right ostia.  The coil was advanced and easily placed and the device withdrawn.  There were three coils into the uterine cavity after removal of the insertion device.  The device was removed and reloaded.  The advice was to advance under direct visualization and the tip was inserted into the left ostia.  This passed easily and the device was inserted.  It was removed easily and three coils again were into the uterine cavity.  The hysteroscope was then removed and the ThermaChoice ablation was performed.  The uterus was then sounded to 9.5 to 10 cm.  The ThermaChoice balloon was primed and pressure was drawn to a negative 150.  The device was then moistened and inserted into the uterine cavity and the balloon was slowly filled with 40 ml of D5W.  The pressure was brought up to 170 and the cycle was initiated.  A full cycle of eight minutes was performed.  At no time there was a significant loss of pressure from the catheter balloon.  After the cycle was complete, the balloon was deflated and withdrawn.  The tenaculum was withdrawn.  No bleeding was noted.  The patient was then awakened, transferred, and taken to the recovery room in satisfactory condition.obstetrics / gynecology, menorrhagia, essure, hysteroscopy, thermachoice, uterine cavity, endometrial ablation, endometrium, fibroids, fluffy, lactated ringer, nulliparous, paracervical block, permanent sterilization, polyps, tubal occlusion, tubal ostia, lactated ringer's, ablation, uterine,
Hysterectomy - Discharge Summary - 2 

ADMISSION DIAGNOSIS: , Microinvasive carcinoma of the cervix.,DISCHARGE DIAGNOSIS: , Microinvasive carcinoma of the cervix.,PROCEDURE PERFORMED: , Total vaginal hysterectomy.,HISTORY OF PRESENT ILLNESS: , The patient is a 36-year-old, white female, gravida 7, para 5, last period mid March, status post tubal ligation.  She had an abnormal Pap smear in the 80s, which she failed to followup on until this year.  Biopsy showed a microinvasive carcinoma of the cervix and a cone biopsy was performed on 02/12/2007 also showing microinvasive carcinoma with a 1 mm invasion.  She has elected definitive therapy with a total vaginal hysterectomy.  She is aware of the future need of Pap smears.,PAST MEDICAL HISTORY: , Past history is significant for seven pregnancies, five term deliveries, and significant past history of tobacco use.,PHYSICAL EXAMINATION: , Physical exam is within normal limits with a taut normal size uterus and a small cervix, status post cone biopsy.,LABORATORY DATA AND DIAGNOSTIC STUDIES: , Chest x-ray was clear.  Discharge hemoglobin 10.8.,HOSPITAL COURSE: , She was taken to the operating room on 04/02/2007 where a total vaginal hysterectomy was performed under general anesthesia.  There was an incidental cystotomy at the time of the creation of the bladder flap.  This was repaired intraoperatively without difficulty.  Postoperative, she did very well.  Bowel and bladder function returned quickly.  She is ambulating well and tolerating a regular diet.,Routine postoperative instructions given and understood.  Followup will be in ten days for a cystogram and catheter removal with followup in the office at that time. ,DISCHARGE MEDICATIONS:,  Vicodin, Motrin, and Macrodantin at bedtime for urinary tract infection suppression.  ,DISCHARGE CONDITION: , Good.,Final pathology report was free of residual disease.obstetrics / gynecology, pap smear, total vaginal hysterectomy, hysterectomy, microinvasive, carcinoma, cervix,
Hemivulvectomy 

PREOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent vulvar melanoma.,OPERATION PERFORMED: , Radical anterior hemivulvectomy.  Posterior skinning vulvectomy.,SPECIMENS: , Radical anterior hemivulvectomy, posterior skinning vulvectomy.,INDICATIONS FOR PROCEDURE: , The patient has a history of vulvar melanoma first diagnosed in November of 1995.  She had a surgical resection at that time and recently noted recurrence of an irritated nodule around the clitoris.  Biopsy obtained by The patient confirmed recurrence.  In addition, biopsies on the posterior labia (left side) demonstrated melanoma in situ.,FINDINGS: , During the examination under anesthesia, the biopsy sites were visible and a slightly pigmented irregular area of epithelium was seen near the clitoris.  No other obvious lesions were seen.  The room was darkened and a Woods lamp was used to inspect the epithelium.  A marking pen was used to outline all pigmented areas, which included several patches on both the right and left labia.,PROCEDURE: , The patient was prepped and draped and a scalpel was used to incise the skin on the anterior portion of the specimen.  The radical anterior hemivulvectomy was designed so that a 1.5-2.0 cm margin would be obtained and the depth was carried to the fascia of the urogenital diaphragm.  Subcutaneous adipose was divided with electrocautery and the specimen was mobilized from the periosteum.  After removal of the radical anterior portion, the skin on the posterior labia and perineal body was mobilized.  Skin was incised with a scalpel and electrocautery was used to undermine.  After removal of the specimen, the wounds were closed primarily with subcutaneous interrupted stitches of 3-0 Vicryl suture.  The final sponge, needle, and instrument counts were correct at the completion of the procedure.  The patient was then taken to the Post Anesthesia Care Unit in stable condition.obstetrics / gynecology, vulvar melanoma, wide local excision, radical anterior hemivulvectomy, posterior skinning vulvectomy, vulvectomy, hemivulvectomy, melanoma, woods lamp, recurrent vulvar melanoma, anterior hemivulvectomy, vulvar, labia, radical, skinning,
Hysterectomy - Discharge Summary 

ADMISSION DIAGNOSES:,1.  Menorrhagia.,2.  Uterus enlargement.,3.  Pelvic pain.,DISCHARGE DIAGNOSIS: , Status post vaginal hysterectomy.,COMPLICATIONS: , None.,BRIEF HISTORY OF PRESENT ILLNESS: , This is a 36-year-old, gravida 3, para 3 female who presented initially to the office with abnormal menstrual bleeding and increase in flow during her period.  She also had symptoms of back pain, dysmenorrhea, and dysuria.  The symptoms had been worsening over time.  The patient was noted also to have increasing pelvic pain over the past 8 months and she was noted to have uterine enlargement upon examination.,PROCEDURE:,  The patient underwent a total vaginal hysterectomy.,HOSPITAL COURSE:  ,The patient was admitted on 09/04/2007 to undergo total vaginal hysterectomy.  The procedure preceded as planned without complication.  Uterus was sent for pathologic analysis.  The patient was monitored in the hospital, 2 days postoperatively.  She recovered quite well and vitals remained stable.,Laboratory studies, H&H were followed and appeared stable on 09/05/2007 with hemoglobin of 11.2 and hematocrit of 31.8.,The patient was ready for discharge on Monday morning of 09/06/2007.,LABORATORY FINDINGS: , Please see chart for full studies during admission.,DISPOSITION:  ,The patient was discharged to home in stable condition.  She was instructed to follow up in the office postoperatively.obstetrics / gynecology, menorrhagia, uterus enlargement, pelvic pain, total vaginal hysterectomy, vaginal hysterectomy, uterus, vaginal, hysterectomy,
Hysterectomy - Discharge Summary - 1 

ADMISSION DIAGNOSES:,1.  Menometrorrhagia.,2.  Dysmenorrhea.,3.  Small uterine fibroids.,DISCHARGE DIAGNOSES:,1.  Menorrhagia.,2.  Dysmenorrhea.,3.  Small uterine fibroids.,OPERATION PERFORMED:  ,Total vaginal hysterectomy.,BRIEF HISTORY AND PHYSICAL:  ,The patient is a 42 year-old white female, gravida 3, para 2, with two prior vaginal deliveries.  She is having increasing menometrorrhagia and dysmenorrhea.  Ultrasound shows a small uterine fibroid.  She has failed oral contraceptives and surgical therapy is planned.,PAST HISTORY: , Significant for reflux.,SURGICAL HISTORY:  ,Tubal ligation.,PHYSICAL EXAMINATION: , A top normal sized uterus with normal adnexa.,LABORATORY VALUES:  ,Her discharge hemoglobin is 12.4.,HOSPITAL COURSE: , She was taken to the operating room on 11/05/07 where a total vaginal hysterectomy was performed under general anesthesia.  Postoperatively, she has done well.  Bowel and bladder function have returned normally.  She is ambulating well, tolerating a regular diet.  Routine postoperative instructions given and said follow up will be in four weeks in the office.,DISCHARGE MEDICATIONS: , Preoperative meds plus Vicodin for pain.,DISCHARGE CONDITION: , Good.obstetrics / gynecology, dysmenorrhea, uterine fibroids, vaginal, total vaginal hysterectomy, menometrorrhagia, uterine, fibroids,