falan42/nurse_detection huggingface dataset:
Sinus problems - Consult 

CHIEF COMPLAINT:, Sinus problems.,SINUSITIS HISTORY:, The problem began 2 weeks ago and is constant. Symptoms include postnasal drainage, sore throat, facial pain, coughing, headaches and congestion. Additional symptoms include snoring, nasal burning and teeth pain. The symptoms are characterized as moderate to severe. Symptoms are worse in the evening and morning.,REVIEW OF SYSTEMS:,ROS General: General health is good.,ROS ENT: As noted in history of present Illness listed above.,ROS Respiratory: Patient denies any respiratory complaints, such as cough, shortness of breath, chest pain, wheezing, hemoptysis, etc.,ROS Gastrointestinal: Patient denies any nausea, vomiting, abdominal pain, dysphagia or any altered bowel movements.,ROS Respiratory: Complaints include coughing.,ROS Neurological: Patient complains of headaches. All other systems are negative.,PAST SURGICAL HISTORY:, Gallbladder 7/82. Hernia 5/79,PAST MEDICAL HISTORY:, Negative.,PAST SOCIAL HISTORY:, Marital Status: Married. Denies the use of alcohol. Patient has a history of smoking 1 pack of cigarettes per day and for the past 15 years. There are no animals inside the home.,FAMILY MEDICAL HISTORY:, Family history of allergies and hypertension.,CURRENT MEDICATIONS:, Claritin. Dilantin.,PREVIOUS MEDICATIONS UTILIZED:, Rhinocort Nasal Spray.,EXAM:,Exam Ear: Auricles/external auditory canals reveal no significant abnormalities bilaterally. TMs intact with no middle ear effusion and are mobile to insufflation.,Exam Nose: Intranasal exam reveals moderate congestion and purulent mucus.,Exam Oropharynx: Examination of the teeth/alveolar ridges reveals missing molar (s). Examination of the posterior pharynx reveals a prominent uvula and purulent postnasal drainage. The palatine tonsils are 2+ and cryptic.,Exam Neck: Palpation of anterior neck reveals no tenderness. Examination of the posterior neck reveals mild tenderness to palpation of the suboccipital muscles.,Exam Facial: There is bilateral maxillary sinus tenderness to palpation.,X-RAY / LAB FINDINGS:, Water's view x-ray reveals bilateral maxillary mucosal thickening.,IMPRESSION:, Acute maxillary sinusitis (461.0).  Snoring (786.09).,MEDICATION:, Augmentin. 875 mg bid. MucoFen 800 mg bid.,PLAN:,nan
SOM - Serous Otitis Media 

Because children need hearing to learn speech, hearing loss from fluid in the middle ear can result in speech delay.  Children begin to speak some words by 18 months.  Children with fluid in both ears can show significant delay in their use of language.  In addition, young children learn to pronounce words by hearing them spoken.  When there is a hearing loss, even a mild one, the spoken words of parents and siblings are distorted to the child with fluid in the ears.  Identification of fluid in the middle ear is important, not only to prevent future speech problems, but to avoid permanent damage to the eardrum and the middle ear.  Most children will have at least one ear infection before the age of four.,With treatment, the ear infections clear up promptly.  Without the follow-up visit, fluid may still be present, even though the child has no complaints or symptoms.  Therefore, it is essential that ear infections be rechecked after initial treatment.  Usually, the presence of fluid results in a "mild conductive hearing loss." This could be as much as 30% hearing loss overall.  After the specialist confirms that fluid is present behind both eardrums, further medical treatment is often advised.  This may consist of additional antibiotics, decongestants, and in some cases, nasal sprays.  If fluid has been present for over 12 weeks, surgical drainage of the fluid is often indicated.  The decision to perform surgery should be based on the response to medical treatment, the degree of hearing loss and the appearance of the eardum itself under the surgical microscope.  Surgery which drains fluid involves a small incision in the eardrum, so that the fluid can be gently removed and a tube can be inserted.  The procedure, medically termed a myringotomy and tubes, or tympanostomy and tube, (BMT if Bilateral) or PET (Pressure Equalizing Tubes), is performed on children under general anesthesia.ent - otolaryngology, tube, bmt, pet, pressure equalizing tubes, serous otitis media, eustachian tube, ear infections, otitis media, middle ear, hearing loss, ear, children, fluid, drain, eustachian, otitis, media, eardrum, infections, middle, loss, hearingNOTE,: 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.,
Septoplasty & Turbinectomy 

OPERATIVE DIAGNOSES: , Chronic sinusitis with deviated nasal septum and nasal obstruction and hypertrophied turbinates.,OPERATIONS PERFORMED: , Septoplasty with partial inferior middle turbinectomy with KTP laser, sinus endoscopy with maxillary antrostomies, removal of tissue, with septoplasty and partial ethmoidectomy bilaterally.,OPERATION: , The patient was taken to the operating room.  After adequate anesthesia via endotracheal intubation, the nose was prepped with Afrin nasal spray.  After this was done, 1% Xylocaine with 100,000 epinephrine was infiltrated in both sides of the septum and the mucoperichondrium.  After this, the sinus endoscope at 25-degrees was then used to examine the nasal cavity in the left nasal cavity and staying lateral to the middle turbinate.  A 45-degree forceps then used to open up the maxillary sinus.  There was some prominent tissue and just superior to this, the anterior ethmoid was opened.  The 45-degree forceps was then used to open the maxillary sinus ostium.  This was enlarged with backbiting rongeur.  After this was done, the tissue found in the ethmoid and maxillary sinus were removed and sent to pathology and labeled as left maxillary sinus mucosa.  After this was done, attention was then turned to the right nasal cavity staying laterally to the middle turbinate.  There was noted to have prominence in the anterior ethmoidal area.  This was then opened with 45-degree forceps.  This mucosa was then removed from the anterior area.  The maxillary sinus ostium was then opened with 45-degree forceps.  Tissue was removed from this area.  This was sent as right maxillary mucosa.  After this, the backbiting rongeur was then used to open up the ostium and enlarge the ostium on the right maxillary sinus.  Protecting the eyes with wet gauze and using KTP laser at 10 watts, the sinus endoscope was used for observation and the submucosal resection was done of both inferior turbinates as well as anterior portion of the middle turbinates bilaterally.  This was to open up to expose the maxillary ostium as well as other sinus ostium to minimize swelling and obstruction.  After this was completed, a septoplasty was performed.  The incision was made with a #15 blade Bard-Parker knife.  The flap was then elevated, overlying the spur that was protruding into the right nasal cavity.  This was excised with a #15 blade Bard-Parker knife.  The tissue was then laid back in position.  After this was laid back in position, the nasal cavity was irrigated with saline solution, suctioned well as well as the oropharynx.  , ,Surgicel with antibiotic ointment was placed in each nostril and sutured outside the nose with 3-0 nylon.  The patient was then awakened and taken to recovery room in good condition.ent - otolaryngology, sinusitis, ktp laser, septoplasty, deviated, endoscopy, ethmoidectomy, hypertrophied, maxillary, nasal obstruction, nasal septum, sinus, turbinates, turbinectomy, partial ethmoidectomy, parker knife, sinus ostium, nasal cavity, maxillary sinus, ktp, mucosa, cavity, forceps, antrostomies, ostium, nasal
Progress Note - Supraglottitis 

HISTORY: , A 59-year-old male presents in followup after being evaluated and treated as an in-patient by Dr. X for acute supraglottitis with airway obstruction and parapharyngeal cellulitis and peritonsillar cellulitis, admitted on 05/23/2008, discharged on 05/24/2008.  Please refer to chart for history and physical and review of systems and medical record.,PROCEDURES PERFORMED:  ,Fiberoptic laryngoscopy identifying about 30% positive Muller maneuver.  No supraglottic edema; +2/4 tonsils with small tonsil cyst, mid tonsil, left.,IMPRESSION:  ,1.  Resolving acute supraglottic edema secondary to pharyngitis and tonsillar cellulitis.,2.  Possible obstructive sleep apnea; however, the patient describes no known history of this phenomenon.,3.  Hypercholesterolemia.,4.  History of anxiety.,5.  History of coronary artery disease.,6.  Hypertension.,RECOMMENDATIONS: , Recommend continuing on Augmentin and tapered prednisone as prescribed by Dr. X.  Cultures are still pending and follow up with Dr. X in the next few weeks for re-evaluation.  I did discuss with the patient whether or not a sleep study would be beneficial and the patient denies any history of obstructive sleep apnea and wishes not to pursue this, but we will leave this open for him to talk with Dr. X on his followup, and he will pay more attention on his sleep pattern.ent - otolaryngology, acute supraglottic edema, obstructive sleep apnea, acute supraglottitis, airway obstruction, parapharyngeal cellulitis, peritonsillar cellulitis, supraglottic edema, supraglottitis, tonsils, cellulitis
Sample Normal Exam - ENT 

NASAL EXAM: , The nose is grossly in the midline with no evidence of fractures or dislocations.  The nasal septum is roughly in the midline with pale boggy mucosa and moderately enlarged inferior turbinates.  There is no pus or polyps in the nose on anterior rhinoscopy.  The airway appears adequate.  No external valve prolapses are observed.,THROAT EXAM: , The oral cavity is clear.  The tongue is clear with no lesions noted and with good symmetrical movement.  The parotid and submaxillary ducts are producing clear mucus with no evidence of stones or infection.  Palate is clear.  The tonsils are not prominent.,No overt neoplasms in the mouth are noted.  Lips are clear.  The voice is adequate no deficits or hoarseness.  The saliva is clear.,EARS:  ,Canals are clear.  Eardrums are clear, moving on insufflation and swallowing.  No discharge is noted in the canals.  Hearing appears adequate in normal tonal conversations.,NECK EXAM: , Neck is supple with no palpable masses.  No lymphadenopathy.  The thyroid gland is not palpable.  The trachea is in the midline.  The parotid and submaxillary glands are not enlarged, are symmetrical and are not tender.  The neck movement is adequate.,GROSS NEUROLOGICAL EXAM: , Cranial nerves II-XII are intact.  Extraocular movements are full with no restrictions.  Patient is alert and responsive.,EYE EXAM: , Sclerae are clear.  Conjunctivae are clear.  Pupils respond symmetrically to light.  Extraocular movements are complete and full.ent - otolaryngology, ent exam, boggy mucosa, inferior turbinates, nasal septum, nose, oral cavity, rhinoscopy, submaxillary ducts, tongue, neck, submaxillary, parotid, parotid and submaxillary, extraocular movements, ent, nasal
Postop Parathyroid Exploration & Parathyroidectomy 

SUMMARY:  ,This patient is one-day postop open parathyroid exploration with subtotal parathyroidectomy and intraoperative PTH monitoring for parathyroid hyperplasia.  She has had an uneventful postoperative night.  She put out 1175 mL of urine since surgery.  Her incision looks good.  IV site and extremities are unremarkable.,LABORATORY DATA:  ,Her calcium level was 7.5 this morning.  She has been on three Tums orally b.i.d. and I am increasing three Tums orally q.i.d. before meals and at bedtime.,PLAN:,  I will heparin lock her IV, advance her diet, and ambulate her.  I have asked her to increase her prednisone when she goes home.  She will double her regular dose for the next five days.  I will advance her diet.  I will continue to monitor her calcium levels throughout the day.  If they stabilize, I am hopeful that she will be ready for discharge either later today or tomorrow.  She will be given Lortab Elixir 2 to 4 teaspoons orally every four hours p.r.n. pain, dispensed #240 mL with one refill.  Her final calcium dosage will be determined prior to discharge.  I will plan to see her back in the office on the 12/30/08, and she has been instructed to call or return sooner for any problems.ent - otolaryngology, parathyroid hyperplasia, parathyroid exploration, pth, hyperplasia, parathyroidectomy, parathyroidNOTE
Parotidectomy 

 Parotidectomy procedureent - otolaryngology, parotidectomy, mixter clamp, auditory canal, buccal, buccinator, curved clamp, earlobe, fascia, fat layer, frontotemporal, mandibular, mastoid process, parotid, parotid duct, parotid gland, preauricular, preauricular incision, sternocleidomastoid, suction drain, temporoparotid, tied with vicryl sutures, vicryl, gland, nerve, sutures, incisionNOTE,: 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.,
ORIF Facial Fractures - Followup 

Mr. ABC was transferred to room 123 this afternoon.  We discussed this with the nurses, and it was of course cleared by Dr. X.  The patient is now on his third postoperative day for an open reduction and internal fixation for two facial fractures, as well as open reduction nasal fracture.  He is on his eighth hospital day.,The patient had nasal packing in place, which was removed this evening.  This will make it much easier for him to swallow.  This will facilitate p.o. fluids and IMF diet.,Examination of the face revealed some decreased swelling today.  He had good occlusion with intact intermaxillary fixation.,His tracheotomy tube is in place.  It is a size 8 Shiley nonfenestrated.  He is being suctioned comfortably.,The patient is in need of something for sleep in the evening, so we have recommended Halcion 5 mg at bedtime and repeat of 5 mg in 1 hour if needed.,Tomorrow, we will go ahead and change his trach to a noncuffed or a fenestrated tube, so he may communicate and again this will facilitate his swallowing.  Hopefully, we can decannulate the tracheotomy tube in the next few days.,Overall, I believe this patient is doing well, and we will look forward to being able to transfer him to the prison infirmary.ent - otolaryngology, fenestrated tube, nasal fracture, facial fractures, orif, tracheotomy, tube, fractures,
Normal ENT Exam 

EARS, NOSE, MOUTH AND THROAT: , The nose is without any evidence of any deformity.  The ears are with normal-appearing pinna.  Examination of the canals is normal appearing bilaterally.  There is no drainage or erythema noted.  The tympanic membranes are normal appearing with pearly color, normal-appearing landmarks and normal light reflex.  Hearing is grossly intact to finger rubbing and whisper.  The nasal mucosa is moist.  The septum is midline.  There is no evidence of septal hematoma.  The turbinates are without abnormality.  No obvious abnormalities to the lips.  The teeth are unremarkable.  The gingivae are without any obvious evidence of infection.  The oral mucosa is moist and pink.  There are no obvious masses to the hard or soft palate.  The uvula is midline.  The salivary glands appear unremarkable.  The tongue is midline.  The posterior pharynx is without erythema or exudate.  The tonsils are normal appearing.ent - otolaryngology, erythema, tympanic, mouth, throat, ears, mucosa, noseNOTE,: 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.,
Otitis Media 

OTITIS MEDIA, is an infection of the middle ear space where the small bones and nerves of the ear connect to the eardrum on one side and the eustachian tube on the other.  The ear infection itself is not contagious but the respiratory infection preceding it is transmittable.  Otitis media is most often seen in infants and young children.  There are several causes including a viral or bacterial infection that spreads to the middle ear by way of the eustachian tubes, nasal allergy drainage blocking the sinuses or eustachian tubes, enlarged adenoids also blocking sinuses or eustachian tubes and eardrum rupture.  Many factors can increase the risk of an ear infection like recent upper respiratory tract illness, crowded living conditions, family history of ear infections, day care, smoking in household, altitude changes, cold weather and genetic factors.,SIGNS AND SYMPTOMS:,*  Irritability.,*  Ear pain, fullness, hearing loss.,*  Infants may pull on ear.,*  Fever.,*  Vomiting.,*  Discharge from ear.,*  Diarrhea.,TREATMENT:,*  Diagnosis is by physical exam and otoscopic exam.  Sometimes fluid from the ear is cultured.,*  Pain relievers, like acetaminophen (Tylenol).  Infant pain relievers are available.,*  Decongestant to relieve symptoms of upper respiratory tract infection.,*  Antibiotics when indicated for bacterial infection such as Amoxicillin or Zithromycin.  Finish ALL antibiotics as prescribed.  Do not stop the medication even if symptoms subside.,*  Avoid swimming until infection goes away.,*  Surgery is sometimes necessary to put in tubes through the eardrum to equalize pressure and drain fluids.,*  Surgery to remove adenoids if they are enlarged.,*  Reduce activity until symptoms subside.,Call doctor's office if symptoms do not improve within 2 days of treatment, and for convulsion, fever, ear swelling, dizziness, twitching facial muscles and severe headache.ent - otolaryngology, ear, ear infection, otitis media, sinuses, drainage, ear pain, fullness, hearing loss, ear swelling, fever, bacterial infection, eustachian tubes, infection, eardrum, respiratory, otitis, media, eustachian, tubes,
Normal ENT Exam - 1 

EARS, NOSE, MOUTH AND THROAT,EARS/NOSE: , The auricles are normal to palpation and inspection without any surrounding lymphadenitis.  There are no signs of acute trauma.  The nose is normal to palpation and inspection externally without evidence of acute trauma.  Otoscopic examination of the auditory canals and tympanic membranes reveals the auditory canals without signs of mass lesion, inflammation or swelling.  The tympanic membranes are without disruption or infection.  Hearing intact bilaterally to normal level speech.  Nasal mucosa, septum and turbinate examination reveals normal mucous membranes without disruption or inflammation.  The septum is without acute traumatic lesions or disruption.  The turbinates are without abnormal swelling.  There is no unusual rhinorrhea or bleeding.  ,LIPS/TEETH/GUMS:  ,The lips are without infection, mass lesion or traumatic lesions.  The teeth are intact without obvious signs of infection.  The gingivae are normal to palpation and inspection.  ,OROPHARYNX:  ,The oral mucosa is normal.  The salivary glands are without swelling.  The hard and soft palates are intact.  The tongue is without masses or swelling with normal movement.  The tonsils are without inflammation.  The posterior pharynx is without mass lesion with good patent oropharyngeal airway.ent - otolaryngology, oral mucosa, lips, hearing, auditory canals, tympanic membranes, traumatic lesions, mouth, throat, trauma, nose, membranes, inflammation, infection, swelling,
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.ent - otolaryngology, metastatic papillary cancer, thyroidectomy, thyroid cancer, papillary cell type, dissection, neck, metastatic, paratracheal, papillary, cancer