falan42/nurse_detection huggingface dataset:
Pathology - Ovarian Cyst 

GROSS DESCRIPTION: ,  Specimen labeled "right ovarian cyst" is received fresh for frozen section.  It consists of a smooth-walled, clear fluid filled cyst measuring 13x12x7 cm and weighing 1351 grams with fluid.  Both surfaces of the wall are pink-tan, smooth and grossly unremarkable.  No firm or thick areas or papillary structures are noted on the cyst wall externally or internally.  After removal the fluid, the cyst weight 68 grams.  The fluid is transparent and slightly mucoid.  A frozen section is submitted.,DIAGNOSIS: , Benign cystic ovary.,obstetrics / gynecology, right ovarian cyst, specimen, ovarian cyst, frozen section, ovarian, frozen, sectionNOTE,: 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.
OB/GYN Consultation - 4 

CHIEF COMPLAINT - REASON FOR VISIT: ,Pelvic Pain and vaginal discharge.,ABNORMAL PAP HISTORY:, Date of abnormal pap:  1998. Findings: High grade squamous intraepithelial lesions. Previous colposcopic exam and biopsies showed mild dysplasia or CIN 1. Patient is sexually active and has had 1 partner. There is no history of STD’s.,PELVIC PAIN HISTORY:, The patient complains of a gradual onset of pelvic pain 1 year ago and states condition is recurrent. Location of pain is left lower quadrant. Severity is moderately severe, intermittent and lasts for 2 hours. Quality of pain is crampy, sharp and variable.  Pain requires NSAIDs. Menstrual quality is light, flow lasts for 7 days and interval lasts for 28 days. There was no radiation of pain.,VAGINITIS HISTORY:, Symptoms have lasted for 2 weeks and persistent.  Discharge appears thin, white and with odor. Denies any itching sensation. Denies irritation. The patient denies any self treatment.,PERSONAL / SOCIAL HISTORY:, Tobacco history: Smoke’s 1 pack of cigarettes per day.  Denies the past history of alcohol. Denies past / present illegal drug use of any kind. Marital Status: Married.,PAST MEDICAL HISTORY:, Negative.,FAMILY MEDICAL HISTORY:, Negative.,ALLERGIES:, No known drug allergies/Intolerances.,CURRENT MEDICATIONS:, There are no current medications.,PAST SURGICAL HISTORY:, D & C.  1993,REVIEW OF SYSTEMS:,Gastrointestinal: The patient has no history of gastrointestinal problems and denies any present problems.,Genitourinary: Patient denies any genitourinary problems.,Gynecological: Refer to current history.,Pulmonary: Denies cough, dyspnea, tachypnea, hemoptysis.,GU: Denies frequency, nocturia and hematuria.,Neuro: Denies any problems, no seizures, no numbness, no dizziness.,PHYSICAL EXAMINATION:,Vital Signs: Weight:  104. BP:  100/70.,Chest: Lungs have equal bilateral expansion and are clear to percussion and auscultation.,Cardiovascular / Heart: Regular heart rate and rhythm without murmur or gallop.,Breast: No palpable masses.  No dimpling or retraction. No discharge. No axillary lymphadenopathy.,Abdomen: Tenderness is located in the left upper quadrant. Tenderness is mild. Bowel sounds are normal. No masses palpated.,Gynecologic: Inspection reveals the external genitalia to be normal anatomically. Cervix appears inflamed, bloody discharge and without aceto-white areas. Vagina appears normal. Vaginal discharge was white and watery.  Uterus is normal anteverted. The uterus is normal size and shape, tender to movement and movable. Bladder not tender. ,Rectal: No additional findings.,LAB / TESTS:, Hgb: 17.1 U/A: pH 6.0, spgr 1.025, trace protein, trace blood,IMPRESSION / DIAGNOSIS,1. Endometritis / Endomyometritis (615.9). ,2. Cervicitis - Endocervicitis (616.0). ,3. Pelvic Pain (625.9).,PLAN:, Pap smear done. Take metronidazole first then the Doxycycline. Return in three weeks for reevaluation.,MEDICATIONS PRESCRIBED: ,Metronidazole 500 mg #14 1 BID for 7 days.  Doxycycline 100 mg #14 1 BID.nan
Physical Exam and Pap - 1 

SUBJECTIVE:,  This 45-year-old gravida 3, para 2, SAB 1 white female presents for exam and Pap.  Last Pap was a year ago and normal.  LMP was 08/29/2004.  Her cycles are usually regular, although that one came about a week early.  Her husband has had a vasectomy.  Overall, she is feeling well.,Health history form was reviewed.  There has been no change in her personal history.  She notes that a brother who was treated 12 years ago for a brain tumor has had a recurrence and had surgery again.  Social history is unchanged.,HEALTH HABITS: , She states that for a while she was really exercising regularly and eating lots of fruits and vegetables.  Right now, she is not doing nearly as well.  She has perhaps two dairy servings daily, trying to cut down.  She is not exercising at all and fruit and vegetable intake varies.  She is a nonsmoker.  Last cholesterol was in 2003 and was normal.  She had a mammogram which was normal recently.  She is current on her tetanus update.,REVIEW OF SYSTEMS:,HEENT:  She feels as though she may have some allergies at night.  Most of her symptoms occur then, not during the day.  She will wake up with some congestion, sneezing, and then rhinorrhea.  Currently, she uses Tylenol Sinus.  Today, her symptoms are much better.  We did have rain this morning.,Respiratory and CV:  Negative.,GI:  She tends to have a little gas which is worse when she is eating more fruits and vegetables.  She had been somewhat constipated but that is better.,GU:  Negative.,Dermatologic:  She noticed an area of irritation on her right third finger on the ulnar side at the PIP joint.  It was very sensitive to water.  It seems to be slowly improving.,OBJECTIVE:,Vital Signs:  Her weight was 154 pounds, which is down 2 pounds.  Blood pressure 104/66.,General:  She is a well-developed, well-nourished, pleasant white female in no distress.,Neck:  Supple without adenopathy.  No thyromegaly or nodules palpable.,Lungs:  Clear to A&P.,Heart:  Regular rate and rhythm without murmurs.,Breasts:  Symmetrical without masses, nipple, or skin retraction, discharge, or axillary adenopathy.,Abdomen:  Soft without organomegaly, masses, or tenderness.,Pelvic:  Reveals no external lesions.  The cervix is parous.  Pap smear done.  Uterus is anteverted and normal in size, shape, and consistency, and nontender.  No adnexal enlargement.,Extremities:  Examination of her right third finger shows an area of eczematous dermatitis approximately 2 cm in length on the ulnar side.,ASSESSMENT:,1.  Normal GYN exam.,2.  Rhinitis, primarily in the mornings.  Vasomotor versus allergic.,3.  Eczematous dermatitis on right third finger.,PLAN:,1.  Discussed vasomotor rhinitis.  I suggested she try Ayr Nasal saline gel.  Another option would be a steroid spray and a sample of Nasonex is given to use two sprays in each nostril daily.,2.  Exam with Pap annually.,3.  Hydrocortisone cream to be applied to the area of eczematous dermatitis.,4.  Discussed nutrition and exercise.  I recommended at least five fruits and vegetables daily, no more than three dairy servings daily, and regular exercise at least three times a week.nan
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.obstetrics / gynecology, neoplasm, needle localized wide excision, needle localized, nonpalpable neoplasm, needle, incision, electrocautery, excision, breast
OB/GYN Consultation - 1 

PAST MEDICAL HX: , Significant for asthma, pneumonia, and depression.,PAST SURGICAL HX: , None.,MEDICATIONS:,  Prozac 20 mg q.d.  She desires to be on the NuvaRing.,ALLERGIES:,  Lactose intolerance.,SOCIAL HX: , She denies smoking or alcohol or drug use.,PE:,  VITALS: Stable.  Weight: 114 lb.  Height: 5 feet 2 inches.  GENERAL: Well-developed, well-nourished female in no apparent distress.  HEENT: Within normal limits. NECK: Supple without thyromegaly.  HEART: Regular rate and rhythm.  LUNGS: Clear to auscultation.  ABDOMEN: Soft and nontender.  There is no rebound or guarding.  No palpable masses and no peritoneal signs.  EXTREMITIES: Within normal limits.  SKIN: Warm and dry.  GU: External genitalia is without lesion.  Vaginal is clean without discharge.  Cervix appears normal; however, a colposcopy was performed using acetic acid, which showed a thick acetowhite ring around the cervical os and extending into the canal.  BIMANUAL: Reveals significant cervical motion tenderness and fundal tenderness.  She had no tenderness in her adnexa.  There are no palpable masses.,A:,  Although unlikely based on the patient's exam and pain, I have to consider subclinical pelvic inflammatory disease.  GC and chlamydia was sent and I treated her prophylactically with Rocephin 250 mg and azithromycin 1000 mg.  Repeat biopsies were not performed based on her colposcopy as well as her previous Pap and colposcopy by Dr. A.  A LEEP is a reasonable approach even in this 16-year-old.,P:,  We will schedule LEEP in the near future.  Even though she has already been exposed HPV Gardasil would still be beneficial in this patient to help prevent recurrence of low-grade lesions as well as high-grade lesions.  Now, we have her given her first shot.obstetrics / gynecology, gravida, ecc, external genitalia, hpv, leep, pap, acetowhite, biopsies, blood with urination, cervical os, colposcopy, intraepithelial, right lower quadrant, squamous, suspicious, vaginal discharge, low grade pap, low grade,
MRI Breast - 1 

FINDINGS:,There are post biopsy changes seen in the retroareolar region, middle third aspect of the left breast at the post biopsy site.,There is abnormal enhancement seen in this location compatible with patient’s history of malignancy.,There is increased enhancement seen in the inferior aspect of the left breast at the 6:00 o’clock, N+5.5 cm position measuring 1.2 cm. Further work-up with ultrasound is indicated.,There are other multiple benign appearing enhancing masses seen in both the right and left breasts.,None of the remaining masses appear worrisome for malignancy based upon MRI criteria.,IMPRESSION:,  BIRADS CATEGORY M/5,There is a malignant appearing area of enhancement in the left breast which does correspond to the patient’s history of recent diagnosis of malignancy.,She has been scheduled to see a surgeon, as well as Medical Oncologist.,Dedicated ultrasonography of the inferior aspect of the left breast should be performed at the 6:00 o’clock, N+5.5 cm position for further evaluation of the mass. At that same time, ultrasonography of the remaining masses should also be performed.,Please note, however that the remaining masses have primarily benign features based upon MRI criteria. However, further evaluation with ultrasound should be performed.obstetrics / gynecology, breast cancer, bilateral breast mri, bilateral breast, iv contrast, contrast, ultrasound, ultrasonography, malignancy, mri, benign, masses, breast
Lysis of Pelvic Adhesions 

PREOPERATIVE DIAGNOSIS: , Multiple pelvic adhesions.,POSTOPERATIVE DIAGNOSIS: , Multiple pelvic adhesions.,PROCEDURE PERFORMED: ,Lysis of pelvic adhesions.,ANESTHESIA: , General with local.,SPECIMEN: , None.,COMPLICATIONS: , None.,HISTORY: , The patient is a 32-year-old female who had an 8 cm left ovarian mass, which was evaluated by Dr. X.  She had a ultrasound, which demonstrated the same.  The mass was palpable on physical examination and was tender.  She was scheduled for an elective pelvic laparotomy with left salpingooophorectomy.  During the surgery, there were multiple pelvic adhesions between the left ovarian cyst and the sigmoid colon.  These adhesions were taken down sharply with Metzenbaum scissors.,PROCEDURE: , A pelvic laparotomy had been performed by Dr. X.  Upon exploration of the abdomen, multiple pelvic adhesions were noted as previously stated.  A 6 cm left ovarian cyst was noted with adhesions to the sigmoid colon and mesentery.  These adhesions were taken down sharply with Metzenbaum scissors until the sigmoid colon was completely freed from the ovarian cyst.  The ureter had been identified and isolated prior to the adhesiolysis.  There was no evidence of bleeding.  The remainder of the case was performed by Dr. X and this will be found in a separate operative report.obstetrics / gynecology, lysis of pelvic adhesions, pelvic adhesions, pelvic, adhesions, salpingooophorectomy, lysis, laparotomy, sigmoid, colon, mass, ovarian,
Low-Transverse C-Section - 4 

PREOPERATIVE DIAGNOSES:,1.  Postdates pregnancy.,2.  Failure to progress.,3.  Meconium stained amniotic fluid.,POSTOPERATIVE DIAGNOSES:,1.  Postdates pregnancy.,2.  Failure to progress.,3.  Meconium stained amniotic fluid.,OPERATION:,  Primary low-transverse C-section.,ANESTHESIA:,  Epidural.,DESCRIPTION OF OPERATION:  ,The patient was taken to the operating room and under epidural anesthesia, she was prepped and draped in the usual manner.  Anesthesia was tested and found to be adequate.  Incision was made, Pfannenstiel, approximately 1.5 fingerbreadths above the symphysis pubis and carried sharply through subcutaneous and fascial layers without difficulty; the fascia being incised laterally.  Bleeders were bovied.  Rectus muscles were separated from the overlying fascia with blunt and sharp dissection.  Muscles were separated in the midline.  Peritoneum was entered sharply and incision was carried out laterally in each direction.  Bladder blade was placed and bladder flap developed with blunt and sharp dissection.  A horizontal _______ incision was made in the lower uterine segment and carried laterally in each direction.  Allis was placed in the incision, and an uncomplicated extraction of a 7 pound 4 ounce, Apgar 9 female was accomplished and given to the pediatric service in attendance.  Infant was carefully suctioned after delivery of the head and body.  Cord blood was collected.  _______ and endometrial cavity was wiped free of membranes and clots.  Lower segment incision was inspected.  There were some extensive adhesions on the left side and a figure-of-eight suture of 1 chromic was placed on both lateral cuff borders and the cuff was closed with two interlocking layers of 1 chromic.  Bleeding near the left cuff required an additional suture of 1 chromic after which hemostasis was present.  Cul-de-sac was suctioned free of blood and clots and irrigated.  Fundus was delivered back into the abdominal cavity and lateral gutters were suctioned free of blood and clots and irrigated.  Lower segment incision was again inspected and found to be hemostatic.  The abdominal wall was then closed in layers, 2-0 chromic on the peritoneum, 0 Maxon on the fascia, 3-0 plain on the subcutaneous and staples on the skin.  Hemostasis was present between all layers.  The area was gently irrigated across the peritoneum and fascial layers.  There were no intraoperative complications except blood loss.  The patient was taken to the recovery room in satisfactory condition.obstetrics / gynecology, pregnancy, meconium stained amniotic fluid, low transverse c section, amniotic fluid, meconium, peritoneum, blood, chromic, fascial, amniotic, incision,
Low -Segment C-Section 

PREOPERATIVE DIAGNOSIS:  ,Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,POSTOPERATIVE DIAGNOSIS: , Pregnancy at 42 weeks, nonreassuring fetal testing, and failed induction.,PROCEDURE: , Primary low segment cesarean section.  The patient was placed in the supine position under spinal anesthesia with a Foley catheter in place and she was prepped and draped in the usual manner.  A low abdominal transverse skin incision was constructed and carried down through the subcutaneous tissue through the anterior rectus fascia.  Bleeding points were snapped and coagulated along the way.  The fascia was opened transversally and was dissected sharply and bluntly from the underlying rectus muscles.  These were divided in the midline revealing the peritoneum, which was opened vertically.  The uterus was in mid position.  The bladder flap was incised elliptically and reflected caudad.  A low transverse hysterotomy incision was then constructed and extended bluntly.  Amniotomy revealed clear amniotic fluid.  A live born vigorous male infant was then delivered from the right occiput transverse position.  The infant breathed and cried spontaneously.  The nares and pharynx were suctioned.  The umbilical cord was clamped and divided and the infant was passed to the waiting neonatal team.  Cord blood samples were obtained.  The placenta was manually removed and the uterus was eventrated for closure.  The edges of the uterine incision were grasped with Pennington clamps and closure was carried out in standard two-layer technique using 0 Vicryl suture with the second layer imbricating the first.  Hemostasis was completed with an additional figure-of-eight suture of 0 Vicryl.  The cornual sac and gutters were irrigated.  The uterus was returned to the abdominal cavity.  The adnexa were inspected and were normal.  The abdomen was then closed in layers.  Fascia was closed with running 0 Vicryl sutures, subcutaneous tissue with running 3-0 plain Catgut, and skin with 3-0 Monocryl subcuticular suture and Steri-Strips.  Blood loss was estimated at 700 mL.  All counts were correct.,The patient tolerated the procedure well and left the operating room in excellent condition.obstetrics / gynecology, nonreassuring fetal testing, anterior rectus fascia, pennington clamps, fetal testing, low segment, induction, suture,
LEEP 

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

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

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