falan42/nurse_detection huggingface dataset:
Vaginal Hysterectomy 

 Vaginal Hysterectomy.  A weighted speculum was placed in the posterior vaginal vault.  The cervix was grasped with a Massachusetts clamp on both its anterior and posterior lips.surgery, omentum, massachusetts, vaginal hysterectomy, vaginal vault, vaginal mucosa, vicryl suture, hysterectomy, ligaments, speculum, ligated, vaginal, sutureNOTE,: 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.,
Umbilical Hernia Repair 

PREOPERATIVE DIAGNOSIS: , Umbilical hernia.,POSTOPERATIVE DIAGNOSIS: , Umbilical hernia.,PROCEDURE PERFORMED: , Repair of umbilical hernia.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,PROCEDURE IN DETAIL:  ,The patient was prepped and draped in the sterile fashion.  An infraumbilical incision was formed and taken down to the fascia.  The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia, and then the wounds were infiltrated with 0.25% Marcaine.  The skin was reattached to the fascia with 2-0 Vicryls.  The skin was approximated with 2-0 Vicryl subcutaneous and then 4-0 Monocryl subcuticular stitches, dressed with Steri-Strips and 4 x 4's.  Patient was extubated and taken to the recovery area in stable condition.surgery, marcaine, steri-strips, mattress sutures, umbilical hernia, repair, umbilical, hernia,
Upper Endoscopy  

PROCEDURE:,  Upper endoscopy with removal of food impaction.,HISTORY OF PRESENT ILLNESS: , A 92-year-old lady with history of dysphagia on and off for two years.  She comes in this morning with complaints of inability to swallow anything including her saliva.  This started almost a day earlier.  She was eating lunch and had beef stew and suddenly noticed inability to finish her meal and since then has not been able to eat anything.  She is on Coumadin and her INR is 2.5.,OPERATIVE NOTE: , Informed consent was obtained from patient.  The risks of aspiration, bleeding, perforation, infection, and serious risk including need for surgery and ICU stay particularly in view of food impaction for almost a day was discussed.  Daughter was also informed about the procedure and risks.  Conscious sedation initially was administered with Versed 2 mg and fentanyl 50 mcg.  The scope was advanced into the esophagus and showed liquid and solid particles from mid esophagus all the way to the distal esophagus.  There was a meat bolus in the distal esophagus.  This was visualized after clearing the liquid material and small particles of what appeared to be carrots.  The patient, however, was not tolerating the conscious sedation.  Hence, Dr. X was consulted and we continued the procedure with propofol sedation.,The scope was reintroduced into the esophagus after propofol sedation.  Initially a Roth net was used and some small amounts of soft food in the distal esophagus was removed with the Roth net.  Then, a snare was used to cut the meat bolus into pieces, as it was very soft.  Small pieces were grabbed with the snare and pulled out.  Thereafter, the residual soft meat bolus was passed into the stomach along with the scope, which was passed between the bolus and the esophageal wall carefully.  The patient had severe bruising and submucosal hemorrhage in the esophagus possibly due to longstanding bolus impaction and Coumadin therapy.  No active bleeding was seen.  There was a distal esophageal stricture, which caused slight resistance to the passage of the scope into the stomach.  As this area was extremely inflamed, a dilatation was not attempted.,IMPRESSION: , Distal esophageal stricture with food impaction.  Treated as described above.,RECOMMENDATIONS:,  IV Protonix 40 mg q.12h.  Clear liquid diet for 24 hours.  If the patient is stable, thereafter she may take soft pureed diet only until next endoscopy, which will be scheduled in three to four weeks.  She should take Prevacid SoluTab 30 mg b.i.d. on discharge.surgery, dysphagia, removal of food impaction, distal esophagus, stomach, distal esophageal, esophageal stricture, upper endoscopy, food impaction, endoscopy, aspiration, sedation, bolus, impaction, esophagus,
Urgent Cardiac Cath 

PROCEDURE: , Urgent cardiac catheterization with coronary angiogram.,PROCEDURE IN DETAIL: , The patient was brought urgently to the cardiac cath lab from the emergency room with the patient being intubated with an abnormal EKG and a cardiac arrest.  The right groin was prepped and draped in usual manner.  Under 2% lidocaine anesthesia, the right femoral artery was entered.  A 6-French sheath was placed.  The patient was already on anticoagulation.  Selective coronary angiograms were then performed using a left and a 3DRC catheter.  The catheters were reviewed.  The catheters were then removed and an Angio-Seal was placed.  There was some hematoma at the cath site.,RESULTS,1.  The left main was free of disease.,2.  The left anterior descending and its branches were free of disease.,3.  The circumflex was free of disease.,4.  The right coronary artery was free of disease.  There was no gradient across the aortic valve.,IMPRESSION: , Normal coronary angiogram.,surgery, cardiac catheterization, coronary angiogram, angiogram
Umbilical Hernia Repair - 1 

PROCEDURE PERFORMED: , Umbilical hernia repair.,PROCEDURE:,  After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table.  The patient was sedated, and an adequate local anesthetic was administered using 1% lidocaine without epinephrine.  The patient was prepped and draped in the usual sterile manner.,A standard curvilinear umbilical incision was made, and dissection was carried down to the hernia sac using a combination of Metzenbaum scissors and Bovie electrocautery.  The sac was cleared of overlying adherent tissue, and the fascial defect was delineated.  The fascia was cleared of any adherent tissue for a distance of 1.5 cm from the defect.  The sac was then placed into the abdominal cavity and the defect was closed primarily using simple interrupted 0 Vicryl sutures.  The umbilicus was then re-formed using 4-0 Vicryl to tack the umbilical skin to the fascia.,The wound was then irrigated using sterile saline, and hemostasis was obtained using Bovie electrocautery.  The skin was approximated with 4-0 Vicryl in a subcuticular fashion.  The skin was prepped with benzoin, and Steri-Strips were applied.  A dressing was then applied.  All surgical counts were reported as correct.,Having tolerated the procedure well, the patient was subsequently taken to the recovery room in good and stable condition.surgery, fascial defect, umbilical hernia repair, curvilinear umbilical, hernia sac, metzenbaum scissors, umbilical hernia, bovie electrocautery, electrocautery, hernia, incision, umbilical,
Vacuum D&C 

PREOPERATIVE DIAGNOSIS: , Blighted ovum, severe cramping.,POSTOPERATIVE DIAGNOSIS:,  Blighted ovum, severe cramping.,OPERATION PERFORMED: , Vacuum D&C.,DRAINS: , None.,ANESTHESIA: , General.,HISTORY: , This 21-year-old white female gravida 1, para 0 who was having severe cramping and was noted to have a blighted ovum with her first ultrasound in the office.  Due to the severe cramping, a decision to undergo vacuum D&C was made.  At the time of the procedure, moderate amount of tissue was obtained.,PROCEDURE:  ,The patient was taken to the operating room and placed in a supine position, at which time a general form of anesthesia was administered by the anesthesia department.  The patient was then repositioned in a modified dorsal lithotomy position and then prepped and draped in the usual fashion.  A weighted vaginal speculum was placed in the posterior vaginal vault.  Anterior lip of the cervix was grasped with single tooth tenaculum, and the cervix was dilated to approximately 8 mm straight.  Plastic curette was placed into the uterine cavity and suction was applied at 60 mmHg to remove the tissue.  This was followed by gentle curetting of the lining as well as followed by suction curetting and then another gentle curetting and a final suction.  Methargen 0.2 mg was given IM and Pitocin 40 units and a 1000 was also started at the time of the procedure.  Once the procedure was completed, the single tooth tenaculum was removed from the vaginal vault with some _____ remaining blood and the weighted speculum was also removed.  The patient was repositioned to supine position and taken to recovery room in stable condition.surgery, pitocin, single tooth tenaculum, vaginal vault, vacuum d&c, blighted ovum, speculum, tenaculum, curetting, blighted, cramping,
Ulnar Nerve Transposition 

PROCEDURE:,  Subcutaneous ulnar nerve transposition.,PROCEDURE IN DETAIL: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion.  The arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg.,A curvilinear incision was made over the medial elbow, starting proximally at the medial intermuscular septum, curving posterior to the medial epicondyle, then curving anteriorly along the path of the ulnar nerve.  Dissection was carried down to the ulnar nerve.  Branches of the medial antebrachial and the medial brachial cutaneous nerves were identified and protected.,Osborne's fascia was released, an ulnar neurolysis performed, and the ulnar nerve was mobilized.  Six cm of the medial intermuscular septum was excised, and the deep periosteal origin of the flexor carpi ulnaris was released to avoid kinking of the nerve as it was moved anteriorly.,The subcutaneous plane just superficial to the flexor-pronator mass was developed.  Meticulous hemostasis was maintained with bipolar electrocautery.  The nerve was transposed anteriorly, superficial to the flexor-pronator mass.  Motor branches were dissected proximally and distally to avoid tethering or kinking the ulnar nerve.,A semicircular medially based flap of flexor-pronator fascia was raised and sutured to the subcutaneous tissue in such a way as to prevent the nerve from relocating.  The subcutaneous tissue and skin were closed with simple interrupted sutures.  Marcaine with epinephrine was injected into the wound.  The elbow was dressed and splinted.  The patient was awakened and sent to the recovery room in good condition, having tolerated the procedure well.surgery, neurolysis, ulnar, periosteal, flexor-pronator mass, ulnar nerve transposition, medial intermuscular septum, nerve transposition, intermuscular septum, flexor pronator, ulnar nerve, nerve
Upper Endoscopy - Foreign Body Removal 

PROCEDURE:, Upper endoscopy with foreign body removal.,PREOPERATIVE DIAGNOSIS (ES):, Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS (ES):, Penny in proximal esophagus.,ESTIMATED BLOOD LOSS:, None.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,After informed consent was obtained, the patient was taken to the pediatric endoscopy suite. After appropriate sedation by the anesthesia staff and intubation, an upper endoscope was inserted into the mouth, over the tongue, into the esophagus, at which time the foreign body was encountered. It was grasped with a coin removal forcep and removed with an endoscope. At that time, the endoscope was reinserted, advanced to the level of the stomach and stomach was evaluated and was normal. The esophagus was normal with the exception of some mild erythema, where the coin had been sitting. There were no erosions. The stomach was decompressed of air and fluid. The scope was removed without difficulty.,SUMMARY:, The patient underwent endoscopic removal of esophageal foreign body.,PLAN:, To discharge home, follow up as needed.surgery, upper endoscopy, endoscopy, endoscopy suite, esophagus, foreign body, foreign body removal, esophageal foreign body, stomach,
Tympanostomy & Myringotomy Tube Placement 

PREOPERATIVE DIAGNOSES:,1.  Chronic otitis media with effusion.,2.  Conductive hearing loss.,POSTOPERATIVE DIAGNOSES:,1.  Chronic otitis media with effusion.,2.  Conductive hearing loss.,PROCEDURE PERFORMED: , Bilateral tympanostomy with myringotomy tube placement _______ split tube 1.0 mm.,ANESTHESIA:  ,Total IV general mask airway.,ESTIMATED BLOOD LOSS:  ,None.,COMPLICATIONS: , None.,INDICATIONS FOR PROCEDURE:,  The patient is a 1-year-old male with a history of chronic otitis media with effusion and conductive hearing loss refractory to outpatient medical therapy.  After risks, complications, consequences, and questions were addressed with the family, a written consent was obtained for the procedure.,PROCEDURE:,  The patient was brought to the operative suite by Anesthesia.  The patient was placed on the operating table in supine position.  After this, the patient was then placed under general mask airway and the patient's head was then turned to the left.,The Zeiss operative microscope and medium-sized ear speculum were placed and the cerumen from the external auditory canals were removed with a cerumen loop to #5 suction.  After this, the tympanic membrane is then brought into direct visualization with no signs of any gross retracted pockets or cholesteatoma.  A myringotomy incision was then made within the posterior inferior quadrant and the middle ear was then suctioned with a #5 suction demonstrating dry contents.  A _____ split tube 1.0 mm was then placed in the myringotomy incision utilizing a alligator forcep.  Cortisporin Otic drops were placed followed by cotton balls.  Attention was then drawn to the left ear with the head turned to the right and the medium sized ear speculum placed.  The external auditory canal was removed off of its cerumen with a #5 suction which led to the direct visualization of the tympanic membrane.  The tympanic membrane appeared with no signs of retraction pockets, cholesteatoma or air fluid levels.  A myringotomy incision was then made within the posterior inferior quadrant with a myringotomy blade after which a _________ split tube 1.0 mm was then placed with an alligator forcep.  After this, the patient had Cortisporin Otic drops followed by cotton balls placed.  The patient was then turned back to Anesthesia and transferred to recovery room in stable condition and tolerated the procedure very well.  The patient will be followed up approximately in one week and was sent home with a prescription for Ciloxan ear drops to be used as directed and with instructions not to get any water in the ears.surgery, chronic otitis media with effusion, conductive hearing loss, bilateral tympanostomy, myringotomy tube placement, cortisporin otic drops, otitis media, tympanostomy, tympanic, membrane, otitis, media, effusion, conductive, hearing, ear, tube, myringotomy
Tympanostomy 

PREOPERATIVE DIAGNOSIS: , Adenotonsillar hypertrophy and chronic otitis media.,POSTOPERATIVE DIAGNOSIS:,  Adenotonsillar hypertrophy and chronic otitis media.,PROCEDURE PERFORMED:,1.  Tympanostomy and tube placement.,2.  Adenoidectomy.,ANESTHESIA:  ,General endotracheal.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room, prepped and draped in the usual fashion.  After induction of general endotracheal anesthesia, the McIvor mouth gag was placed in the oral cavity and a tongue depressor applied.  Two #12-French red rubber Robinson catheters were placed, 1 in each nasal passage, and brought out through the oral cavity and clamped over a dental gauze roll placed on the upper lip to provide soft palate retraction.,Attention was directed to the nasopharynx.  With the Bovie set at 50 coag and the suction Bovie tip on the suction hose, the adenoid bed was fulgurated by beginning at the posterosuperior aspect of the nasopharynx at the apex of the choana placing the tip of the suction cautery deep at the root of the adenoids next to the roof of the nasopharynx and then in a linear fashion making serial passages through the base of the adenoid fossa in parallel lines until the entire nasopharynx and adenoid bed had been fulgurated moving from posterior to anterior.  The McIvor was relaxed and attention was then directed to the ears.,The left external auditory canal was examined under the operating microscope and cleaned of ceruminous debris.,An anteroinferior quadrant tympanostomy incision was made.  Fluid was suctioned from the middle ear space, and a tympanostomy tube was placed at the level of the incision and pushed into position with the Rosen needle.  Cortisporin ear drops were instilled into the canal, and a cotton ball was placed in the external meatus.,By a similar procedure, the opposite tympanostomy and tube placement were accomplished.,The patient tolerated the procedure well and left the operating room in good condition.surgery, robinson catheters, palate, tongue, tympanostomy, adenoidectomy, chronic otitis media, oral cavity, adenotonsillar hypertrophy, tube placement, hypertrophy, nasopharynx, adenotonsillar,
TURBT - 1 

PREOPERATIVE DIAGNOSIS:  ,Bladder cancer.,POSTOPERATIVE DIAGNOSIS: , Bladder cancer.,OPERATION:  ,Transurethral resection of the bladder tumor (TURBT), large.,ANESTHESIA:,  General endotracheal.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid.,BRIEF HISTORY: , The patient is an 82-year-old male who presented to the hospital with renal insufficiency, syncopal episodes.  The patient was stabilized from cardiac standpoint on a renal ultrasound.  The patient was found to have a bladder mass.  The patient does have a history of bladder cancer.  Options were watchful waiting, resection of the bladder tumor were discussed.  Risk of anesthesia, bleeding, infection, pain, MI, DVT, PE were discussed.  The patient understood all the risks, benefits, and options and wanted to proceed with the procedure.,DETAILS OF THE OR:  ,The patient was brought to the OR, anesthesia was applied.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in the usual sterile fashion.  A 23-French scope was inserted inside the urethra into the bladder.  The entire bladder was visualized, which appeared to have a large tumor, lateral to the right ureteral opening.,There was a significant papillary superficial fluffiness around the left ________.  There was a periureteral diverticulum, lateral to the left ureteral opening.  There were moderate trabeculations throughout the bladder.  There were no stones.  Using a French cone tip catheter, bilateral pyelograms were obtained, which appeared normal.  Subsequently, using 24-French cutting loop resectoscope a resection of the bladder tumor was performed all the way up to the base.  Deep biopsies were sent separately.  Coagulation was performed around the periphery and at the base of the tumor.  All the tumors were removed and sent for path analysis.  There was an excellent hemostasis.  The rest of the bladder appeared normal.  There was no further evidence of tumor.  At the end of the procedure, a 22 three-way catheter was placed, and the patient was brought to the recovery in a stable condition.surgery, transurethral resection of the bladder tumor, transurethral resection, bladder cancer, bladder tumor, bladder, turbt, insufficiency, tumor
Ulnar Nerve Decompression 

PREOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,POSTOPERATIVE DIAGNOSES: , Left cubital tunnel syndrome and ulnar nerve entrapment.,PROCEDURE PERFORMED: , Decompression of the ulnar nerve, left elbow.,ANESTHESIA: , General.,FINDINGS OF THE OPERATION:,  The ulnar nerve appeared to be significantly constricted as it passed through the cubital tunnel.  There was presence of hourglass constriction of the ulnar nerve.,PROCEDURE: , The patient was brought to the operating room and once an adequate general anesthesia was achieved, his left upper extremity was prepped and draped in standard sterile fashion.  A sterile tourniquet was positioned and tourniquet was inflated at 250 mmHg.  Perioperative antibiotics were infused.  Time-out procedure was called.  The medial epicondyle and the olecranon tip were well palpated.  The incision was initiated at equidistant between the olecranon and the medial epicondyle extending 3-4 cm proximally and 6-8 cm distally.  The ulnar nerve was identified proximally.  It was mobilized with a blunt and a sharp dissection proximally to the arcade of Struthers, which was released sharply.  The roof of the cubital tunnel was then incised and the nerve was mobilized distally to its motor branches.  The ulnar nerve was well-isolated before it entered the cubital tunnel.  The arch of the FCU was well defined.  The fascia was elevated from the nerve and both the FCU fascia and the Osborne fascia were divided protecting the nerve under direct visualization.  Distally, the dissection was carried between the 2 heads of the FCU.  Decompression of the nerve was performed between the heads of the FCU.  The muscular branches were well protected.  Similarly, the cutaneous branches in the arm and forearm were well protected.  The venous plexus proximally and distally were well protected.  The nerve was well mobilized from the cubital tunnel preserving the small longitudinal vessels accompanying it.  Proximally, multiple vascular leashes were defined near the incision of the septum into the medial epicondyle, which were also protected.  Once the in situ decompression of the ulnar nerve was performed proximally and distally, the elbow was flexed and extended.  There was no evidence of any subluxation.  Satisfactory decompression was performed.  Tourniquet was released.  Hemostasis was achieved.  Subcutaneous layer was closed with 2-0 Vicryl and skin was approximated with staples.  A well-padded dressing was applied.  The patient was then extubated and transferred to the recovery room in stable condition.  There were no intraoperative complications noted.  The patient tolerated the procedure very well.surgery, ulnar nerve entrapment, ulnar nerve, ulnar nerve decompression, cubital tunnel syndrome, ulnar, nerve, fascia, decompression, cubital, tunnel