falan42/nurse_detection huggingface dataset:
Suction, Dilation, & Curettage - 1 

PREOPERATIVE DIAGNOSIS: ,Incomplete abortion.,POSTOPERATIVE DIAGNOSIS: ,Incomplete abortion.,PROCEDURE PERFORMED:, Suction dilation and curettage.,ANESTHESIA:  ,General and nonendotracheal by Dr. X.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,SPECIMENS: , Endometrial curettings.,DRAINS: , None.,FINDINGS:  ,On bimanual exam, the patient has approximately 15-week anteverted, mobile uterus with the cervix that is dilated to approximately 2 cm with multiple blood colts in the vagina.  There was a large amount of tissue obtained on the procedure.,PROCEDURE:  ,The patient was taken to the operating room where a general anesthetic was administered.  She was then positioned in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.  Once the anesthetic was found to be adequate, a bimanual exam was performed under anesthetic.  Next, a weighted speculum was placed in the vagina.  The anterior lip of cervix was grasped with the vulsellum tenaculum and due to the patient already being dilated approximately 2 cm, no cervical dilation was needed.  A size 12 straight suction curette was used and connected to the suction and was placed in the cervix and a suction curettage was performed.  Two passes were made with the suction curettage.  Next, a sharp curettage was performed obtaining a small amount of tissue and this was followed by third suction curettage and then a final sharp curettage was performed, which revealed a good uterine cry on all sides of the uterus.  After the procedure, the vulsellum tenaculum was removed.  The cervix was seemed to be hemostatic.  The weighted speculum was removed.  The patient was given 0.25 mg of Methergine IM approximately half-way through the procedure.  After the procedure, a second bimanual exam was performed and the patient's uterus had significantly decreased in size.  It is now approximately eight to ten-week size.  The patient was taken from the operating room in stable condition after she was cleaned.  She will be discharged on today.  She was given Methergine, Motrin, and doxycycline for her postoperative care.  She will follow-up in one week in the office.obstetrics / gynecology, uterus, anteverted, dorsal lithotomy position, weighted speculum, mobile uterus, vulsellum tenaculum, bimanual exam, vagina, tenaculum, dilation, bimanual, cervix, suction, curettage,
TAH - Discharge Summary 

ADMISSION DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Symptomatic fibroid uterus.,DISCHARGE DIAGNOSES:,1.  Severe menometrorrhagia unresponsive to medical therapy.,2.  Severe anemia.,3.  Symptomatic fibroid uterus.,4.  Extensive adenomyosis by pathological report.,OPERATION PERFORMED: , On 6/10/2009 total abdominal hysterectomy (TAH).,COMPLICATIONS:,  None.,BLOOD TRANSFUSIONS: , None.,INFECTIONS: , None.,SIGNIFICANT LAB AND X-RAY: , On admission hemoglobin and hematocrit was 10.5 and 32.8 respectively.  On discharge, hemoglobin and hematocrit 7.9 and 25.2.,HOSPITAL COURSE AND TREATMENT:  ,The patient was admitted to the surgical suite and taken to the operating room on 6/10/2009 where a total abdominal hysterectomy (TAH) with low intraoperative complication was performed.  The patient tolerated all procedures well.  On the 1st postoperative day, the patient was afebrile and all vital signs were stable.  On the 3rd postoperative day, the patient was ambulating with difficulty and tolerating clear liquid diet.  On the 4th postoperative day, the patient was complaining of pain in her back and abdomen as well as incisional wound tenderness.  On the 5th postoperative day, the patient was afebrile.  Vital signs were stable.  The patient was tolerating a diet and ambulating without difficulty.  The patient was desirous of going home.  The patient denied any abdominal pain or flank pain.  The patient had minimal incisional wound tenderness.  The patient was desirous of going home and was discharged home.,DISCHARGE CONDITION: , Stable.,DISCHARGE INSTRUCTIONS:,  Regular diet, bedrest x1 week with slow return to normal activity over the ensuing 4 to 6 weeks, pelvic rest for 6 weeks.  Motrin 600 mg tablets 1 tablet p.o. q.8h. p.r.n. pain, Colace 100 mg tablets 1 tablet p.o. daily p.r.n. constipation and ferrous sulfate 60 mg tablets 1 tablet p.o. daily, and multiple vitamin 1 tablet p.o. daily.  The patient is to return on Wednesday 6/17/2009 for removal of staples.  The patient was given a full explanation of her clinical condition.  The patient was given full and complete postoperative and discharge instructions.  All her questions were answered.obstetrics / gynecology, adenomyosis, total abdominal hysterectomy, fibroid uterus, postoperative day, hemoglobin, hematocrit, therapy, menometrorrhagia, anemia, fibroid, uterus, tah, hysterectomy, abdominal,
Spontaneous Vaginal Delivery - 1 

PREOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 39 plus weeks gestation.,2.  Gestational hypertension.,3.  Thick meconium.,4.  Failed vacuum attempted delivery.,POSTOPERATIVE DIAGNOSES,1.  Intrauterine pregnancy at 39 plus weeks gestation.,2.  Gestational hypertension.,3.  Thick meconium.,4.  Failed vacuum attempted delivery.,OPERATION PERFORMED: , Spontaneous vaginal delivery.,ANESTHESIA: , Epidural was placed x2.,ESTIMATED BLOOD LOSS:,  500 mL.,COMPLICATIONS: , Thick meconium.  Severe variables, Apgars were 2 and 7.  Respiratory therapy and ICN nurse at delivery.  Baby went to Newborn Nursery.,FINDINGS: , Male infant, cephalic presentation, ROA.  Apgars 2 and 7.  Weight 8 pounds and 1 ounce.  Intact placenta.  Three-vessel cord.  Third degree midline tear.,DESCRIPTION OF OPERATION: , The patient was admitted this morning for induction of labor secondary to elevated blood pressure, especially for the last three weeks.  She was already 3 cm dilated.  She had artificial rupture of membranes.  Pitocin was started and she actually went to complete dilation.  While pushing, there was sudden onset of thick meconium, and she was having some severe variables and several late decelerations.  When she was complete +2, vacuum attempted delivery, three pop-offs were done.  The vacuum was then no longer used after the three pop-offs.  The patient pushed for a little bit longer and had a delivery, ROA, of a male infant, cephalic, over a third-degree midline tear.  Secondary to the thick meconium, DeLee suctioned nose and mouth before the anterior shoulder was delivered and again after delivery.  Baby was delivered floppy.  Cord was clamped x2 and cut, and the baby was handed off to awaiting ICN nurse and respiratory therapist.  Delivery of intact placenta and three-vessel cord.  Third-degree midline tear was repaired with Vicryl without any complications.  Baby initially did well and went to Newborn Nursery, where they are observing him a little bit longer there.  Again, mother and baby are both doing well.  Mother will go to Postpartum and baby is already in Newborn Nursery.obstetrics / gynecology, thick meconium, cephalic presentation, intrauterine pregnancy, gestational hypertension, spontaneous vaginal delivery, delivery, vaginal, placenta, newborn, meconium, apgars,
Spontaneous Vaginal Delivery 

PREOPERATIVE DIAGNOSIS: , Term pregnancy at 40 and 3/7th weeks.,PROCEDURE PERFORMED: , Spontaneous vaginal delivery.,HISTORY OF PRESENT ILLNESS:  ,The patient is a 36-year-old African-American female who is a G-2, P-2-0-0-2 with an EDC of 08/30/2003.  She is blood type AB -ve with antibody screen negative and is also rubella immune, VDRL nonreactive, hepatitis B surface antigen negative, and HIV nonreactive.  She does have a history of sickle cell trait.  She presented to Labor and Delivery Triage at 40 and 3/7th weeks gestation with complaint of contractions every ten minutes.  She also stated that she has lost her mucous plug.  She did have fetal movement, noted no leak of fluid, did have some spotting.  On evaluation of triage, she was noted to be contracting approximately every five minutes and did have discomfort with her contractions.  She was evaluated by sterile vaginal exam and was noted to be 4 cm dilated, 70% effaced, and -3 station.  This was a change from her last office exam, at which she was 1 cm to 2 cm dilated.,PROCEDURE DETAILS:,  The patient was admitted to Labor and Delivery for expected management of labor and AROM was performed and the amniotic fluid was noted to be meconium stained.  After her membranes were ruptured, contractions did increase to every two to three minutes as well as the intensity increased.  She was given Nubain for discomfort with good result.,She had a spontaneous vaginal delivery of a live born female at 11:37 with meconium stained fluid as noted from ROA position.  After controlled delivery of the head, tight nuchal cord was noted, which was quickly double clamped and cut and the shoulders and body were delivered without difficulty.  The infant was taken to the awaiting pediatrician.  Weight was 2870 gm, length was 51 cm.  The Apgars were 6 at 1 minute and 9 at 5 minutes.  There was initial neonatal depression, which was treated by positive pressure ventilation and the administration of Narcan.,Spontaneous delivery of an intact placenta with a three-vessel cord was noted at 11:45.  On examination, there were no noted perineal abrasions or lacerations.  On vaginal exam, there were no noted cervical or vaginal sidewall lacerations.  Estimated blood loss was less than 250 cc.  Mother and infant are in recovery doing well at this time.obstetrics / gynecology, roa position, arom, labor and delivery, spontaneous vaginal delivery, term pregnancy, contracting, meconium, lacerations, pregnancy, contractions, vaginal,
Radical Mastectomy 

PREOPERATIVE DIAGNOSIS:,  Invasive carcinoma of left breast.,POSTOPERATIVE DIAGNOSIS:,  Invasive carcinoma of left breast.,OPERATION PERFORMED:,  Left modified radical mastectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR THE PROCEDURE:  ,The patient is a 52-year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast.  The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy.  She is aware of the risks and complications of surgery, and wished to proceed.,DESCRIPTION OF PROCEDURE:  ,The patient was taken to the operating room.  She underwent general endotracheal anesthetic.  The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well.  The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner.  The recent biopsy site was located in the upper and outer quadrant of left breast.  The plain incision was marked along the skin.  Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site.  The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia.  Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle.  The dissection was started medially and extended laterally towards the left axilla.  The breast was removed and then the axillary contents were dissected out.  Left axillary vein and artery were identified and preserved as well as the lung _____.  The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection.  Care was taken to avoid injury to any of the above mentioned neurovascular structures.  After the tissues were irrigated, we made sure there were no signs of bleeding.  Hemostasis had been achieved with Hemoclips.  Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps.  The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips.  The drains were sutured to the chest wall with 3-0 nylon sutures.  Dressing was applied and the procedure was completed.  The patient went to the recovery room in stable condition.obstetrics / gynecology, invasive carcinoma, chest wall, neck, axilla, modified radical mastectomy, radical mastectomy, invasive, carcinoma, mastectomy
Preeclampsia 

REASON FOR CONSULTATION: , Management of blood pressure.,HISTORY OF PRESENT ILLNESS: , The patient is a 38-year-old female admitted following a delivery.  The patient had a cesarean section.  Following this, the patient was treated for her blood pressure.  She was sent home and she came back again apparently with uncontrolled blood pressure.  She is on multiple medications, unable to control the blood pressure.  From cardiac standpoint, the patient denies any symptoms of chest pain, or shortness of breath.  She complains of fatigue and tiredness.  The child had some congenital anomaly, was transferred to Hospital, where the child has had surgery.  The patient is in intensive care unit.,CORONARY RISK FACTORS:,  History of hypertension, history of gestational diabetes mellitus, nonsmoker, and cholesterol is normal.  No history of established coronary artery disease and family history noncontributory for coronary disease.,FAMILY HISTORY: , Nonsignificant.,SURGICAL HISTORY:  ,No major surgery except for C-section.,MEDICATIONS:,  Presently on Cardizem and metoprolol were discontinued.  Started on hydralazine 50 mg t.i.d., and labetalol 200 mg b.i.d., hydrochlorothiazide, and insulin supplementation.,ALLERGIES: , None.,PERSONAL HISTORY: , Nonsmoker.  Does not consume alcohol.  No history of recreational drug use.,PAST MEDICAL HISTORY:,  Hypertension, gestational diabetes mellitus, pre-eclampsia, this is her third child with one miscarriage.,REVIEW OF SYSTEMS:,CONSTITUTIONAL:  No history of fever, rigors, or chills.,HEENT:  No history of cataract, blurry vision, or glaucoma.,CARDIOVASCULAR:  No congestive heart.  No arrhythmia.,RESPIRATORY:  No history of pneumonia or valley fever.,GASTROINTESTINAL:  No epigastric discomfort, hematemesis, or melena.,UROLOGIC:  No frequency or urgency.,MUSCULOSKELETAL:  No arthritis or muscle weakness.,SKIN:  Nonsignificant.,NEUROLOGICAL:  No TIA.  No CVA.  No seizure disorder.,PHYSICAL EXAMINATION:,VITAL SIGNS:  Pulse of 86, blood pressure 175/86, afebrile, and respiratory rate 16 per minute.,HEENT:  Atraumatic and normocephalic.,NECK:  Neck veins are flat.,LUNGS:  Clear.,HEART:  S1 and S2 regular.,ABDOMEN:  Soft and nontender.,EXTREMITIES:  No edema.  Pulses palpable.,LABORATORY DATA: , EKG shows sinus tachycardia with nonspecific ST-T changes.  Labs were noted.  BUN and creatinine within normal limits.,IMPRESSION:,1.  Preeclampsia, status post delivery with Cesarean section with uncontrolled blood pressure.,2.  No prior history of cardiac disease except for borderline gestational diabetes mellitus.,RECOMMENDATIONS:,1.  We will get an echocardiogram for assessment left ventricular function.,2.  The patient will start on labetalol and hydralazine to see how see fairs.,3.  Based on response to medication, we will make further adjustments.  Discussed with the patient regarding plan of care, fully understands and consents for the same.  All the questions answered in detail.nan
Suction, Dilation, & Curettage 

PREOPERATIVE DIAGNOSIS: , Missed abortion.,POSTOPERATIVE DIAGNOSIS:  ,Missed abortion.,PROCEDURE PERFORMED: , Suction, dilation, and curettage.,ANESTHESIA: , Spinal.,ESTIMATED BLOOD LOSS:,  50 mL.,COMPLICATIONS: , None.,FINDINGS: , Products of conception consistent with a 6-week intrauterine pregnancy.,INDICATIONS: , The patient is a 28-year-old gravida 4, para 3 female at 13 weeks by her last menstrual period and 6 weeks by an ultrasound today in the emergency room who presents with heavy bleeding starting today.  A workup done in the emergency room revealed a beta-quant level of 1931 and an ultrasound showing an intrauterine pregnancy with a crown-rump length consistent with a 6-week and 2-day pregnancy.  No heart tones were visible.  On examination in the emergency room, a moderate amount of bleeding was noted.,Additionally, the cervix was noted to be 1 cm dilated.  These findings were discussed with the patient and options including surgical management via dilation and curettage versus management with misoprostol versus expected management were discussed with the patient.  After discussion of these options, the patient opted for a suction, dilation, and curettage.  The patient was described to the patient in detail including risks of infection, bleeding, injury to surrounding organs including risk of perforation.  Informed consent was obtained prior to proceeding with the procedure.,PROCEDURE NOTE:  ,The patient was taken to the operating room where spinal anesthesia was administered without difficulty.  The patient was prepped and draped in usual sterile fashion in lithotomy position.  A weighted speculum was placed.  The anterior lip of the cervix was grasped with a single tooth tenaculum.  At this time, a 7-mm suction curettage was advanced into the uterine cavity without difficulty and was used to suction contents of the uterus.  Following removal of the products of conception, a sharp curette was advanced into the uterine cavity and was used to scrape the four walls of the uterus until a gritty texture was noted.  At this time, the suction curette was advanced one additional time to suction any remaining products.  All instruments were removed.  Hemostasis was visualized.  The patient was stable at the completion of the procedure.  Sponge, lap, and instrument counts were correct.obstetrics / gynecology, missed abortion, intrauterine pregnancy, dilation, curettage, suction, intrauterine
Pelvic Laparotomy 

PREOPERATIVE DIAGNOSIS: , Large left adnexal mass, 8 cm in diameter.,POSTOPERATIVE DIAGNOSIS: , Pelvic adhesions, 6 cm ovarian cyst.,PROCEDURES PERFORMED:  ,1.  Pelvic laparotomy.,2.  Lysis of pelvic adhesions.,3.  Left salpingooophorectomy with insertion of Pain-Buster Pain Management System by Dr. X.,GROSS FINDINGS:  ,There was a transabdominal mass palpable in the lower left quadrant.  An ultrasound suggestive with a mass of 8 cm, did not respond to suppression with norethindrone acetate and on repeat ultrasound following the medical treatment, the ovarian neoplasm persisted and did not decreased in size.,PROCEDURE:  ,Under general anesthesia, the patient was placed in lithotomy position, prepped and draped.  A low transverse incision was made down to and through to the rectus sheath.  The rectus sheath was put laterally.  The inferior epigastric arteries were identified bilaterally, doubly clamped and tied with #0 Vicryl sutures.  The rectus muscle was then split transversally and the peritoneum was split transversally as well.  The left adnexal mass was identified and large bowel was attached to the mass and Dr. Zuba from General Surgery dissected the large bowel adhesions and separated them from the adnexal mass.  The ureter was then traced and found to be free of the mass and free of the infundibulopelvic ligament.  The infundibulopelvic ligament was isolated, entered via blunt dissection.  A #0 Vicryl suture was put into place, doubly clamped with curved Heaney clamps, cut with curved Mayo scissors and #0 Vicryl fixation suture put into place.  Curved Heaney clamps were then used to remove the remaining portion of the ovary from its attachment to the uterus and then #0 Vicryl suture was put into place.  Pathology was called to evaluate the mass for potential malignancy and the pathology's verbal report at the time of surgery was that this was a benign lesion.  Irrigation was used.  Minimal blood loss at the time of surgery was noted.  Sigmoid colon was inspected in place in physiologic position of the cul-de-sac as well as small bowel omentum.  Instrument, needle, and sponge counts were called for and found to be correct.  The peritoneum was closed with #0 Vicryl continuous running locking suture.  The rectus sheath was closed with #0 Vicryl continuous running locking suture.  A DonJoy Pain-Buster Pain Management System was placed through the skin into the subcutaneous space and the skin was closed with staples.  Final instrument needle counts were called for and found to be correct.  The patient tolerated the procedure well with minimal blood loss and transferred to recovery area in satisfactory condition.obstetrics / gynecology, lysis of pelvic adhesions, salpingooophorectomy, pain-buster pain management system, adnexal mass, pelvic laparotomy, pelvic adhesions, rectus sheath, vicryl sutures, adhesions, pelvic
Pre-Eclampsia & Eclampsia 

PRE-ECLAMPSIA, is a very serious condition unique to pregnancy in which blood pressure, the kidneys and the central nervous system are compromised.  It usually occurs from the 20th week of pregnancy to 7 days postpartum.  The cause is unknown.  It is also known as pregnancy-induced hypertension or toxemia of pregnancy.,ECLAMPSIA, is the end-stage of the pre-eclampsia process.  The vast majority of women who develop pre-eclampsia are pregnant with their first child and are towards the end of their child-bearing years.  There are identifiable risk factors for developing pre-eclampsia:  family history of pre-eclampsia, previous pregnancy with pre-eclampsia, multiple gestation, and a hydatiform mole (an intrauterine growth that mimics pregnancy).  A chronic high blood pressure and underlying blood vessel disease increases the risk.  Pre-eclampsia ranges from mild to severe to eclampsia as the end-stage.  Untreated pre-eclampsia can result in a stroke, fluid-build up around the lungs, kidney failure, death of baby and death of mother.,SIGNS AND SYMPTOMS:,MILD PRE-ECLAMPSIA:,*  Significant blood pressure increase even if you are still within the normal blood pressure limits.,*  Swelling in the face, hands and feet which worsens in the a.m.,*  Gaining more than a pound a week, especially in the last trimester.,*  Routine prenatal checkup reveals protein in the urine.,*  Seizures are possible.,SEVERE PRE-ECLAMPSIA:,*  More blood pressure increase.,*  Further swelling in face, hands and feet.,*  Visual disturbances.,*  Headache.,*  Irritability.,*  Abdominal pain.,*  Tiredness.,*  Decreased urination.,*  Seizures possible.,*  Nausea and vomiting.,ECLAMPSIA:,*  Symptoms worsen.,*  Seizures.,*  Muscle twitches.,*  Coma.,TREATMENT:,*  Diagnosis - blood tests, urinalysis, blood pressure monitoring.,*  Mild preeclampsia can be treated at home.  Severe symptoms require hospitalization and possible early delivery of the baby, often by cesarean section.,*  Daily weighing.,*  Daily monitoring for protein in urine.,*  Medications to lower blood pressure if preeclampsia is severe.,*  Magnesium sulfate or other anti-seizure drugs may be necessary to prevent seizures.,*  Get lots of rest! Lay on your left side to help circulation.,*  Follow any dietary advice given by your doctor.,*  Get regular prenatal checkups! Eat a nutritious diet and take your vitamin supplements.,*  Never take any medications that are not prescribed or recommended by your physician.,*  Call the office if your headaches become severe, you have visual disturbances or if you gain more than 3 pounds in 24 hours.,RESTRICTING CAFFEINE:,You should reduce your intake of caffeine by cutting back on coffee and other caffeinated beverages like soda.  In addition, you should avoid chocolate that also contains caffeine.,RESTRICTING SALT:,You are to restrict your salt intake by reducing or eliminating table salt from your meals and avoiding foods that are high in salt concentration.  For more information about which foods are high in salt, read the label of any foods you intend to consume and look for sodium content.nan