falan42/nurse_detection huggingface dataset:
Diagnostic Laparoscopy 

TITLE OF OPERATION:,  Diagnostic laparoscopy.,INDICATION FOR SURGERY: , The patient is a 22-year-old woman with a possible ruptured ectopic pregnancy.,PREOP DIAGNOSIS: , Possible ruptured ectopic pregnancy.,POSTOP DIAGNOSIS: , No evidence of ectopic pregnancy or ruptured ectopic pregnancy.,ANESTHESIA: , General endotracheal.,SPECIMEN: , Peritoneal fluid.,EBL: , Minimal.,FLUIDS:,  900 cubic centimeters crystalloids.,URINE OUTPUT: , 400 cubic centimeters.,FINDINGS: , Adhesed left ovary with dilated left fallopian tube, tortuous right fallopian tube with small 1 cm ovarian cyst noted on right ovary, perihepatic lesions consistent with history of PID, approximately 1-200 cubic centimeters of more serous than sanguineous fluid.  No evidence of ectopic pregnancy.,COMPLICATIONS: , None.,PROCEDURE:,  After obtaining informed consent, the patient was taken to the operating room where general endotracheal anesthesia was administered.  She was examined under anesthesia.  An 8-10 cm anteverted uterus was noted.  The patient was placed in the dorsal-lithotomy position and prepped and draped in the usual sterile fashion, a sponge on a sponge stick was used in the place of a HUMI in order to not instrument the uterus in the event that this was a viable intrauterine pregnancy and this may be a desired intrauterine pregnancy.  Attention was then turned to the patient's abdomen where a 5-mm incision was made in the inferior umbilicus.  The abdominal wall was tented and VersaStep needle was inserted into the peritoneal cavity.  Access into the intraperitoneal space was confirmed by a decrease in water level when the needle was filled with water.  No peritoneum was obtained without difficulty using 4 liters of CO2 gas.  The 5-mm trocar and sleeve were then advanced in to the intraabdominal cavity and access was confirmed with the laparoscope.,The above-noted findings were visualized.  A 5-mm skin incision was made approximately one-third of the way from the ASI to the umbilicus at McBurney's point.  Under direct visualization, the trocar and sleeve were advanced without difficulty.  A third incision was made in the left lower quadrant with advancement of the trocar into the abdomen in a similar fashion using the VersaStep.  The peritoneal fluid was aspirated and sent for culture and wash and cytology.  The abdomen and pelvis were surveyed with the above-noted findings.  No active bleeding was noted.  No evidence of ectopic pregnancy was noted.  The instruments were removed from the abdomen under good visualization with good hemostasis noted.  The sponge on a sponge stick was removed from the vagina.  The patient tolerated the procedure well and was taken to the recovery room in stable condition.,The attending, Dr. X, was present and scrubbed for the entire procedure.surgery, peritoneal fluid, sanguineous fluid, ruptured ectopic pregnancy, diagnostic laparoscopy, intrauterine pregnancy, ectopic pregnancy, trocar, ruptured, ectopic, tortuous, pregnancy,
Dental Restoration 

PREOPERATIVE DIAGNOSIS: , Dental caries.,POSTOPERATIVE DIAGNOSIS:,  Dental caries.,PROCEDURE: , Dental restoration.,CLINICAL HISTORY:  ,This 2-year, 10-month-old male has not had any prior dental treatment because of his unmanageable behavior in a routine dental office setting.  He was referred to me for that reason to be treated under general anesthesia for his dental work.  Cavities have been noted by his parents and pediatrician that have been noted to be pretty severe.  There are no contraindications to this procedure.  He is healthy.  His history and physical is in the chart.,PROCEDURE:  ,The patient was brought to the operating room at 10:15 and placed in the supine position.  Dr. X administered the general anesthetic after which 2 bite-wing and 2 periapical x-rays were exposed and developed and his teeth were examined.  A throat pack was then placed.  Tooth D had caries on the distal surface which was excavated and the tooth was restored with composite.  Teeth E and F had caries in the mesial and distal surfaces, these carious lesions were excavated and the teeth were restored with composite.  Tooth G had caries in the mesial surface which was excavated and the tooth was restored with composite.  Teeth I and L both had caries on the occlusal surfaces which were excavated and upon excavation of the caries in tooth I the pulp was perforated and a therapeutic pulpotomy was therefore necessary.  This was done using ferric sulfate and zinc oxide eugenol.  For final restorations, amalgam restorations were placed involving the occlusal surfaces both teeth I and L. A prophylaxis was done and topical fluoride applied and the excess was suctioned thoroughly.  The throat pack was removed and the patient was awakened and brought to the recovery room in good condition at 11:30.  There was no blood loss.surgery, cavities, carious lesions, throat pack, composite teeth, occlusal surfaces, dental restoration, dental caries, dental, teeth, caries,
Delivery Note - 8 

DELIVERY NOTE: , The patient is a very pleasant 22-year-old primigravida with prenatal care with both Dr. X and myself and her pregnancy has been uncomplicated except for the fact that she does live a significant distance away from the hospital.  The patient was admitted to labor and delivery on Tuesday, December 22, 2008 at 5:30 in the morning at 40 weeks and 1 day gestation for elective induction of labor since she lives a significant distance away from the hospital.  Her cervix on admission was not ripe, so she was given a dose of Cytotec 25 mcg intravaginally and in the afternoon, she was having frequent contractions and fetal heart tracing was reassuring.  At a later time, Pitocin was started.  The next day at about 9 o'clock in the morning, I checked her cervix and performed artifical rupture of membranes, which did reveal Meconium-stained amniotic fluid and so an intrauterine pressure catheter was placed and then MDL infusion started.  The patient did have labor epidural, which worked well.  It should be noted that the patient's recent vaginal culture for group B strep did come back negative for group B strep.  The patient went on to have a normal spontaneous vaginal delivery of a live-term male newborn with Apgar scores of 7 and 9 at 1 and 5 minutes respectively and a newborn weight of 7 pounds and 1.5 ounces at birth.  The intensive care nursery staff was present because of the presence of Meconium-stained amniotic fluid.  DeLee suctioning was performed at the perineum.  A second-degree midline episiotomy was repaired in layers in the usual fashion using 3-0 Vicryl.  The placenta was simply delivered and examined and found to be complete and bimanual vaginal exam was performed and revealed that the uterus was firm.,ESTIMATED BLOOD LOSS: , Approximately 300 mL.surgery, amniotic fluid, contractions, pitocin, meconium, cervix, labor, vaginal, delivery, intravaginallyNOTE,: 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.,
Delivery Note - 6 

DELIVERY NOTE: , This is an 18-year-old, G2, P0 at 35-4/7th weeks by a stated EDC of 01/21/09.  The patient is a patient of Dr. X's.  Her pregnancy is complicated by preterm contractions.  She was on bedrest since her 34th week.  She also has a history of tobacco abuse with asthma.  She was admitted here and labor was confirmed with rupture of membranes.  She was initially 5, 70%, -1.  Her bag was ruptured, IUPC was placed.  She received an epidural for pain control and Pitocin augmentation was performed.  She progressed for several hours to complete and to push, then pushed for approximately 15 minutes to deliver a vigorous female infant from OA presentation.  Delivery of the head was manual assisted.  The shoulders and the rest of body then followed without difficulty.  Baby was bulb suctioned, had a vigorous cry.  Cord was clamped twice and cut and the infant was handed to the awaiting nursing team.  Placenta then delivered spontaneously and intact, was noted to have a three-vessel cord.  The inspection of the perineum revealed it to be intact.  There was a hymenal remnant/skin tag that was protruding from the vaginal introitus.  I discussed this with the patient.  She opted to have it removed.  This was performed and I put a single interrupted suture 3-0 Vicryl for hemostasis.  Further inspection revealed bilateral superficial labial lacerations that were hemostatic and required no repair.  Overall EBL is 300 mL.  Mom and baby are currently doing well.  Cord gases are being sent due to prematurity.,surgery, preterm, rupture of membranes, preterm contractions, contractions, pregnancy, deliveryNOTE,: 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.
Delivery Note - 2 

Pitocin was started quickly to allow for delivery as quickly as possible and the patient rapidly became complete, and then as she began to push, there were additional decelerations of the baby's heart rate, which were suspicions of cord around the neck.  These were variable decelerations occurring late in the contraction phase.  The baby was in a +2 at a 3 station in an occiput anterior position, and so a low-forceps delivery was performed with Tucker forceps using gentle traction, and the baby was delivered with a single maternal pushing effort with retraction by the forceps.  The baby was a little bit depressed at birth because of the cord around the neck, and the cord had to be cut before the baby was delivered because of the tension, but she responded quickly to stimulus and was given an Apgar of 8 at 1 minute and 9 at 5 minutes.  The female infant seemed to weigh about 7.5 pounds, but has not been officially weighed yet.  Cord gases were sent and the placenta was sent to Pathology.  The cervix, the placenta, and the rectum all seemed to be intact.  The second-degree episiotomy was repaired with 2-O and 3-0 Vicryl.  Blood loss was about 400 mL.,Because of the hole in the dura, plan is to keep the patient horizontal through the day and a Foley catheter is left in place.  She is continuing to be attended to by the anesthesiologist who will manage the epidural catheter.  The baby's father was present for the delivery, as was one of the patient's sisters.  All are relieved and pleased with the good outcome.surgery, labor, delivery, pitocin, tucker forceps, apnea, cerebrospinal fluid, contraction, epidural, episiotomy, fetal heart tones, baby was delivered, baby's heart rate, heart rate, catheter, placenta, cordNOTE,: 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.,
Delivery Note - 5 

DELIVERY NOTE: , This is a 30-year-old G7, P5 female at 39-4/7th weeks who presents to Labor and Delivery for induction for history of large babies and living far away.  She was admitted and started on Pitocin.  Her cervix is 3 cm, 50% effaced and -2 station.  Artificial rupture of membrane was performed for clear fluid.  She did receive epidural anesthesia.  She progressed to complete and pushing.  She pushed to approximately one contraction and delivered a live-born female infant at 1524 hours.  Apgars were 8 at 1 minute and 9 at 5 minutes.  Placenta was delivered intact with three-vessel cord.  The cervix was visualized.  No lacerations were noted.  Perineum remained intact.  Estimated blood loss is 300 mL.  Complications were none.  Mother and baby remained in the birthing room in good condition.surgery, perineum, placenta, rupture of membrane, artificial rupture, cervix, delivery, inductionNOTE,: 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.,
Delivery Note - 10 

DELIVERY NOTE:  ,This is a 30-year-old G6, P5-0-0-5 with unknown LMP and no prenatal care, who came in complaining of contractions and active labor.  The patient had ultrasound done on admission that showed gestational age of 38-2/7 weeks.  The patient progressed to a normal spontaneous vaginal delivery over an intact perineum.  Rupture of membranes occurred on 12/25/08 at 2008 hours via artificial rupture of membranes.  No meconium was noted.  Infant was delivered on 12/25/08 at 2154 hours.  Two doses of ampicillin was given prior to rupture of membranes.  GBS status unknown.  Intrapartum events, no prenatal care.  The patient had epidural for anesthesia.  No observed abnormalities were noted on initial newborn exam.  Apgar scores were 9 and 9 at one and five minutes respectively.  There was a nuchal cord x1, nonreducible, which was cut with two clamps and scissors prior to delivery of body of child.  Placenta was delivered spontaneously and was normal and intact.  There was a three-vessel cord.  Baby was bulb suctioned and then sent to newborn nursery.  Mother and baby were in stable condition.  EBL was approximately 500 mL, NSVD with postpartum hemorrhage.  No active bleeding was noted upon deliverance of the placenta.  Dr. X attended the delivery with second year resident, Dr. X. Upon deliverance of the placenta, the uterus was massaged and there was good tone.  Pitocin was started following deliverance of the placenta.  Baby delivered vertex from OA position.  Mother following delivery had a temperature of 100.7, denied any specific complaints and was stable following delivery.surgery, spontaneous vaginal delivery, rupture of membranes, gestational age, vaginal delivery, intact perineum, prenatal care, gestational, placentaNOTE,: 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.,
Delivery Note - 7 

DELIVERY NOTE:,  The patient is a 29-year-old gravida 6, para 2-1-2-3, who has had an estimated date of delivery at 01/05/2009.  The patient presented to Labor and Delivery with complaints of spontaneous rupture of membranes at 2000 hours on 12/26/2008.  She was found to be positive for Nitrazine pull and fern.  At that time, she was not actually contracting.  She was Group B Streptococcus positive, however, was 5 cm dilated.  The patient was started on Group B Streptococcus prophylaxis with ampicillin.  She received a total of three doses throughout her labor.  Her pregnancy was complicated by scanty prenatal care.  She would frequently miss visits.  At 37 weeks, she claims that she had a suspicious bump on her left labia.  There was apparently no fluid or blistering of the lesion.  Therefore, it was not cultured by the provider; however, the patient was sent for serum HSV antibody levels, which she tested positive for both HSV1 and HSV2.  I performed a bright light exam and found no lesions anywhere on the vulva or in the vault as per sterile speculum exam and consulted with Dr. X, who agreed that since the patient seems to have no active lesion that she likely has had a primary outbreak in the past and it is safe to proceed with the vaginal delivery.  The patient requested an epidural anesthetic, which she received with very good relief.  She had IV Pitocin augmentation of labor and became completely dilated per my just routine exam just after 6 o'clock and was set up for delivery and the patient pushed very effectively for about one and a half contractions.  She delivered a viable female infant on 12/27/2008 at 0626 hours delivering over an intact perineum.  The baby delivered in the occiput anterior position.  The baby was delivered to the mother's abdomen where she was warm, dry, and stimulated.  The umbilical cord was doubly clamped and then cut.  The baby's Apgars were 8 and 9.  The placenta was delivered spontaneously intact.  There was a three-vessel cord with normal insertion.  The fundus was massaged to firm and Pitocin was administered through the IV per unit protocol.  The perineum was inspected and was found to be fully intact.  Estimated blood loss was approximately 400 mL.  The patient's blood type is A+.  She is rubella immune and as previously mentioned, GBS positive and she received three doses of ampicillin.surgery, nitrazine pull and fern, rupture of membranes, spontaneous, membranes, nitrazine, streptococcus, pitocin, perineum, hsv, laborNOTE,: 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.,
Delivery Note - 3 

DELIVERY NOTE: , On 12/23/08 at 0235 hours, a 23-year-old G1, P0, white female, GBS negative, under epidural anesthesia, delivered a viable female infant with Apgar scores of 7 and 9.  Points taken of for muscle tone and skin color.  Weight and length are unknown at this time.  Delivery was via spontaneous vaginal delivery.  Nuchal cord x1 were tight and reduced.  Infant was DeLee suctioned at perineum.  Cord clamped and cut and infant handed to the awaiting nurse in attendance.  Cord blood sent for analysis, intact.  Meconium stained placenta with three-vessel cord was delivered spontaneously at 0243 hours.  A 15 units of Pitocin was started after delivery of the placenta.  Uterus, cervix, and vagina were explored and a mediolateral episiotomy was repaired with a 3-0 Vicryl in a normal fashion.  Estimated blood loss was approximately 400 mL.  The patient was taken to the recovery room in stable condition.  Infant was taken to Newborn Nursery in stable condition.  The patient tolerated the procedure well.  The only intrapartum event that occurred was thick meconium.  Otherwise, there were no other complications.  The patient tolerated the procedure well.surgery, nuchal cord, spontaneous, nuchal, delee, delivered, meconium, placenta, vaginal, perineum, delivery, infantNOTE,: 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.,
Delivery Note - 1 

The patient presented in the early morning hours of February 12, 2007, with contractions.  The patient was found to be in false versus early labor and managed as an outpatient.  The patient returned to labor and delivery approximately 12 hours later with regular painful contractions.  There was minimal cervical dilation, but 80% effacement by nurse examination.  The patient was admitted.  Expected management was utilized initially.  Stadol was used for analgesia.  Examination did not reveal vulvar lesions.  Epidural was administered.  Membranes ruptured spontaneously.  Cervical dilation progressed.  Acceleration-deceleration complexes were seen.  Overall, fetal heart tones remained reassuring during the progress of labor.  The patient was allowed to "labor down" during second stage.  Early decelerations were seen as well as acceleration-deceleration complexes.  Overall, fetal heart tones were reassuring.  Good maternal pushing effort produced progressive descent.,Spontaneous controlled sterile vaginal delivery was performed without episiotomy and accomplished without difficulty.  Fetal arm was wrapped at the level of the neck with the fetal hand and also at the level of the neck.  There was no loop or coil of cord.  Infant was vigorous female sex.  Oropharynx was aggressively aspirated.  Cord blood was obtained.  Placenta delivered spontaneously.,Following delivery, uterus was explored without findings of significant tissue.  Examination of the cervix did not reveal lacerations.  Upper vaginal lacerations were not seen.  Multiple first-degree lacerations were present.  Specific locations included the vestibula at 5 o'clock, left labia minora with short extension up the left sulcus, right anterior labia minora at the vestibule, and midline of the vestibule.  All mucosal lacerations were reapproximated with interrupted simple sutures of 4-0 Vicryl with the knots being buried.  Post-approximation examination of the rectum showed smooth, intact mucosa.  Blood loss with the delivery was 400 mL.,Plans for postpartum care include routine postpartum orders.  Nursing personnel will be notified of Gilbert's syndrome.surgery, delivery, gilbert's syndrome, membranes, cervical dilation, contractions, labia minora, labor, labor and delivery, trimester, uterus, vaginal delivery, vaginal lacerations, vulvar, fetal heart tones, fetal heart, heart tones, postpartum, vaginal, fetal, lacerationsNOTE,: 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.,