falan42/nurse_detection huggingface dataset:
I&D - Perirectal Abscess 

PREOPERATIVE DIAGNOSIS:,  Perirectal abscess.,POSTOPERATIVE DIAGNOSIS:,  Perirectal abscess.,PROCEDURE: , Incision and drainage (I&D) of perirectal abscess.,DESCRIPTION OF PROCEDURE: , The patient was taken to the operating room after obtaining an informed consent.  A spinal anesthetic was given, and then the patient in the jackknife position had his gluteal area prepped and draped in the usual fashion.,Prior to prepping, I performed a digital rectal examination that showed no pathology and then I proceeded to insert an anoscope.  I found some small internal hemorrhoids and no fistulous tracts.,Then, the patient was prepped and draped in the usual fashion and the abscess area, which was in the left gluteal side, was incised with a cruciate incision and drained.  All necrotic tissue was debrided.  The cavity was digitally explored and found to have no communication to any deeper structures or to the colorectal area.  The cavity was irrigated with saline and then was packed with iodoform gauze and dressed.,Estimated blood loss was minimal.  The patient tolerated the procedure well and was sent for recovery in satisfactory condition.surgery, hemorrhoids, incision and drainage, perirectal abscess, cavity, i&d, perirectal,
I&D & Wound Closure - Scalp Lacerations 

PREOPERATIVE DIAGNOSIS: , Scalp lacerations.,POSTOPERATIVE DIAGNOSIS: , Scalp lacerations.,OPERATION PERFORMED: , Incision and drainage (I&D) with primary wound closure of scalp lacerations.,ANESTHESIA:,  GET.,EBL: , Minimal.,COMPLICATIONS: , None.,DRAINS: , None.,DISPOSITION: , Vital signs stable and taken to the recovery room in a satisfactory condition.,INDICATION FOR PROCEDURE:  ,The patient is a middle-aged female, who has had significant lacerations to her head from a motor vehicle accident.  The patient was taken to the operating room for an I&D of the lacerations with wound closure.,PROCEDURE IN DETAIL:  ,After appropriate consent was obtained from the patient, the patient was wheeled out to the operating theater room #5.  Before the neck instrumentation was performed, the patient's lacerations to her scalp were I&D'ed and closed.  It was noted that the head was significantly contaminated with blood as well as mangled.  It was decided at that time in order to repair the lacerations appropriately, the patient would undergo cutting of her hair.  This was shaved appropriately with shavers.  Once this was done, the scalp lacerations were copiously irrigated with a scrubbing brush, hexedine solution together with peroxide.  Once this was appropriately debrided with regards to the midline incision with the scalp going through the midline of her skull as well as the incision on the left aspect of her scalp, the wounds were significantly irrigated with normal saline.  No significant debris was appreciated.  Once this was done, staples were used to oppose the dermal edges together.  The patient was subsequently dressed sterilely using bacitracin ointment, Xeroform, 4x4s, and tape.  The neck procedure was subsequently performed.surgery, drainage, incision, primary wound closure, lacerations, wound closure, scalp lacerations, scalp, i&d,
I&D - ORIF Wound 

TITLE OF OPERATION:,1.  Irrigation and debridement of postoperative wound infection (CPT code 10180).,2.  Removal of foreign body, deep (CPT code 28192).,3.  Placement of vacuum-assisted closure device, less than 50 centimeter squared (CPT code 97605).,PREOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,POSTOP DIAGNOSIS: , Postoperative wound infection, complicated (ICD-9 code 998.59).,PROCEDURE DETAIL:  ,The patient is a 59-year-old gentleman who is status post open reduction and internal fixation of bilateral calcanei.  He was admitted for a left wound breakdown with drainage.  He underwent an irrigation and debridement with VAC placement 72 hours prior to this operative visit.  It was decided to bring him back for a repeat irrigation and debridement and VAC change prior to Plastics doing a local flap.  The risks of surgery were discussed in detail including, but not limited to infection, bleeding, injuries to nerves and vital structures, need for reoperation, pain or stiffness, arthritis, fracture, the risk of anesthesia.  The patient understood these risks and wished to proceed.  The patient was admitted, and the operative site was marked.,The patient was brought to the operating room and given general anesthetic.  He was placed in the right lateral decubitus, and all bony prominences were well padded.  An axillary roll was placed.  A well-padded thigh tourniquet was placed on the left leg.  The patient then received antibiotics on the floor prior to coming down to the operating room which satisfied the preoperative requirement.  Left leg was then prepped and draped in usual sterile fashion.  The previous five antibiotic spacer beads were removed without difficulty.  The wound was then rongeured and curetted, and all bone was cleaned down to healthy bleeding bone.  The wound actually looked quite good with evidence of purulence or drainage.  Skin edges appeared to be viable.  Hardware all looked to be intact.  At this point, the wound was irrigated with 9 liters of bibiotic solution.  A VAC sponge was then placed over the wound, and the patient's leg was placed into a posterior splint.  The patient was awakened and then taken to recovery in good condition.,Dr. X was present for the timeouts and for all critical portions of the procedure.  He was immediately available for any questions during the case.,PLAN:,1.  A CAM walker boots.,2.  A VAC change on Sunday by the nurse.,3.  A flap per Plastic Surgery.surgery, irrigation and debridement, removal of foreign body, vacuum-assisted closure device, foreign body, postoperative wound, wound infection, infection, wound, orif, debridement, vacuum,
I&D - Penoscrotal Abscess 

PREOPERATIVE DIAGNOSIS: , Penoscrotal abscess.,POSTOPERATIVE DIAGNOSIS:,  Penoscrotal abscess.,OPERATION: , Incision and drainage of the penoscrotal abscess, packing, penile biopsy, cystoscopy, and urethral dilation.,BRIEF HISTORY: , The patient is a 75-year-old male presented with penoscrotal abscess.  Options such as watchful waiting, drainage, and antibiotics were discussed.  Risks of anesthesia, bleeding, infection, pain, MI, DVT, PE, completely the infection turning into necrotizing fascitis, Fournier's gangrene were discussed.  The patient already had significant phimotic changes and disfigurement of the penis.  For further debridement the patient was told that his penis is not going to be viable, he may need a total or partial penectomy now or in the future.  Risks of decreased penile sensation, pain, Foley, other unexpected issues were discussed.  The patient understood all the complications and wanted to proceed with the procedure.,DETAIL OF THE OPERATION:  ,The patient was brought to the OR.  The patient was placed in dorsal lithotomy position.  The patient was prepped and draped in the usual fashion.  Pictures were taken prior to starting the procedure for documentation.  The patient had an open sore on the right side of the penis measuring about 1 cm in size with pouring pus out using blunt dissection.  The penile area was opened up distally to allow the pus to come out.  The dissection around the proximal scrotum was done to make sure there are no other pus pockets.  The corporal body was intact, but the distal part of the corpora was completely eroded and had a fungating mass, which was biopsied and sent for permanent pathology analysis.,Urethra was identified at the distal tip, which was dilated and using 23-French cystoscope cystoscopy was done, which showed some urethral narrowing in the distal part of the urethra.  The rest of the bladder appeared normal.  The prostatic urethra was slightly enlarged.  There are no stones or tumors inside the bladder.  There were moderate trabeculations inside the bladder.  Otherwise, the bladder and the urethra appeared normal.  There was a significantly fungating mass involving the distal part of the urethra almost possibility to have including the fungating wart or fungating squamous cell carcinoma.  Again biopsies were sent for pathology analysis.  Prior to urine irrigation anaerobic aerobic cultures were sent, irrigation with over 2 L of fluid was performed.  After irrigation, packing was done with Kerlix.  The patient was brought to recovery in a stable condition.  Please note that 18-French Foley was kept in place.  Electrocautery was used at the end of the procedure to obtain hemostasis as much as possible, but there was fungating mass with slight bleeding packing was done and tight scrotal Kling was applied.  The patient was brought to Recovery in a stable condition after applying 0.5% Marcaine about 20 mL were injected around for local anesthesia.surgery, i&d, penoscrotal, penile biopsy, cystoscopy, urethral dilation, incision and drainage, fungating mass, penoscrotal abscess, abscess, urethral,
I&D - Neck Abscess 

PREOPERATIVE DIAGNOSIS: , Left neck abscess.,POSTOPERATIVE DIAGNOSIS: , Left neck abscess.,OPERATIVE PROCEDURE: , Incision and drainage of left neck abscess.,ANESTHESIA:  ,General inhalational.,DESCRIPTION OF PROCEDURE: , The patient was taken to operating room and placed supine on the operating table.  General inhalational anesthesia was administered.  The patient was draped in usual fashion.  The prominent area of the left submandibular swelling was noted and a 1-cm incision was outlined with a marking pen and the area was infiltrated with 0.5 mL of local anesthetic using 1% Xylocaine with epinephrine 1:100,000.  The incision was performed with a #15 blade.  An 18-gauge needle and 10 mL syringe was used to evacuate a small amount of the purulence from the abscess cavity.  This was submitted for culture and sensitivity, anaerobic cultures and Gram stain.  The cavity was opened with a small hemostat and a great deal of grossly purulent material was evacuated.  The cavity was irrigated with peroxide and saline.  A 0.25-inch Penrose drain was placed and secured with a single #3-0 nylon suture.  A 4 x 4 dressing was applied.  Bleeding was negligible.  There were no untoward complications.  The patient tolerated the procedure well and was transferred to the recovery room in stable condition.surgery, i&d, incision and drainage, neck abscess, drainage, cavity, incision,
I&D & Foreign Body Removal 

PREOPERATIVE DIAGNOSIS:,  Foreign body, right foot.,POSTOPERATIVE DIAGNOSIS: , Foreign body, right foot.,PROCEDURE PERFORMED:,1.  Incision and drainage, right foot.,2.  Removal of foreign body, right foot.,HISTORY: , This 7-year-old Caucasian male is an inpatient at ABCD General Hospital with a history of falling off his bike and having a root ________ angle inside of his foot.  The patient has had previous I&D but continues to have to purulent drainage.  The patient's parents agreed to performing a surgical procedure to further clean the wound.,PROCEDURE:,  An IV was instituted by the Department of Anesthesia in the preoperative holding area.  The patient was transported to the operating room and placed on the operating table in a supine position with a safety strap across his lap.  General anesthesia was administered by the Department of Anesthesia.  The foot was then prepped and draped in the usual sterile orthopedic fashion.  The stockinette was reflected and the foot was cleansed with wet and dry sponge.  There was noted to be some remaining periwound erythema.  There was noted to be some mild crepitation about 2 cm proximal from the entry wound.  The entry wound was noted to be over the third metatarsal head dorsally.  Upon inspection of the wound, there was noted to be hard foreign filling substance deep within the wound.  The entry site from the foreign body was extended proximally approximately about 0.5 cm.  At this time, a large wooden foreign body was visualized and removed with a straight stat.,The area was carefully inspected for any remaining piece of foreign body.  Several small pieces were noted and they were removed.  The area was palpated and there was no more remaining foreign body noted.  At this time, the wound was inspected thoroughly.  There was noted to be an area along the third metatarsal head more distally that did probe to the bone.  There was no purulent drainage expressed.  Area was flushed with copious amounts of sterile saline.  Pulse lavage was performed with 3 liters of plain sterile saline.  Wound cultures were obtained, aerobic and aerobic.  The wound was then again inspected for any remaining foreign body or purulent drainage.  None was noticed.  The wound was packed with sterile new gauze packing lately and dressings consisted of 4x4s, ABDs, Kling, and Kerlix.,The patient tolerated the above procedure and anesthesia well without complications.  The patient was transported to the PACU with vital signs stable and vascular status intact.  The patient is to be readministered to the pediatrics where daily dressing changes will be performed by podiatry.  The patient had a postoperative pain prescription written for Tylenol, Elixir with codeine as needed.surgery, incision and drainage, removal of foreign body, purulent drainage, foreign body, metatarsal head, orthopedic, metatarsal, i&d, incision, drainage, foot
I&D - Buccal Space Abscess 

PREOPERATIVE DIAGNOSES,1.  Right buccal space abscess/cellulitis.,2.  Nonrestorable caries teeth #1, #29, and #32.,POSTOPERATIVE DIAGNOSES,1.  Right buccal space abscess/cellulitis.,2.  Nonrestorable caries teeth #1, #29, and #32.,PROCEDURE,1.  Incision and drainage of right buccal space abscess.,2.  Extraction of teeth #1, #29, and #32.,ANESTHESIA,GETA,EBL,20 mL.,IV FLUIDS,900 mL.,URINE OUTPUT,Not measured.,COMPLICATIONS,None.,SPECIMENS,1.  Aerobic culture was sent from the right buccal space abscess/cellulitis.,2.  Anaerobic culture from the same space was also obtained.,PROCEDURE IN DETAIL,The patient was identified in the appropriate holding area and transported to #13.  The patient was intubated by anesthesia orotracheally using a #7 ET tube.  The patient was induced in effective sleep using a propofol and gas inhalation anesthetics.  Following intubation, the patient's mouth was cleaned with chlorhexidine and a toothbrush following placement of a throat pack.  At that point, approximately 5 mL of 2% lidocaine with 1:20,000 epinephrine was injected for a right inferior alveolar block, as well as local infiltration in the right long buccal nerve area as well as the right cheek area.  Local infiltration also was done near the tooth #32.  At this point, a periosteal elevator was used to loosen up the gingival tissue of the teeth #1, #29, and #32; and all 3 teeth were extracted using simple extraction, using elevators and forceps.  In addition, the previous Penrose drain was removed by removing the suture, and the incision that was used for I&D on the previous day was extended laterally.  A hemostat was used to puncture through to the right buccal space.  Approximately, 2.5 to 3 mL of purulence was drained, and that was used for Gram stain and culture, as mentioned above.  Following copious irrigation of the area, following the extraction and following the incision and drainage, 2 quarter-inch Penrose drains were placed in the anterior as well as the posterior section of the incision into the buccal space.  At this point copious irrigation was done again, the throat pack was removed, and the procedure was ended.  Note that the patient was extubated without incident.  Dr. B was present for all critical aspects of patient care.surgery, abscess, #7 et tube, aerobic culture, anaerobic culture, extraction of teeth, geta, alveolar block, buccal space, caries, cellulitis, copious irrigation, extraction, teeth, nonrestorable caries teeth, buccal space abscess, nonrestorable caries, caries teeth, throat pack, buccal,
I&D - Buttock Abscess 

PRINCIPAL DIAGNOSIS: , Buttock abscess, ICD code 682.5.,PROCEDURE PERFORMED:,  Incision and drainage (I&D) of buttock abscess.,CPT CODE: , 10061.,DESCRIPTION OF PROCEDURE:  ,Under general anesthesia, skin was prepped and draped in usual fashion.  Two incisions were made along the right buttock approximately 5 mm diameter.  Purulent material was drained and irrigated with copious amounts of saline flush.  A Penrose drain was placed.  Penrose drain was ultimately sutured forming a circular drain.  The patient's drain will be kept in place for a period of 1 week and to be taken as an outpatient basis.  Anesthesia, general endotracheal anesthesia.  Estimated blood loss approximately 5 mL.  Intravenous fluids 100 mL.  Tissue collected.  Purulent material from buttock abscess sent for usual cultures and chemistries.  Culture and sensitivity Gram stain.  A single Penrose drain was placed and left in the patient.  Dr. X attending surgeon was present throughout the entire procedure.surgery, incision and drainage, purulent material, penrose drain, buttock abscess, i&d, drainage
Hysteroscopy & Endometrial Ablation 

PREOPERATIVE DX:,1.  Menorrhagia,2.  Desires permanent sterilization.,POSTOPERATIVE DX:,1.  Menorrhagia,2.  Desires permanent sterilization.,OPERATIVE PROCEDURE:,  Hysteroscopy, Essure, tubal occlusion, and ThermaChoice endometrial ablation.,ANESTHESIA: , General with paracervical block.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS:,  On hysteroscopy, 100 ml deficit of lactated Ringer's via IV, 850 ml of lactated Ringer's.,COMPLICATIONS: , None.,PATHOLOGY: , None.,DISPOSITION:  ,Stable to recovery room.,FINDINGS:,  A nulliparous cervix without lesions.  Uterine cavity sounding to 10 cm, normal appearing tubal ostia bilaterally, fluffy endometrium, normal appearing cavity without obvious polyps or fibroids.,PROCEDURE: , The patient was taken to the operating room, where general anesthesia was found to be adequate.  She was prepped and draped in the usual sterile fashion.  A speculum was placed into the vagina.  The anterior lip of the cervix was grasped with a single-tooth tenaculum and a paracervical block was performed using 20 ml of 0.50% lidocaine with 1:200,000 of epinephrine.,The cervical vaginal junction at the 4 o'clock position was injected and 5 ml was instilled.  The block was performed at 8 o'clock as well with 5 ml at 10 and 2 o'clock.  The lidocaine was injected into the cervix.  The cervix was minimally dilated with #17 Hanks dilator.  The 5-mm 30-degree hysteroscope was then inserted under direct visualization using lactated Ringer's as a distention medium.  The uterine cavity was viewed and the above normal findings were noted.  The Essure tubal occlusion was then inserted through the operative port and the tip of the Essure device easily slid into the right ostia.  The coil was advanced and easily placed and the device withdrawn.  There were three coils into the uterine cavity after removal of the insertion device.  The device was removed and reloaded.  The advice was to advance under direct visualization and the tip was inserted into the left ostia.  This passed easily and the device was inserted.  It was removed easily and three coils again were into the uterine cavity.  The hysteroscope was then removed and the ThermaChoice ablation was performed.  The uterus was then sounded to 9.5 to 10 cm.  The ThermaChoice balloon was primed and pressure was drawn to a negative 150.  The device was then moistened and inserted into the uterine cavity and the balloon was slowly filled with 40 ml of D5W.  The pressure was brought up to 170 and the cycle was initiated.  A full cycle of eight minutes was performed.  At no time there was a significant loss of pressure from the catheter balloon.  After the cycle was complete, the balloon was deflated and withdrawn.  The tenaculum was withdrawn.  No bleeding was noted.  The patient was then awakened, transferred, and taken to the recovery room in satisfactory condition.surgery, menorrhagia, essure, hysteroscopy, thermachoice, uterine cavity, endometrial ablation, endometrium, fibroids, fluffy, lactated ringer, nulliparous, paracervical block, permanent sterilization, polyps, tubal occlusion, tubal ostia, lactated ringer's, ablation, uterine,
I&D - Auricular Hematoma 

PREOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,POSTOPERATIVE DIAGNOSIS: , Recurrent severe right auricular hematoma.,TITLE OF PROCEDURE:,  Incision and drainage with bolster dressing placement of right ear recurrent auricular hematoma.,ANESTHESIA: , Xylocaine 1% with 1:100,000 dilution of epinephrine totaling 2 mL.,COMPLICATIONS:,  None.,FINDINGS: , Approximately 5 mL of serosanguineous drainage.,PROCEDURE: , The patient underwent an incision and drainage procedure with stay suture placement on 05/28/2008 by me and also by Dr. X on 05/23/2008 for a large near 100% auricular hematoma.  She presents for suture removal; however, there is still fluid noted now at the antihelix fold above the concha bullosa below previous sutures placed by Dr. X.  It was recommended that this area be drained through the previous incision and drainage incision which has healed and wound care by the patient appears to be very poor if any at all being performed which may be complicating matters.  Consent was obtained.  The patient is aware that the complications with this ear area severe and auricular deformity is inevitable; however, quick prompt aggressive drainage addressing fluid collections offers a best chance for improvement from an already very difficult situation.,The area was prepped in the usual manner, localized and the previous incision was reopened with a curved hemostat and about 5 mL of serosanguineous drainage was noted.  A through-and-through Keith needle bolster dressing was applied with cottonoid pledget on both sides of the ear to help compression.  She tolerated this procedure very well.surgery, bolster dressing placement, antihelix fold, incision and drainage, bolster dressing, auricular hematoma, auricular, hematoma, incision, drainage