smoh/medical-transcriptions huggingface dataset:
Tubal Ligation - Laparoscopic  ( Obstetrics / Gynecology)
Description:  Desires permanent sterilization.  Laparoscopic tubal ligation, Falope ring method.  Normal appearing uterus and adnexa bilaterally.

PREOPERATIVE DIAGNOSIS:,  Desires permanent sterilization.,POSTOPERATIVE DIAGNOSIS: , Desires permanent sterilization.,PROCEDURE: , Laparoscopic tubal ligation, Falope ring method.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS: , 10 mL.,COMPLICATIONS: , None.,INDICATIONS FOR SURGERY:  ,A 35-year-old female, P4-0-0-4, who desires permanent sterilization.  The risks of bleeding, infection, damage to other organs, and subsequent ectopic pregnancy was explained.  Informed consent was obtained.,OPERATIVE FINDINGS: , Normal appearing uterus and adnexa bilaterally.,DESCRIPTION OF PROCEDURE: , After administration of general anesthesia, the patient was placed in the dorsal lithotomy position, and prepped and draped in the usual sterile fashion.  The speculum was placed in the vagina, the cervix was grasped with the tenaculum, and a uterine manipulator inserted.  This area was then draped off the remainder of the operative field.,A 5-mm incision was made umbilically after injecting 0.25% Marcaine, 2 mL.  A Veress needle was inserted to confirm an opening pressure of 2 mmHg.  Approximately 4 liters of CO2 gas was insufflated into the abdominal cavity.  The Veress needle was removed, and a 5-mm port placed.  Position was confirmed using a laparoscope.  A second port was placed under direct visualization, 3 fingerbreadths suprapubically, 7 mm in diameter, after 2 mL of 0.25% Marcaine was injected.  This was done under direct visualization.  The pelvic cavity was examined with the findings as noted above.  The Falope rings were then applied to each tube bilaterally.  Good segments were noted to be ligated.  The accessory port was removed.  The abdomen was deflated.  The laparoscope and sheath was removed.  The skin edges were approximated with 5-0 Monocryl suture in subcuticular fashion.  The instruments were removed from the vagina.  The patient was returned to the supine position, recalled from anesthesia, and transferred to the recovery room in satisfactory condition.  Sponge and needle counts correct at the conclusion of the case.  Estimated blood loss was minimal.
Ultrasound OB  ( Obstetrics / Gynecology)
Description:  Ultrasound OB - followup for fetal growth.

REASON FOR EXAM: , Followup for fetal growth. , ,INTERPRETATION: , Real-time exam demonstrates a single intrauterine fetus in cephalic presentation with a regular cardiac rate of 147 beats per minute documented. ,FETAL BIOMETRY:  ,BPD = 8.3 cm = 33 weeks, 4 days,HC = 30.2 cm = 33 weeks, 4 days,AC = 27.9 cm = 32 weeks, 0 days,FL =  6.4 cm = 33 weeks, 1 day,The head to abdomen circumference ratio is normal at 1.08, and the femur length to abdomen circumference ratio is normal at 23.0%.  Estimated fetal weight is 2,001 grams.  ,The amniotic fluid volume appears normal, and the calculated index is normal for the age at 13.7 cm.  ,A detailed fetal anatomic exam was not performed at this setting, this being a limited exam for growth.  The placenta is posterofundal and grade 2., ,IMPRESSION: , Single viable intrauterine pregnancy in cephalic presentation with a composite gestational age of 32 weeks, 5 days, plus or minus 17 days, giving and estimated date of confinement of 8/04/05.  There has been normal progression of fetal growth compared to the two prior exams of 2/11/05 and 4/04/05.  The examination of 4/04/05 questioned an echogenic focus within the left ventricle.  The current examination does not demonstrate any significant persistent echogenic focus involving the left ventricle.
Tubal Ligation  ( Obstetrics / Gynecology)
Description:  Laparoscopic bilateral tubal ligation with Falope rings.

DIAGNOSIS: , Multiparous female, desires permanent sterilization.,NAME OF OPERATION: , Laparoscopic bilateral tubal ligation with Falope rings.,ANESTHESIA: , General, ET tube.,COMPLICATIONS:,  None.,FINDINGS:  ,Normal female anatomy except for mild clitoromegaly and a posterior uterine fibroid.,PROCEDURE: , The patient was taken to the operating room and placed on the table in the supine position.  After adequate general anesthesia was obtained, she was placed in the lithotomy position and examined.  She was found to have an anteverted uterus and no adnexal mass.  She was prepped and draped in the usual fashion.  The Foley catheter was placed.  A Hulka cannula was inserted into the cervix and attached to the anterior lip of the cervix.,An infraumbilical incision was made with the knife.  A Veress needle was inserted into the abdomen.  Intraperitoneal location was verified with approximately 10 cc of sterile solution.  A pneumoperitoneum was created.  The Veress needle was then removed, and a trocar was inserted directly without difficulty.  Intraperitoneal location was verified visually with the laparoscope.  There was no evidence of any intra-abdominal trauma.,Each fallopian tube was elevated with a Falope ring applicator, and a Falope ring was placed on each tube with a 1-cm to 1.5-cm portion of the tube above the Falope ring.,The pneumoperitoneum was evacuated, and the trocar was removed under direct visualization.  An attempt was made to close the fascia with a figure-of-eight suture.  However, this was felt to be more subcutaneous.  The skin was closed in a subcuticular fashion, and the patient was taken to the recovery room awake with vital signs stable.
Tubal Fulguration - Laparoscopic   ( Obstetrics / Gynecology)
Description:  Laparoscopic tubal fulguration.

A 1 cm infraumbilical skin incision was made.  Through this a Veress needle was inserted into the abdominal cavity.  The abdomen was filled with approximately 2 liters of CO2 gas.  The Veress needle was withdrawn.  A trocar sleeve was placed through the incision into the abdominal cavity.  The trocar was withdrawn and replaced with the laparoscope.  A 1 cm suprapubic skin incision was made.  Through this a second trocar sleeve was placed into the abdominal cavity using direct observation with the laparoscope.  The trocar was withdrawn and replaced with a probe.,The patient was placed in Trendelenburg position, and the bowel was pushed out of the pelvis.  Upon visualization of the pelvis organs, the uterus, fallopian tubes and ovaries were all normal.  The probe was withdrawn and replaced with the bipolar cautery instrument.  The right fallopian tube was grasped approximately 1 cm distal to the cornual region of the uterus.  Electrical current was applied to the tube at this point and fulgurated.  The tube was then regrasped just distal to this and refulgurated.  It was then regrasped just distal to the lateral point and refulgurated again.  The same procedure was then carried out on the opposite tube.  The bipolar cautery instrument was withdrawn and replaced with the probe.  The fallopian tubes were again traced to their fimbriated ends to confirm the burn points on the tubes.  The upper abdomen was visualized, and the liver surface was normal.  The gas was allowed to escape from the abdomen, and the instruments were removed.  The skin incisions were repaired.  The instruments were removed from the vagina.,There were no complications to the procedure.  Blood loss was minimal.  The patient went to the postanesthesia recovery room in stable condition.
Tubal Ligation - Postpartum  ( Obstetrics / Gynecology)
Description:  Postpartum tubal ligation and removal of upper abdominal skin wall mass.

PREOPERATIVE DIAGNOSES:,  Multiparity requested sterilization and upper abdominal wall skin mass., ,POSTOPERATIVE DIAGNOSES:  ,Multiparity requested sterilization and upper abdominal wall skin mass.,OPERATION PERFORMED: , Postpartum tubal ligation and removal of upper abdominal skin wall mass.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,DRAINS: , None.,ANESTHESIA: , Spinal.,INDICATION: , This is a 35-year-old white female gravida 6, para 3, 0-3-3 who is status post delivery on 09/18/2007.  The patient was requesting postpartum tubal ligation and removal of a large mole at the junction of her abdomen and left lower rib cage at the skin level.,PROCEDURE IN DETAIL:,  The patient was taken to the operating room, placed in a seated position with spinal form of anesthesia administered by anesthesia department.  The patient was then repositioned in a supine position and then prepped and draped in the usual fashion for postpartum tubal ligation.  Subumbilical ridge was created using two Ellis and first knife was used to make a transverse incision.  The Ellis were removed and used to be grasped incisional edges and both blunt and sharp dissection down to the level of the fascia was then completed.  The fascia grasped with two Kocher's and then sharply incised and then peritoneum was entered with use of blunt dissection.  Two Army-Navy retractors were put in place and a vein retractor was used to grasp the left fallopian tube and then regrasped with Babcock's and followed to the fimbriated end.  A modified Pomeroy technique was completed with double tying of with 0 chromic, then upper portion was sharply incised and the cut fallopian tube edges were then cauterized.  Adequate hemostasis was noted.  This tube was placed back in its anatomic position.  The right fallopian tube was grasped followed to its fimbriated end and then regrasped with a Babcock and a modified Pomeroy technique was also completed on the right side, and upper portion was then sharply incised and the cut edges re-cauterized with adequate hemostasis and this was placed back in its anatomic position.  The peritoneum as well as fascia was reapproximated with 0-Vicryl.  The subcutaneous tissues reapproximated with 3-0 Vicryl and skin edges reapproximated with 4-0 Vicryl as well in a subcuticular stitch.  Pressure dressings were applied.  Marcaine 10 mL was used prior to making an incision.  Sterile dressing was applied.  The large mole-like lesion was grasped with Allis.  It was approximately 1 cm x 0.5 cm in size and an elliptical incision was made around the mass and cut edges were cauterized and 4-0 Vicryl was used to reapproximate the skin edges and pressure dressing was also applied.  Instrument count, needle count, and sponge counts were all correct, and the patient was taken to recovery room in stable condition.
Total Abdominal Hysterectomy - Followup  ( Obstetrics / Gynecology)
Description:  Postoperative day #1, total abdominal hysterectomy.  Normal postoperative course.

POSTOPERATIVE DAY #1, TOTAL ABDOMINAL HYSTERECTOMY,SUBJECTIVE: , The patient is alert and oriented x3 and sitting up in bed.  The patient has been ambulating without difficulty.  The patient is still NPO.  The patient denies any new symptomatology from  6/10/2009.  The patient has complaints of incisional tenderness.  The patient was given a full explanation about her clinical condition and all her questions were answered.,OBJECTIVE:,VITAL SIGNS:  Afebrile now.  Other vital signs are stable.,GU:  Urinating through Foley catheter.,ABDOMEN:  Soft, negative rebound.,EXTREMITIES:  Without Homans, nontender.,BACK:  Without CVA tenderness.,GENITALIA:  Vagina, slight spotting.  Wound dry and intact.,ASSESSMENT:,  Normal postoperative course.,PLAN:,1.  Follow clinically.,2.  Continue present therapy.,3.  Ambulate with nursing assistance only.,
Tubal Sterilization & Coagulation  ( Obstetrics / Gynecology)
Description:  Laparoscopic tubal sterilization, tubal coagulation.  

PROCEDURE:  ,Laparoscopic tubal sterilization, tubal coagulation.,PREOPERATIVE DIAGNOSIS: , Request tubal coagulation.,POSTOPERATIVE DIAGNOSIS: , Request tubal coagulation.,PROCEDURE:  ,Under general anesthesia, the patient was prepped and draped in the usual manner.  Manipulating probe placed on the cervix, changed gloves.  Small cervical stab incision was made, Veress needle was inserted without problem.  A 3 L of carbon dioxide was insufflated.  The incision was enlarged.  A 5-mm trocar placed through the incision without problem.  Laparoscope placed through the trocar.  Pelvic contents visualized.  A 2nd puncture was made 2 fingerbreadths above the symphysis pubis in the midline.  Under direct vision, the trocar was placed in the abdominal cavity.  Uterus, tubes, and ovaries were all normal.  There were no pelvic adhesions, no evidence of endometriosis.  Uterus was anteverted and the right adnexa was placed on a stretch.  The tube was grasped 1 cm from the cornual region, care being taken to have the bipolar forceps completely across the tube and the tube was coagulated using amp meter for total desiccation.  The tube was grasped again and the procedure was repeated for a separate coagulation, so that 1.5 cm of the tube was coagulated.  The structure was confirmed to be tube by looking at fimbriated end.  The left adnexa was then placed on a stretch and the procedure was repeated again grasping the tube 1 cm from the cornual region and coagulating it.  Under traction, the amp meter was grasped 3 more times so that a total of 1.5 cm of tube was coagulated again.  Tube was confirmed by fimbriated end.  Gas was lend out of the abdomen.  Both punctures repaired with 4-0 Vicryl and punctures were injected with 0.5% Marcaine 10 mL.  The patient went to the recovery room in good condition.
True Cut Needle Biopsy - Breast  ( Obstetrics / Gynecology)
Description:  True cut needle biopsy of the breast.  This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.

PREOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,POSTOPERATIVE DIAGNOSIS:,  Carcinoma of the left breast.,PROCEDURE PERFORMED: , True cut needle biopsy of the breast.,GROSS FINDINGS:  ,This 65-year-old female on exam was noted to have dimpling and puckering of the skin associated with nipple discharge.  On exam, she has a noticeable carcinoma of the left breast with dimpling, puckering, and erosion through the skin.  At this time, a true cut needle biopsy was performed.,PROCEDURE: , The patient was taken to operating room, is laid in the supine position, sterilely prepped and draped in the usual fashion.  The area over the left breast was infiltrated with 1:1 mixture of 0.25% Marcaine and 1% Xylocaine.  Using a #18 gauge automatic true cut needle core biopsy, five biopsies were taken of the left breast in core fashion.  Hemostasis was controlled with pressure.  The patient tolerated the procedure well, pending the results of biopsy.
Total Abdominal Hysterectomy  ( Obstetrics / Gynecology)
Description:  Total Abdominal Hysterectomy (TAH).  An incision was made into the abdomen down through the subcutaneous tissue, muscular fascia and peritoneum.  Once inside the abdominal cavity, a self-retaining retractor was placed to expose the pelvic cavity with 3 lap sponges.
Three-Week Postpartum Checkup  ( Obstetrics / Gynecology)
Description:  The patient comes for three-week postpartum checkup, complaining of allergies.

CHIEF COMPLAINT:,  The patient comes for three-week postpartum checkup, complaining of allergies.,HISTORY OF PRESENT ILLNESS:,  She is doing well postpartum.  She has had no headache.  She is breastfeeding and feels like her milk is adequate.  She has not had much bleeding.  She is using about a mini pad twice a day, not any cramping or clotting and the discharge is turned from red to brown to now slightly yellowish.  She has not yet had sexual intercourse.  She does complain that she has had a little pain with the bowel movement, and every now and then she notices a little bright red bleeding.  She has not been particularly constipated but her husband says she is not eating her vegetables like she should.  Her seasonal allergies have back developed and she is complaining of extremely itchy watery eyes, runny nose, sneezing, and kind of a pressure sensation in her ears.,MEDICATIONS:,  Prenatal vitamins.,ALLERGIES:,  She thinks to Benadryl.,FAMILY HISTORY: , Mother is 50 and healthy.  Dad is 40 and healthy.  Half-sister, age 34, is healthy.  She has a sister who is age 10 who has some yeast infections.,PHYSICAL EXAMINATION:,VITALS:  Weight:  124 pounds.  Blood pressure 96/54.  Pulse:  72.  Respirations:  16.  LMP:  10/18/03.  Age:  39.,HEENT:  Head is normocephalic.  Eyes:  EOMs intact.  PERRLA.  Conjunctiva clear.  Fundi:  Discs flat, cups normal.  No AV nicking, hemorrhage or exudate.  Ears:  TMs intact.  Mouth:  No lesion.  Throat:  No inflammation.  She has allergic rhinitis with clear nasal drainage, clear watery discharge from the eyes.,Abdomen:  Soft.  No masses.,Pelvic:  Uterus is involuting.,Rectal:  She has one external hemorrhoid which has inflamed.  Stool is guaiac negative and using anoscope, no other lesions are identified.,ASSESSMENT/PLAN:,  Satisfactory three-week postpartum course, seasonal allergies.  We will try Patanol eyedrops and Allegra 60 mg twice a day.  She was cautioned about the possibility that this may alter her milk supply.  She is to drink extra fluids and call if she has problems with that.  We will try ProctoFoam HC.  For the hemorrhoids, also increase the fiber in her diet.  That prescription was written, as well as one for Allegra and Patanol.  She additionally will be begin on Micronor because she would like to protect herself from pregnancy until her husband get scheduled in and has a vasectomy, which is their ultimate plan for birth control, and she anticipates that happening fairly soon.  She will call and return if she continues to have problems with allergies.  Meantime, rechecking in three weeks for her final six-week postpartum checkup.
Suction, Dilation, & Curettage - 1  ( Obstetrics / Gynecology)
Description:   Suction dilation and curettage for incomplete abortion.  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.

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.
TAH - Discharge Summary  ( Obstetrics / Gynecology)
Description:  Total abdominal hysterectomy (TAH).  Severe menometrorrhagia unresponsive to medical therapy, severe anemia, and symptomatic fibroid uterus.  

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.