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Mild-to-moderate diverticulosis. She was referred for a screening colonoscopy. There is no family history of colon cancer. No evidence of polyps or malignancy. | Surgery | Colonoscopy - 22 | PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES:, The patient is a 56-year-old female. She was referred for a screening colonoscopy. The patient has bowel movements every other day. There is no blood in the stool, no abdominal pain. She has hypertension, dyslipidemia, and gastroesophageal reflux disease. She has... |
Colonoscopy. Rectal bleeding and perirectal abscess. Normal colonoscopy to the terminal ileum. Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen. | Surgery | Colonoscopy - 16 | PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum an... |
Universal diverticulosis and nonsurgical internal hemorrhoids. Total colonoscopy with photos. The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck. | Surgery | Colonoscopy - 17 | PREOPERATIVE DIAGNOSIS: , Colon polyps.,POSTOPERATIVE DIAGNOSES:,1. Universal diverticulosis.,2. Nonsurgical internal hemorrhoids.,PROCEDURE PERFORMED:, Total colonoscopy with photos.,ANESTHESIA:, Demerol 100 mg IV with Versed 3 mg IV.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE: ,... |
History of polyps. Total colonoscopy and photography. Normal colonoscopy, left colonic diverticular disease. 3+ benign prostatic hypertrophy. | Surgery | Colonoscopy - 13 | PREOPERATIVE DIAGNOSIS: , History of polyps.,POSTOPERATIVE DIAGNOSES:,1. Normal colonoscopy, left colonic diverticular disease.,2. 3+ benign prostatic hypertrophy.,PROCEDURE PERFORMED: , Total colonoscopy and photography.,GROSS FINDINGS: , This is a 74-year-old white male here for recheck colonoscopy for a history of... |
Colonoscopy. The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum. | Surgery | Colonoscopy - 12 | PROCEDURE IN DETAIL: , Following instructions and completion of an oral colonoscopy prep, the patient, having been properly informed of, with signature consenting to total colonoscopy and indicated procedures, the patient received premedications of Vistaril 50 mg, Atropine 0.4 mg IM, and then intravenous medications of... |
Screening colonoscopy. Tiny polyps. If adenomatous, repeat exam in five years. | Surgery | Colonoscopy - 20 | PREOPERATIVE DIAGNOSIS: , Screening. ,POSTOPERATIVE DIAGNOSIS:, Tiny Polyps.,PROCEDURE PERFORMED: , Colonoscopy.,PROCEDURE: , The procedure, indications, and risks were explained to the patient, who understood and agreed. He was sedated with Versed 3 mg, Demerol 25 mg during the examination. ,A digital rectal exam... |
Colonoscopy in a patient with prior history of anemia and abdominal bloating. | Surgery | Colonoscopy - 2 | PREOPERATIVE DIAGNOSES:, Prior history of anemia, abdominal bloating.,POSTOPERATIVE DIAGNOSIS:, External hemorrhoids, otherwise unremarkable colonoscopy.,PREMEDICATIONS:, Versed 5 mg, Demerol 50 mg IV.,REPORT OF PROCEDURE:, Digital rectal exam revealed external hemorrhoids. The colonoscope was inserted into the re... |
Colonoscopy. The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum. | Surgery | Colonoscopy - 11 | MEDICATIONS:,1. Versed intravenously.,2. Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent was obtained, the patient was placed in the left lateral decubitus position and sedated with the above medications. The Olympus video colonoscope was inserted through the anus and was advanced in re... |
Colonoscopy with terminal ileum examination. Iron deficiency anemia. Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty. | Surgery | Colonoscopy - 19 | INDICATION: , Iron deficiency anemia.,PROCEDURE: ,Colonoscopy with terminal ileum examination.,POSTOPERATIVE DIAGNOSIS:, Normal examination.,WITHDRAWAL TIME: , 15 minutes.,SCOPE: , CF-H180AL.,MEDICATIONS: , Fentanyl 100 mcg and versed 10 mg.,PROCEDURE DETAIL: ,Following the preprocedure patient assessment the proced... |
Colon cancer screening and family history of polyps. Sigmoid diverticulosis and internal hemorrhoids. | Surgery | Colonoscopy - 10 | PREOPERATIVE DIAGNOSES: , Colon cancer screening and family history of polyps.,POSTOPERATIVE DIAGNOSIS:, Colonic polyps.,PROCEDURE:, Colonoscopy.,ANESTHESIA:, MAC,DESCRIPTION OF PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the ce... |
Colonoscopy. Change in bowel habits and rectal prolapse. Normal colonic mucosa to the cecum. | Surgery | Colonoscopy - 15 | PROCEDURE:, Colonoscopy.,PREOPERATIVE DIAGNOSES: , Change in bowel habits and rectal prolapse.,POSTOPERATIVE DIAGNOSIS: , Normal colonoscopy.,PROCEDURE: ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve... |
Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids. | Surgery | Colonoscopy - 14 | PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES: ,1. Normal operative site. ,2. Mild diverticulosis of the sigmoid colon. ,3. Hemorrhoids.,PROCEDURE: ,Total colonoscopy.,PROCEDURE IN DETAIL: ,The patient is a 60-year-old of Dr. ABC's being evaluat... |
Juxtaductal coarctation of the aorta, dilated cardiomyopathy, bicuspid aortic valve, patent foramen ovale. | Surgery | Coarctation of Aorta | HISTORY: , The patient is a 4-month-old who presented with respiratory distress and absent femoral pulses with subsequent evaluation including echocardiogram that demonstrated severe coarctation of the aorta with a peak gradient of 29 mmHg and associated dilated cardiomyopathy with fractional shortening of 16%. A bicu... |
Colonoscopy due to rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease. | Surgery | Colonoscopy - 1 | INDICATION: , Rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.,PREMEDICATION: ,See procedure nurse NCS form.,PROCEDURE: , |
Left upper extremity amputation. This 3-year-old male suffered amputation of his left upper extremity with complications of injury. He presents at this time for further attempts at closure. Left abdominal flap 5 x 5 cm to left forearm, debridement of skin, subcutaneous tissue, muscle, and bone, closure of wounds, p... | Surgery | Closure of Amputation Wounds | PREOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,POSTOPERATIVE DIAGNOSIS: , Left upper extremity amputation.,PROCEDURES:,1. Left abdominal flap 5 x 5 cm to left forearm.,2. Debridement of skin, subcutaneous tissue, muscle, and bone.,3. Closure of wounds, simple closure approximately 8 cm.,4. Placement of ... |
Iron deficiency anemia. Diverticulosis in the sigmoid. | Surgery | Colonoscopy | PREOPERATIVE DIAGNOSIS:, Iron deficiency anemia.,POSTOPERATIVE DIAGNOSIS:, Diverticulosis.,PROCEDURE:, Colonoscopy.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and th... |
Closure of multiple complex lacerations. Multiple complex lacerations of the periorbital area. | Surgery | Closure of Complex Lacerations | PREOPERATIVE DIAGNOSIS:, Multiple complex lacerations of the periorbital area.,POSTOPERATIVE DIAGNOSIS:, Multiple complex lacerations of the periorbital area.,PROCEDURE PERFORMED:, Closure of multiple complex lacerations.,ANESTHESIA: , Local 1% with epinephrine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , None.,COM... |
Repair of bilateral cleft of the palate with vomer flaps. | Surgery | Cleft Repair | PREOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,POSTOPERATIVE DIAGNOSES: , Bilateral cleft lip and bilateral cleft of the palate.,PROCEDURE PERFORMED: , Repair of bilateral cleft of the palate with vomer flaps.,ESTIMATED BLOOD LOSS: , 40 mL.,COMPLICATIONS: , None.,ANESTHESIA: , General ... |
Trimalleolar ankle fracture and dislocation right ankle. A comminuted fracture involving the lateral malleolus, as well as a medial and posterior malleolus fracture as well. Closed open reduction and internal fixation of right ankle. | Surgery | Closed ORIF - Ankle | PREOPERATIVE DIAGNOSES:,1. Trimalleolar ankle fracture.,2. Dislocation right ankle.,POSTOPERATIVE DIAGNOSES:,1. Trimalleolar ankle fracture.,2. Dislocation right ankle.,PROCEDURE PERFORMED: , Closed open reduction and internal fixation of right ankle.,ANESTHESIA: ,Spinal with sedation.,COMPLICATIONS: ,None.,ESTIM... |
Clear corneal temporal incision (no stitches). A lid speculum was placed in the fissure of the right eye. | Surgery | Clear Corneal Temporal Incision | CLEAR CORNEAL TEMPORAL INCISION (NO STITCHES),DESCRIPTION OF OPERATION: , Under satisfactory local anesthesia, the patient was appropriately prepped and draped. A lid speculum was placed in the fissure of the right eye.,The secondary incision was then made through clear cornea using 1-mm diamond keratome at surgeon's ... |
Right distal both-bone forearm fracture. Closed reduction under conscious sedation and application of a splint was warranted. | Surgery | Closed Reduction - 1 | PREOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Right distal both-bone forearm fracture.,INDICATIONS:, Mr. ABC is a 10-year-old boy who suffered a fall resulting in a right distal both-bone forearm fracture. Upon evaluation by Orthopedic Surgery team in the emergency depa... |
Left distal both-bone forearm fracture. Closed reduction with splint application with use of image intensifier. | Surgery | Closed Reduction - 2 | PREOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,POSTOPERATIVE DIAGNOSIS: , Left distal both-bone forearm fracture.,PROCEDURE:, Closed reduction with splint application with use of image intensifier.,INDICATIONS: , Mr. ABC is an 11-year-old boy who sustained a fall on 07/26/2008. Evaluation in the em... |
Bilateral open mandible fracture, open left angle and open symphysis fracture. Closed reduction of mandible fracture with MMF. | Surgery | Closed Reduction - Mandible Fracture | PREOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,POSTOPERATIVE DIAGNOSIS: , Bilateral open mandible fracture, open left angle and open symphysis fracture.,PROCEDURE: ,Closed reduction of mandible fracture with MMF.,ANESTHESIA: , General anesthesia via nasal endot... |
Cleft soft palate. Repair of cleft soft palate and excise accessory ear tag, right ear. | Surgery | Cleft Repair - Soft Palate | PREOPERATIVE DIAGNOSIS: , Cleft soft palate.,POSTOPERATIVE DIAGNOSIS: , Cleft soft palate.,PROCEDURES:,1. Repair of cleft soft palate, CPT 42200.,2. Excise accessory ear tag, right ear.,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , The patient was placed supine on the operating room table. After anesthesia was ... |
Circumcision and release of ventral chordee. | Surgery | Circumcision & Chordee Release | PREOPERATIVE DIAGNOSES: , Phimosis and adhesions.,POSTOPERATIVE DIAGNOSES: ,Phimosis and adhesions.,PROCEDURES PERFORMED: , Circumcision and release of ventral chordee.,ANESTHESIA: ,Local MAC.,ESTIMATED BLOOD LOSS: , Minimal.,FLUIDS: , Crystalloid. The patient was given antibiotics preop.,BRIEF HISTORY: , This is a ... |
Circumcision. Normal male phallus. The infant is without evidence of hypospadias or chordee prior to the procedure. | Surgery | Circumcision - Infant | PROCEDURE: , Circumcision.,PRE-PROCEDURE DIAGNOSIS: , Normal male phallus.,POST-PROCEDURE DIAGNOSIS: , Normal male phallus.,ANESTHESIA: ,1% lidocaine without epinephrine.,INDICATIONS: , The risks and benefits of the procedure were discussed with the parents. The risks are infection, hemorrhage, and meatal stenosis. ... |
Circumcision. A dorsal slit was made, and the prepuce was dissected away from the glans penis. | Surgery | Circumcision - 6 | PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,DETAILS OF PROCEDURE: ,The child was placed in a Circumstraint board and restrained in the usual fashion. The area of the penis and scrotum were prepared with povidone iodine solution. The area was draped with sterile drapes,... |
Release of ventral chordee, circumcision, and repair of partial duplication of urethral meatus. | Surgery | Circumcision - 5 | PROCEDURES:,1. Release of ventral chordee.,2. Circumcision.,3. Repair of partial duplication of urethral meatus.,INDICATIONS: , The patient is an 11-month-old baby boy who presented for evaluation of a duplicated urethral meatus as well as ventral chordee and dorsal prepuce hooding. He is here electively for surgic... |
Circumcision procedure in a baby | Surgery | Circumcision - 3 | CIRCUMCISION,After informed consent was obtained the baby was placed on the circumcision tray. He was prepped in a sterile fashion times 3 with Betadine and then draped in a sterile fashion. Then 0.2 mL of 1% lidocaine was injected at 10 and 2 o'clock. A ring block was also done using another 0.3 mL of lidocaine. G... |
Circumcision in an older person | Surgery | Circumcision - 1 | CIRCUMCISION - OLDER PERSON,OPERATIVE NOTE:, The patient was taken to the operating room and placed in the supine position on the operating table. General endotracheal anesthesia was administered. The patient was prepped and draped in the usual sterile fashion. A 4-0 silk suture is used as a stay-stitch of the glan... |
Normal Circumcision | Surgery | Circumcision - 4 | The patient tolerated the procedure well and was sent to the Recovery Room in stable condition. |
Left and right coronary system cineangiography. Left ventriculogram. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncompliant balloon x2.
| Surgery | Cineangiography - 1 | REASON FOR CATHETERIZATION:, ST-elevation myocardial infarction.,PROCEDURES UNDERTAKEN,1. Left coronary system cineangiography.,2. Right coronary system cineangiography.,3. Left ventriculogram.,4. PCI to the left circumflex with a 3.5 x 12 and a 3.5 x 8 mm Vision bare-metal stents postdilated with a 3.75-mm noncom... |
Left and right coronary system cineangiography, cineangiography of SVG to OM and LIMA to LAD. Left ventriculogram and aortogram. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angioplasty unable to pass stent. | Surgery | Cineangiography | PROCEDURES UNDERTAKEN,1. Left coronary system cineangiography.,2. Right coronary system cineangiography.,3. Cineangiography of SVG to OM.,4. Cineangiography of LIMA to LAD.,5. Left ventriculogram.,6. Aortogram.,7. Percutaneous intervention of the left circumflex and obtuse marginal branch with plano balloon angi... |
Circumcision. The child appeared to tolerate the procedure well. Care instructions were given to the parents. | Surgery | Circumcision - Child | PROCEDURE: , Circumcision.,Signed informed consent was obtained and the procedure explained.,The child was placed in a Circumstraint board and restrained in the usual fashion. The area of the penis and scrotum were prepared with povidone iodine solution. The area was draped with sterile drapes, and the remainder of t... |
Placement of cholecystostomy tube under ultrasound guidance. Acute acalculous cholecystitis. | Surgery | Cholecystostomy Tube Placement | PREOPERATIVE DIAGNOSIS:, Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,PROCEDURE:, Placement of cholecystostomy tube under ultrasound guidance.,ANESTHESIA: , Xylocaine 1% With Epinephrine.,INDICATIONS: , Patient is a pleasant 75-year-old gentleman who is about one week sta... |
Circumcision procedure (neotal) | Surgery | Circumcision - 2 | CIRCUMCISION - NEONATAL,PROCEDURE:,: The procedure, risks and benefits were explained to the patient's mom, and a consent form was signed. She is aware of the risk of bleeding, infection, meatal stenosis, excess or too little foreskin removed and the possible need for revision in the future. The infant was placed on... |
Laparoscopic cholecystectomy. Gallstone pancreatitis. Video laparoscopy revealed dense omental adhesions surrounding the gallbladder circumferentially. | Surgery | Cholecystectomy Laparoscopic | PREOPERATIVE DIAGNOSIS: ,Gallstone pancreatitis.,POSTOPERATIVE DIAGNOSIS: , Gallstone pancreatitis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal and local injectable Marcaine.,ESTIMATED BLOOD LOSS: , Minimal.,SPECIMEN: , Gallbladder.,COMPLICATIONS: ,None.,OPERATIVE FINDINGS: ... |
Open cholecystectomy (attempted laparoscopic cholecystectomy). | Surgery | Cholecystectomy - Open | PREOPERATIVE DIAGNOSIS (ES):,1. Cholelithiasis.,2. Cholecystitis.,POSTOPERATIVE DIAGNOSIS (ES):,1. Acute perforated gangrenous cholecystitis.,2. Cholelithiasis.,PROCEDURE:,1. Attempted laparoscopic cholecystectomy.,2. Open cholecystectomy.,ANESTHESIA:, General endotracheal anesthesia.,COUNTS:, Correct.,COMPLICATIONS:, ... |
Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy. | Surgery | Cholangiopancreatography (Endoscopic) | PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesi... |
Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruction with Gore-Tex mesh. | Surgery | Chest Wall Tumor Resection | PREOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology.,POSTOPERATIVE DIAGNOSIS: , Left chest wall tumor, spindle cell histology with pathology pending.,PROCEDURE: ,Resection of left chest wall tumor, partial resection of left diaphragm, left lower lobe lung wedge resection, left chest wall reconstruc... |
Laparoscopic cholecystectomy with cholangiogram. | Surgery | Cholecystectomy & Cholangiogram. | PREOPERATIVE DIAGNOSES:,1. Cholelithiasis.,2. Acute cholecystitis.,POSTOPERATIVE DIAGNOSES:,1. Acute on chronic cholecystitis.,2. Cholelithiasis.,PROCEDURE PERFORMED: , Laparoscopic cholecystectomy with cholangiogram.,ANESTHESIA: , General.,INDICATIONS: , This is a 38-year-old diabetic Hispanic female patient, with... |
Left pleural effusion, parapneumonic, loculated. Left chest tube placement. | Surgery | Chest Tube Placement | PREOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,POSTOPERATIVE DIAGNOSIS: , Left pleural effusion, parapneumonic, loculated.,OPERATION: , Left chest tube placement.,IV SEDATION: , 5 mg of Versed total given under pulse ox monitoring, 1% lidocaine local infiltration.,PROCEDURE: , With the patie... |
Delayed primary chest closure. Open chest status post modified stage 1 Norwood operation. The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. | Surgery | Chest Closure | PROCEDURE:, Delayed primary chest closure.,INDICATIONS: , The patient is a newborn with diagnosis of hypoplastic left heart syndrome who 48 hours prior to the current procedure has undergone a modified stage 1 Norwood operation. Given the magnitude of the operation and the size of the patient (2.5 kg), we have elected... |
Removal of chest wall mass. The area of the mass, which was on the anterior lower ribs on the left side was marked and then a local anesthetic was injected. | Surgery | Chest Wall Mass Removal | PREOPERATIVE DIAGNOSIS:, Chest wall mass, left.,POSTOPERATIVE DIAGNOSIS: , Chest wall mass, left.,PROCEDURE:, Removal of chest wall mass.,DESCRIPTION OF PROCEDURE: , After obtaining the informed consent, the patient was brought to the operating room where he underwent a general endotracheal anesthetic. The time-out ... |
Chest tube insertion done by two physicians in ER - spontaneous pneumothorax secondary to barometric trauma. | Surgery | Chest Tube Insertion in ER | PREOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,POSTOPERATIVE DIAGNOSES:,1. Right spontaneous pneumothorax secondary to barometric trauma.,2. Respiratory failure.,3. Pneumonia with sepsis.,INFORMED CONSENT: , Not obtained.... |
Right hemothorax. Insertion of a #32 French chest tube on the right hemithorax. This is a 54-year-old female with a newly diagnosed carcinoma of the cervix. The patient is to have an Infuse-A-Port insertion. | Surgery | Chest Tube Insertion | PREOPERATIVE DIAGNOSIS: , Right hemothorax.,POSTOPERATIVE DIAGNOSIS: , Right hemothorax.,PROCEDURE PERFORMED: , Insertion of a #32 French chest tube on the right hemithorax.,ANESTHESIA: , 1% Lidocaine and sedation.,INDICATIONS FOR PROCEDURE:, This is a 54-year-old female with a newly diagnosed carcinoma of the cervix.... |
Bilateral pleural effusion. Removal of bilateral #32 French chest tubes with closure of wound. | Surgery | Chest Tube Removal | PREOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,POSTOPERATIVE DIAGNOSIS: , Bilateral pleural effusion.,PROCEDURE PERFORMED: ,Removal of bilateral #32-French chest tubes with closure of wound.,COMPLICATIONS:, None.,INDICATIONS FOR PROCEDURE: , The patient is a 66-year-old African-American male who has been in the... |
Repeat low-transverse cesarean section, bilateral tubal ligation (BTL), extensive anterior abdominal wall/uterine/bladder adhesiolysis. Term pregnancy and desires permanent sterilization. | Surgery | Cesarean Section & BTL | PREOPERATIVE DIAGNOSES:,1. Term pregnancy.,2. Desires permanent sterilization.,POSTOPERATIVE DIAGNOSES:,1. Term pregnancy.,2. Desires permanent sterilization.,PROCEDURE:,1. Repeat low-transverse cesarean section.,2. Bilateral tubal ligation.,3. Extensive anterior abdominal wall/uterine/bladder adhesiolysis.,ANES... |
Left hip cemented hemiarthroplasty and biopsy of the tissue from the fracture site and resected femoral head sent to the pathology for further assessment. | Surgery | Cemented Hemiarthroplasty & Biopsy | PREOPERATIVE DIAGNOSIS:, Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,POSTOPERATIVE DIAGNOSIS: , Closed displaced probable pathological fracture, basicervical femoral neck, left hip.,PROCEDURES PERFORMED:,1. Left hip cemented hemiarthroplasty.,2. Biopsy of the tissue from the... |
Right subclavian triple lumen central line placement | Surgery | Central Line Placement | PREOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,POSTOPERATIVE DIAGNOSIS:,1. Severe chronic obstructive coronary disease.,2. Respiratory failure.,OPERATION:, Right subclavian triple lumen central line placement.,ANESTHESIA: , Local Xylocaine.,INDICATIONS FOR OPERATION: ,... |
Insertion of central venous line and arterial line and transesophageal echocardiography probe. | Surgery | Central Venous & Arterial Line | INDICATIONS FOR PROCEDURES: , Impending open-heart surgery for atrial septectomy and bilateral bidirectional Glenn procedure.,The patient was already under general anesthesia in the operating room. Antibiotic prophylaxis with cephazolin and gentamicin were already given. A strict aseptic technique was used including ... |
Central line insertion. Empyema thoracis and need for intravenous antibiotics. | Surgery | Central Line Insertion | PREOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,POSTOPERATIVE DIAGNOSES,1. Empyema thoracis.,2. Need for intravenous antibiotics.,PROCEDURE:, Central line insertion.,DESCRIPTION OF PROCEDURE: , With the patient in his room, after obtaining the informed consent, his left deltopector... |
Cauterization of epistaxis, left nasal septum. Fiberoptic nasal laryngoscopy. Atrophic dry nasal mucosa. Epistaxis. Atrophic laryngeal changes secondary to inhaled steroid use. | Surgery | Cauterization - Epistaxis | PREOPERATIVE DIAGNOSIS: , Epistaxis and chronic dysphonia.,POSTOPERATIVE DIAGNOSES:,1. Atrophic dry nasal mucosa.,2. Epistaxis.,3. Atrophic laryngeal changes secondary to inhaled steroid use.,PROCEDURE PERFORMED:,1. Cauterization of epistaxis, left nasal septum.,2. Fiberoptic nasal laryngoscopy.,ANESTHESIA: , Neo-... |
Ultrasound-guided placement of multilumen central venous line, left femoral vein. | Surgery | Catheter Placement | PROCEDURE PERFORMED: , Ultrasound-guided placement of multilumen central venous line, left femoral vein.,INDICATIONS:, Need for venous access in a patient on a ventilator and on multiple IV drugs.,CONSENT: , Consent obtained from patient's sister.,PREOPERATIVE MEDICATIONS: , Local anesthesia with 1% plain lidocaine.,P... |
Temporal cheek-neck facelift and submental suction assisted lipectomy to correct facial and neck skin ptosis and cheek, neck, and jowl lipotosis, and facial rhytides. | Surgery | Cheek-Neck Facelift | PREOPERATIVE DIAGNOSIS: , Facial and neck skin ptosis. Cheek, neck, and jowl lipotosis. Facial rhytides.,POSTOPERATIVE DIAGNOSIS:, Same.,PROCEDURE: , Temporal cheek-neck facelift (CPT 15825). Submental suction assisted lipectomy (CPT 15876).,ANESTHESIA: , General.,DESCRIPTION OF PROCEDURE: , This patient is a 65-yea... |
Normal cataract surgery. | Surgery | Cataract Surgery | NORMAL CATARACT SURGERY,PROCEDURE DETAILS: , The patient was taken to the operating room where the Rand-Stein anesthesia protocol was followed using alfentanil and Brevital. Topical tetracaine drops were applied. The operative eye was prepped and draped in the usual sterile fashion. A lid speculum was inserted.,Unde... |
Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye. | Surgery | Cataract Extraction - 2 | PREOPERATIVE DIAGNOSIS: , Cataract, left eye.,POSTOPERATIVE DIAGNOSIS: ,Cataract, left eye.,PROCEDURE PERFORMED: ,Extracapsular cataract extraction with phacoemulsification and implantation of a posterior chamber intraocular lens, left eye.,ANESTHESIA: , Topical.,COMPLICATIONS: , None.,PROCEDURE: , After the inductio... |
Cataract to right eye. Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye. | Surgery | Cataract Extraction & Vitrectomy | PREOPERATIVE DIAGNOSIS: , Cataract to right eye.,POSTOPERATIVE DIAGNOSIS: , Cataract to right eye.,PROCEDURE PERFORMED: ,Cataract extraction with intraocular lens implant of the right eye, anterior vitrectomy of the right eye.,LENS IMPLANT USED: ,See below.,COMPLICATIONS: , Posterior capsular hole, vitreous prolapse.... |
Right carpal tunnel release and right index and middle fingers release A1 pulley. Right carpal tunnel syndrome and right index finger and middle fingers tenosynovitis. | Surgery | Carpal Tunnel Release - 8 | PREOPERATIVE DIAGNOSES:,1. Right carpal tunnel syndrome.,2. Right index finger and middle fingers tenosynovitis.,POSTOPERATIVE DIAGNOSES:,1. Right carpal tunnel syndrome.,2. Right index finger and middle fingers tenosynovitis.,PROCEDURES PERFORMED:,1. Right carpal tunnel release.,2. Right index and middle fingers... |
Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty. | Surgery | Cartilage Loose Body Removal | PREOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,POSTOPERATIVE DIAGNOSIS: , Left knee medial femoral condyle osteochondritis dissecans.,PROCEDURES:, Left knee arthroscopy with removal of the cartilage loose body and microfracture of the medial femoral condyle with chondroplasty.,AN... |
Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification. A peribulbar block was given to the eye using 8 cc of a mixture of 0.5% Marcaine without epinephrine mixed with Wydase plus one-half of 2% lidocaine without epinephrine. | Surgery | Cataract Extraction - 1 | PROCEDURE PERFORMED: , Extracapsular cataract extraction with posterior chamber intraocular lens placement by phacoemulsification.,ANESTHESIA:, Peribulbar.,COMPLICATIONS:, None.,DESCRIPTION OF PROCEDURE: ,The patient was brought to the operating room after the eye was dilated with topical Mydriacyl and Neo-Synephrin... |
Cataract extraction with lens implantation, right eye. The lens was inspected and found to be free of defects, folded, and easily inserted into the capsular bag, and unfolded. | Surgery | Cataract Extraction | PROCEDURE PERFORMED:, Cataract extraction with lens implantation, right eye.,DESCRIPTION OF PROCEDURE: , The patient was brought to the operating room. The patient was identified and the correct operative site was also identified. A retrobulbar block using 5 ml of 2% lidocaine without epinephrine was done after adeq... |
Left carpal tunnel release. Left carpal tunnel syndrome. Severe compression of the median nerve on the left at the wrist. | Surgery | Carpal Tunnel Release - 6 | PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Left carpal tunnel syndrome.,OPERATIVE PROCEDURE PERFORMED:, Left carpal tunnel release.,FINDINGS:, Showed severe compression of the median nerve on the left at the wrist.,SPECIMENS: ,None.,FLUIDS:, 500 mL of crystalloids.,URINE OUTPU... |
Carpal tunnel syndrome. Open carpal tunnel release. A longitudinal incision was made in line with the 4th ray. The dissection was carried down to the superficial aponeurosis, which was cut. The distal edge of the transverse carpal ligament was identified with a hemostat. | Surgery | Carpal Tunnel Release - Open | PREOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: ,Open carpal tunnel release.,COMPLICATIONS: ,None.,PROCEDURE IN DETAIL: ,After administering appropriate antibiotics and general anesthesia the Left upper extremity was prepped and draped in the u... |
Right carpal tunnel release. Right carpal tunnel syndrome. This is a 54-year-old female who was complaining of right hand numbness and tingling of the median distribution and has elected to undergo carpal tunnel surgery secondary to failure of conservative management. | Surgery | Carpal Tunnel Release - 9 | PREOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE:, Right carpal tunnel release.,ANESTHESIA:, Bier block to the right hand.,TOTAL TOURNIQUET TIME: , 20 minutes.,COMPLICATIONS: , None.,DISPOSITION: , Stable to PACU.,ESTIMATED BLOOD LOSS: , Less th... |
Right carpal tunnel syndrome. Right carpal tunnel release. | Surgery | Carpal Tunnel Release - 7 | PREOPERATIVE DIAGNOSIS: , Right carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Right carpal tunnel syndrome.,PROCEDURE PERFORMED: , Right carpal tunnel release.,PROCEDURE NOTE: ,The right upper extremity was prepped and draped in the usual fashion. IV sedation was supplied by the anesthesiologist. A local block ... |
Right open carpal tunnel release and cortisone injection, left carpal tunnel. | Surgery | Carpal Tunnel Release - 4 | PREOPERATIVE DIAGNOSIS: ,Bilateral carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Bilateral carpal tunnel syndrome.,PROCEDURES:,1. Right open carpal tunnel release.,2. Cortisone injection, left carpal tunnel.,ANESTHESIA: , General LMA.,ESTIMATED BLOOD LOSS: , Minimal.,COMPLICATIONS:, None.,INDICATIONS:, This p... |
Carpal tunnel syndrome. Endoscopic carpal tunnel release. After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fashion, the arm was exsanguinated with Esmarch, and the tourniquet inflated to 250 mmHg. | Surgery | Carpal Tunnel Release - Endoscopic | PREOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Carpal tunnel syndrome.,TITLE OF PROCEDURE: , Endoscopic carpal tunnel release.,ANESTHESIA: , MAC,PROCEDURE: , After administering appropriate antibiotics and MAC anesthesia, the upper extremity was prepped and draped in the usual standard fas... |
Left carpal tunnel release, left ulnar nerve anterior submuscular transposition at the elbow, lengthening of the flexor pronator muscle mass in the proximal forearm to accommodate the submuscular position of the ulnar nerve. | Surgery | Carpal Tunnel Release - 3 | PREOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome (354.0).,2. Left ulnar nerve entrapment at the elbow (354.2).,POSTOPERATIVE DIAGNOSES:,1. Left carpal tunnel syndrome (354.0).,2. Left ulnar nerve entrapment at the elbow (354.2).,OPERATIONS PERFORMED:,1. Left carpal tunnel release (64721).,2. Left ulnar nerv... |
Endoscopic release of left transverse carpal ligament. | Surgery | Carpal Ligament Release - 1 | PREOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS:, Carpal tunnel syndrome.,PROCEDURE: , Endoscopic release of left transverse carpal ligament.,ANESTHESIA:, Monitored anesthesia care with regional anesthesia provided by surgeon. ,TOURNIQUET TIME: , 12 minutes.,OPERATIVE PROCEDURE IN DETAIL: ,... |
Left endoscopic carpal tunnel release and endotracheal fasciotomy. | Surgery | Carpal Tunnel Release - 2 | PREOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,POSTOPERATIVE DIAGNOSIS: , Left carpal tunnel syndrome.,OPERATIVE PROCEDURE:,1. Left endoscopic carpal tunnel release.,2. Endotracheal fasciotomy.,ANESTHESIA:, General.,COMPLICATIONS: , None.,INDICATION: , The patient is a 62-year-old lady with the aforementione... |
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Datos de alta calidad es lo que necesitas.
Traducción Mediante ChatGPT.
Inicialmente, se preparó el dataset para la traducción, ajustando el formato de los datos para asegurar su compatibilidad. La API de ChatGPT se utilizó para traducir el contenido, prestando especial atención a la precisión y el contexto específico del lenguaje médico. Tras la traducción, se revisaron y ajustaron las traducciones para corregir cualquier inexactitud y asegurar que los términos médicos y las descripciones de los procedimientos mantuvieran su significado original y relevancia clínica.
Limpieza de Datos Post-traducción Rag utilizando ChatGPT.
Después de traducir el dataset, se llevó a cabo una limpieza exhaustiva de los datos. Este proceso implicó la normalización y estandarización del texto para garantizar la coherencia en todo el dataset. Se eliminaron elementos innecesarios como caracteres especiales, filas faltante, valores nulos. Asegurando que el dataset final fuera accesible, analizable y procurar ser de la más alta calidad.
Este enfoque garantizó que el dataset no solo estuviera correctamente traducido del inglés al español, sino también limpio y preparado para cualquier análisis o aplicación posterior, maximizando su valor para profesionales y analistas en el ámbito médico.
Desarrollo de un Modelo Bilingüe Compacto para la Clasificación y Diagnóstico en Transcripciones Médicas.
Centrándome en el desarrollo de modelos compactos pero potentes, inspirándome en estructuras de 2 billones de parámetros al estilo de GEMMA, mí proyecto se especializa en mejorar un modelo bilingüe capaz de analizar transcripciones médicas en inglés o español. El objetivo es que pueda determinar y comunicar tres elementos clave en español o ingles: la especialidad médica apropiada para el caso, una descripción concisa del mismo, y el diagnóstico principal. Este enfoque busca la manera de procesar y entiender las transcripciones médicas en contextos bilingües. Otorgando a los profesionales de la salud una herramienta para la asignación rápida y precisa de casos a las especialidades pertinentes, facilita diagnósticos iniciales y mejora significativamente la gestión y respuesta ante las necesidades de los pacientes.
Aprox tokens utilizados.
Conclusión.
El proceso de traducción y limpieza de datos, especialmente en el sector médico, es esencial para asegurar que la información sea precisa, confiable y útil para el análisis y la toma de decisiones. Al emplear herramientas avanzadas como la API de ChatGPT para la traducción y aplicar meticulosas técnicas de limpieza de datos, se puede mejorar significativamente la calidad de los datasets. Esto no solo facilita la investigación y el análisis en el ámbito de la salud, sino que también contribuye a una mejor atención al paciente y a la eficiencia operativa dentro de las instituciones médicas. Teniendo encuenta lo anterior, la inversión en la precisión y limpieza de los datos es fundamental para impulsar avances y mejorar los resultados en el sector de la salud o diferentes campos.
Origen de los datos en ingles.
https://www.kaggle.com/datasets
Inconvenientes en el proceso (para mi).
Demora en la api de chatgpt (inferencia)
Demora en la iteracion del Rag para saber si los datos dados por chatgpt estaban correctos (inferencia)
Campos nulos, vacios.
Incoherencias.
presupuesto.
Numero de filas antes y despues de la depuracion.
Datos inicial: +-4998
Datos finales: +-4007
conjunto de datos dividido en.
es: Español.
en: ingles.
Nota.
Si encuentras errores por favor avisar (lo hice solo y Chatgpt guiño guiño).
modelo entrenado con el conjunto de datos.
https://huggingface.co/somosnlp/Sam_Diagnostic
Hecho.
NickyNicky
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