falan42/nurse_detection huggingface dataset:
Esophagogastroduodenoscopy - 10 

PREOPERATIVE DIAGNOSIS: , Nausea and vomiting and upper abdominal pain.,POST PROCEDURE DIAGNOSIS:  ,Normal upper endoscopy.,OPERATION: , Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.,ANESTHESIA:,  IV sedation 50 mg Demerol, 8 mg of Versed.,PROCEDURE: , The patient was taken to the endoscopy suite.  After adequate IV sedation with the above medications, hurricane was sprayed in the mouth as well as in the esophagus.  A bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus, stomach, and pylorus.  The first, second, and third portions of the duodenum were normal.  The scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for H. pylori.  The scope was retroflexed which showed a normal GE junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia.  The scope was withdrawn at the GE junction which was in a normal position with a normal transition zone.  The scope was then removed throughout the esophagus which was normal.  The patient tolerated the procedure well.,The plan is to obtain a HIDA scan as the right upper quadrant ultrasound appeared to be normal, although previous ultrasounds several years ago showed a gallstone.gastroenterology, h. pylori, forceps, antral biopsies, ge junction, esophagogastroduodenoscopy, pylori, esophagus, antral,
Endoscopy With Biopsy 

PROCEDURE:,  Upper endoscopy with biopsy.,PROCEDURE INDICATION: , This is a 44-year-old man who was admitted for coffee-ground emesis, which has been going on for the past several days.  An endoscopy is being done to evaluate for source of upper GI bleeding.,Informed consent was obtained.  Outlining the risks, benefits and alternatives of the procedure included, but not to risks of bleeding, infection, perforation, the patient agreed for the procedure.,MEDICATIONS: , Versed 4 mg IV push and fentanyl 75 mcg IV push given throughout the procedure in incremental fashion with careful monitoring of patient's pressures and vital signs.,PROCEDURE IN DETAIL:  ,The patient was placed in the left lateral decubitus position.  Medications were given.  After adequate sedation was achieved, the Olympus video endoscope was inserted into the mouth and advanced towards the duodenum.gastroenterology, coffee-ground emesis, gi bleeding, upper endoscopy, iv push, esophagus, duodenum, mucosa, stomach, endoscopy, biopsy,
Endoscopy - 4 

PROCEDURE: , Endoscopy.,CLINICAL INDICATIONS: , Intermittent rectal bleeding with abdominal pain.,ANESTHESIA: , Fentanyl 100 mcg and 5 mg of IV Versed.,PROCEDURE:,  The patient was taken to the GI lab and placed in the left lateral supine position.  Continuous pulse oximetry and blood pressure monitoring were in place.  After informed consent was obtained, the video endoscope was inserted over the dorsum of the tongue without difficulty.  With swallowing, the scope was advanced down the esophagus into the body of the stomach.  The scope was further advanced down to the antrum and through the pylorus into the duodenum, which was visualized into its second portion.  It appeared free of stricture, neoplasm, or ulceration.  Samples were obtained from the antrum and prepyloric area to check for Helicobacter, rapid urease, and additional samples were sent to pathology.  Retroflexion view of the fundus of the stomach was normal without evidence of a hiatal hernia.  The scope was then slowly removed.  The distal esophagus appeared benign with a normal-appearing gastroesophageal sphincter and no esophagitis.  The remaining portion of the esophagus was normal.,IMPRESSION:,  Abdominal pain.  Symptoms most consistent with gastroesophageal reflux disease without endoscopic evidence of hiatal hernia.,RECOMMENDATIONS:,  Await results of CLO testing and biopsies.  Return to clinic with Dr. Spencer in 2 weeks for further discussion.gastroenterology, duodenum, stomach, hiatal hernia, endoscopy, antrum, hiatal, hernia, gastroesophageal, scope, esophagus, abdominal
Epigastric Herniorrhaphy 

PREOPERATIVE DIAGNOSIS: , Epigastric hernia.,POSTOPERATIVE DIAGNOSIS: , Epigastric hernia.,OPERATIONS:,  Epigastric herniorrhaphy.,ANESTHESIA: , General inhalation.,PROCEDURE: , Following attainment of satisfactory anesthesia, the patient's abdomen was prepped with Hibiclens and draped sterilely.  The hernia mass had been marked preoperatively.  This area was anesthetized with a mixture of Marcaine and Xylocaine.  A transverse incision was made over the hernia and dissection carried down to the entrapped fat.  Sharp dissection was carried around the fat down to the fascial edge.  The preperitoneal fat could not be reduced; therefore, it is trimmed away and the small fascial defect then closed with interrupted 0-Ethibond sutures.  The fascial edges were injected with the local anesthetic mixture.  Subcutaneous tissues were then closed with interrupted 4-0 Vicryl and skin edges closed with running subcuticular 4-0 Vicryl.  Steri-Strips and a sterile dressing were applied to complete the closure.  The patient was then awakened and taken to the PACU in satisfactory condition.,ESTIMATED BLOOD LOSS: , 10 mL.,SPONGE AND NEEDLE COUNT: , Reported as correct.,COMPLICATIONS: , None.gastroenterology, hibiclens, epigastric herniorrhaphy, epigastric hernia, herniorrhaphy,
Endoscopy Template 

INDICATIONS:,  Dysphagia.,PREMEDICATION:,  Topical Cetacaine spray and Versed IV.,PROCEDURE:,:  The scope was passed into the esophagus under direct vision.  The esophageal mucosa was all unremarkable.  There was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis.  The scope was passed on down into the stomach.  The gastric mucosa was all examined including a retroflexed view of the fundus and there were no abnormalities seen.  The scope was then passed into the duodenum and the duodenal bulb and second and third portions of the duodenum were unremarkable.  The scope was again slowly withdrawn through the esophagus and no evidence of narrowing was present.  The scope was then withdrawn.,IMPRESSION:,  Normal upper GI endoscopy without any evidence of anatomical narrowing.gastroenterology, dysphagia, cetacaine spray, esophagus, esophageal mucosa, duodenum, scope was passed, upper gi, gi endoscopy, gi, endoscopy, scope
Endoscopy - 3 

PROCEDURES PERFORMED: , Endoscopy.,INDICATIONS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,  Esophageal ring and active reflux esophagitis.,PROCEDURE: , Informed consent was obtained prior to the procedure from the parents and patient.  The oral cavity is sprayed with lidocaine spray.  A bite block is placed.  Versed IV 5 mg and 100 mcg of IV fentanyl was given in cautious increments.  The GIF-160 diagnostic gastroscope used.  The patient was alert during the procedure.  The esophagus was intubated under direct visualization.  The scope was advanced toward the GE junction with active reflux esophagitis involving the distal one-third of the esophagus noted.  The stomach was unremarkable.  Retroflexed exam unremarkable.  Duodenum not intubated in order to minimize the time spent during the procedure.  The patient was alert although not combative.  A balloon was then inserted across the GE junction, 15 mm to 18 mm, and inflated to 3, 4.7, and 7 ATM, and left inflated at 18 mm for 45 seconds.  The balloon was then deflated.  The patient became uncomfortable and a good-size adequate distal esophageal tear was noted.  The scope and balloon were then withdrawn.  The patient left in good condition.,IMPRESSION: , Successful dilation of distal esophageal fracture in the setting of active reflux esophagitis albeit mild.,PLAN: , I will recommend that the patient be on lifelong proton pump inhibition and have repeat endoscopy performed as needed.  This has been discussed with the parents.  He was sent home with a prescription for omeprazole.gastroenterology, active reflux esophagitis, ge junction, distal esophageal, active reflux, reflux esophagitis, dysphagia, esophagus, scope, ge, junction, endoscopy, esophageal, reflux, esophagitis, distal, balloon
EGD With Photos & Biopsies. 

1.  Odynophagia.,2.  Dysphagia.,3.  Gastroesophageal reflux disease rule out stricture.,POSTOPERATIVE DIAGNOSES:,1.  Antral gastritis.,2.  Hiatal hernia.,PROCEDURE PERFORMED:  EGD with photos and biopsies.,GROSS FINDINGS:  This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia.  She has a previous history of hiatal hernia.  She was on Prevacid currently.  At this time, an EGD was performed to rule out stricture.  At the time of EGD, there was noted some antral gastritis and hiatal hernia.  There are no strictures, tumors, masses, or varices present.,OPERATIVE PROCEDURE:  The patient was taken to the Endoscopy Suite in the lateral decubitus position.  She was given sedation by the Department Of Anesthesia.  Once adequate sedation was reached, the Olympus gastroscope was inserted into oropharynx.  With air insufflation entered through the proximal esophagus to the GE junction.  The esophagus was without evidence of tumors, masses, ulcerations, esophagitis, strictures, or varices.  There was a hiatal hernia present.  The scope was passed through the hiatal hernia into the body of the stomach.  In the distal antrum, there was some erythema with patchy erythematous changes with small superficial erosions.  Multiple biopsies were obtained.  The scope was passed through the pylorus into the duodenal bulb and duodenal suite, they appeared within normal limits.  The scope was pulled back from the stomach, retroflexed upon itself, _____ fundus and GE junction.  As stated, multiple biopsies were obtained.,The scope was then slowly withdrawn.  The patient tolerated the procedure well and sent to recovery room in satisfactory condition.gastroenterology, odynophagia, dysphagia, gastroesophageal reflux disease, antral gastritis, hiatal hernia, difficulty swallowing, esophagus, stomach, duodenal, egd, biopsies, hiatal, hernia,
Endoscopy 

PREOPERATIVE DIAGNOSIS: , Anemia.,PROCEDURE:,  Upper gastrointestinal endoscopy.,POSTOPERATIVE DIAGNOSES:,1.  Severe duodenitis.,2.  Gastroesophageal junction small ulceration seen.,3.  No major bleeding seen in the stomach.,PROCEDURE IN DETAIL: , The patient was put in left lateral position.  Olympus scope was inserted from the mouth, under direct visualization advanced to the upper part of the stomach, upper part of esophagus, middle of esophagus, GE junction, and some intermittent bleeding was seen at the GE junction.  Advanced into the upper part of the stomach into the antrum.  The duodenum showed extreme duodenitis and the scope was then brought back.  Retroflexion was performed, which was normal.  Scope was then brought back slowly.  Duodenitis was seen and a little bit of ulceration seen at GE junction.,FINDING: , Severe duodenitis, may be some source of bleeding from there, but no active bleeding at this time.gastroenterology, upper gastrointestinal endoscopy, ge junction, gastrointestinal, esophagus, endoscopy, stomach, duodenitis, bleeding
EGD with Biopsy - 1 

PROCEDURE PERFORMED: , EGD with biopsy.,INDICATION: , Mrs. ABC is a pleasant 45-year-old female with a history of severe diabetic gastroparesis, who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago.  She was admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.  A CT scan done yesterday revealed evidence of feeding tube remnant still seen within the stomach.  The endoscopy is done to confirm this and remove it, as well as determine if there are any other causes to account for her symptoms.  Physical examination done prior to the procedure was unremarkable, apart from upper abdominal tenderness.,MEDICATIONS: , Fentanyl 25 mcg, Versed 2 mg, 2% lidocaine spray to the pharynx.,INSTRUMENT: , GIF 160.,PROCEDURE REPORT:,  Informed consent was obtained from Mrs. ABC's sister, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications.  Consent was not obtained from Mrs. Morales due to her recent narcotic administration.  Conscious sedation was achieved with the patient lying in the left lateral decubitus position.  The endoscope was then passed through the mouth, into the esophagus, the stomach, where retroflexion was performed, and it was advanced into the second portion of the duodenum.,FINDINGS:,1.  ESOPHAGUS:  There was evidence of grade C esophagitis, with multiple white-based ulcers seen from the distal to the proximal esophagus, at 12 cm in length.  Multiple biopsies were obtained from this region and placed in jar #1.,2.  STOMACH:  Small hiatal hernia was noted within the cardia of the stomach.  There was an indentation/scar from the placement of the previous PEG tube and there was suture material noted within the body and antrum of the stomach.  The remainder of the stomach examination was normal.  There was no feeding tube remnant seen within the stomach.,3.  DUODENUM:  This was normal.,COMPLICATIONS:,  None.,ASSESSMENT:,1.  Grade C esophagitis seen within the distal, mid, and proximal esophagus.,2.  Small hiatal hernia.,3.  Evidence of scarring at the site of the previous feeding tube, as well as suture line material seen in the body and antrum of the stomach.,PLAN: , Followup results of the biopsies and will have radiology replace her gastrojejunal feeding tube.gastroenterology, recurrent nausea and vomiting, egd with biopsy, nausea and vomiting, gastrojejunal feeding tube, feeding tube remnant, recurrent nausea, gej feeding, gastrojejunal feeding, proximal esophagus, hiatal hernia, feeding tube, egd, biopsy, nausea, vomiting, gej, gastrojejunal, duodenum, esophagitis, multiple, distal, biopsies, hiatal, hernia, antrum, esophagus, feeding, tube, stomach,
Endoscopy - 2 

PREOPERATIVE DIAGNOSIS:,  Melena.,POSTOPERATIVE DIAGNOSIS:,  Solitary erosion over a fold at the GE junction, gastric side.,PREMEDICATIONS: , Versed 5 mg IV.,REPORTED PROCEDURE:,  The Olympus gastroscope was used.  The scope was placed in the upper esophagus under direct visit.  The esophageal mucosa was entirely normal.  There was no evidence of erosions or ulceration.  There was no evidence of varices.  The body and antrum of the stomach were normal.  They pylorus duodenum bulb and descending duodenum are normal.  There was no blood present within the stomach.,The scope was then brought back into the stomach and retroflexed in order to inspect the upper portion of the body of the stomach.  When this was done, a prominent fold was seen lying along side the GE junction along with gastric side and there was a solitary erosion over this fold.  The lesion was not bleeding.  If this fold were in any other location of the stomach, I would consider the fold, but at this location, one would have to consider that this would be an isolated gastric varix.  As such, the erosion may be more significant.  There was no bleeding.  Obviously, no manipulation of the lesion was undertaken.  The scope was then straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Solitary erosion overlying a prominent fold at the gastroesophageal junction, gastric side – may simply be an erosion or may be an erosion over a varix.,2.  Otherwise unremarkable endoscopy - no evidence of a bleeding lesion of the stomach.,PLAN:,1.  Liver profile today.,2.  Being Nexium 40 mg a day.,3.  Scheduled colonoscopy for next week.gastroenterology, ge junction, melena, olympus gastroscope, solitary erosion, descending duodenum, esophageal mucosa, esophagus, gastric side, pylorus duodenum bulb, stomach, liver profile, colonoscopy, ge junction gastric, junction gastric, endoscopy, duodenum, scope, solitary, junction, gastric, erosion,
EGD Template - 4 

 Common description of EGDgastroenterology, lateral supine position, stomach, duodenum, stricture, egd, advanced, scopeNOTE,: 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.,
EGD Template - 3 

without difficulty, into the upper GI tract.  The anatomy and mucosa of the esophagus, gastroesophageal junction, stomach, pylorus, and small bowel were all carefully inspected.  All structures were visually normal in appearance.  Biopsies of the distal duodenum, gastric antrum, and distal esophagus were taken and sent for pathological evaluation.  The endoscope and insufflated air were slowly removed from the upper GI tract.  A repeat look at the structures involved again showed no visible abnormalities, except for the biopsy sites.,The patient tolerated the procedure with excellent comfort and stable vital signs.  After a recovery period in the Endoscopy Suite, the patient is discharged to continue recovering in the family's care at home.  The family knows to follow up with me today if there are concerns about the patient's recovery,from the procedure.  They will follow up with me later this week for biopsy and CLO test results so that appropriate further diagnostic and therapeutic plans can be made.,gastroenterology, gastric antrum, distal duodenum, distal esophagus, esophagus, duodenum, clo test, upper gi tract, upper gi, gi tract, egd, endoscope, gi, tract, structures, distal, biopsyNOTE,: 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.,
EGD with Biopsy - 2 

TYPE OF PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS:,  Abdominal pain.,POSTOPERATIVE DIAGNOSIS:,  Normal endoscopy.,PREMEDICATION: , Fentanyl 125 mcg IV, Versed 8 mg IV.,INDICATIONS:  ,This healthy 28-year-old woman has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.  She has had similar episodes couple of years ago and was told, at one point, that she had gallstones, but after her pregnancy, a repeat ultrasound was done, and apparently was normal, and nothing was done at that time.  She was evaluated in the emergency department recently, when she developed this recurrent pain, and laboratory studies were unrevealing.  Ultrasound was normal and a HIDA scan was done, which showed a low normal ejection fraction of 40%, and moderate reproduction of her pain.  Endoscopy was requested to make sure there is not upper GI source of her pain before considering cholecystectomy.,PROCEDURE: , The patient was premedicated and the Olympus GIF 160 video endoscope advanced to the distal duodenum.  Gastric biopsies were taken to rule out Helicobacter and the procedure was completed without complication.,IMPRESSION:  ,Normal endoscopy.,PLAN: , Refer to a general surgeon for consideration of cholecystectomy.gastroenterology, hida scan, endoscopy, gallstones, olympus, esophagogastroduodenoscopy with biopsy, biliary colic, colic type, greasy foods, normal endoscopy, esophagogastroduodenoscopy, biliary, colic, greasy, foods, cholecystectomy, biopsy,
EGD & PEG Tube Placement 

PREOPERATIVE DIAGNOSES:,1.  protein-calorie malnutrition.,2.  Intractable nausea, vomiting, and dysphagia.,POSTOPERATIVE DIAGNOSES:,1.  Protein-calorie malnutrition.,2.  Intractable nausea, vomiting, and dysphagia.,3.  Enterogastritis.,PROCEDURE PERFORMED: , EGD with PEG tube placement using Russell technique.,ANESTHESIA: , IV sedation with 1% lidocaine for local.,ESTIMATED BLOOD LOSS:  ,None.,COMPLICATIONS:  ,None.,BRIEF HISTORY: , This is a 44-year-old African-American female who is well known to this service.  She has been hospitalized multiple times for intractable nausea and vomiting and dehydration.  She states that her decreased p.o. intake has been progressively worsening.  She was admitted to the service of Dr. Lang and was evaluated by Dr. Wickless as well all of whom agreed that the best option for supplemental nutrition for this patient was placement of a PEG tube.,PROCEDURE: , After risks, complications, and benefits were explained to the patient and informed consent was obtained, the patient was taken to the operating room.  She was placed in the supine position.  The area was prepped and draped in the sterile fashion.  After adequate IV sedation was obtained by anesthesia, esophagogastroduodenoscopy was performed.  The esophagus, stomach, and duodenum were visualized without difficulty.  There was no gross evidence of any malignancy.  There was some enterogastritis which was noted upon exam.  The appropriate location was noted on the anterior wall of the stomach.  This area was localized externally with 1% lidocaine.  Large gauge needle was used to enter the lumen of the stomach under visualization.  A guide wire was then passed again under visualization and the needle was subsequently removed.  A scalpel was used to make a small incision, next to the guidewire and ensuring that the underlying fascia was nicked as well.  A dilator with break-away sheath was then inserted over the guidewire and under direct visualization was seen to enter the lumen of the stomach without difficulty.  The guidewire and dilator were then removed again under visualization and the PEG tube was placed through the break-away sheath and visualized within the lumen of the stomach.  The balloon was then insufflated and the break-away sheath was then pulled away.  Proper placement of the tube was ensured through visualization with a scope.  The tube was then sutured into place using nylon suture.  Appropriate sterile dressing was applied.,DISPOSITION:  ,The patient was transferred to the recovery in a stable condition.  She was subsequently returned to her room on the General Medical Floor.  Previous orders will be resumed.  We will instruct the Nursing that the PEG tube can be used at 5 p.m. this evening for medications if necessary and bolus feedings.gastroenterology, protein-calorie malnutrition, nausea, vomiting, peg tube placement, russell technique, peg tube, egd, protein, dysphagia, malnutrition, enterogastritis
EGD Template - 2 

The patient was placed in the left lateral decubitus position, medicated with the above medications to achieve and maintain a conscious sedation.  Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.,The Olympus single-channel endoscope was passed under direct visualization through the oral cavity and advanced to the second portion of the duodenum.,FINDINGS:,ESOPHAGUS:  Proximal and mid esophagus were without abnormalities.,STOMACH:  Insufflated and retroflexed visualization of the gastric cavity revealed,DUODENUM:  Normal.gastroenterology, gastric cavity, lateral decubitus position, endoscope, olympus, egd, visualization, cavity, duodenum, esophagusNOTE