falan42/nurse_detection huggingface dataset:
Esophagogastroduodenoscopy - 12 

PREOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Hiatal hernia.,POSTOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Hiatal hernia.,3.  Enterogastritis.,PROCEDURE PERFORMED:  ,Esophagogastroduodenoscopy, photography, and biopsy.,GROSS FINDINGS: , The patient has a history of epigastric abdominal pain, persistent in nature.  She has a history of severe gastroesophageal reflux disease, takes Pepcid frequently.  She has had a history of hiatal hernia.  She is being evaluated at this time for disease process.  She does not have much response from Protonix.,Upon endoscopy, the gastroesophageal junction is approximately 40 cm.  There appeared to be some inflammation at the gastroesophageal junction and a small 1 cm to 2 cm hiatal hernia.  There is no advancement of the gastric mucosa up into the lower one-third of the esophagus.  However there appeared to be inflammation as stated previously in the gastroesophageal junction.  There was some mild inflammation at the antrum of the stomach.  The fundus of the stomach was within normal limits.  The cardia showed some laxity to the lower esophageal sphincter.  The pylorus is concentric.  The duodenal bulb and sweep are within normal limits.  No ulcers or erosions.,OPERATIVE PROCEDURE: , The patient is taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position.  The patient was given IV sedation using Demerol and Versed.  Olympus videoscope was inserted into the hypopharynx and upon deglutition passed into the esophagus.  Using air insufflation, panendoscope was advanced down the esophagus into the stomach along the greater curvature of the stomach through the pylorus into the duodenal bulb and sweep and the above gross findings were noted.  Panendoscope was slowly withdrawn carefully examining the lumen of the bowel.  Photographs were taken with the pathology present.  Biopsy was obtained of the antrum of the stomach and also CLO test.  The biopsy is also obtained of the gastroesophageal junction at 12, 3, 6 and 9 o' clock positions to rule out occult Barrett's esophagitis.  Air was aspirated from the stomach and the panendoscope was removed.  The patient sent to recovery room in stable condition.surgery, biopsy, gastroesophageal reflux, gastroesophageal reflux disease, duodenal bulb, gastroesophageal junction, hiatal hernia, enterogastritis, endoscopy, esophagogastroduodenoscopy, gastroesophageal,
Esophagogastroduodenoscopy - 11 

PREOPERATIVE DIAGNOSIS:,  Recurrent right upper quadrant pain with failure of antacid medical therapy.,POSTOPERATIVE DIAGNOSIS: , Normal esophageal gastroduodenoscopy.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with bile aspirate.,ANESTHESIA: , IV Demerol and Versed in titrated fashion.,INDICATIONS: , This 41-year-old female presents to surgical office with history of recurrent right upper quadrant abdominal pain.  Despite antacid therapy, the patient's pain has continued.  Additional findings were concerning with possibility of a biliary etiology.  The patient was explained the risks and benefits of an EGD as well as a Meltzer-Lyon test where upon bile aspiration was performed.  The patient agreed to the procedure and informed consent was obtained.,GROSS FINDINGS: , No evidence of neoplasia, mucosal change, or ulcer on examination.  Aspiration of the bile was done after the administration of 3 mcg of Kinevac.,PROCEDURE DETAILS: , The patient was placed in the supine position.  After appropriate anesthesia was obtained, an Olympus gastroscope inserted from the oropharynx through the second portion of duodenum.  Prior to this, 3 mcg of IV Kinevac was given to the patient to aid with the stimulation of bile.  At this time, the patient as well complained of epigastric discomfort and nausea.  This pain was similar to her previous pain.,Bile was aspirated with a trap to enable the collection of the fluid.  This fluid was then sent to lab for evaluation for crystals.  Next, photodocumentation obtained and retraction of the gastroscope through the antrum revealed no other evidence of disease, retroflexion revealed no evidence of hiatal hernia or other mass and after straightening the scope and aspiration ________, gastroscope was retracted.  The gastroesophageal junction was noted at 20 cm.  No other evidence of disease was appreciated here.  Retraction of the gastroscope backed through the esophagus, off the oropharynx, removed from the patient.  The patient tolerated the procedure well.  We will await evaluation of bile aspirate.surgery, bile aspirate, esophageal, gastroduodenoscopy, kinevac, oropharynx, esophagogastroduodenoscopy, gastroscope
Esophagogastroduodenoscopy - 1 

PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS: , A 1-year-10-month-old with a history of dysphagia to solids.  The procedure was done to rule out organic disease.,POSTOPERATIVE DIAGNOSES: , Loose lower esophageal sphincter and duodenal ulcers.,CONSENT: , The consent is signed.,MEDICATIONS:  ,The procedure was done under general anesthesia given by Dr. Marino Fernandez.,COMPLICATIONS:,  None.,PROCEDURE IN DETAIL:,  A history and physical examination were performed, and the procedure, indications, potential complications including bleeding, perforation, the need for surgery, infection, adverse medical reaction, risks, benefits, and alternatives available were explained to the parents, who stated good understanding and consented to go ahead with the procedure.  The opportunity for questions was provided, and informed consent was obtained.  Once the consent was obtained, the patient was sedated with IV medications and intubated by Dr. Fernandez and placed in the supine position.  Then, the tip of the XP-160 videoscope was introduced into the oropharynx, and under direct visualization, we could advance the endoscope into the upper, mid, and lower esophagus.  We did not find any strictures in the upper esophagus, but the patient had the lower esophageal sphincter totally loose.  Then the tip of the endoscope was advanced down into the stomach and guided into the pylorus, and then into the first portion of the duodenum.  We noticed that the patient had several ulcers in the first portion of the duodenum.  Then the tip of the endoscope was advanced down into the second portion of the duodenum, one biopsy was taken there, and then, the tip of the endoscope was brought back to the first portion, and two biopsies were taken there.  Then, the tip of the endoscope was brought back to the antrum, where two biopsies were taken, and one biopsy for CLOtest.  By retroflexed view, at the level of the body of the stomach, I could see that the patient had the lower esophageal sphincter loose.  Finally, the endoscope was unflexed and was brought back to the lower esophagus, where two biopsies were taken.  At the end, air was suctioned from the stomach, and the endoscope was removed out of the patient's mouth.  The patient tolerated the procedure well with no complications.,FINAL IMPRESSION:  ,1.  Duodenal ulcers.,2.  Loose lower esophageal sphincter.,PLAN:,1.  To start omeprazole 20 mg a day.,2.  To review the biopsies.,3.  To return the patient back to clinic in 1 to 2 weeks.surgery, esophagogastroduodenoscopy, esophageal, biopsies, endoscope
Esophagogastroduodenoscopy 

PROCEDURE:, Esophagogastroduodenoscopy with biopsy and snare polypectomy.,INDICATION FOR THE PROCEDURE:, Iron-deficiency anemia.,MEDICATIONS:, MAC.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration.,PROCEDURE:, After informed consent and appropriate sedation, the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum. The duodenal mucosa was completely normal. The pylorus was normal. In the stomach, there was evidence of diffuse atrophic-appearing nodular gastritis. Multiple biopsies were obtained. There also was a 1.5-cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum. There was mild ulceration on the tip of this polyp. It was decided to remove the polyp via snare polypectomy. Retroflexion was performed, and this revealed a small hiatal hernia in the distal esophagus. The Z-line was identified and was unremarkable. The esophageal mucosa was normal.,FINDINGS:,1. Hiatal hernia.,2. Diffuse nodular and atrophic appearing gastritis, biopsies taken.,3. A 1.5-cm polyp with ulceration along the greater curvature, removed.,RECOMMENDATIONS:,1. Follow up biopsies.,2. Continue PPI.,3. Hold Lovenox for 5 days.,4. Place SCDs.surgery, esophagogastroduodenoscopy, iron-deficiency, iron-deficiency anemia, anemia, biopsy, endoscope, esophageal mucosa, esophagus, hiatal hernia, polypectomy, snare polypectomy, esophagogastroduodenoscopy with biopsy, iron deficiency anemia,
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.surgery, h. pylori, forceps, antral biopsies, ge junction, esophagogastroduodenoscopy, pylori, esophagus, antral,
ERCP 

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 anesthesia.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, aspiration, and post ERCP pancreatitis.,DESCRIPTION OF PROCEDURE: ,After informed consent and appropriate sedation, the duodenoscope was inserted into the oropharynx, down the esophagus, and into the stomach. The scope was then advanced through the pylorus to the ampulla. The ampulla had a markedly abnormal appearance, as it was enlarged and very prominent. It extended outward with an almost polypoid shape. It had what appeared to be adenomatous-appearing mucosa on the tip. There also was ulceration noted on the tip of this ampulla. The biliary and pancreatic orifices were identified. This was located not at the tip of the ampulla, but rather more towards the base. Cannulation was performed with a Wilson-Cooke TriTome sphincterotome with easy cannulation of the biliary tree. The common bile duct was mildly dilated, measuring approximately 12 mm. The intrahepatic ducts were minimally dilated. There were no filling defects identified. There was felt to be a possible stricture within the distal common bile duct, but this likely represented an anatomic variant given the abnormal shape of the ampulla. The patient has no evidence of obstruction based on lab work and clinically. Nevertheless, it was decided to proceed with brush cytology of this segment. This was done without any complications. There was adequate drainage of the biliary tree noted throughout the procedure. Multiple efforts were made to access the pancreatic ductal anatomy; however, because of the shape of the ampulla, this was unsuccessful. Efforts were made to proceed in a long scope position, but still were unsuccessful. Next, biopsies were obtained of the ampulla away from the biliary orifice. Four biopsies were taken. There was some minor oozing which had ceased by the end of the procedure. The stomach was then decompressed and the endoscope was withdrawn.,FINDINGS:,1. Abnormal papilla with bulging, polypoid appearance, and looks adenomatous with ulceration on the tip; biopsies taken.,2. Cholangiogram reveals mildly dilated common bile duct measuring 12 mm and possible distal CBD stricture, although I think this is likely an anatomic variant; brush cytology obtained.,3. Unable to access the pancreatic duct.,RECOMMENDATIONS:,1. NPO except ice chips today.,2. Will proceed with MRCP to better delineate pancreatic ductal anatomy.,3. Follow up biopsies and cytology.surgery, endoscopic retrograde cholangiopancreatography, biopsy, brush cytology, cholangiopancreatography, pancreatitis, endoscopy, duodenoscope, wilson-cooke tritome, ampulla, common bile duct, ercp, endoscopic, biliary, pancreatic, duct, biopsies, cytology
Escharotomy 

PREOPERATIVE DIAGNOSES:,  32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,POSTOPERATIVE DIAGNOSES: , 32% total body surface area burn to the bilateral upper extremities and neck and anterior thorax with impending compartment syndrome of the right upper extremity.,PROCEDURES  PERFORMED:,1.  Lateral escharotomy of right upper arm burn eschar.,2.  Medial escharotomy of left upper extremity burns and eschar.,ANESTHESIA:,  Propofol and Versed.,INDICATIONS FOR PROCEDURE: , The patient is a 72-year-old gentleman who was involved in a propane explosion where he sustained significant burns to his bilateral upper extremities, neck, and thorax.  The patient was transferred from outside facility and was found to have significant burns with impending compartment syndrome of the right upper extremity.  The patient had a _____ between his left and right upper extremity and very tight compartment of his right upper extremity.  It is felt the patient would need an escharotomy of his right upper extremity to maintain perfusion to his right arm and hand.,DESCRIPTION OF PROCEDURE:,  After appropriate time out was performed indicating the correct procedure, correct patient, and all parties involved, the patient's right upper extremity was placed in anatomical position.  An electrocautery device was readied and used to incise making make an incision on the lateral aspect of the patient's right upper extremity.  Starting just below the right humeral head, an incision was made through the burn eschar down to underlying subcutaneous tissue.  The incision was carried from the right humeral head down to just below the antecubital fossa on the right upper extremity.  All dermal bridging was taken down and was opened without any excessive bleeding.  Next, a medial incision was made starting at the axilla down to just below the medial epicondyle of the right upper extremity.  Again, the incision was carried through the entire of the eschar down to underlying subcutaneous tissue.  All bleeding was made hemostatic with electrocautery and all dermal abrasions were taken down.  At the completion of the procedure, the patient had improved right distal radial pulse and his compartment was much softer.  Silvadene cream was placed within the escharotomy incision and wrapped in Kerlix.  The patient tolerated the procedure well, and there were no adverse events during or after the procedure.surgery, lateral escharotomy, medial escharotomy, eschar, anterior thorax, underlying subcutaneous tissue, bilateral upper extremities, impending compartment syndrome, arm burn, extremity burns, humeral head, burn eschar, compartment syndrome, escharotomy, humeral, burns
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.surgery, hibiclens, epigastric herniorrhaphy, epigastric hernia, herniorrhaphy,
Epididymectomy 

EPIDIDYMECTOMY,OPERATIVE NOTE:  ,The patient was placed in the supine position and prepped and draped in the usual manner.  A transverse scrotal incision was made and carried down to the tunica vaginalis, which was opened.  A small amount of clear fluid was expressed.  The tunica vaginalis was opened and the testicle was brought out through this incision.  The epididymis was separated off the surface of the testicle using a scalpel.  With blunt and sharp dissection, the epididymis was dissected off the testicle.  Bovie was used for hemostasis.  The vessels going to the testicle were preserved without any obvious injury, and a nice viable testicle was present after the epididymis was removed from this.  The blood supply to the epididymis was cauterized using a Bovie and the vas was divided with cautery also.  There was no obvious bleeding.  The cord was infiltrated with 0.25% Marcaine, as was the dartos tissue in the scrotum.  The testicle was replaced in the scrotum.  Skin was closed in two layers using 3-0 chromic catgut for the dartos and a subcuticular closure with the same material.  A dry sterile dressing and compression were applied, and he was sent to the recovery room in stable condition.surgery, scrotal incision, 0.25% marcaine, bovie, epididymectomy, chromic catgut, epididymis, fluid, scalpel, scrotum, sterile dressing, testicle, tunica vaginalisNOTE,: 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.
Endotracheal Intubation - 1 

PROCEDURE PERFORMED: , Endotracheal intubation.,INDICATION FOR PROCEDURE:  ,The patient was intubated secondary to respiratory distress and increased work of breathing and falling saturation on 15 liters nonrebreather.  PCO2 was 29 and pO2 was 66 on the 15 liters.,NARRATIVE OF PROCEDURE: , The patient was given a total of 5 mg of Versed, 20 mg of etomidate, and 10 mg of vecuronium.  He was intubated in a single attempt.  Cords were well visualized, and a #8 endotracheal tube was passed using a curved blade.  Fiberoptically, a bronchoscope was passed for lavage and the tube was found to be in good position 3 cm above the main carina where it was kept there and the right lower lobe was lavaged with trap A lavage with 100 mL of normal sterile saline for cytology, AFB, and fungal smear and culture.  A separate trap B was then lavaged for bacterial C&S and Gram stain and was sent for those purposes.  The patient tolerated the procedure well.surgery, nonrebreather, respiratory distress, falling saturation, endotracheal intubation, lavage, breathingNOTE
Endotracheal Intubation 

PROCEDURE: , Endotracheal intubation.,INDICATION: , Respiratory failure.,BRIEF HISTORY: , The patient is a 52-year-old male with metastatic osteogenic sarcoma.  He was admitted two days ago with small bowel obstruction.  He has been on Coumadin for previous PE and currently on heparin drip.  He became altered and subsequently deteriorated quite rapidly to the point where he is no longer breathing on his own and has minimal responsiveness.  A code blue was called.  On my arrival, the patient's vital signs are stable.  His blood pressure is systolically in 140s and heart rate 80s.  He however has 0 respiratory effort and is unresponsive to even painful stimuli.  The patient was given etomidate 20 mg.,DESCRIPTION OF PROCEDURE:  ,The patient positioned appropriate equipment at the bedside, given 20 mg of etomidate and 100 mg of succinylcholine.  Mac-4 blade was used.  A 7.5 ET tube placed to 24th teeth.  There is good color change on the capnographer with bilateral breath sounds.  Following intubation, the patient's blood pressure began to drop.  He was given 2 L of bolus.  I started him on dopamine drip at 10 mcg.  Dr. X was at the bedside, who is the primary caregiver, he assumed the care of the patient, will be transferred to the ICU.  Chest x-ray will be reviewed and Pulmonary will be consulted.surgery, metastatic osteogenic sarcoma, respiratory failure, bowel obstruction, blood pressure, endotracheal intubation, endotracheal, sarcoma
Epidurogram 

PREOPERATIVE DIAGNOSES:  ,1.  Right lower extremity radiculopathy with history of post laminectomy pain.,2.  Epidural fibrosis with nerve root entrapment.,POSTOPERATIVE DIAGNOSES:  ,1.  Right lower extremity radiculopathy with history of post laminectomy pain.,2.  Epidural fibrosis with nerve root entrapment.,OPERATION PERFORMED: , Right L4, attempted L5, and S1 transforaminal epidurogram for neural mapping.,ANESTHESIA:,  Local/IV sedation.,COMPLICATIONS: , None.,SUMMARY: , The patient in the operating room in the prone position with the back prepped and draped in the sterile fashion.  The patient was given sedation and monitored.  Local anesthetic was used to insufflate the skin and paraspinal tissues and the L5 disk level on the right was noted to be completely collapsed with no way whatsoever to get a needle to the neural foramen of the L5 root.  The left side was quite open; however, that was not the side of her problem.  At this point using a oblique fluoroscopic projection and gun-barrel technique, a 22-gauge 3.5 inch spinal needle was placed at the superior articular process of L5 on the right, stepped off laterally and redirected medially into the intervertebral foramen to the L4 nerve root.  A second needle was taken and placed at the S1 nerve foramen using AP and lateral fluoroscopic views to confirm location.  After negative aspiration, 2 cc of Omnipaque 240 dye was injected through each needle.,There was a defect flowing in the medial epidural space at both sides.  There were no complications.surgery, laminectomy, radiculopathy, nerve root entrapment, epidural fibrosis, nerve root, epidurogram, neural, epidural, foramen, nerve, needle