falan42/nurse_detection huggingface dataset:
Gastroscopy 

PREOPERATIVE DIAGNOSES: , Dysphagia and esophageal spasm.,POSTOPERATIVE DIAGNOSES: , Esophagitis and esophageal stricture.,PROCEDURE:,  Gastroscopy.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum, to the third portion of the duodenum.  The hypopharynx was normal and the upper esophageal sphincter was unremarkable.  The esophageal contour was normal, with the gastroesophageal junction located at 38 cm from the incisors.  At this point, there were several linear erosions and a sense of stricturing at 38 cm.  Below this, there was a small hiatal hernia with the hiatus noted at 42 cm from the incisors.  The mucosa within the hernia was normal.  The gastric lumen was normal with normal mucosa throughout.  The pylorus was patent permitting passage of the scope into the duodenum, which was normal through the third portion.  During withdrawal of the scope, additional views were obtained of the cardia, confirming the presence of a small hiatal hernia.  It was decided to attempt dilation of the strictured area, so an 18-mm TTS balloon was placed across the stricture and inflated to the recommended diameter.  When the balloon was fully inflated, the lumen appeared to be larger than 18 mm diameter, suggesting that the stricture was in fact not a significant one.  No stretching of the mucosa took place.  The balloon was deflated and the scope was withdrawn.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Esophagitis.,2.  Minor stricture at the gastroesophageal junction.,3.  Hiatal hernia.,4.  Otherwise normal upper endoscopy to the transverse duodenum.,RECOMMENDATIONS:  ,Continue proton pump inhibitor therapy.gastroenterology, duodenum, esophagus, gastroscope, stomach, upper endoscopy, transverse duodenum, gastroesophageal junction, hiatal hernia, gastroscopy, endoscopy, esophagitis, gastroesophageal, hiatal, esophageal, hernia
Flex Sig - 3 

PROCEDURE: , Flexible sigmoidoscopy.,PREOPERATIVE DIAGNOSIS:,  Rectal bleeding.,POSTOPERATIVE DIAGNOSIS:  ,Diverticulosis.,MEDICATIONS: , None.,DESCRIPTION OF PROCEDURE:  ,The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal descending colon.  At this point, stool occupied the lumen, preventing further passage.  The colon distal to this was well cleaned out and easily visualized.  The mucosa was normal throughout the regions examined.  Numerous diverticula were seen.  There was no blood or old blood or active bleeding.  A retroflexed view of the anorectal junction showed no hemorrhoids.  He tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Sigmoid and left colon diverticulosis.,2.  Otherwise normal flexible sigmoidoscopy to the proximal descending colon.,3.  The bleeding was most likely from a diverticulum, given the self limited but moderately severe quantity that he described.,RECOMMENDATIONS:,1.  Follow up with Dr. X as needed.,2.  If there is further bleeding, a full colonoscopy is recommended.gastroenterology, olympus, gastroscope, rectal bleeding, flexible sigmoidoscopy, colon diverticulosis, descending colon, diverticulosis, hemorrhoids, flexible, sigmoidoscopy, colon
Flex Sig 

MEDICATIONS:,  None.,DESCRIPTION OF THE PROCEDURE:,  After informed consent was obtained, the patient was placed in the left lateral decubitus position and the Olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of *** cm to the proximal descending colon and then slowly withdrawn.  The mucosa appeared normal.  Retroflex examination of the rectum was normal.gastroenterology, flexible sigmoidoscopy, flex sig, olympus video colonoscope, colonoscopeNOTE,: 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.,
Exploratory Laparotomy 

PREOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,POSTOPERATIVE DIAGNOSIS: ,  Leaking anastomosis from esophagogastrectomy. ,PROCEDURE: ,  Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,COMPLICATIONS:,  None. ,ANESTHESIA: , General oroendotracheal intubation. ,PROCEDURE:  , After adequate general anesthesia was administered, the patient's abdomen was prepped and draped aseptically. Sutures and staples were removed. The abdomen was opened. The were some very early stage adhesions that were easy to separate. Dissection was carried up toward the upper abdomen where the patient was found to have a stool filled descended colon. This was retracted caudally to expose the stomach. There were a number of adhesions to the stomach. These were carefully dissected to expose initially the closure over the gastrotomy site. Initially this looked like this was leaking but it was actually found to be intact.  The pyloroplasty was identified and also found to be intact with no evidence of leakage. Further dissection up toward the hiatus revealed an abscess collection. This was sent for culture and sensitivity and was aspirated and lavaged. Cavity tracked up toward the hiatus. Stomach itself appeared viable, there was no necrotic sections. Upper apex of the stomach was felt to be viable also. I did not pull the stomach and esophagus down into the abdomen from the mediastinum, but placed a sucker up into the mediastinum where additional turbid fluid was identified. Carefully placed a 10 mm flat Jackson-Pratt drain into the mediastinum through the hiatus to control this area of leakage. Two additional Jackson-Pratt drains were placed essentially through the gastrohepatic omentum. This was the area that most of the drainage had collected in. As I had previously discussed with Dr. Sageman I did not feel that mobilizing the stomach to redo the anastomosis in the chest would be a recoverable situation for the patient. I therefore did not push to visualize any focal areas of the anastomosis with the intent of repair. Once the drains were secured, they were brought out through the anterior abdominal wall and secured with 3-0 silk sutures and secured to bulb suction. The midline fascia was then closed using running #2 Prolene sutures bolstered with retention sutures. Subcutaneous tissue was copiously lavaged and then the skin was closed with loosely approximated staples. Dry gauze dressing was placed. The patient tolerated the procedure well, there were no complications.gastroenterology, drainage, oroendotracheal, intubation, intra abdominal, abdominal abscesses, jackson pratt, exploratory laparotomy, anastomosis, esophagogastrectomy, mediastinum, abdomen, stomach
Esophagoscopy & Foreign Body Removal 

PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:,  Esophageal foreign body, US penny.,PROCEDURE: , Esophagoscopy with foreign body removal.,ANESTHESIA: , General.,INDICATIONS: , The patient is a 17-month-old baby girl with biliary atresia, who had a delayed diagnosis and a late attempted Kasai portoenterostomy, which failed.  The patient has progressive cholestatic jaundice and is on the liver transplant list at ABCD.  The patient is fed by mouth and also with nasogastric enteral feeding supplements.  She has had an __________ cough and relatively disinterested in oral intake for the past month.  She was recently in the GI Clinic and an x-ray was ordered to check her tube placement and an incidental finding of a coin in the proximal esophagus was noted.  Based on the history, it is quite possible this coin has been there close to a month.  She is brought to the operating room now for attempted removal.  I met with the parents and talked to them at length about the procedure and the increased risk in a child with a coin that has been in for a prolonged period of time.  Hopefully, there will be no coin migration or significant irrigation that would require prolonged hospitalization.,OPERATIVE FINDINGS: , The patient had a penny lodged in the proximal esophagus in the typical location.  There was no evidence of external migration and surrounding irritation was noted, but did not appear to be excessive.  The coin actually came out with relative ease after which endoscopically identified.,DESCRIPTION OF OPERATION: , The patient came to the operating room and had induction of general anesthesia.  She was slow to respond to the usual propofol and other inducing agents and may be has some difficulty with tolerance or __________ tolerance to these medications.  After her endotracheal tube was placed and securely taped to the left side of her mouth, I positioned the patient with a prominent shoulder roll and neck hyperextension and then used the laryngoscope to elevate the tiny glottic mechanism.  A rigid esophagoscope was then inserted into the proximal esophagus, and the scope was gradually advanced with the lumen directly in frontal view.  This was facilitated by the nasoenteric feeding tube that was in place, which I followed carefully until the edge of the coin could be seen.  At this location, there was quite a bit of surrounding mucosal inflammation, but the coin edge could be clearly seen and was secured with the coin grasping forceps.  I then withdrew the scope, forceps, and the coin as one unit, and it was easily retrieved.  The patient tolerated the procedure well.  There were no intraoperative complications.  There was only one single coin noted, and she was awakened and taken to the recovery room in good condition.gastroenterology, portoenterostomy, foreign body removal, proximal esophagus, coin, esophagoscopy, esophageal, esophagus,
Esophagoscopy & Foreign Body Removal - 1 

PRIMARY DIAGNOSIS:,  Esophageal foreign body, no associated comorbidities are noted.,PROCEDURE:,  Esophagoscopy with removal of foreign body.,CPT CODE: , 43215.,PRINCIPAL DIAGNOSIS:,  Esophageal foreign body, ICD-9 code 935.1.,DESCRIPTION OF PROCEDURE: , Under general anesthesia, flexible EGD was performed.  Esophagus was visualized.  The quarter was visualized at the aortic knob, was removed with grasper.  Estimated blood loss 0.  Intravenous fluids during time of procedure 100 mL.  No tissues.  No complications.  The patient tolerated the procedure well.  Dr. X Pipkin attending pediatric surgeon was present throughout the entire procedure.  The patient was transferred from OR to PACU in stable condition.gastroenterology, esophagus, foreign body, esophagoscopy, esophageal,
Esophagogastroduodenoscopy with Biopsies 

PREOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Chronic dyspepsia.,POSTOPERATIVE DIAGNOSES:,1.  Gastroesophageal reflux disease.,2.  Chronic dyspepsia.,3.  Alkaline reflux gastritis.,4.  Gastroparesis.,5.  Probable Billroth II anastomosis.,6.  Status post Whipple's pancreaticoduodenectomy.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with biopsies.,INDICATIONS FOR PROCEDURE: , This is a 55-year-old African-American female who had undergone Whipple's procedure approximately five to six years ago for a benign pancreatic mass.  The patient has pancreatic insufficiency and is already on replacement.  She is currently using Nexium.  She has continued postprandial dyspepsia and reflux symptoms.  To evaluate this, the patient was boarded for EGD.  The patient gave informed consent for the procedure.,GROSS FINDINGS: , At the time of EGD, the patient was found to have alkaline reflux gastritis.  There was no evidence of distal esophagitis.  Gastroparesis was seen as there was retained fluid in the small intestine.  The patient had no evidence of anastomotic obstruction and appeared to have a Billroth II reconstruction by gastric jejunostomy.  Biopsies were taken and further recommendations will follow.,PROCEDURE:  ,The patient was taken to the Endoscopy Suite.  The heart and lungs examination were unremarkable.  The vital signs were monitored and found to be stable throughout the procedure.  The patient's oropharynx was anesthetized with Cetacaine spray.  She was placed in left lateral position.  The patient had the video Olympus GIF gastroscope model inserted per os and was advanced without difficulty through the hypopharynx.  GE junction was in normal position.  There was no evidence of any hiatal hernia.  There was no evidence of distal esophagitis.  The gastric remnant was entered.  It was noted to be inflamed with alkaline reflux gastritis.  The anastomosis was open and patent.  The small intestine was entered.  There was retained fluid material in the stomach and small intestine and _______ gastroparesis.  Biopsies were performed.  Insufflated air was removed with withdrawal of the scope.  The patient's diet will be adjusted to postgastrectomy-type diet.  Biopsies performed.  Diet will be reviewed.  The patient will have an upper GI series performed to rule out more distal type obstruction explaining the retained fluid versus gastroparesis.  Reglan will also be added.  Further recommendations will follow.gastroenterology, gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, whipple's pancreaticoduodenectomy, billroth ii anastomosis, gastroesophageal reflux, alkaline reflux, reflux gastritis, gif, esophagogastroduodenoscopy, dyspepsia, gastritis, anastomosis, pancreaticoduodenectomy, biopsies, alkaline, reflux,
Esophagogastroduodenoscopy & Gastrostomy Tube Insertion 

PREOPERATIVE DIAGNOSES:,1.  Neuromuscular dysphagia.,2.  Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSES:,1.  Neuromuscular dysphagia.,2.  Protein-calorie malnutrition.,PROCEDURES PERFORMED:,1.  Esophagogastroduodenoscopy with photo.,2.  Insertion of a percutaneous endoscopic gastrostomy tube.,ANESTHESIA:,  IV sedation and local.,COMPLICATIONS: , None.,DISPOSITION: , The patient tolerated the procedure well without difficulty.,BRIEF HISTORY:  ,The patient is a 50-year-old African-American male who presented to ABCD General Hospital on 08/18/2003 secondary to right hemiparesis from a CVA.  The patient deteriorated with several CVAs and had became encephalopathic requiring a ventilator-dependency with respiratory failure.  The patient also had neuromuscular dysfunction.  After extended period of time, per the patient's family request and requested by the ICU staff, decision to place a feeding tube was decided and scheduled for today.,INTRAOPERATIVE FINDINGS: , The patient was found to have esophagitis as well as gastritis via EGD and was placed on Prevacid granules.,PROCEDURE: , After informed written consent, the risks and benefits of the procedure were explained to the patient and the patient's family.  First, the EGD was to be performed.,The Olympus endoscope was inserted through the mouth, oropharynx and into the esophagus.  Esophagitis was noted.  The scope was then passed through the esophagus into the stomach.  The cardia, fundus, body, and antrum of the stomach were visualized.  There was evidence of gastritis.  The scope was passed into the duodenal bulb and sweep via the pylorus and then removed from the duodenum retroflexing on itself in the stomach looking at the hiatus.  Next, attention was made to transilluminating the anterior abdominal wall for the PEG placement.  The skin was then anesthetized with 1% lidocaine.  The finder needle was then inserted under direct visualization.  The catheter was then grasped via the endoscope and the wire was pulled back up through the patient's mouth.  The Ponsky PEG tube was attached to the wire.  A skin nick was made with a #11 blade scalpel.  The wire was pulled back up through the abdominal wall point and Ponsky PEG back up through the abdominal wall and inserted into position.  The endoscope was then replaced confirming position.  Photograph was taken.  The Ponsky PEG tube was trimmed and the desired attachments were placed and the patient did tolerate the procedure well.  We will begin tube feeds later this afternoon.gastroenterology, neuromuscular dysphagia, protein-calorie malnutrition, esophagogastroduodenoscopy, endoscopic, gastrostomy, percutaneous, gastrostomy tube, percutaneous endoscopic gastrostomy tube, protein calorie malnutrition, abdominal wall, dysphagia, stomach, abdominal, neuromuscular, tube,
Esophagogastroduodenoscopy with Biopsies -2 

PREOPERATIVE DIAGNOSIS: , Refractory dyspepsia.,POSTOPERATIVE DIAGNOSIS:,1.  Hiatal hernia.,2.  Reflux esophagitis.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with pseudo and esophageal biopsy.,ANESTHESIA:,  Conscious sedation with Demerol and Versed.,SPECIMEN: , Esophageal biopsy.,COMPLICATIONS: , None.,HISTORY:,  The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.  She has been on multiple medical regimens and continues with dyspeptic symptoms.,PROCEDURE: , After proper informed consent was obtained, the patient was brought to the endoscopy suite.  She was placed in the left lateral position and was given IV Demerol and Versed for sedation.  When adequate level of sedation achieved, the gastroscope was inserted into the hypopharynx and the esophagus was easily intubated.  At the GE junction, a hiatal hernia was present.  There were mild inflammatory changes consistent with reflux esophagitis.  The scope was then passed into the stomach.  It was insufflated and the scope was coursed along the greater curvature to the antrum.  The pylorus was patent.  There was evidence of bile reflux in the antrum.  The duodenal bulb and sweep were examined and were without evidence of mass, ulceration, or inflammation.  The scope was then brought back into the antrum.,A retroflexion was attempted multiple times, however, the patient was having difficulty holding the air and adequate retroflexion view was not visualized.  The gastroscope was then slowly withdrawn.  There were no other abnormalities noted in the fundus or body.  Once again at the GE junction, esophageal biopsy was taken.  The scope was then completely withdrawn.  The patient tolerated the procedure and was transferred to the recovery room in stable condition.  She will return to the General Medical Floor.  We will continue b.i.d proton-pump inhibitor therapy as well as dietary restrictions.  She should also attempt significant weight loss.gastroenterology, refractory dyspepsia, hiatal hernia, reflux esophagitis, esophagogastroduodenoscopy, esophageal, pseudo, esophageal biopsy, ge junction, hiatal, hernia, esophagitis, antrum, gerd,
Esophagogastroduodenoscopy - 9 

PREOPERATIVE DIAGNOSES: , Malnutrition and dysphagia.,POSTOPERATIVE DIAGNOSES: , Malnutrition and dysphagia with two antral polyps and large hiatal hernia.,PROCEDURES: , Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.,ANESTHESIA: , IV sedation, 1% Xylocaine locally.,CONDITION:,  Stable.,OPERATIVE NOTE IN DETAIL: , After risk of operation was explained to this patient's family, consent was obtained for surgery.  The patient was brought to the GI lab.  There, she was placed in partial left lateral decubitus position.  She was given IV sedation by Anesthesia.  Her abdomen was prepped with alcohol and then Betadine.  Flexible gastroscope was passed down the esophagus, through the stomach into the duodenum.  No lesions were noted in the duodenum.  There appeared to be a few polyps in the antral area, two in the antrum.  Actually, one appeared to be almost covering the pylorus.  The scope was withdrawn back into the antrum.  On retroflexion, we could see a large hiatal hernia.  No other lesions were noted.  Biopsy was taken of one of the polyps.  The scope was left in position.  Anterior abdominal wall was prepped with Betadine, 1% Xylocaine was injected in the left epigastric area.  A small stab incision was made and a large bore Angiocath was placed directly into the anterior abdominal wall, into the stomach, followed by a thread, was grasped with a snare using the gastroscope, brought out through the patient's mouth.  Tied to the gastrostomy tube, which was then pulled down and up through the anterior abdominal wall.  It was held in position with a dressing and a stent.  A connector was applied to the cut gastrostomy tube, held in place with a 2-0 silk ligature.  The patient tolerated the procedure well.  She was returned to the floor in stable condition.gastroenterology, antral, polyps, gastrostomy, endoscopic gastrostomy, hiatal hernia, abdominal wall, gastrostomy tube, esophagogastroduodenoscopy, malnutrition, dysphagia, abdominal
Esophagogastroduodenoscopy with Biopsies - 1 

PROCEDURE: , Esophagogastroduodenoscopy with gastric biopsies.,INDICATION:,  Abdominal pain.,FINDINGS:,  Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.,MEDICATIONS: , Fentanyl 200 mcg and versed 6 mg.,SCOPE: , GIF-Q180.,PROCEDURE DETAIL: , Following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation and side effects of medications and alternatives were reviewed.  Questions were answered.  Pause preprocedure was performed.,Following titrated intravenous sedation the flexible video endoscope was introduced into the esophagus and advanced to the second portion of the duodenum without difficulty.  The esophagus appeared to have normal motility and mucosa.  Regular Z line was located at 44 cm from incisors.  No erosion or ulceration.  No esophagitis.,Upon entering the stomach gastric mucosa was examined in detail including retroflexed views of cardia and fundus.  There was pyloric channel and antral erythema, but no visible erosion or ulceration.  There was a 2 cm polypoid pyloric channel tissue which was suspicious for inflammatory polyp.  This was biopsied and was placed separately in bottle #2.  Random gastric biopsies from antrum, incisura and body were obtained and placed in separate jar, bottle #1.  No active ulceration was found.,Upon entering the duodenal bulb there was extensive erythema and mild erosions, less than 3 mm in length, in first portion of duodenum, duodenal bulb and junction of first and second part of the duodenum.  Postbulbar duodenum looked normal.,The patient was assessed upon completion of the procedure.  Okay to discharge once criteria met.,Follow up with primary care physician.,I met with patient afterward and discussed with him avoiding any nonsteroidal anti-inflammatory medication.  Await biopsy results.gastroenterology, gastric biopsies, duodenal erythema, inflammatory polyp, pyloric channel tissue, pyloric channel, esophagogastroduodenoscopy, pyloric, duodenal, duodenum, polypoid,