falan42/nurse_detection huggingface dataset:
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.surgery, protein-calorie malnutrition, nausea, vomiting, peg tube placement, russell technique, peg tube, egd, protein, dysphagia, malnutrition, enterogastritis
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.,surgery, 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 & Colonoscopy 

PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1.  Normal colon with no evidence of bleeding.,2.  Hiatal hernia.,3.  Fundal gastritis with polyps.,4.  Antral mass.,ANESTHESIA: , Conscious sedation with Demerol and Versed.,SPECIMEN:  ,Antrum and fundal polyps.,HISTORY: , The patient is a 66-year-old African-American female who presented to ABCD Hospital with mental status changes.  She has been anemic as well with no gross evidence of blood loss.  She has had a decreased appetite with weight loss greater than 20 lb over the past few months.  After discussion with the patient and her daughter, she was scheduled for EGD and colonoscopy for evaluation.,PROCEDURE: , After 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 was achieved, a digital rectal exam was performed, which demonstrated no masses and no hemorrhoids.  The colonoscope was inserted into the rectum and air was insufflated.  The scope was coursed through the rectum and sigmoid colon, descending colon, transverse colon, ascending colon to the level of the cecum.  There were no polyps, masses, diverticuli, or areas of inflammation.  The scope was then slowly withdrawn carefully examining all walls.  Air was aspirated.  Once in the rectum, the scope was retroflexed.  There was no evidence of perianal disease.  No source of the anemia was identified.,Attention was then taken for performing an EGD.  The gastroscope was inserted into the hypopharynx and was entered into the hypopharynx.  The esophagus was easily intubated and traversed.  There were no abnormalities of the esophagus.  The stomach was entered and was insufflated.  The scope was coursed along the greater curvature towards the antrum.  Adjacent to the pylorus, towards the anterior surface, was a mass like lesion with a central _______.  It was not clear if this represents a healing ulcer or neoplasm.  Several biopsies were taken.  The mass was soft.  The pylorus was then entered.  The duodenal bulb and sweep were examined.  There was no evidence of mass, ulceration, or bleeding.  The scope was then brought back into the antrum and was retroflexed.  In the fundus and body, there was evidence of streaking and inflammation.  There were also several small sessile polyps, which were removed with biopsy forceps.  Biopsy was also taken for CLO.  A hiatal hernia was present as well.  Air was aspirated.  The scope was slowly withdrawn.  The GE junction was unremarkable.  The scope was fully withdrawn.  The patient tolerated the procedure well and was transferred to recovery room in stable condition.  She will undergo a CAT scan of her abdomen and pelvis to further assess any possible adenopathy or gastric obstructional changes.  We will await the biopsy reports and further recommendations will follow.surgery, esophagus, gastroscope, hypopharynx, rectum, fundal gastritis, antral mass, hiatal hernia, egd, hernia, polyps, colonoscopy,
EGD - Colonoscopy - Polypectomy 

PROCEDURES:,1.  Esophagogastroduodenoscopy.,2.  Colonoscopy with polypectomy.,PREOPERATIVE DIAGNOSES:,1.  History of esophageal cancer.,2.  History of colonic polyps.,POSTOPERATIVE FINDINGS:,1.  Intact surgical intervention for a history of esophageal cancer.,2.  Melanosis coli.,3.  Transverse colon polyps in the setting of surgical changes related to partial and transverse colectomy.,MEDICATIONS:,  Fentanyl 250 mcg and 9 mg of Versed.,INDICATIONS:,  The patient is a 55-year-old dentist presenting for surveillance upper endoscopy in the setting of a history of esophageal cancer with staging at T2N0M0.,He also has a history of adenomatous polyps and presents for surveillance of this process.,Informed consent was obtained after explanation of the procedures, as well as risk factors of bleeding, perforation, and adverse medication reaction.,ESOPHAGOGASTRODUODENOSCOPY:,  The patient was placed in the left lateral decubitus position and 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:,1.  ESOPHAGUS:  Anatomy consistent with esophagectomy with colonic transposition.,2.  STOMACH:  Revealed colonic transposition with normal mucosa.,3.  DUODENUM:  Normal.,IMPRESSION: , Intact surgical intervention with esophagectomy colonic transposition.,COLONOSCOPY: , The patient was then turned and a colonic 140-series colonoscope was passed under direct visualization through the anal verge and advanced to the cecum as identified by the appendiceal orifice.  Circumferential visualization the colonic mucosa revealed the following:,1.  Cecum revealed melanosis coli.,2.  Ascending, melanosis coli.,3.  Transverse revealed two diminutive sessile polyps, excised by cold forceps technique and submitted to histology as specimen #1 with surgical changes consistent with partial colectomy related to the colonic transposition.,4.  Descending, melanosis coli.,5.  Sigmoid, melanosis coli.,6.  Rectum, melanosis coli.,IMPRESSION: , Diffuse melanosis coli with incidental finding of transverse colon polyps.,RECOMMENDATION: , Follow-up histology.  Continue fiber with avoidance of stimulant laxatives.nan
EGD Template - 1 

 Common description of EGD.surgery, duodenal mucosa, duodenal, esophageal mucosa, fundus, egd, entire, mucosaNOTE,: 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 - 1 

HISTORY OF PRESENT ILLNESS:,  Briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus.  He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture that may need to be dilated, or any other mucosal abnormality.,PROCEDURE PERFORMED: , EGD.,PREP: , Cetacaine spray, 100 mcg of fentanyl IV, and 5 mg of Versed IV.,FINDINGS:,  The tip of the endoscope was introduced into the esophagus, and the entire length of the esophagus was dotted with numerous, white, punctate lesions, suggestive of eosinophilic esophagitis.  There were come concentric rings present.  There was no erosion or flame hemorrhage, but there was some friability in the distal esophagus.  Biopsies throughout the entire length of the esophagus from 25-40 cm were obtained to look for eosinophilic esophagitis.  There was no stricture or Barrett mucosa.  The bony and the antrum of the stomach are normal without any acute peptic lesions.  Retroflexion of the tip of the endoscope in the body of the stomach revealed a normal cardia.  There were no acute lesions and no evidence of ulcer, tumor, or polyp.  The pylorus was easily entered, and the first, second, and third portions of the duodenum are normal.  Adverse reactions:  None.,FINAL IMPRESSION:  ,Esophageal changes suggestive of eosinophilic esophagitis.  Biopsies throughout the length of the esophagus were obtained for microscopic analysis.  There was no evidence of stricture, Barrett, or other abnormalities in the upper GI tract.surgery, length of the esophagus, food impacted, lower esophagus, upper endoscopy, entire length, eosinophilic esophagitis, egd, dysphagia, solids, impacted, endoscopy, mucosal, endoscope, biopsies, barrett, stomach, stricture, eosinophilic, esophagitis, esophagus,
EGD - 2 

PROCEDURES PERFORMED: , Esophagogastroduodenoscopy.,PREPROCEDURE DIAGNOSIS: , Dysphagia.,POSTPROCEDURE DIAGNOSIS: , Active reflux esophagitis, distal esophageal stricture, ring due to reflux esophagitis, dilated with balloon to 18 mm.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attention to benefits, risks, alternatives.  Risks explained as bleeding, infection, bowel perforation, aspiration pneumonia, or reaction to the medications.  Vital signs were monitored by blood pressure, heart rate, and oxygen saturation.  Supplemental O2 given.  Specifics of the procedure discussed.  The procedure was discussed with father and mother as the patient is mentally challenged.  He has no complaints of dysphagia usually for solids, better with liquids, worsening over the last 6 months, although there is an emergency department report from last year.  He went to the emergency department yesterday with beef jerky.,All of this reviewed.  The patient is currently on Cortef, Synthroid, Tegretol, Norvasc, lisinopril, DDAVP.  He is being managed for extensive past history due to an astrocytoma, brain surgery, hypothyroidism, endocrine insufficiency.  He has not yet undergone significant workup.  He has not yet had an endoscopy or barium study performed.  He is developmentally delayed due to the surgery, panhypopituitarism.,His family history is significant for his father being of mine, also having reflux issues, without true heartburn, but distal esophageal stricture.  The patient does not smoke, does not drink.  He is living with his parents.  Since his emergency department visitation yesterday, no significant complaints.,Large male, no acute distress.  Vital signs monitored in the endoscopy suite.  Lungs clear.  Cardiac exam showed regular rhythm.  Abdomen obese but soft.  Extremity exam showed large hands.  He was a Mallampati score A, ASA classification type 2.,The procedure discussed with the patient, the patient's mother.  Risks, benefits, and alternatives discussed.  Potential alternatives for dysphagia, such as motility disorder, given his brain surgery, given the possibility of achalasia and similar discussed.  The potential need for a barium swallow, modified barium swallow, and similar discussed.  All questions answered.  At this point, the patient will undergo endoscopy for evaluation of dysphagia, with potential benefit of the possibility to dilate him should there be a stricture.  He may have reflux symptoms, without complaining of heartburn.  He may benefit from a trial of PPI.  All of this reviewed.  All questions answered.,surgery, distal esophageal stricture, reflux esophagitis, distal esophageal, esophageal stricture, barium swallow, esophagogastroduodenoscopy, esophagitis, esophageal, heartburn, stricture, endoscopy, reflux, dysphagia
Ear Laceration Repair 

PREOPERATIVE DIAGNOSIS:,  Bilateral ear laceration deformities.,POSTOPERATIVE DIAGNOSIS:,  Bilateral ear laceration deformities.,PROCEDURE:,1.  Repair of left ear laceration deformity Y-V plasty 2 cm.,2.  Repair of right ear laceration deformity, complex repair 2 cm.,ANESTHESIA: , 1% Xylocaine, 1:100,000 epinephrine local.,BRIEF CLINICAL NOTE: , This patient was brought to the operating room today for the above procedure.,OPERATIVE NOTE: , The patient was laid in supine position, adequately anesthetized with the above anesthesia, sterilely prepped and draped.  The left ear laceration deformity was very close to the bottom of her ear and therefore it was transected through the centrifugal edge of the ear lobe and pared.  The marsupialized epithelialized tracts were pared to raw tissue.  They were pared in a fashion to create a Y-V plasty with de-epithelialization of the distal V and overlap of the undermined from the proximal cephalad edge.  The 5-0 chromic sutures were used to approximate anteriorly, posteriorly, and anterior centrifugal edge in the Y-V plasty fashion to decrease the risk of notching.  Bacitracin, Band-Aid was placed.  Next, attention was turned to the contralateral ear where an elongated laceration deformity was pared of the marsupialized epithelialized edges anteriorly, posteriorly to create raw edges.  This was not taken through the edge of the lobe to decrease the risk of notch deformity.  The laceration was repaired anteriorly and posteriorly in a pleated fashion to decrease length of the incision and to decrease any deformity toward the edge or any dog-ear deformity toward the edge.  The 5-0 chromic sutures were used in interrupted fashion for this.  The patient tolerated the procedure well.  Band-Aid and bacitracin were placed.  She left the operating room in stable condition.surgery, bilateral ear laceration, dog-ear deformity, ear laceration deformity, band aid, laceration deformity, ear laceration, laceration, deformity, ear, repair
Ear Examination 

PREOPERATIVE DIAGNOSIS: , Right tympanic membrane perforation.,POSTOPERATIVE DIAGNOSIS: , Right tympanic membrane perforation along with chronic otitis media.,PROCEDURE: , Right ear examination under anesthesia.,INDICATIONS: , The patient is a 15-year-old child with history of a right tympanic membrane perforation following tube placement as well as right conductive hearing loss.  Exam in the office revealed a posterior superior right marginal tympanic perforation.  Risks and benefits of surgery including risk of bleeding, general anesthesia, hearing loss as well as recurrent perforation were discussed with the mother.  The mother wished to proceed with surgery.,FINDINGS:,  The patient was brought to the room, placed in supine position, given general endotracheal anesthesia.  The postauricular crease was then injected with 1% Xylocaine with 1:200,000 epinephrine along with external meatus.  An area of the scalp was shaved above the ear and then also 1% Xylocaine with 1:200,000 epinephrine injected, a total of 4 mL local anesthetic was used.  The ear was then prepped and draped in the usual sterile fashion.  The microscope was then brought into view and examining the marginal perforation, the patient was noted to have large granuloma under the tympanic membrane at the anterior border of the drum.  The granulation tissue was debrided as much as possible.  Decision was made to cancel the tympanoplasty after debriding the middle ear space as much as possible.  The middle ear space was filled with Floxin drops.  The patient woke up anesthesia, extubated, and brought to recovery room in stable condition.  There were no intraoperative complications.  Needle and sponge was correct.  Estimated blood loss minimal.surgery, chronic otitis media, middle ear space, tympanic membrane perforation, otitis media, hearing loss, middle ear, ear space, ear examination, membrane perforation, tympanic membrane, anesthesia, membrane, tympanic, ear, perforation,
Dual Chamber ICD Implantation 

PROCEDURE:,1.  Implantation, dual chamber ICD.,2.  Fluoroscopy.,3.  Defibrillation threshold testing.,4.  Venography.,PROCEDURE NOTE: , After informed consent was obtained, the patient was taken to the operating room.  The patient was prepped and draped in a sterile fashion.  Using modified Seldinger technique, the left subclavian vein was attempted to be punctured but unsuccessfully.  Approximately 10 cc of intravenous contrast was injected into the left upper extremity peripheral vein.  Venogram was then performed.  Under fluoroscopy via modified Seldinger technique, the left subclavian vein was punctured and a guidewire was passed through the vein into the superior vena cava, then the right atrium and then into the inferior vena cava.  A second guidewire was placed in a similar fashion.  Approximately a 5 cm incision was made in the left upper anterior chest.  The skin and subcutaneous tissue was dissected out of the prepectoral fascia.  Both guide wires were brought into the pocket area.  A sheath was placed over the lateral guidewire and fluoroscopically guided to the vena cava.  The dilator and guidewire were removed.  A Fixation ventricular lead, under fluoroscopic guidance, was placed through the sheath into the superior vena cava, right atrium and then right ventricle.  Using straight and curved stylettes, it was placed in position and screwed into the right ventricular apex.  After pacing and sensing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscle with Ethibond suture.  A guide sheath was placed over the guidewire and fluoroscopically placed in the superior vena cava.  The dilator and guidewire were removed.  An Active Fixation atrial lead was fluoroscopically passed through the sheath, into the superior vena cava and then the right atrium.  Using straight and J-shaped stylettes, it was placed in the appropriate position and screwed in the right atrial appendage area.  After significant pacing parameters were established in the lead, the collar on the lead was sutured to the pectoral muscles with Ethibond suture.  The tract was flushed with saline solution.  A Medtronic pulse generator was attached to both the leads and fixed to the pectoral muscle with Ethibond suture.  Deep and superficial layers were closed with 3-0 Vicryl in a running fashion.  Steri-strips were placed over the incision.  Tegaderm was placed over the Steri-strips.  Pressure dressing was applied to the pocket area.surgery, venography, defibrillation threshold testing, venogram, dual chamber icd implantation, dual chamber icd, superior vena cava, seldinger technique, pectoral muscle, steri strips, dual chamber, ethibond suture, superior vena, vena cava, dual, chamber, icd, implantation, fluoroscopy, atrium, pectoral, vein, fluoroscopically, vena, cava, lead, guidewire,