falan42/nurse_detection huggingface dataset:
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.surgery, portoenterostomy, foreign body removal, proximal esophagus, coin, esophagoscopy, esophageal, esophagus,
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.surgery, antral, polyps, gastrostomy, endoscopic gastrostomy, hiatal hernia, abdominal wall, gastrostomy tube, esophagogastroduodenoscopy, malnutrition, dysphagia, abdominal
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.surgery, 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 - 7 

PREOPERATIVE DIAGNOSIS:,  Positive peptic ulcer disease.,POSTOPERATIVE DIAGNOSIS:,  Gastritis.,PROCEDURE PERFORMED: , Esophagogastroduodenoscopy with photography and biopsy.,GROSS FINDINGS:,  The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.,Upon endoscopy, gastroesophageal junction was at 40 cm, no esophageal tumor, varices, strictures, masses, or no reflux esophagitis was noted.  Examination of the stomach reveals mild inflammation of the antrum of the stomach, no ulcers, erosions, tumors, or masses.  The profundus and the cardia of the stomach were unremarkable.  The pylorus was concentric.  The duodenal bulb and sweep with no inflammation, tumors, or masses.,OPERATIVE PROCEDURE: , The patient taken to the Endoscopy Suite, prepped and draped in the left lateral decubitus position.  She was given IV sedation using Demerol and Versed.  Olympus videoscope was inserted in the hypopharynx, upon deglutition passed into the esophagus.  Using air insufflation, the scope was advanced down through the esophagus into the stomach along the greater curvature of the stomach to the pylorus to the duodenal bulb and sweep.  The above gross findings noted.  The panendoscope was withdrawn back from the stomach, deflected upon itself.  The lesser curve fundus and cardiac were well visualized.  Upon examination of these areas, panendoscope was returned to midline.  Photographs and biopsies were obtained of the antrum of the stomach.  Air was aspirated from the stomach and panendoscope was slowly withdrawn carefully examining the lumen of the bowel.,Photographs and biopsies were obtained as appropriate.  The patient is sent to recovery room in stable condition.surgery, antrum, esophageal tumor, varices, strictures, masses, duodenal bulb, peptic ulcer, duodenal, esophagus, esophagogastroduodenoscopy, panendoscope, peptic, inflammation, ulcer, disease, stomach
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.surgery, 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 - 8 

PREOPERATIVE DIAGNOSIS:, Chronic abdominal pain and heme positive stool.,POSTOPERATIVE DIAGNOSES:,1.  Antral gastritis.,2.  Duodenal polyp.,PROCEDURE PERFORMED:,  Esophagogastroduodenoscopy with photos and antral biopsy.,ANESTHESIA: , Demerol and Versed.,DESCRIPTION OF PROCEDURE: , Consent was obtained after all risks and benefits were described.  The patient was brought back into the Endoscopy Suite.  The aforementioned anesthesia was given.  Once the patient was properly anesthetized, bite block was placed in the patient's mouth.  Then, the patient was given the aforementioned anesthesia.  Once he was properly anesthetized, the endoscope was placed in the patient's mouth that was brought down to the cricopharyngeus muscle into the esophagus and from the esophagus to his stomach.  The air was insufflated down.  The scope was passed down to the level of the antrum where there was some evidence of gastritis seen.  The scope was passed into the duodenum and then duodenal sweep where there was a polyp seen.  The scope was pulled back into the stomach in order to flex upon itself and straightened out.  Biopsies were taken for CLO and histology of the antrum.  The scope was pulled back.  The junction was visualized.  No other masses or lesions were seen.  The scope was removed.  The patient tolerated the procedure well.  We will recommend the patient be on some type of a H2 blocker.  Further recommendations to follow.surgery, endoscopy, gastritis, clo, histology, antrum, heme positive stool, esophagogastroduodenoscopy, duodenal, polyp, antral,
Esophagogastroduodenoscopy - 6 

PROCEDURE IN DETAIL: , Following premedication with Vistaril 50 mg and Atropine 0.4 mg IM, the patient received Versed 5.0 mg intravenously after Cetacaine spray to the posterior palate.  The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.  The upper, mid and lower portions of the esophagus; the lesser and greater curves of the stomach; anterior and posterior walls; body and antrum; pylorus; duodenal bulb; and duodenum were all normal.  No evidence of friability, ulceration or tumor mass was encountered.  The instrument was withdrawn to the antrum, and biopsies taken for CLO testing, and then the instrument removed.surgery, cetacaine, pylorus, antrum, duodenum, upper esophagus, esophagogastroduodenoscopy, descending, esophagusNOTE,: 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.,
Esophagogastroduodenoscopy - 5 

MEDICATIONS:,1.  Versed intravenously.,2.  Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent, the patient was placed in the left lateral decubitus position and Cetacaine spray was applied to the posterior pharynx.  The patient was sedated with the above medications.  The Olympus video panendoscope was advanced under direct vision into the esophagus.  The esophagus was normal in appearance and configuration.  The gastroesophageal junction was normal.  The scope was advanced into the stomach, where the fundic pool was aspirated and the stomach was insufflated with air.  The gastric mucosa appeared normal.  The pylorus was normal.  The scope was advanced through the pylorus into the duodenal bulb, which was normal, then into the second part of the duodenum, which was normal as well.  The scope was pulled back into the stomach.  Retroflexed view showed a normal incisura, lesser curvature, cardia and fundus.  The scope was straightened out, the air removed and the scope withdrawn.  The patient tolerated the procedure well.  There were no apparent complications.,surgery, duodenal bulb, gastric mucosa, olympus video, video panendoscope, gastroesophageal junction, esophagogastroduodenoscopy, gastroesophageal, pylorus, stomach, esophagus, scopeNOTE
Esophagogastroduodenoscopy - 13 

PROCEDURE PERFORMED: , Esophagogastroduodenoscopy performed in the emergency department.,INDICATION: , Melena, acute upper GI bleed, anemia, and history of cirrhosis and varices.,FINAL IMPRESSION,1.  Scope passage massive liquid in stomach with some fresh blood near the fundus, unable to identify source due to gastric contents.,2.  Endoscopy following erythromycin demonstrated grade I esophageal varices.  No stigmata of active bleeding.  Small amount of fresh blood within the hiatal hernia.  No definite source of bleeding seen.,PLAN,1.  Repeat EGD tomorrow morning following aggressive resuscitation and transfusion.,2.  Proton-pump inhibitor drip.,3.  Octreotide drip.,4.  ICU bed.,PROCEDURE DETAILS:  ,Prior to the procedure, physical exam was stable.  During the procedure, vital signs remained within normal limits.  Prior to sedation, informed consent was obtained.  Risks, benefits, and alternatives including, but not limited to risk of bleeding, infection, perforation, adverse reaction to medication, failure to identify pathology, pancreatitis, and death explained to the patient and his wife, who accepted all risks.  The patient was prepped in the left lateral position.  IV sedation was given to a total of fentanyl 100 mcg and midazolam 4 mg for the initial EGD.  An additional 50 mcg of fentanyl and 2 mg of midazolam were given following erythromycin.  Scope tip of the Olympus gastroscope was passed into the esophagus.  Proximal, middle, and distal thirds of the esophagus were well visualized.  There was fresh blood in the esophagus, which was washed thoroughly, but no source was seen.  No evidence of varices was seen.  The stomach was entered.  The stomach was filled with very large clot and fresh blood and liquid, which could not be suctioned due to the clot burden.  There was a small amount of bright red blood near the fundus, but a source could not be identified due to the clot burden.  Because of this, the gastroscope was withdrawn.  The patient was given 250 mg of erythromycin in the Emergency Department and 30 minutes later, the scope was repassed.  On the second look, the esophagus was cleared.  The liquid gastric contents were cleared.  There was still a moderate amount of clot burden in the stomach, but no active bleeding was seen.  There was a small grade I esophageal varices, but no stigmata of bleed.  There was also a small amount of fresh blood within the hiatal hernia, but no source of bleeding was identified.  The patient was hemodynamically stable; therefore, a decision was made for a second look in the morning.  The scope was withdrawn and air was suctioned.  The patient tolerated the procedure well and was sent to recovery without immediate complications.surgery, gi bleed, anemia, cirrhosis, stomach, fundus, hiatal hernia, esophagogastroduodenoscopy, erythromycin, varices, esophagus,
Esophagogastroduodenoscopy - 2 

PROCEDURE:,  Esophagogastroduodenoscopy with biopsy.,REASON FOR PROCEDURE:,  The child with history of irritability and diarrhea with gastroesophageal reflux.  Rule out reflux esophagitis, allergic enteritis, and ulcer disease, as well as celiac disease.  He has been on Prevacid 7.5 mg p.o. b.i.d. with suboptimal control of this irritability.,Consent history and physical examinations were performed.  The procedure, indications, alternatives available, and complications i.e. bleeding, perforation, infection, adverse medication reactions, possible need for blood transfusion, and surgery associated complication occur were discussed with the mother who understood and indicated this.  Opportunity for questions was provided and informed consent was obtained.,MEDICATIONS:  ,General anesthesia.,INSTRUMENT: , Olympus GIF-XQ 160.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:,  Less than 5 mL.,FINDINGS: , With the patient in the supine position intubated under general anesthesia, the endoscope was inserted without difficulty into the hypopharynx.  The proximal, mid, and distal esophagus had normal mucosal coloration and vascular pattern.  Lower esophageal sphincter appeared normal and was located at 25 cm from the central incisors.  A Z-line was identified within the lower esophageal sphincter.  The endoscope was advanced into the stomach, which was distended with excess air.  The rugal folds flattened completely.  The gastric mucosa was entirely normal.  No hiatal hernia was seen and the pyloric valve appeared normal.  The endoscope was advanced into first, second, and third portion of the duodenum, which had normal mucosal coloration and fold pattern.  Ampule of Vater was identified and found to be normal.  Biopsies were obtained x2 in the second portion of duodenum, antrum, and distal esophagus at 22 cm from the central incisors for histology.  Additional two antral biopsies were obtained for CLO testing.  Excess air was evacuated from the stomach.  The scope was removed from the patient who tolerated the procedure well.  The patient was taken to recovery room in satisfactory condition.,IMPRESSION:,  Normal esophagus, stomach, and duodenum.,PLAN:,  Histologic evaluation and CLO testing.  Continue Prevacid 7.5 mg p.o. b.i.d.  I will contact the parents next week with biopsy results and further management plans will be discussed at that time.surgery, olympus gif-xq 160, diarrhea, gastroesophageal, esophagitis, reflux, clo testing, esophagogastroduodenoscopy with biopsy, endoscope, esophagus, stomach, duodenum, esophagogastroduodenoscopy