smoh/medical-transcriptions huggingface dataset:
Colonoscopy - 17  ( Gastroenterology)
Description:  Universal diverticulosis and nonsurgical internal hemorrhoids. Total colonoscopy with photos.  The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.

PREOPERATIVE DIAGNOSIS: , Colon polyps.,POSTOPERATIVE DIAGNOSES:,1.  Universal diverticulosis.,2.  Nonsurgical internal hemorrhoids.,PROCEDURE PERFORMED:, Total colonoscopy with photos.,ANESTHESIA:,  Demerol 100 mg IV with Versed 3 mg IV.,SPECIMENS: , None.,ESTIMATED BLOOD LOSS: , Minimal.,INDICATIONS FOR PROCEDURE:  ,The patient is a 62-year-old white male who presents to the office with a history of colon polyps and need for recheck.,PROCEDURE:,  Informed consent was obtained.  All risks and benefits of the procedure were explained and all questions were answered.  The patient was brought back to the Endoscopy Suite where he was connected to cardiopulmonary monitoring.  Demerol 100 mg IV and Versed 3 mg IV was given in a titrated fashion until appropriate anesthesia was obtained.  Upon appropriate anesthesia, a digital rectal exam was performed, which showed no masses.  The colonoscope was then placed into the anus and the air was insufflated.  The scope was then advanced under direct vision into the rectum, rectosigmoid colon, descending colon, transverse colon, ascending colon until it reached the cecum.  Upon entering the sigmoid colon and throughout the rest of the colon, there was noted diverticulosis.  After reaching the cecum, the scope was fully withdrawn visualizing all walls again noting universal diverticulosis.,Upon reaching the rectum, the scope was then retroflexed upon itself and there was noted to be nonsurgical internal hemorrhoids.  The scope was then subsequently removed.  The patient tolerated the procedure well and there were no complications.
Colonoscopy - 18  ( Gastroenterology)
Description:  Possible inflammatory bowel disease.  Polyp of the sigmoid colon..  Total colonoscopy with photography and polypectomy.

PREOPERATIVE DIAGNOSIS: , Possible inflammatory bowel disease.,POSTOPERATIVE DIAGNOSIS: , Polyp of the sigmoid colon.,PROCEDURE PERFORMED:  ,Total colonoscopy with photography and polypectomy.,GROSS FINDINGS: , The patient had a history of ischiorectal abscess.  He has been evaluated now for inflammatory bowel disease.  Upon endoscopy, the colon prep was good.  We were able to reach the cecum without difficulty.  There are no diverticluli, inflammatory bowel disease, strictures, or obstructing lesions.  There was a pedunculated polyp approximately 4.5 cm in size located in the sigmoid colon at approximately 35 cm.  This large polyp was removed using the snare technique.,OPERATIVE PROCEDURE:  ,The patient was taken to the endoscopy suite, prepped and draped in left lateral decubitus position.  IV sedation was given by Anesthesia Department.  The Olympus videoscope was inserted into anus.  Using air insufflation, the colonoscope was advanced through the anus to the rectum, sigmoid colon, descending colon, transverse colon, ascending colon and cecum, the above gross findings were noted.  The colonoscope was slowly withdrawn and carefully examined the lumen of the bowel.  When the polyp again was visualized, the snare was passed around the polyp.  It required at least two to three passes of the snare to remove the polyp in its totality.  There was a large stalk on the polyp.  ________ the polyp had been removed down to the junction of the polyp in the stalk, which appeared to be cauterized and no residual adenomatous tissue was present.  No bleeding was identified.  The colonoscope was then removed and patient was sent to recovery room in stable condition.
Colonoscopy - 14  ( Gastroenterology)
Description:  Colonoscopy. History of colon polyps and partial colon resection, right colon.  Mild diverticulosis of the sigmoid colon.  Hemorrhoids.

PREPROCEDURE DIAGNOSIS: , History of colon polyps and partial colon resection, right colon.,POSTPROCEDURE DIAGNOSES:  ,1. Normal operative site.  ,2. Mild diverticulosis of the sigmoid colon.  ,3. Hemorrhoids.,PROCEDURE:  ,Total colonoscopy.,PROCEDURE IN DETAIL:  ,The patient is a 60-year-old of Dr. ABC's being evaluated for the above.  The patient also apparently had an x-ray done at the Hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed.  She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push.  Digital rectal exam was done, unremarkable.  At that point, the Pentax video colonoscope was inserted.  The rectal vault appeared normal.  The sigmoid showed diverticula throughout, mild to moderate in nature.  The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized.  The scope was passed a short distance up the ileum, which appeared normal.  The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area.  The scope was then retroflexed, and anal verge visualized showed some hemorrhoids.  The scope was then removed.  The patient tolerated the procedure well.,RECOMMENDATIONS:  ,Repeat colonoscopy in three years.
Colonoscopy - 2  ( Gastroenterology)
Description:  Colonoscopy in a patient with prior history of anemia and abdominal bloating.

PREOPERATIVE DIAGNOSES:,  Prior history of anemia, abdominal bloating.,POSTOPERATIVE DIAGNOSIS:,  External hemorrhoids, otherwise unremarkable colonoscopy.,PREMEDICATIONS:,  Versed 5 mg, Demerol 50 mg IV.,REPORT OF PROCEDURE:,  Digital rectal exam revealed external hemorrhoids.  The colonoscope was inserted into the rectal ampulla and advanced to the cecum.  The position of the scope within the cecum was verified by identification of the appendiceal orifice.  The cecum, the ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, and rectum were normal.  The scope was retroflexed in the rectum and no abnormality was seen.  So the scope was straightened, withdrawn, and the procedure terminated.,ENDOSCOPIC IMPRESSION:,1.  Normal colonoscopy.,2.  External hemorrhoids.
Colonoscopy - 16  ( Gastroenterology)
Description:  Colonoscopy.   Rectal bleeding and perirectal abscess.  Normal colonoscopy to the terminal ileum.  Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.

PROCEDURE: , Colonoscopy.,PREOPERATIVE DIAGNOSES: , Rectal bleeding and perirectal abscess.,POSTOPERATIVE DIAGNOSIS: , Perianal abscess.,MEDICATIONS:,  MAC.,DESCRIPTION OF PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  The preparation was excellent and all surfaces were well seen.  The mucosa throughout the colon and in the terminal ileum was normal, with no evidence of colitis.  Special attention was paid to the rectum, including retroflexed views of the distal rectum and the anorectal junction.  There was no evidence of either inflammation or a fistulous opening.  The scope was withdrawn.  A careful exam of the anal canal and perianal area demonstrated a jagged 8-mm opening at the anorectal junction posteriorly (12 o'clock position).  Some purulent material could be expressed through the opening.  There was no suggestion of significant perianal reservoir of inflamed tissue or undrained material.  Specifically, the posterior wall of the distal rectum and anal canal were soft and unremarkable.  In addition, scars were noted in the perianal area.  The first was a small dimpled scar, 1 cm from the anal verge in the 11 o'clock position.  The second was a dimpled scar about 5 cm from the anal verge on the left buttock's cheek.  There were no other abnormalities noted.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Normal colonoscopy to the terminal ileum.,2.  Opening in the skin at the external anal verge, consistent with drainage from a perianal abscess, with no palpable abscess at this time, and with no evidence of fistulous connection to the bowel lumen.,RECOMMENDATIONS:,1.  Continue antibiotics.,2.  Followup with Dr. X.,3.  If drainage persists, consider surgical drainage.
Colonoscopy - 13  ( Gastroenterology)
Description:  History of polyps.  Total colonoscopy and photography.  Normal colonoscopy, left colonic diverticular disease.  3+ benign prostatic hypertrophy.

PREOPERATIVE DIAGNOSIS: , History of polyps.,POSTOPERATIVE DIAGNOSES:,1.  Normal colonoscopy, left colonic diverticular disease.,2.  3+ benign prostatic hypertrophy.,PROCEDURE PERFORMED: , Total colonoscopy and photography.,GROSS FINDINGS: , This is a 74-year-old white male here for recheck colonoscopy for a history of polyps.  After signed informed consent, blood pressure monitoring, EKG monitoring, and pulse oximetry monitoring, he was brought to the Endoscopic Suite.  He was given 100 mg of Demerol, 3 mg of Versed IV push slowly.  Digital examination revealed a large prostate for which he is following up with his urologist.  No nodules.  3+ BPH.  Anorectal canal was within normal limits.  No stricture tumor or ulcer.  The Olympus CF 20L video endoscope was inserted per anus.  The anorectal canal was visualized, was normal.  The sigmoid, descending, splenic, and transverse showed scattered diverticula.  The hepatic, ascending, cecum, and ileocecal valve was visualized and was normal.  The colonoscope was removed.  The air was aspirated.  The patient was discharged with high-fiber, diverticular diet.  Recheck colonoscopy three years.
Colonoscopy - 15  ( Gastroenterology)
Description:  Colonoscopy.  Change in bowel habits and rectal prolapse.  Normal colonic mucosa to the cecum.  

PROCEDURE:,  Colonoscopy.,PREOPERATIVE DIAGNOSES: , Change in bowel habits and rectal prolapse.,POSTOPERATIVE DIAGNOSIS: , Normal colonoscopy.,PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced through the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice.  The preparation was poor, but mucosa was visible after lavage and suction.  Small lesions might have been missed in certain places, but no large lesions are likely to have been missed.  The mucosa was normal, was visualized.  In particular, there was no mucosal abnormality in the rectum and distal sigmoid, which is reported to be prolapsing.  Biopsies were taken from the rectal wall to look for microscopic changes.  The anal sphincter was considerably relaxed, with no tone and a gaping opening.  The patient tolerated the procedure well and was sent to recovery room.,FINAL DIAGNOSIS: , Normal colonic mucosa to the cecum.  No contraindications to consideration of a repair of the prolapse.
Colon Cancer Screening  ( Gastroenterology)
Description:  Routine colorectal cancer screening.  He occasionally gets some loose stools.  

HISTORY AND REASON FOR CONSULTATION:, For evaluation of this patient for colon cancer screening.,HISTORY OF PRESENT ILLNESS:, Mr. A is a 53-year-old gentleman who was referred for colon cancer screening.  The patient said that he occasionally gets some loose stools.  Other than that, there are no other medical problems. ,PAST MEDICAL HISTORY:, The patient does not have any serious medical problems at all.  He denies any hypertension, diabetes, or any other problems.  He does not take any medications.,PAST SURGICAL HISTORY: ,Surgery for deviated nasal septum in 1996.,ALLERGIES:, No known drug allergies.,SOCIAL HISTORY: ,Does not smoke, but drinks occasionally for the last five years.,FAMILY HISTORY:, There is no history of any colon cancer in the family.,REVIEW OF SYSTEMS:, Denies any significant diarrhea.  Sometimes he gets some loose stools.  Occasionally there is some constipation.  Stools caliber has not changed.  There is no blood in stool or mucus in stool.  No weight loss.  Appetite is good.  No nausea, vomiting, or difficulty in swallowing.  Has occasional heartburn.,PHYSICAL EXAMINATION:, The patient is alert and oriented x3.  Vital signs: Weight is 214 pounds.  Blood pressure is 111/70.  Pulse is 69 per minute.  Respiratory rate is 18.  HEENT: Negative.  Neck: Supple.  There is no thyromegaly.  Cardiovascular: Both heart sounds are heard.  Rhythm is regular.  No murmur.  Lungs: Clear to percussion and auscultation.  Abdomen: Soft and nontender.  No masses felt.  Bowel sounds are heard.  Extremities: Free of any edema.,IMPRESSION: ,Routine colorectal cancer screening.,RECOMMENDATIONS:, Colonoscopy.  I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection.  The patient agreed for it.  We will proceed with it.  I also explained to the patient about conscious sedation.  He agreed for conscious sedation.
Colonoscopy - 10  ( Gastroenterology)
Description:  Colon cancer screening and family history of polyps.  Sigmoid diverticulosis and internal hemorrhoids.

PREOPERATIVE DIAGNOSES: , Colon cancer screening and family history of polyps.,POSTOPERATIVE DIAGNOSIS:,  Colonic polyps.,PROCEDURE:,  Colonoscopy.,ANESTHESIA:,  MAC,DESCRIPTION OF PROCEDURE:  ,The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum.  The preparation was excellent and all surfaces were well seen.  The mucosa was normal throughout the colon and in the terminal ileum.  Two polyps were identified and were removed.  The first was a 7-mm sessile lesion in the mid transverse colon at 110 cm, removed with the snare without cautery and retrieved.  The second was a small 4-mm sessile lesion in the sigmoid colon at 20 cm also removed with the snare and retrieved.  No other lesions were identified.  Numerous diverticula were found in the sigmoid colon.  A retroflex through the anorectal junction showed moderate internal hemorrhoids.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Sigmoid diverticulosis.,2.  Colonic polyps in the transverse colon and sigmoid colon, benign appearance, removed.,3.  Internal hemorrhoids.,4.  Otherwise normal colonoscopy to the terminal ileum.,RECOMMENDATIONS:,1.  Follow up biopsy report.,2.  Follow up with Dr. X as needed.,3.  Screening colonoscopy in 5 years.
Colonoscopy - 12  ( Gastroenterology)
Description:  Colonoscopy.  The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum. 

PROCEDURE IN DETAIL: , Following instructions and completion of an oral colonoscopy prep, the patient, having been properly informed of, with signature consenting to total colonoscopy and indicated procedures, the patient received premedications of Vistaril 50 mg, Atropine 0.4 mg IM, and then intravenous medications of Demerol 50 mg and Versed 5 mg IV.  Perirectal inspection was normal.  The Olympus video colonoscope then was introduced into the rectum and passed by directed vision to the cecum and into the terminal ileum.  No abnormalities were seen of the terminal ileum, the ileocecal valve, cecum, ascending colon, hepatic flexure, transverse colon, splenic flexure, descending colon, rectosigmoid and rectum.  Retroflexion exam in the rectum revealed no other abnormality and withdrawal terminated the procedure.
Colonoscopy - 11  ( Gastroenterology)
Description:  Colonoscopy.  The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum. 

MEDICATIONS:,1.  Versed intravenously.,2.  Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent was obtained, the patient was placed in the left lateral decubitus position and sedated with the above medications.  The Olympus video colonoscope was inserted through the anus and was advanced in retrograde fashion through the sigmoid colon, descending colon, around the splenic flexure, into the transverse colon, around the hepatic flexure, down the ascending colon, into the cecum.  The cecum was identified by the presence of the appendiceal orifice and the ileocecal valve.  The colonoscope was then advanced through the ileocecal valve into the terminal ileum, which was normal on examination.  The scope was then pulled back into the cecum and then slowly withdrawn.  The mucosa was examined in detail.  The mucosa was entirely normal.  Upon reaching the rectum, retroflex examination of the rectum was normal.  The scope was then straightened out, the air removed and the scope withdrawn.  The patient tolerated the procedure well.  There were no apparent complications.,
Clostridium Difficile Colitis Followup  ( Gastroenterology)
Description:  Still having diarrhea, decreased appetite.

SUBJECTIVE:  ,The patient seen and examined feels better today.  Still having diarrhea, decreased appetite.  Good urine output 600 mL since 7 o'clock in the morning.  Afebrile.,PHYSICAL EXAMINATION,GENERAL:  Nonacute distress, awake, alert, and oriented x3.,VITAL SIGNS:  Blood pressure 102/64, heart rate of 89, respiratory rate of 12, temperature 96.8, and O2 saturation 94% on room air.,HEENT:  PERRLA, EOMI.,NECK:  Supple.,CARDIOVASCULAR:  Regular rate and rhythm.,RESPIRATORY:  Clear to auscultation bilaterally.,ABDOMEN:  Bowel sounds are positive, soft, and nontender. EXTREMITIES:  No edema.  Pulses present bilaterally.,LABORATORY DATA:  ,CBC, WBC count today down 10.9 from 17.3 yesterday 26.9 on admission, hemoglobin 10.2, hematocrit 31.3, and platelet count 370,000.  BMP, BUN of 28.3 from 32.2, creatinine 1.8 from 1.89 from 2.7.  Calcium of 8.2.  Sodium 139, potassium 3.9, chloride 108, and CO2 of 22.  Liver function test is unremarkable.,Stool positive for Clostridium difficile.  Blood culture was 131.  O2 saturation result is pending.,ASSESSMENT AND PLAN:,1.  Most likely secondary to Clostridium difficile colitis and urinary tract infection improving.  The patient hemodynamically stable, leukocytosis improved and today he is afebrile.,2.  Acute renal failure secondary to dehydration, BUN and creatinine improving.,3.  Clostridium difficile colitis, Continue Flagyl, evaluation Dr. X in a.m.,4.  Urinary tract infection, continue Levaquin for last during culture.,5.  Leucocytosis, improving.,6.  Minimal elevated cardiac enzyme on admission.  Followup with Cardiology recommendations.,7.  Possible pneumonia, continue vancomycin and Levaquin.,8.  The patient may be transferred to telemetry.
Colonoscopy - 1  ( Gastroenterology)
Description:  Colonoscopy due to rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.

INDICATION: ,  Rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.,PREMEDICATION: ,See procedure nurse NCS form.,PROCEDURE:  ,
Colon Polyps - Genetic Counseling  ( Gastroenterology)
Description:  Genetic counseling for a strong family history of colon polyps.  She has had colonoscopies required every five years and every time she has polyps were found.  She reports that of her 11 brothers and sister 7 have had precancerous polyps.  

REASON FOR CONSULT: , Genetic counseling.,HISTORY OF PRESENT ILLNESS: , The patient is a very pleasant 61-year-old female with a strong family history of colon polyps.  The patient reports her first polyps noted at the age of 50.  She has had colonoscopies required every five years and every time she has polyps were found.  She reports that of her 11 brothers and sister 7 have had precancerous polyps.  She does have an identical twice who is the one of the 11 who has never had a history of polyps.  She also has history of several malignancies in the family.  Her father died of a brain tumor at the age of 81.  There is no history of knowing whether this was a primary brain tumor or whether it is a metastatic brain involvement.  Her sister died at the age of 65 breast cancer.  She has two maternal aunts with history of lung cancer both of whom were smoker.  Also a paternal grandmother who was diagnosed with breast cancer at 86 and a paternal grandfather who had lung cancer.  There is no other cancer history.,PAST MEDICAL HISTORY:,  Significant for asthma.,CURRENT MEDICATIONS: , Include Serevent two puffs daily and Nasonex two sprays daily.,ALLERGIES: , Include penicillin.  She is also allergic seafood; crab and mobster.,SOCIAL HISTORY: , The patient is married.  She was born and raised in South Dakota.  She moved to Colorado 37 years ago.  She attended collage at the Colorado University.  She is certified public account.  She does not smoke.  She drinks socially.,REVIEW OF SYSTEMS:  ,The patient denies any dark stool or blood in her stool.  She has had occasional night sweats and shortness of breath, and cough associated with her asthma.  She also complains of some acid reflux as well as anxiety.  She does report having knee surgery for torn ACL on the left knee and has some arthritis in that knee.  The rest of her review of systems is negative.,PHYSICAL EXAM:,VITALS:
Colonoscopy  ( Gastroenterology)
Description:  Iron deficiency anemia.  Diverticulosis in the sigmoid.

PREOPERATIVE DIAGNOSIS:,  Iron deficiency anemia.,POSTOPERATIVE DIAGNOSIS:,  Diverticulosis.,PROCEDURE:,  Colonoscopy.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon to the cecum identified by the ileocecal valve and the appendiceal orifice.  Preparation was good, although there was some residual material in the cecum that was difficult to clear completely.  The mucosa was normal throughout the colon.  No polyps or other lesions were identified, and no blood was noted.  Some diverticula were seen of the sigmoid colon with no luminal narrowing or evidence of inflammation.  A retroflex view of the anorectal junction showed no hemorrhoids.  The patient tolerated the procedure well and was sent to the recovery room.,FINAL DIAGNOSES:,1.  Diverticulosis in the sigmoid.,2.  Otherwise normal colonoscopy to the cecum.,RECOMMENDATIONS:,1.  Follow up with Dr. X as needed.,2.  Screening colonoscopy in 2 years.,3.  Additional evaluation for other causes of anemia may be appropriate.
Cholecystostomy Tube Placement  ( Gastroenterology)
Description:  Placement of cholecystostomy tube under ultrasound guidance.  Acute acalculous cholecystitis.

PREOPERATIVE DIAGNOSIS:,  Acute acalculous cholecystitis.,POSTOPERATIVE DIAGNOSIS: , Acute acalculous cholecystitis.,PROCEDURE:,  Placement of cholecystostomy tube under ultrasound guidance.,ANESTHESIA: , Xylocaine 1% With Epinephrine.,INDICATIONS: , Patient is a pleasant 75-year-old gentleman who is about one week status post an acute MI who also has acute cholecystitis.  Because it is not safe to take him to the operating room for general anesthetic, I recommended he undergo the above-named procedure.  Procedure, purpose, risks, expected benefits, potential complications, and alternative forms of therapy were discussed with him and he was agreeable to surgery.,TECHNIQUE: , Patient was identified, then taken to the Radiology suite, where the area of interest was identified using ultrasound and prepped with Betadine solution, draped in sterile fashion.  After infiltration with 1% Xylocaine and after multiple attempts, the gallbladder was finally cannulated by Dr. Kindred using the Cook 18-French needle.  The guidewire was then placed and via Seldinger technique, a 10-French pigtail catheter was placed within the gallbladder, secured using the Cook catheter method, and dressings were applied and patient was taken to recovery room in stable condition.