Sample Type / Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy with Biopsies - 1
Esophagogastroduodenoscopy with gastric biopsies. Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.
(Medical Transcription Sample Report)
Esophagogastroduodenoscopy with gastric biopsies.INDICATION:
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:
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.
surgery, gastric biopsies, duodenal erythema, inflammatory polyp, pyloric channel tissue, pyloric channel, esophagogastroduodenoscopy, pyloric, duodenal, duodenum, polypoid,
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