Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Surgery
Sample Name: Esophagogastroduodenoscopy

Description: Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia
(Medical Transcription Sample Report)

PROCEDURE: Esophagogastroduodenoscopy with biopsy and snare polypectomy.

INDICATION FOR THE PROCEDURE: Iron-deficiency anemia.

MEDICATIONS: MAC.

The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration.

PROCEDURE: After informed consent and appropriate sedation, the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum. The duodenal mucosa was completely normal. The pylorus was normal. In the stomach, there was evidence of diffuse atrophic-appearing nodular gastritis. Multiple biopsies were obtained. There also was a 1.5-cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum. There was mild ulceration on the tip of this polyp. It was decided to remove the polyp via snare polypectomy. Retroflexion was performed, and this revealed a small hiatal hernia in the distal esophagus. The Z-line was identified and was unremarkable. The esophageal mucosa was normal.

FINDINGS:
1. Hiatal hernia.
2. Diffuse nodular and atrophic appearing gastritis, biopsies taken.
3. A 1.5-cm polyp with ulceration along the greater curvature, removed.

RECOMMENDATIONS:
1. Follow up biopsies.
2. Continue PPI.
3. Hold Lovenox for 5 days.
4. Place SCDs.

Keywords: surgery, esophagogastroduodenoscopy, iron-deficiency, iron-deficiency anemia, anemia, biopsy, endoscope, esophageal mucosa, esophagus, hiatal hernia, polypectomy, snare polypectomy, esophagogastroduodenoscopy with biopsy, iron deficiency anemia,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are 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 been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples