Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy with Biopsies - 1

Description: 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)

PROCEDURE: Esophagogastroduodenoscopy with gastric biopsies.

INDICATION: Abdominal pain.

FINDINGS: 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: GIF-Q180.

PROCEDURE DETAIL: 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.

Keywords: gastroenterology, gastric biopsies, duodenal erythema, inflammatory polyp, pyloric channel tissue, pyloric channel, esophagogastroduodenoscopy, pyloric, duodenal, duodenum, polypoid,
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