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: Gastroscopy

Description: Esophagitis, minor stricture at the gastroesophageal junction, hiatal hernia. Otherwise normal upper endoscopy to the transverse duodenum.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSES: Dysphagia and esophageal spasm.

POSTOPERATIVE DIAGNOSES: Esophagitis and esophageal stricture.

PROCEDURE: Gastroscopy.

MEDICATIONS: MAC.

DESCRIPTION OF PROCEDURE: The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum, to the third portion of the duodenum. The hypopharynx was normal and the upper esophageal sphincter was unremarkable. The esophageal contour was normal, with the gastroesophageal junction located at 38 cm from the incisors. At this point, there were several linear erosions and a sense of stricturing at 38 cm. Below this, there was a small hiatal hernia with the hiatus noted at 42 cm from the incisors. The mucosa within the hernia was normal. The gastric lumen was normal with normal mucosa throughout. The pylorus was patent permitting passage of the scope into the duodenum, which was normal through the third portion. During withdrawal of the scope, additional views were obtained of the cardia, confirming the presence of a small hiatal hernia. It was decided to attempt dilation of the strictured area, so an 18-mm TTS balloon was placed across the stricture and inflated to the recommended diameter. When the balloon was fully inflated, the lumen appeared to be larger than 18 mm diameter, suggesting that the stricture was in fact not a significant one. No stretching of the mucosa took place. The balloon was deflated and the scope was withdrawn. The patient tolerated the procedure well and was sent to the recovery room.

FINAL DIAGNOSES:
1. Esophagitis.
2. Minor stricture at the gastroesophageal junction.
3. Hiatal hernia.
4. Otherwise normal upper endoscopy to the transverse duodenum.

RECOMMENDATIONS: Continue proton pump inhibitor therapy.

Keywords: surgery, duodenum, esophagus, gastroscope, stomach, upper endoscopy, transverse duodenum, gastroesophageal junction, hiatal hernia, gastroscopy, endoscopy, esophagitis, gastroesophageal, hiatal, esophageal, hernia,
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