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 - 10

Description: Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps. Nausea and vomiting and upper abdominal pain.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Nausea and vomiting and upper abdominal pain.

POST PROCEDURE DIAGNOSIS: Normal upper endoscopy.

OPERATION: Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.

ANESTHESIA: IV sedation 50 mg Demerol, 8 mg of Versed.

PROCEDURE: The patient was taken to the endoscopy suite. After adequate IV sedation with the above medications, hurricane was sprayed in the mouth as well as in the esophagus. A bite block was placed and the gastroscope placed into the mouth and was passed into the esophagus and negotiated through the esophagus, stomach, and pylorus. The first, second, and third portions of the duodenum were normal. The scope was withdrawn into the antrum which was normal and two bites with the biopsy forceps were taken in separate spots for H. pylori. The scope was retroflexed which showed a normal GE junction from the inside of the stomach and no evidence of pathology or paraesophageal hernia. The scope was withdrawn at the GE junction which was in a normal position with a normal transition zone. The scope was then removed throughout the esophagus which was normal. The patient tolerated the procedure well.

The plan is to obtain a HIDA scan as the right upper quadrant ultrasound appeared to be normal, although previous ultrasounds several years ago showed a gallstone.

Keywords: surgery, h. pylori, forceps, antral biopsies, ge junction, esophagogastroduodenoscopy, pylori, esophagus, antral,
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