Medical Specialty:

Sample Name: EGD with Dilation

Description: EGD with dilation for dysphagia.
(Medical Transcription Sample Report)

INDICATION: Recurrent dysphagia.

PREMEDICATIONS: See procedure nurse NCS form.

PROCEDURE: Consent PAR conference was held. After signing the informed consent, premedications were given. The patient was placed in the left lateral decubitus position and monitored with blood pressure cuff and pulse oximeter throughout the procedure. Hurricaine spray was placed in the back of the throat. The Olympus endoscope was passed under direct visualization through the cricopharyngeus into the esophageal area. It was passed through the esophagus with identification of the EG junction and into the stomach. A portion of the stomach and the rugal folds were visualized. The scope was passed into the antral area with visualization of the pylorus. The pylorus was cannulated and the duodenal bulb and the second position of the duodenum were visualized. The scope was passed back into the stomach where the cardia, fundus, and lesser curvature were visualized in a retrograde manner. The following findings were noted:

1. The esophagus was significantly tortuous and somewhat shortened with a large hiatal hernia with the EG junction at approximately 30 cm. It was difficult to tell if there was significant narrowing in the esophagus with the significant tortuosity and the scope passing into the stomach. No resistance was noted to the endoscope.
2. The stomach was abnormal with a very large sliding type hiatal hernia.
3. The duodenum was normal.
4. A Savary wire was placed in the antrum and the scope was removed. Positioning the wire by markings, a #14 French dilator was passed without difficulty into the stomach area. There was some resistance to a #16 French dilator, although at that time it had passed to approximately 40 cm and I suspect we were through the EG junction area. This may have been curling in the hiatal hernia, I opted not to use further force to advance the dilator further.

The scope was removed and the patient tolerated the procedure well.

IMPRESSION: Very large hiatal hernia and tortuous esophagus, probably with mild peptic stricture, dilated to #14 French. I may even have gotten the #16 French dilator through, but it was not passed all the way into the stomach area because of some resistance which I suspect was curling in the hiatal hernia.

PLAN: I will have her follow up with my nurse practitioner in approximately 10 days. If her dysphagia is improved, we will simply observe. If she continues to have dysphagia, we will bring her back and attempt to re-dilate her with a #15 French dilator. She will continue Aciphex long term.

Keywords: surgery, egd, hurricaine spray, olympus endoscope, savary wire, cricopharyngeus, decubitus, dilator, duodenum, dysphagia, esophagus, hiatal hernia, peptic, pylorus, stomach, tortuosity, egd with dilation, tortuous, scope, hiatal, hernia,