Medical Specialty:

Sample Name: Esophagogastroduodenoscopy - 11

Description: Esophagogastroduodenoscopy with bile aspirate. Recurrent right upper quadrant pain with failure of antacid medical therapy. Normal esophageal gastroduodenoscopy.
(Medical Transcription Sample Report)

PREOPERATIVE DIAGNOSIS: Recurrent right upper quadrant pain with failure of antacid medical therapy.

POSTOPERATIVE DIAGNOSIS: Normal esophageal gastroduodenoscopy.

PROCEDURE PERFORMED: Esophagogastroduodenoscopy with bile aspirate.

ANESTHESIA: IV Demerol and Versed in titrated fashion.

INDICATIONS: This 41-year-old female presents to surgical office with history of recurrent right upper quadrant abdominal pain. Despite antacid therapy, the patient's pain has continued. Additional findings were concerning with possibility of a biliary etiology. The patient was explained the risks and benefits of an EGD as well as a Meltzer-Lyon test where upon bile aspiration was performed. The patient agreed to the procedure and informed consent was obtained.

GROSS FINDINGS: No evidence of neoplasia, mucosal change, or ulcer on examination. Aspiration of the bile was done after the administration of 3 mcg of Kinevac.

PROCEDURE DETAILS: The patient was placed in the supine position. After appropriate anesthesia was obtained, an Olympus gastroscope inserted from the oropharynx through the second portion of duodenum. Prior to this, 3 mcg of IV Kinevac was given to the patient to aid with the stimulation of bile. At this time, the patient as well complained of epigastric discomfort and nausea. This pain was similar to her previous pain.

Bile was aspirated with a trap to enable the collection of the fluid. This fluid was then sent to lab for evaluation for crystals. Next, photodocumentation obtained and retraction of the gastroscope through the antrum revealed no other evidence of disease, retroflexion revealed no evidence of hiatal hernia or other mass and after straightening the scope and aspiration ________, gastroscope was retracted. The gastroesophageal junction was noted at 20 cm. No other evidence of disease was appreciated here. Retraction of the gastroscope backed through the esophagus, off the oropharynx, removed from the patient. The patient tolerated the procedure well. We will await evaluation of bile aspirate.

Keywords: surgery, bile aspirate, esophageal, gastroduodenoscopy, kinevac, oropharynx, esophagogastroduodenoscopy, gastroscope,