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: EGD Template - 3

Description: Common description of EGD.
(Medical Transcription Sample Report)

The patient was sedated with intravenous fentanyl 75 mcg and intravenous Versed, 5 mg, both titrated over the first ten minutes of the procedure time to achieve adequate sedation for the procedure. Cetacaine spray was applied to the hypopharynx for local anesthesia. The upper endoscope was passed,
without difficulty, into the upper GI tract. The anatomy and mucosa of the esophagus, gastroesophageal junction, stomach, pylorus, and small bowel were all carefully inspected. All structures were visually normal in appearance. Biopsies of the distal duodenum, gastric antrum, and distal esophagus were taken and sent for pathological evaluation. The endoscope and insufflated air were slowly removed from the upper GI tract. A repeat look at the structures involved again showed no visible abnormalities, except for the biopsy sites.

The patient tolerated the procedure with excellent comfort and stable vital signs. After a recovery period in the Endoscopy Suite, the patient is discharged to continue recovering in the family's care at home. The family knows to follow up with me today if there are concerns about the patient's recovery
from the procedure. They will follow up with me later this week for biopsy and CLO test results so that appropriate further diagnostic and therapeutic plans can be made.

Keywords: gastroenterology, gastric antrum, distal duodenum, distal esophagus, esophagus, duodenum, clo test, upper gi tract, upper gi, gi tract, egd, endoscope, gi, tract, structures, distal, biopsy,
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