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EGD with Cold Forceps Biopsy Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  History of Crohn's disease with a recent colonoscopy done, which was negative.
2.  Continued epigastric pain.
3.  New onset constipation.
4.  Occasional rectal bleeding.

POSTOPERATIVE DIAGNOSES:
1.  Mild antral gastritis.
2.  Gastric polyp in the proximal body.
3.  Irregular-appearing squamocolumnar junction.

PROCEDURE PERFORMED:
Esophagogastroduodenoscopy with cold forceps biopsy.

SEDATION:  Monitored anesthesia care per the anesthesiology department.

DESCRIPTION OF PROCEDURE:  The risks and benefits of the procedure were discussed in detail with the patient and all questions were answered in the clinic. An informed consent was then obtained.

The patient was placed in the left lateral decubitus position and sedated as outlined above. The video endoscope was then inserted through the mouth and advanced to the second portion of the duodenum under direct visualization without any difficulty. Duodenoscopy revealed a normal-appearing postbulbar duodenum as well as duodenal bulb. The scope was then withdrawn to the stomach. The gastroscopy revealed linear antral erythema and a few superficial erosions consistent with mild antral gastritis. Multiple antral biopsies were obtained for histopathology to rule out Helicobacter pylori infection. The remainder of the visualized mucosa in the distal gastric body appeared grossly normal. Retroflexion revealed a normal-appearing angularis as well as gastritic cardia and fundus. There was no evidence of a hiatal hernia. A small 3 mm polyp was noted in the proximal gastric body. This was biopsied with cold forceps. The scope was then withdrawn through the distal esophagus. The squamocolumnar junction was at approximately 38 cm and appeared slightly irregular. Biopsies were obtained to rule out short-segment Barrett's esophagus.

Air was then removed from the patient's stomach and the scope was then withdrawn. The patient tolerated the procedure well. There were no apparent complications noted.

IMPRESSION:
1.  Mild antral gastritis.
2.  Gastric polyp.
3.  Irregular-appearing squamocolumnar junction.

RECOMMENDATIONS:  Will follow up on the biopsy result. If there is any evidence of a Helicobacter pylori infection, will initiate triple-based therapy. If the distal esophageal biopsies reveal Barrett's esophagus with no dysplasia, the patient will need a repeat surveillance esophagogastroduodenoscopy in 2 to 3 years. Will prescribe the patient Carafate to see if this improves her epigastric pain and will also order an ultrasound of the liver and gallbladder to rule out biliary causes of her pain.  Advise the patient to call my office in 1 week to get the biopsy results and to hold all aspirin and NSAID products for 10 days. The patient should followup with her primary care physician on her routinely scheduled appointment and she can follow up with me in 4 to 6 weeks for followup visit.

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DESCRIPTION OF PROCEDURE:  The risks and benefits of the procedure were discussed in detail with the patient, all questions were answered, and informed consent was then obtained. The video endoscope was inserted through the mouth and advanced to the descending portion of the duodenum under direct visualization without any difficulty. Duodenoscopy revealed a normal-appearing postbulbar duodenum as well as duodenal bulb. The scope was then dropped to the stomach. Gastroscopy revealed a normal-appearing antrum as well as distal gastric body. Retroflexion revealed a normal-appearing angularis as well as gastric cardia, fundus, and proximal gastric body. There was no evidence of a hiatal hernia. The scope was then withdrawn to the distal esophagus. The squamocolumnar junction was mildly irregular at approximately 45 cm. Multiple biopsies were obtained to rule out short-segment Barrett esophagus. The remainder of the esophageal mucosa appeared grossly normal. I tried to visualize the pharynx to the best of my ability. Limited visualization revealed no gross abnormalities. Air was then removed from the patient's stomach. The scope was then withdrawn. The patient tolerated the procedure well. There were no apparent complications noted.