Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Endoscopic Ultrasound Using Color Doppler MT Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Pancreatic cancer.

POSTOPERATIVE DIAGNOSES:
1.  A 3.8 x 2.4 cm head of pancreas mass.
2.  Dilated pancreatic duct in the head and tail of pancreas.
3.  Gallbladder sludge.
4.  Common bile duct stent in place.
5.  No obvious celiac lymphadenopathy.

PROCEDURE PERFORMED:
Endoscopic ultrasound using color Doppler flow.

PHYSICIAN:  John Doe, MD

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old woman with a history of pancreatic cancer. Endoscopic ultrasound is being performed for staging purposes. The risks, benefits, and alternatives to the procedure were explained including but not limited to infection, bleeding, aspiration, perforation, adverse medication reaction, missed diagnosis, and missed lesions. The patient verbalized understanding and signed the informed consent form.

DESCRIPTION OF PROCEDURE:  The patient was placed in the left lateral decubitus position and given incremental doses of propofol, fentanyl and Versed. The procedure was performed using the Olympus GF-UE160 radial echoendoscope. The oropharynx was sprayed with topical anesthesia through a bite-block.

The echoendoscope was inserted through the oropharynx, esophagus intubated, then advanced to the transgastric level of 46 cm at which point the celiac artery take-off was identified. There was no adjacent lymphadenopathy. At the transgastric level at 44 cm, the body and tail of pancreas was identified. At the body of the pancreas, the pancreatic duct measured in maximal dimension 0.6 cm and tail of pancreas was also dilated at 0.2 cm. The pancreas at these sites was somewhat lobulated in appearance, consistent with inflammation. The visualized left kidney appeared normal. Spleen was visualized and also appeared normal. In the antrum of the stomach, the gallbladder was filled with sludge and was somewhat thickened in appearance. The common bile duct stent was identified and surrounding the stent was a mass in the head of the pancreas measuring a maximum dimension of 3.8 x 2.4 cm in size. It abutted the portal vein but did not appear to involve within it. There was also a plane between this lesion and the superior mesenteric vein. There was no adjacent paraduodenal lymphadenopathy. The uncinate process appeared normal as well as the ampullary region. The visualized portion of the liver appeared normal.

Air was then withdrawn and the echoendoscope was removed. The patient tolerated the procedure well. There were no immediate postoperative complications. The patient’s vital signs were monitored throughout the procedure and remained stable.

CONCLUSION:  The patient is a (XX)-year-old woman with pancreatic cancer. Endoscopic ultrasound today shows a 3.8 x 2.4 cm mass in the head of the pancreas that abuts the portal vein but does not appear to be invading it nor does it appear to involve the superior mesenteric vein. There is no celiac lymphadenopathy. Endoscopic ultrasound stages as a T2N0Mx lesion.