Over 500 Medical Transcription Sample Reports For Medical Transcriptionists!!

Upper Endoscopy Medical Transcription Sample Report

DATE OF PROCEDURE: MM/DD/YYYY

PREOPERATIVE DIAGNOSIS: Not given.

POSTOPERATIVE DIAGNOSES:
1. Sliding hiatal hernia plus possible short segment Barrett and mild esophagitis.
2. Antral gastritis.
3. Duodenitis.

PROCEDURE PERFORMED:  Pan upper endoscopy and biopsies.

PHYSICIAN:  John Doe, MD

INDICATION: Chronic heartburn with anemia, possibly iron deficiency.

PROCEDURE: Using the Olympus thin video gastroscope under IV sedation in the form of intravenous Diprivan, the patient underwent pan upper endoscopy and biopsies without apparent complications.

FINDINGS: In the esophagus, there was evidence of a sliding hiatal hernia with possible short segment Barrett and esophagitis. This was photographed and biopsies were taken of the distal esophagus. There were no ulcerations or evidence of neoplasms. Stomach showed some gastritis, particularly in the antrum, where they may have been some scar from previous ulcer disease. Biopsies were taken of the antrum as well as a CLOtest. Also showed a small hiatal hernia but no evidence of masses. Duodenal bulb showed duodenitis and it was photographed. No ulcers. The second duodenum appeared normal. A biopsy was taken of the antrum also to rule out the possibility of Helicobacter pylori and a biopsy of the gastritis site. He tolerated the procedure well.

IMPRESSION:
1. Sliding hiatal hernia, possible short segment Barrett.
2. Antral gastritis.
3. Duodenitis.

PLAN: Continue Aciphex 20 mg a day. The patient is to have an anemia workup including iron, total iron binding capacity, B12, folic acid level and hemoglobin electrophoresis because of the possibility of iron deficiency versus thalassemia minor on his labs. He is also to have an alkaline phosphatase and a GGTP.

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Early satiety.
2.  Weight loss.
3.  Abnormal gastric folds on CT scan.

POSTOPERATIVE DIAGNOSIS:
Grade 1 esophagitis, otherwise normal upper endoscopy.

PROCEDURE PERFORMED:
Esophagogastroduodenoscopy with biopsy.

ENDOSCOPIST:  John Doe, MD

CONSENT:  Risks and benefits of the procedure were discussed with the patient, including bleeding, perforation, and sedation side effects including respiratory depression. The patient verbalized understanding and wishes to proceed with the procedure.

FINDINGS:  The patient was placed in the left lateral decubitus position. The Olympus video endoscope was passed under direct visualization into the esophagus. The squamocolumnar junction was located at approximately 40 cm from the incisors. The Z-line was slightly irregular. Biopsies were obtained for histology. On retroflexed viewing of the stomach, the fundus and cardia were normal. The body and antrum were normal. The duodenal bulb and second portion of the duodenum were normal. Antral biopsies were obtained for CLOtest.

SPECIMENS:
1.  Antral biopsies for CLOtest.
2.  Distal esophageal biopsies.

COMPLICATIONS:  No immediate postprocedure complications.

IMPRESSION:
Grade 1 esophagitis, otherwise normal upper endoscopy.

DISPOSITION:
1.  The patient is to call Dr. John Doe for the biopsy results.

2.  We will proceed to colonoscopy.

DATE OF PROCEDURE:  MM/DD/YYYY

PROCEDURE PERFORMED:  Upper endoscopy.

ANESTHESIA:  Versed 2 mg and propofol 150 mg IV.

INDICATIONS:  Heartburn and GERD.

ASA CLASSIFICATION:  Class 2.

PROCEDURE IN DETAIL:  After informed consent was obtained from the patient, the patient was placed in the left lateral decubitus position and connected to standard monitoring equipment for heart rate, blood pressure, and pulse oximetry. After the provision of intravenous medication, the adult flexible Olympus upper endoscope was passed per the mouth to the second portion of the duodenum and retroflexion was performed in the stomach.  The second portion of the duodenum and stomach were endoscopically normal. There was a small hiatal hernia with a hiatus at 4 cm insertion of the Z line and 36 cm insertion at the Z line. The Z line was a sizable punched out white lesion ulcer, which was biopsied utilizing cold forceps and sent for histopathology. There were also two tongues of salmon-pink colored mucosa that was quite reddened, extending proximally for a short distance from the Z line, and these were biopsied utilizing cold forceps and sent for histopathology as well.  There were no immediate complications.

PLAN:  At this time, follow up on the results of biopsies, which may help direct subsequent management.

Colonoscopy and EGD Sample Reports