REFERRING PHYSICIAN: John Doe , MD
PROCEDURE PERFORMED: Esophagogastroduodenoscopy
with esophageal variceal band ligation.
INDICATION: Hematemesis.
DESCRIPTION OF PROCEDURE: Informed consent was obtained and conscious
sedation was achieved with Demerol and Versed. Total sedation used was 75 mg of
Demerol and 7 mg of Versed. The patient tolerated the procedure well. The
patient was placed in left lateral position and video EGD scope was introduced
into the hypopharynx and advanced under direct vision up to the second portion
of the duodenum without difficulty.
PROCEDURE FINDINGS:
1. The distal
esophagus showed evidence of large esophageal varices with some of them having
red wale sign indicating recent hemorrhage and also high risk for re-bleeding.
2. Stomach showed
evidence of erosive gastritis, but no active bleeding.
3. The duodenum was
normal.
The endoscope was withdrawn and a Saeed Six Shooter band
ligation device was placed at the tip of the endoscope and the endoscope was
reintroduced. Six bands were placed at different columns, specifically
targeting the areas of red wale signs. The band ligation was successful. However,
since there were significant varices, a total of ten bands were placed using
another Saeed Six Shooter band ligation device.
DIAGNOSES:
1. Esophageal varices
with signs of recent hemorrhage, high risk for re-bleeding.
2. Erosive gastritis.
RECOMMENDATIONS:
1. Continue proton
pump inhibitors.
2. Start nadolol 40
mg a day.
3. See the patient in
the office in about two weeks.
4. The patient will
need a repeat upper endoscopy and band ligation in about three weeks.
Thank you, Dr. Doe, for the opportunity to participate in this
patient’s care.
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