DATE OF PROCEDURE: MM/DD/YYYY
PREPROCEDURE DIAGNOSES:
1. Abdominal pain.
2. Hiatal hernia.
3. Cholecystitis.
POSTPROCEDURE DIAGNOSIS: Hiatal hernia but normal esophagus and mild gastritis.
PROCEDURE PERFORMED: EGD with biopsy and check for Helicobacter pylori.
SURGEON: John Doe, MD
DESCRIPTION OF PROCEDURE: After the patient was brought to the endoscopy suite, she had an IV started and was appropriately monitored. She was then placed in the left lateral decubitus position with the mouth exposed. The patient was given 3 mg of Versed and 50 mg of Demerol IV push in increments. She had her mouth sprayed with medication to numb it and then had a bite block placed in her teeth.
The scope was then easily passed into the superior esophagus with a single swallow and the esophagus carefully inspected all the way down to the hiatal hernia, which was easily reducible. There was no sign of esophagitis. Careful examination of the stomach revealed what appeared to be very mild gastritis in the lowest portion of the stomach. This area was biopsied and also checked for H. pylori. The scope was then easily passed into the duodenum, which appeared completely normal. The scope was then carefully brought back into the stomach, reversed in direction and again reinspected the area of the esophagogastric junction. This appeared normal other than a small hiatal hernia. The scope was then straightened and easily withdrawn through the stomach and the esophagus, again noting no esophagitis. The scope was then removed, and the patient was taken to the recovery room in satisfactory condition.
EGD Medical Transcription Sample Report 2
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Epigastric pain in a patient with a previous history of peptic ulcer disease.
POSTOPERATIVE DIAGNOSES:
1. Esophagitis.
2. Moderate-sized hiatal hernia.
PROCEDURE PERFORMED: EGD.
ANESTHESIA: Versed 4 mg, fentanyl 75 mcg.
DESCRIPTION OF PROCEDURE: After adequate sedation, the upper endoscope was inserted and advanced in the duodenum under direct visualization. The scope was withdrawn and the mucosa inspected. The second portion of the duodenum was normal. In the duodenal bulb, there was a small deformity, which may have been where the previous ulcer was seen. The stomach was normal with no evidence of residual gastric ulcerations or erosions. Retroflexion view in the stomach was normal. Direct visualization from the proximal stomach disclosed that there was actually a moderate-sized hiatal hernia and that approximately the proximal third of the stomach is above the diaphragm. At the lower esophagus Z line area, there was erosive esophagitis that had grade B to C level. No evidence of Barrett’s esophagus or strictures. Otherwise, the esophagus was normal. The scope was completely withdrawn from the patient. The patient tolerated the procedure well with no immediate complications.
RECOMMENDATIONS:
1. Continue high-dose proton pump inhibitors.
2. There is no evidence of residual ulceration. We will go ahead and await the ultrasound results, which is being done later today. If that is negative, then a CAT scan may be appropriate to further delineate her abdominal discomfort.
EGD Medical Transcription Sample Report 3
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Heme-positive stool and anemia after negative colonoscopy.
POSTOPERATIVE DIAGNOSES:
1. Tiny duodenal ulcer with duodenitis.
2. Antral gastritis, biopsies taken.
PROCEDURE PERFORMED: Esophagogastroduodenoscopy with biopsy.
ANESTHESIA: None additional after colonoscopy.
DESCRIPTION OF PROCEDURE: After adequate sedation, the upper endoscope was inserted and advanced to the duodenum. Under direct visualization, the scope was withdrawn and the mucosa inspected. Duodenum second portion and third portion were normal. In the duodenal bulb, there was miniscule duodenal ulcer with no active bleeding. There was some surrounding duodenitis. There was no blood or fresh blood in the duodenum or stomach. The stomach, antrum, and distal body had erosive gastritis. Biopsies were taken. Retroflexion view in the stomach was normal with no evidence of old blood or fresh blood there. The esophagus was normal. The scope was completely withdrawn from the patient. The patient tolerated the procedure well with no immediate complications.
RECOMMENDATIONS:
1. We suspect anemia of chronic disease, but the upper GI findings may have contributed somewhat to the anemia and may have also contributed to the heme-positive stool.
2. We will change her Pepcid to Protonix.
3. We will await the biopsies. If the biopsies show H. pylori, then eradication should be considered.
EGD Medical Transcription Sample Report 4
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Gastrointestinal bleed.
POSTOPERATIVE DIAGNOSES:
1. Bezoar.
2. Diabetic gastroparesis.
3. Suboptimal dilated stomach, food obscures much of the duodenum and stomach.
4. Duodenitis.
PROCEDURE PERFORMED: Esophagogastroduodenoscopy.
DESCRIPTION OF PROCEDURE: The patient received conscious sedation with Versed 2.5 mg IV push, Hurricaine pharyngeal spray. Conscious sedation was monitored with blood pressure, pulse, pulse oximetry, and EKG. The Olympus GIF video endoscope was introduced into the pharynx and into the duodenal bulb. This procedure was difficult. There was a hiatal hernia. We do not see any evidence of esophageal varices. A bezoar obscures the fundus. The body of the stomach, the greater curvature and lesser curvature, is better seen and looks normal. There is prepyloric antral deformity, and there is food impacted in the prepyloric antrum and in the pyloric channel of the duodenum. The duodenum seems edematous. There may be some focal erosion, but we really cannot see the duodenum. Prolonged attempts to cleanse this, moving the endoscope up and down, were unsuccessful in cleansing this food from this passage. There very well could be ulcer disease there. There was no active bleeding. We could not evaluate the second portion of the duodenum whatsoever.
ASSESSMENT:
1. Duodenitis.
2. Hiatal hernia.
3. There could be ulcer disease. There was no active bleeding.
PLAN:
1. He will need a repeat EGD. He has diabetic gastroparesis complicated by bezoar.
2. We are going to add Reglan to his regimen, put him on a clear liquid diet. He will probably need a repeat EGD after some liquids next week.
