DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Iron-deficiency anemia.
POSTOPERATIVE DIAGNOSIS: Very mild gastritis.
PROCEDURE PERFORMED: Upper endoscopy with biopsy.
ENDOSCOPIST: John Doe, MD
SEDATION: Additional 2 mg of Versed and 5 mg of Valium.
SPECIMENS: CLOtest, small bowel biopsy, and distal esophagus.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient was made aware of the risks and benefits of having an upper endoscopy done. She understands the complications, including sedation adverse effects, especially respiratory depression, bleeding, infection, or perforation. The patient has decided to go ahead with the procedure.
The patient was placed in the left lateral decubitus position, and a flexible Olympus upper video endoscope was then passed by direct visualization into the esophagus, which appeared normal, except for some minimal irregularity at the Z-line; the GE junction at 35 cm. The scope was then passed into the stomach where there was some very mild bile staining. The duodenal bulb and second portion were unremarkable. Antrum and body biopsies were taken for CLOtest to rule out Helicobacter pylori. The scope was then again advanced back into the small bowel where biopsies were taken to exclude sprue.
The scope was then withdrawn back into the stomach. On retroflexion, a good view of the cardia and fundus was obtained. No other abnormalities were noted. The scope was then straightened and withdrawn into the distal esophagus where biopsies were taken of the minimally irregular Z-line. The scope was then withdrawn. The patient tolerated the procedure well.
IMPRESSION: No obvious source for anemia on the upper endoscopy.
RECOMMENDATIONS:
1. Await biopsy results.
2. We will need to have a small bowel follow-through.
Sample #2
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right upper quadrant pain and dyspepsia, despite Kapidex.
POSTOPERATIVE DIAGNOSIS: Mild gastritis and mild distal esophagitis.
PROCEDURE PERFORMED: Upper endoscopy with biopsy.
ENDOSCOPIST: John Doe, MD
SEDATION: Per Anesthesia.
SPECIMENS: CLOtest; small bowel biopsy, rule out sprue; and distal esophagus.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The patient was made aware of the risks and benefits of having an upper endoscopy done. She understands the complications, including sedation adverse effects, especially respiratory depression, bleeding, infection and perforation. The patient has decided to go ahead with the procedure.
The patient was placed in the left lateral decubitus position, and the flexible Olympus upper video endoscope was then passed by direct visualization into the esophagus, which appeared normal until reaching the distal most portion, where there was an irregular Z line seen at 40 cm. The scope was then passed in the stomach where there was a gastric lake, which was biopsied, and there was moderate diffuse gastritis. The duodenal bulb and second portion were unremarkable.
The scope was then withdrawn back into the stomach where, on retroflexion, a good view of the cardia and fundus was obtained and no other abnormalities noted. The scope was then straightened, and antral and body biopsies were obtained for CLOtest. Small bowel biopsy was taken to exclude sprue. Distal esophageal biopsies were taken as well. The scope was then withdrawn. The patient tolerated the procedure well.
IMPRESSION: Continued stomach irritation on Carafate and Kapidex, which is likely due to the bile.
RECOMMENDATIONS:
1. Continue Kapidex.
2. Continue Carafate but should be on four times a day, if she is not already.
3. If that does not help, may need to consider an antispasmodic.
