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SAMPLE EGD (ESOPHAGOGASTRODUODENOSCOPY) REPORT
PREPROCEDURE DIAGNOSIS:
Abdominal pain and anemia.
POSTPROCEDURE DIAGNOSES:
(1) Duodenal ulcer. (2) Giant duodenal diverticulum. (3) Hiatal
hernia and Schatzki ring.
PROCEDURE PERFORMED:
Esophagogastroduodenoscopy with biopsy.
ENDOSCOPIST:
Michael Jones, M.D.
ASSISTANT:
Jane
Doe, L.P.N.
REFERRING PHYSICIAN:
George
Washington, M.D.
ANESTHESIA:
Demerol 25 mg IV push, Versed 3 mg IV push.
INSTRUMENT USED:
GIF-160 video chip endoscope.
EXTENT OF EXAMINATION:
Second
portion of the duodenum.
DESCRIPTION OF PROCEDURE AND FINDINGS:
Informed consent was obtained. The video gastroscope was
introduced into the esophagus, stomach, and duodenum with the
following findings:
1.
The vocal cords and larynx were normal.
2. The esophagus was completely normal, except for a Schatzki
ring at the bottom part at 37 cm.
3. Between 37 and 40 cm, a small-sized hiatal hernia is noted.
Retroflexed view shows no other abnormality other than this
hiatal hernia.
4. Stomach is completely normal.
5. Duodenal bulb is impressive for ulcer with good depth. This
is a 1-cm sized, clean-based, benign-appearing ulcer. Biopsies
were taken from the antrum for Helicobacter pylori.
6. Second portion of the duodenum around the papilla shows a
giant diverticulum which is very thin-walled. Internal organs
could be seen through this thin wall.
DIAGNOSTIC IMPRESSION:
The
patient's symptoms are probably from the duodenal ulcer. This
may have been contributed to by the aspirin.
PLAN:
1. Hold aspirin, if possible.
2. Prevacid 30 mg every day.
3. Return to see me in about 2-3 weeks.
4. If Helicobacter pylori is positive, she will require
treatment.
Thank you, Dr. Washington, for the referral.
The
scope is retroflexed or the maneuver is retroflexion - it is
NEVER retroflex! :)
SAMPLE UPPER ENDOSCOPY REPORT (EGD) COMBINED WITH COLONOSCOPY
DATE
OF PROCEDURES:
01/01/2005
PROCEDURE(S) PERFORMED:
(1)
Esophagoscopy. (2) Gastroscopy. (3) Duodenoscopy. (4)
Colonoscopy.
ENDOSCOPIST:
Kris
Kringle, M.D.
ASSISTANT:
Shirley Temple, R.N.
PREMEDICATIONS GIVEN:
Sublimaze 62.5 mg IV, Versed 0.25 mg IV, ampicillin 2 grams IV,
gentamicin 50 mg IV, because of history of valve replacement,
Cetacaine spray.
INDICATIONS FOR THE PROCEDURE:
This
is an 84-year-old female with weight loss. She has been on
aspirin. She has had heme-positive stool.
Esophagogastroduodenoscopy is done to rule out gastric carcinoma
and colonoscopy is done to rule out colonic lesion.
DESCRIPTION OF PROCEDURES: EGD:
The
esophagogastroduodenoscopy was performed under direct
visualization using the Olympus GIF-140 video chip endoscope.
The esophagus, stomach, pylorus, duodenal bulb, and the duodenum
to the third portion were normal including on retroflexion,
aside from a small hiatal hernia and some mild diffuse erythema,
consistent with gastritis, but no ulcerations and no erosions.
The scope was withdrawn.
COLONOSCOPY:
Then
in the left lateral position, the rectal examination revealed no
mass. The PCF-140 video chip colonoscope was inserted through
the anus and advanced through a moderately tortuous colon all
the way to the cecum. The position was confirmed by
identification of the ileocecal markings. There was scattered
particulate stool obscuring small parts of the mucosa. There
were small hemorrhoids on retroflexion but no other
abnormalities. The endoscope was withdrawn. The patient
tolerated the procedure well.
DIAGNOSTIC IMPRESSION:
1. Hiatal hernia.
2.
Gastritis.
3.
Hemorrhoids.
4.
Heme-positive stool. The etiology of that is not clear. It could
be from hemorrhoids, gastritis, or possibly small bowel source
with weight loss. It is less likely, but always possible,
because of inadequate prep and tortuosity, missed colonic
lesion.
SUGGESTED PLAN:
1. Preparation-H p.r.n.
2.
Small bowel series and if negative for malignancy, barium enema
if the patient will allow that when she sees family physician
for followup.
3.
I discussed the above with the patient and the PCP. She will
make an appointment to see him in two to three weeks.
SAMPLE COLONOSCOPY REPORT
PREPROCEDURE DIAGNOSIS:
Colon
cancer screening and rectal bleeding.
POSTPROCEDURE DIAGNOSES:
(1)
Extensive diverticulosis throughout the colon. (2) Internal
hemorrhoids - the cause of bleeding. (3) Ulceration of the
sigmoid diverticulum. Differential diagnosis: Mild
diverticulitis or aspirin-induced ulcer. (4) Multiple small
rectal polyps.
PROCEDURE PERFORMED:
Colonoscopy with snare polypectomy.
ENDOSCOPIST:
Michael Jones, M.D.
ASSISTANT:
Jane
Doe, L.P.N.
REFERRING PHYSICIAN:
George
Washington, M.D.
ANESTHESIA:
Demerol 25 mg IV push, Versed 2 mg IV push.
INSTRUMENT USED:
PCF-AL160.
EXTENT OF EXAMINATION:
Cecum.
QUALITY OF PREPARATION:
Excellent.
DESCRIPTION OF THE PROCEDURE AND FINDINGS:
Informed consent was obtained. Rectal examination by finger was
unremarkable. The scope was introduced all the way up to the
cecum without any difficulty. There was extensive diverticulosis
throughout the colon.
The
following findings were noted in a very well-prepped colon:
1.
Cecum and ascending colon also showed some mild diverticulosis.
2.
Transverse colon shows moderate diverticulosis.
3.
Sigmoid and descending colon show extensive diverticulosis. A
single diverticulum in the sigmoid colon is very large and has
ulceration in the middle of it. This suggests the patient had
acute diverticulitis, but more likely nonsteroidal-induced
ulceration.
4.
Rectum is unremarkable except for multiple small superficial
polyps which are most likely hyperplastic. Also, internal
hemorrhoids are noted.
DIAGNOSTIC IMPRESSION:
The
patient's rectal bleeding is probably coming from the internal
hemorrhoids with the finding of polyps incidental.
PLAN:
1. Follow up polyp pathology. Most likely, this will be
hyperplastic. If hyperplastic, the value of further
colonoscopies in this 80-year-old lady in not so perfect health
is limited.
2.
In 5 years, we can review how she is and consider a colonoscopy
and followup. I would favor the approach of not performing any
further intervention at that time.
Thank you very much, Dr. Washington, for the referral. |