Medical Specialty:
Gastroenterology
Sample Name: Esophagogastroduodenoscopy - 7
Description: Positive peptic ulcer disease. Gastritis. Esophagogastroduodenoscopy with photography and biopsy. The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Positive peptic ulcer disease.
POSTOPERATIVE DIAGNOSIS: Gastritis.
PROCEDURE PERFORMED: Esophagogastroduodenoscopy with photography and biopsy.
GROSS FINDINGS: The patient had a history of peptic ulcer disease, epigastric abdominal pain x2 months, being evaluated at this time for ulcer disease.
Upon endoscopy, gastroesophageal junction was at 40 cm, no esophageal tumor, varices, strictures, masses, or no reflux esophagitis was noted. Examination of the stomach reveals mild inflammation of the antrum of the stomach, no ulcers, erosions, tumors, or masses. The profundus and the cardia of the stomach were unremarkable. The pylorus was concentric. The duodenal bulb and sweep with no inflammation, tumors, or masses.
Photographs and biopsies were obtained as appropriate. The patient is sent to recovery room in stable condition.
Keywords: gastroenterology, antrum, esophageal tumor, varices, strictures, masses, duodenal bulb, peptic ulcer, duodenal, esophagus, esophagogastroduodenoscopy, panendoscope, peptic, inflammation, ulcer, disease, stomach,