Sample Type / Medical Specialty: Gastroenterology
Sample Name: EGD with Biopsy - 1
Description: Patient admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.
(Medical Transcription Sample Report)
PROCEDURE PERFORMED: EGD with biopsy.
INDICATION: Mrs. ABC is a pleasant 45-year-old female with a history of severe diabetic gastroparesis, who had a gastrojejunal feeding tube placed radiologically approximately 2 months ago. She was admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube. A CT scan done yesterday revealed evidence of feeding tube remnant still seen within the stomach. The endoscopy is done to confirm this and remove it, as well as determine if there are any other causes to account for her symptoms. Physical examination done prior to the procedure was unremarkable, apart from upper abdominal tenderness.
MEDICATIONS: Fentanyl 25 mcg, Versed 2 mg, 2% lidocaine spray to the pharynx.
INSTRUMENT: GIF 160.
PROCEDURE REPORT: Informed consent was obtained from Mrs. ABC's sister, after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation, and allergic reaction to the medications. Consent was not obtained from Mrs. Morales due to her recent narcotic administration. Conscious sedation was achieved with the patient lying in the left lateral decubitus position. The endoscope was then passed through the mouth, into the esophagus, the stomach, where retroflexion was performed, and it was advanced into the second portion of the duodenum.
1. ESOPHAGUS: There was evidence of grade C esophagitis, with multiple white-based ulcers seen from the distal to the proximal esophagus, at 12 cm in length. Multiple biopsies were obtained from this region and placed in jar #1.
2. STOMACH: Small hiatal hernia was noted within the cardia of the stomach. There was an indentation/scar from the placement of the previous PEG tube and there was suture material noted within the body and antrum of the stomach. The remainder of the stomach examination was normal. There was no feeding tube remnant seen within the stomach.
3. DUODENUM: This was normal.
1. Grade C esophagitis seen within the distal, mid, and proximal esophagus.
2. Small hiatal hernia.
3. Evidence of scarring at the site of the previous feeding tube, as well as suture line material seen in the body and antrum of the stomach.
PLAN: Followup results of the biopsies and will have radiology replace her gastrojejunal feeding tube.
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