Sample Type / Medical Specialty: Gastroenterology
Sample Name: Endoscopy

Description: Upper gastrointestinal endoscopy.
(Medical Transcription Sample Report)


PREOPERATIVE DIAGNOSIS: Anemia.

PROCEDURE: Upper gastrointestinal endoscopy.

POSTOPERATIVE DIAGNOSES:
1. Severe duodenitis.
2. Gastroesophageal junction small ulceration seen.
3. No major bleeding seen in the stomach.

PROCEDURE IN DETAIL: The patient was put in left lateral position. Olympus scope was inserted from the mouth, under direct visualization advanced to the upper part of the stomach, upper part of esophagus, middle of esophagus, GE junction, and some intermittent bleeding was seen at the GE junction. Advanced into the upper part of the stomach into the antrum. The duodenum showed extreme duodenitis and the scope was then brought back. Retroflexion was performed, which was normal. Scope was then brought back slowly. Duodenitis was seen and a little bit of ulceration seen at GE junction.

FINDING: Severe duodenitis, may be some source of bleeding from there, but no active bleeding at this time.

Keywords: gastroenterology, upper gastrointestinal endoscopy, ge junction, gastrointestinal, esophagus, endoscopy, stomach, duodenitis, bleeding,