Sample Type / Medical Specialty: Gastroenterology
Sample Name: Esophagogastroduodenoscopy
Description: Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia
(Medical Transcription Sample Report)
PROCEDURE: Esophagogastroduodenoscopy with biopsy and snare polypectomy.
INDICATION FOR THE PROCEDURE: Iron-deficiency anemia.
The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration.
PROCEDURE: After informed consent and appropriate sedation, the upper endoscope was inserted into the oropharynx down into the stomach and beyond the pylorus and the second portion of the duodenum. The duodenal mucosa was completely normal. The pylorus was normal. In the stomach, there was evidence of diffuse atrophic-appearing nodular gastritis. Multiple biopsies were obtained. There also was a 1.5-cm adenomatous appearing polyp along the greater curvature at the junction of the body and antrum. There was mild ulceration on the tip of this polyp. It was decided to remove the polyp via snare polypectomy. Retroflexion was performed, and this revealed a small hiatal hernia in the distal esophagus. The Z-line was identified and was unremarkable. The esophageal mucosa was normal.
1. Hiatal hernia.
2. Diffuse nodular and atrophic appearing gastritis, biopsies taken.
3. A 1.5-cm polyp with ulceration along the greater curvature, removed.
1. Follow up biopsies.
2. Continue PPI.
3. Hold Lovenox for 5 days.
4. Place SCDs.
Keywords: gastroenterology, esophagogastroduodenoscopy, iron-deficiency, iron-deficiency anemia, anemia, biopsy, endoscope, esophageal mucosa, esophagus, hiatal hernia, polypectomy, snare polypectomy, esophagogastroduodenoscopy with biopsy, iron deficiency anemia,