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.
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!
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