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Biliary colic. Laparoscopic cholecystectomy. Laparoscopic examination showed no injury from entry. Marcaine was then injected just subxiphoid, and a 5-mm port was placed under direct visualization for the laparoscope.
Gastroenterology
Laparoscopic Cholecystectomy - 5
PREOPERATIVE DIAGNOSIS: , Biliary colic.
gastroenterology, veress needle, gallbladder, laparoscope, laparoscopic examination, endotracheal intubation, laparoscopic cholecystectomy, biliary colic, abdomen, cholecystectomy, endotracheal, umbilicus, laparoscopic,
3,501
Acute cholecystitis. Laparoscopic cholecystectomy. The abdominal area was prepped and draped in the usual sterile fashion. A small skin incision was made below the umbilicus. It was carried down in the transverse direction on the side of her old incision. It was carried down to the fascia.
Gastroenterology
Laparoscopic Cholecystectomy - 4
PREOPERATIVE DIAGNOSIS: , Acute cholecystitis.,POSTOPERATIVE DIAGNOSIS:, Acute cholecystitis.,PROCEDURE PERFORMED:, Laparoscopic cholecystectomy.,ANESTHESIA: , General.,ESTIMATED BLOOD LOSS:, Zero.,COMPLICATIONS: , None.,PROCEDURE: ,The patient was taken to the operating room, and after obtaining adequate general a...
gastroenterology, laparoscopic, cholecystectomy, cholecystitis, gallbladder fossa, laparoscopic cholecystectomy, acute cholecystitis, gallbladder
3,502
Chronic cholecystitis. Laparoscopic cholecystectomy. Patient with increasingly severe more frequent right upper quadrant abdominal pain, more after meals, had a positive ultrasound for significant biliary sludge.
Gastroenterology
Laparoscopic Cholecystectomy - 8
PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS: ,Chronic cholecystitis.,PROCEDURE PERFORMED: ,Laparoscopic cholecystectomy.,BLOOD LOSS: , Minimal.,ANESTHESIA: , General endotracheal anesthesia.,COMPLICATIONS: , None.,CONDITION: , Stable.,DRAINS: , None.,DISPOSITION: ,To recovery room and to...
gastroenterology, abdomen, bovie cautery, endotracheal anesthesia, laparoscopic cholecystectomy, cystic duct, chronic cholecystitis, abdominal, laparoscopic, cholecystectomy, cholecystitis, gallbladder,
3,503
Cholecystitis and cholelithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. The patient received 1 gm of IV Ancef intravenously piggyback. The abdomen was prepared and draped in routine sterile fashion.
Gastroenterology
Laparoscopic Cholecystectomy - 7
PREOPERATIVE DIAGNOSIS: , Cholecystitis and cholelithiasis.,POSTOPERATIVE DIAGNOSIS: ,Cholecystitis and cholelithiasis.,TITLE OF PROCEDURE,1. Laparoscopic cholecystectomy.,2. Intraoperative cholangiogram.,ANESTHESIA: ,General.,PROCEDURE IN DETAIL: ,The patient was taken to the operative suite and placed in the sup...
gastroenterology, cholangiogram, cholecystitis, cholelithiasis, ancef, endotracheal, umbilicus, veress needle, c-arm fluoroscopy, intraoperative cholangiogram, laparoscopic cholecystectomy, laparoscopic, cholecystectomy, gallbladder, cannula,
3,504
Cholelithiasis; possible choledocholithiasis. Laparoscopic cholecystectomy and intraoperative cholangiogram. A small incision was made in the umbilicus, and a Veress needle was introduced into the abdomen. CO2 insufflation was done to a maximum pressure of 15 mmHg, and a 12-mm VersaStep port was placed into the umb...
Gastroenterology
Laparoscopic Cholecystectomy - 6
PREOPERATIVE DIAGNOSIS:, Cholelithiasis; possible choledocholithiasis.
gastroenterology, choledocholithiasis, cholangiogram, co2 insufflation, umbilicus, common bile duct, bile duct, laparoscopic cholecystectomy, cystic duct, intraoperative, laparoscopic, cholecystectomy, cholelithiasis, endotracheal, gallbladder, cystic, duct,
3,505
Laparoscopic cholecystectomy. Biliary colic and biliary dyskinesia. The patient had a workup for her gallbladder, which showed evidence of biliary dyskinesia.
Gastroenterology
Laparoscopic Cholecystectomy - 10
PREOPERATIVE DIAGNOSIS: , Biliary colic and biliary dyskinesia.,POSTOPERATIVE DIAGNOSIS:, Biliary colic and biliary dyskinesia.,PROCEDURE PERFORMED:, Laparoscopic cholecystectomy.,ANESTHESIA: , General endotracheal.,COMPLICATIONS:, None.,DISPOSITION: ,The patient tolerated the procedure well and was transferred to ...
gastroenterology, electrobovie cautery, laparoscopic cholecystectomy, biliary colic, biliary dyskinesia, biliary, laparoscopic, cholecystectomy, colic, abdomen, dyskinesia, gallbladder
3,506
Laparoscopic cholecystectomy.
Gastroenterology
Laparoscopic Cholecystectomy - 1
PROCEDURE:,: After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced. The patient was then prepped and draped in the usual sterile fashion. An #11 blade scalpel was used to make a small infraumbilic...
gastroenterology, laparoscopic, calot, ochsner clamps, additional ports, cholangiogram, cholecystectomy, cystic duct, duodenum, epigastric, fascia, gallbladder, infraumbilical skin incision, infundibulum, pneumoperitoneum, triangle of calot, laparoscopic cholecystectomy, liver bed, epigastric port, port site, cystic ar...
3,507
Appendicitis. Laparoscopic appendectomy. CO2 insufflation was done to a maximum pressure of 15 mmHg and a 12-mm VersaStep port was placed through his umbilicus.
Gastroenterology
Laparoscopic Appendectomy - 3
PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:, Appendicitis. ,PROCEDURE: , Laparoscopic appendectomy. ,ANESTHESIA: , General with endotracheal intubation. ,PROCEDURE IN DETAIL: ,The patient was taken to the operating room and placed supine on the operating room table. General anesthesia was admini...
gastroenterology, foley catheter, co2 insufflation, endotracheal intubation, laparoscopic appendectomy, appendectomy, intubation, cecum, laparoscopic, appendicitis, endotracheal, abdomen, mesentery, umbilicus, appendix,
3,508
Laparoscopic cholecystectomy due to chronic cholecystitis and cholelithiasis.
Gastroenterology
Laparoscopic Cholecystectomy - 2
PREOPERATIVE DIAGNOSIS:,1. Cholelithiasis.,2. Chronic cholecystitis.,POSTOPERATIVE DIAGNOSIS:,1. Cholelithiasis.,2. Chronic cholecystitis.,NAME OF OPERATION: , Laparoscopic cholecystectomy.,ANESTHESIA:, General.,FINDINGS:, The gallbladder was thickened and showed evidence of chronic cholecystitis. There was a gr...
gastroenterology, cholelithiasis chronic, inflammatory reaction, cystic artery, laparoscopic cholecystectomy, common duct, chronic cholecystitis, gallbladder bed, cystic duct, cystic, gallbladder, duct, inflammatory
3,509
Standard Laparoscopic Cholecystectomy Operative Note.
Gastroenterology
Laparoscopic Cholecystectomy
The patient's abdomen was prepped and draped in the usual sterile fashion. A subumbilical skin incision was made. The Veress needle was inserted, and the patient's abdominal cavity was insufflated with moderate pressure all times. A subumbilical trocar was inserted. The camera was inserted in the panoramic view. T...
gastroenterology, gallbladder, laparoscopic cholecystectomy, midepigastric trocar, double hemoclips, laparoscopic, cholecystectomy, midepigastric, trocars, hemoclips, trocarNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLi...
3,510
Acute appendicitis with perforation. Laparoscopic appendectomy. A CT scan of abdomen showed evidence of appendicitis with perforation.
Gastroenterology
Laparoscopic Appendectomy - 4
PREOPERATIVE DIAGNOSIS:, Acute appendicitis with perforation.,POSTOPERATIVE DIAGNOSIS: ,Acute appendicitis with perforation.,ANESTHESIA:, General.,PROCEDURE: , Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE: , The patient is a 4-year-old little boy, who has been sick for several days and was seen in our Emerge...
gastroenterology, adhesions, peritoneum, purulent debris, umbilical fascia, peritoneal cavity, laparoscopic appendectomy, appendectomy, constipation, purulent, debris, umbilical, appendix, abdomen, laparoscopic, perforation, appendicitis,
3,511
Chronic cholecystitis without cholelithiasis.
Gastroenterology
Laparoscopic Cholecystectomy - 3
PREOPERATIVE DIAGNOSIS: , Chronic cholecystitis without cholelithiasis.,POSTOPERATIVE DIAGNOSIS: ,Chronic cholecystitis without cholelithiasis.,PROCEDURE: , Laparoscopic cholecystectomy.,BRIEF DESCRIPTION: , The patient was brought to the operating room and anesthesia was induced. The abdomen was prepped and draped a...
gastroenterology, chronic cholecystitis without cholelithiasis, laparoscopic cholecystectomy, cystic duct, cystic artery, endo catch, chronic cholecystitis, laparoscopic, cholecystectomy, abdomen, cholecystitis, cholelithiasis, gallbladder, cystic
3,512
Laparoscopic appendectomy. The patient is a 42-year-old female who presented with right lower quadrant pain. She was evaluated and found to have a CT evidence of appendicitis.
Gastroenterology
Laparoscopic Appendectomy - 5
PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS: , Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General endotracheal.,INDICATION FOR OPERATION: , The patient is a 42-year-old female who presented with right lower quadrant pain. She was evaluated and found to have a CT e...
gastroenterology, gia stapler, laparoscopic appendectomy, appendectomy, endotracheal, mesoappendix, laparoscopic, appendicitis, appendix
3,513
Laparoscopic cholecystectomy. Acute cholecystitis, status post laparoscopic cholecystectomy, end-stage renal disease on hemodialysis, hyperlipidemia, hypertension, congestive heart failure, skin lymphoma 5 years ago, and hypothyroidism.
Gastroenterology
Lap Chole - Discharge Summary
PROCEDURE:, Laparoscopic cholecystectomy.,DISCHARGE DIAGNOSES:,1. Acute cholecystitis.,2. Status post laparoscopic cholecystectomy.,3. End-stage renal disease on hemodialysis.,4. Hyperlipidemia.,5. Hypertension.,6. Congestive heart failure.,7. Skin lymphoma 5 years ago.,8. Hypothyroidism.,HOSPITAL COURSE: , Th...
gastroenterology, end-stage renal disease, lymphoma, cholecystitis, congestive heart failure, skin lymphoma, gallbladder wall, laparoscopic cholecystectomy
3,514
Ruptured appendicitis.
Gastroenterology
Laparoscopic Appendectomy - 1
PREOPERATIVE DIAGNOSIS:, Acute appendicitis.,POSTOPERATIVE DIAGNOSIS:, Ruptured appendicitis.,PROCEDURE:, Laparoscopic appendectomy.,INDICATIONS FOR PROCEDURE:, This patient is a 4-year-old boy with less than 24-hour history of apparent right lower quadrant abdominal pain associated with vomiting and fevers. The p...
gastroenterology, ruptured appendicitis, acute appendicitis, laparoscopic appendectomy, laparoscopic, ruptured, abdominal, peritoneal, periumbilical, appendicitis, appendectomy,
3,515
Repair of juxtarenal abdominal aortic aneurysm with 14 mm Hemashield tube graft.
Gastroenterology
Juxtarenal Abdominal Aortic Aneurysm Repair
PREOPERATIVE DIAGNOSIS: Large juxtarenal abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS: Large juxtarenal abdominal aortic aneurysm.,ANESTHESIA: General endotracheal anesthesia.,OPERATIVE TIME: Three hours.,ANESTHESIA TIME: Four hours.,DESCRIPTION OF PROCEDURE: After thorough preoperative evaluation, the pati...
gastroenterology, inferior left renal artery, semi continuous prolene suture, juxtarenal abdominal aortic aneurysm, inferior mesenteric artery, continuous prolene suture, abdominal aortic aneurysm, hemashield tube, inferior mesenteric, renal artery, aortic aneurysm, aneurysm, iliac, endarterectomy, viscera, hemashield,...
3,516
Appendicitis. Laparoscopic appendectomy. Infraumbilical incision was performed and taken down to the fascia. The fascia was incised. The peritoneal cavity was carefully entered. Two other ports were placed in the right and left lower quadrants.
Gastroenterology
Laparoscopic Appendectomy - 2
PREOPERATIVE DIAGNOSIS: , Appendicitis.,POSTOPERATIVE DIAGNOSIS:, Appendicitis.,PROCEDURE PERFORMED: , Laparoscopic appendectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS:, Minimal.,PROCEDURE IN DETAIL: , The patient was prepped and draped in sterile fashion. Infraumbilical incision was per...
gastroenterology, mesoappendix, endocatch, laparoscopic appendectomy, appendix, umbilical, laparoscopic, appendectomy, appendicitis, fascia, infraumbilical
3,517
Laparoscopic appendectomy. Acute appendicitis.
Gastroenterology
Laparoscopic Appendectomy
PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Acute appendicitis.,OPERATIVE PROCEDURE:, Laparoscopic appendectomy.,INTRAOPERATIVE FINDINGS: , Include inflamed, non-perforated appendix.,OPERATIVE NOTE: ,The patient was seen by me in the preoperative holding area. The risks of the procedure ...
gastroenterology, appendix, endobag, laparoscopic appendectomy, acute appendicitis, appendectomy, umbilically, abdominal, pneumoperitoneum, laparoscopic, appendicitis, suprapubic, mesoappendix,
3,518
Pneumatosis coli in the cecum. Possible ischemic cecum with possible metastatic disease, bilateral hydronephrosis on atrial fibrillation, aspiration pneumonia, chronic alcohol abuse, acute renal failure, COPD, anemia with gastric ulcer.
Gastroenterology
Ischemic Cecum - Consult
REASON FOR CONSULTATION: , Pneumatosis coli in the cecum.,HISTORY OF PRESENT ILLNESS: ,The patient is an 87-year-old gentleman who was admitted on 10/27/07 with weakness and tiredness with aspiration pneumonia. The patient is very difficult to obtain information from; however, he appears to be having frequent nausea ...
gastroenterology, ischemic cecum, metastatic disease, bilateral hydronephrosis, chronic alcohol abuse, acute renal failure, copd, anemia, gastric ulcer, pneumatosis coli, cecum, aspiration pneumonia, aspiration, ischemic, atrial, metastatic, hydronephrosis, fibrillation, pneumatosis, pneumonia,
3,519
Debridement left ischial ulcer.
Gastroenterology
Ischial Ulcer Debridement
PREOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,POSTOPERATIVE DIAGNOSES: , Nonhealing decubitus ulcer, left ischial region? Osteomyelitis, paraplegia, and history of spina bifida.,PROCEDURE PERFORMED: ,Debridement left ischial ulcer.,AN...
gastroenterology, debridement, ischial ulcer, ischial region, osteomyelitis, paraplegia, spina bifida, decubitus ulcer
3,520
Exploratory laparotomy, lysis of adhesions, and right hemicolectomy. Right colon cancer, ascites, and adhesions.
Gastroenterology
Hemicolectomy
PREOPERATIVE DIAGNOSIS: , Right colon tumor.,POSTOPERATIVE DIAGNOSES:,1. Right colon cancer.,2. Ascites.,3. Adhesions.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Lysis of adhesions.,3. Right hemicolectomy.,ANESTHESIA: , General.,COMPLICATIONS: , None.,ESTIMATED BLOOD LOSS: , Less than 200 cc.,URINE OUTPUT...
gastroenterology, colon tumor, ascites, adhesions, lysis of adhesions, exploratory laparotomy, colon cancer, transverse colon, hemicolectomy, laparotomy,
3,521
Nausea and abdominal pain after eating - Gall bladder disease - Laparoscopic cholecystectomy scheduled.
Gastroenterology
GI Consultation - 4
CHIEF COMPLAINT:, Nausea and abdominal pain after eating.,GALL BLADDER HISTORY:, The patient is a 36 year old white female. Patient's complaints are fatty food intolerance, dark colored urine, subjective chills, subjective low-grade fever, nausea and sharp stabbing pain. The patient's symptoms have been present for 3 ...
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3,522
A male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom.
Gastroenterology
Hepatic Encephalopathy
REASON FOR ADMISSION: , Hepatic encephalopathy.,HISTORY OF PRESENT ILLNESS: , The patient is a 51-year-old Native American male with known alcohol cirrhosis who presented to the emergency room after an accidental fall in the bathroom. He said that he was doing fine prior to that and denied having any complaints. He w...
null
3,523
Right upper quadrant pain. Nuclear medicine hepatobiliary scan. Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.
Gastroenterology
Hepatobiliary Scan
NUCLEAR MEDICINE HEPATOBILIARY SCAN,REASON FOR EXAM: , Right upper quadrant pain.,COMPARISONS: ,CT of the abdomen dated 02/13/09 and ultrasound of the abdomen dated 02/13/09.,Radiopharmaceutical 6.9 mCi of Technetium-99m Choletec.,FINDINGS:, Imaging obtained up to 30 minutes after the injection of radiopharmaceutical...
gastroenterology, radiopharmaceutical, gallbladder ejection fraction, nuclear medicine hepatobiliary, hepatobiliary scan, quadrant, nuclear, technetium, choletec, ejection, fraction, cholecystitis, scan, abdomen, injection, gallbladder, hepatobiliary, medicine
3,524
Gastrostomy, a 6-week-old with feeding disorder and Down syndrome.
Gastroenterology
Gastrostomy
PREOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,POSTOPERATIVE DIAGNOSES:,1. Feeding disorder.,2. Down syndrome.,3. Congenital heart disease.,OPERATION PERFORMED: , Gastrostomy.,ANESTHESIA: , General.,INDICATIONS: ,This 6-week-old female infant had been transferred to C...
gastroenterology, feeding disorder, down syndrome, congenital heart disease, mic-key tubeless, nurolon, subcutaneous tissue, fascia, syndrome, stomach, gastrostomy
3,525
GI Consultation for Chrohn's disease.
Gastroenterology
GI Consultation - 3
PROBLEM: ,Prescription evaluation for Crohn's disease., ,HISTORY: , This is a 46-year-old male who is here for a refill of Imuran. He is taking it at a dose of 100 mg per day. He is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years. In fact,...
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3,526
GI Consultation for chronic abdominal pain, nausea, vomiting, abnormal liver function tests.
Gastroenterology
GI Consultation - 2
PROBLEM: ,Chronic abdominal pain, nausea, vomiting, abnormal liver function tests., ,HISTORY: , The patient is a 23-year-old female referred for evaluation due to a chronic history of abdominal pain and extensive work-up for abnormal liver function tests and this chronic nausea and vomiting referred here for further e...
null
3,527
GI Consultation due to rectal bleeding, positive celiac sprue panel
Gastroenterology
GI Consultation - 1
PROBLEM: ,Rectal bleeding, positive celiac sprue panel.,HISTORY: ,The patient is a 19-year-old Irish-Greek female who ever since elementary school has noted diarrhea, constipation, cramping, nausea, vomiting, bloating, belching, abdominal discomfort, change in bowel habits. She noted that her symptoms were getting i...
gastroenterology, bleeding, abdominal discomfort, belching, bloating, bowel, celiac sprue, change in bowel habits, constipation, cramping, diarrhea, gluten-free, nausea, rectal, vomiting, inflammatory arthritis, rectal bleeding, gi, inflammatory, sprue, celiac, gluten, diet,
3,528
GI bleed. Upper gastrointestinal bleed. CBC revealed microcytic anemia.
Gastroenterology
GI Bleed - Discharge Summary
CHIEF COMPLAINT:, GI bleed.,HISTORY OF PRESENT ILLNESS:, The patient is an 80-year-old white female with history of atrial fibrillation, on Coumadin, who presented as outpatient, complaining of increasing fatigue. CBC revealed microcytic anemia with hemoglobin of 8.9. Stool dark brown, strongly OB positive. The pa...
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3,529
Gastroscopy. Dysphagia and globus. No evidence of inflammation or narrowing to explain her symptoms.
Gastroenterology
Gastroscopy - 2
PROCEDURE:, Gastroscopy.,PREOPERATIVE DIAGNOSIS:, Dysphagia and globus.,POSTOPERATIVE DIAGNOSIS: , Normal.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced through the oropharynx and passed carefully through the esophagus and stomach, and then through the gastrojejunal anastomosi...
gastroenterology, olympus gastroscope, gastric pouch, gastrojejunal anastomosis, dysphagia, globus, esophagus, mucosa, gastric, gastroscopy, gastrojejunal, inflammation
3,530
Dysphagia, possible stricture. Retained gastric contents forming a partial bezoar, suggestive of gastroparesis.
Gastroenterology
Gastroscopy - 1
PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSES: , Dysphagia, possible stricture.,POSTOPERATIVE DIAGNOSIS: , Gastroparesis.,MEDICATION: , MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the hypopharynx and passed carefully through the esophagus, stomach, and duodenum. The hypopharynx was ...
gastroenterology
3,531
Gastroscopy. A short-segment Barrett esophagus, hiatal hernia, and incidental fundic gland polyps in the gastric body; otherwise, normal upper endoscopy to the transverse duodenum.
Gastroenterology
Gastroscopy - 3
PROCEDURE: , Gastroscopy.,PREOPERATIVE DIAGNOSIS: , Gastroesophageal reflux disease.,POSTOPERATIVE DIAGNOSIS:, Barrett esophagus.,MEDICATIONS: , MAC.,PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenum to the transverse duodenum. Th...
gastroenterology, olympus, gastroscope, barrett, gastroesophageal reflux disease, transverse duodenum, barrett esophagus, hiatal hernia, gastroscopy, endoscopy, hiatal, duodenum, esophagus, hernia,
3,532
Gastrointestinal Bleed. An 81-year-old presented to the emergency room after having multiple black tarry stools and a weak spell. She woke yesterday morning had a very dark and smelly bowel movement.
Gastroenterology
Gastrointestinal Bleed - ER Visit
ADMITTING DIAGNOSIS: , Gastrointestinal bleed.,HISTORY OF PRESENT ILLNESS: ,Ms. XYZ is an 81-year-old who presented to the emergency room after having multiple black tarry stools and a weak spell. She states that she woke yesterday morning and at approximately 10:30 had a bowel movement. She noticed it was very dark...
null
3,533
Followup of laparoscopic fundoplication and gastrostomy. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feeding access.
Gastroenterology
Fundoplication & Gastrostomy Followup
REASON FOR VISIT: , Followup of laparoscopic fundoplication and gastrostomy.,HISTORY OF PRESENT ILLNESS: , The patient is a delightful baby girl, who is now nearly 8 months of age and had a tracheostomy for subglottic stenosis. Laparoscopic fundoplication and gastrostomy was done because of the need for enteral feedin...
gastroenterology, decannulation, enteral feeding, feeding access, laparoscopic fundoplication, gastrostomy, airway, laryngotracheoplasty, laparoscopic, fundoplication,
3,534
Acute gastroenteritis, resolved. Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.
Gastroenterology
Gastroenteritis - Discharge Summary
ADMITTING DIAGNOSES,1. Acute gastroenteritis.,2. Nausea.,3. Vomiting.,4. Diarrhea.,5. Gastrointestinal bleed.,6. Dehydration.,DISCHARGE DIAGNOSES,1. Acute gastroenteritis, resolved.,2. Gastrointestinal bleed and chronic inflammation of the mesentery of unknown etiology.,BRIEF H&P AND HOSPITAL COURSE: , This pat...
gastroenterology, nausea, vomiting, diarrhea, gastrointestinal bleed, mesentery, hemoglobin, hematocrit, gastrointestinal, periumbilical, gastroenteritis, hemorrhoids
3,535
Pediatric Gastroenterology - History of gagging.
Gastroenterology
Gagging - 3-year-old
HISTORY OF PRESENT ILLNESS: , This is a 3-year-old female patient, who was admitted today with a history of gagging. She was doing well until about 2 days ago, when she developed gagging. No vomiting. No fever. She has history of constipation. She normally passes stool every two days after giving an enema. No rec...
gastroenterology, g-tube, peho syndrome, tube site, gagging, constipation, endoscopy, peho, hemoglobin, hematocrit, intubated, bleeding, blood, fundoplication, tube,
3,536
Foul-smelling urine and stomach pain after meals.
Gastroenterology
Foul-Smelling Urine
CHIEF COMPLAINT:, Foul-smelling urine and stomach pain after meals.,HISTORY OF PRESENT ILLNESS:, Stomach pain with most meals x one and a half years and urinary symptoms for same amount of time. She was prescribed Reglan, Prilosec, Pepcid, and Carafate at ED for her GI symptoms and Bactrim for UTI. This visit was i...
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3,537
Flexible sigmoidoscopy due to rectal bleeding.
Gastroenterology
Flex Sig - 1
INDICATION: , Rectal bleeding.,PREMEDICATION:, See procedure nurse NCS form.,PROCEDURE: ,
gastroenterology, rectal bleeding, digital rectal exam, pentax video, anal verge, angiodysplasia, colonic mucosa, diverticula, endoscope, flexible, flexible sigmoidoscopy, hemorrhoids, masses, polyps, rectum, sigmoidoscopy, sphincter tone, internal hemorrhoids, bleeding, rectal
3,538
Flexible sigmoidoscopy. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon.
Gastroenterology
Flex Sig - 2
PROCEDURE IN DETAIL: , Following a barium enema prep and lidocaine ointment to the rectal vault, perirectal inspection and rectal exam were normal. The Olympus video colonoscope then introduced into the rectum and passed by directed vision to the distal descending colon. Withdrawal notes an otherwise normal descendin...
gastroenterology, flexible sigmoidoscopy, flex sig, colonoscope, olympus video colonoscope, rectumNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribe...
3,539
Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids. Poor prep with friable internal hemorrhoids, but no gross lesions, no source of bleed.
Gastroenterology
Gastrointestinal Bleed - Discharge Summary
DIAGNOSIS ON ADMISSION: , Gastrointestinal bleed.,DIAGNOSES ON DISCHARGE,1. Gastrointestinal bleed, source undetermined, but possibly due to internal hemorrhoids.,2. Atherosclerotic cardiovascular disease.,3. Hypothyroidism.,PROCEDURE:, Colonoscopy.,FINDINGS:, Poor prep with friable internal hemorrhoids, but no gross...
gastroenterology, atherosclerotic cardiovascular disease, colonoscopy, gross lesions, bowel prep, gastrointestinal bleed, internal hemorrhoids, hemorrhoids, gastrointestinal, prep
3,540
Esophagitis, minor stricture at the gastroesophageal junction, hiatal hernia. Otherwise normal upper endoscopy to the transverse duodenum.
Gastroenterology
Gastroscopy
PREOPERATIVE DIAGNOSES: , Dysphagia and esophageal spasm.,POSTOPERATIVE DIAGNOSES: , Esophagitis and esophageal stricture.,PROCEDURE:, Gastroscopy.,MEDICATIONS:, MAC.,DESCRIPTION OF PROCEDURE: , The Olympus gastroscope was introduced into the oropharynx and passed carefully through the esophagus, stomach, and duodenu...
gastroenterology, duodenum, esophagus, gastroscope, stomach, upper endoscopy, transverse duodenum, gastroesophageal junction, hiatal hernia, gastroscopy, endoscopy, esophagitis, gastroesophageal, hiatal, esophageal, hernia
3,541
Female with intermittent rectal bleeding, not associated with any weight loss. The patient is chronically constipated.
Gastroenterology
Gastroenterology - Letter
Sample Address,Re: Mrs. Sample Patient,Dear Sample Doctor:,I had the pleasure of seeing your patient, Mrs. Sample Patient , in my office today. Mrs. Sample Patient is a 48-year-old, African-American female with a past medical history of hypertension and glaucoma, who was referred to me to be evaluated for intermitten...
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3,542
Flexible sigmoidoscopy. Sigmoid and left colon diverticulosis; otherwise, normal flexible sigmoidoscopy to the proximal descending colon.
Gastroenterology
Flex Sig - 3
PROCEDURE: , Flexible sigmoidoscopy.,PREOPERATIVE DIAGNOSIS:, Rectal bleeding.,POSTOPERATIVE DIAGNOSIS: ,Diverticulosis.,MEDICATIONS: , None.,DESCRIPTION OF PROCEDURE: ,The Olympus gastroscope was introduced through the rectum and advanced carefully through the colon for a distance of 90 cm, reaching the proximal de...
gastroenterology, olympus, gastroscope, rectal bleeding, flexible sigmoidoscopy, colon diverticulosis, descending colon, diverticulosis, hemorrhoids, flexible, sigmoidoscopy, colon
3,543
Exploratory laparotomy, release of small bowel obstruction, and repair of periumbilical hernia. Acute small bowel obstruction and incarcerated umbilical Hernia.
Gastroenterology
Exploratory Laparotomy & Hernia Repair
PREOPERATIVE DIAGNOSIS:,1. Acute bowel obstruction.,2. Umbilical hernia.,POSTOPERATIVE DIAGNOSIS:,1. Acute small bowel obstruction.,2. Incarcerated umbilical Hernia.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Release of small bowel obstruction.,3. Repair of periumbilical hernia.,ANESTHESIA: , General wit...
gastroenterology, endotracheal intubation, acute bowel obstruction, umbilical hernia, exploratory laparotomy, release of small bowel obstruction, repair of periumbilical hernia, incarcerated umbilical hernia, incarcerated, bowel, hernia, exploratory, laparotomy, abdomen, umbilical, obstruction,
3,544
Flexible Sigmoidoscopy.
Gastroenterology
Flex Sig
MEDICATIONS:, None.,DESCRIPTION OF THE PROCEDURE:, After informed consent was obtained, the patient was placed in the left lateral decubitus position and the Olympus video colonoscope was inserted through the anus and advanced in retrograde fashion for a distance of *** cm to the proximal descending colon and then sl...
gastroenterology, flexible sigmoidoscopy, flex sig, olympus video colonoscope, colonoscopeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medica...
3,545
Exploratory laparotomy, low anterior colon resection, flexible colonoscopy, and transverse loop colostomy and JP placement. Colovesical fistula and intraperitoneal abscess.
Gastroenterology
Exploratory Laparotomy & Colon Resection
PREOPERATIVE DIAGNOSIS: , Colovesical fistula.,POSTOPERATIVE DIAGNOSES:,1. Colovesical fistula.,2. Intraperitoneal abscess.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Low anterior colon resection.,3. Flexible colonoscopy.,4. Transverse loop colostomy and JP placement.,ANESTHESIA: , General.,HISTORY: ,Thi...
gastroenterology, intraperitoneal abscess, colovesical fistula, low anterior colon resection, flexible colonoscopy, transverse loop colostomy, jp placement, exploratory laparotomy, colon resection, descending colon, transverse colon, colostomy, colon, laparotomy, aparotomy, fistula
3,546
Leaking anastomosis from esophagogastrectomy. Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage.
Gastroenterology
Exploratory Laparotomy
PREOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,POSTOPERATIVE DIAGNOSIS: , Leaking anastomosis from esophagogastrectomy. ,PROCEDURE: , Exploratory laparotomy and drainage of intra-abdominal abscesses with control of leakage. ,COMPLICATIONS:, None. ,ANESTHESIA: , General oroendotracheal intub...
gastroenterology, drainage, oroendotracheal, intubation, intra abdominal, abdominal abscesses, jackson pratt, exploratory laparotomy, anastomosis, esophagogastrectomy, mediastinum, abdomen, stomach
3,547
Esophageal foreign body, US penny. Esophagoscopy with foreign body removal. The patient had a penny lodged in the proximal esophagus in the typical location.
Gastroenterology
Esophagoscopy & Foreign Body Removal
PREOPERATIVE DIAGNOSIS: , Esophageal foreign body.,POSTOPERATIVE DIAGNOSIS:, Esophageal foreign body, US penny.,PROCEDURE: , Esophagoscopy with foreign body removal.,ANESTHESIA: , General.,INDICATIONS: , The patient is a 17-month-old baby girl with biliary atresia, who had a delayed diagnosis and a late attempted Kasa...
gastroenterology, portoenterostomy, foreign body removal, proximal esophagus, coin, esophagoscopy, esophageal, esophagus,
3,548
Esophagoscopy with removal of foreign body. Esophageal foreign body, no associated comorbidities are noted.
Gastroenterology
Esophagoscopy & Foreign Body Removal - 1
PRIMARY DIAGNOSIS:, Esophageal foreign body, no associated comorbidities are noted.,PROCEDURE:, Esophagoscopy with removal of foreign body.,CPT CODE: , 43215.,PRINCIPAL DIAGNOSIS:, Esophageal foreign body, ICD-9 code 935.1.,DESCRIPTION OF PROCEDURE: , Under general anesthesia, flexible EGD was performed. Esophagus ...
gastroenterology, esophagus, foreign body, esophagoscopy, esophageal,
3,549
Exploratory laparotomy, lysis of adhesions and removal, reversal of Hartmann's colostomy, flexible sigmoidoscopy, and cystoscopy with left ureteral stent.
Gastroenterology
Exploratory Laparotomy - 1
PREOPERATIVE DIAGNOSIS:, History of perforated sigmoid diverticuli with Hartmann's procedure.,POSTOPERATIVE DIAGNOSES: ,1. History of perforated sigmoid diverticuli with Hartmann's procedure.,2. Massive adhesions.,PROCEDURE PERFORMED:,1. Exploratory laparotomy.,2. Lysis of adhesions and removal.,3. Reversal of H...
gastroenterology, reversal of hartmann's colostomy, flexible sigmoidoscopy, cystoscopy, ureteral stent, lysis of adhesions, exploratory laparotomy, hartmann's colostomy, abdominal wall, immediately, adhesions, colostomy, sigmoidoscopy, bowel, anastomosis, abdominal
3,550
Esophagogastroduodenoscopy with biopsies. Gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, probable Billroth II anastomosis, and status post Whipple's pancreaticoduodenectomy.
Gastroenterology
Esophagogastroduodenoscopy with Biopsies
PREOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Chronic dyspepsia.,POSTOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Chronic dyspepsia.,3. Alkaline reflux gastritis.,4. Gastroparesis.,5. Probable Billroth II anastomosis.,6. Status post Whipple's pancreaticoduodenectomy.,PROCEDURE PE...
gastroenterology, gastroesophageal reflux disease, chronic dyspepsia, alkaline reflux gastritis, gastroparesis, whipple's pancreaticoduodenectomy, billroth ii anastomosis, gastroesophageal reflux, alkaline reflux, reflux gastritis, gif, esophagogastroduodenoscopy, dyspepsia, gastritis, anastomosis, pancreaticoduodenect...
3,551
Esophagogastroduodenoscopy with photo. Insertion of a percutaneous endoscopic gastrostomy tube. Neuromuscular dysphagia. Protein-calorie malnutrition.
Gastroenterology
Esophagogastroduodenoscopy & Gastrostomy Tube Insertion
PREOPERATIVE DIAGNOSES:,1. Neuromuscular dysphagia.,2. Protein-calorie malnutrition.,POSTOPERATIVE DIAGNOSES:,1. Neuromuscular dysphagia.,2. Protein-calorie malnutrition.,PROCEDURES PERFORMED:,1. Esophagogastroduodenoscopy with photo.,2. Insertion of a percutaneous endoscopic gastrostomy tube.,ANESTHESIA:, IV se...
gastroenterology, neuromuscular dysphagia, protein-calorie malnutrition, esophagogastroduodenoscopy, endoscopic, gastrostomy, percutaneous, gastrostomy tube, percutaneous endoscopic gastrostomy tube, protein calorie malnutrition, abdominal wall, dysphagia, stomach, abdominal, neuromuscular, tube,
3,552
Esophagogastroduodenoscopy with pseudo and esophageal biopsy. Hiatal hernia and reflux esophagitis. The patient is a 52-year-old female morbidly obese black female who has a long history of reflux and GERD type symptoms including complications such as hoarseness and chronic cough.
Gastroenterology
Esophagogastroduodenoscopy with Biopsies -2
PREOPERATIVE DIAGNOSIS: , Refractory dyspepsia.,POSTOPERATIVE DIAGNOSIS:,1. Hiatal hernia.,2. Reflux esophagitis.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with pseudo and esophageal biopsy.,ANESTHESIA:, Conscious sedation with Demerol and Versed.,SPECIMEN: , Esophageal biopsy.,COMPLICATIONS: , None.,HISTORY...
gastroenterology, refractory dyspepsia, hiatal hernia, reflux esophagitis, esophagogastroduodenoscopy, esophageal, pseudo, esophageal biopsy, ge junction, hiatal, hernia, esophagitis, antrum, gerd,
3,553
Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement. Malnutrition and dysphagia with two antral polyps and large hiatal hernia.
Gastroenterology
Esophagogastroduodenoscopy - 9
PREOPERATIVE DIAGNOSES: , Malnutrition and dysphagia.,POSTOPERATIVE DIAGNOSES: , Malnutrition and dysphagia with two antral polyps and large hiatal hernia.,PROCEDURES: , Esophagogastroduodenoscopy with biopsy of one of the polyps and percutaneous endoscopic gastrostomy tube placement.,ANESTHESIA: , IV sedation, 1% Xylo...
gastroenterology, antral, polyps, gastrostomy, endoscopic gastrostomy, hiatal hernia, abdominal wall, gastrostomy tube, esophagogastroduodenoscopy, malnutrition, dysphagia, abdominal
3,554
Esophagogastroduodenoscopy with gastric biopsies. Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.
Gastroenterology
Esophagogastroduodenoscopy with Biopsies - 1
PROCEDURE: , Esophagogastroduodenoscopy with gastric biopsies.,INDICATION:, Abdominal pain.,FINDINGS:, Antral erythema; 2 cm polypoid pyloric channel tissue, questionable inflammatory polyp which was biopsied; duodenal erythema and erosion.,MEDICATIONS: , Fentanyl 200 mcg and versed 6 mg.,SCOPE: , GIF-Q180.,PROCEDURE...
gastroenterology, gastric biopsies, duodenal erythema, inflammatory polyp, pyloric channel tissue, pyloric channel, esophagogastroduodenoscopy, pyloric, duodenal, duodenum, polypoid,
3,555
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.
Gastroenterology
Esophagogastroduodenoscopy - 7
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 d...
gastroenterology, antrum, esophageal tumor, varices, strictures, masses, duodenal bulb, peptic ulcer, duodenal, esophagus, esophagogastroduodenoscopy, panendoscope, peptic, inflammation, ulcer, disease, stomach
3,556
Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.
Gastroenterology
Esophagogastroduodenoscopy - 4
PROCEDURE: , Esophagogastroduodenoscopy with biopsy and colonoscopy with biopsy.,INDICATIONS FOR PROCEDURE: , A 17-year-old with history of 40-pound weight loss, abdominal pain, status post appendectomy with recurrent abscess formation and drainage. Currently, he has a fistula from his anterior abdominal wall out. It...
gastroenterology, olympus gif-160, pcf-160, endoscopy, crohn's disease, aphthous ulcers, esophagogastroduodenoscopy, endoscope, esophagus, duodenum, mucosal, stomach, biopsies, colonoscopy
3,557
Esophagogastroduodenoscopy. The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum.
Gastroenterology
Esophagogastroduodenoscopy - 6
PROCEDURE IN DETAIL: , Following premedication with Vistaril 50 mg and Atropine 0.4 mg IM, the patient received Versed 5.0 mg intravenously after Cetacaine spray to the posterior palate. The Olympus video gastroscope was then introduced into the upper esophagus and passed by direct vision to the descending duodenum. ...
gastroenterology, cetacaine, pylorus, antrum, duodenum, upper esophagus, esophagogastroduodenoscopy, descending, esophagusNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample ...
3,558
Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.
Gastroenterology
Esophagogastroduodenoscopy - 3
PROCEDURES:, Esophagogastroduodenoscopy and colonoscopy with biopsy and polypectomy.,REASON FOR PROCEDURE: , Child with abdominal pain and rectal bleeding. Rule out inflammatory bowel disease, allergic enterocolitis, rectal polyps, and rectal vascular malformations.,CONSENT:, History and physical examination was per...
gastroenterology, esophagus, stomach, duodenum, rectal polyp, polypectomy snare, olympus gif-160, endoscope was advanced, clo testing, polyp head, terminal ileum, polypectomy, biopsies, esophagogastroduodenoscopy, ileum, mucosa, colonoscopy,
3,559
Chronic abdominal pain and heme positive stool, antral gastritis, and duodenal polyp. Esophagogastroduodenoscopy with photos and antral biopsy.
Gastroenterology
Esophagogastroduodenoscopy - 8
PREOPERATIVE DIAGNOSIS:, Chronic abdominal pain and heme positive stool.,POSTOPERATIVE DIAGNOSES:,1. Antral gastritis.,2. Duodenal polyp.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with photos and antral biopsy.,ANESTHESIA: , Demerol and Versed.,DESCRIPTION OF PROCEDURE: , Consent was obtained after all risks ...
gastroenterology, endoscopy, gastritis, clo, histology, antrum, heme positive stool, esophagogastroduodenoscopy, duodenal, polyp, antral,
3,560
Esophagogastroduodenoscopy. The Olympus video panendoscope was advanced under direct vision into the esophagus. The esophagus was normal in appearance and configuration. The gastroesophageal junction was normal.
Gastroenterology
Esophagogastroduodenoscopy - 5
MEDICATIONS:,1. Versed intravenously.,2. Demerol intravenously.,DESCRIPTION OF THE PROCEDURE: , After informed consent, the patient was placed in the left lateral decubitus position and Cetacaine spray was applied to the posterior pharynx. The patient was sedated with the above medications. The Olympus video panend...
gastroenterology, duodenal bulb, gastric mucosa, olympus video, video panendoscope, gastroesophageal junction, esophagogastroduodenoscopy, gastroesophageal, pylorus, stomach, esophagus, scopeNOTE
3,561
Esophagogastroduodenoscopy, photography, and biopsy. Gastroesophageal reflux disease, hiatal hernia, and enterogastritis.
Gastroenterology
Esophagogastroduodenoscopy - 12
PREOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Hiatal hernia.,POSTOPERATIVE DIAGNOSES:,1. Gastroesophageal reflux disease.,2. Hiatal hernia.,3. Enterogastritis.,PROCEDURE PERFORMED: ,Esophagogastroduodenoscopy, photography, and biopsy.,GROSS FINDINGS: , The patient has a history of epigastric abdo...
gastroenterology, biopsy, gastroesophageal reflux, gastroesophageal reflux disease, duodenal bulb, gastroesophageal junction, hiatal hernia, enterogastritis, endoscopy, esophagogastroduodenoscopy, gastroesophageal,
3,562
Esophagogastroduodenoscopy with biopsy.
Gastroenterology
Esophagogastroduodenoscopy - 2
PROCEDURE:, Esophagogastroduodenoscopy with biopsy.,REASON FOR PROCEDURE:, The child with history of irritability and diarrhea with gastroesophageal reflux. Rule out reflux esophagitis, allergic enteritis, and ulcer disease, as well as celiac disease. He has been on Prevacid 7.5 mg p.o. b.i.d. with suboptimal contr...
gastroenterology, olympus gif-xq 160, diarrhea, gastroesophageal, esophagitis, reflux, clo testing, esophagogastroduodenoscopy with biopsy, endoscope, esophagus, stomach, duodenum, esophagogastroduodenoscopy
3,563
Esophagogastroduodenoscopy performed in the emergency department.
Gastroenterology
Esophagogastroduodenoscopy - 13
PROCEDURE PERFORMED: , Esophagogastroduodenoscopy performed in the emergency department.,INDICATION: , Melena, acute upper GI bleed, anemia, and history of cirrhosis and varices.,FINAL IMPRESSION,1. Scope passage massive liquid in stomach with some fresh blood near the fundus, unable to identify source due to gastric ...
gastroenterology, gi bleed, anemia, cirrhosis, stomach, fundus, hiatal hernia, esophagogastroduodenoscopy, erythromycin, varices, esophagus,
3,564
Esophagogastroduodenoscopy with bile aspirate. Recurrent right upper quadrant pain with failure of antacid medical therapy. Normal esophageal gastroduodenoscopy.
Gastroenterology
Esophagogastroduodenoscopy - 11
PREOPERATIVE DIAGNOSIS:, Recurrent right upper quadrant pain with failure of antacid medical therapy.,POSTOPERATIVE DIAGNOSIS: , Normal esophageal gastroduodenoscopy.,PROCEDURE PERFORMED:, Esophagogastroduodenoscopy with bile aspirate.,ANESTHESIA: , IV Demerol and Versed in titrated fashion.,INDICATIONS: , This 41-ye...
gastroenterology, bile aspirate, esophageal, gastroduodenoscopy, kinevac, oropharynx, esophagogastroduodenoscopy, gastroscope
3,565
Patient presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days.
Gastroenterology
ER Report - Stomach Pain
CHIEF COMPLAINT:, Stomach pain for 2 weeks.,HISTORY OF PRESENT ILLNESS:, The patient is a 45yo Mexican man without significant past medical history who presents to the emergency room with complaints of mid-epigastric and right upper quadrant abdominal pain for the last 14 days. The pain was initially crampy and burning...
null
3,566
Ivor-Lewis esophagogastrectomy, feeding jejunostomy, placement of two right-sided 28 French chest tubes, and right thoracotomy.
Gastroenterology
Esophagogastrectomy, Jejunostomy, & Chest Tubes
OPERATION,1. Ivor-Lewis esophagogastrectomy.,2. Feeding jejunostomy.,3. Placement of two right-sided #28-French chest tubes.,4. Right thoracotomy.,ANESTHESIA: ,General endotracheal anesthesia with a dual-lumen tube.,OPERATIVE PROCEDURE IN DETAIL: , After obtaining informed consent from the patient, including a tho...
gastroenterology, ivor-lewis, esophagogastrectomy, jejunostomy, thoracotomy, dual-lumen tube, chest tubes, bovie electrocautery, chest, endotracheal, electrocautery, abdomen, gastric, esophagus, tubes, vicryl, stomach,
3,567
Endoscopic retrograde cholangiopancreatography (ERCP) with brush cytology and biopsy.
Gastroenterology
ERCP
PROCEDURE:, Endoscopic retrograde cholangiopancreatography with brush cytology and biopsy.,INDICATION FOR THE PROCEDURE:, Patient with a history of chronic abdominal pain and CT showing evidence of chronic pancreatitis, with a recent upper endoscopy showing an abnormal-appearing ampulla.,MEDICATIONS:, General anesthesi...
gastroenterology, endoscopic retrograde cholangiopancreatography, biopsy, brush cytology, cholangiopancreatography, pancreatitis, endoscopy, duodenoscope, wilson-cooke tritome, ampulla, common bile duct, ercp, endoscopic, biliary, pancreatic, duct, biopsies, cytology
3,568
Esophagogastroduodenoscopy with biopsy, a 1-year-10-month-old with a history of dysphagia to solids.
Gastroenterology
Esophagogastroduodenoscopy - 1
PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS: , A 1-year-10-month-old with a history of dysphagia to solids. The procedure was done to rule out organic disease.,POSTOPERATIVE DIAGNOSES: , Loose lower esophageal sphincter and duodenal ulcers.,CONSENT: , The consent is signed.,MEDICATIONS:...
gastroenterology, esophagogastroduodenoscopy, esophageal, biopsies, endoscope
3,569
The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm.
Gastroenterology
Endovascular Abdominal Aortic Aneurysm Repair
PREOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,POSTOPERATIVE DIAGNOSIS: , Abdominal aortic aneurysm.,OPERATION PERFORMED:, Endovascular abdominal aortic aneurysm repair.,FINDINGS: , The patient was brought to the OR with the known 4 cm abdominal aortic aneurysm + 2.5 cm right common iliac artery aneurysm. A Gor...
gastroenterology, gore, common iliac artery aneurysm, abdominal aortic aneurysm repair, abdominal aortic aneurysm, common iliac, aortic aneurysm, iliac artery, artery, aneurysm, iliac, abdominal, aortic, arteries,
3,570
Esophagogastroduodenoscopy with biopsy and snare polypectomy - Iron-deficiency anemia
Gastroenterology
Esophagogastroduodenoscopy
PROCEDURE:, Esophagogastroduodenoscopy with biopsy and snare polypectomy.,INDICATION FOR THE PROCEDURE:, Iron-deficiency anemia.,MEDICATIONS:, MAC.,The risks of the procedure were made aware to the patient and consisted of medication reaction, bleeding, perforation, and aspiration.,PROCEDURE:, After informed consent an...
gastroenterology, esophagogastroduodenoscopy, iron-deficiency, iron-deficiency anemia, anemia, biopsy, endoscope, esophageal mucosa, esophagus, hiatal hernia, polypectomy, snare polypectomy, esophagogastroduodenoscopy with biopsy, iron deficiency anemia,
3,571
Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps. Nausea and vomiting and upper abdominal pain.
Gastroenterology
Esophagogastroduodenoscopy - 10
PREOPERATIVE DIAGNOSIS: , Nausea and vomiting and upper abdominal pain.,POST PROCEDURE DIAGNOSIS: ,Normal upper endoscopy.,OPERATION: , Esophagogastroduodenoscopy with antral biopsies for H. pylori x2 with biopsy forceps.,ANESTHESIA:, IV sedation 50 mg Demerol, 8 mg of Versed.,PROCEDURE: , The patient was taken to th...
gastroenterology, h. pylori, forceps, antral biopsies, ge junction, esophagogastroduodenoscopy, pylori, esophagus, antral,
3,572
Upper endoscopy with biopsy. The patient admitted for coffee-ground emesis, which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding.
Gastroenterology
Endoscopy With Biopsy
PROCEDURE:, Upper endoscopy with biopsy.,PROCEDURE INDICATION: , This is a 44-year-old man who was admitted for coffee-ground emesis, which has been going on for the past several days. An endoscopy is being done to evaluate for source of upper GI bleeding.,Informed consent was obtained. Outlining the risks, benefits...
gastroenterology, coffee-ground emesis, gi bleeding, upper endoscopy, iv push, esophagus, duodenum, mucosa, stomach, endoscopy, biopsy,
3,573
Intermittent rectal bleeding with abdominal pain.
Gastroenterology
Endoscopy - 4
PROCEDURE: , Endoscopy.,CLINICAL INDICATIONS: , Intermittent rectal bleeding with abdominal pain.,ANESTHESIA: , Fentanyl 100 mcg and 5 mg of IV Versed.,PROCEDURE:, The patient was taken to the GI lab and placed in the left lateral supine position. Continuous pulse oximetry and blood pressure monitoring were in place....
gastroenterology, duodenum, stomach, hiatal hernia, endoscopy, antrum, hiatal, hernia, gastroesophageal, scope, esophagus, abdominal
3,574
Epigastric herniorrhaphy. Epigastric hernia.
Gastroenterology
Epigastric Herniorrhaphy
PREOPERATIVE DIAGNOSIS: , Epigastric hernia.,POSTOPERATIVE DIAGNOSIS: , Epigastric hernia.,OPERATIONS:, Epigastric herniorrhaphy.,ANESTHESIA: , General inhalation.,PROCEDURE: , Following attainment of satisfactory anesthesia, the patient's abdomen was prepped with Hibiclens and draped sterilely. The hernia mass had b...
gastroenterology, hibiclens, epigastric herniorrhaphy, epigastric hernia, herniorrhaphy,
3,575
Normal upper GI endoscopy.
Gastroenterology
Endoscopy Template
INDICATIONS:, Dysphagia.,PREMEDICATION:, Topical Cetacaine spray and Versed IV.,PROCEDURE:,: The scope was passed into the esophagus under direct vision. The esophageal mucosa was all unremarkable. There was no evidence of any narrowing present anywhere throughout the esophagus and no evidence of esophagitis. The...
gastroenterology, dysphagia, cetacaine spray, esophagus, esophageal mucosa, duodenum, scope was passed, upper gi, gi endoscopy, gi, endoscopy, scope
3,576
Patient with dysphagia.
Gastroenterology
Endoscopy - 3
PROCEDURES PERFORMED: , Endoscopy.,INDICATIONS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:, Esophageal ring and active reflux esophagitis.,PROCEDURE: , Informed consent was obtained prior to the procedure from the parents and patient. The oral cavity is sprayed with lidocaine spray. A bite block is placed. Versed IV 5 m...
gastroenterology, active reflux esophagitis, ge junction, distal esophageal, active reflux, reflux esophagitis, dysphagia, esophagus, scope, ge, junction, endoscopy, esophageal, reflux, esophagitis, distal, balloon
3,577
EGD with photos and biopsies. This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and odynophagia. She has a previous history of hiatal hernia. She was on Prevacid currently.
Gastroenterology
EGD With Photos & Biopsies.
1. Odynophagia.,2. Dysphagia.,3. Gastroesophageal reflux disease rule out stricture.,POSTOPERATIVE DIAGNOSES:,1. Antral gastritis.,2. Hiatal hernia.,PROCEDURE PERFORMED: EGD with photos and biopsies.,GROSS FINDINGS: This is a 75-year-old female who presents with difficulty swallowing, occasional choking, and ody...
gastroenterology, odynophagia, dysphagia, gastroesophageal reflux disease, antral gastritis, hiatal hernia, difficulty swallowing, esophagus, stomach, duodenal, egd, biopsies, hiatal, hernia,
3,578
Upper gastrointestinal endoscopy.
Gastroenterology
Endoscopy
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 inserte...
gastroenterology, upper gastrointestinal endoscopy, ge junction, gastrointestinal, esophagus, endoscopy, stomach, duodenitis, bleeding
3,579
EGD with dilation for dysphagia.
Gastroenterology
EGD with Dilation
INDICATION: ,
gastroenterology, egd, hurricaine spray, olympus endoscope, savary wire, cricopharyngeus, decubitus, dilator, duodenum, dysphagia, esophagus, hiatal hernia, peptic, pylorus, stomach, tortuosity, egd with dilation, tortuous, scope, hiatal, hernia,
3,580
Patient admitted because of recurrent nausea and vomiting, with displacement of the GEJ feeding tube.
Gastroenterology
EGD with Biopsy - 1
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...
gastroenterology, recurrent nausea and vomiting, egd with biopsy, nausea and vomiting, gastrojejunal feeding tube, feeding tube remnant, recurrent nausea, gej feeding, gastrojejunal feeding, proximal esophagus, hiatal hernia, feeding tube, egd, biopsy, nausea, vomiting, gej, gastrojejunal, duodenum, esophagitis, multip...
3,581
Melena and solitary erosion over a fold at the GE junction, gastric side.
Gastroenterology
Endoscopy - 2
PREOPERATIVE DIAGNOSIS:, Melena.,POSTOPERATIVE DIAGNOSIS:, Solitary erosion over a fold at the GE junction, gastric side.,PREMEDICATIONS: , Versed 5 mg IV.,REPORTED PROCEDURE:, The Olympus gastroscope was used. The scope was placed in the upper esophagus under direct visit. The esophageal mucosa was entirely norma...
gastroenterology, ge junction, melena, olympus gastroscope, solitary erosion, descending duodenum, esophageal mucosa, esophagus, gastric side, pylorus duodenum bulb, stomach, liver profile, colonoscopy, ge junction gastric, junction gastric, endoscopy, duodenum, scope, solitary, junction, gastric, erosion,
3,582
Common description of EGD
Gastroenterology
EGD Template - 4
null
gastroenterology, lateral supine position, stomach, duodenum, stricture, egd, advanced, scopeNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed med...
3,583
Common description of EGD.
Gastroenterology
EGD Template - 3
without difficulty, into the upper GI tract. The anatomy and mucosa of the esophagus, gastroesophageal junction, stomach, pylorus, and small bowel were all carefully inspected. All structures were visually normal in appearance. Biopsies of the distal duodenum, gastric antrum, and distal esophagus were taken and sent...
gastroenterology, gastric antrum, distal duodenum, distal esophagus, esophagus, duodenum, clo test, upper gi tract, upper gi, gi tract, egd, endoscope, gi, tract, structures, distal, biopsyNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpos...
3,584
Esophagogastroduodenoscopy with biopsy. Patient has had biliary colic-type symptoms for the past 3-1/2 weeks, characterized by severe pain, and brought on by eating greasy foods.
Gastroenterology
EGD with Biopsy - 2
TYPE OF PROCEDURE: , Esophagogastroduodenoscopy with biopsy.,PREOPERATIVE DIAGNOSIS:, Abdominal pain.,POSTOPERATIVE DIAGNOSIS:, Normal endoscopy.,PREMEDICATION: , Fentanyl 125 mcg IV, Versed 8 mg IV.,INDICATIONS: ,This healthy 28-year-old woman has had biliary colic-type symptoms for the past 3-1/2 weeks, characteri...
gastroenterology, hida scan, endoscopy, gallstones, olympus, esophagogastroduodenoscopy with biopsy, biliary colic, colic type, greasy foods, normal endoscopy, esophagogastroduodenoscopy, biliary, colic, greasy, foods, cholecystectomy, biopsy,
3,585
EGD with PEG tube placement using Russell technique. Protein-calorie malnutrition, intractable nausea, vomiting, and dysphagia, and enterogastritis.
Gastroenterology
EGD & PEG Tube Placement
PREOPERATIVE DIAGNOSES:,1. protein-calorie malnutrition.,2. Intractable nausea, vomiting, and dysphagia.,POSTOPERATIVE DIAGNOSES:,1. Protein-calorie malnutrition.,2. Intractable nausea, vomiting, and dysphagia.,3. Enterogastritis.,PROCEDURE PERFORMED: , EGD with PEG tube placement using Russell technique.,ANESTHES...
gastroenterology, protein-calorie malnutrition, nausea, vomiting, peg tube placement, russell technique, peg tube, egd, protein, dysphagia, malnutrition, enterogastritis
3,586
Common description of EGD.
Gastroenterology
EGD Template - 2
The patient was placed in the left lateral decubitus position, medicated with the above medications to achieve and maintain a conscious sedation. Vital signs were monitored throughout the procedure without evidence of hemodynamic compromise or desaturation.,The Olympus single-channel endoscope was passed under direct ...
gastroenterology, gastric cavity, lateral decubitus position, endoscope, olympus, egd, visualization, cavity, duodenum, esophagusNOTE
3,587
Upper endoscopy, patient with dysphagia.
Gastroenterology
Endoscopy - 1
PROCEDURE:, Upper endoscopy.,PREOPERATIVE DIAGNOSIS: , Dysphagia.,POSTOPERATIVE DIAGNOSIS:,1. GERD, biopsied.,2. Distal esophageal reflux-induced stricture, dilated to 18 mm.,3. Otherwise normal upper endoscopy.,MEDICATIONS: , Fentanyl 125 mcg and Versed 7 mg slow IV push.,INDICATIONS: , This is a 50-year-old white...
gastroenterology, lateral decubitus position, gastroesophageal reflux disease, gerd, normal upper endoscopy, mucosa was normal, esophageal reflux, stricture dilated, upper endoscopy, distal, esophageal, aciphex, biopsies, dysphagia, endoscopy, reflux,
3,588
Common description of EGD.
Gastroenterology
EGD Template - 1
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gastroenterology, duodenal mucosa, duodenal, esophageal mucosa, fundus, egd, entire, mucosaNOTE,: Thesetranscribed medical transcription sample reports and examples are provided by various users andare for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports.These transcribed medic...
3,589
Esophagogastroduodenoscopy, patient with dysphagia.
Gastroenterology
EGD - 2
PROCEDURES PERFORMED: , Esophagogastroduodenoscopy.,PREPROCEDURE DIAGNOSIS: , Dysphagia.,POSTPROCEDURE DIAGNOSIS: , Active reflux esophagitis, distal esophageal stricture, ring due to reflux esophagitis, dilated with balloon to 18 mm.,PROCEDURE: , Informed consent was obtained prior to the procedure with special attent...
gastroenterology, distal esophageal stricture, reflux esophagitis, distal esophageal, esophageal stricture, barium swallow, esophagogastroduodenoscopy, esophagitis, esophageal, heartburn, stricture, endoscopy, reflux, dysphagia
3,590
EGD and colonoscopy. Blood loss anemia, normal colon with no evidence of bleeding, hiatal hernia, fundal gastritis with polyps, and antral mass.
Gastroenterology
EGD & Colonoscopy
PREOPERATIVE DIAGNOSIS: , Blood loss anemia.,POSTOPERATIVE DIAGNOSES:,1. Normal colon with no evidence of bleeding.,2. Hiatal hernia.,3. Fundal gastritis with polyps.,4. Antral mass.,ANESTHESIA: , Conscious sedation with Demerol and Versed.,SPECIMEN: ,Antrum and fundal polyps.,HISTORY: , The patient is a 66-year-o...
gastroenterology, esophagus, gastroscope, hypopharynx, rectum, fundal gastritis, antral mass, hiatal hernia, egd, hernia, polyps, colonoscopy,
3,591
Problems with dysphagia to solids and had food impacted in the lower esophagus. Upper endoscopy to evaluate the esophagus.
Gastroenterology
EGD - 1
HISTORY OF PRESENT ILLNESS:, Briefly, this is a 17-year-old male, who has had problems with dysphagia to solids and recently had food impacted in the lower esophagus. He is now having upper endoscopy to evaluate the esophagus after edema and inflammation from the food impaction has resolved, to look for any stricture...
gastroenterology, length of the esophagus, food impacted, lower esophagus, upper endoscopy, entire length, eosinophilic esophagitis, egd, dysphagia, solids, impacted, endoscopy, mucosal, endoscope, biopsies, barrett, stomach, stricture, eosinophilic, esophagitis, esophagus,
3,592
Diagnostic laparotomy, exploratory laparotomy, Meckel's diverticulectomy, open incidental appendectomy, and peritoneal toilet.
Gastroenterology
Diverticulectomy & Laparotomy
PREOPERATIVE DIAGNOSIS: , Acute appendicitis.,POSTOPERATIVE DIAGNOSIS: , Perforated Meckel's diverticulum.,PROCEDURES PERFORMED:,1. Diagnostic laparotomy.,2. Exploratory laparotomy.,3. Meckel's diverticulectomy.,4. Open incidental appendectomy.,5. Peritoneal toilet.,ANESTHESIA: , General endotracheal.,ESTIMATED BL...
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3,593
Esophagogastroduodenoscopy and colonoscopy with polypectomy
Gastroenterology
EGD - Colonoscopy - Polypectomy
PROCEDURES:,1. Esophagogastroduodenoscopy.,2. Colonoscopy with polypectomy.,PREOPERATIVE DIAGNOSES:,1. History of esophageal cancer.,2. History of colonic polyps.,POSTOPERATIVE FINDINGS:,1. Intact surgical intervention for a history of esophageal cancer.,2. Melanosis coli.,3. Transverse colon polyps in the setti...
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3,594
Patient with complaint of symptomatic cholelithiasis.
Gastroenterology
Discharge Summary - Cholelithiasis
ADMISSION DIAGNOSIS: , Symptomatic cholelithiasis.,DISCHARGE DIAGNOSIS:, Symptomatic cholelithiasis.,SERVICE: , Surgery.,CONSULTS:, None.,HISTORY OF PRESENT ILLNESS: , Ms. ABC is a 27-year-old woman who apparently presented with complaint of symptomatic cholelithiasis. She was afebrile. She was taken by Dr. X to th...
gastroenterology, medifast, liquid diet, symptomatic cholelithiasis, symptomatic, cholelithiasis, discharge,
3,595
Dysphagia and hematemesis while vomiting. Diffuse esophageal dilatation/hematemesis
Gastroenterology
Dysphagia & Hematemesis
CHIEF COMPLAINT: , Dysphagia and hematemesis while vomiting.,HISTORY OF PRESENT ILLNESS: , This is a 53-year-old African American female with 15 years known history of HIV and hepatitis B, and known history of compensated heart failure, COPD, who presented today with complaint of stuck food in her esophagus, bloody cou...
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3,596
Patient with a history of a Nissen fundoplication performed six years ago for gastric reflux.
Gastroenterology
Discharge Summary - 10
ADMITTING DIAGNOSES:, Hiatal hernia, gastroesophageal reflux disease reflux.,DISCHARGE DIAGNOSES:, Hiatal hernia, gastroesophageal reflux disease reflux.,SECONDARY DIAGNOSIS: , Postoperative ileus.,PROCEDURES DONE: , Hiatal hernia repair and Nissen fundoplication revision.,BRIEF HISTORY: , The patient is an 18-year-o...
gastroenterology,
3,597
Modified Barium swallow (Deglutition Study) for Dysphagia with possible aspiration.
Gastroenterology
Deglutition Study - Modified Barium swallow
EXAM: , Modified barium swallow.,SYMPTOM:, Dysphagia with possible aspiration.,FINDINGS:, A cookie deglutition study was performed. The patient was examined in the direct lateral position.,Patient was challenged with thin liquids, thick liquid, semisolids and solids.,Persistently demonstrable is the presence of pene...
gastroenterology, aspiration, deglutition study, thin liquids, thick liquid, semisolids, solids, modified barium swallow, barium swallow, dysphagia, deglutition,
3,598
CT scan of the abdomen and pelvis with contrast to evaluate abdominal pan.
Gastroenterology
CT Scan of Abdomen & Pelvis with Contrast
EXAM: , CT scan of the abdomen and pelvis with contrast.,REASON FOR EXAM: , Abdominal pain.,COMPARISON EXAM: , None.,TECHNIQUE: , Multiple axial images of the abdomen and pelvis were obtained. 5-mm slices were acquired after injection of 125 cc of Omnipaque IV. In addition, oral ReadiCAT was given. Reformatted sagit...
gastroenterology, ct scan, abdominal pain, multiple axial images, abdomen and pelvis, adrenal glands, chest ct, coronal, gallbladder, kidneys, liver, lymphadenopathy, nodules, osteoblastic, osteolytic, pancreas, sagittal, spleen, with contrast, free fluid, ct, abdomen, pelvis,
3,599
Generalized abdominal pain, nausea, diarrhea, and recent colonic resection. CT abdomen with and without contrast and CT pelvis with contrast. Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100 mL of Isovue-300.
Gastroenterology
CT Abdomen & Pelvis - 8
CT ABDOMEN WITH AND WITHOUT CONTRAST AND CT PELVIS WITH CONTRAST,REASON FOR EXAM: , Generalized abdominal pain, nausea, diarrhea, and recent colonic resection in 11/08.,TECHNIQUE:, Axial CT images of the abdomen were obtained without contrast. Axial CT images of the abdomen and pelvis were then obtained utilizing 100...
gastroenterology, abdominal pain, nausea, diarrhea, colonic resection, axial ct images, ct abdomen, isovue, inflammatory, urinary, bladder, abdominal, colonic, wall, thickening, axial, bowel, contrast, attenuation, pelvis, ct, abdomen