- Medical Report 7 1 Operative Report Patient Doe John 123456 Medical Record Date Roome 200 Preoperative Diagnosis 1 (450.59 KiB) Viewed 55 times
MEDICAL REPORT 7.1 OPERATIVE REPORT PATIENT: Doe, John 123456 MEDICAL RECORD #: DATE: ROOME: 200 PREOPERATIVE DIAGNOSIS: Reflux esophagitis gastritis, bleeding prepyloric ulcer, diverticulos s. SURGEON: Jonn Jones M.D. OPERATION: 1. EGD with biopsies with injection of bleeding preoyloric ulcer. 2. Colonoscopy. ANESTHESIA: Sedation INDICATION FOR THE PROCEDURE:This 68-year-old gentleman presented with history of G b'eeding. Patient had been vom ting Also, he had been passing sorre dark colored bowe movements and some bright red blood in the stoo's. It was decided to go ahead and do an EGD and colonoscopy to find the source of beeding. DESCRIPTION OF THE PROCEDURE: 1. EGO with bioosies with injection and cauterization of the bleeding ulcer. With the patient in the left lateral position scope was introduced Proximally, the esophagus was found to be norina_Distaly, the patient had evidence of grade 1 refux esophagitis Scope was entered into the stomach.On entering the stomach, there was evidence of diffuse gastritis in the stomach Multiple biopsies were taken and sent for histopathology and study for Hoylori AJ maneuve was done A look at the fundus was made. Fundus had evidence of gastritis Scope was then straightened up At the level of the pylorus, there was a bleeding oyloric ulcer. The ulcer was injected with Epinephrine to control the bleed- ing Following this, the scope was introduced through the pylorus into the first and second parts of the duodenum This was found to be normalScope was withdrawn On withdrawing the scope, another close look at the stomach and the esophagus was made. With the exception of the reflux esophagitis, gastritis and bleeding prepyloric ulcer, no other lesion was found