T7-1A OPERATIVE REPORT, ESOPHAGOGASTRODUODENOSCOPY

Essay

T7-1A OPERATIVE REPORT, ESOPHAGOGASTRODUODENOSCOPY
POSTOPERATIVE DIAGNOSIS:
1. Moderate gastritis with superficial ulcerations in the gastric antrum.
2. Large duodenal bulb ulcer, 1.5 cm (centimeter) in size, not bleeding. No vessel.
3. Large 2-3 cm post bulbar ulcer, not bleeding. No vessel.
PROCEDURE PERFORMED: Esophagogastroduodenoscopy
INDICATION: This is a 63-year-old white male alcoholic who has respiratory failure and pneumonia. This morning he developed bright red blood from his NG tube. His hemoglobin was around 9 and has fallen to 7.8. The endoscopy is indicated to rule out esophageal varices.
PREOPERATIVE MEDICATION: Patient is on a Versed drip.
PROCEDURE: The flexible Pentax video double channel endoscope was passed without difficulty into the oropharynx. The gastroesophageal junction was seen at 40 cm. Inspection of the esophagus revealed no erythema, ulceration, exudate, friability, or other mucosal abnormalities. The stomach proper was entered, and immediately seen in the antrum was erythema, friability, and some superficial gastric ulcerations, not bleeding. We entered the pylorus and could see a large 1.5-cm moderately deep duodenal bulb ulcer with no vessel or pigmented areas. Beyond this in the post-bulbar ulcer was a large 2-3 cm superficial post bulbar ulceration, not bleeding, without visible vessel. Photographs were obtained. On retroflexion, no lesions were seen. The patient tolerated the procedure well.
IMPRESSION:
1. Moderate gastritis with superficial gastric ulcerations, not bleeding.
2. Duodenal bulb ulcer, 1.5 cm, moderately deep, with no vessel, clot, or pigmented areas.
3. A post-bulbar 2.5 to 3 cm (centimeter) stomach ulceration, superficial, not bleeding.
SUGGESTIONS:
1. Continue IV (intravenous) Protonix.
2. Follow hemoglobins.
T7-1A:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________