請幫忙看一下胃鏡報告

來源: dogmommy 於 2016-04-29 15:55:42 [檔案] [博客] [舊帖] [給我悄悄話] 本文已被閱讀：次 (2040 bytes)

Anesthesia Required Next Case: No
Procedure: Upper GI endoscopy
Indications: Epigastric abdominal pain
Medicines: Fentanyl IV 75 mcgs, Lidocaine 4% Spray 1
dose, Mylicon po 1 cc, Versed IV 4 mgs
Complications: No immediate complications. Estimated
blood loss: None.
Estimated Blood Loss: Estimated blood loss: none.
Procedure: After obtaining informed consent, the
endoscope was passed under direct vision.
Throughout the procedure, the patient's
blood pressure, pulse, and oxygen
saturations were monitored continuously.
The Endoscope was introduced through the
mouth, and advanced to the second part of
duodenum. The upper GI endoscopy was
accomplished without difficulty. The
patient tolerated the procedure well.
Findings:
The Z-line was irregular and was found at the
gastroesophageal junction.
A single small papule (nodule) with no bleeding and no
stigmata of recent bleeding was found in the prepyloric
region of the stomach. Staining chromoscopy with methylene
blue was performed. Biopsies were taken with a cold
forceps for histology.
The exam of the stomach was otherwise normal.
The examined duodenum was normal. Biopsies were taken with
a cold forceps for evaluation of celiac disease.
Impression: - Z-line irregular, at the
gastroesophageal junction.
- A single small papule (nodule) with no
bleeding and no stigmata of recent
bleeding was found in the stomach.
Chromoscopy performed. Biopsied.
- Normal examined duodenum. Biopsied.
Recommendation: - Await pathology results.
- The findings and recommendations were
discussed with the patient.
- If pathology reveals intestinal
metaplasia w/o dysplasia, the patient
will require repeat EGD w/