SUTTER COAST HOSPITAL
EXAMPLE - OPERATIVE REPORT, Tien Nguyen, D.O.
[DATE OF OPERATION and SURGEON automatically added by
iTran]
PREOPERATIVE DIAGNOSES:
1. Chronic nausea.
2. Intermittent dysphagia.
POSTOPERATIVE DIAGNOSES:
1. Small hiatal hernia.
2. Gastritis.
3. Gastric ulcers.
4. Duodenal bulb inflammation.
5. Duodenitis.
OPERATIVE PROCEDURE: Esophagogastroduodenoscopy with cold
forceps biopsy of the antrum.
ANESTHESIA: Conscious sedation using Versed, a total of
5 mg, and fentanyl, a total of 100 mcg.
COMPLICATIONS:
None.
ESTIMATED BLOOD LOSS:
Negligible.
OPERATIVE INDICATIONS: The patient is a 61-year-old
Caucasian male who presents with a complaint of chronic
nausea for several months. He stated he is also having
intermittent dysphagia, although he denies any weight loss.
The recommendation was for an EGD and indicated procedure.
DESCRIPTION OF PROCEDURE: The risks, benefits,
complications and alternatives were discussed with the
patient, and consent was obtained. The patient was taken
to the endoscopy suite. A timeout was taken to identify
the patient, procedure and his allergies.
He was given 4% lidocaine solution to gargle, then he was
placed in the left lateral decubitus position. The back of
his throat was sprayed with 2% Cetacaine spray and a bite
block was inserted. We began sedating, starting with 5 mg
of Versed and 50 mcg of fentanyl. Then, a well-lubricated
pediatric endoscope was gently advanced through the
oropharynx and down the esophagus with no difficulty. The
esophagus was essentially normal; no evidence of
strictures, no varices and no bleeding. A minimal amount
of dysplastic changes were noted at the GE junction.
Inside the stomach, the scope was retroflexed and a small
hiatal hernia was noted. There was diffuse gastritis
noted, mainly in the antrum and prepyloric area. The scope
was advanced into the pylorus. There was inflammation
noted in the duodenal bulb. We also noted inflammation
without any active bleeding inside of the first portion of
the duodenum. The scope was pulled back into the
prepyloric area, whereby a cold forceps biopsy was taken
for SRU. Another cold forceps biopsy was taken in the
antrum near one of the gastric ulcers. Then, I evacuated
the stomach of as much of the air and fluid as possible. I
removed the scope and the bite block completely. The
patient tolerated the procedure well and was taken to the
Recovery Room in satisfactory condition.
RECOMMENDATIONS: I recommend that the patient be placed on
Nexium daily for another 2 months, and for the patient to
begin on a low-acidic diet. Also, I recommend the patient
stop smoking.