Upper endoscopy

PROCEDURE:  Upper endoscopy.

INDICATION:  Epigastric pain.

Indications, risks, benefits, alternatives and limitations explained to the patient.  Risk of anesthesia, perforation, bleeding, infection, cardiopulmonary risk, morbidity, and mortality was discussed possibly missing a lesion, polyp, growth, mass, and cancer was discussed.  Risk of cold biopsy, hot biopsy, and polypectomy was discussed.  Oropharyngeal injury, sore throat, bronchitis, aspiration pneumonia, and sinusitis were discussed.  All these discussions were done in the office.  She understood all of the above.  All her questions were answered.  She agreed to the procedure.  She came to the endoscopy unit.  She had no further questions or concerns.  Physical exam was grossly negative.  She then gave an informed consent.

She was taken to the endoscopy room.  Anesthesia provided sedation.  The scope was advanced to esophagus, stomach and duodenum.  Third portion, second portion, and bulb were normal.  Pylorus was normal.  Antrum and body was examined.  There was presence of gastritis.  Biopsy was taken.  On retroflexion, _____ fundus and cardia were normal.  The stomach insufflated very well.  No abnormal folds were seen.  Esophageal gastric junction was normal.  Esophageal mucosa was normal.  Procedure completed.  The patient tolerated the procedure well.

IMPRESSION: Gastritis and epigastric pain.  Workup so far was negative.  Etiology was unclear.

PLAN:  Continue Protonix and I have recommended, she do DISIDA scan with ejection fraction and we will follow up in the office in 2 weeks.  We will make further recommendations depending on the clinical course and findings of the above results and the biopsy.