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QUESTION

Surgical Case #3 Operative Report Procedure: Esophagogastroduodenoscopy Instrument Used: Olympus GIF-100 Premedication:

Surgical Case #3

Operative Report

Procedure:

Esophagogastroduodenoscopy

Instrument Used:

Olympus GIF-100

Premedication:

The patient was premedicated with a total of Fentanyl, 50 mcg, and Versed, 4 mg, intravenously.

Indications:

The patient has presented with recurrent dysphagia. She has a history of a Schatzki's ring, which has been dilated in the past.

Procedure:

The endoscope was inserted from the mouth into the esophagus without difficulty.

The esophageal mucosa was normal. A reformed Schatzki's ring was located at the Z line, which was at approximately 29 cm. The endoscope could be inserted through this area with no resistance. The ring was located above a 3-cm hiatal hernia. The stomach, duodenal bulb, and descending duodenum were all normal. After the endoscope was withdrawn, a #60 French Maloney dilator was passed with very mild resistance. The patient tolerated the procedure well, and there were no immediate complications.

Impression:

1. A reformed Schatzki's ring, which was dilated

2. A 3-cm hiatal hernia

Code(s): ___________________________________________

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