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Manipulative Procedures Example 7

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Gastroscopic Report

  • Hospital No.: 000025
  • Ward/Clinic: E606
  • Date: 01/08/91
  • Name: Eva Eton
  • Age: 62
  • Race: White
  • Sex: Female

Diagnosis R/O:

  • Carcinoma of stomach
  • Brief G.I. History: Bloat, loss of appetite and epigastric discomfort
  • Pertinent Physical Findings: Loss of weight-10 lbs.

Gastric Analysis: Total_____ Free_______ Histamine_________
Stool Examination_____________ Blood Count_____________


Summary G.I. X-rays:

Two-35 mm pictures taken with esophagoscope camera

Gastroscopic Findings:

The fiberoptic gastroscope was passed into the stomach with ease. There is a fungating mass constricting the antrum. There are hemorrhagic and necrotic areas in the mass. The esophagoscope (flexible fiberoptic scope) was also placed in the stomach and a small Bx of the mass was obtained. A small shallow transverse laceration of the esophagus was incidentally noted.

Impression:

Prob. adenocarcinoma of the stomach

C.A. Pendergast, MD