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Manipulative Procedures Example 8

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Gastroscopic Report

  • Hospital No.: 000026
  • Ward/Clinic: Surgery
  • Date: 02/26/91
  • Name: Selden McGlutton
  • Age: 56
  • Race: Black
  • Sex: Female

2/8/91

Diagnosis:

Obstruction due to old ulcer disease or malignancy

Brief G.I. History:

Loss of appetite, bloating and occasional bouts of vomiting of retained food

Pertinent Physical Findings:

Epigastric mass

Gastric Analysis:

Total _____ Free ________ Histamine _________

Stool Examination _______________ Blood Count ______________


Summary G.I. X-rays:

Gastroscopic Findings:

Gastroscope was passed into the stomach without difficulty. The antrum was identified and observed constriction by an extrinsic mass lesion.

No intrinsic mucosal lesions were seen but the entire antrum could not be seen because of the degree of constriction.

There was no peristalsis seen to move into the area of constriction. Because of a large amount of retained secretions, adequate visualization of the remainder of the stomach was not attempted.

Impression:

Malignant disease involving the antrum - constricting the antrum.

Adrian Maison, M.D.