Esophagogastroduodenoscopy (EGD) Report

Attending Physician:[select name="attending" value="Seth Lapin, DO|Aaron Tokayer, MD|Dmitriy Khodorskiy, MD|Elliot Fuhrer, MD|Ira Mayer, MD|James Park, MD|Linda Lee, MD|Manol Jovani, MD|Michael Kantrowitz, DO|Negar Niknam, MD|Yuriy Tsirlin, MD"]
Fellow:[select name="fellow" value="Tanuj Chokshi, DO|Samantha Ehrlich, MD|Sadat Iqbal, MD|Steve Obanor, MD|Kaveh Zivari, MD|Larisa Garkusha, MD"]
ASST/Nurse:
Indication:[checkbox name="indication" value="Abdominal pain|Epigastric pain|Melena|Anemia|Acute post-hemorrhagic anemia|Diagnosis and surveillance of Barrett's esophagus and esophageal cancer|Dysphagia|Odynophagia|Screening for esophageal varices|Gastroesophageal reflux disease (GERD)|Gastric ulcer|Duodenal ulcer"]
Consent:[checkbox name="consent" value="Informed consent was obtained form the patient after providing any opportunity for questions"]
Preparation:[checkbox name="preparation" value="EKG pulse, blood pressure, and oxygen saturation monitored"]
Instrument:
Anesthesia:Administered by[checkbox name="anesthesia" value="Anesthestiologist|Emergent Department|MICU|SICU|CTICU|CICU"]
Procedure: The gastroscope was gently passed through the incisoral orifice into the oral cavity and under direct visualization the esophagus was intubated. The endoscope was passed down the esophagus, through the stomach, and into the 3rd portion. Color, texture, mucosa, and antomy of the esophagus, stomach, and duodenum were carefully examined with the scope. The patient tolerated the procedure well and there were no complications. After completion of the examination, patient was transferred to the recovery room. Preparation was adequate. No problems or issues. Complications: None

Findings:
Oropharynx: [checkbox name="oropharynx" value="Normal"] [text name="variable_1" default="sample text"]

Esophagus: [checkbox name="esophagus" value="Normal|Proximal, mid, and distal esophagus appeared normal"] [text name="variable_1" default="sample text"]

EG-Junction: [checkbox name="egjunction" value="Normal|The Z-line appeared regular and was identified at x cm from the incisors"] [text name="variable_1" default="sample text"]

Cardia: [checkbox name="cardia" value="Normal|Hill Grade I hiatus|Hill Grade II hiatus|Hill Grade III hiatus|Hill Grade IV hiatus"] [text name="variable_1" default="sample text"]

Fundus: [checkbox name="fundus" value="Normal"] [text name="variable_1" default="sample text"]

Body: [checkbox name="body" value="Normal|Mildly erythematous and congested mucosa.|Random biopsies were obtained via cold biopsy forceps at the lesser and greater curvatures for histopathology and H. pylori testing."] [text name="variable_1" default="sample text"]

Antrum: [checkbox name="antrum" value="Normal|Mildly erythematous and congested mucosa.|Random biopsies were obtained via cold biopsy forceps at the pre-pyloric region for histopathology and H. pylori testing."] [text name="variable_1" default="sample text"]

Pylorus: [checkbox name="pylorus" value="Normal"] [text name="variable_1" default="sample text"]

Duodenum Bulb: [checkbox name="duodenumbulb" value="Normal|Random biopsies were obtained via cold biopsy forceps for histopathology and to assess villous architecture."] [text name="variable_1" default="sample text"]

2nd Portion: [checkbox name="2ndportion" value="Normal|Random biopsies were obtained via cold biopsy forceps for histopathology and to assess villous architecture."] [text name="variable_1" default="sample text"]

3rd Portion: [checkbox name="3rdportion" value="Normal|Random biopsies were obtained via cold biopsy forceps for histopathology and to assess villous architecture."] [text name="variable_1" default="sample text"]

Impression: 
[textarea name="variable_1" default="sample text"]
Plan: 
[textarea name="variable_1" default="sample text"]
CPT Codes: [textarea name="variable_1" default="sample text"]
EBL:[text name="variable_1" default="sample text"]

Attending Physician:
Fellow:
ASST/Nurse:
Indication:
Consent:
Preparation:
Instrument:
Anesthesia:Administered by
Procedure: The gastroscope was gently passed through the incisoral orifice into the oral cavity and under direct visualization the esophagus was intubated. The endoscope was passed down the esophagus, through the stomach, and into the 3rd portion. Color, texture, mucosa, and antomy of the esophagus, stomach, and duodenum were carefully examined with the scope. The patient tolerated the procedure well and there were no complications. After completion of the examination, patient was transferred to the recovery room. Preparation was adequate. No problems or issues. Complications: None

Findings:
Oropharynx:

Esophagus:

EG-Junction:

Cardia:

Fundus:

Body:

Antrum:

Pylorus:

Duodenum Bulb:

2nd Portion:

3rd Portion:

Impression:

Plan:

CPT Codes:

EBL:

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0.53, 32 form elements, 118 boilerplate words, 12 text boxes, 3 text areas, 15 checkboxes, 2 drop downs, 61 total clicks
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