OPSX29GradyKent
MCCG240 Case Scenario OPSX29 Grady, Kent.html[10/21/2021 10:55:46 AM]
Outpatient Surgery
Patient Case Number: OPSX29-Grady, Kent
Patient Name: Kent Grady DOB: 07-13-70 Sex: M
Date of Service: 01-22-XX Surgeon: Mary Hollister, MD
Pre-Operative DiagnosisAcute Pancreatitis
Post-Operative DiagnosisEsophageal Varices
Procedure Performed: EGD & Endoscopic ultrasound
Anesthesia: Conscious sedation Complications: None
PROCEDURES:1. EGD2. Endoscopic ultrasound.
INDICATIONS:1. Acute pancreatitis.2. Abnormal CT scan, rule out pancreas head mass.
PROCEDURE #1 EGD:The Olympus GIF-190 forward-viewing video-endoscope was lubricated and advanced into thehypopharynx. The scope passed into the esophagus. Examination of the stomach was performed instraight and retroflexion views. The scope was passed into the second portion of the duodenum.
FINDINGS:1. Grade 1 esophageal varices x1.2. Food debris in the proximal stomach, otherwise, normal stomach.3. Normal duodenum.4. Acute and chronic pancreatitis
PROCEDURE #2 ENDOSCOPIC ULTRASOUND:The Olympus linear echoendoscope was lubricated and advanced into the hypopharynx. The scopepassed through the esophagus, stomach, pylorus second portion duodenum. With the water-fillingtechnique of the balloon and lumen, endoscopic ultrasound examination performed. The pancreasparenchyma appeared with diffuse inhomogeneity, hypoechoic foci, lobulation, and a few calcifications inthe head of the pancreas. The main pancreatic duct was not dilated, and it had thickened borders. Foldsfeatures are suggestive of chronic pancreatitis. The common bile duct was dilated measuring 9 mm.There was free fluid around the pancreas body and tail. The splenic vein was distended, consistent withportal hypertension.
OPSX29GradyKent
MCCG240 Case Scenario OPSX29 Grady, Kent.html[10/21/2021 10:55:46 AM]
RECOMMENDATIONS:1. Alcohol abstinence.2. Repeat EUS in 3 months.
Dictating Clinician: Mary Hollister, MD
Electronical Signed By: Mary Hollister, MD
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