Discussed endoscopy and H. pylori negative pathology results.
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Risks/benefits of EGD discussed with patient including bleeding, infection, perforation, and death. Possibiliy of the need for interventional radiology or surgical intervention also discussed if endoscopy unsuccessful.
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Risks and benefits of ERCP discussed with patient including bleeding, infection, perforation, pancreatitis, and death. Risk of pancreatitis stated as 15% for moderate pancreatitis and 1% for severe pancreatitis. Patient agreeable to proceed with ERCP.
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Risks and benefits of ERCP discussed with patient including bleeding, infection, perforation, pancreatitis, and death. Risk of pancreatitis stated as 15% for moderate pancreatitis and 1% for severe pancreatitis. Patient agreeable to proceed with ERCP. Hand out describing procedure given to patient.
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Hematemesis -
Differential diagnosis includes gastric ulcer, gastritis, esophagitis, and Mallory-Weiss tear.
Risks/benefits of EGD discussed with patient and family including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy.
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Hematochezia - differential diagnosis includes bleeding from hemorrhoids, diverticulosis, arteriovenous malformation, and less likely from colon cancer. Risks and benefits of colonoscopy including bleeding, infection, perforation, and death discussed with patient. Patient agreeable to proceed with colonoscopy. PT/INR and Golytely ordered. NPO after midnight.
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Epigastric abdominal pain - Differential diagnosis includes peptic ulcer disease[]. Risks/benefits of EGD discussed with patient including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy.
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Hematemesis -
Differential diagnosis includes gastric ulcer and esophageal varices.
Risks/benefits of EGD with possible variceal banding discussed with patient and family including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy.
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Hematemesis - Differential diagnosis includes gastric ulcer, gastritis, esophagitis, and Mallory-Weiss tear. Risks/benefits of EGD discussed with patient and family including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy. Higher risk procedure considering age and cardiac comorbidities[]. A total of 35 minutes were spent face-to-face with the patient during this encounter.
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