Esophagogastroduodenoscopy with variceal banding and control of hemorrhage. Esogphagus - Grade 2 esophageal varices with stigmata of recent bleeding including cherry red spots. Banded times three with eradication of varices. Bleeding from the varices during the procedure had stopped at the end of the procedure. Esophagus was otherwise normal.
Gastritis with edema and portal hypertensive gastropathy in the antrum, body, and fundus.
Duodenum was normal.
Propranolol 10 mg PO BID on discharge titrated by heartrate. Octreotide drip for three days. Clear liquid diet today, soft diet tomorrow, then resume low sodium diet the next day barring complications. The patient needs to follow up with gastroenterology to discuss repeat EGD in 2 weeks. Message was sent to clinic for follow up. Bleeding source was esophageal varices.
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Variceal Banding Recommendations: Propranolol 10 mg PO BID on discharge titrated by heartrate. Octreotide drip for three days. Clear liquid diet today, soft diet tomorrow, then resume low sodium diet the next day barring complications. Bleeding source was esophageal varices. The patient needs to follow up with gastroenterology to discuss repeat EGD in 2 weeks. ...Read more
Acidic and alkali substances can lead to esophageal injury. Strictures can form weeks to years later.
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Alkaline caustic ingestion can lead to an increased risk of squamous cell carcinoma of the esophagus.
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Blood in the fundus, body, and antrum interfering with visualization. Grade 2 esophageal varices with nipple sign[]. Banded times three with eradication of varices.
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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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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.
...Read more
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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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. Patient counseled on avoiding alcohol use.
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Hematemesis - Differential diagnosis includes peptic 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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Melena -
Differential diagnosis includes gastric ulcer and esophageal varices.
Risks/benefits of EGD with possible variceal banding discussed with patient[] including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy. [] Octreotide drip.
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Iron deficiency anemia - Differential diagnosis includes gastric ulcer, gastritis, esophagitis,[] and less likely colon cancer. 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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