Text from report

Queensland Government

QEII Hospital Endoscopy Unit

nt Name:

Greig, Margaret

of Birth:

15/10/1950

Admit Type:

73

Gender:

Procedure Date:

14/06/2024 12:24 PM

Outpatient

Female

n:

Procedure Room 1

UR Number:

2067950

care Billing Code:

30473 Gastroscopy

edure Staff:

Richard Lee, Staff Specialist, Jung Hyun (Gloria) Yang, RN, Stephanie Hopes, RN, Sharon Wood, Operational Services Officer, Luke Huang, Anaesthetist

uesting doctor: Emily Lim, MBBS, FRACP

erring doctor: Reggie Ba-Pe, MBBS Browns Plains Family Practice Village Square Unit K4, 18 Commerce Drive BROWNS PLAINS, QLD 4118

Upper Gl endoscopy

ications:

Weight loss

ocedure:

edications:

ocedure:

Monitored Anaesthesia Care

After informed consent was obtained, the instrument was passed under direct vision. The Endoscope was introduced through the mouth, and advanced to the third part of duodenum. The upper Gl endoscopy was accomplished without difficulty The patient tolerated the

procedure well.

Total Procedure Time:

11 Minutes 40 Seconds

Complications: No immediate complications

Findings:

Impression:

-Diffuse, white plaques were found in the upper third of the oesophagus and in the middle third of the oesophagus Biopsies were taken with a cold forceps for histology The SC junction was regular and was found 40 cm from the incisors. There was a 2cm long segment of likely columnar-lined oesophagus seen from 40cm to the top of the gastric folds situated at 42cm Regular MS and MV patterns under magnified NBI examination. Biopsies were taken from 40, 41, 42cm and labelled as such. Only two biopsies per level were taken due to persistent oozing from the biopsy sites

-A small hiatal hernia was present

-Patchy mild inflammation characterised by congestion (oedema), erythema and granularity was found in the gastric body and in the gastric antrum. Biopsies were taken with a cold forceps for histology.

The cardia and gastric fundus were normal on retroflexion.

-The examined duodenum was normal Biopsies were taken with a cold forceps for histology

Oesophageal plaques were found, suspicious for candidiasis. Biopsied.

- Z-line regular, 40 cm from the incisors

Small hiatal hernia. Gastritis. Biopsied

-Normal examined duodenum Biopsied.

Recommendation:

Patient to return to General Practitioner for follow-up Please review histology and eradicate H pylon if detected, with a 2 week course of Nexium HP7 if there are no contraindications to this or a history of failed therapy Check success of eradication therapy with a urea breath test to be performed at 4 weeks after completion of therapy, while off PPI

-If candidiasis was confirmed, treat with 10 days of amphotericin B lozenges. -Consider repeat endoscopy in 3 years for Barrett's surveillance if IM was confirmed on biopsies today

-If H pyori is negative and Barrett's oesophagus was confirmed, recommend once daily PPI long term.

-Specimens have been sent to Envoi Pathology (tel 07 3552 6400)

-Perform a colonoscopy today

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Queensland Government

QEII Hospital Endoscopy Unit

Patient Name:

Date of Birth

Age

Room:

Greig Margaret

15/10/1950

73

Procedure Room 1

Medicare Billing Code:

30473 Gastroscopy

Procedure Date:

Admit Type:

Gender:

UR Number:

14/06/2024 12 24 PL

Outpatient

Female

2067950

Dr R. Lee

Richard Lee, Staff Specialist

Signed Date: 14/06/2024 1.12:14 PM

This report has been signed electronically Richard Lee, Staff Specialist

Queensland Government

Greig, Margaret

QEII Hospital Endoscopy Unit

ient Name:

ate of Birth:

Age:

Room:

Procedure Date:

Admit Type:

Gender:

15/10/1950

73

Procedure Room 1

UR Number:

Medicare Billing Code:

32222 32229

14/06/2024 12:26 PM

Outpatient

Female

2067950

Richard Lee, Staff Specialist, Jung Hyun (Gloria) Yang, RN, Stephanie Hopes, RN. Sharon Wood. Operational Services Officer, Luke Huang Anaesthetist

Reggie Ba-Pe. MBBS Browns Plains Family Practice Village Square Unit K4, 18 Commerce Drive BROWNS PLAINS, QLD 4118

Procedure Staff:

Requesting doctor: Referring doctor:

Emily Lim, MBBS, FRACP

Indications:

Positive faecal occult blood test. Weight loss

Procedure:

Colonoscopy

Medications:

Monitored Anaesthesia Care

Procedure:

After informed consent was obtained, the instrument was passed under direct vision. The Colonoscope was introduced through the anus and advanced to the terminal ileum The colonoscopy was performed without difficulty The patient tolerated the procedure well. The quality of the bowel preparation was good

Scope Withdrawal Time: 11 Minutes 11 Seconds

Total Procedure Time:

15 Minutes 35 Seconds

Complications: No immediate complications

Findings:

-The terminal ileum appeared normal

Impression:

-The right colon was examined with two passes

-A 2 mm polyp was found in the mid rectum. The polyp was Paris classification Ila

(superficial, elevated) The polyp was removed with a cold snare. Resection and retrieval

were complete A few small-mouthed diverticula were found in the sigmoid colon Non-bleeding internal haemorrhoids were found during anoscopy. The haemorrhoids were small

-The exam was otherwise without abnormality.

One polyp removed.

Small haemorrhoids and diverticulosis

Recommendation:

Discharge patient to home. Resume regular diet.

Repeat colonoscopy in 5 years for surveillance if the resected polyp returns as an adenoma or SSL, otherwise does not need routine surveillance

- Specimens have been sent to Envoi Pathology (tel 07 3552 6400), a copy of these results will be sent the general practitioner Findings will be reviewed by the surveillance clinical nurse and any change to the recommended surveillance interval will be sent the general practitioner

- After histology review, the patient will be entered into the QEII Surveillance Register reminder will be sent to the patient and nominated GP when the surveillance date approaches. It is the patient's responsibility to maintain current contact details and Gl

nomination with Metro South Health Service

Dr R. Lee

Richard Lee, Staff Specialist

Signed Date: 14/06/2024 1 14:43 PM

This report has been signed electronically Richard Lee, Staff Specialist

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