gastroenterology medical records sample
Content
GASTROENTEROLOGY #5
HISTORY AND PHYSICAL EXAMINATION
CHIEF COMPLAINT:
The patient is a 50-year-old black woman present with four to six weeks history of
episodes of post perennial upper gastric distress. She had been taking large doses of
Salicylates for the relief of hyperemic symptoms. She experienced upper abdominal
bloating and distention after eating even small amounts of food. She complaints poor
relationships to the type of food she ate, there was no fatty or fried food in colors and
what occur shortly after eating. There was no dysphagia, polynausea, polyvomiting,
polyhemoptysis or visible melena. X-rays revealed a normal cholecystogram. The x-rays
of the upper gastrointestinal tract reveal a rounded radiolucent filling defect on the
greater curvature of the prepyloric and proportions of the stomach. She was admitted to
the hospital for further study.
PHYSICAL EXAMINATION: The Physical examination was generally unremarkable
except for an obese protruding abdomen. There were no abdominal masses, tenderness or
organomegaly.
LABORATORY STUDIES: Reveal a normal hemogram and near analysis, normal
electrolytes, normal SMA12 chemical profile. Stool showed traces of occult blood.
Histolax stimulated gastric analysis revealed fasting free Hcl 40 mEq/L; fifteen minutes75 mEq/L; Senicholine, thirty minutes-70 mEq/L; Senicholine, forty-five minutes-55
mEq/L. Senicholine, sixty minutes-53 mEq/L. Gastric cytology revealing no tumor cells.
Gastroscopy was performed and supported critical impression, which was that having a
hard mass on the greater curvature aspect of the stomach, that was decided to operate.
PREOPERATIVE DISCUSSION: Benign tumors at the stomach are uncommon. They
represent 10 to 15% neoplasms of the stomach. Any moment appeared to be equally
affected with peak incidence of 50 to 60 years of age. Pathologically, the following types
of tumors are observed; solitary and multiple polyps, adenomas, multiple polyposis,
leiomyoma, neuroma. A displaced islet of heterotophic pancreas also may present as a
tumor. Pancreatic rests are most commonly located along the greater curvature of the
antrum. The definite diagnosis can not be made by x-ray examination alone because
these small filling defects may resemble those produced by other benign tumors or even
by an early carcinoma. The clinical behavior of benign gastric neoplasm depends on their
size, location, tendency to ulcerate, bleed, obstruct or undergo change. But upper gastric
discomfort may occur in some patients whereas others may experience ulcer-like
symptoms or the syndrome of pyloric obstruction if the growth is near the pylorus. In this
case, pressure spot films of the suspicious area noted on fluoroscopy clearly
demonstrated the tumor.
CONCLUSION: It is decided to operate to remove the tumor.
HISTORY AND PHYSICAL EXAMINATION
CHIEF COMPLAINT:
The patient is a 50-year-old black woman present with four to six weeks history of
episodes of post perennial upper gastric distress. She had been taking large doses of
Salicylates for the relief of hyperemic symptoms. She experienced upper abdominal
bloating and distention after eating even small amounts of food. She complaints poor
relationships to the type of food she ate, there was no fatty or fried food in colors and
what occur shortly after eating. There was no dysphagia, polynausea, polyvomiting,
polyhemoptysis or visible melena. X-rays revealed a normal cholecystogram. The x-rays
of the upper gastrointestinal tract reveal a rounded radiolucent filling defect on the
greater curvature of the prepyloric and proportions of the stomach. She was admitted to
the hospital for further study.
PHYSICAL EXAMINATION: The Physical examination was generally unremarkable
except for an obese protruding abdomen. There were no abdominal masses, tenderness or
organomegaly.
LABORATORY STUDIES: Reveal a normal hemogram and near analysis, normal
electrolytes, normal SMA12 chemical profile. Stool showed traces of occult blood.
Histolax stimulated gastric analysis revealed fasting free Hcl 40 mEq/L; fifteen minutes75 mEq/L; Senicholine, thirty minutes-70 mEq/L; Senicholine, forty-five minutes-55
mEq/L. Senicholine, sixty minutes-53 mEq/L. Gastric cytology revealing no tumor cells.
Gastroscopy was performed and supported critical impression, which was that having a
hard mass on the greater curvature aspect of the stomach, that was decided to operate.
PREOPERATIVE DISCUSSION: Benign tumors at the stomach are uncommon. They
represent 10 to 15% neoplasms of the stomach. Any moment appeared to be equally
affected with peak incidence of 50 to 60 years of age. Pathologically, the following types
of tumors are observed; solitary and multiple polyps, adenomas, multiple polyposis,
leiomyoma, neuroma. A displaced islet of heterotophic pancreas also may present as a
tumor. Pancreatic rests are most commonly located along the greater curvature of the
antrum. The definite diagnosis can not be made by x-ray examination alone because
these small filling defects may resemble those produced by other benign tumors or even
by an early carcinoma. The clinical behavior of benign gastric neoplasm depends on their
size, location, tendency to ulcerate, bleed, obstruct or undergo change. But upper gastric
discomfort may occur in some patients whereas others may experience ulcer-like
symptoms or the syndrome of pyloric obstruction if the growth is near the pylorus. In this
case, pressure spot films of the suspicious area noted on fluoroscopy clearly
demonstrated the tumor.
CONCLUSION: It is decided to operate to remove the tumor.
