Chapter 3: The Digestive System | Shana Laquisha's Chart Note


Patient Name: Laquisha, Shana
ID Number: 569801
Examination Date: March 1, 20xx

Upper GI

Patient has a history of Crohn's disease and uncontrolled diarrhea.

Swallowing mechanism appears normal. There is no evidence of aspiration (drawing of gastric contents into the throat). Proximal esophagus appears normal. Fundus (base) of the stomach distends well. There is no suggestions of abnormal rugae (fold) pattern in the upper region of the stomach. The body and pyloris (passage at the lower end of the stomach that opens into the duodenum) of the stomach appear normal. There is a high-grade obstruction in the extreme distal end of the stomach. There is just a 2 to 3 mm passage of contrast agent beyond an "apple core" obstructing lesion. This certainly has to be considered a carcinoma; direct visualization is indicated. The duodenal bulb, loop, and proximal jejunum appear normal.

A 2 to 3 mm obstructing lesion in the distal end of the stomach, possibly carcinoma.

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