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Unisoft's gi reporting tool

The Central Hospital
GASTROSCOPY REPORT
Stephen Rainey
1234567890
21/11/1958
Case note No: X123456
Procedure date
Hospital:
Referring Cons: Dr Merrick
Indications
Consultant/Endoscopist
Abdominal pain, haematemesis and raised WCC.
Nurses: S/N Jane Minkle & Sr Erin Kalidar OESOPHAGUS. Moderate candida suspected at (a). STOMACH. Gastritis: severe erythematous/exudative with no bleeding, severe Instrument
raised erosive with no bleeding and severe haemorrhagic with recent bleeding at (c). DUODENUM. Duodenitis: severe and oedematous associated with erosions Premedication
Diagnoses
OESOPHAGUS. Candida and oesophagitis/other.
STOMACH. Gastritis.
DUODENUM. Duodenitis.
Medication
Fluconazole 50 mg oral o.d. for 1 week and Pantoprazole
40 mg (iv) b.d. for 6 weeks was prescribed.
Follow up
Return to the ward. Awaiting histopathology results.
middle oesophagus to the loweroesophagus (photographed) b: An area extending from the bulb middle body to the pylorus(photographed) Specimens taken
Biopsy (x1 site a, x2 site b and x2 site c) The Central Hospital
Site a: An area extending from the middle Site b: An area extending from the bulb to the Duodenitis: severe and oedematous associated with erosions and nodularity.
Site c: An area extending from the middle body to the pylorusGastritis: severe erythematous/exudative with no bleeding, severe raised erosive with no bleeding and severe haemorrhagic with recent bleeding.
HISTOLOGY
3rd January 2003
Container
ID
Specimens
1 oesophageal biopsy from (a)
Unisoft Medical Systems
First Floor

2 upper duodenal biopsies from (b)
7 London Road
Enfield

2 gastric biopsies from (c)
DoB (Age) 21st November 1958 (44 years)
NHS Inpatient (B7)
Indications. Abdominal pain, haematemesis and Dr Merrick (General Medicine)
OESOPHAGUS. Moderate candida suspected at (a). erythematous/exudative with no bleeding, severe raised erosive with no bleeding and severe haemorrhagic with recent bleeding at (c). DUODENUM. Duodenitis: severe and oedematous associated with erosions and nodularity at (b).
the bulb to the third part(photographed) Diagnoses. OESOPHAGUS. Candida and oesophagitis/other.
Produced by Unisoft's GI Reporting Tool. Call 0208-367 2103 if modifications to this form/layout are required.
The Central Hospital
ERCP REPORT
Stephen Rainey
1234567890
21/11/1958
Case note No: X123456
Procedure date
Hospital:
Referring Cons: Dr Merrick
Indications
Consultant/Endoscopist
Abnormal enzymes and jaundice.Ultrasound imaging Nurses: Sr Siobhan Rae & Sr Erin Kalidar Report
Cannulation via the major papilla to the bile duct was successful using
Instrument
a sphincterotome, and to the pancreatic duct was not attempted. Visualisation: The whole biliary system except the gall bladder, but not the pancreatic system. Contrast media used: hepatobiliary; full Premedication
strength contrast and half strength contrast.
PAPILLA. Major: no previous surgery at (a). BILIARY. Stricture: irregular and with upstream dilatation at (b). Using the duodenoscope the following upper tract observations were noted.
STOMACH. Gastric ulcer: early healing (regenerative mucosa evident) in the greater curve prepyloric region.
Diagnosis
AMPULLA. Normal.
BILIARY. Extrahepatic: stricture: probably malignant.
Therapeutic procedures
Papillotomy: using bow string, with no
bleeding. (site a)
Stent insertion: one straight (length 12 cm,
diameter 10 Fr) (b)
Follow up
Advice/comments
Suggest spiral CT to look for mass lesion
The Central Hospital
COLONOSCOPY REPORT
Stephen Rainey
1234567890
21/11/1958
Case note No: X123456
Procedure date
Hospital:
Referring Cons: Dr Merrick
Indications
Consultant/Endoscopist
Following up a transverse colectomy within the last Nurses: S/N Jane Minkle & Sr Siobhan Rae Bowel preparation with two sachets of Picolax was good.
The colonoscope was inserted via the anus to the caecum. The Instrument
caecum was identified positively by transillumination and the tri-radiate caecal fold.
Calibre: post operative stricture (length 5cm) at (b). Lesions: 1 Premedication
pedunculated polyp (10mm) excised, retrieved and sent to labs from (a).
The rest of the examination to the point of insertion was normal.
Diagnoses
Colonic polyps and post operative stricture.
Therapeutic procedures
Polypectomy: 1 excised (site a)
Balloon dilatation (b)
Follow up
Awaiting histopathology results. Further colonoscopy in 3
months.
a: Distal descendingb: An area extending from the proximal descending through the anastomosis tothe proximal ascending Specimens taken
HISTOLOGY
3rd January 2003
Container
ID
Specimens
1 colonic pedunculated polyp from (a)
Unisoft Medical Systems
First Floor
7 London Road

Indications. Following up a transverse colectomy within the last month. Previous carcinoma.
DoB (Age) 21st November 1958 (44 years)
NHS Inpatient (B7)

Calibre: post operative stricture (length 5cm) at (b). Lesions: 1 pedunculated polyp (10mm) excised, Dr Merrick (General Medicine)
retrieved and sent to labs from (a).
The rest of the examination to the point of insertion Diagnoses. colonic polyps and post operative proximal descending throughthe anastomosis to theproximal ascending Produced by Unisoft's GI Reporting Tool. Call 0208-367 2103 if modifications to this form/layout are required.

Source: http://www.unisoftmedical.co.uk/pdf/The_full_set_of_UGI_sample_reports.pdf

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Microsoft word - new patient history and welcome 1_10.doc

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