Chapter 3 The Digestive System 131 RADIOLOGY REPORT Patient Name: Laquisha, Shana ID Number: 569801 Examination Date: March 1, 20xx EXAMINATION Upper GI INDICATIONS Patient has a history of Crohn’s disease and uncontrolled diarrhea. PROCEDURE 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 suggestion 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. CONCLUSION A 2 to 3 mm obstructing lesion in the distal end of the stomach, possibly carcinoma. Assessment Interpret Shana Laquisha’s Chart Note Directions: After listening to the dictated recording and reading the chart note on Shana Laquisha, provide the medical term that matches each defi nition below. Example: inflammation of the diverticulum Answer: diverticulitis 1. pertaining to the duodenum ________________________________________________ 2. nearest the point of origin ________________________________________________ 3. cancerous tumor ________________________________________________ 4. an expandable organ that breaks food down for absorption by the body located between the esophagus and small intestine ________________________________________________ 5. tubular structure that carries food from the pharynx to the stomach ________________________________________________ 6. the section of the small intestine between the duodenum and the ileum ________________________________________________ 7. chronic, infl ammatory bowel disease characterized by thickening and gradual erosion of the inner lining of the intestinal wall ________________________________________________
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