Carolina Cavalcanti Figueiredo

ORIGINAL TRANSLATION Patient Name: XXX Hospital Identifier: XXX Exam Date: September 29th, 2015 Requesting Doctor: XXX, CRM XXX Report Number: XXX Birth date: June 6th, 1958 UPPER DIGESTIVE ENDOSCOPY Exam performed with the patient under intravenous sedation, cardiorespiratory monitoring and nasopharyngeal catheter continuous positive airway pressure. ESOPHAGUS: showed esophagus route and caliber within normal endoscopic standards. The mucosa was slightly opacified in the distal segment and without erosions. The Cardia was slightly half-open. There was no erosion, no Barret's esophagus, no hiatal hernia nor varices. STOMACH: showed good expansibility with the air insufflation and no anatomic alterations. There was no stasis nor food remainings. To the rear-view, we could see the Cardia half-open. Mucosal folds of the trophic body. The mucosa of the antral region showed a slight hyperemia with small flat erosions, no signs of bleeding. The pylorus was centered and without deformity allowing easy transposition. No active ulcer or neoplasia was found. DUODENAL BULB: no deformity, intact mucosa without erosions. Following the tract to the distal region of the second part of the duodenum showed a normal aspect mucosa without any signs of atrophy. Conclusion: 1- Mild non-erosive esophagitis. 2- Mild erosive antral gastritis. We haven't performed a biopsy due to the existing double platelet aggregation. Dr. XXX CRM XXX This report was electronically signed 2015 10:38:57 Page Copies of this medical report can be found online www.hcor.com.br or requested or requested from Hcor Phone:- Extension: 5124 / 5141