DEPARTMENT OF SURGERY

S.C.S.M.S.R. SOLAPUR

UPPER GASTROINTESTINAL EDOSCOPY REPORT

Name ________________________________________________________ Date ________________

GLC No. _______________Indoor/ OPD No. __________________ Endoscopy No._______________

Age ___________ Sex _________ Scope used ____________ Endoscopist _____________________

Referred by _______________________________________________________________________

Indication ________________________________________________________________________

Radiology No._________________ Date ______________ Diagnosis ________________________

Previous endoscopy Anesthesia_______________________________________________________

ENDOCOPY FINDINGS
Esophagus:

Gastroesophageal junction:

Stomach

Dudeneum

Biopsy ___________ Rapid Urease Test for H. Pylori _________________________

Endoscopic Diagnosis: _______________________________________________________________

_______________________________________________________________

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Further Management: _______________________________________________________________

_______________________________________________________________

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