DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Colonoscopy with polypectomy.
INDICATIONS: Family history of colon cancer in her brother. She also had ileal ulcerations and may have been secondary to her Celebrex.
CONSENT: The procedure, its risks, benefits and alternatives were explained to the patient in the presence of the nurse, and she consented to proceed.
MONITORING: The patient had continuous pulse oximetry and intermittent blood pressure monitoring throughout the procedure.
PREMEDICATIONS: Fentanyl 75 mcg and Versed 5 mg.
DESCRIPTION OF PROCEDURE: After adequate premedication, the initial perianal inspection and digital rectal exam were normal. Olympus PCF-160AL endoscope was inserted atraumatically into the rectum and advanced with ease to the cecum. The cecum was identified by the ileocecal valve, appendiceal orifice, and typical anatomy. The endoscope was then slowly withdrawn circumferentially inspecting the lumen. The terminal ileum was entered at 15 cm and was normal. The endoscope was then slowly withdrawn circumferentially inspecting the lumen. No areas of mucosal abnormality, polyps or masses were noted. In the sigmoid colon, there was a flat 8 mm polyp, and it was cold snared and removed. The endoscope was then withdrawn, and retroflexion in the rectum yielded normal view. The endoscope was withdrawn, and the procedure terminated. The patient tolerated the procedure well.
IMPRESSION:
1. Sigmoid diverticulosis.
2. Sigmoid polyp, removed.
3. Healed ileal ulcerations, on Pentasa and Celebrex.
RECOMMENDATIONS:
1. We can probably wean her down on Pentasa, as we believe the ileal ulcerations were secondary to the Celebrex, which she no longer takes.
2. The patient will follow up routinely with Dr. John Doe. High-fiber diet.
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DATE OF PROCEDURE: MM/DD/YYYY
PROCEDURE PERFORMED: Colonoscopy with polypectomy.
INDICATIONS FOR PROCEDURE: History of colon polyps many years ago. He has had normal colonoscopies over the past 10 years.
CONSENT: The procedure, its risks, benefits and alternatives were explained to the patient in the presence of the nurse, and he consented to proceed.
MONITORING: The patient had continuous pulse oximetry and intermittent blood pressure monitoring throughout the procedure.
PREMEDICATION: Fentanyl 50 mcg IV given slowly in small increments. Versed 2.5 mg IV given slowly in small increments.
DESCRIPTION OF PROCEDURE: After adequate premedication, the Olympus PCF-160AL colonoscope was inserted atraumatically into the rectum. Initial perianal inspection and digital rectal exam were normal. The scope was advanced with ease to the cecum requiring some abdominal pressure. The cecum was identified by ileocecal valve, appendiceal orifice, typical anatomy and light location. Preparation was excellent other than some stool from numerous diverticula. Diverticulosis was noted in the hepatic flexure, ascending colon, descending and sigmoid colon. In the descending colon, at 37 cm, was a sessile 5 mm polyp that was cold snared and removed. Extensive diverticulosis was noted on the left side of the colon. The scope was then withdrawn and retroflexed yielding a good view of moderate-sized internal hemorrhoids. The patient tolerated the procedure well, and there were no complications.
IMPRESSION:
1. Moderate-sized internal hemorrhoids.
2. Extensive left-sided diverticulosis with minimal right-sided diverticulosis.
3. Small descending colon polyp removed.
RECOMMENDATIONS: The patient should have a repeat colonoscopy in five years if the polyp is adenomatous.
