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Colonoscopy to Ileotransverse Anastomosis Medical Transcription Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  High-risk colon polyp surveillance status post right hemicolectomy with ileotransverse anastomosis for large tubulovillous adenoma of the transverse colon.
2.  History of small bowel carcinoid tumor.

POSTOPERATIVE DIAGNOSES:
1.  Small benign polyps and superficial, possibly ischemic, ulcers of the side-to-side ileotransverse colon anastomosis.
2.  Tiny benign rectosigmoid colon polyps.
3.  Moderate sigmoid colon diverticulosis with no acute diverticulitis.

PROCEDURES PERFORMED:
1.  Colonoscopy to ileotransverse anastomosis and into the distal ileum.
2.  Hot and cold biopsies of the ileotransverse anastomosis.
3.  Hot forceps polypectomy, rectosigmoid colon.

ENDOSCOPIST:  John Doe, MD

PREP:  Fleet Phospho-soda, with excellent prep and visualization entire extent of examination.

FINDINGS:
1.  Intact side-to-side ileotransverse colon anastomosis with postsurgical changes and a couple of small 2 to 3 mm hyperplastic-appearing polyps and a couple of small, less than 5 cm superficial ulcerations with white exudate base in the anastomosis blind pouch areas.  There was wide patency of the anastomosis ileal and colonic openings and lumen.
2.  Normal distal ileal mucosa.
3.  Moderate number of small as well as occasional large-mouth diverticula localized at the sigmoid colon with no acute diverticulitis.
4.  Two tiny 2 to 3 mm benign-appearing sessile proximal rectal and rectosigmoid area hyperplastic-appearing polyps removed with hot biopsy forceps.
5.  Normal colonic vascularity with no evidence of arteriovenous malformations.

ANESTHESIA:  Demerol 100 mg and Versed 10 mg, both slow IV push, titrated.

DESCRIPTION OF PROCEDURE:  After obtaining informed consent, the patient was placed on the left side and subsequently sedated with IV Demerol and Versed, titrated.  The external perineal area was inspected and appeared normal.  Digital rectal examination revealed no evidence of tenderness, masses or strictures.  The finger was used as a guide to insert the Olympus video colonoscope through the anus into rectum.  A small amount of air was insufflated to distend the lumen.  The scope was then easily advanced proximally using the push/pull technique all the way to the level of the transverse colon, where there was noted to be a side-to-side ileal Billroth II-appearing saddle-type anastomosis of the ileum and transverse colon that was widely patent.  The scope was advanced into the ileum proximal to the anastomosis and this was inspected and appeared normal.  The scope was then withdrawn back to the anastomosis where there were postsurgical changes with a couple of ischemic-appearing ulcerations that were small and shallow along with a couple of small hyperplastic and inflammatory polyps.  Cold biopsies were obtained of the ulcerated areas and hot biopsy forceps were used to remove a couple of these small polyps with an Endostat II power source with monopolar coagulation, current setting of 20.  Another couple of tiny polyps were also removed with hot biopsy forceps and the same current power setting from the rectosigmoid colon region.  No other biopsies were taken.  Prior to withdrawal of the scope from the patient, air was removed from the colon with the patient tolerating the procedure well with no evidence of immediate complication.  He was transferred to the recovery area in stable condition.

IMPRESSION:
1.  Some postsurgical mucosal changes seen in the area of the side-to-side ileotransverse colon anastomosis with some ischemic-appearing ulcerations.  There was no evidence of gross neoplastic changes involving the mucosa.
2.  The rectosigmoid polyps are also more likely to be hyperplastic.
3.  Moderate sigmoid colon diverticulosis.

RECOMMENDATIONS:
1.  High-fiber diet with avoidance of nuts, seeds and popcorn.
2.  Carcinoid screening workup to include a 24-hour urine collection for 5-HIAA, upper endoscopy down into the duodenum, barium small bowel follow-through x-ray examination, and nuclear medicine octreotide scan.
3.  Repeat colonoscopy in 3 years for colon polyp surveillance.