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EGD and Colonoscopy with Cold Forceps Polypectomy Sample

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1.  Chronic upper abdominal pain.
2.  Gas/bloating.
3.  Reflux.
4.  Change of bowel habits.

POSTOPERATIVE DIAGNOSES:
1.  Chronic upper abdominal pain.
2.  Gas/bloating.
3.  Reflux.
4.  Change of bowel habits.
5.  Grade 1 esophagitis.
6.  Mild erythematous gastropathy.
7.  Duodenitis.
8.  Rectal polyp.
9.  Hemorrhoids.

PROCEDURE PERFORMED:
1.  Esophagogastroduodenoscopy with biopsies.
2.  Colonoscopy with cold forceps polypectomy.

PHYSICIAN:  John Doe, MD

ANESTHESIA:  Fentanyl 75 mcg IV, Versed 7 mg IV, and topical benzocaine spray.

SPECIMENS:
1.  Duodenal and gastric biopsies.
2.  Rectal polyp.

COMPLICATIONS:  None.

BLOOD LOSS:  Minimal.

CONSENT:
Informed consent was obtained prior to the initiation of the procedure.  All questions were answered.

ESOPHAGOGASTRODUODENOSCOPY:
The esophagogastroduodenoscopy was the first procedure performed. The patient was given topical benzocaine spray and placed in the left lateral decubitus position. Following the administration of appropriate anesthesia, a diagnostic gastroscope was advanced under direct vision to the second portion of the duodenum without difficulty. Examination of the esophagus revealed a normal-appearing Z-line at approximately 35 cm from the incisors. There was patchy erythema consistent with a grade 1 esophagitis. Examination of the stomach revealed a normal gastric cardia, fundus and body. No ulcerations or erythema was appreciated. The patient's stomach was somewhat J-shaped in nature with some angulation at the region of the pylorus. However, it should be noted that there were no ulcerations present, though some patchy erythema was appreciated in the region of the distal stomach. Biopsies were obtained for histology. Examination of the duodenal bulb revealed patchy duodenitis without ulceration. The visualized second portion of the duodenum was normal. Duodenal biopsies were basically to look for other sources of abdominal discomfort including malabsorption syndrome such as celiac disease. The gastric biopsies were to evaluate for potential Helicobacter pylori.

IMPRESSION:
1.  Grade 1 esophagitis.
2.  Erythematous gastropathy.
3.  Duodenitis.

RECOMMENDATIONS:
1.  Await pathology results.
2.  Proceed with colonoscopy.

COLONOSCOPY:
The patient was repositioned and a digital rectal exam was performed. No significant masses or lesions were palpated. Following this, a variable stiffness pediatric colonoscope was advanced under direct vision to the cecum without difficulty. The patient did require some sigmoid pressure for deep cecal intubation. The patient's colon preparation was good with clear identification of the appendiceal orifice as well as the IC valve. The patient did have some residual material present, though this did not interfere with the examination. Careful examination of the colonic mucosa was then performed as the scope was slowly withdrawn. The exam of the cecum, ascending, transverse, descending, and sigmoid colon were otherwise endoscopically unremarkable. Retroflexed views in the rectum revealed a diminutive rectal polyp in addition to nonbleeding internal hemorrhoids. The rectal polyp was removed using cold forceps polypectomy technique and retrieved for pathology. Air and fluid were then aspirated. The scope was withdrawn and the procedure terminated.

IMPRESSION:
1.  Rectal polyp.
2.  Hemorrhoids.

RECOMMENDATIONS:
1.  Await pathology results.
2.  Written instructions were given to the patient to contact the office for followup visit in the next 3 weeks.