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Colonoscopy and Upper Endoscopy Sample Report / Example

DATE OF PROCEDURE:  MM/DD/YYYY

PROCEDURES PERFORMED:  Colonoscopy and upper endoscopy.

INDICATIONS FOR PROCEDURE:  Previous history of polyps and chronic reflux disease.

CONSENT:  Informed consent was obtained from the patient after explaining the risks, benefits, possible complications and alternatives to the procedures. The patient is well aware of possible complications, including but not limited to bleeding, perforation, reactions to medications, missed lesions, infection and aspiration.

The patient was given premedications for both procedures by the nurse anesthesiologist. The colonoscopy was performed first.

COLONOSCOPY:  With the patient comfortable in the left lateral position, a well-lubricated colonoscope was introduced into the rectum. She was noted to have severe diverticulosis of the sigmoid colon with narrowing and distortion of the colon, perhaps somewhat fixed. It was somewhat difficult to negotiate past this area, and the patient needed to be repositioned onto supine and right lateral positions. In these positions, we were able to advance into mid sigmoid and then positioned back onto her supine position briefly to get past the sigmoid. The patient remained otherwise on the right lateral side throughout the colonoscopy. The colonoscope was advanced all the way down to the cecum, eventually, without difficulty. She was noted to have severe diverticulosis throughout the colon, most impressive in the sigmoid colon. There were also several stool balls noted throughout the colon, probably from the diverticula. Careful inspection, otherwise, with washing revealed no obvious polyps. A long segment in the sigmoid colon was somewhat hard to examine due to narrowing and redness and being fixed. This area was hard to insufflate. Retroflexion in the rectum revealed moderate internal hemorrhoids.

IMPRESSION:
1.  Severe diverticulosis throughout the colon, most impressive in the sigmoid colon.
2.  Internal hemorrhoids.
3.  No polyps seen on this exam. The patient will need a colonoscopy in 5 years for followup.

UPPER ENDOSCOPY:  After the colonoscopy, the patient was repositioned for an upper endoscopy. Her dentures were removed. A mouthpiece was placed. When she was comfortable, a well-lubricated upper scope was introduced into the posterior pharynx and under direct visualization advanced all the way down to the duodenum, up to the third portion, without difficulty. Second and third portions of the duodenum appeared normal. At the apex of the bulb, a small superficial ulcer was noted with slightly erythematous mucosa surrounding. Antrum revealed a similar area, which was a very superficial pale area, appearing to be an ulcer with erythema surrounding. Two other areas were noted which appeared to be old scar tissue. The rest of the stomach and the body and fundus appeared atrophic and pale. Biopsies were obtained separately from antrum and body. Retroflexion revealed a normal cardia. She was noted to have a hiatal hernia extending from 40 to 36 cm from the incisors. The patient also was noted to have a nonobstructing Schatzki ring at the GE junction. The rest of the esophagus was normal.

IMPRESSION:
1.  Small duodenal ulcer with erythema.
2.  Antral small ulcer with erythema and scar tissue.
3.  Atrophic body and fundus.
4.  Hiatal hernia.
5.  Nonobstructing Schatzki ring.

The patient tolerated both procedures well.