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Colonoscopy Medical Transcription Procedure Sample

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Screening.

POSTOPERATIVE DIAGNOSIS:  Screening.

PROCEDURE PERFORMED:  Colonoscopy to cecum.

ANESTHESIA:  IV Versed and fentanyl.

ESTIMATED BLOOD LOSS:  None.

COMPLICATIONS:  None.

SPECIMENS:  None.

DESCRIPTION OF PROCEDURE:  The patient was brought to the endoscopy suite and placed in the left lateral decubitus position. After induction of IV sedation, the Olympus video colonoscope was passed to the cecum without difficulty. Cecal intubation was confirmed by the identification of the appendiceal orifice, the ileocecal valve, and cecal strap by palpation. Upon withdrawing the colonoscope, all mucosal surfaces were inspected. There was no evidence of malignancy, neoplasia, polyps, or mucosal abnormalities. Retroflexion in the rectum showed small internal hemorrhoids.

IMPRESSION:  Normal colonoscopy to the cecum.

RECOMMENDATIONS:  The patient is to have repeat exam in 10 years.

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DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Surveillance colonoscopy.

POSTOPERATIVE DIAGNOSES:
1.  Surveillance colonoscopy.
2.  Diminutive polyp ascending colon.

PROCEDURE PERFORMED:  Colonoscopy to the cecum with polypectomy of a 6 mm polyp, ascending colon.

ANESTHESIA:  IV Versed and fentanyl.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS:  None.

SPECIMENS:  Ascending colon polyp.

DESCRIPTION OF PROCEDURE:  The patient was brought to the endoscopy suite and placed in the left lateral decubitus position. After induction of IV sedation, a digital rectal exam was performed. He had a few external skin tags, but no other perianal abnormalities. Digital exam was normal. The Olympus video colonoscope was then passed to the cecum with extreme difficulty. The ultimate position, which allowed cecal intubation, was prone. Cecal intubation was confirmed by the identification of the appendiceal orifice, the ileocecal valve, the cecal strap by palpation. Upon withdrawing the colonoscope, all mucosal surfaces were inspected. The prep was noted to be adequate. There was some liquid stool, which was easily aspirated. In the ascending colon, there was a 6 mm sessile polyp, which was removed using forceps in its entirety. Specimen was retrieved for pathological analysis. Throughout the colon, there was pandiverticulosis. There seemed to be a fixed loop of colon in the patient's pelvis that was likely sigmoid, which was difficult to reduce, as it appeared to be fixed. This created quite a bit of resistance and multiple positioning had to be performed in order to intubate the cecum. There was pandiverticulosis and diverticular changes noted. There was no other evidence of mucosal abnormality, polyp or cancer. Retroflexion in the rectum was unremarkable.

IMPRESSION:  A diminutive polyp, ascending colon. Await pathology results.

RECOMMENDATIONS:  The patient should have a repeat exam in five years.

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DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Age-appropriate colon cancer screening.

POSTOPERATIVE DIAGNOSES:
1.  Left-sided diverticular disease, mild.
2.  Exam is, otherwise, normal to the cecum.

PROCEDURE PERFORMED:  Colonoscopy.

PREMEDICATIONS:  Demerol 75 mg IV and Versed 6 mg IV.

INSTRUMENT:  Olympus video colonoscope.

DESCRIPTION OF PROCEDURE:  The patient was placed in the left lateral decubitus position and the endoscope inserted rectally without difficulty. The instrument was inserted and advanced with ease through the rectum and sigmoid colon. There was left-sided diverticular disease. Descending colon was entered, splenic flexure crossed, and the transverse colon entered. Hepatic flexure was identified and crossed to the ascending colon, where the cecum was identified by localization of the ileocecal valve and cecal sling. The instrument was withdrawn through the transverse, descending, sigmoid colon, and rectum. Procedure was terminated. The patient tolerated the procedure well.

IMPRESSION:
1.  Left-sided diverticular disease, mild.
2.  Otherwise, normal exam.

PLAN:  Colonoscopy is recommended in 10 years.

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