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Colonoscopy Medical Transcription Sample Reports

PREOPERATIVE INDICATION:  History of colorectal polyps.

POSTOPERATIVE FINDINGS:  Normal colonoscopy.

TYPE OF PROCEDURE:  Colonoscopy to cecum.

DETAILS OF PROCEDURE:  After informed consent was obtained from the patient and intravenous access was initiated, cardiopulmonary monitoring was begun and the patient was then placed in left lateral position. A visual inspection of the perianal area revealed no abnormalities. A digital rectal examination revealed no masses. An Olympus video colonoscope was inserted into the rectum and advanced without difficulty to the ileocecal area, which was identified by its landmarks, palpation and transillumination. There are no intraluminal lesions. The scope then was withdrawn from the patient, again under direct vision, and no intraluminal lesions are present. The patient agrees to followup visits with all her physicians, including me.

FINAL DIAGNOSIS:  Normal colonoscopy.

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Rectal ulcer.

POSTOPERATIVE DIAGNOSIS:  Rectal stricture.

PROCEDURE PERFORMED:
1.  Colonoscopy via stoma.
2.  Flexible sigmoidoscopy.

SURGEON:  John Doe, MD

ANESTHESIA:  Fentanyl 100 mcg and Versed 5 mg.

INDICATIONS FOR PROCEDURE:  The patient is a (XX)-year-old female who presented to this office after being referred about four months ago with severe rectal ulcerations, rectal perforation, and peritoneal sepsis. The patient underwent diverting colostomy. She now presents for a colostomy closure.

DESCRIPTION OF PROCEDURE:  Informed consent was obtained. The patient was taken to the endoscopy suite and placed in the supine position.  After adequate intravenous sedation, the stoma was digitalized.

The colonoscope was then inserted into the stoma and easily advanced to the cecum. The ileocecal valve and appendiceal orifice were identified. The entire colonic mucosa was then carefully and circumferentially inspected upon slow withdrawal of the scope. The entire mucosa up to the stoma, including the cecum, ascending and transverse, descending and sigmoid colon, was normal. The patient was then placed in the left lateral decubitus position. Digital rectal exam showed a stricture at about 6-7 cm. The flexible sigmoidoscope was placed and there clearly was still a small posterior perforation in this area with a stenotic area in the mid rectum. We were able to advance the scope through the area and the colon above was totally normal.

The patient tolerated the procedure well without any complications.  Postoperatively, she was transferred to the recovery room in stable condition.

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Recurrent rectal bleeding.

POSTOPERATIVE DIAGNOSES:
1.  Grade 2 to 3 internal hemorrhoids.
2.  Diverticulosis.

PROCEDURE PERFORMED:
Total colonoscopy.

ATTENDING DOCTOR:  John Doe, MD

ANESTHESIA:  IV monitored anesthesia care by Anesthesiology.

DESCRIPTION OF PROCEDURE:  Digital examination and inspection showed no rectal masses.  The prostate showed questionably enlarged irregular right lobe.  The Olympus colonoscope was introduced into the rectum and the scope was advanced without difficulty to the cecum.  The ileocecal valve and the appendiceal orifice were identified.  The preparation was excellent.  The scope was gradually withdrawn.  The colonic mucosa was inspected as we proceeded distally.  There were rare right-sided diverticula.  There was a moderate amount of sigmoid diverticulosis.  The U-turn maneuver in the rectum showed grade 2 to 3 internal hemorrhoids.  The colon was deflated.  The scope was withdrawn.  The patient tolerated the procedure well.

IMPRESSION:
1.  Questionably enlarged prostate.
2.  Internal hemorrhoids.
3.  Diverticulosis.

PLAN:
1.  High-fiber program, routine hemorrhoidal care.
2.  PCP followup for prostate.

3.  If the patient fails to respond to routine hemorrhoidal care, infrared coagulation of internal hemorrhoids might be considered.

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