Sample Type / Medical Specialty: Gastroenterology

Sample Name: Colonoscopy - 1

Description: Colonoscopy due to rectal bleeding, constipation, abnormal CT scan,
rule out inflammatory bowel disease.
INDICATION: Rectal bleeding, constipation, abnormal CT scan, rule out inflammato
ry bowel disease.
PREMEDICATION: See procedure nurse NCS form.
PROCEDURE: After informed consent was obtained, the patient was placed in the le
ft lateral position and the above medications were titrated with adequate sedati
on. Monitoring was provided throughout the entire procedure. Digital rectal exam
was performed revealing normal sphincter tone and no external hemorrhoids. The
Pentax video colonoscope was inserted into rectum and advanced under direct visu
alization, without difficulty, to the cecum, where the cecal strap, appendiceal
orifice, and the ileocecal valve were identified. The quality of the preparation
was good. The colonoscope was then withdrawn while carefully examining the muco
sa.
The colonic mucosa appeared normal with normal vascularity and haustral markings
. No masses, polyps, AVM/s or diverticula were seen. On retroflexed view in the
rectum, there are small internal hemorrhoids.
The endoscope was removed and the procedure terminated. The patient tolerated th
e procedure well without complications.
IMPRESSION:
1. Small internal hemorrhoids.
2. Otherwise normal colonoscopy.
PLAN: Continue fiber, increase to two tablets twice a day for a total of four ta
blets. Also try NuLev.
FOLLOWUP: In the office in approximately four weeks if her symptoms do not resol
ve.
Keywords: gastroenterology, bleeding, ct scan, digital rectal exam, pentax vide
o, rectal, cecal strap, cecum, colonic mucosa, colonoscope, colonoscopy, constip
ation, hemorrhoids, ileocecal valve, inflammatory bowel disease, lateral positio
n, bowel disease, internal hemorrhoids, inflammatory,