Medical Specialty:

Sample Name: Colonoscopy - 14

Description: Colonoscopy. History of colon polyps and partial colon resection, right colon. Mild diverticulosis of the sigmoid colon. Hemorrhoids.
(Medical Transcription Sample Report)

PREPROCEDURE DIAGNOSIS: History of colon polyps and partial colon resection, right colon.

1. Normal operative site.
2. Mild diverticulosis of the sigmoid colon.
3. Hemorrhoids.

PROCEDURE: Total colonoscopy.

PROCEDURE IN DETAIL: The patient is a 60-year-old of Dr. ABC's being evaluated for the above. The patient also apparently had an x-ray done at the Hospital and it showed a dark spot, and because of this, a colonoscopy was felt to be needed. She was prepped the night before and on the morning of the test with oral Fleet's, brought to the second floor and sedated with a total of 50 mg of Demerol and 3.75 mg of Versed IV push. Digital rectal exam was done, unremarkable. At that point, the Pentax video colonoscope was inserted. The rectal vault appeared normal. The sigmoid showed diverticula throughout, mild to moderate in nature. The scope was then passed through the descending and transverse colon over to the hepatic flexure area and then the anastomosis site was visualized. The scope was passed a short distance up the ileum, which appeared normal. The scope was then withdrawn through the transverse, descending, sigmoid, and rectal vault area. The scope was then retroflexed, and anal verge visualized showed some hemorrhoids. The scope was then removed. The patient tolerated the procedure well.

RECOMMENDATIONS: Repeat colonoscopy in three years.

Keywords: surgery, partial colon resection, diverticulosis, colon polyps, rectal vault, colonoscopy, polyps, hemorrhoids, sigmoid,