Medical Specialty:

Sample Name: Colonoscopy - 1

Description: Colonoscopy due to rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.
(Medical Transcription Sample Report)

INDICATION: Rectal bleeding, constipation, abnormal CT scan, rule out inflammatory bowel disease.

PREMEDICATION: See procedure nurse NCS form.

PROCEDURE: After informed consent was obtained, the patient was placed in the left lateral position and the above medications were titrated with adequate sedation. 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 visualization, 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 The colonoscope was then withdrawn while carefully examining the mucosa.

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 the procedure well without complications.

1. Small internal hemorrhoids.
2. Otherwise normal colonoscopy.

PLAN: Continue fiber, increase to two tablets twice a day for a total of four tablets. Also try NuLev.

FOLLOWUP: In the office in approximately four weeks if her symptoms do not resolve.

Keywords: surgery, bleeding, ct scan, digital rectal exam, pentax video, rectal, cecal strap, cecum, colonic mucosa, colonoscope, colonoscopy, constipation, hemorrhoids, ileocecal valve, inflammatory bowel disease, lateral position, bowel disease, internal hemorrhoids, inflammatory,