Sample Type / Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 10

Description: Colon cancer screening and family history of polyps. Sigmoid diverticulosis and internal hemorrhoids.
(Medical Transcription Sample Report)


PREOPERATIVE DIAGNOSES: Colon cancer screening and family history of polyps.

POSTOPERATIVE DIAGNOSIS: Colonic polyps.

PROCEDURE: Colonoscopy.

ANESTHESIA: MAC

DESCRIPTION OF PROCEDURE: The Olympus pediatric variable colonoscope was introduced into the rectum and advanced carefully through the colon into the cecum and then through the ileocecal valve into the terminal ileum. The preparation was excellent and all surfaces were well seen. The mucosa was normal throughout the colon and in the terminal ileum. Two polyps were identified and were removed. The first was a 7-mm sessile lesion in the mid transverse colon at 110 cm, removed with the snare without cautery and retrieved. The second was a small 4-mm sessile lesion in the sigmoid colon at 20 cm also removed with the snare and retrieved. No other lesions were identified. Numerous diverticula were found in the sigmoid colon. A retroflex through the anorectal junction showed moderate internal hemorrhoids. The patient tolerated the procedure well and was sent to the recovery room.

FINAL DIAGNOSES:
1. Sigmoid diverticulosis.
2. Colonic polyps in the transverse colon and sigmoid colon, benign appearance, removed.
3. Internal hemorrhoids.
4. Otherwise normal colonoscopy to the terminal ileum.

RECOMMENDATIONS:
1. Follow up biopsy report.
2. Follow up with Dr. X as needed.
3. Screening colonoscopy in 5 years.

Keywords: gastroenterology,