Sample Type / Medical Specialty: Gastroenterology
Sample Name: Colonoscopy - 19
Description: Colonoscopy with terminal ileum examination. Iron deficiency anemia. Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty.
(Medical Transcription Sample Report)
INDICATION: Iron deficiency anemia.
PROCEDURE: Colonoscopy with terminal ileum examination.
POSTOPERATIVE DIAGNOSIS: Normal examination.
WITHDRAWAL TIME: 15 minutes.
MEDICATIONS: Fentanyl 100 mcg and versed 10 mg.
PROCEDURE DETAIL: Following the preprocedure patient assessment the procedure, goals, risks including bleeding, perforation, missed polyp rate as well as side effects of medications and alternatives were reviewed. Questions were answered. Pause preprocedure was performed.
Following titrated intravenous sedation the flexible video endoscope was introduced into the rectum and advanced to the cecum without difficulty. The ileocecal valve looked normal. Preparation was fair allowing examination of 85% of mucosa after washing and cleaning with tap water through the scope. The terminal ileum was intubated through the ileocecal valve for a 5 cm extent. Terminal ileum mucosa looked normal.
Then the scope was withdrawn while examining the mucosa carefully including the retroflexed views of the rectum. No polyp, no diverticulum and no bleeding source was identified.
The patient was assessed upon completion of the procedure. Okay to discharge once criteria met.
RECOMMENDATIONS: Follow up with primary care physician.
Keywords: gastroenterology, polyp, endoscope, mucosa, iron deficiency anemia, ileocecal valve, terminal ileum, colonoscopy, anemia, rectum, ileum,