Sample Name: Colonoscopy - 9
Description: Patient with history of polyps.
(Medical Transcription Sample Report)
PREOPERATIVE DIAGNOSIS: Prior history of polyps.
POSTOPERATIVE DIAGNOSIS: Small polyps, no evidence of residual or recurrent polyp in the cecum.
PREMEDICATIONS: Versed 5 mg, Demerol 100 mg IV.
REPORTED PROCEDURE: The rectal chamber revealed no external lesions. Prostate was normal in size and consistency.
The colonoscope was inserted into the rectal ampulla and advanced under direct vision at all times until the tip of the scope was placed in the cecum. The position of the scope within the cecum was verified by identification of the ileocecal valve. Navigation was difficult because it seemed that the cecum took an upward turn at its final turn, but the examination was completed.
1. Small polyps, sigmoid colon, resected them.
2. Diverticulosis, sigmoid colon.
3. Small rectal polyps, obliterated them.
4. Submucosal lesions, consistent with lipomata as described.
5. No evidence of residual or recurrent neoplasm in the cecum.
Keywords: gastroenterology, ileocecal valve, sigmoid colon, polyps, ileocecal, submucosal, electrocautery, bleeding, rectum, rectal, sigmoid, cecum, scope, colonoscopy,