SAMPLE #2
O'CONNOR HOSPITAL
FELIX TAM, M.D.
COLONOSCOPY/EGD
_________________________________________________________________
ASSISTANT:
ANESTHESIOLOGIST:
DATE OF BIRTH:
10/04/1927
PREOPERATIVE DIAGNOSES:
1.
Weight loss.
2.
Heme-positive stool.
3.
Dyspepsia.
POSTOPERATIVE DIAGNOSES:
1.
Small nonbleeding external hemorrhoids.
2.
Two sigmoid polyps, removed.
3.
Otherwise normal colon examination.
4.
Normal esophagus.
5.
Suboptimal examination of the proximal stomach.
6.
Small 1 x 0.5 cm ulcer at angularis of stomach.
7.
Normal duodenum.
OPERATION:
1.
Colonoscopy with polyp removal and photographs.
2.
Esophagogastroduodenoscopy (EGD) with CLOtest and
photographs.
INDICATIONS FOR PROCEDURE: See the dictated history and physical
for indications and informed consent.
TECHNIQUE: The patient was placed in the left lateral decubitus
position in the endoscopy suite. During the procedure, a total
of 175 mcg of fentanyl and 1.5 mg of Versed were given
intravenously to the patient for sedation.
Inspection of the anus revealed very small nonbleeding
hemorrhoids with no thrombosis and no bleeding. Digital
examination of the rectum revealed no masses, no tenderness, and
good sphincter tone. An Olympus video PCF-160AL colonoscope was
inserted into the rectal area. It was advanced all the way to
the cecum. The ileocecal valve could be well seen. Bowel
preparation was good. The patient was put in the supine
position.
The scope was withdrawn. The cecum, ascending, transverse,
descending and sigmoid areas were examined again. The scope was
also retroflexed in the rectum. There were two polyps at the
sigmoid, one at 20 cm and one 30 cm. Both polyps were small,
measuring about 0.5 cm. By using polypectomy snare, using the
standard technique, both polyps were removed. There was good
hemostasis at the polypectomy site. No other lesions were found
in the colon. Specifically, no ulcerations, masses or other
polyps were found. No diverticular outpouches were found. No
lesions were found in the rectum. The scope was withdrawn.
Cetacaine spray was applied to the hypopharynx. An Olympus GIF160 upper endoscope was inserted in the esophagus under direct
vision. The hypopharynx was sprayed with Cetacaine. The
esophagus appeared normal. The squamocolumnar junction was
situated at 45 cm from the gumline. The scope was advanced into
the stomach. The stomach mucosa was somewhat atrophic. At the
angularis of the stomach, there was a 1 x 0.5 cm superficial
ulcer noted. There was no evidence of any active bleeding from
the ulcer.
There was no evidence of Barrett's esophagus, hiatal hernia, or
other lesions. The lower esophageal sphincter was competent. No
lesions were found in the esophagus.
The scope was advanced into the duodenum. The pylorus sphincter,
first, second and third portions of the duodenum appeared to be
normal.
The scope was withdrawn. Two biopsies were taken from the antrum
and stomach for CLOtest. The scope was retroflexed and at that
time, it was noted for the first time there was a small amount of
blood at the gastroesophageal junction. The patient was gagging
and retching quite a bit. The scope was withdrawn. Irrigation
was done at the gastroesophageal junction and no lesions were
found. The scope was withdrawn to the esophagus. No lesions
were found in the distal esophagus. The scope was inserted into
the stomach again. Different areas were examined. The scope was
retroflexed again. There was a small amount of blood at the
squamocolumnar junction area. Irrigation was done and no lesions
were found. When the scope was retroflexed, the patient was
gagging quite a bit. There was no active bleeding. The decision
at that time was not to do a biopsy of the stomach ulcer because
of the patient's gagging. It was felt that the gagging may make
bleeding at the squamocolumnar junction area worse. No lesions
were found there though. The scope was withdrawn.
The patient tolerated the procedure well with no complications.
At the end of the procedure, the vital signs were stable.
Abdominal examination was benign.
ASSESSMENT:
1.
The rectal bleeding may be on the basis of hemorrhoidal
condition. Heme-positive stool may be related to gastric
ulcer condition.
2.
Bleeding at the squamocolumnar junction may be related to a
Mallory-Weiss tear; however, no definite Mallory-Weiss tear
could be identified today. The gastric ulcer is most likely
benign; however, malignancy is a consideration. Biopsy or
repeat upper GI series in the future are different ways to
make sure there is no gastric malignancy.
The patient has been told to avoid aspirin and nonsteroidal antiinflammatory agents. She is to continue Nexium at this time.
She is to see me in one month for follow-up.