www.Online-Medical-Transcription-Course.com

COLONOSCOPY

HISTORY: A 65-year-old female patient presents for an elective inpatient colonoscopy.  The indications for the procedure were diarrhea and hematochezia. 

CONSENT: The benefits, risks, and alternatives of the procedure were discussed and informed consent was obtained from the patient.

PREPARATION: EKG, pulse oximetry and blood pressure were monitored.

MEDICATIONS:
1.  Demerol 50 mg IV before the procedure.
2.  Versed 2.5 mg IV throughout the procedure

PROCEDURE: The endoscope was passed under direct visualization to the cecum confirmed by appendiceal orifice, cecal strap and ileocecal valve. Retroflexion was performed in the rectum. The quality of the preparation was adequate. Due to excessive looping and inability to reduce the scope effectively and due to patient's body habitus, we were only able to advance the scope into the cecum. We were not able to advance the scope into the terminal ileum. There were numerous diverticuli present in the sigmoid and the descending colon. There was segmental colitis of the transverse colon starting in the mid transverse colon and extending to the hepatic flexure. There was mucosal edema, diffuse erythema, and shallow ulcerations.  Biopsies were obtained from the transverse colon and sent for histopathology and cultures (viral, fungal, AFB). The rest of the colon appeared normal. Moderate non-bleeding external hemorrhoids were present.

COMPLICATIONS: There were no complications associated with the procedure.

IMPRESSION:
1. Numerous diverticula in the sigmoid and descending colon. Procedure code: 562.10. 
2. Segmental colitis of the transverse colon between mid transverse colon and hepatic flexure. Procedure code: 558.9.
3. Biopsies were obtained from the transverse colon and sent for histopathology and cultures (viral, fungal, AFB). 

DIFFERENTIAL DIAGNOSIS: 
1. Medication-induced colitis, from NSAIDs. 
2. Infectious, ischemic, IBD (Crohn's). 
3. Moderate non-bleeding external hemorrhoids. 

RECOMMENDATION:
1. Avoid NSAID use.
2. Followup results of biopsies.
3. Further management as per primary inpatient service. 

PROCEDURE CODE:  45380: Colonoscopy to cecum and biopsy.