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COLONOSCOPY

HISTORY: A 62-year-old female patient presents for an elective outpatient colonoscopy.  The indication for the procedure was average risk screening for colon cancer.

PHYSICAL EXAMINATION: The patient's clinical history and physical examination were performed and are documented in the patient's record.

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

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

MEDICATIONS: Versed 2 mg IV before the procedure.

PROCEDURE: The endoscope was passed under direct visualization to the ileocecal valve confirmed by landmarks, appendiceal orifice, cecal strap, and ileocecal valve.  The quality of the preparation was good.

FINDINGS: There were multiple large diverticula present in the transverse colon.

COMPLICATIONS: There were no complications associated with the procedure.

IMPRESSION: Multiple large diverticula in the transverse colon. 

RECOMMENDATION:
1. High fiber diet.
2. Avoid seeds, nuts and kernels.
3. Repeat colonoscopy in 5 years.
4. Follow-up with physician in 2 weeks.

PROCEDURE CODE: 45378: Colonoscopy to cecum.