www.Online-Medical-Transcription-Course.com

COLONOSCOPY

HISTORY OF PRESENT ILLNESS: A 45-year-old male patient presents for an elective outpatient colonoscopy. The indications for the procedure were for a history of gastrointestinal bleeding.

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

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

MEDICATIONS:
1. Midazolam HCL 2 mg IV before the procedure.
2. Demerol 50 mg IV before the procedure.

PROCEDURE: 
A rectal exam was done. Moderate non-bleeding hemorrhoids were present at right lateral and left lateral positions. The endoscope was passed with ease under direct visualization to the sigmoid and confirmed by landmarks. The quality of the preparation was inadequate precluding a complete examination.

COMPLICATIONS: There were no complications associated with the procedure.

IMPRESSION: Moderate non-bleeding hemorrhoids were present.

RECOMMENDATION: Follow-up with colorectal surgery in 2 weeks.