Study Result
Impression
COLONOSCOPY PRPCEDURE REPORT EXAM DATE: 06/12/2023
INDICATIONS:
The patient is a 81 year old male here for a colonoscopy due to surveillance for personal history of colorectal cancer.
PROCEDURE PERFORMED: Colonoscopy with snare
MEDICATIONS: Nasal oxygen, MAC
DESCRIPTION OF PROCEDURE:
During intra-op preparation period all mechanical & medical equipment was checked for proper function. Hand hygiene and appropriate measures for infection prevention was taken. A physical examination was performed. After the risks, benefits and alternatives of the procedure and sedation were thoroughly explained, informed consent was verified, confirmed and timeout was successfully executed by the treatment team. The EG29-i10 (K111578) EC38-i10L (A113168) endoscope was introduced through the anus and advanced to the terminal ileum which was intubated for a short distance. The scope was then completely withdrawn from the patient and the procedure terminated.
QUALITY OF PREP:
Adequate for the indication and for the standard follow up guidelines. The Boston Bowel Prep Score was Boston Scale Right colon 2, Transverse colon 2, and Left colon 2. Total BBPS=6.
A digital rectal exam was performed and revealed no abnormalities of the rectum>
COLON FINDINGS:
Three sessile polyps were found in the ascending colon. A polypectomy was performed with a cold snare. The resection was complete and the polyp tissue was completely retrieved. S/p right colectomy with normal anastomosis. The colon mucosa was otherwise normal. Retroflexed views revealed internal hemorrhoids. Otherwise the examination was normal.
ESTIMATEDE BLOOD LOSS:
None.
COMPLICATIONS:
There were no complications.
IMPRESSIONS:
1. Three sessile polyps ranging from 5 to 8 mm in size were found in the ascending colon; polypectomy was performed with a cold snare.
2. S/p right colectomy with normal anastomosis
3. Normal colonoscopy otherwise.
4. Retroflexed views revealed internal hemorrhoids.
RECOMMENDATIONS:
await pathology results
REPOEAT COLONOSCOPY:
Polyps were found, therefore your next colonoscopy 3 years. Reason for surveillance interval: personal history of colorectal cancer.
The attending physician performed the entire procedure.