BIRTHDATE: 01/03/42
INDICATIONS: The patient is a 77 year old male here for a colonoscopy due to personal history of colon cancer and post right hemi colectomy.
PROCEDURE PERFORMED: Colonoscopy, surveillance.
MEDICATIONS: Nasal oxygen, Zofran 4 mg IV, Midazolam (Versed) 3 mg IV, Midazolam (Versed) 2 mg IV, and Meperidine (Demerol) 50 mg IV.
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 attending physician was present during the entire procedure. The EC-3490Li(A111606) endoscope was introduced through the anus and advanced to the cecum, which was identified by the ileocecal valve. The scope was then completely withdrawn from the patient and the procedure terminated.
QUALITY OF PREP: Adequate prep after lavage. A digital rectal exam was performed and revealed internal hemorrhoids.
COLON FINDINGS: Normal mucosa was found in rectum seen upon the retroflexed view, in the rectum, sigmoid colon, descending colon, at the spolenic flexure, in the transverse colon, and at the hepatic flexure. Normal surgical anastomosis. Retroflexed views revealed internal hemorrhoids. Otherwise the examination was normal.
ESTIMATED BLOOD LOSS: None
REPEATE EXAM: 3 years
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