DATE OF PROCEDURE: MM/DD/YYYY
INDICATION FOR PROCEDURE: The patient is a (XX)-year-old patient with a history of diabetes. He has noted abdominal gas, bloating and nonvoluminous, nonbloody diarrhea, which has been intermittent without associated weight loss or bleeding.
PREOPERATIVE DIAGNOSES:
1. Abdominal gas, bloating.
2. Diarrhea.
POSTOPERATIVE DIAGNOSES:
1. Gastritis, isolated to the gastric body.
2. Shallow, clean-based gastric ulcer.
3. Gastric biopsies performed.
4. CLOtest performed.
5. Small bowel biopsies performed.
6. Normal colonoscopy to the cecum.
7. Random biopsies of the rectosigmoid.
PROCEDURE PERFORMED: Endoscopies.
ENDOSCOPIST: John Doe, MD
ANESTHESIA: Versed and fentanyl.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: An informed consent was obtained, the patient was monitored by continuous pulse oximetry, blood pressure cuff, and electrocardiogram. The patient is ASA classification 2 and cleared for conscious sedation.
In the left lateral decubitus position, the diagnostic Pentax gastroscope was inserted under direct visualization into the esophagus. This was grossly normal. The gastroesophageal and squamocolumnar junction were both identified at 40 cm. The stomach was entered and examined in both antegrade and retrograde fashion. Involving the gastric body, there was erythema consistent with mild gastritis. There was also a shallow, clean-based ulcer in the gastric body on the greater curvature. It was benign in appearance. Random biopsies were performed. CLOtest of the antrum and angulus were performed. The duodenal bulb as well as the second portion of the duodenum were normal. Biopsies were performed to rule out malabsorption.
The patient was then positioned for colonoscopy, and a normal rectal exam was performed. There was evidence of external hemorrhoids. The diagnostic Pentax colonoscope was inserted under direct visualization to the cecum with clear identification of the ileocecal valve and appendiceal orifice. Overall, the preparation was adequate. Areas of retained stool were flushed and aspirated. Photodocumentation was obtained. The examination was not difficult. The colonoscope was withdrawn and the mucosa carefully examined. The mucosa was normal. Due to the patient’s symptoms, random biopsies of the rectosigmoid were performed. Retroflex examination in the rectum was normal.
PLAN: Will follow up on the biopsies. The patient was instructed to avoid all aspirin and nonsteroidal anti-inflammatories. The prescription for omeprazole, which the patient was previously given and did not start, it is recommended that the patient begin this. We will follow up on the biopsies, and the patient will be scheduled for a followup endoscopy to confirm healing. The patient is to call to schedule a followup.
