SIGMOIDOSCOPY REPORT

 

                PATIENT NAME :  Mr. Abc Albert                                  ATTENDING PHYSICIAN : Dr. Kailash  Singhvi M.D

 

PATEINT ID         : 123456789                                            REFERRING PHYSICAN   : Dr. Thomas  M.D              

 

DATE OF BIRTH: 12/21/1975       AGE: 26 Years      SEX: Male          EXAM DATE: 5TH MAY 2000

 

a.Rectum

b.Sigmoid colon

CONSENT          :    None

 

PREPARATION:   None

 

INSTRUMENT  :   Video Olympus CF type 100 Colonoscope

 

INDICATION   :   Patient has h/o lower Abdomenal pain and lower GI bleeding

 

PROCEDURE     :   After placing the patient in the left lateral decubitus position,

                                 the colonoscope was gently inserted into the rectum and

                                 under direct visualization advanced to Sigmoid Colon, color, texture, mucosa       

                                 and anatomy of the rectum and Sigmoid Colon were carefully examined with the    

                                 scope. The patient  tolerated the procedure well and there were no complications.               

                                 After completion of the examination, patient was transferred to the recovery room.

 

ANESTHESIA   :   IV Conscious sedation

 

 

 

FINDINGS

               

                RECTUM                            -  Internal Hemorrhoid          

                SIGMOID COLON            -  Very Inflammed. Biopsy taken

                                                                Diverticulosis

                DESCENDING COLON   -  None

               

                IMPRESSION                  -   Internal Hemorrhoid     455.0

                                                               Sigmoditis558.9

                 

           

                PLAN                                  -  Wait for Pathology report

                                                                Highfiberdiet

                                                                 Follow up in 2 weeks.