Posted 11/4/2013 9:11 AM (GMT -7)
Indications: Rectal bleeding (569.3). Mucus pr. Abd cramps. Screening for family history of colorectal cancer (V16.0). Procedure Codes: Colonoscopy with biopsy Procedure: The CF-Q180AL-2501226 colonoscope was passed with ease through the anus under direct visualization and advanced to the terminal ileum, confirmed by appendiceal orifice, cecal strap (crow's foot), ileocecal valve, landmarks, and photographs. The scope was withdrawn and the mucosa was carefully examined. The quality of the preparation was good. The views were good. The patient's toleration of the procedure was good. Rectal U-turn was performed. Findings: 23 cm. 25 cm. The ileum appeared to be normal. Three cold forceps biopsies were taken from the ileum. The specimens were collected for rule out Crohn's disease. 0-23 cm revealed loss of vascular pattern, 3+ erythema, 2+ friability, 2+ granularity diffusely, worst in the rectum. Otherwise, the colon appeared to be normal with intact vascular pattern. 12 cold forceps biopsies were taken from the whole colon 23 cm - cecum. The specimens were collected for rule out ulcerative colitis, rule out Crohn's disease, and rule out dysplasia. Impression: Ulcerative proctosigmoiditis. Recommendations: Follow-up on the results of the biopsy specimens. PCP follow up for vaccination update - needs to be current for Varicella, MMR, diptheria/pertussis. Yearly flu shot. Pneumovax. GI office can give hep A and B vaccines if not done. Once Path back, decide about restarting Asacol HD vs switching to Lialda. Would also treat with Rowasa enemas bid x 2 weeks and then taper pending course. Pay attention as to how stress relates to symptoms. May later use Bentyl also as needed. Defer immunologic or biologic therapy at present. Colonoscopy recommended. Further recommendations pending above and course. Consent: The benefits, risks, and alternatives to the procedure were discussed and informed consent was obtained from the patient. Preparation: EKG, pulse, pulse oximetry and blood pressure were monitored throughout the procedure. Medications: Monitored anesthesia care (MAC) given. Rectal Exam: Normal rectal exam. Unplanned Events: There were no unplanned events. Estimated Blood Loss: None. Comments: Pathology Specimens: Three cold forceps random biopsies taken from the ileum. 12 cold forceps random biopsies taken from the whole colon.Version 1, electronically signed by Dr. STEPHEN DEUTSCH on 10/30/2013 at 14:24.