Sample Report: Colonoscopy with Polypectomy
PREPROCEDURE DIAGNOSIS: Unexplained gastrointestinal bleeding.
POSTPROCEDURE DIAGNOSES
1. Two small sessile polyps in the sigmoid colon. Hot biopsy ablation performed.
2. Internal hemorrhoids.
PROCEDURE PERFORMED: Colonoscopy with polypectomy using hot biopsy forceps.
DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was placed in the left lateral position. Medications were given to achieve and maintain optimal sedation. The video colonoscope was introduced through the anal opening into the rectum and was advanced up to the cecum. The appendiceal opening and ileocecal valve were identified. The colonoscope was withdrawn. The only significant findings were two small sessile polyps in the sigmoid colon. These were removed using hot biopsy forceps. Internal hemorrhoids were noted. The rest of the exam was unremarkable. The colonoscope was withdrawn. The patient was transferred to the recovery room in stable condition.
IMPRESSION: No significant pathology that can explain gastrointestinal bleeding.
PLAN: Transfuse two units of packed red blood cells since the hematocrit is 25; maintain the hematocrit and consider further gastrointestinal evaluation if the gastrointestinal bleeding persists.