Gastro Medical Transcription Report
PREOPERATIVE DIAGNOSIS:
History of Crohn disease with nodularity and deformity of the ileocecal valve region now followed with colonoscopy.
POSTOPERATIVE DIAGNOSES:
Severe deformity of the ileocecal valve region with ileal stricture formation status post biopsy, separate polypoidal process appearing within the caput cecum in the periappendiceal region status post biopsy submitted in a separate container.
TITLE OF OPERATION:
Colonoscopy with biopsies.
PROCEDURE:
After the patient was placed in the left lateral decubitus position, the doctor administered anesthesia until the patient was sedated.
Once adequately sedated, the video pediatric colonoscope was introduced into the patient’s rectum and advanced into the cecum. Cecal location was confirmed by characteristic architecture and transillumination in the right lower quadrant. Within the caput cecum in the periappendiceal region, a polypoidal process was noted. Biopsies were obtained. The instrument was withdrawn to the ileocecal valve area, which had significant stricture formation, scarring and nodularity and a separate set of biopsies were obtained of this region. The instrument was withdrawn to the ascending and transverse colons where it was noted to have diverticulosis. In the rectum, no further pathology was seen. The instrument was withdrawn from the patient’s anus.
The patient tolerated the procedure well and returned to recovery room in satisfactory condition.
