DATE OF PROCEDURE: MM/DD/YYYY
REFERRING PHYSICIAN: Jane Doe, MD
ENDOSCOPIST: John Doe, MD
PROCEDURE PERFORMED: Colonoscopy and biopsy.
INDICATIONS: The patient is a pleasant (XX)-year-old male who was apparently diagnosed with autoimmune hepatitis and treated with Imuran and prednisone, who has had problems with chronic diarrhea. He has had stool studies which have been negative and has between 6 and 8 bowel movements per day.
A physical examination done prior to the procedure was normal.
MEDICATIONS: Fentanyl 150 mcg and Versed 8 mg intravenously given throughout the procedure.
INSTRUMENT: CF-180AL.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient after the risks and benefits of the procedure were carefully explained, which included but were not limited to bleeding, infection, perforation and allergic reaction to the medications, as well as the possibility of polyps being missed within the colon.
The colonoscope was passed through the rectum, all the way towards the cecum, which was identified by the presence of the appendiceal orifice and ileocecal valve. This was done without difficulty and the bowel prep was good. The ileocecal valve was intubated. The distal 12 to 14 cm of the terminal ileum was examined. The colonoscope was then slowly withdrawn and a careful examination of the mucosa was performed with withdrawal time exceeding 7 minutes. There was evidence of a diffuse colitis seen from the rectum all the way towards the cecum with decreased mucosal vascularity, diffuse erythema with multiple ulcers seen throughout the colon. There was loss of a normal haustral fold seen within the colon. Evaluation of the examination of the terminal ileum revealed marked erythema with punctate ulcer seen within the terminal ileum.
Biopsies were obtained from the terminal ileum and placed in jar #1. Biopsies were obtained randomly from the colon and placed in jar #2. Retroflexion was not performed due to the diffuse severe colitis seen within the rectum.
ASSESSMENT:
Diffuse ileocolitis highly suggestive with presence of Crohn’s disease.
RECOMMENDATIONS:
1. Follow up results of the biopsies.
2. Obtain an IBD-7 serological study, ANA, and anti-liver-kidney microsomal antibody along with a CBC and CMP.
3. Begin prednisone 40 mg p.o. daily and taper for 1 week and taper over the next 2 weeks.
4. Begin Pentasa 500 mg 2 tablets p.o. t.i.d.
5. Follow up in clinic.
6. Obtain a small bowel follow-through.
