VA Palo Alto Health Care
3801 Miranda Avenue, Gl #111
Palo Alto, CA 94304

COLONOSCOPY PROCEDURE REPORT

NAME:
SSN#:

SEX:
DOB:
STATUS:
ENDOSCOPE:
MEDICATION:

John Matz
129231265

Male
10/6/1980, 36 yr old
Outpatient
PCF H190L #2406044
Midazolam (Versed) 5 mg IV, Fentanyl 125 meg IV, and Benadryl 25 mg IV

DATE:
PROCEDURE:

ENDOSCOPIST:
ASSISTING MD:
ASSISTANT:
Visit ID:

07/21/2016
Colonoscopy, surveillance, Colonoscopy with snare, and Colonoscopy with biopsy
Jazu Wizas
Kobla Khan, RN
Mary Jones, RN, Daniel Fale, and Mary Turner, RN
3160721123041

INDICATIONS:   The patient presents for high risk patient with personal history of colonic polyps (last colo 2007 with 2 >15mm pedunculated polyps) and suspected colovesicular fistula from diverticulitis, r/o malignancy prior to surgery.

PROCEDURE:   The procedure, its indication and alternative options were explained to the patient. The choice of intravenous sedation, the risks of the procedure and intravenous sedation including bleeding requiring transfusion, perforation, cardiorespiratory depression, and the possibility that lesions could be missed were discussed. Patient's consent was obtained. The patients medical and drug history, physical status ASA Class II, the results of relevant diagnostic studies and the choice of sedation and procedure were assessed prior to the administration of intravenous sedation.

Before the procedure began the Patient Pre-Procedure Verification Checklist was verified (correct patient identified with full name and full SSN, valid IMED consent with procedure, anticoagulants stop date and INR, antiplatelet stop date, unique equipment/device, PEG only and antibiotic given). Time Out was completed and verified (correct patient name, full SSN, procedure, allergies, and anticipated specimen).

A digital rectal exam revealed external hemorrhoids. The endoscope was introduced through the anus and advanced to the cecum, which was identified by both the appendix and ileocecal valve. The quality of the prep was good (small amount of feces or fluid not interfering with the exam) . The instrument was then slowly withdrawn while examining the mucosa circumferentially.

Two 5 mm sessile (0 - Is) polyps were found in the ascending colon. Polypectomies were performed with a cold snare. It was placed in Bottle A. A single 3 mm sessile (0 - Is) polyp was found in the descending colon. A polypectomy was performed with cold forceps. It was placed in Bottle B. Ten or more diverticulae were found in the sigmoid colon. No clear evidence of fistula opening, and no malignancy found. Retroflexed views revealed no abnormalities. The scope was then completely withdrawn from the patient and the procedure terminated.

The patient tolerated the procedure well and there were no immediate complications. The patient was cared for as planned according to standard protocol. The pulse, BP, and 02 saturation were monitored and documented by the physician and the nursing staff throughout the entire procedure. The patient was then discharged to recovery in stable condition and with appropriate post-anesthesia care.

COMPLICATIONS:   There were no immediate complications.
IMPRESSION:

  1. Two sessile (0 - Is) polyps were found in the ascending colon; polypectomies were performed
  2. Single 3 mm sessile (0 - Is) polyp was found in the descending colon; polypectomy was performed
  3. Ten or more diverticulae were found in the sigmoid colon<
RECOMMENDATIONS:
  1. await pathology results
  2. follow-up: surgery clinic as scheduled.
REPEAT EXAM:  3 year(s) for Colonoscopy, pending biopsy results.

SUGGESTED ICD9:

  1. V12.72 Personal history of colonic polyps
  2. 455.5 External hemorrhoids with other complication
  3. 211.3 Benign neoplasm of the colon
  4. 562.10 Diverticulosis of colon (without mention of hemorrhage)
LEVEL OF COMPLEXITY: nbsp; Level II - Colonoscopy with polypectomy (stalk <2cm), APC, decompression tube, or banding of varices and hemorrhoids. Colonoscopy with level I complexity but with previous failed/incomplete procedure or emergency case outside of normal hours. (Level of Complexity was determined based on Cotton et al. GIE 2011;73:868-74)

SUGGESTED CPT:  
  1. 45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)
  2. 43585 Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
  3. 45380 Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple

eSigned: Jazu Wizas, MD 07/21/2016 14:02

COLONOSCOPY DISCHARGE INSTRUCTIONS

ENDOSCOPIST: Jazu Wizas, MD

GENERAL:

Due to the sedation you received you may experience light headedness, dizziness, or sleepiness following your procedure. Do not stay alone. The effects of the sedation you have been given may last 24 hours.

  • Do not drive or operate machinery or perform heavy lifting for 24 hours.
  • Do not drink any alcoholic beverages for 24 hours.
  • Do not make important personal or business decisions or sign any legal documents for 24 hours.
  • Occasionally there is some discomfort and redness noted at the I.V. site. If the discomfort is not relieved by the application of warm towels, 3-4 times a day, then notify your physician.
  • You may experience a "bloated" feeling due to the air that was introduced to your body during the procedure. You may be more comfortable once you pass this air. You may try drinking warm liquids, walking, or belching.
  • If biopsies were taken you will recieve a letter in 2-4 weeks with your results.

    STANDARD INSTRUCTIONS:
    - Resume regular diet.
    - Rest today, resume normal activity tomorrow.
    - Resume all medications.
    -Follow-up with your primary care physician.

    OTHER INSTRUCTIONS:

    1. await pathology results
    2. follow-up: surgery, as scheduled.

    CAUTIONS: If you experience any bleeding, abdominal pain, nausea, vomiting, chest pains, fever, difficulty in breathing, or swallowing, contact 650-493-5000 and ask for the GI doctor on call. If you are unable to reach the physician, call 800-455-0057 or go to the Emergency Room.

    If you have questions call the GI lab at 650-493-5000 x64838 between 8am-6pm.

    
    Page 4 of 4                               Patient Name: Matz, John
    						 SSN #: 129231265