COLONOSCOPY PROCEDURE REPORT
Patient Name: Doris Dean Richards
Referring Physician: Sandra Peebles, MD
Date of Procedure: October 10, 2023
Sex/Age: F/50
DOB: November 16, 1973
Patient ID: RIC147
Attending Physician: Doris Robertson, MD
Scope Used: CF-Q180AL-2704565
INTRODUCTION: A 50-year old Caucasian female patient presents for outpatient colonoscopy.
INDICATIONS: Increased risk screening. Screening for family history of colorectal cancer. Code B16.0.
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: Propofol, per Miller Travis, CRNA, anesthetist.
PROCEDURE The endoscope was passed with ease through the anus under direct visualization. It was
extended to the cecum. The scope was withdrawn and the mucosal was carefully examined. The quality
of the preparation was good.
FINDINGS: There was evidence of mild diverticulosis in the sigmoid colon. Small hemorrhoids were
found. No unplanned events occurred.
IMPRESSION: Mild diverticulosis, code 562.10, found in the sigmoid colon. Hemorrhoids: 455.6.
RECOMMENDATIONS Follow up appointment with referring physician. Start high fiber diet. Repeat
colonoscopy recommended in 5 years. Procedure code: 45378 - Colonoscopy.
________________________________
Doris Robertson, MD, Gastroenterology
DR:MJ
D: 10/31/2023
T: 10/31/2023
C: Sandra Peebles, MD, Internal Medicine
Johnson, Mallory Case 6-2
