Case 2 Exam Skillbuilding Report 5
OPERATIVE REPORT
Patient Name: Ralph Gleason
Patient ID: 110567 Age: 87 DOB: 05/31/---- Sex: M
Date of Admission: 04/04/----
Date of Procedure: 04/04/----
Admitting Physician: Martha C. Eaton, MD Geriatrics
Surgeon: Bernard Kester, MD General Surgery
Preoperative Diagnosis: Hematochezia.
Postoperative Diagnosis: Hematochezia; inactive at this point.
Procedure: Colonoscopy.
Anesthesia: Sedation.
Specimen Removed: None.
Pre-op Meds: Versed 3 mg, intravenous. Fentanyl 50 mcg, Intravenous.
Estimated Blood Loss: None.
Urine Output: None.
Complications: None.
Preparation: Golightly.
RESULTS: Fair, with some areas better than others. Definitely small lesions could have been easily missed in view of the prep results.
INDICATIONS: The patient is an 87 year-old male admitted with hematochezia associated with over anticoagulation. The patient has history of fecal incontinence after surgery for anorectal fistula. His hematocrit has remained around 34%-35%. No further bleeding since admission has been identified.
(Continued)
OPERATIVE REPORT
Patient Name: Ralph Gleason
Patient ID: 110567
Date of Procedure: 04/04/----
Page 2
DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient and the guardian after discussing alternatives, indications, benefits, and risks. At the procedure in the GI lab the patient was placed in the left lateral decubitus position, medications administered. Once the patient was sedated, an anal exam was performed which revealed no obvious hemorrhoids. Digital exam revealed a reduced sphincter tone. There was some nodularity in the anal canal. The prostate was somewhat enlarged but without nodules. Then the scope passed through the anus and under direct vision up to the level of the cecum. Throughout the colon, especially on the left side, there was pseudo-membranes of whitish-yellowish coloration, under which a reddish mucosa was identified. In some spots there were tiny pieces of clot associated with the
Patient Name: Ralph Gleason
Patient ID: 110567 Age: 87 DOB: 05/31/---- Sex: M
Date of Admission: 04/04/----
Date of Procedure: 04/04/----
Admitting Physician: Martha C. Eaton, MD Geriatrics
Surgeon: Bernard Kester, MD General Surgery
Preoperative Diagnosis: Hematochezia.
Postoperative Diagnosis: Hematochezia; inactive at this point.
Procedure: Colonoscopy.
Anesthesia: Sedation.
Specimen Removed: None.
Pre-op Meds: Versed 3 mg, intravenous. Fentanyl 50 mcg, Intravenous.
Estimated Blood Loss: None.
Urine Output: None.
Complications: None.
Preparation: Golightly.
RESULTS: Fair, with some areas better than others. Definitely small lesions could have been easily missed in view of the prep results.
INDICATIONS: The patient is an 87 year-old male admitted with hematochezia associated with over anticoagulation. The patient has history of fecal incontinence after surgery for anorectal fistula. His hematocrit has remained around 34%-35%. No further bleeding since admission has been identified.
(Continued)
OPERATIVE REPORT
Patient Name: Ralph Gleason
Patient ID: 110567
Date of Procedure: 04/04/----
Page 2
DESCRIPTION OF PROCEDURE: Informed consent was obtained from the patient and the guardian after discussing alternatives, indications, benefits, and risks. At the procedure in the GI lab the patient was placed in the left lateral decubitus position, medications administered. Once the patient was sedated, an anal exam was performed which revealed no obvious hemorrhoids. Digital exam revealed a reduced sphincter tone. There was some nodularity in the anal canal. The prostate was somewhat enlarged but without nodules. Then the scope passed through the anus and under direct vision up to the level of the cecum. Throughout the colon, especially on the left side, there was pseudo-membranes of whitish-yellowish coloration, under which a reddish mucosa was identified. In some spots there were tiny pieces of clot associated with the