PRADER, BRACKER, & ASSOCIATES A Complete Health
PRADER, BRACKER, & ASSOCIATES A Complete Health Care Facility 159 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6789 PATIENT: VANCE, TOMIKA ACCOUNT/EHR #: VANTOM001 DATE: 12/09/22 Attending Physician: Salvatore L. Bloome, MD Indications: Ulcerative enterocolitis Procedure: Colonoscopy Instrument: Olympus video colonoscope CF 100L Anesthesia: Versed 4 mg; Demerol 75 mg MAC < 30 min HISTORY: This is a 71-year-old female admitted to the ambulatory surgical center for a colonoscopy. Due to her chronic enterocolitis, she is at high risk for a malignancy of the colon, and, therefore, this screening is being done. She has been informed of the nature of the procedure, the risks, and the consequences, as well as told of alternative procedures. She consents to the procedure. PROCEDURE: The patient is placed in the left lateral decubitus position. The rectal exam reveals normal sphincter tone and no masses. A colonoscope is introduced into the rectum and advanced to the distal sigmoid colon. Due to a marked fixation and severe angulation of the rectosigmoid colon, the scope could not be advanced any further and the procedure was aborted. On withdrawal, no masses or polyps are noted, and the mucosa is normal throughout. Retroflexion in the rectal vault is unremarkable. SCIENCE HEALTH SCIENCE NURSING OST 247
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