Documenting a gastroenterology list
Colonoscopy and gastroscopy reports, histology letters with the surveillance interval, and reminder letters when it comes due.
A colonoscopy, dictated before the next patient
Colonoscopy for a positive bowel screening FOBT. Propofol sedation, anaesthetist present.
Prep good, Boston 8. Caecum at six minutes, appendiceal orifice and ileocaecal valve photographed, TI intubated and normal. Withdrawal eleven minutes.
Three polyps. Six millimetre sessile in the ascending colon, cold snare. Four millimetre sessile in the transverse, cold snare. Fourteen millimetre pedunculated in the sigmoid, hot snare, clip to the stalk. All retrieved.
Moderate sigmoid diverticular disease, nothing else.
Surveillance interval once the histology is back. Letter to the GP then.
Indication
Positive iFOBT, National Bowel Cancer Screening Program.
Sedation
Propofol, anaesthetist present.
Preparation and extent
BBPS 8. Caecum reached at 6 min; AO and ICV photographed. TI intubated, normal. Withdrawal time 11 min.
Findings
- Ascending colon: 6 mm sessile polyp, cold snare, retrieved
- Transverse colon: 4 mm sessile polyp, cold snare, retrieved
- Sigmoid: 14 mm pedunculated polyp, hot snare, clip to stalk, retrieved
- Moderate sigmoid diverticular disease
Complications
Nil.
Plan
Surveillance interval on histology. Letter to GP.
The letter once histology is in
Dr Samuel OkaforRiverside Medical Centre
RE: Ahmed, Farid (DOB 02/05/1964) · Synthetic patient
Dear Dr Okafor,
Thank you for referring Mr Ahmed after a positive screening FOBT. I performed a colonoscopy on 15 September. The examination was complete to the terminal ileum with good preparation.
Three polyps were removed. Histology shows tubular adenomas with low-grade dysplasia at 6 mm and 4 mm, and a 14 mm tubular adenoma with low-grade dysplasia, completely excised. There was moderate sigmoid diverticular disease.
Because one adenoma was 10 mm or larger, I recommend surveillance colonoscopy in 3 years, in September 2029. My rooms will send him a reminder. He does not need further screening FOBTs in the meantime.
Kind regards,Consultant gastroenterologist
Also drafted
- Gastroscopy reports
- In the same order: indication, sedation, findings by region, biopsies and the plan.
- Surveillance reminders
- To the patient when the interval comes due, and again if the booking lapses.
