CDDC Procedures

Past Medical History: - Patient has a history of well-controlled hypertension diagnosed 5 years ago, managed with medication. No previous surgeries explicitly mentioned. Current Medications: - Lisinopril 10mg once daily. No herbal supplements mentioned. Social History: - Non-smoker, occasional alcohol consumption (1-2 units per week). Works as a retired school teacher. Lives with spouse. Exercises regularly (walking 3 times a week). Family History: - Mother had a history of colorectal polyps, diagnosed at age 60. Father had a myocardial infarction at age 70. No family history of inflammatory bowel disease or other significant GI conditions. History of Presenting Illness: - Patient is a 68-year-old male presenting for a routine screening colonoscopy due to family history of colorectal polyps. He reports no current gastrointestinal symptoms such as abdominal pain, rectal bleeding, changes in bowel habits, or unexplained weight loss. He feels generally well and denies any recent illness. The patient was keen to proceed with the screening due to his mother's history. Previous GI Investigations: - Patient underwent a gastroscopy 3 years ago which showed mild gastritis, managed with lifestyle modifications. No previous colonoscopies. Physical Exam: - General: Alert and oriented, appears well. Abdomen: Soft, non-tender, non-distended. No palpable masses or organomegaly. Bowel sounds present. Rectal exam not performed prior to procedure. CONSENT TO PROCEDURE The rationale behind gastroscopy was explained to the patient. The consent form was explained to the patient by the nurse and the patient was consented to the risks and benefits including the 1:1000 risk of perforation or bleeding, and a 5% miss rate of adenoma or mass with gastroscopy as well as the cardiorespiratory risks of sedation. In addition, I reviewed the procedure and consent form with the patient, and ensured the patient was satisfied with the explanation and no further questions. Verbal consent was obtained and witnessed by myself and the staff nurse. The patient was brought to the endoscopy suite and was placed in a left lateral decubitus position. Procedure Note -- Gastroscopy: Sedation was administered by anesthetist. - Oesophagus: Normal calibre and mucosa. No erosions or strictures. Z-line at 38cm, regular. Stomach: Fundus, body, antrum all normal. No lesions or ulcers. Duodenum: Bulb and second part normal. No active inflammation or masses. Procedure Note-- Colonoscopy: Sedation was administered by anesthetist. Digital rectal exam was normal tone, no masses, no blood. The colonoscope was introduced to the anus and advanced to the colon and all the way to the cecum which was identified by the appendiceal orifice and ileocecal valve. Bowel preparation was excellent. Ottawa bowel prep score was 2/14. The terminal ileum was intubated. It appeared normal, with no erosions or ulcerations. No biopsies were taken from the terminal ileum. Careful examination of the colon demonstrated: Terminal ileum: Normal. Ascending colon: Normal mucosa. One 5mm sessile polyp was identified approximately 10cm from the cecum, removed by cold snare polypectomy. Base was clean. Transverse colon: Normal mucosa. No polyps or lesions. Descending colon: Normal mucosa. No polyps or lesions. Sigmoid colon: Normal mucosa. One 3mm hyperplastic-appearing polyp was noted and removed with cold forceps biopsy. Rectum: Normal mucosa. No polyps or lesions. Retroflexion: Normal views of the rectum and anal canal. No haemorrhoids or fissures. The patient tolerated the procedure very well. The scope was withdrawn and the procedure terminated. The patient was sent to the recovery area with no immediate complications. Assessment and Plan: - 68-year-old male undergoing screening colonoscopy due to family history of colorectal polyps. Procedure completed successfully to the cecum. Two polyps removed: one 5mm sessile polyp in the ascending colon and one 3mm hyperplastic-appearing polyp in the sigmoid colon. Gastroscopy revealed mild gastritis as previously noted. - Pathology results for polyps to follow. We will provide your office with a recommended interval for a follow up colonoscopy once the pathology has been reviewed. If the polyp proves to be adenomatous, all first degree family members over the age of 40 to be screened for colorectal cancer with a colonoscopy. Thank you for allowing me to participate in the care of your patient. Sincerely, Dr. Anya Sharma, Gastroenterologist Date: 1 November 2024