Gastroscopy Colonoscopy

DATE: 11/01/2024 PROCEDURE: "Gastroscopy and Colonoscopy" PRE-PROCEDURE DIAGNOSIS: - Chronic abdominal pain - Iron deficiency anemia - Suspected inflammatory bowel disease POST-PROCEDURE DIAGNOSIS: "[]" HISTORY OF PRESENTING ILLNESS: The patient is a 45-year-old female who was referred by her primary care physician due to chronic, intermittent abdominal pain, primarily in the lower right quadrant, ongoing for approximately six months. She also reports a recent diagnosis of iron deficiency anemia, unresponsive to oral iron supplementation. Her symptoms include bloating, occasional diarrhoea alternating with constipation, and fatigue. She has no significant past surgical history related to the gastrointestinal tract and her last colonoscopy was 10 years ago, which was unremarkable. Recent laboratory tests showed low haemoglobin and ferritin levels. CONSENT: "Informed consent was obtained after having reviewed the rationale and alternatives for the procedure as well as its risks, which include but are not limited to: sedation-related adverse effects, aspiration, post-procedural chest or abdominal discomfort, less than one percent risk of perforation with dilation potentially requiring surgical intervention and infection." SEDATION: "Intravenous conscious sedation consisting of midazolam 2.5 mg and fentanyl 75 mcg. ;procsedation" PROCEDURE: "Gastroscopy: After a time out, with the patient in the left lateral decubitus position, the gastroscope was inserted into the oropharynx and carefully advanced with direct visualization to the level of the cricopharyngeus. Esophageal intubation was performed without difficulty. The gastroscope was gradually advanced and the entire esophageal mucosa was carefully visualized. The gastroscope was further advanced into the stomach and the mucosa of the gastric fundus, body, and antrum were slowly surveyed. The gastroscope was subsequently advanced into the duodenum for evaluation of the first and second portions. Satisfactory mucosal views were achieved with the use of irrigation and suctioning of all pools of residue, mucus and fluid, and retroflexion. The gastroscope was removed. The patient tolerated the procedure well. Colonoscopy: The patient was repositioned. Digital rectal examination was performed. An adult colonoscope was inserted into the rectum and advanced with the use of water insufflation and positional changes to the level of the cecal pole. Normal cecal pole landmarks were identified with clear visualization of the ileocecal valve and appendiceal orifice. Photographs were obtained. The colonoscope was carefully withdrawn. Satisfactory mucosal views were achieved with the use of dynamic positional changes, irrigation and suctioning of all pools of residue, mucus and fluid, segment reassessment, and retroflexion. The colonoscope was removed and the patient was returned to the recovery room having tolerated the procedure well." QUALITY INDICATORS: "1. Bowel prep: Excellent 2. Extent of examination: Terminal ileum 3. Withdrawal time: 10 minutes 4. Technical difficulties: None 5. Unplanned events: None" ASSESSMENT AND PLAN: "[]"