Consult Colonoscopy

Clinician Specialty: Gastroenterologist DATE: 01/11/2024 PROCEDURE: "Colonoscopy" PRE-PROCEDURE DIAGNOSIS: - Change in bowel habits - Iron deficiency anaemia - Positive faecal occult blood test POST-PROCEDURE DIAGNOSIS: - Diverticulosis, sigmoid colon - Haemorrhoids, internal, grade 2 HISTORY OF PRESENTING ILLNESS: Mrs. Eleanor Vance is a 68-year-old female referred for colonoscopy due to recent onset of altered bowel habits, including increasing constipation alternating with looser stools over the past six months, accompanied by intermittent abdominal bloating. She also reported a positive faecal occult blood test as part of a national screening programme and was found to have iron deficiency anaemia on routine blood work. She has no personal history of inflammatory bowel disease or colorectal cancer. Her last colonoscopy was 10 years ago, which was reported as normal. PAST GI HISTORY: - Gastro-oesophageal reflux disease (GERD) – managed with PPIs - Previous cholecystectomy (2010) PAST HISTORY: - Hypertension – managed with ramipril - Type 2 Diabetes Mellitus – managed with metformin - Osteoarthritis – managed with paracetamol as needed MEDICATIONS: - Ramipril 5mg once daily - Metformin 500mg twice daily - Pantoprazole 40mg once daily - Paracetamol 500mg as needed ALLERGIES: - Penicillin (rash) FAMILY HISTORY: Her mother was diagnosed with colorectal cancer at the age of 75. Her father had a history of diverticular disease. No other significant family history of gastrointestinal diseases or polyps. SOCIAL HISTORY: Mrs. Vance lives with her husband in a detached house. She retired two years ago from her job as a primary school teacher. She is mobilising independently without aids. She is a non-smoker and reports occasional alcohol consumption (1-2 units per week). No history of illicit substance use. PHYSICAL EXAM: "The abdomen was soft, non-tender, with no hepatosplenomegaly or masses. Cardiovascular, respiratory, lymph node, and dermatological examinations were normal." INVESTIGATIONS: - Faecal Occult Blood Test (FOBT) 15/09/2024: Positive - Full Blood Count (FBC) 20/09/2024: Hb 10.2 g/dL (low), MCV 78 fL (low) - Previous Colonoscopy (2014): Normal 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, bleeding, missed lesions, perforation potentially requiring surgical intervention, and infection." SEDATION: "Intravenous conscious sedation consisting of midazolam 3 mg and fentanyl 50 mcg." PROCEDURE: "After a time out, 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 retroflection. 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: Caecum reached 3. Withdrawal time: 12 minutes 4. Technical difficulties: [None] 5. Unplanned events: [None]" ASSESSMENT AND PLAN: The colonoscopy revealed diverticulosis in the sigmoid colon and grade 2 internal haemorrhoids, which are likely contributing to her altered bowel habits and some of her anaemia. No polyps or suspicious lesions were identified, which is reassuring given her symptoms and positive FOBT. The patient tolerated the procedure well with no immediate complications. She will be advised on dietary modifications to increase fibre intake and ensure adequate hydration to manage her diverticulosis and constipation. A follow-up appointment will be scheduled in 4-6 weeks to discuss the results in detail and review her iron deficiency anaemia, including the need for iron supplementation. Surveillance colonoscopy will be recommended in 5 years due to her family history and age.