Gastroscopy or Colonoscopy Procedure Follow-up Note

Clinician Specialty: Gastroenterologist Findings: Esophageal findings: Mild oesophagitis noted, no strictures or dilation identified. Stomach findings: Erythema in the antrum with a 3mm non-bleeding polyp, biopsied. No ulceration. Small bowel findings: No abnormalities noted upon inspection of the visible small bowel. Ileum findings: Terminal ileum appeared healthy with normal villous pattern. Colon findings: Diverticulosis present throughout the sigmoid colon. Two small sessile polyps (4mm and 6mm) found in the descending colon, both removed via cold snare polypectomy. No active bleeding. Hemorrhoid findings: Internal haemorrhoids, grade II, non-bleeding. Plan: Biopsy result instructions: Biopsy results for the gastric polyp and descending colon polyps will be available in approximately 7-10 working days. The patient will be contacted by telephone with the results and further management recommendations. Pain management instructions: For persistent abdominal discomfort, take paracetamol as needed. If pain is severe or unmanageable with over-the-counter medications, please call Dr. Thomas Kelly's office at 020 7946 0000 during business hours or go to the nearest Emergency Department after hours. Dietary restrictions: Maintain a soft, low-residue diet for the next 48 hours to aid recovery and minimise bowel irritation. Avoid spicy foods, alcohol, and nuts for this period. Anti-acid and steroid medication instructions: Continue current omeprazole 20mg once daily for 4 weeks. No steroid medications were prescribed post-procedure. Follow-up communication timeline: The patient will receive a call within 10 days with biopsy results. A follow-up consultation with Dr. Thomas Kelly is scheduled for 1 November 2024, to discuss long-term management and surveillance. General post-discharge endoscopy instructions: "If local freezing was used, you cannot eat or drink for one hour after the procedure." "If you have received sedation, you are considered impaired for the next 24 hours. Please do not: "- Drive" "- Travel alone by public transportation" "- Sign legal or financial documents" "- Use power appliances or tools" "- Cook or pour hot liquids" "- Drink alcohol" "- Go to work or do business" "- Take responsibility for another person (e.g. baby, small child, or individual in poor health)" "- Do strenuous activities like bike riding, swimming, or climbing ladders" "You may: "- Take medications as scheduled unless told otherwise by your doctor." "The following is normal: "- Nausea, vomiting and/or diarrhea may occur with your next meal." "- You may feel light headed, drowsy or forgetful due to the sedative." "- Sore throat for 2-3 days." "- Mild redness or soreness at the IV site. Apply a warm, wet compress if necessary." "Call my office and/or go to the Emergency Room for: "- Chest pain and/or vomiting of blood." "- Severe and worsening pain with a deep breath." "- Shortness of breath." "- Chills and/or a fever of 38.0°C or greater"