CDDC Procedures

Past Medical History: - [past medical history and previous surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Current Medications: - [current medications and herbal supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Social History: - [social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Family History: - [family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) History of Presenting Illness: - [current issues, reasons for visit, discussion topics, history of presenting complaints] (Write in paragraph form. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Previous GI Investigations: - [previous gastroscopy or colonoscopy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Physical Exam: - [physical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 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. - [gastroscopy findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Procedure Note-- Colonoscopy: Sedation was administered by anesthetist. Digital rectal exam was [digital rectal exam findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). 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 [bowel preparation quality: excellent|good|adequate|suboptimal|poor] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). Ottawa bowel prep score was [Ottawa bowel preparation score (1-14)/14] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). The terminal ileum was [terminal ileum intubation status: intubated|not intubated] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). It appeared [terminal ileum appearance] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.). [biopsies taken during colonoscopy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Careful examination of the colon demonstrated: Terminal ileum: [findings in terminal ileum] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Ascending colon: [findings in ascending colon] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Transverse colon: [findings in transverse colon] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Descending colon: [findings in descending colon] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Sigmoid colon: [findings in sigmoid colon] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Rectum: [findings in rectum] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Retroflexion: [findings on retroflexion] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 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: - [assessment and plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [results from colonoscopy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 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, [Clinician name and credentials](Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)