Consult Colonoscopy

DATE: [date of procedure] (Write as a single date, today's date.) PROCEDURE: "Colonoscopy" PRE-PROCEDURE DIAGNOSIS: [pre-procedure diagnosis and indications for the procedure] (Write as a list of brief points. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) POST-PROCEDURE DIAGNOSIS: [post-procedure diagnosis] (Do not put in information in this section from historical endoscopy reports. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) HISTORY OF PRESENTING ILLNESS: [description of the patient's presenting illness, including demographics, referral information, history of current symptoms, relevant past procedures, and recent clinical events] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PAST GI HISTORY: [list of relevant past gastrointestinal diagnoses, procedures, and related conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of brief points. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PAST HISTORY: [list of relevant past medical history, including chronic conditions, surgeries, and other significant health issues] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of brief points. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MEDICATIONS: [list of current medications, including dosage, strength, and route] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list of medications with details. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) ALLERGIES: [list of known allergies or statement indicating no known allergies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a list or a single statement. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) FAMILY HISTORY: [description of relevant family medical history, including specific diseases or conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) SOCIAL HISTORY: [description of the patient's social history, including occupation, living situation, caregiver status, mobility, and history of tobacco, alcohol, or illicit substance use] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraphs of full sentences. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) PHYSICAL EXAM: "The abdomen was soft, non-tender, with no hepatosplenomegaly or masses. Cardiovascular, respiratory, lymph node, and dermatological examinations were normal." INVESTIGATIONS: - [summary of relevant investigations, including dates and key findings from lab work, previous procedures, or imaging] (Write as a list of brief points. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) 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 [] mg and fentanyl [] mcg." (Insert exactly from quotes. Do not put in information in this section from historical endoscopy reports) 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: [] 2. Extent of examination: [] 3. Withdrawal time: [] minutes 4. Technical difficulties: [None] 5. Unplanned events: [None]" (Insert exactly from quotes. Do not put in information in this section from historical endoscopy reports) ASSESSMENT AND PLAN: [summary of assessment findings and the proposed plan, including follow-up, further investigations, and management strategies] (Write in paragraphs of full sentences. 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.)