Med Transcription

1 Pages 231 Words

PROCEDURE: Flexible sigmoidoscopy , biopsies of rectum.


INDICATIONS: The patient is a 32-year-old white male who has frequent episodes of watery, crampy diarrhea with a sense of urgency and tenesmus. He clearly associates these episodes with certain kinds of foods , specifically milk products, colas, certain fruits, and vegetables. He has no diarrhea or cramping episodes when he avoids these foods. There is no history of nocturnal diarrhea. Overall, he feels that he can adequately control his symptoms with modifications of diet. However, we felt that , given his symptoms of proctalgia , a flexible sigmoidoscopy might help exclude other causes.

CONSENT: The risks, benefits, and alternatives to the procedure, including risks of bowel perforation, bleeding, and death were explained to the patient. The patient understood and provided written, informed consent.

PROCEDURE: The patient was placed in the left lateral decubitus position. A digital rectal examination was performed. The Pentax ES3801 video sigmoidoscope was advanced to 60 cm without difficulty. The preparation was adequate. All mucosal surfaces were viewed, including a retroflex view of the rectum. Four biopsies were taken of the rectal mucosa.

FINDINGS
1. Normal prostate to digital rectal examination.
2. Normal colon and rectal mucosa.
3. Mild internal hemorrhoids.



IMPRESSION: No colorectal cause for diarrhea. The patient clinically has lactase deficiency.

RECOMMENDATIONS: Continue to avoid dairy products . Supplemental calcium. Followup by phone for biopsy results....