Home  | About Us  | Services  | Training | Order Forms | Certification Prep Course  | Coding Tips  | Coding Quizzes  | Contact Us

Restuccio Healthcare Group / Ritecode.com - Medical Coding Consultants

The Medical 
Banner Exchange
This site is a member of the Medical Banner Exchange

Op Report 2

PROCEDURE: Sigmoidoscopy

INDICATIONS: Performed for evaluation of anemia, gastrointestinal Bleeding.

MEDICATIONS: Fentanyl (Sublazine) .1 mg IV Versed (midazolam) 1 mg IV


PROCEDURE: A history and physical examination were performed. The procedure, indications, potential complications (bleeding, perforation, infection, adverse medication reaction), and alternative available were explained to the patient who appeared to understand and indicated this. Opportunity for questions was provided and informed consent obtained. After placing the patient in the left lateral decubitus position, the sigmoidoscope was inserted into the rectum and under direct visualization advanced to 25 cm. Careful inspection was made as the sigmoidoscope was withdrawn. The quality of the prep was good. The procedure was stopped due to patient discomfort. The patient otherwise tolerated the procedure well. There were no complications.

FINDINGS:  Was unable to pass scope beyond 25 cm because of stricture vs very short bends secondary to multiple previous surgeries.  Retroflexed examination of the rectum revealed small hemorrhoids.  External hemorrhoids were found.  Other than the findings noted above, the visualized colonic segments were normal.

IMPRESSION:  Internal hemorrhoids  External hemorrhoids  Unable to pass scope beyond 25 cm due either to stricture or very sharp bend secondary to multiple surgeries. Unsuccessful Sigmoidoscopy.  Otherwise Normal Sigmoidoscopy to 25 cm.  External hemorrhoids were found.

Access the online version of these 24 Op Reports for only $39. 
Includes "hints", answers and explanations for each Op Report
Keywords Approach Explanation # of Procedures
ICD-9 Answer CPT Answer Multiple Choice Next Op Report 3