OPERATIVE REPORT, SIGMOIDOSCOPY

OPERATIVE REPORT, SIGMOIDOSCOPY 

LOCATION: Inpatient, Hospital 

PATIENT: Frances Miller 

SURGEON: Larry P. Friendly, M.D. 

PREOPERATIVE DIAGNOSIS: Diarrhea. 

POSTOPERATIVE DIAGNOSIS: Mild resolving patchy colitis, nonspecific, infectious. The patient should still be worked up for fever as the colitis may not be the cause of the fever. 

PROCEDURE PERFORMED: Flexible sigmoidoscopy. 

INDICATIONS: 42-year-old white female with SLE and chronic renal failure on hemodialysis who has had diarrhea. Her stools were negative. She did well but on the day of discharge she began having diarrhea again and was readmitted today. She has had only one stool within the last four hours. The stools mostly seem to be nocturnal. She has had no antibiotics recently, no one else is ill. 

DESCRIPTION OF PROCEDURE: The Pentax videosigmoidoscope was inserted without difficulty to 50 cm. Careful inspection of the mid and distal descending, sigmoid and rectum revealed patchy erythema, minimal friability and some mild edema. There was no discrete ulceration, no exudate. No biopsies were obtained. The patient tolerated the procedure well. 

IMPRESSION: Mild patchy colitis that appears to be resolving consistent with infectious colitis. PLAN: The diarrhea is slowly resolving and probably will resolve spontaneously. We will check the stools but no treatment for now unless she continues to be symptomatic, if so I would give her ciprofloxacin. I would continue to workup the fever as you are doing.

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