Chapter 3: The Digestive System | Sally Nguyem's Chart Note

CHART NOTE

Patient Name: Nguyem, Sally
ID Number: 22316
Examination Date: March 1, 20xx

PROCECURE
Flexible simoidoscopy

INDICATIONS
Patient is an 81-year-old female for routine screening flexible sigmoidoscopy. Patient has a maternal history of Crohn's disease and a paternal history of diabetes.

PROCEDURE
The 60 cm simoidoscopy was introduced to 40 cm and was well tolerated. Erythematous, nonbleeding polyp, less than 1 cm, was found between 35 and 40 cm. Retroflex (backward) viewing is negative. Patient tolerated the procedure well.

DIAGNOSIS
Polyp at 35-40 cm on flexible simoidoscopy screen examination.

PLAN
She is referred to a gastroenterologist for colonoscopy. We discussed the risks of colonoscopy, its benefits, and the procedure. The patient was provided with a brochure describing the procedure and instructed to contact the office with any questions.